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Patients are not customers

February 1, 2015

Recently I wrote about the problems with Maintenance of Certification requirements.  One of the phrases I read repeatedly when I was researching the piece was “the patient as customer”.  Here’s a quote from the online journal produced by Accenture, the management consulting company:

Patients are less forgiving of poor service than they once were, and the bar keeps being raised higher because of the continually improving service quality offered by other kinds of companies with whom patients interact—overnight delivery services, online retailers, luxury auto dealerships and more. With these kinds of cross-sector comparisons now the norm, hospitals will have to venture beyond the traditional realm of merely providing world-class medical care. They must put in place the operations and processes to satisfy patients through differentiated experiences that engender greater loyalty. The key is to approach patients as customers, and to design the end-to-end patient experience accordingly.

Except for one thing.  Patients are NOT customers.

The definition of a “customer” is a person or entity that obtains a service or product from another person or entity in exchange for money.  Customers can buy either goods or services.  Health care is classified by the government as a service industry because it provides an intangible thing rather than an actual thing.  If you buy a good, like a car, you voluntarily decide to shop around and get the best car you can for the price.  Even a vacation, especially a vacation package or a cruise, is a good.  A nice dinner, while a good in the sense of the food, is also a service.  You buy the services of the cook and servers.

Here is why the patient shouldn’t be considered a customer, at least not in the business sense.

1. Patients are not on vacation.  They are not in the mindset that they are sitting in the doctors 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.  Which leads to number 2:

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

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

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.

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.

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.

Many hospitals are now focusing on what they call “patient-centered” care, which, because they are businesses, means that they are focusing on keeping customers by providing good customer service.  “Customer service” is defined by Wikipedia as the provision of service to customers before, during and after a purchase.  And of course “service” in this case refers to the intangible assistance the customer is buying.  Good customer service, then is…what?  Providing a good product?  Having a real person on the other end of the help line?  Doing anything the customer wants?

Turns out the definition of good customer service changes depending on the industry you’re in an and what product you’re selling.  Here is Stuart Leung from the salesforce blog:(http://blogs.salesforce.com/company/2014/04/what-is-good-customer-service.html)

“We all know that good customer service is crucial, but once you get down to trying to define what goes into it, not everyone is on the same page. To some, good customer service is as simple as solving problems and offering solutions in an expedient manner. To others it means overall pleasantness and politeness from those who represent the frontlines of the company.  Others define it as when a company is willing to give their customers anything and everything that they want — you know, the customer is always right approach – no matter how unreasonable some of those demands may be. There isn’t a right or a wrong, because the factors of what makes customer service “good” also depend heavily upon what specific things a particular customer may hold valuable or their expectations from what industry competitors do.”

Ah.  The factors that make customer service good depend upon the individual values and expectations of the customer.  Here is one way in which health care is very much like being a waitress:  you take all comers.  Health care workers are exposed to all the varieties of humanity, temperament, background, values, and expectations.  And all this within the context of a situation in which the customer doesn’t want to be there and wishes he or she didn’t have to buy the service.

The patient is a person, not a customer. We must approach each patient with humanity, not customer service.

 

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13 Comments
  1. We pay 39 percent to Federal, 6.2 to SSI tax, and 2.2 to Medicaid. Also , 8.2 percent sales tax. Plus,all the other misc taxes we pay daily. Then we pay about 500-800 a month for a family of 4 for health insurance. Another 5000- 10,000 in a deductible, then the 50-100 co-pays. Of course, we are limited to which Drs. we can see for that cost. Or which hospitals. Or which medicines. Or which medical devices. So while I agree patients are not always directly paying (though we do until the deductible is met for at least 1/3- 1/2 of the year, we are paying through the nose. From a purely fiscal standpoint, we are customers paying a large bill for a “service.”

    We are more “clients” then “customers.”. Very similar to being a client of a Lawyer. The Lawyer has gone to great lengths and years of education to be allowed by law to provide legal counsel. Same difference with Drs. Because of the costs we try to avoid seeking legal advice.

