"Creating Little Health Ambassadors" - Ken Korber, President of the Association of Family Practice PAs and NPs

DR. RISHI DESAI: Hi I'm Dr. Rishi Desai  and today on Raise the Line, I'm happy to be joined by Ken Korber, President of the Association of Family Practice PAs & NPs, and a clinical instructor at Mount St. Joseph University’s PA Program in Cincinnati. Ken is also the author of children's books - which is pretty awesome -  and his latest is called “Grace Fights COVID-19: A Training Manual for the Musical Adventures Bug Squad."  I hope I said that just right. 

We're going to be talking a lot about the role Family Practice plays, learn about PAs and NPs, how they fit into the healthcare landscape, what's ahead really for those professions given COVID-19 and really beyond that. Ken, thank you so much for joining us today.

KEN KORBER: I’m happy to be here. Thanks for inviting me.

DR. RISHI DESAI: Let's just start out by understanding your own career path and what got you into becoming a PA.

KEN KORBER: Long, long story because I'm an old guy. It started with just an inherent like for science. My dad was a biology teacher, so that drove the conversations at home when I was a young kid and I was interested in med school, did not get in, met a PA when I was doing research at Yale for some transplantation work, and she introduced me to this concept of a PA in vascular surgery.  

I looked into that as an alternative to reapplying to med school and got in. Graduated in 1991 from Hahnemann's Program in Philadelphia, then I went into vascular surgery as a house officer here in Chicago. I did that for about five years and started a family with my wife, who is a nurse. We wanted a better quality of life instead of being on call every third night, so I switched over to cardiology and did more outpatient hypertension, dyslipidemia management, these types of things, in an academic position at the University of Illinois. 

Over the next five years, I did that medical side of things for patient care and then slowly got into medical education both as a medical writer and faculty for CME programs within the PA world  - so peer-to-peer kinds of platforms -  then made a major career shift and became a published children's book author, mainly because I saw that there was a need for trying to extend the outpatient encounter time from 10 minutes to something that the patients could sort of reinforce at home.

I thought pediatrics was the best way to do it. It would be with children's books and some spin-off stories about characters and help with their health messages that came along with it. That's where I'm at today doing that as a nonprofit, and we'll see where it goes.

DR. RISHI DESAI: That's awesome, Ken. I'm just marveled by the fact that you said when you started in 1991, or when you were going through training in 1991 versus 2020. It's been about three decades. What has changed in terms of how people understand and appreciate the role of a PA in healthcare?

KEN KORBER: When I was a student back then, we only had 60 programs in the U.S., and each program had about 50 or so students. The gross numbers were not really there from an impact perspective for a program that started in 1967 or so at Duke. When the corpsman came back from Vietnam, they tried to insert these technically trained people into the healthcare system, and Dr. Stead down there implemented a training program for PAs to fast pace them into healthcare delivery. That's how it all started. 

When I went to school, we were sort of in our infancy, adolescent stage in terms of the profession, but tons of change has happened since then. I was a student when we had paper charts. I used to write my H&Ps by hand in the patient charts that were in binders on the wards. Now, it's EHR. Everything's totally tech-savvy and tech-heavy. That obviously brings along whole new skill sets that have to be taught to PA students, so that two and a half decades worth of clinical experience has certainly evolved. That’s probably the easiest way to describe it.

DR. RISHI DESAI: How do you explain to folks that may not be familiar with the role of a PA versus an NP versus an MD versus an RN? How do you break down the roles of all the different players on the team?

KEN KORBER: Historically, the sort of the pitch to the patient was that the PA was someone who could extend the time of the physician who was still the quarterback of the team in terms of care, and we could pick up some of the patient education time that was necessary, freeing up the doctor to do new patient consults, more complex care, things that they were trained at that we weren't, because we were trained in more of a holistic primary care kind of model that gave us broad-based skills but not a whole lot of specific and specialized experiences. 

As a student, you were taught, “When you hear of hoofbeats, think about horses and not zebras,” and the zebras were what the physicians knew about and were experienced with. So we could take care of the run of the mill things that were encountered for the most part in outpatient settings and then supplied some technical support in inpatient positions as well to surgeons or to subspecialty physicians. Now, the NP thing, I had always worked with nurse practitioners at the bedside, for 20 years, and at the grassroots level. It was similar in terms of tasks that were implemented and executed. The training and background are usually a little different.  From my knowledge and experience, advanced practice nurses or nurse practitioners were trained in advanced clinical care after they already had RN degrees. They had pretty good historical track records of patient care experience.

