It's my honor to welcome Dr. Vivek Kahl. Dr. Kahl is the Siegel Watson Professor of Medicine and former Division Chief in the Gastroenterology and Hepatology Division at the University of Rochester Medical Center. His clinical research and medical education efforts are focused in therapeutic endoscopy and endosurgery, interventional endoscopic ultrasound, and advanced ERCP. He also specializes in esophageal endotherapy for births and esophageal cancer and has expertise in complex interventional endoscopy, especially in patients with GI cancer care. I've had the privilege of working with Dr. Kahl for many years as we developed our collaborative practice together, and certainly he served as a mentor not only for myself but for many other APPs. Dr. Kahl serves on national committees with the ASGE and the American College of Gastroenterology, and he is currently the chair of the ASGE Reimbursement Committee. He is secretary general of the World Gastroenterological Organization. He also serves as the ASGE rec advisor to AMA and on several other national and international task forces. Dr. Kahl, thank you for being here today. I'll turn it over to you. Thank you very much, Sarah, for that kind introduction, and congratulations to you and Dr. Vickari for this course. I'm happy to be here, and thanks for having me again this year on this very unique course that the ASGE has set up. My privilege to be here. Jill, that was a fantastic talk, and I'll try to speak to the collaborative relationship that forms the basis for those clinical practice paradigms that you referred to. So let me see if this works, and I think it does. Okay. My charge is to speak to the collaborative relationship that APPs and physicians can develop and work with in the care of their patients, and then some. This is a model, as Sarah referred to, that we have put in place for a long time now at our center, and it's something that we speak to as well nationally and have published as well. These are my disclosures. The objectives of this talk are to highlight the value of APPs in clinical practice, describe the APP physician team concept as it applies to both outpatient as well as inpatient practices, and really highlight some of the strategies and illustrative examples of how this can be done, how this should be done, and how this has worked for us and others, and finish up with practice goals. Now the factors that really determine successful APP integration into practices, because the first point is to integrate the APPs formally as well as successfully in the practice, are listed on this slide. These materials are available to you as enduring materials, so I won't belabor the slide too much. But as you can see here, the roles and responsibilities obviously range from initial patient triage all the way through team-based care principles and then all the way to patient satisfaction. In there somewhere, many practices will shift some of the established patient responsibilities to the APP, so that's a big part of the experience there as well. But there's other things that APPs can be integrated to, even in a purely clinical practice setting. In terms of the key principles for successful collaboration, those are listed on this slide. And I think it's really important for a system, for a practice, to have what we call buy-in. And buy-in is basically understanding the value of an APP to a practice and then defining the roles and responsibilities to fulfill that value proposition. I do believe, and this is really important, is that there has to be mutual trust, respect, and a true partnership sentiment, similar to what physicians have for their physician colleagues. I think that without that being in place, it's very difficult to plan a successful outcome. The team-based approach to practice operations has really become the mantra nowadays in modern American medicine. And I think that no matter which setting that you're in, it's important to understand that it's not about a particular provider. It is about the team, and ultimately it's about the patient. One thing that in my time as a physician manager, if you will, or a division chief, that I learned was that people respond very positively to fair compensation and vice versa if you're not being fair to them. So compensation comes in many forms. We can have a discussion on that in the panel discussion. It does include benefits and perks, some tangible, many intangible, but I think it's the entire value proposition of a particular employment situation that needs to be considered. But I think unless these terms are fair, they are at market value or higher, or they bring some special additional value to the APP, it's going to be difficult to retain that person, hire that person, and then eventually retain that person. An area that Sarah and I have worked very closely together over the last decade or so is emphasizing the concept of professional development. This is really something that is a launchpad for many motivated, interested, and qualified APPs in any practice setting. It doesn't have to be academics. And this is something that physician collaborators should keep an eye towards to make these careers successful and for a better outcome for the practice as a whole. The collaborative practice model, in my mind, is born out of necessity. Right now, with the post-COVID scenario especially, GI was always underserved. But now, especially after the pandemic, there are huge access issues. GI is a procedural specialty, and the physician is typically involved in endoscopy and procedures. So there's a relentless high concept volume. These