A federal district court ruled that California may prohibit nurse practitioners with doctoral degrees from using “doctor” or “Dr.” in the ways covered by statute, finding the restriction protects patients from misleading advertising about provider qualifications. Judge Jesus G. Bernal of the US District Court for the Central District of California denied the nurse practitioners’ motion, granted the state’s, and upheld Business & Professions Code § 2054.
Section 2054 makes it a misdemeanor for anyone without a physician’s license to use “doctor,” “physician,” the prefix “Dr.,” or other terms implying physician status (1) “in any sign, business card, or letterhead, or, in an advertisement,” and (2) “in a health care setting that would lead a reasonable patient to determine that person is a licensed ‘M.D.’ or ‘D.O.’”
Three nurse practitioners with Doctor of Nursing Practice (DNP) degrees—Jacqueline Palmer, DNP; Heather Lewis, DNP; and Rodolfo Jaravata Hanson, DNP—brought a First Amendment challenge seeking to use “Dr.” while disclosing they are nurse practitioners, not physicians.
The court credited evidence of patient confusion. Patients have assumed Palmer was a medical doctor; she agreed that some people take “doctor” to mean physician and that DNPs’ use of “doctor” without clarification makes it less clear for patients whether they are medical doctors. Hanson testified he ensures patients know he is not a physician if they call him “Dr.”
Judge Bernal analyzed the challenged uses as commercial speech and applied the Central Hudson framework. He held California has a substantial interest in protecting consumers from misleading advertising and concluded § 2054 directly advances that interest and is a “reasonable fit” to it.
On program differences, the court relied on the record for these plaintiffs' DNP programs: all three programs were online with no in-person classes; for these plaintiffs, the programs had no courses in anatomy, biology, biochemistry, immunology, physiology, pathology, or pharmacology; and some DNP programs can be as short as one year. Palmer also recalled her admissions requirements as having a master’s degree and “writing a paper about why she wanted to be a DNP.”
The court noted scope of practice does not change with the DNP credential: “There is nothing that a nurse practitioner that has a DNP can do that a nurse practitioner that does not have a DNP cannot.” All three plaintiffs became NPs before obtaining their DNPs.
Marketplace effects also figured in the record. Hanson testified he believes “he will attract more patients if he can call himself ‘Dr. Hanson’… because ‘[i]f patients were given the opportunity to pick between two clinics, one with Dr. Hanson and one with Mr. Hanson written on it, most would gravitate to the former.’”
The case record included recent enforcement against Sarah Erny, DNP: $19,750 in civil penalties and a separate $2,500 citation from the Medical Board of California for using “Dr.”, with an order to “immediately cease and desist use of the initials ‘Dr.’”
The opinion recounted that California amended § 2054 via SB 1451 to clarify the prohibition “in a health care setting” and allow Doctors of Osteopathy to use “Dr.”; the Board of Registered Nursing supported the bill only if nurses with terminal degrees could use “Dr.” regardless of setting with disclosure.
The court rejected the plaintiffs’ “less restrictive alternatives” arguments (e.g., reliance on disclosure rules and general false-advertising laws), explaining—citing Ninth Circuit precedent—that commercial-speech limits need only be a reasonable fit. In quoting American Academy of Pain Management v. Joseph, the court likened § 2054’s restriction on “Dr.”/“doctor” to limiting the term “board certified” to those meeting statutory qualifications.
Professional associations filed on both sides, including the American Association of Nurse Practitioners, The American Association of Nurse Attorneys, and the California Association of Nurse Anesthesiology supporting plaintiffs, and the California Medical Association and American Medical Association supporting defendants. The opinion notes AMA survey results indicating 39% of patients believe a DNP is a physician, which Palmer said was consistent with her understanding.
The court upheld §2054 under intermediate scrutiny, finding documented patient confusion and a reasonable fit with California’s consumer-protection goals.
Source: United States District Court
