Mid-level is offensive to patients, physicians, and PAs. Stop saying it.

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

The Origin of Mid-Level

The first use of the term mid-level 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 mid-level practitioner as an individual practitioner, other than a physician, dentist, veterinarian, or podiatrist. Pharmacists, psychologists, audiologists, and chiropractors are also considered mid-level 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.

“Mid-level” 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

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). It’s common knowledge that physicians train for 4 years in medical school before structured on-the-job training known as a residency. 

The Origin of PAs

A physician shortage developed during the Second World War and PAs were created to fill that gap. Eliminating the nonessentials in traditional medical training, PAs were designed to practice medicine after 2 years vs 4. The catch, however, was that PAs would continue to work closely with physicians for the rest of their careers. The apparent gap in their training times makes 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 unfortunately, so are salaries and respect. 

The only problem is, there’s nothing “mid-level” 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 Lipitor prescribed by the PA works just as well as when it’s prescribed by the physician. 

Some might suggest that PAs manage cases of “mid-level” 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. 

And it’s not just me, either. If you did an internet search for mid-level provider or mid-level practitioner, the majority of the hits would be from articles similar to this one. No one likes the term mid-level. 

Everyone Agrees: Mid-level is Out

PAs don’t like mid-level

PA Jim Anderson made this point, “By calling us mid-level 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 physicians being referred to as high-level providers. Second, the term implies that if mid-level 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 “mid-level 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 “mid-level provider”, Dr. Sacks politely points out the harm it does, “While I’m certain that wasn’t their intent, as I’m confident they don’t think that I provide mid-level care, I recommend they choose different words so people that don’t know don’t misunderstand their intention.”

Nicole Mason, DMSc, PA-C agrees. “‘Mid-level’ 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,” says Dr. Mason.

The American Academy of PAs (AAPA) is also firmly against using terms such as mid-level 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 health care 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 mid-level

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

This is ultimately why “mid-level” refuses to die: it seemingly 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 mid-level

But it’s not just NPs and PAs, physicians don’t like mid-level 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 mid-level 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. 

Calling PAs “mid-levels” hides the fact that they often train physicians how to do their job. Celebrity physician Zumbin 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.” 

Another 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 mid-level care to me.  

Patients don’t like mid-level

What kind of message does it send when a hospital or physician hires a “mid-level”? 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, but oftentimes patients 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, mid-level care and PAs wouldn’t lead 400 million patient visits a year.

Competency, Not Credentials

And this is really the point: 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 humanity. 

6 Comments

  1. MN

    Being offended is a choice. I’ve not been offended by this name and phrasing. Ever.

    While you may be, this article title is an assumption that we all are offended. We are not all offended.

    • Bano

      Don’t tell me, we are not physicians and that we should go to Medical school… stop this useless illogical notion.
      This is the time to come out and don’t be scared to stand on your own.
      Our profession is the best of all the medical professions… just get evolved.
      Even water gets spoilt by being stagnant, PA profession needs complete evolvement without being stagnant…
      stagnant makes matter rotten, inertia makes matter fresh, active and refined…..
      Come out of this mental block that we are some low level or mid level or some advanced level third rated professionals.
      Take full responsibility of your patients, be independent, change the name and get your profession in your hand before it is too late.
      Wake up before this profession becomes EXTINCT.

  2. Bano

    Mid level is highly offensive, insulting and equal to work place harassment by putting PAs profession under the carpet as if PAs are some second class marginalized professionals who are providing inferior quality of the patients care while it is a big fact that PAs are providing the most superior quality of care out of all of their competitors like MDs and DOs.
    NPs are not their competitors because NPs are trained Nurses who later do some unstructured and random online and few online learning and then shadowing out primary care and gyn clinics. They are trained on nursing modules. While PAs/MDs are trained on Allopathic module and DOs are as osteopathic module.
    The name PA needs to change immediately as it gives false perception to the patients as if we are inferior health care workers.
    Our title should be DGM, Doctor of General Medicine. The reason this name is PAs are highly skillful Allopathic medical professionals trained in General medicine and general surgery exactly with the same curriculum and much more as Allopathic medical college students, the only difference comes with residency when PAs start their job right after graduation and board certification at job training and they become the best after 2-3 years of job training.
    While MDs get in to residency training for 3 years.
    Doctors ( other than PHDs) are the professionals who examine the patients , do testing, diagnose their illnesses and then make treatment plans.
    PAs and MDs do exactly the same thing that’s why PAs should be called DGMs( Doctors of General medicine) and if they go for surgical side then S should be added to DGM like DGMS.
    Please stop insulting PAs. Enough is enough!!!

  3. Larry Payton

    What’s in a name?
    Our Past Doesn’t Have To Be Predictive Of Our Future.
    In 1974 when I graduated from the USPHS PA Program on Staten Island, New York PA’s were then often referred to as Physician Associates. Many of us were military trained and field medicine experienced who honed and expanded those skills in PA Programs that were themselves elevated by our presence.
    So, 47 years later and retired, when I check on my former colleagues it seems the most significant accomplishment in our profession is that we can now call ourselves Physician Associates, again.
    This profession must reinvent itself. It must step up and take it’s earned place alongside Physicians, Nurses, Pharmacists, Osteopaths, Psychologists and the other fully validated medical professionals from around the world.
    Walking to the rear and slightly to the left of the medical establishment by applauding and promoting an auxiliary status is out of step with the history, training, experience and the superior care you provide, the skill you demonstrate, the courage you exhibit every day under fire of COVID19, and the challenge of a second class designation among health care providers.

    Respectfully 
    L. Payton PA, PA-C, PA (Retired)

  4. PA Furey

    If I’m not mistaken, Dr. Stead used the “Fast-Track” MD program from WWII. These are 3-year programs that exist even today. Pumping out MDs with full title’s, privileges, and licensing.

    Many PA programs are already 3-years, and some also require MCATs. We arguably do more clinical hours these days (MD students get to go home at 5pm, are allowed to miss a significant number of days each rotation due to test taking activities, and aren’t evaluated by their preceptors in a pass/fail model). When I trained at USC, if you missed 2 days of a rotation you better be dying, 3 days and we would have to repeat the rotation. We would do 24 hour shifts, since the laws didn’t apply to us, and our preceptor reviews were scrutinized under a pass/fail model (something that most preceptors were wholly unaware of). I was also accepted into a residency program, and passed the optional surgical certification.

    So, yea, I think mid-level is a little demeaning.

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