Two hundred sixty five chiropractors (51.2%) completed and returned the survey. Respondents were mostly men (N = 207; 78.1%) and had been in practice for a median of 12 years (IQR 8-20 years). Most were in multidisciplinary group practices (N = 204; 77.3%) and most (N = 208; 78.5%) were satisfied with their number of weekly patient contact hours. The majority (N = 247; 95.0%) believed that chiropractors should sell health products and 89.4% (N = 236) currently sold health products from their practices. The quantitative survey results are presented elsewhere . This paper reports on the analysis of the volunteered, qualitative comments.
The written comments of 107 respondents were transcribed, yielding approximately 30 pages of double-spaced typed text. The text was entered into the Ethnograph (qualitative analytic) software . The first author (SP) reviewed, coded and summarized the textual data using qualitative description. Qualitative description is a low-inference interpretation that focuses on describing "the facts ". codes and summary was reviewed against the raw data by the two other authors (JG, GM). No discrepancies in interpretation occurred.
The following themes emerged.
Conflict of interest
Several commentators readily acknowledged the potential for a conflict of interest to exist when treating chiropractors were also involved in health product sales. Respondents spoke generally about the potential for conflict of interest to occur when any health care practitioner "over treats" a patient.
Some respondents were very clear in their opinion that product sales crossed an ethical line (2-165 They are unethical and inappropriate when they are central to revenue generating strategies). Several were aware of instances in which chiropractors appeared to push products sales ( e.g., 2-149 "I have some concern with practices which profess to be strongly "anti-allopathic" against the "pill and a bill" practices of medicine yet you always leave the clinic with a bag of supplements to assist this and prevent that;" 2-187 "The concern I have is when it is dispensed/promoted as a profit centre. This has created lots of bad will when patients are encouraged to buy bags of products...")
Others held a more ambivalent position, where the motivations toward practitioner profit or patient well being were sometimes described as "hard to distinguish. Some likened keeping these interests in balance as a fine line or something that one had to be constantly mindful of (2-220), while others admitted feeling uncomfortable about engaging in the practice ( e.g., 2-149 "I try to satisfy my guilt for carrying this type of stuff by having a low margin").
Finally, some respondents experienced no conflict of interest at all and felt that health product sales fit well within their practices. (e.g., "...The feedback I got from patients describing the knowledge base I had was greater than anyone they had met got me to realize the time and money spent on my education was not only valuable but that it was worth charging a full fee. I am exceptionally comfortable with this position.")
A second category of responses centred on practices or behaviours that respondents believed mitigated potential conflict of interest.
To this end, chiropractors described provisions to minimize perceived conflicts of interest. Most often, chiropractors talked about the mark-up they placed on products sold, attempting to minimize conflict of interest by selling products at cost or for a very small mark up. Others acknowledged a profit margin. The descriptions ranged from statements like the practitioner was "not out to make money (2-35)" to a "very modest mark-up" to a "small profit" to "fair market value." The labor costs associated with maintaining a product inventory, and for spending the time discussing such products with patients were also presented as justifications for how costs were structured (2-21 "Keeping stock and dealing with GST is laborious...." 2-581 "It is time consuming to advise patients on why these products are helpful and to advise them on proper consumption levels etc. to advance their recovery. The mark-up on products 20-30% is poor compensation for the time").
Despite supporting sales generally, several respondents expressed their opposition to multi-level marketing.
A second initiative undertaken to alleviate the perception of competing interests was the efforts to ensure products were purchased voluntarily. Chiropractors used terms like '"don't hard sell" and "unpushy" to emphasize that purchases were at the patient's discretion. Some noted they directed patients to other places where such purchases could be made (2-08 "When I make recommendations to patients re: products I always advise them that they don't need to purchase them from our clinic and I provide other potential sources"). A few acknowledged they had observed aggressive marketing among their colleagues ( e.g., 2-74 Some DCs are very pushy about selling products and thus make good money from it).
Another theme that emerged in the comments was how product sales were justified by the respondents. Several arguments were identified including professional role, scope of practice and quality assurance considerations.
Most commonly, respondents believed that product sales were consistent with their duty or obligation to act in patient's best interest. Products that promoted health or healing were viewed as enhancements to patient care and in line with the chiropractor's role ( e.g., 2-219 "I feel I use health care products the same way I use my adjustments - that is for the good of the patient). Within this argument, a range of perspectives was again evident. While some viewed any contribution to health as a justification for product sales ( e.g.,2-339 In regards to supports ( e.g., in-soles, pillows) they are a mandatory prerequisite to patient health and if I do not carry them, I would be doing my patients a disservice) others suggested that product sales should be based on clinical need and response to a presenting condition only.
Some chiropractors further argued that sales were well within their scope of practice and fields of expertise ( e.g., 2-137 Chiropractors...receive extensive training in the appropriate use of those health products and as such have the right and responsibility to prescribe these products to patients if they would be of benefit). A few suggested that the training and resulting expertise that chiropractors had with respect to the use of health products generally, and nutritional products specifically, is far superior to other disciplines, in particular medicine.
Contrasting with these perspectives, some cautioned that chiropractors might not have the necessary expertise to support certain product sales ( e.g., 2-103 I think some chiropractors overstep their boundaries and make nutritional supplements a huge part of their practice without proper educational back-up). Others believed that there were limits to what chiropractors should be offering to enhance patient well-being (2-551 "As chiropractors do not take kindly to other practitioners doing spinal manipulation, I think it reflects poorly on our profession when we get excessively involved by areas better served by naturopaths ( e.g., supplements) and podiatrists (foot assessment and orthotics))
Some practitioners asserted that they could attest to the quality of the products they sold, in contrast to the potentially unknown quality available on the general market. References were made to products being of "very good quality," or "best quality available."
Practitioners also spoke of having researched the products that they sold, with a few citing specific sources such as peer reviewed literature or manufacturers' standards.
Some believed that product sales were a convenience offered to patients and were justified on the basis of patient demand. Further to this, some chiropractors noted they only sold products available to health practitioners or that were otherwise hard to find or unavailable. A few suggested that having products readily available enhanced treatment compliance.
Ethics and regulation
A group of respondents averred that professionalism and ethics in practice were a matter of individual integrity. If a chiropractor was ethical as an individual, there was no reason to doubt his or her integrity in professional practice. Similarly, respondents acknowledged that there are typically a few people in any professional group whose actions are not consistent with the values of the whole. Specifically considering product sales, respondents focused on the practitioner's intent, that is, where engaging in sales clearly for the patient's well being was acceptable whereas engaging in it for profit was not.
Finally, although individual integrity was noted to be critical in the maintenance of professionalism in practice, some spoke of the need for the profession to monitor individual practices and sanction those who clearly violated standards of practice. A need for guidelines, education and awareness for chiropractors relating to product sales was identified.