I am Rebecca, obviously. Yeah. So, Mohammed Bilal, and I'm an assistant professor of medicine at the University of Minnesota and an advanced endoscopist at the Minneapolis VA. And really, thank you to Dr. Gleason and Dr. Mergener and the ASGE for having us. And I'm going to be talking a little bit about academic. As you will see, there's a lot of overlap as your first year goes by. And I just want to put a disclaimer that it's not that both of us have figured out how to do this year, and we're sort of figuring this out every single day as we go. So I'll let Rebecca sort of introduce herself, and then we'll get going. Oh, thank you. Yes. And we'll talk a little bit more later, but as Dr. Mergener mentioned, thank you, I did join a private practice group about a year ago that has 13 partners and about three advanced practice providers. And yeah, so we're kind of going to tag team because there are a lot of overlaps, of course, with the first year on the job. And then we'll try to narrow it down, kind of how there might be some differences between our two. Yeah. That worked. Okay. As you can see, we're still figuring this out. Oh, so I guess I'm up first. Yeah. So this is just a little bit about, I work for the Digestive Health Clinic in this private practice group in Idaho, in Boise, Idaho. We just recently, when I joined, it's delayed a little bit because of COVID and things, but we opened a second ASC about 20 miles or so down the road. And so we provide coverage as well to the community hospitals affiliated. So I do have one week every six to eight weeks where I'm covering the hospital, and in between we cover this other regional medical center as well while we're in the IEC or in the clinic. And this is sort of where I am at right now in the Minneapolis. It looks great right now in the summer, and I don't want to even tell you how it looks in the winter. And then next slide. So we decided to sort of break it up into some tips, and these are, like I said, lessons that we have learned and still continue to learn. So the first thing I think Dr. Mergener pointed out a little bit in his talk is this is like towards the last, like a lot of you are second years and third years, the last sort of half of your fellowship. So learn as much as you can, and once you've sort of figured out, especially for those of you over the next few months, figured out what job you're going to go to, try to figure out what is going to be the need in that practice. So for example, you might go to a place where you are expected to do EMRs, or you're expected to read capsules, or you're expected to read manometries. And try to refine some of those skills once you go on to your practice. Yeah, and that kind of takes us to the next step of how can you be prepared to do that, not only in the training now in your last year or two, but collecting those materials as well. Right? So the example that he gave is I'm responsible for reading a lot more manometry than I really was during fellowship. So keeping any kind of book or handouts that you were given would be very helpful to me now other than up to dating every time. So to that same extent, things like quadri settings that you use, just to have easy access is very helpful. Also, EMR systems may change. And so you might have tons of dot phrases that you've saved from your current medical record system that won't necessarily translate. It's not an epic, but make sure you kind of copy and paste those because those still will be very, very helpful for you. So that I've appreciated. If there's something that you're always referencing, make sure you just have it handy because the pace is going to get a lot faster. And so if you are constantly referencing the guidelines for elevated LFTs or something like that, maybe you want to make sure you save that. We'll talk more about necessarily billing, and that will come up different. The other thing is how to prepare. When I first got there, it was helpful, but it also took some time with getting the contacts for, I mean, you're going to be seeing a patient in clinic, and you're going to want to refer them to a nutritionist, and I don't know anyone in the area. I just moved to Boise. So if I had, you know, getting, kind of doing your homework and getting who people refer for nutrition. I mean, surgeons, maybe you'll be a little more familiar with. Oncologists, hopefully you'll be a little more familiar with. But sometimes a patient really wants, you know, do you have a recommendation for a PCP because you really want them to get a PCP and things like that. Do you have anything to add for those? No, I think that was, you know, like for just an anecdote, like when I placed my first esophageal stent, you know, my advanced fellowship, I was just clicking on, and then the whole esophageal stent diet would come, and I'm like, wait, how many days do they need to be on liquids? How many days do they need to be on soft food? So just like a so small thing that you're doing in your fellowship, once you go into practice, you might not be available for that. So all those things that you sort of do on a daily basis, especially if you're going to a different institution, try to make sure that you have those templates, you copy those, you know. There's several softwares, like for example, in our fellowship program, we use a lot Evernote. We put all sort of our notes in Evernote, and we all have access to that. So I refer it all the time to see, you know, like I'm doing like a celiac plexus block. So, you know, what is the mixture that I need for different drugs that I need? Versus, you know, in my new place, they might not just know it, versus in your fellowship in a busy program, you're like, I'm doing a celiac block, and all the nurses know exactly what to prepare. So that's just a couple examples that came to mind. And ours in