Patients are NOT Customers

Screen Shot 2015-03-21 at 4.26.26 PMRecently 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:()

“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.

Shirie Leng is a physician-blogger based in Boston.


27 replies »

  1. We are nothing more than chart numbers with as many billing codes as they can slam into it. We are customers, we are paying directly for these unwanted services. If you would like I will send you all the bills the insurance doesn’t pay them. Every patient gets the same lousy service, no exceptions, you are not an individual person. If you want the mercy of anesthesia you must pay for that yourself or you can just suck it up. You can’t bank your own blood or have any say in scheduling. You are left scared and a mental wreck waiting weeks and months to get results, explanations and finally the surgery you need. The only way the doctor knows my name is by the paper he is holding in his hand when he walks in the door. All we can do is hope that they are better at procedures than actual personal care because that part doesn’t exist anymore. Welcome to socialized medicine, get fed down the chute like cattle.

  2. Your full of bs.
    I spent 5 hrs sitting waiting for some quack to spend 5 seconds to tell me it’ll be OK in 2 days.
    Well it’s been long past 2 days and hurts like hell.
    We are customers and should be treated with respect and courtesy just like any other relationship. They are paid by us to perform a task in certain guidelines for a paycheck.
    Under your guidelines working at a grocery store is the same thing and they should not care about satisfaction either.

  3. This is the problem!!! Patients ARE ABSOLUTELY customers! This is the view that makes my blood boil.

    Medical care is a service industry! We pay our insurance and they pay the doctors. Doctors have wanted this view for years—ever watch an episode of House? A lot of doctors have total disdain for their patients. The author of this is WRONG in a fundamental way.


    Get over it! Patients are customers no matter your opinion!

  4. The focus on patient-centered and value-based care has placed the patient in the role of “customer,” bringing with this title all nuances of servitude and service that customers expect. I would have to agree with Dr. Shirie Leng, that patients are not customers and, as such, healthcare providers are not servants beholden to upholding “good customer service,” since this means something different to every person. The challenge that we now face as a medical community is how to meet the goals of patient-centered care and patient expectations, while simultaneously providing appropriate, safe, and guideline-based care.

    Value-based care, which is at the core of the Affordable Care Act, is transforming health care, both literally in terms of financial reimbursement structures for hospitals and physicians, but also psychologically in the way that patients and physicians perceive the way in which care should be delivered. However, the issue arises when we collectively attempt to define terms such as “health,” “value,” and “quality.” Consider the following definitions of “health” cited by Jennifer Bresnick in Health IT Analytics:

    “Health can be considered at a single point in time or in terms of improvement or decline over several months or years. It can mean a full return to wellness after an acute episode with a defined treatment pattern, such as a broken leg The best possible degree of wellness while suffering from one or more chronic diseases. Health can be physical, mental or behavioral emotional, or socioeconomic. It can depend on genomics, circumstances, educational levels, and lifestyle choices far outside of a provider’s control. Health status and health outcomes can be measured in thousands of different ways, depending on which metrics are being used. And it can differ drastically when seen from the viewpoint of a clinician as opposed to through the eyes of the patient herself.”

    This latter statement is perhaps the most important. Being on different sides of the white coat, patients and physicians may define the aforementioned terms differently, making it all the more difficult for each to play his or her part in health care. Concrete definitions of quality are universal, however, referring to metrics such as improvements in efficiency and safety. Missteps occur when these terms take on abstract, personalized definitions, which is typically the case. The problem is further complicated by the fact that without discrete definitions, it is impossible to develop measures to accurately and adequately assess quality care. The bevy of patient questionnaires and surveys given to patients to assess their inpatient or outpatient care experiences are hardly the bastions of reliability. They are easily riddled with biases that have nothing to do with quality patient care. Why should a physician, who follows appropriate clinical guidelines for safety be penalized if a patient was simply having a bad day or was refused a medication he or she was demanding on the grounds of improper care? Similarly, on the flip side, why should patients be judged or criticized for being late to an appointment if there were structural issues that prevented them from making it on time, such as limited parking or delays in public transportation?

    It is clear that there is a need for understanding and reflection for both parties involved. However, here is where Dr. Leng’s argument becomes crystal clear – the patient cannot be the customer and physicians are not obligated to give the patient exactly what he or she wants if it is not in his or her best interest. The unfortunate truth is that sometimes patient care can feel that way with the degree of patient and family demands becoming greater and greater. The patient-physician relationship can already be strained
    without the added pressures of value-based care given the time constraints of the clinic. Appointments are typically limited to 15 to 20 minutes at most, making it nearly impossible to cover all of a patient’s needs. How then are we as clinicians supposed to stuff “value” into the equation when it is such a subjective behemoth?

