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Patient or client? If in doubt, ask

Peter C. Wing, MB, ChB

CMAJ 1997;157:287-9

[ résumé ]

Dr. Wing is Clinical Professor of Orthopedics at the University of British Columbia and Director of the Spine Program at the Vancouver Hospital and Health Sciences Centre, Vancouver, BC.

Reprint requests to: Dr. Peter C. Wing, Director, Spine Program, Vancouver Hospital and Health Sciences Centre, 2733 Heather St., Vancouver BC V5Z 3J5; fax 604 875-5858; pwing@interchg.ubc.ca

This article has been peer reviewed.

© 1997 Canadian Medical Association (text and abstract/résumé)

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Abstract

Do people seeking health care prefer to be called "patients" or "clients"? To try and answer this question the author surveyed 101 people attending a back-pain clinic and found that most (74) preferred "patient." Given the implicit assumptions inherent in the use of specific labels, the author advises clinicians to evaluate carefully the attitudinal implications of using a particular term and to ensure that preferences are respected.

Résumé

Les personnes à la recherche de soins de santé préfèrent-elles se voir comme des «patients» ou comme des «clients»? Pour essayer de répondre à cette question, l'auteur a interrogé 101 personnes à une clinique de soins du dos et a constaté que la plupart (74) préféraient le mot «patient». Étant donné les hypothèses inhérentes au qualificatif choisi, l'auteur conseille aux cliniciens d'évaluer attentivement les répercussions sur les attitudes de l'utilisation de certains termes et de s'assurer qu'on respecte les préférences des intéressés.

Does it empower consumers in our health care industry to become stakeholders if we call them "clients" rather than "patients"? As I expect it does for many readers, the recent trend to refer to people seeking health care as "clients" implies to me a component of human interaction that I would expect in the business world rather than in a trusting, helping relationship.

The Shorter Oxford English Dictionary on Historical Principles1 defines a client as "one who is at another's call," "one who is under the protection or patronage of another, a dependent" or "a customer." It defines a patient as "a sufferer," "one who is under medical treatment" or "a person . . . to whom . . . something is done."

I have accepted the term "patient" without question and have been using it over the years as freely as others appear to use "doctor" when referring to me. However, some health care professionals believe that conventional terminology conveys unacceptable attitudes. Others decry the proposed change to "client" and believe it is possible to change our attitudes, behaviours and use of names as needed.2­8 Given the implicit assumptions inherent in the use of specific labels, what should we call the people we serve?9,10

After an extensive review of the literature, I found a lot of opinion but almost no research on the issue. The use of "client" to refer to a patient appears to date back at least to 1970, when the nursing faculty at Wichita State University espoused the term in a specific contxPluckhan11 considered the term "patient" inappropriate for the healthy person seeking health-maintenance advice or going for an annual physical examination and added that it was a term associated with the hospital setting, although health care in future was expected to be provided in ambulatory settings. The American Nurses Association Code for Nurses, developed between 1971 and 1976, eventually adopted "client" as the more universal term.12 The term "client" has also been strongly promoted in the occupational therapy setting by Herzberg,13 who, although accepting that "patient" was relevant in sickness, decried its use in the areas of prevention and health maintenance. She viewed it as a stigma in the mental health field and a reason for a person to forfeit the right to be heard in a therapeutic relationship. She suggested that a "patient" cannot actively participate in the therapeutic process. However, she identified the critical link implied by the term "client" to financial remuneration but added that it is the preferred term used by occupational therapists. King14 suggested that neither "patient" nor "client" was universally appropriate in the occupational therapy setting. Herbert9 questioned the use of these terms in nursing, stating a preference for an all-encompassing word.

