patient vs. client

[Manicsleep]

One of the places we contract with is thinking about changing their handouts to call behavioral health patients 'clients' and when we found out about it we were not very happy. They are willing to listen but they have apparently been told that being called patient is somehow a bad thing to do.

I feel the exact opposite. I wanted to see what other people felt about this. I did a search and didn't see this discussion. Also, if I am wrong and client really is the better way, I want to know why.

I have strong reservations about the word client and the word has a dirty connotation for me. I agree that we are also in a business but that is not our only job or perhaps even primary job. If someone's health is in danger, I am obliged to help them and not worry about billing.

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[billypilgrim37]

I am pretty adamant about calling the folks I see patients. I can absolutely appreciate the 'client' or 'consumer' terms, because the attitude involved with using these terms involves empowering the patient to make choices and have a strong voice in their care. But if I wanted to work with clients, I would have gone to law school or got an MBA. I went to medical school. The patient-physician relationship is something we think is special, and we spent a lot of time internalizing our role in that relationship. I feel an obligation to a patient, but I don't think I owe a client anymore than the guy at the Verizon store owes me when he sells me a Droid.

I don't mind when other mental health providers call their folks consumers or clients. But I don't feel comfortable with it. The relationship implied by 'client' does not imply the sort of relationship where I have the legal obligation to involuntarily commit someone if they are in danger due to their illness.

 

[Doc Samson]

Huge pet peeve of mine -

This all started out with the move away from language thought insulting to patients. Can't publish an article anymore if you say "the patient suffered" or "was a victim of". Not even PC to say "comorbid" anymore.

The latin root of patient is "patiens" - one who suffers, thus the move to client. However, the latin root of client is cliens - a plebian sponsored by a patron benefactor. Sources differ as to the derivation of the word - some say it is a corruption of cluens (to hear, because they were at the beck and call of their patron) or if it's the other meaning of cliens (one who leans or relies upon).

To my mind, it's far more demeaning to tell someone they're either:

a) at my beck and call

or

b) relying upon me

than

c) suffering

This, of course, doesn't even begin to get into the fiduciary responsibilities of the doctor-patient relationship that "clients" or "consumers" aren't entitled to. I remember reading an article a very long time ago that described the gradual erosion of medical ethics in post-WWI Germany that ultimately resulted in the crimes of Mengele et al. The authors made a great argument that it could all be traced back to German medicine transitioning to more of a business like relationship with their "clients."

 

[OldPsychDoc]

Only the third post in the thread and we have to invoke Godwin's Law?

Huge pet peeve of mine -

This all started out with the move away from language thought insulting to patients. Can't publish an article anymore if you say "the patient suffered" or "was a victim of". Not even PC to say "comorbid" anymore.

The latin root of patient is "patiens" - one who suffers, thus the move to client. However, the latin root of client is cliens - a plebian sponsored by a patron benefactor. Sources differ as to the derivation of the word - some say it is a corruption of cluens (to hear, because they were at the beck and call of their patron) or if it's the other meaning of cliens (one who leans or relies upon).

To my mind, it's far more demeaning to tell someone they're either:

a) at my beck and call

or

b) relying upon me

than

c) suffering

This, of course, doesn't even begin to get into the fiduciary responsibilities of the doctor-patient relationship that "clients" or "consumers" aren't entitled to. I remember reading an article a very long time ago that described the gradual erosion of medical ethics in post-WWI Germany that ultimately resulted in the crimes of Mengele et al. The authors made a great argument that it could all be traced back to German medicine transitioning to more of a business like relationship with their "clients."

 

[Ibid]

Desperately trying to find the most positive sounding generic term which every one can subscribe to is laudable but ultimately diminishes the autonomy of the individual.

What is important is understanding why any particular word is used in any given context, including words used by professionals or people seeking self definition or reclaiming words.

The right word for a generic handout may not be the right word for an invoice, just as the right work for case notes may differ again.

Most of the relationships people have with staff of mental health care providers are not doctor patient relationships but other professionals. That may be one reason to use a different generic term. Not that the word patient is wrong, just inappropriate if the service user really only ever sees a social worker or nurse.

I find the word, people, works in nearly every case. When it does not service user is the generic term that I use.



