And now we're to the last talk of the day and this talk and the Q&A following stands between us and the adult cold beverage on the East Coast, lunch on the West Coast and probably green tea in the Midwest. This is GI and Endoscopic Practice 2022 and beyond. I've been charged with predicting the future so be gentle on me here. Let's see if I can move the slide on. There we go. So the objectives of this talk are to discuss the recent advances, summarize them in some form in GI hepatology and of course can't get away from the impact of COVID and which we are still in the pandemic. To learn about some of the current best practices in GI endoscopy and how the space has evolved, highlight the role of innovation and technology in GI practice as a whole and then discuss some emerging themes both procedurally and practice-wise and summarize that. So this is my attempt at freelancing. I did get a D in art class but you can see here the GI is in the middle and everything ranging from innovation to insurance coverage, virtual meetings, robotic endoscopy, remote health monitoring, burnout which was discussed very well by Dr. Vickari today, digital security which is coming, DEI, so many topics, so many things that intersect with our daily practice with the concept of best medical practice in 2022 and beyond and clearly there's not room enough on a slide to talk about all the aspects that engage, interface and affect our practices and our professional lives on a daily basis. So that's just kind of sort of the scope of the problem but it's also exciting to see that we are actually practicing in this era. So where do we stand in 2022? It is now clear that GI and hepatology is a very highly sub-specialized specialty and that it is extremely in high demand across the country and in many parts of the world and that it's increasingly technology-driven, that innovation is at the core of our practice models and of our clinical care. We also know that revolutionary endoscopic advancements have occurred such as those some of which were shown today earlier in talks. Increasingly especially in IBS and IBD and cancer care, the multi-disciplinary service line oriented approach has become really more popular. It is increasingly more well established across larger systems and these progressive maneuvers so to speak are not in one part of the other. They are in all settings, in academic settings, in large health systems, in private practice models and even the smallest practices have had to pivot and become more progressive over time. Another important aspect is the increased recognition and incorporation of APPs into practices, practice care models, clinical care models and this course is in no small part a testament to that and the attendance and participation and engagement in this course is reflective of that as well. Finally to those of us and this applies to physicians and nurses and APPs and all levels of providers, GI is an extremely sought after specialty which is highly rewarding. It's quite impactful in the care of our patients and also profitable at all levels if performed efficiently. So with that said there are still some challenges and some of these are inherent innate to the concept of practicing in this in the real world. There are significant concerns around workforce attrition and underserved regions remain across the country and this is accentuated by the post-pandemic state. As I will show you with some data, screening and surveillance and elective care has suffered the most across the spectrum. So that's one aspect that we got to contend with going forward. The other issue that has emerged in the last 10 to 15 years with the increased emphasis on endoscopy and clinical care models that are procedurally driven, there seems to be a concern, generically speaking, that GI consultants have moved from more of a cognitive specialty from 60s, 70s and 80s now to a more procedural based specialty and that's not necessarily all bad or a weak point but it's a recognition of the state of flux which has required other models to come in and fulfill that cognitive space issue. So we can talk about that in the Q&A a little bit. On top of that, data quality, especially in endoscopic practice, has traditionally been weak in terms of the relative lack of endoscopic trials that are prospective, randomized, double-blind and large volume as compared to some of the non-endoscopic data in liver disease and IBD that certainly is much more robust in many areas. Reimbursements have continued to decrease year on year. We're doing more to make us whole on a daily basis and the folks who perform and operate in ASCs can testify to that on a daily basis. There is a concern that super specialization is leading to a relative fragmentation of care and that has been studied as well and is a concern going forward and the difficulties in standardizing quality across practice settings and health systems when they acquire new entities, new platforms, different practices that are heterogeneous in their nature is a continual challenge even for the best leaders in the field. And finally, of course, we have arrived at a place where we have recognized healthcare disparities. They do exist. They are sometimes very difficult challenges to surmount. DEI has emerged as a major paradigm that we need to look at and put in position in our professional lives and the cost of care and many, many other barriers. So there are significant challenges and they're not going to go away in the next decade but that we'll have to address them one-on-one in whatever form that we can. Now this slide here talks a little bit about how we kind of have transitioned through the pandemic and what the best practices and best endoscopy units have done to stay above the fray so to speak and not drown in the tragedy that we've all suffered in the last two and a half years. So what are the strong principles that have come out here? Communication amongst team members, showing empathy across