California’s law on who can use the title ‘dr.’ threatens livelihoods of healthcare professionals

September 19, 2023 | By BRITTANY HUNTER
Nurse talks to patient

When Sarah Erny was born, her father took one look at his infant daughter and knew she’d be a doctor someday. He even wrote it down in her baby book. Some kids get toys for their birthday, but Sarah got MCAT prep books.

While it would be nearly 40 years before she went down the healthcare path, Sarah would eventually fulfill her father’s hope, earning a Doctorate of Nursing Practice (DNP)—the highest degree available in advanced nursing. As she embarked on her career, her patients and colleagues affectionately referred to her as “Dr. Sarah.”

But that endearing (and accurate) title would create a nightmare for Sarah after the Medical Board of California, the San Luis Obispo County District Attorney’s Office, and the Board of Registered Nursing came after her for violating a law that forbids Doctors of Nursing Practice like Sarah from calling themselves “Dr.,” even if they also clarify that they are nurse practitioners, thus jeopardizing her career and forcing her to leave the state.

Born to care

Sarah has always taken great pleasure in caring for others—a calling she heard early on in life.

As a newborn, she was adopted by her mother, who was a nurse, and her father, who was a paraplegic confined to a wheelchair. Sarah’s mom was the breadwinner of the family, so Sarah was raised by her father during the day. At a young age, she learned not only how to care for her father’s needs, but also to find great satisfaction in helping him.

When she speaks about her dad, who died when she was just 23, Sarah’s entire face lights up.

“You would forget he was in a wheelchair,” she recalls. “He was one of those people that didn’t look at disability as a problem, and we just go through life. It’s how I grew up in my mindset. I have a weird ability to look at disabilities and say, ‘Okay. But what can we do? What can we do with this?’”

Sarah grew up, married young, and had four children before getting a divorce. During her married years, her husband didn’t allow her to go to school, which limited her career choices. But at 38, Sarah found herself starting over. Sarah began working for an associate provost at the University of Kentucky, who pushed her to go back to school. She loved the idea, at least in theory, but she was almost 40 years old, and the idea of starting her career from scratch seemed unrealistic.

“You’re too old to go into nursing at 38,” she kept thinking to herself. But her boss assured her that her fears were untrue. At his encouragement, she took a chance, went back to school, and exceeded even her own expectations.

“I went to school at the University of Kentucky to get my bachelor’s and then went to Vanderbilt for my master’s and my doctorate,” she explains.

Sarah also remarried, this time to a man who supported her career ambitions.

Sarah felt called to go into healthcare. It was what her father had wanted for her. Besides, not only had Sarah’s adopted mother been a nurse, but her birth mother was as well. Following in their footsteps would allow her to honor their legacies.

The only conundrum she now faced was deciding which field to pursue.

“I sat and seriously looked at my choices,” she remembers. “Do I want to be a physician? Do I want to be a PA? Do I want to be a nurse practitioner?”

The choice became clear.

“I went the nurse practitioner route on purpose because I really believed that nurses looked at patients the way I would. I had already started to study herbalism, and so I was pretty jaded against a lot of stuff that happens in medicine. I got into functional medicine and autoimmune diseases, and the things that I work mostly with now.”

She and her husband moved to California to pursue her dreams.

For Sarah, helping her patients is about more than just diagnosing and sending them home with medication. That is not to say she is against medication; she just likes to look at the bigger picture and make sure she can see all angles of the situation.

“I love a puzzle,” she says. “And I love putting the puzzle together, and the patients need somebody that will do that.”

When it came to her patients, solving puzzles often meant treating the underlying issue of vitamin deficiencies and making sure her patients could correct those issues before doling out medication. And her patients loved her for this. In fact, she was so loved, at the height of her career she was treating about 650 people.

Sarah loved her work and was completely unprepared for what would happen next.

