study of meetings between general practitioners and
representatives of pharmaceutical companies
lecturer, Marjorie Weiss, lecturer, Tom Fahey,
of Primary Health Care, University of Bristol, Bristol BS6 6JL
to: M Somerset email@example.com
To examine the interaction between general practitioners
and pharmaceutical company representatives.
Design: Qualitative study of 13 consecutive
meetings between general practitioner and
pharmaceutical representatives. A dramaturgical
model was used to inform analysis of the transcribed verbal
Setting: Practice in south west England.
Participants: 13 pharmaceutical company representatives
and one general practitioner.
Results: The encounters were acted out in six scenes.
Scene 1 was initiated by the pharmaceutical
representative, who acknowledged the relative
status of the two players. Scene 2 provided the
opportunity for the representative to check the general
practitioner's knowledge about the product. Scene 3 was
used to propose clinical and cost benefits
associated with the product. During scene 4, the
general practitioner took centre stage and challenged aspects
of this information. Scene 5 involved a recovery
strategy as the representative fought to regain
equilibrium. In the final scene, the representative
tried to ensure future contacts.
Conclusion: Encounters between general practitioners
and pharmaceutical representatives follow a
consistent format that is implicitly understood by
each player. It is naive to suppose that
pharmaceutical representatives are passive resources for drug
information. General practitioners might benefit from someone
who can provide unbiased information about prescribing
in a manner that is supportive and sympathetic to
the demands of practice.
What is already known on this topic
Pharmaceutical representatives influence physicians'
prescribing in ways that are often unacknowledged by
the physicians themselves
Meetings with pharmaceutical
representatives are associated with increased
prescribing costs and less rational prescribing
What this study adds
Meetings between pharmaceutical representatives and
general practitioners follow a consistent format that
is implicitly understood by each player
General practitioners may
cooperate because representatives make them feel
of information are known to have a greater influence than
scientific sources on general practitioners' prescribing
Over 20 years ago, Avorn et al found that
although physicians believed that drug advertisements and
pharmaceutical representatives had a minimal effect on
their prescribing behaviour, they held advertising
oriented beliefs about the efficacy of drugs such
as cerebral vasodilators and dextropropoxyphene.
A recent survey of 200 general practitioners and
230 hospitals doctors found that information
about the last new drug prescribed was derived from
pharmaceutical representatives in 42% of cases.
A systematic review also found that meetings with
representatives were associated with requests by
physicians for promoted drugs to be added to the
hospital formulary and with changes in prescribing practice,
including increased prescribing costs and less rational prescribing.
evidence, why do general practitioners continue to meet
pharmaceutical representatives? Do they regard such encounters
as an effective method of accessing new drug
information? The amount that pharmaceutical
companies spend on these promotional activities
implies that the industry believes that they are effective.
We explored the general practitioner-pharmaceutical
representative encounter using the dramaturgical
model proposed by the sociologist Erving Goffman.
One of the
authors, who is a general practitioner (TF), met all
pharmaceutical representatives (seven men and six women) who
requested an appointment with him at his practice during
January to June 2000. With the
representatives' signed consent, he recorded the
meetings; otherwise, as far as possible, the meetings were
conducted routinely. The meetings lasted 10-25 minutes.
The representatives were promoting a range of
products, including new drugs and topical applications.
We annotated and
coded full transcripts of the meetings. MS and MW
independently devised a framework for the analysis. The final
framework was agreed through discussion among all three authors.
We concluded that our interpretation of these categorised
data would be enhanced by following the model adopted by
Goffman as this provides concepts that are useful
in understanding face to face interactions.
Goffman proposed that the context of an interaction
might be regarded as a stage, the individuals at the
centre of the interaction as actors, and the interaction
itself as a (managed) performance. A person's
"performance" is shaped by the need to
provide the other person in the interaction with an
impression that concurs with personal goals for the meeting.
This analogy provided the framework for our findings.
categories from the transcripts were classified under the
following themes: stage setting, the roles of the players,
the performance, and the finale.
