Mid-Levels: the Staffing Solution of the Future?


Our mortality is both certain and universal. We are born, live and die, pretty much following the path of maturation, procreation and disintegration as homo sapiens have done for the past 175,000 years.

EPs must wrestle with the appropriate training, supervision, and CME of mid-level providers.


Our mortality is both certain and universal. We are born, live and die, pretty much following the path of maturation, procreation and disintegration as homo sapiens have done for the past 175,000 years. Prudentius wrote in the first Christian epic – a long, allegorical poem called Psychomachia – about the internal struggle that takes place in every human soul visited by grace. This intense struggle must also take place in every emergency doctor’s soul when supervising mid-levels. What is the correct supervision? Where does it begin and end? How does the law view supervision and its concomitant legal responsibilities? The bigger question, the long and short, is if the mid-levels can see all cases with only elective supervision. What is the real role for physicians? Are we to be merely consultants on an ad-hoc basis and supervise as a protocol and policy, or are we to be involved in all aspects of the patient’s care including, heaven forbid, actually examining the patient.

As I sit penning this epistle, I am surrounded by medico-legal cases which have come to me for my review during the past few months. The number of these cases that involve mid-levels and the supervision question is staggering. Why? Simple binomial expansion. We have gone from the late 1990s, when perhaps 3 to 5% of the patients were attended to by mid-levels, to today where estimates run close to 20%. There are credible papers on this subject that suggest, in certain academic centers, up to 27% are seen by providers other than doctors. At the risk of losing the few friends I have left since starting this column, and refusing to relinquish the rectitude of this most difficult question, let’s begin.

When asking such a question, the probity of the discussion is essential. I wish to bring light, not just heat, to the discussion. You don’t have to like me asking these questions, but at least hear me out. As the lawsuits pile up and the consternation runs abroad in the land, physicians who are usually grounded in fact and science totally abandon this method of dispassionate discourse when it comes to analyzing these questions. They yell, they scream, and they fall back into regressive modes only because it is different. There has been no national review of this issue on which we can depend for credible information. What should constitute the training of an emergency medicine PA or advanced practice nurse (APN)? What should be the logical progression in supervision as they mature into experienced clinicians? How should we as physicians help plan for and demand continuing medical education for physician extenders? Which clinical problems must always be presented to the supervising physician, or is it always judgmental?  


If you believe any of this is simple, guess again. I have medico-legal cases where the chief complaints seem innocent enough. Headache, sore throat, back pain, etc., which seem ideal for the PA or APN in the fast track setting. Right? These are the last three cases that have come to me this week. The last question for plaintiff’s counsel I want to hear at deposition is, “So, Dr. Henry, do you think it is within the standard of care to have a mid-level send the patient home to follow up in two days at the subarachnoid hemorrhage clinic?” Incidentally, the defendant doctor in this case freely admits his federal provider number was used to bill the patient’s insurance and simultaneously admits to merely signing the chart and never seeing the patient. Let’s see how well this plays in front of jurors who on average make about 1/6th per year what the doctor does and have watched the cost of their insurance programs and deductibles skyrocket over the past two years.

I think our readership understands that in a nation that is financially devastated and in horrendous debt, the cost of “who is doing what” is not moot. The federal government will continue to ask probing questions about what they are getting for their money. For us, the only reasonable defense is an offense, and the only real offense is information.

I will be in Washington DC in May. What are the answers to these painful questions? How do you defend the physician workforce needs when you have no idea whose actually doing what kind of work? This column is more than a diatribe from the mind of a doctor badly damaged by alcohol and social diseases. This is a challenge to ACEP, CORD, SAEM and any other acronym you would like to add, to start getting a handle on the 800-pound gorilla in this new, large EMS vehicle. We either must diffuse the problem and provide policies to resolve the issues, or someone (or something) who you do not like will do it for you. We must make the future by defining, under various conditions, what constitutes not ideal, but acceptable staffing levels and configurations. To do less is to accept Nero’s program of fiddling while Rome burns.

Have the courage to ask your favorite professional society about how they are approaching this question and how they are going to encourage the bulk of their membership to accept this research. We do our residents, the future of the specialty, a disservice by not involving them. I have now visited 116 of the 169 residency programs in this country, both MD and DO, and I can tell you that they are all over the map on this issue. Some use mid-levels extensively but do not allow the residents to supervise them. This gives them no training for what they will encounter when they get, of all things, a real job. I have seen programs that use no mid-levels at all. This again does not introduce the residents to extensive delegation of duties, which will be a part of their ever-expanding world. There are no simple answers. Our only mistakes would be not to admit that there is a question on the table and to fail to formulate some reasonable answers.


