S02_E07 - Understanding Healthcare's Alphabet Soup

Speaker 1: 0:04

Welcome to the Healthy Matters podcast with Dr. David Hilden, primary care physician and acute care hospitalist at Hennepin Healthcare in downtown Minneapolis, where we cover the latest in health, healthcare and what matters to you. And now here's our host, Dr. David Hilden.

Speaker 2: 0:20

Hey everybody, it's Dr. David Hilden, your host of the Healthy Matters podcast. This is episode seven, and you may have noticed in healthcare, there's a lot of letters after people's names. I mean, whatever happened to just the good old md? Well, now there's PA and there's np, and there's C R N A and a P P, and all of these people make up your healthcare team. Today we are gonna break all that down. There's three big ones that we're gonna focus on, that being np, which stands for Nurse Practitioner pa, which stands for Physician Associate, and A P P, which stands for Advanced Practice Provider. These are the colleagues of mine that I work with every day here at Hennepin Healthcare on our healthcare team. To help us sort all this out, I have brought in one of my best friends from the hospital, Megan McCoy. She is the director of the Advanced Practice Provider Center here at Hennepin Healthcare. Megan, thanks for being with

Speaker 3: 1:14

Us. Thanks, Dr. Hilden. I love that you called me your best friend, although I think everyone's your best friend. Everybody knows that a

Speaker 2: 1:19

Little bit like that. I could, I think I called you one of my best friends, but I think you're my best friend,<laugh>. Oh, thanks. I told everybody about your title. You're the director of the A p P Center. Mm-hmm.<affirmative>. What's that?

Speaker 3: 1:28

So a p P stands for Advanced Practice Providers. And here at Hennepin, that definition changes a little bit wherever you go. But here at Hennepin, that means physician assistants, nurse practitioners, nurse midwives, nurse atheists, chiropractors, acupuncturists, dental therapists, and optometrists. It's a group of about 300 people.

Speaker 2: 1:48

Well, that's a lot of folks. And you are in charge of a center that, that organizes all those

Speaker 3: 1:53

Folks. They don't report to me. But, um, my role is really support of them and advocacy for them, um, at sort of an ad administrative level.

Speaker 2: 2:02

So there's 300 people. You gave a lot of names and things in different roles. Yep. Let's try to sort those out a little bit. Sure. You, you're a pa I am. And you happen to have a specialty in ear, nose, and throat. Yep. So talk about what a PA is.

Speaker 3: 2:15

So physician assistant is a healthcare provider that goes to graduate school after college and learns all sorts of general medicine. So it's a two to three year program depending on where you go. And you sit in the classroom for half of it, and you do clinical rotations for half of it, and then you come out and you practice medicine. What's different between pa, uh, and physician is that we don't do a residency. There are PA fellowships. So you can take a, a one year extended course, so to say we have a PA fellowship here in our emergency department where you can graduate from PA school and then spend a year in the ED sort of learning more, but it's not necessary to practice medicine. Uh, we take boards, we have to re-certify every 10 years, and we see patients in all sorts of settings. We do history and physicals, we diagnose, we write prescriptions, we can do procedures, and we can go to the operating room and assistant surgery.

Speaker 2: 3:09

So I'm gonna get right to the second half of PA physician assistant. I send people to you mm-hmm.<affirmative> directly many times. Oh, I know. Yeah.<laugh>, you know, if I need someone to see an ear, nose, throat problem, I'm, I'm as likely to send them to you by my own request mm-hmm.<affirmative> than I am to one of your physician colleagues. So what's the deal with the word assistant?

