Friday, December 21, 2007

physicians' titles

So, last weekend the hospital released me to continue my treatment as an outpatient, then two days later on my first outpatient visit , they re(-)admitted me. Now I'm released again, but have been told to bring a packed bag to my outpatient visits...so you can expect my posts to continue to be erratic for a while. The good news is that I don't actually feel poorly, so I can blog when I have access to the Internet. The bad news is that I have plenty of time and desire for blogging when in (the) hospital, but no access to the blog. Catch-22.

So, the combination of dealing with a lot of different doctors and watching daytime reruns of ER left me thinking about the differences in doctors' titles/roles in American and British hospitals. I must admit that, despite having watched a lot of medical dramas and having read a lot of medical thrillers and memoirs in my youth (the better to feed my hypochondria), I've never been clear on what exactly an (AmE) attending physician is/does or how a (BrE) senior house officer relates to a (BrE) registrar. So, with a lot of help from Wikipedia, I've been trying to teach myself the ins and outs of these titles.

Let's start before we get to the hospital ward. In the UK, your regular doctor, the one you see in their (AmE) office/(BrE) surgery, is your GP or general practitioner. In AmE, the insurance-driven name for such people is primary care physician, but most people would just call that doctor my doctor or their family doctor (who works in or operates a family practice--a term that is found in both countries, but in my experience is more common in the US). The term general practice is also known in the US, but one doesn't hear people talking about their GPs.

When your GP/primary care physician decides that you require more speciali{s/z}ed attention, they refer you to a specialist--but in BrE they're likely to say that they're referring you to a (specialist) consultant. The experience of such referral can be somewhat different in the two countries. Let's say your usual doctor wants you to see a gastroenterologist. In the US, they say "I'm going to refer you to Dr. Guts." Then you get an appointment with Dr. Guts and meet Dr. Guts at that appointment. In the UK, you are referred to Mr Entrails' clinic (more on the 'Mr' shortly). Maybe you will see Mr Entrails--you're likely to on the first visit, at least--but you might see someone else in his clinic team, or firm (the term that Wikipedia reports--not one I've come across in the patient's seat). The consultant Mr Entrails has overall responsibility for your care, but a variety of more junior doctors might see you. Mr Entrails' clinic will most likely be located on hospital grounds, whereas American Dr. Guts will probably see you in an office complex--often one built specifically for medical offices.

In a hospital context, there are different titles (and responsibilities) for specialist doctors at different levels of training. In the UK, there's apparently been a move to 'moderni{s/z}e' medical career paths in the National Health Service, though I've seen little evidence of the changes reported on this NHS site. It says that a new title, Specialty Registrar [StR], replaces Senior House Officer [SHO] and Specialist Registrar from August 2007. But I was being seen by SHOs and Specialist Registrars at our hospital. So, I don't know if the new title applies only to people who have started since August 2007 or whether it's been abandoned, since when one hits the link for further info on the NHS site, one gets a 'page not found' message. For a comparison of new and old titles, see the table on this Wikipedia page. I'm going to stick with the old titles, since they're the ones I've experienced. [NB: Yes, it's specialty, not (BrE) speciality. This is one of many examples of BrE medical jargon being closer to AmE than to non-jargon BrE.]

So, in the UK, you're a medical student, then once you qualify as a doctor, you go on to be a house officer (Pre-Registration House Officer in the old system, Foundation House Officer in the new). After this, the doctor has a choice of going the GP route (which involves more training, but not all the titles I'm about to reel off) or undergoing specialist training for a minimum of two years as a Senior House Officer, followed by 4-6 years of further training and increased responsibility as a Specialist Registrar. One takes exams to go from one level to the next, with the highest level being Consultant. The amount of time one needs to train for these various positions varies by the specialty, culminating in the Certificate of Completion of Training after exams from the specialist college (e.g. the Royal College of Obstetricians and Gynaecologists). All of this is overseen by the General Medical Council, which determines the standards for entry onto the specialist registers that allow one to work in hospitals as a consultant.

