One of my mentors at Duke, I asked him for advice before I went out into practice and he said be humble. I thought I was pretty humble, but stumbled pretty hard my first year with that. Dr. Mergener, did you ever stumble with humility? On a daily basis, I do. Absolutely. What advice would you give? Well, it's sort of along the same lines where I made the biggest mistakes and later on by pure damn luck stumbled into better situations. Thank you, Lyle. Sorry. So where I made the biggest mistakes early on was to think way too narrow about my interview and the job I wanted to take because I came out of training with a group that was fairly prominent in interventional endoscopy and then had the opportunity to join someone who at the time was among the main major interventional endoscopists in the world. And that seemed so tempting that that became sort of the predominant consideration. Had I spent more time at that institution, looked more at the administrative side, the overall circumstances, I would have saved me a lot of headaches. I later on then stumbled into a much better work situation but not by thinking about it. It was really by pure luck where I ended up in a situation where instead of working, you know, 18 hours a day, I worked four days a week. I spent a lot of time with my kids and I did a few fewer complicated interventional cases but overall the job worked much better for me. So being more mindful, as I was trying to say in my talk, about the circumstances around your career. You've been so career-oriented by default up until this point. Thinking about all the other elements I think is just critically important. I would endorse that a hundred percent. Those are words words of wisdom. So this is fast-pitch softball here. Feel free to jump up. Any topic is open for discussion. Now's your chance. You do have our emails, I think. Be sure you put you were at the third-year fellows course so you don't run into the rubbish bin. This is for the whole panel. What obstacle or biggest challenge do you think our generation currently faces going into practice and in today's climate and what is your advice on how we should tackle that? Take that one on. First, whoa, okay then. I'll go first. Not to listen to people who tell you they have the answer to that question. It is so massively difficult to predict the future, you know, a year ahead of time, two years ahead of time in our specialty, let alone five years, ten years ahead of time. You hear wonderful talks from very eloquent people who have no clue any more than you and I do. So taking it in small steps, you know, thinking about the next few weeks, the next few months, rather than in large chunks of, you know, what do we think the specialty will look like ten years down the road because the honest answer is no one knows. I'll just add to that and I would filter out the negative voices. Klaus is right. Things change slowly but he showed you in the slide, I think it was from 2000 and then recently the end of GI has been coming for decades. Drew and I kind of laughed about it. It's been coming forever. There will be changes. There'll be slow changes and your practice today will be different in 20 years but I think the end of GI is nowhere in sight. I think the future is bright. It just will be different and it'll take time to get there. Kira, did I see your hand up and then Jason will go to you. Go ahead. If you were starting now, what would most excite you? What are you excited about in GI even if you don't have time to take advantage of it at this point in your career? You want to take that challenge? I can tell you what excites me is the stuff that you guys do. I trained 25 years ago. We had a great training program. I thought I am nowhere near the level of you are in terms of your skill set. What you can offer patients is so far beyond the zipper that they used to get that it just it is awe-inspiring to me. So use that and know how excited we are about that and engage, continue to engage with the people that give that to you which is your faculty and your professional societies. They can help amplify that and you can help amplify their work but you guys have other answers. Dr. Gleason, what do you think? I mean, I think if it were to be sort of looking at things endoscopically, you know, I would have loved to have had perhaps an opportunity to go to Japan or other countries to see how other people do things. I'm very curious about what happens outside my own boundaries and my own wall because I think there's an awful lot to be learned from other people and how they do it. Whereas when you're in one establishment, Monday to Friday, all the time, any downtime that you have, you really want to try and keep that as precious. Historically, I didn't do that and I regret if it was one of my Colleen questions regrets is that the downtime, I didn't preserve it and ring-fence it and I really should have done that. I would love to travel to other countries and see how they do things. I mean, there are a number of endoscopists in South America who do phenomenal things and I'd love to see it. I'd love to learn from them. I was gonna say that, you know, obviously I'm endoscopy focused, but I think one of the things exciting about our career that I think we've seen in our lifetime when I was a medical student early on, you know, and I was in Pakistan, so hepatitis C, people used to get interferon treatments and, you know, we would remember that they would just have like horrible headaches and I mean it's an amazing miracle that now they take a pill eight weeks and it's gone. So, I mean, in our specialty alone, I think over the decade, that's probably one of the most fascinating, you know, miracles of modern medicine that we've been