Suzanne Gordon: Does the use of medical titles have an impact on patient safety?

suzanne_gordonA couple of months ago, I was invited to speak at an East Coast medical school and hospital. The group of physicians who extended the invitation—a female surgeon, and female and male internist—took me out to dinner the night before my talk. During the dinner conversation, we were all on a first name basis when we addressed each other directly. When, however, one of the three physicians mentioned something one of his or her colleagues had been working on or accomplished, he or she spoke about that physician in the third person i.e. as “Dr Smith has spent a lot of time working on this issue,” or “Dr Jones just published a paper on such and such.” When they referred to my writing or work, I was not Ms Gordon or Professor Gordon, but Suzanne.

I was struck by this mode of address precisely because I was asked to teach medical students and residents about patient safety and interprofessional teamwork. Modes of address are, in fact, central to both. When I asked them about this, they told me that it’s important that physicians be respected because they know so much.

This is by no means the first time I—as a non-physician and non-PhD ( I am a proud graduate school/doctoral program drop-out)—have encountered this particular doctor dilemma. As a patient, and an older one at that, most docs I meet in the exam room call me Suzanne as they introduce themselves as Dr so and so. If I am on a panel with physicians, I am invariably addressed as Suzanne, while the physicians are Dr…

In North America this practice is embedded in institutional culture. In the clinical setting most physicians address or refer to nurses and other professionals and healthcare workers by first name and expect—particularly in front of patients—to be addressed with their last name and title. (Even when they are on a first name basis, they refer to each other as Dr…) Non-MDs almost always introduce physicians to patients or other staff with last name and title (while they introduce themselves with first names only—sometimes even omitting to mention that they are a nurse, PT, or dietician). When they directly address physicians in front of patients, they usually use last name and title even if they are on a first name basis with the physician outside the exam room. When I ask them why this asymmetry of address, they invariably inform me that patients need to know who their physician is and that this physician must be respected. Apparently patients don’t need to respect—or even be able to identify the role of—nurses, PTs, OTs, social workers, or other personnel with whom they are in contact.

This practice is also common when no patients are present. When I recently gave teamwork workshops at a major Canadian teaching hospital, a bioethicist complained that the minutes of ethics consults routinely identify physicians as Dr X, Y, or Z, while the expert bioethicist is identified only by his or her first name.

Why is this practice a problem? It’s because how people address one another can impact patient safety. As the sociological and socio-linguistic literature has amply documented, how people address one another creates and reinforces status differentials that inhibit the sharing of information, as well as the collaborative decision-making, and interprofessional cross-monitoring that is at the heart of patient safety not to mention patient-centered care.

As sociolinguists explain, referring to another person in the first person and while insisting that you be addressed with last name and title, is, in English, the equivalent of using the French, German, or Spanish informal and less polite form of the second person pronoun you—tu, or du—when you are addressed with the more formal, polite form of the second person pronoun—vous, usted, or sie. In these languages, such asymmetrical forms of address are used by adults or masters to address either children or servants.
In English, a language that has no formal and informal form of the second person pronoun, this reaffirms status differences and asserts power over people who are both verbally infantilized and put—and kept—in their place lower down on the status hierarchy.

If we want patients and non-MD staff to speak up with information and insights that might prevent patient harm then it’s important that physicians understand the dangers of steep hierarchies and the difference between reverence and respect.

Respect comes from the Latin, respectare as in “look again. ” Although it involves a feeling of admiration for someone’s accomplishments or knowledge, respect is a two way street, allowing for mutuality, solidarity, and questioning. Reverence on the other hand comes from the Latin venere—to venerate. It depends on the kind of distance and mystery that is designed to produce the feelings of fear and awe, and behaviors of deference and obedience in the presence of a deity.

As a number of influential studies have documented, we patients have a hard time questioning our doctors or pointing out potential sources of harm (like, for example, the fact that a physician has not cleaned his or her hands). The same is true for non-MD staff. Which is why it is so important to signal to patients—as well as everyone involved in their care—that it is safe to question the physician, point out potential safety problems, or contribute vital information necessary to sound decision-making.

My colleague, patient safety physician Michael Gardam, explains it best. ““I always introduce myself to patients and staff as, Hi, I’m Michael Gardam—I’m the tuberculosis/ ID doctor who will be seeing you—working with you—today.

“I started doing this a few years ago after an experience I had when I was on call. I had just finished seeing a patient for a post operative wound infection. There were very few notes to go by and the patient looked good to me—I didn’t think it was that big a deal. When the nurse read my note she did not agree with my assessment at all—apparently a lot had gone on over the past few days that was not documented. She let my assessment stand, because ‘you are Dr. Gardam—you’re an important guy and I didn’t feel comfortable saying anything.’ At that point I decided I will do everything within my power to try to break down those barriers—this isn’t a theoretical thing—people are actually getting harmed because we don’t feel comfortable speaking to each other.”

Suzanne Gordon is a healthcare journalist and co-editor of The Culture and Politics of Healthcare Work Series at Cornell University Press. Her latest book is Collaborative Caring: Stories and Reflections on Teamwork in Healthcare, which she co-edited and she is co-author of Beyond the Checklist: What Else Healthcare Can Learn from Aviation Teamwork and Safety. Most importantly she is a patient.

Competing interests: None declared.

See also: The title “Doctor” is an anachronism that disrespects patients.