In the US, you're a medical student, then for your first year in the hospital you are an intern, which may or may not be considered the first year of your residency, during which you are a resident (physician). This can also be called house officer, as in the UK. After residency, one may or may not get a fellowship for sub-specialty training, before going on to be an attending (physician) [or staff physician] the equivalent of a (BrE) consultant.

In the UK, medical training begins at the undergraduate level--which is to say, people can be 'medical students' from their first year (BrE) at university. In the US, medical school is for (AmE) graduate/(BrE) post-graduate students, and the undergraduate students do pre-med degrees, which cover a lot of science, but also, like other US undergraduate degrees, a liberal arts curriculum. (Law training differs in a similar way in the two countries.)

At least, that's how I understand all this. Anyone with better knowledge is welcome (as ever) to correct me in the comments.

Now, a few words on what you call these people. In the US, medical doctors, no matter their specialty or status, are usually called Dr. [Surname]. In the UK, there's a kind of reverse snobbery, in that GPs and more junior specialists are called Dr [Surname], whereas surgeons and other consultants go back to being Mr or Mrs or Miss--though I've only met men in the consultant role so far, so I can't vouch for the actual use of Mrs and Miss. (Note that BrE tends not to put a (BrE) full stop/(AmE) period at the end of title abbreviations like Dr, Mr or Mrs, while AmE almost always does.) Here, I'll rely on Wikipedia again:
In the United Kingdom, South Africa, Australia, New Zealand, Canada and other areas whose culture was recently linked to the United Kingdom, the title Doctor generally applies to both academic and clinical environment. "Registered medical practitioners" usually do not have a doctorate; rather, they have the degree of Bachelor of Medicine (usually conjoint with Surgery). Cultural conventions exist, clinicians who are Members or Fellows of the Royal College of Surgeons are an exception. As an homage to their predecessors, the barber surgeons, they prefer to be addressed as Mr, Mrs, Ms or Miss, even if they do hold a doctorate. This is first because they have normally achieved another degree - that of Master of Surgery (MCh from the Latin magister chirurgiae) from a university. When a medically-qualified person passes the notoriously difficult examinations which enable them to become a member of one or more of the Royal Surgical Colleges and become "MRCS", it is customary for them to drop the "doctor" prefix and take up "mister". This rule applies to any doctor of any grade who has passed the appropriate exams, and is not the exclusive province of consultant-level surgeons. In recent times, other surgically-orientated specialists, such as gynaecologists, have also adopted the "mister" prefix. A surgeon who is also a professor is usually known as "Professor", and similarly a surgeon who has been ennobled, knighted, created a baronet, or appointed a dame uses the corresonding title (Lord, Sir, Dame). Physicians, on the other hand, when they pass their "MRCP" examinations, which enable them to become members of the Royal College of Physicians, do not drop the "Doctor" prefix and remain doctor, even when they are consultants. In the United Kingdom the status and rank of consultant surgeons with the MRCS, titled "mister", and consultant physicians with the MRCP, titled "doctor", is identical. Surgeons in the USA and elsewhere may have the title "doctor".

So, there we go. Probably a topic that interests me much more than you, but what are blogs for, if not self-indulgence?

Oh, and by the way, one of the registrars has added to the Canadian count. So, that's 12. The nurses just asked where I was from. Score one for the nurses!

16 comments:

Dana said...

So glad you're out of the hospital! (And so of course you can tell I'm American). I lurk usually, but the happy news made me de-cloak.

I wonder if the use of "mister" as the surgeon's title in Great Britain tends to lead to even more self-selection of males as surgeons. Of course, even in the US, there are not many female surgeons. Still, I am glad that "doctor" feels so gender neutral.

John Cowan said...

Americans don't talk about their GPs because they don't have any. There may be some older doctors still in general practice, but newer primary-care doctors are all specialists, either family practitioners, the specialty that has essentially replaced general practice, or else internists, who practice internal medicine. Most internists treat only adults, but some have enough pediatrics training to treat children as well.

Intern was once a technical term for the first year of hospital residency after graduating from medical school, but all such people are now residents, with intern surviving as a slang term, sort of like freshman in AmE. Consequently the former first-year resident is now a second-year resident, and so on.

