Dr. Andrew Morley was worried. Too many of his patients were ignoring his advice or failing to take their medication properly, a problem many physicians face. Further, too many sick patients were not returning for follow-up exams.
Hypertension patients, in particular, concerned the doctor. Untreated, high blood pressure can lead to a stroke, heart attack or kidney failure.
"Many physicians would say that compliance is the patient's problem, but I knew better," says Morley, a family physician from Decatur, Ga. "My clinical expertise was excellent, but what good was that if I wasn't reaching my patients?"
To get his patients more involved in their treatment, Morley became one of a growing number of physicians to use marketing techniques. First, he made it easier for his hypertension patients to comply with their treatment. He dropped the fee for checking patients' blood pressure, reasoning that patients were reluctant to pay -- especially if they were feeling good -- so many did not return for checkups.
Next he reduced a 15-minute office visit for a blood pressure check to five minutes and lengthened his office hours so people could drop in before or after work and at lunch. And he decided to honor credit cards.
Most important, Morley involved his patients in their treatment. He discussed their condition with them and their families and distributed literature on hypertension. He and the patients agreed on and signed a "contract," often written on no more than the back of an envelope, specifying the treatment, free blood pressure checks and a schedule for follow-up office visits.
All this worked. Within a year, Morley's compliance rate rose from 35 percent -- already twice the national average for hypertension compliance -- to 70 percent. "My patients were more interested in their condition and in complying with their treatment," Morley says. "That made for better medicine."
Although marketing has long been recognized as a valuable business tool, the medical community traditionally shunned it as unprofessional self-promotion. But now, faced with competition from an increasing number of doctors and clinics, many physicians are using marketing to get new patients and hold onto the ones they have.
In 1950 there were 149 doctors for every 100,000 Americans, but by 1982 that number had jumped to 191 and is expected to reach 243 by 1990 and 271 by 2000, says the U.S. Public Health Service. The total number of physicians is expected to grow at three times the rate of the U.S. population.
Washington has the most physicians per capita of any region in the United States. The D.C. area has some 573 physicians per 100,000 population, according to the American Medical Association. Next highest is Massachusetts with 306 physicians and New York state and Maryland ith 300 each.
As a result, more and more doctors are sending out new practice announcements, advertising, giving their patients newsletters and other printed information and relocating or opening satellite offices.
Forty percent of physicians have used at least one marketing technique, concludes a 1983 American Medical Association survey. Most likely to use these techniques are those in practice less than 10 years, members of a group of physicians practicing together or doctors located in the West.
Marketing, says Stephen Brown, president of the American Marketing Association and a professor at Arizona State University, is a way to focus a medical practice on the patient as a consumer.
"Physicians have always marketed their services in the sense that they developed their practice," says Brown, who specializes in advising hospitals and doctors. "Marketing includes the way you talk to your patients or lay out your office. Physicians have just not thought of that as marketing before."
Brown says marketing involves several steps: Determining objectives, assessing one's practice, evaluating the competition, analyzing consumer choices and desires, and then selecting a strategy that includes services offered, prices charged and location.
Like Morley, some Washington area doctors are using marketing to attract and retain patients and improve their care.
One is Dr. Norman Cowen, an orthopedic surgeon who must calm the fears of parents whose children face reconstructive hand surgery. Cowen specializes in creating usable hands in young children born with deformed ones. It is a difficult, costly procedure that typically requires several operations and 18 months to complete.
"I almost have to be a psychiatrist," Cowen says. "The children are fine; it's the parents whose confidence I have to gain. They are nervous and anxious. Many have been turned off by other doctors who have told them that nothing can be done for their child. Many parents think they somehow are to blame for the deformity. The children will do only as well as their parents will let them."
Cowen's office is designed to relieve fears and relax tensions. No sterile doctors' quarters, it has been recently relocated to a townhouse on Capitol Hill. The street is tree-lined and the yard attractively landscaped. Inside, soft pastels, plush carpeting and brightly colored paintings create an aura of confidence.
