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Beliefs, perceptions and behaviours of GPs towards generic medicinesSuzanne S Dunne*, Bill Shannon, Walter Cullen and Colum P Dunne

Centre for Interventions in Infection, Inflammation and Immunity (4i), Graduate Entry Medical School, University of Limerick, Limerick, Ireland.

*Correspondence to Suzanne S Dunne, Graduate Entry Medical School, University of Limerick, Limerick, Ireland; E-mail: suzanne.dunne@ul.ie

Received August 23 2013; revised April 4 2014; Accepted April 20 2014.

Abstract

Background. To benefit from cost-savings associated with generic medicine use; in June 2013, Ireland introduced generic substitution and reference pricing. The attitudes and behaviours of health care professionals may influence successful implementation of such changes.Objectives. To assess perceptions of GPs in Ireland regarding generic medicines in the time lead-ing up to the enactment of the new legislation and for the first time in at least the prior decade.Methods. Detailed one-to-one semi-structured interviews performed with a representative cohort of 34 urban- and rural-based GPs in Ireland.Results. Thirty of the participating 34 GPs prescribed generic medicines actively. Predominantly, participants believed that generics worked as effectively, and were of the same quality, as origi-nator medicines. However, 32 GPs reported receiving patient complaints regarding generics; almost a third reported complaints of increased or altered side effects. Thirty-two GPs stated that they would take a generic medicine, although one in seven would choose the originator if offered a choice. A minority of GPs were of the view that generics are manufactured to a poorer quality than originators and may be a risk to patient safety.Conclusion. This study of GPs’ attitudes towards generic medicines in Ireland highlights that this key stakeholder group has generally positive attitudes towards both generic medicines and the new legislation. However, variable knowledge about generic medicines and concerns regarding patient experience, clinical effectiveness and manufacturing quality were identified. GPs’ opinions could negatively influence patient opinions; enhancing such opinions may prove important in successfully implementing the new legislation.

Key words: GPs, generic drugs, patient education, perception, professional education, qualitative research.

Introduction

In June 2013, Ireland signed a new Act into law [the Health (Pricing and Supply of Medical Goods) Act 2013] (1), paving the way for generic substitution and reference pricing for the first time in that market. As a consequence of the new legisla-tion, Irish patients became more likely than ever to encounter generic medicines.

The opinions of GPs are key factors influencing the views that patients exhibit towards generic medicines (2). Such influ-ence, in addition to their own role as prescribers, means that GP perceptions are potentially important for the successful

implementation of the proposed changes, that is, to increase the use of generic medicines in Ireland. Despite this, to the authors’ knowledge, the most recent peer-reviewed publica-tion on this topic, with respect to Ireland, dates from 1997 (3). Moreover, a PubMed search (June 2013) identified just 17 publications internationally in the last 10 years on the topic of physician perceptions of generic medicines (six of which were not in English)—only seven of which were specifically related to GP opinions (4–10) [four of which (5,8–10) were not in English].

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The most recent paper on Irish GP perceptions of generic medicines, from 1997 (3), stated that a majority of prescribers (75%) had concerns about the reliability and quality of gener-ics. Additionally, a separate 1997 report (prepared for the Irish Minister for Health regarding a previous attempt by the Irish Government to increase usage of generic medicines) stated that over a third of Irish GPs believed that generic medicines were unreliable and of poor quality (11). That report further identi-fied that half of the physicians surveyed reported that generic substitution increased patient confusion and a quarter of the participants reported that patients returned to them with com-plaints of confusion or dissatisfaction with changes in their medication.

At the time of writing, Ireland is on the cusp of a major modi-fication in health care practices, with many potential hurdles to be overcome (12). An assessment of the opinions of relevant health care professionals is not only timely but also has the potential to highlight areas where challenges may arise during implementation of the proposed changes. Our objective was to assess the beliefs, attitudes held and behaviours towards generic medicines amongst GPs—as representatives of prescribing phy-sicians in Ireland—in the time leading up to the enactment of the new legislation.

Methodology

Invitation letters (which included details of the study) were sent to a total of 65 GPs located in the South of Ireland (these comprised the cohort of practices affiliated with the Graduate Entry Medical School in the University of Limerick at the time of the study). The letter was followed up with a telephone call, 1–2 weeks later, for those GPs who had not already accepted, and interviews were arranged with those who consented to participate. Purposeful sampling of partici-pants, based on geographical location, was used at this stage in order to ensure geographical spread of participants—tak-ing into account both urban and rural locations (18 urban, 16 rural).

