So tonight we're going to be talking about Euroguide and APPs throughout the lifespan. And so I think we're going to have a real lively discussion, hopefully, with everybody that's joining. I've been communicating with some people via email and there's a lot of attendees that kind of want to share their stories of how they started out in practice and, you know, how they were able to gain skills and some of their frustrations and things like that. And hopefully we'll really be able to help some of the APPs that are new to practice this evening. Thanks, Dr. Starr. I don't have any- Do you mind if I give a quick introduction of you so our audience knows who you are? Oh, yeah. Yeah. Okay, perfect. So welcome, everyone. Welcome to the AUG's Euroguide webinar series. I'm Dr. Christine Vaccaro. I'm a member of the AUG's Education Committee and moderator for today's webinar. As Dr. Starr mentioned, today's webinar is titled Eurogynecology Advanced Practice Providers Through the Lifespan. Our speaker is Dr. Julie Starr. Julie Starr, APRN, PhD, is an advanced practice nurse and clinical researcher with 16 years of experience in the field of urogynecology. She is passionate about treating women with pelvic floor disorders, including bladder and bowel control problems, pelvic organ prolapse, pelvic pain, sexual pain, and recurrent urinary tract infections. She speaks both nationally and internationally on the treatment of pelvic floor disorders in women. Julie is currently practicing at Aguirre Specialty Care in Parker, Colorado. And like she discussed, she's going to be inviting other speakers. And again, if they could limit their time speaking to five minutes so that everyone can participate that she has invited to speak tonight. And just a few reminders before we begin, a few housekeeping items. The presentation will run approximately 45 minutes. After the last 15 minutes, the webinar will be dedicated to Q&A. AUGS designates this live activity with a maximum of a one AMA PRA credit, category one credit. To claim your CME credit, you must log into the AUGS e-learning portal and complete the evaluation following the completion of the webinar. This webinar is being recorded and live streamed. A recording of this webinar will be made available on the AUGS e-learning portal. Please use the Q&A feature of the Zoom webinar to ask any speaker questions. We will answer them at the end of the presentation. Use the chat feature if you have any technical issues. AUGS staff will be monitoring the chat and can assist. Okay, Dr. Starr, you may begin. Okay, welcome, everybody. I'm really excited to be here. This webinar is really meant to be an open forum, you know, to allow attendees to participate in the discussion as best we can. Most of the audience consists of APPs, either urology or urogynecology. And then some women's health nurse practitioners are also in attendance. And there's a variety of attendees that are new to the practice and also many seasoned APPs. So we'll be able to kind of share our experiences and learn from each other. Like Christine said, we're going to be starting out with having several APPs share their experience. And then if you have questions just in general for that specific person, you can, again, use the chat box. And then there'll be time at the end, if we have time, if anybody else that's not on the list to share wants to share some things, that would be awesome. And then at some point, I'm hoping to do kind of a brief review of the recently updated APP AUGS competencies and the training list. So I'm going to pull that up and hopefully go through that. If anyone hasn't seen that, I provide a link to that site. It's a great way to kind of learn and know what kind of skills that you need as an APP in urogyne and also a good list of resources. And this is really an opportunity, I think, to network with other APPs. I think when you start out doing this, a lot of times if you're not in the practice with another advanced practice provider, you're kind of on your own with a physician and hopefully that person is wanting to actively train you. But it can really help to have colleagues through the AUGS organization that can kind of help you to learn too. I have no disclosures. And these are our objectives today. And we're going to start out with Leah Barker is going to be the first to speak this evening. Leah is a longtime colleague of mine. And when we first joined AUGS way back in the day, there was no APP special interest group. We were just wandering around the conferences, kind of trying to find other people that, you know, were like us. And so we eventually, after a couple of years, formed a small group and eventually, thanks to Leah, formed a special interest group. She was also pivotal in coming up with the competencies and really working hard to get those past the AUGS board and onto the website. So Leah has been a seasoned APP for many, many years. And she's now in the central Massachusetts area. And she's going to speak a little bit longer than five minutes, I'm hoping, because she's going to talk about a little bit about productivity and RVUs that I think will be valuable information for the attendees. So, Leah. Great. Thank you so much for having me. So I have worked in the field of urogynecology for about 25 years, which is hard to believe I'm not that old. As Julie said, I work with Reliant Medical Group, which is a multi-specialty private practice in central Massachusetts. I live in Worcester. I work currently with two physicians and another APP who sees about 5% of her time is spent in urogyne. The rest is general gynecology. So a typical day for me, well, a typical week for me, I work 