And I'm going to talk a bit about onboarding and then go into that continued professional development. I don't have any disclosures. And so what I thought I would do is just start with providing a little bit of a background and kind of a national landscape of APP practices, and then go into roles of APPs in GI practice. And then touch on the onboarding process, and then highlight some goals and identify challenges of really enhancing that APP role. And then finally looking at some strategies where we can really optimize our role. And so I always like to start with this best jobs, US News 2022 nurse practitioner was rated number two, and physician assistant number three. And then looking at the US Bureau of Labor Statistics that projected growth from 2019 to 2029 so 10 year projected growth for PAs is 31% and for NPs is 45%. And that's pretty remarkable. And then looking at some of the drivers for growth, certainly there has been an increased demand for services, and part of that's because there's a greater number of insured patients and aging population. And as the patients get older they have multiple comorbidities, and we have new therapies procedures and medications available. And then there's this physician shortage, and so initially the projection had been about a third of physicians will be 65 years of age or older by 2028. And so when we envision a physician shortage. It's a really large range over here when we look at this red arrow for the physician shortage of 2034 somewhere between about 38,000 and 124,000. But what I kind of took away from this is if our last benchmark data was over here in 2019 at under 20,000, we're looking at probably doubling likely tripling or quadrupling that physician shortage. Some of that is certainly driven by COVID but this was a problem even preceding COVID. And so just a quick overview between NPs and PAs. A lot of our practices are driven by state licensure. And so nurse practitioners are RNs who then have graduate level education, either master's or doctoral. They can have a bachelor's degree plus additional training or a master's degree. They were both established in the 1960s. The nurse practitioners are about 235,000, about 133,000 PAs in the United States as of last year. Nurse practitioners recertify every five years, and they just have a board renewal. PAs recertify and actually have to take the certification exam every 10 years, similar to the physicians. I think the other thing that's important to highlight is nurse practitioners, more than 25 states permit independent practice. And this is the updated graph of that. I'm excited to report that New York State recently got added just earlier this month to have full practice for our nurse practitioners. And so I suspect that we'll see this continue to increase over the next one to two years. And then every year, the NCCPA reports the top specialty PA areas. And so I thought it was good to highlight gastroenterology is 1.6%. It's one of the top internal medicine subspecialties that PAs are going into. So once you have somebody who's joining, either yourself or another APP, and that's joining the practice, one of the most important things we can do to set them up for success is to have a good onboarding process. And as part of the onboarding, I wanted to highlight some of the things that I think can be really helpful. First and foremost is introduction to the team. Who is everybody and what role do they play? And I think those face-to-face introductions to the best of our ability is really important, so that we can start to establish that relationship of rapport with each other. I know it's a bit more challenging sometimes during the COVID pandemic. Many people have staff that are off-site as well. But having a way that they can just have that dedicated time to really understand and appreciate who everybody is. So having that onboarding is super important, and I think this can be one of our biggest challenges if you're learning a new system. As part of that also, I would add that if you are able to use Dragon, maybe setting up some assigned time so that they can do that Dragon training and get used to it. We have two APPs in our practice, and I would say probably 50% of them use Dragon. But most of them are kind of hit or miss. So depending on the clinic, the situation, the day, probably even our mood, we may or may not type or use Dragon. And so to just have that flexibility and to be able to really adapt to whatever's working for us at that moment has been really helpful for a lot of us. During that orientation process, it's important to have a review of office policies and procedures. I know some places kind of have them all in a binder. Some places use a shared folder on the computer. But I think it's important to sit down with the right people to review them. And then also, where can they find those for reference in the future? Physician mentorship cannot be understated. Dr. Call will talk to us a bit about the APP physician collaboration next. But I think that one of the important things we can do during this orientation process would be to really set aside some time. And whether that's on a weekly basis or a few times a week or maybe even 20 minutes every day, just some dedicated time to sit down and review any complex patients or questions that you may have and start to really establish that mentorship. And projected time can be really helpful in being successful at that. I've also found that having APP shadow other services can be very helpful. And so looking at things like thoracic surgery, colorectal surgery, interventional radiology, oncology, surgical oncology, places that we refer to a lot that our patients we send to that we do this multidisciplinary care with, I think it's helpful for a lot of reasons. One is that you get to know who's there. And so if you're over in colorectal surgery, you're working with their group, and now you've met them, you have a little bit more of a personal relationship should you need to call them and have discussions with them. I think also you can have a better understanding of what patients will experience when they get into that practice. And so if you're referring a patient there, will there be testing that happens at the time? Will they see an APP and a physician or just an APP? Gives you a little bit of a better understanding of that. And I think finally, it helps from our education. So what do they do and why do they do it? Competency evaluations are also an important part of that onboarding and orientation process. How can we make sure that they're getting the training and education that they need, and that they're getting up to speed at the rate that we would expect them to? And then last, but certainly not least, are those education resources. One of the things that we've talked