I invite the faculty back for our question and answer session. Thank you. Joe, if you don't mind, I'm going to start with you. When you were talking about the art and science of that quality patient visit, one of the things that has come up is nonverbal cues. You gave some great examples for those in-person visits. What about for people who are doing telemedicine? You have the video, but you really only have the facial expressions. What are some things that APPs can be doing in that aspect? I think you're still muted, Dr. Bakari. I think my wife and girls many times would like to mute me, but probably this morning is not the time to do that. Sorry about that. I think from the perspective of the provider who's looking at the computer, I think there is still a way to make this personal and not artificial with the computer. I think it starts by tone of voice, level of voice, obviously dressing professionally, and that's where the nodding and the smiling really comes in. Because there's not a whole lot more you can do with body language, because you might only see part of the image like you're seeing of me. If you crossed your arms, one wouldn't know it. I think it's more verbal tone, making sure we let the patient speak. We want to jump to questions quickly, but making sure we let the patient speak. On the flip side, and there's not much we can do to control it, but the patient also has to be engaged, and we really can't control that. We've seen some strange things happening with patients doing their visits in a car or maybe not dressing appropriately during our visits. Maybe some guidelines from the practice for those type of visits on the website could help. But just doing our best to not roll our eyes, not have negative body language, and definitely trying to keep our surroundings quiet. Distracting noises, me making an espresso in the background doesn't help as the machine fires up. It sounds funny, but we know all things have happened. Same principles, keeping it relaxed mostly through tone and body language from the shoulders up. Thank you. That's great advice. This next question, I'm going to ask Dr. Call and then Jill. If you're interested in becoming more involved in clinical research or scholarly work within GI, what advice do you have to help to break into that area? Dr. Call, from the physician perspective, if you could comment on that. First question we have to say is, yes, it's doable. The second question is, how and with whom? There you have two options. In the building, you can have a physician champion who's already doing it, and that's somebody that you would look at in terms of being a mentor for that. If that is not an option, particularly if you're in a smaller practice off-site and don't really have affiliations with a big educational setup, then you need to look outside the building. Outside the building, those opportunities come. It's 2024 where the world is more connected than ever before. The opportunities come from online engagements with people that you've met before, or more likely to come from attending regional and national meetings in person, typically, where you listen to a lecture or you are looking at a research presentation or you're interested in a topic that a symposium is held on, you go up to that person and you make contact and you go from there. That has happened to me and has resulted in some tangible products down the line. So there is opportunity to do that both within the building and outside, depending on where you are, who you meet, what your focus is, and then follow through on that. Because typically, a person will give you a contact information and will be receptive, but then you have to do the legwork, follow up, and show that you're really motivated and actually can follow through with that engagement. Thank you. Jill, any comments from an APP perspective? Anything else to add to that? Yeah, I think to advance our scholarly work, it's going to be important to publish and to present. And there are several nurse practitioner journals that are open for articles. It's a matter of identifying the journal and then reviewing the guidelines on what they're looking for, the word count, whether there's an abstract. Also, you can send a query to the editor to see what topics that they're interested in. I had, I'm actually on the nurse practitioner advisory, editorial advisory board, and there are different topics that they're looking for. And I recently submitted a manuscript for review on the new 2023 Celiac disease management guidelines. So you can even reach out to nurse practitioner journals to say you'd like to be a reviewer because everyone on this program today has an expertise in gastroenterology versus a generalized advanced practice provider or family, you know, someone that works in family specialty areas. So everyone has a keen interest here and you can, and every journal is looking for reviewers. That's a given. And you learn how to write by reviewing and reading other people's articles as well. And then as far as public speaking, a lot of times people will publish first before public speaking. And start by public speaking by offering to give a community education lecture. That's how I started. And I thought, well, gee, I know more than my patients do. So I could do that. And so next thing you know, you are putting yourself out there as a community education resource. And you'll be surprised, you know, within that community center, whether it's a senior center, you know, you'll be getting more calls and it'll just give you more confidence to provide public speaking. And next thing you know, you can submit an abstract to your local conference or to your national conference. But even your local conferences, look at your local state nurse practitioner and physician assistance conference. These are generalist conferences. And I always look at them to see, okay, what GI content are they being offered? What's hot and new that you're seeing in your practice every day that you'd like to communicate to the family practice, advanced practice provider? Thank you. That's great advice. I'm actually gonna stick with you for a couple of billing questions. So the first one is in a hospital-based practice, there's a separate GI clinic and the APPs have been instructed that they need to bill as an established patient if the patient has been seen by any provider in the hospital in the last three years, regardless of the specialty or department. Is that the case? So that's a unique inpatient billing question. I would reflect or deflect back to the hospital coding guidelines. That would be my best advice. Thank you. The next one is with time-based coding, the time when you're reviewing the patient's chart the night before does not count. Is that