Anna Claire Vollers | (TNS) Stateline.org

When Vernon Langford sees patients, he typically wears a white lab coat with his title — “Dr.” — and his credentials as a nurse practitioner stitched on the front.

“My credentials are on any jackets I have, the shirts I wear. If I have a name tag, it’s on that,” said Langford, who works as a primary care provider in Seminole County, Florida. He holds a doctorate of nursing practice, the highest degree available in his field. Like a Ph.D., it confers on him the “Dr.” title, but he says he explains to patients what that means, and how his role and education differ from that of a physician: “When I meet anyone, I want to make sure I’m educating them about who I am.”

A Florida bill lawmakers considered this year would have barred Langford and others with similar credentials from using the “Dr.” title in clinical settings. The bill was amended to exclude nurse practitioners before it reached the desk of Republican Gov. Ron DeSantis, who vetoed it without explanation. But Langford, who is president of the Florida Association of Nurse Practitioners, expects the legislation to reemerge.

Under pressure from physicians groups, an increasing number of states are weighing similar restrictions.

The debate is a symptom of a broader battle in health care: Amid a shortage of doctors and an explosion in the number of nurse practitioners with doctorates, many nursing groups are pushing to expand what nurses can do without physicians’ supervision. Physicians, meanwhile, are pushing to keep nurse practitioners and physician assistants under their oversight, arguing that giving more autonomy to providers with less rigorous training could put patients at risk.

Nurse practitioners and physician assistants argue they deserve to be able to practice to the fullest extent allowed by their education and credentials, and that — like anyone who’s earned a doctorate — they should be able to use the title conferred on them.

“It has nothing to do with ego or wanting to be something I’m not,” Langford said. “If I worked hard and earned a doctorate, I can use the title of ‘Dr.’”

Other non-physician providers who have doctoral degrees, such as optometrists and pharmacists, often use the “Dr.” title, although some states have considered bills backed by physicians groups that would limit those providers as well.

The American Medical Association and other physicians groups argue allowing nurse practitioners with doctoral degrees to use the “Dr.” prefix in a clinical setting will confuse patients.

“For me, it’s worrisome when a nurse practitioner or a physician assistant is being perceived as a physician,” said Dr. Rebekah Bernard, a family physician in Fort Myers, Florida, who is also the outgoing president of Physicians for Patient Protection, a group that advocates for physician-led care. “We don’t have the same training or education. Patients should know who’s taking care of them so they can make informed decisions about their health.”

The “Dr.” title has long been associated with physicians who hold an M.D. (In fact, The Associated Press Stylebook, which Stateline uses, directs that “Dr.” be reserved for physicians, which is why only those individuals are given the title in this story.) Advanced practice registered nurses, often called nurse practitioners or APRNs, can be primary care providers. They can diagnose and treat some conditions and prescribe medications, and more than half of states allow them to practice without physician supervision. But they have had a less extensive medical education than physicians, and they are limited in what they can do for patients.

Now physicians and nurses organizations are pouring millions of dollars into state-level lobbying and title transparency campaigns as more states take up the issue.

Georgia approved a new law in May that dictates how non-physicians can identify themselves to patients. Lawmakers in North Carolina introduced a similar bill that stalled in committee. Indiana (2022) and New Jersey (2020) have approved title transparency laws in recent years.

In California, a nurse practitioner named Sarah Erny agreed last year to pay nearly $20,000 to settle a civil case brought by the district attorney of San Luis Obispo County. She holds a doctoral degree in nursing and had called herself “Dr. Sarah” on her website and social media. Officials said she’d violated California state code by failing to adequately explain to the public that she was not a medical doctor. The incident prompted three other California nurse practitioners with doctorates to sue the state earlier this year for the right to use the “Dr.” title.

‘Truth and transparency’

Dr. Carmen Kavali, an Atlanta plastic surgeon, was involved in writing Georgia’s new title transparency law. Kavali, who has been active with physician advocacy groups such as the Georgia Alliance for Patient Protection Foundation and Physicians for Patient Protection, said she used Indiana’s law and part of Illinois state code as blueprints.