32 hours. Four of those hours are dedicated to my administrative role. I'm the division director of urogynecology for my group, mostly because the other two doctors didn't want to do it. But I feel really proud to be a nurse practitioner who is a division director. I don't think there are very many other APPs in that role in the United States. In my average day of seeing patients, I have one hour of administrative time, which is also known as lunch hour. So I see somewhere between 15 to 17 patients a day. Follow-up patients I see for 20 minutes, new patients I see for 40 minutes. Of those, three to five per day are consults and the rest are follow-up patients. I do not round in the hospital. I have privileges in the hospital, so I can write orders, things like that, but all of our surgeries are outpatient. In the waybacks, when we were keeping people one or two nights, I did round and I loved it. But hopefully none of us are needing to round because they're not staying overnight, at least not very often. I am lucky enough to have either an RN or an LPN or a medical assistant who is assigned only to me. She rooms for me. She cleans the rooms, things like that. It's not always the same person, but I am fairly easygoing. And so basically, as long as the patient is in the room, I can do the rest. I'm fairly self-sufficient, as I think all of us are. When I'm working with a new person who may not necessarily be in urogynecology, I'll either go in my schedule and the appointment notes and write, you know, check PBR, check urine, undress, whatever. And basically they can do it and then get out and I can get on with my day. I perform most of the procedures that we all have learned, including pessary fittings, vulvar biopsies, endometrial biopsies, trigger point injections. I am a women's health nurse practitioner, so I've only ever done women. So I've, you know, those things, most of them I learned pretty early in my career. Trigger point injections, I did learn within the past, I don't know, maybe 10 years. It's a great skill. So if you're not doing it and you're interested, then bug the physician that you work with until they're willing to train you. It's not hard. I also, within the past, oh, maybe four or five years, have learned to do P&Es, which is the office procedure to do for interstem or exonics. I've loved doing that. I've gotten really good at it. The only problem that I've run into is some of the insurances that I work with have refused to pay when I'm the one that does it, which really sucks. They say it's not within a nurse practitioner's like scope of practice, which is ridiculous because there's MPs that do much more risky things. But anyway, so I've had to sort of accommodate for that. I, in the past, did urodynamic testing myself. I don't anymore, mostly because it doesn't make sense for me to do it. The procedure itself, I don't think, has much in the way of RBUs associated with it. I do interpret urodynamics when they're my patients or if the physician's not in the office, reading or interpreting our urodynamics does have a fairly good RBU value to it. So if you're able to do that, if you're able to learn, it's a really valuable skill. And if I can do it, you can do it. So I worked in plain old OBGYN for a couple of years, and then I really wanted to work in a tertiary care academic setting. So I was lucky enough to find a job in urogynecology and I watched for a long time. That's how I learned. The physician that I worked with also gave me textbooks that I read. I went to the OR with him. He was a reviewer for the Oggs Journal, and so he would give me articles and we would talk about them. He was very generous with his time. Once I felt sort of on my feet, I started attending the Oggs PFD week, and that also has been really valuable for me, not only to learn what's being presented, but also to network with other people like Julie. It's as she said, really valuable to have people in your pocket that you can call and say, what would you do? Especially if you're a solo nurse practitioner or PA in your particular practice. I made a lot of mistakes in the beginning. I still make mistakes, of course, but I just want to, I don't know, like reassure you if you feel like you don't know what you're doing and you're bumbling along and you say the wrong thing or do the wrong thing. Like luckily we don't work in cardiology and we're not going to kill anyone. When I started, the physician who I mentioned that trained me left the practice after about nine months, and that was tough because he was it, he was the only person, and so I had to go back to doing OB-GYN, which I left because I didn't love it, but I did it. In my first job, there was terrible administrative support. It was back in the day when we had to pull charts and the charts were never pulled or they couldn't find them. I had a really long commute. I was commuting three hours a day. I got overwhelmed and burned out and ended up leaving that job and going to work for up-to-date where I didn't see patients at all, so I have subsequently worked with three other urogyne practices. I feel like the one I'm in now is great, I think partially because I have a seat at the table being the division director. I can help to make policy and ask questions and get answers, and so I don't think that that has to be only because I'm division director. I think any of us have the ability to ask questions and get answers. It's just a matter of being persistent. The best practices that I have worked in have had open lines of communication, leadership that's willing to listen and act. Listening is one thing, but acting is another. A partnership between providers is