Use of the Doctor Title In Clinical Settings

The clinical title of “doctor” was, for many years, synonymous with physician. However, this is no longer true. A number of clinical disciplines have moved towards doctorate-level training as a requirement for clinical practice and licensure. Clinical psychologists, chiropractic physicians, optometrists and pharmacists are doctorate-level providers. Currently, nurse practitioner and anesthetist programs and physical therapy programs also are moving in this direction.

In each case it has been argued that these increasing levels of training are necessary, given the increasing complexity of medical practice. Others have cogently asserted that such requirements are simply a heightened barrier to limit entry into the field with adverse economic consequences to the cost of health care. Regardless, it is clear there is a proliferation of nonphysician “doctors” in the clinical environment. The potential confusion to patients is compounded by the quiet displacement of physicians in primary care settings by advanced practice clinicians.

Recently resolutions 211 and 232 of the American Medical Association House of Delegates asserted (1) that confusion, injury and a breakdown of quality medical care would result from persons not trained as medical doctors and doctors of osteopathy misrepresenting themselves as doctors in clinical settings, (2) that the quality of care rendered by individuals with the nurse doctoral degree is not equivalent to that of a physician and (3) that nurses and other nonphysician providers who hold doctoral degrees and identify themselves to patients as doctors will create confusion, jeopardize patient safety and erode the trust inherent in the true patient-physician relationship. In so doing they resolved to pursue a course of action to counter such misrepresentation by nurse doctoral programs, their students and graduates.^1,2 Additionally, by 2007 seven states had statutes or regulations prohibiting a nurse practitioner from using the “doctor” title.³

Clearly this is a topic fraught with passion and controversy. With prior similar such controversies as the legitimacy of chiropractic medical practice, the role of physicians in the debate was often seen as protectionist and imbalanced. It will be regrettable if this historical pattern is repeated.

Health care professionals who earn a doctorate in a recognized field of scholarly and clinical endeavor merit the title “doctor.” At the same time there must be clear and effective safeguards in place to protect patients and to assure appropriate disclosure of credentials and training. At a minimum printed materials such as letterhead, business cards and brochures should be unambiguous. Labeling of white coats and ID badges similarly should be forthright. Guidelines for appropriate advertising also should be adopted.

The practice by some states of appending the title doctor to license types below the doctorate level must be discontinued. For example, licensure of an acupuncturist in the state of Rhode Island⁴ does not require doctoral level training but the license designation is “Doctor of Acupuncture.” Similarly, honorary titles, even when awarded by academic institutions, have no place in clinical settings. The title “doctor” may not be synonymous with physician but it must connote achievement of an actual doctorate in a recognized clinical discipline.

State medical and nursing boards have the obligation to speak authoritatively and introduce balance and reasonableness into what must be a national dialogue. The Federation of State Medical Boards has the opportunity to foster the development of a uniform national standard through the development of model guidelines with collaboration from other stakeholder groups.