JRSM >
Volume 99, Number 4 >
Pp. 197-199
Correspondence to: N Ibery
E-mail:
nibery{at}gmail.com
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Design An e-mail questionnaire sent to all members of ENT-UK (The British Association of Otolaryngologists—Head and Neck Surgeons), who had registered an e-mail address with the ENT-UK secretariat.
Setting The specialty group of otolaryngologists in the UK.
Participants 723 recipients of e-mails, who were members or fellows of a surgical Royal College and, by convention in the UK, entitled to adopt the title Mr, Miss, Ms or Mrs.
Results 304 recipients of the e-mail questionnaire responded. 39% were not
aware of any proposals to change the convention, addressing surgeons as
`doctor' in the future. Overall, 61.8% were in favour of retaining the current
convention and retaining the title Mr or a female equivalent. Applying the
null hypothesis that most surgeons would not like to change a title, the
2 test produced a highly significant P value of
0.0002. Of female respondents, however, only 43% supported retention of the
current convention. Using Fisher's exact test to compare female and male
respondents, the two-sided P value was highly significant at 0.006,
with female respondents favouring the title of doctor.
Conclusions A large proportion of ENT surgeons in the UK responded to the questionnaire. They were unaware of proposals to change the current convention of address for surgeons. A significant number of those responding were in favour of retaining the current convention. The small proportion of female respondents indicated a preference for being addressed as `doctor'.
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The late Hugh Phillips, president of the Royal College of Surgeons of England described the convention as `... old tribalism', continuing, `we have to get rid of it'.1 Mr Phillips, describing the current situation as anachronistic, told the BMJ:
`there has been concern recently about who people are in the Health Service—who is actually treating you? It is not always absolutely clear to the patient, I suspect, and it is not even clear as to whether someone is a doctor. I think that there is a legitimate case for concern'.2
Other observers have been less measured in their views. The medical editor of the Sydney Morning Herald, described the convention of addressing surgeons as Mr, as `an outrageous piece of inverted snobbery', tempering this remark with the possibility that it may be a `harmless historical quirk', retained perhaps because of the English medical class system?3
In the UK, the division of physicians and surgeons into `doctor' and Mr derives from the medieval origins of physicians as educated graduates, and the surgeons as apprentices (usually for 7 years) of barber-surgeons. (It should be noted, that in the 18th century, an MD could be purchased from Aberdeen or St Andrews universities for £20.)4 In France, the first official organization of barber-surgeons was founded in Rouen in 1096. A similar organization was formed in London in 1308,5 and it was not until 1745, that George II separated the barbers and surgeons by an act of parliament, and in 1800 that the Royal College of Surgeons was formed in England.6
There is another important derivation of the distinction; in the UK, unlike many other countries, MD is not a licensing qualification to practise medicine. The typical double bachelor's degree, MB BS or equivalent, does not, strictly speaking entitle the holder to the title of doctor. In the USA, doctors, dentists, vets and non-medical PhDs all qualify with a doctorate, hence the plethora of `doctors'.
Physicians and surgeons have adopted the style MD to differentiate themselves from other `doctors'.
At the same time in the UK, dental surgeons in general dental practice, who also hold a bachelors degree, are now styling themselves Dr. We are uncertain as to the origin of this creeping doctorization.
| Box 1 The questionnaire The Royal College of Surgeons of England has proposed that surgeons are in the future, addressed as Doctor rather than Mr/Miss/Mrs/Ms. Are you aware of the proposed changes? Do you agree with this proposal? Would you prefer surgeons to use any alternative title? Thank you for taking part in this questionnaire.
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The derivation of the titles is different; the word doctor derives from the Latin meaning teacher or instructor, and in the 16th century was in common usage to mean any learned man or a medical practitioner. In contrast, the title Mr is a 16th century variant of Master, derived from the Latin, meaning master or teacher. It was Henry VIII in 1540 who gave surgeons the right to be addressed as Master, following the Act of Parliament that united the barbers and surgeons of London.7
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TOPSUMMARYINTRODUCTIONMETHODSRESULTSDISCUSSIONREFERENCES |
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| RESULTS |
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Of all respondents 61.8% were against the change of title from Mr to Dr, while 6.6% were undecided or did not mind either way (Table 2). Of those against the change, 64% were consultants and 58% SpRs.
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Applying the null hypothesis that most surgeons would not like to change a
title, the 2 test produced a highly significant P
value of 0.0002. Analysing the respondents by gender, 13.8% of all respondents
were female (Table 3). Of
these, 43% were against the change of title to doctor. Of male respondents,
66% were against the change. Of female respondents, however, only 43%
supported retention of the current convention. Using Fisher's exact test to
compare female and male respondents, the two-sided P value was highly
significant at 0.006, with female respondents favouring the `doctor'
title.
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| DISCUSSION |
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TOPSUMMARYINTRODUCTIONMETHODSRESULTSDISCUSSIONREFERENCES |
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Strengths and weaknesses
We recognize the selection bias of the sample, due both to the response
rate and the limitation by the use of electronic communication. The survey was
done amongst surgeons in one field of surgery and it is not necessarily
representative of surgeons in other disciplines.
Also, of 723 e-mails sent only 304 responded (42%). As the survey was done
via electronic mail we accepted a less than 50% return rate. In order to put
things in perspective from 419 (58%) who did not respond at least 247 (59%) of
them would have needed to disagree with current convention, in order for
findings to be different (2 test was performed with P
value of 10-8).
It is also important to note, that the large majority of responders were found to be mainly senior surgeons and consultants, thus they may not reveal the opinion of younger surgeons in general.
Related studies
There has been no research in the UK on this subject. In the UK and
Australia, there are regional differences in the convention. In ENT
departments in Glasgow, colleagues are addressed as Mr and Miss, whereas in
Edinburgh, there is a long-standing tradition of addressing ENT surgeons as
`doctor'. In Australia, a questionnaire study of urologists found marked
polarization of preference between the states of New South Wales and Victoria.
In the former, 91% preferred the title of `mister' and in Victoria, 85.7%
preferred to be addressed as
`doctor'.3
Interestingly, all the female urologists from Victoria who took part,
preferred the title `doctor'.
Meaning of the study
This study demonstrates that most senior surgeons in the field of Head and
Neck/ENT surgery, in England, would still prefer to use a title Mr. It is
important to note that the study does not imply that the surgeons in the other
fields are of the same opinion. However, this gives an evidence-based opinion
poll which until now has not existed.
To follow the Royal College of Surgeons of England argument, the confusion will continue and increase as consultant nurses, information analysts, senior audiologists and many others with PhDs, senior managers with DBAs, and those who buy their doctorates from the Internet (plus ça change), also style themselves `doctor'. Did the public believe that John Reid, when Secretary of State for Health was really a `doctor'?
In a hospital where the senior author works, the distinction is helpful. At least eight consultants share the same surname, and telling the ENT surgeon from the diabetologist, the psychiatrist from the urologist, the dermatologist from the ophthalmic surgeon and the anaesthetist from the colorectal surgeon are readily and easily achieved by this 600-year-old `pretentious'4 tradition.
It seems less likely that the public will mistake the suited leader of the ward round as non-medically qualified practitioner, than mistake the PhD nurse specialist in scrubs as a doctor.
Some of the free text suggestions for an alternative title were not printable in a reputable scientific journal, but of those that were, Sir was the most popular—perhaps we should just stick with plain old Mister.
As regards the consultation with surgeons promised by the Royal College of Surgeons—we await this with interest.
| Footnotes |
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