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ROCHESTER, Minn. — When you write your doctor through an online patient portal, do you remember to address them as "Doctor"?

For nearly one-third of all messages sent from Mayo Clinic patients to their doctors between October 2018 and 2021, this simple but meaningful courtesy was neglected, with correspondents addressing their physician by their first name instead.

That was the finding of authored by a team from Mayo Clinic Scottsdale and published in the journal JAMA Network Open. It is believed to be the first study to put hard numbers on a so-called "untitling" phenomenon that is excessively directed at female physicians and physicians of color and which contributes to burnout.

The authors, three physicians from the department of dermatology at Mayo Clinic Scottsdale and a researcher from the department of quantitative health sciences, looked back over 90,830 messages sent from 34,829 patients during the period of review.

The authors were Dr. Yul W. Yang, Dr. Jamison Harvey and Dr. Shari Ochoam with researcher Richard Butterfield. They conducted the study by utilizing a natural language processing algorithm to scan the electronic communications and identify how physicians were addressed based on formality.

The study learned that of the over 90,000 messages sent, 29,498 messages from 14,958 patients — or 32.5% of all messages — included the physician's first name in the greeting or salutation.

The study collected age, gender, degree, training level and specialty data on the physicians addressed — although not racial or ethnic information. It also collected the age and gender of the patients writing them.

Though women physicians received slightly more than half of all messages to physicians, after adjusting for a host of variables, "women physicians had more than twice the odds of being called by their first name," according to the authors.

The study also found that physicians holding a doctor of osteopathic medicine degree were two times more likely to be addressed by a first name, and that primary care physicians had a 50% greater chance of being addressed informally.

Men committed the untitling practice more often than women, it found. Women were 40% less likely to write to a doctor with first-name-using emails.

Among their recommendations, the authors suggested workplaces could take steps to address a creeping informality in the physician-patient relationship or workplace, and to address the unconscious biases believed to be at work. It suggested this be carried out through "formal guidelines" — — and "direct patient education."

In an accompanying editorial, Dr. Lekshmi Santhosh and Dr. Leah Witt from the University of California, San Francisco described untitling as "a subtle but important form of unconscious bias," one that was "not unique to health care" and one "reported to be experienced by women from minoritized racial and ethnic groups with more frequency."

The authors placed the practice within the demoralizing context of a crush of electronic health record overload that overwhelmingly consumes the time of female physicians, according to research, the cumulative toll of which they compared to "a thousand small cuts" and which was "a critical contribution to burnout."

News of the Mayo Clinic study quickly drew a number of affirming responses from physicians on Twitter, with both female and male physicians recounting experiencing or observing similar experiences.

"I was shocked the first time this happened to me," wrote Dr. Stephanie Fong Gomez, a pediatrician in Oakland, California, "and it probably won't be the last."

"They finished four years of undergrad, four years of medical school, endured three to seven years of residency (some going on to get other degrees!), work 50 to 90 hrs a week," asked Dr. Charlie Wray, Associate Professor of Medicine at UCSF, "and you still can't call female physicians 'Doctor' when you email or send them a message?"

"Oh yes," wrote Dr. Courtney Martin, an OB-GYN surgeon in California, "lots of MyChart messages that address me as Courtney or Ms. Martin. This is even after I have performed SURGERY on them."

It was, she said, "So weird."