Whom should we really call a “doctor”?

I write in response to the Letter to the Editor, May 28 2018 by Drs. Asfour and Winter. I enjoyed this letter and its short history of the use of the title doctor.

I take issue however with some sections of this letter.

Drs. Abdul-Fattah A. Asfour and Dr. James P. Winter describe themselves as “... the social and physical scientists who conduct and evaluate published research.” I can refer the two professors to this very journal as a minimum to see the high level of conducting and evaluating published research done by MDs. Thousands of other medical journals will substantiate this facet of medical doctor research scientists.

Drs. Asfour and Winter make reference to obtaining a PhD “... normally obtained after six to eight years of hard work past the bachelor’s degree.” I would like to point out that every physician in Canada puts in a minimum of six post bachelor’s degree years just to qualify to practice as a family physician. Many family physicians add on an extra year or two to acquire extra training in anaesthesia or obstetrics for example, and it is common for specialists to add an additional minimum of four to twelve years of study after graduation from medical school.

Drs. Asfour and Winter when referring to themselves as doctors, describe themselves as the “ ... the real one. We are the ones who teach the others.” Medical doctors have a thousands of years history of teaching – dating back to the times of Hippocrates (460 – c. 370 BC). This tradition continues today with virtually every physician. We take our responsibilities in teaching very seriously.

This contribution, which I hope clarifies some points of fact is not to be construed as an attack on any professional or group of professionals. The main purpose here, as with the letter from Drs. Asfour and Winter, is to educate the public and perhaps the professionals among us as well.

Sandy J. Murray BSc MD CCFP FCFP CIME
Family Physician
Red Deer County, Alberta

Reference
1. Asfour A-F, Winter J. Whom should we really call a “doctor”? [letter]. CMAJ 2018;190:E660.FREE Full TextGoogle Scholar

Competing interests: None declared

A teaching counterpoint in response to “Whom should we really call a ‘doctor’?”

A number of interesting points were made by the authors of the letter. Although the latin root of the word doctor does indeed have the meaning of teacher, the same root is used to refer to a person who is learned or skilled1. It cannot be realistically stated that a physician would not meet this definition. The authors correctly point out that medical school is considered undergraduate education, however no physician can practice solely with this degree. The physician’s offices that they enter and so blithely remark that only they are “the real” doctors in, are operated by persons who have completed a residency, which is always a post-graduate degree requiring additional years of study and practice.

Ironically, one of the authors appears to hold a PhD in Engineering, which a recent study2 showed is the academic field where PhDs are least likely to become professors. It would seem strange to try and take sole ownership for a term describing a teacher when the majority of individuals in some fields with that designation do not actually have teaching as a part of their professional practice.

In contrast, the CanMEDS framework3, which “identifies and describes the abilities physicians require to effectively meet the health care needs of the people they serve” has a key role of “Scholar.” This is defined as “a lifelong commitment to excellence in practice through continuous learning and by teaching others…”. Additionally the Hippocratic oath explicitly states that it is the role of the physician to teach (“that by precept, lecture, and every other mode of instruction, I will impart a knowledge of the Art…”)4. This teaching role is essential to the training of physicians who are instructed, mentored and supervised by other physicians through every step of their training.

Perhaps of greatest significance however is the simple fact that the meaning of words change over time. Sometimes this is through legal interventions, such as the modification of the definition of marriage in Canada to include non-heterosexual unions, while at other times it is due to a shift in cultural understanding. For example, if someone were to yell on an airplane “Is there a doctor on board?!” it would be implicitly understood that there is a medical emergency, not an urgent need for teaching.

I do agree with the authors that a careful evaluation of the definition of doctor should be undertaken. In fact, it should be carefully regulated to avoid misconceptions and confusion, especially when the health and wellbeing of the public is at stake, regardless of the historic origins of the term.

References:
1. Wheelock F. Wheelock’s Latin. 6th ed. New York, NY: Harper Resource; 2000.

2. Chiose, S. Engineering, science PhDs least likely to work as professors, study finds. The Globe and Mail. https://www.theglobeandmail.com/news/national/education/new-study-sheds-.... Published April 26, 2016, Updated May 16, 2018. Accessed December 5, 2018.

3. Royal College of Physicians and Surgeons of Canada. About CanMEDS http://www.royalcollege.ca/rcsite/canmeds/about-canmeds-e

4. Nuland, S. Doctors: The Illustrated History of Medical Pioneers. New York, NY: Black Dog & Leventhal; 2008.

The authors bring up the interesting question “who is a doctor?”

