Eden, we have any questions on your end? We do. We do, of course. The first one I think might go towards Jill. With patients who have DM, would you recommend them taking split dose the morning of six to eight hours before the procedure since there may be some questionable gastroparesis? So yes, that's a good question, and I would agree with that. The other consideration you want to make with your diabetic patients is that if they're on oral agents, if they're on insulin, we try to bring them in, well, we do bring them in first thing in the morning. So if they're going to be changed on their diet the day before, we recommend that they follow up with their endocrinologist to manage their medications, either oral. Usually their insulin we'll have them follow up with, but we assure them that they're going to be getting a lot of sugar during that day before, but definitely to check their blood sugars and to follow up with their endocrinologist if they're on any insulin agents, but we try to bring, unless it's an emergency or urgent procedure, we try to bring all our patients in in the morning. This is a very important point, prepping the diabetic patient or prepping the patient with a significant non-diabetic comorbidity. Special attention needs to go to this and our clinic nurses are very helpful and have been set up as a group to assist our providers in managing these questions as well. The other time that this becomes important is when you have a patient coming or patients coming from long distances and certainly this is a big problem in middle America and it's a big country where patients travel 100, 200 miles sometimes, they really need to come in the night before, especially if they have an early morning procedure so that they can prep comfortably within 10, 15, 20 minutes of the hospital and not be pulling over on a ride from a long distance. So bowel prepping the complex patient or a patient who's coming from a long distance is a science unto itself and again goes back to what we call patient-centric practice. You have to care about these things and factor them into your clinical practice for the outcome to be successful. Other questions, Eden, on your end? Yes. Are the aspirin recommendations different for 81 milligram versus 325 milligram for high-risk bleeding procedures? Sarah, I'll let you answer that. I have very strong feelings on aspirin, but I'll go next after you. They are not different, no. Go ahead, Dr. Kaul. Oh, I was just going to say, I think most of the faculty here will agree with me. I think aspirin really can be and should be continued through most of endoscopy. It is in the guidelines and there may be some physiologic differences between the 81 and the larger dose, but at the end of the day, those platelets that aspirin affects is mostly irreversible. But study after study has shown that the overall mortality of stopping aspirin is higher than the morbidity and the grief that you get with continuing aspirin, which is usually not significant. So please continue the aspirin through the process and the other guidelines are in place. They're not perfect, as Sarah pointed out to some of the challenges, but it's the best information we have right now. So next we have a billing question. If a patient is taking antithrombotic medications and is due for a screening colonoscopy, are we able to bill for an office visit to educate the patient and coordinate holding the medication with the prescribing provider? Jill. So my recommendation and what I teach on is that you would use time-based coding. So you're going to be able to spend the time face-to-face and doing your record review depending on what code, but it would be time-based coding. So many years ago, the guidelines for covering screening colonoscopy consultation, they removed that. So currently, if you use the Z code for screening colonoscopy for your office visit, and that's just for screening colonoscopy, and you bill either an established patient visit without a record review, then they would not cover that. But if you do time-based coding, and I'll ask my other colleagues what they do in their practice, then you can cover it, then that is medically necessary, you can bring the patient in and bill for that. Yeah, I agree. We would do time-based coding as well. And I would say that the same thing goes for your patients that maybe have a complex medication regimen with their diabetes. And if you bring them in to talk about how can we best follow prep. Or the other thing that I always think about is our gastric bypass patients. Sometimes they have a hard time with the volume. And oftentimes, I will still do the same prep rather than give them a different prep, but I'll have them start it much earlier and go much slower and talk about ways that we can get them through it. And so you can bill for those under a time-based code. And my kind of comment on this is more on the philosophical lines. The conflict, the tension between best practice patient care versus the financial aspects of medicine has always been there, it'll always be there, no matter how better we get with codes and billing and the nuances of clinical practice. But I think one general guiding principle, this is for new providers who are just coming on board, have a long career ahead of them. If ever there's a conflict between best practice