All right, it is 8 o'clock Eastern Time, 7 o'clock Central, and we are about to start our webinar. And I think I have the green light to go ahead and begin. So welcome, everyone. My name is Scott Hollenbeck, and I'm the ASPS President-Elect and the Chair of Plastic Surgery at the University of Virginia. This is an exciting program. We have over 200 people that have signed up, and it really indicates the interest in this topic. And the topic is, The Value Added in Your Practice with Nurse Practitioners and Physician Assistants. And this is part of a webinar series that we're starting. So I'm really excited that you're here for the opening and the first one of these in this session. I'd like to actually start with some data, which many of you may find to be interesting. Many of you are aware of this, but from 2013 to 2019, the share of U.S. health care visits delivered by non-physicians, such as nurse practitioners and physician assistants, increased from 14 to 26%. So a quarter of all health care visits in the U.S. are now performed by nurse practitioners and physician assistants. Really, really amazing growth, and I think we're all aware of that. In fact, the U.S. Bureau of Labor Statistics estimates that between 2019 and 2031, the number of nurse practitioners in the U.S. will increase by 80%, and the number of physician assistants by nearly 50%. Contrast that to the growth of physicians, which is expected to be over the next decade about 5% increase. So really a dramatic change and shift in the overall workforce within health care. According to a study by Dr. Sam Lenz' group from B.I. Deaconess published in PRS in 2020, both physician assistants and nurse practitioners appear to have a positive financial effect on plastic surgery and plastic surgery-related practices, and you're going to hear more about that tonight. How does that happen? How is that possible? Many people think of NPs and PAs as a cost, but there's data to show that there's a positive financial impact on practices. Another interesting study published by Jeff Janis and his team at Ohio State and PRS Go in 2023 looking at the concept of independent clinics indicates that independent APP clinics improve patient access to care, they generate revenue, they directly and downstream, and they increase opportunities for growth in APPs. I think we'll hear more about that paper because we have some Ohio State people with us tonight. With that background, I'll stop. Hopefully that set the stage for what you're going to hear tonight. I want to remind any of our PA and NPs listening tonight that you may join ASPS as an allied health affiliate member. To qualify for this, you must be working with an ASPS member plastic surgeon. We value what you bring to our practices, I can tell you that, and our patients, and we want you as partners in our efforts for access and advocacy and education and innovation. I want to remind you that if you have a question, please submit that in the Q&A feature. The chat is open now. I'm going to go off script for a second and just indicate the immediate value add. You're going to hear from a physician assistant that works with me, Nicole Brooks, but just today while I was in the operating room, she was called to see one of my patients who unfortunately was having some issues with a small hematoma, and she actually drained that in clinic. That's just an example of how my services can be expanded, and together working as a team, we can take care of more patients, get better outcomes, and deal with problems sooner. So I'd now like to move to our panelists. We have a really exciting group of panelists. We go to the next slide, please. I've introduced myself, and I mentioned Nicole Brooks. She's up there on the list. Nicole's a physician assistant, works in the Department of Plastic Surgery here at the University of Virginia. We also have Patrick Kearns, who's a physician assistant, works at Ohio State University. And we have Neil Fine, who's one of our ASPS member surgeons, who's a clinical associate professor at the Feinberg School of Medicine, Northwestern University. And so I want to turn it over to Patrick Kearns, who's going to tell you a little bit about his experiences and his perspectives. Patrick, take it away. I'll see you all at the end for questions. Thank you, Dr. Hollenbeck. I'd like to first start by thanking ASPS for providing us this platform for APPs in plastic reconstructive surgery to come together and have a place to feel at home. There's been a handful of us that have been involved in an APP work group to help set up this webinar and kind of make this all come together and happen. So I'd like to thank Angie Oswald, Yazzie Dunn from ASPS, and Keri Betlock, Nicole Brooks, and Julie West for their involvement in the work group over the past couple of years. We're very excited to be hosting this inaugural webinar and many more in the upcoming future. Next slide, please. So I think it may or may not have been mentioned, but our audience today is about half surgeons, half APPs, nurse practitioners, and PAs. So we have a very broad audience tonight. We're going to try to give information that's helpful to all of us. We're going to start off with some history regarding PAs and NPs and how to best utilize us. I feel like this quote, even back in 1978, is very real, even for today. Next slide, please. The webinar objectives for today will be to understand PA and NP education pathways and growth, discuss APP utilization in private and academic settings, specifically in our compensation models and the benefits of having an APP in your practice. And these viewpoints will be coming from APPs and MDs as well. So you get a little bit of a variety from different perspectives. Next slide, please. So in a little bit of history, PAs were born out of a shortage of primary care physicians in the mid-1960s. Dr. Eugene Stead at Duke University put together the first class of PAs in 1965. The first class consisted of four Navy corpsmen who had received medical training during their military service, but no formal certificate or license to practice medicine back in the States. So he based the curriculum for the PA program off of his knowledge of the fast-tracking training of doctors during World War II. And fast forward to the year 2000 was the first year that all 50 states had authorized PAs to practice. So we are still young in our development. Next slide, please. Nurse practitioners. So nurse practitioners also date back to the 1960s, where Dr. Loretta Ford and Dr. Henry Silver developed the first NP program at University of Colorado, and this was aimed at increasing access to primary care. Since that time, NPs have grown rather rapidly. Today, there are over 270,000 nurse practitioners that are licensed in all 50 states, and they practice under the rules and regulations of each state in which they are licensed. Nurse practitioners can also get a degree as a master's or a doctorate. Their educational model mimics that of a nursing content with didactic and clinical components together. Majority of their clinical exposure is in primary care, with an opportunity to complete specialty clinical rotations. And in order to work in the operating room, nurse practitioners need to acquire a separate first assist certificate. Next slide, please. After graduation, whether it's for PAs or NPs, there is kind of a new growing trend, and that is a NP or PA fellowship or residency. The term is used kind of interchangeably. However, these fellowships are not required. They are definitely becoming more commonplace now. These fellowships offer a more specialized training in a particular area of practice. They typically are one year in duration after their formal schooling, and to my knowledge, there's currently