Physicians have also taken a polar view. Johnson6 noted that a "patient" is a person somewhere in the health care system who should be so designated, quoting the definition in Webster's Third International Dictionary ("recipient of any of the various personal services" and "a client under the care of a physician"). Fischer15 emphasized the obligations and responsibilities due to "patients" but not to "clients." Hodgkin16 stressed that the physician and the patient must work hard together to achieve a cure and that patients cannot be considered as "mere vessels of disease." Pickering17 noted that there is no convincing evidence that anyone benefits by being termed a "patient," expressing concern that the sickness label can enhance disability. He stressed that a person's diseased relationship with normality is (often) more under the physician's influence than the disease itself. He focused on the issue of normality in preference to the use of a specific term such as "client" to redress the problem. Underlying these concerns is the theme that the terminology should be situation-specific: "patient" for the acute care situation and "client" for other situations,8,14,18 such as when preventive or palliative care is needed or when a person functioning normally in the community requires a service such as the provision of an orthosis. Keks19 suggested that "affirmation of the patient role in rehabilitation is not necessarily helpful, especially when the problem of abnormal illness behaviour is an issue."19

Social training has taught me that it is common courtesy to ask a person what he or she wishes to be called. Based on this concept, and Pargiter's suggestion that the "patient/client" should have the last word,20 I arranged for a survey of a group of people attending an ambulatory back-pain clinic in a teaching hospital.

Survey and results

A total of 101 people registered at the back-pain clinic who were visiting for the first time or for follow-up between June and December 1995 were given a short letter, signed by me as director of the clinic, that read:

Dear Friend,

We are in a caring profession, where we try to help you with medical issues. There is an interesting discussion in hospitals at this time about the term that we use for the people we try to help. Perhaps you can help us clarify this question by indicating below which you would prefer.

Would you prefer to be known as: (Please indicate below)

(a) A client

(b) A patient

Thanks for your help.

The greeting "Dear Friend" was used deliberately to avoid introducing either of the terms "client" or "patient." An equal number of letters were prepared with "client" or "patient" as the first option, and the letters were shuffled before being given out.

In all, 53 received the letter with "patient" as the first option and 48 had "client" as the first option. Almost three-quarters (74) stated a preference for "patient," and 19 chose "client"; the remaining 8 had no preference. Unsolicited comments included:

I am here for help not to use you. ["patient" preference]

I am not doing business with you, nor do I want to be paying directly for this service. You are a service I think Canada is admired for, and I am at your mercy. ["patient" preference]

It doesn't really matter. A patient receives treatment. A client receives a bill. [no preference]

What's in a name?

The preference, at least in this setting, is clear: most people wish to be called "patient." We must heed that preference. Inevitably, however, the unanswered question arises: What are the characteristics of people who prefer one or the other term? I did not attempt to answer this question, nor did I try to compare the preferences of the clinic attendees with those of people in an acute care setting or in an advice-seeking setting outside a hospital. Elliott and White21 found that 87% of a group of visitors to a hospital open-day would prefer to be called "patient" instead of "client" or "health care consumer." They found little difference in response between men and women but noted that the preference for "patient" increased with age.

An issue that has been, and should be, a concern to health care professionals is whether our attitudes and behaviours are shaped (especially adversely) by our use of a particular term for the people we wish to help. Imrie4 suggested that the use of "patient" provides us with a daily reminder that sick people suffer. Atkinson22 questioned the use of "sufferer" as an alternative, with its passive connotation, but reminded us that there may be large parts of their lives when sick people do not suffer; there are also large parts of their lives when sick people are not patients.

Raphael and Emmerson23 closely examined the clinical and political implications of using "client" instead of "patient" and listed 8 major concerns that could result from such use, summarized here:

  • Loss of the benefits of the biopsychosocial version of the medical model, which is an appropriate construct for a large number of human diseases.

  • 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 doctor­patient relationship.

  • Lack of recognition of the importance of the doctor­patient relationship and its confidentiality.

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

  • Implication of effective choice of treatment and responsibility for remuneration, two conditions that cannot be met in all disease states and economic situations. (For example, a man with paranoid schizophrenia, dangerous to himself and society, has no insight or ability to make decisions about treatment that, although associated with risks, may control the condition.)

