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Doctors and Lawyers: Consumers, Patients and Clients

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Q. What do Paul Krugman (Nobel-prize-winning economist) and Scott Greenfield (criminal defense attorney) have in common?

A. Both are occasionally wrong, but never in doubt.

Q. What’s the difference between Paul Krugman and Scott Greenfield?

A. In the recent case of markets and professional ethics, one of them is wrong—and it’s not Krugman.

 

Krugman recently wrote in his NY Times column a piece called Patients Are Not Consumers, about how doctors and medicine (and patients) are being degraded by a simplistic emphasis on market ideology to the exclusion of ethics. Krugman is more right than wrong in this timely piece.

Politicians and supposed reformers talk about the act of receiving care as if it were no different from a commercial transaction, like buying a car — and their only complaint is that it isn’t commercial enough.

Krugman isn’t saying health care isn’t commercial; he’s saying it’s not only commercial.

Greenfield attempts to hijack the medical metaphor on behalf of lawyers in a post called Take the Lead, saying that lawyers and the law (and legal clients) are also being degraded by a simplistic emphasis on market ideology.

But Greenfield, by contrast, is more wrong than right. He confuses professionalism with witch-doctoring, and does his cause no good.

Doctors, Patients and Consumers

Market-as-solution is increasingly being exposed as an imperfect ideology except on the political fringes. (You could say that about government-as-solution too, but it’s a straw dog with no teeth—socialists are polling badly in the US these days).

This is legislatively relevant today, as Krugman points out, in the program put forth most recently in Congressman Ryan’s economic proposal. Here’s Krugman:

The idea that all this can be reduced to money — that doctors are just people selling services to consumers of health care — is, well, sickening. And the prevalence of this kind of language is a sign that something has gone very wrong not just with this discussion, but with our society’s values.

Krugman is an economist; but one who does not believe homo sapiens is equivalent to homo economicus. He’s an economist who believes in ethics, which makes him both interesting and relevant in my book.

Of course, that’s not the whole story. There are reasonable claims to be made for consumerism in healthcare. HBS’s Regina Herzlinger has for years argued—very cogently, e.g. in Who Killed Health Care?–that the entire US system desperately needs more consumer–and market–orientation. As someone with recent experiences of loved ones in hospitals I can attest to the need for intelligent process design and change management skills.

Yet Krugman’s no absolutist. It wouldn’t surprise me a bit to find that he’s familiar with Herzlinger’s work and that he favors it. He doesn’t say that health care isn’t commercial—just that it’s not only commercial.

He’s talking about the excess that comes not from reasonable people applying reasonable market principles but from ideologues.

Lawyers, Clients and Consumers

Which brings us to Mr. Greenfield. Trying to hitch a ride on Krugman, he says, “Doctors don’t have consumers. They have patients. Lawyers don’t have consumers. We have clients.”

“All marketers lie,” according to Greenfield, “because without lies they would get no leads.” Which may be your first tip that we’re in true-believer territory.

In particular, Greenfield finds the term “leads” a morally offensive term.

“…I was offended by his characterizing clients as leads, that this was a marketing term and it fundamentally conflicted with what lawyers do. Lawyers do not seek ‘leads,’ I told him. We seek clients. I thought it was outrageous.

“We don’t sell used cars. We are responsible for people’s lives. We used to be, anyway. And people who are responsible for the lives of others don’t think of them as leads or consumers.”

Witch-Doctoring

When someone starts talking about being “responsible for the lives of others,” get your megalomania sniffer out. Greenfield’s parallel here isn’t with doctoring—it’s with witch-doctoring.

In my experience, most law firms are still a long way from being touched by market forces, much less dominated by them. The idea that marketing is in fundamental conflict with client service makes as much sense as an Ayn Rand Daycare Center.

Krugman integrates ethics and economics. Greenfield is anti-integration when it comes to law and economics—there can be no compromise with the devil. Such intolerance, I find, is closely correlated with cases of the Hammer-Nail Syndrome.

The Hammer-Nail Syndrome

All professions are prone to the hammer-nail syndrome; if I own a hammer, you must be a nail. And Greenfield is a poster child. Consider a case from his own files.

You may recall about 18 months ago Tiger woods got into major PR trouble for backing a car out of his driveway and allegedly being on the wrong end of a 3-iron from his wife? Greenfield’s advice at the time was crystal-clear (as always—sometimes wrong, never in doubt):

“Even worse than the civil lawyer is the flack, whose only concern is how things will play out in the media. ‘But it won’t look good for you if you don’t meet with the police, Tig.’ And it won’t look good if he’s arrested based on his statements to the police either, but the latter will go on much longer than the former. Flacks tend to be more concerned with appearance than reality. [italics added]”

In Greenfield’s world-view, Woods should have ignored the PR “flacks” around him and immediately gotten not just a lawyer, but a good criminal defense attorney. Because what ol’ Tiger had was not a communications problem, but a legal problem.

