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Healthy Skepticism International News

October 2002

CHAPTER THREE: ANALYSIS AND DISCUSSION

In this analysis, the discursive constructions and linguistic devices drawn upon and utilised by doctors in their discussions on pharmaceutical representatives, gifts and samples were analysed using Billig’s (1987; 1991; Billig et al., 1988) theoretical perspective of rhetorical thought and argument being informed by common sense ideologies and Potter’s (1996) discursive approach of the epistemological and action orientation of talk.  Particular attention was paid to the doctors’ rhetorical constructions of the warrants for seeing pharmaceutical representatives, and receiving ‘gifts’ and samples.

Common sense ideologies of business and information/knowledge were identified as two prevalent ideologies informing the doctors’ talk.  The two repertoires of ‘Business’ and ‘Information/Knowledge’ are presented in which the rhetorical use of these ideologies are discussed.  Within each of these ideologies, the discursive and linguistic resources and the rhetorical linguistic devices drawn upon and utilised by the doctors in their constructions of pharmaceutical promotion and medical practice are analysed in detail.  Fine-grained discursive analysis of the epistemological and action orientations (Potter, 1996) of the extracts representative of the accounts and descriptions of each repertoire are concurrently presented.

3.1         THE ‘BUSINESS’ REPERTOIRE

‘Business’ discourse is a commonsense ideology of contemporary western society.  This discourse was frequently drawn upon and utilised by doctors in the focus group discussions to categorise and justify the promotional practices of pharmaceutical companies and their own complicit involvement.  Within the ‘business’ discourse, pharmaceutical companies and their representatives were unquestionably categorised by the doctors, as operating ‘businesses’ and behaving according to the ‘rules of business’.  As such, their activities were rendered unproblematic by being accepted as ‘normal’ and ‘ethical’ practice in the business context, and correspondingly accepted with little need for question.  In the ‘business’ discourse economic trade of time and expertise for money is understood, and accorded primacy to which all other principles are subjugate.

Throughout the discussions, the doctors categorised themselves as ‘businessmen’, operating ‘businesses’ in the ‘business’ world.  In so doing, they positioned themselves within the ‘business’ discourse, utilising it to advantageously deflect blame and imputations of unethical behaviour, as well as manage any consequent problematic identities from their relationship with pharmaceutical companies.  Business values of time-efficiency, cost-efficiency and free-market competition are drawn upon to justify and rationalise their views and personal behaviour in their involvement with the pharmaceutical industry.

Furthermore, this ‘business’ categorisation of pharmaceutical companies and their activities, as well as the doctors’ involvement with them, serves to distance the activities of pharmaceutical companies and the doctors from the ethical dilemmas that arise from the context of the ethical practice of medicine.  This ‘business’ discourse serves to render the business practices of pharmaceutical companies as ‘normal’ and ‘ethical’ in a business context.  Moreover this discourse served to rationalise and justify their own behaviour, and deflect attention from the ethical implications in the ‘doctor and patient’ context.

Frequent pharmaceutical company sponsored lunchtime meals and representative presentations are seemingly rendered unproblematic within the ‘business’ discourse, and are described as the way pharmaceutical representatives present themselves in “that context”.  It’s just the way ‘businesses’ do business, not the way the doctors have requested it.  This is illustrated in Extract 1 below, where Allan in his explanation, is attempting to justify receiving several free lunchtime meals a week, as well as deflect any undesirable identity and unethical behaviour imputations on his part:

Extract 1


ALLAN Well, I probably see(.) three(.) pharmaceutical representatives a week(.) and er(.) that’s(.),

LYNDA Mm.

ALLAN that’s(.), that’s a sort of lunchtime meal(.) set up where we(.), we set that up from our(.) advantage(.) point of view(.) because we can get(.) sort-of half a dozen doctors to actually see them without interrupting consulting so(.),

LYNDA Right.

ALLAN but it’s on the, it’s on the fore(.)warned(.) scenario that er, there’s no expectation to bring lunch, but they always do.

LYNDA Right.

ALLAN So it’s er(.), it’s(.) you-know, part of their way of presenting themselves in that context but(.), it’s not the way that we’ve actually requested it, it’s just(.) you-know, it’s just a way for us, to sort-of from our point of view, to keep the pressure off of them, to sort-of interfering with our limited time for consulting.


