Monday, May 9, 2011

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"!


Dial Doctors said...

Are patients consumers? Yes, even though it may appear to distort the relationship. I personally like the term “patient” but as a psychologist I've been taught to call them clients.

I polled my friends and family members and asked them:
1) Are they offended by the term consumer (in health care of course)?
2) Would you care if your doctor called you a consumer?
3) What is the ideal term to use?

1) 20/20 said they don't believe it to be offensive
2) 20/20 said no
3) 20/20 said they didn't care as long as they received health care.

Maybe my family members are too different from the population but I don't think people should be focusing on semantics right now. There’s too many things way too serious going on…

RM said...

I agree with Dr. Krugman, do we really want the sacrosanct relationship between the doctor and the patient to be reduced in meaning to a financial transaction. Health care decisions must be based on need and not ability to pay otherwise we run the risk of doctors making medical decisions based on ability to pay.

Jim Sabin said...

Dear "Dial Doctors" -

I'm sorry for the delay in responding to your comment - I've been away.

What a great experiment you've conducted! I'm not aware of any real surveys about the topic, but I know from my own practice that many folks don't like the term "consumer" even though they appreciate respect for their preferences and want to be in the driver's seat for setting the goals for treatment and the criteria for success.

Almost 40 years ago, Aaron Lazare wrote a brilliant paper on "The Customer Approach to Patienthood," in which he demonstrated the value of treating our patients as if they were customers. I agree with you that semantics is not the issue - it's the moral implications of the concept of "consumer" that matter.



Jim Sabin said...

Hello RM -

Thank you for your comment. I agree 100% with your view of the clinical relationship as "sacred." It shouldn't be reduced to a commercial transaction. But as I said in my response to "Dial Doctors," there are some positive implications of the concept of "consumer" or "customer" as well. For me those implications are inherent in a proper understanding of what it means to care for a "patient."