So, it's my pleasure to kick off today. We're going to do a bit of a panel discussion, third-tier fellowship training, pros and cons. Howard Lee, who's faculty at Baylor College of Medicine as a hepatologist, and a good friend of mine, Andy Storm, coming from the Mayo Clinic, and myself. And we're going to talk a little bit about fellowship training, so if you gentlemen want to come up here, and Howard's got some slides to start with. And again, I think, like I said, a little bit about this family tree, so Andy and I were both in the Chris Thompson lab at various time points in our life, and got to connect on the standard practice committee here, so it's kind of fun to be able to reconnect with friends. So, yep. You have slides, right? Yes. Yeah, so I'll run them. How about I run them? It's okay. You're on. So, and again, a lot of these are meant to be panels today. Some of them were talks, and we kind of converted them, and so, again, we want to be able to take questions and think about some of these things, so most of these are going to be meant as talking points, but a little bit to give you history, a little bit about what we do and why we do it, so thanks, Howard. Good morning, everyone. My name is Howard Lee, and I am a gastroenterologist and a transplant pathologist in Baylor, Houston, Texas, and it's really my honor today, I want to thank organizing committee and course directors and ASG for giving me the opportunity, so we start with our day with the panel discussion about third-tier fellowship training and pros and cons, and I'm sure a lot of you guys think about, you know, am I, do I need to do the third year, do I want to do, so I think it's a great topic to discuss at the senior fellow course, and we're going to have a couple slides just to kind of show, I, first of all, I don't have any disclosure, and the biggest disclosure is that I'm a transplant pathologist, so I thought about asking who's interested in transplant pathology, but I feel I will not want to embarrass myself here, so, yeah, we borrowed some slides from Dr. Schoenberg from last year who gave this similar talk, so well, the third-tier fellowship, you know, including transplant pathology, advanced endoscopy, CBD, you solve disease and motility, medical pancreatology, and bariatric endoscopy, there's nutrition, and a whole bunch of couples, third-tier fellowship out there, so what are the pros of doing third-tier fellowship? First of all, I think you will have a dedicated time to learn new skills, and you can, it can kind of differentiate you from others, and also open opportunities, whether you're going to private practice or academic, they open up job searching, marketing, networking, and promotion, and research, and the other benefit, I think, well, especially for me is, you know, as a transplant pathologist, one of the biggest thing I was concerning is it actually allowed me more time for research in general GI fellowship, so, and also allowed me for more time to do procedures I didn't get to do that much during my transplant year, and also the third one is, I think, for a lot of people, that it allowed you to train in different institutions, so you can have a different set of teachers, and equipment, and procedures, especially if you're interested in learning certain procedures. You can have opportunity to have different mentors, and funding, and research opportunities, and I think it also, there's a benefit of, if you are thinking about relocating, like, if you have a specific area in the country that you want to practice as attending, I think, you know, moving to that place, and do advanced fellowship there, I think that does bring up some job searching benefit as well, given your faculty there might know some local people. So what are the cons? First of all, as you know, most of the fellowship require extra year in most cases. In transplant pathology, we can do two plus one now, but in a lot of cases, like advanced endoscopy, you know, there are some places that even require two years of training, so that's definitely a con to think about, and relocation. In some cases, again, we talk about if you're changing a place, you might want to consider your family, and there's a cost of doing that as well. Also, there's a lot of uncertainty around with it, so, you know, I think a lot of third tier fellowship, because other than transplant pathology, most of them are not ACGME, so the curriculum can be very different in different places, and also, you know, including, like, how many percentage of time that you get to spend on your specialty procedures or clinics versus, you know, some program will probably still do, you do a good amount of GEN or GI stuff, so that's something definitely to consider. Other things to consider, I think, you know, we break down to three levels, what new skills you want to learn, and do I really need these new skills, and are these skills really require additional year of training? I think those are the three big questions that you should ask yourself before you make that decision. So, you know, there's several procedures that's probably not as well covered in the general fellowship, you know, including liver transplant, post-liver transplant care, complicated IBD care, odometry reading, motility, ERCP, US, of course, you know, most of the places that have advanced fellowship, general GI fellow will probably not be able to have experience doing any of those, EMR, ESD, complex polypectomy, stenting, ablation, PEG, endoscopy, hemorrhoid bleeding, POMS, bariatric endoscopy, and et cetera. So there's a good number of procedures, and if you are interested