clinic, a lot of the providers have their own handouts. For instance, you want to describe a FODMAP diet to a patient, and they have kind of the resources. So if you have your favorite one, that'd be easily adopted. And then, you know, this is wherever you go. So for, you know, Rebecca obviously will talk a little bit about general GI, but like I do advanced endoscopy. So one of the things that I think has been a really rewarding learning experience for me has been sort of building your team, because especially a lot of you are, as I know from interacting with a lot of you over the last, since yesterday, are going into advanced endoscopy fellowship. All advanced endoscopy fellowship programs are robust and big programs. So you have, you know, experienced nurses and technicians, and you're doing all these complicated procedures, but you will go into practices or where you will be expected to be, you know, leading an advanced endoscopy suite or building. So for example, for me, like at the VA, you know, one of my clinical sites, I have, you know, there was not a formal advanced endoscopist there for a couple of years. So I had to sort of train the nurses and techs, and this was a new role for me because I was used to, you know, I've had background in medical education, so I know how to teach medical students and residents and fellows, but all of a sudden, I was like, how do I motivate now nurses or to provide like cutting-edge procedures and, you know, start bariatric endoscopy or full thickness resections? So first thing I did is I, you know, met with the advanced endoscopy nurse who was there, and I sat with him for an hour in my office, and I'm like, tell me what you want from me, how you want me to be, you know, deal with you guys in the room. How do you want me to give you guys feedback? And you tell, and then I told them what I expected of them. And the second thing I did is I talked to our charge nurse, and I was like, I don't want like there's 15 different nurses rotating through my advanced endoscopy room. Let's figure out who are the four or five dedicated nurses, and we'll want to train them and work with them alone so that they are there because, you know, there's so many equipments and if you are used to an ex, you know, Boston, I have no conflicts of interest, the Boston Scientific stand in your fellowship, but a similar stand might be of Cooke. And the deploying mechanism might be literally, you know, a minute difference, but if you don't know that difference, that could be a make or break in a case where you did so many. So it's important to make sure they are aware. So I told them, like, if you are never comfortable with an equipment, I want you guys to tell me, and I empowered them so that they didn't feel like saying no is not. And you know, create a culture of collaboration and empowerment where they feel comfortable speaking up. Like, hey, you know, because sometimes you're doing a complicated procedure and you're tunneled vision and you're, and these are role applies to general GI procedures. Like you don't do something that you don't do very often, for example, a PEG tube. So you might just be going in the rhythm and, you know, nervous as your first month out as a faculty, and you might miss a small step. So the more your nurses feel empowered and engaged to say, hey, I think you're missing this step. And they are not like, oh, you know, this doctor is going to get upset with me. So because you don't have an attending behind you, so they are sort of a safety check. And then, you know, make sure you appreciate their input. So if they ever pinpoint or, you know, there's been points where, you know, I'm deploying an over the scope clip and they caught something that, oh, it's not all the way down. At the end of the procedure, I'm like, hey, thanks so much for doing that. You know, I go tell the Chardoners. So they feel like they are equally involved in the cure of the patient as I am. And I always say, you know, if we did a complicated procedure, like I started full thickness resection at the Minneapolis VA, and I'm like, this is not my success, this is all of our success, and they feel involved. And I'm nice to them. I take them out to dinner here and there. I buy them lunch here and there. And what that does is, at the end of the day, if there's a late case, and we all know the late case is always the complicated case, then I don't have, they stay late for me, even if it's not their late date. And that's a difficult culture to develop, a lot of us who experience working at a VA. But based on those roles, you're able to do that. And that's how a lot of your attendings who've developed successful advanced endoscopy programs or endoscopy practices, that's what they've done. So I definitely think that those are important things that, they're still helping me and help me help them. So we wanted to share with them. I don't know if you have anything else to add on that, Rebecca. Oh, I didn't, this is my only, like, in the times of COVID group setting, there's a lot of young, we were volunteering at a Shakespeare Festival locally for our group, but, and there's a lot of children there, they're high school children. I guess the other part of a team that might be different, and maybe in private practice compared to an academic setting that I first, that I've interacted much more with, for instance, our billing department than I ever had before. And I think that that, just all the people in the team, and just talking about how important it is, but there's interesting things that you can find out through there, right? I didn't realize, kind of a different thing from fellowship, but there might be a patient where you want to not charge for that procedure, for instance, and I can easily email the billers and say, please don't charge this patient for this, whatever