This is one of my favorite topics. It was really a topic that came about from all of the meetings that we go to, from networking with people across the country, and kind of the organic discussions that happen to talk about, what are we currently doing in our roles? What are other people doing? What can we do different? What can we do better? I don't have any relevant disclosures to this presentation. I'm going to start with a polling question. Which of the following is most important for successful onboarding of a GIAPP in their first year? Some brands have mentorship and structured training programs. Exactly. And 100%, I like to be perfect. The second polling question for you guys, opportunities for professional development include which of the following? If we're going to talk about onboarding, I'm always also going to talk about professional development. I like to look forward. And so what of the following are opportunities for professional development? Excellent. Exactly. We're going to talk about all of these briefly as we go through the next 20 minutes. And the last one, just to make sure everybody's awake, which of the following strategies is most effective in providing early career support for a GIAPP? Perfect. Regular check-ins is really important. I'm going to talk about that as we talk about the onboarding part. So really, what I'm looking to do is I want to first talk about, what are the various roles of APPs in GI practice? And then I'm going to describe what I view as the optimal onboarding process, recognizing that there's differences within practices, within roles, and that that onboarding is going to look a little bit different depending on what your current position is. I also want to highlight some goals and look at the challenges for optimizing the role of APPs. If we're going to look at goals, we've got to be able to recognize what those barriers are and what can we do to overcome those. And then finally, those opportunities for professional development. Because if we're onboarding somebody, I'm already thinking about, how do we keep them? How do we get you into GI and keep you in GI? And professional development is really important for that. And Dr. Call shared this earlier this morning. I'm not going to go through it word for word. But what I really want to think about is modern GI practice is different than what it was 15 years ago for sure. Even if I look at my own personal career, I have been a PA for over 15 years. I haven't always been in GI, but the majority of my career has been. When I first started, I'm in a big medical university. We had single digit PAs in the hospital. And when I interviewed for my first position in the hospital, same health system I work at currently, the physician said to me, why should I hire you? I've never hired a PA before. We don't necessarily have those conversations anymore. We have over 700 PAs. We have over 1,200 APPs total within our health system. And so the role of the APP has definitely become more well-established, whether you're a PA or an NP. We've also looked at a transition. We're more autonomous. We're doing more things. We're working to the top of our scope of practice. And so there's definitely been a shift in that. And so when I think about things, I like to put things in buckets. It just helps to organize my brain. Primary goal of APPs in most clinical practices is going to be that direct patient care. It's going to be new patient visits, follow up, the continuity visits. Could be telemedicine, could be some inpatient consultations. Some APPs are doing ancillary procedures like paracentesis or gastrostomy tube changes, anoscopy, certainly communication, working with patients and family members, education, informed consent, and then triaging those phone calls. There's also that indirect patient care, though. And so that complex care coordination and interdisciplinary communications, that's so important that many APPs are really taking the lead on. Sometimes it's prior authorization support. It's risk stratification of patients for endoscopic procedures, that pre-procedure coordination. And then we look at the administrative. And some of these administrative tasks are really more related to professional development and personal interests. But certainly patient advocacy, advocacy for colorectal cancer screening, advocacy for quality improvement projects affect us all, as well as mentorship. And there's a lot of different clinical practice models. And I bring this up because no matter what clinical practice model you're in, that onboarding is still going to be super important. And so when I look at this, I look at that co-management or that integrated care team, where the physician and the APP are really co-managing a shared patient panel. A lot of times in a clinic setting, that means the patients are going to be scheduled on the physician's template. The physician or the APP may bill for that. If we look at a physician-led or independent model, the physician's really managing those higher complexity cases while the APP is seeing generally follow-up visits. Each physician in the APP will have their own templates. Each will bill for their own patients. And then there's the autonomous or independent model where the APP is seeing patients from the beginning to the end. They're overseeing their care plans. They're consulting with the physician when needed. But they have their own scheduling template and their billing. And in many situations, there's a combination of models, where you may have some of those shared visits and some independent visits or some combination thereof. And of course, there's different clinical practice settings, too. So there's APPs primarily in ambulatory, some in inpatient, and then there's some who do a little bit of both. Dr. Call talked about the physician-APP collaboration. And this is really important to successful onboarding into a practice, to be able to come in and develop that relationship and have a physician that you can discuss patients with and really work to enhance your own role within the practice itself. And so again, looking at some of those key principles, it's really having