Welcome to today's webinar. I'm Bhoomi Davey-Helker, and I will be your moderator for today's session. Just a reminder that we will take questions throughout the webinar, and you can submit them by typing them in the question box on the left-hand side of the event window. Today's webinar is titled Urogynecology Office Practice, Practical Tips for Success, and is being presented by Dr. Raymond Foster. Dr. Foster is a native of Mesquite, Texas. He attended the United States Military Academy at West Point, where he earned a bachelor's of science in chemistry. After almost 10 years of active service as a commissioned officer in the infantry, Dr. Foster returned to school with the intent of training to become a physician. He earned a master's of science in molecular and cellular biology and a doctor of medicine from the University of Missouri School of Medicine. After medical school, Dr. Foster completed four years of residency training in obstetrics and gynecology at the Texas A&M University Health Sciences Center. Upon conclusion of residency training, he moved with his family to Chapel Hill, North Carolina, where he underwent three years of fellowship training in FPMRS at Duke University. During his time in fellowship, Dr. Foster earned a master's of health sciences degree with a major in clinical research from Duke University. Dr. Foster is certified in both obstetrics and gynecology, as well as FPMRS. He and his wife have four children. Dr. Foster is currently a tenured associate professor of obstetrics and gynecology at the University of Missouri School of Medicine. He also continues to serve as a colonel in the U.S. Army Reserve. Without further ado, I'll turn it over to Dr. Foster for a much-anticipated lecture. Thank you very much, Dr. Dovey. I hope everybody can hear me well. And thank you all for signing in and listening to this lecture. I'll start off by saying we gave kind of a bigger talk than this, a four-hour workshop at AUGS in Nashville, or the AUGS-IUGA meeting in Nashville, where we really had five faculty that talked about different areas of how to build an office practice. The slides that I'm going to go through with you this evening are actually my portion of that workshop. And part of what I did was introduce what other people were going to talk about. And I actually left those bullets in these slides because I think it would be good for you to hear some of the other things that you need to be thinking about, besides just the part that I was responsible for that I went over. At the University of Missouri, just to tell you a little bit about our practice, we have, I think, about 25 faculty, and maybe 20 or 21 of those are clinical. We have, I think, four or five PhDs on our faculty. We have all five of the normal clinical divisions. And I think for the last five years, maybe a little bit more than that, I've become personally interested in – and part of that's because of my role in the department here – but in how do you manage an MFM clinic efficiently or a Uruguayan clinic or the general OBGYN clinic, or how do you incorporate office procedures into a busy clinic, or how do you incorporate teaching with residents, medical students, fellows, et cetera. And so that kind of – we kind of started, or I started, trying to figure out how I was going to make all that work. And anyway, so I put together a little talk, and we're going to go through it. And I only have 18 slides. It's actually going to go, I think, fairly quickly. And I actually am not committed to getting through these slides. If we don't make it through the end of the slides, that's fine with me. So what I'm saying is I welcome you to ask questions, and we can have – you know, I can address issues as we go through this if you'd like to do that. I have no – nothing to disclose. So who might be here? Who might be listening to a talk about running a FPRMS office practice? So there may be some senior fellows that have logged in that are thinking about, you know, I'm about to establish a practice in an academic setting or an employed non-academic setting or even private practice, and I need some tips on what kind of – how would I negotiate? How would I ask for the things that I need so that I can be successful kind of from the very beginning? There might also be some people on this webinar right now who are, you know, my age, 40s, 50s, mid-career, who grandfathered into FPRMS, and they maybe in the past run a full-scale general OB-GYN practice, but now they really want to move their practice into a pelvic floor practice, and they're looking for information or tips about what would be – how would be a good way to transition to that. Or maybe there are people that are already practicing solely urogynecology, either in academia or employed practice outside of academia, and those people are just looking for new ideas to help make their practice more profitable or more efficient. And hopefully we can talk about a few things throughout these next 16 or 17 slides that will apply to somebody who might be in any of those three groups. So what do we want to accomplish? Well, I think, first of all, I want to impress upon you that you have to have a vision for your practice in terms of what kind of a practice are you looking for. And I'm going to give you in the next few slides – I'm going to give you an example. When I was transitioning from Duke to the University of Missouri, one of the things that was part of my vision for my practice – so you'll see what I – kind of what I mean in more of a realistic example. And then how do you negotiate to achieve that vision? If you have a vision, you're going to either meet with a chairman or you're going to meet with some business leaders of your non-academic employed practice or you're going to meet with some of the business leadership of your health system, and you're going to need things. You're going to need square footage and staffing, and you're going to need office equipment, et cetera. How do you put together something so that these people are going to be behind you and they're going to want to support you so that you can be successful? And can you set up a practice that capitalizes on the changing landscape? And I'm going to not say much more about that now, but I'm going to give you an example where actually we are trying to do that right now. A lot of – at least in the Midwest, and I don't know where each of you all are from, but a lot of the bigger surgeries, hysterectomies for sure, are really shifting from general OBGYN to oncology and to gynecology. And we're trying to figure out how we want to fit into that, how we want to absorb that practice that's not traditionally pelvic floor or cancer. What about marketing? And I'm not going to say anything about that, but that's something that at the Nashville – I forget what you call those – the workshop. I'm sorry. At the Nashville workshop, one of the hours that we did during the workshop was Ryan Stratford talking about using social media and things like that. I don't know a lot about that, but I would encourage you to go on the website for MOGS and look at – I understand our slides and stuff are posted to that website. Look at that information. It's actually quite good. What about recommendations about the nuts and bolts, you know, hiring support staff? Clinic template I think is really important. So how do you