Thank you, Joe, that was a great start to today's course and a lot of great tips there that I'm sure that we'll talk a little bit more about in our upcoming Q&A. This is one of my favorite things to talk about. And so we'll take it just a little bit of a different direction and talk about the APP role itself and how can we continue to expand and grow and achieve that professional career growth and success that we're looking for. And so what I thought we would do is we'll spend just a couple of minutes really talking about what's the role of APPs in GI practice. And then we can look at what an optimal onboarding process might look like. Some of those key things we want to make sure that we're able to get both information-wise and also just practice-wise. And then some goals and challenges that we come across when we talk about optimizing the role of APPs. And finally, some opportunities for professional development. So to start, U.S. news every year comes out with the best jobs report in 2024, the best healthcare jobs. Number one was nurse practitioner. Number two was physician assistant. This is based on the job market, work-life balance, salary, and the potential for advancement. And if we look at all of the jobs, not exclusive to healthcare, nurse practitioner was number one and PA was number five. And that's been that way consistently for many years. We also see this projected growth. And so the U.S. Bureau of Labor Statistics publishes this. For the 10-year growth, 2022 to 2032, NPs are expected to grow 37% and PAs 27%. Why is that growth so high? There's really two big reasons. One is the demand for services. So we now have more patients that are older, that have multiple comorbidities, that are more medically complex and challenging. We have a greater number of insured patients who are seeking healthcare services. And we have newer therapies, procedures, and medications. And the second reason for that is that physician shortage. And so there's a lot of different estimates that are out there. But one of the more recent ones is estimating a deficit of up to 124,000 physicians by the year of 2034. And GI is projected to be one of the top fields that has that physician deficit. And so we're seeing there's more and more reliance and need for other providers, such as APPs, to help to fill that gap. This was from the fall, October of 2023. It was published in Becker's. And they overall noted that about 145,000 providers were lost in the healthcare workforce in one year alone, 2021 to 2022. Of those, it was over 71,000 physicians and about 48,000 APPs. And then this was more recently. This was just at the end of February. I was scrolling through Apple News and saw this article pop up where they're talking about practices in South Carolina, in particular, that are using APPs. And I don't think this is unique to South Carolina, but it was just good timing that I had come across this article. So let's talk about what onboarding means. If we're going to integrate APPs into GI practices, I really think there's five key things that everybody should be thinking about and focusing on. And the first one is defining the role of the APP. And it may be a practice that already has it well-established, and they have other APPs, and that role is pretty clear from the beginning. It may be somebody who has a unique skillset. And so that role that maybe already exists is going to be tailored a little bit differently to be able to leverage and utilize that skillset to the full potential. Or it may be brand new. Maybe it's a smaller practice that doesn't have any APPs yet, and they're talking about bringing the first person in. The second thing is really looking at what's the scope of practice and credentialing requirements. And this is a tough one for me to really generalize because it does differ. It differs between NPs and PAs. It's going to differ depending on the state. So it's hard to say exactly what that is for every individual one. We can provide some resources that are available at the national and the state levels. And certainly everybody should be familiar with what those are. The third thing is what's the reporting and leadership structure? And so in larger practices, oftentimes an APP may report to an APP. And there's been some actual good data recently that suggests that there's higher career growth and career satisfaction when APPs report to APPs. In some other smaller practices, though, APPs are still going to report to physicians or even to administrators. And I think that anybody who's coming into a new position should have a good understanding of what is that leadership structure and who would they go to. The fourth thing is APP and physician collaboration. Dr. Call is going to talk to us a little bit later this morning about that. And then finally, that formal orientation and onboarding program. Orientation and onboarding are used a little bit differently depending on the practice. For the purpose of today's, I'm going to talk about onboarding as the all-inclusive, bringing somebody into the practice and including that clinical didactic education as well as an introduction to the practice itself. So let's start with what are the role of GI APPs in clinical practice? In my mind, when we talk about GI, I really separate this into kind of three buckets. The first is that clinical care. So the new patient visits, the follow-up visits, it may differ depending on the practice needs and the level of experience of the APP. APPs can see acute and chronic complaints. They can order, interpret, manage labs, imaging, pathology results. Certainly that development of the assessment and plan like Dr. Verkari just talked to us about. And then other clinical tasks. And so things like prior authorizations, really thinking more about the peer-to-peers that require a provider's input, those appeals, being able to help patients gain access to medications. Then I think about that periprocedural aspect. And so for my pre-procedure support, it's really patient education. APPs are uniquely positioned to be able to provide patients with that specialized patient education and take the time to answer their questions, talk to the family. Informed consent can be another aspect of it. And so going through procedure, what is it? What do they expect? What are the benefits of it? What are the risks of it? What are the alternatives? And having that discussion so that the patient, when they do sign that consent form, is well-informed and comfortable