in any of them, you know, that's definitely something that you should consider, especially if your institution does not have the mentor and the faculty or the volume of these procedures. And the other question is, you know, do I really need this new skill set? What are the benefits that it can bring? We kind of talked about a little bit in the beginning, but also, it kind of adds variety to your workdays if you can do specific procedures, you know, not just EGD and colonoscopy. It kind of grants niche in the clinical research and also make you more valuable in your institution or your group, and also potentially open new lines of business and practice. What are some of the cons to think about? So most endoscopies lose actually many of the skills that learn in fellowship due to kind of narrow practice patterns, and the institution you practice or the group you practice might not require the skill you learn, and actually does not always bring higher reimbursement. So this is especially for transplant pathology, by the way. So what are some of the things to think about? So do I really need additional fellowship training? So I think one thing to think about is actually the cost will be higher. It will be a lot harder for you to learn new skills as attending, because then you will be the last one that's responsible for the patient on the paper, and there's a significant consequence to attempting to do things that you're not trained as attending. There is challenging to learn new procedures in private practice. Probably a little bit easier, but still not easy in the academic environment. So we all know that to learn new skills, a long repetition review are necessary to master a new skill, even after adequate training. So those are the things to really think about. And the other things to think about is, you know, there's really not fellowship that teach a skill that's out there, and there's not enough time fellowship to master many of this. And new procedures come out every day, every year, basically. But how to know what is needed, how to learn the skill needed, and how to get credential and safely begin practicing these skills is highly variable. There are some alternatives out there I want to mention. You know, some of the procedure you can probably learn from industry, society-sponsored courses, or you know, there's some mini-fellowship provided in some programs and some institutions, even overseas as well. But those are probably a little bit narrower in scope. You might not want to learn as much as you can. Again, you don't get that, probably doesn't get that much repetitive practice that you would get for a dedicated year-long fellowship. Also some of the programs allow you to build in your third year, but it may not be available. And also, like, kind of compress the time that you can do your general GI procedures. So kind of share a little bit about my story. So I did my residency at Duke, and then I have, because of visa family issue, I went back to Taiwan, actually been in the hospital for three years. Now when I come back for GI fellowship, I was thinking about, I know I want to deliver, but I was thinking about general hepatology versus transplant hepatologist, and you know, talking to my mentors in society, I know, you know, finding a job in academic, sometimes even private setting as a hepatologist, you really need that transplant year of training. So I was thinking about, you know, third year versus four year. There are things to consider. I was considering about the scoping time I mentioned earlier, and then, you know, and I want to do some research during my general GI fellowship and the family. And also my husband actually was in New York City at that time, so I was also thinking about stay at Duke versus, you know, going to New York. So there are things to think about. I was thinking about do I really need to relocate after, you know, and leaving the environment I'm familiar with for like six years, and then doing a, learning a new environment, and also thinking about their curriculum, you know, some of the transplant hepatology fellowship, they, you're the primary, basically the primary attending where hospital is on the service, and you know, that might take away some of my learning time to dedicate for hepatologist. So I ended up decide to stay at Duke, and I ended up doing a four year, because I wanted to make sure I have enough research and scope time during my general fellowship. You know, I really think that was, you know, thinking back, I really think it was a really good decision for my career, because, you know, I was able to focus on learning. That year I just focused on learning post-transplant care, basically rounding with the surgeons to see the post-transplant cases in the hospital and do outpatient liver clinic. I was able to do electives with positive care, hemat, transplant ID, pathology, to learn really the whole scope of hepatology. I was able to do some research time, I got 60K of research grant internally, and I probably won't be able to do it if I do everything in three years, and also complete my summer research and publish in, you know, CGH and CID. So that was, I think, you know, thinking back, for personally, there's a lot of factors to consider, but I think it is, I was still, you know, thinking back, I still think I made the right decision for myself. But, you know, it is not necessary in everybody's case to have to do a third year fellowship, and I'll have the rest of the panelists talk about experience, and we'll open up for Q&A. Great. Thanks, Howard. Andy, why don't you tell us a little bit about your path