Physicians are territorial with honorifics. A patient hears “Dr. Smith” and silently fills in the rest—medical school, residency, board certification. That assumption sits at the center of a fresh federal ruling in California.
On September 19, 2025, a federal judge in the Central District of California upheld the state’s long-standing restriction on using “doctor”/“Dr.” in clinical settings. Three nurse practitioners with Doctor of Nursing Practice degrees argued the law violates the First Amendment. The court disagreed, calling that usage by non-physicians in clinical contexts “inherently misleading” commercial speech. The case—Palmer v. Bonta—now stands as a guidepost for titles at the bedside in California.
The statute—and why it matters
California’s Business and Professions Code § 2054(a) (“Section 2054”), makes it a misdemeanor for a non-physician to use “doctor,” “physician,” or the prefix “Dr.” in a health-care setting in a way that would lead a reasonable patient to think the person is a licensed MD or DO. The recent ruling quotes the operative language and ties it to the state’s consumer-protection mission. Translation: titles that cause patients to assume physician qualifications are off-limits in clinical care unless you hold an MD or DO.
The court leaned on common sense and prior authority. Patients commonly equate “doctor” with physician in medical environments. When non-physicians use “Dr.” at the point of care, even with extra letters after the name, the court found a risk that patients will misread the signal. The judge labeled such usage by the plaintiffs “inherently misleading,” which places it outside robust First Amendment protection.
How we got here
The lawsuit began in 2023. Three California NPs with DNPs (doctorates) challenged Business and Professions Code § 2054 after another high-profile enforcement episode. One involved a DNP ordered to pay civil penalties and scrub “Dr.” references from online listings. Pacific Legal Foundation represented the NPs; organized medicine filed amicus briefs supporting the state’s position. The case closed with summary judgment for the state on September 19, 2025.
One more brick in the wall: in 2024, SB 1451 amended § 2054 to clarify that osteopathic physicians may use “Dr.” and to focus the restriction on health-care settings. The Legislature kept the core protection intact—patients in clinics, hospitals, and offices should not be left guessing about who is, and is not, a physician.
What the ruling doesn’t say
A doctorate is a real academic credential. Pharmacists, psychologists, physical therapists, and many others earn one. The court did not denigrate those achievements; it looked at how titles function in clinical contexts. Outside patient-care settings—think academia—customs differ. Inside an exam room, the state gets extra deference to prevent confusion that affects health decisions. The practical bottom line: California nurses with doctorates cannot call themselves doctors with patients. Unless the case gets appealed and overruled.
Guidance for those affected in California to avoid a hefty fine
1) Clean up badges, door plates, voicemail, and scripts.
In California clinics, “Dr.” and “doctor” belong to MDs and DOs when patient care is in play. NPs, PAs, and other clinicians should use their professional titles—“Nurse Practitioner,” “PA,” etc.—without the “Dr.” honorific. Cross-check staff introductions and templated greetings. A pleasant greeting that starts with “Hello, I’m Taylor, your nurse practitioner today” ages well under this ruling.
2) Train the front line.
Reception, call centers, and MA teams often create the first impression. If a patient asks for “the doctor,” staff should clarify roles without editorial comment. Patients want the right clinician; they also want transparency. The ruling underscores that clarity is not optional.
3) Sanity-check marketing.
Websites, online scheduling, provider bios, and third-party profiles (Healthgrades, Google Business, Yelp) should mirror what a patient will see and hear in the clinic. Audit for stray “Dr.” prefixes next to non-physician names. The enforcement story in the case file featured exactly that problem—platforms and profiles that required cleanup. Better you find those first.
4) Rehearse a graceful explanation.
Interdisciplinary teams are here to stay. Patients still ask, “Who’s the doctor?” A short script helps: “I’m Ashley Brown, a nurse practitioner. I diagnose, treat, and prescribe within my license. Dr. Patel is the physician leading the team today.” No eye-rolling. No turf war. Save the oxygen for patient care.
5) Mind the line between “credential disclosure” and “title inflation.”
Listing degrees after a name is fine; flashing “Dr.” in a clinical setting for a non-physician crosses the line in California. If you oversee a group with mixed credentials, the safest pattern is: Name, professional license, role. Examples: “Jordan Smith, DNP, Nurse Practitioner”; “Casey Lee, PharmD, Clinical Pharmacist.” The academic degree follows the name; the spoken title in clinic remains the licensed role.
6) Review your compliance plan post-SB 1451.
The amendments clarified parts of the statute and reaffirmed the focus on health-care settings. If your policies relied on older language, refresh them now. Include spot checks for scrubs embroidery, lab coats, and signage. “Dr. Taylor, FNP-C” stitched on a white coat will sink an otherwise tidy compliance story.
Common questions I’m hearing
Q: Our DNP introduces herself as “Dr. Garcia, Nurse Practitioner” to patients. Okay?
Not in a California clinic. The court treated that phrasing as inherently misleading in this context. The safer introduction is “I’m Maria Garcia, Nurse Practitioner.” Degrees can live in the bio and on the website; the spoken clinical title should not invite physician confusion.
