Healthcare PolicyPhysician Office Issues

MID-LEVEL PROVIDER: What Does That Mean?

A popular term used frequently, at least in the medical community, is “mid-level provider.” This is the name given by the Drug Enforcement Administration to nurse practitioners, physician’s assistants, nurse midwives, nurse anesthetists, and clinical nurse specialists who, as non-physician providers, are permitted to prescribe and dispense controlled substances (narcotic analgesics, sleeping medications, etc.). But the individuals who populate this category of practitioners are unhappy with that name. They would prefer to be called “advanced practice clinicians” or “advanced practice providers.” The reason for their discontent is their feeling that the term seems to ignore the post-graduate training and advanced educational degrees that many of them have. It implies they are of lesser importance or less qualified to diagnose and treat patients on their own. They say that most MLP’s have “at least a master’s degree and many hold doctorates.” They are “highly trained to care for and manage a variety of illnesses.” “There is nothing “mid” about either an NP or a PA. …..we provide a high level of care. Our skill set, education, training, and knowledge go above and beyond what would be considered mid-


Well, I think this is probably true in large academic centers and “ivory tower” medical institutions who have the ability to attract and employ the “cream of the crop” of graduates. But what is true of physicians and surgeons is true of NP’s and PA’s. They weren’t all at the top of their class and aren’t all as capable as we would like them to be. There are good ones and there are less good ones (I refuse to say “bad”). Some are simply smarter, better trained, more compassionate, and better listeners than others. That’s just the way things are. And just like physicians (of whom I’m very critical) one has to be cautious in choosing the practitioners to whom they trust their health care decisions. 

As a physician I’m biased in thinking that only MD’s or DO’s can provide high quality care, but I know in today’s environment that’s heresy. I have personally been on the receiving end of care from a PA, and know these practitioners make correct diagnoses and prescribe appropriate treatment. At least they do what I would have done. Those PA’s and NP’s who practice in a specific specialty become particularly adept at delivering good care. My wife had a total knee replacement. She saw the surgeon for the initial consult and pre-operatively but never again. All her hospital and post-op care and emergency calls were handled by his PA. This man was a true “extension” of the surgeon. We developed trust in his ability, and he became her provider. This is one example of the positive end of the bell-shaped curve. 

One negative consequence of the growth of NP’s and PA’s, however, is the decline in the value and pertinence of primary care physicians. Family physicians are declining in number because of the public perception that they are no more capable than a good MLP. PA’s and NP’s finish their training in less time than MD’s, and more people are choosing the shorter, less rigorous MLP career path than are entering Family Medicine residencies. So the market for MLP’s is alive and well. Some MLP’s are willing to practice in areas physicians reject. Rural areas and small towns in particular can’t find MD’s but hire MLP’s who have no qualms and are happy to serve. 

So, unfortunately for Family Medicine, advanced care practitioners are doing the work and practicing in locations where MD’s are unwilling to go. Many states have state-funded rural clinics run by MLP’s who are the only providers around for miles. It’s too bad everyone can’t have a doctor who is perceived as knowledgeable and caring. There are simply too many people who need high quality care for physicians to see them all. That’s where PA’s and NP’s come in to fill that void. One academic nurse practitioner stated, “There are too many people who need high-quality, dedicated providers; we are such providers….”

I suspect in the future the term “mid-level provider” will be replaced by “advanced practitioners.” But physicians need to change their attitudes, be better listeners, make personal sacrifices to better serve their patients, and regain some of the prestige and respect they’ve lost in recent years. Our PR image needs a wholesale renewal. I’ve become a cynic because so often I hear people complain about the personal treatment, or lack thereof, they experience from a physician. If we don’t make some significant changes, we will cease to be taken seriously and be summarily replaced by these practitioners. I hope that never happens. 


“Advanced Practitioners are not Mid-level Providers,” Bishop. Journal of Advanced Practice Oncology, Vol. 3, No. 5, pp 287-288, Sept/Oct 2012. regimens/practitioners

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