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Healthy Skepticism International News

October 2002

CHAPTER TWO: METHODOLOGY

2.1         DISCOURSE ANALYSIS

The discursive analytical approaches of Michael Billig (1987; 1991; Billig et al., 1988) and Jonathon Potter (1996), amongst others, were used in this study to analyse general practitioners’ talk on the controversial and ethically dilemmatic issues of pharmaceutical promotion and medical practice.  Both these approaches are outlined below in order to impart some understanding of the discursive approaches informing the analyses presented in this study.

Billig et al.’s (1988) discursive approach stresses the importance of shared social knowledge, as understood in ‘the thinking society’ of Social Representations Theory (Moscovici, 1984), but extends this by emphasising the way in which thinking takes place through the dilemmatic aspects of ideology and common sense.  The individual thinker is not the focus of attention, but the contrary aspects of socially shared beliefs which give rise to dilemmatic thinking (Billig et al., 1988).

Ideology informs the dilemmatic aspects of common sense, and is reflected in both the thinking of the contemporary society and its cultural and ideological history (Billig et al., 1988).  Ideology and common sense, rather than being a complete and unified set of beliefs, are “reproduced as an incomplete set of contrary themes, which continually give rise to discussion, argumentation and dilemmas” (Billig et al., 1988, p. 6).  Contrary themes of common sense exist in all societies in the forms of opposing maxims, proverbs and folk wisdom, and antithetical pairs of shared beliefs, images and moral values (Billig et al., 1988).  The existence of these opposing images, word, evaluations and maxims permit not only the possibility of social dilemmas, but also of social thinking itself (Billig et al., 1988).  In dilemmas, these socially shared images, representations, and values are seen in conflict.  Without the presence of such contrary themes, social dilemmas could not be experienced, and deliberations and much of thought would not be possible (Billig et al., 1988).  Ideological themes of dilemmatic character can be found in all conversations, routines and interviews (Billig et al., 1988).

Furthermore, if thinking and arguing are linked, then the rhetorical skills of argument are closely linked to skills of thinking (Billig (1987; Billig et al., 1988) and the capacity for using rhetoric, can be considered as a universal and pervasive feature of everyday situations and meaning (Billig, 1987).  Within this notion of thinking and arguing however, not all members of a society think, argue or are perplexed about the same things (Billig et al., 1988).

‘Attitudes’, within this theoretical approach, represent a stance on matters of controversy rather than individual cognitive evaluations (Billig, 1987), and as such are inseparable from the contemporary controversies of commonsense ideologies (Billig, 1991).  Every ‘attitude’ in favour of a position is also, either implicitly or explicitly, a stance in opposition to a counter position and is constructed rhetorically to justify a position and criticise the counter-position (Billig, 1991).

Potter’s (1996) discourse analytic approach asserts the discursively constituted nature of ‘reality’, in that “reality enters … human practices by way of categories and descriptions that are part of those practices.  The world is not ready categorised … it is constituted … as people talk it, write it and argue it.” (Potter, 1996, p. 98).  Descriptions are themselves also reflexive, in that they both describe the world as well as constitute it (Potter, 1996).  In descriptive accounts, ‘realism’ and ‘factuality’ are worked up through rhetorical devices and techniques contextual to specific situations (Potter, 1996).  These discursive techniques however, do not guarantee that specific versions will be treated as ‘factual’ or ‘reality’, as techniques may be “deployed effectively or badly, … undermined vigorously or accepted credulously” (Potter, 1996, p. 102).

Both offensive and defensive rhetoric are utilised in the building up of the ‘factuality’ of accounts (Potter, 1996).  Offensive rhetoric are the descriptions designed specifically to undermine alternative descriptions, and constitute the procedures by which ‘factual’ versions are built up, while defensive rhetoric are the descriptions or procedures that provides protection against discounting or undermining (Potter, 1996).  Discursive constructions such as the ‘empiricist’ discourse, detail and narrative (including focalisation and ‘witness’ as a category entitlement), and consensus and corroboration (including active voicing) are some of the linguistic and rhetorical devices used in everyday talk to construct versions as ‘solid’ and ‘factual’.

