When I use a word . . . What is a physician?

Doctor or physician?

I was surprised when I first learnt, some time ago, that in the summaries of product characteristics (SmPCs; previously called data sheets) of certain drugs it is specified that they should be used “at the discretion of the physician,” often when advising about use in special groups, such as pregnant women or children. Surprised, not because advice was required, but because a physician was specifically required, not just any doctor. Indeed, I estimate that the term “physician” occurs 3–4 times more often in such sources than the word “doctor.” Furthermore, the two terms often seem to be being used interchangeably. In at least one case, for example, they were used as if they were synonymous, with advice that the product was to be used “under the direction of a physician” followed almost immediately by the instruction that “if the usual dose [was] less effective or its duration of action reduced, [the patient] should not increase either the dose or frequency of treatment, but should consult their doctor.” Perhaps this implied two different medical practitioners, but the frequency with which the two terms seem to be used interchangeably made me doubt that.

What is the difference between the two terms, and are “doctor” and “physician” synonymous. Indeed what is a physician? What, as you might put it, is the summary of physicianly characteristics?

Doctors

The IndoEuropean root DEK meant to take or accept, and therefore to learn. The reduplicated form gave the Greek verb διδάσκειν, to learn, from which we get didactic. From the Latin derivative discere, to learn, we get discipline and disciple.

By association, DEK also meant to teach, giving the Latin verb docēre, to teach. That gave us English words such as doctrine, dogma, doxology, and words ending in –dox, heterodox, orthodox, unorthodox, and paradox. Some mistakenly think that “paradox” means two doctors, but perhaps that stresses why having a second opinion may be a good idea—or not.

The word “doctor” is the noun derivative in Latin from the supine form of docēre, doctum. It is defined in the Oxford English Dictionary (OED) as “A teacher, an instructor; a person who provides instruction in a particular area of knowledge.”1

Doctors were originally primarily regarded as teachers, and this sense first appeared in English in the late 14th century. They did not have to have a doctorate in their subject. Anyone “whose learning or skill in a particular branch of knowledge entitles him or her to speak authoritatively on it,” including authoritative lawyers and theologians, could be called a doctor.

At about the same time, the term “Doctor of decrees [sic]” was introduced, defined as “A person who holds the highest degree awarded by a university faculty, graduate school, or other approved academic institution.”1 The term “doctor” then gradually accrued other referrents, describing what we would now call doctorates, although that term did not emerge until the end of the 16th century.

At that time the title of doctor, as awarded to medical graduates, was limited to those with doctoral degrees, typically known as doctors of medicine or doctors of physic. However, by the middle of the 16th century “doctor” had been extended as a title of respect to medical graduates without a doctorate. Hence, for example, Shakespeare’s doctors, such as Doctor Butts, the King’s personal physician in All Is True, co-written with John Fletcher and later given the title The Famous History of the Life of King Henry VIII (1623).

So, anyone with a doctorate in any subject, entitled to use such postnominals as DD, DLitt, DMus, DPhil, or DSc, doctors of divinity, letters, music, philosophy, or science, also became entitled to use the title “Doctor.” The title was also extended to those who, without having been awarded a doctoral degree, nevertheless had achieved a similar level of academic proficiency.1 And the title of doctor was also accorded as an honorific to members of the medical profession, whether or not they also had a doctorate.

So today a doctor may be someone with a non-medical doctorate or a medical graduate whether or not they also have a doctoral degree, such as DM or MD. Today in the UK the basic medical degree is not a doctorate, but a double baccalaureate, Bachelor of Medicine and Bachelor of Surgery, often abbreviated MBBS or MBChB. In other countries the degree is often MD.

Paradoxically, those who become doctors in the UK and a few other countries, but then go on to be surgeons with a higher surgical qualification, become known as Mr or a corresponding female title. And although dental surgeons in many countries are also accorded the honorific Dr, in the UK they are also called Mr, Ms, Miss, or Mrs. In medieval times surgeons were often barbers, and although even by the 18th century medical doctors had doctorates, surgeons did not and did not merit the title “doctor.” Moreover, the physicians had their own college and were authorised to supervise the work of the surgeons.2

When the Royal College of Surgeons was founded in 1800, the surgeons established the degree of MRCS. This allowed surgeon-apothecaries, who later became what we now call general practitioners, to gain the degree, along with the Licentiateship of the Society of Apothecaries. This annoyed the hospital surgeons, who preferred to be distinguished from the GPs, who were now licensed to practice not only pharmacy and surgery, but medicine and midwifery as well.3 The elite surgeons styled themselves “pure surgeons,” made themselves fellows of their college, and retained the title of Mr as a badge of honour.