are all the reasons for the unmet need that needs to be fulfilled, and the APPs definitely do that, and most certainly in those states where nursing practice is restricted as well, I think the APPs also bridge that gap as well. I already referred to the principles that are important in there, but I think the scope of practice can be pretty broad in terms of clinical practice and all the way to some basic procedures and ancillary testing and all that I'll get through. I am a big believer in no margin, no mission. So this relationship has to be financially feasible. I think even if you have all the principles in place, if the financial model is not sustainable, it's going to be difficult to carry out this concept. I do believe that long-term successful collaborative relationships are possible, and we have many examples of these across the American nation, both in private practice as well as in academic practice, and ultimately any relationship, whether it's a personal relationship or a professional relationship, has to have a win-win component. And when I speak to young physicians as well as APPs and they're negotiating or looking at a new offer, I tell them that definitely they should negotiate and look out for themselves, but they should also look out for the system that they're entering and making sure that when they deliberate, that it's a win-win argument, not a win-lose argument, which is very off-putting to the employer as well. Now, the concept is good, but we do live in a world that is regulated by policy. And so these are some of the examples of collaborative practice agreements that are in place. Some of these are state regulations, many are institutional. These forms are there, they exist. You'll have to sign off on these. This is an example for a PA, a physician collaboration, and the next one is for an NP. And these do have meaningful value because they serve as the founding documents for this relationship, and it is also required in many cases by policy. Now the case for the APP physician collaboration, as I said, is a significant unmet need in the medical space right now, not just in GI, it's throughout the medical care model. But I do believe that there is an important role for an inpatient APP as well, where we can do timely consults, improve communications, improve patient satisfaction, and a reduced burnout for everybody involved. So the outpatient gap that I referred to earlier is definitely there, but there's also a huge opportunity on the inpatient side, which typically for most GI practices is another big difficult area to fill, both in private and academic settings. So I think the APPs really have stepped up here, and certainly at our institution, it has been a fulfilling experience for both the division as well as the involved APPs, and we have two of them, and we can talk about that as well. This is a team-based model I was referring to. The physicians and APPs work together. The shared visit concept was discussed by Jill already. There's also a huge opportunity for independent billing, inpatient care, and then of course facilitating the peri-endoscopic aspects of clinical practice, some of which now are also reimbursable, but others are built into the role as well. As Sarah has demonstrated in her career, others have as well, especially also on this faculty, that education, training, and clinical research can be a part of your profile as well, and then of course other roles that folks can play. Now, colonoscopy and flexible sigmoidoscopy has been demonstrated as a proof of principle. However, this has been done and or contemplated. These have been done in very structured environments with very high level of competency assessments and training similar to that what we have for our trainees and fellows, so this is definitely doable. And I would say that in the post-pandemic era when our waiting times and the time to procedure is even more longer than it used to be before, I think this is something that practices are looking at again, and the scope of practice again can be defined by the state as well as the institution with the proper training. Patient education is definitely an area where APPs definitely help, and I have to say that this is an area where our industry partners, and we are thankful to them for supporting educational events, but also for patient education, they have entire sections in the corporate industry where they typically call upon APPs to help with that, and with the appropriate sign-offs, this can be a huge advantage to an individual practice to set up these type of modules. Now, what are the examples of meaningful collaboration? Obviously, you know, the most important pivotal role is that of providing high-quality patient care, but training is there as well, new skillset acquisitions such as learning motility in a motility lab and setting that up, professional development I already referred to, and then of course, you know, one area that I find is a challenge, has been traditionally a challenge, is for entities, institutions, practices, leadership in institutions to come up with meaningful support such as that for CME support and offering APPs meaningful leadership roles in their practices so that they are able to provide an additional level and layer of competence for administrative matters. I think this is an area that certainly can require some more attention, but I wanted to mention that here, that once you get into that level of engagement with an APP, you're well beyond, you're well beyond clinical practice alone, you have professional development built into it, you are investing