Mid-level practitioner

Mid-level practitioners, also called advanced practice providers and non-physician practitioner, are health care providers who have a defined scope of practice. The term mid-level refers to the complexity of healthcare situations they handle, not the quality of the care provided. This means that they are trained and legally permitted to provide healthcare in fewer situations than physicians but more than other health professionals. For example, a mid-level provider may be trained for and legally permitted to perform minor or moderate surgical procedures, but not trained for or legally permitted to perform complex or experimental surgeries.

Mid-level practitioner
Occupation
SynonymsAssistant practice clinicians, non-physician practitioner, Advanced Practice Provider
Occupation type
Professional
Activity sectors
Medicine, health care
Description
Fields of
employment
Clinics, hospitals

Because of their diverse histories, mid-level providers' training, functions, scope of practice, regulation, and integration into the formal health system vary from country to country. They have highly variable levels of education and may have a formal credential and accreditation through the licensing bodies in their jurisdictions.[1] In some places, but not others, they provide healthcare independently, particularly in rural and remote areas, to make up for physician shortages.[2]

Definitions

The World Health Organization includes in this category all healthcare providers with all of the following qualifications:[2]

  • trained and legally authorized to provide healthcare,
  • having at least two years training at university or other institution of higher education, and
  • able to diagnose and treat medical conditions, within the scope of their training and licensure, by prescribing medication and/or performing surgery.

Terminology

US professional organizations for physician assistants, nurse practitioners, nurse anesthetists, clinical nurse specialists, and Certified Nurse-Midwives prefer the term Advanced Practice Provider (APP). They are concerned that "mid-level" will be misunderstood as indicating that they provide only a medium quality of care to patients, or that it does not adequately convey the extent of their education, which in the US often includes a master's degree or other advanced degree in a healthcare field.[3] Nurse practitioners in the US are required to receive at least 500 hours of clinical training.[4]

Other providers prefer their specific professional title (such as "nurse practitioner") to any category.

MLPs by country

India

In 2019, a new mid-level health care provider role was introduced in India, known as Community Health Officer (CHO). The role was intended fo support the Health and Wellness Centres in community level in India.[5]

South Africa

In 2008, a new mid-level practitioner role was introduced in South Africa, known as clinical associates. The role was intended to support the district hospital workforce.[6]

United Kingdom

Mid-level practitioners in the UK are known as Advanced Clinical Practitioners (ACP) and is an evolution of many differing professions which use various titles such as ‘Extended Scope Practitioner’ or ‘Advanced Practitioner’. Historically there has been debate over the consistency of quality in these senior clinicians and therefore it became necessary to generate a distinguished definition of the ACP role. The ACP:

  • Is a registered healthcare practitioner with a minimum of 5 years clinical experience (2 years in a senior clinical role)
  • Has acquired expert knowledge and complex decision making skills which may be an extension of their traditional scope of practice
  • Will undertake a two-year level 7 (Master's degree) training course in Advanced Practice
  • Will maintain training and CPD requirements [7]

This is an emerging role and is showing a good deal of promise in meeting the demands of the UK's rapidly evolving healthcare requirements. ACPs may practice in the acute setting (ED, critical care, medical or surgical wards) or community General Practice / family medicine. The majority can independently assess, investigate (through blood science / imaging / labs etc.), diagnose and formulate a treatment including prescribing medications or referring to specialist care. Physician associates practising in the United Kingdom is the equivalent title to physician assistant.

The deployment of ACPs is considered to be part of a Value Based Recruitment framework driven by Health Education England (HEE). This seeks to appoint clinicians based upon their competencies, values and behaviours in support of collaborative working and delivering excellent patient care.[7]

United States

In the United States, mid-level practitioners are health care workers with training less than that of a physician but greater than that of nurses and other medical assistants.

