Mixing Metaphors in Pharmacy Education is a Bad Solution for Students

• educational customers
• consumerism
• professionalism
• metaphor
• fiducial obligations

Three thought-provoking essays published in the American Journal of Pharmaceutical Education focused on the deleterious effects of consumerism on pharmacy education. Cain et al convincingly argued that a student sense of entitlement can undermine professional education: “Grade inflation, student incivility, altered classroom practices, and decreased faculty member morale are all potential after effects of teaching students who hold academic entitlement beliefs.”¹ As a response, Karpen’s letter offered a pharmacy student’s refreshing perspective on what students legitimately expect from the educational establishment.² Finally, Holdford’s clever and insightful essay, “Is a pharmacy student the customer or the product?” warned of the threats to education posed by a related emerging trend, the identification of students as “customers” of the educational system.³ Although Holdford’s diagnosis was insightful, his proposed cure was less so: he suggested the alternative to viewing students as customers was to view them as educational products we deliver to our real customers: the students’ future employers and the public who would consume the students’ services. While many of his observations were on target, this remedy would likely exacerbate rather than correct the problem, for it retained the consumer mentality that underlay the designation of student as customer in the first place. Nonetheless, this student-as-customer model is indeed a pressing issue because, in both education and medicine, a consumer mentality is increasingly threatening care. A more radical solution is needed—one requiring a better understanding of both the essence of professionalism and the uses and misuses of metaphor.

Some may argue that it does not make a difference what we call students,⁴ but this is not a pedantic quibble over terminology. Nomenclature sets up paradigms that govern our thinking, actions, and structures. To think of students (or patients) as customers is to think metaphorically: that is, to attribute to one entity the characteristics of another in order to provide clarity or insight.⁵

Metaphors are not merely rhetorical or poetic devices that do nothing more than clothe our preexisting ideas in fancy dress. They are extremely important organizational tools in the formation of our ideas and structure of our daily practices. Lakoff and Johnson argued in Metaphors We Live By that metaphors are generative, theory-constitutive. In other words, we organize our work and our lives differently, for instance, depending upon whether we see the human mind as a wax tablet, a landscape, a web of relations, a spread sheet, or a neural network.⁶ Metaphor is instrumental even in the development and dissemination of scientific theory; while the traditional metaphor for the Newtonian cause-and-effect universe is a billiard table, a warped Einsteinian universe of space-time is more easily conceived by the metaphor of the universe as a billiard table in which the slate surface has been replaced by a flexible net.⁷

Nonetheless, metaphor continues to evoke apprehension, and perhaps appropriately so. For instance, Susan Sontag acknowledged but declaimed the power of metaphor in Metaphor and Illness, which argues that metaphor should be banned from medical discourse.⁸ Herself a “victim” of cancer (note the metaphor here), Sontag contended that military, magical, and romantic metaphors used in talk about diseases categorized, demoralized, shamed, isolated, and silenced patients. In her later work, AIDS and Its Metaphors, Sontag acknowledged that her earlier strident condemnation of metaphor was combative and unrealistic: “Of course, one cannot think without metaphors. But this does not mean there aren’t some metaphors we might well abstain from or try to retire.”⁹

This is more to the point. Metaphors open a window onto reality but thereby blind us to other perspectives: as the philosopher Martin Heidegger pointed out, “every revelation is a darkening,” or as Ralph Waldo Emerson more succinctly observes, “every advantage has its tax.” Metaphors are even more powerful when they operate below the threshold of conscious awareness, when they are so much part of our thought processes that we don’t recognize they exist—just as a fish knows nothing of humidity. At that point, metaphors can be dangerous: we not only live by metaphors, as Lakoff and Johnson suggested—we can die from them as well. Of course in the context of pharmacy education, I am using the term “die” metaphorically to refer to negative consequences, but all too tragically history demonstrates the unimaginable atrocities that were justified by a metaphorical dehumanization of a group of people as “parasites” on society. Metaphors have serious consequences—both for good and evil. Thus the goal should not be to eliminate metaphors but to raise them to consciousness so that they then can be analyzed and evaluated and thereby can be more effectively employed or excised.

