One of the questions came on early. Dr. Ahmed was do you do an upper endoscopy with with every us that you do. How do you, how do you approach that and we can, in the interest of time keep the answers quick and busy, and I'll go around the table. So, not always. I do it if the patient hasn't had an endoscopy ever, or if I'm, you know, if I think that there may be some unanticipated finding, but if I have a pictures from another endoscopy for a sub epithelial lesion I'll typically just go ahead with a Very good. Good. What do you do. Yeah. Great question in it for a mucosal based lesion esophageal cancer rectal cancer staging. I always go in with the endoscope first. But the vast majority I'll go straight with the linear without without a radial, and I'll touch upon this with my lecture later on but with rectal lesions. Not only I think is a regular flexing or scope first but if you're going to have an a lower lesion, I find in that situation, a radial helps you and I'll touch, touch on that later on on my top. Yeah, you know, it's been my practice to do an upper endoscopy and every new patient that I have never scoped before. I think at the extremes of age. The geriatric patient presents unique challenges in the foregut certainly post operative patients, and anywhere I have a pre test probability that I might have a higher likelihood of trouble going in, and might I add that you know we can talk about it through the EGD US court actually was developed with having both components in in there so. But you know I'll give you a typical example of where we may not necessarily do an EGD every time which is a pancreatic cancer surveillance patient for example that is coming at a regular interval, we may go directly with the linear endoscope. So that's a great question. And so, other questions start with Dr. Ahmed's talk in the beginning. Why, why is that why is the US F&A, F&B, RVU so low compared to a diagnostic relatively lower compared to diagnostic EGD do you have the silver bullet answer why we are not paid what we deserve. Let me actually. Well that's an interesting question and I actually don't have an answer to that because I trust me as you're sweating and struggling through a really difficult case, you wonder why this is so low but I, I don't have a clean answer to that. Yes, really do. And, you know, some years ago these reimbursements went drastically down about, about six or seven years ago, maybe a little more even both us and the RCP reimbursements went down about 35% right away in one year. And I think that's a big point of communicating that to our membership, and there was a lot of discussion around it but, you know, my simple answer in my hair my when I wear my reimbursement hat, and I serve in that role for the SG is that the federal government has a finite amount of money. And if money goes up somewhere and spending, it has to come down somewhere so it's a zero sum game, get any ideas on that. I think you're preaching to the choir here we'd all, you know, especially then if you add the core element I, you know, I think subjectively I think if you're doing core biopsies. You know you're, you're providing so much value that that should even add a little bit more than an FNA. So, right. Hopefully we'll get some change. I mean one before you finish I you know there's a great question on that open access and I'll let you, you know, carry on but I just have some thoughts on that. Absolutely. Yeah, yes. One quick thing we make that you know because the reimbursement is so low. That's why when you think about setting up a practice you cannot have these one hour uss, because you will not yet you have to have, it's basically being driven in part by what the RV use our for the procedure. That is true and I you know I understand the sentiment and just for the sake of, you know, debating that because we all debate in high school. The, you know, the flip side though is you know we are all training, not all but many of us are training fellows, and many times training staff. And sometimes, especially now in the post pandemic era, the throughput through a unit can be challenging and so I think that one has to keep in mind both the efficiency aspect of it, and, and what resources and or what obligations you have in the procedure, what sedation you're having some are lucky to have deep sedation and quick recovery and quick out others are not there are still a lot of us being done with moderate sedation. So I think, but but it is important to have efficiency in your work schedule to compensate for some of this to a point. The second important point is to really make sure that you get paid for what you're doing so documentation of what you're doing is important and performing and claiming those interventions that you did documenting them is important that's going to optimize and maximize your, your billing in that so I think enough on that question came up here is if you're in a practice where us is already set up, and you need more equipment, how do you go about that. You know, so that's one question there was, how do you escalate the status of your practice and easy answers there. Yeah, you can actually escalate it and it will all depend on your past performance and projections like I talked about. So, if I mean I just a very simple kindergarten level math on this would be if you are not utilizing your current equipment or showing a return on investment on the capital equipment that you already have a system will be very reluctant to invest more in it. So that's why I keep going back to the metrics that you have to follow and your business administrator will be really in the mix here. Right. So past performance in this case will dictate future efforts. So get a shot. How do you, you know, improve your skill that you, you, you know, hired a lot of people over the years, many from advanced fellowship trainings and so forth. How do you suggest the further enhance their skill sets once they are practicing us what any easy recipe there. You know that I think it all goes back to experience and volume, you know, depends on. I think most practices now you have, you know, other people already performing us. So I think