Twitter. I'm not joking. So I always say this, I borrowed this from Dr. Soren, but time is the fire in which we burn, right? So when you're in attending, time is money, right? And this is true, like you may not like this, this may not be the world you envision, but it's just it's just the way that it is. It's true whether you're in academics or whether you're in practice, especially now that academics has gone kind of to the RVU model. And in endoscopy, right, a lot of labs, like the nurse manager's job, like is to make sure the lab runs smoothly, but your job is in part to make sure that you work hand and glove with the nurse manager to keep your endoscopic practice running smoothly. You know, when you're a fellow, this doesn't really enter into your thinking. You can go slow, you know, like take whatever time you want, and it doesn't really kind of factor into the way that you view your day or how things are supposed to go. But when you're the attending, immediately, like, you know, you finish your fellowship on June 30th and you start your job July 1, and then they will expect you to be efficient, period. So you better be ready to kind of move into that world. If you get a chance, you should watch Randy Pouch's video on YouTube called Time Management. Randy died about 15 years ago. He had pancreatic cancer, but he wanted to accomplish a lot between his diagnosis and his death, and he made a video about how he used every minute of his day to try to get a lot done because he had very finite time. It's really worth a watch. So again, when you're a fellow, you don't really have any control, right? You don't make the schedule. You don't even have your own schedule, right? You don't really get to decide what's on your list, what you do. You don't get to say yes or no to anything. Like, you're on a rotation, you do the scopes associated with that rotation, right, or their order or what kind of sedation. Like, you have no say. So unfortunately, like, we don't really train you guys to kind of run your own room endoscopically when you're in fellowship. But one of the nice things about being an attending is you have a lot of control, right? But it cuts both ways because if you have a lot of control, it also means you are responsible. So if it goes well, you get like the plot, it's if it doesn't go well, you get the blame. So it's just critical to your success as an endoscopist. You've got to move with alacrity, right? You've got to get to the schedule, right? On the schedule that you plan to do that day, you cannot be the person who is chronically behind. And you guys all know who that person is. Like, in your fellowship, there's that one attending who's never, ever, ever on time. And like, it sounds funny, but it's not, right? The patients get mad. Delays tend to stack up, right? So if the first case is 30 minutes late, then the second case will be 45 minutes. And then all of a sudden, like, the one o'clock case is getting done at 4.30. And that patient is pissed. And that patient's gonna go on healthgrades or vitals.com and say something nasty about you guys, right? Because I, you know, like, my whole day was ruined waiting around for this procedure. You'll make less money if you run behind. It's just true. You will stay late. You will also cause staff to stay late. And then if staff stay late, staff have to be paid overtime. And then the hospital will start to notice that every time you're on, we're paying four hours of overtime to the staff, right? And then you'll get a call from the COO. Like, this is literally how it happens. Again, whether you're at university or a private job. And it all kind of feeds back, right? You'll also start to run into issues with anesthesia, right? Because anesthesia may start cutting you off, right? They may say, well, look, you know, you run so late every day. We can't keep somebody in your room. Nobody else does this, you know, after six o'clock. We're no longer supporting your cases, right? Then you may be telling patients in the waiting room, we're not going to do your procedure that you've been waiting here four hours for. So anesthesia or sedation really, really varies wildly based on where you are. And for example, at our site, we use MAC or general anesthesia for every single case. We don't use conscious sedation or fentanyl and Versed anymore, practically for anything. It's actually, in many ways, it's the least efficient and the highest risk way to go. But some places, especially VAs, still use a lot of conscious sedation. They really, really, really do differ in terms of efficiency, turnover time, and things like that. It really isn't an ideal plan for every patient or every type of procedure. We have universal anesthesia access all day long and we bounce back and forth between MAC and general anesthesia all day long. And like, before every single case, the anesthesiologist and I will talk for like literally 15 seconds and we'll say like, here's what we're planning to do, here's the type of sedation, here's how to position the patient, do they need antibiotics? Like that's like our 15-second huddle. And it's very, very, very effective. Right now, you guys probably don't know your anesthesiology attendings, but you're gonna get to know your anesthesiology attendings very, very well when you're in attending, right? And you're gonna have like a running dialogue with your anesthesia provider all day, every single day, right? Because, you know, they need to know what drugs, is this patient ASA 1, is this patient ASA 4.7, right? Like, how long is this gonna take? How deep do I have to go? Do I have to paralyze them? Like, this is what anesthesia is thinking, right? So you have to balance safety with efficiency, right? Not every person can go under