The implications of the customer/business metaphors for students and education are ones that must be considered more consciously, for they predispose us to beliefs and practices that threaten professionalism and the best interests of those whom professionals serve. Ironically, “attempts to restructure pedagogical cultures and identities to comply with consumerist frameworks may unintentionally deter innovation, promote passive and instrumental attitudes to learning, threaten academic standards, and further entrench academic privilege.”¹⁰

Of course consumerism in higher education is only one manifestation of a sweeping cultural trend that has been building since assembly-line mass production in the early 20th century. A number of cultural forces—including innovations in management strategies and psychological advertising of the 1950s, consumer advocacy movements of the 1960s, and, more recently, the proliferation of electronic media—⁵contributed to the emergence of consumerism. In today’s world, Rene Descartes’ aphorism, cogito ergo sum (“I think therefore I am”) has given way for some to consumo ergo sum (“I consume, therefore I am”). As a result, people and processes are commodified, and self-identify is coupled not with what we are or do but with what we have.¹¹

Particularly in the1980s, consumerism became more prominent in American education as a result of such social and economic developments as changing student demographics, resource constraints imposed upon universities, and changing government policies. Competition for students, along with a concurrent call by a skeptical public for greater accountability, led to hiring a proliferation of college administrators, many with business backgrounds, who had been schooled in consumer-driven strategies such as enrollment management, resource allocation, and strategic planning.¹² The thinking was that market competition would drive colleges to enhance education, produce greater accountability, and result in a greater return on a financial investment.¹⁰ This commodification and commercialization of education as a product sold to consumers by service providers echoed through President Obama’s 2013 State of the Union address in which he urged students, “get the most bang for your tuition buck.”¹³

For business-oriented administrators, “student-as-customer” may not be a metaphor at all, but a fact—a rational approach to ensure institutional survival and growth. Proponents of a student-as-customer paradigm frequently are motivated by laudable intentions to not only produce greater accountability for the educational process but to also enhance relationships between students and faculty members. Too often students have not been given the care and respect they deserve by virtue of being students. Further, the student-as-customer movement is sometimes associated with advocacy for student-centered education, which focuses more on student interests, abilities, and learning styles.^14,15 Thus, the customer model is meant to be a corrective for faculty members who are indifferent or rude to students, who know students only by number, or who are unapproachable, authoritarian, or paternalistic. The model, moreover, is a corrective to faculty members who treat students worse than customers.

While these goals are admirable, the consumer model of education conflicts with faculty members’ professorial model that regards the “business” of education to be the pursuit of truth, a goal they see as threatened by a consumer focus.⁵ More is at stake here than a power struggle between faculty members, administrators, and students, resulting in a faculty member’s diminished control of educational standards, curriculum, learning strategies, and assessments. The consumer mentality within the classroom can be subversive. To take the measure of student satisfaction as an indicator of institutional success not only promotes a debilitating student sense of entitlement but denigrates rather than elevates students. And it runs counter to our obligations as professionals.

A profession (I have argued elsewhere) differs from an occupation by the nature of the relationship a provider has with the persons served.^16-19 Lawyers represent clients, clergy have responsibility for a congregation, medical practitioners care for patients, and teachers guide students. Carpet cleaners, personal trainers, telemarketers, insurance sales representatives, IT specialists, some financial advisors, fashion consultants, etc., perform useful services for customers. It is not simply a matter of terminology. With customers, providers have an economic or market relationship. As customers, we expect to be treated well and perhaps even be treated as though we are always right. But we also recognize the wisdom of caveat emptor. We must beware because the relationship we have with our providers is mercantile. No matter how ethical or trustworthy the provider or seller is, his or her primary obligation is not to us but to the business; he or she is not committed to putting our best interests first. Ethics and good business practices may motivate the business person to treat us with respect but that is a decision determined by a desire for repeat business, not an obligation to act in the customer’s best interests.

