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Healthy Skepticism International News

October 2002

3.2 THE ‘INFORMATION/KNOWLEDGE’ REPETOIRE

The information/knowledge repertoire draws upon the common sense maxim that ‘information is knowledge’. Within this information/knowledge common sense, all communication is regarded as information, and is equated with knowledge. This notion of knowledge is based on quantitative rather than qualitative characteristics of the promotional material and the apperception that more ‘information’ begets more ‘knowledge’. The contextual and rhetorical nature of the communication is not conceded. Within the doctors’ talk, this common sense notion of information/knowledge both informs their thinking about promotional information and is utilised in their rhetorical constructions to justify their involvement with pharmaceutical promotion. ‘Promotion is information’, and its common sense antithetical maxim ‘promotion is marketing’ are both evident in the doctors’ accounts of pharmaceutical promotion. These opposing categorisations of promotional material are utilised in consort to deflect imputations of ethically unsound behaviour by concurrently constructing the promotional material as ‘information’, and themselves as unable to be influenced by pharmaceutical ‘promotion’. This information/knowledge repertoire utilised by doctors in their accounts of pharmaceutical promotion concurrently seeks to inoculate against medical ethics concerns and adverse promotional influence issues inherent in their involvement with pharmaceutical promotion. In this repertoire, pharmaceutical promotion is formulated in part as valid and useful ‘information’ not otherwise available from pharmaceutical industry-independent sources. The ‘information’ categorisation of the material presented in pharmaceutical presentations is also strengthened by invocation of the ‘empiricist’ discourse claims throughout the repertoire. The categorical power of the ‘empiricist’ discourse is enlisted early in the rhetorical construction of promotion as ‘information’, and has powerful appeal to doctors by further invocation of ‘evidence-based’ medicine values. The construction of pharmaceutical promotion as information/knowledge through the ‘information/knowledge’ repertoire serves to justify the frequent ‘free-lunch’ promotional presentations of pharmaceutical representatives, but is a difficult rhetorical argument to traverse. To be successful, it requires concurrent declarations of the recognition by doctors of promotional distortions or ‘marketing’, together with the descriptions of the promotional information as valid and useful ‘information’. This dual approach effectively discounts imputations of the doctors being naive to the possibility of the adverse influence of biased information. Carefully balanced offensive and defensive rhetoric is required in order for this repertoire to be successful. The ‘information/knowledge’ categorisation of material presented in the lunchtime meetings is partly constructed by description of the lunchtime presentations as being a vehicle for the early delivery of new ‘empirical information’. This description has powerful appeal through its invocation of ‘empirical’ and ‘evidence-based medicine’ values, such as keeping abreast of new research as it appears (see The ‘Business’ Repertoire, Extract 2: F1: 42-43). Further explicit categorisation of promotion as information is seen in Extract 14 and Extract 15 below: Extract 14 DAVID: They(.), are better trained in marketing and presentations. They’re not bad with their information. (F2: 402-403) Extract 15 BRETT: Um(.), I guess in a way that um, ( ) doctors see pharmaceutical reps, I guess um-, when you-, when a rep comes in you’re partly interested to see what information that have to offer you(.), (F4: 734-736) As seen in Extract 12 (see The ‘Business’ Repertoire), ‘knowledge’ is created from the equitable balance of the quantities of information received from each pharmaceutical company. Knowledge is further refined from information by the balancing of opposing information from competing companies. In Extract 16 below, the categorisation of ‘promotion’ as simply delivery of ‘information’ is clearly evident from this doctor’s unquestioned description of promotion as being an opportunity for companies to present their “proven … scientific basis” (line 48) for whatever competitive edge the companies possess (lines 49-50): Extract 16 ALLAN The manufacturers you-know, obviously are keen to promote, um, but ye-um, it(.), it(.). LYNDA When you say manufacturers are keen to promote(.), um(.), what would you be= ALLAN Promote that they have proven that they’ve got a scientific basis er, for their product name, being better than someone else’s, or be-(.) having a new indication um, for other uses. (F1: 44-50) Primary to the success of this ‘information/knowledge’ repertoire is the explicit and detailed description of the influence techniques utilised in pharmaceutical promotion. This serves to both formulate doctors as promotionally aware and categorise the promotional influences of pharmaceutical representatives as obvious and benign. Promotional naivety and potential for influence is effectively discounted with this rhetoric, as seen in Extract 17, lines 90-94 below (see also Appendix I, F1: 61-66): Extract 17 ALLAN … 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 Mm. 