Bioethics Forum Essay
Physician or Provider? What’s in a Name?
A recent policy paper from the American College of Physicians said that the term provider should not be used for physician. Noting concern that provider deemphasizes professional identity and important differences between physicians and nonphysicians, the paper frames the choice of words as “an ethical matter.”
The language we use has important ramifications for the moral judgments we make. Challenging an ethical position often begins with challenging its wording. The words we use to describe clinical relationships will come to bear on those relationships. The word provider has a valence of market transaction. Insofar as the word leads medicine further down a path away from patient-centered care and toward commodification, then ethicists ought to consider whether the word is worthy of the goods of healthcare.
But concerns over medicine’s commercialization aren’t exclusive to physicians — nonphysicians who provide healthcare goods to patients share such concerns. This makes me wonder whether the policy paper is primarily motivated by the commodification of healthcare or the prestige of the physician.
The paper notes that provider“obscures differences in training and expertise,” which suggests that physicians are at the top of a knowledge hierarchy. This is true much of the time. But the term physician does not automatically tell us all we need to know about the person providing us with care. People should not uncritically accept that a physician is by default more knowledgeable or capable or informed than, say, a nurse practitioner with a university appointment. Some physicians, for instance, are skeptical of lifesaving vaccines, and they attempt to bolster their view by referring to their physician title.
We should avoid cultivating a medical culture in which patients think that only the word of a physician is worth believing. There is a shortage of physicians in rural and under-resourced areas, but the number of nurse practitioners and physician assistants/associates is increasing. Surely the growing availability of these professionals is a good thing for individual and public health. Undercutting their expertise could have negative consequences for both.
We also shouldn’t overlook the gender dynamics at play when it comes to naming professionals in clinical spaces. Women make up about 80% of nurse practitioners and more than 60% of physician assistants. These professionals are on the frontlines of public health. Might the “Call me a physician!” demand reflect gender bias?
Additionally, it is difficult to imagine that insurance reimbursement rates aren’t part of this discussion. There have long been arguments about whether PAs and physicians should be reimbursed at the same rate. Medicare pays PAs 85% of the amount it pays to physicians, unless the PA can bill under a supervising physician (what’s known as incident to billing). It’s in physicians’ financial interest to remind the public — and insurers — that even when they perform the same procedure as one of their team members or trainees, they are worth more money.
All of this leads to my main question: Whom does the naming policy serve? It’s hard to argue that it’s patients. Such a strict hierarchical approach, where the physician is seen to sit peerlessly at the top of Medicine, risks harming the foundation of shared decision-making. It also risks shoring up the medical clericalism that bioethicists have encouraged practitioners to be on guard against. Ensuring that physicians carry themselves at all times as members of a profession is a noble goal. But calling a physician a physician doesn’t magically cultivate professionalism in a practitioner.
There is nothing inherently wrong with the word provider. Parents provide for their children. My husband provides for me. I try to provide for my students. My PA provides me with clinical judgment and reassurances. My physician, who sometimes collaborates with my PA, provides me with similar goods. People we are in relationships with provide us with care and kindness and pick-me-ups and friendship. There is no reason to get rid of the word provider just because it also happens to be used in transactional contexts. And there is no reason to insist that healthcare professionals who are also physicians be referred to exclusively by the second word. Patients go to healthcare professionals because we want to be provided for, and it makes sense for our language to reflect that.
Brandon Ambrosino, PhD, is a bioethicist and theologian at Villanova University. @BrandonAmbro, LinkedIn Brandon Ambrosino
Why not just say healthcare “professional,” and call it a day?
I tend to use “clinician” to be encompassing of all those who serve “patients.” I do find the term “provider” to be troubling — not because of the hierarchy that the article contends “physician” implies, but because it is so generic and transactional. Provider can apply to a car dealer, a heroin dealer, and just about anyone else in business – most of whom do not make any sort of covenant with the purchaser. I acknowledge the challenge of using “physician” to include NPs, PAs, chiropracters, naturopaths, social workers, therapists, and anyone else who is presumed by the “patient” to be working in the patient’s best interest. Sometimes, just for keeping the prose workable, I have to define “physician” to include all of us, like in the Handbook for Mortals, a book for the public. But mostly in professional writings, I’d use “clinician” to be inclusive and “physician” to mean those who have MD or DO degrees and licenses. What a patient uses is up to the patient, and we have to be adaptable and accommodate the patient’s understanding and language.
Good idea re: “clinician.” But I do wonder if some physicians might level the same criticism against the word: that it erases important distinctions. But I like the idea! As for the word “provider” having a transactional valence: I hear the criticism. But I also realize that even terms like “treatment plan,” “co-pay,” and “coverage” call to mind transactions, and for most practices, these terms will be in play. As you note, our language is not perfect, and the best thing to do is try and accommodate patients, which often means using their terms.
Why not say “clinician” and leave it at that?
I too use the term “clinician” in my writing and when speaking to patients about who will be taking care of them. I do not like the term “provider” and find it not only to be transactional but does not express any care.
It is biased and harsh to assume and accuse physicians of not wanting to called providers because of money and hierarchy. . I was not, of course, privy to the discussion of the ACP, and this may be true, but it may not be.
Physicians have longer training than non-physician clinicians, the vast majority with specialty and subspecialty training and board certification. That is not true of PAs and NPs. The reimbursements need to reflect the additional years spent training.
PAs and NPs can speak up for themselves and decide what they wish to be called.
To me – when speaking about the group of people who care for patients- say clinicians – and then physician, physician assistant, or nurse practitioner when talking about the specific clinician. Let’s let patients know who is caring for them and what their training is.
I appreciated your courage to present this issue and examine the various reasons why it matters for the American College of Physicians. What wasn’t mentioned was the damage this kind of posturing does to the much needed shift to interprofessional collaboration. We need everyone on the team to work together considering the complicated patients we see, especially older patients. We don’t need petty fights about titles.