Are you a patient or a client?

Depending who you’re asking, you might not always get the same answer.

I had just begun working at a psychiatric hospital in Ontario when this quirky word suddenly became part of my vocabulary – client. I had met countless patients before but these clients, it would seem, represented a new hurdle. What is a client? What do they want? Do they like the Raptors? Do they drink water?

Well as I would come to learn, clients are not so different from patients. Clients breath air, live in cities, and walk among us. They suffer from depression, anxiety, mania, and psychosis. They have addictions.

So what makes a client? Themselves.

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Medicine is rooted in a millennia of traditions. Some of the principles of medicine still used today date back as far as the Ancient Greeks. Hippocrates, and the Hippocratic oath, remain a quasi-initiation at the front end of most medical schools. Leonardo DaVinci, and his drawings of the human body, can be considered to still have an impact on the field of medicine today.

With all history, we tend to focus on the highlights, and leave the dark corners undiscussed and ignored.

Paternalism is part of medicine’s darkest legacy. What is paternalism? Here’s a long, winded answer.

In broad strokes, medicine is super #$%&ing complicated. No doctor understands all of medicine perfectly, and we certainly don’t expect a patient/client to understand all, most, or even some, of medicine. As a physician, my job is to explain the relevant information to you, so that you can make your own decisions. I have the responsibility to give you the required information, and to ensure that whatever I do, is in your best interests. This results in something called a fiduciary relationship, meaning that if you need a test ordered, it is on me to order that test, even if it’s seven o’clock in the evening on a Friday and the Blue Jays are about to take their first swing. Fiduciary relationships are a great and essential part of medicine. I reiterate my comments on just how complex medicine is! However, there are also some unwanted side effects.

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As a doctor, if you are under my care, as we would say in the field, I am taking ownership of your care. This doesn’t mean I own you or your property, but basically that I am the captain steering the boat that is your health into harbour. Ownership in many ways is how things get done in medicine. If nobody feels responsible, than who would make sure your x-ray was ordered or that the proper consultations had been made, after all. Like all captains, we have a natural aversion to back seat drivers. “I know how to lay the anchor, so bug off!” kind of deal. We can even start feeling this way when the patient has different opinions from our own. Sometimes, we can even have a natural tendency to dismiss a patient’s thoughts when they conflict with our own. This would be paternalism, or in other words, a medical care model where the doctor’s wishes are given the highest priority, although presumably to save your life (whether or not you want your life saved – a whole other discussion there).

In another time, only decades ago, you might find that this is actually how medicine was practiced. What the doctor says goes. Forced sterilization and lobotomy being some more infamous examples. Today, we know better.

You are the captain, and I am the first mate. I help you navigate, but it’s up to you to steer. As a physician, it’s my job to listen to your concerns and give them thoughtful reflection, no matter how they may conflict with my own thoughts. This doesn’t mean ordering unsafe medications or needless tests, but giving an honest, thoughtful, patient-centred approach to care in all respects. This is the opposite of paternalistic medicine.

So what does this have to do with the whole patient/client conundrum?

Patient is a physician-born word. It’s language we have always used to describe those we care for and it’s comfortable. But some people take offense to that word, and that’s OK. This is particularly important in psychiatry. The reasons for this? They’re many and complex, the stigma associated with being a “mental health patient,” born out of 20th century mass media being the most surface-level example. In psychiatry, the word “client” carries particular meaning, and has more voluntary connotations than “patient” can sometimes imply, given the history of (at times necessary) coercive treatment in psychiatry. The point is not every “patient” likes the word, and they have a right to not be addressed that way. Mental illnesses are to many, after all, not considered illnesses, and people would prefer to describe their experiences as something akin to psychological distress.

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At the hospital I worked at in Ontario, the alternative term adopted by the institution was ultimately “client.” (As a side note, we borrowed this word from out psychologist colleagues!) They chose to institute an institution-wide movement to address every single patient as a client. As you can see from reading this blog, I obviously don’t do that. But I also do not call everyone a patient. The reality is, I am more comfortable with the word patient and it’s been what I’ve always used. But the moment my client or patient or glerblegerker let’s me know that they disagree with the idea of being a patient, I’m quick to change my language with them. It’s about them, after all.

So you tell me – are you a patient or a client?

 

 

Editor’s note: Mental illnesses are true illnesses from my perspective, but not because of any of the particular symptoms you have – hear and chat with the voices in the empty room all you want. To me, your experience is an illness when it begins to interfere with your functioning and safety.

Dr. Travis Barron is a resident physician in Toronto, Canada.

Take a minute

“I’m not taking those anymore.”

“Which ones?”

“The big ones there, for night time.”

“Why don’t you want to take them?”

“I don’t even know what they’re for.”

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Medicine is complicated. Twenty three years of schooling later, and I still find myself stumped with some of the patients I encounter in various medical disciplines.

Imagine how the patients feel.

One thing I’ve come to appreciate in my time as a physician, is how much we can take our knowledge for granted. Things that seem so obvious to me, like why do I get heart burn when I lay down, often mistify the patient, by no fault of their own, but simply by virtue of the fact that medical science isn’t part of traditional education.

Doctors forget this. Myself included. Which brings me to today.

I met a gentleman today with a number of chronic illnesses. As these things go, a number of illnesses means a number of medications. It can often be overwhelming to the doctor, let alone the patients. It can be difficult for patients to keep track of why certain medications were started, and how long they should be continued. Let alone what each individual pill looks like.

Don’t worry. As a physician my job is to help you keep track of these things, and to make sure you’re taking what you should, whent you should.

But that doesn’t mean leaving you in the dark.

“I had something stuck in my stomach,” the gentleman from the clinic said. “I was in the hospital for a few weeks… They cut me open, did something.” Tears began to fall and I moved closer. “I used to be so healthy, so active. Now, I can barely move. I’m terrified every night when I go to bed. ‘Will this be my last? I hope I go in my sleep… At least it’s painless.'”

He was terrified.

As you’ve heard me preach time and time again, knowledge is empowering. The opposite is also true. Ignorance is paralyzing.

This gentleman had no idea what had happened to him. They cut him open and entered his body and he was in the dark. Traumatizing? You tell me. Sure, many physicians had reminded him time and time again what had happened, but this information isn’t always easy to retain. To him, he felt abandoned. He had quit his medication, not only because he felt like he was taking pills blindly, but also as a form of protest. This man, who put his lives in our hands and felt so disempowered, had one last way to assert his control. By refusing.

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“I can understand. That sounds absolutely terrifying. Of course you’re anxious. I want to help you through this. I am going to help you.”

I sat with the patient for a while and discussed with him his illnesses, and his medications. He was beaming by the end.

And maybe the same thing will happen tomorrow. He might forget. And that’s ok. It’s not his responsibility to understand the medicine perfectly, I did eight years of medical education to achieve that. And trust me, I’m still working. What’s important, is that we as physicians remember the value of taking a minute to check in and make sure our patients feel educated, and included.

Dr. Travis Barron is a resident physician in Toronto, Canada.