I'm a physician. My group employs 2 PA's and 1 NP. They function well within clearly defined boundaries once fully trained (which takes years to complete). In my specialty, we have several areas in which the physician extenders are unable and should not attempt to provide diagnostic or therapeutic services. These are areas of higher risk, complicated decision-making, and more difficult patients who may not accept direction as willingly from a mid-level practitioner. These disease states require training not as a medical student (which has the least impact on our ability to provide care), but a 3 year residency and a 2-3 year fellowship. Our PA's and NP are appreciative that we don't ask them to work on these cases. My MD degree is not what allows me to take on those cases--but the 5 years of training I received after medical school. Some of those years involved 100+ hour weeks under close supervision at academic centers. This cannot be duplicated in a practice setting.

Some might narrowly apply my experience to my sub-specialty. As a patient, I'm perfectly happy to have a PA or NP assist on a surgery for my hernia or cholecystectomy; or to have a CRNA anesthetize me for these relatively uncomplicated cases in a healthy patient. If I need bypass surgery or emergency vascular/trauma surgery, I absolutely want an anesthesiologist who has seen my case hundreds of times under appropriate supervision in a training environment. The volume of data to be rapidly processed and procedural skill required to manage that case is the reason mid-level practitioners are not the primary caregivers.

So I agree with you when you say mid-levels are an important part of our health care system (and I employ them because I agree with you). I disagree with the notion that they are able to provide all the same services with the same level of competency. Mid-levels will agree with me on this. If they don't, I don't want them taking care of me or my family; or working in my office. Every medical student is taught to recognize when they are in over their head--when to call for a specialty consult. Mid-levels are all taught the same principle. State medical boards make sure that we all understand. I read the quarterly reports which outline the sad outcomes of the few who don't remember.