Friday, December 23, 2011

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.


Anne Marie said...

Thanks Aaron,
I know my friend Jonny Tomlinson, @mellojonny, also has a post about patients as consumers churning over in his head. We're both in the UK where we have universal access to healthcare which is funded through general taxation. Those who pay most in taxes generally use less healthcare resources than those who are poorer. Healthcare is trying to make up for some of the disadvantages which social circumstances determine for some. So why do we fund healthcare this way? Because we believe that everyone has a right to healthcare based on their need not their ability to pay.
McDonalds are primarily interested in making more profit. They might kick themselves for not understanding their customers so they can deliver ever more of what they desire.
When we talk about patients as consumers are we focussing on what people desire rather than what they need? 
Of course these needs and desires are not in opposition. It is up to professionals and patients together to decide how their desires can be matched to this needs. And at a higher level we might decide to reorganise some of our healthcare systems to do these jobs better.
But healthcare providers are, we hope, not motivated by making money. They don't want to understand the concerns of the patients and public better just so that they can sell them more product or a higher value product in order to make more money. 
Where healthcare is universally funded we want to improve services so that we can maximise the benefit from the resource that we allocate from taxation. And I suppose that deep down some of us our concerned that if we start thinking about patients as consumers we will start thinking about them in the same way as McDonalds, and not just McDonalds but every company which has a product to sell and an aim to maximise profit.
So if we start to think as patients as consumers we have to ask ourselves , what is lost and what is gained? Who benefits and who loses? The answers to these questions will differ depending on how are healthcare systems are funded.

RedHeadedStepMD said...

I think my main issue with the concept of patients as consumers is that it misses what I believe is the core issue in American Health Care.

Is healthcare a basic human right or is it a privelege? If it is a basic human right, the underlying tenets of consumerism are in direct conflict. If its a privelege, then they are in line and the business models that drive consumerism can be applied.

Consumerism as a model to probe, generate new ideas, help dispel assumptions are great. However, as an individual who believes that health care is in fact a basic human right, I abhor the way consumerism as a concept seems to be replacing health care as a right.

(As a basic right, this doesn't mean that we shouldn't strive to provide humanistic, caring, healthcare, just that it is not driven by financial availability, happiness and patient satisfaction)

astupple said...

Anne Marie,

Thank you for your insight. Yes, we hope doctors are not motivated by money, and I'm not encouraging them to be so. However, we are providing a service, and obviously optimal provision necessitates a keen awareness of the patients' motivations. What I'm suggesting is merely that we can, and ought, to take a page from the business world in order to optimize service delivery.

I think we spend too much time assuming patients are seeking us for the reasons that we expect them to seek us for, and not enough time thinking about their actual motivations. This is market research, and there are people who have figured out how to do this well, and we should emulate them in this regard.

Finally, I'm not talking all-or-none here. I certainly hope we are flexible enough to apply some consumerism without helplessly sliding down a slippery slope to pure commoditization!


I agree with you on the human right part. All I'm suggesting is that people are not deranged to think that maybe cares more about them than their doctor when they get immediate and convenient support from Zappos, but can't even email their doctor. Many patients want the convenience they get from retailers, and they may in fact prefer to be commoditized.

The point of this post is that, rather than make sweeping statements, we should instead devote more effort to figuring out what it is that THEY want.

Thank you for reading and commenting!

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Mike Moore said...

Great Post Aaron! We have so many assumption about what both "the system" (i.e Providers & Payers) and what Patients want and need from healthcare. Sometimes I think we have more of a "crisis of expectations" from healthcare, rather than a true "crisis" in healthcare.

e-Patient Dave said...

I'd go a step further - I don't think it's possible to wait for the market research, when we're right in the middle of a caterpillar turning into a moth. We have to just realize, I assert, that the molecule over there that's part of a bristle might momentarily be part of a wing.

The tension and insanity arise, I think, when a party sitting in one context hears a statement made in another and is convinced the speaker meant it in the listener's context. Hate results.

astupple said...

e-Patient Dave,

Wow, caterpillar-moth imagery, very nice. Are we patients dreaming that we're consumers, or consumers dreaming that we're patients?

