This is really a course that we put together for you guys. The idea behind it was that we think you get plenty of clinical training and probably some non-clinical aspects during your fellowship, but not maybe all non-clinical aspects that you might need when you're trying to understand what's out there in terms of your options after fellowship, how to approach practices in various practice environments. So what this so-called senior fellows course is hopefully doing for you is providing you with those non-clinical aspects. There's a long list of things we could be including in this kind of course. It's always a compromise, and that's why I'm asking you to please give us feedback after we're done. Let us know what topics we should be including next time around, what topics worked, what didn't work, also what speakers worked and didn't work. What I'm going to try to do for the next few minutes is to just very briefly make some general remarks. This is the least important of all the topics we've included in the talk, but I thought it would be interesting, if not interesting, then at least necessary to make a few remarks about sort of the overall environment we're all going to be practicing in because it does affect us. And I am coloring this from the perspective of someone who wasn't born in this country and comes from European health care systems, so I apologize ahead of time if I'm not overly enthusiastic about what we all have to deal with here. I will go through the slides quickly because this is really more about the interaction with you. For this particular talk, it's probably the least important to have a long Q&A, but I want to leave plenty of time certainly for the next talks for us to have extended Q&A sessions. So let's see how it goes. My main point here is that when you talk to your attendings, I'm virtually certain that this is what you're already hearing. It's been a rough last five years, 10 years, depending on how old your attendings are, 15 years, 20 years. Everything is sort of pushing the rock up the hill. The demand is going down. Costs are going up of running a practice. Regulatory mandates, you know, having to use electronic medical records, having to do this, that, and the other. Payment reform, we've talked about for a long, long time. It seems to be coming very slowly. We're still practicing in a fee-for-service environment where every service we provide gets paid separately, but slowly but surely, we might be changing to other systems. Hospitals are getting larger, practices are getting larger, payers are consolidating. You see these mega-entities now evolving. And then there's always the talk about, you know, what's going to be replacing colonoscopy as the screening test? Will it be Cologuard? Will it be FIT testing? The person who is going to help us determine that is sitting in the back of the room, Jason Dominitz, who is probably running the most important study that's currently going on in gastroenterology. And we've, I suspect, heard a little bit about it yesterday. If not, we'll hear about it some more. Lots of changes is the bottom line. So when you talk to some of your disgruntled, more cynical attendings, there's always this talk about, this is really not heading in the right direction. Everything is going the wrong way. Are we heading towards the perfect storm? I would mostly point out that Colleen, Jason, and I did our fellowship at the same place. And there was an attending back in the mid-1990s when I came through for fellowship who was telling me at that point that I made the absolute wrong decision to go into GI. It was too late. Reimbursements were cut. Everything was going down the drains. I'm coming too late into this. So my main point here, and you see this editorial from Dan Podolsky from 20 years ago and now 21 years ago where there was a perfect storm. There's going to be the next perfect storm in five years, 10 years, what have you. So with excuse to Mark Twain, I think GI's death has been greatly exaggerated. And I firmly believe we've all made an excellent choice. And hopefully you went into GI for a good reason because you like what you're doing and you're not just looking to get the colonoscope to the cecum one more time. You can do so many things in a specialty. You're just starting to learn which side is up and down and left and right on the endoscope. But once you're done with your fellowship and you've figured out you want to be in academia, give it a try. If that doesn't work out for you, you've got plenty of time to switch over to private practice. There's jobs in industry as our friends from our industry sponsors will tell you. They're looking for physicians to work with them. There's in politics, in finance, everywhere. So it's a very, very broad specialty. There's obviously increasing demand for our services. And I'm just listing a few pathologies here that are on the rise. There's continued demand for endoscopic services. We don't need to go into the argument here of will colonoscopy be replaced for screening even if it were still the final common pathway. And there are other endoscopic technologies that are constantly coming online. So I personally, maybe I'm naive, but certainly over the last 20 years and now almost 30 years, I haven't seen the decline of GI. And depending on, again, how cynical the colleagues are that you talk to, you might get what I think is the wrong impression. So I think we're in a good place. In terms of what's going to happen over the next 5, 10 years, what's your world going to look like as you go out from fellowship into your practice environment, I think Peter Thiel said it well. We don't know, essentially. What we have