and how you got to be here and kind of your training specifically. Yeah, so briefly, I took a more circuitous path, but it was also, it also started at Duke, so you're getting a lot of Blue Devil love this morning. So Howard and I shared Duke roots, I was there for undergrad. And then everywhere I've been, they forced me out. So I don't, maybe you shouldn't listen to me, I've never been, I've never been chosen to stay where I was. And so I think like a lot of you, everyone experiences this, you have an idea that your current institution is the right place for you. I'm someone who's very dedicated to a place once I'm there, and yet I've changed locations every time through steps of training. So I went up to Philadelphia to Jefferson for medical school. I had no desire to go into GI whatsoever, really liked surgery, but I saw that everyone was getting divorced in surgery, and I had just gotten married, so I figured I should probably go into medicine. In medicine, I loved procedures, so I thought cardiology was probably the way to go. And found that I didn't get along with cardiologists, I think I joked too much for the cardiologists, they're very serious people. And so I found myself really getting along with ICU docs and the GI folks. And it wasn't until I saw endoscopic suturing and some of the therapeutic GI stuff that I thought, oh man, this is for me. Ended up switching at the very end of residency, where I had moved to Baltimore, and had canceled my interview up at Brigham and Women's actually, and said, no thank you, I'm going to stay at Baltimore. And my mentor there said, you're crazy, you've got to go see people and meet people. So I went up, or actually I reached out to the program coordinator, they said, no, you said no, we've given away all the spots. They called me the day before the last interview and said, come on up. I went up and saw and met the team there and really fell in love with the group. Went up to Brigham then for training, and same thing, I was sure I wanted to stay in Boston forever. And was convinced to go do an interview at Mayo, and I have no desire, and I still really don't have a desire to live in the Midwest, no offense to the Chicago crew, but it was a really spectacular hospital, a spectacular opportunity, and so I went out for that one year, and then I've been at Mayo for five years since. So for me, my story would tell you that changing location, even though it hurts sometimes, every move was the most painful thing I'd done up to that point. Moving places, I think, is something I would encourage anyone who asked me to do. So even if it's something you wouldn't choose for yourself, that move, I think some of the things that Howard highlighted, you get new experiences, you see how a new system works, it really prepares you then, I think, for a career. Thanks, Andy. And tell us a little bit about the bariatric training you got. Yeah, and so in a way, I've gotten two of these, I've actually never heard it called third tier, but in- I think about it first tier, but no. These third tier fellowship trainings, I do think any opportunity that comes to you is supplemental. I'll also acknowledge I had no desire whatsoever to manage obesity. Unfortunately now, you are all obesity doctors, right? You can't be a doctor in America and not be an obesity provider in some way, some fashion. So while I was at Brigham and Women's, one of the things that you could do during your fellowship, and I would encourage anyone who had an opportunity to get supplemental training, I mean, while you're a trainee, you're totally protected. So this is the time to learn. I was offered a bariatric endoscopy fellowship at Brigham and Women's, and a lot of the folks who liked advanced endoscopy were doing that at the time. And so while at the time I had no interest in bariatrics or metabolic disease, I'll be honest, my least favorite part of internal medicine by far was metabolic disease, was endocrinology. I just, I couldn't understand why anyone would consider that. And now that's a big part of my research interest, right? So I spent a lot of time talking and thinking about diabetes. So it's funny where these things will take you. I would say if you have these opportunities for training during fellowship, why not take advantage of them? So if you have an opportunity to spend more time in liver transplant clinic and you love liver transplant, of course you're going to do that. For me, it wasn't exactly what I wanted to do, which was learn ERCP, but this bariatric elective or fellowship really during my general fellowship was one of the most valuable things I've done and really, really formed my future career. Thanks, Andy. Yeah. So my story is a little different and I'm a pediatrician and so you're like, well, why, how are you sitting here? Well, one of the reasons I'm here is that I am the transplant hepatology fellowship director for our pediatric program. And I double as a therapeutic endoscopist and my passion is an endoscopy. But coming out of fellowship from Boston Children's and Mass General, I really thought that doing both and again, for in pediatrics, we concentrate a lot of things. So PSC, varices, and transplant certainly had a lot of parallel to things that might be needed, say for ERCP and therapeutics. But as a second and third year fellow, I got to spend a fair bit of time at the Brigham and that was at the very beginning of suturing. And I probably did three clips on a pig and that was probably more than they had done all year, even with the experts that they had at Boston Children's. But really felt that this was going to be a path for