decide how many new patient visits you're going to see, how many pre-op visits, how many post-op visits, et cetera? If you want to be profitable and you want to be productive, that clinic template is so important, and I'm going to talk some more about that later as well. What about reimbursement? In Nashville at our workshop, we had an hour – actually not this year, but this is the second year we've done the workshop. Last year we had an hour dedicated to Mitch Schuster, the chairman of the OGS coding and billing committee, really kind of caught us up on some of the billing and coding issues that are important for urogynecology. I would challenge you if you're – especially if you're one of the senior fellows that's walking in to set up a new urogyne practice, make sure that you talk to people like Mitch and that you have some idea about how billing and coding works in urogynecology and how you want to structure your clinic template so that you take advantage of offering some of the services that are more profitable. Can you improve – can I improve my efficiency and productivity by hiring a mid-level provider? I think – and if I do hire that person, what can they do? I think this is huge, and I think towards the very end of the talk, I'm going to give you some of my own insight about a couple of things. One is clinic template, and one is incorporating mid-level providers into the practice. This is – in fact, I would tell you if there's one single thing that I really did right that has made my practice profitable, it's judicious use of mid-level providers. And so we'll talk a little bit about that in a few slides as well. And then some people that are in an academic setting or maybe people that are not in an academic setting but are kind of an adjunct practice to a nearby academic medical center, you know, you want to be involved with learners, students, and residents, and so forth. And is there a way that you can incorporate those kinds of people into your practice without sacrificing productivity? And we had Dr. Keo Nohara from UC Riverside at our workshop in Nashville, and he spent a whole hour talking about ways to incorporate learners into your practice to maximize their experience and what they learn without sacrificing your own productivity, your own profitability. So what's your vision? I'm going to give you an example of – kind of a concrete example of something that could be part of your vision to developing a practice that's going to be efficient and profitable. I'm actually from Texas, but I live in the state of Missouri. I work at the University of Missouri. So take a look at the geography of the state of Missouri. There's roughly 6 million people in the state of Missouri, and those 6 million people or 90% of them are divided in three communities, Kansas City, St. Louis, and Springfield. And the University of Missouri is right in the geographic center of the state, in Columbia, Missouri, right there along I-70. It's a college town of about 135,000, 140,000 people. And so our catchment area for our hospital is actually 25 counties. I would say 80% of my patients come from outside Boone County, which is the county that I'm in, and probably 20% of the patients I see drive more than two or three hours to come one way to come see me. So I had a vision that I proposed when I was still in fellowship, negotiating to come to the University of Missouri. I wanted to do what we call one-stop shopping, where a patient could be referred to our practice. Records could be reviewed in advance. The patient could be seen. On the same day, she could have preoperative evaluation. If she needed cardiac clearance, we would have support available that we could even get within reason. We could get things like that done on the same day. Preoperative evaluation, including urodynamic testing, office cystourethroscopy, et cetera, would all be available on the same day. And now I've been here 12 1⁄2 years, and we've been doing one-stop shopping that entire time, and it's been hugely successful. But this idea caught the attention of the person that I was negotiating with who happened to be my chairman. He said, this is something that I can really get behind because I see this as something that not only if it's successful in your division would be good for you, I would like to see you show other division directors how to do the same thing. And so a lot of our clinical business now across the department comes from this type of a business model or this type of a service level where we can see people efficiently and get them to the operating room quickly. So these people that come, and I do one-stop shopping on Tuesdays essentially, which doesn't really matter, but we kind of have it organized where we have the staff to do that on one particular day of the week. And this is just an example. So this is something that I thought would be important, but I needed equipment, I needed staffing, I needed square footage, and I had a document that showed the people that I was negotiating with, this is what I would need to make this a clinical reality. And I can tell you that not only my chairman, but the health system were absolutely 100% in to support me. I want to shift gears and talk about something else. So I mentioned earlier in the talk that the landscape is changing a little bit, at least in the Midwest. I saw a presentation at SDS last year. The median number of hysterectomies done by a general OB-GYN doctor in North America now is 3.7. So the question is, if that's true, then where are all those surgeries going? And I can tell you in the Midwest, complicated gynecology is really being done by GYN oncology divisions and urogynecology divisions. So the way I kind of got into this was I got a call from a chief of staff of our health system who had talked to a faculty member in the orthopedic surgery department who was not happy because his wife had an ovarian cyst and she was having pain. And she had an appointment for six months later, and he called back and expressed his displeasure, and then they readjusted her appointment to wait two months. So I started looking at our general divisions, like why is that? And I started talking to some of the journalists, and it turns out when I looked at their clinic templates, they set up their clinic templates for about 90% obstetrics and about 10% or less, depending on the provider, slots available for GYN. So I tried to figure out why, and I'm going to show you what I learned from doing that. If you tell your nurse I want you to open up 10 spots in my clinic next week for a complicated gynecology, you know, no pap smears, no refill birth control, but abnormal uterine bleeding, postmenopausal bleeding, adnexal mass, whatever, complicated gynecology, and then you assume that there are X number of return visits and X number of ultrasounds that you perform in the office, endometrial biopsies, et cetera, and then you make some reasonable assumptions about treatment, including how many people might get an IUD, how many people might get better with birth control pills, et cetera, and you assume that one of those 10 women goes to the OR and gets a TLH. And I did the numbers in terms of RVUs, making reasonable assumptions about what would happen in a normal general gynecology practice to those 10 women. It comes out to a total of 46.75 work RVUs. So now let's just say that you