Talk:Nurse practitioner

Mid-level once again
On Wikipedia we follow the best available sources, and for this article that means the World Health Organization. We cannot use lesser sources to undercut their description of this profession as a Mid-level practitioner, even if the NP professional orgs dislike that categorization - particular not sources that are being misused per WP:SYN. This has been a target for edit warring by sockpuppet accounts for a long time. It's not going to happen. MrOllie (talk) 15:19, 20 November 2023 (UTC)


 * You cannot simply remove information that is appropriately sourced from this article. The overwhelming majority of professional organizations and government entities no longer use the term mid-level provider. The WHO article listed is from 2010 and is wildly outdated by newer studies and resources. With my edit I supplied peer reviewed sources that included physicians within the studies. I also included references to major medical organizations such as the American Medical Association and the American College of Emergency Physicians who refer to NPs and PAs as advanced practice providers and no longer use the term mid-level provider. Additionally in keeping with the belief of neutrality I did not replace the term mid-level provider but instead placed the term advanced practice provider alongside of it. My edit is supported by facts and your removal of the information should be reversed. Hue16459 (talk) 15:43, 20 November 2023 (UTC)
 * You cannot simply remove information that is appropriately sourced from this article. It is not appropriately sourced, as I just got done saying. What you did was throw a bunch of unrelated stuff in to try to construct a WP:SYN argument, and you did so with lower-tier sourcing in an attempt to undercut a top-tier source, the WHO. MrOllie (talk) 15:45, 20 November 2023 (UTC)
 * There is no lower tiered sourcing. The WHO article is form 2010 and is wildly outdated and the term mid-level practitioner has obviously been replaced by the term advanced practice provider by almost all professional organizations and government entities.The most recent CMS guidelines do not use the term mid-level nor do any recent communications from the medical community. Hue16459 (talk) 15:59, 20 November 2023 (UTC)
 * Additionally, the sources were not being misused according to WP:SYN. All sources provided concluded that the appropriate term is advanced practice provider and that the term mid-level practitioner is generally no longer used by most organizations. Hue16459 (talk) 15:49, 20 November 2023 (UTC)
 * The most recent CMS guidelines do not use the term mid-level <- that kind of reasoning is exactly what is forbidden by WP:NOR. MrOllie (talk) 16:10, 20 November 2023 (UTC)
 * With my original edit I included peer reviewed scientific journals that are timely and interdisciplinary. Peer reviewed sources are tier 1 sources. I am not understanding how the reasoning that a term is outdated and no longer used is forbidden. The evidence vastly supports the fact that the term mid-level has been replaced. Irrespective of that fact placing both terms next to eachother allows the reader to draw their own conclusion and helps alleviate bias. Hue16459 (talk) 16:17, 20 November 2023 (UTC)
 * Your personal evaluation of what the evidence 'vastly supports' is what is forbidden by WP:NOR. At any rate, I'm done arguing here until the SPI comes back. (That is not an invitation for you to continue to edit war) MrOllie (talk) 16:20, 20 November 2023 (UTC)
 * I am not an SP and to settle this dispute I recommend the term middle-level practitioner is simply removed and replaced with healthcare provider as this is a broadly accepted international term. This term is neutral and free from bias in either direction. It is also what is listed on the physician assistant page. Hue16459 (talk) 16:52, 20 November 2023 (UTC)
 * @Hue16459, the "marketing" aspect of the language is a perennial problem for this article. Just so I can understand you better, are you saying that nobody is a mid-level practitioner, or that some healthcare providers are, but NPs are above them? WhatamIdoing (talk) 23:44, 20 November 2023 (UTC)
 * I believe that the term health care provider is a more appropriate term and it is a term that is defined in United States Code. The term health care provider also covers both nurse practitioners who practice with full authority and nurse practitioners who practice with restricted authority. By definition a nurse practitioner with full practice authority is not a mid-level provider as the law grants them independent practice authority that has the same rights and privileges to that of a physician. I would agree that in states with restricted practice authority a NP could be considered a mid-level practitioner because their work is overseen by a physician. That being said 27 states grant full practice authority as well as the US government when NPs are employed by the uniformed services or the Department of Veterans Affairs. Mid-level practitioner is therefore not the most correct term to define nurse practitioners as it does not include the majority of nurse practitioners. 