All right, good evening, everybody. Thank you for joining us for our webinar series about onboarding nurse practitioners and PAs into plastic surgery practice. My name is Julie West. I'm a physician assistant at The Ohio State University, and I am going to be moderating tonight's session. On your screen right now is instructions on how you can submit questions throughout the presentation. Everybody will be muted, and the speakers' cameras will be on during their presentation. At the bottom of your slide, you can submit through the Q&A feature, and then at the end, we'll address as many of the questions as possible. This webinar is going to be recorded, and it will be available online after. You have access to it if you're an ASPS member, and if not, the email address shown here, you can reach out. I just want to say thank you to everybody for joining us while we get our slides up here. First off, we want to thank ASPS for giving us the platform to host and have these webinars. This is our second webinar in the Advanced Practice Provider, Nurse Practitioner, PA webinar series. We hope to continue this through ASPS. We're hoping to have a panel there and potentially continue with the webinar series into 2025. I think that there's definitely a desire in the plastic surgery community to learn about, to train, and to engage physician assistants and nurse practitioners, and so I, again, we're really grateful for this platform. Tonight's panel is meant to be that, a platform. It's not all-encompassing, but it is one that we hope to talk about intentional onboarding of nurse practitioners and PAs in your practice, why it's important, and hopefully to give tips and tricks on doing so effectively. Our speakers tonight are great, and I'm super grateful and honored to be on the panel with them. First up, we're going to talk, Michaela Zeltman is going to start. She is a physician assistant that works at Ohio State, and she works in our hand group with Dr. Ryan Schmucker, who's one of our other panelists. He'll be speaking last, and they are a good surgeon-PA pair, and so I think we're going to see some perspectives between the two of them, and then also, you know, just different vantage points. Carrie Bettelock is a nurse practitioner at Washington University in St. Louis. She's the lead in their plastic surgery and hand division, and she's an excellent resource, and so I am super excited for this panel. Michaela, if you want to go to the next slide. Our objectives tonight are going to be to discuss onboarding strategies, identify potential challenges, look at the timeline for training and onboarding, and then, again, at the end, Dr. Schmucker will be kind of offering the perspective from a plastic surgeon, and I'm going to leave it to Michaela now to take it away and start us out. Great. Thank you so much. Thank you, everyone, for joining us, so let's get right into it. You have hired an NP or a PA. Now what do you do? How do you integrate them into your practice? Well, we believe there are two key components of successful integration into a plastic surgery practice, and the first is intentional onboarding. I'll define this here in a moment, and that's what I'm going to be spending the bulk of my time discussing, but the second is culture. There has to be a culture that recognizes the benefits of NPs and PAs in the practice and aligns itself with providing a network of support and opportunities for their growth and development. Dr. Schmucker will touch on this a little bit more during his presentation. So when I say intentional onboarding, what do I mean? Well, I think this can be summarized by the following definition. It's a consistent and organized onboarding infrastructure that promotes the intentional incorporation of an NP or PA into the practice through a defined curriculum and strategic integration into an independent practice. So like Julie mentioned, I work at Ohio State, so here we've developed a specific onboarding plan for NPs and PAs that meets the goals defined here. I'll share with you the specifics of our onboarding plan, but know that I'm very aware that this cannot be a one-size-fits-all model. What we've done in the academic setting is likely going to be different from what's needed in a private practice setting, but my goal is to share broad concepts. Thanks, Ayla. Yeah. I'm going to interrupt you for a sec. The slides are only showing the presenter view, not the speaker view. Okay. Hold on one second. All right. Angela, are you able to share your version of it? And then I will just not screen share mine and I'll just ask you to advance the slides. Sure. Yeah, I'm actually going to ask Devin if she can pull that up on her side as the host. Great. Thank you. Thank you, sorry to mess up your mojo there, but. No, totally fine. I thought it was just my view of it, and I was like, nope. No, thank you, I appreciate it. So is this working? Yes, it's perfect, there you go. Okay, so like I was stating, at Ohio State, we've developed an onboarding plan, and I'll share with you the specifics of what that looks like, but please know that I understand it cannot be a one-size-fits-all model. My goal is to share broad concepts that can be applied as you see fit into your practice. So we'll dissect this definition in order to better understand in how to develop an onboarding plan. Next slide. But before we get started, why does it matter? We all know the significant value that an NP or PA can bring to your practice, but the simple addition of this role in your practice doesn't guarantee the results that you're looking for. It doesn't guarantee financial returns, improved access, better outcomes. In order to reach those outcomes, we have to invest time in proper training of the NP and the PA. When an organization takes time and effort to invest in their employees, the employee feels valued. They understand what's expected of them. They feel connected and aligned to the goals of the organization and feel supported by their employer. This leads to increased job satisfaction, and the cost of NP or PA turnover can be detrimental. So one way to decrease likelihood of this turnover is by being very intentional with your onboarding plan. Next slide. So what do I mean by the cost of turnover? A study by the American Association for the Physician Leadership in 2020 looks specifically at the financial implications of NP or PA turnover, both directly and indirectly. So indirect costs. They're those not measurable factors, the things that can vary widely between organizations and can be hard to calculate, but are equally as important as