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Mid-Level Providers – It’s Time to Rethink this Common Name for Physician Assistants and Nurse Practitioners July 23, 2010
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Folusho Ogunfiditimi, MPH, PA-C About the Author
Folusho Ogunfiditimi, MPH, PA-C

“Who we are and what we are!”

The American Academy of Nurse Practitioners (AANP) recently released a memo voicing their strong opposition to the term “Mid-Level Providers (MLP)” and “Physician Extender” as an aggregate reference to Nurse Practitioners (NP) (1). In 2008, the board of directors of the American Academy of Physician Assistants (AAPA) approved an AAPA House of Delegates resolution to refrain from the use of the term “Mid-Level Provider” (2).  However, many federal agencies, such as the Drug Enforcement Agency (DEA) (3), the Centers for Medicare and Medicaid Services (CMS) (4),  professional organizations such as the American Academy of Family Practitioners (5),  and health institutions, (including the author’s institution)  Henry Ford Health System (HFHS) (6) ,  have all referred to NPs and PAs as Mid-Level Providers or as Non Physician Practitioners (NPP), as a collective nomenclature to reference these specific groups of health care practitioners.

The professional and clinical abilities of PAs and NPs have been well established (7, 8, 9), however, this well established reality is at risk of damage due to misrepresented perceptions of patients and professional colleagues. By maintaining and continuous use of the reference “MLPs”, a long lasting disservice to our patients and to our colleagues can occur. A general consensus that not only eradicates this name but also develops an appropriate common nomenclature that captures the essential strengths of these health care professionals is needed to fortify the professional standards held by PAs and NPs. The AAPA (1) and the AANP (2) have taken the individual (and appropriate) stand of referring to their prospective health care professionals by their established degrees, but this is not the solution. Using their established degrees as a nomenclature is analogous to a referencing a medical doctor by their varying degrees [i.e. Medical Degree (MD) or a Doctor of Osteopathy (DO) or Medical Bachelor, Bachelor of Surgery (MBBS)] instead of the appropriate reference of Physician, or a reference to an attorney by their multiple arrays of degrees [i.e. Bachelor or Law (LL.B), or Doctor of Jurisprudence (JD)]. Professional degrees such as MDs, JDs and Pharm-Ds all have well defined nomenclatures (Physician, Attorney, Pharmacist) that distinguishes what they are from what degree they obtained. A degree in Physician Assistant studies or a degree in Acute Care Nurse Practitioner, or Family Practice Nurse Practitioner or Pediatric Nurse practitioner studies only defines who we are and does not reference what we are or what we do. An appropriate nomenclature that captures “what we do” is needed for PAs and NPs.

“PAs and NPs in the Limelight”

Now, more than any other in our profession, is the time for this discussion. The United States Congress is on the verge of passing a landmark historical health care reform bill that emphasizes and expands the use and role of PAs and NPs. In Senator Baucus “ Call to Action – Health Care Reform 2009” bill, the roles of PAs and NPs are frequently interchanged and referred to as Non-Physician Practitioners(10). CNN Money and Payscale.com recently ranked the PA profession the #2 job and the NP Profession as the #4 job in its 50 Best Jobs in America based on job satisfaction, growth projection and salary (11).  These recent external exposure to the PA and NP professions highlight the need for PA and NP leaders to foster, improve and enhance their  relationship and growth patterns in an attempt to provide standard quality health care delivery systems. Developing and implementing a common, appropriate and equitable aggregate nomenclature for both of these professions would be a good example of that enhanced relationship.
 
“Nomenclatature Suggestions”

The AANP has suggested aggregate nomenclatures terms such as “Licensed Independent Practitioner”, “Primary Care Practitioner”, “Health Care Professionals” or just plain “Clinicians” (1) . The AAPA has suggested names like Non Physician Practitioner (NPP) (2) . In both circumstances, these suggestions indicate a lack of broad perspective on the part of each organization, a lack of integration, an affinity for a display of independence of profession or an emphasis on what the profession is not. I.e. Non-Physician. This isolated approach and stance taken by the respective professional organization demonstrates a lack of interest in the discussion or more appropriately, a lack of understanding of the importance of the debate. It also demonstrates each professional organizations comfort with the individual reference to professional title of PA or NP as adequate. Though these titles are individually appropriate, a more commonly applicable name is needed to substitute and facilitate the expansion, use and collective assessment of these providers. An effective aggregate nomenclature will foster integration and inter relations between both professions as we anticipate comprehensive and interchangeable scope of practice in health care delivery systems across the country.  As a PA or an NP, a continuous evasion of the discussion or lack of interest in the debate will only result in solutions constructed and implemented by external stakeholders such as Physicians, Third Party Payers and Legislators. PA and NPs leaders have to be the source and contributors to this solution.

