Patients or customers? Answer shapes attitudes

Staff and docs make those distinctions every day

Thom A. Mayer, MD, FACEP, FAAP, and Robert J. Cates, MD, MF, chairman and vice chairman, respectively, of the Department of Emergency Medicine at Inova Fairfax Hospital in Falls Church, VA, developed a customer service training program that helps staff view the interaction between patient care and customer service. This is an abridged version of an article that first appeared in The Satisfaction Report, published by Press, Ganey Associates in South Bend, IN, the nation's largest patient satisfaction measurement firm.

One of the essential dilemmas that all health care customer service training faces is developing a concise, clear, meaningful, and pragmatic answer to the question: "Are they patients or are they customers?"

Not surprisingly, many staff approach this question with a bit of an acerbic mindset. After all, they are not working in a hotel, a department store, or McDonald's.

Rather than giving them customer service definitions, we developed an exercise that helps the staff realize that they have their own way of distinguishing among customers and patients.

Ask your staff to consider these scenarios:

A 55-year-old female is brought to the emergency department by paramedics, who were called to her house because of her sudden onset of crushing, substernal chest pain. As soon as the paramedics walked in the door, she had a cardiac arrhythmia, requiring electrical conversion. She now presents to the emergency department with a normal cardiac rhythm, but with continued chest pain and an electrocardiogram which clearly shows that she is having myocardial infarction.

Is this a patient or a customer?

A 3-year-old child is brought to the emergency department by his parents at 3 a.m., having been seen at the pediatrician's office at 3 p.m. the previous day, where a diagnosis of left otitis media was made and the child was started on an antibiotic and given a "starter pack" to use at home, as well as fever control instructions. The parents bring him in at 3 a.m. with a temperature of 99.2, stating that they "can't get the fever down."

Is this more of a patient or more of a customer?

This scenario is exactly the same as scenario two with one exception. Now the child is your child.

Is this more of a patient or more of a customer?

The central character of the first situation is universally rated as a patient, while the family in the second are universally rated as customers (and the parents are often identified as the primary customers). As you might imagine, the third scenario causes the needle to waver a bit, as the staff realize that they would be likely to classify their child as a patient, not a customer, even with the low-grade fever.

Patients are considered to be more acutely ill, are "real emergencies," have very little choice where they seek their health care, and are largely dependent upon the health care provider. Customers, on the other hand, are seen as having substantial choice, are more independent, and have substantially more control over the health care encounter than do patients.

One of the customer service rules is: The more horizontal they are, the more they are patients. The more vertical they are, the more they are customers.

Having been asked to develop training for entire hospitals and health care systems, we have also developed scenarios for outpatient settings, intensive care units, medical-surgical units, and even long-term care facilities.

All of the scenarios have been illuminating to staff, who realize that they have an internal barometer by which they rate the people that they see as being patients or customers. Further, this internal rating occurs on a daily basis, so that an individual "patient" in the health care system may actually change from being a patient to a customer over the course of his or her hospitalization.

Patients are more dependent, passive, and have less choice in the health care system because they are more acutely ill. In most cases, control in "patient scenarios" lies with the health care provider, who is often busily providing life- or limb-saving interventions.

Customers, on the other hand, are more independent, more actively participate in health care interaction, and have substantially more choice as to where and how to seek such health care. Customers have far more control in the health care interaction than do patients, a fact which many health care workers tacitly resent.

That resentment must be uncovered and addressed in any health care customer service training because it is an essential feature of the distinction between customer and patient interactions.

Do you know how to handle customers?

Health care professionals, in general, have a high degree of clarity with regard to how to take care of "patients." Yet because there have been so few effective customer service training interventions in health care in the past, many health care professionals are very unclear about how to approach the "customer," who still has the technical health care needs but has substantially more power and control over the encounter than does the patient.

Let's imagine that you could perform a "patient-customer" autopsy on any given patient at any given time. Even the acutely ill individual may be 80% patient but still 20% customer. Why not develop a strategy where we treat the patient percentage with technical competence and the customer service percentage with customer service skills?

So what is the answer to the question: Are they patients or are they customers?

They are always both, to varying degrees. Health care organizations must help their staff understand this dynamic. Then they have a substantial foundation for an excellent customer service program. Without it, the pragmatic side of customer service is difficult to enact.

[Editor's note: Thom Mayer will present a session on "Are they patients or are they customers?" at the Press, Ganey conference, Nov. 10-11, in San Antonio, TX. For more information, call Beth Regrut at Press, Ganey, (800) 232-8032 or e-mail:]