14 minute read
The Last Word
Advertisement
Dr Dev Patel argues why it’s more appropriate to use the term ‘patient’ rather than ‘client’ in aesthetics
I have considered the ‘patient’ vs. ‘client’ debate on many occasions. I am sure most would agree that the aesthetic environment we work in is somewhat unique. For the medics amongst us, this is far removed from working within the NHS and seeing non-paying ‘patients’ presenting with more established symptoms of physical and mental illness. If you say ‘client’ for an antiageing case, do you still use ‘client’ for an acne case seeking chemical peels? After all, acne is an established skin condition.
Definitions Let us first examine the respective definitions of ‘client’ and ‘patient’ as given by the English Oxford dictionary:1
Client: a person who uses the services or advice of a professional person or organisation. I can certainly see how this fits with what goes on in my own clinic – I am a professional person – a doctor in my case – providing services to people. Patient: a person who is receiving medical treatment, especially in a hospital or a person who receives treatment from a particular doctor, dentist etc. Clearly, this also fits with what I do and my occupation is specifically stated within the definition.
If both definitions work on the surface, we need to consider the modern connotations of these terms. As our ‘customers’ come first (yet another term we could arguably use), let us first consider the connotations of each label. Assistant professor at Northwestern University Prosthetics-Orthotics Center John Brinkmann wrote an article on this very topic, examining the differences between ‘client’ and ‘patient’. In Table 1, Brinkmann gives an opinion on how these two labels communicate differing levels of care and personal involvement in the relationship.2 The Latin routes of these terms (Table 2) should also be considered, but it is the third column that is most relevant: what the possible connotations are and what does each term ‘say’ to the end-user? Additionally, I think it is just as important to consider what the use of each term implies to the practitioner; I have never had a single patient – and I will now use that term as I usually would – question my use of this label; not one. Even in mainstream medicine, we have evolved from the paternalistic relationship model, which focuses on the doctor’s agenda rather than the patient’s. In fact, one of the four biomedical ethical pillars is based on respecting patient autonomy; a principle I have been tested on in many medical exams over the years.3 In an aesthetic setting, I would even argue that when aesthetic practitioners were purely doing what patients asked of us, the patient did not often end up looking their best. We have almost moved in the opposite direction to mainstream medicine’s model of communication; now, the patient asks for lip fillers and I may have to tell them they need their chin treated instead. Practitioners have had to claim back some autonomy, to ensure we give the patient what they need and not what they want.
Term Focus Defining question
Patient
Client Care – the practitioner is responsible for providing care Expertise and service – the client is hiring a professional to do something for him or her What care do you need?
What are you paying me to do?
Term
Patient
Client Origin
From the Latin word patiens; originally meant one who suffers; to undergo suffering or to bear A person receiving or registered to receive medical treatment; synonyms: sick person Can be construed as stigmatising as its usage may enhance perceived disability and impairment; connotations of passivity and deference; can be interpreted as paternalistic, evidence of inherent power inequities, and a reflection of the dominant biomedical approaches
Latin root meaning dependent; Latin cliens meaning follower, retainer One that is under the protection of another; one who engages the professional advice or services of another Carries connotations of an agency relationship, whereby one individual purchases professional services from another; specifically selected to avoid a connotation of being sick or ill; linked to financial renumeration
Definition Possible connotations
Table 2: The origins of the terms ‘patient’ and ‘client’. Table adapted from Brinkmann2
Why do practitioners use ‘client’? One repeated argument in support of using ‘client’ has been that use of the word ‘patient’ implies a lack of autonomy on behalf of the customer.3 Another common argument for ‘client’ is that our customers are not – in general – ill. I think this is a fair point; in fact, we are unlikely to treat someone with a chemical peel or dermal fillers for example, if they are acutely unwell. However, I believe it is short-sighted to consider this point alone. Whether my patient brings a disease of the body or mind or not, they are seeking advice and usually treatment for their skin’s health and wellbeing, and, in turn, their mental wellbeing. For me to consider their concern, even if it is just a frown line, I must call upon my cumulative clinical experience to establish rapport, glean a thorough history of their concern and their general health. I must then examine their skin and the issue at hand, before discussing treatment options and deciding on a mutually agreed management plan. When the time comes, I will need to obtain informed consent for whichever treatment is due to be performed. I will then administer the treatment, keeping in mind practices established in mainstream medicine (e.g. infection control). Why I only use ‘patient’ So, what is it I am highlighting here? The fact that by using the word ‘patient’ I am reinforcing in my own mind the responsibilities of the role I have in this patient-practitioner relationship and the standards and ethical principles on which it is based. I also wish to remind the patient of this. They are walking into a confidential environment where they may offload their grievance at their frown lines as well as any ‘mental baggage’ that comes along with it. This may, in turn, influence the course of our consultation and ultimate treatment plan. It reminds them that giving me a thorough medical history is important and cannot be quickly skipped over, as one does when visiting a spa for a massage. Most importantly, it reinforces to my patient that the treatment they have is a medical treatment, which brings established risks with it; for example in the case of dermal fillers, potentially rare but catastrophic complications such as blindness can occur, which certainly needs medical attention. I should add that the same applies to my team of aesthetic therapists; they are told from day one the significance and importance of using the term ‘patient’. They are also seeing patients presenting with medical concerns such as pigmentation and acne and need to make the same careful assessment, before utilising corrective treatments such as laser or chemical peels. We have all encountered cases of substandard practice in aesthetics with little or no consultation and almost everything else that follows being equally as shocking. In these cases, I am sure it is a ‘client’ walking through the door and the relationship is very much transactional (no offence intended towards any respected colleagues who favour ‘client’; it is a matter of personal choice). At the other end of the spectrum, I work in a CQCregistered clinic and whether I am faced with a rash or a person wanting lip enhancement, I am a doctor throughout, utilising my clinical experience to diagnose and ultimately ease the suffering of a rash or improve the self-esteem of my patient. Either way, not one aspect of my principles of practice from clinical to ethical, can be dismissed. The care, trust, level of intimacy and responsibility within the medical practitionerpatient relationship is unique and calling my patients ‘patients’ reinforces this subconscious message to all involved.
