I had just graduated from nurse practitioner (NP) school and was on the job hunt. Skimming through a few job descriptions the word “mid level provider” caught my attention. Having never heard that word, I assumed the job wasn’t meant for an NP.
The next time I saw “mid level providers”, a recruiter called my cellphone telling me there was an open position for a “physician extender” in rural Colorado. A what? It’s interesting how you can be an extension of someone who isn’t even present.
Then, a naive new-graduate, I didn’t quite grasp the scope of the problem. Although I did know one thing, neither of those titles captured who I was or what I did.
As I’ve progressed through my career, I’ve heard myself called a “midlevel provider,” “physician extender”, and “nonphysician” over and over again. Nowadays my jaw tightens, and I gauge whether this is an appropriate situation to explain why these terms are offensive.
The time is now. This post will explore the words “midlevel provider,” “physician extender,” and “nonphysician”, describing their historical uses and detailing three key reasons why this vocabulary should be eliminated.
What is a Mid Level Provider?
The term “mid level provider” was created by physicians to refer to medical providers such as nurse practitioners and physician assistants. It is perpetuated by physician-led organizations and physician-centric corporations (Hoyt, 2012). The U.S. Department of Justice’s Drug Enforcement Administration uses “ midlevel practitioner” to describe professionals other than physicians, dentists, veterinarians, or podiatrists who dispense controlled substances. The Centers for Medicare and Medicaid have also referred to NPs and PAs as “physician extenders” but has more recently used the term “ nonphysician practitioners.”
Is the Term Mid Level Provider Offensive?
Yes. Not only is “midlevel” a judgment on the quality of care that an NP or a PA provides, but it’s also misleading in regards to scope of practice. For example, in many states, a nurse practitioner has full practice authority and is recognized as a primary care provider. To call an NP primary care provider a “midlevel practitioner” suggests a lack of autonomy that is simply untrue.
More than that, the context of the term is important. Midlevel is mostly used in combination with the phrase, “midlevel creep,” a pejorative and harmful idea that has been discredited by academic research and the American Association of Nurse Practitioners (AANP).
What is Mid Level Creep?
Mid level creep refers to the belief that “midlevel” providers like NPs and PAs are increasingly encroaching on the territory of physicians, taking on responsibilities and roles previously reserved for medical doctors. The term is exclusively used in a pejorative sense, and is credited as contributing to undesirable outcomes like worse patient care and increased employment difficulty for qualified physicians.
Midlevel creep is sometimes used interchangeably with scope creep, which refers to legislation over the last decade that has expanded the legal practice authority of PAs and NPs. Scope creep and mid-level creep are linked by the belief that the increased practice authority of physician assistants and nurse practitioners is harmful to patient care.
The American Medical Association (AMA), the leading lobbying group for physicians, has heavily promoted the idea, and uses it to attempt to block legislation that would grant NPs and PAs more practice authority and less physician supervision.
“Scope creep” has been uniformly condemned by the AANP as ” an outlandish campaign of disinformation” that “insults and degrade the outstanding care delivered by NPs in more than 1 billion health care visits each year.” It has also been disproven by peer-reviewed academic research.
Is is telling that scope creep, an idea that NPs and PAs are inherently inferior to physicians, has become better known within the medical community as midlevel creep.
Why It’s Time to Get Rid of the term “Mid Level”
It Devalues Expertise
Describing NPs or PAs as “midlevel” doesn’t just imply, but asserts that they are providing something less than “high-level” care. However, ample evidence demonstrates that the services offered by these professionals is just as safe and effective as those provided by their physician colleagues.
Both NPs and PAs earn advanced degrees and undergo exhaustive course work, high-tech patient case simulations, and extensive clinical practice hours. Moreover, both clinicians pass national board certification exams and may specialize in any variety of medical specialties. The terms “midlevel provider,” “physician extender,” and “nonphysician” undermine the expertise and contributions of NPs and PAs.
“Midlevel Providers” Confuses Patients
Imagine you are a patient and being told, “The midlevel will see you now.” Naturally, you might wonder, “Who?” Using vague, collective vocabulary to describe NPs and PAs can confuse patients. When receiving healthcare services, all patients expect and deserve the highest level care no matter who they are seeing. NPs and PAs are held to the same standard of care as physicians, offering the similar services of assessing, diagnosing, and treating medical conditions. By using more accurate terminology (i.e., NP and PA), patients can be assured they are receiving the best care at all times.
It Impedes Teamwork
In its seminal publication, “Crossing the Quality Chasm,” the Institute of Medicine called for interdisciplinary collaboration to solve the significant problems facing modern healthcare. Using a term like “midlevel” perpetuates a hierarchical healthcare system, which impedes this need for teamwork. Most NPs and PAs dislike the terms “midlevel,” “physician extender,” and “nonphysician.” When they hear themselves described this way, it decreases morale and divides the team.
Take a Stand Against the use of “Mid Level Practitioners” and “Mid Level Creep”
To stop the use of these terms, everyone must take a stand. First, recruiters should remove this language from job descriptions, contracts, and business discussions. Employers and administrators specifically need to demonstrate their respect for NPs’ and PAs’ expertise by removing this language from company websites. Other healthcare professionals should stand up for their colleagues if someone uses this degrading language. Finally, both NPs and PAs should never allow someone to call them something that undermines their unique contributions to healthcare.
NPs and PAs Weigh In on “Mid Level” and “Physician Extender”
I recently started a discussion thread about this topic on the American Association of Nurse Practitioners LinkedIn page. The overwhelming majority agreed that these terms should not be used to describe NPs or PAs.
Some of the comments that stood out most to me were:
- “I will not apply for jobs using midlevel provider, or extenders. It’s insulting to my profession and education.” —Nurse Practitioner in Florida
- “It would be nice if nurse practitioners received the respect and recognition they’ve earned through good patient care.” —Nurse Practitioner in New Hampshire
- “I have been truly blessed to work with MDs that actually appreciate, value, and acknowledge what we do and who we are.” —Nurse Practitioner in India
- “How do you extend a physician? It is suggesting that somehow we are not capable of working independent and we must be attached to a physician. I am a Nurse Practitioner of the highest level, and I am an extension of no one.” —Nurse Practitioner in Florida
- “I am fairly certain they are not referring to us as midlevel providers to degrade us, but rather they’re unaware of how offensive it can be.” —Nurse Practitioner in California
- “The term ‘midlevel’ is often used in a denigrating manner, lessening our worth and contribution to healthcare. This term should be retired and the contribution to healthcare overall made by all professionals should be recognized and validated.” —Nurse Practitioner in Texas
Barton Associates also conducted a poll on its Facebook page, asking NPs and PAs which term were most offensive. Approximately 1,380 NPs and PAs weighed in on the discussion. Here are the results:
- Midlevel (487 votes)
- Noctor (356 votes)
- Physician Extender (335 votes)
The poll also asked which term was the preferred term (other than NP or PA). Here are those results:
- Provider (919 votes)
- Healthcare Professional (122 votes)
- Clinician (115 votes)
Let’s be straight: If there is ever a group of people who are called a name that makes them feel disrespected or devalued, the solution is always to stop. If you’re in doubt as to what you should call an NP or a PA, just use “NP” and “PA.”
Now, let’s get back to patient care.
Note: this article was originally written by Dr. Melissa de Capua in 2015 and was updated by the Barton team in 2023 with new data.
