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From 1 to 22 APPs: Growing Together to Serve Our Patients · Voices of Otolaryngology

0:13
Well thank you. Welcome to Voices of Otolaryngology
0:15
I am beyond excited.
0:17
I'm jumping out of my seat.
0:18
If you look very, very closely here with the doctor or Doctor, The?
0:24
The Doctor Nora Perkins. Welcome.
0:26
Thank you so much for having me. I'm excited to be here.
0:28
Yes you are.
0:29
Our inaugural OTO Forum videocast.
0:33
Amazing, amazing.
0:34
I've started off with a stronger combination here. Right.
0:36
Let's go.
0:37
All right, I love it.
0:38
Yeah, but you were also telling me
0:39
in full disclosure that there's somebody who has a better radio voice than we do.
0:44
That's true.
0:44
So, yes, my partner, Gavin Stetson, it is really hard to beat that
0:48
like smooth South African - it's not a drawl.
0:51
And it's definitely it's very pleasant to listen to.
0:54
So does he say stuff like, you know we were operating
0:56
we got in the skull base. There's a little bit of fluid.
0:58
We just patched it up. Everything's okay.
0:59
Carotid’s heal will be all right. Totally. Yeah.
1:01
Have a good day. And he just walks in and the families just feel great. Great.
1:04
It's reassuring.
1:05
Yeah.
1:05
And, you know,
1:05
he ends everything up through the credits with an onwards and forwards.
1:09
And I try to sort of I tried to adopt it.
1:11
For meetings where I'm standing in. And it doesn't work.
1:14
Well, tell us what you're presenting this afternoon at OTO Forum.
1:17
So I am presenting, incorporating APPs into a private practice.
1:22
And sort of the best ways to do, an art practice in Albany.
1:26
We have a number of APPs and we have for a number of years.
1:29
So I think probably 25 years ago was the first APP who joined the practice.
1:34
So kind of an early adopter, I would say, at least for the early 2000’s probably.
1:38
Yeah. Yeah, exactly, exactly.
1:40
And since that time we’ve really grown the number of APPs in the practice,
1:44
partly because we've really had a successful experience,
1:47
but also because we need access, you know, I'm sure like other practices,
1:51
we don't really have enough physicians to fill the need for our community.
1:55
So we've sort of used APPs to help fill that void and improve access
2:00
for our patients.
2:01
When I visited you all, your practice is beautiful.
2:03
Thank you.
2:04
And thank you for hosting me.
2:05
Unbelievable practice.
2:07
What you built is very special.
2:09
In the market, in the community, the rise of APPs have been
2:14
is exponential or asymptotic .Can you walk our members through that?
2:17
So early 2000s, you hired your first APP.
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And how many do you have now?
2:21
We are onboarding our 21st and 22nd, So I actually can't believe that.
2:27
Yeah. Can you walk us through sort that how you grew.
2:29
So I joined the practice in 2011.
2:33
And at that time there were I think they had just hired the fourth app.
2:37
So there was an initial between that 2020 11 kind of slow growth.
2:41
Right.
2:41
You have one, you have two. You have three for over ten years.
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But it had been a very successful experience.
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The practice had found that the apps were well liked by the patients.
2:51
They were excellent colleagues delivering really good care.
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So it was a very positive experience.
2:57
I think the change between 2010 and now 2025
3:00
has been consolidation in our community of entities.
3:04
So we used to have a number of 1
3:07
to 3, four person practices in the community.
3:10
And over that 10 to 15 year period, it really consolidated to our group.
3:15
We have ten physicians in our group now.
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And the academic medical center
3:21
who has maybe 13 or 14 physicians.
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And so there was a need in the community for care,
3:27
and we haven't had that very positive experience with the apps.
3:31
Just continued adding more and more and more apps
3:34
because we continue to have patient demand for access to care.
3:38
I think with Covid, a lot of practices also noticed,
3:41
you know, primary cares weren't necessarily seeing their sick patients.
3:45
You know, they just didn't have capacity. Right.
3:47
So we needed to sort of take on some of that capacity.
3:50
And we can't make ents as quickly. Right.
3:53
But we can bring on apps, teach them EMT
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because I do think that's a critical part to a successful incorporation.
4:01
And then have them working with us, you know, as our colleagues.
4:04
Wonderful. You know, sometimes I feel obsolete.
4:07
I can just probably leave, and you can just keep going.
4:09
You're answering so many questions that our members are going to have.
4:12
So in the first decade, you went from one to about three or 4 or 5.
4:18
And then in the last 15 years you've gone from four or 5 to 22. Yes.
4:23
And could you tell us a little bit about their practice?
4:26
Do they practice independently?
4:28
And I know this set up, but it's yeah kind of describe it - Of course.
4:31
Yeah.
4:32
So in our practice the apps have independent schedules.
4:36
And we found that to be very, successful for the apps themselves.
4:41
You know, these are people who have chosen to go into this path of medicine.
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Highly trained.
4:47
They did not not get into med school.
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That was they never were interested in that.
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So they enjoy, at least in our practice, having an independent schedule.
4:55
We kind of cap that around 20 or 21 patients a day.
4:59
So we're trying.
5:00
So it's excellent. Yes, exactly.
5:03
And we're not high volume, I would say, like,
5:05
even my practice, I like to be at around 30 patients a day.
5:07
So I'm not seeing 45, 30 a day.
5:11
But, but but it's what we hear from yeah.
5:12
It's, you know, it's kind of a nice it works for me.
5:14
But when we sort of keep the, apps in that sort of ten session,
5:19
it allows them to deliver really comprehensive care.