29 CFR § 825.125, and 45 CFR § 160.103 both include nurse practitioner in the definition of a health care provider and have no definition for mid-level practitioner. Additionally, 21 CFR § 1300.01(b28) which is the only CFR that refers to mid-level practitioners and is listed as a reference for mid-level practitioner on this page states "Mid-level practitioner means an individual practitioner, other than a physician, dentist, veterinarian, or podiatrist, who is licensed, registered, or otherwise permitted by the United States or the jurisdiction in which he/she practices, to dispense a controlled substance in the course of professional practice. Examples of mid-level practitioners include, but are not limited to, health care providers such as nurse practitioners, nurse midwives, nurse anesthetists, clinical nurse specialists and physician assistants who are authorized to dispense controlled substances by the State in which they practice." Additionally the overwhelming majority of peer reviewed medical journals and professional organization, including those of physicians, no longer use the term mid-level practitioner to describe NPs presumably because of its conflict with full practice authority.. Based on this information I believe that using the term health care provider is the most appropriate adjustment to this article. Hue16459 (talk) 00:20, 21 November 2023 (UTC)
 * Also, using the generalized term health care provider also removes any chance of future argument over the use of mid-level practitioner or advanced practice provider. Hue16459 (talk) 00:24, 21 November 2023 (UTC)
 * One could also simply remove any additional term other than APRN all together. "A nurse practitioner (NP) is an advanced practice registered nurse (APRN) that is trained to assess patient needs, order and interpret diagnostic and laboratory tests, diagnose disease, formulate and prescribe medications and treatment plans." Hue16459 (talk) 00:48, 21 November 2023 (UTC)
 * I notice that you said By definition a nurse practitioner with full practice authority is not a mid-level provider. Where exactly can I read this definition? WhatamIdoing (talk) 00:55, 21 November 2023 (UTC)
 * Dictionary.com defines mid-level as occurring at or having a middle or intermediate position or status. In practice there are generally two different definitions that have been used throughout peer reviewed sources for mid-level practitioners, one is providing care at a level less then that of a physician, and the other is having training that is less then that of a physician. Certain states with restrictive practice authority do use the term mid-level practitioner because the NPs that practice in that state work under the scope of practice of a supervising physician. In contrast however the NP scope of practice in full practice authority states are not dependent on, or an extension of, the care rendered by a physician or other health care provider, and these states do not use the term mid-level practitioner. On a federal level the only reference to mid-level practitioner is listed in 21 CFR § 1300.01(b28) or the controlled substance act which states "Mid-level practitioner means an individual practitioner, other than a physician, dentist, veterinarian, or podiatrist, who is licensed, registered, or otherwise permitted by the United States or the jurisdiction in which he/she practices, to dispense a controlled substance in the course of professional practice. Examples of mid-level practitioners include, but are not limited to, health care providers such as nurse practitioners, nurse midwives, nurse anesthetists, clinical nurse specialists and physician assistants who are authorized to dispense controlled substances by the State in which they practice." However, this CFR was last updated April 2011 and there is no reference to this term in any other CFR that has been published since. The states that have granted full practice authority since 2013 has increased from 17 to 27 plus DC and 3 territories. Because the majority of NPs now have full practice authority it makes sense that the term mid-level practitioner is no longer generally used. In modern practice within the US the term nurse practitioner is included in the definition of health care provider in 29 CFR § 825.125, and 45 CFR § 160.103 or is referred to individually as an advanced practice registered nurse. Most recently 38 CFR § 17.415 is the law that granted nurse practitioners employed by the Department of Veterans affairs full practice authority as was published December 2016. This CFR makes no reference to the term mid-level practitioner. The term mid-level practitioner is supported in restricted practice states where by definition the care of an NP is below that of a physician and the care is in fact supervised by a physician. However, the evidence does not support the use of the term in full-practice authority states where NPs practice is not only licensed by the Board of Nursing but also is completely removed from the supervision of a physician. Because of the generalized conflict in the terminology, and the majority of NPs working with full practice authority, the terminology of this page should be update to the overarching term health care provider, or the terminology should be removed completely as in my previous recommendation relying solely on the term APRN which makes it clear NPs are nurses. Hue16459 (talk) 02:16, 21 November 2023 (UTC)
 * A generic definition for unrelated uses of the word is irrelevant. So what we've got is that NPs are called mid-levels:
 * because, using the definition seen in the first sentence of Mid-level practitioner, they have less formal training than physicians, and/or
 * because their scope of practice is at least slightly more restricted than a physician's.
 * Do you think that either of those reasons are generally false? For example, do you believe that most NPs have the same, or more, years of education than most physicians?  Do you think that most NPs can provide all the same medical care as, or more care than, most physicians?
