In these days of public involvement and active participation, has the term “patient” become an offensive anachronism or does it capture what is positive about the special relationship between health workers and ill people? A former chairman of the Patients’ Association and a clinician argue for and against “patients.”
. 1999 Jun 26;318(7200):1756–1758. doi: 10.1136/bmj.318.7200.1756
BMJ. 1999 Jun 26;318(7200):1756–1758.
The word “patient” conjures up a vision of quiet suffering, of someone lying patiently in a bed waiting for the doctor to come by and give of his or her skill, and of an unequal relationship between the user of healthcare services and the provider. The user is described simply as suffering, while the healthcare professional has a title, be it nurse or doctor, physiotherapist or phlebotomist.
Patient comes from the Latin “patiens,” from “patior,” to suffer or bear. The patient, in this language, is truly passive—bearing whatever suffering is necessary and tolerating patiently the interventions of the outside expert. The active patient is a contradiction in terms, and it is the assumption underlying the passivity that is the most dangerous. It is that the user of services will remain passive in sickness, allowing the healthcare professional to take the active part and tell the user what to do. The passive patient will do what he or she is told, and will then wait patiently to recover. The healthcare professional is the healer, while the recipient of healthcare services is the healed, and does not need to take a part in any decision making or in any thinking about alternatives.
MARK MCCONNELL
An unequal relationship
Clearly this is a gross overstatement, but there is some truth in it. The word patient does conjure up that sense of passivity, because that is its true meaning; the idea of active participation sits poorly with it. Thus, the strongest argument against the use of patient to describe a user of health services is that word indicates immediately the unequal nature of the relationship and “objectifies” the person who is the user. The professional knows what to do, and the recipient does as instructed. The user becomes passive; the provider becomes all knowing, all healing, all powerful. This describes a type of relationship between healthcare professionals and their patients which may have sat happily with ancient ideas of respect for doctors, but it fits poorly with modern views of users taking an active part in their own health care, and, indeed, taking responsibility for some of their own recovery.
The well patient
But there is another argument for removing the use of the word patient from the vocabulary of the relationship between the healthcare professional and user, the argument we all too often forget. Many of the encounters between healthcare professionals and the public are not about healing as such, but about the activities of normal life—making choices about lifestyle, optional services we might want, or advice on matters such as fertility or cosmetic surgery. That relationship is very different from the relationship predicated on an image of disease striking the innocent victim, whose suffering can be alleviated only by the healthcare professional with his huge God-given skill. Today’s relationship is one of equals, with the professional adviser giving his or her fellow citizen useful advice.
These are the main arguments against using patient, quite apart from the sense of a grateful patience in suffering that sits with the word and fits poorly with our modern view that we can have rapid “fixes” and that we can, ourselves, take action. Not to mention the fact that suffering is no longer thought of as ennobling. That romantic and often Christian view of the ennoblement of the spirit though suffering has been overtaken by a view that suffering is unnecessary and, indeed, often bad for you, unless it is for a specific purpose such as acquiring a beautiful body.
Alternatives
What are the alternatives? The first is obviously “user” of services—for healthy or not, patient in attitude or not, the person who uses healthcare services is patently a user. But user is hardly a felicitous expression. An alternative might be “client,” yet client conjures up a quite different kind of relationship of purchaser and provider, often anything but the case, at least directly speaking. The same is true of the term “consumer,” from the modern consumerist language that led to the term patient seeming curiously old fashioned as well as inaccurate. But consumer of health services suggests a constant ingestion of pills and potions, rather than the wide array of services, such as healthy living advice and exercise, or the prosecution of those selling such items as contaminated meat.
None of these is absolutely right, which no doubt accounts for the long lasting use of patient, despite its overtones. Yet consumers of healthcare services are undoubtedly their users and their active recipients, rather than their passive accepters. If we are to see greater participation in their own care by users of services, and greater public awareness of what can and cannot be done, then the term user, despite its lack of elegance, at least conjures up an active role. It could even suggest an equalisation of status between health professional and service user that is nearer the climate in which modern health services should be provided. The active patient is a contradiction in terms, but the confident service user, informed and participative, is someone one might hope to see in most healthcare settings.
BMJ. 1999 Jun 26;318(7200):1756–1758.
To paraphrase Viscount Falkland’s well known maxim, if it is not necessary to change something, it is necessary not to change it. Change takes time, effort, and resources. So if we are to replace the ubiquitous term “patient” with something else, we must be sure that it is necessary to do so. More specifically, we should be confident that:
The word has undesirable connotations which have a bad influence on doctors’ attitudes to the people who come to them for help and advice
There is an alternative word that would serve the denotative function of patient without carrying its putative adverse connotations
The change in terminology would bring about an improvement in attitudes.
My case for retaining the term patient is based on my belief that none of the above points holds.
What’s wrong with “patient”?
