Mid-level practitioner

Mid-level practitioner
Occupation
SynonymsPhysician’s Assistant, Nurse Practitioner, non-physician practitioner,
Occupation type
Professional
Activity sectors
Medicine, health care
Description
Fields of
employment
Clinics, hospitals

Mid-level practitioners, also called non-physician practitioners, 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.

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, 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.

Nurse practitioners in the US are required to receive only 500 hours of clinical training, whereas Physician Assistants are required to gain at minimum 2,000 hours during their clinical training. This is compared to approximately 15,000 for a physician, MD or DO[3]

MLPs by country

Mid-level practitioner in Canada

In Canada there are four identified allied primary health practitioners. They include: physician assistant, nurse practitioner, midwife and anesthesiologist assistant. These four providers are identified under the national occupational competency: NOC 3124: Allied Primary Health Practitioners.[4] Nurse Practitioners are permitted to provide several, but not all, of the health care services physicians provide.[5]

Mid-level practitioner in 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 to support the Health and Wellness Centres in community level in India.[6] Community Health Officer (CHO) also called Mid Level Health Provider (MLHP) and non-physician practitioner, are trained health care providers who have a defined scope of practice.[7] In India, only Nursing and AYUSH Practitioner are eligible for this cadre.[8] This means that they are trained and legally permitted to provide healthcare in fewer situations than physicians but more than other health professionals.[9][10] In india, Community Health Officer is another name of Mid-Level Practitioner.

Recently in India, Community Health Officers at Ayushman Bharat Health and Wellness Centres are now allowed to supply certain medicines to the patients, as they have been included in Section 23 of Schedule K of Drugs and Cosmetics Rules, 1945.[11] In India, Community Health Officer (CHO) is the another name of mid-level practitioner.[12]

Ministry of Health and family welfare, Government of India published guidelines for prevention and controlling of COVID-19 cases in rural area of India. According to guidelines Symptomatic cases can be triaged at village level by tele-consultation with Community Health Officer (CHO), and cases with comorbidity or low oxygen saturation should be sent to higher centres.[13][14][15][16]

Mid-level practitioner in 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.[17]

Mid-level practitioner in 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 [18]

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, 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). This seeks to appoint clinicians based upon their competencies, values and behaviours in support of collaborative working and delivering excellent patient care.[18]

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.

Mid-level practitioner in 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. S2CID 54401967.
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."[19][20] 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. 1 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. ↑ "Statement Regarding Nurse PractitionerStudentsandDirect Care Clinical Hours" (PDF).{{cite web}}: CS1 maint: url-status (link)
  4. ↑ "NOC 2011 - 3124 - Allied primary health practitioners". 6 January 2012.
  5. ↑ "NPS ordering ultrasounds and X-rays".
  6. ↑ "Health and Wellness Centres under Ayushman Bharat". pib.gov.in. Retrieved 2020-01-14.
  7. ↑ "Over 12 lakh people treated for free under Ayushman Bharat; 10000 Wellness Centres operational". Jagranjosh.com. 2019-02-23. Retrieved 2021-05-18.
  8. ↑ "Why we need community health providers". Hindustan Times. 2019-08-13. Retrieved 2021-03-29.
  9. ↑ "Ministry of Health & Family Welfare 2020 ACHIEVEMENTS". www.pib.gov.in. Retrieved 2021-03-30.
  10. ↑ "Roles and responsibilities of mid level health provider-Indian Journals". www.indianjournals.com. Retrieved 2021-03-29.
  11. ↑ Bureau, Medical Dialogues (2021-03-03). "Anganwadi Workers, Community Health Officers at Ayushman Bharat Health and Wellness Centres now under Schedule K of Drugs and Cosmetics Rules". medicaldialogues.in. Retrieved 2021-03-29.
  12. ↑ "NMC Bill's Mid-Level Community Health Provider An Interim Option: Health Ministry". NDTV.com. Retrieved 2021-07-20.
  13. ↑ "Centre issues guidelines on Covid-19 management in rural, peri-urban areas". The Indian Express. 2021-05-16. Retrieved 2021-05-18.
  14. ↑ "Centre releases Covid-19 guidelines for rural areas, focus on surveillance, screening". Hindustan Times. 2021-05-16. Retrieved 2021-05-18.
  15. ↑ "Amid rising COVID-19 cases in rural areas, Centre's guidelines to contain virus spread – Check here". www.timesnownews.com. Retrieved 2021-05-18.
  16. ↑ May 16, PTI /; 2021; Ist, 13:42. "Govt issues guidelines on Covid management in rural, peri-urban areas | India News - Times of India". The Times of India. Retrieved 2021-05-18.{{cite web}}: CS1 maint: numeric names: authors list (link)
  17. ↑ 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.
  18. 1 2 "East Midlands Advanced Clinical Practice Framework" (PDF). National Health Service. 28 November 2014. Archived from the original on 27 December 2016.{{cite web}}: CS1 maint: unfit URL (link)
  19. ↑ "Mid-Level Practitioners Authorization by State". U.S. Department of Justice Drug Enforcement Administration, Office of Diversion Control. Retrieved 13 June 2019.
  20. ↑ "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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