BackTable Urology
Ep. 190 Optimizing BPH Care: Insights from Physician-APP Collaboration with Dr. Arpeet Shah and Nicole Hollander
Tue, 24 Sep 2024
Learn how Advanced Practice Providers (APPs) can boost workflow efficiency and improve patient experience in your urology practice. In this episode of the BackTable Urology podcast, host Dr. Jose Silva speaks with Dr. Arpeet Shah and advanced practice nurse (APN) Nicole Hollander, about the role of APPs in benign prostate hyperplasia (BPH) patient care. --- CHECK OUT OUR SPONSOR Boston Scientific Rezum Water Vapor Therapy https://www.bostonscientific.com/rezum --- SYNPOSIS Hollander and Shah discuss the importance of effective APP training and onboarding. Dr. Shah shares his wisdom on structuring an APP program to ensure that new practitioners are educated, compliant, and satisfied; all while helping to address the current urologist shortage. The discussion also covers BPH workflows, effective follow-up, and staying up to date on evolving medical knowledge in the context of innovations such as GreenLight Laser and UroCuff. --- TIMESTAMPS 00:00 - Introduction 06:58 - Nicole’s APP Journey 07:42 - Training APPs 12:22 - BPH Workflow 21:04 - Deciding on Procedures for BPH 26:40 - Rezum 33:40 - Ensuring APP Clinical Excellence and Compliance 36:34 - APP Career Development and Retention 40:31 - Looking Ahead
this week on the Backtable Podcast.
Taking things slowly and making sure that things are done right from the beginning is a very important thing, developing good habits. So that's exactly how we do it. And every practice can be unique, but we felt that figuring out how to compliantly document things while you're in parallel, also learning the topics of urology was really important and they kind of went hand in hand.
And that's how we set up our onboarding is when a new APP comes, they'll shadow first and they'll start documenting, kind of act as a scribe within the practice and then start seeing patients like when you were a resident, when you would go see the patient and go outside, talk to your attending, kind of figure out a plan together and then both go back in and then slowly developing an independent schedule.
But at the end of the day, we want all of our advanced practice providers on an independent schedule. And I think Making sure that they have that confidence and that autonomy really brings a lot in terms of satisfaction from their job.
Hello and welcome back to Backtable Urology Podcast, your source for all things urology. You can find all previous episodes of our podcast on iTunes, Spotify, Backtable.com. Now a quick word from our sponsors. Today's Backtable podcast is sponsored by Boston Scientific's Urology Division.
Boston Scientific is dedicated to transforming lives through innovative medical solutions that improve the health of patients around the world. This includes solutions for benign prostate hyperplasia, or BPH, one of the most prevalent urologic conditions facing men today.
Boston Scientific's Resume water vapor therapy is a minimally invasive BPH treatment that provides urologists with an efficient, durable solution that reduces prostate volume while preserving sexual function.
With proven efficacy, durability, and lower clinical progression rates than daily medications, AUA guidelines support a short decision-making process for the consideration of Resume as a first-line treatment and alternative to medications. Additionally, if insufficiently treated, BPH can negatively impact bladder function, making earlier intervention valuable for patients.
Give your patients an alternative to daily medications and long-lasting BPH relief with resumed therapy. Now, back to the show. This is Jose Silva, ASIUS host this week, and I happen to introduce Dr. Arpit Shah and Nicole Hollander,
Dr. Cha completed medical school at the University of Illinois at Chicago College of Medicine, then did residency also in Chicago at Loyola University Medical Center, and proceeded to do a fellowship in endorhology and minimally invasive surgery, also at Loyola University. He currently practices urology in the greater Chicago area.
He is part of associate urological specialist and is the director of APP program at the group. Nicole Hollander is an advanced practice registered nurse who specializes in urology. She earned her BSN and MSN from University of Miami. And she's a board certified family nurse practitioner and is also part of the urology associate urological specialist. Nicole and Arpit, welcome to Backtable.
Thank you.
Thanks for having us. No, no, it's going to be good. So Arpit, I was reading your website and I saw that you're the director of APP program. So let's go on and dive into that. I mean, what does it mean? What it is? How did you create it? What happened? What led to the creation of an APP program?
Sure. I think a lot of urology practices are in a very similar situation as we were pre-COVID and really entering into COVID, where there's just been a tremendous shortage of urology providers and an ever-growing patient population. So we were noticing that in our community, And in our surrounding areas that patients were having to wait weeks, months to see a provider.
