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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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36 replies »

  1. 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.

  2. 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.

  3. 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 detest this term the most? Because I have non-physician colleagues who are quick to use those above terms to try to be peer equivalents to me, while they are not. Maybe there are non-physician professions that it is completely acceptable to call the person in need of treatment patient, and if the environment calls for a separate term and the person in treatment is not distressed by the label, then the provider can use it! But, when people who are not doctors are too uncomfortable to call someone patient, and yet are manipulating for peer equivalency by, what it is to me in dumbing down terminology, then it is offensive and inappropriate. And tolerance of such inappropriateness only further devalues all providers!
    Hope that clarifies my position in this debate! Onwards and upwards?!

  4. 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 be treated rudely and like their time and money doesn’t matter. I am not talking about profits, I am talking about maximizing the VALUE for the patient. I am more aware of this because my salary is directly affected by my ability to run my office well AS A BUSINESS.

  5. 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!

  6. 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 to say medicine is “not a business” ignores the fact that…well…it is. You may find that a dirty word, but I guess you don’t see your income vary widely based on how your volume is, how well charges are input, and how well your billing staff keeps up on AR. My salary depends on those things. It really does. So I find it very important to be efficient in my use of my time. The side benefit of this is that my patients are happy, as I am not wasting their time either. I don’t neglect good care for the sake of money (that is not only bad medicine, it is very bad business). Good business means I offer the most care as efficiently and effectively as possible. The more I can do that, the more satisfied my patients/customers will be.
    How can that be a bad thing?

  7. 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.

  8. 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 who cares for the uninsured has to raise money and manage the budget. He has staff to pay, and his efficiency is rewarded by allowing him to give more of himself.
    I have seen far too many very good doctors neglect the business side and so lose the ability to use their skill, and lose the passion they have for care. They run their offices poorly and so turn off patients.
    My primary goal is to practice medicine, not make money. I make money so that I can practice, and my ability to do one is directly related to the other. It is a straw-man argument to say that we should focus on care. I have never said otherwise. I simply said that we should not ignore the other aspects, as they directly impact our ability to give care and the patients’ ability to receive it. This is not complicated. Read the post!

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

  10. 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 generalize, pause and reflect first!

  11. “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.

  12. “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!

  13. 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 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.

  14. So, is it your passion and compassion to go to your office each day, or to balance your ledger? When you read what Osler wrote over 110 years ago, I hope you will see it applicable to today. I can’t wait for the lame defenders of the status quo to rationalize, minimize, and downright insult the foundations that solidfy the basis to medicine.
    Or, will they wimp out because I am calling them on it first!?

  15. “the money follows the practice and will pay the bills and provide a standard of living that is appropriate and responsible”
    Sorry, that’s not the case any more. I know many excellent physicians who have been forced to close their practices because they didn’t know how to run a business. EVERY decision made in my practice begins with a thorough financial analysis. This may not be idealistic enough for you, but it allows me to sleep at night and know that I will be able to open my office and serve my patients in the morning.

  16. First, per Ms G-A, you’re close, but I’ll have it up tomorrow night, and the readers can choose if it fits, or if it gives them fits.
    As to PCP, all I can say in reply is “what the hell!?” No, I am not advocating people shirk their responsibilities to their financial and staff obligations, but that the practice of health care is not driven by the money, but the money follows the practice and will pay the bills and provide a standard of living that is appropriate and responsible. But, you read this blog and there are too many people, both posters and commenters, who are focused on the money first and are critical of profit, or are protecting it.
    Hey, I went into medicine to help people, and I will not be corrupted by the path that has been laid these past two decades or more. And all this farce of health care legislation is going to do is pave it with reinforced concrete of continuing the pay offs, rationing the care in the meantime, and destroy the process in the end.
    Personally, both the Republican and Democrat parties could die off tomorrow and I would not shed one single tear for the stalwarts and lackies who drive them along. Not that I have much faith in this Tea Party, but, they are blazing a new trail that I hope people of substance and good character will take over. And one agenda is to rewrite the efforts to redirect health care where it should be traveling.
    Again, take the damn F-O-R out of profit in this profession!

  17. I think Dr. E is looking for this Osler quote:
    “The practice of medicine is an art, not a trade; a calling, not a business; a calling in which your heart will be exercised equally with your head.”
    And I think I sort of agree with him that the business part, although present and necessary, should not be the one part that drives the definition of what medicine is.

  18. Exhausted:
    I enjoy your posts, but I have absolutely NO idea of what your point is here. Are you saying I shouldn’t pay my staff? That I shouldn’t worry if I bounce checks? That the best thing for my patients is to go bankrupt and close my office?
    Please clarify.
    Thanks

  19. Was it Bob Cratchet in “A Christmas Carol” that said the following: “mankind is our business”?
    A play on words, an extension of a philosophy, an interpretation, some other explanation?
    And your new posting is to prove what? Saying it another way validates your position? Face it, people disagree with this perspective of health care is a business. At the very least, this attitude diminishes the value of our profession.
    It is a shame there are others out there who have echoed my opinion and say nothing now.

