A Physician's Lament

PERHAPS I AM MISTAKEN, BUT I THOUGHT THAT AFTER four years of medical school and three years of residency I was a physician. A medical doctor, if you will. For my first 10 years in practice, this label seemed to suffice. But over the last several years, I increasingly find myself called a ""provider'' by health managers, insurance companies and hospital administrators.

Excuse me if I get a little testy here, but I am not a provider. I didn't go to Provider School (and I hope I never have to). I do not belong to the American College of Providers. I refuse to join the American Providers Association, even if it is working in the interest of providers everywhere.

My patients have never called me a provider, nor have I ever heard a patient use the term when speaking about nurse-practitioners, nurses, psychologists, optometrists, respiratory therapists, pharmacists or any other noble health professional.

Funny word, this ""provider.'' What does it signify, and why has it suddenly become a popular catchall term that lumps together health professionals who each have a distinct and important role in the health-care team? The use of the term blurs the very real distinctions among health-care workers. It affects how medical professionals are viewed and how they view themselves. Not to overstate the case, it also can diminish the physician-patient relationship, the bond that is the core and essence of health care.

Maybe I'm old-fashioned, but I believe that there's nothing wrong with calling physicians ""physicians.'' It is a precise use of the word and an accurate, unambiguous label. Patients call me a physician frequently, and they don't mean it as a pejorative. They also call me ""doctor'' or ""doc,'' both of which are acceptable.

Nor is there anything wrong with calling nurse-practitioners ""nurse-practitioners.'' It is a venerated profession, and I am proud to be working side by side with such dedicated and conscientious people. Patients call them nurse-practitioners without hesitation. There is nothing demeaning about the title. These professionals bring unique and indispensable skills to the health-care team. It occurs to me that hospital administrators and others who use the term ""provider'' may have the impression that the title ""nurse- practitioner'' is of lesser stature, and that this slight can be remedied by lumping physicians and nurse-practitioners under the same heading.

I feel similarly about other health-care personnel. There is nothing disrespectful in identifying someone, correctly, as a pharmacist, or a psychologist or a physical therapist rather than calling them all providers. My patients could not maintain themselves as healthy members of their communities without the help and involvement of these highly skilled professionals. In fact, I could not perform my duties as a physician without these other members of the health-care team. I cannot do the work of a respiratory therapist or a dietitian, two of the health professions that are being reclassified as providers. I am not familiar with their field of expertise, and I rely heavily on their involvement in caring for our patients.

Another reason I object to the term ""provider'' has to do with my beliefs about how health is maintained. Good health is not something that physicians or other health professionals can provide to a patient. Maintaining good health requires a partnership between the physician, the other members of the health-care team and the patient. Many of society's most common and serious health problems are due to a person's lifestyle: smoking, lack of exercise, alcohol abuse. Health-care professionals can work with patients to help them keep on a healthy track, and we can try to patch up those problems of their own making, but we cannot supply good health. Parents are providers to their children; they provide for their needs. Physicians cannot play this role in their doctor-patient relationships. Partners or advisers, maybe. In recent decades, we have moved appropriately beyond the patronizing view of omniscient, all-powerful physicians making decisions on behalf of their patients with minimal input from them. The doctor-patient relationship today is healthier as a result.

By homogenizing the various health-care professions into a single group, the term ""provider'' dilutes what makes each job unique and important in its own right. It implies an interchangeability that does not correspond to reality. From there it is only a short step to viewing providers as just another line item on an insurance company's expense roster. Spending on providers becomes just another budget category, like electricity, phones, X-ray films, pharmaceuticals, IV solutions and pacemakers.

By this thinking, the key link in health care - the physician who has that special quality, the mastery of the healing arts - is reduced to a budgetary item, subject to the same manipulations as any other expense. Health-company administrators can decide to lower their expenditures on the provider line by forcing patients to see cheaper providers. Money can also be saved by reducing the number of providers available for a given population of patients.

Such thinking is the logical outgrowth of viewing health care as a profit center. The problem is that health care, though it may be a business, is not just any business. It is a unique enterprise, whose success rests fundamentally on the doctor-patient relationship. This special, almost magical relationship is weakened when physicians and other health professionals acquiesce to the ""provider'' label.

I would wager that few of the insurance-company executives promoting the provider idea go see a provider themselves when they or their loved ones are sick. No, they'll visit a physician, and the best damn one they can find. I don't fault them for that. It is an opportunity that should be available to everyone.

I know that a number of people will use the P word unwittingly. Even some of my best friends use the term. But for me, I can't do it and I won't. You can call me self-righteous, or harebrained or a windbag. Just don't call me a provider.