told your nurse, next week I want you to open up 10 slots in my clinic for new OB women that have a new diagnosis of pregnancy, okay, and you make some assumptions. You make an assumption that one person miscarries, three women have a C-section, and six women end up with a vaginal delivery. And you don't make any assumptions about, you know, you bill for an amniocentesis during the pregnancy or you bill for an external cephalic version or you bill for a cerclage or, you know, all the other stuff that ends up being a lot of RVUs in some pregnancies. Just the global billing for those 10 slots you opened up in your clinic, 299.88 RVUs. And even though we're an academic practice here, we are very much paid by productivity, and so we're incentivized to be productive. So the general OB-GYN doctors that work in our department aren't stupid. They realize that if they slant their load towards obstetrics, they're going to personally do much better. So now back to how this applies to kind of our practice. So I decided, well, there's an opportunity. I could put together a plan and I could potentially capitalize on that by not only helping these patients that need to be treated for AUB or adnexal masses or whatever, but also help our practice. And so I went to the health system and I actually gave a talk for about an hour. I'm just going to show you a couple slides that I showed them to make our case. So median contribution margin, MCM, that is kind of a word that means something to hospital administrators. And what that means is if somebody's admitted to the hospital for, you know, abdominoplasty, it takes into account what they're paid on the hospital, the facility side for that, and then minus all the expenses, what it costs for the IV fluids, the nursing care, the room itself, the housekeeping, you know, et cetera, and then what money is left over. And they look across, you can see on this slide here, they look across commercial payers, Medicare, Medicaid, self-pay, et cetera, and the median contribution margin for a hysterectomy in my health system is $3,500. And then I showed them some more data about the market opportunity for hysterectomies in mid-Missouri, et cetera. But how does that $3,500 compare? Well, if you're getting a tonsillectomy, the median contribution margin is just $3,100, or laparoscopic colostectomy, it's $2,600. So it actually compares favorably to most things that are going on in the hospital. So back to kind of why is this important to my practice. So I put together a plan as part of my vision for our practice here that we would develop, you know, we call it something like the Missouri Center for Advanced Gynecologic Care or something like that, and I wanted to have some more square footage. I wanted to have some staff, some office equipment. I wanted to have a hospital to help me hire a small army of mid-level providers, nurse practitioners, and these nurse practitioners could see the patients. They could do the pelvic exams, collect endometrial biopsies, try them on IUDs, try them on birth control pills, order ultrasounds. They could do all this preliminary workup, and then when the patient needs a hysterectomy, we would have the urogyne division, and this is going to be, in our case, a collaborative effort between urogynecology and gynecology. We would have the surgeons from urogyne and from gynecology be willing to take them to the operating room for oophorectomy or hysterectomy or whatever they need. Anyway, the short story is the hospital has decided to commit enormous resources to this, and they like this idea because it serves a need that we needed in our region, and at the same time it makes good business sense not only for the hospital but also for my department, my division. And that's just two examples of kind of, you know, when you're developing your vision, thinking about, you know, what is it that I can do or what is it that I can offer that is going to get my chairman or my health system behind me. I think in your practice also you need to think about, you know, for example, do you want to do office procedures? Is that going to be a part of your urogynecology practice? Things like intravascular Botox, PNAs, PTNS, office Cysto, et cetera. Do you want to use an NP or a PA to offer non-surgical management? I'm going to stop here and talk a little bit about this and about our clinic template. This is where I wanted to fit that part of the discussion in because I think for our success that we've had here, this has actually been the most important component. So I actually uploaded as a handout for this webinar, we have a centralized scheduling system at the University of Missouri, which I personally don't like, but it's the cards that I've been dealt. Here it's called, you know, quote, the source. We have 543 physicians and university physicians, and every physician has a, quote, the source website where these schedulers will open. When somebody calls for an appointment, they will open up this website and it will tell them what types of patients you will see, won't see, what types of diagnoses you accept, et cetera. And I included the information from the source for myself, my partner, and three of my four nurse practitioners that you can download as a handout just to see it. But in a nutshell, we have designed our clinic template and we have designed how we divide up referrals between the mid-level providers and the surgeons so that everybody is practicing at the top of their license. And I'll just give you some rules that we have. First of all, the surgeons and myself and my partner, we do not, all capital letters, do not see return patients. When we're in clinic, we're seeing level four new patient consults all day long. So if you want to wear a pessary and you need to come back in periodically and have your pessary cleaned, you will not see me. You will see one of the mid-level providers. If you want to be managed on DDAVP and you have to have your doses adjusted and labs drawn periodically, you will see a mid-level provider. If you want to have pelvic floor rehabilitative therapy, you will see a mid-level provider. And if you look at how we wrote up the scheduling information for the source, you'll see that, for example, I don't see patients and my partner doesn't see patients under the age of 25 or over the age of 79 because statistically those patients are unlikely to have surgery. So if you're 23 years old and you have dyspareunia, we will see you as a new patient consult, but you will see Julie or Devin or Debbie. You'll see one of the mid-level providers who are actually really good with those types of diagnoses, but you don't need to see a surgeon. So the other thing, so we've not only compartmentalized who sees what, and as I just said, we've also compartmentalized the fact that the surgeons are in the clinic to see new patients. Our schedule does not get filled up with pessary cleaning, so it stays open to continually get new patients into our practice. And the other thing I'll say about our clinic template is we have found, and I think other people I've talked to around the country for different reasons actually don't agree with this part, but we have found in our practice that we're much more efficient if, for example, in my schedule, Monday is a new patient consultation day. Tuesday is a pre-op day. I do nothing but pre-ops all day on