So, I want to thank Doug Rex for giving us the opportunity to have the GO21 conference and thank the attendees for their patience as we had to defer this to later in the year. And of course my co-directors and the wonderful ASGE staff. We get 30 minutes of a fire, so I literally am beside my fire tonight, to pick the brain of Dr. Rex, Dr. Mergener, Robbins, Vickery, and Aliparthy. So Doug, I think, if you, do you have any introductory remarks that you would like to make? Well my, thanks Colleen, my introductory remarks are really to say thank you to you and to Bruce and to Laitha for putting the course together. It's always a lot of work to put one of these courses together. And so thanks guys very much, I really appreciate it, as well as to all of you who have attended today. And I want to thank the panelists, Klaus and David and Joe Vickery, and Laitha, thanks so much. So some of the earlier topics were around the value of colonoscopy program at ASGE, and then of course we have the multi-society task force, and the society's releasing information and endorsement of earlier screening. Can you tackle that in terms of how we're handling that volume, it's welcome, and strategies that we're putting into place for that patient population, how is it being received by the payers? So I will tell you that the ASGE, two, three years ago, we began to respond to some of the messaging about screening, and the fact that the public, as well as our primary care physicians, are hearing a lot about screening with non-colonoscopic methods, and we still have a very strong sense that colonoscopy is a very viable alternative for screening. We saw a report the other day about volumes of procedures in the U.S., and over the past decade or so, colonoscopy volumes have stayed pretty steady, and upper endoscopy also. There's been some changes in different age groups, but overall, those are still the cornerstones of our practice. There's some individual procedures that have had some changes, as we all know, FlexSig has kind of fallen off the table. Upper endoscopic ultrasound has been the biggest growth area, about a six-time increase in volume, but volume-wise, colonoscopy is still the cornerstone, and we definitely want to get the message out that colonoscopy is a viable option. We have this program we call the Value of Colonoscopy, which is really designed to send that message to primary care physicians. We've got a lot of different activities. The current chairs of it are Joe Vaccheri from Rockford, Illinois, who's one of our ASGE counselors, and also John Cohen, who is another counselor and is from New York. Joe, I might turn it over to you for a minute to ask how you feel about this issue of 45 to 49-year-olds. It's a group that is over 20 million people. Every five-year segment in the U.S. is more than 20 million people. We don't know how they're going to be screened. We hear that it may make sense to screen them with non-colonoscopic methods, but I think there's an opportunity with regard to colonoscopy. Can you tell us a little bit about some of the specifics that the campaign is doing, some of the tools that you've used in Rockford? I'm sure that would be helpful. I'll tackle the first one. We did cover a fair amount of the VOC in my talk today, but I think the 45 to 50, I think some of the impact of what screening tool we use may be local, and why I say that, we've had three payers so far approve colonoscopy for the 45 to 50-year-old group in Rockford, and one of them is Blue Cross Blue Shield. Obviously, that was welcome news for us, so I'll be interested to see how much local impact there is on driving which test will be used. My guess is there'll probably be a wide array of use amongst the test depending on the primary care's choice, and then access to colonoscopy if there are long wait lines and poor access that may change a primary care's approach to what test they order, but I think we could tie this into the value of colonoscopy campaign. We went over some of the key components on my talk this afternoon, and I mentioned that hopefully in the spring, we'll have a new initiative that could really be helpful for groups to promote at a grassroots level the value of colonoscopy and tie in growth if they have capacity in their unit. I think a big point will be capacity, and if they don't have capacity with their current hours, would they expand their hours? I think if that doesn't happen, access could drive which test are used in each market. Yeah, we're starting to see some of these folks coming in, and so I do think that there's an opportunity. I think from the ASG standpoint, we felt like the best way to deal with it is to try to handle the whole issue of screening in your own backyard. We don't really have the resources to compete with some of the marketing for non-colonoscopic methods of screening. We've tried to create some tools that I guess I didn't hear the earlier talk by Joe, but are available through the VOC campaign that you can use to try to get this message out, and Joe's done that very successfully. I think it's really a great model for how to do things, but I use the expression, you got to do it in your own backyard. You got to speak to your own primary care physicians. You have to go to grand rounds, go to medical staff meetings, use some of the tools that we've created to get the message out that colonoscopy is still a great way to screen. And Doug, if I can add to that, if you've not joined with other