Brendan, I am most interested in your response "let the patient decide". Do you mean to take a survey of society (all are potential patients) and discover the consensus regarding the issue or do you mean to ask a patient at the time of the service "I have a PhD in nursing, should I call myself or you call me "Doctor Mary Jones"? "Benefit of the patient" includes clarity of the professional relationship. ..Maurice.

I don't want to belabor this issue, but in respect to a clinical "primary care giver" (which also means that the care giver is not dependent on the supervision and authorization of management of the patient by some other individual such as a licensed physician), if the nurse with the PhD degree was only trained as a nurse and has not been clinically trained and certified and licenced as a nurse practitioner or physician's assistant then such a nurse cannot be the patient's clinical "primary care giver" in my opinion. However, Brendan, I agree with you that irrespective of the nurse's clinical training and licensing, it would be proper and to the benefit for the patient to be made aware of the nurse's training and responsibilities and academic degree and to be allowed to decide whether to call the nurse "Doctor" in their relationship. The only point of confusion would be if the patient, in a clinical or hospital setting, spoke to a physician or some other individual and referenced the nurse with a title of "Doctor". ..Maurice.

Charles, in a hospital/clinical situation, unlike in an academic environment, "doctor" to virtually every patient means "physician", I can't see how it is "disrespectful" to a qualified clinical care giver to omit the designation of "doctor" if using that word may produce ambiguity and confusion by the patient or others in that hospital or medical clinic environment and context.. To me, respect for any healthcare giver should be based on the giver's behavior and value to the patient and not an academic title. There may be some physicians and other providers who deserve disrespect for their behavior. On the other hand, I can understand why, regarding the Question presented, each of us would want to defend our titles. ..Maurice.

@Rona and Maurice: There is a bit more confusion for nurses since the practitioner level is lower than the doctorate. A nurse saying I'm Dr. Smith your nurse says that I have a higher level of education than another nurse might. But there is also confusion when the practitioner level is the doctoral degree. A dentist who says I'm Dr. Smith but doesn't say I'll be treating that molar you've been complaining about might confuse a patient and a psychiatrist might say I'm here to talk to you about those flashbacks that wake you up at night. The treating physician, a medical doctor, might say I'll make sure you see whatever specialist you need. In each case a doctoral degree gives information about level of education, but function, not degree, minimizes ambiguity or confusion. And I certainly agree with Maurice that salary should be based on education and skills but am curious if you feel that in a hospital those with a PhD, PsyD, DDS, should not be called doctor.

Maurice,
I think the answer to this question is obvious. In a clinical setting everyone should be required to wear name badges with their professional degrees on them. That way, the patients will know who everyone is, and those who have earned a doctorate in a field other than Medicine will still get the respect of being called "doctor," while not creating any confusion. In a non-clinical setting, who cares?

Personally, I think anyone with an earned doctorate deserves the title, but it should not be allowed to confuse the patient. Please note, I have assiduously avoided using the terms "health care provider" and "consumer." I have no objection to anyone being called "doctor" if they've earned it and wear their degree(s) proudly, but I did not spend all those years in medical school and residency to become a "health care provider;" I am a physician.

Maurice,
When I am in court, or a hearing, or another "legal" context, it is a mixed bag. Sometimes I am referred to as "doctor," but most times as "mister." More importantly, though, when I am referred to as "doctor," it is because of my medical degree, not my law degree. Although the JD is a doctorate. It is simply convention and tradition to use "mister" because originally, attorneys were awarded an LLB instead of a doctorate.

Charles, an excellent point you just made regarding psychiatry and being identified by a more generic titles of "medical doctor" and "physician".

Now.. I have a question for Eric. I started this Question with an excerpt from the New York Times article: " A bill proposed in the New York State Senate would bar nurses from advertising themselves as doctors, no matter their degree. A law proposed in Congress would bar people from misrepresenting their education or license to practice. And laws already in effect in Arizona, Delaware and other states forbid nurses, pharmacists and others to use the title “doctor” unless they immediately identify their profession." Eric, from the viewpoint of your profession as a lawyer, how do you look at these proposed laws or those which apparently are already in some states in terms of violation of the Constitutional direction regarding freedom of speech? For a nurse to identify herself (or himself) with a "doctor" prefix is a matter of free speech isn't it? It is not a designation which is delivered out of "whole cloth" (knowingly false) since it represents the nurse's valid educational title and a title that is commonly used by others and applied to others with a doctorate degree? Or is this an example of a Constitutional limitation of free speech when the word "fire" is yelled out in a crowded auditorium when there is no fire and the intent of a individual who yells is to cause panic? In this example, the potential is for harm. What argument could be given to support those state nurse laws Constitutionally: attempt to mislead? ..Maurice.

Maurice,
The answer to your question, like most anwers in law, is not straight forward. In fact, it may well be that it will be litigated somewhere for just the reasons you stated. With that being said, however, I'll give you my own opinon.

