Doctor Who? Honorific titles and their influence on patients’ perceptions of healthcare professionals

In the 11 December 2020 edition of the Wall Street Journal, ¹ Joseph Epstein, a former adjunct professor at Northwestern University, wrote an opinion piece which suggested Jill Biden, wife of the 46th US President Joe Biden, was not entitled to use the honorific ‘Dr’ as she was not medically qualified (Dr Biden received her Doctorate in Education from the University of Delaware in 2007). Among several ill-considered comments, it was one especially that piqued our interest: ‘A wise man once said that no one should call himself “Dr” unless he has delivered a child’. It was not the absurdity and gendered nature of this statement, but the notion of what it meant to use the title ‘Dr’ within a healthcare professions context. As we considered this further, we asked ourselves could use of the honorific title ‘Dr’ (or that matter ‘Doctor’) influence patients’ perceptions of the skills, expertise and qualifications of the healthcare professionals they interacted with?

The title, ‘doctor’, stems from Latin, for ‘teacher’, itself from docēre, meaning ‘to teach’. ² This title is conferred on a person by a university on completion of a doctoral level degree. In colloquial usage, the term refers to medical doctors despite many primary medical degrees being at a Bachelor’s or Master’s level. The use of the title ‘doctor’ for medical graduates is said to have commenced in the 17th century, particularly in Scotland, as a means of recognising the respect and prestige medical schools considered should be accorded to such graduates. ³ The honorific title ‘Doctor’ instils an innate sense of confidence in a healthcare professional, communicating a social signal to patients regarding their practitioners’ level of knowledge, skill, expertise and an assumed level of training, qualifications and professional regulation. In a healthcare setting, use of the title ‘doctor’ was once largely reserved for medically qualified practitioners, ⁴ but it is increasingly being adopted by various health professions other than medicine, including chiropractors, osteopaths and dentists.^5,6

Regulations imposed upon health professionals by healthcare accrediting agencies across the world attempt to achieve transparency of education, qualifications and skills by enforcing an accompanying denotation of practitioner qualifications and profession with any use of the title ‘doctor’ (for example, literature^{7 –12}). However, use of informal references by non-medical practitioners as ‘doctor’ and use of the term ‘Doctor’ as a noun in advertising may potentially confuse members of the general public (for example, literature^13,14). The American Medical Association’s Truth In Advertising campaign investigated patients’ understanding of healthcare professional roles between 2008 and 2018. ¹⁵ The results revealed widespread confusion about which health professionals were medical doctors. Only 55% of respondents in 2018 agreed it was easy to identify who was a licensed medical doctor by the services they offer, their title and/or other licensing credentials, compared with 41% in 2014, 51% in 2010 and 46% in 2008. While 70% of respondents could correctly identify an anaesthesiologist as a medical doctor, 42% incorrectly identified a psychologist as holding a medical qualification. When asked what was important to them, 88% of respondents were in favour of healthcare professionals being required to display their qualifications and licensure. These results are telling: patients want to understand the specific role and qualifications of their healthcare professional, but many struggle to do so.

The aforementioned findings suggest confusion may arise among patients regarding which doctors are medical professionals, and which hold non-medical doctorates. ⁵ Indeed, the AMA has lobbied to limit the use of the title ‘doctor’ within the United States to medical doctors (allopathic and osteopathic), dentists and podiatrists.^16,17 This move has not been without pushback from other non-medical health professionals in possession of doctoral level degrees. ¹⁶ We believe in this context there is a broader issue to consider – is there potential for misconception of the specific skills, qualifications and evidence base behind practices of healthcare professionals based purely on an honorific title? This misconception may be a source of wrongful implied trust based on the social connotations of their legally adopted title, as well as the social contract that healthcare professionals will act in the best interests of their patients and maintain professional standards related to privacy, confidentiality, beneficence and sexual continence.

This has been explored to some extent in the public domain (for example, literature^{18 –21}) but discussion has been limited to the broad question of, ‘… who can call themselves Dr? …’. We contend there is limited empirical research exploring honorific title use by healthcare professionals, and no effort has been made to synthesise what is known about honorific title use with current regulatory frameworks used by accrediting agencies, to better understand if there is genuine transparency of qualifications, training and skills of registered and non-registered healthcare professionals.

