When doctors go retail: Is it OK to sell products?
It's not just about income, some say, but about helping patients navigate through the 'gimmicky stuff'
From the January 1999 ACP-ASIM Observer, copyright © 1999 by the American College of Physicians-American Society of Internal Medicine.
By Daphne R. Howland
As organized medicine examines the controversial issue of whether physicians should sell products to their patients, a growing number of physicians say they see nothing wrong with the practice.
Physicians who sell health care products such as vitamins and nutritional supplements vigorously defend the practice, saying that it helps patients navigate an emerging area of health care while posing no more conflicts of interest than many other aspects of medicine. Critics, however, are uncomfortable with even the potential conflict of interest that exists when physicians attempt to boost their income by pitching products to their patients.
"Doctors should not be in the retail business," said David Fleming, FACP, vice chairman of the department of internal medicine at the University of Missouri Medical School in Columbia and a member of the College's Ethics and Human Rights Committee, which is currently looking at the issue. "It's a slippery slope, using your professional powers of prescription to drive your practice economically."
Some in medicine disagree with that assessment. When the AMA's ethics council released a preliminary report to its House of Delegates last summer concluding that physicians should not sell health-related products to patients, it encountered fierce opposition. Dermatologists, plastic surgeons and ophthalmologists protested that the recommendations would condemn broad categories of products like skin peels or creams that they said are necessary components of their practices. As a result, the AMA sent the report back to its ethics council for revisions and did not adopt it as official policy.
Much of the dissension at the AMA meeting came from physicians who sell products closely linked to their specialty, but many primary care physicians who sell more generic nutritional supplements and vitamins feel the same way. While most of the physicians interviewed for this story readily admitted that they enjoy the extra income they get from selling products to patients, they also said they did it to help patients select the most appropriate products for their needs.
David Cislowski, MD, an internist and cardiologist in Visalia, Calif., sells nutritional supplements, some of which feature St. John's wort and other ingredients, to his patients. He derives about 3% of his income from the sale of supplements. But more importantly, he said, the products help him work with his patients to prevent disease. "I got into this because I wanted to do more with prevention," Dr. Cislowski said.
Dr. Cislowski explained that he feels good about selling nutritional supplements to his patients because he trusts the ingredients and potency of the products, which are distributed only to physicians. He said that he shares the manufacturer's philosophy that patients should take supplements only under the supervision of their doctors.
Practitioners like Dr. Cislowski point out that physicians are the best arbiters of efficacy and quality in a world where patients are using vitamins, herbs and therapies that are unregulated and that vary widely in quality, with or without the help of their physicians. Far from pushing these products on their patients, they say they are helping steer patients to items that have some scientifically proven benefits—and away from products that are unsafe.
"People are paying for vitamins and minerals out of their own pockets," said Justo Gonzalez, MD, a Dallas anesthesiologist and pain specialist. "There are many people out there who are getting less than the real thing or are taking something they shouldn't. As a physician, monitoring what people take is critical."
And while selling products directly to patients may require physicians to carefully balance their financial well-being with their patients' interests, supporters point out that medicine is full of such choices. "Everything I do in medicine I can potentially make income from," Dr. Cislowski said, pointing out that he earns income from every office visit or catheterization he perfoms. "When I do a catheterization, when a patient comes in for a visit, I make an income. I know doctors who do an EKG every visit. Orthopedists sell crutches. Ophthalmologists sell glasses. Anything can be abused."
While most physicians would probably agree that dermatologists should be allowed to sell special skin creams to their patients, many are concerned that the products patients are clamoring for—and physicians are delivering—are not clinically effective. Worse than just profiting from their powerful relationships with patients, critics say, some physicians are peddling products that do little, if any, good.
Dr. Fleming from the College's ethics committee acknowledges that conflicts of interest are inherent in the practice of medicine, but he believes that physicians must adhere to scientific principles to maintain society's respect in the long run. In his view, many of the nutritional supplements being sold to patients do not meet the highest standards.
"Physicians and all health care professionals who are paid for what they do and for what they recommend are always in a conflict of interest," Dr. Fleming said. "'Is that EKG absolutely necessary for that patient?' I continually challenge myself that way. But when it's things that don't have a lot of scientific basis or proof—when we go into the business of selling such products—we're losing the trust of our patients."
Even supporters acknowledge that potential problems do exist. Dr. Cislowski, for example, said that he generally uses the following premises to keep the trust and confidence of his patients: "Physicians must be in control of the therapeutic benefits of natural medicine, vitamins and supplements; physicians must help integrate conventional and complementary medicine; and physicians must not allow patients to self-diagnose."
The Beer Medical Group, a primary care practice in Los Angeles that specializes in HIV care, has responded to patient demand by adding a number of services like acupuncture, Chinese medicine and stress management programs. The group is currently in the process of choosing a line of vitamins and herbal supplements to market from the office.
"There has been such a push from the public that we've had to educate ourselves about some of these alternatives," said Victor Beer, MD, who owns the practice. Dr. Beer says his medical training made him initially reticent about some therapies and supplements, but he now believes that he and his colleagues need to learn about the products—or patients will simply begin to try to heal themselves.
To make sure that the practice endorses only those therapies that are scientifically sound, Beer physicians are reading publications like the Journal of Alternative Medicine to keep up on the scientific evidence—or lack thereof—of the therapies patients request. "There is a lot of flashy, gimmicky stuff," Alex Del Rosario, ACP-ASIM Associate, a Beer internist, said of some of the therapies patients request. "We're not willing to just jump on the bandwagon. But there is documentation, some good scientific papers backing up a few of the more alternative additives."
Some physicians are getting even more involved to ensure that patients are getting only proven products and therapies. Robert Gleser, MD, a Denver internist, has embraced alternative therapies like acupuncture in his practice and even has his own line of vitamins. Dr. Gleser produces and sells only those nutritional supplements that he believes have merit and whose quality he can control.
"Our product line is very limited," Dr. Gleser said. "We're very careful. We wanted to be able to sleep well knowing that we know what we're giving our patients."
Daphne R. Howland is a freelance writer based in Portland, Maine.
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