Next, it's my pleasure to introduce Sarah Enslin. Sarah Enslin is a physician assistant at University of Rochester Medical Center. She received her degree from Rochester Institute of Technology and has over 10 years of experience as a practicing PA and GI. She is the advanced practice provider manager for the university medicine service line and co-lead advanced practice provider for the division of gastroenterology and hepatology. In addition to her administrative responsibilities, she has a very busy clinical practice with a special interest in pancreatic, pancreatic ovarian disease and GI oncology. She routinely lectures at the Rochester Institute of Technology physician assistant program and is a preceptor for APP students from four colleges and universities. Sarah is a member of the ASGE practice operations committee and section editor for advanced practice providers for ASGE's newest journal, IGIE, which you will hear more about later. Sarah, the audience is yours. Thank you, Jill, for that warm introduction. I'm really excited to be here today and I'm thrilled to be able to start the day of my presentations with this one, one of my favorite topics, optimizing the role of APPs and clinical practice. And that's really to say, how do we do what we do to the best of our ability to the top of our license and with the most impact for patient care? And so for the next 20 minutes or so, I'm really going to talk about the background and national landscape of APP practices, roles of APPs and GI practice. What are some of the optimal or suggested onboarding processes? And then look at what are the goals and some challenges of enhancing the APP role. And finally, we can look at some strategies. So why is this topic so important? I always like to start with this. I think this is a really important thing for us to highlight and to remember, US News and World Report, best jobs, number two in 2023 was nurse practitioner, number four was physician assistant, and both have been in the top five for the last several years. Also importantly to know is the US Bureau of Labor Statistics projected growth. So from 2021 to 2031, we're looking at a growth of PAs by 28% and nurse practitioners by 40%. And what are some of those drivers for growth? Two things that I think are really important for us to recognize. There's definitely an increased demand for services. There's a greater number of insured patients. We do have an aging population and these patients have multiple comorbidities. There are new therapies, procedures, and medications. And then there's also the physician shortage. And so by 2028, one third of physicians in the United States are estimated to be 65 years of age or older. And the estimates for the physician shortages are up to 124,000 physicians by 2034. And that number really has accelerated after the COVID pandemic. Nurse practitioners, state practice environment in 2023 is shown in this. And this is also something that is rapidly changing. And what I really want to highlight in this is that there's a difference in state practices. And that goes for both nurse practitioners and PAs. But I think it's important to acknowledge the differences. And when we talk about optimizing our role, it does look a little bit different depending on what our state regulations are. This was an article in Gastroenterology and Endoscopy News for the APP Corner that I just wanted to highlight. It really took a minute to do a Q&A with some of our top physician and APP leaders around the country. And it goes through incorporation and use of advanced practice providers, some of the onboarding mentorship and collaboration, research opportunities, leadership opportunities, and then finally national society involvement. And the link is there if anybody's interested in reading it in detail. And breaking it down a little bit further, the NCCPA publishes every year kind of a breakdown of PAs and their specialty practice areas. And so GI actually went down a little bit. 1.6% of PAs are in this workforce. And so let's take a step back and say, in clinical practice, what is the role of APPs? What should we be doing? And I broke that up into three areas. And this is obviously really kind of generalizing things. But clinical assessment, we just heard about creating a quality GI note, new patient consults and follow-up visits, acute and chronic complaints, interpretation of results, the labs, the imaging, the pathology, that development of assessment and plan. Pre-procedure support and post-procedure support are also really big roles of APPs in GI practice. And so from a pre-procedure standpoint, it's the patient education, informed consent, pre-procedure testing and labs, anticoagulation management, optimization of patient's comorbidities. And that might be working with ancillary services like cardiopulmonary, collaboration with the primary care physician, post-procedure, you know, those discharge prescriptions can be a big thing. I always think about my patients who have had Barrett's esophagus undergoing ablation and they need their post-procedure pain medications or people who, you know, come in with significant esophagitis and you have to make sure that they're getting what they need. I mean, that includes following up on prior authorizations and making sure that there's not barriers to them being able to get them. Education can be a really big one. I put it under post-procedure support, but really that falls in every category. Post-procedure phone calls and visits, interdisciplinary care coordination. So are we referring them to somebody else? Are we managing them in coordination with oncology or allergy and rheumatology or pulmonary? And then recognition of complications. One of the big things that we always talk about when we're onboarding new APPs to our practice is how do we recognize when you're calling a patient after a procedure, what could be a potential complication and what intervention can we do early? What do delayed complications look like? What are the things we should be asking patients to try to recognize those? And then I mentioned earlier that really our practice