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Wednesday, July 22, 2009

Primary Care "Provider"

I am ashamed to admit that I actually felt annoyed tonight over being referred to as a "primary care provider." It is hard to explain that after 21 years of education and another 23 years of practice as a specialist in Internal Medicine, I would be bothered by this.

One of my patients that I have cared for for 20 years was admitted to the hospital after going to the ER with abdominal pain. I was not informed of his admission and the hospitalist became the attending physician. The patient called me today from his hospital bed to inform me. He actually had a previously scheduled appointment with me in the office today and, good patient that he is, was calling to say he couldn't make it. He assumed I already knew he was admitted to the hospital. I asked him to have the attending doctor call me as soon as he/she made rounds.

Fedex Man by Ed Yourdon via FlickrI got the call from a young-sounding hospitalist who did not know my name and wondered if I was the "primary care provider." When I replied that I was his physician, she then said, "Oh, I don't usually call the primary care provider." That phrase just stopped me cold. It is so "insurance" sounding. So contrived and replaceable. Primary care provider ... delivery man ... vacuum cleaner salesman ... Roto-Rooter man. It's the doctor you can dismiss if you are a hospitalist, one or two years out of training.

"I don't usually call the primary care provider."

Guess I better get thicker skin.

Toni Brayer, FACP, is an ACP Internist editorial board member who blogs at EverythingHealth, designed to address the rapid changes in science, medicine, health and healing in the 21st Century.

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16 Comments:

Anonymous Anonymous said...

I hope that any Roto-Rooter men reading your post also have thick skins. Yes, physicians spend longer in school than most and do important work, but does that make them superior all other professions or trades? Is really so painful to be lumped together with everyone who "provides" a valuable service to society, whether it's health care or plumbing repair?

July 23, 2009 at 12:22 PM  
Anonymous Susan Lee, MD FACP said...

As an internist I too am irked by being called a Primary Care Provider, PCP, gatekeeper. I did not become an internist to be labeled one of these terms.

July 23, 2009 at 12:55 PM  
Blogger DrJHO7 said...

Toni, your thoughts and reaction to the "provider" thing are right on the mark. Yes we are providers, just as we are consumers, patients, parishioners, clients, family members, motorists and other various monikers. However, our professional identity is "Physician", or more specifically, "Internist".

When we were labeled as PCP's by the insurance industry as part of the managed care movement in the late 80's/early 90's, we lost some identity, and in a way, became something less than physicians. The low esteem of the primary care medical specialties of family medicine, internal medicine and pediatrics is partly sustained by this system-wide demotion that has been placed on us. I have long felt that an important part of the resurrection of these specialties must be the reclaiming of our identity as medical specialists.

Our patients respect us for who and what we are. The insurance industry, the government, the pharma industry and indeed our own profession will need to come on board with this recognition and respect for these important specialties if there is to be any hope for internal medicine or family medicine to become sought-after career choices by medical students (obviously in addition to other reforms), again.

I have recently brought these specific issues to the attention of the physician leadership of ACP, the editors of the ACP Internist, and other professional entities to try to heighten awareness and get a dialog going. ACP already has policy supporting this, but we really need to elevate the discussion to our profession so that it gets fixed from the top down, and from the bottom up.

John O'Neill, D.O., FACP
Governor, DE Chapter, ACP

July 25, 2009 at 11:07 AM  
Blogger Jim Purdy said...

I don't have any sympathy for the arrogance of people who are offended by the labels or titles (or lack thereof), but I think the failure to communicate with the patient's physician was inexcusable. (I'm just a patient.)

July 26, 2009 at 12:29 PM  
Blogger Ken said...

As Physicians, we have undertaken a special burden that no other group of "providers" of goods or services has voluntarily accepted to my knowledge: that is the burden to put the interests of our patient (or client, or customer) FIRST. If there are some among us who don't accept that burden themselves, then I agree calling them "providers" is appropriate. For me, it is no more arrogant to insist on being called a Physician than it would be to insist on being called Senator, or General. We have earned it.

