May 28, 2021

By Amanda J. Chaney, DNP, APRN, FNP-BC, AF-AASLD; Elizabeth K. Goacher, PA-C, MHS, AF-AASLD; Andrea A. Gossard, APRN, CNP; John D. Lingerfelt, CAE; and Lisa M. Richards, MSN, FNP, AF-AASLD

With the advent of the nurse practitioner (NP) and physician assistant (PA) professions in the 1960s to address the shortage of primary care providers in the United States, medicine was faced with the challenge of how to describe this new category of healthcare providers. The term “mid-level provider” became nomenclature, both casually and formally, in an era that viewed physicians as the head of the organization with a hierarchical structure that ordered all other players accordingly. While the term “mid-level” was used out of necessity at the time, it was an inaccurate descriptor, insinuating that these providers were in some way less than physicians and greater than nurses, medical assistants, and nursing assistants. We posit that as healthcare has evolved to embrace the team approach to care, it is time to use the power of words and accurately address nurse practitioners and physician assistants as advanced practice providers (APP).

NPs and PAs spend on average six years in graduate education to become board-certified in their respective specialties. In addition, there are several fellowship programs and additional specialty training that exist to further education and expertise. While this contrasts with the more extensive medical training necessary to become a physician, there is growing evidence to support that healthcare services by APPs can provide equivalent or even better outcomes and reduce costs. Within our specialty, Elliot B. Tapper, MD, and colleagues reported in the January 2020 issue of Hepatology that patients receiving care by an APP had higher rates of hepatocellular carcinoma (HCC) screening, variceal screening, use of rifaximin after discharge for hepatic encephalopathy, reduced 30-day readmission risk, and 50% reduction in mortality. When patients experienced collaborative MD/APP care, these findings were even more impactful. For many, if not all, institutions or private practices, the financial stability and success of the practice falls heavily on shoulders of the clinicians including NPs and PAs.

Use of the term “mid-level” to describe APPs discredits their education and experience, and devalues their work. It supports the outdated view of medicine as a hierarchy. The downstream impact of this should be considered in the context of potential impact on work culture. Hierarchical microaggressions contribute to systemic devaluing of a person based upon their role. The costly impact of burnout in the healthcare workforce has been repeatedly demonstrated. To use the more accurate descriptor of “advanced practice provider” would be a simple way to strengthen our collective work to reduce burnout and support workplace resilience.

Inside an institution or private practice, poor mental health and toxic work conditions can have a catastrophic effect on the bottom line. According to a publication in The Lancet Global Health from November 2020, poor mental health was estimated to cost the world economy approximately $2.5 trillion per year in reduced productivity in 2010. That cost was projected to rise to $6 trillion per year by 2030. Poor mental health and toxic or non-supportive working conditions cause provider burnout, and burnout can lead to declining patient care and patient satisfaction scores, leading to drop in perceived or actual lack of quality of care.

Additionally, use of the term “mid-level” may imply discredit to your institution or practice. To address a member of the team as “mid-level” with colleagues, fellows, medical students, or patients insinuates that your hospital, institution, or practice does not hire the best medical professionals available. That perceived lack of quality in the team can affect not only the current staff and their feelings of loyalty to the workplace, but also the talent from which you can recruit.

So at the end of the day, we ask healthcare providers and health administration leadership to consider their words, because they are powerful. Be accurate. Be mindful of where medicine is headed now—a team sport, not a hierarchy. Retire the term “mid-level” and address nurse practitioners and physician assistants as advanced practice providers.