groups in your state or where your healthcare is local to have a similar forum with your payer, you've missed an opportunity because they will listen to you, and often the payer also has grand rounds for their medical staff and their clinical staff. If you can give an objective overview like the one Joe's described from ASGE, they really do welcome that, and it's made a difference for at least one of our payers. Aetna, UHC, Cigna, Blue Cross Blue Shield, Anthem, I think are the payers that are currently covering screening at age 45 at least in our area. Doug, would you mind talking to us about some other strategic initiatives for ASGE this year, the DEI initiative, for example? Yeah, so we are, it's really a priority for us, Colleen, DEI. In general, in GI, we are underrepresented for both women and for minorities. So beginning with our diversity and inclusion committee, for which Jennifer Christie, who is the vice president of the organization, is the chair and has been the chair, we're looking really throughout the organization at opportunities to expand the representation, so within our leadership as well as within our membership. And we are going to be doing some things to improve our pipeline, possibly going down even to the level of college students and trying to interest minority groups in careers in medicine, and then within medical students and residents, trying to encourage them to enter GI. We've got clear evidence that the patient populations often appreciate and are best served by having people that look like them as their physicians. We also want to try to get directly involved in trying to improve patient outcomes, particularly with regard to colorectal cancer screening. So we are raising money and hoping to get a, probably in some underserved populations, specific underserved populations, screening programs going that will be based on fecal testing because that seems to be the most feasible way to get the actual screening done, but then also to get colonoscopy done for patients that are positive. So we want to get involved in that level too. So this is going to be a major area of fundraising for us and expanded programming. And we also want to improve our services to women, to women in the society who are members. So we're expecting in the near future that we will have an established women's committee, and they're going to be charged with a same kind of thing throughout the organization, improving and increasing the number of women who are in leadership positions, both as far as committees, structure, boards, presentations at our national meetings, but also interest in GI among women. And there are a lot of specific issues that we are going to be interested in, and things such as ergonomics and handling endoscopes and the differences that men and women have with trying to deal with the instruments. So we're looking forward to that also. But I appreciate your bringing it up because it's going to be a huge focus for the organization. That's exciting to hear. I also really appreciate the work that you and our advocacy group, HPPC, under Bruce's leadership, have done on prior authorization. I know you spoke to this earlier this year in a video I saw with you in class on bowel preparations. Would you like to speak to that? You know, I think everybody's just very, very frustrated with the whole issue. And so, yeah, we're doing what we can in specific areas, prior authorization, step therapy, issues that are challenges for our members in terms of cost. With regard to bowel preparation, we specifically had one of the major insurers restrict access to really all the prescription bowel preparations. And we all feel that bowel preparation is the worst part of colonoscopy. We just completed a survey at my own place, and I can tell you that patients still tell you that it's the worst part of the procedure, and it's the most likely thing that they're going to cite as a deterrent. So we really don't want to be restricted to four liter PEG-ELS preps, which are our main sort of generic preps. And so we organized a very large campaign, got a lot of social media activity about this particular effort, and had phone calls from patients. That's really probably the most effective way to have some impact on this. And so it's been a challenge, but we think we've made some headway with it. And so, yes, absolutely, it's a priority to try to stop some of this effort we have to put into prior authorization. Thank you. So we have with us tonight Lakeisha Mayo, which is quite a blessing. Lakeisha's Chief Policy and Member Engagement Officer with ASGE. Lakeisha, would you mind stepping in and just reviewing the broader bill for us and how that might impact our practices? Are you talking about the Improving Seniors' Timely Access Care Act? I know, Bill, our government affairs consultant was on earlier today, and I think she gave a wonderful presentation on this issue. But what it would do is actually increase transparency and streamline some of the efforts around prior authorization. And the bill was introduced. It's a bipartisan bill. We've supported this bill for the last two legislative cycles, and we're hoping that it will move forward. It's gotten a lot of support in the House. I had to click around there for just a minute, Lakeisha. I'm so sorry. Doug, thank you for still sticking with us on this. We've been talking through today about other tools that we can use in our practice in terms of what's been adopted through the