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Patients lost at the health care checkout

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Frank Bowden |  28 May 2009

'Patient customers' by Chris JohnstonI first heard the term when I was a student. 'Client-centred therapy' was a fashionable US approach to psychotherapy and even then, when my bulldust receptors were still primitive, I found the word annoying.

'Client' was used sparingly in Australia in a medical context until the incipient managerialism of the 1980s allowed it to creep into more common use. From the outset, its adoption has been largely divided along professional lines: from surgeons and physicians — who never use it; to psychiatrists and nurses — who sometimes use it; to allied health practitioners — who favour it.

I was once, alas, fortunate enough to be invited to a 'workshop' to help write my hospital's mission statement. In this medical Tower of Babel, the doctors talked about their patients, the managers counted their clients and the community representatives defended themselves as consumers.

Promoters of the terms 'client' and 'consumer' want to change the way the sick person is considered by the health system. And how could this not be a good thing? The consumer movement, beginning in the 1970s, forced medical institutions and professions to take stock of the way they dealt with human beings.

But it came at a cost: if you call sick people 'clients' you risk turning healing into a commodity to be purchased (or rationed). Customers buy 'things' and so doctors compete to sell them: if you employ the words of the marketplace, you set the tone for the behaviour of the stallholders.

If medicine is constructed principally as a business activity, then the ethics of the healing hand that have driven the profession for millennia may be replaced by the workings of the invisible hand of Dr Smith.

The word 'patient' comes from the Latin patiens: 'one who suffers or endures'. If you have ever been one, then you get it. 'Client' on the other hand, is derived from cliens — a 'follower' or 'retainer' and was originally used in ancient Rome to describe the relationship between a plebeian and a noble.

I am intrigued that those seeking to change the perceived power balance between doctors and the people they treat, should abandon a term which describes the state of being sick, in favour of one that, from an etymological basis at least, actually highlights the inequality.

And what of the egregious term 'customer'? Although its origins are Middle English, a person of my vintage may recall the 1960s television program Pick a Box where Bob Dyer greeted us in his American accent with the words 'Howdy customers'.

Perhaps that's how we should welcome the sick at the doors of the emergency department: flashing lights and a word from our sponsor. Why not go the whole way and put up a sign saying 'the customer is always right'?

Well, for one thing, because they're not. The rule exists for shopkeepers so they can maintain their patronage. Placating a few grumpy and/or ignorant people each day is the price of good 'word of mouth'.

But a professional encounter is something different. If a patient believes the swelling in his groin is caused by the bubonic plague then he is almost certainly wrong. If he demands that you prescribe mega-doses of vitamin C for his HIV infection instead of antivirals then he needs better advice. If the voices from the microwave say Martians have landed then this is a call for help, not an opportunity for the sale of a laser gun.

The task of the salesperson is to find out what people want; the duty of the doctor is to find out what they need. And when you are sick you usually have no idea what you want, except to be better. To ensure that you do get better, the society has to guarantee the integrity of the training and the behaviour of the people who are looking after you. Some would call this a performance indicator — I call it a professional obligation.

Boosters see clients as autonomous agents who carefully choose the services they desire. They argue that if we call them patients, they will be suborned by a patriarchal profession and have less choice and autonomy. This is often true: that's the point. There is no time to google local cardiologists when you wake in fright with crushing chest pain; no scope for auditioning obstetricians when your waters break on the bus home ...

It is ironic that the person who is most often referred to as a client is the one who uses psychiatric services. Calling those who are depressed 'clients' will not make it easier for them to find a doctor equipped to treat their condition, nor will it improve government funding. Indeed, the language is an inhibitor of reform as it suggests there is a group out there ready to effect change and all we need to do is respond to the market forces.

The crisis in mental health services is a failure of our whole society — we have ignored the human rights of those who are least able, while they are sick, to be their own advocates. It is only when we recognise that the problem is an anticipatable responsibility of government and of the professions that we see action.

