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The New Zealand Medical Journal

 Journal of the New Zealand Medical Association, 25-July-2008, Vol 121 No 1278

Use of inappropriate titles by New Zealand practitioners of acupuncture, chiropractic, and osteopathy
Andrew Gilbey
Abstract
Aim This study aimed to explore whether practitioners of acupuncture, chiropractic, and osteopathy 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 rates differ between practice types.
Method Secondary data, the New Zealand Yellow pages telephone directory, were analysed for potentially misleading use of the title ‘Doctor’.
Results Some practitioners of acupuncture, chiropractic, and osteopathy appeared to use the title ‘Doctor’ in a way that could imply that they are registered medical practitioners, when there was no evidence this was in fact true. This occurred significantly more often among chiropractics than acupuncturists or osteopaths.
Conclusion Practitioners should be aware that if they are not registered medical practitioners, then using the title ‘Doctor’ whilst working in healthcare is unlikely to comply with the Health Practitioners Competence Assurance Act 2003. Misleading use of the title ‘Doctor’ should therefore be discontinued at the first available opportunity.

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’.)

Methods

The 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.

Results

120 (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
Practice type
Is the prefix 'Doctor' or ‘Dr' used?
Total
Yes
No
Acupuncture
Chiropractic
Osteopath
27
120
9
100
26
134
127
146
143
Total
156
260
416
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
Practice type
Does the title imply the practitioner is a medical practitioner when there is no evidence that they are?
Yes
No
Technical excuse
Unable to determine
Total
Acupuncture
Chiropractic
Osteopath
16
107
8
105
27
134
4
12
1
2
0
0
127
146
143
Total
131
266
17
2
416

Discussion

Strong 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:
  • To gain competitive advantage over practitioners not using the title;
  • To confer both prestige and a sense of credibility to practices for which the both scientific rationale and evidence-base are not as strong as for mainstream medicine (which is why such practices are complementary and/or alternatives to mainstream medicine);
  • CAM practitioners have not read, or have chosen to ignore, the HPCAA and are unaware what they are doing is potentially illegal;
  • Practitioners who have been conferred with the degree of Doctor of Chiropractic/Osteopathy or higher degree, such as PhD, genuinely (albeit wrongly) believe that they are entitled to use the title ‘Doctor’ in the course of their CAM practice; and
  • Some CAM practitioners refuse to accept there are theoretical and evidential differences between CAM and mainstream medicine and intentionally flout the HPCAA legislation.
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:
  1. Rafferty AP, McGee HB, Miller CE, et al. Prevalence of Complementary and Alternative Medicine Use: State-Specific Estimates From the 2001 Behavioral Risk Factor Surveillance System. Journal of Public Health. 2002;92(10),1598–1600.
  2. Molassiotis A, Cubbin D. Thinking outside the box: complementary and alternative therapies use in paediatric oncology patients. European Journal of Oncology Nursing. 2004;8(1):50–60.
  3. Wilson K, Dowson C, Mangin D. Prevalence of complementary and alternative medicine use in Christchurch, New Zealand: children attending general practice versus paediatric outpatients. N Z Med J. 2007;120(1251). http://www.nzma.org.nz/journal/120-1251/2464
  4. Ernst E. New Zealanders’ love affair with “alternative” medicine: reason for concern? N Z Med J. 2006; 119(1233). http://www.nzma.org.nz/journal/119-1233/1953
  5. Andrews GJ, Peter E, Hammond R. Receiving money for medicine: Some tensions and resolutions for community-based private complementary therapists. Health and Social Care in the Community. 2003;11(2), 155–67.
  6. Health Practitioners Competence Assurance Act; Wellington, NZ: Ministry of Health; 2003. http://www.legislation.govt.nz/act/public/2003/0048/latest/link.aspx?search=ts_act_Health
  7. Medical Council News; The right to the title ‘doctor’. Wellington: NZ Medical Council of New Zealand; 2006;42:5.
  8. Yellow Pages Group; Homepage; Auckland, NZ: Yellow Pages Group; 2007. http://www.yellowpagesgroup.co.nz
  9. Yell Direct; Online Advertising Information; General Advertising Guidelines. Reading, UK: Yell Group Plc; 2007. http://yp.cergis.com/adpolicies/_general_ad_guide.asp?nav=contact&dt
  10. Statistics New Zealand; Quick stats about a place; Wellington, NZ: Statistics New Zealand; 2007. http://www.stats.govt.nz/census/census-outputs/quickstats/aboutAPlace.htm
  11. Medical Council of New Zealand; Find a registered doctor. Wellington, NZ: Medical Council of New Zealand; 2007. http://www.mcnz.org.nz/FindaRegisteredDoctor/tabid/267/Default.aspx
  12. New Zealand Chiropractors’ Association; New Zealand Chiropractors’ Association WebPage; Auckland, NZ: New Zealand Chiropractors’ Association; 2007. http://www.chiropractic.org.nz
  13. Osteopathic Society of New Zealand; Welcome to the official website of the Osteopathic Society of New Zealand; 2007. http://www.osnz.org/go/index.php
  14. New Zealand Register of Acupuncturists; General information; Wellington, NZ: New Zealand Register of Acupuncturists; 2007. http://www.acupuncture.org.nz
     
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