Speaker 3: 3:32

Yeah. Well, interesting you said that. Uh, it actually just changed at the highest level. The American Academy of Physician Associates now, uh, has changed the word assistant to associates. So PAs date back to the sixties. And they were started in the army basically as a cheaper way to get medical care cuz there was a shortage of doctors. Just as there's a shortage of doctors now and assistant was a word that they came up with. Um, and it is a misnomer, right? Because yes, I need a supervising physician to report to, meaning I can't open my own practice. I can't open my own e n t practice. So I do need, uh, legally to have a physician supervisor, but they don't need to be in the same building as me. They don't need to see my patients. For me, in a surgical subspecialty, I rely on my surgeon colleagues to take my patients to the operating room and, and do these procedures that I can't do myself. But in the clinic setting, I'm very much independent as you know,

Speaker 2: 4:28

Do I have to start calling you a, an associate? Now you do. It's very convenient. You didn't have to change the a letter at

Speaker 3: 4:34

All. There was a little bit of thought process there. Mm-hmm.

Speaker 2: 4:36

<affirmative> not bad at all. Okay. So what is a nurse practitioner? Many people, I think, um, especially in clinics mm-hmm.<affirmative>, they say, well, I'm going to see a nurse practitioner.

Speaker 3: 4:45

Yeah. I mean, and they're very similar, right? Especially in, in a clinic setting, there's nothing that a PA can do that an NP can't. And vice versa. The training is a little bit different for a nurse practitioner, you have to be a nurse first. There are PAs that are nurses and then go to PA school. But yes, for a nurse practitioner, you have to be a nurse first. And they're taught on a nursing model, which is different than a medical model. The nursing model is more about chronic care of long-term disease. They're very much about treating the patient. Whereas the medical model is more treating the disease and the diagnosis and doing procedures and operating and things like that.

Speaker 2: 5:18

That sounds an awful lot. Like you're saying like the nurses are caring for the people and the PAs and doctors are not, are not<laugh>. Is that the deal?

Speaker 3: 5:26

No, but the, but the care model, the teaching model is a little bit different. Not to say that you don't see NPS in surgery. In fact, our entire P surgery department here is nps. So there's a lot of crossover. Another big difference between NPS and PAs as NPS in 27 states do have independent practice. So they do not need a supervising physician to sign off on anything. They can open their own practice and just work autonomously like

Speaker 2: 5:53

That. That's controversial. I think

Speaker 3: 5:54

It is controversial. The other controversial piece is, um, a lot of NP programs are now doctorates. And so technically as a nurse practitioner, even though it's a dnp, you can be called doctor, which outside of healthcare is fine, but I think in the walls of this institution is a little bit confusing. If you're a nurse practitioner going by doctor. And now of course there are a few PA programs that are doctoral as well.

Speaker 2: 6:18

So, okay, so to further muddy the waters, what about chiropractors? They go by Dr. So-and-so and certainly dentists do and

Speaker 3: 6:25

And optometrist.

Speaker 2: 6:26

And optometrist do, yeah. Mm-hmm.<affirmative>. So they go by doctors. Right? Well,

Speaker 3: 6:29

And it's fair because that's their degree. And I'm not saying that it's wrong, but I do for, from a patient perspective, it is confusing.

Speaker 2: 6:35

It's sort of like your educational degree versus your clinical role.

Speaker 3: 6:40

Correct.

Speaker 2: 6:40

As long as patients know who you are and what

Speaker 3: 6:42

You, I think that's the bottom line. As long as they know that you didn't go to medical school, that you went to another type of graduate program, then that's fine and you're more than capable of taking care of them. Okay. So

Speaker 2: 6:52

We've talked about the various levels of training. We've talked about nps, we've talked about PAs, we've talked about, um, chiropractors and like, but if, if you take one of those groups like PAs, like you, that doesn't mean you might be in any specific department. In other words, you could work anywhere in the hospital. And the same for nurse practitioners. Yep. So I guess my question is this. Where might a patient encounter an A P P

Speaker 3: 7:14

Everywhere, if you're in the hospital admitted to the surgical icu, if you're in the clinic seeing a specialist, if you're out in the community at a primary care clinic, uh, we are everywhere.

Speaker 2: 7:27

Yeah, you really are. So you could be, um, wheeled in the scalpel.