about for many years is that we don't have the same type of background education for APPs in GI. And very grateful to ASGE for developing this course, as this is one really important educational resource that we can now use. And this course is available as well afterwards. And so if you have new APPs who are joining this summer, maybe they're new graduates, they can still register for this course at a later date and be able to take it virtually. And I just wanted to give an example. This is one of our orientation kind of checklists, if you will. And so this is just looking at week two, and I just snapped part of it. But what we do is we try to outline what we would expect to be completed during that week. And so really giving them a clear idea of how many notes do we want you to be able to do. And a clinic in our world is half a day. So ideally, by the end of the week, they're doing two clinic notes per half day. And that would be on their own being sent to their preceptor to review, or the physician if they're with a physician, and really getting the feedback on those notes. And then we like to create our favorite lists for labs and so making sure that we put them on this list has helped us to focus and make that a priority, so that it doesn't get overlooked depending on how busy the day goes. And then looking at our note templates and how to do smart phrases. Always want to take some time to review the imaging tests that are available. Why do we order what we order when we order it? Hydrogen breath test is something that we do and so taking time to do that and usually we'll also try to get the APP to kind of just shadow the administration and the interpretation of those. And then we also try to focus on a couple either procedures or physical exam findings or clinical topics and so week two just tends to be anemia. And so the basic workup of anemia, always using the available guidelines, anything that we can get nationally through ACG or other organizations, and then including those like patency capsules and double balloon procedures. What are they and when would we use them? There are seal banding this week and digital rectal exams. We have videos for both of those that we review with the APPs and billing codes. And so again, just an example, we do this for the first four weeks of their orientation, just to make sure that the APP knows exactly what's expected, but I think also it's importantly helpful for our preceptors. And so if it's somebody who's new to precepting or they're just want to make sure that they're hitting everything they need to hit, this gives us a good guideline. And I think on the expectations topic, part of it also is just to make sure that we're telling them what our end goal is. And so we're going to start with a certain number of patients per week, but by three months or four months or whatever it is for your practice, that you'll be at full. And what is full capacity? That's different for most practices around the country, just depending on the needs and the way that our roles are structured. I think one of the other things that a lot of people talk about is, are there specific diagnoses that should be maybe started with when they have a brand new APP? So do you start with GERD and anemia and dysphagia, and then the next week you'll add some more or do you just start clinic and see a little bit of everything with the support from your preceptors? During orientation, I think it should be addressed. Should there be some specialty and some subspecialty training built in? And then again, kind of those expectations for when we'd expect that you'd be full speed. And I'll say that, you know, expectations, it's important to be very clear, but you also want to be flexible and adaptable. And so we do want to be able to modify that as well and make sure that we're providing the education and the training that somebody needs and understanding it might be more than somebody else. And then in terms of GIA hepatology and fellowship programs around the country, there are three formal 12-month postgraduate programs currently. And so that's John Hopkins Swedish Medical Center and Mayo Clinic in Rochester. These programs are developed to really provide that specialty education and training. And it gives you that didactic learning, research, clinical inpatient and outpatient training. And then APB also offers a APP hepatology fellowship program. I think these are great opportunities where instead of an APP getting in and learning on the job, they can get this extra year of training. Oftentimes these programs have developed also so that you'll do the fellowship and then hopefully stay within that organization. So once you've really been onboarded and you're in practice and you're up to full speed, one of the things that I emphasize a lot in our group is really optimizing that role. And the reason for that is we want to make sure that we're continuing on that continuous growth and education and professional satisfaction. And so some of the goals of that would be to provide efficient and high quality patient care. So increasing the access to care, increasing patient satisfaction, increasing your referring provider satisfaction and improving those quality outcomes. When you look at optimizing your role, you want to have that collaborative practice. And so that APP physician relationship and that shared patient management, optimizing reimbursement. So either through your independent billing, or you may also do some shared billing, maximizing the physician endoscopy time. We have that unique ability to be able to see the patients and refer them on for endoscopy. We can also manage a lot of those background tasks so that the physician can spend the time doing what they do best. Professional development, getting new skills, increasing your complexity of patients, taking on leadership roles, for some practices performing procedures. Research, I think clinical research is a great place for APPs to continue to learn and grow. And then any kind of additional education. And then finally, this all kind of leads to that improved retention. So your job satisfaction, your professional growth, your opportunities for advancement, and your sense of belonging to a team. There are a lot of challenges with this though. And so just to highlight a few of them. There can be a misunderstanding or a lack of awareness of the scope of practice of APPs. And in part, that's because the role of the APP really does vary widely. It varies because of your state or even your institutional regulations. It also varies depending on the needs of the practice or the practice type, so academic practices versus private practices. There is a lack of specialization training. Again, getting better. We have three fellowship programs in the country now, but we only have