So, we can go ahead with some questions for this session before we wind up and close this course out. Eden, we have anything from your end? Absolutely. You know this audience, they got questions, they're good. Down to the wire. Hyperplastic polyp in the stomach, is that potentially pre-cancerous? Is it concerning? Dr. Vickery? So, I'll make some comments and then John or Vivek can jump in because it's not really a straightforward, simple question. For hyperplastic polyps in the stomach, a few small polyps that you remove if they're hyperplastic, I think the risk factor there is low. But once you start to get to larger polyps in the stomach that are hyperplastic, perhaps greater than 10 millimeters, and multiple larger polyps that turn to be hyperplastic, I think the literature would support, most of us would agree, we need to remove these polyps. I will tell you, these are at a higher risk for bleeding. I've seen some of the worst post-polypectomy bleedings I've ever seen when removing these polyps. So, we should remove them, but be aware that bleeding is a high risk and we should explain that to our patients. And I'll let John and Vivek chime in. John, please go ahead. I think just two details that I can offer. I think one is it depends on the context in which these hyperplastic polyps are arising. So if, as Dr. Vicari is suggesting, they're arising as incidental findings, small ones without other underlying gastric mucosal disease, then that's one thing. But if they're arising in the setting of intestinal metaplasia, a chronic gastritis, et cetera, then that's a different story, then they're more important. And the second thing is that if they're causing symptoms, then that's a whole different story too. So if people are experiencing chronic blood loss and anemia from them, or they're so big that they're causing gastric outlet obstruction, then clearly they need to come out. Yeah, that's a very important point. The AGA clinical practice guidelines came out a couple of years ago talking about gastric intestinal metaplasia and the stratification of risk. In the Western world, GIM is, you know, gastric cancer is a little bit less of an issue, but the family history, intestinal metaplasia, complete versus incomplete type is a risk factor, atrophic gastritis, and so forth. The other area where I find gastric polyposis assumes a different connotation is in the syndromic variety where patients with FAP, Lynch syndrome, Puget-Jeger syndrome, other types of foregut predispositions, we take them much more seriously. But in the last two decades, we've received a lot of referrals for large gastric polyps, and we've always wondered which ones to take out, which ones not to take out, but typically the ones that are two centimeters or larger, there is some suggestion in the literature that they may harbor some preneoplastic pathology, even though the superficial biopsies may be inflammatory or hyperplastic and so forth. So I would refer you, the audience, to a nice review on this, an up-to-date, actually, which has summarized the recent recommendations. So it's safe to say that most larger polyps at this time, unless the patient's overall condition prohibits it, we are offering endoscopic resection, and to Joe's point, the gastric resections, they do bleed more significantly than the colonic ones, and so do the duodenal ones. So this has to be really done at a center where they have the capability to manage this. Most of these procedures are done with general anesthesia with airway protection, not in the least because of the bleeding that can reflux back and make the patient aspirate if your airway is unprotected, but also because some of these lesions are very large, and the removal of them per orally can be quite challenging. And so that is one of the limitations in this realm. That's a great question. And our next question is, we have someone asking Dr. Vickery for a little clarification on when you said that colonoscopy should be the first test offered. This person says, when I'm doing a consent, I review that Cologuard is technically an option for average risk patients, but it's much less preferred because of X, Y, and Z, and how colonoscopy is much better, that it can be therapeutic, et cetera, et cetera. It sounds like you all are on the same page, but any additional clarification from you? No, I think that approach is perfectly acceptable. When I say that colonoscopies prefer a test, we are all data-driven and should be evidence-based driven, and that is the current recommendation. And so that's the genesis of that comment. However, your approach, I think, is fantastic. If your goal is to be the patient advocate, and if the best test available for that patient in your discussion is FIT or Cologuard, by all means, charge ahead. We want to screen as many people as possible. In the last week, I found two colon cancers, one in a 52-year-old who came in completely asymptomatic screening, and another one in an 81-year-old who, in the fall, I tried to talk out of coming in for a screening test, and she was healthy. And she said, no, I want to come in. And boy, was she right. So any test, anything we can do, I'm on board. And any approach makes sense to me. It's very interesting. When it goes back to, I think, the role of us as APP, MD collaboration, and the team, and we review these referrals, sometimes they're very insidious. I just found one from Friday that was sitting in my Epic inbox. A patient referred to you for screening colonoscopy. And generally speaking, I don't get too many of these. So every time I get a screening colonoscopy referral, I will dive a little bit deeper. And in this particular case, in 2014, this patient, 2014, this currently 83-year-old patient had had a colonoscopy by a fairly expert endoscopist in the