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.   

Wayne Hansen, ARNP, NP-C, MSN,CCRN, CEN
Well put and I wholeheartedly agree. Thanks.
We still have a long way to go to clarify the confusion and negative connotations that this term embodies.
12/3/2014 6:55:33 PM

Cynthia M Bratcher
Mr or Ms Canon,
Independent practice in the ED I am employed is not an option. This is regulated by the facility and state regulations, and I should have made it clear that I was speaking of my own experience only. Thank you for allowing me to clarify the point.
11/19/2014 8:00:36 AM

J Canion
Mrs. Bratcher

I am a Nurse Practitioner and I have a problem with one aspect of your article. Saying that we have no illusions about independent practice in the emergency setting. I'm curious what exactly you mean by that statement. I solo cover ERs and I'm not sure your statement is appropriate or beneficial to our profession.

Thanks for your time.
11/16/2014 10:26:18 PM