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Viewpoint
May 28, 2021

Promoting Trust and Morale by Changing How the Word Provider Is Used: Encouraging Specificity and Transparency

Author Affiliations
  • 1Department of Family Medicine and Community Health, University of Wisconsin School of Medicine and Public Health, Madison
  • 2Division of General Internal Medicine, Harvard Medical School and Massachusetts General Hospital, Boston
JAMA. 2021;325(23):2343-2344. doi:10.1001/jama.2021.6046

Use of the term provider in health care originated in government and insurance sectors to designate health care delivery organizations. In 1965, Medicare began using provider for entities qualifying to receive Medicare reimbursement.1 Over the years, the use of the term has expanded to include an ever-enlarging set of individual health care professionals who qualify for payment, especially those in primary care, in addition to institutions (eg, hospitals, clinics, treatment centers) and third-party payers. As such, the term has become part of everyday language in health care delivery, for example, the popular use of the phrase primary care provider. While convenient and a source of pride for some, such use also poses risk for unintentional and potentially detrimental consequences.2

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    18 Comments for this article
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    Strongly agreed
    Boris Golosarsky, MD, FASAM | Integrative Health Center Nashua, New Hampshire
    I strongly support the long overdue article. Patients want to be patients, not commodity consumers. The term is perpetuated by corporate governance. Obscenely compensated corporate leaders hijack medicine. The CEO of a local community hospital is compensated almost twice as much as the President of this country. Why? Because they can. Regardless of the high cost of private insurance, deductibles cover almost all care, besides critical care.

    When patients lose their trusted stressed-out doctors they are forced to see a revolving chain of “providers." Morale has never been so low. The Covid pandemic exposed nationwide weakness in
    management and loss of agility. It is time for effective health care reform. National critical care coverage combined with patients' personal outpatient care choices will restore trust in the system. Middle-man consumption of almost 8% of health care cost will be significantly reduced. The only institutional recipient of government funds will be called provider again.

    The “provider” terminology is another symptom of the systemic disease.
    CONFLICT OF INTEREST: None Reported
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    A Rose is a Rose
    Henry Jackson, MD | Retired
    I am in total agreement. I am a retired VAMC career physician (Internal Medicine) who often had to clarify my role to new patients who were unsure "who my doctor is" because my name was listed as their Provider. Some would actually ask "Are you a real doctor?" As one would correctly intuit, the federal government seems to be on the forefront of such 1984-like "Newspeak." As noted in the article, this works both ways. The term "consumers" is a poor enough term for patients, but at my hospital I was actually sent a form requesting data on my "customers." I reported that I was not a shoe salesman, and thus had no customers.
    CONFLICT OF INTEREST: None Reported
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    A Rose By Any Other Name.....
    Andrew Golden, MD | Kaiser Permanente
    Trust and respect is earned through the individual interaction and relationship with a patient. Despite being labelled "provider" most of my career my patients all know me as and refer to me as "Doctor." I would say that "most" not "some" may argue that replacing the term provider is a frivolous exercise given the many other pressing issues for health care." Your advocacy of this point seems related to your own pride. Your effort would be more successful if the authors were not all MD's but included other "providers."
    CONFLICT OF INTEREST: None Reported
    Excellent Deconstruction of "Provider"
    M Grayson Miller MBA MA LPC, MBA, MA Family Therapy | Affiliated Researcher at Center for Autism Research and Treatment, Semel Institute for Neuroscience & Human Behavior at UCLA
    I started as an MBA in the oil and gas industry in Houston developing corporate planning systems models and directing the design and development of corporate mega-systems for 20 years. I always emphasized the interactions of the individual people for each specialty that meshed together in a coordinated team effort.

    During a Master's Degree in Marriage and Family Therapy program and subsequent residency I became fascinated with serious and persistent mental illness (SPMI) and was hired by a psychiatric hospital in Houston as a therapist on a 32-bed psychiatric ICU (PICU). With my administrative capability and
    my love of team building, I became the PICU Director in 18 months.

    One of my jobs was helping my utilization review team negotiate with insurance companies, especially on diagnoses of first episode schizophreniform disorder, which in 6 months changed to schizophrenia. I described our multidisciplinary approach while they wanted to dictate a treatment plan with fewer "Providers" and a much shorter length of stay.

    I can relate to the statement "This is especially problematic in the increasing number of specialties that make use of team-based care, in which each member serves a special role and makes a much-valued and often unique contribution to care."

