Gregory M. Weiss, MD

I have been practicing in healthcare in one capacity or another for over twenty years. My first job in the hospital was moping the floor in the operating room (OR) at an academic medical center. From there I became an anesthesia technician in the same OR. Being surrounded by ambitious and knowledgeable people I choose to take things a bit further and applied for a second bachelor’s degree in nursing at the same university where I worked.

I practiced nursing for a few years and progressed into nursing graduate school at which time I decided to apply for medical training. I was accepted, attended medical school, completed residency, two fellowships, and here I am today. But what am I? It has become increasingly clear that healthcare practitioners and physicians, in particular, are experiencing a rather serious identity crisis. But is it really a crisis or simply sour grapes?

Over the last couple of decades, the term “provider” has infiltrated the medical community much to the chagrin of many physicians. On the one hand, the insurance companies and health systems have sought and found a term that they can use to convey a broader concept to their patients, that concept being that many different people may “provide” you with services and care. On the other hand, many physicians consider this term a marginalization or even an insult to their lofty stance in the hierarchy of clinical care. I can clearly see both sides of this debate, however, I have a different take on the motivation behind the controversy. But first, let’s look at some definitions.

The definition of provider is a person or thing that provides something, a breadwinner. At first glance, that definition isn’t helpful. A deeper dive into the word provide reveals that a provider gives someone else something that they need. In the case of a healthcare provider, this “thing” that is given is literally “health” “care”.

Now, this care can consist of putting a cold compress on a forehead or performing quadruple heart bypass surgery but at the core is the concept of providing care at some level. As a former nurse and a contemporary physician, I can identify with providing something for my patients. I personally don’t feel the slight. So, why all the wounded egos? I believe this issue is merely a spinoff from much larger movement within the medical community, one of identity, priority, and entitlement.

Perhaps owing to the long path I took to medicine I considered it the deepest honor to be selected to literally carry the lives of thousands of other humans in my hands. Not for one instant did I ponder the lofty nomenclature that would be granted to me upon completion of my training. I guess I was too preoccupied with learning to be a physician to be proud of the moniker. 

This brings up a really interesting point. Why is it that physicians are so desperate to be called doctors by everyone they encounter? Is it because we have studied so much more than everyone else? Is it because we are deserving of more respect than those not achieving such a high level of education? Would it surprise you to know that we are only one type of doctor in a giant sea of non-medical doctors?

Recently, the First Lady made some headlines because some not-so-well-informed pundit took issue with her calling herself a doctor. That pundit was mistaken of course because the first lady had earned a doctorate in education. The word doctor itself comes from the Latin docēre which means to teach. So, doctors are teachers, not necessarily medical practitioners. The type of doctor that practices medicine is called a physician. This fact in itself serves to dilute the narrow conception most physicians have about being called “doctor”. So why then are so many physicians possessive of the title?

I mentioned earlier that the basis for the backlash against being called providers comes from a larger more tenacious movement within the medical community. Physician doctors (a more apt description akin to calling lawyers juris doctors) have long felt the sting of their profession being marginalized by the exponential rise in non-physician providers performing care traditionally administered solely by physicians. 

The most poignant example of this can be found in my profession where a concerted campaign exists on the part of the nurse anesthetist lobby aimed at convincing state and federal government agencies as well as the general public that physician anesthesiologists are generally obsolete. Outside of the OR nurse practitioners and physician’s assistants practice medicine with increasing autonomy. The truth is that many physicians feel at best that no one knows the difference these days and at worst they fear for their jobs. On a more personal note, many physicians feel that they have earned the title and that they are due the respect that comes with it.

The truth is that the objection to being lumped in with other healthcare providers is hypocritical and completely unnecessary. Physicians who express woe over the increasing responsibility quite frankly given to practitioners by them were the very people who started the name game in the first place. 

The term midlevel provider is seen by nurse practitioners, doctors of nursing practice, nurse anesthetists, and physician assistants as an insult to their training and abilities. The fact is that all of these non-physician advanced clinicians came to be out of physicians’ desire to possess extensions of themselves in an effort to see more patients and yes, realize greater revenues. History has taught us that, over time, one should be careful what one wishes for.

My take is simple. I am what I am. Maybe my perspective is owed to my long path to medicine or possibly my deep connections to nursing as a profession, but I don’t see any problem with being called a provider. After all, I provide high-quality medical care to every patient I see. 

Frankly, if a patient thought I was a jockey or a valet I wouldn’t think twice of it. I know what I am and if my patients are comfortable with me, as their valet, anesthetizing them and keeping them safe during surgery far be it from me to argue the point. I know that seems trite but aren’t I there for them rather than I or them for me? We shouldn’t need validation. We have degrees and certificates, a paycheck, privileges, and affiliations. Where did the “I’m honored to be chosen to have patients put their lives in my hands” go to? 

