Distinctions That Define and Divide   /   Summer 2021   /    Essays

Too Many Doctors in the House

The use and abuse of a title.

Ronald W. Dworkin

Scholars at a Lecture, 1736–37, by William Hogarth (1697–1764); Artokoloro/Alamy Stock Photo.

Fifteen years ago, when a book I wrote went to press, I had a fight with my editor, who wanted my name on the front cover to be followed by my credentials: MD, PhD. (I am an anesthesiologist. I also have a PhD in political science.) I threw a fit because I did not want to be called “doctor.”

More recently, the writer Joseph Epstein criticized First Lady Jill Biden, who holds an EdD, for calling herself “doctor.”11xJoseph Epstein, “Is There a Doctor in the White House? Not if You Need an MD,” Wall Street Journal, December 11, 2020, https://www.wsj.com/articles/is-there-a-doctor-in-the-white-house-not-if-you-need-an-m-d-11607727380. Biden’s defenders responded by saying anyone who has earned an MD a PhD, or a professional doctorate should be called “doctor.”

Why this confusion and controversy over who should be called “doctor”?

Another mystery is the explosion in the number of non-MD doctors over the last century. In 1900, there was one physician for every 568 persons in the United States. Today, there is one physician for every 290 persons.22x“How to Study Medicine” and “The Obligations of the University to Medical Education” (pamphlets, 1910), Carnegie Endowment Archives, Columbia University, File: Medical Education: 1900 to 1920; https://www.unz.com/print/Outlook-1910oct01-00272/ and https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6986669/, respectively. Aaron Young et al., “A Census of Actively Licensed Physicians in the United States, 2016,” Journal of Medical Regulation 103, no. 2 (2017): 7–21, https://web.archive.org/web/20171215170531/http://www.fsmb.org/Media/Default/PDF/Census/2016census.pdf. In 1900, there was one PhD for every 200,000 persons in the United States and no one who held a professional doctorate. Today, there is one non-MD doctor for every fifty-eight persons, a more than 3,400-fold increase since 1900. By comparison, there was a mere twofold increase in the number of physicians over the same period.33xLori Thurgood, Mary J. Golladay, and Susan T. Hill, US Doctorates in the 20th Century: Special Report (Arlington, VA: National Science Foundation, 2006), http://link.umsl.edu/portal/U.S.-doctorates-in-the-20th-century-electronic/yRXZYe9EV6g/. Reid Wilson, “Census: More Americans Have College Degrees Than Ever Before,” The Hill, April 3, 2017, https://thehill.com/homenews/state-watch/326995-census-more-americans-have-college-degrees-than-ever-before. Wilson reports that 2 percent of Americans have doctorates. Subtracting the number of physicians from the total produces the datum one in fifty-eight.

What explains the increase?

The answers to these questions lie in a deeper understanding of how science has changed the meaning of the doctorate.

The Machine View of Work

The title “doctor” was originally awarded to those who taught Latin under the church’s supervision during the Middle Ages. Over time, schools of theology, medicine, and law grew up and awarded doctorates, yet there was nothing “scientific” about these degrees, as recipients mastered an existing body of knowledge in order to teach it or practice it, rather than to advance knowledge.

The seventeenth-century scientific revolution changed things. Scientists now saw the universe as a medley of forces and objects to be studied in the pure dry light of the intellect. Human beings themselves gradually became objects of study. The new attitude found expression in the degree of philosophiae doctor, first awarded by a German university during the same period and dominant in European academia by the first half of the nineteenth century. The trend soon spread to the United States, with Yale awarding the country’s first PhD in 1861. The result was progress in the form of new knowledge, but also the introduction of a fallacy: the machine view of science.

Many scientists believe that just as a machine can be completely described and defined, so can all of nature’s phenomena. Yet the concept contains a falsehood, for no part of nature actually resembles a machine. A machine is a collection of parts put together to fulfill certain definite actions, and no others. A washing machine fulfills the purpose of washing, a stopwatch fulfills the purpose of marking time, and both fulfill these purposes only. Their parts promote the machine’s particular purpose, and because scientists agree to view the machine according to its one purpose, a machine’s parts can easily be described, and a thousand scientists will describe the machine in the same way. But no natural object fulfills just one purpose, or even a few purposes, that everyone can agree on. Instead, every natural object fulfills an endless series of purposes.