Several general features were characteristic of all
the meetings. Firstly, each was initiated, and to some extent
led, by the representative. Secondly, although deference was
always shown towards the general practitioner, it was not
always apparent who was interviewing whom because each
party posed similar numbers of questions. Thirdly,
some questions recurred at almost every meeting yet
they were managed (in most cases) without either
party showing outer signs of weariness. Finally, beneficial
outcomes for the general practitioner included the receipt
of gifts, promotional material, and potential psychological
benefits (see below). For the representative, a
guarantee of increased sales seemed less essential
than establishing a positive relationship and
grounds to return for further meetings.
general practitioner's role within the interaction
includes potential purchaser, information seeker,
and recipient of gifts. However, these characteristics are
not compatible with the desired image of a general
practitioner (a knowledgeable person who is not
easily influenced). Two central strategies were
used to reconcile this conflict. Firstly, the general
practitioner presented himself as a sceptic. This is
illustrated by the tactic of questioning the
information provided. Secondly, he refused to
commit to the implicit aims of the meetingin
other words, he did not agree to prescribe any
representative's role within the interaction includes
potential vendor, educator, and donor of gifts. Personal
goals for the meeting include being in control of its agenda
and influencing its outcomes. To achieve these goals, the
representative must show impartiality, awareness of
primary healthcare priorities, and an appreciation
that valuable time has been generously surrendered.
The management and delivery of a friendly (but knowledgeable)
and somewhat submissive interaction assists this compromise.
The performance is typically played out in six
scenes corresponding to six objectives for the representative.
These scenes are led by the representative, but the
general practitioner (having played this role
before) anticipates and tacitly follows the script.
Each scene is described below and examples of the different
behaviours are given in the box. Further examples appear on
Rep: "Thank you for your time, it's for a
really quick chat about. . ." (Meeting 2)
Rep: "Here's two diaries. . .did you want
a desk one as well?" (Meeting 1)
Rep: "Maybe you are aware of [product]?"
GP: "No, I'm not, to be honest with you."
Rep: "Well that's fair enough; that's good
news. So hopefully I can inform you."
Rep: "Well just to summarise the news for
today. Reduction in [the price of the drug] and some
new clinical evidence for you to read in your own
time." (Meeting 5)
Rep: "So I don't know if you agree with this
but when I speak to hospital doctors they say that a
meta-analysis of studies is probably the most
stringent sort of argument that you can have really. . .so
if they show [name of drug] to be very effective. . .would
you use [it]? (Meeting 10)
Rep: "It's £4.17 for 28 days so it does
fit in nicely as a cheaper alternative. . .The
new consultant at [hospital]
he is certainly switching patients over to [name of
drug]." (Meeting 1)
Rep: "Do you accept, if you are getting
similar levels of cholesterol lowering, you would
expect to achieve the morbidity and mortality
GP: "Yeah. Well, it is always this difficulty
that you are looking at intermediate outcomes. I think
the advantage that you are fighting against for [the
two rival products] is that they have been shown to
reduce coronary events in trials, while these updates
you have shown me are just intermediate outcomes. So
my mind is open about that." (Meeting 7)
Rep: "I am only supposed to be talking to
people who are the decision makers as to what is going
on with drugswhich
I gather you are?" (Meeting 4)
Rep: "I think one of the reasons why a lot of
doctors are using [drug name] is cost. . .there's
a lot of pressure on you isn't there?" (Meeting
Rep: "Before I go I've got a couple of other
things you might like. Would you like a paediatric
stethoscope? (Meeting 11)
Rep: "All right, and I'll drop in these charts
in a few weeks." (Meeting 13)
Scene 1: Acknowledgment of relative
status (give general practitioner the impression he is the
most important person)
performances begin with a brief acknowledgment of the
relative status and importance of the two players.
The representative expresses appreciation of the
vital and time consuming nature of the general practitioner's
work. The greeting is accompanied by present giving. This
serves as a token of appreciation for the doctor's valuable
time and induces a sense of obligation. For the
representative, the act of present giving raises
their subordinate status to that of equal (or even
Scene 2: Check general practitioners'
ability (find out what they already know)The
representative then assesses the general practitioner's
knowledge and current practice. This is best conducted in
a non-confrontational style. The general practitioner is
allowed to emerge as entirely correct, although
perhaps with the potential to do better.
