Do I have clients or patients?

One of my duties involves teaching nurse practitioner students. Nursing is quite different from medicine, and many of the linguistic markers of nursing differ significantly from medicine. As more physicians' assistants and nurse practitioners enter the primary care world there will be a bit of a culture clash. For instance, my NP students often refer to a physical exam as an "assessment", a misnomer which I do not allow them to use with me. Assessments come after you have spoken to and examined a patient. Another difference is in the common use of "client" in referring to patients. This debate seems to have originated in the late 80s or early 90s, and perhaps in psychiatry, but it spread rapidly. Its growth also coincided with the growth of HMOs and other managed care.

Language means something beyond the words themselves, and what we call the people we care for matters.

A patient is literally a "sufferer", whereas a client is more literally a "customer" (although its roots in Latin refer to a much more specific relationship).

There are some pretty serious implications to calling a patient a "client". A patient is someone who is suffering, and to whom we have an obligation to help. We are expected to put their needs above our own as much as is possible.

A client is a customer. We provide a service, they pay a fee.

As paternalism receded in favor of autonomy as a medico-ethical value, many felt that "client" somehow empowered a patient---as they were paying for a service they were on more equal footing with the doctor. As a patient, a doctor is "acting" upon them, rather than partnering with them.

What a load of bullshit.

The first day of my pathology class, Dr. Alexander Templeton looked at us and asked, "Why does a patient come to see you? Come on, don't be shy. Tell us. Why do they come to see you?" After a few answers taking jabs at common illnesses, he shouted, "No, no, no! They hurt and they want you to make them feel better!"

If someone is a client, I have no obligation to make them feel better. If they come to me a gallbladder problem, my obligation is to order the correct tests, make the correct referrals, and collect my fee. If someone is my patient, I'm obliged to do all of that, plus try to make them feel better.

There have been a few small studies that polled patient to find their preference, but I don't think this helps---it isn't a matter of democracy, but humanity.

The authors of these studies listed some important disadvantages to "client", some of which are:

⢠Denial that the person has an illness or that certain
treatments (e.g., drug therapy for schizophrenia) may
be important in helping a sick person.

⢠Denial of access to the sick role, from a failure to
recognize that society allows sick people or patients
certain rights to be cared for, and even denial of access
to these rights.

⢠Lack of protection (by the use of the term "client"
per se) against the power and dependency that can
exist in a doctor-patient relationship.

⢠Lack of recognition of the importance of the doctor-
patient relationship and its confidentiality.

⢠Lack of the special elements of care and compassion
implicit in the term "patient."

In this tug between paternalism, autonomy, and language, it is important to remember one fact: a patient comes to you for help, and as a doctor or a nurse, you are obliged to help them. Sure, you can't (and shouldn't) work for free, but between "client" and not working for free, there is a lot of ground. The most generous spin I can put on this is that a patient is a special subset of client, but that doesn't work for me. There just isn't the same compassion in a doctor-client relationship as their is in a doctor-patient relationship.

I never see clients, only patients, and that's the way I'm going to keep teaching it.

__________
Peter C. Wing, MB, ChB. Patient or client? If in doubt, ask. Canadian Medical Association Journal. 1997;157:287-9.

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Personally speaking, there is a distinct difference in the development of electronic health records exchange systems regarding the doctor-patient relationship, and "customer confidentiality" vs. "patient privacy". One is still largely considered sacrosanct, the other, not so much.

Interesting that a larger portion of patients surveyed in the link actually preferred "client" or "consumer", though...

It's everywhere. Don't get me started on the havoc wrought by calling students "customers"...

I got in big trouble when an acquaintance who was a nurse rather pointedly "corrected" me when I referred to a "patient".
She: "You mean client!"
Me: "I mean patient. Clients are for lawyers and prostitutes."
Rude, yeah, but I was pissed off.
Now what is the corrct term for someone that is having an autopsy? They're not patients, because they're not suffering. They're not clients, because they didn't hire you for a service.
I call them subjects - anyone else have any ideas?

By T. Bruce McNeely (not verified) on 23 Apr 2008 #permalink

Thank you so much for posting this. I started in Psychology and have been working in the Disability/Community Services sector. I have had to use client for most of this, and it makes sense when we are providing a service not a treatment. One organisation I have worked for went through a whole renaming period and tried different lables until the client got pissed off and asked to go back to client. ("Consumer of what? You come, you take me shopping, you take me back home. What exactly have I consumed?")

