Ethical Considerations for Chiropractic “Backending”
Leslie M. Wise, D.C.
A definition is always in order when a new term is being put forth, especially if that term may have diverse meanings in multiple contexts. “Backending” is used in the computer industry, to differentiate hidden, unseen parts of an application from the visible, user interface. It is used in demographics and data collection to distinguish intentionally collected information from information which must be secondarily gleaned from the original entries. In sales, it means selling someone something they didn’t come in to buy. It is in this latter context that we will consider the extremely common practice of chiropractic backending, which occurs when a patient comes in for chiropractic services and leaves with two sets of orthotics, six bottles of vitamins, a knee brace, a carpal tunnel strap, a $200 pillow and a lifetime subscription to Chiropractic Health magazine.
I can already hear my detractors: “But all those things are good for the patient. We’re doing them a great service!” That was the excuse of the Myrtle Beach chiropractor busted by the board of examiners in the early 80s for running nude hot-tub encounter groups in his office. His logic was that the sessions reduced stress, and lower stress means better health. Whether or not things are good for people is not the issue here. We will come to the true issue shortly.
One of the differences between a hardware store owner and a doctor is that the store owner is a merchant and the doctor is a professional. The merchant subscribes to the mercantile ethic of “buyer beware,” and the doctor is beholden to the professional ethic of “let the buyer trust.” The mercantile ethic may consider fair and honest service, but is primarily concerned with a profit motive and the merchant’s best interests, whereas the professional ethic must consider altruistic service and the best interest of the patient always must be supreme. When a doctor starts selling merchandise in a professional office, an immediate potential conflict of interest is created, causing the schizophrenic doctor to choose between serving the patient’s best interests and selling those 10 cases of special feel-good vitamins before they expire next week. The patient is placed in the uncomfortable position of deciding whether to be compliant with the doctor’s recommendations, or buy his vitamins at Wal-mart. He risks the doctor’s displeasure while making an economic decision, and is obviously reluctant to alienate this person because of his authority position.
Professions have created codes of ethics that specifically address the subject of conflicts of interests. They generally advise that professionals, because of their adherence to higher ethical standards than the general public, should scrupulously avoid conflicts, and even avoid the appearance of conflicts by always taking the high road in matters of money and profit.
Just how common is the practice of backending among chiropractors? The 2007 Chiropractic Economics Salary Survey indicates that 88 percent of DCs answering their poll receive income from ancillary products, with pillows, nutritionals, and orthotics being the top sellers. We can see that mercantilism is alive and well in our profession, and these products have become associated with chiropractic in the minds of the public. Many chiropractors depend on product sales for a considerable additional revenue stream without which their total income would suffer. Given the fact that backending is a widespread practice, and that DCs do not see it as compromising their professional integrity, it is unlikely that a prohibitive pronouncement from a conservative chiropractic magazine is going to change matters, so what if I offer a few considerations for thought on the practice? (I feel like Moses offering Ten Suggestions for Consideration.)
- Items or products should be offered with an extremely soft- sell approach, respecting the autonomy of the patient
- Items or products should be related to the chiropractic mission and aimed at helping us accomplish our mission (no vinyl siding)
- Items or products should be of highest quality and offered with a modest profit margin. If alternative sources are available, disclose that fact.
- If you invented the product or own the company providing it, full disclosure should be offered concerning your interests
- If you enter the world of mercantilism, do it with the Sears Roebuck, no questions asked, 100% money back guarantee.
I would hope that chiropractors focus on providing chiropractic services in a manner that emphasizes the professional ethic, not the mercantile approach. Patients need to feel with certainty that we are absolutely concerned with their best interests in every situation, and that is a tricky matter when they get the feeling that we’re just pushing product and generating profit. Obviously we are not the only profession to deal with this sticky situation. The American Medical Association (2005) has issued policy statements on physicians who sell stuff. Their attitude is “Welllllll, if you must…….” The AMA allows sale of health related products, but is not crazy about the idea. Don’t even think about selling non-health related items. But the fact is only 30 percent of physicians belong to the AMA so their pronouncements have little weight in the marketplace. The ACA and ICA are relatively quiet about this practice, with no specific rules covering the topic.
We live in a new world, and must adapt to new ways of doing things, but I hope that we can maintain our professional integrity while living in this new world.
References
American Medical Association. (2005). E-addendum III: council on ethical and judicial affairs clarification of sale of products from
physicians’ offices (E-8.062 and E-8.063).
Chiropractic Economics. (2007). 10th annual salary and expense survey. 53(8).