really important. It's no good if one of the providers you work with doesn't like the other one or does things completely differently. It's very hard on you because if Dr. Smith treats every bacteria in the urine and the other doctor treats nothing unless they're bleeding in their bladder or whatever, it's hard for you to remember sometimes what their preferences are. I think the other thing that's really important is a willingness to do more than your share some of the time. You don't have to do that all of the time, but it's kind of like a marriage. Sometimes you do 80%, sometimes you do 20, so having people that you work with who are willing to sort of bear the load when you can't or if there's a patient that you just can't stand or they can't stand you or whatever the situation that they're willing, they're able to take the patient on. The worst places that I've worked in have had a lack of leadership or leadership that was basically powerless. Whether it was requiring me to see every person who called and want an appointment no matter how many I already had scheduled or always being expected to do more than my share. I really think that part of the key to happiness in this field, whether it's urogynecology or cardiology, is having boundaries and being able to stick with them. There certainly is no perfect urogynecology practice, medical practice anywhere, but there certainly are better ones and worse ones. So in terms of advice that I can give you, I would say if you're having issues with scheduling, review your schedule in advance. I do this for the physicians that I work with as well as for myself. If you see things that are booked either wrong because you don't see that diagnosis or you're not given enough time or there's 20 patients when your max is 18, being able to identify those things early and being able to move people around, I think is important. If staff is constantly overbooking you without your permission, you need to meet with them and say, what are the challenges? Why does this keep happening? Hear them, let them hear you, and hopefully it won't continue to happen. Say no when you need to, when that patient is 30 minutes late and you've got to go pick up your kid, don't say yes. I try to say yes as often as I can, but you end up working a 10 hour day and it's not fair to you or your family or yourself if you're always having to do more than you need to. My other advice is pre-chart. Every morning I spend about 20 minutes, 30 minutes max pre-charting, and I literally spend two or three minutes per chart just figuring out why they're coming. And I only pre-chart on follow-ups. I don't pre-chart for new patients. It's really, really helpful. It helps me to close the notes faster. I used to think it was a huge waste of time to pre-chart because what if they didn't show up? But I now am fully committed to it because it definitely has saved me time. The physicians, you know, working with physicians, I think, as I've said, communication is really key. I, in my office, have a monthly meeting with the other providers and the practice manager, and we go through, you know, OK, this is happening with nursing, this is happening with scheduling, this is happening in the OR, we need to work on these things. And I'm the one that makes that happen. If it weren't for my, and it's not just me as division director, I think you have the power to have this, to call this kind of meeting as well, but it's really, really important to keep those lines of communication open. And if you've got nothing to talk about, then talk about a journal article. I think, you know, continually learning is so important with this job. It's a very narrow field, but it's very, very deep. There's always more to learn. So my recommendations for people who are new to practice, I have two pieces of advice. Number one, be kind. It sometimes is really hard. The last patient I saw today basically demanded surgery. I'm obviously not a surgeon. So when she went up to make her appointment for urodynamics, she told the scheduler or she told the nurse that she was going to have to make an appointment for the next day. She told the scheduler, or she told the secretary, tell Leah to call the surgical schedule and book me. Like she was so indignant and rude. And I just smiled and was sweet with her the whole time. That is very hard to do sometimes. And I can't always. But being kind is so important for both staff and patients. And then set your boundaries, like I said. So I see that there are some questions. I think that, yeah, no, nothing for me. So. All right. That is all I have. I am going to stick around, though. So if you have any questions, I'll be here. Thanks, Leah. Now we're going to hear from some new APPs to the practice. Lindsey Buckert is going to go next, if you're there. Can everybody see, like, Leah's face and or should we just do a. Lindsey, can you hear us? Yes. Can you hear me? OK. Hello. There you are. Hi. Hi, Julie. Hi. Thank you so much. Thank you for giving us this opportunity as advanced practice providers to get together and also for asking, asking me and others to share our experiences. I find that I'm always in any setting that I've been in as a nurse practitioner. I'm always wanting to connect with other APPs and, you know, work together, run things by each other. So I'm really thrilled to be a part of this group today. So I live in the Chicago area. I have been a women's health nurse practitioner for about 10 years. My experience has been largely in family planning. I've done a lot of trans and gender diverse gender affirming hormone therapy. And I've also worked in Planned Parenthood and done a lot of family planning