No disclosures. I think some of the points Kate and then raised near the end are a very nice transition. You know, predicting the future is always difficult and a lot of times we want something earth shattering, perhaps a little provocative. And I do have something at the end, but I think we need to really look to the past a little bit. I need to understand what's happening with the physician workforce, understand the patient demand and access problems that we have in medicine in order to really fix some of the things that perhaps should have been fixed a long time ago. So our future again looks to the past and tries to better what we've done. And then we'll take a look at APPs in the GI workforce and looking at the future, looking at ways that you can diversify, expand your skill set to improve professional satisfaction. I loved medicine. I really enjoyed practicing and seeing patients, but it was always nice to have a little something extra. So getting involved in society work, being involved in committees, getting involved in research. So finding other passions within the practice, obviously the practice would have to buy in, helps diversify your skill set and really provide some personal satisfaction. And we'll finish up by talking about that with the future APPs and something a little provocative at the end. So physician workforce. We have an aging GI specialty. In addition to an aging GI specialty, we are seeing a wave of early retirements from gastroenterology. In fact, one of my partners is either retiring today or early next week, and he is 55. So if you have an aging specialty with age expected exit from the field and early retirement, that creates a workforce issue. We have a static supply of GI fellows. We've only had a few new fellowships over the year. Some of these are in smaller hospitals. I'm not trying to be critical of them or demean them, but we certainly have had a static supply of fellows. And if we're going to increase our supply of fellows, we really need our societies and large institutions to step up and create high quality additional spots. All of this has led to a gastroenterologist shortage of approximately 2,600. I've seen some numbers that are a little lower, some numbers that are a little higher, but the one that is most commonly thrown around is 2,600, and that is a very large number. Part of the physician workforce shortage is because the needs of the physician or the numbers of GI physicians were determined many years ago when the United States had a much smaller population. And those workforce studies were flawed and they underestimated the need based on the population they were working with, never mind adding the growth to the country. We now have about 340 million people in the United States, and that's as of end of 2024. Specifically for GI, the U.S. population over age 50 is projected to be 126 million in 2025, and that is a large source. That patient population is a large source of our patients. And then important to us as it relates to the new screening guidelines or newer screening guidelines for colon cancer, the U.S. population between the age of 45 to 49 is 20 million. So whether we start with colonoscopy or finish with colonoscopy because there is a positive fit, there is a positive multi-targeted stool DNA, or there is a blood-based screening test for colon cancer, we are going to see many more patients in this age group. So that tells us a lot about our physician workforce shortage. What about patient demand and access? So adding this to a physician workforce shortage, the population is growing, as I pointed out. We also have an aging population. As of 2024, there were about a little over 100,000 people over the age of 100. That number is expected to quadruple by 2050. Many more people are living into their 90s and upper 80s. So as we age, we have an increasing burden of chronic disease. So that's one source of an increasing burden of chronic disease. We also have an obesity problem in our country, and we see many of these patients with GI-related signs and symptoms, as well as advanced GI procedures. And so couple this with an inadequate physician workforce, and we clearly have a problem for patient demand and access. The current workforce, based on what we just discussed as physician workforce, is incapable of meeting the demands of our patients, specifically in a timely manner as it applies to access. And therefore, we don't deliver high-quality care if we can't see people that need to be seen in a timely manner. So let's take a look at where we started with APPs and why it's important that we really, as we've seen, build our APP programs. So in the early years of APPs—and this would be, say, 20 years ago—APPs just filled the need. There was really no—it was just kind of this natural evolution that physicians were starting to learn that they could not see all of the patients, so they started to use APPs. However, it was the need of the organization, the need of the physician, and frankly, in some ways, just to—not necessarily from a quality standpoint—improve access. The physicians were looking to keep up their business model. It lacked structure, and it lacked organization, specifically as it related to developing an APP program. And where it really suffered was there was no structure in onboarding and no structure in education, which was a real negative early on in the process, and it just kind of flowed from there. Daily schedules were very dynamic. There were a lack of manners, and we can go on and on. So as time moved on, and as time moves on, we really need to develop high-quality, properly trained APPs that have structured and defined schedules, that have access to high-quality education, that are led by APPs, and that are allowed to grow beyond just