(F1: 17-32)


In Extract 1 above, Allan first describes the meetings with pharmaceutical representatives as a “lunchtime meal”, but after pausing, exchanges the word “meal” for “set up” before continuing (line 20).  This demonstrates an attempt in his talk to re-categorise the meetings as “set ups” rather than “meals”, and in so doing deflect the imputation of the intent of using the meetings with representatives as a way of gaining several free lunchtime meals each week.  He further deflects attention from the previous problematic category of “meals” and adds emphasis to the “set-up” category, by re-using the words in his next phrase of talk - “… we(.), we set that up from …” (lines 20-21).  With this phrase, he also accomplishes a change in relationship or footing to the description, from personal and individual ownership of the account seen at the beginning of the extract- “Well, I …” – (line 17) to group ownership - “… where we(.), we …” – (line 20) and continues in this group footing to the end of the account of lunchtime meetings.  This footing distances the account from himself, and in doing so serves to disperse any blame for the “set ups” and consequent undesirable identities across a collective of unspecified doctors.  Justification of the lunchtime meeting time is attended to by Allan with his explicit description of the meetings being deliberately set up at lunch time, in order to take “advantage” of having “half a dozen doctors” to see the representatives “without interrupting consulting” (lines 22-23).  This justification draws on the ‘business’ discourse principles of time-efficiency as legitimisation of the lunch meeting time, and as such attempts to deflect any imputations of deliberately taking “advantage” of the free meals for any other less judicious reasons.  Justification of the lunchtime meetings is also given further warrant by reference in the account to not “interrupting consulting” (lines 22-23), thereby utilising the ethically commendable legitimisation of upholding primary obligations to their patients of being available for consultation in all working hours.

At this point in the account, attention to justification and legitimisation is momentarily abandoned, and Allan states categorically that the representatives are aware of the doctors’ lack of expectation for them to bring lunch - “fore(.) warned”(.) scenario that er, there’s no expectation to bring lunch” – but rejoins that “they always do” (lines 25-26).  In this construction, he directly attends to the problem of the doctors appearing to take advantage of free meals by explicitly describing their lack of intent to procure, with his description of the doctors holding “no expectation” of lunch, thereby placing responsibility for the free meals on the pharmaceutical representatives.  The representatives are thus constructed as having an unsolicited ‘propensity’ to bring free food.  The free meals are further warranted by the ‘business’ discourse in Allan’s account, by explanation of their behaviour as - “it’s … part of their way of presenting themselves in that context”- (lines 28-29).  This description of – “in that context” - both constructs the relationship of pharmaceutical companies with doctors as established and places the events within the realms of the ‘business’ discourse, further deflecting any blame for the receipt of the lunchtime meals from the doctors.  This construction within the ‘business’ discourse ‘normalises’ these meals, by constructing them as the usual and ‘normal’ practice of ‘business’ to give business lunches.  Irrespective of all these warrants however, Allan further restates the meals are not requested by the doctors – “it’s not the way that we’ve actually requested it” – implicating his concern with not appearing to procure (lines 29-30).  Further justification is attended to by re-iteration of the justification of not interrupting consultation time, together with the added construction of a favour to the representatives, by the description of - “keep[ing] the pressure off of them” (lines 31-32).

Being a ‘good businessman’ within the ‘business’ discourse also entails being at the ‘cutting edge’ and knowing what’s available as it becomes available.  Doctors, in their explanations of why they see pharmaceutical representatives, also utilise this business-wise concept of being ‘up-to-date’ as valid justification for their involvement with pharmaceutical promotion.  This justification is demonstrated in Extract 2 below, where Allan gives account of their reasons for seeing pharmaceutical representatives as being to keep up to date with pharmaceutical products (lines 35-36) and new research (lines 42-43), as they come out.

 

Extract 2


ALLAN Um(.), it’s-(.), I mean, our attitude at the moment, is generally that(.), you-know, we want to be kept up to date with pharmaceutical products as they come out.

LYNDA Right.

ALLAN Er(.), so, I mean, from our point of view, we see there are some, sort-of, legitimate benefits to us and our patients, that we’re aware of what’s coming out.