I encourage you to visit the Stanza della Segnatura, in Rome, where Rafael painted two pictures which face each other in a very modest-sized room. The physical distance is small but they are separated by both philosophy, time and eternity. One, the school of Athens, emphasizes the accomplishments of man as Aristotle debates with Plato while surrounded by the great men of science. On the opposite wall is the

“Disputata” or Disputation of the Sacraments, where the Eucharist is surrounded by the great men of faith. They represent opposite views of the world, but they exist together. Wise people of very different opinions must debate this mid-level issue if we are going to control our destiny. I warned you early on that you might not like this debate, but don’t shoot the messenger. Aristotle, in his Polemics, stated, “It is the mark of an educated man to be able to entertain a thought without accepting it.”


  1. Julie Crites on

    I am an Advanced Practice Nurse who specializes in Emergency Medicine. I received my training at one of only a handful of programs in the country that offer specialty training to NP’s in emergency medicine, Emory University’s ENP program. I agree that guidelines, certification and CME should be required. They program at Emory places the NP student with an Emergency Medicine resident at Grady Hospital in Atlanta, Ga. You work side by side with the resident, this allows both the NP student and the resident a real life experience of working in the ER setting and the capabilities/limitations that exists. The Emergency Nurses Association has been working towards a certification exam for NP’s trained in emergency medicine, this exam would give NP’s the appropriate credentialing for competency skills and knowledge. There is no denying that mid-level use has increased and will only be in greater demand in the future. MD’s, NP’s, and PA’s must work together for the greater good of the patient.

  2. Patrick Connell on

    I supervised PA’s in a community hospital setting for over 10 years. I now work in an academic medical center where there are no mid-levels in the ED.

    We found PA’s properly supervised to be useful and cost-effective. We had a large practice and had as many as 10 PA’s on staff at any one time.

    Our strategy for hiring, training, and supervising PA’s was the following:
    —new PA’s to the ED setting were required to do a 3 month “internshhip” which consisted of a didactic lecture series on emergency medicine practice (roughly 40 hours). Additionally, the new PA was required to shadow an experienced ED physician mentor for all his/her shifts during that period. We found that new PA graduates were often more receptive and “malleable” to this sort of training/mentorship.
    —each PA was then assigned to a physician supervisor. Ideally, they would work the same shifts though this doesn’t always work out in practice.
    —we developed a list of cases that were appropriate for PA’s to see. And yes, this is not perfect: a sore throat could be Ludwigs and a backache could be an epidural abscess.
    —PA’s essentially ran every case by the supervising physician and it was the physician’s choice to see the patient personally or not. If I didn’t see the patient, the case was billed under the PA’s Federal and State number.
    —PA’s were required to meet with their supervisor once a month to review cases, problems, and areas in need of improvement.
    —It takes time to develop a trust relationship with a mid-level. My experience was that we had some truly outstanding PA’s with a broad fund of knowledge and substantial experience.
    —After working with and personally supervising PA’s for nearly a decade, I would not hesitate to have one of my PA’s involved in my care when I have the big one.
    —It is important to always remember that a PA is a “physician extender.” You are the one responsible for the patient legally and morally. A good PA is like a second year resident in many ways and needs some latitude but a watchful eye from the supervisor in the ED setting.

  3. Doctor Henry,

    Thanks for bringing this up. My employer in undergoing significant scrutiny from CMS regarding this. Feel free to email directly if you want to learn about our struggles in a university setting

    My initial training was in Epidemiology so I concur that team science hasn’t been applied to this supervisory challenge. In addition, we haven’t studied the regional variations in midlevel practice and education. Finally training funds for APNs hasn’t kept pace with the needs. That has translated into clinical instruction that is limited by under capitalization.

    Our vulnerable patients deserve better. Thanks for exposing this controversial area.

  4. Top reason NOT to be a PA or nurse: the “poor PAs” discussion that makes egocentric doctors seem infallible while nurses and PAs are lacking, along with the belittling use of the term “extender” to push down anyone who is not a doctor. Top reason to become a doctor: anyone with a modicum of intellect realizes self-preservation dictates not relying on doctors.

  5. Stephen Lyons, MS,PA-C, DFAAPA on

    I applaud Dr. Henry for one of the very few well-thought-out discourses on this critical issue. It is an accurate, dispassionate view of the real questions in need of sensible answers. So often we see good answers to the wrong questions, or emotion-filled (and thus usually skewed) answers to the right questions. In my 35 years as a practicing, board ceritfied PA-C, I have discovered some very obvious (at least to me) universal truths.

    1) All MDs are not gods any more than all PA-s are are wanna-be’s.
    I’ve met some incredibly smart and skilled physicians, and some incredibly stupid ones. The same is true for PAs and NPs in about the same proportions.

    2) No matter how many years I have been in practice, I still don’t generally have the depth of knowledge of even my much younger physician collaborators.

    3. Medical judgement doesn’t come WITH degees, whether MD,DO,PA, or APN…….it comes BY degrees, as in years of experience.

    4. Let us work on how to respect each other, and research the best ways to work together for the good of the patients, rather than against each other for the good of our egos.

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