 * I notice that you refer to US legislation very often. I thought that NPs were licensed in multiple countries, so a US legal definition is not really appropriate for an article on a worldwide profession. WhatamIdoing (talk) 04:27, 21 November 2023 (UTC)
 * In general a nurse practitioner with full practice authority is capable of providing the same level of care as a physician who practices in the same specialty. By law a patient who sees a family nurse practitioner with full practice authority can receive all of the same services as a patient that sees a family medicine physician. Also in general the education of nurse practitioners and physicians cannot be directly compared as nurse practitioners practice the nursing model and physicians practice the medical model, while both professions are licensed by different boards. Nurse Practitioners have 4 years of undergraduate nursing education and 2-4 years of post graduate nursing education. A physician has 4 years of graduate medical education followed by a residency that on average is 3 years. It is of no debate that physicians have much greater clinical training requirements than NPs due to residency training but on a generalized level the education level for both providers are at the graduate level. I reference US law because NPs primarily exist in the US as this is where the profession started. Other countries have only adopted NPs realistically within the last 20 years. I have attempted to conduct research on NP training in the UK, CA, and AU as it relates to the use of the term mid-level practitioner and have been unable to find official resources that use this title. The UK and AU refer to NPs as advanced clinical practitioners and in Canada the terminology is allied primary health practitioners. In fact while searching for the term mid-level practitioner the only information that is easily accessible is the Wikipedia page for the term and upon reviewing the information presented in that page there are no references for the term being used to identify nurse practitioners as mid-level providers in other countries and the only reference for the UnIted States is the controlled substance act CFR I previously mentioned from 2011. The page uses the definition of “do not have as extensive of an education as a physician” to define the term mid-level provider although there is no reference to support this definition. Also this is irrelevant because if a nurse practitioner had the same level of education as a physician then they would be a physician. The same can be said for dentists and podiatrist who have the highest level of training in their field, and independent practice authority, but are not by definition physicians. Realistically there is not even a need to include the term mid-level practitioner on the page because the recognized title by every government organization and licensing body is advanced practice registered nurse. Hue16459 (talk) 05:11, 21 November 2023 (UTC)
 * Additionally a physician educated in the UK has a MBBS degree which is a bachelor degrees and these physicians are in fact not doctors as this term is for individuals who possess a doctorate. A UK educated physician may also complete a residency in the US and practice as a physician with only a bachelors degree. Both the UK and US require nurse practitioners to have masters degrees so in this case a NP actually has more education than a physician although their ability to practice remains equal. Furthermore NP and physician education cannot be fairly compared because medical school does not allow a graduate to be licensed as a physician. Medical school only teaches the basic concepts required to pursue licensure through a residency program. For instance a medical doctor must complete psychiatry residency to be medically licensed as a psychiatrist. In contrast psychiatric NP school education is completely related to psychiatry and upon graduation an NP is legally allowed to be licensed as a psychiatric NP. As a final point a physician is legally allowed to refer a patient to a nurse practitioner for care. If a patient needed a mental health referral both a family NP and a family physician could refer the patient to either a psychiatrist or psychiatric NP. This supports the fact that both professions can provide an equal level of care under the law. Hue16459 (talk) 05:52, 21 November 2023 (UTC)
 * The MBBS is a bachelor's in name only; it is not a four-year degree, and it's taken in a country where what Americans call a "four-year degree" frequently takes only three years. Comparisons should be same-country to account for these differences.  Here's my count:
 * In the US:
 * 4 years for a bachelors + 3 years for a masters = US NP in 7 years
 * 4 years for a bachelors + 4 years for medical school + 3 years for family practice residency = US physician in family practice in 11 years
 * and in England:
 * 3 years for a bachelors + 2 years for a masters + 2 years clinical experience = UK NP in 7 years
 * 5–6 years for a MBBS + 2 years foundation + 2 years specialty = UK family practice physician in 9–10 years
 * In both cases, the NP has less formal education than the physician. WhatamIdoing (talk) 06:26, 21 November 2023 (UTC)
 * So you are using the definition of mid-level practitioner of anyone with less training than a physician? If so can you please provide the reference you used to come this conclusion? Hue16459 (talk) 15:01, 21 November 2023 (UTC)
 * The WHO paper linked below says "There are multiple definitions of mid-level health workers because it is not a single occupational category (5-7), but most of them agree that mid-level health workers are those who have received shorter training than physicians (between 2–4 years) but will perform some of the same tasks as physicians (6, 8). Therefore a mid-level health worker is not a medical doctor, but provides clinical care (may diagnose, manage and treat illness, disease and impairments) or engage in preventive care and health promotion (8)." WhatamIdoing (talk) 16:14, 21 November 2023 (UTC)
 * The question becomes why is the term mid-level practitioner the default language when the WHO is the only organization that appears to use it even though it does not appear to have been used by the organization since 2017. Additionally, all the references the WHO used to develop this definition are not from this decade, and by the WHOs own admission contested. The definition presented refers to all healthcare providers other than physicians including those that are not professionals or licensed as independent providers. The US, UK, AU, and CA all refer to NPs as some sort of advanced practice provider as well as all licensing regulatory bodies that certify NPs. The only reference outside of the US controlled substance act from 2011 where NPs are referred to as mid-level practitioners are in US states with restrictive authority and by law NPs must be directly supervised by a physician and therefor provide care at a level below that of a physician. Upon reviewing all other health profession pages on wikipedia the NP page is the only one that refers to NPs as being mid-level practitioners. The preponderance of the evidence tends to show that the term mid-level practitioner is not the best available term to define NPs through current research or through professional communication in countries that certify NPs. Hue16459 (talk) 17:41, 21 November 2023 (UTC)
