PRESIDENT’S PARAGRAPH
Responsibility
by David Donohue, MD
Does use of the "p word" further demoralize physicians? Or is "provider" (short for “healthcare provider”) merely a technical term employed while discussing healthcare issues or workforce requirements? Are prickly physicians who deplore the term disparaging non-physicians?
The American Academy of Family Physicians (AAFP) weighs in: "The term 'provider' is one of bureaucratic origin and has no significance or relevance beyond that created by regulators and insurers. The effect of the term is to create confusion among individuals seeking care, especially those seeking care within a managed care environment. The implication is that 'providers' are interchangeable, and patients can expect to receive the same level of care from any 'provider.' Use of the term is especially inappropriate if it is employed as a tactic to confuse and thereby encourage use of health care professionals of less cost to the insurer."1
Traditionally, the term “healthcare professions” encompassed Medicine, Nursing, and Allied Health;2 members of these groups possessed unique skills, attributes, and cultures. Ignoring or denying the unique skills and cultures of these groups obscures spheres of responsibility and bewilders patients and their families.
In the “physician culture,” the exigencies of medical school and postgraduate training may have excessively emphasized personal responsibility, leading doctors and their patients to consider a bad result the consequence of a botched intervention or the betrayal of a character flaw such as dearth of will; inability to persist or endure to the end; failure to “see things through.”
The elements of “assuming responsibility" may variably include authority, control, power, leadership, management, influence, and duty. Loss of equipoise might manifest as arrogance, obsession, despotism, pushiness (this pejorative unfairly applied with disheartening regularity to women), manipulativeness, self-righteousness, or obduracy. As organizational encroachment on autonomy appears to wrest the privilege of directing a patient's care, a sense of ineffectiveness intensifies the physician's self-doubt in the gloom of the less-than-ideal outcome. Shame looms. "Failure of character."
This is a big problem. It, even more than disgust with “inadequate reimbursement,” underlies the unhappiness of many physicians.
In our society, for better or worse, cultures and norms have stressed physician accountability and recognition of individual achievement or failure. After all, someone is responsible for the patient. Someone must master the details, synthesize, advocate, go to the wall, lead. Will this remain the role of the physician? Is this a job for a case manager? An ethics committee? Will physicians continue to attempt balancing the elements of personal responsibility, preserve the unique relationship with patients, orchestrate better care for them, and lead?
We must rapidly figure out how best to do it, with input (attentively heard) from every “provider”—be they physician,3 nurse, or allied health professional. There is still time as, to date, imposing financial incentives and manipulating information to change attitudes and culture have proven ineffective, thanks to attitudes deeply embedded in institutional cultures and professional norms.4
Sources:
1Provider, Use of Term (Position Paper). [cited 2019 September 8, 2019]; Available from: https://www.aafp.org/about/policies/all/provider-term-position.html.
2The web site of the Association of Schools of Allied Health Professional describes "Allied Health" as those health professions that are distinct from medicine and nursing. It includes dental hygienists, diagnostic medical sonographers, dietitians, medical technologists, occupational therapists, physical therapists, radiographers, respiratory therapists, and speech language pathologists. Allied health professionals are said to comprise 60% of the healthcare workforce.
3Offri, D. Is Exploiting Doctors the Business Plan? NYT June 18, 2019
4Moses, H., III, D.H.M. Matheson, and G. Poste, Serving Individuals and Populations Within Integrated Health Systems: A Bridge Too Far? Serving Individuals and Populations Within Integrated Health Systems. JAMA, 2019. 321(20): p. 1975-1976.