Forum on CAM/IM Practitioners-Natural Products Industry Relationship: 6 Voices

Summary:  With six new voices, the Integrator conversation on the optimal relationship is enriched. Interestingly, 5 of the 6 wrote as educators. Commenting are Morgan Martin, ND, chair for natural childbirth at Bastyr University; Bill Manahan, MD, co-founder of the American Board of Holistic Medicine; James Winterstein, DC, president of the National University of Health Sciences; Sherman Cohn, JD, professor of law at Georgetown University Law Center; Lou Sportelli, DC, president of Integrator sponsor NCMIC; and an anonymous naturopathic physician. This is a rich selection of diverse perspectives.

In the third part of this dialogue on practitioner-industry relationships, I concluded with a serious question which began with wonderment about why few were responding. This set of responses is rich! When my colleague David Matteson - who works with both industry and professional clients - and I cooked up the idea of this forum, this is what we were hoping to stimulate. Practitioners and industry are mutually dependent. They are in bed. And as one discussant says, the earlier in the bedroom dance the better for being clear and direct in trying to forge an optimal relationship.

1.   Ignoring this issue is like a diabetic not checking his/her PSA

Morgan Martin, ND, LM

Morgan Martin, ND, LM, chairs the natural childbirth department at Bastyr University. Martin was last referenced here in her battle to keep her program secure at Bastyr, and to keep midwifery secure in the naturopathic profession. (The NDs are close to ending all their midwifery programs despite the profession's argument that it should be considered primary care.) Martin provides a
 useful image for this natural products-practitioner dialogue, responding first to my qeustion about whether there is shame here..

"It is an honorable issue to explore and the earlier in the bedroom dance the better.

"I would encourage the creation of safe venues for exploration of this and related issues. Seems like professional conferences are the natural place to begin, since that’s where the representatives gather together. It would take an outside entity to create the forum, as neither party would be inclined to do so themselves. Keep writing on it. We all need it.

"What would be a good analogy? Like… ignoring this issue is like not checking your PSA or hemoglobin A1c when there is a family history of disorders in this area. If I don’t know I’m becoming diabetic, I can continue to enjoy those daily desserts and not feel bad about it."

Morgan Martin, ND, LM
Bastyr University

Comment: And one thinks of the frog in slowly boiling water ... I confess to have been a happy beneficiary of the more expensive foods one sees laid out during breaks at conferences with pharmaceutical sponsorship.

2.    Important, but, I am embarrassed to say, boring to me

Bill Manahan, MD

Integrator advisor Bill Manahan, MD, is an individual who has been a mentor to me in a number of ways. It doesn't appear he's going to be providing much guidance on this topic.

"In this (latest) Integrator Blog, you asked why there is not more attention given to the relationship between CAM practitioners and the natural products companies.  Excellent question.  Probably every reason you listed as a possibility combines to make sure the topic stays on a back burner.

"Personally, I am embarrassed to say, it is a topic that is boring to me.  Is it an important topic?  Definitely.  Are natural healers influenced by advertising and product endorsements in the same manner as medical doctors have been?  Probably.  Do CAM practitioners enjoy making a profit from nutraceuticals they prescribe and then sell to the patients?  The practitioners that I have observed doing that certainly do enjoy making a profit on the products they sell to their patients.  Is it ethical to do that?  I suspect that is a topic for an entire other discussion.

"I certainly do not know the answer, John, but I do appreciate you at least bringing it into our consciousness.  Thank you."

Bill Manahan, MD
Co-Founder, American Board of Holistic Medicine
Minneapolis, Minnesota

Jim Winterstein, DC

Jim Winterstein, DC, president of National University of Health Sciences, is a leader among chiropractors in promoting and educating students toward a broad scope practice. This includes the use of vitamins, nutrients and botanicals, much like naturopathic doctors and integrative medical doctors. He has expanded NUHS's service offering to include programs in acupuncture and Oriental medicine and in naturopathic medicine. Winterstein's vision was the focus on an interview in the Integrator last year.

