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Should Doctors Treat Their Patients Like Customers?

Customer or patient?

I can’t remember; are they patients or our customers?

Are our patients really customers? Are they clients? Does this term, borrowed from the business world, really hold water in the current climate of health care? I believe if you ask most practicing physicians and nurses, other than those in charge of administration of groups and hospitals, they would say that they have patients, not customers, and that the whole idea is driving them batty.

The customer service model is very popular. Entire lectures and conferences exist to enforce this enlightened way to view patient care. I understand the drive, to an extent. The people we see in our hospitals and emergency departments need to feel valued and need to feel we are competent and caring. This matters especially in highly competitive markets because the ones who are happy keep coming back. This also matters because people who feel valued may be less likely to sue us. There is some logic to the customer service world view.

Unfortunately, there is madness in the mix. Especially in these days of enforced charity, these days of compulsory volunteerism on the part of professionals, customer is the last word we would use for some of those who receive our services.

First of all, customers in the business world have unique characteristics, identifying traits, if you will. Customers shop for bargains (usually not pressured by a perceived emergency to buy a car at the first dealership they come to), then they pay for the product or service they receive. When a customer enters a retail store and purchases clothing or food, they immediately provide that business with cash, credit card, or check. If they leave with the product but do not pay, they are subject to criminal penalty. If they write a bad check, they may be penalized with a fine from the store, or may be arrested for a pattern of writing bad checks.

However, no one is penalized for abusing our system of health care. Very few in positions of authority are even willing to use the term abuse because it might seem unkind or might lack a certain politically correct sense of compassion. But that falsely inflated sense of compassion has resulted in a wholesale abdication of discernment. And it has infected the medical and nursing professions. Now we are afraid to use our own knowledge and good sense in deciding who is ill, who is not, who is lying, and who is speaking the truth. Every complaint and perception of every customer is given equal weight and validity.

Worse, even as the abuses grow and salaries drop, even as physicians and nurses leave their professions in frustration and exhaustion, enlightened persons in positions of authority are devising new ways to encourage patients to use our services for free and are adding new services we are supposed to supply, also for free.

This makes it difficult to view the world with a customer service mentality. Night after night, patients come to emergency departments with ridiculous dramas with confabulated stories concocted to receive narcotics and sedatives, with complaints they would never waste money on with a real doctor. And they do it because they won’t have to pay anything. They ride with their neighbors, who happen to be coming to the hospital, and check in because I was here anyway, knowing that the professional on site is responsible for their well-being, knowing they can sue if he makes a mistake, and knowing they owe that person, ultimately, nothing. Not even the respect to keep them from saying, It’s about time, when their wait is long. These customers are draining the life from medicine.

What do businesses do? In the nonmedical business world, there are also customers who cause trouble. They purchase and return constantly. They try to steal. They attempt to create self-inflicted injuries on store property with an eye toward lawsuits. They cheat on special deals. Do businesses try to encourage them to continue coming to the store? No. Do managers look over the customer satisfaction surveys of shoplifters and wring their hands? Do they apologize to clients who assault their employees, and offer them coupons to continue being valued customers? Try it sometime, and see how welcome you remain.

This customer service drive has caused us to apply a twisted kind of democracy to our policies, where every client has an equal vote in whether the physician, nurse, or hospital is doing a good job. But even democracy, without proper checks and balances, just allows the tyranny of the masses. And the masses, especially the masses of health care customers, are not uniformly enlightened enough to tell us how to conduct the age-old business of medicine. If they are, and we believe they are, we should simply put prescription drugs, x-rays, and lab tests in vending machines and take ourselves out of the system.

In the end, however, there is a more perverse, more dangerous aspect to using the terms customer and client to refer to those persons we once saw as patients. Once, we revered our patients because of our ethical, professional, and even spiritual dedication to their needs and our skills, rather than fawning after them for their money. Now, we are too committed to the belief that we deserve a certain amount of money. Now we are enslaved to houses, cars, ex-wives, and ex-husbands. We believe that our children need sports cars when they leave for college, and that we have to retire in golf communities. Because we are so indentured, we are, as a profession, willing to bend for anyone to edge the bottom line upward. And so we are prostitutes to even the worst customers, to satisfaction surveys, to financial credentialing. Doctor and dollar, it seems, sound so much alike.