three. And so having that hands-on onboarding program is so important. It can be hard to accurately quantify the total reimbursement, which I'll discuss in a minute, and then needing that buy-in. So the buy-in from your physicians and the administration to expand the APP role. So APP compensation can be really hard to capture. A few different models that have been used are those work RVUs. People also have done just patient visits, a number, or patient panel size, how many patients is an APP following. There was a study that was done that showed that over 30% of work that was completed by APPs at an academic medical center did not generate RVUs. And so that's things like your patient education, your care coordination, your medication refills, procedural counseling, telephone calls, research. And that's a lot of time. So benchmarking total APP productivity can be very challenging. As we look at optimizing the role of the APP, we also are finding that it's really important to have a dedicated leadership structure. So small groups, you may have a medical director or somebody that you're kind of reporting to. But as we're starting to grow, to be able to have this structure. So when I take a look at that and I look at what are the contributions of each, from an institution or a health system contribution, you need somebody who's overseeing the state and license regulations, who's looking at that organizational structure, the leadership support, support for educational initiatives, and that may be CME time and money, wellness and burnout prevention initiatives, opportunities for advancement and compensation. Looking at it from a practice or a divisional standpoint, having those regular meetings with leadership, being at the table and a part of those discussions. Quarterly reviews, setting and reevaluating your RVU targets, or other areas that you're going to mark your productivity, whether it's patient panel size or some people also do a combination of RVU targets plus in basket productivity. We're also looking for barriers for productivity and how can we make more efficient workflows, and then that open and transparent communication. And that collaboration with our physicians is so important. So having a clearly identified structure. Is it one APP, one physician? Is there a dedicated secretary? Having accessibility to that position, so when you need that support and backup. Also troubleshoot issues, complications, adverse events, having shared decision making and shared workload. This was an article that Dr. Call and I wrote together recently. We're very fortunate to have Gastroenterology and Endoscopy News, who's very supportive of the GIAPP role, and so they have helped us to develop this GIAPP corner. This was published just last month. I did put the web link here, and if you haven't seen it, I encourage you to take a look because I think it highlights a lot of these features. And then looking at opportunities for professional development. I mentioned these a little bit prior, so looking at seeing more complex patients, participating in research, your academic and scholarly work. Anything from interpretation of motility procedures to performing motility procedures to even some endoscopic procedures. And then CME opportunities and certainly tuition benefits. And this is a great example of CME opportunities. All of you are here today to be able to continue to learn and grow and hopefully take some of these tips back to your practice and help to refine that APP role. And I just took a look on PubMed. I wanted to highlight some of the APP work. And so there was a great article that was done in 2019, Clinical Gastroenterology and Hepatology on incorporating APPs into gastroenterology practice. There was one that was just done this fall, the role of APPs in the care of non-alcoholic fatty liver disease. There was a case study that was published by Patrick Horne, advanced hepatocellular carcinoma with tumor thrombus that was in clinical liver disease. And then also things like these case presentations, this was a poster that was presented at a national conference. And so as much as we can say we want to continue to increase our growth and we kind of refine that role. It's also important to the practice, the institution and the health center. And I think with that professional development, you get a greater feeling of worth, you get that sense of being valued, that professional satisfaction, leadership opportunities and increased competence. And that also leads to the increased retention. And so with the retention we have reduced turnover, experienced providers, increased morale, increased productivity, and reduced cost. And so just to summarize some of these points, the effective APP onboarding programs are essential to successful implementation of APPs into GI practices. And that's your clinical education and dystopic procedures, the intro to health system and your EMR training. Optimizing the APP role helps to increase your access to care, patient and referring provider satisfaction, and maximizes reimbursement, and it increases physician endoscopy time. APP compensation models should account for your non-RVU generating work, and this is really important because that's what leads us to that good patient care, and also provider satisfaction. And so that's things like your patient education, your phone calls, those electronic messages, prior authorizations, and then any research and scholarly work. And using APPs to the extent of their practice leads to a higher job satisfaction and retention, and ultimately reduced cost. A couple questions. Optimizing the role of APPs helps to achieve all of the following except reduce burnout, I'm sorry, reduce reimbursement, increase access to care, reduce burnout, increase physician endoscopy time, or increase professional satisfaction. Choose the one best choice. Absolutely. So most people got it, reduce reimbursement. So optimizing the role of APPs does not mean that has to be lower reimbursement, it means that we're doing what we do as efficiently as possible, which in many cases will actually increase it. Opportunities for professional development include which of the following? Leadership roles, participation in clinical research, academic and scholarly work, tuition benefits, or all of the above. Excellent. I put this one here on purpose because I just wanted to drive home that point one more time that professional development is really important for us and to think about things that we want to do and have those discussions with our leadership and our physician mentors, to be able to continue to provide the best patient care we can, but also continue to grow ourselves. Thank you.

onboarding

professional development

APP practices

patient care

professional development opportunities

access to care