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| Journal of the New Zealand Medical Association,
25-July-2008, Vol 121 No 1278
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Use of inappropriate titles by New Zealand
practitioners of acupuncture, chiropractic, and osteopathy
Andrew Gilbey
The use of complementary and alternative medicine (CAM) in
Western society is both prevalent and increasing.1
In New Zealand, rates of 38% in 2004 and
70% in 2007 have been
reported.2,3 Ernst’s observation of
“New Zealanders’ love affair with ‘alternative’
medicine” may therefore be
appropriate.4
Generally, CAM tends to be provided “through small
private business financed by out-of-pocket payments made by privately paying
clients”, rather than by the state.5
Accordingly, as with any business operating in a free-market,
practitioners must compete for a finite pool of clients.
One way in which CAM practitioners may gain competitive
advantage is through being better qualified in their area of practice. The New
Zealand Yellow Pages telephone directory reveal a wide variety of qualifications
are stated by practitioners, although as most qualifications are stated as
acronyms it is not always clear to what qualification the acronym might refer.
For example, the acronym DC or DO could indicate that the practitioner is a
Doctor of Chiropractic/Osteopathy or, conversely, has a Diploma in
Chiropractic/Osteopathy (either of which may or may not be accredited). Some
acronyms may also indicate membership of an industry body, as opposed to a
qualification per se, whilst others may indicate qualifications, but
ones irrelevant to the advertised CAM practice.
In addition to their qualifications, some practitioners add
the title ‘Doctor’ (Dr) to their name in their Yellow Page
listings/advertisements.
The title ‘Doctor’ is not protected in New
Zealand. It is therefore perfectly acceptable for people to use a play on words,
such as ‘The Car Doctor’ or ‘Hose Doctor’, as their
business name, or even, in principle, to refer to themselves as Doctor in
everyday life. However, according to New Zealand’s legislative framework
relating to the provision of CAM, such play on words is not permissible for
those who work in healthcare.
The Health Practitioners Competence Assurance Act 2003
(HPCAA) states that “a person may only
use names, words, titles, initials, abbreviations, or descriptions stating or
implying that the person is a health practitioner of a particular kind if the
person is registered, and is qualified to be registered, as a health
practitioner of that kind”.6
In answer to a number of queries from the public, the
Medical Council News sought to make clear the intent of the HPCAA by stating
that practitioners of CAM should not “do anything to suggest that he or
she practices or is willing to practice medicine unless he or she is a medical
practitioner and holds a current practising certificate” and, “when
the title ‘Dr’ is used in a health service provider environment, it
is easy for the public to be misled and believe the person they are dealing with
is a registered medical practitioner”.7
When a CAM practitioner uses the title of
‘Doctor’ in the course of their business, if they are not a NZ
registered medical practitioner, it is possible that, according to the Act, they
commit “an offence punishable on summary conviction” by monetary
fine.6 Use of the title ‘Doctor’ by
CAM practitioners who have a traditional non-medical doctorate (e.g. DSc, PhD,
or DPhil) or other ‘doctorate’ (e.g., a first-degree doctorate from
an un-recognised college or university) may also be misleading, according to the
intent of the HPCAA, as explained in the Medical Council
News.7
Ultimately, the HPCAA legislation concerning inappropriate
use of the title ‘Doctor’ by a health practitioner would have to be
tested in court of law. Currently, it may be that no complaint has so far been
laid, but it may also be that the Act is ignored and is perceived to have little
or no legal bite.
Aside from failing to comply with the HPCAA, if CAM
practitioners advertise their services in a style that could imply that they are
registered medical practitioners, it could be argued that they are guilty of
self-aggrandizing behaviour (as they are using a prestigious title to which they
are not truly entitled). In addition, implying oneself to be a registered
medical practitioner, when there is no evidence that this is true, may deny
prospective clients the ability to make an informed choice about their
healthcare provision, which is a cornerstone of modern healthcare.
Inappropriate use of the title ‘Doctor’ in
telephone directories is less likely to occur in the United Kingdom due to
tighter control over the wording of advertisements placed in the UK Yellow Page
directories. In contrast to the New Zealand Yellow
pages,8 where no similar guideline could be
found, the General Advertising Guidelines of
the UK Yellow Pages explicitly states that, “The title
‘Doctor’ or ‘Dr’ may be used provided the Advertiser is
a qualified medical practitioner”.9
This study aimed to explore whether practitioners of
acupuncture, chiropractic, and osteopathy in New Zealand use the title
‘Doctor’ in a way which could imply that they are registered medical
practitioners, when there is no evidence that they are, and if so, whether such
rates differ between practice types. (Of the CAM practices currently advertised
in the New Zealand Yellow Pages, acupuncture, chiropractic, and osteopathy
practices were selected for analysis as only these practice types appeared to
have practitioners who used the title ‘Doctor’.)
MethodsThe source of the secondary data analysed, the New
Zealand White and Yellow Pages telephone directory, was freely available in the
public domain (e.g., in any public library). The data were analysed to identify
whether practitioners of acupuncture, chiropractic, and osteopathy, used the
title ‘Doctor’ in a way that could imply they were registered
medical practitioners when there was no evidence that they were.
The following inclusion/exclusion criteria were used.
