Jennifer Mensik Kennedy, president of the American Nurses Association, remembers the day well. She was at a meeting of administrators at the hospital where she worked and the physicians there were addressing each other by first name. Mensik Kennedy assumed everyone would be on a first name basis. But when she followed suit, the informal tone of the meeting quickly changed.

“I was corrected,” she recalled. “They said, ‘No, no, no, this is Dr. Smith.’”

Mensik Kennedy, who has a doctorate in nursing, was indignant. She thought to herself: “Well then, if I’m going to call you, Dr. Smith, you’re going to call me, Dr. Mensik Kennedy.”

It was not the first time that she’d experienced such an “air of disrespect” from medical doctors who don’t view other health care practitioners with doctoral degrees, but not M.D.s, as being actual doctors.

The incident reflects a long running debate within the medical establishment over who should be allowed to formally and legally call themselves “doctor”. Associations representing medical doctors, nurses, physician assistants and other health care professionals have lobbied state lawmakers, medical licensing authorities and government regulators to either limit the use or label of “doctor” to those who have M.D.s, or to expand it to anyone in the medical field who has a doctorate.

Lawmakers in Georgia recently stepped into the fray by approving a new law that strictly limits nonphysician health care providers from calling, or commercially promoting, themselves as doctors even if they hold a doctoral degree.

The “Health Care Practitioners Truth and Transparency Act,” which went into effect in May, regulates how Georgia “health care practitioners” ranging from physician assistants and nurse practitioners to pharmacists, psychologists and occupational therapists, refer to themselves. It prohibits the use of “doctor” or the prefix “Dr.” by a health care provider who is not a licensed doctor of medicine (MD) or doctor of osteopathy (DO) in any advertisements. Violation of the law could result in the loss or suspension of the practitioner’s license.

Laws regulating use of the title of doctor have been in effect since at least 2011. Illinois bans use of the title in advertising but allows health care practitioners to refer to themselves as doctor in interactions with patients as long as the practitioners clarifies their specific role. Texas and Kentucky allow the use of doctor in advertising but only if the practitioner also lists the specific type of doctoral degree held. Other states, including California, Connecticut and Arizona have made it a misdemeanor or a felony for anyone who is not a licensed physician to use the term at all.

Lawmakers in several states continue to introduce similar bills. A proposal was introduced in Florida this past spring that would have required nonphysician practitioners to inform new patients of their profession and to wear a name tag that listed “the profession … under which the practitioner is practicing” at all times. It was vetoed by the governor in June.

In an industry already facing staffing shortages following the COVID-19 pandemic, the debate over ownership of the title is not just about academic prestige—although physicians argue it is key to distinguishing their level of clinical education and scope of practice for patients. It’s also about money; deciding who can advertise their academic and clinical experience to instill confidence and attract patients. Nonphysician medical practitioners say being more transparent with patients should not mean diminishing their level of education or devaluing the degrees they earned.

“I’ve earned the right with my Ph.D. to be called Dr. amongst peers with doctoral degrees,” said Mensik Kennedy.

‘Using It Appropriately’

Dr. Carmen Kavali, a plastic surgeon and board member of the Medical Association of Atlanta, helped write the Georgia law and considers it an important transparency measure.

“In general, anyone who’s earned the title of doctor by completing a doctoral degree certainly has literally earned the title,” Kavali said. “It’s just using it appropriately, and making sure that in a clinical setting patients understand exactly who is treating them.”

Although the Georgia legislation applies to many categories of providers, she noted it places particular attention on nurse practitioners and physician assistants because they are most likely to be working in a primary care or multi-specialty setting.

“If you walk into a physical therapy practice … if that person introduces themself as doctor, you pretty much know they’re a doctor of physical therapy … That’s not true when you’re at the hospital,” Kavali said. “If you’re going to say, ‘I’m Dr. so and so,’ in a clinical setting to a patient and you’re not a physician, then you should immediately clarify.”

A series of surveys conducted by the American Medical Association between 2008 and 2018 found that 61 percent of patients falsely believed that a Doctor of Medical Science, or D.M.S., the doctoral degree for a physician assistant, was equivalent to a medical doctor. Nearly 40 percent believed the same for a nurse with a Doctor of Nursing Practice, or D.N.P. degree. In comparison, only 19 percent of patients believed a nurse practitioner to be equivalent to a doctor and 17 percent did so for a physician assistant.

