Patient or Client -- What shall I call you?

A rose by any other name would still demand my skills, knowledge, and dedication to the Regulated Health Professions Act. Or something like that...

In the RMT community in Ontario there is a conversation that has been happening ever since I graduated in 2009. Are the people I touch my patients or my clients?

When I graduated, the CMTO, the College of Massage Therapists of Ontario (the people who give us the license to use the titles we use here and ensure we continuously deserve the privilege) used the word Client. Some many years before hand it had been decided that most RMTs and the people they worked with preferred the term client and so that was what the CMTO would refer to the people we work with as. Many RMTs followed suit.

Recently the CMTO went through its documents and changed the word 'client' to 'patient.' Perhaps in response to growing concerns about using the term client when the RHPA, that is the Regulated Health Professions Act -- the document that outlines what all regulated health professionals in the province of Ontario are expected to follow -- only uses the term patient. In the community, concerns had to do with disciplinary actions taken against RMTs who had mistreated the people they work with being "thrown out" because the term "client" was used. Others felt it made us, the RMTs, look less professional or clinical than our other RHPA colleagues. Many feel it places us elsewhere in the professional health care provider hierarchy than is our due. Others feel the term client is a more appropriate descriptor for the way the people we treat tend to be in our therapeutic relationships.

For the record, I use the term patient in all of my documentation and often when I discuss the people I treat in a sort of third person way ie. "my patients can park on site in the spot marked Jen Fleming RMT." Only once have I had push back from someone who did not feel it an appropriate term for them and, when in conversation with them, should the need for such a term arise, I use client.

But it has gotten me wondering, perhaps philosophically, about these terms, what they mean, what they describe, and how those meanings align with the actual relationships that are occurring between RMTs and the people they treat.

According to the RHPA 1991 a person becomes a patient according to the following:

1. An individual is a patient of a member if there is direct interaction between the member and the individual and any of the following conditions are satisfied:

i. The member has, in respect of a health care service provided by the member to the individual, charged or received payment from the individual or a third party on behalf of the individual.

ii. The member has contributed to a health record or file for the individual.

iii. The individual has consented to the health care service recommended by the member.

iv. The member prescribed a drug for which a prescription is needed to the individual.

So basically, once we have met, I have collected personal information from you and created a file, have rendered a service and received some form of payment, you are now my patient. Circumstances that may omit you from this include provision of emergency services, (ie if I give CPR to someone on the street or administer a naloxone kit they are not my patient) or if the service is minor in nature (I give someone a little bit of an arm rub because their tennis elbow is bothering them while we watch their kid play little league), I've done everything I can to refer them to another professional effectively ending the therapeutic alliance, or if there is a pre-existing sexual relationship (which is a whole other ball of wax we aren't talking about here today).

A member of the health professions is a person who has completed the necessary training and has met and demonstrated the required knowledge and skill minimums needed to obtain licensure from their respective college. You can learn more of the details of becoming an RMT from the College of Massage Therapists of Ontario website.

When I am at work, I am always an RMT based on the definition of an RMT in Ontario so am always governed by the laws outlined in the Massage Therapy Act 1991 and the RHPA. And once I have completed an appointment with you in which I provided massage therapy, created a file with your personal information, and have received some form of payment, you are now my patient.

But... does the relationship and the nature of the exchange between myself and my patient always unfold as a therapist/patient relationship? Or does there come a point when the recipient of my work is functioning more like a client?

I think first of all the biggest point of contention is agency. Traditionally the term patient denotes vulnerability and submission to the clinician's plan of action. It places the clinician in the decision making role, serving out what they think is the best possible solution to the problem their patient presents with. In our modern world, though, personal agency, the right to choose, and consent have become huge topics of consideration for many people.

It's true, too, that modern people are much more savvy about health, health care, and treatment options that might be available to them. They have access to information a level of literacy that enables them to comprehend that information in ways the people of our past did not. Additionally, stories have come to light, either shared privately or publicly, of professionals abusing the hierarchical nature of the clinician/patient relationship, mishandling a person's health concerns, having a poor treatment plan, or missing the diagnostic mark completely. In these instances, people have had to exercise a lot more agency and self-advocacy for their own safety. Adjacent to this are people living in places where health care access is not universal, forcing the individual to come up with solutions themselves, learning as much as they can to try and solve their problems on their own. All of this creates a public that is not nearly as ignorant of how their bodies work and more desirous of having some input in what will happen to them.

To which I say, good. Good. You should have input, your wishes for your care are important. Do keep advocating for yourself, asking questions and being heard.

