Conflict of Interest and Sales Q&A

Some of the following examples have been adapted with thanks to College of Dietitians of Ontario¹

• Accepting gifts or other benefits for referring a client to any other service or program.
• Offering gifts or other benefits to another professional who has referred a client to you for receiving a client referral from another professional.
• Coercing clients to purchased endorsed products or participate in research that directly benefits you.
• If you have a private practice in addition to working in an acute care role, referring clients to your private practice as the sole option for their follow-up care.
• If you have a private practice and another regulated or unregulated profession, referring between the two without provision of options.
• Providing only one option for product or service purchase when you benefit directly from the sale of that product or service.
• Selecting a foodservice supplier on the basis that the supplier offered a gift, or another personal benefit.
• Personal use of food service supplier access and discount (i.e., purchase of a birthday cake for a family member)
• Failing to disclose disclaimers of affiliation or sponsorship with a hosting company (i.e., pharmaceutical company) when providing a presentation.

Please don’t hesitate to reach out to the CDBC at info@collegeofdietitiansbc.org if you would like to discuss your potential conflict of interest circumstance with us.

Refer to “Where’s the Line?” Professional Boundaries in a Therapeutic Relationship included in the CDBC Patient Relations Program, which will provide you with considerations related to the client-professional therapeutic relationship. Per 1(d) of the Conflict of Interest and Sales Policy, “When a dietitian is in a position to profit or gain from a personal incentive related to their practice and services (gift/donation), they should avoid accepting the incentive”.

Yes. RDs can recommend vitamins and minerals for oral use to patients as they relate directly to the practice of dietetics.  Under the Pharmacy Operations and Drug Scheduling Act, Schedule 3 Drugs (selected from the pharmacy shelf) and Unscheduled Drugs (available outside a pharmacy setting), which include vitamin and mineral supplements not intended for enteral or parenteral use, may be recommended to patients as they relate directly to the practice of dietetics.

Exceptions include supplements for which the active ingredient dosage exceeds the dosage guidelines for Unscheduled substances (available outside a pharmacy setting).

Options for supplements must be offered to clients, per Marketing Standard 2(f) and dietetic care cannot be compromised if a client chooses one brand over another or elects not to purchase, per the Conflict of Interest and Sales Policy 3(a).

Yes, dietitians in BC can partner with food brands or companies, however there are some important considerations. Refer to CDBC Marketing Standards and the Policy on Conflict of Interest and Sales for details.

A private practice dietitian can seek out contract opportunities to grow their client base. This may include partnership with dietetic-related brands/companies. This is a very tenuous relationship that must be approached carefully and ethically?.

To provide appropriate dietetic care, a dietitian must assess each client and develop a nutrition care plan. If the sponsored brand/product has a role in the nutrition care plan, the dietitian may endorse it. Complete transparency that the dietitian is benefiting from endorsement of the product (by way of the partnership) is absolutely required. However, the caveat and limitation, per the CDBC bylaws, a dietitian “must provide options for the sale of dietetic products” (Standard of Practice 8.3) and reflected in Marketing Standard 2(f).

This means that exclusive partnership with a product or brand can likely not occur, since a dietitian cannot justify the exclusive endorsement of the sponsored product/brand as the right choice for all clients.

For more information regarding the differences between recommendation and endorsement, please refer to Q2 of the Marketing Q&A. For more information on the rationale behind avoiding exclusive brand sales, please refer to Q9 of the Marketing Q&A.

There are two considerations here: (1) Conflict of Interest, and (2) approval status of supplement.

Conflict of Interest

1. Conflict of Interest from a counselling/selling perspective: Per the Conflict of Interest and Sales Policy 3(b): “Wherever possible, dietitians ensure the separation of sales from provision of nutrition services. Selling dietetic-related products/services should be separated from healthcare functions, such as counselling in the context of a therapeutic relationship.” In this situation, you may choose to work with a colleague who does the counselling while you do the selling, so as to reduce the perception of conflict of interest.
2. Conflict of Interest from a product sale perspective: It is also important to consider Conflict of Interest and Sales Policy 3(d): “Dietitians must offer clients at least one alternative to a specific product or brand. (CDBC Standard of Practice 8: “A Dietitian identifies and manages any real, perceived or potential conflict of interest”, specifically Indicator 3: “Provide options for the sale of dietetic products”. This includes the development and production of one’s own line. Counselling a client and then proceeding to endorse your own product without making recommendations of similar products could be seen as a conflict of interest. This activity puts the dietitian first and disregards the client’s best interest, since no one supplement or product is going to be the right choice for all clients.

Product/supplement approval status in Canada: The other piece of supplement or product development for sale to take into account is any food product or supplement that you are involved in developing must meet Health Canada requirements. See Q3 of the Enteral Nutrition Q&A which discusses how enteral and oral products are approved in Canada, which is especially important to  understand if you plan to make your own products for sale.