general anesthesia or nor should they. Kind of a dark truth is that many anesthesia providers simply can't work in GI. It's just, it's a very, very fast-paced environment. You know, like I said earlier when I was up at the panel, like, we routinely do 14 to 15 advanced cases per room per day. So that is not a room for somebody who is slow. And I think, I have to look around, well, Bill is, Bill is in the back. But other than Bill, I can say this because I think I'm that, other than Bill, I think I'm the oldest person in the room. But if the anesthesiologist shows up and they have a gray beard, I'm doomed. Like, like, I know, like, ah, the day, the day is messed up because it's hard. Like, you need somebody who can go fast, right? So, like, for example, we really, really prefer CRNAs and AAs that are staffed by an attending because it's just a fact they, they tend to be much, much faster. Some anesthesia attending struggle out of the OR. Like, they've been in the OR, you know, since the Reagan administration. And it's really, really hard for them not to be in the OR where they have every single possible support mechanism at all times. And endoscopy, you know, they have to be willing to sort of be more independent and fly on their own. So we have a no-fly list. And if somebody really, really struggles in GI twice, we call the head of our anesthesia group and we say, don't ever send them again. And like, because we are such a big revenue generator for the hospital and the hospital system, like, they have to pay attention to that. So we've had some people that have come up to me in the hall and be like, hey, they never put me in GI. And I'm like, I wonder why, it's so strange, you know. But we've literally kind of like, we've shown them the door. As they say, we've handed them their hat. We often employ what's called the care team model. One anesthesia attending supervises two CRNAs. The really, really good thing about this is the attending is doing the pre-ops, right? So they're consenting the next case while you're doing your current case. So then as soon as you're done, that patient is woken up and then the CRNA can just go out and then just roll the next one back because the pre-op's all been done. Whereas if you just have an anesthesia attending, they have to do all the pre and all the post on everybody. And typically the anesthesia attending is present for, like, the induction of anesthesia or the intubation and then they walk out of the room and it's just you with the CRNA or the AA. We can't get this all the time because this is very, very highly in demand, like OB and interventional radiology and interventional cards. Like, they've all realized, oh my god, this is a much better way to go too. So there's a lot of competition and some of this too depends on where you live in the country. And for example, in certain parts of the country there's almost no CRNA or AA presence and in other parts of the country it's dominant. So we're kind of in the gray zone. We get it about 40% of the time, but I wish we could get it every day. So should you work out of two rooms, right? Like, two rooms is very appealing because you can bounce rooms, right? Like, as soon as one patient is done, they can put the next one to sleep and then you can just go, go, go, go, go. And sometimes, for example, people on Twitter will post their schedule like, oh, I did 37 procedures today, right? And those people are almost always using two rooms, often with a scribe, right, or somebody who is doing 90% of their documentation. It is amazing what you can do in two rooms. And for example, for us it's hard to get two rooms, but once in a while, if we're really in a pinch, they will give us a second room. And like, like, once I finished clinic and I had had eight procedures scheduled for the half day afternoon, and then between, you know, when clinic started and clinic ended, I added on six more ERCPs. So it was noon and I had 14 advanced cases. And anesthesia said, we'll give you a second room. And I said, great. And we were done by 530, you know, because we were just bang, bang, bang, bang, bang, bang, bang, bang, bang. And it was fantastic. But it's very hard to get because there's a lot of competition for rooms, right? So it's often hard to give two rooms to one doctor. If you can get it, it's great, but it's hard. And recognize, too, that if you are going to two rooms, you're gonna be like that guy. Like, it's, it's exhausting. Like, you know, you don't drink a lot of water because you're not gonna get a chance to go to the bathroom. Should you, should you eat, right? Should you eat, right? We were just talking about this here today over lunch, right? There's pros and cons to a lunch break, right? Like, and I go back and forth about this, and I mostly am in the no column. Like, if you eat, like, it's more humane, it's more civilized, right? You feel better. Like, you need, like, a pause in the middle of the day, right? The staff will really like it. The staff will appreciate the fact that you are letting them stop. Because remember, the staff run a lot harder than you do in a lot of ways that you don't realize. They're washing scopes, they're running up and down to the scope room. You know, like, the staff work very hard. And it does give you time to kind of physically, mentally, and emotionally kind of regroup for the afternoon. You will always lose momentum. The afternoon virtually always proceeds slower than the morning. It's just how it is, right? Like, it's often very difficult to replicate the pace and efficiency of the morning in the afternoon, especially if you take a break. I usually skip lunch, because almost always if the staff say to me, or the, or the nurse practitioner says, can I, can I put