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Arlene Wright is a healthcare professional, but she prefers not to be referred to as a doctor.
"I usually tell my patients that 'your majesty' or 'your highness' is acceptable," she stated.
Wright has been working as a nurse for over two decades in Fort Myers, Florida. She started her career as a teenage candy striper in Upstate New York hospitals and gradually obtained an associate's degree in nursing, followed by a bachelor's, master's, and eventually a doctorate of nursing practice in 2013.
Throughout her career, Wright has always identified herself as a nurse practitioner to her patients. She does not emphasize her doctorate or attempt to deceive patients into thinking she holds an MD degree.
However, when lawmakers in Florida proposed a bill that would prohibit her from using the title of doctor, Wright was taken aback.
"I have never seen anyone abuse their title, nor have I witnessed anyone else doing so," she explained. "This legislation singles out individuals and creates a negative atmosphere based on the actions of a few."
The Florida bill aimed to restrict non-physicians from using titles such as doctor of medicine, physician, medical resident, and hospitalist. (Governor Ron DeSantis vetoed the bill in June.) A similar measure became law in Georgia this year, and Indiana is set to implement it in 2022. In California, a nurse practitioner was ordered to pay nearly $20,000 for advertising herself as "Doctor Sarah" under a law that several nurses are currently challenging.
Florida and Georgia are just two examples of states grappling with the issue of granting nurse practitioners and other medical professionals more autonomy. This question has become emotionally charged for many healthcare providers and time-consuming for state and federal groups advocating on their behalf.
In recent years, hundreds of laws have been proposed to expand the scope of practice for non-physician medical professionals, according to the American Medical Association (AMA). The AMA and its allies have invested millions of dollars in opposing these proposals. More than half of the states no longer require physician supervision for nurse practitioners, who can complete their degrees with as little as 10% of the clinical hours required for doctors.
Doctors and nurses have differing views on the matter. The AMA sees it as less experienced professionals attempting to evade physician oversight, while the American Association of Nurse Practitioners frames it as a fight for "full practice authority."
Regardless of the terminology used, the extent to which non-MDs are allowed to test, diagnose, prescribe, and treat illnesses, as well as what they should be called while doing so, is reshaping healthcare, especially in underserved areas. As the authority of nurse practitioners and other medical professionals expands, patients in these communities may receive healthcare without ever or rarely seeing a doctor.
"People have embraced the idea that we can make do with fewer doctors by utilizing physician assistants and nurse practitioners," stated neurosurgeon Bernard Robinson in an AMA video, referencing a nationwide shortage of doctors reported by the Association of American Medical Colleges.
The AMA takes a more direct stance, asserting that "patients deserve care led by physicians." Its advertising campaign, which supports title bills similar to those in Georgia and Florida, aims "to ensure patients can easily answer the question, 'Who is a doctor?'"
Expanding auth
ority on a state-by-state basis
When the first nurse practitioner program was established in the United States in 1965, its goal was to complement the work of doctors.
"The PNP was not meant to replace physicians," wrote nurse Loretta C. Ford, co-founder of the country's first nurse practitioner training program, in 1997. "The relationship was envisioned as collaborative and collegial."
Nurse practitioners, who hold a master's degree or doctorate in nursing and have passed certification exams, are a type of advanced practice registered nurse. In the United States, there are over 350,000 nurse practitioners who have long advocated for independence.
For many years, nurse practitioners have been licensed to provide certain types of care but have been restricted by outdated state laws that require them to be supervised by physicians. However, the number of states granting nurse practitioners full practice authority without physician supervision has been steadily increasing. In 1994, only five states allowed this, but by 2005, the number had grown to 27 states and Washington, D.C.
While nursing organizations have been actively promoting their cause, doctors' groups have been relatively quiet, according to Carmen Kavali, a plastic surgeon from Georgia who has been involved in policy debates. Kavali believes that doctors were slow to act because they didn't believe legislators would allow nurse practitioners to treat patients independently. The American Medical Association (AMA) held the position that individuals who did not attend medical school or complete a residency should not be able to independently treat patients.