me. And I looked at several different positions. I looked at a job at Phoenix Children's to actually work with Paul to train me and kind of went a different path. There's less and less advanced endoscopy training where you can do it kind of as a third year or even as faculty. But basically, I negotiated to come on as faculty and then get the advanced training. So I was really lucky. Again, a lot of this is the right place, right time. And one of the reasons I feel so strongly about doing advanced training is that you kind of pick up some tools along the way and you never know when you're going to need them. Well, I was very lucky. In fact, I met Isaac Reichman at one of these ASGE courses in the spring, as well as I had met Doug Adler, who's here with us as our esteemed faculty, on my first day at Boston Children's. We had an introduction with all the different fellowship programs. And so I got to meet a few people that were in Houston at the time and said, hey, great, come to Houston. We'll train you. And again, right place, right time really worked out. And Spyglass was just taking off. My mentor was one of the primary people working with that device. And so I got to present at DDW and all the adult GI sessions and got to bring that to pediatrics really early. And so that really was, again, right place, right time. Doing that advanced training really paid off and, again, was able to kind of develop. And I certainly have had the opportunity, both wearing the liver transplant hat, taking the CAQ, which I recommend, because you never know when you're going to need it. So for example, we had a faculty member, the head of liver left, and I was the only other person that had the CAQ, the board certification for transplant hepatology. So I served the interim year, helped bring actually an old mentor of mine to help run the department. And so you just never know. There was a little bit of money that came with that, but not enough to do all the hard work that you all do in advanced training. But again, I think it gives you the opportunity, as Howard said, to do a little bit more research, focus in a specific area. Again, meet lots of people, get in front of a poster and talk, get some oral presentations and get involved in these societies. And so, again, endohepatology is now a thing. It wasn't probably when I was first getting involved, but certainly we now have an advanced training program for advanced endoscopy and pediatrics that partners with adult GI programs. And at the same time, again, growing the advanced hepatology program, as well as some of these other advanced programs that exist, I think is really important. But certainly, like I said, I think you never know what experience you're going to need. And whether it's a pandemic or some other unusual event, there are sometimes skills that you have acquired that actually become really valuable. And so I think that's another thing that a lesson learned is that, you know, pick up as many skills as you can, but within reason, right? So I wouldn't take seven years and do, you know, fellowship after fellowship after fellowship, but several people have done things like that and become very successful. So you have to know yourself. Again, you mentioned lifestyle. Certainly you don't, you know, a one-year fellowship, I talked to a fellow recently in the last two or three years that kind of situations worked out that we had an available spot and they had a situation that worked out that they were available and said, hey, come to Houston for the year. These are all the great things you're going to get. And I really think that this will be valuable. And I think if you, I know if you ask that person now, they would say, absolutely. And so again, I think you have to balance life and everything else, finances and where you are in the world. And I think it certainly matters. But certainly want to take questions from people. We certainly have a few other questions we can, I can ask our, my co-panelists and some of the other faculty. Ashley. So I just want to make a comment. So, you know, you can do advanced training, but there's also other things that I have examples in my place where I had a third year fellow who wanted to learn how to take out big polyps, which I think is a great skill. In fact, if I never did another ERS or ERCP and just did big polyps, I would be fine with that. But he spent the last six months with me. We would line up all the big polyps and we would, you know, and I was sort of learning it. It was a number of years ago or sort of trying to figure out which snares we liked and what injectate we liked. And so we sort of worked together. And so now he does big polyps and he actually practices near me. So he sends me the befores and after pictures all the time. So he's taking away my business. But so you can do that. Or we have another faculty who started getting involved with cystic fibrosis patients. So she's made that her niche. She didn't do an extra year of training to do that, right? She just did it within the course of you identify a need where you're practicing and you do it. Another one of my former fellows, who's now faculty with me, became interested in esophagology and motility. So she spent three months with Mike Vasey down in South Carolina. Now, she did take time out of practice to do it, and now she does all the motility. So there are things within, and I don't know, you can speak about the transplant hepatology. I understand that people are not becoming board certified because you can do that without being board certified. So an extra year is great, but there are also things within, when