Season 2: Episode 31 - The PA Model in the Netherlands

Season 2: Episode 31 - The PA Model in the Netherlands

Sat, 3/12 11:08AM • 39:36

SUMMARY KEYWORDS

pa, netherlands, physicians, patients, profession, hospital, primary care, students, doctor, role, years, shortage, specialties, education, nurses, bas, work, people, started, surgeon

00:01

We respectfully acknowledged the University of Arizona is on the land and territories of indigenous peoples. Today, Arizona is home to 22 federally recognized tribes, with Tucson being home to the Ogden and yaqi. committed to diversity and inclusion the university strives to build sustainable relationships with sovereign Native nations and indigenous communities through education offerings, partnerships and community service.

00:36

Welcome to this episode of the PA path podcast, I'm your host, Kevin Lohenry. We are glad you could join us as we seek to better understand the PA profession

00:52

you have to go for it because there was nothing was, of course, a tunity to develop yourself also in that direction, and meeting ministries and kind of physicians organizations that started off day one.

01:09

Well, hello and thank you for joining us today we are taking a tour of the PA profession around the world. And today we learned about the profession in the Netherlands. We speak with Quintin Driessen, about his role in starting the PA profession and his experiences as a PA over the past two decades. The Netherlands were the first in Europe to start this profession. And they have a unique model of education that will be the envy of all of our pre pa listeners and probably quite a few of our faculty as well. As always, you may learn more about our guests and their institutions on our PA path podcast.com website. We hope you enjoy the conversation. Good morning or good afternoon and I believe

01:50

Yeah. Hi. How are you? I'm fine. Yeah, good.

01:55

Good. Quinton. I'm Kevin Lohenry. It's very nice to meet you.

01:59

Likewise, Sir Kevin. Yeah. Nice to meet you.

02:02

Did I pronounce your name correctly? Quinton? Yeah. Okay, excellent.

02:07

Is it like like to prison? Okay, and

02:11

is it venden? tration?

02:13

Yeah, it is just plain so Driessen. But, okay. Yeah, yeah.

02:18

A wonderful, wonderful. Well, thank you so much. Well,

02:22

thank you for the opportunity. If you could

02:25

maybe share a little bit about your own journey to becoming a PA first, it would be really interesting to hear how you ended up not only as a PA, but then as a leader in your profession national.

02:36

Well, like like many Bas, you started pa education when you already had some backgrounds, and I had already an experience of 20 years in healthcare. So after my high school, I started a study of physiotherapy, which I broke up after two and a half years. And then I became a registered nurse in a hospital in Amsterdam, the same hospital where I was born. And you follow when in hospital training to nurse and after debts and often working several functions in hospital, I worked on yours for an insurance company with sort of a healthcare maintain this organization. And afterwards, I went back in hospital as a intensive care nurse. And that was about nearly 20 years ago, in 2003. I get acknowledged for first timers, the PA program that was starting. So I was working on several specialties and departments in in hospital, which was a really rich, very rich experience. And then I was about 14 years ago, I had a family with four kids, and was still hungry to get some further and learn more. So that was about 2003. And shall I go on or

04:07

professionals I read started in the Netherlands around 2001 as a pilot and then the University started picking it up in 2003 and started to grow. And actually, as I understand it, really the first PA programs in Europe as well.

04:21

Yeah. So in Europe, we didn't know PAC at all, though, in Germany in the military fields. You had VAs working from the United States, and but really not in public just in a military role. So that that was the first BA program in Europe. Yeah.

04:42

And you entered that program in 2003.