LYNDA Mm.

ALLAN Um(.), and(.) also it’s a way of er(.), of being kept abreast of, sort-of, new studies, as they come out.  (F1:34-43)

 

The qualifying phrase “as they come out” is adjoined after each reference to products and studies, and adds further warrant to these justifications as it serves to construct pharmaceutical representatives as the first source of such information.  This justification is not surprising, as pharmaceutical companies actively promote the supposed beneficial utility of pharmaceutical representatives as being the first source of information about new drugs (Griffith, 1999).  In this account, these justifications are constructed as being based on valid and continually reviewed considerations of the utility of seeing pharmaceutical representatives, by the use of such constructions as “our attitude at the moment” (line 34) and “from our point of view” (line 38).  This construction of validly reasoned decision-making once again protects against the problematic identity of doctors being coerced by the largesse of pharmaceutical companies and of ‘having their snouts in the trough’.  Thus the doctors’ involvement with pharmaceutical promotion is constructed as being informed by legitimate considerations, independent of largesse and completely unfettered.  This is indicated in Extract 2 by reference to there being “legitimate benefits” (line 39) in seeing pharmaceutical representatives, not only to themselves or their businesses, but also to their patients:

In Extract 3 below, Allan describes promotion as an expected ‘business’ practice of pharmaceutical manufacturers, and in keeping with the ‘business’ discourse, normalises and makes acceptable this promotion to doctors.  The talk also serves to indicate the doctor’s awareness of the promotional ‘business’ intent of the presentations:

 

Extract 3


ALLAN: The manufacturers you-know, obviously are keen to promote, um, but ye-um, it(.), it(.).          (F1: 44-45)

 

Within the ‘business’ discourse, the promotional bias promulgated by each company, and thereby the pharmaceutical presentations, is understood to be kept-in-check by the natural free-market forces of ‘business’ in their competition for market-share as seen in Extract 4 below.  Each company keeps the other ‘honest’ (lines 83-85) and from “being way out of appropriateness” (lines 87-90).  This stated belief in competition as the ‘gate-keeper’ acts again as a further inoculation protecting against the criticism that promotional material may be biased.  Conversely however, it also acts to allow a confidence in a standard of ‘honesty’ being maintained, and partially legitimates promotional information being taken as reasonably reliable and useful in the consideration of product choice (lines 96-103):

 

Extract 4


ALLAN But there was a er(.), there was an apology, that one of the er(.), I think it was one of the ACE inhibitor manufacturers, gave recently, because they you-know, they presented their data in such a way that that er, you-know the percentages that they were quoting was significantly mis-(.) misleading enough, that they had to sort-of re-supply, sort-of, information, sort-of reminding the doctors saying, you-know, that we only represent sort-of, every five years you treat someone that you would be making you-know, one in x patients have, sort-of, a lower, sort-of you-know, one less outcome in treating 14 people for five years.

LYNDA Mm.

ALLAN So(.), yer-um(.), and that’s a(.), that’s an unusual(.) thing to happen.  I don’t know where that one was actually, sort-of, pushed from(.), probably from one of their competitors.

LYNDA Right.

ALLAN But, I mean(.), to some extent, ah-um:m(.), it to me, it seems, that the(.), yo-(.), you-know(.), the er, the companies tend to keep each other, sort-of, more or less(.), in terms of er, the, you-know, being way out of appropriateness, because a lot of what gets presented, is obviously, is competitive da-da-da, “our product versus x”.

LYNDA Mm.

ALLAN So we get that quite a lot.

LYNDA Right.

ALLAN But, I mean, in some respects that’s, I mean that’s, useful as it can highlight you-know, sort-of, you-know, potential reasons why you might(.),

LYNDA What?

ALLAN =consider a product(.), their product to be more appropriate for your patient(.),

LYNDA Mm.

ALLAN sort of(.), than another product.        (F1: 72-103)

 

This free market-produced ‘honesty’ is re-iterated even more strongly later in the same doctor’s dialogue (See Appendix H, F1: 1062-1068).

