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Patients, clients, users or customers: what should we call people attending sexual health services?
  1. Joanna Loudon1,
  2. Aisling Baird2,
  3. Zara Haider3,
  4. Eleanor Sein4,
  5. Indhu Prabakar5,
  6. Ailsa Gebbie6
  1. 1Medical Student, NHS Lothian Family Planning Services, 18 Dean Terrace, Edinburgh, UK
  2. 2Subspecialty Trainee in Sexual and Reproductive Health, Centre for Contraception and Sexual Health, Victoria Health Centre, Nottingham, UK
  3. 3UCL Partners Darzi Fellow and Subspecialty Trainee in Sexual and Reproductive Health, NHS Camden Provider Services, The Margaret Pyke Centre, London, UK
  4. 4Medical Student, NHS Bristol Sexual Health Service, Central Health Clinic, Bristol, UK
  5. 5Subspecialty Trainee in Sexual and Reproductive Health, Liverpool Community Health/Liverpool Women's Hospital, Sexual & Reproductive Health, Liverpool, UK
  6. 6Consultant Gynaecologist, NHS Lothian Family Planning Services, 18 Dean Terrace, Edinburgh, UK
  1. Correspondence to Ms Joanna Loudon, NHS Lothian Family Planning Services, 18 Dean Terrace, Edinburgh EH4 1NL, UK; j.loudon-2{at}sms.ed.ac.uk

Abstract

Background and methodology In sexual health clinics there is debate on whether to call service users ‘patients’ or ‘clients’ and this mirrors an ongoing dialogue in the medical literature. The authors undertook a questionnaire survey in five UK centres of clinic attendees and staff to assess their preference.

Results 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 difference between preference for ‘patient’ between doctors and nurses was statistically significant, with most doctors preferring the term ‘patient’. Out of a total of 84 nurses, there was equal preference for ‘patient’ and ‘client’ (38 nurses in each group). Comments from attendees and staff who responded generally emphasised the concept of the ‘caring’ role of the health professional towards people attending the services.

Discussion and conclusions 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. The authors therefore conclude that the terminology in sexual health services should revert to predominantly using the term ‘patient’.

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Background

The ‘labels’ we use for the people we care for as health professionals, both collectively and individually, are thought to be important and should reflect the services we provide for them. The Oxford English Dictionary defines a patient as “a person receiving or registered to receive medical treatment”1; the origin of the word ‘patient’ being derived from the Latin patiens meaning “I am suffering”. The traditional concept is of a patient ‘suffering’ and being a supplicant in the contract between the ill person and the health professional.

Key message points

  • There has been a recent trend in UK sexual health services to call people who use these services ‘clients’ rather than ‘patients’ on the grounds that they are not ill.

  • Overall in this study, people using these services and staff working there preferred to retain the term ‘patient’, and the main justification for this was that this term embodied the concept of ‘caring’.

It has been debated for some time that people attending sexual health services in the UK for contraception and for testing and treatment of sexually transmitted infections should not be called ‘patients’, as attendees are generally well people. Most do not attend in the context of ill health or ‘suffering’. Belfield comments that patients, consumers, users and clients are all terms used for men and women who attend for sexual health services: in her writing she uses the word ‘consumers’ for consistency.2 There has been no universal agreement about what attendees should be called but the discussion has led to some UK services and sexual health agencies wholeheartedly adopting the term ‘client’. Many people feel the term ‘client’ has overtones of a business relationship, which sits uncomfortably with the health professionals' role.

There has been a move away from the traditional paternalistic model of medicine over several decades towards the idea of partnership with patients, emphasising the holistic nature of health care and the role of the patient as an individual. The increased influence of psychology and sociology, the psychosocial model of illness, the attack on medical hierarchy and early sociological work in the 1940s suggesting that the sick role was in some way stigmatised, have all stimulated debate over the terminology of ‘patient’.3 4 There is a sentiment that the usage of the term ‘client’ empowers the patient.4 The discussion has reached the literature of psychiatric and traditional medicine.5 6

The debate remains alive. We designed and administered a questionnaire to discover what people who use these services would like to be called and what the staff members who work within these services wish to call them.

