3.3            DISCUSSION

Within the doctors’ talk about pharmaceutical representatives, gifts and samples, two main repertoires were evidenced; the ‘Business’ repertoire and the ‘Information/knowledge’ repertoire.  Both repertoires represented both a way of thinking about pharmaceutical promotion and medicine, as well as a way of justifying involvement with pharmaceutical promotion amidst the ethical controversies of involvement within medical practice.  Within both these repertoire inherent categories were drawn upon, developed within the talk and utilised to justify involvement with pharmaceutical promotion.

The ‘Business’ repertoire represented the common sense ideologies and maxims of ‘business’, such as ‘time is money’, ‘economic rationalism’ and ‘free-market competition’ or ‘equal opportunity’.  Other common sense ideologies drawn upon in support of the ‘Business’ repertoire was the notion of the balance of opposites creating a balanced whole.

The common sense ideologies and maxims represented in the ‘Information/Knowledge’ repertoire were ‘information is knowledge’ and a quantum-based notion of more information being equitable with more knowledge.  Within these common sense notions of knowledge, promotional material was regarded as information and equated with knowledge.

Possible Interventions

The discourse analytical findings of this study would suggest that any interventions designed to reduce the influence of pharmaceutical promotion in medicine would need to address the common sense ideologies of doctors that inform both their thinking and medical practice.  This approach would involve further exploration of the range of explicit and implicit categorisations of pharmaceutical promotion, medical practice, and their role as doctors, not only within the medical system, but also within the wider social and economic context within which medicine is practiced.  Countering the common sense ‘business’ discourse, and its use in the categorisation and justification of professional behaviour in medical practice, can be achieved in a number of ways.  The reaffirmation of medicine by doctors as professional practice, rather than commercial business, would assist in the countering of the ‘business’ repertoire by grounding the practice of medicine in medical ethical principles rather than commercial business ideologies.  Re-categorisation of themselves as ‘medical professionals’ rather than ‘businessmen’, and their patients as entrusted recipients of valuable medical skill and therapeutic interventions rather than ‘customers’ or ‘consumers’, within this medical professional framework would also further counter common sense ‘business’ notions of medicine.  Interactive post-graduate continuing medical education (CME) in the complex ethical issues of general practice could assist in the active construction/re-construction by doctors of a personally constituted ‘medical profession’ discourse, shifting common sense thinking from the ‘business’ discourse to the ‘medical profession’ discourse.  Development/redevelopment of this medical discourse may also recursively assist individual re-evaluation of medical professional practice and personal commitment to the principles of medical ethics.

The ‘Information/Knowledge’ repertoire could also be effectively countered, as for the ‘Business’ discourse, by reaffirming ‘information’ as rhetorically constructed communication specific to a context, and ‘knowledge’ as personally constructed from the evaluation and assimilation of information, rather than unconscionably accepting information as knowledge.  This critical approach to the common sense ideology of information/knowledge is equated with the psychological notion of scepticism.  Further to this, the active construction of pharmaceutical company information as ‘promotion’ would assist in countering the common sense ideology that ‘information’ is equitable with ‘knowledge’.  The category of ‘promotion’ rather than ‘information’, together with epistemological change of intent of related objects (pharmaceutical representatives and pharmaceutical company ‘gifts’) to that of influencing prescribing to increase sales, profits and market-share, should make the practice of being involved with pharmaceutical promotion more apparent as incongruent with the ethical practice of medicine.  Active replacement of the entrenched descriptive term of ‘detailing’ with ‘promoting’ of pharmaceutical representatives would also reduce the adverse effect of this term in sustaining pharmaceutical promotion as ‘information/knowledge’.  Pharmaceutical companies have vested financial interest in actively constructing pharmaceutical promotion as information to doctors.  This categorisation serves to legitimise pharmaceutical promotion to doctors, as well as justify their involvement.  Acceptance of ‘gifts’, including lunches, assists in maintaining and strengthening this adverse categorisation by activation of the ‘information/knowledge’ construction as justification for involvement.

Several other solutions to the problem of pharmaceutical promotion and the prescribing practices of doctors are possible.  Easily accessed and continuously updated pharmaceutical company-independent sources of information on new drugs would vastly reduce, if not eliminate, the doctors’ stated need to see pharmaceutical representatives for any reason other than to receive the largesse of pharmaceutical companies.  Text-based alternative sources of information are currently available.  An independent and academically based medical advisory body on pharmaceutical prescribing (similar to DATIS) could disseminate information and advise interactively on new drugs, together with comparative prescribing information on older therapeutic group drugs.  Peer review meetings of new drugs could also be organised within practice groups.  If continued pharmaceutical representative presentations were considered essential, prior peer review of new drugs could provide a basis from which to critically evaluate the drug information presented.  This process would provide the practice required to improve and sustain high levels of critical appraisal skills in pharmaceutical prescribing.

Methodological Reservations

Several methodological observations and recommendations of this study warrant mentioning.  Inter-personal interaction and the ensuing discussion differed between the focus groups.  Composition of the groups may account for these differences as the groups differed in both number of participants, and relationship to Dr. Mansfield and each other.  In the focus groups with two or less participants (F1, F2 and F4), rather than five (F3), the interaction and discussion appeared to be more unreserved and qualified, and thus more conducive to the aims of the study.  A far greater variety of discursive constructions of the range of justifications for involvement with pharmaceutical promotion were evidenced in the talk of these groups.

The presence of Dr. Mansfield (Director of Healthy Skepticism, formerly MaLAM) on the responses of focus group participants was unknown, as no comparative focus groups without his presence were held.  Future studies of this nature may incorporate this design variation.  In this study however, his presence was considered necessary and more potentially enhancing than detrimental, given the specialist and complex nature of medicine, the expert status of the general practitioners, and the complexity of the controversial medical issues surrounding pharmaceutical promotion.  His presence thus facilitated rather than hindered debate and argument around these potentially sensitive issues.

A set of interview questions and statements designed to stimulate discussion on the issues of pharmaceutical representatives, ‘gifts’ and samples, were used as a guide to the questioning and inquiry in the focus groups.  This allowed greater flexibility in stimulating and maintaining continued discussion on these issues.  On occasions differences in responses were apparent due to the form of inquiry used.  In future studies of this nature, asking a series of fixed questions of each participant with no wording variations, may add further differential interpretative data to the discourse analysis of each participant’s constructions.

Selection bias effects were also unaccounted for in this study design as the participants were either asked to volunteer from a sub-population of metropolitan MaLAM-subscribing general practitioners (self-selection bias), or were specifically requested to participate in the focus groups.  It is possible that these self-volunteered participants were more polarised in their opinions and views on pharmaceutical promotion than other MaLAM-subscribers.  Many of the participants who knew Dr. Mansfield may have been personally motivated to participate in the focus groups.  In one of the focus groups (F3), the MaLAM-subscriber bias was partly addressed by the participation of four non-MaLAM subscribers with one MaLAM subscriber.  As this study was not intended to be representative of attitudes and responses of general practitioners to the issue of pharmaceutical promotion and medicine, but rather to illustrate some of the discursive patterns and rhetorical constructions utilised by general practitioners in their talk of the reasons and justifications for being involved with pharmaceutical promotion, these biases were not of particular importance.