Doc Sampson
If you ever come across that article I would live to see it. I have never come across quite that take. If I always thought hospital admins, propaganda, a resource squeeze and the state where the major conduits along with a few evil people who happened to be physicians.

http://www.regent.edu/acad/schedu/uselesseaters/text/2743414051_1.pdf

For balance "he of the black dog" (his depression) When he was a cabinet minister in 1910 Churchill wrote to the Prime Minister (Asquith) noting that:
"'the unnatural and increasingly rapid growth of the feeble-minded and insane classes, coupled as it is with a steady restriction among all the thrifty, energetic and superior stocks, constitutes a national and race danger which it is impossible to exaggerate".

 

[Doc Samson]

Only the third post in the thread and we have to invoke Godwin's Law?

I like to be more meta than that - I'm quoting someone else who invoked Godwin's Law

 

[Manicsleep]

I tried looking at a few studies and for the most part the term patient was preferred by persons with mental illness. I think this would be higher in an inpatient setting when being seen by physicians.

To the etymological origins: This has been thrown around a little bit although I have never bothered to learn the meaning of the origins of 'client.' Now that I looked it up and read Samson's post I really don't see how that plays to the favor of 'client' at all.

There is also a contention that 'patient' implies that they are supposed to not complain (the verb form of the word not the noun) which creates a power differential. Also, it makes us equal with other professions like lawyers etc. But I don't like those arguments because we use the noun form of patient and most people go through ethics courses talking about paternalism etc.

I also like billy's argument that I really don't want to be equal with other professions in the sense that its a transaction where I provide a service and the client gives me money. True especially of certain very old professions.

There is more to healthcare than money and I did internalize that. I see healthcare as a right and the Doctor-Patient relationship is part of that. Thanks for the input.

 

[loveoforganic]

I'm not sure where I've gathered this impression, but for some reason patient is in my mind as "the one treated by a psychiatrist" and client as "the one treated by a psychologist," with psychiatrist taking priority if treated by both. Maybe the push for terming them clients just started in the psychological community (wouldn't be hard to believe).

At any rate, going back to the etymological roots of a word to determine the right one to use seems awfully silly. Words change.

(insert image of harley riders from southpark here. All of the image URL's have f** in them, so can't post)

 

[Manicsleep]

I'm not sure where I've gathered this impression, but for some reason patient is in my mind as "the one treated by a psychiatrist" and client as "the one treated by a psychologist," with psychiatrist taking priority if treated by both. Maybe the push for terming them clients just started in the psychological community (wouldn't be hard to believe).

At any rate, going back to the etymological roots of a word to determine the right one to use seems awfully silly. Words change.

I would agree that the roots of the words shouldn't be important but when its given as a reason for changing labels, it becomes part of the conversation. Basically, its important if people think its important. I think the idea that patients are supposed to sit back and wait without complaint (patiently) is ridiculous and all of us have seen patient's rights notices etc. We have also all gone through ethics courses and they are integral in our day to day practice whether we realize it or not.

 

[Therapist4Chnge]

I'm not sure where I've gathered this impression, but for some reason patient is in my mind as "the one treated by a psychiatrist" and client as "the one treated by a psychologist," with psychiatrist taking priority if treated by both. Maybe the push for terming them clients just started in the psychological community (wouldn't be hard to believe).

I've never seen the person receiving treatment called anything but a patient in a hospital (or Veteran in a VA). I've seen some people want to push "consumer", though I think is a poor framing of the relationship.

 

[loveoforganic]

I've never seen the person receiving treatment called anything but a patient in a hospital (or Veteran in a VA). I've seen some people want to push "consumer", though I think is a poor framing of the relationship.

I said I don't remember where I gathered that impression I want to say it was from one of my psychology professors, but I really don't remember anything specific

 

[kugel]

I definitely use "patient."
The same person is often a "client" of other providers and a "consumer" of services from the public mental health system, but he is a "patient" of mine and I am his "physician" today.

