Sam Chang: Hi, my name is Sam Chang. I'm a urologist at Vanderbilt University Medical Center, and I have the great fortune of many times meeting with true experts in their field. Today is no different. I'm surrounded by greatness actually, which is something that I really actually don't use that term quite often, but I do today because we really have some of the leaders in the advanced practice field, advanced practice provider field, that really I want them to actually show some of the great work that they're doing, number one.

Number two, help actually identify key ways that different providers can actually integrate into different types of practices to provide actually significant inroads to improvement of care for all our patients and to actually improve the quality of care for the providers themselves as well. So we have actually today advanced practice providers that I know personally and have worked with or worked with currently that will give some insight into their individual roles.

So today we have Taylor Brewer, we have Meredith Donahue, both from Vanderbilt University Medical Center, and we have Tara Cumming, who's at the Texas Urology Group based in San Antonio. So I'll start off. You guys have a brief presentation, and I'll turn it over to you all.

Meredith Donahue: Perfect. Thanks. Dr. Chang. Here is Taylor to get us started.

Taylor Brewer: Yeah. Thanks, Dr. Chang, for putting this together. I think it's great to talk about the different roles that APPs have across urology because it can be broad. I have been in urology at Vanderbilt University Medical Center for eight years. I am only ambulatory, so outpatient only, and I was hired in at the faculty level eight years ago. I also have the fortune of leading our advanced practice provider group. It is me, the sole PA, and 10 nurse practitioners. And so kind of have roles in integrating new APPs that we hire into practice. The day-to-day kind of difficulties that we may face sometimes come through me to go up to other folks.

And so I have the privilege of being an APP in our department, but also leading them. And that's been a good joy of mine. I also have some roles nationally with some urology groups. So I'm on the board of the Urologic Association of Physician Assistants, which is specifically a PA group for urology PAs. But we do have nurse practitioner members and nurse practitioners that come to our annual conference. And so we kind of think of ourselves as for PAs and by PAs, and we kind of do things that help urology PAs further their education and practice. And then I also have been on the AUA Membership Committee for three years.

And so that is basically the committee that improves APP membership for the American Urologic Association. So we are the fastest-growing group in the AUA year over year. And so that's been great to see, and I've been lucky to be a part of that. And then we also select the AUA APP of the year. So that's our committee's big job. And it's a big job because a lot of wonderful submissions every year. And so picking one APP is challenging. Yeah. And then I think we were asked to kind of say what we think APPs bring to the table. And I think that you would be hard-pressed to find many APPs that don't practice evidence-based care.

They're the ones going to the conferences and learning and alongside the physicians and really trying to optimize their practice to ensure that they are doing the best thing for the patient every time. And so I think we offer that. And then we allow the surgeons to have optimization of their time in the operating room because let's be honest, that's what they want to do. They want to operate, number one. And so we, whether it's through seeing patients in clinic and helping optimize that, or as my colleagues across the country do, and actually helping in the OR as a first assist, we help the surgeons do what they love most.

And then we are obviously oftentimes the first point of contact for patients in the clinic setting. And so there's... we definitely increase access to patient care. There are many studies that show that we're going to have a urology physician workforce shortage in the coming years. And so I think APPs fill that gap in whatever way fits whatever practice style. So I think we have a lot of different ways that we can increase patient access. And then, trends nationally that I see in my roles, there's definitely trends for APPs to practice at the top of their licensure.

So there's been a lot of movement at the AUA level and desire from both urologists and APPs to do more procedures, which I think helps us practice at the top of our scope and increases job satisfaction and ultimately, again, helps the physicians be in the operating room, which we can't do. That's the one thing that APPs can't do. And then, there are initiatives through the UAPA, Urologic Association of Physician Assistants, AUA, and SUNA to offer additional procedural training for APPs.

So I think that everyone's kind of in alignment on that idea. And then there are so many different ways that APPs can be utilized in a urology setting, ambulatory, inpatient, OR, call, procedures, a combination of any and all of them. But I think that the key thing is that we're moving towards a trend nationally to maximize scope of practice for APPs in general and then also in the field of urology.

Meredith Donahue: Awesome. Thanks Taylor. And I think highlighting your slide, let's see if I can go back, is optimizing surgeon time. Obviously, our time is so important, but the way to encourage surgeon utilization of APPs is saying, "Hey, we can get more patients in. We can see more patients. We can get you in the OR more and provide that access for patients." All right, Tara?

Tara Cumming: Yes. Hi, I'm Tara Cumming. I've been a nurse practitioner for nine years. I'm currently working as an outpatient nurse practitioner at Texas Urology Group in San Antonio. I started my career at Vanderbilt, so that's how I know all these wonderful people. And I'm the sole nurse practitioner for five urologists. And I currently work in a sort of hybrid telemedicine role. I see in-office clinic one day a month, and then the rest of my month is done virtually. And so I'm responsible for outpatient evaluation, new and return patients, and I see general urology. Before I started in a telemedicine role, we kind of had to brainstorm what are our visits that we could seamlessly see in this setting.

