{"id":2977,"date":"2015-12-24T10:32:44","date_gmt":"2015-12-24T09:32:44","guid":{"rendered":"https:\/\/blogs.bmj.com\/medical-ethics\/?p=2977"},"modified":"2015-12-24T10:32:44","modified_gmt":"2015-12-24T09:32:44","slug":"r-e-s-p-e-c-t","status":"publish","type":"post","link":"https:\/\/blogs.bmj.com\/medical-ethics\/2015\/12\/24\/r-e-s-p-e-c-t\/","title":{"rendered":"R-E-S-P-E-C-T"},"content":{"rendered":"

Here’s an intriguing letter from one John Doherty,\u00a0published in the\u00a0BMJ<\/em>\u00a0yesterday<\/a><\/span>:<\/p>\n

\n

Medical titles may well reinforce a clinical hierarchy and inculcate deference in Florida, as Kennedy writes,\u00a0but such constructs are culture bound.<\/p>\n

When I worked in outback Australia the patients called me \u201cMate,\u201d which is what I called them.<\/p>\n

They still wanted me to be in charge.<\/p>\n<\/blockquote>\n

Intriguing enough for me to go and have a look at what this Kennedy person had written. \u00a0It’s\u00a0available here<\/a><\/span>, and\u00a0the headline goes like this:<\/p>\n

The Title “Doctor” in an Anachronism that Disrespects Patients<\/strong><\/p><\/blockquote>\n

Oooooo-kay<\/em>. \u00a0A strong claim, and my hackles are immediately raised by the use of “disrespect” as a verb – or as a word at all. \u00a0(Don’t ask me why I detest that so; I don’t know. \u00a0It’s just one of those things that I will never be able to tolerate, a bit like quiche.) \u00a0But let’s see… \u00a0It’s not a long piece, but even so, I’ll settle for the edited highlights:<\/p>\n

\n

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

A while ago I spent some time shadowing hospital doctors. On one of my shifts, a woman was brought to the emergency department. \u00a0A physician entered the patient\u2019s room and introduced himself in the usual way.<\/p>\n

\u201cHello, Ms Smith,\u201d he said, \u201cI\u2019m Dr Jones. I will be taking care of you.\u201d \u00a0The woman visibly stiffened after hearing this introduction. \u00a0This seemed odd, until I heard her reply: \u201cWell, isn\u2019t that nice? I\u2019m Dr Smith,\u201d she said. \u00a0It turned out that she held a doctorate in clinical psychology.<\/p>\n

\n

The woman\u2019s point was clear: she introduced herself to the physician with her title because she wanted to be treated as his equal<\/p>\n<\/div>\n<\/blockquote>\n

\n

And calling her “Ms” doesn’t do that? \u00a0Precludes it? \u00a0I don’t see how. \u00a0In a hospital, the medic is wearing a professional hat; the patient isn’t. \u00a0Most 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\u00a0context anyway. \u00a0(For my money, it’s a bit non-U to insist on it in<\/em> an academic context as well.)\u00a0 The point is, it’s not unreasonable to call people Mr or Ms, and it’s not a\u00a0faux pas<\/em> even if they’re the sort of person who insists that the bloke from Ocado calls them “Dr”.<\/p>\n

Oh, and I don’t believe that this encounter happened anyway. \u00a0Minor quibble.<\/p>\n

Titles have the power to shape interpersonal relationships. \u00a0By using the title \u201cDoctor\u201d (from the Latin\u00a0docere\u2014<\/em>\u201cto teach\u201d) when addressing physicians, we are saying that the physician is the one in charge. \u00a0And by introducing themselves with this title, physicians implicitly reinforce the same idea. \u00a0These practices do not encourage them to respect their patients.<\/p><\/blockquote>\n

This is simply an instance of the etymological fallacy, isn’t it? \u00a0“Doctor” is, in this context, a job title. \u00a0It tells everyone what the speaker is, to wit: a doctor. \u00a0I do wonder whether Kennedy is trying to find a problem where none exists. \u00a0I know that noone ever introduces themselves as “Plumber Jenkins” or “Deli-Counter Team Leader Kapoor” or even “Surgeon Chang”\u00a0– though they\u00a0may introduce themselves as Second Lieutenant Garvey or Nurse Gladys Emmanuel\u00a0– but\u00a0that 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.<\/p>\n<\/div>\n

\n
\n

By bestowing the title \u201cDoctor\u201d on physicians we, as clinicians and patients, have chosen to set them apart from everyone else. \u00a0But physicians no longer call the tune in clinic as they did 50 years ago. \u00a0Titles that signify who is in charge are anathema to today\u2019s interprofessional, team based approach to healthcare delivery.<\/p>\n<\/div>\n

\n

But how, without using a title, can we identify physicians in the clinical setting? \u00a0This question implies that, without the title, patients won\u2019t know who is in charge. \u00a0This is similar to the objection posed by those who disagree with calls for clinicians to stop wearing white coats.\u00a0\u00a0In both cases, potential problems can be easily circumvented\u2014for example, \u201cHello, my name is Joan Smith, and I\u2019ll be the physician on your healthcare team today.\u201d \u00a0Badges could still be used with the care provider\u2019s name and role.<\/p>\n<\/div>\n<\/blockquote>\n

\n

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. \u00a0Would it be OK to say “I’m the doctor on duty today”? \u00a0And if so, wouldn’t “Doctor Smith” do the job much more efficiently? \u00a0Or is the complaint that the word “Doctor” is used at all<\/em>? \u00a0If that’s it, it’s a losing battle.<\/p>\n<\/div>\n

