Sunday, October 16, 2011

The Customer Approach to Patienthood

An article about "The New Language of Medicine" in the October 13 issue of the New England Journal of Medicine makes a powerful argument against the use of economic concepts like "customer," "consumer," and "provider" for the caretaking relationship between clinicians and patients. I've never met a doctor or nurse who didn't share the authors' perspective:
The words “consumer” and “provider” are reductionist; they ignore the essential psychological, spiritual, and humanistic dimensions of the relationship — the aspects that traditionally made medicine a “calling,” in which altruism overshadowed personal gain...Business is geared toward the bottom line: making money. A customer or consumer is guided by “caveat emptor” — “let the buyer beware” — an adversarial injunction and hardly a sentiment that fosters the atmosphere of trust so central to the relationship between doctor or nurse and patient. Reducing medicine to economics makes a mockery of the bond between the healer and the sick...We believe doctors, nurses, and others engaged in care should eschew the use of such terms that demean patient and professional alike and dangerously neglect the essence of medicine.
But history is more complicated than "The New Language of Medicine" suggests, starting with the fact that "customer" language, when first introduced 36 years ago, was profoundly humanistic.

In 1975, Aaron Lazare, who was then director of the walk-in clinic at the Massachusetts General Hospital, wrote a brilliant article - "The Customer Approach to Patienthood." Lazare used the concept of "customer" to emphasize the clinical and ethical imperative for clinicians to pay close, respectful attention to their patients' requests. He and his colleagues were writing about mental health care, but their insights apply across the board in medicine:
Some professionals find the word "customer" crass. We believe it is a useful metaphor to describe a relationship in which the patient has the right to ask for what he wants, to negotiate, and to take his business elsewhere if he so desires, while the clinician has the obligation to listen, negotiate, and offer treatment that meets his professional standards. This "customer" relationship, we believe, is in the best interest of both parties.
Unfortunately, Lazare and his colleagues' superb work did not get the attention it deserved. In a recent poll, 78% of physicians said that most health care professionals provide compassionate care, but only 54% of patients said that they do.

Insofar as "customer" language construes health care as a commercial transaction governed by "caveat emptor" it's pernicious and should be fought against. But insofar as it reminds us that medical ethics and clinical excellence require top flight "customer service" as envisioned by Lazare, it should be embraced!

(For an earlier post on this topic, see here.)


eric said...

Jim--"Participant" is the term that CMS has mandated that we use to refer to our "patients/customers." I fear that my dream of a single payer may become reality, because of the byzantine system that CMS has mandated to operationalize "customer service." May I explain. I work at Program for All-Inclusive Care of Elders, which contracts with CMS to provide care to high-risk elders, with the goal of keeping our elders in their homes and out of nursing homes. CMS has ordered that we fill out a "service request form" for everything that a participant requests, from a pain pill to an MRI to a cane to a cab ride. This form includes spaces for team discussion and assessment and final resolution. CMS has also ordered that we fill out a "grievance form" for every dissatisfaction that our participants express, from cold soup to denial of the requests noted above. The grievance process has multiple levels of appeal.
Is this the way to enhance "customer service" or "quality patient care"?
Freedom of choice was not high on the list of freedoms that our country's founders had in mind. Freedom of speech, religion, assembly, the press, were and are important. But a choice between a Ford or a Chevy, an MRI or a CT scan, should be of less importance to our government. Mandating freedom of choice to the "n"th degree distracts from the true "business" of health care.

Jim Sabin said...

Hi Eric -

I know and admire the PACE program, so I am especially pained at the thought that CMS, with good intentions, is creating bureaucratic burdens for hard-working, caring clinicians. My guess is that concerns about (a) fraudulent billing and (b) capricious denials underlie the bureaucratic systems. I'm sure the aim is not to harass and burden clinicians, but it sounds as if that's the impact on you and your colleagues.

There must be better ways to pursue valid goals like encouraging "customer service" (in Lazare's sense of the term) and fraud prevention. If outcomes were well ascertained requirements like the ones you describe could perhaps be done away with.

It's always good to hear from you!



Anonymous said...

Do you think the language framework PCORI is articulating--questions asked from a patient's decision making viewpoint--is an improvement?

Jim Sabin said...

Dear Anonymous -

Thank you for this interesting and relevant question.

For readers not familiar with PCORI, I quote it's mission statement here:

"The Patient-Centered Outcomes Research Institute (PCORI) helps people make informed health care decisions – and improves health care delivery and outcomes – by producing and promoting high integrity, evidence-based information – that comes from research guided by patients, caregivers and the broader health care community."

PCORI and what Lazare conceptualized as the "customer approach" are similar in spirit in their patient-centered approach to health care. But there's a significant difference in emphasis. PCORI's mission is analagous to what Consumer Reports has done for decades, but health care has lacked - reliable information on what we already know we want. In business terms, Lazare's aim was more analagous to market research. He enjoined clinicians to find out and work with what patients are really concerned about, not what we as clinicians believe they should be concerned about!

I appreciate your making this connection for me!