Trust and Direct-to-Consumer Medicine: A Prescription for Trouble?

A rapidly emerging industry has come on the medical care scene – direct-to-consumer medicine via e-commerce. You simply go to an e-commerce platform, describe your symptoms or what you want, and voila! – the prescription arrives at your door, as easy as ordering a book on Amazon. Commonly ordered prescriptions include pills for erectile dysfunction, hair loss and anxiety.

You could say direct-to-consumer medicine is like Uber, a disruptor of the normal supply chain that provides better service from the comfort of your computer or handheld device. You trustingly initiate a transaction with a complete stranger and, after verifying the identity of the driver, you feel safe.

In her book Who Can You Trust? How Technology Brought Us Together and Why It Might Drive Us Apart, author Rachel Botsman describes the Trust Stack – ideas, platforms/company and other people. With direct-to-consumer medicine, you first must trust the idea of buying prescription drugs online. This idea is easy to trust because you have previously ordered a number of goods online – there is familiarity.   Secondly, you have to trust the company or the platform. Again, we use new platforms all of the time, and we tend to trust that they will provide what we expect.

It’s the last element of the Trust Stack that gives me pause – other people; in the case of direct-to-consumer medicine, it’s the physician or clinical team. Can I trust a physician or clinical team I have never met and who will never get to know me and my medical and psychological history? Can I trust that this person is truly qualified – is he or she board certified and up to date? I cannot see that certificate or license on the wall.  Am I going to be safe – an underpinning of trust?  Health conditions that seem simple might be a harbinger of something more serious. If I order a prescription online, who can I ask about side effects if they occur?

For me, having a relationship with my physician and the care team is paramount – they know me and I know them. What disturbs me about online retail medicine is the lack of face-to-face conversation between the patient and the clinician. That’s antithetical to medical professionalism and the principles of our signature campaign Choosing Wisely, which is based on conversations between patients and physicians about the most appropriate care.

Perhaps this new genre of medicine is a generational phenomenon – direct-to-consumer engagement makes health care more accessible, and following standardized algorithms for care makes it more reliable. Patients can be trusted to provide accurate symptoms, and they know what they need. Maybe restricting medical e-commerce to a few conditions will not impact the need to build a relationship with a physician, and the physician can be “informed” about these new medications.

Certainly, I would not say that this is a trust builder in health care. This approach to care could feed a narrative about finding alternatives to a health system you already mistrust. It also could be part of a wider movement to mistrust expertise, science and facts based on evidence. Today it’s erectile dysfunction medication; tomorrow it’s anti-depressants and ADHD medications obtained online.  Again, with my Choosing Wisely cap on, I worry about what the lack of conversations will do to the overuse of pharmaceuticals and other medical services.

This is an important conversation – it touches on what kind of health system and patient interactions we want for the future. I have to believe there will be a need for high-touch conversations between patients, providers and health promoters. As I age and my health moves into what I hope will be a slow decline, I don’t want to dial up care. I do want a health care system that is highly responsive to my needs and that I can dial into sometimes. That includes new ways of communicating, like physician portals. If we don’t get this right, we will have a growing number of alternative ways to get care – but some will be advantageous and others will be potentially harmful to our health.

Daniel B. Wolfson
EVP & COO, ABIM Foundation