a pretty good sense for, all of us, I think is what may not change. And that has to do with the U.S. health care system and the framework we're living in and sort of the foundational aspects of health care in this country that are just providing some hurdles that will just be difficult to overcome. And not likely to change is the tremendous cost of the U.S. health care system that is heading in the wrong direction, the tremendous complexity of the system here in this country. And those two factors drive consolidation, as I said earlier, in essentially all aspects of practice. In terms of the cost, it's really mind-boggling when you start looking at some numbers. And this is just listing the economically biggest countries by gross domestic product with the U.S., of course, leading the pack, and then China, Japan, Germany. Germany's annual GDP a couple of years ago pre-COVID was, as you can see, almost $4 trillion. If U.S. health care was a country, U.S. health care, the overall cost of U.S. health care would come in just behind Germany as the fifth largest economy of the world. That's how expensive U.S. health care is. All the Mercedeses we produce, all the schnitzels we eat in Germany barely get beyond the cost of U.S. health care. That's just, in a country of 85 million, that's just mind-boggling to me. And there's all kinds of metrics we could look at. If you look at per capita expenditure of health care in this country, here you see the U.S. is by far and away leading the pack, the average being somewhere in less than half of the cost. So it's a very, very costly health care system. The reason that is important to all of us is there is no money. So when next year Medicare, when other payers, when society looks at how to finance what we're doing, I think we'd be crazy to expect that reimbursements for us will go up and not down. There will be continued pressure on physician, hospital, and other payments. And that's just driven by the overall situation here. Secondly, as I said, it's an extremely complex system. Now, it seems that that comes as a surprise to at least some people. And most famously, as you all recall, this was the statement made a few years ago by President Trump, to which I at the time mentioned that he could have just asked the immigrant, because I could have explained to him the complexity of some of the other systems. And this is simplified, but by and large, this is how the German system works. First of all, everyone at every age has health care insurance, 90 percent. And this is true for many of the other European countries. There's variations on the scheme. But by and large, the majority, in Germany at least, is in a publicly funded system of 110 or so insurance carriers. If you're well off, you can buy supplemental insurance or can be completely in what's called a private insurance system. That's the 10 percent there. But you have to be in one or the other. It's not linked to employment. So if you lose employment, you don't lose automatically your health insurance. So bottom line is everyone has insurance, and it's a relatively streamlined system. Uwe Reinhardt, who was a very famous US health economist, unfortunately passed away early, came up with this explanation of how, in comparison to the German system, the American system works. And if anyone likes the painter Mondrian, that's sort of what it looks like to me. So first of all, not everyone at every age has insurance, but you have to consider there's different categories of humans. There's the young, the working age, the older people. And then there's folks who are well off and folks who are poor. Now for this one here, for the young that are poor, we have Medicaid. In most states, there are 50 states, Medicaid is administered statewide. So there's variations on the scheme. The broad middle class, if you have employment, that's where you fall. So typically, you are covered, although every job, every employer has a different system here. Of course, if you're super rich, there's Disneyland, and you don't have to worry about it. Young here, the older folks, they have Medicare, of course. But drugs aren't necessarily all covered. Some have supplemental insurance, some don't. In the near poor, that's where most of the uninsured are. There are, in the near poor area, if you're young, then children are covered by some supplemental programs now, but not all of them. The very elderly sometimes have Medicare and Medicaid. And this little square has the QIMBYs, the Qualified Medicare Beneficiaries, SLIMBYs, Low Income Medicare Beneficiaries, the QI1, the QDWI, and the QI2. And this, my friend, is the simplified version of U.S. health care. It's just really, it boggles the mind. You can look at how many insurance companies we have. Look at the last line, private payers. There's lots and lots of them. But that's not all of it, because as I said before, every employer essentially then gets a custom-tailored program with one of these private payers. So it's really a mess, is the bottom line. And famously, Duke University, where Colleen and Jason and I did our fellowship, they have 900 beds, and a few years ago, they had 1,300 billers just to deal with the complexity of the system. Vancouver General Hospital, where Rob Entz leads GI, has about 850 beds. They have three billers in Canada, because it's a completely different system, and it's more streamlined. So that's a very long way of saying, if this isn't a complex system, then I haven't seen one yet. Third and last, the costs and the complexity and the fact that we're essentially broke when it comes to financing health care drives massive consolidation, because everyone is trying to get together