The term mid-level practitioner or mid-level provider is related to the occupational closure of healthcare. This concept centered around physicians as the ultimate professional responsible for healthcare. As healthcare demands have increased in the United States due to an aging population, a physician shortage and the implementation of the Patient Protection and Affordable Care Act of 2010 there has been a shift toward more independence in practice for professionals such as physician assistants, nurse practitioners, pharmacists, dentists, podiatrists and dental therapists.

Concerns about terminology

In recent years some organizations and specialties have proposed the discontinuance of the term mid-level in reference to professional practitioners who are not physicians. Each organization prefers to use their specific title, and physicians' organizations are concerned about title inflation.

Professional Health Care Organizations' positions on the term mid-level practitioner.
Organization Position Preferred Alternative Position paper
The American Academy of Physician AssistantsAgainstPA*A Guide for Writing and Talking About PAs (PDF), American Academy of Physician Assistants, 2018, retrieved 5 August 2020
The American Academy of Nurse PractitionersAgainstNurse practitionerUse of Terms Such as Mid-Level Provider and Physician Extender (PDF), American Academy of Nurse Practitioners, 2015, retrieved 10 April 2016
American Association of Nurse AnesthetistsAgainstNurse anesthetistDevi, Sharmila (2011). "US nurse practitioners push for more responsibilities". The Lancet. 377 (9766): 625–626. doi:10.1016/S0140-6736(11)60214-6.
National Association of Pediatric Nurse PractitionersAgainstPediatric nurse practitioner"Pediatric Nurse Practitioner Professional Profile and FAQ" (PDF). National Association of Pediatric Nurse Practitioners. March 2015. Retrieved March 27, 2019.
American Academy of Family PhysiciansAgainst use of "provider" in generalspecific titles"Provider, Use of Term (Position Paper)". American Academy of Family Physicians.
American Academy of Emergency MedicineAgainstAdvanced Practice Provider"American Academy of Emergency Medicine". AAEM - American Academy of Emergency Medicine. Retrieved 2019-03-27.

*preferred even over physician assistant, which was what the acronym historically stood for

Drug Enforcement Administration

The term mid-level practitioner as found in the DEA classification in Section 1300.01(b28), Title 21, of the Code of Federal Regulations is used as a means of organizing drug diversion activities. The term mid-level practitioner as defined by the DEA Office of Diversion Control, "...means 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."[8][9] Some health professionals considered mid-level practitioners by the United States DEA include:

See also

References
  1. Lehmann, U (2008), Mid-level health workers: The state of the evidence on programmes, activities, costs and impact on health outcomes - A literature review (PDF), Geneva: World Health Organisation
  2. Mid-level health providers: a promising resource to achieve the health Millennium Development Goals (PDF), Geneva: World Health Organization, Global Health Workforce Alliance, 2010
  3. Bishop CS (2012). "Advanced practitioners are not mid-level providers". J Adv Pract Oncol. 3 (5): 287–8. PMC 4093350. PMID 25031957.
  4. "Statement Regarding Nurse PractitionerStudentsandDirect Care Clinical Hours" (PDF).
  5. "Health and Wellness Centres under Ayushman Bharat". pib.gov.in. Retrieved 2020-01-14.
  6. Doherty, J; Conco, D; Couper, I; Fonn, S (2013). "Developing a new mid-level health worker: lessons from South Africa's experience with clinical associates". Global Health Action. 6: 19282. doi:10.3402/gha.v6i0.19282. PMC 3556716. PMID 23364079.
  7. "East Midlands Advanced Clinical Practice Framework" (PDF). National Health Service. 28 November 2014. Archived from the original on 27 December 2016.CS1 maint: unfit URL (link)
  8. "Mid-Level Practitioners Authorization by State". U.S. Department of Justice Drug Enforcement Administration, Office of Diversion Control. Retrieved 13 June 2019.
  9. "Mid-Level Practitioners Authorization by State Chart" (PDF). U.S. Department of Justice Drug Enforcement Administration, Office of Diversion Control. Retrieved 11 June 2011.
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