PAs, in the old days, were corpsman, technically skilled individuals or EMS people that had some basic patient encounter experience but needed to be trained up in terms of medical model care. That's why we were trained alongside medical students, physicians, and residents because we wanted to function within a medical model setting. That allowed us to go into all specialties because we worked right next to residents and medical students.

DR. RISHI DESAI: Do you ever find that there is a communication gap? Obviously, one group is trained in a medical model, like you're saying, and then NPs were prior RNs, and there's a whole nursing model. Is there ever a sort of miscommunication between the people that work and have trained in these different paradigms?

KEN KORBER: At the patient bedside, not so much because it was diagnostic, interventional or prognosis-centered in terms of the critical thinking and problem solving. But once you get into academic worlds and medical administrations and hospital settings where you're further away from the actual patient encounter activity, then you start getting into philosophical things and logistical things that sometimes muddy the water between the members of the healthcare team. But hopefully, the current team care model, which is sort of flourishing now, might solve some of those communication challenges. It's still sort of a moving target, I think.

DR. RISHI DESAI: You mentioned the analogy of horses versus zebras and horses are more common, and they're the ones that PAs and NPS are trained really well to manage. I think the horses, if we're going to name them, in the U.S. at least would be diabetes, heart disease, cancers of various sorts. These are the things that, as you know, really dominate healthcare costs and the things that affect the majority of Americans. COVID-19 is now one of those horses, unfortunately. 

In terms of growth, healthcare jobs are one of the few sectors that are growing rapidly and among them, PAs and NPS are huge growth areas. Do you see any change in the way that maybe there is a public perception around it, or the training itself might have to change as we start accommodating more and more students that are interested in those fields?

KEN KORBER: Fundamentally, I think that when you're in healthcare, and certainly my experience has been that, once you've graduated as a certified, licensed PA or other healthcare provider, your training doesn't stop at that point. This whole notion of self-directed learning and lifelong learning is why we all have to have continuing education credits to maintain our licenses. That helps move us along. 

COVID is the perfect example. Three months ago, nobody knew about COVID, and managing patients. All of a sudden, respiratory therapists become very important members of the team because the patients are prone. They're intubated for a month or longer. It's just incredible, the types of things that are needed to be learned, evaluated, and then implemented with this whole new disease process that's sort of in front of every single person in the world as a global pandemic. 

That's a great example of how we have to change with the environment. That's a given. You don't go into this profession thinking that you can practice the way you practiced 20 years ago and have a beneficial outcome for your patients or optimal prognosis for your patients if you practice in that old model. You have to stay up to date. That's just how it goes.

DR. RISHI DESAI: Part of that staying up to date also, I think, reflects on the latter part of your story, as you transitioned and now you're an author, trying to get information in the hands, in this case of kids and their families. What do you think of the role of education outside of the office visit and how that's grown or changed over time?

KEN KORBER: We were very fortunate in the old days when I could spend 45 minutes with a patient to talk about their diabetes or talk about their hypertension where now, with RVUs and productivity and all that stuff, you're only allowed to spend 10 minutes. That's it. You can't get everything reinforced or accomplished at that point with your adult patients who have multiple comorbidities or multiple questions. You're kind of stuck.

Often the patient education element of that whole equation dropped off just because the treatments and the activities took up time and took up a big part of that isolated patient encounter in a clinic or at the bedside.  So as I got experience over time, I said, “There's got to be a better way to tweak that and sort of stretch that clinical education with the patients beyond that,” and pediatrics was the best way to do it because it's children's books, it's storytelling. It totally makes sense to them.

The health literacy issue was huge among adult patients as well as with kids so I just happened to say, “Let me just look at pediatric patient care and use the books as engagement tools,” and that's what we're doing. We're trying to measure the effectiveness of that inpatient education outside of the office setting. I've been presenting posters and other qualitative research data on that to show that there's a change in knowledge and a longitudinal change in behavior, which is what we want to do with the patients. 

DR. RISHI DESAI: Ken, I'm a pediatrician, and also, you may not know, a dad of a three-year-old, so I'm really excited to read Grace Fights COVID-19 to Skyler. Do you mind just sharing what the story is about and any sort of even anecdotal feedback you've gotten from parents and kids?

KEN KORBER: That's what drove it all. I have Musical Adventures of Grace as a commercial little story series. Winter, spring, summer, and the spin-off stories came from those original characters. There are about 11 characters in total. My thought was, “How do I bridge my career of 20 something years with this newfound notion of being a children's book author in the world of children's books where 5,000 are made every year, either self-published or through traditional publishers?” 

