Dr. Jacob Appel: Why call anyone ‘Dr.’?
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The controversy over incoming first lady Jill Biden’s use of the title “Dr.” — spurred by essayist Joseph Epstein’s recent jeremiad in The Wall Street Journal against holders of nonmedical doctorates who embrace the label — largely has focused on the sexism confronted by female Ph.D.s and Ed.D.s (such as Biden) and their right to be proud of their credentials. Most commentators have taken for granted physicians are justified in so styling themselves, although several critics have questioned the use of the title even by M.D.s outside the medical context. As a physician myself, I propose an alternative criteria for the use of the title by M.D.s: Never.
Americans have embraced the use of the title by physicians without reflection as though this use is timeless and universal. Neither is the case. Before the mid-18th century, the title largely applied to scholars, not healers. Surgeons still are addressed as “Mr.” in Great Britain — no matter how impressive their diplomas.
No logical reason exists for wedding invitation envelopes and business letter salutations and registration forms at the dental office to separate medical doctors from untitled lay people. One might argue physicians have worked hard to obtain their credentials. Yet barbers and plumbers and farmers also work hard — often harder, for less pay — and they have not carved out special honorifics to peacock themselves.
But does it really matter if we honor physicians with a superfluous title? If our goal is quality patient care, the answer is yes. In some fields, such as the military, titles serve a useful purpose in clarifying hierarchy and preserving order. Similarly, it is important to know who is the captain on a ship and who is the purser. In contrast, in a hospital, roles are clear.
Emphasizing hierarchy is often counterproductive. Having medical students and nurses and aides on a first-name basis with attending physicians increases the likelihood that they will raise clinical concerns and even question potential medical errors. In the busy urban emergency room where I work, I strongly encourage the staff to call me by my first name: They already know I am a physician. This helps remind them I am also a human being, capable of mistakes and open to correction. Dropping “Dr.” is a way to affirm that all of our jobs are equally valuable.
Yet the use of “Dr.” in direct patient care is even more problematic. Over the past 50 years, American medicine has witnessed a shift away from benevolent paternalism toward an autonomy-based model in which patients are encouraged to make their own informed decisions. Minimizing the imbalance of power between provider and patient is crucial so patients feel comfortable asking challenging questions and advocating for themselves. Unnecessary trappings of authority might make physicians feel more confident, but they do little to serve patient needs.
I am not urging a mass grassroots challenge to medical prerogatives. There is merit in Miss Manners’ exhortation to allow people “to call themselves what they want.” (If I ever encounter Elizabeth Windsor, I will swallow my republicanism and address her as Your Majesty.) And there is room for exceptions: Some patients will never feel comfortable dropping the title, while for others, a title enforces boundaries that serve therapeutic purposes. I am also sympathetic to the concerns of female physicians, particularly those from backgrounds underrepresented in medicine, that a title helps establish their authority and — it is distressing to report in 2020 — prevents them from being mistaken for nurses.
All I ask is physicians and patients reflect upon the use of such titles. When I teach first-year medical students, I instruct them to ask every patient at the initial encounter, “How would you like to be addressed?” Maybe they should also be asking: “How would you like to address me?”
Jacob Appel, M.D., is director of ethics education in psychiatry at the Icahn School of Medicine at Mount Sinai.