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In her inbox on the Mayo Clinic patient portal, the dermatologist Jamison Harvey receives some messages from patients that read more like a casual text to a friend than a request for medical expertise: “Hey Jamison, can you look at this spot?”

She introduces herself to patients as Dr. Harvey, the title she’s earned over 12-plus years of medical training. Yet, even after her introduction, they might still address her by her first name. Curious, Harvey and colleagues embarked on a study comparing the experiences of other doctors.

Their findings, published recently in the Journal of the American Medical Association: Between men and women physicians, “there’s a pretty big mismatch in the formality of the titles,” Harvey said. Women physicians were more than twice as likely as their male colleagues to have patients omit their “Doctor” titles when addressing them.

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To see these differences, the authors used a natural language processing algorithm to comb through nearly 91,000 messages sent from patients in the Mayo Clinic electronic medical record, picking out the greeting and closing salutations of each message. They found, in addition to women M.D.s having more than twice the chance of being called by their first name, that the chance was even greater for doctors of osteopathic medicine and primary care physicians. Women patients addressed physicians by their first name but were less likely than male patients to do so. There was no difference based on patients’ or physicians’ age, or the physicians’ level of training.

The study is “a neat demonstration of how electronic health record data can be used to identify bias and disparities, especially between patients and physicians, and how physicians are treated,” said Melanie Molina, a clinical fellow at the University of California, San Francisco, who published a perspective on microaggressions in her field of emergency medicine.

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Another study author, Yul Yang, noted that the electronic health record messaging platform offered an “unfiltered look into [doctor-patient] dynamics that haven’t been addressed very well,” where other research methods such as video recording and post-appointment surveys risk influencing patients’ behavior during the process.

For Lekshmi Santhosh, an associate professor of Pulmonary and Critical Care Medicine at UCSF, the study underscores the inequitable and often uncompensated nature of working in the electronic medical record. Previous work has found women physicians already receive a higher volume of patient messages than their male colleagues, spending more time after hours catching up on these messages. “Women physicians are in this impossible bind of running behind on clinical work… in the context of working so hard, spending so much more time and taking such care to craft a reply to each one of these messages, to then get a dismissive reply with your first name is quite jarring,” she said.

The omission of these women doctors’ titles (or “untitling”) is subtle, but these remarks accumulate among other experiences of bias in medical settings into what Santhosh and colleague Leah Witt described as “death by a thousand cuts” in an accompanying commentary of the study in JAMA. This can ultimately lead to burnout and attrition in the medical workforce.

“An instance where a woman physician’s credentials are put into question, especially if it occurs regularly on a daily basis, [can] have a negative impact on her and her self-image,” Molina said, adding that it can lead them to doubt their sense of belonging in medicine or even their own abilities as doctors. “Struggling with these kinds of feelings while also being responsible for patient care helps neither the physician nor the patient.”

There’s a distinction between being on a first-name basis with your doctor and untitling, which refers to instances in which doctors have not previously said they would like to be called by their first name or a name other than their “Dr.” title. One limitation of the new study is that the electronic health record data does not include whether physicians and patients had previously agreed to be on a first-name basis. Molina noted that these results from outpatient settings, where patients have many points of contact with their doctors, might also differ from those in acute care settings, where doctors meeting patients for the first time can be mistaken for other ancillary staff. “It’s when you walk into the room for the first time and the patient talking on their phone says, ‘Hang on, the nurse just walked in.’”

The study also did not look at differences in race or ethnicity among physicians; women of racial minorities have reported experiencing more untitling in fields outside medicine.

Despite these limitations, the authors say their study reveals an unconscious bias among patients – about what exactly, they don’t know. “We weren’t able to study that,” Harvey said. Perhaps, she said, “they don’t see women as natural physicians,” or, “it’s more that they feel like they have a better relationship with the female physicians.”

After Santhosh’s commentary was published in JAMA, many women physicians reached out to tell her “that is so true, that happens to me all the time,” sharing with her other examples of microaggressions they’ve experienced at work. “People have brought up stories saying, ‘This is why I always have to wear my white coat because otherwise people don’t think I’m a doctor – even though I run the division,” Santhosh said. Her hope is that this research on how women physicians are addressed will lead to greater awareness and urgent action about the universe of disparities that come with the title of “Doctor.”

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