reason. So we, I'm fortunate, we have a, I have a primary nurse that's assigned to my panel with me. And so that relationship has been very important to develop over this past year as well. And then, I think this cannot be emphasized enough, we talk about finding a mentor to succeed, to get into residency, to get into fellowship, to get into advanced fellowship, but finding a mentor during your practice is equally important. So if you, whether you want to do an academic practice or a research practice, education is going to be your focus in academia, or it's going to be clinical practice. And I think Dr. Gleason mentioned this yesterday, Dr. Vicari, everybody mentioned this yesterday, Dr. Dominic's, that the mentor doesn't need to be in your same field. You can have a life mentor. You can have a mentor who tells you, you know, how do you balance work and life? How do you get involved in national societies or local organizations, or how to work with industry? They can be from your department, they could be local, or they could be outside. And then very important in your, in your, in academics, but even in, Rebecca can add to that, but even in private practice, know your local referral base and talk to them. You know, when I, when I do a procedure that was referred by someone, give them a call back and say, hey, you know, this is what we found, this is what we did. And you will, that will go a long way in building your practice, and just getting your name out there. And then based on that one call, you're going to get 15 more referrals because they're going to talk about it. And then the last thing that I think has been extremely valuable for me is the concept of peer mentors. So all of you guys here today are, it's an opportunity forever to know each other and collaborate with each other and talk to each other, because you guys are going to go into different practices, learn different things, and exposed to different diversity in your practice. So stay in touch. So, you know, Jen and I met at a ACG conference two years ago, and we exchange notes all the time. And I've learned so much from her. And Rebecca and I have known each other through social media for the last couple of years, even though this is the first time we've met in real. So I, and if I do a complicated procedure, and I'm like nervous about calling my actual mentors, and they'll be like, you're asking me such a silly thing. We went over this 200 times. I call my peer mentors, and I'm like, hey, tell me everything that has gone wrong in your one year of practice when you start doing this procedure. And I'm like, tell me every single complication. What do I do if I misdeploy the axis in the gallbladder? And I go over every single thing because I feel really comfortable with them, asking all those questions that I might not. So I cannot emphasize the importance of peer mentors more in your practice. Yeah. And I think maybe it's different in a private practice versus, you know, a lot of my mentoring or clinical questions. And I've learned over time, kind of, who do I ask if I want to be maybe more aggressive in this case? Or who am I asking if I want to be maybe less aggressive in this case? But additionally, I was fortunate to start with another fellow recent graduate as well. And so together, we've been able to learn kind of the ropes, and that's been very valuable. So this is sort of going back to that point I made that, you know, are you doing a complicated procedure? And that doesn't necessarily need to be an advanced endoscopy. You know, you might be, some of you might be the first ones in a small practice that you were starting in EMR. Or you're doing something that is not complicated, but you don't do every day in your practice, or you never did it every day in your fellowship. So make sure that you review all the equipment and steps with your staff. You communicate the plan with anesthesia, or if you're using sedation. And the reason I say that, and then, is because sometimes when you're doing something new or something complicated, especially when you're early on, and I do that, and it still happens to me, you get, you're nervous, you know, and you have all this pressure. There's no attending behind you. There's no one to ask. So if you've discussed everything with your staff, they'll be like, hey, you know what? You said that we need to do this, but you never did this. And I'm like, oh, thank you for pointing that out. So take that extra five minutes and make sure that your staff is on board. And then have a senior colleague, peer mentor, someone available around, like, hey, can you be around if I'm doing this procedure? Or maybe nowadays, virtually, if you have. And then, you know, I think Dr. Mergener mentioned that, but as a fellow, you never realize the importance of collaborating with industry. You know, because collaborating with industry seems like, oh, you're just, like, working with industry. But what it really means is that, like I said, there's new equipment coming out, and some of you might have been trained in, like, for example, Olympus scopes, and now you go to and you're using a Pentax scope. So work with your local industry representatives so that they can tell you all those. Don't hesitate to reach out to them. And they can also train your team for any new equipment that you want. And I have found them to be extremely helpful. And I cannot emphasize the importance of building that relationship with your local industry representatives, especially for the equipments that you use every day. And kind of piggybacking off of that, I have a different slide that was similar to that. But working to the standards of my group was, I think, something that I wish I had known more about asking before I started. For instance, where we are in Idaho, therapeutic resources are limited. So we have