That relationship gives him rights and protections, and it means that I will NOT do things that I believe are significantly against his health interests - even if he demands them. Unlike a lawyer who is bound to refuse an excellent plea offer if the "client" rejects it, or a salesman who is happy to sell a product known to be dangerous when used as the "consumer" intends - I cannot do those things. But I truly enjoy negotiating a treatment plan that we can both live with. I will do everything I can to achieve the outcome the patient desires and in the manner he desires - within the boundaries of ethical and legal practice of medicine, and without jeopardizing other "patients," since I have an equivalent duty to them.
"Jeopardizing other patients," would be things like:
- permitting immediately dangerous conditions around other patients, or
- putting the system/hospital in jeopardy of having its doors closed to future patients, or
- losing my license and therefore my ability to help future patients, or
- providing treatments that are ridiculously expensive without good cause since that unnecessarily drains the money needed to treat others.

 

[Manicsleep]

The more I think about it, research it etc. I am really going to fight to keep the usage of the word patient over anything else.

It is not only equal but superior.

The human being with the illness is a patient in the hospital, in the office and when they are at home. They are dealing with whatever condition it may be and therefore they are the patient. They may sometimes use services, become customers or other things but first and foremost they are patients. As physicians, this is what we must address first and foremost as well. The business aspect always comes later and is secondary to being healers.

 

[Doc Samson]

The more I think about it, research it etc. I am really going to fight to keep the usage of the word patient over anything else.

It is not only equal but superior.

The human being with the illness is a patient in the hospital, in the office and when they are at home. They are dealing with whatever condition it may be and therefore they are the patient. They may sometimes use services, become customers or other things but first and foremost they are patients. As physicians, this is what we must address first and foremost as well. The business aspect always comes later and is secondary to being healers.

A-f@#$ing-men

 

[michaelrack]

But if I wanted to work with clients, I would have gone to law school

If you were female and wanted to do something more honorable than law, you could have been a call girl and worked with clients

 

[Ibid]

Better get that campaign going then. Not fussed personally but where I am it has been game over for a long time. Patient is verboten.

 

[kugel]

Better get that campaign going then. Not fussed personally but where I am it has been game over for a long time. Patient is verboten.

Can you tell us what kind of agency/facility that is?

 

[Manicsleep]

Something from across the pond regarding NHS physicians.

http://www.dailymail.co.uk/news/art...llion-NHS-jargon-brands-patients-clients.html

 

[whopper]

Other mental health professionals call their customers "clients," not "patients."

It doesn't matter IMHO what the name is so long as both that person and I understand where our relationship is supposed to be. The term "patient" has specific legal and ethical considerations that make it different than the term "client."

If people want to use the term "client," I don't mind so long as their understanding is they're still a patient. Otherwise, using a different term could cause some confusion. A restaurant has clients, a high class escort has clients. They don't have patients. We do.

So if someone does want to change the term we use, I hope they're mindful of that. There are several times in Court where specifically have to point out the person I evaluate is not my patient and the Court would see that as very different than a client. The client is the lawyer--who hired me to do the evaluation. Want to intermingle the patient/client term? Fine. It's going to make Court proceedings with psychiatrists even more confusing.

 

[Majesty]

It doesn't matter IMHO what the name is so long as both that person and I understand where our relationship is supposed to be. The term "patient" has specific legal and ethical considerations that make it different than the term "client."

If people want to use the term "client," I don't mind so long as their understanding is they're still a patient. Otherwise, using a different term could cause some confusion. A restaurant has clients, a high class escort has clients. They don't have patients. We do.

Want to intermingle the patient/client term? Fine. It's going to make Court proceedings with psychiatrists even more confusing.

The problem is that is does matter. That name is actually the crux of the matter. Names and labels are very important.

A lot of physicians are being duped into "not minding" when their professional and ethical values are slowly sapped away. Its more than just confusion. It is about how we treat the patient. The more we call them client or customer, it becomes a part of how we view them, internalize them as a previous post stated. Even if we tell ourselves that to me its still a patient.

Whopper, I know that you are somewhat of a psychology apologist, perhaps thats your viewpoint or perhaps because they employ you. However, you are very wrong on this point and I strongly disagree and encourage you to reevaluate your thinking behind this.

