Advance Practice Providers Are Not Midlevel. Derogatory title for nurse-midwives is egregious

A Benign Adjective That Became A Malignant Noun

Years ago, I worked in a hospital-owned and administrated Certified Nurse-Midwifery group. Practice meetings occurred, periodically, to discuss administrative concerns and other pertinent issues regarding patient care in our clinic. One particular meeting was assembled to meet and welcome a new hospital CEO who was making rounds on the various clinics and departments. Executives had a tendency to come and go in this hospital so these meetings were not a new experience for our group. I have no clear memory of other meetings that I attended, but this one stands out.

We were arranged in a circle of chairs with the honored position at the top of the circle. After introductions, our new chief executive sat down and surveyed our small assembly; a mere speck in his new domain. He settled back in his chair, with clasped hands behind his perfectly coiffed and hair-sprayed head, and stretched out his long legs so that we could admire him. The only other details that I recall were his angora wool socks, and calf-leather loafers (probably Italian). I felt sure that he wouldn’t adopt this demeanor when meeting the endocrinologists next door, but he appeared very relaxed and casual with our group of women.

Midlevel Madness

To be fair, he might not have been prepped, but it was immediately clear that he had no idea who we were or what we did. After speaking for several minutes of his plans for the hospital, he began to reveal a vision for our clinic, and the “mid-levels” staffing it. After a couple of seconds, I understood that he was referring to us, the nurse-midwives. It was confusing: what was he talking about? Was he really calling us mid-levels? It had to be a mistake. . . He was and it wasn’t. And, it seems, I’ve never gotten over it.

Regrettably, when irate, my mouth will engage ahead of my brain. I responded with an enthusiastic level of indignation, probably over-reacting to this obvious insult that had landed in our little meeting. Our new, high-level, executive did not address my concern and the meeting ended soon after.

Looking back, I can accept that this brand-new CEO had no intention to insult us. He might not have had any previous experience in hospital management? Regardless, the chances that this person was going to be an advocate for nurse-midwifery were non-existent. We never saw him, again. I heard, later, that he had departed the position of CEO after about eight months; taking along his fuzzy socks and expensive shoes. I was not sad.

What did not depart is the term, “mid-level”. And the negative connotations attached to it. In American hospital corporate jargon, this miserable label has caught on and continues to gain momentum.* It can be found, too often, in hospital communications, directives, and random articles. It has become a new Word of the Day in Merriam Webster, for all I know. As a descriptor, it is as insulting, now, as it was then.

“Mid-level practitioner” was coined by a precocious “mid-level” in the U.S. Department of Justice Drug Enforcement Administration (DEA) to specify non-physician healthcare providers who could potentially prescribe controlled substances.

(He or she has wisely remained anonymous and, hopefully, in witness protection.)

Mid-level, in DEA context, describes someone other than a physician, dentist, veterinarian, or podiatrist, who is licensed, registered, or otherwise permitted to dispense a controlled substance in the course of professional practice.[1] Medicare has used the term, “non-physician practitioner”, when referring to advanced practice clinicians. Being described as something you are not, instead of what you so brilliantly are, lacks as much clarity as mid-level. Although variations on the same theme, these terms make clear that CNMs/CMs are not high-level, a category plainly intended for doctors to occupy.

“Mid-level providers” are intended to exist, dead-center, within arcane vertical hierarchies of hospital healthcare. Physician care is on top, with descending levels representing less-than-optimal care?Nurse-midwives, and other advanced practice professionals, find themselves the undeserved occupants of the “mid”-position in this healthcare status layer cake . CNMs are, however, in very good company. Contrary to the obvious implications created by this objectionable designation, nurse-midwives, nurse-anesthetists, nurse practitioners in all specialties, and physician assistants individually practice at the highest levels of their individual scopes of practice. Advanced practice nursing professionals, and PA’s, are licensed independently, and their individual standards of practice were never “designed to be dependent on or an extension of care rendered by a physician”.[2]

**Middlle of the road . . . .**
**unsplash-image**

A Term That Needs to Be Eradicated

Legitimacy issues already plague the profession of certified nurse-midwifery. Along with frightening historical misconceptions, CNMs do not need the added burden of a label that insinuates delivery of mediocre care. Defining any segment of healthcare this way begs this question: “Can you contemplate anything associated with ‘middle’ that is a desirable state of being?” Consider these words and phrases: middle-of-the-road, mid-life crisis, middle of a tax audit, mid-way, midriff, middling, middle child syndrome, middle schoolers (!), middle of nowhere, middle finger . . . The antonym for “middle”? Distinctive, Special, Unique. Ouch.

Outdated Hierarchies of Care Serve Only Those At the Top

Physician-dominant hierarchies of care, encouraged by for-profit hospital corporations and government healthcare entities, have contributed little to the advancement and wisdom of cooperative healthcare teams. Vertical hierarchies discourage the unique needs of patients, and are consistently found in hospitals that have perpetuated unhealthy cultures of care. Exclusive hierarchies in patient care can also encourage an increasingly inadequate and restrictive delivery of care. Competent and well-educated providers, from different educational backgrounds, should not have to endure corporate discrimination based on an idea that only medical school education can ensure the very best level of care. Finally, if mid-level providers actually do exist, which providers do we identify as low-level?

It gets worse. With the participation of “mid-level” providers: legislatures, hospital staff bylaws, Medicare, Medicaid, and other entities, support laws requiring direct “Supervision”. It is automatically assumed that “mid-levels” must be supervised by those that are designated as “high levels”.

