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What is a Patient?

What is a patient?  What do they do?  What’s their role in the doctor’s office?  Are they chassis on a conveyor belt?  Are they puzzles for doctors to solve?  Are they diseases?  Are they demographics?  Are they a repository for applied science?

Or are they consumers?  Are they paying customers?  Are they the ones in charge?  Are they employing physicians for their own needs?

It depends.  It depends on the situation.  It depends on perspective.

Some physicians are very offended when the “consumer” and “customer” labels are applied to patients.  They see this as the industrialization of healthcare.  We are no longer professionals, we are made into “providers” – a sort of smart vending-machine made out of flesh.

Patients, on the other hand, get offended when doctors forget who pays the bill.  They see the exam room as a right, not a privilege.  They think they should be the most important person in the exam room, being treated with respect rather than having to bow at the altar of doctor knowledge.

Who is right?

It depends.

My perspective in my practice has been shaped over the 16 years of being in medicine.  It has been shaped by the fact that patients have paid my salary.  It has been shaped by the fact that they can choose to leave my practice any time they want.  I have to give them good medicine, but I also have to work for their business.  I am not talking about practicing bad medicine so that they stay with me, I am talking about everything else about the doctor visit.  So what are the roles in the doctor’s office?  Here’s my perspective:

1. I run a business – I have to pay the rent, pay my staff, pay for immunizations, and (hopefully) have money left for me.  This means that efficiency is king.  If I don’t run the business well, I end up not being able to practice medicine.  On the other hand, the better I run the business, the more chance I have to slow down because the cash-flow gun is not held to my head.  The patient in this case is my customer.

2. I treat a bunch of patients – One of the things that prevents pandering to the demanding patients is the fact that I am interested in the care of all of my patients. If I let one person dominate my time or demand to be seen, it will hurt my other patients.  The patient is the center of the universe of our office, but I mean “patient” in the global sense; it is not a single patient, but the care of our entire patient population.  The patient in this case, is a consumer – one of a group of people using the service I render.

3. They pay me for my expertise – I am a medical doctor who they are consulting for my opinion based on my training.  They are not seeing me “to get a prescription” or “to have tests ordered.”  There are times when it ends up looking like this, but it is always my obligation to give them the best medical care possible.  Sometimes that means that I don’t give people antibiotics and don’t order tests that they want.  The patient in this case is a patient – a person receiving medical care.

4.  I am not God – I don’t know all.  I don’t sit on a higher chair than my patients.  I have knowledge about medicine and a ton of experience.  They have just as much life-experience as I do, and they know their own bodies better than me.  The whole encounter is about fusing that knowledge together and coming with a plan from both sets of knowledge.  My patients are not idiots, and so I need to listen to them.  I expect them to listen to what I say only after I have listened to what they say.  The patient in this case is a participant in their care.

5. It’s their choice in the end – Patients don’t have to follow my advice.  They don’t have to check their sugars or lose weight.  They don’t have to stop smoking or get tests done that I order.  My job is not to make them do that, it is simply to point them in the direction that I think is best for them.  I should not take offense when they don’t do as I say; I should instead look to make sure the cause of noncompliance is not poor communication on my part.  The patient in this case is autonomous.

6.  I am giving care, not practicing science – In the end, I am a caretaker.  I don’t cure everyone.  All of my patients eventually die.  I work to relive pain, I try to help people avoid preventable problems.  I also sit at their side when they suffer, offering companionship, not expertise.  I have a unique opportunity: people build a relationship with me based on their pain and their need.  In this case the patient is a human being.

I am not sure why people bristle at calling patients consumers; that’s what they are.  They are also customers, participants, autonomous, and humans in need.  This is not an “or” proposition.  If we forget the humanity of patients and just treat them as customers, they lose.  But they also lose if we forget that they are paying us and demand our respect and our attention to their needs.  We are as much servants as we are professionals.  Signing up to be a doctor means you agree to give yourself to your patients.  All of them.  It’s hard, and it’s complicated.  It’s a human-human relationship.

Rob Lamberts, MD, is a primary care physician practicing somewhere in the southeastern United States. He blogs regularly at Musings of a Distractible Mind, where this post first appeared. For some strange reason, he is often stopped by strangers on the street who mistake him for former Atlanta Braves star John Smoltz and ask “Hey, are you John Smoltz?” He is not John Smoltz. He is not a former major league baseball player. He is a primary care physician.

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mayweather vs cotto ticketspcpMargalit Gur-AriepcpJames Recent comment authors
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Guest

Aw, this was a really nice post. In idea I would like to put in writing like this additionally – taking time and actual effort to make a very good article… but what can I say… I procrastinate alot and by no means seem to get something done.

