When it comes to professional terminology and labels to refer to different occupations, language is constantly evolving. For the unaware, using an outdated title can be an innocent mistake. Even if unintentional, using the wrong designation can be extremely embarrassing—or worse—offensive.
For advanced practice nurses (APNs) and physician assistants (PAs), there are a number of identifiers that carry with them patronizing or degrading undertones. Mid-level practitioner and mid-level provider are the most common, but you may also hear physician extender, limited license provider, non-physician practitioner, and allied health provider, which are all considered derogatory by the American Association of Nurse Practitioners (AANP) and should be avoided.
Why all the acrimony? What’s the story behind this controversy? Does the term “mid-level” serve any purpose in healthcare? Are there any designations that should be used instead?
Years ago, it was acceptable to refer to administrative personnel as “secretaries” or custodial staff as “janitors.” We have since moved on from such nomenclature because they have developed potentially demeaning connotations. Gender-specific titles such as “policeman,” “fireman,” or “mailman” have all fallen out of fashion and been replaced by gender-neutral designations like “police officer,” “firefighter,” or “mail carrier.” These were all conscious decisions made as a society to use more inclusive language. It’s time to apply the same approach to healthcare and eliminate terms like “mid-level provider” that imply a hierarchy within clinical practice.
At its most basic, the term “mid-level” is not particularly inaccurate. Nurse practitioners (NPs), nurse anesthetists, clinical nurse specialists, nurse midwives, and PAs all demand advanced degrees and additional training beyond what registered nurses (RNs) and licensed practical nurses (LPNs) must complete. However, these APNs and PAs do not have to go through the same amount of preparation as physicians. Simply put, the education and experience needed to obtain licensure fall in the middle of what is required for nurses and doctors.
Many experts and healthcare providers make the case that using “mid-level practitioner” suggests that APNs and PAs deliver mediocre—or mid-level—care. However, this isn’t the best argument because to say that “mid-level” speaks to quality of care is to say that the very existence of “mid-level practitioners” implies that RNs or LPNs provide low-level care. Yet you’ve probably never read an opinion piece by an RN or LPN complaining about their “low-level” status.
The term “mid-level practitioner” began as an administrative designation coined by the US government. The Drug Enforcement Agency (DEA) uses “mid-level practitioner” as an identifier to help organize its drug diversion activities. The DEA Office of Diversion Control offers the following definition of “mid-level practitioner”:
“an individual practitioner, other than a physician, dentist, veterinarian, or podiatrist, who is licensed, registered, or otherwise permitted by the United States or the jurisdiction in which he/she practices, to dispense a controlled substance in the course of professional practice.”
In addition to the DEA’s use of “mid-level practitioner,” Medicare uses another less-than-flattering term to describe APNs and PAs: “non-physician practitioner.” In response to the rise of advanced practitioners as well as the expansion of Medicare, the Balanced Budget Act of 1997 modified how the Medicare program paid for services delivered by these healthcare providers and set the level of reimbursement. Similar to the DEA’s use of “mid-level practitioner,” Medicare’s classification of “non-physician practitioner” was established as an administrative identifier for the program’s CPT code set used to describe medical, surgical, and diagnostic services for financial and analytical purposes.
The healthcare field is so completely saturated with highly technical terms and job titles that shorthand is needed to simplify conversations with patients and make subject matter a bit more accessible. For this reason, instead of talking about “registered nurses” or “licensed practical nurses,” we just refer to “nurses.” Rather than always specifically talking about an “oncologist,” “pediatrician,” or “general practice physician,” we use “doctor.” It’s necessary to have an alternative for “nurse practitioner,” “nurse anesthetist,” “clinical nurse specialist,” “nurse midwife,” and “physician assistant” that allows for practical grouping while giving these dedicated healthcare specialists the respect they deserve.
Catherine S. Bishop, Doctor of Nursing Practice and Oncology NP at Sibley Memorial Hospital in Washington, DC, made the case for a change in terminology in the Journal of the Advanced Practitioner in Oncology and suggested an excellent alternative:
“There is nothing ‘mid’ about either an APN or a PA. I think all would agree that we provide a high level of care. Our skill set, education, training, and knowledge go above and beyond what would be considered mid-level ... Let us stand together and request that the adopted terminology of mid-level, physician extender, and non-physician practitioner be abolished. If we are referred to as a group, call us advanced practitioners. Otherwise, let us simply be called what we are: nurse practitioners and physician assistants.”