Medicine without doctors? State laws are changing who treats patients.

Arlene Wright is a doctor, but she doesn’t want people to call her one.

“I usually tell my patients ‘your majesty’ or ‘your highness’ is fine,” she said.

Wright has been a nurse for more than 20 years in Fort Myers, Florida. She began working in hospitals as a teenage candy striper in Upstate 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.

Still, when Florida lawmakers began considering a bill that would have prevented her from using her title, Wright was taken aback.

“I’ve never abused or borne witness to anyone abusing their title,” she said. “It’s singling people out, creating a bad atmosphere through legislation for the actions of a few.”

The Florida bill would have prevented non-physicians from using several titles such as doctor of medicine, physician, medical resident and hospitalist. (Gov. Ron DeSantis vetoed it in June.) 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 nondoctor medical professionals’ work, the American Medical Association (AMA) says, noting that it and allies have put millions of dollars into fighting back. More than half of states no longer require a physician to sign off on the work of a nurse practitioner, who can have as little as 10 percent 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 they do so—is a question that is 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 health-care system while rarely or never seeing a doctor.

“Individuals have taken 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 itself puts it more bluntly: “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 program began in 1965, it sought to supplement doctors’ work.

“The PNP was not a substitute for the physician,” nurse Loretta C. Ford, who co-founded the country’s first nurse practitioner training program, 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 United States, and they have long pushed for independence.

For decades, 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 and Washington, D.C., do.

As nursing organizations were busily spreading their message, doctors groups were comparatively quiet, said Carmen Kavali, a Georgia-based plastic surgeon who has been involved in policy debates since she was a medical student. Kavali 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 of the AMA’s position.

But state lawmakers were quickly swayed. The nurse practitioners had produced studies showing they could treat patients safely—particularly in primary care settings—and had shown them to legislators all over the country.

Much of that research is robust, said economist Bianca Frogner, who leads the University of Washington’s Center for Health Workforce Studies. The National Academy of Medicine concluded more than a decade ago that advanced-practice nurses should be allowed greater autonomy.

“Rather than blaming the nurse practitioners for filling in some gaps where they’re certainly needed, we should be asking why we can’t get enough physicians into some of these communities to begin with,” Frogner said.

‘Assertions of authority’

While nursing groups often cite “50 years of research” in their favor, doctors’ groups marshal their own arguments.

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 license practitioners continue to attempt to practice medicine and rely on false assertions of authority,” one proposal to the AMA in 2006 reads.

The American Association of Nurse Anesthesiology responded that the resolution relied on “witch-hunt logic” and “McCarthyistic tactics.” As doctors fight scope-expansion bills, nursing professionals have said physicians are trying to protect their turf—and their higher salaries—at patients’ cost.

Independent-practice proposals have become pricey for nurses and doctors alike. Since 2006, the AMA partnership has awarded more than $3.5 million to groups working on the issue.

As medical lobbies have spent, governors and state legislators have collected.

Groups supporting DeSantis (R) received hundreds of thousands of dollars from medical groups in the 2022 election cycle, including at least $125,000 from the Florida Medical Association and tens of thousands from groups representing optometrists, nurse anesthetists and chiropractors. Professional groups for doctors, optometrists, chiropractors, and pharmacists also number among donors who support Georgia Gov. Brian Kemp (R).

In North Carolina, as state legislators considered expanding nurses’ authority, health-care groups and individual physicians paid them. A pro-physician group called NC Citizens for Patient Safety donated $138,000 to Tim Reeder (R) in 2022 as he ran against one of the bill’s sponsors, state Rep. Brian Farkas (D), a North Carolina Health News analysis found. Reeder, an MD, beat Farkas by 354 votes and has become one of the nursing bill’s most vocal opponents, the Carolina Journal reported.

The back-and-forth lobbying in statehouses has tired some state lawmakers, according to Kavali, the Georgia plastic surgeon.

“They told us: ‘We’re tired of hearing this. Can you all just stop bickering?’ We’re not bickering,” Kavali said. “We’re trying to protect patients here.”

An economics working paper published by the National Bureau of Economic Research compared physician- and nurse-practitioner-led care in more than 1 million emergency room visits to Veterans Affairs hospitals, where nurse practitioners can practice without physician approval. The study found that being seen by a nurse practitioner increased the length of hospital stay by 11 percent.

The majority of 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 such as Botox and beauty services. There’s less research about how nurse practitioners perform compared with doctors in these specialized areas, though up to 90 percent of nurse practitioners are trained in primary care, said Stephen Ferrara, president of the American Association of Nurse Practitioners.

Doctor groups say the longtime national standard of 500 clinical hours for training nurse practitioners isn’t enough, especially as online nursing programs 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.

‘Why did I go through all that school?’

Rebekah Bernard’s parents were registered nurses. She grew up playing in the hospital day care and eavesdropping while they talked about patients on the drive home.

They often warned her, “Whatever you do, don’t be a nurse,” Bernard recalled. The job was too difficult, they said.

Bernard went into medicine anyway, becoming a family physician in 2002 and starting a six-year stint working in rural Florida.

There, she was newly out of residency and tasked with supervising a nurse practitioner and a physician associate. Each had their own patients, though Bernard checked her colleagues’ decisions.

“How could they do things the same as me? Why did I go through all that school?” Bernard said she remembers thinking.

Years later, Bernard found a group of doctors who had the same concerns. What started as a social media discussion has become an advocacy group called Physicians for Patient Protection; Bernard is its president. It’s one of several organizations dedicated to advocating for physician supervision of nurse practitioners and physician associates, from state medical groups to Reddit forums.

The issue animates many nurse practitioners, too.

Dwayne Hooks, who teaches and works as a nurse practitioner in Georgia, said he has long believed nurse practitioners can deliver primary care as good or better than that of doctors.

Just as a primary care physician would refer a patient to a specialist, Hooks said, nurse practitioners can seek another opinion when cases go beyond their expertise. The main difference between primary care doctors and nurses, he said, is that the latter brings a “nursing philosophy” that is more holistic and treats patients more individually than physicians might.

“Nurse practitioners develop these relationships with patients to be able to treat them as the individual and have the patient as the center of the universe,” Ferrara said.

A lack of rural care

Doctors, nurse practitioners and their representative bodies all say they want to do what’s best for patients.

Fifty million 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.

Kavali said instead of turning away from doctors, the government should increase the federal cap on Medicare-funded residency spots and further incentivize work in underserved areas. Ferrara said nurse practitioners can fill those roles immediately, if states allow.

Nurse practitioners are expanding their practice ability to new places nearly every year. Nursing training programs, including doctoral ones, have also ballooned, meaning there will be many more nurses with the “Dr.” title.

For nurse practitioners such as Hooks and Wright, these trends represent a recognition of what nurse practitioners have always been qualified to do.

To physicians such as Kavali and Bernard, it means for many Americans, seeing a doctor may be out of reach.

“A lot of patients really have no idea. They just see somebody in a white coat,” Bernard said.