To the Editor:

After reading Drs. James Glazer and Kimberly Merris’ editorial “When Customer Service and Patient Care Collide” [March 2004, page 14], I am struck by the negative tone of the article. Certainly, the doctor-patient interaction is a unique transaction between a consumer and a service provider, but it remains a transaction. Like the authors, I do not see myself as a generic company employee, nor do I want to embrace the terminology of a patient as a client or health care consumer. However, I think it is better for us to get off our high horses and try to ensure that the doctor-patient encounter includes not only high-quality, evidence-based, comprehensive medical care, but also that the environment of the encounter and the pre- and post-tasks related to the encounter are geared to efficient and customer-friendly standards. I am confident that sensitivity to patients as customers can improve the doctor-patient encounter without necessarily demeaning the interaction by equating it to someone selling a hamburger.

To the Editor::

"When Customer Service and Patient Care Collide” is a demonstration of what some doctors today think about their patients, customers and fellow human beings. There is a host of scientific evidence to support that when patients feel like they are respected, important and not just names with illnesses, outcomes are better. The article implies that good customer service will cause a decrease in successful medical outcomes. Where is the scientific evidence for this comment? The article implies that money spent on physician customer service training is not a good use of resources. Based on whose research?

As president and founder of T.C.A. Companies, a consulting and training company, I would like the authors to describe the difference between customers and patients, as well as the difference between a business model of customer service and a medical model of customer service. Customer service is a human interaction and has nothing to do with business models or medical models. Customer service in its purest form is the interpersonal skill of dealing with another human being. Mother Teresa was a tremendous example of customer service. Was she a business model? You state that patients, physicians and administrators must not lose sight of how medicine is different from the business world. How is medicine different? Why should patients, nurses and other staff not receive good customer service from a doctor?

Health care today is in desperate need of improved customer service, not only for the patients but for the nurses and staff as well. As a customer-patient, I was offended by the audacity and attitude of this article.

To the Editor:

The authors of “When Customer Service and Patient Care Collide” did a major disservice to the practice of medicine, especially family medicine, when they stated that improving customer service is in conflict with providing good medical care. Customer service is not about accepting that the customer is always right but about providing the customer with excellent service, both medical and otherwise.

The first problem is one of terminology. The notion that a patient is not a customer is wrong. A customer, according to Merriam-Webster’s Collegiate Dictionary, is one that purchases a commodity or service. The patient may pay for this service in cash, through insurance or may never pay. Patients are also our clients (i.e., people who seek the professional advice or engage services of another). Physicians must treat each patient as a paying customer or as a client engaging our services.

The second problem is determining if physicians are in business. Obviously, we are. We sell our practices, our services and ourselves. We receive remuneration by way of cash, Medicare, Medicaid, etc. We must leave behind the egocentric belief that we are better than any other service provider. It is true that a plumber may not deal directly with human lives, but his job is no less important.

A third problem is that research has shown that a patient is less likely to sue a mediocre physician who he or she likes than one who is an excellent physician but lacks basic bedside courtesy. Having good bedside courtesy is equivalent to good customer service. This makes the patient feel that he or she is the most important person to the physician at that particular moment of the doctor-patient interaction.

The sudden increase in boutique clinics is due largely to physicians who have realized the need to combine customer service with the practice of medicine. As usual, the early pioneers are the ones who profit from change. Why should we make this care something only an elite few can afford when we can strive to provide it to all our patient-customers?

Authors’ response:

If there is a theme that runs through all three letters, it is a misunderstanding of our fundamental premise. Like Dr. Adams, we believe that physicians should strive for excellence in all aspects of patient care. Our questioning of the axioms of customer service represents an attempt to preserve those relationships that physicians and patients value most. By adopting the language of business, especially in terming patients “customers,” we raise an artificial barrier of commerce as a defining and ultimately distancing aspect of our clinical relationships. We most honor our patients by celebrating the best traditions in medicine rather than letting corporate advisers convince us that we should emulate Enron or WorldCom.

It is not surprising that Mr. Spiller was offended by our essay, since he works for a customer service consulting firm. His company will sell you a “Service First” set of videos and offers an entire menu of franchised in-house customer service seminars, along with a promise to “increase your market share.” Mr. Spiller’s concept of “customer service in its purest form” may not be very different from our “patient care.” However, we doubt that Mother Teresa would have referred to the millions of desperately poor whom she helped as “customers.” She saw herself as a partner and peer of the populations she served. Mr. Spiller infers points from our editorial that we simply do not make. We imply nothing about a relationship between customer service models and medical outcomes. Instead, we directly state that we must develop our own, unique ways of evaluating our relationships with our patients. We do our patients, our profession and ourselves a disservice by forcing business models onto our medical relationships.

A wealth of literature (selections were referenced in our article) demonstrates that subjective assessments of medical care are correlated with cost but are not objective markers of quality. This proves what many of us find intuitive: Patients sometimes come to us with an agenda. They may want fen-phen for weight loss, narcotics for chronic back pain or whole-body MRI scanning for complaints of fatigue. It is an essential part of our pact with our patients and society that we give them the care they need. Sometimes this is not the same as the care they want. Unlike servers at McDonald’s, whose jobs involve only dispensing the menu items their customers order, we believe our role also involves advising and educating. We call this set of priorities and privileges patient care, not customer service.

Dr. Ishmael returns us to a crucial point when he reminds us of the importance of terminology, though in his rush to look up words in the dictionary, he too misses the point of our piece. A dictionary might define a physician as a “doctor of medicine,” but I think we all would agree that this does little to describe, let alone define, the myriad images, memories, associations and identities each of us has with that word. It does little justice to the anguish we feel when our patients die or the joy we share with them as we attend their childbirths. What it means to be a physician is complex, just as what it means to be a customer transcends a facile dictionary definition. Our paper points out ways in which the term “customer” instills an inaccurate, if not negative, connotation into the physician-patient relationship.

Physicians may embrace the value of maximizing profits. They may even embrace the value of practicing “customer-friendly medicine” with the goal of minimizing medicolegal risk, but let’s not delude ourselves into believing that we do this for the benefit of our patients. If we focus on practicing good medicine, not simply friendly medicine, we may protect ourselves just as much as the incompetent but affable physician in Dr. Ishmael’s example.

Recognizing the responsibilities inherent in and unique to the practice of medicine is not egocentric. We don’t honor our patients and the trust they give us by pretending that we are businesspeople; rather, we must do more than simply buy and sell our services. To be sure, there is a market for boutique medical providers who focus on a business model, just as there is a market for physicians who dispense prescriptions over the Internet. But we think most of us envisioned more as we stood to take the Hippocratic oath and pledged to come to the benefit of the sick.