5:23
We have a lot of, ancillaries in our practice.
5:25
As you know, we have audiology and hearing aids.
5:28
We have allergy.
5:29
And so with a little extra time,
5:32
the patients can talk about their sleep apnea.
5:34
They can talk about their hearing concerns.
5:36
They can talk about allergy and health conditions.
5:38
Exactly. Exactly.
5:40
So it's a really nice kind of way
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to sort of a little more holistically approach a patient.
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And so they do have their own independent schedules.
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They see new and follow up patients.
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So it's kind of when a patient is making an appointment,
5:54
they can say, I would like the first available with whomever.
5:57
They can say I would like to only see Doctor Perkins for whatever reason.
6:01
But we we definitely have found that
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I don't think
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limiting patient type is particularly helpful
6:10
because with training the the patient who comes in to see the app,
6:15
like, let's say they've had five sinus surgeries
6:17
and they're looking for a six month surgical consultation. Right.
6:20
Not maybe the best set up, but if that happens because the patient
6:23
says I want to be seen tomorrow and therefore I'm going to see the VA,
6:27
that's fine.
6:27
The PA can say, great, let me get this history.
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Let me, you know, maybe get some updated imaging,
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make sure that you're on all the appropriate medical management.
6:37
You know, is there an allergy component we're going to get you teed up to,
6:41
then meet with the surgeon for this, you know.
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Six thing through that example.
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So then in that case then with they then expedite that.
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Exactly.
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So making sure that everything has been done, because we all know that
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sometimes we see patients who are coming to us for perhaps a surgical opinion,
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but they haven't actually done all of the medical stuff we might like them to do,
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or they haven't had the imaging or the workup
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that we would really need to sort of have that discussion about surgery.
7:07
So the Pas in, in our practice, part of the training is it's
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actually a I should go back to this.
7:13
Our training is about a 24 week period, so it's quite long.
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The first 8 to 10 weeks is really just shadowing.
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So a new PA who's joining our practice is spending 8 to 10 week
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working with all the physicians, the other APIs.
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To really kind of learn how our practice work,
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how each individual provider kind of might do things slightly differently.
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And then there's also an educational, component where they're responsible
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for learning sort of specific disease state along that time period.
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And we give them resources to do so, including the,
7:45
basic in advanced, allergy courses, which are awesome.
7:48
I can't promote those enough.
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And you give those, you give them to, you invest.
7:52
Yes. Invest.
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And it's an - - I'm saying it's correct.
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It's an investment of time.
7:57
Because during that 8 to 10 weeks,
7:59
there is no revenue generated by that person.
8:01
That's okay.
8:02
And then during that sort of second, you know,
8:05
10 to 12 weeks, they are ramping up slowly with their own schedule.
8:09
So a little bit like a med student would be, perhaps, or a resident
8:12
where they're seeing some patients independently
8:14
and then sort of presenting - Do you mind walking our members through that ramp up?
8:17
Sorry.
8:18
Love how specific you're getting
8:19
because these are the questions I get across the country.
8:21
So about an eight week onboarding. Yes.
8:23
By the way, the otolaryngology core curriculum in a few
8:26
weeks will be able to be rolled out to the physician assistants.
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Just want you to know that.
8:30
I think that's such - So please incorporate that.
8:32
Yes, definitely.
8:33
I think it's such an excellent opportunity because a lot of questions that
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we receive also,
8:38
just as somebody who has a lot of, APPS, is how do you train these people?
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You know, what resources are available?
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So I think the Academy having this very clear resource is an
8:47
so you do basic and advanced allergy, which you like to do shadowing
8:51
for 8 to 10 weeks, and eventually you'll add on OCC?
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100%.
8:55
But then talk to me through how do you ramp them up? Okay.
8:57
So they've they've started to have their own schedule.
9:01
They may only have three patients in the morning and three in the afternoon.
9:04
So three per session right.
9:06
So that's plenty of time to really kind of like fully evaluate the patient.
9:10
Be comfortable with the EMR, find a resource
9:13
if they need me to kind of review their treatment plan,
9:17
before they even go back and see the patient.
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For example, if they say, hey, I've reviewed this chart
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and I'm, you know, I want to make sure I'm on the right track with this plan.
9:25
They can find somebody to review it with.
9:27
So initially they're seeing three a session.
9:31
Do you have a lead or head physician assistant?
9:33
We do.
9:34
So they could maybe go. There is a resource. Exactly.
9:36
And so we do have sort of some, some
9:39
set in place resources.
9:41
Right. There are there's a lead physician assistant.
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There's actually an
9:44
educational lead physician assistant who's kind of a separate person.
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And then there's a number of other more experienced physician assistants.
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There's also a number of physicians and I'm sort of getting off track.
9:54
I apologize, but one of the things that makes this work
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is we have an incredibly collegial culture in the practice.
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And what I mean by that is there is never, ever
10:05
any negative, feedback for a question, a pulled me aside.
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I have a question on attending this workup You'll you'll help 100%.
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And I think that's really critical to making this work, because if somebody -
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it’s kind of like working with residents, if somebody is hesitant to ask you
10:20
a question, you know, that's not a good culture.
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That's not going to be successful.
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Mistakes can happen.
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Things can be missed.
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But if if it's a really open culture where questions are encouraged,
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collaboration is encouraged -
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then I think that it's a much safer environment
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because I know that there can be hesitation of,
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well, gee, is this person didn't do a five year ENT residency, like,
10:41
how am I going to trust them with the care of my patients, right?