no focused plastic surgery fellowship. However, there are several fellowships throughout the country that offer plastic surgery rotation, so much more teaching within plastic surgery, along with other surgical specialties for that fellowship. Next slide, please. So what's the difference? What's the difference between PAs and NPs? Really, the education model is slightly different. PAs are taught more of a medical model. NPs are taught more from a nursing model. There's more or less exposure to surgical specialties within their training. Again, PAs get operating room exposure and training during their schooling, and nurse practitioners require a first assist certificate that is separate. Does it really matter? No, it ultimately doesn't matter. Most practices use APPs interchangeably. Both require exposure and on-the-job training because it is a surgical specialty and not that much training happens within their formal schooling. Next slide, please. So the growth, looking at the growth of both professions over the past 10 years, it's easy to see that both fields are growing at a tremendous rate, and our presence in the surgical specialties and plastic surgery specifically is definitely on the rise. Next slide, please. Specifically, plastic surgery, as of 2020, the NCCPA specialty reports, there were almost 1,000 certified PAs in plastic surgery. Between 2010 and 2020, the number of practicing PAs in the United States grew by 73% to almost 130,000 PAs. So we're going to move on from a little bit of this history of APPs, and we're going to focus on more of the hats that APPs wear within their surgical subspecialties in academic and private practice. In the slides to follow, we will highlight these hats. Next slide, please. So I'm going to use my role as a PA to discuss the role of APPs in an academic setting. Specifically, I'll talk about what our practice here at Ohio State, and then we'll move on to a national level from survey data that we have collected. Next slide, please. So academic APP hats. So APPs in the academic world can wear many hats. It's important to note that when APPs enter their first academic practice out of school, they start off with two hats. They focus on clinical practice, much like junior faculty starting off in their practice, learning, and then number two, learning the specialty similar to a resident that's in training. Plastic surgery specialty skills and knowledge were not taught specifically in PA or NP school. Once we understand both the clinical practice and specialty learning has to take place at the same time for an APP, we can alter the practice so that we can help it run well, both from a faculty and an APP standpoint. Our clinic models adapt to the experience of the APP, and we'll discuss those further soon. As the APP grows in their experience, so does the number of hats that we wear. Once we are comfortable in the clinical focus and plastic surgery knowledge, we are usually interested and asked to participate in things like research, mentoring, other leadership opportunities, more organizational involvement, and all that can lead to career advancement. And this also leads to wearing more hats. Next slide, please. So in a clinical model, a little bit of our onboarding process, and then as we as we grow in experience, these are kind of the the clinical models that we use, and each one is meant for a little bit different learning style and as you grow through your career. So first, the resident model, the APP acts in place of a resident physician by seeing patients on the attending surgeon's schedule. They present these patients to the surgeon and assist in either orders or notes. The APP starting out in starting out in the specialty, it's a great opportunity to learn and follow along, follow along the surgeon for increased comfort and hands-on experience with physical, physical exam, patient assessment, formulating a clinical plan, and so on. I'm formulating treatment plans and therapies, and then and then we move on to our parallel model where we have an independent PA clinic that runs alongside the attending attendings clinic that allows us to become comfortable with running our own schedules and allows for increased autonomy and more importantly, offload the attending schedule and still have the attending present if certain needs arise. The independent model, which I believe the independent model is where an APP can be best utilized to maximize the surgeon's overall efficiency. In this role, the APP is seeing his or her own scheduled patients, but in still in collaboration with the surgeon and within their scope of practice. Clinics occur on separate days or and or before a surgeon's clinics. Well, the majority of the patients that we see in these clinics are in their global period. So they're not necessarily billable, but this allows APP to see these to see these patients and open up slots on the attending schedule to see more new patients and very likely increased productivity. Productivity. Another form of the independent model are procedural clinics. This allows us again to offload patients from the surgeon's schedule and allow the APPs to practice at the top of their at the top of their license. These procedures are performed independently and it is important to highlight that all of our APPs have been trained and reviewed by the attending surgeons for which they are supervised. Next slide, please. So using these clinic models over the past several years, our institution has made a large effort to increase APP clinic footprint within within our clinics. And we, if you can see, we have increased all of our visit types and about a 370% increase in a number of visits that our PAs have seen over the past several years. And so what what are all these numbers really mean? It means time. It translates to time. So next slide, please. So the most valuable thing that we have is time. And what's not always shown in the academic setting is the financial impact that APPs have, but we can put it we can really put it into time. The 90 day global period represents a lot of our visits do not equate to direct funding, but it is an indirect source of revenue, freeing up the surgeons to see more new patients, spend more time in the OR, conduct research or administrative duties. Next slide, please. So our operating room hat. So outside of the clinic in the operating room, we can be the first assist. We can help decrease operative time, allows the surgeons to be present for the critical portions of the case, increase case volume. Quite often this translates into running two rooms. That increases billing. We can also be a second assist, even though we can't bill for the second assist. We can speed up cases by helping close donor sites. We can also help with education of junior residents and or students. And in my experience that the PA is the ever constant in the OR. The OR seems to always be changing, whether it's rotations of residents or OR staff. The APP is the one who knows the surgeon's preferences and can help the OR run smoothly. Next slide, please. We also can wear an inpatient hat. We have dedicated inpatient APPs, a part of our work group that works with the residents. And this really forms a nice true team dynamic. They help with any of the floor needs and consults. APPs have a tremendous amount of knowledge. And so they help to nurture our interns. And they're the ones who stay on service. And so they are, again, the constant of our inpatient team. Next slide, please. So we wanted to look at what it looks like on a national level. So we conducted a survey to PAs in plastic reconstructive surgery at academic institutions. We had a 50 question survey and our survey focused on the benefits, compensation, role and value that PAs had within their