fortunate to see in our lives and who knows what, you know, we're gonna see in the next 20-30 years. I think you guys have amazing opportunities to do what you're passionate about. I mean, if you want to do a lot of endoscopy, you can do that. If you want to do a lot of clinical GI that's not endoscopy oriented, you can do that and you can change over the years. You know, it doesn't have to be one thing for the next 40 years. So, I think you've got a lot of opportunities to customize what you want within reason, you know, you have to negotiate and there's trade-offs as you heard about earlier, but I think you've got awesome opportunities. Yeah, thanks. I just want to jump back to that that last question about the future and the cautions and I was telling Joe, one of my favorite quotes from Yogi Berra is, you know, the future is not what it used to be and yes, there's been all this change, but my biggest concern and I call it kind of the double-edged scope is that is colonoscopy and it is, you know, it is the procedure and the tool that has saved, you know, millions of lives, arguably, and allowed us to get the salaries and the positions that we have. So, that's on the good side, but I just would want people to be cautious about kind of the the addictive quality of screening colonoscopies and how that can undermine and kind of track careers into this kind of opioid of easy, repeatable procedures and block out the creative nature and the intellectual part of the specialty. So, recognizing, you know, all the value of it from disease prevention to income generation, but don't lose sight of, don't let it corrupt the rest of your practice and kind of usurp all the other things that are fascinating about GI. Well said. Well done. Well stated. Al? Well, I think that continuing to advance and get better with the high-level procedures we do makes us invaluable, but we've also got to figure out how to be like Kaiser. We can't do everything for a CPT code. We've got to do things for the right reason, because otherwise we can't afford it. We can't afford to do everything that we're doing. So, how do we function better in a Kaiser-type situation? So, actually, we have a representative here from Kaiser. Linda, would you like to say anything in particular to defend where you work? So, for those of you that don't know, Kaiser is a multi-specialty physician-led organization. It started out on the West Coast. I'm in Southern California. It's very regional, and what it is, it's physician-run. So, the partners that make the decisions are every physician in the group. They are sort of an HMO, sort of accountable care type of organization as well, and we take care of... It's great population health, great for all cancer screenings, mammograms, colonoscopy, FIT testing, and it's quality-based. The benchmarks they use are based on quality benchmarks and not so much how many RVUs are generated. And so, I love where I work, and the nice thing is you take care of the whole patient. It's not just all GI, but it's really a partnership between yourself, other specialties, and I think it makes sense in the long run. They've got Epic, which they renamed HealthConnect. It's a beast, you know, in terms of figuring out the data to try to get the best clinical outcomes and not so much more procedures, more testing, things like that. They really try to look for good clinical outcomes, and some of our data from colonoscopy screening come from the group up in Northern California with Doug Corley and company, and that's important stuff. You practice. They make evidence-based decisions on kind of what's on formulary, but it's all physician-run, right? And so, I think that's the way to go kind of in the future is we have to take leadership and ownership of this, or else somebody's going to come in, like private equity, sorry guys, to kind of run it for you, and I don't think people want that, you know? I think the physician-patient partnership is the way forward. Jennifer, I can see back there behind the... Do you want to comment? Is Rebecca still here? There you are. You want to jump in on either one of the fast pitch or just comment about this discussion? Yeah. Oh, I don't know about that. I'm lost because I think we went... I was still thinking about Kira's question about what excites people most, and not that I'm in my career very far at all, but I am inheriting a lot of patients from my partner that just retired, and what excites me and the reason I'm inheriting is because I've tried to build an IBD specialty practice, but that's really exciting because he has been in practice for more than 30 years, and most of his patients are on sulfasalazine, and just... And not in a... You know, I just think that there's a lot of opportunity for these patients that maybe weren't there a decade ago, and that really excites me. All right. Let me slow it down just a minute and ask the faculty to answer this question. What's the one thing you wish you had asked or asked for with your partner before you made your decisions about going into the job? Okay. maybe I'll piggyback on the last question. I thought I was jumping into the Kaiser, which I was not prepared to do. But I'll just maybe first comment. So I just finished my training. And I'm going to be starting my first faculty position in about two weeks. And so one of the sort of, if I had only known, or right now I'm realizing, just pieces of advice, I would say, is that everybody who goes through training will graduate with pretty similar skill set, knowledge level. And there's jobs in every type of specialty within GI and every type of practice. And at the end of the day, it really has to be what's going to make you happy. Coming home at the end of the day, like, did