A flower, for example, has an infinite number of purposes in life, since it means different things to different people. It cannot be circumscribed by the human intellect. Scientists can take a flower, isolate it from nature, then describe it exhaustively as if it really were so isolated. But ask a thousand people to describe the same flower, and the descriptions will be different. People disagree simply because they feel differently; they are different persons.

How well today’s possessors of nonmedical doctorates adapt to the machine view of science determines the public’s comfort level in calling them “doctor.” Let’s look at physicians first.

 

The Doctor as Medical Specialist

During my residency, one of my anesthesiology instructors taught me how to place an epidural as an unlit cigarette dangled from his lips. He looked like a car mechanic taking a peek under the hood.

Many physicians today are highly compensated, narrowly specialized tradespeople. Science has turned the human body into a machine, with parts, and by narrowing down the part that doctors specialize in, groups of doctors can agree on that part’s purpose, thus making the part resemble a small machine. Medical specialists seem more scientific for this reason, although they also more nearly resemble mechanics. The more closely a professional approaches the machine view of science in the United States, the stronger the public’s inclination becomes to call that person “doctor.”

That is why scientific medicine tends to focus more on disease than on health. According to some older philosophies, a person, to be really healthy, must be a unit, an entirety, involving the thoughts and passions of the mind itself. But a person in his or her entirety is more natural and less like a machine. A person has an infinite number of purposes, and no group of doctors can agree on which is most important. Although physicians sometimes speak of health in this unitary way, describing it as “wellness,” it is a term they dance around, because the description of “wellness” is open to debate, unlike the description of a diseased body part that fails in its single purpose. Hence, they make a fetish of disease, write about disease, and are usually seen only where disease is. As generalists, primary care doctors sometimes resist this tendency, but specialists eagerly embrace it, which is why it is hard for a great primary care doctor to be a narrow-minded person, while an anesthesiologist who is narrow minded can be a great success.

The machine view of science has even turned physicians into machines of a sort. Machines are admired for being foolproof. An Americanism first coined in 1902, when the assembly line came into being, the word foolproof, means safe against human error—in other words, safe against the fool. The machine view of science incorporates this sensibility. It distrusts human beings; it has little faith in their resourcefulness, because human beings possess an emotional side that puts them at risk of imprecision and inefficiency. Whenever possible, the machine view encourages people to use machines to protect themselves from errors native to living creatures.

Thus, medicine strives to lower the error rate among physicians and make them more foolproof—more like machines. Researchers push checklists, time-outs, and other protocols to protect against error.44xSee, for example, Atul Gawande, The Checklist Manifesto: How to Get Things Right (New York, NY: Picador, 2010), and Peter Pronovost, Safe Patients, Smart Hospitals: How One Doctor’s Checklist Can Help Us Change Health Care from the Inside Out (New York, NY: Penguin Plume, 2011). The more exactly physicians follow protocols, even if just reflexively—in fact, better if just reflexively—the less chance there will be that their imperfections will come into play. Ancillary machines also help. With a pulse oximeter, for example, even a fool can now diagnose low oxygen levels. More recently, researchers have floated the idea of building a machine to track a doctor’s eye movements to check whether the doctor is maintaining focus while caring for patients.55xElizabeth Henneman et. al., “Eye Tracking: A Novel Approach for Evaluating and Improving the Safety of Healthcare Processes in the Simulated Setting,” Journal of the Society for Simulation in Healthcare 12, no. 1 (February 2017): 51–56, https://journals.lww.com/simulationinhealthcare/Fulltext/2017/02000/Eye_Tracking__A_Novel_Approach_for_Evaluating_and.8.aspx. A machine to check the machine.

Unlike a human being, a machine is all sureness and no chance. The more nearly physicians approach the machine standard of excellence, the more the public confers respect through the “doctor” title.

Doctors as Scholars and Professors

For that very reason, I, on the other hand, felt robbed of half my humanity and grew to dislike the title “doctor.” The British offer a sensibility more to my liking. Surgeons in the United Kingdom have traditionally been called “doctor,” while other physicians are addressed as “Mister” (or, presumably, “Ms.”), with the latter considered to confer higher status, a kind of throwback to the old notion of the “gentleman.” In British surgical practice, the patient has historically been viewed as a dysfunctional machine. In contrast, nonsurgical physicians in the British tradition cultivate a humanistic dimension, or at least aspire to, as the nonsurgical patient is viewed more like the sea whose movements are too complicated to explain, and whose depths bring up other knowledge besides mechanics.