related services. But I felt like at this point in my career, I wanted to really hone in on a family planning approach. Hone in on a specialized area. And so I'm really excited. I started to I started mid-September, actually. So it's barely it's barely been two months at the University of Illinois Health System in Chicago. So it's an academic setting and it's also growing right now. So we just had two new attendings or two attendings that are new to us join around the same time. So there's a lot of transition happening. And I feel pretty, pretty content with this because it's giving me a chance to have some time to really jump into learning and educating myself. I am reading a lot of textbooks. I'm spending a lot of time observing. I've had opportunities to shadow in the O.R., which has been really mind opening and has really taught me a lot about the like the perioperative process for patients. When I'm up and rolling, I will be working in the outpatient side for most of the time. I know that I'll have some admin time for group administrative responsibilities and then also for my own follow-up and I'm going to be typically seeing follow-up patients. I will be doing office procedures. Right now I'm working on learning the Eurodynamics. It's been a lot, but it's really exciting. I enjoy learning at this level. I'm going to attend the APP course for OGS in the spring, so I think that will be also be helpful and I'm glad to have some months, like six or seven months of experience, so that I can actually have a little bit more of a perspective to bring with when I take the course. But mostly one of the things that I mentioned to Julie earlier is that I'm interested in learning from others about how they have or ways that they have found to increase access for trans and gender diverse patients, ways that they may have like bridged disciplines within their institutions. And that's something that once I actually am fully competent on my own, I would love to be able to improve access for the community. So that's my spiel. Thank you so much and thank you again, Julie. Thanks so much for sharing, Lindsay. I know how intimidating it can be when you first start out in this field. So if you're not familiar with the core competencies on the OGS website, it's a great checklist. I'll provide a link for that here before we finish up. So now we're going to hear from Emily Shelley, who's also new to Euroguide. Hi there. Hi, Emily. Can you hear me okay? Yes, we hear you. Okay. So I'm Emily. I just started in Euroguide also in September, late August. I have been a PA now for 15 years almost. And I have a background in internal medicine. And then the last seven to eight years, I've been working in colorectal surgery. My supervising physician there closed her practice to move states. And at her office, I had a lot of experience in sacral nerve modulation for fecal incontinence. And so it kind of was a natural transition over to urogynecology. Well, I say that, but I do feel like it's been a steep learning curve. I have been doing a lot of shadowing, observing both my supervising physician and another APP in the group. It is a hospital owned practice, which is one physician and then one other APP. I've been able to observe in the OR as well, which has been pretty new for me. And I've really enjoyed that, learning a ton. But I'm now starting to see my own patients and have my own schedule. So I'm not seeing a lot per day just yet, kind of slowly building my schedule. But I do have a mix of consults and follow ups. And eventually, I'm hoping to learn also how to do the PNEs myself, because I do very much enjoy the interstem patients and seeing all of those fecal incontinence, urinary incontinence patients. So I mean, I think my biggest challenge right now is really just trying to keep up with all the new things that I'm trying to desperately learn. Some days, I feel like I'm kind of drowning. Some days, I feel like I have a handle on it. But it's very different from colorectal surgery, even though it seems like it would have a lot of overlap. But so far, I'm really loving it. I work part time. So, you know, that's wonderful in one aspect. But also, I feel like it kind of hinders me from being in the office so much and getting a lot more practice that way. But so far, so good. And I'm looking forward to being proficient at the job, hopefully, in the very near future. It'll happen, Emily. I hope so. Yeah, it's overwhelming at first. And but it's great that you have the support of other advanced practice providers in your clinic. That's huge when you start out. So. So helpful. Yeah. Okay. And now we're going to hear from Natasha Hartwig, who's also new to Urogyne. Hello, can everyone hear me okay? Hi. So I'm a new PA in general. I'm two years out of school. My first job out of school is with neurosurgery. So a lot of different body parts. That practice ended up closing due to administrative decisions. So I transitioned to urogynecology. I started in April, but I was in maternity leave from June to August. So all in all, I've been in urogyne for four months. So very new. Our practice is still fairly new. We're building up. We're kind of building it up from ground up. So I work with two urogynecologists. They're new to the organization as well. We work in the hospital group. So we're still trying to figure out kinks. I work with one nurse practitioner, but she does a lot of the work. So we're still trying to figure out kinks. One nurse practitioner, but she does more general gynecology. So as far as the urogyne APP, it's just me. So I don't really have anyone to lean on. As far as training, I did two months of just shadowing. After