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- Mary Norine Walsh, MD, FACC, President, American College of Cardiology∗ ()
- ↵∗Address for correspondence:
Dr. Mary Norine Walsh, American College of Cardiology, 2400 N Street NW, Washington, DC 20037.
“What's in a name? That which we call a rose
By any other name would smell as sweet.”
—William Shakespeare, Romeo and Juliet (1)
I remember the first time someone called me “doctor.” It was during my first clinical rotation in my second year of medical school. My attending physician, a revered general surgeon and gifted teacher, referred to all medical students on our rotation as “doctor” in front of our patients and when he was addressing us. The title lent gravity to what we were doing: interviewing, assessing, and attempting to diagnose and help our very first patients.
I also remember the first time someone called me “doctor” once the title had become a legitimate one. It was on the day of my medical school graduation and the title was shouted at me by my cousin out of a car window as she was driving away from the graduation ceremony. I remember the thrill. The hard-earned title finally fit. And I am sure that my nurse practitioner, physician assistant, and clinical pharmacologist colleagues felt similar pride when they attained, and were addressed by, their rightful titles.
But, somehow over the past several years, like many of you reading this, I have become nothing more than a “provider.” All of the other talented clinicians I work with are also labeled as “providers.” How did this happen? And more importantly, how have we let it happen? And why do we propagate the use of this term?
“Provider” is an insurance term. It is often preceded by the word “billing.” The Centers for Medicare and Medicaid Services (CMS) defines a provider as:
Any Medicare provider (e.g., hospital, skilled nursing facility, home health agency, outpatient physical therapy, comprehensive outpatient rehabilitation facility, end-stage renal disease facility, hospice, physician, non-physician provider, laboratory, supplier, etc.) providing medical services covered under Medicare Part B. Any organization, institution, or individual that provides health care services to Medicare beneficiaries. Physicians, ambulatory surgical centers, and outpatient clinics are some of the providers of services covered under Medicare Part B (2).
The term is also defined in the Health Information Technology for Economic and Clinical Health Act, enacted as part of the American Recovery and Reinvestment Act of 2009, to promote the adoption and meaningful use of health information technology.
“Health care provider” has the meaning given such term in: “Provider of services (as defined in section 1861(u) of the [Social Security] Act, 42 U.S.C. 1395au), a provider of medical or health services (as defined in section 1861(s) of the Act, 42 U.S.C. 1395as), and any other person or organization who furnishes, bills, or is paid for health care in the normal course of business.” (3)
So, providers are, in fact, any person, institution, or facility that furnishes some type of health care service to a patient and submits a bill for the same. But, what has caused this evolution from the individual titles of doctor, nurse practitioner, and physician assistant to the universal provider? And, far worse, our nurse practitioner and physician assistant colleagues are given the moniker “mid-level providers,” not only suggesting that they are not quite up to snuff, but also implying that registered nurses and other such health care professionals are at the bottom of the barrel.
It is difficult to track the evolution of these terms, but it is likely that they proliferated with the integration of physicians and other clinicians into hospital systems and the creation of large physician networks. In the wake of the change from private practice to an employed model, all staff with the capacity to generate income became collectively known as “providers.” The increasing integration of advanced-degreed nurses and physician assistants into health care systems almost certainly contributed. In my large, integrated practice, we often now receive e-mails from our administrative staff with a request to “forward to your providers.” Not too many years ago, I recall those same types of e-mails being sent with a request to “forward to your doctors.” Similarly, I recall the implantable cardioverter-defibrillator, cardiac resynchronization therapy, and pacemaker industry lumping talented cardiologists, electrophysiologists, and cardiac surgeons together, and referring to these professionals as simply “implanters” in their interactions regarding device placement. Talk about underscoring the economic imperative.
More important than this evolution is the extraordinary way that we have acquiesced to this change and adopted the term ourselves. From podiums, on slides, in the published scientific data and even on social media, physicians have begun to refer to themselves as providers. This may, of course, often be very well-intentioned. In attempts to be inclusive of the entire team, we use the broader term to avoid exclusion. But, how often do you hear a patient refer to “my provider” rather than “my doctor” or “my nurse”? Nor do we tend to explore the importance of the “patient-provider” relationship as a construct that is important in health care quality and outcomes.
I suggest that we work hard to buck this trend. Let us start with making certain that our talented nurse practitioner and physician assistant colleagues are referred to with appropriate respect. Our strong embrace of team-based care for our patients with cardiovascular disease makes the issue of how we address our talented colleagues especially important. The American College of Cardiology has grappled with the issue of appropriate titles and names in many venues. One of them is in our own scientific papers. In a document addressing cardiovascular workforce issues several years ago, we adopted the term “nonphysician practitioner” (4). This was a good start, but the “nonphysician” part was felt by some to be as pejorative as “mid-level provider” or the even more insulting, “physician extender.” Over time, improved terms such as advanced practice professional (APP) have been used in a more respectful attempt to address our talented colleagues.
So, let us push back on all fronts. Use inclusive terms such as “professionals” or “clinicians” as alternatives to “provider” when addressing the broader community of health care professionals and insist that others follow suit. Do not be afraid of using “doctors” or “physicians” when making specific reference to them and avoid the pejoratives “mid-level” and “extender.” We all deserve the respect that our hard-earned titles have afforded us. Let us make certain that these titles continue to be used.
- 2017 American College of Cardiology Foundation
- ↵Shakespeare W. Romeo and Juliet. II;ii:43–4.
- ↵Centers for Medicare & Medicaid Services. Glossary. Available at: https://www.cms.gov/apps/glossary/default.asp?Letter=P&Language=English. Accessed April 25, 2017.
- ↵Social Security Administration. Compilation of the Social Security laws. Available at: http://www.ssa.gov/OP_Home/ssact/title18/1861.htm. Accessed May 8, 2017.
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