Now my partner is studying nursing, to upgrade from Personal Carer, and has just done a mental health placement at a big long-term locked facility where the label is "client". We both thought that was a load of bullshit. I'm more disturbed than anything by the suggestion that people in a locked mental health facility aren't being treated as curable (or at least improvable) "patients". In practical terms, most of them may well be in a holding pattern, but in ethical terms? Wrong, oh so very wrong.

Hell yeah! My SO is a nurse, only one year out from the RN program. She kept referring to her "clients," though she had some vague dislike for the term. It drove me up the wall, but I wasn't sure why. My thoughts ran along the lines of "Hey, I'm not here to buy a fucking vacuum cleaner, I'm feeling like shit! Help me get better!" I always hated thinking of health care as a business. It trivialized the whole process (it's an appendectomy, not a cell phone plan!), and the profit motive (and thus the "anti-paternalist" label of client) has done medicine a great disservice.

Thanks for making a more articulate argument than I.
I hope my foaming rant wasn't too unintelligible.

Lawyers have clients. What else needs to be said?

From the patient/customer standpoint, I don't really care what you call me. In certain circumstances, I am shopping for services. There are professionals that I have come to trust. There are others I don't know and will have to develop relationships. (I actually spend much more time as in an advocacy role with my wife as the patient, but it is the same argument.)

I get the feeling from many older doctors they think I should trust whatever they tell me because they are the doctor and I am the patient. I can't possibly have the insight and understanding they do. I should do whatever they tell me to do and not ask questions. They know what's best for me and I should just shut up and do it. My parents felt that way too. They wouldn't question what a doctor told them. Second opinion? Why bother. This guy has the lab coat and the stethoscope around his neck. He must know what he is talking about, right?

I honestly don't care what you call me as long as everyone understands that I am ultimately responsible for my own health. If I ask how you arrived at your conclusions or why you recommended a certain treatment, don't be offended. If I didn't have a certain amount of faith in you, I would just thank you and move on. If I am still asking questions, it is because I still respect your opinions and honestly want your advice. But, I have to understand it.

I am reminded of the old joke that I'm certain you have heard. Question: What do you call the guy that was last in his class at med school? Answer: You call him Doctor. As a patient/customer/consumer, how do I know the difference in a good doctor and a not so good doctor until we develop a relationship?

Veterinarians have both patients and clients. One belongs to the other.

You cure a patient and you continue to treat a customer.

I should have said client, not customer. Given that insurance has no customer service, it becomes very easy to become confused if you are a client, patient, or a customer.

Lawyers have clients. What else needs to be said?

What else, indeed? That comment epitomizes the attitude on display in this whole thread. At least the woo-woos tend to treat the people around them with some respect.

Doctor is an occupation. Medicine is a business. Stop kidding yourselves.

By Anonymous (not verified) on 23 Apr 2008 #permalink

I hate the New-Agie re-evaluation of words with a long tradition of use. Health-professionals diagnose and treat patients. Since chiros are not health professionals, I call people who go to chiros "customers" and I also refuse to call chiros "doctors," they have only earned that title in their ill-educated judgment.

Anon wrote: "Doctor is an occupation. Medicine is a business. Stop kidding yourselves."

Are you certain that's the attitude you want from your doctor when you come to her in pain or with a complicated cluster of symptoms that don't make much sense? An occupation is something I do to pay the bills. The practice of medicine deserves and demands more of its practitioners. The few doctors I know who feel as you do are shitty doctors whom I wouldn't trust to prescribe me an aspirin.

I think the pro-"patient" position breaks down when you consider well-care. Do you treat "patients" at childhood and adult annual checkups? Perhaps not in hospitals, but this is a huge part of some doctors' lives. The definition, "They hurt and they want you to make them feel better!" is barely relevant to a huge portion of modern medicine. Is an otherwise healthy person with high cholesterol a patient? They don't hurt and they are living a normal life, but they want expert advise. Sounds a bit like going to a lawyer to me.

While I appreciate the sentiment behind this, I'll lean that this is also an example of medical doctor exceptionalism. You could write a similar text for many professions including lawyers that lists your ethical responsibilities beyond getting paid. Yes patients are special and unique compared to other professions, but they are also pay money and are clients. Feel free to call patients "patients," but client isn't an epithet.

