for GI health care in the United States from practice managers to director of endoscopy to managing partners and it is my privilege to introduce first for you Dr. Joe Ficari who is managing partner at Rockford GI. He joined the practice in 1997 and has been in a leadership position either with the group or with practice management or with ASGE almost throughout his entire career. Joe's now chair of the practice management committee and we are very happy to have you with us this afternoon. Thank you Joe. Today I'm going to be speaking about just the first two objectives that we have here today, the value of colonoscopy and physician burnout. I chose the value of colonoscopy because it's I think an important topic at the local level both from the perspective of the practice, the patients and competitive technologies and then we'll switch to physician burnout to end the discussion. As gastroenterologists, we have a great understanding of the value of colonoscopy both from the perspective of the organization and the business aspect and the patient care aspect but if we wish to effectively compete with other technologies such as FIT, multi-targeted stool DNA and other emerging technologies, I think the best way to start to compete is by educating our primary physicians followed by our patients. I think we should start by educating our primary physicians. Primary physicians have the most influence over patients when it comes to patient's decision making whether they're going to actually follow through with testing and then secondly go ahead and start to educate our patients. So, to best promote the value of colonoscopy, I really think this is done at the local level through a value of colonoscopy campaign or program and I'll wrap up this section a little later and talk about a program we put together that was very successful. Obviously, as practices, we don't have the deep pockets that some of the other competitive technologies have for advertising and marketing but I think we can be very effective at the local level. As gastroenterologists, we understand the literature better than our non-gastroenterology colleagues when it comes to all of the screening tests and I think this is important because especially for those patients who choose to undergo tests other than colonoscopy to screen for colonoscopy, I think it's very important that we educate our primary physicians and our patients about the appropriate indication for the other competing technologies. We had an abstract at DDW this year and we looked at referrals that were sent for positive coloGuard tests and 15% of those tests that were positive were done for inappropriate reasons. So, I think it's important that we educate our patients and referring physicians about the use of other screening tests beyond colonoscopy. So, as you start to build your program to promote the value of colonoscopy, I would start, as I said, with the primary physicians. The ASGE has a value of colonoscopy task force that has put together a very nice section on our website which you can access multiple educational resources and opportunities. There are guidelines, there are videos from experts, there are patient testimonials, and there are some very good lectures with slides and some of the lectures have slides with notes that you could use at hospital grand rounds and that you could modify to use for in-office presentations if you wish to go speak to your primary care physicians and referring physicians in their office. Some of the more popular presentations that we've noted on the website from feedback through website hits include colon cancer screening, the basics, colorectal cancer screening, and surveillance strategies, and one that's been very popular both from the standpoint of the presentation but also a video is choosing among colorectal screening tests the appropriate or correct test for patients. So, those can be very helpful as you start to educate your primary physicians. You can also share the guidelines with primary care physicians and refer them to the website. There are guidelines on the United States Preventative Services Task Force. There's a quick summary. There's also a very nice video summarizing the findings of the task force and you can use these materials for grand rounds and, as I said, if you wish to go to the primary care physicians to speak to them on these topics in their office. When it comes to educating patients, I think we want to start that process with office visits. After primary care physicians, we as specialists can greatly influence the decision making of patients or the choices they make for the test they choose. So, we spend time with our patients when they come to clinic visits discussing screening for colon cancer even if they're there for other reasons and we also have our nurses talk about that during the visit. We then refer patients to the ASG website where they can view video patient testimonials which can be very helpful in educating patients and getting them to pursue screening for colon cancer. Something we have found to be very effective has been fact sheets. So, we have a very simple front and back sheet of a paper with facts about the different types of tests that are available. We highlight the value of colonoscopy and we leave them in our office in ASC and we actually give them to every patient in the office and when they leave the ASC. Once again, refer patients to the ASG website. There's a very good patient section. It's very easy to read. The material's easy to read. The patient testimonials can be very effective. There are some videos that they can watch. Some of the videos that have been popular are which tests should you get and this video looks at the different tests, colonoscopy, fit test, and multi-target DNA. There's also a nice section on tips, on colonoscopy, on polyps, and bowel prep. Again, very simple, very easy to read and these can be very effective tools in educating your patients. If I were to summarize the important points I would cover when I'm speaking to the primary care physicians that refer to your office, I would summarize the tier test, the tier system that looks at