Tuesday. Wednesdays and Thursdays I'm in the OR all day. Friday morning is 20-minute slots all morning long for my post-op visits. And then Friday afternoon is our department grand rounds, faculty meeting, and all that. So all of our clinic templates with the two surgeons in my practice, we are very homogeneous. And the reason I think it's been good for us is because the nurse and the doctor team working together kind of get in the mode of, hey, we're pre-op today. We're doing urodynamics. We're doing office systo. We're signing consents. We're teaching women how to self-cap. You know, we're just in the mode, and we're really moving quickly through pre-ops. And the same with new patient consultations. We kind of get in the groove, and we're actually very efficient at doing that well. The other thing I'll say about our practice, and I should have said this at the very beginning of the presentation, efficiency is a big deal to us, and even in our clinic meetings we talk about it a lot with staff, with our check-in staff, our nursing staff, the surgeons, the mid-levels. I have two surgeons, four mid-levels, five nurses, two check-in staff, and one administrative assistant. With the exception of two of those people, all of us have young children at home. I've got four kids. My partner has two. And so it's important to us that we work smart and not necessarily hard. So we try to do things so that notes are finished by the end of the clinic day, but we've been productive. We've seen 10 or more level four consult patients, and five or six of them have been referred to pre-op, and four of them have been referred to follow up with the mid-levels. So everybody has done a lot of work, and the documentation is done, and we're ready to go home and be with our families at a reasonable time. What else? Let's see. Back to your vision. Will you see some of the general gynecology things that I was talking about? I mean, would you be willing in your practice, if those hysterectomies were available to you, would you be willing to do that? I mean, some pelvic floor centers don't want to do that. People, the surgeons say, I went to fellowship to learn how to take care of pelvic floor dysfunction, and that's what I want to do. I don't want to take care of menorrhagia. We look at it a little bit differently here. What type of office testing do you want to provide? Do you want to offer UDS in your practice, intellectual manometry? We have one of our nurse practitioners trained in ARM, and she does a lot of it, and we get referrals specifically for ARM from the gastroenterology practice at the university. Do you want to do diagnostic scopes in your clinic? Do you want to do an internal ultrasound? All of the stuff we offer in our practice. What about research? And this is probably not the best time to talk about that. This lecture is not the right format, but you need to think about that. I mean, do you want to collect data? All of our patients, for example, all of our new patients get a packet of information they fill out, which includes a PFIQ and a PFDI-20, et cetera. And so we have mountains of data from the patients that we have taken into this practice. We also have 100% of the patients that get surgery in this practice, and we do between the two of us about 500 surgeries a year, 100% of the surgeries get enrolled in an IRB-approved protocol, a surgical database. So we use that data for quality assurance. We also publish a lot of that data. We also have a pelvic floor therapy registry, so we prospectively enroll people that are referred for comprehensive pelvic floor rehab with our mid-level providers, and we published one study out of that registry already, and we have another one that's in the works now. And that kind of research doesn't slow us down. We have the staff or the surgeon or the mid-level consent them for whatever database we want them to be in. It takes a couple of minutes, and then the data can be abstracted from the chart later and placed in the database, and we have people that help us do that. What about Steve? Yeah. I was just going to ask a quick question, two quick questions. In terms of the database, do you enter the information into the database, or are you retrospectively looking through the charts in the future? No. So, for example, with the surgical database, the patient, when they sign a surgical consent form for the actual surgery, I also pull out a consent form for the IRB-approved surgical database. They sign it at the same time, and then our department research nurse will, that day or the next day, will enter them into the database. It will be their name, their chart number, what the procedure they had done, and a few other things that we want to collect. Mainly what it is, so it's being prospectively collected, but it's a repository. So let's say that we want to see what our seven-year outcomes are in InterStim. I'll go back and pull all my InterStims out of that database that I did seven years ago. We'll contact those patients either with a phone call, some kind of information to fill out, or maybe in some cases, if it's a prolapse study, we'll actually get them to come back in so we can examine them and get information from them back in the clinic. And the consent form that we sign them up for gives us permission to cold call them in the future and ask them if they would be willing to come back in for an exam or whatever. Does that answer the question that you asked? Yeah, no, that's really, really helpful. And so it sounds like there's a research nurse who reaches out to them the next day or who looks through the chart and formally enters it into a more structured system. Yeah, so we have, our department has what's called, and we developed this a couple years ago, RSC, the Research Success Center. We realized that our clinical faculty weren't doing a lot of research because they simply didn't have the time. And so the faculty decided to hire a research coordinator and a research nurse, and we have a little office for them, and we have computers and file cabinets, everything that they need. And at the end of the year, the total cost of that RSC, that Research Success Center, is divided by FTE. So if you're 1.0 clinical FTE, you pay X number. And so it costs the faculty a few thousand dollars that it may have otherwise gone to their bonus or whatever. But it's allowing us, I mean, we're all in. The faculty are glad that we're doing it because it's providing us the support that we need so we can publish little retrospective reviews or even prospective papers. Anyway, that's probably more than you wanted to know, but that's how we work it in our department. Was there another question you had? Yeah, that's fabulous. We have a couple of other questions that are listed here from some of the attendees. One is, can you repeat your staff that you have in your clinic? So we have two surgeons, myself and Dr. Duarco. We have four nurse practitioners. we have five, I beg your pardon, we have six nurses, and we actually have seven because we just got approved by the health system for a PRN nurse. And that's an RN that you pay a .10 salary to, but she's available to come in if I want to double book pre-ops and do extra urodynamics, I can bring her in and I can put on more surgeries, for example. So we have seven if you count her, but she's just not in the office often. And then we