you're a third year that maybe you start recognizing or you've identified a practice and they say, we would love to have you, but we really need someone who does X, Y, or Z. Or you might notice that at that practice, they don't have someone who does something, and you realize that you can make yourself even more valuable. I mean, you don't have to have a niche, but you also don't have to do a fourth year to do some of these things. So it's something also to think about. I mean, a year is not a big deal, and I agree. You're gonna be, I mean, I've been in practice for almost 20 years, and I'm like, when can I retire? And I did five years of fellowship, so I thought it was a big deal at the time. Like, oh, do I do this extra year? And you're head scratching one year in the grand scheme, although you've been training for forever, so you'll probably wanna get a job. So I think those are things that you can do without an extra year. It's a great point. Go ahead, Gabrielle. Just to piggyback on that, are these mini fellowships, some of the things that you mentioned, are they widely available to find, or are they kind of something more along the lines of, oh, I met this person, and they have a place for me for three months? I mean, I think you can do either. One of our advanced fellows actually went to Japan to do some ESD. So you can, it's again what Doug was saying about people you meet. So you come to these courses, you meet somebody who, like, hey, can I come hang out with you for a couple of months, or what, you know, I don't know. It's, there's lots of different opportunities that I think, again, you know, I just had a fellow who went to the Brigham and did bariatrics in advance, and I'm trying to explain to him, like, endobariatrics is becoming a thing, but it's not quite a thing. I mean, no one gets paid for doing these things. So I was trying to convince him, all you have to learn is how to do overstitch, and you'll be, you know, you'll be fine. So, you know, you do have to think about, you know, how long you wanna train. I don't think you can do, go two months and learn how to do endobariatrics. I think it depends upon what it is. I mean, like, big polyps is an extension of tools that you're already learning how to do. So a lot of these are sort of extensions of things you're already learning, so that's a little bit different, I think. Like transplant hepatology, if you have a place that does a lot of transplant, you can obviously, right, I mean, you can learn those, all the things you need to know without doing more time. And there's programs, like, in the US, there's, I think, there's still a guy in Montreal you can spend a month or two with him, and you pay a bunch of money. But I think you're- A lot of money. A lot of money, yeah. But I think your point is important, Ashley, that, so one of the things I think, and especially when you have a tight job market or something you're really interested in, sometimes you have something to offer a program, but they have something they need. So you don't wanna do obesity, but they have CF, and you really wanna do that. And so you can barter a little bit of, hey, I'll do that, but you're gonna get me trained in this. And so I think there is some give there, and I do think, again, a lot of networking, of saying, hey, I have a friend in Mayo who maybe you could go spend some time in learning bariatrics there. I have a colleague who is at Children's Hospital of Philadelphia, and he did his sabbatical for his professor year at Hop, and he was the advanced endoscopy fellow. And so there are numerous pathways. Again, I spent several sessions with Karen Woods seeing enteroscopy when I was a junior faculty. And so, again, it's just a matter of kind of being in the right place at the right time and meeting people, and so I think that's always, and again, I have a fellow, to Ashley's point, so my current partner, she trained, she did it after doing her three years of pediatrics, did an IBD year, she got the Pfizer grant, and then got another grant to do advanced endoscopy, so she did another year. So there is value in that, and again, just like endohepatology, clearly there's a role for advanced therapeutics and inflammatory bowel disease, so there's certainly overlap so that you're not, these extra years are not mutually exclusive. I think seeing that there's a path and trying to think about where you're gonna be, not your five-year plan, because I don't even have one, I don't think, but kind of thinking about things that make sense and so that you can explain it when you're sitting in a group of 15 interviews when you have one, something like that. But your time is quickly going away from you, so the easiest time to do these mini rotations or sabbaticals is while you're a fellow, because your salary is very low. Your ability to be protected through malpractice insurance is much easier. You're usually covered by your home institution, and then rotating at an academic center, same thing, we'll be able to cover you. So having the Stanford fellow who came for two months this year to do endobariatrics with us was very easy. If he had tried, if Doug said I wanna come for two months and do something, that's a little bit more challenging because we have to get that physician credentialed. But a fellow visiting can have hands-on time just through a fellowship rotation. So use your time wisely. If there are things you think you wanna do now is definitely the time to reach out. And this is one of those it-never-hurts-to-ask things. Worst case, Doug tells you no, you can't come learn two-year-old ERCPs, right? Please, come. Doug. And