the spectrum not just with our patients but amongst ourselves, the ability to be flexible like the old Darwinian phrase which says it's not the best person, it's the person who's most adaptable or that species that will survive which is most adaptable. So adaptability, flexibility, being able to change your direction as a need of the hour requires. We have been humbled by the pandemic and that is not an easy feat to achieve at the levels that we practice. We are used to delivering success after success and do good by our patients but we have been humbled in the last 24 to 30 months. Many of our leaders have done well by listening and responding after taking in absorbing what the situation is telling them, what their staff is telling them. Those that have not done well in that realm have not done well for the system. We have continuously been required to be creative and innovative and I think that is going to be a huge element along with flexibility and adaptability that will propel us forward into a more successful future. So coming down to the data, a couple of slides looking at, and this is very recent data, this is a WEO or the World Endoscopy Organization effort recently published looking at the impact of endoscopic training, impact of the pandemic on endoscopic training for example. Now I'll remind you that we've had a whole generation of trainees that will be graduating in this June that have functioned primarily in the pandemic and so 93% of the respondents here, these are program directors, telling us that they had negative impact of the pandemic and this impact was felt more on the European side than necessarily even in America and that we will require to focus on optimizing novel platforms for endoscopic training and equally importantly assessment of those competencies. So the vast majority have felt that the endoscopic training opportunities decreased by 51 to 99% during this time and this will have an impact on in the years to come. Similarly, looking at clinical care, this is a retrospective study published in JAMA Oncology looking at the sharp decrease in overall cancer screening, breast, colorectal, prostate being the biggest ones and up to 80% decrease and absolute numbers are mind-boggling and this is what Aaron was just referring to last few minutes is that we have this huge backlog of elective procedures that has developed along with a workforce attrition. This is a bad combination, this is not an equation that portends any degree of comfort for any of us but these are the facts and this is the state we are in right now. Now here's a meta-analysis of 25 studies and again looking at the fact that colorectal cancer screening has decreased and continues to remain a backlog. Emergent colonoscopy procedures of course increased because whatever room we had left we were triaging patients at the highest level of priorities but overall referrals and elective endoscopy is really has taken a huge hit and this is very recent data here. Having said that, there have been some opportunities that have come to the forefront. So the impact of the pandemic has also resulted in increased innovation and jump-started a lot of paradigm. So here is a pill cam that is novel and different than the ones that you had before. There is the impact of pandemic on healthcare innovation has led to home healthcare testing in terms of breath tests, telemedicine opportunities and at-home endoscopy through these smart pills and of course an enhanced emphasis and investment in digital tools for patient communication, open notes, my chart messaging and so forth and on the other side of the equation, if you look at the hardware, we now have single use endoscopy, disposable endoscopy that is now FDA cleared at multiple levels, several companies investing in that space and of course the paradigm of artificial intelligence that is not only looking at how to enhance the endoscopy procedure itself but also how we can improve operations and scheduling and all other aspects of practice which will be more to come in the years going forward. So with that in mind, a lot of progressive thinkers in the field are now talking about and potentially in some areas going back to the drawing board and looking at non-contact architectural design where you have anytime a newer building goes in, it goes in with the mindset that how can we develop something better infrastructurally where there is a preparedness for a future event where we have automated doors, reconfiguration of endoscopy units for flow, negative pressure rooms so we can do COVID positive or similarly infected patients and not have to go to the OR every time. Small examples of what might be coming down the road and what budgets might need to be factored in when we build new complexes. Increased adherence to guideline and database recommendations will I think be more important because access is limited and there is that much little room to deviate from what is standard of care so to speak because the most eligible and the highest priority patients will need to get in first and the guideline-based recommendations become even more important. As innovation progresses alternatives to colonoscopy which remains the bread and butter for most practices will emerge and continue to emerge and some are already in practice today but I think this will be a major focus because the denominator is so large. Automation of processes will be important, simple things like informed consent that we are writing papers and stuff, assigning papers on both sides will be more and more electronic. Further sophistication of pre-procedure evaluation protocols might be in place and digital tools might be used for that. Simulation-based training for fellows and trainees will be increasingly utilized and simulation has been at least in the endoscopy field not that sought after as much as it has in the laparoscopic or surgical fields but it has become clear that non-patient-based training coming into the patient