However, nurse practitioners were able to sway state lawmakers by presenting studies demonstrating their ability to safely provide care, particularly in primary care settings. Economist Bianca Frogner, who leads the University of Washington's Center for Health Workforce Studies, supports the research conducted by nurse practitioners and believes that instead of blaming them for filling gaps in healthcare, the focus should be on why there is a shortage of physicians in certain communities.
Physicians' groups have countered nursing groups' arguments with their own research. In 2006, the AMA and other physicians' groups started funding research to challenge the key arguments made by allied health professionals in support of their measures in state legislatures. The AMA received proposals asserting that mid-level or limited license practitioners were attempting to practice medicine based on false claims of authority.
The debate over independent practice for nurse practitioners has become costly for both nurses and doctors. Since 2006, the AMA partnership has awarded over $3.5 million to groups working on this issue.
Medical lobbies have also made significant financial contributions to governors and state legislators. In the 2022 election cycle, groups supporting Florida Governor Ron DeSantis received hundreds of thousands of dollars from medical groups, including the Florida Medical Association and various professional groups representing optometrists, nurse anesthetists, and chiropractors. Similar donations were made to Georgia Governor Brian Kemp by professional groups supporting doctors, optometrists, chiropractors, and pharmacists.
In North Carolina, as legislators considered expanding nurses' authority, health-care groups and individual physicians made donations. A pro-physician group called NC Citizens for Patient Safety donated $138,000 to Tim Reeder, an MD, who ran against state Representative Brian Farkas, one of the bill's sponsors. Reeder, who won the election by a narrow margin, has become one of the nursing bill's most vocal opponents.
According to Kavali, a plastic surgeon from Georgia, state lawmakers are tired of the back-and-forth lobbying on nurse practitioner practice laws. They have asked for the bickering to stop, but Kavali argues that they are trying to protect patients. A study published by the National Bureau of Economic Research compared physician-led and nurse practitioner-led care in Veterans Affairs hospitals and found that being seen by a nurse practitioner increased the length of hospital stay by 11 percent. While most research on independent nursing practice focuses on primary care, some nurse practitioners have expanded into other areas such as pain-management clinics and medical spas. However, there is less research on how nurse practitioners perform compared to doctors in these specialized areas. The number of recommended clinical hours for advanced-practice nurses has increased to 750 from 500, but it is still significantly less than the 10,000 to 16,000 hours of clinical training that doctors undergo. This discrepancy is a central issue for doctors who advocate for stricter practice laws. Rebekah Bernard, a family physician and president of Physicians for Patient Protection, became concerned about nurse practitioners' level of training when she had to supervise them early in her career. She wondered why they could do the same things as her despite her extensive schooling. Bernard's concerns led her to start an advocacy group called Physicians for Patient Protection. Nurse practitioners like Dwayne Hooks believe they can deliver primary care as well or better than doctors. Hooks argues that nurse practitioners can seek another opinion when cases go beyond their expertise, just like primary care physicians would refer patients to specialists. He also believes that nurse practitioners bring a more holistic and individualized approach to patient care. Both doctors and nurse practitioners claim to want what is best for patients, especially in underserved rural areas where an estimated 50 million Americans live without adequate care. Nurse practitioner advocates argue that expanding their practice authority will allow them to work in these areas.
Certainly! Here is the revised version of the article:
Between 2008 and 2016, the number of rural primary care practices where nurse practitioners worked increased, according to a peer-reviewed study analyzing health workforce data. However, the most significant growth was observed in states that had limited and restricted scopes of practice.
Meanwhile, the shortage of primary care doctors has worsened.
Kavali suggested that instead of disregarding doctors, the government should raise the federal cap on Medicare-funded residency positions and provide additional incentives for work in underserved areas. Ferrara argued that nurse practitioners could immediately fill these roles if states permitted.
Nurse practitioners are continuously expanding their practice to new locations almost every year. The number of nursing training programs, including those at the doctoral level, has also significantly increased. As a result, there will be a greater number of nurses with the title of "Dr."
For nurse practitioners like Hooks and Wright, these trends signify a recognition of their long-standing qualifications. However, for physicians such as Kavali and Bernard, it means that many Americans may not have access to medical care.
Bernard stated, "Many patients are unaware. They simply see someone wearing a white coat."