If College related bylaws, ethical principles, standards and policies are not followed by a registrant and this is discovered by a member of the public (could be a client or another health professional) or a fellow registrant, this can result in a complaint to the College. It is in fact, an obligation as a registrant of a regulated health profession that is governed under the Health Professions Act, that a complaint MUST be reported if discovered. Please have a look on the Complaint section of our website, which will outline the complaint process, from the perspective of a member of the public. The College is legally required to follow up with all complaints.

No. All RDs are expected and required to conduct themselves in a professional manner. It is inappropriate for you to bill family members who have insurance coverage for nutrition services. This is considered unethical under the CDBC Code of Ethics, Principle 1 – ‘A Registered Dietitian complies with law and policy at all times by… avoiding any situation which could be perceived as improper.’ This situation is also considered unethical under the CDBC Code of Ethics Principle 4 – ‘A Registered Dietitian demonstrates inclusion, honesty and integrity at all times when interacting with clients by… avoiding any situation which could be perceived as non-inclusive or dishonest.’

Under both Principles, billing an insurance company for nutrition services provided to a spouse may be perceived as using professional status for personal gain. Additionally, in the interest of protecting the public, you must know the difference between the boundaries of a personal and a professional relationship to know if the boundary becomes blurred or is crossed.  Family, friends or acquaintances should be referred to another practitioner. In circumstances where all attempts to find another practitioner have been exhausted and no other options are available, you are expected to provide quality care/services without allowing the dual relationship to compromise professional judgment. Please see the CDBC’s resource Where’s the Line? Professional Boundaries in a Therapeutic Relationship for more information.

It is important to manage any conflict of interest that may arise, and if conflict of interest can’t be managed, you would have to recuse yourself. More than likely, the most common reason for potential conflict of interest in this situation could likely result from a blurred line in the relationship between public and private services. You are encouraged to review the Patient Relations Program “Professional Boundaries: Where’s the Line” (button at the top of the page). Additionally, you could review CDBC Code of Ethics – Principles and Guidelines (also at the top of the page), which may help you talk through the considerations necessary to make a decision.

Having said that, here are a few considerations:

• Is the client the one forging the therapeutic relationship? Refer to Marketing Standard 1(i). In the case of past patients, who are no longer followed in your public healthcare location, you no longer have a therapeutic relationship with them and if they initiate contact with you, this would be an appropriate way to begin a new therapeutic relationship.
• In the case of the client’s planned discharge from your public healthcare workplace, would you be in a position where you would follow your patient simultaneously at both your public and private places of work? This may be interpreted as a conflict of interest and you should separate these roles, so that, for example, if you wish to take this client on privately, another dietitian could see the patient in the public setting. Once the patient is discharged, if they are requesting follow-up by a dietitian in private practice, and you feel there is warranted need to do so, Standard of Practice 11 indicates that you should refer to a healthcare professional (in this case a dietitian working outside the in-patient setting). In this case, you may be able to provide your client/family with options for out-patient dietitians focused in the appropriate areas, and refer to 8-1-1 HealthLink BC for a comprehensive way to find a private practice dietitian. It is possible that you could be among a list of possible private practice dietitians from which this client could choose.
• Is there an alternative? Does the discharging program have any referral strategies already in place for patients who are no longer being followed?
• If you are fairly new to Private Practice, you are encouraged to review CDBC Privacy Guide, and become familiar with consent requirements (Consent to Nutrition Care Policy and Guidelines), as well as timeliness of delivery and record keeping standards.

Ultimately, the most important aspect of the management of this situation is to ensure that the client knows they have a choice so they don’t feel pressure to see you simply because you have already had a therapeutic relationship with the client at your public workplace.

There are some potential or perceived conflict of interest concerns with this type of scenario, especially for dietitians who work in public healthcare who also have a private or fee-for-service practice.

As part of a complete nutrition assessment, a dietitian should take financial concern/constraint into account, resulting in a nutrition care plan whereby a client has been offered or referred feasible, accessible, and affordable products and services with which to follow up. This would embody Standard 14 of the CDBC Standards of Practice. In addition, the principles of Marketing Standards must be taken into account, ensuring that the client has options and is not being offered one product or service for follow-up.

Advocating for the client and referring to an appropriate healthcare professional is key to appropriate follow-up for each client. Having said that, it is possible that the example of dietitians who work in fee-for-service positions in larger chain grocery stores, may not have the knowledge of the locally available public healthcare services for their clients. For example, consider a situation where a dietitian may be located in another jurisdiction and speaking virtually to a resident of BC. In this circumstance, it is understandable that a dietitian may not be knowledgeable about specific publicly available dietetic services; however, a service such as HealthLink or its provincial equivalent (Provincial and Territorial Helplines and Websites | HealthLink BC) should always be an option whereby a fee-for-service dietitian can refer a client to find follow-up dietetic care appropriate for their client in their own area. The resulting referral will connect clients to options, both fee-for-service, as well as public healthcare, in their local communities.