One-to-one interviews were performed with consenting par-ticipants between June and August 2012 [all interviews except one (which was face-to-face) were completed via telephone]. See Table 1 for interview questions. Interview lengths were as fol-lows: minimum—9 minutes 25 seconds; maximum—23 minutes 48 seconds; mean—15 minutes 39 seconds. Interviews, which were recorded (with each interviewee’s permission), were semi-structured. Additional assessment of opinions was completed using a series of structured, closed questions to which partici-pants could select from predefined answers. In that instance, a five-point Likert scale was used with a single response allowed for each question, selected from: strongly agree, agree, neu-tral, disagree and strongly disagree. Participants were free to

volunteer additional commentary on each question and were also offered the opportunity to express freely any additional opinions or views at the end of the interview session.

The study instrument was informed by a recently published review of the usage of generic medicines and how policy changes to promote the use of generic medicines may affect health care provision (13). To ensure understanding by participants, questions were subjected to cognitive testing with three GPs who were asked the questions, allowed to provide responses and after responding were asked what their understanding of the questions was. Where necessary, amendments were made to questions. The responses of these GPs were not included in analysis.

Analysis of data

Using a grounded theory approach (14), interviews were tran-scribed, verbatim, and imported into NVivo (version 9) for anal-ysis. Specifically, transcripts were open coded for themes relating to interviewee opinions, perceptions and behaviours, including any other emerging themes using an inductive, thematic process. Results were analysed, using a constant comparative method whereby data generated during the interviews were compared with all of the data from the interviews already analysed. When 4–5 consecutive interviews did not lead to the emergence of any new themes, it was determined that data saturation had been achieved and the interview process was concluded.

Coding

Responses were open coded into a thematic framework, based on themes emerging from the data. On completion of open cod-ing, further analysis was performed to amalgamate similar codes into a unifying code, where possible. After the first five interviews had been analysed, all investigators discussed the coding themes in order to reach consensus on the emerging thematic frame-work. The coding framework included (but was not limited to) such themes as: opinions regarding safety and efficacy; previ-ous experience with use of generics; personal preferences; beliefs regarding historical usage of generics in Ireland; experiences with patient reports regarding generics; prescribing rationales; personal knowledge of, and attitudes towards, generic medicines and opinions regarding the proposed legislative changes.

Results

ParticipantsThe response rate was 52%, 34 of the 65 GPs invited to par-ticipate. Participants were located in the South, South-East and Midwest of Ireland in counties Limerick, Tipperary, Kerry, Kilkenny, Cork and Waterford (Table 2).

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GP behaviours regarding generic prescribing

A majority of GPs, 30 of 34 participants, stated that they pre-scribe generic medicines actively and that, in general, they pre-scribe generics in preference to originator medicines. While the primary reason stated for this was the reduced cost, other reasons given included: being in a practice, or having a per-sonal ethos, that was in favour of generic prescribing; patients’ preference for a generic; being more familiar with the generic name and knowledge/awareness of employment provided by generic medicines manufacturers in Ireland. A  relevant quota-tion provided is:

- My attitude would be that as long as the product has the appropriate approval by the regulatory authorities in Ireland … that with a few exceptions, and by exceptions I would talk

about a few anti-epileptic preparations and warfarin prepara-tions … generic preparations are so similar as to be the same … entirely interchangeable. [GP2, male, aged 50–64 years]

Most of the GPs (28/34) stated that there are times when they would preferentially prescribe the originator rather than an equivalent generic medicine. These situations included: require-ment for narrow therapeutic index drugs and those which are not readily interchangeable (e.g. anticonvulsants, anticoagu-lants, etc.); habit, combined with being more familiar with pro-prietary (i.e. trade) name, thus facilitating prescribing; patient preference or request; variability in the presentation of gener-ics and the potential for this to cause stress or confusion for patients; the originator being the same price or cheaper than the generic; holding an opinion that the originator medicine was better (having had more experience with, or trust in, the originator medication) and having had experience with poor (or ‘cheap’) packaging of generics.

