Midlevel is offensive to patients, physicians, and PAs. Stop saying it.

Is the term midlevel provider offensive? Yes, yes it is. And worse yet it’s not even close to being an accurate description of the care provided by PAs and NPs. So where did the term midlevel provider or midlevel practitioner come from and what should we be saying instead? Let’s start with the origin of the term itself.

The Origin of Midlevel

The first use of the term midlevel practitioner appeared in the 1970 Federal Comprehensive Drug Abuse Prevention and Control Act, also known as the Controlled Substances Act. Title 21, Section 1300.01(b28) defines the term midlevel practitioner as an individual practitioner, other than a physician, dentist, veterinarian, or podiatrist. So pharmacists, psychologists, audiologists, and chiropractors are also considered midlevel practitioners except most of them don’t have the training or authority to prescribe controlled substances like PAs. Medicare, on the other hand, uses the term “non-physician practitioner” to describe advanced practice nurses (NPs) and PAs (which isn’t a whole lot better).

“Midlevel” was a bureaucratic term and was never meant to imply anything regarding the quality or the complexity of care PAs are trained to manage. On the contrary, studies indicate that PAs provide care on par with physicians. That makes sense since some MDs actually train alongside PAs.

So why has the term stuck around? On a superficial level, it might make sense. Medicine has traditionally been practiced by physicians (at least for the last 100 years or so). And it’s common knowledge that physicians train for 4 years in medical school before structured on-the-job training known as a residency. Anything less than that might seem like a compromise.

The Origin of PAs

A physician shortage developed during the Second World War and PAs were created to fill that gap. PAs were created to be Associates, not Assistants. Eliminating the nonessentials that prolonged traditional medical training, PAs were designed to practice medicine after 2 years instead of 4. The catch, however, was that PAs would continue to work closely with physicians for the rest of their careers. The apparent gap in training time and the similarity of their duties make comparison inevitable. Though the gap isn’t as wide as it appears.

Formal training isn’t the only area where PAs appear to fall short of their MD counterparts. Educational debt is significantly lower for PAs and NPs than for physicians. But regrettably, so are salaries and respect. 

The big problem is though that there’s nothing “midlevel” about the care PAs provide. Patients expect (and deserve) the same diagnoses and the same treatments regardless of who is providing the care. The cholesterol test ordered by the PA is the same one ordered by the MD. The medication prescribed by the PA works just as well as when it’s prescribed by the physician. 

Some might suggest that PAs only manage cases of “midlevel” complexity. But there’s no evidence of this either. This author has diagnosed everything from cancer to rare genetic diseases. There’s no difference between the cases I manage and the ones the physician in our practice manages. 

The Learning Curve

To be fair, this hasn’t always been true. As a new PA, I was quick to consult with my physician employer and refer complex cases to internal medicine specialists. After 10 years, and additional clinical training as a Doctor of Medicine Science, both referrals and consults are few. A new-grad MD is better prepared than a new-grad PA, no doubt about it. But over time, the gap narrows.

Everyone Agrees: Midlevel is Out

If you did an internet search for ‘midlevel provider’ or ‘midlevel practitioner’, the majority of the hits would be from articles similar to this one. No one likes the term midlevel. 

PAs don’t like midlevel

PA Jim Anderson made this point, “By calling us midlevel providers, the title makes clear that we most certainly are not ‘high-level providers,’ a category I assume is intended for physicians to occupy. However, I’ve never heard of physicians being referred to as high-level providers. Second, the term implies that if midlevel providers exist, then ‘low-level providers’ must too. Who would that be? Nurses?”

Dr. Mike Sacks, a PA, and Doctor of Medical Science, points out that “midlevel practitioner” is often used as a derogatory term meant to belittle PAs. And when it’s used by those who don’t know any better, “it still feeds a narrative that was intentionally created by those who do mean PAs harm.”

“Every time a friend or colleague uses it and we don’t correct them, we allow this derogatory term the opportunity to proliferate to the extent that it winds up in legitimate research journals and media reporting,” says Dr. Sacks.

When a physician colleague or another non-clinician friend uses a term like “midlevel provider”, Dr. Sacks politely points out the harm that it does. “While I’m certain that wasn’t their intent, as I’m confident they don’t think that I provide midlevel care, I recommend they choose different words so people that don’t know don’t misunderstand their intention.”