According to the actions they perform, ‘factual’ accounts are described as having two distinct orientations; action orientation and epistemological orientation (Potter, 1996).  Action orientation of an account refers to the way in which a description or version is used to accomplish an action (Potter, 1996).  This may be the production of an inferred request, deflection of issues of blame or negative attributions, or the management of a problematic or potentially undesirable identity in sensitive or controversial contexts where explicit formulations are not proffered (Potter, 1996).  Epistemological orientation of an account is described as the procedures used to “build its own status as a factual version” (Potter, 1996, p. 108) and is treated as a form of action itself (Potter, 1996).  Both orientations are carefully utilised in constructions of everyday accounts so as to produce descriptions that are accepted as ‘reality’ or unconjectured ‘truth’ (Potter, 1996).

Discourse is also organised around two distinct clusters of practices (Potter, 1996).  These are the practices which involve different constructions of the agent, such as constructions of interest/disinterest and the building up of category entitlements; and the practices that make the description separate and external to the actor, such as the ‘empiricist’ discourse, production of corroboration, or descriptions as narrative (Potter, 1996).

Within this interest and category entitlement approach, stake inoculation refers to the way in which versions are constructed in order to inhibit the imputation of stake and interest, and the subsequent discounting of the description’s ‘facticity’ (Potter, 1996).  Category entitlement is the strategic utilisation of categories, constructed to provide entitlement to knowledge within a context, and a degree of accountability for the description (Potter, 1996).  Every category has epistemological implications, and provides the agent with epistemological entitlements and rhetorical power (Potter, 1996).  Footing within this approach, first described by Erving Goffman (1981), refers to the range of relationships agents have with their descriptions and is concerned with the management of personal or institutional accountability (Potter, 1996).

These stake inoculations and category entitlements are used by agents in their constructions of descriptions in order to protect against the discounting of the ‘facticity’ of their account, and to protect the credibility or epistemological entitlement of the agent as source.  In everyday constructions of ‘reality’, these offensive rhetorical strategies of category entitlement, and defensive rhetoric strategies of stake inoculation, are utilised in consort in the building up of the ‘facticity’ of accounts or the acceptance of an account as unproblematic (Potter, 1996).

This study will predominately use Billig’s notion of common sense ideologies and Potter’s discursive approach to analyse the talk of general practitioners on the sensitive issue of pharmaceutical promotion and medical practice.


2.2         COLLECTION OF DATA

Sixty-five MaLAM subscribing general practitioners in the Adelaide Metropolitan area and environs were each sent a personally addressed letter (Appendix A) outlining the aims and purpose of the study, and inviting the recipients to attend a focus group.  Recipients were requested to indicate their interest in attending a group by ticking a box and faxing the letter to MaLAM.  Those interested in attending a focus group were contacted by phone, and invited to attend one of three Adelaide regional-area focus groups.

The letter fax-back response rate for focus group participation was low (14%) with nine responses received, six ‘yes’ and three ‘no’.  Subsequent to this, Dr. Peter Mansfield (Director of Healthy Skepticism, formerly MaLAM) personally requested two further MaLAM-subscribing general practitioners to take part in the focus groups, one of whom attended.  A MaLAM-subscribing respondent also enlisted four of her non-MaLAM subscribing medical practice colleagues to attend in the same focus group (Focus Group 3).

Prior to commencement of the main focus groups, a pilot focus group (Focus Group 1) was conducted with one MaLAM subscriber (the other participant did not attend).  Three main study focus groups were then conducted.  Of these main study groups, the first (Focus Group 2) and last (Focus Group 4) each had two male MaLAM-subscriber participants (with non-attendance of a further male participant in the last focus group).  Participants in the first two main study groups (Focus Group 2 and 3) were from the same practice, but in the last group (Focus Group 4) the participants were unknown to each other.  Dr. Mansfield attended all the focus groups.  The focus group sessions ranged in duration from 45 to 75 minutes.

