Hiring, Onboarding and Training APPs Save

A group of experts and interested parties who are gonna talk about, I think, the really the first step in this, in delivering better health care for where you practice, where I practice, and that is sort of the hiring, onboarding, and training of APPs. So, I want to thank the sponsor of our, I'll thank the sponsors at the end, and we have a bunch of sponsors who've been very kind and very interested in supporting all things APP. We're gonna begin by, having our faculty tonight introduce themselves. Kayla, why don't you start?

I'm Kayla Alexander. I'm a nurse practitioner in rheumatology and I work with Doctor. Philip Meese at Seattle Rheumatology Associates.

And Corey.

Hi, I'm Corey Dooing. I am a rheumatology nurse practitioner, adult nurse practitioner. I work at the University of Washington clinically, but I also teach in the School of Nursing here at the UW.

Excellent. Doctor. Meese. Hello, Jack. Thanks for having us.

My name is Philip Meese. I'm a rheumatologist based in Seattle. I work at Seattle Rheumatology Associates, but I'm also involved at a national and international level in research education, particularly in the PSA and spondyloarthritis arena, but also now increasingly in CAR T cell arena and treating lupus patients, for example. And I've been one of the, I believe, longest advocates for use of advanced practice practitioners or APPs in the country really, starting back in the year 2000, when I first started working with a nurse practitioner. And now I work, with a trio, two nurse practitioners and one physician assistant.

So we are a quartet for, in the care of of our large rheumatology patient panel. So I'm delighted that Jack is is embracing and encouraging and supportive of of this movement, which I think is going to be really important for delivery of rheumatology care in the future.

So I think that's a great beginning because I want to start right there actually. How did we all come together? And so let's go back to Corey and Kayla and ask you both how did you get into rheumatology? I mean, you could have made a whole lot more money going somewhere else. Right?

How did you end up in rheumatology, Kayla?

I actually found out I have axial spondyloarthritis myself. And I found that out in my first quarter of nurse practitioner school. And Corey happened to be my instructor at the time. And so I had kind of a crash course learning rheumatology. But I think I would have found my way to rheumatology anyway, just because the diseases are so fascinating to me.

Just the continuity of care and getting to see people actually improve is really satisfying.

Corey. Yeah, so when I started twenty three years ago, I had a mother who had rheumatoid arthritis. I had a bachelor's degree in biology, so I loved science. I had a friend who graduated just before me in the program, had looked into a practice that was a part time position and said she loved it. She couldn't do it though because she needed full time.

I interviewed there and it was rheumatology and I thought, you know, I want to go into chronic disease. I certainly was not intimidated by rheumatology as a specialty. And what I loved about that practice at the time is that there were other nurse practitioners there who could help me model my role because as a nurse practitioner in rheumatology back then, was pretty unusual. And so that's how it all started. It was actually with Philip.

All things go through Philip. So were the advanced practice providers felt thrust upon you in the beginning or did you choose to hire one and why did you?

So the very first nurse practitioner I worked with was actually on our end at the time before she went through training to be a nurse practitioner. And so I've been a long term working with me in that capacity. And then she started, doing weekend and night school, at a local university to become a nurse practitioner and then stayed with me. But, what ended up happening is she became so good at what she did and a really charismatic person. And and so she was picked up by the pharmaceutical industry people to and went on and into pharma.

And then Corey and I worked together. And then over time, what I've found is that it's just I can't even imagine being able to practice without working with an APP that by by my side for so many reasons, not just the fact that I'm lazy and and and hate keeping records and all that sort of thing and can't figure out how to order an x-ray. It has more to do with the fact that I feel like the patient is getting the best care when there's always someone here in the clinic and not gallivanting off to ACR meetings and whatnot. And then also the fact that think of age and sex of many of our patients with rheumatic diseases, younger females. And I think that they see me as a person with a lot of experience, hopefully a certain amount of wisdom, some gray hair certainly, bringing in that to the care program.

