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Today on physicians taking back medicine, we are talking about the P word provider, a term meant to simplify healthcare, has instead blurred the lines and led to a devaluation of physicians. Our guests today are on a mission to restore clarity truth and the title physician, please

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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 so. You may be seated

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when rheumatologist Dr Robert McLean was inaugurated as President of the American College of Physicians in April of 2019, he asked his fellow physicians to take the no provider pledge, and did they actually stand up? And, you know, the people

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stood up, smiled, got some claps, and probably at least three or four people came up to me after we were like, Oh my gosh, thank you so much. That was great. And it kind of hit me like, wow, this really is something. And it kind of became my moniker. So whenever the whole year I was president, the president of the Chair of the Board of Regents, attend all of the different committee meetings, and there are many of them through the year, and at the beginning of each of those meetings, I said, Hey, listen, I want people to take this pledge. And we did the pledge again at the committee meeting. And if somebody you know, slips out the word provider, they got to throw $1 in the kitty or something like that.

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I love that idea. In fact, I think I'm gonna steal it. And anytime I'm in charge, I'm gonna say, before we begin, let's take the no provider pledge. So people really had a strong reaction to it. And, you know, let's dig into why that is. Because, you know, sometimes people say, What's the big deal? Oh, provider physician. Why do you guys get so upset and riled up about this? Explain to the listener, maybe somebody that doesn't know too much about the background, why has the word provider become so offensive to position?

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Well, when one looks at where it started, I mean, there are people who go back historically and actually go back to I think it's Nazi Germany when as a way of marginalizing and minimizing the impact of the doctors and jury, I believe many of whom were Jewish, that the word providers started getting used. I think that's off the radar of most of us. I became aware of it when in the 1990s it started to become a major part of the insurance industry in managed care. And as insurance companies started to control their care, dollar more and more, it was to their benefit to group everyone providing care into larger buckets so that they could justify not paying as much from one group to the other. So while it kind of elevated physician assistants and nurse practitioners to physicians and others, it effectively brought everyone onto one level. Now that's great for everyone on the team, but it is confusing, and it doesn't recognize that there are differences in training, as you are well aware, significant differences in training, and that has been further complicated by the nurse practitioners then developing this strategy to get doctors of nursing practice, which becomes even more confusing

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nowadays in clinics, just because someone refers to themselves as a doctor doesn't mean they're a physician.

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That's Dr Marcia Haley, a radiation oncologist and board member with physicians for patient protection.

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In many ways, this benefits the healthcare system, because if they don't have to hire physicians to say, cover clinics or cover the ER, this can be financially beneficial to them. And so that professional confusion is beneficial to the healthcare system in many ways. And so I, I think that's, it's part of a broader narrative that we've seen in probably in the past 10 years.

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Dr McLean says that he's noticed this in his practice,

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in my role as a primary care doctor or as a rheumatologist, I pay attention to people's care, and I look through the electronic record and I see all the different people they see. And I will routinely say, Oh, I saw the. You received the dermatology office, and they'll say, Oh, I saw Dr Smith or Dr Jones. And I'll look in the chart, and I'll see that, no, it was the PA, where's an APRN? And I'll say, but that they're not a doctor. They were a PA, like, oh, real. Sometimes it's Oh, really, I didn't know. And they're actually sometimes okay with a frequently open air that because they got good care, and they're happy with the person, and they know them. Sometimes they're kind of surprised, and sometimes they're like, like, Well, does it really make a difference? Of course, at that point, I bite my lip until I'm practically bleeding, and I'll say, well, actually, you know, it does, and it does in many cases, for pretty standard, routine stuff. You know, well trained, well trained is the focus APR, A's or pas, who have been experienced, are probably just as good as many doctors at doing a lot of things, but, but they're not as good at some of the subtleties, especially if they are just out of training. And the biggest concern I explain is that the training that they have is really quite dubious and really hard to track down.

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Dr McLean is referring to a progressive trend of declining nurse practitioner education over the last two decades.

