I’ve written lots here in the past about names – the issues of how we address each other, and how we permit patients and their families to address us.

During the process of writing those posts I made some changes to how I thought, which altered some of my behaviours. I wanted to share here some other thoughts that have accompanied this, and points that have been made to me.

Firstly, people don’t pick up very fast on the cues. Actually, that’s a gross over-generalisation. Some people pick it up very fast – but they’re the exceptions – especially among families. When a family member says “Thanks Ian” or similar at the end of a consultation, the vividness with which I notice this tells me that this is still unusual, and I can feel the tension of a norm being overturned. However, in many situations I’ve found that need to explain to them that I’ve just called myself Ian, and that’s what I expect them to call me. The lower in the hierarchy they are – or perceive themselves to be – the more likely they are to require explicit permission. I replied several times using my given name in an email conversation to a medical student, but still they addressed me as Dr Wacogne – in each and every reply.

This would bring me to my second point, which was well made by a surgical colleague of mine who has superb grasp of team factors and crew resource management – mostly because he’s had to function in a much more stressed environment than I usually experience. He was teasingly dismissive of my penchant for given names – after I called him out for using his surname – by pointing out that it is the culture that makes the difference. He is, of course, right. We can bring to mind the exquisite awkwardness of an encounter where someone insists that they are addressed or that we behave towards them informally and it feels entirely wrong in the context of the prevailing culture. If I were to translate loosely into the language of the sitcom, we can imagine the embarrassment as the boss’s husband drunkenly shares some intimate detail at a Christmas event…

So, is the first names thing tokenism? I think it isn’t. I think that instead it is social signalling. (The quickest and easiest way to understand social signalling is to think of the way that someone walks when they need to leave a lecture, passing between the audience and the presenter; the way that they half bend over and walk gingerly. If anything it makes their exit more noticeable, but what it does is socially signal that they are sorry to leave.) The first names remind me – and my team – that this is the way that we are going to try to behave towards each other.

Does it have adverse effects? There’s a fascinating article I picked up via twitter – I am honestly not a regular reader of Vanity Fair – which details the issues that went on in the cockpit of the Air France jet which crashed between Brazil and France. I’d really recommend reading it – but not on an airplane. One of the important things was the skew that had happened; they’d taken on the use of first names, but perhaps not the underlying culture, which itself had, maybe, taken the first names as an indicator that sloppiness was OK.

So, again, we come back to culture. And as I was reminded, and need to remind myself again, culture eats strategy for breakfast. (Good, but business oriented, discussion of this here)  In fact, culture eats pretty much anything for breakfast – because if you want to do something that “isn’t the way we do things around here” then the first thing you have to alter is “the way we do things around here”.

My last point to my surgical colleague – and I should stress, friend – was that if he was keeping his title “Mr” then he ought to address all of his team with the same level of courtesy; using their title if they used his, dropping theirs if they didn’t. Might make for a nice old fashioned feeling ward round?