Years ago, when I worked in the food service industry, servers were encouraged to engage in something called "suggestive selling." "Have you tried our new cheesy jalapeno poppers?" we were supposed to ask our customers. "Would you like seasoned fries instead of regular fries with your burger?" This was a way for restaurants to increase profits and for servers to boost tips.
According to the consumer research firm Mercantile Systems, suggestive selling -- also known as "up-selling," or "add on selling," "uses value-added suggestions to add items to your customers' original purchase."
Not a bad idea, right? Take a willing customer ready to spend money on your products or services and coax them into spending a bit more on products they didn't know they needed, but might enjoy. Indeed, the above website mentions that despite its somewhat dubious reputation, suggestive selling is "one of the easiest, most cost-effective ways to increase revenue, profit and customer satisfaction."
Suggestive selling has become standard practice in recent decades, penetrating almost all industries. One of those industries is healthcare. The trouble with suggestive selling in healthcare is that there is a big difference, ethically, between suggesting a customer upgrade to innocuous seasoned fries and suggesting a patient try a prescription to an anti-depressant drug as a cure for the blues, or take an antibiotic for a mild infection a healthy body is capable of fighting on its own.
Part of the problem with suggestive selling in the healthcare industry is that when a medical professional makes a suggestion to a patient for a procedure or prescription, most of us aren't armed with the knowledge to say no. We trust our doctors implicitly. We take what they offer and worry about how to pay later. Doctor knows best, right?
Further complicating matters is exactly who is doing this suggestive selling in the doctor's office. Is it the doctor, or an unseen player hovering behind the scene? Who gains from a patient partaking of a product (e.g. a drug) that might not be needed but that brings increased profits to…well, who, exactly? And how are patients to know whether purchasing a suggested prescription drug is really in their best interests?
These questions beget other a more fundamental, serious question: Whom can a patient really trust if the bottom line isn't healing, but financial gain? How can we trust that a physician will aim to "avoid the trap of overtreatment" if overtreatment promises increased profits?
The practice of up-selling by our most educated, trusted authorities is designed to go unquestioned. Its methods are much subtler and more successful than that of the restaurant server touting extra side sauces. At a restaurant, a customer knows that a server stands to gain from adding pricier food items to the bill, thus increasing his tip. You know that when the server begins suggesting expensive add-ons that you're subjecting yourself to the art of persuasion on the part of the sales person. Depending on how hungry you are and how much money you want to blow, you have the power to choose whether you want that side of guacamole or not.
Not so in the doctor's office, where subtle suggestive selling starts before you even see a doctor. Enter a doctors' offices of any stripe (general practitioner, dentist, even veterinarian) and you'll undoubtedly find yourself a captive audience for 10, 20, 30 minutes or longer with little to do but be taken in by propaganda disguised as informative posters and brochures on a variety of health concerns. After this period of indoctrination, many a doctor enters her office ready to hand out costly prescriptions to frightened patients.
Case in point: recently, I brought my five-year-old golden retriever in to the local vet for a rabies booster. I also wanted the doctor to take a quick look at a self-inflicted wound my dog incurred while being cared for by relatives when we were on a recent vacation. My dog has separation anxiety, and he has a perplexing habit of licking and biting his hip when we're away. This behavior caused a small wound that, at the time of our vet trip, was just beginning to heal.
When we first arrived at the vet's office, the receptionist reviewed our files. She said that in addition to a rabies booster my dog needed a laundry list of other services, from boosters to a fecal exam. The full cost of these services was $120 or so. I opted out of one or two but accepted the rest, simply because they sounded important.
We were then led into the doctor's office, where, naturally, we had to wait for about 10 minutes. That's not terribly long – it was just enough time for us to be able to take in the half dozen "public service announcements" plastered to the walls. Every single one of them (including a few models, e.g. a plastic dog heart with plastic heartworms pouring out of the center) was sponsored by a pharmaceutical company.
One striking ad involved roundworm. Did you know that your dog's untreated roundworm infection might cause your small child to go blind, or your infant to contract a horrid skin disease? To prevent this frightening parasite from ravaging your perfect children and killing your dog, remember to treat your canine friend with brand X roundworm drug. That is what the poster would have you believe, anyway. Of course, I am guessing the odds of a child getting a roundworm infection from the average dog are slim.
