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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.

By Christina Johnson MD, PhD

I remember how excited we felt about starting college. At the minority prefreshman program, we met with the new director of multicultural student services and the new African-American chaplain, who were both deeply interested in our success. This is because we were the largest class of Black and Hispanic students the school had ever seen. We had all grown up in the hip hop 1980’s, but we also represented the last cultural vestiges of the 1960’s and 1970’s. Most of us were active members of student committees and groups that promoted cultural pride and educational success. We had watched Eyes on the Prize in school or with our parents and understood the significance of struggle. We knew the Fresh Prince, Parliament Funkadelic and Nirvana. Our experiences ranged from public schools to exclusive boarding schools. We felt that we were culturally ready for college.

The problem was that the school had not yet been prepared for us. We sat one day in the Unity House meeting room with several deans and administrators who were deeply concerned. They heard that many of us intended to go into health careers. They welcomed us to the campus and told us that we should feel at home. Then they encouraged us to consider other careers, because it was not likely that we would make it into medical school (the odds were so low), and it would be more realistic to consider other options. This is before any of us wrote a paper, fretted over a chemistry calculation, or dissected a frog. We understood that they were well intentioned. What they meant was that there was unlimited potential for growth and learning in college and that we should be open to the possibilities of exploring all our interests. What they didn’t know was that we had met them before. 

I met them when I sat in front of a panel for a scholarship interview, and they expressed their surprise at my great scores—for a minority, public school student. I would meet them again while arriving for a research training program at the National Institutes of Health and being mistaken as the new secretary. Then again, when interviewing for medical school with a medical director who thought I must be interested in the MD/PhD program only because of the money involved—surely my interests weren’t purely academic. They were the same professors who encouraged me to consider traveling around Europe to “find myself” when I told them I was interested in medicine. These were gatekeepers to the realm of academic possibilities, and they knew that we were unlikely to succeed.

What they did not realize was that I had prayed about what I was supposed to do in life, having been urged to decide by the ever-looming threat of preteen pregnancy and the dropout rates in my neighborhood. I made the decision to become a doctor when I was 12 years old, and it was then that I decided I belonged to that community. The concurrent presence of negative voices along my journey did not dissuade me, but they affirmed my belonging to the shared struggle experienced by my family, friends, and community in pursuing our collective dreams. Their attempt to advise us to make decisions based on our putative limitations were already a part of our lived experience. It is true that during college many of us found our niche in other fields. However, those decisions arose freely as a part of the normal exploration of interest and identity that occurs in the college environment. Indeed, many of us did become medical professionals.

Much of my journey to becoming a physician and a researcher has been marked by academic curiosity and perseverance, incredible mentorship, and family support.  Medicine is where my community focus and intellectual fervor align. However, it is the thread of rejection that has been a constant motivator. It is the reason why I am not just a clinician, but a community educator, an advocate, and a mentor. It has allowed me to see belonging to this community as both an earned privilege and a gateway for others to adopt a posture of belonging as they pursue their goals.

By Jennifer Hammonds,LCSW and Alicia Markley, MPAS, PA-C

Bob arrived to establish receive care in our rural site clinic. As the nurse was going through the rooming process with the patient, she noticed he seemed very apprehensive about answering questions. Bob began to open up to the nurse about a recent negative experience he had at a local emergency room. He had presented to the ER for abdominal pain. Throughout the visit, Bob could hear the ER staff at the nurse’s station, laughing, joking about him, and speaking negatively about him and his concerns. This experience was traumatic, and fear of having this happen again had caused him to put off seeking medical care for some time. The nurse was rightfully upset on the patient’s behalf and wanted to put him at ease in our clinic.

This is a glaring example of health disparity, but why was Bob treated differently? Bob is a transgender individual. Bob’s legal name is Barb.

Research has shown that LGBTQ patients experience higher levels of discrimination, stigma, and stress and are at higher risk for poor health outcomes. Our primary goal is to provide quality patient care for our patients. All our patients. This nurse took a step back and looked at her ability to provide culturally competent care for this patient. She naturally wanted to treat this, and every patient respectfully, but she knew that she had some obvious questions about how to address certain situations.

This incident sparked a conversation between the two of us. As a whole, the clinics seem to be adept at being LGBTQ sensitive toward our adolescent patients, but we weren’t sure about our adult population. How comfortable is our nursing staff in asking patients for pertinent, though sensitive, health information? Do our front desk staff know how to address patients when their insurance card information differs from the information provided by the patient? Is our clinic known in the community as being LGBTQ friendly, or are we missing the big picture? We quickly realized that we were uncertain about many of these things. Questions often spark the need for answers, so we decided to embark on a project, one that would, hopefully, highlight our strengths, as well as areas in need of improvement.

We decided to begin simply, with a survey of all staff, nurses, faculty, residents, and social workers, to determine our comfort level, knowledge base, and understanding of LGBTQ patients and their healthcare needs. We used a SurveyMonkey tool, knowing full well that this was a less-than-scientific method of data collection.It nonetheless served our purpose of information gathering.

The responses were quite interesting. Many professionals expressed having only basic knowledge of LGBTQ patient needs but were willing to learn anything we could teach them. A few identified as being a member of the LGBTQ population and were delighted to learn of our project intent. The feedback received engaged us fully, and we made it our goal to find the best resources to educate ourselves and provide the best quality care to all patients in our community.

Herein lies the rub—the two clinics within our residency program provide two vastly different perspectives. One is located within the University City limits with a significantly diverse population. The other resides in a homogenous, rural area that has limited exposure to people of different backgrounds. As our goal of education began to take shape, it was necessary to consider our audience as well. Luckily for us, the National LGBTQ Health Education Center had a tremendous amount of learning material, PowerPoint presentations, and seminars available for use. Both clinics were receptive and engaged with the material presented, and subsequent nonscientific polling suggested that the exercise was a beneficial one.

Throughout this process, we both deepened our own intellectual and emotional understanding of our patients and cemented our belief that our colleagues were dedicated to providing the most positive and beneficial care to our patients, no matter their gender or orientation. We plan to revisit these training materials yearly with hope that we can continue to grow and fulfill our mission of meeting health care needs through education, patient care, research, and service to the community.