APPENDIX H

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 the 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.

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)

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 represents 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)

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)

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)

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)

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)

LYNDA: That’s business?

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

LYNDA: Mm.

PETER: Mm. So at the moment you’re selling for(.) gifts and knick-knacks, but it would be better, for it to be more straightforward?

DAVID: Yeh. Let’s make it a straightforward tras-(.), ca-(.), cash transaction. After all(.), what's the value of a knick-knack to me? It might cost them seventy dollars to buy some knick-knack, that I put two dollars worth, of value on.

LYNDA: Mm.

DAVID: And it’s taxable. The government would get the money back.

DAVID: Eh. Honestly, the be(.)-, the best ploy is to give samples. Tha-, that’s it(.), if you’ve got the samples, you go ‘round and looking for them and you do(.) tend to prescribe in that way. And that’s why we’ve got this lovely(.), well set up, well displayed, drug cupboards, we’re they can come on along, and they can stack their bits and pieces, because(.) we’ll use the thing!

LYNDA: Right, and so when they come=

DAVID: And more importantly, if what you want isn’t there, but you know that there’s an alternative, you’ll use the alternative!

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!

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.

PETER: So David, do 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)

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)

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: 87-103)

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 its 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)

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: 250-267)

ALLAN Of course, educational weekends are very attractive to us, because, it means you get lots of CME points out(.), in the one way.

LYNDA Mm.

ALLAN Er, in one weekend, you can(.), er get(.), you-know, the vast bulk of the year’s CME points out=

LYNDA Mm, and you think that that’s a useful(.),

ALLAN Well it=

LYNDA =er(.), educational session?

ALLAN Well I-. ((Exasperated breath)). We wouldn’t actually go to them unless the er(.), I mean if the educational content-(.), but most of them are usually set up with a mixture of(.), lectures and small group tutorials.

LYNDA Mm.

ALLAN And they usually cover(.), I mean(.), they tend to have, a strong emphasis on cardio-vascular medicine. Um(.), which obviously, makes up a large part of general practice.

LYNDA Mm.

ALLAN Um(.), but they usually include other(.), a variety of other topics as well. Everything from plastic surgeons teaching you how to suture again, to er(.), commonly, you get medico-legal(.), sort-of, updates.

LYNDA Right.

ALLAN Which are obviously(.), relatively ( ) topics, but ( ) general practitioners these days. F1: 518-542)

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.

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.

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)

LYNDA: So you think, they might play on the fact that you haven’t got time(.) and you probably aren’t aware of(.), well new drugs, because they’re there to tell you about new drugs?

DAVID: Actually if I can just come(.), I(.), I’m working um, er, um, a very limited area of medical practice, and because of the fact that I go to lunch with my(.), two co-workers on more occasions(.), I’m not coming down here. And I actually feel behind in(.) my(.) understanding of general practice(.), because I’m not getting interaction with other(.) viewpoints, as Allan said, from other people here. And also, I’m not keeping up with other new drugs, that are coming on. (F2: 218-228)

DAVID: I’m effected by the fact that I’ve heard of it. Like that drug that Allan mentioned before for systolic hypertension(.), never heard of it(.), nobody’s detailed me about it(.), and obviously I haven’t bothered to read it, because it’s not of interest. If I had samples in my area I might actually go along and think(.), “what the hecks that”. I’ve been looking in my drug cupboard for about six months, at a drug that’s sitting next to Luvox and I’ve(.), actually the other day(.), because I was doing a bit more of a thoughtful rummage, I pulled it out, and I looked at it and saw what it was(.), and it’s the other brand name of that particular one. So its taken me six months to even bother(.), to look at(.), the information that’s written on it, to tell me what the drug is.

LYNDA: Mm.

DAVID: Because I didn’t know that it was, and nobody had told me about it. It was a ‘me-too’ drug, fortunately, but(.),

LYNDA: Mm.

DAVID: yep, you-know(.), unless it’s there(.), it’s detailed to me, I don’t know about it. (F2: 714-731)

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

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

PETER: Yeh.

‘BUSINESS’ REPERTOIRE EXTRACTS

‘INFORMATION/KNOWLEDGE’ REPERTOIRE EXTRACTS