Many of us dislike the term mid level when it is used to describe us. This dislike is something many NPs and PAs agree upon strongly. For us to banish the word forever we will have to educate people or at least let them know it is not proper to use it to describe PAs and NPs. One problem is the Federal government uses the word when it comes to describing us, especially the DEA and Bureau of Narcotics. Both the American College of Clinicians and the American Academy of NPs has come out with strong statements against the use of this word. 

Recently a speaker from the Bureau of Narcotics and Dangerous Drugs (BNDD) was going to speak to a group of NPs and possibly PAs in Missouri. A number of NPs had emailed him and asked him not to use the word mid-level. It seems he said that was the word he will use until it is changed.

The NPs who requested this change told us this story; “The presenter from the Bureau of Narcotics and Dangerous Drugs (BNDD).  refused to modify the wording used in his presentation. He stated that the presentation his organization designed is for all mid-level practitioners and not just the nurses. The term “mid-level provider” encompasses physician assistants and other clinicians in addition to advanced practice nurses, as he stated is in state and federal laws. And even though his primary audience for this activity was APRNs, he was not willing to make this change to his presentation to address just this group of practitioners.” 

The state is matching the language in the federal regulation. 
21 CFR 1300.01(28), where the DEA defines who are mid level practitioners. 

The DEA has a separate box to check on their application for mid level practitioners Also, the BNDD and DEA do not want to have to re-write rules and application forms every time a new licensure type gets new controlled drug authority.  By having these classes, we can register everyone in the future without a lot of amendments.

Missouri has two types of authorized mid levels........the APRNs and the PAs. 

The DEA nationwide has....APRNs, PAs, DCM, HMD,MP, ND,OD, or RPh.

In the new registration system designed, the BNDD will have four separate applications.

People will click on the appropriate type of application for their licensure type: 
o Doctors 
o Businesses 
o Mid Level Practitioners 
o Dentists--who get their own special application because of all the mandated extra availability survey questions they have to answer. 

So, when faced with a situation we want to change, how can we get it changed? I believe our first action should be a letter and a phone call to the BNDD asking them to change our category to “Prescribers” or PAs and NPs. “Doctors” can have their category, “dentists” theirs, but we are not in the middle anymore. We want to be taken out of the “mid level” category. It does not accurately describe our professions or what they do. Prescribers, or just NPs and PAs will work fine thank you. Leave the term mid level for all of the other professions who have not objected. Not us.

Here is a sample of what our message should be. Print it out and mail it ASAP, or even better make up your own message. If you have to-hand write it, but send it off today. As there is no person at this point to communicate with, let’s see if we are answered and by whom. I would ask all organizations that agree with us to begin a campaign to effectively end this designation.

Dear Sir or Madam:  

As a PA or nurse practitioner I would ask that you to create a new category and please remove my profession out of the “mid level” designation in 21 CFR 1300.01(28). Two national groups have issued statements against this term and many of us find it offensive. Briefly midlevel suggests that there are higher and lower professions. Your thought would obviously be that some professional groups are higher, some lower and some in the middle. It also suggests that our education or level of care might not be the best. Sort of like calling us “Second Place” provider; not at the top but not at the bottom. That is what middle means. 

Who do you officially feel is the higher level and as interestingly, who is in the lower level? Midlevel was originally used in the 1970s to describe a place between a physician and a nurse. I think both the NP and PA professions have outgrown and moved past that type of thinking. 

Please omit this language to describe PAs and NPs as soon as possible. Both professions find it offensive and please call us NPs and PAs, or prescribers. 
I look forward to your response. 

Thanks, 
YOUR NAME, TITLE ADDRESS, EMAIL 

Mail that letter to the address below and let’s see if we get any action. If you don’t, maybe they are right. Maybe we deserve to be in the middle.

Drug Enforcement Administration 
ATTN:  Chief--Liaison and Policy Section/ODL 
8701 Morrissette Drive 
Springfield, Virginia 22152

Phone is (202) 307-7297 

Dave has been a PA, and later NP, leader for thirty years.  He strongly believes that NPs and PAs must work together to insure a better future for both professions.  Most recently Dave has been busy launching another dream; Clinician 1, the first internet community for PAs and NPs.  In October 2008, Dave was honored by the New Jersey State society of PAs with its “Lifetime Achievement Award”.

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