    We come to you for your expertise, experience and opinion.

    Just as with a Lawyer, we have a choice to find a Dr. that suits us and our pocketbook best. I can see 3 different Drs. for basically the exact same set of symptoms/disease and walk away with 3 very very different medical opinions. Same thing with a Lawyer. 3 different Lawyers will provide 3 different but equally legal opinions.

    I certainly wish all Drs. saw us as humans, people first, but not so much. A doubled booked appointment is worth more. A less complex patient takes less time leaving more time for more patients, patients with certain insurance coverage are seen, and others are not. etc.

    Drs. need to pay their bills too. They need to pay of extreme costs of medical school and malpractice insurance etc. Those costs have ballooned for them in the past 10 years as well.

    From my perspective, if I at least get a Dr. willing to even try to provide good customer service? I am better off then most. When I find the elusive Dr. who truly puts the human experience first? I will quit looking.

    • The problems you see with double booked appointments and more insurance and less complex problems don’t actually come from the doctor. That’s what people don’t understand. The doctor is rarely responsible for booking, and most would willingly take any one who comes in the door, despite insurance or complexity. The doctor is in most cases just the face of everything that frustrates people. It is the system that doesn’t see you as human.

      • Why do Drs. continue to encourage such a system then? Clearly they are very aware it is not beneficial to patients. Where is their responsibility to the patient in this? 5 minute appointments can hurt a patient, patients unable to take a few hours off work for a 5 minute appointment go without care even with money or insurance. Patients use Urgent cares and ER
        s for their primary care because of Drs. unwillingness to correct a system they created. We have tried to stick to private care practices as much as possible for our family, but they are being swallowed by hospital systems at an alarming rate. If a Dr. truly cared they would not participate in a system that hurts patients and Drs. They can just say No. But, then they won’t make as much money, less stability… who wants to have such a high risk job with no safety net- even if the safety net is hurting patients.

      • We can’t correct it because we didn’t create it. And actually, if doctors did say No they wouldn’t make less money, they’d likely make none. However, your question is a valid one, and one that the medical profession has been asking itself. It’s a big ship to turn.

  2. Matthew permalink

    Actually, patients are customers, but this is lost to physicians because we too lose sight of where our paychecks ultimately come from. I have been fortunate to work throughout East and southern Africa, where the students endearingly refer to patients as “clients” on rounds. They have payed for a service, for expertise, as patients indirectly do here. And they treat them with this respect.

    The only obligation of patients to their doctors in the realm of medical ethics is payment for expertise rendered. In return, you owe patients, your clients, autonomy (among other things). They can reject or choose their treatments as they see fit, and rightfully should. This doesn’t translate into “they get what they demand.” But they can choose which nuances of your expertise they wish to accept and which they choose to reject. Beneficence and non-maleficence, in turn, keep them from demanding something of you they don’t need (per your expertise), but you had better believe they have and deserve the right to look elsewhere for their needs.

    I’ve enjoyed your thoughts and I agree with you (and the data) that patient satisfaction shouldn’t drive health care decisions. But this doesn’t mean they are not clients or customers… ethically, there is no denying that.

    • Interesting. The problem is that what you’re saying completely takes the patient off the hook. If the only obligation the patient has to the doctor is monetary compensation, but the doctor’s obligations are limitless, then where’s the balance?
      Also, Beneficence and non-maleficence are medical ethical principles, not patient ethical principles. The patient is, apparently, under no obligation to first do no harm to the doctor. Just ask Michael Davidson.

      • Matthew permalink

        It’s not supposed to be balanced. It’s not a partnership, it’s a professional relationship. Your position as the professional comes with more ethical obligations. That’s why you’re the one getting paid for it.

        That said, “physician” and “patient” are only professional and ethical categorizations as I said and you reiterated. There is also an underlying “human” and “human” relationship there as with any interpersonal interaction. This protects the doctor “person” from physical or emotional harm from the patient “person”…which gets violated in the event of verbal abuse, physical abuse, and…unfortunately…murder.

