What’s in a name, “Doctor” James?

Romeo and Juliet, Act II, Scene II

What’s in a name? That which we call a rose by any other name would smell as sweet. So Romeo would, were he not Romeo call’d, retain that dear perfection which he owes without that title.

I saw a consult the other day, an older gentleman with a new cancer requiring complex evaluation and extended care. Scary, hard stuff, but with the possibility of remission or cure; it is the kind of case oncologists relish as we get to use knowledge, a pile of technology, and have the opportunity to make a difference.

After reading his file, taking a history, and doing a thorough exam, I sat down with this patient and his adult son. We reviewed his case in detail; cause, effect, stage, treatment, alternatives, side effects and prognosis. While the father was not sophisticated and was somewhat withdrawn, his son was very bright and had done his Internet homework. Much of the conversation was spent responding to the son’s questions; an in-depth discussion and consultation.

There was just one hiccup. One peculiarity.   Any observer would have taken note and been surprised. Though his son has no medical background, though he is 20 or more years younger then I, though we had never met, during the entire consultation he called me “James.”

James, where did you train?”

James, why does my Dad need an ECHO?”

James, why are you recommending that urologist?”

James, what do you think about nutrition?”

James, what stage is the cancer?”

Not once did he use the word “doctor” or any other formal address. He was never directly rude, nor overtly angry, and he listened carefully to my answers. His understanding of biology and oncology is rudimentary, but he was not ignorant or confused. Nonetheless, while he never asked permission to use the first familiar, he did not use my title.

I have at least a hundred patients who call me James, Jimmy, Dr. James, Dr. Bowtie, Dr. S, Herr Doctor or Jim. I have no need of an ego-massaging label. The difference is that we have long-standing relationships and those patients have usually asked permission. We are friends, colleagues, in battle against the dread disease. I gain satisfaction to have built relationships where mutual respect is expressed in this way. Even so, when the proverbial excrement hits the spinning blades, many of those patients revert to Doctor. That makes emotional sense to me. The moments with this man, do not.

I did not respond directly to the son’s cultural faux pas. I did not correct him, change answers to his queries, or shift my focus away from him or his father. Nonetheless, it bothered me, so that I had to monitor my response and projected emotions. This simple variation signaled an alert about the son, the father and likely their relationship to family and world.

The son used “James” verses “doctor” to establish control. He was signaling to me, and probably his father, that he could handle this terrible situation. He wanted me to know that he would not be pushed around or bullied. He sought to diminish the power and value of my experience, control and guidance. This would not be the physician as paternal director, but as docile docent, available advisor or skilled servant.

OK, I get it. By putting me “in my place,” it would be easier to ignore or modify my recommendations. He is frightened, but for perhaps for the first time in his life he must protect and lead his father. Therefore, he must establish intellectual and emotional dominance, even in a relationship whose goal is not power, but healing.

This slight difference in communication norm makes me wonder about the dynamics of this family and sends warnings about their ability to deal with the complications of care. Perhaps he is preparing to speak with other family members, and thus building a foundation. Years of experience tell me that they may be prone to making bad decisions.

There may be a history in this family or in the son’s own life of betrayal by a medical expert or critical life guide. Have there been lies or significant loss because of bad or malicious advice? It is even possible that they have been “warned” about me, but then why seek my advice at all?

There could be cultural differences I did not detect. There is the remote possibility that the son lacks the basic social grace to comprehend the inappropriate nature of his address. This seems unlikely, because he used “James” more often than others say “doctor,” as if he was making a point, but it is possible that instead of the word presenting a clue to deeper complexity, he might be clueless.

I choose to believe that it is a matter of trust. He is quietly screaming that he does not accept me simply because I have a diploma. I will have to prove myself. I will have to be patient, educate and listen. Go the extra mile and give him the room to cope with medical realities and the immense change of a critically ill close relative. Support him, as I will support his father.

Juliet was wrong. A rose by another name does not smell as sweet. This, after all, is the point of Shakespeare’s masterful tragedy. The names and titles we give each other may be only words, labels, sounds, but they signal vital feelings and subtle ideas. While I as healer might accept any name, moniker or title, for a patient the label can signal fear, confusion and pain.