  20. Of course a physicians’s office is a business. It is taxed as one, after all.

  21. Exhausted: I guess you can say that, but the distinction between care and business is a false one. You must define “business” different from me. My practice is a business. It is. It offers care in exchange for money. I earn my living from it. My staff earns their money from it. We have a business plan and have an accountant and attorney who help us manage the business properly. If I don’t offer care, I can’t have a business; but if I don’t run the business well, I can’t offer care. Both are true.
    Why is it so offensive to identify that people pay for their care? Care costs money. People exchange money for that care. That’s business. I am NOT saying that the business should define the care. I say (for the n’th time): the reason I call it a business (besides the fact that it’s accurate) is to underline how we’ve let our patients down. We think ‘care is all that’s important’, so we order a gazillion tests, make people wait for hours, and don’t strive to make the experience in our offices as good as possible. We figure as long as we are “practicing good medicine” it will offset the rest. It doesn’t. That’s why people are flocking to other types of care. People are tired of us treating them as “specimens” or “diseases.”
    One of the most important parts of the care I give is to run the business well. A well-run business lets me focus on care.

  22. Great rob.You had done a nice job by placing exact role of patient and doctor.Actually,now a days all doctors forget that the patient is also a ‘man’.In his painful life he required a person who will taking his care.He is not only money bank to provide money to you.I like your post.Keep update it!

  23. No, sir, it is not business, it is care, and I am truly disappointed you want to defend it as business.
    Try to talk to the physicians who were your mentors and respectable trainers in your upbringing. They may be retired or just elusive to find, but, they will say the same if not corrupted. When I get back and forward Osler’s statement, I hope it resonates for you.

  24. Exhausted: It IS a business. We have a product and trade it for money. We have overhead, cash-flow, monthly profit/loss reports, and since I own it I get what’s left over. By all definitions what I do is a business (even legally – it’s an S-Corp, LLC). And if I don’t work, I don’t get paid.
    I do not suggest calling patients “customers” or anything else. I simply think we as a profession have neglected customer service because we didn’t remember our patients were paying our salaries. We need to not take them for granted and ignore the fact they are paying money to be with us. It is our duty to them to make that money well-spent.

  25. Ah, where is Mr Holt or his tech crew to delete these spam invaders. Purity 12, get lost!
    Dr Lamberts, are you making an assumption that by having an office, that equates to running a business? Am I the only person who believes that there are interactions between people in this society that is outside the realm of business? God, when you start stretching definitions to fit the convenience of terminology, sanity is lost! As example, we have to now wait for a ruling from the Supreme Court to know whether the actions by an idiot minister and his constipations, er, congregations, meet the definition of Free Speech to disrupt funeral services for people who died defending this country. Uh, duh, I am surprised this idiot is still alive! Offend grieving people who are not at all involved in his crusade. Now that is a death wish, maybe Mr Phelps should be psychiatrically hospitalized for covert suicidal behavior!
    The USA Today, in the Business section today, has a cover story on the lawsuits filed to try to strike down Obamination Care before more doctors have to put up “out of business” signs. Yeah, well if more of us would just remind everyone that health care is not a business, thus not in the jurisdiction of politicians, then maybe these intrusions that just keep getting more and more rationalized and minimized would be squashed.
    By the way, what’s with the comments about the hat? Gives the man a uniqueness. Oh, I forgot, we all have to look like one another, individuality is not accepted under this regime called Obama and his minions.
    Do you people know what these idiots in Congress do when the cameras go off at CSPAN? The same crap you and I do without cameras or reporters in our face. Hey, you elected them. It’s called REPRESENTATION!!!

  26. Excellent discussion about the different roles that both doctors and patients play in their relationships to one another.
    I’ll add another role to those I think the doctor needs to wear, and that is skill at behavior change.
    Competent physicians are skilled at treating the symptoms, diagnosing the disorder, and in identifying desirable behavior changes.
    The truly effective doctor is one who understands each patient and behavior change science well enough to facilitate this in their patients before it leads to serious medical issues.

  27. Very well said, Rob. Hospital personnel sometimes forget that it is the patient who pays them so he could get the quality care and assistance he needs.

  28. Great exploration of the many faces of being a patient, and a physician. In an ideal, faraway place, money might really be “no issue,” but in reality money is there, staring everyone in the face. I run into the same arguments with artists. Yes, we do art for the love of art and to produce thought-provoking enjoyment for the world, but at the end of the day money has to be part of the equation: try putting on a theatrical performance without any financial backing whatsoever. That doesn’t mean you should put money ahead of making good art; it does mean that you have to seriously consider how much something will cost before deciding a particular effect or routine absolutely has to be done a certain way.
    To go back to Yana’s commment, the same is true for children whose parents keep them home for a day due to a cold or the flue. These kids don’t really need to see the doctor: they just need a day of rest to get over the worst of the symptoms. However, the kids won’t be excused from school without a doctor’s note (even though the schools don’t really want them their sick either). The problem is that people abuse this system: many kids and adults plead “sick” while enjoying the ski slopes or the beach. Faced with that type of deception, employers and schools clamp down and everyone suffers. I’m not sure how to solve that problem.

