You know, you get three years, and you get everything crammed in, and what I found with people that we've hired, a mixed bag of levels of training. And it really depends on your training program, how much good information and good training you get. Some programs are great. You know, you get a ton of practical experience, you can handle the scope fine. Others I've seen, you know, you kind of wonder, you know, what they're teaching. You know, they don't know how to do a peg. They haven't, they've never used an over-the-scope clip. Every bleed is a disaster. And it's not their fault, it's just what the experience is, and the truth is, those first couple of years coming out of training, you have to learn more. In fact, you could argue that you do your real training once you get out, and there's nobody, you know, leaning over your shoulder saying, you know, turn here, twist here, and grabbing the scope from you and making your life miserable. So you know, how do you learn those things? And we can start with, you know, what you learn in the first practice. And that's really important, that first year, what you, how you solidify those skills from fellowship. And I alluded to some of that, you know, our recent fellows kind of talking about their first year, so I won't dwell on that too much. But it is really important, as everybody says, you know, to have a situation where you have mentors, and you have people that you can go to, and you're not just kind of sent into a room, and the door is shut, and it's just you and the patient and the nurse, and it's like, okay, perform, you know, make sure that that's a perfect colonoscopy, or do that upper, or it's two in the morning, and you're coming in with a bleeder, and you know. I mean, you've done that every night on call, but then suddenly it's you, and you know, there's nobody around. And it can be kind of terrifying. So the other part of that is you learn a lot of things, and in some practices, you won't use some of those skills, especially if there's not much of a call rotation, and some of those skills atrophy. You know, you're doing screening colonoscopies, and this is, again, this is my bias. If you're doing screening colonoscopies all day long, when you're finally asked to do something therapeutic in a bleed situation, call, or something in the hospital, you may have forgotten how to do it, and then that's really tough. So I apologize, I put this together on the flight. Let's see. And yeah, the other part is, you know, training doesn't stop when fellowship stops, and I have seen, in kind of the real world of practice, a lot of gastroenterologists who really their skill sets and their ability to do things stopped in, you know, 1995. They just never really picked up anything new after that, and what their fellowship trainers told them in 1995 was gospel, and everything after that is irrelevant. As we all know, these things, especially GI, changes so quickly. So many new devices and skills that, you know, some of which you need to know, others which, you know, you may not. But I would also say that being able to learn new things and new devices and new techniques is really interesting. It kind of keeps things interesting, so you're not just doing the same thing and life doesn't stop after fellowship. Let me just stop right there, and before, and any particular questions about, you know, the basic skills, your fellowship skills, and how you're going to kind of keep those going after you start practicing. Most of that was handled from before. Okay. I have a question about, like, when do you know when to say, like, no, I can't do this? For example, because we're so, I guess we're all kind of high achievers in college, but sometimes we come across, like, a very difficult situation, and when to say, hey, maybe I can't do this, maybe just the IR, like, for example, a couple weeks ago we had a big, you know, ulcers, large physical lessons, our patient's speed was only, like, 70, blood pressure was, like, very low, and I was, like, let's go, let's attack, let's just hold off, let's just, like, fight on. When do you learn? Hopefully, yeah, hopefully you don't learn that too late. It's really important to kind of say no, because there is a lot of hubris, and there is a lot of kind of personal expectation that you put on yourselves that I should be able to handle this, and I will dip into anecdote quite a bit. My first job, and this is, we're going way back, my first, well, my fellowship was a two-year GI fellowship, so after two years of GI fellowship, I thought I knew everything. There was only that much to know in the 90s, but, you know, I had a handful of ERCPs, but my first job, they were asking me to do ERCP, and I was, like, yeah, I can put a catheter and a cannula in a pula and a bile duct, how tough can that be, and I'm sure I caused pancreatitis and incomplete studies on the few people that I tried on, and I realized I was not helping people, and if I wanted to do this right, I needed more training, and that it was only then that I kind of realized that my training was inadequate and that some of this stuff couldn't be self-taught, and so it is the smart and wise gastroenterologist who realizes soon, sooner than I did, that I was out of my realm, I was beyond my training, and in the old days, in the 80s, it really was, you know, you learn by doing, you learn at the VA, you know, it's kind of see one, do one, teach one, really was, you know, not just a joke, but it was kind of how we learned, I don't think I saw it attending my, you know, my whole internship, it was all with a second-year and third-year residents were teaching us. That has changed, the expectations, the liability is so much higher, you just don't want to do that, if you're not trained in it, if you don't have, you know, whatever the societies are recommending in terms of volume and confidence, you shouldn't be doing it, even if there are, is pressure to do that, there's somebody somewhere most of the time that you can transfer to, you can do something, and you can kind of hold your