Ethical Standards In the Doctor’s Office
Dear Dr. Roach: I go to a group of excellent dermatologists, but one aspect of their practice bothers me. Often, the doctor will recommend a “product,” which the practice sells to the patient. These “products” are not cheap. I spent almost $60 at my last visit for two 4-fluid-ounce tubes of hand cream and sunblock/moisturizer. When the doctor literally hands you the tubes and says you need them, it’s hard to say “no.” However, I wonder if I could not buy the equivalent products at the drugstore for far less. I am questioning the need for these products and the ethics of selling them out of a medical practice. — A.R.
Answer: I think you are right to be concerned. The way your doctor is suggesting that you buy the product they recommend is perilously close to coercion. Although I occasionally disagree with the American Medical Association, I completely agree with its recommendations on this subject, which I’ll summarize:
∎ Sell only products proven effective
∎ Limit sales to products that serve immediate, pressing needs (such as crutches)
∎ Sell the item at cost or give it away for free
∎ Disclose any financial arrangements
∎ Don’t sell any products available only through physician’s offices.
It sounds to me like your dermatologists haven’t met all of these ethical standards. I think it would be reasonable to tell your doctor that you aren’t comfortable spending so much money and ask if he or she could recommend a less-expensive option.
Dear Dr. Roach: I am 66 and have multiple sclerosis. Should I get the shingles vaccine? On the one hand, I know it is recommended for everyone. However, I do have a compromised immune system, and it could be risky to inject a virus. Neither my family doctor nor my neurologist has an opinion — they say it is a toss-up. — D.E.P.
Answer: There are two issues here: Could the shingles vaccine, which is a live virus, cause shingles? And secondly, can it cause your multiple sclerosis to flare? Both of these are somewhat controversial.
The first question is less so. There is recent evidence that between the MS (or other autoimmune diseases) and its treatment, the immune system is still good enough to prevent any viral disease. The second question is more problematic, with MS experts divided in their opinions. Normally I would ask you to seek your doctors’ opinions, but since they haven’t been much help, I will just say that the risk of causing a flare of MS is theoretical and small, but the downside of shingles is so great that I would, in general, recommend the vaccine to someone in your position.
People on high-dose steroids or other medications that suppress the immune system should not get the vaccine. Neither should people with leukemia, lymphoma or advanced HIV.
Dear Dr. Roach: I have knee pain after a meniscus tear and was told I have bone on bone. I paid $1,000 cash for a stem-cell injection, twice, which was not covered by insurance. Is this legal? — D.H.
Answer: Yes, it’s legal, as long as the doctor was licensed. That doesn’t mean it works or is a good idea. The most recent data on platelet-rich plasma and stem-cell injection has not been as promising as hoped. Standard treatments include Tylenol or NSAIDs and exercise. For bone-on-bone disease, hyaluronan (Synvisc) may be of some benefit, but knee replacement is by far the most effective treatment.
Dr. Roach regrets that he is unable to answer individual letters, but will incorporate them in the column whenever possible. Readers may email questions to ToYourGoodHealth@med.cornell.edu or write to P.O. Box 536475, Orlando, FL 32853-6475.