CHICAGO - When Barbara Felt-Miller talked squeamishly about sitting in on patient exams as a drug company sales representative, the American Medical Association listened.

Her testimony helped convince the AMA to adopt its first policy on "shadowing," a practice that sometimes involves payments to doctors of hundreds of dollars a day. Felt-Miller told the medical association that some doctors never sought patients' permission to have her present during exams.

The AMA's new policy opposes "shadowing" unless patients' consent and privacy issues can be properly addressed.

"I can't imagine why a pharmaceutical sales rep would need to be involved" in patient exams, AMA trustee Dr. Ronald Davis said after Tuesday's vote.

While the policy doesn't specifically address the ethics of doctors accepting money for shadowing, Davis called the payments "very inappropriate" and said the policy would require doctors to tell patients if they are being paid.

Companies say the practice is educational and lets their employees better understand doctors' jobs. Critics say it's another way for drug companies to influence doctors' prescribing habits.

Miller testified in an AMA committee Sunday that she formerly worked for two major drug companies that required her to engage in shadowing.

She said the practice made her uncomfortable, especially witnessing patients in their doctor-issued paper gowns undergoing routine but intimate procedures including pelvic and rectal exams.

"It was embarrassing, almost voyeuristic that I'm sitting in on these exams," she said in an interview. "I can't imagine how it feels for the patient."

Dr. Howard Chodash, a Springfield, Ill. gastroenterologist, said he has allowed sales reps to shadow him but gives the money they offer to charities.

The new policy says doctors should work with drug companies to create guidelines to ensure that sales reps don't intrude on the doctor-patient relationship.

Some physicians questioned whether patients could ever give proper consent without feeling subtly pressured by their doctor's request to have a stranger present.

"It's more than just the 'yuck' factor that we're dealing with," said Dr. Michael Williams of Johns Hopkins University. "If it really is educational, let's find a way to protect our patients."

Dr. David Fassler, a Burlington, Vt. psychiatrist who drafted the anti-shadowing proposal, said the AMA's endorsement may make the practice scarce.

But Ed Sagebiel, a spokesman for Eli Lilly and Co., said the AMA's policy echoes the company's own, which says patients' consent should always be obtained before a sales rep is allowed to observe.

In other action Tuesday, the AMA said embryo cloning for research is ethical and endorsed so-called boutique medical practices catering to wealthy patients. The practices, which charge extra fees for special services that may include house calls and same-day test results, are acceptable but should never promise to give better care, the AMA said.

The new cloning policy says research cloning offers promise in helping lead to development of treatments for a wide range of disease. It does not support reproductive cloning and is strong in its call for proper oversight.

It puts the nation's largest organization of doctors officially at odds with the Bush administration, which opposes all cloning, research or reproductive. The U.S. House earlier this year passed a White House-backed ban on any form of the practice.

University of Pennsylvania bioethicist Art Caplan said the AMA may have been emboldened to endorse the procedure because of recent research challenging whether such early embryos could ever develop into human life.

He said the AMA action likely won't sway the Bush administration but could influence what happens in the Senate on cloning.

The 260,000-member AMA represents less than a third of the nation's doctors but Caplan said it still has clout in Washington.

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