We're going to go ahead and get started. Thank you for still being here at 3 o'clock on a Monday. Welcome to the session titled Pulmonary Critical Care APP Fellowship Programs. On behalf of my fellow speakers, we would like to thank CHEST and the Association of Pulmonary APPs for inviting us to join you today. If you scan that QR code, you'll be linked to the AP APP podcast. I'm Rachel Adney from Stanford Medicine Children's Health, let me get that right, and I have nothing to disclose. Today we're going to be discussing the history and importance of APP fellowships and how to design, launch, and run a program in pulmonary or critical care. Let me give you a little personal background before I get started. So I am a pediatric NP who has been in practice for over 20 years, and I joined the faculty at Stanford 12 years ago in pediatric pulmonology. Quickly we realized that in order for me to become a provider who had the breadth and the depth to provide care to critically, medically complex children, a formal training program would be beneficial. At that time, in 2012, there was very limited options. So I created and completed an APP fellowship in pediatric pulmonology with the help of my physician colleague, Dr. John Mark. Okay. So let's jump into the what, when, and why of APP fellowships. First off, what is an APP fellowship? It's a postgraduate program designed to help APPs transition into a new role, practice setting, or subspecialty. They're typically a year long, and most are salaried or benefited positions. The goal is to build clinical and professional confidence and knowledge beyond what was obtained in school. Training is based on core competencies for specialty certification, sometimes mirroring an M.D. or fellowship model. The fellowships allow APPs to gain knowledge and in-depth exposure to complexities of specialty care and healthcare systems. They sometimes include a component of a boot camp, professional development, skill enhancement, and refinement, often through didactic and hands-on training. This can be especially important in departments where onboarding a new graduate is complex and difficult. Looking at the history of advanced practice provider postgraduate programs, as we all know, in the 1940s, the first APN roles were developed, including nurse anesthetists and midwives. In 1965, Dr. Loretta Ford with her physician colleague, Dr. Henry Silver, created the first official NP training program at the University of Colorado. And PAs began postgraduate fellowship training in the 1970s. Montefiore Hospital in New York introduced PAs as house officers in the surgery service in 1971, and they began the first PA postgraduate fellowship program in 1973. Norwalk Hospital Yale School of Medicine followed in 1976. Community Health Center Incorporated in Connecticut began the first official NP residency in 2007. And they had found that new graduates had a confidence and competency gap, thereby limiting their ability to serve as primary care providers. So that led to the development of an intensive, full-time extended immersion training program, a.k.a. residency, to address that gap. As we know, postgraduate training programs for physicians and dentists are supported at the federal level, and yet the lack of these funding sources for APPs have been a big barrier to program development. However, universities, institutions, and clinical organizations have recognized the need for further training, and there now exist over 250 programs in the country. Additionally, programs can now be accredited by the Advanced Practice Provider Fellowship Accreditation body. National APP leaders came together to create this credentialing body using evidence-based criteria, and it conveys program excellence. On to the why. Oops, sorry, I skipped a slide. Let's look at this study from 2021 from the Journal of the American Association of Nurse Practitioners. They looked at the effect of completing a postgraduate training on primary care NP transition to practice, and they studied outcomes including role perception, practice autonomy, team collaboration, job satisfaction, and intent to leave. More than 8,000 primary care NPs responded, and what they learned was that 10% of PCNPs had some version of postgraduate training, and those that did were more likely to have a minority background and serve underserved populations. Training programs build confidence and mastery of the PCNP role, which employers build as the key to productivity. Results also showed that they were more likely to participate in team-based care, which improves utilization and care quality. Results also showed that improved recruitment and retention were benefits to the employers, reduced turnover, and benefited rural and underserved communities. In a different study in the Journal for Nurse Practitioners, they looked at why an organization would want to create a program, and what they found was that nationwide the cost to recruit and onboard an APP was about $70,000. However, within that first two years of practice, the APPs had the lowest engagement and highest risk of leaving. So they created a pilot program that included individualized orientation, professional development, resiliency cohorts, clinical team collaboration, and mentorship, focusing on clinical, organizational, and