But then they've also got someone that they can really relate to emotionally and be at their level as they go through experience of their disease. I think it's the best overall way of delivering care to our patients.

Oh, in my fellowship, Artie Cavanaugh was a little bit behind me. Our chairman was Peter Lipsky, and we were gonna get into translational clinical trials and biologics and all kinds of things. And Peter's first hire was to steal a nurse practitioner from the hemophilia clinic that he knew through his wife who was working in the hemophilia clinic. And I knew nothing about nurse practitioners. And I quickly learned, I got to work hard to keep up with this woman.

She knows way more about how to get stuff done and how to take care of patients than I do. And together, we all learned how to do clinical trials. And we were amazingly prolific in that. But in addition to that, we were learning rheumatology at the same time. So after twelve years at UT Southwestern, I moved on to another teaching program in Dallas, and my first hire was a nurse practitioner.

And it was the best hire of my life. I've probably in my career, I probably worked with about four or five. And every time it's been a home run, meaning they just make everything better. They make me better. They make the patients happier.

They're glue for the clinic there. It's just been such a great delight. And this is our motivation, both Doctor. Meese and I and Corey and Kayla, to be out here talking about APPs, what we can do, what we can do together, how care can only be better when we have, I think, a full contingent of people who really, really care. So that's what we're doing this month in Mission APP Partners in Care.

I do want to thank the sponsors of these four Tuesday night rheumatology sessions we're going to run 7PM Eastern Time. That's the four sessions we're going to do. We have five sponsors, AbbVie, Eli Lilly, Johnson and Johnson, Novartis, Sanofi, and kudos to them for making APPs a priority. So tonight we're going to talk about hiring, onboarding, and training, sort of like the first step that you need to consider. A lot of this stuff I didn't know, and we're going to have discussions based on a survey that I did and RheumNow did yesterday, a one time survey, we got 91 responses, almost 80% rooms and 20% APPs.

And there are differences in how these are going to be answered between rooms and APPs, but you can imagine that. But most are from private practice, 20% from academia, 10% are hospital based. So we went into this asking a number of questions, but I want to sort of set the stage. Recent stats from the Bureau of Labor show that NPs and PAs are in the top 10 of the fastest growing occupations in the next ten years, going up to thirty, thirty four. They expect a 40% growth in NPs and 20% in PAs.

The median pay in 2024 is about 130,000. And the new jobs that are going to be added in the next ten years is 128,033 respectively. Why? Well, we know there's a tremendous shortage in healthcare for providers, really in rheumatology, there's a gigantic shortage, that's only going to get worse. I mean, I keep reading the manpower reports and they're just not good.

So the good news is that over time, APPs have had an increasing role in delivery of healthcare, you know, more so in specialty care than in primary care. And that's where we see the benefits. We know that they're influential. Everyone tells us it's so. Those of us who work with them know it so.

And, you know, they'll see pharma reps just like we will. I think they're a little more likely to see pharma reps than we will. That number used to be about 80% for MDs and is now down into 60s and 50%. It's about the same for APPs, but I know as a group, they're highly influential. So I asked the question, how would you recruit an APP into your practice and how would you interview an APP?

And when I look at these results, and these are the results of about 88 on average, some of these are about 70 respondents. I think that it basically says most people don't know what they're doing. They said, job postings, right? I mean, how are you going to find? And then how are you going to find a rheumatology fellow?

Good luck with that. Well, you go to a program, you'd ask around, how are you going to find an APP? The options are here. You could do job postings, you could get involved with the APP training programs, word-of-mouth, hire a recruiter, social media, no one knows really how to use. No one really thinks that salary and signing bonus are influential.

When in fact, they're incredibly important as our incentive packages. And then the next question is, who should do the interview? Who should choose your APP? If you're someone experienced like the four of us, and you're doing the interviewing and the choosing, it's not that hard. You know the skills, you see the interest.

What did we hear from Corey and Kayla? They were motivated. You know, they're problem solvers. They're interested in one on one care. They didn't rush to get a hospital job or an ER job.