And we felt that we weren't serving our community correctly. And so the only way to kind of catch up and provide the needs of the patients in our community was to increase our providers. And with such a shortage of urologists, we knew we needed to utilize and harness the power of advanced practice providers to help us take care of our patients. We were also having other issues in terms of burnout.
Urologists have a highest degree of burnout compared to any other specialty, according to some studies. And we felt that advanced practice providers could help our physicians stop them from burning out. And when we looked at our patient population even more closely, we were noticing that several, there was high rates of attrition.
And, you know, we're going to talk a little bit about BPH and how we manage our patients, but we looked at our attrition rates for BPH and it was 60 to 70% of patients at that time. And it's much better now. We're not coming for a second visit. And so we felt that there was, you know, just, we just needed all the help we could get.
When developing a program, though, we wanted to make sure we had a unified mission in terms of what was best for our practice, not necessarily what was the needs of an individual physician. And so having a unified, standardized kind of thought in terms of how we would utilize APPs into our practice was really important.
And then, you know, when we brought them in and we started growing the program, there's a lot of work that goes into running an APP program, whether it comes from onboarding, you know, making sure that they're clinically excellent, that they're following pathways and really up to date with the ever-changing knowledge that's coming out there.
And they're compliant from a documentation standpoint, a billing standpoint. We needed to kind of have somebody in charge and kind of one voice leading that program. And it's almost like leading a company.
You know, you need to make sure that all of the people in your company are growing and developing, that we're meeting their needs of their career goals and we're meeting the needs of the practice. So that's what the mission was. And We started in 2022 with one full-time equivalent APP.
There were 16 urologists, and we've gone up to eight full-time equivalents in a short amount of time and feel like we will continue to grow. Good.
And Nicole, was this your first job?
Yes, this was my first job right out of nursing school or right out of getting my master's.
And why urology?
So my dad's actually a urologist. So I had a little bit of a brief background in urology. But to be honest, I kind of fell into it. I had been looking for a job in Chicago and I couldn't really find a job. And I found this and Dr. Shaw and then our other doctor, Dr. Patel. We really vibed with one another. I think we really hit it off and I followed them.
And, you know, I realized, oh, this could be something I like. And now, you know, I really like urology, something that I'm definitely passionate about.
And describe those first month, I mean, and Arpit, you can add some if you want, but definitely when an APP starts to practice, are you throwing to seeing patients or how is that process? Is it shadowing first? Just describe how your program is running.
So you can ask Dr. Shah. I was the most nervous person. I was like, I don't know, I'm not doing anything right. So basically what we did is I followed Dr. Shah for, how long was it? Do you think a couple months?
Three or six months. Yeah.
A few months. And so I kind of watched him document. We worked on documentation first. I think that was one of the most important things we needed to work on. And, you know, obviously, as I followed him, I learned along the way different things. You know, I take notes. He would have actually like once a week say like, oh, OK, this week we're going to talk about this topic.
And, you know, I take notes. I actually have like a whole binder. in my office. And then like slowly we started to give me patients. So I started to do some telehealth on my own to kind of like warm me up. And Dr. Shaw had to push me a little bit and see patients in the office. But eventually we got there. And, you know, I think really a lot of the learning happens when you are pushed.
You know, sometimes people need that little push. I think that a lot of the learning I did was actually when I started practicing, but I definitely needed those months with Dr. Shah to, you know, get a base and understand what I was doing, especially because I'd never done it before.
I would kind of mirror that. We're trying to build a standardized way of onboarding. And that's not only locally in my practice at AUS, but we're part of the large urology platform called Solaris. And we're working that on onboarding for APPs on a national level. And it You know, we don't realize how fast our advanced practice providers actually catch up and are getting thrown in to see patients.
And sometimes we have to remember that urology residencies are six years with four years of med school beforehand. And so, you know, taking things slowly and making sure that things are done quickly. right from the beginning is a very important thing, developing good habits. So that's exactly how we do it.