clearly defined roles. As you come in an APP, what is the expectation for you, both in administrative and inpatient care? Having that mentorship. And I think mentorship comes in a lot of different ways. So I'll talk about that a little bit, too. Fair compensation, successful onboarding, performance expectations, that team-based approach, inclusion and practice discussions and operations and workflows, and then back to that professional development. So if we look into the onboarding, I really like to call it transition to practice. And so this is really a support for newly graduated, newly hired APPs. And it's looking to bridge the gap between education and independent practice. The second part of onboarding is going to be when you really are looking at the logistics of the practice. It's the EMR training. It's making sure that you know, how do you put a referral in? Who's your office staff? Who's going to help you with some of those other tasks? In a transition to practice program, the goal is clinical competence. It's to promote retention, it's quality of care, and it's professional growth. And there's a lot of different components to onboarding. The ones that I really focus on is first that introduction to GI practice. What is the practice's missions, values, and culture? Who are the team members and what are the roles? It's nothing like walking into an office when you don't know anybody, the front desk staff just kind of look at you. It's really knowing who they are, being able to walk in, call them by name, say hello, and start to feel like you're a part of that practice. Second, I always focus on the clinical training and education. And so that's, what are your common GI conditions? What are the procedures? I think an introduction to endoscopy is really important, especially if it's somebody who doesn't have any background into GI. So being able to observe some of those procedures, see what the workflow looks like, an introduction to your endoscopy team, including the nurses and the techs. And then the practice protocols and clinical guidelines. Integration into the care team is always important as well, looking at what is everybody's role? What does that collaborative practice model look like? And what's the best way to communicate with people? Some people have strong preferences, whether it's through the electronic medical record, or it's via text, or it's page. I'm really getting to understand where do you fit into that, and how do you best communicate with those that you will need to. Administrative orientation is also important, like I mentioned earlier. So having time to train for the EHR, billing, coding, and regulatory compliance, practice management, scheduling, and patient flow. And then finally, it's really looking at what are your educational opportunities? Who can you find to be your mentor? And what does that performance evaluation structure look like? I think ramp up periods are essential, but more than being essential, I think it's important to actually have it outlined. For somebody to come in and say, I expect that you'll be fully onboarded within six months. This is what I think it's gonna look like. For the first two weeks, you're gonna predominantly shadow. Weeks two to four, I want you to see two patients per clinic on your own, from start to finish, discuss it with your preceptor, and be able to complete that note, and then shadow if you have time beyond that. When you get to weeks four to eight, I want that to be increased to three patients per week. And really lay it out, because at that point you're able to then say, okay, I know that by the end of this week, this is what I'm really targeting to achieve. Sometimes people will also pick specific diagnoses. So focusing on something, and just for example, I'm saying we're gonna start with GERD and IBS. And so predominantly you're gonna see GERD and IBS patients for one to two weeks, and then expand it from there. Depending on your practice setting, there may be specialty, subspecialty, subsubspecialty training. So looking at things like pancreatic obiliary or motility testing. And then what is that timeframe for that full schedule? And we have to recognize that everybody learns differently. And so we do pivot. Sometimes we're not going as fast as we think we will, and we stop, we pivot, we say, okay, what are the tools that are needed in order to get you back up to speed? And sometimes the opposite happens and somebody really is thriving and they're learning and they're getting it very quickly. Maybe they already have EHR training, so they're able to do these patient visits a little bit faster. And we pivot and we actually increase that speed. And this is just an example of what our onboarding looks like. I just pulled it from week two. And so what the goal is in terms of writing notes per clinic as well as some of the other kind of metrics that we're using. And this is really helpful because it's not always myself or my co-lead who is orienting our new APPs. We have a large group and so we'll assign two preceptors. So it helps the preceptors to make sure that everybody's getting what they need, but also it helps the new APP to know what their expectations are for that week. And then performance metrics. And this is something that's debatable depending on your practice setting again and kind of what the goals are. There's a lot of different ways to look at APP performance. And I think it really has to be individualized depending on what your own role is. So if you're predominantly clinical, the productivity metrics can be really good. Looking at maybe patient volume or the visits per day, maybe how many procedures do you generate from the patients that you're seeing or the number of clinical hours that you're spending. Work RVUs can also be useful. Sometimes the clinical quality metrics are helpful. So looking at adherence to clinical guidelines, preventive care, are your patients getting counseling for timely colorectal cancer screening? If you're inpatient, especially outcome measures such as length of stay and timely discharge, and then patient satisfaction. Compliance with the regulatory requirements. I