Abstract
BACKGROUND
Physicians are concerned that patients are confused by the professional titles used by nonphysician practitioners.
OBJECTIVE
To assess how commonly used medical titles and specialty descriptors are understood by adult Californians in relation to the practitioner's actual training and qualifications.
METHODS
A 60-question multiple choice online survey was conducted on California adults aged 18 to 99 years. The survey was designed to yield a 3.0% margin of error. Given the demographic diversity of California, participants were sourced from multiple opt-in survey panels and balanced for age, income, gender/race/ethnic diversity, education, community type, geography, and political ideology.
RESULTS
A total of 1,033 subjects (24.6% response rate; 4,206 potential participants) met the inclusion criteria for the survey. Participants demonstrated significant confusion by the medical and specialty titles used by nonphysicians in California. Only 9% (N = 91) of participants correctly matched a practitioner's level of training and qualifications with the medical or specialty titles provided in the survey. The understanding of medical titles also varied between age groups and across geographic locations in the state. Of the participants, 88% supported legislation to restrict the use “doctor” and “-ologist” terms to physicians only.
CONCLUSION
The results underscore the need for California to provide additional regulation and legislation regarding title transparency.
In modern health care systems, patients interact with various types of practitioners including physicians, medical/surgical subspecialists, certified registered nurse anesthetists (CRNAs), and other non-physician practitioners (NPPs). Although each practitioner is important for delivery of excellent patient care, there are significant differences in their training and education.
Surveys have found that patients frequently mistake a NPP for a specialty-trained physician.1,2 When this happens, patients may express feelings of anger over the misperception/perceived deception, as well as diminished trust in the health care system.3 In addition, this breach of trust erodes the patient–clinician relationship, adversely impacting adherence to treatment plans and overall health outcomes.4 These negative effects could be amplified among vulnerable groups, for example patients from lower socioeconomic backgrounds or those with language barriers.5
Complicating this issue has been the growing adoption of “Doctor/Dr.” titles and other medical specialty descriptors (“-ologist” terms) by some NPPs in clinical settings.6 This trend has the potential to create further patient confusion about the education, credentials, licensure, and level of training of their caregiver. This is of particular concern in specialties such as dermatology and anesthesiology where NPPs are frequently employed. Indeed, the issues of “Title Transparency” and medical “Truth-In-Advertising” have become top advocacy priorities for the American Academy of Dermatology (AAD), American Society of Dermatologic Surgery Association (ASDSA), California Society of Anesthesiologists (CSA), and the American Society of Anesthesiologists (ASA).
In California, only physicians can legally use the term “Doctor” or “Dr.” prefix in clinical and public settings without further elaboration of their educational credentials.7 California's Business & Professions Code (BPC) section 2278 allows nonphysicians to use the term “Doctor”; however, they must disclose the degree they hold next to their name (i.e. Ph.D., DVM, DNP, etc.). However, the use of medical specialty titles by NPPs is far less regulated in California. As such, some NPPs are operating under professional titles traditionally used by physician specialists such as “Naturopathic Dermatologist,” “Naturopathic Oncologist,” “Nurse Cardiologist,” “Nurse Intensivist,” “Naturopathic Pediatrician,” or “Nurse Anesthesiologist.”8–11
Recognizing that medical titles are being used by NPPs in California, the authors conducted a survey to assess the perception and understanding of such titles among California adults.
Methods
The authors collaborated with Seven Letter Insight, a national market research firm with extensive experience in California polling and demographic analysis to create the survey. A list of 60 survey questions was generated by the research firm and finalized by the authors. Study participants were presented with multiple choice questions about their knowledge, perceptions, and preferences of various clinical scenarios. The online survey was active from October 31, 2023 to November 7, 2023. Potential participants were sourced from hundreds of incentivized opt-in survey panels across California. The survey was conducted using nonprobability sampling of online panels of English and Spanish-speaking adults aged 18 to 99 years. The panels were balanced for age, income, gender/race/ethnic diversity, education, community type, geography, and political ideology. Given the large population of the state, the survey was designed for sample size of 1,000 participants with a goal of a 3% margin of error at the 95% confidence level interval. To determine the margin of error, the normal approximation for large samples approach was used and set to the 95% confidence level.