Dr Dev Patel is founder and medical director of the multiaward winning Perfect Skin Solutions. He has previously served as both a Naval doctor and NHS general practitioner. He is a UK and global KOL and speaker at various international aesthetic events and recently led the first communication workshop for Merz UK.
REFERENCES
1. English Oxford Dictionary – online version 2019 <https:// www.oed.com/> 2. Brinkmann, J. 2018 (Apr). Patient, Client or Customer: What should we call the people we work with? The O&P Edge. <https://opedge.com/Articles/ViewArticle/2018-04-01/ patient-client-or-customer-what-should-we-call-the-peoplewe-work-with> 3. Beauchamp and Childress; Principles Biomedical Ethics,
OUP, 5th edition 2001.
THE NEXT WEBINAR FOR HEALTHCARE PROFESSIONALS HOSTED BY AESTHETICS JOURNAL IN ASSOCIATION WITH GALDERMA WILL BE
IT WILL BE HELD ON MONDAY OCTOBER 14 AT 7PM.
How do I guarantee my place on ‘Abobotulinum toxin A in Action: Key Principles & Treatment for Lateral Canthal Lines’ Webinar’?
1. Registration will be open in the coming weeks! Join the Aesthetics website for free and tick ‘Get communications from Aesthetics with up-to-date news, features and events’ in your profile to be notified when registration is live! 2. Once registration is live you will be prompted to use your DocCheck* password to confirm that you are a
Doctor, Nurse or Dentist and able to access this webinar (if you registered for the last Aesthetics webinar, your
DocCheck account will be valid) 3. Tick the box to confirm that you would like to sign up for the webinar. You’ll then receive reminder emails for the event closer to the time to ensure you don’t miss out! *What if I don’t have a DocCheck login? Register with DocCheck for free www.doccheck.com/register Please note that you will need to provide the following when you have registered your contact details: - A PDF of your record on the register downloaded from the GMC/NMC/GDC website as appropriate AND proof of ID (passport or driving licence) - OR your personal certificate from your medical qualification Your information will be checked and once it has been verified you can then visit the Aesthetics webinar page, use your DocCheck password and confirm you would like to sign up for the webinar by ticking the box. If you have any issues with your DocCheck verification please contact cream@doccheck.com IMPORTANT: You will need to register and provide proof of your medical qualification to DocCheck by Tuesday October 8 in order to guarantee that your registration will be processed in time for access to the webinar
Azzalure Prescribing Information (UK & IRE) Presentation: Botulinum toxin type A (Clostridium botulinum toxin A haemagglutinin complex) 125 Speywood units of reconstituted solution (powder for solution for injection) Indications: Temporary improvement in appearance of moderate to severe: • Glabellar lines seen at maximum frown, and/or • lateral canthal lines (crow’s feet lines) seen at maximum smile in adult patients under 65 years, when severity of these lines has an important psychological impact on the patient. Dosage & Administration: Azzalure should only be administered by physicians with appropriate qualifications and expertise in this treatment and having the required equipment. Botulinum toxin units are different depending on the medicinal products. Speywood units are specific to this preparation and are not interchangeable with other botulinum toxins. Reconstitute prior to injection. Intramuscular injections should be performed using a sterile suitable gauge needle. Glabellar lines: recommended dose is 50 Speywood units divided equally into 5 injection sites, 10 Speywood units to be administered intramuscularly, at right angles to the skin; 2 injections into each corrugator muscle and one into the procerus muscle near the nasofrontal angle. Lateral canthal lines: recommended dose per side is 30 Speywood units divided into 3 injection sites; 10 Speywood units to be administered intramuscularly into each injection point, injected lateral (20 - 30° angle) to the skin and very superficial. All injection points should be at the external part of the orbicularis oculi muscle and sufficiently far from the orbital rim (approximately 1 - 2 cm); (See summary of product characteristics for full technique). Treatment interval should not be more frequent than every three months. The efficacy and safety of repeat injections of Azzalure has been evaluated in Glabellar lines up to 24 months and up to 8 repeat treatment cycles and for Lateral Canthal lines up to 12 months and up to 5 repeat treatment cycles. Not recommended for use in