that, I started first assisting in the OR. So now I do one to two days of OR in a week, mostly vaginal cases. And the other three days in the clinic, they're training me to do robots. So it's a lot of learning there, but I have to get my laparoscopic cases out of the way first. As far as kind of learning overall, I've just been mostly learning by shadowing. My MDs have provided me AUGS articles to use. I attended the APP course earlier this year, which was super helpful. And as far as support in the office, I have an MA that's assigned to me, which makes things easier. We have three RNs that mostly do office procedures. So they're the ones that do the AUGS. They do PTNS. So as far as procedures with me, like the only thing that I really have to learn is how to do an EMV and a vulvar biopsy, because we're trying to get away from doing general gyne. So overall, it's, I'd say a steep learning curve, like working with a different body part. The most challenging thing to me is just, there's no like straightforward answer whenever I ask someone, what reference books do you like using? Because my MDs don't have any books on their shelves. I've been given articles. It seems like as far as you're concerned, it's more a learn as you go, no general concepts. So if anyone has better tips on that, that'd be great. But that's where we're at right now. And thanks for giving us the opportunity to have this forum. Thanks so much, Natasha. Good luck to you. Now we're going to hear from some more experienced APPs. Next is Yangi Forbron. She's been a urogyne NP for nine years. Hi, can you hear me? Hi. Yes. Hi. Yangi Forbron. Yes, I've been a urogyne nurse practitioner for nine years now. And I currently work at Maine Health Urogynecology in South Portland. And I work with five physicians, four urogynecologists, one vulvovaginal specialist, and I'm one of two APPs in the practice. And we're an academic practice. So I typically see about 14 patients a day, mostly all follow-up patients, occasionally a new patient, but lower urinary tract symptoms, bladder pain, pestering management. We do a lot of perioperative management, UTIs, and we also do quite a bit of telehealth. And I don't round in the hospital and I don't have a one-to-one support staff, which makes it a little challenging. So typically, our support staff are running for two providers. We're pretty short staff with our medical assistants and nurses in our practice. The practice that I work in, medical assistants and nurses in our practice, the procedures that I do include urodynamics. So I started doing UDS about two years ago, and I also do interpretation of that. And I do pessaries, interstem management, endometrial biopsies, let's see, training experience. So I started a large academic urogyne practice in Providence, Rhode Island in 2015. So I worked there for two years and I worked alongside a fantastic group, including an experienced nurse practitioner, Leah, who really trained me. And I got to ask lots of questions and bounce a lot of ideas back and forth. So that was very helpful for me. Because prior to that, I had done some family planning and college health. So when I got into urogynecology in 2015, it was a brand new experience and a lot to learn. Let's see, challenges. So some of the positive things I think really are the team environment. The positive team environment really goes a long way. Currently in my practice, I have a very supportive practice manager. So we have a great working relationship. And that is always helpful. And another thing in my practice, so I've been at my practice for about 7 years now, is that I'm included in a lot of decision-making, even though I'm not, I don't hold any kind of formal leadership titles. But my division director and practice manager will often ask me about how to do templates, orientation, onboarding. I'm invited to interview our physician candidates when we're hiring. So that makes me feel very valued. And that's one aspect that I really like about my current practice. Some of the challenges. Being at a smaller practice for our medical group definitely has some lack of visibility and lack of opportunity for leadership opportunities as a nurse practitioner, compared to some of my colleagues who are in a larger group setting. They have several APPs in their group. They, I think, just get more opportunities to sit on various committees and have formal leadership opportunities as a nurse practitioner or PA. Other challenges. I lost my nurse practitioner colleague this summer. So it's been a rough stretch of a few months for me. But we just recently onboarded a new grad nurse practitioner. So I'm very excited that we filled that role and happy to have her. And then recommendations for those new to the specialty. I think really just finding something within the field that sparks your interest, whether it's a clinical area that you really want to delve into or a different part of practice management, quality improvement, teaching, really finding something that brings you a lot of joy, will keep you going. And then I think when times get tough, your schedule's very busy. You're feeling burnt out. You're seeing complex patients. Just trying to remind yourself what brought you into being a provider and into urogynecology, whether it's a personal value or something that aligns with that organizational mission. Going back to that can be really helpful to get you through some tough times. Thank you. Thank you, Youngie. How lucky for you that Leah got to train you. Did she use the core competencies? I want to know. That was a long time ago, so I can't recall, but I think we did, right? I don't think they did. I'm not