Skip to main content

Doctors as Priests, Providers, and Protectors - Part 1

The Three Faces of the Physician is the subtitle of a recent article in Psychiatric Times by Ronald L. Pies, MD, Professor in Psychiatry at SUNY and Tufts, Editor in Chief Emeritus at said e-zine, bioethicist, and aspiring mensch.  Dr. Pies and I have been allies on a certain DSM revision.  We once butted heads over the nature of suicide.  And he has provided valuable assistance in the science chapters of my soon to be published book Prozac Monologues: Are You Sure It's Just Depression?  His (typically) thoughtful examination of the shifting role of physician calls for a response from the side of the relationship, the confessant, consumer, and cared for, aka patient.  My (typically) thoughtful response will be in three parts, starting in the middle of this alliterative stew.

Pies has many problems with the title provider.  It blurs the distinctions among the various health care team members, their roles, responsibilities, and contributions.  It obscures the dignity of a highly educated, hard working and dedicated profession.  It compromises the relationship with its counterpart, the consumer who comes to the exchange overvaluing what she has learned from her internet searches and trying to tell the doctor what to prescribe.

Consumer Movement

Pies traces the origins of the provider usage to two things, the consumer movement in medicine and the encouragement of the insurance industry.  There are good things to be said about the consumer movement, he acknowledges.  I will list a couple of them here.

My mother's generation never questioned what the good doctor said, never provided information in response to a question it did not occur to the doctor to ask, basically considered their illnesses to be an interruption of the doctor's busy schedule.  My generation now comes to the visit prepared, having researched the meds most likely to be prescribed, wanting to know more, expecting to learn.

Okay, sometimes pushy.  But consider, I brought the possibility of Bipolar II to my provider's attention after six unsuccessful antidepressant trials and a positive result on the Mood Disorder Questionnaire.  She rejected that diagnosis until I returned with my wife who told the story of a hypomanic episode more convincingly than I had.  My being an educated and assertive consumer helped that doc help me.

And expecting quality care.  I came to that doc after realizing I was not required to return to the one before, who had prescribed AD trials #4, #5, and #6.  When I was not prepared to take antidepressant #7, it was time for this consumer to find a new provider.

No Dignity in Being a Consumer

Nevertheless, some of us patients are pushing back on our own designation in this relationship, particularly in the charged issue of medication compliance.  I complained once to the doc who had prescribed #4,  #5, and #6 that when she didn't return urgent phone calls, it damaged my trust and threatened our relationship.  She rushed to correct me, I don't do relationships.  I treat psychiatric disorders with pharmacology."  There was no improving my relationship with that doctor, because there was no relationship.  I could consume or leave.

The consumer movement was intended to turn patients into participants in our own health care.  But the subtleties of the word shape relationships well beyond the doctor's office.  Its use in advocacy groups turns those advocacy groups into providers, and those for whom they advocate into persons who can choose to consume their services or not.  We struggle in such groups to be participants who can shape the group itself.

Provider/Consumer is a Financial Transaction

Provider and consumer are handy shortcut words, useful for assigning computer codes and creating metrics that measure efficiency.  Doctors' frustrations at patients who want five more minutes to become more educated consumers butt up against patients' frustrations at docs who glance at their watches while they answer a question.

How did we get here?  How did we get anywhere in our broken health care system -- it serves the bottom line of the insurance companies.  That's where such language comes from.  It describes an essentially financial transaction.

We don't have health care in the US.  We have a hostage situation.  The battle of consumers v. providers only keeps us distracted from the ka-ching.

Later posts in this series:

Doctors as Priests
Doctors as Priests - The Look
Doctors as Protectors

Photo of Dr. Ronald Pies from
Flair from
Photo of baby being fed byCurtis Newton, used under Creative Commons license
image of cash register from Microsoft clipart


Popular Posts

Anosognosia and Amador

Anosognosia. It means lack of insight. But from the mouth of Xavier Amador, it’s his ticket. He tells you he knows why your son or daughter won’t take meds. And you are desperate for the answer, aren’t you. Because schizophrenia is a terrible disease and your beloved child is sick and won’t take the meds. The meds would make everything alright. So you are desperate and Xavier Amador throws you a lifeline, a promise that once you understand this unpronounceable word, you can learn how to get your child to take the meds.

He must be right, right? Because he is a psychologist and he can pronounce it. And then the kicker, he also loved somebody with schizophrenia, and he says he got him to take the meds. So NAMI invites him to give the spotlight lecture, and for the rest of the convention, parents hear every other presentation through the filter of this new word that they cannot pronounce.

Here is how you pronounce it:

But really, why bother? It means lack of insight. But you have heard o…

Loony Saints - Margaret of Cortona Edition

Every once in a while, Prozac Monologues reaches into my Roman Catholic childhood's fascination with saints, especially the ones who today might be assigned a diagnostic code in the DSM.  Twice, Lent Madness has introduced me to new ones that I share with you.

A few years ago it was Christina the Astonishing.

Today it's Margaret of Cortona.  If you're a Lent Madness regular, you'd expect Margaret to be a shoe in for the first round of voting, where her competition is a stuffy old bishop/theologian, because Margaret became a Franciscan and, more significantly, her story features a dog.  Lent Madness voters are suckers for dogs.

Trading Symptom Relief for Side Effect Relief

Why do people stop taking their psych medication?

Psychiatrists spend a lot of time on this question. They used to call it noncompliance. Then they figured out that the word fed the power struggle between doctor and patient. Now they call it nonadherence. Me, I am not convinced that the word change reflects an attitude shift on doctors' parts, i.e., that they have changed their attitudes toward noncompliantpatients,haveabandoned the power struggle themselves, and instead want to partner with their patients. I suspect the word change is a cosmetic shift designed to change the patient's attitude.

Psychiatric Times regularly publishes articles on why patients don't take their meds and best practices for improving adherence. Suboptimal adherence is pervasive among individuals with chronic health conditions, including psychiatric disorders... However, many mental health practitioners ascribe nonadherence to the mental illness itself.

Xavier Amador thinks it is because we don't…