 

[Ibid]

Manic

The Times, Telegraph, Independent and Guardian are the serious newspapers in the UK and cover the full range of editorial from across the political spectrum between them. The Mail is a tabloid celebrity gossip scandal rag. Just look on the sidebar of the link you posted.

http://www.youtube.com/watch?v=5eBT6OSr1TI

There was a move to use the word client in the UK a few years ago but this was in the context of a socialised service where one of the problems was that people often received a rather brusque and impersonal service, especially in hospital. Its use was meant to address a poor service culture rather than be precise about peoples relationships directly. The poor service culture was a big problem so that was the priority. The use of the word client was intended to help address the fact that people were being treated badly.

The service culture in the NHS has been addressed to some extent but certainly the problematic use of client and consumer is well understood especially in the context of a socialized service that historically has not focused on people choosing one service or another. I have not heard or seen client in print for a long time.

Service user is the most common generic term and patient is not forbidden, it just is used less and less.

The use of patient/service user is typical as in the General Medical Council link below.

http://www.gmc-uk.org/about/valuing_diversity_effective_communication.asp

From the Royal College of Psychiatrists. The quotation below is a typical example of the way the use of “people” and “service user” have become ubiquitous.

http://www.rcpsych.ac.uk/campaigns/fairdeal/whatisfairdeal.aspx

e.g. “Engagement with service users and carers must be meaningful not tokenistic. People with direct experience of mental health problems or a learning disability should have a central role in the design and deliver of mental health service.”

Kugel

No prizes for guessing. 1.2 million staff. $250 billion budget, serves a population of aprox 60 million in an area roughly the size of Texas. It is a highly socializing bureaucracy, so while their will be some diversity the generic term service user will be fairly universal in adult mental health.

In this sticky thread essential articles http://forums.studentdoctor.net/showthread.php?t=289443 post #32 by erg has an article attached “The death of phenomenology” that charts the decoupling of American and Anglo Europsychiatry up to the 70s before the publication of the DSM 111. I am not saying this is happening again in one way or another but it certainly may. The article posits a midadlantic movement that included John Hopkins (I think), any way the suggestion is that there is a huge diversity in North American Psychiatry and I expect that is probably true. Of course I don’t know.

 

[Doc Samson]

Whopper, I know that you are somewhat of a psychology apologist, perhaps thats your viewpoint or perhaps because they employ you.

Uncalled for and entirely beside the point. Weakens your point (that I happen to agree with). Keep it civil or go elsewhere.

 

[Manicsleep]

The problem is that is does matter. That name is actually the crux of the matter. Names and labels are very important.

A lot of physicians are being duped into "not minding" when their professional and ethical values are slowly sapped away. Its more than just confusion. It is about how we treat the patient. The more we call them client or customer, it becomes a part of how we view them, internalize them as a previous post stated. Even if we tell ourselves that to me its still a patient.

Well our group basically told the people over at the facility and we found out that it was non physician mental health providers who were trying to get it changed. Told them it would be a poor choice and they appear to agree after we educated them. Surprisingly people never think of the obvious "how would I like to be treated" question. I know I wouldn't want to be treated as just some client if I had an illness.

 

[whopper]

Whopper, I know that you are somewhat of a psychology apologist, perhaps thats your viewpoint or perhaps because they employ you. However, you are very wrong on this point and I strongly disagree and encourage you to reevaluate your thinking behind this.

I'll just leave it at this.

If you think I am a psychology apologist state why. It should be better than simply because there's a disagreement between us. Name calling should be beneath physicians. (Second time you've done that as far as I remember.)

I'm also in a position where I could leave my job where a psychologist is my employer at any moment for other opportunities. Right now, I have 4 places trying to have me work for them and actively calling me. I just happen to like where I'm working for now. The comment on my employment status is out of line, extremely unprofessional, and if you actually knew my employment situation, very off base. I'm actually having more stress from turning down jobs than looking for them because I've been offered a lot of good opportunities.

I actually think we agree that there is a problem with a name change though we disagree on why.

I got no problem with you writing that you disagree and that you think I should reevaluate. I'll take that from your post and ignore the rest.

 

[Doc Samson]

If you think I am a psychology apologist state why.

Majesty and Whopper - feel free to continue this via PM if you'd like, just don't post it here.