Georgia’s law requires non-physicians, such as advanced practice registered nurses and physician assistants, who have doctorates and use the title “Dr.” to tell patients each time they interact that they are not a medical doctor. They must make their credentials clear to patients verbally and in advertising, on their websites and in other forms of communication. The law also requires them to wear an identifier, such as a name tag, that lists the type of license or degree they hold.

“Truth and transparency isn’t something that should be arguable,” Kavali said. “Why would more information for a patient ever be bad? If it takes a few extra words to clarify what your licensure is, how is that harming the patient?”

The American Association of Nurse Practitioners, in a statement to Stateline, said it supports the right of nurses and other providers to use the “Dr.” title when they have doctorates. The organization opposes legislation that would prohibit nurses and other professionals from “clearly representing their credentials to patients and the public.”

Kavali and other physicians point to a report, funded by the American Medical Association, that found that 39% of patients surveyed in 2018 incorrectly believed that a person who holds a doctor of nursing practice degree, known as a DNP, is a physician, while another 11% said they weren’t sure.

The American Medical Association reports having given more than $3.5 million in grants to member organizations to help them fight efforts to expand the roles of nurse practitioners and other non-physicians. One of those grant recipients was the Medical Association of Georgia, Kavali said.

The AMA also makes model legislation available to state medical associations and other member organizations. Aspects of the organization’s Health Care Professional Transparency Act have turned up in state laws in Georgia, Florida and elsewhere.

Kavali said physician advocates in Texas and Tennessee have reached out to her for guidance on how to strengthen their own provider identification laws.

More nurses, more doctorates

One reason the issue is being debated now is that there are so many more nurse practitioners. Their numbers more than doubled from 2010-2017, driven by what researchers at Montana State University and Dartmouth College called “a remarkable expansion” in the number of college programs, which now graduate almost as many new nurse practitioners as medical schools do physicians.

And the past 15 years have seen an explosion in the number of nurse practitioners earning the relatively new doctor of nursing practice degree, or DNP. It’s a doctoral-level degree, educationally on par with a Ph.D. But while Ph.D.s generally are research-focused, a DNP focuses on advanced clinical training or on preparing nurses for health care leadership roles.

“As more people get doctorates, there’s this desire to keep the ‘Dr.’ title only to physicians, which doesn’t make a lot of sense,” said Langford. “We use the term ‘Dr.’ in education, we use it for chiropractors and optometrists. If you’re telling people who and what you are, there’s no confusion there.”

The debate is playing out in the middle of a nationwide physician shortage.

Jobs for nurse practitioners, however, are projected to grow 45% from last year to 2032, according to the U.S. Bureau of Labor Statistics, a rate much faster than the 3% average for all other occupations or 9% for other health care practitioners.

In a health care market that’s increasingly run by behemoth health care systems, advanced practice nurses can be a less expensive alternative to physicians. Bernard, the family physician in Florida, tells the story of a friend who worked part time as an emergency department physician in Louisiana and recently lost her job when the company that owned the hospital let go its part-time staff and replaced them with nurse practitioners.

“To me, the culprit is legislative policy that hasn’t changed in years, and corporations trying to save money while not worrying so much about patient care,” Bernard said.

Research on how the growth of non-physician practitioners affects patient care is mixed. Some studies have shown the quality of care delivered by nurse practitioners and physician assistants is comparable to care by physicians, and that nurse practitioners decrease unnecessary hospitalizations. Other studies have found that nurse practitioners and physician assistants are more likely to order diagnostic tests and referrals that could be unnecessary.

Vicky Stone-Gale, a nurse practitioner in Plantation, Florida, who holds a doctorate of nursing practice and is an associate professor at Frontier Nursing University, said concerns about misrepresentation of the doctor title are overblown.

“I don’t know any nurse practitioners who would go into a patient’s room and introduce themselves as a doctor without also identifying themselves as a nurse practitioner,” Stone-Gale said.

Professional organizations work to educate new nurse practitioners about what they can and can’t say when it comes to communicating their credentials, she said.

“Using that ‘doctor’ title and saying you have a doctor of nursing practice is not wrong,” she said. “We worked hard to get that degree, just like any other specialty.”

Stateline is part of States Newsroom, a national nonprofit news organization focused on state policy.

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