with that decision. Pre-procedure testing and labs, certainly with that background knowledge, knowing the risk of the procedure. Do we need to have anticoagulation management? Do we need to know what their blood work is ahead of time? Do they have thrombocytopenia for any reason? Does that need to be corrected? And then I think that collaboration with ancillary services and complex care coordination is another really important aspect. So patients who have significant cardiopulmonary disease, do we need to work with other services to optimize that? Or are there things that we can do? Do we need an anesthesia consult before they undergo some of these procedures? And then on the post-procedure support side, certainly being able to provide them with prescriptions if they need it, education, post-procedure phone calls and follow-up visits, reviewing their pathology results. And then I think one that's kind of unique to our role, a lot of times we are the first touch of phone calls. And these may be patients who are calling that have some delayed complications or adverse events. And so being able to efficiently triage those, work with our physician partners, and be able to take care of those patients. So when we talk about onboarding and we're thinking about all of those roles that APPs can do, and really kind of hopefully paring it down to what are going to be the expectations of the APP and the practice. The introduction to the practice and the institution is a really big one. And it's just as simple as who is who? Where do we go when we need something? How do we get around? Where are the restrooms? Where's the break room? Those little things can make somebody feel much more welcome. EMR training, most of us are using electronic medical records, if not all of us. And so when you do those classes, I'm sure most of us remember, you kind of go in, you're following commands, you're mirroring their screen, you're doing exactly what they tell you. But it's not until you sit down and you start to really fumble yourself that you're really starting to learn it. Office policies and procedures, it's a great time during onboarding to be able to spend the time to understand those, ask questions about them, to develop a mentorship. And that can be with a physician, can be with an APP, ideally will be with both. I really feel strongly about having APP shadow other services when we have the opportunity to do so. I think it's a little bit more challenging in community practices, but it can happen if you have good relationships with them. And the ones that I think the most about is colorectal surgery, thoracic surgery, hematology, interventional radiology, and even radiologists. We're going to have a whole section on interpreting some radiology images, but it's a great place to learn when you have the opportunity to do it. And as you're onboarding APPs, we tend to have a little bit more time in the beginning as we're building our practice to be able to do these things. Competency evaluations is another really important part. I have not met somebody who does not want to exceed expectations. The challenge that I see though, in my current leadership position, is that if somebody doesn't know what the expectations are, it's hard to meet or exceed them. And so to be very upfront about the expectations, and then to have those ongoing competency evaluations to say, here's where you're at, this is where I expect you to be, or you're moving a lot faster than I thought you would through this process. So let's talk about what else we can do. How can we do things differently? Or to pivot the other way, maybe you're a little bit behind where I'd expect you to be, and that's okay, but let's talk about how we can get you back to where we want you to be. And then finally, those educational resources, and I think this is another really important part. Dr. Verkari had talked a little bit about guidelines. So where do we find these guidelines? What guidelines are out there? How can we reference them? How do we use them in our discussions and our thought processes? Also, who's using up to date? Are there any apps that we're using? How do we find low FODMAP diets, not for ourselves and for our patients? And so I think things like that are really important to take the time to do. Other things that I think about is that physician collaboration. So developing that relationship and that trust. Patient management is, in my opinion, one of the hardest things that we teach because it is so variable. I don't know what the patient's going to send in a MyChart message next. It's very difficult to predict. Sometimes we get things that we have to sit back and really think about. Sometimes they're really quick answers. And so being able to spend some time really dedicated to answering those messages, returning those phone calls, reviewing those results, I think it's a great time to teach things like pathology as well. If NAPP is coming into a GI practice and is not familiar with endoscopy, procedure observation can be really helpful. And it can be helpful to watch it from multiple aspects. And so following around an admission nurse. And what is the process? Because patients will ask questions. We're better able to explain those things when we've seen it. Following the physicians to see what they do. And when we understand the procedures and we're thinking about patients calling in with post-procedure complaints, we may be able to better triage those. And then the discharge process too. How awake are they? That's one of the questions I hear all the time. What's the process? Does the physician come out and talk to the patient and the family? What do they call the family? Just so that we have a better idea of those things. Like I mentioned before, the guideline review, the unit policies and procedures, the pre-procedure patient preparation. Once you get used to the electronic medical record, I think optimization training is a really valuable tool. And so we use Epic in our system. We have Epic optimization trainers that we can request. And they will actually come and kind of shadow what we do for a half day. And then they're giving us active feedback. And so for example, there was one tab that I could never find that I search all the time for and they were able to pin it for me. A lot of the recommendations that come up automatically when you're doing it is you don't use these tabs often, let's get rid of them, but I didn't want to get rid of it and so they were able to