practice model components. The pilot program cost $200,000, and what they found was that after that program the engagement level increased from 14th percentile to 50th percentile, and the turnover reduced from 14.5% to 9%. So they estimated that there would be an annual savings of over $5 million based on that 4.5% reduction in turnover alone. What they also found was that there's a 15% increase in productivity at six months and almost 12% increase at 12 months. So based on those results, of course, that organization created an MP residency. And one final study looking at APP fellowships from the program director perspective. This was a national survey of postgraduate PA program directors, and about half of the 72 responded. What they found was that, what they reported was that programs provided value to the sponsoring institution in terms of diversified recruitment, retention of staff, interprofessional collaboration, and professional development. Almost all agreed that recruitment and retention of postgraduate trainees are part of meeting workforce demands and retaining career staff. 76% of those program directors believe that their program improved decision making and autonomy of APPs in the clinical setting. And 93% believe their program fostered interprofessional collaboration. Thank you for your attention. That was the what, why, and when of APP fellowships. And now I'm pleased to introduce you to Vinny DiRienzo. Thanks, Rachel. I'm here to tell you guys about the how. My name is Vinny DiRienzo. I'm a physician assistant in the medical ICU at the University of Rochester Medical Center in tropical Rochester, New York, which is about 36 degrees right now. So my wife's very upset I'm here alone. Getting into this here, one of the other things that I'm particularly passionate about, I'm one of the co-directors for the Advanced Practice Provider Adult Critical Care Medicine Fellowship at our institution. You guys probably figured that out as to why I'm here today. So let's get into it. You've had a wonderful time at CHESS. You listened to our talk. You've decided that you want to go home and start a fellowship of your own. How do we figure out if we need one? There's a litany of gap analysis tools available online for free. Rachel talked about the APPFA, which will come up a few times today in our talk. They have a free service for you that can kind of assess where your program's at, whether it's a new program that you're trying to get off the ground or one that you're looking to move towards accreditation. This can help assess the needs of the institution, your individual learners, your workforce, and see if the fellowship is really something that's going to address those needs. When we were getting ours off the ground about nine years ago, the biggest and I think most important piece was the grassroots effort that we really had to create buy-in amongst all of our stakeholders. Our faculty colleagues, the APP leadership amongst the ICUs that we were going to rotate through, and also our new learners. We had students coming through. We had our nursing colleagues that were going back to nurse practitioner school. Was this something that they were going to be interested in? Were they going to apply to it? Or were we going to be sitting there holding our paperwork, proud of ourselves for nothing? What really helped in the pitch was an understanding of the institution, where it was at when we made the pitch for the program, but also where it was going in the next one, five, ten years. We were in an area of growth about ten years ago when we got this thing started. We were adding two additional ICUs. We were adding multiple FTEs to all of our adult critical care APP groups. We found that this was really going to be the solution to a lot of the issues that were coming up at the C-suite level. We'll talk about making that pitch here in a little bit, but we're going to talk about the fun stuff first. You've decided we want to start a fellowship. We've addressed the question, do we actually need one? How do you actually put one together? The curriculum is going to be the thing that's going to set your program apart and make it actually worthwhile for your learners in your institution, so how do we put this together? The good news is you don't have to reinvent the wheel. There's a lot of information out there. The easiest way to put a curriculum together is to pick an organization who's going to be offering you accreditation or something that you're going to be striving for in the first few years of your fellowship program and build those things off of that structure. The APPFA, I think, is going to end up leading the way here. I've got nothing to disclose, by the way, but I do accept cash, Venmo, and personal checks, but the APPFA is doing something that's pretty unique, and it is an amalgam of our nurse practitioner and physician assistant colleagues coming together and getting a unified definition of accreditation for postgraduate training programs. That being said, some institutions are still trying to catch up to the school of thought, so if you need credential-specific accreditation, it's still offered through some of the other organizations listed up there. So we've got a rough structure of what we're going to do here. Now how is our program