Of course, the professional is paid for services, but the relationship with those served is not mercantile but covenantal or fiducial. That is, a profession is built upon faith.^4,17,20 The essence of professionalism, that which distinguishes it from an occupation, is the obligation to maintain a fiducial relationship with a patient/client/student. That means that when faced with important matters that touch us deeply (ie, our health, wealth, knowledge, or even soul), we are forced to turn to a professional because we do not have the knowledge to determine a best course of action, and, further, we cannot even evaluate the recommendations and performance of the professional. As the Code of Ethics for Pharmacists says, patients must offer the professional the “gift of trust,” and in return the professional promises that the trust is warranted.²¹ The professional promises a fiducial obligation, a relationship of faith in which the best interests of the person served will be the primary determinant for all services. Again, this is the essence of professionalism, the sine qua non. A professional does not simply have a “contract” with the public (a contract being a legal document requiring witnessed signatures necessitated in the first place by suspicion) but enters into a “covenant” based upon trust.

Most people instinctively shudder at physicians who refer to their patients as “customers” and are horrified by pastors who voice elation at the number of customers in the pews, but many of these same people enthusiastically support the metaphor of students as customers—some of whom are the same instructors in IPPEs who solemnly lecture their students that even in a community setting they are dealing with patients, not customers. One reason for confusion regarding the status of the student is higher education’s dual system of administration and learning, with only the former being related to business.^5,12 Higher education in many respects is a business, and administrators and staff thus may have a different relationship with students than do faculty members, one that is more mercantile in nature. Recruiting and retaining students who become loyal, contributing alumni requires a great deal of business acumen. Marketing strategies and consumer-oriented policies and practices are necessary for institutional longevity. Though “client” would perhaps be a more apt term, “customer” may be justified as a designation for the people who enroll in our schools. “Students,” however, are the people who enter the classroom, clinic, and other curricular settings. As one instructor observed, students may be customers in the hall of an institution, but “consumerism stops at my classroom door. . . . when they enter my classroom I expect them to earn, not buy, their grades.”^22,23 Just as doctors and pharmacists have a fiducial obligation to act in the best interest of patients, faculty members have a fiducial obligation to students that involves setting high standards, caring for and about students, not tolerating uncivil or unprofessional behavior or attitudes, and ensuring graduates are prepared to honor their own fiducial obligations to the people they will serve. Customer satisfaction is not an appropriate measure of institutional success unless, from the time of their entry into the program, all students enthusiastically endorse these same goals and values.

The customer metaphor thus undermines the foundation of professionalism, that which distinguishes it from an occupation by substituting a fiducial relationship for an economic one. It undermines trust. Educators are professionals. As educators, we have a fiducial obligation to the people we serve, who include students and the public that will benefit from our students’ care. Our promise to both is to act in their best interest, that is, to commit ourselves to their success in a way that transcends business practices, customer satisfaction, and even self-interest.

Holdford’s paper, however, argued that “the idea of student consumerism is based upon a fundamental misunderstanding of the primary customer of pharmacy education,”³ and his rhetorical strategy was to transfer the term “customers” from students and apply it to the patients that the students eventually will serve. Such a move invites fresh perceptions of our mission as pharmacy educators, but it also perpetuates the consumer orientation rather than eradicates it, once again revealing how insidiously unexamined metaphors can be deeply embedded in our thinking. At bottom, the consumer paradigm remains untouched; only the names of the players have changed—and to their detriment. Better to break free altogether from the tyranny of the metaphor.

To think of students as customers is a denigration, but the identification of students as products is a further, albeit unintentional, humiliation. Another disturbing trend of contemporary culture related to consumerism is the reification of people, the perception and treatment of others as things rather than as persons. Martin Buber’s distinction between 2 types of relationships is pertinent here.²⁴ We can establish “I-it” relationships in which other people are merely things with which we must deal as we would with other objects. In this “having” mode of I-it relationships, we “have” friends, “have” guilt, “have” an education, “have” customers; it is a world of commodification and consumerism. Most experienced faculty members can distinguish students who are interested in getting a degree as opposed to seeking to be educated. In “I-Thou” relationships, we acknowledge the other as a subject, not an object, a person to be treated always as an end in oneself, not as a means to other goals and certainly not for self-profit. This is a relationship not of having but of being, a relationship which, like a fiducial responsibility, requires trust and sensitivity to unique individuals. It is not legalistic but deeply human and personal (“thou” being the English familiar form of “you” as “tu” is in French or Spanish or “du” in German). Buber’s I-Thou principle can engender a more patient-centered practice when pharmacists choose to view “difficult” patients not as problems (things) but as people with their unique histories, goals, pains, emotions, and values.²⁵ In student-centered education, similarly, students are not things; neither faculty members nor students are “its.”

