About that customer thing....

Medical school did not prepare me for 2019; it sure isn't what I expected it to be when I matriculated at Baylor College of Medicine some 36 years ago. I chose to go into medicine because I thought I could do some good, and I thought it would be rewarding to help sick and injured people get better, because, let’s face it, everyone wants to be a little bit of a hero, right? It all sounded very exciting, meaningful, and medicine was well respected. As a doctor I thought my life would mean something.

Well, that was in the old days, in 1983, and it was true for a while. I loved connecting with people and being able to make a difference in their lives. Their smiles and their confidence made me feel incredible and grateful, and I didn't mind the long, crazy hours without food or sleep. It was enough that I could help someone in need. 

But that was in the before-time. Before entrepreneurs decided that health care was a great way to make their next fortune. Before insurance companies dictated what procedures we could order and what medications we could prescribe. And definitely before medical practices and hospitals were gobbled up by corporate tycoons whose primary interest was profit, not people. We physicians signed on with these insurance companies and merged our practices to corporations because our operating costs were higher than our reimbursements if we did not. The independent medical practice is now a rare phenomenon, since it gets compensated only a fraction of the amount for the same service as the practice that belongs to a large collective. And these collective groups are rarely operated by physicians.

Today the relationship between physicians and patients is different. People don’t really respect doctors anymore. Doctors get blamed for everything. We are supposed to be able to make you better no matter what your problem is, and—no matter whether or not you take our advice on treatment. And we're supposed to be able to do it right now. There’s been this unspoken “truth” floating around out there, that no one should ever suffer and everyone should be curable. If not, someone must be to blame. It’s usually the doctor.

I don’t know where this came from, but it’s just not true. Some things we can only make less miserable. And some things, maybe, we shouldn’t fix. That’s the subject for another blog.

Doctors are reprimanded by their patients for not spending enough time with each one, but we are also taken to task for not documenting a hundred thousand bits of information in each patient’s chart. Only about a quarter of that information is necessary to understand the treatment of the patient: what we found, what we think, what we recommend. So we or the next physician can look at the chart and know how to proceed. The rest of it is strictly for billing purposes for your insurance company. I’ve heard numbers as high as 75% of a hospital intern’s time is spent on their tablet "documenting." That’s where the patient-contact time is going, and that is what we hate. Or should I say, the “customer”-contact time?

Yes, my friends. You are no longer "patients." You are "customers;" consumers of health care.

We are also required to make our “customers” happy, above all else; make sure our patients customers are pleased with our care, so they will give us good Press Ganey scores on customer satisfaction surveys. If we don’t get the good scores, we are obviously “bad doctors”. Poor scores could accumulate because we didn’t recommend a medicine advertised on TV that interferes with other conditions you may have, yet even after we have revealed this information, you still wanted to give it a try—because, well, the commercial looked so enticing. Or perhaps we explained that the potential risks of a procedure you read about actually outweigh the benefits to you in your given situation. But the scores could also mean you didn’t like the coffee creamer selection in the waiting room. If we get poor scores, we lose our standing, our bonuses, and your hospital may not get the appropriate Medicare compensation. Gotta keep everyone happy.

I didn’t go into medicine to make a lot of money. I figured I’d be comfortable, able to put my kid through school, live in a decent house in a nice neighborhood, and have a nice car. “Nice” for me is my 2010 Subaru Outback. I like it just fine. It has over 90,000 miles on it, and I’ve been happy with it for every single one of those miles. 

So, this customer thing. I always thought that patients were sick, suffering, vulnerable humans, maybe even a little bit scared. They’d cut themselves, maybe broken a bone, had a fever they could not explain, or just felt lousy. Maybe their appendix ruptured or they were having a heart attack. They needed help. That’s where we physicians would come in, to fix them up, give them medicines if indicated, and reassure them. And their families. I never dreamed that they would show up in my office angry, demanding inappropriate treatment because the media told them it would cure them instantly, and then become incensed that I had taken care of someone sicker than they were first. 

Someone walked into my office one day wanting to be screened for strep throat because they were with a friend who had it. If they weren’t even sick yet, why were they so angry that I took care of the patient who was having an anaphylactic reaction to the nuts in her banana muffin? Or the person with a new onset cardiac dysrhythmia, who was terrified, having trouble breathing, and had a fever of 102? How could the not-yet strep-infected patient say to me that the cardiac patient should have gone to the hospital instead of wasting her time because I didn't pause for a few minutes to order a rapid strep test while I attended the cardiac patient? Medical school did not prepare me for this.

When we treat patients like customers, is it any surprise that they behave like convenience is a cardinal index of quality?

This customer thing. A patient came in with classic influenza, in the height of flu season. His flu test was positive for Influenza A. He insisted he knew his body better than anyone, and that the flu test was wrong. He has never had the flu and he will never get the flu, he said. He demanded high dose clindamycin, which is a powerful antibiotic, and prednisone, which is an immune suppressant. I explained to him that antibiotics do not work against the flu, since it is a virus and not a bacteria, and that the steroid in this case could make him worse. He said to me “I realize that is your opinion, but I did not come here for your opinion, I came for my medicine. Send it my pharmacy now.” (Or I will give you a zero Press Ganey score). 

Yeah, this customer thing. If we do the right thing, we get slammed. If we do the wrong thing (not that we would), we get sued. Our malpractice carriers used to teach us to empathize and document everything. Our corporate bosses tell us to cut the time we spend on each patient so we can see more patients per hour. We no longer get risk management courses to help us minimize human error; we get compliance seminars, so we can bill for maximum revenue. 

This customer thing is about money, just as the word suggests. It is not about your health. When your doctor’s office sends you a survey to fill out, it is not about how well your malady was treated. And don’t be fooled, it is not even about how friendly the front desk staff was to you. It is about whether you can be counted on to patronize their institution again. Yes, patronize. Dear patients, you are no longer sick, suffering, vulnerable, possibly scared human beings. You have become consumers of health care. 

The media preys on consumers, you know; entices them to buy this drug or go to that corporate hospital system. You’ll be in and out in a half hour, they say about their urgent care clinics. Our hospital is the most up-to-date—except they may be referring to the interior décor. Take this pill and you’ll be well (if you don’t suffer any serious side effects from the enormous list, one of which is nearly always death). No, the surveys come from the same place the Apple TV surveys come from, or Verizon Wireless surveys, or your Subaru dealer.

This is the Voice of Greed, the voice which has crept into every venue of our lives from the water we drink to the “must-have” clothes we buy, to the food we eat. Of course, it is in health care now, too. No aspect of life is exempt.

This is to let you know that your doctors are as outraged as you are, and we miss our time with you.

Please note: Blog is never medical advice.