the question is, you know, are you in a solo, you know, on an island by yourself or do you have other people. And, you know, at our place we have five and the sonographers I'm probably the senior most but I think some of the junior folks are way more interventional which I don't do so it, you know, even to this day after having done this for 25 years there are cases that I don't quite feel comfortable and like I think it's this. I'll just have somebody else come in the room so you know it's not a matter of pride or ego that just because I'm the senior most person that I have to be the one with the answers we all share and learn from one another so I think that's a good I think that's amongst your, you know, other members in your group if you have that capability. You know, I think that's very, you know, that's a very important culture and ethos perspective we have the same in our unit and believe me, we are better off for it so highly encourage if you have more than one practitioner to have that collegiality but most importantly the patient benefits from that. In the moment. Secondly, you benefit from that and then it also creates the concept of a team with your nursing and other staff members, where this is a one unit, one team approach. Can I comment on that as well. How do you use your skills. Do you go to courses do you schedule cases with your senior partner, how do you, how do you go about it. So, I, first of all, I completely second what Gary said that you know there's no shame in asking for a second opinion, we still do that hey you know popping your head in and and and, you know, we exist in enriched environments meaning we have colleagues who are willing to do it sometimes you may be the only one doing it. The so ask for help if you need it or share it with whichever group, you should have a tribe in when you're doing these. When you're doing advanced endoscopy. The one other thing I want to add is that even when you become experienced, sometimes it can you know you can become complacent. I personally always sometimes go back and look at simple diagnostic us videos or just how to look at the pancreas and it's just a little reminder to myself, or a refresher, especially if you do a lot of like these screening for pancreatic cancers I can see how you can sort of become, you know, complacent. And if you want really advanced, like what you said Vivek going to courses, looking at videos looking at online classes, and just being remaining engaged in the community is the best way to do it right I think there's a lot of online resources including websites that courses are held at it and t other places, you know, proctorships are in place visiting fellowships are in place. I know for a lot of people who are already well advanced in their careers. They still went to other places and spent a day or a week or three months and acquired these skill sets all depends on what your level of investment is what the goal is and so forth. So one of the questions that we all struggle with folks is when you have a submucosal or sub epithelial is the correct term lesion in the C come out of the right colon, we still don't have really great technology to do a colonic us. How do you approach that problem you have a 1.5 centimeter firm nodule in the C come. What do you do with that mini probe that scans, what do you do you want to take that guess you want me to take that I mean many probes all we have I mean we've been pretty successful we actually have presented this in poster form, several times we've done you know probably over 50 ish cases And so I think a mini probe can help and these are high frequency probes for folks that don't know, one of our endosynographers actually uses the mini probe for larger polyps and trying to assess whether he's going to do an EMR in the colon or not. That's another kind of a neat indication so right now that's all we have I think there are other companies that are, you know, the newer generation scopes that are coming out that potentially, you could you know get a colonoscope all the way down to the So, for instance, the device which is not FDA approved yet endosound where you put the ultrasound probe on the tip of any scope, you can get it wherever you can put a scope you can do an ultrasound and again that's not FDA approved yet, but those are kind of intriguing That's, I'm glad you brought that up because that is coming and for a lot of the folks on this session today will be practicing for the next two or three decades, this is the kind of technology, which will be, you know, a game changer for those type of indications No, I think, I mean, many probes, to be honest, I personally find them very frustrating, and I'm not a huge fan, and especially in the right side of the cecum and I think, so you know what do you see in the right side of the cecum you typically see appendiceal mucosal, you can see just, and you take these just very seriously in other parts of the body rather than the stomach because they can have a different biological behavior. So, I do give a lot of weight to what the endoscopic appearance and the feel of the lesion is when you probe it with a biopsy forceps. We can use many probes, I personally haven't found them to be extremely helpful but a CT scan is the other way to go. I agree and you know we published a small series of seven or eight patients were young patients had, as you said, you know, concerning appendix and, you know, certain percentage of them were significant lesions, including appendiceal carcinomas and and so forth. So, in a young patient who has a firm sizable lesion that you're not happy with imaging, I would get a CT, and at least get a multidisciplinary input, a cectomy is not the end of the world, even today and I think it's it's what's best for the patient is what you need to keep in mind. So one of the questions that I know Grace you wanted to address this is about direct access us. What are the common indications and how do you set you know how do you go about direct access us is that something we should even be doing your thoughts on that. Each of you, please. So out of about 1400 of our cases I would, you know, maybe not the