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Patients, Clients, Consumers: The Politics of Words.

While engaged in the quarterly pleasure reading Families, Systems and Health, in this case the most recent number, subtitled "Special Issue on Consumers and Collaborative Care" (18[2], 2000), I was struck by how strongly that rather recently adopted term "consumer" has lodged itself in our professional language.

Knowing that words are (and are used as) political instruments, I began a frenetic etymological journey as a starting point for disentangling potential language conundrums, exploring the etymological roots and evolving meanings of "consumer" and associated words, shaking in the process the branches of synonyms and antonyms to see whether any succulent fruit may fall from them(1) .

There is a saying in Spanish "A las palabras las carga el diablo" (that is, "Words are loaded by the Devil"). Regardless of the controversial participation of Beelzebub in all this, words, those malleable inhabitants of our social space, far from being pristine(2), are in fact, living things, the evolving product of an interaction between genes and milieu. Words' meanings, therefore, shift with shifts in context. Further, words carry families of meanings, as they resonate with their synonyms: why did we chose this and not that word to refer to a given event, or object, or person; their antonyms: what is the opposite meaning that this word reminds us as a contrast (sometimes a mirror counter-image that bites the tail of the original word); their associative chains: what other utterances come to mind paired to this word; their ethical resonance: what moral order do they evoke; their instructive component: what do they hint us in terms of behaviors; and their emotional context: what passion do they evoke, what memory?

Allow me to share the results of my armchair incursion into the wilderness of semantics as well as some musing that derived from it(3).

To start with, the word consumer derives from the Latin composite cumsumere, that is, to use up, to take up wholly (DEL, DME- please see References for these abbreviations). In its twentieth century usage, a "customer or a patron is a buyer, someone who purchases something from another'(DPWE). When exploring its synonyms, we find "user, buyer, purchaser ... vendee, emptor; shopper, marketer; customer, client, patron, patronizer, regular, Fr. habitue" (SF). But, already in the 1987 edition of RHD, "1.a person or thing that consumes; 2. Econ. A person or organization that uses a commodity or service."

"Aha! `A person who uses a service' fits the current meaning of `consumer' in the lingo of health," we could rush to propose. Even further, we could argue that the usage of that word has been inspired by the noblest of contexts, the socially responsible Consumer Movement, namely "A modern movement for the protection of the consumers against useless, inferior, or dangerous products, misleading advertisement, unfair pricing, etc...." (RHD). (Please also see Frank's, 2000 lucid article on the subject in the above mentioned issue of this very journal.) That movement not only advocated on behalf of the weak, the helpless, and the suckers, but championed their cause by actively defending them. For that purpose, it created the role of the consumerist, "also called consumer advocate, a person who is dedicated to protecting and promoting the welfare and rights of the consumers...."(RHD).

However, that role and that description, when applied to the field of health, entailed a powerful sleight of hands: it transformed the patient-professional dyad into an unholy triad, as it carries with it the assumption that there is an implicitly dangerous, exploitative relationship between a naive consumer(4), who needs protection by a benign advocate(5) against a conniving exploiter(6). And who, pray, are the actors that represent these three characters in the current mental health scenario: the (until recently called) patient, the (recently created) managed care representative and the (until recently called) doctor, or professional, now called provider.

Before exploring who had responsibility for this script, with the inherent debilitating effect of the unavoidable interest on the part of the benign advocate to maintain his own role--and salary--by maintaining the other two as conniving and as naive, I would like to add a footnote to the erudite discussion of the above-mentioned article by Frank (2000). The Consumer Movement had for many years a rather meek presence in the field of mental health, its terrain being at the most prepared by denounciations such as Clifford Beers' early autobiographic account (1939) of his vicissitudes as psychiatric patient, and movies such as "The Snake Pit" and "One Flew over the Cuckoo's Nest." The Consumer Movement expanded exponentially thanks to the ferment of the Civil Rights movement, and gained added strength with the romantic anti-psychiatric discourse of the '60s and the widespread consumer empowerment of the '70s. In the field of mental health the most visible exponent of that movement has been the National Alliance for the Mentally Ill (NAMI), founded in 1979 as a grass-roots coalition of patients and families of patients diagnosed with schizophrenia. NAMI was in its origins reacting reasonably to the family bashing experienced by relatives of patients with schizophrenia exposed to professionals' behavior congruent with the dominant psychoanalytically oriented approach that was dominant in the psychiatry of the `60s and early `70s. Closer to home, family therapy approaches were equally family blaming, at least until the message of the psycho-educational approaches helped us to think otherwise. To that family-as-a-cause-of-the-problem ideology, NAMI countered by espousing a biology-is-all disease argument. The basic ideological stance of that organization, as it profiled in the past fifteen years, has been that schizophrenia is a brain disease, genetic in origin, with families playing no role in its development or maintenance, and amenable only to biological and educational treatment (Cf., e.g., Mosher and Burti, 1989). In its quest, NAMI found staunch allies? in the powerful biologically oriented contingent of the traditional psychiatrists' organizations.

