Okay, I think we're good to get started here. So thanks again everyone for coming over to our session here. I would like to introduce my co-presenter for the first talk here. He is also my co-chair for the APP committee, Dr. Joseph Vacari. Joe Vacari is a board certified in gastroenterology. He attended medical school at Creighton University, completed his residency and chief residency in internal medicine at Creighton University, and completed his G.I. fellowship in gastroenterology at the Cleveland Clinic Foundation, where he became the chief fellow in gastroenterology from 1996 to 1997. Dr. Vacari joined Rockford Gastroenterology Associates in 1997 and previously served as managing partner. He has held a faculty appointment at the University of Illinois College of Medicine at Rockford since that time, holding the academic rank of clinical assistant professor of medicine. Dr. Vacari has served as chair of the ASGE Practice Operations Committee, currently co-chairs the ASGE Advanced Practice Provider Committee, and previously served as counselor of the ASGE Governing Board. He is a journal reviewer for the American Journal of Gastroenterology and section editor for Advanced Practice Providers for IGIE. Dr. Vacari has presented numerous lectures and presentations to students and residents and physicians and advanced practice providers, both locally and nationally. Joe, the audience is yours. Well, thank you, Caitlin, and welcome, everyone. I think this will be a fun session to talk about some things that really need to be discussed as we move forward and continue to evolve the role of APPs in GI practice. There we go. No disclosures, sorry about that. So, my objectives. Why APP leaders? Well, if we look at all fields of medicine, in fact, all fields in general, leaders come from the groups within that field. So, it just makes sense that APPs should lead APPs. And that will start the first part of the talk with that. And then towards the end, I want to define types of leadership and types of intelligence that really create the foundation for any type of leader in healthcare, whether that's a physician, an APP, or a business administrator. Polling question one. We'll start with a few polling questions. Which of the following statements is true? Every successful project is the result of great leaders. Not all great leaders are the same. C, personal traits and characteristics define leadership. D, all of the above. We'll give you guys a moment to answer the question again. Which of the following statements is true? Every successful project is the result of great leaders. Not all great leaders are the same. Personal traits and characteristics define leadership style. D, all of the above. Correct. The correct answer is D. All of these are important for great leadership. Which of the following types of intelligence is consistent with successful leadership? A, interpersonal intelligence. B, interpersonal intelligence. C, verbal linguistic intelligence. D, all of the above. And I've made these pretty simple because all of these points from both questions will be covered and important for leadership. Correct. All of the above. All right. Again, I made those easy on purpose. Let's go ahead and move on to the next slide and get into the body of the talk. So, why APP leaders? Physician leaders, nurse leaders, administrative leaders, all lead their own departments. And unfortunately, historically and in many practices today, both private and academic, we have these leaders leading APPs, which is far from ideal. And I would actually ask the question, is this really APP leadership? And the answer is no. We need APPs leading APPs. GI practices need to develop and maintain APP leaders. As Dr. Call talked about, this is one of the areas of career development. And once we develop and maintain APP leaders, we must let them lead as part of a leadership team. So, what happens when we have non-APP leaders leading APPs? We end up with non-APP solutions. The view that's taken when non-APP leaders lead is one more greatly slanted towards the organization and the organization's needs and not those of the APP. So, very simple. We can look at how your schedules are arranged. When we have non-APPs leading and developing schedules, we end up with schedules that tend to be overbooked to short amount of time for high quality patient care and quality time with patients because it's not from the perspective of what the APP needs. So, we end up with inconsistent processes related to the work that you do, so your schedule, and how your schedule is designed leading to inconsistent work effort. Inconsistent processes related to APP and non-APP policies tend to go across the organization. So, when we have non-APP leaders leading, we have inconsistent treatment of APPs in the clinic, perhaps from clinic A to B, and perhaps from the clinic to the hospital. Although there may be subtle differences, we need consistent processes. And the biggest problem we've seen when non-APP leaders lead is how we develop onboarding and how we develop competency assessment. Onboarding is one of the most important pieces to a long and successful relationship between the APP and the practice. So, what happens when we let APPs lead? APPs fully understand their needs and they tend to develop processes that flow more efficiently and consistently. A very simple