one therapeutic guy for our group, and he's spending all of his time doing EUS and diagnosing pancreatic cancer, right? We're not referring large polyps to him versus in my academic training. I would say I had less large polypectomy training because that went to therapeutics and we had a therapeutics fellow. And if I had known that, I would have spent more time. And so instead, I was trying to learn that and taking the time from my therapeutic colleague while I was a new attending. So I guess knowing what's kind of expected. And so that is kind of not a necessary complex procedure, but PEG placement, for instance, in our group is a single provider process. And in fellowship, right, there were two of us. There was the attending and the fellow or two fellows. And so all of a sudden, I had to figure out, how am I doing everything? How am I holding this? How am I doing the skin as well? So that was a little bit of it. And that's where, you know, talking to the nursing staff and so knowing, okay, what are you guys familiar with doing in a PEG placement? And what am I expecting you to do versus what are you expecting me to do here? And that communication, that was an example of kind of just the standard that's been set. And we can talk about it. It got mentioned last night too, you know, clip placement, I feel like was a very different thing for us in fellowship and when you would place clips versus in our practice where it just kind of was emphasized that clip placement is probably less done than it had been and balancing, well, when should I actually be doing that? And that was something. But I feel like I also brought to the group new and kind of cut and, I wouldn't say, the fresh from fellowship things, right? People weren't really ordering anorectal manometry much, but it has to go through our local surgeon's office. I don't necessarily, but I'll read them, for instance. And so doing much more anorectal manometry or kind of pushing the curve more towards a cold polypectomy and meeting that standard and bringing some new IBD management as well. Oh, this is just kind of like a thing for a break and kind of advice that I had gotten along the way in this last year about keeping your practice broad, for instance. You know, if you're being offered, you know, do you do RFA? Well, I'm not going to say no. If someone's willing to work with me, I will do RFA kind of thing. Or in practice with confidence, I think some of the feedback I got really early on was that the pathologist was saying my biopsy bites were a little small. And so they had said, maybe you need to be a little more confident with your biopsies. So I mean, maybe you'll get that feedback as you go, and I wanted to get that feedback. But I guess this one is me, too. So I think this is a very difficult tip and a very difficult slide, and obviously there's a lot of nuances. This is Dr. Jorgensen had given this talk previously and gave this tip, but work hard and make a good first impression, but try to find some work-life balance, too. How you're going to do that I think is going to be an art, and I think it's going to last throughout. This is my first year, right? But I think it was helpful in a way, so it's good to set boundaries as long as you're willing to pitch in and help when it's really needed. What's been interesting in the times of COVID, where we started, I started when the partners maybe had had less productivity than they were used to, and I started with another hire, and we were asked to do more clinic than was in our contract or was initially expected for us. And would we work on our day off? I typically work four days a week, and we work our fifth day every once in a while and do an extra clinic. What is the boundary do you set, but also wanting to be there to work and be productive and help out when you can? And so I think that is something to keep in mind. She had offered the advice of taking a vacation day after call if you can. I think that's probably your preference if you only get so many vacation days, if you're not planning on taking weeks at a time, maybe that is a nice option for you. Yeah. I told Rebecca that she has to do this one because I struggle myself every day to maintain work-life balance. And I guess that kind of goes into this one, but you can take it from there. Yeah. No, I think we've talked about it. As you go in, you have this imposter syndrome sometimes to feel like, well, maybe I need to prove myself to someone. You have to remember that every single attending that you've ever worked with goes through that in their first few months. And if someone said that they didn't, that's probably dangerous. So nobody expects you to know that. Your nurses, techs, they have seen people start on July 1st as an attending, and just like when we started first-year fellows. So nobody expects you to know everything. It's okay to take a pause. It's okay to ask another colleague. And I do it all the time. So it's important to know your local resources, know your surgeons, know your radiologists, know your intervention radiologists. one of the advice that I got when I was graduating my advanced fellowship was like, you know, the first few months, don't do any EUS until you've reviewed the imaging with the radiologist. And I was like, oh, this looks a little excessive. But then the first week, I was like, I got burnt. And now I do go to the radiologist, and that's improved my radiology skills tremendously, even though I thought I was better, but you realize you're not. And then don't just take a pause. Sometimes I even ask my general GI colleagues, I'm like, you know, what do you think? Do you think this 90-year-old, I should do this procedure or not? And what do you, you know, what would you do if this was your dad? And I get really great input and insight because, you know, they're thinking