And every practice can be unique, but we felt that figuring out how to compliantly document things while you're in parallel, also learning the topics of urology was really important and they kind of went hand in hand.
and and that's how we set up our onboarding is when a new app comes they'll shadow first and they'll start documenting kind of act as a scribe within the practice and then start seeing patients like when you're a resident when you would go see the patient then go outside talk to your attending kind of figure out a plan together and then both all go both go back in and then slowly developing an independent schedule
But at the end of the day, we want all of our advanced practice providers on an independent schedule. And I think making sure that they have that confidence and that autonomy really brings a lot in terms of satisfaction from their job.
And I repeat, are your APPs getting paired with a specific urologist or essentially is for them to grow and then target different urologists with the practice that specialize in any niche? Yeah.
The answer is yes to kind of all of that. So it really depends on the needs of the practice. We want our advanced practice providers at first to be able to work on all disease states with different providers and really have kind of being able to work with every part of our practice.
And then as they grow and once you're a year into the practice, if there is a particular niche that you feel that you want to really dive into, it's our job as a practice to make sure that we give that opportunity to the advanced practice provider.
And Nico, was there any niche that you wanted to go into urology when you got on board or you just wanted to get a hands on everything urology?
At first, I don't think I was sure I kind of needed to dip my fingers into different things, but I ended up really liking BPH and there's so much you can do with BPH. So that's kind of the direction I went. And now I interpret all the Eurocuffs. So we do a Eurocuff day every Tuesday. One of the nurses does the Eurocuffs.
And then the next day, I have a day where I go over all the results with the patients and kind of talk about next steps. Yeah, so I ended up really liking BPH and That's kind of like the bread and butter of urology, I think, too. So it's been really interesting and I really enjoy interpreting the urocobs and I think I've gotten pretty good at it.
And I'm going to ask you that question again in terms of Urocov, but so let's talk about BPH and Arbita. Can you go with the workflow of how a patient is evaluated in the office?
Yeah, so our BPH program is really, I think, robust and I'm really proud of what we've built. It's a combination of utilizing patient navigation services, our advanced practice providers, nursing kind of at every level, and then the physician to drive things home and But we have all new patients are seen by the physician. We really try to make that happen.
I think it starts the patient journey off in the way that a lot of patients want. They want to see a doctor. And then if a patient has significant urinary symptoms based on AUA symptom score, We'll, you know, we'll trial a med if they have not. And then, you know, we really care. And I personally really care about objective testing.
I think the days of saying you have urinary symptoms, we're going to do a TURP are kind of over because we have so many options in terms of the surgical management and all the procedures that are available. And we know that certain procedures work better for certain prostates and certain work better for other prostates. So I am just a huge proponent of objective measuring.
And so objective measurements come with three things, you know, cystoscopy, transrectal ultrasound of the prostate, and then some form of uroflow, urocuff, uroflow, urodynamics, depending on kind of what your practice wants. And we usually start with Eurocuff in our practice. And it's because it's a great non-invasive test that, you know, we don't have to put anything into a patient.
And patients certainly appreciate that to get some baseline measurements. And then, you know, the Eurocuff test is done by our MAs. on a day and then they're interpreted by our advanced practice providers where we've spent a tremendous amount of time educating our advanced practice providers on how to read Eurocuffs. I can tell you A lot of them can read them better than physicians.
I can tell you, Nicole, if I have, sometimes I will ask her, what does she think about a uro cuff to give me a second opinion or a urodynamics, you know? And so education is important there. And then Nicole will read the uro cuff. And if the patient needs that objective testing, it gets put back onto the physician to do a cystoscopy and trust. We'll usually do that on the same day.
And then at that point, we have all kind of the necessary measurements to make an assessment on how the patient is doing with meds, without meds, if they need surgery, what surgery they need, and we can go from there.
And let's say when that patient goes to NICOL and it's a telehealth visit, is it the patient is in person? In person.
We usually do a telehealth visit. So I have a telehealth day on Wednesdays and most of my day is just interpreting UroCovs, you know, seeing what they need next. So a majority of those patients on that day are UroCov patients.
Yeah, the reason why we picked telehealth is multifold. So one is patients are already coming in for their UroCuff. To have them come in again, I mean, it's a big burden on taking time off from work. So telehealths are just, they seem more easier for the patient. It's easier for the practice as well, where one of our big limitations is just space, having enough rooms to see patients.
And so you're taking that part of the equation, kind of you're solving it. And then the third point is this allows Nicole a week to review all her Eurocups. And should she have any questions between the time of the Eurocups and when the patient has their telehealth appointment, she can review it with the physician. If the test is not done correctly, we can ask the patient to come and do it again.