Physicians

The IndoEuropean root BHEU, to be, dwell, exist, or grow, gave, among a very large range of derivatives, a variety of Greek words related to the verb fύω, to bring forth or produce: fύσις, the result of growth or nature; fῠtοn, a plant; fῠσικός, natural, inborn, or native; and a host of others.

From these, via Latin, we get physic, which in English, from the early 14th century, meant a purgative, but later any medicine. Soon after that it came to mean a healthy habit, then medical treatment in general, then the art or practice of healing, the medical profession in general, and finally medical science itself, all within the 14th century.4

The plural version, physics, emerged somewhat later, at the end of the 15th century, and was originally applied to natural science in general or a treatise on it. It took until the early 18th century before it came to mean what it means today, “the branch of science concerned with the nature and properties of non-living matter and energy, in so far as they are not dealt with by chemistry or biology.” 5

Other derivatives include physiology, apophysis, diaphysis, epiphysis, and hypophysis, phytochemical, phytoestrogens, and phytohaemagglutinin, and many words ending in –phyte, such as aerophyte, bryophyte, cyanophyte, and dermatophyte, down to xerophyte, zoophyte, and zygophyte.

But “physician” is the earliest of the lot, dating as it does from the early 13th century, when it meant “a person who is trained and qualified to practise medicine; esp. one who practises medicine as opposed to surgery.”6 Which is what it means, more or less, today.

However, that “esp.” in the definition is crucial, since it rules out exclusiveness. In some places the two words “doctor” and “physician” are taken to be synonymous, although for my money, in the UK at least, to be regarded as a physician you should be an ordinary member or fellow of one of the Royal Colleges of Physicians.

The distinction between a physician and a surgeon was well put by the military surgeon John Woodall (1570–1643) in his preface to the supposedly “benevolent reader” in the 1639 edition of The Surgeons Mate or Military and Domestic Surgery (1617): “And whereas there hath been a question amongst some of the Ancients, by what name they may most properly call the Artist; the more learned sort are justly stiled [sic] by the title of Physicians, and the more experienced sort are called Chirurgions, or Surgeons, by means whereof, sometimes there hath grown difference and offence, which I do advise each discreet Surgeon to avoid, and that they give the Physician his due honour and precedence, comparisons being odious and unmannerly amongst good men.” By “experienced” Woodall meant “dextrous”—later he referred to “Chirurgia” as “the Handy part of healing.”

Physician associates

There has been a great deal of controversy recently about physician associates (PAs) in the UK, and the British Medical Association has issued a report, in which it asserts that PAs, acting well outside their competence, have made incorrect clinical decisions in place of doctors, have introduced themselves as doctors (which they are not), have dangerously prescribed medication (something they are not permitted to do), and have taken part in surgical procedures for which they were not qualified.7

I cannot comment on these assertions, although if true they would be important infractions. What I do want to comment on is the term “physician associate.” The term consists of two nouns, the first of which is used attributively, i.e. as if it was an adjective. And as a result, the term is ambiguous.

In illustration of this, take another example. If someone told you that they were using a robot surgeon8 to assist them in their clinical practice, a term in which the noun “robot” is being used attributively, just as the term “physician” is used in the term “physician associate,” you would have no doubt that what they were using was a robot.

Thus, the term “physician associate,” constructed in the same way, is susceptible of a similar interpretation, i.e. that such an individual is a physician who is acting in association with, as it might be, another physician or some other health professional. But the term is intended to have a different meaning altogether—an individual, not a physician, but acting in association with one.

Physician associates or assistants, although only recently introduced in the UK, are not new. The Russian word фельдшер, which was introduced into English in 1877 in the Anglicised spelling, “feldsher,” of the German transliteration, feldscher, was “a person with practical training in medicine and surgery, but without professional medical qualifications; a physician’s or surgeon’s assistant; a local medical auxiliary.”9 There have been physician assistants in Germany at least since the 1950s10 and in the USA since 1960,11 and the Chinese have had barefoot doctors since 1968.12

When patients are introduced to a physician associate, do they think that they are being advised and treated by a physician? And what do the physician associates themselves think, given the inherent ambiguity in their title?