in a career, and that is where it sat in my mind. The practice models were somewhat referred to in the previous talk as well, but the most common practice model is that of clinical practice, outpatient, inpatient, or some degree of mixed inpatient and outpatient activity. It does increase access and throughput. I've seen that in my own clinic where I can definitely see more patients in a given half day than if I was left alone or if I was only with a fellow. Timely communication is another attribute that I feel is very important. A lot of the times we are busy running around and or traveling or preparing educational materials and lectures, so patient care cannot wait. And I think that I do rely on my APP and other team members to facilitate this along with me, especially for serious diagnoses and or for critical illness. There are different models depending on practice needs. So the APP physician shared outpatient visits is what we have a lot in place. We also have other practices that have physician sees new patients only and or sees the most of the new patients and the APP will only see the follow-ups. And there are some hybrid models as well out there. The APP independent practice model is something that we are trying to encourage, obviously with proper training, onboarding experience, and we have not had any issues with this as we have developed it. This is something that's definitely viable and it's something that we can talk about offline as well. The APP inpatient model is something we started a few years ago and other practices have as well, and it has its own value-added proposition, as I mentioned earlier. When you have a collaboration set up, it allows for clear division of tasks. It's so-called the divide and conquer strategy, really allows for a lot of patient-centric care, education, satisfaction-oriented performance, but mostly I think it really improves communication, improves access, and it is a better day for that patient in that practice in my mind. Billing and reimbursement was a whole talk, as you just heard, but suffice it to say that if the APP is seeing patients independently, it is reimbursed at 85% of the physician's schedule. The documentation burden is important and is there for both providers, but reimbursement is a complex topic, as Jill referred to, and it varies by a lot of variables that play into it. The shared and split-service model is something that is in place. There is some discussion about changing the nature of it, which you heard in the previous talk. More to come on that, but for now, complexity is a big part of it, but the physician has to document their part of it fairly significantly and separately in the same note and actually has to perform it. So, at that point, you will get the 100% reimbursement, but all of that will be in place. The Incident II model is not particularly something we recommend strongly. It is being used in some practices. These requirements can be difficult to meet. The physician must see the patient first for an initial visit, and then the APPs can only see the patient for follow-up. The physician must be present and available and involved in the course of treatment. So, the burden is a little bit higher, a little different, and for some reason, maybe for good reason, it is a red flag item for auditors. So, probably the last option that you may want to choose in the current environment. So, here is reflected a summary of the last couple of slides. Independent practice at 85% of physician schedule, shared and Incident II practices at 100% because of MD involvement. Now, obviously, this is all nice and good, and as we know well, though, that the real world does not come with its problems. So, any time that we are delegating, collaborating, sharing, bringing newer members into the team, even with the best intentions, there is always a possibility of problems arising. So, in the APP physician collaborative practice model, what kind of problems might come? So, vicarious liability is a unique legal concept in medical and other jurisprudence where a physician may be held responsible for the acts of those who are working with them and under, you know, their supervision. So, that is something that does happen, does not happen very often, but that can be invoked in a legal suit. Negligent supervision is something that comes up more commonly where a physician, you know, is not found to be in a position where they are supervising the practice or the care, you know, to the level that is expected, and a lot of that falls on the physician side, but these have to be something that we have to be wary of and not let happen, and it's bad for patient care, it's bad for the practice reputation, and it obviously is a setup for failure. Negligent hiring refers to those situations where people are not competent for the position, and that applies to all level of providers where the recruitment process has not vetted the candidate for the job. There are some previous bad experiences that were overlooked or not looked for, and that the provider ends up having a difficult time, so it's best avoided, but these are some of the areas where we need to be cautioned. So, most common malpractice claims in this setting relate to inadequate supervision, as I referred to earlier, and then there are some others that relate to competency diligence, such as untimely or delayed referrals, and the lower bullets are thankfully less common. They do portend a criminal intent, which, of course, most of us don't have, but inadequate supervision and untimely or delayed referrals, especially in the realm of cancer, are