Our first question we're going to direct to Dr. Vicari. Dr. Vicari, can you comment on the new ability for patients to view their own notes and how this will alter our note writing? I'm finding it frustrating when patients read the notes and send me messages saying things like it didn't say XYZ or you wrote this wrong. Any thoughts there? Yeah, it's actually, it's an outstanding question. I think as it relates to our note writing, I think if, as you've heard this morning, high quality, write a high quality note, put the facts in the note, be a good listener when you're listening to the patient. All you can do is write a good, accurate note. If I really had the answer to how to stop this, I think we could all share in the wealth and become rich. But patients don't always remember what they said to you. They don't remember the conversations. And so I think we're going to have to accept that we're going to get these messages. When you respond, respond with respect and kindness. Even though you may be right, it is not that time to prove that you're right. But I don't know how we can completely avoid it other than to do really good work, except that many times they are incorrect in their memory of the event. And for now, perhaps AI as we go forward may help with some of this, but there's really no way to prevent it. Any comments from other panelists on that? Yeah, I think I totally agree that it's a nuanced thing, Joe. It's challenging because I think we used to think of writing the note as being writing to a clinical audience of other providers and associates. Now we're also writing to the patient. And so we have to be exceptionally careful, I think, about how we write things, verbalize things. Word choice is important. The phraseology is important because it has to be acceptable to everyone. And it's a perpetual document and can even be accessed outside your institution at will. There's actually been some discussions that we should be writing in a language that's more understandable for patients. So I think this is a nuance that's going to be new for all of us, especially experienced clinicians. Yeah, I was just going to say, wise counsel from Drs. Vicari and Martin. I think my two cents, if the visit, and increasingly they are, or at least most of the time they are telemedicine visits, but especially for in-person visits, I think the quality of the visit, the trust, the empathy, the relationship that is established in the in-person visit goes a long way in mitigating any concerns that the patient has or will have. I think if the visit is contentious or if they feel that the visit is not, you weren't totally into their issues. And then on top of that, the language is not diligent, then that is a recipe. Now, since open notes and digital messaging came into our practice some time back, there was a huge concern around the same lines. But I must say, and Sarah can comment, because I don't see every last complaint. Sarah is very good at deflecting a lot of the stuff. But I don't think we've seen the tsunami of issues that we had originally anticipated. And I think the team from Wisconsin that came with that taught us about this were right. I think the data also suggests that there is not a huge swell of issues. But I do believe that the visit itself sets the stage for a positive outcome. So we have a question here. And Jill, I know you're the moderator for this session, but it seems right to start with you on this one. This person writes, I know there were some recent changes and reimbursement for inpatient charting. Does that affect inpatient consultation notes as well? So they're transitioning to eliminate consultation notes, the actual product, the CPT codes. But you still are utilizing the inpatient initial visit and the follow visits, so the subsequent visits. So those CPT codes are still in place. So those haven't changed. And our next question is, do your APPs, we'll direct this one to Dr. Call. Do your APPs ever receive a bonus based on RVU? How do you feel about RVU versus salary for APPs? How come the payment model is so different for MDs than APPs? And this person in particular loved what you said, you can only live so long on fresh air and love. Yes, I am one of the few people that I have the privilege of receiving some advice. Most people don't want to talk to me anymore. But this one gentleman, you know, he told me this almost two decades ago, and he says, you know, it's very difficult to just, you know, talk is good, but you got to walk the walk. An institution needs to be able to walk the walk. Elizabeth Evans asked this question, and we are grateful for her attendance today. Thanks, Elizabeth, for asking this question. As Sarah will tell you, I've been a big champion of, you know, right sizing the monetary compensation for our team. Now, the practice setting will dictate what type of models are there. In the university setting, typically, and Sarah can connect me is we do not have a structured incentive model, I would be the first person to support the Dean if this went this way. But there certainly should be a consideration for that. The flip side of that is remember that every time there's an incentive model, it does, the carrot does come with a little bit of a stick, there is a target that you got to meet. And then, you know, there's a sort of a competition to meet or exceed that target. If you don't meet it, there's some disappointment on both sides. So approach the concept of incentives very cautiously. And the Mayo Clinic has done a great job with it. They have kept the incentive portion of