The AMA today officially came out against "shadowing" of patients by pharmaceutical and medical-device sales representatives, but it also gave its stamp of approval to so-called boutique practices that charge retainers or other fees to provide personalized services to patients.
Additionally, delegates at the organization's annual meeting in Chicago voted in favor of physicians taking an active role in identifying and reporting medical errors. The House of Delegates had defeated two earlier attempts to recommend voluntary error reporting.
"This is a very momentous occasion for organized medicine," says Leonard Morse, M.D., chair of the AMA Council on Ethical and Judicial Affairs.
The report adopted today defines an error as "an unintended act or omission, or a flawed system or plan that harms or has the potential to harm a patient." It recommends that physicians play an active role in developing error-reporting mechanisms--including the means for investigating reports--and in reporting "impaired and/or incompetent colleagues" to prevent harm to patients.
According to the report, "An expression of concern need not be an admission of liability."
In opposing the controversial practice of shadowing, the House of Delegates sets a new policy that asks physicians to ban sales reps from clinical encounters without the full knowledge and consent of patients.
"It would hypothetically allow the presence of a pharmaceutical sales representative in a clinical situation with the patient's full and informed consent," says AMA Trustee Ronald Davis, M.D. However, he says that shadowing in no way should compromise patient confidentiality.
Davis says that physicians also have an ethical responsibility to disclose to patients whether they are receiving an honorarium from a drug or device maker.
The AMA went ahead with the resolution despite recent developments to limit sales reps' influence on physician behavior, including the pharmaceutical industry's adoption of standards, the advent of HIPAA privacy regulations and an HHS guidance warning that shadowing was a "suspect" activity that could violate anti-kickback laws.
"I'm not sure if (these) will result in the elimination of shadowing," says Davis.
The AMA takes a more cautious stance on retainer medicine.
Last year, the AMA Council on Medical Service determined that boutique-type practices in which patients pay retainers or other annual fees for personalized service do not violate an AMA policy that allows for multiple tiers of healthcare service but said that the Council on Ethical and Judicial Affairs is more suited to study the ethical implications.
Today, AMA delegates adopted the ethics council's determination that retainer fees and contracts are fine as long as the proliferation of boutique practices does not limit access to care or compromise the quality of care provided to those who do not pay retainers.
"The overarching issue for the AMA is that we support a pluralistic healthcare system," Davis says. AMA ethical principles already say that physicians have the right to choose the environment in which to practice and, except in emergencies, the patients they wish to serve.
However, Morse says that a retainer contract "cannot be promoted as more and better" care.
"If, in the eyes of the patient, it is an urgent matter, that patient should have direct access to the doctor," Morse says. "The quality of care should be no different for patients who have contracted for the service and those who have not."