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The term "midlevel"


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I often ask M, an experienced NP, basic clinical questions and reserve more complex questions for my SP and other docs, but today my SP had a talk with me and said "I know you ask M a lot of questions, but M is another midlevel. I rather you ask me or the other MD if you have questions." I've heard him use the term multiple times before, and understand that he means well, but the tone he used with "midlevel" just made me feel kind of uneasy. Anyone experience this too? I expect the feeling come with being a midlevel, but today was the first time I really felt it, and just wanted to vent it out here.

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I've been called worse!

 

I agree with ventana, just educate your SP.  I wouldn't quit my job over this, provided everything else is OK.  Also, I think it is reasonable for your SP to ask you to come to him with your questions, rather than an NP.

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In most cases it's not worth fighting. The reason why I say this is that it makes you come off as pretentious, and will only cause friction between you and the docs.

 

I hate the term too, because it implies there is a "low level" provider....which is who?

 

I work in a very large HMO/health plan and mid-level is common language around here. It got under my skin at first, but as long as I get paid and have a professional SCOPE, I dont really care anymore. They are starting to use "APP" which is nice. More appropriate.

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I personally would start quietly looking for new jobs. Maybe its an overreaction, but I personally would not want to be supervised by a guy/gal who was more concerned with titles than treating patients.

 

I've mellowed a little in my old age, but I also think there's something to the idea of noting carefully the way people use terminology, and allowing it to give you hints about their attitudes toward relevant practice. Back in 2010 when I was interviewing for my second job, I had a really nice talk with the recruiter for one of the local hospital systems' EDs, and when I went in to speak with the department head, it was cool to know that the newly-promoted Chief of Staff for the hospital had come from the ER. Then, I chatted a bit with one of the staff docs. He was trying to tell me about their new commitment to using PAs to the best of our ability.

 

"You're Assistants," he said, "we should make sure you have the chance to assist us as much as possible."

 

Then he went into more detail when I asked specific questions: most if not all of the level 2 and 3 stuff would be managed by PAs, which would free up the docs to do the more complicated stuff.

 

I told them no thanks, when the recruiter called me to ask how it had gone.

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We can learn from everyone we work with - nurse, tech, MD/DO, NP, whatever.

 

Is the doc uneasy that someone besides him/her can answer questions? Is there a lack of confidence in that particular NP?

 

It depends on your comfort level with the situation and the particular doctor - but education is a possibility.

 

Starting conversations about teamwork and group learning and channeling others' experiences to learn as much as possible. If the reception is negative or chilly at best - then you know, not gonna work.

 

I worked with one doc who was unbelievable - eventually actually got fired. I told a patient my opinion of her rash - doc ended up seeing her a few days later - patient never picked up the Rx, by the way - told the patient I had no idea what I was talking about and was "just a PA" after all...... Then went on to recommend IDENTICAL treatment which actually worked when actually used. I was livid. She actually documented in her note that "the assistant" had incorrectly diagnosed the condition. There are no nice words I can use for this doc - none.  I told admin I wouldn't work with her anymore and if they ever even contemplated putting me on her license, I would quit and then sue them.

 

So, got to find out what kind of doc this is - open, receptive, collegial  --- or ego driven, title driven and untrusting. 

 

Do what to can to educate when you can. Sometimes it is not worth banging one's head on the sharp rock.

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I'm with ya on this one reality check, while most docs bring more to the table than they take, there are a select few that realize the only thing earning them their 250,000 dollars a year is their title, so they belittle other providers in an attempt to keep their sinking career afloat. 

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We all come at this from our own experiences, but there is nothing "midlevel" that the courts think you do. The only ones who consider you "midlevel" are the DEA (for classification purposes) and CMS for reimbursement issues so they can pay less.  But, the FTC has already ruled, at least twice now, that there is no difference in services provided, and that the CMS rules may not be legitimate as services provided are services provided.  Your physical you do for a patient is no different than the "doctor" who learned the same thing. The standard of care is just that, the standard, and your doc, you, and your NP colleague are all held to it.

 

SEMPA has written a position statement that this is no longer an acceptable term by which to refer to PAs and if one wants to lump PAs in with NPs, then the only acceptable nomenclature in Advanced Practice Provider.  This has been supported by ACEP as well.  Showing such stuff to your physician colleague may set you up for failure in that system, but it doesn't sound like a great situation to begin with, and it sounds like your physician is concerned more with status than patient care.  FP physicians routinely call into our ER (only staffed by PAs) looking for guidance as to whether or not something they are treating needs to come in for further treatment.  In a system where casting of medical practitioners has been removed, we all get along and play well in the sandbox.  I can see why your doc may want you to ask questions of him (that is a whole other can of worms) but make no mistake, midlevel is a derogatory term.  And it is used as such.

 

G
 

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Guest JMPA

I often ask M, an experienced NP, basic clinical questions and reserve more complex questions for my SP and other docs, but today my SP had a talk with me and said "I know you ask M a lot of questions, but M is another midlevel. I rather you ask me or the other MD if you have questions." I've heard him use the term multiple times before, and understand that he means well, but the tone he used with "midlevel" just made me feel kind of uneasy. Anyone experience this too? I expect the feeling come with being a midlevel, but today was the first time I really felt it, and just wanted to vent it out here.

your sp is correct, there is no justification in the court of law. As a PA, you cannot be supervised by a nurse.