practice. We had 91 respondents from 35 different academic programs, which was a pretty significant response rate. So, next slide, please. And then, so the national level, what did we find? We found that PAs work, most of them work with other APPs. Majority had independent clinics similar to ours. Majority of them worked with one or more surgeons. Next slide, please. We wear many hats in the patient care setting. This slide, there was many respondents that said that they worked in multiple different areas, including the clinic, the operating room, inpatient. So wearing several hats during their day. Next slide, please. This is the knowledge that APPs have within plastic surgery. We're utilized in a variety of subspecialties. This is an amazing amount of knowledge that has been acquired with APPs working in these specialties. Next slide, please. Compensation, so we looked at compensation from an academic standpoint. Almost all are paid a salary through their medical center and almost half had some type of bonus opportunity. Next slide, please. From a billing and revenue standpoint, it is important to note that even with residents and fellows present, that we can generate revenue when first assisting. A specific note must be mentioned as an example on this slide. APP can bill if the procedure falls under the Medicare First Assist procedure list. And it also needs to be noted that there was no other qualified first assist available. Reimbursement for APPs come at 85% of what the surgeon fee would be for clinical or surgical services. And then we also generate revenue through our independent aesthetic procedures or independent procedures that are minimally invasive. So what did all this show from a national standpoint? Next slide, please. The academic setting creates value for APPs and their careers. These bullet points here were noted from our survey as to what PAs value in the academic senate. Next slide, please. But what do all these hats worn by the APPs show? Shows academic team value. Academic plastic surgeons have pressures to be clinically productive, prolific in research and rise in their academic ranks. They may benefit from a highly skilled teammate and PAs and MPs are just that. So thank you for your time on the academic side of things. I'm gonna turn things over to Nicole. Patrick, thank you so much for that introduction. I'd like to start off by thanking ASPS for the opportunity to speak with you all tonight. My name is Nicole. I'm a physician assistant at the University of Virginia Medical Center in Charlottesville, Virginia. I've been a practicing physician assistant for the past seven years. I started my career in aesthetic private practice in New York City prior to making the transition into academics. Next slide. So this data actually comes from the National Commission on Certification of Physician Assistants. It was published in April of 2023. The data reflected in the report includes aggregated responses from PAs who are board certified as of December 31st, 2022. There were 1,068 plastic surgery PAs which makes up 1% of physician assistants. So how are we spending most of our time? The vast majority of PAs that we are conducting physical exams and obtaining medical histories, performing procedures, counseling and educating patients and their families. And all of those things and more can be done in a private practice setting. Next slide. So one of our primary roles as a PA or NP is seeing patients in the clinic setting. We can see initial visits, do medical histories, physical exams, procedural visits. This is especially important if in a private practice you have a medical spa as well as clinical procedures. So in terms of medical spa procedures, that's your neuromodulators, your injectable fillers, chemical peels, IPL, laser treatments, ultrasound skin tightening, microneedling, PRP injections, cryolipolysis, radiofrequency skin tightening. Your clinical based procedures, these are things like surgical excisions, your lumps and bumps, shape biopsy, earlobe repair, maybe piercings. You have preoperative counseling or preoperative education. So your chance to sit down and review their surgical clearance. In my experience, our practice at the time, we partnered with a PCP who would perform all of our medical clearance. And then I sat down with each of our patients to discuss the perioperative period, make any recommendations, skincare products or supplements. Again, it's another opportunity to discuss any products that you have as part of your medical spa, as well as providing post-op prescriptions and mentioning any concierge services. So things like private duty nursing, manual lymphatic drainage, accommodations, transportation, et cetera. And then your standard post-operative visits. So these are things like suture removals, dressing changes, and wound care. Next slide. So this comes from a paper, Steinbecker et al. The Rise of Physician Assistants and Nurse Practitioners in Medically Necessary Noninvasive Aesthetic Procedures for Medicare Beneficiaries. This was published in PRS in July of 2021. It's a retrospective study. It actually looks at the top 10 noninvasive aesthetic procedures performed by both PAs and NPs. Procedures were extracted from ASPS Statistical Report of 2019. So in total, approximately seven and a half million noninvasive aesthetic procedures were performed by nurse practitioners and PAs. Some of the limitations of this study, it's a retrospective study. It only includes the top 10 highest volume aesthetic procedures and it examined Medicare beneficiaries. So it did not analyze data from healthier or younger patients who may be better suited to receive these types of procedures, likely underestimating the engagement of APPs in medically necessary aesthetic procedures. Next slide. As the clinic templates, Patrick kind of briefly mentioned this. There's a couple of different models. You have the paired-shared. And so that is sort of an entry-level model. You're working off the surgeon's template. APP's work contribution in this model is considered almost invisible in the sense you're typically working off this surgeon's template. So you don't have an independent. You're basically seeing patients with them or in conjunction with them. But some of the benefits, the surgeon spends less face-to-face time with patients, allowing the potential to see more patients in a single day. APP is maybe helping with performing documentation or EMR. Maybe they're taking photos. Then you have a parallel clinic. So working on separate templates, but at the same time. In this case, the physician assistant or nurse practitioner is seeing perhaps their standard post-op patient, allowing the surgeon to see either an initial visit or caring for a more complex patient. And then the independent clinic. So an APP has his or her own template under his or her own name. And typically this would be where you're having procedures independently performed. And this is where you're gonna be seeing your highest revenue. Next slide. Another one of our roles is assisting in the operating room. So again, in private practice, we had a surgical suite. So potentially you have a surgical suite or an ambulatory surgical center that you're operating out of. And we have the opportunity to first assist. So decreasing interoperative time, increasing case volume, and it's billable. Also, you can help with OR turnover. So in my experience, I was helping to turn over the room. Maybe I was consenting the next patient. I maybe was recovering our prior patient in the recovery suite, helping pick instrumentation for the next case, making sure we have all the case requests, implant orders, and materials available. Next slide. So this comes from an article from Lynn et al at Harvard Medical