and the finances related to that action, the clear winner is best practice. That'll stand you in good stead and will position you very, very well vis-a-vis patient care. And this is not an individual position. This needs to be the position of the practitioner, of the unit, of the institution. That's where the overall philosophy and the culture of a practice comes right to the forefront. Other questions, Eden? Yeah, we have a scenario here. We've recently started using split prep for a majority of our inpatients prior to colonoscopy. One of our physicians requires all his patients to do a full 4,000 milliliter prep evening prior followed by 2,000 milliliter morning of procedure. Is there a measurable difference between the split prep of 2,000 milliliters day before in comparison to 4,000 milliliters day before? I find our patient compliance is very low with this amount of prep. I don't know if there's been a way to objectively look at that or measure that, at least yet. But I will say that we have done a full 4,000 mLs one day followed by 4,000 mLs the next day as a extended prep, and it works very well. Patients may not like it, so I think a lot of the education is needed to some element, some handholding. I guess my question would be why they feel that they need that aggressive of a prep, and maybe there's some level of experience behind that. Or if, I don't know their situation, but maybe they're an advanced endoscopist and they need to have a very clean colon for the types of procedures they do. I guess that would be kind of more of where my question would go. Right. Erika, there is a question here on sedation. It says, if a patient is requesting not to be sedated, it does happen every so often, an unsedated endoscopy, does anesthesia or the sedating provider of the day still get to charge? Not in our ASC. So if the anesthesia provider is not being requested to be there, then they can either kind of fill in in other ways or just take a 30 minute break or whatnot, but they don't get paid to be on call. Or they can hold the patient, right? Now, I think that's the correct answer. If there is services not provided, it should not be billed nor reimbursed. The same thing applies for the moderate sedation charge that we use. So other questions from the audience or Eden, do you have any other questions that we can address right now? Yeah, absolutely. And we want to run a couple of polls in this session too. So first, I just want to circle back to the first session since this is our APP session. How do you suggest pay and compensation become more transparent? This is a tough one. The only person who can answer it is Dr. John Martin, because he works at the Mayo Clinic. The Mayo has always been the beacon for salary transparency. But short of that, I think this is a problem that most entities struggle with. Transparency when it comes to compensation is a difficult topic. The way I've seen this addressed the best is right from the top. This is a discussion that starts top down. And regardless of which entity you're in, the parameters for compensation, the way it's going to be handled, the way incentives will be handled, benefits will be shared, really needs to come from the top. Usually there's a board in academics, there's a dean, chair, division chiefs, but it frequently gets muddled up for a variety of reasons, which we cannot get into here. But it is an important concept. It's difficult to manage. Very few entities have been able to do this right. And it remains a bone of contention across medical practice, the financing side of it in terms of transparency. But I'll let the others on the group, faculty, kind of weigh in on this very important question. Yeah, I think I agree. So when questions have come up and kind of across my plate with that, I do typically just go right to the supervisors and have them start to have that conversation. Because I think it's a really difficult thing. There are many people who wish there was more transparency, but there are quite a few who also prefer to keep it private. I think there's a lot of nuances potentially built into it as well. And so, you know, there can be differences in pay because of regional differentiation. If you pick up extra time for a call, some APPs do. If you're doing inpatient, sometimes there's some increased pay for that versus outpatient only. If you do procedures, you may be getting more compensation for that. And so I think that if it becomes transparent, then there has to be some kind of metric where you're able to better interpret it. And that's something that is really challenging to do without having our top leadership. If I could jump in, if we have time, at least from the practice or private practice model. It is at Vivex, right? It's a very difficult topic. The easy piece is the benefits. So making sure that the benefits are fully explained, fully transparent. And so I think that's the easy piece. In our practice, and I see John Martin's hand up, so I'll be brief, our payment model is similar to, I believe, his. Everybody gets paid the same. Physicians get paid the same. It's one pot. It gets split. And the providers are also paid the same, including bonuses based on the time they work. Full-time versus one that's 80% and one that's, I think, 40%. So it's pretty easy in our model, a lot more difficult if you're