Rob
Guest

I sighed because I am not one of those people and I wanted you to hear my point instead of having the reaction to the people who say “they aren’t patients.” That is the difference; I am saying they are best in considered in many ways. Getting caught thinking of them in only one way will get you into trouble.

ExhaustedMD
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ExhaustedMD

Final comment here: First of all, what is with the sigh intro? I sense you are a provider and take care seriously, yet, you defend this use of a term that just plays into the hands of our detractors and manipulators. They are patients in the office, when we talk to insurers or other administrative contacts, when we talk amongst colleagues, and when we present them in clinical care venues. When you start talking about people as customers/clients/whatever else is a business term, it only allows others to lump it into the business mindset. You want to know why I… Read more »

Rob
Guest

Sigh. Nobody calls them customers UNLESS THEY ARE TRYING TO MAKE A POINT. You miss the forrest for the trees. You can’t get beyond the word to see the meaning of what I am saying. You don’t address WHY I am using the term, objecting so much to the fact that I use it in the first place. I never call them customers in my office. I called them that in this post to point out that we need to address the issue of poor service in HC. Patients have it bad enough being sick; they don’t also need to… Read more »

ExhaustedMD
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ExhaustedMD

How many of your colleagues around you call people they provide care for “customers”?
This rationalization only amplifies the adage “hear the lie enough and it becomes the truth.”
I truly believe physicians who practice as care providers with the same passion that brought them to medical school do not use such capricious terms. I know I do not!

Rob
Guest

So you infer that since I put “I run a business” as my first point, it is the most important? No, it was a point of emphasis. Since (I believed) it was obvious that the primary reason for practicing medicines was to care for people, I did not think it needed to be number 1. That would weaken the point of this post, which was that the patient being a paying customer is ignored, railed against, and scorned by docs like you. I think that is a big mistake. It is certainly not the primary job of a doc, but… Read more »

ExhaustedMD
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ExhaustedMD

I did. #1. “I run a business.” Your first point. The sentence seems simple and direct to me. You did not say “I am a doctor and have to run things as a business.”
Process is as important as content. I don’t get the impression you are a businessman, nor that income is your primary agenda, but, you could have presented it better to reinforce that care comes before cost.
Face it, when you rationalize that patients are customers, you have compromised your position.

Rob
Guest

Medicine should not be driven by the business, but it should not ignore it either. I am tired of people getting all huffy, saying that docs shouldn’t think about the business or focus on running it well. We have been very foolish, have been taken advantage of by the insurance industry, the hospitals, and nearly everyone else. Docs are constantly having office staff and managers embezzle money from them (I have seen it many times) because they don’t think of it as a business. As much as it distresses people, it does take money to practice medicine. Even my friend… Read more »

Yana
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Yana

That makes sense, ExhaustedMD. I mean your last paragraph. And pcp is correct that my statement was a gross generalization.

ExhaustedMD
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ExhaustedMD

Thanks Yana, I didn’t think Bob sounded right, but, maybe for the rastafarian version, if I spelled that right. “Ya mon, you gotta the three ghosts commin’ to get ya, mon, so don’t be doin’ the ghanga tonight, mon. Monkind, that wasa our business, and we ain’t gonna do them good if we watcha the purse strings, ’cause it ain’t irie, mon.” As per PCP repeating your(Yana) comment, anyone going into health care to make a buck first is a moron, because there are easier professions to get trained that will make more an income stream, so again, before you… Read more »

Yana
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Yana

Not the reggae singer because it was Jacob Marley 😉

pcp
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pcp

“there are no doctors with “old school” values – I like to think they exist, but I just live in the wrong place – and the doctors seen most often today did not necessarily go into the profession because of a passion for the art and science, but for the income potential.”
Gross generalization. I have never met a single doc who went into primary care because of the income potential.

Yana
Guest
Yana

Wonderful quote!

ExhaustedMD
Guest
ExhaustedMD

“You are in this profession as a calling, not as a business: as a calling which extracts from you at every turn self sacrifice, devotion, love and tenderness to your fellow men. Once you get down to a purely business level, your influence is gone and the true light of your life is dimmed. You must work in the missionary spirit, with a breadth of charity that raises you above the petty jealousies of life.”
William Osler, circa late 1800’s
And, per my wife, it was Bob Marley who said “mankind is our business.”
Not the reggae singer!

Yana
Guest
Yana

I think I get what you’re saying, ExhaustedMD – “…the practice of health care is not driven by the money”, that is, one should not be going into the profession for that reason. And I agree 100%. I understand financial management as well, and think it is relevant to everyone and every household. What the medical profession and industry has become is due to the focus on obscene amounts of money, and part of that is related to the irresponsible handling of money and finances by many people in various professions. What I have seen is that there are no… Read more »