example is how you interact with your triage nurse and how the triage nurse communicates with you through the task basket. The task basket should be for those communications that are very important. In our practice, a number of years ago, the APPs task baskets were being inundated with messages that were unnecessary, like a notification of medicine refills, notification that Mr. Smith was coming into clinic. That's because these task assignments and the guidelines for the triage nurses were not developed by APPs. Once we had APPs develop these processes, the whole process changed and became much more efficient. So, we need to develop and implement APP-specific workforce processes, programs, and solutions that are aligned with organizations. Another example would be the subspecialty clinic. This occurs in both the academic and private practice, and we've seen subspecialty clinics develop in parallel with position subspecialty clinics. We know when the APP leader is involved in developing the subspecialty clinic, we have a much more efficient specialty clinic, both from the perspective of scheduling and from the perspective of how care is delivered. When we develop our APP leaders, we need a defined lead APP, so one overall APP leader. Practices that are large may have section APP leaders. The APP leader should work with and support physicians and should have a physician champion or mentor to help develop their leadership skills. The APP works as part of the overall leadership team with physicians, nurses, and administrative leaders. In my mind, now we have a team, different aspects of the organization working together, understanding the individual needs and value of each of the components. In my mind, medicine is the ultimate team sport, and for it to be the ultimate team sport and deliver high-quality care, APPs need to lead APPs. Here's another example of what happens when we have APP leaders leading, and this is turnover. A couple nice studies that APP leaders impact in a positive manner, patient engagement, APP administrative engagement, and most importantly, turnover. Turnover for an organization is emotionally and physically exhausting, especially when it comes to providers, so we need to limit the amount of turnover. A coalition of studies showed that when APPs are involved in leading from the perspective of onboarding, education, collaboration with physicians, developing these programs, we can reduce turnover to less than 2%. The reasons for less turnover when APPs lead is multifactorial, but one of the most important points I found very interesting, there's an inverse relationship between utilization and turnover. Specifically, when APPs are underutilized or used as scribes or used as task basket managers and not utilized at the top of their licensure, they tend to leave. There's an increase in turnover, so with APP leadership, we can maximize use of APPs and let them practice at the top of their degree. APPs are indispensable to delivery of quality care. We've known that for years and timely access to care. Prior to APP leadership and those practices that have successfully developed APP leadership, APPs filled the need. As I said, historically, they were used maybe as scribes, as task basket managers, just as workers to offload a physician work. We know that can no longer happen and we need to develop APP leaders and APPs to practice on their own in parallel and to some degree in collaboration with physicians. APP leadership growth in time should parallel physician leadership. When I first joined my practice in 1997, we had a very loose physician leadership program. Ultimately, it became patient-focused and organization-focused and we need to develop our APP leaders along those parallel lines. We need to have patient-focused leadership and organization-focused leadership. There was a very nice study and this was only with physician assistants that show us that APPs want to lead. In this study, 92% of physician assistants agreed or strongly agreed that they aspire to be leaders and their leadership aspirations range from managing hundreds of APPs in a large institution to perhaps project management or subsection management in smaller groups. With that as a background, let's look at leadership styles and types of intelligence that are important to building great leaders. Every successful project is the result of great leaders. We cannot have successful leadership without developing great leaders. Not all great leaders are the same and not all great leaders lead the same. However, all great leadership, especially in medicine, has one thing in common and that is the concept of service, of service to the patients and service to our organizations, specifically employees of an organization. Personal traits and characteristics also have an important component in defining leadership style. Historically, eight types of leadership styles have been described. For medicine, I think there are three important leadership styles, transformative leadership, participative leadership, and servant leadership. Transformative leadership requires leaders to inspire and motivate employees toward achieving their goals. So, this is really an inspirational, motivational type of leadership. What are the benefits or pros of this type of leadership? Well, since it's inspiring and motivates, it tends to focus very strongly