you want to be writing grants that day? Did you want to be doing just endoscopy? And I think as you go through the interview process, sometimes people tend to get lost in the weeds. And it's really important to remember what you went into the interview wanting, not what you left the interview thinking they wanted. So I think, really, just make a list for yourself of your priorities. And continue to talk to your family, your partner, your friends throughout that process. But try to not get swayed too much by what practices and positions ask of you. And really just remember what you want and what you want to ask them to do for you. So that's my piece of advice. So if no partner considerations, Jason? Well, I'm trying to think of the answer to your question, Colleen. And it's been 24 years, so maybe I've gotten senile and forgot. But I think my wife and I had a lot of long conversations about this. And I don't have any regrets. I mean, I've been in the same job for 24 years. Or I've been at the same institution. My job has changed a lot over the years. But I think we made the right choice, even when we're looking at it now, I think we made the right choice, even when we looked at all the options. And it was a very open and frank discussion. We made compromises. I mean, you know, but we made compromises in what kinds of things we were looking for as a couple. And it's worked out great. So I think it was a good process. Obviously, it is a partnership. Having that word partner was what Colleen used. And so I think you need to treat it that way. So I mentioned my husband's a musician. He's actually a saxophonist, a classical saxophonist. And as much as I enjoy teaching the LEAD program about having career goals and setting out five- and 10-year plans, we actually never did that. We took turns going to school. I would go to school, and he would work at Wendy's. And he would work on his master's. And I would do my residency. And our whole life has been really kind of bouncing that back and forth. And I think it's important to know that sometimes it's just not a linear trajectory. It doesn't all work out like you think that map is going to. But it's so much fun on the way. And you have to be a little bit flexible. Anybody else? I was just going to say, I wish I'd had a Joe Vicari when I was looking at the city. I felt like back in 85, nobody counseled you, or there were no, like a high school counselor helps you. Why couldn't I have a graduating GI counselor show me what's going on around the country, what are the different kind of careers you can do? It narrowed my focus, because I just didn't have a broad enough perspective. It wasn't until I was 10 years in I started to do this. And I thought, whoa, I can do all this. I wish I'd had that earlier on. Me too. Can I say, I would love to have had a Dr. Shal Nunn. She would have liked to have had a Dr. Shal Nunn. I mean, I'm sort of mid-career at the moment. I've had an opportunity, yes, to do some leadership courses, and yes, be assigned a coach for a short period of time. But even though it was a short period of time, it was actually an experience, and an interaction, and a partnership, I suppose, that I truly enjoyed. And it very much helped me with all the concepts of things like stretch exercises, and going outside your comfort zone, working in challenging situations, or conflict management and resolution, things like that. I would have loved to have had that experience 10 years ago, and that partnership with someone 10 years ago, and then to follow that through intermittently over time. So I wish I had a Dr. Shal Nunn. Well done. I'm sure I speak for all the faculty when I say you do have us. You've got Dr. Mergener, and Dr. Nunn, and Dr. Shambra, and Dr. Beccari. You have our emails. This is a fantastic group to be with, to learn from, to interact with. For us as faculty, your engagement is what actually brings the energy to the room. So we kind of expect that to continue as you move along that path. So feel free to reach out to us. Just remind us that you're in the Third Year Fellows course. Other comments from the faculty, or questions? Can I just ask any questions from virtual land? Nope, they've all gone for Margaritaville. Smart people. Can I ask anyone in the audience have any particular questions that they would like to ask that are still unresolved, unanswered? We've got about five minutes. It's like Jeopardy, you'll have a tick-tock, tick-tock. How did you guys deal with the first complication you had in independent practice? Or once you were out of fellowship, how do you emotionally go into the next case after something like that? Who would like to tackle that one? It's me. As they say in the house of God, take a deep breath and check your pulse first. Check your own pulse before you get into those, get overworked about the complications. I had experiences of a couple of complications during my advanced year, during general GI fellowships. You learn from your attendings. You see how they handle it. And hopefully by then, you've already established a good relationship with your surgeons. You know your surgeons from referrals for colon cancers and things like that. You know who you can rely on. It's just this is a job where we do high-risk procedures. You're going to have complications. Take advantage. I remember in my advanced year, I had ERCP perforation. I went with the patient to the OR, see what the surgeon is going to see. If you have the opportunity to do that, take advantage of that and see how they're approaching what you, how they see what you've just been able to see from the endoscopy standpoint. I don't know. My first one in practice, just take a deep breath. All who you can trust in your practice or