So I'll make one serious comment, all kidding aside, because it did seem like there was kind of a skew against academics here, subtle, but you might have picked it up. You know, what really gets me out of bed is my research, and I've been doing a ton forever. I typically publish about 40, 50 papers a year. And it's important to think about doing that. And you guys can contribute to the literature in a very meaningful way. And if you take a practice job straight out, you are likely to never do that. And if you're really, really busy in a clinical year, maybe you see 2,000 patients. But if you write a paper that's read by thousands of physicians, you could affect the care of tens or hundreds of thousands of people. So just remember, too, like, you guys are all reading those journals, and that's because people decided to contribute. So remember, there's financial rewards, but there's other rewards beyond just that. Okay. Let's talk about endoscopic efficiency. And I don't think any of you guys have actually scoped with me, but I'm known for running a very tight ship in the lab, and I get a lot done in a day. Like, 12 to 13 therapeutic cases a day is very common in my room. So as I always like to say, time is the fire in which we burn. I didn't make that quote up, but I think about it all the time, right? And as the attending, whether you are in University of whatever or private group whatever, gastroenterology associates, they all have the same names, right? Time is money. And that is just a truism, right, no matter what. Whatever job you take, right, university, hybrid, traditional practice, right, you've got to be efficient, because no matter where you are, I guess unless you're at the VA like Ashley, you're on the RVU model, right? VA, not known for efficiency. Everywhere else, you've got to be efficient, right? And this is no more true than anywhere else than an endoscopy, right? And when you're a fellow, you're not really on the clock. And they actually, at most places, they build an extra time for procedures done with fellows. We did that at University of Utah. We built in extra time slots, or the slots were bigger if there was a fellow involved, right? But as an attending, that's, with rare exception, not going to be the case, right? You're going to be expected to go quickly and to function at a very high level in a very consistent manner. On the top right, that's Randy Pouch. He died about a decade ago, and he gave a very famous lecture called The Last Lecture, where he looked back on his life as he was dying of pancreatic cancer. But he made another lecture that didn't get very much attention that I actually got a lot more out of called Time Management, because he was dying of pancreatic cancer, and he had a lot he wanted to get done. He talked about how he organized his day to basically make every second count. And I watched that a few times, and it really, really affected me. He talked about email, working on the computer, handling paper, like how do you make everything as quick as possible? So when you're the fellow, you have virtually no control, right? Like you're on the consult team, or you're on somebody's outpatient endoscopy list, or you're just doing whatever, right? You're kind of just glommed on to some sort of existing template or schedule that you had no say in. But when you're the attending, you have quite a lot of control, right? But it cuts both ways. You have a lot of control, but you also have a lot of responsibility. So if it goes well, you get the rewards. If it doesn't go well, it reflects very poorly on you, right? So just keep that in mind. So efficiency is just, it's difficult to overemphasize how critical this is going to become to your success, right? And in endoscopy, you need to move through your day in a very, very timely and efficient manner, right? If you don't, right, people will notice, and they will notice in the worst way possible. Like if you can't get a scope done on time, you can't finish on time, you're always behind, right? Patients get pissed, right? You get negative reviews online, right? I sat there in that lobby two hours fasting, dying of hunger, right, waiting for my colonoscopy. You will de facto see fewer people, right? Therefore, that will translate to reduced revenue under virtually every model out there. You will stay late, you will keep staff late, which now you don't care about if you keep the staff late. Let me tell you, when you're the attending, you cannot keep the staff late because you will have very unpleasant meetings with the nurse manager and her superiors at the hospital, and then staff won't want to be in your room, right? Anesthesia will start to say like, well, look, we're cutting you off. Like it's five o'clock. These are elective cases. We're not doing elective cases after the end of the day. Like this happens to people all the time, especially in their first couple of years out of their figuring stuff out. Now you guys aren't used to negotiating with anesthesia, right? Your hospital has set it up, and whatever the system is, that's the system you've trained under, right? But I spend more of my day dealing with anesthesia than almost anybody else, right? So like you could use conscious sedation, which