Descriptively, the answer depends on jurisdiction. In several European nations such as Germany and Poland a doctor is a holder of an academic doctorate. Graduates of undergraduate medical education are called “physicians”―in case of latter only after full registration having passed an examination and completed an internship―and not “doctors”. Many do complete a doctorate in medicine or medical sciences and for this reason alongside historic association of medical practitioners with these degrees recently graduated physicians may be addressed as doctors however are discouraged from addressing themselves as such by legislation.

But keeping the above in mind the answer to the question “who is a physician?” also depends on jurisdiction. Given the historical difference between practitioners of medicine, there are those where a “physician” is a specialist in medicine or at least one who is a member of a college of physicians; this is meant to make clear the distinction between such persons as opposed to surgeons, psychiatrists, general practitioners or junior medical practitioners working in any field including junior medical trainees who have not gained admission to a college of physicians. All of these are known simply as “doctors”. In other systems they are all physicians, as despite history all medical practitioners including surgeons study medicine.

Interestingly, even the question of “who is a professor?” depends on context. In the United Kingdom, Poland, and Germany the holder of an academic chair is a professor. In the first they may also be an emertius one such a chair. In the latter only if they have been awarded the academic degree of Professor (and holders of such as always professors regardless of academic position. Given that in Canada as well as the United States there are full professors who do not hold either the aforementioned degree or even an academic doctorate but rather professional degrees in medicine, there is the humorous scenario where while presenting research findings in Berlin or Szczecin one may be, at the same time, a professor but not a doctor.

Australia has attempted to provide some clarity to the public in distinguishing between academic doctors and medical practioners by restricting this latter term in legislature. But ensuring clarity in a public exposed to globalized popular culture may be difficult. Even ensuring clarity amongst an educated class of academics when exposed to different contexts in conferences through conferences and literature might be difficult. Such clarity in English speaking audiences might require agreements between various parties in at the very least Canada, the United States, the United Kingdom, the European Union, and potentially also India. All of these might be accustomed to their own traditions.

In normative terms, “who should be called a doctor”, even limiting ourselves to the premise that current usage should reflect historical usage of the Latin word, may depend on knowing more above this context. Going back to the so called Medieval Universities, was the term “doctor” used referring serving faculty with doctoral degrees? Is so it could be argued neither the medical practioner in the United Kingdom with only an undergraduate degree in medicine nor the Doctor of Philosophy degree holder working in industry without academic appointment should be called doctors. We might wish to look even further back in time to when Latin “dooer” became “doctor”. If at this time a “doctor” is one who conducts “dooer” then the faculty of an elementary school might be called “doctors” but not so the academic doctorate holder working in industry or clinical medicine. However if the term “doctor” at this time reflects the status of a learned person who “teaches” whether undergraduates by giving lectures, graduates by supervising study, the academic world & public at large by publishing research, or their patients by providing medical advice, both might be “doctors”. Maybe, just maybe, we might decide that despite historical usage, this is the one we might wish to adopt now. There may be an argument that a pharmacist holding a PharmD holder educates whether by providing information to patients in the community pharmacy, assisting medical practioners select medications in the hospital, or publishing in the literature. The approaches might be different in the same way as they are different for an academic depending on whether they address undergraduate audiences, peers, or the general public. However all cases require making use of achieved academic learning. Whether this learning is remotely equable between the PharmD and PhD holder is not for myself, a very junior medical practitioner, to say.

I agree that PhD graduates are entitled to use the title "doctors."<1> When I studied pharmacy at a Canadian university, I addressed many of the faculty members as "doctors," unless they told me not to. That is a gesture to recognize their PharmD and PhD titles. It is legal to use the title "doctor" as long as you are not impersonating a physician.<2>

Several British medical schools schedule the students’ final exams prior to their final year clerkship. When my schoolmates have passed their final exams, many are happily declaring themselves as "doctors" on the social media. It is almost like they are unaware that the medical school and regulatory bodies also evaluate their other attributes, such as professional ethics, before granting them the doctor titles.

Similarly, I have seen Canadian medical students self-proclaiming as "doctors" as soon as they find out their residency match results or pass their LMCC part 1 exams. I understand most of these self-proclaimed doctors eventually received their doctor titles. It is fine to celebrate, but not fine to disregard the legal regulations. It is like a hockey team self-declaring as the champion after leading 1-0 in a best-of-seven series.

When we are scorning non-medical professionals for misusing the title "doctors," please remember that many of our colleagues are living in glass houses.

References:
1. Asfour AA, Winter JP. Whom should we really call a “doctor”? CMAJ. 2018;190(21):E660-E660.
2. Collier R. Who is entitled to the title of “doctor”? CMAJ. 2016;188(13):E305-E305.