#1: Customers, Patients, Ostriches and Turbulence

sully-with-blood-drops2

Welcome to Incision and Drainage. On this blog, we’re going to drain some pus.

Of course, we’ll talk about a lot of things, but if I do my job right, most of the topics will be provocative. I like controversies in medicine and health care. I like the fuzzy gray areas, where the laminar flow of clear-cut clinical decisions degenerates into turbulence, where the evidence (or lack thereof) supports more than one point of view.

So I should have plenty of stuff to bloviate about, as is my wont. Why the hell would we give vitamin K to any human patient? Do we really believe ECASS 3 and push t-PA at 4.5 hours? After more than a quarter century, why do we still wring our hands over who should get a head CT?  Why does Lewalski wear red shoes? What’s he trying to say? More or less fluids for hemorrhagic shock? Do we really need more EM subspecialties? Hell—do we need the ones we’ve got? Why is it, exactly, that a patient in the ED “belongs” to a particular doctor, but not to a particular nurse? Is it rational, or even ethical, to board patients in our ED when a growing body of literature says we shouldn’t?

Oh, yes, there’s plenty to talk about. Plenty to argue about. Plenty to get hot about. And I’m the kind of guy who believes that a really successful journal club is the one that ends with a fist fight. Laminar flow is boring. Turbulence is mysterious, maddening,  and beautiful.

So that’s what I hope to do with this column. Create turbulence.

Patient as Customer

I’m going to kick this off with a concept that has wormed its way into health care over the last couple of decades: the patient-as-customer. This is an idea that appeared at about the time that the era of the Medicare orgy was stumbling to a close. It was clear that the health care pie was going to get smaller, that hospitals and physicians would have to practice in a more explicit and scrutinized fashion, that expenditures would have to be justified, and that American medicine would generally have to become leaner and more competitive.

In other words, health care was a “business,” an “industry.” True, of course, but that’s a bit like saying that an ostrich is a bird, and then expecting it to behave like any other bird. And so, for the last 25-30 years, our approach in the US has been to treat healthcare more and more as if it were any other industry, and then wonder why it continues to get more and more FUBAR with each passing year. Naturally, treating health care as a business means that you have to shoehorn its institutions and values into configurations that make businessmen and administrators feel more at-home and comfy. And from there it’s easy to see how we get to the idea of the patient-as-customer.

Of course, an ostrich isn’t just any bird, health care is not just any industry, and—let me just say it as bluntly as as I can—patients are not customers.

Now, before any of my colleagues holds up an objecting finger, let me just say that I’m pleased to report that I have yet to hear any of you—not a single physician, ever—refer to one of his or her patients as “my customer.” So the good news is that, even though the administrator class within healtcustomersh care continues to push this concept, physicians don’t seem to be swallowing. Maybe that’s because, at some innate level, physicians know the difference. They know what a customer is, and they know what a patient is, and they made a decision to devote their lives to serving the latter, not the former. And despite all the PC propaganda, all the attempts at indoctrinating us with this particularly insidious and subversive example of Newspeak, physicians haven’t bought in. Yet.

That’s because we know, or should know, that patients are not customers. Here, for your consideration, and to celebrate the maiden voyage of this blog, are just ten reasons why not.

1. The relationship is fundamentally different.
A customer enters into a commercial relationship with a merchant. A patient enters into a healing partnership with a physician. Everything else flows from this critical distinction.

2. Customers are “always right,” or at least they may reasonably expect to be treated as such. But ask yourself: when the patient swears to you that he’s “just got the stomach flu,” do you shrug, accept his diagnosis, and sell him a bottle of Pepto? You better not. No, our patients are most certainly not always right. In fact, sometimes they need to be told that their behavior is irresponsible, idiotic, or self-destructive.

3. Customers are legally entitled to a product only if they can pay for it. Right now, in this country, the debate over health care entitlement is about to boil over. But it has already been established—morally and legally—that patients are entitled to emergency care whether they can pay or not. This puts our patients squarely outside any classical understanding of  what a “customer” is.

4. Merchants may refuse service to any customer. You might think this is a restatement of #3 above, but look more closely. This goes beyond the ability to pay. A paying customer can buy only if a merchant will sell. An emergency department cannot and must not refuse to treat any patient, paying or otherwise.

5. The doctor-patient relationship enjoys legal privilege. The customer-merchant relationship does not.

6. Termination of service. When a customer enters a commercial relationship, either party may terminate that relationship as long as the contract so permits. Once a patient enters the emergency department, the physician has a duty to treat, and as long as treatment is indicated only the patient or his legal surrogate may terminate the relationship.