have two front office check-in staff, and we try to deal with one, but with lunches and having somebody come early so we can get the 8 o'clock patients checked in before the 8 o'clock starts so we can actually be seeing the patient at 8 o'clock. So that person comes in early and leaves early, and then the other person comes in later and leaves later. So for us, it takes two check-in staff. And then I have an administrative assistant that my partner and I split the expense for, and we actually sold 30% of her time to the department. She does all the credentialing for the department, and so my partner and I split 70% of her, but she stays in our physical space 100% of the time. So we essentially have her 100% of the time, but she also does some stuff for the chair. Got it. And then another question we have here is, who does your urodynamic testing? Is it a mid-level or an RN? So it's been actually an LPN, or some states call it LVN, but we have just converted most of our nursing spots. And that was another thing I could go into how I kind of made a pitch to the leadership for our health system to convert our LPN spots to RN spots, and it has tremendously helped our practice. The direct answer to the question is RNs now do all the urodynamic studies. Great. Great, thank you. And then what about teaching? You guys will decide, or maybe you won't decide if you work in an academic health center, do you want to involve any learners such as students or residents or even fellows in your practice? I'll tell you, NP students have been great for us because when I was negotiating to come here, it just reminded me of a story. When I was negotiating, I was a second-year fellow at Duke, and I was negotiating to come here, I told my chairman or a future chairman over the phone that part of my vision would be to build a practice where women would have a real choice. They say, you know, I want surgery, or doctor, I really want my complaints addressed, but I don't want surgery. And so I really wanted to have some mid-level providers that will offer non-surgical management. And what I got told was, good luck, you know, getting, you know, the mid-level providers in Missouri are so scarce, you can't, you know, you can't get them. So what I did was I got on the phone, and I called the dean of the nursing school from North Carolina, where I was at the time, and I told her that I was coming to the University of Missouri, and I would like to volunteer to be a clinical preceptor for her nurse practitioner program. And I think they had to get out the AED and shock her after I said that, because she had never had a doctor volunteer to do that. So and it turned, excuse me, it turns out that the first nurse practitioner student that came to my clinic is named Julie Starr. Julie's now been with me for 12 and a half years after I hired her, and she has been on multiple OGS leadership committees. She is on the APP course, the Advanced Practice Provider course that OGS now runs. She basically designed that course and has been the, on the committee chair or whatever with two other physicians for the last three years for that course. So and then I've, and I've actually gotten two other nurse practitioners the same way by letting them kind of come to our clinic, see what we do, see if we like them, and then hiring them. And it's been, it's a really nifty way for us to get a scarce resource here in Missouri. What percentage of time do you want to spend in the clinic versus in surgery? And a lot of that's going to depend on, I think, on how you set up your template, meaning if you're spending a lot of time cleaning pessaries and refilling Mirabegron, you're not going to post a lot of cases. If you're letting your mid-levels do those kinds of things, and you're spending your time continually getting new patients into your practice, and your scheduling template is set up so that you're not seeing dyspareunia, you're seeing somebody who's got prolapse or incontinence, you're going to need more surgery time. You're going to need more OR time versus clinic time. So a lot of that's going to really be driven by how you want to set up your practice. Will you accept referrals from L&D? This is another thing that was part of the vision that I negotiated for when I first came here. I said, you know, I really want to have a practice, and we call it Healthy Bottoms, and there's a long story behind that name. And so essentially what happens is we negotiated a deal with the labor and delivery nurses when they see a woman who has a baby who has a third or fourth degree or other significant pelvic floor trauma during delivery, they fill out a slip of paper, and all the general OBGYN doctors and even the family medicine doctors that deliver babies have given us permission to let the nurses refer us patients. But anyway, the L&D nurse faxes down a sheet to our clinic that says Mrs. Jones is in room 27, and she had a baby last night, and she had a third degree obstetrical laceration, et cetera, and my nurse practitioners check the fax machine when they come in in the morning. They run up to the floor if somebody had an OB injury, and they round on the patient. They get them started on a bowel regimen. They get them started on permer and vaginal cream if they're going to be breastfeeding. They get them started on pelvic floor exercises. They give them realistic expectations about what to expect in terms of sexual pain, bowel symptoms, et cetera. They give them a business card, and they schedule a two-week follow-up at our clinic. And then they monitor the perineum for wound breakdown, et cetera. And you know, so I get a couple of fistulas a year. I get some perineal revisions out of it. The patients get first-class care, excellent care from our nurse practitioners who actually really enjoy taking care of these patients. In fact, I'll tell you kind of an interesting story out of that. When we opened up that Healthy Bottoms Clinic, the very first patient we saw was a faculty member in the internal medicine department in our university, and this is, you know, 12 years ago, 10 years ago. And my nurse practitioner came into my office and said, I'm seeing, you know, this patient, this Dr. So-and-so. She would really like to just talk to you for just a few seconds. So I walked down the hall and introduced myself. And she said, you know, this is my third baby, and so I just have one question. I had a significant tear of the first two, and nobody gave a damn. So what changed? Why is it all of a sudden you guys care? And I thought, that is really interesting because, you know, that's not how I perceived it, but that is how a patient perceived it, that we had not really paid a lot of attention to pelvic floor trauma and OB. Anyway, that's been a really big part of our practice, and I'm hoping the downstream benefit to our practice is going to be, you know, this 23-year-old who has a baby who got excellent care after she had a third or fourth relaceration, when she's 35 or 39 or 42 and she has stress incontinence, she's going to remember how we reached out to her and took good care of her, and she's going to come back here and let us take care of her for her urinary incontinence complaints, for example. Are you willing to perform joint cases? This is an interesting question, too, because I'll tell you, when I got here, all the generalists wanted to know