community. And the attestation at the bottom was, this patient has an extremely difficult sigmoid colon, and she would have been 75 at the time. So probably, as per the guidelines, they were looking at doing the last colonoscopy at that time. And they said that in future, if there is ever a need for colonic evaluation, non-invasive tests should be considered. So appropriately, we have referred this patient to our clinic. And most likely, Sarah will end up seeing this with me. And we'll go over this 83-year-old patient, the pros and cons of colonoscopy at the age of 83, albeit with the prior history of colon polyps, but with a very difficult sigmoid colon, which who knows what has become of that sigmoid colon in eight years? Probably more. So if this patient had come as a direct colonoscopy on the table, that, I think, would have been an injustice to the patient's care. So that's kind of a real life, just from yesterday. Our next question is, why does Cologuard have a higher false positive? If it's looking at something more specific, like the methylated markers seen in polyps versus hemoglobin on a FIT? I think the false positive rate, the methylation, like with any test, is imperfect and has a false positive rate. But I think the higher rate comes from the combination with the FIT test. To ideally perform a FIT test, we would love to have patients off aspirin, avoiding certain vegetables that can cause a false positive. So it really comes from other sources of blood that are making the FIT portion of that test positive. So in the abstract we presented, we concluded that patients in our practice, many of these people had hemorrhoids, and that may have been a source of the false positive. We can't tell for sure. So there are a number of reasons that we can have the FIT portion of that test and the FIT have false positives. Yeah, Cologuard is both false positive and false negative. Now, colonoscopy also has a miss rate of 12% to 15% on polyps. That's been well reported over the years. But at least one thing I think we can all agree on is that a reasonably good prep at colonoscopy performed by a reasonably experienced colonoscopist is very difficult to, near impossible, to miss a large colon cancer, especially if the exam is complete. So I think on balance, the optical examination is a more direct examination. But as disruptive technology that I presented yesterday, as it gains traction, I am confident that more and more sophisticated testing will become available, not just for colorectal cancer screening, but for other cancer prediction, cancer detection, and so forth. So that is the nature of evolution, and we cannot go away from that. Other questions? Yeah, let's talk about hyperplastic polyps in the right side of colon. So should those be considered sessile serrated adenomas? I'm going to have maybe John or Vivek jump in. I don't want to be hogging everything. And Vivek, as a therapeutic colonoscopist, some of these can be large polyps. So it'd be nice to have you weigh in on what they mean and what the larger ones mean. Yeah, so the hyperplastic subcentimeter of typically three to five millimeter subcentimeter polyps in the sigmoid colon and rectum are typically the one that we consider benign. But once you move proximal to the splenic flexure, that is anywhere between the cecum and the splenic flexure, proximal colonic polyps that are hyperplastic or sessile serrated, they fall in this whole bag of descriptors, such as sessile serrated adenoma, hyperplastic polyps in the proximal colon. We have been asked to treat them very similar to adenomas in the last decade or so. And that's what has been our practice, because studies have shown that they have a certain rate of progression to neoplasia, which is not too dissimilar. In fact, in some cases, more rapidly progressive than the adenomatous cohort. So I think the proximal hyperplastic polyp has to be taken seriously. Agreed. I think from a clinical standpoint, treat them like they're adenomatous polyps. End of story. Thank you, John. That's more eloquent than anyone can put. Well, I don't know about that, but I mean, just, you know, as a practical standpoint. It's really true. So let's see. Cancer risk associated with PPI use. That's one of my favorites. So once the New York Times article went up with PPI and everything from magnesium to dementia and everything in between was included, a lot of those are associations. You like that one, John? Yeah, I love it. You know, New York Times, I love it. It's not only popular on CNN, but it finds its way in medicine as well. The cancer risk or other risks associated with PPI use were all by association. Association studies are weak in terms of scientific quality of evidence. And once they looked at it more deeply, the guidance came out that a lot of these were debunked. So my take on this is that if a patient has a clinical indication for PPI use, please proceed with prescribing it and reassuring the patient. Of course, there are a lot of patients out there on PPIs that do not need to be or do not necessarily benefit from it. But for those patients who need it, the benefit far outweighs any risks. Short answer, no known human cancer risk, some carcinoids and rats. I want to emphasize one point, if I may, that Vivek made. You know, a lot of patients will come in asking questions about this. They know about PPIs, the sophisticated patients. So kind of have something in your bag of tricks that's pre-planned, your explanation as to why it's important and why this poor association with dementia. Kidney disease is the one that seems to spook a lot of people, as does the dementia. And so have a nice game plan going in. It's reassurance, reassurance, reassurance. And then talk about the poor quality of life that the impact of heartburn and