Several reasonable options have been discussed in national, local forums and health institutions, terms such as Advanced Practice Practitioner, Advanced Clinical Practitioner, Licensed Physician Partners, and Allied Health Practitioners have generated some interest and used by employment agencies looking to attract both PAs and NPs, however, no general consensus has been reached or discussed at in-depth and practical level. Opposition from internal, external and special interest groups and other challenges such as the inclusion or exclusion of other allied health professions have also stymied any practical solutions. At HFHS, our Mid-Level Provider Council (MLPC), composed of PAs, NPs, Nurse Midwives, and Nurse Anesthetist, has commissioned a special work group to investigate, develop and seek general consensus on a more appropriate terminology. One that appropriately defines our practical ability while clearly exemplifying our professional capabilities to our patients.

Summation:

Now is the time for national leaders of PAs, and NPs in particular, to join forces on multiple issues, but specifically on this single well defined challenge, in an attempt to navigate around future ventures geared towards professional development of both professions and enhanced ability to provide quality and effective health care to all patients around the country. Names like “Mid-Level Provider” or “Physician Extender” or “Non Physician Practitioner” should be re-evaluated, with re-defined boundaries, roles and responsibilities of the PA and NP to properly reflect their education, professionalism and contribution to the delivery of quality health care in the United States and around the world. The similarities between roles and duties of PAs and NPs in particular require PA/NP leaders, physicians, hospital administrators, practitioners and managers to contribute to this debate and develop an appropriate nomenclature that will encompass the abilities and education of these highly skilled health care providers without diminishing their accomplishments or misrepresenting their abilities to patients. As health care evolves and with reform looming in the very near horizon, it is time to address this interesting and ever so controversial debate.
 
References

1. American Academy of Nurse Practitioners (AANP). Use of Terms Such as Mid-Level Provider and Physician Extender. (August, 2009). http://www.aanp.org/NR/rdonlyres/5AC2D9E3-74FA-4BF2-BF2F-1E424A62E516/0/MLP.pdf

2.   American Academy of Physician Assistants (AAPA) News. Interest on “Mid-Level” and “Advanced Practice Clinician”. March 30th, 2008. Vol. , Issue  pg. http://community.advanceweb.com/blogs/pa_1/archive/2008/03/25/aapa-bod-don-t-use-midlevel-or-advanced-practice-clinician.aspx 

 

  • 3. Drug Enforcement Agency  (DEA). Mid-Level Practitioners Authorization by State http://www.deadiversion.usdoj.gov/drugreg/practioners/index.html

  • 4. Centers for Medicare and Medicaid Services. http://www.cms.hhs.gov/MLNGenInfo/ 

    5. American Academy of Family Physicians. Mid-Level Provider Issues. 2009. http://www.aafp.org/online/en/home/practicemgt/specialtopics/mlpissues.html 

    6. Henry Ford Health System. Mid-Level Providers. 2009. http://henry.hfhs.org/body_dept.cfm?id=9248

    7. Buch, K., Genovese, M., Conigliaro, J., et.al. Non-Physician Practitioners Overall Enhancement to a Surgical Residents Experience. J. of Surgical Education. 2008;65, (1), 50-53. 

    8.
    Hooker, Roderick. Physician assistants and nurse practitioner: the United States Expereince. Medical Journal of Australia. 2006; 185 (1): 11. 

    9.
    Grey, M. My Opinion: NPs ad PAs should work together. N J Nurse. Jul-Aug 1992; 22 (4):12 

    10.
    Senate Finance Committee – Senator Max Baucus. Call to Action – Health Care Reform 2009. http://finance.senate.gov/healthreform2009/finalwhitepaper.pdf 

    11.
    Cable News Network (CNN) Money. Best Jobs in America 2009. http://money.cnn.com/magazines/moneymag/bestjobs/2009/index.html


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    abcdefg (Pakistan) on 11 Feb 2012 at 6:04 am

    If you think of the word associate in terms of different academic ranks, associate professor is usually considered a mid-level, tenured professor, versus a senior professor.