Scene 3: Outline clinical and cost
benefit of product (mention name of "expert"
established the general practitioner's knowledge
and use of the product under discussion, the
representative's next task is to argue for its clinical (and
cost) benefits. Published research that shows its value
(in selective aspects) is described. Then, after
assessing the general practitioner's critical
appraisal skills, the representative initiates a discussion
about the research. To round off the scene, the
representative will, whenever possible, mention an
"expert" who is prescribing the drug.
Scene 4: General practitioner takes
scene is acted out if the representative trespasses on
territory that is familiar to the general
practitioner. The general practitioner shows
increased resistance to the persuasive devices in use. In
earlier scenes, the general practitioner showed his
resistance by refusing to make emphatic statements.
For example, the product in question is "not
often used" rather than "never used," and the
costs of various comparable treatments are
"unknown." The interaction has remained
polite and restrained. However, under some
circumstances the response can become more forceful, although
still polite. The triggers for this mode of response are
more direct questions, more extreme factual
statements, and, most importantly, statements that
threaten to conflict with the intellectual expertise of
the general practitioner.
Scene 5: Reinforcement of role (emphasise
that you understand how hard the general practitioner works)
with potential rebellion, the representative has to
switch tactics and re-establish the characteristics
of amenability, understanding, and empathy. Direct
compliments and sympathy are universally acceptable.
Scene 6: Reaching closure (ensure
opportunity for subsequent performance)Finally,
the meeting concludes with more gifts, reinforcing
the sense of obligation. In addition, by not having all
of the literature or gifts immediately to hand, the
representative is able to secure a legitimate
reason for a return visit. The best representative
performances induced an apology from the general practitioner
if, for example, he was unable to accept an invitation to
attend an educational session.
For the general practitioner, successful management of
the encounter results in a pleasant interaction and a welcome
respite from usual workday demands. When consulting with
patients, general practitioners have to display a
caring and sympathetic demeanour. In contrast, in
meetings with representatives they can show
superior knowledge, be the object of flattery, and receive
sympathy. General practitioners view the meeting as
successful if they believe they have been in
control and have acquired several free gifts or
educational opportunities. There may also be lively clinical
debate about the merits of different products. This is accompanied
by the comforting knowledge that, as the prescriber, the
general practitioner will always ultimately hold the winning
For the representative, success can be
measured by the sense of obligation induced. Alternative Treatments of
gifts, positive reinforcement of the general
practitioner's knowledge, and a general demeanour of
sympathy and attentive listening have facilitated this aim.
Although the positive relationship resulting from this
encounter may not guarantee future prescribing of
the company's product, it will make it more likely.
representatives are adept at taking advantage of people's
aspiration to meet someone who is impressed by their knowledge
and sympathetic about the challenges they face and who will
therefore shower them with gifts. This aspiration may be universal
in the workplace. It seems that general practitioners are
willing accomplices in their own exploitation.
provides insights into the general practitioner-representative
encounter. However, it has limitations. Firstly, we
did not analyse the transcripts by traditional qualitative
techniques. This was because the encounters were not
true interviews, merely recordings of routine
meetings. Secondly, only 13 encounters were
recorded, which could have limited the diversity in
representatives' styles. Finally, the
representatives were aware that the meeting was
being recorded, and this may have influenced their behaviour.
findings will strike a chord with many, and they concur with a
recent guide published in Pharmaceutical Marketing
that acknowledges the role of medical education as "a
potent weapon to be used by the marketer in supporting
promotional activities."Others have described techniques used by the
One of these is "reciprocity," in which
someone who is given a gift will feel bound to make
repayment. The obligation is repaid through
prescribing the company's product. Our study confirms that
this marketing technique is a fundamental tactic in meetings
between general practitioners and pharmaceutical representatives.
may perceive these meetings and the industry's support of
medical postgraduate education as benign, the industry clearly
believes they are a cost effective way to increase prescribing
of their products. Neither the pharmaceutical companies
nor their representatives are altruistic or
unbiased. What may be needed, therefore, is a third
player to provide unbiased educational information about
pharmaceutical products and offer sympathetic pastoral care
to general practitioners. The company representative
would then exit stage left.
We thank the
pharmaceutical company representatives who took part in the
study and Tom O'Dowd for suggesting the phrase "a willing
accomplice in their own exploitation."
authors contributed to the study design, data analysis, and
writing of the manuscript. They will all act as guarantors.