04:45

Yeah. And would you say is right in 2001. There was a first pilot for group of Bas, directly to wreck surgery and emergency department that that started the sort of program, just developing and changing on the run. But 2003, the program was really accreditated and started off in depth and dynamic. And the whole idea that different from the USA, you started in half 60s, really with a big shortage of physicians. In a very big country in rural areas, the Netherlands, we have a wonderful system, a small country, short lines between health care, government, etc. It was more here that we were looking forward that we had a Ministry of Health, who was looking forward well, and she said she was a doctor herself. Well, in 2020, we have a real shortage on from physicians and hand on the patients due to people getting older and all the technical developments in care. And she was thinking about how are we going to change that. And she foresaw that a lot of doctors were really very highly specialized, doing well, rather simple work work. And she thought, well, we should form a medical mid level provider instead of that. So that was the idea. And I think we in the Netherlands were very lucky that the idea came from a government and that was willing to cooperate starting off this introduction of new profession.

06:32

Absolutely. That kind of paved the way for success, I would imagine.

06:38

Because, well, we had all the troubles and you know, in America, you went through the process, doctors weren't really waiting for us didn't see the problem, either did the hospitals or the primary care organizations? So yeah, there was a really strong pushing up this new concepts, like you are selling something you but you have to tell people that they have a problem they need it.

07:09

In the United States, when the government tells us, they're here to help us, we're usually a little bit skeptical.

07:14

Yeah. Yeah. So the skepticism wasn't really huge. And really, the first years it was really swinging, swimming against the stream, like a Solomon. And well, that really was a hard time, but also a very interesting time. And it really formed you as a human being. This development, so yeah, but you know all about it's great grades, personalities, professors in medicine, with lots of experience, and they really knew how to put you on your little place down under, I like anecdotes. One of my colleagues is in our university in the PA program. And we started in the same group in 2003. And it was the story about the terrific surgery, who was had a surgeon was on a very podium, and when we walked in rounds, on the on the wards on top on first place, getting the professor and then well all the other doctors and on the end of the road, there was a BA student, that was my colleague, and the patient that wave aside, all the doctor says and said hello to the PA student, because he had learned him, him from starting off his admission in awards. And he took him along the whole progress before operation and after operation. And he was addressing to the PA students and they are stood the thoracic surgeon a bit ashamed. You have to talk to me. That's typical. That's typical. The need for a PA in that process of a patient coming in, in hospital for a big operation. And it needs a human being who takes him through the process. And maybe in all humility, we bas are very good in that role. Standing beside a patient and knowing and talking his language and bringing something different than a young medical students who has a lot of theoretical, gosh, but not so many skills in communication.

09:36

And we're many of the first PhDs in the Netherlands similar to you and that they had extensive experience as nurses are in the healthcare system. Is that still the case today or was that just to get going?

09:49

Still Are you in the Netherlands we have only a master's program, are you You can only enter if you have a bachelor in healthcare with working experience. So, yeah, we see of course, nowadays, a lot of students in bachelor programs who are already planning to become a PA, and well, they know I need two years and then I upon, but still we have also a big group of students who are in their 40s. With with a lot of experience. Yeah, you have to be a physiotherapist or nurse and some of those. Yeah,

10:26

sure. And that differs from your medical school track in the Netherlands, your medical students go right out of undergraduate training into their graduate trainees, as doctors.

10:36

Yeah. Yeah. Well, they normally they have a year between. But yeah, it is similar, I think USA.

10:45

And I think, at least my experience in the United States, I think that that that's where we're different sociologically as a profession. And I'm really delighted to hear it's similar in the Netherlands in that that experiential piece of working with patients for at least two years, or more, I think, has always been a hallmark of our profession and our ability to relate to patients, because we're often already in the in the trenches, if you will, providing patient care, before we become PA students. And so it's just natural for us to have a different outlook in that group of as you described, the surgeon and all the physicians, etc.

11:22

And still, the, it is really a very big transformation that these nurses have to go through. Because it's not just we have these communication skills, but we really have to learn to think, different and active. It is unbelievable. It's impressive how people make this change in two and a half year. Of course, it's not only this two and a half year of the PA program, because afterwards is Long live learning. And still a lot of competencies I have learned after finishing the program, but it is really incredible. Because Oh, that's what you have to tell them all the time. How is thing? How is it possible that you do in two and a half year what I did as a physician in 10 years, and if you have to explain that to patients or relatives are not the same. As a doctor, still you come very close through another way. Another process? It is amazing.