that's hard, because the microphone is like over here. Talk to Ashley's, and then. So a couple things. One is, some people do these like a liver year to try to get into GI. That's totally different than doing a liver year after GI. So I think that for these fourth years, like I always tell people, don't commit to a fourth year unless it's really all you wanna do. Like you have to have passion for it. Oh, wow, thank you, man. You guys hear that? So like I see a lot of people are like, I don't know what to do. I guess I'll do this advanced endoscopy year. And then they discover they don't really like advanced endoscopy. Like they didn't go into it because they were passionate. They did it because they were like, I'm not so thrilled with general GI. And then what happens to those people is they join a practice, and then two years after their advanced year, they discover that they've done 30 ERCPs, right? And they wasted a year, right? And that cuts off the last year of practice, right? A year where you'd be making a lot of money, right? Because you can only work so many years. Every year you're in training, you cut that off. So like I see a lot of people doing these advanced years that I don't get a sense that this is really, really what drives them. So like I always say to people, you're gonna do the last thing you trained in. That's what you're gonna do forever. Everything else is gonna kind of fall away, and you're gonna do that last little thing. The other thing is, Ashley, I also did a five-year fellowship because Ashley and I are old enough that when we did our advanced training, they wouldn't let you do ERCP and EUS in the same year often. So I did my ERCP year at Mayo where I had been a fellow in Rochester. And then I realized during my ERCP year, I wanted to do EUS. And then at DDW, I just kind of winged a fellowship. Like I reached out to people, like I had a lot of coffee with people, and then Doug Pleskow at the BI Deaconess where I'd been a resident said, yeah, we'll train you in EUS. And he said, we don't have a first. We don't have an EUS fellowship, but you could be our first. And then my first job was at UT Houston, and I went to them and said, will you pay? And they said yes. So like literally in about 72 hours, I made an EUS fellowship for myself. So like you can kind of, if you're a good schmoozer, you can kind of, you can play a game and make a lot of stuff for yourself completely outside of ordinary channels. And there's still an opportunity to learn some of these advanced procedures like Ashley said. And although ERCP now has kind of gone towards a more dedicated fellowship, my kind of funny story is that as a third year fellow, I went over to the Brigham and the fellow, the advanced fellow really was never around. And so actually there was more opportunity. And I was just trying to figure out how to use the duodenoscope. I wasn't even really doing ERCP. And funny enough, and Doug may remember this, but when I came to Houston, that same fellow actually had taken the job at UT and really wasn't around. So I was able to do cases. And so I was following this guy and actually even more cases for me to be able to do. So you just never know, again, right place, right time. But there are always opportunities if you're kind of keeping your ears open. And again, you gain mentors as you go. I got a piece of advice, which I haven't really followed, but I think like to share. One of the hepatologists at Boston Children's said, you're interested in all these things. You gotta pick something because you want someone to come into your office and ask you about and be the expert in this. And you really do wanna carve a niche for yourself, but at the same time, there are ways of having multiple niches. But I think the principle is there is that you really wanna be seen as the person that does X. Now you don't wanna pigeonhole yourself, but at the same time, it is good to have an expertise. I think people value that. And programs when they're looking to hire, like I said, they may have a gap and sometimes you're the person that has to identify that gap for them. That's true in pediatrics. There are still numerous places that don't have advanced endoscopy. Some of them still think that that's okay. I would argue that they need it. But until they start seeing that US News cares about it and that we care about it as a society, they don't realize it. So sometimes you have to bring that to people's attention even if it's not in your direct field. Yeah. I want to piggyback to that question. So I think, yeah, the mini fellowship is a lot of them are hard to find. A lot of the time you have to reach out to people and kind of create your own self. I think a lot of our faculty say the same thing. I have a question for Andy. This is from the virtual audience. Do you expect the shift in the traditional paradigm of advanced endoscopy training to be only pancreatic obiliary or only third space or bariatric endoscopy? So specialized third tier in bariatrics, third space, in addition to the current US ERCP. Yeah, so it's a tricky question. This is predicting the future. I hear a lot of our panelists saying to you, be careful about this extra year and use it well. If you're gonna use it, make sure it's something you need because I can think of a number of really great fellowships around the country where in those three years of general fellowship, you can leave a competent US and ERCP provider. And I think, again, those of us who have done the advanced endoscopy fellowship, those of us who offer it to our fellows, I think there are big advantages to doing that