seeing patients for career development. You are not scribes. You are not test basket managers. You are providers of high-quality healthcare and have become indispensable to the field of GI. So if I try to predict the future, I believe based on what we've just discussed—physician, workforce being inadequate, demand issues—your future is excellent. As I said, APPs, you have become indispensable to the successful operations of, I should say, all GI practices, and we have to make sure that success is based in the delivery of high-quality care. You are an important part of the GI team, and we need to continue to develop the GI team. And as we look to the future, how do we attract APPs to GI? How do we offer career development? How do we build high-quality providers? How do we reduce turnover? And how do we provide the necessary skills and education to create high-quality APPs? And as I said earlier, I'm big into teams. How do we create high-quality teams, starting with the nursing staff, its communication with the APPs, and the APPs and their interaction and communication with their leader, APP leader, and the rest of the leadership team? Well, the basics are very simple. We need to develop formal instructor orientation and onboarding, formal instructor education process, and need to look beyond APP-physician collaboration just with patient care and look for other ways to develop your careers. When it comes to orientation and onboarding, and I think this is where many practices, including my practice, which is a high-quality practice, have failed to recognize early on that this is about time, time, and more time. We need to understand the background of our APP that we hire. Not every APP that we hire is the same. Some are coming right out of schooling. Some are coming from a dermatology practice. Some are coming from a surgery practice. So each person that we hire, although some of the basics are the same, we have to understand their needs if we want to help them build value to themselves and to the patients as well as the organization. So the orientation should be an extensive, should include an extensive practice review, excuse me, historically and where the practice is currently operating and where it is moving. We have to define your specific role within the practice. What type of patients will you see? Will you be based in the clinic or the hospital? How will you collaborate with a physician? How will you collaborate with your physician mentor and your APP mentor? What type of support will you receive from the practice? What are your productivity expectations? A very simple example we had early on when we put together our schedule for the outpatient clinic, we really focused on just filling slots. And over time, we realized that our APPs were taking their work home and doing their records at home, which we, in the onboarding process, told them we didn't want them to do and realized the organization failed them. So we have to understand their productivity, but we had to give them time during the day and we gave them a carved out time slot to do their records, which, yes, may mean they see one less patient perhaps or two less patients, but their overall productivity is still excellent and their professional satisfaction when it comes to productivity was high. We need to educate you in a structured way in coding and billing, EMR, and all the ancillary services that are provided in the practice. And this requires meetings and more meetings, which I know can be difficult at the onset, but this is important to build our team. So time, time, and more time. Onboarding, when it comes to education, there should be a robust in-house education process, and then the group needs to promote education early on, provide the financial resources, and the time to attend regional and national education programs, whether it's a course like this online, whether it's a live course like GAP, or whether it's an ACG program, which has some on-demand. So all of these things are some on-demand. So all of the finances and support and time needs to be provided. You need to have access to up-to-date. You should be joining the society so you can get GI journals, textbooks as needed, guidelines. You should be fully informed of the practice protocols, and this requires a dedicated physician leader or mentor and an APP leader or mentor if one exists in your practice. All of this helps build the foundation for your growth as a clinical provider and sets the foundation for a process of ongoing productivity and performance evaluation. Remember, we are building a GI team. Orientation onboarding has to be slow. It must be deliberate. For someone who perhaps is experienced and joining a practice, they may need rest time, perhaps three months, but some people may need up to six months, and some people, like in our practice, need an extra month. I realize many of you already know this, and perhaps you should share some of these slides with some of your physician and administrative leaders. This is all about time, deliberation, and teaching you right from the outset. Basically what I've described is optimizing a process that already existed and focusing on you as the APP, your needs professionally and personally as it comes to vacation policies and other aspects of your employment contract. And so what we're talking about is optimizing and redesigning care models that support you through teamwork. I used a task basket example earlier as just having your task basket inundated with messages that you don't need. So the roles of the team members that support you, physicians, RN, perhaps an AMMA and other APP leaders need to be well-defined to provide you the structure and support you need so that you are practicing as efficiently as you can and handling