correct? No, it doesn't. It doesn't. I know it has to. So really, if you wanted to review your records, you have to get up at five o'clock in the morning if you don't have a commute time to review the number of patients that you're seeing that day. No. And then the problem is sometimes I'll experiment my own different practice workflows. And so I'll review two days prior, understanding I can't use it as it's time, and I'll make some short notes. We have a little flag that we can put in some scripted notes, but sometimes I don't remember. So it's like, where's the effort? Where's the bang for the buck of using the time to review before if you're not gonna remember all this data? Again, we have to realize that we're being bombarded by all this data, and we wanna have information as fresh as possible too. And there's one more question for you right now, Jill. When it comes to public speaking, the question is, does this come with liability concerns and how do you limit your risk? So you, presentations that you give. So this is a good question for me, especially after giving coding and billing guidelines. You know, my, and I did not give the disclaimer, but the disclaimer is that's the most current information at that time, but you still need to go to the original sources of the references, which is what I try to do is provide you the primary resources. But you always have to go back to your own coding and billing guidelines because, and in policy guidelines. So I'm not gonna give you specific, payer specific guidelines. As far as risk related to public speaking when you're giving a general GI content, you're gonna be giving information that's true and best to your knowledge and based on your experience and based on clinical practice guidelines. Thank you. So I'm gonna move it to Caitlin. Caitlin, there's a question that's asking about APP orientations and really asking how long do we think a successful orientation should be? And would that include didactic sessions as well? From your experience, any thoughts to that? Yeah, Sarah, I think you said it well that everybody's gonna learn at their own speed. Our experience with onboarding at University of Colorado has been anywhere from, you know, a month to upwards of two to three months. So I think there's a wide variety depending on what the candidate is bringing in, what experience they have. Are they a new grad? So I think it's going to have to be really individualized for each person. And I do think a certain amount of didactic level can be helpful if they have something in place or even working along, if you're at a teaching hospital, working along with fellows because there's a lot of didactics built in there that it would be easy and convenient for the trainee to kind of piggyback off that as well. Thank you. And I'm kind of curious from the physician standpoint, Dr. Vicari or Dr. Call, what are your thoughts on the APP orientation and kind of that timeframe to have somebody up and running and become a productive from an RVU standpoint? Sure, I'll jump in and then Vivek can. I think Caitlin's right. Everybody learns differently and at different speeds. So I think it's important for practices to remain flexible. If someone is seasoned, they've been out in the field, whether it's GI or some other internal medicine field, maybe they're ready in a month. Others that are just brand new graduates, they may take three months or even four months and that's okay. APPs are critical to the successful operations of a GI practice. And so we need to take the time and effort to invest in them, invest what they need, because rehiring and hiring and losing people, it's emotionally and financially exhausting. So we should do what is best for the practice and what is best for the individual. So take the time, the group should have a baseline plan, but everybody learns differently. And on didactics, if the group, if you're in a private practice or in a smaller group that may not be able to provide in-house didactics, that's why you have a course like this. It's on demand. There are other resources you can use. So if there's nothing in-house, talk to your mentor or your physician, collaborator, administrator and say, I need some didactics and I know there are things out there and get those for you to access. Yes, I agree with that. I think the level of experience in prior training of the candidate weighs heavily into this. The atmosphere, culture, efficiencies, proficiencies within the practice weigh heavily into this. Number three is the nature of the practice that person is going to be part of, what the scope of work is, how complex the clinic is. And number four, of course, if there's any non-ENM type of activity that is expected as well in terms of additional skillsets. So it's a complex question, but for the most part, a protocolized onboarding binder, if you will, with a time-bound process, with re-evaluations built into it at every step is the way to go and typically will take about two to three months for a completely new person. Having said that, I think I am a believer in getting to a point where you can do the bread and butter work and get started because it's extremely frustrating. I know it is for me. If I am in a new position or if I'm starting, expected to start a new job, and then I'm actually not doing what I'm supposed to do. And especially for fresh graduates, they're out of training, they've been training a long time, they want to go, they want to get going. And I think, you know, the other concept that I talk about is sometimes some things you really only learn on the field. There's only so much simulation that can happen. You know, what Sully Sullenberger did with that plane in New Jersey, there was no manual for that. I'm obviously giving an offline analogy, but sometimes you have to learn on the field as well. So there will come a time at which your in-house coach and mentor will have to say, okay, you know what? Enough onboarding, let's get started. And we'll be iteratively adjusting it as we go along for the next three to six months. I know we do that for our advanced trainees when they finish their fellowships, they come in and they spend the first couple of years relearning some of the complex techniques while they have been fully trained. So long answer, I'm sorry, but a lot to it, obviously. Thank you. There's another question that really builds off of that. And so the question is, as a new graduate APP who's starting in GI, how often should competency and performance evaluations be done in the first year to help me grow in the specialty? This is something that I actually hear all the time. No matter where I am, people are asking this question. So I think we do it every six months in the first year. I think that is a really important