School titled The Impact of Physician Extenders and Med Levels in Plastic Surgery. It was published in PRS in May of 2023 with the goal to identify the economic value and evaluate the effectiveness and safety of independently provided services by physician extenders in plastic surgery. It was a PubMed search, initially yielding 182 articles. And then after qualitative review, 10 articles were selected, specifically looking in this chart at the economic value. So Malloy et al looked at first assist in adolescent reduction mammoplasty. And this was an overall reduction in operating time by 34 minutes when using a PA first assist compared to a resident first assist. Chow et al compared the efficiency and financial gains after the introduction of PAs in the practice of two breast reconstruction surgeons in an academic health center. Looking at data from the one year period before and the one year period after the introduction of PAs. The results after the integration of PAs demonstrated an increase in monthly payments. And this is per month per surgeon and ultimately annual charges. So they saw pretty significant increase, also significant improvement in clinical productivity. So the encounter time for surgeons were shorter for all clinic types, including consults, pre-op global and non-global visits, allowing for the addition of nine patients during an eight hour clinic day. And they calculated financial gain using the calculation. So increase in surgeon payments associated with employing a PA, plus the payments directly attributed to the work performed by a PA, minus the cost of employing the PA. So that led to a net financial gain of roughly $33,000 a year. Resnick et al, looking at the removal of impacted third molars with IV sedation. So PAs obtained the consent, provided local anesthesia and wound closure, resulting in a reduction of surgeon involvement by 19.2 minutes. And there was no significant difference between post-op complications. And then lastly, Holtman et al, looking at PA run clinic versus a resident clinic, which showed an increase in financial returns of the entire plastic surgery practice and an increase in patient access. Next slide. So ultimately, what does this show? That you can increase your surgical volume by reducing OR time in the OR and increasing the number of surgical procedures performed on a weekly basis, increasing the number of patients actually being seen in clinic, freeing up other team members to deal with more complex cases, reducing physician workload, in turn, reducing burnout by having shared responsibility, decreasing your patient waiting time, so increasing access to care, increasing revenue, lengthening the time a patient spends with a healthcare professional, and care coordination. Next slide. So how did these two places differ? Next slide. For one, the team. So in private practice, you have a surgeon, you may have a physician assistant or a nurse practitioner, a practice manager, maybe a receptionist or somebody working the front desk, patient care coordinator or surgical coordinator, and plus or minus an esthetician. And I can say from our group, we contracted with an anesthesiologist group, a scrub tech, and a circulator nurse on our ORDs. So they may be a part of your team as well. Next slide. In terms of billing, in private practice, we had predetermined fees. So there was a flat fee for consultation that could be applied towards a scheduled surgery. You had a surgery cost, which included your anesthesia fee, facility fee, surgeon fee, materials cost. We also worked with a medical photographer to do pre and post-operative photos. So there was some photography fee as well. For minimally invasive procedures, so again, affiliated with your medical spa, we had flat fees in terms of procedures. We did offer bundled packages. So for instance, if a patient bought like three treatments, they would receive a marginal discount if they purchased that upfront. And then also any revenue that came from skincare products. PAs and NPs can bill as first assist, but again, you should note nurse practitioner needs a registered nurse first assist. And then just something, an interesting thought about having a surgical PA or NP, medical spa PA or NP or combination. So somebody who does both, somebody who works in the medical spa and also helps in the OR. In my experience, I did both. And I think Dr. Fine might talk a little bit more about his experience. In terms, oh, next slide. In terms of postgraduate training. So in private practice, the expectation is that the surgeon or supervising physician will be providing the hands-on training. You may or may not have other nurse practitioner or PA colleagues who you can consult with. Truthfully, I received a lot of my training from medical device representatives who are coming in and showing you how some of these med spa devices work, maybe what settings to pick, and an aesthetician who can teach you about chemical peels and other treatments available as part of the medical spa. Next slide. At compensation, I was salaried. I did have the opportunity for a bonus. It was based off of productivity, merit, the amount or the volume of new patients I was bringing into the practice, as well as any skincare revenue. Next slide. Things to consider. So the surgeon and NP or PA relationship. So I think one of the most important things to think about is really kind of defining from a surgeon perspective, what is it that you're looking for with your practice? Are you looking for somebody to help you in the OR? Are you looking for somebody to help you with notes? Are you looking for somebody who is going to run independently and have an independent clinic? And then also from the PA and nurse practitioner perspective, are you looking for growth? Are you looking for, how do you define growth? And what does that look like for you? What kinds of responsibilities do you wanna have in a practice and as you become more comfortable? On-call responsibilities. So I shared on-call responsibilities, non-disclosure agreements. In my experience, I did sign an NDA. I also had a non-compete. It was a 20 mile radius with a one year specialty clause. Professional fees. So these are things like your license, DEA, organizational dues, tuition reimbursement, things of that nature. And advertising. In private practice, advertising is huge. So educating the front desk to be able to offer for NP or PA services is the practice that you're joining do they add you to their website, social media accounts, email distributions that people know that an NP or PA can also offer those services as well. Next slide. Continuing medical education opportunities and funds. So these are things like journal club, grand rounds, various monies to attend conferences, things to think about. In my experience, I did not have that in private practice. Caseload variability, so the surgeon that you're working with, they may be interested in facial aesthetics or body contouring, so you may not see sort of the same caseload variability that you would see in an academic setting. Employment benefits, so things like medical, dental, vision benefits, 401k, cell phone use, laptops, those types of things can vary wildly between an academic center and private practice. Career advancement, we see a little bit more in terms of research opportunities, leadership opportunities in an academic setting versus private practice. And then collaboration, so you may not have other APP colleagues or residents to consult with if you're in a small private practice, and so that's also something to consider. Next slide. Those are my references, so thank you all for your time, and with that, I'd like to turn it over to Dr. Fine. All right, thank you. Thank you, Nicole, and thanks to