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Nurse practitioners as a field, the idea was that you took nurses who had been active, seasoned nurses for years, who now were going to the next level, and as we know now, so many of them go straight from getting their BA and their RN, and they go straight into APRN programs. They've never been working as a nurse. They are not seasoned or experienced at all. They go through an APRN program, which in many cases is online and has like clinical rotations that they have to arrange on their own. There's no organized programs yet. When you look at the programs that have given them their degree, it says they've done X number of hours and X number of rotations of dubious quality or certainty. And it is really concerning. And when I interact with nurses or APRNs even, and say, Oh, what are you doing, or how are you doing? A number of them will will admit to me that they are not ready to be out there, independent and and the idea that that is being pushed as a political force is concerning to them.

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Dr McLean was early in his career when he sat in on some of the first discussions with legislators as they were considering allowing unsupervised practice for nurse practitioners. He notes the slippery slope from first requiring close physician oversight to now allowing nurse practitioners to supervise each other.

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When I was getting involved in advocacy in the mid late 90s for our Connecticut Chapter of the American College of Physicians, one of the first topics that came up as I was starting to engage with state legislators on things. There was a bill the late 1990s for nurse practitioners at that point to to be able to have independent practice. It started back then, and other states had it, and the nurse practitioner lobby is very strong and effective and compelling. Saying, Hey, there's a there's a shortage of doctors. We need to get out there, get trained, and we don't need to have doctors. You know, looking over our shoulder, I was with a group of doctors through a group of nurses, met with a couple legislators for the public health committee, and it was my first real experience with advocacy in person, and it showed me how incredibly important it is, kind of getting to the what can be done about it, for physicians to be active advocates in this space and explain so what we came up with in the late 1990s and it becoming the law, was that they had to have their first three years of being licensed as an APRN, they had to have a collaborative arrangement or agreement with a physician who essentially was stating that they were overseeing those inspectors in their treaty, whether they were on site or not. They effectively said that they were reviewing charts for reviewing the work done after the three years, they could be independent. We could not stop that. More recently, they're trying to get the law changed so that the collaborative agreement can be with other nurse practitioners who are already in practice. And it's like, whoa. You don't know what you don't know, which is tremendously true, and especially in primary care and areas where patients are coming in with what I would say is undifferentiated conditions, they're not yet diagnosed. You got to have a lot of experience and knowledge to even know what path to go. You don't know what algorithm to go down. Out and they have relatively nonspecific symptoms, and the training of nurse practitioners tends to be very algorithm, recipe driven.

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I think one of the biggest challenges that you've identified with the term provider is that it seems to have been used as a way to lump all clinicians together under one umbrella. So you you know patients are encouraged to, oh, you're going to see your provider, and they often assume it's a physician. So physicians are kind of being potentially brought down a level where non physician practitioners like NPs and PAs are then being brought up, and then we're all kind of considered at this same level. However, there is a huge difference in training. And to become a physician is highly standardized, highly rigorous. And I remind our listeners that prior to 1910, it wasn't that way. It wasn't until the Flexner Report came out in 1910 which said, you know, you can't just apprentice your way into medical knowledge. And what we do when we allow a nurse practitioner to work under a physician or a collaborative agreement for X number of hours. That is essentially an apprenticeship. It's only as good as the person that is in charge of you, what their field is, what experience they're letting you do. It's only as effective as how the apprentice is taking it, as far as are they actually putting the effort into learning what needs to be learned. And then when they're released from that apprenticeship, they only know what they learned during that time period. And so to say, like, oh, well, now you can go and do anything. We don't say that's okay for physicians. So therefore, how is it okay for anybody else?

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One of the things which I think really makes medical school and residency training so different is the experience you get in those trainings with seeing sick people, both inpatient and outpatient. The best way to understand how to walk into a room and recognize if someone's sick or not is having seen a lot of sick patients, and follow them through the course of their sickness and whether they recover or not. And that typically happens in the hospital, if all you're doing is wellness care. And you know, walk in type illnesses, the spectrum of exposure is not as broad as it might be.

