What’s in a name? The (Mis)Use of Formal Titles in the Hospital

Introducing the Problem

In any hospital, there are many different types of workers who help to provide quality patient care and keep patients safe. Of all those who work in the hospital, however, only doctors receive a formal title in day-to-day conversation. Whether it’s from other medical professionals or patients, attending physicians are almost always called Dr.  On the other hand, nurses, physician assistants, medical students, and even resident physicians less frequently receive formal titles in the hospital.

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Growing up in a Caribbean family, I was taught that titles are a sign of respect, especially for those older than I am. To this day, I still refer to my parents’ friends as Aunty, Uncle, Ms. or Mr. So, in the hospital, it was basically second-nature for me to refer to attendings as Dr. After all, most attendings fall into the “respect your elders” category when it comes to age.

However, once I got to business school I was pleasantly surprised by the informal nature of greetings and interactions. Everyone in business organizations I’ve encountered is referred to on a first name basis. Though hierarchy is sure to abound on the basis of experience, responsibility, and power, the use of first names allows the business relationships to be built on a more equal footing.

As I transitioned back into the medical setting after my first year at business school, my perspective had changed. I no longer wanted to accept the existing title hierarchy as status quo.  Now, it’s hard for me to come to terms with the fact that in the hospital, all attending physicians are called Dr. unless they tell you otherwise. On the other hand, those who are often more entrenched in the day-to-day care of patients – nurses, medical students, and sometimes resident physicians – are referred to by their first names.

You might be wondering to yourself… I don’t see the problem…What’s the big deal about calling a doctor “Dr.”? If that point piques your interest, hold tight! That’s exactly what I’ll discuss!

Unequal Use of Titles in the Hospital

I started a conversation on Twitter a few weeks ago about the inequitable use of titles in the hospital. Something about the new-found freedom to call my mentor by her first name struck a chord. (Read the tweets if you’re curious to know more.) I wondered…why was I so happy to call someone I’ve known for four years by her first name? I realized that despite my new life in the business world, the unequal distribution of formal titles in the hospital was engrained in me.

To discuss the inequity of titles in the hospital, I’ll break my points down by medical role. Then, I’ll propose two solutions to the issue of (mis)used titles in the hospital.

It’s not lost on me that I’ve ordered these following subheadings to mirror the medical hierarchy. Old habits die hard.

Attending Physicians

Official title: Dr. – by everyone

Defining the role: Attending physicians, or attendings, are the “top dogs” in the hospital, clinically speaking at least. The weight of lawsuits responsibility and decision making for patients lies mostly on their shoulders. Attendings don’t need anyone to co-sign their notes. They can see patients for as much or as little time as they want. Attendings also make a lot of money.

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Below is one of the most commonly given reasons for the use of the title “Dr.” to refer to attending physicians:

Attending physicians have worked hard to get to where they are and deserve the title of Dr. They sacrificed time, money, and life experiences to be where they are today.

I wholehearted agree that attendings deserve the utmost respect. H.O.W.E.V.E.R. I’d say that the rest of a patient’s treatment team should receive that same level of respect. Don’t nurses, scrub techs, PAs, medical students, and residents work hard too? We’ve also sacrificed years, money, and life experiences for the sake of patient care. Yet, in the hospital setting, non-attendings are most commonly referred to on a first name basis, especially by other medical professionals. As a result, we provide patient care in a setting that cements unequal power dynamics. Moreso, the title-based power dynamics often exacerbates the gender and racial inequalities that continue to exist in the medical field. Though this is changing, senior attendings are typically older white men, while the remainder of patients’ treatment teams are more diverse by race and gender.

Resident Physicians 

Official title: Dr. -by patients / first name – by other medical professionals

Defining the role: Resident physicians, or residents, have completed medical school and are licensed to practice medicine upon completion of an intern year (and Step 3). In academic hospitals, residents perform the majority of hour-to-hour, patient care at the physician level. Residents take ownership of patients, pre-round, round, write notes and orders, call consults, get collateral information, and teach medical students.

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Of all the medical roles I’ll discuss in this post, residents are in a gray area. Although they are FULLY physicians, they are not automatically bestowed the formal title “Dr.” In my experience, most patients will refer to residents as “Dr.”; however, most other medical professionals refer to the residents by their first name.