I think, at the core, physicians ultimately endeavor to impress each other more than garner respect and admiration from advanced practice nurses and physicians’ assistants or even from patients. Are advanced practice non-physician providers eating into our market share? Yes, they are but they are also improving access to care for many rural and inner-city at-risk patients. Am I a provider? Well yes, I am.



This column represents the views and opinions of the author and may not necessarily represent those of the publication. 

Articles

Dr. Gregory Weiss weighs in on the ongoing debate over using the term provider to refer to doctors, which has recently been reignited on social media. 

Your Provider Will See You Now, with Gregory Weiss, MD

Stress has long been associated with a variety of medical conditions. Theories for this range from an increase in detrimental behaviors like eating, drinking, and smoking to systemic inflammation created by heightened sympathetic nervous system activity. Intense psychosocial stress has been associated with some severe forms of cardiac disease.

A form of heart failure known as Takotsubo cardiomyopathy, which is predominantly found in women, can occur after intense emotional stress such as the loss of a spouse and is known as broken heart syndrome. Dr. Dimitriy Panov, of the Institute of Cytology and Genetics, in Novosibirsk, Russia sought to determine if men experiencing extreme fatigue and stress, a condition called vital exhaustion, are at higher risk for heart attack than the general male population. Dr. Panov presented his findings at the ESC Acute CardioVascular Care 2021 Online Congress on March 14, 2021.

When asked what vital exhaustion is Dr. Panov states:

"Vital exhaustion refers to excessive fatigue, feelings of demoralization and increased irritability."

The purpose of this study was to see if heart attacks were occurring in men without prior cardiovascular disease who were suffering from vital exhaustion. Vital exhaustion was measured utilizing the Maastricht Vital Exhaustion Questionnaire and data were extracted from the World Health Organization via the MONICA project.

Vital exhaustion is thought to stem from exposure to intractable problems in the individual’s life including prolonged exposure to psychological stressors. Symptoms were classified as none, moderate, or high and patients were followed for 14 years with the primary outcome being experiencing a heart attack.

Dr. Panov and colleagues found that over two-thirds of the men studied had suffered from vial exhaustion. When compared to those without vital exhaustion, men with moderate or high levels had a nearly 3-fold greater risk of a heart attack within five years, a 2 ¼-fold greater risk within 10 years, and a 2-fold greater risk over 14 years. Interestingly the risk of heart attack in men with vital exhaustion was higher in widowed, divorced, and never married men than in married men. Dr. Panov believes that the reason for this finding is less social support.

"Living alone indicates less social support, which we know from our prior studies is an independent risk factor for myocardial infarction and stroke."

These findings could not have come at a better time. Over the last year, the global pandemic of COVID-19 has led to dramatic increases in social isolation, psycho-social and economic stress, and has resulted in unprecedented mortality leaving countless loved ones without a spouse, parent, or sibling. This combination of stressors represents a perfect storm capable of significantly increasing the incidence of vital exhaustion in the greater population. To make matters worse, evidence suggests that people experiencing acute coronary syndromes may be delaying or even foregoing travel to the hospital out of fear of coronavirus. We have to do better, on several levels, to combat these challenges head-on.

Looking at ways we can make a difference in this population, Dr. Panov suggests,

"Efforts to improve well-being and reduce stress at home and at work can help reduce vital exhaustion. Involvement in community groups is one way to increase social support and become less vulnerable to stress. Together with a healthy lifestyle, these measures should be beneficial for heart health."

Identifying men at risk for or experiencing vital exhaustion may prevent subsequent heart attacks if mitigating strategies aimed at reducing stress, eliminating isolation, and improving overall wellbeing are put into action. This may be accomplished through identification in the primary care setting of those at highest risk. This is a situation where mental health is closely linked to physical health and we as clinicians must look at the whole patient so as not to miss the forest for the tress. As specialists it is easy to focus on cardiovascular issues, that’s what we do, but we should be able to recognize the signs of vital exhaustion and realize that, even in seemingly healthy patients, the risk may be heightened for heart attacks.

Finally, credit should be given to Dr. Panov and colleagues for illuminating a hidden killer. In a time when mental health is in a fragile state, special attention should be paid to the effect extreme stress has on the hearts as well as the minds of men struggling to get by. Front line clinicians are the gatekeepers and with watchful eyes, we can protect their hearts and their lives.