from a different hand. So don't, you know, your colleagues are only going to respect you more for asking their advice and opinion and taking a pause. And don't feel that you, you know, the pressure that you, if you ask, it's a sign of weakness. It's a sign of strength. Yeah. And I think to that extent, also over the past year, it's morphed for me a little bit. In the beginning, right, the first month out of, you know, of attending, I was texting all my former co-fellows, right? Any question that was coming up, what would you do here, what would you do here, we had this huge thread going with all of us. And obviously, I still reach out to them, but now it's more morphed into me asking my partners, you know, as you get more familiar with who you want to approach and things like that. So I emailed my, you know, former attendings for advice and that in very difficult situations as well. And, you know, I just wanted, and, you know, I know we talked about peer mentors again, but as most of you guys know, I cannot finish a talk without making a plug for social media. So especially in COVID, we realized when we weren't meeting like this for a year and a half that, you know, we were still able to engage and get opinions from others and talk and see what people are doing, how people are, you know, dealing with COVID or how they are doing endoscopy. So, you know, social media is definitely a great tool where you're able to work with different people and know how they do different things in practice. And I've learned so many different things by just seeing like an advanced endoscopy that someone will share from, you know, Germany or Japan and they'll be like, oh, you know, we do this. And you're like, oh, that makes, or just a tip on, a small tip on how to do a, you know, a day-to-day procedure. And you're like, that makes perfect sense. Or someone says, hey, this, if I use, do this, then the hemo spray doesn't clog. And you're like, wow, that's a genius. So you're, you know, we are all, as Dr. Mergener said, they're sort of protected or in our bubbles because we train at a place, we work with the same attendings, but there's 10 different ways to do the same thing and there's no right or wrong. It's nice to know all those things in your toolbox. So even if you're not an active participant, just by being there, following conversations, listening to people, you know, it's just the modern, one of the additional modern ways of learning in addition to all these other educational tools we have. So take advantage of that because it's free and everybody has access to it. So. Yeah. And, and my, the nurse that I work with has been so helpful in like a different sense, but in terms of knowing what tests are going to be covered by the insurance company up front or what, you know, this patient's insurance is not going to cover the rifaximin, give them the samples kind of, that's been so helpful in saving time or, you know, an IBD medications and this person's insurance, you know, January 1st change, and now you're going to have to make sure they've had six weeks of steroids. I mean, just these little things that they've pick up on and has been really helpful. And you know, early on, you also want to build a reputation and you know, I think we talked to some of the, you know, you guys yesterday and it's like, you know, once you first start, take the time before you start doing something to introduce to your collaborators. So for NGI, we're going to collaborate with colorectal surgeons, esophageal surgeons, foregut surgeons, interventional radiologists, oncologists. The first time you're calling your colorectal surgeon shouldn't be, and you're like, hey, I'm the new GI guy here is when you're dealing with a perforation. So talk to them, meet with them. And in terms of, you know, we talked a little bit about it earlier in building, building practice is slightly different from being a fellow because, you know, as a fellow, you're doing so much work in some of the busy programs. You are seeing 20, 22 consults and if someone puts a consult for occult blood positive, you're like, oh, another consult that, you know, could have been seen as an outpatient. But as when you're in practice, you know, one of the best ways to build practice, someone calls you, that's an ask for help. Someone needs your expertise. And all you have to say is, you know, sounds good, I'll take care of it. You know, and that goes a long way of people knowing that you're available, you're accessible, you're easy to talk to, you will, because a primary care physician might just have a small question and you just say, you know what, that's no problem at all, we'll do this. And then that will help get the word out, will build your brand, and then build a brand of being safe. You know, people should trust you that if I send this patient to Bilal or Rebecca, and I know that they are going to take the best care, they're going to be thoughtful. So it's, I don't ever, you know, don't be shy away from being aggressive, but don't be overtly, so find that, you know, middle ground, just like anything in life, being in moderate, where you do what's best for the patient, but always remember that early on you still want to be safe, have low adverse events, and always do right by your patient. And educate your referring physicians. You know, if they don't, that education should be like, oh, this is the wrong consult, you're like, ah, absolutely happy to take care of them. By the way, you know, for ATC, you don't really need a biopsy. But it's not like, you know, where they feel comfortable coming to you with silly questions, because that's how you're going to build a practice in your regional area. Oh, and I wanted to bring us back, kind of as we conclude, I do have to give credit to my mom for giving me some of this advice, actually, she's a primary