sure. Yeah, because that was in the fall of 2015. But I'm very lucky that Leah is a fantastic mentor and a great colleague of mine. Well, I'm going to share the link before this is over for all of you that are new. And so I highly recommend that you print those out and utilize the resources on there as well as the kind of the skill checklist with your other providers in the office. It's very helpful. And Julie, we're using that checklist currently for our new grad nurse practitioner. Oh, yeah. So we're very thrilled to have that. Yeah. Okay, we have another. Is Amanda, did she make it? Amanda Heap. She's a seasoned APP. Three years she's been in the practice, I believe. Yeah. Is that right, Amanda? That's right. Do you feel seasoned? I feel like just recently do I start, I started feeling seasoned. Yeah. So I'm a nurse practitioner. I'm at the University of Washington in our public health center. And we are very closely connected both physically down the hall as well as kind of a lot of consultations with general urology and a kidney stone center. And I work with four urogynecology, urogynecologists, and then one urologist who does female urology slash urogyne. And just to put it out there, we are in the hiring process or looking for another urology trained female urology, urogyne, MD, DO. So let me know if you have anybody you have in mind to want to move it to Seattle. I'm the only nurse practitioner, only APP in the public health center. One of the PAs in general urology has a lot of experience in female urology and urogyne. And that's been incredibly helpful getting me to feel confident in this field. I work, I see about 10 to 13 patients a day. I have five new patients a day for 40 minutes and six to eight returns 20 minutes. And then I have a 60 minute visit for a new pelvic pain patient. I don't know about other people's practices, but we see a lot of pelvic pain at UW. So I maintain my own practice. I do a lot of initial visits that end up going to surgery with one of my colleagues. And then I do a lot of, some follow up for other providers and some acute post-ops. And then I do a lot of pessary fittings for everybody as well. I'm only in the clinic, no rounding or hospital things. I do have my own medical assistant, which is very helpful. Though sometimes that's not always the same MA every day, but it is a dedicated person working with me. And let's see procedures that I do. I really have pretty limited to pessary fittings, PTMS. I do interstitial management, endometrial biopsies, and occasional vulvar biopsies. But that's kind of it in terms of procedures. So challenges when I came to this practice, I came from primary care. So I wasn't a new provider, but it definitely was a big shift, even having a strong background in reproductive health and primary care. I shadowed for about a week. And then my panel was opened slowly and the recommendation was just see anything, you'll get better at it. And that was very, very challenging. But I asked a lot of questions. I took a lot of time. I made a lot of safe mistakes, I guess, which is what happens. And a lot of like, I don't know, I'm going to think about this. And then I would take time, ask questions and call patients back. So I encourage you to do that if you're new, and you don't know what's going on. You don't have anybody who is available, sometimes always at the time to ask questions. And then I think also my lack of surgical experience and not having any OR time, it made it difficult to, other challenges made it difficult to recognize post-op complications. And so I spent a lot of time having another provider come in when I was doing a post-op, acute post-op evaluation to say, Oh, does this paranormal actually look normal because it looks really gnarly versus this isn't, you know, maybe an infection or a level of deficit that isn't maybe good. So that was that was definitely challenging. And then even just the hands on the pest refitting, you know, having a script would have been or something to kind of guide me through how to how to just get started with that. And not just having to try like everything under the sun before finding it out, figuring out what works now. It's obviously very different having a lot of experience with it. Positive experiences in my practice is I feel very lucky to have a lot of time with patients. It is, I feel I mean, maybe just coming from primary care, still a little burned out, even though it's been a number of years, but having 40 minutes of a new patient or 20 minutes for the return just feels very luxurious. I'm able to assess a lot of issues in the same visit. I feel like I'm able to connect with people in a way that feels very satisfying and provide patients with some really hands on solutions for conditions that are so detrimental for, you know, whether it's it's life threatening or not, probably many times not, which is nice, but also how we can, you know, really kind of change the course of people's lives so quickly, you know, you put a pester in, and somebody just feels better immediately, which is pretty amazing. I have great colleagues, and we have a very collaborative practice. And that's, that's also very wonderful for me, and challenges or negatives. I think, you know, just seeing a lot of pelvic pain, I think is challenging. Not always having the answers or being able to help people is part of medicine. But it is, it is frustrating sometimes. So recommendations that I have for people that are new to the practice is going to the AUGS APP conference, that was really helpful to get familiar with common conditions and how to evaluate them. I think there was a session on pessaries that was also really helpful. I