Customer or patient?

I can’t remember; are they patients or our customers?

Are our patients really customers? Are they clients? Does this term, borrowed from the business world, really hold water in the current climate of health care? I believe if you ask most practicing physicians and nurses, other than those in charge of administration of groups and hospitals, they would say that they have patients, not customers, and that the whole idea is driving them batty.

The customer service model is very popular. Entire lectures and conferences exist to enforce this enlightened way to view patient care. I understand the drive, to an extent. The people we see in our hospitals and emergency departments need to feel valued and need to feel we are competent and caring. This matters especially in highly competitive markets because the ones who are happy keep coming back. This also matters because people who feel valued may be less likely to sue us. There is some logic to the customer service world view.

Unfortunately, there is madness in the mix. Especially in these days of enforced charity, these days of compulsory volunteerism on the part of professionals, customer is the last word we would use for some of those who receive our services.

First of all, customers in the business world have unique characteristics, identifying traits, if you will. Customers shop for bargains (usually not pressured by a perceived emergency to buy a car at the first dealership they come to), then they pay for the product or service they receive. When a customer enters a retail store and purchases clothing or food, they immediately provide that business with cash, credit card, or check. If they leave with the product but do not pay, they are subject to criminal penalty. If they write a bad check, they may be penalized with a fine from the store, or may be arrested for a pattern of writing bad checks.

However, no one is penalized for abusing our system of health care. Very few in positions of authority are even willing to use the term abuse because it might seem unkind or might lack a certain politically correct sense of compassion. But that falsely inflated sense of compassion has resulted in a wholesale abdication of discernment. And it has infected the medical and nursing professions. Now we are afraid to use our own knowledge and good sense in deciding who is ill, who is not, who is lying, and who is speaking the truth. Every complaint and perception of every customer is given equal weight and validity.

Worse, even as the abuses grow and salaries drop, even as physicians and nurses leave their professions in frustration and exhaustion, enlightened persons in positions of authority are devising new ways to encourage patients to use our services for free and are adding new services we are supposed to supply, also for free.

This makes it difficult to view the world with a customer service mentality. Night after night, patients come to emergency departments with ridiculous dramas with confabulated stories concocted to receive narcotics and sedatives, with complaints they would never waste money on with a real doctor. And they do it because they won’t have to pay anything. They ride with their neighbors, who happen to be coming to the hospital, and check in because I was here anyway, knowing that the professional on site is responsible for their well-being, knowing they can sue if he makes a mistake, and knowing they owe that person, ultimately, nothing. Not even the respect to keep them from saying, It’s about time, when their wait is long. These customers are draining the life from medicine.

What do businesses do? In the nonmedical business world, there are also customers who cause trouble. They purchase and return constantly. They try to steal. They attempt to create self-inflicted injuries on store property with an eye toward lawsuits. They cheat on special deals. Do businesses try to encourage them to continue coming to the store? No. Do managers look over the customer satisfaction surveys of shoplifters and wring their hands? Do they apologize to clients who assault their employees, and offer them coupons to continue being valued customers? Try it sometime, and see how welcome you remain.

This customer service drive has caused us to apply a twisted kind of democracy to our policies, where every client has an equal vote in whether the physician, nurse, or hospital is doing a good job. But even democracy, without proper checks and balances, just allows the tyranny of the masses. And the masses, especially the masses of health care customers, are not uniformly enlightened enough to tell us how to conduct the age-old business of medicine. If they are, and we believe they are, we should simply put prescription drugs, x-rays, and lab tests in vending machines and take ourselves out of the system.

In the end, however, there is a more perverse, more dangerous aspect to using the terms customer and client to refer to those persons we once saw as patients. Once, we revered our patients because of our ethical, professional, and even spiritual dedication to their needs and our skills, rather than fawning after them for their money. Now, we are too committed to the belief that we deserve a certain amount of money. Now we are enslaved to houses, cars, ex-wives, and ex-husbands. We believe that our children need sports cars when they leave for college, and that we have to retire in golf communities. Because we are so indentured, we are, as a profession, willing to bend for anyone to edge the bottom line upward. And so we are prostitutes to even the worst customers, to satisfaction surveys, to financial credentialing. Doctor and dollar, it seems, sound so much alike.

And what about our customers? When they were patients, we took risks, we stayed up all hours. We strove for excellence for them, as well as for our own material success. We sat at the bedsides of patients with meningitis, we stalked the sources of epidemics, we were bound to them by more than gold. We still do it for customers and clients, but I fear it is with less fervor, less certainty. Witness the lack of call coverage, the unwillingness of young physicians to be available, the early retirements, the desire for nonclinical careers in medicine and nursing. Is it worth my life to care for a customer? Is it worth my health to save a client? Are they worth time away from the ones I love? The danger and the cost always seemed acceptable for patients, to whom I had a sacred duty. It seems less so for customers and clients.

I don’t expect it to stop. I’m sure we’ll keep getting bombarded with reminders about customers and their needs, and more to the point, their desires. But I’d like to see a little reality injected into the discussion. Because so far, we’ve steadily lost track of what it really means to be a customer and what it really means to be a patient. And difference, on every level, is more than semantic. It’s monumental