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Be careful with the nomenclature that a nurse cannot be a supervisor.  This is correct from the perspective of providing clinical assessment oversight, however they can serve as clinic managers (as in my case) and your immediate supervisor.  I'm fortunate that mine understands the role and that any clinical questions are bumped up to my SP (hasn't been a case with myself thus far).  Me personally?  I don't care who I answer to as long as I have clinical access to my SP should a question arise, and as has been noted previously, the paycheck cashes.

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your sp is correct, there is no justification in the court of law. As a PA, you cannot be supervised by a nurse.

 

Asking a question to a colleague is completely different than supervision. 

 

It sounds like the physician is being a jerk. However, there are usually two sides. Is there a chance that the NP has been showing themselves to be less than reliable as a provider? There's a chance the physician is actually just trying to lead you in a better direction. 

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I know some people hate the term "midlevel", but in the context of the OPs quote, what other word could have been used in its place? I don't know of any other term that encompasses both NPs and PAs, unless you want to use clunky jargon like "non-physician provider" (as if that'll catch on).

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I know some people hate the term "midlevel", but in the context of the OPs quote, what other word could have been used in its place? I don't know of any other term that encompasses both NPs and PAs, unless you want to use clunky jargon like "non-physician provider" (as if that'll catch on).

Well, in the context of the quote he could have just said "NP," since he was referring to one person. I don't like non-physician either because it only defined by what the group is not. I doubt FM docs would like it if I referred to them as Non-IM physicians. Honestly it's not that often it's you have to refer to PAs and NPs as a group, and when you do it's not that much extra effort to just say both names or say advance practice providers. We take the time and effort to say internal medicine physicians, vascular surgeon, and gastroenterologist.

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I like Advanced Practice Provider or APP - no one will ever know what it means, though.

 

Right now, I would be happy if disgruntled patients who are being weaned off controlled substances did NOT call me "THAT GIRL" or "THAT WOMAN" who took away my (insert drug name here) when complaining to the office manager. Never mind sound medical decision making....

 

It would also be thrilling if patients stopped referring to their specialist appt as "Well, I don't know what you expect, I ONLY saw their ASSISTANT" - despite a full evaluation, thorough plan of action and follow up appt or scheduled surgery.

 

Deep Sigh

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No one can make you feel inferior without your consent.  Shout out to my girl, Eleanor Roosevelt.

 

Physicians have to think they're superior to "midlevels" or else they went to 2 more years of school, underwent a residency, racked up a $100,000 of more debt and wasted at least 5 extra years of their lives for nothing.  When you start feeling like you're getting put down remember why you decided not to be a physician and let them think what they want.  You know you're fabulous, right?

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Lauren R has a very good point. The cold hard uncomfortable truth is that, in terms of very many of the reasons for very many office and ER visits, the education and training of a Board-certified MD or DO specialist is simply overkill. Nice to have, no doubt; but really, what patients need is someone smart, with decent training, who knows how to think and what do to, how to recognize the signs of something that doesn't fit the algorithm, and how to help. You don't need to be a doctor to have those skills, or that training.

 

This bothers some of the MDs a lot. Weirdly, sometimes it seems to bother them more when they're around us, while they can just kind of push the NPs out of sight and out of mind, but whatever. It doesn't have to make sense, because it's almost always an emotional and not a logical objection. So, we get language like "Midlevel." It's silly, because it reinforces the idea that there are levels.

 

I mean, there ARE levels, but not in that way, really. I'm sure in whatever city you live in, there are elite diagnosticians, and elite proceduralists, and clinicians with elite-level bedside manner. Meanwhile, there are those who are pretty awful, and then there are those in the middle. This is without regard to their credential, although to be sure the super-nerds in any field are going to be the ones with the most education, and that is right and proper. "Midlevel" is a snappy term that suggests a much more rigid hierarchy, and that's too bad.

 

I just tell people, "Midlevel? Ehh. If war broke out next week and we were all drafted, Dr. Smith over there would be a Captain and I'd be a Lieutenant. We'd both be officers, and probably doing just about the same thing in different units." I don't get hung up on ranks, because in the day to day world, what we should care about is knowledge and skills. As a category, the docs get more school time and they get structured residency training. That's nothing to sneeze at, and it definitely gives them more and better chances to learn and grow and get good. But it's not the only way, is the thing.

 

Don't get me started on "Advanced Practice Provider." My practice isn't advanced, it's just my practice. And advanced compared to who, anyway? Compared to what everybody thinks we know and do, I guess.

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Funny thing with rank

 

If I went into the Military I would likely be a 0-4 or possibly an O-5 with the perfect package- far outranking the new Doc at O-3.....

 

So the "mid-level" outranks the doc....

 

In many ways I think the military rank system has a lot of great points. A 20 year PA or RN is likely going to outrank any new grad doc (sort of Neurosurg or surgical specialist with LONG residency). And this makes sense.... Time if value and value is rank, and although their is a different level of education, the RANK deserves respect....

 

 

I DESPISE the term mid level and correct anyone who calls me it. They can call me just about anything else......

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I think I have kinda stumbled upon the answer to this.  The issue is that the term "Health Care Provider" is being utilized by a large number of professions at this point, including RNs.  The term isn't good because it is confusing whether the emphasis is on the provider portion or health care portion.  Individuals employed in health care do provide health care, hence the term health care provider is being applied to multiple professions.

 

I don't necessarily agree or disagree with any of it, but I thought I would share that I see a lot of non-APPs using the term HCP to describe what they do.

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