    To me, the word "Provider" is dehumanizing and depersonalizing, failing to recognize the individual skills of each person on the team. IMHO the "standard of care" insurance companies want is different from a "good bedside manner" that treats the patient with respect, listens and responds to their questions, builds trust, and makes it safe for patients to disclose more and more of their internal experience. Then and only then can the clinician make the correct diagnosis, especially on PICUs with SPMI patients.
    CONFLICT OF INTEREST: None Reported
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    The P-Word Should be "Professional" not "Provider"
    William Phillips, MD, MPH | Department of Family Medicine, University of Washington, Seattle, Wa. USA
    Drs. Beasley, Roberts, and Goroll offer compelling arguments for avoiding the use of the term “provider” when referring to clinicians and health care professionals. They call for professional societies to cease and desist (1). I agree and extend the call to avoid the p-word in our own language, practice groups, and organizations.

    The term “providers” debases caring professionals. It may seem like convenient shorthand for the mix of physicians, nurse practitioners and physician assistants, and other clinicians. The fact that it is used that way by health systems, employers, insurers, and bureaucrats should alert us to the insidious attack
    upon professionalism and caring.

    The term “provider” is a strategic weapon in the war to commoditize medical professionals, patients, and health care (2). A provider feels more impersonal than a doctor, nurse, or counselor. The impersonal becomes the interchangeable. Provider contracts are more manageable than caring relationships.

    We must take charge of the language we use and the labels we accept. “Clinician” is patient-centered, focused on persons, relationships, and care. “Provider” is service-centered, focused on contracts, services, and widgets.

    When patients use the term “provider,” counsel them on the special clinician-patient relationship. When other health professionals use the term, encourage them to take pride in their own professions and qualifications. When your employer uses the p-word, walk out of the room. They must be talking about someone else.

    References

    1. Beasley JW, Roberts RG, Goroll AH. Promoting trust and morale by changing how the word provider is used. Encouraging specificity and transparency. JAMA. 2021; published online May 28. doi:10.1001/jama.2021.6046

    2. Phillips WR. Watching our words. Washington Family Physician. 2021; (Spring):12. Accessed May 28, 2021. https://epubs.democratprinting.com/publication/?m=63420&i=703514&p=12
    CONFLICT OF INTEREST: None Reported
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    Consistent With Every Physician With Whom I Have Discussed
    O Lauter, MD, MBA, FACP, FHM | Chief Medical Officer, Atlantic Medical Group, Atlantic Health System, Morristown, NJ
    Excellent article and I fully agree. "Provider" is an expression of disrespect to physicians and advanced practice clinicians. It is a flash point. A conversation with a physician that includes "provider" ends as soon as that word is read or heard. Why keep fighting the battle? Let's listen to the "voice of the customer." If the overwhelming majority of physicians feel offended by "provider" stop trying to convince them to feel otherwise. Change your language! Our organization uses "clinician" which has been adopted by many other medical groups. It is inclusive and more efficient than speaking or typing "physicians and advanced practice clinicians." It is time for a change. A change for the better.
    CONFLICT OF INTEREST: None Reported
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    Provider, Professional, Paternal?
    Just Leif, RN, BSN, MHA | Whidbey Health
    Part of the emphasis on the generic professional role has been motivated by the need to better respect the autonomy of the patient role. Thus patients are not now patients but "clients" to some.

    In a [generically] paternalistic system, the trust necessary for an effective healing relationship was easily presumed to extend to the professional "provider." This is today an unacceptable blurring of personal boundaries. So the emphasis should not be on the commercial aspects of care, as the authors agree, but on the personal ethical boundaries of the professional role. Historically we have moved beyond who can
    put their name on a shingle, to how we play on an inclusive team, which includes the informed patient.

    The authors are correct in saying it is not about the words, per se, but it is rather about clarifying the limits of the professional role as sine qua non of the powers uniquely wielded by an effective healer. A patient-centered perspective would be about protecting not group prerogatives but the trust of the patient, and thus the integrity of the varied roles and duties in a professional team of "providers."
    CONFLICT OF INTEREST: None Reported
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    "Provider" - Words matter
    Elvira Lang, MD, PhD, FSIR, FSCEH | Hypnalgesics, LLC d/b/a Comfort Talk®
    Besides the trappings of the use of the term "provider" described in the Viewpoint, the term purveys an even more misleading notion: that there are individuals or institutions that can "provide" or give health to another person. As physicians, we should rather be coaches who help patients help themselves.
    CONFLICT OF INTEREST: Founder and owner of Comfort Talk
    Are we a business?
    Dilipsinh Solanki, MD | Private Practice
    We, the doctors, nurses, NPs, and PAs, provide a service, i.e. health care. We do that as part of a system that facilitates this activity (eg hospitals, clinics, cancer centers, labs, imaging centers). For all this the people who need it are required to pay. To Wall Street we collectively qualify as an industry and that is what they call us: the health care industry. People who provide services are “ providers”. People who receive (“consume”) the services are consumers, not patients. Forbes, and I am sure others, have a regular section noting every new development in all medical fields because it involves a supplier (pharma, medical equipment, tests, imaging).