interface will become very important and of course we are all familiar with the employees working from home and that is likely not going away in the near future and some adjustment or compromise there will have to be sought after. Now this paper is so the so-called gastro SWOT analysis. SWOT analysis is strength, weakness, opportunity and threat is used in business in corporate America and in the boardroom, c-suites in pretty much every aspect of life and this is an analysis that actually started by the Spanish group there but also spearheaded by the WGO endoscopy chair there Professor Joost and has included many representatives from Johns Hopkins Cleveland Clinic and the Mayo Clinic and this group came together and did an analysis of where GI stands and this is just hot off the press so I wanted to share this with all of you. So what the high level elevator pitch of this paper is that the GI landscape has significantly changed and is continuing to change. The GI diseases are on the rise, the demand is significant and a lot of it has to do with the unhealthy lifestyles and the environmental factors that have been at play for years. It's not something that has happened overnight. Now they do acknowledge the fact that the specialty is obviously extremely specialized but with that comes the threat of fragmentation where you have organ specific doctors and not whole body doctors. So their senses from this group which is an international group is that the future of gastroenterology really will be driven by technological innovations which we're already seeing that therapeutic or intervention endoscopy in any form will take a larger space in the room that big data and AI will drive a lot of the decision making both at the clinical practice and at the operational level and that increasingly there will be a emphasis on targeted treatment the so-called personalized medicine whether it be cancer or some other sort of some other entity. So this is an interesting paper that should be looked at and I think down the down the road many years later this will be looked back and said this was this was one great assessment that was done as to where things would be several years down the road. So the high-level analysis again a little bit more detail speaks about the innovation aspects that will be coming forward that telemedicine and virtual conferencing is going to be here to stay in no small part due to the fact that it really has a positive impact on the carbon footprint. So people are traveling across the world, across the countries for meetings and such a lot of that will be toned down to a great degree and so life will change along those lines. The next big topic is artificial intelligence and this is a paper from the technology committee from the ASGE, a very talented group here relatively recent paper came out in the pandemic and talks about the emerging role of AI in endoscopy. The ASGE also has a task force on AI and it is quite active and there will be a very very good AI symposium at DDW in three weeks that I encourage those who are attending to try and sign up for. So the challenges for AI which is basically three types of approaches, deep learning, machine learning and then eventually mimicking human behavior is going to look at what are the unmet needs that are clinical and operational, what is the cost of AI and who will pay for the incorporation of AI in my practice and how will it impact my future practice. These are all relatively unanswered questions at this time because all said and done AI is still in its infancy as it comes to GI. The other question that comes to mind naturally is that will non-endoscopic providers such as APPs will have to do more with the AI platform than some other folks. I think that's a definite possibility and then what will be the overall impact on the human workforce, we don't know that. Single-use endoscopes are here, multiple such devices are now FDA approved. There are two duodenoscopes and there's some data on it as well and there will be more data at DDW on these. A super slim gastroscope was just approved and we talked earlier about non-GI providers doing endoscopy, APPs potentially with the slim endoscope without sedation and so forth but there are other caveats that go along with that paradigm and it's not as simple as just having an endoscope in an office. The FDA has encouraged transitioning to these endoscopes for example, however the cost functionality and adoptability of these remains a question across practices across the country. Increasingly waste recycling is becoming an issue, there's a climate change working group with the WGO that I'm a part of as well as a green endoscopy group. So these discussions are coming up really rapidly in every quarter, there is some new information in along these lines so stay tuned for this to become a bigger discussion down the road. Telemedicine is here, we've all used it, I love it for the roles that it plays in my practice. It really received a huge jump start in the pandemic, it has been widely adopted, it's quite efficient. However, the platforms especially on the patient end remain relatively clunky and especially when you're delivering this platform in rural America with a wide variety of connectivity at hand. It's unclear when the reimbursement will expire especially for phone visits. I do firmly believe that it will not fully replace in-person visit experience on both sides patient and provider and I think there are some ethical and medical legal issues that have not been completely sorted out with this. So it serves a great role, it's going to be a huge component of the future work paradigm but I don't think that it delivers the whole story as we all acknowledge. Next paradigm is the GI hospitalist paradigm that has emerged. We've had the opportunity to dwell on it a little bit, some publications with prominent hospitalists across the country and Sarah was part of it as well. So this is here and many of the academic