help me get it back. Now I'm not spending those five minutes trying to find it every time I need it. And then finally the reimbursement and compliance training. Jill's going to talk to us about billing and coding. I think that that's a piece that's really important especially for new graduate APPs or APPs who are transitioning maybe from a different role like inpatient to outpatient and being able to understand what can we bill for and how do we bill appropriately. And then if we look at our clinic schedule and so again it's about setting expectations and what is that ramp up period and so having those clearly defined expectations. Is it a number of patients per week and do we start to accelerate that number of patients over what period of time? Are there specific diagnoses that we have APPs start to see first? For some practices they'll say we're going to work on these five diagnoses and then they open their schedules for those five diagnoses and then they start to expand from there. Others do a more global approach. Is there specialty and subspecialty training in that? And then the time frame for a full schedule. And again we have to pivot. Everybody's unique and different and we learn differently and we come in with different experiences but to have that expectation is really helpful from the beginning. And this is just an example of kind of what we use. We really set up the first six weeks in this form and it does a few things. One I think it sets those expectations. Secondly we have a fairly large group and so new APPs who come in may be rotating amongst multiple people. They do have primary preceptors but we want them to see the differences and so like Joe was talking about right the art and science of a visit. Well we all do it a little different. That's the art part of it. And so to be able to observe what other people are doing and take bits and pieces from everybody to make it uniquely your own. So when we do that whoever's with them is able to then take a look at this. And you know you may come in on a Monday it's completely open. Check off a few of those things. By Friday whoever they're with can make sure that they're meeting those. It also may change. So sometimes you may be with somebody who's not an expert in hepatology and so maybe the banding of varices doesn't happen that week but then the next week could be with somebody with hepatology. And I think finally even if you have a small practice it's a good way to make sure that we're hitting on everything because it's hard to keep track and we can't always predict what patients are on our schedule during that orientation period to make sure that somebody's seeing everything that we want them to see. And so it just helps us to kind of keep a broader approach to things. So once you're there you're on board and you're seeing the number of patients you're supposed to see. The next part is really that professional development and career advancement. And so we'll talk a little bit about that. And this is done in many different ways. The first way is really looking at it clinically. So seeing more complex patients or developing specialty clinics. Maybe developing some of those procedural skills. And then we can go into more from an academic standpoint. So CME opportunities, tuition benefits, academic and scholarly work, leadership roles. We'll go through some of these. This is just an example. So Gastroenterology and Endoscopy News has an APP corner. Dr. Call and I have been doing specialty clinic series and so we're taking panelists from around the country who are in different practice settings who are doing these specialty clinics and asking questions. And so I bring this up if anybody's looking for more detailed information. It might be helpful to hear what are other people doing in their practice. How are they successful? How do they get the education and the training they need to develop these unique specialties? This was an article that was published in 2019 in the Journal for Nurse Practitioners by Elizabeth Evans and colleagues. And they really were looking at that treat-to-target approach in IBD and how do APPs fit into that role. So again, another clinical aspect of things. And then this one in 2020 from Hepatology that looked at the quality and outcomes of care in patients who have cirrhosis who have an APP involved in their care team. And what they looked at with this was really those quality outcomes. So for patients who have cirrhosis, they looked at the rates of HCC screening, the rates of variceal screening, and they saw that those were higher when an APP was involved in the care team. And they weren't talking about patients who only see an APP, but just ones that also had an APP included in that team. They also looked at things like patients who were discharged home from a hospitalization for hepatic encephalopathy. Standard of care is put them on Zyfaxan. So what's the rates of patients meeting that requirement? And this is not an all-inclusive list of procedures, but I did want to provide some examples. I think every year we talk a little bit about procedures itself. So depending on the skill set, the needs of the patients in that population, what services are available in your area, there are several things that APPs can do, again, depending on the scope of the license. And so it really goes at that state level. But large volume paracentesis, percutaneous liver biopsy, usually ultrasound guided, fibro scans, hydrogen breath tests, APPs generally will at least be able to interpret those. Many may perform fibro scans in the office as well. Motility, both esophageal and erectile. Some will do high-resolution anoscopy and hemorrhoid banding, gastrostomy tube management, nasogastric feeding tubes, and then sometimes even endoscopic procedures. CME opportunities such as this course certainly can help to work towards that professional development, that ongoing knowledge acquisition. And then there's a lot of opportunities for scholarship and research. And so a few examples, case reports and series, taking a patient that may be presented a little bit uniquely, who had a different course than what would be expected, can be a learning opportunity for colleagues. So being able to write that up and share it with others. Review articles where you take all the most up-to-date information, synthesize it, and then are able to release it within essentially a complete summary of what's currently available. And it lends itself often to be a best practice. Clinical