 

[Doc Samson]

Well our group basically told the people over at the facility and we found out that it was non physician mental health providers who were trying to get it changed. Told them it would be a poor choice and they appear to agree after we educated them. Surprisingly people never think of the obvious "how would I like to be treated" question. I know I wouldn't want to be treated as just some client if I had an illness.

Have to agree that under the guise of "destigmatization", this name change issue is basically a power play by non-physician providers. Since they can't have "patients" (perhaps with the exceptions of psychologists and NPs), they (not the patient) are the one to feel excluded or lessened by the doctor-patient relationship - e.g., a social worker would have to refer to "your patient" or "my client." If they're clients to all the providers, then linguistically at least, everyone's equal. Notice how nurses aren't insisting on the name change - they get to have patients too.

 

[whopper]

Majesty and Whopper - feel free to continue this via PM if you'd like, just don't post it here.

Very much agree.

If I were in a setting where they told me they wanted me to change the term "patient" to "client." I'd tell them I would not do so unless the patient signed forms specifying that they really are patients despite the name.

The idea of the above is so ridiculous that it would cause anyone reading the form as a patient to wonder what type of operation was going on. The patient/doctor relationship is specific in several of it's legal definitions. If a place wanted to muddle around with that, they're playing with legal fire. Several of the patient/doctor laws are written to protect doctors and institutions as much as the patient.

 

[Majesty]

Very much agree.

If I were in a setting where they told me they wanted me to change the term "patient" to "client." I'd tell them I would not do so unless the patient signed forms specifying that they really are patients despite the name.

I strongly disagree with that sentiment.
I am not trying to offend anyone here but it is this particular direction of thought that I disagree with. Names and labels are extremely important. Assuming that the patient does sign these forms and are treated as patients. So what. That name is changed and a label of client is assigned.

It is just not the way I think of the people I treat. Changing that name will forever corrupt that thinking. Pre-meds, med students, people going to see the doctor will see that interaction as a doctor-client relationship as opposed to the doctor-patient relationship. Those words have powerful meanings and undertones.

Ask Winston Smith.

 

[whopper]

Another inconsistency is if the organization has more than mental health providers, e.g. it's in a hospital, it's not like the IM doctors are going to start calling their patients clients (or are they)?

 

[nancysinatra]

The patient/doctor relationship is specific in several of it's legal definitions. If a place wanted to muddle around with that, they're playing with legal fire. Several of the patient/doctor laws are written to protect doctors and institutions as much as the patient.

This is an interesting thread.

I'd say it's not just a legal issue, it's an ethical and historical issue. Even if all the laws in the US changed tomorrow, I'd personally feel obligated to patients in a way that providers of other services are not obligated towards their "clients." I am not sure about this, but do law or business or psychology school graduates take an oath of any kind? At a minimum we should feel bound by the hippocratic oath, regardless of the laws.

If anyone follows the pre-med and med student forums for any length of time, I would say, there is a change in attitude among would-be doctors from the way doctors were portrayed, say, on TV 30 or 40 years ago. Obviously I'm generalizing here but there are many threads devoted to money and seeing medicine as a business. (Whereas there are very few saying "I just want to be a source of knowledge and healing in my community." The ones that post such things are usually high school students or very early undergraduates.) Also just with the expansion of so many lucrative subspecialties and procedural fields, there is an emphasis on seeking wealth and prestige as opposed to whatever people used to seek in medicine. I noticed this for sure in med school too, where EVERYONE seemed to want to go into fields like GI, plastics or derm. And look at the scandals about disclosure of funding sources in our own field. I'm not making broad accusations but ethics are cultural as well as individual, and subject to change over time, not always in the best ways. If the name changes to "client" that's a step in the wrong direction in my opinion.

Can anyone imagine if the clergy decided to stop calling their parishioners "parishioners" and reduced them to "clients?" The clergy is also a fiduciary profession.

 

[michaelrack]

Can anyone imagine if the clergy decided to stop calling their parishioners "parishioners" and reduced them to "clients?" The clergy is also a fiduciary profession.

"Parishioner" is a term mainly used by the Catholic Church. I think it is hard to generalize among the various denominations (even if one limits oneself to the Christian Churches). What do you mean that it is a fiduciary profession?

