Blog Posts


What’s in a Name? Three Reasons to Stop Calling Us Mid-Level Providers and What to Call Us Instead

Posted on Tue, Nov 11, 2014
What’s in a Name? Three Reasons to Stop Calling Us Mid-Level Providers and What to Call Us Instead

Cynthia M. Bratcher, MSN, APRN, FNP-C. CEN
The term “mid-level provider” has been used by medical organizations for billing purposes to classify non-physician providers: dentists, pharmacists, physical therapists, podiatrists, and even dental hygienists (AANP, 2009). 
Nurse practitioners are independently licensed providers, but we are also often referred to as mid-levels.
“Mid” is the abbreviation for middle, and when used to describe quality in healthcare, the term is misleading at best, and unacceptable, at worst. The term “mid-level” care creates the notion that any care not being performed by the physician is substandard or inadequate, which is why using the term “mid-level providers” to classify non-physician providers has harmful consequences for both patients and the healthcare team.
In addition to the insinuation that we are less capable of accurately assessing and diagnosing patient’s illnesses than physicians, here are three reasons you shouldn’t refer to us as mid-level providers.

  1. It makes doctors question our ability. Nurse practitioners and physician assistants work in the emergency department simply because the quantity of patients exceeds the supply of physician providers. Physicians don’t want to share patient care responsibilities with clinicians who have medium or mid-level ability. Physicians have to trust their team members to perform with the highest precision and quality — every time. And we do. When the physician is with a patient who requires resuscitation, the nurse practitioner or physician assistant is managing many other patients with high acuity illnesses. We bring 100% to the care we provide, but the label mid-level suggests otherwise. 
  2. It confuses patients. Patients expect the same high quality care, regardless of which type of provider is caring for them. The patients expect providers to accurately diagnose their illness and provide a plan for getting completely well, not “mid-level” well. We are held to same standard of care as the physicians and by using a more accurate label, patients can be more assured that they are receiving the best care possible from all team members.  
  3. It brings down team morale. “Mid-levels” use the same information as physicians prior to calling a physician about an admission, yet conveying those findings from someone without physician credentials is unacceptable to many physicians. Some physicians refuse to take our calls about patients requiring hospitalization, they interrupt us as we are discussing our findings and ask to speak to one of our physicians, which requires repetition of exams. Your willingness to talk to us makes us feel like valuable members of the team. 
Several alternate terms to replace “mid-level provider” have been suggested, but “advanced practice providers” is the title most widely used and accepted.
Nurse practitioners and physician assistants have no illusions about independent practice in the emergency setting.  The advanced knowledge of our collaborating physicians is our most valued resource. We rely on them when the situation requires their expertise; however, the greatest portion of our day is spent using our own knowledge to provide excellent care, not mid-level care, which is why our designation should reflect that excellent care for both the sake of our patients and for the sake of our professional relationships with the entire healthcare team.
I don’t think that changing the language will be the magic bullet to changing attitudes of the level of care we provide, but I do believe that eliminating the term “mid-level providers” can facilitate the health care system into recognizing the high-quality and value of care provided by nurse practitioners and physician assistants, which would result in a more positive relationship between all healthcare team members.  
American Association of Nurse Practitioners. “Use of Terms Such As Mid-Level Provider and Physician Extender”. 2009. Web. 1 November, 2014.
Cynthia M. Bratcher, MSN, APRN, FNP-C, CEN is a nurse practitioner at EmCare.  She has a special interest in trauma and authored two chapters of the Trauma Nurse Core Curriculum provider manual, seventh edition.  She has 25 years of emergency nursing experience at an EmCare partner hospital, and she continues to teach ACLS, PALS, and TNCC.   


