View source for Mid-level practitioner

{{Short description|Clinical health care provider}}
{{POV|date=August 2023}}{{Infobox occupation
| name               = Mid-level practitioner
| synonyms           = advanced practice practitioner, advanced practice provider, advanced practice clinician, advanced clinical practitioner, advanced clinical provider, non-physician practitioner, non-physician provider, physician assistant (hyponym), nurse practitioner (hyponym), advanced practice nurse (hyponym)
| pronounce          =
| image              =
| imagesize          =
| alt                =
| caption            =
| official_names     =
| type               = [[Professional]]
| activity_sector    = [[Medicine]], [[health care]]
| competencies       =
| formation          =
| employment_field   = [[Clinic]]s, [[hospital]]s
| related_occupation =
}}
'''Mid-level practitioners''', also called '''non-physician practitioners''', '''advanced practice providers''', or commonly '''mid-levels''', are [[health care provider]]s who assess, diagnose, and treat patients but do not have formal education or certification as a [[physician]]. The scope of a mid-level practitioner varies greatly among countries and even among individual practitioners. Some mid-level practitioners work under the close supervision of a physician (such as doing pre-op and post-op assessment and management, thus allowing surgeons to spend more of their time operating), while others function independently and have a scope of practice difficult to distinguish from a physician. The legal scope of practice for mid-level practitioners varies greatly among jurisdictions, with some having a restricted and well-defined scope, while others have a scope similar to that of a physician. Likewise, the training requirement for mid-level practitioners varies greatly between and within different certifications and licensures.

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 [[Health care license (disambiguation)|licensing bodies]] in their jurisdictions.<ref name="WHO review">{{citation |url=https://www.who.int/hrh/MLHW_review_2008.pdf |last=Lehmann |first=U |title=Mid-level health workers: The state of the evidence on programmes, activities, costs and impact on health outcomes - A literature review |location=Geneva |publisher=World Health Organisation |date=2008}}</ref> In some places, but not others, they provide healthcare, particularly in rural and remote areas, to make up for [[physician shortage]]s.<ref name="promising">{{citation |publisher=World Health Organization, Global Health Workforce Alliance |title=Mid-level health providers: a promising resource to achieve the health Millennium Development Goals |location=Geneva |date=2010 |url=https://www.who.int/workforcealliance/knowledge/resources/Final_MLP_web_2.pdf}}</ref>

== Definitions ==
The [[World Health Organization]] includes in this category all healthcare providers with all of the following qualifications:<ref name=promising />
* 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.

==MLPs by country==

=== Canada ===

In Canada there are four "allied primary health practitioners" identified under the [[National Occupational Classification]] (NOC) section 3124: [[physician assistant]], [[nurse practitioner]], [[midwife]], and [[anesthesiologist assistant]].<ref name=NOÇAHP2011>{{Cite web|title=3124 - Allied primary health practitioners|publisher=[[Statistics Canada]]|website=[[National Occupational Classification]]|url=https://www23.statcan.gc.ca/imdb/p3VD.pl?Function=getVD&TVD=122372&CVD=122376&CPV=3124&CST=01012011&CLV=5&MLV=5|date=November 21, 2011|access-date=June 29, 2022}}</ref> Nurse practitioners are permitted to provide several, but not all, of the health care services physicians provide.<ref>{{Cite web|url=https://www.cno.org/en/news/2018/april-2018/nps-ordering-ultrasounds-and-x-rays/|title = NPS ordering ultrasounds and X-rays}}</ref>