  29. Exhausted: “The customer is always right” is wrong. The only way for this to not be a business is for care to become nationalized. You say, “when you cheapen the practice of care to about making money first, you have lost the soul that attracted you to the practice of care in the first place” – but the entire healthcare crisis is about the mis-management of the financial side of medicine. We have been spending away on the credit card without thinking of how it will get paid. It sounds noble to say “damn the expense, I’m doing everything for this person!” but it is dumb to not consider the financial side of everything. Do I consider finances first? Well, if I don’t have a staff and if I don’t have enough revenue to pay my own salary, I won’t practice any more. The business side happens first in terms of timing, not priority. The business exists to do two things: to care for people, and to make money doing it. My nurses have to get paid. My family needs me to earn a salary. To say otherwise is to be in denial of reality.
    Now, I don’t put the “customer first” at the cost of medical integrity. I don’t put one patient ahead of the entire practice. That’s what the other points were all about. It IS a balance between these roles. I don’t feel I am giving an opinion here, I am just describing what I see.
    Yana: I can’t disagree with that. Just don’t get upset at me for deifying doctors, because I don’t ask for that. I want to respect people and give them their money’s worth. I am very tired of docs feeling like patients come in to the office for the doctor’s benefit. No, we are being paid by patients to do a job, and that motivates me to work hard for them and give them what they pay me to do. I want to justify my charges by the care I give. That’s what it means to run a business.

  30. I will add my perspective as a customer. I am a puzzle, and I want a diagnosis – an accurate one. I want value for the price that is being paid to the service provider, regardless of who is paying it. It isn’t okay with me to pay a $100 copay while the insurance company is paying $35,000 for an operation/procedure that ought to cost $3,500. This is why insurance companies cannot pay claims for necessary care. It’s a lottery, but obviously this scenario is beyond the doctor’s office.
    It is true that you and every physician is running a business. A household is a business as well. It is desirable for every member of our society to run his financial affairs as though he is running a business.
    I am interested in a diagnosis, appropriate testing and treatment that I cannot otherwise get because I can’t order the tests myself or prescribe medication when needed. I want you to have more than training; I want you to have excellent instincts and an inherent talent that makes you particularly suitable for your line of work.
    You may know that you are not God, but society seems to go along with the idea that you are. If I miss work for more than 3 days, I am required to provide doctor’s verification that I can return to work. This means that I am expected to pay money even when I do not need a doctor. I would like to be afforded the autonomy to decide whether I need a doctor at any given time. A majority of illnesses are self-limiting. Getting necessary and desirable care is a good thing. Doctoring as a hobby or to fulfill requirements is a waste, and potentially harmful physically, while absolutely harmful financially to the customer and the other folks who aren’t getting their insurance claims paid. It is the utmost of folly to require a doctor to excuse a person from jury duty. Whether a person can serve on a jury is 100% of his own determination. I wonder what you think of that, if you have been approached and paid to make such an excuse.
    I want to get something of value from a doctor visit. I want something done or some relevant knowledge gained. I don’t see a value in paying for your (overpriced) education and simply being in your company. My responsibility is to stay away unless I have good reason to believe you can give me something I need. I can fail at that, and for that I may pay a financial price, but am counting on you to save me from paying a price with my health through inappropriate and unnecessary treatment.

  31. Hmm, let’s examine the adage I love so much -NOT- : the customer is always right.
    No, the failure in whoever coined that dumbass phrase missed the main point, but, was somewhat correctly alluding to a principle that most business people still forget to this day: the customer is always right, in speaking his/her opinion, but in the end, the opinion could be wrong!
    Ah, how sad society clings to falsehoods way beyond their rightful passing. And so, my dear colleague, you make the mistake of accepting business principles apply to the practice of medicine, but, it is not a service that people can just shrug off and find another server or good.
    We take care of people. Find me another profession outside the practice of clinical care that is as intimate and trusting that is what is the patient-physician relationship, and I will acknowledge your equivalent if it truly rings similarly.
    Face it, Dr Lamberts, when you cheapen the practice of care to about making money first, you have lost the soul that attracted you to the practice of care in the first place. And, I feel I am correct in assuming this when your first point is “I run a business”. Osler has a great quote to clarify this point, which I do not have on me at this time, but I will share with the readers when I can access it at the end of the week.
    It seems too many colleagues have rationalized and minimized this intrusion too much, too long!
    It just validates the attacks by our detractors.
    ExhaustedMD, physician about just as long as Dr Lamberts

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