They went with outpatient medicine that suits their style. In some places, it's a committee. And again, most of these 80% of the answers are coming from rheumatologists. APPs actually chose a higher number of APPs. It was like 40% would say that APP should be doing the hiring for other APP jobs in their center.

And then the question I asked that mirrors something I asked back in 2017 is, what's your next hire? In 2017, everybody was waiting to hire another rheumatology fellow. They don't exist. They're zebras. They're unicorns.

They're hard to get. And very few people were thinking of APPs. It looks like here in this survey from yesterday, that more are considering a PA or nurse practitioner, 45%. Back in 2017, more than half, 58% were not hiring an APP to meet their clinical demands. Now, it's only about a quarter are not hiring.

But there's still a lot of holdouts for experienced or inexperienced rheumatologists. One more slide. Well, I wanted to stop here because Corey actually published this and looked at this issue recently in the recent episode edition of the rheumatologist. Again, just came out days ago, tips for recruiting and onboarding advanced practice providers. Corey, do you want to start to address this question and how people should, how we should go about hiring people and what are the important first steps?

Right. I mean, I think that there's no right or wrong way, obviously, but I do think that there are sometimes ways that you can, get into finding out who's available. You know, practitioner programs are present throughout The United States and there are intense needs for clinical practical people to work with them for their clinical practicums and is Most of these times they just need a few hours, a few days just to observe to see what rheumatology is like. It's a fantastic way for them to get exposed if for no other reason that they're going to be making referrals into rheumatology if they're working in primary care. But also it's a way to see, could this person be somebody who's interesting and might be a good fit for my particular practice?

It exposes you to a variety of different students and then the word-of-mouth with the students and their own cohort. Maybe they don't want to go into rheumatology, but just like in my case, they might have somebody in their program who's interested in that. I think that's by far the best way. Most of these programs have capstone projects, and so presenting if there's a clinical problem that needs to be solved within your clinic, getting free labor, a doctoral student to help you with that project is a great way to introduce a student into rheumatology. And most of this is by word-of-mouth.

There's getting to know who's out there in the nurse practitioner nursing field is a great way.

When I was hiring my, I think my second or third APP, I asked around, I called the program, I asked other APPs, and amazingly, the same name came up, Leilani, Leilani. And I interviewed her, hired her, and everyone said, How'd you find her? How'd you get her? Because she was like, everyone knew how good she was. Philip, what's been your secret to having so many skilled and wonderful providers join your practice?

How does that work?

Well, let's see. I think, first of all, there's a community of APPs within the Seattle region. At least one of the PA that has come to work with us was working in another rheumatology practice, thought that the grass was gonna be a little bit greener on this side, and so came over and joined me. And so that was one way. Another was Lynn, our nurse practitioner who had moved here from Florida, had been in primary care previously but then saw a posting that we had put out and came in and realized what a rich and incredibly varied experience it was to work in rheumatology with our immunologic diseases and the various protean ways that of symptom and sign manifestation.

So it became a bit of more of a challenge and an interesting one than than what she was experiencing in primary care and so came on board. And then Kayla was actually introduced to us by Corey who we're very grateful to for having made that introduction. I think Kayla's had an opportunity to work with several different rheumatologists. And I asked her earlier today, sort of what what perceptions of differences between our styles, my style and working with her and teaching, that sort of thing versus as compared to others. I'm wondering, Kayla, do you want to make a few comments about that?

Because I think one of the things that I've heard over the years is if you bring in a nurse practitioner and then end up funneling all of your fibromyalgia patients to them, then that's awful. Now that's not what you wanna do. And or just have them see, you know, some routine follow ups, that need methotrexate monitoring. I think that the really exciting thing about working in rheumatology has to do with really getting deeply into complex diseases and then working as a team together to to care for those patients. So back think to Kayla, comments you wanna make about differences?