Get to Know October’s Clinician of the Month: Denise Sexton

Posted on Tue, Oct 07, 2014
Get to Know October’s Clinician of the Month: Denise Sexton

EmCare has more than 10,000 clinicians serving communities across the country and we want to share their stories with you. Get to know these hard-working, difference-makers right here with our monthly “Clinician of the Month” blog post. This month's clinician of the month is celebrated in tandem with Emergency Nurses Week and features one of EmCare's many talented emergency nurses. Do you know a clinician who should be featured? Email!

Denise Sexton has 20 years of healthcare experience to EmCare partner hospitals, and over 15 years specifically in the emergency department and in leadership roles.

As a Divisional Director of Clinical Services for EmCare, Denise’s strength in leadership and diverse clinical skills provides a solid foundation for improving hospital operations, not only in the E.D, but also with services including hospitalist programs, observation units, operating rooms and critical care units. Denise uses her education and experience to o­ffer expertise and broad perspectives for E.D. and inpatient managers.

When she is not busy helping EmCare partner hospitals achieve their goals, Denise enjoys spending time with family, gardening and being outdoors.


Get to know Denise!


How do you fight burnout? If you love what you do then the risk of burnout is low. I truly love my job and enjoy every day of it. When I get stressed out, I go outside and work. I spend as much time as possible working in the garden and around the farm. I find that is my best stress reliever.

The one piece of healthcare advice I wish everyone would follow is ___. Take care of yourself. As healthcare providers we spend all of our time taking care of everyone else and forget that we need care too.

What’s been your proudest moment during your career? One busy night in the ED I took care of a patient who was going to die in a short period of time. His family was 6 hours away and was attempting to get there to be with him. I sat with him as much as I could and talked to him. As I kept in contact with the family I would go and talk with him to let him know that they were coming in hopes that he could hang on until they got there. They shared personal information about him with me so I could talk to him. Unfortunately he passed before they could arrive at the hospital. The family came after I got off shift but we had an area that they could sit with him until they were ready to leave. They sent the kindest letter to me afterwards about how much it meant to them that he did not die alone and that the updates and talking to him meant a lot to them. I still have the letter that they sent me.

I hope my patients remember me as ___.  I hope that the facilities I work with remember me as helpful and a great resource person to turn to when they need assistance.


An E.D. Doctor Who’s Not an M.D.

Posted on Mon, Jan 14, 2013

An EmCare-Affiliated Doctor of Nursing Practice Provides Insight into Her Growing Field


mileypic.jpg“Hi. My name is Dr. Miley, I’m one of the Nurse Practitioners. What brings you to the ER?” That’s how I start most of my conversations with patients. Most patients are there for medical care and don’t think much about the introduction, but some ask “What does that mean?”

It’s a great conversation that I enjoy having. I am one of a growing number of nurse practitioners who holds a Doctorate of Nursing Practice (D.N.P.) degree. The D.N.P. is widely considered the penultimate training for clinical nursing education. After graduating with my master’s degree as a Family Nurse Practitioner, I felt like there was more to learn. I wanted more knowledge. I admit I should have probably gone to medical school, but my opportunities for a medical degree seemed limited.

My first degree program was in pre-pharmacy. I really thought I wanted to be a pharmacist. However, I was swept off my feet and married. I didn’t just pick an “Average Joe,” I married an Air Force Airman.

I always enjoyed the adventure the military offered. I got a new house every few years. I got to decorate, unpack, settle our four kids in school and, oh yeah, find a new job. My pre-pharmacy degree was not much help. So after we moved to Georgia, I decided the kids were old enough and I needed to go back to school. During my first semester, though, I found out child number five was on his way with his expected arrival during my schooling. Despite this unexpected (but welcomed) arrival, my husband remained supportive and somehow I made it through nursing school. I graduated with my associate degree in nursing.

This degree offered lots of flexibility. I no longer had to worry about what career I would work in. Nurses remain in great demand.

Even though I was working and raising children, a friend convinced me I should join her in earning a bachelor’s degree. The next year I graduated with my Bachelors in Science-Nursing.