 * It's probably the default wording on Wikipedia because it happens to match the article title on our article about the subject: Mid-level practitioner. WhatamIdoing (talk) 17:45, 21 November 2023 (UTC)
 * Yes and that article relies solely on the WHO definition and the US controlled substance act as the basis of its existence. Information that is outdated by almost 10 years and a term that even the American Medical Association no longer uses to describe NPs. In fact the term used for medical billing in the US which once was mid-level practitioner has now been replaced with nonphysician practitioners Hue16459 (talk) 17:58, 21 November 2023 (UTC)
 * My point of argument for removing the reference to any type of identification other then APRN is that the further classification of the term is not relevant to the NP career field or information that benefits the reader. The NP page is a standalone page for the NP profession not an aggregate page of providers where a group term needs to be used. There is no benefit to the reader to further define an NP as a non-physician provider as by its very existence it is a non-physician provider. Modifying the page to read "A nurse practitioner(NP) is an advanced practice registered nurse (APRN) that is trained to assess patient needs, order and interpret diagnostic and laboratory tests, diagnose disease, formulate and prescribe medications and treatment plans." is the most appropriate way to define the field in all the countries that license NPs. Also it would aline the page to all other wikipedia health profession articles which do not have further classification as mid-level or non-physician providers. Hue16459 (talk) 18:41, 21 November 2023 (UTC)
 * The fact that possible flaws exist in other articles isn't really a good reason to do the same here. Basically, what I'm hearing is "I don't like being called 'mid'; I want to be called 'high'."  And that's fair – nobody likes being told that they're 'less than' – but it's also marketing, which makes me nervous. WhatamIdoing (talk) 20:11, 21 November 2023 (UTC)
 * Missouri law now allows for the licensure and practice of assistant physicians who are graduates of a medical school but are ineligible for licensure as a physician due to being unable to complete a residency training program. These doctors may only refer to themselves as assistant physicians and are required to maintain a collaborative practice agreement with a supervising physician. The law states "The collaborating physician is responsible at all times for the oversight of the activities of and accepts responsibility for primary care services rendered by the assistant physician." Additionally the law further states that "an assistant physician shall be considered a physician assistant for purposes of regulations of the Centers for Medicare and Medicaid Services (CMS)". This means that medical school graduates are classified as mid-level practitioners under both the WHO definition and the controlled substance act referenced on this page which refer to terminology from 2011. The modern appropriate terminology recognized by CMS is non-physician practitioner.  Hue16459 (talk) 20:33, 21 November 2023 (UTC)[ reply]
 * Unfortunately, the Missouri law doesn't define what "residency" means to them, but since they specify USMLE #2, I suspect (but can't prove) that this is not a Residency (medicine) of the sort that is run by National Resident Matching Program. WhatamIdoing (talk) 18:31, 22 November 2023 (UTC)
 * The assistant physician position is for MD/DO graduates who cannot receive licensure as a physician because they were not matched into a residency. This relates to the conversation in the thread below also. Hue16459 (talk) 21:36, 22 November 2023 (UTC)
 * Please see my most recent post to the thread below for a full breakdown. Hue16459 (talk) 00:07, 23 November 2023 (UTC)
 * The WHO was still using that language to describe NPs in 2017. I don't know if they've changed their style since then (I didn't see anything relevant to either support or disprove it). WhatamIdoing (talk) 23:58, 20 November 2023 (UTC)
 * I reviewed this article and if you look at the studies they used to define mid-level practitioner they used the studies which are identified as references 5,6,7,8,9. 5 is from 2001, 6 is from 2008, 7 is from 2004 and 8 is from 2013, and 9 is from 2010. Additionally, in further researching study number 8 from 2013, the definitions used to define mid-level practitioner are listed in table 1 and are from 2001, 2004 and 2008. The definition from 2008 states "Mid-level workers are health-care providers who are not professionals but who render health care in communities and hospitals. They have received less (shorter) training and have a more restricted scope of practice than professionals." This study is a meta-analysis that aimed to determine if mid-level practitioners are as effective as physicians and "for the purpose of this study, a mid-level health worker was defined as a health-care provider who is not a medical doctor or physician but who provides clinical care in the community or at a primary care facility or hospital. The definition includes midwives, nurses, auxiliary nurses, nurse assistants, non-physician clinicians and surgical technicians." The researchers effectively grouped healthcare providers into two categories physicians and non-physicians for the purpose of comparing non-physician providers. The studies that were used from the meta-analysis were from 1973 to 2012. I was unable to find any reference to these studies including nurse practitioners with full practice authority. Additionally, the definition used to describe mid-level practitioners specifically states they have a more restricted scope of practice then professionals. Full practice authority nurse practitioners are both considered professionals and have the same scope of practice as physicians therefore they do not meet this 15 year old definition of mid-level practitioner.Hue16459 (talk) 15:38, 21 November 2023 (UTC)
 * The wording about "professionals" may be misleading, especially to Americans. Back in the day, there were three professions:  doctor, lawyer, and priest.  We use the word more generously these days.