part of it. Those are formal evaluations. We have a form that's online that the APP does a self-eval and then the lead or the manager will also do an eval. And we sit down together and we talk about where are you? Where should you be? And what are the goals moving forward for the next six months? I think even more than that though are those informal meetings. And so we really shouldn't be relying on these evaluations only at that formal evaluation time. And that goes for the experienced APPs as well. If we only have that one touch point a year, it's very difficult to mentor and really help somebody achieve their goals. I was reading in New York Times, I think over the summer, so a few months ago, they were talking about stay interviews. And so having this unscripted time where you can sit down and just have a conversation about goals and are you making progress towards them? So for example, somebody who wants to start to get into clinical research and maybe they have some things that they're working towards, they're reaching out to some people to just be able to have a touch point in three months, maybe in between those performance evaluations. As a new graduate coming in, I think it's important to have those weekly. And it may only be five minutes sometimes, sometimes it may be longer, but just those things to say, how are things going today? And get feedback because everybody learns different as we've said. And so do we need to pivot that orientation? Do we need to change the way that they're learning or any of the focus that they have to make sure that they're getting what they need? Dr. Call, I have a question for you. In places of independent practice, such as the VA, do you recommend still addressing a collaborative agreement of some kind of formal established collaborative relationship? In my experience, once NPs are independent providers, the physicians may not feel the importance of this relationship because they are no longer benefiting. Right, so the VA is a unique health system in the world. No other country has a system like the VA. Having said that and having worked in one for several years, I can speak to it firsthand. There is a VA and then there is a VA. There are about 170 of them and they're not all the same. Some VAs are so big and so complex that they're even more complex than some big universities. Others, not so much. So it really depends on what the practice is and how many people are in the practice, what the scope of the practice is. Some VAs, like the one we have in Rochester, are only outpatient clinic VAs. It's not even an in-house facility. So I think it's a nuanced question. It cannot apply to all VA practices, but I think it really boils down to less about the VA setting, more about the practice setting, the scope of the practice, the size of the practice, the complexity of the referrals, and how many people are involved and how they view practicing in that particular environment. So it is true, if it is a relatively small practice where everybody is independent, there may not be that much of a fertile ground for collaboration, such as to what we spoke about this morning, but that in more medium and larger size practices, the opportunities might abound. Thank you. In the last two minutes of this Q&A, I'm going to ask Kaitlyn and Jill. I'm going to kind of combine two questions. It may be two parts, but the first is what's the best advice for a new APP who's entering into GI? And the second one is for a new APP who's in a busy practice, how can they help to learn and grow when they're feeling overwhelmed and feel like they don't always have support readily available? So Kaitlyn, if you want to take that one first. Kaitlyn, you're still on mute. Sorry, I was on mute. I said that was a tough one. Those are tough ones. I was a new grad. I went directly in actually to pediatric GI. And I think, you know, there's only so much reading and preparing that you can do. So do that. But know that when you enter practice, you're going to learn so many things so quickly, keep a journal as best you can. But I think expect to be overwhelmed. I think that's kind of the best way to do it. You're going to learn so much, especially in the first few months and know that that's okay. Know that you don't know that. Know you can only read so much and come in with a positive attitude and do everything you can to keep learning. I mean, that's still the case now, so. Thank you. Jill, any advice that you have? Yeah, I think I want to dovetail on what Kaitlyn said that was spot on, is that no matter if you're inexperienced, you come in as a new grad and or if you're an experienced family practice nurse practitioner coming into gastroenterology, there's still the sense of imposter syndrome that we don't know why we're there. We're not good enough. I don't have enough information to be able to take care of my patients. I'm going to hurt someone. I'm going to miss someone. And there is a sense of hum or anxiety that we do want to have some caution with our practice. We do want to have a little bit of cortisol for stress. It doesn't hurt us to wake up at five o'clock in the morning saying, oh shoot, I forgot to order the stool calprotectin on that patient I saw yesterday with diarrhea. And you know what? It's okay to add additional orders after you've seen the patient within 24 hours. It's okay to keep thinking about the patient because that's what we're there for. And we're thinking about them. And I can tell you from a career over 20 years, patients love the fact that you are thinking about them. I'll tell them I reviewed your chart last night and it's a Sunday night. And someone I've identified that's potentially complex that I need to put some thought into it. Patients enjoy that because they know that you care about them. As far as specifically that didactic information to look at, look at those textbook resources. The Mayo Clinic has a great prep for the GI boards that I purchased that I've looked at before and review the Q&A questions. And then engage your physician colleagues and ask them questions. Also reach out to your specialist and engage a relationship. I'll have pulmonologists refer patients to me directly where we need to rule out a chronic cough and he feels that it may be related to laryngeopharyngeal reflex disease. So develop those relationships with your specialists that you become comfortable with. And you'll find that the physicians outside specialists will be referring to you directly too. Sarah, is it time for us to take a little break? It is. Thank you, everybody. We'll continue to answer these questions in the Q&A box. So please feel free to continue to put anything that you have there.

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imposter syndrome