What’s in a name? Romeo and Juliet at St.Emlyn’s

romeo and juliet

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Juliet:
“What’s in a name? That which we call a rose
By any other name would smell as sweet.”

Romeo and Juliet (II, ii, 1-2)

Here at St.Emlyn’s we are interested in lots of things. Some are really clinical, but we are also very interested in the human side of medicine and in particular in reflecting on how we might improve as a clinician. One question that came up recently is the use of first names in the ED. Basically, do you use your first name in the workplace with colleagues, seniors, juniors, nurses, hospital staff and patients?

Is this an important question you might ask? Well I think it is as names are important. Names tell people who we are, but in the healthcare setting we also have a bunch of titles that are linked to what we do and I’m interested in how these are used.

I have been lucky enough to visit many different hospitals recently and it is interesting to see how clinicians refer to each other and presumably to patients too. In our own practice I see docs rotate through the department as trainees or as consults and again there is great variation and I wonder if it matters.

 

Introductions

So, what should we do when we meet patients? Should I introduce myself as ‘Simon’ or perhaps as ‘Professor Carley’, and does it even matter what we say at the beginning of a consultation?

There is plenty of work from psychologists that tell us that first impressions are important and although non-verbal clues are arguably the most important I believe that language also counts. Over the years I’ve used lots of different approaches. Permit me to take you through my titular  journey……

When I first qualified I introduced myself as DOCTOR Carley (emphasis intended) as I was probably a little insecure in my role and felt that the badge lent credibility to uncertain clinical skills. I’m not sure it did but as an emotional crutch it worked for me. I suspect that the stethoscope, white coat, badge, Oxford Handbook in the pocket and Med school tie also gave some clues but in my internal assessment I still felt a bit of fraud and leaned on the title for support.

A little later on in my career I became a Fellow of the Royal College of Surgeons and earned the right to call myself Mr MR, that’s MISTER Carley when answering the phone.  This was a different reason, I had a little more self confidence than in my houseman years but the change in title and use in practice was all about belonging to a new club. The title of Mr associated me with a specialism, a feeling of joining a team of surgeons who I aspired to be at that time. This was a feeling of separation from those who had turned away from the craft of surgery, and I see similar behaviours now. Junior surgeons answer the phone with a firm and slightly stressed ‘Mr’ in the months after getting fellowship. I don’t begrudge them this really, I was just the same. Patients frequently found it a little tricky to understand, some asked when the doctor was coming (sometimes after a full surgical exam which was a little disconcerting), others considered me young to be a consultant (I was an SHO at the time), so clearly it was not an effective title to others. It just felt good for me.

As a registrar in EM I bobbed back and forth between Mr and Dr until really quite late on in my training.

I can’t really remember when I decided to change, but I think it was when I was working with the rather inspirational Pete Driscoll in Salford (a doctor who had fantastic patient engagement) that I realised that introductions are really important.

So, I decided to change from ‘Hi, I’m Mr/Dr Carley, what brings you here’ …. to …. ‘Hi, I’m Simon, one of the doctors here, how can we help?’

Now this is not a scientific study and I have no data but I found that it was easier to engage with patients if I used my first name. When patients come to the ED they are often frightened and unsure of what is happening. We appear with vast numbers of organsiational and physical cues that we are in a position of power over them. The uniforms, the appendages (stethoscopes etc.), the technical terms and the fact that we already know something about the patient from the triage notes mean that we generate an enormous ‘power distance’ between the patient and ourselves.This can compromise our ability to get a good history and exam from the patient, may then reduce our ability to diagnose and lead to poor patient outcomes.

So basically I think it’s a bad idea and we should do what we can to reduce the ‘power distance’ between patients and clinicians.

I believe that this does work for me and I encourage others to do the same. If you don’t do this already, give it a try and see if makes a difference. I think it does and I think you will find that it does too.

 

What about colleagues?

Do you use your titles when speaking with colleagues? I don’t think most people do but I have been surprised to see some teams use formal titles even when talking between colleagues at the same grade. I’m not sure I understand that, but each to there own. At least when clinicians are at the same grade it’s a level playing field, but what about when juniors communicate with seniors?

Arguably this is exactly the same issue as when we speak to patients, perhaps even more so as in hospital medicine hierachies are explicit and culturally embedded. Hierachies are dangerous though as they can inhibit communication.  It’s vital that juniors are empowered to speak up and question everything around them, including the decisions of seniors, and I believe that titles inhibit this. As seniors and teachers we should again be doing as much as we can to reduce this inhibitory power distance between ourselves and our learners.