I’ve seen residents prefer to be called by their first name by other medical professionals because

1. Residents are typically on the younger end and try to be less stuffy than the older attendings
2. (New) residents often feel as though they don’t know what they’re doing, so being referred to by their first name instead of Dr. takes some of the pressure off.

My main issue with the use of first names for residents is the divide that this creates between attendings and residents. Yes, residents are technically still in training, and the attendings are their bosses, but as in the business world, I see an equal use of first names (or equal use of the title Dr.) as the best course of action to disrupt existing power dynamics.

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Medical Students

Official title: Student Dr. – by almost no one / first name or “the student” – by basically everyone

Defining the role: Medical students participate in clinical rotations to learn the ropes of medicine. We interact with patients and other medical professionals so that we can gain both clinical knowledge and clinical skills. In many instances, medical students help to lighten the load of the residents, nurses, and attendings, but hospitals and outpatient clinics should be able to be wholly functional without medical students (though I’ve heard anecdotally of instances where this is not the case).

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Medical students have no power, but some responsibility. Moreover, patients and nurses often aren’t sure what role the medical student is capable of playing or what role they should play. So the med students are stuck in a weird limbo. “Student Dr.” has too many syllables, “Dr.” is technically inaccurate, and being called by your first name leaves room for you to be mistaken for a nurse or technician (especially as a student of color).

One of the faculty members at my medical school alma mater refers to all of his students as “Dr.” I remember the first time he referred to me as Dr. Jordan. I appreciated this gesture because it was his way of recognizing me as a future colleague, not just a student. Given the fact that medical students sit at the bottom of the totem pole, I believe that the unequal use of titles in the hospitals negatively impacts us as we try to gain confidence about our roles as future physicians.

Nurses, Physician Assistants, Respiratory Therapists, and Other Medical Staff

Official title: first name – by most / Ms. or Mr. – by some patients

Defining the role: The short answer is that medical professionals in these roles truly do the majority of the minute-to-minute work of taking care of patients in the hospital. Physicians often direct care, but in the hospital, nurses, PAs, and MAs deliver a large proportion of care. I could (and probably will) write a whole post about the difference between the roles that nurses, PAs, and therapists play in the hospital. For now, though, I’ll focus on what name they’re referred to in the hospital because this post would get too long otherwise.

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I’ve never heard a nurse referred to by anything other than his or her first name, both by patients and by physicians. On the flip side, most nurses call their patients Mr. or Ms. and they call attendings Dr. This bothers me because nurses and other medical professionals who truly do the majority of the hands-on work aren’t given respect by way of a formal title in the hospital. How hard would it be to refer to nurses as Nurse So-and-so? Or what about calling the phlebotomist Mr. So-and-so? This small change has the potential to ensure that we give the often overlooked members of the medical team the respect that they deserve.

Framing the Solution

Now that you have a better understanding of the (mis)use of formal titles in the hospital, let’s get to the final question.

What can be done to shift the unbalanced power dynamic enforced by the unequal use of titles in the hospital?

In my opinion, there are two options for getting rid of the unequal use of formal titles in the hospital:

1. We get rid of titles altogether and equally refer to all medical professionals by their first name, OR
2. We refer to all care providers by a formal title.
   • Attendings : “Dr.”
   • Residents : “Dr.”
   • Medical Students : “Student Dr.”
   • Nurses : “Nurse”
   • PAs/MAs etc : “Mr.”

To me, the interesting part of all of this is the simplicity of the solutions. Despite the comments I’ve heard from physicians about wanting to hang on to the title of Dr. as a form of “manners” or “respect,” we must really consider if this title does more harm than good. In my mind, keeping the status quo is not an option. As the demographics in medicine continue to shift, the existing naming hierarchy hangs on to days of old when physicians were all white men and nurses were white women. The formal titles in the hospital are at danger of continuing to force racial and gender divides as older docs are still more commonly white men, and non-physician medical professionals are people of color.

Summary

As we think about the changing racial and gender make up of providers within the medical field, we must reevaluate the inequitable use of titles in the hospital. My suggestions above require that we either lighten up with the formalities of referring to only attendings as “Dr.” OR we put some respect on everyone’s names and use formal titles universally.

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I really want to know your thoughts on this! Are you on #TeamCallMeDoctor or #TeamFirstNames? Leave a comment below. I’m interested in having a dialogue about this!

Peace and blessings,

Dr. Atasha Jordan