- I’d be more inclined to go with the brand name purely so that the patient gets the same thing each time … For older patients it can cause a lot of confusion when they’re getting different brands at different times. [GP11, male, aged 50–64 years]

- It can be stressful for people adjusting [to different aesthetic presentations], people have the perception that [generics are] different so if somebody’s comfortable on the branded prod-uct I won’t change them. [GP8, male, aged 40–49 years]

Table 2. Demographics

Demographic n

Gender Male 28Female 6

Age profile 18–29 030–39 440–49 1050–64 20

65+ 0

Table 1. Study instrument: semi-structured interview questions

What is your understanding of what a generic medicine is?What is your understanding of how a generic medicine differs from an originator medicine?What is your understanding of bioequivalence? To the best of your knowledge, what percentage difference is allowed in terms of bioequivalence between an originator medicine and an equivalent generic product?What is your understanding of why generic medicines are cheaper than originator medicines?What do you believe about how generic medicines compare to brand-name medicines?Do you prescribe generic medicines actively?Do you ever prescribe generic medicines in preference to originator medicines? Please explain why.Do you ever prescribe originator medicines in preference to generic medicines? Please explain why.What is your opinion as to why use of generic drugs in Ireland has historically much lower than other European countries?Have you ever had a patient report that a generic medicine, which you prescribed for them, didn’t work as effectively as a originator medicine? If yes, what type of medicine(s) have you seen this with? If yes, can you please give some brief details of what the patient reported having experienced? What action did you take in this case? Did you then prescribe the originator medicine? If yes, was there any reported lack of efficacy from the substituted originator medicine?Have you ever had a patient report that a originator medicine, which you prescribed for them, didn’t work as effectively as a generic medicine? If yes, what type of medicine(s) have you seen this with? If yes, can you please give some brief details of what the patient reported having experienced? What action did you take in this case?Are you aware of the Government’s proposed plans to introduce reference pricing and generic substitution in Ireland? What is your opinion of this proposed change in Irish legislation?

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When asked about the reasons for the historical high usage of generic medicines in Ireland, the most commonly stated reason (23/34 participants) was the influence of the pharmaceutical indus-try, most usually in the form of visiting medical representatives.

GP opinions regarding quality and efficacy of generics

GPs predominantly believed (31/34) that generic medicines were generally of the same quality as the originator medicine (Table  3). Likewise, the same number believed that generics worked as effectively as originators, being equivalent to the originator, although one GP adamantly held the converse view. Indeed, one-eighth of the GPs (4/34) stated that, in their opinion, generics may be dangerous compared to originator medicines.

- … [generics and originators] compare very well. For example I’m on a generic statin versus the originator statin and I’m just as well off on it. [GP12, male, aged 50–64 years]

- there’s a chance that they’re not really the same thing at all … my suspicion is that they’re the same, but in the absence of knowledge, you begin to suspect that they are inferior… [GP13, male, aged 50–64 years]

Regarding production of generics, almost three quarters of the GPs (24/34) believed generic manufacturing to be of the same standard as that of the originator. However, one in eight held the view that generics are manufactured to a poorer quality.

Tellingly, while 32/34 GPs said that they would take a generic medicine themselves, five GPs expressed a preference for orig-inator brands, when offered a choice between originator and generic medicines, even if more expensive.

GP experiences with patient complaints related to generic medicines

Thirty-two of the GPs reported having received patient com-plaints regarding generics. Where patients reported a negative experience with a generic, GPs stated that the patients pri-marily complained of complete or partial lack of efficacy (e.g. inhaler effect wearing off sooner, etc.). Furthermore, almost a third of the GPs (10/34) reported that patients had complained of altered or increased side effects when taking a generic medicine.

- Sometimes patients actually ask for a specific, named med-icine that they feel works better than a different medicine they’ve had before… It’s more to do with patient prefer-ence… that they would think or say that one medicine didn’t suit as well or they didn’t like how it tasted or went down. [GP7, female, aged 30–39 years]

In most of the cases above (28/32), GPs reported that they sub-sequently prescribed the originator medicine for the patient.

