Maggie McKay (Host): As the women's healthcare landscape evolves, adding advanced practitioners such as Certified Nurse Midwives, Nurse Practitioners, and Physician Associates to the practice care team is becoming more common. Today, we're talking with Dr. Tracey Banks about her experience working with APPs. Welcome to Women's Health Perspectives, a podcast from Unified Women's Healthcare.

I'm your host, Maggie McKay. Thank you so much for being here today, Dr. Banks. Would you please introduce yourself?

Tracey A. Banks, MD, FACOG: Well, thank you for having me, Maggie. Yes, my name is Tracey Banks. I am the founder of Adriatica Women's Health in McKinney, Texas. I founded the practice 25 years ago and we are an all female practice in McKinney that's also under Unified Women's Health Care.

Host: I love that. Let's just start with what is an APP?

Tracey A. Banks, MD, FACOG: APP stands for Advanced Practice Provider, and that is like a catch all term that encompasses Certified Nurse Midwives, Nurse Practitioners, and Physician Assistants. They're sort of physician extenders.

Host: And what changes have you seen regarding advanced practitioners over the last several years?

Tracey A. Banks, MD, FACOG: Several. I think when Nurse Practitioners or APPs started the market, they were mostly in the emergency room space as Physician Assistants. With the shortage of physicians over the last few years, we're seeing them in all aspects of healthcare, in the hospital, in the office, and also in urgent care centers.

So we're seeing an increasing number of APPs in the healthcare space, as well as I think physicians are getting more comfortable with them as well. So that's why their numbers are increasing.

Host: That sounds awesome. What is a CNM and how can they practice in Texas now?

Tracey A. Banks, MD, FACOG: Sure, CNM stands for Certified Nurse Midwife, and that's a distinction from a lay midwife. So a certified nurse midwife is a midwife that's undergone an exam and all of the certifications that are required by the state. In Texas, only certified nurse midwives are quote unquote legal. Lay midwives are kind of carry over from the back in the good old days when there was a midwife that came to the house and delivered the baby.

But now there are strict regulations and certifications for midwives. So midwives can also do a lot of things that OBGYN can do. They can deliver babies, do prenatal care, and do well woman exams.

Host: What does their scope look like at Adriatica Women's Health?

Tracey A. Banks, MD, FACOG: Sure. So we've employed midwives for about the last 15 to 17 years. And in our practice, the midwives have their own separate group. So there are four of them and they have their own patients. Each midwife patient, however, does have a physician back backup. So in the obstetrical space, our nurse midwives tend to take care of low risk patients who are probably usually have a vaginal delivery, but there's always a physician backup. So if the patient becomes high risk or requires a C-section or something of that nature, there is a physician backup for that patient. But they can do pretty much everything prenatally that we do.

Host: I bet that the pregnant mother is so happy to hear that, that there's a backup. You know, I don't know. I would think like the more, the better, just in case.

Tracey A. Banks, MD, FACOG: Right, because then it'll be 95 percent of the time everything is beautiful and lovely, but it's that 5 percent where everything can hit the fan. And so it's great to have reassurance that there's a physician backup should something become high risk or should something change.

Host: Definitely. Dr. Banks, what does the day to day partnership with Advanced Practitioners look like at your practice?

Tracey A. Banks, MD, FACOG: So our practice, we not only have physicians, we have Certified Midwives, as I mentioned, and we also have Nurse Practitioners. So the nurse practitioners pretty much do a lot of the gynecological services. They perform women examinations, they can counsel on birth control, UTIs,vaginal infections. They even can perform minor procedures such as colposcopies or hystro sonograms and other biopsies in our office.

So they do quite a bit and they help really take the load off of the physicians as well. The midwives, on the other hand, can also do a lot of that as well. They tend to be more obstetrical focused, but they still do birth control counseling. They still work up abnormal bleeding, UTIs, that nature as well. So a lot of the APPs do a lot in the office of what we do.

Host: And are there hesitations or misconceptions physicians may have around partnering with CNMs or other APPs?

Tracey A. Banks, MD, FACOG: I think so. I think it's kind of become a while for physicians to get comfortable with APPs, especially midwives, because as an obstetrician, we know the horror stories, we know all the things that can go wrong, but when you hire a qualified certified nurse midwife, they know their limitations. They know when to call, they know what they can and can't do.

And it really is a team and a partnership. We get asked a lot by patients, well, what's the difference between an OB and a midwife? And I think that midwives tend to, have a more natural process for the labor process. They do more natural remedies. But just because you have a midwife doesn't mean you can't have an epidural, means you can't have drugs. They also manage those things as well. And in fact in our practice we will have patients who we know are going to have a C-section but they still want to see their midwife for their prenatal care because maybe they saw them with their previous pregnancy and then as a physician we basically just see them when it's time to perform the C-section. So the midwife can be there the whole time as well.

Host: That's interesting. See, I didn't know that. I thought when you had a midwife you don't get any of the drugs.

