When doctors are called providers

Impersonal and self-absorbed as Manhattan may be, it’s still embarrassing to cry on West 32nd Street.  I looked for a store, any store, and ducked inside.  The pace of my steps and angle of my head as I buried myself into a back corner, thumbing through pants twice my size, gave me away.  A store clerk walked over and asked if I was okay.  I knew I’d have to meet her eyes, unable to hide the tell-tale redness and puffiness of my own.  I asked if they had a bathroom I could use.

Being Manhattan, there was no customer bathroom, but the store clerk very gently led me to the staff bathroom and told me to take the time I needed.  After five minutes of some fairly heavy crying, I spent the next ten desperately trying to disguise what I had just done.  I scrubbed my face until it hurt and molded my expression back into that of stoic, aloof New Yorker.  My insides didn’t feel much better, but at least my outsides didn’t betray that anymore.   I emerged, thanked the clerk, and took comfort in the fact that I’d never see her again.

My little episode had only intensified the all-consuming ringing in my ears.  The tinnitus had started two years ago, suddenly and unrelentingly.  Five doctors and five clean bills of health later, I was left with the unchanging advice: “We’ve ruled out anything organic and tinnitus isn’t dangerous, so you’ll just have to get used to it.”  No follow-up appointment necessary.

I was left to my own devices–which included the Internet, snake oil supplements, and my own obsessive mind–and I wasn’t using them well.  Besides being sleepless, irritable, and depressed, the far more damning thing was that I was without any hope.  I couldn’t imagine being able to live happily in my body.

Thinking back, I still can’t figure out why it didn’t dawn on me to consider a psychiatrist instead of an ENT or a neurologist.  The idea to see him wasn’t even my own.

After getting to know me, the psychiatrist eventually suggested medications.  I wasn’t afraid of the side effects, and I began immediately.

A year and a half later, everything is much better, objectively and subjectively.  Though not gone, the auditory disturbances are manageable to the point where they hardly register emotionally.  I don’t much like talking about it, for reasons better articulated by Russell Crowe’s character in A Beautiful Mind:  ”I still see things that are not here. I just choose not to acknowledge them. Like a diet of the mind, I just choose not to indulge certain appetites.”

Of course, most times I go to the doctor, for any purpose, I am asked about the reasons I am on certain medications.  Usually my answer is acknowledged, and the appropriate empathetic response is conveyed.

Recently, I was surprised by one doctor’s version of empathy: “Oh, yes, tinnitus can make you literally want to drive off a bridge.”

Of course, this doctor doesn’t know that 18 months ago, I broke down in midtown Manhattan and wondered how I could live out the rest of my life at this rate.  She assumes by my demeanor that I am well-adjusted and perhaps always have been.  She doesn’t know that sometimes when I listen with my stethoscope for a patient’s heartbeat and I hear ringing, that familiar fear makes my own chest tighten.  Or that sometimes I “indulge” in anxiousness when a tinnitus spike occurs that I cannot ignore.  Or that the very condition she was treating me for was creating such a spike at that moment.

Regardless, I was in “no acute distress,” as the medical lingo goes.  I let it go.

I wasn’t even angry with her off-the-cuff remark.  I say silly things to patients on a weekly basis, and the only reason it isn’t more frequently is that I only see patients once a week.

What reminded me of her remark was a piece by Dr. Danielle Ofri in the New York Times, which was inspired by a New England Journal of Medicine article by Dr. Jerome Groopman and Dr. Pamela Hartzband.

All three doctors rail against the term “provider” instead of “doctor” for a number of reasons: the generic term connotes sterility, commodification, distance, and interchangeability.  ”The words we use to explain our roles are powerful,” Groopman and Hartzband explain.  ”They set expectations and shape behavior.”

This is all fair.  And, as a medical student, I should be in especially staunch agreement.  But I’m not.  As a patient, I’ve seen far more “providers” than “doctors.”

I went to the doctor who made the unfortunate comment about my tinnitus because I had an unrelated problem.  She took me seriously, she diagnosed me correctly, she prescribed the appropriate medications, and I got better.  Technically, flawless.  She provided excellent care.

