Defining our identity does not include the ‘P word’

“Please stand, raise your right hand, and repeat after me: I pledge not to use the word ‘provider’ when referring to physicians, and further to encourage my colleagues to do the same.” Half in jest, I made this request of the audience when I took office as ACP President in April. But the enthusiastic response made me realize I had hit a nerve.

In considering why, I have come to realize names and labels are inherently connected to identity. So what exactly underlies our identity as internists?

In June we saw the close of another academic year, and we welcomed another class of internal medicine residency graduates to our specialty field. They have met the qualifications to be internal medicine specialists. Their training included a rigor and breadth that are quite distinct from other specialties and make them proficient in the comprehensive care, including preventive care, of medically complex adult patients. And after passing the initial certifying examination from the American Board of Internal Medicine that tests knowledge in those areas, they will receive the added designation of being “board certified.”

It is worth considering the competencies that need to be demonstrated through an internal medicine residency. To highlight a few from the Accreditation Council for Graduate Medical Education, they include aspects of synthesizing information, managing complex patients, and managing and leading teams. Our training gives us a background in the broad field of internal medicine that other clinicians lack.

But being a physician is much more than that. We have “caring” relationships (see my President's Message in the June 2019 ACP Internist). Our identity is intertwined with these intensely personal and intimate relationships that are fundamentally different from all other types of relationships. Patients share things with us as physicians that they share with nobody else, including close family. They want and need a number of attributes in a physician: knowledge, expertise, kindness, caring, attentiveness, a willingness to explain, and offers of reassurance.

Such a fundamentally unique and sacrosanct relationship as that between patient and physician is not merely “providing” a health service. And that is why the term “health care provider” is so inappropriate. The patient-physician relationship does not consist of simple transactions where we provide and patients consume. That marketplace terminology implies that health care can be conceptualized as just another commodity.

But it cannot fully capture the role that we as physicians play, and I don't believe most patients want the relationship to be framed in that manner either. Marketplace terms must not be applied to the essence of what we do: Help people who are suffering, manage complex problems, counsel patients on how to live … and how to die.

Such a fundamentally profound relationship requires trust. Trust enables us to help people in their times of need and is the essence of the patient-physician relationships that we all find so meaningful in our work.

Meaningful, trusting relationships cannot exist without time and effort. Relationships are at the center of all we do as physicians. Relationships with our patients are some of the most gratifying aspects of being a physician.

The primacy of this relationship has been eroded with the commoditization of aspects of the health care delivery system. While the technology and finances of the “medical-industrial complex” have driven it, we have allowed that central relationship to diminish in importance, just as we have allowed our relationships with each other to disappear. Yet, I think we would all agree that relationships with colleagues are tremendously significant for the intellectual camaraderie as well as the emotional support we give each other. Simple colleague interactions with “curbside consults” in person or by phone that are so intrinsic to our intellectual development and enthusiasm in residency fade quickly once in practice. We do not make the time for them. Many have noticed that physician lounges in hospitals no longer exist. Would hospital administrators have repurposed that space if physicians were actually using it? Yes, we are allowing it to happen.

Even when practicing in group situations, we isolate ourselves. The systems of health care data work are now neatly placed into various “in baskets” (results, refills, messages) centered on individual physicians. While “patient-centered care” is laudable, the parallel “physician-centered work” is not. So we spend every possible minute digging away at the endless items, alone, with our computer, leaving little time or energy to maintain professional and personal relationships. In the exam room, focus on the computer screen leads to neglect of the patient-physician relationship. Everywhere else, we neglect our other relationships.

We must retake control of what we do and how our identity is defined. Do not allow yourself to be called a “provider.”

Yes, there are business aspects to health care delivery that we cannot ignore. But we need to bring the lexicon back to what is truly needed for our patients and for our physicians. In the patient-physician relationship space, much of our professional work has indeed been defined as transactions, where everything is a CPT code with a number or a relative value unit. But there is more recognition than ever that much of the work that physicians do is not captured this way and that payment models need to change.

With all the money flowing through the health care system, health care “services” definitely need to be tracked by the administrative “bean counters.” But we physicians do much more than provide beans; we are involved in the whole meal! By analogy, we are simultaneously chefs, who create the menu with the specific foods (treatments) most appropriate on a given day, and sommeliers, offering personalized counseling and advice.

So my patients can refer to me as a health care chef/sommelier with whom they have an ongoing meaningful relationship (and maybe a great meal), but not as a “health care provider.” As an internist, I know my identity: uniquely qualified to diagnose and manage medically complex adult patients comprehensively, including their general preventive care.

And by the way, this terminology issue was raised through the ACP Board of Governors way back in 2008. Hence, it has been ACP policy since 2009 to eliminate use of the term “provider” and “prescriber” in lieu of “physician” in all publications and communications. Pass it on.