I've certainly had the experience of being sent to Dr. Guts and meeting his younger associate Dr. Bowles instead, or perhaps Bowles first and Guts afterwards. In addition, more and more U.S. insurance companies are offering plans in which you do not need to be referred to a specialist by a primary-care doctor, but can choose your own specialist.

jhm said...

There is a species of doctor in the US (who take umbrage at he suggestion that they are not, in fact, doctors) that have their positions for some term less than one year, yet are not residents, as far as I can determine: the Fellow.

Since I was required to see my Doctor (the one officially assigned to my case) every year, I would never see the same "Fellow" twice. The visits would consist of nurses' evaluation [wait] Fellow's evaluation {wait...wait] the Doctor pops in and makes it all offical [go home]. This may be more of an academic taxon, but I couldn't help be amused at 'fellow' (apparently a unisex term) being given such exalted status.

dearieme said...

In everyday speech I distinguish "the quack" from "the sawbones". The trick is not to use these cheerful dismissives in front of the medical tradesmen.

P.S. I do hope that yours are tradesmen supreme.

zhoen said...

There are Interns, at least in surgery. They are uniformly raw and troublesome. Fellows are usually doing a Fellowship, they could operate on their own, but are going for specialized training to be specifically certified, as for total joints, or hands, or pediatrics, or transplants, working with Attending surgeons.

Worked with a Brit surgeon who was amused that he'd gotten himself all the way to Mr in England, came to the States, and now gets Dr. Orthopedic Surgeon.

Insurance definitions are changing the titles by fiat, but here in the US, once they pass the boards, we call 'em Doctor to their face. Quack to their back.

JM said...

In the US students don't graduate college with a "pre-med" degree. They are on a "pre-med" track. They usually get a degree in chemistry, biology, biochemstry, bioengineering, or something similar.

They can really graduate with any degree as long as they have taken certain prerequisite classes such as the dreaded organic chemistry, and have passing scores on the MCATs as well as fulfill whatever other requirements there are.

Same goes for pre-law kids. Usually they are political science, public affairs, criminal justice, or psychology majors.

potentilla said...

whereas surgeons and other consultants go back to being Mr or Mrs or Miss

No, only surgeons. All other consultants are Dr. (And yes, female surgeons are Mrs or Miss, or for all I know Ms).

The reason for the discrepancy between titles in your hospital and titles on the various NHS sites describing MMC is probably that MMC (and especially MTAS, the related process for placing junior doctors) has been a total disaster and is currently sort of half-implemented and having all sorts of luminaries do reviews of it. I can direct you to various sites giving more abstruse detail if you are interested.

Anonymous said...

I am a Canadian medical student and really enjoyed your post. I find the Canadian system similar to the American system more so than the British in terms of the semantics. I do agree with jm's post regarding "pre-med" being a track. This is because when you do your undergraduate degree there is no gurantee that you will be accepted into medical school (apart from a few US programs that have a 7year combined undergrad+medical degree with guaranteed acceptance). So once you obtain your undergrad or Bachelor's you apply for medical school to obtain a medical degree. There are many exceptions however, in Canada you can apply to medical school after your 2nd/3rd year of undergrad. Also in Quebec, you can apply after CEGEP which is like prep-school or first-year of college and fast-track straight to medical school. I won't get into the details...because I would go on for hours.

Also, here in Canada we refer to family doctors as GP's as well. And all are family doctors as opposed to the US where a general internist can also be your primary-care physician. In Canada, general internists mostly practice in the hospital and their residency tends to be a year or two longer than in the states (depending on the province).

As to seeing the medical student, resident, fellow or staff/attending physician it all depends where you are being seen. There is no general intern year in Canada anymore, you are accepted into a residency program. Similarly in the US it may still be referred to as "internship year" but it is part of your residency program and can be alternately called first-year residency. Fellows are those that are subspecializing within their specialty. For examply, an ENT surgeon who does a fellowship in nose specialities. Usually fellowships are helpful especially if you would like to work in a large academic/tertiary/quaternary centre.
The confusing thing is when an internist does a fellowship in cardiology and then subspecializes within cardiology to do a fellowship in interventional cardiology for example. That is because the subspecialties withing internal medicine and pediatrics are called fellowships as well as any additional subspecialty training you do. A bit confusing I know.