and save costs and save resources. Sometimes with the argument that care coordination is important and you can share data across larger entities, and that is all true. But what's also true is a lot of what's currently driving consolidation is just negotiating cloud, to get large enough to be able, as a hospital and health system, to have more cloud when you negotiate with payers, for payers to get larger so they have larger patient panels and have larger negotiating cloud. And then GI practices, likewise, the same way. When we went through fellowship, the largest practice, GI practice in this country, private practice, was in Dallas with 56 providers. Currently, as of last week, there's a multi-state consortium, the GI Alliance, also led out of Dallas that just cracked the 500 provider mark. So we now have these mega practices in the US. And maybe we'll get a chance to talk a little bit during Q&A about what that means for you. It means a couple of things for sure. One is when you're part of that kind of an entity, you might formally be in private practice, but you're essentially an employee in a structure that has similar committee and leadership structures as a large health system. They have a board, they have various leadership structures, and you're not necessarily really as an individual in a 500-person practice making much individual decisions, obviously. On the benefit side, on the plus side, if you're part of that kind of an entity, their size allows them to subspecialize. So some of these large practices have very high-level interventional endoscopy groups, for example, in a private practice environment outside of a traditional tertiary center practice. They have large IBD teams. So there are opportunities now outside of academia and outside of the traditional hospital employment model in these larger practices, where if you have a certain sub-interest, a subspecialty interest, you might fit in very nicely. So pluses and minuses there. But it's definitely a corporate environment that we're heading towards, and that is very, very unlikely to reverse. When Chal Nunn, who's going to talk to us a little bit later today, came through his fellowship, we'll ask him again later, but I suspect there were lots and lots of practices in your environment, Shell, that were quite small, two, three, four providers, right? Do they still exist in Virginia? Are a few of them surviving or not much? Yeah. So we're clearly seeing that consolidation trend. So finally, then, path forward predictable trends. We're going to have to continue to figure out how to be more efficient and essentially do more for less. Now, again, if it's worth anything to you, even 20, 25 years ago when you talked about these issues, people said there's no possible way we could run any faster than we're running. And since then, we've found ways. We've added non-physician providers, advanced practice providers to our practice. We've divvied up work differently. We've sub-specialized. So there's most certainly practice innovations that have happened during your professional lifetime that we can't imagine just yet. Consolidation will continue. Again, the payment models are changing at a glacial pace, but will continue to change. And the main thing that's going to happen to all of us and has happened over the last few years, will continue to happen, is change will continue. So what you're doing today, what you're starting with these kinds of courses, which is, of course, trying to come and learn about a specific topic, but also learning, getting to know each other, and building your network, in my mind, is the most critically important thing you can possibly do for yourself. Colleen mentioned it, and I want to emphasize it one more time. If nothing else, the ability for me to speed dial Drew, or Colleen, or Jason, or Chal, if I have a question, a clinical question, I can call Ferga at Mayo. The ability, because of the way I am now networked, that I wasn't 10, 15, 20 years ago, is priceless. And likewise, when practice issues change, you'll hopefully be in a nice practice, good colleagues, high quality group, but the ability to go outside the boundaries of wherever you work and connect with people nationally and sometimes internationally on clinical topics is really something you need to proactively work on. You're currently all in environments, in a way, this doesn't sound very appropriate, that's very protected still. You're in an academic environment. You have easy access to your attendings. You probably have their cell phone numbers. A lot of that will go away for those of you who are getting out of fellowship into a non-academic environment. You'd be surprised. They're busy. They might take your call here and there. Maybe they won't. They definitely won't take your call if you don't even have their contact info. So make sure, and also among each other here, we'd be happy to share contacts if you haven't exchanged them. That, I firmly believe, is the most important thing you can do. And I'll skip the COVID issue. I put it in mostly because you can't do a talk anymore without mentioning COVID. And of course, there's gonna be a lot of uncertainties coming out of this pandemic, hopefully, knock on wood, eventually. And we're not quite sure how that's gonna play. Currently, and once again, you have the opportunity still today, talk to the faculty here. They're from all kinds of different work environments. Talk to Joe Vicari, what COVID has done to your practice. As a matter of fact, I'd be interested in, so is the practice volume, are you guys back to 100%? Are you at 120%, at 70%? Where's your practice at? Short, we are seeing volumes across all