Results
A total of 4,206 potential participants were initially contacted resulting in 1,033 completed surveys meeting the inclusion criteria for analysis (24.6% response rate, Figure 1). The majority indicated that they had previously encountered physicians (88%), nurse practitioners (70%), or physician assistants (63%) in medical settings. To assess their understanding of the titles used by clinicians, participants were asked about their sentiments and preferences when presented with various hypothetical practitioner titles, abbreviations, and clinical scenarios.
Figure 1.
Study demographics.
Participants were asked for their preference to see a “doctor” or a “physician” for their health care—32% of respondents preferred a “doctor,” 20% indicated a “physician,” and 23% indicated no preference. Of those surveyed, 24% indicated there was no difference in the meaning between these two terms. Responses to this question varied geographically, with women and coastal residents more likely to report no meaningful difference between these two terms. Alternatively, Los Angeles County residents were more likely choose a “doctor” over a “physician” for their care.
When asked for their preference to see a physician versus a nurse practitioner for their medical care, 62% preferred a physician, 10% a nurse practitioner, and 27% indicated no preference. In addition, 2% of participants, particularly those from rural communities, did not perceive a difference between these types of practitioners.
When presented with a scenario of a new skin lesion, most participants (65%–76%) preferred to see a dermatologist for their care. A small number of participants (3.4%) felt there was “no difference” between a “dermatologist,” a “nurse dermatologist,” or a “dermatological nurse.” Of the participants, 25% indicated that they would not be comfortable seeing a nurse practitioner for their dermatologic needs.
Similarly, 70% of participants preferred a physician to administer their anesthesia compared to 7% for a “nurse anesthesiologist.” A majority of the respondent (55%) preferred receiving anesthesia from an anesthesiologist versus 8% from a “nurse anesthetist.” A smaller number, 4% of participants indicated there was “no difference” between an anesthesiologist, a “nurse anesthesiologist,” or a “nurse anesthetist.” Half of the participants (50%) reported that they would not be comfortable with a nurse practitioner administering their anesthesia.
An overwhelming majority (91%) of adults felt that an accurate understanding of the title(s) and qualifications of their clinician(s) was essential for providing their informed consent to receive care. A large number (76%) believed it was very or extremely important to know the training, education, and licensure of their practitioner. During a medical visit, 79% indicated it was very or extremely important to know the type of health care provider they see and 63% believed it was important to be informed whether they were being treated by a physician or nurse practitioner.
Participants were also asked to correctly match medical credential abbreviations to the corresponding practitioner type. Although most individuals were confident that an “MD” is a physician, their uncertainty increased dramatically when presented with other clinician abbreviations (Table 1). Most participants (91%) failed to correctly identify a physician from a nonphysician using the credential abbreviations provided in the survey.
TABLE 1.
Which Title Identifies a Physician?
| Definitely % (N) | Probably % (N) | Don't Know % (N) | Probably Not % (N) | Definitely Not % (N) | |
| CRNA | 8.0% (82) | 14.0% (143) | 34.0% (347) | 16.0% (164) | 27.0% (276) |
| DNP | 11.0% (112) | 18.0% (184) | 37.0% (378) | 16.0% (164) | 18.0% (184) |
| DO | 26.0% (266) | 17.0% (174) | 34.0% (347) | 14.0% (143) | 10.0% (102) |
| FNP-C | 4.0% (41) | 15.0% (153) | 41.0% (419) | 19.0% (194) | 21.0% (215) |
| MD | 71.0% (726) | 12.0% (123) | 10.0% (102) | 4.0% (41) | 3.0% (31) |
| NP | 11.0% (112) | 17.0% (174) | 29.0% (296) | 16.0% (164) | 27.0% (276) |
| PA | 15.0% (153) | 20.0% (204) | 26.0% (266) | 15.0% (153) | 24.0% (245) |
Practitioner misidentification was also observed when participants were asked to identify physicians from nonphysicians using medical specialty titles and descriptors in current or proposed use (Table 2). Of the participants, 65% felt that nonphysician use of these titles made it more difficult and confusing to distinguish nonphysicians from physicians. Only 56% and 41% percent of participants, respectively, confidently identified a dermatologist and an anesthesiologist as physicians.
TABLE 2.
