What’s in a Title? Establishing Clear Expectations and Professional Culture Through How We Address Our Colleagues.

What’s in a Title? Establishing Clear Expectations and Professional Culture Through How We Address Our Colleagues

Kelly M. Roberts, PhD, LMFT; P.K. Grafton, DO; Jaspreet Kaur, DO

“Bye, Doctor [male intern last name]. Bye, [female resident first name],” said the male attending physician as the residents left the continuity clinic.

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“What’s in a name?” wondered the female resident, having been casually addressed with her first name multiple times, in comparison to colleagues addressed with their professional titles. 

This interaction, however, was particularly unsettling for her and raised multiple internalized questions. Was this the attending’s attempt to encourage the intern to use his newly earned title and foster professional development, or was this an attempt to demean her? Was it intentional or unintentional? Conscious or subconscious? Did the matter warrant further attention and discussion? Would failure to contend with the issue affect her performance or growth?

This wasn’t the first instance of title imbalance; multiple versions of this same scenario had been raised by residents over the course of two years, yet our program wasn’t realizing lasting change. Meetings were held based upon this particular instance, and since that time everyone involved has reflected on multidimensional aspects related to title utilization.

As a debriefing exercise, we are sharing combined administrator and resident perspectives covering a few title utilization conceptual areas such as identity formation, power differentials, programmatic culture, and clarity of expectations

Identity Formation

Becoming a physician involves more than acquiring medical knowledge and developing clinical skills. Physicians also need to develop professional identities—physician, community leader, medical board member, etc. These identities start long before medical school but must be cultivated during school, residency, fellowships, and throughout attending practice. Students and residents establish evolve their identities through social experiences, patient encounters, and educational time spent with attending physicians and mentors. Helping students and residents form their professional identities, and function appropriately within them, is a critical component of the medical education system. The title of “doctor” is one that a student will need guidance and education growing into and maintaining.

Power Differentials and Hierarchies

Physician burnout and well-being is a current hot topic. Many studies discuss the use of Maslow’s hierarchy of human needs as the potential framework for addressing wellness. Part of this hierarchy is esteem. A physician’s esteem is tied to multiple internal and external factors. Especially during residency training, external factors play a large role in physician esteem. After working through undergraduate, medical school, and then additional years of residency, achieving the title “doctor” has significant and powerful meaning. Hearing patients, attendings, and nurses refer to you as “doctor X” is empowering. While on the flip side, being addressed without your title by a superior can leave you questioning their respect and opinion of you as a physician.

Professional Culture

Residents are encouraged to use their titles in lieu of first name when introducing themselves to patients or nurses at most training programs. The formality of titles is generally lax when residents are amongst their colleagues in resident work areas, call rooms, and table rounds. However, the title strategically finds its place during bedside rounds, a formal setting involving patient care. Deciphering between the appropriate use and setting for casual versus formal communication is foundational in building trust and respect, and is unique to training programs. A 2017 study examined the likelihood of professional titles usage during introductions at internal medicine grand rounds and found females introduced male speakers with formal titles 95% of the time in comparison to 49% male introducing female speakers. Female introducers in general were more likely to use professional titles when introducing any gender speaker in comparison to male introducers.

Clarity of Expectations

The possibly unintentional variation in formality may undermine the expertise of female physicians and impact their professional growth. In a training environment, it is imperative to follow a unified, though not necessarily formalized process for addressing resident physicians—male and female—as they advance in their professional roles. Establishing the appropriateness of casual versus formal communication is unique to institutions given its multifactorial nature; although universally clarifying expectations could enhance sensitivity and potentially mitigate existing gender bias in medicine.

Our Own Process

One exercise that assisted with defining a few of these elements was the decision to deploy an STFM CONNECT post over this topic. The following quotes pulled from that post demonstrate the diversity of perspectives offered at the time:

…Lopsided use of titles is arrogant to my ear. My ego and confidence as a physician are not wrapped up in a title.

…This is something that physicians in a larger community, such as where I practice now, rarely have to consider.  But in small towns, physicians interact with their staff and their patients in a host of very close ways that would be quite avoidable – and even considered of questionable ethics – in regions of higher population density.  The use of the title allows us to take a step back and be more “objective” while continuing to address health issues of those for whom we care (care, in every sense of the word).

…I call residents “Doctor” so the patients, nurses, others, and they themselves know who they are and their role, especially important for URM and women. They are not expected to be the patient’s friend, nurse, pal, aide, etc. They are expected to be each patient’s physician.

Attendings hold immeasurable power to propitiate, or stunt, resident growth on a daily basis. As members of STFM, externalizing your own questions will undoubtedly prevent residents from internalized struggles about their own identity, helping them own, with all the rights and responsibilities, the true and noble title of doctor.