Doctors Selling Supplements & Other Conflicts of Interest
In the World of Functional, Integrative & Holistic Medicine
I’ll use the term functional medicine ( to also include integrative and holistic) and though I’ll use “doctor,” much of what I’ll discuss applies to other health practitioners. This perspective is based on my experience in this medical community.
A survey published in March 2010 by the Nutrition Business Journal, a trade publication, of 600 medical doctors, naturopathic physicians, chiropractors, nutritionists, and other practitioners revealed that 76% sell supplements in their office. (From Consumer Reports). I would expect this to be much higher now, 13 years later.
As my mother often says, “Don’t get me started.” Somehow, that seems fitting here. I have hesitated to write about this topic sooner. The practices I’ll describe are so ubiquitous, I don’t believe all professionals participating recognize the inherent problems. I’ve also hesitated because I’d rather not be that seemingly self-righteous person, in my own professional community, taking a highlighter to what I see as a conflict of interest that degrades the doctor patient relationship and degrades this field of medicine for all of us…. But... I’m obviously not that hesitant….so here I go.
Doctors and Money
It should be no surprise that those of us who are functional medicine doctors, just like conventional doctors, make money by charging for the services we provide. It may be a surprise, that much of what we do is unseen and does not occur in the actual appointment. This can be research and writing treatment plans, which are complicated relative to conventional medicine. What may be an even bigger surprise, however, is the amount of money that patients can unknowingly be paying their doctor beyond their appointment fees..
You may have heard of the medical industrial complex - “a network of interactions between pharmaceutical corporations, health care personnel, and medical conglomerates to supply health care-related products and services for a profit.” You may have even heard of the wellness industrial complex, which similarly speaks to this collision between wellness and capitalism.
But there is yet to be a name for the industrial complex involving “the network of interactions between supplement companies, speciality labs, health related products and functional, holistic and integrative doctors or practitioners.”
I’m confident the American Medical Association (AMA) has its own conflicts of interest. Still, I find this useful:
AMA Code of Ethics
Opinion 8.063 - Sale of Health-Related Products from Physicians’ Offices
… “Selling” .…dispensing items that are provided from the physician’s office in exchange for money…includes the activity of endorsing a product that the patient may order or purchase elsewhere that results in direct remuneration for the physician….
…In-office sale …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 … should not sell any health-related products whose claims of benefit lack scientific validity. … should rely on peer-reviewed literature and other unbiased scientific sources that review evidence in a sound, systematic, and reliable fashion. [My note: This part is made difficult by the fact that functional medicine is individualized. There are many variables that can not be studied in isolation, the way a simple medication trial would be. More on this important topic in another newsletter.]
(2) Because of the risk of patient exploitation and the potential to demean the profession of medicine, physicians who choose to sell …must take steps to minimize their financial conflicts of interest. The following guidelines apply:
(a)... limit sales to products that serve the immediate and pressing needs of their patients. For example, if traveling to the closest pharmacy would in some way jeopardize the welfare of the patient (e.g., forcing a patient with a broken leg to travel to a local pharmacy for crutches)...
(b) Physicians may distribute other health-related products to their patients free of charge or at cost ….
(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. …
(4) Physicians should not participate in exclusive distributorships of health-related products which are available only through physicians’ offices.
10 Examples of Conflicts of Interest in Functional Medicine
In Office Selling. This used to be unimaginable, but in functional medicine, it became the norm. If it is less the norm now, that is because, …
Online Sales. Doctors can now use online companies that allow them to dispense supplements virtually. From one company…..”Over 70,000 practitioners treating 5M+ patients use (this company) to send virtual treatment plans, dispense healthcare’s best supplements, and improve health literacy. Also from their website a section for doctors/practitioners titled, “Making a profit from patient orders'' and other sections..”Receiving your payouts,…view your current balance,” etc… Many would argue that these companies help with patient compliance, are more convenient for patients, and can better assure quality control of products. While all that may be true, many if not most are collecting money that is not communicated to the patient. Keep in mind, relative to what could be administrative costs for a doctor selling supplements in their office, there is not much in the way of administrative tasks here.
