We have any questions from the audience? We sure do. For Q&A. Yeah, we sure do, Dr. Martin. The first one I'd like to actually direct to you. Does anyone work in a facility where APPs perform screening colonoscopies? Yeah, I do not work at such a facility. I would ask if any of the other faculty work at a location where you have APPs who actually are the procedure provider. I do not. Hi, it's Jill. I do not as well. But I've had friends throughout the years that have had strong mentors and supporters in their institutions. So for example, I had a friend that worked at UC Davis. And she pioneered doing diagnostic colonoscopies and polypectomies. But since she's retired, then no one's filled in that gap. I also have a good friend who does diagnostic and screening colonoscopies in Alaska. So a lot of times, it's going to depend on the physician champions, endoscopic champions, at that facility and the need that's assessed. To expound on this, because I think this is a super interesting issue, and the faculty here know that we've actually discussed this amongst ourselves many times before. Any opinions about what's keeping that practice of APPs performing endoscopic procedures from expanding? I'm not going to. I'll let Vivek comment on that. I'll be brief. But I do have a slide in my basic colonoscopy talk that will at least make us think about the future. So I'll at least allude to that. And I'll let Vivek jump in. Oh, please go ahead, Joe. I don't want to steal my own thunder on the slide. Oh, OK. OK, you meant on this. OK, I'm sorry. No, I just wanted to say that this is indeed a fascinating topic. And we actually came pretty close a few years ago to establish this paradigm along the lines of what Johns Hopkins has pioneered several years ago. And actually, Sarah and another partner were almost ready with that. A couple of points on that. Number one, a lot of the scope of practice is regulated by state bodies, insurance coverage, institutional policy, and so forth. So some of those systemic issues are beyond our reach. Second point, it is definitely a paradigm that is being re-invoked, including at our institution, given the difficult access we have now in the post-pandemic era. Third point, a lot of colonoscopy and upper endoscopy is being done in Middle America by non-gastroenterologists. And for the most part, it's being done well. I think when you look at the resource allocation for GI endoscopy, it is highly variable. It tends to be concentrated on the coast and the big cities. In the middle part of America, I think Jill mentioned Alaska being an example, not in the middle. But remote enough. So I think there is something here. The key tenets that we looked into were really availability and championship by the physicians, time and space allocation for the interested APP, and training. When we had almost developed this, the bar that we had set for training was actually almost double that for a first year or second year fellow as per the ASGE guidelines. So there's a lot to this that we've obviously thought a lot about. It's not an easy topic to cover in a small discussion. But there is something here that we need to look at. And I think given the amount of business, if you will, that's available, the eligible population that has expanded now with the 45-year age, marquee age now, I think if it is done well, if it is done properly and positioned well, safely, there is room for everybody to be at the table. It's a rather interesting absence, isn't it? I mean, APPs have been in the OR for decades. They're not the primary surgeon, but they've been there in an assistive capacity far longer than I've been practicing medicine. So its uptake in the endoscopy realm has been slow. And that's a good point. And at least in the limited data on the topic when we reviewed it last, the quality parameters from an APP productivity in this realm was actually at or above those from their physician peers. This is very, very interesting. But I'm not surprised. We should save the rest of it for Joe, I guess, right? I'm sorry, Joe. No, my slide remains unscathed, so we're going to be OK. No doubt. All right, Eden, keep us honest. What else you got? OK. And folks, if you want to raise your hand, we can open a phone line if you would like to, or the computer line. I don't know what we call it nowadays. But if you'd like to ask a question live, we do welcome that as well. Dr. Martin, I'm going to circle back to you again. Is there a protocol that guides which patients should be scheduled for procedures within the hospital setting versus the outpatient endoscopy center? Yeah, that's a loaded question, which was why I asked for it to be brought to this live Q&A session. And I think if I had to give a one sentence answer to that question, and I'm going to start it with that, it's dependent on the practice, and it's institutionally dependent. So there are different clinical reasons to prefer the site where the procedure is undertaken. And there are also reimbursement-related incentives to shepherd certain procedures to certain procedure locations. With that as a preamble, I want to open this up to the panelists. So how do you decide which patient to send? Where are you going to do it? At your ASC, or are you going to do it in the hospital? Obviously, it depends on the procedure. But sometimes one could go to one place, one could go to another, and it's practice dependent. What are those practice dependencies? Yeah, I think as a part of a practice that has our own ASC, the first question is always, where is the insurer going to pay for it? And so whether it's Medicare or whether it's commercial insurance, the majority of those are now pushing procedures to the ambulatory surgical center because the cost is significantly lower than the same procedure at the hospital. So that's usually kind of the first layer that gets sorted out. The second layer would be more kind of patient or procedure-related questions. Obviously, some of the more complex procedures, the longer procedures that are going to require equipment that we might not typically have at our ambulatory surgical center, those are going to be the ones that get directed to the hospital. So in our practice, those are kind of the two questions that really dictate where the procedure is performed. I was going to mention in our practice, one of our policies is that if that patient has a BMI over the age of 50 and or other comorbid conditions with