Patient-view vs. provider-view health care

This will be somewhat of a digression from the usual fare here at the Manifesto. While I moonlight as a commentator about religion, race and free speech, the bulk of my daylight hours are spent applying my skeptical gaze to the Canadian health care system. The story I want to talk about today doesn’t really have much to do with the regular topics here, but I found it interesting, and last time I checked this was my blog 😛

Health care is a complex and multifaceted beast that has unique challenges. In many senses it can be thought of in terms of a business – patients are ‘customers’, health care practitioners are ’employees’, and health is the ‘product’ that you are ‘selling’. This analogy breaks down pretty spectacularly for reasons I will go into later, but for the time being it is helpful to think of it as a business. What would you call something like this?

With the NHL playoffs just around the corner, the College of Physicians and Surgeons of B.C. has issued an advisory to the province’s 11,000 doctors, reminding them that talking about anything other than the task at hand in the operating room is unprofessional and inappropriate. The matter arose after the college received a complaint from a patient who heard his surgeon talking hockey with the scrub nurses during the elective procedure for which he was given a local, not a general, anesthetic.

That’s shitty customer service, right? Imagine you went to the bank, and while they were helping you at the counter, the tellers were talking about the latest gossip about Justin Bieber? You’d be annoyed with their level of unprofessionalism, to say the least. While your business might be completely routine for the tellers, so the point where they didn’t really have to concentrate much to do it, it’s still rude to chat about non-related matters while you’re providing a service to your customers.

This issue highlights an interesting dichotomy in the provision of health care – that of ‘patient-view’ and ‘provider-view’ types of administration. In patient-view administration, the goal is to provide the highest quality services to each patient, and to construct the system in such a way as to maximize the ease that patients move through the system. Provider-view administration seeks to maximize the efficiency of the system, such that the largest number of patients can be served as quickly as possible.

It brings to mind one of my favourite examples of what I call “first-floor/third floor problems”. Picture a hospital that routinely sees patients in the radiology department. In order to streamline the process, patients are routed through offices on the first floor when they come in the door. This ensures that people don’t mistakenly go to the wrong department, and that all of the relevant information is available about each person before they see a doctor. Very efficient, right? Well imagine that the third floor also houses several inpatient beds. A person receiving inpatient care on the third floor that needs a scan needs to go to the first floor for processing, and then back up to the third floor to receive their scan. From a patient-view perspective, this is a huge waste of time and resources, but from a provider-view perspective it is an unfortunate consequence of something that is otherwise a good system.

Similarly, we have an example here of surgeons who, from a provider-view perspective are providing a high-quality service in a quick and efficient way. These are specialists that can perform routine operations with a nearly-perfect success rate, and their chatting does not affect that success in any meaningful way. However, the individual patient doesn’t give a rat’s posterior – she wants the undivided attention of her health care provider.

The part that makes this issue even more interesting is the level of emotional investment in an operation versus at a bank counter. A rude teller is annoying, but even if they screw up it’s no big deal. A distracted surgeon is potentially fatal to the patient, a fact that is made even more urgent considering the expected power dynamic between patient and physician. This is where the business model breaks down – health care is a need that has components that are not within the comprehension of the vast majority of people (including those involved in providing said care). To expect market forces to operate in the same way as they would in a bank (go to a different teller if you don’t like the one you’ve got) is simplistic, because it neglects the phenomenon of need. This will undoubtedly be the topic of a post to follow, but I am butting up against my word limit already and it’s too big to flesh out in the space remaining.

There is a careful balancing act of patient- and provider-view arguments that is required to deliver high-quality and sustainable care. Patient-view care is incredibly resource-intensive to manage, as it requires the consideration of each individual patient’s unique situation. Provider-view care can neglect the non-medical welfare of the patients as they move through the system, and can be quite myopic when it comes to the satisfaction of users of the health care system, thus undermining public support for the system.

In my own small way, I look at this issue from a particular angle and try to influence policy that will result in an equitable and sustainable mix. It is precisely because these issues are so difficult to put a precise handle on that I find them so interesting.

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  1. says

    Good post, I look forward to more in the future. Although given the colossal failings of the (US) banks over the past couple years, I’m not convinced they’re the ideal market-driven example; then again no analogy is ever perfect (otherwise it’s just the exact same thing).

  2. says

    From a customer service perspective, the analogy works. Obviously at the administrative level it is meaningfully different to run a bank than a hospital. I could have used Taco Bell just as easily, but at the time of writing I had my mind on my money and my money on my mind.

  3. Kate says

    Glad I came across this post! I’ve been working in business the past few years (former Bio major, premed tract) and after a few eye-opening events, mainly one very poorly run practice with an otherwise competent and likable physician, I’m making the leap to get back into healthcare (I know, maybe I’m crazy). But like you, I found such a strong parallel between customer service and patient care. And I saw a lot of TERRIBLE and non-existent customer service during my mom’s bout with colon cancer. I was absolutely appalled at the customer service or “patient care” we received. No returned phone calls. No follow ups (no blood tests after chemo). Things that, as a sales/customer service rep, left undone would have left me sales-less and fired. And I sold roofing equipment… not something as precious as health!!

    However, that being said, I’ve also worked on the admin side of things in a manufacturing business. Overhead must be reduced. Profit must be maximized. A business won’t survive any other way. So. A manufacturing plant that also does 100% direct sales must find a way to limit the overhead with efficiency while not compromising customer service which maintains the customer base. In this particular model, ya can’t have one without the other.

    It really is a quite fascinating topic. Thanks for the post. I’ll be looking for more!!

  4. says

    It’s a really fine line, and many people are woefully unaware of the dichotomy – focusing their effort and attention only on whichever side they practice on.

    Out of curiosity, whereabouts are you located? I know the Canadian system pretty well, and have what I would call passing familiarity with the US system, but I know the realities can be quite starkly different in other countries.

    Thanks for sharing your experience.

  5. Kate says

    I’m in California. I can’t claim that I’m too familiar with the inner workings of the Canadian system… just the basic difference that it’s publicly funded as opposed to private. And of course healthcare has been a huge hot button in our country right now with all of the proposed “healthcare reform” etc. There are many stark differences between the two systems. It is interesting though that the dichotomy is present in both system models… with a similar “failure” (if that’s not too harsh) in recognizing and addressing it.

  6. says

    Yes, the problems of administration (and failure is not too strong a term) are not related to who funds it. Of course, when the administrative body exerts as much influence over the provision of care as the insurance companies do, you end up with more top-down problems. The government funds care here, and provides general guidelines for what things are funded and what aren’t, but those decisions are made chiefly by physicians rather than bean-counters like myself.

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