Data collection was restricted to the Auckland, Christchurch, and Wellington
area Yellow Pages available during the first week of October 2007. These three
directories covered an area where approximately 54.7% of New Zealand’s
population lived, according to the 2006 New Zealand census
data.10
To test whether a practitioner using the title
‘Doctor’ was actually a registered medical practitioner, the names
of all CAM practitioners using the title ‘Doctor’ were cross-checked
against the list of registered medical practitioners in the corresponding New
Zealand White page directories and also the NZ Medical Council register of
medical practitioners (as at 6 Nov 2007).11
If a practitioner used the prefix ‘Doctor’
and the suffix DO, DC, or PhD they were not counted as using the title
‘Doctor’ in a way intended to imply they were a registered medical
practitioner, as they could potentially have the qualification Doctor of
Chiropractic/Osteopathy or Doctor of Philosophy and [wrongly, but genuinely]
believe they may use the title. (It should be noted, however, this criterion is
lenient, as these qualifications refer to a ‘doctorate’ they would
only provide at best a technical excuse for use of the title
‘Doctor’ in CAM practice—if they refer to diplomas, then they
offer no justification whatsoever, technical or otherwise.)
If a practitioner practiced in more than one area (e.g.
chiropractic and osteopathy), they were counted twice (so rates of misleading
use of the title ‘Doctor’ were represented evenly across practice
types). When a practitioner advertised twice under the same practice type, they
were counted once (so as not to artificially inflate the rates for any practice
type); the listing most likely to mislead was the one retained (e.g., if the
title ‘Doctor’ is used in one advertisement, but not another, then
the former was entered for analysis, whilst the latter was not).
No practitioner was approached in person, or contacted
by phone, facsimile, email, or conventional mail.
Results120 (82%) chiropractics, 27 (21%) acupuncturists, and 9 (6%)
osteopaths were found to use the title ‘Doctor’ in their NZ Yellow
Pages advertisement/listing. This difference was highly significant,
χ2 (2, N=156)=136.50, p<0.001. Table 1
shows the number of practitioners using the title ‘Doctor’, by
practice type.
Table 1. Practitioners using the title Doctor,
by practice type
107 (73%) chiropractics, 16 (13%) acupuncturists, and 8 (6%)
osteopaths appeared to use the title ‘Doctor’ in a way that could
imply they were registered medical practitioners, when there was no evidence
this was true; the difference in use of titles between practice types was highly
significant, χ2 (2, N=397)=202.54,
p<0.001; practitioners of chiropractic were 6.7 times more likely than
acupuncturists and 13.4 times more likely than osteopaths to use the title of
‘Doctor’ in this way.
There were 17 practitioners for whom there was a
‘technical excuse’ for using the prefix ‘Doctor’ as they
also added the qualification suffix of DC, DO, or PhD, meaning they may be a
Doctor of Chiropractic/Osteopathy or Philosophy. It was not possible to
determine whether two CAM practitioners were registered medical practitioners
due to vagueness in the wording of their Yellow Page listings/advertisements.
Practitioner count by practice type and use of title is shown in Table 2.
Table 2. Use of title, by practice
type
DiscussionStrong evidence was found that practitioners of
chiropractic, and to a lesser extent acupuncture and osteopathy, respectively,
sometimes use the title ‘Doctor’ in a way likely to imply that they
are registered medical practitioners when there was no evidence that this was
true.
Using a title that could imply to prospective clients that
they are consulting a registered medical practitioner, when in reality they are
not, is both misleading and illegal.6 Such
practice also denies clients the ability to make informed consent about their
treatment and could potentially lead to delays in seeking out mainstream medical
care due to confusion over the status of the practitioner.
So why might the title ‘Doctor’ hold such an
attraction to those who work in healthcare but who are not registered medical
practitioners? Five possible explanations are:
It was difficult to speculate
why the rate of misleading use of title differed significantly between practice
types. It was, however, interesting that misuse of the title
‘Doctor’ occurred 6.7 times more often among chiropractics than
acupuncturists, and 13.4 times more often among chiropractics than osteopaths.
No evidence could be found to suggest that that an
organisation representing each practice type (New
Zealand Chiropractors' Association, Osteopathic Society of New Zealand, and
New Zealand Register of Acupuncturists) either encouraged or discouraged use of
the title ‘Doctor’ amongst its
members.12–14
If the New Zealand Yellow Pages were to adopt the criterion
with regard to use of the title ‘Doctor’ that is currently used in
the General Advertising Guidelines of the United Kingdom Yellow Pages, then much
of the current confusion would cease. As such, it is recommended that the New
Zealand Yellow Pages should be made aware (e.g. by communication from the
Medical Council of New Zealand) that current practice of allowing CAM
practitioners to use the title ‘Doctor’ in their advertisements may
encourage an activity, the legality of which is highly dubious.
It is further recommended that CAM practitioners who are not
medically registered practitioners must accept that in New Zealand they are not
entitled to use the courtesy title ‘Doctor’ and cease to do so at
the earliest available opportunity. It is suggested that a ‘period of
grace’ be allowed (e.g. until the NZ Yellow Pages have been notified of
the implications of this practice and the subsequent print-run has occurred)
prior to the legality of this behaviour being challenged.
Although it is recommended that inappropriate use of the
title ‘Doctor’ should cease, it may be interesting to explore
whether the use of the title ‘Doctor’ in CAM affects the size of any
placebo effect that may occur.
It should be noted that although all possible efforts were
taken to determine if any CAM practitioner using the title ‘Doctor’
was also a registered medical practitioner, it is possible that due to
inconsistencies in records available, some such cases were not identified.
Competing interests: None known.
Author information: Andrew Gilbey,
Lecturer, College of Business, Massey University (Turitea Campus), Palmerston
North
Correspondence: Andrew Gilbey, College of
Business, Massey University, Private Bag 11 222, Palmerston North, New Zealand.
Fax: +64 (0)6 3569099, Ext 4767; email: a.p.gilbey@massey.ac.nz
References:
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New Zealanders’ love affair with
“alternative” medicine: reason for concern? N Z Med J. 2006;
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