All of the great teachers that I know thrive on interaction and engagement with trainees. Learning is at its best when we share experiences and discuss topics in an open and safe way. For those who have tried to flip the classroom this year you will know that interactive learning only works when trainees feel that they can interact and if they perceive a great power divide they will not feel that they can do this. As a senior in the department the distance will always exist through explicit hierachies, but if there is anything that we can do to lessen this then we should. using a first name and talking to trainees as equals is one small step in this process…. and it’s completely free and takes no time.

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I also think that there is a patient safety issue here. I live in fear of a junior colleague letting me do something dangerous because they do not want to correct the Prof. This is a genuine issue for all senior docs who can make mistakes just like everyone else. In the airline industry there are many examples of junior staff in the cockpit feeling unable to speak up about dangers leading to disaster. The airline industry has learned a great deal about this and has worked to encourage juniors to speak up, with part of this being about reducing barriers to communication. It is something that we can learn from in healthcare too.

 

So what?

Well perhaps not that much really. If  you already use your first name with patients and colleagues then all of this will be old hat. If you don’t then I invite you to try.

Exercise 1. For you next shift try introducing yourself to every patient and their family as ‘Hello my name is YOUR FIRST NAME, how can we help…..

See how that feels and reflect on whether it changes the consultation. It won’t always but I think you will find that it does for some. If you can cope with the experience of using your first name with patients then you are ready for exercise 2.

Exercise 2. If you are senior clinician ask that your juniors to use your first name. That’s all of them right down to med students, and whilst we are at it that goes for all the people on your team, all the support staff that make the department work. See how it feels and reflect on whether it improves communication in your team. Some colleagues won’t be able to do this and to be honest it’s up to them if they want to keep using your title, in some cultures that’s just the way it is, but even by inviting them to use a first name is a small but useful step in lowering power distance.[/learn_more]

[learn_more caption=”Not going to do it”] Fair enough. There are reasons why you might not want to do this. Perhaps in your institution it is the norm, even the expectation, to use titles. If that’s the case and you don’t want to stand out then fine.

However, if you recognised yourself in the somewhat vain descriptions of myself at the start of this post then just ask yourself whether you use your title to prop up your internal anxieties  in response to your personal imposter syndrome.  I can only tell you that I’ve been there and the reality is that you already have the power and authority that comes with the job and that it is your clinical actions that will determine your worth, not the title you use.

You may ask if I use my current title much these days and the truth is not that much in the ED. I do wheel it out in formal meetings, in research settings and in relation to University work. It is also used if I feel the need to make myself feel important, (though in truth it’s sometimes used when I have my own personal imposter syndrome in full flow). However, that’s for the admin side of life. In clinical practice I don’t use it much at all as it’s not usually necessary and it can get in the way for all the reasons described above.

 

What else can I say but, thanks, and……..

My name is Simon, one of the docs who contribute to St.Emlyn’s.

Thanks for reading.

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21 Comments

  1. Matthew Oliver

    As an English trained Doctor now working in Sydney I’d be lucky if I get called anything other than “mate”. In the States it was “Dude”.
    On a more serious note, the culture over here in Oz seems to have abandoned the calling seniors ‘Dr or Prof.’ in Emergency Departments. I’ve found this great and really breaks down that boundary between registrar and consultant.
    However, I’m currently doing a med reg job and it’s back to the old ways. So I find myself less forthcoming with my seniors.

    It is the same with patients, and see that there tends to be a better rapport with Dr’s in ED than with the medical teams.

    Perhaps its just that we’re more friendlier folks in ED!

    Reply
    1. Simon Carley (Post author)

      You may well be right!

      I suspect my antipodean colleagues may not see a problem in their practice as it does seem a little formal. In the UK I know of departments where even consultants talk to each other in formal terms (always), which I find odd.

      @drgdh tells me that he has been told to always use titles in the past (hospital policy), in my trust Dr/Mr/Prof have been removed. There is little consistency in policy, though I believe it’s the personal interaction that matters most.

      Vb

      S

      S

      Reply
  2. Janos P Baombe

    Great reference to CRM in ED, an emerging field in medicine and EM.
    May I recommend the following link and podcast: http://podcasts.bmj.com/emj/2012/03/21/crew-resource-management-with-nick-crombie/
    http://blogs.bmj.com/emj/2012/05/16/crew-resource-management-in-the-ed/

    Reply
  3. Dr. Rob Evison

    Have been in new zealand for last 10 years and introducing myself by my first name and this seem to be the norm, at least in the urgent care setting. In sharp contrast, I would never consider this is in Canada where I was a Gp in the 1990’s. Maybe times are a “changin” but maybe Australia and NZ are less hung up on title.

