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My Patients ARE Customers Too

I read with great interest a recent editorial by Dr. Scott Haig, an Assistant Clinical Professor of Orthopedic Surgery at Columbia University College of Physicians and Surgeons who also is in private practice in the New York City area. The piece appeared in Time online and you can read it here.

I saw a reflection of my thoughts for years and years. Patients are not “customers,” because they’re patients. The word “customer” is demeaning to our “patients” and can’t characterize the relationship healthcare givers have with the individuals we treat. We touch the very soul of some patients and they do ours as well. “Customers” are lumped into the same dustbin as “business.” And everyone knows when you are talking business, you’re talking money. And in the “practice” of medicine, we’re above all of that, because we sacrifice for our “patients” in a way a businessman could not ever imagine for mere “customers.” That’s how I used to think. But my thoughts have evolved.

Patients are my customers. They’re also my clients. They’re my buyers.  They’re also a revenue stream. They are the reason I exist. They can be all these things. Even simultaneously. It’s a continuum of words that are commonly crossed over. Especially with the transition of the “practice of medicine” to the “business of healthcare,” that leaves physicians and other healthcare professionals feel passed by.

When I first heard my patients being referred to as “clients,” it was from a social worker. I remember I jumped on that! “Your CLIENT is NOT MY PATIENT!!!!” I said. But here’s when I started to change my perception a bit.

I was walking the mile of direct care workers preparing a new keynote speech for the State of Pennsylvania’s first ever “Direct Care WorkerConference” a few years ago. In preparation for any speech to a new “dot of healthcare audience,” I spend a day or two observing the work of that particular “dot,” to provide value interpretation of the specific ”healthcare dot” during the program. This has afforded me a broader perspective than I had when I practiced medicine for  “patients,” and has allowed me to appreciate all the contributions to care a wide variety of  individuals provide.

I remember, while observing in a long term residential facility, I called one of the elderly ladies moving about with a walker a “patient.” Vera, my direct care worker I was shadowing said, “she’s not a ‘patient,’ she’s a ‘resident.”

Vera went on to explain, “She’s not a patient because she’s not sick, she’s just old.”

Wow. That was a wake-up call to the doctor in me. I coudn’t argue with this logic. So when I’m in the grocery store and  see a person whose gallbladder I’ve liberated, am I seeing a “patient” or a “customer?” Or a “client?” He’s not sick now. He’s all better because when he was MY PATIENT, I got rid of the offending gallbladder. Now he’s fine. So what is he?

I could call him a “former patient,” but if he returns to me because of a health issue, (and I genuinely hope if the occasion comes up again that he needs my services, he will choose ME and not someone else), he may be my “patient” again. Was he a “patient” before his gallbladder acted up? If I met him at a Rotary Club meeting years ago when I was giving an informational lunch program, (read: Marketing), on the new laparascopic cholecystectomy technique that my partner and I introduced years ago, what was he then? Sometimes he may be a patient, other times he may be a customer? It’s really a circle.  Perhaps the right way to address him would simply be by name.

It might be instructive to look at the etymology of the word “patient.” The Latin root “pati” means to suffer or endure. Patients endure maladies. “Customer” isn’t quite the same. Customer derives from the Middle English word, “custome,” and came to refer in an informal sense of a chap or fellow when it became ”customer.” But usually the word was typically prefixed with a pejorative, such as a “tough” customer or an “ugly” customer. How today we might characterize a criminal or other miscreant. While current usage meanings may have changed,  it is apparent that “patient” is a much more sympathetic term.

What came first, the chicken or the egg? The “customer” or the “patient?” Or the phoenix or the flame to cite J. K. Rowling’s recent Harry Potter and the Deathly Hallows book, “the answer is a circle has no beginning.” The real answer is, it doesn’t matter. A rose by any other name is just as sweet.

To me and my physician peers, nursing associates, and other “healthcare dots” who call their customers/clients/revenue sources “patients,” it’s about US, not our patients per se. We use the word “patient” as a way of honoring a person who has entrusted their care into our hands. If others, even other “healthcare dots” in this ecosystem of healthcare we are all evolving in, choose to call patients, “customers,” that’s really their right to appear unenlightened about how we caregivers honor our “patients.”