And vasectomy consults are pretty common. Acute stones, post-op, and stone follow-ups, recurrent UTIs, whether they're a new patient or follow-up patient, BPH, and out... OAB follow-ups are kind of my bread and butter. The value that telemedicine can bring to our practice, it's going to help to expand your patient access without sacrificing quality care. And San Antonio in particular, we have patients who come and see us from surrounding areas two to four hours outside of the city, who actually... there's no urologist in their towns. And so having this telemedicine option is really nice for them.

They love not having to travel that distance and then still get the same quality care that we can offer. Much to what Taylor and Meredith just spoke on, it's going to help to free up your physicians for focusing on their surgical and office care. And so that's been a big benefit for us as well. And then, as far as when we go to integrating telemedicine into the practice, there are a couple of things that we had to troubleshoot going through this, but keeping the lines of communication open. So every day, I have a group chat with the folks in my office, and we communicate throughout the day. And so, making sure that we have a point person that can also help with supporting you.

And so we have another virtual staff member who not only does she help with my patients getting on Zoom, she does billing and scheduling, but one of her primary roles is to make sure that these patients have their Zoom links, they get them... she gets them on the Zoom call, troubleshoots their audio/video so that when I arrive into the appointment that everything's good to go. You also have to have supportive physicians as well. So if I see someone as a new patient and I feel strongly or even a follow-up that they need an exam, having some flexibility with somebody in the office to go in and examine them.

So you really have to have that support there as well. We also talk about aranging the template appropriately. So, doing your best to batch your in-office Zooms first, and then having the home Zooms in the afternoon. It is a little bit difficult to go in between one versus the other. And then just making sure you have some flexibility in your schedule for add-ons. I'd say a lot of the patients that I see on a day-to-day are somebody who walked into the clinic that thinks they have a UTI, or somebody that has been seen at urgent care or ER, that has an acute stone event. So that flexibility is key.

Meredith Donahue: Tara, about how many patients are you seeing virtually a day, would you say?

Tara Cumming: It's feast or famine over here. So I would say 10 is a good day.

Meredith Donahue: Yeah. I think it's just super impressive how y'all have made telemedicine work because it's tough, it's tough to do, and you're doing it really, really well.

Tara Cumming: It takes a lot of practice.

Meredith Donahue: Okay. Well, I'm Meredith. This is a lot of words on this slide, but I am the director of our APP Fellowship. I am a nurse practitioner, been in practice almost seven years. I was laughing because we're all 7, 8, 9 years in. I did our urology APP Fellowship my first year out of NP school. And again, now I'm in the director of the fellowship, and I'm really involved nationally with the urology APP fellowships around the country. We are accredited. There are a total of 12 accredited fellowships in the country right now.

Typically, or how most urology fellowships run and how I run our fellowship, is the fellow has... the first eight to nine months of the 12 fellowship, the fellow rotates through all subspecialties of urology, and that is in clinic with the MDs and APPs. They spend one day observing in the OR, which I think has proven to be a really valuable piece of the fellowship, to be able to talk to a patient pre-op, let's say, about their radical prostatectomy.

They go into the OR, they're able to see the actual surgery, and then even in that rotation, they're seeing patients one day and then also six weeks, which is just a really... and that's for... that goes for every surgery that we do. So in clinic with MDs and APPs observing in the OR, the fellow spends one day a week doing inpatient consults. I think that's a really valuable piece as well, especially with things... with consults like difficult Foley placements, hematuria workups, starting those things is all really, really valuable. Get a lot of hands-on care.

And then within each subspecialty, the fellow has assigned readings to go along with what they're learning in the clinic. So when they're on their male recon, they read about urethral stricture disease and erectile dysfunction. When they're on their female pelvic floor rotation, they're reading about bladder prolapse, recurrent UTIs. When they're in their endo and stone rotation, they're learning about, they're reading about stones and endo urology. And then with their oncology rotation, that includes kind of the hematuria workups, prostate cancer, bladder cancer, kidney cancer guidelines.

The second three to four months of the fellowship, the fellow actually has their own clinic, and it's very protected. Typically, we do two to two and a half days a week in clinic, and they're protected on the number of patients that they're seeing. So the first month, they start low, and each month we increase the number of patients that they're seeing in a day, so that when they finish the fellowship, they're ready to go. They are ready to see a full template just like the experienced APPs.

Throughout the fellowship, the fellow again has their assigned readings, but they're also required to go to resident teaching conferences. We have specialty conferences during the week. So, for example, in oncology, we have tumor board once a week. So when the fellow is on their oncology rotation, they're coming to tumor board once a week. And lastly... I feel like I could talk about this fellowship for an hour, but lastly, the fellow must complete some sort of research or QI project.

It's really been across the board on what our fellows have done and our current... our previous fellow and our current fellow are kind of tag teaming their... or their quality improvement project, I'll call it, with training or teaching the nurse residents proper Foley care because a lot of nurses come out of nursing school and they put in one catheter in school and then they're thrown to the wolves. So our fellow is currently working on providing teaching on Foley care for new RNs.