But, Groopman and Hertzband write when we use a term like “provider,” it ignores “the essential psychological, spiritual, and humanistic dimensions of the relationship.”

From a patient’s point of view, though, all it takes it one insensitive comment from the physician to lose that humanistic dimension.  When my doctor made that remark, I relegated her to the impersonal role of provider, someone incapable of understanding my experience but capable of treating my physical problem.  I just wanted to get better.  As Dr. Ofri writes, “It makes [physicians] feel like a vending machine pushing out hermetically sealed bags of ‘health care’ after the ‘consumer’s’ dollar bill is slurped eerily in.”  That is exactly how I saw my doctor.

Was I happy with the care I got?  Sure.  If I have another problem, will I see her again?  Probably.  Was I bothered by her remark?  A little.  Did I care?  Not really.  I didn’t care because I depersonalized her immediately after.  If I cared, the remark would hurt.  I don’t want to hurt.  Is that fair to the doctor?  Maybe not, but I care more about me.

This example is far from unique, for me and for others as well.  There are many reasons people dislike doctors, and many of these reasons are not particularly fair.  But when the same complaints are heard over and over again (“He doesn’t listen to me!”  ”I can’t believe she said that!”  ”He doesn’t understand!”), one has to wonder which came first–the term “provider” or the doctor acting like one.

I’m not dismissing the argument that “provider” is irksome or suggesting that we shouldn’t spend space discussing its consequences.  But I wanted to spend some space on rationalizing why patients may already think in these terms: on how in many cases physical provision of health care is exactly what doctors do, and on how depersonalizing doctors can actually protect patients when their emotional or humanistic care is lacking.  And the term “provider” sometimes fits, even if doctors don’t want to wear it.

“But words do influence us,” Dr. Ofri writes about what doctors are called.  Yes, they do.  Now let’s take those thoughts and apply them to what doctors say too.

Shara Yurkiewicz is a medical student who blogs at This May Hurt a Bit.

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  • http://briarcroft.wordpress.com/ Emily Gibson

    Shara, I suspect the physician who made the remark about tinnitus really believed she was being empathic, and you are right, she could have expressed it in a way that elicited your experience with tinnitus rather than making the blunt statement. 

    I don’t see the connection to doctors becoming “health care providers” in modern parlance though.  The term started over thirty years ago, about when HMOs started labeling patients as “consumers”, another distasteful and inaccurate term.  I find fewer references to patient consumers these days, but with the plethora of non-physician clinicians working alongside doctors, especially in primary care (and many of the physical therapists, nurses and nurse practitioners also have their doctorate degrees now), the term provider is meant to be all-encompassing for clinicians.  I don’t object to being a physician-provider, as long as I don’t lose my sensitivity to what the patient is really asking for and needing.  Whether I can “provide” it or not is always an issue, so I’m more concerned that I won’t live up to that “provider” label in the patient’s perspective.

    What is another universal term for clinicians? It won’t be long and physicians will be the minority in the health care realm of primary care.  Beats me.  Seems as though we should respond to the needs of the patient no matter what we are called.  Emily

    • ProudOkie

      Emily,

      I would rather you not be in the minority! We need you and your specialties! You sound like a wonderful physician!

      Proud Okie

  • http://distractible.org/ Dr. Rob

    Great post.  I am a tinnitis sufferer as well.  Although I don’t wish it on anyone, I am far more sensitive for the sufferings I’ve experienced.  I agree that getting the degree doesn’t make one a “doctor.”  It’s a holy calling, in many ways, yet many treat it as something they are entitled to do.  

    • Molly_Rn

      Tinnitis like arthritic pain seems so over blown when some one else complains about it, but very real and miserable when you have it. I have finally realized that I will never again hear nothing, never hear silence. The different noises and ringings will persist until I die. Just one arthritic finger and I am astounded that people go about their daily lives with both hands suffering from arthritis. There is empathy and there is understanding, not necessarily the same.