I think

I have had several onboarding experiences now and all of them have been vastly different, but all of them have also been very positive. And I think the commonality between them all is that the rheumatologist I was working with, each one of them was so supportive and available to me and enthusiastic about my learning. And so it really didn't matter, even though the actual mechanics of the onboarding and getting my schedule going and number of patients being seen per day, all of that was so different. But I felt great at every single job, every rheumatologist I've worked with has been so good. And it's been because of the support.

Oh, without getting into training yet, because we will get into training. What has the onboarding process been? Does anybody here want to advocate for hiring an APP and then giving them, you know, four weeks of protected learning time before you throw them into the deep waters of a cutaneous vasculitis or something like that? Or is it active mentorship? Kayla, there must have been other APPs behind you that were basically looking for words of wisdom from you at the outset.

How did you handle that?

I think the key to success is working together to figure out what the needs are of each person. And when I had first started, I did a nurse practitioner residency program and then went into rheumatology after that. And I knew very little about rheumatology then compared to what I know now. And so, there was through the ACR, there's an APP fellowship funding opportunity they have where the rheumatologist can take on a new APP that has not been in rheumatology before, and they get funding to set aside time in their schedule for that for precepting. So, I didn't have anything structured like a month set aside, but it was more, you know, an hour at the end of the day to go over the patients or sometimes in the morning before seeing the patients so that the rheumatologist had that paid time, they didn't have to overextend themselves.

I think that as a general template would work pretty well for most people.

In your article, you mentioned this, the ARP division of the ACR, you're past president of, has an NPPA onboarding toolkit. What does that entail?

Right. So there's an NPPA curriculum guideline that's been developed based on the ACGME template. It is a document that outlines those areas of training that should be considered for a new NP or PA entering into rheumatology. And it was crosswalked with the various learning opportunities within the ACR, ARP to make sure that we covered all of those areas with learning tools. So it really is kind of a checklist of things that should be covered.

Philip, what's the first month look like when you hire an APP? What are your A

lot of shadowing. A lot of shadowing. So it currently is the case that each of our APPs sees each new patient kind of like a fellow would and then comes in, discusses them with me, then I go back in and we see the patient. We do the same thing with the second visit. And then after that it becomes, it really is varied.

So in some instances the APP is completely able to manage a patient ongoing without needing to see me or maybe seeing me once a year or once every half year. And in other cases, the patient and the APP are more comfortable with me seeing the patient every time. So it really varies a lot. But back to the beginning stages, a lot of shadowing and a lot of just spending time teaching about how to do a joint exam, looking at a skin lesion together and trying to think about what does this represent, thinking through the differential diagnosis together. It's very much like admittedly how you are with fellow when you're teaching them and then as they gain more and more deep knowledge and experience, you don't have to go into that in as much depth.

Yeah. So the other, I'll add to that by saying, they need to know the standards of care. They don't need knowledge, they can get the knowledge, you're going get the knowledge, but they need to know the thinking, you discern this from that, when you start thinking outside the box, when things are not classic, are the, you know, that kind of things. Just some numbers on who employees and how many are employed. In 2017, a survey of two eighteen rheumatologists mostly said that, again, 48% were not employing an NP or PA.

Well, I recently did that just yesterday. And you can see the numbers here. The numbers that have employed no is down to 26%. So there's been this slow increase in the numbers who are employed. And it's not just one.

It's sort of evenly split between one APP, four or more APPs, two or three APPs. That's pretty interesting. And when I asked the audience, how many APPs are working in The United States? No one really knows this number. I can tell you at RheumNow, our registration list is about 1,000.

I think I know for certain it's over 1,300. I believe the number is probably 2,000, but I think nobody really knows. Any of you have any crystal ball here as to how many are out there? Nobody does. Okay.

So who do you prefer to work with? Again, in 2017, it was 65% wanted the young rheumatologists, and only 31% were waiting for an APP. I did a survey in 2025, that's the one yesterday. Who are you most likely to hire next? It's split.

