Legislation defining who should be allowed to use the 'doctor' title, and especially whether specialist nurses were allowed to do so, have created sharp divisions between physicians and nurses in the US, notes MedicalBrief.
Three California nurse practitioners with doctorates (DNP) sued the state earlier this year over its law that only physicians can call themselves doctors, saying it violates their first amendment right to use the honorific title without fear of regulatory repercussions.
Under California’s Medical Practice Act, individuals cannot refer to themselves as “doctor, physician, or any other terms or letters indicating or implying that he or she is a physician and surgeon…without having…a certificate as a physician and surgeon”.
Instead, reports Medscape, nurse practitioners certified by the California Board of Registered Nursing, may use titles like “Certified Nurse Practitioner” and “Advanced Practice Registered Nurse”, corresponding letters such as APRN-CNP, RN, and NP, and phrases like paediatric nurse practitioner to identify specialisation.
Individuals who misrepresent themselves are subject to misdemeanour charges and civil penalties.
But the non-profit organisation Pacific Legal Foundation argues that after “years earning their advanced degrees and qualifications…they should be able to speak truthfully about them in their workplaces, on their business cards, the internet, and social media, so long as they clarify they are nurse practitioners”.
State lawmakers’ attempts to clarify the roles of physicians and nurse practitioners have seen mixed results. Florida legislators recently passed a Bill to prevent advanced practice nurses from using the honorific title, reserving it only for MDs and DOs.
In May, Georgia lawmakers passed the Health Care Practitioners Truth and Transparency Act. It requires advanced practice nurses and physician assistants with doctoral degrees who refer to themselves as doctors in a clinical setting to state they are not medical doctors or physicians.
Still, some health professionals say the designation should only be used in academic settings or among peers, and that all doctoral degree holders should ditch the moniker at the bedside to ease patient communications.
When Florida lawmakers began considering the Bill, Arlene Wright was taken aback.
She’s a doctor, but she doesn’t want people to call her one. She has been a nurse for more than 20 years in Florida. She began working in hospitals as a teenager in New York, progressing through an associate’s degree in nursing, then a bachelor’s, then a master’s, then finally a doctorate of nursing practice in 2013.
Wright has always told patients she’s a nurse practitioner, she says. She doesn’t flaunt her doctorate or try to mislead patients into thinking she has an MD.
The Florida Bill would have prevented non-physicians from using several titles such as doctor of medicine, physician, medical resident and hospitalist.
A near-identical measure became law in Georgia this year and Indiana in 2022. California ordered a nurse practitioner to pay nearly $20 000 for advertising herself as “Doctor Sarah,” based on a law that several nurses are now challenging.
Florida and Georgia are two of many states contending with how much independence to give nurse practitioners and other medical professionals. It’s a question that has become emotional for many medical providers and time-consuming for many state and federal groups lobbying on their behalf.
The past several years have seen hundreds of laws proposing to expand non-doctor medical professionals’ work, the American Medical Association (AMA) says, noting that it and allies have put millions of dollars into fighting back.
The Washington Post reports that more than half of all states no longer require a physician to sign off on the work of a nurse practitioner, who can have as little as 10% of the clinical hours as doctors before getting their degree.
Doctors and nurses don’t agree on what to call the issue. To the AMA, it’s a matter of less experienced professionals attempting to escape from physicians’ supervision. To the American Association of Nurse Practitioners, it’s a battle for “full practice authority”.
Whatever its name, how much leeway non-MDs have to test, diagnose, prescribe and treat illness – and what they should call themselves while doing so – is a question changing medical care, particularly in underserved areas.
As nurse practitioners’ and other medical professionals’ authority expands, patients in those communities could eventually move through the healthcare system while rarely or never seeing a doctor.
“Individuals have the notion that we can get by with fewer doctors (by) using physicians’ assistants and nurse practitioners,” neurosurgeon Bernard Robinson said in an AMA video, citing what the Association of American Medical Colleges says is a nationwide doctor shortage.