asteroid regurgitation can have if it's not properly treated. I think that, you know, that's such a wise response because, you know, I think when push comes to shove, patients come in and they're not sure how to weigh these things. You know, it's kind of like when I'm getting a consent for an ERCP, you know, and I tell them, well, you know, it's a 5 to 10% risk of inducing procedure-related pancreatitis. But, you know, on the other hand, if I don't take your bile duct stone out, you have a really high risk of acute gallstone pancreatitis, which is likely to be a heck of a lot more severe than your average ERCP-related pancreatitis. And at the end of the day, you no longer have a 0% pancreatitis risk option available to you. It's either post-ERCP pancreatitis or gallstone pancreatitis. And if I were you, I'd take the post-ERCP pancreatitis risk of 5 to 10%. And, you know, I think it's the same thing here. It's like, what are your options? You want to stop PPIs? Well, we don't have anything medical that's anywhere close to as effective. And you want to consider invasive procedures, including surgery. Some of those patients end up back on PPIs. So, you know, I think if you sort of get practical and let them know what their options are, no PPIs, weaker drugs, invasive operations, etc., that may result in still a need for acid suppression, I think that can make the, you know, these sort of theoretical risks, it couches them properly. Eden, do we have time to have Sorel perhaps weigh in with a couple practical tips on that topic? Absolutely. Yeah, I was just looking at the guideline. There is a little area on the guideline that talks about this specific concern that can be used. So that's a good resource on the long-term PPI issues and the GERD guideline. But otherwise, I don't have anything new to add to what has already been said. So there's a practical question here. A patient comes in, he's a mid-60-year-old, has some chronic constipation, which is neither here nor there. But the patient is in a wheelchair, has some musculoskeletal challenges. And the question comes up is, there was a colonoscopy 15 years ago, a patient is average risk by history. Should we recommend Cologuard? Should we consider colonoscopy? Would it be OK to offer colonoscopy for a positive Cologuard? Comments on that, Joe and John? Anybody else as well? Anybody? I'm more than happy to weigh in. If Sarah, Jill, or Erica want to chime in as well, please do. I think this is really more where the art of medicine comes in than the science. If we are going to offer someone a FIT test or Cologuard, that means we have to be prepared to do a colonoscopy. That means we have to be prepared to do a colonoscopy. And in my mind, I have to ask myself, if that patient is sitting in a wheelchair, they have constipation, they're going to be difficult to prep, they'll need at a minimum a constipation prep or perhaps a more extended prep, will we have to make special accommodations at the hospital? Will they be safe to get up and down to deal with the consequences of the prep? And so perhaps the risks outweigh the benefits. If this person does the prep, falls, breaks a hip, we have a real acute problem. And I don't mean this to sound negative or demeaning in any way, but just because we can do a test doesn't mean we should do it. And perhaps this patient should not have any screening to be in their best interest. I think I would just say from this scenario, you know, I think this is where that shared decision making really comes into play. There are certainly some wheelchair bound patients that are 60 years old that are otherwise very healthy. And I have gone through great lanes to admit patients in the past to safely prep them with nurse assistants and do colonoscopies because I think they would tolerate a surgery should they have a colon cancer. And if they have a long lease of life, certainly we want to do what we can from a screening standpoint within reason. By the same token, there are some 60 year olds that are wheelchair bound that have multiple comorbidities. And you kind of take a step back and say, what are we looking to achieve at this? So I think that it really is an individualized discussion based on the patient's entire medical history and picture. And it really does involve patient and their family as well to look at what they're looking for. Right. So my takeaway from that is that the wheelchair is just about a weak surrogate marker for that decision making. I think we really have to look at the patient as a whole. But don't forget Joe's point earlier on, and this applies to Barrett surveillance as well, is that once you embark on a certain pathway, you should be prepared to complete the circle there. And so what that means is that if you do go with the Cologuard, something comes up, then you're looking at a colonoscopy as the next step. And this is what we talk about with pancreatic cysts, with Barrett surveillance. You know, when we look at really older patients, 89, 91, 87 for pancreatic cysts, what will that FNA achieve in that patient? That FNA will likely only set them up for infection, pancreatitis, and the morbidity and cost associated with an EOS, especially in these COVID times, perhaps some COVID exposure, who knows. So be prepared to finish the discussion if you start one. Don't start nothing, won't be nothing, is the message here from an old Brooklyn mentor of mine. Other questions? Let's see. So Yeah, you know, let me throw this one over to our longtime APP faculty so Sarah, Jill and Erica. How do you choose topics, each year for this course everyone's really pleased this person said this was excellent. How did you know what your colleagues wanted to hear you obviously hit the nail on the head this year. Oh, thank you. We appreciate that comment