And people are looking at APPs as much as they're looking at fellows. But when you ask them pedal to the metal here, when you're thinking about rheumatology manpower, who's going to do that? Most people still think it's by a hair actually, going to be training more rooms. And the good news is rheumatology training programs are up 28%. Rheumatology positions and applications are up 52 to 58%.

And that's all good, well, and fine. But we're going to get into training. Back in 2017, 70% were trained according to rheumatologists receiving on the job training. In 2025, a survey I did, I think about eleven months ago, you can see that the number is about sixty plus percent are still getting on the job training. Right?

And then when I asked the next question, how should they be trained? It should be coursework, mentors, and on the job. Corey, do you want to comment on this?

Well, I would agree. I think that there's become much better opportunities for learning for APPs. These courses didn't exist when I first, came into the field and now they really are really focused towards the learning needs of nurse practitioners and PAs. So this coursework can be very foundational, but it certainly requires additional ways of learning.

Okay, let mentioned that she did a residency, there are fellowships out there in Connecticut and in North Carolina. But then there's all this coursework that you can do. The ACR has got a modular approach called the advanced rheumatology course that you can sign up for. The RAP website, rap.org has a really good number of modules covering the expansive rheumatologists called into their Step Into Room program that you have access to if you're a RAP member. And then there's another ACR online curriculum for residents that might work for APPs as well.

And APPs can get certified in musculoskeletal ultrasound, which can be a valuable way of learning and becoming excellent at rheumatology. Kayla, what's your recommendation as far as training?

I did all of those things that you have listed there. I also did the board review certification course for rheumatology fellows, which I felt was very good. It was so structured, you know, every disease state. And those the ones that you have listed, definitely used as well, but I think more for reference, like picking out different topics. But yeah, got all the rheumatology textbooks.

I read every one of them, I think that was available to me the first year and went to conferences. And it was definitely a commitment that whole first year. But all of those are very good.

I think if you had access to the ACR course and the RAP courses, and you engage them based on the patient you saw today, that's tremendous way to learn. As opposed to trying to learn all of rheumatology, like you're studying for the boards, that's not the best way to learn. Philip, what were you going to say?

I was going to say that, yes, this is, using a word that Corey used, foundational and important. But so many of our patients don't fit into a textbook, and we use that phrase a lot, and the many undifferentiated states and subtle differences in the way patients articulate their symptoms. So I think all of these things are important, but the other, the key thing is being in the room with the two of us together and hearing how we both interact with the patient, how the patient articulates their symptoms and signs, and then hearing how, I mean, when I'm thinking about a patient and their diagnosis, I've got all these forty years of experience to bring into it. What Kayla is doing is tapping into that. She can see the thought process that I go through.

And I think that there's nothing quite as important as that, having that time to see the thought process that an experienced rheumatologist goes through.

Yeah. So this is a little out of place, but independence is a big thing in the advanced practice world. Rheumatologists in 2017 said that only 9% of their APPs are independent. That's changed over time. Now it's up to about 26%.

I'm sorry, it's only 17, but it's a doubling. But most people that are practicing are mostly independent with back round support from the MD, but a minority are being co managed. And then it's also reflected here, a new patient consult comes in, how comfortable are you with letting the advanced practice provider see that patient? It's either a very common or common practice. That's 58% of the audience that responded here thought that that's the way up.

25% said never, meaning they're doing what Philip was talking about. They're going to use the APP to see OA, boring follow ups, fibromyalgia, gout that hasn't had a flare in twenty three years, you know, that person is leaving your practice. You know, you spend a lot of time, money, effort, and interest in training that person, and they're going to leave your practice unless you make them help them to be an independent practitioner just like you. And the last question had to do with salary. We asked people, what's the starting salary?

I don't think most people know this. I remember hiring APPs back in the 90s and thinking, my God, we're paying them 65,000 a year, you know, like it was, you know, selling, giving away the bank or something. Well, it's gone up quite a bit and as has your salary, as has everybody's salary. But you can see that most of our respondents didn't know the right answer. And this is the starting salary for a new hire, an inexperienced person at a school, maybe have some background, but a new hire.