I recently heard a doctor talking on Radio National. 'I don't like the word patient,' he said. 'It creates a barrier between the doctor and the person who is suffering.' Etymological nit-picking aside, I believe he is simply wrong. The thousands of people I have seen in a professional capacity have always referred to themselves as 'patients'.

To be a patient is to place yourself, sometimes literally, in the hands of another person, to give them your trust and to expect it to be honoured. To become a patient is an intimate, self-revelatory and necessarily conscious act. What happens between a doctor and a customer sounds more like a financial transaction.


Frank BowdenFrank Bowden is Professor of Medicine at the Australian National University Medical School in Canberra. 

 


Frank Bowden

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Let's settle for redressing the power imbalance between clinicians and people they treat by embracing the terminology of person (patient if you like) centred care.

I recommend Don Berwick's take on this: here

Russell McGowan 25 May 2009

Indeed! One of the things that makes our relationship with patients so special is that we have to relate to our punters appropriately whether they are sick or well, from unconscious at one extreme to brandishing internet print-outs at the other. Solicitors and prostitutes have clients who are usually in possession of their faculties. I have patients. Nurses and hospital administrators can choose for themselves!

Alex Hope 26 May 2009

The use of 'patient' by health professionals serves a useful practical purpose by succinctly describing a person who is in a outcome-oriented care relationship with us. Patients' real issues are somewhat different I think. One is that the operation of the health care system and the behaviour of the people in it does make patients feel powerless - any moderately intelligent insider can see it and realise that enormous effort on every level is required to change the situation. It's up to us to educate our concerned critics that it's not simply a matter of semantics. Another is that from patients' perspective, the condition of being a 'patient' isn't 'fixed' - they can be a 'consumer with rights' after waiting 45 minutes in your waiting room or being treated rudely or being denied the opportunity of informed consent, a 'patient' in your office, and a 'customer' when paying at the desk or reading the litany of notices about payment policies that litter the walls of many a waiting room. They can hardly be expected to ring a bell for us when they change 'mode': surely it is up to us to detect this and behave accordingly?

Peter Crothers 27 May 2009

Great insight and we need to listen.
Having weathered a problem of mental health in our family recently I came to realise the enormous trust one is required to put into the doctor -patient relationship when such illness manifests itself. The relationship becomes deep, intimate and frightening for all concerned with the patient. Our outcome has been excellent because those involved have had this intimate and loving relationship with all concerned ... doctor-client hardly fits the bill.

Judy 28 May 2009

Does terminology matter? Do the words we use have an effect?

I recall hearing the story of one European doctor who was researching arthritis of the knee. He rang up a major hospital and was perplexed when he was told that there had no one with this problem. After some thought, he rang back and asked about osteosarcoma of the knee. There were lots of clients with that problem which was almost invariably fatal over time. This doctor started to wonder about the words spoken over patients: arthritis crimps your lifestyle but no one expects to die of it; people do expect to die of a sarcoma.

Are words a spiritual and psychological implant in the body? Do they affect the course of disease, even life and death? Increasingly I think so. If healing – even in some cases – depends on the words a doctor uses, surely it calls everyone to a higher responsibility.

Anne Hamilton 28 May 2009

Thank you Frank Bowden for a the sane, clear, wonderful way you have expressed what I have known, but have been unable to put into words. Our 'consumer values' threaten to subsume all in their path, education, health, even religion bow to the business model, to society's detriment.

Pirrial Clift 28 May 2009

I think 'patient' is the perfect word to describe the situation, as anyone who has ever awaited medical attention can testify. Patience is, indeed, a great virtue in a situation perhaps fraught with pain and anxiety. I'm just thankful to live in a country where we have excellent medical attention (most of the time) and it is usually delivered with consideration and in a timely manner.

