Are you a Patient, Consumer, or a Client? Or Something Else Entirely?

If you haven't gathered by now, I'm a big fan of John McManamy's work.  If you don't know McManamy, he's a patient advocate who's articulate, intelligent, and knowledgeable about the science of mental illness.  He is an unapologetic critic of much of the psychiatric establishment.

One of his articles concerns the use of the word "consumer" to describe those of us who live in the mental health morass.  McMamany decries the use of this word mainly because "consumers" have choices.  Most mentally ill people have very little choice in the services we receive and the medication options available to us.  Moreover, he points out, "consumers" are usually consulted as to their needs and wishes, and their experience with the product.  He writes:

"Tell me, when was the last time someone invited you to participate in a Risperdal or Abilify focus group? When was the last time your psychiatrist asked you to fill in a customer satisfaction survey?"

The answer, of course, is "never".  We are not Big Pharma's customers, the health insurance companies are.  We are not the insurance companies customers, employers are.  Your employer does not give you a choice in insurance providers -- some of them only offer minimal coverage, others only offer coverage through one specific HMO, and others will give you a choice between one specific HMO and one specific PPO.  That, of course, assumes that your employer provides health insurance at all.  Or maybe you rely on an underfunded, overstaffed public program.  Or maybe you're unemployed and uninsured.  How much choice do you have then?



Which brings me to my own issue with the word "consumer".  As McManamy says, the word implies we have some choice.  I also believe it assumes a fair bit of privilege.  To me, the word "consumer" implies a certain, desirable demographic -- middle class or upper middle class.  Those who are just scraping by, living hand to mouth, they don't have much purchasing power, and they don't have much, if any, choice.  They're not a "consumer demographic" that anyone concerns themselves with.

McManamy prefers the word "patient" to consumer.  I can see why; it, at least, implies that our care providers have some responsibility to us.  Personally, I admit to seeing myself as my doctor's "patient" rather than his "consumer" (I don't eat him with a side of greens, after all).  But a lot of people don't like to think of themselves as "patients", and I don't blame them.  It's another word with an implied hierarchy.  Doctors take care of patients.  Patients do what their told.  Patiently.

My mother spent many years in the field of health care policy, and she remembers the shift to the language of "consumer" instead of "patient".  The hope was (and I'm not sure how well this was ever realized) that by thinking of themselves as "consumers", people would educate themselves about their health care options and learn to question their doctors' decisions.  It's been well-established that the crankiest "patients" get the best care.

 Personally, I advocate the use of the word "client".  It's a word that is used in the law, in which the "client" retains the services of a qualified expert, in this case a lawyer, for a specific purpose delineated by the client.  The lawyer consults with and advises the client on how best to achieve the client's goals.  The lawyer does not dictate to the client

It's telling that this word is also often used by therapists, who are generally into encouraging things like autonomy and self-efficacy.  I don't think I've ever heard a therapist refer to "my patients" (and certainly not "my customers" or "my consumers!") -- possibly because this is a privilege reserved for MDs.  In spite of my pdoc's MD, I think I could revision our relationship as one of expert/client instead of doctor/patient.