Physicians are Providers

Even if they are more than that

I embrace the idea that having strong opinions,but holding them lightly, is a key to lifelong learning (and, more generally, to being an interesting person).

I have always been put off by other terms for my job other than doctor. I’ll accept ‘physician’, though it sounds a little self-important. I hate the term ‘provider’ and ‘practitioner’ almost as much as I despise it when people refer to my patients as ‘clients’. However, when I read the ACP paper that Dr. Huddle discusses here, I was put off. I could not really articulate why I felt that way until Dr. Huddle did it for me.

Adam Cifu

The American College of Physicians (ACP) views itself as a guardian of professional identity—important for professionals and their work. In its latest attempt to encourage physicians to be their best selves, the ACP is concerned about how physicians are named in public discourse and how those names may alter professional self-conception. “Physicians are not providers,” we are told. “Provider” fits those offering goods or services to buyers in commercial transactions. It is an inaccurate and reductive term for professionals who care for patients. Physicians must be careful to avoid “motivations economic and not ethical.” The forces of commerce threaten the professionalism of professionals; they must resist their blandishments, including any labels suggesting an economic aspect of clinical work.

The ACP’s position paper reflects a longstanding professional conceit—the assertion that professionals care about their clients, unlike the unfortunate creatures in the world of business and commerce who care only about profit. The ACP grudgingly admits that commerce exists in medicine but insists that it must be kept firmly within bounds—in this case, by avoiding any language connoting or alluding to its existence in professional work. Any whiff of the commercial endangers the ethical in professional life—or so we are led to believe.

This erroneous stance—valorizing professionals as champions of the ethical, not to be confused with those whose motives are purely acquisitive—issues from a long and not wholly mistaken tradition of thought about professional work. It is nevertheless an error and, paradoxically, subversive rather than protective of a proper professional self-conception. The grain of truth in it is that physicians are not merely providers; that is, the care they provide is an economic good—valuable and scarce—but they offer it in a different key than do providers in the world of commerce. The essential difference is in the degree to which ends are shared between buyer and seller and in the seller’s regard for the good of the buyer. In ordinary commercial transactions, sellers must deal fairly and consider the customer’s interest, but need not make the customer’s good their own in the way a physician must.

The physician’s provision is more demanding. She must not only provide competent care; she must discern the patient’s individual good and tailor her care to that good. Patients are vulnerable, and physicians must respond to that vulnerability with judgment, nurturing, and self-restraint at the margin of professional actions, possibly beneficial to the physician but not the best way forward for the patient. In the world of commerce, the customer determines her good not unaided but mostly uncontested; in the world of medicine, the physician partners with the patient to clarify as well as to further that good, keeping her own pecuniary interest in check. [AC1]

That said, it is deceptive to suggest that physicians are not economic as well as ethical actors or that physician-patient interactions are not transactional as well as relational. And it is a caricature of business ethics to assert that “business transactions need not focus on values or consider the interests of consumers before those of stockholders and owners.” The ACP is not wrong to contend that commerce and its norms may subvert professionalism. The remedy is not, however, to assert that commercial considerations should play no role in professional work.

In place of a supposed contrast between “ethics” and profit-seeking, the ACP would do better to articulate the more nuanced differences that actually distinguish professional from business norms. In the course of business, businessmen and women seek to gain, but in doing so also help customers to advance their own interests. They must bargain fairly and deliver the promised goods for the agreed-upon price. Professionals share self-interest with businesspeople, but unlike them, subordinate that interest to more demanding fiduciary obligations. That both are paid for services demonstrates their kinship without abolishing their differences. Ideally, both are ethical; both are also (economically) self-interested.

Physicians should welcome analyses of professional work that focus on its economic aspects, including the physician’s role as “provider”. The task for professional ethics is to discern practice arrangements that can be economically competitive and efficient while also encouraging physicians to offer patients the wise and compassionate guidance their profession demands in the course of providing excellent care. It is also to encourage an accurate view of professional identity. Physicians are and ought to be self-interested; but that self-interest should be capacious enough to include professional ideals alongside economic concerns, with the latter properly disciplined and subordinated. That might be achievable if these aspects of professional self-interest are allocated their due and proper limits in the professional’s self-conception. It is less likely to be if the commercial aspects of professional work are obscured by the suggestion that commercialism is evil or, at best, deeply suspect.

Physicians need not be threatened by being named “providers” unless the suggestion is that the patient visit is merely a commercial transaction—which, to my knowledge, is almost never the case when physicians are named “providers.” In the right context, the term serves a useful purpose in highlighting a particular economic aspect of professional work. The danger is not in acknowledging that aspect, as the ACP contends; it is in supposing that professional ethics are somehow strengthened or protected by denying its existence. Physicians should be secure enough to admit that they care about income while also aspiring to Francis Peabody’s ideal of really caring for the patient in their work. Their task is to live in the tension between these aspects of who they are, not to deny the existence of one of them.

Thomas Huddle, MD is Professor Emeritus of Medicine at the UAB Heersink School of Medicine. He served on the ACP Ethics, Professionalism, and Human Rights Committee from 2018 to 2022.