 

[Manicsleep]

If I were in a setting where they told me they wanted me to change the term "patient" to "client." I'd tell them I would not do so unless the patient signed forms specifying that they really are patients despite the name.

Just because a patient is willing to turn the patient-doctor relationship into a client relationship doesn't mean that is what should be done. One peice of confusion is that money exchanging hands doesn't necessarily make the person a client.

Also, once you change the name, the mentality behind it changes. There has been a lot of work done on labels.

 

[235750]

Just because a patient is willing to turn the patient-doctor relationship into a client relationship doesn't mean that is what should be done.

There's a very popular thread in this forum that is titled somewhere along the lines of "How can psychiatrists make big $$$?". I don't think patients can be blamed for this name change. MANY psychiatrists would love to change the patient/provider dynamic if it makes them more money.

One peice of confusion is that money exchanging hands doesn't necessarily make the person a client.

I agree completely. Just because one makes a living treating sick people does not subtract from the physician/patient relationship.

That said, again if you look at that other thread, you'll see many physicians talking about treating the unhappy wealthy. Many psychiatrists see only patients, but many others aspire to have more 'clients' as it means more money.

 

[Manicsleep]

There's a very popular thread in this forum that is titled somewhere along the lines of "How can psychiatrists make big $$$?". I don't think patients can be blamed for this name change. MANY psychiatrists would love to change the patient/provider dynamic if it makes them more money.

Nobody is blaming patients. They aren't trying to change the name.

Also, trying to make money is not wrong as long as its done ethically.

How would you categorize "many" because if you mean a majority or anything close to that, then I would say you are grossly mistaken. If "MANY" means 6 or 8 psychiatrists out of all the psychiatrists then you are probably right because there are always outliers.

 

[235750]

How would you categorize "many" because if you mean a majority or anything close to that, then I would say you are grossly mistaken. If "MANY" means 6 or 8 psychiatrists out of all the psychiatrists then you are probably right because there are always outliers.

I would never suggest that the majority of psychiatrists (or psychiatrists in training) are primarily fixated on money.

All I know is this: that on this forum, "how can psychiatrists make big $$$?" is one of the most popular threads. And like I said, a lot of the ideas that get thrown around are to do with treating the unhappy wealthy.

I have always thought that SDN is not representative of typical premeds or physicians. Still, it is evident there are psychiatrists who would like nothing more than to get be greatly compensated for taking care of rich people who have questionable pathologies. Whether or not they are outliers...I cannot say.

Also, trying to make money is not wrong as long as its done ethically.

I was not and am not making ethical judgments, merely observations. If you strive for making a business treating wealthy people with no insurance, then your aim is to work with clients, not patients. That is all in my humble opinion of course...which as a second year med student puts me above the janitor

 

[Doc Samson]

All I know is this: that on this forum, "how can psychiatrists make big $$$?" is one of the most popular threads.

A bit of a red herring since almost all of the posts on that thread were an iatry vs. ology flame war.

 

[235750]

A bit of a red herring since almost all of the posts on that thread were an iatry vs. ology flame war.

There are plenty of other popular threads where aspiring psychiatrists told us about their wonderful career aspirations, and then OPD straightens them out. It's a pattern that has repeated itself more than a couple of time.

Also, as I recall the iatry vs. ology flame war didn't start until about halfway in the thread when the topic of psychotherapy was brought up as a money making concept. Then Whopper mentioned that he got most of his referrals from psychologists, manicsleep criticized the "variability in quality" of psychologists, and then all hell broke lose.

 

[Manicsleep]

I was not and am not making ethical judgments, merely observations. If you strive for making a business treating wealthy people with no insurance, then your aim is to work with clients, not patients. That is all in my humble opinion of course.

I disagree with that opinion. I would prefer to treat people without insurance altogether. The perfect system would be one where there was no middleman because the middle man just takes money out of the pie.

The fact that you, in medical school, associate money paid to physicians with clients is surprising to me. I would have hoped you would have learned something about medicine prior to coming into medicine. It certainly cannot be news to you that physicians, working for insurance, medicare, VA or cash, all earn a living.