extra year of training. But honestly, for a lot of routine ERCP, we're not gonna have enough ERCP docs out there with just the ERCP fellowships. And so if, again, for some routine ERCP, probably for EUS, there is a role for some of the fellowships who can bundle that into your three years. When it comes to advanced endoscopy in particular, you're right, it's become so big. It's become such a beast in terms of the number of subspecialties within advanced endoscopy that I think there's gonna be, you're gonna see separation. So in our own program, we offer, I think which is what most programs are doing now, very bread and butter, high yield, high volume, EUS and ERCP. And that should be the guarantee of any advanced fellowship, I think, today. And then from there, you can pick your kind of third skill. So during the second half of the year in particular, someone can focus on third space and poem. They can focus on bariatrics. They can focus on, maybe they need to clean up their large polyp and luminal stenting. So it kind of provides you that opportunity. That's a one-year fellowship. The only two-year fellowship that immediately comes to mind is Hopkins, although there are a couple of them. Is Duke two years as well? Yeah. They recently offered that one-year option too, but that has been two years. So that's a huge commitment. You're gonna be PGY eight or nine at that point, which is, that's asking a lot in my opinion. That's really to help create the next academic leader. So if you're considering those programs, it's because they give you a full year or plus of research time. And that's to help you build out your academic CV with the hopes that you'll be an academic leader in advanced endoscopy. So that's not for everybody. But yeah, I think the future will absolutely have to involve a little bit more subspecialization within advanced endoscopy. You already see pure advanced bariatric fellowships like at the Brigham. You can go spend time, even some of the private practices. One of my med school classmates, it's a small world, but one of my med school classmates has a purely endobariatric practice, makes millions of dollars a year, working out of Cary, North Carolina. He has now an office in Atlanta just doing endoscopic sleeve procedures. So we just FDA approval for these devices recently, CMS coverage through a temporary code is already here. So we're seeing insurance coverage. So I think some of these specialties, bariatrics has moved a lot faster than third space, for example. ESD still doesn't have appropriate billing and reimbursement codes, but bariatrics is there now. So I think we will see more. We're thinking through that ourselves. How do we offer just that to someone who just wants to learn bariatrics? For now, I think these ad hoc mentorships, so reaching out to someone that you know after you've shown some interest in the field can get you that training. For example, one of the Stanford third year fellows came and spent two months with us this year and will be starting a bariatric program at the Stanford VA. So you don't necessarily need that fourth year. I just want to comment. I didn't mean that you could do two months a year. I very much disagree with basic ERCP. How do you know that a stone case is gonna be easy? Oh, that's bread and butter, but you go in, there's a diverticulum, you gotta put a PD stand, you gotta do a needle knife. So I totally do not agree with, and I want to clarify, that ERCP should be done by someone who did a couple in their third year. Absolutely not, and I think that is going away because you can kill people with an ERCP. I mean, there are other things I suppose you can kill people with, but ERCP is simple enough and you're like, oh, I just go in and I make a cut and get a stone out, but people can die from that, and people who are like 25 years old who have a biotic stone can die. I mean, honestly. So I'm talking large polyps. I'm talking things that are like extensions of what you do. I don't, you know, I'm not sure that I agree with going someplace and doing two months of something. I mean, how many ERCPs are you gonna be doing? How many are native papillas? I don't know that I agree with that. I don't agree with that. But I think these other. There'll be some state programs, you know, where honestly the fellows will finish in three years. Some of you may know this and may be doing this yourselves. They'll finish with more ERCPs than an academic program will get ERCPs. So I think of Wake Forest. I think probably most practicing ERCPists didn't do a fourth year at this stage of the game. They're older. I mean, those are the ones. I mean, honestly, when I applied for advanced fellowship, there were like 15 programs. Now there are 75. So, you know, the people before me, you know, the people who trained me didn't do fourth years. This would be a great debate, actually. Do you need a fourth year? And I think I would probably be, I would be happy to play the devil's advocate against an academic in that, you know, I think there probably is a role for that, you know, rural physician who can do, can pull off doing maybe 100, 150 ERCPs a year, has maybe general GI fellowship training in that procedure, and is the person who's gonna help my family member when they're fly fishing in Montana and they develop, you know, cholangitis or something. I, you know, I want there to be access to those procedures. And unfortunately, we don't all have, you know, Doug Adler next door. So I would say, if you feel that you've, you know, reached a certain threshold of skill, if you feel comfortable, I think it's okay to not have that