Speaker 3: 7:30

Oh yes. I do a lot of procedures. In fact, uh, not so much now. Uh, my old practice, before I had this job, about 50% of what I did was skin cancer removal. And I was out in, um, Illinois, rural Illinois, a lot of farmers out in the sun and they all got skin cancer. And I had two half days a week where all I was doing was cutting skin cancer out all by myself as a pa cutting skin cancer out.

Speaker 2: 7:53

So you then you got into E N T. So let's just use your career as an example. So you do ear, nose, throat, I do ear wax, boogers and snot basically.

Speaker 3: 8:01

Yep. The nice thing about being a PA or an NP is you come outta school knowing everything. Uh, and we don't have to do a residency, as I mentioned before. So I get to choose whatever field, whatever specialty I'd like to do. And if I don't like it, I'll choose something else. So when I, uh, graduated, I was looking for a job in rural Illinois and um, I was doing a clinical rotation in, in spine. And the spine surgeon was best friends with the E N T surgeon and they didn't have an opening in spine and E N T did. And I said, yes, I'll take a job. And that was 15 years ago. Um, and I've loved every minute of e n t boogers, earwax

Speaker 2: 8:36

And snot snot. That's what, that's what, that's what I always tease you about is like that's what you deal with all day long. All day long. So in a, so a, a nurse practitioner by the same, by the same methods could be in a variety of places as well.

Speaker 3: 8:48

Yep, absolutely.

Speaker 2: 8:49

Earlier you said that it started in the army cuz it was a cheaper way to get healthcare. Um, uh, and there was a shortage of doctors. Could that be true today?

Speaker 3: 8:58

Oh, for sure, for sure. Dr. Hilden. Yes, absolutely. There is a shortage of doctors. Less and less students are choosing to go to medical school because of cost and length of time and they're choosing to go to PA school or NP school. It's faster. You can come out right away. You don't have to do a residency. We're all knee deep in student debt. You can start making money quicker. And organizations see the financial advantage of doing that as well because we're cheaper. We don't make as much money as you doctors.

Speaker 2: 9:26

Okay. Megan, you're calling me Dr. Hilden. You've called me a whole lot of things since I<laugh> since you and I have worked together and I've gotten to know one another. Uh,

Speaker 3: 9:35

It's a very professional setting,

Speaker 2: 9:37

Dr. Yeah, it's a very professional setting I think. Yeah, yeah.<laugh><laugh>. Lots of great information here. We're gonna take a quick break and when we come back we're gonna answer the question, is it okay to be seen by a nurse practitioner or should you hold out for a doctor? We're also gonna talk about the various pathways into medicine, including n NP and PA school. And then I'm gonna ask Megan, what's the weirdest thing you've ever pulled outta someone's ear? Stay with us. We'll be right back.

Speaker 1: 10:03

You're listening to the Healthy Matters podcast with Dr. David Hilden. Got a question or comment for the doc. Email us at Healthy matters hc m e d.org or give us a call at six one two eight seven three talk. That's 6 1 2 8 7 3 8 2 5 5. And now let's get back to more healthy conversation.

Speaker 2: 10:26

So our healthcare system sort of has grown, um, over the years into being one where the doctor was way at the center of it and everyone else was kind of in that periphery and everyone went to see their doctor and it was all about, it was very doctor centric. And fortunately we've moved away from that a little bit. So Megan, my doctor retires, I make a new appointment, I get scheduled with a nurse practitioner. What can I expect? Uh, should I be okay with that?

Speaker 3: 10:51

Yes, you absolutely should be okay with that. The thing about seeing an a p P over a physician is, there's a few things that you should know. One is we have less training out the door. Right? And that's, we'll just be really upfront and transparent about that. We don't do a residency. Our clinical hour expectations during our training is less than a physician. But that does not mean you're not going to get adequate care. And we already talked about team-based practice. Well, apps are expected to work in teams. So if you see that nurse practitioner, chances are if she hasn't been or he has not been practicing for a long time, they are going to talk to a physician in their clinic, perhaps their supervising physician about the things that they saw you for if they're not comfortable or if they have any questions.