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The difference in rigor of training is one of the reasons that Dr naran elajba has been speaking out against the use of the word provider. As a published author, newspaper columnist and practicing pediatrician. Dr alajba is a vocal critic of the use of the P word

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when you strip the title of people who have worked their tail off for a decade to save the lives of patients, I think people think it's about ego, and I want to be really clear that I don't really care what you call me. I really care that you understand who I am and what I've done to get where I am, to be at the bedside, saving your life. But when you have new people coming out to practice, it's not well established. They don't have a panel of patients who know what they've done and where they've been. And I think it does a real disservice to all of us who are giving up our 20s, sometimes our 30s to do this, and people don't understand what it's like to give up your 20s. I mean, you you essentially, you don't either date or, you know, keep your marriage together. It's hard to have kids like you. Literally, I lost my entire 20s. I mean, I went into medical school when I was 19, I came out and joined my dad when I was 27 I lost the whole darn time period. I can barely remember anything other than like, wanting to rub two quarters together, making 20,000 that first, you know, second and third year, like we did back then in residency. And so I think it does us a disservice, and it leads to burnout, dissatisfaction, frankly, the Why did I do this? And the problem is people, people may not think about it until they go into that hospital and there isn't a doctor there or the emergency room, which we are getting to the point where there will not be doctors in the emergency room. People keep saying every day to me, why don't why aren't there any family docs? Why aren't there any internal medicine docs? And I said, no one wants to do this job. I love my job, but who's going to do this job? And in 20 years, there won't be anyone, and you won't have a doctor. And people will say, Well, I don't understand. Why are they retiring? Well, this is why. I mean, you don't even call me a doctor anymore. Now I'm a provider, and now nobody knows whether the lab technician or I am the person providing your cure. Hey, I respect the lab technician. I know what they do is completely different than what I do. Yeah. But you know what? They didn't give up their 20s, and I think that's a really important point. So I know you just you touched on a nerve for me, because the word provider, I think, is disrespectful. I think it's dangerous, and I think it's actually, literally leading to more suicide of physicians.

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Radiation Oncologist Dr Marsha Haley says that failing to acknowledge and distinguish the difference in physician training adds insult to injury for already struggling doctors.

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Medicine is changing in a way that is negatively affecting doctors. Governmental policies and reimbursements have made it extremely difficult for physicians to own their own practices, so now, most physicians have lost autonomy and are now employees of corporate medical groups, in many cases, the takeover of local hospitals by these corporate groups has led to prioritizing profits above the well being of patients and staff. Doctors have been fired and replaced with, quote, providers who did not attend medical school or residency, stressful work settings, work life challenges, lack of support, exhaustion, lack of autonomy, and longer work hours are all contributing to the rising physician suicide rate, which is twice that of the general population. So any support that we can give to our physician colleagues, I believe, is very important.

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One way of showing support for physicians is by using their correct title rather than the word provider. Says Dr Haley, she showed an example of a doctor's Day message that locked physicians with non physician practitioners, citing this as an example of the type of messaging that demoralizes physicians. The Post was from a hospital, and it said we would like to thank our clinic providers for what they give every day. Hashtag, national doctors day. Hashtag, thank you. And the post included six photographs, three physicians on top and the bottom row showed several nurse practitioners. All of these individuals were wearing white coats. At the bottom of the pictures was the title, clinic providers. Here's Dr alajba.

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To me, actually, this is the the worst Twitter or whatever this, I think this was on Twitter or Facebook, but the worst one I've seen, and I'll tell you why. To me, when you look at it, it's very striking, because you have six people in pictures with all different letters after their name, and just to clarify, and D is medical doctor. Do is Doctor of osteopathy, and an A or N, P is a registered nurse practitioner. And then we have an acute care nurse practitioner. We have a family nurse practitioner. And what's amazing is they all look the same, right? Like, I guess, I've never seen a better form of propaganda, which is what this is. I mean, it's like the classic propaganda look all these six people look the same. They all have white coats. You know, they're they're all doctors, and you can see any of them, and they don't say 500 hours, 500 hours, 500 hours, 20,000 the guy and then probably did 20,000 hours. And so to me, this is the best example of what provider does. Provider is created to make everyone look the same and and that's the real insidious point.

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Here's Dr Marcia Haley on this post and others like it, the thing

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that bothered me the most was that physicians felt hurt by this one physician, which really affected me, said that this tells me that this healthcare institution doesn't value their physicians. They don't give due recognition to their hardworking, burned out physicians, who have sacrificed blood, sweat and tears. And I heard this over and over again during doctors week by doctors that their institutions either gave tone deaf messages such as, you know, dear practitioners, dear providers, happy provider's day, you know, really not recognizing physicians, and I hope that other healthcare institutions will take note and recognize their doctors appropriately when I go into the emergency room, or, God forbid, a loved one goes into the emergency room, I want there to be a highly trained physician available to take care of me or my loved One. And this appropriation is part of a larger pattern to obscure the different education levels of staff that are taking care of patients. And in a way, it confuses the patients and it's not clear who's taking care of you.