pandemic. Those have ranged everywhere from incorporation of really embracing telehealth from, at least in my group, naysayers to employees working to the highest level, their licensure and trying to improve staffing efficiencies. What kind of observations do you have on how the pandemic's impacted your practice? And I guess we could keep it positive maybe for now. Well, I mean, I think telehealth is fantastic. I, you know, my experience is I'm sure the same as many others. I find it to be incredibly efficient, but also many of the platforms I think, you know, don't function perfectly well and can be frustrating getting patients onto them. And many of our elderly patients struggle with them. I'm really concerned about the possibility that we will not get any payment for straight phone calls because I think there's certainly a segment of my population, maybe it's because I'm older and I've got a lot of older patients that still can't handle the platforms that we have. But I think it's a change that's here to stay. I'm still doing more than half of my visits as telehealth. And I think it's great. It's great for the environment. Fewer smaller carbon imprint, you know, driving back and forth to doctor's offices. So I just love it. I'm interested. I know we've got Klaus and Dave on the phone too. And if you've got comments about that. But we certainly want to continue to support telehealth and we're going to actively advocate for it and keep it as broad as possible from a coverage standpoint. I'm looking it up to the panel for this. I found telehealth to be really an amazing advantage as well. Something that I can integrate if I have time in between room turnover, especially at the hospital where that room turnover can spill over to 45 minutes or an hour. So I agree with Doug. That's been fantastic. The flip side, though, is that I've started to get report cards from patients. And while my marks are pretty good on the physical in-person encounters, the telehealth experience has been pretty woeful. So there's a lot of room for improvement there. But happy it's here to stay. I've also heard that there's concerns about ongoing reimbursement for that. I don't have an update, at least from the hospital side, but wondering if anyone here knows if that's still a viable model financially. I believe as long as the PHE is extended, telehealth is allowed. I don't think it's allowed across the state borders at this point, but advocacy is still ongoing about all of those aspects. Sorry, I had to chime in. I'm calling. Is it OK if I go ahead with the question I have? Please do. Doug, this is a question for you and this is something that I thought as a colonoscopy guru, you may be able to answer. In our practice, and I know this is not unique to my practice, I found often that folks staying updated with the newer techniques in terms of whether it's polyp removal or examination, all of those things, for example, AI, that's going to be sort of trialed in my practice, found it to be difficult. Do you have any tips on how we can train, so to speak, an old dog for new tricks and keep everyone updated with the evolving techniques? Well, that's a fair question. You know, it gets at how many people, how many of us out there really are working at it, Latha, to stay up to date with the latest techniques. I will say from a colonoscopy standpoint, I feel like the ASGE is doing a number of good things and I would point you to these SUTAB tips of the week. We're trying to organize our educational efforts around general endoscopy on the one hand and advanced endoscopy on the other. I think increasingly, endoscopists sort of identify themselves as either advanced or interventional and that is a smaller segment of our society. It's a segment that is very active in the organization because they're all about endoscopy, but the bulk of our practicing members are what I would call general endoscopists. They're sometimes called basic, but I think that's the wrong term. I think they do general endoscopy and we have had a lot of advances in the performance of our routine procedures and particularly in colonoscopy. We've made it safer through this, what I call the cold revolution, moving more and more toward cold resection. So a couple of the things that I would say to look for to summarize these, one of this are these tips of the week that I put out every week that will cover a lot of the basics of general colonoscopy and how to perform resections and the principles that we follow, including cold resection. And we are having a series in GIE of what we call top tips. And these are gonna be divided among an advanced editor and a general editor. And the initial ones, Pratik Sharma put out one about how to perform a good upper endoscopy. I'm gonna do one about how to achieve insertion in an anatomically difficult colon. So the things that are relevant to people whose endoscopy practice is really focused primarily on upper endoscopy and colonoscopy and how to get better and how to handle difficult cases. We are starting a new podcast series through the publications committee that is gonna be coming out once a month. The first one is out and it's Jonathan Biscaglia is interviewing Sachin Wani on Barrett's esophagus and really, really basic issues about how to perform the Seattle Protocol and do you need to do the Watts procedure and a lot of basic questions that I think general endoscopists need to know about. So there are a lot of resources for the specific