everybody who's put this together. Let's just go to the next slide. I'm a plastic surgeon at Northwestern. I did work for 15 years as a academic medical school employed surgeon, so I'm used to training residents, and then in 2009, I shifted gears and opened my own private practice, so I'm gonna focus mostly on the private practice. So what can my PA do, what can a PA do? Well, your PA can do whatever you can do, whatever you can train your PA to do, and so especially if you're used to training people, you just train them up, have them do whatever you're doing. If you're used to training residents, you train residents to do what you're doing, and you expect at the end of their training, they can pretty much do what you're doing, and so that's what I do, and that's what I expect, and that's what happens for me in my practice. It's really just limited by what you can do. Let's go to the next slide. Now, an NP, I've worked with some NPs. I don't have as much experience with NPs, but from my perspective as somebody who's in private practice, what can NPs do? Well, depending on the laws in your state, they can work more independently, so if you have a satellite office, they can work in that satellite office. They can do things in the satellite office, see patients, bill for office visits if you're doing insurance, and they can do that really more independently, whereas PAs require, to some degree, some type of supervision. If you're asking them to work in the OR, though, they're gonna need some additional training, and I have done that. I've seen that, so that can happen, but that's an additional hurdle for an NP to work in the OR. Next slide. So what do my PAs do? So specifically, I'd like to speak to that. So in private practice, I have PAs. I have two different categories of PAs. I have PAs who are primarily on the surgical side of the practice, and then PAs who work in the med spa. So I have two med spas, one that's integrated as part of my surgical practice, and then another freestanding med spa that is staffed, really, with PAs. Next slide. So for me, the primary aspect of my life and my practice revolves around my surgical practice, and my surgical practice is really dominated by my time spent with my patients. My time spent with my patients is spent in conjunction with my PA. She and I see everybody. We see people together. We see people independently. When I have, so we have two surgical PAs. We currently have two surgeons. I really don't see my fellow surgeon that much. Same when I was in an academic practice, and there were five of us. We don't see each other that much because we're all busy, but when you're busy seeing your patients and you have a colleague, so I work with my PA as a colleague. So I operate with her after a certain number of years of training, just like with residency. She operates just like I do. She does what I do. My cases are primarily in the breast realm. We're doing mostly breast surgery, both breast cosmetic and breast reconstruction. She's pretty much doing one side during the surgery. I'm watching her just like I would watch a resident, but we'll switch back and forth. If there's something that's maybe more difficult or more unusual, we'll switch sides. But most of the time, she's just gonna do half the case, which means I'm gonna do this in half the time. It takes me a certain amount of time to do, say, place a tissue expander. We did that today. So I'm placing a tissue expander on one side. At the same time, she's placing a tissue expander on the other side. At the end, when I'm done, I'm looking, I'm checking. We're seeing how even things are. Is everything the way we want it? Okay, it is. Okay, I just did a bilateral tissue expander in the same time that it took me to do one side, but actually two sides happened in the same time. Same thing happens when we're seeing patients. I use an MA more as a scribe. It's not really good utilization of a PA skillset to have them scribe for you specifically. That means you're in the same room, you're doing the same time. Two people who could operate more independently are operating together. That doesn't really make sense. So I use a MA to primarily scribe for me. But when we have other issues that are more unusual or people are having difficulties, I will usually see them in conjunction with my PA, Lexi. So she handles also the patient calls and emails. She does computer documentation and EMR stuff for me. I just don't really enjoy EMR work. I can do it, but it's not where I'd like to spend my time. So she's very facile at it and she takes care of the EMR documentation. I bill for her as a first assistant. That helps support her salary. It doesn't actually totally offset the salary, but it goes a long ways towards offsetting that salary. Patients also feel more supported often by her. We'll find that she actually connects with them or talks to them in a way they feel safer or better about mentioning different things with her. We will often be in the operating room, they'll be asking, is Lexi here? You know, I just feel better if she's gonna be here. So it just makes everything a little bit better. Next slide. So on the med spa side, I currently have four PAs. Now, one of them is a very high level PA. She's super good, super experienced, and she actually runs the med spa. I help her and support her, but she's the one who recruits, hires, manages, trains. I don't train people how to do med spa stuff. As you just heard from Nicole, you're gonna learn med spa stuff from somebody who knows med spa stuff. And that can be estheticians or the providers of the equipment who will come in and train you. I don't know how to run those things, and I don't know the best way to inject different types of fillers. I don't do that, but my PAs do, and they teach each other. She's gonna do all of the things that all of our PAs do, plus she's able to actually run this. Now, that means you have to recruit and help maintain that person. Let's go to the next slide. I think this is a big deal. We heard earlier that time is money and things go faster if you use PAs. Surgery goes faster. That's true. All those things are true, but it's also the quality of the time. I think the quality of time is very important. For me, if I'm collaborating and working with someone, I'm having a better experience. If it's just me working, trying to work faster, and I'm working faster, but I'm isolated by myself, I don't feel as good about it. So I really enjoy and like the collaborative aspect, but then again, that's just me. But that's what I'm looking for. So if I'm looking for a PA who's a good fit for me, this is somebody who really wants to work together and collaborate, and we're just gonna do everything together. These are the issues that go into physician burnout, but I'm gonna say for me, burnout, not such a big issue because I've got all of these things under control, and it's really having a PA who's very good helps with that. Next slide. So why wouldn't you have a PA? Well, some people think it's too expensive to hire a PA, and in fact, it does cost money to hire a PA. If you have a good PA and you wanna keep this PA, you need to pay her or him. In Chicago, I asked around, if you wanna hire a good RN in the downtown Chicago area, or you wanna hire a PA, you're gonna pay approximately $50,000 more per year for a PA as opposed to an RN. The RN is not likely to generate additional revenue for you. They're gonna help you do things and help you run your office, but they're not gonna be able to go to the OR and bring in revenue as a first assist. They may be able to inject for you. I find it's difficult to do both. This for me is the reason that a PA is gonna be a good PA. It's gonna be a better choice for me. Let's go to the next slide. So