The healthcare arena’s figurative boxing match between physicians and nurses over who besides those with Medical Doctor (MD) or Doctor of Osteopathic Medicine (DO) can claim and advertise ‘doctor’ or ‘Dr.’ ensues. Recent advocacy efforts among healthcare professions have renewed attention to the decade-plus wrestle. For example, in response to the ruling of The People of the State of California v. Sarah Anne Erny, three nurses in California are pursuing legal action against state officials to upend the Business and Professions Code Section 2054 of the state’s Medical Practices Act. The legal complaint on behalf of the three nurses, who hold doctorates of nursing practice (DNP), invokes the first and 14^th amendments to entitle them and other doctorate-nonphysicians rights to the honorific. While the ‘doctor’ and ‘Dr.’ prefix is coveted, so too are the reasons for who should use it.

According to an article in Becker’s Hospital Review, the American Medical Association (AMA) and American Association of Nurse Practitioners (AANP) agree that MDs and DOs are allowed to use the ‘doctor’ and ‘Dr.’ title. The associations disagree, however, about nurses with doctoral degrees. The AANP favors doctorate-nurses using ‘doctor’ or ‘Dr.,’ whereas the AMA opposes. Though for different reasons, both contend their stances aim to prevent deception and provide clarity to patients.

As a standalone matter of semantics, perhaps the AMA has reason to consider the AANP’s stance. In an article in The Washington Post about the three nurses’ lawsuits, one of the plaintiffs quoted said physicians do not monopolize the ‘doctor’ or ‘Dr.’ honorific. That is true. According to Cambridge Dictionary, ‘doctor’ is defined as a person that holds either a medical or doctorate degree. By definition, then, any person with an MD, PharmD, DC, DNP, and any other doctoral are ‘Dr.’ or ‘doctor.’ In this way, the AMA and AANP conflict is malarkey. If one earns a doctorate degree, one is ipso facto ‘Dr.’ and ‘doctor.’ Based on semantics, both physicians and doctorate-nonphysicians would deserve to decide in what settings to attribute the prefix to themselves without legal ramifications. The differing state laws on healthcare professional titles, however, indicate semantics is perhaps a thin argument.

For example, while California and Iowa do not extend ‘Dr.’ and ‘doctor’ to nurses, the states are not aligned on other licensed healthcare professions’ usage. In California, Section 2054 limits the use of ‘Dr.’ and ‘doctor’ to licensed physicians. In Iowa, the General Provisions, Health-Related Professions Code Section 147.74 stipulates licensed physicians can also use the honorific ‘Dr.’ or ‘doctor.’ The legislation permits the same to chiropractors, dentists, podiatrists, optometrists, and doctoral-degree-holding physical or occupational therapists, psychologists, speech pathologists, audiologists, marital and family therapists, mental health counselors, and pharmacists. As with California, in Iowa the abbreviated or spelled out appropriate type of licensure must accompany the name when the honorific is used. The inconsistencies, though, across state laws suggest less an argument about semantics and more one about equity.

In a STAT News op-ed, a trio of authors, who together satisfy MD, Ph.D., RN and DNP, synthesized a linguistic historical analysis of the word ‘doctor’ into a point that educational paths taken to earn doctoral degrees are often arduous and intense. Doctoral-conferring programs in healthcare may vary in structure, demand, and length, but each requires a considerable investment from individuals in pursuit of them. The doctorate rewards the achievement. In this sense, the ‘Dr.’ and ‘doctor’ prefix for doctorate-level nurses communicates respect for scope of expertise and acknowledges through proper title designation the range of professions contributing to the healthcare ecosystem.

In a healthcare context, however, those years of training are serious reasons for the AANP to weigh the AMA’s position. An article in Medical Economics reported that, according to the Primary Care Coalition, a family practice doctor trains “about 15,000 to 20,000” more hours than a nurse practitioner. The article and Association of American Medical Colleges describe the timeline to train physicians: medical school is four years, residency another three, and, if residents pursue fellowship, then one to three more. Physician training can take at least seven years. According to Nurse Journal, the years nurses train at the DNP level depends on the path: From registered nurse is four to six years, bachelor’s of science in nursing is three to four, and master’s of science in nursing is one to two. There are several trajectories available to earn the DNP, whereas the path for MDs or ODs is standardized. While doctorate-nurses end training with the DNP, physicians must continue even after they earn the MD or OD. That difference in training counts in clinical settings.

When patients receive care, their visit can entail encountering physicians and nonphysicians. The people traffic might be enough to give patients the impression that DNPs using the ‘Dr.’ or ‘doctor’ prefix obtained physician-level training. According to the AMA’s 2020 “Truth in Advertising” campaign results, a reported 50% of participants answered ‘yes’ or ‘not sure’ in response to whether DNPs were physicians. While The Washington Post article and STAT News op-ed explain the confusion is addressable through introductions and education, that does not guarantee patients would understand the scope and depth behind the training in relation to their care.

Core to arriving at a resolution for the ‘Dr.’ and ‘doctor’ title is evidence-based data, which is limited right now. The AMA’s campaign results report can serve as a first step for identifying the answer. Perhaps there is opportunity for the AMA and AANP to partner and conduct surveys of various patient populations to understand interpretations of ‘Dr.’ or ‘doctor.’ Otherwise, without patient feedback, the debate might live on another decade.