Introduction

In the United States of America (USA), the biopharmaceutical sector generates nearly $1.2 trillion in economic output annually when direct (biopharmaceutical industry revenue), indirect (vendor and supplier activity), and induced effects (additional private economic activity) are considered [1]. Financial relationships between the leaders of influential professional USA medical associations and industry are extensive: 72% of such associations have financial ties to industry [2]. The marketing of opioid products to physicians in the USA was associated with increased opioid prescribing and higher mortality from overdoses [3]. The pharmaceutical industry in France has one of the largest promotional budgets of any country [4]. The pharmaceutical industry represents 100,000 jobs, and with its 54-billion-euro annual turnover, is the fourth biggest contributor to the French Trade Balance (0.15% of the Gross Domestic Product). The role of pharmaceutical sales representatives (sales reps) is regulated by the government through a Sales Visit Charter and a certification procedure but, despite more stringent regulatory requirements than in North America, the information concerning drugs provided by sales reps to GPs remains poor [5, 6]. The Sales Visit Charter promotes good practices such as the presentation of approved product information including side effects and contraindications. Despite strict regulations (health authorities can impose fines of up to €10,000 or 10% of a product’s annual sales revenue) [7], key provisions within the Sales Visit Charter, such as mentioning adverse effects, precautions and contraindications are rarely respected [5, 6]. Pharma sales reps are not allowed to provide content for continuing education courses. A national fund for continuing medical education finances free courses for GPs and compensation for the loss of three days’ worth of medical income while training. This non-biased continuing medical education is mandatory [8]. Initial and continuing medical education are supposed to be provided by impartial experts but these experts can be opinion leaders with financial ties to the industry [9–12]. Despite these measures, the pharmaceutical industry still plays an active role in research and in general practitioner (GP) training from the preclinical years to continuing medical education [11]. The French National Health Authority, “Haute Autorité de Santé” (HAS), encourages professionals and health care facilities to address the issue of sales visits and provides tools such as a French translation of the World Health Organization’s guide “Understanding and responding to pharmaceutical promotion: a practical guide”. HAS also provides guidance to health care facilities on how to regulate sales visits [13, 14].

French primary care is mainly organized as a private, independent service, although financed by the public health system. Like most primary care providers in France, GPs mainly work in private practice and are paid on a fee-for-service basis. Group practice is now dominant among GPs and 81% of GPs younger than 50 declare that they work in a group [15]. Since the 2000s, teamwork in multidisciplinary primary care centers has been developed, mainly to maintain primary care services in low-income areas. In France, GPs meet an average of 5.6 sales reps per week, and spend an average of 55 minutes per week with them [16]. Nine out of ten GPs in France were offered a gift from a pharmaceutical company between 2011 and 2016 [17].

Accepting gifts from sales reps or meeting them is correlated with excessive, more expensive and less rational prescribing [18]. A recent study confirmed this finding about French GPs using indicators such as the prescription of antibiotics, benzodiazepines and vasodilators [17]. Free drug samples and gifts of food and drink in the office are not allowed in France, but GPs still receive gifts and invitations to restaurants since the law allows for exceptions. Promotional budgets could therefore be viewed as an investment that ensures an increase in the number of prescriptions [4, 17, 19]. A report by the French Inspectorate General of Social Affairs (Inspection Générale des Affaires Sociales–IGAS) studied the information GPs receive about drugs. The report concluded that, after the drug database Vidal, sales rep visits were the second most used source of information for practitioners, despite a negative opinion held against detailing visits [4]. This situation is problematic on a financial level (costs are indirectly born by the community via medication prices) as much as on a social and ethical level (citizens’ demand for more transparency and more independent training for prescribers) and on a public health level because of potentially inadequate prescribing practices [4, 20, 21]. Therefore the independence of prescribers remains an essential goal [22].

In 2003, British GPs reported that they received visits from sales representatives for six major reasons: the convenience and availability of information about drugs; the legitimacy of reps as a source of information; out of courtesy; to receive gifts; social and intellectual interaction; to conform with organizational and cultural norms [23]. The reasons GPs gave for seeing reps were reported in “neutral” and “legitimate” terms, as GPs largely believed in their own immunity to commercial marketing strategies. Another qualitative study pointed out that French GPs’ interactions with sales reps provided them with information that was easy to access and easy to use [24]. GPs also described a lack of confidence in their own pharmaceutical knowledge when leaving university [24].