    One way is to make patient education and communication the center of the physician-patient model. Creating comprehensive education programs and material on a patient’s given medical condition can improve understanding and facilitate improved compliance. Since physicians often lack the time to properly and fully counsel patients in the span of a single visit, external channels of communication should be optimized. With the prolific spread of Smartphone technology and Internet access, information can be disseminated quickly and easily. Multiple start-up companies around the country are developing telemedicine and mobile platforms to connect patients with health care providers outside of the clinic setting, making it easier to educate and communicate with patients. We should harness these valuable tools in order to develop educational modules and open communication tracts for patients.

    Additionally, physicians and patient alike need to maintain a check on their expectations. As a patient, it is reasonable to expect safe, personalized, high quality care that minimizes adverse events. The benefit of value-based care and access to information is that it provides patients with the agency that they long lacked in the patient-physician power struggle. However, there is inherent danger in providing patients with too much agency in their care. The patient doesn’t always know what’s best. But, then again, neither does the physician. Yet, the hierarchy exists because the doctor has education, training, and experience that far surpassses that of the lay patient and that is why physicians cannot simply be in servitude to their patients.

    Clinicians must yield this power carefully and thoughtfully, however. As physicians, we need to understand the structural and societal reasons for a patient’s behaviors and actions rather than simply judging the outcomes of those decisions. Likewise, patients need to understand that their agency is necessary, but only to a point. A physician needs to be able to perform his or her job appropriately without being swayed by demand and the pressures of value-based care.

    However, we must not forget that money talks and without it patient care does not exist. Many suggestions have been made to promote value and quality from a financial standpoint. Specifically, transitioning from a fee-for-service model to a salaried model is one of these options. When the incentive to see more patients and bill under the umbrella of “value-based care” is taken out of the equation, it can become easier to focus on the quality and safety of care without feeling pressured to adhere to patient demands. As progress in health care is slow, only time will tell if this will become a reality.

    Regardless, value-based and patient-centered care is the new wave and revolution of modern-day health care. Patients are the owners of their own bodies and their health care. Physicians must continue to make recommendations and decisions in the best interests of their patients. This partnership and understanding between the patient and physician is the only way that health, quality, and value will be realized.

  5. I just called to get Cat scan results today for my partner and had to remind the person answering the phone that I was a customer paying for services and not an imposition that they could just dismiss. She changed her rude tone completely and I got the information I needed very quickly. The usage of the word Patient is oxymoron as there is nothing Patient about having a broken leg and being Patient waiting for it to be fixed. I agree with some points the author is making but all business falls into U.C.C. code. The word patient originally meant ‘one who suffers’. This English noun comes from the Latin word patiens, the present participle of the deponent verb, patior, meaning ‘I am suffering,’ and akin to the Greek verb πάσχειν (= paskhein, to suffer) and its cognate noun πάθος (= pathos). We are all customers of the medical establishment regardless of what category word the establishment bogs us down with.

  6. I understand your point but it seems to be caught up in semantics. I can easily counter each of your points. 1) As a home owner, I am often in a position of seeking services that I do not necessarily “want” such as a plumber or roofer. But I have a problem that needs a solution and I need to hire a professional to remedy that problem. I do not want to spend the time or money dealing with the issue, but if I do not, the problem will likely get worse. This is hardly vacation mode. 2) Patients are not forced to seek care in most cases, with the exception of emergency or life-saving care. There is always the option to decline service. 3) Patients most certainly are paying for the service one way or another. 4) Outcome metrics can (and should), measure the overall experience – especially since the majority of patients are seeking care for chronic conditions. 5) The patient is right to expect to be treated with compassion and professionalism. This would play out in helping the patient come to a better understanding of why the recommended course of treatment is, from the professional’s perspective, appropriate for the problem, thus serving the patient’s needs. 6) Patient satisfaction does correlate with quality of care – care being how the service is delivered, hopefully with compassion and, well, care.

    When I was a child my next door neighbor was a nurse. I had, and still have, a chronic illness and one thing she said to me that I never forgot was that I did not have to accept poor service from a healthcare professional. I have changed physicians once or twice over the years once I felt that our relationship was not a good match, when I believed that my doctor was not providing me the service that I needed. I agree that healthcare professionals must approach the patient with humanity as you say, but there is nothing wrong with patients expecting to receive high quality service from healthcare professionals, especially when they are most vulnerable.

