Illuminating the shadow

The CMAJ reports that BC's Fraser Health Region has banned "physician shadowing" by pharmaceutical and medical equipment representatives. This is a significant, often ignored, ethical issue in medical practice.


I've attended Oncology Rounds with a drug rep present and raised a question about his/her presence. I was assured that a confidentiality agreement had been signed. OK, let's say that confidentiality is looked after, then.

But, what about the physicians' ability/willingness to speak freely and openly about their opinion on a patient's care? Multi-disciplinary cancer rounds often require frank discussion about some difficult situations. There may be disagreements about therapeutic approaches. The meeting's purpose is to air those differences and freely debate treatment options.

The discussion relies on a certain "therapeutic detachment", that is, the ability to suggest a treatment option (or withholding of an option) without necessarily believing it's appropriate for the patient. Some physicians may be uncomfortable in sharing their opinion in the presence of an "outsider" who may misinterpret their intent.

This is only one example in the debate about pharmaceutical reps and clinical practice. The Company We Keep: Why Physicians Should Refuse to See Pharmaceutical Representatives offers a broader discussion of the issue. The comments about this paper are as interesting as the paper, and cover the range from those who piously refuse to interact with reps to those who are indignant that anyone would believe that their professional integrity and judgement could be compromised by a rep. (Those of you in the second camp should check out this article.)