And if you look at it across the board, you know, I'll show you some data on this and get some comment. This is looking at the, again, Bureau of Labor Statistics, new physician hires 239,000, PAs 130, nurse practitioners 126. And then this is data from Medscape on the left nurse practitioner data on the right physician assistant data. And that's where the right answer comes out to be around 130,000 as the first starting salary. You know, a nurse practitioner I hired back in 2017 was making 120.

That same person now is making over 150. You know, a new person hired today would be much still higher, probably 130, 135. The hourly rate full time according to Medscape was $92 an hour, part time was $86 an hour. Who wants to jump in? And Corey, maybe you should make the definitive comment here on salaries and where they're going.

I mean, I think this is a really hard question to answer because it varies so dramatically in different parts of the states or different parts of the country. So I believe if you look at the data, the West Coast has the highest salaries of course the, know, so it's hard to just look at one number for our entire US.

And I wanted to throw down a number just to put a stone in your shoe and let you walk around on it for a while as you consider the next NP or PA that you're going to hire. Kayla, would you be surprised to know that while most APPs have said that they're probably underpaid, the salary wasn't the main reason they took the job?

That's not surprising. No.

Yeah. I I was surprised at that. I would would think that, you know, that it would be the number one reason, but it was often like the number three reason, you know. And you want and they want it and most APPs want their salary to be competitive. And then it depends on the other incentives.

You get to work with Doctor. Meiss, you get to do research, you get to go to a meeting, and maybe there's other things that are part of the package. I

would say for students, the number one thing that they're looking for when they're graduating is support and a practice that will help them grow and learn, and they're not going to be left out in the cold. So if you're presenting that to your student, to a new graduate, that's what's going to draw them in.

I like that, which is why getting involved in the APP programs is really important. I started teaching at the physician assistant program in Dallas in the last year, and I love it. It's great. And maybe if I'm entertaining enough, interesting enough, maybe people will say, I should think about that rheumatology thing. And I'm very clear in saying rheumatologists are the happiest of specialists, and then you have to provide some evidence why.

And then if you can dazzle them in a lecture, that's great. But at least you're tied to the program, maybe you can make your influence there. Philip, do you want to make a final comment on this?

Right. So can you imagine working with anybody more interesting and entertaining than Jack? Can't.

It's absolute hell every day. It's absolute hell every day.

I would think that it would be something to jump out of bed for and come in to the clinic and say, What have we got going today, Jack? So, but in all seriousness, I think that it's important to develop a collegial, very respectful, and very involved relationship that where you can have interchange of ideas, you have the freedom to to say to each other, no, I don't think that's the right way to go here. I think we should go this way. And to be able to respect and understand and support. I think Corey's use of that word is very important in order to give that person real satisfaction and imbue them with the meaning of taking care of these patients who have such complex lives and their illness really impacts them.

And then as Kayla said earlier, to see them getting better with the types of transformational therapies that we have now, that's gotta be extremely rewarding. And I think that it's not a surprise to me that the salary may be third down the list compared to the richness, and depth of experience and relationships that are developed in a chronic rheumatology practice.

You know, we have a few comments. John Tesser, our friend from Arizona, who has worked with, you know, Paul Cush, as well, who's gone into retirement. But John and Paul and their group, they currently employ 50 advanced practice clinicians. 50. That's amazing.

And kudos to them for taking that on. They clearly have a lot of experience in this. Christian asked a question, at what point is it appropriate for an APP to see new patients? And is it the same across the board? My answer to that would be, you're going to know just like you would know in training a fellow.

I worry about brand new fellows being new consults, and I want to supervise them all the time. But you see competency and competency and you cut them loose. I mean, if I have truly a leukocyte classic vasculitis patient in Room 2, and a fibromyalgia patient in Room 1, the nurse practitioner is going into Room 2. And if it's a new patient, you know, we split them right down the middle because they can see him just as well as I can. And until you believe that and witness that, it is going to be a little bit of a question in the mind of many as Christian indicates.