To become more than a machine, I earned a PhD in political philosophy after getting my MD. Yet I found the same problem haunting academia.

Whether in the natural sciences, the social sciences, or the humanities, professors narrow their focus to comport with the machine view of science. Nonscientists face the bigger challenge, as they study people, who do not at all fit the machine view of science.

To compensate, some nonscientists abstract from their subject matter. Rather than study people, they study concepts about people. These concepts can be studied in isolation, disconnected from reality, with large numbers of faculty agreeing on their purpose—the basic premise of the machine. This enables some professors, for example, to write successfully about “liberalism” and “conservatism” despite having no contact with other human beings.

Some nonscientists study actual people, but they agree beforehand to look at all people in the same way. This has the effect of causing the people being observed to mimic single-purpose machines. In one paradigm, for example, all people are judged according to their relative “power.” This turns human relations into a matter of “domination,” “structures,” “bodies in space,” and “resistance.” Professors who follow this paradigm sometimes write like mechanical engineers.

Other nonscientists narrow their area of interest, and isolate it, so that a single purpose and a set number of parts might define it. The area of interest begins to approximate a tiny machine. For example, the study of nineteenth-century German naval history in the North Sea is highly quantified, a matter of who won, and in what time and place, and with how many ships. Nonscientists who study in this area operate as if it were an isolated world.

Unlike PhDs, many people with professional doctorates have an easier time adapting themselves to the machine view of science. Doctors of optometry and audiology, for example, deal not just with concepts, but with real objects—the eye and the ear. Like physician specialists, they can easily agree on an object’s single purpose. Some of these professionals even work with actual machines, further strengthening their claim to doctorhood.

“Doctors of education” (EdDs), on the other hand, deal primarily with people and abstract concepts. Given their inability to adapt to the machine view of science, the public hesitates to call these professionals “doctor.”

Like physicians, PhDs and holders of professional doctorates risk being turned into machines. As they increasingly specialize in order to become more foolproof, more of them will be needed to cover the same amount of territory. The public will grow increasingly conflicted about the “doctor” title as a result. Being a doctor conveys high status, yet being a machine conveys a low one. It is hard to say whether being called “doctor” in the future will constitute praise or an insult.

Looked at from another angle, the public grades “doctoring” according to how foolproof it is. No variations are wanted among doctors, for variations invite uncertainty, unpredictability, error, and bad service. Musicians and artists, on the other hand, are expected to have variations. They are even admired for them. They are not expected to be foolproof machines. Many physicians, PhDs, and people with professional doctorates crave the “doctor” title for a status that is growing increasingly questionable, while musicians and artists have no need for it. Indeed, they would probably be a little disgusted if offered it.

A Doctor Only Sometimes

I prefer to be called “Mister” in most of my life. In my capacity as a PhD academic, I am far from foolproof, and therefore a bad machine, and so do not feel that I deserve the title. When practicing anesthesiology I am a better machine, yet I encourage patients to call me by my first name, having grown up in the egalitarian atmosphere of Southern California. Only when dealing with hospital staff do I retain the title “doctor,” and only because in a medical emergency it helps to establish the chain of command needed to make decisions.

That may be the real value of the “doctor” title: It is a very useful thing, provided you can make other people believe it is important. It frightens the multitude in the direction in which the doctor wishes to go. In the operating room, when events go south, saving a patient’s life often depends on this corralling of people to work under command. Whenever people are required to act together, there must be a chief; otherwise, confusion and disorder result. The “doctor” title makes this possible during an emergency.

The problem arises when the “doctor” title is used more broadly—for example, in public policy. Here, average people with good sense are wrongly cowed by the title. They defer to the doctor when they should defer to someone else. The need for someone to direct the activities of all toward the same end still exists, but that someone is not necessarily the person carrying the title “doctor.”

Humanity has invented but few devices for choosing its leaders. In our scientific age, we have settled on the “doctor” credential. The most important quality of a leader is that of being acknowledged as such, and being a doctor helps in this regard. The “doctor” credential mesmerizes people, which is why so many Americans crave it. But the qualities that make a good leader, and that lead to sound decisions, do not always appear after several years of course work in a doctoral program; nor are they necessarily recognized through examination. Choosing a leader is a problem that does not admit of a perfect solution, but society can probably do better than to rely on the title “doctor.”