10:44
And I think the way that you do that is through education,
10:47
but then also through creating a really, really open culture
10:50
where they are not hesitant to have you take a second look at a weird ear
10:54
or even like this looks funny on the larynx and you know, it's the PDL.
10:58
It looks funny, right?
10:59
If you've never seen that before, or if somebody has a healthy larynx
11:02
and you've only seen abnormal larynxes,
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It can be really nice to just kind of have another set of eyes.
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And the buck stops with you.
11:10
You are a pretty huge resource in the community.
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If I send a family member to you for hoarseness,
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I expect that you'll - if there's a dysplastic lesion, you'll find it.
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And I might need to call in a partner or another person.
11:20
We do the same thing.
11:22
Exactly: “Nora come take a look at this.” So you ramp them.
11:25
It's now 8 to 10 weeks. Yeah.
11:27
You ramp up three in the morning, three in the afternoon.
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Yes. And then they're kind of slowly ramping.
11:32
Sure.
11:32
They kind of ramp I would say to variable degrees like the speed changes.
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It's a little bit personality dependent.
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If this is a new graduate who is not only learning ENT,
11:43
but learning how to practice, right.
11:45
So that might be a little bit of a slower ramp up.
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If this person came with 15 years of experience in a, you know, primary care,
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then they're probably more able to ramp up quicker.
11:54
And you open these slots for anything.
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Or do you focus on - We open them for anything.
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We haven't done yet when, you know, so they could see a 90 year old,
12:01
they could see my mother and then they could see my six month old.
12:05
Yes. Exactly. Yep.
12:06
So they can see everything.
12:08
And we do have some APPs
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in the practice who have kind of focused on pediatrics.
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And so they do spend some dedicated time with, the pediatric APPs
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There's some additional educational resources that are sort of pediatric
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focused as far as like
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comment management problems and pathways and things like that.
12:29
Then.
12:32
Then they have
12:33
those templates could be constructed in that certain way. So.
12:37
Right.
12:38
And so, you know, you have the kid who has,
12:40
let's say they have something simple, right?
12:43
Recurrent otitis media.
12:45
Okay.
12:45
Let's make sure that we have all of the questions that we want to ask about.
12:49
Like, did they pass their newborn hearing screening? Right.
12:51
Did they have (inaudible) all those kinds of things
12:53
that are like silly, like when you think about them,
12:55
but they're important questions
12:56
and they're things that you expect to have been asked and answered.
13:00
so just making sure that they're following those algorithms.
13:03
Yes. But then you drive quality for your community, for audiologists,
13:07
for the referral family.
13:08
So when we have algorithms (inaudible).
13:10
Yeah, exactly. And they're helpful. They help keep us.
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They help make sure that we aren't missing things that we're following.
13:16
You know, a cadence. It's.
13:17
Where did you do your training? In Albany.
13:19
So I trained in Albany.
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I was actually super fortunate to train with, the group that I joined.
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I left for a short period and then moved back because my, well,
13:29
my husband is from the area, so I moved back and I knew
13:32
pretty much who I wanted to join.
13:34
You're a native of Albanian.
13:35
I don't know if that's probably not right, but yeah.
13:38
Yes, exactly.
13:39
Yeah.
13:39
The reason I ask is, I remember my co fellows and fellowship.
13:44
I did fellowship at Children's Boston.
13:46
So David Perry Kinsey Rodriguez, David Perry, Arizona private practice,
13:49
Kinsey Rodriguez, academic Dave, Kimsey and I would round
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and patients would give doctor Rodriguez Kinsey Rodriguez chocolate.
13:58
And on Christmas she got all these cards and Dave and I got nothing.
14:02
We just looked at each other.
14:03
I mean, we never won teaching awards, but people loved Kinsey.
14:06
Yeah.
14:06
I bet you patients love the physician assistants.
14:09
And I bet you they call.
14:11
And no offense to you, but they don't want to see me.
14:13
They want to see Joe Smith, the physician assistant.
14:17
You are absolutely right. You're absolutely right.
14:19
So patients like, let's say, somebody has been working
14:22
with a physician assistant
14:22
in the practice for a number of years on their allergy management.
14:25
And something is different, right.
14:27
They've got a new symptom.
14:28
And the says, you know, I do want you to see Doctor Perkins at the next visit.
14:31
Let's just get another opinion, another set of eyes on this.
14:33
Great.
14:34
They see me and then they say, okay, it was nice to meet you.
14:36
I'm going to go back and see. They don't want to see me.
14:38
They are super happy with the person they've been working with.
14:41
You know, my visit was probably more brief.
14:43
It was not as comprehensive.
14:45
I didn't ask about the grandkids, you know,
14:47
so they really do develop really nice relationships.
14:50
Just as a random comment: I'm obsessed with.
14:51
I use Claude.
14:53
And so when I put things into Claude, you're ready for this.
14:55
Claude will say you may need to work on your tone.
14:58
You lack empathy. Oh, my. Goodness, that's incredible.
15:01
Yeah. No, I'm not saying you don't like I've been like.
15:03
But love that feedback, right?
15:04
Yeah, yeah, yeah, yeah, but the physician assistants will spend time.
15:07
Yeah. So look at a holistically your right.
15:10
So can I call your practice and ask to see you specifically? Yes.
15:14
That's amazing. Yes.
15:15
Just like you would ask to see a specific physician.
15:18
You can ask to see any specific physician assistant.
15:20
But that doesn't cannibalize your own practice.
15:22
No, I mean there is a demand.
15:23
And I think I would be really surprised.
15:26
I mean, maybe in certain geographies, right.