interventional ones but the non interventional certainly the diagnostic and other referral base. 80 85% of ours are open access so the first time I meet the patient is probably the last time I'll meet the patient and that's a really tough challenge especially with pancreatic cancer and FNA. So I've got to establish that rapport with the patient. So I've got to do it correctly and that's a whole nother topic but how do we get excellent open access, you know, you have to have coordinators right i mean without a good team. She'll our coordinator will have all the paperwork that the imaging the, the prior endoscopy the history, and they we just divide it up. And so, since I don't do the interventional us aspect I take a lot more of the diagnostic us and the pancreatic cancer stuff. So we'll, and it has to be fast I mean you have to look at your hand baskets in our epic system within that day and give an answer so I do a quick overview and say okay this is appropriate not appropriate but usually the intake person has all the data already. So I and mostly, these are folks that know when any us is indicated so by putting them through another clinic visit that's going to really slow things down. So any emergency us we have them in the door within three to five days for pancreatic masses and things and that's the only way we can do it because if you have to bring them into clinic it's not going to work so it takes a team we look at the paperwork all the data, and we give a quick answer and then we get the patient schedule without having seen them up front. That's a good somebody knows what do you do. So that's exactly what Gary said we look at the records beforehand do not have routine office visits. The one thing I would add though is that we know where the patients are coming from. So you have a trust system with the referring physicians, sort of, you know, you, you know, there's a, if it's a completely unknown and it's a complicated case then you will do a quick telemedicine now post pandemic, my APP will do it, or you will get more but for the most part, that's the day I'll meet the patient. And like Gary said, probably the last time I see them so yeah and you know, those are good words of wisdom and a couple of comments I'll add is, you know, we are in the post pandemic era where we are now very comfortable with video console so I do employ the paradigm of video consultation on the fly with these patients. Sometimes I even do it, you know, in between cases, depending on the turnover time. So that's an easy one to do, provided they can do a video visit and some of the older patients coming from different places may not be able to do it and then the phone would be the way to go. The second point is to do a formal E consult. And those are reimbursed. And the third, which I think should not last but not the least, is most of the intervention endoscopist and teams are working as a team with the other best practice providers, the nurse navigators like it is mentioned, I think some of the team members can certainly in the background, you know, either with collaboratively with the physician or on their own, kind of vet the patient situation. Look at blood thinners, look at foregut anatomy, look at the age of comorbidities, maybe do a visit, and that does provide a buffer of safety and best practice, you know, metric before they come onto the table. And we do that very liberally. And that's worked out very well for us. So, yes, you know, we do have a direct access paradigm, but we do try very hard to do some form of review between all of the comments that we've done between the three of us that we talked about. Easy. Yes, go ahead. I'm not updated but the concepts are the same and how they go about putting a mathematical term for the administrators and I've urged the folks that have that question to look up Doug Fagle, his paper, and please do go ahead and faculty, go ahead and answer these questions. We're lucky to have a lot of engagement. One such question. Very quickly we can answer this do you do flow cytometry for lymph nodes for lymphoma my answer is yes. You know, but so seems like everybody's doing it. A thickened bile duct wall, how do you make it thin, what do you, what do you do with you have a thick bile duct wall. Do you have any bile duct thinning agents? No. It depends on the clinical context right so if your patient is coming with colon jiters, you're going to have a thick by the wall. If you have a chronic inflammatory disease such as PSC sometimes or other systemic diseases you might find that, you know, recent pancreatitis, which is resolving can create that so it depends on the clinical context of course you know some forms of biliary will will will will be there as well but any comments on the thickened by the wall. I mean it could be just from chronic, you know, it may not be a malignant thing you just had like you said get get the proper context I mean there's different types of clandestine carcinomas, you know, that are well documented. Just to FNA the wall itself, I think, unless there's a some sort of focal mass effect, I would probably say that's not going to have a high. That's a patient that it might just be a transient thing and you know it's not wrong to bring patients back. Right, right. I use an alternative imaging modality right. We are in the formally in the break session now we'll have, you know, for 10 minutes or so but for for us. I'm okay continuing or if you want to take a break. You know that's fine. But for a seems like a lot of folks are still on there. Yeah, I think there was one question that I do want to answer which was, why use us staging for cancers if you're not going to get new argument anyways I think that's a very important question. I think us still has wait, because, first of all, you can actually rule in or rule out more advanced disease, meaning patient a T for. Secondly, you may actually have more superficial disease and you can send the patient for surgery rather than new argument. So I think us has a very very important role in in in staging cancers, even in the world of, you know, much broadly applied and that's why it's in the NCC and guidelines, more often