Health Care Reform Articles - February 10, 2022

Editor's Note -

 Today's blog posting is a single article, from The American Journal of Medicine (The American Journal of Medicine, Vol 134, No 12, December 2021) .  

In it, Dr. Salvatore Mangione describes some of the corrosive effects of applying the corporate model to medical care, as is taking place throughout the health care system in the US. We are unique throughout the world in the degree to which we have permitted large, national and international for-profit publicly traded or other investor owned corporate entities to take over our health care system. Corporate culture has now infected many institutions in the non-profit sector as well.

In this article, Dr. Mangione describes some of the extensive damage being done, to health care workers as well as patients, by this invasion.

-SPC

COMMENTARY

The Language Game: We Are Physicians, Not Providers

I speak Spanish to God, Italian to women, French to men, and German to my horse.—Charles V

When Charles V spoke those words, political correctness was certainly a thing of the future. Yet, there was an impor- tant message in his quip: Words matter. Language is much more than a way of communicating; it is a reflection of the character of the people who created it. Italian, for example, does not have a word for “privacy” and, thus, had to adopt it from English. But it does have 34 different terms for “coffee,”1 which says quite a bit about the Italians.

Words reflect how we think, but more importantly they influence how we think and, thus, shape how we ultimately act. This is why the recent shift in medical terminology warrants attention. Not only because it has introduced a new jargon but also because that jargon mirrors and, in turn, is likely to have influenced the downgrading of the patient-physician relationship. Concerningly, such lexicon is being accepted by younger physicians, thus threatening to make these changes a fait accompli.

We are referring to the adoption by medicine of the lan- guage and metrics of business, so that academic efforts have been transmogrified into relative value units; physi- cians into providers; and patients into clients, customers, and consumers. Virtual telemedicine visits have become desirable “billable encounters.” Of course, practices must be organized and financially viable. But we must avoid any- thing that even subtly erodes the true purpose or perception of medicine’s core mission.

One of these terms has a creepy past that, once recog- nized, should give serious pause to its ongoing use. The term “provider(s)” first appeared in Medline English-lan- guage articles only 55 years ago in 1965, primarily in

Funding: None.
Conflicts of Interest: None.
Authorship: All authors had access to the data and a role in writing

this manuscript.
Requests for reprints should be addressed to Salvatore Mangione, MD,

Associate Professor of Medicine, Sidney Kimmel Medical College of Thomas Jefferson University, 1001 Locust Street − Suite 309C, Philadel- phia, PA, 19107.

E-mail address: salmangione@gmail.com

0002-9343/© 2021 Published by Elsevier Inc. https://doi.org/10.1016/j.amjmed.2021.06.031

reference to group practices, hospitals, and networks.2 Yet, as of April 2021 we found 24,692 Medline entries that included “provider(s)” in their title. Of these, 193 were pub- lished in the 1970s; 1044 in the 1980s; 3049 in the 1990s; 4854 in the first decade of this century; and 12,256 in the second one. Curiously, it appears to have been accepted more in the United States than in the United Kingdom and more in internal medicine than in family medicine (Figure).

Some may salute “providers” as a neutral term of inclusivity, wrapping all members of a “health care team” in a cloak of equality in purpose, independent of specific functions within the team. But, as we shall describe, there is more to the history of this term than meets the eye.

Recently, organized medicine has removed eponyms linked to physicians who did not live up to the standards of their medical oath. And here is the irony of “providers.” The term was first introduced by the Nazis in the 1930s when trying to debase German physicians of Jewish descent.3 There were 1253 pediatricians in Hitler’s Reich, and almost half were considered Jewish by the Nuremberg Laws of 1935. When the Nazis ascended to power in 1933, the German Society of Pediatrics asked these physicians to resign. By 1938 the government simply revoked their licenses, so that instead of being called “Arzt” (ie, “doctors”) they were demoted to “Krankenbehandler,” that is, mere “practitioners” or “health care providers.” The term “Krankenbehandler” ultimately was applied to all Ger- man physicians of Jewish descent. Not only did they have to put it on their prescription pads, letterheads, and practice signs, but they also had to display it with a Star of David and the specification that they could only treat Jews. Soon after, mass deportations began. Words have societal implications.

