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The Mid-Level Shuffle

POSTED ON IN Latest News BY Chris Centeno


This week I’ve had two physician assistants contact me looking for a job injecting Regenexx patients as they had been previously employed by stem cell clinics. I had to tell both of them that at Regenexx we don’t allow mid-levels to perform our procedures. So what’s a mid-level, and why could this be a problem at some stem cell and PRP clinics?

What Is a Mid-Level?

Given our mill-type medical-care system, if you’ve been to the doctor a few times in the last decade, you’ve more likely seen a physician assistant (PA) or nurse practitioner (NP) than the actual MD or DO provider. These lesser-trained and less-experienced providers are called mid-levels. Let’s compare and contrast the training between these health care workers and the actual doctor.


As the chart above shows, a mid-level has far less training than a physician and has no specialization. In fact, many doctors train longer in a specific area after medical school than the length of time they spent in general medical education. Hence, if you see a mid-level, you’re never going to get the same level of expertise as you can get by seeing the “real doctor.”

The Stem Cell Clinic Mid-Level Shuffle

Stem cell treatments can be pricey, typically in the $4,000–$10,000 range. In essence, many of these procedures are as expensive as a typical plastic surgery procedure. However, patients signing up for a facelift, liposuction, or breast augmentation would never let a physician assistant or  nurse practitioner perform the procedure; they want a highly experienced and expert surgeon to be the one sculpting their new visage. Why then would a patient allow a mid-level to perform a stem cell procedure? Let’s explore that further.

First, many patients might not know that the provider they are seeing in their chiropractor’s office or in their orthopedic-surgeon’s clinic isn’t a real doctor. I’ve seen some mid-levels that are introduced as “Doctor…” Second, most patients just believe that these procedures are simple joint injections; however, they are not. Take a minute to look at these specific videos to see that these procedures, done correctly, are microsurgery performed through a needle, which would be inappropriate for a mid-level to tackle.

Dr. Bashir Performs a Hip Procedure

Dr. Pitts Performs a Neck Procedure

Dr. Schultz Performs a Shoulder Procedure

Dr. Centeno Performs an Ankle Procedure

Why Would a Stem Cell Clinic Not Use a Real Doctor?

Physicians who are highly skilled in how to inject specific structures inside a joint using ultrasound and fluoroscopic guidance are few and far between. Hence, they are expensive, generally costing the clinic three to four times as much as a mid-level. Hence, if you’re a clinic that wants to maximize income, the best way to do that is to hire a mid-level to perform the procedures. Is this the best for the patient? Nope. But if the patient has no idea that he or she is being cheated, who cares?

The upshot? Mid-levels should not be performing stem cell procedures, period. You now know the difference. If you find that the person who is performing your injection is a mid-level, don’t walk but run to the exit!  Now you know the difference, so don’t be cheated out of the expertise needed to perform these complex injections!


    larrnan says

    As a consumer-I totally agree with you. I have had some experience with PA and I was personally very concerned and 'frightened" with the PA's desire to prescribe medications(with many dangerous side effects) rather than address lifestyle changes.
    if I am having PRP or stem cell injections into my joints,I want a physician with experience and a great track record to do the procedure.


    Chris Centeno says

    I can certainly understand. It does vary state to state, but in many states supervising physicians have a pre-agreed list of medications a PA can prescribe. Schedule ll substances like Opioids generally require additional licensure. I agree about PRP or stem cell injections into my joints! I am lucky enough to work with several Doctors who fit the bill, but here are a whole list of equally qualified and experienced physicians:


    Baja says

    I'm married to a PA and my father was a PA (since the early years of the PA career field back in the 70s). My general experience with PAs is that they're more likely to spend extra time with the patient and be more compassionate. Nearly every time I see a "real" doc, I'm left feeling cold and as if he didn't even hear what I had to say. I feel blessed if the doc gives me an extra minute or two, while PAs will just about spend as much time as you need as the patient--they're not as concerned about the "numbers" (read: $$$).

    On another note, my wife is a PA in the USAF and I'm willing to bet her experience rivals that of civilian doctors/physicians with the same number of years practicing. She is consistently consulted by her "real" doc coworkers and peers about her experiences and professional medical opinions.

    Too bad you've seen the type of PAs you say you've seen--there're bad apples in every certain bunch. I see it in my profession and I'm sure you've seen it in yours.


    Chris Centeno says

    Baja, this post isn't meant to be negative toward PAs or NPs. The issue is that neither should be performing complex surgical procedures whether that be arthroscopic surgery or advanced Interventional Orthopedic procedures. While we don't use any physician extenders because of the concierge nature of our practice (i.e. each patient gets one solid booked hour with the doctor for an evaluation and has his or her personal cell phone number and e-mail), there are practices where I bet the PA or NP gives you more time than the doctor.