Which Degrees Are Physicians?
| Definitely% (N) | Probably % (N) | Don't Know % (N) | Probably Not % (N) | Definitely Not % (N) | |
| Aesthetic Surgeon | 45% (460) | 26% (266) | 8% (82) | 13% (133) | 7% (72) |
| Anesthesiologist | 41% (419) | 22% (225) | 8% (82) | 18% (184) | 10% (102) |
| Dermatologist | 56% (572) | 22% (225) | 6% (61) | 12% (123) | 5% (51) |
| Doctorate Nursing Practice | 19% (194) | 23% (235) | 10% (102) | 30% (307) | 19% (194) |
| Medical Doctor | 76% (777) | 17% (174) | 2% (20) | 3% (31 | 1% (10) |
| Naturopathic Doctor | 37% (378) | 23% (235) | 12% (123) | 19% (194) | 10% (102) |
| Nurse Anesthesiologist | 11% (112) | 21% (215) | 9% (92) | 28% (286) | 31% (317) |
| Nurse Dermatologist | 11% (112) | 17% (174) | 8% (82) | 30% (307) | 33% (337) |
| Nurse Pediatrician | 14% (143) | 20% (204) | 9% (92) | 27% (276) | 30% (307) |
| Nurse Practitioner | 13% (133) | 22% (225) | 8% (82) | 24% (245) | 33% (337) |
| Optometric Surgeon | 56% (572) | 21% (215) | 8% (82) | 12% (123) | 4% (41) |
| Physician Assistant | 15% (153) | 24% (245) | 6% (61) | 26% (266) | 29% (296) |
| Physician Associate | 17% (174) | 26% (266) | 10% (102) | 28% (286) | 19% (194) |
Rates of practitioner misidentification increased when participants were shown non-physician titles such as “Physician Associate” and “Doctorate of Nursing Practice.” Correct identification of non-physicians decreased from 29% to 19% by changing the title of “Physician Assistant” to “Physician Associate” and 33% to 19% by changing “Nurse Practitioner” to “Doctor of Nursing Practice.” Rates of practitioner misidentification remained high even after attaching a “nurse” prefix to the title to help identify the clinician with 69% and 67% of participants, respectively, still unable to correctly identify a “nurse anesthesiologist” or “nurse dermatologist” as a nonphysician. The survey also revealed that clinician misidentification was particularly problematic for participants with less formal education and/or English-proficiency.
When presented with information regarding medical “Truth-in-Advertising” laws in other states, 88% of respondents supported enacting similar legislation in California to limit the use of doctor and medical specialty (“-ologist”) titles to physicians only. Most participants (79%) supported the idea of specifically prohibiting non-physicians from using these terms in medical settings. Virtually all (91%) respondents supported laws mandating accurate disclosure of the clinician's title(s) and qualifications when obtaining informed consent.
In the context of encountering harmful or misleading medical “misinformation” online, 97% of participants believed that it is essential to have accurate information about the health care practitioner who provides information in this manner. Most (89%) respondents indicated that their ability to make informed medical decisions could be compromised if the practitioner's title inaccurately characterized or even exaggerated the capabilities of the practitioner.
Discussion
The complexity of health care systems in California requires the contributions of physicians and NPPs working as a team to provide excellent patient care. But concerns have emerged regarding the risks to patient safety from the increasing use of NPPs in health care, owing to their abbreviated clinical training.12 Among these concerns, the adoption of doctoral and medical specialist titles by NPPs is increasingly encountered. In addition to potentially compromising patient–clinician trust, the use of these titles by NPPs can make it more difficult for patients to discern physicians from NPPs. In the worst instance, patients may receive substandard care, or become injured, by a practitioner whose title(s) misled the patient to believe that the clinician had greater qualifications than they possessed.13,14
Many states have enacted laws governing the use of “doctoral titles,” but some states have recently strengthened their statutes in response to NPP use of specialty (“-ologist”) titles/terms in medical settings. Medical “Truth-in-Advertising” legislation has been enacted in Tennessee (HB-2451, 2024), Georgia (SB197, 2023), and Indiana (SEA239, 2022).
In California, the effectiveness of a medical title transparency law hinges upon a person's understanding of the type of practitioner and the titles they use. This is because in California, the determination of an illegal title representation relies upon a “reasonable person's interpretation” of the facts of the case. The relevance of this point was probed in the design of the authors' survey to examine the perceptions/impacts of title misappropriation by NPPs, as well as the way adults in California understand medical titles/terms.