 * I'm not sure that a full-practice authority NP actually has the same scope of practice as physicians. Looking at your description of the psychiatric NP, I don't see how a psychiatric NP would have the training to provide all forms of emergency medical care, or why it would be considered in scope.  I'm sure they could be useful at the scene of a car wreck; after all, a registered nurse or a paramedic would also be useful in such a scenario.  But every US physician is required by US law to provide all forms of emergency medical care as needed in such situations, and it is therefore in scope for all of them, even those who have specialized in something entirely unrelated.
 * Similarly, one hears of physicians doing one-off custom or experimental medicine, but one never hears of an NP doing that. The separation of complex conjoined twins, for example, is always lead by a physician and never an NP.  NPs may do major surgeries (at least here in the US), but they do surgical procedures that they have been specifically trained for; they don't design new ones.  This therefore makes me doubt the claim that NPs have completely the same scope of practice as physicians.   WhatamIdoing (talk) 16:23, 21 November 2023 (UTC)
 * Physicians and NPs are both restricted in practice to their specialized training. For instance you can only compare a family NP with a family physician. A family physicians scope of practice and a full authority family NPs scope of practice are exactly the same. You cannot however compare a family NP with a surgeon the same way you cannot compare a family physician with a surgeon. All US physicians are not capable of providing all forms of emergency medical care. A family physician is not trained or board certified to provide the same care as an emergency medicine physician. The same goes for surgeons; an orthopedic surgeon cannot perform neurosurgery. Medicine is a highly specialized field and although physicians all have the same general education from medical school their residency training is what qualifies them to be board certified and actually practice in a particular field. A medical school graduate who does not complete a residency cannot be licensed to practice medicine. I am not arguing that NPs have the same training as physicians as I also believe there are significant gaps in NP education. However, NP training is not designed to be equivalent to MD training, if it was then NPs would be physicians but that is not the purpose of their role. NPs are stand alone professionals who are licensed to practice nursing. In the most simplistic form the field of medicine is only separated into two categories physicians and non-physicians. Therefore it is immaterial to further classify the role of an NP as being trained to a lesser degree than physicians. All non-physicians will always be trained to a lesser degree than physicians otherwise they would be eligible for licensure as physicians. This is no different then saying a medical doctor is a type of non-nursing trained physician, by there very definition physicians are not trained in nursing. Hue16459 (talk) 16:49, 21 November 2023 (UTC)
 * And yet:
 * Every US physician I've spoken with about it says that if they pass a car wreck, they are legally required to stop and render medical aid, even if they are not specialized in emergency medicine and their actual specialty (assuming they have one; AIUI getting a medical license does not require attending a residency, and becoming board certified is not required to practice) is far removed from that field, and
 * At least here in California, physicians are not restricted to their specialized training. An NP who wants to do acupuncture in California must get a separate acupuncture license; a physician who wants to do acupuncture in California can legally do so immediately, with no additional training.  (We might wonder whether that's sensible, but it is legal.)
 * WhatamIdoing (talk) 17:28, 21 November 2023 (UTC)
 * No healthcare provider is legally required to render aid unless they are working in their professional capacity. A doctor or nurse that observes an accident can legally pass by without any threat to their license and any care they do provide is covered by good samaritan laws. "A physician has no duty to help an injured or sick individual unless there is a preexisting physician–patient relationship or other statutory or contractual relationship." I would also say all physicians are not created equal a dermatologist stopping at a trauma scene would be worthless outside of basic first aid, an EMT would probably have a better chance of saving your life. All us based physician must complete residency to be eligible for state licensure. A medical school graduate may use the post nominals MD but they have no license to practice medicine. "Physicians who wish to practice medicine in the United States must complete an accredited residency training program in the United States or Canada." Hue16459 (talk) 17:49, 21 November 2023 (UTC)
 * https://www.inspiraadvantage.com/blog/md-without-residency-what-are-your-options#:~:text=Can%20You%20Get%20An%20MD,medicine%20as%20an%20independent%20physician. Hue16459 (talk) 17:51, 21 November 2023 (UTC)
 * From : "When are doctors legally obliged to stop and render assistance to injured persons at road accidents?  Unlike the USA, South Africa (SA) does not have 'Good Samaritan' laws that oblige doctors to stop at road accidents."  Ergo, in the USA, doctors are obliged to stop at road accidents.  This may not true in Louisiana (your source); Louisiana is unique among the 50 states for being based on French civil law instead of English common law.
