Empowerment and the P-Word

This is my first President’s Column—writing one, that is, rather than reading and then thinking about one. Hopefully after reading this (and future President’s Columns) you will believe there was thinking involved somewhere in this process also. While this is my maiden voyage, I have had decades of role modeling from previous presidents’ writings that have inspired me, informed me, provoked my thinking, and supported my growth. My predecessor in my current chair position at the Medical College of Wisconsin (MCW) was Alan David, one of my many important mentors. Alan served as STFM President in 1990-91, as did MCW’s Richard Holloway who served in 1993-94. Looking at a list of the Past Presidents on STFM’s website, I am struck by what a talented group they have been, which has helped realize STFM’s vision of being “the indispensable academic home for every family medicine educator.” There is, of course, still a lot of work to do, because the neighborhood around that home is in constant change, and the needs of its inhabitants are clearly rapidly changing as well. Our core values, “diversity, excellence, integrity, nurturing, openness, and relationships” have been my lived experience in this special organization. They will serve us well as touchstones going forward.

Anyone who attended our 2024 Annual Spring Conference in Los Angeles was inspired by our plenaries and Renee Crichlow’s president’s address, all of which had an underlying thread of addressing serious issues with our current health care system and consequently our challenging teaching environments. To me anyway, family medicine educator empowerment and rejection of the status quo was this year’s unifying theme. P.J. Parmar’s plenary, “Family Medicine as Social Justice,” about Ardas Family Medicine at Mango House in Aurora, Colorado serving refugees, asylees, and undocumented people challenged us to think outside the corporate health care box through real-world actions. Kevin Grumbach’s STFM Foundation 2024 Blanchard Lecture, “Family Medicine and the Counterculture Revolution for Our Times,” gave us all much to think about and provided some vocabulary to describe what we are seeing in a corporatizing, consolidating, and klepto-capitalist ¹ system. Renee Crichlow’s “Primary Care Moonshot: A Joyful Practice” ² addressed practice-based empowerment through redesign, from the ground up. Tanner Dean’s “Generative AI for Research and Education: From Theory to Practice” spoke of empowerment in a different context—that of an academic family medicine educator utilizing AI that provides new opportunities.

Having been inspired by this year’s speakers, may I suggest something you can easily do starting today, if you haven’t already? My suggestion may be the first humble step to achieving these bigger ideas that are absolutely essential for our patients. It requires no funding, no persuasion of public officials, nor even any planning meetings.

Stop using the “P-word.”

Immediately. And politely tell everyone else you meet to do the same. Especially your students, residents, and faculty colleagues. We are otherwise doing ourselves, patients, and yes, future generations an unwitting disservice by using that intentionally disempowering label. I am not surprised to hear insurers or others who are benefiting from the current medical-industrial complex use the word. But I die a little death each time I hear a resident or faculty member use that dispiriting term.

The word is—“provider.”

I have a 45-minute talk on this if it would be helpful for reinforcement purposes. I can send you the PowerPoint slides, which can be used in whole or perhaps better in part to start interactive discussions in your own department or program. I can also be your virtual presenter if needed. My fee is $0. I think all of us taking this small step together is that important.

Why? Words matter. (This should be a friendly reading audience on that point; readers of this journal are academics after all.)

As Erica Jong wrote in her memoir, Language matters because whoever controls the words controls the conversation, because whoever controls the conversation controls its outcome, because whoever frames the debate has already won it." ³

George Orwell had the same idea. Thought and language are deeply interconnected, and language is the basis of human thought that shapes the way we and others see the world. One only needs to look at the state of political discourse in our society to know this is true. Labels are weaponized and the truth is subjugated or even totally crowded out for the purpose of taking or keeping power.

So, let’s start with reframing the debate and its participants, with us self-empowered to first define ourselves, rather than trying to win the debate on others’ terms and being co-opted by adopting their labels for us. Let’s start with something we can all do, and teach our future ranks, using a counterculture and pragmatic mindset, that confronts the disempowering effect of that term.

I won’t go into all the history and arguments against the use of the P-word, and why it harms us and our patients. Many commentaries have been written about this, some of which I keep in a file on my computer’s desktop for easy sending to help gently educate whenever needed. One suggestion is a 2021 commentary by two STFM members. ⁴

Rather than the P-word, use “clinician” if you must collectively use only one word to describe people of multiple professions who care for patients. Better than that, use people’s professional titles of “physician,” “psychologist,” or “clinical pharmacist,” and so forth, whenever possible. Each time you do so, you honor your colleagues' vocation in a small way.

Specifically for those of us who teach family medicine, there is a responsibility to provide a robust written curriculum. Perhaps more importantly we need to pay closer attention to an unwritten, hidden curriculum that serves the same STFM core values mentioned above. The word “provider” is contrary to those values of diversity, excellence, integrity, nurturing, openness, and relationships. The word disproportionately negatively affects women, underrepresented physicians, and all those in primary care fields. It favors lowest common denominator, homogenized minimums rather than celebrating excellence. It lacks integrity, the quality of being honest and adhering to moral principles, with its deliberate obfuscation. Describing a human being with an inanimate term (a provider can be a company or organization) or solely as an economic driver (“provider for one’s family”) is opposed to nurturing. As far as openness, when you think about your own clinical institution’s hierarchies with you in the “provider” class, is transparency the first thing that comes to mind? And relationships are cast to the side in a transaction-based, impersonal “provider”-staffed world.

So here is an action item: talk about this at your upcoming orientations later this spring and to incoming faculty this summer and fall to help create a more professionalizing culture. Make this an agenda item for your next faculty meeting and make a consensus decision. Not everyone will get it; consensus rather than unanimity is ok. There always are and always will be late adopters.

Perhaps our main task as educators is to assist our students and residents in professional identity formation. If that is going well, everything else we want to see follows. None of our learners ever dreamed of becoming a “provider.” Let’s assist them in obtaining what they really want for themselves and their patients. Let their empowerment begin with us.