  • Shara Yurkiewicz

    Thanks for writing, Emily. I agree that the doctor who treated me was just trying to be nice, and I didn’t hold what she said against her.  In fact, I bet many patients would have appreciated that she acknowledged the problem. It probably beats dismissal.

    But when one argues that we should use the term “doctor” or else we ignore “the essential psychological, spiritual, and humanistic dimensions of the relationship”… well, that to me sounds a bit heavy-handed and does not reflect the experiences I have had as a patient.  Sometimes a doctor really does just provide the care you need, and I don’t think that’s necessarily a bad thing.  I used this particular anecdote as an example of such a sterile experience from my point of view.

    I spent a bit of time in D.C. doing policy work and I used the term “provider” all the time because it was the only catch-all phrase apart from “clinician” that I could think of.  In medical school, there is definitely scorn towards the term.  Personally, I don’t care what I’m called, but I respect that others think “doctor” is a title that they have earned.

    FYI, when I originally posted this on my blog, it elicited a pretty interesting discussion: http://blogs.plos.org/thismayhurtabit/2012/01/03/713/#comments

  • sFord48

    The term “provider” is more accurate with the use of nurse practitioners and physicians assistants in the mix.

    • ProudOkie

      As a Nurse Practitioner, I am to be called a Nurse Practitioner in that “mix”. I will call you a physician. You don’t have the final say anymore. I know it hurts but I’m independently here to stay. Carry on……

      Proud Okie

      • sFord48

        Sorry, I am a not a doctor…just a patient…not sure why you are so offended that medical care can be provided by different types of providers.  You’re in the mix whether you have an independent practice or not.

        I used to see an independently practicing ARNP but she retired.  Probably the best care I have ever received.  I would consider another ARNP practice if one was close by.

        • ProudOkie

          I apologize and jumped to the conclusion you were insinuating that MDs/DOs are called “providers” because of NPs and PAs working in the same place. My apologies – as AvengerCorp did, many prefer to relegate us to a level of “where we should be” through their world view. There are many world views and customers have the right to choose who they see for their healthcare. A “mid-level” is not a healthcare provider; a Nurse Practitioner is….so I challenge those physicians offended by the term “provider” to stop using the term “mid-level”. I ALWAYS use the term “physician” when referring to that profession – that is what they are and they deserve the respect of the title. When I am around a group of physicians who use the term mid-level, I make sure and refer to them as a provider somewhere in the conversation. I only want to be labeled as I am – a Nurse Practitioner….makes perfect sense!!! Again, my apologies.

          Proud Okie

      • http://www.facebook.com/people/Jason-Simpson/100001631757606 Jason Simpson

        You are a liar.  NPs are NOT independent in Oklahoma.  Give us your real name so I can look you up on teh Oklahoma Nursing Board website and find your supervising physician.

        • ProudOkie

          This is an excellent example of the vitriol and hatred toward NPs, the free market,  and many of the services we provide. In my very few discussions with physicians on this site, I have never been personally attacked although the discussions are heated. Please do not disprect others when posting. I would hope the moderator would remove this comment….so, for Jason, a “caveat” – aside from needing a physician to sign an agreement at the BON in OKLAHOMA for issuing presecriptions, NPs are INDEPENDENT in Oklahoma. In seventeen states and DC, NPs are completely independent….so, as mentioned earlier, independent NPs are here to stay. Carry on.

          Proud Okie

          • http://distractible.org/ Dr. Rob

            No, he was just being a troll.  Saying things like “You are a liar” is meant to do nothing but inflame. If you post on sites like this, expect that type of response.  It’s not good, but it happens.  If he meant to discuss the situation, he would have said: “I thought that Oklahoma requires supervision by a physician.  Can you explain?

            On the larger point, I think people are nit-picking here.  Your point was that docs (or NP’s) who don’t treat patients with care and compassion are reducing them to a commodity.  When they do that, they themselves are not worthy of the professional title.  If you want to be treated respectfully (as a provider or as a commenter), then you should be respectful and sympathetic.  That is a point that is still escaping some folks, and always will do so.

