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Background  Recent qualitative studies indicated that physicians interact with pharmaceutical representatives depending on the relative weight of the benefits to the risks and are also influenced by a variety of experiences and circumstances. However, these studies do not provide enough information about if, when, how and why their attitudes and behaviors change over time.    Methods and Findings  A qualitative study using semi-structured face-to-face individual interviews was conducted on 9 Japanese physicians who attended a symposium on conflicts of interest held in Tokyo. Interviews were designed to explore chronological changes in individual physicians' attitude and behavior concerning relationships with pharmaceutical representatives and factors affecting such changes. Their early interaction with pharmaceutical representatives was passive as physicians were not explicitly aware of the meaning of such interaction. They began to think on their own about how to interact with pharmaceutical representatives as they progressed in their careers. Their attitude toward pharmaceutical representatives changed over time. Factors affecting attitudinal change included work environment (local regulations and job position), role models, views of patients and the public, acquisition of skills in information seeking and evidence-based medicine, and learning about the concepts of professionalism and conflict of interest. However, the change in attitude was not necessarily followed by behavioral change, apparently due to rationalization and conformity to social norms.    Conclusions  Physicians' attitudes toward relationships with pharmaceutical representatives changed over time and factors affecting such changes were various. Paying attention to these factors and creating new social norms may be both necessary to produce change in behavior consistent with change in attitude.

Chronological Changes in Japanese Physicians' Attitude and Behavior Concerning Relationships with Pharmaceutical Representatives: A Qualitative Study