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Kate was expecting a routine doctor visit -- get her blood pressure checked, get her medications refilled. Her primary care doctor had previously written a letter of support for bariatric surgery, but the insurance denied it. Since the surgery might be off the table now, the doctor suggested Kate try something else: a meal replacement weight-loss plan.

The doctor had been involved with a company called Optavia for 20 years, and told Kate she could buy the products from her. She wouldn't make money from the sales, she said.

"She's like, 'People have great results,'" said Kate, a product manager at a software company in Florida, who spoke with MedPage Today on the condition of anonymity.

Still, it struck Kate as odd. "Just the way she expressed it. It sounded like the structure was very much like she was below someone else," Kate said.

A Google search suggested to Kate that Optavia was a multilevel marketing (MLM) company, where salespeople are incentivized to recruit others to sell their products -- but can be left with less money than they started with.

After that experience, Kate decided to get a new doctor: "I'm never going back to her," she told MedPage Today.

As the pandemic has taken a toll on healthcare workers well-being, some MLM companies have seen an opportunity in pitching healthcare providers, including doctors. While the programs may be legal, they raise ethical questions about whether physicians should be selling to their patients -- and whether these arrangements can damage trust in the physician-patient relationship.

Medical Office Sales

There are scant data on how often doctors sell products as part of an MLM program, but MedPage Today found several examples where doctors were involved, suggesting the practice isn't uncommon.

Robert FitzPatrick, an MLM expert and author of the book Ponzinomics, said he gets many calls and emails from people affected by MLMs. "Many doctors are involved in these schemes. ... Oh my god. I mean, I've seen it over and over and over again."

FitzPatrick said he'd even visited a doctor once who tried to recruit him for a now defunct MLM called , which sold an ephedrine weight-loss product.

Karl Nadolsky, DO, an endocrinologist at Spectrum Health in Michigan, said the sale of dietary supplements and meal replacement products is not uncommon in the world of obesity medicine. Inevitably, some of the companies distributing those products are MLMs.

"To me, it's all the same," Nadolsky said. "They want people to sell their product out of the office."

Stephen Barrett, MD, a consumer advocate who ran the website (now part of the Center for Inquiry), said his daughter's physician distributed vitamins as part of an MLM company.

And Grace LaConte, a business consultant with a special interest in MLMs and predatory marketing tactics, has written about doctors who sell products out of the office. LaConte used to sell for MLMs, but now speaks out against their tactics and keeps on her website an of every health-and-wellness MLM.

Her uncle, a surgeon, for years sold Amway -- a long-established MLM that sells health, beauty, and home care products.

Not Illegal, So What's the Harm?

Because supplements and foods aren't pharmaceuticals or medical devices, there's nothing legally stopping medical professionals from promoting or selling them, according to several health law and consumer protection experts interviewed by MedPage Today.

Pieter Cohen, MD, a researcher at Harvard who studies supplement safety, said there's probably nothing illegal about selling a meal replacement or an herbal remedy, but he stressed that selling MLM products to patients is ethically inappropriate.

"It deceives patients to thinking that these products have more evidence to support their use in their care because the physician or clinician is recommending them," Cohen told MedPage Today. "And then it's a double whammy, because [the patient is] more likely to use it, of course. They might feel pressured to, and the provider's also profiting from it."

"There's a power differential," said Stacie Bosley, PhD, an economist at Hamline University in St. Paul, Minnesota. "These people may not even know enough about the things they're putting in their body to know if this is something that they truly would otherwise do."

The American Medical Association states in its that physicians selling health-related products "raises ethical concerns about financial conflict of interest, risks placing undue pressure on the patient, threatens to erode patient trust, undermine the primary obligation of physicians ... and demean the profession of medicine."

LaConte said most physicians she's talked to are against the practice.

"Someone who supposedly has taken a Hippocratic oath to do no harm, if that person then leads [their patient] down a path of potential financial ruin? It just goes against everything that I've ever thought about the medical industry," she said.

Barrett said there are "some situations where it may not be unethical" to sell products out of the office -- dermatologists recommending products that they think are effective and inexpensive, for example. MLMs, however, are different, he said, "because the products are never worth the money."

Unintended Consequences

Kate, the patient whose doctor recommended Optavia, remembers being surprised by the suggestion.

"I mean, she's a medical doctor," Kate said. "Maybe mistakenly, but I usually associate people who get involved [in] MLMs with people who are really struggling financially." Indeed, showed that a large proportion of those who sign on to MLMs are motivated by a low income or debt.

Kate's doctor had stressed that she wouldn't make any money on the sale. Maybe she did genuinely like the product. But even without a profit, LaConte and Barrett said, pitches like these could end up harming patients.

"Multilevel products are never good value, never ever, and so recommending it is bad medicine, whether you profit from it or not," said Barrett. Optavia's "Essential Optimal Kit" comes in a , and costs nearly $400.

In a statement emailed to MedPage Today following the publication of this story, Optavia said its "coaches" hold no inventory and "assume very little financial risk to start a coaching business."

Besides the dubious value, there are other, indirect ways a patient could be affected. Some MLMs restrict purchases to large quantities or monthly subscriptions, which can run up costs and tempt the purchaser into becoming a seller themselves.

LaConte said she's had friends with chronic pain, fibromyalgia, or rheumatoid arthritis who started using MLM products, which often offer steep discounts or other incentives to "members" -- people who sign up for auto-shipment or who purchased a starter-pack for selling products, "and then that company sucks that person into being a reseller themselves, so they are tied in at multiple levels with products that they believe have helped to heal either pain or some other condition."

In Kate's case, the interaction permanently broke the trust she had with her doctor.

"She is set up in that position where she can have access to people who have struggles with weight ... and so she's kind of exploiting that," Kate said. "That's how it felt to me."

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