in your referral so you know. And yeah, it'll work out. I mean, you should have the experience of seeing some of them in fellowship and just take advantage of learning from those opportunities so you can stand on your own two feet when you're in practice. Klaus talked earlier about communicating. Communicating often express your concern. I hope you can say you remember the potential complication we talked about. This is what's happened. It can be emotionally devastating, and it can be one of those things that you relive. So hopefully, you have a partner you can trust at work, I mean. And this is one of the instances where you actually might want to talk to your life partner and explain what you're going through because they are an incredible support for you. And they're going to love you, period. But there should be someone at work that you can talk with about it, and they'll help you get through that. It's not easy, but you should listen to what Samit tells you and just realize that it's a human. Jason? Yeah, I think it's really important to find somebody to talk to about it. I have a colleague who had a fatal complication from an ERCP, and I think it was quite devastating for them, understandably so. And as the chief of GI, I got them plugged in with the employee assistance program, and they had counseling, which I think was vitally important for that individual. I had a fatal complication of one of my procedures, and it's been over a decade, and I remember it vividly. And I remember sitting in the IR suite while they were trying to stop the bleeding on this person. And actually, what was really the most helpful thing, really shocked me, was one of the surgeons came in, a surgeon who was not known for being empathetic or compassionate. And he stood by my side for like three hours while I worked, and he told me about a routine cholecystectomy gone bad where the patient died. And just having him there by my side made a world of difference to me. And I ended up going to the patient's funeral, and I still carry that burden. I don't think I did anything wrong. I wouldn't have done anything differently, but it's part of our business, unfortunately. But it helps to be forgiving of your colleagues when they have complications. Tell them that it's OK. Help them through it, and hopefully they'll do the same for you. You have to try to forgive yourself. Even if you do nothing wrong, I still feel this guilt and I think you can sense it. But it's hard. It's part of our business. But you think about how many lives you saved. All right, I'm going to flip it back maybe to just for a couple of minutes, something more lively and hopefully a fun thing to end on. Anybody, who's the person you called to get your first job and how? 10 seconds. How did you get your first job? Jova Carey. You cold called him? No, so I talked to a couple of my mentors in fellowship, both General GI and Advance, and both hooked me up with one of our current partners, Bob Tukral. And Tukral then directed me to Carey. So Dr. Carey was the first person I met when I was interviewing. One of our best hires ever. Drew? Yeah, my mentor knew me well enough to know where I wanted to go and what I wanted to do and knew everybody in ASGE and plugged me into my dream job out of my Advance Fellowship. So introduced you, literally. Yes, it's like an arranged marriage. And it worked well. I did cold call. I knew where I wanted to be because I knew where I wanted my first job. I knew where I wanted to be because I knew where I wanted my family to be. And I called my brother-in-law, who's an internist, and asked him who the best gastroenterologists were in Chattanooga. And I called him up and asked him if they needed a new partner. They interviewed me. My story's similar to Drew's. Names you will all know. Gary Falk was my mentor at Cleveland Clinic. He said this group in Rockford's hiring. I spoke to Jim Frakes. So both of these guys are past presidents, and that's how the story went. Anybody else? The fellowship director at Duke, John Cohen, knew about the job in Seattle from Tuan Nguyen, who used to be at the VA. It was all word of mouth. I don't think they ever advertised the job. And that's how I found out about it. Klaus? That's not very helpful to the fellows here. The first one had to do with geography. I trained at Duke and was going back to Germany. So it was all about where in my area could I find a job. But then the first job coming back to the US happened exactly like some of you said. It was essentially my mentor, who knew what I was looking for, knew everyone around here and called me and said, hey, there's a job in Seattle. What he didn't tell me is that I then had to work with Drew. He didn't know that. So it was my mentor reaching out to me, not the other way around. Jennifer? Rebecca, how did you get your first job? Yeah, mine was a little more casual, I guess. I was scoping on service. And my attending said, oh, what do you think you're doing next year? And I said, well, I'd love to be in Boise, but I don't really know what's around there yet. Oh, well, one of my co-fellows, when I was a fellow here, works at a group there. Oh, great. I'll just email. Let's just connect in email. So all very casual, and it worked out that way. So I'm going to end with that, because you just saw the whole spectrum of the most casual of introductions to mentoring and sponsoring at its best. It's going to be as intricate and complicated or as simple, maybe, as you want to make it. But there are great jobs out there. And it's actually one of the funnest jobs on the planet, as I mentioned earlier. Let me turn it back over to Virga. It's 544.

gastroenterologists

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hepatitis C