direct costs. Examples of this includes loss of productivity, whether that's the number of patients being seen, the number of surgeries being done, an increase in administrative tasks, like the dreaded peer-to-peers, which can lead to loss of patient revenue, a change in team dynamics, and lots of other things. So these are difficult to quantify, but I'm sure you can imagine the significant impact that they have on a practice. And direct costs are measurable factors, with direct costs and attributable dollar amounts that we can see in the table here. So their study estimated that the direct cost alone for NP or PA turnover could range from $85,000 to $115,000. Now, obviously, this is gonna be practice-specific, but I personally think that it really demonstrates how much of an investment an NP or PA can be for your practice and how expensive it can be for turnover rates. Next slide. So let's take a deeper look in how we can avoid this turnover by intentional onboarding, starting with the intentional incorporation of the PA or NP into your practice. Next slide. Now, I was very intentional with my word choice here. I didn't say that we are going to incorporate them into the clinical practice yet. Don't worry, we'll get there. But I said that we are going to incorporate them into the practice. We start with the human part. We start with the community part. So first, the NP or PA is an extension of your practice, a reflection of your team, a part of your work community. As a physician, it's important to demonstrate the value of the NP or PA by clear endorsements of them to both the rest of your office staff as well as patients. So what do I mean by that? From a staff perspective, walk them around, let them meet the team, send an email bio introduction, do an introduction of them at the next staff meeting. From a community perspective, provide a script for your schedulers or receptionists about their role, elaborate on their training, emphasize that this is an extension of your practice and the trust that you have in the NP or PA. If you're in a private practice setting, take a day to go around to the local referring physicians and have them introduce themselves. Second, find out who they are and do it on purpose. We are all probably familiar with a similar Dolly Parton quote, but I want you to find out who they are. This is both for the PA and the NP and the physician. Developing relationships in the workplace builds trust and it builds rapport. You're not going to trust your patients with someone you don't know. Therefore, take time to get to know them as a human. What are their likes? What are their dislikes? How do they prefer communication? How do they take criticism? What do they do for fun on the weekends? I get that this might be a lot for some people and it might not be your style, but again, the goal is to build trust and mutual respect. This does not mean that you have to be best friends outside of work by any means, but it means that you've invested enough in the working relationship to build trust. And that is essential for a surgical NP, PA and physician relationship. Trust and mutual respect is the foundation of a successful NP, PA and attending relationship. Next slide, please. Now we spent some time talking about the intentional incorporation of the NP or the PA into the practice. Let's talk a little bit more about what I mean by a defined curriculum. Next slide, please. The goal of a defined curriculum is to provide an opportunity for the NP or PA to develop the skills and knowledge to feel comfortable treating any patient and confident in their diagnostic skills. Additionally, it provides the attending physician an opportunity to confirm knowledge and skills and therefore continue to build trust in the relationship. However, this does take open and honest communication. Danger occurs when we assume that someone knows something or when we are afraid to ask questions. Do not assume that an NP or PA knows every nuanced component of plastic surgery. It took you forever to learn these skills. Our training is extremely broad, especially for a new grad or someone who's never been a part of this type of practice. Expect that their knowledge is at the level of an intern. You can adjust your teaching based on their reaction to the training, but it's always better to start low, go slow and ensure that everyone is on the same page. And in the same breath as an NP or PA, don't be offended by simple questions. Embrace an opportunity to hear something presented in a different way or to learn something new. Now, to achieve these goals, an onboarding curriculum can be simplified into four components, a specific timeframe, indications, skills and expectations. And we'll look at each of these individually and I'll demonstrate how we incorporated these into onboarding programs here at OSU. Next slide, please. Now, this is a very busy slide and by no means I'm expecting you to look at this or read it or fully comprehend it, but my goal is to show you a timeline of our onboarding process. So we have based our program on a minimum three-month onboarding period for any NP or PA regardless of their skill level. A new hire is given a three-month schedule on their first day of training outline exactly what they are going to be doing on a daily basis. It's very specific, including where to go, when to be there, who they're working with, the type of day they're gonna have. Like I stated before, our goal is for this talk to provide a framework for an onboarding process that can be adapted to your skill, but this is what we've done at OSU. Now, I will preface this by saying that I work in a hand surgery practice. So the examples that you'll see here is gonna be more specific to hand surgery, but you can certainly adapt them to the needs of your practice. Next slide, please. Within the schedule that I just presented to you, we have dedicated didactic time that's built in at least once a week. It is so easy and convenient to have a new hire just jump in and learn on the fly. Trust me, I get that. However, I personally believe, and we've shown that dedicated didactic time is critical in order for the NP or PA to get the most comprehensive education and for the attending physician to ensure that there is consistent patient care provided to their patients. Again, danger occurs when knowledge is assumed. This can be controlled with intentional didactics. So what we did here at OSU is we developed a weekly didactic series based on residency guidelines that was specialty-specific for us. In our team, we have a wonderful team of four, now five, NPs