So now I'd like to welcome Dr. Vivek Kaul and Andrea Gossard for our next presentation. Dr. Vivek Kaul is the C.L. Watson Professor of Medicine and former Chief of Gastroenterology and Hepatology 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 Barrett's and esophageal cancer. He has specific expertise in complex interventional endoscopy, especially in the patient with GI cancer. Dr. Kaul has extensive experience in collaborating with and mentoring subspecialty APPs in gastroenterology and hepatology. Dr. Kaul is the Chair of the ASGE's Reimbursement Committee, as well as the Society's EUS Special Interest Group. He also serves as the alternate ASGE RUC Advisor to the American Medical Association. Andrea Gossard is a certified nurse practitioner, clinical associate in gastroenterology and hepatology, and an Associate Professor of Medicine at Mayo Clinic in Rochester, Minnesota. Her clinical and research interest includes autoimmune liver and biliary tract disease, including primary sclerosing cholangitis, primary biliary cholangitis, and autoimmune hepatitis. In addition to her clinical practice, Andrea is actively engaged in leadership of nurse practitioners and physician's assistance practice within her own department, the Midwest Regional Practice and the Mayo Clinic Enterprise. Vivek, Andrea, the audience is yours. Thank you so much, Jill, and my sincere thanks to you and Dr. John Martin for inviting us to present here at this, one of my most famous, favorite courses in the world that I get to do. I also want to thank the ASGE and Dr. Joe Vicari for helping develop this task force under whose auspices this particular course is held. It is my great pleasure to present on this very unique topic with a fantastic co-presenter, Ms. Andrea Gossard at the Mayo Clinic. It's been a great time developing this talk. This is not a topic that is very commonly addressed as Andrea and I, when we researched it, found out. So most all of this work is original and the sentiment is really geared to, you know, speak to the development of academia and academic prowess and scholarship and some elements of clinical research that both private and academic practice-based advanced practitioners can do. And this is a recipe that will be somewhat elucidated in the second half of this presentation. So Andrea will present some of the data and some of the concepts in the first half, and then we'll have a conversation which is somewhat structured in the second half, which will try to tease out some of the recipe aspects of this. I want to say this from a personal journey of nearly a quarter-century and working at least half of that closely with the very, very fantastic and prolific APP, Sarah Enslin, this is certainly an aspect of your professional development that will open doors, build your CV, and really set the stage for a great career. So with that, I will ask Ms. Gosar to go ahead and start the presentation, and we'll join in back after the halfway stage here. Andrea, welcome. The floor is yours. Good morning, everyone. Thank you for this opportunity to present today. I had the pleasure of working with Dr. Call to create this presentation, and we look forward to the question-and-answer session in a bit as well to kind of go through some of these concepts. So we just had the chance to listen to Sarah describe how to establish as a clinician in clinical practice, and I recognize that there are additional sort of facets to each of our professional journey to think about what can we do to promote the profession and increase our own visibility as contributors to research and understanding of the APP role, as well as the science of the disciplines that we're engaged in. So first are disclosures. Mine simply include my engagement with GAP as well as ASLD, and Dr. Call's are listed there. So polling question number one, do you participate in clinical research? So the minority are participating in clinical research, but 16 percent, it looks like those opportunities are there, which is exciting to see. So second polling question, all of the following are opportunities for scholarship and research except? Very good. Excellent. Thank you. Okay, so our objectives today are to discuss the value of APP participation in scholarly activity and research, to describe opportunities for our APP colleagues for engaging and participating in such activities, both in a private and academic type settings, and then to reach out to our activities, both in a private and academic type settings, and then to review the importance of our society involvement and support for APP advancement. This is something that we have certainly seen progress quite a bit over the past several years with much greater inclusion of APPs than we have seen in the past. We will then have a brief time for discussion and some question and answer. So what is the value of research and scholarly activity for APPs? Well, the value would be the same across anyone who's engaged in the fields that we as APPs and physicians and scientists are involved in. We want to be able to answer important clinical questions through the research that we perform. In addition, and we see this across the board for APPs in particular, we're hoping to influence our current and future practice with improved patient outcomes, efficiencies of our clinical practice structures, and to be part of innovation, potentially with pharmaceutical