What’s in a name? Perhaps more than Shakespeare recognized. How we use even the most commonplace words can set wheels in motion, establish tough-tochange attitudes and affect the dynamics between groups of people. One setting in which this occurs is hospitals-and, the most responsible parties may be the hospitals themselves. Thinking in marketing terms, hospital executives have referred to the physicians with privileges in their institutions as “customers”. This has set in motion a series of unintended consequences altering the collaborative atmosphere, manifested by physicians now viewing themselves as customers.

We propose that the use of the term “physician as customer” in describing a physician’s relationship to a hospital creates a set of assumptions and expectations that are incorrect, and that lead to a misstatement of the benefits and responsibilities that accrue to both parties. In traditional English usage, the word customer refers to a buyer of goods or commodities. Continued use of such a term supports a premise that the physician part of the relationship is to be the recipient of goods or services, without any attendant obligations or responsibilities, reinforcing a set of expectations and behaviors entirely at odds with hospital desires and the physicians’ professional code of responsibility. The term is detrimental to the proper functioning of the system, minimizing the professional obligations of the physicians relative to the needs of the system.

What is the proper functioning of the system? As stated by the Advisory Commission on Consumer Protection and Quality in the Healthcare Industry (1998), and reiterated by the Institute of Medicine in Crossing the Quality Chasm (2001), “All health care organizations, professional groups, and private and public purchasers should pursue six major aims; specifically, health care should be safe, effective, patient-centered, timely, efficient and equitable.” For these aims to be met, hospitals and health systems need to create environments in which physicians are allies in patient treatment, not favored customers of the institution.

In the last several years, multiple professional organizations, including The American College of Healthcare Executives (ACHE) and the American College of Physicians (ACP) have focused on the increasingly fractious relationships between physicians and healthcare organizations. Certifying organizations, specifically JCAHO and Magnet, have reflected on the importance of effective interdisciplinary collaboration in their certifying standards. Why is the issue of physician-hospital collaboration so resistant to change? Semantics may be a large contributing factor.

Many physician organizations promulgate ethical guidelines for their members. For instance, The Annals of Internal Medicine published the Ethics Manual, 5th edition, in its April 2005 edition. In the section on Professionalism, The Manual describes Medicine as ,”A profession …that its members must teach and expand, by a code of ethics and a duty of service that put patient care above self interest.” In The Changing Practice Environment section, the manual notes that “Parsimonious care that utilizes the most efficient means to effectively diagnose a condition and treat a patient respects the need to use resources wisely and to help ensure that resources are equitably available.” The troublesome issue of resource allocation is described in the section entitled ”Physician and Society ”. Resource allocation decisions are most appropriately made at the policy level rather than entirely in the context of an individual patient-physician encounter. These guidelines would suggest that physicians owe their best efforts to provide superb patient care within the context of a team and under resource constraints decided by others. The principles do not validate physician autonomy and control as ruling forces in physician-hospital relationships.

We urge the retirement of the term “physician as customer”, and its replacement with the term “critical ally”. A physician, by nature of his profession alone, is not entitled to equity in a relationship as a factor in decision making. There is no exclusion of the physician-hospital relationship in this requirement. Physicians must always place the patient first. Financial interests, autonomy concerns and physician quality of life issues are always secondary.

The realignment of expectations for the physician-hospital relationship in this paper focuses on the expectations of the physician and does not imply or expect a reciprocal change in hospital behavior. Environments that support physician behaviors consistent with their professional obligations of service and professionalism by recognizing these values will enhance physician quality of life and practice. Professionalism and patient care, not marketing, should drive the behaviors of all stakeholders in the healthcare world. With the focus on those areas, and the recognition of that by the public, the marketing war will be won as a result.

Many in the quality realm have made similar observations. Don Berwick has said that every system is perfectly designed to get the results it gets. Others have noted that the definition of insanity is doing the same thing over and over again and expecting different results. To achieve different results, the system must change. Treating physicians as “critical allies” in patient care will help bring about these changes. Change in physician-hospital relationships will come about through the facilitation of positive attitudes embracing the physicians’ responsibilities for patient care and the continued wellbeing of the health care system. Usage of language that supports this mission will be an effective tool.

Written by David Sorin, Esq. and Lynn Helmer, MD