- I give them what they want. It is pointless arguing. [GP26, male, aged 50–64 years]

Table 3. Study instrument: structured questions and GP responses

n = 34

SA/Aa SD/Db Nc

Do you strongly agree, agree, neither agree nor disagree, disagree, strongly disagree with the following statements: Generic medicines are generally of the same quality as originator medicines. 31 3 0 Generic medicines are generally poorer quality than originator medicines. 3 30 1 Generic medicines are generally better quality than originator medicines. 0 25 9 Generic medicines work as effectively as originator medicines. 31 2 1 Generic meds work better than originator meds. 0 31 3 Generic meds don’t work as well as originator meds. 4 27 3 Generic medicines may be dangerous compared to originator meds. 4 29 1 Generic meds are as safe as originator meds. 30 2 2 Generic medicines are manufactured to the same quality as originator medicines. 24 5 5 Generic meds are manufactured to a poorer quality than originator meds. 4 25 5 Generic meds are manufactured to a higher quality than originator meds. 0 28 6 Generic meds are cheaper to buy than originator meds. 30 2 2 Generic meds are cheaper because they are of inferior quality to originator meds. 1 32 1 If I were ill, I would be happy to take a generic med if my doctor prescribed it for me. 32 1 1 If I were ill, I would prefer to take an originator med rather than a generic med, even if it is more expensive. 5 23 6

aStrongly agree/agree.bStrongly disagree/disagree.cNeutral/no opinion.

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- … if they had had the brand name medicine previously and it worked well for them, I’d put them back on that if that’s what they wanted. [GP29, female, aged 50–64 years]

Without exception, no further reports of lack of efficacy/contin-uing issues were received by the GPs from patients subsequent to prescribing of originator medicines. It is not surprising then that relatively few GPs (9/34) reported any attempt at educat-ing/persuading the patient as to the equivalency of generics. Conversely, a fifth of GPs (7/34) reported having experienced patients describe how originator medication did not perform as well as a generic. In that scenario, GPs reported that the patient had, in most cases, received the generic first and subsequently switched to the originator. Thus, their preference was for the medication they were first exposed to.

- Patients are fickle…different size, colour of tablet makes all the difference. You can have people having one branded generic and actually liking it and then it’s out of stock and the chemist gives them a different branded generic and they don’t like that one, or it doesn’t work. But I do believe that these are just issues of belief really, rather than any actual dif-ference between the tablets. [GP8, male, aged 40–49 years]

Almost one in three GPs (11/34) expressed the opinion that patients are prejudiced against generic medicines, leading to a nocebo effect; hence that patient complaints about generics are often imagined rather than actual. (The nocebo effect is a detri-mental effect on health produced by psychological or psychoso-matic factors such as negative expectations. It is, essentially, the opposite of the placebo effect.)

- There’s a huge placebo effect with any medication; patient belief is very hard to measure. You’ll get people who’ll take one tablet of something and tell you it doesn’t suit - that they felt their blood pressure was rising and impossible things to gauge - when people have these beliefs it’s very hard to work against that. [GP8, male, aged 40–49 years]

- I would often downplay the significance of [issues reported by a patient when taking a generic medication] and suggest to the patient that it had very little to do with the fact that it was a different drug and try to resist, to some extent, the tendency to revert to the originator, but … if a patient is very adamant about it, it’s the lesser of two evils to prescribe the originator brand. The placebo effect is very powerful and can’t be discounted. [GP24, male, aged 30–39 years]

Knowledge and opinion of proposed legislative changes

Three quarters of GPs (25/34) were aware of the Irish Government’s plans to introduce new legislation for generic substitution and reference pricing, with an additional four being

vaguely aware. Complete ignorance of the proposed changes was relatively rare (5/34).

With regard to the new legislation, more than half of the GPs (19/34) expressed a positive opinion. However, 9/34 emphasized their desire to retain the option to prescribe originator medicine and not have it substituted (which is allowed for in the Act to facilitate optimized patient care based on physician discretion and experience with specific patient need).

Other opinions of generic medicines

Branded generics were favoured by GPs as being reputable; GPs held the view that they can have knowledge of the product in terms of where it is manufactured and how it has worked in the past relative to other (non-branded) generic preparations.

- … with the uncertainty of the equivalence of bioavailability I tend to go for the proprietary drug, or a branded equiva-lent where I know the exact company that’s producing the branded generic, so I have some idea what the patient is get-ting. If I prescribe by generic I have no idea what the patient is getting. [GP17, female, aged 50–64 years]

Substitution by the pharmacist, however, was mentioned as a potential issue in this regard (9/34), although almost a fifth of the GPs (6/34) believed that pharmacist decisions on what to dispense may be based on profit margins. The disconnect between what is prescribed and what is eventually dispensed, and the impact that this potential change could have on patients, was also a concern expressed by some GPs.