Product promotion by pharmaceutical representatives is conveyed in the doctors’ talk as “publicity”, or merely introducing a new product to doctors and making them aware of what’s available.  In this way promotion is viewed as merely ‘detailing’, and is devoid of the intention of influence on prescribing, supposedly leaving doctors free to consider and choose the best product available.  The pharmaceutical representative thus is constructed as influentially benign and merely the vehicle of ‘information’ delivery or ‘publicity’, as seen in the following extract:

 

Extract 5


LYNDA So you think it would be an effective way of introducing a new drug(.) to the market and that sort of thing(.) or?

ALLAN Um:m(.), I mean, promotion is, I think, almost everything from the point of view of introducing a new product onto a market.  Um:m(.), if you don’t have(.), you-know, if you don’t have people aware of your product, I mean, that’s step one(.), they’re not going to use it.

LYNDA Mm.

ALLAN I mean, one of my colleagues, unbeknowns to me(.), David has been putting, sort-of, these three-year long, progesterone subcutaneous pellets, u:um, as contraceptives.  I knew he was putting in some devices, but I didn’t know that he was, you-know(.), that this particular thing was going on.  I didn’t even know the cost of it!

LYNDA Mm.

ALLAN I mean, if I don’t understand the product, there’s no way that I can, sort-of(.),

LYNDA Mm.

ALLAN =offer it to people as a(.), as a(.), so, I mean, publicity is(.), is everything!      (F1: 248-267)

 

In Extract 5 above, “promotion” is first explained as being “almost everything” (lines 250-251) in the introduction of a new product to the market, but later in the same account an extreme case formulation (Pomerantz, 1986) is used to strengthen the justification for seeing pharmaceutical representatives – “publicity is(.), is everything” – and the word “promotion” is exchanged for “publicity” (lines 266-267).  Narrative, in the form of an example of another doctor, is also used to describe publicity as being necessary in order for doctors to be aware of a product (lines 256-261), and serves to objectify this notion of publicity.  Furthermore within the narrative, Allan adds a further cost-awareness justification for promotion from the ‘business’ discourse - “I didn’t even know the cost of it!” (lines 260-261).

The ‘business’ discourse is also used to explain and legitimise the way drugs are researched and presented to doctors by pharmaceutical companies, by referencing economic-rationalist ideology as part of the way the ‘business’ world is.  This is illustrated in Extract 6, lines 763-770:

 

Extract 6

LYNDA   Still a gap in medical information for sort-of(.), comparative(.).
PETER   Yeh.
ALLAN   Yes=
LYNDA         (    ) prescribing.
ALLAN   And the, and the reason for that is(.), because nobody funds, understandably, nobody funds, overall(.), drug versus drug trials.
LYNDA   Mm.
ALLAN   Er, within a class.
LYNDA   Because?
ALLAN   Because(.), who’s going to benefit from it?
LYNDA   Mm.
ALLAN   And who’s going to pay for it?            (F1: 759-770)


The ‘free market’ ideology of the ‘business’ discourse, upholding fair business trading, also conveniently warrants involvement with pharmaceutical promotion sessions, and in this case the ‘education’ evenings as seen in Extract 7 below:

Extract 7


ALLAN         I mean, the only(.),you-know(.), I don’t mind them sponsoring education evenings, um, you-know(.), I don’t know that it’s fair for them not to have an opportunity to display product information(.),


    (F2: 536-539)

Ontological gerrymandering (Woolgar & Pawluch, 1985) is the construction of a ‘straightforward realist’ analysis by the agent, in which one range of objects/phenomena are selected and formulated to constitute an account, while other potentially relevant categorises are ignored and omitted from the account.  In this way David, in Focus Group 2, attempts to ‘gerrymander’ or contextualise medicine entirely within the domain of business, while ignoring the relevance of medical ethics principles.  His account of medicine and pharmaceutical promotion is entirely constructed within the ‘business’ discourse and its inherent ‘business’ categorisation.  Reference to business principles of economic exchange, such as time for money, and his narrative on supermarkets as an example of business practice, attempts to unproblematically construct medicine as general business, devoid of any other non-business considerations peculiar to medicine.  The ‘business’ discourse is thus utilised to legitimise the practice of medicine as a business.  A specific example of this is the utilisation of the ‘business’ discourse to legitimise the idea of the direct payment of cash to doctors from pharmaceutical companies for their time.  “Charging for time” (line 548) and “covering overheads and costs” (lines 549-550) are ‘business’ discourse constructions utilised in Extract 8 below to legitimise the idea of doctors receiving money from pharmaceutical companies.  Categorisation of the relationship between doctors and pharmaceutical companies as merely a business relationship, with only the inherent rules of the fair business exchange of ‘time for money’, seeks to render the relationship as seemingly straightforward and ethically unproblematic:

 

Extract 8

DAVID:  I(.), I(.), object to silly pens and thermoses.  What I would like to do is(.), I would like to charge them, for my time(.), to listen to what is going, on at the rate that covers my overheads(.), and my costs.
ALLAN:  It’s er=
DAVID:  So, if I’m charging thirty two dollars for a fifteen minute consultation with a patient(.), the drug company should say, “right(.), we are making an appointment with you doctor H.. We want to sit down, and we will pay you thirty two dollars and fifty cents cash”, at the time, same as any other patient does, and give you the information..

    (F2: 547-557)

This description of a straightforward ‘business’ relationship is juxtaposed against a description of the current relationship of “under the-(.), market bribes,” as seen in Extract 9 below.  This rhetorical construction attempts to categorise the ‘cash for time’ idea as ethically sound, by comparison alone, with the current unethical relationship with pharmaceutical companies, rather than with the explicit description of the ethical value of such a ‘business’ relationship:

Extract 9


DAVID:        So.  No(.), if every drug company was doing exactly the same situation, if they were paying for the use of my time, which I believe is important(.), then there’s none of this under the-(.), market bribes, and a quick trip over to Canberra, or Port Lincoln, or Sydney, to go out on a bus, or a yacht, or anything else.  They are paying for a service.  They are paying for your time, which you are taking out of your=

ALLAN:        Why are=

DAVID:        =life.                                              (F2: 570-578)


This ‘business’ discourse is further simplistically utilised in Extract 10 to discount the inherent ethical problems of such a proposal by reference to the equal business opportunity of the pharmaceutical companies to promote, and thereby supposedly equalise the influence of all companies on the prescribing practices of doctors.  This is once more a construction of an equal mix of opposing forces creating balance, and would seem to be informed by a common sense ideology of balance of opposites creating a harmonised whole.  This construction is also informed by the common sense ideology of ‘equal opportunity’ – equal access to all, therefore fair, equitable and balanced:

Extract 10


DAVID:  No.  I honestly don’t think so(.), I mean, they’ve all got an equal opportunity to come and see me, the same as patients have got an opportunity to come and see me(.), and the patients come in, they use up fifteen minutes of my time; they pay for it.

LYNDA:  That’s business?

DAVID:  Yeh(.), well(.) it’s a business.  I’m selling my time to drug reps.


                                                                    (F2: 593-598)


The self-categorisation of doctors as ‘businessmen’ is clearly demonstrated in this extract in line 598, “…it’s a business.  I’m selling my time to drug reps.”.  Earlier in this extract David does not challenge my prompt “That’s business?” (line 597) but displays an element of hedging of this ethically problematic business categorisation, as seen by his extended pronunciation and pause-punctuated words – “Yeh(.), well(.) – at the beginning of line 598, before iterating – “it’s a business.  The emphasis by David of it being “a” business rather than any general notion of business, together with his further specification of that business as being “… selling my time to drug reps.”, serves to distance ‘this’ business from business in general.  In doing so he attempts further to justify the ethically problematic categorisation of medicine as business.

In Extract 11 below, the influence of samples are dealt with in the same way, using the ‘business’ notion of free and fair-market opportunity, with the comment that “It’s an even playing field” (line 670), informed again by the common sense ideology of ‘equal opportunity’, together with the re-iterated common sense ideology of the balancing of opposites creating a balanced whole, as indicated by “…if they’re all allowed to actually=” (lines 668-669).  Corroboration or mutual consensus is constructed by Allan’s repetition of David’s comment “It’s an even playing field” (line 671).  This use of exactly the same phrase, makes the point more definitive as well as appearing more ‘objective’ and ‘out there’, rather than personal opinion or rhetoric:

 

Extract 11


LYNDA:  Yeh.  Well samples um(.), have been um(.), indicated as being one of the things that reps are encouraged to use=

DAVID:  Huh, great idea.

