Maggie McKay (Host): Welcome to Women's Health Perspectives, a podcast from Unified Women's Healthcare. I'm your host, Maggie McKay. 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.

Joining us today is Dr. Nichelle Satterfield and Dr. Gunter, both with UWH of the Carolinas. Welcome. Dr. Nichelle Satterfield is an OB-GYN physician at Durham Women's Clinic, and Dr. Barrett Gunter is an OB-GYN and Medical Director at UWH of the Carolinas. Thank you both for being here.

Nichelle Satterfield, MD: Absolutely.

Barrett Gunter, MD: Thanks for having us, Maggie.

Host: Yes. So, Dr. Gunter, let's start with you. What was the primary driver for initially adding APPs to your practice?

Barrett Gunter, MD: You know, I've been in a fortunate position ever since I was an intern at Vanderbilt University Medical Center. I actually worked with midwives then, and they taught me a lot on labor and delivery. So, I've really been surrounded by midwives and advanced practice providers my whole career. And actually, when I joined Durham Women's Clinic, we had two midwives on staff then.

So, it's really just been an evolution that team-based care has always sort of been built into my practice. And today, the concept of collaborative team-based care, I think, is even more important as we look at opportunities to diversify our workforce. We're going to be having upcoming problems with physician capacity in the future. So, it just makes sense to have advanced practice providers as part of your team.

Host: And Dr. Satterfield, would you please tell us how you and your team currently partner with advanced practice providers or APPs, which roles, what the app to do, any state restrictions, et cetera?

Nichelle Satterfield, MD: Yes. So right now, at our practice during and women's clinic, we have five midwives. We also have a PA and a nurse practitioner, that all work in our practice. And kind of the way we partner with them is they're seeing patients In the office and have, you know, normal schedules the same way that the physicians do. When we're on call at the hospital, we always have a physician and a midwife on call together, which is really great so that it allows there to be two of us taking care of all of our laboring patients. And, you know, it can get really busy sometimes. So, it's really nice to have that team approach and be able to help each other out on call.

Barrett Gunter, MD: Nichelle, don't you also believe that having advanced practice providers really helps to enjoy the practice of medicine a little bit more. Like when you're on call, having a midwife with you, it is hard being on call these days as a OB-GYN provider and just having that sort of team-based approach, I think, is invaluable. And I also think the patients really appreciate the ability to work with a midwife, but knowing that a physician is in the background and able to help out as well.

Nichelle Satterfield, MD: Yes, absolutely. You know, I think that a lot of low-risk labor management, you know, does not absolutely need physician care. And a lot of patients are seeking midwifery care for their births. And so, that's been a great way that we incorporate midwives onto our team. And we also do all of our own triaging when we're on call. And so, I think that makes a huge difference instead of using an answering service, which a lot of physician practices use because they can't be on the phone the whole time they're on call. Our midwives take the majority of the triage calls themselves. And certainly, we help as well. And I think that's really great for our patients, because they're always talking with the person that's actually there on call.

Host: What would you say are the biggest benefits you've experienced from this model, and were there any surprises? Dr. Gunter?

Barrett Gunter, MD: You know, I think when you have advanced practice providers as part of your healthcare team, that sends a message maybe to anyone that may want to consider joining your practice. For example, we mentioned being on call and having a midwife to sort of share those responsibilities. I mean, I look at that as a perk with a practice that has midwives. But also, within the everyday office-based setting, the midwives really provide a bulk of the prenatal care, which gives the physicians an opportunity to maybe see more GYN patients or to participate more in some surgical procedures. So, having that capacity really sort of opens up a lot of opportunities.

Host: Any surprises?

Barrett Gunter, MD: I mean, I think it really is a perk when you're recruiting someone to know that, when you're on call, you're not doing that solo. And Nichelle can speak a little bit to sort of the work-life balance and burnout in physicians. And I think having a diversified workforce and APPs is a real plus to extending your career.

Nichelle Satterfield, MD: I echo what Dr. Gunter shared of, I think, absolutely a huge benefit is getting to share in the workload when you're on call and being able to really work as a team and help each other and not feel like you're doing it all yourself, which is great.

 I think definitely, in the office, it allows me to see more GYN patients. And I do a lot of surgery and a lot of procedures. And so, it allows me to focus more of my clinic time on that and a little bit less on sort of routine OB care.