is Fenton-Versed. Don't use that. It's the worst, right? You could do MAC, monitored anesthesia care, which essentially is propofol-based sedation, or you could use general anesthesia, right? And these are very, very different forms of sedation. It changes turnover time, recovery time, risks, safety, all sorts of things, right? In my practice, because of the nature of what I do, I bounce back and forth between general anesthesia and MAC all day long. And once in a great while, I'll do an unsedated case, but I don't use any conscious sedation. No more Fentanyl and Versed. That's the most high-risk thing you can do, believe it or not. So stay away from that. And you have to have a good relationship with anesthesia. You have to understand their point of view, their concerns, right? You can't treat your anesthesiologist too harshly and expect to survive. And this is something that probably you guys haven't really thought about, but a big part of your day is going to be your relationship with whoever is sedating your patients, unless you're sedating them yourself, which is true in only a few states, right? So I have a running dialogue all day, every single day, with whoever my anesthesia provider is, right? I use MDs, CRNAs, and anesthesia assistants, AAs, right? Just depends on whatever I get from anesthesia that day, right? And we're always talking about their needs and my needs and how can we get this done in the quickest and the safest way. A sad fact is that many anesthesiology attendings cannot work in GI. They cannot do it. It's too fast. They're used to, I'll go to the OR, I'll do three cases today, I'll stare at my phone for two and a half hours at a time while the surgery goes on, I'll tweak a dial or two. GI is boom, boom, boom, boom, boom. And some of them just can't do it. So like, I'm 53. I think, I'm looking around, I believe I'm the oldest person in the room, so I'm allowed to say this as the oldest person in the room. Like, if I come in in the morning and I see a 60-year-old anesthesia attending, I'm on the phone with the head of anesthesia saying, why is this person in my room? Like 80% of the time, they can't do it. They just physically cannot do it. And then by noon, we're two hours behind and I'm saying, can you swap this person out? If I see a young go-getter CRNA, I know I'm going to have a great day because they can do it. We have a no-fly list. And if a provider is just too slow, like, I'll put in a complaint. Our nurse manager will put in a complaint. The charge nurse will put in a complaint to ensure that that person doesn't come back. Because I can't be completely dependent on this person who cannot keep up with the pace that I need to do. Doug, are you OK with interruptions? I guess I am. Sorry. How do you do that in a time when we're all struggling to hire enough CRNAs? How can you get away with saying, not only do we not have enough CRNAs, but we're going to ask this person to never come work with us? GI is the highest revenue-producing group in the hospital. So leveraging that. Yeah. And we just say directly, like, we're not saying they're a bad doctor. We're not saying they don't provide good care. We're not saying the patients were unsafe. We're saying send them elsewhere. That's kind of how we do it. We often employ what's called care team, which I think is kind of the best of all worlds, where we have an anesthesia attending, supervising two CRNAs or AAs or a combination thereof. So the attending is doing pre-ops. So they're working one case ahead of us, pre-opping the patient that we're going to see next. And the CRNA or the AA is in the room with me. And then that way, as soon as the case is done, the next one is ready to go. And that's very, very efficient. So we have care team maybe 70% of the time in our lab. Sometimes they send us a regular anesthesia attending. But that's a very, very efficient way to go. And if I have a care team model, I know I'm going to be on time the whole day. It's a little more labor intensive, because it's three people doing the work of two. But the CRNAs and AAs cost much, much less than an anesthesia attending. So again, you guys probably haven't thought about this stuff at all. But your relationship with anesthesia is absolutely critical. Should you have two rooms? Some places will say, well, we could run two rooms for you. If you can run two rooms, that is with two anesthesia teams and two GI staff, it's miraculous. You could turn through an incredible volume of cases in a day. You could do an entire day's work in four hours. You could do two days' work in eight hours. It's very, very impressive. It's very hard to do, because there's a lot of competition for rooms and staff, and it's difficult for the nurse manager to juggle. But if you do it, recognize you are going to run. You're like that guy. You are going to run the entire day, and you're not going to have 60 seconds to go to the bathroom. Like, put a Foley in, right? That's the day. About a week ago, I was supposed to start cases after clinic, and then they were using my room for some broncs, and the pulmonologist got four hours behind. So then I showed up at 1 o'clock, and they were like, she's four hours behind. I was like, oh. And I had a half