So we have a good test and we have good data. And so all of those things kind of really promote a telehealth visit.
And repeat, let me ask you something about billing. I mean, are you billing for the Urocov on the day of the nurse visit? And is Nicole able to bill for the interpretation also? So you're billing for both things? Yes. Yeah. Yeah, we are. Nicole, so what are some of the questions that patients ask when you talk to them with the Urocov, after Urocov?
They always ask me, why was I put on Tamsulos and what does it do? I think that concept is sometimes hard to grasp. A lot of times they ask me, you know, to kind of explain like the pressure flow relationship.
So Dr. Shaw uses this analogy, you know, when blood is pumping through the heart and the arteries and there's blockage, your heart pumps and pumps and pumps really hard for a long time or eventually your heart can give out. So we kind of say that in relation to the bladder, you know, Your bladder pressure is really high.
It's pumping really hard and working overtime to get that urine out through the urethra where eventually your bladder can fail because they're like, I don't really understand, you know, why we have to do this if I'm not having symptoms. And a lot of times, you know, their uro cuff will look terrible, but they say they have no symptoms.
And you look at the uro cuff and you're like, OK, well, maybe we should just take a look and see. So it's really just explaining, you know, why we're seeing what we're seeing and making it more easily, you know, interpreted.
And I think, just like you mentioned, I think that's the perfect analogy about the heart. Some people don't understand that. In every cubicle I have pamphlets that they show the damage of the bladder. They seem to understand that. Those are the best pictures. Yeah, we love those.
Those are the best pictures.
I think patients... want to know what's going on, right? And so by giving them their data, by giving them an analogy that they're very familiar with, and then showing them their own UroCuffs, showing them the pictures, showing them their bladder pressures, their flow rates, telling them what's normal, what's not, is really important. We do the same thing with Cysto, right?
Before I do a cystoscopy, I will go through pictures of normal and abnormal bladders and normal and abnormal prostates. And if you can show them what the normal and abnormal are, and then you do the cystoscopy, and you tell them, look at the screen, tell me what you see here, it's very clear to them. And then they're the ones who are saying, well, I need to get something done. I do have problems.
I realize this, and I think it's all about patient education.
Also, UroCuff is a really good way to make sure that they follow up. So a lot of times if, you know, a patient is like, you know, I just want to stay on medication for now. I'm not really interested in a procedure. I'll be like, OK, well, maybe we should repeat the test in three to six months to see if anything's changed.
And usually like, yeah, yeah, that's a good idea because, you know, they want to help themselves. But sometimes at the time it takes a little push to get them to do a sister or something. So I feel like it's really helped make sure that my patients follow up and don't just get lost.
And sometimes they do get a little bit of improvement with Flowmax, for example. And because they do get a little bit of improvement, they get used to being so bad that just a little bit of relief is good enough for them. But they don't understand that the damage will continue, that bladder damage will continue.
Yeah, and this is why when we look at national Medicare data, we see such high failure rates with BPH procedures. It's because we're intervening too late, right? We're intervening when the bladder has already failed.
And to expect that after somebody's in heart failure, if we stent them, that their heart's going to get back to normal is, you know, a very common sense that it's not going to get better just with that. And so early intervention is important.
The other thing, you know, we actually published a study on this is that we looked at all of our patients who are following up, satisfied on medical therapy for BPH. And I think medical therapy works for a lot of people. But we did UroCuffs on them and 62% had abnormal UroCuffs. So, you know, even these are patients who are coming in saying they're satisfied on medication.
So getting that objective data to them is just really important.
Yeah, that guy with 150-gram prostate that said, I'm perfect. But, you know, you do a cystoscopy, severe trabeculation, I mean, definitely you're not perfect. RP, when do you start talking, or Nicole, when do you start talking about possible procedures to the patient?
I kind of explained it a little bit after their UroCuff. Like, you know, if we do the cystoscopy, you know, eventually it might lead to you having some sort of minimally invasive procedure that can kind of open up the prostate so you don't have these symptoms and you don't further damage your bladder. So I'll kind of give them like a brief rundown just so they know what they're going into.
And I do always tell them, you know, Even if you get a systo, it doesn't mean you have to do something, but it's a good way to at least see what's going on. But usually I kind of preface them after their UroCuff when they do decide to do a systo or a truss or whatever it is. And then I think Dr. Shaw ultimately decides what's best for them.
