Patients as Consumers: The Milkshake Mistake

I keep running up against the tension over characterizing patients as consumers. Although Nobelist Paul Krugman explicitly said "Patients are not Consumers" in a NYTimes column this past April, other business and economics notables, such as Clayton Christensen, encourage innovation in the world of medical care delivery modeled on consumer service industries.

Personally, when musing casually about patients as consumers, I've found myself alternately rebuffed (for blaspheming the sacred doctor-patient relationship) and encouraged (for probing methods of caring for patients' true needs) by my medical seniors. I've since learned to test the sensitivities of my audience before even hinting at comparing patients and consumers.

Here, rather than attempt to put the issue to rest, I simply want to present one example where viewing patients as consumers stands not only to improve their care, but to actually deepen the humanist goals of those who are otherwise afraid of commoditizing a covenant.

The Milkshake Mistake

Clayton Christensen and others have used a case study of McDonalds to illustrate the value of stepping inside the consumer's shoes. Specifically, how do you see the value of your service, not as what you think the consumer should desire, but as what they truly seek.

The example, adopted from an article in the Harvard Business Review, has been termed the Milkshake Mistake. Briefly, McDonalds was conducting product research on how to sell more milkshakes. Researcher Gerald Berstell was surprised to discover that most shakes were purchased by early morning commuters who used the shakes as a one-handed tasty breakfast that was easy to eat and kept them awake in the car. After Berstell had examined the milkshake from the consumers' perspective, McDonalds could abandon their assumptions about what consumers wanted from their milkshakes, and instead tailor milkshake delivery more precisely to their consumers true needs.

As Christensen details in The Innovator's Prescription, this speaks powerfully to health care. Providers, with their years of training and advanced expertise, may have assumptions about the desires of their patients that are not consistent with what patients truly seek from their doctors. Although this kind of market research draws directly from the business world, and baldly views patients as consumers of a service, it nonetheless stands to improve the doctor-patient relationship by clearly identifying motivations and needs.

A candidate milkshake mistake in medicine is the negative views about one of my favorite medical apps, Skin of Mine, which I've written about here. Physicians to whom I've shown the app often reject it, saying "patients want their doctor, not a phone," or "how can they trust it?" The potential milkshake mistake in these rejections is that many patients prioritize not missing work to get their skin evaluated above a face-to-face interaction with a doctor.

The crucial point for those, like Krugman, who rail against commodifying the doctor-patient relationship is this: until the market research is completed, we're just guessing whether "patients want their doctor," or whether they simply prefer convenience. Until we consider that patients are like consumers, we may in fact be cheapening the doctor-patient relationship by relegating how we optimize care to our own guesswork.

Threat Vs. Opportunity: Framing Change (in medicine)

According to Professor Michael A. Roberto, groups can frame change in two ways, as a threat or as an opportunity.

Framed as Threat:

Advantages- Groups commit significant resources to face threats; their response is rarely insufficient. Also, they are more inclined to take risks.

Disadvantages- Groups' responses are typically rigid and based on strategies that worked well in the past; change "calcifies outdated models of how the world works."

Framed as Opportunity:

Advantages- Groups utilize more diverse, divergent, and creative thinking. They develop and capitalize on new strategies for achieving their goals.

Disadvantages- Groups don't commit sufficient resources and don't take risks.

Roberto concludes that the best response to change is, unsurprisingly, a mix of both. Groups should marshall significant resources, be prepared to take risks, but also encourage divergent and creative thinking while guarding against reliance on outdated strategies.

He uses the newspaper industry as an example. The most successful papers fully invested in exploring how they could use the internet to better tell the news by developing rich, interactive websites, incorporating bloggers, and publishing multimedia. 

Perhaps this is a good lesson for how the medical world can consciously look to optimally frame the changes that the digital revolution hold for us? Here, I apply Roberto's five rules about optimal framing to the medical world:

Rule 1– Don't allow leaders to force their particular frame on those underneath them. Basically, allow doctors, residents, and med students the freedom to pursue their own vision, sheltered from insistance on what won't work.

Rule 2– Don't stick to one or two stock assumptions of the situation. Rather, welcome different overall perspective, some broad, some narrow. Perhaps embracing social media and other digital tools may relieve doctors' already considerable time burden?

Rule 3– Abandon hardened metaphors. Perhaps the doctor-patient relationship needs drastic revision?

Rule 4– Bring implicit assumptions to the surface. A classic is the assumption that patients want to see a doctor rather than wanting to feel their questions answered and to have solutions offered (see the rampant use of alternative therapies.)

Rule 5– Change the reference points. The need for truly patient-centered care is growing in relevance. Perhaps we should focus on patient concerns for empathy and communication rather than just disease status, like blood pressure and hemoglobin A1C.

Any contributions of examples for the five rules?

"The test of a first-rate intelligence is being able to hold two opposed ideas in the mind at the same time, and still retain the ability to function." F. Scott Fitzgerald The Crack Up 1936

On the Edge: Social Media and Med Students

                                                                            Le berceau (The Cradle) - Berthe Morisot 1872


There's a rich literature about the contributions that fringe, or edge, group members contribute to a field.


In his book Cognitive Surplus, Clay Shirky offers the example of Berthe Morisot's influence on impressionist painting. As a female, should could not have full membership in the impressionist club of the day, the Cooperative and Anonymous Association of Painters, Sculptors, and Engravers. 


Rather than mitigating her impact, Morisot's edge status actually prompted more exposure of impressionism in the wider art community. 


Shirky's point is that members operating at the margins of groups, members who are not full ensconced within a group's traditions and hierarchies, can be a broadening and enriching force.


And so, I submit to you that medical students are similarly on the edge, and can therefore broaden and enrich the applications of social media and other digital tech developments.