and, you know, I think that a lot of it comes from these evaluations. And so the questions that you guys are asking in the course evaluations we really do take the time to go through all of those we read all of the comments and then from our own clinical practices as well, Jill Erica and I kind of take a step back we work with our physicians to say what are the things that are continuing to come across everybody's plate. And then we bring some additional education to Erica Jill. I was going to say exactly what you said Sarah, we'd take a step back and look at our own practice and see what clinical conundrums come up and or what do we see on a routine basis. And then looking at the surveys as well to look at because the needs assessment is so important to see what the gaps are in our community. I echo what Sarah and Jill said as well and I think it's so helpful, as we did yesterday to see what the spectrum is of knowledge. That's also really helpful, knowing how many years of experience some of the APPS has had in the audience and, and of course what they're interested in and want to know. And then lastly I was going to say it's also timely topics of what's going on in the gastroenterology community and industry so we're just as interested as we think our colleagues are so we take that information and present that as well. Right, and you know some of the topics are really bread and butter abnormal LFPS abnormal imaging can't get away from those. But I think every time we look at the feedback which comes in droves, thankfully and we expect that again this time. We expect some nuanced topics that find their way into the curriculum, and that will continue to be the case as as the as the medicine evolves as an interesting question here somebody has a has a. See here is a patient who has good but doesn't want to take PPI. Because of a variety of concerns. What do you tell that patient. What would you tell them john what would you tell them and settle PPI, no go good, a problem, sir, all you first. Yeah, I think it's just still having that discussion with them for alternatives are they willing to try at least h2 blockers I know there's a lot of over the counter products people come in and use by just having that discussion with them if you don't want to take the risk of that risk of esophagitis risk of Barrett's. And ultimately, you know, there are a few patients absolutely do want to take the PPI is and that's kind of their choice. So to escalate it to an endoscopic fund application which is now well established, and or laparoscopic under application. The, as you very appropriately in your fantastic session determined that are educated us that you have to determine that the good and the appropriate esophageal testing, because now you're going to the invasive level of management, and most certainly fund application remains an option for the bona fide patient with good. does not have contraindications to those interventions. So, yeah, and you know to add to that, the importance of having the discussion that none of those procedures leads to 100% durability, and many of those patients do actually end up back on medication. And you don't want your patient to be surprised. I'm sorry. Sorry, go ahead. I will often do a 24 pH and impedance and these patients, because I think being able to give them objective evidence they truly do have acid reflux can be helpful when they think that they have a low acid state and that it's not acid itself. And the same token if they impeded and shows that it's non acid reflux then you can start talking about alternative therapies, then no matter how many PPI is you give them it's not going to get better anyway if it's a non acid reflux situation. And so I think this is really where I'm able to leverage that testing and use that. Other times I have people who are very resistant to the testing, but this class of patients tend to be a little bit more willing to do it. I have another question here, how would you train new APPs in a busy understaffed GI practice. That is how much interaction with docs who are rarely in the clinic. Does anyone have a good training plan that you'd be willing to share. Who wants to go first on that one. I'm the moderator so I can sit back. I'll start, I think. You really need to, from an APP perspective, if you're being hired on to this really busy GI practice, and they don't have time to train you properly. I think you need to have a discussion about that you know most of us are not GI trained as we saw yesterday there's three fellowship programs there's no residency program. If you're joining a GI group and you have no GI experience that that needs to be discussed at the interview process of, you know, what's, what's the plan what's, what's my kind of education plan going to be how am I going to become up to speed because that's not fair for anyone that's not fair for you. That's not fair to the doc that's not fair to the staff. So there's, there's got to be an education plan. Any comments on this very, very important topic and likely a very likely prevalent scenario in the country, in many places. Yeah, I completely agree with Erica I think the other thing is to establish a set time where you can meet with the physicians. And so if there is a break in their schedule for lunch at the end of the day something to have that park yourself in their office and have those discussions so that you can start pointing out the things that you are struggling with and where you could use the additional help and how can you get those resources, because I think a lot of that is to have that open and transparent communication and finding ways that you can facilitate that is super important. I'm sorry I was offline there for a second trying to answer some questions. We, we have something