than even we clinically practice actually and, you know, the other thing that I answered that on, you know, in the moment is that, you know, it allows us us TNM staging allows us to speak the same language, and when we are talking the cancer language, and it's the same metric oncologists understand what we're saying, and vice versa so that's important. So, as I said, we are in the break. What do you guys want to do take a few five minute break 10 minute break or continue with the questions we do have a lot of questions here. I mean non police starts here in about five six minutes six minutes so keep going. Maybe we can do one or two more questions and then otherwise. Yes, of course. So let's do this one here for us, you know for MRI for rectal cancer, you know, do you still do us or you just do MRI at this point. So, I'm actually going to cover this in my lecture, because, you know, we have some really strong data that that we're hopefully getting published. We still are colorectal surgeons for them. There are certain cases that I think the rectal ultrasound can give you more information, but in general MRI especially in Europe and other places has overtaken the primary modality for staging but there's a place for. That is correct and we look forward to that talk knows that what do you do. Yeah. There was one question that I want to just answer I think it says to routinely perform a full us exam and evaluating for a gastric nodule I don't. I like I said I did this should really be, you know, you're answering a very focused question, in most cases, or you should be. So I go look at the nodule but I don't look at the, unless it's relevant don't look at other organs. So, Vivek, curious to hear what you and Girish do. Yeah, you know, I have mixed feelings on this, in the sense that I almost always do what you said, but I am also aware that going back to the technical aspects of the US exam. The, the, the development of the US codes and the billing paradigms were did not keep in mind that you're going to, you know, just see one strand of tissue so I think that depending on the background story of the patient. I may take a quick look at the pancreas but then the other question comes up is, if you do go into the second duodenum, and God forbid you have a duodenal perforation for an esophageal nodule. Where does the law stand on that so this is a complex topic. I do not know that anybody has a perfect answer for it. I would say say you know whatever is you feel in the moment is the best practice, certainly answer the question, and do anything else that's that can be safely done in your clinical judgment would be fine. Just adding to that, when we had trainees, Vivek. I always say answer the question first. We teach our trainees the station approach which is the right training. The other thing is, you know, a lot of these patients are being being done on propofol they're not intubated you know so many of our patients have OSA issues and DSAT, so it'd be a shame if we have to pull out the scope and we can't go in, and we haven't answered the question because we're looking around. So I will always answer the question first. If all things are equal, then I'll, you know, look around and do it. And as I said, I think use the clinical judgment, be smart about it use common sense. You know, if you have the expertise, experience, comfort, and a good reason, and justification. You can you can you can extend your exam safely, but do be aware that you know of all the of all the parameters that we were discussing that one question that comes up from Dr. Chopra is that I'm a solo endoscenographer or just a paradigm somebody who's been in practice. If you're doing something new. He has found it very useful to call their mentors and get their input before doing the case. I think that's a paradigm that is utilized fairly frequently and continue should continue to be utilized. We're all available, you know, to to answer this and I think modern technology has really helped us I remember many cases over the years, have benefited from FaceTime and, and all those type of video calls in the moment, not necessarily to learn the basics check triple check, especially in the pandemic when our industry colleagues have not been able to come around and be a serve as a resource or in person engagements have gone down so I think this is an important question. If you're doing something now, or something after a long hiatus. It doesn't hurt to pre prep and then do some intra procedural reviews, what do you think guys. I totally agree. It's not about us. It's about the patient, you know, so that's basically the I think the bottom line, it's not about our egos, it's about patient care. Right. So, with that, I think we're coming to address most of the questions. There's one here says, if we use suction do we do dry suction or wet suction I know wet suction was very hot a few years ago, what happened to it at all the discussion dried up. I use no suction on anything I mean I would say 98% I go with no suction. If for some reason I think there's a question what scan cellularity then I'll use a little bit of suction, or just suction to just put it into the formal and for a fixative, but in general and you know we did a study on this section versus no suction I mean nothing novel, and we found that no suction yielded, just the same side of logic yield with a lot less bleeding, which makes sense. Yes, that's that's true knows that what do you do. I do depends on my mood of the day I suppose. That is the best. Combinations I really I mean I think when I'm doing a salvage, then I use all techniques, because it's like okay whatever works. This is second go around. But the first time I, I do use suction. I use suction. I'll just say quickly if you're doing a rapid onsite evaluation and you're on your second pass of no suction, say the second measure a pass, and you get nothing. Then everybody will be going to some suction. So that's just the practical aspect. With that, I think we have addressed all of the questions you guys are fantastic.

upper endoscopy

linear endoscope

radial endoscope

reimbursement rates

direct access ultrasound

patient rapport