Dr. Who? Titles and Power in the Patient-Physician Relationship

I was raised to address people by their last names until invited to call them by their first names. In university, I always called my instructors "Professor" or "Doctor" unless invited to do otherwise.

In written correspondence, I refer to a person as Mr./Ms. /Mrs./Dr. (unless or until they sign their message with their first name, in which case I understand this to be an invitation to refer to them as such).

But I hate, hate, hate when physicians address me by my first name and introduce themselves as "Doctor". Immediately I bristle, knowing that they are setting up a power dynamic where they are privileging their role over mine. I know you're are a physician...I'm here to consult with you, if you told me your name, I would still be quite clear about the purpose of this encounter.

One of my favourite med-bloggers, Dr. Jessica Otte tackled this thorny issue a few months ago in a post "What's in a name? Doctors, titles and pretence" she tells readers that with patient introductions, she says: “Hi, I’m Dr. Otte but you can call me Jessica if you like." I would love it if my physician were to introduce herself to me this way. It makes her role clear, but is also attentive to the patient's comfort. It is unpretentious and sets a tone of shared power.

Whether it be respect, authority, closeness, familiarity or hierarchy, how one uses first names, last names and titles sets the tone of a relationship.

Dr. Jennifer Middleton, author of the blog The Singing Pen of Doctor Jen, took this topic up recently in a post "What ever happened to Doctor?"

Unlike most other businesses and professions, we physicians have a sacred contract with our patients. They allow us into the most private and intimate details of their lives. In return, we pledge to maintain stringent professional boundaries related to our behavior and give them the best of our intellect and compassion. Being addressed as "Doctor" is a constant reminder to me - and to everyone I interact with - of the oath I took to fulfill that pledge.

Please hold me accountable, and keep calling me "Doctor."

I think I understand where Dr. Middleton is coming from here, but I'm not sure I agree that a title is necessary to establish clear boundaries in a professional relationship. For example, my husband is lawyer and law professor; certainly his profession obliges him to maintain confidentiality and to be privy to intimate details of his client's lives. He holds two undergraduate degrees, three masters degrees and a doctorate and yet, he never uses an honorific with his clients. Despite being on a first-name basis, I don't for a moment think that the boundaries of his client relationships are unclear.

Similarly, my priest always introduces himself by his first name. He doesn't mind if people prefer to call him "Father", but in no way do I think that his sacred contract and requirement for confidentiality is diminished by forgoing the use of a title.

Dr. Synonymous responded on his blog to Dr. Middleton's post, saying: In the late 70's, we also had resident physicians who didn't want to be called "Doctor". It seemed that the "denial" of doctor "status" was one way to "power down" and not be threatening or aloof from patient "status".

Dr. Synonymous (also known as Dr. A Patrick Jonas) goes on to quote The Healer's Power, by Howard Brody, MD, PhD (1992): "To be compassionate in response to the suffering of the patient is therefore one of the most powerful things a physician can do: but this is possible only to the extent that the physician is willing to adopt a position of relative powerlessness, to acknowledge that the patient's suffering has incredible power over him and that he cannot remain unchanged in the face of it. This is a major irony of the physician-patient relationship, in which a sense both of one's own healing power and of one's necessary humility forms a synthesis of the apparent contradiction of power and powerlessness."

Dr. Jonas summarizes the meaning he takes from this quote, writing, "Some physicians may not feel ready for this type of struggle for professional development and don't want to fully accept the title of Doctor."

With all due respect to Dr. Jonas, I don't agree with this conclusion. While this may be true for some physicians, I think that the opposite could be true. Perhaps being on a first-name basis with patients can also be construed as a marker in professional development. It could demonstrate a sense of coming into one's self as a professional, whereby the physician trusts enough in their knowledge so as not to require the deference of a title in order to feel comfortable in their role.

The New York Times discussed this issue in 2009, Exam Room Rules: What's in a name? . Anne Marie Valinoti, MD struggles with this in her practice, but also raises an interesting issue of the use of titles between colleagues: "This got me thinking of how, in my own career, I have always been addressed as “Dr. Valinoti.” Freshly minted M.D.’s, some as young as 25, get a title of respect while seasoned nurses in the hospital are Betty, Kaye or Nancy.

I remembered the absurdity of this situation when, as an intern, I was addressing critical care nurses with decades of experience by their first names while they deferentially called me “Doctor.” These were women who had started their careers when I was still playing with Barbie dolls, yet where were their professional titles? Like most things in medical training, I got used to it, and it became second nature."

The comments to this article were fascinating. Some doctors insisting that they worked hard and deserved a title, to some not caring whatsoever. Patient comments were similarly diverse, some most comfortable with more formal introductions and others preferring first names.

One theme that stood out for me is that patients seem to prefer that their physicians use the same tone of formality (Mr./Ms./Mrs./Dr.) with their names as the physician uses with their own. Symmetry seems to be the key feature when it comes to introductions.

One last comment, I noticed (perhaps because I am on the path towards a PhD myself) that there was a certain tone of animosity in the NYT comments section from physicians who resent using titles for non-MD colleagues who also have access to the title 'doctor' (doctorate-level nurses, chiropractors, naturopaths, research PhDs).

Clearly this is a divisive topic. I'm curious how much time and discussion attention to power dynamics actually receives in medical education. Please feel free to weigh in your thoughts on titles...

In the meantime, you may call me Penelope.