In response to Sarah Erny being fined $20,000 for using the title Dr, three nurses with DNP degrees sued CA.
The history of PhD vs DNP vs MD degrees and how the title of Doctor has evolved over the course of history.
Gendered biases inform discrepancies between physicians and nurses, despite the common goal of excellent patient care.
Nursing CE Central
The title of Dr. has long been awarded to educators, physicians, and other masters of their field. However, there have been multiple attempts in recent years to deny doctors the proper use of their title due to a lack of physician experience, from California nurse Sarah Erny to first lady Jill Biden.
In the case of Sarah Erny, the state charged her with fraud and fined her $20,000 for the use of her earned title. In response to this charge, three nurses with doctorates have filed a joint suit against the state to allow for the “truthful and accurate self-description using the title “Dr.” or term “doctor.” This article compares the DNP vs MD degrees and gives a brief history of how different types of doctors evolved to hold the same title.
Sarah Erny is a nurse practitioner with a Doctor of Nursing Practice Degree and a PhD in Mind-Body Medicine. On the advice of her supervising physician, who told Sarah that she needed to “own her degree” she was referred to as Dr. Sarah, nurse practitioner.
However, after an anonymous call, Erny was accused of fraudulently presenting herself as a physician. In 2022, three years after the original investigation, the state sought to suspend Erny’s nursing license and nurse practitioner certificates, as well as fine her $20,000 for the “reasonable costs of investigation and enforcement of the case.”
Under CA Business & Professions Code Section 2054, no one may refer to themselves with the title “doctor or physician, the letters or prefix Dr., the initials M.D., or any other terms or letters indicating or implying that he or she is a physician and surgeon, physician, surgeon, or practitioner.”
This code wrongly implies that the prefix “Dr.” exclusively belongs to practicing physicians.
The case also accuses Erny of “gross negligence” and “unprofessional conduct” for over-prescribing testosterone therapy, despite the fact that nurse practitioners are well within their right to prescribe testosterone for hypogonadism and peri/post-menopausal issues and no evidence to substantiate their claim that Erny was overprescribing.
In an effort to not lose her license, Erny settled the case. This settlement means that in addition to the fine, Erny forfeit the use of the Dr. prefix in the future, must make periodic online searches to ensure she’s not referred to as a Dr. online, and correct patients/staff that may refer to her as Dr. Sarah.
Unfortunately, that was not the end of this case. In January of 2023, the California Medical Board and Board of Nursing filed their own complaints each with their own demands of payment under threat of losing her license in California.
On Sarah Erny’s GoFundMe page, she discussed moving to Washington State where she currently holds a nurse practitioner license. In Washington State, The perception of DNP vs MD degrees is much less severe as nurses are able to practice independently, as well as refer to themselves by the prefix Dr. if they hold a doctoral degree.
Currently, the future of Sarah Erny’s case remains unsolved as the state of California continues its barrage of complaints and suits.
Three nurses in California are not pleased with the state’s attempt to deny them their earned degrees. On June 6th of this year, Jacqueline Palmer, DNP, Heather Lewis, DNP, and Rodolfo Jaravata-Hanson, DNP filed a complaint claiming “California has appropriated a common title used by a variety of educated professionals and reserved it for legal use by only a select group of professionals—licensed physicians and surgeons.
As shown in Jacqueline Palmer et al v. Rob Bonta et al, the state of California is attempting to rewrite the history and legacy of Doctors in order to exclude the very originators of the title.
Doctor originally comes from the Latin verb “docēre,” meaning to teach. The earliest doctors were theological scholars in the catholic church. This was later more broadly applied to distinguished scholars, researchers, and teachers who were awarded PhDs (Doctor of Philosophy), the highest graduate award available by a university.
As PhDs are research-based degrees, they are often earned by those in academic settings looking to make innovations in their field of specialty. PhDs often take 6 to 8 years to earn after completing an undergraduate degree.
Sarah Erny received her PhD in Mind-body Medicine with a specialization in integrative mental health. In addition to her advanced courses like clinical psychopharmacology and contemporary neuroscience-psychology, she also had to generate new knowledge in her field through a written dissertation.
Dissertations, and the oral defense of the dissertation, are the final steps needed to earn a doctoral degree. They are typically 100 to 300 pages long and represent expertise in the given topic. The defense of a dissertation showcases the application of the research and how this contribution can be built upon in the future.
In the 12th century, the word physician (coming from the French word psychic meaning to treat or remedy) was used to differentiate those who administered medicine from surgeons. Physicians were often university educated, while surgeons were trained under barbers.
