Doctors and Profits
Are the new money-making schemes compromising your care?
By Beth Howard
This article appeared in the September, 1999 issue of New Woman.
Like any group of workers faced with a pay cut, some doctors went searching for ways to catch up when managed-care policies took a bite out of their income. That's understandable, but several new practices that produce profits for physicians can compromise the medical care you receive. Here are three controversial enterprises you might encounter at a doctor's office and questions to help you determine whether they're in your best interest.
WATCH OUT: Your doctor tries to sell you vitamins, supplements, or other products.
Eye doctors and dermatologists have peddled health-related products - contact lenses, eyeglasses, and skincare lines - for years. Now, a rising number of physicians in other specialties are following suit, bolstering their income with the sale of dietary supplements - vitamins, herbs, and weight-loss aids - often at premium prices. According to the Nutrition Business Journal, conventional and alternative medical doctors sell nearly $400 million of dietary supplements to patients each year. Some physicians even sell non-health-related goods in the office, from Amway products to magazine subscriptions.
This practice gives you the convenience of buying a desired product on the spot, but experts see problems. "It exploits the power of the physician over the patient," says Donald E. Saunders Jr., M.D., director of the Center for Bioethics at the University of South Carolina. Even well-meaning practitioners can end up subtly coercing patients into buying their wares. "Patients might purchase something they feel no need for, just to keep on the good side of the doctor," notes Dr. Saunders.
Medical groups have hotly debated the issue, generally discouraging the practice but not banning it outright. The American Medical Association, for example, recently recommended against members' selling health-related goods in the office, but they stopped short of outlawing doctor-commerce, due to member protest.
What to do: "If a physician is pushing products as a part of your treatment regimen, I'd be suspicious," says Michael Donio, director of projects for the People's Medical Society. Request studies that prove the product's health benefits and ask if it can be purchased elsewhere at a better price. If the idea of your doctor selling you any product makes you feel uncomfortable, consider finding a new practitioner.
WATCH OUT: Your doctor wants to recruit you for a clinical trial of a new drug.
Once confined to university medical centers and research institutions, trials of many new drugs now take place in doctor's offices around the country. This growing practice allows pharmaceutical companies to reach a greater number of test subjects than ever before and to speed the development of new medications. In order to access this rich pool of trial subjects, however, drug companies pay doctors from $1,000 to $4,500 for each patient enrolled. Small wonder that the number of physicians contributing to clinical trials has increased threefold in the last decade.
Patients may benefit, too. "Study participants may receive free drugs, free treatment, and improved follow-up care," says Lori Karan, M.D., an assistant professor in the division of clinical pharmacology and experimental therapeutics at the University of California.
But the financial incentives that doctors receive can create a conflict of interest. "In research institutions and universities, a review board looks at every trial and makes sure each patient has given informed consent, and that investigators are only enrolling patients who have an illness that the drug might work for and who are without risk factors that would rule out the medication's use," says Dr. Saunders. "These checks and balances don't exist in a doctor's private office. Where there's money to be made, there's the temptation to sign up patients who aren't ideal candidates." Patients may blindly trust their doctors and join a trial without considering the risks involved.
What to do: "Patients should ask, 'What's in it for me? What are the risks? And what's in it for my doctor?'" says Dale Austin, deputy executive vice president for the Federation of State Medical Boards. "These are legitimate questions."
If you are asked to be in a drug trial, you should find out why the doctor thinks you're a good candidate. As part of the informed consent process, you should be given detailed printed information about the drug being studied that spells out its risks, benefits, and potential side effects. Your doctor should also provide information about who should not be using the drug and should clearly state that you can withdraw from the trail at any time. It's also important to find out whether you'll get necessary care if you have a bad reaction to the drug and whether you'll be offered another treatment if the drug doesn't work.
Even if you are the perfect subject for a drug trail, remember that you have the right to refuse. Says Dr. Karan: "Patients should never be coerced or inappropriately persuaded to participate in clinical trials."
WATCH OUT: Your doctor wants to perform a surgical procedure in the office. More doctors are doing operations in their private offices, partly because technological advances have made it possible, but also to boost flagging incomes. Doctors with hospital privileges can make more money when they do procedures in the office: doctors without privileges can offer lucrative surgeries they never had a chance to perform before. Today about 25 percent of all outpatient surgeries are performed in the doctors' offices, up from 5 percent in 1981. These include many cosmetic procedures, biopsies, and hernia and cataract operations.
In many cases, in-office surgeries are perfectly safe. Patients say the office environment is more pleasant and convenient than a hospital, and the cost of surgery is generally cheaper. But patients should think twice before agreeing to an in-office procedure, experts say. The farther the office is from a hospital, the farther a patient is from emergency equipment and personnel if problems occur. The risks increase when the surgery involves general anesthesia, which paralyzes breathing and requires the use of respirators during surgery. In addition to a respirator and other basics, "a doctor's office should be fully equipped with the monitoring devices, state-of-the-art anesthesia machine, and resuscitation apparatus available in any hospital," says Ellison C. Pierce Jr., M.D., a Harvard anesthesiologist and executive director of the Anesthesia Patient Safety Foundation. "Unfortunately, beyond the basics, these standards are rarely adhered to."
In fact, doctors' offices are largely exempt from the regulations that govern surgery in hospitals and surgery centers, and, with rare exceptions, physicians do office-based surgeries with no oversight. What's more, any doctor can operate in a private office - including those who lack the training or credentials to perform surgery in a hospital.
Practitioners aren't required to report problems that arise during office surgeries, so there are no statistics on safety lapses. Some alarming reports have surfaced, however; five people died in New York City between 1993 and 1998 from complications associated with liposuction done in a doctor's office, according to a report published in the New England Journal of Medicine.
What to do: New Jersey, California, and Florida have laws regulating some aspects of surgeries performed in physicians' offices, and a few other states are considering similar legislation. Until there are protections in place, says Ervin Moss, M.D., executive director of the New Jersey State Society of Anesthesiologists, "ask your doctor, 'If I wanted to do this surgery in the hospital, could you perform it?' If he says yes, that means he's credentialed to perform surgery in a hospital. A negative answer should be a red flag."
For surgery involving general anesthesia, Bruce Brookens, M.C., a member of the board of directors of the American Society of Anesthesiologists, recommends asking the following questions: Will a physician be providing the anesthesia? (And if it's a nurse anesthetist, who will supervise?) Have the doctor and anesthesiologists worked together in the past? Can I speak to the anesthesiologist ahead of time to discuss preparation for surgery? Negative or evasive answers should be cause for concern.
Finally, patients should know what hospital the physician is affiliated with and how complications will be handled. "Doctors should have an emergency follow up system, so that if there are problems, you will be transferred to an intensive care unit," says Dr. Pierce. "There should be arrangements with a hospital and ambulance company in effect."
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