“Patients find it increasingly difficult to identify who is or is not a physician,” the American Medical Association wrote in a statement via email. “Truth in Advertising laws … provide common sense clarity and transparency for patients, ensuring patients have the basic information necessary to make informed decisions about their health care.”

Some physicians also argue that the time and training required to earn a D.N.P. or D.M.S., which typically range from two to four years of postgraduate study, are not equivalent to those of an M.D. or D.O., which requires four years of medical school and a minimum of three years of residency. The lack of differentiation in title, along with an increased push by nurse practitioners and physician assistants to be able to practice without the oversight of a physician, doesn’t reflect that and is a disservice to patients, they argue.

“Any law or policy that expands scope of practice for non-physicians could potentially lower the standard of care in rural and urban underserved areas where the primary care physician shortage is most severe,” the American Academy of Family Physicians said via email. “To that end, policymakers must clarify the roles of physicians and non-physician clinicians.”

Dr. Michael Champeau, president of the American Society of Anesthesiologists, supports such measures.

“There are rigorous accreditation requirements, the curriculum, the years of training … We, in the United States, have done a pretty good job of ensuring minimum standards of quality for physicians,” he said. “I don’t think that there’s been that same degree of rigor in terms of creating a system where the quality of the education of a Doctorate in Physiotherapy or a Doctorate in Education or a Doctorate in Nurse Practice.”

‘All or None’

Despite questions about the quality and rigor of the education of health care practitioners that don’t have MDs, the number of providers pursuing a doctoral degree is growing. Some specialties, including pharmacology and physical therapy now require a doctorate. According to the American Association of Colleges of Nursing, D.N.P. enrollment in the U.S. has skyrocketed from 70 students in 2003 to over 41,000 in 2022.

Stephen Ferrara, president of the American Association of Nurse Practitioners, sees the growing number of health care providers with doctoral degrees as “a strength” that should be “welcomed and embraced by all in health care.”

Instead “we continue to see physician associations bring forward legislation to limit patient access to this information,” Ferrara said via email. “It’s time to move past anticompetitive and punitive measures that prohibit or infringe on nurse practitioners and other health professionals from accurately communicating their education.”

Many nurse practitioners and physician assistants argue that transparency with patients and the ability to advertise their academic credentials and their qualification for a larger scope of services can coexist.

“PAs with doctorate degrees should feel empowered to use the title that communicates their highest level of education in appropriate settings,” Folusho Ogunfiditimi, president of the American Academy of Physician Assistants, said in an email. “PAs have always, and will always, support complete transparency when it comes to medical titles. Being a PA is something to be proud of.”

Underpinning that pride is “knowledge base and education,” said Mensik Kennedy, of the American Nurses Association.

She noted that physicians are quick to compare a nurse practitioner to a neurosurgeon, but there’s a big difference between the medical training of a neurologist and of a family care physician. She believes “there’s not much difference” between the training primary care doctors and nurses get in college.

At the same time as some states push to limit the titles of nonphysicians with a doctorate degree, lawmakers in at least eight states are considering legislation that would expand the scope of medical services nonphysicians can provide as a way to address shortages in primary care.

“If we want to look at apples and apples, let’s kind of uncover that a little bit more,” Mensik said. “These advanced practice nurses have seven, eight, nine years of education in health care and all those clinical hours … [physicians] tend to not respect the knowledge base and education that nurses bring to the table.”

Battle for Business

While both physicians and nonphysicians tend to say their positions on this issue are not about power or egos, Jon Porter, a Texas lawyer who specializes in defending physicians and nonphysicians before licensing boards, said “that’s exactly what it is.”

The doctor title “has cachet,” he said.

Porter believes complaints about the misuse of the title in states that regulate it, don’t often originate from licensure boards which are “not proactive agencies,” but from the health care workers who view each other as competitors.

In many ways, it’s a battle for business, Porter explained. Calling oneself a doctor “is a wonderful advertising tool for whomever earns it,” he said.