But still, I felt the need to do more. While working in Interventional Radiology, I began to notice the nurse practitioners (N.P.s) with whom I worked. I noted that one N.P. in particular was able to insert central lines, work on clotted dialysis ports, complete biopsies, and perform various other procedures. He worked independently and was able to care for some of the more critical patients.

I decided to go back to school for my Master in Science Nursing-Family Nurse Practitioner degree. One big difference between working as a physician assistant and nurse practitioner is the degree that is required. I stayed in the emergency department as a nurse practitioner. After all, the majority of my nursing experiences were based in the emergency department. The E.D. just feels like home to me: total managed chaos. There is something about the excitement that starts and ends just as quickly that keeps me in the emergency room.

When asked to be in the inaugural class of my alma mater’s Doctoral of Nursing Practice (D.N.P.), I was thrilled. More knowledge, more information, more understanding in the medical field, and better resources - all good things to have in this ever-changing field of medicine. When asked what I wanted to complete as a capstone project, I knew it had to be something emergency-room based. I studied “chest pain in the young adult (under age 40) who presents to the emergency room.” My study has been accepted and is pending publication in the Journal of Emergency Nurses.

In today’s clinical environments, where the rapid expansion of scientific knowledge is only outpaced by the demand for health care services, it is imperative that clinical practice experts master additional competencies,” says Dr. Susan Eley, chair of the Department of Advanced Practiced Nursing at Indiana State University.

I have earned a doctorate much like those in business, pharmacy and education can earn. There is this misunderstanding that I wanted to complete the degree so I could use the doctor title. Quite frankly, you can call me Kathy for the rest of my life - it has worked for the first 38 years and I will still answer to it without hesitation. Truth be told, I am sometimes caught off guard and don’t answer when I hear “Dr. Miley.”

I continue to assist with bedside and clinical care. Of course, I’ve been approached to teach and I do this in my spare time (limited to one or two classes a semester). But my passion is still bedside care. I still find it rewarding to help others despite all of the changes and difficulties in health care. Nurse practitioners often work side by side with a team of medical providers in the emergency rooms. Each hospital is set up differently in terms of the types of patients I see, but no matter what I enjoy what I do. Having the doctorate degree only offers me more knowledge and a personal sense of accomplishment.

“The expectation of the D.N.P. prepared nurse practitioner is congruent with other professions and demonstrates additional and expanded knowledge and skills consistent with those of other clinical based professions, such as podiatrists, optometrists, pharmacists, and physical therapists,” says Dr. Eley. “No longer can the advanced practice nurse remain in the mid-level role. Nurse practitioners’ skills and knowledge place them in a role of top performers and the attainment of the Doctor of Nursing Practice degree reflects those qualifications.”

Emergency rooms are often considered a “catch all” for the underinsured or uninsured and they continue to be the point of entrance for access to medical care. Physicians are vital in this environment. However, for those times when the physician line is large and wait times for non-critical patients (those without life-threatening conditions, the physician extender can assist.

“Extenders ‘extend’ a physician’s ability to see each patient as need without sacrificing the level of quality and attention given to them,” says Chris Loman, M.D., Medical Director of Emergency Medicine at Major Hospital in Shelbyville, Ind.

If patients don’t hear my introduction, it is easily visible on my name tag: Dr. Kathryn Miley, Family Nurse Practitioner. I’m not here to mislead anyone. I’m here to help alleviate the congestion in the emergency room.

A Board-certified nurse practitioner can perform both routine and acute care, including ordering lab work, wound care and diagnostic workups. This specialized care affords patients a number of benefits including shorter wait times, attentive treatment and management, great coordination of care, continuous access to a medical professional, and accurate diagnosing with necessary treatment(s) or referral to appropriate medical care.

“Extenders are a key resource within the E.D. at Major Hospital, both for physicians and patients,” Dr. Loman says. “Simply put, they fill a role to deliver health care more quickly, efficiently and compassionately than can be done by physicians alone.”