and PAs who divided the content amongst ourselves and we created individual lectures and presentations based on each topic. These were saved in public folders for access in the future and our current PPs and residents even use those lectures on a regular basis. But here's an example of some of the lectures that we did. We also had guest lecturers come in and provide things like Dr. Moore coming in and providing an EMG review, anesthesia reviewing the type of anesthesia that is used for different procedures and why. Julie gave a wonderful presentation on wound care and wound healing principles. And all of these are available for reference for a new hire at any point in time. Now, in our academic setting, we're also really fortunate enough to have regular planned didactic education opportunities. And in order to build the foundation that's needed for an NPR PA to thrive in such a nuanced topic, such as plastic surgery or in my field, hand surgery, they need to be given protected education time. So in our team, that meant requiring our new hire NPR PA to go to any resident related education opportunity that was related to our specialty. In private practice, it might be that you set aside a half day a week to go through the dedicated education components for at least the first year. Next slide, please. A defined curriculum must also include teaching skills, both clinically and procedurally. So similar to how we developed a list of lectures, we also developed a list of skill requirements that were built from resident guidelines and adapted them to fit our practice. We incorporated these skills into the scheduled didactic lectures, and we tried to incorporate skills early on in the teaching process so that they could have more meaningful co-clinics and surgical experiences with the attending physician later on. So this included things in our practice, such as physical exam, image and study interpretation, and clinical decision-making. Procedurally speaking, this included things like casting and splinting, injections, independent procedures, and first-assist skill. However, I know that not every skill can fit perfectly into this little box that we've created. So in order to supplement that, we created a competency checklist. Here's an example of the competency checklist that we created for hand surgery, but this sort of functions as a self-guiding tool for the new hire. It allows them to have full knowledge of the expectations from the beginning and the ability to seek out topics or skills or cases that have not been categorized in their onboarding program. This should be reviewed with the new hire before they start independent practice to confirm that the skills are adequate. Next slide, please. And finally, a defined curriculum must include expectations. This is your opportunity to develop clear expectations from the beginning, both as an NP or PA and as the attending physician, because I do not want your practice or your experience to end up like this photo. From the surgeon's perspective, determine your vision for the NP or the PA in your practice and share it with them. Be very clear of your expectations. Discuss any metrics, especially if salary is going to be directly related to billing. Do you want them to see patients independently? If so, in what capacity are they seeing post-ops, new patients, follow-ups? Are they going to the OR? Are they rounding? Are they taking call? What are the indirect patient care expectations? Peer-to-peers, in-basket, phone calls, research. Again, I can't reiterate to you enough, share your vision. As a PA, I can speak for some of us in the profession and say that we are people pleasers. We want to know what you want so that we can exceed your expectations and help the practice thrive. PAs and NPs going into a surgical practice, I believe have a great understanding of the fact that this is a team approach to healthcare and appreciate having expectations set. From the NP or PA perspective, you should also share your vision. You went into this career with expectations of how you'd practice, as well as what the physician-APP relationship would look like. Talk about this early so that everyone can align their goals and their vision. Additionally, it's really important that you understand what your scope of practice is based on your state and also your center that you're working. Don't assume that your surgical team knows all of these expectations. Understand your scope of practice and voice them thoroughly at the beginning. Next slide, please. So we've talked about the intentional incorporation and we've defined the curriculum for their learning, but how do we integrate them into an independent practice? Next slide, please. The answer is in a stepwise fashion. Here at Ohio State, new hires start with dedicated time shadowing directly with each attending physician and or their associated NP or PA, if applicable. Once done shadowing each attending, which is going to be different based on the number of attendings and the practice setup that you have, they move on to a resident model where the new hire is in clinic with the attending physician, seeing patients, discussing diagnosis and treatment plans. This really allows for an opportunity to have the attending physician preferences learned and reinforced and to reiterate the material that's being taught in the concomitant didactic lectures. Once the residency model is complete, we move on to parallel clinics. This is where the NP or PA is having their own clinic in a different hallway or a different space as the attending physician, but at the same time as the attending physician. This proximity allows for independence, but also creates a safety net for the NP or PA if concerning issues arise. And then finally, you transition to independent clinics. Again, in our practice, that doesn't occur until at least three months of the above stated processes have been completed, but these can be done completely separate from the attending physician. It doesn't mean though that the attending physician is not involved. They are available via call, text, email, chart reviews, however you determine that to work in your practice. Next slide, please. So in summary, intentional onboarding is a consistent and organized onboarding infrastructure that promotes the intentional incorporation of an NP or PA into the practice, which will develop relationships, build trust. It includes a defined curriculum of indications, skills, and expectations to develop the knowledge and skills that they need to safely and accurately treat your patients, and it's followed by a