Speaker 2: 11:36

So in that, exactly that setting. And I, I can think of several of the nur, they happen to all be nurse, they're not all nurse practitioners. There's a couple of PAs in my clinic as well mm-hmm.<affirmative> and we share information all the time. Yep. One of them might bring an EKG that I help read and interpret and then I might might go and ask a question of them about some, about a patient as well. So we do talk to each other all the time. So what do you say to a patient that says, I don't want that person. I wanna wait and I'll wait an extra month to see the doctor.

Speaker 3: 12:07

Sure. I mean that's your, that is your choice. I can, you know, try and convince you otherwise about how, if it were me, I've been doing this for 15 years, essentially I've done three residencies back to back to back. Cuz e d residency is five years. Um, I have to take boards every 10 years. I have to re-certify. I have to keep up my continuing medical education. And if you have a problem that I've never seen or I don't know what to do, I've got four physician colleagues that I can run it by who will help me out. I think the other thing to keep in mind too, when you go to see an a p P over a physician is in a lot of places we have longer appointment times. So we get to spend more time with you and talk through more things than a physician who probably has a million other patients to see that day. Which is also really nice cuz you're waiting a long time to see us and then we can spend the time back with you.

Speaker 2: 12:54

One of the other things people might not know is that they think that, uh, because you're a physician that well they must be, um, a better communicator or they're gonna be better in the exam room or that they're gonna be better at all the skills of clinical medicine, which isn't really the case.

Speaker 3: 13:08

No, it's not. In fact, I would argue a lot of times that apps are better at that. Uh, they have better bedside manner. We are more empathetic for our patients. Hey,

Speaker 2: 13:17

I'm pretty empathetic.

Speaker 3: 13:18

You are pretty empathetic.

Speaker 2: 13:19

What do the doctors that you work with, I mean the physicians who went to med school, um, what reception do you get? Are you fully accepted? Yes. Into the healthcare teams?

Speaker 3: 13:29

Yes. In my department, I feel very lucky. Yes. I know from my administrative role that that is not the case across the institution

Speaker 2: 13:38

Because I have heard that and I've heard that across the country Yeah. That sometimes the struggle is to become accepted as an equal part of the team. Yeah.

Speaker 3: 13:44

And I think we're always gonna have that. Right. Um, I think that there are a lot of physicians that potentially feel threatened, um, by apps in their practice. I am very fortunate. I am, I am certainly looked at as one of the team. And in fact I held a leadership role. I was the medical director of our department for several years before I had this job, which oversees the apps and the physicians, uh, in an operational way. And so I am very much included in my department. I wish I could say that was the case across the board, but it's not. Do

Speaker 2: 14:12

You see this trend towards a more diversified team of healthcare practitioners? Do you see that expanding?

Speaker 3: 14:20

Yes. And I think it's the best thing for the patient. I think the more people that you have taking care of you, the better outcomes you will see.

Speaker 2: 14:27

You said there's 300 of you at Hennepin. Uhhuh,<affirmative>. Is that normal? Uh, there's only, I think there's about 400 doctors. Well, there's a lot more doctors that come and go, but of the main staff, I think there's about 400. Mm-hmm.<affirmative>. So you're a, you're a significant portion of the healthcare providers in this organization. Is that typical,

Speaker 3: 14:44

That percentage, that ratio? Uh, the ratio itself is getting smaller. The percentage of apps, uh, compared to physicians as getting higher at organizations. And I think it comes back to that care for cost thing, right? Like we can give great care, we're well trained and we cost less.

Speaker 2: 15:01

So during the pandemic, for instance, so many people are leaving healthcare mm-hmm.