ones you talked about. I really, I hope people will look at that SUTAB tip of the week. It's something that you don't have to be a member to look at, you can just go on the website and access those videos. We do have some material that is just accessible to our members, but others that are just available to everybody and I think it's good stuff. I hope that answers the question, but I think it's a real problem that you're getting at because I certainly see in referrals that I look at and I'm sometimes asked to do sort of a long distance proctoring or something of someone's performance and they're still using hot forceps on diminutive polyps or removing things that are under 10 millimeters with hot snares and having complications that aren't necessary. And so it is a challenge to disseminate what we think is solid best standard of care to everybody that's out there. And I'm interested in how big groups, we've talked to Jim before about, can we develop programs for these large consolidated groups to get education directly to them? And we're very interested in developing that kind of partnership. I think you bring up great suggestions and solutions to this problem. And I hear you in that one needs to be open to learn, to be able to sort of talk to these new techniques. And I've found that oftentimes the more senior physicians are not as open and not as a personality just because they feel comfortable with what they've been doing and they may not be comfortable just changing what they've been doing for so long. And within my practice, I've found it to be very easy to talk to the newer associate physicians. And in fact, they're very open for feedback and want to learn the right way. And I've actually monitored or just sort of been a fly on the wall for a couple of them, looking at their positioning, ergonomics, their polypectomy techniques. And I must say that I personally felt the Lower GI Star course that I attended a few years ago for ASU was just an unbelievable program. And so I hear you. And it's not an easy solution, but it is so important because in the end, it delivers the right care that we have actually sort of dictated in text but actually puts it in practice. And I think it's really important to develop those tools that hopefully we can disseminate and help everyone adapt. Colin. Yeah, I think that's a very interesting comment. And so there are a couple of scales for these techniques to measure quality. One is the DAPA scale, direct observation on polypectomy skills. And another one is the CSPAT, which is shortened and very appropriate for cold snaring. But it's interesting in the US, we don't do as much of what you're talking about. I think that that's really a brilliant idea. Probably the next step in quality, the next direction we need to take is to start to look at the quality of resection. Canada has in a couple of the provinces a program where they actually are systematically going around and watching everybody do colonoscopy and making recommendations about this. And I don't know that we can pull that off the way we deliver care in the United States, but if we can pull it off within our practices, we can potentially improve outcomes. And like I said, I think that'll be the polypectomy in colonoscopy will be the next big area for quality measurement. Doug, I had a sister question. You may have just partly answered it, but I'd like to pose it to Dave and to Joe also. And that is, does ASG have a remediation package? I'm not sure you could ask, for example, an endoscopy center in Dave's case or Joe's to look at all of these videos for someone who you think might not be measuring up to the mark. How do these practices in New York and Illinois handle a situation either within your group or outside your group in terms of remediating those who just aren't measuring up to the mark? What kind of practical tips can we give them? So we actually had a situation where we felt one of the younger partners, this is going back a while, was deficient in some areas of colonoscopy. So we set up a remediation just within our practice. We did some proctoring with individuals that had high sequel intubation rates. We did some proctoring with people who had high adenoma detection rates. And then we had some more senior skilled partners that were good at getting through difficult colons. So it was, we invested the time. They were actually in the room with this physician and he watched those physicians do colonoscopy and vice versa. So we set up our own program and it was very difficult because it's hard to tell one of your younger partners that things aren't going well and we need to fix you. Or if they're not fixed, that's a more difficult discussion. Thankfully, everything worked out, but that's our experience with remediation. It does take some group courage to take that on. Dave? Yeah, it's a tough one for us as well. We struggle with anything more sophisticated than adenoma detection rate. Initially, we thought that by publicizing everybody's ADR in a initially de-identified and then identified fashion, that that would be enough to move the needle, but it turns out that that's not. And then next level up was to pass around various video tips and sort of self-directed learning. That didn't work either. Then we moved over to the advent of wide spectrum endoscopy, and that moved the needle a little bit in terms of ADR, nothing to say about quality per section, by the way. And then that company went out of business, and