Charlie or King Charles: Do Titles Matter?
Rebecca Margolis DO, FAOCA, Jennifer Lau, MD and Myron Yaster MD
Increasingly I’m feeling more and more like Statler and Waldorf, the 2 old guys in the balcony on the Muppets show. There is a certain formality that I expect in doctors, whether it’s me as a patient or me as a doctor being entrusted with the life of my patients. When initially meeting patients/parents or my own primary care doctor, I always shook hands and introduced myself as Dr. Yaster. I thought and taught that this formality was essential in establishing the doctor-patient relationship.
And when meeting patients and their families I cared how I looked as I introduced myself as well. When meeting with patients in my doctor role in Baltimore, I insisted that I and my team wear a white coat or sports/suit jacket and when appropriate a tie as well. I expected the same from my PCP too. Indeed, I loved my PCP in Baltimore who fit this role (and he did a complete physical exam too including chest percussion!). In Colorado, white coats were rare and ties? Fahgettabout! Indeed, my doctor dressed like he had just come in from working the garden. Zoom made this even worse. And ties? My recent trip to the symphony and to shul/temple for Jewish high holidays services have convinced me that ties have gone the way of spare tires in new cars. So when I saw this article I thought “perfect” and asked Dr. Rebecca Margolis who is a leader in SPA’s Well-Being committee to write this with me. She asked one of her colleagues, Dr. Jennifer Lau, Director of DEI at the Children’s Hospital Los Angeles to assist. But first Statler and Waldorf: Myron Yaster MD
Original article
Harvey JA, Butterfield RJ, Ochoa SA, Yang YW. Patient Use of Physicians’ First (Given) Name in Direct Patient Electronic Messaging. JAMA Netw Open. 2022;5(10):e2234880. doi:10.1001/jamanetworkopen.2022.34880
Societal norms have long dictated that physicians are formally addressed as “doctor” by patients, inherently establishing respect of the physician-patient relationship. A previous survey revealed that 75% of doctor’s report being called by their first name with 61% of physicians reporting annoyance at this practice.1 The practice of not using a person’s proper title (“untitling”) was explored in today’s JAMA study which conducted a retrospective review of patient messaging to physicians in the electronic medical record and used a natural language processing algorithm to identify the greeting and/or closing salutation used by patients and to classify these greetings based on formality.
>90,000 patient messages were evaluated and of those 32.5% included the physician’s name in the greeting or closing salutation. Women were >2X as likely as men to be called by their first name. Osteopathic physicians had nearly twice the odds and primary care physicians had about 50% greater odds of being called by their first name. Women patients had approximately 40% lower odds to address their physicians by first name. There was NO difference based on patient or physician age or whether the physician was in training.
Addressing physicians differently depending on their gender, degree, or specialty is a microaggression which is a form of unconscious bias. The bias being that a “Doctor” looks like an older white man with a MD. Similar studies at academic meetings and grand rounds have shown that women frequently experience untitling when introduced by men.2 The unsettling notion about untitling is that perhaps that it represents the tip of the iceberg amongst an undercurrent of disrespect of healthcare providers. The current climate of the U.S. healthcare system is one of mistrust, misinformation, and frightening increases in violence against healthcare providers. Healthcare workers are five times more likely to experience workplace violence than employees in any other industry.3 Healthcare providers are being provided with emergency panic buttons, performing active shooter drills, and receiving training on how to handle bullying from patients and families (it’s not just surgeons bullying anesthesiologists anymore!).
As we advocate to “flatten the hierarchy” does that include the loss of our hard-earned titles? As a female osteopathic physician who is frequently confused to be someone other than the attending anesthesiologist, I think like most things in life: it’s nuanced. There have been times families have called me “Rebecca” that I sense stemmed from a deep sense of trust, comfort, and connection and then there have been the maddening instances where I have spent 30 minutes counseling a family before a complex procedure only have them ask when the doctor will be there. But it’s not just women: the president of the Canadian Medical Association, Alika Lafontaine, (a sturdy 6’3” indigenous man) has been confused as both security and housekeeping. While this study did not examine race, other studies have shown that this type of microaggression lands even harder on our minority colleagues. Untitling is one of many microaggressions suffered by underrepresented physicians. Some may say “it’s no big deal” but you must examine the privilege you have to not be bothered by this. We already see women and minorities receive lower pay and make up less of the leadership- it should not be difficult to see how untitling is yet another form of devaluing AND it’s something we are doing to ourselves. Another papercut on a person already covered. As the “rewards” for being a doctor (social status, compensation, autonomy of practice) have evaporated perhaps this sign of respect for the sacrifice is becoming increasingly important—especially to those that are often marginalized.
We’ve raised lots of interesting and perhaps controversial issues in today’s PAAD. What do you think? Send your responses to Myron (myasterster@gmail.com) and I’ll post them in the PAAD.
References
1. Farber NJ, Novack DH, Silverstein J, Davis EB,Weiner J, Boyer EG. Physicians’ experiences with patients who transgress boundaries. J Gen Intern Med. 2000;15(11):770-775. doi:10.1046/j.1525-1497.2000.90734.x
2. Files JA, Mayer AP, Ko MG, et al. Speaker introductions at internal medicine grand rounds: forms of address reveal gender bias. JWomens Health (Larchmt). 2017;26(5):413-419. doi:10.1089/jwh.2016.6044
4. Molina MF, Landry AI, Chary AN, Burnett-Bowie SM, Addressing the Elephant in the Room: Microaggressions in Medicine. Annals of Emergency Med. 2020; 76 (4): 387-391.doi: 10.1016/j.annemergmed.2020.04.009