Legislation addressing the dangers of mid-levels can be found in Statutes and medical staff by-laws. Of interest, supervisory requirements, are never specifically defined. Physicians can become deeply alarmed, to the point of requiring chest compressions, when there is a hospital/clinic directive to supervise mid-level providers. Panic predictably sets in when individual scopes of practice are not understood or misconstrued. In the case of certified nurse-midwives, full practice authority is maintained within a well-defined scope of practice (See ACNM Standards for the Practice of Certified Nurse-Midwifery). In more than half the States, advanced healthcare providers can practice independently per Statute. States passing full practice authority are increasing.[3] When care decisions require expertise beyond the scope of CNM practice, the process requires physician consultation and/or collaboration, not supervision. In select circumstances, total transfer of care is appropriate. More frequently, physicians and midwives have been known to successfully co-manage patients with acute care requirements.

Another day in rural prenatal clinic
Finding Dan unsplash image

Use and Abuse

After years of bias and avoidance, healthcare corporations and independent physicians are finding ways to use CNMs/CMs for purely economic purposes. Hospitals are contemplating ways to utilize potentially dangerous mid-levels so more patients can be crammed into a day’s clinic schedule. But this is not the problem. Of course, CNMs/APNs/PA’s can competently attend to patients in a busy clinical/hospital practice, increasing the number of individuals who can be seen and billed.

When unable to find independent specialty jobs, except in difficult or remote places, advanced practice providers may be vulnerable to being lured into a hospital corporate fold. In a busy specialty practice, advanced practice providers can attend to the same types of patients as the doctors. The problem is that they are not being paid commensurate with their responsibilities and increasingly acute patient load.

For some nurse-midwives, this situation may also provoke professional identity issues because the patient populations they are being recruited to care for are increasingly remote from normal. It is not surprising, in these settings, that CNMs/CMs are getting the work done and still managing to deliver care as midwives**; at least to the extent that they can in very high-risk care situations.

Will these realities eventually require a new iteration of midwife which requires changes in, or abandonment of, a midwifery model of care? Will a midwifery philosophy of care remain pertinent when treating patients exhibiting higher levels of risk? CNMs/CMs do have the education, knowledge, and skills to attend to higher-risk levels of care in collaborative environments. But how might it change the practice of certified nurse-midwifery and certified midwifery, if at all?

1. J Adv Pract Oncol. 2012 Sept-Oct; 3(5): 287-288.

2. American Association of NURSE PRACTITIONERS. Stanik-Hutt, J., Newhouse, R.P., White, K.M. (2013) The quality and effectiveness of care provided by nurse-practitioners. Journal for Nurse-Practitioners, 9(8), 492-513.

3. AAP News. Letter to the Editor: Term ‘mid-level provider’ outdated, offensive. May 24, 2016.

* When receiving hospital communications using the term, midlevel, it can be personally satisfying to respond back, explaining how insulting the term is to you, as a professional, and requesting that they stop referring to your career in this disrespectful way.

** The word, Midwife, comes from old English, meaning "with“(mid) “wife”(woman). No present or historical associations with “middle” or “mid-level”.

Relevance For Practice

Situation:

As a clinician, use of derogatory terms in your workplace allows you to assess what culture of care exists. Unhealthy care cultures exhibit insensitivity to non-physician professionals such as a lack of cooperation and respect from physician and nursing colleagues, alike. Nurse-midwifery remains controversial as legitimate healthcare due to decades of historical legend and misconception. Corporate healthcare has not done much to elevate the profile of nurse-midwifery. Hospital administrators will elevate the physician staff, as the money-makers, and will consistently cater to this reality. Midwifery garners far lower levels of regard. As a result, midwives in certain hospital systems are susceptible to decreased morale, decreased performance, and career burnout.[4]

Vulnerability:

Along with fatigue and burnout, hospital-based midwives may exhibit anxiety, depression, and frustration. Despite love for their work, midwives are leaving hospital practice and abandoning midwifery, altogether. Corporate healthcare systems may not be relied upon for moral or financial support, especially when there has been an unexpected, random birthing event. Hospital administrations and physician staff may be quick to assume midwife culpability and risk management might appear to even expect a mistake. Despite training and education to function at the highest levels within their scope of practice, CNMs/CMs exposed to an atmosphere of distrust and disrespect can only experience so much without emotionally faltering under the pressure. Furthermore, disdain and animosity from labor/delivery and nursery/NICU staff can add to the pressures in the workplace.[5]

Risk Assessment/Duty:

Following ACNM standards of practice and the supporting documents decreases the chances that you will be involved in a lawsuit. If you have not yet figured it out, CNMs/CM’s have a lot to prove. It may seem unfair that you are subject to a higher level of scrutiny than your colleagues. In maternal-child practice, midwifery is the specialty that has the most to offer, and also the most to lose, due to society’s misconceived notions, and collegial distrust. In order to overcome this, you must strive to be fully present in your work in the midst of professional, family, and institutional pressures. This also involves a willingness to ask for help. In hostile work environments this might feel impossible but your patients’ needs must take precedence over your fears and discomfort.

Duty to your patients is implicit in midwifery care. If there is any other duty to be considered, here, it is to perform well, educate colleagues when you can, and strive to raise expectations at every opportunity.

4. Open Access Maced J Med Sci 2018 Nov 25; 6(11): 2228-2232

5. Erin M. Wright, CNM,DNP, et.al. Midwifery Professional Stress and Its Sources: A Mixed-Methods Study. Journal of Midwifery and Women’s Health. Vol 63, No. 6, November/December 2018

http://www.midwivesontrial.com/articles/mid-level-mortification

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