on the vision and tends to be successful at developing vision and strategic plans. It aligns employees with the company values, which in medicine is very simple, patients, patients, patients, and providing high quality care. It tends to be strong in building relationships within the organization and we know that millennials respond well to this style. Some of the cons, since this is inspiring and motivational, if the leaders get a little too aggressive or too overzealous, we can have agendas and projects that are overly ambitious, which may require continuous motivation, which over time certainly could be fatiguing. And then, it could unintendedly create excess competition. For those who lose sight of what the overall goal of the organization is and perhaps they're looking for personal gain, you could create unnecessary competition. These cons are minimal. The pros certainly outweigh the cons. Participative leadership, everyone on the leadership team is involved and works together. So, this is my second favorite style of leadership because it really promotes the team and it allows many people to get involved and sometimes from the most unlikely sources, we come up with the best ideas for our organization. Pros, there's a sense of inclusion and a sense of ownership within this style of leadership. It promotes engagement and many of the employees and staff find this to be a very satisfying type of leadership. It increases creativity and innovation, which is important to all types of organizations, but certainly in medicine where we have lots of innovation coming at us at a rapid speed. The cons, since many people are involved or can be involved in the leadership team at varying levels, you can have too many cooks and sometimes that cannot allow us to focus on what our goals are. Because of that, sometimes we can see a slower, less productive decision-making process and if we don't remain focused, it could be difficult to achieve a clear and focused direction. Again, these cons, I think, are minimal. The pros greatly outweigh the cons. Last, servant leadership. This concept comes out of a gentleman named Roger Greenlee. This places value of the team ahead of the individual. The leader leads from a position of service, so service is everything in this type of leadership. From the top of leadership to section leadership, it's service and a selfless nature, which I think is ideally suited for medicine. Obviously, the most important aspect of leadership in medicine is patience. We have a saying in my practice, every time we do what's right for patients, the financial and business model successfully flows. Patients, patients, and high-quality care for patients. Pros, it's a collaborative and supportive work environment. Again, many people can be involved in this type of leadership. It increases job satisfaction and morale because many people are involved, they feel needed. Most humans like the concept of service, especially those working in medicine. Career development is a very important part of this type of leadership, and career development has always been important to me, so career and staff development. Cons, like the previous type of leadership participative, we can see a slowing down of the decision-making process. I think this is a minor detail. Organization goals and financial outcomes could be neglected if we go too far with the service concept. As long as we balance service with understanding, we have a business to run, which is very easy to do, then this model is an outstanding model of leadership. In my opinion, servant leadership is the best style for medicine and health care because it starts with a basis of service and always doing right for our patients. It builds strong leaders and it builds leaders that build people, again, career development, which I think is very important for APPs as we move forward and we'll talk more about that in my next talk. Strong leaders learn over time that they can trust other leaders in their organization, and this leadership style is perfect at that. Micromanaging in leadership, I think, is a very bad thing, and when I was managing part of my group for 13 years, I did not micromanage. My concept, my acceptance of servant leadership allowed me to avoid micromanaging and trust my leaders, and it allows us to focus on the most important thing we do, and that's patients, patients, patients. I'll finish up with a slide on intelligence. A couple of slides on intelligence. There are eight types of intelligence that were described by a Harvard psychologist named Howard Gardner. The three most important in medicine, in my opinion, are interpersonal intelligence, interpersonal intelligence, and verbal linguistic intelligence. Intrapersonal intelligence is someone who is introspective. They're self-reflective. They're aware of their emotions and motivators, which makes them good at motivation. They're also very good at controlling their emotions. They very much understand their strengths and weaknesses, and their ability to look at themselves critically, especially from the standpoint of weaknesses, is very important. I think really good leaders are not afraid to evaluate themselves and understand their weaknesses, and always look to improve upon those weaknesses. Intrapersonal intelligence. Interpersonal intelligence, this type of intelligence understands and interacts