    Reply
  4. Femke Geijsel

    Having worked in both the Netherlands (where dr-pt contact is formal and uses titles and surnames) and Australia (where first names are the norm; and depending on your patient you will get called “doc” or “luv”) I agree with your arguments. It automatically makes the patient contact more equal and you’re much more likely to get all the information out of the history you need. (you’re also more likely to get all the details you don’t want, but that’s an aside) It makes it easier to discuss controversies and choices with your patients, and I feel I am being perceived as honest and thrust worthy. However, I’m not sure it’s just in the name, a big part of it might be culture; when I treat Dutch patients (tourists, not migrants) in an Australian ED, using my first name and the non-formal approach (in Dutch, like in French and German, there is a formal and non-formal version of “you”), I still end up with an hierarchical and formal patient-doctor relationship that is hard to convert into the more open, less formal (and far more useful) ones I am now used to.

    Reply
  5. Mel Venn

    As a female doctor in an ED where we all wear scrubs, I am mistaken for a nurse even if I introduce myself as “Hi, I’m Mel, I’m one of the Emergency docs.”
    On paediatrics I introduced myself to kids as “Dr Mel” which they seem to like.
    Have never really used my title in person (as a PhD or a MBBS doc) and would feel silly doing so, but it does help when making phonecalls to GP practices and other hospitals.

    As has been said above, Aussies are pretty casual – but only in some places, and in some departments. I certainly have senior colleagues who will always be Mr or Prof and others who will always be Boss, Mate or Terry.

    Reply
    1. Simon Carley (Post author)

      Hi Mel, good to hear from you post SMACC, it was lovely to meet you.

      Like Casey below, getting mistaken for another health professional happens to all of us. However, I think that that the gender biases in society still exist. Some patients and staff still associate women with nursing, men with doctoring and that is something we have seen in practice over here, even though in our department we have a good gender mix in all professions.

      I had not thought of kids specifically and I do like the ‘Dr Mel’ idea. I still use the same approach in kids as I do in adults, but your version has obvious merits and I know a fair few paediatricians who do something similar.

      Cheers & see you in Brisbane next year (hopefully).

      S

      Reply
  6. Kirsten Walthall

    Great post Simon.

    This is something I’ve always found quite challenging and rather confusing, and still do.

    I’ve never introduced myself as “Dr Walthall” but then maybe that’s simply because I’m so used to nobody ever being able to pronounce my surname correctly (since junior school) that I generally pretent it doesn’t exist, and the “Dr” bit sounds important – which I have no illusions about being.

    In terms of what I call my Consultants it’s a bit all over the place.
    The ones I met before working with them (deanery meeting/conferences/life support courses etc) tend to be called by their first name, ones which were my reg’s also get called by their first name. Then it depends on the ethos of the department.

    Currently, the foundation docs and CT1/2s call the consultants Dr/Mr (as I did when I was last here). The middle grades call most of the consultants by their first names.
    ST3 feels like no mans land, you don’t really belong to either group of trainees.

    So I have a mix of Consultants who were reg’s who get called by first names (because changing to call them Mr/Dr would just seem strange), then Consultants (that to me have always been Consultants) who still get called Dr/Mr by me – some of whom find it all terribly amusing and call me “Dr Walthall” (or varients) in return – and lastly, some new Consultants, who introduced themselves as “my name is [first name] I’m one of the Consultant” making the confusion of what to call them so much simpler.

    Bw
    K

    Reply
  7. caseyparker207

    The main downside to the Aussie tradition of calling everybody “mate” – regardless of sex, race, relationship etc is that we can never remember anybody’s real name!

    It is tough to write in the notes: “The fracture management plan was discussed with Dr ….. mate (sounded like a queenslander ) from St Elsewhere’s.”

    Actually, I have had long conversations with patients where I have gotten up to leave and they have asked ; “will the doctor be here soon….”

    Hmmmm… pause, “umm actually I am the Doctor… mate…” **Awkward silence…
    Why did you think I was asking all those questions and sticking my finger…..

    So it is possible to be a little too casual, even in Broome! Socks are not an option
    Casey

    Reply
  8. Charlotte

    Great post.