companies or device companies. In addition, acquiring new skills through the research that we perform, statistics and modeling, of course, promotion and career development. So for many NPs and PAs across the practice, we're now seeing those be much more engaged in clinical research and scholarly activity than we've seen in the past. This has afforded kind of much more visibility to our roles and the unique features of our profession. And for those of us that have a clinical practice, you know that doing that day in and day out might begin to be rather monotonous. And so this offers an opportunity for some variation to your clinical responsibilities. We have many colleagues, Sarah being one of them, who have achieved knowledge, or I'm sorry, pardon me, a key opinion leader or subject matter expert status. And this then leads to invitations for presentations at annual meetings or CME type of settings, and maybe involvement with advisory boards or groups where we're looking at really optimizing patient care. So opportunities for scholarship and research. I think about this when I first maybe wrote or authored my first paper. It was a case report of an interesting patient situation that I'd encountered in clinical practice. Case reports are something that, you know, fortunately, it's in essence telling a story about what you've seen in your clinical settings. So that could be something that's of great value and can be shared with others through publication in NP or PA journals or otherwise. Review articles are always a nice opportunity. I found that when you engage in writing a review article, not only are you providing benefit to the reader, but you yourself are staying abreast of the latest information on a particular topic. Of course, being part of clinical research trials, maybe not necessarily as the principal investigator, but as a co-investigator, seeing the patients as they return for their follow-up visits or co-authoring the manuscript. And then, of course, presentation at national meetings. I alluded to this earlier with the reference to societies and greater visibility for NPs and PAs. Most of the societies, AGA, ACG, ASGE, ASLD, have an NPPA-led CME activity. And, of course, there's GAP, which is exclusive to APPs. And so, we know that there are those opportunities out there to really showcase our APPs and the contributions that they've made. QA projects are always an opportunity, oftentimes within our clinical work units. And then, editorial assignments or peer review for professional journals. So, you may note that once you've authored a publication or two, you will be pinged for expert review of further publications, which is a terrific opportunity, again, for our APPs. These are some examples of the contributions that have been made by others in the field. So, Sarah is listed here. And I know that she authors this GI APP Corner, which is a terrific sort of venue for providing sort of advertisement, if you will, or marketing of what APPs are doing. We have newsletters through GAP, as well as, oftentimes, our own NP and PA journals, such as these two that are a great venue to have our NPs and PAs submit their publications and have them authored in a venue for people to be able to view going forward. There are also opportunities when we work with our physician colleagues to co-author important, again, review articles or novel concepts within our respective journals. I have oftentimes asked the physicians that I work with, if you're being invited to provide a publication, please allow us or consider whether or not we have APPs on our team that could be contributing authors. And that has been a nice pathway into publication. We also, as mentioned previously, have the opportunity to present at national meetings. I think we've got Jill on the big screen here for her contributions at GAP, which was held in the fall of last year. These are terrific venues to consider your foray into public speaking and getting in front of a, or behind a podium in front of an audience. You know, we, beyond just having sort of the, the plenary session, oftentimes there are workshops for smaller scale contributions, a little bit less intimidating for the very first few talks that you'd be providing. There are also the opportunities for poster presentations, again, authored by Sarah here, along with Dr. Call. These are terrific ways to sort of showcase your contributions and the science that you have contributed to. So, the fundamentals and essential requirements that we consider sort of most important for an APP to excel in this space really include a variety of components. We recognize that most NPs and PAs are primarily hired for their clinical activity, and so some support from administration or leadership is, of course, necessary so that these goals can be achieved. Physician mentorship I cannot speak to loudly enough. We know that in our training oftentimes we have a relatively limited amount of education in this area, and I have, you know, personally, and I suspect most of my APP colleagues have learned a great deal from physicians who have perhaps more training and then have excelled in in being in creating these contributions. Partnership with trainees, residents, and fellows are a terrific resource to align with if they're in your practice. Funding may be limited, but at a minimum, if you have some time that's allocated, recognizing much of