any leadership role or anything else to do and John can comment on it to a relative minimum, whereas the motivation for work is not necessarily the money. But I do understand the concept. It shouldn't be too much different for physicians and APPs, I don't think in the modern era of medicine, but we don't have it yet. But I think some form of intelligent, balanced incentive structure should be there in place. Yeah, I'll just add, I know that there are many places, particularly private practices that do this really well. I think one of the challenges, especially in large institutions, is really having that dedicated structure and that workflow. And so if you are utilizing APPs as primarily providers and less of that in basket and kind of clinical but not provider-related work, it's probably a little bit easier to have an incentive-based structure. And so as we look to really build those resources now, right, as the APP roles are growing and becoming more defined, I think role clarity and really being able to build up resources behind them, such as clinic nurses or care coordinators, you might be able to build an incentive model a little bit easier or a little bit more clearly. I think it probably is something that is going to, we'll see more and more as time goes on. It's going to be important in the future, but right now, many academic centers struggle with quantifying an APP work. I would also add that incentive comes in many ways, time, support, CME funding, opportunity to do other things and just see patients. So I should have mentioned that up front, but I personally look at incentive, you know, and after two decades in the business, I feel if I just get more time, that's worth more than money to me. So keep that in mind early on. We have a few questions coming in on that note of time. And so the questions really are, well, there's twofold. Do we have data on how many patients APPs are seeing during the day? And this person is specifically asking outpatients. And then we have a couple of people asking, do you have a recommendation for visit time for new versus follow-up patients? And would that depend on the diagnosis, examples being new IBD or cirrhosis? Who would you like to answer that, Jill? Sarah, would you like to go ahead and start? And I can add some color from my clinical practice when I hear from other colleagues. Yeah. So maybe we can even go around and kind of say what we're doing, because I do think that this varies quite a bit. In part, I think it depends if you're in a subsub specialty versus general GI, are you seeing new patients and follow-ups or a mixture? What's the goals of your clinic? And so I can tell you at our institution, we have made new patients and follow-ups the same length. And the reason that we've done that is for multiple different reasons, but one of the big ones was if a patient cancels a follow-up visit, you couldn't put a new patient in there because the slot wasn't long enough. And so we found that it averages itself out by making them the same length. If somebody cancels last minute, we can get that urgent new patient in without really stressing our group too much. And so our utilization actually has increased quite a bit for that reason. So I think that the number of patients people are seeing really does vary, probably somewhere between eight and 14 and a half day session would be my best estimate. Sarah, can I just jump in real quickly? Are you working at the same place of service the whole time? We have another question from a person who's kind of rushing between settings between the clinic and the hospital. Yeah, that's a great question. So in my role, I am in different office buildings, potentially moving halfway through the day, but still on the ambulatory service. There are definitely many roles where they're a hybrid, where they do a portion of outpatient scheduled visits and inpatient. And then there's some people who are inpatient only. There are also some APP roles where they're designated to be inpatient on certain days and then outpatient on certain days. And so we can see a variety of that. There are definitely challenges if you're somebody who's going back and forth, whether it's between two different locations with scheduled visits, or if you're going inpatient and outpatient and really being able to manage that time. And I think those are important times to have those conversations with leadership, with what's working, what's not working, how can we adjust templates to make it so that it's a little bit more feasible and manageable. I was going to say from a generalist GI perspective, my template is 30 minutes, similar with Sarah across the board. So whether it's a follow-up visit or a new consultation, and approximately it's going to be between 15 and 17 patients per day. Sometimes you may add a patient in at lunchtime in case there is a portal message that I really want to spend some time talking to the patient. So I've really transitioned my practice to try to add those portal messages in a visit to give better satisfaction to patients and to myself too, to know that I'm actually providing better, more comprehensive care to patients. So I think that that's been more well-rounded as far as my practice that I've seen to transition. I'd be interested to hear from Andrea. Andrea, you're in a subspecialty area, which is becoming much more commonplace that you see advanced practice providers really taking that generalist role and then transitioning into a subspecialty. So share your experiences with the audience. Sure. Yeah. So here at Mayo Clinic, we