Q: Does the ruling reach non-patient-facing settings?
The statute zeroes in on health-care settings tied to patient care and consumer perception. A grand rounds slide deck at a university lands in a different bucket than a clinic intake desk. Still, many systems unify style across environments to avoid mixed signals when the same clinician steps into clinic that afternoon.
Q: We practice near a state line. Do neighboring rules match?
States vary. Some permit “Dr.” by non-physicians with immediate clarification of profession; others restrict clinical usage much like California. If your team crosses borders, write state-specific scripting and badge templates.
Q: What about an acupuncturist with a doctorate degree in California?
§ 4936. Unprofessional conduct; unauthorized use of the title “Doctor” or the abbreviation “Dr.” (a) It is unprofessional conduct for an acupuncturist to use the title “Doctor” or the abbreviation “Dr.” in connection with the practice of acupuncture unless he or she possesses a license that authorizes the use or possesses an earned doctorate degree from an accredited, approved, or authorized educational institution as set forth under Chapter 8 (commencing with Section 94800) of Part 59 of Division 10 of Title 3 of the Education Code, which is in acupuncture, oriental medicine, a biological science, or is otherwise related to the authorized practice of an acupuncturist as set forth in Sections 4927 and 4937. (b) The use of the title “Doctor” or the abbreviation “Dr.” by an acupuncturist as authorized in subdivision (a) without further indicating the type of license or degree which authorizes that use shall constitute unprofessional conduct.
Separately, California’s general rule on the “doctor/Dr.” title says non-physicians may not use it in a way that implies they’re practicing medicine or otherwise misleads patients. In other words, don’t let the title suggest you’re an MD/DO. Clear labeling—e.g., “Licensed Acupuncturist”—keeps you on the safe side.
“Dr. Jane Lee, DAOM, L.Ac. (Licensed Acupuncturist)”
“Dr. Alex Chen, PhD (Biological Sciences), Licensed Acupuncturist”
Final thoughts
The First Amendment claims in Palmer made for interesting reading.
The first inquiry is whether the speech is unlawful or misleading. See Joseph, 353 F.3d at 1106.8 If it is either, then the commercial speech is not protected at all by the First Amendment. See id. In refining the commercial speech doctrine, the Supreme Court has distinguished between “inherently misleading” speech and “potentially misleading” speech. See In re R.M.J., 455 U.S. 191, 202–03 (1982).
When “advertising is inherently likely to deceive or where the record indicates that a particular form or method of advertising has in fact been deceptive,” the advertising enjoys no First Amendment protection. See id. The government may ban this type of commercial speech entirely without satisfying the remaining three Central Hudson factors. Id. However, if the speech is only “potentially misleading,” in other words, “if the information also may be presented in a way that is not deceptive,” the speech regulation must satisfy the remaining three factors specified in Central Hudson. Id. at 203.
Here, “the record indicates that [Plaintiffs’] particular form or method of advertising has in fact been deceptive,” and thus, the speech enjoys no First Amendment protection. See R.M.J., 455 U.S. at 202–03. It is undisputed that Plaintiffs either used “Dr.” or “doctor” in advertising materials and/or healthcare settings prior to learning about the legal actions against Sarah Erny.
Plaintiffs so concede when they agree that the use of “Dr.” or “doctor” in healthcare settings without further clarification generally refers to licensed physicians or surgeons.
Plaintiffs concede—and the Court agrees—that California has a substantial interest in “protecting consumers from those who falsely hold themselves out as licensed physicians but [who] have not been duly licensed.”
Here, Section 2054 does not limit Plaintiffs’ ability to describe themselves as DNPs or to otherwise accurately state their credentials. (See DMSJ Reply at 13.) Instead, like the regulation in Joseph, Section 2054 restricts the use of “Dr.” or “doctor” to individuals who “meet the statutory qualifications” associated with these professional titles. See Joseph, 353 F.3d at 1111 (“The legislation at issue in this case does not restrict a physician or surgeon from advertising that he or she had special training or continuing education with a non-qualifying board. Instead, it restricts the use of the term ‘board certified’ to signify certification by boards that meet the statutory qualifications. In the situation of the Academy, a physician or surgeon can advertise his or her membership in the Academy or special education received, but simply cannot use the term ‘board certified’ or its equivalent.”). Accordingly, the Court finds that the “California legislation, even if not the least restrictive restriction, is a reasonable fit between the legislature’s ends and the means chosen to accomplish those ends.” See id. (“The [Supreme] Court has generally said it is up to the legislature to choose between narrowly tailored means of regulating commercial speech.”) (citing Bd. of Trs., 492 U.S. at 479).
The judge viewed the record through a clinical lens: patients in exam rooms rely on quick cues. The ruling treated “Dr.” by non-physicians in that space as too risky. Health-care leaders now have a clear marching order in California. Unless the plaintiffs try another round in appellate court.
What do you think?