you have a great PA. I have a great PA. How did this happen? Because I've worked with also a PA who wasn't as good of a fit, and all the PAs are just gonna be like doctors. They're individuals. They're people. So you have to kind of work together on this. You have to meet somebody. So one way you meet somebody is you can have PAs. PAs are looking for experience. There's a PA program in your town. They do not have specific rotations in plastic surgery often, but they're looking for rotations in plastic surgery. If you offer the ability to have a PA do a rotation in your office, you're gonna get a chance to see them and meet them. So that's actually how I met my current PA, Lexie. She actually worked to get a rotation with our office. We do a lot of teaching, so that it doesn't take a lot away from us. We're used to that, and we're gonna have that, but it allows us to see people. You then recognize their skillset. There is no actual residency. I think of it more as a residency. So there's no real residency for a PA in plastic surgery. That's you. You as a plastic surgeon can train other plastic surgeons. Well, then you can train a PA who can be essentially an extension of you as a plastic surgeon. Has to do with your ability to train them, their ability to take that on. Next slide. And then here, we talked about how do you retain somebody? It's not easy to retrain somebody, but I think you can think about this. How would someone retain you? Do you work in an academic center? How are they keeping you? Are you working in a group practice? How is that happening? So this is something that you have to figure out. If you provide a good work environment, you have to pay in the benefits. As a private practice, you can pretty much decide what that is. We buy phones. We help with travel and further training, educational training. So we give benefits. If someone's gonna leave your practice, you'd wanna know why. Why are they leaving your practice? Well, they're leaving your practice because somebody else is offering them something better. Or perhaps they're moving. So that happens too. So there are times when if somebody needs to move location, you can't do too much about that. But you can work to make sure that you're offering somebody who's worth keeping, you offer them enough to keep them. Next slide. So, or a surgical PA. If you do breast body open surgery, you really should have a PA. I don't think see any reason why you shouldn't do that. But if you do primarily facial procedures, and you're doing primarily cosmetic surgery, it's not clear that a PA is actually gonna be that great for you. So give that some thought. Next slide. The med spa PAs. Okay, what's the story on the med spa PAs? You have to pay injectors especially, and you have to set up a good environment for them. And it's hard to hold on to these people because they have a lot of options. You have to decide how much you can afford to pay them. But then if they're good, they're probably worth it. For the PAs out there and NPs out there, it's very difficult. You start your own product. You can't take home more than half the money you bring in unless you're like working at home. So you have to kind of decide do you really wanna run the business? But if someone has their own patients, I'm not feeding you the patients. You have your own clients. You're bringing them in. You're running the show more or less, and we're working together where you're more independent. 50% is pretty much the max that you would think that you would be able to take home after you have the cost of goods sold, after you factor out that price. Next slide. So in the real world, I believe it's really about finding good people. You can have great RNs. I've worked with great RNs. If you have a great RN, you just wanna keep this RN. She's just great. You love working with her. But a PA is gonna be the most versatile. That's what I'm gonna say. And speaking to the idea, can a PA do both work in the spot and inject and help you in the OR? I've tried that. Some, it's very difficult. I think if you have a busy surgical practice and the things are changing in surgery and your surgery just got changed or your surgery is running over because that PA or RN or NP has their own schedule of people to inject and you're gonna want them to go there and then you're gonna have conflict in schedule. So I found that to be difficult. So with that, I think I'm gonna take it out to questions. Thank you so much. Well, I wanna thank the panel for a really incredible presentation and lots of information there, some data, some personal experiences and Dr. Fine for kind of bringing it all together there in terms of his perspective as a surgeon. Wanted to remind everybody, we have the Q&A open for questions. I think this is really what we all look forward to. We've got a few minutes. I'm gonna start right away with one that we got kind of early on. And that was, have you noticed any difference in PA training done in the traditional university setting versus a for-profit institution? And I'll open this up to Nicole and Patrick to see what they say. Go ahead, Nicole. What exactly do we mean by for-profit institution? Yeah, I wondered as well. I guess what that would mean maybe would be a health system that stands alone, not affiliated with a medical center or an academic medical center like a university versus a traditional university-based hospital. Yeah, I think probably case variability. So probably some more complex care in a university or academic setting versus a standalone setting. And probably also some more interaction with residents in terms of training, which I think is valuable training. Patrick, do you have any thoughts about that? I agree with that. I think one of the things to look at, and I don't know if I've necessarily had experience with for-profit students, but one of the things to look at when you're looking at the schools that they're coming from are potentially their PANCE scores. So their board scores that the PAs take at the end of schooling in order to become certified. It gives a good representation as to the education that's provided at that institution. And I would just say that realistically, it's more about the person, who is this person, rather than where they trained. And then if I look at the training a little bit like looking at training at the medical school level, this is a basic broad overall training that you're getting. When you're talking about exactly what you're doing, more specific, that's more like the residency part of it from the plastic surgery side. And so that's really, the training happens after you get the job. The training didn't really happen in school. Great, now I'm gonna move to the next question. It says there was a comment about 85% of the surgeon fee as it pertains to services provided by, I think in this case, we're talking about a PA, but perhaps involves NP as well. Patrick, that was your response, but I'm actually gonna ask, I'm gonna bring Julie online. Julie West is one of our organizers here and Julie, sorry to call on you here last second if you're available to answer that. Otherwise, Patrick, maybe while Julie's getting logged in, maybe you can comment on that. Yes, so it's according to the Medicare is that they kind of set the standard for the reimbursement for APPs. And so if I was seeing a new patient in the clinic and I was gonna bill for their new patient visit and then Dr. Fine was gonna see that patient and bill for that patient, I would only get 85% of the total fee that Dr. Fine would have if he was seeing them independently and I was seeing a different patient independently. So that is where the 85% comes from. Yeah, okay. And Julie, did you wanna expand on that or I want you to say hi to everybody. You've