informally formal I would say. Since we teach medical students in our practice we have a program of lectures and introductions at the hospital for medical students so we've used that to help train our inpatient NPs and we use the lecture series for the third and fourth for the fourth year medical students for all the new NPs and it's a pretty robust lecture series on many different organ systems so they attend all those lectures. They certainly have less time, more time rather, and less patience when they start we give them at least six months. They are closely aligned with a mentor and certainly can ask anybody in the practice but that's about as informally formal as we get. I think there's a great need for something formal and perhaps that could be a topic for us, the faculty to think about and work on for the future. Yeah, I mean I think the, you know, the comments about binders and videos and you know tutorials, they can only take you to a certain length right so I think, yes, for the quick learner and for somebody who is able to absorb everything with a sponge and apply that on a continual basis to, you know, enhance their practice and their skill sets that's one thing and even that takes a long time and, and maybe not as satisfying but I think the question really was that when you don't have simply of anyone to run things by, or to, you know, formally or informally when Dutch base every so often to address difficult questions that lack of mentorship and championship is really hurts the practice it hurts, I think the overall the patient care and I think I think that is that is a gap, I suspect, which is why the question was asked. And we can certainly address this in a symposium format. Next time around. In our organization, we actually assigned for the first two weeks mentor for a block in the morning and a block in the afternoon. So it rotates through seven different gastroenterologists so they may have clinic Wednesday afternoon but that Wednesday morning would be with me. And then Thursday, Thursday morning would be with another gastroenterologist and then we have another APP so our manager took this role on our practice manager and she just went through come through all of our schedules. So those four hours would be assigned to someone. And then, if the majority of the time the gastroenterologist would be in clinic but in the morning. They're not in clinic they're doing procedures, so you would have two other APPs that would help with the morning orientation but even the afternoon we just make sure that we go through all the different communication tools that we have either face to face Tiger text secure chat within our epic system, and part of that onboarding is okay how do you present a case that succinct that you can put together via text, but even that that takes a long time to do that and you're, you're mentoring someone even through that process, and sometimes we see it's not appropriate you have to call the call the gastroenterologist or run the case by us if we're on site, the APP. Yeah, and I think it's on the same team as the question came up yesterday around physician who simply never rounds on patients that you're supposed to see together I think, you know, that's you know every course leaves me with a with a with a little mark on my, on my psyche but I think that that is that happens. But you know I'll give you a concept from our own regional practice which Sarah has been very instrumental in developing over the years. We're looking at putting something you know a few miles away from the big, big house, and a huge emphasis is on figuring out how to do that. It's easy to place two APPs or new and you know need space and looking to go, but we're also trying to put a physician in the building. At the same time, so that the physician is available upstairs downstairs somewhere. As, as these new people start their practice so that it may not happen for for a couple of weeks but when it happens they need that resource, and they can certainly feed off of each other for their clinical practice needs. So any advice for somebody who's in a situation where the physicians are private practice, so not getting any real mentorship, because their private practice doctors are rotating through. So when she's on her inpatient GI service she's not getting a lot of Sarah and Eric have just opened a consultative practice on Sundays. I'm just kidding. No, it's a go ahead guys. I don't want to make light of it Sarah Eric. Yeah, I want to be crass and just say we're recruiting APPs all the time so the answer is leave and come work with us. I mean seriously right, it's not even a supervision issue that's a little strong I don't like that word. I think it's more of a collegial association kind of thing that's implied in this relationship right. I mean, as a speaking as a physician physicians in a group have that amongst each other and that should be had with the APP as well so I mean you know john you and I probably spend more time in rooms 2345 and six. I mean that's part of, you know, taking care of people and helping junior colleagues and or people who have a question. Agree. Sorry, good john just to wrap up I mean you know for me I think it's, it's more a situation where, you know, I need to talk to Sorrell and he needs to talk to me and we have questions for each other and if neither has questions, something's wrong with your practice. Yeah, I'm an East Coast Italian who grew up in a very loud family and if I didn't jump in and jump in loud I would just sit in the corner and perhaps swallow and admire. So, you know, I think to add to john and Vivek's comments which are very important it's beyond collegiality it's an organizational leadership problem. You know, as you've learned from this course you're our colleagues and the