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By LINDSEY TANNER : AP Medical Writer
Jan 18, 2003 : 6:58 am ET
CHICAGO --
Some doctors are letting drug company sales representatives
sit in while they treat patients -- a practice called "shadowing" that is
being questioned by at least one professional group.
An organization of psychiatrists says it intends to
ask the American Medical Association to review the ethics of the practice.
Sales reps have been known to sit in doctors' offices
and examining rooms and observe routine checkups, various treatments and
diagnostic tests, even child psychiatric therapy. Some doctors are paid
hundreds of dollars in return.
Some, if not all, of the pharmaceutical companies
require the doctors to obtain the patient's consent.
The companies say these preceptorship programs, as
they are formally known, are purely educational, allowing sales reps to
learn more about doctors' jobs and better serve physicians who use their
products. But critics see the efforts as an unethical marketing attempt that
violates the privacy of the doctor-patient relationship.
It is unclear how widespread the practice is, but the
players include major pharmaceutical companies like Eli Lilly and Co.
Lilly spokesman Ed Sagebiel said the practice began
at Lilly at least five years ago and involves doctors of many types around
the country. Sagebiel said Lilly's reps are told just to observe, not
participate. Lilly's policy says participating doctors must obtain patient
consent.
But critics say confidentiality and consent are
especially problematic when psychiatric patients and children are involved.
Some question whether parents can adequately represent their children's
wishes.
The American Academy of Child and Adolescent
Psychiatry plans to raise the issue at the AMA's annual meeting in June in
Chicago.
Dr. David Fassler, a Vermont psychiatrist and member
of the academy's governing council, said he wants the AMA to come out
against the practice unless patients have "full knowledge and informed
consent."
"It seems quite inappropriate to have non-clinical
personnel present during therapy sessions," Fassler said in an interview
this week. "I'm also concerned that patients may not always feel free to say
no when asked by their doctor if something like this would be OK."
The AMA does not have policy on shadowing, but one is
needed -- especially if doctors are being paid, said Dr. J. Edward Hill,
chairman of the AMA Board of Trustees.
"I would be extremely concerned about that being an
ethical behavior," he said. He added: "We don't want anybody interfering
with the patient-physician relationship, whether it's a pharmaceutical
representative or anybody. That's such a sacred trust."
While the extravagant freebies that drug companies
have lavished on doctors have come under increased scrutiny in recent years,
the industry's presence in examining rooms is less well-known. But some
recent cases have raised concern among doctors and prompted calls for an end
to the practice.
In one of those cases, a Lilly sales rep in Maryland
sat in on a psychiatric therapy session involving children.
In another case, Parke-Davis, now part of Pfizer
Inc., is accused of illegally marketing the epilepsy drug Neurontin for
unapproved uses through tactics that included sitting in on patient visits.
The allegations were contained in a whistle-blower lawsuit filed last year
in Boston. The case has prompted an investigation into Parke-Davis'
marketing practices in 47 states.
David Waterbury, an assistant attorney general in
Washington state who is overseeing the Parke-Davis probe, said that even if
sales reps are not overtly marketing, their presence would probably make a
doctor reluctant to recommend another company's drug to a patient.
"If the person's there from `X' company, is the
doctor going to have a lot of discussions about the virtues of `Y' company's
drug? I think not," Waterbury said.
Lilly pays doctors $250 for one half-day session or
$500 for allowing a sales rep to accompany a doctor all day, Sagebiel said.
Doctors may be paid directly or their fee can be donated in the physician's
name to a medical school or a charity, he said.
Sagebiel said paying doctors is appropriate because
they are providing a valuable service. "It helps the reps have a hands-on
observation to the challenges of a physician and helps them to be a better
partner," he said.
Dr. Bill Arnold, an Indianapolis psychiatrist, said
he has been paid to take part in several such programs involving Lilly and
others. He defended the practice as a way to give sales reps exposure to
medicine the way it is practiced.
"They've heard about schizophrenia and heard about
Alzheimer's; here it is -- live," Arnold said. "They're going to market
their products anyway, so instead of them trying to beat down my door, why
not have them learn about what the market's really like?"
Arnold said the money is minimal given the amount of
time shadowing takes away from his practice: "It's not a lucrative thing to
do at all."
A Pfizer spokesman declined to comment on the
Neurontin case.
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