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You must have successfully completed all preclinical training, basic core clerkships (internal medicine, neurology, pediatrics, psychiatry, obstetrics and gynecology, or surgery), and all portions of the clinical training prerequisites required for the elective for which the application is being processed.

Acceptance is contingent upon you achieving adequate grades in basic science and core clinical courses equivalent to Saint Louis University courses. Adequacy and equivalency shall be determined by the Saint Louis University School of Medicine. Visiting students are eligible for clinical Year 4 electives only.

Applications that are incomplete or have not met the eligibility requirements will not be processed.

How can we best keep our brain fit as we grow older? It's well known that regular cognitive activity, for example brainteasers, sudokus, or certain video games in middle and old age tends to protect against cognitive decline and dementias like Alzheimer's. But many of us regularly engage in adult education classes, for example learning a language or a new skill. Is such adult education likewise associated with a lower risk of cognitive decline and dementia?

Yes, according to researchers from the Institute of Development, Aging and Cancer of Tohoku University in Sendai, Japan who have shown for the first time, in a new study in Frontiers in Aging Neuroscience.

Here we show that people who take adult education classes have a lower risk of developing dementia five years later. Adult education is likewise associated with better preservation of nonverbal reasoning with increasing age."

Dr Hikaru Takeuchi, study's first author

UK Biobank

Takeuchi and his co-author, Dr Ryuta Kawashima, a professor at the same institute, analyzed data from the UK Biobank, which holds genetic, health, and medical information from approximately half a million British volunteers, of which 282,421 participants were analyzed for this study. These had been enrolled between 2006 and 2010, when between 40 and 69 years old. On average, they had been followed for seven years by the time of the present study.

Based on their genotype at 133 relevant single-locus polymorphisms (SNPs) in their DNA, participants were given an individual predictive 'polygenic risk score' for dementia. Participants self-reported if they took any adult education classes, without specifying the frequency, subject, or academic level.

The authors focused on data from the enrollment visit and third assessment visit, between 2014 and 2018. At those visits, participants were given a battery of psychological and cognitive tests, for example for fluid intelligence, visuospatial memory, and reaction time.

1.1% of participants in the demo developed dementia over the study's time window.

Reduced risk of developing dementia

Takeuchi and Kawashima showed that participants who were taking part in adult education at enrollment had 19% lower risk of developing dementia than participants who did not. This held true for both Caucasian people and those of other ethnicities.

Importantly, results were similar when participants with a history of diabetes, hyperlipidemia, cardiovascular diseases, cancer, or mental illness were excluded. This means that the observed lower risk wasn't exclusively due participants with incipient dementia being prevented from following adult education by symptoms of these known co-morbidities.

The results also showed that participants who took part in adult education classes kept up their fluid intelligence and nonverbal reasoning performance better than peers who did not. However, adult education didn't affect the preservation of visuospatial memory or reaction time.

Randomized clinical trials necessary

"One possibility is that engaging in intellectual activities has positive results on the nervous system, which in turn may prevent dementia. But ours is an observational longitudinal study, so if a direct causal relationship exists between adult education and a lower risk of dementia, it could be in either direction," said Kawashima.

Takeuchi proposed that a randomized clinical trial be done to prove any protective effect of adult education.

"This could take the form of a controlled trial where one group of participants is encouraged to participate in an adult education class, while the other is encouraged to participate in a control intervention with equivalent social interaction, but without education," said Takeuchi.

How can we best keep our brains fit as we grow older? It's well known that regular cognitive activity, for example, brain teasers, sudoku, or certain video games in middle and old age, tends to protect against cognitive decline and dementias like Alzheimer's. But many of us regularly engage in adult education classes, for example, learning a language or a new skill. Is such adult education likewise associated with a lower risk of cognitive decline and dementia?

Yes, according to researchers from the Institute of Development, Aging and Cancer of Tohoku University in Sendai, Japan who have shown for the first time, in a new study in Frontiers in Aging Neuroscience.

"Here we show that people who take adult education classes have a lower risk of developing dementia five years later," said Dr. Hikaru Takeuchi, the study's first author. "Adult education is likewise associated with better preservation of nonverbal reasoning with increasing age."