Yeah, for our patients, all of our new patients who have BPH automatically get a, through email, text, get a copy of our BPH booklet, which is just an introductory booklet on all of the tests that we have diagnostic, and then a quick blurb, short paragraph on all the procedures that are out there so they can have some early education on it. But really, we wait until the objective is
data is gotten. So until we figure out their size, shape, and flow rates, and then you can introduce the procedures that will actually work, that will benefit a patient. I mean, there's no reason to, you know, offer a Urolift, in my opinion, on, you know, somebody with a very, very large prostate.
And so you don't want to introduce it too early where patients, you know, are tied to a particular therapy that just won't work for them. We don't want to offer, you don't want to, you know, kind of withhold that information either. It's just kind of slowly introducing that concept.
Right now, I mean, I see a lot of patients, Europe is doing a good job, I guess, getting the information out there because I see a lot of patients asking for it. But then when you do the testing, I mean, trilobal prostate, intravascular compound, hey, you're not a candidate. So, yeah, so like you mentioned, and you mentioned you give them like a brief pamphlet of everything or...
Yeah, so we have a... You created that one? Yeah, through our practice. It's all QR code based. It's all virtual. We used to have printouts, but we do have printouts for our patients who just don't want anything virtual or electronic, I should say. But that booklet kind of gives an introduction to our program. It actually has our pathway. written out.
So, you know, you're going to have AUA symptom scores. You're going to have, these are the tests that you could consider. There's going to be a little blurb about each test. And then all the procedures that we offer, whether, you know, green light, urolith, resume, simple prostatectomy, aqua ablation, all the things that we can offer a patient will be listed there.
Okay, so the patient has BPH symptoms, is obstructive. Then describe that process of deciding. Are you guys doing procedures in the office or strictly in ASC? It's a mixture.
We have office, ASC, and hospital. So it's all those things. I also sit on the clinical board of BPH for Solaris, our national group. And Physicians are very passionate about how they feel about particular procedures. There's no way we can convince every physician to say that this is right or this is wrong or this is better. And I don't think that that's the goal of any of this.
The goal of this is to make sure physicians are doing all the diagnostic tests before they make a decision. We've all seen that patient that's in the hospital that you know, has like a 200 gram prostate, came in with retention and had a procedure that's really not made for that kind of a prostate. Eight clips.
Yeah, we see, you know, eight Urolift clips and a 200 gram prostate and the patient's as confused as you are about why they're there. And so it's impossible to say which procedure is better and convince it to all your group. And that's not the goal. We still know that there's still somewhat of an art in medicine.
And, you know, we want the physicians at the end who are going to do the procedure deciding what procedure they feel is right. And that's good. And I think that's what we want. But we want to make sure that they got all the testing, that they have all the information, because that tends to make sure that they choose correctly. And you're a center of XLO of resume. Are you doing them in the office?
Yeah, we do 100% of our resumes in the office. We utilize a combination of local and local anesthesia, just a prostate block and Pronox. which is a patient-controlled delivered anesthetic. The key thing about Pronox is it kind of gets out of your system in a couple minutes after using it.
So we really think it's a drive-in, drive-home procedure, meaning you could drive in, get your BPH procedure, drive home, and
Specifically for our patient population, where it's difficult for them in terms of getting off from work or, you know, having the support from family necessarily to bring them into the office, this is a really kind of, it's a procedure that really strikes them as an appropriate thing for them.
And those are the things you talk to with the patient. We have this in the office, you're a candidate versus something a little bit more invasive, which will be in the hospital. And you start deciding what's the process and going through that.
Yeah. So I'll tell everybody, you know, there's, you know, eight or 10 things we can do from a procedural standpoint for your prostate. Once we get the objective data, we'll bring it down to two or three. And then we talk about it. And, you know, one of the benefits for resume specifically is that it can be done in the office and patients can drive in, drive home. You can do it on blood thinners.
I think I have done many on blood thinners. They're okay. Done for a variety of prostate sizes and shapes. You know, if you see a median lobe, you don't see a median lobe, it's fine. And the biggest thing is it's reproducible despite surgeon skill, right? We're really utilizing the technology to do the work.
It's not like, oh, I'm very good at doing terps or he's very good at doing, you know, a simple prostatectomy or whatever the case might be. There's really normalization of surgical skills with resume. And I think that makes it very enticing.