    I normally introduce myself as Charlotte Davies one of the Doctors – and then let the patients choose what to call me.

    Knowing what to call colleagues is a little bit more difficult!

    Reply
    1. Simon Carley (Post author)

      Colleagues are more difficult in many ways 😉

      There is a skill set of not ever using someone’s name that some juniors develop when they have been invited to use a first name but cannot feel that they can do so. There should be a name for it…..

      S

      Reply
  9. Natalie May

    I like it! Great points and interesting discussion so far.

    I wonder if anyone has studied whether patients listen/recall? I introduce myself as “Natalie May, one of the doctors here in the Emergency Department” and never tire of the frustration of being called nurse five minutes later… 🙁

    Reply
  10. Ian Wacogne (@ian_wac)

    Hi Simon,

    Great minds and all that; wrote on this re: professionals over at the Archives of Disease in Childhood blog just this week: http://blogs.bmj.com/adc-archimedes/2013/04/07/whats-in-a-name/
    I didn’t address the doctor/patient thing, but will do this in the future – the main issues for me are having an unpronounceable surname, but also having a sort of belief that the title has some sort of therapeutic value…

    Ian

    Reply
    1. Simon Carley (Post author)

      Great post Ian, really like the examples in your blog post. Certainly made me think about the language we use with colleagues.

      Will look forward to hearing more.

      S

      Reply
  11. drtmr

    Great post Simon,

    I have swung back and forth between Tim, Dr Tim and Dr Rogerson!

    I seem to introduce myself as Tim to the little people and Dr Rogerson to the more ‘senior’ patients as I sometimes wonder if they prefer that…perhaps I could ask!?

    As ever a challenge for tomorrow…

    Reply
  12. richardbody

    Great post – look at all the comments! I always used to introduce myself as ‘Rick’ until I was reprimanded by a patient who felt strongly that I should be ‘Dr. Body’, and later by a colleague who thought the same. Now, I try to gauge what the patient’s expectation is likely to be, and I aim at meeting that. Who knows if I get it right? Only the patients – maybe I should ask them one day.

    In fact, I’m already mentally planning the work to derive a clinical decision rule!

    Reply
  13. Dino Druda

    Great post and discussion. I went to med school in the UK, did a three year medical rotation and then moved to Australia and switched to ED, so have seen both the more formal and informal ways of doing this. I am now an ED consultant working in a tertiary hospital ED in Melbourne, and I usually introduce myself to patients as “Hi, I’m Dino, one of the doctors”. Occasionally, for more senior patients, when I guage that they may prefer a degree of formality, I will introduce myself as Dr.
    Within the department itself, we are all on first name terms, with docs of all grades, nurses, allied health and orderlies, and it just seems natural to me.
    However, I do find it difficult sometimes when making telephone referrals to specialist consultants who I do not know. I usually use their title, because it seems like the right and courteous thing to do. I will usually open with “Hello Dr X, it’s Dino Druda here, one of the emergency physicians…”, which may be a bit of a double standard using their title and my first name. I would be interested to know how others do this, because it always feels a little awkward, but then so does using someone’s first name over the phone in a professional conversation when I have never met them before.

    Dino

    Reply
  14. Heather Murray

    Hi – interesting conversation and one I’ve had with colleagues and trainees. I introduce myself as Dr.Murray, because just like your other commentator, as a female physician many people don’t realize I’m a doctor unless I lead with this information. Even if I say “I’m Heather, the emergency doctor.” Once our ED got a complaint letter from an older patient who felt she had received good care (from me) but was annoyed that she had not seen a doctor! I feel like introducing myself this way does not create a barrier – in fact my name tag has my first name on it, and many patients will proceed to call me Heather even when I have not introduced myself this way. I used to find this off putting, but have now decided its a marker of approachability.

    Reply
  15. Gareth Roberts

    SImon I find this quite interesting. In Manchester I think we have a very relaxed and open department. The concept of reducing to the power distance is a very valid one in trying to minimise paternalism in health care.. I think the trick is knowing from the off what kind of a patient ( or family) you are dealing with. I tend to introduce myself as Gareth but have on occasion been met with my name is Mrs whatever!!!

    Reply
  16. Andy Webster

    Great article agree with everything you said Prof!

    Used my first name with patients and juniors for a long time. Some juniors do find it difficult to overcome particulary overseas docs from Asia. That is presume the hierarchical structure they were used to in their training. One of our locums calls me sir. That is a strange feeling!

    Reply
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