care provider, but I feel like it's really been pertinent to, we talked about building your reputation and how important that is, but I think if you're doing right by your patients, I think that your reputation will follow, and keeping that in mind. Yeah. All right, so then we wanted to thank Dr. Jorgensen, because she did provide some of the tips from a previous talk. She was involved in this course last year. Yes. Well, take any questions. Thank you. So, Mohammed and Rebecca brought a number of really important points, reflecting their various experiences that they've had. So in order to make sure that you get an opportunity to ask questions, this is obviously something that is very near and dear to you. We'd like to sort of see who has a question to ask either of them. Go ahead. Yeah. So, I've got some answers on this, but I think it's, and I would love to hear what both of you have to say, but how long does it take you to achieve efficiency? Because I certainly have not done a full day's worth of colonoscopies, so how long does it take for you to get to a place where you are achieving the same level of efficiency as your partners? Yeah. I think, you know, it'll be variable for, I think, all of us, just because there are some things that you're going to be more comfortable with and some things that you're not going to be comfortable with. I would say that it took me maybe around, you know, three to four months to get, like, more efficient than when I first started. Like I can give you, you know, example that when you're doing a U.S. and, you know, first time I see the mass in my first day, I, like, have to 100 times make sure that that's the mass before I biopsy it. And now I do it, like, maybe, you know, then I started doing it 10 times in my mind, now I do it three times. So it's like a natural progression. But then, you know, there are some other things that you'll get. So it's very important in your, one, to talk to your partners and see what works, you know, and find out. And there's a really good ASGE talk from our video tip of the week from Doug Rex on this topic where he goes over his day-to-day efficiency model and how he does it. But it's like asking your colleagues, like, do you want to, you know, do your consent first and do the, you know, procedure, then do the report. So maximize your efficiency in some of the other things and then take time in things that you are less comfortable with. And then same thing with procedural steps, like, you know, you might be really, you know, try to make up more time for a straightforward procedure so that you can give yourself a little bit more time in doing, for example, a pet cube that you're not super comfortable with. So think about your whole day. Prepare as much as you can. I can't tell you that the most preparation I've ever done in my life for cases has been in this advanced year because I literally walk through each step of the procedure the day before and how quickly I'm going to go through and I tell my team, this one's going to take long. I talk to anesthesia. This one's going to be quick. And you try to, and you know, obviously unexpected things can happen. So think about efficiency is also equally important because you're only going to be able to accomplish all that. So I think if you prepare all those things, think about those things, think about how do you maximize your efficiency in between procedures so you can take a little bit more time during procedures. So those kinds of things I think will be helpful. But I'm sure it'll vary. I don't know, Rebecca, if you have anything to add on that. I mean, I think you said a lot, a lot, very well. I'm not sure I have too much to add. I think it probably took about the same time, a couple months. I'm not sure I would say I'm necessarily even as efficient as my partners are. And a lot of that comes from things like I had to learn to be more comfortable with large polypectomy, right, that were taking longer time in the beginning. And I do think, and certain kind of efficiencies, once you learn the system of your ASC or wherever you're scoping, it's going to flow much more easily. I got some advice from a partner too about kind of the, how much chatting you need to do depending on the indications. You know, screening, colonoscopy, they just, you know, just go do the consent and they want to get in and out too. And that was good advice, I think, versus someone else who's there for their, you know, initial EGD for epigastric pain and wants to talk a little bit longer. So I think it, probably a couple months, but that's going to vary on a lot of things. We have a question from the virtual audience. Perfect. So for a new GI attending who's mainly in an outpatient ambulatory center doing procedures, how would you go about getting an endoscopy slot on the inpatient side? So if you have a patient who's higher risk, like has a high BMI or OSA, and you need really an anesthesia slot, how do you go about doing those procedures if you're primarily outpatient based? I'm sure that varies very much based off of the practice and the practice that you're joining is probably going to have a system for that. Certainly you wouldn't be alone in needing that. So we have certain comorbidities that need to be done at the hospital, for instance, certain BMI cutoffs, and those are automatically set up so the scheduling department does them. And if I run into a patient who was scheduled in the IEC and I feel that's not appropriate, we need to do it at the hospital, you know, I can just contact our scheduling department and work on the schedules that way. But I think it's going to be very, very dependent on where you're practicing. They should have something in place, but that's a good question for you to ask. Any other questions from the virtual audience, Jen? Not at the moment. I think