July 28, 2009 at 12:30 AM  
Anonymous Toppell, FACP said...

I am not fond of being referred to as a "provider", but I am not offended. I AM offended by hospitalists, or physicians without responsibility. They are arrogant, intrusive and the number one cause of patient calls to the hospital ombudsman. Unfortunately, they are creatures of the insurance companies and allowed to function by harried primary care physicians in their stead. They are offensive and the cause of repeat, unnecessary testing and cost.

July 28, 2009 at 7:02 AM  
Blogger Joseph W. Blackston, MD, JD said...

Thanks Dr. Brayer, and your "offense" was LONG overdue, in my opinion.

The correct response to the query "are you Mr. X's primary care provider?" is not a yes or no answer, it is, at least in your case, "NO, I am his DOCTOR!!"

I do not have "thin skin" but I did NOT go to "provider school." I did not go through a difficult and challenging "provider residency" with every 3rd & 4th night call. I did not spend time in the "Intensive provider Unit" at a large metropolitan hospital taking care of critically ill patients. I do not work in a "provider room" where people come to have their runny noses "provided for," as well as the GSW to the chest.

Internists are a specialty, and should be referred to as such. We would never think to call a surgeon and ask him, "are you the patient's primary abscess-lancer?"

July 28, 2009 at 11:12 AM  
Anonymous Anonymous said...

get over it...
and besides not all PCP's these days are physicians. some are NP's and PA's. (I know, I know - more howls of protest at the thought of being lumped in with these lesser 'providers').

July 28, 2009 at 12:05 PM  
Blogger Jim Purdy said...

One of the comments above said:
"... hospitalists, or physicians without responsibility. They are arrogant, intrusive and the number one cause of patient calls to the hospital ombudsman. Unfortunately, they are creatures of the insurance companies"

That's very scary to me as a patient. I hate hospitals that engage in massive over-ordering of expensive (high-profit) and unnecessary tests.

July 28, 2009 at 4:41 PM  
Anonymous Anonymous said...

In my opinion, the purpose of the moniker "provider" is to generalize the function "doctor" to other non-doctor "providers". In this fashion nurse practitioners, PA's, Chiropractors, hairdressers, and bare feet communist elementary school graduates are seen as coverable "providers" in the financial equation of medicine.

Supply and demand. The provision of residency to DO and MD graduates represents a physician monopoly, presently being whittled away by foreign graduates (many good in my opinion), and other non-physician care providers. Increase the supply of "doctors" and then endeavor to increase the acceptability of non-physicians, and you then are able lower physcian reimbursement.

Why do a residency to be the best you can be for your patients and yourself when you can get away with a four year degree somewhere? How many codes, nights without sleep, stress full exams, intensive evaluations make a physician?

This erosion of identity harms not the physicians of today, as much as it will devastate the provision of care in the future. Who will want to be a "Doctor" when you make nearly the same money for the same title with less than 1/4 the training?

Those pollitically correct types who did not want to offend the new proud members of our clique will hopefully live to see the untoward consequences of their choice.

I foresee a future where 20 "care providers" will see 8 patients an hour, with a physician viewing progress of all 20, by computer, on call if you will to address things if a "provider" gets in over their head.

Upset or failing patients will ratchet up to a second tier "cleaner" - specialist tier with a provider/doctor/apology rep there to clean up the mess.

Obama will have a special ticket to the third level, but the physicians and "care providers" will not be allowed. The country will not be able to close the marxist gap, where providers are unable to benifit from what they produce. (piano makers tearing down the walls of a factor to get pianos they are denied during the ultimate capilist collapse).

I'm not a marxist - but hopefully the trolls recognize the irony

July 28, 2009 at 9:44 PM  
Anonymous Clinton said...

I'm a fourth year medical student and I'm looking forward to being a primary care physician/provider someday. It puzzles me that you feel differently... it must have been the hospitalist's tone.

