Patients Are Not Customers ?!?

I recently came across a blog post on KevinMD entitled “Patients are not customers. Here are 6 reasons why” written by Dr. Shirie Leng, an anesthesiologist in Massachusetts. She introduces the post comparing how we purchase goods and services, such as a car or food in a restaurant and how we exchange money for goods and services. She mentions that “Health care is classified by the government as a service industry because it provides an intangible thing rather than an actual thing.” Dr. Leng goes on to give 6 reasons why patients are not consumers. My thoughts on the points she raises are in italics below hers. I disagree with Dr. Leng and think that patients are consumers of products, goods and services we produce and are customers within the consumer-producer model whether we administer preventive care, perform surgery or render a pathology interpretation.

In pathology in particular, we consider our clinical colleagues, other laboratories and hospital partners often as are customers – please them and referrals keep coming and contracts renewed but we must not lose sight of who is the ultimate customer – the patient.

1. Patients are not on vacation.  They are not in the mindset that they are sitting in the doctor’s office or the hospital to have a good time.  They are not relaxed; they have not left their troubles temporarily behind them.  They have not bought room service and a massage. They are not in the mood to be happy.  They would rather not be requiring the service they are requesting.

Granted. We are not offering cruises to Alaska or the Italian Riviera or even one free hour on a jet ski in the Gulf of Mexico off the coast of Alabama. That’s because we are not in the entertainment/hospitality/travel business. We are in the healthcare business. Patients do not schedule when they are going to get sick or their tumor comes to their attention or when they break a limb. That is why it is called “Emergency Room” rather than “Scheduled Room”.

This is why using a slogan such as “The Happiest Place on Earth” won’t work for any hospital and why “Making Dreams Come True” only works when you have planned for a magical vacation and a week break from taking care of patients or cooking for people or selling cars.

2. Patients have not chosen to buy the service. Patients have been forced to seek the service, in most cases.

True for selected instances. I do choose to get my annual physical every five years whether I need it or not. I carefully research the doctor, his/her office staff, parking, whether or not vending machines with sugary sodas are in the lobby, what magazines they subscribe to and if I am “in-network”. I might do the same for the imaging center or laboratory and may choose not to get the service at all. Granted if you break your leg skiing in Colorado your choices may be limited but you didn’t have to choose to go skiing so far from home. A heart attack in the office may limit your options but even for major surgeries, while you didn’t ask for inflammatory bowel disease, you do have options, just as you do for what kind of car, house, insurance or hamburger you buy. We are essentially forced to buy these items as well and try to make educated decisions based on the options available to us. Or take the bus and the prescribed routes they travel.

3. Patients are not paying for the service. At least not directly.  And they have no idea what the price is anyway.

Healthcare is analogous to education. Someone else pays for the benefit while someone else actually receives the benefit. In fact the working person who pays a portion of the premium for the insurance sponsored by their employer may actually derive less benefit from the “healthcare benefits” than his/her beneficiaries, particularly if that person chooses not to get sick or break their leg skiing and gets an annual physical every 5 years annually. It is no different than education which we do not seem to question; one pays the tuition, someone else earns the credits and degree(s) and complains about all the work and their teachers and peers but not how much it costs necessarily. That is the job of parents and grandparents and extended family that pay for the benefit for someone else.

4. Patients are not buying a product from which they can demand a positive outcome.  Sometimes the result of the service is still illness and/or death.  This does not mean the service provided was not a good one.

Ask anyone who has been on a cruise ship that lost power and running water if they demanded a positive outcome or someone who bought a “lemon” of a car or dishwasher that didn’t wash dishes if they can demand a positive outcome at the outset and be guaranteed a positive outcome. Or else. These are assumptions we make in consumer-producer models, particularly in free market fee-for-service or goods exchanges. If everyone could successfully demand a positive outcome for goods and services in exchange for something the person selling the goods or services desires then we wouldn’t need customer service departments, return counters or lawyers.

As physicians we are taught a few “intangible things” that we must remember. Full disclosure, consent, patient autonomy, beneficence, non-maleficence and a few other “intangible things” since healthcare does not produce any “tangible things”.

If a patient refuses a blood transfusion or surgery, some of these principles or “intangibles” may become real “tangibles” like further illness or death. The outcome may not be positive but the expectation should be lowered. This by the way is different than if a patient chooses cosmetic surgery and is not pleased with the outcome. Their expectations may have been higher than could be reasonably attained. 

As physicians and patients we should strive for best outcomes or better outcomes anticipating the outcome may not always be positive.

5. The patient is not always right. A patient cannot, or should not, go to a doctor demanding certain things.  They should demand good care, but that care might mean denying the patient what the patient thinks he or she needs.  The doctor is not a servant; she does not have to do everything the patient wants.  She is obligated to do everything the patient needs.

Hard to argue with this one. I respect Dr . Gregory House because this was one of his underlying philosophies. And everyone lies. Patients lie. Since you can’t trust them then you are free to do what you think is best.

6. Patient satisfaction does not always correlate with the quality of the product. A patient who is given antibiotics for a cold is very satisfied but has gotten poor quality care.  A patient who gets a knee scope for knee pain might also be very satisfied, despite the fact that such surgery has been shown to have little actual benefit in many types of knee pain.

Again, hard to argue with this one as someone who has had 2 knee surgeries with the most advanced, latest technology each time to cure the ill and heal the wounded. Many hours and millions spent on R&D and thousands more on the actual OR time, procedure, equipment, recovery and braces but my knee still hurts which I can now blame on the surgeries, the doctor, the therapists, the brace company, rather than skiing. Perhaps I would have been better off breaking my leg and stopped skiing rather than thinking I could get a new knee when the time came.