Shortly after I earned my Medical degree and started to practice Psychiatry and Psychoanalysis, patients morphed into "clients." This was a change that grew out of a laudable move to "empower" people, to help them be more in charge of their health and welfare, and to equalize the power relationship between those who were now to be referred to as "Providers" and those who were the "Consumers" of health care. I have always been uncomfortable with the shift, but at least in the New York Mental Health arena, it was one of those Politically Correct ways of speaking that quickly became ubiquitous and rarely examined. I almost never use (or used) the terms myself; patients remained patients while "clients" and "consumers" seemed to be slightly unserious designations for people who came to us in distress. However, as with so many changes that have occurred without much resistance or thought, there are more subtle ways in which such re-naming has damaged and continues to damage our health care system and our patients.
I will try to show who benefits from this change, who loses and why, and a possible way to arrive at a synthesis in which Doctors and patients can both benefit. My focus is on the field of Mental Health, though much of my commentary is applicable to the overall field of Medicine.
First, some context for the change:
In the late 1960's, where so much of our current cultural pathology first took root, all hierarchies, all authority, and all power relationships were to be opposed in the name of equality.
Medicine was no exception to the rule. Despite the fact that Medical School took four years of rigorous study, followed by at minimum a four year apprenticeship as an Intern and then Resident, patients were encouraged to question their Doctor's knowledge and authority and Doctors were instructed to treat their patients as equals who were equally capable of making their own decisions on their own health care.
As with so many paradigm shifts, there are aspects to this that are laudable and ultimately quite helpful to patients; unfortunately, there is also much that is more covertly damaging to the patients and the overall health care system. I will try to describe some of the trade-offs involved in the shift and then perhaps offer a way to synthesize the two viewpoints that are captured by the short-hand of "patient" and "client."
Lets start with noting who benefits from the change from patient to client/consumer.
Clearly, some individuals have benefited tremendously from being seen as an at least equal participant in the treatment situation. Once the patient is no longer merely a passive subject of his own medical care, he can be encouraged and expected to take on greater responsibility for his condition and treatment. This is a nice theory that actually works for some people and every patient should have the opportunity to know as much as he or she can comprehend about their condition and their treatment. Unfortunately, in practice, this schema breaks down on the most fundamental levels, which I will get to in later posts.
The primary beneficiary of the change is the Insurance industry, followed closely by the entitlement industry (and yes, it is an industry at this point), with significant unintended benefits to the legal profession, as well.
The Insurance industry benefits from the comoditization of health care by homogenizing treatment at a "lowest acceptable common denominator." Once Doctors are "providers" and patients are "consumers", the personal relationship between the doctor and patient can be marginalized; Doctors and patients are fungible* (nee interchangeable). This saves the Insurance companies a lot of money. They can offer lower and lower amounts of reimbursement, knowing that patients have very little ability to determine the core competency of their doctors. As in every profession, 50% of all Doctors are statistically average with competency ranging from 25-75% of optimal in their field; 25% of Doctors are then below average and 25% are above average. The insurance companies can appeal to the 25th percentile of competence and pay much less than if they were targeting the top 10% of the doctors in a field. This is just math, not anything particularly sophisticated. From there, it is an easy task to offer "evidence based treatment" approaches, generally funded by interested parties, which shows that patients with a particular condition benefit from particular medications and treatments. The Insurance companies happily pay for drugs, knowing that medications are much less expensive than Psychotherapy (or combined treatment), and the drug companies churn out a constant spate of scholarly articles proclaiming the efficacy of this or that medication for all the emotional and psychiatric problems that people are prone to. Replacing a personal relationship with a drug saves time and money and is easier for both the Doctor and the patient. Since the hierarchy of medicine has not really been abolished, the Insurers can pay minimum reimbursement to mostly young, inexperienced social workers in those cases where they can be convinced the patient needs therapy as well as medication. The minority of Social Workers who actually see themselves as interested in helping patients make intrapsychic changes and who obtain post-graduate work in Psychotherapy and Psychoanalysis usually end up stopping their involvement as providers because the system is designed to marginalize them and prevent adequate treatment. After all, even with reduced fees for social workers, therapy tends to cost more than drugs.
The end result is more people taking drugs, more social workers pushed into agencies that devote themselves to the pursuit of entitlements (any time you see a clinic which proclaims "health care is a right, not a privilege", beware of the entitlement mentality), and more pressure to expand the pool of people, called clients and consumers, who increasingly look outside of themselves for opportunities to change how they feel.
The costs of this simple linguistic change and the way in which lawyers have reaped immense benefits from it will be among the topics of my next posts On Clients & Patients.
*My thanks to commenter ELC for pointing out my poor syntax. Doctors are considered interchangeable equivalents in the new system and patients are reduced to interchangeable collections of symptoms.
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