Dementia Care Gaps: What the “Physician vs. Provider” Debate Reveals
- 5 days ago
- 6 min read
Dementia Care Gaps: What the “Physician vs. Provider” Debate Reveals
Structure shapes experience and outcomes.
Families caring for someone with dementia rarely debate professional titles. They are asking whether the medical system can meet their needs.
A recent ethics and policy article published by the American College of Physicians in Annals of Internal Medicine, titled “Physicians Are Not Providers: The Ethical Significance of Names in Health Care: A Policy Paper From the American College of Physicians,” reignited discussion about the term “provider.” The authors argue that the word diminishes the ethical and professional identity of physicians and risks reducing the patient–physician relationship to a transactional model.
Language does matter.
Titles communicate training, scope, and accountability. Patients deserve clarity about who is caring for them. In many states, including California, the use of “physician” and the clinical use of “doctor” are regulated to prevent misrepresentation. Precision protects the public.
Yet the intensity surrounding this debate suggests something larger.
There is no confusion about what to call a physician.
“Doctor” and “physician” are precise, legally defined, and culturally established.
The instability arises elsewhere.
“Provider” has been criticized as commercial and flattening.
“Mid-level” is widely regarded as reductive.
Alternative terms such as “clinician” or “health care professional” attempt neutrality but do not fully resolve the tension.
Tension in terminology reflects the reality that modern care is delivered by teams, not by a single decision-maker.
When language generates this degree of friction, the issue may not be linguistic.
It may be structural.
The Commercialization Paradox
The critique of “provider” often rests on the concern that it reflects the commercialization of medicine.
Yet modern medical practice is overwhelmingly corporate. Most physicians are employed by health systems. Productivity is measured in RVUs. Scheduling is compressed. Reimbursement models reward volume over conversation. Burnout rates remain high across specialties.
If medicine feels commercialized, vocabulary did not cause it.
Business models did.
Language may symbolize discomfort, but it does not create it.
Why I Used the Word “Provider”
When I wrote The Arc of Conversation: A How-to Guide for Goals of Care Conversations (Springer, 2025), I intentionally used the word “provider.”
Not to obscure training distinctions.
Not to flatten hierarchy.
Not to diminish physicians.
I used it because the communication failures I was addressing were systemic.
Goals of care conversations occur across settings — primary care, cardiology, hospital medicine, emergency departments, long-term care, hospice. They are conducted by physicians, physician assistants, nurse practitioners, nurses, social workers, discharge planners, and interdisciplinary teams. The breakdowns I was describing were not confined to one credential. They reflected structural incentives and training patterns that shape how serious illness is discussed.
The breakdowns were not limited to physicians alone. In many cases, nurses, social workers, and discharge planners — professionals who often spend the most time at the bedside and develop deep trust with patients and families — recognized the need for goals-of-care discussions. They frequently understood family concerns, safety risks, and evolving priorities. Yet institutional hierarchy often required them to defer to physicians for formal decision-making conversations, even when they understood that critical discussions about goals and priorities had not yet occurred. In many cases, the patient and family had not been directly asked about their values, preferences, or thresholds for intervention. Decisions proceeded in the absence of that clarity.
When those physicians were operating under compressed schedules, productivity pressures, or training models focused on acute stabilization rather than longitudinal planning, meaningful discussions about patient values and family priorities were delayed or avoided.
The result was a failure of alignment between institutional structure and the needs of families facing serious illness.
In my book, in that context, “provider” functioned as a systems term.
Families experiencing poor communication do not experience hierarchy first.
They experience clarity or confusion first.
Dementia Care Gaps Become Visible Under Stress
In dementia care, structural weaknesses become visible.
Outside of specialized memory clinics, families frequently encounter delayed or incomplete diagnosis, misinterpretation of psychiatric symptoms, inconsistent medication management, insufficient assessment of driving safety, and fragmented communication.
These dementia care gaps are rarely the result of indifference. They reflect limited subspecialty exposure to longitudinal neurodegenerative care, significant time constraints in general practice, and systems built around acute stabilization rather than progressive cognitive decline.
Driving safety provides one of the clearest examples.
Families report documented episodes of unsafe driving — including traveling the wrong direction on a highway, becoming disoriented on familiar routes, or demonstrating impaired judgment at intersections — followed by recommendations for a formal DMV road test or suggestions to limit driving to daytime hours or the immediate vicinity of their local neighborhood.
Professional guidance is explicit: dementia is associated with progressive impairment in executive function, visuospatial processing, divided attention, and judgment — all critical for safe driving. Clinical guidelines advise that clinicians counsel patients and families about increased crash risk and consider driving cessation when safety concerns are documented.
