Dear Provider

We are physicians who often commute together to and from work, and like many others we’ve used our car pool time to complete various work-related tasks (like going through the mail). One day, during a particularly lengthy ride, we realized that many of the e-mails, letters, and pamphlets we were receiving bore the salutation “Dear Provider.” Some had modifiers, such as “Health Care Provider,” or “MassHealth Provider,” and even “Stroke Provider.” Typically, they came from administrators—within our department and hospital and from outside agencies and industries—but also increasingly from clinicians referring to other clinicians as providers. We were piqued by these observations and questioned why professionals taking care of patients—physicians, physician assistants, nurse practitioners, and other clinicians—were being called providers. After all, teachers are not called “educational providers,” attorneys are not described as “legal services providers,” and US senators are not referred to as “legislative providers.” For clinicians, what are the implications of tacitly accepting provider as the label for our professional identity? Does it really matter what we and others call ourselves?

The origins of the provider label as applied to clinicians can be traced to regulatory forces outside the profession. The first use of the term provider in connection with health care appears to have been in Title XIX of the Social Security Amendments of 1965 that established Medicare and Medicaid. This bill refers to “any provider of services” in the sense of a contractor being paid for delivering health-related products and services. The specific term health care provider first appeared in the literature three years later, in an article by Donald Madison¹ in which he wrote about a grant proposal that included the concept of a “patient advocate” as one who facilitates “understanding and cooperation between health care provider and patient.” To our knowledge, the first application of the term to individual clinicians was in a statement by New York State Senator Seymour R. Thaler (D, Queens) who used the phrase “physicians and other providers” during a senate debate regarding Medicaid reimbursement procedures.² Over the ensuing four decades there has been a dramatic rise in usage of the term health care provider, according to our search of publications indexed by Journal Storage (JSTOR) and the Institute for Scientific Information (ISI). Notably, this rise occurred first in the nonbiomedical literature tracked by JSTOR; about 15 years passed before there was a surge in biomedical usage revealed by ISI. By 1993 the label had become so pervasive that it was the subject of a column by William Safire,³ who wrote about a letter he had received from Dr David A. Worth of Union, New Jersey, expressing distress at being called a health care provider “rather than a doctor, a physician or a professional.” It was suspected that the renaming of clinicians as providers was a sign of the ongoing industrialization of medicine.

From a purely semantic point of view, the term provider is a peculiar descriptor of our work. In the common use of the term, providers are suppliers, dispensers, or provisioners operating on a large scale to deliver existing products and services to markets. On the other hand, clinicians are trained to focus on the diagnosis and care of the individual patient. The clinical method requires testing hypotheses, searching for hidden assumptions, exercising inductive logic, and applying other elements of critical thinking. Helping individual patients often hinges on tailored, nuanced analyses of clues elucidated using this approach. Our professional commitment is centered on our patients, just as teachers are committed to their students, attorneys are committed to their clients, and US senators are committed to their constituents.

But it seems to us that there is another serious problem when clinicians are labeled providers. Social scientists are well aware of the power of language. Labeling and name-calling can shape one's self-concept, which in turn influences behavior (a theory known as symbolic interactionism^{4 - 5} ). Thus, language becomes a tool for transforming an individual's identity, a kind of “self-fulfilling prophecy” that defines a person's internalized role. We believe that the title provider could be acting in this way to subliminally alter our own professional self-concept and behavior. We submit that such a transformation is already under way for many clinicians, shifting the clinical encounter from patient-centered to task-oriented. Nowadays, patients are quickly “plugged in” to templated workups; progress notes have become computerized inventories of completed tasks; and when we ask residents on teaching rounds “What do you think?” we often hear “I think I want to get an MRI.” It appears that the time and effort spent by providers packaging patients through the system is displacing most other clinical activities. While high throughput protocols can be effective when diagnoses and treatments are known, is there compelling evidence that this is the best way for solving the unknown?

Physicians and other clinicians are also aware of the power of language. We have learned to attend to the accuracy and precision of language in our case presentations, description of syndromes, and counseling of patients. So we should be asking why have we accepted the designation provider for ourselves. This is a question that is beyond the scope of this car pool, but we might gain initial insights by going back to clinic and asking our patients for their thoughts. After all, our oath has always been to serve our patients first. For that matter, has anyone ever heard patients identify the clinicians taking care of them as providers?