"I recently had the opportunity to read the column by Michael Levin and I think his proposal on a 'Statement of Purpose' for integrative medicine is excellent and we should all adopt it.  More than a decade ago, the chiropractic college presidents met and developed a so called 'chiropractic paradigm' which I signed at the time although there was much with which I did not agree. One aspect did stand out for me and it was our 'Statement of Purpose,' which said rather simply, 'Our purpose is to optimize human health.' Now if we add Michael’s part we really have it with 'and reduce healthcare costs.' This should be a statement of all practitioners, all professions and all supporting commercial enterprises.

"But, on to the second part which deals with the relationship between professions, or institutions or practitioners and commercial enterprises which provide service and products to those entities. Here at (National University of Health Sciences) we have a basic policy which says 'we will accept and encourage support from all businesses which support our mission and are inclined to be philanthropic toward us, however whatever is given must be given without strings.' We do see other institutions getting money we do not get, but we are ethically bound not to follow that pathway. Our clinicians, for example, in our clinics must be free to chose those products and services that will best serve their patient – not the company from whom a particular product comes. We think this is the only to keep the process clean.

"All not-for-profits must solicit donations from many sources and often one reads of attached strings. We strive not to let that happen here, and so far we have been successful even as we see ourselves passed by on some occasions. We sleep well, however!"

Jim Winterstein, DC, President
National University of Health Sciences
Lombard, Illinois

Sherman Cohn, JD

Sherman Cohn, JD, is a professor of law at Georgetown University. This former Watergate lawyer has held numerous positions in the leadership of acupuncture and Oriental medicine over the past two decades. He was last seen in the Integrator commenting on ???.

"You have not heard from me because I have agreed with all that has been said.  Fortunately or unfortunately, as a current member of a board that needs money, I recently participated in a discussion of how to convince the Natural Product Companies to contribute.  And as a past officer and member of other boards of organizations that held annual conferences, it was clear that but for exhibitors paying a part of the freight, the conferences could not have been held -- at least not without increasing the price of registration significantly and thus, we thought, reducing attendance.   Unless membership is willing to support organizational work at its true cost, without soliciting from providers who make money through the work of the profession, some relationship is a part of necessity. 

"In neither the legal profession nor in the CAM/IM professions with which I am familiar, is membership willing to bear the full freight through a dues structure.  Or, to put it another way, in none of these professions has leadership (including myself) had the courage to raise 'dues' or registration fees to the level necessary for solicitation of support to become unnecessary. Thus, if we are going to make a change in the 'natural order' of things as we have experienced it, we must start with convincing leadership to have the courage to be honest with membership as to what it costs to run a successful organization, including conferences, with subsidization or other support -- including ads in journals -- and to price membership accordingly.  

"While we are looking at this issue, let us not forget nonprofit and governmental sources of money.   Once any cause becomes wedded to receiving money from another source, there is potential of becoming addicted and thus subject to strings.   (Thus, the Golden Rule:  'He who has the Gold, sets the Rules!')  An easy example is the federal government.   A great threat -- perhaps the greatest -- that has come to the 'independence' of state and local government arose when President Richard Nixon proposed, and Congress enacted, 'revenue sharing.'   At first it was free money, but once the states and local government were addicted, strings began appearing.  A great example today is education.  Once it was wholly a state area of governance.  But then the federal government began to throw money at it.  The states eagerly accepted -- only to find that the federal government began to "regulate" by setting requirements to continue to receive the money.    This happened with higher education once the federal government began to insure loans to students.  Today, no university, college, or other school of higher education could survive if their students do not receive federally insured loans -- much less Pell grants.   But, more and more, the federal government, through the accreditation agencies -- which must be approved by the federal government -- puts conditions upon what schools must do to remain accredited.

"Thus, the picture is a big one and quite complicated. To simply say that 'we,' whomever we are, will remain completely independent of all outside influences means that 'we' already are completely financially independent, perhaps through some great, disinterested donor (are there such people?), or through a membership that supports the entire profession and all of its activities through dues.  If there be such an organization, I have yet to find it.

"None of these remarks take away from the very important comments of David Matteson, Adrian Langford, and Michael Levin.  Each gives us cautionary signals.  As we make our pitches for financial support, we should do so conscious of the potential pitfalls -- many of which we recognize that others have fallen into.  That, too, is your point, John, and it is well taken."

Sherman L. Cohn, Professor of Law
Georgetown University Law Center

Lou Sportelli, DC

Lou Sportelli, DC, who has been an observer of healthcare trends for decades, focuses his comments on how the relationship question may shift as Big Pharma buys into the field more.

