I am a physician, not a provider, and Groopman agrees


Category : Medical Rants

Pamela Hartzband, M.D., and Jerome Groopman, M.D. have written a brilliant piece in the current NEJM – The New Language of Medicine.  In this piece they explain why some have adopted the term provider and customer rather than the traditional physician and patient.

The words we use to explain our roles are powerful. They set expectations and shape behavior. This change in the language of medicine has important and deleterious consequences. The relationships between doctors, nurses, or any other medical professionals and the patients they care for are now cast primarily in terms of a commercial transaction. The consumer or customer is the buyer, and the provider is the vendor or seller. To be sure, there is a financial aspect to clinical care. But that is only a small part of a much larger whole, and to people who are sick, it's the least important part. The words “consumer” and “provider” are reductionist; they ignore the essential psychological, spiritual, and humanistic dimensions of the relationship — the aspects that traditionally made medicine a “calling,” in which altruism overshadowed personal gain. Furthermore, the term “provider” is deliberately and strikingly generic, designating no specific role or type or level of expertise…

And my favorite quotes from the article –

Beyond introducing new words, the movement toward industrializing and standardizing all of medicine (rather than just safety and emergency protocols) has caused certain terms that were critical to our medical education to all but disappear. “Clinical judgment,” for instance, is a phrase that has fallen into disgrace, replaced by “evidence-based practice,” the practice of medicine based on scientific data. But evidence is not new; throughout our medical education beginning more than three decades ago, we regularly examined the scientific evidence for our clinical practices. On rounds or in clinical conferences, doctors debated the design and results of numerous research studies. But the exercise of clinical judgment, which permitted assessment of those data and the application of study results to an individual patient, was seen as the acme of professional practice. Now some prominent health policy planners and even physicians contend that clinical care should essentially be a matter of following operating manuals containing preset guidelines, like factory blueprints, written by experts.2 These guidelines for care are touted as strictly scientific and objective. In contrast, clinical judgment is cast as subjective, unreliable, and unscientific. But there is a fundamental fallacy in this conception. Whereas data per se may be objective, their application to clinical care by the experts who formulate guidelines is not. This truth, that evidence-based practice codified in clinical guidelines has an inescapable subjective core, is highlighted by the fact that working with the same scientific data, different groups of experts write different guidelines for conditions as common as hypertension and elevated cholesterol levels3 or for the use of screening tests for prostate and breast cancers.

So Hartzband and Groopman understand.  As I talk with physicians throughout this country, physicians understand.  One can easily argue that much of the angst in medicine today derives from these semantics.

I am a physician.  I strive for excellent clinical judgment.  I care for patients, who seem to want a caring, thoughtful physician.

Be wary of inaccurate semantics.  Through these semantics we denigrate physicians and possibly harm patients.  

We should champion individualized, patient centered care rather than accepting a fantasy that one can develop rules to improve medicine.  If we ignore clinical judgment, we lose our professional excellence, harming ourselves and our patients. 

Comments (7)

Thank You! I am a physician in practice and I am happy to see that this was in the NEJM.
Reducing medicine to protocols and guidelines (rather than using them as a starting point only) guarantees failure in any complex or difficult case. 
Also, the market system model is totally inappropriate for medicine. People are not choosing a flavor for their soda they are fighting for their health in a vast jungle of bureaucracy and complex medical information.

Yeah, this would have been a really great article- 20 years ago, when all this stuff was first going down. But Elvis has left this building.
Where were these guys then, when doctors were losing the handle on medicine, in large part fo their own accord?
Forget about reversed, does anyone really believe this trend won't continue,  let alone get worse?
These guys are stage coach drivers, wondering what that distant sound is, not knowing it's a train whistle

It is never too late to speak the truth.
You should never abandon hope.
The more we explain these problems, the more likely we are to stopping that out of control train.

Words matter and dehumanizing terms to describe us and our patients should be rejected.  When we don't speak out, we essentially give a free pass.  If this is our tactic, then we can't complain afterwards.  I am not a provider and I don't care for health care consumers.

Dr. C- Fight the good fight. I agree with you but I am by no means hopeful
Dr. K – In your eyes, you are not . Perhaps in your patients eyes you are not. But in today's medical care community you are. We failed to complain 20 years ago and the next generation of physicians doesn' t understand how the profession has been co-opted by outside forces.

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