messages and tasks and patients that are appropriate for you. So the group needs to clearly define the patients you see, perhaps you're interested in general GI, perhaps you're ultimately interested in a subspecialty clinic, which we'll talk about. So who you see and how you see them in parallel or in collaboration. The clinical and non-clinical work expectations need to be defined. Again, I use that example of taking your work home. We do not want that to happen. So that needs to be clearly outlined in your process. We need to provide the necessary financial and administrative infrastructure so that you can be successful. And ultimately we need action plans and metrics so that you develop over time. Optimization actually starts with physician leadership. Physician leadership needs to buy into this process of a slow and deliberate process of onboarding and orientation and as does administrative leadership. The physicians need to identify a physician champion for APP so that they understand, develop and promote your professional growth. As I've mentioned a number of times already, this costs money and administrative time. The most important thing the physicians and administrators needs to understand is your needs to be successful and efficient and the value you bring to the patients and the practice. And you bring a tremendous amount of value. You practice differently than physicians. Physicians form procedures and more and more they are spending time doing procedures and less time in clinic. That is very different than the work you do. And that value needs to be understood and your needs need to be understood. This occurs through transparent communication from the leadership. As Caitlin said, we need APPs, both leaders and all team members participating in meeting so that your voices are heard and policies can be changed and good strategic plans can be developed moving forward. This allows us to create and continually support new care models. APP optimization greatly reduces turnover. There was a nice study out of Stanford when they really focused on including APPs in their leadership and including APPs in their meetings and created a true team. They reduced their turnover by 22% over a year's period of time. GI practices must develop strategic plans, develop and grow long-term relationships with APPs. As I've said earlier, turnover is emotionally and financially exhausting. Our clinical core won't change. We have clinic APPs, we have hospitals APPs, we have hybrids and part-time APPs. And I think these will continue going forward without much change. And where I do see some change, we'll begin with the next section of the talk. So let's start with subspecialty clinics. We already have subspecialty clinics. It's a little more common in academics than in private practice, but we are seeing subspecialty clinics for APPs in private practice. And the model of the physician subspecialty clinic, it really serves well for developing our APP subspecialists. We have an increased patient demand for GI care. And as we see these patients living longer and the burden of disease change, we will need more subspecialty care within GI and there just aren't enough physician to do that. As I alluded to earlier, physicians in GI are becoming mostly endoscopists and less gastroenterologists. So this really opens up opportunities for those interested in becoming a subspecialty APP. The APP subspecialty clinic really needs the investment from the practice in relation to time that the APP will need to learn the subspecialty area they like and would like to become an expert in as well as the finances. So there needs to be APP interest to develop their careers, open up a new career opportunity and hopefully develop a long relationship with the group and give you a new avenue for professional happiness or interest. The practice in APP must pursue this interest with a strong strategic plan for success, which includes money and the time to develop this interest. Some of the areas include IBD, hepatology, esophagology, advanced endoscopy. One of our hospice nurse practitioners has become an expert in radiology. We know that successful practices with vision have successfully implemented subspecialty clinic. There's a very nice study in hepatology that the data supports the value role of APPs in subspecialty clinics. In this particular study, the rehospitalization rate was lower and the complication rate was lower in clinics that were managed by APPs and in conjunction with the low rates of hospital admissions and complications that we see in physician subspecialty clinics. So APPs can do it just as well as physicians. This takes education, collaboration and mentorship. And then we do have formal fellowships, which I'll come back to in a future slide. So this is an area where there will be growth in the future and I see as a great opportunity. We already talked about leadership. This was just a reminder for me to tell you that leadership is an opportunity for your career development and another source of professional and personal happiness. So clinic research and clinical research and quality improvement. Clinical research, it's always fun to be part of a team. I enjoyed clinical research. It can promote professional and personal happiness. Again, it diversifies and increases your skillset and it gives you a new way to enhance your patient care and gives you kind of a different perspective on understanding patient care. You can be involved in many areas of clinical research as Dr. Cole referred to, whether that's patient recruitment, data analysis, writing abstracts, writing manuscripts. It's another way to be part of a team, diversify your skillset and you will need carved out time to become part of this. Quality improvement is another fun