Marketing the ER

At many of the nation's hospitals, business is brisk in the emergency department. For large portions of the day (and round the clock in some institutions), all of the treatment rooms are full, patients too sick to stay in the waiting area until there is a room for them are lying on gurneys in the hallways, and there are more in the waiting room.

And yet, as they drive to work, doctors and nurses who care for all of those patients see billboards advertising the services they provide.

You know the one-word question that crosses their minds: "Seriously?"

So why are ED services being marketed? Marketing is all about generating business. If you are advertising your emergency department, there are basically two ways to get more business. The first is to get patients to seek medical care who otherwise wouldn't. If you've read earlier essays in this blog, you know what I think about that. There is a small group of patients for whom that is an appropriate, ethically responsible thing to do: patients with symptoms of something serious, like a stroke, who might not realize their symptoms are cause for concern or that they should seek care promptly rather than waiting around to see if the symptoms will go away. But otherwise, we should not be trying to increase total demand for ED services.

The second way is to take "market share" away from someone else. If that someone else is the ED at a competing hospital, and your place has excess capacity, go right ahead. Tell people you have better doctors, better nurses, shorter waits, a friendlier atmosphere. Tell them whatever you want, as long as it's true, or at least not demonstrably false. But if you're already at or above capacity, don't do it.

If the someone else from whom you are taking "business" away is the patient's primary care doctor, because the patient doesn't need an appointment, and you never close, and you see everybody today whether the problem is urgent or not, that could be OK. "Really?" I hear you asking. Well, yes, IF the local primary care doctors are busier than one-armed paper hangers and your ED has excess capacity, which means seeing more patients doesn't overburden the available resources and helps cover overhead. But that's not the case in most communities, and part of the effect of ED marketing is, indeed, to take patient visits away from the office of the doctor who knows them. This is unwise and not responsible stewardship of health care resources.

Not long ago I saw a bit of marketing fluff (yes, that is advisedly pejorative) from a highly respected tertiary care, academic medical center in my city (not the one where I work) in which one of the emergency physicians was quoted as saying his staff cared for patients with everything from colds to heart attacks. You know what I thought. Colds? Please! You have now officially given permission to people to seek care in the ED for a cold, instead of going to a drugstore.

(Remember those commercials? "Sudafed - Aisle 5." I like Sudafed - the original, that you can still get by asking the druggist, not the new "PE" version that's allowed on the shelf because you can't use it to make crystal meth. And no, I don't own stock in the company that makes it.)

This kind of marketing has many unfortunate effects. One of them - the one that bothers me the most - is that it tends to support the theory that, in health care, supply generates demand. That theory has gotten us into a lot of trouble. It was propounded by Joseph Califano, Secretary of Health, Education & Welfare during the Carter administration. As a result of Califano's influence, funding for medical education was cut in order to restrain growth in the supply of physicians (and thereby restrain growth in demand for their services). Our current shortage of physicians is due in large measure to that mistake.

If we don't want policymakers thinking lots of people use the ED for non-emergencies, which is what they think now, the least we should do is make sure our marketing targets people who have emergencies. I liked one billboard used by a hospital where I worked years ago. It showed a guy falling off a ladder. If he got hurt badly enough to need medical attention, the billboard suggested, our place was his best choice. I believed that, and I wanted him to come to our place even if we were busy.