No, definitely. I mean, I do some resumes and the patients do great. As a surgeon, you don't see that instant gratification of the whole, but definitely you just have to trust the technology and let the prostate shrink because it will, it will shrink. How long are you leaving the cancer?
Typically three days. If a patient's in retention, I leave it in for two weeks. I think one of the complaints about resume from patients and providers is the irritative symptoms that occur afterwards. And they tend to last longer than your other BPH procedures. And that's the truth. They have irritative symptoms that last longer than the average BPH procedure.
Patients aren't worried about it if you let them know beforehand. You let them know the day of the procedure. You let them know when the catheter comes out that things are going to get worse before they get better. You know, as a physician, it took a little bit to not have that immediate gratification to see an open cavity. And I took every chance I could in getting a cystoscopy.
I have a patient that grows hematuria a year later. I was, you know, I was doing a cysto on them. Because I wanted to see. And sometimes you'd have patients get CAT scans and you could see the defect. The defect is significant. And there's no doubt about it. What's the largest you're doing? I mean, I know off-label, how big will you go?
So, you know, for particularly comorbid patients who are in urinary retention... I have a 90-year-old who comes in, urinary retention, 120, 130-gram prostate. I'll try it. I think it's worth a try. I usually, for patients with just BPH, not urinary retention, I'll do My average is one stick per 10 grams. So a 50-gram prostate, I would do five sticks.
When we started with Pronax, patients were so comfortable that we were over-sticking patients. And I think their results were great, but their irritative symptoms lasted longer. But for those patients in retention, like the 90-year-old who comes in, I'll do 120, I'll do 130 gram prostate as long as they know that it's off-label and they know that it might not be successful, but it's worth a try.
It's either that or nothing. Keep the catheter. And Nicole, are you the one seeing the post-op or who's seeing the post-op?
Yeah, so the nurse practitioners normally see the post-ops. So like with resume, they'll come in. We do avoid trial as long as they pass, you know, we take out the catheter. Then typically we'll have them follow up in six weeks or six to eight weeks and then three months. That's like the typical kind of pathway we follow afterwards.
And let's say you have a patient after any procedure of BPH starts getting overactive bladder symptoms. Are you treating them or they're going to Dr. Chow?
You know, I don't always treat that just because a lot of those symptoms they're feeling is because they just had the resume. So I think it's like Dr. Shaw said, really important to drive that point home to them. Like you're going to have symptoms afterwards. You're going to feel like I made you worse, but you're going to get better. It just takes time.
So, you know, depending on the patient, let's say it's. You know, it's been a long time and they're having, you know, overactive bladder symptoms. Maybe I'll give them some samples, but I try to hold off until they're, you know, a good few months outside of the procedure because I think it does take a little bit.
And sometimes you can confuse overactive bladder for, you know, post-procedure symptoms.
And I agree. I just ask him to see what you do, because most of the time, even though you explain the patient what to expect, some of them, they think they're going to wake up like nothing happened. And, you know, so I just wanted to know, how do you deal with those more difficult that are trying to say, hey, you made me worse?
Sometimes it takes some convincing.
Yeah, it's certainly difficult and certainly reiterating it over and over again is necessary. There's a great platform actually called Vidscripts. I'm not sure if you're familiar with it, but these are pre-recorded videos that are sent out to the patient on a particular cadence around when a procedure is done. And I think that patients really appreciate it. So when
When they're having their irritated symptoms one week, two week, four weeks out from the procedure, if they get a little video saying that you might still be having this and this is normal, it puts them at ease. But yeah, certainly, you know, it's easy for us to say it on our side to say that things are going to get worse before they get better.
But living through it is obviously a different story.
Yeah, I sometimes find myself just doing a prescription because sometimes it's just easier than just continuing repeating myself. Go ahead, Nicole.
Dr. Shah does a really good job of telling patients beforehand what's going to happen afterwards. He'll even say, after this procedure, you're going to say... I don't like Dr. Shaw. He messed me up. He says that beforehand. And it's really honestly, it lasts in their head.
And when I see them, they're like, when I kind of explain to them, like, OK, over the next few weeks, you'll be feeling these things. They're like, yeah, Dr. Shaw told me. So they're like, you know, they're prepared. So it's really important you tell them beforehand and set, you know, realistic expectations.