I thought that maybe this patient encounter extension or stretching that encounter would be the way to do it, so I reached out to some of my commercial Musical Adventure readers and parents, and just asked for feedback in terms of what was happening in their worlds in this March, April, May period, where we have this huge pandemic, this new normal, this change in social behavior that is unprecedented. 

A lot of them were expressing anxiety to me about, “How can I adequately explain coronavirus to the youngest member of the family, to a two or three-year-old. How do I explain to them that they can't see their friends? How do I explain to them that they can't go outside, that they have to wear a mask, that they're not going to school, that mommy and daddy are always around now?

Those were sorts of real practical anxiety-inducing triggers for parents, and I said, “We got it.” and I looked around for resources. I said, “What's out there for COVID from that perspective.” In March, I found nothing, and I said, “Let's use my characters and present a little COVID story to the kids to make it resonate with them so that they're not living in a world with all these question marks running around their heads.” It gave parents a tool, an initial tool, to start that conversation, or at least to trigger an ability to answer questions that the kids will come up with, that they ask every day. 

I was fortunate, so we pulled together CDC data and information and went back in March to talk about the basic things like how to wash your hands, why people are wearing masks around you and what a coronavirus looks like, as a coloring picture in the book to just get them a little more comfortable with the whole idea of this coronavirus and COVID-19 infections and all that stuff without it being overwhelming and fear-inducing within the kids. I wanted to make it a fun-filled activity, as best as you could with this disease process.

It became an activity book - - the importance of handwashing, what a germ is, something basic like how parents explain what a virus to them is, what social distancing means. If you put your arms up and turn around, that's six feet between you and the next person, little things like that to make it relevant to them as an audience, and yet also reinforce the social behaviors that have to be done, just for safety sake.

That's what the book became, an activity book. I give it away with grants that I have from either industry or education associations, and we just make it available in doctor's waiting rooms. We're giving it to teachers if they want to use that as part of their curriculum in the fall. That's where it's going. It's a good thing.

DR. RISHI DESAI: This initiative strikes me as being very similar in purpose as the Reach Out and Read movement. I believe the Bush Foundation was a huge supporter of this as well, right? 

KEN KORBER: Right. We actually got a nice letter from Michelle Obama when they were in office about these books. It was just another way to induce exercise in kids in a way that was so relevant. Plus, the win for me is that, even if they hate the characters or they don't like the story subjects, I'm helping them learn to read, which is kind of a win-win. 

We're trying to help them be good citizens, and if we can get music to them, vocabulary and health promotion messages on top of that, that's a triple win for us, so we're trying to create these little health ambassadors within their families, and I'll see how we can reinforce that as time goes by.

DR. RISHI DESAI: I think that's a really beautiful way of phrasing it, “Creating little health ambassadors," because, right now, we have a lot of challenges around masks and the challenge around vaccines is around the corner with COVID at least. We know that there's a huge anti-vaxxer movement because of the concern around the science and the real base of scientific literacy that we have in America and in many parts of the world as well. I think that makes perfect sense.

KEN KORBER: We're very careful about being apolitical for the whole thing. I haven't gotten into the anti-vaxxer stuff too much, but we do explain what a vaccine is in the COVID book, just very basic so that they're not afraid of needles and all that stuff.

DR. RISHI DESAI: It strikes me that this is foundational, though. This whole idea of creating fine foundational appreciation if nothing else for both literacy and science seems really, really cool, and being led by someone from your background is even cooler.

KEN KORBER: It was fun to be able to find that bridge between my current life and my previous world. Just to give you another generic example, we have a toothbrushing book that has a jingle on it that plays music for two minutes. They know to brush their teeth until the music stops, and then they read about Grace and her friends and the biggest tooth contest as part of the bedtime story activity, so it's bedtime brushing together. 

We're going to do dietary stuff with a chef in Sweden. We're going to work on a book together and do clean cooking for kids of all ages. That's a whole other thing. We were doing a low-salt book to showcase the DASH diet, those kinds of things. So anything that's pediatric is fair game in terms of trying to not dumb it down but make it relevant to that audience as a reading group, emerging reader group.

DR. RISHI DESAI:  That's really interesting. I'm so captivated by what you said about little health ambassadors now. Have you heard stories about the little health ambassadors telling mom or dad about healthy behaviors? In my generation— I'm 10 years after you in terms of when I trained so now it’s 20 years out -  but one of the things that was not known was around plastics and cooking your foods, and certain things were not really appreciated. Now you see “BPA-free” everywhere, and I get that sort of feedback from my three-year-old.  Have you heard little anecdotes around brushing your teeth, diet, clean food, all those other things you just mentioned?