The physician patient relationship exists outside of that. If you plan to treat people, pay for nursing, malpractice, the medications etc out of your own pocket, not charge anyone a dime ever and say that is the only way for a physician-patient relationship to exist then good for you. Let me know, I will send many referrals your way.

Or is there some problem with cash or treating people who are wealthy that chaps your hide?

 

[billypilgrim37]

I disagree with that opinion. I would prefer to treat people without insurance altogether. The perfect system would be one where there was no middleman because the middle man just takes money out of the pie.

I think you're mincing his point. In current clime, someone doing well enough to be able to pay market level cash for a psychiatrist appointment is functioning at a high level, perhaps at a level so high that it would preclude them from meeting most criteria for most DSM diagnoses. Hence, a practice focused on these high-functioning individuals would be based around treating people who were not the target patient population of psychiatry, but rather on wealthy people who want to improve themselves the same way a yacht might improve themselves. At least, I think this is what he was getting at.

This used to be my outlook as well, though it no longer is. I'm still sympathetic to psychiatry as a public good, and have a vague distaste for cash-only practices, but only that, a vague distaste, like I have for olives and pickles.

 

[Doc Samson]

I think you're mincing his point. In current clime, someone doing well enough to be able to pay market level cash for a psychiatrist appointment is functioning at a high level, perhaps at a level so high that it would preclude them from meeting most criteria for most DSM diagnoses. Hence, a practice focused on these high-functioning individuals would be based around treating people who were not the target patient population of psychiatry, but rather on wealthy people who want to improve themselves the same way a yacht might improve themselves. At least, I think this is what he was getting at.

This used to be my outlook as well, though it no longer is. I'm still sympathetic to psychiatry as a public good, and have a vague distaste for cash-only practices, but only that, a vague distaste, like I have for olives and pickles.

But this stance presupposes that only patients meeting DSM-IV diagnostic criteria are suffering.

Aside from that, a patient might be doing very, very well in the occupational realm of functioning, but failing miserably in every other (e.g. every celebrity that ends up in treatment) and thus still easily meet DSM criteria for impact on functioning while still making money.

 

[Manicsleep]

1) First lets talk about only the people with the ability to pay full published rates. We will also assume that functioning equals making money, although it doesn't.
a) Wealthy people have husbands, wives, children, parents.
b) The wealthy can themselves retire or get disability etc.
c) Mental illness is not limited to the poor. Just like schizophrenia and drug use is not limited to african americans.

2) Have you heard of a sliding scale

3) You can still bill the insurance yourself if you go to a cash practice.

4) What does this have to do with patient vs client.

I have a distaste for those who make judgment before considering everything. Wanting to avoid insurance as much as possible doesn't mean the patients aren't treated. They are actually treated better because there is more time and a LOT LESS paperwork.

 

[billypilgrim37]

But this stance presupposes that only patients meeting DSM-IV diagnostic criteria are suffering.

Aside from that, a patient might be doing very, very well in the occupational realm of functioning, but failing miserably in every other (e.g. every celebrity that ends up in treatment) and thus still easily meet DSM criteria for impact on functioning while still making money.

Agreed. You and I had discussions probably about two years ago (I remember because most of them were me writing deliriously at 3 in the morning during pgy1 call), and let me suffice it to say that we probably now agree much more than disagree now. Part of being a resident is that you do get to learn things over time!

I still don't like the "skim the easy cream off the top to make a lot of money and leave the poorly reimbursed, sicker populations to someone else" business model. But that's a political bias of mine, and one that I'm perfectly happy with. I'm never going to be able to function in a private practice, because the sort of patients I wish to focus on will inevitably be on public insurances at fairly high rates.

I find little issue with the psychodynamic therapy + med management cash only practices my psychodynamic supervisors run, and those practices are, admittedly, aimed at the functional-but-suffering (and the med management rather rudimentary). But that's not "skimming the cream off the top," that's simply offering an entirely different service that insurance does not reimburse well enough to sustain a physician's salary. I don't think any of my supervisors are doing this to get rich, they're just doing the work they find most valuable.

And, ManicSleep, I wasn't so much arguing for the point as clarifying what I thought ILDS' point was (not about the insurance itself, but about the sort of pts with or without it), a point that I used to argue for pretty heavily.

