I recently saw a post in Yahoo questions entitled, “Is it illegal for a medical student to introduce themselves as ‘Doctor’ before they have received their MD?”

One of the answers that was rated highly was “I think it is more unethical than illegal.” Clearly, if a student is deliberately misrepresenting themselves as a ‘doctor’, it is grounds for disciplinary action.  More often than not, this misrepresentation is not deliberate on the part of the student.  For example, some of our prior work demonstrates that medical students often report that they were introduced by other physicians as a doctor to a patient and that to a lesser extent, students may not correct someone who mistakes them to be a doctor.

Complicating matters is the propagation of the term “student doctor” at some institutions which is especially problematic.  After all, how many patients will be quickly discern that ‘student doctor’ actually refers to ‘medical student’ and not a ‘doctor’?  Unfortunately, patients who hear the term ‘student doctor’ may not hear the term ‘student’ and just zero in on the ‘doctor’ part, as they often wait patiently for their doctors to see them in the hospital.   This brings us to the problems of how doctors are named in teaching hospitals.  The system could not be more confusing.

• Interns. This is probably one of the most confusing terms in a teaching hospital.  Interns are doctors who have graduated medical school and are in their first year of a residency training program.  Of course, ‘intern’ is also the universal term for all those college students trying to get a short term experience on their resume by ‘interning’ there first.  So, why would a patient think an intern is a doctor?   After all, you would never put your faith in the legal ‘intern’ at the law firm to defend you in a lawsuit.   To make matters worse, there is the opposite problem.  Intern is often mistaken for ‘internist’, who is actually a doctor who has completed their internal medicine residency and otherwise a ‘doctor for adults.’  (Patients are more familiar with their “PCP” or ‘primary care physician,’ which could refer to either an internist or a family physician).
• Residents. Residents can refer to any doctor who has graduated from medical school and is in a residency training program (including interns). The term “residents” originates from William Osler’s era when residents did live in the hospital.  Of course, they don’t live there anymore  which would violate worker’s rights not to mention their regulated duty hours… but we still call them residents.  The other name residents are often referred to is as “PGY1” (post graduate year) which is certainly not an improvement.
• Housestaff. One of our premed college students just asked me what this term was this week.  I explained that while this does sound like the butler, maid, or cook a fancy estate, this term actually refers to the hospital as the “house” that the residents live in as the staff.  So all residents (including interns) are part of the ‘housestaff’.
• Fellow. This is perhaps one of the most disconcerting names for a physician as it may sound like it refers only to male doctors (and conjure up images of young man from England with excellent manners i.e. he’s a fine ‘fellow’).  In fact, a fellow is a doctor who has completed residency and is getting advanced training in a certain subspecialty.
• Attending. Attending to what you may wonder?  The attending physician is actually the doctor who has completed training and is legally responsible for the care provided by residents.  In other words, this is the ‘boss’ doctor as my residents sometimes introduce me to the patients on our team.

A few years ago, we tried to improve the situation for our patients by having doctors introduce themselves with baseball cards with their pictures on the front and the roles of the doctors were displayed on the back.  While we were able to increase the percentage of patients who knew who their doctor was, we were surprised to discover that fewer patients stated they understood the roles of the doctors.   How did we make it worse?  Perhaps ignorance is bliss.  By trying to unlock the secrets of these names, patients realized the names we use in teaching hospitals are confusing.

However, this confusion is more than just a name, it is also a patient safety issue.  After 18 year old Lewis Blackman died in a South Carolina teaching hospital without an attending evaluation when his family kept asking to see the doctor, a new law in his honor aims to address the issue.  It requires that patients receive written materials describing the roles of the trainees on their team and also how to contact the attending if they have a concern.  More recently, the ACGME, which accredits US residency programs, has included a mandate in its now infamous policy restricting resident work hours that states “residents and faculty members should inform patients of their respective roles in each patient’s care.”  While it is not certain how this will be implemented at every teaching hospital across the land, it’s certainly time to make our naming system easier and more transparent for patients to understand.

Vineet Arora is an internal medicine physician who blogs at FutureDocs.

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