actually going to look for the folks that are applying? Identifying what your ideal structure is is going to be unique to your institution, your educational goals for your learners. In our shop, we advertise about an 80% clinical and 20% didactic spread, as some of our physician colleagues up there with our APP fellows. So what does that didactic portion look like? And this can be the, I think, most intimidating thing to piece together. There are standards set by ACGME, and that will come up again this afternoon, but there's also a litany of other resources available to you to get this thing started. So the Society of Critical Care Medicine offers virtual critical care rounds, which is an online learning module, 30 to 40 lectures. There's adult and pediatric versions of that, going anywhere from basic physiology to kind of advanced practice stuff before they get into the units. We also offer from that same organization the fundamentals of critical care support, and what's great about that course, that's an in-person course with both didactic and practical portions, but we teach it concurrently with our physician fellows. So our APP fellows and our physician fellows are training together before they even hit the unit. So a lot of time, that interprofessional relationships are starting right on day one. Some of the other things we offer throughout the year are the alphabet soup you see up there, ENLS, ABLS, ATLS. Those are all going to be specific to your training needs, but one of the ones that we're happy to offer is the AFSET course from the American College of Surgeons. This is a cadaver anatomy advanced skills course. So we actually have a cadaver lab where we bring our learners in. We're able to do advanced procedures with the cadaver, thoracoscopy tubes, surgical airways, subclavian lines, things that we don't typically see that often on the units. Things to identify as you go beyond that initial phase and kind of all these fancy letter organizations, you do have to put some work in yourself to put together a curriculum, but it doesn't mean that you have to do all of it. There's some things that our institution that we take advantage of. Our medical school that we're affiliated with offers a problem-based week-long course for critical care medicine for the third and fourth year medical students, and we actually plug our fellows into that week-long course as well. And then we have our own boot camp that we do for a week before they hit the unit. So there's about three weeks worth of training that our fellows do before they're even hitting the units to give them kind of that fundamental knowledge they need to succeed. Once you've identified those initial training opportunities, the ongoing training is really where you can get creative with this. So we take advantage of all the things that we have available at our large academic center. We've got Grand Rounds, M&M. One of the things that's offered in our ICUs daily, we have a faculty member from our many critical care service lines offer a talk at three o'clock that all of our learners are invited to. So again, building that interprofessional relationship at the lower level right from the get-go. Specifically for our APP fellows, every other week we offer a conference where they come in, they present either a case or a journal report, and then we also offer an additional didactic lesson for them as well, typically in an advanced topic that they haven't gotten up to that point. So once you've identified those learning goals for your folks, we move into the clinical rotations. This is really going to depend on where you're at and what opportunities you have available to you. In our shop, we have five adult ICUs. We have our medical ICU, our surgical ICU, which deals with solid organ transplant. We do liver and kidneys at our shop, as well as a lot of our vascular patients. We have our neuromedicine ICU, which is a mix of neuromedicine as well as neurosurgical critical care needs. Our burn trauma ICU, which includes a lot of our emergency general surgery folks. And then we are an ECMO center and a cardiac transplant center, so our cardiac surgery ICU deals with those patient populations as well. Importantly for our folks, to help with their education as well as their job prospects, we rotate them through one of our affiliate hospitals as well in the UR medicine system. So we have two community affiliates right now that we use that are mixed medical surgical ICUs. They're differently resourced, and I think great learning opportunities because typically there are not other learners in that same environment, so our fellows are able to take advantage of those opportunities. We also offer a month of elective time. I think this is particularly important to build in as you're starting off because that elective time becomes your flex time. So if you have a learner who's struggling, you can put an additional core rotation into that time, or for the one that is excelling, they can really customize that educational opportunity. So our folks have done amazing things with this. We've had our learners rotate through palliative care, infectious disease, interventional radiology, the cardiac cath lab. So really based on what they want to do post-fellowship, they can take advantage of this time and