Why physician is not the same as provider [PODCAST]

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Calling a doctor a provider sounds harmless. The American College of Physicians says it isn’t. Janet Jokela, former treasurer of the American College of Physicians, professor, and medical educator, discusses the KevinMD article “Physician vs. provider is an ethics issue, not just style.” She walks through how the word “provider” entered medicine through Medicare in 1965 and ended up lumping physicians together with hospitals and insurance companies as interchangeable “providers of services.” You will hear why the Latin root of compassion (to suffer with) names something physicians do that corporate entities do not, why the ethical obligations physicians take on (do no harm, beneficence, patient autonomy, justice) do not apply to insurance companies or hospital systems in the same way, and why allowing the language to blur that line accelerates the deprofessionalization of medicine. You will hear what to say when someone calls you a provider, and what to call mixed clinical teams instead.

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast. Today, welcome back Janet A. Jokela, former treasurer of the American College of Physicians, professor and medical educator. Today’s KevinMD article is “Physician versus provider: Is it an ethics issue, not just style?” Janet, welcome back to the show.

Janet A. Jokela: Thanks so much, Kevin. Delighted to be here.

Kevin Pho: All right. So tell us about this latest article, why you decided to write it and share it on KevinMD, and then, of course, about the article itself.

Janet A. Jokela: Sure, sure. Thank you, Kevin. This issue has been something percolating around the ACP and many, many other places as well for a number of years.

At first, very bluntly, if you will, it came to my attention during ACP President Emeritus Robert McLean’s inaugural address. And this is to the ACP in 2019, and he said, “Take a pledge. Pledge that you’ll never use the word provider, always use the word physician when describing ourselves.”

So, it has been something that had been on my mind certainly for a long time, and I’ve been doing that. It puzzled me a little bit initially when this position paper came out from the ACP, like ethics? How is this an ethics issue? And I tell you, Kevin, after reading the article and then also listening to this other related podcast about the article, it’s like, oh my goodness, this has everything to do with ethics, and absolutely this is something we should do.

Kevin Pho: All right. So give us a little bit more context on the history between physician and provider. How did that term provider even enter the lexicon, and how did it spread to be so prevalent as it’s being used today?

Janet A. Jokela: Yeah, great question, and a very important question. The term provider has been in use for a long, long time.

I think it came into more prominent use in 1965 when Medicare came on board and we started down that path with Medicare. And so the term provider was used to describe any, quote, “provider of services.” And unfortunately, you think of us as physicians or others such as nurses, people delivering direct patient care got lumped together with hospitals or insurance companies or other providers of services.

And that’s when things started to get all muddy and all blended together, and that’s when it started.

Kevin Pho: All right. And why did the ACP decide to take up this issue? Of all the other health issues that are pressing, why this particular one did they specifically write a position paper on?

Janet A. Jokela: Right, exactly. And, Kevin, that was something that crossed my mind, too. I mean, we’re in this era of all these unbelievable things going on, if you will, in health care and science and everything else, and then why this issue?

That said, talking with Robert McLean about this and hearing some of his thoughts about it, and then also the ethics committee’s thoughts, this was something that had been percolating quite a long time within ACP, and I’m sure many other places too.

So there have been plans in place for such a paper to be explored and worked on for some time, and then COVID hit and everything got waylaid. So this came back to the forefront. And again, reading this, I think it is really important, and I’m really glad that the ACP did this, and I’m really proud that the ACP did this. It’s an important issue, and I think it was timely and a good thing to be done.

Kevin Pho: Now let’s talk about the paper itself, of course, for those who didn’t get a chance to read it, and may have thought, like you did, about why this issue is so pressing. Tell us the key points, the key takeaways that you came away with and you want readers to come away with after reading this position.

Janet A. Jokela: Right. You know, Kevin, I was really touched by this paper. Just reading it and thinking, “All right, we’ll keep an open mind and see where this is all going.” But the paper starts out, the authors Macy and Carney start out by talking about the origins of words that are associated with us.