 

[Manicsleep]

Having a preference for a certain type of patient is fine. My point was that it has absolutely nothing to do with the person being a client. They aren't under any circumstances.

We run a separate medicare clinic (only possible because we share revenue with the cash/insurance part of the practice) and all the psychiatrists also see SMI patients when we do inpatient work and to a lesser degree consults.

To imply that cash practices are skimming the easy cream off the top is ignorant. It comes with its own set of issues and problems but if you mean that its much more fulfilling, you are right. Also, we are not leaving the poorly reimbursed to someone else.

So you will work with the poorly insured, spend 10 minutes with them every few months while they do not get better. Good for you. The holier than thou attitude will change because you will realize that under the current system, it is very hard to sustain a practice that is fulfilling if you actually do what the government/HMOs tell you to do. But good luck. Someone has to be the drone, its not going to be me.

 

[billypilgrim37]

We run a separate medicare clinic (only possible because we share revenue with the cash/insurance part of the practice) and all the psychiatrists also see SMI patients when we do inpatient work and to a lesser degree consults.

Right, I'm certainly not attacking your practice. This sounds like an entirely ethical model.

To imply that cash practices are skimming the easy cream off the top is ignorant.

Thank you for the unwarranted insult. You didn't even have to buy me dinner first.

Also, we are not leaving the poorly reimbursed to someone else.

Acknowledged. So I'm wondering why you have such a defensive tone at this point?

So you will work with the poorly insured, spend 10 minutes with them every few months while they do not get better. Good for you. The holier than thou attitude will change because you will realize that under the current system, it is very hard to sustain a practice that is fulfilling if you actually do what the government/HMOs tell you to do. But good luck. Someone has to be the drone, its not going to be me.

That's a lot of assumptions about me. I pretty clearly laid out in my posts that my attitudes were different than what I articulated above. And I think saying I don't like cash-only practices the way I don't like pickles is, well, not exactly fighting words.

Not everybody here is trying to punch you in the gut every time they have a slightly different opinion about something. And it's not particularly my job to figure out why you always come out swinging.

 

[Manicsleep]

I still don't like the "skim the easy cream off the top to make a lot of money and leave the poorly reimbursed, sicker populations to someone else" business model.

In current clime, someone doing well enough to be able to pay market level cash for a psychiatrist appointment is functioning at a high level, perhaps at a level so high that it would preclude them from meeting most criteria for most DSM diagnoses. Hence, a practice focused on these high-functioning individuals would be based around treating people who were not the target patient population of psychiatry, but rather on wealthy people who want to improve themselves the same way a yacht might improve themselves. At least, I think this is what he was getting at.

This used to be my outlook as well, though it no longer is. I'm still sympathetic to psychiatry as a public good, and have a vague distaste for cash-only practices, but only that, a vague distaste, like I have for olives and pickles.

Maybe you need to read your own posts where you:
Compare patients suffering with mental illness to a yacht and working with these people is like working on a yacht.
Minimize their illness by saying that they couldn't possibly meet DSM criteria.
Say that those who work with them give you a vague distaste (oh please pardon us your holiness, didn't mean to offend you) and comparing them to pickles and olives.
Anyone who works with them is skimming off the top and leaving the poor and sick (becaues everyone knows only the poor are sick and mentally ill) to someone else.

Your implications are typical of antiquated ideas where the poor and minorities are drug users, mentally ill and more likely to commit crime. I am sure that you know what to do with "those people" as well.

You think calling you ignorant is unwarranted? I have a lot more choice words for you that probably would get me kicked off the forum. Ignorant is being nice and hoping you are a resident that just doesn't know any better yet.

 

[billypilgrim37]

You think calling you ignorant is unwarranted? I have a lot more choice words for you that probably would get me kicked off the forum. Ignorant is being nice and hoping you are a resident that just doesn't know any better yet.

Hey, there's always PM! Abuse away!

 

[Majesty]

Rich or poor. Patients are patients. Cash, insurance or medicare. Patients are still patients. High functioning or not, patients are still patients.

Of course, I wish I could cherry pick and get the easy patients but I don't know if those lines are divided by payment type.