Speaker 3: 15:05

<affirmative>. Yeah. I see apps stepping up to fill that gap. For sure. Again, with so many students applying to graduate school to build

Speaker 2: 15:13

The need, somebody told me that there's a, um, uh, like a crisis in primary care of enough people mm-hmm.<affirmative>, um, to go into it and that we're gonna need some 40 or 50,000 practitioners going forward. I imagine that those will be filled by not just doctors or maybe not the majority will be doctors.

Speaker 3: 15:30

They're gonna be PAs and mps. I

Speaker 2: 15:32

Think so. Absolutely. Yeah. And it's, it's a system that's really gonna work. And so if you are out there and you're wondering about, about your nurse practitioner that you're seeing in clinic or your PA you're seeing in clinic, I think you're in good hands. Agreed. So when you're deciding to go into medicine, what drew you to going into PA school?

Speaker 3: 15:48

Uh, finances, actually for me personally, uh, when I was in college, I was pre-med. I started to sort of see the bills coming through for my college education and then thinking about how much med school was gonna cost and how I'd have to not be able to pay it back until after my residency. And it gave me a lot of heartburn. And I, I remember vividly going to see my dermatologist on some summer break and I saw a pa uh, and I had never seen a PA before and I was like, this is great. This is exactly what I wanna do and it's a shorter amount of time and I get to start paying back my loans faster. And the rest was history.

Speaker 2: 16:24

That's a legit reason. Yeah. Do you think that's a common thing? Is that, is that it's slightly less expensive? Because isn't it also true that most PAs are graduating with a lot of debt?

Speaker 3: 16:35

Uh, yeah. Yes they are. Yes they are. Um, I do, I think finances is a, is a legitimate, uh, reason to choose PA over med school for sure. And and what I tell my students too, uh, college students and high school students is if you want to practice medicine and know for sure that you don't wanna operate, then you should go to PA school or NP school if you know I wanna be a surgeon, you'll have regrets if you go to PA or

Speaker 2: 17:02

NP school. Mm-hmm.<affirmative> mm-hmm.<affirmative> shift to nurse practitioners a little bit. And I wanna kind of talk about why someone becomes a nurse practitioner. And I wanna put it in the context of nursing and the stressors of nursing the last few years. If it's taught us almost nothing else, it's how hard registered nurses work. Well, they always have, but it really came into focus. Yeah. This last few years. RNs in the hospital mm-hmm.<affirmative> and in the clinics and all over the place in the operating rooms kept us going, kept the whole healthcare system going, but did so at great personal stress. So I've talked to a lot of nurses and they say that being a nurse is really hard and as much as I wanna be in healthcare, I want to be the one writing the orders. Mm-hmm.<affirmative> and I and, and so many nurses I see are going into nurse practitioners school.

Speaker 3: 17:47

Yeah. They get to make the, the medical decisions. Right. As a nurse, you're following orders. Uh, I mean you're helping people, right. That's why we all decided to go into healthcare. But I think that there are people who want to be making the decisions instead of just following them.

Speaker 2: 18:01

What is the job market like and, and how many people are going into PA school? A nurse practitioner school. And what does it look like when you graduate?

Speaker 3: 18:09

Have you seen the US world and news report that just came out in 2023? No. Nurse practitioner was the number one job in the us Uh, and I think PA was number three or four. Uh, the outlook for these jobs is huge. There are a lot of openings, there are a lot of organizations that want to hire PAs and nmps over MDs and there's a lot of people trying to get into PA and MP school. The competition is, is really high. I tell students all the time, I'm like, I don't know if I'd get into PA school these days just because of how competitive it is. They're saying that PA school is more competitive than med school. It's become very popular despite the salary difference between the

Speaker 2: 18:49

Two jobs. You're smart enough Megan. You kidding? In<laugh>.<laugh>. I know you would. Okay, so before I let you go, you see patients. I see patients. What's the weirdest thing you've ever pulled outta someone's ear?

Speaker 3: 19:00

<laugh>. Where to begin? I have pulled countless weird things out of ears and noses. Mostly children, but randomly an adult where you're like, why is this Barbie shoe in your ear?