 * AIUI the process in the US is:
 * Medical school
 * Internship year (sometimes called "postgraduate training" or "postgraduate year" these days)
 * Pass USMLE Step 3 test
 * Get medical license (=legally allowed to practice medicine at this point)
 * Residency
 * Board certification exam (optional)
 * Here's the link to the requirements in California, which you will notice don't mention residency at all. The source you linked to looks completely unreliable to me. WhatamIdoing (talk) 20:08, 21 November 2023 (UTC)
 * Per the California requirements you linked
 * To be eligible for a P&S License, you must have:
 * Attended and graduated from a U.S., Canadian, or an international medical school approved by the Board pursuant to Business and Professions Code (BPC) section 2084;
 * Received credit for either 12 (United States and Canadian medical school graduates) or 24 (international medical school graduates) months of board-approved postgraduate training (BPC section 2096); and
 * Passed all required examinations (BPC section 2170).
 * Hue16459 (talk) 20:41, 21 November 2023 (UTC)
 * @Hue16459, yes, exactly. But that 12 months of board-approved postgraduate training is the internship, not the residency.  It's #2 in the list I gave you above. WhatamIdoing (talk) 18:23, 22 November 2023 (UTC)
 * Ok, I think we are debating two different issues here. My initial statement was confusing and I apologize, when I stated "a medical school graduate who does not complete a residency cannot be licensed to practice medicine" I meant a graduate who was never matched into a residency. To clarify the first year of residency is your "internship" year but this is still residency and is referred to as PGY-1. Although there are transitional residency programs where the first year is a standalone program these are still programs you have to match into so if a physician never matches they will never be able to get a license. Some specialties have intern year built in, but some make you do it separately, often at a different hospital of your choosing during the match. The programs where it is not integrated are what are called advanced programs meaning you match into second or "advanced" year, but still have to line up a first year through the match. That being said only 37 states for DOs and 33 states for MDs allow licensure after the first year. At the outset of residency, residents are licensed to practice through a training certificate. This is a form of license issued to physicians who are in accredited residency programs that permits them to practice under supervision until fully licensed. Technically, I guess at this point you could quit residency and practice as a general provider but you would pretty much be unemployable as a physician. Outside of starting your own practice I doubt anywhere besides maybe an urgent care would hire you. A family physician completes a 3 year residency so for a person who quit residency to ever get a job in family medicine is pretty unlikely in my opinion. Also although board-certification is technically optional it is pretty much a requirement to get hired in a hospital. We are also starting to splinter the main purpose of this talk article away from the issue at hand which is should an NP, especially one with full practice authority, be categorized as a mid-level practitioner, and a term that generally hasn't been used in new research or practice in the last then years, and has been replaced by the term advanced practice provider or even more recently non-physician provider. As I mentioned above an NP is a standalone profession and this wikipedia page is solely for the NP profession so comparing their training to MDs is not necessary or appropriate. However this thread does build on my most recent addition to the other post as it relates to the newest addition to advanced practice providers, assistant physicians, who are now eligible can now be licensed in 6 states. While a physician could technically practice as a general practitioner in 37 or 33 states with only 1 year of postgraduate training they are still a licensed physician who may practice without supervision. An assistant physician however is an MD or DO graduate who did not get matched into residency and who is therefore ineligible to ever be licensed as a physician. That means in these 6 states that patients could be seen by a medical school graduate with no post-graduate training and therefore only four years of medical training. I am not counting the 4 years required for undergraduate schooling because although an undergraduate degree is required for application to medical school is not actually medical training, and although you most likely need to complete certain prerequisite courses during your bachelors degree, some schools like the Alix School of Medicine at Mayo Clinic actually have no prerequisite courses. This means a person with a degree in photography could technically be accepted to medical school. Also undergrad is not counted when referring to PAs for this exact same reason so it's disingenuous to count it for physicians as actual medical training. Arizona is one of these 6 states and offers what they refer to as a transitional training permit. In Arizona this license is restricted to only three years but in Missouri the license of an assistant physician does not have any time limitations. I bring up Arizona specifically because unlike Missouri Arizona also has full practice authority for NPs. That means in Arizona an MD/DO with a transitional training permit has restricted practice and must be delegated by a licensed physician while an NP has no restrictions to their practice. This also means that by definition an MD/DO doctor can meet the definition of mid-level practitioner and shows specifically why this term has evolved over times and is no longer used. Also this means that NPs not only have a broader scope of practice than assistant physicians but they have more training in their field. An NP has 