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My biggest concern about profiting from our pharmacy sales is that the prospect of money in my bank account will sway my objective judgment and encourage me to sell things to patients that they don't need. My experience with laboratory testing makes me think this happens, even if I'm unaware of it. Several decades ago, we adopted a practice in our clinic to discount lab fee charges to just above our cost. I noticed my habit of ordering tests changed over the ensuing months; I was less eager to run tests that from my new point of view seemed suddenly less necessary now that I wasn't profiting from each requisition I filled out.
While all of us who practice medicine would wish that we could live in an ethical world, this isn't the case. The very fee for service structure of our modern medical system has inherent faults: "Many studies have concluded that paying physicians for each service that they provide creates incentives for physicians to increase the volume of services, which also increases their income and society's spending for health care."2
That our medical doctor colleagues engage in practices that might violate their own standards should not be an excuse for us. It is time for us to assess what the right thing to do is.
Our clinic has yet to decide whether to change our current practice of marking supplements to retail. Unlike Dr. Yarnell, we do not have secondary sources of income. Some products are already sold at cost, in particular expensive items that we hope cancer patients will take long term. Should we discount everything to near cost? I don't know. Eric makes it sound like a simple ethical choice. If finances are the deciding factor, then the answer is already clear. As naturopathic doctors, we should be guided by what is best for the patient, not by our financial needs.
Until such a time as there are American Opaletka's ready and willing to provide the services that we now perform in our clinic's back room, I think that as a profession we may need to continue with the status quo, as ethically questionable as it may be. Whatever your view of this issue, we all need to admit there is an uncomfortably large elephant sharing our clinics with us.
In the midst of my writing this piece for the Townsend Letter, the New York State attorney general's office has accused four national retailers, Walmart, Walgreens, Target and GNC, of selling dietary supplements that were fraudulent and in many cases contaminated with unlisted ingredients (February 3, 2015, New York Times article, "What's in those supplements?")3
The authorities say they had run tests on popular store brands of herbal supplements at the retailers, which showed that roughly four out of five of the products contained none of the herbs listed on their labels. In many cases, the authorities said, the supplements contained little more than cheap fillers like rice and house plants, or substances that could be hazardous to people with food allergies. There will be arguments regarding the validity of the testing methods used. The idea that these box-store products are inferior will justify the argument for in-office pharmacies for some of us. Yet it argues even stronger for us to cede this part of our practice to professional pharmacies.
The AMA Code of Ethics in Opinion 8.063 lays it out:
In-office sale of health-related products by physicians presents a financial conflict of interest, risks placing undue pressure on the patient, and threatens to erode patient trust and undermine the primary obligation of physicians to serve the interests of their patients before their own.
(1) Physicians who choose to sell health-related products from their offices should not sell any health-related products whose claims of benefit lack scientific validity. When judging the efficacy of a product, physicians should rely on peer-reviewed literature and other unbiased scientific sources that review evidence in a sound, systematic, and reliable fashion.
(2) Because of the risk of patient exploitation and the potential to demean the profession of medicine, physicians who choose to sell health-related products from their offices must take steps to minimize their financial conflicts of interest. The following guidelines apply:
(a) In general, physicians should limit sales to products that serve the immediate and pressing needs of their patients. ….
(b) Physicians may distribute other health-related products to their patients free of charge or at cost, in order to make useful products readily available to their patients. When health-related products are offered free or at cost, it helps to ensure removal of the elements of personal gain and financial conflicts of interest that may interfere, or appear to interfere, with the physician's independent medical judgment.
(3) Physicians must disclose fully the nature of their financial arrangement with a manufacturer or supplier to sell health-related products. Disclosure includes informing patients of financial interests as well as about the availability of the product or other equivalent products elsewhere. Disclosure can be accomplished through face-to-face communication or by posting an easily understandable written notification in a prominent location that is accessible by all patients in the office. In addition, physicians should, upon request, provide patients with understandable literature that relies on scientific standards in addressing the risks, benefits, and limits of knowledge regarding the health-related product.
(4) Physicians should not participate in exclusive distributorships of health-related products which are available only through physicians' offices. Physicians should encourage manufacturers to make products of established benefit more fairly and more widely accessible to patients than exclusive distribution mechanisms allow.1
Jacob Schor, ND, FABNO
drjacobschor1@msn.com
Notes
1. AMA Code of Medical Ethics [web page]. American Medica Association. http://www.ama-assn.org/ama/pub/physician-resources/medical-ethics/code-medical-ethics/opinion8063.page.
2. Conflict of interest and medical practice. Chapter 6 in: Institute of Medicine (US) Committee on Conflict of Interest in Medical Research, Education, and Practice; Lo B, Field MJ, eds. Washington, DC: National Academies Press; 2009. Available at http://www.ncbi.nlm.nih.gov/books/NBK22944.
3. O'Connor A. What's in those supplements? New York Times. Feb. 3, 2015. Available at http://well.blogs.nytimes.com/2015/02/03/sidebar-whats-in-those-supplements.
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