    Harry12 says

    Thank you, Dr. Centeno, for shedding more light on this issue. For me and my experience, it matters how the practice portrays the physician extender (PA, NP, etc.). If the practice has been forthright and explains why they utilize the services of a PA ( because insurance mandates it, Doctor can be more useful doing more surgery than seeing patients, etc). Insurance plans place so much pressure on doctors to see as many patients as possible. To that end, the doctor may employ a PA or NP to be able to see that number of patients. Is it the fault of the doctor who accepted that insurance plan, knowing that there would be a large number of patients to be seen? Maybe, but most plans are placing these burdens on doctors and the doctors are responding by hiring PAs to “triage” or work up the basics. If the doctor needs to come in, then so be it. If not, the PA has handled it and the practice has saved money.
    Where do practices fall short in portraying the physician extender? A few examples from my experience:
    I pay a $50 copay to see a specialist. Why do I have to pay the SAME COPAY to see a physician extender that I would pay to see the physician who runs the practice and oversees the physician extender? To see my Primary Care Doctor, I pay $15. I get a lot more out of the visit with my Primary Care Doctor than I do with a PA. And no, that is no reflection of the PA; it is saying that my Primary Care Doctor has so much more experience. Fortunately, I have a very compassionate Primary Care Physician.
    I get scared when a practice utilizes a PA to do more than I feel comfortable having the PA do. For example, some surgeons have PAs who finish the surgery or “close” the patient. No thank you. Some optometrists (perhaps considered the PA of the eye care world) have tried to get surgery privileges to do cataract surgery or certain laser procedures. Again, no thank you. Most of the time, nothing will go wrong during a procedure, but if it does, I want the most experienced hands to handle the code. I don’t want someone who has read about it in a book or taken a weekend course. And I don’t want to hear that the MD left the surgical suite, leaving it to the PA to finish the case.
    It is also disappointing when a PA won’t admit to something that is above their experience level. It is very frustrating to speak to a PA, the PA then presents my work up to the MD, and the MD comes in with incorrect information that came from the PA. It has happened very frequently in my experience with specialists who utilize PAs.
    There is no doubt that these regenerative medicine injections should be done by skilled hands. And I think that MDs and DOs should continue to fight for the restriction of certain medical treatments to be done only by them. There is a general “watering down” of job titles and responsibilities in this world. Everybody thinks that we are all equal and why should one person have an elevated title over someone else? Aren’t we all equal? Not in certain cases and when it counts, I want an MD or a DO. I had my first Regenexx regenerative medicine procedure recently. It went very well and I have no doubts that the doctor who did the injections was backed by years of experience and is perfectly capable of handling a code if anything went wrong. Could I have gone to a PA who was offering these? Absolutely yes. One of the practices I see now for certain health issues does regenerative medicine and the PA has been pressuring me to have him do it. No. I went with Centeno Schultz because they have the data, they are the pioneers and thought leaders, and they have MDs and DOs who do the injections. It would have been cheaper and closer to have the PA do it but I don’t want to take that chance. So again, thank you Dr. Centeno for educating us on important topics that help us to understand the often confusing world of medicine. So often we are supposed to get in line and see whomever the practice wants us to. An educated consumer will make better decisions.


    Kitt Richards, PA-C says

    Despite saying you are not denigrating PAs/NPs, you are. I am a board-certified, licensed surgical physician assistant, and it does our profession to scare patients who will likely be seeing PAs in their lifetimes.

    A PA trained to perform surgical procedures, open and/or close surgical cases, 1st assist on surgeries, and perform bedside procedures, injections, suturing simple and complex wounds...even placing chest tubes and intubating obtunded patients! - are trained in exactly the same model as MDs and surgeons, and by the same MDs and surgeons.

    Do you think PAs teach themselves how to do these things? No. We are trained in the same pools as residents/fellows and in the same ORs and on the same inpatient floors and EDs. The only thing we are not allowed to do is perform the lead in a surgery, but we are frequently the 1st assist - which means the surgical professional co-operating across the table from a surgeon - and which used to be the role of another surgeon. Economics (bean counters at hospital) have pressed to free up that extra surgeon to run their own cases and have TRAINED PAs 1st assist. We are trained by the same residents, fellows, nurses, anesthesiologists, and attendings that any other surgeon is trained by. Learning to perform surgical procedures and 1st assist is a team effort, with the whole operating team training new members at all times in the same apprentice-model under which medicine and surgery have always been taught. There's no other way to learn it - you can't learn it from a book. Not even your doctor learned it from a book. They study the books but then do the same bumble-fumble hands-on learning that we all go through.

    Any MD can authorize and teach a PA to learn and perform any procedure that falls within that docs practice/scope of practice. That would include Regenexx, which I would love to learn to provide to my patients! Hell, I've even taught other docs how to perform procedures that I know and they don't. It happens all the time, and it is simply part of the collegial sharing-of-knowledge that is essential to perpetuating the ongoing growth and practice of good medical care


    Chris Centeno says

    Kitt, we don't train PAs. Interventional Orthopedics is a surgical subspecialty no different in complexity than surgical orthopedics, hence, you could only be trained to assist, which isn't usually needed with these procedures. IOF also doesn't train mid-levels.


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    About the Author

    Chris Centeno

    Christopher J. Centeno, M.D. is an international expert and specialist in regenerative medicine and the clinical use of mesenchymal stem cells in orthopedics. He is board certified in physical medicine as well as rehabilitation and in pain management through The American Board of Physical Medicine and Rehabilitation.…

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