Doctors Only.There are some supplement companies that won’t allow patients to order their products directly. Doctors have to be involved and when they set up their account, they decide how much they will receive when they recommend a supplement (with ranges of percentages listed by the company). When the doctor recommends the supplement, they give the patient a code to use when they order. Part of why I’m confident the percentages of practitioners selling are well above 76%, is that more often when I set up such accounts, my declining compensation and declining to submit required tax forms, seems unfathomable to the company’s representatives. Sometimes, they don’t are unsure how to handle this. All of this can raise such questions, as: “Are they trusted doctors or are they glorified supplement sales reps or both?” It can be confusing.
Celebrity Doctors. Smart charismatic leaders sharing a lot of great information…and selling a lot of supplements and products often with their name on them to a lot of people…as if all of their audience needs the same things. Cha…ching (I only include that because I felt the need for a rhyme and, well, because they’re making a fortune.
Specialty Lab Testing. This is an important type of testing that is less likely to be covered by insurance. We typically order these tests from the lab or through a “middle man.” The lab charges their fee and leaves room for the doctor or practitioner to increase the fee for their margin. Some doctors may argue that they add fees to cover administrative costs or lab interpretations, which is fair if that is the case and if communicated to the patient. The clearer alternative, however, could be that the doctor simply charges directly for their expertise, time, and office costs and doesn’t put their fee into the cost of the lab. Even car rentals will list what the added fees are for.
Wellness Tools. In the world of functional medicine, it’s not just about supplements, it can be about saunas, air purifiers, environmental tests and so on. Your doctor may give you an affiliate link so that you can get a discount, however, by using that link, your doctor is likely rewarded. When you consider the cost of a big price item like a sauna, there’s a pretty big reward. And yes, a sauna may be very beneficial, but it’s unlikely you are told how much you are paying for the sauna and how much you are paying to your doctor ... .the doctor you thought you already paid.
One Size Fits All Treatment Programs. Though less common than what I’ve described above, there are one size fits all functional medical practices (an oxymoron) and treatment programs, where they run everyone through the similar extensive testing, similar treatment protocols, and similar appointment schedules, usually requiring an upfront financial commitment.
Educational Conferences. Not unlike conventional medical conferences that are sponsored by pharmaceutical companies, functional medicine conferences are sponsored by companies that sell much of what I’ve discussed (supplements, specialty lab testing, saunas, environmental testing, and various treatment modalities). Between lectures, we are encouraged to visit the vendors. This makes good sense, until you start to listen to the sales pitches: not just of how the product will benefit the patient, but how much you as the doctor will benefit. At one conference I attended, a sauna company thoughtfully laid out how much a doctor could make quarterly and yearly based on their referrals. And yes, it is true that without the sponsors, these conferences may not exist.
Online Summits. Speaking of conferences, you may have noticed online conferences, often called summits, where there is a line up of great speakers. If you ever sign up for one of these, which I’m not deterring you from, they can be very good, expect to be bombarded with marketing. The amount of information can be overwhelming, leaving some to feel the need to follow all the seemingly important recommendations, many of which require purchases. If we were all better able to sit back and see what information resonates for us and our situation, such a conference can be great. But for many, these summits cause stress, fear and the desire to control health outcomes by compulsively buying materials and products that have just been masterfully marketed.
Limbic system retraining & other programs. And lastly, if you do become “limbic” (as just described in #9) from one of the conferences or from this list, your doctor can share a link with you for one of the online limbic system retraining programs. Though there is more than one program available, doctors can give you their affiliate link, tell you which one to do, and receive compensation. Of course, they could also simply tell you which one or two they recommend and have you purchase it directly.
And because this topic seems to call for a second, though short list of 10…
10 Reasons Doctors Should Rethink Selling Health Related Products
As the AMA says, it “undermines the primary obligation of physicians to serve the interests of their patients before their own.”