Commodification and consumerism are thus inconsistent with professional obligation. As pharmacy transitions from a product–oriented ethos to a patient-centered ethos, it would be retrogressive for pharmacy education to reverse this trend; that is, to move toward a product-oriented educational process that depersonalizes students, transforming them into a product (like a pill), and thus stripping them of any claim to a fiducial relationship with an instructor. Students are the center of the educational process, but not as a customer or a product.

This is not at all to quarrel with the claims of Cain et al or of Holdford that an entitlement mentality can undermine education, particularly when it is recognized that professional education requires not only intellectual growth but development in character.

The current “me generation” as a group tends to be more narcissistic, self-centered, affluent, and abounding in self-esteem. Although they might be a minority, some from this generation appear conditioned to “buy in” to the entitlement mentality encouraged by the consumer model of education.²⁶ For students who view education as a commodity to be purchased (at an increasingly rising price) and who thereby view faculty members as hired hands, it is not obvious that a college experience can or should be transformative or life-changing.²³ Such a student-customer may not respond as well to challenging assignments or constructive criticism, expecting instead automatic high grades in exchange for high tuition dollars. Student-customers may prefer passivity in education, expecting the content or “goods” to be delivered to them without a need to think conceptually, deductively, or sequentially. ^5,10

Rather than enhancing faculty member-student relationships, the customer metaphor may compromise “the pedagogic relationship between teacher and learner.”¹⁰ Independently, new social media already undercut faculty member-student relationships, as they promote an expectation of immediacy of response, less decorum, and less respect for both tradition and instructors. When the consumer-oriented perspective further reduces instructors to service providers, they are still less likely to be regarded as respected authorities and more as gate-keepers or even barriers to a degree, now identified as a credit card that enables future consumption.²⁶ A professional relationship involves respect and trust, by both parties. Unable to determine and evaluate the knowledge, skills, and attitudes necessary to be successful in their lives, students must trust faculty members in ways that violate the consumer maxim, caveat emptor—let the buyer beware. On the other hand, faculty members need to trust students and to not see them as potential adversaries requiring faculty members to adopt self-protective maneuvers not in the best interest of students. Wary of negative consequences or even fearful of litigation resulting from student complaints, faculty members can be tempted to pretend not to hear when students are rude or insulting or to look the other way at student cheating when they know that reporting an incident will likely result in a laborious process in which the instructor’s own credibility, judgment, and integrity are challenged. “There are some indications that the pressures of greater student numbers as well as the fear of student complaints and litigation has led to a shift from individually tailored feedback relying on professional judgment to minimal and standardized feedback that meets official criteria and protects academics against student complaints.”¹⁰ Such practices are not in the best interests of students or the public.

Professional education is even more endangered by consumer metaphors because it requires not simply transmission of knowledge and development of abilities but also inculcation of professional values such as altruism and empathy.²⁷ Professional enculturation is in part an attempt to align student goals with those of the profession, and that attempt may not always be pleasant or “satisfying” when, for example, professionalization requires faculty members to challenge students to test narrow but prized assumptions, to recognize their biases and prejudices, to modify deep-seated but unprofessional values, or to adopt a more rigorous work ethic. Few waiters would lecture their customers on inappropriate behavior or rude table manners if they wanted to stay in business. Savvy education peddlers would learn this lesson quickly as well.