if they are following a patient with prolapse and needed a hysterectomy, would it be okay if we did a joint case and they did the hysterectomy and I did the, I came in and did a ball suspension A&P repair or whatever, and I said, sure, that sounds good to me because I wasn't busy and I wanted to get busy quickly, and that was not a good move. What I learned real quickly was that, you know, 80% of the reimbursement goes with a hysterectomy, which takes 25 minutes, and 20% of the reimbursement goes with a two-hour dose of vaginal reconstructive surgery. So we renegotiated after about a year of that, and the generalists and I have this agreement now. If the patient's primary complaint is pelvic organ prolapse, you send the patient to me and I do the entire procedure. If she has a cysticeal or stress incontinence, for example, but her primary complaint is abnormal uterine bleeding, okay, you do the hysterectomy, I'll scrub in and put in a sling or fix a rectocele or whatever, and that agreement has actually worked out, I think, very well. They're very happy with what they get, and I end up doing, you know, 90% of the hysterectomies that way. What is, what's your vision? I recommend, as you're developing your vision, I recommend listing the key points of your vision in bullet format, something, a document in writing, because I think that really helps you to make the case to somebody that's going to provide you with resources that you actually have a thought-out plan. You don't just have your handout for personnel, equipment, staffing, whatever. You actually have a plan. Share this document during your interview, obviously. My chair was, I felt like when he, when I was going through the process with him about the things that I thought I needed in terms of square footage or personnel or staffing or equipment, et cetera, he was, I felt like he was on my side, because I knew that if I'm successful, he's successful, and I knew that he knew that, so I think most chairs will give you a realistic idea of what they can and can't do, and I don't think it's, for the most part, and I can't speak for every chair in the country, it's not a contentious, you know, negotiation kind of thing. It's just being realistic. You know, we can do this, and we can help you in this area, provide these resources, but in this area, we maybe can't. That's not realistic. We can't do that in this health system. We're not set up to give you, you know, 15 RNs in your clinic or whatever. For the workshop, we sent out a computer-generated questionnaire asking people questions that we thought would help us to kind of get our slides honed down to what people wanted to know, and so I'm just going to show you a couple of the questions that I asked and what the responses were. It said, what is your biggest strategic challenge in setting up and or running your practice? And you can read the responses, but, you know, performance of support staff, you know, the right balances, that clinic template, you know, new patients versus follow-ups, and when should you double book, and how do you follow, what metrics should you follow, and how do you collect the data for those metrics? What about marketing? And, you know, I'll let you read the rest of them. It's interesting on both this one and the next one, the electronic medical record came up. A lot of people, I think, are frustrated about the documentation burden, and it's the same here. We've, I'm not going to go into it tonight, but we've actually figured out some ways to be smarter about documentation that has actually been very referring position friendly and have helped us in other ways as well. And then I asked what, and that's strategic, and this asked, what's your greatest or your largest operational challenge on a day-to-day basis? And some of these things are very insightful. People are thinking about, you know, how do I allocate my time, and how do I manage patient flow through my clinic? I mean, these are all things that individual, you know, that are specific to a practice or a type of practice, academic versus non-academic versus even a military practice, for example. Things are done differently. But these are questions that you need to consider when you're looking at the efficiency in your own practice. What do you need? You need, I think, a very detailed written document that's going to have a lot of things on it, like equipment and staff, nursing, et cetera. I uploaded as a handout for this webinar a document that's about eight pages typed. I'm a little bit embarrassed for you to read it because it's 13 years old, and it was written by a second-year fellow, me, when I was trying to negotiate for this job at the University of Missouri. So if you decide to download that and look at it, the details about what types of equipment I asked for and stuff are probably a lot of it's laughable because you wouldn't ask for it now. But the reason I want you to see that is because I want you to see the level of detail that I went to to convince them that I had really thought through what would be necessary to make my practice successful. So I had a separate document. It was kind of a vision, and I don't know what I've done with that document. But the document that I uploaded was a document of things that I needed to support that vision. So the first thing to do was to get my chair and my health system to buy into the type of pelvic... Oh, by the way, I should also say the University of Missouri had never had a pelvic floor surgeon before ever. So I was coming into a situation where they had no idea what they needed or what they wanted, which was, I think, put me at a little bit of an advantage. They were asking me to advise them on what we needed. So I really had to tell them, educate them on what we do and what kind of things we can add to practice. But anyway, so that list that you can download there on the webinar is when I negotiated with my chairman, kind of the last negotiation I had before I decided to come, I pushed that list across the table to him, and he already knew what my vision was. He knew what type of practice I wanted to build and how I could fit in with the rest of the department and help the department. He flipped through that eight-page document in probably 30 or 40 seconds and said, we can do this. And that was the end of the negotiations. He said, this is possible. So again, I don't think it was... I think what made it easy for me or what made it work well for me was the fact somebody was sitting across the table from him who had a plan, who had an actual written document of this is what is going to help this department to be successful. And then just kind of last slide here, and I already said this before, to the extent that it's possible, and it's not 100% of the time, but I occasionally have to see a return for some reason, but to the extent it's possible, do not use your time seeing return patients. If you do that, you're not practicing at the top of your license. Somebody else can manage pessary. Somebody else can refill anticholinergic medication or whatever. You don't need to be doing that. Use NPs and PAs for these return appointments. And I already mentioned before, structuring your clinic template for efficiency. Have a day that you just see new patients all day long. Have a day that you see pre-ops all day long. My partner is new. I just hired