Are the Old Rules Dead? It's a first visit with your new patient, and all is going well. He makes eye contact, appears to be paying close attention as you discuss his cholesterol levels, and readily agrees to a follow-up appointment. And then he says something that stops you in your tracks. "Okay, Bob," he says cheerfully, as he shakes your hand. "I'll see you in 3 months." The smile freezes on your face as you digest this brief interaction. How on earth did you suddenly get on a first-name basis with your patient? And with a nickname, no less! The rules of engagement have certainly changed in the 21st century. In society as a whole, people and relationships have been getting steadily less formal. In many companies, men have shed the suits and ties in favor of khakis and polo shirts—and not just on Casual Fridays. In neighborhoods from Portland, Maine, to Portland, Oregon, kids call their friends' parents by their first name. It's no surprise, then, that this level of informality has crossed over into the medical suite. Developing a good rapport with a patient is essential, and what transpires during a first meeting can set the stage for the ongoing relationship. But unfortunately, there are no definitive guidelines on how physicians and other providers should be addressed, how patients prefer to be addressed, or how staff should introduce themselves. Aside from a few small studies, published data remain scant. According to the literature that is available, some patients have indicated that they prefer that their doctors call them by their first name—although others will bristle at the thought of it, especially if they're old enough to be your grandmother. (No one called Marcus Welby by his first name!) But what about you, as the physician? Do you mind if your patients don't address you with a formal title and instead call you by your given name? Or use that compromise of "Dr + First Name?" Establishing Boundaries Anne Marie Valinoti, MD, a New Jersey-based internist, expressed some misgivings about a patient calling her by her first name, and that it's "one thing I'm still getting used to." Writing in the New York Times, Dr Valinoti pointed out that there "seems to be a void in this area of etiquette: How does one address one's physician?"[1] In her case, she found that it was almost always an older male patient who took it upon himself to use her first name, and usually in a friendly, offhand manner. "It might seem natural if I have had a long-term relationship with these people, caring for them over the years, but often these patients seem to make a decision at the outset to be on a first-name basis with me," she wrote. "I wonder about these people. Are they trying to be chummy? Is it a power thing, making them feel less vulnerable while they sit half naked on the exam table? Do they just call everyone by their first names?" In a letter to the editor of Emergency Medicine News, Robert D. Greene, MD, of Redding, Connecticut, emphasized that a doctor/patient relationship is not a personal relationship. "That does not imply one cannot give empathy, compassion, and understanding," he said. "In fact, it is a requirement of the relationship."[2] But when Dr Greene leaves the office, "[I'm] not going to play golf or go to dinner with my patients as part of my treatment plan. In fact, we often have to remove ourselves from that level of connection to make objective and difficult decisions. That is why doctors should not treat their friends." On a Medscape blog, Gary Stadtmauer, MD, who maintains a private practice in New York City in allergy and immunology, finds that it "happens every now and then and it always takes me by surprise" that a patient calls him by his first name.[3] "I do not know exactly why some patients do this," he wrote. "Any title commands a certain degree of respect but also is a recognition on some level that the parties are not entirely equal. Perhaps that is an uncomfortable situation for some people. Or maybe they were on a first-name basis with another doctor and they are more at ease with physicians on a first-name basis. There are probably more reasons." One physician reader, however, commented that doctors should "get over it" and that "this is the 21st century, and patients count also. If my patients want to refer to me by my first name and it makes them comfortable, I am happy to put them at ease." Comfort With First Names Varies It is impossible to know how many patients address their physician as "Doctor" or use their first name, given the huge diversity of medical practice and cultural/ethnic differences among physicians and patients. There are also very scant data on the subject, and most of what exists is old. "I don't think things have changed very much since then," noted Dr Brian McKinstry, a primary care professor in England, who conducted a study on this subject in 1990.[4] Dr McKinstry explained that in his own practice and institution, "many of the doctors use first names with their patients. Some patients do with doctors, but it's a very definite minority." In his article, Dr McKinstry pointed out that some authors have argued that "using the patient's first name but not the doctor's maintains this unequal relationship, which can be damaging in the long term." Taking it a step further, it has also been suggested that this "induced dependency" inhibits patients' ability to make decisions for themselves and to take responsibility for their health. Richard Harrigan, MD, a professor of emergency medicine at Temple University Hospital and School of Medicine in Philadelphia, says he prefers to be on a first-name basis with patients. He feels that dropping the title of "Doctor" removes the first barrier to establishing the doctor/patient relationship. "I begin the conversation with 'Hi, I'm Rich Harrigan; I'm your doctor,' or something to that effect," he explains. "As I leave the room, I close with something to the effect of 'So, my name is Rich; let me know if you need anything/I'll let you know when your tests are back/Do you have any other questions?' That type of thing." Not surprisingly, this level of informality takes some patients aback, although not all that many. But then, this is the emergency department—where, unlike in primary care