day of ERCP and EUS, so they said, well, we're getting her out, and we're going to give you two rooms. So I started two hours behind in the end, and I finished on time, because they gave me two rooms. And then I was able to just churn through the patients very, very quickly. Should you take a lunch, right? Look around. You may have never noticed that some of your attendings don't take lunch, right? So there's pros and cons, right? It's very civil. Like, that was nice sitting out there eating that Mexican food. It was nice. Like, we all got a break, got to regroup, right? You feel better. You feel more like a person. But you'll do fewer cases, right? And you will lose momentum. You will see the afternoon goes slower than the morning, right? People get a little postprandial. They're further from their morning coffee, right? If you don't take a lunch, you'll definitely get more done. You will make more RVUs, and you will make more money. But it can breed ill will with the staff, because they're getting paid $16 an hour. They want a lunch, right? Like, they don't really care about you and your RVU target and trying to get a $100,000 bonus above your goal based on product. Like, they don't care about any of that. So you have to balance that. You don't want to incur the wrath of the staff. If you're always trying to work through lunch, and they're having to take their lunch and shifts to accommodate you, like, that may come back to bite you. It helps to buy them lunch every once in a while. We buy lunch a lot for our staff. Pizza goes a lot. You'd be amazed what, like, tomato sauce, cheese, and bread does for people. It's incredible. But you don't lose momentum, and you really do get more done. So I generally, they, at our place, they have a mandatory lunch from 12 to 1. And everybody knows that I'm going to say at 11.55, let's start at 12.30. Like, can we push that down? So that's kind of how I've done it. Like, I can't not take any lunch, because it's too hard on the staff. But they will start at 12.30, because they are hopefully going to get out a little bit earlier. So that's kind of how I do it. And that is my lunch about three days a week, right there, a Gatorade bar. Like, it's just really tough. Like, I'm running to the floor trying to staff a consult or two. The nurse practitioners and clinic needs me to just pop my head in on a patient. So a 20-gram protein bar, 320 calories, can carry you till dinner if you have to. It's not ideal. That's my schedule for just a random day. I pulled it off of Twitter. And those are not diagnostic EGDs. Those are therapeutic procedures. So that's like an average day. RT means round trip. That means the patient's at another hospital getting an ambulance to me. I do the ERCP. They get an ambulance back. That's a round trip. In general, once you've got a few months under your belt, they're going to give you a grown-up template. First, they'll start you off on the training wheels template. Then you get the grown-up template. EGD, 30 minutes. Colonoscopy, 30 minutes. A double, 30 or 45. And I used to do my doubles in the 30s when I did a lot more general GI back in the day. EUS used to be 45 minutes. Now I put almost all my EUSs in 30-minute slots. That includes like an Axios for a cystic gastrostomy. Most EUSs, even interventional ones, can be in a 30-minute slot. ERCP, 45 to 60. ERCP needs extra time for patient positioning and fellows. It's true. But you want the training wheels. In the beginning. Right, in the beginning. Yeah, you want that. But efficiency comes later. PEG tube, 45 minutes. Even though most are quicker, sometimes it can be tricky. And then go cases, I block at 90 minutes. Because then all your efficiency is gone. If I have to scope somebody in the ED or the ICU or, God forbid, the OR, there's no place more inefficient for a gastroenterologist than the OR. Because they're not built for us. And again, that time slot includes everything. Consent, rollback, timeout, positioning, sedation, the actual procedure, me running back to the little area where I have a computer, typing that up in probation, and then talking to the patient after the procedure is over. That's everything in that time slot. But I used to think of it like an episode of Friends. I was like, man, you could get a lot done in the time slot if there's one full episode of Friends to play. So that's kind of how I think about a 30-minute slot. It's like one episode of a sitcom. And they do a lot in an episode of a sitcom. So we can get a scope done. And it's 20 minutes of show and seven minutes of commercial. That's right, commercials. So if you're doing general GI, consider adding catch-up time in. So don't let them schedule you 10 colons in a row. That's kind of a recipe for disaster. Because it's very easy to get behind if you have just back-to-back-to-back-to-back-to-back colons. If you have a loopy colon, a 70-year-old lady who's had five pelvic surgeries and takes high-dose prednisone, that's going to take you a little while longer. So what I used to always do is I would add in EGDs. I would do colon, colon, EGD, colon, colon, EGD. And I could use that EGD to catch up. If I got 5 or 10 or 15 minutes behind, you guys know an EGD can be very well accomplished