Medicine without doctors? State laws are changing who treats patients.

Arlene Wright is a doctor, but she doesn’t want people to call her one.

“I usually tell my patients ‘your majesty’ or ‘your highness’ is fine,” she said.

Wright has been a nurse for more than 20 years in Fort Myers, Fla. She began working in hospitals as a teenage candy striper in Upstate New York, progressing through an associate’s degree in nursing, then a bachelor’s, then a master’s, then finally a doctorate of nursing practice in 2013.

Wright has always told patients she’s a nurse practitioner, she says. She doesn’t flaunt her doctorate or try to mislead patients into thinking she has an MD.

Still, when Florida lawmakers began considering a bill that would have prevented her from using her title, Wright was taken aback.

“I’ve never abused or borne witness to anyone abusing their title,” she said. “It’s singling people out, creating a bad atmosphere through legislation for the actions of a few.”

The Florida bill would have prevented non-physicians from using several titles such as doctor of medicine, physician, medical resident and hospitalist. (Gov. Ron DeSantis vetoed it in June.) A near-identical measure became law in Georgia this year and Indiana in 2022. California ordered a nurse practitioner to pay nearly $20,000 for advertising herself as “Doctor Sarah,” based on a law that several nurses are now challenging.

Florida and Georgia are two of many states contending with how much independence to give nurse practitioners and other medical professionals. It’s a question that has become emotional for many medical providers and time-consuming for many state and federal groups lobbying on their behalf.

The past several years have seen hundreds of laws proposing to expand nondoctor medical professionals’ work, the American Medical Association (AMA) says, noting that it and allies have put millions of dollars into fighting back. More than half of states no longer require a physician to sign off on the work of a nurse practitioner, who can have as little as 10 percent of the clinical hours as doctors before getting their degree.

Doctors and nurses don’t agree on what to call the issue. To the AMA, it’s a matter of less experienced professionals attempting to escape from physicians’ supervision. To the American Association of Nurse Practitioners, it’s a battle for “full practice authority.”

Whatever its name, how much leeway non-MDs have to test, diagnose, prescribe and treat illness — and what they should call themselves while they do so — is a question that is changing medical care, particularly in underserved areas. As nurse practitioners’ and other medical professionals’ authority expands, patients in those communities could eventually move through the health-care system while rarely or never seeing a doctor.

“Individuals have taken the notion that we can get by with fewer doctors [by] using physicians’ assistants and nurse practitioners,” neurosurgeon Bernard Robinson said in an AMA video, citing what the Association of American Medical Colleges says is a nationwide doctor shortage.

The AMA itself puts it more bluntly: “Patients deserve care led by physicians.” Its advertising campaign that has pushed title bills similar to those in Georgia and Florida says it wants “to help ensure patients can answer the simple question, ‘Who is a doctor?’”

When the first American nurse practitioner program began in 1965, it sought to supplement doctors’ work.

“The PNP was not a substitute for the physician,” nurse Loretta C. Ford, who co-founded the country’s first nurse practitioner training program, wrote in 1997. “Their relationship was envisioned as collaborative and collegial.”

Nurse practitioners are one type of advanced practice registered nurse, distinguished by having a master’s degree or doctorate in nursing and passing certification exams.

There are more than 350,000 nurse practitioners in the United States, and they have long pushed for independence.

For decades, their pitch has remained consistent. Nurse practitioners were licensed to provide certain types of care. But they couldn’t because state laws, many decades old, yoked them to supervising physicians.

In 1994, five states allowed nurse practitioners full practice authority — meaning they didn’t need physician supervision to test, treat and prescribe. In 2000, 10 states did. In 2005, 11. Today, 27 states, and D.C., do.

As nursing organizations were busily spreading their message, doctors groups were comparatively quiet, said Carmen Kavali, a Georgia-based plastic surgeon who has been involved in policy debates since she was a medical student. Kavali was one of the lead advocates for the Georgia medical-titles law.

But state lawmakers were quickly swayed. The nurse practitioners had produced studies showing they could treat patients safely — particularly in primary care settings — and had shown them to legislators all over the country.

Much of that research is robust, said economist Bianca Frogner, who leads the University of Washington’s Center for Health Workforce Studies. The National Academy of Medicine concluded more than a decade ago that advanced-practice nurses should be allowed greater autonomy.

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In 2006, the AMA and other physicians’ groups started funding research to rebuff “the key arguments allied health professionals use to advance their measures in state legislatures,” Psychiatric News wrote at the time.

“Some mid-level or limited license practitioners continue to attempt to practice medicine and rely on false assertions of authority,” one proposal to the AMA in 2006 reads.

The American Association of Nurse Anesthesiology responded that the resolution relied on “witch-hunt logic” and “McCarthyistic tactics.” As doctors fight scope-expansion bills, nursing professionals have said physicians are trying to protect their turf — and their higher salaries — at patients’ cost.