          • Shara Yurkiewicz

            Thanks, Dr. Rob.  Some of the comments here are less than inspiring, unfortunately.

  • jul965

    I am a “provider”–a physician assistant in a health care facility which provides inpatient medical care to homeless folks.  I think of the term more to suggest “providing” comfort, support, medical care and connection to other resources that will help our patients improve their lives in many contexts.  We are a team of Drs., Nurses, NPs, PAs, and RNs–there are few egos there that demand distinction by title; we are all humbled by the strength, resilience and the capacity for forgiveness demonstrated by our patients.  We are all lucky and honored to call ourselves “providers” no matter what our degrees!

  • theaznecho

    This is an excellent article you wrote. Many of us starts off in our younger days with empathy to our patients. Soon this empathy fades off because of many factors. The lack of time, the numbers crunch, the whining of some patients who go around in circle are a few of
    them. But at the end of the day, some of us deservingly called physicians will remain mostly empathuc to most of our patients.

  • CorpAvenger

    I agree that the use of language is very important and that the term “Provider” is de-humanizing and therefore disconnecting patients and doctors. I believe that this term was first coined by the “Insurance Industry” because as the author so correctly points such a term implies a kind of “Interchangeability” of parts…. This provider, that provider… Our Network of “Providers”… Degree or training, place of employment or schooling, it all doesn’t matter here, these are our “Chosen Providers” chosen by us, screened by us, and you can only make use of “These Screened and Chosen for you, Providers”….

    As much as I like and respect many Mid-Level Providers, I do believe that if we were to actually discuss this HONESTLY and not have viseral responses or defend and define “turf” here, that most Mid-Levels and their organizations, are happy, fine, content with the general public confusion and lack of understanding the differences in degrees and training as this plays to their professional and economic advantage. Having themselves and the like confused and lumped in with actual D.O.’s and M.D.’s raises their status and perspective in the community local and in general. No offense here, but as the Practice Manager, spouse of an actual MD level Family Physician I see and hear this confusion all the time, hearing paitents refer to the Mid-Level most specialist have perform almost all their office visits for them (as though OV and personal realationships, spending time with their patients is beneith them) as “The Doctor” said this or that. I ask “so you actually saw and discuss this with Dr. Jones???” to which I then get a clarifying “Oh no, I saw his nurse or what have you, whatever she is, but she’s the one I always see and talk to… I not sure I have actually ever met and spoken with Dr. Jones….” We’d love to refer to offices that don’t behave this way but many times, we have little or no choice as so many of them are running their practices this way, these days… Keep the specialist cutting and doing high paying procedures and the Mid-Levels doing the low paying, time consuming Office Visits.

    So, in closing I would like to request that ALL parties involved the Insurance Carriers, the Staff, the Doctors and all the Mid-Levels, all make it a good habit of correcting people, making best us of the most accurate and appropriate professional names, terms when discussing other “Providers”. Then perhaps with lots of practice and proper use on our side, we can hope that the patients start to learn it and catch on… And I believe that all providers should be proud to own their own professional titles… But as I said, not all but way too many Mid-Levels seem to not do this often or well enough to keep these terms clear…. And with that happening so regularly, one has to start to wonder why….

    And of course we all know why the insurance industry likes this… Just as the NHL didn’t promote their stars or enforce the clutching and grabbing before the salary cap….. Having some people actually recognized as being higher leveled, better trained or knowledgeable, having more or better skills means having to recognize that too and therefore pay those better rated and recognized performers better as well. Only after they got the salary cap did the league then start to actively promote their stars now that all clubs had a throttle on how much they were on the hook for paying in full. And the insurance industry has been attempting to find various ways to dehumanize, devalue and homogenize their “Stars” and better Providers too, with all paid the same fee schedules, all patients pay all docs and mid-levels the same exact co-pay or cost share percentages…. We all cost the same, therefore there is no market based reason to choose one provider over another…. even though the FTC and now even the DOJ insist that there is one… Where I don’t know because nothing in the Business of American Medicine resembles an actually Free Market to me….