Speaker 2: 19:14

A Barbie shoe?

Speaker 3: 19:15

A Barbie shoe?

Speaker 2: 19:16

You mean like off the Barbie doll? Off the Barbie doll. And that wasn't

Speaker 3: 19:18

An adult in an adult ear. And the story was my child put it in there. But if you've ever used a Q-tip, which don't, do not use Q-tips, but you know that if you stick it in there too far, it hurts. And this thing was in

Speaker 2: 19:31

There. Did you fish at all? Like with a little, like a little forceps or something? Tools? Yeah.

Speaker 3: 19:35

I have tools.

Speaker 2: 19:35

Mm-hmm.<affirmative>. Okay. You did mention, you did mention Q-tips. And I say this all the time to people. Don't ever put that thing in your ear. I do not. I've seen a couple times. You've probably seen a lot more where that Q-tip went through the eardrum. Sure. Did. Have you and you've seen some of those before? Yes. I have one who was in the shower, you know, like Q-tip in your ear or cotton swab in their ear in the shower. Slipped in the shower. The thing went right through your eardrum.

Speaker 3: 19:56

I had a woman who put a Q-tip in each ear, started blow drying her hair

Speaker 2: 20:01

And with a Q-tip sticking

Speaker 3: 20:02

Out with a Q-tip sticking out and perforated both of her eardrums. Oh my gosh. Simultaneously they

Speaker 2: 20:07

Healed. They did heal up. They did

Speaker 3: 20:08

Heal. Mm-hmm.

Speaker 2: 20:09

<affirmative>. So what, what, what do you fish outta people's noses?

Speaker 3: 20:12

<laugh>? Um, mostly kids. And it's mostly, do

Speaker 2: 20:15

You fish out with children out of noses? No.

Speaker 3: 20:17

<laugh> out of children's noses. Uh, mostly food products. Corn beans. I saw my own three year old kind of tease me one day and goes to put his corn up his nose. I said, do not cuz I don't have my stuff at home.<laugh>,

Speaker 2: 20:30

Don't you<laugh> like, like your, your three year old knows what you do for a living and was saying like, look, look mom, I'm gonna stick this corn up my nose. Oh

Speaker 3: 20:38

My goodness.

Speaker 2: 20:39

So if we were to wrap this up and we've been talking about the various members of our healthcare team, if there's one thing you would want people to know about you and your colleagues in the, uh, in the a p center, what would it be?

Speaker 3: 20:50

We care so much about the work that we do and the mission of this hospital. We are well trained to take care of you and your family. And if there is ever a question that arises, we have our physician colleagues right by our side to help us

Speaker 2: 21:06

Through it. Well, I love working with you, Megan. It's really great to have you as a friend and a colleague. We're talking with Megan McCoy. She is the director of the Advanced Practice Provider Center here at Hennepin Healthcare in downtown Minneapolis. Megan, thanks for helping us break that down today.

Speaker 3: 21:20

You're welcome. Thanks for having

Speaker 2: 21:21

Me. Great to have you on the show. And listeners, thanks for joining us. I hope you'll join us for our next episode. And in the meantime, be healthy and be well.

Speaker 1: 21:30

Thanks for listening to the Healthy Matters podcast with Dr. David Hilton. To find out more about the Healthy Matters podcast or browse the archive, visit healthy matters.org. Got a question or a comment for the show, email us at Healthy Matters hc m e d.org or call 6 1 2 8 7 3 talk. There's also a link in the show notes. And finally, if you enjoy the show, please leave us a review and share the show with others. The Health Matters Podcast is made possible by Hennepin Healthcare in Minneapolis, Minnesota, and engineered and produced by John Lucas At Highball Executive producers are Jonathan and Christine Hill. Please remember, we can only give general medical advice during this program, and every case is unique. We urge you to consult with your physician if you have a more serious or pressing health concern. Until next time, be healthy and be well.