an ethical dilemma?

[Guest guest]

It is interesting that all this recent discussion about how to make

money in practice by convincing people to buy stuff you think they

need happened to coincide with my receiving a current issue of the

American Journal of Law and Medicine (AJLM), which featured articles

on dietary supplements and one defining quackery in America. Thank

you Dave, I doubt this was your intended effect. I was in private

practice for about nine years, mostly in Oregon in clinics I owned

and operated. I was primarily an herbalist and prided myself on not

having patients visit me unless it was necessary. So I passed on a

lot of weekly consult fees and often depended on making a substantial

product sale if a patient called for a refill or came for a monthly

visit. I needed to gross about $100 in herb sales monthly to each

patient to barely justify my time. But I was pleased that I did not

have to see 4-6 patients per hour.

 

Now we have heard some praise for naturos and chiros in marketing

themselves and their products. I have actually heard ten times as

much scorn for these same activities in mainstream circles, but lets

set that aside for the moment. The article on quackery in AJLM is

not at condemnatory of the practices of chiro, TCM or naturo. It

notes that many medical procedures are unproven and that the failings

of modern medicine have created the same void that spurred the first

round of revolt against the medical establishment in the age of

bloodletting before the germ theory of disease had its few great

successes (which must not be underestimated - public health measures

conceived as a result certainly saved far more lives than we ever

will). It does however draw attention to the very dubious nature of

those who write the prescriptions also selling the goods. The reason

is clear. Their is strong motivation to sell lots of stuff, which

may or may not be necessary. We can claim that we would never do

that because we are ethical, but I can tell you that a bug on the

wall watching this debate would be fully justified in being suspicious.

 

I had hoped that some system would develop over the years to supplant

office based pharmacies and health fair recruiting but that never

came to pass and from what I read and what I know, it never will.

You can't make a living unless you sell lots of stuff or see lots of

patients, preferably both. Books and seminars on how to do these

things are quite popular. Now, its reassuring to know that it is not

considered quackery to practice a form of medicine one earnestly

believes in. But it is also sobering to realize that MDs are

forbidden to operate pharmacies or sell drug products from their

offices. NDs likewise are officially advised against this practice

by their own code of ethics published by the AANP (but when there is

no law and money is to be made, there goes the ethics). So what a

bind. No sense being in this field if you can't sell stuff, yet the

temptation to sell unnecessary stuff to either pay the bills or get

rich is probably too much to bear for some or even many.

 

So if every conversation is a sales pitch, then the premise is that

every person you meet needs your services. In other words, they

would all be immensely better off with weekly acupuncture and this

pill or that potion daily. Now the dividing line between a quack,

charlatan and huckster and just someone who practices an unorthodox

form of medicine is whether they know they are committing fraud. In

other words, do you know for sure that what you are selling will

really make much of a difference in the long run. The answer would

have to be no. Consider a substance that is very well researched.

Coenzyme Q. We all should probably take it if we want a few more

good years of life and less likelihood of disease. But even if you

take really good Coq and lots of other good stuff, there is certainly

no evidence that it will lengthen your life. It may prevent some

chronic illnesses, but the only thing we know for sure is that it

treats angina pretty well. I used to like to sell it to my patients

back in the day. You could make a strong case and it was quite

expensive. A 150 mg daily dose could cost the patient 75-100 per

month just for the one pill a day. However back then I never would

have dropped the cash to take it myself. I was pretty convinced by

the research, but I still considered it a luxury for some of my

richer patients. Now its cheap and I take it every day, but only a

superior conman could have gotten me working extra hours to afford my

Coq fix.

 

But that means that the whole enterprise is somewhat speculative.

Informed consent of the patient is letting them know that much of

this is all speculation. Metagenics makes good products and has good

literature with good peer reviewed research. But most of that

research is only suggestive of possible benefits based upon observed

mechanisms. For example, the immune stimulating polysaccharides in

certain mushrooms are not active in small doses and not active at all

in alcohol extracts, yet this is a talking point that one might hear

from a sales rep. Sales reps cannot define the meaning of the

research and none of you should let them. It is your ethical

obligation to sort through the data before making claims to just

make a sale. I always let patients know that most TCM is not proven

by clinical research but rather by history. I can make a strong case

using both history and science, but I would never lie and say

otherwise to make a sale. And I certainly would not claim to

successfully treat illnesses that I have observed to have very poor

responses to TCM (chronic tinnitus and significant hypertension, for

example).

 

In fact, as I have mentioned many times recently, I think the only

response from TCM that is pretty reliable is noniatrogenic relief of

symptoms. That really is a powerful selling point, but it does

depend on something different than good sales pitch. You need to

deliver the goods. If you can convince someone to take a pill for

years (and if you are lucky, they buy it from you instead of the

internet that whole time - good luck), that is impressive. You don't

really need to show any results any time soon. Just take my pill

forever and you get some reward someday for your expense. But if

your focus is relieving symptoms, you have about a week or two to put

up or shut up. Now that's not a good way to insure continual cash

flow, but it is ethical. Or is it? If you truly believe by the

preponderance of the evidence that the pill will do the trick if you

just keep taking it, then it would be unethical to not recommend it.

So you gotta ask yourself, do you believe or are you just making a

sale. If its the latter, that type of behavior will certainly be the

demise of us just as it was the demise of the patent med industry of

the past. And of course, it all hinges on what western does. The

alt med movement in its current form depends to a large degree on WM

sucking in every way. If WM stops sucking, there is going to be a

renewed attack on so-called unproven remedies and history suggests it

will succeed. So we need to check our ethics now and also consider

how we will position ourselves if WM succeeds. Remember no scientist

thought WM would ever amount to anything in the days of Benjamin

Rush. They knew it was an idiotic enterprise. It might be odd to

realize that medicine was not considered to be associated with

science until the later 19th century.

 

 

 

Chinese Herbs