12:24

Yeah. So you became a PA it was it a 30 month program at the time you went through?

12:30

Yeah, yeah. So 30 months master program. Yeah.

12:33

Okay. And then when you graduated, did you end up back at that original hospital in Amsterdam, that you had been a nurse?

12:39

Yeah, no, no, no, I was, I was trained in me in University Hospital. And directly after finishing my education, I started working in primary care. Well, what we call in the Netherlands, it's like, family practitioner who does primary care and, and urgent care. And so in the Netherlands, everybody first sees general practitioner before going to hospital, unless, of course, is picked off the streets by an ambulance. You always see general practitioner first, even if it's quite urgent care. Yeah.

13:20

In that role, are you kind of a family practice person during normal business hours? And then those clinics because of maybe some of the rural nature of some of them, are offering Urgent Care Services after hours? And on the weekends?

13:33

Yeah. So you have you can work as a BA in after hours. And then there's still a primary care setting.

13:40

So you left and you went into primary care?

13:43

Yeah. Because when we started, our group started, they just picked up a few departments in our hospital here. So well, we have to start just pick a few students and go and they Well, I was working in Jain ecology, and they didn't really well, they rather had what we call for law school midwives in a sort of PA role. And I think that more broad and journalistic position shoots me more than then in hospital and that was really wow experience in primary care with all the experience in in hospital that you could develop so, so well in that role, but that was really completely new because there was no pac in primary care. We had one pa from the USA, she was really mushy on the lot. The first one she ended, she came from the states and started working into two or three in primary care. So there was one and then it was a long time, me and and a few others because it was really it was more in hospital that developed quite quickly. The numbers in primary care kids Very low for a lot of years,

15:03

this thing, so the Ministry of Health in your country initiated the profession based on this projection of a shortage of physicians down the road. And my initial presumption was that was going to be a shortage of primary care providers. But it sounds like there was a shortage throughout the various specialties.

15:22

Yeah. And it was not really a shortage. It was. It was more shifting in a workload. And still, we don't really have a shortage. Now, nowadays, although in some regions in the Netherlands, there is a shortage of primary care, health care providers that we see now that there's a lot of young physicians don't find a job, it maybe some specialisms, it's easier to find a job as a physician assistant, then call a cardiologist or a surgeon.

15:56

Turn from a hospital system, I would imagine there is a salary differential between the two that might drive that decision.

16:03

Yeah, it's not that Yeah, but it's not only the salary it is, maybe some doctor spin. That's his point. But it is also the people it's rather institutionalized said his role of OPA and also openers, petitioner, they really see it as a as a function they need rather than putting bring in a physician or a cardiologist or orthopedic surgeon.

16:31

When I started in internal medicine, right out of PA school, my supervising physician was an internist. And at the time, he had a decision to make, he could he could hire another physician, which would then carve out some of his patients, and ultimately, his revenue. Or he could hire a non physician provider, a mid level physician extender, if you will, that could help him manage his patients. So that he continued to retain all of those patients and HMO contracts and things like that. So I think in the end, he went the route of having a PA so that the roughly 20 to 30 people he turned away every day to urgent care, because he was full, could still be seen in his family of providers. Right. Is that a similar thing there that maybe those physicians who are choosing a PA are saying the same thing that I want to keep those patients to be part of my regular process? Yeah,

17:27

I think it is, although love more and more doctors work for a hospital in their own private practice position.

17:35

Yeah, yeah. Okay. So how many years did you spend in primary care before you started to think about education and leadership?

17:42

Yeah, well, leadership started day one of being a student, because there was no professional organization, there was no, there was nothing, there was no legislation. So we just started with the group of students and start started our Dutch APA, in 2004. So you had to go for it because there was nothing. And other than was, was your youth, of course, now you had an opportunity to develop yourself also in that direction, and a meeting ministries and meeting all kinds of physicians organizations that started off day one, and about but after about 10 years, I started in education role, I always I combined it. So I still work in family practice, three days a week and two days I work. But even the first two

18:38

are good. And I think the educators that are listening to this podcast, and we're hearing from many of them over the course of the last year, we really interested in your your educational model, because as I understand it, the students are not in class five days a week, like we have here in the United States, they're actually in the clinic, they're working for the people that are sponsoring them, which provides you a lot a lot of flexibility as a as a program leader.

