The Customer Approach to Patienthood

An article about "The New Language of Medicine" in the October 13 issue of the New England Journal of Medicine makes a powerful argument against the use of economic concepts like "customer," "consumer," and "provider" for the caretaking relationship between clinicians and patients. I've never met a doctor or nurse who didn't share the authors' perspective:

The words “consumer” and “provider” are reductionist; they ignore the essential psychological, spiritual, and humanistic dimensions of the relationship — the aspects that traditionally made medicine a “calling,” in which altruism overshadowed personal gain...Business is geared toward the bottom line: making money. A customer or consumer is guided by “caveat emptor” — “let the buyer beware” — an adversarial injunction and hardly a sentiment that fosters the atmosphere of trust so central to the relationship between doctor or nurse and patient. Reducing medicine to economics makes a mockery of the bond between the healer and the sick...We believe doctors, nurses, and others engaged in care should eschew the use of such terms that demean patient and professional alike and dangerously neglect the essence of medicine.

But history is more complicated than "The New Language of Medicine" suggests, starting with the fact that "customer" language, when first introduced 36 years ago, was profoundly humanistic.

In 1975, Aaron Lazare, who was then director of the walk-in clinic at the Massachusetts General Hospital, wrote a brilliant article - "The Customer Approach to Patienthood." Lazare used the concept of "customer" to emphasize the clinical and ethical imperative for clinicians to pay close, respectful attention to their patients' requests. He and his colleagues were writing about mental health care, but their insights apply across the board in medicine:

Some professionals find the word "customer" crass. We believe it is a useful metaphor to describe a relationship in which the patient has the right to ask for what he wants, to negotiate, and to take his business elsewhere if he so desires, while the clinician has the obligation to listen, negotiate, and offer treatment that meets his professional standards. This "customer" relationship, we believe, is in the best interest of both parties.

Unfortunately, Lazare and his colleagues' superb work did not get the attention it deserved. In a recent poll, 78% of physicians said that most health care professionals provide compassionate care, but only 54% of patients said that they do.

Insofar as "customer" language construes health care as a commercial transaction governed by "caveat emptor" it's pernicious and should be fought against. But insofar as it reminds us that medical ethics and clinical excellence require top flight "customer service" as envisioned by Lazare, it should be embraced!

(For an earlier post on this topic, see here.)