However self aware a doctor is, there is still the potential for these financial considerations to impact their judgment…
Even the appearance of a conflict of interest degrades the trust in the doctor patient relationship.
It is dishonest not to tell someone you are profiting or even adding fees for testing and treatments. If a doctor is not comfortable communicating this to their patients on the office wall, on their website, on their patient’s invoices, it’s arguable they’re being dishonest with their patient and themselves.
Loss of physician autonomy as doctors become dependent on these financial relationships. This can be a significant part of a doctor’s income.
Risk of excessive labs that take the focus off what the treatment priorities should be.
Risk of overprescribing supplements and treatments.
Risk of financial stress for patients.
Risk of excess that is so common in this area of medicine. Many people with complex chronic illness are desperate and can be vulnerable to this type of exploitation.
Demeans the fields of integrative, functional and holistic medicine that otherwise holds so much promise. It is hypocritical for the functional medicine community to be judging conventional medicine for being in bed with Big Pharma, when it has its own financial bedfellows.
For Doctors and Practitioners
If you would like to join me and others in not participating in these practices, know that you don’t “have” to have these financial relationships. You can choose not to mark up labs or supplements. You can set your rates fitting with your expertise, the time you spend, and your office expenses. You can avoid hidden fees. Lastly, you can put on your website that you do not have financial relationships with any lab, supplement or other health product companies. It would be great to see you out there.
I welcome (and expect there to be) other perspectives on this.
For Those in the Role of Patient or Client
I also welcome positive experiences you’ve had as a patient (convenience? reliability? cost saving?) or negative experiences. Does your doctor or practitioner share how much they receive from the test, supplement or product? Though you shouldn’t have to, has anyone inquired?
Thank you for your ongoing interest in this newsletter.
Until next time,
Courtney
P.S. For Paid Subscribers, look out for a mid week post, where I’ll respond to questions I’ve received about the specialty lab testing that I use and why.
I own an integrative health practice and resisted selling supplements at first, but my patients wanted it. I have a large Amish population that does not shop online. If I don't provide a safe option from a reputable company, they will either not comply or buy poor quality products. I also have a lot of patients (rural, conservative community) who do not like to shop online and pay in cash.
I do not upcharge for specialty labs. I tried this for awhile but it felt icky. I work very hard to keep costs contained so that it is more affordable, so product sales do offset that. No one is compelled to purchase from me, but some want that option. There is no perfect system, but my goal is to be fair to my patients, my staff, and myself.
I see your point and generally agree with the conflict of interest. Some of my friends and colleagues are "celebrity docs" and make a fortune online. Some even have their own product lines. Coaching companies and "masterminds" have shaped the functional medicine model. It goes something like this... write a book, develop a supplement line, launch a summit, build a platform, pump out content, and if you're lucky, you will make millions. Many of the online docs don't even see patients anymore. They are full-time marketers. The content produced is often written by copywriters (not doctors) and can be misleading or flat-out inaccurate.
This needs to be clarified for consumers struggling with health issues and needing proper guidance.
I have been practicing functional nutrition for seventeen years. I have never sold products or supplements in my office. I run specialty labs, and some offer practitioner discounts, which I extend to my clients. I recommend supplements, peptides, and other products and have always extended my professional discount. More recently, I signed up with Fullscript, and they allow a 35 percent discount to my clients, and I don't profit. It's much easier now that I don't have to place the order with five different companies on behalf of each client. That admin time was extensive and frustrating.
Many people come to me after spending over 30k and more in functional practices where testing and supplements are the primary income stream. Many of these patients are sick, tired, and toxic from the "treatments" that were supposed to correct functional imbalances found in testing by doctors who learned the protocols at education courses designed by supplement manufacturers! I have yet to meet many functional and integrative practitioners who understand functional medicine. That's the bigger problem if you ask me, and since you didn't, I'll stop here. I'm sure you don't want me to get started! 😉