I am a physician. But modern medicine, with all its complexity and top-down control, has made me a salesman. It’s an odd turn of events, because I remember when we tried to repudiate business and its effects on our practices. We railed against corporate influence in medicine. We were shocked, shocked I say, at the power that drug companies and drug reps wielded. We took a dim view of gifts, knowing as we did that sandwiches and refrigerator magnets were nothing less than powerful talismans that led us down the primrose path. We turned a blind eye to industry sponsored studies. We were, at least in the ER, suddenly deprived of the rare gorgeous drug rep who smiled and handed us pens; tossed her hair and laughed in the midst of our daily misery of drunks and body fluids. We rejected medicine and business and were pure as the driven Diprivan. Sort of …
Turns out, we’re still salesman. If you spend any time in a modern emergency department, you know what I mean. The case manager is the broker of most of these sales, particularly when admissions are what we’re selling.
For example, the 95-year-old, largely independent lady who falls down and hurts her back. It’s painful and she has no family or friends. She can walk, but it’s very difficult. She needs a day or two in the hospital.
First, you try to sell it to the hospitalist. The hospitalist shakes his weary head.
“I can put her on observation, but she’ll get the bill. Medicare won’t pay for this.”
Case manager arrives and pulls out enormous book of incantations and rules. After chanting in Latin or Akadian, she says, “well, she has a few white blood cells in her urine. We might get her to meet inpatient criteria if she has UTI.”
Back to the room.
“Ma’am, did you feel as if you might pass out? Does it hurt when you urinate?”
You call the hospitalist back, who is busy trying to sell a discharge to a family and a few more days of admission to an insurer.
You tell him, “she has a little dysuria and dizziness, and with her fall, maybe it will work.”
Case manager contacted again, more incantations, and she’s admitted. Sale made. Customers? Admitting doctor, case manager, but ultimately Medicare.
Often as not, of course, you don’t make the sale. The pneumonia doesn’t get admitted. At least not the first time. It does get admitted the next day when, as predicted, it worsens. But the Medicare customer (i.e. government agency) is alright with that. Or the private insurance company customer, which is equally culpable. (But then, the private insurers never promised “we will never stand between a patient and her physician.” Just saying.)
Sometimes we make the sale to the patient and in those cases it’s less about finances and more about science and confidence. For instance, there’s this exchange: “You don’t need antibiotics and here’s why.” Fifteen minutes later they give you that blank stare and say, “uh, yeah, so am I getting a penicillin shot for my virus or not?”
The same salesmanship is involved in the “here’s why you don’t need a CT scan or blood test” conversation. If the mommy of little April with the head injury is buying what you’re selling, she thanks you for your time and off they go. If she doesn’t, it’s worried looks, uncertainty, phone calls to her friend the neurosurgeon and you might as well start up the scanner.
We sell our wares to accepting physicians at other hospitals as well. There are the “slam-dunks.”
“This patient has an aortic injury from an MVA and I don’t have a thoracic surgeon.” Done.
And then, there’s the new onset diabetic child: “Yes I do have a pediatrician but he’s not comfortable with this.”
Or the pharyngeal abscess: “Yes, I’m sorry, I do have an ENT. One night out of three.”
Those sales usually go through. But there’s a pause, a hesitancy, a sigh on the other end that says, “I hate you right now.”
Salesmanship in emergency medicine is all about locking in the disposition. I’ve remarked in the past that among my many subspecialties, (drunkologist, anxietrist, regulatologist) I’m a fantastic “dispositionist.” But at the heart of that skill-set lies sales. Convincing everyone involved that my will must be done. That my insight is correct. That what I’m suggesting is best for the patient. (Or at least not harmful for the patient.)
It’s a tough thing, selling admissions to doctors who are tired and annoyed, and who are more than willing for me or you to take the liability and discharge the sick person. And it’s tough to make admissions work when ultimately, the customer is not so much the patient as the insurers, the facilities, the rule-books that are more binding than the Decalogue on Moses’ tablets of stone. It’s also a challenge selling discharges to families who bring their loved one with bags packed and “shields up.”
Who can’t imagine why you wouldn’t admit their grandfather “for just a few days so we can have a break,” or who don’t know why their child’s fever of 104 hasn’t resulted in immediate dispatch of a helicopter.
But that’s where we are. We’re stuck squarely between clinical medicine and salesmanship, struggling with emotions, expectations and a collapsing system. And all of it marinated in the constant threat of litigation, the pressure of patient satisfaction and the growing the imperative not to violate the rules and be fined or censured by the powers that enacted them.
I doubt it will change anytime soon; we have fewer doctors and not nearly enough money to fund the system. So ladies and gentlemen, polish your presentation, shake hands firmly and put on your best smile. Because if my gut is right, we’re in for a lot more sales practice as patients want more, doctors are skeptical or absent, insurers want less done and the government runs too much of the show with no accountability and precious little money.
“Hi, I’m Doctor Leap. Can I interest you in some pain medication and a home-health visit? Fantastic. I’ll talk to my sales manager for a few minutes and be right back!”