varies a lot depending on state. It also varies depending on your GI practice or institutional needs. And so a few different models, and there may be some hybrids of these as well. But the first one on the very far left is the physician-led collaborative model. And so that's when a patient comes in, their new patient visit is done with the physician, and then the physician will have them follow up with the advanced practice provider. In an APP-led collaborative model, the patient will come in, have the new patient visit with the APP, and then the APP may have them follow up with the physician as needed. And that could be at a set interval. Some practices will say the physician will see them once a year and the APP will follow them otherwise. More often though, it would be depending on complexity. If they need to see a physician for a specialty reason, concern, question, something like that. And then there's the shared visit collaborative practice model, where the APP and the physician will see the patient together as that initial visit, and then follow-ups could either be shared visits with the APP alone or with the physician alone. As a new APP coming into a GI practice, onboarding is something that should not be under-emphasized or something that should be breezed through. It really should take the time to look at it. And so, a few things that we think about, you know, it's more than just bringing somebody into the practice and getting them what they need resource-wise. Introduction to the team is a really big part of somebody joining a practice and feeling like they are welcome and part of that team. And so, that includes not only the APPs and the physicians, but it also should be the secretarial, the front desk staff, the administrative team, if there's fellows, including an introduction to them, certainly any of the physicians. I think that that is an important part of being able to say who is who and how do we find them and what is it like to function as a member of this team. EMR training is another big one. It's easy to say you have to take these three classes and then off and running, but we all know there's a lot of nuances to EMR. There's also a lot of really great things if we know that they exist. And so, are there additional training classes or do you have people who help with the optimization of it? So, think of, you know, your smart phrase or your note template creation. An introduction to office policies and procedures is also really important, and that could be more of your kind of human resources stuff. What if you have to call in sick? Do you submit a time card? Kind of those policies and procedures, but then also what do we do for patients who need a procedure? Where do they get the procedure instructions from? What do those procedure instructions look like? Physician mentorship is a really important part. We build this into our orientation, so our APPs will have dedicated office time that is not necessarily in the clinic to sit down with the physicians on a weekly basis. Over time, it does tend to become monthly, but the importance of it is to sit down and be able to have those discussions to review patients, to review results, and start to really establish that collaborative relationship. Shadowing other services has been another thing that's really helpful. And so, if you, depending on your GI practice, if you're subspecialized, you may have only certain ones you want to go to, but as a general GIPA or NP, going to interventional radiology, colorectal surgery, surgical oncology, thoracic surgery, pulmonary, allergy and immunology, they all really work very closely with us. And so, by going and actually shadowing with them, you establish relationships, you now have a point person, you have somebody you can talk to. Also, it gives you the patient perspective. A lot of what we do, if we take a step back and we think about it, what is the patient's interpretation? What's their impression? What are they going through? What's their experience? So, if we've been there, we've seen their office, we know how they run. We can speak a little bit more to that, and that does tend to alleviate some of their concerns. Competency evaluations, for better or worse, is a really important part, not only of our orientation process, but also our ongoing professional development. And so, this is, are you meeting requirements? But I think it's also an opportunity to step back and say, what do you want to do next? What's your career development pathway? And then educational resources. And this may be something like, how do you find National Society guidelines? It also could be, is there a library that's available to you? Do you have access to up-to-date and PubMed? How do we utilize these search tools? And setting expectations is really important in everything we do, but particularly for somebody who is a new APP and new to GI. And so, this is just an example of what we do at the University of Rochester. We have it broken down by week for the first 8 to 12 weeks, and then it goes a little bit longer after that. And so, just a snip of it, I didn't do the whole thing, And so, just a snip of it, I didn't do the whole thing, but really our goal is that we set the expectation for how many patient notes are you starting to write? And then we also talk about, you know, start to do your epic templates. Let's talk about anemia. And so, when we talk about anemia, our goal for that is that they're going to do some reading on their own. And we introduce this on a Monday. So, come Thursday or Friday, you can sit down and say, let's talk about a patient who's coming in and give them a situation and how would we work that up? And then it goes further to say, okay, so they had fecal occult stool that was positive. Their endoscopy and colonoscopy were unremarkable. What are we going to do next? When do we do patency capsules? What does that mean? What's the process for ordering it? Does this patient qualify for a double balloon? What's a contraindication to double balloons? So, it gives us an opportunity to really sit down and have these discussions. And then the