    The term associate may be confusing to some patients because in a business sense the word associate confers a partnership, equal ownership. I wound not consider the partnership between PA/NP and physicians as equal. Physicans are the ones ultimately responsible for decisions being made and PA/NPs must sign off the work they do. If PA/NPs want equality they should take full responsibility for their deicisons and be required to take full malpractice coverage.

    jen (michigan) on 30 Dec 2010 at 9:47 am

    My institution tried to use 'physician extender' for a while, at a high level meeting with section representatives, the first time this term was used i raised my hand and made the following point... I am neither a lego set nor a penis, I do not extend. (when a female uses the word penis in mixed company with a straight face people shut up). I have not heard it since. They are big on using MLP now, i correct people and say I am a nurse practitioner. But I do not know what a collective name should be. The only people who seem to need it are institutions and billing agencies. Perhaps we just stay with NP/PA. There are not other licensed providers that do what we do. You do not hear a collective term for physicians. When an organization refers to medical staff we are included in that heading. I submit changes in documents being voted on crossing out physician and writing in provider.... how about medical provider... keep it simple and to the point.

    jen

    Gwen (Pennsylvania) on 28 Sep 2010 at 2:39 pm

    Licensed Independent Practitioner is appropriate if there needs be a group term.

    On each occasion when referred to as MLP I politely remind I am a CNM there is no mid-level on my certification, diploma or license.

    Tina (Los Angeles) on 01 Sep 2010 at 10:02 pm

    Who is against changing the PA title to reflect reality more truthfully? Why would any group want to conceal the high level of medicine that PA's practice? (and NP's) PA's usually consult with a physician in unusual or extremely complicated situations. This is not "mid-level", and this is much more than an "assistant". My PA program was 107 semester credit hours of gradute basic and clinical science (most MD programs are 120. Considering most master's degrees are 30 to 40 credit hours, and PH.D.'s are 60 to 80, I really don't know why we don't have the title of Doctorate. Are there any other master degrees that require more than most PH.D. programs? Maybe we need a doctorate "bridge program" for PA's that consists of 13 credit hours. I think Physician Associate, or Associate Physician is a more honest and appropriate title. This is not about competing with anyone. I think most physicians would want to know, and would want the public to know, that all of the clinicians out there doing "what physicians do" are actually very highly trained in medicine. This is actually a complement to physicians(ie, not just anyone can do this)

    Scott Urquhart, PA-C (Fredericksburg, VA) on 28 Jul 2010 at 11:01 pm

    Thanks for the article. This has been a thorn in my side since the inaccurate term of Mid-level provider was birthed. I have educator appointments for two university PA programs and don't like to hear PA students referring to themselves as MLP's, especially since this term is not endorsed by the AAPA.
    Problem, this title is unfair and unacceptable to NP's and PA's alike. MLP term is established by large institutional settings for hierarchical identification. The real problem is that it strips us (PA's and NP's) of our professional identities. The other problem is that is implies that we provide not great care just "mid level care". Local hospital ad might read something like this " we are a progressive cutting-edge hospital capable of providing mid level care to meet all of your needs" We are PA's and NP's, so don't confuse the public or downgrade our training/skills with such thoughtless terminology. We as "MLP's ( just kidding) need to stand firm, not accept this terminology, and voice our concerns and opinions to the leaders of the institutions using the terminology. Finally, all PA and NP programs should denounce this terminology with all of their students.

    nurra (New York) on 28 Jul 2010 at 6:48 pm

    Nurse Practictioners do not need a name change but PA's do. Our practice and science is based out of nursing not medicine. Most NP's like myself never wanted to be physcians but carried their nursing education and experience as far as they could with advanced practice. I am not interested in renaming my practice. I am proud to have come from the nursing profession. It is a science of caring and a holistic approach to health with and without medicine . Can PA's say that?

    J. Luther PA-C (Vancouver, WA) on 28 Jul 2010 at 6:40 pm

    I agree the term Physician Assistant does a disservice to our profession. And it doesn't get better with time either. I've heard patients say "I don't want to see the assistant, I want to see the actual doctor". Or the "physician's assistant"; that's just as great, not. Our profession has been establish for so many years now and there's still misconceptions about it, even among some doctors!

    I do believe the title is an important issue. It needs to be changed to more accurately reflect our function and give us the respect we deserve. "Advanced Practice Clinician" is a good thought. I also like the idea of "Associate Physician". I have a neighbor who is the associate principal of a high school. His day to day duties involve many of the same work as the principal, without the same pay and degrees. "Associate Physician" tells the patient we practice medicine similarly to physicians but we are not physicians, without being called their assistants. I think "Medical Provider" is too generic and can include midwives, chiropractors, naturpaths, etc. who function very differently.

