I vividly remember the first time I saw the term “mid-level provider” prominently displayed in the hallway of the hospital and thought, “Who are they referring to?” Within seconds, I received the answer in smaller script displayed below “(NPs/PAs)” and thought, “Why didn’t they just write NPs/PAs?” My reaction to that poster was visceral then and has remained the same every time I have seen or heard the term since.
My most recent encounter with this term was at a meeting where the term was used frequently, along with “physician extender.” As the only nurse practitioner in the room, I reflected on why this term made such a negative impression on me and how it may also serve to confuse and offend the many patients who I care for as well as the nurse practitioner students I educate. I recalled the other common “mid” words in my vocabulary: midnight, not a bad word unless you are having difficulty sleeping or have missed your curfew; midlife, which is usually accompanied by crisis; midwife, colleague, positive; midst, midair, midcycle, midi, midpoint, midriff, midterm, midway, or midwinter —how one considers these depends on one’s point of view and situation, but none are overwhelmingly positive. So I turned to the dictionary and found a positive definition of mid, “central.” I do believe nurse practitioners are central to the care of our patients and their families, as well as to the education of our nurse practitioner students. We are central in the healthcare system, often as the primary care provider, advocate, and coordinator of care for our patients.
My very visceral reaction to being referred to as a mid-level provider is that it implies (loudly) that the care I provide and the knowledge that I have is in the middle, not the best or the worst, just in the middle, mediocre, okay. I did not receive a mid-level education, and I do not provide mid-level care. I did not choose to be a nurse practitioner because I could not be a doctor. I chose to be a nurse practitioner because I wanted to be a nurse practitioner. I believe in the philosophy of nursing and the manner in which nurse practitioners provide care. My education, philosophy, and scope of practice are different from those of physicians. That does not make what I do mid-level, mediocre, or less than that of physicians.
It is also curious that nurse practitioners have been lumped into the same category as physician assistants. The education and scope of practice of each are similar but not the same. Physical therapists, occupational therapists, and pharmacists have escaped being put into the same “box.” No one would argue that the roles of each are the same. Even midwives and nurse anesthetists have somehow escaped. If I look to other professions outside of healthcare, others do not seem to have the same issues; teachers are teachers, accountants are accountants. I could go on and on.
I also asked several of my nurse practitioner colleagues how they felt about the term “mid-level provider.” Their reactions were similar: “I hate it,” “It makes me crazy,” “It is offensive, derogatory,” and perhaps my favorite, “I refuse to buy into the paradigm.” Yet despite the instant outrage when asked about the term, it lives on. My search on the Internet for the origin of the term yielded an article, “The Rise of the Midlevel Professional.”1 Fantastic. What or where have we risen from? Nurse practitioners have been a vital part of healthcare delivery in the United States since the mid-1960s. Research has demonstrated our effectiveness and versatility.2-7 Our patients appreciate the high-quality, cost-effective care we provide.8,9 The care nurse practitioners provide is, at the very least, as good as that of our physician colleagues.4 Isn’t there already enough confusion about who nurse practitioners are and what we do? Do we really need to allow more confusion? I can only imagine the reaction of an adolescent at the check-in desk when asked, “Are you here to see the mid-level provider?” or to a sign above the door reading, “Mid-Level Provider Office.”
I took the first step at that meeting, as the only nurse practitioner in the room—I pushed the microphone button and stated “as a nurse practitioner, I find the term mid-level provider offensive.” There was silence, no argument or comment, but some nodding in agreement. I encourage all nurse practitioners and physician assistants to do the same. Healthcare reform will change how Americans receive and experience healthcare. We need to talk about what we do and how well we do it. Enough is enough! I realize I am preaching to the choir so to speak, but if not us then who is going to speak up for us? There are too many people who need high-quality, dedicated providers; we are such providers and deserve the appropriate respect, recognition, and support from the healthcare community.
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