"Maybe it is early in the morning, maybe I am in one of my very rare cynical moments, but there is or should I say there will be very little difference in any pharma company.  As soon as natural pharma, vitamins, etc. become an economically viable product, the drug companies will simply buy them and incorporate them into their business as a subsidiary or another product line.  Drug companies are simply too large and have too much money to spend, not to own the entire industry.

"Not much different than the oil companies owning all the alternative fuel companies. Same product line extension.

"The drug companies then will have a different interest in education and promotion of their products to all alternative practitioners and direct to consumer advertising making it now 'OK' to take everything from Ester C to Centrum Z.

"If this comes as a shock to anyone there needs to be a conference on awakening from the sound sleep such alternative practitioners have obviously been in for the past 15 years.

"There needs to be a recognition of the value of these products, more research into their mechanisms, and a guard against exclusivity of use - of mechanism which would exclude alternative health care professions which have fought the fight to get them recognized in the first place.

"Eternal vigilance."

Lou Sportelli, DC, President
NCMIC 

Integrator: I am personally intrigued by the relative lack of interest readers have in this question, as I survey my tracking of page views. Is it a dead topic?

Dr. Anonymous, ND: It's a very relevant topic.

Integrator: Is it just too difficult to get out of the box?

Dr. Anonymous, ND: This is an issue that I discuss occasionally with students in the context of being rational in our discourse. One of the major points is that it is hypocritical to lambaste the conventional medical world for being 'in the pockets' of big pharma while the natural products industry and ND education has the same relationship, with similar financial ties, though the absolute dollar values are magnitudes of order less. I give them examples of my own experience working with educators in naturopathic, conventional medicine and other forums - one lecture sponsor asks me if he can have stage time, product reps sponsoring lunches, my need to refuse meetings with salespeople, etc. I try to teach them the value of assessing the credibility of clinical information. Much of this discussion comes in the context of reading relevant research and what the implications of funding and sponsorship entail. I try to teach them to recognize 'fuzzy thinking' by salespeople, pro-CAM arguments, and anti-CAM arguments.

Integrator: Is the nature of the relationship considered a done deal? We've made our beds, now we're sleeping in them?

Dr. Anonymous, ND: As the field grows, and the naturopathic and other complementary healthcare schools mature and gain other funding sources, I believe that the relationship can grow more distant. With more federal funding, at least on the research end, better independent assessments of product quality and efficacy can occur.

Integrator: Do you think that the clinical and educational directions of natural medicine practitioners are not shaped in any way by natural pharma relationships?

Dr. Anonymous, ND: They are, absolutely. Lectures are sometimes given by product salespeople with free lunches. I boycott attending them. The students then are recommending these things next week in clinic...

Integrator: Is this a holier than thou thing? No karma in (natural) pharma?

Dr. Anonymous, ND: I feel that I would be accused of being 'holier than thou' if I discuss these issues in public.

Integrator: Is it not okay to talk about money?

Dr. Anonymous, ND: It's important to talk about money. When I shared my concerns with administration a few years back regarding lecture sponsorship, I was told that, while they understand my concerns, little pharma (natural pharma) contributed substantially to something else at the school which no one else had stepped up to fund. So my solution has been to teach students to see through the marketing half-truths and unsubstantiated claims of the typical product rep, no matter what 'credentials' they have after their name.

Integrator: Is there shame? Are you silent because this is in the shadow?

Dr. Anonymous, ND: This is a shame in our education. I try not be silent but I do understand the hardship of being free of these relationships, both institutional and individual. We don't sell supplements at a clinic where I sometimes work. We asked as local store to set up an account with a distributor so we can send patients to purchase supplements. This was done for ethical reasons. There is a conflict of interest when one is profiting from products that they recommend. I don't have a solution to those whose majority of incomes derive from product sales; but I am very thankful that I don't have to.

Integrator: Or is the subject just plain boring?

Dr. Anonymous, ND:  Not boring to me. On my reading list is Marcia Angell's The Truth About Drug Companies. I am fascinated by Adrienne Fugh-Berman's research as well and recommend it to others with the intention to learn lessons and make analogies with the natural products industry.