Welcome to Incision and Drainage. On this blog, we’re going to drain some pus.
Of course, we’ll talk about a lot of things, but if I do my job right, most of the topics will be provocative. I like controversies in medicine and health care. I like the fuzzy gray areas, where the laminar flow of clear-cut clinical decisions degenerates into turbulence, where the evidence (or lack thereof) supports more than one point of view.
So I should have plenty of stuff to bloviate about, as is my wont. Why the hell would we give vitamin K to any human patient? Do we really believe ECASS 3 and push t-PA at 4.5 hours? After more than a quarter century, why do we still wring our hands over who should get a head CT? Why does Lewalski wear red shoes? What’s he trying to say? More or less fluids for hemorrhagic shock? Do we really need more EM subspecialties? Hell—do we need the ones we’ve got? Why is it, exactly, that a patient in the ED “belongs” to a particular doctor, but not to a particular nurse? Is it rational, or even ethical, to board patients in our ED when a growing body of literature says we shouldn’t?
Oh, yes, there’s plenty to talk about. Plenty to argue about. Plenty to get hot about. And I’m the kind of guy who believes that a really successful journal club is the one that ends with a fist fight. Laminar flow is boring. Turbulence is mysterious, maddening, and beautiful.
So that’s what I hope to do with this column. Create turbulence.
Patient as Customer
I’m going to kick this off with a concept that has wormed its way into health care over the last couple of decades: the patient-as-customer. This is an idea that appeared at about the time that the era of the Medicare orgy was stumbling to a close. It was clear that the health care pie was going to get smaller, that hospitals and physicians would have to practice in a more explicit and scrutinized fashion, that expenditures would have to be justified, and that American medicine would generally have to become leaner and more competitive.
In other words, health care was a “business,” an “industry.” True, of course, but that’s a bit like saying that an ostrich is a bird, and then expecting it to behave like any other bird. And so, for the last 25-30 years, our approach in the US has been to treat healthcare more and more as if it were any other industry, and then wonder why it continues to get more and more FUBAR with each passing year. Naturally, treating health care as a business means that you have to shoehorn its institutions and values into configurations that make businessmen and administrators feel more at-home and comfy. And from there it’s easy to see how we get to the idea of the patient-as-customer.
Of course, an ostrich isn’t just any bird, health care is not just any industry, and—let me just say it as bluntly as as I can—patients are not customers.
Now, before any of my colleagues holds up an objecting finger, let me just say that I’m pleased to report that I have yet to hear any of you—not a single physician, ever—refer to one of his or her patients as “my customer.” So the good news is that, even though the administrator class within health care continues to push this concept, physicians don’t seem to be swallowing. Maybe that’s because, at some innate level, physicians know the difference. They know what a customer is, and they know what a patient is, and they made a decision to devote their lives to serving the latter, not the former. And despite all the PC propaganda, all the attempts at indoctrinating us with this particularly insidious and subversive example of Newspeak, physicians haven’t bought in. Yet.
That’s because we know, or should know, that patients are not customers. Here, for your consideration, and to celebrate the maiden voyage of this blog, are just ten reasons why not.
1. The relationship is fundamentally different. A customer enters into a commercial relationship with a merchant. A patient enters into a healing partnership with a physician. Everything else flows from this critical distinction.
2. Customers are “always right,” or at least they may reasonably expect to be treated as such. But ask yourself: when the patient swears to you that he’s “just got the stomach flu,” do you shrug, accept his diagnosis, and sell him a bottle of Pepto? You better not. No, our patients are most certainly not always right. In fact, sometimes they need to be told that their behavior is irresponsible, idiotic, or self-destructive.
3. Customers are legally entitled to a product only if they can pay for it. Right now, in this country, the debate over health care entitlement is about to boil over. But it has already been established—morally and legally—that patients are entitled to emergency care whether they can pay or not. This puts our patients squarely outside any classical understanding of what a “customer” is.
4. Merchants may refuse service to any customer. You might think this is a restatement of #3 above, but look more closely. This goes beyond the ability to pay. A paying customer can buy only if a merchant will sell. An emergency department cannot and must not refuse to treat any patient, paying or otherwise.
5. The doctor-patient relationship enjoys legal privilege. The customer-merchant relationship does not.
6. Termination of service. When a customer enters a commercial relationship, either party may terminate that relationship as long as the contract so permits. Once a patient enters the emergency department, the physician has a duty to treat, and as long as treatment is indicated only the patient or his legal surrogate may terminate the relationship.
7. Purpose. The primary goals of the commercial relationship are, well, commercial. They are also asymmetrical: the customer seeks to acquire a product or service, preferably at a bargain price, and the merchant seeks to turn a profit. The primary goals of the doctor-patient relationship are completely non-commercial, and they are symmetrical. Both parties seek to relieve suffering, maintain function, and preserve life.
8. Suitability of product or service. A merchant seeks to sell as much product or service to the customer as possible, and customers are at liberty to purchase any legal product or service, whether or not it is unneeded or even harmful. A physician seeks to provide the patient only with what he or she needs, and may not lawfully or morally provide services the physician knows to be unneeded or harmful.
9. Socioeconomic biomarkers. When a lot of customers patronize a lot of businesses, the indications for the economy and society at large are generally positive. When a lot of emergency departments are jammed with sick, nonpaying patients, there’s a good chance that both society and the economy are seriously awry. Health care isn’t just any bird.
10. Sacred vs. Profane. The relationship of the customer to the merchant is temporal and ultimately prosaic. The relationship of the patient to the physician is far more transcendant and, for lack of a better word, special.
Actually, I do have a better word: sacred. The robust analogy to the doctor-patient relationship is not to be found at the mall, but in the church, the temple, the schoolroom, the family gathering. It is not the visit of a patron to a vendor; it is the reaching out of a parishioner to a priest, a firefighter to a victim, a distraught brother to a caring sister. The patient comes to the emergency physician not with a desired transaction, but with pain, fear, sorrow, hope and vulnerability. The patient comes at the moment of birth, at the nadir of loss, at the precipice of death. The patient comes with his or her aspirations, pride, dignity and very life in the balance. Moreover, a good emergency physician adds some of his or her own emotional stakes to the ante. The patient needs and deserves compassion, unconditional positive regard, deep concern guided by informed intelligence, and the physician’s personal commitment to technical excellence. Both patient and physician have more than currency or commerce at stake in this encounter, which has an importance and a meaning and a humanity far beyond the two-dimensional workings of the marketplace.
Perhaps some can see in our work a similarity to selling hamburgers, giving haircuts, or fixing cars. I do not, and I find the comparison degrading and offensive to my patients and to my profession.
Patients are not customers. They are two different things. That’s why we have two different words for them.
Some things don’t have a price. Some things aren’t for sale.
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