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.

Medical Paternalism - A Rant

Last week I had an MRI as part of a work-up to rule out MS. Today I emailed my physician's office to request a copy of the MRI report in advance of my next appointment. (Having my information in advance helps to prepare me for the tone of the appointment and allows me to formulate my questions in advance. In other words, it is very important to me.)

"I'm sorry, but I will have to ask the doctor for permission to send this information to you and she won't be back until Tuesday. Thanks!"

This shouldn't come as a huge surprise, this is from the same office that declined to tell me my blood pressure, because it might confuse me.

You need permission to send me a copy? Why? This is MY information. This is an image of MY head. The results are about ME. What gives you the audacity to think its ok that you and your staff can see the results of my test and withhold it from me?

Perhaps there is concern that I will not understand the results? I am reasonably sure that if I were an MD, an MD's spouse, or even a medical student, this would not be happening. I am frustrated that one needs to be a part of the 'members only club' of physicians to be allowed access in advance of my appointment.

No, I don't want to be patient and wait. In fact, I don't want to be yours or anyone's "patient". I want to be your "client", and you, my service provider. And when I ask for my medical record, I don't want to ask for your permission.

Stop withholding information from me. Your actions are paternalistic and offensive.

Rant over.

the wisdom of ERP

Can anyone explain to me why some physicians are belittling, condescending, and obnoxious towards certain groups of patients?

Today's lack of empathy in medicine comes from ERP, who has chosen to vent his hostility on what he calls "Nutty Patients". He rants about how much he hates to give them a "real" diagnosis (such as Lyme Disease, Lupus, Crohn's) because:

"These diagnoses are like crack to them. They LOVE it. They FINALLY can now say that have a real problem and go on to blame nearly every symptom they ever have on it!"

Of course, ERP makes a distinction about these diseases and the ones that he doesn't believe are "real" (such as Fibromyalgia, Chronic Fatigue Syndrome or IBS), because according to ERP, these are all "psychiatric disorders".

I'm sure in ERP's worldview, my critique of this repulsive post will be written off as "nutty", but I wish that ERP would take a few moments to work on some empathy skills.

ERP - do you know why patients "love" to have a "real" diagnosis?

Perhaps it is because physicians like you, people in positions of power, take pleasure in degrading the experiences of your patients when they cannot be easily verified with an 'objective medical test'.

Do you really think that patients enjoy feeling awful day to day, losing their jobs, dreams, relationships whilst being told that their problems are "all in their head?".

Perhaps if you were in this position, you would understand that being given a diagnosis means having some legitimacy. I have actually felt at times I would rather have a diagnosis of cancer than an unexplained illness, just so that I wouldn't have to deal with the shame of being labelled "nutty".

For the record, I have been evaluated by top mood disorder specialists (Psychiatrists) who agree that my symptoms are not psychiatric in nature.

Trust me, I would be happy with a mental health diagnosis if it came with an effective treatment. But ultimately what I would like is to be afforded some dignity by medical professionals.

diagnosing behind my back

You may recall a few months ago I saw an Internist who discussed the possibility of a diagnosis of fibromyalgia with me...I was not impressed.

I just asked for a copy of her report to my family physician and was shocked to find the following statement "I have diagnosed this patient with fibromyalgia". WTF??

When we discussed fibromyalgia during my appointment, she seemed to agree with me that it did not apply to me (fatigue being my dominant complaint) and even wondered aloud about whether or not fibromyalgia even exists as a clinical entity. She never once touched me during the appointment. In answer to my questions about the validity of 'trigger points', I was told me that "too much knowledge" can be a dangerous thing.

Why did she not tell me her diagnosis in person?

It feels disrespectful to have a diagnosis on my medical file that does not in any way reflect what was said during my appointment. It feels disrespectful to be given a diagnosis that the doctor herself doubts even exists!

But most of all, I am angry that she chose to write this in her report; avoiding saying this conclusion directly to me, face to face.

Open letter to the doctor I saw this morning

Dear Dr. Whatever,
I appreciate that you are filling in for my regular family physician. I understand that you probably do things a little differently than she does; but your practice leaves a few things to be desired.

Despite that you have all of my medical records electronically, I didn't make a big deal over filling out all of your paperwork, with medical history, medications and allergies. If I'm willing to go along with writing all of this down for you, the least you could do is read it. Especially the part where I wrote - "Allergies: I had a rash while taking Doxycyline." Yes, a rash. Some skin redness.

I made myself comfortable and was pleasant while your nurse took my blood pressure. Unfortunately, she refused to share it with me, saying, "the doctor doesn't allow us to share test results with patients." When I raised this with you, you told me that patients aren't sophisticated enough to understand these confusing numbers. (It's only blood pressure for Gawd's sake!) Or, worse, they might want to have a conversation about it!

You walked into the room and stated your name and stared at me. Was that an introduction? Next time you might want to try a greeting, such as "Good morning, my name is______".

I realize that you don't know my medical history, but could you please try take my word for it when I tell you that I use a saline nasal rinse every day. And yes, I do know what saline is.

And finally, when you asked me if anything seems to help my sinus pain, and I told you that a Tylenol-based decongestant seemed to improve symptoms, perhaps lecturing me about the lack of efficacy of these products ("No, that wouldn't have helped, studies have shown that these don't work) was a little uncalled for?

Thank you for your time, I hope not to see you again.

(am I being too harsh?)

forced to keep mirena?

Why do some health care providers feel that they are entitled to force their patients to keep unwanted Mirena IUDs?

I recently came across a blog post from a NP where she vents her annoyance about removing a recently inserted Mirena from a patient who was concerned about the side effects. The majority of the comments she received are almost more disturbing than the original post itself.

Tales like this are repeated frequently across the web - women told that they must keep IUDs that are causing them discomfort. Adding to this concern is the reluctance of other health care providers to remove an IUD that they themselves didn't insert.

I can't for the life of me understand why a provider would be reluctant to remove an unwanted IUD. It is a simple and quick procedure. Do they not believe patient's reports of side effects?

Am I alone in thinking that this kind of behavior is offensive?