Metaphors are literary vehicles to make sense of the world, they bring to life what is otherwise unintelligible. Although phrases like metaphorically speaking and he talks in metaphors imbue a high degree of abstraction, metaphors are powerful and, unless we are being purposefully elusive, specific to the message being portrayed. There is a particular metaphor that is used in healthcare, which is now incredibly pervasive and, whether intentionally or not, has brought to life some unwelcome themes. The pernicious metaphor of the patient as a customer is an unhelpful one and through this blog I will explore why.
That is not to say patient is better mind you; there are some significant positives about our evolution in metaphors to describe ‘the people who need healthcare’. The word patient has its origins in the Latin patior, meaning ‘to suffer or bear’ (Ref). A passenger who subjects their body to treatment by the experts. Thankfully this limp, passive concept is dying a slow and somewhat painful death. As the millenia march on from the origins of medicine, the purpose remains exceptionally unchanged, but how and whom we are helping is constantly changing. A rather recent iteration of the concept of who we help is ‘the customer’. One could say this is a step in the right direction, then again, that may depend on your vantage.
Why it may be useful
Customers have rights and have autonomy and agency over their choice; patients should too. Our patients should have choice in the care they receive and agency in the healthcare system. A significant power differential exists in healthcare, and unfortunately we have a ways to go until this is successfully mediated (Ref, Ref, Ref). Reconceptualising patients as customers can mitigate this power imbalance, but thus far lip service is potentially all we have achieved. Have we renamed patients customers without actually treating them as such?
There may be, however, still some significant unknown factors in the pursuit of real autonomy and agency in healthcare. The point has to be made that when this approach is rigorously analysed, the results seem to be unclear. Randomised controlled trials analysing shared-decision making processes (Ref, Ref, Ref). That could be because what we are really talking about is introducing a systematic format of more inclusive, value-based communication, which is sorely lacking. And potentially this has limited bearing on the outcome of treatment, rather contributes to the experience of care. Regardless of how much we are yet to learn about how to actually implement a better engaged ‘person who needs healthcare’, there are some unsavoury outcomes of using the term customer.
Why it isn’t useful
A satisfied customer is a customer that comes back, a satisfied patient means repeat business. There are clear macroscopic healthcare economic trends producing repeat business in primary care, which is an unwanted and disastrous consequence of Activity Based Funding Models across the globe (Ref). Patients are increasingly becoming more complex, meaning they live longer with more co-morbidities. This requires longer episodes of care and more effortful interaction between many healthcare professionals to ensure their complex care needs are accounted for. These patients are being seen for shorter lengths of time and more often in primary care, with no significant change in funding towards community or other types of care models for most OECD countries (Ref, Ref). These patients are also coming to our doors as physiotherapists, exercise physiologists, chiropractors and in an environment which pays by activity not outcomes, we have very little impetus to create long-term lasting behaviour change. Put simply, treating patients as customers may not be meeting the health needs of our society. If repeat business is our aim, then we are doing well, but is healthcare about something different to this?
Treating patients as customers may not just skirt their needs, it also reduces something so complex as health into a transactional system. If a customer’s computer is broken, he will take it to a professional who repairs computers. I will refer to our customer as a he during this part; for us men are well known to be technologically inept. This still prevalent notion of the body as a machine to be ‘fixed’ is neither accurate nor helpful for our patients, although treating patients as customers may continue to propagate this myth that won’t die. This transactional process forces the patient into reductionist thinking, which risks him missing out on the integral biopsychosocial theatre that the grand play of his health takes place in.
These days, the customer happily receives services without doing so much as the tapping of a card against a machine. If you were lucky enough to exist when coins were a thing, maybe you went to the effort of hopefully searching around in your back pocket for a few minutes before enjoying your service. Customers should be satisfied, as should our patients. But the problem with a satisfied patient is that he will begin to expect certain things and most of these things enhance the service and process of care rather than the outcome. This transactional thinking turns the patients into a passive receiver of care. Once again, is this really what healthcare is about?
Although the concept of a customer in healthcare may be a step away from previous, archaic conceptualisations of ‘the patient’, we have a long way to go in order to get to where we want to be. The term customer is probably more unhelpful than helpful; our patients aren’t customers, they are active and dynamic actors in the process of care. We need to embrace ‘embodied’ thinking and create a context in which patients can conceptualise injury or illness as a rupture in their ability to live in the world in the way they want, not a problem of break-down in a machine-like body (Ref). We need to allow patients to choose treatments based on their ability to mitigate the disruptive potential of injury or disorder, not satisfy a misplaced desire to ‘fix’ a body part.