And if they don't feel that, then they're really happy with you.
No, I guess sometimes that happens. I mean, you have the guy with a big prostate and they're perfect. There's no way of predicting who's going to be having miserable symptoms afterwards. It would be great to know beforehand, like if the Uroco or something will predict who's going to be bad afterwards or who's not, but maybe something for the future. So, Arpit, let's go back to the program.
You mentioned that you have four pillars of your EPIPRO program. How do you evaluate clinical excellence, compliance, productivity, career development?
Yeah, I mean, those are difficult to measure always, but there's a variety of ways that we can make sure that it happens. So in terms of clinical excellence, take, for example, Eurocuffs. You know, we spend a lot of time educating our advanced practice providers with Eurocuff. The folks at SRS who developed Eurocuff help with that educational process, and that partnership is really important.
And we'll have periodic maybe the annual Eurocuff test where we're having our advanced practice providers go through Eurocuff studies, answer several questions about them so we can identify those who need more education, right? So that's just one part of clinical excellence. You know, we can talk about prostate cancer and active surveillance and kind of all the things, you know, we can go through.
But making sure that you have a kind of a robust program, a pathway, and then a way to monitor that pathway compliance. And so there's another thing, you know, we make sure that when patients are seen with BPH that they get an AUA symptom score. And if they have an AUA symptom score above 8, which means moderate to severe symptoms, that at least a discussion is being had about
medications, diagnostic testing, right? And if they refuse, they refuse, but we're going to be monitoring that and tracking that with our advanced practice providers to make sure that they are following the pathways.
All right, Pete, let me, I mean, do you have to go to their chart and look at it or do you have something in your EHR that can detect those things?
I wish we had something in our EHR. Right now it's laborious, but we think it's important. So we have clinical navigators who are nurses or MAs who specialize in different disease states. Our clinical navigator will not only talk to patients to make sure that they're following up. Let's say we have a BPH navigator. They'll remind them, hey, you have your Eurocuff next week.
Make sure you drink plenty of fluids before you come. They're the ones who are doing the Eurocuff test, right? So this is somebody that the patient knows they've talked to. Now they see them doing the Eurocuff test. Those are the same navigators who work with our advanced practice providers and our disease state experts.
And they're the ones who are actually checking in and giving us the data on compliance. So It's laborious right now. I think as EMRs get smarter, as AI comes in and really builds into EMRs, we're going to be able to do that more easily.
When we talk about the other things like compliance, that goes into compliance, but also documentation, doing coding audits, making sure the charts are documented appropriately, giving that feedback back to our advanced practice providers. Say, hey, you're not coding this correctly. We need to change this. We need to make some more educational opportunities in terms of compliance and billing.
And then making sure, you know, the most important thing, we talk about patient attrition in disease states, but there's a lot of attrition with advanced practice providers. You know, a lot of practices say, I hire an advanced practice provider. I get them trained up. They learn urology. And then they leave for another job. And that is a failure on the practice and the program, right?
We have to make sure that we're having discussions with the advanced practice providers that we're making sure that we hit their career goals, right? Whether their career goals are to be able to work part-time, spend time with their family, because a lot are mothers. And then once their kids go to school, to be able to go back to full-time, we have to develop a program that fits that model.
If they start getting bored with their daily run-of-the-mill urology and they want to, you know, be participating in advanced prostate cancer clinic, well, what are ways we can integrate that knowledge and get that to them and build out that program? So we just have to have this constant communication and a real emphasis on the people who are part of the practice.
And so those are kind of all the ways that we look at this. I mean, we can go a million different directions from that. But the four pillars of productivity, they have to be productive. They have to generate income for a practice. They have to see patients. That's how the job exists.
But if they want to do something in a particular field, we got to make sure they do it in a compliant way and that they're getting the education needed to do that. And question, are there, the APPs are training all our APPs or right now? Yes and no, you know, that's the goal, right?
We want, you know, while I sit at the head of our APP program, I would love for me to pass this on to another APP, right? And so that's the goal. Yeah, Nicole, you know, a couple more years. But, you know, that's kind of how we start.
And then when an APP is on board, I mean, do all of them pass through you or depending on what they want, they go to other providers?