The authors' survey revealed that adults are substantially confused by the medical and specialty titles used by NPPs in California. Only 9% of study participants correctly identified physicians from NPPs using a list of professional credential abbreviations. Participants reliably identified a “MD” as a physician, but a wide range of “probable” and incorrect answers were given when they were shown other titles such as a “DNP,” “CRNA,” “PA,” and “FNP-C.” The ability to identify a physician from a NPP diminished when a medical title contained words such as “doctor,” “doctorate,” or “physician associate.”
Some of this uncertainty might be explained in part by the ubiquitous use of the terms “physician” and “doctor” in common language. In California's large urban centers, the authors observed that these terms seemed synonymous, but for regulatory purposes, the California BPC handles them quite differently. Given the disconnect in the use/meaning of these words, it is possible that even appropriate credential qualification by NPPs who address themselves as “doctor” may be insufficient to distinguish them as nonphysicians to patients.
The authors also found significant confusion with medical specialty descriptors (“-ologist” terms). This confusion persisted across the various demographics in the survey including level of education and income. Unlike “Doctor/Dr.” titles, there is much less clarity about the practitioner's level of training from “-ologist” terms. None of these descriptors (i.e. Nurse Anesthesiologist) carry a corresponding Medicare taxonomic code, and none are recognized as occupations/professions by any state or federal licensing body.15 In clinical settings, these hybrid titles resemble those used to identify physicians and that is perhaps why patients are so confused by them. Indeed, Webster's Dictionary defines medical specialists as “Medical doctors who practice a particular medical specialty.”16 The AMA defines the term physician as “limited to those people who have a Doctor of Medicine, Doctor of Osteopathic Medicine, or a recognized equivalent physician degree and who would be eligible for an Accreditation Council for Graduate Medical Education (ACGME) residency.”17 The authors found that most Californians were unable to use common medical titles to accurately categorize clinicians without additional explicit information being provided. These findings are consistent with prior studies of medical titles. An Indiana study in 2021 found similar issues in their state.18 Similarly, a Minnesota study in 2021 demonstrated that most adults were very unfamiliar with 14 medical specialties that were surveyed.19 In an AMA study, only 50% of those surveyed felt it was easy to identify who is a physician using their medical specialization, title, or other licensing credentials.20
The findings in the authors' study suggest that current California regulations on medical titles may be inadequate to give patients the information they need to make appropriate and informed health care decisions. New laws to minimize patient confusion should require all health care professionals to accurately identify their level of training and professional license in all communications, including medical badge identification. Advertising for health care services should be free from deceptive or misleading information. Additional measures should include restricting the use of the term “doctor” to physicians when in medical settings because of how patients use “physician” and “doctor” interchangeably in everyday language. Confusion can also be reduced by specifically prohibiting nonphysicians from using medical titles or specialty designations traditionally restricted to or associated with licensed physicians, for example “dermatologist” or “anesthesiologist.” One way to do this is to link specialty designations to commonly identified standards such as licensure status or ABMS/AOA certification. Finally, information campaigns should be created to truthfully educate the public on the training and qualifications of the various health care practitioners and their credentials.
Conclusion
Accuracy in medical titles is critical, and words matter. Medical titles communicate the practitioner's capabilities and expertise to patients. Public confusion over clinician titles is significant and problematic in California. These results underscore the need for comprehensive and unambiguous title transparency legislation in California.
Limitations
This study was limited to California adults, and the results may not be generalizable to the rest of the nation. The authors' survey was conducted online, and different results might be obtained using other survey methods/formats. Different results might be obtained had the survey had been conducted at other times of the year, such as at year-end or during open-enrolment period.
In terms of response rate, there is some concern regarding the relatively modest response rate obtained. Although a lower response rate does not necessarily equate to nonrepresentative findings, to address potential bias from the response rate, weighting to demographic markers was used to ensure that the final sample reflects the demographic and professional distribution of the population of California.
Acknowledgments
This survey was jointly funded by the California Society of Dermatology and Dermatologic Surgery, the California Society of Anesthesiologists, and the American Society of Anesthesiologists. The opinions expressed are strictly those of the authors. The authors appreciate the contributions of Paul Davis, PhD, Jack Resneck, Jr., MD, in preparing this manuscript.
Footnotes
The authors have indicated no significant interest with commercial supporters.
Contributor Information
Elan M. Newman, Email: elannewmanmd@gmail.com.
Philip R. Levin, Email: plevin36@icloud.com.
Christina M. Menor, Email: cmenor33@gmail.com.
Antonio Hernandez Conte, Email: sedated@bellsouth.net.
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