In each of the focus groups the attendees were welcomed, and introduced to each other and the interviewers.  Anonymity and confidentiality of the study was reiterated, and each participant signed a consent form (Appendix B).  Participants were then asked to read the focus group handout which outlined the topic of discussion and defined the scope of the term ‘gift’ (Appendix C).  Interactive discussion between participants was encouraged together with direct responses to interviewer questions and statements (Appendix D) on the issues of pharmaceutical representatives, ‘gifts’ and samples and the ethical and medical dilemmas incumbent.  The aim of the focus group discussions were to elicit the ethical reasoning and deliberations of the general practitioners, and the discursive devices employed in their talk about the ethical dilemmas of pharmaceutical representatives, gifts and samples in medical practice.  The focus groups were tape-recorded and then transcribed using Gail Jefferson’s system of notation (Potter, 1996) (Appendix E).  Each focus group participant was assigned a pseudonym to ensure anonymity.  The transcribed focus group discussions, including the pilot focus group, were assigned focus group numbers in temporal order of organization (F1, F2, F3, F4) and each group discussion was independently line-numbered from the first to the last line of talk.

Focus groups were chosen as the preferred methodology, rather than individual interviews, as it was hoped the participants would discuss interactively with each other as well as directing responses towards the interviewer.  It was considered that focus groups would elicit more medically and ethically complex responses and debate.


2.3         ANALYSIS PROCEDURE

The talk of each group was subdivided into distinct thematic/issue sections.  Recurring themes/issues were also sorted together and re-read.  The discussions were analysed for the common sense ideologies informing the talk (Billig, 1987; 1991; Billig et al., 1988), and the interest and category entitlement formulations and other discursive rhetorical devices (Potter, 1996).  Discursive repertoires and linguistic rhetorical patterns were identified as they emerged from the readings.  Representative extracts of the repertoires were collated and utilised in the discussion.  These extracts were identified from the source transcriptions by both focus group and line numbers, ie F1: 102-105.

2.4         METHODOLOGICAL ISSUES

The qualitative methodology used in this study assumes that the validity of the analysis is not related to the volume of texts analysed.  The analysis is also concerned with the use of linguistic and rhetorical devices, rather than the participants generating the language (Potter & Wetherell, 1987).  The four focus groups (pilot and three main study focus groups) totalling nine participants were considered to be adequate for this analysis, as a relatively large number of linguistic patterns emerge from only a few texts (Potter & Wetherell, 1987).

The analysis illustrates the linguistic resources and devices that were available to the participants and utilised in their talk within the focus group setting.  Any specific discourses identified in the analysis have generality to the extent that they inform the ethical dilemmas faced by contemporary physicians, from a broad historical and socio-cultural perspective.  Reliability in this discourse analytic study is evidenced, in part, from reproductions of similar socio-cultural discourses within the same historical epoch around the debate of pharmaceutical promotion and medical practice.

Validity, within a discourse analytic approach, is achieved through presentation of the source texts and analytical processes, informing the researcher’s interpretation (Potter & Wetherell, 1987).  Provision of these source texts from which the analysis was produced (Appendices H-K) enables readers to evaluate and assess the adequacy of the analysis presented (Potter, 1996).


2.5       ANALYSIS OUTLINE


Textual or discourse analysis requires a balanced compromise between presentation of enough source texts to allow the reader to assess the validity of the researcher’s analysis, and the desire not to overwhelm with too much detail.  Text extracts presented therefore are restricted to representative extracts best illustrative of the discursive resources and linguistic practices utilised.  A selection of focus group texts is provided for reference in Appendices H and I.

 

 

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...to influence multinational corporations effectively, the efforts of governments will have to be complemented by others, notably the many voluntary organisations that have shown they can effectively represent society’s public-health interests…
A small group known as Healthy Skepticism; formerly the Medical Lobby for Appropriate Marketing) has consistently and insistently drawn the attention of producers to promotional malpractice, calling for (and often securing) correction. These organisations [Healthy Skepticism, Médecins Sans Frontières and Health Action International] are small, but they are capable; they bear malice towards no one, and they are inscrutably honest. If industry is indeed persuaded to face up to its social responsibilities in the coming years it may well be because of these associations and others like them.
- Dukes MN. Accountability of the pharmaceutical industry. Lancet. 2002 Nov 23; 360(9346)1682-4.