  • Dr. Salwitz, I was thinking about this very subject only a few days ago! I am not a doctor but I frequently meet and talk to doctors I never met before - in many different capacities. I hope someday, after you have established a (hopefully) mutually-trusting relationship with this man, you will ask - or will be able to discern - why he chose to call you by your given name. And maybe you can let us know via a future essay. ;-) There is something vitally important about this encounter and what it says about the future of medicine and the doctor-patient relationship.
  • Do you call your patients by their first names without permission? So many doctors do. In our cultures, using a person's given name while expecting them to use an honorific and family name is a strong indication of a power imbalance (teacher-pupil, adult-child, etc.), and I find it insulting. I have no problem with calling you doctor, and I don't even expect you to call me doctor in return. (After all, I have "only" a doctorate degree.) I do expect at last a "Mrs.", though.
    • meyati
      You got it! Here we don't use names. My doctors- say- Hi how are doing. I I say- it's good to see you again-blah, blah, The nurses come out and say Mary and 4 or 5 women stand up. I'm not a fan of the first name----especally when more than 2 doctors are practicing.
  • I would never address my physican by their first name. I find this disrespectful. I personally have been treated by a group of wonderful physicians over the last 14 years. Dr. Salwitz and your team as well as others keeping me cancer free. I have many close relationships with some that I can discuss more intimate details of my life. Never, would I assume this is proper etiquette. No excuse, I as many of your patients have been treated with respect. Please do the same.
  • Doctor, with complete respect, I have to say a word for Dad. After some incomplete and infuriating experiences following my spine fusion, I believe it is a typical cultural faux pas to make these meetings into two-party discussions between the provider and the child. And in my case cancer wasn't even involved. The patient may be less withdrawn or less sophisticated than he seems. The word, the idea, of cancer, , even my DCIS can make us patients so scared that our brains just don't act like our real selves. I salute Janice and Knot for their comments.
  • Dr. Salwitz, you have done a great job exploring the different reasons why this man called you by your first name. It is an interesting exercise, but without asking this man there is no way of knowing for sure. What about writing a post, where you explore what your name and title means for you?
  • D Someya Reed
    There may be more to this story than you are able to tell us but I think it's a huge jump on your part to conclude that this is simply a power struggle and to make it about fear of the patient's condition and the son's ability to handle it. There are a multitude of reasons why this form of address towards you may have occurred. Perhaps the son calls everyone by his/her first name upon first meeting. I worked for a company (of 1,100 employees) where we were only able to use first names for anyone, including the owner, CEO, Board of Directors, you name it. To this day, there are some people whose last names I still don't know. This son may even call his father by his first name. Did he ever refer to him during your session? I have friends who have been raised to call their parents by their first names since they could speak. Other parents have taught their children that they are just as good as anyone else and to ignore any titles or cultural formalities as a rule. I can't begin to remember how many times my own father said, "He puts his pants on the same way I do" and that "This is America, we're all equal." I didn't agree with his standards which did a lot towards defining our relationship but it did give me an earlier understanding of what "the ugly American" was all about. The world itself is becoming less formal every day with social media and the like which reduces each of us to a simple name and, usually, a made-up one at that. You may even have set yourself up for this. Did you introduce yourself as Dr. Salwitz, Dr. James Salwitz or simply James Salwitz? Did you refer to both the patient and son as "Mister X?" Familiarity can beget reciprocity. Did you call them "Mister X" then ask, "May I call you Y?" If so, maybe he felt you wanted to be less formal. Could the son have possibly heard many, or any, others in the hall referring to you as "James, Jimmy, Dr. James, Dr. Bowtie, Dr. S, Herr Doctor or Jim" and felt that you preferred the more familiar form of address? Maybe he felt comfortable with you from the get go. Maybe he felt that you weren't going to either patronize him, talk down to him or refuse to level with him as equally as he may not have wanted to give you the chance to do any of those. But it's obvious that you have an expectation of being addressed formally. You said your ego has no need of a title but you still made it clear in your writing that you want to control when and how it will be used. You wrote of correcting him, his cultural faux pas, his lack of a time-tested relationship and not having granted him your permission. In the end, does it really make any difference? The trust you expect is not automatic. The title "Doctor" is not all (or any) of what makes you good at what you do. Quality by any name is still quality. Juliet was not wrong. A name does not define you. Who you are is how you treat others especially when you are in a position of power over them. Even more so, when they are at their weakest. That is the point of the story.
    • meyati
      excellent points. Also the son may have been quite young. Dr. Salwitz seems to a Southerner, but the family may have been from the west-- much more informal. maybe they had a long-term doctor that they called -Sam"
  • Bridget
    Something about this visit got to your core. The familiar name, the tone, the repetition of your name. Cancer is full of power plays and deep vulnerability. As a patient who has had cancer twice, I understand how odd and upsetting this can be. I have been addressed with 'Hey girl' on the phone. And there was the use of Bridgie, which is a name I have never used. Of course, there was the oncologist who called me by a completely different name every time she saw me. My name didn't much matter and I suspect I was just the 'breast cancer' in room 4. I always call my physicians Doctor. We are not friends, although I feel friendly toward the team and they seem to like me. But I would never take my blouse and bra off for my friends: I am there for a medical exam and for medical advice. I chose the oncologist because of his training and ability, as well as his respect for my privacy and for my views. I feel quite certain that I hold no place in his heart or mind beyond the cordial office visits at this point 6 years out from diagnosis and treatment. He's got more serious issues and more challenged patients to help than I. The first three oncologists I had all introduced themselves by their first names and encouraged me to use them: Paul, Barbara, Matt. Now, if I met them on the street, I doubt any of them would know me. I never used their first names, and if I were to run into them now, I would address each one as Dr. XYZ and then provide my first and last name. That might spark a glimmer of recognition, but maybe not. As for power, I have found great satisfaction in reading all the releases and then noting on the recommendations I do not intend to follow these simple words: Read and Refused. It shakes them up every time, and that always causes more conversation about their assumptions about me. It's my way of standing up to the power in the room. If I don't understand it, or really don't want it, then I claim that power and either obtain more education, or hold my ground. No first names, but maybe the same unsettling effect. It is good to shake the ground now and then.

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