Amanda Wilde (Host): Welcome to the Women's Health Perspectives podcast. Today, we're focusing on a topic that's top of mind for many OB-GYN practice teams: How can we meaningfully expand capacity and support physicians? We're taking a closer look at how care centers have incorporated advanced practice providers into their teams to do just that. Many are hiring APPs to manage demand, support physician workload, and increase access to care. We'll discuss what prompted the change, how responsibilities are structured, what works well, and what to consider before adopting this model.

Let's get started with our guests, OB-GYN physicians, Dr. Mark Palazzolo, and Dr. Steven Suba, who is also Director, UWH of Texas. Welcome to you both.

Mark Palazzolo, DO: Thank you very much. We really appreciate you having us on this morning, Amanda.

Host: Dr. Palazzolo, you are Florida. Dr. Suba is in Texas. So, I want to ask you both this first question, what was the primary driver for adding APPs to your practice?

Mark Palazzolo, DO: Very good question and very appropriate to start there. You kind of hit on a couple of the topics in your introduction. The biggest issue that we have is actually a physician shortage, specifically in Florida. Florida is one of the fastest growing states, so we have a deficit in physicians. Recruiting of physicians is very difficult right now. What we're seeing is a population growth of about 1.5% per year.

The other thing that we have is we have physicians that are retiring. And so, we have OB-GYNs that are retiring and we're not graduating enough. And so, we actually have a deficit of about 10% that'll come in 2030 of a shortage. So, we had to look at alternatives on how we can grow our practice, maintain quality of care, get the patients the access of care that they need. So, that was kind of our real driving force, but it turns out to be much greater and better than that.

If I could just briefly talk a little bit about my specific practice, we, in our practice, have 14 APPs. We have overall 38 providers, but a very large presence. And we're kind of across the board, meaning we have certified nurse midwives, we have physicians assistants, and we also have nurse practitioners. So, we have a plethora of different types of APPs, and they all are very complementary to what we do.

The main reason is you also want the physicians to practice at the top of their license. So, that's a very important concept too. And so, we have different models that we do to make sure that everyone is effectively taking care of patients. And we really wanted to have a sustainable practice that was future-proof and reduce the burnout of our physician. So because of that, we've been able to incorporate it into our practice very nicely.

Host: Well, Dr. Suba, you are in a different market. What was the primary driver for initially adding APPs to your practice? And maybe you can talk too a little bit about how you and your team currently partner with APPs.

Steven Suba, MD: In our market, a little less mature than Dr. Palazzolo when it comes to the use of the APP, specifically with the midwives, but also nurse practitioners, we've had midwives within the practice, but mainly managing in the hospital. So, we had midwives in the hospital managing labor and delivery and the activity.

But then, two years ago, we had two physicians out with leave, and the volumes were there, so we transitioned to bring them into more of the clinical setting. So, we kind of have the two models where one's focusing on the care in the hospital, but also taking up volumes to make up for, in our case, the temporary lack of providers. We have a relatively younger practice. There's only one of us over 60 and you're talking to them right now. And the rest of whom are all in the lower end of the age bracket, which also means they have responsibilities outside of the office and family.

People are talking about the work-life balance being an issue. I think that's where the integration of the APPs to offset some of the volumes and economically keeping everybody whole has been something we've realized in our limited experience right now. But as we're beginning to grow and expand, the lack of being able to-- not really lack of ability to recruit, but being able to recruit, being able to present a model where there's a team that's on call. And that's the biggest, I think, part of it is not just the clinical responsibilities, but whether you're doing 12-hour shifts in general practice or 24-- I think there are still some doing 72 hours-- the ability for, in our case, the midwives to come in and assist and help offset some of the labor, time in the making rounds in the morning, and then managing active laboring patients as well as collaborating in the delivery, not shifting all the deliveries over the midwives, but there are patients who meet the midwives. And it's a different version of care.

Host: Dr. Palazzolo, what are the biggest benefits you've experienced from this model?

Mark Palazzolo, DO: So, the benefits are really improved access. We were to a point where there's a waiting time for our patients to get into the office. And there is a concern about access to care. Prenatal care is one of the most effective form of preventative medicine. But it only works if we can get our patients in a timely fashion. So, we definitely have increased access to care, which is very important.

Another one is increased patient satisfaction. They enjoy having the ability to have different conversations with different providers. Our APPs have a little bit more time in their schedule to work on patient education, answer questions. And so, that dynamic that we have works out very well. Like Dr. Suba, we used a team-based collaborative model, meaning that we don't operate in silos. Our patients see the physicians as well as the APPs. In the office setting, the APPs' focus in on basic prenatal care of our low-risk patients, preventative medicine, as well as routine management of some GYN conditions. And we have escalation pathways in place so that we can get the patients to the right provider.