leverage that towards the job offer that they're hoping to get. One of the tougher challenges with most APP fellowship programs, as Rachel alluded to earlier, not a lot of funding for this. So trying to get folks to buy on now that you've set up this beautiful curriculum, who's actually going to teach this stuff? You've got the directors that will hopefully get some admin time, but trying to recruit those preceptors, again, that are doing most of the learning, 80% of our curriculum is taught at the bedside. How do we get those folks on board? I'm fortunate enough at my shop where everyone has bought into the educational mission of the university, and it's actually a job expectation that they take on some form of learner, whether it be a student, a fellow. So you can build those things into the existing structure, but when you're trying to get this started, getting that buy-in can be kind of tough. One of the things that's important at our institution, we have a clinical advancement ladder that requires some form of investment in education, whether it be through presentation or precepting. So this checks that mark and gets people a little bit more money down the road eventually, just not directly from us. That being said, we also have graduates of the program or folks earlier in their career that are trying to add on those additional things that make us well-rounded providers. So we have some first-time preceptors. So having resources available for those folks and creating a standard for your preceptors are going to create that same standard for your fellowship overall. There's a few tools up here that I've listed for you. The One-Minute Preceptor and the SNAPs. These are open resource, well-published, and importantly, one-page. So if anybody has a short attention span, you can get through this stuff pretty quickly. Let me give you guys a second to get your photos in. All right. The next piece. All right. So there's a lot of building blocks for these folks to succeed, but how can we tell if they're actually succeeding? One of the important things that's gonna come up when you're making this pitch, especially if you're starting a program or starting to morph it into something a little bit more formal, is speaking the same language as our physician colleagues. So we actually pull from the ACGME Critical Care Fellowship clinical milestones, and that's how we set our evaluations for our folks. Now, we modify it a little bit, because obviously in the course of 12 months, you're not gonna be able to achieve the same things you can over the course of two or three years, but focusing on professionalism, interprofessional communication, empathy, clinical reasoning skills, procedural excellence, all those tenets are still there, and it creates a very even playing field, and it creates more buy-in for the program. You're able to have conversations with other folks on the team that are observing the learners while they're out there, and know that you're assessing them the same way, because we're assessing everyone the same way. All right, big deep breath. We've done the fun stuff. We put the curriculum together. We've got our posse of preceptors together there. Now we've gotta go talk to the suits. How do we make the pitch to the suits, right? So this is an understanding of where you're at as an institution, but also where the workforce is overall. So the post-COVID landscape is kind of chaotic, right? There's a lot of moral injury, especially in the ICU. We have folks, we've seen it. A lot of our nursing colleagues that have gone back to school are going anywhere besides the ICU. They had three years of a pandemic, and they're over it, right? We had PA students that weren't rotating through because they heard it was a terrible place, and now no one wants to come to the ICU. That's starting to correct a little bit, but I'll be honest with you, we had kind of a rough recruiting year this year. There was not as many applicants as we had in years past, and I think that's gonna be a piece of it. Now, that being said, our learners weren't the only ones affected by that. The house staff was too. We have plenty of people that said, you know what? I've served my time. I'm gonna get out of here. So how do we do that in a landscape where there's increased moral injury, there's increased educational opportunities, as well as economic opportunities for folks to pursue other careers and maybe go into other aspects of medicine? When you create a program like this, there's things that you can do in the recruitment where you require some service time afterwards. You can also suggest it. In critical care, we always have FTE, so hiring folks into those positions is never an issue. Turnover in critical care is three to five years on average for an APP. So in the lifetime of our fellows, there will be an opening for them. We also have 60 APPs in our critical care service line, so plenty of spots, plenty of spots. Maybe different at other institutions, so again, this is the knowledge of where you're at, but offering this as a solution to expensive locum tenum jobs and kind of plugging the holes with overtime is gonna be pretty important when you're making that pitch. And then if somebody is totally starting out, you're the only APP at your institution and you're trying to