It’s the same type of semantical issue I used to have with “providers.” 

“I’M NOT A PROVIDER, I’M A PHYSICIAN!!!!!” I’d protest.

But I don’t do that anymore either. Not after I had an opportunity to shadow hospital housekeepers and janitors. I was doing a tele-seminar with my friend Steven Rowell on the release of his book Clean Is Not Enough and need to walk the mile in the shoes of these dedicated professionals who keep our hospitals clean and our patients and fellow healthcare workers healthy and happy.

I had an amazing chat with Jeff. Jeff worked in our hospital for years as a housekeeper who was usually working on floors. When Jeff finished with a hard surfaced floor, the shine was so bright you’d need sunglasses. I asked him how he felt about his relationships with physicians in the hospital. He told me for the most part he really liked the doctors. Some, however, treated him like he was invisible, but that was their problem, not his.

He went on to describe something his father had told him. He said that it didn’t matter if our name tag or job description was “doctor,” “nurse,” or “janitor.” We all, what I call the “dots of healthcare,” were what his father told him everyone should be. “Helpers.” We all help people. And if we don’t, well, we should. Jeff called himself a “helper,” because that’s what he, and all of us, really are. It doesn’t matter if we are helping patients directly, or supporting those who do. Because at the heart of it, in a patient-centric healthcare universe, we are all simply “helpers.”

Am I a “provider?” Sure I am. My job description says “physician,” but I am in a very large club when it comes to being a “helper.” Am I a “direct care worker,” a term I’ve heard most commonly with the lower rungs of a healthcare hierarchical system? Of course I am! Truth is, if we simply stopped placing the ladder in a vertical orientation, put it HORIZONTAL, we would all be seen as the equals we all really are.  We are all helpers. Yes, I went to medical school, but I don’t know how to get the floor to shine like Jeff does. He doesn’t know how to take out an appendix, but he could learn. And we can all learn to appreciate the value of the contribution that all the “dots of healthcare” make to ultimately support our customers, our clients,… and our PATIENTS. Jeff’s pride and devotion with his floors equals mine with a great clinical outcome.

Dr. Haig also shares my former feelings about “marketing and sales.” He asserts “The conventional lie is that marketing informs. Maybe it does, peripherally. It’s really done to persuade.” Well, perhaps sometimes, but definitely not at other times. I had always felt that “sales” was a dirty word. A word to describe hucksters and dishonorable businesses. And I was wrong.

I’ve met extraoidinarily honorable men and women,  more honorable than a lot of doctor’s I’ve known, in sales. They are as passionate about caring for customers as we are in caring for patients. While they might not miss quite as many nights of sleep as we do, they do lose sleep over delivering quality for a fair price to both the customer and business. Successful sales, of any kind, medical or otherwise, is based on earning trust with customer/patient’s. It’s the same. The job titles and business descriptions are simply different. But it’s the same.

I now have had the experiences of running both a practice of medicine and a commercial business. Truth be told, we are all in business. If your patient/client/customer asks you for a “business card,” what do you hand him/her? It’s a “business card,” because I never have seen a “practice card.” Like the semantics or not, we are all in the “business of healthcare.” And marketing is part of ALL businesses. What actually is interesting is the difference between a meeting of physicians and of hospital administration types. For programs for non-physicians I’ll offer to send my e-zine to those who would like to put a business card on my table after a speech. For the physicians, I don’t ask for business cards because they usually don’t carry them. They’re back in their offices, like mine was once, in the hardly opened box that they first had created when they started with their practice. Physicians don’t generally use “business cards” at all!

“Marketing” is my word to describe “making the phone ring.” As a pure physician, I resent “marketing.” Why? Well, because I never really felt I needed to do “marketing.” Because, simply, my phone rang enough! In my business, my market is the world, not just my community or folks that can drive to see me. I’ve spoken professinally in 43 states and 5 countries. I didn’t get this business because I hung a shingle out and waited for the phone to ring. I marketed and it’s an ongoing strategy. 

With shrinking provider reimbursement and increasing competition between various permutations of physicians and hospitals alike utility, nay- necessity, of marketing for physicians will become apparent in some markets. We are becoming progressively commodotized, whether we like it or not. It’s just the way it is. And unless we differentiate ourselves from others, and MARKET that differentiation, we become lost in the white noise of commonplace.

