Building legitimacy by criticising the pharmaceutical industry : a qualitative study among prescribers and local opinion leaders

PRINCIPLES: The literature has described opinion leaders not only as marketing tools of the pharmaceutical industry, but also as educators promoting good clinical practice. This qualitative study addresses the distinction between the opinion-leader-as-marketing-tool and the opinion-leaderas-educator, as it is revealed in the discourses of physicians and experts, focusing on the prescription of antidepressants. We explore the relational dynamic between physicians, opinion leaders and the pharmaceutical industry in an area of French-speaking Switzerland. METHODS: Qualitative content analysis of 24 semistructured interviews with physicians and local experts in psychopharmacology, complemented by direct observation of educational events led by the experts, which were all sponsored by various pharmaceutical companies. RESULTS: Both physicians and experts were critical of the pharmaceutical industry and its use of opinion leaders. Local experts, in contrast, were perceived by the physicians as critical of the industry and, therefore, as a legitimate source of information. Local experts did not consider themselves opinion leaders and argued that they remained intellectually independent from the industry. Field observations confirmed that local experts criticised the industry at continuing medical education events. CONCLUSIONS: Local experts were vocal critics of the industry, which nevertheless sponsor their continuing education. This critical attitude enhanced their credibility in the eyes of the prescribing physicians. We discuss how the experts, despite their critical attitude, might still be beneficial to the industry’s interests.


Introduction
There is significant evidence of the influence of pharmaceutical companies' marketing strategies on physicians' opinions, behaviours and prescribing patterns [1][2][3][4][5][6][7][8].These strategies include: direct contact with sales representatives; production of promotional material; distribution of stationery and gadgets embossed with the brand's logo; sponsorship of research projects, scientific conferences, and educational events; and collaboration with so-called "opinion leaders" [3,9].Opinion leaders are defined as experts exerting influence on physicians' decision making: eminent physicians or researchers, respected by the medical community, speakers at scientific conferences, members of advisory boards for the pharmaceutical industry and regulation agencies, participants in consensus conferences, and leaders in continuing medical education [9][10][11][12][13][14][15][16].The pharmaceutical industry has identified opinion leaders as a major element of its marketing strategy since the 1950s: from then on, the industry has been actively recruiting such influential figures, using various strategies, including direct payment [10].From the perspective of the pharmaceutical industry, the return on investment of a "doctor's talk" to physicians has been reported as twice that of drug representatives [17].The literature tends to view the influence of opinion leaders as negative, serving the industry's interests [9][10][11][12][13][14][15][16][17].Another trend in the literature casts opinion leaders as educators, promoting evidence-based clinical practice, developing guidelines and leading quality improvement projects.Opinion leaders as educators are often described as "local" colleagues the prescribers know personally [18][19][20][21][22][23][24].In this article, we report on a study involving two steps, which allowed us to explore these contrasting notions of opinion leader.The first step was inductive, and explored the relationships between physicians and the pharmaceutical industry, focusing on the prescription of antidepressants.In the interviews, local experts in psychopharmacology emerged as a major influence, a trusted source of scientific, unbiased information; notably, they were perceived as independent from the pharmaceutical industry.These experts were involved in continuing education in the area.However, these activities were all sponsored by phar-maceutical companies; therefore, we wondered how the experts perceived their own role as potential opinion leaders, their influence on their colleagues, and their relationship with the pharmaceutical industry.This led us to design a second step, based on initial findings, to explore these issues with them.Our study explored the distinction between the opinionleader-as-marketing-tool and the opinion-leader-as-educator, as it revealed itself in the discourses of physicians and experts.We suggest the boundaries are perhaps less clearcut than they appear.