UK Biobank

Takeuchi and his co-author, Dr. Ryuta Kawashima, a professor at the same institute, analyzed data from the UK Biobank, which holds genetic, health, and medical information from approximately half a million British volunteers, of which 282,421 participants were analyzed for this study. These had been enrolled between 2006 and 2010, when between 40 and 69 years old. On average, they had been followed for seven years by the time of the present study.

Based on their genotype at 133 relevant single-locus polymorphisms (SNPs) in their DNA, participants were given an individual predictive "polygenic risk score" for dementia. Participants self-reported whether they took any adult education classes, without specifying the frequency, subject, or academic level.

The authors focused on data from the enrollment visit and third assessment visit, between 2014 and 2018. At those visits, participants were given a battery of psychological and cognitive tests, for example, for fluid intelligence, visuospatial memory, and reaction time.

1.1% of participants in the demo developed dementia over the study's time window.

Reduced risk of developing dementia

Takeuchi and Kawashima showed that participants who were taking part in adult education at enrollment had 19% lower risk of developing dementia than participants who did not. This held true for both Caucasian people and those of other ethnicities.

Importantly, results were similar when participants with a history of diabetes, hyperlipidemia, cardiovascular diseases, cancer, or mental illness were excluded. This means that the observed lower risk wasn't exclusively due participants with incipient dementia being prevented from following adult education by symptoms of these known co-morbidities.

The results also showed that participants who took part in adult education classes kept up their fluid intelligence and nonverbal reasoning performance better than peers who did not. However, adult education didn't affect the preservation of visuospatial memory or reaction time.

Randomized clinical trials necessary

"One possibility is that engaging in intellectual activities has positive results on the nervous system, which in turn may prevent dementia. But ours is an observational longitudinal study, so if a direct causal relationship exists between adult education and a lower risk of dementia, it could be in either direction," said Kawashima.

Takeuchi proposed that a randomized clinical trial be done to prove any protective effect of adult education.

"This could take the form of a controlled trial where one group of participants is encouraged to participate in an adult education class, while the other is encouraged to participate in a control intervention with equivalent social interaction, but without education," said Takeuchi.

THE leak of question papers, which earlier happened for public and recruitment examinations, has now come to menace national education and society in its epic proportion in that question papers have come to be leaked even in medical admission examinations. The Criminal Investigation Department, on August 13, told the media that hundreds of students who were admitted through unfair means and leaked question papers are now practising as physicians. The CID investigation revealed that the question papers for the medical admission examinations were leaked on at least 10 occasions in 2001–2017. When investigating a related case filed in 2022, the police found that a syndicate involving employees of the Directorate General of Medical Education, physicians, and a number of coaching centres was engaged in the question paper leaks and illegally earned crores of taka from the aspiring medical students. In 2015, a 14-member citizen probe body reported that questions for medical admission examinations were emailed to the test seekers. It goes without saying that the leak of question papers harms the quality of education and lowers the standards of education nationally and internationally, but the consequence is graver when it comes to medical education because it means risking the lives of the larger public by giving a medical certificate in the wrong hand.

In the past few years, question paper leaks were reported for the Secondary and Higher Secondary and their equivalent examinations. In 2018, a good number of people from different parts of the country allegedly communicated with the leakers and got the questions for the SCC examinations. In 2016, the authorities had to postpone the mathematics examinations of Class I and IV at 102 government primary schools in Natore as the question paper was leaked. The question paper-leak business continues in different examinations for public sector employment too. In 2015, a Transparency International Bangladesh report said that a section of government officials was involved in question paper leaks. In October 2022, Biman Bangladesh was to hold a recruitment examination for 10 posts, but two hours before the test, the recruitment process was suspended because the question paper had been leaked. Following the question leak in recruitment tests for five state-owned banks in November 2021, the Bangladesh Bank cancelled the examination as several media outlets carried reports suggesting the question had been leaked. These reported cases expose the pervasive nature of the problem and the extent of moral corruption, not just in education but in other public sectors.

It is heartening that the police are actively investigating the incidents of question paper leaks in medical admission examinations and have arrested a number of people who have put the entire public health system at risk by creating scope for undeserving students to enter the medical education system. However, the government needs to initiate a credible probe to find out how the syndicate remained active for nearly 16 years without facing any action, despite repeated allegations of question paper leaks in medical admission examinations.