KEN KORBER: We did a little subset project with about 138 elementary school kids, kindergarten and first-grade kids. We gave them low-salt diets focused on the Hmong population among children who came from Southeast Asia to the United States. We knew that that population was predisposed to high blood pressure versus the general population. We didn't get into the genetics of it or any of that stuff, but we knew that if we could influence their dietary choice of the amount of salt that they used in their day to day lives, that would be helpful. So we had the teachers teach that through a story about Melody in the classroom, and then they had homework assignments to come back, like a month later, with what salt substitutes the family was able to use just to cut back on how much sodium intake they were doing because like everyone else, we all eat junk food, so this was just a way to target that behavior change. 

We found out that prior to the reading sessions, the kids thought salt was good because it helped make food taste good, something as simple as that. But then we did a follow up survey after they went through their reading sessions and all of a sudden, they learned that too much salt is maybe not a good thing for my body and too much salt is not healthy, and those kinds of switches in terms of knowledge gained. Then the thought was, “Okay, let's take that knowledge gained as these little health ambassadors for their families and see how they can implement it in the home setting and change behavior at the kitchen table through recipe switches.”

We gave them the DASH diet resources and plugged them into that. The thinking is then, a year later, we're going to see if there’s been a change. I don't know how much of a clinical lab intervention we'll be able to manage, but certainly from a knowledge and behavioral thinking of ‘what are you doing now at home’ and almost like a best practice for these little kids in their families.

We definitely want to make them champions because the adults are a lost cause where we're managing the complications of the disease process with the adults. It's much smarter from a health policy perspective to spur change amongst the kids before they get to a point where they're going down that slippery slope of cardiovascular disease. 

DR. RISHI DESAI: My parents and my son obviously represent different generations. When I tell my parents to do X, Y, or Z, it doesn't happen. When my three-year-old tells them, believe it or not, it happens. For example, he’ll talk about cane sugar and limiting the amount of cane sugar, and that phrase now sticks, and my mom talks about it.

I'm like, “Wait, that was from Skyler.” So I totally love your approach. It's so beautiful and elegant.  Have you gotten a lot of feedback or do you sense that NPs, Family Practice PAs, are they also on board with the idea of using these children's books and children as change agents? Does that seem like it resonates, or do you feel like that's still maybe a few years out before that becomes more mainstream?

KEN KORBER:  I think it's a few years out. What we do though to set the table for that, is we offer them copies of the books and just throw them in the waiting room, just leave them there, passively, for your patients. If there's an interest, the next level then is to say, “Okay, let's create a poster that they can put in the exam room, right over the exam table, and say, “Hey, did you read about Melody and her salt story? Did you read about Maestro Vik and his toothbrushing, conducting orchestra story?” If not, they can use that character as a way to initiate a conversation. For right now, it's early stage knowledge advancement. The behavioral stuff is going to take a while before we get the big cohorts for that.

DR. RISHI DESAI: I'd like just to ask this question to you. We're always thinking about ways that we can raise the line of healthcare capacity, not just now but in the future, and you’re in this beautiful crossroads of both having one foot in the world of PAs as well as NPs, so you understand that so well.

What are some things you'd tell current students that are training to become NPs or PAs about how they can be most effective -  not just in the short term with COVID-19 - but even long-term as we need to scale up our healthcare capacity as a country?

KEN KORBER: From the primary care point of view, it's always the whole patient, whole family, whole community -- the holistic attack on sort of the continuum of care.  So the whole patient-centered care, the patient-centered medical homes, the neighborhoods, that stuff. We continually try to reinforce that as part of the team's care. They don't have to be the one source of care or information, so the burden is not on them per se. When they get out there, it's important to use your colleagues and tap into their expertise. 

The football analogy is always a good one. The doctor is the quarterback, but you need wide receivers and you need running backs to score the touchdown. That's a nice visual for them to understand that it's not all about them. It's more about the team. And don't forget the patient. When you don't forget the patient, then you get into the whole disparities of care thing, the comorbidity thing, the social drivers of challenges.

You can become as active as you want in your community. In the back of your mind, you're thinking about Mrs. Jones, who's an African-American female with diabetes versus Mr. Smith, who is a 62-year-old white patient. They may have a totally different scenario in terms of successful management. That comes with the training, and that comes with experience and sort of what you're looking at as optimal care. That's what it boils down to.

DR. RISHI DESAI: That's awesome. I think for so long, the patient has been a spectator in the stands, to carry out your analogy. Maybe, at some point soon, they might become the quarterback managing their healthcare team, as you said. 

Ken, thank you so much for joining us. I really appreciate you taking the time to be with us. I'm Rishi Desai. Thanks for checking out today's show, and remember to do your part to flatten the curve and raise the line. We'll see you next time.