So physician, medicine, and all of that. And the one that really struck or jumped out to me was compassion. And so the origins, the Latin origins of the word compassion mean to suffer with.

Think about that. I mean, that’s what we’re supposed to do. That’s what we do. The word patient is one that is suffering, and that’s where we are. When you dig down to fundamentals, that’s what we do. We suffer with our patients, we care for them, and then all the other principles of biomedical ethics play into that. But that’s what distinguishes us, say, from insurance companies. Kind of a nameless, faceless insurance company, if you will, or other large entities.

But as physicians, certainly one-on-one with patients, that’s what we do. We are there for patients in a very fundamental, important way, and that’s what distinguishes us from everybody else and all of these other entities. So personally, I found that quite moving.

Kevin Pho: And that connotation to suffer with, that’s specific to the word physician. The word provider doesn’t quite capture that. Is that what you’re saying?

Janet A. Jokela: To suffer with is specific to the word compassion.

Kevin Pho: Compassion, OK.

Janet A. Jokela: And that’s where us, as physicians, that’s what we do, to demonstrate compassion, exhibit compassion, and to be with our patients and work on behalf of our patients to do no harm, all those things, in a way that’s unique and important to us as physicians relative to everybody else.

Now, I’m sure other health care professionals have similar ethical obligations and oaths and whatnot. These are features which are unique and special to us as physicians, and those are critical things that we just can’t let go of.

Kevin Pho: Now you mentioned that this has also become an ethical issue.

Janet A. Jokela: Yeah.

Kevin Pho: Dig deeper into why that is and explain it to our audience who may not understand the ethical implications of the physician versus provider debate.

Janet A. Jokela: Right. So you think of us as physicians when we have an ethical obligation to patients, and that means do no harm, the beneficence, patient autonomy, and justice, those things.

And when you think about, say, an entity like an insurance company or a hospital or whatever other entity we’re thinking about, those are often much more impersonal, if you will, and they may have obligations to their boards or their stockholders and their stock owners, all of that. We’re different in that way.

Our first obligation is to our patients in a very fundamental ethical way, and that just blew it open for me. I mean, that was like, oh, of course, of course. And this is why it’s so important to refer to us as physicians and other health care professionals as health care professionals. We don’t want to call nurses, for instance, providers either for the same reasons. They are providing care to patients, which is really critical, and it’s beautiful. I mean, it’s important, it’s so important. It’s what we do.

Kevin Pho: And I always say when you talk about these faceless entities like insurance companies and hospital administrators sometimes, they don’t, of course, take the Hippocratic Oath, and their relationship to patients is fundamentally different than a relationship between a physician and a patient.

Janet A. Jokela: Exactly. Exactly. And that’s the tension. You know, so many of us work for or are employed by some of these entities, and there, not always, but there may be tensions. There probably often are tensions between, say, the C-suite and the front office and what we do in the exam room, and that’s what’s so hard.

And all that aside, I think it’s critical that we do not contribute to the mindset or to the language which misses the very critical things, the very important things that we do, and that’s critical.

Kevin Pho: Now, what’s the message that you want to share with patients regarding the terminology of physicians versus providers? What kind of information do patients need to know about those differences?

Janet A. Jokela: That’s an important question, Kevin. That’s neat. I mean, that’s really important. Now, I doubt, but maybe, maybe it would happen, but in terms of patients asking about this, I would think that perhaps patients may not ask so much about this, certainly not in the course of a quick, busy clinic visit.

But if they were to, and if we were to have the time and the space to talk about that, I think it’s gently the same thing in that physicians, we have a unique educational path and a unique commitment and an oath that we take to devote ourselves to the care of patients, to their benefit and their care, and that’s special, and that’s different from what, say, an insurance company might do or some other entity.

