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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