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.

That relationship is never easy, and it can never be boiled down to a single in a single description.

12 thoughts on “What is a Patient?”

  1. Well, I will ‘fess up to being one of those anti-consumer voices on kevinmd when I blogged that I’m a patient, not a consumer. Of course we pay for healthcare services and expect to get something for our money. My quibble with the consumer label is when we see ourselves as the center of some medical retail universe and reduce doctors to the “Would you like fries with that” role–the same quibble I have with the empowerment label. (Maybe I just don’t like labels.) Yeah, I’m pro-doctor because I have four great ones. And no, I’m not a doormat because I like being under their care; being their “patient.” That doesn’t mean I never asked a question or challenged something. When this stuff starts hardening into that kind of “you’re for us or against us” ideology is when we get into trouble.
    Dr. Rob, you summed it up perfectly–it’s a human-human relationship, and it can’t be boiled down to a single description. If I had to try, my description of a good one would be mutual respect.

  2. This seems to be the common thoughts for when physicians refer to those they’re caring for as “customers” or “consumers”. But using these descriptions and characterizations I would argue that EVERYONE is a either a customer or provider. No longer “students” and “teachers” or “clients” and “lawyers” or “civilians” and “servicemen”. Just customers and service providers.
    Granted, your experience and responsibilities for your office and patient population force you to balance the financial and time scales. Wouldn’t delegating these tasks to a office manager alleviate some of these responsibilities, and free up your worries so that patients stop being consumers, and go back to being patients?

    Patient=suffer(er/ing).

    I guess the reason students and clinicians worry about referring to patients as “consumers” or “customers” is because the connotation then implies that they are no longer suffering, and it might make it easier to dismiss their complaints. Or to think of them as people that can be ignored if we just don’t feel like talking. “Customers” takes away from the connotation that these people are sick, or trying to manage their condition.

    Respectfully,
    @hugosays
    😀

  3. Why not the word ‘client’ as is the current trend in the mental healthcare field. A little less cold, more personal implication than consumer or or customer …

  4. I do not think we should call them anything but “patients.” We just need to understand that the relationship is far more complex and that we as docs have neglected customer service, consumer awareness, and the humanity of the relationship.

  5. Excellent post. In the daily hustle and bustle of a primary care clinic we can forget these essentials. Thanks!

  6. I do indeed “bristle” at the thought of calling patients consumers. I understand that patients and physicians play multiple roles when it comes to medicine, but it seems that the most important of these roles takes place in the exam room. I think the term patient connotates a caring relationship in which the physician listens to the patient with emapthy and compassion. The term “consumer” makes me think of marking ploys with the goal of simply trying to squeeze more money out of the consumer.

  7. As a result of my hydrocephalus, I’ve had vision problems since childhood, which include strabismus or “lazy eye” (each eye drifts to one side instead of focusing directly on one thing). I can generally focus one eye at a time, but it shifts. This makes it very difficult for me to do things like count squares on a graph–I have to recheck myself several times to make sure I haven’t skipped a square, or double-counted another one because my vision shifted mid-count. I see two opthalmologists, one “regular” doctor and one strabismus specialist. I recently had an appointment with the specialist. In the weeks prior to my visit, I went to the trouble of typing out a one-page summary of my ongoing vision problems and the difficulties they cause in my day-to-day life, such as when I’m on the computer (frequently) or when I’m doing my crafts (when I’m not on the computer).
    My doctor’s assistant came into the room wanting to know the purpose of my visit. I explained that it would be easier and faster for her to read my notes than for me to try to explain it. She glanced at the paper and proceeded to ask me questions which would have been answered if she’d read the entire sheet. Same thing with the specialist. He came into the room, asked me the purpose of my visit (?), and proceeded to misquote something I’d written on the paper, asking me why I was there if my vision was good enough to read ten-point font (which isn’t what I said at all…)! I politely pointed out to him he’d misread what I’d written. I then asked him to explain to me one more time why he didn’t think surgery was a good option for me at this time. I know I have memory problems because of my antiseizure meds. I know it can be frustrating to have to explain things to me half a dozen times before they finally “stick” in my mind. I know it can be time consuming to email me, or to print out documents for me so that I have a written record of visit details to refer back to so that I *don’t* have to repeat questions. But when you get right down to it, I *am* a paying customer. I’ve always been a zebra, not a horse. That’s not my choice, that’s just the way it is. So I really don’t appreciate doctors getting visibly annoyed with me when I go to the trouble of printing out a document, and they can’t be bothered to read it. Patients can’t always be put into neat little fifteen-minute boxes. That’s why I type out the notes; if the doctor reads them beforehand our time together can be spent much more productively. I wish my specialist would understand I’m not trying to be a hindrance, but a help.

  8. I appreciate hearing your perspective and I am sure it is not easy to be a physician. More and more, the people who I come into contact with who are physicians seem burned out. I’m so glad that you see the doctor-patient relationship as a human-human relationship, though I would hope that this is not news to other physicians. I’m curious if you have read about self-determination for patients. There is a book called, “Self-determination theory in the clinic: Motivating physical and mental health” by Sheldon, Williams, and Joiner (2003) in which these authors argue that the three basic needs people have are: competence, relatedness, and autonomy. They said that for patients, competence is a need to know how they can reach their health goals and a need to feel they can do the activities corresponding with reaching their goals. Autonomy is a need to make choices related to patients’ health goals. And relatedness is a need for “respect and care” from health care professionals and significant others. It seems like their theory fits with some of what you are saying.
    Personally, as someone who has healed completely from an “incurable disease,” I would say that sometimes, I had to be a pain in the ass patient. In fact, it probably saved my life on one occasion and I can think of a few occasions in which I probably should have asserted myself more. I’m sure that my assertiveness and disagreement with the doctors’ treatment plans was annoying to the doctors. But in the end, I went from being a mystery of science case and almost dying to becoming healthy.

    Patients have a lot of different levels of health literacy. At one time, I gave trainings to physicians in health literacy and what I would emphasize is that it is really important to explain medical information on a level that is most appropriate for the particular needs of the patient. I am well-educated (with a Ph.D.) and I can understand medical information rather easily. When I was really sick, I sought as much information about my illness as I could from credible resources. I asked my physicians to speak to me on a relatively technical level because I understood it and I wanted as much information as possible. I also appreciated a genuine sense of empathy and compassion just as much as I appreciated the physician’s expertise. And I paid them for expertise, yes, but I needed that expertise as a part of a healing milieu of empathy, compassion and kindness.

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