  7. Perhaps medical care would benefit if doctors did view the patient as a customer or client. I think medical care would be better if doctors did realize that people can often pick themselves up and go elsewhere. It may not be immediate – depending on circumstances, but it can happen. People also give family and friends referrals to doctors and also tell them who to stay away from. So there is a good degree of consumerism here.

    I’ve left doctors who have refused to answer my questions and told me that if I’m using them I have to trust them; and those who are too specialized to really pay attention to what is going on and consider that the entire body is a unit and maybe the problem lies “outside their box”; or the ones that make a snap diagnosis without actually paying attention to the entire picture; or disbelieve pain. In fact, too often “patients” are afraid to question their doctors or assume that the doctor must know best even when they sense that something is not right with their care or medication or the way they are feeling. Sometimes this is because of the “doctor knows best” ideology or because the doctor is intolerant, or both. Just because doctors have medical degrees it doesn’t mean they can feel what’s going on in our bodies.

    The fact that the editor of The Lancet, Dr. Horton, has recently come out saying that half of all medical literature is false does not do much to enhance the credibility of a medical profession that often relies too much on data and test results rather than paying proper attention to the symptoms as their patient describes – if they’ve even listened in the first place.

    As a result, I’ve mostly left mainstream medicine for holistic practitioners.

  8. Exactly, I agree with your statement. I am also a doctor and practice in Ayurveda. In Ayurveda it is written that it is our duty to save the lives of human beings from any kind of disease. In India we don’t look for customers but only for patients.

  9. Great post! I very much agree with you patients should not be treated as customers! But in a way i can see why physicians would treat patients as customers (because they are)! There are two side to this argument! Paul @ best whitening strips

  10. The list of why patients should not be considered as customers is perfect to believe that they are not customers.
    Approaching patient as a person and humanity will work far much better for the doctor as well as the patient.

  11. 6. Patient satisfaction does not always correlate with the quality of the product.

    Especially in health care.

    Unfortunately, like many things in the health care industry, there is a lot of “noise.”

    Much of that “noise” comes from those who sell patient satisfaction surveys.

    They love to talk (& lobby) about how “vital” they are to good health.

    But when studies check to see if patient satisfaction actually do correlate with quality health care…

    The results are a bit different.

    ‘Best case’ research shows patient satisfaction have no correlation with good outcomes. ‘

    Other studies are more scary. They show poor outcomes (like death) associated with higher patient satisfaction.

    Yet there still seems to be an argument about how important “satisfaction” is to health care.

    The problem might be the word “satisfaction” is often used interchangeably with “respect.”

    Respect is something completely different than satisfaction.

    Patients and physicians have every right to expect to be (and be) treated with respect.

    However, respect does not imply that you agree with or be happy with what the other person tells you.

    Instead it means that as a physician you respect the decision your patient made to trust you with their health issues.

    Then you honor that trust by providing good clinical judgment and care.

    As a patient it means you respect the education and expertise of your physician.

    Then understand that sometimes what you “want now” from your visit may not be what you “need” for your health.

    It’s the ability to understand, and provide, what is “needed” instead of what is “wanted” that is difficult.

    But it’s also what people are really paying for when it comes to health care.

    Unfortunately, satisfaction, at least initially, comes from getting what we “want” when we want it.

    But “having it your way” often has nothing to do with what is “healthy for you.”

    A fact that Burger King figured that out years ago.

  12. Patient satisfaction should be higher than one would expert from customer sanctification. In the retail market, too many people are willing to accept mediocre service.

    For those of us that are in health care, it is our highest calling to take care of the patient. Yet, we see more people in our industry failing that aspect. Our approach should be holistic. That means taking a patients well being into consideration. Yes, that means how we treat them.

  13. For white-collar professional services, one usually uses the term “client” rather than “customer.” I haven’t looked up exact definitions of the two terms, but I think of customer as being more mass-market and transactional, whereas client implies a need for more personalized attention. I think of the client-professional relationship as being more collaborative too.

    Seeking health care services is certainly different than seeking many other services, especially if you’re feeling sick or feeling afraid.

    I would like to believe that providers will get better at attending to patients’ needs and preferences — esp the need to participate more in their care — just because it’s the right thing to do. But realistically, I think providers will do it because patients will be increasingly able to take their business elsewhere, esp if they can move their health data with ease and if they are paying attention to cost.

