Time to retire the "patient consumer"

A recent article in Health Affairs draws an important distinction between patient-centered care and patients as consumers. We need to retire the concept of patient-as-consumer.

The authors, from the Hastings Center, cite the absence of a true market, the lack of sufficient knowledge and time to make informed choices, and the erosion of physicians’ professionalism as reasons to retire the idea. While these alone are sufficient reasons to do so, we would take it one step further.  We believe that positioning the patient as a “consumer” and the physician as “provider” erodes the trusting relationship between physician and patient, which is the cornerstone of healthcare, and in so doing, contributes to the moral injury of healthcare.

When the patient is a consumer there is a shift in the implied power dynamic. Rather than presenting to the physician seeking his or her expert advice and counsel, the interaction becomes a transactional one in which the physician provides a service and the patient pays for it. In this type of dynamic, the patient-customer is “never wrong,” according to Cesar Ritz’s well-known edict, broadly adopted in the hospitality industry.

This has led to the bizarre situation where rooming staff in clinics now sometimes ask the patient what he or she expects from the visit before the patient has had the benefit of any expert guidance. An MRI? An injection? A prescription? Most of them, answering thoughtfully, would probably say, “I want to feel better, whatever that takes.” But often, web searches or marketing campaigns have already set patients’ expectations, and they want specific diagnostic or therapeutic interventions, before they even receive a differential diagnosis.

When physicians become customer service reps, whose reimbursements and incomes are tied to their patient satisfaction scores, the implications for care are subtle, but important.  Physicians might no longer initiate difficult conversations, giving feedback patients do not want to hear about their weight, their smoking, or their substance use, because they fear patients will score them poorly. In addition, patients may come to their appointment with expectations of testing or medication, so physicians may over-test or overprescribe if there is any way to justify it, to avoid an angry reaction.

But physicians know this is not good care. They know it may lead to delayed prevention measures, and they know when patients don’t need the care they demand. But physicians are caught between doing what’s best for the patient-having the hard conversations, declining testing or a prescription-and protecting themselves. 

Much of the business of medicine, curiously enough, seems to assume patient capabilities on par with fully functioning, knowledgeable, and healthy doctors. It assumes patients have the time, energy, focus, and mental acuity to consider all their treatment options dispassionately. It assumes they can shop around and have equal access to other options (i.e., that their insurance covers other entities equally). And it assumes they can walk away without purchasing care in the moment. That may all be true for well care, preventive care, and some elective services, but it is untrue in the context of illness. Anyone who has ever come down with the flu, been a caregiver for a cancer patient, an elderly parent, or an injured child knows none of those conditions apply.

When the patient is a consumer, the obligation of assessing the value (quality vs. cost) of their care shifts to them. And how many non-physician patients have sufficient knowledge to make deeply informed decisions about their medical care?  How many can ask the second-, third-, or fourth-level questions about quality metrics or the risks of cardiac surgery?

This leaves patients evaluating the things they do have the expertise to compare: How good the food is, how nice the lobby is, how large the rooms are, whether staff members are friendly, and whether they were “delighted” by their encounter. None of these, of course, have anything to do with the quality of care they receive.

Medicine as a whole used to be overly paternalistic to patients.  But we must be vigilant about overcorrecting in the other direction, requiring patients and families to assume responsibilities they are not equipped to manage. Sometimes, we just need to take care of patients when they are ill and ask for a partner when they are better.

Dean is a psychiatrist, vice president of business development, and senior medical officer at the Henry M. Jackson Foundation for the Advancement of Military Medicine.Talbot is a reconstructive plastic surgeon at Brigham and Women's Hospital and associate professor of surgery at Harvard Medical School.