    People's idea of medicine is Marcus Welby, Dr. Kildare and ER, all of which are a fantasy. But we allowed all this to take root in the minds of people and over time the noble profession is now entrenched as a business. And in many ways it is. Note that a lawyer is always called a lawyer, not a legal care provider, there is not a section in Forbes. They have managed to keep their profession a profession, not an industry.

    So this confusion seems too late! Except in the minds of our patients who come to know us and call us doctors and nurses by our first names like they would a good friend. We are providers in an industry and our patients are consumers!
    CONFLICT OF INTEREST: None Reported
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    Definition at the Outset is Essential
    Anil Nanda, MD | Asthma and Allergy Center, Lewisville and Flower Mound, Texas
    “Provider”and “professional” are generic terms. For full transparency, the title of the health care individual should be discussed at the beginning of the patient encounter. The treating individual should identify themselves as physician, nurse, physician assistant, nurse practitioner, etc. Patients often times do not know who is treating them, and this knowledge is vital to the shared decision making process in clinical medicine.
    CONFLICT OF INTEREST: None Reported
    What is Wrong with Accuracy?
    Michael Bryan, MD |
    "Provider" connotes a homogenous group without distinction while in fact there are significant variations in the level of training and education that can be considered lumped together under the "provider" category. I chuckle when I hear people with higher degrees in non-medical fields insist on being addressed as "doctor" when those who have obtained the designation as MD or DO are called "provider" routinely. Why don't we refer to an individual by their actual credentials (MD, DO, CNP, PA, etc.)? This would be respectful and accurate. I suspect the answer is that those who do not have MD or DO behind their name will protest, and it will be fought by the lobbyists for these groups who are always trying to increase their autonomy. Accuracy is honesty, so protesting it seems very disingenuous.
    CONFLICT OF INTEREST: None Reported
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    Yes, A Doctor is a Doctor
    Kent Savage, MHA | Retired Healthcare Executive
    One of the key areas for a healthcare organization's success is how it interacts with its medical, nursing, technical and support staff groups. Much of this with interactions is respect for the individual beyond any respect for the profession. Many healthcare executives greet physicians by their first name once they have become acquainted and comfortable with one another.

    Unlike many of my peers, I had much angst about that type of interaction unless outside of the professional environment. That angst caused me to always greet physicians as "Dr. _________________" whether in public or private
    to demonstrate the respect that I have for their talents, expertise and training. In return, they always respected me even when I was unable to do or to advocate for what they desired.

    Perhaps that angst was (and remains) the product of growing up in a generation that was taught to respect others and their accomplishments in addition to respecting those that may be older by using Mr., Mrs., or Miss (and now Ms. when Mrs. or Miss may not be appropriate) even if they offer their first name as choice of salutation. The practice is not so much from an old fashioned standard where formality was basic courtesy but more so from the stance of respecting the individual for who they were relative to myself.

    I must agree with Drs. Beasley, Roberts and Goroll that the term "provider" is mostly inappropriate when speaking of individuals. So much of health care has become a process, a proverbial book of things that "must" be done, that the intensely personal nature of health care is frequently overlooked. Returning to proper nomenclature for our healthcare professionals falls into this category and, as a patient intent on maintaining that personal relationship has found, is vital to creating and sustaining that personal relationship.

    After all, what can be more personal than a physical examination that is complete in all aspects? Would I allow someone I do not respect to perform that examination? When I consider who has that privilege, it is a doctor, a nurse practitioner, a physician assistant, a nurse or, in some cases, a technologist or technician. It is never, ever a provider. Furthermore, if I do not exhibit respectful interactions with my healthcare professionals, would they even realize how important that relationship is to me?

    Lumping, grouping, classifying, categorizing, etc., is fine for things but it is seldom, if ever, appropriate for people. Dr. X is my primary care physician. Dr. Y is my neurologist. Nurse practitioner Z manages my follow-up care. Ms. A is the Neurodiagnostic technician that performed my electroencephalogram. I do not view them as providers. I view them as respected, trusted individuals who deserve my respect who will, in turn, respect me. It's that simple.

    So, yes, a doctor is a doctor or physician and not a provider just as each and every healthcare professional are what they are in terms of role. Show them that you respect who they are and what they have to offer by using their title or role and they will respect you and, just as in my case as both a patient and a health care executive, the interactions will be far more valuable and affirming for all involved. Most importantly, it preserves a sense of trust in these valuable and noble professions.

    This is an excellent "Viewpoint" by the authors!
    CONFLICT OF INTEREST: None Reported
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    Amen!
    Brian Livermore, MD, PhD | Retired FP
    Although I am retired (rather timely, I will add), I will just say that my patients were never just consumers, and I was never called anything other than doctor and friend! A professional relationship is never just a commoditiy.
    CONFLICT OF INTEREST: None Reported
    The Real Origin of the P Word?
    Sharon Ng, MD |

    The term "provider" is said to have originated in Nazi Germany, where Jewish physicians were "downgraded" to the title of "provider" (1). Is this not true? And if it is, why is it not discussed?