a case on in your lunch hour? I'll say sure, right? Because I get more done, right? And I like getting a lot done. You make more money, right? I'll hit my RVU target a little earlier. And it sounds like, oh, how could that be? But if you add one case on a day, right, just one, that's 20 more cases a month, right? Which is, you know, factor that out over the course of the year. And all of a sudden, you start thinking, maybe I could put two on over lunch, right? You could kind of see, like, very quickly where the mind goes with this, right? The staff may not like it, because if you don't take a lunch, it means that they have to start swapping people out. You know, like, you'll be in the middle of a case, and you look over, and you have another tech. Like, oh, they switched, right? Because they're tagging each other out so that they can get a lunch break, which they don't like as much, but it, but it's a way to do it. I often eat a protein bar for lunch. Like, that's just, you know, I throw it in my bag when I leave the house, and I have a protein bar, and, well, that's not the greatest meal. And I was thinking about RFK Jr. was like, we're eating all these ultra-processed food. Did you guys see he said that? And I was like, oh, that's me. Like, I'm eating all these protein bars. Like, that's ultra-processed foods. But you don't lose momentum. And when you work through lunch, like, people just kind of keep churning away. So it's actually, I don't know, again, I, I kind of, about 80% of the time, I fall to the no-lunch side of things. But different people have very strong opinions on whether they do or don't want this. How long should you schedule, right? When you're the attending, you get to say. And like, for example, every time I schedule something, I tell the scheduler exactly how long I want it to be. They don't get to decide. Like, I'll say 30 minutes under monitored anesthesia care, 40 minutes under general anesthesia. Like, when I send that message, and they, they put it on the way I want. A good rule of thumb is EGD 30 minutes, colonoscopy 30 minutes after about your first year. Your first year, you probably will need more than 30 minutes for a colon. An EUS, when you start out, 45 minutes after a while, you can get them down to 30 pretty easily. ERCP, we generally schedule them for an hour, knowing that we can do almost all ERCPs in less than an hour. And it's almost a way for us to catch up and get a little bit ahead on the schedule. PEG tubes can take a little bit of a while. And anything where you have to leave the lab, all bets are off, right? If you go to the ICU, easily 90 minutes. The OR, could be 90 minutes, could be four hours, right? You don't know. You could get bumped because of trauma. Like, anything could happen in the OR. I will do anything in my power not to go to the OR. Like, the surgeon calls me like, hey, we're in the middle of the colon. Could you come up and take this donut? No. No, I cannot. You know, like, they're like, but, and I'm like, we'll do it tomorrow. Like, it's, you'll lose four hours, right? It's just, it's just not, it's great for the patient, and I admit that it's not great for anybody else. So, like, I just politely demur when they ask me to go to the OR. And remember, like, this time slot is all the stuff on the bottom left, right? This is everything you got to do in that 30 minutes. It's not the scope. It's consent, rollback, timeout, positioning, sedation, procedure, probation, and talking to the patient when the case is over. And again, most of you will take jobs where you don't have a fellow. So, you're gonna have to do all of this yourself, right? So, just recognize you're gonna get quick in a hurry. You can build catch-up time into your schedule, and for example, when I was in Utah, I had a general GI day. I don't really have that anymore, but, you know, they used to do, like, okay, we'll put on 16 colons for you in 30-minute slots. I'm not making that up. That was my general GI day. It was 16 colons over eight hours. And then I started saying, you know, make every third an EGD, because sometimes you get a little behind. There's a big polyp, or the patient's had pelvic surgery, or they've had pelvic radiation, or, you know, something works against you when you get behind. And then, if you have 16 colons, it's very hard to catch up. You're just kind of, you know, it's always a question of how far behind are you? Like, if one case rolls late, every case after that is a problem. When I discovered that if I added in that EGD at regular intervals, it often allowed me to kind of catch up and get back on that 30-minute sort of hamster wheel in case I got behind. It also gave the staff a little bit of a break, because remember, you're not the one giving pressure, and colonoscopy is very physically demanding on your techs. Other things to think about, right? I try to put the highest risk or the toughest case first. That way it's not kind of hanging over you, and then once you get that done, the rest of the day you're just kind of coasting. You're like, oh, we're on the downslope now. Like, we did the highest thing on the super risky patient. One of my partners, he got in trouble because he was scheduling 4 p.m. ESDs. Don't do 4 p.m. ESDs, right? Because he was finishing at eight, nine o'clock, right? When no one was there. The surgeons were gone. Everybody was gone, and he was taking out an 11-centimeter lesion in the cecum, right? You don't want to be doing that, but that was the best. There was a time that he could find to do it. Recognize that the staff's perception of you matters, and like, if you're always late, or you can't stay on time, or you struggle with every colon, like, they're not going to want to work with you. They'll