Sample and data collection
This article reports results based on data collected in two distinct, consecutive steps.The first step was part of a larger study [25] on the factors influencing the prescription of antidepressant drugs.At this stage, the first author recruited a convenience sample of 20 physicians, either through previous acquaintance or by approaching them at continuing education events (workshops in medical congresses and teaching rounds in psychopharmacology organised by the local university hospital).The only criterion for inclusion was prescription of antidepressant drugs.We included 8 general practitioners and 12 psychiatrists.Most worked in an outpatient setting, and there was a mix between private practice and public institutions.All had 10 years or more of professional experience.Hereinafter, we shall call them "prescribing physicians".The first author conducted individual, nondirective interviews with these 20 participants, exploring factors influencing antidepressant prescription.She audio-recorded these interviews and then transcribed them verbatim.In these interviews, local experts in psychopharmacology emerged as the major source of trusted information for prescribing physicians.We name these experts "local" because they were mostly active in a part of French-speaking Switzerland, where they led regular continuing medical education events (conferences and teaching rounds in psychopharmacology).These experts were also "local" in that prescribing physicians knew them personally, at least to some extent (e.g., they were available for clinical advice on demand).Based on initial findings, we decided to recruit an additional sample of four local experts.Two of them were identified by the prescribing physicians, while the two others were identified by the research team as they had had a similar profile of being locally respected and well known for their expertise in psychopharmacology.The research group designed a semidirective interview protocol to explore the local experts' own perception of opinion leaders in general, their own role as opinion leader, and the nature of their relationships with the pharmaceutical industry (see annex).The first author conducted the audio-recorded interviews and transcribed them verbatim.Finally, we completed the interview material with direct observation of the experts engaged in continuing education activities (see appendix for a description of the events).The first author was a nonparticipant observer and took field notes summarising the content of the discussions that took place, with a specific focus on aspects related to the first findings of the interviews with the local experts.

Analysis
The first author analysed the 20 interviews with the prescribing physicians, using qualitative content analysis to identify core themes (i.e., themes which are important in the description of the explored phenomenon) [26][27][28].At this point, the research group reached a consensus on two themes felt to deserve further exploration: (i) a very critical perception of the pharmaceutical industry as manipulative and dishonest, and (ii) a very positive perception of local experts.These themes informed the design of the semi-directive interview with local experts.The first two authors analysed the interviews with the four local experts in parallel.Two major issues emerged from close and iterative reading of the transcripts: (i) a critical attitude toward the pharmaceutical industry and opinion leaders in general, and (ii) a sense of preserving one's independence from the pharmaceutical industry.In the results section, we present the analysed data and illustrative quotes from all the interviews (n = 24), under two general headings: "Criticism of the pharmaceutical industry" and "Local experts as an antidote to the industry's manipulative marketing strategies".The field notes provided additional data on the attitude of local experts toward the industry while they were engaged in continuous education activities; we present them separately.All interviewees provided oral informed consent prior to participating in the study.The Ethics Committee for Research of the University Hospital Lausanne, Switzerland considers that studies involving healthy subjects and not addressing health issues do not require formal approval; therefore, we requested none for this study.

Results
Unspecified quotes are from prescribing physicians; quotes from local experts are indicated as LE1-4.

Criticism of the pharmaceutical industry
Physicians were highly critical of pharmaceutical companies, which they described as greedy, manipulative and dishonest.In their portrayal, the industry is ruthlessly focused on profit, behaving "like sharks".The "language of the industry" is all about "selling substances": companies "want to sell" and, therefore, "the information provided is not objective."Rather, such information is unreliable and biased, if not outwardly dishonest, and therefore "of no interest."For instance, the industry was accused of exaggerating minor differences between competing drugs: "There are few really differing drugs in the pharmacopoeia, contrary to what the pharmas are claiming and want us to believe."The industry was criticised for publishing "dubious studies" which are "not of high scientific quality".Physicians also accused the industry of "hiding side effects to earn millions with a drug."Prescribing physicians discussed the role of conferences and experts in pharmacology as part of the marketing strategies of pharmaceutical companies.These were con-

Original article
Swiss Med Wkly.2015;145:w14240 Swiss Medical Weekly • PDF of the online version • www.smw.chsidered "over-represented at psychopharmacology conferences."Experts intervening at symposia were thought to be "paid by the industry" or to just "want to get known."Local experts were equally critical.They said the pharmaceutical companies conducted unscientific studies ("For their new drugs pharmas conduct completely bogus studies," LE4) for pure marketing purposes ("Some phase III trials are a total marketing fabrication," LE1).Local experts also criticised opinion leaders, again described as being used by the industry for marketing purposes: "Opinion leaders are marketing products; really…If they weren't useful, pharmaceutical companies wouldn't spend so much money on them to promote their products" (LE1).Opinion leaders were sometimes described as liars: "It's terrible to hear somebody telling you at a meeting that antipsychotic X is better than all the others and the next day the same person tells you that, no, in fact antipsychotic Y is the best drug.This actually happens" (LE1)."Satellite symposia" organised by the industry during scientific conferences were described as one place where opinion leaders were particularly active: "You never hear satellite symposia on topics that don't interest the pharmaceutical industry; it's obvious they try to recruit good speakers who are familiar with the products they want to pitch" (LE2).Experts on advisory boards were also cited as part of the industry's marketing strategy: "Advisory boards allow pharmas to adapt their propaganda" (LE2).In summary, both physicians and local experts were highly critical of the pharmaceutical industry, which they described as greedy, manipulative and dishonest.Opinion leaders were mostly portrayed as marketing tools.