always keep this in mind if somebody is late submitting their time cards, they're not up to date on their BLS training or their licensure is lagging behind, they're not getting their required CMEs, I do think that those are performance metrics. And timeliness of documentation as well. So some combination of this works for the majority of people. Clearly defined expectations with benchmarks and targets that are customized to the APP role and level of experience. A combination of the quantitative and the qualitative. And then again, individual metrics really should be complementing your overall team metrics. All of that sounds great, but I fully recognize that there are challenges. There's an inconsistent understanding of the role of APPs. It happens in every practice and every institution. It's still there, although it's better than it was 15 years ago. The other challenge is that the scope of practice varies by both state and by degree. And so for example, I'm in New York State. What I'm able to do as a PA does vary somewhat from what my NP colleagues are able to do. And so you really have to have a good understanding of that in order to be able to outline what your roles and responsibilities are going to be. And there's still a lack of role clarity in a lot of institutions. And so I strongly recommend APPs come into a practice and I really advocate for that role clarity. There's also variable prior training and experience. And so some APPs are going to need some additional onboarding training and resources. And sometimes we do have to, again, pivot depending on what they have as their strengths. And so somebody who is a nurse practitioner who was a RN for 15 years, has great bedside manner, doesn't need to necessarily be trained on the physical exam of a patient, whereas the PA may need some assistance with that. And so being able to recognize what those things are and also as a new APP, being able to advocate for the things that you feel like you could use some additional help with. Physician practice and institution buy-ins can sometimes be a challenge as well as patient acceptance, which Sumit talked a little bit about in the beginning of his last talk. This is now a couple of years old, but I still wanted to show it because I think that it really helps to highlight that. This was the NCCPA 2022 patient survey. And it was really looking at what's the patient knowledge and understanding of PAs. And I compared it to 2018. So on the right, those purple bars are 2018. The orange, yellow, goldenrod color is 2022. I mean, you'll see that there's not much difference. We have not made much difference in four years in helping to clarify what a role of an APP is. Also important, if you look even halfway down, PAs prescribe medications. Only 55% of patients had an understanding that PAs can do that. When you go to like AF, PAs can only accompany patients to exam rooms, measure vital signs, and record information. Almost 45% of patients felt that that was true. Patients can only perform routine medical tasks such as drawing blood, removing sutures, administrating medications while under supervision. 32% of patients. So going in in that first introduction with your patient, sometimes even with the office staff, sometimes with your collaborating physician, and being able to say, this is what I'm able to do from a scope of practice. Let's decide what my role is gonna be. Meeting the patients and saying, my name's Sarah Enslin, I'm a physician assistant. I am your provider. Being able to have those conversations and develop those relationships is really important to success. And when we look at this kind of big picture, what are things that really help successful onboarding? We're looking at physician APP collaboration. And so as Dr. Call was saying, it's this active engagement, it's the frequent communication, it's ongoing education and training and competency assessments. I tell everybody that I meet, whether they're in GI or not, and they're coming into a new role, make the time to sit down with your physician collaborator. I still do it now, 15 years later. Just plan for it every week. Even if you have nothing to bring, sit down and have a conversation about something. Something that came up on labs, some patient that you saw, a question that you have, but it really helps to develop that relationship. I think it's important to encourage APP leaders. With all of that variability we have in our roles between NPs and PAs and states and all the regulatory compliance, to have an APP that's able to provide some insight into that and be able to ensure that there's compliance, I think is really important, especially as our scope of practice continues to change and that role has rapidly changed. Providing support and mentorship and assist in the optimization of the APP role certainly can be done by APPs leading APPs. And then the introduction of the healthcare team to the patients. This is what I like to use. We use it throughout the University of Rochester and many of our care teams, but it really just goes to the patient with their new patient packet. And it says, this is who your care team is. And your care team includes a physician as well as the physician's assistants, nurse practitioners, RNs, medical students, administrative professionals and others. And so you're kind of setting the foundation to say, you'll have one physician overseeing it, but you may meet a lot of people and you may not always see the same team member either. And then if we look at optimizing the role, so we're looking at how do we provide efficient high quality care to patients? We're building that collaborative practice, optimizing reimbursement, getting into the professional development and that improved retention. Mentors are important. Mentors can be physicians, they can be other APPs. Mentors may come from within your institution, they may be outside of your institution and you may have mentors for different things. So you may have a mentor who is really helping you with clinical practice. And then you may have another one who's looking more towards professional development in your own career. I think it's also important that