Of course, Nazi propaganda went beyond medicine. The Third Reich was a master at mobilizing the German language for political gains. To better equivocate and confuse the public, it created an entire Lingua Tertii Imperii,4 wherein deportation was turned into “evacuation,” torture into “intensified interrogation,” and executions into “special treatment.” Orwell discussed these issues in “Politics and the English Language”5 and then further expanded them into the “Newspeak” of Nineteen Eighty-Four. Needless to

Mangione et al Doublespeak in Today’s Medicine

1445

250 200 150 100 50 0 NEJM JAMA AIM JGIM AEM AFM LANCET BMJ 1970s 2010s Total (1970-2020)

Figure Use of “provider(s)” in the titles of Medline articles published by various medical journals. Data obtained by searching English-language articles in Medline that included “provider” or “providers” in their titles. With the exception of the NEJM, there were no entries during the 1970s, and none for BMJ throughout the period 1970-2020. AEM = Annals of Emergency Medicine; AFM = Annals of Family Medicine; AIM = Annals of Internal Medicine; BMJ = British Medical Journal; JAMA = Journal of the American Medical Association; JGIM = Jour- nal of General Internal Medicine; NEJM = New England Journal of Medicine.

say, doublespeak is alive and well; consider “collateral damage,” “friendly fire,” and “downsizing.” Medicine is not immune and has seemingly adopted the corporate-speak of “customer (patient) satisfaction,” “stakeholders,” “enterprise,” “deliverables,” and the latest pandemic dou- blespeak of (inadequately protected) “heroes” for viral cannon fodder, “burnout” for moral injury, and pursuit of “wellness” instead of systemic change, which is what is really needed.

We are not naıve; we fully recognize the fiduciary needs of delivering health care within an enormously complex system. But we also worry about “physician well-being” (aka burnout with loss of professional satisfaction) and the parallel trend in physician early retirements. In trying to understand these phenomena, we must pay attention to the subliminal processes that may be eroding the unique role we are permitted to assume as doctors. These processes include the way in which health systems describe the delivery of care, that is, the linguistic categorization of how we spend our professional lives.

Considering its repulsive past, the term “providers” should have been automatically banned, but instead, it was reintroduced on the pseudo-egalitarian basis that physicians, nurses, nurse practitioners, and physician assistants are all health care providers. Merging groups with different professional identities often confuses patients about the various competencies of their caretakers; more importantly, it robs physicians of their rich past and extended training. All “providers” are not equal. As Victor Klemperer pointed out in his Language of the Third Reich, replacing the term “doctor” with “provider” “sounds disparaging because it withholds the official and customary job title.”4 It also withholds an entire set of traits linked to being physicians.

In fact, doctors have traditionally been viewed as much more than dispensers of medical care. In many countries they have stood at the forefront of society, recognized as multifaceted individuals who have imbued their field and social space with wisdom, compassion, and a cultivated mind.6 Do medical educators really wish our brightest medical students to become “providers?” The inclusion in curricula of our unique past combined with the continued performance of vestigial rites of passage would imply that we still care about the societal role and image of physicians. Student acculturation is still replete with symbolic white coat ceremonies, oaths of high professionalism, and a tradition of naming medical services after exceptional doctors who exemplified virtue and competence.7 Yet, this professional identity formation is already challenged by a culture that values science over the humanities, emphasizes technology over clinical skills, and values a complete review of systems in the electronic medical record far more for its billing impact than for its contribution to thoughtful care.

1446 The American Journal of Medicine, Vol 134, No 12, December 2021

To characterize doctors as mere providers is a linguistic debasement that further reduces our professional identity. It downgrades physicians to practitioners who offer services that others could render. We wonder whether deemphasizing important physician traits has not only contributed to our loss of resilience but also further inhibited the formation of a desirable identity in younger doctors. A component of burnout v. 2021 may very well be the loss of joy in performing at high levels in a debased professional role.

