I'll be back soon

I haven't done a post for three weeks - the longest postless interlude since I started the blog 3 1/2 years ago. It's due to a combination of travel and a spate of more work than usual. I'm going off again for a week - a family trip to Bermuda and then a meeting in Washington DC. There's always lots to talk about in relation to health system ethics. I'll be back in June.

Is Paul Krugman Right that Patients are not Consumers?

President Harry Truman only sought advice from one-armed economists. He didn't want any of this "on the one hand/on the other hand" stuff. But, unfortunately, that's how I have to answer the question about Paul Krugman's much noted recent column "Patients are Not Consumers."

Here's the essence of Krugman's argument:

Here’s my question: How did it become normal, or for that matter even acceptable, to refer to medical patients as “consumers”? The relationship between patient and doctor used to be considered something special, almost sacred. Now politicians and supposed reformers talk about the act of receiving care as if it were no different from a commercial transaction, like buying a car — and their only complaint is that it isn’t commercial enough...

Medical care, after all, is an area in which crucial decisions — life and death decisions — must be made. Yet making such decisions intelligently requires a vast amount of specialized knowledge. Furthermore, those decisions often must be made under conditions in which the patient is incapacitated, under severe stress, or needs action immediately, with no time for discussion, let alone comparison shopping.

That’s why we have medical ethics. That’s why doctors have traditionally both been viewed as something special and been expected to behave according to higher standards than the average professional. There’s a reason we have TV series about heroic doctors, while we don’t have TV series about heroic middle managers...

The idea that all this can be reduced to money — that doctors are just “providers” selling services to health care “consumers” — is, well, sickening. And the prevalence of this kind of language is a sign that something has gone very wrong not just with this discussion, but with our society’s values.

I've never met a doctor or nurse for whom the concept of "consumer" felt right as a way of thinking about their patients. Medical care is a calling, and the call isn't to set up shop to hawk consumer goods. Portraying the doctor/patient relationship as one between provider and consumer is a grotesque parody of the moral core of health professionalism. The comments on Krugman's column overwhelmingly agreed that what a patients expect from doctors and nurses isn't a commercial relationship governed by caveat emptor.

A good doctor loves his patients (in the right way). Patients deserve to feel this kind of regard. The language of "consumer" and "provider" completely leaves out the soul of medicine.

But it's not that simple. In 1999 my friend Julia Neuberger argued that we should chuck out the word "patient" and replace it with a term that better conveys equality, collaboration, and active participation. She favored "user" over "consumer." In the same spirit, my psychologist colleagues use the word "client." Though calling my patients "consumers" or "users of care" sticks in my throat, I completely agree with Julia's view of the clinical relationship. It's clear that while for me, and for the clinicians I respect most, "patient" connotes equality, collaboration, and activism, for many folks "patient" means "passive" and "subservient."

Insofar as the concept of "consumer" is necessary to convey that clinicians want, and need, patients to think for themselves and take an active role in the clinical transaction, then the people we clinicians care for should be thought of as "consumers" as well as "patients"!

The Manners Mother Taught Us

Theresa Brown, an oncology nurse in Pittsburgh, didn't connect her column in today's New York Times to Mother's Day. But I did.

Ms. Brown tells this story about a recent event at her hospital:

It was morning rounds in the hospital and the entire medical team stood in the patient’s room. A test result was late, and the patient, a friendly, middle-aged man, jokingly asked his doctor whom he should yell at.

Turning and pointing at the patient’s nurse, the doctor replied, “If you want to scream at anyone, scream at her.”

Ms. Brown was the nurse, and the column, written with the doctor's permission, is her response.

Bad interpersonal behavior creates patient safety risks. Nurses, and young physicians, stop raising questions or sounding alerts. But Ms. Brown observes that the most corrosive form of bullying isn't the loud tantrum - it's "passive, like not answering pages or phone calls, and tends toward the subtle: condescension rather than outright abuse, and aggressive or sarcastic remarks rather than straightforward insults."

I have the privilege of teaching medical ethics to first year Harvard Medical students. We discuss the deep moral conundrums in which cherished values compete and clash. These are the "capital E" ethical issues that make the evening news. But the "small e" ethics that Theresa Brown writes about are more important for every day patient care.

In the feedback I received from patient surveys over the years I was impressed with how many of the comments focused on behaviors that ultimately derived from the lessons in "good manners" that my mother (and father) taught me as a young child. I remember their saying "if you make an appointment, don't be late." There was no occasion to teach about returning phone calls promptly, but when the mother of my best friend in fourth grade died, they insisted that I call him. And the one time I remember my father spanking me (with a hairbrush, no less!) was after I'd treated someone doing housecleaning for the family with disrespect.

Albert Schweitzer taught that "Example is not the main thing in influencing others. It is the only thing." Ms. Brown follows Schweitzer's lead. The milieu of hospitals and other health organizations will improve when "alongside uniform, well-enforced rules, doctors themselves set a new tone in the hospital corridors, policing their colleagues and letting new doctors know what kind of behavior is expected of them."

This isn't the ethics taught in medical ethics classes. It's closer to the good manners we were taught, or should have been taught, as kids. If we're lucky, the behaviors have become second nature, automatic. But the right kind of example among our teachers and peers can reinforce or reduce our propensity to treat patients and colleagues with ordinary human decency.

I'm sorry my mother isn't alive so that I could thank her for lessons I often groused about as a kid. Insofar as I imbibed the practice of considerate behavior, it's served me as well as any of the fancier lessons I learned later on!