Is There a Provider in the House?

“I said Doctor, Doctor, Mr. M.D. – Can you tell me what’s ailing me?” – Good Lovin’, The Grateful Dead

“I’m a doctor, not a mechanic.” – Dr. Leonard “Bones” McCoy, “Star Trek”

“I’m not a doctor, but I play one on TV. ” – Chris Robinson/Dr. Rick Webber of  “General Hospital”

Ceiling, Bellagio Hotel Lobby

I enjoyed an email exchange with a couple of long-distance friends the other day, Gina (an author and journalist) and Eric (a computer/IT professional), prompted by the follow-up questionnaire Gina received after her recent doctor visit and procedure. Throughout the form, it asked her to evaluate the various aspects of her interaction with her provider. 

This struck her as odd and funny, and we engaged in a generally humorous exchange. A couple of really serious points were made as well.

First, though, it made me think of a new game, playing around with words. Take any fictional character from books, film, television; any famous poetry, literary passage, or song lyric; any famous person or historical figure that contains or references the title “doctor” or “physician”, and substitute “practitioner” or “provider.” Dr. Who, Dr. Strangelove, Dr. Zhivago. Christ the Physician. Dr. Spock (both of them), Dr. Koop. Dr. Gawande. “Doctor, my eyes…”, “Doctor, Doctor, tell me the news…” , “Is there a doctor in the house?” You get the idea. Stilted, clumsy, and the result is often strange if not creepy. We can play the same game with references to the word “patient”, substituting “customer” or “client”.

But wait, we already play that game, it is a daily interaction, and we are getting shockingly accustomed to it. Providers and clients, practitioners and customers. The pharmacy asks for customers to press one number, and providers (or prescribers) to press another when you call in to the voice mail to fill a prescription. You never hear much about a provider-client relationship, or a practitioner-customer relationship. Because those words and phrases are meaningless, the relationship has been excised and removed, leaving behind a sterile, contractual business exchange. There is no care or compassion in that space.

Gina wrote, “I honestly didn’t realize I was seeing a “provider.” I thought I was seeing a doctor. Silly me.” As a patient, she experienced a physician-patient relationship, and it struck her as incongruous as she filled out a customer service questionnaire on a provider, assessing her satisfaction with her experience just as one does after servicing a car or reviewing a restaurant.

The words and the titles matter. There is a unique bond and relationship implied between a physician and patient, at once intimate and professional, with trust, respect, and care in addition to the expectation of technical expertise and knowledge. More than a technician and a scribe, just as the patient is more than lab tests, x-rays and keystrokes on a computer. It is a bond of blood and spirit and flesh and bone (to borrow from John Hiatt), more so than any other relationship. If you steal away the words, you erode the meaning, dissolve the relationship. It isn’t special any more. That may be the point.

Other physicians have written about this, and none better than these: In her piece published in the New York Times, Dr. Danielle Ofri speaks eloquently and passionately, saying “…words do influence us. In a world that is increasingly depersonalized, it is ever more critical to maintain protected spheres of human interaction.” Dr. Pamela Hartzband and Dr. Jerome Groopman, in their piece in the NEJM, say “Reducing medicine to economics makes a mockery of the bond between the healer and the sick” as they discuss the corrupting effect and change in focus inherent in this language shift. These physician authors sharply capture my sentiments, and the words continue to resonate, expressing the displeasure and distaste I share with so many of my physician colleagues. Treating medicine as a series of business interactions and satisfaction scores is dangerous (and costly) to patients just as it is demoralizing to physicians. Dr. Robert Centor in his recent piece on KevinMD identifies the root of the problem, saying, “This conundrum exists because someone sees us as providers and patients as customers. I am not a provider; I am a physician. And the patient is not a customer, he/she is a patient.” I strongly urge the reader to follow the links and read the essays, even as I add my own voice to the chorus.

But it is my friend Eric, speaking as a normal person, a patient, writing, “Last time I checked the original Hippocratic Oath does NOT start out ‘I swear by Apollo the provider…’ I agree wholeheartedly with Dr. Hughes… Note I said ‘Doctor’ Hughes. Not ‘Provider’ Hughes. As a patient I want a Doctor, not a provider. I have a client relationship with my lawyer, accountant and fiduciary. Sorry, no more client slots available. I want a doctor/patient relationship with someone that I am entrusting with my health, wellbeing and in some cases my life itself. A provider/client relationship is fine with my stockbroker, plumber and gardener, but not with my physician.” 

Dr. Shara Yurkiewicz in her post “When Doctors are called Providers” spins a cautionary tale. She describes her own experience as a patient, and what happens to the physician-patient bond when our work begins to reflect back on us as providers rather than physicians. Patient confidence, intimacy, and trust suffer, crumble and dissolve. It is little wonder that patient confidence and trust in doctors is eroding. As physicians, we must brace and shore up the physician-patient relationship, claiming and preserving that space we share with our patients, protecting our bond.

Doctors don’t want to be mere providers, interchangeable with myriad other health care workers. Every culture has healers, and they are revered and valued, and have a unique position in their relationship with the patients. There are many others who provide health care, but it is our doctors who are the healers. These roles are not interchangeable with other providers and practitioners, and to imply as much by grouping them all together – doctors and nurses, physician assistants and pharmacists, psychologists and social workers- each of them with their special atributes in caring for patients in their own special capacity, cheapens and disrespects all of them.

Patients don’t want to be clients or customers. They want more than transactions and technology, tests and pills. They are seen at times when they are most vulnerable, when they are ill—they want to be the patient, with all that is implied by that title; cared for, by professionals who understand the humanity as well as the science and technology in this supremely human interaction, who will look after them, who are bound to them.

Let’s quit playing these word games, and stop the insurance companies, administrators, lawyers, and government from painting us all with this same brush, painting medicine into a corner with the language of business and contract and transaction. It is convenient for them, it suits their goals, it simplifies things. It also takes the heart and soul out of the people at the center of the entire enterprise-the patient and the physician. We must always remember that we are in medicine and it is not just the business of health care. It is the profession, the calling, the science and the art of care for our fellow humans and communities.

I know how doctors feel about this, and I am gratified and heartened to see that patients feel the same, one of the many ways that physicians and and patients are truly aligned, no matter who or what else tries to pretend otherwise.

I leave you with the end of our exchange:

“(Eric) I am developing a pretty substantial forehead sized dent in my desk…Now… that said… Doctor… can you give me something for this desk-induced headache? 

(Me) Of course, Eric, that’s easy. We fix those with two aspirin, then call me in the morning…

(Gina) Well-played, Provider Hughes. Well-played.”