    Same issue can be said for our Nurse Practitioner colleagues. The "Nurse" in the title just doesn't accurately reflect the level of education and does not tell a patient that this person can consult, examine, diagnose, and prescribe like physicians.

    Bernadette Thomas, NP-C (Newark, DE) on 28 Jul 2010 at 10:47 am

    I agree with Dave and Monica, I like the name "Advanced Practice Clinician." No we are all not doctors, but our practice is exactly what the title suggest. I am all for it! No rivalry...just good medicine.

    Ann (NC) on 28 Jul 2010 at 7:24 am

    How 'bout Medical Provider? MP. I'm not a fan of Mid-level Provider because it implies that RN's or LPN's are Low-level providers.

    Through the years, I have seen the failings of the "assistant" part of the Physician Assistant title. And I've seen a TV show that portrays a PA as just that, an assistant, and not a provider (except on rare occasion).
    Recently, I've seen where PAs want to change our title to Physician Associate. It continues to tie us to physicians as non-physicians.

    We provide medical care... so call us Medical Providers.

    Monica (Texas) on 27 Jul 2010 at 11:10 pm

    Whatever term is decided upon needs to serve the patient and public, rather than political agendas or personal feelings on the matter. Quite frankly, nursing has too many levels, and it is no wonder patients are confused at times. We need a common ground to reassure the public that those with the designated title are competent and legal to diagnose and prescribe. I'm glad to hear that Advanced Practice Clinicians was submitted. The title implies competence beyond basic training. It flows well. Sounds pretty classy to me. I think being able to add initials behind the APC designation might be more palatable to many. Ex. APC, FNP-BC etc. It might help decrease the anxiety or offense that seems to be taken by changing to an umbrella term for our professions. So, we adopt a common name, but still keep our individual titles and identity.

    James Devaney (Eugene, OR) on 27 Jul 2010 at 7:39 pm

    This is a debate that has been ongoing in nursing circles for some time regarding NP, CNS, CRNAs, CRNM and now DNP. The most sensible I've seen so far is the Advanced Practice Registered Nurse (APRN). I don't know very much about PA nomenclature but PA practice seems to vary from APRNs in the level of independence afforded APRNs (in many states) contrasted with the dependence of the PA on the MDs supervision. But maybe PAs are more independent than in the past? It may be more disorienting to the general public to mix the various nursing APRNs with NPs. At least at this time.

    Diane Baptista FNP-BC MSN (Albuquerque NM) on 27 Jul 2010 at 3:47 pm

    Call me what I am : Nurse Practitioner or NP preferably FNP; call my PA colleagues what they are: Physician Assitants or PAs. Why so we need one term ?
    We are NP/PAs or PA/NPs... There!! quite simple.

    Dave Mittman, PA (Livingston, NJ) on 27 Jul 2010 at 1:30 pm

    Two different points being discussed.
    Point number one- A group of NPs and PAs did get together and issue a statement. It came from the American College of Clinicians a few years ago and said use both professional names when discussing us, but if you want an umbrella term, call us 'ADVANCED PRACTICE CLINICIANS. A bit "nursey" for PAs at first, but you get used to it fast.
    Number two-Pharmacists, naturopaths, optometrists, physical therapists, chiropractors and many other professions who do not practice at the level of PAs and NPs are called doctor. But I agree there is potential for misidentification so I would say, Hi I am Dr. Eugene Smith. I

    AM A PA so please call me gene or whatever-I think if you are an NP or PA you can and should call yourself doctor but make sure it is clear you are not a physician.

    Dave Mittman, PA

    JAN Marie Guy (Los Angeles California) on 25 Jul 2010 at 1:02 pm

    Greetings!
    A very touchy subject to say the least! Here in California, there seems to be more of an affinity to hire NP's than PA's. Why? Perhaps due to a strong Nurse's Union in the State? Perhaps the term Nurse has more familiarity than the term PA? Perhaps due to billing reimbursement? Who knows?

    Also, since there is now a program whereby Nurses can obtain their doctorate degree, how will they be called? And will that further separate them from the "MLP" title? Will that new title cause others to call them "doc"? What about those of us who are PAs who already have/ or are almost completing our doctorate degrees? Will the title of "doc" cause a misconception in our roles? Does any of this matter? Just thought that I would make a comment and also stir up some ideas regarding how those of us with doctoral degrees will be addressed.... Any thoughts out there? Would love to hear from you :)

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