15:28
And really dense metropolitan areas where there's lots and lots of ENTs.
15:32
But I would say in general, for most practices,
15:36
there's a waiting list to see the physician. Right.
15:38
And so we we are not only not cannibalizing,
15:41
but again, the culture of our practice is that we see each other's patients.
15:45
So we are not possessive of our patients.
15:47
I may see one of Gavin's patients and I may say, oh, hey,
15:51
you need to have some type of surgery.
15:54
He's like, great, do that surgery.
15:56
So we're not possessive of our patients at all.
15:58
That, I think is maybe part of why the culture works for us
16:03
to see each other's patients,
16:05
the APP’s patients, you know, and it it's not possessive at all.
16:08
You know, so I'm obsessed with numbers.
16:10
And can some call me a nerd?
16:12
I think it's an affectionate term of endearment, so What does Claude call it?
16:17
Oh, you're so funny.
16:18
So I'm going to nerd out a bit.
16:21
Tell me if you lose the analogy
16:22
because I don't want to talk numbers as everything is regional.
16:25
Let's call the base salary of a physician assistant: “X”.
16:28
Sure. Okay.
16:29
And your partners, do you mind?
16:31
And we don't have to talk about it, but do you mind?
16:34
How are they compensated?
16:35
And how does the pie grow? How do they win? Yeah.
16:38
So that's a great question.
16:39
And I do think it's important to know.
16:41
So in our region we do have a base salary: “X”.
16:45
And we keep it.
16:46
We try to be very consistent based on years of experience.
16:49
It's you know we try to sort of be transparent.
16:51
And are you consistent with the academic center too?
16:53
You have to be, to recruit.
16:54
We do have to be.
16:55
I will say that we acknowledge that our first year salary
17:00
is probably on the maybe
17:03
like mid to slightly low end of what the academic.
17:06
Exactly.
17:06
Because and we also talk about you know, we have this 24 week training period.
17:12
They don't do that.
17:12
I mean many of these APPs have had experiences where they're
17:16
now a hematology you know, provider day 1 or 2 thrown on the floor.
17:21
Let me interrupt you because I want to say that again.
17:23
You actually said you have a half year.
17:26
Yeah.
17:27
I just thought I want to I want you to know that at 24 weeks, I know. Gee.
17:31
Yeah, you're spending a half year investing.
17:32
And for that first 8 to 10 weeks there is literally no revenue generated.
17:36
Two months. No no billing, no nothing.
17:39
And then it's.
17:39
Yes, but it's an investment again.
17:41
It's an investment in your patients because truly they're getting access
17:45
and they're getting great care.
17:47
It's an investment in your practice because ultimately.
17:50
So I think that's one of the challenges right.
17:53
Retention.
17:53
We want to sort of try during our interview process to determine
17:58
if somebody is interested in a long term kind of marriage.
18:01
Right.
18:01
Are you interested in this long term relationship with us?
18:04
I do think a little bit, that first year salary
18:08
not being the highest, it Actually selects for the right culture.
18:13
I do - Because they now that, hey, I’m gonna stay here -
18:15
Here, we're investing in you in an educational component.
18:18
We're aware that our first year salary is less than if you go work in the hospital.
18:22
But by the way, you're also working nights.
18:24
You're working weekends, you're working holidays.
18:26
In our practice, there's no nights, so there's no weekends.
18:29
There's no holidays.
18:30
We're not the practice. We're not the practice for you.
18:32
But then we talk about yours. Two, three, four.
18:35
So just like a new physician joining the practice,
18:38
we're going to give you kind of like here's what you can expect year one.
18:40
year, what you can expect to year. So what can they expect?
18:42
So “X” is their base.
18:43
So “X” is the base
18:44
after their first three months they're now eligible for a quarterly bonus.
18:49
So this is everybody every physician assistant in our practice.
18:51
And I say physician assistant using it
18:53
interchangeably with APPs Confused because our acknowledge that.
18:56
So you know three months.
18:57
So I've done every 8 to 10 weeks I've just studied. Yes.
19:00
So for your at X three months and just every three months
19:04
every physician assistant is eligible for a bonus.
19:07
Now for your brand new person who has just started seeing patients,
19:12
they're probably not going to get a big bonus
19:15
in that first three month interval, because they just really haven't met
19:19
some of the KPIs that we use to - Sure but they're still getting a spreadsheet
19:23
totally be transparent.
19:24
Yes. “Y” is Nora here and “Y” is where I will be.
19:26
Yes, exactly.
19:27
That's so cool. That took a little bit of time to develop.
19:30
(inaudible) collections.
19:31
No it's not.
19:32
So interestingly, we considered using collections.
19:35
But we didn't really feel entirely comfortable with that.
19:41
We didn't really want to incentivize people to just be
19:44
going for high collections, and their bonus was based off of that,
19:48
so that our our lawyers didn't love that.
19:50
We didn't feel super great about it.
19:52
So what we ended up doing was creating KPIs based off of our physicians.
19:57
So we used our own group of physicians to kind of get normative data.
20:01
And we measure things like,
20:02
you know, procedures per patient, which includes endoscopy, ease serum and.
20:06
Removal control Epistaxis you measure that, not the reviews associated.
20:10
With just the absolute.
20:12
And a little bit it's sort of like, okay, where are the physicians?
20:14
Because that's sort of. About where are we. Yeah, yeah. Fair. fair.
20:16
And then if you're really below that that's kind of concerning, right?
20:20
I mean, I think. You're missing diagnoses people? Right. Exactly.
20:23
Or if you're really high, that's actually also a little bit concerning.
