Who is the patient/client?
This week the podcast of On Being is a conversation between the host, Krista Tippett and physician, Atul Gawande entitled “What Matters in the End”. One of the questions Dr. Gawande asks his patients is “What does a good day look like?”
Dr. Gaweande’s approach to the practice of the art of medicine follows the long standing goal of healing (note cure). This approach was richly symbolized during the AIDS epidemic by a simple switch from identifying AIDS patients as those dying with AIDS to those living with AIDS. This simple switch allowed a significant increase in the quality of life for many. In those early days, prior to effective treatment, most of those living with AIDS would die because of the illness, but the goal became to live until one died. The community – largely the LGBT community in the beginning – created a very organized and loving system for providing practical help to those living with AIDS. Each was assigned a buddy who would take the person to the doctor, help with many practical chores or just listen.
For some a good day is being able to stay in one’s home. For some it is having a listening ear. For still others it is learning how to skype with one’s children or grandchildren. For some it is having choices about treatment without feeling guilty or pressured to do anything to just stay alive even if there is no quality of life.
We counselors would do well to heed the sage advice of Dr. Gawande by asking our clients, “What does a good day look like for you?” The answer may or may not meet the guidelines of Medicaid or some other insurance plans to have measurable goals which are consistent with the treatment plan. The treatment objective the insurance company wants to see may be very different than the one the patient states. In our role as counselors we may need to be creative and/or rethink who the patient is. Far too often, it is easy to fall into the trap of allowing insurance companies to act as if they are the patient/employer. My view is that the insurance company is the employee of the patient/client. Even if the insurance company is Medicaid or Medicare, the employer is the client. Our taxes pay for Medicaid and Medicare.
It is also easy to fall into the trap of thinking that the professional licensing or credentialing board is the client. They are not. It is their job to insure that the clinician is well trained and ready to do the job for which they are employed. It is also their job to guide the clinician in how to best serve their client. What the client needs and wants may not always fall within the guidelines of the licensing or credentialing board. The client may, for example, decide that they need to talk on an unsecured telephone line or email server. The board may say that this is unethical. One then has to make a decision about what is best for the client. To be sure, ethical rules are intended to protect the client and much of the time they may do so. Some of the time they do not.
Dr. Gawande is very simply reminding himself and other clinicians:
Written October 27, 2017
This week the podcast of On Being is a conversation between the host, Krista Tippett and physician, Atul Gawande entitled “What Matters in the End”. One of the questions Dr. Gawande asks his patients is “What does a good day look like?”
Dr. Gaweande’s approach to the practice of the art of medicine follows the long standing goal of healing (note cure). This approach was richly symbolized during the AIDS epidemic by a simple switch from identifying AIDS patients as those dying with AIDS to those living with AIDS. This simple switch allowed a significant increase in the quality of life for many. In those early days, prior to effective treatment, most of those living with AIDS would die because of the illness, but the goal became to live until one died. The community – largely the LGBT community in the beginning – created a very organized and loving system for providing practical help to those living with AIDS. Each was assigned a buddy who would take the person to the doctor, help with many practical chores or just listen.
For some a good day is being able to stay in one’s home. For some it is having a listening ear. For still others it is learning how to skype with one’s children or grandchildren. For some it is having choices about treatment without feeling guilty or pressured to do anything to just stay alive even if there is no quality of life.
We counselors would do well to heed the sage advice of Dr. Gawande by asking our clients, “What does a good day look like for you?” The answer may or may not meet the guidelines of Medicaid or some other insurance plans to have measurable goals which are consistent with the treatment plan. The treatment objective the insurance company wants to see may be very different than the one the patient states. In our role as counselors we may need to be creative and/or rethink who the patient is. Far too often, it is easy to fall into the trap of allowing insurance companies to act as if they are the patient/employer. My view is that the insurance company is the employee of the patient/client. Even if the insurance company is Medicaid or Medicare, the employer is the client. Our taxes pay for Medicaid and Medicare.
It is also easy to fall into the trap of thinking that the professional licensing or credentialing board is the client. They are not. It is their job to insure that the clinician is well trained and ready to do the job for which they are employed. It is also their job to guide the clinician in how to best serve their client. What the client needs and wants may not always fall within the guidelines of the licensing or credentialing board. The client may, for example, decide that they need to talk on an unsecured telephone line or email server. The board may say that this is unethical. One then has to make a decision about what is best for the client. To be sure, ethical rules are intended to protect the client and much of the time they may do so. Some of the time they do not.
Dr. Gawande is very simply reminding himself and other clinicians:
- The employer is the patient/client.
- The clinician patient relationship is one between two (or more) people and not between to roles.
- The most important skills of the clinician may be the art of listening and loving.
Written October 27, 2017
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