There is an obvious conflict of interest in using our influence in the patient - physician relationship to recommend something that we or our company will profit from at the patient's (or insurance company's) expense. Unfortunately, even with the best of intentions sometimes our clinical judgment and recommendations can be clouded in these types of situations. Bad decisions in this arena have led to the well known abuses (inappropriately doing too much) that have occurred under fee for service reimbursement arrangements. This, along with other factors, has resulted in managed care as we now know it. In other words, neglecting our role of patient advocate and putting our interest over that of patients has resulted in the government and business community imposing restraints and control over patient - physician interactions. Some would argue that this restraint has been good and necessary and many (physicians mostly) would argue that business people shouldn't have anything to say about clinical decisions. There is an increasing public awareness that the pendulum may have swung too far the other way with past tendencies to provide unnecessary medical services for profit now giving way to the withholding of appropriate medical care for the same bottom line considerations. In both fee for service and managed care scenarios abuses have occurred when physicians or businesses have lost sight of what matters most - the patient's best interest. The AMA, who has been recently burned by conflicts of interest in the Sunbeam debacle, is now proposing that to avoid conflicts of interest physicians should not sell health related products for a profit through their offices. On the surface this appears to be the right thing for the AMA to say and for physicians to do. The AMA can polish its tarnished image by encouraging physicians to behave ethically and avoid conflicts of interest. However, if we look beneath the surface, there may be some unanticipated negative consequences of adhering strictly to the current AMA recommendations.

What if a physician sells orthopedic splints with a 30% profit margin at a price lower than that available to the patient who purchases these same splints from a store which has a 100% profit margin? Strict adherence to the current AMA recommendations prevents the physician from saving the patient money and making a necessary health related product more affordable. While it is true that a physician could stock these supplies and dispense them at cost to comply with the AMA recommendations I think most would choose not to incur the cost, time and inconvenience without a fair reimbursement for their efforts. There is nothing unethical about being compensated fairly for the time, effort and investment needed to provide a service or product. On the other hand, if the physician decides to sell these splints at twice the market rate and suggests to all patients that they can't live without these splints and furthermore that splints available elsewhere for a lesser cost are inferior then there is clearly an ethical problem.

What if a physician gives a patient a shot of long-acting penicillin for strep throat at a 100% profit margin knowing that the patient is leaving on vacation tomorrow and that compliance with oral medication is highly unlikely? The AMA guidelines impede the physician from making the necessary treatment more convenient to improve compliance. Once again the physician's office could provide this service and product at cost to be considered ethical by AMA guidelines. I suppose if the physician did this at a loss (gave away the penicillin or charged less than it cost) then he or she would be considered not only ethical but virtuous by the AMA. Unfortunately encouraging virtuous physicians to go bankrupt makes for very bad ethics in the long run because the survivors will be the ethically challenged - a sort of reverse Darwinism.

What if a physician sells nutritional supplements through the office and donates all the profit to a non-profit foundation which funds research on the clinical efficacy (or lack thereof) of nutritional supplements? Strict adherence to AMA recommendations would not allow this because they say products should be sold at cost. Following the AMA guidelines in this situation stops the physician from being an advocate for the patient through the promotion of much needed research. The nutritional supplement industry is currently like the "Wild West" because virtually anything goes. The unsubstantiated claims made for a variety of nutritional supplements are legion and the total lack of standardization and quality control is frightening. With surveys showing a 70% increase in the use of herbal supplements in North America over the last year alone the medical community needs to take proactive steps to ensure safety and credible information in this area. To not do so is to shun our responsibility as patient advocates. While it is true that we could sell nutritional products at cost as a convenience to patients, as a way of encouraging compliance and as a way of controlling quality/standardization, this would do nothing to promote desperately needed research. Some would argue that the funding for research should not concern physicians since there are already mechanisms in place for this. The problem with this reasoning is that funding is always in short supply compared to our ignorance and the probability of receiving funding for research is much greater for patentable substances than for non-patentable nutritional supplements. Funding for research should be proportionate to clinical relevance and in the case of nutritional supplements there is a gross inadequacy of funding. The nutritional industry is not about to ante up funds that it can't recuperate through patents and sales. As advocates for our patients we need to take steps to promote safety and credible information through research. 

While adherence to the AMA recommendations in these examples may place some hurdles in the way of unethical behavior ("sins of commission"), it may also tie the hands of physicians who are trying to fulfill their ethical responsibilities to patients and prevent them from doing something positive ( "sins of omission"). The idea that we can eliminate unethical behavior with more rules is akin to the concept of eliminating crime by writing more laws. If we want to eliminate conflicts of interest in the patient-physician relationship why don't we outlaw capitated reimbursement? While we're at it we can also outlaw fee for service reimbursement. Then we can get to the heart of the matter and outlaw recommending any product, service or procedure that you, yourself, supply and thus profit from. You could only recommend services that another physician would then provide. The good intent of these poorly thought out measures would only translate into less good actions by the ethical physicians and more creativity by the unethical. I can just imagine a hair-splitting, evasive physician responding "It depends how you define the meaning of cost," when asked to explain some creative accounting. 

There are numerous maladies afflicting health care as we now know it. Many of these maladies are a direct result of not keeping the patient's best interest first and foremost in our minds. The patient is the cure. If we and all of the involved parties focus on the patient's best interest many of the problems we now face in health care would disappear. The AMA recommendations regarding the sale of health related products should be modified to allow the positive to occur and not merely exclude the negative for the appearance of ethical propriety. An easy win on image, if inappropriately implemented, may actually help perpetuate problems by preventing physicians from being part of the solution. This would not be in the best interest of patients. 

Clearly we need to be patient advocates. If we choose to sell any health related products in our offices it should be done ethically and with our patients' best interest in mind. To do otherwise is to create problems rather than solutions.