  14. Hi Shirie,

    Thanks for opening the discussion, it is one that is raging across healthcare right now, without any clear agreement.

    Your discussion does highlight the huge gap between healthcare practicianers, those who work in healthcare, and the rest of us. We are all healthcare consumers, even you as a doctor – patients – people with a health problem, through to caregivers, wellness consumers, walking well etc.

    But we are really letting terminology get in the way of moving forward. The basic issue is that we are all paying for our healthcare and we are paying ever more each year. It is a service I want and I want to have control of the service I receive. It is my body, it is my health, I live and die by the decisions I make, I want to be a partner in my health outcomes. I may not be the subject matter expert in the relationship but it is my life.

    If you work in healthcare you have a particular view and it is a real pity that it becomes an ‘us versus them’ view. In the end we all need healthcare at some point, it is there for our health, not just for sickness.

    I know doctors and nurses want good outcomes, so do healthcare consumers, but no one has all the answers, there are no guarantees in healthcare, it is a pity we cannot work better together. If that means calling us, customers, then I am OK with that.

  15. I am a physician and have been in practice for almost 20 years. Patients are customers and we have not treated them as such to their detriment and ours. In short order, physicians will report to clipboard-carrying middle managers who are in the midst of changing the entire culture of healthcare and we only have ourselves to blame

  16. But have you thought about the situation from the doctor’s perspective? Maybe you feel slighted, but perhaps the circumstances in the office or in the lives of the people that work there have nothing to do with you. Humanity works both ways.

  17. This is true also of doctors. If health care was run like a fortune five hundred company the employees wouldn’t get treated the way they are either. Doctors are the face of the frustration with the system. People forget they are also victims of the system.

  18. As I point out several times on my own site, statistics about costs and outcomes only go so far. Personal decisions have much more to do with emotion and context than numbers.

  19. Nor can you balance the asymmetry between you and your car mechanic. He (or she) knows more than you. At some point you have to trust.

  20. Your are a customer when you are standing up and a patient when you are lying down. There is plenty of room for consumerism in healthcare.

  21. I must disagree with you. Patients are the customer and if we (healthcare) did a better job of understanding this concept we’d have happier and probably healthier patients. Too often I’ve seen situations where a physician’s office has the attitude that they’re doing the patient a favor by seeing them. This creates an adversarial relationship that creates all sorts of problems. We should treat patients as though they’re customers…we might do a better job of taking care of them

  22. All good points, Dr. Leng, but …

    We can think of the patient/customer/consumer/consumer/client in many different ways, and they will act differently depending on whether they are lying on a gurney after a traffic accident, or shopping for healthcare insurance, or deciding whether to go to their primary care doctor or an urgent care clinic.

    But here is why “customer” really has to be one of the names we think of them with: Any business that treated its customers the way customers are often treated across the complex of healthcare and health insurance would leave nothing but a smoking hole in the ground. Its customers would leave it instantly. Healthcare’s customers have put up with it because they have had no say in the matter, no ways to make choices, no information on which to base it.

    If we are unfolding a new world of healthcare in which the customers actually can choose, actually pay at least part of the cost, and actually have some information on which to choose, any healthcare organization that does not think of them as customers who can take their custom elsewhere will soon be selling its assets to someone else who can do it better.

  23. People find a lot of medical care “shoppable” — whether to go, where to go, how much will it cost are all questions that are being asked with increasing frequency.

    You can call that whatever you want, but it’s a simple fact: more people want more control over the patient-physician relationship than they had in the era of paternalistic, Marcus Welby MD medicine (except when they don’t).

    Yes, people are people first: that means quite often they would like to be informed about costs and outcomes, treated like equals, and respected. Humanity is nice. Customer service is, too.

  24. The nature of the patient-physician relationship is, as Kenneth Arrow pointed, asymmetric.

    We can call the patient what we want but that will not balance the asymmetry.

  25. You got this right Shirie: “The patient is a person, not a customer”

    In fact, the person is a patient only occasionally, and rarely continually, even when ill/injured.

    They’re a patient far less often than most clinicians want to to think of them as. And that’s on you (“you” being clinicians). You’re right, I don’t want Accenture going around pretending that “consumerism” is some magic organizing principle that will transform health care. But neither do I want clinicians continuing to proceed as if “patientism” is the first, best, foremost way of thinking about the person they are treating.

    People are people first, and only occasionally patients. Treat us as people first, and mostly, doc. Make sure your practice embodies that simple idea.