We recently participated in a training session on customer service as part of a required new employee orientation. An administrator from our hospital discussed the importance of running on time, answering phone calls promptly, knowing the costs for the procedures we order and communicating in a culturally sensitive manner. She emphasized the hospital’s new mission statement and policies on appropriate attire and clean floors. She suggested that we accompany patients to their destinations if they ask us for directions. She demonstrated that nurses who do two things at once are often abrupt with patients. While the administrator’s goal was to help us create a better hospital environment for all our patients, her presentation concerned us a great deal. She did not seem to understand that those who bang the drums of customer service may not be making medicine kinder, gentler or better.
Many physicians don’t share our concerns. Despite the fact that they would not prescribe medication without scientific evidence supporting its use, they are blindly jumping on the customer-service bandwagon with little proof that it will help. Some practices have even begun to tie physician compensation and advancement to Likert-scale patient evaluation data.
While it is appropriate to care about how people experience the health care system, we do a disservice to our patients and ourselves when we divert resources into training doctors to follow a business model of customer service. It is a model that only addresses a small part of patient care and patient satisfaction goals.
An important distinction
To be sure, standards of courtesy and professionalism should form the bedrock of any medical practice. Empathy and active listening represent important aspects of patient care. But do we really think these qualities are embodied in the maxim “the customer is always right”? Historically, customer service was a term of art developed to apply to business transactions. It does not translate well to the world of medicine because there are crucial differences between patients and customers.
A traditional business defines relationships by the simple rules of economic exchange. A customer chooses to transact with a certain establishment, and as a result, the establishment’s revenue increases. Customer service is a business idea developed to attract and retain profits. In contrast, a patient transacting for health care may positively, neutrally or even negatively affect revenue. Patients may carry good, poor or no medical insurance. By tradition and legislation, institutions are obligated to care for all of them.
Studies show that the lack of a monetary exchange alone actually negatively affects satisfaction.1 Thus, physicians who donate time and expertise to underinsured patients often suffer from poor patient satisfaction ratings through no fault of their own. Conversely, expensive private physicians may receive fewer patient complaints, even if the quality of care they deliver is poorer than their colleagues’. Evaluating physicians by their patient satisfaction scores paints an inaccurate picture of the actual value of the care and service they render to their communities. There is no evidence that improved customer satisfaction correlates in any way with the revenue physicians generate for their institutions.
Beyond the economics
Doctors know that the physician-patient relationship is about much more than profit. Because of the physicians’ obligations for their patients, the relationship does not lend itself well to the language of customer service. Physicians have a duty to care for patients even after they have terminated the relationship, and if they fail, they can be sued for abandonment. This obligation outweighs any transgressions patients might make, be they related to delinquent accounts, abuse of staff or any other issue. But our obligations have more profound implications too. Our emotional bond with patients often leads us to care for them without regard for profit. An institution has similar, legally mandated responsibilities.
However, patients carry no obligations to us. McDonald’s would not remain in business long if its restaurants delivered free food at home to the needy, but many physicians know all about visiting sick patients at home and then throwing away the bill. We see needs and we try to fill them. We are givers and our patients are recipients. This is an essential part of our task as healers but is ignored in the profit-based model of customer service.
Another crucial factor distinguishing medical relationships from purely economic ones involves patient satisfaction. It is a rare patient who is overjoyed about advice concerning the need for a colonoscopy or alcohol cessation. Yet, as physicians, we frequently must make recommendations or interventions that are painful for our patients. We do so with the knowledge of our ability to ultimately help them. In general, patients come to physicians for the care they need; that is not always the same as the care they want. It is our responsibility and duty to our patients to be mindful of the distinction between the two.
Proponents of customer service models also use patient retention as a benchmark for quality service. However, this may be an inappropriate marker. Few relationships compare to that of physician and patient in terms of intimacy, trust and length of service. Comparing a physician to an electrician ignores these crucial differences. Statistics might show that a physician retains “customers” as well as other businesses, or they might show poor retention. The electrician might have few repeat customers; the physician might have many. But what do these data really mean? A surgeon who sees patients every five years might have poor retention compared to a family physician who sees patients monthly. Using these data to make generalizations about customer-service delivery ignores the crucial uniqueness of the physician-patient relationship as well as the differences between specialties.
“Quality of Life and Patient Satisfaction: ESRD Managed Care Demonstration.” Pifer TB, Bragg Gresham JL, Dykstra DM, et al. Health Care Financing Review. 2003;24(4):45-58.
“Satisfaction With Care: Do Medicare HMOs Make a Difference?” Tudor CG, Riley G, Ingber M. Health Affairs. 1998:17(2);165-176.
“Insurance Type and Satisfaction With Medical Care Among HIV-Infected Men.” Katz MH, Marx R, Douglas JM Jr, et al. Journal of Acquired Immune Deficiency Syndromes & Human Retrovirology. 1997;14(1):35-43.
Defining quality care
Of course the fact that traditional models of customer service apply poorly to the health care environment does not mean physicians and their institutions shouldn’t try to improve. Physicians should become better communicators. They should be mindful of providing prompt and efficient service to their clients. But patients, physicians and administrators must not lose sight of how medicine is different from the business world.Medicine is at a crossroads. For the first time, the administration of health care delivery systems has largely been taken out of the hands of physicians. While this approach has the potential to improve outcomes for everyone involved, it also carries dangers. We must remind our administrators that doctors are not equivalent to company employees and that patients will never be just customers. Instead, we are partners in a complex and dynamic relationship. This relationship needs unique benchmarks for its successes and failures. Quality of care can be measured: hemoglobin A1c ranges for patients with diabetes, operative complication rates for surgeons and waiting room times are only a few examples of objective standards we can use to measure quality. Science helps us discover medications, provide treatments and save lives. Let’s not abandon our scientific approach when we evaluate ourselves.
Editor’s note: What is your opinion of using the business model of customer service in medicine? Should customer service indicators be used to evaluate physician performance? Send your comments to firstname.lastname@example.org, or fax them to 913-906-6010.