make it clear to the nurse manager that they don't want to be in your room. My nickname has always been, wherever I've been, it's always been add-on Adler because people know, like, oh, that guy, he's going to find other cases. You know, like, if you put me on like a desert island with like one tree, I'd be like, who here needs an ERCP? You know, like some people, just like their radar is always on, kind of looking for cases, and that's kind of how I am. So, because I'm always adding on cases, and always filling up my day, like, I have to kind of pay it back to the staff in other ways, and like, for example, I buy lunch for the lab about once a week. I'll just, out of my own pocket, I buy lunch, I'll buy lunch for the entire lab about once a week, and believe me, they notice, right? They get it. Other things to consider, and we talked about this a little bit, is endoscopic injuries, right? So, that's Albert Einstein on the top. That's the same person, right? Right, that's like when he was a fellow, and that's when he was like a GI attending, right? Like, you know, like, you physically change, like, your, you know, like, your joints, and your bones, and your tendons, like, all this stuff wears out. So, just recognize that in the beginning, you can scope at an extremely high pace, and then you may find over time, as you accrue injuries, that you have to have a lighter day, right? Or you have to have that break, and like, you know, for me, I mentioned earlier, I wear that brace. Like, if I don't wear that brace, my hand hurts. If I wear that brace, I'm okay, but I have to wear a brace all day long. The difference between the older attendings in the room and you guys is just time, right? Like, I'm literally, I think I'm like, 57,000 scopes in. Like, that's my actual number, right? And just think how many motions each of those scopes is. So, you could see why over time, like, you start to wear out. Should you work with a fellow, right? And some jobs will have the opportunity to work with a fellow, and there's a lot of benefits to working with a fellow. It is fun, right? You get someone to kind of hang with, and chit chat. There's a lot of, like, banter during the day. You get to teach, which is very rewarding, right? They can do paperwork. Like, for example, with our advanced fellow, as soon as we finish a case, I run out and consent the next one. He's writing the procedure note. By the time I'm done consenting, I open the note and kind of polish it up and sign it. He does the timeout in the next one. So, we're kind of like playing leapfrog all day, the advanced fellow and I. And it does reduce the physical burden on you. Like, I'm sure having a fellow will lengthen my functional work life, because I only take the scope when they're having trouble, right? So, that's less wear and tear on my joint. The big downside to having a fellow is they will slow you down, period, right? Even the best fellow, they cannot go as fast as an attendant, because it's just how humans learn. Like, you learn by practice and repetition over time, right? So, just recognize that, you know, even if you take an academic job, if you're in an RVU model, that fellow will de facto cost you volume in RVUs. And again, like, people start having to make these decisions, like, hmm, right? Remember, too, that if you work with a fellow, you are responsible for them, for every last thing they say, do, write, everything, right? So, that means you have to watch them. So, if the fellow drives the scope through the cecum, right, you're responsible, right, period. In the eyes of the law, you are the guarantor of the procedure, right? So, if the fellow does something dumb or wrong and the patient is hurt, it's all on you. They may sue the fellow, but they will 100% sue you. So, just recognize that, like, the fellow isn't a free ride. The fellow needs to be actively watched all the time, right? I always joke that, like, the minute you take your eyes off the fellow, they make an error. Like, you can never, like, not look at the fellow. And their notes, too. Like, you can't just, like, dot a test in Epic, right, and sign the fellow's note. You have to read the fellow's note and adjust it or adjust your comments in the note to reflect, you know, actually, I agree with the fellow's note except for the following point. Don't just rubber stamp the fellow's note. So, we're three minutes ahead. So, how's that for a vision? So, again, this stuff is really, really, really important. And again, right now, you guys are in that sort of, like, luxury grace period where you don't have to worry about this. Like, you're just on the fellow's salary. Doesn't really matter. But the second you get out, like, all of a sudden, you have to become very, very aware of these things, right? And recognize that in the beginning, you will be inefficient. Like, you're just gonna take a long time. Whether you're doing an EGD or an ERCP or whatever, it just takes time. This is how human brains learn, right? But your efficiency will almost always get better over time. But it's worth, even as a fellow, starting to, like, look around and think about the process. And for example, most of you don't go in the room during the turnover because you're doing over other stuff. Go in the room during turnover and see if they're moving quickly or if they're moving slow, right? Watch how your attendings talk to anesthesia, right? Watch how your attendings are watching the clock. Like, you're probably not even aware of the clock. Like, I'm looking at the clock constantly in procedures because I've got to get the day done, right, in a good and reasonable manner. Thank you guys very much.

time management

endoscopic practice

efficiency

anesthetic practices

teamwork

Randy Pouch