LYNDA:  to(.), to get doctors to(.) get used to using their product, to start the(.), the behaviour of using their product and so on, and the-(.) then to move into a continued behaviour of using their product, so(.), tha-(.), do you think that that might create an ethical problem for(.) the medical profession(.), that sort of promotional influence that supposedly?=

ALLAN:  Well, as(.), as David said before, if they’re all allowed to actually=

DAVID:  It’s an even playing field.

ALLAN:  It’s an even playing field.

LYNDA:  Meaning?

DAVID:  They should bloody well pull their finger out if they want to get their product in the shelves.

We should be selling shelf space like supermarkets!


    (F2: 659-675)


In Extract 12 below, both David and Allan further re-iterate the idea of the creation of a balanced view from the enmeshing of the opposing forces of promotional influence, as previously referred to in Extract 11, lines 668-669.  Once again this draws on the common sense ideology of opposites producing a balanced whole:

 

Extract 12


PETER:  So David, do you think that if you spent more time with the drug companies you’d get a more balanced view?

DAVID:  No, but I-(.), I’d get(.), I’d get(.), I can(.), I can at least get more information and be(.) more informed, and if I saw the opposition drug that’s pushing an area as well(.), eventually(.), I’d get a slightly more balanced viewpoint from it.

ALLAN:      I think-(.).  So you’re saying ‘yes’ to that, to some extent?

PETER:  Yeh.

ALLAN:  There is a fair amount of truth in that.  If you only see a very limited number of reps(.), and you don’t see their opposition(.) you ar-(.), you(.), you, I mean you’re not going(.), I mean oppositions(.) are very useful for giving you(.), sort-of, an alternative picture(.), so that any major distortion that one drug company may have actually fed, you can be sort-of(.) brought into question.

DAVID:  Mm.                (F2: 758-773)


In Extract 12 above, David hedges the problematic view of more information from pharmaceutical companies creating a more balanced view, as posed in Peter’s question to David (line 758-759).  In reply, David firstly explicitly states his disagreement with the proposal of more information creating a more balanced view – “No, but…” (line 760)- but then in his following explanation of the utility of seeing drug companies inadvertly conveys his agreement (lines 760-763).  David’s awareness of the problematic nature or logical fallacy of the proposal is evident from the considerable hedging displayed in line 760 - “but I-(.), I’d get(.), I’d get(.), I can(.), I can …”.  He hedges again and protects himself from criticism for his ‘balance by opposites’ view by using the word “slightly” (line 763) at the end of his explanation.  Allan then corroborates David’s view with his statement alluding to the ‘truth’ of such a view – “There is a fair amount of truth in that” (line 766).  Allan then re-iterates the common sense view of opposites producing balance (lines 766-772).

In David’s continuing discussion on the different forms of direct, and thus unproblematic, business relationships pharmaceutical companies may take with doctors, such as the supermarket metaphor (Extract 11), he refers to the notion of transparency in Extract 13, line 685 below – “at least it’s transparent”.  In doing so, draws upon the oft utilised argument of ‘transparency’ and ‘openness’ as a defence against the occurrence of unethical behaviour.  ‘Fairness’ and ‘evenness’ (line 698) are also used as surrogate ethics in the same way, to justify the business relationship proposed:

Extract 13


DAVID:  I’m being quite serious, because at least it’s transparent.  If you’ve got somebody who says “look you’ve got four metres of display, and you’ve got eight shelves down there, and we are going to sponsor this amount”.  Now there’s obviously gonna be a maximum, because I really can’t see a complete display of whatever, you-beaut major drug, that’s on the market at the moment, at high cost,

LYNDA:  Mm.

DAVID:  so that there’s nothing else in there, because you actually are going want your respiratory areas, which is why have supermarkets have isles in various areas that are set aside for it, but fine(.), you-know(.), again(.), you could(.), have this area, they can pay for it(.), and they could get their reps to come ‘round.  I think it’s a very(.) fair and even way.


                                                                    (F2: 685-698)


As can be seen from the preceding analysis, the ‘Business’ repertoire is a powerful and effective rhetorical discourse.  It is both culturally dominant and self-warranted within an increasingly economic-rationalist western society.

 

 

 

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