Early studies^22,23 in this area focused on perceptions of professional competence and found honorific title adoption had no effect on perceived levels of professional expertise although, interestingly, Brooks et al. found female patients tended to disclose more to low status (i.e. not using the title ‘doctor’) counsellors compared with high status ones (i.e. using the title ‘doctor’). ²⁴ Several authors have noted the potential for confusion among patients regarding surgical qualifications and the use of Mr, Mrs, Miss or Ms compared to ‘Doctor’.^{25 –28}

Phillips and Harris focussed on public perceptions of the capabilities of health professionals based on title of position, as well as public trust for the professional to undertake a medical procedure. ²⁹ They concluded there was indeed a significant influence of title on public perception of professional capabilities, and noted the discrepancy of public trust to administer a general anaesthetic between an anaesthesia practitioner and physicians’ assistants (anaesthesia). The two titles variably describe the same ‘highly trained and highly skilled’ healthcare professional qualified to administer supervised general anaesthetics. This finding underlines the potential confusion surrounding medical titles and this may stem from the suggestion of a professional holding a medical degree based on their adopted title.

Several studies have explored the use of the title ‘doctor’ by complementary and alternative medicine practitioners. Gilbey, in the first of two studies, investigated the impact of adoption of the honorific title ‘doctor’ on the general public’s perception of both ‘practitioner and practice’ within the fields of acupuncture, chiropractic and homeopathy. ⁶ They showed across all three practices adoption of the title ‘doctor’ led to an impression of greater expertise, while it had a variable impact on the respondents perceived ‘scientific’ basis of the therapy. This finding was echoed by van den Brink-Muinen when assessing influences of trust and use of complementary and alternative medicine. ³⁰ They reported a significantly higher level of trust in complementary and alternative medicine practitioners who were ‘certified’ as a ‘doctor’ compared to those who were not (43.1% and 11.7%, respectively).

Extending this work, Gilbey and Perezgonzalez, investigated the rates of adoption of the title ‘doctor’ by various complementary and alternative medicine practitioners in New Zealand. ³¹ They reported participants believed complementary and alternative medicine practitioners who used the title ‘doctor’ as having greater expertise and stated they would be more willing to pay for their treatments, compared with those who were not ‘doctors’. Chiropractic and homeopathic treatments were thought to be more scientific and more likely to be helpful when the practitioner was a ‘doctor’. No practitioner of evidence-based medicine was included in this study, which could have served as an interesting counterpoint to the complementary and alternative medicine practitioners. If this effect was present for complementary and alternative medicine practitioners, but not conventional medical doctors, then this could further represent confusion around roles and a lack of understanding regarding the qualifications of complementary and alternative medicine practitioners. Gilbey and Perezgonzalez speculated complementary and alternative medicine practitioners may be increasingly moving to adopt the ‘Dr’ title to exploit a conferred sense of ‘prestige’ and professional ‘credibility’ that title use may lend to the practices of complementary and alternative medicine. This aspect is of particular interest as some ³² have argued titles can inappropriately shape patient–clinician relationships and reinforce a clinical hierarchy where the patient ought to be deferential to the physician – a position anathema to many complementary and alternative medicine therapies where practitioner–patient interaction is therapeutic, rather than the therapy itself. ³³

Theoretically, current legislation provides a framework for the regulation of the use of honorific titles, including the title of ‘doctor’, by medical and non-medical healthcare practitioners alike. These regulations aim to ensure transparency, avoiding possible confusion or misunderstanding within the public surrounding the qualification, education and skills of healthcare professionals. Based on the available empirical evidence, we question whether the current regulatory frameworks translate to a practical outcome of transparency of education, qualifications and skills. Specifically, does the adoption of the title ‘doctor’ have the potential to compromise patients and their ability to make an informed and knowledgeable decision regarding the provision of their healthcare?

We believe these questions are particularly relevant as use of the title ‘Dr’ may confer a sense of professional credibility to clinical practices for which evidence of validity and efficacy is weak or non-existent. We propose that future research should explore how patients’ perceptions of their healthcare professionals are influenced by whether they have adopted an honorific title. It is vital patient trust of healthcare professionals is based on an understanding of their profession, qualifications and the skills and expertise they convey, and not on the social signals conveyed by their adopted title.