ramp up period also, you know, when we look at clinic schedules, what are those clearly defined expectations? How many patients per week? And when do we expect you to be at a full schedule? There are times that you are going to want to adjust it. So, some people progress faster, some slower. So, you may have to go back and forth a little bit on it, but it gives you an overall understanding of where I expect them to be, and this way they know well ahead of time. The other thing that some places will do is they'll pull out specific diagnoses. So, starting from the beginning, if you look at a patient who is coming in with GERD, you might say, let's do GERD one week. Let's do GERD and constipation week two. Let's do GERD, constipation, and diarrhea week three. Depends on the practice for them. And then do they need that subspecialty or sub-subspecialty training? And what's the best way to give them those resources? Other topics and activities that can be done during this onboarding process, in-basket management is a really big one. I think this is one that we personally have struggled with at times because it's so unpredictable, right? You don't know what phone calls are going to come in on what day, or what MyChart messages are going to come in, or the referrals that you're reviewing are going to vary. And so, this is something that I think is really important. And being able to give somebody who's coming in as a new APP to GI, whether they're an experienced provider or not, the tools to be able to manage the variety of tests that come across our basket. Again, physician collaboration is really important. I think procedure observation is helpful, both from that patient experience standpoint, but also to have a better understanding of what the patient's going through, and then be able to take that and correlate that into, what do I need to think about my patients calling me post-procedure with issues? It's also an introduction to your endoscopy unit team. Guideline review is great. I think picking a guideline and knowing where to find them. I tell everybody, I don't expect you to memorize them all, but you should know what exists and you should know where you can find them so that you can continue to review them. Unit policies and procedures, like we talked about, important to know how the place flows. Pre-procedure patient preparation, that may be like checking labs. Are they in a quaggable state? Do you need to manage them for some reason? Are your serotics, do they have a high INR or low platelets that would preclude a procedure? The optimization training for EMR, and then again, the reimbursement and compliance training. There are GI hepatology APP fellowships available. There's only a couple. There's provider specialty education and training. They typically have a combination of didactic learning, research, clinical inpatient and outpatient training. There are actually four 12-month postgraduate GI fellowship programs now. There's John Hopkins Swedish Medical Male Clinic in University of Colorado. Then the AASLD also does offer a hepatology fellowship program too. You have an APP who comes in and they've been onboarded. Now what's next? This could be somebody who has been there for six months. This could be somebody who's been there for two years or five years or 10 years. What are the things we can do to continue to optimize our position and to work towards that career advancement? The first thing that I always come back to is that patient care. You want to increase the access to care. You want to increase patient satisfaction, referring provider satisfaction, and quality outcomes. Bringing an APP in and really focusing on what can we bring to that practice. Secondly is that collaborative practice. That APP physician relationship, the shared patient management. Reimbursement is important. Multiple ways you can go about this though. There's the independent billing by the APP. There's the ability to maximize physician endoscopy time by having the APP in clinic more or offloading some of those in-basket tasks so the physician can focus on the procedures. The team-based value-based reimbursement, which I know Jill will get into more later today. From a professional development standpoint, how do we help our APPs give them the resources they need to acquire new skills? Another thing is to increase the complexity of the patient population that they're seeing over time. Leadership roles is another great one. The ability to perform or interpret procedures, participation in research, and then education. Education can be onboarding new APPs. It also could be your APP students. All of this ultimately, you're looking to improve retention. We want the job satisfaction, the professional growth, those opportunities for advancement, and the sense that you belong to a team. I just listed a few. I'm sure that there are more of these as well. If you're doing any procedures, that'd be interesting. Feel free to put them in the chat if there's something that I'm missing. There are a lot of different things that we could do. Again, a lot of it's going to depend on your institution and your state and your licensure. A few ones would be the large volume paracentesis, percutaneous liver biopsy, fibro scans, motility, either performing or interpreting. Quite a few people do high-resolution anoscopy and hemorrhoid therapy. Could do gastrostomy tube replacements, nasogastric feeding tube placements or replacements. Then some APPs are doing endoscopic procedures. Compensation structures is always a little bit of a tricky one. A few ways that you can look at it. There are salary-based models. There are models that have a salary plus a bonus. Then there are some APPs who are paid strictly on productivity. That's looking at your work RVUs. I think it's tricky for this reason. There was a study that showed that over 30% of the work that's completed by APPs at a tertiary academic medical center did not generate RVUs. That's things like your specialty patient education, care coordination, medication refills, procedural counseling, telephone, and electronic patient messages. Although