I had just enough time in the doctor's office to read the scary informational posters before the doc came in to examine and immunize my dog. One of his first questions was whether I use an anti-flea medicine such as brand Y. I told him I did not. I used to pay for these products by default, simply because, well, the vet told me to. And who wants fleas? The thing is, though, I'm not comfortable putting an expensive pesticide strong enough to repel fleas and ticks for a whole month on my dog's skin. And since my dog rarely socializes with other animals, I figured doing so was probably unnecessary. I made that decision years ago. Our five-year-old puppy has never had fleas.
The doctor then took a look at my dog's separation-anxiety-induced wound. He couldn't really get a good look at the scab under the dog's fur, so he asked if he could shave the dog's bottom. I agreed. He removed a round section of fur about the size of a dinner plate and then examined the wound. "It's infected," he said. "You'll need both an oral and a topical antibiotic."
Knowing how often antibiotics are needlessly prescribed by doctors, I stared at him in disbelief.
"Really? Is an oral antibiotic really necessary?"
I looked at the wound. The 10-day-old scab was almost gone and resembled an irritated abrasion. It appeared to be healing.
"Yes," the doctor said. "If you don't give him an oral antibiotic he could get a blood infection."
A blood infection? Yikes. That sounds pretty scary.
I was quiet for a moment. Was I the worst dog owner in the world for asking the next question? "How much is that going to cost? I'm already spending over $100 just for the vaccines. I didn't expect to spend that much today."
I could tell he and the vet tech were uncomfortable. He didn't answer my question. Instead, he kind of back-peddled. "Do you have Neosporin in your house?"
"Just put that on the wound."
Wait, what? First I was potentially subjecting my dog to a horrible-sounding blood infection if I didn't consider medicating him. Next I was told that a little Neosporin applied twice daily would do just fine.
It's not that I wouldn't have paid the money for my dog to be treated with an oral antibiotic if he truly needed it. But my gut told me he did not need the extra medicine.
The doctor proceeded to inject my dog with two syringes full of expensive vaccines and sent me on my way. I paid for the visit and left, my wallet $108 lighter.
This is not the first time I've been offered possibly unnecessary meds by doctors within minutes of entering their offices. Every time I go to the vet I end up being talked into vaccines, designer foods, and procedures I don't really think my dog needs. Our beloved dentist has suggested on more than one occasion that I pay to have a protective plastic coating put on my kids' teeth, even though the three of them rarely drink pop and have never had cavities. I've always declined. I once had a doctor so enthusiastic about pharmaceuticals that by the end of the visit she had arranged for me to have about four different prescriptions, all of which seemed unnecessary. The worst was when a former general practitioner offered one of my children a prescription for Ritalin and almost insisted that I take him up on the offer because my daughter would "go from Cs to As in school" by using the cocaine-like drug. I opted for behavioral modification techniques and two years later she seems to be thriving.
Let it be known that I am not against Western medicine. A very capable surgeon saved my life two years ago when he removed my cancerous thyroid. Without a thyroid I will have to rely on synthetic thyroid hormone for the remainder of my days. Levothyroxin is something I can no longer live without, and frankly, I feel it has done me a lot of good. My thyroid level, unlike before, is now regulated. I have been able to lose some weight as a result, my concentration is better, and I have more energy than I've had in years. I am thankful for modern advances in science and medicine.
And I don't mean to entirely dismiss, on an individual level, the hard work of medical professionals, nor even those who engage in pharmaceutical sales. I know a couple of folks in the business of selling pharmaceuticals, as well as a few pharmacists and pharmacy technicians, and I respect them a great deal. I don't even blame the patients who accept or, sometimes, beg for the drugs doctors often distribute like candy. We're all part of this problem. Each of the aforementioned groups is an important cog in this machine. What fuels the machine are two American ideologies operating in tandem: perpetual economic growth and comfort as an inalienable human right. I would argue that both of these ideologies are illusory and damaging to a healthy, sustainable way of life.
When will we say no to suggestive selling in the doctor's office? When will we ask our doctors to say no to pharmaceutical sales people? When will sales people say no to the corporations pushing them to increase sales without regard for ethics? When will we, as consumers, as addicts, stop assuming that we need pills to satisfy every aspect of human discomfort and protect us from every ill, even the most remote?
My dog's doing much better now, by the way. Below are before and after shots of his wound. The first was taken on Friday, August 26, just after I returned from the vet:
We applied Neosporin to the wound for about two days but stopped when we realized he almost immediately licked off the ointment every time. Despite this, he seems to have healed almost completely, as revealed by this photo, taken today:
I monitored him for signs of blood infection throughout the healing process and he never exhibited any abnormal behaviors or symptoms – all the while he was his same energetic self. I think he's going to be just fine.