Klaus Mergner, by chance, did you say you had a question you wanted to ask us? I was curious if I asked you about one issue that you really didn't expect this year. Anything that stumped you during your first year where you would say in hindsight, had I known this, I would have prepared differently, I would have maybe spent some time on X, Y, Z. Anything that came up during the year or not? Maybe not. I think I've mentioned it like five times because for me it was the polytectomy, the large polytectomy, and had I known to prepare for that and gotten more training and fellowship, so that was probably the big one. You know, I think for me it was, you know, and I sort of alluded to that a little bit in how I sort of tackled it, but you're doing all these procedures in a busy fellowship program where everything is an autopilot, you have a tech, you know, who basically can do everything, and they're doing it, you literally know all the instruments, and you're just like doing whatever everybody else is telling you, and then all of a sudden you go and they're like, so what settings do you want for this? What size? And you're like, I don't know, whatever size you guys do, like whatever, like I remember in my first job interview, a very famous advanced endoscopist asked me, in the three months I did my advanced fellowship, he was like, what wire do you use? I'm like, whatever the tech gives me, like I don't know, so I think, but, you know, then you're going to be the one who's going to be making those decisions, and so that definitely was something that I think a lot of our attendings tell us throughout, like try to learn the equipment and try to understand these settings, but it's also not, you know, I will say it's also overwhelming because you're trying to do so many things, so the way I sort of navigated that and I alluded to that is I worked with industry, I, you know, made sure that I had the local representatives be there, they can train the nurses, get me more comfortable with the equipment so that I could really focus on, you know, I don't have to worry about like, you know, where do I need to pull back to deploy this in the first couple of months, I can really just focus on, you know, doing the technical part of those things right, but that was definitely something that, you know, I think that I realize more and more of is very important in fellowship that I wish that I just, you know, spent an extra half day to just learn some of those things, and sometimes that's all it takes, you know. I thought of one more thing if I could add. I don't think I had enough training, and I see probably almost every patient wants to address their hemorrhoids, and that was something that was lacking for me in fellowship training, so any kind of hemorrhoid training experience that you can get, I'd recommend. Yep, absolutely, go ahead. Thank you both for a helpful and practical presentation. One thing that you both brought up is the importance of getting to know your non-GI colleagues, your surgical colleagues, oncology, radiology. What did that introduction look like? You know, was it sending them an email? Was it setting up a meeting? Certainly they're busy, and you don't want to be perceived as like imposing on their time. How did you do that? I think that's a great question. Actually, when I interviewed, I did not meet with any of them, and one of the feedbacks I gave to my bosses for the new hires is like, I literally spend more time with the surgical oncologist on the phone than I do with my sister, maybe, so I was like, I wish that I had met that because if that person ended up being, thankfully ended up being a great colleague, but ended up being someone I did not like, that would have really swayed my decision to work there or not, so I definitely tell, encourage you all, and that was one of the things I wish I had known, thankfully it worked out okay for me, is that once you go on an interview, make it like a priority, depending upon, so if you're an IBD expert, you need to talk to the colorectal surgeon during that interview and see what they feel about, say, you want to do a strict traplasty or other things or, you know, whatever. If you're like a Minnesota gynecologist, like, what do the thoracic surgeon thinks about, oncologist, stuff like that, and then into your next question in terms of meeting with them, you know, I made it a point, and as soon as I got there, I asked my boss, I was like, hey, can you send an email to the forehead gut surgeon, the surgical oncologist, the IR chief, and these people, and introduce me to them, or, you know, your partners, and now that we have two more junior partners, I did the same for them, because, you know, I have the best relationship because of the advances with them, I made sure that I introduced them right away with them, so if they have a, you know, versus she'll believe they can't control, they're not just, you know, the IR doc doesn't know who's calling them, and stuff like that, and I think you'll realize, like I was alluding to earlier in the talk, that as a fellow, you think, oh, you know, it's a different specialty, sometimes there's a little bit of, you know, not that much camaraderie amongst different specialties, but when you're in practice, they want the same relationship for you, because especially we are fortunate to be in a specialty where a lot of other specialties rely on us a lot, and vice versa, so they want to have that relationship, so, you know, if someone is not wanting that relationship, then that's, that person's a problem, you know, that, it's not on you, so I would not be hesitant to reach out to them, and they will appreciate it, that's a great point, by the way. I would say, actually, the expectation would be that you do meet with them, it might be directed by yourself, but bear in mind, when your early