In the United States, the first medical degree was the Bachelor of Medicine, or M.B. followed by the Doctor of Medicine, or M.D. in 1770. These were known as professional degrees as they were focused on a given career’s skillset rather than a research field. There are currently several professional medical degrees in the United States such as:
After completing a bachelor’s degree, prospective MDs must graduate from an accredited medical school. Upon graduation, they are known as MDs but are not certified to practice until they complete a residency training program in their specialty which can take 3 to 7 years. As MDs are doctorate-level degrees, upon graduation they may also refer to themselves as a doctor.
Compared to PhDs and MDs, the Practice Doctorate in Nursing (DNP) is relatively new, gaining popularity in 2004 when the American Association of Colleges Nursing called for master’s-level preparation for APRNs to be phased out in favor of DNP preparation.
Similar to the MD as a professional degree, the DNP is a practice degree meaning it focuses on the practice of nursing rather than researching nursing. These degrees are often for nurses seeking advanced clinical practice roles and for taking on leadership roles in healthcare organizations.
There is currently a push to make DNP degrees a necessary requirement toward becoming an APRN. For potential DNPs with a bachelor’s in nursing, it would take an average of 4 to 6 years to earn a DNP degree.
There has always been controversy around the proper way to address doctors from different education and professional backgrounds. In 1913, the book The Etiquette of To-day attempted to codify this language, stating that medical doctors were to be referred to by name followed by MD while PhD holders are to be referred to more formally with the Dr. prefix before their name.
Some claim that medical doctors provide service not scholarship, meaning their title should be used in everyday life while research doctorates should be dropped outside of academic settings. They compare this to doctoral law degrees (JD) stating that “no sane person refers to layers as ‘doctor.’” However, this comparison ignores the fact that JD is a professional doctorate just like MD, making the two much more similar than either are to a PhD.
Others claim that the title of doctor should be solely used for MDs, citing a societal association between the two terms such as when someone has a medical emergency and people shout, “We need a doctor!” Ignoring the fact that no one with a PhD would lack the context to know if they were the kind of doctor in question, this association also ignores the many other kinds of health professionals that qualify in this example, such as nurses and EMTS, despite not being called doctors.
There biases between DNP vs MD degrees are likely impacted by gender. In 2023, only 12% of all licensed nurses were men and less than 40% of physicians were women. A nurse with 14 years of experience stated that as a “female-dominated career… these healthcare providers[nurses] essentially served as assistants to male doctors, caring for and cleaning up after patients.”
This bias even impacts MDs. One study found that when female physicians introduce male colleagues, they use his professional title 96% of the time, while male physicians introduce female colleagues, they only use her professional title 65.5% of the time. Another study found that female professionals were half as likely to be referred to by their last name compared to their male colleagues. This small change is associated with “lower judgments of eminence, status, and deservingness.”
Despite nurses spending most of their 12–hour shifts directly with patients each day, compared to a physician’s average of 13 to 24 minutes, their knowledge of their patients is often overlooked and undermined in favor of physicians.
Physicians normally take on a supervisory role in clinics, overseeing the work of many nurses and often in many clinics. However, studies have shown that granting nurses more autonomy leads to lower 30-day death rates.
This is not to undermine the value of physicians in healthcare or incite more strife of DNP vs MD degree holders, but rather emphasize that the best patient care comes from equitable collaboration between nurses and physicians. Placing status barriers between them does very little to improve health outcomes for their patients and instead creates hierarchies within the care team. These hierarchies create societal values that in turn inform the value of nurses and physicians which leads us back to Sarah Erny who despite earning her title of Dr. twice over was ruined over a perceived overstep in status.
As pointed out in Jacqueline Palmer et al v. Rob Bonta et al, the Physician and Surgeon certification referred to in section 2054(a) and issued by the Medical Board reads: “The Medical Board of California certifies that [NAME][,] a graduate of [MEDICAL SCHOOL][,] possesses the qualifications, education, and training prescribed by law and is hereby granted a license as a Physician and Surgeon entitled to practice medicine in the state of California.” Nowhere does this certification refer to the term Doctor or Dr. prefix.
As nurses continue to fight for recognition and respect within healthcare facilities, it seems they must also fight to use the very titles awarded to them by their education and experience. Regardless of the comparison of DNP vs MD degrees, nurses deserve to be heard and valued for their daily service to patients.
The future for states like California is unclear. Will they continue to push highly qualified nurses out of the state over a title that serves to recognize their continued commitment to delivering the best patient care possible? Or perhaps nurses like Jacqueline Palmer, Heather Lewis, and Rodolfo Jaravata-Hanson will show them that these laws do more harm than good.
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