Opinion: The Worrisome Rise of Direct-to-Consumer Medicine

If you’re on Instagram, or if you’ve taken the New York City Subway lately, chances are you’ve heard of Hims, the men’s health and wellness company with a penchant for advertisements featuring suggestive cacti and eggplants against pastel backgrounds. The web-based startup targets the young male demographic with skincare products, multivitamins, and erectile dysfunction medications. In January, just a few months after its first birthday, the company joined Silicon Valley’s vaunted “unicorn” club: It received a venture-capital investment that put its valuation at $1 billion.

The ambitious valuation is certainly a remarkable achievement for the young company. But it’s also yet another signal that a new e-commerce market that one might call “direct-to-consumer medicine” is on the rise. Although the companies in this sector have different styles and specialties, they all aim to link patients, pharmacies, and doctors through web apps and the cloud. Their core business models are remarkably similar. First, a self-diagnosing consumer selects a product they think they need. Then, the customer completes an online questionnaire, which is reviewed by a physician if a prescription is needed. A secure messaging platform is available if the customer has questions for the physician before the order is filled and mailed to their door.

These direct-to-consumer companies have historically occupied the periphery of American health care, offering services that often aren’t covered by traditional medical insurance. For instance, there’s Hubble for vision testing and contact lens prescriptions, SmileDirect for mail-order orthodontics, and Keeps for hair loss. But as younger consumers express a growing preference to shop for products and services online, the industry has started to encroach into the territory of traditional primary care. Consumers can turn to Hims and Roman for erectile dysfunction, to Nurx for oral contraception, to Cove for migraines, and to Zero to quit smoking. As more drugs have gone generic, the trend has accelerated, and investors have grown more eager to get in the game.

As a medical student who just finished a rotation in a primary care office, I can see the appeal. Hims in particular has potential to bring stigmatized men’s health topics out of the shadows and connect men to affordable treatments for conditions that they otherwise might not address. Direct-to-consumer medicine is certainly more convenient and discreet than a trip to a doctor’s office, where patients commonly endure long waits only to be rushed through a conversation with a physician who’s weighed down by too many obligations. If a doctor’s office is like Blockbuster, Hims feels more like Netflix.

But I also question whether direct-to-consumer medicine is truly safe for patients. Take erectile dysfunction, or ED. On paper, it seems like a simple diagnosis. In reality, however, it’s a textbook example of the complexity of human health. Sometimes ED occurs on its own, with no identifiable cause. But more often than not, it is a symptom or precursor of other conditions: anxiety, depression, clogged blood vessels, high blood pressure, diabetes, or hormone imbalances.

That’s why the American Urological Association advises physicians treating patients with ED to also screen for the condition’s potential physical, social, and behavioral causes, including relationship issues and drinking and smoking habits. The association recommends, at the very least, checking vitals, performing a genital exam, and — for patients presenting with ED issues for the first time — screening for high cholesterol, diabetes, and other diagnoses commonly associated with ED. For some direct-to-consumer health products, like oral contraception (now offered by Hers, a subsidiary of Hims, among other companies), an online evaluation may be sufficient. But for ED appears to fall far short of the basic AUA guidelines.

The direct-to-consumer companies also present ethical dilemmas. The physicians who work for them may be hamstrung in terms of the scope of the advice they can offer and their ability to follow up with patients to track progress. And they surely must feel some pressure to push their employer’s products. The companies essentially operate on islands of care, where doctors can’t address secondary issues that surface during a consultation and can’t add information to a patient’s home medical record. There’s also the risk of muddying the critical distinction between health and wellness: Hims’ marketing and website design places FDA-approved drugs like propranolol — commonly used off-label to treat performance anxiety — alongside supplements like biotin gummies, conflating the two categories for unwitting consumers.

One could argue that direct-to-consumer medical startups and their venture capital investors are attempting to disrupt primary care by “unbundling” it. This goal contrasts with the vision of primary care enshrined in legislation like the Affordable Care Act, which championed a “patient-centered medical home” where a strong physician-patient relationship is supported by ancillary professionals. Instead, the e-commerce model takes the view that physicians are middlemen clinging to an industry ripe for change — much like taxi cabs, bookstores, and hotels in the days before Uber, Amazon, and Airbnb.

In this technocratic, patient-empowered dream, however, I can’t help but wonder what is lost. During my primary care rotation, I would always begin conversations with patients by asking what prompted their visit. Yet the conversation hardly ever ended there. Our agenda was dynamic, hinged to the information gathered in real time in the exam room. Frequently, we’d shift gears to discuss a patient’s previous diagnoses, to address new concerns such as high blood pressure readings, or to talk about plans for end of life care. We often discussed evidence-based preventive measures — like options for eating healthier, methods to quit smoking, or guidelines for colon cancer screening. In other words, we would act on the concerns of the present, but also anticipate the needs of the future.

In many ways, Hims and other startups are capitalizing on a cultural moment. Their products address a genuine frustration with the current state of American health care, and they are emblematic of what’s likely to be a lasting trend toward commodification in medicine. The companies’ early successes are arguably a smoke signal for traditional primary care — a warning that doctors’ offices must adapt to become less clunky and bureaucratic. The question of whether companies like Hims and Roman are heroes or villains of the health care ecosystem continues to be hotly debated. Christina Farr, a reporter for CNBC, recently tweeted that the rise of personal wellness startups was “the most divisive trend” she’s seen in her years covering health and technology.

I’d like to think there is room for both health care models to coexist. Considering how big the direct-to-consumer market has now become, today’s primary care physicians have a pragmatic obligation to ask patients if they use online wellness companies, to understand which products they offer, and to counsel patients on the potential risks and benefits of those products. If these companies are leveraged correctly, they very well could declutter primary care and break down barriers to access. But we should push for greater regulation to address potential ethical concerns, draw clear distinctions between health and wellness, and establish guidelines that protect our patients.

As more startups like Hims take root, the window of opportunity to set the rules of direct-to-consumer medicine will close. The time to act is now.

Vishal Khetpal is a freelance writer and third-year medical student at the Warren Alpert Medical School of Brown University.