Titles are not as important as what people actually do, and titles can be confusing.
by Joe Goldstein, R.Ph.
Before I start, I want it to be understood that it is not my intention to demean or belittle any individual or group, and I hope it does not come across that way. I am simply trying to help us all to muddle through the fog.
In the seventy or so posts that have appeared in this blog, I have tried to judiciously use the term “doctor”. I usually use it as part of a title (e.g. Dr. Seuss), or in reference to a particular person (e.g. your primary care doctor). I am more likely to use the term “physician” to identify a learned individual who has earned that title. In a hospital, one may encounter any number of people who greet you with, “Hello, I’m Dr. So-and-so”. While it’s likely that person will be a physician, it may not necessarily be so. Their title does not tell you what level of education, training, or experience they have attained.
When I managed a medical office, the confusion about titles became clearer to me. The primary doctor in the practice was an ophthalmologist, a medical doctor (M.D.). He was a physician, and you will see me use that term more frequently in my posts. He employed another ophthalmologist, also an M.D. These individuals completed an undergraduate program, went to medical school, completed an internship, and then specialized during a residency program. They also went through further training in a Fellowship program. They could diagnose and treat diseases, perform surgery, and admit patients to hospitals where they had privileges to do so. They were medical doctors—physicians.
The practice also employed optometrists. They are doctors of optometry. At the time of this practice, optometrists were primarily focused (no pun intended) on addressing the correction of vision issues using lenses, prisms, other devices, as well as eye muscle exercises. Today’s doctor of optometry (O.D.) is trained and skilled in the diagnosis and treatment of eye diseases, including the use of prescription drugs to diagnose and treat many eye pathologies. All this is done within the scope of their state’s laws.
I also learned, at that time, proper decorum in addressing doctors. I always addressed the lead physician by his proper title—doctor—no matter what the setting was. He was my employer, and had not invited me to address him by his first name. I addressed his employee doctors, whether, ophthalmologist or optometrist, as “doctor” whenever in front of patients, or at a conference, or in any public setting. When together socially, or privately, I used their first names. This was not because of any “pecking order”, or because they had requested it. It was simply a way for me to express my respect for their positions.
Back in the hospital, the doctor who visits you may not be a physician. She may be a nurse, more likely a nurse manager or director. Nurses are earning advanced degrees more frequently today than ever. Yesterday’s nurses were trained in hospital-based programs, and were referred to as diplomate nurses. Colleges and universities began to offer nursing programs leading to an Associate’s degree in nursing. Further study and experience could earn a Bachelor or Nursing, or a Bachelor of Science degree. Nurses may continue their formal education with a Master’s degree in Nursing, or even a Doctor of Nursing degree.
The doctor may hold a traditional M.D. degree (allopathic physician). She may have a D.O. degree (osteopathic physician). Or he may have a degree as a naturopathic physician (N.D.). Any of these practitioners may hold additional training and credentials in other types of medicine, including holistic or Ayurvedic (traditional Indian) medicine. Let’s not forget the doctors of podiatric medicine (podiatrists) who have earned a D.P.M.
Until the mid-1970’s, pharmacists who attended a school of pharmacy graduated from school with a Bachelor of Science in Pharmacy degree (B.S.). Not all pharmacists had to do this. Many states “grandfathered” the pharmacists who were already practicing, and either made no changes to their titles, or gave them a new title, such as Qualified Assistant in Pharmacy. Some states differentiated between a pharmacist and a Registered Pharmacist. Organized pharmacy, through a tremendous effort, designed educational programs that led to a Doctor of Pharmacy (PharmD) degree, the entry level degree today. The doctor who visits you in your hospital bed may be a pharmacist. Several years ago there was talk of the State of Maine grandfathering pharmacists with a B.S. degree in Pharmacy to take a new title: P.D. (Pharmacy Doctor). I declined, as I believe a doctorate degree should indicate advanced knowledge and education, gained through didactics and training, not just through experience.
Other doctors who visit you may have advanced academic credentials in their specialty. These may include your respiratory therapist, physical therapist, or occupational therapist. The social worker who helps with your discharge planning may have a doctorate degree in social work, or in psychology. Any of the people who visit you may also have a degree in English, Business Administration, Sociology, Public Health, or any other discipline that awards a doctorate degree. You may be visited by a member of the clergy, and he or she may hold the title of Doctor of Divinity. It is therefore important to know who your visitor is, and what credentials they hold. I don’t know if it’s likely, but you could see a Doctor of Nutrition who manages the food service. How often might you be visited by a Doctor of Facilities Management? So, as you can see, it’s important to know who the doctor is, whether at your bedside, or anywhere else. And don’t wait to be told. You need to ask.
You want your Doctor to be the best at what she does. You want her to have a few years under her belt. You want her to know how to communicate with you, her patient. And communication involves both speaking and hearing. Good communication is a mixture of watching, and feeling, and understanding, and listening. The study of medicine and all the other healing disciplines are very difficult, and involve long hours of hard work. And they should all put more emphasis on good communication.
When my oldest child was a patient at Boston’s Children’s Hospital, at the ripe old age of two months (she is now in her 30’s), I was given advice by the physician I worked for at the time. He said to make sure that someone on my daughter’s medical team had grey hair. He was right. While her young doctors had the knowledge and skill and intuitiveness to interpret all her tests, symptoms and physical signs, they did not yet possess the patience or training or wisdom to properly communicate with her parents, and listen to and evaluate our observations and feelings.
She had been in the hospital for a couple of weeks, after some projectile vomiting, and subsequent vomiting of blood. By that time, I had alienated much of the hospital’s professional staff. I was incensed that I had to meet with an on-call senior resident in the children’s playroom to discuss my daughter’s care, sitting on miniature chairs. And when I questioned some lab results, she admitted she was not familiar with my daughter’s case, and had not looked at her chart. I reacted very negatively. I was infuriated with the hospital’s patient advocate, who didn’t want to meet with me on a Saturday night because she was at a party. I threatened to report her to the hospital administrator. I was livid when, one Sunday, the medical team met with us in front of the nurses’ station, and the senior resident told us they had looked at the obvious causes for her ills, and was now going to look at the esoteric, such as rare parasitic intestinal infections, and inborn errors of metabolism. That was when my meltdown came, and I lectured them all.
I told them all, all the doctors, from the youngest intern, to the residents, to the senior resident, to the GI fellow; to the medical students and nurses on the floor and all the other parents watching. All the M.D.s, D.O.s, and Ph.D.s. Only the attending physician was missing. I was no longer a complacent pharmacist. I was a distraught first-time father, exploding with anger and frustration, and the fear my wife and I shared. And I was ready to call in my own doctor: a Doctor of Jurisprudence. I told them the GI (gastrointestinal) tract was essentially a hollow tube, and that what went in the top was supposed to come out the bottom. If it didn’t, and came back up to the top, there was a blockage somewhere. The chief resident told me I was over-simplifying it, and I replied that I apparently had to make it simple in order for them all to understand. We parted, all of us angry. But one first-year intern heard the message, and listened, and ordered an ultrasound exam for the next morning. Something told him it was the right thing to do. The next day, after a brief surgery, all was fine. I learned a great lesson that day. The doctors had all heard our words. All they had to do was listen.