lines that we've never seen. We are extremely busy. And we have a number of reasons why we think that is we're catching up a little bit, but that doesn't explain the volumes we're seeing. I think people are scared. I think if they have a back pain, now they're running to the doctor. If they have belly pain, they're running to us. What do you guys think, to all the faculty, that means in terms of, for these folks, for the fellows, job opportunities, are they gonna go down? Are they gonna go up? Are they essentially what they were pre-COVID? My crystal ball's not as good as yours, Klaus, but I think over the next at least two to three years, we don't see a great change in our volume. We think we're gonna be very busy for the near future. I think it's hard to see much beyond that period of time. We've got some local factors that are impacting, but I think the job opportunities are great. I think you're gonna be busy for a while. What do you think, Colleen? I think there are enormous workplace opportunities. This happened at a time when the median age for most GI groups is over age 55. I think it has accelerated to retirement plans, and we'll see some gaps there for that reason. And these will be mature practices, so it's not just coming into a practice and trying to start from ground zero. I think people will be busy from the get-go. Anyone else want to weigh in? Drew, you're working in a hospital-based environment. You think there's an effect, a COVID-specific effect, on how you see your group grow or not grow? Yeah, I mean, absolutely. We were protected being hospital-based during the kind of worst of it. When everything else shut down, the hospital was still running, so we were still essentially fully employed. But I agree with Joe. People are nervous. They're freaked out. They're coming in more frequently now. They're catching up on things. They're paying attention to healthcare trends better, so we're seeing higher screening rates and people really being a little bit more proactive. And I see most, and to Colleen's point, it's a bunch of generally old white guys there who are now getting ready to retire. They are getting tired, and they're getting the sprinter van and getting ready to see the country. And so there are a lot of openings, and there's a lot of change and opportunity. Right, and I know we'll talk about that very topic, hopefully for the rest of the day, quite a bit in our Q&A sessions. So that's really all the sort of general remarks I want to make about the healthcare system. Once again, it's a difficult environment. It is pushing the rock up the hill. That'll continue because it's continued for the last 25 years. That's what it's gonna feel like for all of your careers. So you might as well get used to it and not get into the trap of, again, some of the cynical colleagues that we all have. I'm not trying to poo-poo them and criticize them beyond what I think is necessary, but if you only listen to people who say, oh my God, you're too late, Marginal, should have done something else with your life in the early 90s, then I would have missed some very good last few years and a lot of professional development and good fun. And I'm certain it's gonna be the same for you. So we've chosen a good profession and looking forward to seeing where you all land. Last not least, I want to hark back to what Colleen said. We would love for all of you to be involved in ASGE. Colleen mentioned sometimes it can take a little while for you to get in, but do exactly as she said. And the more faculty you get to know through these courses, take their contact info, we'd be happy to communicate and support you with letters when your time comes to apply for committee. There's a couple of folks in the room here who've done that with me already, so make use of it. That essentially the only thing I wanted to slightly, not correct, but put a different spin on it for Colleen, who I think has been the fourth woman president of ASG, is that correct? Out of 77, so clearly not nearly enough, which is why we have Ferga talk about diversity and lead our efforts there. But if you can believe it, paradoxically, we're still doing better than ACG and AGA in terms of that number. If that isn't sad, nothing else is. But it's clearly recognized. And let me just put a slightly different spin on it. ASG was founded, in a way, by a woman. Because Rudolf Schindler had to flee Germany because he would have almost ended up in Dachau. And the reason he got out of a tight spot was Marie Ortmeier, who he knew here in Chicago, who had visited him to see endoscopy in Germany, and who helped him come over here. And who, of course, became our first female president a few years later. But she is the one, in a way, that made ASG the way it is. So there you go. If that isn't enough motivation to keep going and keep pushing, nothing is. Okay, why don't I stop, take a breath, give you a break for 30 seconds, and see if there's any comments, any questions. I'm happily taking comments from faculty about your frustration, cynicism, optimism about where you all are, and any messages for the fellows. Where do you foresee value-based care going in the future? Is that something that you think is probably not going to change, like the fee-for-service model and everything? How close do you think we are towards moving towards that kind of a model? And what impact would that potentially have on GI as a currently fee-for-service, you know, scoping-related model, a lot of our reimbursement through that? Right, so the question is, where do we see value-based care and value-based payment models go? And how fast or not might that develop? First of all, it's sort of, it's