7. Purpose. The primary goals of the commercial relationship are, well, commercial. They are also asymmetrical: the customer seeks to acquire a product or service, preferably at a bargain price, and the merchant seeks to turn a profit. The primary goals of the doctor-patient relationship are completely non-commercial, and they are symmetrical. Both parties seek to relieve suffering, maintain function, and preserve life.

8. Suitability of product or service. A merchant seeks to sell as much product or service to the customer as possible, and customers are at liberty to purchase any legal product or service, whether or not it is unneeded or even harmful. A physician seeks to provide the patient only with what he or she needs, and may not lawfully or morally provide services the physician knows to be unneeded or harmful.

9. Socioeconomic biomarkers. When a lot of customers patronize a lot of businesses, the indications for the economy and society at large are generally positive. When a lot of emergency departments are jammed with sick, nonpaying patients, there’s a good chance that both society and the economy are seriously awry. Health care isn’t just any bird.

10. Sacred vs. Profane. The relationship of the customer to the merchant is temporal and ultimately prosaic. The relationship of the patient to the physician is far more transcendant and, for lack of a better word, special.

Actually, I do have a better word: sacred. The robust analogy to the doctor-patient relationship is not to be found at the mall, but in the church, the temple, the schoolroom, the family gathering. It is not the visit of a patron to a vendor; it is the reaching out of a parishioner to a priest, a firefighter to a victim, a distraught medical_symbolbrother to a caring sister. The patient comes to the emergency physician not with a desired transaction, but with pain, fear, sorrow, hope and vulnerability. The patient comes at the moment of birth, at the nadir of loss, at the precipice of death. The patient comes with his or her aspirations, pride, dignity and very life in the balance. Moreover, a good emergency physician adds some of his or her own emotional stakes to the ante. The patient needs and deserves compassion, unconditional positive regard, deep concern guided by informed intelligence, and the physician’s personal commitment to technical excellence. Both patient and physician have more than currency or commerce at stake in this encounter, which has an importance and a meaning and a humanity far beyond the two-dimensional workings of the marketplace.

Perhaps some can see in our work a similarity to selling hamburgers, giving haircuts, or fixing cars. I do not, and I find the comparison degrading and offensive to my patients and to my profession.

Patients are not customers. They are two different things. That’s why we have two different words for them.

Some things don’t have a price. Some things aren’t for sale.

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10 Responses

  1. Great blog Sully. Generically, we provide a professional service for our patients. In that sense, they are more like clients than customers in the commercial sense. If they don’t like our service, they can go elsewhere. However, I think that emergency medicine is more sacred, to use your words, than medicine in general, as we treat people who come to us not by choice, but by necessity or circumstance. It would be interesting to learn the origin of the word patient. If anyone knows this, please comment. Summary: the doctor-patient relationship describes an ancient and sacred bond. Calling our patients customers is inappropriate.

  2. I looked up the origin of the noun patient. It was from latin then old French to describe a suffering or sick person. The adjective describes one who suffers or endures without complaining.

  3. We don’t have any cure for the pestilance of consumerism and commercialism that has infected our country. We live in a time right now when the “economy is bad”, yet I can see abundance and waste almost everywhere. The standard of living in this country has accelerated disproportionately.

    In 1922 my great aunt was born at home and had to be kept in the oven because she was a little early. Her family was of the most prosperous farmers. Their children each received an orange and a piece of chocolate for christmas, instead of the family sharing the orange and the chocolate. These people were rich in their community. What would they be now?

    Neighbors used to have love for each other and share in difficult times. Prosperity has bred greed and mistrust for each other. If you disagree with me on this I’ll sue you.
    The push for a patient as a customer is no different than any of our other societal changes. Reverse Darwinism at its best will continue to rot us to something Dr. Osler would never recognize.

    Yet, there is something in this catient, pustomer thing. This is a service industry and there isn’t anything wrong with service with a smile. ;]

    -olspuppy

  4. Interesting, but as an administrator and a “consumer” of healthcare, I would counter that there are some aspects of the vendor-customer relationship that would indeed apply to the physician-patient relationship.

    Ultimately, a physician is by nature in a business. You could certainly work for free and charge nothing for your services, but the mere fact that you charge a fee for your services means that this is a business transaction. I will certainly agree that it is a unique relationship, but it is also a business one. An attorney-client relationship is similarly unique in that there is a lot more that goes along with the “contract” between vendor and consumer. Also, whether you like it or not, you face competition from other physicians for that patient and their dollars. It’s the ugly side of the business. In order to compete, any service must compete on price and/or quality. By truly looking out for the patient as that patient’s physician, you are automatically providing the most important part of that quality service. There are other elements that a patient/customer wants, though.

