Welcome to part two of this powerful nine-part miniseries by documentary filmmaker Adam Halbur on the physician assistant model around the world.
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The Advent of the Dutch Physician Assistant
I met Quinten van den Driesschen, a pioneering Dutch physician assistant, at AAPA in Las Vegas, about which he quipped, “In the Netherlands, we say, ‘A donkey doesn’t hit his head twice to the same stone,’ but I’ve been here twice, so….” I'm sure you get the point!
A few weeks later, I caught up with him at his practice in Elst, where he started by explaining the impetus behind the Dutch PA master’s:
The government was looking forward and seeing there would be a shortage on physicians. And our people are getting older and older and need more care…. So they foresaw a shortage on one side, but the other side was that they were thinking, ‘Well, our care costs a lot of money, and we see that a lot of physicians who are highly trained are doing a lot of work which could easily be done by people with another education, on another level.’ ... So they made this program of introducing the PA, and they founded two programs in the Netherlands, at Utrecht and Nijmegen.
In the Netheralands, PAs are a Long-Term Solution to Rising Healthcare Demands and Costs
The Netherlands is one country in which the PA has been implemented not merely on a trial basis but as a long-term government solution to rising healthcare demands and costs. It is also a country where everyone is covered by the national healthcare plan regardless of income.
Van den Driesschen, who in his practice has the same responsibilities and freedom as the general practitioner with whom he works, describes the Dutch healthcare system:
Primary care in the Netherlands is a bit different than primary care in the U.S. because what you see here is all primary care, general practitioners. As soon as you visit an obstetrician or a pediatrician, it is always in a hospital. We don’t have these specialists in primary care. We only work with general practitioners, and PAs, of course. So if you want to go to a specialist, you have to visit the general practitioner first…. Everybody has the same basic insurance. It includes hospital care, but the first 385 euros people pay themselves. When they visit the general practitioner, it’s free. So there is a stimulus to visit primary care, a family practitioner. We think that it controls our costs.
That said, van den Driesschen’s practice has hired some specialists, including specialists in dermatology and mental health, and at the time, he was one of the few PAs in primary care, in which he sees everyone from babies to elderly, often making home visits to provide palliative or other services to the very sick.
Many of his students in the Master PA Program at HAN University of Applied Sciences (Hogeschool van Arnhem en Nijmegen), where he teaches part-time, are specialists in hospitals.
The Dutch "Dual Education" Model
“So in the Netherlands, we have a program of 30 months, and it’s a dual education. Duality means you are partly trained on the job,” said van den Driesschen, explaining the master’s. You can’t apply for the program; you have to apply for a job as a PA in education. So you have to find yourself a physician that wants to train you for two and a half years. And then you follow a program in which you do rotations two days a week, all main specialties; you visit the school one day a week, and you work as a PA two days a week at that specialty with a specialist. So from the beginning, you work as a PA. And after two and a half years you get your master’s degree, but you also have your registration as a physician assistant.
According to Frank Holweg, another pioneering PA and then HAN program administrator, many applicants have already been working in health care for some time.
“Most of our students are nurses, some are physical therapists, so we have quite a range of healthcare professionals, but they all need to change their way of thinking,” he said. “The idea is patients come to you because they have a problem... The students want to solve a problem immediately, and we teach them to analyze first and then go to the solution.”
"It's a Little Weird, One Day You Come to Work as a Nurse and The Next Day You're a PA"
One female student said “in the beginning, it was a little weird. One day you’re coming to work as a nurse, and the next day you’re coming as a PA. So in the beginning you had to find your way.” Another, Marlous said, “You have to grow out of your nursing role and get into your doctor role, especially with the other nurses. You have to tell them what to do. But actually it went very smoothly.”
She was working in cancer care hematology with two other PAs, without the need of a doctor watching over their shoulders because they all knew “what to expect, what not to expect, what we are able to do and what we were not able to do. And I already knew them because I was a nurse in this department before.”
She said PAs, with their generalist knowledge, are a good addition; they are able to pick out urological problems, for example, that a physician specialized in cancer might not catch. I asked her if she would try another specialty in the future. “I'm not sure I would want to,” she replied. “I could go and work at any department that I would want. The question is if they would hire me without experience or not.”
She was quite satisfied with the challenges and rewards performing bone marrow aspirations, installing central venous lines and doing cancer research.
“There's space for everything,” she said, and added, “I just like to help the patients. We have people ... they survive. Some don't ... and even if they don't, there's so much trust they have in you, you can help guide them to their death to their dying. Yeah, so that’s what I do like about my job.”
In addition to his practice and teaching, van den Driesschen is the advocate for the Netherlands Association of Physician Assistants (NAPA).
“I visit hospitals and I visit primary care practices to talk about hiring PA students. And I talk with the doctor about his organization, and he sees that [PAs] really give him tools to change things,” he said. “In the Netherlands, in every hospital, there is a PA working. In primary care, there is still a lot to do. We have about 120 primary care PAs, and we have about 7000 general practitioners. So there is really room for development.”
Knights of the PA Round Table
For his efforts to boost PA numbers and grow the profession, he was knighted in a surprise ceremony in 2012.
“The next moment I was standing there in a football stadium where the mayor of my town came. Well, I was really shocked,” van den Driesschen said, showing me his photo album. “They don’t knight you with a sword here. It’s just that they put on this cross. And that’s it.”
As van den Driesschen drove the river road back to my lodgings in Nijmegen, perched since Roman times along the Waal that recently was widened further to accommodate rising sea levels due to climate change, I began to think of America’s many arteries, of rivers and of humans, and that the U.S. could learn something from the Dutch.
The Anatomy Lesson
I left the next day for Rotterdam and The Hague to catch a ferry for my interviews in London, but not before going to see Rembrandt’s “The Anatomy Lesson of Dr. Nicolaes Tulp” (1632), painted just 12 years after the ship Speedwell, with exiled English Puritans onboard, left Rotterdam to rendezvous with the Mayflower before embarking for the New World. I also grabbed a bite of the West’s metaphor for the very first anatomy lesson, and now a very American fruit: the apple, specifically an Elstar (which van den Driesschen said was named for Elst).
Even old New York was once New Amsterdam, and other than their better Christian values, such as brotherly love, the Pilgrims, and subsequent immigrants, carried with them learning, including the scientific reasoning found in clinical medicine. Let us hope some more good European ideas—universal health care and free college tuition, among others—pass over the waters in the coming years, ideas that are in fact at the very heart of the PA project, and the American one.
The Continued Growth of The Dutch PA
NAPA celebrates 15 years this November, and since his interview in 2017, van den Driesschen related via email that PAs have become accepted more widely by general practitioners, after years of obstruction. 280 PAs are scheduled to graduate in September.
The third installment of this blog series, “Small Acorns or What You Will,” explores efforts to establish the physician associate in the United Kingdom.
Adam Halbur is a writer and teacher living in Tokyo, Japan. A short version of his film As Good As You Can, As Professionally As You Can premiered at the 11th annual conference of the International Academy of Physician Associate Educators. Watch the “American Cheese” segment of the longer version here. Watch a short of the 50th AAPA Conference with interviews from Ruth Ballweg and David Kuhns here. Halbur is entirely self-funded, so if you appreciate his work, please consider making a small contribution to his feature documentary on the Kenyan clinical officer.
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