However, higher year residents and fellows tend to be extremely competent and proficient - which explains why you may see residents and fellows for the most part especially in academic centres. The staff is there because ultimately the care and decisions made are legally the staff's responsibility. For the most part however, residents and fellows mak decisions, prescribe appropriate treatments that staff often agree with and give the go ahead for.

Miles said...

Something similar happens with NCOs in the British armed forces: you go from Mr to Private to Corporal to Sergeant to Staff Sergeant and then back to Mr :-)

Janet said...

John's just been in (the) hospital as well.

I called his consultant "Doctor" by accident once, and was quickly corrected. Also, I'm wondering if it's true that ALL of them wear bow ties?!?!? I haven't seen a consultant without a bow tie yet.

Great post -- as usual!

Janet

lynneguist said...

Sorry potentilla, but I have lots of documentary evidence (in my hospital notes) that all of the consultant gyn(a)ecologists, obstetricians and neonatal p(a)ediatricians at our hospital are Mr/Miss/Mrs by the other staff members--not just surgeons. Janet's experience seems to back this up too.

Kim said...

My husband and I enjoy reading your blog, but this entry was particularly timely. Last night we watched the Dr. Who episode "Smith and Jones" and it takes place in a hospital. We completely understood the rankings of the medical residents/students vs. their head guy running the rounds (Mister). Thanks so much, Lynn!

Bill Filas said...

Forty years ago (although it may still be true today), students at Harvard University typically referred to their professors as "Mr. Smith" (or, rarely in those days, "Mrs./Miss Jones") never "Professor Smith" or "Dr. Smith," even though almost all the faculty had doctorates.

I think this might have been a sort of reverse snobbery--of course the faculty was highly educated, one didn't need to make a big deal out of it--just as one only learned in whispered confidences (or drunken confessions) that one's roommate had a trust fund waiting at graduation.

Dr Kim said...

Lynneguist, potentilla was right. I am a doctor in the UK (incidentally currently doing locum work in canada) and so feel qualified to comment.

Gynaecologists are called 'Mr' or 'Ms' (etc) because they are surgeons. Obstetrics & gynaecology is a surgical specialty. I have no idea why the neonatal paediatricians you saw would be referred to as such. Paediatrics is a medical* specialty and hence paediatricians are all called 'Dr'. Perhaps you came across a paediatric surgeon or the neonatologist was an obstetrician? Similarly, if you were to see a gastroenterologist in the UK, you would be referred to Dr Guts, not Mr Entrails, as Gastroenterology is a medical specialty. Mr Entrails would be perhaps a colorectal surgeon or an upper GI surgeon in a tertiary centre, or a general surgeon in a smaller district hospital.

As the wikipedia quote you used correctly points out, the reason that surgeons are referred to as 'Mr' and 'Miss/Ms' (I've yet to come across a 'Mrs' & I'm not actually sure if that title is used) is a throwback to the time of the barber surgeon, who was an unqualified, cowboy kind of doctor. Physicians have traditionally been the ones to have studied and hold medical qualifications and have always been referred to as 'Dr'.



*The term 'medicine' can be used to encompass both medicine and surgery, but 'medicine' can also be used to mean non-surgical. Hence general physicians (those who practice general(BrE)/internal (AmE) medicine) and also called 'medics'. All the specialties & all the Royal Colleges fall into either the medical or surgical camps.

lynneguist said...

Thanks, Dr Kim, I stand corrected.

Anonymous said...

I think you will find that the title Mr in medical practice is reserved for surgical consultants. The origins of this are indeed based in snobbery but not as you suggest of the inverted type. Surgery was originally performed by barbers and the like, people regarded unworthy of academic titles. Of course this has indeed in the meantime evolved into an inverted snobbery. But if I am not mistaken you are wrong to suggest that all medical consultants are Mr (or Miss or Ms) only surgical consultants. I may be wrong in this but I think not. Dr T