working on some type of production system. John, please go ahead. Thank you. Thanks, Joe. Yeah. I do think that it depends on what you mean by transparency and how broad or widespread that transparency is. Vivek, as you were pointing out, I work at Mayo Clinic in Minnesota, but regardless of which Mayo Clinic institution you work at, we are all salaried. But the degree of transparency is that I know what every other gastroenterologist in my department gets paid. She or he gets paid exactly what I get paid. But I don't know what, say, a general surgeon gets paid. That's business confidential to their department, and they don't know what I make either. And so the transparency across the institution is certainly not published. But I think the bottom line is it depends on what the philosophy and the pay model of your organization is. We're not productivity incentivized at all, and that's the value of the organization. So if you stay late and work extra, you don't get paid more for that. That may or may not be good. But there's more transparency because we don't get that additional compensation. And so there's pros and cons to the transparency thing. And as Sarah was astutely pointing out, really depends on what the philosophy is of the entire group and of the organization. Some individuals are happy to have everybody else know what their pay differential is, but others feel that there's value to maintaining privacy about that. And the leadership may have a different opinion from those on the front line like you and myself. So that would be my contribution to the discussion. Thank you. As I think the audience has gleaned already, this is a vexing topic with many, actually many good things that come out of such a discussion on this topic, such as that the metrics need to be clearly defined, the institutional culture, philosophy and policies on this topic need to be out there, they need to be transparent. But also some things that have evolved in the recent years, which is a huge emphasis on citizenship being a part of the compensation, such that you bring other things to the table rather than just showing your E&M billing, or your productivity in RVUs, that you're a good citizen, a good member of the department, or the practice that you add value beyond patient care as well, that you minimize the noise around your practice, that you elevate others around you, you mentor, you teach, you contribute in many ways that we've already talked about this this morning. And I think division chiefs, practice managers, leaders in practice, have been paying more attention to that, and if they haven't should be paying more attention to that. And I think that really elevates the quality of a practice, and sends the right message to the individual provider that, you know, if they do, if they're good citizens, that is at least valued at the same level, or perhaps even more in some practices, than exactly how much the bean counter is telling you. So, so that's really one of the good things that comes out of this, to me, to me at this stage, when I look back, Jill, or Erica, you have any comments on the compensation point? I think you covered it. Okay. I was gonna step in. So when a nurse practitioners or physicians assistants are hired, they're given a salary range. So, and as Sarah mentioned, usually this is confidential. So it's going to be based on your years of experience once you start working in the department, and then you would get merit raises according to that through your evaluations. What is a beneficial benchmark that Dr. Cowell was mentioning is one of the basic ones is how many patients do you see a month? And what is your E&M coding frequency? So the opportunities are to make sure you're maximizing your coding level, because that's going to generate reimbursement too. So that's still a pretty basic benchmark that we all have to meet. And then important is to compare peer to peer. Currently in our organization, we're looking at more peer to peer support over multi-specialty regions. So we can start supporting each other on a peer level so we can meet these benchmarks. And it's not only just meeting it, it's understanding it. You know, you have speakers here today that have spent a lot of time and energy and courses into understanding the practice management behind all this. So you coming to this program this weekend is your attempt to then start understanding it. And you're going to go back with questions to your practice saying, you know, what is my E&M coding pattern? You know, am I meeting benchmark? And sometimes, unfortunately, it may be a year after you've been in practice, you have this information put in front of you, and it's Greek. So starting to ask those questions, ask for that information, it will empower you and you will understand how am I being graded and how can I do better. And it needs to be said that the larger the entity, the more difficult it is to be flexible for individual practices to do something different for you, do something more for you. And by the same token, take away anything from you. So smaller practices have a little more wiggle room, flexibility, in terms of custom building your compensation and pivoting, you know, positive or negative, depending on how the discussion goes. But larger entities are pretty much fixed in by a lot of the institutional