Local experts as an antidote to the industry's manipulative marketing strategies
Prescribing physicians spoke highly of local experts in psychopharmacology whom they knew personally.They expressed appreciation for the continuing education offered by the experts: "We have regular meetings with [LE2 and LE4], which are very good"; "Psychopharmacological Rounds [with LE2 and LE4], which are sponsored by a pharmaceutical company, are an interesting option because in fact they are clinical and pharmacology workshops where we can interact with colleagues."Local experts were described as highly influential on their prescription practices: "The major part of my continuous training…comes from weekly meetings…We deal with difficult situations that might crop up and figure out a way to solve them with a leader."Most importantly, local experts were perceived as critical and independent from the industry, an antidote to its marketing strategy: "the view of [LE2] will prevail over what a medical rep has told me or what I have read on their advertising material."Indeed, they were said to help the participants develop a critical mind toward the industry: "I think I am becoming more skilled when I discuss with colleagues in the quality circle…When told that such molecule is miraculous, do this, do that, one must keep a critical spirit…I learnt how to develop a critical spirit."(In the Swiss medical context, a "quality circle" is a group of physicians who meet regularly to identify, analyse and solve work-related problems.) The local experts did not readily perceive themselves as opinion leaders.They expressed some embarrassment when the interviewer addressed the issue ("Do you define yourself as an opinion leader?"):"It's an awkward question because it's rather immodest…I can imagine having a small regional impact" (LE1); "I don't believe I have a significant impact, I believe it's up to others to say" (LE3); "I don't know" (LE4).The local experts asserted their intellectual independence from the pharmaceutical industry and its marketing strategies, mostly because of their personal capacity to resist its influence: "Some of the things that the pharmaceutical industry asks me to do, I will never do…I won't show my slides before my presentation" (LE1); "I've never felt I had to give in to the industry" (LE3).Cosponsoring was also mentioned as a counterweight to the industry: "All the lectures given here are multisponsored, so we don't depend on a specific company which might threaten that if we say something bad about it we won't get money for lectures or inviting speakers, etc." (LE4).Guidelines were described as a way to remain neutral as an educator: "In my presentations, I stick to the guidelines" (LE2).Local experts claimed they could express themselves freely during their educational activities with prescribers, and described themselves as critical: "In my latest lecture, I think I made all the possible criticisms about the industry" (LE1); "We don't hesitate with [LE2] to say that this is a bad molecule according to our experience, literature, etc." (LE4).Indeed, direct observation of continuing education events confirmed that the local experts were critical of the industry in general, as well as of specific drugs.In one session, LE1 denounced various practices of the industry (ghostwriting, active withholding of information about side effects, funding of medical journal supplements).LE2 criticised two specific drugs.LE4 named a company which had been sentenced to a fine of US$4 billion for promoting nonevidence-based indications for a named drug.LE3 expressed more neutral views but mentioned the monosponsoring of his presentation as a limitation that the audience should be aware of.However, the local experts expressed awareness of ambiguity in their own relationship with the pharmaceutical industry.They described possible conflicts of interest, more complex than purely financial ones, involving academic prestige and research funding: "Some companies can help you raise your profile, whether by promoting your research, with grants or helping to get publications, etc." (LE1)."Research groups need to be financed for studies.No funding: no study" (LE4).They also argued that the interests of medicine and the general population align in part with those of the industry.From that perspective, interests are not necessarily in conflict: "of course, we serve the industry's interests…epidemiologists, neuroscientists, genet-icists…we do research not for the Good Lord, it has to be useful…and that means business" (LE2).

