Why Doctors Don’t Have Clients

Apr 22, 2015

For many of us who went into psychiatry, relieving the patient’s suffering is not a business enterprise, but an ethical and spiritual calling.

COMMENTARY

“But if thought corrupts language, language can also corrupt thought.”
―George Orwell, 1984

[[{"type":"media","view_mode":"media_crop","fid":"34505","attributes":{"alt":"psychiatry practice","class":"media-image","height":"158","id":"media_crop_7984405483873","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"3675","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","title":" ","typeof":"foaf:Image","width":"135"}}]]Many years ago, I heard a psychiatric colleague quip, “The only people who have clients are lawyers and hookers!” Depending on your point of view, he was being grossly unfair to either lawyers or hookers. In any case, he was trying to make a serious point: physicians do not see “clients”-they treat patients. And doctors are not “providers”; they are-or ought to be-healers. This point was cogently made by Dr Barry L. Farkas, a geriatrician and family physician, in a letter in The New York Times on April 6, 2015.1 Dr Farkas was complaining about a recent piece in the Times (March 29) regarding terminally ill adolescents. Dr Farkas pointedly notes,

. . . when you repeatedly use the term “provider” to describe those professionals in the caring arts-and yes, on our best days, the healing arts-it becomes an eloquently sad commentary on the state of medical care . . . the term “provider” for clinical caregivers, like the term “client” for patients, depersonalizes and commodifies that which is neither and [is] so very much more.

I applaud Dr Farkas for calling out the Times on this, but he was identifying a linguistic trend that has become endemic in our culture-not only in so-called consumer-oriented publications, but also, alas, in some medical circles. And in the UK, patients are routinely referred to as “service users”-ostensibly because they are treated within the publicly funded National Health Service. However, as Dr Hugh McLaughlin,2 Director of Social Work and Social Policy at the University of Salford in the UK notes, the term “service user” actually grew out of the “consumerist tradition of the 1990s and the democratic tradition of developing participation to ensure the suitability of services.” And yet, in one study of psychiatric outpatients in the UK, “patient” emerged as the clearly preferred term when psychiatrists and nurses were caring for the person; “client” and “patient” were equally acceptable terms when a social worker was the designated clinician.3 (In light of my colleague’s sardonic remark, I was amused to see one study participant quoted as saying, “‘I do not like client-it’s reminiscent of prostitutes.”)

My impression is that most psychologists and social workers in the US prefer the term “client” to “patient,” although this may not be the case among some hospital-based clinicians. (I have often wondered if the suicidal, psychotic client, once hospitalized, becomes an “in-client.”) I believe this tradition grew out of the sincere belief that “client” is a more “empowering” term than “patient”-which some non-physicians associate with a paternalistic or authoritarian “medical model.” From this perspective, “clients” are seen as autonomous agents, “patients,” as subservient to the authority of the physician. From the standpoint of etymology, this is an ironic bit of turnabout. In ancient Rome, a “client” was a plebeian under the protection of a patrician; that is, a commoner under the patronage and protection of an aristocrat.4 Thus, a “client” was essentially a dependent person with little or no autonomy.

In contrast, the term “patient” is derived from the Latin verb, pati, meaning “to suffer” or endure.5 This point, it seems to me, is of more than academic interest. When a physician treats a patient, the latter is very often suffering. Indeed, I have argued, over many years, that our very concept of “disease” arose from the observation of human suffering and incapacity, owing to some pathological internal state.6 True, not all persons with psychiatric disease report suffering, and many are able to live full, flourishing lives despite their illness.7 But for others, the suffering is very great indeed-a point barely acknowledged in a recent British report on psychosis.8 For many of us who went into psychiatry, relieving the patient’s suffering is not a business enterprise, but an ethical and spiritual calling. The sterile, soulless terms “service user” and “provider” do injustice to the patient’s misery and the physician’s ministrations.

And yet-perhaps there is a better term than “patient.” The Schizophrenia Awareness Association of India provides a wise and humane alternative.9 To be sure, the SAA clearly recognizes the harsh reality of schizophrenia while also encouraging a hopeful and respectful attitude toward those afflicted with this illness. In addition to the term “patient,” the SAA often uses the Sanskrit term “shubharthi”-literally, a “seeker of well-being.” The corresponding term for the caregiver is “shubhankar”-literally, “a person who is dedicated to others’ welfare.” Perhaps American physicians would do well to look eastward the next time they encounter such a seeker of well-being.

Acknowledgment-I am grateful to the Web site iholger.wordpress.com for acquainting me with the term “shubharthi.” See: https://iholger.wordpress.com/2012/08/10/strangers-scooters-and-a-shortage-of-mental-health-services.

Note to readers: As with all of our blogs, the opinions expressed in this commentary are solely those of the author. Comments not followed by full names and academic titles will either be removed or heavily monitored. –Psychiatric Times

Disclosures:

Dr Pies is Editor in Chief Emeritus of Psychiatric Times, and a Professor in the psychiatry departments of SUNY Upstate Medical University, Syracuse, NY, and Tufts University School of Medicine, Boston. He is the author of The Judaic Foundations of Cognitive Behavioral Therapy; The Three-Petalled Rose; Psychiatry on the Edge (collected essays from Psychiatric Times/Nova Publishing); and the novel The Director of Minor Tragedies (iUniverse).

References:

1. Farkas BL. The language of medicine. New York Times. April 6, 2015. http://www.nytimes.com/2015/04/06/opinion/the-language-of-medicine.html. Accessed April 7, 2015.
2. McLaughlin H. What’s in a name: ‘client,’ ‘patient,’ ‘customer,’ ‘consumer,’ ‘expert by experience,’ ‘service user’-what’s next? Br J Soc Work. 2009;39:1101-1117.
3. Simmons P, Hawley CJ, Gale TM, Sivakumaran T. Service user, patient, client, user or survivor: describing recipients of mental health services. Psychiatrist. 2010;34:20-23.
4. Oxford Dictionaries. http://www.oxforddictionaries.com/us/definition/american_english/client. Accessed April 7, 2015.
5. Wiktionary. http://en.wiktionary.org/wiki/patient#Etymology. Accessed April 7, 2015.
6. Pies R. On myths and countermyths: more on Szaszian fallacies. Arch Gen Psychiatry. 1979;36:139-144.
7. Wootton T. Why I am against remission for depression and bipolar: challenging the premise of remission as the end goal of treatment. April 19, 2013. https://www.psychologytoday.com/blog/bipolar-advantage/201304/why-i-am-against-remission-depression-and-bipolar. Accessed April 7, 2015.
8. Pies RW. Trivializing the suffering of psychosis. Psychiatr Times. December 22, 2014. http://www.psychiatrictimes.com/schizophrenia/trivializing-suffering-psychosis. Accessed April 7, 2015.
9. Schizophrenia Awareness Association. Vision & Mission. http://www.schizophrenia.org.in/home/index.php?option=com_content&view=article&id=112:vision-a-mission&catid=42:about-us&Itemid=141. Accessed April 7, 2015.

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