Vital exhaustion and risk of myocardial infarction in male population aged 25- 64 years in Russia/Siberia. Epidemiological program WHO Monica-psychosocial

," was presented virtually as part of the ESC Acute CardioVascular Care 2021 Online Congress.

A study from the ESC Acute CardioVascular Care 2021 Online Congress is providing clinicians with further insight into the effects of psychosocial stress on the cardiovascular health of men. 

Psychosocial Stress Linked to Heart Attacks in Men

More and more evidence suggests that women are diagnosed and treated differently than men when it comes to acute myocardial infarction (AMI) or heart attack. In fact, research presented at this year’s ESC scientific congress shows that chest pain is misdiagnosed more frequently in women who present to the emergency department than men. 

, Dr. Gemma Martinez-Nadal of the Hospital Clinic of Barcelona states:

"Our findings suggest a gender gap in the first evaluation of chest pain, with the likelihood of heart attack being underestimated in women."

Oddly, it is not just clinicians that start out with a low suspicion for AMI but women themselves that doubt the diagnosis. In this study, Dr. Martinez-Nadal and colleagues examined gender differences in the presentation, diagnosis, and management of patients admitted with chest pain. Researchers collected the emergency physicians’ initial diagnosis based on clinical history, physical exam, ECG, and laboratory studies. From these data a first impression was made by the admitting physician.

From analysis of the data, it was quickly determined that women were presenting to the hospital much later than men following the onset of symptoms. Dr. Martinez-Nadal sounds the alarm:

"This is worrying since chest pain is the main symptom of reduced blood flow to the heart (ischemia) because an artery has narrowed. It can lead to a myocardial infarction which needs rapid treatment."

In addition to presenting later, researchers found that the diagnosis of acute coronary syndrome (ACS) was more likely to be considered the cause of chest pain in men compared to women. Further, the low suspicion of ACS in women was maintained regardless of the number of cardiovascular risk factors or the presence of typical chest pain. Results showed that 5% of women were initially misdiagnosed compared to 3% of men.

These facts, presented at this year’s ESC Acute CardioVascular Care 2021 meeting, are not new to many of us who see gender disparities every day in clinical practice. Dr. Martinez-Nadal does a great job bringing the numbers into the light with this study. The problem here is that, to spite cardiovascular disease being the number one killer of women, it has long been associated more with men. When women themselves have preconceived notions about chest pain being anything other than a heart attack, they put themselves at a serious disadvantage but when we as clinicians do the same, we put their lives in jeopardy.

Having met and treated thousands of patients with acute coronary syndromes, I can tell you that, man or woman, they come in frightened and confused. They expect us to rapidly diagnose and treat them without delay or bias. The truth is that there is bias in medicine and it is our job to recognize it and change our behavior. While men and women may present with different symptoms when experiencing AMI, the level of suspicion should be the same and a uniform workup should be performed.

One place this disparity can be addressed prior to an emergent visit to the ER is in the primary care physician’s office. We should take this information and pass it on to patients. Women with cardiovascular risk factors should be counseled to take chest pain seriously. Just as important as informing them of the symptoms associated with having a heart attack is the encouragement to seek help quickly rather than deny the possibility. Education is one of the most important “treatments” we can provide. This presentation at the ESC scientific congress 2021 places particular emphasis on education. Education for clinicians and patients alike.

The work undertaken by Dr. Martinez-Nadal and colleagues underscores the continuing disparities facing patients due to no fault of their own. The lives of all of our patients are important. In conclusion, we should all spread the words of Dr. Martinez-Nadal in an effort to level the field and expand treatment for women experiencing chest pain.

"Heart attack has traditionally been considered a male disease, and has been understudied, underdiagnosed, and undertreated in women, who may attribute symptoms to stress or anxiety. Both women and men with chest pain should seek medical help urgently,” said Dr. Martinez-Nadal.

No one left behind: improving acute cardiovascular care for women

presented at the 2021 ESC Acute CardioVascular Care 2021 Online Congress on March, 14th 2021.

Dr. Gregory Weiss, a critical care cardiologist, offers perspective on a study examining disparities in the diagnosis and treatment of women who experience acute myocardial infarction. 

Gender Disparities in Acute Myocardial Infarction

A Primary Care Agenda for Brain Health

Slideshows

Just ahead of the International Stroke Conference, the AHA released a scientific statement focusing on brain health and aimed at providing primary care providers an overview of factors influencing neurologic health.

Gregory M. Weiss, MD

Articles

Your Provider Will See You Now, with Gregory Weiss, MD

Psychosocial Stress Linked to Heart Attacks in Men

Gender Disparities in Acute Myocardial Infarction

Understanding the American Heart Association's Scientific Statement on Brain Health