R-E-S-P-E-C-T

Here’s an intriguing letter from one John Doherty, published in the BMJ yesterday:

Medical titles may well reinforce a clinical hierarchy and inculcate deference in Florida, as Kennedy writes, but such constructs are culture bound.

When I worked in outback Australia the patients called me “Mate,” which is what I called them.

They still wanted me to be in charge.

Intriguing enough for me to go and have a look at what this Kennedy person had written.  It’s available here, and the headline goes like this:

The Title “Doctor” in an Anachronism that Disrespects Patients

Oooooo-kay.  A strong claim, and my hackles are immediately raised by the use of “disrespect” as a verb – or as a word at all.  (Don’t ask me why I detest that so; I don’t know.  It’s just one of those things that I will never be able to tolerate, a bit like quiche.)  But let’s see…  It’s not a long piece, but even so, I’ll settle for the edited highlights:

Medical titles reinforce a clinical hierarchy and frame the physician-patient relationship as a deferential one, which is hardly appropriate in person centered care.

A while ago I spent some time shadowing hospital doctors. On one of my shifts, a woman was brought to the emergency department.  A physician entered the patient’s room and introduced himself in the usual way.

“Hello, Ms Smith,” he said, “I’m Dr Jones. I will be taking care of you.”  The woman visibly stiffened after hearing this introduction.  This seemed odd, until I heard her reply: “Well, isn’t that nice? I’m Dr Smith,” she said.  It turned out that she held a doctorate in clinical psychology.

The woman’s point was clear: she introduced herself to the physician with her title because she wanted to be treated as his equal

And calling her “Ms” doesn’t do that?  Precludes it?  I don’t see how.  In a hospital, the medic is wearing a professional hat; the patient isn’t.  Most people don’t have doctorates; those that do don’t wear a special badges telling the world that they do; and in at least some codes of etiquette, it’s terribly non-U for people with a PhD to insist on being called “Doctor” outside of an academic context anyway.  (For my money, it’s a bit non-U to insist on it in an academic context as well.)  The point is, it’s not unreasonable to call people Mr or Ms, and it’s not a faux pas even if they’re the sort of person who insists that the bloke from Ocado calls them “Dr”.

Oh, and I don’t believe that this encounter happened anyway.  Minor quibble.

Titles have the power to shape interpersonal relationships.  By using the title “Doctor” (from the Latin docere—“to teach”) when addressing physicians, we are saying that the physician is the one in charge.  And by introducing themselves with this title, physicians implicitly reinforce the same idea.  These practices do not encourage them to respect their patients.

This is simply an instance of the etymological fallacy, isn’t it?  “Doctor” is, in this context, a job title.  It tells everyone what the speaker is, to wit: a doctor.  I do wonder whether Kennedy is trying to find a problem where none exists.  I know that noone ever introduces themselves as “Plumber Jenkins” or “Deli-Counter Team Leader Kapoor” or even “Surgeon Chang” – though they may introduce themselves as Second Lieutenant Garvey or Nurse Gladys Emmanuel – but that tells us nothing except that several conventions work together in a complex society; and if we’re surprised or confused by that, then there’s really no hope for any of us.

By bestowing the title “Doctor” on physicians we, as clinicians and patients, have chosen to set them apart from everyone else.  But physicians no longer call the tune in clinic as they did 50 years ago.  Titles that signify who is in charge are anathema to today’s interprofessional, team based approach to healthcare delivery.

But how, without using a title, can we identify physicians in the clinical setting?  This question implies that, without the title, patients won’t know who is in charge.  This is similar to the objection posed by those who disagree with calls for clinicians to stop wearing white coats.  In both cases, potential problems can be easily circumvented—for example, “Hello, my name is Joan Smith, and I’ll be the physician on your healthcare team today.”  Badges could still be used with the care provider’s name and role.

It’s hard to tell whether the complaint here is with the idea that some people are in charge, or that they have a title that indicates it.  Would it be OK to say “I’m the doctor on duty today”?  And if so, wouldn’t “Doctor Smith” do the job much more efficiently?  Or is the complaint that the word “Doctor” is used at all?  If that’s it, it’s a losing battle.

But won’t the physician-patient relationship be misconstrued without the separation that a title creates?  In medicine, as in most professions, appropriate boundaries need to be drawn – but the title “Doctor” draws this line in the wrong way.

A professional boundary should create a space that is respectful of an appropriate distance between the two parties.  The hierarchical title “Doctor” instead creates a distinction that the patient is lesser than, and should defer to, the physician.  It is exactly the sort of message that we ought not to send in clinic.

I don’t think I understand that last paragraph; to the extent that I do, the second sentence is false, as far as respect-for-persons goes.  There is no lack of respect implied.  Besides: in respect of medical expertise, it’s reasonable to assume that the doctor does have the edge on the patient; and it’s a desire for medical expertise that takes most people to see the doctor in the first place.

Patients’ rights and autonomy have reshaped the physician-patient relationship in recent years.  Re-educating patients about the importance of practice over titles would be worth the effort to achieve truly shared decision making in healthcare.

