Office-based sales hinge on the patient's best interests

A column that answers questions on ethical issues in medical practice

The Ethics Group provides discussions on questions of ethics and professionalism in medical practice. Readers are encouraged to submit questions and comments to [email protected], or to Ethics Group, AMA, 515 N. State St., Chicago, IL 60654. Opinions in Ethics Forum reflect the views of the authors and do not constitute official policy of the AMA. Posted Oct. 2, 2006.

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During the past 15 years the nonprescription skin care business has expanded rapidly, as can be seen by walking into any pharmacy or looking at the cosmetic counter of any department store. The industry has been a topic of debate among physicians.


Sales of skin care products have reached billions of dollars per year, and it seems to me that dermatologists and plastic surgeons -- those physicians who spend their time dealing with skin care concerns and issues -- are in the best position to recommend the most appropriate skin care product or regimen to their patients.

I refer to this as a "one-stop shopping" platform for dermatologists and plastic surgeons. We understand skin better than any other group and, if dispensing of nonprescription skin care products is done ethically, I find no reason why the practice -- which has become standard practice in the majority of dermatologic and plastic surgery offices across the United States -- should not continue to grow and to thrive. Nevertheless, there are strong advocates of and vocal opponents to the concept of dispensing products from clinical offices.

A look at the guidelines of the professional societies reveals a range of opinions about office-based sales. The American Medical Association's Code of Ethics discourages sales of nonhealth-related products but allows physicians to sell health-related products when there is scientific evidence of their effectiveness; the patient is not coerced; physicians disclose their financial interests in product sales to patients and tell them whether the product is available elsewhere; and physicians are not taking part in exclusive distributorships.

The Code of Ethics for the American Society of Plastic Surgeons and the American Academy of Dermatology's opinion both allow physicians to sell products so long as the best interest of the patient remains the physician's priority.

Articles and commentaries for and against the practice of dispensing cosmeceutical products have appeared in dermatologic literature.

Some thought we were putting our integrity at stake, while others felt making skin care products available to patients was an extension of everyday dermatologic business.

A 1999 article in the Archives of Dermatology criticizing the selling of products as being against the tenets of the profession was met with emotionally charged responses generally defending the sales.

Medicine as a business

The practice of medicine is a business, no matter which specialty one is in. I believe strongly that every one of us entered the field of medicine with the primary mission of taking care of patients to the best of our abilities. But this does not alter the fact that the majority of us are involved in the business operations of a medical practice; the degree of this involvement varies from physician to physician, from group to group and from specialty to specialty.

The practice of dermatology puts the patients' concerns right in front of our eyes, and our goal is to help those patients maintain healthy skin. This is in part the reason for the influx of cosmetic products and procedures into our practice. In many cases, dermatologists have played crucial roles in developing and refining these techniques, so now a broad range of skin care products essential to healthy skin maintenance is available and sought after.

In my practice, I may recommend a patient go to our Medi-Spa and learn about the skin care products we have, but I never insist patients go there, nor will their decision affect their future treatments or care. All personnel in the Medi-Spa environment are licensed medical aestheticians or massage therapists who have received thorough training about the skin care products we sell. We offer numerous products in a variety of price ranges.

Moreover, we offer samples when patients are financially unable -- or unsure as to whether they actually want -- to make the purchase. I consider these procedures and my staff's training essential elements in ethical dispensing of products from the clinical setting.

Putting patients first

A point made in the AMA's opinion is that physicians should not engage in exclusive distributorship. In the many years I have been selling skin care products, I have come across few instances in which a physician has been given exclusive rights to a skin care product or line of products -- that usually doesn't make good business sense for the skin care company. So consumers have a choice of vendors in most locations.

On the other hand, so-called "private labeling" of skin care products is a booming business. It allows a physician to appear to have an "exclusive" product, although the same product exists in many other places with "exclusive" labeling for other physicians. This becomes somewhat tricky, and physicians should inform patients that they are using a so-called private-label supplier. As I have stated, there are few truly exclusive arrangements, and few physicians are in a financial position to create their own unique skin care line.

The ethical dispensing of nonprescription skin care products is a useful tool for promoting maintenance of healthy skin to our patients who are in need of this service. We are specially trained physicians and skin care professionals who know more about the skin than the majority of people who currently recommend skin care products to consumers.

The dispensing should be done in a nonthreatening manner, keeping the best interests of the patient as the No. 1 goal.

Michael H. Gold, MD, medical director, Gold Skin Care Center, Tennessee Clinical Research Center, Laser & Rejuvenation Center, and Advanced Aesthetics Medi-Spa; clinical adjunct assistant professor, Vanderbilt University Medical School.

The Ethics Group provides discussions on questions of ethics and professionalism in medical practice. Readers are encouraged to submit questions and comments to [email protected], or to Ethics Group, AMA, 515 N. State St., Chicago, IL 60654. Opinions in Ethics Forum reflect the views of the authors and do not constitute official policy of the AMA.

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