There are two competing interests involved here. The first, is a person's (a "natural" person, "Citizen's United" not withstanding) right of free speech to honestly advertize their services and credentials, and the government's ability to curtail that right. Your example of yelling "fire" in a crowed auditorium is only partially applicable because, unlike the nurse who advertizes himself or herself as "doctor," there is no inherent benefit to the person yelling "fire." In this case, it is the right of every person to truthfully advertize their legally available services, and generally, the government would be restrained from interfering.

There is one instance in which the government may interfere, even with a "fundimental" constitutional guarantee, and that is where there is a "compelling governmental interest" in doing so (there are a few other qualifications, but I'll skip the academic exercise of citing them for now). Now I know that term seems unreasonably vague, but it has repeatedly been interpreted by the courts as an interest in protecting individuals, protected groups, or the nation itself from harm. There are numeroous examples, but like the person who yells "fire," the ballance is between making sure he or she has their free speech rights, and the right of others not to be physically injured in the stampede that would follow.

I believe a court would rule those laws to be constitutional because they would not, in fact, prevent the individual from advertizing either their services or their credentials, but merely require sufficient clarification to prevent confusion in the general public. In essence, it does not restrict their use of the term, "doctor," it merely requries them to clarify their qualifications so that the public can know who they are dealing with. Therefore, if I were deciding the case, unless someone could convince me otherwise, I would hold that they were constitutional, but their restrictions could no go beyond what I cited.

Here is the response from a physician who wrote to the same topic on my bioethics blog
http://bioethicsdiscussion.blogspot.com/2011/10/contemporary-art-and-education-of.html
..Maurice.
:
At Saturday, October 08, 2011 6:54:00 AM, Billy Rubin said...
Quick thoughts:

a. The "freedom of speech" isn't wrong because it's like shouting "Fire" in a crowded theater, it's because you can't make trade claims falsely. I'm sure a lawyer would be able to phrase this more eloquently and also know the precise legal principle, but the FDA and Federal Trade Commision constantly monitor claims made by manufacturers of drugs and anything else for false claims. RNs calling themselves "Doctor", the naysayers would argue, constitutes a similar false claim.

b. "Anonymous" above takes issue with housestaff who would call themselves "doctor", but this seems to me to be going too far. They're doctors! Perhaps there's a little room for confusion if they introduce themselves as the doctor (implying the attending), but the average Joe finds the terminology of housestaff rank (clerk, sub-I, intern, resident, senior resident, fellow, senior fellow, attending...and that of course leaves out the role of consultants) so confusing that "doctor" relays the basic message, that this person is in some meaningful way responsible for a patient's health.

c. What to do about PAs? They're much more like doctors than they are like nurses, with considerably more autonomy. Many of the PAs I work with are MDs in all but name only. Yet the title "physician's assistant" almost implies something clerical. Them I'd call "doctor".

d. My own personal policy: once I learn that a person has a PhD in whatever field, I call them "doctor" until they tell me otherwise. I do not call them "professor" unless they are full professors. It's as close to a by-the-book system I know of, and it ain't worth the trouble to offend someone who gets worked up over this stuff. (Maya Angelou, the great poet, had received honorary PhD's later in life, and insisted on being formally addressed as "doctor". If I were invited to tea with her, I'd respect her wishes even if I'd have to pucker my lips just a lil' bit before doing so.)

e. I don't really care what patients call me, although hate to say it I've gotten accustomed to being addressed as "doctor". If they call me by my first name, so be it. I do insist that the nurses with whom I work call me by my first name, since I don't call them "Nurse So-and-So".

f. I agree that there are some occasional moments when someone in the health profession might very seriously mislead a patient by referring to themselves as "doctor" when their claim to that title is tenuous, but is the problem really that serious that we need to put laws on the books against it? Wow. I'm in agreement that this could be a policy implemented by particular facilities that need to clarify things.

Dr. Caylor, I agree with your 2 stated goals of not confusing patients and primary focus is to benefit patients. The first is taken care of during an introduction by focus on function: Ï'm Dr. Smith, your dentist, and I came to talk about the molar you've complained about," Ï'm Dr. Taylor your medical doctor (or physician if you like differentiation), and will coordinate your care, I'm Dr. Jones, your psychologist, and was asked to see if you'd like to talk about the flashbacks you have at night". I'll add my earlier comment that a friend, a psychiatrist, is uncomfortable answering questions about general medicine. As I'm sure you know regular practice maintains skills. My friend's discomfort is, I think, a gift to patients. In terms of patient care, saying I'm Dr. Smith your nurse and will discuss what you should be doing when you leave the hospital is not confusing and the title may be comforting. Additional training can be seen by a patient as a plus. Minimizing that training, and not relating training to function, is unnecessary and possibly inconsistent with either goal. Chuck