In the model of health care I was taught in, the model that reflects the dominant culture in North America, with it's hierarchy and deference to those further up in the pyramid, the power dynamic between patient and clinician is stark. It is assumed that you don't know as much as me about the problems you have or the solutions and your role is to just accept what I say and my role is to know everything. In this dynamic, consent is often assumed, compliance is expected, and push back can label a patient "difficult."

To that end, much of our medical system has been developed for practitioner ease. Any person who has been trying to access the specialist they need, or trying to arrive at a diagnosis for some mysterious ailment knows the system was not built to be easy or workable for them but for the people who operate the system. From stage one you are expected to be fairly passive in your care, essentially just saying yes because "doctor knows best..."

To be honest, and in my opinion, that dynamic sucks. I may know a good chunk about bodies, how they work, what some things might mean when they aren't working well, and what some solutions might be to some of those problems. I may even be in possession of some skills that work as solutions. But at no point do I know everything, have all the solutions, or know better than you what would be good for you. I see it more like, I may have some knowledge of options you aren't aware of. Further to that, I just don't like the hierarchical approach and try very hard to lean well away from it. I see our work as collaborative, I see YOU as a resource for your own health care, healing, and growth. It's not on my shoulders to heal or fix you, it's a burden we choose to share and figure out together. For my practice, patient lead goals and care planning is paramount not just for the feel good of it but for the reality of it: you are the only person who is with you 24/7/365 and 366 in a leap-year. The choices you make day to day will have far more impact than even a 2 hours massage once a week ever could. You, not me or any other person, are your greatest resource and as someone who wants to be helpful to you, you better believe I wanna tap into that resource and make the most use of it as possible. You drive, I just help you avoid the pot holes or, uh, the "scenic route."

Which brings me to the term client. Traditionally a client is considered less vulnerable with more agency and input and the nature of the relationship becomes more collaborative. A client is considered a much more active participant in the relationship, utilizing their agency and effort to conduct their healing and growth. In the client/clinician relationship, we are working together, in collaboration, both of us using ourselves as resources and honouring our agency in our relationship. You come to me and present to me your problem, I assess the problem to see if I can find more details about it or get more specific about the issue, and then I tell you what I think I can do for you, what I think you might be able to do for you, and what I imagine our trajectory is likely to be. You give me feedback and I refine the plan as needed, and then together we implement it.

If I were to assess the way I perform my work, the kinds of problems people present to me with, and the solutions they tend to be hoping for, and how the relationship actually functions, objectively, I would say some of the people I work with are indeed clients and others are definitely patients. Not everyone who presents to an RMT is looking for problem solving and solutions with a clear end-point. Some people really just want support for their daily grind. Nothing is likely to change unless some sort of major lifestyle overhaul occurs (or for some, a miracle cure for their illness). My work in those instances is less about problem solving or moving towards a clear end goal and more about providing a positive experience for someone who might just have to suffer somewhat indefinitely. Sometimes it's just nice to have something nice happening to your body for a change, y'know?

And this is where I wonder if people get a bit... sticky or hung up. If I am not doing hardcore problem solving pain management life changing health care work, am I less of a clinician? Am I less of a professional or therapist? If someone presents to me just seeking some good, healthy, safe, appropriate touch, am I less of an RMT? Do I need YOU to be a helpless patient in order to make ME a powerful clinician? See how that dynamic happens so easily? If that last bit didn't bother you at least a little we probably aren't the right fit! LOL

Seriously though, my answer to that is absolutely not. Even if you are just looking for "relaxation and stress management" you deserve skilled hands, a knowledgeable brain, a person capable of assessing the safety of providing care to your unique body, and when you present with adjacent problems that could be better helped by a) a different approach from me, or b) a different person and profession altogether. Even if you function in the relationship more like a client you still deserve the security of working with someone beholden to a system that imposes a set of responsibilities on your care provider.

As a regulated healthcare professional, even if all I am doing is a "relaxation massage" I am still viewing you through my clinical lens; I am still assessing and monitoring you and your body for signs and symptoms of things being off. I am still calculating what the best and safest way for me to work with you is. Not because you are vulnerable and I want to equalize the power dynamic (though I absolutely do want to do that) but because, client or patient, you deserve a clinician who is responsible for helping you get the best out of me, my knowledge, and my skills.

So, patient or client? IMO, it does not matter in the confines of the relationship we have. I am still your RMT, your clinician, and responsible for meeting my professional obligations. On paper you are my patient because those that govern me say that you are, but in my treatment room, we are coconspirators for your best outcome possible.

PS: perhaps the RHPA should be updated to include the term client to cover those people who deserve the quality, skilled care, of a regulated health care provider but are not functioning in the relationship as a patient. Perhaps room for the idea of agency and leveled power dynamics is worth describing and protecting by the laws that govern clinicians.