with people well, so very important in the field of medicine, very important in building leaders, and very important in career development. They understand people's emotions and needs very well, and this type of intelligence has a strong component of empathy and sympathy, which is very important with our patients in medicine, and also important in a good leader. These two combined can also be described as emotional intelligence. I'm a bit of a splitter when it comes to intelligence, so I like to look at intrapersonal intelligence and interpersonal intelligence, and then verbal linguistic intelligence. These people are good with language. They're very good with words. They're very good with body language, and in controlling their language, words, and body language, they tend to have very good memories, and they're excellent teachers, very good at explaining things to all different types of intellects that they may deal with as leaders. So my goal was to just give you a little background on what's happened with leadership with APPs, define some of the characteristics of APP leaderships, and then give you a bit of a foundation of leadership styles and types of intelligence in the event you are looking forward to or looking to become an APP leader. With that, I'll turn this over to Caitlin to finish things up. Thank you, Joe. Thanks so much for that. I'm really glad that you were able to hit those aspects of what leaderships are and what intelligence is, because right now, as APPs, as the more seasoned APPs, we are already leaders. I really liked this graphic. It came out of a paper from, actually from Canada, which is the advanced practice nurse model is what they were using for this paper specifically, that APN, but it broke down the way that APPs provide leadership. Looking at patient-focused leadership and then expanding that to an organization and system-focused leadership. So whether or not we have leader titles in our job descriptions right now, as I mentioned, we are all leaders in the patient-focused care world. We are helping to manage patient-centered care. We help to coach and educate not only our patients, but also any staff we might work with, MAs, nursing staff, depending in your realm, you may be educating students, residents, or fellows, as well as educating our APP colleagues, as well as physician colleagues. People look to you already to lead them, to make sure that we are providing the best possible care for our patients and advocate for them. In addition to advocating for our patients, we advocate for our profession and ourselves, probably on a very regular basis. So even if you feel like I haven't developed all these leadership skills, you have just by being an excellent APP and GI. And I want you to reflect on those when you're thinking about how you can take those next steps and looking at how you might apply those skills you've already developed to go into that bigger organizational role of leadership. So looking a little more specifically at what an APP leader does, they help bridge that area between administration and clinical teams. It may be broad clinical teams, but really specific APPs. I think that time and time again, we have seen that administration, administrators, and even some of our physician colleagues don't have a complete understanding of what an APP is capable of and what roles they can fill within the clinic. So having an APP there firsthand helps bridge that knowledge gap. They help advocate for APPs and ensure scope of practice utilization, which as Joe mentioned earlier, is absolutely essential in retention and keeping APPs in their positions and keeping them happily employed. And then APP leaders act as mentors. They act as educators and they act as policy influencers at levels from clinic all the way up to hospital committees and even state and legislative arenas. So some key responsibilities of APP leaders, workforce development and recruitment, and within that is that essential onboarding role. They help with operational efficiency and workflow optimizations, scheduling appropriately. They help to improve patient outcomes as well as quality improvement. And in doing that, they also help encourage their fellow APPs to work on these programs. And then they also work with APP professional development and retention strategies. So core skills, if you're hoping to become an APP leader, we need to make sure that there's strong communication, negotiation and advocacy, as oftentimes you're going to be working within an interdisciplinary setting with not only administrators, but nursing staff and physician colleagues. You need to have a good business and financial acumen, the ability to look at data, to look at metrics, to be able to really communicate with all parties the value that APPs can bring. And then have excellent team management and conflict resolution skills. So how do we develop APP leaders? I think right now there is a dearth of structured programs. There are less formal programs that you may develop through mentorship, from reaching out to fellow APP leaders or physicians. Within some hospital systems or bigger systems, you may see opportunities for some coaching programs, networking is huge, reaching out to other people through conferences and through your department is a big way to try to learn. There is more formal leadership training in the