her at a fellowship. And so she sees news. I like to keep her close to me so I can help her. She sees news all day long at the same day I do. She's in the OR the same day as I am, etc. But as soon as she's more comfortable, we're going to change that so that patients have more choices about what day they can come for a new patient consultation and what day they can schedule surgery, etc. And so I think if you have a partner, it's a good idea to not both be doing the same thing on the same day. But at least in our practice, when we set up kind of these homogeneous clinics, all new patients, all pre-ops, all post-ops, etc., it really helps us to be efficient. Pre-op, post-op. I don't know, you know, some of the people in this webinar, I don't know who else is listening, but some of you may be in metropolitan areas where all your patients come from within three or four miles of your clinic. Some of you may be in situations like me where you've got people come in from three or four hours away to see you. If one-stop shopping makes sense for your practice, I highly recommend it. It's really helped us build our practice. And this is really important, I think, too. I've gotten a lot of good feedback from referring providers about my ability to communicate back to them and let them know, I saw your patient, this is what I think's going on, she'd like to have surgery, or she'd like to be managed without surgery, or whatever. And I think they really appreciate hearing back from us. I found in my practice, we have found here in this practice, that the best referring physicians are actually, I would say, two categories. One is family medicine, and the other is mid-level providers. In the state of Missouri, we have a lot of rural, federally qualified health clinics that have nurse practitioners in them, which is, I think, mandated as part of the legislation that funds those clinics. And some of my best referrals come from nurse practitioners. The referrals I get from OB-GYNs, I would say, are categorically the worst referrals I get. A lot of them are, the patient came in with uterine prolapse, the general OB-GYN doctor did a hysterectomy, and then sent the patient to me after the post-op appointment when she still had, predictably in my mind, post-hysterectomy prolapse. And so, some of the best referrals we get are from our primary care colleagues, and I've really developed a good relationship with them. And I think I'll stop here and just, I don't know, I'm happy to go back and look at any of the slides, you know, scroll back, or answer questions, or even talk about something that you want to know about our practice that I didn't even bring up. Thank you very much, Dr. Foster, for an amazing presentation. I'm looking, and there are a lot of people engaged, and there are several questions here, so I'll go through a few of them with you. One of them is, how many rooms do you have in your clinic per MD, and how do you structure that? Okay, so we don't need, we have four consultation rooms, we have one room set up for teaching on a pre-op day, the nurse goes in there with the patient, does all the pre-op teaching, including learning how to self-calf, it's got handouts, videos, all kinds of things in that room. And we have two rooms set up that are labs for urodynamics and cystourethroscopy, Botox, all that kind of thing. And then we have four rooms set up for pelvic floor rehabilitative therapy with all the biofeedback equipment, e-stem equipment, all that kind of things in there. So the four consultation rooms, when Danesha, my partner Danesha and I are in clinic the same time, we each get two, but we only see 10 patients a day. Remember, we're not doing 15-minute return appointments. We're seeing 10 new patient complicated referrals. We each see five in the morning and five in the afternoon, so we see, between the two of us, we see 20 new patients on Monday, and we do that with four exam rooms, and it's 20. We don't need more than four. It works very well. Yeah. Can you go through a typical new patient's visit? Do you get a PBR or UA on each patient? How does your administrative staff acquire the records, and how do you ensure that the new patient packet is filled out, etc.? Yeah, so what we try to do, and usually we're booked far enough out that this works well, is we try to mail the packet to the patient once she's referred to our practice from, you know, Dr. So-and-so, and the packet has a bladder diary in it, a three-day bladder diary, instructions on a 24-hour pad weight, if those two things are applicable to them. It's got the PFDI-20 in it. It's got the PFIQ-20 in it. So they walk in and check into our clinic, and oh, it even has what's called fold-a-cup. It's like a graduated cylinder that you can mail flat, and it folds into something you can pee in to measure your urine for bladder diary. So they walk in. They hand a three-day bladder diary to my check-in clerk. They hand a Ziploc bag with their wet pads, which we provide in the packet that we mail out, and they hand them a clean pad that's, you know, in the wrapper still so that we can subtract the dry weight. They hand the PFDI-20 and the PFIQ-20 to the check—all this stuff gets handed to the check-in person. I know their pad weight before I even know if they're African-American or white or Hispanic or whatever. I mean, so I get that information usually before I walk in the room, and hers has got that ready to go. I walk in the room, and my staff has collected records in advance, which I usually look at the night before clinic, not the day that I come in. I usually try it before I go home to flip through the notes for the people I'm seeing the next day. I walk in. I introduce myself. I tell them that Dr. Jones sent records. I had the chance to sit down and look at the records, and I'm really happy that you're here to see us for prolapse or whatever. And then I usually ask the patients, because we try to be very efficient, I usually don't have an open-ended time for them to talk in the very beginning. I start off the conversation by saying women use their pelvis for three things—bladder function, bowel function, sexual function. If you don't mind, I want to ask you about five minutes of questions about symptoms in those three areas. And I go through, and we have kind of a little scripted thing we go through with the patient. I get all that information in four or five minutes, and they agree not to interrupt me and let me do that. And then I say, okay, now you tell me anything that I didn't ask you that you think is important that you want to talk about. And then we kind of go into the open-ended part, and what I find is that most patients say, gosh, I think you've covered everything that I'm concerned about—my bowel movements or my getting up at night or, you know, whatever. Or sometimes I'll add a few things, and then I have them go to the bathroom. I step out, and while they're going to the bathroom, I dictate about 80 percent of the note—everything but the physical exam and the assessment in plan. And then I walk back in the room. I put them up in stirrups. I get a PVR. Every patient gets a post-void residual assessment. I consider that part of the physical exam in a pelvic floor patient. Every patient gets a pop-Q exam. Every patient gets pelvic floor muscle strength testing. We use the modified Oxford scale for that. And then if