AMA News Wire

Nurse practitioners sue for right to use "doctor" label

Sep 23, 2023

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Three nurse practitioners who earned doctorates of nursing practice are suing the state of California, saying that they have earned the right to tout themselves using the term "doctor."

The nurse practitioners claim a California statute that only allows California-licensed allopathic and osteopathic physicians to use the terms "doctor" and "Dr." is unconstitutional. The restriction has been on the books since at least 1937 to avoid patient confusion over the level of education their health professionals have achieved.

Physicians disagree, telling the court that the breadth of physician education and practical training eclipses that of nurses’ training and that the law avoids patient confusion over who is treating them. In addition, physicians tell the court that surveys support patients’ need and desire to only allow MDs and DOs to call themselves "doctor" or "Dr."

In an amicus brief, the Litigation Center of the American Medical Association and State Medical Societies and the California Medical Association (CMA) support the state’s request that the U.S. District Court for the Central District of California Riverside Division dismiss the lawsuit, Palmer et al. v. Bonta et al., and urge the court to uphold the law’s constitutionality, "as many courts before have." A hearing on a motion to dismiss the case is set for Sept. 18.

"Physicians today are educated and trained differently and more deeply and robustly than any other professional health care provider; and industry practice and the law continues to place physicians at the center of medical care," the brief tells the court. "As it was in the early part of the last century, the public continues to view physicians as the pillar of health care and closely associates the term ‘doctor’ or ‘Dr.’ with physicians and surgeons."

AMA President Jesse M. Ehrenfeld, MD, MPH, said that "patients want and deserve clarity and transparency in who is providing their care as there are immense differences in the education, training and qualifications among health care professionals."

He noted that "patients find it increasingly difficult to identify who is or isn’t a physician. The potential for confusion is especially heightened when nonphysician health care professionals use terms that are customarily understood to refer to a physician."

Truth-in-advertising laws such as California’s "have helped prevent this confusion, as well as potential harm to patients, who may be misled into believing they are being treated by a physician when they are not," Dr. Ehrenfeld added. "It is imperative that we follow precedent and keep these laws in place to ensure patients have the basic information they need to make informed decisions about their health care."

Fighting scope creep is a critical component of the AMA Recovery Plan for America’s Physicians.

Patients deserve care led by physicians—the most highly educated, trained and skilled health professionals. The AMA vigorously defends the practice of medicine against scope-of-practice expansions that threaten patient safety.

During their training, physicians learn to be leaders who can coordinate health care teams, solve complex medical issues, identify critical diagnoses and make timely treatment decisions. They are not just trained to handle routine issues, the brief says.

And the training for virtually all physicians goes beyond minimum state requirements. Three-to-seven-year residencies, post-residency fellowships or other subspecialty clinical training are the norm. There are continuing medical education requirements and most physicians complete the American Board of Medical Specialties’ requirements to maintain board certification.

"A nurse practitioner’s skill set simply does not match a physician’s training and education," the brief says. "Nurse practitioner programs cover less material than medical school, are less science-oriented, and lack comparable depth."

Find out in detail why education matters to medical scope of practice, with information on:

• Nurse practitioners compared with physicians.
• Physician assistants compared with physicians.
• Nurse anesthetists compared with anesthesiologists.
• Psychologists compared with psychiatrists.
• Naturopaths compared with physicians.

Visit AMA Advocacy in Action to find out what’s at stake in fighting scope creep and other advocacy priorities the AMA is actively working on.

With nearly 200 unique combinations of acronyms next to primary care health professionals’ names, the potential for patient confusion over who is treating them has only grown since California first required that only MDs and DOs could use the terms "doctor" or "Dr." And the California law isn’t unique, with Indiana, Minnesota and Tennessee among the states that have such truth-in-advertising laws.

"While the laws delineating who can use the term ‘doctor’ have been on the books for decades, the public’s understanding of the physician-patient relationship goes back much further than that," said California Medical Association President Donaldo Hernandez, MD. "Patients understand and have longstanding expectations of who they are talking to when they’re speaking to their doctor. By ignoring that precedent, we risk deceiving or confusing our patients."

An AMA survey (PDF) found that 45% of the adults surveyed "did not agree that it was easy to identify who is or is not a licensed medical doctor by reading what services they offer, their title, and other licensing credentials in advertising materials," the AMA Litigation Center and CMA brief tells the court.

The AMA survey also found that 91% of the respondents "strongly support and prefer" a health care team that is led by a physician, saying that their "years of medical education and training (compared to a nurse practitioner) are vital to optimal care, especially in the event of a complication or a medical emergency."

"A misrepresentation of the practitioner’s level of licensing is misleading and can jeopardize patient safety as a patient may mistakenly believe that the midlevel practitioner possesses the same level of training and qualification as physicians licensed by the California Medical Board," the brief says.

The AMA’s Truth in Advertising Campaign has resource materials (PDF) to support state legislative and regulatory campaigns aimed to ensure that health care professionals clearly and honestly state their level of training, education and licensing whether it is a face-to-face encounter or in advertising, marketing or other communication materials.

Find out more about the cases in which the AMA Litigation Center is providing assistance and learn about the Litigation Center’s case-selection criteria.