In many cases, when families are reporting clear safety breaches, the clinical threshold for action has already been met.
What often intervenes is hesitation.
Modern medicine appropriately emphasizes evidence-based practice. Evidence is inherently probabilistic and population-based. It guides risk estimation and informs general recommendations. Yet families living with dementia confront concrete, observable risk in real time. When a loved one has driven the wrong direction on a highway, the question is no longer statistical. It is practical.
In those moments, continued hedging does not preserve autonomy. It prolongs risk.
Physicians are trained to preserve independence and respect autonomy. These are foundational principles of medical ethics. However, autonomy in dementia is dynamic. Capacity declines over time. Continued framing around independence without equal emphasis on safety can delay necessary intervention.
Families frequently arrive at appointments already carrying the burden of observation.
They have seen the damaged bumpers, the missed turns, the near-misses, the confusion. When clinicians hesitate to act decisively, families are left in an untenable position — forced either to tolerate escalating risk or to pursue legal mechanisms such as guardianship to accomplish what earlier clinical intervention might have addressed more directly.
This is not a matter of insufficient intelligence or absent compassion.
It is a failure of structural alignment between ethical ideals, evidence language, and neurodegenerative reality.
Expertise in the Gaps
In the communities where I practice, I have developed focused expertise in the comprehensive assessment and psychiatric and behavioral management of dementia — an area that receives limited emphasis in many general training pathways outside of subspecialty memory clinics.
This includes comprehensive cognitive and functional assessment, differentiation between primary psychiatric illness and neurodegenerative behavioral symptoms, accurate staging of disease, evidence-informed psychopharmacologic strategy, deprescribing when appropriate, risk assessment related to driving, safety, and supervision, and structured education for families regarding disease mechanisms and progression.
Psychiatric and behavioral symptoms in dementia are frequently misunderstood. When conceptualized accurately, treatment shifts. Medication strategies become more targeted. Non-pharmacologic approaches become more strategic. Families respond with greater calm and confidence.
Over time, my work evolved beyond traditional expectations often placed on physician assistants. I identified persistent dementia care gaps and built my practice around closing them.
When the institutional environments in which I practiced were unwilling to adapt to this model of comprehensive dementia care, I left.
What followed has been the development of a high-integrity, reputation-based practice centered on comprehensive assessment, longitudinal psychiatric management, and structured family education. The outcomes speak for themselves: clearer diagnoses, calmer households, safer environments, earlier hospice enrollment when appropriate, and markedly reduced crisis-driven utilization.
I am proudly a physician assistant.
I practice in Wyoming, where physician assistants may practice with independent authority under state law. My practice is not contingent on day-to-day supervision by a physician. Scope of practice is defined by statute, not hierarchy.
I correct people when they call me “doctor.” They often tell me it does not matter. It matters to me. Titles carry meaning. Scope carries responsibility.
My contributions arise not from challenging hierarchy, but from addressing what families experience on the ground.
Perhaps there is value in outsider perspective.
I insist that families call me Amy. The name derives from the Latin root amore — love — and that is not incidental. My work is anchored in compassion, clarity, and decisiveness when safety requires it.
In dementia care, love and structure must coexist.
The Question Beneath the Debate
Families caring for loved ones with dementia are not asking what their clinician prefers to be called.
They are asking: Do you understand this disease? Can you explain what is happening? Can you keep my loved one safe? Can you guide us through what comes next?
Too often, in practical terms, the answers families receive feel incomplete.
Not because clinicians lack intelligence.
Not because compassion is absent.
But because the current medical system is not structurally designed to deliver longitudinal, comprehensive dementia guidance within routine care models.
The appointment is too short.
The incentives are misaligned.
The hierarchy delays decisive action.
The training emphasis prioritizes diagnosis and treatment over longitudinal education, behavioral management, and functional guidance.
Families leave with prescriptions, referrals, or reassurances — but without clarity.
The gap is not theoretical.
It is lived.
Until systems are redesigned to close dementia care gaps and support comprehensive assessment, psychiatric precision, safety decisiveness, and sustained family education, debates over professional titles will remain peripheral to the experience of those living with this disease.
The crisis is not linguistic.
It is structural.
Amy Shaw, PA-C is a nationally recognized dementia care clinician, educator, and author of The Arc of Conversation: A How-to Guide for Goals of Care Conversations. She is the founder of Better Dementia™, where she helps families understand the what, when, and why of dementia so they can master the how of caregiving with confidence and clarity.