Besides, as a physician, we all market anyway. If you’re a physician, have you ever made a presentation to other physicians about something you’re expert at? Have you ever made a presentation to the public? Have you ever participated in a forum as an expert? Have you ever told a patient you are trained and able to address their problem? Have you published an article? This is all “marketing.” Even “word of mouth” is a form of marketing our patients do for us. Any activity that we engage in as physicians that results in referrals is technically “marketing.” Even simply being “nice.”

How about writing an op-ed piece??? The very article authored by Dr. Haig is marketing. So is this written piece for me. It’s just that I’m writing on a blog and would LOVE the opportunity to be on TIME’s website!

In Dr. Haig’s article, he is very much marketing the reasons why we should NOT call “patients” customers. And to support his marketing efforts, he’s written compelling text to PERSUADE the entities in this “land ruled by the dollar bill” to understand that “patient” can’t be simply exchanged with “customer” to healthcare professionals who care deeply for “patients.” When speaking on businesss issues for physicians, almost invariably I recommend two books to read. One of Jeffrey Gitomers sales books. And Harry Beckwith’s Selling the Invisible. If you’re a physician and sneer at marketing and sales, and never have read a book on marketing and sales, these authors will change your perspectives forever. You’ll also recognize the sales and marketing you do every day in your practices.

Marketing is a very broadly defined word. Persuasion marketing, and sales, is also commonplace, even with physicians. I like to think I’m a pretty good salesman. I even teach folks in medical sales how to sell more effectively to and through physicians. But I don’t tell ‘em to sell snake oil. Today the world is full of a variety of marketing, advertising, and promotion (all subsets of the broadsweeping term “Marketing”). Figuring out how to cut through the white noise of the world with YOUR solution to a problem faced by your patients/customers is the daunting marketing challenge.

Let’s face it. As physicians, we’re pretty good at persuasion. I, and every surgeon, has persuaded patients to have necessary surgery that we feel to be of ultimate benefit for their betterment. Usually it is. But haven’t we all had patients who had less than ideal outcomes because of our surgery? Do I feel anguish? YES! But not about the fact that I used my best professional judgment to do the right thing, to do no harm, to my patient for their benefit. Show me a non-persuasive surgeon, and I’ll show you someone who doesn’t operate much!

Part of “marketing” is education and an awareness of how others perceive the world. We need to educate in our marketing attempts to show the value physicians, nurses, and all the dots of healthcare provide to fill the shrinking labor pool to fill U.S. job markets in healthcare. And, as advanced by Dr. Haig, we need to educate those in healthcare the difference between “patient” and “customer” in a kind and caring fashion.

While physician seem to  resent the words ”customer service,” when I’ve become involved with service initiatives that improve a patient’s perception and reality of the care they receive, it improves not only the patient’s attitude, but is integrally tied in to staff and physician “satisfaction” too.

We are in the “business of healthcare.” Today, third party payers and government control the majority of reimbursement to “providers.” Healthcare quality and “satisfaction”, (check out the Medicare website, check out HCAHPS too), is graded. The grades are based on clinical data points, information gathered by “patient satisfaction survey’s” and generated into statistics. The presence or absence of data directly affects “grades” hospitals, and soon, physicians receive.  While patient care excellence is paramount to “providers,” patient care is shadowed by regulatory issues and public reporting of collected data. Excellence in patient care alone today is not enough. And when reported data infers deficiencies of physicians and hospitals, THAT’s marketing! That’s called “adverse marketing.” And like it or not, we are in an unforgiving and ruthless healthcare market that has forced us to realize the “business” we must engage in to survive competition and shrinking resources.

Patient satisfaction initiatives have served to attend to needs of patients that are often neglected by providers so focused on clinical excellence. It is a combination of clinical excellence and “patient satisfaction” that reaches beyond the immediate physical needs of caring and touches the heart and soul of patients as well. It is compassionate care that meets emotional needs of patients. And if patient satisfaction addresses these issues, doesn’t that support the patient as we would want them supported? Isn’t that an even larger expression of love for our patients?

