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Patient, client, user or customer?

Erlend Hem About the author

The concept of «patient» has its flaws, but the alternatives are even worse

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Photo Einar Nilsen

In essence, what is a patient? The Patients’ and Users’ Rights Act defines a patient as «a person who contacts the health service requesting health care, or to whom the health service provides or offers health care as the case may be» (1). One does not necessarily need to be ill, and being ill is not in itself sufficient – to be a patient in the legal sense, one must have contact with professional helpers. But where can the boundaries of the concept of patient be drawn? For example, women who request contraceptive pills or abortions, or who are in hospital to deliver a baby, will not be considered as patients in the ordinary medical sense (2). They are not ill or injured. They will nevertheless fall within the legal concept of a patient, since they need the assistance of the health services. The same applies to people with hypertension, elevated cholesterol levels or other conditions that increase the risk of disease, but are otherwise healthy and fit. Should they also be referred to as patients?

Many have been critical of the concept of patient. The root of the word «patient» is the Latin word patiens, whose meanings include «(someone) who suffers» or «suffering». This is unbefitting for many of those who contact today’s health services. Some therefore prefer the term «client» (3). Here too, etymology – the study of the origin of words – provides little help. In Latin, cliens is a designation for a person who puts himself under the patronage of a powerful man, or in other words, not particularly more modern or neutral than patient.

Others have pointed out that the concept of patient is historically charged. Previously, the treatment of patients was characterised by paternalism – an omniscient, imperious doctor and a passive, obedient patient; the archetype of a power disequilibrium. The current ideal is the knowledgeable and active expert patient who imposes requirements on his/her doctor (4). It can be claimed that the new patient role is so different from the old one that the concept of patient should be done away with altogether (5, 6). Furthermore, many of those who are chronically ill do not wish to regard themselves as patients in their daily life. They would rather emphasise other and more important aspects of themselves – a person with asthma would prefer to be seen as a family man and professional rather than as an asthma patient (4). This kind of perspective may help cultivate the healthy side of a person, who thus can be liberated from a passive patient role that could accentuate morbidity and prevent healing. Nor would many of those who seek or receive psychiatric help see themselves as patients. Some have argued that «survivor» could be a suitable alternative to the concept of patient. People in nursing homes are often referred to as «residents». If they are very ill, however, this may appear odd.

So what do the «patients» themselves think? There is a host of comments and opinions, but few have taken the trouble to ask those concerned (7). A recent review article shows that the empirical studies available provide no certain knowledge as to what designation is preferred by the people who use mental health services (8).

Finding good alternatives to the word «patient» has thus proven to be difficult. «User», «consumer» and «customer» have been proposed. According to the Patients’ and Users’ Rights Act, the designation «user» refers to something other than «patient». A user is «a person who requests or receives services encompassed by the Health and Care Services Act other than health assistance» (1). As regards the term «customer», many will find it unfortunate to use commercial terms to describe the relationship between the doctor and someone who seeks the doctor’s help. Such usage implies that the doctor is a supplier and the patient a purchaser of services. This could be problematic, for example when people contact their doctor to request antibiotics, addictive drugs, sick leave or an elective Caesarean section. The customer metaphor is unfortunate, because it pulls medicine in a purely economic direction and trivialises the doctor-patient relationship (9, 10). A customer relationship is incommensurate with the traditional value basis of doctors: to provide care for individuals.

It sounds so nice to be a customer – after all, the customer is always right – but the implications are ominous. Responsibility is subtly shifted onto the person in need of help. The most resourceful and competent customers will invariably receive the best product at the best price. As a rule, the rest of us must go to the back of the queue and receive poorer services and products. The term «customer» removes part of the key aspect of our health services – that the community assumes responsibility for us and helps us when we are ill and vulnerable.

1

LOV 1999 – 07 – 02 nr. 63: Lov om pasient- og brukerrettigheter (pasient- og brukerrettighetsloven). www.lovdata.no/all/hl-19990702-063.html (16.4.2013).

2

Warberg LA. Norsk helserett. 2. utg. Oslo: Universitetsforlaget, 2011: 71, 312.

3

Pasient (Store medisinske leksikon). I: Store norske leksikon. http://snl.no/.sml_artikkel/pasient (16.4.2013).

4

Smith R. The discomfort of patient power. BMJ 2002; 324: 497 – 8. [PubMed] [CrossRef]

5

Reeder LG. The patient-client as a consumer: some observations on the changing professional-client relationship. J Health Soc Behav 1972; 13: 406 – 12. [PubMed] [CrossRef]

6

Rada RT. The health care revolution: from patient to client to customer. Psychosomatics 1986; 27: 276 – 9, 283 – 4. [PubMed] [CrossRef]

7

Neuberger J. Do we need a new word for patients? Lets do away with «patients». BMJ 1999; 318: 1756 – 7. [PubMed] [CrossRef]

8

Dickens G, Picchioni M. A systematic review of the terms used to refer to people who use mental health services: user perspectives. Int J Soc Psychiatry 2012; 58: 115 – 22. [PubMed] [CrossRef]

9

Andreasen NC. Clients, consumers, providers, and products: where will it all end? Am J Psychiatry 1995; 152: 1107 – 9. [PubMed]

10

Krugman P. Patients are not consumers. New York Times 21.4.2011. www.nytimes.com/2011/04/22/opinion/22krugman.html?_r=1 (16.4.2013).

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