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: 90-103) As can be seen in Extract 15 above, in this ‘information/knowledge’ repertoire the discursive constructions were often dual in organization. Relatively strong formulations of the promotional nature of the pharmaceutical presentation material (lines 90-94) are presented in consort with concurrent descriptions of the material as useful and valid ‘information’ on which prescribing choices may be based (lines 96-103). This formulation of promotion as ‘information’ on which prescribing decisions may be made however, creates a potentially problematic identity of being influenced by pharmaceutical promotion exactly as intended by the pharmaceutical companies, namely to choose their product over another on the grounds of the promotional material presented. The problem of an influenced identity is immediately addressed by the doctor, as seen in Extract 18 below, by reference to the presence of ‘promotional’ ploys that signify awareness of the promotional influences. “Subtle innuendo” (lines 119-120) and other promotional influences referred to and described by Allan in the form of reported speech - “our product’s now on the formulary at Flinders” (line 105) and “we’ve got our four-star rating” (line 124) – explains the intended effect of the promotion, and in so doing attempts to deflect the imputation of being influenced. The use of reported speech to describe the promotional ploys serves to distance the claims made by the pharmaceutical representative from himself, constituting the account of promotion as ‘out there’ and separate from his own personally held beliefs about the promotion. This rhetorical construction constitutes the doctor as discerning and sceptical of pharmaceutical promotion: Extract 18 ALLAN Um, but I mean, there are lots of(.), of interesting things like, you-know, “our product’s now on the formulary at Flinders”(.) that’s supposed to sort of, you-know, suggest that you-know, therefore it must be a good product(.), I mean, because it’s been put, you-know, on(.), put on the hospital formulary. LYNDA Oh(.). Recent addition(.), ALLAN Yeh. LYNDA that sort of thing? ALLAN Yeh. Yes(.), I mean, those sort of comments that(.) LYNDA Mm. ALLAN that one, sort-of, frequently gets. LYNDA Yeh? ALLAN Which.is(.), good(.), good on Flinders. LYNDA Yeh? ALLAN But I mean(.), what does that mean about the actual(.), sort-of, you-know(.), but I mean, that’s the sort of(.), sort of, subtle sort-of, °innuendo°. LYNDA Promotional? ALLAN Yeh, yeh. LYNDA Mm. ALLAN And, “we’ve got our four-star rating” you-know. “We’re on, you-know, the Flinders hospital formulary”. (F1: 104-125) In Extract 19, the ‘information/knowledge’ construction of pharmaceutical representatives’ presentations as useful, are strengthened by reference to “useful hints” on the “best method” for “phasing in a drug” (lines 553-556). A caveat of not relying on that information alone and potential risk of problems is again immediately applied, protecting the speaker from criticisms of irresponsibly using promotional ‘information’ without censure (lines 558-559): Extract 19 LYNDA Yeh. So do you find um(.), the advantages of using pharma-(.), pharmaceutical representatives is in a sort-of um(.), um, consultative way, in a way, when you’re not familiar with the new drug, and that sort of thing(.), or you wouldn’t use a pharmaceutical rep like that? ALLAN Yes(.), no(.), I do use them like that. LYNDA Mm. ALLAN Yeh, yeh, I mean, be-, because I think, there are a lots of-(.), and it’s all very well to have a(.), you-know(.), an article about a product, er, to tell you that its side effects are this and that, it’s(.), efficiency is this, and its uses are this, um(.), but in terms of(.), things such as(.), you-know, the best method for(.), you-know, phasing in a drug, and you-know(.), there are often quite useful hints to be gained. LYNDA Yeh? ALLAN But it’s also(.), I mean, if you rely on that alone, you put yourself(.), yeh, in a lot of potential risk of problems. (F1: 543-559) Later in the discussion, Allan abandons the ‘useful information’-‘promotional awareness’ rhetoric, and pharmaceutical promotion takes on a much more sinister role of directing decision-making in the choice of best drug for a particular condition. The promotional material of pharmaceutical representatives is once again formulated as ‘information’ otherwise unavailable from other pharmaceutical company-independent sources such as DATIS (Extract 21; Extract 22), and other independent and non-independent sources such as medical magazine and journal articles (Extract 20). The usefulness of pharmaceutical promotion to inform prescribing choice is remarked by Allan at the end of each account of other sources of information, as seen in Extract 20, lines 670-673, Extract 21, lines 708-710 and Extract 22, lines 733-736 below: Extract 20 ALLAN Yeh. Um(.), I read(.), been reasonably diligent in reading, cover to cover, through er, sort-of, several different medical magazines per month. Um(.), the er, the advantages of those that are(.), are potentially, that they will present a topic with a range of treatments, rather than presenting one treatment as the(.), LYNDA Mm. ALLAN you-know, as the treatment for a given condition, but(.), er(.), often for example, I mean, if you were looking at(.), something such as(.), the treatment of(.), hypertension in cardiac failure, which makes up a significant percentage of the cost of the Australian prescribing, I mean, you won’t actually-, in most articles that you look at in the current journals, for general practitioners, you