the different tests that are available. The tier one test being colonoscopy and fit test. So, I would make sure I thoroughly go through that. I would focus on colonoscopy as both a diagnostic and therapeutic test and I think this can really score points with patients. It's one test. It's not getting a test such as a fit test or the cologuard that's positive and then they need another test. They can come in for one test and have it all taken care of in one visit. Another point that I would make with patients is there is less frequent testing over your lifetime with colonoscopy. In theory, it's a test at 45, 55, 65, and 75. So, less testing as opposed to fit test which is yearly testing and with cologuard which is every three years and I would highlight the cost effectiveness. So, I would definitely highlight those points to the primary care physicians. With patients, I would make sure you get them a fact sheet and review that fact sheet or have your staff review the fact sheet. Again, make it simple and there is a sample fact sheet on the website. I would also once again highlight the importance of diagnostic and therapeutic testing with colonoscopy. All kind of one-stop shopping so to speak and then I would highlight less frequent testing. So, how does this work in reality and although we are only an N of one, I'll tell you our experience with our group. In 2018, we noticed a significant drop-off in referrals for screening colonoscopy and a significant uptick in referrals for positive cologuard tests and so we set out to reverse this trend and promote the value of colonoscopy within our area at the grassroots level. One of my partners took the lead on this. He developed a lecture that he gave at Grand Rounds. He modified this lecture and a number of us went to our top of referring primary care physicians went to their office and I would highlight bring lunch not so much for the physicians but for the staff. You can certainly get more people to attend and get the attention a little bit easier with a little lunch. So, you can modify that presentation and we did. We developed a fact sheet and I can't highlight the importance of the fact sheet enough. We electronically sent our referring physicians a copy of the fact sheet so they had it available for their office. We increased our discussions with our patients at our clinic visits. During March of that year, we sent an editorial to the local newspaper essentially outlining the value of colonoscopy and we went on a pretty big campaign on social media. So, how did we do? In the first quarter of March in 2020, we started to see a significant reversal of the trends. We started to see a significant increase in referrals for screening colonoscopy and less referrals for positive for positive cologuards and we also started to hear back from patients about discussions they had with their primary care physicians and we noticed in the notes from primary care physicians the discussions they had with their primary care physicians and how they discussed the value of colonoscopy. Unfortunately, the pandemic hit so we only had a three-month period of time to get data. However, in July of last year when business picked up, we started monitoring this again. You see the funny date of 8-14. Originally, this course was supposed to be over the summer so I have the data through mid-August and it's kind of nice to look at data through that point because we really hadn't started looking at data on 45-year-olds as of August and as we look at the data over 13 and a half months, it was a little hard to figure out how well we did at first but ultimately we were able to tease out the increase in screening that was due to our backlog from the pandemic and and the volume that was truly above and beyond that and we calculate we've had about a 15 to 20 percent increase in screening colonoscopy above and beyond the backlog catch-up for the pandemic so we've been very happy with the results of our campaign. Month after month, we seem to be setting new highs for referrals for screening colonoscopy so we think it's been very effective. It is an ongoing process. It's not something you can do at one time. We continually update and remind our referring physicians of what of the value of colonoscopy and we've made it a top priority within our practice. I'm going to switch gears now and talk about another important that has become important to me and that is physician burnout. I think it's very important that all of us within our groups look at burnout. It's something we should take very seriously. I think it's important we understand burnout from the GI perspective. It's important to understand it globally but I think we we need to understand some of the unique aspects of burnout as it relates to GI and all hope is not lost. There are things we can do to foster well-being and build resistance to counteract physician burnout. So a very simple definition of physician burnout is an emotional, physical, and mental exhaustion caused by prolonged and excessive stress. It's a chronic condition that impacts the well-being of the physician and the ability of the physician to care for patients and the ability of physicians to interact in a professional and respectful manner with staff and in a way when things really reach kind of a sad level the patients can become obstacles, staff can become obstacles, and even worse they in a way can become the enemy in physicians who are truly burnt out. These are some sobering numbers from a Medscape article in 2020. It was February of 2020. So the data that I'm about to show you is pre-pandemic data. It has nothing to do with what could have increased physician burnout during the pandemic. So in this Medscape 2020 publication only 23 percent of GIs were happy at work and happy with their work. More sobering to me is 26 percent said they were burnt out, five percent were diagnosed with depression, and 10 percent had both. And if you add that up that's 41 percent of our colleagues are either burnt out, depressed, or both. And I don't think that's a very happy topic to talk about. When we talk about burnout they generally talk about three pillars