turned into a catch-all phrase with a variety of different models that one could describe as value-based. Sort of at the highest level, what we're talking about is instead of paying for each service separately, we're somehow getting to a system where, you know, on a patient level, on a disease level, payments will occur. You have 100 Crohn's patients per year, this is the payment you get from the insurance carrier. I think by default, almost, the system is gonna have to develop in that direction because fee-for-service is clearly already bankrupting and will continue to bankrupt the system even more. I think it's fair to say, I certainly, and I suspect many of us have been surprised how slowly, how very, very slowly, gradually, we're transitioning to that model. So we're still far away from having the majority of care in that model. There are some pockets, and I want to bring Jason Dominitz in, so in certain environments here in the US, there is experience with value-based care and that might provide a model for the rest of the country. So Jason. Yeah, thanks, Klaus. I mean, in Kaiser and in the VA, we practice basically value-based care. You know, you do what you think is right for the patient and we do, you know, encounter forms and whatnot, but that's not tied, there's no motivation for the physicians, really, to practice on a fee-for-service type model. You know, there's pros and cons to that, but it definitely is happening in the US, and in the VA, they've definitely bent the cost curve. The quality matches that of the private sector at a much lower cost, and Kaiser's done the same thing. Yeah, and to the second half of your question, what's it going to mean for GI specifically, my response would be, we don't know. I wouldn't know to tell you, is that, you know, relative to the rest of the House of Medicine, is that a good thing for GI, is it not such a good thing? You have to believe that part of that kind of a payment and a care model, value-based care, is first of all, you have to measure, you have to show, you have to prove your value, your quality, and to the extent that GI is getting into those kinds of studies, showing that, I had it on a slide and didn't point it out, just as an example, that if we can increase our adenoma detection rate by 1%, then the chances of the patients we scope to get colorectal cancer or die from it go down by several percent. Those kinds of studies, like this one that Doug Corley conducted and ended up in the New England Journal of Medicine several years ago, you know, to the extent that we have that foundation, I think we'll be well off, and again, we are a broad specialty, you know, you could see those kinds of studies in IBD and hepatology, and we're seeing them day by day. Cardiology, I think, is a bit ahead of us in terms of clinical studies related to those aspects, but I think we'll be fine in that sense. Yeah. Yes. What challenges do you expect device development or entrepreneurial ventures to have in GI? So, question, what challenges, device development, entrepreneurial challenges, that's a question we're gonna squarely forward to the person who's done device development, who's had some devices that he played with, a company that he started and is now chairing our Innovation Six, so what do you think about challenges, device development in GI and approaches? The old timers say it was so easy in the old days, you could, you know, go to cook and they'd put your name on something and you'd have the Mergener catheter and everybody would use it and you'd send your kids to private school on that. There are still opportunities out there and this is why the innovation committee is so much fun. Everybody who's been in endoscopy is sitting there struggling with some problem and saying, gee, I wish I had the thing that did this that would do this in this situation and help me out of this. Why hasn't somebody done that? And hey, I'm gonna go into the garage this weekend, I'm gonna make that and make a zillion dollars. That still happens, it doesn't happen as often, mostly because the forces out there are so challenging. If it's not a $10 million a year product, Boston Scientific doesn't even wanna talk to you. Nobody wants kind of the one-off thing and the hurdles to getting things through FDA and all the rest are so challenging now. That doesn't mean that there isn't opportunity for these things, especially in kind of non-physical stuff like apps and social media and 100 things that the old timers didn't even think of and can't do. And in fact, if you can make an app that somebody over 50 can use, you'll see. It depends on it. But these things, GI is the most, I think of all the specialties, seems to have the most kind of frequent updates in new technology. Look at the luminoposing stent and how that dramatically changed everything that we in interventional GI do. Wouldn't have thought about it. And that's one guy, that was Ken Bindler who did this and lost a lot of money doing it, but everybody knows his name. So there's great opportunities out there to do that. And it will be an area of great innovation that we just don't know what they are yet. Yeah, and when you think about it and want to learn about it, talk to, again, talk to some of the faculty, talk to the companies too. There's quite a bit of innovation going on at Pentax, at Olympus, at Fuji. And we're not always aware of what all they are doing. So I think that's a good opportunity. Go to the Medtronic rep, go to the Boston Scientific, the Cook rep, and learn from them what they're doing.

healthcare environment

GI services

career options

networking

rising pathologies

value-based care

entrepreneurial ventures