Analysis: Nurse Practitioners With Doctorates Sue to Gain the Title “Doctor” in California

A Defensive Maneuver

Uncertainty About Medical Titles

As we describe in several articles here on NPSchools.com, both nurse practitioners and physicians play vital roles in modern healthcare. And even though both of these professions diagnose and treat patients within primary care settings, their training is different. They progress through separate educational programs that lead to clearly defined roles in care delivery. 

For example, nurse practitioners must earn master’s degrees and complete advanced training beyond their registered nurse credentials—and in some jurisdictions like California, physicians also need to supervise their practices. 

By contrast, physicians must complete four years of medical school, followed in most cases by graduate medical residency programs. These residencies typically require about five additional years of training for most specialties, such as cardiology, pulmonary medicine, or orthopedics. 

However, many patients seem uncertain about the training of their healthcare professionals. An interesting footnote in the complaint filed against Erny by the district attorney in San Luis Obispo County describes this confusion: 

Nationwide studies indicate the uncertainty of medical titles. See the American Medical Association’s “Truth in Advertising.” Patients are unsure who is—and who is not—a physician. A survey found that 39 percent of the public believe a Doctor of Nursing Practice was a medical doctor. It also found that 19 percent of the public believed a Nurse Practitioner was a medical doctor.

Adding to the uncertainty, many of the categories of healthcare professionals listed in this 2020 AMA survey who practice in California but never earned MD degrees also happen to use the “Doctor” designation. They include dentists, orthodontists, podiatrists, optometrists, and clinical psychologists. 

Nevertheless, a strict reading of the BPC § 2054(a) statute suggests that it’s against the law for anyone who isn’t a physician or surgeon to refer to themselves as “Doctor.” Here’s that key language: 

Any person who uses in any sign, business card, or letterhead, or, in an advertisement, the words “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 under the terms of this or any other law, or that he or she is entitled to practice hereunder, or who represents or holds himself or herself out as a physician and surgeon, physician, surgeon, or practitioner under the terms of this or any other law, without having at the time of so doing a valid, unrevoked, and unsuspended certificate as a physician and surgeon under this chapter, is guilty of a misdemeanor. 

“If you read the law literally, it appears to prohibit even PhDs and university professors from using the title,” said Donna Matias. She’s one of the attorneys at the libertarian Pacific Legal Foundation representing Palmer and her co-plaintiffs. 

And although several states regulate how professionals might use this designation, Matias told the Washington Post that California’s statute is the most restrictive of all these statutes across the nation. 

Note also that the statute doesn’t only set forth civil penalties. This is a criminal statute, saying that anyone who uses these titles in the unlawful ways specified is guilty of a misdemeanor. Yet we rarely, if ever, hear of clinicians like dentists or podiatrists who face prosecution in California or in any other state for referencing themselves as “doctors”—a practice that American society generally condones.

Given this disconnect between the statute’s language and the infrequency of prosecution for all these other professionals, one has to wonder about an important question: Have county prosecutors, working under the direction of California’s Attorney General Rob Bonta, started to target nurse practitioners who hold doctoral degrees? Analyzing Erny’s complicated case in more depth helps yield clues.

“That is Just Not Allowed”

In 2018 Sarah Erny earned a doctorate of nursing practice (DNP) degree from Vanderbilt University in Nashville, one of the highest-ranked healthcare campuses in the world. Soon after, she started practicing functional medicine as a nurse practitioner in San Luis Obispo. 

In 2022 a citizen complained to authorities that Erny had been representing herself as a physician, and an investigation by county and state officials quickly followed. In a now-removed interview on YouTube, she says: 

I have never ever, ever represented myself as a physician. My patients all knew I was a nurse practitioner; it’s the first thing I say when I come in the door in the very beginning. My patients were the ones that started calling me Dr. Sarah because they were proud of me for getting the degree, and they wanted me to own it. . .

I had a clinic on my own as far as practice goes, and we used the term “Dr. Sarah,” and that’s when things went awry.

“I actually have spent a lot of time researching this,” says Tampa attorney Scott Rattigan, a litigator admitted to practice in the federal court system who works with healthcare clients. “She started referring to herself as Dr. Sarah or Dr. Sarah Erny both to her patients, on her website, and on all of her social media posts. And that is just not allowed.”