Other roles that I play at Vanderbilt I run our Intravascular Therapy Clinic for patients with non-muscle invasive bladder cancer. This has become a very, very big, very busy practice within Vanderbilt, but we love it. And then I also help in our Advanced Prostate Cancer Clinic. So we have one clinic a week where we see men with metastatic prostate cancer, castration resistant disease, all those things.

And I assist in those clinics because those are complex patients where we're managing a lot of medications, they need a lot of labs, we're getting genetic testing, and it takes a team to do that clinic. Value to practice. I think I second, again, what Taylor said, just the importance of how we can take a load off and provide good care for patients. I think integrating into practice is where I really want to highlight and just highlighting the importance of APP training in urology.

Coming out of NP school and PA school, we've learned everything. We've learned a lot about a lot, but not a lot about a little, and we get very little specialty training. So, just the importance and highlighting the importance of training new APPs in your group, and it's proven that long-term, that's going to behoove you. If you take the time to train APPs early, that's going to allow your group to retain APPs and keep them productive. I think now I'll hand it over to Dr. Chang.

Sam Chang: Great. Thank you guys so much. You could just tell from that short period of time how many different roles that each of these individuals play and what they can do to contribute to each of the practices. I'm just going to ask a question to each of you as practices consider kind of expanding, integrating, starting with expansion of their APP program. I'll start off with Taylor. Taylor, what should a practice look for when they are interviewing for their first APP?

Taylor Brewer: A good question. I would say that the biggest thing that you have to try to decipher is if the person is a self-learner. So you have to be able to be a self-learner in order to be a good urology APP. Like Meredith touched on, coming out of NP or PA school, we don't get a lot of urology-specific training. And so it's like drinking through a fire hose a little bit for the first year to 18 months.

And so, trying to make sure that the person is dedicated to learning in general, but obviously learning urology is key because it won't happen for you. You have to put in the effort. So I was making sure that they're a self-learner and motivated to do the work that it takes to get to optimize scope of practice.

Sam Chang: Yeah, I think that's a really important characteristic that we probably should focus on, but we really don't. I'm thinking about how that really makes a difference because individuals' roles will adapt and change over time. Let's flip the script.

Tara, you are brand spanking new APP, you've gotten your advanced degree, you've gone through lots of schooling at a young age. You finish at 22 because you're advanced, et cetera, but you finish, you come out. And what should those individuals, as they complete their education training, what should they look for in a practice?

Tara Cumming: Yeah, I think an important part when you're a new nurse practitioner or PA looking for a role is finding a place that's going to have a onboarding orientation that's going to fit your needs, especially if you have no urology background.

That's where when fellowships like Meredith has been talking about are a great resource and a great stepping stone to going into practice. Also, probably looking for some location or a position that's going to help me practice at the scope or at my full autonomy, and somewhere that's going to help me advance and be able to support CMEs, and be able to have that professional growth as well.

Sam Chang: I think that's a really good point. I think we were guilty of it, and I know practices at our academic institutions still are of having APPs basically almost act as scribes coming with us into clinic or doing things that are not close to the level of education and initiative and experience that our APPs have. So I think both those points are really, really important.

So I'm going to end with Meredith. Meredith, so I'm either someone looking at the fellowship, or I am a group looking to hire someone [inaudible 00:21:21]. Is it worth it? Is it something that... Should I mandate that as a practice, or is it someone... something I should do as an APP if I really want to be good, quote, unquote, for an APP and urology practice?

Meredith Donahue: Yeah, yeah. I mean, I want to also preface all this with recognizing that there are 12 fellowships in the country, and I'm pretty sure all of those just take one fellow a year. And so that's not many. And we need a lot more urology APPs in the country. Like Taylor mentioned with the physician, we're going to be having fewer urologists. But to answer the question, I think absolutely 100% a fellowship is worth it. Speaking from a prior fellow... as a prior fellow, I wouldn't change it. I would not change it for the world, and I would do it again. And speaking as on the other side of it, of being in a practice with a fellowship program, it's absolutely worth it.

We have been able to hire most all but two of our fellows over the last seven years, and they have all been able to come out of the fellowship. And like I said, when they come out of the fellowship, they're ready to go. They're seeing full templates. They are independent and ready to go. Versus when we're hiring a new APP who has not done a fellowship, it's very important that we provide them with adequate onboarding, like Tara mentioned. And that's... In my opinion, I think that requires a good three months of onboarding and training. But then, even after that three months, that APP is still not practicing at full capacity, they're not at full templates yet.

Speaking from a financial standpoint of the fellowship, the fellow does not make the full salary of the other APPs, but because they have their own clinic, the position essentially pays for itself. What the APP makes in or what the fellow APP makes in their RBUs, seeing patients essentially pays for that position. So it's good for the new APP because they get a thorough, thorough training in urology, and it's good for the practice because it gives you the best, in my opinion, will provide you with the best APPs, but also financially it makes sense.

Sam Chang: Yeah, that's fantastic. No, we're short on time, so I just wanted to say thanks to all of you all very much in terms of your contributions and your next steps forwards as we advance and improve care for our patients. And so, thanks again for spending some time. I look forward to meeting with the same group again the next year or so to see what other advances you all have all made. So thanks again.

Meredith Donahue: Thank you.