been such a force behind getting this together and it couldn't go by without you at least saying hello to everybody, but I'll turn it over to you. Okay, well, thank you for that. This has been an incredible experience and I'm thankful for everyone that has logged on and for our awesome panel tonight. I think that Patrick hit the nail on the head. I mean, and I think when you're looking at visits and billing, I think the interesting thing is, the surgeon's making money in the OR. And so if we're capable of 85%, if we're talking about $100 and I can bring in 85 and the surgeon's in the OR and I can be seeing a new patient and working them up and getting them ready to meet the surgeon or ready if they're not, I think that that's where we can have value. And in our practice, we have a lot of, we see a lot of the body contouring patients who are not optimized for surgery and we can bill for them and we can put them through and make sure that when they do see a surgeon, they're a surgical candidate. And so many of them are not and they leave with a plan to get optimized, but we're able to kind of capitalize on getting them seen and improving our access, but also making sure that the time that the patients are spending with the surgeon is valuable and leads to surgery, which is where the money is. Yeah, absolutely. I think we saw a slide that showed the incredible growth, especially in academics and with resident limitations and growing centers everywhere. I think it's so clear to many of us in academics that APPs and NPs are an integral part of what we do. Maybe for Dr. Fine, what do you see in the next five to 10 years in the private realm? And do you see a lot of these partnerships developing or any issues coming along? Why has the growth not been as substantial in the private sector? So in private practice, if you're a plastic surgeon in private practice, as mentioned, you make money by doing surgery. So to the degree that a PA or RN first assist, NP first assist can actually make that surgery go faster, that can be helpful. But if you're doing primarily cosmetic surgery, especially facial cosmetic surgery, it's not easy to do that at the same time. And it's just not really gonna be good for that. You're gonna do a rhinoplasty. I mean, these types of surgeries really lead to, I'm a surgeon, I'm doing this surgery. I don't need a PA, PA is not gonna really help me. So then if you're going to have a spa as part of your practice, that's where you're gonna have more independent use of PAs and NPs injecting for you. They can work more independently there. And I think that if you're doing some breast and body work and you're mixing in some insurance work, then I do think our PAs really work with that. So PA is indispensable to my practice, but my practice is not the same as somebody who's gonna do more cosmetic stuff and facial cosmetic stuff, especially. Yeah, so I guess it really depends, as you alluded to, the practice, the nuances of the practice and where that person fits in and how they can help the surgeon the most. We have a couple of other questions, few more minutes, we'll keep going. Do you have any tips for a new NP PA that is less than one year out of school, hired on with a private practice, plastic surgery practice with no prior plastic surgery experience? So I guess early grad, early career, and now they're joining a private practice. Nicole, what do you think? What's the best way to get started? Yeah, so that was my experience. I was the new grad and went right into private practice. I think truly it's such a learning curve, to be honest with you, because you're learning, if you're gonna be in the operating room, you're learning surgical technique. You're also learning all of these neuromodulators, injectables, additional components as part of the medical spa. I think I mentioned during my presentation. So I was in sort of a hybrid position where we operated together and then we had our medical spa component as well. Just be open, make sure, open to opportunity, practice. So anytime somebody in the office is willing to be an active participant, that's a good way to gain knowledge. And just really trying to honestly network as well, like meeting other APPs. I was the only PA in the practice. So I'd come from a surgical program and I was at an academic center doing my training and had residents, and then I was sort of on my own. So a lot of independent learning, but be very open to the opportunity and try and take as much of it in as possible. Ask a lot of questions and give yourself the opportunity to sort of do hands-on experience whenever you can. Yeah, so I think good advice in general for almost anything. It looks like Julie wanted to make a comment, Julie. Oh, well, I just think use your training as, use your residency and your training experience to help onboard your PA, I think. So I had the great opportunity to work with Dr. Fine when I worked at Northwestern. And like one of the phrases he, like, do you remember? It's a seven-year training program. And he would say that all the time and it's like, it's true, right? And I think if you have to come in, whether you're in academics or whether you're in private practice and realize that our training is focused and quick and also broad. And so, put into us what you, what was put into you as an intern and as a junior level resident. And I think, sure, it can be accelerated in some ways and in some areas, but I think like it has to be like a gradual process. It's not gonna happen overnight. Yeah, again, good advice in almost everything aspect of life. Build trust, be engaged, learn and develop every day. Another question, are there any consoles that PAs cannot see independently based on the insurance company the patient has? As in, are there any insurances where PAs cannot bill without the physician also seeing the patient same day? Really practical question. I think in general, a lot of people like an approach where you just see every patient and treat them kind of the same. Irrespective, it gets hard to distinguish, well, let's do this for that insurance and whatnot. But from a practical standpoint, Patrick, are there any insurance programs that we need to be aware of that are different? When it's coming to seeing patients in the clinic, as long as it falls under the scope of your attending surgeon's practice, then it is okay to see any one of those patients within the clinic. Where it becomes, where that changes a little bit is if you're gonna bill for surgical procedures, they must fall under the Medicare First Assist procedure list. So there are surgical procedures where you cannot bill for an APP as a First Assist, but by far the majority of procedures that we do perform in plastic surgery, you can bill for an APP as a First Assist. So that's to look out for. In the clinic, you can pretty much see anybody. And Patrick, you mentioned that list. I've never heard of that. Is there a way to make that available or is it widely available? Do I just type on Google First Assist Medicare or how does that work? Should be able to pull that up. We can, I can find it. We can actually find a way to maybe post that with ASPS's help. Yeah. Get that list out there. That's a good idea. We can establish some resources for people as they're looking into this. And along those lines, maybe for Dr. Fine here, are there resources that help me, an MD, develop my mindset and practice for the assistance of an APP? Articles, literature, things like that. Other than calling Dr. Fine himself and getting help. Neil, what do you think? I'm not really aware of that. I mean, we've seen some articles. The articles are usually going to talk more nuts and bolts numbers about different timeframes, different amounts of money, those types of