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What’s in a Name?

Who delivers high-level care? It must be the MD, of course. So, who delivers the lowest level of care? Nurses?

A colleague recently shared an article on Facebook that was written by a physician. The title “Stop Calling Nurse Practitioners Midlevel Providers”1really grabbed my attention, as oral health care is developing new practitioners that are designated as “midlevel.” In the article, Michael D. Pappas, MD, a pediatrician in Toledo, Ohio, suggests that using the term midlevel provider is “insulting to health professionals as well as to the patients they serve.” The author states that “midlevel provider” isn’t even an official or legal term, but one created by the medical profession. I was only a few sentences into the article and the thoughts were already churning in my head. Then I read this: “‘Midlevel’ implies that he or she provides middle of the road or average care, not high-level care. Who then delivers high-level care? It must be the MD, of course. So, who delivers the lowest level of care? Nurses?”

Legislation across the country is approving dental therapists as licensed practitioners in oral health care. They are highly trained professionals who treat patients and help alleviate access-to-care issues. Dental therapists have the knowledge and training to perform the procedures they are licensed to provide. This article made me think about whether midlevel practitioner is an apt moniker. The United States Drug Enforcement Administration (DEA) does use the term “midlevel practitioner” to name groups of health care professionals as part of its oversight of controlled substances. 2 The DEA defines the term as “an individual practitioner, other than a physician, dentist, veterinarian, or podiatrist, who is licensed, registered, or otherwise permitted by the US or the jurisdiction in which he/she practices, to dispense a controlled substance in the course of professional practice.”3 However, Medicare uses “nonphysician practitioners” to describe these same professionals.2

Does the term “midlevel” imply there are low-level and high-level oral care practitioners? Or worse, does it suggest that there are various levels of care? As a comparison, we don’t call general dentists “midlevel periodontists” or “midlevel endodontists.” They treat patients with these conditions but they do not have the additional training and designation required to be called periodontists or endodontists. Every general dentist I worked with strived to provide the highest quality care, whether in periodontics, endodontics, pediatrics, or other specialty. It would have been insulting to think of them as “midlevel.” This truly gives us food for thought. While the term “midlevel provider” is commonly used today, we can still change the mind-set and the terminology. Naming this emerging group of oral health professionals clinicians, oral care providers, or dental therapists may be more accurate, as they are designed to provide high-quality care for individuals who desperately need it.

 Jill Rethman, RDH, BA
     Editor in Chief


  1. Pappas MD. Stop Calling Nurse Practitioners Midlevel Providers. Available at: Accessed May 15, 2017.
  2. Bishop CS. Advanced practitioners are not mid-level providers. J Adv Pract Oncol. 2012;3:287–288.
  3. US Drug Enforcement Administration. Practitioner’s Manual. Available at: Accessed May 15, 2017.

From Dimensions of Dental HygieneJune 2017;15(6):6. 

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