get more folks on board, so you've got some teammates, right? Going back to some of the literature that our professional organizations provide about the efficiency and the safety of our care is gonna be integral to that pitch if you're really starting from ground zero there. Again, depending on who you're talking to, sometimes the dollars and cents will matter a lot more than all the other things we've talked about so far. When you have somebody who's in a dedicated learning position and most likely receiving a lower salary than a full-time person coming on, going through an orientation program, you can spend some of that year learning really effective billing processes as well as getting them credentialed in other billing opportunities, procedures getting signed up, so when they hit the ground, they're hitting the ground running, right? They can bill for everything that they do, they're ready to go, they know how the system works, they can optimize that critical care time that we seem to struggle to define, right? Especially with some of the shared billing practices that we have now in the unit. This next piece here, this is the air mask analog that I'm sure we've all saw the instructions for in our flight over here, right? Put the mask on yourself first before you put it on someone else. This is one of the ways that we can offload from the rest of the team by having somebody who is trained in our specialty, who is in a protected learning position, so we know what their role is and they know what their role is. So they're not getting burnt out in the first few months because they've demonstrated minimal competency and they've gotten thrown to the wolves, right? So when somebody comes out of this fellowship, they are more than prepared to jump into that role, to offset some of that burden on the rest of the team and instead of having a staff where you've got two AVPs on and one of them is just fresh out of the gate, you've got somebody who's stepping into the role as part of that staff schedule, ready to help out. This next piece here sounds like a threat, but it's not, I promise, but a gentle reminder of what the potential costs of not investing of this program could be, right? Take a look at what your institution is doing. Are we spending an absurd amount of money on overtime? Are we spending money on expensive locums positions? Are we losing staff because we're being overworked and the patient to provider ratio is absurd? How to fund is gonna be tough. This can come from a few different mechanisms. There are scholarships and grants out there through some of the organizations that I listed earlier that you can apply to. In our shop, we have two dedicated FTEs in our critical care service line for the fellowship. We're not obligated to fill those positions based on how many quality applicants we have. However, if we have a year where we have more than enough and we had four fellows, a quick aside, if you're gonna start, don't start with four, too many. But if you have four that are great applicants, we have an opportunity to pull in additional FTEs from across the service line. So with the FMLA changes a few years ago, we had a lot more folks that were on extended leave as they should. But when you have a time limited trial with these fellows only being a year, we can pull some of those FTEs together and actually create additional positions. And that's what we did the year that we had four fellows. So you can get creative with this. It depends on the size of the institution and the resources available to you. And then last but not least, we've given you all the building blocks to put this together. We've told you who to talk to, how to make the pitch. You walk out the door this afternoon and start making phone calls, although I'm pretty sure it'd be after business hours for most of our home shops. Realistically expect 12 to 24 months for your first fellow to get started. There's gonna be roadblocks that you didn't anticipate they're gonna come up. There's gonna be things that take a little bit longer to put together, but it's a great process. You're doing it for the benefit of your learners, for the benefit of your patients. And if you need to make the pitch to the suits for the benefit of the institution too. That's my time. Thank you guys. Thank you. Thank you, Vinny and Rachel. It's been great putting this presentation together. We're obviously very passionate about these programs. So I'm Sarah Tomaszewski. I am the Pulmonary APP Fellowship Director at Prisma Health in Greenville, South Carolina. Currently I think we are the only outpatient pulmonary fellowship. If there is anyone that popped up over the past couple of months, I would love to network with you. So please reach out to me. But I think there's a huge need for both inpatient and outpatient. So Vinny touched on the inpatient critical care curriculum development. And I briefly wanna talk about the outpatient pulmonary fellowship. At our institution, we kinda target these programs more for our family nurse practitioners or adult gerontology grads that did most of their training looking more at primary care. And also PAs as well that wanna look at the outpatient setting. So I would recommend that you first set up your programs to block schedule. Think about all the topics that