also did the AUGS fundamentals course in the first year of practice. And that was, again, really helpful. Some of it didn't apply from a surgical perspective, but otherwise really helpful. Having a mentor that's available as often as possible. That's a really good thing to have and asking lots of questions. We don't really have, you know, I, I think I bought a book from a provider in Australia, and it was super helpful to try to familiarize myself with, with different things. But even just as basic as reading all the iUGA patient handouts, can be really helpful, just kind of get the, that the essence of all the things we have to offer patients. Thank you so much. Yeah. Now we have Megan that will be presenting next. Actually, I'm not sure, but I don't hear Megan speaking. Is it just me? I got kicked out, and then I'm back in. Is everybody else still in? I'm still in, Julie, but I don't know if Megan, who is going to speak, is in. Oh, there she is. Hi, Megan. Okay. Hello. Hi. Yeah, I had that same thing happen where all the things changed, so I'm glad we're back. Hi, everybody. Thanks so much for putting this together. So I would, I guess, be called seasoned. So I have worked the entirety of my career, so that's 20 years now, in only Uruguay. I'm a women's health nurse practitioner by training. I started so long ago that I predated pelvic floor physical therapists. So my first job was actually doing essentially pelvic floor physical therapy for vulvodynia patients. That kind of parlayed into kind of stalking a new grad fellow trained urogynecologist who was coming to the academic institution where I worked, and he didn't know that he needed an NP, but someone told him he needed an NP. So we kind of stuck together and then grew from a one-physician practice to what is now a four-physician practice and a fellowship training institution. Here's the tricky part. I'm both a seasoned NP and now kind of a new NP because I left that job in Ohio that I did for 18 years and moved to Washington, DC. So I am now at George Washington University, another academic medical center, in a very similar situation to what I had at the beginning in Ohio. So I work with a single physician. I took over for a single nurse practitioner. I've only ever worked with me as a nurse practitioner. I've never had additional APP support. So I have always been slightly isolated in terms of my practice style. That's one thing that I feel like I've always really wanted was to have like a group of nurse practitioners that did urogyne that I could bounce things off of and learn from, because I do think we practice in a slightly different way sometimes than our physician colleagues. So I started this job, I started seeing my patient panel essentially two months ago. So I'm kind of new, but kind of old. And that's been interesting because I did feel like very much an expert when I left Ohio. And now I feel like I still kind of know what I'm doing, but I'm learning it in a different context or learning how it works in a different context, which is slightly more challenging than I thought it would be. I see a mix of new and return patients and do procedures that include your dynamics testing, PTNS, sacral nerve stimulation management. I'm not doing PNEs yet. A lot of bladder installations, a lot of pest refitting and management. I see between nine and 13 patients a day, I would say, depends on what the mix is. I do not round in the hospital. I did not round in the hospital in Ohio either. I recently got a medical assistant assigned to me, which has been slightly life-changing. Trying to do all of those hats, I think is very, very challenging, especially if you're kind of new to the system. Let's see. I've been really lucky to train basically just one-on-one with a physician. When I first started, I was working with one physician. It was a new practice and we didn't have a whole lot of patients. We had a decent amount of time. So I really did what would be considered a very intense internship with the one physician that I worked with, which was super helpful because it was only me that had to learn. I really learned the preferences of that particular physician. I do feel like things are changing a little bit. In Ohio, you do definitely have a supervising physician you are really kind of leaning on. In DC, we don't have that. So it's really more on me. But I do think at the beginning, it was really helpful to have a pretty intense one-on-one kind of internship with a clinician. Challenges. So being new, I think the challenges still feel very similar. A lot of times it is scheduling for me, making sure that the patient mix is correct, making sure that the consults are appropriate. I had a vasectomy on my schedule next month and I was like, that's so wrong. So making sure that all those little pieces of things that you don't even think about in a day are really kind of coalescing to make you as successful as possible. I think staffing is really challenging. Like I said, I just got access to a medical assistant. It is very hard to do multiple people's jobs well. I think that's probably throughout the medical system at this point. But really just try and advocate for yourself. You're doing a big job and you do need help doing that big job. Recommendations for those new to the specialty. I'm not sure I would have had a good recommendation for this like three years ago because I felt so un-new. But having just become new, a little bit new again, I guess the first thing I would say is to give yourself grace. I'm terrible at giving myself grace. It's very easy to feel like you're not doing your best work, especially beginning because there are so many