ArcaMax

DEAR DR. ROACH: Your recent column said that the "law" prohibits doctors from getting money from prescriptions. However, they get perks from pharma reps like dinner, golf, etc., and many push supplements on TV. Many "doctors" across the country make their income from prescribing supplements to patients for chronic fatigue syndrome or COVID. -- D.K.

ANSWER: There are statutes that prevent physicians from directly profiting from prescribing certain medications. The Stark Law prevents doctors from referring their patients to entities where the physician has a financial interest. The Federal Anti-Kickback Statute prevents any remuneration (including not only cash but dinners, trips, flights on private planes, and anything else of value) for referrals or for generating business of any sort that is payable by Medicare or Medicaid. While it is possible that some physicians may be doing so illegally, the potential penalties include large fines and prison time.

However, drug companies do sponsor educational meetings, which often include free food and travel. They also pay speaker's fees for the lecturers. By law, these payments must be disclosed, and Medicare allows the public to look up these payments by individual provider, teaching hospital or drug company (OpenPaymentsData.CMS.gov). As I believe that these meetings do have the potential for conflicts of interest, I do not participate, but many physicians do. Medical ethics guidelines do not permit accepting cash gifts.

A recent research letter in the Journal of the American Medical Assocation used the previously mentioned website to identify $1.28 billion in industry payments to physicians. The median general internist received $30 in payments, but the top 0.1% of orthopedic surgeons received an average of $4.8 million each over the 10-year duration of the study.

I also don't agree with physicians who make an income by advertising, marketing or directly selling supplements (in office or through their website). To me, there is a clear conflict of interest in doing so. Physicians are supposed to put their patients' interests above their own (including financial interests).

DEAR DR. ROACH: I have recently been diagnosed with pan-disaccharidase deficiency. I was referred to a dietitian. She was familiar with the disorder but never actually had a patient with it. I have been relying on AI for advice. Where do I turn? -- M.K.

ANSWER: Most people have heard of lactose intolerance, which is caused by the loss of the enzyme lactase. Lactose is a type of sugar that is found in milk, and it is a disaccharide, meaning that it is two simple sugars put together (in this case, glucose and galactose). The body has an easy time dealing with simple one-ring sugars, but some people don't have the enzyme to break the disaccharide into its two components.

There are three other major disaccharides (sucrose, maltose and palatinose), and all of them need to be broken down into two. There are also deficiencies in the enzymes that break down each of them. A person with pan-disaccharidase deficiency lacks all the enzymes to break down disaccharides, so this person will have more symptoms such as abdominal pain, bloating, diarrhea and weight loss.

The hardest part of managing a pan-disaccharidase deficiency is making the diagnosis. One critical person to help you manage these symptoms is a registered dietitian who has extensive training. Even if your dietitian hasn't seen this rare condition before, she should be able to help nonetheless. Of course, a dietitian who does have experience with this deficiency is ideal, but I still recommend a trained human being who can confirm or refute the advice that is given to you by AI.

While there are sucrase and lactase tablets, there aren't enzyme replacements available for maltase and palitinase, so dietary restriction is the key to treatment.

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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.

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