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A small excursion last December has left me questioning the way I run my practice. While visiting our daughter in Israel, my dear wife, Rena Bloom, and I talked our way into a private tour of the Opaletka Pharmacy in Jerusalem. Their Russian pharmacist, Oksanna, took a few minutes to lead us up the back staircase and show us around. Hidden behind a modest storefront across Jaffa Road from the Machane Yehuda shuk, and what on the outside looks like a local neighborhood pharmacy, Opaletka is one of the most comprehensive naturopathic pharmacies I've ever seen.
|Jacob Schor, ND, in front of Opaleta
Rena Bloom, ND, explores the stock, with Oksanna as her guide.
At the top of the staircase, Oksanna pointed out the water filtration system and then several "clean hoods" under which homeopathic mother tinctures are added to lactose pellets. Opaletka's pharmacist and technicians do much the same thing that we do in our office back room, making up homeopathic remedies, mixing herbal tinctures and dry herbs custom for each patient, but on a far larger scale. Multiply our school pharmacies by 10 and you begin to understand how busy they are. Everything they prepare is done in response to prescriptions from local doctors.
Eliezer Opaletka opened this pharmacy back in 1917; he was one of the first qualified pharmacists in the Middle East. Shlomo Ozarenski took over the pharmacy from Eliezer in 1950 but kept the original name. In 1967, Shlomo's son Amnon, also a pharmacist, became interested in alternative medicine. This interest in homeopathy and herbal medicines prompted him to obtain, in the 1970s, the necessary licenses to import vitamins from the US. Opaletka's also became the first pharmacy in Jerusalem to dispense homeopathic medicines. Amnon became the pharmacy manager in 1980. It was Amnon who brought together the full dispensary of herbal medicines that we toured. In my experience there is nothing in the US that competes in size and depth to what I expected to be a little hole-in-the-wall pharmacy.
Opaletka exists in Jerusalem and not in the US for one simple reason. In Israel, physicians are not allowed to dispense medicines from their own offices; to do so would not just be unethical but also illegal. Instead they send prescriptions to Opaletka to be filled.
This has raised the question about our own practice. Dr. Bloom and I, like most of our colleagues, purchase supplements and herbs at wholesale prices from manufacturers and resell them to our patients at the suggested retail price. We make money on these sales. There are some people who say that it is not ethical for physicians to sell products and in particular dispense prescribed herbal or homeopathic medicines from their offices. This is certainly the case for medical doctors.
The rules set down by the American Medical Association (AMA) clearly elucidate that selling "pharmacy" the way we do is unethical. While naturopathic physicians are not required to adhere to the AMA's code of ethics, I like to think of myself as at least as ethical, if not more so, than my medical counterparts.
If we were to follow the AMA rules, then the entire concept of in office dispensaries would be considered unethical.
We rationalize that we provide a service to patients by maintaining these "pharmacies" as we stock difficult-to-obtain products. Even if that were still true, it would still be unethical to profit from these sales. Yet these sales help pay my rent. They provide a steady source of income in a business that seems as if it might not break even without them. We find ourselves debating whether we could stay in business without this secondary revenue stream.
This is something of an elephant in the room. Our profession doesn't like to talk or think about it. While nonprofit in-office pharmacies may be the right thing to do, keeping our doors open to see patients is often viewed as the ethical trump card. The financial necessity and obligation to stay open to care for patients wins out, or at least that is what has until now.
Eric Yarnell, ND, who practices in Seattle, has long provided patient supplies without profit in his private practice. Granted, we should mention that Dr. Yarnell as a professor at Bastyr University, a part owner of Heron Botanicals, and also of Healing Mountain Publishing, has other sources of income aside from his private practice. He is the most vocal proponent I can think of for nonprofit in office sales, regarding that in-office profit-deriving pharmacies are an ethical practice, I asked him what light he might shed on this quandary. Here, in part, is his response:
I reject that most NDs couldn't live without this [pharmacy] income. It's the same argument we've heard in a thousand other settings: "There's no way we can live without oil," "There's no way I can recycle or compost all this stuff," "I couldn't function without a car," and then we justify what we feel is absolutely essential with a million arguments. This is how the human mind works. … I realize I'm in an ivory tower on this supplement issue because I don't derive my living from my practice. Nevertheless, this anecdote I think illustrates my point:
... The more I think about, the more absolutely shocking it is to me that this was, not to my knowledge, ever brought up while I was in school in our ethics class, in any clinic discussion, or anywhere. It was an absolute, god-given fact that every ND would have a pharmacy, would sell at 100% mark-up, and would derive half their income from doing this. … Until Stefan [Ripich, ND] opened my eyes I was selling at the usual ND mark-ups really without even thinking about it. I was noticing though that it was a lot harder to get people to take tinctures when they were so … expensive. That bothered me as it was my core medicine. Anyway, within a year of Stefan making me aware of this argument, rather than trying to justify what I was doing I researched it, thought a lot about it and my motivations, and about how this was a net negative in my interactions with patients. I set my mind to it and completely changed what I was doing because it was the RIGHT thing to do, not because it was profitable.
I [did the following:]
a. jettisoned selling any supplement that people could easily and safely get anywhere,
b. went to selling at cost (which is a mark-up over wholesale by the way, factoring in usually 20% to handle shipping and my costs), and
c. telling everyone that I owned part of Heron which made the medicines they were taking.
I did increase my visit fees, which I hadn't done in several years, to help offset the loss.
Rather than these changes killing my practice … and halving my income, I actually saw my income increase. The number of patients I saw increased, so I had fewer and fewer empty slots in my schedule. People willingly paid my increased fees, and those who really couldn't, I offered a sliding scale (I was all cash at the time). It was remarkable. It really cemented my belief that most people are selling supplements at a profit to make a profit and for none of the other reasons they claim.
… Both students and NDs … become quite irrational in their defense of [this practice.] They immediately start claiming they only prescribe what is necessary and the implication I'm making that they are basically immoral really bothers them. I am making no such statement, [only] … that the profit motive operates quite unconsciously. … That's how people respond. … I continue to bring this issue up all the time in my classes. Many, many hundreds of ND students in the past few years have heard my side of this. Very few have ever been able to argue … effectively against it. More than a few have adopted this approach and they are doing fine in practice. This can and will change ultimately, or it will hurt the profession. It is not ethical or acceptable to continue the way we are doing this.
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