individuals under 18 years of age. Contraindications: In individuals with hypersensitivity to botulinum toxin A or to any of the excipients. In the presence of infection at the proposed injection sites, myasthenia gravis, Eaton Lambert Syndrome or amyotrophic lateral sclerosis. Special warnings and precautions for use: Care should be taken to ensure that Azzalure is not injected into a blood vessel. Use with caution in patients with a risk of, or clinical evidence of, marked defective neuro-muscular transmission, in the presence of inflammation at the proposed injection site(s) or when the targeted muscle shows excessive weakness or atrophy. Patients treated with therapeutic doses may experience exaggerated muscle weakness. Not recommended in patients with history of dysphagia, aspiration or with prolonged bleeding time. Seek immediate medical care if swallowing, speech or respiratory difficulties arise. Facial asymmetry, ptosis, excessive dermatochalasis, scarring and any alterations to facial anatomy, as a result of previous surgical interventions should be taken into consideration prior to injection. Injections at more frequent intervals/higher doses can increase the risk of antibody formation. Avoid administering different botulinum neurotoxins during the course of treatment with Azzalure. To be used for one single patient treatment only during a single session. There is a potential risk of localised muscle weakness or visual disturbances linked with the use of this medicinal product which may temporarily impair the ability to drive or operate machinery. Interactions: Concomitant treatment with aminoglycosides or other agents interfering with neuromuscular transmission (e.g. curare-like agents) may potentiate effect of botulinum toxin. Pregnancy, Lactation & Fertility: Not to be used during pregnancy or lactation. There are no clinical data from the use of Azzalure on fertility. There is no evidence of direct effect of Azzalure on fertility in animal studies. Side Effects: Most frequently occurring related reactions are headache and injection site reactions for glabellar lines and; headache, injection site reactions and eyelid oedema for lateral canthal lines. Generally treatment/injection technique related reactions occur within first week following injection and are transient. Undesirable effects may be related to the active substance, the injection procedure, or a combination of both. For glabellar lines: Very Common (≥ 1/10): Headache, Injection site reactions (e.g. erythema, oedema, irritation, rash, pruritus, paraesthesia, pain, discomfort, stinging and haematoma). Common (≥ 1/100 to < 1/10): Temporary facial paresis (due to temporary paresis of facial muscles proximal to injection sites, predominantly describes brow paresis), Asthenopia, Eyelid ptosis, Eyelid oedema, Lacrimation increase, Dry eye, Muscle twitching (twitching of muscles around the eyes). Uncommon (≥ 1/1,000 to <1/100): Dizziness, Visual impairment, Vision blurred, Diplopia, Pruritus, Rash, Hypersensitivity, Eye movement disorder. Rare (≥ 1/10,000 to < 1/1,000): Urticaria. For lateral canthal lines: Common (≥ 1/100 to < 1/10): Headache, Temporary facial paresis (due to temporary paresis of facial muscles proximal to injection sites), Eyelid ptosis, Eyelid oedema and Injection site disorders (e.g. haematoma, pruritus and oedema). Uncommon (≥ 1/1,000 to <1/100): Dry eye. Adverse reactions resulting from distribution of the effects of the toxin to sites remote from the site of injection have been very rarely reported with botulinum toxin (excessive muscle weakness, dysphagia, aspiration pneumonia with fatal outcome in some cases). Prescribers should consult the summary of product characteristics in relation to other side effects. Packaging Quantities & Cost: UK 1 Vial Pack (1 x 125u) £64.00 (RRP), 2 Vial Pack (2 x 125u) £128.00 (RRP), IRE 1 Vial Pack (1 x 125u) €93.50, 2 Vial Pack (2 x 125u) €187.05 (RRP) Marketing Authorisation Number: PL 06958/0031 (UK), PA 1613/001/001 (IRE) Legal Category: POM Further Information is Available From: Galderma (UK) Limited, Meridien House, 69-71 Clarendon Road, Watford, Herts. WD17 1DS, UK. Tel: +44 (0) 1923 208950 Fax: +44 (0) 1923 208998 Date of Revision: September 2018
Adverse events should be reported. For the UK, Reporting forms and information can be found at www.mhra.gov.uk/yellowcard. For Ireland, Suspected adverse events can be reported via HPRA Pharmacovigilance, Earlsfort Terrace, IRL - Dublin 2; Tel: +353 1 6764971; Fax: +353 1 6762517. Website: www.hpra.ie; E-mail: medsafety@hpra.ie. Adverse events should also be reported to Galderma (UK) Ltd.
