Recently, three nurse practitioners with doctorate degrees (DNPs) sued the state of California, saying the state law preventing DNPs from using the title “Dr.” is the criminalization of a truth. Some states have similar laws, while others allow the honorific “Dr.” to be used by DNPs.
Last year, a California-based DNP was forced to pay almost $20,000 in civil penalties after referring to herself as “Dr. Sarah Erny.” The district attorney in the case cited an American Medical Association survey revealing that many Americans are confused about their healthcare providers' education and training level.
Healthcare providers are divided on the issue, with some saying “doctor” should be reserved for physicians.
In June, three California-based nurse practitioners with doctorate degrees (DNPs) sued the state over its law, stating that only physicians can refer to themselves as doctors.
California law says that any person who advertises that they are a “doctor” or a “physician,” including using the letters Dr. or MD, “without having at the time of so doing a valid, unrevoked, and unsuspended certificate as a physician and surgeon under this chapter, is guilty of [a] misdemeanor,” according to the Medical Board of California.
The three plaintiffs—Jacqueline Palmer, DNP, Heather Lewis, DNP, and Rodolfo Jaravata-Hanson, DNP—filed the complaint with the state’s district court, suggesting that the state officials are “enforcing a law that criminalizes the truthful use of the title “Dr.” by any healthcare professional who is not a licensed physician or surgeon…This is true even where the doctor specifies the specific profession in which he or she has obtained his or her doctorate degree.”
They go on to say that the statute itself violates an individual’s First Amendment right to “truthfully describe themselves and their credentials,” also listing veterinarians, dentists, pharmacists, and physical therapists, as examples of healthcare providers who hold doctorates and, in their perspective, should be able to refer to themselves as doctors.
Their complaint came after a California healthcare provider, Sarah Erny, RN, DNP, was forced to pay almost $20,000 in civil penalties when she referred to herself as “Doctor Sarah Erny” online and in other spaces.
A news release from the San Luis Obispo District Attorney (DA) says that Erny did identify herself as an NP most of the time but that she “failed to advise the public that she was not a medical doctor and failed to identify her supervising physician. Adding to the lack of clarity caused by referring to herself as ‘Dr. Sarah,’ online search results would list ‘Dr. Sarah Erny,’ without any mention of Ms. Erny’s nurse status.”
The DA’s release also cited data from an American Medical Association (AMA) “Truth in Advertising” survey of 850 adults, showing that nearly 40% of respondents “incorrectly identified a Doctor of Nursing Practice as a medical doctor.” In contrast, 19% of those surveyed “believed a Nurse Practitioner was a physician.” As part of the survey, the AMA noted that many patients “are confused about the level of education and training of their health care provider.”
California isn’t alone in an attempt to detangle the terminologies used for DNPs. Florida’s new bill says DNPs cannot refer to themselves as doctors, while Georgia says they can—under the condition that they identify, at work, the fact that they are not medical doctors or physicians. Every state has a differing scope of practice for DNPs.
Healthcare professionals and other experts are divided on the issue: Should DNPs be called doctors?
An article by Gary Gaddis, MD, PhD, published in Missouri Medicine, explores the issue, saying that DNPs could rightfully call themselves ‘doctors’ in an academic setting. “But, to call themselves ‘doctor’ in a clinical setting misleads the patient and perpetrates a fraud which defies their patient’s trust,” he says.
Art Caplan, an ethicist from the Division of Medical Ethics at NYU's Grossman School of Medicine, told Medscape that the term is loaded but meaningful. “I don't use the term "doctor" so much as the only person who's worthy of respect or the only person who's in charge. I use it just to distinguish between the set of skills, responsibilities, data collection, recommendation of therapy, and so on that, in my own head, correspond to different roles that people are doing,” he says.
Caplan goes on to say, “I don't think having a battle over who really gets to use the word "doctor" is the best path forward because it still may lead to confusion. I think the path forward is learning to respect what all parties contribute in the care of patients.”
According to Danielle Kelvas, MD, DNPs should not use the word ‘doctor,’ as reducing patient confusion is the ultimate goal. “Many people are not familiar with all of the different types of medical training,” Dr. Kelvas adds. “It's confusing for a patient to be wondering why a nurse is or is not their physician. I think the best solution is to introduce yourself as a doctor of medicine, doctor of pharmacy, physician, doctor of nursing, or surgeon. Simply calling everyone a ‘doctor,’ whether they're a physician or nurse, is just simply too confusing for a patient.”
In a YouTube video sharing a conversation between a nurse practitioner and a DNP, the channel’s host, “Bridgette NP,” wondered if, because DNPs are largely female, if sexism could play a part in the resistance against the term “doctor.” It’s worth noting that the American Association of Nurse Practitioners (AANP) says that most NPs are female.
Bridgette NP’s perspective echoes a 2020 article published by the Boston Medical Center blog exploring the intersection of gender inequity and medicine. Its author wrote that “efforts to call out implicit bias toward women in medicine can serve to reinforce long-standing assumptions about nurses and nursing…a nurse often sounds like shorthand for someone less accomplished and less important than a physician.”
Stephen Ferrara, president of the AANP, told MDLinx that the doctoral preparation sought by people across various healthcare professions—from pharmacists and physical therapists to psychologists and nurse practitioners—only strengthens the healthcare workforce. “That depth of preparation and knowledge should be welcomed and embraced by all in health care,” he says, noting that the AANP supports the honorific “doctor” in conjunction with the licensure title for DNPs.
“It’s time to move past anticompetitive and punitive measures that prohibit or infringe on nurse practitioners and other health professionals from accurately communicating their education, licensure and certifications to patients and the public,” Ferrara said.