strategic integration of the NP or PA into practice by a stepwise faction of increasing independence. And now we will hand it over to Kari. Thanks, Michaela. Thanks for being here tonight. So Michaela talked a lot about some strategies for onboarding, and I am gonna talk about, go ahead, next slide, some challenges. So even with the most intentional onboarding processes, there are some associated challenges. I'm gonna talk about four challenges that I've personally encountered. These are definitely not all encompassing, but just some challenges that I've personally encountered when onboarding a PA or NP. We will have some time for discussion at the end, so I'm definitely interested if anyone in the audience has experienced any specific challenges that I don't specifically touch on. Next slide. So the first challenge that I'd like to discuss is individual variability. Nurse practitioners and physician assistants are often used interchangeably at many institutions. I know at WashU, that's true. But in addition to variability between individuals, there's actually some variability between the two groups, both in their educational and their training. So when you're onboarding a new NP or PA, it's important to recognize these differences. I think the most obvious is a PA's curriculum is gonna be modeled more off of a medical school model, and they're generally going to have more exposure to surgical specialties during their training compared to a nurse practitioner whose, our educational model is more consistent with an advanced practice of nursing, and most of the training is gonna be done in primary care settings with less surgical exposure. Next slide. So in addition to, it's important to recognize these differences because it means generally speaking, a new PA is going to have more exposure to surgery during their training than a new NP. But this could be true even when onboarding not a brand new NP or PA, but a new to plastic surgery NP or PA. The individual amount of surgical exposure is most definitely going to vary. So things that just seem second nature to a surgeon, even something like prepping and directing in the OR, this could feel completely foreign to a PA or an NP that's new to a surgical practice. So some may have had significant operative experience from a previous job, and others may have never set foot in an operating room. So it's just important to have kind of an understanding of this baseline knowledge to take into account during the onboarding process. Those individuals' training and operative exposure into consideration when you're kind of molding what that onboarding process is going to look like for you. Next. So another challenge, and this is one that we have experienced at Wash U, is some institutions require an NP to have an additional certification, a registered nurse first assist to be able to assist in the operating room. So I just mentioned this because it's something that you should consider when you're during that onboarding process. And if this is true of your institution, you may want to get started on that certification sooner than later, especially if it's a person that's going to spend any time in the OR as part of. Next slide, please. So the second challenge that I want to touch on is the breadth and complexity of the specialty. So functioning in the OR is just one of the many roles that a PA or an NP can work in throughout plastic surgery. And this slide just kind of displays some of the many areas within plastic surgery, NP or PA can contribute. My background is mainly in hand, but throughout my years in plastic surgery, I've gained experience in breast reconstruction, peripheral nerves, some aesthetic and burn. And at Wash U we have APPs working in nearly all of these areas. Next slide. So the wide breadth and complexity of plastic surgery is a challenge that's encountered during this onboarding process. So plastic surgery addresses issues from head to toe. And even within the specialty, there's many surgeons who are going to be sub-specializing. So this slide just depicts a small percentage of what plastic surgery entails. When you're onboarding somebody to the specialty, this can be super overwhelming. I mean, I would argue even potentially impossible in setting that person up for failure. If you're attempting to onboard with new PA or NP to kind of the greatest depths of the specialty possible right off of the bat. Next slide. In addition to a wide breadth and complexity of the specialty, there's just a lot of different roles that your NP or PA can function in within the specialty. So that NP or PA may wear many different hats and it's important during that initial onboarding process to kind of prioritize the specific job which you want them to perform. Next slide. So to overcome this challenge, we found that the focus during that initial onboarding and tailoring the onboarding experience to the specific role leads to greater success than starting out too broad. After that initial experience is mastered, then additional roles and responsibilities can definitely be added and what your PA or NP is doing can be expanded. Next slide. So team dynamics. Team dynamics look different depending on the type of practice. I work at a academic medical center. So in addition to the attending surgeon and your PA or NP, there's fellows, there's residents, there's medical students, there's lots of different people who are kind of all learning. So I think that during that onboarding process kind of balancing the needs of a new NP or PA who is learning the specialty with those of, for example, a recognitive physician who is also to a certain degree learning the specialty is important to kind of recognize. This kind of balance can happen in essentially any area throughout the practice, in the OR, in the clinic, procedures, and it's just something to kind of be aware of during the onboarding process. Next slide. So the last challenge, we've discussed some framework for what an onboarding program looks like at our individual institutions, but there's no formal standardized onboarding program across the board. Different practices certainly will require different processes, but collaborating among PAs and NPs to standardize some of these tried and true practices, it's just gonna help advance our profession in the future. So I hope when we get to the Q&A, we can talk a little bit about what onboarding looks like in all of your practices. Next slide. So the timeline, Michaela spoke to this a bit, and the process of onboarding is, there's lots of individual factors that contribute to an appropriate timeline