Should doctors be salesmen?

I read two interesting sentences today about the act of doctoring.

The first from the White Coat Underground blog:

“Medicine involves a lot of salesmanship.”

The second was from this NY Times health piece highlighting the difficult decisions that arise when recommending procedures to an elderly patient:

“…[Have] you felt that a doctor or hospital was steering an elderly parent toward a test or procedure that just didn’t seem necessary or advisable?”

The notion of selling something to patients gives me heartburn. I don’t look at it that way. But maybe I should?

I don’t consider the office encounter a chance to convince a patient to have a pacemaker, or an ablation, or to take a medicine. (Exception: I do try to sell the benefits of exercise, eating well and getting good sleep.)  Rather, I try to lay out the pros and cons of having a treatment, or having the problem.

I want my patients to know that I believe strongly that they should decide what is best for them. For it is their body, their life, their choice. I want to share, as skillfully as possible, my knowledge, judgement, and experience with them. But I don’t want them to think that I am selling something.

Recently, after a detailed, white-board-aided discussion of AF treatment options (A: live with it; B: take a medicine: C: have an ablation), the patient said this:

“Doc…Let me ask you just one question: Since you are the expert, What do you recommend?”

This patient wanted me to decide. I used to like this. It was easy. I was in my thirties.

But as I age-up in doctoring years, making decisions for people becomes more difficult.

I wonder what this means, other than…wondering too much makes for running behind schedule?

JMM

7 comments

  1. Well, i was being somewhat metaphorical, but i certainly implied (as I have in much of my writing) that there is a place for some gentle paternalism, rather that all out autonomy, that is, leveraging your expert status to deliver what the patient wants.

    The patient generally wants health and often longevity. We are the experts whose advice they seek, and so we must indicate how and why they need to do something. Diet and exercise are an intervention just as an ablation is, albeit one they must do a bit more independently. Many do not wish to, and we “sell” them the idea that they should because they will benefit from it.

    Just as I “sell” the idea of a DRE or a colonoscopy—I do not minimize the short term discomfort, but “sell” the long term benefit, along with the limitations and risks.

  2. Nice take on a tough topic. In my world (ophthalmology) we actually have products that a patient can opt UP to. LASIK, upgraded cataract implants that allow you to see without glasses…stuff they pay out of pocket for. Full disclosure: I make more money if my patient chooses these.

    We have the same aversion to selling in our office, however. About 1/3 of our patients opt to upgrade to the more functional implant lenses. I could easily increase that by at least 50% by using pretty standard, very basic selling techniques. Here’s the rub…it’s still medicine. Still surgery. My job is nothing more than laying out the options and allowing my patient to make up her own mind.

    There’s a fine but real line between reviewing options and making a recommendation vs. selling an option. I like your description.

  3. I think we also need to recognize that we are not “selling” commodities. Our “goods” (procedural services) are not things that the vast majority of patients have the medical expertise to comparison shop. Our “selling” is also using our constantly evolving knowlege of medicine to make reccomendations, which often not only battle myths about care (“doesn’t the cancer spread when air hits it”), but the fact that what we reccomend today is commonly found to be erroneous/outdated in the next year/month/week. Finally, especially in my specailty, oncology, we are often discussing choices between distateful options.

  4. Thanks all, for the thoughtful comments.

    I am struggling mightily with the notion of the gray, blurry, expanding line of “gentle” paternalistic coaching. Since I always strive to do what is right for the patient, I am comfortable nudging patients to what I believe is the “best” choice–if they wish me to. But it scares me to do so, because what is right for me may not be right for them. And how can I really know the patient in a 20-30 minute consultation?

    As my experience grows, I remember not just the triumphs, but also the complications. The elderly patient with severe angina (CAD) or shortness of breath (valvular disease) that turns down heart surgery is two things: limited… yes, but also, alive and not in a nursing home after complicated heart surgery. It’s the same in AF: the palpitations and fatigue aren’t ideal, but worse yet would be an esophageal-atrial fistula or stroke from the ablation.

    And like Dr Dave says, what we think is right decision now, may change to in the future.

    Finally, I am also convinced that too few doctors remind patients that they can choose to live with their disease, or choose symptom management rather than invasive therapies. I immensely dislike hearing a patient tell me that a doctor said they “had no choice.” Really?

    1. Aye, the ‘no Rx’ option is often on the true list, but just as often not verbalized in the discussion. Perhaps we assume the patient understands that? That they can always say ‘no thanks’? Not sure.

      In my world it can be even more complex, where a ‘no treatment’ decision is actually wrong for both patient and society. Think about the 75 or 80 year old man or woman with a dense cataract that grew so slowly they are unaware that they have any visual deficit. They can certainly choose to decline surgery, an option that my group always verbalizes, but if they do they potentially endanger themselves and everyone else on the roads when they drive, for example. How does one get them to the correct endpoint without ‘selling’? Indeed, how does one respond to criticism that the only reason one wishes the patient to choose surgery is because that’s how you feed your kids?

      Very nice conversation on a difficult issue. Thanks.

  5. I was just reading a very powerful patient blog… very moving about how none of her doctors ever told her she could choose no treatment at all … she went to the doctor with bronchitis and left with cancer… and six years later she’s still living with it… and she’s tired. If you’re going to sell medicine, you have to “sell” the opposite too, right? The non treatment?

    Lovely post and reactions.

  6. I would like full disclosure. I hate when surgeonns use “mild discomfort” as a euphemism for “it’s going to hurt like hell”.

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