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have been concerns expressed and even legislation written about
physicians' selling supplements in the office for profit. The American
Medical Association has questioned the ethics of this practice,
although many integrative medical societies support it. While I
agree that there is a potential conflict of interest that we must
be careful about, I contend that forbidding such sales would result
in inferior care and higher costs to the patient for the following
reasons:
1. Quality. Since supplements are not regulated like drugs, there
is a wide variety in the potency, purity, and formulations. If we
know the source of the products we prescribe, we can link this to
clinical outcomes. If we do not know the source, a bad outcome could
result either from an inferior product or from the fact that the
supplement is ineffective for the indication prescribed. How would
we know?
2. Availability. A good number of the supplements I prescribe are
not readily available from local pharmacies or health food stores,
especially since I live in a rural area.
3. Monitoring. It is very difficult to keep track of all the supplements
and medications that a patient is taking. It is easier when most
are either by written prescription or purchased from the office.
4. Choice. Patients have the option to buy their supplements elsewhere.
If this happens and the outcome is not as expected, the physician
will have a more complex situation to evaluate, but the patient
still has the freedom to choose. Many patients prefer to buy their
supplements from their physicians because of convenience and assurance
of the quality they are getting.
5. Treatment Options. Published scientific literature is not as
reliable or as plentiful for supplements as it is for drugs. Thus
clinical experience becomes more important. For me, the best way
to search for new clinical options, especially when the patient
is searching for alternatives to drugs, is to speak with suppliers
face to face. If I am going to invest in their products, I must
have an expectation that they will work well. If they do not, I
will certainly stop buying them. My practice reputation depends
on the effectiveness of my products. Further, I do not want to wait
for years for large clinical trials to be completed, if they are
ever funded, to assess supplements. I want safe products with a
reasonable chance for success that I can try out in my office now.
If they work well, I will continue to stock them.
6. Cost. All of the above takes my and my staff's time. These costs
are not directly reimbursable under the current coding system. If
we opt out of the third-party system, we could charge more for our
office visits to cover this extra service. This would result in
higher out-of-pocket costs for our patients (I have chosen to opt
out but also to charge usual and customary fees). If instead there
is a profit from the sale of supplements (as we have in our office),
there is no need to charge for the extra services that we are providing.
Whether patients buy supplements from us or from another source,
they will usually have to pay a markup that is the difference between
wholesale and retail. If they get their supplements elsewhere, they
would probably have to pay the markup from a health food store in
addition to higher office visit charges by a physician who does
not provide supplements. Thus the cost of medical care would be
higher.
7. Ethics. Physicians should constantly try to minimize costs while
providing excellent care. There is a potential conflict of interest
not only with drugs and supplements, but also with tests ordered,
setting fees, providing quality staff, coordinating care with other
agencies, continuing education, and frequency of follow-up visits.
A potential conflict of interest exists for most of what we do as
physicians, at least in a fee-for-service system. An ethical physician
will always keep the best interest of his patients foremost in his/her
mind. We must continue to examine outside influences and financial
considerations and make the appropriate choices for our individual
practices.
L. Terry Chappell, MD
Past president, International
College of Integrative Medicine
P.O. Box 248
Bluffton, Ohio 45817
chappell@wcoil.com
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