There is no intrinsic difference between the relationship of attorney and client and doctor and patient. In both cases, the client/patient needs help with a problem whose outcome can be life changing. In both cases the professional involved is obligated to do his best to act completely in the best interest of the person seeking his help and in no one else's interest. There are, of course, a very few cases in which both professions must act in the interest of a wider community (for example, a physician who learns of a serious public health threat or an attorney who learns of a serious public safety threat). But in general both professions have the same standards of behavior. The main difference is that physicians enjoy the god-like adulation of the masses, while attorneys must suffer public ridicule. At least until someone needs their services. And no, I am not an attorney.

And if you think that a physician who calls his "patients" "clients" will somehow act less fully in the best interests of his patient/client, then you have a very low opinion of physicians, indeed.

Lawyers have clients. What else needs to be said?

What else, indeed? That comment epitomizes the attitude on display in this whole thread. At least the woo-woos tend to treat the people around them with some respect. Doctor is an occupation. Medicine is a business. Stop kidding yourselves.

Well said.

Are you certain that's the attitude you want from your doctor when you come to her in pain or with a complicated cluster of symptoms that don't make much sense?

Yes, that is precisely the attitude I expect from my doctor. It's also the attitude I expect from my lawyer, from my accountant and from my electrician. They should do their best to look out for me and my interests, within the scope of whatever I hired them to do. If they don't do this, then either they are careless, bad at their jobs or conflicted by self interest.

Many professionals are approached with "serious" or "complicated" problems that confuse or frighten the nonspecialist supplicant. These professionals owe their "clients" the same responsibility and deference that medical doctors owe their "patients".

That said, doctors have the right to choose the words used in their own profession ("patients"), just like lit profs have the right to argue over oxford commas. But I personally don't think the argument has a great deal of impact on objective reality.

A patient is someone who is suffering, and to whom we have an obligation to help.

I think that's the key word there. My doctor has an obligation to help me and do what is in my best interest, not his. A car salesman will try to sell me all sorts of bells and whistles like undercarriage corrosion protection and an extended warranty; things I don't really need, but are very profitable for him. Contrast that with a doctor trying to pressure me into a surgery I don't really need.

But car salesmen don't have clients or patients; they have customers.

I almost made an interesting typo - "care salesmen" instead of "car salesmen." Now that would be a change in terminology that I would definitely prefer not to have. Especially "used care salesmen."

In your discussion, you are making clear you are part of our current crisis in healthcare.

You state: There are some pretty serious implications to calling a patient a "client". A patient is someone who is suffering, and to whom we have an obligation to help. We are expected to put their needs above our own as much as is possible.

When I go for a physical, I am not sick, I am not suffering. The term client makes clear that I have hired the Doctor, he is a paid part of team that I select to assist in maintaining my health and treating me when I'm ill. The Doctor is a vendor of healthcare, I am a consumer of healthcare.

To imply that you need the term "patient" to undescore the need for you to put our needs ahead of your own is a bit scary. You put our needs ahead of yours because you are paid to do so. If you feel less inclined to do so based on what your customers are called, you need to rethink why you are in this profession.

By Skokieguy (not verified) on 24 Apr 2008 #permalink

My but this thread's getting a lot of mileage out of a one line lawyer joke.

If were going to play at amateur etymology, I'll question the link between 'patient' and 'pathos'. Might the term 'patient' have been employed originally to contrast with 'agent'? An agent is simply something that "acts on" another something, namely, a patient. This is all terribly un-PC, of course, since the passivity implied by 'patient' doesn't sit well with people who champion empowerment and autonomy. Then again, while autonomy should _always_ be respected, a usual part of being "sick" is some marked loss of the capacity for autonomy -- and what you don't have, you can very well express.

By bob koepp (not verified) on 24 Apr 2008 #permalink

As I understand it, patient actually stems from a word close to "sufferer." As such, it is assumed to describe the condition of the person going to a physician. It actually seems fairly close to the way some medical personnel refer to hospital patients by their condition. For example, "Could you look at the broken leg in Room 3?"

Given, this, I really don't see the philosophical superiority of using "patient" rather than "client."

Thanks for all the thoughtful responses.

A few points, now that you've given me something to think about.

Chuck:

You cure a patient and you continue to treat a customer.