you wanna cover in a 12 month period. It is amazing how quickly those months fill up with so many topics that we wanna cover in a brief period of time. Each topic gets basically a different week and each week is taught by a variety of teachers, whether it be APPs in our group or physicians or other specialists that may be the expert on that topic of that week. We try to incorporate related clinical experiences. I'm gonna talk about that in the next slide. But I think that makes this fellowship very different and really interesting to our learner as they have more time and less clinic requirements so they can go out into other specialists and learn from other providers. I would highly recommend you start with more basic topics in the beginning. You're getting very pulmonary naive providers coming in, whether they're new grads or maybe a primary care APP that now wants to get into a specialty. So it's really important that they establish a really strong basis so they can really grow in that knowledge as that year progresses. As our outpatient pulmonary fellows are not on a productivity model, they don't have to see patients quite as fast. So we allow them more time during those visits. They can look up things in between patients and spend more time charting and learning about billing and coding a little bit better. So just here's an example of actually my block schedule when we were putting it together. And what I really wanna highlight here is in the first month, if they have a topic such as COPD, we send them to the PFT lab for that day to learn from our RTs that are awesome with PFTs. Also in month two, if we're talking about chronic cough, they spend the day with a speech therapist and learn what's gonna happen if you refer your patient to a speech therapist. And I think it's really best understood by those providers. So here's the different clinical experiences I was talking about. And when we dreamed up these programs, we really thought about if I could do this all over again, and I was a brand new grad, what do I think would have been really, really helpful for me in that first year of being a new provider because it's really scary and it is helpful to have all these awesome experiences. And I think my favorite that we experienced this first year in our program is, I had a lot of favorites, but we really got great feedback about thoracic radiology. So we sent our fellow to sit with a radiologist why he read lung cancer screening scans for the day. And it was just so helpful in our fellow being able to explain nodules and what we were looking at to our patients very quickly. And then also establish relationships with the other specialists that they can reach out to now because they know them. We also send them to the sleep lab or with the DME companies to watch CPAP set up. So you really can dream up what is the best experiences you can provide for these learners. So Vinny touched a little bit about, actually that's evaluations, but it's really important that you have validated evaluations because this is important for accreditation. So thinking about how often you wanna evaluate your learner, weekly, monthly, quarterly, and how in depth those evaluations are gonna be. At our institution, our pulmonary critical care physician fellows use an app called Simple during our critical care fellowship programs. And that's a great app that our doctors or can provide feedback real time with our physician fellows. And we actually tried this, I think we're the first institution as well in the country to have APPs use this app for our inpatient critical care. And since it's very quick, it's much easier to get people to fill it out. So, and it can keep building throughout the year so they can track their progress. So we based our evaluations in the ACGME pulmonary critical care milestones. But realistically, a one year fellowship is not gonna be the same. They're not gonna accomplish as much as a physician fellowship. So we really kind of tailored it to our learners and kind of stretched out what we felt like was most important that they could actually accomplish in a 12 month period. I wanted to point out the new innovations program. Once again, I have no disclosures. It's just what we have our institution. But I would really strongly encourage you not to reinvent the wheel. So meet with your educational chairs, meet with whoever you can meet with that has the knowledge of what you have at your hands at your institution, because it'll make your life so much easier. So we have online portals for our med students and other fellowship programs that we basically use for our APP fellowship program. So we touched on this a little bit earlier, but this is one of the ACGME core milestones. I wanted to highlight that in level five of this program, a physician fellow would present scholarly work at a national conference. That's very unlikely for an APP fellow. That would be a rockstar. So what I did is we stretched out that same box basically. And when you get to level five, the APP fellowship, they're gonna be completing a quality improvement project. So a little bit more tailored to that fellow. So I think recruiting is such a huge part, especially when you have brand new programs, as many people don't even know what they are. So sitting down with your