Drug companies have introduced another strategy to infiltrate public hospitals and try and influence medical prescribing. They are paying undisclosed honoraria to doctors to have their sales representatives sit in on patient consultations.

The strategy is given credibility by describing it as a ‘preceptorship’, which is traditionally a tutorial undertaken by medical students that has ancient roots in medicine drawing on the most hallowed obligations of the Hippocratic oath. In reality it is payment for access to doctors and their patients. I am personally aware that this practice has occurred in at least one public teaching hospital in Melbourne, and I suspect that it is also happening elsewhere. In other countries, the practice has also involved surgical device salespeople scrubbing in to operations.

At one Melbourne hospital’s oncology clinic, for example, a number of young sales and marketing representatives (“reps”) have been sitting in on consultations with cancer patients, and attending meetings and ward rounds where sensitive information is discussed. In return, their companies pay a large amount of money to the oncology medical staff fund. Fortunately, the hospital has this week decided to halt the practice.

It involved patients being very briefly asked by the doctor at the commencement of the consultation, usually as they are walking in and in front of the rep, to give their consent to the rep sitting in on their consultations. They may have been told that it is part of the rep’s training or education but they have not been told that money has been paid to the doctors, and they are not offered any compensation themselves. It is arguable whether they have truly understood the consequences — especially as it also seems that some of the doctors involved have not fully thought these through themselves. The doctors, by their actions, have been giving implicit reassurance about the legitimacy of the rep’s presence and the maintenance of confidentiality.

The companies and those clinicians who had supported this practice argued that it was assisting drug companies to better understand the needs of doctors and patients.

While there may be a grain of truth to this, it is a naïve view that does not recognise the value of this interaction to companies’ sales and marketing strategies. Drug companies do not pay large sums of money from their marketing budget to doctors without expecting something significant in return. They remain very profitable companies.

What the drug companies are trying to do is develop and deepen their personal relationships with clinicians, understand how individual physicians and their patients reach treatment decisions so that they can better position their product against rivals and give their sales pitches more credibility.

No doubt these interactions also contribute to the extraordinarily detailed insights that pharma reps have into individual doctors’ prescribing patterns.

The first of my two major concerns are the lack of adequate informed consent about the purpose and commercial nature of the “preceptorship” and the absence of any prior opportunity for the patient to refuse. The patients trust the doctors and they do not want to upset the doctors.

The second major concern is that drug sales reps have no more right to enter the sacred space within which doctors and patients meet than any person who may “want to help people” such as a taxi driver or postman. In addition, this particular clinic has previously banned all doctor/rep consultations, which are usually uncompensated (apart from the frequent offers of small gifts or invitations to ‘educational events’!) during clinic time.

If there is spare teaching time available in a clinic then I believe it should be used to teach medical students and training health-care workers who we will be depending on for our own future health care.

I am bringing this issue to the public’s attention, not because I want to point the finger at any of my hard-working peers who are basically fine people and fine doctors, but because I believe it is one that merits some broader discussion and analysis by doctors and the general public. It has been banned in some leading US medical schools such as UC Davis in California, and also at Fraser Health in Canada, British Columbia’s biggest health authority.

It would be interesting to know how widespread this practice is in Australian hospitals. Presumably it also occurs in general practice and community settings as well.

If Crikey readers are aware of this practice happening elsewhere, contact: [email protected]

Peter Fray

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