Just a quick note re: a language choice that comes up in all of our work.
In Research Round-Up #016, the Community Health Impact Coalition expressed a preference for the work patient over client. This preference is based on the idea that patients have a right to health (access, equity…), whereas clients typically pay for services in a transaction. The ongoing (global) fight against point-of-care user fees thus jives better w/the word patient.
One of the authors of the “client” study, Ryan Logan, reached out to us following the publication of issue 016 w/the following explanatory note: “For the population of CHWs I worked with in Indiana, they (and the association that organized CHWs) preferred the use of the term client for CHWs and patients for medical professionals (doctors, nurses, etc.). As it was a collaborative project in which I worked closely with the CHWs, I wanted to ensure that my research reflected their verbiage hence the usage of client rather than patient."
Some fields, like reproductive health, are adamant about using “client.” I have also heard folks suggest that “client” sounds more commercial, i.e. “clients are more empowered to make choices” (though of course we all want patients to be empowered too!). The WHO classification of digital health interventions has ‘interventions for clients’ as one of their high-level categories…
I am strongly on the side of patient, but am curious about the experience and opinions of others here.
Hey Madeleine, thanks for thoughtfully posing this question here! Rather than trying to answer, I’ll add a few more questions…
Is the decision about word choice made because of preference (of people involved in giving or receiving care, or other stakeholders), effectiveness towards other ends, or values and vision alignment (“the bigger picture”), or some combination of these? And, if the answer is (primarily) preference, or the word’s effectiveness, is it a coherent strategy to use different words in different contexts?
My sense is that the support for bringing in business terms, such as “client” or “customer”, is basically support for bringing more respect and dignity to a system’s design and people’s day-to-day experiences. That said, I don’t think that business gives us the only framework for respectful human interaction. I’m interested in health systems that work for everyone, and I’m interested in reclaiming the word “patient” by helping create dignified experiences when someone needs care from someone else. I’m also open to using words like people, grandfather, shop owner when its preferred and effective, meeting a person where they are.
Hi,
I also have quite a strong preference for the word patient over client, although in Ethiopia the CHWs usually use the word client.
I wonder if some of this distinction might be to do with the CHWs role, and in a lot of cases they are more like counsellors (in their role on paper anyway, of course, they very often do much more), and perhaps the use of the word client reflects this. In Europe and in my limited experience at least, most counsellor type jobs would refer to “their clients” rather than “their patients”. I think this reflects your comments in items 2 & 3?
I guess this will be one of those terminology things that you’ll never get everyone to be 100% consistent on!
Thanks for posing the question, Madeleine, and for the thoughtful responses, Josh & Alex.
Perhaps it is my background as a social scientist but I tend to err strongly on the side of “patient” over “client” as well. The questions that Josh raises, of preference, effectiveness, and/or alignment are good ones and thought provoking, particularly in contexts where CHWs articulate a preference for the “client” language rather than “patient”.
To me, it seems as though the rise in “client” vs. “customer” vs. “patient” language aligns with broader efforts to frame care provision as a service rather than as a right. I worry that, when “patients” become “clients”, care itself becomes a commodity rather than a responsibility of the state and associated partners. I also worry that this shift in language renders care provision and, indeed, care-seeking as a more individualized responsibility resting with the “customer” or “client” rather than a collective responsibility to “patients” or, indeed, “citizens”, a term that is also laden with political nuance and problematic connotations.
I’ll be interested to see how this conversation evolves!
My early background as a consultant and my more recent background as a participatory design researcher make me respond the question with a clear “It depends!”
We have programs where people visited by CHWs (or Migrant/Community Health Volunteers) are called clients, and others where they are called patients. In messaging we often don’t use any of these terms, but use words such as “mother”, “child”, “people living in your catchment area” etc.
I can imagine geographies, health systems or other contexts where words like “patient” or “client” have connotations different from the ones exposed in this thread. Patients can “suffer” or “lack agency”, while clients or customers might “expect a quality of service”, “need to be satisfied”, etc.
With so many words overloaded with different, even conflicting, meanings and connotations, I don’t think there is a right choice of words. There might be a wrong choice, however, e.g. if it is merely based on preference and doesn’t consider the perspectives and concerns of different stakeholders, including patients/clients.
What does it matter? The words we use and the meanings we give to them influence the relationships between the people in the systems we act. What’s the practical consequence of this? The least we can, or should, do is to be deliberate in the choice of our words and try to make our assumptions and rationale transparent, in a language adequate to the people we are talking to.
What an interesting discussion! I also came across a paper in the BMJ that surveyed people attending or providing care at sexual and reproductive health clinics in the UK. This is what they found:
A total of 1428 clinic attendees and 250 staff members completed questionnaires. 61% of attendees who responded preferred ‘patient’, with 23% expressing no preference. Only 9% of respondents preferred the term ‘client’. 148 (59%) of all staff groups preferred the term ‘patient’ followed by 82 (33%) selecting ‘client’. No staff member opted for ‘customer’ or ‘user’ as the preferred term… The majority of people attending sexual health clinics and medical and clerical staff working in these services expressed a preference to retain the title of ‘patient’. The main justification for this appeared to relate to the concept of caring for people.
I highlighted in bold two points that jumped out to me. As frequently as we in the tech community refer to users, my experience is generally consistent with this article’s finding that health workers and patients seldom prefer that label. I also appreciate the article’s finding that ‘patient’ implies the expectation that providers behave in a caring way. This seems consistent with the idea that the term patient implies certain rights–that’s a valuable lesson that I hadn’t thought through until this thread.
One situation in which I’ve found myself more likely to refer to ‘clients’ is when we’re providing services to someone who isn’t themselves the patient, for example educational messaging sent to the mobile phone of a parent, focused on the care of their child. While the kid is patient in this case, the parent is the person we’re providing the service to, and I’ve often referred the parent as a client. This was my initial impression of why the WHO’s Classification of Digital Health Interventions refers to a category of digital health interventions for clients rather than for patients. Though after this thread, I’m realizing that there may have been various other reasons.
@hhornung’s comment beautifully captures the lesson I’m drawing from this thread as a whole. I do feel more drawn to default to ‘patient’ than was the case to date. Yet my background as an ethnographer and a design researcher makes me partial to searching for the words we can use to meet people where they are–be it patient, client, mother, child, community member or health worker.
This has been a very helpful thread for me! Thank you everyone for sharing these ideas.