‘No Kings’ in healthcare: leaders serve patients by following the clinical problem

Late last year, California upheld its restriction preventing non-physicians from using the title "doctor" in clinical settings, even when they hold doctoral degrees. The Palmer v. Bonta decision has reignited a familiar debate in American healthcare: Who should lead, and why. Framed as a consumer protection issue, the ruling rests on an assumption that patients are best served by a fixed hierarchy, where physicians lead by default and other professionals support.

That assumption no longer matches how care is actually delivered.

For health system leaders, this misalignment has tangible consequences: constrained workforce flexibility, delayed access to care, and avoidable strain on continuity and patient experience.

For most of the twentieth century, organizing healthcare around physician leadership made functional sense. Acute illness, surgical intervention, and rapid decision-making dominated care delivery. But today's healthcare system looks very different. Patients live with chronic disease, navigate fragmented systems, and depend on continuity, access and trust—and when it comes to trust, patients have already decided who they value most.

In 2025, Gallup ranked nurses as the most trusted profession in the U.S., with 76% of Americans rating nurses' honesty and ethics as high or very high. Physicians ranked lower, at 53%. This is not a referendum on competence; it is a reflection of relationship. Trust grows where clinicians show up repeatedly, manage complexity over time, and understand patients in context. While trust alone does not determine clinical leadership, it signals something executives should factor into workforce planning and patient experience strategies.

Dermatology offers a useful illustration

U.S. dermatology clinicians see roughly 44 million office visits each year, most for conditions requiring ongoing management rather than one-time intervention, including persistent acne, chronic dermatitis, eczema and benign lesions. These conditions demand pattern recognition across time, patient education, and coordination with broader health needs. This is exactly the kind of care where nurse practitioners excel: high-volume, behavior-linked, and dependent on sustained relationships over months or years. 

Yet, leadership models still assume authority must remain static, regardless of the clinical problem.

Education pathways help explain why this mismatch persists. Physician training is front-loaded and immersive, building deep diagnostic and procedural expertise early. Nursing education is often distributed across a career, emphasizing adaptation, patient and family education, population health, and care coordination. These are not competing models; they are complementary ones, each suited to different clinical contexts.

The evidence reflects this reality. Decades of outcomes research show that nurse practitioners deliver primary and chronic care outcomes comparable to physicians, often with lower utilization and cost. Nurse practitioners excel in continuity-dependent care. Physicians remain indispensable for acute, rare, and highly specialized conditions. At the same time, widespread physician burnout and persistent workforce shortages make flexible leadership models not only equitable, but operationally necessary. 

The problem arises when leadership is assigned by title rather than by domain. In practice, adaptive leadership already exists, even if policy lags behind.

Serving the underserved

In an underserved community in Petersburg, Virginia, operating under regulations that allow nurse practitioner independence, a doctoral-prepared nurse practitioner leads dermatologic care for patients who would otherwise face long delays or no access. She conducts assessments, performs biopsies, manages chronic disease, coordinates pathology, and follows patients longitudinally. She consults a physician colleague when cases exceed her expertise or require advanced intervention. Collaboration is driven by judgment, not hierarchy. This model remains unavailable in many states, but it demonstrates what becomes possible when leadership follows the problem rather than the title.

Patients know who she is. They know her role. They trust her because she is accountable for their care over time.

This is not an argument against physicians. It is an argument against the assumption that authority must be permanent and unidirectional, regardless of patient need.

Healthcare leadership should follow the clinical problem. When a patient arrives in septic shock, physicians must lead. When a patient requires months or years of chronic disease management, prevention, and education, nurse practitioners are often best positioned to lead. In many cases, leadership should shift as patient needs change. For executives, this shift has practical implications: revisiting privileging and service-line leadership criteria to align authority with clinical domain; designing nurse practitioner-led clinics for chronic and behavior-linked care to expand access and relieve bottlenecks; and adopting dual-identifier standards as a low-cost transparency and risk mitigation step.

The Palmer v. Bonta ruling treats titles as a proxy for clarity. But banning accurate academic titles does not resolve confusion; it obscures reality. Misalignment between title and role can create patient complaints, misdirected expectations, and avoidable legal exposure.

A dual-identifier standard, clearly stating both degree and role in all patient-facing contexts, offers a better solution. "Dr. Dawn Adams, Nurse Practitioner" or "Dr. Marissa Levine, Physician" communicates exactly what patients need to know. It protects against misrepresentation without reinforcing outdated hierarchies or diminishing earned credentials.

Implementation is straightforward: apply the standard to badges, signage, intake forms, and telehealth platforms. Licensing boards already track this information; transparency simply makes it visible.

The question is not whether patients can understand this. It is whether systems are willing to trust them with it.