What do we call ‘them’?: the ‘patient’ versus ‘client’ dichotomy

The choice of a word to name something is more than a basic semantic exercise. Words function as metaphors that literally shape our reality and expectations. Conveying acquired connotations and implications that are a product of the evolutionary dynamics of language, words utilized as nouns for ‘classes of persons’ construct identities and define relationships with other nominative classes.1 The words we select to use reflect the values, attributes, and qualities that we attach to what we are naming. This influences our perceptions and actions. If what we are naming is the object of our actions as health professionals, this will have implications in the realm of our professional conduct. The foregoing should be the context in which we consider the seemingly innocuous question of, ‘What should we be calling “them”?’, ‘them’ referring to the individuals who are the focus of our work as health professionals.2–4 Differences do exist between (and indeed at times within) the various disciplines that comprise the caring professions, including those that administer the budgets and resources utilized to provide such care. The current prevailing dichotomy is between the terms ‘patient’ and ‘client’, with subsidiary terms such as ‘consumer’ or ‘user’ frequently substituted for ‘client’. To best understand this dichotomy, we need to consider the origins and precise meanings of these words. The word ‘patient’ has its origin in the Latin ‘pati’– to undergo, suffer, or bear. Dictionaries reflect this origin when providing the following definitions and synonyms for ‘patient’: ‘bearing, enduring pain quietly without complaint’, ‘a capacity of endurance’, ‘suffering’, ‘victim’, ‘tolerant’, ‘understanding’, ‘calmness’, or ‘that which undergoes some action’.5–9 These definitions reflect the qualities attached by language to the noun. The word thus conveys an implication of illness and a disturbance from ‘norms’ or homeostasis, however recognized.10,11 It implies a passivity (‘object of an action’) that removes responsibility (‘bearing, enduring’), which can be construed as stigmatizing as its usage may enhance perceived disability and impairment. These implications in the construct of ‘patient’ devalue the intrinsic autonomy of the individual to which the label is applied. It is thus best suited for use within a paternalistic model of healthcare relationships focusing on the acute recognition of disease and its management.12 It is an inappropriate term to refer to a healthy individual engaged in activities related to either illness prevention or health maintenance, or perhaps even rehabilitation that emphasizes function over ‘normality’.13 The word ‘client’ to denote a recipient of healthcare has its origin in the mid-twentieth century humanistic approach to psychological counselling of Carl Rogers (i.e. ‘Client Centered Therapy’).14 The word was specifically selected to avoid a connotation of being sick or ill. Utilized extensively within psychology, it has been absorbed, especially within healthcare, into the lingua franca of nursing15 and rehabilitation.16 Users of this term seek to convey a non-medical, humanistic, less acute care model of orientation to healthcare delivery that is thought to be more empowering to the actual recipient of healthcare. The origin of the word ‘client’ is the Latin ‘cliens’ meaning ‘follower, retainer’,5–9 and indeed in ancient Rome, the term was used to connote a plebeian who sought the protection and/or patronage of a powerful patrician.11 A corollary, closely related Latin word is ‘clinare’ which means to ‘incline, or bend’.5–9 Thus dictionaries provide such definitions and synonyms for ‘client’ as, ‘customer’, ‘patron’, ‘one who depends on the protection of others’, ‘source who pays for goods and/or services’, and ‘dependent’.5–9 Paradoxically, the actual root origins of the word hardly convey an aspect of the empowerment quality that was originally sought when employed in healthcare terminology. The use of the word ‘client’ to connote a recipient of healthcare has emerged, not surprisingly, within an era that has increasingly conceptualized medical services as a commodity in which terms of reference originally expressed for business and commerce have been extended to the practice of healthcare itself.10 A paradigm shift has occurred in parallel with our language use, in which there has been a shift of focus at all levels from the ‘altruism of care’ to the ‘bottom line’ that is reflected by increasing corporate or government involvement in their role as commercial providers of goods or services and third party payers. Indeed Rogers, who did much to popularize the word ‘client’ in the healthcare milieu, intrinsically realized the word’s limitations, stating that: ‘the term client does have certain legal connotations which are unfortunate, and if a better term emerges, we shall be happy to use it’.14 Limited objective evidence exists regarding the usage of the terms ‘patient’ and ‘client’ in the healthcare milieu. Utilizing the Personal Attribute Inventory, Goodyear and Parish demonstrated that lay individuals and health professionals negatively evaluated both ‘client’ and ‘patient’ in contrast to ‘typical persons’, especially in relation to mental health constructs.17 While ‘clients’ were more positively evaluated than ‘patients’, differences in the sample studied did not reach statistical significance. More recently, over the past decade a number of studies have surveyed the recipients of healthcare in a variety of settings and a preference for the terminology ‘patient’ for description over ‘client’ has usually been demonstrated, with some exceptions.13,18–24 Indeed when quantified, considerable antipathy amongst recipients for the ‘client’ terminology has been observed with 45% of respondents either ‘strongly disliking’ or ‘disliking’ the term on a Likert scale rating as opposed to 14% feeling similarly for the term ‘patient’. In the same way, a preference for one term or the other has been demonstrated among various clinician groups (i.e. patient-physician/psychologist, client-social workers). From the foregoing it is clear that neither ‘patient’ nor ‘client’ are universally satisfactory terms. This is perhaps inevitable given the enormous heterogeneity of healthcare provision at varying levels in terms of populations served, encounter settings, and clinician groups. Perhaps on an individual level, the common sense of appropriate social behavior should prevail.18 When we encounter someone socially, we inevitably ascertain early in our encounter what he or she wishes to be called and through usage, affirm their choice. Thus the decent and polite thing to do is the one which best promotes self-determination.23 In the individual situation, this would be to determine which self-label (i.e. patient or client) the individual receiving healthcare so chooses. While this may work at an individual level, this does not help us when we try to label a ‘class’ of individuals. At this point, perhaps we need to ask a fundamental question: Why is there even a need for a transfigurative label that distinguishes this ‘class’ of individuals from others, including ourselves? Individual autonomy is the dominant moral value of modern Western society, which has been reflected in the evolution of contemporary medical ethics.26 Both terms, ‘patient’ and ‘client’, mitigate to some degree individual autonomy. Our duty of owing moral obligations is to the greatest extent, accorded to those individuals, who like ourselves, are recognized as a ‘person’.27 It is the quality of ‘personhood’ that provides both moral autonomy and protection, as we see ourselves as persons and intuitively seek to treat others as we wish ourselves to be treated (i.e. the Golden Rule). Even a cursory survey of recent history reveals that every legally based denial of rights to a ‘class’ of individuals in the modern era has flowed from the mistaken premise of this ‘class’ as being less than persons. At a fundamental level, the distinction into ‘patient’ or ‘client’ is flawed because our ‘us’ is indeed part of their ‘them’. The healthcare professional providing care today may be the coronary ‘patient/client’ of tomorrow who, with appropriate intervention, may return to being the care provider of the future. By utilizing distinctive terminology in a way we are questioning or diminishing an equality between provider and recipient of moral agency and authority. This is clearly an undesired goal of our use of language in a contemporary healthcare context. So, what do we call ‘them’? What’s wrong with ‘persons’, ‘individuals’, ‘humans’, ‘adults’, ‘children’, ‘men’, ‘women’? Is that not what they truly have been, are and always will be till they die?

Fetched live from OpenAlex and de-inverted. Abstracts are not stored in this database: the inverted indexes are 8.6 GB of the frame’s 9.3 GB of text, and the host has 13 GB free.