I really like the language post that you referenced... have you seen the tone of the debate change much since last December?

e-Patient Dave said...

I wouldn't say it's the tone of the debate that's changed - or if it has, it doesn't interest me much. What's new, this fall, is the realization of different contexts, different sociological levels. This shines a light on why when one person notices something (in their context), and speaks it, and another person hears those words in a different context, we get "Them's fightin' words!!" and we're off to the races.

The reason that interests me is that I'm actively interested in creating change, not just someday but in the foreseeable future, so the question I obsess about is "What could be said that would make any difference??" One thing that makes a difference is "Look: here's how that soul sees things - you can see that it's reasonable. What's actually happening here is x - AND also y is happening, in your view." Then apparently hostile positions can have bridges built between them.

And I do see that happening. For instance, physicians at the meetings where I speak are starting to see that it's no failure on anyone's part if a patient has seen an article that the physician hasn't; and highly activated patients are starting to see that it's unreasonable to expect perfection from physicians, who in turn are subjected to a culture that *expects* perfection. A dysfunction merry-go-round, I say.

And all this is why in my TEDx talk the tag line / chant at the end wasn't a one-side "Patient power!" or "Doctors Might Kill You," it was "Let Patients Help." THIS is the gaping gap that we can easily bridge: to just open our minds, all of us, to the opportunity of patients being more active participants in care - and thus to do what we can to teach them how.

Note: pretty quickly this does lead to patients being engaged in the design of milkshakes...

civisisus said...

Dave DeB is being too polite.

Doctors and any clinicians who do not get that people aren't waiting (and waiting...and waiting...) for doctors and clinicians to categorize them, to schematize them, anymore - and increasingly, that they have tools to pursue "just good enough" options & alternatives - will be irrelevant; will be ignored.

Anonymous said...

Thank you for thought provoking post. One thought from me in response - should we not be asking ourselves 'how can I best serve' opposed to what services should we provide. The first question brings us into the moment with the care recipient, from their we can listen and provide.
Andy Bradley

e-Patient Dave said...

Y'all might also have a look at Aaron & me goin' at it :-) on the e-patient post's comments.

astupple said...

Andy- Interesting point. To me, the next question after asking "how can I best serve" is to ask "what does the patient need most?" This second question brings us back to the milkshake- if they want "x" and I'm prepared to give them "y", then we have a few things to discuss. If instead I just assume that they're seeing "y" the same way that I am, then I have not served them the best that I can.

Thanks for commenting!

AfternoonNapper said...

I firmly believe that there is a workable medium of the traditional doctor-patient relationship and the patient-as-consumer concept. You are spot on in addressing assumptions vs. needs. I have been seeing my family doctor for nine years now. We have a good relationship. I'm straightforward and participate in my care. He listens to me but also isn't afraid to tell me no. Recently, I felt as though something was physically off. I've had a history of hypothroydism, felt that many of my symptoms matched up, did some research, called my doctor and asked for a blood test. Granted, a blood test is an easy enough thing to do, and for a patient with a specific history wanting to check for that specific illness, it makes a lot of sense to run the test. But my doctor and I were able to reach this middle ground I speak of because we skipped the actual patient-doctor visit. I didn't waste his appointment time, so he could spent it with someone with more pressing needs, and I got my blood test before the end of the year and a new deductible. The end result? I was right. My doctor's nurse called with the results, and I was put on a medication that has improved how I feel. It was efficient and effective. My example is of course one that puts great responsibility on the patient, and until our overall health literacy and engagement improves, we can not believe that "the customer is always right."

Breakwall said...

Thanks Aaron, I enjoyed your post. Two things immediately came to my mind. 1) Doctors (in the US) are very motivated by money and even moreso as reimbursements have decreased coincident with increased overhead. We're not going to do something if we're not adequately reimbursed and I don't think that's changing anytime soon. 2) Understanding what the patient really wants is paramount to delivering excellent and efficient care. When I see a new patient on my list who I'm seeing for 'Frequency' it's really important that I understand whether this actually means eccessively frequent urination or 'do I have prostate cancer' or 'I said frequency but really want to discuss my erectile dysfunction' which I need to know because erectile dysfunction might increase this patients risk for MI/stroke. Where I frequently fall short is when I assume I know what my patient wants and I shouldn't do that. Ford Motor Co and Apple can tell me what I want and I'll probably follow their lead. As a physician, I need to understand exactly what my patients want. And that takes time and as we all know, time is money.