career, like the two guys here, you are their peer, they may have been already at work for 5, 10, 15 years, but you are their peer, you're all now in a level playing field, so it behooves them to meet with you, and you can, you know, build a collaborative practice, you get to know each other, you get to know who to refer to with certain problems, etc., so, and the reason why I'm just sort of belabouring the point is because when you raised the question, you said, should you email them, should you meet them face-to-face, you don't want to bother them, you've gone beyond that, you are now their peer, so don't forget that, that's really important, you don't have to be deferential, you have to be respectful, but not deferential all your life, okay? Any other questions? Yeah? I'm wondering, from a clinical standpoint, like in clinic, I mean, Mohamed, I don't know how much clinic units I have anymore in your practice, but like, especially for Rebecca, could you give us maybe your top three efficient tips in clinic to help you get through your day and not feel like totally spent by the end of it? Yeah. No, that was a big part of the learning curve, like in the efficiency question that came up earlier, and part of it may take time and know, like, what your MAs can do for you in clinic versus what you need to do for yourself with your patients, is it going to be, I think, helpful. Finally, getting familiar, and maybe this fellowship might be a good time to do that, but getting familiar with your spiel, like for IBS patients, for instance, I tend to take up maybe more time, so I have my specific, you know, I have a kind of a spiel for patients that don't want to try any medications, and then ones that only want medications, and kind of just have that just ready to go, for like, what am I going to offer, and obviously you tailor it to each patient, but I think that really helped me to just like have it almost, even the constipation, like, set up, like, these are the options that I can offer, and just like knowing that I have that in my head helps, and obviously, as we all know, but reviewing the chart beforehand is going to make you much more efficient in there, I think that's probably, any thoughts from your side? No, I think, you know, reviewing ahead of time, you know, sort of making sure that you have a little bit of plan, review there, and, you know, your review process, if you're, like, for example, if you were at University of Michigan, and you're going to stay on faculty at University of Michigan, you already know how to review the chart, and what to look for, but you go to a new place, you'll need to figure out electronic medical record, you know, where things are scanned, and do where outside records are, so the more you've done that before time, you know, that will make your day go by, you know, day go by, go by easier, and then same applies to clinic templates, right, like, a lot of clinic time is not just clinic, but it's eventually writing notes, so if you have, like, obviously, like you said, I don't do much clinic, but for, like, having templates for, you know, IBD, like what health care maintenance they need, and making all those things will make your notes efficient, things that you do every day, like if you have an IBS sort of spiel, maybe that's in a template, so that will make your, you know, make you more efficient and get out and go home at a sooner time after you're done with your notes. And I'd say one of the other aspects is, and you'll be able to judge yourselves independently, when you're doing your notes, are you a better typist, or is it better to do it as dictation? And even if dictation isn't available where you're going, I think they can easily modify that with an IT, you know, person, I personally, I dictate everything, because I'm not the greatest typist. So there are, you know, different ways to skin a cat, but certainly templates are paramount importance. So if you've got a little bit of downtime before you start your job, you know that they're going to be the pearls or the pertinent points, and the pertinent negatives that you want in each and every note, and you might as well just create the templates in advance, and at least when you arrive, you're ready to go. Any other thoughts, whether it's in room or virtual audience, before we move to our next exciting presenter? Oh, yeah, okay. I have one last question, I'm assuming, but both of you did not stay in your parent institution where you trained, so you moved out, so what was kind of, you know, it's not to be a personal question, but like, what was your thought process behind moving to another place, where I'm pretty sure, like, you know, the programs would have loved to have you in their own place as well. They're like, no, we want to get rid of you. Well, you know, it's... 20 seconds. You know, I was on a visa, so, you know, for me, I had to leave to go somewhere else, so that was one of the reasons, but in general, you know, I tell this to residents, I mean, some people are geographically bound because of family, but everybody I mentor, and a couple of them, you guys are here, every time I tell you, the more you go, add diversity in your training, eventually, in the long term, it'll help you, so I think, you know, I've trained at four different... This is my fourth institution, and I, you know, did residence somewhere else, fellowship, advanced fellowship. So I think that's, you know, given me a lot of different perspective, and definitely keeps helping me every day, so that was at least my thought process. And Rebecca will give you the final word. Okay. I love the University of Washington in Seattle, but my preference was, we wanted to be near one of our families, so we went with my husband's family, and that was really it, yeah.

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