20:26
So you reward the band. Yes. Exactly.
20:29
So we look at things like that office visits capped.
20:32
So that's we're trying to kind of encourage people to like take add ons.
20:36
So we have an urgent care in our office, and we do have physician assistants
20:40
who are dedicated to cover the urgent care.
20:42
But we want a culture of yes.
20:44
And, you know, this is something that I noticed immediately
20:47
when I joined the practice.
20:49
If somebody calls up and says, hey, can you see my patient today?
20:51
They've got something weird.
20:53
It's always yes.
20:53
So how does office visits Cab define that?
20:56
So I'm gonna get physician assistant.
20:57
I have 10 in 10 in my template.
20:59
Yes. So let's say you have ten and ten in your template.
21:02
You get a kind of full points toward your bonus
21:05
if you kept 17 of those patients.
21:07
And what that means now, some of that's out of your control, right.
21:09
Patients who no show.
21:11
But if somebody cancels and you say, hey, I'll see one of the people
21:15
from Urgent Care Do you know how fair that is?
21:17
She will tell me to give you 5% notion to get I.
21:20
Yeah, exactly. And if I want for it, give me those urgent care.
21:22
We're trying to make it reasonable and terrific.
21:25
Achievable and access.
21:27
And also just you know what it is.
21:29
So, you know, if you didn't hit the, Yeah.
21:31
Why you didn't, you know.
21:33
I'm going to now pull some people from urgent.
21:34
So those. Are, those are two the.
21:36
Main thing is for other things that we do.
21:38
We have sort of an audiology care, category and that includes like
21:42
sort of number of audiogram conversion to hearing aids, similarly with allergy.
21:47
And then the last one we kind of consider like a
21:52
it's I should be a gimme.
21:53
It's the time frame between your visit and when it was billed
21:57
and the note was completed. Oh, that's a freebie.
21:59
And we want that to be within.
22:00
I think it's 24 hours or 36 hours or something reasonable.
22:04
So everybody should get that.
22:05
But it's also just a that's a good practice, right?
22:07
So let's go back to (inaudible) Yes.
22:10
This is phenomenal.
22:11
By the way, I was going to try
22:12
to keep this to 20 minutes, but I don't care hours Sorry.
22:14
So fun I don't feel sorry. You have an hour lecture today.
22:17
I made a lot. Right. All right.
22:18
Thank you. This is awesome.
22:20
So, physician assistant every quarter - Has an opportunity for a bonus.
22:26
So you have your salary.
22:27
Yes it is.
22:28
So they receive it
22:29
kind of almost like you would like our audiologists get commissions for certain.
22:32
Yes mechanisms. Yes.
22:34
And you can see if I didn't hit my full bonus why didn't I?
22:38
And what can I change in the next quarter so that I can hit my full bonus?
22:42
My son plays, varsity baseball, and I try to make a lot of his games.
22:46
Yeah, so if I cut my template play back to make the game
22:50
during baseball season, I will have less. Yes.
22:54
And you know what?
22:55
That's okay because you're aware of it.
22:56
So even in youth, like.
22:58
I make it up in the off season. Exactly.
22:59
And I think transparency is so important.
23:02
It doesn't have to be like, again, we weren't entirely comfortable,
23:06
like sharing collections, being transparent with, you know, here's
23:10
what you collect it like that becomes a little bit a little bit weird.
23:14
And there's there has to be
23:15
an understanding of like what the overhead is
23:17
and what the cost of goods are and things like that.
23:19
So it gets a little bit,
23:21
I think, difficult, unless you're really in the weeds of running a practice.
23:24
So x x is their base. Yes.
23:27
So are you able to tell me what percent is at risk?
23:30
Is it .12. No bags points here.
23:32
It's probably going to be oh, you're going to make me do math now.
23:35
Maybe like point maybe like 20% over the year.
23:39
Yeah. Right. So yeah. So then
23:41
like.
23:42
Yeah.
23:42
So it's going to be 1.04 x or point.
23:44
Oh yeah I got it. So 4% of course. That's terrific. Thank you.
23:47
And I think they'll really help our members.
23:49
Yeah. So the total at risk is 20%. Yep.
23:52
And then you said in year 234 they make more.
23:55
Is that because you give increases for tenure the longer you're there.
23:59
And again just use X kid I'm putting you in an I'm coming.
24:02
No no no it's fine.
24:03
So yes.
24:04
So we we kind of annually do merit bonuses.
24:07
That's sort of like practice wide across the practice.
24:10
And so the APPs you know fall into that category.
24:14
Like let's say you're year five and you're going into year six.
24:16
They're sort of an amount.
24:17
But then there's also we do
24:19
look at like market adjustments just to make sure that we're sort of.
24:22
So every now they might have a step up. Exactly.
24:24
But between the years one into
24:26
we're recognizing you've completed your training.
24:28
You know.
24:29
And we're going to give you like let's say you were at 45% of MGMA
24:33
or something like that, right? You're just a little below.
24:35
Well, now you're probably going up to 70% or something.
24:37
So like it's a pretty big jump.
24:39
It's a pretty big jump because we're aware that that training period is over.
24:44
So where you weren't collecting much for six months that first year, And
24:47
I do think that I mean I don't think money keeps people.
24:50
But I do think that you need to be aware that it is important to make sure
24:56
that you're competitive in your market, that you are, you know,
25:00
you might not be the highest because, again, if I'm working thoracic surgery
25:04
nights, weekends, whatever, overnights, that I'm probably going to be higher.
25:08
But I think you need to be aware that, you know, your your salary’s competitive.