19:05

Yeah, well, we have a wonderful system, of course, and our students are really very lucky because they don't pay again, is incredible. So you have to find a physician or an organization that hires you as a student from day one. So you are sure you have a job after two and a half years and you only go to classes one day a week. And you work from day one, as a PA student on the department or awards or wherever and in the role of assistant assistant back and roughly you work two days a week, but in that decision, you go to school one day, you follow rotations two days a week. So our systems we have a module dual system 30 year months and every three months you have new Module which is follows the dead specialisms of medicine. So you have surgery for three months in internal medicine for three months and so on. You go to school, you you study knowledge about surgery, and you follow rotations in surgery the same time. So that is a wonderful mix of, of knowledge and practice. And the same time you do are in school one day, we could be a students that work in different fields. And you discuss all this medical problems from different kinds of views and experience. So it's a wonderful mix of theory and practice.

20:44

I can imagine so if you if you're facilitating that group on that one day a week, you might have a case that that kind of touches on all the different aspects of specialty care. Wow, wow, that's really interesting.

20:59

And so so yeah. What can I say about that? When we say well, we study things, you can't learn internal medicine, medicine in three months. So we pick out like, five big problems like like liver diseases like anemia, like heart failure, you you go very deep in this. And the way of studying this problem should lead you to be able to transfer your knowledge to other problems in internal medicine. So we don't study, we don't learn it all. Because then you will be like medical students, we have the same digital is the same books. They are? Well, half of it is in Americans. Are your similar to your books in the United States. But you of course, you can read it all. But you you are examined, or you you are assessed on five themes in internal medicine, and of course, there are more problems, problems and then only five. But that's the difference between a doctor and a medical student. And

22:12

yeah, and then the 30 months total. Are you consistently rotating every three months for 30? Months? Yeah,

22:19

yeah. Well, that's it that's a bit shorter, because we have a speciality modules. And then the last half year is his graduation. So if that is your scientific research and development on the work spot, so it's about eight modules with rotations, and then a half year graduation.

22:42

So most of your faculty, are there that one day a week to help facilitate some of these case based discussions. Is that correct? So sorry, I saw you so the faculty, so the faculty in your university program, are they typically there for that one day a week to help facilitate those conversations on the cases? Yeah, and and topics? And then the rest of the time? They're working clinically? Yeah,

23:06

exactly. Wow. And well, we, as educators, we visit them on the same spot where they rotate and where they work. And it gives us a lot of information, what is happening in healthcare, and how the student is really developing on the learning spot. Yeah.

23:29

And gets on clear acquainted. So what I'm hearing you say is, students are in class one day a week, they're working for their sponsor as a PA student, two days a week, and then they're on a rotation, which would be likely at a different location in a rotating specialty, two days a week. Okay,

23:47

and then their sponsor, or their department position that pays them to pay them for five days a week.

24:01

Then, our governments subsidize the sponsor, or the institution for almost about 45 to 50% of their wage. So yeah, and of course, so they don't pay 100% a day, roughly 50%. And we also say that our students have to, they have to work these two days. And maybe in after one year or in your year two, they really start being productive, as well. So they are responsible for awards, and maybe for patients in the first year and maybe 10 places in secondary or primary care. They see five patients a day and their two they say See 10 patients a day. So they are unproductive.

24:51

So you kind of alluded to how the medical community accepted the PA profession or various stages of acceptance. Early on, how about the nursing community, how did they see this kind of professional helping or

25:04

there's still a lot to say about this acceptance by the medical centers, but maybe we can have some more time about it later. But the nursing, what we see that they really enjoy working with Bas part of them, they are looking forward to see what it is. That's something I want to do in future. But they really see that it works. The PA on our on the board brings something else and the surgeon on board. And the nurses, they find that these pa state they talk a bit their language, they know how they are more emotionally involved and as respected. So they are working as a team. And so the acceptance is really very good.

