The business of healthcare

Dr. Robert M. Fleisher discusses advertising, ethics, and professionalism

We find The Top Docs awards in just about every city with a magazine touting the best burger, the best pizza, the best of everything. How does that make you feel if you didn’t go to the TOP DOC?

I’m the best! No, I’m the best! So, who is the best when everyone claims to be the best doctor in the land? Patients forever asked if I knew their heart doctor because “He’s the best.” I never heard of him but kept that to myself.

In historical tradition, professionals, including healthcare providers and lawyers, weren’t permitted to advertise their services. It was considered unethical and was a reason to refuse entry into professional societies. Advertising by lawyers, doctors, hospitals, and almost every professional began as a legal challenge by lawyers.

The ethics of advertising goes back to 1908 when the American Bar Association set its first code of ethics, “The Canons of Professional Ethics,” which forbade all advertising. However, it wasn’t until 1977 with the Supreme Court ruling in Bates v. Arizona State Bar, which stated lawyer advertising is partially protected by the First Amendment. From that case, lots of attempts by various states to reign in advertising failed, with court challenges making the practice of advertising commonplace. While there are still ethical restrictions in place, most have gone by the wayside or are no longer followed.

In medicine, professionals deemed the restrictions and ethical importance ever more critical than in the legal profession. Before the lawyers decided to have ethics, in 1847, the American Medical Association wrote its code of ethics. Without ambiguity, the AMA forbade any form of advertising, deemed it “highly reprehensible” and “derogatory to the dignity of the profession.” The ethics rules would save unsuspecting patients from ill-trained, money-motivated providers hawking expensive, unproven cure-alls.

By 1975, the FTC accused the legal profession of “restraint of trade.” Then, coupled with the 1977 Supreme Court ruling, the end of ethical restraint of advertising began for all professions.

Healthcare professionals in the early days, even as late as the 1970s, began to practice with great disdain for advertising. These feelings lasted until all the court challenges resulted in what we see today — massive advertising by most healthcare providers, hospitals, and medical device and prescription drug makers.

One early example of dental advertising goes back to the days of Painless Parker (born Edgar R.R. Parker but legally changed his name to Painless when accused of false advertising). He was described as “a menace to the dignity of the profession” by our own American Dental Association. As a graduate of Philadelphia Dental College, which would eventually become my alma mater, Temple University School of Dentistry, he began to practice and for 6 months, had no patients. That’s when he hired one of P.T. Barnum’s ex-managers to take his show on the road. As one of the early advocates for advertising, he did manage to establish a chain of dental offices, employing more than 70 dentists and grossing over $3 million per year. It sure seems like advertising pays, and our profession has accepted the practice full-heartedly, backed by legal precedent.

From 1997 to 2019, spending on direct-to-consumer healthcare advertising skyrocketed from $2.1 billion to $9.6 billion. Today, advertising by professionals is accepted and well-entrenched. While authorities designed the advertising restrictions to distinguish between a trade and a profession, and all the trust and dignity associated with the latter, advertising has many benefits. For example, awareness of procedures, medicines, and outcomes may be admirable. However, what happens to the patient who just had a procedure by Dr. A at hospital B, only to hear on the radio that Dr. C at hospital D is the best and most highly rated place to go? The level of confusion, the degrading of trust, and the appearance of self-serving promotion goes a long way to take doctors off their pedestals and place them next to lawyers. Is it any wonder that lawsuits against doctors, once a taboo, have become commonplace?

There’s something tawdry about advertising healthcare, and while some restrictions and guidelines still exist, we have truly become a business to the potential detriment of professionalism.

Since we are not going to change the state of healthcare promotion, let’s look at the business of healthcare. Of course, profit should not be the prime motivator in the healthcare professions. However, there is nothing wrong with selling medicine as long as doctors place the health and welfare of the patient above all else. While we think of the plastic surgeon or the cosmetic dentist as the salespeople of the healthcare industry, every doctor is really selling something to someone, as ignoble as that sounds. Even the oncologist and cancer surgeon are selling their particular protocol and service. After all, who doesn’t go for a second opinion?

Most patients don’t understand the medicine, even after explaining it well. What they do understand are the components of bedside manner. If you are a doctor with a great bedside manner, they come back to you. When you have it, you’ve essentially sold them on you as much as, if not more than, the protocol.

There is nothing wrong with selling medicine as long as doctors place the health and welfare of the patient above all else.

Once the student graduates from one professional school or another, they get exposed to an onslaught of programs and lectures explaining how to make more money, spend less time in the office, and accomplish better service. The problem with these promises is that the only one achieving these noble goals is the person on the lecture circuit spending less time in the office, making a lot of money from all the attendees, and providing better quality in that they are not in the office performing iatrogenics.

The big business of medicine is not all bad. Wherever there is a lot of money, innovation and technology flourish. For example, once dentists realized that they could sell cosmetics and advertise the procedures, money poured into new materials that might never have been developed without the promise of big profits.

In medicine, many technologies and new and exciting drugs may have never come to pass without the extensive research dollars generated by the pharmaceutical companies. The promise of vast riches will make an artificial heart and the cure of cancer realities.

When you develop your selling philosophies and protocols for elective treatment, you must make sure you are not pushing unnecessary procedures or procedures your patients cannot afford. Many lecturers tell you how to help patients find the money for procedures you convince them they need. You have to ask yourself if they truly need the service or if you are pushing it past many other things they may now have to do without because you sold them a bill of goods.

Finding patients easy credit for elective procedures may put them in debt for years. You have to be a compassionate practitioner and make sure you aren’t part of the vehicle that takes the patient to bankruptcy.

Before advertising in healthcare, patients and doctors had a different mindset. Patients came in when they had a problem, and doctors addressed the problem. Prevention and lifestyle were encouraged, but there was little, if any, selling. Now gurus teach you how to advertise effectively, literally chart monthly production, increase sales of the most lucrative procedures, offer financing for better case acceptance, and encourage staff to sell for participating in production goals that have to go up continually. This protocol sounds a lot more like corporate America than the medical profession.

You have to ask yourself what distinguishes you as a professional. Patients aren’t stupid. They can often see through all the hype and recognize a promoter. Your credibility rapidly fades when the patient perceives you as a salesperson. It’s imperative to learn that a big part of being compassionate is not selling your patients things they don’t need and can’t afford.

We have gone from an era where doctors weren’t allowed to make claims of superiority to daily advertising that makes claims, direct or implied, that one hospital and its doctors are better than all others. So maybe it’s time to rethink professionalism.