In response to Randy Danielsen's editorial "The PA Name Game," a nurse practitioner furthers the conversation by calling for an end to the use of "midlevel" to describe both PAs and NPs.
Randy Danielsen’s editorial “The PA Name Game” (Clinician Reviews. 2011;21:cover, 3-4, 6-7) could not have come at a better time. As the health care reform debate continues, NPs and PAs—separately and together—are being brought into the spotlight as possible solutions to long wait times, with increased opportunities to assist in specialty care and fill in the primary care gaps in this country.
Similar to Dr. Danielson’s discussion of the proposed name change from physician assistant to physician associate, I would like to take this opportunity to point out to my NP and PA colleagues another, often overlooked perspective to the titling of our similar professions. I cringe to the point of tooth-grinding as the term midlevel provider continues to catch on as an acceptable collective designation for NPs and PAs. I fear that midlevel provider will begin to taint different professional forums as an acceptable alternative to other titles.
The ambiguity of how to “lump” together or “tag” physician associates/assistants and nurse practitioners—all advanced practice positions with a minimum of a master’s degree, and in many cases a doctorate—has prompted ongoing debate. As such, it continues to be examined from different perspectives and viewpoints.
I would like to make a statement that I hope my NP and PA colleagues will consider: Labeling us midlevel providers is insulting, misleading, and just as inappropriate as some of the other titles that have been thrown out there. When I practiced in Connecticut, instances of hearing “midlevel” used were few and far between. When I came to Texas three years ago, I discovered that here it is more the title of norm, and NP/PA positions are even listed as midlevel provider on job and recruiting Web sites.
Much to my dismay, the physicians refer to us as their “midlevels,” as do the faculty and staff at the PA programs here in my new environment. Many of the PAs also refer to themselves as “midlevels” with pride, and I have since heard my NP colleagues doing the same.
The term midlevel provider indicates that there in fact is a higher level of care that the patient is not receiving: The public often views this as the care of the physician. More importantly, “midlevel” indicates there is a lower level of care: the care of the nurses who are with the patient for long periods of times, carrying out treatment plans, providing wound care, preventive care, and patient teaching, and serving as an advocate, a voice, and an extension of the patient. I challenge anyone to argue that they are “low-level” care providers.
However, just as NPs and PAs grapple with professional matters such as names and titles and explanations of what our role is, so do nurses. I find it highly insulting to refer to us as “midlevels,” implying that there are those who are providing “low-level” care, such as our fellow nurses, nurse assistants, and medical technicians.
Furthermore, by law, NPs and clinical nurse specialists (CNSs)—regardless of their additional education, training and certification—have all been and still are practicing nurses. We are just practicing nursing in a more “advanced” role, so to speak, as an NP or CNS. “Midlevel” negates our history and the importance of the traditional nurse’s role.
I would also like to point out to Dr. Danielsen that the public is not as clear about the role of the RN versus the NP as he suggests. Many people, including professionals (even physicians), do not know the difference between an RN and an NP. One could argue that in many settings, NPs’ role and position get very muddy and will even overlap with both the RN and the physician counterpart. Many times, when my patients ask, “What is an NP?” I have to start with, “Do you know what a PA is?” They often will reply, “Yes.” I am then able to explain my role based off their current understanding of the PA role.
I am encouraged by my colleagues’ continued interest in how to define our professions by role and title, even though in the end we are all working to provide care and compassion for our patients. However, while Romeo and Juliet looked beyond their surnames and other categorical rhetoric in their tale, they still had to contend with the public perception of their labels.
Let us not forget: Debate over our titles (whether they be physician associates, advanced practice providers, or the label of tomorrow) does not relieve us of our responsibility to care for our patients. We are still contending with the acceptance of our professions, defining our roles, and explaining what a PA and an NP actually are to the public. That public consists of the physicians we need to work with and the patients we need to take care of in order for our role to exist. This “rose” is just as vital for our professions’ progression.