Nicole Mason, DMSc, PA-C agrees. “‘Midlevel’ implies an inaccurate hierarchy and lower standard of care provided in clinical medicine. Considering PAs have clinical outcomes comparable to physicians, as well as fewer malpractice payments and fewer DEA adverse actions, this coined term fails to capture the full extent of a PA’s training, competency, and scope of practice,” she says.

The American Academy of PAs (AAPA) is also firmly against using terms such as midlevel that are “offensive to PAs but are also relics of the past.”

In their 2018 media style guide, AAPA reminds us that “today’s PAs collaborate with physicians. It is common for a PA to serve as the lead on care coordination teams and see patients in all settings without a physician present. In fact, in many rural and underserved areas, a PA may be the only healthcare provider for hundreds of miles. Thus, phrases like ‘physician-led teams,’ and/or ‘the PA is supervised by a physician,’ are also inaccurate.”

NPs don’t like midlevel

Is there really a hierarchy in medicine with high-level, midlevel, and low-level care? Nurses don’t think so! The American Association of Nurse Practitioners (AANP) states that terms such as midlevel providers and midlevel practitioner “originated decades ago in bureaucracies and/or organized medicine”. The same goes for “physician-extender” and “non-physician practitioner”.  

This is ultimately why “midlevel” refuses to die: it ostensibly puts all non-physicians in their place, that is, below physicians. Not in an informative sort of way but in a “higher-up-on-the-totem pole” sort of way. It’s as if the things learned in medical school were not available anywhere else and were impossible to obtain in any other way. We agree with the AANP that “these terms confuse health care consumers and the general public due to their vague nature”. They’re also just flat-out false. 

Physicians don’t like midlevel

But it’s not just NPs and PAs, physicians don’t like midlevel either. Dr. Michael Pappas is board certified in both general pediatrics and pediatric critical care medicine and he “hates it” when PAs and NPs are referred to as midlevel providers. “It is insulting to health professionals as well as to the patients that they serve,” he wrote in a 2014 blog.

“Children and their parents want to receive excellent medical care delivered to them by a kind and gentle clinician. MDs don’t have a market on that one. If, as a clinician, you can provide excellent medical care with humility, then you provide the highest level of care available. I don’t care if the initials after your name are MD, NP, PA, or DOA,” he says. 

Board-certified dermatologist and Chief Medical Officer of LaserAway, Will Kirby, DO shared his thoughts in a social media post, “Clinicians of all types should work together for the collective benefit of the patient with no regard to antiquated, hierarchical nomenclature and insulting terminology designed to suppress, control, and subjugate (like ‘physician extender’ or ‘midlevel provider’).”

Calling PAs “midlevel” also hides the fact that they often train physicians how to do their job. Celebrity physician Zubin Damania, MD credits a PA for teaching him how to perform critical, life-saving procedures: “Central lines, chest tubes, all of that was taught to me by my surgical PA when I was training.” 

A physician told me about a time in his training when he was a resident and was working with an experienced PA. They were about to perform an invasive procedure when the patient asked that it be done by the physician rather than the PA. The physician looked at the PA and said, “How many of these have you done?” “A few thousand”, came the reply. The physician looked back at the patient and said, “Well, this is my first one.” The patient promptly changed his mind. That doesn’t sound like midlevel care to me.  

Patients don’t like midlevel

What kind of message does it send when a hospital or physician hires a “midlevel”? If the name were a true reflection of the type of care provided, employers would be guilty of malfeasance. It would also reflect poorly on the physician collaborating with the NP or PA (where applicable).

Plenty of patients prefer their PA as their primary care provider and others see the PA and MD interchangeably. Practices rely on the income generated by PAs. None of this would be conscionable if the PA provided substandard, midlevel care and PAs wouldn’t lead 400 million patient visits a year.

Competency, Not Credentials

The bottom line: Medical care should be about competency, not just credentials. If you’re trained, you’re trained. But, as Dr. Pappas suggests, it’s also about attitude. Give me a new grad PA, compassionate yet humble, hungry for knowledge, and a commitment to evidence-based practice over a world-renowned doc who just doesn’t care anymore. You can teach the practice of medicine, but you can’t readily teach kindness and compassion. 

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