for onboarding. It's going to be a highly individualized process, and it's really difficult to quantify how long this process should take. Generally at WashU, it's ideal if that initial onboarding process is a minimum of three months. We recognize that it's gonna take much longer than this for someone to become comfortable in their, truly comfortable in their role, and especially in multiple areas. And we generally expect it to take closer to one year or more before the NP or PAs truly mastering the role. And additionally, we like to kind of have that year under their belt before we're really adding a ton of additional roles or responsibilities to their position for which they were onboarded. Next slide. Okay, that's it. Thank you. Okay, let me share my screen here. Can everybody see this okay? Yes. Okay, perfect. So excellent talks by Carrie and Michaela. Thank you guys for having me on the panel. This is going to be the shortest perspective only because I want to defer most of the kind of question and answer to the NPs and PAs, but wanted to give kind of a surgeon's perspective to what has been presented so far. And I think that we can all appreciate how wonderful life can be when you have a nurse practitioner or a PA that is excellent and doing a great job and how difficult things can be when that dynamic isn't the way that you want it to be. And so what we want to talk about tonight is how do you build that relationship to be a productive team together? So I don't have any disclosures relevant to this talk. Really the basis for what we're talking about is the basis for being a good leader of any team. So as a surgeon, you are by default the leader of your team, but you have to lead with kindness and mutual respect at the outset. So even though your position as a surgeon puts you with your training at the head of the team, you can't take that attitude into your interactions with the rest of your team members. And this obviously is true of NPs and PAs, but also of secretaries, schedulers, nurses, anyone in your office. Kindness and mutual respect have to be the basis for this relationship. And then bringing on a new nurse practitioner or PA they have to understand that you have some investment into their career beyond what they can do for you. So investment into their career means talking to them at the outset and understanding their goals. So their goals may be to get into the operating room more. Their goals may be to be very patient facing. And sorry, that's my dog. We'll let him out. Their goals may be to be academically productive and to do more from a national organization standpoint. And so understanding those goals at the outset is gonna help you invest in their career in a meaningful way. Throughout the process of onboarding then you have to be available and you have to be approachable. There's gonna be a lot of questions and the way that you respond to those questions initially over the first few weeks to months of this person joining your practice is really gonna dictate how they feel about approaching you in the future about questions that they may be embarrassed to ask. We all remember as residents and as trainees kind of being unsure of ourselves and not wanting to ask a dumb question but if you are approachable and if you are available for those kinds of questions which we all have, then I think that sets the relationship up to grow in a positive direction. And then finally, this should be fun. This is a team for those of us that have played on any sort of team or been part of a group that achieves goals together. It should be a fun process and you set the tone for the attitude of the entire group. And so making it a fun process to learn and integrate into the team should be a point of emphasis. So the goals, your goal as a surgeon for integrating an NP or PA into your practice should be that an excellently trained team member can be all of these things below. So they can be the available affable touch point for your patients. Excuse me. As a surgeon and as any surgeons on the call between operating, seeing patients in clinic, taking care of your charts, having time for family and yourself outside of work, there's not a lot of extra time to do all of the things that are required for you, including returning patient calls or answering patient questions. We all know patients think of 10 extra questions as soon as they leave the office. If you have a touch point for your patients on your team that can answer those questions and or bring those questions for you or even filter those questions to the ones that are most appropriate for you, that is incredibly valuable from the standpoint of saving time and also making the patients feel that they're heard. This part about being a pillar of consistency in your surgical practice is really true. When I see post-op patients, they're not always disappointed to see me instead of Michaela, but sometimes they are. She does an excellent job of seeing post-op patients and she is the consistent part of my practice that they expect to see and are willing to reach out to with questions. You can also, when well-trained, have a reliable, dependable practitioner who can be trusted with independent care of your patients, not just any patients, but your patients. And it's not easy to hand over control of patients that are under your care. We assume liability as surgeons and we assume ultimately the responsibility for all the things that happen under our care. But when you have trained and spent the time pouring into an NP or PA that's part of your team, to the point where you can trust them, that's an incredible thing for your practice overall. And then as far as academics go, a reliable NP or PA can be trusted to onboard residents and fellows into your rotation and keep your practice running smoothly as people cycle in and out. And that consistency matters for those of us in academics. So a lot of this has been covered before, but I just want to emphasize if you're not, if you're failing to plan, you're planning to fail. So you have to have a plan to ramp up with well-defined goals in mind that you have not only thought of, but also communicated to your NP or PA. You cannot make assumptions about clinical knowledge. Like Michaela mentioned, NP and PA training is very broad and it's very excellent, but it's not specific to plastic surgery. In fact, even medical students we know who rotate on our services have no idea what we're doing most of the time. And so you can't assume anything when it comes to onboarding a new member of your team. Plastic surgery, we've all spent six plus