While I was recently speaking with a group of physicians, a comment was made regarding mid-level providers.  Somewhat succinctly and pointedly, it was mentioned that the direction of health care is such that patients are more frequently unable to see a physician in primary care settings, specialty clinics and emergency departments.  This is not a new circumstance, but a growing and developing integral transformation in health care occurring over several decades.  Interestingly, the same physician’s practice has MLPs as part of the staffing model, with a very large patient base and a well-regarded reputation.  What is paradoxical is that over the years many patients have commented that they have not seen their PCP at all within that practice, they are seen exclusively by a midlevel in the office who they have come to accept as the provider who knows them better than anyone else in the group, and they are quite satisfied with their PA-C/APRN relationships. 

Of occupations and industries, it is noted that the majority of new jobs from 2012-2022 will come from health care.  Currently, the projections are that advanced practice registered nurse (APRN) and physician assistant programs will continue to grow at rapid rates, about 31-38%, respectively.  That is greater than the cumulative growth of all the other healthcare-related professions forecasted during this period.  Both of these advanced provider post-undergraduate programs were started in the mid-1960s by physicians and nurses.  They were premised on physician shortages, limited healthcare dollars to support the ongoing need for increasing access to primary care and increasing demographics that would exceed the growth and revenue capabilities of traditional healthcare education. 

The same circumstances exist today.  However, the impending demand on health care by baby boomers and rapidly changing delivery and reimbursement models must dually serve to accelerate processes to safely and consistently support the clinical competencies of mid-level providers.  Overall, there is enough unbiased data to substantiate that these allied health professionals (a seemingly more appropriate reference than mid-level providers) have been extremely necessary and successful entities to the delivery of health care. 

There is concern regarding disparity between post-graduate education programs, both didactically and clinically.  It is not realistic to expect graduates to wait years before they have enough clinical encounters, let alone unlikely to ever receive procedural training, to safely work with a reasonable degree of autonomy.  This creates unfillable voids in the job market for the minority who honed their skills over years and who leave their positions while randomly perpetuating a fair amount of preventable risk and exposure.  From this somewhat schizophrenic means of obtaining post-graduate clinical training, there is a dichotomy that understandably exists among many physicians.

Some physicians feel threatened when allied providers with less rigorous training and experience are being considered to be given more autonomy working under their supervision for less compensation.  More risk for less reimbursement, that’s a viable strategy, maybe so for med-mal litigation.  Others see the opportunity to expand practices through scalability without addressing the concomitant risk.  Additionally, as it relates to APRNs, there is variability amongst the 50 states regarding the degree of independence APRNs have in treating and diagnosing patients as well as prescribing.  A unified front is required to support the evolution of allied healthcare professionals by eliminating the irregularities between clinical rotations and the limited number of post-graduate training programs.

OTJ (on the job) training should not be the accepted methodology for allied health providers to gain the necessary clinical experience they must have, as they continue to practice medicine outside the guardrails of what would be considered simply a clinical assistant.  Most physicians who have worked with PAs and APRNs should relate to this intimately.  Additionally, many seasoned allied health providers find the title of mid-level to be demeaning and not even remotely close to the amount of autonomy that many have or the complexity of decision making and care they render.

When I was working in a research lab prior to medical school, my principal investigator put forth the question as to “what I would be once I graduated from medical school?”  I was quick to answer, “A doctor.” He enlightened me with this, “You will not be a doctor.  You will have a graduate degree in medicine.”  Without the graduate completing a residency, thousands of patient encounters in an accredited clinical training program simply don’t exist.  Ongoing genesis of residencies, variable in length between 12-18 months, are being established for allied health providers. This should become mandatory. 

The certification and governance of these programs should be and will likely become more regulated.  This is why it caught me off guard last week when I heard of a PA student nearing completion of the curriculum and that there were not enough clinical slots available for all the students in the class.  Some students were directed to self-study at home in order to complete the program, and they were just hoping to find someone to hire them.

The evolution of allied health professionals is a needle mover for the future of health care.   Through standardized post-graduate training, there should be less scrutiny of allied providers.  There are physicians who have very little awareness of the current state of practice for allied healthcare professionals and those who are willing to simply increase the future state of practice boundaries by expanding supervisory ratios without first addressing much of the aforementioned educational and training incongruancies.

Of all my physician assistant colleagues I spoke with over the past week, not one was aware that they could be a member of the NHMS.  There is opportunity for the NHMS to pull more new members forward through greater recognition and shared focus in the development of allied healthcare professionals.  Career development and leadership opportunities can grow appropriately in the state, particularly with Medicaid expansion and greater need for primary care access and viable medical home models all amongst an aging population.  Cultivating allied healthcare programs and their graduates is a great opportunity for the future of health care.  


Lukas Kolm, MD, MPH, FACEP

Please send your comments or questions to president@nhms.org or post a comment below.



Great column, Lukas. The idea of at least brief (1 year?) post-grad training for our (what we call them in Concord) advanced level colleagues is a good one, hearkening back to the "rotating internship" concept of MDs in the early specialty training days. Especially now that supply is beginning to meet demand, such standardization could have great value. And it's required in so many other allied fields, including doctoral level psychology. And as you mention, language is important. There's no closing this barn door, so I hope NHMS and others can exert leadership here.

Gary, thanks for your supportive comment. We all need to stoke the fire on this. Regards, Lukas