recruiters and giving them a very concrete description of what you're looking for is very, very helpful. Make sure your job posting is really accurate. I know at my institution, they're very vague. So it's important that you list the degree requirements, if they're gonna be contractually bound to a job at the end of the 12 months, or are they free to go, what their hours may be like, that you can talk to them about that over the phone. But as much details as you can possibly get on there is helpful, especially in the beginning. You're recruiting a younger cohort of people for the most part, and a lot of them use social media. So if you can get things out on social media, that will drum up interest in your programs. And as APPs, you have a lot of personal connections with many different universities. So we have a lot of APPs at our institution, and we went to many different programs to get our graduate degree. So ask your colleagues to reach out to their old professors and send out your information about your fellowship. When we set ours up, I think I emailed every organization within 200 miles of our hospital, and they were all so supportive about sharing this opportunity with their students. So I would highly recommend you doing that. The nurse managers also have the inside track on who's graduating NP school. So reaching out to them, saying, hey, I have this opportunity, is really helpful. Reaching out to local organizations, and then networking at conferences like these. So this is a plug for my website, but I just wanted people to see it if you wanna mimic it, but that QR code's to our website at Prisma Health. Website, making a website actually isn't as hard as you think, as long as your institution, marketing department is willing to help out, and it didn't cost us any money. So that's really important. On the website, you wanna include the schedule, the requirements, the competencies, they're gonna be expected to do by the end of their fellowship. I really think the core faculty's important, because your fellow's gonna wanna know who's gonna be teaching them. And so including your picture, and a little bit of bio about you. Our website also has our previous fellow, and kind of where they came from. So the next cohort of people can say, oh, I'm kind of like them, this might be a great program for me. I try to take pictures of all the learning activities that we do, I know people roll their eyes sometimes when we say group picture, come on, but it really helps make your website more interesting to look at, and for candidates, because it's fun to see what kind of things you might be involved in. And then also, we made a promo video, we tried to make it really fun, where we kind of did it after work on a Friday, and got food, and we just had a great time with it. But it turned out really well, and once again, it didn't cost us anything, because we use our internal media department. So once you have this wonderful website, and all your candidates, applicants start rolling in, you really need to think about that first year, how long you plan to keep that application open. So I would recommend your first year have a rolling timeline, because you're not sure how quickly people are gonna apply, or how many. So you hate to pick the first three people that apply, and then a month later, 20 more roll in. So set yourself kind of a standard, and think about what, if you're looking for new grads, what graduation dates you're looking for. After the first year or two, you may say, that's a lot, I kind of want to have a very specific timeline, and when I'm gonna have those candidates apply, and we're gonna interview, and make our decision. That might be a little bit easier moving forward after you have an established program. Also, it's really important to consider a scoring tool for these applicants. If you get 50 applicants, and a lot of them are good, you need to have some sort of ranking system, so you can really remove your own personal bias from looking at these resumes. I would recommend utilizing core faculty of your fellowship to try to keep it consistent that the same people are reviewing the resumes, and interviewing the candidates, so you can really pick the best candidate. And then lastly, I know we talked about accreditation a bunch of times, but all I want to say about this is set your program up like you want it to be accredited. So even if you're not sure if you ever will actually apply, it will make your life so much easier down the road. It adds a lot of rigor to your program, and if you do apply, it will really elevate your program among others, because it is accredited. So they actually have a free info session in November, so if you're interested in making one of these programs, I would recommend you just listen in, and hear everything that goes into getting these accredited, because it's a lot, and if you're gonna put all this work in, you definitely want to set yourself up for success. And so with that, I think that's it, so I think we're gonna take questions if anyone has any. Thank you.

Pulmonary Critical Care APP Fellowship Programs

specialized training

postgraduate programs

clinical and professional confidence

didactic and hands-on training

accreditation for APP fellowship programs

recruiting and selecting fellows