Funding: MS is in
receipt of an NHS national primary care researcher development
award and TH an NHS research and development national
primary care career scientist award, but the study had no
interests: During the course of this research TF acquired 15 pens,
two stethoscopes, eight jotters, two desk planners, a
fluffy toy, and innumerable invitations (none accepted) to
meetings at which a "local expert" would
be lecturing as a prelude to a slap-up dinner.
Avorn J, Chen M, Hartley R.
Scientific versus commercial sources of influence on the
prescribing behaviour of physicians. Am J Med
1982; 73: 4-8
McGettigan P, Golden J, Fryer J,
Chan R, Feely J. Prescribers prefer people: the sources
of information used by doctors for prescribing suggest
that the medium is more important than the message. Br
J Clin Pharmacol 2001; 51: 184-189
Wazana A. Physicians and the
pharmaceutical industry: is a gift ever just a gift? JAMA
2000; 283: 373-380
Goffman E. The presentation of
self in everyday life. Harmondsworth: Penguin, 1959.
Goffman E. Asylums: essays on
the social situation of mental patients and other
inmates. Harmondsworth: Penguin, 1961.
Goffman E. Stigma: notes on the
management of spoiled identity. Harmondsworth:
Cialdini RB. Influencescience
and practice. 2nd ed. Glenview, IL: Scott, Foresman,
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Commentary: dramaturgical model gives valuable insight
head of social sciences.
Spa University College, Bath, BA2 9BN
Somerset et al
provide valuable data about the under-researched area of
general practitioners' prescribing behaviour and the part
played in this by the "educational" efforts of drug
company representatives. They acknowledge the
limited scale of their sample and the fact that
taping the conversations may have affected the interactions.
analyse the conversations using the dramaturgical model
developed by the American sociologist Erving Goffman. His
accounts of life in hospital wards, prisons, monasteries,
and other institutions are based on an eclectic range of
sources, including autobiography, overheard
conversations, journalism, and anecdote. For
advocates of the dramaturgical method, the minutiae of
conversational encounters convey a great deal about wider
structures of power and influence.
that in order to have effective interpersonal encounters
individuals must put on a performance: hence the use of
the term dramaturgical. Analysis rooted in this perspective
regards the theatre as a metaphor for understanding
conversational encounters. Conversations are bound
by rules and possess a pattern similar to any
theatrical exchange. For performances to be successful, both
parties must pay some attention to their own demeanour while
offering an appropriate level of deference to the other
participant. Social embarrassment ensues if either
reads the signs incorrectly or makes false
assumptions. When mistakes are made, rapid repair work
What does it
exposes the ritualised nature of interactions between general
practitioners and drug company representatives. Even
though each conversation follows a consistent format, moving
through scenes 1 to 6, no one wrote the
script, fixed the lights, or checked the make up
(or perhaps they didwe
are not told).
Supporters of the
dramaturgical tradition argue that everyday talk is sustained
and made possible by the exchange of symbolic and
ritual politeness. This engenders respect for all participants
and allows faces to be saved. In this example, the
pharmaceutical company representative must convey
the proper degree of respect for the professional
status of the doctor while simultaneously trying to
establish his or her credentials as a knowledgeable, detached,
and scientific professional.
and unequal relations between the participants pose particular
challenges for the players in terms of the establishment
and maintenance of self respect. There is an uneasy (hidden)
dimension to these conversations. Each party is unwilling
or unable to make explicit what they really want from
the encounter. The self respect of doctors depends,
in part, on the belief that their prescribing
decisions are based on an informed appraisal of
costs and benefits. The idea that their judgment can be bought
in exchange for dinner in an excellent restaurant or the
gift of a fluffy toy strikes at the heart of
professional self esteem.
The paper is
valuable because it uses a method of data analysis that offers
a rare insight into the private encounters between doctors
and pharmaceutical representatives. A follow up study could
test the hypothesis that the youth and physical attractiveness
of the pharmaceutical representative influences the
frequency and length of encounters with general
practitioners. Further work is also needed to test
the relative attractions of the various small gifts
exchanged in these encounters. Just how many desk diaries
does a doctor need?