        You have every right to terminate a physician-patient professional relationship on either professional or personal grounds…as does the patient. Just like with any other customer/service relationship. As the professional you just have a few more restrictions to the manner by which this is terminated (ie, you have to care for the patient until transition to another provider is complete or given ample time to get completed, to honor beneficence, non-maleficence, etc). They just need to pay the bill on the way out.

        I’d love for things to be balanced…but it ain’t.

  3. Great piece. We work in perhaps a rare number of professions where either one of us can bid each other goodbyes on a hospital discharge and say “I hope not to see you again” because frankly, the hospital, the ED, or the clinic is not a place folks choose to be. I always preface it with “here, but perhaps it will be nice to see you in the community”. On the other hand we rarely want to see the plumber again or the drain unclogging contractor again either.

    I have felt that the Press Ganey scores are a horrible way to measure patient care and in many cases customer service. I cannot do much about the lack of parking in the hospital or clinic, but it counts against me if that does not receive a perfect score. I can do things about sitting down, introducing myself, establish good eye contact and closing with asking if there are any more questions and have tried to fully incorporate this in my daily encounters with patients.

    It interesting that there are no Press Ganey questionnaires or surveys asked of me if I have to deal the the front office, billing or a return phone call from a clinician regarding my health. The surveys are only provided if I have a direct encounter with a physician, NP or PA or as a provider myself by my patients.

    As an NP hospitalist, much of the day is problem solving and for some reason this week has been with a lot of patients with dementia who are depressed, giving up, and withdrawing into themselves. I have had the privilege of slowly getting to know a female patient not much older than myself who has been becoming more and more immobile to the point she is having significant complications and emotionally withdrawing from her family. She has asked nurses to stop asking her questions, saying it is none of their business. I approached her differently, finding out she was from the same area as I was raised and disclosing a little of my background so she could relate to me personally and remember who I am. She asked me why I was asking so many questions and I told her that we seemed to have a lot in common where we have been and that I like to get to know my patients.

    This morning I asked her “how is my California friend doing?” She actually asked me a couple of questions and was the most engaged I have seen her despite her dementia and depression. I think it is important in some cases to have a way to emotionally anchor yourself to a patient to get them to “awaken” and become engaged in their surroundings. I am sorry, but I don’t think that is something we see in standard customer service training manuals.

    So my other life is that of a ski instructor. This is definitely a service you want to convince your student customers to come back to, or at least have them became engaged to the sport. On of the measures of success in ski lessons is something called conversion which is does that person return either for more lessons or do they purchase additional lift tickets or a pass.

    I use the very same thing, of asking questions about people’s motivations, experiences, expectations, and what they do for a living as it gives good clues as to how to be a more effective instructor. This engages them, they think you are personally interested in them (I am) and what you can share of yourself is something they will remember about you.

  4. Alan permalink

    Are you aware of http://wh.gov/i220E

    It’s a movement to take steps toward protecting health care providers. We could use your help to spread the message.

    Thanks.

    http://pedsresident.blogspot.com/2015/01/a-message-from-colleague.html?m=1

    http://crabdiaries.com/in-memoriam-dr-michael-davidson/

  5. Josef chemtob permalink

    The advent of telemedicine as a way to monitor patients after discharge may improve patient satisfaction. The CMS has decided to correlate patient satisfaction with reimbursement in a very serious way. Many at the american Telemedicine association have argued against this correlation. It really speaks to the heart of this discussion.

    If I, as a provider, decide to withhold narcotics I don’t believe the patient needs currently I can be penalized financially and so could my employer. What about bad outcomes? If my family member dies and the hospital did everything they were supposed to do, but I am not happy because of the result, I can cost them actual money!!!

    I am not sure why CMS decided on this (to save money of course!) but it’s a very slippery slope.

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