25:13
And if your culture is good, your work life balance is good.
25:17
I think those are the things that keep people.
25:19
If people are happy.
25:20
Again, having an independent practice, I think is
25:23
generally a fulfilling thing where we want to provide medical care.
25:27
I think it can be really challenging for
25:29
APPs to be on that sort of shared schedule where they're not really independent,
25:35
they're almost working as scribes or or kind of like, you know, as a resident
25:39
where you're sort of going in and doing the initial thing,
25:41
but you really don't have any ultimate control of the plan in the office.
25:44
Visit.
25:45
I think that that can be frustrating, and that may be an area
25:49
where retention can be a challenge.
25:50
Yeah, it's just unbelievable.
25:52
So let's continue as I don't have a piece of paper in front of you.
25:55
So I may add another variable.
25:56
So physician comp oh no no, no.
26:00
Physician collections is a why
26:04
physician collections is a why.
26:06
What are the APP's across the country.
26:09
You don't have to be to your profits because you benchmarked.
26:11
So 0.3.4.
26:13
Collections of practices is different than that. Yeah.
26:16
So it doesn't have to be figures and else give us an idea.
26:18
So I would say our AP collection can be close to y.
26:24
Got it. Yes.
26:25
Or let's say 0.5 of y.
26:28
yeah fine. So half half. Yeah okay.
26:30
But it can reach close to it because of utilization of ancillaries.
26:35
Sure, sure. Yeah.
26:37
That's the variable that I think
26:38
because the downstream utilization or audio grams etc..
26:41
So how do you invest in the APP’s past
26:47
past six months of onboarding.
26:49
So I am ten years into your practice how are you continuing to invest in me
26:53
as an APP? Yes.
26:54
So they do get CME money every I think it's maybe
26:59
do you want me to tell you the amount? I think this is fair.
27:01
It's like $5,000 every two years for CME.
27:04
So it's a yeah I think it's a very like a huge amount reasonable
27:08
you know kind of offering.
27:10
How do they use that?
27:10
Where do they go?
27:10
So they have to use some of it for you know
27:14
yes of course the annual meeting, you know some of it has to be ENT specific.
27:18
So like going to that ENT
27:20
for the PA training course, we've had many PAs attend that.
27:24
But then some of it can be PA specific So if they want to be involved
27:27
in like the state PA society, they can use it for that as well.
27:30
So it's a little combination of those two things.
27:32
And the lead PA and education PA help adjudicate that.
27:36
I don't want them attending ortho courses and leaving me to be in ortho. right.
27:39
But I do think there's a like they have to recertify in general things.
27:44
So there is a need to maintain some of that general knowledge.
27:48
But I think, you know, again, we do want them doing ENT specific
27:52
courses as well.
27:53
So the other thing I should throw out there.
27:55
So for our lead PA, she has goals
27:58
that kind of like any manager would a manager of a department.
28:02
And those goals, do have a bonus tied to them.
28:05
So that's unique.
28:06
And then the person who's running the education for the PA
28:09
also does have an additional stipend for that.
28:11
And do they have a day or half for the admin?
28:15
Yeah.
28:15
The, the manager has a half day a week of admin time.
28:19
And the, I think the education maybe has like a quarter day
28:24
or half day every other week.
28:25
Where do they sit in the governance structure and board meetings?
28:28
Yeah.
28:28
So we don't have them, for example, like, you know, in our, in our governance,
28:32
we have an executive committee and then we have the partners.
28:34
So they're not involved in those immediate meetings, which I think is reasonable
28:38
for a subset of the partners.
28:40
Yes, it's a subset of the partners.
28:41
But we do have well, our lead PA, the manager of the department
28:47
meets with our CEO, who's Gavin, on a I want to say every other week
28:52
that of cadence.
28:53
I rally every other week or once a month.
28:56
And then. To address the needs.
28:58
And exactly, exactly.
28:59
And then we have a provider meeting every month that brings all the doctors,
29:03
all the PA's together, for some education and also just kind of, like, concerns.
29:08
So if there's things that need
29:09
to be reviewed with the whole practice, all the providers, we review that.
29:12
And then quarterly we do what we call pod meetings,
29:15
which is sort of all of the pads and pods are just kind of the way
29:19
our practices set up, like, you know, hallways or corridors or whatever.
29:22
The PA who are in those pods meet with Gavin and myself
29:26
and just review like any kind of it's almost like the airing of the grievances.
29:30
Right?
29:30
It's sort of like, are there concerns, are there issues,
29:32
are there processes that you've seen that are not working?
29:35
Do you have, you know, solutions that you think would work better?
29:38
So it's really just meant to be an opportunity on a little bit
29:41
of a smaller scale to kind of like meet with, Gavin and myself.
29:47
If I was to go to a grocery store, a ball field, a baseball field in Albany,
29:51
and I ask about your practice and ask about the physician assistance,
29:55
what do you think people would say?
29:56
So I think it would be a very favorable experience.
30:00
I'm sure they'd rave about it.
30:02
I so we use a lot of, reviews, right?
30:07
We solicit reviews and whatnot because,
30:09
like it or not, I do think that's important. Right.
30:12
And our PAs probably get us.
30:14
They do better than they get at least as many reviews as we do.
30:17
You know, they are getting reviewed regularly.
30:19
Patients love them. Yes.
30:21
And we sometimes, you know,
30:22
we try to share this with, just the practice when it happens.
30:25
But people will specifically call thank you know, a PA
30:28
even through urgent care because urgent care, you know,
30:30
brings in things that sometimes are not ENT Right.