years intensively training in this. And we've all spent a lot of time six plus years intensively training in this. You should expect a timeline for masteries that's similar for your NP or PA. And that means five, six, seven years sometimes. And that's okay. They may master things sooner. It may take them a little longer, but this is a long-term process and should be viewed as such. And then expectations are really key as well. Your NP or PA's role in your practice should be well-defined from the beginning relative to the other team members. If you expect them to do all of your surgical consenting, you need to tell them that at the outset. Any ambiguity in this area or overlap with other team members can really lead to frustration. So clear communication is key. When it comes to clinic, the other presenters spoke about this a little bit, but you really have to scale your approach when it comes to onboarding someone new. It has to start with direct shadowing. They need to observe your demeanor, your approach, the way you conduct an exam, and your discussions with patients about surgical planning. All of this, you want them to be able to mirror your expectations. So they're learning the surgery, the surgical side of plastic surgery, but they're also learning you and your approach. And everyone is different, especially in plastic surgery. There are lots of ways to do the same thing. And so they need to learn your preferences and your approach to patients. So that direct shadowing component couldn't be more important. After you reach the period where you've done that direct shadowing for a while, the parallel clinics can be really helpful. And in fact, we still use this in our practice. A lot of my post-ops end up in Michaela's clinic, one hallway over from me. She sees them all independently. If they need to see me for any reason, or there's any concern, or I need to look at x-rays, all of that is, I'm available to pop over and do that. However, it frees me up to see more new patients. And the same thing goes for things like non-operative fractures that I'm seeing. Those all go to her clinic. I trust her to look at the x-rays the second time around, as long as everything's good, to start motion. And again, if I'm treating a fracture non-operatively, I see them once and I don't see them again unless there's a problem, because I can trust her to handle that. And then finally, the goal being to transition to independent clinics. And when that happens, it can really double, at least double the efficiency of your surgical practice. In the OR, it's just like when we were medical students. The training begins outside the OR. Suturing shouldn't happen for the first time in the setting of the operating room when the patient is on the table. It should be guided practice outside the OR with training models that we all are familiar with, and familiarizing them with the most common instruments that you use. Once you're in the OR, however, you really have to be verbal, even though some of us tend to be more quiet in the operating room, or you're kind of in your head thinking through things. For a new NP or PA, you really need to narrate your thought process. They want to know, and as they should, the smallest details of why you're doing what you're doing. And that includes your surgical setup and prep and drape, intraoperative steps, post-op dressings and orders. If that team member understands the why, why you're doing these things, that increases their knowledge retention and allows that learner to then apply that knowledge in different scenarios. So making sure that you're narrating through your own thought process is really key to helping them understand what's going on and why it's going on. Another part of this onboarding process really is feedback. And I think it's key to discuss a plan for this at the beginning of the onboarding process. Sometimes immediate feedback is really helpful, especially in the operating room. Delayed feedback is obviously preferable in clinic when you're busy and seeing patients. And for some people, immediate feedback is a little intimidating at first, especially before they get to know you. But you do need to have a formal feedback mechanism for you to give them feedback, but also for them to give you feedback as a surgeon. Is what you're doing, you may think you have the best onboarding program in the world, but if it's not working for that particular person, you need to know about it. And so the feedback has to travel both ways. That being said, you also need to, in addition to the formal feedback, that daily encouragement is crucial for the person that you're onboarding growing into the position you want them to be in. And that's just part of being a good leader is encouraging the people around you and kind of motivating them to continue to work hard. And finally, I think this is important as well. You can't neglect CME when it comes to your NP or PA. Helping to subsidize their in-person or virtual conference attendance is really key to their development and their engagement in the specialty of plastic surgery. All NPs and PAs, just like us, love to go to conferences, communicate with other people in similar situations, build some community, and it helps broaden their perspectives, always for the better. And it also allows opportunities for those that are interested in doing things like this, involvement in speaking, teaching, and getting more and more engaged in national organizations. So in summary, when we're talking about onboarding NPs and PAs, this really requires an intentional structured approach with really clear goals and expectations that are communicated at the outset, graduated, slowly graduated autonomy and consistent constructive feedback. Thanks. Thank you. Okay, I'm gonna ask the panelists to come back on camera if possible. Thank you all for your talk. We've got a few questions. The first question, and just for the audience members, if you wanna send them through, use that Q&A button down at the bottom of your screen and feel free to send them on in. But the first question is actually for Michaela. Carrie and Dr. Schmucker, please feel free to chime in if you have anything. But Michaela, the question is about your lectures that are part of the onboarding structure. How does it work for your group? Is it the person giving a lecture with the trainee that go to it or is it your whole team makes the time when someone's onboarding and it's education for everybody? Followed by, because you're at an academic medical center, do you also include the resident curriculum as part of the