The Silent Restructuring: Why Advanced Practice Providers Are No Longer Midlevel
Picture this: a renowned chef, trained at the finest culinary institutions, stands in a restaurant kitchen. His dining room is full of starving customers. Orders are piling up, and the chef is overwhelmed.
Beside him stands a sous chef, differently trained but ready to help. But they’re not allowed to cook; not because they lack the skills, but because tradition says only the head chef can touch the stove. Meanwhile, people are left unfed.
Now imagine this isn’t a restaurant, but a hospital. And the people left waiting aren’t just hungry. They’re sick, and too often, unseen.
Welcome to American healthcare.
We are facing a care capacity crisis, and the workforce that could solve it is already here. But cultural lag and structural inertia are keeping advanced practice providers (APPs) sidelined at a time when we can least afford it.
A Silent Restructuring: The Myth of the Middle
Across urgent care centers, critical care units, and behavioral health clinics nationwide, a quiet but very consequential shift is underway. No policy change announced it and no credentialing board codified it, but it’s happening.
Advanced practice providers (APPs) are no longer “midlevel.” They are quickly becoming foundational to how care is delivered in America.
As a pulmonary critical care physician who has practiced across the spectrum, from bedside procedures in trauma bays to telehealth consults, I’ve seen this transformation firsthand. And frankly, we need to stop pretending it’s temporary or ancillary. It’s time to recalibrate our language and our leadership structures to reflect the reality that nurse practitioners (NPs) and physician associates (PAs) are indispensable to modern healthcare.
The phrase “midlevel provider” has long been used as a shorthand for NPs and PAs. It was a convenient euphemism, one that implied usefulness and competence within a pecking order. But the very premise of “midlevel” rests on a hierarchy that no longer reflects how care is actually delivered.
Consider the data: the U.S. faces a projected shortage of up to 124,000 physicians by 2034, according to the AAMC. Meanwhile, the NP workforce is expected to grow by 40% between 2022 and 2032. Today, over 355,000 NPs are licensed to practice in the U.S., with more than half specializing in primary care. In rural and underserved areas, they often are the care.
In states like Arizona, Oregon, and Washington, where full practice authority is granted, NPs routinely serve as primary care providers without physician oversight. In psychiatric care, Psychiatric-Mental Health Nurse Practitioners (PMHNPs) are filling access gaps in communities that haven’t seen a psychiatrist in years. In intensive care units, I’ve worked shoulder-to-shoulder with APPs who manage ventilators, titrate drips, and lead codes.
These are not auxiliary roles.
That said, this shift isn’t about replacing physicians. It’s about restructuring the system for the benefit of patients. APPs don’t replicate the physician path, they complement it. And when supported by the right infrastructure—clinical oversight and mentorship, collaborative protocols, smart compliance systems—they can dramatically expand the reach of healthcare.
Where APPs Are Stepping Up
The shift may be most evident in psychiatric care. The surge in demand for mental health services has collided with a national shortage of psychiatrists. With over 160 million Americans living in mental health professional shortage areas, PMHNPs are often the only accessible behavioral health providers. Across the country, PMHNPs are leading telepsychiatry platforms, running behavioral health clinics, and offering evidence-based care to patients who would otherwise go without.
Between 2011 and 2019, the number of PMHNPs treating Medicare patients grew by 162%, according to a 2022 Health Affairs study. Over that same period, psychiatrist-patient encounters declined by 6%. By the end of the decade, PMHNPs accounted for nearly 30% of all mental health prescriber visits, and in rural areas with full practice authority they provided the majority. This is a meaningful change in how mental health care is delivered across the country.
Similar shifts are occurring in intensive care. Acute care NPs are now integral to many ICU coverage models, especially at night and during surge periods. They’re not “physician extenders,” in the same way that on a baseball diamond, a wide receiver is not a “quarterback-extender.” They’re core members of the care team, often with more continuity on the unit than rotating residents or fellows.
Emergency medicine, geriatrics, and chronic disease management are other domains where APPs have stepped in to maintain continuity and improve clinical performance through specialized focus and patient rapport. A 2022 JAMA study found that patient outcomes for chronic disease management were equivalent when comparing NP- and physician-led care teams.