    So let’s all vow to one another to start making sure we all use the best and most appropriate term when discussing other “Providers” in public to try and start to clarify this for the general public and in doing so, for ourselves as well….

    • ProudOkie

      So, those are the terms you have decided to use? Yes, let’s all get on the same page as you suggest – it’s very simple – physicians are physicians and the term “provider” is offensive to them; Nurse Practitioners are Nurse Practitioners; the term “mid-level” is offensive to them. It’s okay to offend the NP and horrible to offend the physician? I don’t care where my status is elevated – most of my customers at my clinic see me BECAUSE I am a Nurse Practitioner. It’s comical how you use the terms of your choosing and then say “let’s use these and all get along”. I have a challenge for you – call everyone what they are – eliminate the term mid-level from your vocabulary. I did not graduate from “mid-level” school. Your entire post denigrates NPs and then asks us all to get along. Take the blinders off – at my private clinic, the name has my title in it, when you walk in the door, you MUST sign a notice that there are no physicians in my clinic and you will always be treated by a Nurse Practitioner or I won’t treat you – full disclosure, and yet nothing changes. Are you okay with customers seeing NPs in the free market with full disclosure? Because that is what is happening. You assume if everyone knew they weren’t seeing a physician they would run like the wind – you are wrong. We see at least 30 patients a day in a town of 2,500. So, we agree, right? No more mid-level – only physician and nurse practitioner. Your husband isn’t offended, I’m not offended, patients know exactly who they are seeing and everyone is taken care of. Are you okay with that?

      Proud Okie

      • ProudOkie
        • http://www.facebook.com/people/Jason-Simpson/100001631757606 Jason Simpson

          By Oklahoma State Law, NPs are REQUIRED to have a physician “collaboration” or whatever you want to call it.  If you go to the Oklahoma State Board of Nursing and look up any NP, it will have a section on their online profile that lists “supervising physician.”  

          So you are lying to everyone here by implying that you practice independently.  That is ILLEGAL under Oklahoma State Law.  It may be true that your physician “supervisor” is never on site and has no clue what you are doing, but thats simply an example of his egregious and ridiculous medical malpractice than a testimony to your “independent” practice.

          • ProudOkie

            Again, no personal attacks Jason – see my other post…and trust me, many physicians on this site will attest to the fact that even employed NPs have their own panel of patients that a physician never sees. So, this would make most of the physicians in any state a terrible example of medical malpractice (which is not true in reality because this is simply the way healthcare is delivered). It has already been proven in the completely independent states that NPs practicing at the top of their scope cause no harm and do not increase liability issues. But this was all discussed long before you showed up. So, as stated earlier, we are independently here to stay. In Oklahoma, that includes independent diagnosis and treatment aside from prescriptions. All of the posters here are well educated and know which states are independent and which states are not. I would hope the moderator would remove your post above as well. It is a well stated opinion aside from the elementary attack. Aside from that, thanks for the response.

            Proud Okie

      • SidewaysShrink

        In Washington State, NPs have independent practice.  In addition to running my own private practice in psychiatry I have founded a nurse run nonprofit agency to provide sliding scale psychiatric care to uninsured adults who do not qualify for Medicare or Medicaid.  I like your approach Proud Okie. Keep speaking up. 

  • Shara Yurkiewicz

    Just an addendum, because I don’t think the post was clear enough on this point:

    I completely acknowledge that it is difficult to know your audience, particularly if your audience is a first-time patient. I purposely chose this example over a lot of egregious ones because I knew it was one that was open to interpretation. Some people definitely would have appreciated the doctor’s sympathy. I personally found that she overshot her hyperbole to the point of alienation. I tried to explain my feelings by giving a bit of my background and how depressed I actually was at one point.

    I think her way of talking to me was immensely preferable compared to the doctors who dismissed me entirely. I just found this “gray” interaction more interesting to write about, precisely because it generated the discussion of “Was what she said really all that bad?” and “How can I possibly please all patients, with differing sensibilities, all the time?”