Are you “Jane” or “Dr Smith”? Does formality between trainers and trainees affect training and clinical practice?

In medicine junior team members often use a title and surname to address their seniors. Hannah Mitchell and colleagues ask whether this affects clinical practice and training.


Authors: Hannah K Mitchell, Alice L Fulton, Michael R Fertleman, Caroline R Fertleman

Publication date: 02 Dec 2015.

Read the original article at BMJ Careers here.


Hospital medicine has a clearly defined team hierarchy: a consultant leads a team of juniors. Often formal relationships exist between consultants and junior staff, with juniors using a title and surname to address the consultant in charge. The way in which we address each other at work affects the working dynamic. Surnames might be considered to distinguish seniority, whereas first names indicate approachability. Many doctors change the way in which they introduce themselves when they become consultants to the form of title and surname. But this is not widespread in other professions.

Evidence indicates that patients want to call their doctor by their professional title.[1] This has obvious benefits in terms of keeping a professional distance and engendering both trust and confidence. But do these benefits apply to the medical team? Is it important that team members use formal address?

Medical hierarchy is based on skill and experience. Those at the top carry the most responsibility and make the most weighted decisions. It helps both patients and doctors to know who they should approach when they need help or feel that something is beyond their own experience.

But for a hierarchy to work effectively there must be a free flow of information between the ranks. Juniors must feel able to approach their seniors when they need their advice, and seniors must be willing to impart their wisdom. This is particularly important in fields such as medicine where team members are expected to progress up the ranks.

In his book Outliers Malcolm Gladwell uses the Korean aviation industry as an example of how hierarchal culture affects safety.[2] To tackle their poor safety record, Korean Air evaluated communication between pilots in the cockpit and found that flights where co-pilots were of the same rank had a lower rate of crashes than flights in which there were two or more ranks between co-pilots. It was postulated that more junior members of the team were afraid to voice concerns to senior co-pilots.[2] [3]

The term “authority gradient” is used to describe the perceived or actual balance of decision making power or the steepness of command hierarchy in a situation.[3] A steep authority gradient implies a domineering leader and one directional decision making. It may prevent lower ranking team members from questioning their seniors if they think that something is unsafe or if they don’t understand something.

Authority gradients can also be applied to medicine.[4] Decisions need to be made on a daily basis, and differences of opinion regularly exist. If juniors are unable to question or challenge consultants, it can have potentially catastrophic effects on patient safety. It is also a barrier to juniors’ learning.

We wanted to find out if the use of formal or informal address in hospitals bears any relation to authority and approachability among medical teams and whether it has any effect on training.

We surveyed 138 foundation trainees at St Mary’s Hospital and the Whittington Hospital in London to find out how juniors addressed their senior colleagues and whether this related to team dynamics.

For the majority of their placements, junior doctors reported using formal address when communicating with consultants. Only 11% of foundation year 1 doctors used their consultant’s first name, although this figure increased to 45% among foundation year 2s. Many reported that they would feel uncomfortable addressing their consultants in an informal way.

We found distinct trends across the specialties, with informal address being more commonplace in paediatrics, emergency medicine, and psychiatry. Only 3% of F1s in general surgery were encouraged to use their consultant’s first name, compared with 100% of those in paediatric placements.

We found an association between senior approachability and the use of first names. Foundation doctors encouraged to call their consultant by their first name all reported that they felt able to approach their consultant with a query, compared with 71% of those who used more formal address. They were also more likely to feel part of the team. However, formal address did not have any bearing on how comfortable juniors would feel contacting their consultant if they made a mistake.

Competing interests: We have read and understood BMJ policy on declaration of interests and have no relevant interests to declare

References

Makoul G, Zick A, Green M. An evidence-based perspective on greetings in medical encounters. Arch Intern Med 2007;167:1172-6.
Gladwell M. Outliers: the story of success. Penguin, 2009: 177-224.
Wiener EL, Nagel DC. Human factors in aviation. Gulf Professional Publishing, 1988: 716.
Cosby KS, Croskerry P. Profiles in patient safety: authority gradients in medical error. Acad Emerg Med 2004;11:1341-5.
Hannah K Mitchell foundation trainee Whittington Hospital, London
Alice L Fulton foundation trainee St Mary’s Hospital, London
Michael R Fertleman consultant geriatrician St Mary’s Hospital, London
Caroline R Fertleman consultant paediatrician Whittington Hospital, London