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I asked Dr Robert McLean what steps we can take to reclaim our professional identity and autonomy.

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That's kind of one of the questions we want to get to. How do we do that? And part of it, I think, is being a thorn in the side respectfully. It's, it's, it's not letting it go. Whenever you hear the word provider to stop in the tracks when we I saw you at the end. Ama meeting, you know, a month ago, and I'm known for this among my ACP delegation, and literally, whether it was Dr Oz or Dr white, or somebody, if they occasionally, if the word slipped out, I had like, three people that would turn around and look at me and kind of shake their head, and I would just kind of nod, you know. And now the AMA, in fact, I think the AMA does have some policy against the provider Word, and the ACP has policy that was, you know, passed by the Board of Regents in like 2010 not to use a word that goes back a long time. So this has been resonating for a long time now. At the same time, I will tell you the Annals of Internal Medicine, one of the big journals is the flagship journal for the ACP, but there's a firewall so they can't tell the editor what to do. But I am frustrated when sometimes, you know, opinion pieces or non researchers get through and the authors use the word provider. And I'm like, why didn't the editor say, Hey, listen, we'd rather you not use that word. I think that there again, if, if the doctors are reading other doctors using that word in our own literature, that is tacit approval. Yes, I think we need to push back on that.

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I call it tireless repetition. And I think the more of us that do that, the more we normalize that, calling out, the better we are going to be. And one of the things that really resonated with me was what you said, that the fundamentally unique and sacrosanct relationship between a physician and a patient is not simply providing a health care service, and that's why the term is so inappropriate. It makes it seem like our relationship is just a marketplace, a commodity, and really the relationship is what really matters by calling as provider, you're taking away the whole calling of the practice of medicine and just turning it into a Business Exchange.

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It's exactly right. It's we are relational, we are not transactional. And that is the pushback, and that is the challenge we have because we are in a culture now, or a society that has allowed medicine and healthcare to be treated as a commodity like apples and oranges. As a result of that, we are allowing middlemen to make lots of money and profit on it, the insurance companies making lots of money on it. Now, private equity increasingly making lots of money on it. I think the private equity intrusion increasingly visible in recent years is starting to, I think, make more people kind of raise the question like, is this is healthcare really appropriate to be treated this way, because we've known this for years as we push back on it, the market, commodification of health care is really the problem. And as you said, we are not just providing care. We're not deliverers. You know, I'll say to an attorney, are you a legal advice provider like, No, I'm child. It won't

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happen until paralegals are allowed to practice law without a lawyer supervision, which will never happen because the lawyers make the laws. But I guarantee you, if paralegals were allowed to practice unsupervised or independently, they might start calling them legal providers. It wouldn't surprise me, absolutely.

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And so I think there's that so everyone, everyone's frustrated with the the influence of the market on healthcare delivery, everyone except the middlemen who are making lots of money, really not the hospitals or the doctors.

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You know, I think that this pushback against the commoditization of medicine is so important to regaining the trust of patients. And you say that really, our patients don't want this relationship to be framed in a transactional way. And you write 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. And you also go on to say that meaningful, trusting relationships take time, and they take effort, and we're losing that time as well, and I think that's also something we have to push back against. Just in conclusion, a couple other things that you wrote in your article, really just that sums it up for me, which is, we must retake control of what we do and how our identity is defined. And you know, of course, you're making the point about, do not allow yourself to be called. A provider, but I would say we can take that even further to say that it's way past time for physicians to retake control of what we do and our identity, and so you're so inspiring because you're doing that, and I hope that our listeners will also feel galvanized to realize that we're not just cogs in a wheel. We're not just quote providers. We're physicians, and what we do matters, and we can make a choice to decide to take back control and change the system and make it better. I hope you enjoyed this episode of physicians taking back medicine, a new podcast by medical economics. I'm your host, Dr Rebecca Bernard, bringing you stories of day to day physicians, just like you who are working to improve the health care system. Thanks for listening, and we'll see you on the next episode. You you.