Why You Are Not A Midlevel

The term midlevel never sat well with me. I used to tolerate it, but now it just pisses me off every time I see the word.  Why?  

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Because it is so limiting and it devalues us as a profession. No matter how hard you work or how much you achieve, the term “midlevel” qualifies your accomplishments to something akin to saying “nice job . . . for a girl.”

Semantics are very powerful. If you think a word is just a word and you are not influenced by it, it’s probably because you haven’t really thought about it. Semantics is the study of the relationship between words and meaning and its extremely powerful. Let’s take a couple of examples and see how your attitude changes:

Description A                              Description B
Garden Flower                                 Weed
Adult Book                                        Pornography
Glass half-full                                   Glass half-empty
Incentive                                            Bribe
Borrowing                                          Stealing
Nurse Practitioner                           Midlevel


A garden flower and a weed are the same things, but your perception of the plant changes based on the words used to describe it.  Now imagine how a patient feels when the medical assistant says one of the following:

The midlevel will see you now.

The non-physician will see you now.

The physician extender will see you now.

Do you want to see any of these people? What do these terms even mean? Even physician assistants are talking about changing their designation to physician associate. But PAs didn’t have the luxury of naming themselves as nurse practitioners did, because they really were created to be a physician’s assistant. It’s hard to be independent when you are referred to constantly as an assistant to someone. Though I’m sure being lumped in as a midlevel hasn’t done their cause any favors.

Imagine calling anyone in any other profession a midlevel and see how it changes your perspective and expectation of that person.

A midlevel journalist.

A midlevel dentist.

A midlevel executive.

A midlevel president.

The funny thing is when physicians were called clinicians they were offended by this term, it was too base for them. Now imagine if you introduced your attending as a midlevel physician, “Mrs. Brown, the Midlevel Dr. Smith is here to see you.” This example seems ridiculous in this context, right? Why say midlevel at all? Why can’t Dr. Smith just be a doctor and NP Jones be a nurse practitioner and RN Black is a nurse.

Midlevel is a Derogatory Term

The term midlevel is derogatory and if you don’t think so, I challenge you to call anyone else in any other profession a midlevel and see if they are offended. In the above example, the assumption is there is someone more senior and better than you. And the reverse assumption is that there is someone below you.

When you apply this hierarchy in the medical field, the assumption is that the physician is superior to the midlevel and the nurse is inferior.

One of the most important traits I teach my NP students is that you are always a NURSE first and foremost. NPs aren’t better than nurses and they aren’t lesser than doctors, they are simply different roles. Other nurses I have worked within the past chose different pathways, whether it was to be an expert at the bedside, work in management or something else, but why do we have to say we as nurses are less than doctors? Nurses aren’t lesser than anybody, they are equal partners in healthcare. And to continue putting all of us on this hierarchical continuum is detrimental to nursing x2 and insulting.

It’s always annoying when someone well-meaning says to you “you are so smart why didn’t you go to medical school?”

I went to nursing school because it was my passion, not because something else was too hard or was going to take too long to accomplish. And like other nurses, I was constantly asking what else can I do? How else can I help? How can I make an impact? This desire to care, passion for patients and nursing care and constant need to do more is what drove me to become a nurse practitioner and what drives me to continually be successful as a nurse.

Yes doctors do more courses in hard a.k.a. “important” science like physics and cell biology and nurses do more courses in soft a.k.a. “silly” sciences such as communication, caring and interprofessional relationships.

But which skill set do you think is more useful when you are working one on one with a patient? Do you think Mrs. Jones wants a rundown on the cellular dysfunction of her islet cells or do you think she wants to understand how this affects her life with her grandchildren and what her options are? And is this why NPs are not as important or as “high-level” as doctors? Because we focus on people and not bench science?

How many courses in physics and advanced cellular microbiology do you need to counsel a patient on how to make lifestyle changes to improve health? I would argue none. When was the last time a patient wanted to know the chemical composition of their lipid medication? Has anyone considered that physicians spending so much time on these very “important” hard sciences could be a colossal waste of time in clinical medicine?

Yet nurse practitioners are devalued because we didn’t spend enough time studying molecular physiology. Who cares?

Ironically, medical schools are starting to understand that emotional intelligence is more powerful and more useful than the hard sciences and they are making strategic moves to incorporate more soft “silly” sciences into their curriculum.

In fact, many medical schools are transitioning enrollment to weed out people who have only done the hard sciences in favor of people who have some personal skills and who can actually talk to patients on a normal, human level.

There is certainly enough room in the medical field for both NPs and MDs to teach patients how to promote health and wellness.  And there is a role for both types of expertise. I’m sure there is a role for advanced cellular microbiology and I am certainly glad someone else studied it because I have no interest in the topic.

This lack of interest doesn’t make me a lesser or an inferior provider. And don’t tell me I’m not worth as much as a doctor.  I’m not in between a doctor and a nurse as a nurse practitioner. I’m a colleague of both. We all bring different strengths to the table and as long as the term midlevel exists this arbitrary hierarchy will continue to exist–and not in our favor.

Where did the term Midlevel come from?

I was curious as to where this term midlevel came from so I did a quick search for the history of the term “midlevel” and of course came immediately across the amazing Wikipedia!

According to Wikipedia, midlevel is a term to describe the category of health care providers who are considered “below” the physician. Again this idea that midlevels are below physicians just reinforces the hierarchy and that notion that only physicians can be leaders in healthcare.

Really would you want a midlevel leading the way in healthcare reform? A person who is inferior to the physician? I personally want the best leader, be it an NP, an MD, a PA, an MBA, a clinical psychologist, etc. Whoever has leadership skills and can make a difference.

The term midlevel seems to have originated with the Drug Enforcement Agency where it is used to designate permission to dispense a controlled substance in the course of professional practice.

The term midlevel doesn’t just refer to nurse practitioners and physician assistants, it includes medical social workers, pharmacists, clinical psychologists, euthanasia technicians, dentists, optometrists, physiotherapists, and some others.  ALL of us lumped together and below the physician.

Although, for whatever reason, the term midlevel colloquially refers to nurse practitioners and physician assistants. I highly doubt if you walk into your local retail clinic and ask for the midlevel that you will be directed to a pharmacist. Somehow, pharmacists, optometrists, etc., evaded this derogatory term and they are just referred to what they are, a pharmacist, an optometrist, a clinical psychologist.

Is there a particular reason we can’t just be referred to as nurse practitioners or NPs? Granted the term “nurse practitioner” requires extra breath as it’s a five-syllable term, whereas midlevel are three, however, NP only requires two syllables of your breath.

I would encourage NPs to embrace the term nurse practitioner and insist on being called what you are. Don’t let other professions name us or build us into where they think we belong on the totem pole. And don’t let people who “embrace” being midlevels convince you that somehow we can swing this term into a positive.

If there is a subgroup of practitioners who enjoy being “midlevels” and want to be called such then my suggestion is this:  Let us make a conscience decision.  There will be those of us who choose to be nurse practitioners and everyone else can be designated as midlevels.  Hmm, where do you think midlevels will end up in this hierarchy?

I will leave it up to you which category you want to be in.

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Catie Harris

Catie Harris, PhD, MBA, and Registered Nurse is the NursePreneur Mentor who has empowered hundreds of nurses to monetize their knowledge and skills in business, while inspiring them to change the way healthcare is perceived and delivered. Through her intensive mentorship programs, Catie shows nurses how their nursing knowledge can transcend the hospital system into a profitable business.

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