P&S Journal: Fall 1996, Vol.16, No.3
Changing Medical Lexicon and Alternative Care Modalities (Insights of an Older Physician)
The new wave is here. American medicine is in the midst of a sea change. For care givers the sea is turbulent, the compass erratic. Resting on the oars is not acceptable. Health care providers must adjust to change; indeed, help to define change or risk foundering. This requires new priorities and an updated lexicon to accompany innovative thinking.
Our community hospital, to its credit, is in step with the now not so new thrust in marketing that preoccupies the health care service industry across the nation. The other day at a Strategic Planning Committee meeting I anachronistically referred to a client of mine as a patient. Silence was followed by an undercurrent of murmuring, disapproving if not manifestly hostile. Aware of being out of step, I asked for patience from younger committee members, indicating that I must and would adjust to the designation "client" which almost everyone agrees now best defines the relationship that should exist between consumers and providers.
That evening I called up my lawyer son and asked how his clients were doing; he indicated that all was well. I then asked why, in my experience, in an adversary situation lawyers appeared logical and, on occasion, erudite yet seemed to hold in escrow a quantum of energy and not expend themselves on the client's behalf. He rejoined that it behooved a lawyer to remain aloof and objective. This explained why opposing lawyers could, at the end of the day, sit down and bend the elbow together, as good colleagues should. Perhaps some aspects of this culture warrant medicine's examination.
The following day began a weekend and the occasion to travel to New York to observe a rugby game involving graduate students, including physicians in training. In the early going aggression and spleen were not blatant, yet in the afternoon at the final playoff, an emotional charge was manifest, adding a dimension to the play beyond that predicated upon talent and training. This adrenergic additive carried the day for the medics over a disciplined business school team of quality. Statistically, the sample was too small to warrant generalization but it sufficed to reinforce my prejudice that optimal performance, medical practice at its best, required more than dispassionate application, the keystone for our friends in law.
The following Monday, in making hospital rounds, there was occasion to ask for help from Social Service in client discharge-planning in semiprivate Room 460. Preceding me into the room, and confronting two beds, the health-care adjuvant confronted a choice and queried, "Which of you is Dr. Smith's client, please?"
The response, expressed with some vigor, was, "What is this client crap? I am Dr. Smith's patient. I hope he is not abandoning me." Albeit colloquial, there was a certain charm in the alliteration employed and the irreverence of hospital authority implied. Nonetheless, politic support of hospital function required that I remonstrate my patient for not being current and to request a more passive acceptance of the client-physician relationship. I then proceeded to read aloud from a manual detailing the cost-benefit ratio and considered alternatives to a rectal examination, an enteric tract bleed having complicated his therapy for an acute cardiac event; in preparation for his discharge to home it was prudent to document the absence of occult blood. The now compliant client signed, indicating risk comprehension. The examination and discharge were effected.
That evening, having been called to the hospital for a problem, I was pleased to see one of our pastors making calls. To express collegiality, I nodded and asked how his clients were faring. The pastor, apparently lacking a terminology update, seemed momentarily nonplussed by the term "client." Wishing to make redress and establish a more personal interchange, I professed that I had started out as a sinner before God but that mother, after acclimating to my existence, had suggested, in a tender moment, that I was a child of God. After time and the reading of Martha Graham, who proclaimed that in professional life, as in dance, with diligence, one could become an athlete of God, I aspired to that estate, but would now update to become a client of God. The irony, if any, was abstruse; he expressed a few words of commiseration and left, I suspect still ministering to souls and children of God, not clients, in spite of our exchange.
Later that same evening, rather down and discomforted in this marketing world with proprietary lexicon, I stopped at the office and, in the quiet, considered that a little R&R might encourage a measure of equanimitas. Would not a more sanguine state of mind serve my clients better? A New York newspaper rested in the waiting area. In the theater section was an advertisement for an escort service. Less than secure about New York City travel, I thought a service might have merit and put through a call on the 800 number. A distaff voice brightly answered with, "My name is Jill. Hello, John, how may we best meet your needs? Our customers are in the driver's seat, so to speak." The address form seemed rather too familiar but agreeable enough. Had I revealed my name, I questioned, caught off-guard and amazed. "I know lots of Johns," she responded. Ah, just a statistical probability marketing trick, but rather neat. She then asked if my intent was to become a client, cementing my initial positive impression. Certainly I could trust this escort service. "Yes, I would like to become a client, but will you describe the spectrum of service provided?"
Without hesitation, she replied that it was extensive, bridging from limited to trips around the world. "We can provide a varied bag of tricks." Although this implied a substantial support system, in an effort to evidence my sophistication and by way of friendly jest, I indicated that it was my ambition to take a trip to heaven. Apparently unflustered, she indicated that for a slight additional consideration this might indeed be workable.
Now, really intrigued, I wanted to be objective if not hard-nosed and queried, "Do you folks have a screening test or policy?"
The answer was an immediate, "Yes, we screen negatively for blue coats with brass buttons." Looking at my blazer, the silver buttons were reassuring. Jill further indicated a preliminary financial screening indicative of good business practice.
Cautious, however, I questioned, "How about assessment-need evaluation and plans related to that?" With no thought-collecting hesitation, she stated that assessment and evaluation of needs were routinely employed prior to effecting a plan of action, adding that in their view, basic human needs had a demonstrable universality although the nuances might vary. She went on to say that their system espoused the holistic approach and subscribed to the WHO's (World Health Organization) dictum that good health transcends the absence of disease, requiring a positive sense of well-being.
Well, as you may perceive, I could find no chinks in their armor and considered that all was in order, saying, "This sounds like a first class escort service. My hat is doffed to you."
"Never mind the hat, just give your American Express number," she replied. I complied, but then realized that we had failed to formally introduce ourselves and requested, "What may I call you, Ms., Miss, Mrs."
"It is not our custom to give our full names over the phone, John. It is not professional." I admonished, "Don't be sticky, you know mine."
Now in playful voice she posited a riddle, "What alliterates, rhymes with little, and provides for Main Line jewels? Think on that and get back to me; reverse the charge. Of course, I am sort of a sport, you know, genealogically speaking."
"You folks are really on the stick," I gushed.
"I rather like your metaphor. We try to be," she acknowledged. "We have combined innovation with traditional values, passed down through generations; indeed a Mayflower heritage, providing Pocahontas pleasures for the original john, Smith. We have preserved bedrocking attributes, classical American, imbued through sylvan family life in Greek Revival along the Delaware, isolated from urbanity, discretion, derived from distinguished diplomatic service, passed on as legacy."
I left the office singing "I'll Build a Stairway to Paradise," feeling much good will toward the human race and persuaded that "client" was not only politically correct but also a happy choice. Yet, on second thought, driving home, I self-questioned, "Was the conclusion precipitous, not fully considered?" On reflection, this escort service and evaluation of their methods was not properly the province of an individual but rather deserved consideration at committee level. Perhaps an on-site visit was in order. Minimally, might not we learn how to become more user friendly? This will be brought up at the next Strategic Planning Committee meeting.
That night, my head upon the pillow, thoughts turned to more deep-seated needs and I folded my hands in a moment or two of prayer. "Dear God, this is John speaking. I would like to become your client. I can pay. No, I am in the HMO, you know, I can co-pay. I want to go to Heaven."
All seemed well with the world and there followed the most restful sleep experienced in months.
Dr. Wood retired in November 1994. He is attending and emeritus chief of the cardiovascular department at Mercer Medical Center in Trenton, N.J., and emeritus associate clinical professor at the New Jersey College of Medicine and Dentistry, Rutgers Division. He is a member of the Board of Trustees of Mercer Medical Center.