Billboard Therapy: Doctoring vs the Dollar

Kate Hitchcock, MD, PhD


July 29, 2021

"Publicity is exactly like poison. It can't hurt you until you swallow it."

–Rip Engle, 1962, often incorrectly attributed to Joe Paterno

For better or worse, medicine in these United States is a business. One hundred percent of the decisions we make are influenced by the dollar, which completely determines the options that are available for us and for our patients. Every doctor therefore lives on a series of slippery slopes, and any student of the human condition knows without checking that some of us have better crampons than others. But I think that nearly all of us are working hard to stay high on the incline.

In oncology, all of the stakes of that effort are high. Every decision is a potentially mortal one, and both diagnostic tests and treatments are shockingly expensive. In that context, the manner in which our tools are advertised matters a great deal.

Who among us has not been asked for immunotherapy, even if we are not medical oncologists? A very smart doctor of my acquaintance calls stereotactic, hypofractionated radiotherapy "billboard therapy" for its potential to appeal to patients and bring them to a specific practice. Another asked me one day if the state-of-the-art equipment for which my department was agitating was really useful or if we were just participating in the radiation oncology arms race. What makes discussion of all of these tools especially pivotal is that they are much more expensive than the alternatives they are intended to replace.

So, what is a good oncologist to do? The dregs of the profession might make treatment decisions based on what is most profitable for them, but the overwhelming majority of us try hard never to be influenced by such thinking. It would be naive, though, to believe that we are not susceptible to the same frailties as our 7 billion other neighbors.

In the US we have all seen juries decide in favor of plaintiffs who successfully sue deep-pocketed companies, even when the weight of evidence seems to suggest that the company is not definitely at fault. After all, the company is not an individual with feelings, and it has so much money that it's hard to imagine any actual person suffering from such a decision. Do we, 100% of the time, steer away from borderline-useful, expensive treatments as assiduously when our patients are fully insured as when they are paying out of pocket?

Now, what happens when you bring in the element of the patient thinking we're bad doctors if we don't use the new, shiny, super-hyped treatment from the full-page ad in the middle of their Sunday news? Unfortunately for all concerned, movies and social media have trained the consumers of our services to believe that doctors are either lazy, Big-Pharma–loving fools unwilling to educate ourselves about thrilling fringe treatments or that we somehow reserve the very best treatments only for special patients and those who ask just the right questions after hunting through the comments sections of medical websites looking for unturned stones of medical miracle.

Those ideas make for suspenseful fiction and lots of likes on inflammatory tweets but are incredibly harmful to the doctor-patient relationship. Add, then, to this terrain the craft of skilled advertising personnel who know just how to appeal to a cancer patient desperate for good news, and you have a scenario ripe for unintentional/unavoidable excessive costs in cancer care, costs driven by the patients themselves. People afraid for their lives are all too ready to swallow that particular poison. And to fire a doctor who tries to get in their way in doing so.

How do you talk with your patients about well-publicized treatment options that are not right for them?

Please join the discussion below, but if you need to communicate with me offline you can reach me at

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About Dr Kate Hitchcock
Kate Hitchcock, MD, PhD, is a radiation oncologist, biomedical engineer, and retired aircraft carrier driver who grew up as a Wyoming cowgirl. When she is not at the hospital, you can find her with Carolyn, Mary, Tyler, Nick, Marlee, and Colby the barking dog, enjoying the natural splendor of the great state of Florida. She thinks you should visit sometime and try to solve the puzzle of why the natives have so carefully shunted all of the tourists toward the House of Mouse. Connect with her on Twitter: @hitchcock_kate


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