July 29, 2009 at 6:55 AM  
Anonymous BWL said...

The term "provider" started out with the insurance industry and irked me quite a bit then, it still does.

A physician treats patients over time with individual thought and care. It's hard to deny a physician who wants something for a patient and impossible to argue that something is not needed unless one is of equal stature and possessed of all the facts. So the insurers started calling us "providers".

A wheat farmer is a "producer" of a standard commodity, a rail car full of wheat. The FDA inspects this product to ensure that it is standard. One car of hard red winter wheat should equal any other.

Using the term "provider" turns your work into an interchangeable commodity. CPT helps with this fiction by saying that there are only five levels of service that you can "provide" in your office. Imagine a McDonalds with only five prices for a "meal"!

So a "provider" is anyone who can supply those five CPT codes. Now even insurers are being referred to as "providers" because they buy CPT codes and mark them up and resell them. And you can get the same codes cheaper if they come from a NP or PA. Commodities are not traded on quality, they are traded on price.

Primary care is in trouble partly because it is competing on price with cut-rate "providers". Government price-fixing by the RBRVS has capped prices below a physician's cost of production and predictably, the physician supply of this commodity is disappearing from the market to be replaced by lower cost suppliers, or not replaced at all. Adam Smith's hand is not so invisible here.

So you are not being overly sensitive to object to being a "provider" unless that is what you are. The hospitalist in the original post was obviously a "provider" and has no problem with the term. A physician of your age and experience (same as mine) remembers a time when you were a "physician", and that was and still is deserving of more respect than a "provider".

Bruce Landes, MD
physician

July 29, 2009 at 8:39 AM  
Blogger Jim Purdy said...

As a patient, I find this discussion strange.

I don't care whether you are called a physician, or a doctor, or a provider, or an MD, or an Osteopath, or a Chiropractor, or a naturopath.

Just as I don't care whether your prominently framed diploma came from Harvard or from a state university.

What I do want is somebody who listens to me and responds to my concerns.

In today's society, we need more doctors who listen and communicate with patients, not a bunch of folks who insist on being addressed by titles.

Of course, based on my four-year bachelor of science degree, my name is followed not by MD, but by BS.

July 29, 2009 at 9:15 AM  
Anonymous Anonymous said...

I find it strange that several patients here feel that it does not matter about titles yet they point out to us that their degree gives them the right to follow their name by BS. I not only have a BS but also an MD. I am proud of each and worked hard to obtain each--including working to put myself through school. I always address fellow physicians as doctor---this includes dentist and veterinarians as well. In my practice you receive respect. I also address my patients as Mr. or Mrs. as befits their status in life. I think it is a show of respect---if you have lived 70 years you deserve respect. I think the provider label is obnoxious because it is an insurance label---a government label---something to relegate us to less than professionals---a nameless entity.

July 30, 2009 at 1:06 PM  
Blogger Child Psych said...

Anonymous July 28, 2009 9:44 PM said:

In my opinion, the purpose of the moniker "provider" is to generalize the function "doctor" to other non-doctor "providers"....Increase the supply of "doctors" and then endeavor to increase the acceptability of non-physicians, and you then are able lower physcian reimbursement.

I agree--the same thing has happened for mental health professionals--we are all now mental health providers: psychiatrists, psychologists (me), social workers, marriage and family therapists, pastoral counselors, etc, and with the exception of psychiatrists (as physicians) are all lumped together in insurance provider directories. And paid essentially the same for the same CPT code.

July 31, 2009 at 4:03 PM  
Anonymous Disability Insurance Quote said...

I would have to agree with the comment Ken makes. Look at Feinstein asking the general to refer to her as Senator. The title is earned, and I think the hospatilist should have a little more respect and ask for your name and then refer to you as that.

August 19, 2009 at 4:23 PM  

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Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Auscultation
Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Richmond, Va., with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

DrDialogue
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

FutureDocs
Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

KevinMD
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

Prescriptions
David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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