Wednesday, December 19, 2007

What's in a name? A really long post, that's what

Today's post comes to us courtesy of the Reader Mailbag, where a sharp and doubtless lovely person named Barb writes:

OK, so I've got a question for you.

Is there a "proper" form of address for a PA? or is it an individual preference?

I ask because at my husband's neurologist's office the ratio of time spent with the PA to time spent with the doctor is running roughly 25 to 1 in the PA's favor. Calling her by her first name seems somehow not quite right, (too casual and familiar, I think); but calling her Ms {lastname} feels off-kilter, too.

Ahh, yes, Barb, one of the eternal questions of PA-dom. This is just one more way in which the pioneers of the field... how do I say this kindly... kinda screwed us (without meaning to, of course).

The best answer is that it's an individual preference, and if it were me, I'd just go ahead and ask your PA how she feels about it. It could be a non-issue, or you could prompt the kind of long-winded discussion I'm about to launch into. I agree, that using "Ms. ______" in the context feels weird, as though you're talking to a grade-school teacher or you're entertaining a guest in the parlor for tea.

Within the PA profession, there are some even sillier ways to try and be formal, there are ways to just ignore the difference between an MD and a PA, and then there's the first name thing. There's no perfect answer. In my experience, most of the time fellow practitioners of all levels use first names with one another, and patients call everybody "doctor" whether they are one or not.

In the small town where I shadowed a PA for 8 or 10 weeks, everybody in town was on a first-name basis anyway, so those PAs used the trusty first name basis. One guy explained that the weirdest part about practicing medicine in the same small town where you grew up was the collision of the social roles -- guys he had played football with now needed yearly prostate checks; their wives, some of whom he had dated in those high-school days and some of whom had turned him down flat, needed Pap smears. And come to mention it, so did some of their moms. So the small-town factor was bigger than the problem of what to call people.

Even so, I couldn't help noticing that with the MDs, many of the townsfolk seemed reassured by the ability to use the title "Doctor" in speaking with them, probably for the sense of decorum and legitimacy it imparts. After all, when you're in the exam room getting that super-personal exam, I imagine it's easier if you can think of those gloved hands as belonging to "doctor" somebody, rather than "good ol' Bill, the kid who really loved tater tots, and peed his pants in third grade*."

The really nervous patients called the PAs "doctor" too, out of a sense that they basically do the same job. And for all that's about 99% true, it's still incumbent on the PA to gently say, "actually, no, I'm not a doctor. I have a [Master's / Bachelor's / Whatever] degree in Medicine, not a doctorate. So just call me _______, okay?" And I've heard a few versions of that speech, in many settings. After a few years out of school, PAs seem to settle into a mode where they will give it their best shot, and if a patient insists on saying "doctor" anyway, correcting every usage doesn't seem to help.

From its conception, the PA role was always meant to dispense with that kind of formality and social hierarchy. It was the Sixties, after all, and there was a legitimate need to question all the stuff that had built up over the years, around the idea of doctor-hood. No doubt there are situations and people even today, around which rather a lot of that not so desirable, paternalistic, know-it-all identity has built up. On the other side of the coin, fewer of today's patients listen to what somebody says just because they have extra letters after their name... for better and for worse.

PAs were meant to be different in several ways, and that lack of entitlement was one of them. The profession grew in part out of wartime experiences that proved to the grander institution of capital-M Medicine that a competent, hardworking man or woman could be trusted with serious medical stuff even though they'd had less of the advanced hard-sciences-style training -- as long there was a solid foundation in how to think about and how to perform the component tasks of medicine, and as long as the conditions were right. Meaning, if help is available from some Captain not so far away, you can trust a Lieutenant to patch somebody up M*A*S*H style, or treat all the runny noses on base. As a matter of fact, the PA can be trusted to treat 3,000 runny noses and STILL catch that one brain tumor, with the right training. And so that's the training we get.

But for all that, in the planning stages it was decided that we should never really try to cross over into that special, ill-defined, highfalutin' area that marks where official doctor-hood starts. Some of it is politics, of course. Some is a return to the good ol' accessible "country doc" spirit of the earlier 20th century (and Star Trek), and some is a look forward to a more competency-based way of thinking, where a person's title means less than their skills. Over the years this has played out in good ways and bad.

We saw a video in one of our classes last term, demonstrating some ethical dilemmas and providing a point of departure for some really good discussions. One thing everybody commented on was the way the people in white coats were calling one another "PA Smith" and "PA Jones," as in, "I see here in your chart that you spoke to PA Jones about this." Our instructors assured us that we would not have to act like gigantic dorks and call one another "PA" anything. It turns out that's how it's done in the military, bless their hearts, but after all that's an environment where titles give important information and everybody has one. Calling somebody by a first name there might be an embarrassing breach of protocol.

And lastly, I was really fascinated by something I noticed back in my job at the County ER: as the Emergency Med residents got farther and farther in their training, they seemed to appreciate the PAs more and more. The way this manifested sometimes was that the senior residents, the ones about to graduate and go out into the world to become attendings, would be talking with patients and refer to the PAs as "doctor [lastname]." I found this to be pretty weird, but eventually caught on that it was the same kind of shorthand that patients use, where the word "doctor" doesn't mean "person who has completed a terminal degree that's beyond what other fields might consider a grad program," it means "person who completed a program sufficient to allow that person to provide medical care," and even more than that it means "person who provides medical care."

Which is all pretty cool, I suppose, because it means that in some places, the idea of competency over credentials is becoming the reality. And that's nice. But I specifically didn't want to be, and don't want to be, a doctor. So I will be correcting people, both patients and colleagues, at least once.

Hope that answers the question, Barb. Thanks for reading!

* There is no story about any of the nice practitioners in that town peeing themselves. At least, not as far as I know.


Barb said...

I rather suspected that it was going to boil down to "Just ask her what she prefers," but I appreciate both the history and the philosophizing. Thanks.

Febrifuge said...

It's what I do. :)