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Job titles in health care should be in service of patient safety, not status elevation

Cathal T Gallagher is professor of healthcare ethics and law at the University of Hertfordshire.

There has been significant debate recently around how best to name the newest healthcare profession to seek regulation under the umbrella of the Professional Standards Authority (PSA).

Originally called physician assistant (PA), it was changed to physician associate in 2013 by the UK Association of Physician Assistants, which was the professional body for PAs at that time. This change was backed by the government as the Department for Health and Social Care felt the term ‘assistant’ would hold the profession back from becoming regulated.1

After the death of a constituent who had been misdiagnosed by a PA mistakenly identified as a GP, Barbara Keeley MP noted on the floor of the House of Commons that ‘The title of the role … sounds extremely grand, even grander than a general practitioner’.2 This was quickly followed by the British Medical Association’s call for a reversion of the PA title from ‘associate’ to ‘assistant’.3

“Even the term ‘practitioner’ … is potentially confusing since all who practise a healthcare profession are — by definition — practitioners.”

More recently, during approval of the Anaesthesia Associates and Physician Associates Order in the House of Lords, Baroness Finlay of Llandaff tabled an amendment expressing the House’s regret that the title would not ‘revert to the more accurate “physicians’ assistant”.’4 She noted that ‘patients seen by a physician associate sometimes think that they have seen a doctor. The term … gets muddled with the … associate specialist doctor, who often has years of experience’,4 going on to ask whether physician associate, which is so misleading, would become a protected title after the passing of the order, as no medical titles are protected.

The Minister, Lord Markham, did not address this question directly in his response, but stated that ‘we need to look at an overhaul of titles … [which] will be part of a full GMC [General Medical Council] consultation process over the next couple of years’.4 His evasive answer does, however, raise the question of how healthcare professionals are identified in clinical settings and what legal restrictions are needed. This applies not only to PAs, but also to those identifying as ‘practitioners’, and specifically ‘advanced clinical practitioners’, which has become a consensus umbrella term to encompass the wide range of registrars who work in advanced roles.

What’s in a name?

The primary purpose of any title used in a clinical setting should be to help patients clarify which member of the healthcare team they are interacting with, not to elevate the holder’s status. Introducing oneself as an advanced practitioner without qualifying the area in which one practices at an advanced level (for example, advanced nursing practitioner) may lead a patient to believe they are being attended to by one class of professional, when it is another. (The author recently experienced this while he thought he was being treated by a physiotherapist.) The obvious patient safety implications of this have recently received significant coverage in the media.5,6

“The title ‘Doctor’, as used by physicians in the UK and Commonwealth, is currently an honorary one.”

Even the term ‘practitioner’, which was deployed as a universal term in the context of advanced clinical practice,7,8 is potentially confusing since all who practise a healthcare profession are — by definition — practitioners. A simpler, more intuitive, profession-specific hierarchy (such as podiatrist; senior podiatrist; principal podiatrist) would eliminate any possible confusion among patients about who was treating them.

Who should be called a doctor?

The title ‘Doctor’, as used by physicians in the UK and Commonwealth, is currently an honorary one. It is a courtesy title given as a mark of respect, in the absence of the usual qualifying criteria, namely a doctoral-level qualification.9 Other healthcare professionals may wish to use this title to access the esteem enjoyed by the medical profession and may even argue that they have a greater right to use it than physicians with bachelor’s degrees. This and the recent proliferation of professional doctorates in healthcare subjects, including DNurs (nursing) and DClinPsych (psychology),10 necessitates a discussion of who can and should be referred to as a doctor in healthcare settings, and of what must be done to ensure that those who should not cannot.

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. When the ‘man on the Clapham omnibus’11 tells a fellow passenger he is on his way to see his doctor, he does not mean the holder of a professional doctorate in nursing, nor a pharmacist with a PhD. Rather, he and his travelling companion both understand this term to refer to a medical practitioner.

There are many spheres of endeavour where the title of doctor can (and should) continue to be enjoyed by those who are not medical practitioners. I work at a university where, for many, the distinction between doctor and professor is an important one; however, none but the most pompous would insist on the use of either title outside academia. Except, perhaps, where doing so might bring some economic advantage as, for example, in advertising their healthcare business to a public for whom the word ‘doctor’ is understood to mean ‘medically qualified’.

Recently, it has become accepted that dentists and veterinary surgeons may refer to themselves by the title ‘doctor’. There is no legal provision for this; rather, in 1995, a decision was made by the General Dental Council that the use of this title was not an issue of serious professional misconduct and would no longer be pursued through its fitness to practise procedures. Similarly, a decision by the Council of the Royal College of Veterinary Surgeons in 2015 removed the threat of disciplinary action such that [n]othing prevents veterinary surgeons using the courtesy title “Doctor” or “Dr” … if they wish to’.12 There is no need — other than vanity — for either of these professions to be referred to as doctors; our passenger on the number 88 bus causes no confusion by stating ‘I have an appointment with my dentist’ or ‘I’m taking my dog to the vet’.

Legal protections

The title of doctor is not protected in UK law in the same way as other professional titles including dietitian, optometrist, pharmacist, physiotherapist, orthoptist, and radiographer are.13–15 Anyone using these titles who is not registered with the relevant regulator commits an offence. The Medical Act 1983 restricts the use of the name or title of physician, doctor of medicine, licentiate in medicine and surgery, bachelor of medicine, surgeon, general practitioner, or apothecary to those on the medical register,16 but does not impose any such restriction on the title of doctor.