in three or four minutes, especially if it's negative. And most of them are negative, right? So just recognize that you can tweak your template so you're still seeing the same number of people, but you're kind of slotting them in a way that allows you to stay on target. Also give staff a break, too. Like, you guys don't realize how physically demanding a colonoscopy can be for the staff, especially if, like, I almost never ask for pressure. But if you're one of those docs who ask for pressure every colonoscopy, and that may be a lot of you guys, right? That's very hard on the staff. Like, you know, look at that person who's giving that pressure at the end of that case when they take their gown off. They're all sweaty because they're really working, right? Well, you're just playing with the scope. You know, maybe they're pushing on a 300 pound person's belly for half an hour. Other things to consider. I try to put the hardest or riskiest or most challenging case of the day first, or as close to first as I can. You don't want that hanging over you, especially if you're starting to do something new. I started doing G-poems about a year ago. Now I don't care where I do the G-poem. But in the beginning, I really did, because I was a little tenser when I did it, because it's very involved, and it's a risky procedure, and it was something relatively new for me. And I was always trying to do them first. Then I could feel like, well, the rest of the day, I can just kind of coast, because the tough one is behind me. So a classic error is the tough polypectomy, or the difficult peg, or the ESD, or the Bill Roth II ERCP, or the EDGE procedure at 4 o'clock, right? That's not going to go well, because you're tired. Staff are tired. They want to go home. And then you're combining all that with the sicker patient who needs something more complicated. And my poor partner, Dr. Louie, who's not here to defend himself, but he once, his schedule got messed up, and there was miscommunication. And they put an ESD on for him as his last case at 4.30. And I think he finished it at 10. You know what I'm saying? It was a really tough ESD. And I said to him the next day, man, you should have done that first. And he was like, don't I know it. You know what I'm saying? It was a big dustup. You've got to be aware of the staff, right? The staff have real needs, right? And the staff, they love you, and they love being in GI, and they have no loyalty at all. None, none. Because they'll go to an ASC and do simple cases for $2 more. And most of them want to go to nursing school, or NP school, or MA school. Like, you're not a tech for a long time, right? Like, that's a one to three year job. So recognize, like, they're not really invested the way you're invested. So their threshold to go is low. So you want to make a lot of money, and you want to be busy. They're making nothing, right? So you know, they're not going to be super gung ho if you're not just adding on, but especially staying late. And for example, in Utah, my nickname was add-on Adler, right? That was what everybody in the hospital knew, because every single day, I found an add-on. Every single day. I never met an add-on I didn't like, right? But that having been said, I tried very hard not to run over. You know, and if I put on one more, I would be like, guys, it's just 30 more minutes, and I promise we'll get out on time. And I had to balance that very, very carefully. Like, I wanted referrings to know that I could be agile and get somebody on that day if they really needed to go. But I did not want to incur the wrath of my nurse manager, and my staff, and the head of nursing in the hospital. And I didn't want staff to say in their exit interview, well, you know, Dr. Adler stays too late all the time, and I have to go home to my family, right? So you've got to just kind of balance that. So yeah. Got a question, which I think is a good one. If you do the toughest case first, yeah, from the chat, don't you run the risk of delaying all the rest of your cases? Or do you kind of pattern what you're going to do, I'm guessing? Yeah, I mean, I block out enough time for that tough case, right? I know how long that tough case is going to take. So I would build the day around that. And like, when I, for example, whenever I send a patient to my scheduler, like I send them one line, like, this patient needs the RCP with me in two weeks for stent removal, 30 MAC. That means 30 minutes under monitored anesthesia care. Or 45 GA. Like, I can just tell them, like, eh, this is how long it's going to take. So if I think that first case is going to be tough or long, I block it that way. Remember, staff may not want to be in your room if it's a mad dash all day, right? And they're staying late. So other stuff to consider, right? The average, if you extract the faculty, the average age in this room is probably about 32, right? Which means you guys are all invincible. Just invincible in your own minds, right? But the reality is the overwhelming bulk of you are going to incur endoscopic injuries. It's just going to happen. We weren't designed to do these incredibly repetitive, forceful movements again and again and again and again and again, tens of thousands, hundreds