mentors are acknowledging APPs. So APPs that have leadership potential, how are we actually working with them and bringing them up? The other role of mentors though, that's important from day one is that constructive feedback. It's the opportunity to be able to say, I noticed this, this is what I wanna see next time. Or this is one of the ways that you can make your notes more succinct and also more clear. Here's how we can better develop your differential diagnosis. Mentors can also provide those professional development opportunities as well as support guidance and counsel for any conflict resolution. There are formal mentorship programs. They exist in a lot of different places like AAPA, AANP, the Crohn's Colitis Foundation, the American Association for Liver Disease has one and so does ACG. And then if we look at opportunities for professional development, we're talking about clinical development first. And I typically will start there with somebody who's new to GI. It's really looking at, once we get you fully onboarded into your role, is there a sub-sub-specialty that you're interested in and do we need that in our practice? Are you interested in procedures or ancillary tests? Or are you ready to see patients that are more complex? There's also opportunity for scholarship and research and certainly CME tuition benefits, national society roles and leadership positions. And just a couple examples as we go through. These slides are here. I'm not gonna go through them all but you'll have them to reference in the future. As we look at specialty clinics, Gastroenterology and Endoscopy News has a GI APP corner. And in that, Dr. Call and I have written several case series that are looking at different specialty clinic series for hepatology, for IBD. So you could always go back and reference those, really looking at panelists from across the country in a Q&A format. It may help you if you're interested in developing if you don't already have one at your institution. Lots of different opportunities for scholarship and research. And so the impact of APPs on team-based models and patient care outcomes. This was a paper that was published a few years ago looking at patients with cirrhosis who had APPs on the care teams. And what they saw was that when you had shared visits and an APP was involved, they actually had the best outcomes and the lowest 30-day readmissions compared to those patients who didn't have an APP involved in their care. This is a clinical review that was just published this month actually, that was looking at recommendations for management of MASH by APPs. See any opportunities such as this course. And then Innovations of GIE is an online only gold access journal, and it does have an APP section there as well. We have the GAP newsletter, and then the Gastroenterology and Endoscopy News. So if you're looking for APP focus, these are three good places to start. There's also opportunities to be on the editorial boards, and then certainly APP leadership, which can look different. There's formal roles as listed here, but there's a lot of other leadership opportunities. And I like this visual. The small circle is that those formal leadership roles that I just showed on the last slide, that bigger blue circle is really all of the leadership opportunities that exist. And this could be things like teaching at a school, could be serving on committees, leading quality improvement projects, lots of opportunities for this. And then we look at the challenges. And so there is still a misunderstanding or lack of awareness of the scope of practice. There's lack of specialization training coming out of school. It can be difficult to accurately quantify total reimbursement and work effort. And we're always looking, what's the ROI? And so to be able to really be able to put that on paper when it's not directly related to revenue. Buy-in from your physician partners and the administration for those expanding roles and fair compensation is still variable. Can be tough to manage patient expectations and accept the enhanced APP role. And burnout is real. Burnout is that energy depletion and exhaustion that can lead to depersonalization, reduced professional efficacy, and strikingly, the burnout rates for APPs is up to 50%. And we talk about work-life balance. This is my dog. He's my third child. When I'm working late at night, this is exactly what he does. He jumps up, paws on the laptop, paws on my lap, saying, okay, it's time to close your laptop and play with me. Or puts a tennis ball on the computer. It's really looking at, how do we balance everything we're doing with everything outside of work? I like to call it work-life satisfaction, not work-life balance, because it feels like it's a tug and pull when we use the word balance, but it is achievable. Things like flexible schedules, having mentors, having direct access to your collaborating physician, a positive learning environment, and fair compensation all can help with that. And as I was making this presentation, I was thinking how incredible it is that for five years in a row, I've been able to put a very similar slide up because NP and PA have been in the top five for at least that long. This is the U.S. News and World Report Best Jobs 2025. So finally, just bring it all back together. Effective onboarding is crucial for successful integration into GI practices. If we optimize the role of APPs, we're able to not only improve access to patient care, but also improve patient and referring provider satisfaction, maximize our reimbursement, and increase our physician availability for other things like endoscopic procedures. Professional development can start from day one. That helps to boost engagement and retention, enhances career support, and ultimately impacts quality of life. And there's a lot of different opportunities for professional growth. Find a mentor who's there to advocate for you and will help you to find the things that you're interested in and really get you connected to some of those opportunities. Thank you.

Advanced Practice Providers

gastrointestinal practices

onboarding

mentorship

professional development

burnout