California’s bizarre “Dr.” ban

For some reason unbeknownst to her, an anonymous complainant contacted the state Medical Board  and reported Sarah for her use of the title “Dr.”

A directive baked into California’s Medical Practice Act makes it a crime for any healthcare professional other than licensed physicians or surgeons to call themselves “doctor” or put “Dr.” on signs, business cards, or letterhead, or in ads. Anyone caught violating this prohibition faces fines and loss of license.

The prohibition often is justified as helping to protect patients from fraud or injury. But the truth is that California’s restriction of the word “doctor” has nothing to do with patient protection. California is appropriating the word “doctor” for certain protected professions: licensed physicians and surgeons. Oddly enough, neither “Dr.” nor “doctor” appears anywhere on physicians’ or surgeons’ certificates issued by the state.

To say Sarah was confused would be an understatement.

“I had actually asked both the Nurse Practitioner Association and the board of nursing if it was okay [to use the title ‘Dr.’],” she says. “And they were like, ‘Well, just as long as you let everybody know you’re a nurse practitioner.’ Everything, every piece of anything that you will find on me had ‘Dr. Sarah Erny’ on it, but underneath was ‘Nurse Practitioner.’”

But these assurances were empty, as Sarah continued to face retribution for calling herself “Dr.”

California’s singling out for punishment Doctorates of Nursing Practice like Sarah is strange: The term “Dr.” is hardly exclusive to MDs. Chiropractors, veterinarians, and dentists often use the title, and accurately so. It’s also commonplace for PhDs in any field to refer to themselves as “doctor.” Yet, those professions are not being targeted.

Sarah wasn’t trying to hoodwink her patients.

“I’ve never presented myself as a physician,” she says. She uses the “Dr.” title because she’s proud to hold a Doctorate of Nursing Practice, a degree that empowers her to help patients. To her, California’s decision to go after her—even though countless others in the healthcare industry use the title—represents “a ridiculous line in the sand.”

Not only was Sarah’s license in jeopardy, but she was also being slapped with over $20,000 in fines.

As devastating as it was, Sarah and her husband decided to leave California and relocate to Washington state, where she received her license and could truthfully call herself “Dr. Sarah Erny, DNP” without running afoul of the law.

In the end, it’s Sarah’s patients who have suffered the most from California’s persecution of her. Many cannot afford to get the same level of treatment they received from Sarah prior to the state’s crackdown.

“My patients were the ones that paid the price,” Sarah says.

She now has more freedom to help patients in Washington, but it will take years for her to recover financially from the incident, and she has to rebuild her patient base from scratch.

“Long term, I’m not worried. Short term, I worry every month,” she says.

Despite all the setbacks, she remains optimistic, an attitude she adopted from her father.

“One of the lessons I learned from my dad is I’ll come out on my feet, no matter what,” she says. “I can reinvent myself again.”

Just because Sarah decided to leave California doesn’t mean she didn’t fight.

“I’m not afraid of confrontation,” she says. “I don’t like injustice. And like I said, the injustice I feel is more for my patients. I mean, I’m not happy with what happened to me. The [government] took a lot from me financially, emotionally, mentally. But that was not my biggest pain. It was the injustice for my patients.”

The government cannot hijack a commonly used word and reserve it for a narrow range of preferred jobs. Nor can it police the use of truthful language to limit career opportunities. People should be able to accurately describe themselves by their profession without government censorship.

If she could afford to hire a lawyer, Sarah would sue to recoup the losses she has suffered as a result of California’s enforcement actions against her.

Instead, Sarah is sharing her story to help Pacific Legal Foundation clients still in California, as their rights and livelihoods remain under threat so long as the state has the power to enforce the ban on the use of “Dr.” by anyone not a physician or surgeon.

PLF has filed suit on behalf of DNPs Jacqueline Palmer, Heather Lewis, and Rodolfo Jaravata-Hanson, seeking to vindicate their right to truthfully self-describe their credentials without risking their licenses or livelihoods.