of burnout. The first is emotional exhaustion which typically results from a constant demand for more work. It also is from increased work at home and after you leave the office. And unfortunately I think in some ways the electronic medical record has been great but in some ways it has forced some of our colleagues to take their work home. And another source of emotional exhaustion is struggling in dealing with insurance companies to get imaging tests approved, endoscopic tests approved, infusions approved. These are just some examples of variables that can lead to emotional exhaustion. The second pillar of burnout is depersonalization and that results in a loss of empathy for our patients and I would add our colleagues. And this is where as I alluded to earlier we can see our patients and our colleagues as an obstacle and even the enemy. And really this is in direct opposition to what we all went into medicine for and that is we now are losing that opportunity to help and heal our patients. And then the final pillar of burnout is the low sense of personal accomplishment and self-value that physicians who are burned out see. And this one's especially hard I think for us to look at because as a physician we've all excelled academically, we've had great accomplishments. I think being a physician should be a very rewarding and very happy field but unfortunately when you burn out it becomes the exact opposite. So what are some of the aspects that are unique to GI? And I think one of the unique aspects of GI that can perhaps lead more or put us down the path to burnout are both we need to have expertise from a cognitive and procedural standpoint. So there may be some increased pressure received by our colleagues that they need to be experts of both and everything within those cognitive procedural aspects. There's the financial pressure to succeed, the financial pressure to increase production both from perhaps the practice or the employer and individual needs and that has become worse during the pandemic, adverse events from procedures can increase burnout, lack of confidence in procedural schools, in young colleagues that perhaps they never get over that increases skills, and then the pressure to do more with less, to do more with less staff, to do more with less time. But hope is not lost. There are opportunities to foster well-being and resilience. There are personal interventions that can be done, institutional interventions that can be done, and we know that both types of interventions can lead to improvements. One thing to do is to assess the status of your career. What's important to you at where you are in your career? What sparks joy? What brings you happiness? You have to say no. We cannot be everything to everyone at all times, and I think we must say no, and it's appropriate to say no. We have to follow our passions, find things that bring interest, that make you happy, and we'll touch on that more in the next slide. Set boundaries, what you can do, what you will do, when you can do it, and you have to set time for yourself, and that's a way of being selfish. Set time for exercise, reading, sleep, meditation, learning a new language, art classes. Find things to keep your mind happy and occupied outside of medicine. Find value in your job. So at work, find things that you have a passion about. Is it teaching? Is it research? Is a committee work within your practice? Is a committee work with a society? Is it providing subspecialty care in IBD or liver disease? And find ways for your group or the organization you work for to make that happen, and most importantly, take time off. This is probably the single most important thing we can do to avoid burnout, and I think it's so important. I think it merits one slide in caps. We have to take time off to do the things for ourself to keep us emotionally healthy, both at work and at home, to have that balance between work and work life and home life. I think we should be taking a minimum of eight weeks vacation. We take 11 weeks vacation in my group, and I just think it's so important to have time away from work. Institutions can influence well-being. We need to identify supportive leaders in our institutions, leaders that promote health, that promote a healthy work-life balance, and promote the environment to do that. There could be opportunities to promote self-care and activities outside the organization that the organization provide, flexible work hours, gym memberships, and again, time off, time off, time off, time away from the practice. Support staff. We need to have the appropriate amount of support staff so that we can have work that is non-clinical moved away from us and have help in completing that administrative and non-clinical work. We cannot be taking our work home at night. That just extends the work day, and it is not only counterproductive. It is certainly counterproductive for a happy and healthy work-life balance. We need to gain control of our scheduling and flexibility. We should not be double booking. We should limit add-ons. In fact, in our practice at this time, for various reasons, we have highly encouraged the providers to avoid add-ons completely. It tends to cause a great deal of stress for the physicians, for the nurse practitioner providers, and for the staff. I think we really need to gain control of our scheduling and flexibility. This is probably behind time off as ways to avoid burnout. A few pearls I would leave you with for both. I think within our practices, we should be making our top priority, or one of our top priorities, the value of colonoscopy and build a campaign around it. The ASGE has great resources on their website for both physicians and patients. As far as burnout, it is a very real entity, probably amplified during the pandemic. We should identify and address physician burnout, and identify the tools that can be important to help reverse this trend of burnout, which can have negative impacts, obviously, on the physician, but negative impacts on the practice. Thank you for your time.

Dr. Joe Ficari

Rockford GI

colonoscopy

physician burnout

gastroenterology

primary physicians