Another unexpected and generous ally of NAMI has been the most profitable -- and tax-wise heavily sheltered-- industry in the United States (Angell, 2000), the pharmaceutical industry. The drug manufacturers provided and continue to provide generous subsidies to NAMI, which, not surprisingly, became a powerful lobby advocating a biological focus for mental health practices. To complete the circle, the pharmaceutical industry also subsidized the main psychiatric organizations until they became dependent on those monies. In fact, currently, both the American Psychiatric Association's Annual Meetings and NAMI's infrastructure itself would have an uphill battle to maintain its current structure without the drug industry's subsidies. The pharmaceutical companies, in addition, have become the major economic supporters and, in many cases, the actual shadow creators, of a variety of currently mushrooming organizations that are, or appear to be, consumer-oriented. All these organizations voice a biologically-oriented approach to the understanding and treatment of depression, obsessions-compulsions, phobias, PTSD, and many others. Not surprisingly, all those seemingly grass-roots organizations have adopted a biologically oriented ideology and are strong supporters of pharmacological treatments of most psychiatric disorders (for which psychotropic drugs have been revolutionary) ... and most human foibles(8).

An ideological disclaimer of this author is in order here. I am a strong supporter of the Consumer Movement in the fields of health and mental health; we professionals need patients' watchdog organizations to keep us clean, focused, and less arrogant. I have been a supporter of NAMI in word and action (and even a proud recipient of an "Exemplary Psychiatrist" Award from that organization). I am also in support of guild organizations, each one caring for the wellbeing of its professional members. What I am highlighting here is the dangerous alliance of those organizations with the pharmaceutical industry, which has strongly penetrated with a benefit-based ideology and language, both the Consumer's Movement and many professional organizations and is undermining, as I will discuss below, the very nature of the healing encounter. As another, rather fatalistic, Spanish proverb, generally applied to mismatches and other relational fascinations goes: "Dios los cria, y ellos se juntan" (God creates them and they manage to find each other).

The picture of this complex reality should be further muddled by adding a third, even more powerful, economic group that has been playing an increasingly central role in the field of health, namely, the insurance industry and their representatives or partners, the managed care companies. For the record, managed care companies are for-profit concerns placed in between the insurance carrier and the health professional, with the aim of reducing expenses by controlling the nature of the doctor-patient, or healthcare specialist-customer relationship, governing at a distance not only the economic side of that relationship, as they arguably are supposed to do, but deciding at a distance who is going to provide which service and for what. At the service of this task, the managed care industry has been the main, and rather successful, advocate for the currently in vogue use of the words "provider" and "consumer," the former a term that encompasses generically all those who interact professionally with a consumer of healthcare services, namely, the patients or clients. This interplay of economic interests has contributed substantially to the paradigmatic shift in medicine marked by the resurgence of a biomedical model (Eisenberg, 1986; Glenn, 1988)at the expense of the struggling bio-psycho-social paradigm (Engel, 1977).

The word provider has a rather fuzzy meaning. It has its roots in the Latin providere (before-see) to foresee (hence Providence but also provision--referring to eatables--and, indeed, provisional) (DEL, DME). Its synonyms are rather telling: "1. Supporter, ... head of household, breadwinner ... Informal: one who brings home the bacon; 2. Patron, giver, donor, contributor, backer, funder, angel, bestower ... Informal: Sugar daddy. 3. Supplier, furnisher, procurer, purveyor, provisioner, caterer" (SF).

What could be the interest of the managed care industry in favoring the new meaning of the word, namely, "all those who provide services to patients." I can see only one answer: to de-differentiate the different professions within the health team, blurring the boundaries of the specific body of knowledge and wisdom that evolved over time for each profession within the healthcare team. Interestingly, it is precisely the existence of that specificity, with areas of overlapping, indeed, that allows for cross-disciplinary collaboration. By de-expertizing they are able to reduce payments for professional services across the board, and to reduce the role of the most costly professionals, loading the lower cost professionals with activities carried on before by the others. "Most costly" means here MDs, and "lower cost" means nurse practitioners, marriage and family therapists, and social workers, with psychologists inhabiting an intermediate zone. The reason is purely economic--and not in the actuary sense of a rational organization of healthcare, but in the more blatant one of the managed care industry making money for their own for-profit organizations' coffers(9).