won’t actually get(.), anything greatly obvious in terms of like, why you prescribe this product, over another. LYNDA Mm. ALLAN Um(.), I mean, currently overseas studies, such as the HOPE trial, may have(.), sort-of, been more particular about a particular agent, you might want to prescribe,(.) but in terms of general practice journals(.), although they’re very useful overviews, in terms of actually(.), from the point of view of pharmaceutical prescribing, um(.), you-know, often in terms of partic-, picking a particular(.), product, um, they can be(.), unhelpful. (F1: 652-673) Extract 21 ALLAN Um(.). I think DATIS is very good for pointing out specific(.), drug interactions and side-effects, um(.), I wouldn’t have said that they(.), were particularly useful from the point of(.), of, pointing you in a particular direction. (F1: 707-710) Extract 22 ALLAN DATIS pharmacists, is more looking at the side-effects and drug interactions, rather than(.), getting a lot of useful information, I think, from my point of view, in looking at why would I, use this particular product. We had one recently that came out about er, antidepressants(.), and I can assure you(.), maybe antidepressants is not really a good example, but I mean(.), I suppose it highlights the issue, the certainly, I don’t think, there’s any particular, sort-of agenda, from the point of view of saying, you-know, you-know, this is the best product to prescribe (F1: 727-736) At the end of the focus group discussion, when asked to comment generally (rather than in reference to his own personal behaviour and attitudes) on whether seeing pharmaceutical representatives and receiving gifts and samples was unethical, the promotion-aware and ethically-contrite identity is reaffirmed by Allan in his detailed account of the dilemmas doctors face in their involvement with pharmaceutical promotion. This is seen in Extract 23 below: Extract 23 LYNDA ((Laughs)). So, overall what would you(.), think(.), do think that um, I mean, some(.), people, consider it’s um, unethical, to see pharmaceutical representatives, and to receive gifts(.), ALLAN Yeh. LYNDA and to have samples(.) from(.), ALLAN Yeh. LYNDA pharmaceutical companies. ALLAN Yeh. LYNDA Um(.), what would be your comments on that(.) position? ALLAN I(.), I think if-, if you-know, you’ve got good grounds, for keeping things under very tight control um, because there’s (a) the interest of keeping the cost of pharmaceuticals to the country down to an, an absolute minimum um, I think, you-know, that’s probably the biggest thing on the, the sort-of agenda, and I think, you-know, allowing drug reps to er, to influence doctors by any form of coercion, bribery, whatever you want to call it. LYNDA Mm. ALLAN Um, to potentially sort-of, more expensive products is one of the best, sort-of, ways to increase the cost of the system. LYNDA Mm. ALLAN Um, secondly, the er, you-know, beyond that er, you-know, there’s also the sort-of, issue of what’s in the patient’s best interests, you-know, are you prescribing from evidence-based medicine, or are you prescribing you-know, potentially not the best product for the patient. LYNDA Mm. ALLAN Um, because someone’s a slick-, slick sales person, LYNDA And you don’t realise that(.)= ALLAN and you don’t really, yeh, you really= LYNDA there’s some persuasion or? ALLAN ( ) LYNDA Do you think that that could be the case, and you wouldn’t recognise it, or(.), as with the case with some=? ALLAN I, I think, I think it’s always got to be possible, LYNDA Mm. ALLAN because(.), I mean, you’re allowing them to present you with data and information and er(.), you-know, that data is clearly, is(.), is putting their product in the best possible light. (F1:989-1026) The form of rhetorical construction seen in the extract above and throughout the doctor’s talk is described by Wetherell and Potter (1992), in their analysis of racist talk, as the principle/practice rhetorical device. This takes the form of giving account of rights or ethical principles, thereby constructing an ethical/moral identity of the agent, but then immediately undercutting these principles by presentation of the practical difficulties of realisation of these principles in ‘the real world’. This undercutting of the principles effectively counteracts any personal implications or requirements for ethical action from the agent. From the viewpoint of common sense ideologies, the ‘principle’ is often constructed from liberal egalitarian ideology, while the ‘practice’ is economic rationalist in nature. Within the information/knowledge repertoire, this principle/practice construction is evident from the way in which the ‘real world’ of information on new drugs is constructed. Involvement with pharmaceutical promotion is necessary because of the inherent limitations in pharmaceutical company independent information and also the time constraints of practicing medicine. Pharmaceutical company ‘information’ is readily available, easily communicated and ‘up-to-date’, making it useful and convenient in the process of prescribing choice.

 

 

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What these howls of outrage and hurt amount to is that the medical profession is distressed to find its high opinion of itself not shared by writers of [prescription] drug advertising. It would be a great step forward if doctors stopped bemoaning this attack on their professional maturity and began recognizing how thoroughly justified it is.
- Pierre R. Garai (advertising executive) 1963