Rumberger said...

All very interesting points. My take-away from this is fairly simple; in milkshake terms. Is the milkshake a need or a want? The patient came to us for a milkshake. They heard that you make the best in the area. In the US, your milkshake isn't free, it's either paid for by the patient, the patient's employer or the government, mostly after the patient "enjoys" their milkshake. Now, let's take a little time to ask the patient which flavor of milkshake they want, if we have that milkshake in stock (they want banana and we only make vanilla). If they keep asking for banana, then maybe we should follow the trend...keeping in mind that as a physicians, you would want to warn the patient that too many banana milkshakes may lead to problems down the road and may not be the best for them, even though they asked for a certain flavor to begin with. As a business, you have to be able to afford to buy the bananas to make the milkshake that the "customer" came in for to begin with....

astupple said...

Afternoon- Intriguing story. The thought that came to mind while reading was a minor quibble: by "saving" your doc an office visit, you've actually deprived him/her of revenue. So, your story works very nicely FOR YOU, because YOU save by not needing a visit (which is the way it should be, of course). So, your story is great largely because your doctor is comfortable, for whatever reasons, with foregoing the revenue of seeing you prior to the blood test. I hear a strong need to change reimbursement.....

Breakwall- Thanks for your comments- all this certainly takes time/money.... Somehow, I deeply feel that altering reimbursement must come BEFORE we can serve our patients as well as Apple and Ford can serve their customers.

Rumberger- A thought that comes to mind regarding need vs. want: the key about the milkshake mistake is in looking a level deeper than want/need. The researchers instead looked at the JOB that the milkshake was performing. This offers a richer explanation for whole phenomenon, which then offers McDonalds an opportunity to better serve need/want.

So, when a patient comes to see their doctor with a sore throat, the JOB that they want this visit to do for them may be, if they're a school teacher, that they want to know if they're contagious. They may not want relief, just assurance. said...

I am coming in on this conversation very late in the game. Many important points were raised.

My perspective is that of a management consultant and many time patient.

My first lesson in patient as customer came when a surgeon coerced me to consent to letting my step mother observe a very personal physical exam when I was 19. About 15 years later my boss charged her doctor for making her sit in his waiting room - wasting her valuable time. Those were hours that she could not bill to a client. A few years later, I told my physician that he was fired for not listening to me and behaving in an arrogant fashion. He was shocked - as you might imagine.

Now, after another 15 or so years, I am still amazed at how patient (customer) unfriendly doctor offices and healthcare settings are, from the first encounters with the receptionist to the bills I receive. In between those bookends, I now get good care from my personal doc who maintains a practice of ~ 250 patients and lives a modest lifestyle. He is a good doctor and good guy. I wish he could spend time with his patients and make a good profit at it.

I am a patient, a customer, and an adult. I want what I want, and I realize that I shouldn't be catered to when it comes to treating an illness. That is not a conflict with being a customer.
As a customer I want other things such as being listened to, efficient processes, not being exposed to the nasty back-office conflicts, and maybe even a spare office to use while I wait.

As a consultant, I face similar issues as doctors when it comes to doing what is best for my clients. Wants are not always in the client's best interest, so I have to navigate delicate situations to come up with solutions. Often that means having a conversation with the client to discern his position (the solution he has in mind) from his interests (what he thinks the solution will give him).

As I have begun working with physicians, I have become aware of the gaps in their training. The docs I have worked with were not prepared to handle difficult interpersonal conversation, how to handle difficult people, or how lead an organization to serve customers/patients.

Training in these areas seems to have been regarded as crass or beneath the venue of med school. As a result, many physicians are not prepared for the actual work that awaits them when they enter healthcare institutions.

It's not "their fault." It is a system issue.

Srikanto Bormon said...

GREAT post. I found this as I was writing an article, albeit from a different viewpoint, about the same thing.

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Quinn said...

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