Generally supportive of generic substitution, more than a third of the GPs (12/34) were of the view that no more money than is necessary should be spent on medications. The rising cost of new medications was referred to, as were cost savings achievable by increased use of generics and the potential for such savings to contribute to the funding needed to improve the availability of such new treatments. Only a small number of par-ticipants (4/34) referred to the potential impact on research and development that may be brought about by increased usage of generics.

Education

Lack of knowledge, or the requirement for education on the topic of generics, for both GPs and patients, was a recurring theme. That requirement was reinforced by the fact that while most GPs (31/34) could provide a correct explanation as to what a generic medicine is, none knew the bioequivalence tolerance limits for generics as set by pharmaceutical regulators involved in generic drug approvals (although 30/34 could provide a cor-rect explanation as to what bioequivalence is).

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A relatively small number of GPs (6/34) also expressed doubts about the origins of generic medicines, stating that they would like to have some formal assurance of the quality of generics available on the market (and, thereby, showed lack of awareness of, or confidence in, the functions of regulatory authorities).

- If we could be satisfied that the agency who are testing all these drugs, if they could give feedback and reassurance to all GPs that the efficacy and the bioavailability and all of these [generics] were 100% - but I don’t think that information is readily available. [GP1, male, aged 50–64 years]

- [there are] no guarantees over quality of the [generic] product or over where it’s made … in the developing world, at lower cost, and shipped here, and then sold under branded generics … you’d want reassurance about quality standards, and you’d want information about where they were manufactured and their licensing laws. [GP16, male, aged 40–49 years]

- There doesn’t seem to be the same control of generics, there are so many different generic companies, and I would feel that there isn’t the same quality control… We genuinely don’t know where they’re coming from. They say they’re manufac-tured in Ireland but the components could be brought in from anywhere. [GP31, female, aged 50–64 years]

Discussion

While there have been numerous publications dealing with generic medicines: their development and market introduction, subsequent use and aspects of acceptance or otherwise; there is relatively limited recent literature regarding the attitudes of physi-cians towards these products. Indeed, we found only three origi-nal English language papers published between 2003 and 2013 focused specifically on GP perspectives (4,6,7). This paper is the first published exploration, using semi-structured interviews, of GP perceptions and behaviours relating to generic medicines in Ireland. While attitudes in this cohort appear to have improved since the last published (but less comprehensive) study in this area, from 1997 (3), GPs in Ireland still express some negative opinions of generic medicines and demonstrate reticence towards their use.

In a comprehensive narrative review, Hassali et al. (15) col-lated international studies published between 1980 and 2008 and coalesced the collective views of physicians as: accepting of generic substitution under policy and economic pressures but having concerns regarding generic drugs’ overall quality, relia-bility and switchability. That review further theorized that those concerns may prevent full adoption of generic drug prescrib-ing and substitution by physicians, which could lead to escala-tion in health care costs for governments, insurers or consumers directly (15).

Cognizant of the concerns expressed by Hassali et  al., we determined that attitudes to generic prescribing have changed

appreciably in the Irish GP cohort in the intervening time period since 1997 (3), with a majority of the interviewed GPs stating that they currently prescribe generics actively in preference to originator products (versus just 2% of GPs 16  years prior). Furthermore, while the 1997 study found that 75% of prescrib-ers were concerned about the reliability and quality of generic drugs, the outcomes of our interviews contrast starkly, with 31/34 GPs currently believing generics to be comparable to the originator medicine in terms of quality and efficacy.

Current concerns of GPs in Ireland appeared to centre on the potential for patient stress and confusion that may be caused by the changing aesthetic characteristics of generic preparations, relative to the originators. This, in fact, was held as a reason for the continued prescription of originator medicines (i.e. ‘do not substitute’ prescriptions) and could represent a possible stum-bling block for successful implementation of the new legislation in Ireland and, more explicitly, have the effect of significantly reducing the targeted savings associated generic substitution and reference pricing.

