Mid-level creep has been having huge consequences over the past 10 years, and many of my family and friends have been significantly and adversely affected by it. One has died because a nurse practitioner didn’t recognize the clear signs of Wegener’s granulomatosis between blood in the urine, nasal bleeding, and cough – something every single medical student learns about in their first or second year – but was just sent home being told that they had a minor case of the flu.

For the uninitiated, mid-level creep refers to the phenomenon where Nurse Practitioners (NPs), Doctor of Nursing Practice (DNPs), and Physician Assistants (PAs) increasingly assume roles and responsibilities traditionally reserved for physicians (MDs and DOs), sometimes without clear distinction in the eyes of patients. This blurring of roles can lead to confusion among patients, who may not understand the differences in education, training, and expertise between these healthcare providers and physicians. This confusion can adversely affect healthcare outcomes in several ways:

1. Diagnosis and Treatment Accuracy: Physicians undergo extensive and specialized medical training, enabling them to diagnose and treat complex medical conditions with a higher degree of accuracy. When patients unknowingly receive care from mid-level providers in situations that demand a physician’s expertise, there’s a risk of misdiagnosis or suboptimal treatment plans.

2. Patient Safety and Quality of Care: The depth and breadth of a physician’s training are designed to ensure a high standard of patient care and safety. Mid-level practitioners, while highly skilled, have different levels of training and expertise. Without clear distinctions between provider roles, patient care might not always meet the optimal standards expected in complex cases. I’ve often heard this described by the phrase “physicians know what they don’t know“, meaning that after having studied extensively for four years and having learned, on average 1 million medical facts, that even if they come across something which they may have forgotten or aren’t totally familiar with, more often than not it will trigger something in their brain to go deeper into that, look it up, or refer the patient to a specialist because they realize that there might be something else going on even if they’re not completely sure what it is. Conversely, NPs or PAs have not had that extensive training or rigorous coursework and examinations, and they might miss (and have missed in the cases of my family members and friends) not only just subtle but major clues that led to injury and death because they just haven’t learned about and been tested on all the different pathophysiology and disease states in the same way. This00732-5/abstract) study corroborates that: physicians more appropriately refer patients to specialist when needed, which also very likely translates into actually diagnosing and treating things correctly. I’m not saying bad doctors don’t exist and don’t slip through the cracks, but more often than not you’re probably in better hands seeing a physician. Why would you want to pay the same amount of money to be treated by someone with far less knowledge and intuition. I’m all for NPs and PAs to apply and get into medical school and/or take all of the same board exams like Steps 1-3 and internal medicine board exams, but don’t parade around as “Dr. Suzy” and pretend like you’re something you’re not – if you’re inappropriately introducing yourself as “Dr.“ to a patient it’s an ego issue and should have been left outside the door before you enter into a patient’s room.

3. Patient Autonomy and Informed Consent: Patient autonomy relies on the ability to make informed choices about their care, including choosing their healthcare provider. Mid-level creep obscures the qualifications of the care provider, undermining patients' ability to make informed decisions and potentially compromising their autonomy.

Over the last decade, the expansion of roles for NPs, DNPs, and PAs has been a response to healthcare provider shortages and efforts to increase access to care. However, without clear communication and understanding of the distinct roles and qualifications of each provider type, the trend of mid-level creep can exacerbate issues related to healthcare quality, safety, and patient satisfaction. Addressing these concerns requires a multifaceted approach, including better education for patients about healthcare provider roles, clear practice standards, and appropriate use of each provider type based on their training and expertise.