The last thing I put up here was how to build job satisfaction. We kind of talked about this. Having competitive salary, mentoring, providing the APP an interesting scope of work or a challenging scope of work. The guidelines say that they should work with one or two as opposed to 22 physicians. That way they learn better and then you become a more cohesive team in delivery.

Investing in their ongoing education, and then as Corey suggested, dedicated time for feedback, whether that's before the patient, after the patient, or during lunch, those kinds of things. Corey, do you want to comment on this?

Yeah, I would say that I think one of the best things that I've found in my years of practice is having a dedicated time, whether it's Friday at lunch to go over cases that came up through the week. That's certainly very important. It just makes for a great way for you to come back to patients and say, Well, I'll be speaking with so and so on Friday. That's a good question that want to ask or something along those lines. It's a great support.

But I think another thing that's really important that is really underutilized is the mentoring and how important mentoring has been for helping to keep NPCs and PAs in their jobs. Mentoring can be with their physician colleagues, but I also think it's really, really important for new, especially new NPs, PAs in rheumatology to find another NP or PA to help them develop their practice style, to help them answer questions that come up, to provide that mentoring. That might be hard to find if you're a provider that is if you're the only NP or PA in your practice. So, making sure that you connect them with others whether it's through the national organizations or you know, in the case of Kayla and myself, you know, we we've stayed in touch throughout the years and I've provided some mentoring for her as well. Making sure that you promote that, as a very important aspect, think is key.

Jack, just to add one little thing to that is that if you have a practice where you're doing clinical research, if you have a practice out of which you're also producing academically by coauthoring articles, if you're in a practice where you're able to go and teach, give give webinars, that sort of thing, Getting the APP to be involved with that in in conjunction with your doing that is, I think, very rewarding from a variety of points of view. It it is a way of varying the practice so that you're not just seeing only seeing patients, but you're also teaching. You're also doing clinical research. You may I think that increases the interest level when, the nurse practitioner goes to the ACR meeting, for example, and sees some of their own research being presented. This is all, added benefits.

So authorship is a nice, really nice carrot for anyone in medicine. And then it's actually, it's another way of supplementing income. It's extra income when the APP is either the blinded examiner, is a co investigator, is a lead investigator, is doing the ultrasound, whatever, and you're going to get paid kind of 100% of what you should get paid as opposed to something discounted by insurance. And that goes to the APP. And that's basically part of the incentive package.

I was going say, Kayla, you work in a situation where you have other APs as a big support. I think that's really important because one, it's not just you complaining about Doctor. Meiss not buying good coffee, which he's known to not do, you know, sometimes. But now you got three of you saying, we're not coming in unless you buy better coffee. You want to comment on working with other APPs as a job satisfaction?

Yeah, I think that's been huge actually. I really can't overstate that because at my previous job, I was the only nurse practitioner, the only APP with two rheumatologists. And so coming in here, the two of them have been with Doctor. Meese for decades, and they really are like my older sisters. And I can go to them with anything.

And as much as Doctor. Meiss is available to me all the time whenever I need anything, they are as well. So, you know, their experience combined is invaluable.

Yeah. John Tesser has used an important word. Collegiality is basically the standard operating procedure when you have partnered care practices. And he says with the APCs, they see all the new patients and they present them to John or another attending just as a fellow would, and then they manage them. And sometimes they don't even need to present them, I would imagine.

So anyway, think that this has been really a very good session. I want to thank again our sponsors for supporting this in the weeks to come. Next week, we're going talk about room cases and how guidelines fit in. We're going to talk about APP controversies and misconceptions, and then end our month with comorbidity management in our rheumatic disease patients. So thanks to Corey and Kayla and Philip for an interesting discussion.

Please tell your friends about this. And again, RoomNow Live is coming up in February. You can register now. Good night, everyone.

We hope you enjoyed this TNR podcast devoted to advanced practice practitioners. This podcast was sponsored by AbbVie, Eli Lilly, Johnson and Johnson, Novartis, and Sanofi.