And it's also led to increase efficiency without any loss of quality. We always want to make sure that our quality of care and patient satisfaction maintains where it is. So, what we're finding is a strong patient acceptance. I've had patients that have been mine for 18 years. And it's lovely when I see them walk down the hall, and they give me a thumbs up or they're happy with the care they received from one of our APPs. So, that's been an excellent kind of surprise in this. And it's really improved team morale. And so, all the providers on the team are really satisfied with how we've been able to incorporate this into our care.

Host: So, there were some big benefits you were expecting, but some surprises as well. Was that true for you, Dr. Suba?

Steven Suba, MD: Absolutely. I couldn't have said it better. You see things that come about with the relationship that the patients have with our APPs. And watch that develop and complement the model you already had in place.

Host: Well, Dr. Suba, staying with you, what advice would you give to a peer hesitating to add an APP model?

Steven Suba, MD: I'd say identify where the concerns are of the individual, what their needs are, and what they're targeting with the expansion in addition of an APP, adding them in clinic volumes if they're having a tough time to recruit, seeing if there is a manner in which they can work with what's going on in the hospital and the volumes, what's their biggest stress point.

From that standpoint, identifying and knowing what you're recruiting for. I think there are some preconceived ideas. I guess the best way of putting it, that it'll remove the responsibility or maybe give too much responsibility and ownership of issues to the physician when I've often used it as a model of back when we were residents, no matter how long ago, as a fourth-year chief resident, you had responsibilities and owned that, and you trusted those that were the third and second year residents below you. There were issues they wanted to cover, and there were ones that they didn't want to and came to you that. I think that's just getting the understanding of how the model works. In Texas, unfortunately, most of the markets, there's not been a big involvement with APPs. Gradually, it's been evolving though.

Host: We mentioned from the patient side all the benefits there have been. Dr. Palazzolo, what has been the most challenging aspect? Is there a downside to adopting this model?

Mark Palazzolo, DO: Whenever you start something new, there's always challenges, but you always want to turn those into opportunities to improve outcome and patient care and improve cost effectiveness of the practice and be good stewards for our insurance partners.

The biggest challenge is to make sure that we invest in onboarding and mentorship of our new midwives or nurse practitioners or physician's assistants. We want to make sure that everyone is on the same page, and that they understand that we will all work collaboratively together. And then, the flip side is for the physicians too. One of my physicians made a comment to me that said, "Hey, Dr. Palazzolo, I don't feel comfortable with this. I feel like I'm training my replacement," is what she said to me. And so, we had to do a redirect on that and say, "Really, This is not a replacement. This is an augmentation of the practice so that we can give better patient care." So, I think making sure that everyone is aligned and communicating appropriately, those are the biggest challenges.

I think it's important to understand the scope of what you need in your practice and make sure that you have the right fit and the right hire the first time. So, what I've learned over the time is that it's actually better to have more people involved in the interviewing process. That way, we can make sure we have the right fit for the right position that we're filling for if it's hospital-based or if it's office-based. So, all in all, there are definitely some challenges, but it's definitely worth it for the smiles on our patients' faces and we're able to get them in quicker. And then, the team morale that's been improved and better work-life balance for our physicians.

Host: Dr. Suba, would you add anything to that?

Steven Suba, MD: The only thing I might add is when looking at the midwifery model, having experienced within the last 10-- about 10 years ago, brought in a large group of birth center midwives. And there's a cultural difference between birth center and hospital-based midwifery we found not just for the physicians themselves, but for the nursing staff of the hospital in labor and delivery.

Be prepared and be aware of that fact. I think whenever you're bringing in the midwives, as Dr. Palazzolo said, both with your providers so they understand the relationship going in, and you have champions. But what we experienced a number of years ago was a cultural shift, I guess, is a kind way of putting it. But, you know, right now, our midwives are being led by someone who's been involved in midwifery for-- I don't want to age her-- but quite a while, and trained at a university center.

And there's also a distinction with certified nurse midwives, and then some experiences, especially with maybe more senior physicians, I guess, would be the kind way of putting that with the late midwifery experiences, you know, in the past, and currently it can still happen. So, I think that's the one thing that off-puts a number of individuals whenever the first-time they've heard about this and trying to introduce them.

Host: Yeah. And as Dr. Palazzolo has said, there are always adjustments to be made when you make improvements, but it sounds like this very collaborative approach is working well on both sides and communication is key. Well, thank you both for helping us understand how APPs work and how these models work, and how they can be adapted to the needs of each individual community.

Mark Palazzolo, DO: Yes. Thank you for your time. Such an important topic. And at this point in our practice, we could not move forward without our awesome APPs. They're an awesome complement and augmentation to our group, our physicians, and most importantly, our patients. So, thank you for such an important topic.

Host: And thanks for joining us for today's discussion. If you're considering adding an APP to your team, remember that Unified provides structured support including up to $50,000 in funding for eligible growth hires to help make recruiting and onboarding more accessible for care centers. To explore whether your practice qualifies or to start the request process, reach out to the provider recruiting team. They're here to guide you through each step and help you determine if an APP model is the right fit for your practice. Thanks again for listening, and we'll see you next time.