own, you know, in a bad bleed, you can spray hemo spray and get yourself 48 hours of, you know, get out of jail free time, usually, and things like that. Yes? So, I think the confusing part for me is how do you, like at some point, you know, let's say you go to a STAR course and you learn ESD, right, at some point, you have to try that on somebody, right, so then, like, how do you navigate that? So yeah, we're not going to have a lot of time, but I'm going to get right to that, and so there's a bunch of things, and in a three-year fellowship, you are not taught, and some of it is by choice, you're not taught ERCP because it's another year, EUS takes, you know, two or three hundred cases just to know what you're looking at, things like that. Then there's this kind of therapeutic soft, you know, deep enteroscopy. You can learn deep enteroscopy almost on your own with a little bit of training. You can learn complex polypectomy because it's just an extension of what you already know by doing more with some people. YouTube University is great for that. You can watch a bunch of cases. My first G poem, you know, I was, I watched several YouTubes, you know, I'd done a bunch of esophageal poems, and so it wasn't that big of a leap, but I hadn't done it, and so, you know, what do you do? Do you say, I can't do this, I need to bring somebody in from the outside to do this, or, you know, can you extend what you know safely to do something else? You can if you have a plan B, if things go wrong, okay, if your patient knows that this is, you know, you're early, you're in a hurry, you don't have to say, you're the first person I've ever done this on, I've never actually done this, but I really want to try new. You should be upfront and honest. You don't have to be overly honest to freak them out because they're looking to you to kind of, but, so, in this kind of therapeutic light area, the courses are very helpful. As a start, just as a start, the hands-on, because it's never, you know, it's not a live person, you're doing ex vivo things on pigs, pig stomachs, and cow stomachs, and you can learn some of the mechanics, but it is useful if you have somebody in your group who has done this, and you can have somebody more senior doing it with you, even if they haven't done it. If they have more experience and they are adept at getting out of trouble, they know how to do stitching, things like that, you have your Virovescos, whatever exactly it is, and it's the right patient to do that on, or you can go, if you have a referral place, an academic center nearby that you're really comfortable with, and you send them a bunch of stuff, you've sent them, you know, three ESDs, and you say, hey, can I watch, you know, while you do this next ESD? I want to kind of, I've taken some courses, I want to watch from you to do that. And then, what you can do, you can get industry to help you, because the people who sell these tools really want you to do it and buy their stuff. So they will often, in the right setting, if you're doing something kind of newer, they will bring an expert in. They will pay them to come there. They won't have privileges at your hospital, but they're there to kind of help you and kind of guide you if you do it. We did that with our first poems. I'll tell you the whole poem experience in a minute. But that can be very helpful. And some of these reps, I have the Irby rep that we had, a guy named John Day, has been in more poems than anybody in practice, and was more helpful in some of our first few cases than some of the physicians who had done their 20 or 30. So there are resources to do that. But for more complex things, so you really want to learn ESD, well, you're not going to do that in an ASGE weekend. You're not going to do that even with 10 cases with one of your partners. Some of the things you really, if you're committed to doing it, at least at this stage, you may have to go somewhere for an extended period, whether it's three or four weeks. A lot of academic centers have connections with South Asia where they do a lot of these all the time, and you might be able to get some funding and go over and become the ESD person. And one of the things about gaining these skills, is there a need in your group? Is it something that's really going to add value that somebody's going to support you doing, especially in an academic center? It's often easier in academics to do some of these advanced things because they're used to being on the cutting edge. It's harder in a private group because they'll say, why would you want to do ESD and spend three hours doing this when you could do six colons in that time and help our bottom line? So it's tougher sometimes, and you have to justify what you want to do with it. But for you personally, learning some of these new skills can really, again, like I talked about some other things, can differentiate you from those around you. Give yourself a niche, give yourself a name within an organization and a special skill that carries with it, you know, added referrals, personal satisfaction, being an expert at something that other people aren't doing. And so what I was talking with some of these guys earlier was deep enteroscopy is a great kind of an entry therapeutic because not many people do it. It's not that dangerous. It's very learnable. And a lot of people don't want to do it because it's time consuming and takes you away from some of these other things. But it's incredibly valuable, and if you're the person in the community who's doing it, suddenly everything kind of comes to you and you're viewed as, two minutes, holy moly. So but that's just kind of the beginning. So I went back and I did, when I realized that I was undertrained, I went back and did a third year of an advanced fellowship. And it wasn't advertised, and it was a whole, this is my kind of unique story, and only because I wanted to be in New York, I had some reasons to be there, I sent a letter to the program director at Columbia and said, look, you know, I've been an ER doc before, you don't