It starts with me. And then we certainly have our APPs visit. We're not all in one clinic and one site. So we want to make sure that they go through the various locations. If there is an APP that they want to shadow, we make that happen and we make sure that everybody's learning from everybody. And so I'm not in the office every day.
So the days I'm in the office, I really, especially at the beginning, I like to have that hands-on, one-on-one conversation. time with a new app but you know the other days when i'm not in the office we're pretty flexible
And I mean, for us at Serology, I mean, we know what we got into and it turns repetitive. So, I mean, we do the same thing over and over and over. We would try to keep up to date, up to times and try to use new technology. And that's the way that we keep engaged and not bored. But Nicole, I mean, for an APP, how does that look like? Just keeping engaged, challenging yourself?
I think that, you know, the APP program and Dr. Shaw and there's a couple other doctors that are involved a little bit. They've done a really good job of allowing us to like, you know, if we have an idea, there's something that we want to bring to light. They always are like, okay, you know, let's make a game plan. Let's get it moving. They're always willing to listen.
You know, like recently I've been kind of interested in women's health and we don't really have a women's health program. So, you know, we've been talking about that and You know, I have to make a presentation and present it to them, but they're more than happy to support, you know, whatever goals I have and whatever, you know, I'm interested in. So I feel really lucky for them.
They've been really great.
So what's the idea to have BPH and RealMoon?
I dabble in a little bit of both.
Yes. BPH is always bread and butter. I'd tell her never leave it, but certainly women's health is a big need. The other thing that I think we, you know, I think the evolution of utilizing an APP is going to be with procedures. Pretty soon, we're going to be having so many procedures that a urologist, as a physician, as a surgeon, is not going to have bandwidth to do them all.
So it might be, it might start with cystoscopy, cystostent removal, truss, and then kind of building that. We have a lot of our nurse practitioners will do testopels, they'll do hydrocele aspirations and sclerosis in the office. And I think that continues to engage and grow them as practitioners.
Yeah, but my APP says to us, Henry, and it's out of need, definitely out of need. And to keep her engaged, I don't have a program as structured as yours. I'm going to steal a lot of things that we talked today. But definitely, it really helps. And like you mentioned, the way she grasps things so fast.
I have mentioned for us, 10 years of training, six, and then four of medicals, and then six of urology. And she grasps it very fast. So, yeah. So, the plan is to have Nicole start doing some cystos.
Actually, absolutely. You know, what our rate limiting step at this point is space. It's still how many rooms we have. We can always get more systems, you know, and there's disposable systems if we need to. We try not to utilize disposables, but, you know, it's just just space. And then, you know, there's a shortage of staff across the country.
So we have to make sure that the foundation is there before we really make the program.
Yeah, I would say right now, I would say half of my patients, or not even half, but yeah, I would say half. Of the surgical patients that I see in the OR, Becky, my APP, she was the one that did the workup, and I mean, she's been flawless. And the patients are happy, and yeah.
She sounds awesome.
She's been a great addition. I mean, she's... I'm new to this EIPP system. I was put it that way. But yeah, it's amazing.
What you get in is what you get out, right? You have to invest in your advanced practice providers and really make them feel like they're They're the level of provider where they're, you know, they're at the level of you in terms of a physician. And they certainly are in the office. I mean, they should be able to do anything that a physician can do.
And definitely for us, the idea is to not only have, I mean, we have talked about the BPH clinic, but really doing the body dysfunction and incorporate some women and doing the... neuromodulators that go on incontinent stuff. So, and have the entire world of the urinary system, in that sense. So our bit, anything else you wanted to add? I think we covered a lot. I think it was a great topic.
Anything else you want to add? No, I'm good. Nicole, anything else?
I don't think so. Four of our APPs were like their jaws dropped when I told them that we're going to be on this podcast. Awesome. They listened to you religiously. And so, I mean, it was like they were like fangirls, you know, they were really excited.
No, I mean, and this topic is all, I mean, thank you for sharing this. I wrote it to you in the email. I mean, this is great and it will definitely... change our practices for sure. I know.
It has to, right? We can't do it alone. More urologists retiring than are coming in. Patients keep piling up. So we have to harness the power of APPs.
And like you mentioned, I mean, also having the APP happy, keeping them up to the level, to the highest level possible to the licensure. and keeping them engaged and continue evolving together. Well, Dr. Cha, Nicole, thank you for being back table. I really enjoyed this conversation. Until next time.
Thanks for having us.
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