First of all, what is wrong with the word as it stands? Yes, it is tainted etymologically. Its root, the Latin “patiens” (one who suffers), implies someone who is passive; someone who (quite unlike the modern consumer of health care), being supine, is at risk not only from deep vein thrombosis but also from adopting a deferential attitude to doctors. Furthermore, this patient will obey nurse’s orders, however inconvenient, irrational, and non-evidence based. She will comply with treatment rather than agree to it. She will overhear her diagnosis and its management rather than discuss and challenge it. Finally, she will gratefully endure medical mishaps instead of having recourse to the courts, where (it is rumoured) justice is to be found. Actually, most people (including the author) are unschooled in etymology. Damning words by their remote origins is as useful as appealing to Wolfe Tone or the Battle of the Boyne to settle current disputes in Ulster.
Meanings change
All right, then, someone will argue, the word patient still suggests someone who is patient and will put up with anything; who will, for example, sit meekly for hours in a clinic instead of getting up and playing hell. In short, the word sits ill with the modern idea of the patient as consumer, as an equal partner with her doctor, nurse, or therapist. This argument, too, cuts little ice. Words acquire new meanings through custom and usage, and the extensive use of the word in its clinical context has secured its new meaning. In short, words, like their speakers, move on. Besides, if patient really were an offensive hangover from an age of authoritarian clinicians and cowed, passive patients, why has it retained unchallenged supremacy in the United States, the centre of consumerist medicine, where the patient is quite definitely a partner?
No obvious alternative
Let us suppose that the continuing use of patient were having a detrimental effect on the attitudes of doctors and nurses to people who come to them for help, what word would we put in its place? “Health seeker” would focus on the promotion of health as opposed to the mere sorting out of sickness, but it would be more than a little absurd. Imagine using the term “ambulatory health seekers” for an outpatient clinic. A more obvious choice would be “client.” Social workers have clients, and this is a noble effort to correct the “means test” ethos that saw the benefits seeker as a supplicant. But lawyers also have clients, and the use of this term in health care might capture the sense that doctors sometimes have of the patient as a prelitigant. What about “customer”? Shops have customers, but the implicit contract between a doctor and an ill person is totally different from that between a retailer and a shopper. Someone who is ill and seeking help—unlike someone who is purchasing a pair of socks or a pound of sausages—is often vulnerable, certainly worried, sometimes uncomfortable, and frequently frightened. Customer, like the other obvious choices—clients, consumers, and users—erases something that lies at the heart of medicine: compassion and a relationship of trust. Trust and compassion may stink of paternalism (or maternalism), but without them medicine stinks. The distinctiveness of patient reminds us of the vulnerability of the ill person and the often harrowing responsibilities of the doctor or nurse; something frequently forgotten in the consumerist world picture. So while the term patient may be steeped in the abuses of the past, is also captures what is positive about the special relationship between health workers and ill people.
Would change mean improvement?
Even if there were a case for change, and a satisfactory alternative, would there be any reason for thinking that this would drive improvements in doctors’ attitudes and behaviour? Most linguistic reforms reflect rather than bring about changes in attitudes. There are cases where the veto of a word may change attitudes—for example, banning the word “nigger.” A less striking example is the discouragement of people from using “he” to mean “he or she.” This may have played a small part in reversing the marginalisation of women. Nearer to home, there have been terminological changes that have made a difference. I wince whenever people use the obsolete term “epileptics” to refer to people with epilepsy; it seems to imply that people are identical to their illness. This implication, however, is not carried by the rather general term patient; we are used to the notion that we are patients at some times and not at others. Moreover, there are many instances of linguistic reform failing to change anything; for example, the introduction of “Ms” to deal with the inequity whereby a woman’s mode of address revealed her marital status while a man’s did not.
Even if introducing new terms such as consumer were effective, the effect might be for the worse. Replacing patient with consumer might foster the notion of doctors and nurses as functionaries in a healthcare business whose product is as many litigation-free units of care in as short a time as possible. Empathy and compassion would be seen as threats to productivity ... after all, they take time, don’t they?
I therefore find no grounds for replacing the word patient at present. And the absence of such grounds is itself grounds for not introducing this labour intensive change. To proscribe the term patient would be to detract from what is distinctive about medical practice. Better to improve that practice so that the connotation of patient becomes wholly positive.
A final point. This “referenceless,” data-free airing of opinion is a regression—the kind of primitive medical discourses that the BMJ should steer clear of—defensible only as the beginning of the debate. If the debate were worth pursuing, the next steps would be to research what people actually think about the word patient, what they think about the alternatives, and whether there is any evidence that terminological change of itself brings about alterations in the collective consciousness or whether it merely follows it. Whether the NHS Research and Development Programme would think this a worthwhile project into which to direct resources is an interesting question. But until we have any data, we should conclude that it is necessary to leave well alone. Think of the all the new verbal habits we would not have to learn, all the new stationery we would not have to buy, all the new signposts we would not have to erect, all the money and consciousness that could be saved for ... er ... patient care.