Doctors and speech acts

In my acclimatization to being a resident, there are a lot of things that have taken some getting used to.  The first is claiming a greater responsibility over patient care than one had during medical school: when I sign an order now, it becomes reality—a lab is drawn, an EKG is performed, a consult to another specialist is transmitted.  What I order and sign actually matters.

Another, more subtle, oddity is being referred to as “Doctor.”  The first time I heard it, I was taken aback for a moment.  The first time I referred to myself as Doctor, it fell odd on my ear, like wearing a jacket that didn’t quite fit right.  A couple months into residency, I now regularly introduce myself to my patients as Dr. Server.  It’s gotten easier, but it is still something feels unusual, and sometimes, even fraught.

I have grappling with why my introductions have felt so awkward as a novice physician.  I think it is because my introduction–like my orders in the electronic medical record–also changes reality in nontrivial ways.  Referring to myself as “Doctor” when I meet a patient for the first time irrevocably alters the structure of the relationship I have with that person.

I have started thinking of these introductions as “speech acts.”  In a thorough summary of the literature on Stanford’s fabulous Encyclopedia of Philosophy, a “speech act” is defined as “a type of act that can be performed by speaker meaning that one is doing so”.  While not exactly the same as other commonly-discussed speech acts—such as saying, “I do” leading to a change in marital status—the statement of “I am your Doctor” seems to accomplish a similar change in social reality, by establishing that one is “doctoring.”  To my (admittedly-limited) knowledge, there have been a few discussions of speech acts in medicine, but none on introductions per se.  It seems to me that introducing oneself as “Doctor” acts as a promise—a well-theorized speech act—that a physician will take on responsibilities for safeguarding a patient’s health and privacy.  The utterance establishes a special, fiduciary relationship with another person, sort of like saying, “I do.” In this regard, the illocution cements a supremely sensitive compact.

Herein lie the stakes, and the kernel of my discomfort.  Referring to oneself as “Doctor” asserts a power over a patient’s body. This is a sort of power that I am not used to wielding over other people.  My discomfort is, I think, for good reason. Historically, Medicine has a dark history of using biomedical rhetoric as a means of justifying violence and exploitation for professional advancement.  Doctors participated in cruelty “in the name of science,” cementing the profession’s social position as votary to the powerful.

Within my own specialty of psychiatry, this power feels especially weighty.  As I make regular trips down to the Emergency Room to evaluate patients, the introduction of oneself as The Psychiatrist establishes a complex power relationship amidst an already complex social and clinical situation.  Certain statements uttered by a patient in this emergency setting can serve as a justification for the abridgment of their rights in the name of their safety.  Given those stakes, the power differential is palpable and often quite uncomfortable.

It essential to struggle with the bodily power that the illocutionary act of “I am your Doctor” establishes, but things resist simple reduction to “badness”.  Asserting oneself as “Doctor” can also allow professionals to deploy that same power over the body to advance justice.  In recent years, physicians have powerfully asserted that “Abortion is healthcare” and disseminated evidence showing the health benefits of gender-affirming care.  In our social and political world, identifying as a doctor in public forums has real impact.  It permits physicians to expand their advocacy into “lanes” that doctors have not traditionally ridden in—such as gun violence, hunger, or homelessness.  Finally, the title allows doctors of different identities to affirm the legitimacy of their seat at the table, militating against social structures that have led patients like them to be ignored, abused, and pathologized by Medicine.

In sum, the politics of deploying the title “Doctor” isn’t an easy subject.  I don’t pretend to have solved anything in this post.  I simply want to share that even thinking in this very basic way has been helpful as I come into my own as a new physician.  Introducing myself as “Doctor” is surely a power move, as all speech acts are. But now when I introduce myself, I am reminded to consider the sorts of political projects I could lend my power to: rigid hierarchies and exploitation, or earnest care for the vulnerable.

Image courtesy of RMHare, reproduced without changes under Creative Commons License.

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