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AMA: Be open about drug reps in exams

The Association also gave its opinion and presented guidelines on boutique medicine and stem cell research.

By Tanya Albert, AMNews staff. July 7, 2003.

Chicago -- If you're going to invite a drug rep into the exam room, you better let the patient know exactly who that person is.

If the patient isn't OK with the idea, the pharmaceutical sales representative can't sit in on the exam.

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The American Medical Association set these new guidelines at its Annual Meeting in response to requests from drug sales reps to shadow doctors for a day for educational purposes.

Some physicians are paid up to $500 a day if they consent to the arrangement. But many fear -- particularly when they get a second shadowing request from the same pharmaceutical salesperson -- that the drug rep is only trying to find out what drugs the doctor is prescribing.

"I don't allow second-time shadowing," said Illinois gastroenterologist Howard Chodash, MD, who added that he donates any money he gets from the arrangement to charity.

Also of concern is that patients aren't being properly informed about who is sitting in on their exams. Former pharmaceutical sales representative Barbara Felt-Miller confirmed that fear.

Felt-Miller told physicians that when she shadowed doctors during the five years she made calls on their offices as a sales representative, doctors often didn't explain to patients who she represented.

"My concern today is for patient privacy," said Felt-Miller, who has been treated for Crohn's disease for 26 years. "I never took an oath. The things I viewed in the exam room were left up to my discretion [to talk about or not]."

She said patients have a right to know that.

The AMA will work with the pharmaceutical industry to establish guidelines that would protect patients and prevent inappropriate intrusions into the patient-physician relationship.

Boutique medicine

Offering retainer services that allow patients to pay more for additional services such as 24-hour access to a doctor's cell phone is ethically acceptable as long as physicians follow some guidelines, the AMA said.

Among the ethical guidelines physicians should follow when operating what is commonly called "boutique medicine" is that the physician has to be available for emergencies for all of his or her patients and that he or she can't promote a retainer contract as a promise for more or better diagnostic and therapeutic services.

While retainer practices can let a doctor and patient develop a more personalized relationship, "there should be no difference in the quality of care between the two patients," said Leonard Morse, MD, chair of the Council on Ethical and Judicial Affairs at the time the council's report on boutique medicine was written.

For example, a doctor has to see a patient who needs the most urgent care when he or she has a practice that includes both patients with retainer contracts and those without. Physicians must always provide care on the "basis of scientific evidence, sound medical judgment, relevant professional guidelines and concern for economic prudence," the AMA said.

Here's a look at the other guidelines doctors should follow when establishing retainer contracts that include services such as longer visits, guaranteed availability by phone or pager, counseling for healthy lifestyles and other personal services:

• When a physician and patient create a retainer contract, both must be clear about the terms of the relationship and must agree to them.
• Patients must have the ability to opt out of a retainer contract without a financial penalty or "undue inconveniences."
• Physicians converting from a traditional practice to a retainer practice must help transfer their non-participating patients to other physicians.
• Physicians should bill insurance companies honestly for reimbursement, so it is desirable that retainer contracts clearly separate special services and amenities from reimbursable medical services.

As part of its study of boutique medicine, the AMA looked at concerns that the practices may become so popular with physicians that patients who don't want to pay extra for "non-medical services" would have a hard time finding a doctor. That does not appear to be happening at this point, and economically, it is likely that a community would have a hard time supporting more than a handful of retainer practices, the AMA found.

Embryonic stem cell research

Noting that physicians have differing ethical opinions and that science can't resolve the divide, the AMA said cloning stem cells for biomedical research is consistent with medical ethics and that individual physicians need to remain free to decide whether to participate in stem cell research or use its products.

"We've supported their personal beliefs," said Michael S. Goldrich, MD, CEJA chair. "Physicians need the ability to object and the ability to participate."

There has been heated national debate over using embryonic stem cells for biomedical research, with the conflict centering on the moral status of embryos.

Some scientists and physicians believe that embryonic stem cell research may help develop treatments for diabetes, Parkinson's disease and other diseases that might not otherwise be developed using adult stem cells alone.

"Research has to go on," said Connecticut pediatrician Myron Genel, MD, former chair of the Council on Scientific Affairs. "The major reason is we need to know whether or not the potential from adult stem cells and embryonic stems cells is equivalent."

Those who believe that destroying an embryo is destroying life oppose the research and are upset with the AMA's stance.

"We're talking about an organization that actually advocates creating human life for the sole purpose of destroying it through highly speculative, questionable and unethical research," David Stevens, MD, Christian Medical Assn. executive director, said in a statement.

While leaving the decision whether to participate in research up to individual physicians, the Association said there needs to be monitoring to ensure that embryonic stem cell research is used only if it's uniquely promising. Also, the AMA said research subjects must give their informed consent and be told of all relevant risks and benefits.

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Copyright 2003 American Medical Association. All rights reserved.
 

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