advanced training. But if you have an opportunity, you can put yourself in that position. I think it's, I mean, again, I- You'll come to ASG- Well, again, you're talking to a program director, right? Yeah. You're talking to a program director, right? So I, obviously, I think it's important. That's how I spend my time. And again, I'm a low, compared to many of you, I'm a low volume ERCPist, doing kids that are, you know, less than 10 kilos up to 300 pounds, right? So I have my days sometimes like yours and sometimes not at all. But, you know, we have a large transplant fellowship, or the large transplant program. So we have volume. But certainly, I think the path that I took of doing it, you know, I had two full days a week for almost two years, and got several hundred ERCPs in the US, is probably not a thing anymore. It's certainly, there are programs, you know, if you went to a program that didn't have an advanced fellowship, they're likely to train their second and third years to have lots of procedures. Again, are you gonna get those critical volumes? And again, we think about, specifically in pediatrics all the time, about what are the numbers to competency? Again, that's a whole nother argument, a whole nother conversation. But, you know, you really can't be assessed for competency until you've done your training. And then you can really be assessed. And again, many of you have written on these topics. But again, I think to Ashley's point, there are certain procedures, right, that bode well probably for, I don't wanna put words in your mouth, that bode well for getting a focused training. And there's others that probably do require a more focused, or a more dedicated program. I'm also biased in that I, again, like for pediatrics, like I really want not a triple threat, but like if we're gonna train you to do hepatology, or that I really wanna see that you are gonna develop as a leader in the field, that you're going to, or be researching in this area, or be part of advocacy. We don't talk about that much as another kind of pillar. But there's certainly ways of being experts and learning to develop. And again, your program may not have that. In pediatrics, we require advocacy, just as an example, for FDA approval of devices and equipment, right? That doesn't really, it's not an issue for the adults. And so again, some people have expertise in that, and you can kind of harness that to kind of move forward. But certainly there's, in terms of doing or not doing the training, I think it is a, you know, to do or not to do. And again, I think if you have the, a place to go and it makes sense, I think, go for it. Like I, there's very few negatives to doing the advanced year. Again, it's your time, it's your future career earning. As Doug said, it's one extra year before you can retire, and one less year of making real money. So I think those things are real factors. But for the purpose of time, is there any other questions from the audience for this panel? I have one more question that came from the virtual audience. The question was, for those, someone who's considering, say, a community practice, as what they already know that this is what they want to do with their career, is it necessary to do a third-tier fellowship to have a niche in a particular field as you look at a community practice? What are your thoughts? I think yes, yeah. I mean, everyone needs to have something that they're interested in, I think, to stay in love with GI, to stay in love with what they're doing. So I think it's important, actually. And when I look at, you know, I have family that are in a large community practice in Pennsylvania. Three of my siblings are docs, and they are, they're all in community practice. And they get a lot of joy out of that one thing that people from all over the community and other community practices send to them to deal with. So my brother, I can't imagine this. Like, TMJ is his thing, right? So he's an oral surgeon. And that's gotta be the worst problem out there, but he's known as the TMJ guy. And so I think having that probably brings you some satisfaction. And it does bring you recognition and definitely helps with your referral patterns as well. Maybe not necessarily a third-tier, but having someone who's a third-tier but having some sort of niche, you think, is helpful. And there are a lot of examples here within the faculty, probably in the audience too, of self-made people, right? Who seek out this EUS opportunity or this pediatric advanced endoscopy opportunity that's not really a thing, but they wanted to make it their thing. So I think there's no limits as to what practice setting you're in to make something like that work. Yeah, and the comment about someone off in Montana, I would like to... We train people to go to West Texas knowing that they're gonna be there and maybe to train someone so they're in Montana if you're fly fishing and have a bile duct injury or something so that there are experts kind of in the periphery that they don't have to stay at Boston or Utah or somewhere. So anyway, I think that's a great session. We're gonna move on to our next talk, which is which practice setting is best for me. And I'm gonna add Doug Adler to the mix, but we're gonna talk about private practice, academic large group and a hybrid kind of academic private practice. And so Linda, if you could come up, Steven and Paul Berggruen, come on down and we'll talk a little bit. Thank you for the current panelists. Thank you.

third-tier fellowship training

gastroenterology

pros and cons

new skills

job opportunities

networking

research

challenges