The long battle over who should be called 'Doctor'

iStock.com/Sandi Smolker

By Emma Wilkinson

Recent debate in the UK over the roles of both physician associates and doctors-in-training has brought the issue of job titles in healthcare into sharp focus.

The difference between “associate” and “assistant,” or “junior doctor” and “resident,” may, to the public, appear secondary to the job of caring for patients. Yet healthcare titles are meant to reflect the specific responsibilities and skills that go with that role, come with expectations from colleagues and patients and can impact authority and trust.

Heated debates over physician associate titles in the UK have also incorporated concerns about scope of practice, public understanding and professional boundaries.

When the PA role was introduced to the UK more than 20 years ago, it was originally called physician assistant. The name was changed in 2013 in a move backed by the government to improve regulation of the role.

The primary purpose of a title should be to make clear to patients which healthcare team member they are interacting with

In the US, initially following the lead from the UK, there have been more recent moves to switch from assistant to associate for PAs to reflect their role working collaboratively with doctors. But that too has led to a debate over whether patients may be confused. In Canada it’s assistant; New Zealand, associate.

The BMA had argued the term physician associate was never appropriate for the role because it “mistakenly implied some sort of parity”.

In her report into the role of PAs in the NHS, Professor Gillian Leng agreed. A key concern raised during the review was that patients being cared for by a PA may feel they had seen a doctor when they hadn’t.

Informing patients

Writing in the British Journal of General Practice, Professor Cathal Gallagher, who specialises in healthcare ethics and law at the University of Hertfordshire, noted that this debate also extends to advanced clinical practitioners.

He stressed the primary purpose of any title in a clinical setting should be to help make clear to patients which member of the healthcare team they are interacting with – “not to elevate the holder’s status”.

These days there are pharmacists, nurses and midwives who have the title doctor because they have a professional doctorate.

Gallagher notes, “the groups of professionals currently entitled to be addressed as ‘Doctor’ within a healthcare setting do not align with the general public’s understanding of the word”.

Dr Partha Kar, consultant in diabetes endocrinology at Portsmouth Hospitals NHS Trust is also an honorary professor at the University of Leicester. But he says he does not use that title when introducing himself to patients because it is not relevant.

“My professor title is an honorary title, so that's a very good example of why I don't use it in a clinical setting. It's to do with how I do health policy with the University of Leicester. If I'm doing a lecture on health policy, I will say that I'm a visiting professor so I’m very clear with how I introduce myself.”

The nub of the issue is whether the patient understands what the healthcare professional’s basic role is within the team – eg, nurse. Focusing on whether people are called ANPs, PAs, etc, misses the central point, he adds.

“If you're a member of the public, you're walking in, the question becomes, well, do I understand what they are trained to do?” With the proliferation of healthcare roles, this is becoming ever more confusing for the public.

Doctors, by degrees

Historically speaking, the title of doctor has been really hard won, explains Agnes Arnold-Forster, writer and historian of medicine at the University of Edinburgh.

The concept of a doctor specifically as a member of the medical profession that is well regarded and respected is relatively recent.

Doctorates were about studying books for long periods – often a pursuit of members of the aristocracy with lots of time and money. They had very little practical experience and expertise and there wasn’t a lot of trust from the public.

“Over the course of the 19th century, they undergo a big PR campaign, and they try very hard to promote themselves as humanitarian, invested in people and the good of the nation.

“Part of that, it's really establishing the doctor title as an important way to differentiate themselves from other people who they claim don't have relevant expertise, training or qualifications,” she says.

Surgeons, on the other hand, followed a different path, Arnold-Forster explains. In the early days of the profession, they learned by apprenticeship so had lots of practical knowledge but were not entitled to call themselves “doctor” because they didn’t actually have doctorates.

In time, surgeons came to turn this non-doctor status on its head, noting that their learning wasn’t on paper – but rooted in a deep understanding of how the human body actually works. The hangover from that is even now, when doctors of all kinds earn the same medical degree, surgeons in the UK have retained that Mr/Ms status.

“The thing that started out as a point of inferiority, the fact they don't have doctorates, becomes a point of pride,” Arnold-Forster says.

Resident doctors

Returning to the present, one of the most recent controversies about medical titles has been around the renaming of “junior” doctors to “resident” doctors two years ago. This move aligns with terminology used in other countries and reflects that those in training include senior clinicians with high levels of responsibility.

The title debate is inextricably linked with unhappiness around pay, conditions and career paths

This change made by the BMA in 2024, was intended to be a simple transition. But the title debate is inextricably linked with unhappiness around pay, conditions and career paths.

“The clinical workforce has got a lot more complicated than it was even 20 years ago with a lot of different people crowding into that field,” Arnold-Forster adds. For some doctors, it may feel like their standing within their workplace or even wider society has been eroded, she says.

A change in the doctor-patient dynamic, where more patients are engaged in their health care, Googling diagnoses, and asking for second opinions rather than taking the doctors word as gospel add a further aspect to this issue, Arnold-Forster believes.

“For some doctors, what they expected from their job is not exactly what they're getting. Being a doctor in the UK is not well paid like it is in the US, for example, but there is job stability and social prestige.”

But if being a doctor doesn’t come with a certain amount of respect, job stability and decent pay, the title becomes part of the way to push back, she adds.

What titles are for

As Kar notes, there are many practical reasons why it is really important that patients know who they're speaking to and what their position signifies in terms of expertise.

Apart from titles themselves, many NHS trusts use colour-coded uniforms for nurses, midwives, pharmacists and other healthcare staff so that patients can distinguish different roles.

Doctors are seldom required to wear specific colours of scrubs or uniforms, though the BMA did recently introduce doctor-specific badges and lanyards to enable patients to identify medical doctors amid “the plethora of non-doctor roles”.

In many cases, knowing who is speaking to you can make a big difference: if a patient is seeing a healthcare professional with the expectation that they will be able to prescribe a medicine, for example, and that doesn’t happen, they are going to be dissatisfied, Arnold-Forster says.

“But then there are also situations where I think it really doesn't matter so much as people make it out,” she argues. And the level of detail a patient wants will vary.

Dr Anne Noble, a GP in Sheffield, says at the start of her career her “newly bestowed title felt somehow justified by the hard work and tough conditions of the job”.

But many years down the line she has begun to wonder what the purpose of a title is and whether it contributes to an unnecessary hierarchy.

"The NHS works in teams of professionals, all of whom work hard for their qualifications," she says. “A flatter structure within teams allows for an open culture and safety for patients.

“Working in a team who feel comfortable challenging me is far more important than any letters in front of my name.”

---

‌
‌
‌
‌
‌
‌