there's—you know, if they're sent here, obviously, for a fistula or for, you know, diverticulum or whatever—whatever targeted exam I need to do based on, you know, a particular complaint that will occur, I examine everyone for atrophy, obviously. And then I set them up, and I say, you know, this is what I hear you telling me. This is what I see on physical exam. And I try to repeat all that back to them so they feel like that I actually did listen to them, and I understand that they're really upset about a lot of nocturia or whatever. And I understand that, you know, and I explain to them that we have a staging system, and it's kind of like cancer, but nobody dies of prolapse. And you have a stage two cystic seal, you know, and kind of try to put it in terms they understand. And then I say, you have three choices. You can do nothing, you can have non-surgical management, or you can have surgery. And I pretty much say that to every patient we see, and because we're pretty smart about the way we schedule patients in to see the surgeons for new patient appointments versus new patient appointments with the mid-levels, probably—I saw—I saw in one no-show this Monday, and so I saw nine patients, and I sent seven of the nine for pre-op. So I saw two people that wanted non-surgical management, seven people wanted surgery. So then—so then if they want surgery, I put the orders in for—I give them their primarine cream and their, you know, their PAL regimen that we want to start them on, for example. I send them up to the front desk to schedule a pre-op appointment, and then I see them back on a subsequent Tuesday, which is the day that I do pre-op evaluations. And by the way, the other good thing about doing pre-ops on a single day is that a lot of our pre-op patients will get some kind of study, urodynamics or systole or something, and you really need extra nursing support for that. So it really helps us to plan for nursing support by—by batching all that together. Does that answer the question? Yeah, that—that was really a wonderful overview of a very efficient and productive clinic. One of the other questions here is, how many urodynamics or systoles do you end up doing on your pre-op day? We have enough time to do six. Okay. So I do six—and a lot of times I'll double book my pre-op slot so that I'll have a—let's say a patient is pre-oping for a rectocele repair, and I have another patient pre-oping for a blue plate special—TBH, AMP, sling, systole, et cetera. So I know that the one that's getting the blue plate is likely going to have—is going to have urodynamics. The rectocele repair is not. So the nurses can be doing the urodynamics and all that while I'm sitting down with the rectocele signing consents and whatever. So we kind of just plan that out so that we can get—usually can get—at a minimum, get six pre-ops done, but usually we can get 12 done on a pre-op day. Yeah. We have a question regarding compensation. What are the goals that you usually set for compensation for your advanced practitioners? So that's a hard question because when I came here, the way our chairman pays the faculty, for example, is he looks at our market potential. He looks at the—what is it—AAMC 50th percentile data and all that, and there really isn't—there is data for nurse practitioners, but there really isn't any data to guide you on nurse practitioners that do pelvic floor stuff. And so I just kind of took a guess on the first one I hired, and I mean, I'll tell you now, I think the lowest paid nurse practitioner I have, I want to say is $83,000, and the highest is $90,000 or $89,000, maybe something like that, and we expect the nurse practitioners to cover their salary, and I tell them that when I hire them. So you're going to be doing a lot of procedures, pessary fittings. You're going to be doing interstem reprogrammings. You're going to be doing biofeedback and rectomanometry, so it shouldn't be that hard for a nurse practitioner who is efficient to cover her expenses, because the way we run things in our department, if a nurse practitioner is at a deficit, that deficit gets charged to the physician. So I have four nurse practitioners, and let's say between the four of them, they have a $20,000 deficit with their expenses. Then my partner and I each get $10,000 deducted from our bonus. So I have an incentive to make sure that they're working productively, so that's why I have a very, very clear conversation with them when I hire them about you are expected to cover your expenses, and we review that every year at their annual review. We have time for one more question. Can you help us understand the case that you make to the business administration for RNs versus LBNs or MAs? Yeah, so that was a tough one. I'm going to tell you what was really going on versus some of the things that I told them in addition to what was really going on. In our community, in our health system, I don't own my clinic. I work for the University of Missouri, and so it's a hospital-based clinic, which means that the nurses actually work for the hospital. I mean, they report to me, and I evaluate them and all that, but they are paid by the hospital. Their salary is set by the hospital, and because of Walmart, it pays so well in our community, we were having LPNs leave to go work at Walmart, and they were some good nurses. They were good people. They liked us. We liked them. It was purely kind of an economic thing, and it was just the turnover was getting insane, so that was what really started me wanting to get a higher level of nursing, but in addition to that, the nurses in our clinics do real nursing. I mean, they don't just blood pressure put a patient in a room. Our nurses do a lot of teaching, a lot of preoperative and postoperative teaching. We get over 130 phone calls a day for nurse callbacks. We do, you know, the nurses do a lot of procedures. I mean, without the doctor present in the room, the door's closed, so when I explain that, what we're really hiring is procedure nurses. I explain to them our phone volume. I explain to them the complexity of the patients we see. I'm not seeing a 20-year-old that needs her tubes tied. I'm seeing an 81-year-old who's on, you know, 13 medications, who's got heart failure, who needs a complex surgery, you know, et cetera. They saw the wisdom in having nurses that were more stable that would stay with our clinic, so they converted three of my six LPN positions to RN positions, and that just happened about three weeks ago, and we just hired the first two, and they started, actually, one of them started today. The other one starts Monday. Wow, that was incredibly, incredibly helpful, Dr. Foster. On behalf of the Augs Education Committee, I'd really like to thank you for this amazing presentation. To everyone here, I'd like to remind you that our next webinar is titled Vaginal Repair of Urinary Tract Fischla, and will be presented by Dr. Grace Chen on November 13th, and thank you again, Dr. Foster, for all those valuable tips and tricks. I'm sure everyone here really, really appreciated it. Thank you for having me. I enjoyed it.

Urogynecology Office Practice

Practical Tips for Success

Dr. Raymond Foster

Mesquite, Texas

University of Missouri School of Medicine

Urogynecology expertise

Clear vision for practice

Setting goals

Efficient clinic templates

Effective communication