Approximately one in eight of the participants in our study believed that generics might be dangerous compared to origi-nator medicines, a result that effectively mirrored the views expressed by GPs in previous studies (4,6,16). However, in contrast with those reports, Irish GPs did not necessarily indi-cate lack of confidence related entirely to the quality of generic medications. Rather, they expressed views regarding the unsuit-ability of equivalence for generic substitution with some drugs, such as antiepileptic medicines and the fact that excipients may differ between the originator and equivalent generic formula-tions (for example a GP reported a patient having had an aller-gic reaction to a red dye excipient in a generic product, which was not part of the originator formulation). This may not be an unreasonable concern, as evidence has been published regard-ing the problematic consequences that arise from differences between excipients used in originator medications and their generic counterparts (17).

A potential confounding factor is that GPs in our study expressed the belief that most negative experiences reported by patients are due to nocebo effects, resulting from patients’ nega-tive preconceived notions about generics. A public health con-cern arising from this, possibly as an area for future research, is whether or not GPs receiving complaints about altered side effects associated with usage of generic drugs are reporting such to the pharmaceutical regulator as adverse events. Related to this is the fact that as many as 1 in 20 adverse events go unre-ported (18).

With respect to the historical reasons for high prescription of proprietary medicines in Ireland (rather than more cost-effective generic equivalents), GPs believed that influence was brought to bear on prescribing physicians on behalf of the proprietary pharmaceutical industry. There is considerable evidence in the

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published literature describing the influence that marketing by pharmaceutical companies has on physicians, often without physicians recognizing their vulnerability to such practices and how this can impact patient care (19–23).

However, views and experiences of the GPs in this study cor-respond with our previously reported attitudes of Irish patients (24) and highlight the fact that a high degree of prescribing is influenced, even mandated, by patient preference or demand. For instance, 32/34 GPs indicated that patients had reported issues with generic medication. Of these, 28 then acceded to their patient’s wishes and prescribed the originator medication in place of the generic. This indicates that, from the point of view of successful implementation of generic substitution and reference pricing, the customer/patient group is a key stake-holder cohort to persuade. Additionally, while patient knowl-edge of what works best for them is important, there may be a role for GPs in educating or convincing patients to accept generic medicines, and, therefore, supports such as websites with appropriate and understandable information could aid GPs in this (25).

In addition to education of the general public, GPs stated that they would like to see some assurance of generic medi-cine quality from the responsible authority for pharmaceuticals in Ireland: the Irish Medicines Board (IMB). Concerns were expressed regarding origin of medicines, with references made to the growth of pharmaceutical manufacturing, particularly generic products, in countries such as India and China. Those views represent an educational opportunity, implying that at least some GPs are not aware that the IMB applies the same stringent procedures to all medicines approved for the Irish mar-ket, regardless of their origins. An analogous need for interven-tion was documented in the UK, with a 2006 survey showing that 37% of GPs had never heard of the British pharmaceu-tical regulatory authority (Medicines and Healthcare Products Regulatory Agency) (26).

A possible limitation of this study could be the manner of par-ticipant selection as all GPs participating had a university affili-ation. As these individuals had some involvement with teaching and training, their mindsets may differ from those who do not have any link with academia. This argument, however, is some-what mitigated as recent research, completed in the same region as our study, has shown that prescriptions coming from univer-sity-affiliated teaching hospitals are almost never written generi-cally (27). A further potential limitation may be gender and age balance. However, our cohort generally reflects the current situ-ation in Ireland with most established GPs being 40–60 years of age (and the greatest number of these being 50–60 years) and the role currently being dominated by men (approximately three to one). However, a strength of this study in the number of subjects used for qualitative interview; this compares favourably with

the only other interview-based study that could be found on this topic, which reported on 10 GPs (16).

In conclusion, this paper is the first published exploration of GP attitudes utilizing semi-structured interviews in an Irish context. It is clear from this study that Irish GPs appear to have a relatively positive view towards generic medicines, albeit tem-pered with a concern for their patients’ abilities to deal with sometimes confusing changes in medication. Moreover, in an era when usage of generic medicines is an increasing and necessary facet of cost control in health care provision, this study provides some insight into persistence of negative opinions and uncer-tainty regarding generic medicines by GPs in Ireland.

AcknowledgementsThe authors wish to express their sincere thanks to all of the GPs who took part in these interviews.

DeclarationFunding: Faculty of Education and Health Sciences, University of Limerick, Ireland.Ethical approval: Research Ethics Committee of the Irish College of General Practitioners.Conflict of interest: none.

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