or other specialties, there's generally little time to establish a relationship with patients. However, even though Dr Harrigan emphasizes the use of his first name, it varies as to what patients actually end up calling him. "Many don't call me anything," he says, figuring some may have forgotten his name. "But I feel I've broken down a potential barrier by not introducing myself as 'Dr Harrigan.'" One Doctor's Naming Journey Then there are physicians, such as Roger Suss, MD, a lecturer in the department of family medicine at the University of Manitoba in Winnipeg, Canada, who change their views over time as to what they should be called by the patient (or vice versa). When he was fresh to the practice of family medicine, he recalls being a little hesitant as to what he should call himself. Because his name is pronounced like "Dr Seuss," the famous children's book author, it seemed almost humorous for him to be introducing himself that way. He then decided upon using his full name—Roger Suss. The results were interesting. Some would choose Dr Suss, which to him suggested a preference for a "traditional" doctor/patient relationship. Others would use Roger, suggesting a desire for a less hierarchical relationship on a more equal footing. However, he realized that at least to some patients, his reluctance to openly refer to himself as the doctor may have suggested to them that he wasn't quite ready for the job. "I've come to realize that some people like a more egalitarian relationship with their doctor, and some like a more hierarchical relationship," he says. "As a young man, I projected my value of egalitarianism onto others." "I continue to introduce myself as Dr Suss. I view it as a danger sign if my patients want to call me by my first name, but I don't confront it," he explains. As for patients, he generally greets them by their full name when he introduces himself. If they're significantly older, he calls them by title (Mr, Ms, etc.) but otherwise shifts into using their first name unless there's a reason not to. On the occasion when there's tension in the relationship, he'll switch to using the title. Peer-to-Peer Etiquette Another issue in the first name/title situation are coworkers—namely those who help you care for patients, such as nurses, other physicians, and residents. For some reason, nurses have by and large been appropriated to "first name only" status. In old black-and-white movies, nurses dressed in starched white uniforms and even stiffer caps are usually called "Nurse Kaplan" or at least "Miss Ramirez." Somewhere along the line, title/last name has been replaced with a first name, and in many hospital settings, a nurse's name tag only has a first name ("Maria, RN"). Dr Valinoti notes a bit of injustice in this situation. "Freshly minted MDs, some as young as 25, get a title of respect while seasoned nurses in the hospital are Betty, Kaye, or Nancy." During her intern days, she recalls the "absurdity of this situation" when addressing critical care nurses who had decades of experience by their first names while they deferentially referred to her as "Doctor." "These were women who had started their careers when I was still playing with Barbie dolls, yet where were their professional titles?" Dr Valinoti says. However, depending on the hospital unit, clinic, or practice, the rules of name etiquette can vary tremendously. In many settings, everyone's on a first-name basis. In others, things are more formal. Sometimes, first names will be used exclusively when staff are alone, but then they'll revert to the more formal titles in front of patients. In the military, nurses can outrank doctors, so there's never a question of what name to use. Dr Suss feels that physicians should call one another by first name in most settings. "My residents get used to calling me Dr Suss and often feel uncomfortable when they graduate and I insist they call me by my first name," he says. "The symmetry reflects the fact that we have become equals in responsibility. I no longer give them feedback on their practice, except occasionally as a peer." He also encourages his staff to call him by his first name. "In front of patients, I prefer that they call me by title, but I'm prepared to call them by title if desired," he says. "The question is tied to one's interpretation of hierarchy. I consider other staff to be equals in that we both work for the hospital; no one asks me about hiring or firing them, they don't report to me, I don't set their schedules or discipline them if there are problems...but not everyone sees it that way." Is 'Doctor' Becoming Too Stuffy? Dr Harrigan uses his first name with all staff, whether they're nurses, pharmacists, other attending physicians, or residents. "I always use my first name," he says. "It seems utterly ridiculous to me that we go around calling each other 'Doctor.' How pretentious." He notes that many of his residents often call him by title, largely owing to custom, protocol, and his age—57. "But after a while, I get them to call me 'Rich,'" he adds. But on the opposite side, Sean P. Dent, a board-certified acute care nurse practitioner, notes, "I can relate to using first names. It breaks down barriers and can ease the unspoken tension that can develop among healthcare team members. It 'levels the playing field,' in a manner of speaking." Ultimately, however, and by default, the physician should be referred to as 'Doctor' unless they prefer otherwise. "At the end of the day," Dent says, "the physician has earned the title and it should be their decision, and their decision alone, that determines how they're addressed." References Valinoti AM. Exam-room rules: what's in a name? New York Times. December 14, 2009. http://www.nytimes.com/2009/12/15/health/15case.html Accessed October 4, 2015. Greene RD. Please call me doctor. Emergency Medicine News. 2006;28:10. http://journals.lww.com/em-news/Fulltext/2006/03000/Please_Call_Me_Doctor.14.aspx Accessed October 2, 2015. Stadtmauer G. Atopic topics: Please call me doctor. Medscape. May 8, 2013. http://boards.medscape.com/forums/?128@@.2a57d4a4!comment=1 Accessed October 3, 2015. McKinstry B. Should general practitioners call patients by their first names? BMJ. 1990;301:795-796. Abstract Source