onboarding and do the new PAs or NPs get access to that? Yes, great question. So typically in our setting, what we do is we have one NP or PA that's responsible for giving the lecture. We let the entire group know when that lecture is going to occur. So if anyone happens to have free time, they are welcome to join in. We tell them exactly where it's located. It's not necessarily mandatory for the whole team to go to that, but everyone has the opportunity to do it. And then like I said before, we have everything recorded. So it's always available for anyone to reference at any point in time, which is really helpful for consistent learning. And yes, we 100% have the new hire AP, nurse practitioner or PA go to any resident education and that is protected education time for them. There is no expectation of them to have any other clinical, surgical, procedural responsibilities during that time. And we try to maintain that for the first year so that they can get the same experience as a resident, again, so they can just continue to fill their knowledge. Yeah, I would have to say, so I'm in Plastics at Ohio State and we have 21 APPs in our group. And we try, it's hard when the clinical demands obviously get so high that it's hard to protect that time. And then I think some of it also depends on how many people you're onboarding at once. It's easier when it's just, it's one. It's a little bit harder when you have multiple people coming on. Carrie, what about at Wash U? Yeah, I think that Michaela does a much better job of this than we do, to be honest with you. So we are new MPs and PAs certainly have access to our weekly fan conference that happens every Monday evening. We have a weekly lecture every Wednesday morning. Something that we've rolled out within the last year for our PAs and MPs at our institution is we call them Lunch and Learns, but essentially we've been inviting different surgeons in the group to kind of talk about like what they do. And I think one of the disadvantage sometimes to being in a specialty that is so complex is we kind of all live in these little silos. And like for me, for example, sometimes I forget that plastic surgery and just nail bed lacerations and 96-year-olds with distal radius fractures, they see a lot of those things. So it's really nice to have, you know, our surgeons that do cleft palate, you know, kind of talk about that and, you know, what that diagnosis and treatment and all of those things have. Roll those out. We are aiming for quarterly. We kind of found it hard to do them more often than that just because of clinical demands, but that's something that we've been trying to do. Thank you. We've got a question that came through and I think regardless, you know, obviously all of the panelists and myself are in academic medical settings, but I think, you know, throughout, especially probably throughout Dr. Schmucker's training, he likely had experience in a private practice setting. So I'm gonna aim this question a little bit at you, but I think we all can chime in on this. If there's not a nurse in the plastics office, how do you make sure new PAs or NPs are not inundated with nursing tasks such as in-basket messages, patient phone calls, FMLA paperwork? How do you protect them from that? And what would be strategies to protect them, I guess? Yeah, I think this is kind of spoke to this a little bit in my presentation about how roles are defined at the outset. And it's hard because all those things need done and everyone has a limited bandwidth. And so I think making sure that the load is shared by everybody that's qualified. So if you have an NP or a PA, they can't be responsible for answering all of the phone calls if there's not an RN helping as well. The same thing, so you have to pitch in a little bit as well. And so it has to be kind of a shared load, especially at the outset, before you kind of divide and conquer. And I also think that there are, depending on who is in your office, I guess it depends on their level of training and their level of engagement. But there's a lot of the paperwork stuff there's a lot of the paperwork side of things that can be done by the secretarial staff and should not be done probably consistently by someone who is trained as highly as an APP. So inbox messages and patient phone calls should be shared by anyone who's involved in patient care, not just dumped on one person as those can be ridiculously draining over time. But also I think it's important to just outline the roles that everyone's playing at the very beginning. Yeah, and along with that, I would say to outline what your expectations are for the practice. I mentioned that a little bit, but we talk a lot in the PA world about top of licensure work. And if your goal is to have your NP or PA producing revenue for your practice, which I know is different in an academic setting, but you have to define what that looks like. Answering patient phone calls, patient messages, things like that while helpful to the practice, peer to peers, whatever it might be, very helpful to the practice, but those are not billable tasks. So you have to recognize that if that's the role that you want them to play, A, they have to want to do that too, because it's daunting and it's not necessarily top of license work, but you have to understand that your overall revenue and the productivity from a cost perspective is going to be different if they are inundated with those tasks. Thank you. Question for all the panelists and anybody's free to chime in. If we say that our intentional onboarding is three months, we expect it to take about a year, what do you do or how do you handle when onboarding may be going slower for someone or not well? Just gonna leave it at that. So I think that something that I try to do is check in during that initial onboarding process. So not necessarily like here's day one and I'll talk to you in a few days type of thing. So I think keeping a pretty close just eye on how things are going during that process, I think that you can get a good sense of if it seems to be going well. And I think that's also in how you present kind of yourself in the team as well, so that that person is also, they feel comfortable voicing concerns or being able to say like, hey, I don't feel comfortable, I need more of this and kind of having those two way conversations. But I think that trying to check in frequently early on really helps. And then sometimes that timeline has to be adjusted and both parties kind of have to be agreeable that it's going in the right direction. Sorry, the only thing I was gonna add to