Methods

Participants

Questionnaires were completed by people attending sexual health services and their staff in five centres in the UK (Edinburgh, Nottingham, London, Bristol and Liverpool). Attendees were given the questionnaire by clinic receptionists on their arrival and asked to complete it prior to their consultation. Staff members were both e-mailed the questionnaire and given a paper copy.

Design

A brief questionnaire was designed in which men and women attending sexual health clinics were asked to select the preferred description from a list including ‘patient’, ‘client’, ‘customer’ or ‘user’. Respondents were also given the option to state that they had no preference or suggest another name and were asked to state their age, sex and the type of clinic they were attending.

The questionnaires administered to staff members gave definitions from the Oxford English Dictionary of ‘patient’, ‘client’, ‘customer’ and ‘user’ and asked staff to state their preferred term for people attending clinics. Members of staff were asked to state their professional group as ‘doctor’, ‘nurse’ or ‘administration and clerical’. Both questionnaires provided space for free-text comments to be written.

Setting

Clinics were a mixture of family planning, genitourinary medicine (GUM), integrated services and other specialist clinic services. Questionnaires were distributed to people attending the clinics during a 1-week period between May and September 2010 depending on the location. Members of staff were asked to complete the staff questionnaire in the same week. The questionnaire was piloted with clinic attendees in the Edinburgh centre prior to the commencement of the study. Formal ethical committee approval was unnecessary for a service evaluation questionnaire study of this type and this was confirmed by a local ethics committee chairperson.

Analysis

A calculation was made of the proportion of doctors preferring by dichotomous variable (yes/no) the term ‘patient’, compared with the proportion of their nursing colleagues. To assess the significance of this difference, a Chi-square (χ2) test was used at one degree of freedom, and the p value was determined.

Results

The total number of responses received from attendees at the sexual health clinics was 1428. The response rate was consistently high but varied from 88% to 100% between the centres with a mean response rate of 89% (1429/1606 attendees offered the questionnaire).

Figure 1 shows the responses from the 1428 attendees at the sexual health clinics. Of those who responded, 874 (61%) stated that they would prefer to be known as a ‘patient’ when attending the clinic, 328 (23%) had no preference and 134 (9%) wished to be referred to as ‘clients’. Only 2% wished to be either ‘customer’ or ‘user’, respectively. Other terms suggested by people attending the clinics included ‘guest’ and ‘visitor’.

Figure 1

Overall attendee and staff preferences.

There were no significant differences between men and women in the terms preferred. However there was an interesting trend of the term ‘client’ being acceptable as first choice to only 7% (24/328) of those aged 13–20 years but rising consistently with age to 19% (10/52) of people aged over 50 years.

Although the numbers were extremely small, all attendees at colposcopy and sexual problems clinics (n=13) wished to be known as ‘patients’. People attending designated HIV clinics had the highest preference to be called ‘clients’, with 42% (n=5/12) selecting this option.

Six per cent of clinic attendees (n=86) wrote a free-text comment. All additional comments were, except one, from women and were mainly from older attendees. A selection of the written comments is shown in Box 1.

Box 1

Selected comments from clinic attendees

  • “I think that patient sounds professional and that is how I like to be called.” (Female, 35 years, Nottingham)

  • “Although you are not actually ill when you come to the clinic, I believe using a different term would give patients the idea they were not seeing properly trained staff.” (Female, 32 years, London).

  • “I detest the idea that people using the NHS are customers or clients.” (Female, 35 years, Edinburgh)

  • “Are you selling something or am I buying something? Customer and client takes away the caring feel.” (Female, 25 years, Liverpool)

  • “Customer suggests we are buying a product so I would not like to be referred to as this. Client makes it too formal and user has connotations of taking drugs. Patient is the most relevant word to use.” (Female, 20 years, Edinburgh)

Questionnaires were returned by 250 members of staff (Figure 1). The response rate varied depending on the centre with a mean overall rate of 62% (250/403 staff offered the questionnaire completed it). One hundred and forty-eight (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 staff preferences according to profession are shown in Figure 2. Of 72 doctors, 52 preferred ‘patient’ compared with 38/84 nurses. This was statistically significant (χ2=11.85, p=0.001; 1 df). The numbers of nursing staff preferring ‘patient’ versus ‘client’ was equal (38 nurses in each group out of 84 in total).