So I think it’s the same thing, and I think it’s important that it’s done in a way of, or with a tone of, humility, OK? And that we’re here to serve patients. We’re here, we’re on their same side. We’re here with them. And physician describes what we do and who we are, and it’s at its roots. Fundamentally, we’re here to serve patients and to take care of them.

Kevin Pho: Now, of course, this debate has been going on for many, many years on KevinMD, and I see it, of course, on a lot of these physician forums. And a cynical view would be that Medicare and insurance companies like to, and hospitals like to, refer to physicians and nurse practitioners and physician assistants all as providers because they may see us as interchangeable, and by using that same terminology, it makes it easier for them to, say, replace physicians. Do you think that the term provider contributes to the deprofessionalization of the physician profession and makes it easier for medical systems to replace physicians if they aren’t being called physicians in the first place, they’re just under that generic provider term?

Janet A. Jokela: I think it certainly could, and it very likely does, I’m so sorry to say. It’s easy to call everybody a provider, but the fact is we’re not. And the last thing we want to do is contribute to our own deprofessionalization or, in addition, the deprofessionalization of nurses or anyone else delivering direct care to patients. We’ll put it that way.

It can be such a slippery slope, and it’s a little bit of a chicken or the egg type thing, which came first, the term leading to just more lumping everybody all together as providers, or did that happen first and then the term followed?

But certainly, the language reinforces the mindset, I think, that you just described, and that’s something that we just cannot afford to have any more entrenched than it already is.

Kevin Pho: Now let me ask you next about practical tips. So what should physicians do if they’re being called providers? Should there be a gentle correction? I know that ACP, of course, wrote this policy paper when describing mixed clinical teams. Are there, is there any other terminology that you recommend? So practically, how can we move forward now that we’ve established the ethical basis between provider and physicians? What are some next steps?

Janet A. Jokela: Sure, sure, sure. I do think, Kevin, it starts one physician, one person at a time. So when we do hear the word, say verbally, if we hear the word, to gently step in, and not in a condescending, offensive kind of way, if you will, but to gently step in and say something. We’re physicians, not providers. But just to figure out a tactful, gentle way to say that. I think it’s important that we speak up and we do that.

I have colleagues who, say, receive forms to sign or fill out that have the word, it says provider and then sign your name. They cross that out and write the word physician on the form, and then sign their name, and to the point where their staff are trained to do the same thing, all right? To cross out the word provider and put the word physician.

So I think it requires a collective effort on all of our parts to do this in whatever little scenarios or bigger scenarios we may find ourselves in, and just keep pushing.

Kevin Pho: So in terms of describing mixed clinical teams and sometimes as physicians, we are in leadership positions, right? Should everyone be addressed individually as nurse practitioners, physician assistants, and physicians? Is there any other terminology that you could address these clinical teams as a group? So what do you suggest?

Janet A. Jokela: Yeah, yeah. Thank you, Kevin, and thank you for that question. It’s an important one. The recommendation in the paper, and certainly is something that I do my best to adhere to, is to use the term clinicians, right, implying that they’re caring for patients, or health care professionals, right? That’s it. Because those terms by definition cannot mean insurance companies, right, or other faceless entities. But for individuals who are providing direct patient care in whatever capacity, either clinicians or health care professionals is a good way to go.

Kevin Pho: We’re talking to Janet A. Jokela. She’s the former treasurer of the American College of Physicians. She’s a professor and medical educator. Today’s KevinMD article is “Physician versus provider is an ethics issue, not just style.” Janet, as always, we’ll end with some take-home messages that you want to leave with the KevinMD audience.

Janet A. Jokela: Sure. Just three brief messages. One, we’re physicians, not providers. Two, other health care professionals such as nurses and other folks are health care professionals or clinicians. And then three, when we do hear the word provider used inappropriately, to speak up and gently correct that misuse of the term, because if we don’t speak up, who will?

Kevin Pho: Janet, as always, thank you so much for sharing your perspective and insight. Thanks again for coming back on the show.

Janet A. Jokela: Sure. Thank you so much, Kevin.

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