    Reference

    1. https://thedeductible.com/2019/02/08/if-you-call-me-a-provider-i-will-assume-you-are-a-nazi/

    CONFLICT OF INTEREST: None Reported
    While We’re at it, Let’s Get Rid of the Term “Ancillary Provider”
    Joel Tsevat, MD, MPH | University of Texas Health Science Center at San Antonio
    Beasley, Roberts, and Goroll make a compelling case to avoid using the term “provider” as it relates to healthcare professionals. One point they highlight is that the term can be offensive, disparaging, and demoralizing to healthcare professionals providing patient care.

    But if professionals such as physicians and nurses find the term demeaning, think about those referred to as “ancillary” providers: medical assistants, physician assistants, social workers, medical interpreters phlebotomists, diabetes educators, speech therapists, audiologists, pharmacy techs, and countless other key professional members of the healthcare team (1). Merriam-Webster defines ancillary as subordinate, subsidiary, auxiliary, or supplementary (2). Subordinate connotes
    power differential, even inferiority, and supplementary can be construed as helpful but perhaps not necessary. What could be more offensive, disparaging, or demoralizing than that?

    Ancillary providers deserve our full respect as essential partners on the healthcare team. As we push to get rid of the term provider, let’s get rid of the term ancillary, too.

    References

    1 https://payrhealth.com/resources/blog/list-of-ancillary-services-in-healthcare/; accessed 7 June 2021

    2 https://www.merriam-webster.com/dictionary/ancillary; accessed 6 June 2021

    CONFLICT OF INTEREST: None Reported
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    Getting Access to the Medical Care You Want
    Binh Ngo, M.D. | Keck USC School of Medicine
    We could not agree more with the opinions of the authors. The term "provider" is demeaning to physicians who have spent many years in training to engage in medicine. However, we want to highlight the problem for patients who are seeking care for health conditions. If you are healthy and do not need help, it is not so important to understand credentials and experience. It is when you are ill that it is so important to find the right physician to deal with your issues. This is a complex search, particularly when your medical insurance limits choices. In the present health care environment, it is essential to furnish more rather than less information to patients seeking to deal with their medical problems. The categorization of "provider" does nothing to help but rather hinders the ability to make informed decisions as to where to go to deal with health concerns.
    CONFLICT OF INTEREST: None Reported
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    And This is What is Left of Primary Care
    Alan Zelicoff, MD | None
    Much as I agree with the authors, the pleading for recognition of the primary care physician's unique (or even leadership role) is so much tilting at windmills. Nurse practitioners and, more recently physician assistants have successfully brokered a completely independent role as deliverers of primary care in most states in the US, with every reason to believe the juggernaut will roll on. Far from being more or less exclusively part of a "team", NPs and PAs now have, for all practical purposes, independent clinics delivering primary care that is superficially indistinguishable from that of MDs and DOs. Put another way, the veil is so opaque that all but the most sophisticated of users (formerly "patients") are unable to tell the difference.

    In my neck of the woods, erstwhile mid-level practitioners have established direct primary care (DPC) offices, and have not been shy about promulgating "integrative medicine" clinics (with all of the worthless-if-not-dangerous infusion therapies including ketamine on demand, chelation, and even stem cells), let alone acute and complicated chronic disease management. Should those MDs seeking a way out of the horrific burdens of the EHR and endless administrivia seek salvation with DPC practices, they should know that they are now facing competition from less well trained practitioners. Apparently the market doesn't care (although of course there are exceptions).

    Medical students have taken note, with an ever dwindling minority of graduates pursuing a primary care career. Whether or not this will adversely impact the real world care of complicated (and especially elderly) patients remains to be seen; the studies purporting to show some equivalence between independent NPs and physicians in primary care are, at best, contrived.

    So the point is this: doing primary care well requires either 11 years of post-high school study and training, or it requires 6 (or in the case of PAs, even less). Which one is it? It cannot be both. Opinion writers would, in my view, best be allocate their words to debating such meaningful policy questions. Whining about naming is a merely another symptom of the demise of primary care medicine.
    CONFLICT OF INTEREST: None Reported
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    The patient's viewpoint
    Melissa Yorks, MLS | National Library of Medicine
    I would like to give the patient's viewpoint as I don't see any here. I too like this article. I can't tell you how many times I've had no idea what the title of the person seeing me is. Many PA's, nurse practitioners, technicians and even physicians don't seem to feel it is necessary to introduce themselves. In my youth the person was either a nurse or the doctor. Now you never know if it's your first time there. And with personnel turnover not even just your first time there. Telling me they are my "provider" tells me nothing.
    CONFLICT OF INTEREST: None Reported
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