Just last week I was contacted by an acquaintance about
Viagra. He was not a physician and got
the prescription through an online business that specializes in dispensing
hair loss, erectile dysfunction, anxiety, and depression medications. When I
see these businesses advertising that combination of medications it always
piques my interest. Why these medications? Comparing them with the most prescribed drugs
in the US – 3 antidepressants are in the top 20 - sertraline, trazodone, and
escitalopram. They can double for
anxiety medications. Viagra (sildenafil)
is 157 and Cialis (tadalafil) is 172. Finasteride
can be used for both hair loss and prostatic hypertrophy and it is number
72. Topical minoxidil is not on the
list. It is not like there is a shortage of prescriptions for any reason.
My contact person had talked with one of the online
prescribers and was not sure about how he was supposed to take the medication.
Should he take it every day or just on the days he was going to have
intercourse? Reading the prescription
label and the information he was sent was not helpful.
More of these online prescribing services seem to be
advertising every day. They promise cost
effectiveness, the same medications that your physician would prescribe, ease
or use, and no embarrassment. How many
times have you been in line at your clinic or pharmacy and had a staff person
belt out some information about you that you preferred stay private? That line on the floor separating you from
the other patients is not enough distance to muffle a receptionist shouting
through plexiglass. The online service
promises to send you the medication in a plain brown wrapper.
The real downsides to this new relationship are never
mentioned. No access to your records to check for contraindications, drug-drug
interactions, pre-existing medical conditions, the status of your liver and
kidney function, or allergies. No access to your physician who may know you so
well that they can say if taking a new medication would be advisable or not. No
detailed discussions of risks, potential benefits, and unknowns. For me that discussion
has taken longer than most of the telemedicine visits I have heard
about. And most importantly – no access
to somebody who knows your situation if something goes wrong.
There is a real issue about how much information these rapid
online prescribers keep on file and what it is used for. Do they list your major medical
conditions? Does that lead to marketing?
Does that lead to data mining to develop sufficiently large programs to make
more money off you? Recall that wherever
your data is on the Internet, somebody is trying to profit from it.
That brings me to a stark conclusion about capitalism that I discovered too late in life. Growing up in the US, you are sold on the idea that capitalism and democracy are the mainstays of the country. We are special because of both and we do both better than anyone else in the world. The wealthy are idealized and everyone aspires to be wealthy. If you can't get wealthy maximizing your material possessions seems to be a substitute.
American products are good because our environment
producers entrepreneurs and competition among entrepreneurs produces superior
products. Think about that for a
second. The entrepreneur gets all the
credit. Forget about all of the science and engineering behind any
product. The faceless people laboring
behind the scenes are hardly ever mentioned. If you are industrious enough, you
might be able to find out who holds the patents but in the end they are all
property of a large company. And that
company is there for one reason – to make as much money as possible.
In a service industry like medicine corporate profits were
initially hard to come by because it was a cottage industry of private
physicians. Even as the corporate
takeover began in the 1980s, physicians resisted to some extent as a powerful
mediating class between corporate interests and the interests of physicians and
patients. The end run around that physician mediation was hiring them as
employees. Initially corporations proposed
that they were going to make primary care more accessible and minimize
specialists. In the end that was merely
a tactic and they acquired specialty care as well as primary care. Today most physicians are employees and have
minimal input to their practice environment.
They are essentially told by middle managers how to practice medicine. They work by default for companies like
managed care companies and pharmacy benefit managers that waste physician time
to rubber stamp their rationing procedures.
The profits from the corporate takeover of medicine are high. It is after all a recipe for making
money. There is a stable subscriber base
fearful of medical bankruptcy and the corporation can decide how much of those
funds it wants to spend. In thinking of new ways to make more money,
telemedicine is the latest innovation. Convenience is a selling point. It has
been used for decades to reach people in rural areas who would have a hard time
travelling long distances to clinics.
But the current model is more like Amazon online shopping. If you have condition x, y, or z – contact us
and we will get you a prescription. Better yet, let’s take the pharmacy middle
man out of the picture and prescribe and sell you the medication at the same
time.
A recent commentary in the NEJM pointed out the potential problems
of the new relationship between pharmaceutical companies and telehealth firms
(1). It is as easy to imagine as the following thought experiment. Suppose you are watching a direct-to-consumer
ad about a weight loss drug. You go to
the suggested web site where it tells you to make a telehealth appointment the
same day for a nominal fee. One study showed that 90% of patients referred
through this sequence got a prescription for the advertised drug. The pharmacoepidemiology, quality of care,
and legal ramifications of these arrangements are unknown. The scrutiny is nonexistent compared with the
claims that physicians were being influenced for decades by free lunches. That matches my suspicion that the physician
conflict of interest hype was more a political tactic than reality to suppress any objections to the
political and corporate takeover of medicine.
That brings me to the Bill Gates (2) comment. Expectedly he is an unabashed promoter of
computer technology and the latest version – artificial intelligence or AI. His thesis is that AI will commoditize
intelligence to the point that humans will not be necessary for most things including
teaching and medicine. No mention of the conflict of interest. The company he founded – Microsoft is currently
heavily marketing computers with an early version of AI. A couple of years ago
they also changed to a license for life model.
In other words when you buy a Microsoft computer or software package –
you no longer own it outright. You must
pay a monthly licensing fee if you use it or if they decide not to support your
computer any more – you must upgrade it to continue paying monthly fees for a
long as you use your new computer. Or
until they tell you again that you have to buy a new one. Even though intelligence is “free” Microsoft
and all of the other major tech companies are not really giving it away – they have
a recipe for making money off of you for the rest of your life.
There is a reason that doctors don’t know much about
business or politics. Both are highly corrupting influences. Medicine is a
serious profession that is squarely focused on mastering a large volume of
information and technical skill and keeping that current. Businesses on the
other hand are focused on every possible way they can get your money and they
are very good at it. If it comes down to an AI program providing medical care
that is all you really need to know.
George Dawson, MD, DFAPA
References:
1: Fuse Brown EC, Wouters OJ, Mehrotra A. Partnerships
between Pharmaceutical and Telehealth Companies - Increasing Access or Driving
Inappropriate Prescribing? N Engl J Med. 2025 Mar 27;392(12):1148-1151. doi:
10.1056/NEJMp2500379. Epub 2025 Mar 22. PMID: 40126465.
2: Richards B. Bill Gates Says AI Will Replace Doctors,
Teachers and More in Next 10 Years, Making Humans Unnecessary 'for Most Things'. People Magazine March 29, 2025. https://people.com/bill-gates-ai-will-replace-doctors-teachers-in-next-10-years-11705615
Graphic Credit:
Click on the graphic directly for full information on the Wikimedia Commons web site including CC license. It is used unaltered here.