team approach to GI is really I think quite a formidable force so I think it's a leadership problem. It requires communication requires getting the right people in leadership positions to promote the APP program in the practice, and I'll tell you it's 100% in my practice, working with APP is a great source of professional satisfaction. It is fun to make rounds at the hospital. We're all learning they they teach me as much as I teach them. It's fun in the clinic. You saw those silly pictures of us sharing a moment of drinking a cappuccino that I assure you that happens every single day we take a minute or two, we shoot the breeze about unimportant and important topics. So collegiality leadership professional respect professional happiness. I just think we have a great opportunity as a team to achieve all those goals. Thank you. Two or three questions real quick I'll try to answer, then we'll do the final comments and then back to Eden so ENT says you have LPR persistent symptoms the patient comes to you. Very quickly, our approach is to double the dose of PPI give it a trial and if the symptoms don't go away or then it's likely not reflux. Then we have apple cider vinegar for good. I do not have any personal experience with this, but I think it does taste good. You know I think it's out there and you know in the community people do use it. Other question how many patients a day should an AP PC with a 10 hour workday I think we addressed it yesterday. Joe opine that it would be about 20 minutes for a follow up maybe 30 for a new patient, and also the comment was. We're not allowed to see any new patients I think if you're competent well trained and confident, you should be allowed to see new patients with the appropriate consults complexity level. Let's see, I think that's pretty much it. Do you want to initiate the closing ceremony now. Why don't we just do one more because I'm in as a new and then we'll consider this the last one. So here's the scenario. And this might be for a PPS. I am a new NP, I manage patient questions pre and post endoscopic procedure and other administrative tasks, not seeing patients with the physicians, so oftentimes I'm struggling with a lack of knowledge is there's no proper training. As of now I just asked physician case by case upon patients questions when, what can I suggest to the physicians on proper training, what would be the best way for me to learn. When I start Sarah and then maybe we can go around. My suggestions would be to have a conversation and see if you can join them in the endoscopy unit for half day blocks, you can have conversations about the procedures themselves, what things should I be thinking about in terms of complications. If a patient calls me what are red flags that I should be looking at. You see an unprepped colon what would be a way to salvage this bowel prep, how can I help patients get this done more accurately or more thoroughly. Or if you see some abnormal findings, tell me about these findings, what are we going to do regarding treatment. So I think that's a really great way to get an introduction into endoscopic procedures, but also start to open those lines of communication, and it may help guide some of the conversations and maybe help them identify what your needs are as well. Also look at your professional resources, look at your professional societies within gastroenterology, predominantly ASG and AGA. There are clinical guidelines that I have been established so those are guidelines that you should be familiar with and use as a resource and after a while, believe it or not, it's going to be routine. As long as you have those guidelines next to you and you practice evidence based medicine, then you're going to become very comfortable with your additional readings and experience. And I would say that in the beginning the learning curve is steep, you know, like majority of us don't come in with a lot of GI experience so you do feel like you have a question with every single patient. Building on that, learning from those questions, possibly asking your physician mentor if you can go with them for a day in their morning or, you know, when they see a patient and ask what were they asking the patients before the procedures, how are they following up from procedures. I think it's great to actually see procedures because we don't scope. So that can be very helpful. And a lot of times the physicians are in a different kind of headspace when they're scoping I find that they're a little bit more easygoing easier to talk to and it just, it helps the relationship as well so I would definitely recommend that. Yeah, the only thing I'll add is that I think it's important to remember that it takes a couple years to feel like you are a gastroenterology specialist. And so when our APP start I always tell them you're going to be more comfy at one year, but you're going to feel much better between years two and three. And at year three people usually come back and they're like, you're right, we're good now. Now we feel like we got it we still have a lot of questions, but we're a lot more confident in our practice, it really does take that time. And so you have to be committed to giving it that time to continue to learn and grow. Yeah, I agree with everything I was saying what was helpful for me is in my email in my inbox I would make files for all the disease processes and I would keep asking questions until you really have a good handle on it and then you'll have the file available to go to go review either that being a study or how do we treat that. And as you said that takes time, but you'll get to the point where you see patients independently without supervision. Down the road.

gastroenterology

hyperplastic polyps

stomach

PPIs

training

APPs

endoscopic procedures