A Perkins 28 May 2009

What you describe in your article is true for many services provided by governments or privatized entities. When you use the services of CentreLink, you are referred as customer not a citizen. When I go to see the doctor , I consider myself a patient not a customer or consumer. All this managerialist terminology should be scrapped and call things by their proper name.

Terry Stavridis 28 May 2009

Thank you,Frank. Having recently been a patient in the hands of three very caring and skilled doctors,as well as several other health professionals, I could not agree with you more. I also concur with A Perkins; we are also blessed to live in a country where we have, on the whole, I think,such women and men who continue to undergo rigorous training to provide such a service.

Maryrose Dennehy 28 May 2009

The problem with the 'doctor/patient' relationship is the baggage it carries from the time when doctors were semi-gods and patients their humble and thankful beneficiaries. Maybe managerialism got the language wrong, but the relationship between doctor and doctored must surely have to be one of joint problem-solving. I bring my body and my sensation of systems, the doctor brings her/his knowledge and skill. Together, jointly, we work to resolve the problem. That way the power imbalance to which Russell McGowan refers is done away with. Call it what you will, it's the nature of the relationship that matters.

Tom Jones 28 May 2009

Thank you for reminding us of the essence of the declaration all doctors accept when they go into the practice of their chosen profession; The Hippocratic Oath!

Whenever I have to visit a specialist, a 'clinician', I am always test their assistance against that portrayed in the Henry Lawson story "That There Dog of Mine!"

John W McQualter 28 May 2009

Yes, words matter. Language is powerful, evocative, influential and life changing. Words form us and words are an expression of who we are.

My contribution to the matter is that 'patient' has some implicit meanings. It implies a power relationship and a receptive rather than engaging attitude in the relationship. It's a nuance which has often had me thinking about the negative edge of 'patient'.

Leigh Newton 29 May 2009

"Patients" refer to themselves as such because of history. However, what some doctors (professors) forget is that they are HIRED for their expertise by their patient/client/customer. Doctors, like lawyers, do have a special relationship with their patients/clients/customers because of the vulnerability of the latter. The patronising attitude of Professor Bowden is an unwelcome reminder of the distance some medical practitioners believe should exist between themselves and those who pay their salaries.

Patricia 29 May 2009

I read your article with interest. I wonder if Client - a term used by the aged care industry is appropriate. I started a business wanting to care for the elderly in their own home, by default I too refer to my aged people as clients - what do you consider more appropriate? www.carebeyondmeasure.com is my website.

Sam Tayeh 03 June 2009

I'm with Frank. I believe the push to rename patients as clients or consumers is to reinforce what those who now run health care/insurance would have us believe; that patients & providers have a choice. A stark example can be seen in the 2005 ‘Not for Service’ Report published after the last huge Federal Government spend investigating the appalling provision of Mental Health ‘Care’ in this country.

The Report is named from what a mentally ill patient was told when she called her local hospital triage service seeking acute care – the Mental Health Team had classified her ‘Not for Service’. Imagine the outcry if a patient with cardiac or pulmonary disease were classified in this way.

For the past decade I have struggled with severe mental illness & in the last 8 months a rare cranial nerve problem, during this time I have been on the receiving end of much derision from some health care providers, as though I somehow choose to be sick. When I see a health care professional I am a patient. I do not choose to be sick, if I had a choice I would be a fully functioning, financially contributing member of society!

Helen Coles 08 June 2009

I have been an RN since 1987, now studying Speech Path and have now just been diagnosed with Leukaemia. So I'm now on the receiving (consumer/customer/client) side of service provision. The whole concept of a 'patient' being the passive recipient of the benevolent services of a physician is sickeningly paternalistic. I insist on being an active and accurately informed member of my health care team. I (we clients) are the one and only reason everyone else in the health team exists.

I have witnessed what happens to so called passive patients receiving benevolent care from their Dr who 'knows best'. Also, having spent the majority of my career working with people with renal disease, requiring transplantation, I find the accompanying cartoon to this article offensive.

Andrew Smart 11 June 2009

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