Patient as Customer. Student as Customer.

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I was having a discussion with my wife this week about this topic – she is in medical training right now, so when she comes from the hospital the topics are always interesting.

If you consider someone as a patient, there is a sacred, Hippocratic, oath that defines the relationship. The white coat represents more than a simple transaction, but a level of trust, honor, and responsibility that we have built into our society. As an outcome of that, however, sometimes a doctor takes a paternalistic view on their relationship with patients: they know what’s best, and that’s that. On some level, I’m sure you have witnessed this. And for the most part, it’s good, right? But that’s not how a market-driven relationship works. In a customer-based relationship, the work is in service of the customer, who is always right– so, the exact opposite. It is their money, after all.

We were discussing how it would be *so nice* if care providers, and the healthcare system more broadly, treated patients as customers. Among the seemingly endless issues with modern healthcare, many point to the fact that the patient is not a customer, as they are in other industries. And thus, creating a system that optimizes their needs is much lower priority, since they are simply a passive participant in a machine where they lack agency. So what if they had agency? Perhaps the level of service, the resources, and the general efficiency of the system would improve for those who had the ability to pay. But is that true? First of all, would that improve the system for everybody? Not only that (which is a political economy question), but secondly, do we even want that? A chef or driver insisting that I advise them on the best way to prepare a meal or travel to a destination is great, but a doctor asking me whether I should get a procedure? Surely not, right?

As an analog, we considered the schoolteacher. In a student-teacher relationship, a student relinquishes an element of agency: they do what they are assigned, with the implicit understanding that it is for their benefit, whether or not they can obviously see that. The most celebrated educators in the world still hold this cache, and teach whatever they want – and sometimes that is driven from a rational economic marketplace, but oftentimes it isn’t. Plenty of tenured (or similar) professors at our most prestigious institutions are shit teachers, if you stack them against a field of peers. And some students feel the weight of honor and sacred power in doing what the teacher says, and will spend 25, 30 years doing that. But others less so.** A college sophomore might think they only need computer science courses for their education, and as a consumer in an open marketplace, surely they ought to be able to choose, and society will be the better for it, right? What of an 11th grader? Or a 9th grader? Or a kindergartener’s parents? If you think this is a false equivalency, and ‘student’ should in fact be a ‘consumer’ but ‘patient’ should stay sacred, what is different? If you think the opposite, why?

I don’t know my answer to either yet: I lean towards customer/consumer for both scenarios, and believe that if you give me more agency and resources to understand my body, I ultimately know it better than anybody else, and thus ought to be able to decide about all of it. Similarly, there are infinite learning styles and ways to become an educated and productive member of society, and more choice ought to be better than less. But I’m not sure. The honor (really), trust, and sacred nature of the oaths care providers and educators take in caring for our society have real power, and I hope they aren’t lost in the shuffle.

** As an aside, William Dereciewicz has a number of brilliant reflections on the higher education subject, as well:

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