    A patient does, in fact, want the ability to choose their physician. They want someone they trust, someone who will do all the things you outline in your post. They also want someone who is prompt, somewhere where they are comfortable, and someone who they feel is really concerned for their comfort and care. If they are restricted from choice by their insurance company, for example, there is bitter complaining. If they are taken to a different hospital than the one they choose, there is complaining.

    Now to specific points I had about your points. I completely agree with points 1, 2, and 3. Although with point three, if the patient CAN afford to pay, they can also afford to choose the best level of care they can find. Their level of service is definitely different than those who can not pay. Point four is correct, but only for emergency medicine. Point 5 is correct, but does not take into account other similarly protected relationships such as attorney-client. Point 6 is correct, however I must note that when an emergency medicine shift is over, that individual physician passes the care of the patient to a completely new physician whom the patient may not want. In a sense, the further service of the first physician terminates at the end of the shift (although you are still responsible for the services already provided). Point 7 is true, but the harsh reality is that if a profit is not made, you won’t be open to care for the patient for long. Point 8 is true enough, although with the exception of cigarettes, alcohol, and motorcycles, it’s generally unlawful for anyone to sell something harmful to a customer. Point 9 is accurate, but I don’t know that it furthers your point. There are other industries which are counter-cyclical to an economy, such as the fact that thrift store sales go up with the economy goes down. Finally, I never argue with someone who says something is sacred. That usually means there’s no way to have an unbiased discussion! :-)

  5. [...] Aggravated DocSurg and at Detroit Receiving’s EM Blog. [...]

  6. @Matt, who said:

    ***Ultimately, a physician is by nature in a business. You could certainly work for free and charge nothing for your services, but the mere fact that you charge a fee for your services means that this is a business transaction. I will certainly agree that it is a unique relationship, but it is also a business one.

    The problem with this argument is that it relies on defining “business” so broadly that it quickly loses its meaning. For example, is the criminal justice system a “business?” Your criteria above would suggest that it is, because, after all, judges, lawyers and police don’t provide this service to the public for free. They work for money. Is a pastor running a church a “businessman” because his parish pays him? Was Mozart a “businessman” because he took payment for his work? Perhaps, according to your argument, and yet these kinds of activities are generally not understood to be commercial “business” in any ordinary sense of the word. Most human work product is compensated; calling all of it “business” quickly robs the word of any discriminatory power.

    Of course, my explicit beef wasn’t with the substitution of the word “business” for “health care” (although, yes, I find that concept objectionable as well) but of the word “customer” for “patient.”

    ****An attorney-client relationship is similarly unique in that there is a lot more that goes along with the “contract” between vendor and consumer.

    True, but advocates, like physicians, don’t call their clients “customers,” presumably because, like physicians, they recognize that the relationship transcends other commercial relationships.

    ****Also, whether you like it or not, you face competition from other physicians for that patient and their dollars. It’s the ugly side of the business.

    I would put it differently. I would say that business is the ugly side of medicine.

    ****In order to compete, any service must compete on price and/or quality. By truly looking out for the patient as that patient’s physician, you are automatically providing the most important part of that >quality service. There are other elements that a patient/customer wants, though.

    I don’t necessarily contest any of this. I would hasten to point out, however, that I am aware of no objective evidence that competition improves the quality of medical care. Indeed, I think you can make a case that it has had the opposite effect. In fact, while the United States has the most robust business/competitive-oriented model of any industrialized nation, some study suggests that the overall quality of our health care falls somewhere between that of China and Iran.

    Moreover, I think you have overstated the role of patient choice in the American system–or any other health care system. At Burger King, you can have it “Your Way,” but that doesn’t fly in medicine. It’s all very well to maximize patient choices, but the reality of medicine is that sometimes you run out of choices.

    Also, I have found that HMOs, hospitals and insurance companies love to talk about patient choice and free markets when it suits them, not so much when it doesn’t. It starts when the patient gets picked up by the ambulance. I like to say that you could tell the paramedics that you live closest to Henry Ford, that your doctor is at Ford, that your records are at Ford, that your recent surgery was at Ford, that you would prefer to be taken to Ford–and that you are in fact the President and COO of Henry Ford Hospital….and they would bring you to Receiving anyway. And then if you decided you like the doctors at Receiving better after all…oops! No go. Your insurance forces us to transfer you back to Ford. Now you’re back at Ford, and you tell the doctor on call you want YOUR doctor. No dice, your doctor’s in the Caymans for a tax seminar/pina-colada symposium. Well, you say, I’m sick of all this trouble. Just cut the damn leg off, I don’t want it anymore. Umm….no. Customers are always right. Patients are not.

    ****A patient does, in fact, want the ability to choose their physician. They want someone they trust, someone who will do all the things you outline in your post….[if not](snips) there is complaining.