5-6 years of training in the field of nursing which again is its own distinct field of professional training and practice. I removed 2 years from the NP to subtract the 2 years of a BSN that is not actually nursing school but is purely academic for degree purposes I also used 3 years for MSN and 4 years for DNP. I understand that nursing school in itself is undergraduate but it is a requirement to go to NP school and is factored into the educational pathway so it should be counted as part of an NPs training. Also during nursing school nursing student are performing clinical practice in the hospital. I also understand that the clinical practice nurses perform and that medical students perform is not the same but again the field of nursing and medicine are separate and distinct. Arizona also allows physicians to be licensed after one year of post graduate training so referring back to your scenario above this licensed physician with full practice authority would have 5 years of medical training while an NP would have 5-6 years and both would have the same scope of practice. I understand that we have now gotten so specific that this debate is no longer referring to broad topics but either side can always find reasons to justify an action in either direction. Now with all of that being said I hope I have proven my point why the term mid-level practitioner is no longer an appropriate term. Also referring to all the previous information I have provided I believe that I have shown that the term is irrelevant, no longer used in modern practice, and has been replaced by more appropriate terms such as APP or NPP. I also fall back onto my previous request to modify the page to just simply remove the title modifier as NPs are a standalone profession whose existence should not be compared to physicians as they practice through two different models and in two different fields. Also this page is for NPs alone not a group of non-physician practitioners so adding that term is irrelevant for the reader. It is clear to the reader that an NP is not a physician and is instead an advanced practice registered nurse which is the only title needed. Hue16459 (talk) 00:06, 23 November 2023 (UTC)
 * Also this page is referring to NPs on an international level and no country outside of the United States uses the term mid-level practitioner to define an NP. The only international reference is the WHO paper that was published last in 2017 and was recommending non-physician providers to countries who did not employ advanced practice non-physician providers. As I previously documented this was referring to studies published before 2008 for establishing a definition. The WHO also is an agency with no authority to carry out medical programs and simply provides recommendations to the international community as it relates to medicine. NPs are licensed by their individual countries or states and their existence does not rely in any way on the WHO so the terminology the WHO used for the last time 6 years ago is irrelevant. Hue16459 (talk) 00:25, 23 November 2023 (UTC)
 * I agree that the world is a messy place, with occasional exceptions, but the fact remains that nearly all physicians have more training that nearly all NPs. One might have the occasional general practitioner with less training, and one could have an NP who decided to get a PhD, but the overall outcome is that they have less training.
 * The definition of mid-level provider is "less training than a physician". NPs have less training than physicians.  The question is why we should avoid an accurate word.  In looking back through prior discussions, it seems that the overall feeling is that it's somehow insulting to say that they're "mid" – like their mental hierarchy is CNA for low, RN for middle, and MDs for high, and the NPs want to be perceived as more similar to MDs than RNs, and therefore want to be considered "high" instead of "mid".  It doesn't seem to have anything to do with the actual meaning of the term.  (The MDs' mental model seems to be RN for low, NPs/PAs/COs for mid, and MDs for high.)
 * Related to this, I wonder if you'd object to saying "NPs are healthcare practitioners with less training than physicians" instead of "NPs are mid-level practitioners". It means the same thing, but it doesn't use the word "mid-level" in plain text. WhatamIdoing (talk) 16:01, 24 November 2023 (UTC)
 * The issue is NPs are trained in nursing not medicine so they don't actually have less training than physicians, they have the highest training in the field of nursing. An NP is a nurse that is trained in nursing and practices nursing as licensed by the board of nursing. NPs are not licensed by boards of medicine and are a completely seperate profession from physicians. NPs do have more training in nursing, which is what they practice, than a physician as physicians do not practice nursing. Much like say a dentist who is not a physician but practices dentistry not medicine. This is why NPs have full practice authority while PAs do not. Also, I would still argue the definition of mid-level is disputed and generally referring to working below or under the supervision of a physician. The overwhelming majority of NPs in the United States and internationally have full practice authority and therefore they are not supervised by, work under, or otherwise provide care that is less then the care available from a physician. The term mid-level has not been generally used since around 2010 for this reason. The most appropriate modifier to use would be non-physician practitioner (the most recent evolution of the term) however even using a modifier beyond APRN is not necessary. Additionally, this page explains the training required to be an NP so it is clear to the reader that an NP is both not a physician and does not have the same training as a physician. Hue16459 (talk) 16:26, 24 November 2023 (UTC)
 * The highest training in nursing can still be less than the highest training in medicine.