Figure 2

Staff preferences according to profession.

Thirteen free-text comments were made by staff (5% of total). Selected comments from staff are shown in Box 2.

Box 2

Selected comments from staff

  • “Client – sounds like a prostitute and solicitors have clients. Customers – refers to having your car serviced. User – sounds like a drug user.” (Nurse, Nottingham)

  • “Any individual seeking consultation from a health care professional is a patient, hence this must be retained.” (Doctor, Liverpool)

  • “Clients and customers sounds like money should change hands.” (Clerical staff member, Edinburgh)

  • “Call them patients but think of them as customers.” (Doctor, London)

Discussion

Although modern sexual health clinics in the UK have developed from a background of very traditional family planning and GUM clinics, they are among the most forward looking and innovative National Health Service services and aim to offer holistic and de-stigmatised care to a wide range of people. The World Health Organization defines sexual health as a state of physical, mental and social well-being in relation to sexuality.7 To our knowledge, there has been no other published study conducted within sexual health services to address the issue of what is an acceptable term to call people who access these services. This study was conducted in five sexual health services across the UK and showed very consistent findings. For this type of questionnaire, we had a high response rate from both attendees and staff but clearly there could still be bias as those with strong feelings may have been more likely to complete the questionnaire.

Various arguments have been put forward as to why the word ‘patient’ should or should not be used in the modern health care setting. Naseem et al.8 addressed this issue in the field of mental health, finding that people attending a psychiatric clinic prefer to be called ‘patients’ above anything else. Ramdass et al.9 carried out a study across medical disciplines in the developing world, again finding that 80% of people prefer to be referred to as ‘patients’. In an HIV/AIDS Innovative Model of Care Knowledge Base there is distinction drawn between the use of the term ‘patient’ to cover agencies providing medical care and use of the term ‘client’ to cover those providing predominately psychosocial services.10 Ratnapalan discusses the role of levels of illness severity as a continuum, and whether certain categories of suffering naturally engage the term ‘client’. He argues cogently for the retention of patient across all grades of illness and well-being.5

Finally, it should be noted that the term ‘client’ has an ancient Roman origin from the term cluere (to listen, follow or obey) and described a person of lowly status and of a moderate kind of slavery, dependent upon a benefactor and at the call of his patron.11

Conclusions

The majority of people attending sexual health clinics and the staff working in these services overall expressed a clear preference to retain the title of ‘patient’. The main justification for this appeared to relate to the concept of caring for people. The other suggested titles had alternative and negative connotations and were often linked to financial transactions such as found in commerce and industry.

Unless another, novel word can be identified and used in the future, we suggest that the current terminology (usage of the term ‘patient’) should be retained within the context of sexual health as other titles are less acceptable. The connotations of words do change over time and perhaps waiting for a semantic drift in the precise meaning of the word ‘patient’, rather than adopting a new term, should be the approach taken to resolve this issue in the future. Following this survey, one sexual health service has reverted to calling their attendees ‘patients’ again and adopted the word ‘patient’ in patient group directions and in-house leaflets.

In conclusion, there seems to be an overwhelming preference for the preservation of the word ‘patient’ in sexual and reproductive health, rather than adoption of any alternative term. What matters most of course is how we as health care professionals treat the person in front of us.

Acknowledgments

The authors would like to thank Toni Belfield (Specialist in Sexual Health Information) and Professor Anna Glasier for constructive comments during the preparation of the study and both Charles Loudon and Fiona Cowan for help with data collection and analysis.

References

View Abstract

Footnotes

  • Competing interests None.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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