Really, Scott? Is that how we’ll remember the Tiger Woods fiasco—as a case in criminal law? Would you have coached him to just say, “I didn’t do anything illegal, I didn’t break any laws?”

Being blinded by antipathy to marketing means you can’t see a marketing issue when it hits you like, well, a hammer in the head.

What Real Professionalism Looks Like

This is not what real professionalism looks like. The legal profession should reject the ‘high-priest slash witch doctor’ view of the law as being apart from the rest of human commerce, just as I think Krugman does.

Professionalism must include ethics. To me, that means treating our clients and patients as intelligent equals in a joint search to make things better in their part of the world. Your expertise is not a license to bloviate, much less to be respected for doing so. Your expertise is an attribute that, if you treat clients decently, will be perceived as such and rightly so.

That means—let me spell it out—if you’re not proactively seeking opportunities to improve the world via your expertise, then you’re not behaving as a professional.

  • If you have a cure for smallpox and you just sit in your office aggressively waiting for the phone to ring from enlightened smallpox victims—you’re unprofessional. Go look for “leads,” preferably in places where you’re likely to find smallpox victims. You might save some lives.
  • If you’re a lawyer doing corporate work for a client and you see a real estate issue, but choose not to mention it because ‘you don’t sell’—you’re unprofessional. That’s a ‘lead’ and you’re not unethical for pursuing it—you’re unethical if you don’t.
  • If you refuse to treat your client or patient as an intelligent adult consumer by insisting they first respect you for your black-robed witch-doctor status—you’re unprofessional. Go look for leads, defined as people whom you can help. Don’t demand respect; earn it.

Scott says he’s responsible for his clients’ lives. I suggest that’s a bad rule for the rest of us.

We’re not responsible for our clients’ lives; they are. Our job is to help them—not live their lives for them.

Evaluating Paulson and the Biggest Trust Me Since Iraq

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Economist Paul Krugman , in his NY Times blog, wrote yesterday about The Trust Problem raised by the bailout proposed by US Treasury Secretary Paulson, Fed Chairman Bernanke, and President Bush. Never mind the merits of the case. The point Krugman is raising is about trust:

"The whole premise of the bailout push has been “We’re the grownups, we know what we’re doing, just trust us.” Sorry, but that’s how Colin Powell sold the Iraq war. Fool me once, shame on you, fool me twice … you shouldn’t get fooled. " [revised last line courtesy of GW Bush]

I try not to write about US politics in this blog: but this issue is non-partisan, arguably international—and undeniably huge. It’s an 800 pound gorilla for trust—it can’t be ignored. If trust as a social issue isn’t relevant here, I don’t know where it would be.

So—for someone focusing on trust, these are interesting times. And Krugman’s observation is valid. Let’s evaluate it.

The Trust Equation suggests Trustworthiness is a function of (credibility + reliability + intimacy), all divided by the self-orientation of the one who would be trusted. How does Paulson fare?

As Krugman points out, Paulson’s got a ton of Wall Street cred—less so as a Treasury Secretary. Only months ago he was calling the economy firm, and one gets the strong sense he’s making this up as he goes along—like the rest of us. As evidence, Krugman contrasts Paulson’s plan—which famously and clearly called for no oversight—with his testimony of yesterday, which welcomed oversight. For credibility—maybe a B-minus.

On reliabilty, it’s tough for anyone. Reliability takes repeat experiences. But no one has this issue on their resume. One has to stretch to find comparable experiences, and unfortunately, the line stretches to another Bush cabinet member—Colin Powell and Iraq. Another good man who, it turns out, blew smoke at us. Given that track record, anyone in Paulson’s chair rates a C-minus at best.

The third factor, intimacy, is mainly determined by a willingness to be open and transparent about oneself. Paulson has done nothing to explain the theory behind his plan, which of course leads people to wonder if he has one—or if so, why he’s hiding it. Worse yet, given his mixed credibility and his (and anyone’s) inability to have a track record on this issue, that opacity makes him look even worse. In particular, it calls into question the demand by Paulson (and Bush) for immediate action, and the dire consequences if the demand is not met. Got to give him a D.

Self-orientation, the lone factor in the denominator, is the most powerful of the four. I don’t think anyone doubts Paulson’s commitment, nor his good intentions. Then again, most people this side of psychopaths have good intentions.

It’s not a good sign that he acquiesced to a political demand to reduce high compensation for masters of the universe who would be rescued. It suggests not only that Paulson is politically tone-deaf, but that his plan was not free of moral hazard. It’s not that Paulson is in it for himself, but it suggests there’s a lot in it for his old buddies. And absent a "theory of the case," or data, this looks pretty self-oriented. Another D, I’d say.

Remember the National Lampoon Magazine cover of the cute dog with a guy pointing a pistol its head? "Buy this magazine or we’ll kill this dog," the tag line said.

It sold a lot of magazines. Will it sell a mega “trust me” for a mega-bailout?