 * Are you familiar with the problem of the Euphemism treadmill? So long as the facts are "less training than physicians", we will ever be in search of "the most recent evolution of the term" to try to make the factual "less" seem like the desirable "more".  WhatamIdoing (talk) 16:53, 24 November 2023 (UTC)
 * I may be mistaken but I believe a wikipedia page is supposed to refer solely to a single topic. NPs do not practice medicine and MDs do not practice nursing so comparing their training is irrelevant as they will never have the same training or they would be the opposite profession. This page is solely for nurse practitioners so the information should be presented individually not in comparison.  Hue16459 (talk) 17:12, 24 November 2023 (UTC)
 * I also linked to a definition of mid-level provider that did not define the term as "less training than physicians" but instead having to be "supervised by a physician". An NP is the highest level provider of nursing care and this page is presenting information that is specific to NPs.  Hue16459 (talk) 17:16, 24 November 2023 (UTC)
 * In searching the WHO website the term mid-level practitioner (MLP) was replaced by the term mid-level health worker (MLHW). Please review most recent publications from the WHO.
 * 2021 "A WHO review defines a MLHW as follows: “A mid-level health worker is not a medical doctor, but provides clinical care (may diagnose, manage and treat illness, disease, and impairments) or engages in preventive care and health promotion.” Mid-level health workers are also those whose training has been shorter than doctors (2 to 4 years) but who perform some of the same tasks as doctors. ii,iii"
 * "iii In this brief, we consider graduate nurses/Registered nurses as being outside the purview of the category of MLHWs, unless where trained nurses themselves undergo to become clinicians performing functions similar to doctors (for e.g. nurses who take up the bridge course to become CHOs at Health and Wellness Centres). Nurse practitioners who undergo more prolonged training are also excluded from this definition." Hue16459 (talk) 20:10, 24 November 2023 (UTC)
 * Most recent publication from the WHO published in 2021 specifically excluded NPs from the term mid-level health worker.
 * This WHO publication defines a MLHW as follows: “A mid-level health worker is not a medical doctor, but provides clinical care (may diagnose, manage and treat illness, disease, and impairments) or engages in preventive care and health promotion.” Mid-level health workers are also those whose training has been shorter than doctors (2 to 4 years) but who perform some of the same tasks as doctors. ii,iii"
 * "iii In this brief, we consider graduate nurses/Registered nurses as being outside the purview of the category of MLHWs, unless where trained nurses themselves undergo to become clinicians performing functions similar to doctors (for e.g. nurses who take up the bridge course to become CHOs at Health and Wellness Centres). Nurse practitioners who undergo more prolonged training are also excluded from this definition."
 * Hue16459 (talk) 21:41, 24 November 2023 (UTC)
 * Recommend edit to the page: "A nurse practitioner(NP) is an advanced practice registered nurse (APRN) that is trained to assess patient needs, order and interpret diagnostic and laboratory tests, diagnose disease, formulate and prescribe medications and treatment plans." Hue16459 (talk) 21:47, 24 November 2023 (UTC)

reformatting of page
Does anyone have an objection to me reformatting the page to have the sections of "Nurse practitioners in the United States" and "Nurse practitioners outside the United States"? Because there is a United States category the information for US NPs is needlessly repeated in the scope of practice and licensing categories. I believe placing all the information as it relates to each country together provides the best user experience and allows the removal of information that is duplicated up to three different times. Hue16459 (talk) 18:50, 21 November 2023 (UTC)


 * I have begun this project. Hue16459 (talk) 00:21, 25 November 2023 (UTC)
 * Wikipedia is a global encyclopedia. Splitting an article into the US vs everyone else is not appropriate here. MrOllie (talk) 00:27, 25 November 2023 (UTC)
 * I have changed the grouping. Hue16459 (talk) 00:47, 25 November 2023 (UTC)
 * What is the protocol for inclusion or removal of information if there is one source that says one thing but one source that says the direct opposite? Should both be listed side by side contesting each other or should the information be removed in general? Hue16459 (talk) 02:37, 25 November 2023 (UTC)

Lohr et al. study summary is not appropriate for the opening paragraph
The opening paragraph currently ends with the sentence: "One study found that although reasons for referrals to specialists are similar for both physicians and NPs, the quality of documentation in the referrals may be lower for NPs." MOS:LEAD's nutshell states: "The lead should identify the topic and summarize the body of the article with appropriate weight." MOS:OPEN states: "The first paragraph should define or identify the topic with a neutral point of view, but without being too specific. It should establish the context in which the topic is being considered by supplying the set of circumstances or facts that surround it. If appropriate, it should give the location and time. It should also establish the boundaries of the topic; for example, the lead for the article List of environmental issues succinctly states that the list covers 'harmful aspects of human activity on the biophysical environment'".

Dedicating a sentence out of a four-sentence opening paragraph to summarizing a 2013 study where physicians rate their perceived referral quality of NPs does not seem to meet the guidelines for inclusion in the introductory paragraph. This study summary should be removed, or at minimum, moved elsewhere in the article. Wikipedialuva (talk) 11:48, 6 February 2024 (UTC)