30:34
People come in and they're, for example, somebody might be sort of
30:37
in some sort of a-fib like nuance that a-fib.
30:39
Right. Because they're short of breath. Yeah. I'd send them out the door.
30:42
do. We call EMS,
30:44
we do, we do.
30:45
We send them out the doors.
30:46
How do they know how to manage it better than I do?
30:48
Frankly, yes.
30:50
Well, not even but they just, you know,
30:51
they take their pulse and I'm like, oh, good call.
30:53
That was a smart idea. Yeah.
30:54
We go right here to take the pulse.
30:56
So, you know, there's just things where the PAs are
30:59
delivery, incredible care.
31:03
You know, in, in sort of helping expedite care for patients
31:06
and patients are really, really appreciative
31:08
and they reach back out and, you know, call the management and say, hey,
31:11
thank you.
31:12
I want to shout out this person for helping out my dad who came to
31:16
urgent care. Yeah, it's really amazing.
31:18
Yeah.
31:19
When we thought he was having exactly we thought maybe his asthma
31:22
was acting up or is, you know, he was nasal polyps, right?
31:25
Yeah, exactly. Wow. So,
31:29
What isn't going well?
31:31
I took 36 minutes to be your friend.
31:33
I know. What? What isn't going well?
31:35
So I think one challenge that we have, like, we we worry about retention.
31:40
But I will say that our, our rate of people leaving
31:45
unless they're moving geographically at those.
31:48
Yeah is very, very low.
31:50
And so I think that that's going well.
31:52
But I do think it's a concern, you know, we don't (inaudible) Yes.
31:56
Exactly.
31:57
So there's a challenge with sort of like finding that right size.
32:00
We have two more physicians joining us in the fall.
32:03
And you know, I feel like for us, we're feeling like that sort of 1 to 2
32:09
ratio feels pretty good when it starts to get like,
32:12
if a lot of the physicians are operating or out of the office, it can get a little
32:16
overwhelming for the physician who's there to be the resource.
32:20
So right sizing I think is a little bit of a challenge.
32:23
Also, geographic location is, you know, our office in Albany is huge, right?
32:29
So we have 54 exam rooms or something like that.
32:32
So there's always people there for help, for assistance.
32:35
We have one other office that is smaller.
32:38
We have about 4 to 5 providers there.
32:40
But on the rare occasion some holiday or something,
32:43
if somebody is there alone or you know, without a physician,
32:47
like that's something that we're trying to navigate
32:49
and make sure it's safe and everybody feels comfortable.
32:52
We have a third location that's opening.
32:54
So, you know, as we sort of get a little geographically
32:57
less concentrated, I think that can be a challenge.
33:01
There was another area that, Gosh, I was trying to.
33:04
It's escaped me.
33:05
Yes. Retention, geography.
33:08
Oh, yes. Here's a good one.
33:10
So I had, wonderful opportunity to talk with one of the residents
33:14
who is attending the OTO Forum, which I love.
33:17
Right.
33:17
And we were talking about the APP talk that we're going to have later.
33:20
And she said, I had a concern about a practice I was looking at
33:24
because they said
33:25
that I would be responsible for overseeing four of the PAs or the APPs.
33:29
Right. And I was I don't know what that means.
33:32
You know,
33:32
that sounds like a lot for me when I'm just starting to learn how to practice.
33:37
And I'll say, when one of the physicians who's joining us this fall,
33:39
that was a big concern was sort of the what does this mean?
33:42
What is the legal implication?
33:44
And what I have told all of these, the residents, this is kind of like
33:50
working with your junior residents
33:51
in that you're actually used to working with people who are, you know,
33:55
maybe not as experienced as you are, but they're your colleagues.
33:59
And so you're used to doing this.
34:01
Obviously, legal implications can vary state to state,
34:04
but as long as you're maintaining safety and compliance
34:06
with all those things, I think that's reasonable.
34:09
I don't think that's an area of concern.
34:11
But I think just thinking about it like you're working with your twos,
34:14
your threes, you know, you're working with your residents who maybe aren't
34:17
quite as experienced as you are, but they're incredibly capable.
34:20
They're incredibly smart, they're incredibly motivated.
34:23
And when you kind of compare it to that, I think it's a lot more comfortable.
34:28
We're used to that, and we like that.
34:30
We like teaching in collaborating and working with people.
34:33
So I think it can be a really nice opportunity to kind of teach
34:37
And remind me, for the audience, my understanding is your advanced
34:41
practice providers do everything they'll do (inaudible).
34:44
They'll do flexible, nasopharyngoscopy.
34:47
They'll do.
34:47
endos, correct? Yes. Okay. Yeah. Other than procedures perhaps.
34:50
Correct. Yeah. And again I think that can vary by state.
34:53
Absolutely, they’ll scope a patient.
34:55
Scopes.
34:55
Control of epistaxis, Perry tonsils or abscess drainage.
35:00
Yeah, those things probably are the mainstay of, of their procedures.
35:06
We had a, PA who moved to, to New Mexico,
35:10
unfortunately lucky to whoever's in New Mexico working with her.
35:13
But anyway, she was an audiologist
35:15
who had been trained previously with, microscopes.
35:17
So she would do, like myringotomies,
35:19
or she would do, like, trans tympanic injections.
35:21
So that was really unique.
35:23
So you might find somebody who came from a, you know, procedural background
35:27
who could do a little bit more.
35:28
I forgot to ask you,
35:29
what is your role in the practice vis a vis advanced practice providers?
35:33
Is it your passion?
35:34
Are you the liaison? Yeah, I am the liaison.