Isn’t that what compassion really means? From the Latin derivation, “com” meaning with and again, “pati” meaning to suffer, compassionate literally means “to suffer with.” Compassionate care, “customer service,” “service excellence,” or what ever “initiative du jour” the moniker may be in healthcare are all the same when we ”suffer with our patients.”  When a hospital/physician/nurse or other “dot” of healthcare, as well as a non-healthcare business walks the emotional mile of the patient/customer, it is in the spirit of service to others. And, all things being equal, results in positive “marketing” of the seller.

As physicians, it is our responsibility to provide value interpretation of what we do, and how we feel about our professionalism. Expressing that in a way to honor “customers” as “patients” is part of that. But we must learn also to recognize that “marketing” is one way to achieve this. Sharing our opinions to other dots of heathcare, so they can gain insight into our, and their own contributions to patient care is more important than semantics. If we get hung up on the semantics, we’ll never achieve integration of the mutual values we all bring to patients.

Together, while we maybe broken into particular cultures and different occupations and skills, we each take our own shape from different aspects of caring for our patients/customers/clients. The word itself doesn’t matter to a patient as long as the caring is genuine and we stay compassionate. We are not all the same, we are usually very different. But all of us are deserving of honor and respect. It’s not really all that important what we are called, or what we call the people we care for.

 If we treat “marketing and sales” or “patient/customer satisfaction” as subjects not worthy of our attention we, and ultimately our patients, will lose. If we remain insular and spend too much of our energies arguing semantics, I’m afraid we will get more of what we’ve already suffered as healthcare professionals. Loss of autonomy, diminished professional respect, and slipping reimbursement. Seeking to have open dialogue with others outside of our personal perspectives is healthy and productive. If we have not walked the mile of others, (even… although it goes against every natural fiber in my physician being… third party payers and governmental healthcare bureaucracies!), we cannot understand different perspectives and purposes fully. Hospitals must not remain a place for nurses, doctors, and patients exclusively. It must be a place for everyone to serve the needs of each other, all as helpers.

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  1. admin wrote:

    It’s always bad when the author has to write the first comment. I felt compelled to write an extensive posting on this subject, partially because I feel so passionate about expanding horizons for everyone in healthcare to understand that we must embrace, educate, and co-exist with others outside of healthcare to make it all work. To really connect all the dots. Tray

    Posted on 27-Jul-07 at 9:15 am | Permalink
  2. sorry, colleague, but I see your argument meandering around the central issue here; is the patient-physician relationship a covenant or is it a contract? You will understand immediately that the covenant implies a higher duty; things that “satisfy” a customer (doing elective surgery on a full stomach? filling that “extra” pain prescription) do not satisfy the terms of the covenant. Customers status also allows us to be caught in “dual-agency” positions, where our business interests vis-a-vis insurers and institutional providers conflict with our expected patient advocacy responsibilities. You and I both know that this happens on a daily basis in practice, and the one path leads to a Mercedes Benz, and the other to a Honda. There is nothing wrong with others calling their patients clients; especially if they are not their patients. There is nothing wrong with showing compassion to folks that our not patients; you and I both do it every day. My internist is a friend of mine. When he is over for a barbecue, he is Jim. When I am on his examining table, he is Dr. B; it reminds us both that our clinical relationship is different than, and separate from (although inevitably informed by) our personal friendship.

    I have some (old) published stuff on care covenant and dual agency; let me know if you want it.

    Thanks for the opportunity to opine. Nice Blog…

    Mitch Keamy

    Posted on 02-Sep-07 at 5:47 pm | Permalink
  3. admin wrote:

    Thank you Mitch. You’re very much on target. The relationship between a patient and a physician is a covenent of the highest order but the current climate of the “business of healthcare” also requires this relationship to also be a contractual one as well. Acknowledging, and addressing both of these relationships simulataneously is important… and I’d appreciate the “dual-agency” information… I haven’t read about that. Maybe that’s why I drive a Honda! Tray…

    Posted on 04-Sep-07 at 3:25 pm | Permalink
  4. tray- e-mail me a fax #. some of this stuff is easier to fax than scan/convert.


    Posted on 04-Sep-07 at 4:07 pm | Permalink

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