a BMI of 45, then recommendations would be at the hospital. And to expound on what Dr. Shields was saying, there are also issues related to reimbursement for the various devices that are used that may be or may not be fully reimbursed. And that can drive the practice patterns of which patients are likely to be sent to one location rather than another. I think that's a reimbursement reality. There's definitely part of access also. And so if the patient is a healthy individual, sometimes our ASCs that are a little further away from the hospital, they may not be able to access from the hospital, we can get them in quicker. And so sometimes it goes based on that as well, even though it may not be as convenient of a location. I think that it's really important to have clear inclusion and exclusion criterias though. And it does vary from practice to practice, but being able to go back and reference that, particularly if you are a non-procedure performing APP, I think that that really does help to reduce a lot of errors to know exactly what the expectations are. Great. Just to follow up on that, we encourage all of our APPs when they see a patient in the clinic, if they're just not sure, if it's, you know, some of these patients are kind of on the fence whether they should be done at the hospital or whether they should be performed in the ASC. And it's really important to maintain open communication. And we encourage them, you know, if they're not sure, come find somebody who would be, one of the physicians who would be doing the procedure. And we can give a little bit of guidance and work together and figure out the best location for the patient. Thank you for that, Aaron. Other comments? Eden, what else do we have? So a sedation question for you, Dr. Martin. For ASA, do you recommend stopping ASA 325 or lowering it to 81 for procedures? Yeah, I'm going to actually give that to Sarah because that was Sarah's talk. So Sarah, can you comment on aspirin dose? Yeah, so we don't change aspirin dose prior to procedures. We continue them on whatever dose that they've been advised to take per their cardiologist. Yeah, that's the same for us. I think, you know, times have changed with aspirin. You know, we used to use aspirin, but now we're using aspirin. And I think, you know, times have changed with aspirin. You know, we used to use it mainly as a pain reliever and a fever reducer, and now it tends to be used for cardiovascular reasons. And, you know, you have a lot of patients that are on stents, like Sarah was mentioning. And so it can be very detrimental to their health to stop that aspirin and the likelihood that keeping it on when you do endoscopic procedures, that that's going to have any negative effect is basically nil. So we don't stop it, period. And we don't reduce the dose. Yeah, if there's one key takeaway message from that lecture, I think nationally, is never stop aspirin, you know, for elective procedure coming in. The ASG recent guidelines and all Tri-Society guidelines and high-quality data are very clear. Especially for cardiac patients, the mortality and morbidity is much higher the moment you start stopping aspirin. And to be very honest, outside of some bizarre situations that do develop, and I'm dealing with one this week, for complex case scenarios, for the vast majority of endoscopically induced bleeding, it can be controlled either with endoscopy or with international radiology. But lost myocardium and brain tissue can never be really retrieved. So that's one single key takeaway message from this lecture, which is an amazing lecture. Thanks. Yeah, if you're only going to remember two things from, you know, procedure preparation from this section of talks, please remember, don't stop aspirin and do split dose your colonoscopy prep. Both are high-quality evidence-based recommendations. So our next question may be good to go around the table with Dr. Martin, and if so, you just let us know who you'd like to begin with. The person writes, there are multiple clinicians and team members that work with a patient from their office consult to day of procedure, to follow-up clinic visit post-procedure. How can we help communicate with and support patients if they are receiving conflicting information and education on their care at different points during their experience? I do think we should all answer that one because this is highly practice dependent, although there are important tenets that we all follow regardless of our practice, the way our practice is organized. We do need to keep a consistent message to the patient. But it's also equally important to not actively throw your colleagues under the bus. Let me be frank about that. That doesn't make them look good and it sure as heck doesn't make you look good either. Because when push comes to shove, the patient is going to be anxious and they want to feel confident in your hands and the hands of the entire team that cares for them. And so it is a nuanced communication. If you feel that another provider or caregiver has given a message that is not completely precise, I think it is imperative and absolutely necessary for you to correct that by giving the proper advice. However, there's a right way and a wrong way to give that proper advice. The way I would do that, and this happens not infrequently in my practice because in my practice, more often than not, the procedure provider is not the patient's longitudinal care provider nor even the person performing the specialty consultation. And so I may say, well, I understand what doctor so-and-so or provider so-and-so said. One thing that's important to consider in your particular situation, however, is this, this, and this. And so given those specificities, as the person who's going to do your procedure, I would like to suggest that we do things this way and here's why. And when it's done, I think in that sort of a well-explained, engaging way, and then you give the patient an opportunity to ask questions, all the right information gets into the patient's hands and everybody on the team saves face. That way, the confidence that the patient has in the entire team remains intact. Others on the team, do you have anything to add to that? I'm sure you do. I'm going to toss it to Aaron. We're both at the same practice, so I think one of us can answer for both. Yeah, I think, John, you hit most of the key points there. Obviously, education amongst the staff plays a big role