And so, in our practice, the midwives and our NP and PA see the majority of the low risk obstetric visits. And then, we're able to see some of the higher risk obstetric patients, and then focus more on GYN. So, I think it really increases our productivity in the office. And I think patients, it's something that they really want.

 I think, for a long time, our reputation as a practice in the community was that a lot of patients came to us because we employed midwives. We were sort of a much earlier adopter of that care model. And now, a lot of the other groups have followed suit. But for a long time, Durham Women's Clinic and one of our other kind of sister practices that we take call with Chapel Hill, we were some of the main groups that had them.

Host: And what advice would you give to a peer who is hesitating to add an APP model?

Barrett Gunter, MD: I think, there are a lot of physicians that are in practices that do not have APPs. And what you don't know, you don't know. They're such a valuable resource, and I would encourage anyone that doesn't have plans to engage with APPs to consider it, especially as the ability to recruit physicians might become more challenging in the future with the shortage that's expected with physicians by 2030. So, you can get ahead of the game and begin to think about changing your model and how you would sort of integrate advanced practice providers in your practice.

Host: So, what's been the most challenging aspect or a downside to adopting this? In other words, what should other physicians think about as they make the change?

Nichelle Satterfield, MD: One of the more challenging aspects with advanced practice providers, there does tend to be a little bit more turnover in those kind of roles. Historically, with hiring physicians, it's a lot of Investment. And I think that, for most of us, we're going to, you know, sort of stay at the practice where we start for a good long while. And I think that sometimes with APPs, there can be a little bit more turning over, because there is not a dedicated residency for most PAs or NPs. They certainly have more dedicated training, but they can still work in a sort of a variety of practices.

And so, I think that that's been one of the more challenging aspects for us, is we feel like we'll have a really well-established midwifery team. And then, someone will leave, and then we have some turnover. And so, that's really the main thing that I would say. I don't think there's a downside of adopting it. But I do think that sort of the buy-in is just a little bit different than it might be with a physician joining a private practice. I.

Host: Dr. Gunter, anything to add to that?

Barrett Gunter, MD: Sure. One of the benefits, I think, in being a physician within UWH of the Carolinas is that we actually have a recruiting team. So, it can be challenging finding talent and retaining talent. We have a provider support program where we can compete with some of the academic medical centers or other large healthcare systems to recruit our advanced practice providers with a sign-on bonus and retaining bonus.

As you know, it takes a while for a new clinician to sort of ramp up and be sort of full with their schedule. Nichelle mentioned one other thing, that our physicians also serve as great mentors for our PAs and nurse practitioner as well as certified nurse midwives. And I think having that mentorship is really important and, you know, our APPs being recognized that they're valuable to the team and just can enjoy what they're doing.

Host: So in closing, is there anything else either of you would like to add that you'd like people to know?

Barrett Gunter, MD: I cannot imagine practicing without advanced practice providers. The on-demand sort of aspects of call are really challenging these days. And it's just great to have a team-based approach to take care of patients. When you think about the financial aspects of running a practice, and Nichelle alluded to this a little bit, the overhead with an advanced practice provider is not quite as high as a physician with salary benefits, but also malpractice insurance. So, that has been, I think, a real plus.

Host: Dr. Satterfield, anything to add in closing?

Nichelle Satterfield, MD: Yeah. I think, for me, similarly to Dr. Gunter, I, trained in residency and worked with midwives. So, I have always known midwives as being a part of the team, and NPs and PAs as well. And I think that we all have different skills in our training that we bring to the table. I certainly have learned a lot from the midwives I've worked with over the years, and they continue to teach me things all the time. And it's been a great model for us and I think that I definitely would not want to practice without them.

Host: Thank you both for sharing your expertise and teaching us about this. Very interesting and informative. Thank you for being here.

Barrett Gunter, MD: Thanks, Maggie. Great topic.

Host: Again, that's Dr. Nichelle Satterfield and Dr. Barrett Gunter. 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 recruitment 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.

To explore all our Women's Health Perspectives episodes, visit the Unified OB-GYN Intranet from the tile on your Okta dashboard. I'm Maggie McKay. To learn more, please visit unifiedhc.com. Thanks for listening to Women's Health Perspectives, presented by Unified Women's Healthcare.