Page 7 of the district attorney’s complaint presents an example of one of these references from Erny’s website. It depicts a screenshot image of a Google search results listing that includes “Dr. Sarah Erny” not once, but twice—in the page’s title and the first line of the description. But nowhere in this language do we find essential clarifying phrases like “nurse practitioner” or “NP” or “doctor of nursing practice” or “DNP” that would lead one to expect that she’s not a physician. 

Google did not create this language—it was created deliberately by Erny, since Google typically captures character strings directly from the web page HTML code’s “Title” and “Description” meta tags. Adjusting the text in those tags will adjust the search result’s language shown to viewers. And on Google, which controls more than 90 percent of the overall market share for search, millions of people could view such a result. “Commercial digital search engines such as Google can populate search results to capture Defendant’s title as ‘Dr. Sarah Erny.’ As a result, the public is misled to believe that Defendant is a medical doctor,” says the complaint.

Erny’s settlement also requires that she regularly perform the following steps: “Conduct electronic searches of ‘Sarah Erny’ to determine if any third-party medical provider digital platform is advertising or listing Defendant as ‘Doctor’ or by the prefix ‘Dr.’ and to make diligent efforts to remove these references. Such searches shall occur monthly the first year. . .”

However, during our research for this article in August 2023—ten months after her stipulated settlement agreement—we still found a listing for Erny on the popular third-party medical provider platform Healthgrades. 

Indeed, that listing still displayed her name as “Dr. Sarah Cole Erny, DNP” and although it clearly states that she’s a nurse practitioner, the language of her settlement agreement nevertheless does not allow her to use the “Dr.” designation. 

Of course, California will probably not be able to enforce the settlement because, to avoid further penalties like delicensing, Erny has since moved to Washington State and opened a new practice.

Policy Objective: Encouraging Transparency

Erny’s complaint suggests that she may have repeatedly referenced herself as Dr. Sarah Erny, Dr. Erny, or Dr. Sarah in hundreds of instances while failing to clarify that she is a DNP and not a physician. Accordingly, it’s probably not reasonable to suspect that California might be targeting nurse practitioners with doctoral degrees based on the actions of the officials in this single case.

In fairness to Erny, it’s important to point out that she claims to have called both the California Board of Registered Nursing as well as the California Association for Nurse Practitioners upon moving to the state from Kentucky to ask about guidelines for using designations like “Doctor.” She says that both of these organizations gave her incorrect advice about what language was permitted under California law and administrative regulations.  

Nevertheless, these instances do suggest a pattern of behavior on the part of Erny that indicates a lack of transparency. Moreover, Rattigan points out that encouraging transparency into the education, training, and experience of healthcare practitioners seems to be the overriding policy objective of regulators, prosecutors, and courts across the nation when faced with cases like hers. He adds:

Misrepresenting yourself is misleading to the public. . .However, in the medical profession, you need to be very careful to not mislead the public. Not only can you mislead the public by falsely calling yourself “Doctor,” but also you can mislead them in other ways. 

For example, Iʼm certainly not going to call myself Dr. Scott and wear a white coat and stethoscope on my website, giving the impression Iʼm a medical doctor when Iʼm a lawyer. You need to state the discipline you received your PhD in.

How DNPs Can Avoid Prosecution

Finally, since this story broke, other lawyers besides Rattigan have weighed in with their analysis of the steps that doctoral nurse practitioners, their practice collaborators, and their clinical organizations all need to take if they want to avoid prosecution. For example, healthcare attorneys Rebecca Hoyes and Annalee Lee with the AmLaw 100 firm Polsinelli LLP in San Francisco offer this advice: 

Healthcare professionals and healthcare organizations should be cognizant of how the term is being [used] in their workplace to avoid unwanted disciplinary actions or fines unless and until the law about using the term “doctor” has been altered. 

Permitting nurses to reference themselves as doctors may impact a patient’s expectations regarding the level of care they are receiving. This could become an issue should a malpractice lawsuit arise. 

Additionally, misleading use of the term “doctor” by a professional or organization could be considered a violation of the law relating to false advertisement, which makes it a misdemeanor to disseminate untrue or misleading statements, or could be considered aiding and abetting the unauthorized practice of medicine. 

Editor’s Note: NPSchools.com uses “Dr.” for all interviewees and contributors with doctoral degrees (DNP, MD, PhD, EdD, etc.) to pay respect to their academic achievement.