Another word that competes timidly with "customers" in the semantic market is the term client. In fact, some members of an interdisciplinary team, especially those clinicians without a doctorate, such as the MFTs, may prefer to refer to people who consult with them as "clients" rather than "patients:" the word "patient" evokes in the public mind the complementary word "doctor." And while there are colleagues with a doctorate in nursing, in social work, and in psychology, still the word "doctor," "anyone who has been granted a doctor's degree" (DPWE), evokes in the public the image of an MD. In fact, the word doctor derives from the Latin docere, to teach, and was originally applied to great scholars--St. Thomas Aquinas, for instance, was called Doctor Angelicus, but since middle ages has been used to refer mainly to the doctors in medicine (DME). "Client," in turn, has been used to refer to "1. A person or group that uses the professional advice or services of a lawyer, accountant, advertising agent, architect, etc.; 2. A person who is receiving the benefits, services, etc., of a social welfare agency, a government bureau, etc.; 3. A customer...." (RHD)(DPWE). Its synonyms expand the collage: "1. Customer, patron, patronizer, regular, ... buyer, purchaser.; 2. Dependent, follower, protege, student, pupil, disciple, attendant, supporter, backer, adherent"(SF). While potentially evoking a variety of associations utterly unrelated to the healing practices, there is nothing in that word's resonances that would lead to question its use. In fact, "client" comes from the Latin cluere, to listen--originally, one who listens to advice, in turn derived from the Greek "to hear" (an alternative etymological hypothesis relates it to clinare, to lean, such as in "inclination," to lean toward) (DEL, DME). It could be argued, hence, that, for the sake of the team harmony in interdisciplinary practices and collaborative healthcare, we may chose to transform patients into clients. However, when nobody is listening, I will still refer to the people who consult me professionally as patients. After all, patient is" A person who undergoes medical care or treatment...." (RHD).("Patient" derives from the Latin pati, to suffer. The patient is he or she who suffers [DEL, DME]. Browsing into its family of synonyms, we can find "sick or ill person, infirm person, hospital case, case; asylum inmate, convalescent, outpatient, shut-in, valetudinarian; sufferer, victim." Other associations of the word "patient" or "patience" leads us to the sets enduring/stoical; serene/placid, and tenacious/unremitting [SF]).

Summarizing, while "patient" may be etymologically the most appropriate word to refer to those who consult us for reasons of dis-ease, its usage may be questioned mainly in terms of its evoking the guild-based, perhaps potentially exclusionary, notion of "doctor" in the sense of "MD.(10)" "Client," in turn, while evoking a mixed counter-role of "advisor," "seller," and "guru," may be more palatable for the different members of an interdisciplinary practice. But both terms, patient and client, appear to risk extinction, vacated by the new terminology. And that brings me back to the subtitle of the latest issue of this very journal. By accepting uncritically the term "consumer," we may find ourselves sliding down a slippery slope, co-opted by the insurance/managed care multi-billion dollar industry, by the pharmaceutical multibillion dollar industry, and perhaps by the guild interests of some independent practitioners traditionally less compensated for their services. That trend leads to the revival of the partition of the patient/client, a painting-by-the-number dismemberment of people into body (the territory, but in a short consult, please, of the internist, generalist, family practitioner, family nurse practitioner, and nurse), the brain (the biological substratum of "the mind," under the care of the psychiatrist turned psycho-pharmacologist), the psyche (evaluated by the psychologist turned psychometrician), the meaningful others (managed by the nurse or by the marriage and family therapist or counselor), and the social stuff out there (managed by the social worker or the case worker).

The argument used by the insurance/ managed care industry and by many politicians who support, and are supported by it to justify its existence is that the finite pie of health expenditures is excessive, and growing(11). If we expand our view to obtain a broad point of comparison, the U.S., 2nd among all developed nations in terms of GDP Index (the #1 is tiny Luxembourg) and 1st in terms of % of GNP devoted to military expenditures, ranks 23rd in terms of life expectancy at birth, 27th in terms of infant mortality rate. And, as a coup de grace, comparing this time only the 15 most developed nations, the U.S. ranks 7th in terms of percentage of GNP spent on health (UNDP, 2000). In fact, and against the tapestry of the unprecedented profit of both the pharmaceutical and the insurance industry, the quality of care and of services in the US continues to erode and the gap(12) between services for the wealthy and insured and for the poor and uninsured continues to increase.

There is something very disquieting in this whole macro-picture--that is the effect of questioning terms that keep the context out of focus. If we choose to remain complacent with words "loaded by the Devil," we risk maintaining over our eyes and minds the veil of mystification(13) that helps us not to see.