    Yep. See above. But that just says that patients, like customers, want to have choices and be treated with respect. Of course, so do clients and defendents and voters and husbands and wives and brothers and sisters and students and…well, everybody. That doesn’t mean that everybody’s a “customer.” If the word means everything, it means nothing. Let’s go back to Burger King and flip it on its head. Because you, like a patient, want to have choices and be treated with promptness and respect and kindness and burgerly compassion doesn’t make you a Burger King “patient.” There is overlap between what patients need and what customers need, yes. But that doesn’t make them the same at all.

    ****Now to specific points I had about your points. I completely agree with points 1, 2, and 3. Although with point three, if the patient CAN afford to pay, they can also afford to choose the best level of care they can find. Their level of service is definitely different than those who can not pay.

    That is an absolutely correct and succinct statement not only of fact, but also of a lamentable human injustice.

    ****Point four is correct, but only for emergency medicine.

    True, but it underscores the difference between medicine (and law, and certain other professions) and mere commerce. If my roof is on the verge of collapse, it is a true emergency for me, one that could devastate me personally. But no vendor I approach is obligated to come to my aid, especially in disregard of my ability to pay. That’s because in that situation I am merely….a customer.

    ****Point 5 is correct, but does not take into account other similarly protected relationships such as attorney-client.

    Again, I recognize these other special relationships, which, like those of physician-patient, transcend commercial relationships.

    ****Point 6 is correct, however I must note that when an emergency medicine shift is over, that individual physician passes the care of the patient to a completely new physician whom the patient may not want.

    Yes, this has always been a sticky wicket for emergency medicine, and for medicine in general. But the transfer of a patient in no way abrogates or discharges the duty to treat. I think it is most helpful to regard it rather like one officer relieving another. The person may have changed, but the mission remains in place and office being discharged is continuous.

    ****Point 7 is true, but the harsh reality is that if a profit is not made, you won’t be open to care for the patient for long.

    You and I both know that most health care “profits” are not forthcoming from the physician-patient relationship itself, but are in fact highly subsidized–which I think is a point in furtherance of my argument.

    ****Point 8 is true enough, although with the exception of cigarettes, alcohol, and motorcycles, it’s generally unlawful for anyone to sell something harmful to a customer.

    Matt, the pig is a filthy animal, and bacon is very, very bad for you. Firearms…well, let’s not get into firearms. And my point went beyond mere harm and into the realm of need. If you want to buy 7000 lbs of peanut butter as a hedge against inflation, you can find somebody who’d be happy to sell it to you. But if you want a Rx for a medicine you don’t need–even a relatively benign one–no ethical physician would write one for you, regardless of the prospect of profit.

    ****Point 9 is accurate, but I don’t know that it furthers your point. There are other industries which are counter-cyclical to an economy, such as the fact that thrift store sales go up with the economy goes down.

    Point taken.

    *****Finally, I never argue with someone who says something is sacred.

    Never? Given all the foregoing, are you sure?

    ****That usually means there’s no way to have an unbiased discussion!

    Perhaps not. But then, I never claimed to be unbiased!

    Thanks for your thoughtful comments. Glad to see the post generated some turbulence. :^)

  7. Loved this post! Reminded me of nursing school in the early 90′s where the word patient was substituted with client in nearly every textbook. Methinks everyone should reread 1984.

  8. Wonderful post.

    I think this is very timely, considering all of the discussion of the octuplet birth in California. I have seen a lot of people say that the fertility doctor is somehow obligated to provide IVF to anyone who can afford it, and must transfer as many embryos as the patient desires. People invoke slippery slope arguments if anyone questions the medical ethics of such practice. I always reply that medicine is not the same thing as ordering off of a menu. Responsible, ethical practitioners have to weigh risks and harms and provide informed consent, which is hardly the same thing as immediately agreeing to whatever the patient requests.

    Thanks for an organized list of why this is true for medicine in general. Of course, IVF or other fertility treatments are rarely provided without ability to pay, unlike emergency medicine, but many of the other points apply.

  9. i work in a large academic medical center, and do not do patient care.

    i have good insurance.

    it took me 7 years to find a primary care provided who even approximates what you seem to be talking about, and she’s not an MD. I now have some continuity of care, and if i get hit by a truck, i feel like i would refer to her as “my” doctor. A couple of chronic conditions are now under good control and she has made appropriate referal to a specialist to deal with another problem.

    Notice i said 7 years under the best possible conditions, and the physician i am happy with is a DO.

    i think your discussion of the doctor patient relationship is highly theoretical for most patients.

  10. anne vinset,
    What was your point?
    This discussion was on not calling patients as customers, because physicians regard patients, as way more important and special, than they would regard customers.
    Your comment was irrelevant to the discussion.

    If you want your doctor to call you ” Customer”, just let them know. They will try to oblige.

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