form of an MBA or MHA. I also found in researching for this talk that a few schools are providing certificates or fellowships in formal APP leadership. I saw Stanford had one that's a four month program and it's all online. Others I saw through Duke and UCSF are more fellowships and you'd have to be local in that area, but they are emerging. And I think that offers some promising areas for us to try to help more formally develop APP leaders. And I encourage you to get involved in hospital committees or provisional organizations as well to develop leaders. Then there's this other concept of a structured career ladder for APPs, which I find very interesting. And I think it could be implemented across multiple practice settings. It does require buy-in from the practice managers, but there's the concept that you can have beside a point system to multiple categories that allows APPs to basically climb and advance within their career. So some of the subcategories might be service, clinical excellence, demonstrating leadership, education, quality improvement projects, and these benchmarks to advance up and levels should be difficult, but they should be attainable. And it's this type of career ladder setup has been found to also help retention and improve APP enjoyment of their position. So, and since we're looking at a wide range of providers here that work in different settings, I wanted to just state that, I think there will be different APP leadership structures and models that will apply differently for all of us. So there's the direct APP oversight model where you would have an APP leader managing APP teams. And then there's more of a dyad leadership model, which may be better in certain smaller clinical practices where you have an APP paired very closely with the physician to manage, to lead over APPs. And then there's leadership councils where we see collaborative leadership groups for decision-making. And this, I think we see at higher levels more within hospital systems, but there are multiple ways to approach APP leadership. And so best practices to make sure that there's an effective leadership structure include clear reporting structures. This is essential, making sure APP leaders have administrative time so they are not overburdened by their already likely very busy clinical schedule. And then ultimately integration into hospital governance. Taking all that information in, you want to be an APP leader, what steps might you take? I think speaking to Joe's earlier slide, first, intrapersonal intelligence. Let's do a self-assessment. I think it's really important to look at what do I like, what don't I like, what interests me, what is not as interesting to me. You know, if you don't like managing people, maybe you don't want to be that conventional APP leader. Maybe you're more interested in joining committees with workforces. Maybe you're more interested in quality improvement projects. There's multiple ways to lead rather than that just defined APP lead position. It's important to understand your organizational structure and identify key stakeholders. And then once you're through that, it's engage current leadership. Let them know you want to get involved and put your name out there for different types of projects. And one thing that I think is absolutely essential is if there is anywhere that decisions are being made that affect APPs, that affect our workloads, that are about APPs, there absolutely has to be an APP at that table helping make that decision. So identify areas where APPs are not represented and advocate for APP representation in those areas. So we have a group of, a good group here, a good size of group here, and I'm sure some of us have already done quite a bit of leadership. I was hoping now that we could all engage in the chat to talk about what maybe you have done to successfully become a leader so we can share and grow with each other here as well. I'll give you guys a few minutes to type some ideas in there. I also have a slide and we'll see how much we can cover here. So this is great because I think this highlights as well how many areas there are for APPs to grow and the range that we have from practice settings. So thank you for sharing everybody. I'm going to also advance the slide here and share with you the other thoughts that I had come up with. So hospital committees, we've seen that here. Conference involvement, getting involved in your committee, ASGE, AGA, local and state legislative opportunities, professional organizations, areas where we're looking at scope of practice, workflows, clinic templates, quality improvement projects. As I mentioned earlier, any policy that affects APPs should have APPs involved. So key takeaways here, APP leadership is critical for professional growth and healthcare efficiency. Building strong APP leaders requires mentorship, education, and structured career pathways. Thoughtful leadership structure ensures APPs have a voice and drive positive change. Good leaders grow other leaders. Be open to saying yes because you never know where these opportunities might lead. Thanks for sharing everybody. So now I will turn the mic back over to Joe and he will be discussing the future of APPs in GI.

Advanced Practice Providers

gastroenterology

APP leadership

servant leadership

mentorship

organizational change

interpersonal intelligence