Trust

In our last meeting, my partner brought to the table a dietary supplement that he thinks has a fair amount of scientific merit. He has started recommending these to some of his patients and has even started taking them himself. Since he is not one to jump on bandwagons, his recommendation bears a good amount of weight in my eyes. I will probably look into it myself.

This supplement, however, is not sold in stores but instead through a local distributor. Additionally, our recommendation of the patient to get the supplement could result in a "commission" payment from the distributor.

But there is no way we would let that happen.

A few years back, some colleagues in town started selling another dietary supplement. They were convinced that this combination of vitamins and fiber would be of benefit to their patients; it could lower cholesterol, help with digestion, and even help with weight loss. These physicians were very excited about the fact that this could actually help patients, and they could make extra money on it as well.

Initially, their patients (many of whom we shared with these doctors) were receptive, and even excited. Anything that would lower cholesterol and potentially help with weight loss would be fine with them. Eventually, however, the real intent of their recommendation began to be called to question. Were the recommendations based on what was best for the patients, or was it because the physician could make extra money? I had patients personally complain to me about the fact that they were "exposed to a sales pitch."

The problem was, these doctors were using their professional credentials to improve their ability to sell a product. When patients learned that the doctors were profiting from the sales (substantially, I must add), the trust the patients had in what the physician said was called into question. Even the doctors seemed confused by whether the patients needed these supplements, or if it was their own desire to make a profit. After losing some patients over this issue, most of these doctors have stopped allowing this practice.

Trust is one of the most important things a patient can give me. They come to me because they have questions they feel I am qualified to answer. From a financial transaction standpoint, the patient is paying me to give them confidence: confidence that everything is OK, confidence that if there is a problem then we will have a plan to fix it, and confidence that any treatment I choose will be the right choice. I build that confidence by explaining things to them and by making sure I listen to their concerns. Once trust is undermined, it is hard to regain that confidence from the patient.

We have been extremely careful to avoid doing anything that would undermine the trust of our patients. Anything that has the appearance of conflict of interest has been off-limits in our practice. This gets tricky when it comes to ordering tests that we do in our office. We had access to x-ray equipment a few years back and found that we were not ordering enough to justify the equipment. We generally only ordered x-rays if we really felt they were necessary, but when we were suddenly financially motivated to order more x-rays, it made us feel very uncomfortable. If we had done x-rays in our office from the start, we probably would not have noticed it; but the fact that we had practiced for many years in a conservative fashion showed us the conflict. We realized that we were feeling pressure to order them when good clinical judgment would do just as well, and so we stopped this arrangement within a few months of starting it.

So how did we handle the suggestion of my partner? Fortunately, I my two other partners are of the same mindset as me, so we found a solution that would work well. We would allow physicians to suggest this supplement and even have the "commission" come back to the practice. But any money from the sales of this supplement would go into a charity fund that would either help our patients who have no insurance, or go to some medical charities that we feel strongly about. My initial partner (who founded our practice) is presently working in Kenya in a pediatric ICU in a mission hospital, and another physician from our practice is leaving us this summer to work in the inner city among the poor. Hopefully this extra money will allow us to support some very worthy causes. Additionally, we will make sure that patients are aware of the fact that we are not making money off of these supplements.

The total amount of money we could make off of this stuff is not enough for us to risk the trust that we have from our patients. In truth, even if it was highly profitable, I have no desire to sit in the position of having to decide between what is best for my wallet or what is best for my patient. Maybe I am "pie in the sky," but I would rather have less money and keep my most precious commodity intact: the trust of my patients.