New patients and their parents are ushered into a comfortable second-floor den and shown a 14-minute video cassette. In it, Cowen explains in simple terms how the surgery is done and what will happen to the child. He also offers to put parents in touch with others whose children have undergone the procedure.
Parents, patients and visitors are greeted by a smiling, warm staff, whom Cowen has involved in both the medical and marketing effort. Nancy Calabrese, for example, Cowen's medical director, tells parents how their child will be taught to use his or her hand and new fingers.
"We want the kids and their parents to be fully knowledgeable about what is going to happen," Calabrese says. "We spend days and weeks counseling them before we operate."
As part of that process, pictures of children's hands -- before treatment, during surgery and through rehabilitation -- decorate the walls of Cowen's examining room. Some are not pretty. "We use the pictures so each child can see his or her own progress," he says. "It also lets them know that they are not alone."
A marketing approach has even been used in physical therapy. A third-floor attic has been finished and set up as a play area filled with toys that kids have to manipulate with their hands and fingers. The back yard, too, has been outfitted with ropes, swings, ladders and a geodesic jungle gym that encourage children to use their hands.
Cowen hired a public relations agent to, as he puts it, "bypass the doctor referral system. That was the only way to get word of our work to the general public." Cowen's public relations efforts have succeeded in getting his work into newspaper stories and television programs such as "That's Incredible."
Meanwhile, in Bethesda, a different medical practice has adopted independently many of the same marketing techniques with much the same purpose as Morley and Cowen. The Neurology Center is a 14-physician, 130-person staff group practice that specializes in disorders such as epilepsy, Parkinson's and Alzheimer's diseases and multiple sclerosis.
"Most people are concerned when they have to see a neurologist," says Dr. Marvin Korengold, the center's senior physician and president. "They are frightened by symptoms that could signify a serious abnormality. We try to put them at ease."
Like Cowen's townhouse, the Neurology Center's examining and office rooms are brightly colored and carpeted. They contain little or no foreboding diagnostic equipment. The tables and chairs are arranged so physician and patient face each other as equals.
One of Korengold's primary concerns is epilepsy, a neurological disorder marked, at least at the onset, by seizures or short blank spells. About 1 percent of Americans have epilepsy. Korengold is particularly worried about how epilepsy's social and psychological dimensions affect patients' willingness to comply with treatment.
"Epileptics, especially teen-agers, feel isolated," he says. "They aren't able to drink or drive. That is a big problem for teen-agers, who may be under intense peer group pressure to be like other kids. We try to help them discover that they aren't alone."
To do that, Korengold has created an epilepsy center within the Neurology Center, staffed by physicians, nurses and psychological social workers specializing in the disorder. Epilepsy patients come in on the same day and are seen in a section of the office set aside for them.
The center is organizing groups so epileptics can get together to hear speakers, see films and, most important, Korengold says, find out from each other how to deal with epilepsy. In separate groups, parents will discuss ways to encourage teen-age epileptics to follow their treatment.
In addition, Korengold and his staff often speak with their teen-age epileptics alone with no parents in the room. "We want the physician to be the teen-ager's advocate, not the parents'," he says. "We level with them on what causes seizures and what they can do about it."
Epilepsy is not the only neurological disorder that the Neurology Center has specially packaged. Separate centers, each with its own staff, literature and support groups, have been set up -- or soon will be -- for back and neck problems, multiple sclerosis and Parkinson's and Alzheimer's diseases.
Like some other physicians, Korengold sends out newsletters. But instead of going to current or prospective patients, the Neurology Center's newsletters go to other Washington area physicians. It tells them about new developments in neurology that may be of use in their practice and mentions health seminars the center sponsors. That helps them treat patients better, Korengold says, and boosts the chance for referrals to the Neurology Center.
Marketing, say proponents, benefits both the doctor and the patient.
In Morley's case, he doubled the number of patients who came back to see him and -- despite offering free blood pressure checks -- earned an extra $5,000.
"Marketing results in a higher quality, more cost-effective level of care," Morley says. "It would be unethical not to market health care. If our medical system is as good as we think it is, we have to use all appropriate techniques to bring quality care to all Americans."