things, but not actual training. Not actually, how do you make this work? And what I would just emphasize a little bit, what Patrick had mentioned is, PAs are an extension of you. If you have the capacity, the ability to do something, it's within your scope of business, then your PA is, that's the same. Scope of business, scope of practice for a PA who works for you is the same as your scope of practice. But what is your ability? They're going to, very few of them are going to come to you trained. So that means you need to train them. So for me in surgery, I'm used to training. It's not a problem. As Julie mentioned, you want to be fully trained. That's seven years, a seven year program. But on the spa side, I don't do training in the spa. I have a PA who helps with training. We're going to be more interested in hiring a fully trained spa person to inject and do things. Unless you have training available, the training piece has to come from you. Yeah, really great point. You got to put the work in and do the time with the person and help them develop. Couple other questions. This is a good one. What is your experience with patients being open to seeing APPs versus surgeon for cosmetic surgeries? Maybe Dr. Fine, maybe Nicole, you could talk about your experience where patients give you a hard time when you went to see them. But Dr. Fine, what do you think about that? Sure, so what I'm going to say about that, and I know some other plastic surgeons who do this as well. If you have somebody who's knowledgeable and good, you can have a cosmetic patient see that patient first. I will often do that. I don't always do that, but Lexi, my current surgical PA, will typically see a patient first, go over some things first, take some pictures, and then I will come in after. If I'm not available, she can see this person because she can honestly present herself to somebody who does surgery, surgical knowledge. I can go through with you. Are you a good candidate? As Julie mentioned, do people even know what surgery can do for them? A well-trained PA who really knows surgery, the type of surgery you're doing, including cosmetic surgery, is going to know, are you a good candidate? What makes you a candidate? How can we talk about that? I can show you some pictures. I can show you some things. I know a plastic surgeon who does that specifically and says, you want to see me? You're going to see my PA first, and you're going to talk to my scheduling person about how much this costs and when are we going to schedule it? You see these two people first. Once that happens, then you see me. I mean, you're always going to want to see your patients before you actually operate on them. But part of a screening process, that's where that can really work out. And then you don't see so many people who really aren't candidates. You can use the PA as really more of a screening tool. Yeah, and in fact, applicable in residency programs too. Even residency programs that have an aesthetic component, you often have residents that go in and see, and in many cases, they may even have less experience and knowledge than your surgical PA, for example. Nicole, have you encountered that issue in your career? So I'll echo a lot of what Dr. Fine said in regards to surgical patients. I think a lot of it also has to do with education at the front desk. So how the practice is presenting a PA or an NP, if they're educating patients and saying, I have a qualified individual who can also be available, that is huge in terms of helping from a medical spa standpoint. From a surgical standpoint, I think in order to be able to talk about a procedure and be a good candidate, you have to have a good understanding of what's happening in the operating room to be able to answer patient questions and have the confidence to see patients and evaluate them properly. So that's what I would say about that. Yeah, yeah, good point. And that implies that you've got to make sure your team, your APP team, your PAs and NPs are getting to the OR so that they can actually see these cases. So maybe that's a hint for me, Nicole, but one last question here and then we'll shut it down. Can a well-trained PA run a satellite cosmetic office or does an MD need to be present? This is getting into some issues that often revolve that are at the state level at times in terms of what's allowable with supervision and so forth. Patrick or Julie, any understanding of that particular topic? Like, do you have to have your surgeon there with you if you're offsite somewhere on your own? No, I don't believe so, but you're right. This is getting into a really hot topic and sticky situation, but I think, no. But I think the key is well-trained and clearly I'm completely biased because I've been in academics like my entire career, but I think there's a physician oversight and a medical director in a lot of places, but no, they don't physically have to be there. And I think maybe I'll just stop there. I don't know if Dr. Fine has anything to add there, but. Yeah, I would say that some of this question, as I would interpret the question, is more of a legal issue. So on a practical standpoint, is this person capable of doing something? If you've trained them and they're capable, just like draining that hematoma, I mean, if you're capable of doing it, you're trained to do it, you can do it. That's totally okay on that standpoint. Then there's the legal standpoint. Legal standpoints have to do with what state you're in, because there's gonna be different laws in different states that's governed by state law. So you would need to know what the state law says. Also, what I would say about that too, is the NPs mostly in state law, certainly in Illinois, they can actually practice independently. The PAs need some form of supervision. The supervision doesn't have to be in the same building, but it has to be readily available or within some type of availability. So some of this has to do then with how available are you? What is the actual distance? How are you going to interpret readily available? This is more of a legal question. You're gonna wanna talk to your lawyer about that. And Dr. Fine, if I can just interject, I know that that does differ state to state when it comes to NPs, but that is slightly different in Missouri. And it is related to distance from your collaborator, but to echo Julie's sentiments, I think well-trained is definitely the most important when it comes to that. Yeah, couldn't agree more. This is gonna be a state law question. Yeah. Well, fantastic. I think that's the end of our questions and also marks the end of our inaugural session here. Really excited to be part of this. There is a QR code on the screen there available for you to scan. If you would like to learn more, become an affiliate member ASPS. This is just the start. We plan on involving more and more of you all in our educational programming, including our annual meeting. Plastic Surgery, the meeting being held this year in San Diego in the fall. Please look forward to that. We hope to have offerings there that you would find valuable. And also throughout the year with these webinars and other educational depots that we talked about where we can put helpful information on there. So we have a email address there as well for you to contact member services. I wanna thank the panel for a really wonderful session. And I look forward to seeing you all in the near future in person. Have a good night, everybody. Good night. Thanks, Scott. Thank you all. Thank you.

Plastic Surgery

Nurse Practitioners

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Healthcare Growth

Operational Efficiency

Patient Access

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Healthcare Delivery

Scott Hollenbeck