=== India ===
In 2016, a new mid-level healthcare provider role was introduced in India(Dealing With modern Medicine), known as Community Health Officer (CHO) or Nurse Practitioner, Physician Associate/Assistant. The role was intended to support the community-level Health and Wellness Centres in India.<ref>{{Cite web|url=https://pib.gov.in/newsite/PrintRelease.aspx?relid=188246|title=Health and Wellness Centres under Ayushman Bharat|website=pib.gov.in|access-date=2020-01-14}}</ref> '''Community Health Officers (CHOs) and Physician Associate/Assistant (PA)''', also called '''Mid Level Health Providers (MLHPs)''' and '''non-physician practitioners(Physician Associate/Assistant),''' are trained in Health Sciences model who have a defined scope of modern medicine practice.<ref>{{Cite web|date=2019-02-23|title=Over 12 lakh people treated for free under Ayushman Bharat; 10000 Wellness Centres operational|url=https://www.jagranjosh.com/current-affairs/over-12-lakh-people-treated-for-free-under-ayushman-bharat-10000-wellness-centres-operational-1550908231-1|access-date=2021-05-18|website=Jagranjosh.com}}</ref> In [[India]], [[Nursing]], '''''[[Ministry of Ayush|AYUSH and Healthcare Professionals]] (Healthcare profession like Physiotherapy, Physician Assistant/Associate, Optometrist Etc. prescribed in NCAHP ACT 2021, NCAHP,MOHFW, Government of India)'''''are eligible for this cadre. This means that they are trained in Modern Health Sciences model and legally permitted to provide healthcare in fewer situations than physicians but more than other [[health professional]]s.<ref>{{Cite web|title=Ministry of Health & Family Welfare 2020 ACHIEVEMENTS|url=http://www.pib.gov.in/Pressreleaseshare.aspx?PRID=1684546|access-date=2021-03-30|website=www.pib.gov.in}}</ref><ref>{{Cite web|title=Roles and responsibilities of mid level health provider-Indian Journals|url=http://www.indianjournals.com/ijor.aspx?target=ijor:tnnmcjchn&volume=8&issue=1&article=011|access-date=2021-03-29|website=www.indianjournals.com}}</ref> In India, Community Health Officer or Nurse practitioner, Physician Associate/Assistant are other names for mid-level practitioner.<ref>{{Cite web|title=NMC Bill's Mid-Level Community Health Provider An Interim Option: Health Ministry|url=https://www.ndtv.com/education/nmc-bill-2019-mid-level-community-health-provider-an-interim-option-says-health-ministry-2081246|access-date=2021-07-20|website=NDTV.com|language=en}}</ref> Apart from doctor and nurses there was a list of Healthcare providers as recently [[Ministry of Health and Family Welfare|NCAHP,Ministry of Health and Family Welfare]] published Guideline in Ayusman Bharat digital Health Mission  control of health related cases in rural areas of India. According to these guidelines, symptomatic cases can be triaged at village level by tele-consultation with a Physician Associate/Assistant or a Community Health Officer (CHO).<ref>{{Cite web|date=2021-05-16|title=Centre issues guidelines on Covid-19 management in rural, peri-urban areas|url=https://indianexpress.com/article/india/centre-issues-guidelines-on-covid-management-in-rural-peri-urban-areas-7317350/|access-date=2021-05-18|website=The Indian Express|language=en}}</ref><ref>{{Cite web|date=2021-05-16|title=Centre releases Covid-19 guidelines for rural areas, focus on surveillance, screening|url=https://www.hindustantimes.com/india-news/centre-released-covid-19-guidelines-for-rural-areas-to-check-its-spread-101621146135876.html|access-date=2021-05-18|website=Hindustan Times|language=en}}</ref><ref>{{Cite web|title=Amid rising COVID-19 cases in rural areas, Centre's guidelines to contain virus spread – Check here|url=https://www.timesnownews.com/india/article/amid-rising-covid-19-cases-in-rural-areas-centre-s-releases-guidelines-check-here/757618|access-date=2021-05-18|website=www.timesnownews.com|language=en}}</ref>

<ref>{{Cite web|agency=PTI|date=May 16, 2021|title=Govt issues guidelines on Covid management in rural, peri-urban areas |url=https://timesofindia.indiatimes.com/india/govt-issues-guidelines-on-covid-management-in-rural-peri-urban-areas/articleshow/82677861.cms|access-date=2021-05-18|website=The Times of India|language=en}}</ref>

=== 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.<ref>{{cite journal |last1=Doherty |first1=J | last2=Conco |first2=D |last3=Couper |first3=I |last4=Fonn |first4=S |doi=10.3402/gha.v6i0.19282 |pmid=23364079 |pmc=3556716 |title=Developing a new mid-level health worker: lessons from South Africa's experience with clinical associates |journal=[[Global Health Action]] |date=2013 |volume=6 |pages=19282}}</ref>

=== United Kingdom ===
Mid-level practitioners in the UK are known as '''Advanced Clinical Practitioners''' (ACP) or '''Advanced Practitioners''' (AP) and occurred as an evolution of many differing professions which use various titles such as 'Extended Scope 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 <ref name="framework">{{cite web|url=https://hee.nhs.uk/sites/default/files/documents/East%20Midlands%20Advanced%20Clinical%20Practice%20Framework.pdf|url-status=unfit|archive-url=https://web.archive.org/web/20161227202329/https://hee.nhs.uk/sites/default/files/documents/East%20Midlands%20Advanced%20Clinical%20Practice%20Framework.pdf|archive-date=27 December 2016|title=East Midlands Advanced Clinical Practice Framework|website=National Health Service|date=28 November 2014}}</ref>

ACPs may practice in the acute setting (ED, critical care, etc.) or community [[General Practice]] / Family Medicine. The majority can independently assess, investigate (through blood tests / imaging etc.), diagnose and formulate a treatment plan including prescribing medications or referring to specialist care.