have a number of NPs and PAs within our GI practice, and all are actually very subspecialized. So we have those that are exclusively in IBD, exclusively the esophageal clinic, and I, of course, am in the liver clinic. And our consults are typically, we'll have an hour for a new visit and then 40 minutes for a follow-up or return visit. So total through the day, probably eight to 12, maybe a very busy day would be 14. If we're on procedures, meaning fibro scans, of course, we do a number of those for half days, and that may be six to eight. But we have community-based NPs and PAs for our regional Mayo practices that are seeing more general indications and might see more patients than that just based on, again, complexity. I attended liver connect over this past weekend and listened to a PA who was in a practice where they were actually seeing 30 liver patients a day, which I've never heard of that many. That seems unsustainable in my mind, but I'm very grateful for the hour for new consults and 40 minutes for an annual visit, so. And just to keep in mind, keep those questions coming in, folks. If we don't answer them live, we do have, our panelists are typing in answers as well. Just want to follow up with our APPs on this. Have you found a method to navigate any disconnect from the front staff schedulers with achieving balance and workflow in what you're doing? Just to round out our discussion there. Sarah, did you want to start us or? Yeah, so I guess I'm not entirely clear on what they're looking for with the balance aspect. Is it balancing the clinic template or balance and making sure things are getting scheduled? I don't know if you have any- Yeah, I think Sarah, you're an expert in this area, right? Because post pandemic, there's obviously a lot of turbulence in the staffing in the front desk activity across all practice settings. So I think the question here is, you have planned a day a certain way and based on scheduling or other issues, it ends up being a different type of a morning for you. How do you handle that? I think that's my take on that question. Either on the over, like double booked, triple booked or having open slots, both sides. Yeah, so I think the big thing when anything changes in my mind is always communication. And so if you end up in a situation where all of a sudden you are double booked, or even if a patient just comes super late, and now you have multiple people who are roomed at the same time, just popping your head in and letting them know, I know you're here. I'm with the next patient. I'll be there soon. I think that communication is really important. I also think that follow-up communication with the front desk staff is important. And so we, like Dr. Call was saying, have had a lot of turnover recently and have some difficulty with staffing. And so particularly when it's new people who maybe don't know me or in my practice style, to be able to then follow up with them at the end of the clinic and say, hey, what happened? I saw that this is what went on. We were able to work through it, but make sure you let me know next time if a patient is checking in late so we can set expectations for that patient. Or what if I wasn't available at the time? We have to have that communication back and forth. What's the best way to communicate? Is it that I want you to page me or text me, or do you want to just pop your head back and find me? And I think really establishing kind of those expectations together can be really helpful. Everything changes, unfortunately. A lot of it is at least to some degree out of our hands. And so being able to be flexible and really focus on, at the end of the day, our goal is patient care. And so if there's a way to see that patient, particularly if they're already there in front of you, we want to. If patients fall off, then it's an opportunity. So you can either go to your colleagues and say, hey, I'm free. All of a sudden I have all these no-shows or cancellations. Can I help you? Are you behind? What do you need? Or catch up on the in-baskets, pop down and see procedures if you can do that. I think there's a lot of things we can do to fill our time. It's usually the other end of things that can be a little bit more challenging. Absolutely. Well answered. And communication and strict oversight of your schedule and not be overemphasized. The ultimate message here is when you have a lemon, make lemonade. That's the message. And I think it's a better day. I think that the lemonade that I've made in our office that I want to share is I've actually had a Lunch and Learns and just sat with the front office staff, just blocked out 15 minutes just to go over them what the role of the advanced practice provider is. Because we're getting new staff and turnover as well. So just educating them on what we can do and what our capabilities are and just remind them to communicate with us. If they ever have a question about a clinical patient, then they can feel freely to come to us directly. And that's made a world of difference in our clinic, having that open dialogue. And if you have 15 minutes, 20 minutes and the patient fell off, go grab those endoscopy pictures for your case report that you're writing. Wonderful discussion. We're coming to our morning break, Jill. Shall we reconvene at 1045 a.m. Central Time? That sounds great, Eden. Eden, thank you very much. And thank you, everyone, for an amazing attendance this morning and presentations. Thank you.

patients' notes

note writing process

patient engagement

word choice in notes

incentive structure for APPs