\n
\n

But won\u2019t the physician-patient relationship be misconstrued without the separation that a title creates? \u00a0In medicine, as in most professions, appropriate boundaries need to be drawn – but the title \u201cDoctor\u201d draws this line in the wrong way.<\/p>\n

A professional boundary should create a space that is respectful of an appropriate distance between the two parties. \u00a0The hierarchical title \u201cDoctor\u201d instead creates a distinction that the patient is lesser than, and should defer to, the physician. \u00a0It is exactly the sort of message that we ought not to send in clinic.<\/p>\n<\/div>\n<\/blockquote>\n

\n

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. \u00a0There is no lack of respect implied. \u00a0Besides: 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.<\/p>\n<\/div>\n

\n
\n

Patients\u2019 rights and autonomy have reshaped the physician-patient relationship in recent years. \u00a0Re-educating patients about the importance of practice over titles would be worth the effort to achieve truly shared decision making in healthcare.<\/p>\n<\/blockquote>\n<\/div>\n

For sure, practice is important. \u00a0And I’m tempted to agree that titles aren’t all that important. \u00a0A medic who is introduced\u00a0as Alice Brown or Bob Robinson is doubtless going to get respect; but\u00a0if patients have an unwarrantedly cowed attitude to medical staff, that’s not likely to be corrected by ditching “Doctor”. \u00a0And, honestly, I don’t see what autonomy or patient rights have to do with it.<\/p>\n

Incidentally, while there might be (arguendo<\/i>)\u00a0an 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. \u00a0And 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,\u00a0tu quoque<\/em>.<\/p>\n

The piece puts me in mind of something that Nick Cohen wrote for the\u00a0Spectator<\/em> last January<\/a><\/span>. \u00a0Apparently, 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. \u00a0This was, apparently, the wrong descriptor to use. \u00a0Cohen’s point was simple: Cumberbatch was obviously making a progressive point, and to focus on one word is to lose that. \u00a0He 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:<\/p>\n

Spastic\u00a0too was once a euphemism that became an insult. \u00a0In 1994, the Spastics\u2019 Society changed its name to \u2018Scope\u2019 because children were \u2018shouting you big spastic\u2019 at each other in the playground. \u00a0No good did the substitution do. \u00a0As current dictionaries of slang\u00a0report\u00a0\u2018scopey\u2019 \u00a0is now \u2018a byword for spaz\u2019.<\/p>\n

I have seen half my generation of leftists waste their lives and everyone else\u2019s time in petty and priggish disputes about language. \u00a0They do it because it\u2019s easy, and struggles for real change are hard. \u00a0They 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.<\/p>\n

They do not understand that the only way to judge a language is by its use. \u00a0When, in Cumberbatch\u2019s case, generations of linguistic sticklers have insisted that \u2018coloured\u2019 should replace \u2018negro,\u2019 then \u2018black\u2019 should replace \u2018coloured\u2019 then \u2018African-American\u2019 should replace \u2018black\u2019 and now \u2018people of colour\u2019 should replace \u2018African-American\u2019, they are missing the persistence [of] racism. \u00a0If they had genuinely tackled it, they would have no need to demand self-censorship or linguistic change. \u00a0But as I said before, tackling social problems is difficult, while playing language games is what middle-class intellectuals are trained to do.<\/p><\/blockquote>\n

I think that he’s on to something here. \u00a0If people want to use a word to insult someone, they will. \u00a0It’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.<\/p>\n

And it’s possible that the same kind of thought applies in the “Doctor” case. \u00a0Introducing oneself as “Doctor” does not serve as good evidence of a lack of respect. \u00a0If 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. \u00a0A doctor\u00a0might<\/em>\u00a0call himself “Doctor Jones” as a means of lording it over the patient. \u00a0But it’s the lording it over the patient that should worry us, not the convention about how medical staff introduce themselves.<\/p>\n

For what it’s worth, doctors and patients calling each other “mate” is also fine.<\/p>\n","protected":false},"excerpt":{"rendered":"

Here’s an intriguing letter from one John Doherty,\u00a0published in the\u00a0BMJ\u00a0yesterday: Medical titles may well reinforce a clinical hierarchy and inculcate deference in Florida, as Kennedy writes,\u00a0but such constructs are culture bound. When I worked in outback Australia the patients called me \u201cMate,\u201d which is what I called them. They still wanted me to be in […]<\/p>\n

Read More…<\/a><\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[1240,575,968,963,563,475,2745,576,1544,472],"tags":[],"class_list":["post-2977","post","type-post","status-publish","format-standard","hentry","category-blogosphere","category-bmj","category-clinical-ethics","category-curios","category-language","category-politics","category-professionalism","category-the-art-of-medicine","category-the-nhs","category-thinking-aloud"],"yoast_head":"\nR-E-S-P-E-C-T - Journal of Medical Ethics blog<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/blogs.bmj.com\/medical-ethics\/2015\/12\/24\/r-e-s-p-e-c-t\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"R-E-S-P-E-C-T - Journal of Medical Ethics blog\" \/>\n<meta property=\"og:description\" content=\"Here’s an intriguing letter from one John Doherty,\u00a0published in the\u00a0BMJ\u00a0yesterday: Medical titles may well reinforce a clinical hierarchy and inculcate deference in Florida, as Kennedy writes,\u00a0but such constructs are culture bound. 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