of thousands of times. I'm like 40-something thousand scopes in at this point. So that's probably millions of dial manipulations, right? And elevator compressions, right? You're not built for that, right? So when you're young, you can scope all day. No problem. When you guys hit about 40, 42, 43, and earlier for the women, because your hands are smaller, right? And it's the same scope, right? You're going to start to have musculoskeletal injuries. And you're going to go home. You'll be driving home. And you'll be like, my wrist hurts, or my neck hurts, or my elbow hurts, or my shoulder hurts, or my back hurts. And I used to lay in bed and think my thumb hurts. Like, I used to lay in bed and say to my wife, like, my thumb is killing me, right? So that means that you can't do 16 procedures in a day, right? You're going to have to dial back. I'm going to show you how you can at the next talk. But are you the tortoise or the hare? Are you going to run like crazy in the beginning and then slow down? Or are you just going to keep the same pace up? None of you guys have scoped with me. I wear a brace on my left hand every day, all day. And if I wear that brace, I don't hurt. And if I forget that brace, I hurt at that night. So it's for my thumb. And I have like, it's like, it was like IBS. Like, I went to the orthopod. And I was like, my thumb hurts. And they x-rayed it. They were like, looks fine. And I was like, but it hurts. And they were like, ah, you're OK. It's functional. And I was like, hmm. But the answer was, I'm sure I have some sort of tendinopathy in my hand. But the joint looks good, and the bone looks good. But believe you me, if I don't wear that brace, it hurts. If you ever catch a photo of me in my Twitter, follow me on Twitter. But if you ever see a photo of me on Twitter, you can see the brace on my hand. Like, I put it on in my car before I get out of my car. And I don't take it off until I get back in the car at the end of the day. Because I'm so careful about it. Almost done. Should you work with a fellow? So there's a lot of pros to working with a fellow. It's a lot of fun, especially when you're near your training. You get to be the attending. You get to chat. It's a good time. You get to teach. You can say, hey, go consent that person. And you're liberated from some of these tasks. And it really does reduce the physical burden on your hands. But there is a downside. It will. They will slow you down. It's like going to the DMV in Zootopia. It's going to slow you down. And you're going to be like, as they're like dorking around in the sigmoid, you're going to be like, oh my god. I was never like this. And in reality, most of you won't work with fellows. Maybe 70%. Reality. You're going to go out to practice somewhere. Remember, you've got to be responsible for them. You have to teach them. They're not there to be your servant. You're not the servant of the attending now. The attending's job is to teach you. And they've got to really watch. You can't take your eyes off the screen just because you're not holding the scope. And you've got to look even more carefully. You've got to watch everything. We were talking about legal issues a little bit over lunch. Any error the fellow makes is your fault. Fellow perforates, your fault. Fellow misses a polyp, your fault. You're the guarantor in the eyes of the law. So you've got to watch everything. And you have to check their notes. If they write the procedure note, you don't just sign it. You've got to go over with a fine-tooth comb and then go over the changes you make with the fellow. So again, lastly, endoscopic efficiency is super critical. Tied to your revenue, no matter where you are. Unfortunately, we all live in this terrible RVU model world. But I don't think we're getting out of it any time soon. In the beginning, you're going to be very, very inefficient. And it's just true. You will be astounded at how good you will get. He made, the other guy made this point earlier. You're going to get so fast, you can't believe it. Sometimes on a weekend, if I'm on call, they'll be like, hey, there's a stone case. I don't call the fellow for that on the weekend. I'll just run in and do it. It's like in, down, act, up, cut, sweep, out. And I'll pull the scope out and I'll say to the nurse, what was my scope in to scope out time? And she'll say, four minutes. Because there's no fellow. You know what I'm saying? Like you get very, very, very, very fast, right? But that takes time, right? I've been doing ERCP for a long time. Like that efficiency comes slowly over many, many years. You've got to pay attention to your processes, like ask what works, look what doesn't work. And if something doesn't work, don't accept it, right? That's called the normalization of failure, right? Don't just get used to like, oh yeah, we suck at doing this. Or our IV team is terrible. And we always lose all this time getting IVs in. Like figure out why that's happening and change your IV team or change your process or whatever. So just recognize, right? Don't just accept the system like it is, make it better. Thanks guys. Thank you.

efficiency

endoscopy procedures

gastroenterologist

academic researcher

patient care

anesthesia providers