25:54

Now let's talk about the position acceptance.

25:57

And reducing acceptance is well when when they are on their own golf clubs. And maybe they say, Well, this is nothing. And then I never heard of it. And but after experience, and working with BA as a member of their team, they are really very, very empathetic, and to share stick. But we had a lot of hard work with the physicians organizations, as well more on level of talking about legislation, or like some specialties are really trying to decrease the competency frame of the PA. And so that that was really hard work. And then again, we had big support of our government, because we did these talks together as the first years. And now we are working together with our Napa, our Dutch APA, on all speciality organizations, making documents to give sort of a framework that every so every internal medicine or every surgeon knows what you can expect from a PA, are you really make good appointments with VA is that the probate process? Well, it took, of course 20 years, and it still isn't finished. But yeah, the first years they were really reluctant. And then they became enthusiastic. And now you see that, that departments and specialties are really looking for and looking well. What's worked for force do we need for the next five or 10 years? What developments are coming on our way? And should we take a doctor should be taking petitioners up take a PA it's more their consciences have different roles and respecting them more.

27:51

And your health system actually is covered by your taxes Correct. You have a national health system. So there has to be an economic component.

28:01

So in analogy, everybody has an insurance. So the accessibility of of care is really on a common high level. And the reimbursement of care delivered by PA is also arranged in the first few years should always be a doctor shaking hands occupation, and then he could pride his bill to the insurance company. And now it can be that the patient doesn't see the physician at all, or maybe only online in the operating room. And then the PA takes care of the reimbursement process.

28:39

The PA is first to fifth in the O R as well.

28:43

Now, of course, completely different scale. And we are really a small country with about 18 million inhabitants. I think we have about 12,000 general practitioners, maybe we have about 20,000 physicians. And so I think in the US you have about another 150,000 graduate bas or even more. Yeah, so we are now in 2000 PS. It's like it's small amounts compared to the US but they really are everywhere in healthcare. We started more in hospital care. Only the last three years we are developing in primary care and more in elderly care. Still, about 70% of us are working in hospital care, but in all fields,

29:40

and there's no national certification exam correct.

29:44

We don't have a certification exam now. We have a national competency framework. That is all we have five universities, five programs that do this pa education and we are record straight by law. So the health care law, you have to be record straight it's and that can only be within a block of accredited program, that there was a uniform be a level of education, but not a certification exam. But when you are registered, you have to reregister after five years, and you have to prove your CME. And we do that in the same system as physicians, or CME is registered within the same system. And in a quality register, that we just discussed this afternoon, we I had a meeting with with UK and Germany, German colleagues about also this better, because we know the American, the Americans work within that national exam, the British are working with the national exam, we don't. And the recognition worldwide of Bas is still in development. So if you want to work here in the Netherlands, do you would be allowed if you had a permit. And if you spoke the language, as you know, we have a committee that is going to examine your your sci fi and your competencies. But there's more than exam.

31:22

Can you share a little bit about what it's like to be a practicing pa in the Netherlands, a typical day,

31:27

a typical day, my day is as I started 730 and reading the pulse of last night, what happens in emergency departments, etc. And then I see from eight to five, about 30 or 40 patients and do visit people at home to twice a day. I think I do minor surgery, I implant IUDs I talk with physicians in hospital, I write letters, I write referrals. And I supervise the nurses in our practice and medical assistants in the practice, I visit people at home. If they are really very sick and they go to die in a short time, they have my phone number so I go there at night or in the weekends, to palliative sedation. I don't know if you know what I say is right. For us, as also if if people are really in very low pain, or they're very short of breath, and they really suffering very badly, and we know you are going to die. And then it's gonna take two weeks or something like that. We bring in cutaneous needle and give them morphine, and it has allowed them and they really are in coma. And then they slowly are

33:04

Yeah, yeah, we did that hospice here in the United States as well.

