Learning To Sell No’s To Patients Effectively

As I am doing more of my phone shifts and getting my own virtual practice off the ground, I’m realizing that I am a terrible salesman. I actually thought I was pretty good at “sales”, in as much as a doctor practices sales techniques. It’s critical to know how to sell to patients, something that’s easily done when the patient is cooperative and exponentially harder when they are demanding.

Let’s talk a little about why sales techniques are important for doctors to develop and what makes for a good and bad salesman/saleswoman.

Sales In Medicine

For a physician, selling comes in handy when we need to convince a patient of our competency, to help them buy into a certain lifestyle and, very importantly, to say no to a patient without alienating them.

If you are an efficient doctor then you likely will walk into the room with just the right amount of elevated energy, make and maintain eye contact, introduce yourself and start out with something that helps you connect with the patient.

If the patient waited for a long time, or if they got into it with your front desk staff, then expressing an awareness of that situation will create an immediate bond and from there on you’d have to fuck up big to unearn the trust that you established.

You then sit/stand in a manner that matches the patient’s physical presence and try to match their energy as much as possible, proceeding with a couple of open ended questions.

You let the patient say every last thing on their mind, maybe tease out a few more things. Then you go on to ask more guided questions, which shows them that you know what’s going on. You don’t ask questions which confuse the patient, you guide them towards the diagnosis which you’re about to make.

You then gently approach your treatment suggestion and feel out the patient’s attitude towards it. You feel out what the patient’s impression was of whatever was going on with them, what they thought it might be, what their fears are and what treatment they were hoping for.

That’s it. That right there is efficient selling and works quite well. If done well, you can easily see a massive volume of patients, not feel drained and have a lot of happy customers. It’s tried and true.

Selling To The Unhappy Customer

I realized just a couple of days ago that I am really good at keeping happy patients happy, without ordering unnecessary tests or prescribing medications that they don’t need.

You think that’s easy? Think of your colleagues who couldn’t connect with their patient to save their lives or others yet who seem to constantly get into it with their patients.

In a given shift of seeing 40 patients, I would say I have about 2-3 such patients. That’s way too high and is a reflection of my own insecurities and lack of competence.

You see, I’m an HMO baby. I started out as an attending in an HMO, so I’m all about efficiency, cutting costs and managing my numbers.

A well-run HMO will tell you how many MRI’s you’ve ordered, how many bouncebacks you’ve had, how long your average patient waited, what your patient satisfaction score was, how many antibiotics you ordered, how many lab tests you ordered and how often you referred patients.

Therefore, I have no problem avoiding unnecessary testing with the average patient. Yet, as we all know too well, there are always a couple of patients during every shift, insistent on a specific management. Let’s call these the problem patients because they are the passive-aggressive, the needy, the demanding, the excessively scared, the angry and the bossy.

This unhappy customer, this problem patient, isn’t the root of the problem. The issue is that I don’t like it when someone tells me what to do, I don’t like to be told that I should order them an MRI or prescribe them antibiotics. It’s a combination of offending my fragile ego and fucking with my mojo. I’m a docta‘, damn it.

Pleasing The Problem Patient

I am not sure how to word this, I guess the point of being a doctor and earning them dollars is to make sure that we don’t get sued, that we don’t harm patients and that we don’t ruin our patient satisfaction scores.

Ironically, just like Starbucks and LA Fitness, patients now can rate me online. It’s great because there is transparency. It’s terrible because I have no recourse.

It’s not like I can reply with “Yea, but this person is hooked on opioids and is a drug seeker!” – I’d look like a fool and I’d be sharing private patient information online.

I am now realizing that I need to learn how to say no to the drug seeker, the person who constantly wants to abuse off-work notes, the person who wants an MRI for every little boo-boo and the parent who wants an antibiotic anytime their snotty little toddler catches a cold.

I am not the best candidate for this job because I view myself as a competent doctor, I don’t make my decisions lightly. When I say no to an antibiotic or a CT of the abdomen I weigh all the pro’s and con’s and am aware of the risk of not doing so, therefore possibly risking a sepsis or a missed CA in the patient.

It requires a lot of patience, explanations, and ingenuity in order to come up with alternative options for the patient that will satisfy both their desires and satisfy my ego that I practiced my “evidence-based medicine“.

When a patient is demanding, rude, condescending, and bossy, I usually don’t spend much time trying to have them leave as a happy customer.

Once again, I’m an HMO baby, if they are pissed that I didn’t refill their oxy even though every other doctor before me clearly has refilled it, then I tell them to exit the room after they are done cursing me out. If they don’t leave then I let them cool down in the room, and if they still don’t leave then I’ll tell my nurse to kindly ask one of our big & ugly’s to escort them out.

This, my friend, is a display of horrible selling techniques. I essentially am dismissing the person who has a URI but wants antibiotics. I am minimizing the person’s fear of a torn ligament in the knee by poo-pooing their demand for an MRI, even if they are 70 years old and generally inactive.

Why It’s Beneficial To Develop Good Selling Techniques In Medicine

In conclusion, I can say that with the easy patients (90%) I do a fine job of customer service. And that I pretty much drop the ball completely with the other 10%. It’s not that I always get into it with them, but undoubtedly they leave dissatisfied.

Also, I use the word customer service because most of what I do is customer service. You can call it patient care if you like but the US medical system has steadily diminished the expert opinion of a physician and placed more emphasis on patient perception of care.

Good selling techniques are important for many reasons. I am not sure that I fully buy into this, but there is an important aspect of trying to make the patient feel more satisfied, regardless of whether their demands are rational or irrational.

Another important aspect is that I won’t always be an HMO baby. I’m all grown up now, wearing my big boy diapers and trying to make it in the private world. The private marketplace is a lot less forgiving than an HMO. And though an HMO can have a much steeper learning curve, it can also protect a physician a bit too much.

Selling To A Patient Isn’t Compromising My Medical Morals

Don’t worry, I haven’t sold out. Ain’t now way that I’m going to refill someone’s opioids who is clearly hooked on them, just so that I can please them or rush them out of my office.

Whether other clinicians agree with this or not, I will point out to them that they are using too much of it, that they are likely habituated and that they are displaying suspicious behavior for addiction. That I will gladly refer them to addiction medicine but won’t, under any circumstance, refill their opioids. I will give them a TCA or gabapentin, pregabalin or duloxetine to control their pain.

One successful method with which I can refuse the patient’s demand without making them feel dismissed is to get a lot more creative with alternatives.

If I can make the patient feel heard by finding out exactly why they want the particular intervention that they are demanding and then offer multiple other options, then it’s less likely that they will think me to be callous or curt.

The patient, in the end, may leave unhappy that they didn’t get their way. But even for the most splitting and passive-aggressive of patients, it’s really hard to demonize the doctor who spent the extra time explaining and really trying to come up with alternative options.

Another way to say this, I need to learn to sell my no’s to the patient. Sure, I can always focus on the 90% and ignore the 10%. However, I wouldn’t continue to improve if I do that and chances are that in the private world the marginalized 10% will be much more highly represented.