For sure, practice is important.  And I’m tempted to agree that titles aren’t all that important.  A medic who is introduced as Alice Brown or Bob Robinson is doubtless going to get respect; but if patients have an unwarrantedly cowed attitude to medical staff, that’s not likely to be corrected by ditching “Doctor”.  And, honestly, I don’t see what autonomy or patient rights have to do with it.

Incidentally, while there might be (arguendo) an admirable enough sentiment on display here, in an article that’s so concerned by the way that language comes across, to talk about “re-educating” people for the sake of what is essentially a political point seems a bit Maoist and incompatible with the rights and autonomy touted.  And if Kennedy’s response to that were to be that that misses the point, and we should look at what is meant in the wider context rather than getting hung up on the superficialities of specific words… well, tu quoque.

The piece puts me in mind of something that Nick Cohen wrote for the Spectator last January.  Apparently, Benedict Cumberbatch had caught some flack for talking about how a lack of opportunities for some people in his profession seemed to correlate with ethnicity; in doing so, he’d talked about “coloured” actors, rather than people of colour.  This was, apparently, the wrong descriptor to use.  Cohen’s point was simple: Cumberbatch was obviously making a progressive point, and to focus on one word is to lose that.  He then gave a couple of other examples of how a zealous desire to get the “right” language misses the morally important point that the language might sometimes indicate, and sometimes obscure:

Spastic too was once a euphemism that became an insult.  In 1994, the Spastics’ Society changed its name to ‘Scope’ because children were ‘shouting you big spastic’ at each other in the playground.  No good did the substitution do.  As current dictionaries of slang report ‘scopey’  is now ‘a byword for spaz’.

I have seen half my generation of leftists waste their lives and everyone else’s time in petty and priggish disputes about language.  They do it because it’s easy, and struggles for real change are hard.  They do it because correct form identifies social class and confirms your membership of a privileged group, as surely for the middle-class left as the upper-class right.

They do not understand that the only way to judge a language is by its use.  When, in Cumberbatch’s case, generations of linguistic sticklers have insisted that ‘coloured’ should replace ‘negro,’ then ‘black’ should replace ‘coloured’ then ‘African-American’ should replace ‘black’ and now ‘people of colour’ should replace ‘African-American’, they are missing the persistence [of] racism.  If they had genuinely tackled it, they would have no need to demand self-censorship or linguistic change.  But as I said before, tackling social problems is difficult, while playing language games is what middle-class intellectuals are trained to do.

I think that he’s on to something here.  If people want to use a word to insult someone, they will.  It’s the insult, not the word, that matters; changing the word will not make the insult go away, and the insult may well coopt the word anyway.

And it’s possible that the same kind of thought applies in the “Doctor” case.  Introducing oneself as “Doctor” does not serve as good evidence of a lack of respect.  If a doctor is failing to respect his patient, introducing himself as “Doctor” is, at the absolute most, an epiphenomenon; getting worked up about that misses the real moral problem.  A doctor might call himself “Doctor Jones” as a means of lording it over the patient.  But it’s the lording it over the patient that should worry us, not the convention about how medical staff introduce themselves.

For what it’s worth, doctors and patients calling each other “mate” is also fine.

  • John O’Malley

    Yes, I read it too and mea culpa , I am guilty of using the title in inappropriate areas of life when I dont need to . In my defence I am so used to using the title it becomes second nature and I don’t (I think?) use it for any superiority purposes.
    What is interesting, if one goes by the theory that the title is just one that says what you are doing in the context of a doctor/patient relationship , is that fact that doctors often post retirement continue to use the title so it must have something to do with self worth and identity.
    But let’s not discuss what we call patients because that is a true minefield……Love… Darling……Mate…..Mr/Mrs/Miss…. Fred….. You…………

    • I believe that using a medical doctorate in real life, or post retirement, is perfectly U. I think the idea is that a medical doctorate (that is, MBChB, rather than MD) is technically honorary, so has the same status as “Sir” or “Lady”. By contrast, a PhD simply indicates that you’ve not had the imagination to leave school…

      There was a minor controversy a few years ago when Newsnight called Mo Mowlam “Ms”, rather than “Dr”; but the defence offered was that she held a PhD, and since the discussion wasn’t academic, it was perfectly proper to use Ms.

      But… well, you’ve met me, and so you know that I’m the least polite person in any given room.

  • Inge

    I found this blogpost very interesting to read, especially because I come from a country where medics never introduce themselves with their medical title. They introduce themselves with their first and last name, just as patients do. This blogpost really made me think that there are different approaches all over the world. However, I do think it creates distance between patient and medics, when patients are expected to use medical titles. I would like to ask you for feedback on my blogposts, since I am a young student and I would love to read the comments from more experienced bloggers. Thank you in advance!

    https://ethichub.wordpress.com/2015/11/03/death-penalty-right-or-wrong/
    https://ethichub.wordpress.com/2015/10/27/euthanasia-a-personal-choice/