That's one of the dumbest comments you've ever left, and that's saying something. You followed it with a largely correct observation that insurance companies don't give two shits about you.

Anon:

...That comment epitomizes the attitude on display in this whole thread. At least the woo-woos tend to treat the people around them with some respect.

Doctor is an occupation. Medicine is a business. Stop kidding yourselves.

Woo's don't treat people with respect---they are clever charlatans who make you feel all warm and fuzzy while reaching over to steal your wallet. I agree, medicine is most certainly a business, but a very different kind of business. If you're lucky, your doctor understands this.

Bsci:

I think the pro-"patient" position breaks down when you consider well-care. Do you treat "patients" at childhood and adult annual checkups?

When people come to me for well-patient visits, they are not usually coming to fulfill some "checklist", but to be reassured that they are doing everything necessary to maintain their health and screen for disease. It is not all that dissimilar from a sick visit.

MarkP:

There is no intrinsic difference between the relationship of attorney and client and doctor and patient

I think that is true to a certain extent. Lawyers have special obligations to their clients that other business people do not have to their customers. It is a different set of obligations than a physician has, but it is under-recognized. To quote an aphorism, "there is nothing so expensive as a cheap lawyer."

And if you think that a physician who calls his "patients" "clients" will somehow act less fully in the best interests of his patient/client, then you have a very low opinion of physicians, indeed.

I don't have a low opinion of physicians, just people in general. The more you encourage a strict business relationship, the more a physician will act that way.

Skokieguy:

To imply that you need the term "patient" to undescore the need for you to put our needs ahead of your own is a bit scary. You put our needs ahead of yours because you are paid to do so. If you feel less inclined to do so based on what your customers are called, you need to rethink why you are in this profession.

I think you make a good point, but I disagree. If I'm selling lawn equipment, my job is to make money. Period. If I'm caring for patients, I do quite a bit of non-reimbursed work, which means I have made a particular type of sacrifice for my patient. Language affects peoples' perceptions of their roles and responsibilities. If I am simply a hired gun to check your cholesterol and make a recommendation, then you should not expect me to do a whole lot of hand-holding. Sounds silly, but I think it's true.

Try to remember, I didn't start the lawyer jokes...some of my best friends...

I've always wondered whether those who advocate for the mentally ill use "client" or "consumer" to promote a sense of agency or so as not to offend those with anosognosia ?

By Denice Walter (not verified) on 24 Apr 2008 #permalink

I'm assuming humor, but it raises a good point. I do think trying to avoid offense is a problem, if it sacrifices truth. Deceiving patients is almost never a good idea, even if it seems in their best interest. Avoiding offense is easy, but usually misguided---I've had a number of patients get angry when I told them they were obese (in as nice a way as possible) but to avoid it is to avoid helping them.

"You followed it with a largely correct observation that insurance companies don't give two shits about you."

That is probably the dumbest ad hominem attacks you have ever given, and that is saying a lot.
What you should have said was They dont give two shits about anyone.

Point taken.

You're still a wacko, though.

If you were a psychiatrist, I would sue you for mal-practice. Since you are just an internist, you are just opinionated and this blog is proof of that.

it isn't a matter of democracy, but humanity

May I suggest that instead it is a matter of humility? It doesn't matter much to me, but I prefer client specifically because it discards the paternalistic baggage. There is a tendency for doctors to view the patient's health as their project - you demonstrate this mentality in this quote:

If someone is my patient, I'm obliged to do all of that, plus try to make them feel better.

The idea of going beyond what the patient wants to what you precieve they need is the core issue here. This doesn't matter all that much in most fields of medicine since the practical results of both approaches tend to be the same, but the history of psychiatry provides plenty of examples of the paternalistic view resulting in substantial harm, which is why the nomenclature change took root there. This imperious attitude (demonstrated quite aptly in your expression of apathy for what the patient would prefer be called) does damage the doctor-patient relationship as it casts the doctor as an authority figure rather than someone who's there to help. Beyond simply leaving the patient intimidated, this seems to encourage patients to lie about their behaviors to avoid condemnation, which can be a serious matter when the issue at hand involves more than fibbing to the dentist about how often you floss.

I appreciate the sentiment, Matt, but the point is that a doctor is and authority figure, by nature of possessing knowledge you need that you don't have access to. Yes, patient autonomy is critical, but no patient is served by a physician who says, "You have heart disease. What would you like to do about it?"