"Line-up" at the hospital happens at the beginning of every new shift. The head nurse reads a printed message from the hospital administration to all the other nurses and aides. They're not her words nor her thoughts, but simply messages from above that are hers to enforce. During the readings, I'm often making rounds or sitting there writing in charts, listening. But I can never listen to line-up for long. The bureaucratic illogic of the messages I can ignore; the management's false concern and manipulative guile can be fun to trace out — like the plot in a bad TV show. But what's so repulsive about line-up is what they call the sick people in those rooms — the people on their backs with tubes in their noses, broken bones, cancers, strokes and infections, who can't dress or eat, or even empty their bladders without the physical help of those nurses. They call sick people "customers."
It probably began innocently enough, perhaps as a semantic slip. First came the term "outcome-based" medicine, which refers to the practice of determining the value of a treatment by seeing what happens to the patients you do it to. (The shiny new label aside, it's the way we've always done things in medicine.) Then "patient satisfaction" emerged as a relevant outcome parameter — or, the thing you check to see if the intervention was actually a good idea. That seemed reasonable too — is there a better goal than having a happy patient? From there, it was only a side-step to "customer satisfaction." Just like they talk about in ads for car dealerships.
But, in the hospital, this unassuming slogan turns the unhappy people whom we undress, stick things into and tell heartbreaking things, like "You have six months," into customers.
Patients are those for whom good, young doctors forgo happy nights of beer and dancing. Patients are the ones great nurses worry about, sit up with and linger to take care of, when they could be home with their kids. We continue to study the journals and the books for patients, even when we're 60 and can barely see the words on a page anymore. We take them on knowing they won't pay a dime, knowing they're going to complain, knowing their prognosis stinks. We know how vulnerable patients are — that they literally lie open to us — and that our oath is to do for them what is best. And the best is often not that which "satisfies." To stop giving a narcotic, to do the bigger operation, to deliver devastating news — none of that is satisfying. It is not exactly a good business, selling painful best choices to customers. But it can be the best medicine. The great physician will often prescribe what's unsatisfying, looking farther down the road past "customer satisfaction" to patient well-being.
In a land ruled by the dollar bill, it's perfectly fine to advertise to customers and attempt to take them for all they're worth. Everyone knows that marketing — the ads, commercials, T-shirts and arthritis talks in the backs of diners — is designed to get money from customers. The conventional lie is that marketing informs. Maybe it does, peripherally. It's really done to persuade. But is it fine to persuade patients, so you can squeeze more money from them? Is it fine to scare patients into tests and iffy treatments, to persuade people who aren't sick — who are not patients — that they need treatment anyway? It is far from fine to treat patients like customers.
The incursion of business practices into our profession has made uncomfortable bedfellows of those with an avocation and those without. The union leaves our professions, especially the nurses, in a fragile state right now. If you derail the dignity and mission of what we do, we'll simply stop and do something easier. Indeed, it's happening. Nearly 150,000 nursing jobs languish unfilled today in the U.S. (We've already lured over every nurse that Ireland and the Philippines had to offer, and now we're recruiting in sub-Saharan Africa.) And these are good-paying jobs. There's a doctor shortage too — and those jobs pay even more.
What's wrong? The answer is simple: we've lost sight of that boring and corny moral imperative to do what's right for those in need, to love your patient as yourself. That approach has always driven good medicine. Not customer satisfaction.
The brightest ray in our garden: I have not heard one doctor nor a single nurse — outside of line-up — use the C-word. I hope I never do. However the insurance companies and businesses and politicians want to shape the way medicine is practiced in this country, if my children expect good care when they get to a hospital, it has to remain a place for nurses, doctors — and patients.
Dr. Scott Haig is an Assistant Clinical Professor of Orthopedic Surgery at Columbia University College of Physicians and Surgeons. He has a private practice in the New York City area.