D. Joy Riley, M.D., M.A.
Executive Director
Family and friends of Dr. Robert D. Orr recently gathered in Vermont to mark his passing. Due to previous COVID restrictions, this celebration of his life took place almost a year after his passing. Dr. Orr, a nationally-recognized physician and medical ethicist, was a mentor to many, many physicians and medical students, including this writer. He is sorely missed.
It is fair to say that Dr. Orr despised the term “provider” as an appellation of a physician. He once surprised a colleague of mine who had submitted a paper to him. He told my colleague that the paper was unpublishable with that “four-letter word” in it. The “four-letter word,” it turns out, was “provider.” Why would “provider” elicit such a response?
Farr Curlin and Christopher Tollefsen in their new book, The Way of Medicine: Ethics and the Healing Profession (University of Notre Dame Press, 2021), provide at least one explanation. They contrast the “Way of Medicine” with the “PSM,” or “provider of services model.” In the Way of Medicine, health is a knowable good, and refers to the “well-functioning of that organism as a whole” (p 4). The PSM holds health as “only a subjective and socially constructed concept” (p 4). If the latter is true, then a patient can ask for anything that he/she thinks is desirable.
Moreover, today’s various institutions of medicine — hospitals, medical schools, insurance companies, and regulatory agencies, to name a few — exert pressure on clinicians to adopt the PSM (p 18). These entities may “threaten to withhold external goods and even to inflict institutional sanctions against those practitioners who, for example, refuse to cooperate in interventions that they believe contradict the purposes of medicine” (p 18).
Curlin and Tollefsen cite the work of Gerald McKenney in tracing the origins of the provider of services model to Rene Descartes and Francis Bacon. In the rush to reduce suffering, “medicine comes to relieve any condition that an individual experiences as a burden” (p 8).
C. Ben Mitchell finds the provider of services model more than lacking: “The PSM is a consumerist model where the customer is always right. Medical professionalism and the duty to do good and not to harm is traded for a ‘provider’ who does what the autonomous customer wants whether or not it truly serves the consumer’s health and well-being. My grocer is my provider of tomatoes and cucumbers. My physician enters into covenant with me not to ‘provide’ but to ‘care’ in the deepest sense of that word. Medicine is not a commodity and physicians are not providers.”
The provider of services model has caused a number of harms, including the physician-patient relationship. But the reality is even worse. The term “provider” has a dark history from the last century — the 1930s, to be exact. According to a December 2021, article in The American Journal of Medicine, the term was used to discredit physicians of Jewish descent in Germany. Here is what happened:
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 German 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.
It is no wonder that Dr. Orr saw “provider” as a four-letter word.