Nobel laureate and cardiologist Bernard Lown warned us that, “doctors of conscience have to resist the industrialization of their profession.”8 Nobel-prizewinning economist Paul Krugman put it simply: “The idea that all this can be reduced to money—that doctors are just ‘providers’ selling services to health care ‘consumers’—is, well, sickening. And the prevalence of this kind of language is a sign that something has gone very wrong not just with this discussion, but with our society’s values.”9

The language game of today’s medicine is the latest attempt to industrialize our relationship with the patient by turning it into another financial transaction. Like Orwell’s Newspeak, this will define how the public sees us and how we ultimately see ourselves. Hence, it should be resisted. But how?

The first step toward healing is always awareness. We need to call out the doublespeak to our students and col- leagues and urge them to reject it or at the minimum to recognize the disconnect between how they are referred to in practice and the lofty professional ideals of the Hippocratic oath. Secondly, we need to remind the young generation of the rich tradition of their past, so that they can resist being reduced to technicians; and third, we need to inform the public that if they are dissatisfied with the medical-industrial complex, we are not happy either. The burnout epidemic is evidence for that.

Yale historian Timothy Snyder recently published a disturbing report on his personal medical ordeal.10 In that indictment he did not accuse physicians. Instead he saw them as covictims of a humongous machine more obsessed with profit than service, and wherein doctors have become cogs. In fact, he urged physicians to take charge. This is also an economic necessity. Currently, the United States spends almost twice as much on medical care as other wealthy countries11 and, yet, gets little extra in return.12 Changing all this is not going to be easy, but we might start by resisting demeaning terms that rob our profession of what still makes it the most honorable one of all.

ACKNOWLEDGEMENTS

The authors wish to thank Ms. Jennifer Wilson for her edi- torial assistance.

Salvatore Mangione, MDa Brian F. Mandell, MD, PhDb,c Stephen G. Post, PhDd aAssociate Professor of Medicine, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, Penn bProfessor and Chairman of Academic Medicine, Department of Rheumatology and Immunologic Diseases, Cleveland Clinic Lerner College of Medicine at Case Western Reserve University, Cleveland, Ohio cEditor-in-Chief, Cleveland Clinic Journal of Medicine, Cleveland, Ohio dDivision Head, Medicine in Society, Director, Center for Medi- cal Humanities, Compassionate Care & Bioethics, Stony Brook University School of Medicine, New York, NY

References

1. Fumelli L. 34 modi diversi, tutti italiani, di prendere un caffe al bar. October 31, 2014. Available at: https://www.agrodolce.it/2014/10/31/ tutti-i-modi-per-prendere-un-caffe-al-bar/. Accessed March 17, 2021.

2. Goroll AH. Eliminating the term primary care “provider”: consequen- ces of language for the future of primary care. JAMA 2016;315 (17):1833–4. https://doi.org/10.1001/jama.2016.2329.

3. Saenger P. Jewish pediatricians in Nazi Germany: victims of persecu- tion. Isr Med Assoc J 2006;8(5):324–8.

4. Klemperer V. Lingua tertii imperii: Notizbuch eines Philologen ("The Language of the Third Reich: A Philologist’s Notebook"). Leipzig, DDR: Reclam Verlag; 1947.

5. Orwell G. Politics and the English language. Horizon 1946;13 (76):252–65.

6. Mangione S, Wilson JF, Herrine SK. The archetypes of medicine: a job description for the 21st century. Am J Med Sci 2019;357(2):87–92. 7. Chandran L, Iuli RJ, Strano-Paul L, Post SG. Developing “a way of being”: deliberate approaches to professional identity formation in

medical education. Acad Psychiatry 2019;43(5):521–7.
8. Joseph R. Doctors revolt!. New York Times February 24, 2018. Avail- able at: https://www.nytimes.com/2018/02/24/opinion/sunday/doc-

tors-revolt-bernard-lown.html. Accessed March 25, 2021.
9. Krugman P. Patients are not consumers. New York Times April 22, 2011. Available at: https://www.nytimes.com/2011/04/22/opinion/

22krugman.html. Accessed March 25, 2021.
10. Snyder T. Our Malady: Lessons in Liberty from a Hospital Diary.

New York, NY: Crown Publishing; 2020.
11. Papanicolas I, Woskie LR, Jha AK. Health care spending in the United

States and other high-income countries. JAMA 2018;319(10):1024–39. 12. Ho JY, Preston SH. US mortality in an international context: age variations.  

Popul Dev Rev 2010;36(4):749–73.