35:37
Sorry, we should have done that. No, no, no that's fine.
35:40
And it really I do feel strongly about it, like because I think it is
35:44
I think it's a need for health care.
35:47
I think if, if we're going to sort of be able to provide care to people
35:51
in a timely manner, that we really need
35:54
to embrace this sort of extension from, you know,
35:58
from physicians to include APPs I don't think it's a threat.
36:02
I think it's an opportunity for us to just kind of open
36:06
our own schedules more, be more efficient, you know, offload
36:11
some, some of the stuff that maybe I don't need to be seeing your six month
36:15
allergy follow up, you know, so I think it it can be really helpful.
36:19
A personally, as a physician, I think it can kind of relieve
36:23
some of the stress that we feel.
36:25
I think it can be really, really beneficial as far as,
36:29
work life balance, I think for patients, access
36:32
is incredibly improved when we just have more providers.
36:36
But again, I think it's really important
36:38
for those providers to be well trained How much time is spent in oversight?
36:41
if you want it to be actually weekly, monthly.
36:43
Probably weekly, I'm going to say maybe like 2 to 4 hours.
36:48
So a real amount.
36:48
But that's because you have to dozen. Yes. Exactly.
36:51
And that's not even like direct oversight.
36:53
That's kind of exactly.
36:55
Yeah, yeah, yeah.
36:57
One more question.
36:59
What do you see as the future?
37:01
And are we able to recruit APPs?
37:04
How is the market.? Yeah.
37:05
So the market that you are just overall.
37:07
Yeah, of course I think it is good actually.
37:09
So Dave
37:10
Malen was just talking about audiologists and the challenges of just not there.
37:14
You know, there's not enough audiologists,
37:15
but I think there are increasing numbers of programs training APPs.
37:20
I think it's become sort of a very visible field that people know about.
37:24
So people are going, you know, choosing
37:25
after their undergraduate to go into a program to become an APP.
37:30
One thing that I think has been very helpful
37:33
from a recruitment standpoint, we partner with a lot of the local programs
37:37
to offer an ENT shadowing experience.
37:40
Because like any training program, it's always a challenge to find places
37:44
for your students to go and shadow,
37:46
we found it really helpful for literal recruitment.
37:49
So people who decide, I really like this and we've had this prolonged interview
37:53
with them.
37:54
We like them, so they can join our practice thereafter.
37:57
Or if they go into the community as a primary care physician, they know us.
38:02
They're familiar with us.
38:03
They're an excellent referral source.
38:05
Yeah.
38:05
I wonder I'm looking at and our team here on the staff.
38:08
I wonder if the Academy of Otolaryngology should have a booth or some way
38:13
in their national meeting, I think like, and you know, Uncle Sam, we want you.
38:17
Yeah.
38:17
They need to know what an amazing specialty we have. Yeah.
38:20
Just as we reach out to med students, I don't know, what do you think about that?
38:24
I think it's a really smart idea because ENT, right?
38:26
We're a small.
38:27
We're so small and people don't really know what we do necessarily.
38:31
And if they didn't happen to either have an ENT problem or,
38:34
you know, happen upon an ENT shadow experience best and brightest.
38:37
Exactly.
38:38
But if they have an opportunity to come to an ENT office, people like it.
38:43
I mean listen we're great right?
38:45
But your turn.
38:46
I was going to say your turnover must be other than those leaving,
38:49
like New Mexico. Charge. You must be very low.
38:51
It's low, it's incredibly low. Yeah, yeah, yeah.
38:53
Which is I can't thank you enough.
38:55
Anything you want to end with for the group?
38:57
We're going to have our our. Goodbye.
38:59
I'll tell you that in a second. But anything that you would like to?
39:02
I honestly,
39:02
I think we've hit all of the points, but I would the only thing I would say is
39:06
I definitely would encourage people who are on the fence to really consider
39:10
this option of adding APPs to your practice.
39:13
Gavin, myself, we are all happy to talk about this with anybody.
39:17
Because I really do think it's going to be a critical part
39:21
of us maintaining independence and staying successful in the future
39:25
By providing access, because if we don't provide it, others will. Yes.
39:29
And we're seeing that when we talk about scope of practice.
39:31
And also this allows us to
39:33
to make sure that the quality of the care meets our standards.
39:36
Right.
39:37
Because we found, like with our urgent care example,
39:40
the quality of care that patients are getting for ear,
39:43
nose and throat urgent care complaints in our practice,
39:46
you know, is incredibly higher than just going to our regular urgent care.
39:49
And that's not saying anything against regular urgent care.
39:51
They don't have scopes.
39:52
They don't have like the ENT
39:54
specific knowledge that we have, but we're providing a higher level of care.
39:58
And so by kind of embracing it, we can control that quality,
40:01
make sure our patients are getting the kind of care that we think they deserve.
40:04
And we always end these podcasts, with a good bye.
40:07
And I think we both know
40:09
how we're going to say, what are we going to say at the end?
40:10
What does he always say?
40:12
Onwards and forwards.
40:13
Oh, you wanted to say fired up?
40:15
Now we can say rally go. Onwards and forwards!
40:17
Onwards and forwards. Thank you very, very much.
40:20
This was fantastic. Super helpful for our members.
40:22
This is Doctor Nora Perkins from Albany.
40:24
Please reach out to her.
40:26
They are incredible friends of the Academy.
40:28
And I think you encourage, right? To reach out?.
40:30
Oh we do. Yeah.
40:31
Please reach out Thank you very much. Yeah.
40:33
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40:34
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40:37
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40:40
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40:42
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40:44
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40:45
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40:51
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