and HR and legal policies that are in place. And they in turn look to the national benchmarks. And needless to say, the benchmarks that are referred to are more on the modest side. But by the same token, the expectation for RVU should be also on the same line. So for example, if your compensation is around the 75th percentile, then the RVU target should be around the 75th percentile. And in general, there's about a 5 to 15% variance allowed on both sides of the equation before which the carrot or the stick comes into play. So this is a complex topic. Clearly, there is another question that I will propose, if there are no others, is one which, how do you address those physician partners, address, unquote, who don't round on patients after you've done the new patient consult? I assume it refers to the inpatient setting. What do you do in that case? This is an interesting question. We can go through this real quick with all the faculty who are on, please. Sarah, you want to start with that? How do you, is it a special chamber you bring them to? That's right. You know, I think it depends. I think it depends on your level of experience and your comfort. And you know, certainly if they are taking pride in the fact that you are a provider and you did the consult and you presented it to them and they're comfortable with it, if you're not, I certainly would encourage you to speak up and make sure that they know that. Because if the expectation is that you can build for that yourself and they don't need to see them, but you feel differently, I think that's where you need to have those lines of communication open. You know, I think the way that you could look at it would be to say, this is what I'm thinking. I'd love for you to come back and see them. Can you do a physical exam with me? If needed, take them to that back chamber and have that conversation. Yeah, I'm very good at that. No, I think the flavor of the question is probably more around the place where the APP feels, quote unquote, someone, you know, left alone, where they might, he or she might, thinks might benefit from that engagement, from that input. So I think I would take it in that light. But most certainly, you know, if you are comfortable, competent, you know, experienced enough to handle the situation on your own, by all means, feel empowered to deliver that task, you know, with whatever degree of physician participation there is. But certainly, if there's an expectation, a need, an unmet need, or a requirement, or a perception that, you know, you could, you and or the patient would benefit from additional input, that should be sought. And if that becomes a recurring issue, that needs to come back to the leadership to have that transparent conversation around collaboration. Other comments on this, please? I think something else is just making sure, what is your question, you know, if you want your physician colleague to round on the patient, is it that you are concerned about something in the physical exam? Is it that you're concerned about the trending H&H or the LFT, you know, making sure that that physician colleague understands what it is that you want done? I mean, I guess if you present it like, hey, you know, I'm just really concerned about this abdominal exam this morning, he was kind of rigid, I'd like to go back with you this afternoon, and maybe we can do that again. And just kind of having what's the question? What do you want from them? Because, I mean, our docs are busy scoping in the hospital, we're rounding on patients, I will tell them if there's something that I'm concerned about, but I make sure that my question is concise, so they know what I want, versus, can you just go round on this patient? It's like, well, okay, you know, so making sure that you're concise. That's a very good point, Erica, I think the specificity of the ask is really, really positions you well. If there is a one or two point question that needs to be addressed specifically, you'll likely get farther ahead with that. And I think it'll be much appreciated on the other side as well. But sometimes it's a more global question. But I think if you know what you what you're really looking for, that makes the discussion much easier. Jill, you had a comment on this too? Or Joe and John, you were on, please feel free. No, I just support Erica. Because it's just so important that they know exactly what we want. Especially in the time of COVID. We did a lot of communication with Tiger text, and secure chat, and we didn't see them face to face. And we didn't have that luxury of the actual face to face dialogue. So we really learned how to be very succinct, put that question out there. And if I wasn't, and I didn't get a response, I'd say, hey, why don't you answer my tiger text? And he'd say, I didn't know what question you're asking me. That can boil down to something as simple as that. But I think if there's an expectation, such as when we put together our inpatient model, it was an expectation that fellows and the inpatient consult attending will literally be there at a moment's notice. And definitely co-sign and or co-consult on those initial few weeks and months when the person was on boarding. So it depends on the situation. But I think my personal goal with these models is that certainly on the inpatient side, is that the