And what about our customers? When they were patients, we took risks, we stayed up all hours. We strove for excellence for them, as well as for our own material success. We sat at the bedsides of patients with meningitis, we stalked the sources of epidemics, we were bound to them by more than gold. We still do it for customers and clients, but I fear it is with less fervor, less certainty. Witness the lack of call coverage, the unwillingness of young physicians to be available, the early retirements, the desire for nonclinical careers in medicine and nursing. Is it worth my life to care for a customer? Is it worth my health to save a client? Are they worth time away from the ones I love? The danger and the cost always seemed acceptable for patients, to whom I had a sacred duty. It seems less so for customers and clients.

I don’t expect it to stop. I’m sure we’ll keep getting bombarded with reminders about customers and their needs, and more to the point, their desires. But I’d like to see a little reality injected into the discussion. Because so far, we’ve steadily lost track of what it really means to be a customer and what it really means to be a patient. And difference, on every level, is more than semantic. It’s monumental.

*This blog post was originally published at*

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Richmond, VA – In an effort to simplify inpatient medical billing, one area hospitalist group has determined that “altered mental status” (ICD-9 780.97) is the most efficient code for use in any patient work up.

“When you enter a hospital, you’re bound to have some kind of mental status change,” said Dr. Fishbinder, co-partner of Area Hospitalists, PLLC. “Whether it’s confusion about where your room is located in relationship to the visitor’s parking structure, frustration with being woken up every hour or two to check your vital signs, or just plain old fatigue from being sick, you are not thinking as clearly as before you were admitted. And that’s all the justification we need to order anything from drug and toxin screens, to blood cultures, brain MRIs, tagged red blood cell nuclear scans, or cardiac Holter monitoring. There really is no limit to what we can pursue with our tests.”

Common causes of mental status changes in the elderly include medicine-induced cognitive side effects, disorientation due to disruption in daily routines, age-related memory impairment, and urinary tract infections.

“The urinalysis is not a very exciting medical test,” stated Dr. Fishbinder. “It doesn’t matter that it’s cheap, fast, and most likely to provide an explanation for strange behavior in hospitalized patients. It’s really not as elegant as the testing involved in a chronic anemia or metabolic encephalopathy work up. I keep it in my back pocket in case all other tests are negative, including brain MRIs and PET scans.”

Nursing staff at Richmond Medical Hospital report that efforts to inform hospitalists about foul smelling urine have generally fallen on deaf ears. “I have tried to tell the hospitalists about cloudy or bloody urine that I see in patients who are undergoing extensive work ups for mental status changes,” reports nurse Sandy Anderson. “But they insist that ‘all urine smells bad’ and it’s really more of a red herring.”

Another nurse reports that delay in diagnosing urinary tract infections (while patients are scheduled for brain MRIs, nuclear scans, and biopsies) can lead to worsening symptoms which accelerate and expand testing. “Some of my patients are transferred to the ICU during the altered mental status work up,” states nurse Anita Misra. “The doctors seem to be very excited about the additional technology available to them in the intensive care setting. Between the central line placement, arterial blood gasses, and vast array of IV fluid and medication options, urosepsis is really an excellent entré into a whole new level of care.”

“As far as medicine-induced mental status changes are concerned,” added Dr. Fishbinder, “We’ve never seen a single case in the past 10 years. Today’s patients are incredibly resilient and can tolerate mixes of opioids, anti-depressants, anti-histamines, and benzodiazepines without any difficulty. We know this because most patients have been prescribed these cocktails and have been taking them for years.”

Patient family members have expressed gratitude for Dr. Fishbinder’s diagnostic process, and report that they are very pleased that he is doing everything in his power to “get to the bottom” of why their loved one isn’t as sharp as they used to be.

“I thought my mom was acting strange ever since she started taking stronger pain medicine for her arthritis,” says Nelly Hurtong, the daughter of one of Dr. Fishbinder’s inpatients. “But now I see that there are deeper reasons for her ‘altered mental status’ thanks to the brain MRI that showed some mild generalized atrophy.”

Hospital administrators praise Dr. Fishbinder as one of their top physicians. “He will do whatever it takes to figure out the true cause of patients’ cognitive impairments.” Says CEO, Daniel Griffiths. “And not only is that good medicine, it is great for our Press Ganey scores and our bottom line.”

As for the nursing staff, Griffiths offered a less glowing review. “It’s unfortunate that our nurses seem preoccupied with urine testing and medication reconciliation. I think it might be time for us to mandate further training to help them appreciate more of the medical nuances inherent in quality patient care.”

Dr. Fishbinder is in the process of creating a half-day seminar on ‘altered mental status in the inpatient setting,’ offering CME credits to physicians who enroll. Richmond Medical Hospital intends to sponsor Dr. Fishbinder’s course, and franchise it to other hospitals in the state, and ultimately nationally.


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