“The title of doctor is not protected in UK law in the same way as other professional titles … “

The safest and simplest way to avoid confusing patients and consumers of healthcare is to proscribe use of the title ‘Doctor’ by those who do not possess a medical qualification. One way of achieving this would be for each of the nine healthcare regulators overseen by the PSA to amend their respective professional guidance to prohibit the use of the honorific by its members in connection with the provision of health care unless they are medically qualified.

Given that the guidance for dentists and vets has recently moved in the opposite direction,12 and the need for some degree of uniformity between nine separate regulatory bodies, this is unlikely to produce a consistent outcome across the professions.

A much simpler and more persuasive way to introduce the proposed changes is to amend the Medical Act 1983 to ensure that only those who are currently registered (or provisionally registered) with a licence to practice with the GMC may refer to themselves by this title in healthcare settings. In addition to its simplicity and its elegance, this approach has the additional benefit of unilaterally prohibiting the use of the honorific by those without a medical degree and thus rendering obsolete any existing guidance on this matter from other regulators.

The over-arching objective of the GMC in exercising its functions is to protect the public — including, in this case, to protect them from being misled.16 The insertion of a new subsection encircling the title of doctor in that protection under certain circumstances would prevent its use in health care by those who are not medically qualified and — crucially — currently practising the profession of medicine.

References
1. Straughton K, Chase A. United Kingdom physician associates. Social Innovations Journal 2021; 8: 1–5.
2. UK Parliament. Physician associates. Volume 735: debated on Thursday 6 July 2023. 2023. https://hansard.parliament.uk/commons/2023-07-06/debates/D98F2ABE-7B33-4748-B88E-ED7243469131/PhysicianAssociates (accessed 2 Apr 2024).
3. Ireland B. Call for alternative regulator of – and to rename – physician associates. 2023. https://www.bma.org.uk/news-and-opinion/call-for-alternative-regulator-of-and-to-rename-physician-associates (accessed 2 Apr 2024).
4. UK Parliament. Anaesthesia Associates and Physician Associates Order 2024. Volume 836: debated on Monday 26 February 2024. 2024. https://hansard.parliament.uk/lords/2024-02-26/debates/4ED09D68-187C-4325-B4F3-E9F23712FD0C/AnaesthesiaAssociatesAndPhysicianAssociatesOrder2024 (accessed 2 Apr 2024).
5. BBC News. Call for physician associate clarity after misdiagnosis death. BBC News 2023; 15 Jul: https://www.bbc.co.uk/news/uk-england-manchester-66211103 (accessed 2 Apr 2024).
6. Searles M. Man died from rare heart problem after being discharged from hospital. The Telegraph 2023; 21 Oct: https://www.telegraph.co.uk/news/2023/10/21/death-heart-problem-doctor-physician-associate (accessed 2 Apr 2024).
7. Health Education England, NHS England, NHS Improvement. Multi-professional framework for advanced clinical practice in England. 2017. https://www.hee.nhs.uk/sites/default/files/documents/multi-professionalframeworkforadvancedclinicalpracticeinengland.pdf (accessed 2 Apr 2024).
8. Imison C, Castle-Clarke S, Watson R. Reshaping the workforce to deliver the care patients need. 2016. https://www.nuffieldtrust.org.uk/sites/default/files/2017-01/reshaping-the-workforce-web-final.pdf (accessed 2 Apr 2024).
9. UK Parliament. This table of xontents lists column numbers, headings, time lines and names of Members in the Commons Hansard Debates text for Friday 19 Jan 1996. https://publications.parliament.uk/pa/cm199596/cmhansrd/vo950119/debindx/60119-x.htm (accessed 2 Apr 2024).
10. Boud D, Fillery-Travis A, Pizzolato N, Sutton B. The influence of professional doctorates on practice and the workplace. Studies in Higher Education 2018; 43(5): 914–926.
11. LawTeacher. Hall v Brooklands Auto-Racing Club: legal case summary. 2021. https://www.lawteacher.net/cases/hall-v-brooklands.php (accessed 2 Apr 2024).
12. Royal College of Veterinary Surgeons. Code of professional conduct for veterinary surgeons. https://www.rcvs.org.uk/setting-standards/advice-and-guidance/code-of-professional-conduct-for-veterinary-surgeons (accessed 2 Apr 2024).
13. UK Parliament. Opticians Act 1989. 1989 Chapter 44. https://www.legislation.gov.uk/ukpga/1989/44/data.xht?view=snippet&wrap=true (accessed 2 Apr 2024).
14. UK Parliament. The Health Professions Order 2001 (2002 No. 254). https://www.legislation.gov.uk/uksi/2002/254/contents (accessed 2 Apr 2024).
15. UK Parliament. The Pharmacy Order 2010 (2010 No. 231). https://www.legislation.gov.uk/uksi/2010/231/contents (accessed 2 Apr 2024).
16. UK Parliament. Medical Act 1983. 1983 Chapter 54. https://www.legislation.gov.uk/ukpga/1983/54/data.xht?view=snippet&wrap=true (accessed 2 Apr 2024).

Featured image by Markus Spiske on Unsplash.

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