have to pay me, just don't put me on call at night, and I'll come and I'll work for free for a year if you train me in EUS. And I'll make my money at night in the ER, and I'll make more than I would as a fellow anyway. So it's kind of a win-win. And, you know, suddenly they were like, wow, I can have a free fellow, and it ended up being a perfect setup. I got great experience, they didn't have to pay for me, I didn't have to go through a special match. And these advanced programs, they're not Medicare-based. Lots of places will take you on in certain circumstances to do special advanced training. My third fellowship was when I wanted to do ERCP. In my original, that first year in practice when I realized I didn't know ERCP and nobody was really teaching it well, people weren't teaching people ERCP unless you did a special third year in ERCP. And in the early days, it was either EUS or ERCP. Anyway, one of my partners was one of the regional experts in ERCP, and I'd been working with Dick Kazarek for 10 years, who was also kind of a giant in this world. I was in his room doing EUS while he's doing ERCP, learned a lot of stuff indirectly. Then when this other ERCP guy and I went off to start a new practice, we did a mini-fellowship where I taught him EUS for a year and he taught me ERCP, and a lot of these were combined cases. You've got a pancreas mass. So I would let him do the EUS while I trained him. He would have me do the ERCP while he trained me. And within a year, we got 400 cases and got great experience. So now 12 years later, I have huge volumes of ERCP and I'm the guy that they send this to. So again, another nontraditional way of getting experience from your peers, especially if you have something to offer in exchange. You don't have to if you have an aging, retiring doc in your group and they're going to be lacking a therapeutic person and they're looking at hiring somebody just for therapeutics or they could train in-house. You can do something like that, but you have to be willing to give something up. If you're learning new stuff, it's going to cost you time, money, and effort, and you just have to be willing to kind of let that go again as an investment in your future to make things more interesting, different, and ultimately be able to do things that you weren't able to do before. POEM was one of our biggest challenges. So at my institution, this was about six years ago, I had heard about POEM and it said, this is something that we should be doing in GI. I went to our thoracic surgeons and they said, why would you want to learn POEM when hellermyotomy is such a great procedure? POEM is going nowhere. I said, well, I really kind of want to learn this, and I went to a course in Oregon. It's a three-day course. Lee Swanson was great, but I wouldn't, I would in no way be willing to do POEM on that first patient just with a three-day course. So our thoracic surgeons actually realized that we were going to be doing it sooner or later. So they went to the course and they started learning about POEM and we did our first 20 cases together. So I did this with our thoracic surgeons, combined cases. They're much more comfortable in that region, but they're not very good endoscopists. So we had the safety valve of having thoracic surgery there. If something went wrong, they learned POEM while we learned POEM. We showed them the endoscopic things, how to close the defects. They showed us anatomy and it became a win-win and there suddenly was a significant amount of volume. And before we knew it, we had 50 cases between us writing papers and it was very collaborative. So it doesn't always work like that. A lot of new GI procedures are encroaching on somebody's turf, okay? You're always taking something from the general surgeon. Sorry, that's the way it goes. But if you can get them to buy into it and do something with you and have that safety valve of having capable backup, you can sometimes get a win-win situation. And this is just the beginning. There's dozens of other new technologies out there, some of which you need formal training, some of which you can just kind of learn with a rep and the right support in your institution. Does anybody have kind of a thing that they want to learn, that they think they're going to want to learn once they get out of current training, or that you might be under-trained in that you'd need some refreshment? Yeah, yeah, and that's huge. And nobody's really training that now because it's not well-defined. And in the next 10 years, that's going to be big. So understanding endoscopic suturing, getting a chance to do as much of that as possible, understanding even some of the ESD as you oppose things together, it will be really important. And then you can take those skills comfortably to that next level. But endoscopic suturing is a very important thing, and you can learn that in your fellowship if there's somebody doing it. It's just repetition. For us, like colorectal does all the hemorrhoidal banding. So yeah, I've got a slide on that. So you know, it turns out that a lot of people want to do banding. I want nothing to do with it. But it's a big source of revenue, and it's a big source of patient satisfaction. And that's something that you can learn with the reps. You may piss off your colorectal colleagues. It depends on how, you know, where the practice patterns are, you know, if you can get them not to do screening colonoscopy, but they can have the hemorrhoids. It's easy to do. Understand that we had a patient in our community die, a 58-year-old guy, you know, outpatient hemorrhoidal banding who got a necrotizing fasciitis. There are these rare complications that do happen, even with hemorrhoidal banding. So you just need to understand what the risks are. And the red flags when things are starting to go wrong. Yeah. Okay. Is it time to change? Sorry about that. If anybody has any questions, I can give you, you know, hours of, you know, where to go and what to do and how to learn something new.

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