The AMA is more direct: “Patients deserve care led by physicians.” Its advertising campaign that has pushed title Bills similar to those in Georgia and Florida says it wants “to help ensure patients can answer the simple question, ‘Who is a doctor?’”
Expanding authority, state by state
When the first American nurse practitioner programme began in 1965, it sought to supplement doctors’ work.
“The PNP was not a substitute for the physician,” nurse Loretta Ford, who co-founded the country’s first nurse practitioner training programme, wrote in 1997. “Their relationship was envisioned as collaborative and collegial.”
Nurse practitioners are one type of advanced practice registered nurse, distinguished by having a master’s degree or doctorate in nursing and passing certification exams.
There are more than 350 000 nurse practitioners in the US, who have long pushed for independence.
Their pitch has remained consistent. Nurse practitioners were licensed to provide certain types of care. But they couldn’t because state laws, many decades old, yoked them to supervising physicians.
In 1994, five states allowed nurse practitioners full practice authority — meaning they didn’t need physician supervision to test, treat and prescribe. In 2000, 10 states did. In 2005, 11. Today, 27 states do.
As nursing organisations were spreading their message, doctors’ groups were comparatively quiet, said Carmen Kavali, a Georgia-based plastic surgeon was one of the lead advocates for the Georgia medical-titles law.
She said the AMA was slow to act because doctors didn’t think legislators would allow nurse practitioners to see patients unsupervised.
“Why would anyone think that somebody who didn’t go to medical school and do a residency should be able to treat patients independently?” Kavali said.
But state lawmakers were quickly swayed. Nurse practitioners had produced studies showing they could treat patients safely, particularly in primary care settings, and had shown them to legislators countrywide.
‘Assertions of authority’
In 2006, the AMA and other physicians’ groups started funding research to rebuff “the key arguments allied health professionals use to advance their measures in state legislatures”, Psychiatric News wrote at the time.
“Some mid-level or limited licence practitioners continue to attempt to practise medicine and rely on false assertions of authority,” one proposal to the AMA in 2006 reads.
The American Association of Nurse Anaesthesiology responded that the resolution relied on “witch-hunt logic”.” As doctors fight scope-expansion Bills, nursing professionals have said physicians are trying to protect their turf – and their higher salaries – at patients’ cost.
An economics working paper published by the National Bureau of Economic Research compared physician- and nurse-practitioner-led care in more than 1m emergency room visits to Veterans Affairs hospitals, where nurse practitioners can practise without physician approval.
The study found that being seen by a nurse practitioner increased the length of hospital stay by 11%.
Most research on independent-nursing practice focuses on primary care. But some advanced-practice nurses have ventured into other parts of medicine, working at pain-management clinics and medical spas, the latter of which offer treatments like Botox and beauty services.
There’s less research about how nurse practitioners perform compared with doctors in these specialised areas, though up to 90% of nurse practitioners are trained in primary care, said Stephen Ferrara, president of the American Association of Nurse Practitioners.
Doctor groups say the long-time national standard of 500 clinical hours for training nurse practitioners isn’t enough, especially as online nursing programmes proliferate.
The number of recommended clinical hours for advanced-practice nurses rose to 750 from 500 last year. But graduate nursing school is often less time-intensive than physicians’ training; doctors often complete between 10 000 and 16 000 hours of clinical training.
The mismatch is central to why so many doctors care about practice laws.
Doctors, nurse practitioners and their representative bodies all say they want to do what’s best for patients.
Some 50m rural Americans live in areas without adequate care, according to some estimates. Nurse practitioner advocates often say expanding their practice authority will allow them to work in lesser-served areas.
Between 2008 and 2016, the number of rural primary care practices where nurse practitioners worked increased, a peer-reviewed study of health workforce data found. But the fastest growth occurred in states with reduced and restricted scopes of practice.
The shortage of primary care doctors, meanwhile, has deepened.
Medscape article – Nurse Practitioners Sue State Over Right to Use ‘Doctor’ Title (Open access)
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