What’s the news: Three nurse practitioners (NPs) are appealing a ruling by the U.S. District Court for the Central District of California that upheld a state law prohibiting them from using the terms “doctor” and “Dr.” The NPs—who hold doctorates in nursing practice—had claimed the law, which allows only California-licensed physicians to use those terms, was unconstitutional.
The restriction, which is in Section 2054 of the California Business and Professions Code, has been on the books since at least 1937 to avoid patient confusion over the level of education their health professionals have achieved.
In his ruling in Palmer et al. v. Bonta et al., U.S. District Judge Jesus G. Bernal treated the use of the titles as commercial speech, rejecting the nurse practitioners’ First Amendment challenges. Notably, the judge relied on AMA survey research (PDF) showing that 39% of patients are confused and wrongly believe that a person holding a doctorate in nursing practice is a physician.
“The record and common sense support the conclusion that Section 2054 directly advances California’s substantial interest in protecting consumers from misleading advertising by medical professionals,” Bernal wrote in the ruling.
In an amicus brief submitted to the 9th U.S. Circuit Court of Appeals supporting the district court’s ruling, the Litigation Center of the American Medical Association and State Medical Societies and the California Medical Association (CMA) further summarize the legitimate government interests served by the restriction.
“The original purpose of Section 2054 remains as relevant and vital today as in 1937 when the statute’s predecessor was originally enacted. Especially with modern day advances in medicine, physicians are educated and trained differently and more deeply and robustly than any other health care provider,” the brief says. “As it was in the early part of the last century, without surprise, the public continues to view physicians as the pillar of health care and closely associates the terms ‘doctor’ and ‘Dr.’ with physicians and surgeons.”
In addition, the brief notes, “the right of physicians to exclusively call themselves ‘Dr.’ or ‘doctor’ under Section 2054 is founded upon an entire regulatory scheme under California law that imposes and privileges the highest standards of responsibility and authority on physicians, and no other practitioner. Permitting other health care practitioners such as nurse practitioners to assume that title simply because they hold a non-MD or -DO ‘doctorate' degree betrays the interconnectedness between the title ‘Dr.' or ‘doctor’ in health care and the laws that give meaning to that position within health care.”
The amicus brief in this case is just one example of how the AMA is fighting scope creep, defending the practice of medicine against scope of practice expansions that threaten patient safety and undermine physician-led, team-based care.
Why it’s important: 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.
Research from the AMA 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,” says brief from the AMA and the CMA.
Moreover, misrepresentation of a health professional’s level of licensing “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 state medical boards,” the brief says, noting that differences in training between physicians and nurse practitioners has been shown to produce disparate outcomes. “Recent studies have found significantly increased levels of prescription of opioids and overprescription of antibiotics by nurse practitioners compared to physicians, especially when the nurse practitioner is not practicing under physician supervision.”
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.”
Read more from the AMA on what sets apart physicians and nurse practitioners.
Learn more: The AMA Truth in Advertising Campaign has a model bill and resource materials 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.
Also, 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.
Explore further the cases in which the AMA Litigation Center is providing assistance and learn about the Litigation Center’s case-selection criteria.