This sense of entitlement that jeopardizes professional education is tacitly endorsed by the academic world when campus leaders and external reviewers institutionalize the student-as-customer metaphor through the adoption of evaluation criteria and methods centered on customer satisfaction. Student evaluations of faculty members are an extension of the consumerist philosophy.^{12, 23} Properly conducted and analyzed, student feedback to courses can be valuable in enhancing the educational experience, but if faculty members perceive that the primary institutional goal is to keep customers happy (whether that perception is accurate or not), they can be tempted to react from their own self-interest rather than from the public good and the welfare of the student. If student satisfaction ratings play a significant role in decisions regarding faculty member salary, promotion and tenure, teaching awards, and even continued employment, faculty members can be faced with an ethical dilemma: acting in the best interest of the students and the profession or giving the students what they as customers want and expect. Holdford’s satiric “8 Point Customer Promise,” written from within the student-as-customer paradigm, is a clever reductio ad absurdum of the educational consumer mentality, but the parody unfortunately rings true to some extent for those faculty members who believe their teaching is being compromised by unreasonable expectations derived from a market economy. Without a clear, public display of support for faculty members who attempt to resist grade inflation and to uphold standards despite student complaints, other faculty members may learn that a path of least resistance is the best route to promotion and tenure.

Nonetheless, pharmacy student Stephen Karpen should have felt entitled and was perhaps too modest in his expectations.² Student-centered education should not be conflated with the student-as-customer metaphor, for in fact it is antithetical to it. Students are more than customers. Pharmacy students should expect that instructors will meet their fiducial responsibility to do what they can to ensure student success. Holdford captured this key point when he rewrote his “8 Step Customer Service Promise,” this time with the customer being the future patients of the students. In particular, his “Point 8” reaffirmed the obligation that is the essence of professionalism: “Success: Your success is our success. We pledge to do everything we can to help you succeed. The rest is up to you.”³ This foundational promise within the teacher-student relationship is far from a commitment to customer satisfaction or a pragmatic concession to a student sense of entitlement, for the definition of success is determined by experts in the field who have fiducial obligations both to students and to the public to provide competent and caring practitioners. Attempting merely to “satisfy” students can be an impediment in this process when student goals and desires do not align with those of pharmacy educators.

Finally, it is important to note that this is not simply a reactive plea to return to the good-old days of pharmacy education. Certainly, some elements of corporatization of health care and education are both inevitable and necessary to deal with emerging trends in a rapidly changing, complex, technological society.¹⁶ But the establishment of fiducial relationships does not depend on a nostalgic fantasy of simpler times as depicted in a Norman Rockwell painting. As Zellmer noted in his search for the soul of pharmacy,²⁸ the hearts and souls of individual practitioners, whether in the health fields or in education, are the primary forces that will help to transition pharmacy from an occupation to a profession with a foundation in fiducial obligations and trust. Still, faculty members must not be hindered by academic policies, practices, and assessments formulated on the basis of a largely unexamined paradigm fostered by the student-as-customers metaphor, a paradigm which, ironically, though meant to enhance student status, actually debases students and endangers the fiducial relationship that faculty members owe to them.

Metaphors are important. We need to give them more attention. Suppression of the student-as-customer metaphor is in the best interest of all the key players in pharmacy education. Its elimination can mitigate the student sense of entitlement that makes it more challenging for faculty members to inculcate the knowledge, skills, attitudes, and values necessary for professional service. At the same time, students would be better served if faculty members were evaluated not on customer satisfaction but on their fiducial commitment to place student success as one of their highest priorities. Finally, the elimination of a customer model would benefit the public, for pharmacy school graduates who have been nurtured by caring professionals will more likely honor fiducial obligations with patients since graduates would have learned first-hand what it means to serve students and patients, rather than enter into mercantile relationships with customers.

D’Eon and Harris asked in their title, “If students are not customers, what are they?”⁴ Holdford provided a valuable service in identifying important issues in pharmacy education as he attempted to answer this question. His title, though, presented us with a false dilemma: “Is a pharmacy student the customer or the product?” The answer is neither. It is time for the teaching profession to excise entirely business metaphors and to acknowledge that the best word for our students is not “customers,” nor “clients,” nor “products,” but students.

• Received April 2, 2014.
• Accepted June 24, 2014.

• © 2014 American Association of Colleges of Pharmacy