33:08

So this is not ultimacy adamjee. It's just give them medicine and they die immediately. Yeah, it's comfort care. Now it's called sick care. And so in the Netherlands, we can almost do anything as a PA, but we can't get attention with the other Comfort Care. Sure. So it doesn't not every day, but most times once a month, you have such a patient in your practice. And so it's a very full day, it's a really busy, busy PA and I think most of our BNSF was similar days that of course, if you were to do the job 20 years, then you are on a lower level than when you are just graduates and that's the lovely thing of this profession that you are never ready and you can always develop and we have we always work with a physician. So we are autonomous but we always you work in a call collaboration setting. If you do are I obviously lucky that that my my position really enjoyed my development. So there were no boundaries at all. Yeah, you see that more and more that that's why I think primary care is now getting really popular for the lice nowadays because you see you can can develop more than well in the hospital where there's more erratic system and you have to deal with other doctors who are being trained and educated a little bit yeah, job.

34:50

Wonderful. And then salaries. What do PA is right out of PA school, what can they receive,

34:57

it is about between 3500 euros and 6000 euros a month. Okay, so to compare, I think $1 is about one. Yeah, $1 is much point seven Euro. So, yeah, normally would be, I think about 80 $90,000 a year for good goods. Position PA, this is a bit less than in the US, I think.

35:32

And you do not pay for malpractice in your country or do you we are

35:36

discovered by the hospital or the primary care organization. So we don't pay for it. We are just covered. That's great.

35:46

Yeah, that is great. And then also about six weeks of holiday a year. Is that right? Yeah. That's the one I think everybody over here is watering their mouths over that would be wonderful to have that mentality.

35:59

That's in general that in us, you don't have a lot of certification.

36:04

Now, I think, you know, I always I was very fortunate to work with a group that was very generous and understood that you were going to work very hard, like you do so. So they want you to be well prepared to take good care of patients, and you need to have downtime. So I when I first started in practice that I had three weeks of vacation, and a week of CME but that was that was pretty generous. I think most of our grads are coming out of PA school with two weeks.

36:31

I wouldn't survive

36:33

well today. I mean, I think the Europeans have always had a very good philosophy about that.

36:38

And maybe not so much with us. Well, this has been really interesting.

36:41

Quinn, I really do appreciate you taking the time, especially at the end of your day there to share with our audience about what's going on in the Netherlands. I think it's, uh, congratulations on such a sustained success.

36:55

Well, I take that, but we really were in, in America, you know, we had a model when we started, there was a model, and there was a be a USBA. So we could think about how do I have to grow? We had really helped a few people came to the Netherlands like like Ken Harvard's and rootball work. We got support from the APA, in beginning of our professional organization. So I like like Rick roars Ephesus, with us. And so we had help, there was a big brother, that was really, really good. And certainly we went a different way in our education. But the two professions are really they are similar. And so So I think we all could choose to be able to work in the US, and you USBs to be able to work here.

37:52

And that may happen one day we shall see right. But

37:55

remember, we are really small country, so don't come over.

38:02

Yeah, Quinton, thank you so much and best of luck to you and you're welcome,

38:06

my pleasure.

38:35

I like to thank my guest Quintin Driessen. For his visit with us and his insights into the PA profession in the Netherlands. It was a real joy to learn more about the European movement and the Netherlands unique curriculum. Tune in next week as we speak with Dr. Deborah Herman and Dr. Tamra ritsema. From George Washington University's PA program. We speak with him about the evolution of the PA profession in London, England and throughout the United Kingdom. And we also talked about some of the unique aspects of George Washington's program, and the importance of research in our profession. Until next time, we wish you success with whatever path you are walking in life. And thank you for joining us. The purpose of this podcast is to provide news and information on the PA profession and is for informational purposes only. The views and opinions expressed in this podcast are those of the speakers and guests and do not necessarily reflect the official position or policy of the University of Arizona.