Discussion
Prescribing physicians expressed a high degree of trust in the local experts, who emerged as potent sources of knowledge and information.They were clearly perceived as an

Original article
Swiss Med Wkly.2015;145:w14240 important, positive influence on prescription practices.In that sense, the local experts in our sample can be considered the "educational" opinion leaders that we described in the introduction.We believe, however, that the pharmaceutical industry considered them opinion leaders in the more classical, "marketing" sense.The sales representatives in the area regularly cite our experts as references.Furthermore, and most importantly, the industry indeed sponsors the continuing education events that we observed.We therefore think that our local experts offer an interesting opportunity to explore how these competing definitions of "opinion leadership" can be articulated.The local experts criticised opinion leaders for being tools of the pharmaceutical industry.Assuming a position of modesty, they did not define themselves as opinion leaders and, in contrast to the supposed complacency of the latter, they claimed to keep their independence.Were they minimising their own susceptibility to industry influence as well as their role in marketing strategies?The literature reports that opinion leaders struggle to perceive themselves as retaining independence and integrity despite their links with the industry (using, for instance, rationalisation to overcome cognitive dissonance [15]), and tend to underestimate or minimise its influence on them [13,15,29].Our local experts emphasised the industry's influence in general, but asserted their own independence.And, indeed, they were very critical of the pharmaceutical industry, both during interviews and when they spoke to their colleagues at continuing education events.Because their critical attitude was described repeatedly by prescribing physicians, we believe it is unlikely to be due to an observer's presence.Most importantly, this critical attitude seems to contribute significantlyto their credibility in the eyes of prescribing physicians.Therefore, our results raise the following question: what is the benefit to pharmaceutical companies of sponsoring such vocal critics?In other words, were our local experts, at the end of the day, beneficial or not to the industry's interests?One of them addressed the issue: "I think what they believe or hope is that, with all we are doing, some interest is kept alive, drugs are prescribed, and more or less correctly prescribed.If the prescriptions are not correct they may be in trouble, so I feel this is the chief reason they might have to be interested in us" (LE2).In part, the suggestion here is that the industry wants physicians to prescribe appropriately.It would, however, appear somewhat naïve, considering all the criticism expressed above about the conflicts of interest between the industry and good clinical practice: if all the industry wants is better prescriptions, there is no conflict of interest.But LE2's suggestion is more subtle: the industry might see a benefit in the very existence of continuing education in psychopharmacology, because it keeps alive an interest in prescription.Indeed, the real efficacy of antidepressants in depression has been seriously debated over past years [30].Continuing education events in psychopharmacology are occasions to discuss drugs at length, and likely to strengthen the role of medication in the physician's armamentarium.From this perspective, criticism from these local experts is not a problem for the industry, and to the extent that it legitimises them in the eyes of prescribers, it is indeed beneficial.It reinforces the message that prescribing is complex and im-portant, that it must be done appropriately.In that sense, the fact that experts criticise the industry is no guarantee their message is not influenced, in the final analysis, by the very marketing strategies that they are criticising.This is, of course, speculation: we do not know why most pharmaceutical companies active in the field choose to sponsor our experts, nor evaluate the impact of our experts on the volume of prescriptions for antidepressants in the area.More general limitations of our study are the local context, sampling strategy, and small sample size, which can all limit generalisability.However, the interviewees' criticism of the pharmaceutical industry comes as no surprise [31].And the importance of maintaining a critical spirit toward it is probably a fairly common position among physicians.Therefore, the relationship between being a vocal critic of the industry and having legitimacy in the eyes of peers is likely to hold true beyond our local context.Our study suggests one possible pattern of the relationship between physicians as prescribers, local experts and the pharmaceutical industry.Prescribing physicians personally know local experts, whom they trust because they are critical of the industry, and are therefore perceived as independent and promoters of critical thinking.Local experts are highly critical of the industry and do not perceive themselves as opinion leaders, whom they consider either corrupt or manipulated.This strengthens their own feeling of independence as well as their credibility.The industry supports local experts despite their criticism because it believes that the very existence of a continuing education in psychopharmacology, and whatever is said there, increases the volume of prescriptions, particularly for antidepressants: thus, it is better to be criticised than to sink into oblivion.As Oscar Wilde said, "there is only one thing in the world worse than being talked about, and that is not being talked about" [32].

Disclosure statement :
This research received no specific grant from any funding agency in the public, commercial or notfor-profit sectors.Competing interests: None.Authors' contribution: ALP and MS are co-first authors and contributed equally to this work.Correspondence: Anne-Laure Pittet, University Institute of the History of Medicine and Public Health (IUHMSP), Avenue deProvence 82, CH-1007 Lausanne, Anne-Laure.Pittet[at]unil.ch