then we moved over to CAPS. And so with some of the physicians enjoy using CAPS and that's moved our ADR up a little bit, but nothing has been better as you've indicated than simply going into the room in a very non-threatening manner and observing and providing tips. But it's hard. It's kind of painful for everybody. And I'm not even sure that that's really the right thing to do, to chase the ADR. And I think we tried to look at cancer rates and missed cancer rates and interval cancer rates as a more potent indicator that there may be an underlying problem, but it's definitely not a one size fits all solution. And I think you have to really know the members of your group. And be prepared to have an awkward conversation. I think everybody's aligned, but it's not a passive process. I have a follow-up question to that. What do you all think about training our ancillary or team members in terms of the techniques or ADRs or the time? Because the same nurse or tech is with different physicians. And sometimes they do talk about what the other physician does, but they don't usually disseminate the information. But what are the thoughts on training those that are constant figures in our rooms? I mean, I think it's a great idea to get everybody involved in looking for polyps. There are two aspects of detection. One of them is exposing all of the mucosa. That's the one I think that's harder for the techs and the nurses to talk about, to say, you know, doctor, you're really coming out of the colon too fast. You don't have it distended well enough. You need to go back and forth and you need to check the right colon twice. That's a tall order, but they can look for polyps. But I do agree that if you have somebody who is a low performer, the first thing to do is to focus on their technique. It's not just slowing them down. It's actually performing the tasks of basically looking behind the folds, getting the colon distended and cleaning up. Those are the aspects of it. And it's hard to standardize that. I think beyond ADR, you can say a little bit about technique, but you have to kind of go in and watch people do it. And there are educational programs that have been quite successful. These have been shown in Europe. Mike Wallace did one of these. So you can improve people if you focus on technique. I think with regard to resection, one of the things, the first things to do is to standardize it. It's to standardize the methods if you can. If we have a standardized method that we ask people to follow. Literally, don't use electrocautery on lesions that are 10 millimeters or smaller, et cetera. I mean, I can send it to people. It's just a one-page thing. It goes through the resection of a whole set of everything in the colorectum. So there are tools if we make the effort with low performers that will improve outcomes performance. Colleen, if I may add, ASGE also has some resources. We have a sample remediation plan that we can show it members as well on our website, and we can send the link for people as well. How do we find that, Lakeisha? If we went to the ASG website as a member or non-member, what do you search for? I would go under our quality and safety section on our website. We need to make sure we share that with all of our practice managers and site leaders. That's terrific, exactly what we need. We have what we need. One of the other things I wanted to ask you, and the same during the course and beyond, I learned about some of the things that I used to focus on, but not many do in terms of electrocautery setting, whether it's Irby or a different machine one is using, and the equipment. Are there any resources to train and educate on what the appropriate equipment is, even for a cold snare, for example? And when they are using the hot snare, if they're not using a standardized equipment that sort of automatically chooses the settings for you, how do you educate those that are not just in the training process, but they're already trained and are in practice? Well, that's a really good point. So we've actually been talking about this, and we wanna develop a full-fledged program basically on training in energy so that people really understand what coagulation current is, the differences between forced and soft coagulation, cutting current, when to use it. And I think that the resources that are available are not quite what they should be. So I think it's a really good point. It is a little bit machine-specific. Everybody has different machines that are out there, cautery sources. Right now, probably the best machines are microprocessor-controlled units. And if you don't have those, certainly when you replace your fixed output generators, you should go to a microprocessor-controlled unit. But I think a lot of people don't understand principles of electrocautery. And we've recently been discussing and recognized that we need to create a program about what kind of call it the energy program to try to improve people's understanding and how to use the machine. Everybody should be facile with the machine and not just expect the technicians and the nurses in the room to set it up. So your point's really well taken. We all need to do better. So I'd like to thank Dr. Rex and our panelists for the excellent discussion tonight. We could continue on without stopping, literally.

colonoscopy program

earlier screening endorsement

telehealth

diversity in GI

prior authorization challenges

bowel preparation

future ASGE initiatives