We railed against corporate influence in medicine. We were shocked 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 ED, 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 propofol. Sort of....
Turns out, we're still salesman. You know what I mean if you spend any time in a modern emergency department. The case manager is the broker of most of these sales, particularly when admissions are what we're selling. The largely independent 95-year-old woman falls down and hurts her back. It's painful, and she has no family or friends. She can walk, but it's difficult. She needs a day or two in the hospital. First, you try to sell it to the hospitalist. He shakes his weary head. “I can put her on observation, but she'll get the bill. Medicare won't pay for this.”
The case manager arrives and pulls out an enormous book of incantations and rules. After chanting in Latin or Akkadian, she says, “Well, she has a few white blood cells in her urine. We might get her to meet inpatient criteria if she has an 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, who is busy trying to sell a discharge to a family and a few more days of admission to an insurer.
“She has a little dysuria and dizziness, and with her fall, maybe it will work,” you tell him. The case manager is contacted again, more incantations, and she's admitted. Sale made. Customers? Admitting doctor, case manager, and 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” (the government agency) is all right with that. Or the private insurance company customer, which is equally culpable. (It's not like the private insurers ever promised they would never stand between a patient and her physician. Just saying.)
Sometimes we make the sale to the patient, and it's less about finances and more about science and confidence in those cases. Take this exchange: “You don't need antibiotics, and here's why….” Fifteen minutes later, he gives you that blank stare, and says, “Uh, yeah, so am I getting a penicillin shot for my virus or not?”
This is the same salesmanship 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, and phone calls to her friend the neurosurgeon, and you might as well fire up the scanner.
We sell our wares to accepting physicians at other hospitals as well. Some are slam-dunks. “This patient has an aortic injury from an MVA, and I don't have a thoracic surgeon.” Done. And 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 sales lays at the heart of that skillset, 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).
It's a tough thing, selling admissions to doctors who are tired and annoyed and more than willing for me to take the liability and discharge the sick person. And it's tough to make admissions work when the customer is ultimately not so much the patient as the insurers, the facilities, and the rulebooks 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 they 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 is marinated in the constant threat of litigation, the pressure of patient satisfaction, and the growing 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. Polish your presentation, ladies and gentlemen, 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 Dr. Leap. Can I interest you in some pain medication and a home-health visit? Fantastic. I'll talk to my sales manager, and be right back!”
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