some of those are not being charged, I know by some academic centers, research, teaching, and the administrative and leadership positions. How do we benchmark what APP productivity and work effort is? So how do we benchmark what APP productivity and work effort is? That can definitely be challenging, something that we have to acknowledge and be a little bit creative if you're going to do a productivity-based structure. It all sounds great, but we have to acknowledge there's also some challenges in optimizing the role of the APP. And so a few things that come to mind, misunderstanding or lack of awareness of the scope of practice of APPs. It varies widely, but also changes. So it can be hard to keep up with those changes and to know that we're constantly optimizing our role and utilizing our license to the top of its ability. Lack of specialization training can also be a barrier. You know, we come in and a lot of what we learn in specialty positions are on the job. It can be hard to accurately quantify total reimbursement work effort, buy-in from physician partners and administration for expanding roles and fair compensation. And I do think this has been improving across the board over the last several years, and then managing patient expectations and the acceptance of that enhanced APP role. And I thought this was interesting. This was the NCCPA 2021. They do a patient survey. And so it was looking at the expectations from a four-year time period and kind of comparing what does the patient think that PAs do? And so most of the patients know that PAs can do a history and examine patients about 80%. Still seems a little bit low, but if you go down about halfway down for PAs can prescribe medications, just over half of patients knew that PAs can prescribe medications and just over half know that PAs can do treatment plans. And if you look at other medical tasks, the very last one, like drying blood, removing sutures, changing dressings, only 30%. And so not only do we have the expectations of our colleagues, but really it's making sure that we're also continuing to educate patients. And I think a lot of that can come from that team-based approach. So if you're working closely with a physician and they're seeing a patient in the office to be able to say, I'm going to have you see my colleague. Sarah Ancelin's a PA. We've worked together a long time. She's going to see you. She will develop a management plan. She'll touch base with me as needed. And kind of that handoff will help to, I think, increase the patient knowledge and the patient understanding and their acceptance. And then a few strategies. And so if we break this up into who we're targeting, institution health systems can look at the state and license regulations. And we'll talk about it a little bit later today, but this is where having a dedicated leadership team is really important. Having an organized structure, leadership support, support for educational initiatives, wellness and burnout prevention initiatives, opportunities for advancement, and then fair compensation. And from a division or a practice contribution, regular meetings with leadership, quarterly reviews, setting and then reevaluating the RVU targets or some kind of productivity metric, identifying and remedying any barriers to productivity, and then that open and transparent communication. And our collaborating physicians are oftentimes our mentors, and they are the ones that are really going to bat for us. And so being able to clearly identify what your structure is, having accessibility to the physicians, troubleshooting issues, complications, and adverse events together, and that shared decision-making and that shared workload. And so a few practice pearls as we wrap up. Effective APP onboarding programs are essential for successful integration into GI practices. And that's your clinical education, endoscopy procedures, intro to health systems, and EMR training. Optimizing the role of APPs helps with increasing your access to care, patient and referring provider satisfaction, maximizing your reimbursement, and increasing physician endoscopy time. APP compensation models can help with physician endoscopy time. APP compensation models should account for non-RVU generating work. This is important for patient care, it's important for provider satisfaction and success, and that's both APPs and physicians. And so that's the time that you spend in that specialty patient education, your phone calls, your electronic messaging, prior authorizations, if you're doing a lot of peer-to-peers or appeals, your teaching, research, and scholarly work should also be accounted for. And then using APPs to the extent of their scope of practice leads to not only improved efficiency, but also that higher job satisfaction retention. And so I have a couple polling questions. Optimizing the role of APPs helps to achieve all of the following except. There's only one right answer this time. Perfect. Yeah, so optimizing the role of the APPs ideally is going to increase access to care because you are opening up spots to be able to see patients in clinic, whether they're new follow-ups or both. It should reduce burnout if we're doing that team-based model well. We're taking that load off the physicians, but we're doing it in a team-based manner, so they are sharing the workload. Looking to increase operational efficiency and professional satisfaction. Hopefully, the providers are more satisfied with this, and if they're not, then it's probably time to take a step back and reevaluate what we can do differently. So opportunities for professional development include which of the following? Leadership roles, participation in clinical research, case reports, and case series, or all of the above? Leadership roles, participation in clinical research, case reports, and case series, or all of the above? Oh, you guys are making me look good today. That's right. It is all of the above. And with that, I will hand it back to Jill.

physician assistant

advanced practice providers

gastroenterology

collaborative practice

professional development

patient care