pieces that you have to figure out. But we are all in healthcare for a reason. And you are probably doing the best you can at that moment. And you will learn with each little stumble. So give yourself some grace. I also echo, I think it was maybe Leah that mentioned setting boundaries. I'm very bad at setting boundaries. Or at least I was in my like younger days. I think it is really easy in healthcare to say yes. And quite challenging to sometimes say no. But you getting burnt out helps no one. So take that time to really consider the yeses and the nos. You can't always say no, but you also can't always say yes. So really consider boundaries as it pertains to your particular situation. Thanks, Megan. That's all really good advice for people. We just really have a few minutes to kind of look at any questions in the chat. Something came through about the SUNA organization. So Society for Urologic Nurses Association is a really also a great society to be a part of. They have a lot of educational things on their website, CME opportunities as well. So I would encourage you all to check out SUNA. Tashi, did you want to show any questions? I have a couple of questions that I saw in the chat that I wanted to make sure that we addressed, Julie. First, I just want to say, wow, you guys are super impressive and super valuable. And as a urogynecologist, I wish I spent most of my time in the military. We didn't have APPs, but I wish I would have had one. You guys sound amazing. I have some questions, but I do want to make sure we get through what was in the Q&A. There was one here, and maybe Julie or any other panelists know if the on-demand APP course and the spring APP course have a lot of overlap. Tiffany wants to know if she did the on-demand APP course, if it's worth also going to the in-person AUG's APP course. Oh, I think absolutely. I mean, it's when you're in person, you're going to meet everybody. And that's when you really learn a lot. That's when you collaborate with people. That's when you're saying, you know, how in the world do I get this shelf pessary out? You got any tricks? You know, it's all happens kind of in between the lectures, you know, when you're networking. And for those that are new and you don't have an APP in your practice to train you, you can meet people at this conference and you can, I would highly encourage you to encourage your practice manager to pay for you to go and spend two or three days with somebody and just immerse yourself with another Euroguide APP. You're going to learn so much just with one-on-one and it's going to benefit your practice and you as well. Perfect. And then the next question, Julie and panelists, are anyone of you performing cystoscopy as a part of your routine procedures? I don't, but I know that there are MPs and PAs within our field that do. There's not a reason you can't. I think it's sort of like learning colposcopy. You just need to be present for a lot and learn what's normal and what's not. Perfect. And then for Alexandra, I think the question was about PNE and basically, Alexandra, that's a procedure for neurostimulation. So that's what that is. But if you guys want to elaborate more, but I think she wasn't, she was unclear what PNE and it's actually PNE percutaneous nerve evaluation is what that stands for. I know we only have a few minutes left. There was another question from Melanie about expand on the diagnoses that are allowed for telehealth. Can you flip back to my slide that shows the APP and that article, it says resources. I just want everybody to see that before they check out. Oh, okay. So I just wanted to point out this core competencies and that's the, the, the link to the website to get these. It's huge. You guys, even if you're seasoned, you can find all the updated musculoskeletal evaluations and everything there. And then this article that just came out just a couple of weeks ago, this really was, this was a survey that looked at actually urology nurse practitioners, but you're not going to find a lot of information out there on urogyne NPs. And what they talked about was, you know, salary ranges, how much, you know, admin time everybody's getting, do you get compensated for education and things like that. So you can use the information in this article at your next evaluation to really advocate for yourself and get some reimbursement for, for education and other things. And I'm not the one to answer that last question. Actually, I don't know if anybody else wants to weigh in. Yeah, that seems more telehealth, telehealth broad, not specific to APPs is my guess. Yeah. And I think it varies by state. There's not in Massachusetts. We can see any diagnosis virtually as long as they're within the state. So I think it depends on your, your state's policies or institutions policies. Amazing. Well, that takes us right up to the hour. So in conclusion, on behalf of AUGS, I'd like to thank all of our faculty, leading us Julie Star here for this excellent webinar. Please be sure to register for upcoming webinars on December 18th. Join Dr. Mickey Karam. And I'll also be the moderator for that as he presents a webinar titled use of radio frequency energy in the vaginal canal and on the vulva therapeutic and aesthetic indications and outcomes. Please follow AUGS on Twitter and Instagram and check out the website for more information on upcoming webinars. Thank you all for joining and have a great evening. Thanks again, everybody. Thanks for your time. Thanks Leah.

urogynecology

Advanced Practice Providers

American Urogynecologic Society

pelvic floor disorders

mentorship

continuous education

networking

professional growth

core competencies