These observations highlight the seemingly ambivalent position of GPs, who believe in their own ability to resist the influence of reps but not necessarily in the ability of other GPs [9]. They are well aware of the reps’ commercial role and hold a rather negative opinion of them, describing reps as advertisers who are trying to influence them to prescribe in a less efficient way [3]. However, their behavior remains rather favorable towards the pharmaceutical industry, as they still predominantly receive sales rep visits (80% of practitioners in France) [11, 23, 25]. So far, no study has attempted to understand the ambivalence of GPs: why do so many of them receive sales rep visits even though they hold a rather negative opinion of the pharmaceutical industry? This study explores GP experiences to better understand their ambivalence.

Method

Results

The material is composed of 10 interviews carried out from April to December 2014, of an average duration of 50 minutes (median of 46 minutes), for a total duration of 8 hours and 22 minutes.

The ten practitioners were 30 to 59 years old, and almost all of them charged the approved National Health rate. Two of them were women. Six of them worked in an urban environment; the other four worked in rural or semi-rural areas. One practitioner no longer received detailing visits. Two GPs received one sales rep visit a day, and one met with ten a week. Only one of them had a paid subscription to an independent journal, four of them declared reading free journals, and three took part in peer groups. These characteristics are summed up in Table 1.

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Table 1. Demographics and practice characteristics of the ten GPs interviewed.

https://doi.org/10.1371/journal.pone.0261661.t001

All but one GP spontaneously mentioned sales reps when discussing the scenarios. When the physician did not address the issue spontaneously, the interviewer raised the subject specifically. The three scenarios did not each elicit a different pattern of responses, which was expected since the research question was not about the drugs discussed in the scenarios, but about the GP-rep relationship. Transcripts, or excerpts of responses, can be grouped into the following categories: motivations, physicians’ perceptions, and values.

Discussion

The analysis of GPs’ motivations, perceptions and values revealed mechanisms that contribute to the understanding of the ambivalence between opinions and behaviors towards sales reps: cognitive dissonance, experience-based rationale and the use of sales reps as a substitute for scientific literature, which can be linked to a lack of self-efficacy. The GP-rep relationship can be considered as a part of a continuum: the GPs interviewed described meeting with sales reps as something mandatory during initial training. Therefore, meetings with sales reps can be considered as social learning and part of the hidden curriculum. Lempp and Seale defined the hidden curriculum as a set of influences that function at the level of the organizational structure and culture and that include, for example, implicit rules individuals must follow to survive in the institution, such as customs and rituals, as well as aspects taken for granted [42]. Six learning processes belonging to the hidden curriculum of medical schools have been identified: loss of idealism, adoption of a “ritualized” professional identity, emotional neutralization, change of ethical integrity, acceptance of hierarchy, and the learning of less formal aspects of “good doctoring.” Together they contribute to the enculturation of students as they become practitioners and members of the medical profession. Therefore, meetings with sales reps can be considered as a part of the hidden curriculum, which is maintained by the forces described above (practical reasons, substitute to training, cognitive dissonance, etc.).

The cognitive dissonance theory is well established and has been proven within the population at large but it has rarely been studied among GPs in France. This study brings new data suggesting that the mechanisms used to reduce cognitive dissonance may contribute to the GPs’ ambivalence. An American qualitative study published in 2007 suggested that GPs felt cognitive dissonance when meeting sales reps [43]. The authors described psychological processes of denial and rationalization used to reduce this state of cognitive dissonance: avoiding thinking about the conflicts of interests, denying the fact that the relations with pharmaceutical companies have an impact on GP behavior, denying their responsibility, itemizing techniques used to remain unbiased and claiming that meeting sales reps brought a benefit to patients. While this study was carried out in a cultural and societal context very different from the French one, the existence of another study identifying signs of cognitive dissonance brings external coherence to our own results.

Another qualitative study in 2007 in the USA explored the reasons why prescribers from various health professions continued to interact with pharma sales reps [44]. Most prescribers believed that overall sales rep interactions were beneficial to patient care and health practice. They either trusted the information provided by sales reps or felt that they were equipped to evaluate it independently. Despite acknowledgment of study findings to the contrary, prescribers stated that they were able to effectively manage interactions with reps such that their own prescribing was not adversely impacted. These data were consistent with our findings and interpretations.