The deployment of ACPs is considered to be part of a Value Based Recruitment framework driven by Health Education England (HEE){{Citation needed|date=April 2021}}. This seeks to appoint clinicians based upon their competencies, values and behaviours in support of collaborative working and delivering excellent patient care.<ref name="framework" />

==== Physician Associates ====
Physician Associates (PAs) practising in the United Kingdom is the equivalent title to [[physician assistant]], these clinicians are described as "dependent practitioners", meaning that they require supervision at all times by a physician. They cannot prescribe medications nor can they request tests that use ionising radiation such as X-rays.

=== 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 or 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]], 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 [[Job title inflation|title inflation]].
{| class = wikitable
|+ Professional Health Care Organizations' positions on the term ''mid-level practitioner''.
!Organization
!Position
!Preferred Alternative
!Position paper
|-
|The [[American Academy of Physician Associates]] || Against|| PA* ||{{citation
|url=https://www.aapa.org/wp-content/uploads/2018/12/How_to_Talk_about_PAs_FINAL_December_2018.pdf
|title=A Guide for Writing and Talking About PAs
|publisher=[[American Academy of Physician Associates]]
|date= 2018
|access-date=5 August 2020}}
|-
|The [[American Academy of Nurse Practitioners]] || Against|| [[Nurse practitioner]] ||{{citation
|url=https://www.aanp.org/images/documents/publications/useofterms.pdf
|title=Use of Terms Such as Mid-Level Provider and Physician Extender
|publisher=[[American Academy of Nurse Practitioners]]
|date= 2015
|access-date=10 April 2016}}
|-
|[[American Association of Nurse Anesthesiology]]|| Against || [[Nurse anesthetist]], nurse anesthesiologist || {{cite web |title=CRNAs should not be referred to as "mid-level practitioners," "nonphysicians," "physician extenders," "dependent practitioners," or "allied health practitioners" – position statement. |website=Issuu |publisher=American Association of Nurse Anesthesiology |year=2019 |url=https://issuu.com/aanapublishing/docs/4_-_certified_registered_nurse_anesthetists_advan |access-date=5 January 2025}}
{{cite journal |doi=10.1016/S0140-6736(11)60214-6 |title=US nurse practitioners push for more responsibilities |journal=The Lancet |volume=377 |issue=9766 |pages=625–626 |year=2011 |last1=Devi |first1=Sharmila |s2cid=54401967 }}
|-
|[[American Academy of Family Physicians]] ||Against use of "provider" in general || specific titles || {{cite web |url=https://www.aafp.org/about/policies/all/provider.html |title=Provider, Use of Term (Position Paper) |website=[[American Academy of Family Physicians]]}}
|-
|[[American Academy of Emergency Medicine]] || Against ||Advanced Practice Provider||{{Cite web|url=http://www.aaem.org/|title=American Academy of Emergency Medicine|website=AAEM - American Academy of Emergency Medicine|language=en|access-date=2019-03-27}}
|}
<nowiki>*</nowiki>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|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."<ref name="DEA midlevels">{{cite web |title=Mid-Level Practitioners Authorization by State |url=https://www.deadiversion.usdoj.gov/drugreg/practioners/mlp_by_state.pdf |website=U.S. Department of Justice Drug Enforcement Administration, Office of Diversion Control |date=December 4, 2024 |access-date=January 5, 2025}}</ref> Some health professionals considered mid-level practitioners by the United States DEA include:<ref name="DEA midlevels"/>
{{col-begin}}
{{col-2}}
* [[Ambulance service]]s
* [[Animal shelters]]
* [[Chiropractor|Certified chiropractor]]s
* [[Traditional Chinese medicine|Doctors of Oriental Medicine]]
* [[Animal euthanasia|Euthanasia technicians]]
* [[Homeopathy|Homeopathic physician]]s
{{col-2}}
* [[Medical psychology|Medical psychologist]]s
* [[Naturopathy|Naturopathic physician]]s
* [[Nurse practitioner]]s (including [[Nurse midwife|nurse midwives]], [[nurse anesthetist]]s, and [[clinical nurse specialist]]s)
* [[Optometrists]]
* [[Physician assistant]]s
* [[Pharmacist|Registered pharmacist]]s
{{Col-end}}

==See also==
* [[Advanced practice nurse]]
* [[Allied health professions]]
* [[Anesthesiologist Assistant]]
* [[Certified Nurse‐Midwife]]
* [[Feldsher]]
* [[Health human resources]]
* [[Nurse anesthetist]]
* [[Nurse practitioner]]
* [[Pathologists' assistant]]
* [[Physician assistant]]

==References==
{{reflist}}

==External links==
* [https://www.who.int/workforcealliance/knowledge/themes/midlevel/en/ Global Health Workforce Alliance: mid-level health workers]

[[Category:Health care occupations]]