(1) Funny words, "conundrum" and "frenetic" (and its cousin "frantic"), the former a whimsy term that had its origins in the slang of British Universities' spoofs, probably parodying a Latin scholastic phrase, and the latter rooted in the Greek frenitis, i.e., "inflammation of the brain!"

(2) From the Latin pristinus, "ancient," derives its current meaning of "innocent," i.e., "uncorrupted by civilization."

(3) "Musing," by the way, shows two possible Latin etymological roots: "To meditate inspired by the Muses," or "To loiter." You, the reader, will have to decide which applies here.

(4) "Naive" is the feminine of the French naif, meaning natural, simple, in turn from the Latin nativus, native, as in "I'll give you glass beads, you give me gold."

(5) "Benign" derives from the Latin benus, good, and genus, born, that is, "born good" or "born to do good."

(6) "Conniving" has a cute etymology. It comes from the Latin cum, together, and niguere, to wink, that is, to signal complicity, or to turn a blind eye.

(7) "Staunch," originating in the Latin stagnare, "stopping the flow of blood," to move later from the healing arts to the nautical world, with the meaning "water tight," and then to the metaphoric realm of "tight," as is its current use.

(8) "Foibles" originates in a mispronunciation of the French faible, "weak," imported probably during the era of splendor of the Sun King, when all that was French was fashionable for the English nobility.

(9) A more conciliatory approach to managed care and its interface within the healthcare system can be found in Dohert and Heinrich (1996).

(10) The MD's centrality in the healthcare team has been both highlighted and questioned in many venues, including this journal. The "doctor's power" has also been underlined, both in its oppressive and its empowering side (Goodrich and Wang, 1999).

(11) According to an unpublished but widely cited managed care outcome study by Rosenheck et al. at Yale University (cf. DHHS/NIH, 1998), managed care has been able to reduce the utilization of mental health services by 44% but, at the same time, that population increased absenteeism by 22% and utilization of medical services by 36%, offsetting any actuary benefit. There are other studies of the effect of managed care, but most of them have been paid for or controlled by that industry itself, and therefore cannot be taken at face value.

(12) A word of remote Icelandic origin, meaning "abyss."

(13) "Mystification," by the way, is a modern concoction, from the Greek mytos and the Latin ficare, that is, fable-making.

REFERENCES

Angell, M. (2000): The Pharmaceutical Industry -- To whom it is Accountable (Editorial). New England Journal of Medicine, 342 (25): 1902-04.

Beers, C.W. (1939): A Mind that Found Itself. New York, Doubleday.

Dohert, W.J. and Heinrich, E.L. (1996): Managing the Ethics of Healthcare: A Systemic Approach. Families, Systems and Health. 14(1): 17-28.

Engel, G.L. (1977): The need for a new medical model: a challenge for biomedicine. Science, 196: 129-36. (See also the Special Section dedicated to Engle and his work in Families, Systems & Health, Vol. 14, No. 4, 1996).

Eisenberg, L. (1986): Mindlessness and brainlessness in psychiatry. British Journal of Psychiatry, 148: 497-508.

Frank, A.W. (2000): All the things which do not fit: Baudrillard and Medical Consumerism. Families, Systems and Health, 18(2): 205-216

Glenn, M. (1988): Random Notes: The resugence of the biomedical model in medicine. Family Systems Medicine, 6(4): 492-500.

Mosher, L.R. and Bueti, L. (1989): Community Mental Health: Principles and Practice. New York, W.W.Norton.

The Random House Dictionary of the English Language. Second Edition_ Unabridged. New York, Random House, 1987. (RHD)

Rodale, J.I: The Synonym Finder. Emmaus, PA, Rodale Press, 1978. (SF)

Rosenthal et al. (1998): Unpublished Study, cited in Department of Health and Human Services, National Institute of Health Publication No.98-4322, 1998.

Shaw, Harry: Dictionary of Problem Words and Expressions. Revised Edition. New York, McGraw-Hill, 1987.(DPWE)

Skeat, W.E.: Etymological Dictionary of the English Language. New York, Perigee, 1980 (DEL)

UNDP (United Nations Development Program): Human Development Report 2000. New York, Oxford University Press, 2000.

Weekley, Ernest: An Etymological Dictionary of Modern English. London, Dover, 1960 (DME)

Carlos E. Sluzki, M.D., Director, Center for Psychiatry and Behavioral Healthcare, Santa Barbara Cottage Hospital, Pueblo at Bath Street, Santa Barbara CA 93102-0689; email: cslnzki@sbch.org.
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Author:SLUZKI, CARLOS E.
Publication:Families, Systems & Health
Date:Sep 22, 2000
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