way to improve your knowledge in GI and to help patients in a different way. You can become involved in the quality improvement within your practice, part of a committee, hospital QI projects, hospital committees. Again, this enhances patient safety, improve patient outcome, which are important to all of us as providers. It increases and diversifies your skillset and it can promote professional and personal happiness. All of these two areas, we're going to see growth of APPs involved in these areas, like we saw physician growth over time in these. And it's an important part of your professional and career development. All right, let's talk a little bit about GI fellowships. There are general GI fellowships. The pros, if you know you want to go into GI coming out of a program or you're in another field and want to switch into GI and you think you have some time and the group will support you before you join them to do a GI fellowship, I think that's great. Part of the problem is we've traditionally seen some high turnover within the field of GI. So people leaving GI programs and becoming APPs and other practices, I've seen numbers as low as 10 or 12% and as high as 17 or 18%. And so that is potentially a difficulty in GI fellowship, because if you do a GI fellowship, you're really looking at a long-term relationship. Subspecialty fellowship, if you want to do a subspecialty fellowship and they do exist, tells me you're probably bought in for a long-term relationship. So I see perhaps the future, more likely subspecialty fellowships. There are a number of subspecialty fellowships that exist. And I think, and I have a slide on AI, AI can maybe mitigate time away from the practice. The cons again, the person has to be really committed. And if they're not, this is a difficult path to go if they're not committed to GI. And endoscopy fellowship, we'll come back to that. This is the provocative part and we'll come back to that. One slide on AI, AI is going to really revolutionize the way you practice and make your life easy through assisted workload management, your task basket and other tasks that you do that are not directly related to patient care will diminish. It will help you in your clinical decision support, specifically at point of service when you're seeing patients to get information to better help you manage the patients and beyond. It's going to have a huge impact on education, how you receive education and really refine the quality of the education. There'll be professional development opportunities and then emerging technologies, which is a nice segue into the provocative part of my talk. Let's finish up with, could APPs have a role in procedures in the future? Well, if they did, we'd all have to understand that their level of training experience would have to parallel that of physicians. There'd have to be a desire. Doing procedures is very different than just seeing, than performing only cognitive services and state regulations would have to allow it. Historically, APPs have done anoscopy, hemorrhoidal banding, paracentesis, liver biopsy. And there have been some studies that looked at the role of APPs in providing sigmoidoscopy colonoscopy. And just to be brief, these were successful studies where procedures were done well by APPs. Specialized training would have to take place. That's potentially a negative. This would not be a short process. And at the moment, none of this is really widely practiced. Benefits, it enhances patient access. It reduces wait times. It promotes teamwork. We'd have to develop quality metrics that are in parallel with physicians, but also perhaps unique to you as APPs. We'd have to have ongoing competency and obviously guidelines and protocols would have to be followed. There's a gastroenterologist shortage, as I pointed out. We have an increased demand for procedures and a lack of timely access. This is purely a theoretical model and only, as far as I know, my opinion, so I'm only sharing my opinion, there would have to be an APP endoscopies fellowship. Time would have to be determined. How long? Would this be only diagnostic EGD? Would this be colonoscopy? Would this be sigmoidoscopy? APP would, AI would greatly aid your learning experience, both from a procedure technique and a computer-aided diagnosis, which has really come a long way. For instance, in helping you diagnose a polyp and helping you determine what type of polyp and looking at other mucosal lesions. I could envision a team of a physician endoscopy leader supervising two to three rooms. The APP performs the procedure with computer-assisted diagnosis and the physician leader is needed. There'd have to be great communication for the team. And in essence, the gastroenterologist would become the therapeutic general endoscopist. You as the APP endoscopist might find a polyp that needs to be removed. And then perhaps the gastroenterologist comes in. Purely a theoretical model. Sorry to go through this quickly. I've already overstayed my welcome with time, but I just wanted to throw this out there as something provocative. We talked about a lot. I think the future is very bright in all aspects of GI for APPs. As we talked about in the other lecture, we have to build APP leaders, which I think is critical to the future of APPs. Sub-specialty GI APPs are going to be very important, but so is getting involved in quality and research. I think GI fellowships will be important and really be influenced by AI, making it a lot easier to actually not leave home and perhaps complete a GI fellowship. And could we envision a day where there is a GI endoscopist? Thank you, and I'll turn it over to John.

Advanced Practice Providers

gastroenterology

physician shortage

professional development

AI in healthcare

GI procedures