Thursday, 31 July 2014

Patients of Selling

The way hospital departments “sell” patients to each other has been parodied but seldom studied. Peter Nugus, Jackie Bridges, and Jeffrey Braithwaite explore the rules of the game
“Since…gomers [Get Out of My Emergency Room] don’t die…the tern [intern] had to find other ways to turf them…The problem with the turf was that the patient might bounce, i.e. get turfed back…The secret of the professional turf that did not bounce, said the Fatman [a supervising Resident], was the buff…‘Because you gotta always remember: you’re not the only one trying to turf. Every tern and resident in the House of God is lying awake at night thinking how to buff and turf these gomers somewhere else.”
“‘[That doctor’s] so scared of missing something by sending the patient back home that he admits them all. He’s a sieve…he lets everyone through…Be a wall. Don’t let anyone in.’…A mind-boggling thought: the delivery of medical care consisted of buffing and turfing the seeker of care to somewhere else. The revolving door with that eternally revolving door always waiting in the end.”


Everyone’s got something to sell. Retailers sell products. Workers sell their labour and skills. Everyone sells their status and knowledge; academics and clinicians are prone to this.

Emergency clinicians sell patients. Why? Emergency departments the world over are under pressure to diagnose and treat patients efficiently, and move them on as possible. There are always new patients arriving in the queue. Who’s the buyer? The rest of the hospital. In the UK, in particular, GPs package patients for the hospital, too.
The novel House of God by Samuel Shem satirises the games and strategies that characterise the transfer of patients. With similar irony, Innes wrote about “Successful hospitalisation of patients with no discernible pathology.” Innes prescribed 11 “admission techniques” variously appropriate depending on the particular type of “difficult consultant” encountered.

So, the concept of selling patients has been parodied. Studies have examined case-shaping for organisational relevance; patient disposals; interdepartmental identity and communication; mutual alignment of goals in referring patients; and how consumers communicate emergencies. We wondered why the game of selling to, from, or within the hospital had not been seriously studied.


The way to understand behaviours as they happen is to observe them and the people who enact them. This study draws on observations and interviews in two tertiary referral hospitals in Sydney, Australia, from a larger study examining the organisational work of emergency clinicians. We examined interactions between and within departments, drawing on structured observations and staff experiences derived from 28 semi-structured interviews that were audio-recorded and transcribed. Nurses and doctors from the emergency departments and four inpatient departments across the two hospitals were interviewed. Observations included accompanying junior, mid ranked, and senior emergency doctors and emergency nurses for a full shift each in each emergency department, comprising 24 full shifts and about 110 hours of structured observation, generating approximately 800 pages of field notes (box).
Interview and observational field note excerpts are coded according to the primary participant being observed or recorded, whether a senior doctor (staff specialist) (SD), junior doctor (intern) (JD), team coordinator (nursing unit manager) (TC) or senior nurse (SN). FN signifies general field notes observed in unstructured observations. References also indicate whether the data were derived from Hospital A or Hospital B, which of the first or second shifts contributed the data in the case of structured observations, and the page number of the original field notes in which those particular data were recorded. For instance, “SNB2: 21” indicates that the excerpt of evidence was taken from page 21 of the field notes recorded during the second shift of the senior nurse of Hospital B. Names of participants have been changed to protect their identities.

Telling and selling
Selling emergency patients involves sorting them into categories appropriate for potential inpatient admission. Patients admitted to the hospital are ultimately transferred to a specialty ward in the hospital if they require more than 24 hours in hospital. To transfer the medical care of the patient out of the emergency department, emergency doctors need to persuade an inpatient medical or surgical team to admit the patient formally under the care of their department.
This exchange demonstrates that one of the roles of emergency clinicians is to decide, from a range of specialty teams and departments, where and under whose care to transfer the patient. They have to figure out who is most likely to consummate the deal and purchase the product.
A medical ward round in one of the emergency departments typically focused on inpatient admissions. A resident, referring to a particular inpatient service, said: “[They’re] a bit of a wall”. An emergency staff specialist responded: “Good luck.” Other doctors laughed. In a field interview after the shift the registrar, citing terms from House of God,explained that a “wall” asks a lot of questions and is reluctant to admit patients even when the relevance of the condition to their specialty is “obvious.” She believed that “sieves” were very rare (MDA2: 42). 

Teaching the new sales force

The need to progress patients’ journeys makes patient marketing an inherent part of emergency department work, and part of the craft of emergency medicine. Emergency interns often have difficulty persuading inpatient team doctors to become involved in the care of emergency department patients. They often fail to appeal to the organ-specific requirements of doctors representing particular inpatient teams. Frequently, interns described at length the history of the patient, which did not provoke a commitment from the inpatient registrar to become engaged in the sale.
There are hard lessons to be learned in fulfilling the needs of inpatient teams. Selling patients usually requires minimising and maximising various aspects of the case to target a particular medical or surgical specialty. The excerpt below involved a call made by an emergency intern to an after-hours medical registrar. The intern’s supervising consultant listened eagerly.

Discussion and conclusion

Selling patients—packaging and marketing them—is an under-recognised component of clinical work. Is this life imitating art or art imitating life? Shem, a psychiatrist, parodied much about the lot of young doctors. As satire, his book trades on exaggeration. Our study shows that selling does occur, and that concepts about marketing and knowing the rules of “the game” are integral to clinical work.
Game-playing and strategies to sell things to others are ubiquitous human phenomena. There are elaborate clinical and organisational pressures on clinicians to discharge or transfer patients, such as the “four-hour rule” in the UK. Clearly, the policy and organisational environments influence clinical practice. Selling may be widespread, including GPs selling patients to hospitals. Undoubtedly, they are mediated by knowledge, skills, seniority, experience, and interpersonal relationships.
Different hospital departments provide specialised services. It might not be a bad thing for clinicians to defend the boundaries of their department and put their interdepartmental colleagues to the test to see that patient transfers are appropriate. Selling strategies by well intentioned doctors might work well most of the time, because they are designed to ensure that patients receive the right care from the most relevant team at the right time.
Some patients might be transferred on the basis of quality of selling rather than patient need. How will we know? Bringing the politics of patient journeys to the surface might engender clarity, as might fair bargaining practices.The rules should be out in the open. One troublesome thing is that such skills are learned on the job rather than explicitly taught, with the benefits of business school research.

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