  • Implication that people are not sick and hence not eligible for certain health care subsidies that might apply, for example, to someone with diabetes.
The question of patient autonomy versus medical paternalism is occasionally raised as a possible reason to justify the use of "client." However, the concern, although perhaps valid, should be addressed by our continually and critically reviewing how we care for people, with due regard for their ability to make and articulate decisions at different stages of disease, rather than by changing our terminology with no concern for preferences.

Paternalism is appropriate in certain situations: in families and in professional medical relationships. We no more expect a person with multiple trauma injuries to make management decisions than we expect our infant children to fend for themselves. However, in the same way we eventually transfer responsibility to our children in a healthy parental paternal relationship, often earlier than we find comfortable, we must recognize our patients' need for autonomy and enhance our accountability to them and their agencies as we practise medicine. We do this by treating our patients as equals in all but information, remembering the source of the name "doctor" (the Shorter Oxford definition is "a teacher, instructor; one who inculcates learning, opinions or principles"1). We must also elicit their expectations of the doctor in this relationship.24 As yet, however, our patients have no wish for a name change as part of that process.

"Patient" remains the best single term for the person receiving health care, and I believe that its use must be continued in general health care institutions until an alternative is clearly preferred. We should review our use of the term in settings where "client" may be preferred by those we serve, perhaps in the occupational therapist's, psychologist's or vocational consultant's office, or indeed in the well-person situation.

I thank Karen Burlingame for administering the questionnaire, and the patients and clients for completing it.

References

  1. Onions CT, editor. The shorter Oxford English dictionary on historical principles. 3rd ed. Oxford (UK): Oxford University Press; 1986.
  2. Annen AA. Letter to my patient [letter]. CMAJ 1994;150:123.
  3. Greenwood J. Why not let the name evolve [letter]? Nurs Manage 1992;23:12.
  4. Imrie DD. "Client" versus "patient" [letter]. CMAJ 1994;151:267.
  5. Johnson CA. Letter to my patient [letter]. CMAJ 1994;150:1055.
  6. Johnson EW. Patient -- or client? [editorial]. Am J Phys Med Rehabil 1989;68(4):161.
  7. George CRP. Patients and clients [letter]. Med J Aust 1988;149:568.
  8. Shum N. Patients and clients [letter]. Med J Aust 1989;150:167.
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  10. McCoy K. Patient vs client -- Should it be a quandary [editorial]? Insight 1993;18(2):3,7.
  11. Pluckhan ML. The use of the word "client." Kans Nurse 1972;Oct:1-2.
  12. Davis C, Davis J. "Nurse": dynamic terms for a dynamic relationship. Nurs Manage 1992;23(3):42-3.
  13. Herzberg SR. Client or patient: Which term is more appropriate for use in occupational therapy? Am J Occup Ther 1990;44(6):561-3.
  14. King LJ. Patient/client dichotomy unwise [letter]. Am J Occup Ther 1986;40(1):51.
  15. Fischer H. "Patients" versus "clients" [letter]. J Pediatr 1987;111(1):157-8.
  16. Hodgkin P. Medicine is war: and other medical metaphors [editorial]. BMJ 1985;291:1820-1.
  17. Pickering WG. A nation of people called patients. J Med Ethics 1991;17:91-2.
  18. McCallum LW, Dykes JN, Painter L, Gold J. Patients and clients -- again [letter]. Med J Aust 1989;151:358.
  19. Keks NA. Are patients clients or people [letter]? Med J Aust 1991;154:432.
  20. Pargiter RA. Are patients clients or people [letter]? Med J Aust 1991;154:432.
  21. Elliott J, White H. Patients are patients [letter]. N Z Med J 1990;103:593.
  22. Atkinson JM. The patient as sufferer. Br J Med Psychol 1993;66(pt 2):113-20.
  23. Raphael B, Emmerson B. Are patients clients or people? Med J Aust 1991;154:183-4.
  24. Uhlmann RF, Inui TS, Carter WB. Patient requests and expectations. Med Care 1984;22(7):681-5.

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| CMAJ August 1, 1997 (vol 157, no 3) / JAMC le 1er août 1997 (vol 157, no 3) |