research, presentations at national meetings, participation, or even the development of quality improvement, quality assurance projects. Editorial assignments is another one. And just for anybody who maybe isn't aware and wants to look at some of these, some of these GIAPP-focused journal sections and newsletters, ASGE has innovations in gastrointestinal endoscopy, IGIE, and there is a APP Engel that's published there in the interdisciplinary section. And so this was an article on incorporating APPs into gastroenterology hospitalist teams. There's also an article that was recently published on eosinophilic esophagitis, so there's some clinical information there as well. GAP, gastroenterology advanced practice providers, has bridged the GAP newsletter. And then gastroenterology and endoscopy news with the APP corner. And just an example of scholarly work, this was a review article that was published a couple years ago looking at Barrett's esophagus management in the elderly. And this was an editorial review that Karen Hanson wrote about three years ago, I think, in Crohn's and colitis that was looking at the utilization of biosimilars in patients who have IBD. So another aspect of professional development and that career growth is leadership structure. And we talked a little bit about APPs reporting to APPs versus APPs reporting to physicians or administrators. I don't know that there's a right or a wrong answer there, but I think that as we are growing the APP field, we're recognizing that there is value in having an APP leader of some form. There's this rapid growth in the profession, there are these unique policies and regulations, and it can be tough to keep up with. As inclusive as we are by saying APP, there are some unique differences between NP and PA, and we have to be aware of those, particularly as it pertains to scope of practice and our licensure. APPs are key stakeholders oftentimes in those practice operations. By having APP leaders, we're increasing their involvement, and it may lead itself to increased retention as well. And I won't go through all of these, you guys will have access to these slides, but really looking at leadership responsibilities, I think it goes everything from advocacy to optimization to that onboarding, and then really looking at the operational aspects too. So what are those staffing models? What are the clinical advancement models? How are we doing with recruitment and retention? And there's a lot of different leadership roles. I kind of just put some ideas of titles that go from that top level management to mid-level management, and even to a department level management. And then there's other things, right? So there's director positions, such as director of a motility lab, there's somebody who's leading quality improvement projects, or serving on local, state, or national committees. There's teaching and director positions at the local universities and schools, APP education officer, DEI officer, wellness officer, all of these are really great options to continue to grow in our careers. So it all sounds great, but we have to also acknowledge there are some challenges with that. And one of the big ones that I think we continue to see is a misunderstanding or lack of awareness of the scope of practice of APPs. And the fact that the role of APPs really does vary widely, some of it based on our licensure, some of it also just based on the needs of the practice. I think that the misunderstanding piece, we still see both at our practice level, but we also see it with the patients. And a great example of that, in 2021, the AAPA voted and passed to change the role of the APA to AAPA voted and passed to change the name from physician assistant to physician associate. Now, it's been a little bit slow to be really accepted by every state. And so a lot of people, myself included, still say physician assistant until New York state were to adopt that. But really, the reason for doing that was to make it more reflective of the role. And so the feeling was physician associate was more reflective of the PA clinical training and expertise. And perhaps that would be helpful for the patients and our colleagues alike. That lack of specialization training can be a barrier. It is a barrier that can be overcome with a good orientation and onboarding program and continued mentorship of the APP. It can be hard to accurately quantify total reimbursement. There was a study a long time ago that came out that really aimed to focus on how much of the APP work effort is non-RVU. And it was nearly 50%. So I think that that's another big part. How do we value the amount of work that's being put in? And maybe that's those peer to peers or those appeals, those phone calls, the amount of patient messages that we're answering. Some of that we can now bill for, but not all of it. Another challenge can be buy-in from physician partners and administrators, and that can be not only for adding the APP, but I think also for expanding the roles and for fair compensation, and then managing the expectations and the acceptance of this advanced APP role. So to summarize, I think effective onboarding programs are essential for successful integration of APPs into the GI practice. I would argue it's also equally effective for any other team member. Optimizing the role of APPs will help with increasing access to care, patient referring provider satisfaction, maximizing reimbursement, and increasing position endoscopy time. Using APPs to the extent of their scope of practice and investment in professional development will lead to higher efficiency, improved job satisfaction, and ultimately better retention. So two questions for you guys before I turn it over. The first one is the first one is just a review, which I just summarized nicely for you. Optimizing the role of APPs helps to achieve all of the following except. Yeah, so the group is right. So optimizing the role of APP is actually supposed to improve provider satisfaction, and that is both for physicians and APPs. And the second question. Opportunities for professional development include which of the following? Exactly, I love 100 percent. So leadership roles, clinical research, clinical advancement, all of those are ways that we can continue our engagement and our learning and growth.

Advanced Practice Providers

Gastroenterology practices

APPs in clinical care

Onboarding programs

Professional development opportunities

Scope of practice misunderstandings