something that we need to watch out for. So, how do we mitigate these risks? I think the most important thing that this course and other efforts aim to achieve is really feed into the training and competency aspect of APP development. I think there are significant training opportunities well beyond the original certification. Knowledge of state regulations, institutional policies is important. It's really important to develop standardized onboarding protocols, and these are really helpful. It is also important to allow for time for new, especially new grads and people with less experience to come on board, especially if they are coming into complex practice scenarios. Regular performance reviews are important, and I know how much time Sarah and her colleague Vicky spent on this, and this is really key in keeping the machine going well and staying above board. Compliance monitoring is obviously a part of, a big part of American medicine and corporate structure, and that cannot be something that can be overemphasized. Now, the strategies to build these collaborations are listed here. Obviously, once you have a good practice environment in place, you're doing good work. I think what comes next is investment in each other, and this slide refers to those concepts of investment that are two-way streets, but I do believe that I think the onus and the charge falls more on the physicians. They are the senior partners in this. They are the folks who have more training and more experience sometimes, and they really need to bring this in and make this happen. So, inclusion, open constructive communication, clear performance expectations, allowing professional development opportunities, and then, of course, assisting with conflicts, which is a big part. Once you assist a partner with a conflict, I can tell you any endoscopist that I've helped with managing a complication became a lifelong friend, an unconditional friend and colleague, right? So, once you assist a partner with conflict resolution, that is the absolute cementing of that relationship, so please keep that in mind. Successful collaboration and taking it to the next level, this is where a lot of my time is spent now that we've done the groundwork, at least in our institution, is to really focus on professional development and really build this individual into the next generation leader, allow them opportunities, bring them in, increase your productivity on the scholarly side, and make them real partners in your entire, you know, professional life. There's also community engagement, industry relations, everything listed here can be done well, it can be done successfully with exceptionally good outcomes, as many have shown over the years. So, practice pearls, the APP Physician Collaborative Model has tremendous value in my mind, and unless and until the entity believes in this value, there is buy-in, it's going to be difficult to develop any level of successful collaboration, no matter how much research you do on it. The strategies have been well-defined, I do believe that the access, the collaboration does lead to increased access and improved patient satisfaction and quality. There is a caveat, you know, when you do shared clinics or incident two billing, you need to adhere to the guidelines and that you need to do that anyway for documentation and billing in any practice setting. My big emphasis is that after you have achieved the first goal of becoming a good clinical provider, providing good shared visits and such, and good patient care, I would encourage each one of you to look at the next level of this engagement, which is doing something beyond clinical work in the realm of professional development, whichever form it takes, it doesn't have to be the same thing for everybody, but work to the fullest scope of your license and really squeeze out every opportunity within your work environment that it affords you. So, those would be my recommendations, and with that, I think we go to the polling questions. So, the key principles for creating a successful APP MD collaborative partnership are all of the following except. Now, this is an except question, and give them a few seconds here. So, basically, out of the five choices, one is wrong. You're seeing here level of financial incentive. That is the most preferred answer, two-thirds at least got that right. So, that's correct. That's absolutely right. You know, although I am a big believer in no margin, no mission, I think that that is not necessarily the founding principle, and all the others listed on this, including practice buy-in, trust, respect, mentorship, and professional development are much, much more important. So, you guys, most of you got that right. Let me see. The next one here is another except question. So, I'm totally against the grain now. All of the following are strategies which contribute to a successful APP MD collaborative relationship except. So, strategies. This is a strategy question, which I did spend some time on. Open, constructive, construct clear performance expectations, exclusion from practice discussions, and career and professional development opportunities. Which of these is not a good strategy? Let's take a look. Wow. Is that the first hundred percent? Let's see. I may have missed the first one. Yeah, no, this is great. Now, we'll have a war going here. Last year, we had a big challenge around the hundred percent, but this is great. So, I think my job here is done. Thank you very much.

Dr. Vivek Kahl

gastroenterologist

collaborative practice

advanced practice providers

physicians

patient care