this may be on discretionary time, really just securing that time to create the product and submit would be of utmost value. From an APP perspective, I think it's essential that we all maintain an updated CV, including any contributions from a speaking perspective, publication, but also mentoring. We have many students that may be coming through or colleagues that you've mentored. All of those are important components to an up-to-date CV. Creating your NIH biosketch so that you can have an appropriate reference and introduction when you are presenting. City training, which is something that you'll need if you're engaged in clinical research that is renewed every three years. And then awareness of clinical guidelines and protocols, as well as clinical expertise, which as Sarah had alluded to, many of us really garner through our clinical practice as we're onboarded, because much of the time, our preparedness in our programs is a little bit focused on general education and less so on our subspecialty areas. So ensuring you have a venue to build that subspecialty expertise is key. Communication skills, of course, and interest and desire in professional development and career advancement. The gaps and hurdles that we face as APPs are not dissimilar to our physician colleagues. The opportunity for mentorship, training and education, protected time, which we recognize is oftentimes difficult to secure. Institutional support, which may not necessarily equate to time or funding, but is present. And then, of course, ideally, if you're able to, securing some funding. Partnership with trainees and physicians, as I'd referenced, is really key. That's a terrific platform for oftentimes the first foray into publishing, and it helps to build your skill set. So necessary partnership in my mind. And national society support and advocacy. So we talked about this. GI and hepatology societies in general have been very welcoming to NPs and PAs, which is not the case in all disciplines. So this has been exciting to see. If you're not aware, GAP is gastroenterology and hepatology for the advanced practice provider. This is an APP-led organization. We do have a professional development subcommittee that is always looking for membership. There are many opportunities in that organization, as well as other organizations that are listed here. So practical tips, show interest, and as I mentioned, ask to get involved. That's going to be your first step to securing an opportunity. Attend high-quality meetings to see firsthand, such as this meeting. Negotiate protected time if you are able to. Physician mentorship is crucial, and I completely agree that this is necessary as you begin. Resources, we all have kind of our go-to resources, whether it be up-to-date, PubMed, but make sure you become comfortable with searches and understanding how to get to the latest, most up-to-date information. Read case reports, and oftentimes if you're considering a case report, this is the recommendation I provide, is look to other case reports and model after that with your own case report. Review articles are a great educational opportunity, and of course, being aware of the pivotal clinical trials that affect your clinical practice. Ask questions, join a QA project, reach out to peers who have published, and consider reaching out to editors. As I mentioned, we have our APP journals, and of course, there's many MD journals that are available, so seek out the opportunities and pursue them to achieve this goal. So we're going to turn it over to a bit of a conversation between Dr. Call and I, and I would first ask, what roles can an APP have in clinical research? Thanks, Andrea, that was a fantastic presentation, and you know, this is an important question. I think in my mind, the APP can serve several roles, and again, my comments really are comments, unless otherwise specified, really allude to both the private practice setting and the academic setting. These are generic principles, so you know, you can be a primary author, a principal investigator in a small project, or you can be a co-investigator or a sub-investigator, depending on the nature of the project, and the projects can range from a case report or a case series write-up to a QA review that you have done in the hospital setting or in the outpatient setting that then turns into an abstract with the appropriate IRB approval, and then may turn into a paper. There are other roles folks can play. I have also seen some APPs dabble with the clinical research coordinator role in some way, working with a clinical research coordinator hand-in-hand, facilitating some of the clinical aspects of that role, while the main clinical research coordinator handles the operational and regulatory documents and so forth. So there is a wide variety of roles that folks can play, but I think it ranges from what type of project you're doing. I agree with you completely. I think that over the 20 years or so that I've been in hepatology, I participated in each of those roles at some point or another, so I agree with you. Another question, what training opportunities are available for APPs who want to get involved in clinical research? So I think the best initial training and mentorship, as you alluded to, is within your own house. So depending on the practice that you're in, if you're partnering with a physician attending collaborator or with a trainee