that, I definitely agree. The only thing I was gonna add to that is there everyone learns at a different pace, obviously. And this is not dissimilar to what we do with residents who are either falling behind or having difficulty with the program is it has to start with figuring out why they're struggling and then oftentimes rolling back the program to a previous step and advancing a little more slowly with a targeted, a little bit more intentional approach tends to be the right call for helping along someone that's struggling in those scenarios. Yeah, I agree. It can be super challenging. And I think a lot of it is the expectation management, right? And sometimes, you know, PA is coming out of school or NP is coming out of school is, you know, thoughts about what a job is gonna be and then what it really is or the needs are different. And so, you know, you never know what somebody's rotation experience is like. And so I think that that can be challenging. We have another question. And the question is about as a small private practice, are there recommendations for didactic resources to help make onboarding easier? Like Michaela, you obviously said you all created stuff and then, you know, sort of cheating in an academic medical center, you know, we can piggyback on some of the resident curriculum that is there. But I think like, does anybody have any good resources? I know that ASPS and maybe our education folks can chime in here, but I think actually ASPS has a really good education on their website through their, I'm gonna butcher the word, but like the EdNet thing or something. Right, ASPS? Yes, you're right. And it is EdNet. So, but there is plenty on there that is all available to all the members. And then I think, you know, what's important too is obviously focusing on, you know, knowing the role, right? It is hard. I had a surgeon actually, he spoke at our last webinar, Neil Fine, and he would always say, well, this is a seven year program, you know, for the residents. And so, you know, you're not gonna learn it all in a day. You're not gonna learn it all in a year. And so thinking about, I met with our new intern class earlier today that are starting, you know, in a couple of weeks. And I said, you know, we have some new PAs starting and, you know, you get six years to kind of get up and running. We expect them to be functional, you know, in a much shorter amount of time. And, you know, they're practicing independently. Certainly we're not, you know, performing surgeries and things like that. But I mean, from a patient care standpoint, understanding, you know, that whole pre and post and perioperative course, like we're, a lot's expected when you come out. So I think that that's just important to realize and give people grace. We have another question. Are there any financial incentives to completing this training or transition to practice programs for any of the speakers? I know at Ohio State, we don't have any financial incentives for completing an onboarding program. We just hope that our time and effort into it, like yields years of service. Carrie, what about you? No, we don't either. Is the question asking about specific programs prior to applying for a job or? I think it's saying, it's vague, and it's only the question that's saying, are there financial incentives to completing this training or transition to practice program? No, there are not specific financial incentives other than, you know, onboarding into a specific job, I guess. Yeah. And then another, oh, go ahead. Sorry, Michaela. Sorry, I was just gonna say, before I came into academic medicine at Ohio State, I worked in a private practice setting where we had a similar structured onboarding process, and there wasn't any incentive at the end of that onboarding process, but there was financial incentive at the end of the first year you met certain goals that were strategically aligned with the success in the onboarding process. Okay. The questioner, the person writing that question actually clarified and saying it was this training program. They're asking, did they pay for it? Another question is, do we on the panel have any recommendations for specific plastic surgery courses or certifications for PAs or NPs prior to applying for jobs in plastic surgery? I think that's hard. I don't know of any specific courses personally. Maybe there are some out there, but I think that's such a large part of what we do. And I know at least for me personally, it was just some of that on the job training that I got. And because what plastic surgery does is so specialized and it does somewhat vary institution to institution, but I know I'm extremely thankful for some of my surgeon mentors when I first started out, they took a ton of time and I'm sure that I slowed them down tremendously. I've been with our group almost 11 years now. So I'd like to think that that's paid off on the other end, but I don't know of any specific programs that are necessarily going to give anyone the skillset to kind of work in plastic surgery without working in plastic surgery. Yeah. And I would say for us at Ohio State, I mean, we are, you know, in plastics, when we're looking at new, new techniques, when we're looking at new, new PAs or NPs coming in, certainly experience, which, you know, a lot of times we're getting new grads applying. And so it's like, did they spend their elective time on plastics? Do they have other plastics experience or hand experience, whatever? And then, you know, we're not, it's not a requirement surgical fellowship. So I would say are becoming a little bit more, you know, common. And so, you know, obviously I think it's like a bit of a leg up, you know, if you've got a surgical fellowship, obviously there's none currently specifically in plastics, but all right, well, I am getting the times up. And so some people are leaving, but I just want to say thank you again to Dr. Schmucker, Kerry, and Michaela, and again to ASPS for giving us this platform. Clearly lots to discuss. And so our contact information should be available. All of us are happy to field any questions and continue the conversation. Please keep, you know, keep in contact and keep an eye out for other nurse practitioner and physician assistant focused content from ASPS. And thanks again for joining. Have a good night. Thanks guys. Thank you everyone. Thank you.

onboarding

nurse practitioners

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plastic surgery

structured program

training

team dynamics

certifications

ASPS resources

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