And in telehealth, it is often the NP who is the first, and sometimes only, point of care for patients across rural communities and healthcare deserts.
This fundamental shift is already happening, and it’s being operationalized. Many health systems and digital health companies are building their care models around APPs.
Medicine Is a Team Sport
The question facing healthcare isn’t “who should lead?” It’s “how do we work better together?”
Of course, physician education is broader and more intensive for a reason, and far exceeds the medical training received by APPs. In high-acuity and diagnostically complex scenarios (critical care, trauma surgery, oncology) there is no substitute for a physician’s expertise.
But healthcare is not a monolith. The ecosystem spans across many disciplines and acuity levels. In many of these arenas, APPs are fully equipped to lead care, especially when integrated into interdisciplinary teams that ensure patients are routed appropriately.
Medicine is a team sport. The physician is the quarterback, but the best care models today don’t rely on a single clinician at the top of a hierarchy. They are multidisciplinary teams that pool their strengths to improve access, safety, and outcomes. That includes physicians, NPs, PAs, nurses, pharmacists, social workers, care coordinators, technologists, and more.
To extend my sports analogy: no quarterback has ever thrown a touchdown without a teammate to receive the ball.
When every clinician is empowered to practice at the top of their license, with clear roles, shared goals, and mutual respect, patients receive faster diagnoses, more coordinated care, and better outcomes. And providers experience less burnout, because the burden doesn’t fall disproportionately on any one person.
Rather than flattening the distinctions between roles, we should build systems that reflect and respect them. Align scope, training, and supervision to patient needs. In my opinion, that is a moral imperative, not just a regulatory exercise.
The Real Crisis: Infrastructure
Too often, the conversation around APP scope of practice focuses on whether NPs and PAs should do more. But why haven’t we built the operational systems to support and equip them for what they’re already being asked to do?
Healthcare leaders know the truth. Regardless of laws on the books, APPs are already carrying massive responsibility. What’s lacking isn’t capability, its infrastructure. Credentialing processes are slow, collaboration agreements are inconsistent, and compliance protocols are manual and error-prone. Plus, continuing education is often generic and out of sync with real-world demands, a gap that’s especially consequential given the current structure of APP training.
If we truly want safe, scalable care, we need to invest in the systems that activate this workforce intelligently, respecting the contributions of physicians while building a workforce model that does not rely solely on them to deliver access.
So what does this mean? First, we need to make it easier to facilitate clinical collaboration and surface risk patterns. Quality assurance and oversight should be embedded into the routines of everyday practice, not buried in spreadsheets and logs as a perfunctory documentation role.
We also need workforce education platforms that actually educate; targeted, modular, and clinically relevant to each provider’s setting and scope. APPs enter practice through variable training pathways, yet once in the field, they’re expected to navigate high-acuity environments with little structured support. Learning should happen regularly, not once a year in a conference room or on a laptop.
Perhaps most importantly, we should re-examine what leadership in healthcare really means. Too often, “physician leadership” is conflated with title or tenure. But “leadership” is a function, not a credential. It’s the ability to shape systems, coach teams, and drive change toward better patient care. That includes physicians, but also APPs, nurses, technologists, and administrators who understand the frontline realities and are willing to steward them forward. We need to elevate leaders by measure of their impact, not just by degree.
The Path Forward
The restructuring of the healthcare workforce is not loud, but it’s real, and it’s happening in clinics, hospitals, and virtual visits across the country.
The physician will always have a unique and central role in medicine, but that doesn’t make the contributions of APPs any less valuable. It’s time we drop the labels and recognize what needs to happen: a fundamental shift of the clinical workforce toward a more team-based, role-appropriate, and access-focused model.
This future is not physician-led or APP-led, but patient-led, supported by care teams equipped with the tools and trust they need to do their best work.
Let’s retire the term “midlevel.” Not as a political statement, but as an acknowledgment of reality. Our healthcare system’s future depends on how we equip and empower APPs from here.
Rafid Fadul, MD, Co-Founder & CEO, Zivian Health