In 2003, a British study explored the reasons why GPs received sales rep visits. Even though the societal context is very different from ours, [23] the similarities are startling. The British study revealed six major reasons for receiving sales rep visits and all of them were spontaneously cited by the GPs we interviewed. Some of their observations are surprisingly similar to ours: “Just because I have a pen with the name of a drug on it doesn’t mean I’m going to prescribe it” (England, 2003). “It’s not the pen that writes the prescription, it’s me!” (France, today). Or: “If it wasn’t for the drug reps, we’d be left high and dry” (England, 2003). “If the reps won’t talk about it with us, who will?” (France, today). The British study also revealed that sales reps fill the need for continuing medical education: “Vioxx, I did prescribe based on what I was being told by the rep. […] I did perceive that I had a particular need for a new alternative.” However, contrary to the results of the British study, French GPs did not use “neutral and legitimate” words to speak about detailing visits. Most of them seemed embarrassed to talk about it, suggesting a shift in perspective. The fact that “times have changed” was raised in every interview of French GPs confirms that sales reps are fewer than before, and receiving their visit is considered as less legitimate. Several French GPs said that sales reps were fewer and brought gifts less often. Other observational studies have arrived at the same conclusion [25, 45].

In contrast to a study published in 2018, [46] physicians talked relatively little about regulations and did not talk about drug-specific safety scandals such as those regarding rofecoxib (Vioxx) and benfluorex (Mediator). This difference is likely due to the interview guide, which sought to explore the reasons for the discordance between attitude and behavior and did not encourage these themes to emerge. Likewise, physicians did not talk about the Sales Visit Charter, suggesting that it remains relatively unknown more than 10 years after its adoption. Instead, they described a decrease in the frequency of medical visitors and in the size of the gifts offered to them. This decrease in the number and volume of gifts is confirmed by the analysis of the national “transparence-santé” database [45]. This decrease was used by doctors as an argument to trivialize the impact of sales rep visits on their practice. Although we can welcome the decrease in gifts, this trivialization may contribute to ongoing GP ambivalence towards sales visits.

Conclusion

This work suggests three types of possible explanations to understand why some GPs receive sales rep visits while holding a negative opinion of them. The first is practical, such as to obtain information about new drugs, for convenience, and for social bonding. The second type of explanation is more social or cultural and is to remain within accepted codes of inter-personal relations and personal or professional characteristics (politeness, courtesy, welcoming the other person). When GPs lack confidence in their own experience and judgment capacities, when they experience personal or professional difficulties and are not active in searching for continuing education, sales reps are able to position themselves as information carriers. The third type of explanation concerns psychological factors such as cognitive dissonance, which is a well-established social psychology theory, and which helps understand how individuals whose behavior is not compatible with their opinions maintain a feeling of mental balance.

These observations lead us to consider the hypothesis that meetings with sales reps during initial training shape the GP-reps relationship which is then maintained over time by the three broad explanations described above. It has been demonstrated that the prohibition of gifts or samples has a positive influence on prescribing practices well over several years after students leave the university [48, 49]. These data bring external validity to our hypothesis. In 2017, Scheffer et al. ranked French medical universities according to their policy for managing conflicts of interest. At that time, the authors stated that French universities were behind a large number of countries, [50] despite some local initiatives and the willingness of French students to learn [21, 51].

Studies showed that this topic was still not adequately addressed by medical authorities, even though ten years have passed since the benfluorex scandal which led to a profound crisis in the French health sector [52–54]. Some changes in the initial training could be introduced to incorporate our findings and previous suggestions: prohibiting professors from receiving gifts from sales reps, nudging them towards greater independence, providing a basic curriculum for all medical students, developing and supporting existing awareness actions for students and health professionals in France or elsewhere [21, 55–58]. Continuing medical education could also be enhanced. GPs effectively felt the lack of free, non-biased and easy-to-access educational options that match their organizational constraints. French continuing medical education still suffers from a lack of independence and transparency in conferences and clinical practice guidelines despite the legal obligation for experts to disclose competing interests [44, 59]. The development of convenient, non-biased, and individual continuing medical education is therefore a public health necessity. Developing and valuing the independence of experts who speak at conferences and in learned societies is also necessary for the development of a culture of independence in health [2, 45, 60].

Previous studies raised the issue of inadequate application of the legislation in France, [7] which could explain why the GP-industry relationship is similar in France, Canada and the USA despite regulatory differences. In the French context, in which individual GPs are often overwhelmed by their working conditions and in which complex psychological factors are at work, GP-rep relationship issues may be more societal and political than individual.

Supporting information

Acknowledgments

First, the authors thank the study participants. They also thank the reviewers and the editor for valuable comments that helped to improve the manuscript, the Office of International Scientific Visibility, Université Côte d’Azur, for proofreading, Catherine Regent (PhD) for proofreading and editing, and Pr. Jean-Baptiste Sautron, (GP) Pr. Isabelle Milhabet (IM, psychologist), Pr Isabelle Feroni (IF, sociologist), Dr. Carol-Anne Boudy (GP), Dr. Nicolas Hogu (GP) and Kamel Tribeche (clinical psychologist) for their proofreading and their critical advice.