ultimate goal is that the APP becomes an independent provider and is able to deliver the vast majority of those consults. And that represents growth, and that's the right thing, and also adds to their productivity bottom line. Wonderful. We have a couple other questions I want to try and sneak in, if I may, before we go to break. And we do have two polling questions. What time frame should be allowed to build up a clientele for new GI practice within a specialty group? You can start next Monday, we'll get you busy right away. Sarah, you have an answer to that? Because you spend a lot of time with this part of onboarding. Yeah, you know, I think it's highly variable depending on your practice model. And so if you are working mostly independently, you're going to get that quite a bit quicker than if you're doing a lot of shared visits. As with anything, that panel is going to come with time. I would say we try to get our APPs up to full volume within six months. They're about 70 to 80% by three months. And then we take a little bit of time to get them that last 20% or so, because we want them to be able to focus on their continued education and not get overwhelmed and bogged down by details too quickly. But I think to carry a full panel kind of long term, not just the one visits that you see and get rid of, probably takes a bit longer than that. Okay, and got a scenario here. This person says when I got hired, I brought up the question of bonuses for productivity. As I know, this is offered in other specialty and GI practices. I was told that it's something that could be discussed. This was said by the recruiters before starting employment. The recruiter referred to the administration, physicians, once I would be at the phase of seeing patients independently. Is this typical? And how is it best to approach this question of bonuses with the administration or a mentor? That's a great question. Simply put, in the interest of time, number one is that these type of bullet points are in your contract. So if you are entering a practice with these type of incentives in place, make sure that they are in your contract. Number two, there is almost no time where a mentor is not the correct place to start. So especially early in practice, if you have a physician champion or another colleague champion, mentor, somebody you can trust and have a confidential discussion, that's absolutely a fine place to start. And in fact, that'll provide you reassurance if you're on the right track and or dissuade you if you're on the wrong track, appropriately, dissuade you. And then that person can actually also help bring your case to the senior leadership. So that would be my answer to that. Okay, we're going to sneak in two more questions, and we're going to do our polling questions and we'll go to lunch. And this first one's for you, Sarah. What do you consider a full panel or full volume? Yeah, so six patients per session is full for us, 30 minute visits, so 12 in a day. Okay, and I think you might have just answered the next question. What is the average number of patients outpatient that the GI and PPA sees per day per hour would love to get a sense? So you just answered that again, right? Wonderful. All right. Well, if you don't mind, Dr. Call, I'm going to run our polling questions really quickly before we go to break. Is that fine? Absolutely. Okay. And then did you want to read them or would you like me to read them or? Let's see. I don't quite see. Okay, I'll just go ahead and read them now. How long have you been a GI APP? Are you a new graduate? You're an APP new to GI, less than a year, one to five years, more than five years, or I am not an APP. We know we have a mixed audience here today. This is going to help us gear our future education, which we hope to be not only this course, but more wide ranging. Is that right? Sarah and Dr. Call? Fully agree. Absolutely. Okay. Just so everybody, I'm going to go ahead and share the results so everybody can see we have a nice distribution here. Sarah, any thoughts on that? Yeah, that's a great distribution to see that there's ranges from brand new graduate to more than five years, almost equal. This almost looks like a manufactured response, but it's amazing to see this distribution. Great. Next question, please. Okay. And then this is the only thing between us and lunch here is how did you hear about the APP course? And you can select all that apply here. So we've got ASG communication as a member, email communication as a non-member, you received maybe our brochure, your manager practice recommended the course, the ASG website or promotion through society group networks. And that includes our faculty here. If a faculty member reached out to you, feel free to make that selection. And we have a really nice response here. I'm going to give it another second or two and just so everybody can see. So nice. So we're reaching you different ways. Our goal really is to make sure that we're tailoring our content to everybody and that we're able to reach as many people as possible to be able to provide this information. So thank you for answering those very helpful as we look ahead at next year.

gastroenterology practice

diabetes mellitus

preparation for procedures

aspirin in high-risk bleeding procedures

billing for office visits

unsedated endoscopy