Thursday, August 25, 2016

The Salesman-Doctor

Image Credit: Flickr
Author: Edward Siegel, MD MBA
RSA Secretary-Treasurer '13-'14
Originally Published: Common Sense March/April 2014

I remember one of the early classes at my business school, when the lecturer asked how many of the students had been in sales prior to starting their MBA. I was one of the minority of students who raised their hands, as most of my classmates were in fields like engineering, consulting, and finance before starting their MBA program. Then the lecturer asked how many of us thought we would be in sales after graduating with our new degree. Though my memory is hazy, I think I was the only person to raise his hand. The lecturer asked me why I wanted to be in sales, and I told her that it wasn’t because I wanted to be in sales, but that I was going to be required to be in sales — that all of us, no matter what our background, skills, or abilities — were at one point going to have to sell ourselves to get jobs, convey the value of our ideas, and work with others. I went on to say that I had been working in sales in one form or another since I was a teenager, and that being a salesman was nothing to be ashamed of.

I think that most of my classmates felt that being in sales was beneath them, especially if they had earned an MBA and a ticket out of the lower-end job pool. If business school students didn’t think they would have to stoop to doing sales, how do you think doctors approach the concept that they too are in sales?

The truth is, we as doctors are increasingly being graded, measured, and rewarded just as salesmen are — based on how well our “customers” are satisfied by our work. The preeminent organization that is grading the nation’s doctors is Press Ganey Associates. In 2011, Press Ganey sent out 70 million patient satisfaction surveys for over 10,000 health care organizations. That year Press Ganey logged $217 million in sales with over $80 million in profits (EBITDA*). Hospitals across the country, including my own, contract with Press Ganey to obtain patient satisfaction surveys and then compare themselves to hospitals in their region that are similar to them in size, that have similar patient bases, etc.

At Press Ganey’s recent annual conference, over 2,000 hospital administrators paid over $1,000 each to be told how to run their hospitals better. One of the keynote speakers at this conference was Jillian Michaels, who is a trainer on the TV show The Biggest Loser. I wonder if those attending the conference appreciated the irony of someone who isn’t a doctor, but pretends to be a health expert on television, telling hospitals and doctors how they should be taking care of people.

Unfortunately, joking about the absurdity of having people who are not doctors or hospital administrators being pawned off as having the authority to lecture doesn’t diminish the power of organizations like Press Ganey. If anything, their influence is growing by leaps and bounds. For example, part of the Affordable Care Act calls for reducing reimbursements to hospitals with poor patient satisfaction scores by some $850 million.

On the individual level, doctors — including those in the emergency departments — are being told how to manage their practices based on the results of patient satisfaction surveys. Those of us who find ourselves saying “no” to things like unwarranted requests for antibiotics and narcotics may find ourselves on the wrong end of a bad patient satisfaction grade, even as we practice good medicine and care for our patients.

How important will this be in our lives once we become attendings? A recent survey by the Hay Group, a management consultancy, found that 66% of their surveyed health care groups rely on patient satisfaction scores to measure and reimburse their physicians — a 23% increase over the previous two years.

If you’re told that your value as a doctor and your paycheck will be based on patient satisfaction, what do you do? A survey of more than 700 emergency physicians found that 59% admitted they increase the number of tests they order because of patient satisfaction surveys. Compound this by the number of tests obtained as defensive medicine, and one can find billions of dollars being spent not to protect patients, but to protect doctors from patient complaints.

To be fair, holding a mirror up to the world of medicine has a lot of value. Our department and those around the country are constantly taking steps to improve patient care and reduce unnecessary costs. I recently joined a committee to help improve patient satisfaction, focusing on how we treat the family members of our patients in the ED. Without the information on this topic generated from our Press Ganey surveys, we would not have known that this was a problem or how important it was to our patients.

Similarly, we frequently read or hear about innovations made by institutions to improve care. Many of these innovations come as the result of patient feedback to surveys like those obtained by Press Ganey. Sycamore Medical Center in Miamisburg, OH recently published the results changes made in their ED’s patient flow. By making changes in how patients were being cared for, they were able to reduce their left-without-being-seen rate from 4% to 0.04%, while raising their patient satisfaction scores from the 70th percentile to the mid-nineties. The hospital is continuing to hone its practice by making case managers available at peak times, using walkie-talkies instead of overhead pages to reduce unwanted noise, etc. All these changes — and their positive effect on patient care — were driven by patient satisfaction surveys.

As a doctor, I rely on the skills I learned as a salesman almost every day. Sometimes it is convincing a patient with a sore throat but no Centor criteria that they don’t need antibiotics, sometimes it is convincing a septic patient that they need a central line. The common thread is getting a patient to accept a level of care that they weren’t expecting when they came to the ED, and getting them to feel that they were part of the decision-making process. Just as my classmates in business school didn’t want to believe that they were all in sales, neither do my fellow doctors. The truth is, however, that we are in a business that is almost as reliant on customer satisfaction as that of a run-of-the-mill salesman. We may not like this reality, but the sooner we can learn to work within it the better off we will be.

Additional References

1. ED Redesign Improves Patient Flow, Satisfaction. Hospital Case Management. 21(4):53-4, 2013 Apr.

2. Falkenberg, K. (2013, Jan 21). Why Rating Your Doctor is Bad for Your Health. Forbes.

3. Grafstein E. Wilson D. et al, A Regional Survey to Determine Factors Influencing Patient Choices in Selecting a Particular Emergency Department for Care, Academic Emergency Medicine. 20(1):63-70, 2013 Jan.

4. Walker, A. Perverse Incentives, Tennessee Medicine.106(5):7-8, 2013 May.

*EBITDA = earnings before interest, tax, depreciation, amortization

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