Tracey A. Banks, MD, FACOG: That is a common misconception. That is very common. But no, just because you have a midwife doesn't mean you can't have your epidural.

Host: Okay. Good to know. Um, how do you think adding these professionals to the care team can impact patient satisfaction?

Tracey A. Banks, MD, FACOG: I definitely think that midwives tend to spend more time with patients in the labor process. And some, a lot of patients want that. They want the extra, I don't want to call it hand holding, but just a more natural process. Some of the natural remedies, the massages and things like that midwives do, a lot of times a physician might not do that.

Having a midwife in your practice helps you to offer different labor choices for your patients. They can decide what kind of birth experience they want and know that you also provide that more natural process that a lot of time a busy OB just frankly doesn't have time to give.

So I think that can be a great asset to the practice. Other assets could be that our midwives do our rounding or most of the rounding for us. So that really helps us with our work life balance. When we're busy on call and doing surgeries and delivering babies, there's also a midwife on call at the same time, who may have her own patients in labor, but has some downtime to actually round. So that makes our life a little bit easier. In some practices, the APPs will also take first call for them when on call and take those phone calls. So I think definitely having APPs in your practice enhances the work life balance.

Host: And what about physician satisfaction? Has working with Advanced Practitioners improved your own experience?

Tracey A. Banks, MD, FACOG: Oh, absolutely. You know, just by the virtue that they do our rounds for us, that helps ease off a lot of the when I'm on call, it helps ease off a lot of the tasks I have to do in an already maybe stressful day. Also it offers more of a collaborative feel to the practice. All our nurse practitioners, they also have a physician backup.

So there's much more of a collaboration. When a nurse practitioner has a question about a patient, we sit and we talk about it, we have meetings where we talk about difficult patients so that we all learn and it's more of a team approach and a team effort, which I think also appeals to the work life balance in that we don't feel like you're just on the island doing your own thing.

Host: And we know it's getting more challenging to recruit OBGYNs across the industry. Has that been a factor at your practice?

Tracey A. Banks, MD, FACOG: Well, we tend to be in Texas, we tend to be more impeded by the current laws that are going on in Texas right now. So yes, I think, hiring an APP, they can do a lot of what a physician does. In a shortage that we are experiencing with physicians, you know, there are more APPs that are looking for jobs.

And so it has made it easier for us to meet the demand of the patients. I'm in a very fast growing area of Texas. So, by hiring an APP, which when you hire a physician, you really have one particular time of the year where you can get like a new grad or physician, whereas APPs are usually looking for jobs throughout the year.

So it can be a lot easier to hire an APP, to help with the demand that busy practices have. So absolutely.

Host: Dr. Banks, are there other advantages you or your colleagues have found?

Tracey A. Banks, MD, FACOG: The main one, as I mentioned, is the collaborative approach, the team approach. You know, I feel like I have an extension of myself with my patients. In our practice, each physician kind of has their own nurse practitioner. So when I'm checking labs on a patient or something is abnormal and my schedule is booked out for months, I could have them follow up with my nurse practitioner.

The patients know that we are a team, we work as a team and that she represents me. So it's able me to see more patients to meet the needs of the patients better. So I think that's a great asset, to any busy OBGYN practice.

Host: What advice or tips would you give your peers about working successfully with advanced practitioners?

Tracey A. Banks, MD, FACOG: So the main one I would say, and this is worth hiring anyone and a new physician as well, is try to hire for personality and fit. Most physicians and APPs are well trained, they've gone through all the regulations and the guidelines and the certification. But the main thing I think is to hire for personality and fit because in our practice we like to think of ourselves as a family and we get to choose this family.

We get to decide who's a part of this family and we want people who kind of mesh in with us as well. The other thing is don't rush the orientation process. I think, I've learned from my mistakes, you know, when you hire a nurse APP, you really want to have them shadow you, get to know your workflow, get to know your processes.

You know, you don't want to just throw them in by fire. I think the greatest success is to have a good orientation process where they really get to learn your workflow and that of the hospital, where you take them under the wing, let them shadow you till they feel comfortable to going out there and seeing patients on their own.

And then we start them slowly. We don't give them a full schedule right away. We start them, slowly and we increase as they get their sea legs, so to speak.

Host: Don't want to scare them off. It's so true about getting people that all fit together. Cause when you think about it, you probably spend more time with them than your own family. So.

Tracey A. Banks, MD, FACOG: Yes. Yes.

Host: You want to have the same philosophies. And well, thank you so much for sharing your expertise on this. I mean, I learned a lot, so I'm sure a lot of other people will as well.

Thank you, Dr. Banks. We appreciate your time.

Tracey A. Banks, MD, FACOG: Thank you for having me. This has been fun. Thank you.

Host: Again, that's Dr. Tracey Banks. And if you'd like to learn more, you can go to unifiedhc.com. Thanks for listening to Women's Health Perspectives presented by Unified Women's Healthcare.