level person or another APP, for that matter, who has more experience, I think learning from them the basics of how to get involved with clinical research is really key. Most health systems and certainly most academic institutions have in-house resources available through the various departments, whether you're surgical or medicine, for obtaining training in this realm. Then comes the national societies, and the ASGE, along with other societies, have several resources available from time to time that are not only useful for the physician sector, but also useful for advanced nursing as well as for APPs. And then, of course, the national meetings usually have a lot of research symposia that are dedicated to the basics and, of course, more advanced discussions as well. And then there is finally doing your own reading and kind of doing your own research, pun intended, online. Nowadays, we're all digital, so gathering information from a variety of sources on your own as well. But initially, it starts with mentorship and guidance from your collaborator within the building. Thank you. So I think that this is an excellent question. How do you choose topics? From my perspective, I sort of see this that when it's something that's particularly novel, if the physicians that I work with have not seen this in their career despite being in practice for years, then it's something where we oftentimes I'll ask the question, is this worth writing up? What do you think? Right. So I think what I found personally useful, and this is the absolute honest truth, is that if I'm excited about a particular clinical scenario, whether it's a clinical medicine scenario or if it's an endoscopic or procedure-related event, I usually get, you know, if I'm excited enough, you know, I'm going to write it up in some form or at least present it in poster form at a national meeting or encourage the trainees or APPs or even nursing in some cases to position that. So I think topics, events, scenarios, clinical vignettes that impressed you, that you were excited about, most certainly amazing, successful clinical outcomes, fantastic, you know, success stories, but also sometimes outcomes that didn't quite pan out are important for the world to know because, you know, everybody learns from both the good and the negative outcomes. So that's, I think, a big bucket starting out. But then again, you know, you look around yourself, you're all engaged in education and raising awareness in a variety of ways. Look around what are the hot topics of the day? Where are there unmet needs and gaps in our sphere? And check with your colleagues whether it'd be a good idea to get invested with those type of topics. So I think those are some of the strategies, so to speak. But most certainly, I think if there's already an ongoing project within the building, then I would certainly explore the opportunity to join that first, learn the basics, learn the nuts and bolts of it, and then build confidence and experience, and then apply that to other areas and other potential sources. Very good. Thank you. So in the interest of time, I'm going to go to the last question. I am in a small private practice GI group. How can I fulfill my scholarship and clinical aspirations? I recognize that in my setting, I'm in an academic center where I really, it is different, and I know that. So what are your thoughts on that? Well, Andrea, you're absolutely right. It's a little bit easier lift if you're in an academic setting, certainly in a large, reputable academic setting. But I don't want to discount the opportunities and the possibilities for a relatively smaller system. I think it really boils down to your own personal motivation, your career goals, and your interest level. But also, if you're somebody who wants to break the monotony of the daily clinical practice and wants to do a little bit more to build your CV, which will subsequently open up doors for you and enhance your professional development, then that's the primary motivation to get involved with this. And how do you do it? So again, most private practices nowadays even are fairly reasonable size and have, more often than not, clinical research units built in. So that's a good place to start. Speaking with your physician collaborators and your APP colleagues about case reports, case series, potential review articles. Approaching now, we have several journals, as you pointed out, approaching the editorial boards of those journals and saying, I'm interested in writing up a certain topic or what are the opportunities. Then, of course, as I mentioned, the digital and online world is very, very useful because there are courses on writing, there are courses, basic courses on biostatistics, and of course, in national meetings and the society websites. I would just say that, you know, instead of attending, and I have nothing against any particular specialty, but attending another endoscopy course or another liver meeting or another IBD chapter meeting, you know, once in a while sprinkle in these additional enhanced add-on learning experiences that actually go a long way in building your career overall. Very good. Thank you very much for the opportunity to present and Dr. Call and I will be available in the question and answer session and I'll turn it over to you now, Dr. Call.

APP

clinical research

scholarly activity

mentorship

training

private practice