in all of this as well. If a particular member of the team is consistently giving information that's not exactly right, your best option is to interrupt that and give them some additional education so that the patients are getting the right message. I think our clinical teams, they do work hard to try to have some of the same reliable information and we take time as physicians to try to really educate our staff from the techs to the nurses to the APPs to make sure that the common questions and situations that they're running into, that they have the tools to answer correctly. We work very closely with our triage nurses. I think this is probably where this sort of thing would come up the most. We all have our own triage nurse and the APPs in our group also have their triage nurse and they're addressing a lot of the questions directly when the patients call in, so we take a lot of time with our individual triage nurses to make sure that they have good information and a good knowledge base so that they can answer a lot of these questions. It's good for patient satisfaction. Ultimately, it saves us a lot of time in the long run with not having to double back and fix information that wasn't given correctly. It can be really disconcerting, can't it, Aaron, when you're a patient? I mean, we're all patients as well as caregivers, right? And when we get sort of different information from different people, it can be challenging. One thing, though, that I do try to remember in the appropriate situation is to, you know, explain to patients that, you know what, there isn't always one right way to do things or one right answer. You know, I take care of this patient, have taken care of this patient for a long time procedurally who is a rabbi. And his wife had gotten different messaging from me and from a couple of other providers and wasn't happy about the situation. And I said, well, you know, honestly, there really isn't data to drive the answer to this particular question. And so it's a matter of best professional expert opinion, and there are different expert opinions. And so you're going to receive different interpretations and that that's not dissimilar to, you know, a Hasidic, a conservative, and a reform rabbi giving different interpretations of a scripture in the Torah. And she took that to heart and got it, and that was the end of that discussion. And so I think couching things in a way that people understand and that relates to their life is really important. And if the answer is that there's no one right answer, explain that to them. And I think that's also an important piece of information. Donna, I was just going to add, I'm sorry. No, go ahead, Sarah. I was just going to add, you know, I think the other part of this is, particularly as APPs, is good documentation. And so it's not just providers, right? So they have multiple touch points with nursing, with schedulers, with multiple other people. And so the more clear our documentation is, the less room for error. And I think about that in the sense of even anticoagulation, right? So if I want a patient to come in for an EGD and they're on blood thinners, do I want them to hold it or not? And if I want them to hold it, what am I requesting that hold for? The more we put on that scheduling instruction, the more documentation that's there, the less room there is for somebody else to interpret it in a different way and less potential that there's going to be some error or miscommunication. And also one more thing, don't fight congressional debates on the chart. I think it's important to maintain a level of decorum in the record. And so the other point is we all see a diverse spectrum of patients. We are constantly rushed. And the point I'm making is that there is a variation in patient literacy. There is also the important aspect of how much time you've actually spent explaining. I cannot say how many times I have said the same thing for the millionth time to 10 different patients, and they take away 10 different messages sometimes. So be cognizant of the fact that your partner inside or a colleague outside may really not have said anything too much different. It's what the patient took away from that. That to me is always fascinating. And I'll frequently see patients in the pre-admit area. I just saw them Wednesday. I saw them yesterday. And the first question I ask them, again, based on my experience with this, is do you know why you're here? And at least 30% of the time, you know, despite a Level 5 consult the day before, you know, it's unclear to them because they are overwhelmed with that pancreatic mass situation. They're listening to you, perceivably, but they may not be really with you mentally. So I think there is a lot to this discussion. Outside of the overt, you know, deviation from standard care and all that, but as Aaron said, you know, as practice managers and practice senior consultants, if you do recognize a trend of deviation that is outside the three standard deviations, that needs to be addressed as part of the QA process. That is a whole different discussion. I was going to say that. Really appreciate it. Yeah. And the only other thoughts I could add is just what Dr. Kahl recommended is start looking at trends. If there's one specific provider that is not providing enough information for a patient that you're seeing, especially if it's flowing over into the endoscopy center, then that can be addressed. Or concurrently, I'll see patients in follow-up after procedure, say six months, I'm reviewing their procedures, because it may come up in conversation. And I'll mention during the colonoscopy, it noted that they had mild diverticulosis in the sigmoid colon. And patients will say, well, I didn't know that. Why didn't someone tell me about that? And then again, you're having this supportive conversation. Well, this is a common finding. And then you get into the conversation, the difference between diverticulosis and diverticulitis. So this is a common that we've all come encountered. And as Dr. Martin said, you know, supporting our colleagues and providing that additional information, because patients don't always hear what we say to them. Thank you very much, Jill. Really appreciate that. I have a polling question, actually, Eden. Anybody hungry? It's lunchtime.

endoscopic procedures

screening colonoscopies

advanced practice providers

diagnostic colonoscopies

communication and education

patient care