and large health system practices are gravitating towards incorporating this into their practices. So the impact of a GI hospitalist program is shown on this slide, it's a multi-fold impact which is listed here and again it does you know factor in the inpatient GI focused APP and the collaborative aspect of the relationship between the physicians and the APPs as well as the positive impact it has on interdisciplinary care, reduced LOS and costs and that's already been looked at and it looks very favorable. This is the impact on endoscopic operations, this is a recent paper that came out in a dedicated issue that John Vargo edited, the past president of the ASGE. We had the opportunity to contribute to this and this is a GI hospitalist impact specifically on endoscopic operations and all the attributes are listed here and these will be available for you to review in the enduring material. This is really probably the only paper of its kind and we were fortunate to work with a group like this on this. Moving on to disruptive technology, disruptive technology is the way that society makes progress. We've already experienced the incorporation of stool DNA testing but there are newer things coming. Barrett screening is up for discussion with the non-endoscopic sponge or cytosponge based products. There are some pivotal trials that are currently underway on these devices and so on and so forth. The motorized magnetic small bowel capsule, motorized small bowel endoscopy, remote home monitoring modules and so on and so forth. The list is quite endless, it's difficult to cover that on a slide or even in a lecture but this is here to stay and you'll see a lot of this activity at DDW on the exhibit side if you find the time to go around and if you're attending. Disruptive practice paradigms of course are, dive a little bit more deep into the bone marrow of what we do every day, right? So value-based approaches instead of volume is capturing the fascination of both health system leaders as well as the consumer. Population health has been in place since Obamacare came in and has its pros and cons but we've all had to contend with it. Private equity takeovers of smaller entities is a reality of today's world and it has significant advantages but obviously the entities that get taken over might have a slightly different view on that. The elimination of paper, electronic messaging I've already alluded to but increasingly the emphasis on service line based subspecialty care. I talked to a lot of people across the country which are reinventing their programs, their departments, their divisions and one of my recommendations always is to look at it through the prism of how can you bring specialties together to deliver a singular consensus-based care to the patient rather than having fragmented approaches. Increasing transparency, accountability, quality metric benchmarking. I was doing an ERCP note the other day and the patient's family member was able to read the note in real time through open notes. I have never seen that before. Focusing more on the role of the APP in modern GI practice, it is now evolved and established and we've talked a lot about the various platforms in which the APP can participate, contribute very meaningfully and really be an integral part of this practice paradigm. I believe the role will mature further and I think there will be an increased involvement with ancillary testing which will be a need as well as an attribute. AI platform may allow APPs to engage a little bit more because there will be a lot of AI related work that will be non-endoscopic I believe and of course they are huge partners in delivering our digital health initiatives especially on the patient communication side. The talk on avoiding burnout with Dr. Vickari was amazing and this is just a slide to show that we've moved from work-life balance to an integration concept and aligning and the priorities and managing those boundaries will not be easy but it is the way to go and we'll all find our happy medium with this hopefully down the road as well. This is a paper came out in a PA publication, the JAPA which some of you may be well familiar with. Increased dissatisfaction with higher work hours, it's a no-brainer, satisfaction of work-life integration going down with as a number of hours per week increases. So the 10-hour day times four is where this comes in. Obviously, we're all familiar with the DEI initiatives across institutions, across our fields but there's still a significant amount of healthcare disparity that exists, workplace equity issues are there especially for folks in leadership roles and I think there's a major movement not just at the individual practice level but also at the society level for all the major societies in GI that are really working hard to make this a new reality and this will take time because these inequities didn't develop overnight and therefore the reparation nets or the correction of the anomaly will not occur overnight either but I think the key principle here is inclusion so that everybody has a representation, has a seat at the table, feels empowered and then we make progress one step at a time. I mentioned earlier, I talked about the concept of value in that context, it was about the value of the provider or APP or a physician for that matter but here the concept of value is what the patient perceives and what the clinical practice believes in so increasingly I think we'll try to move from a volume-based paradigm to a more value-based paradigm where outcomes are important, patient satisfaction is important, best practices get a higher emphasis than how many cases you did per day. This is a difficult one because we're used for decades and decades to one paradigm and suddenly we transition to a different paradigm which is in the better interest of the patient but again we'll take some time and we'll probably mature a little bit more in the next decade or so. So finishing up here with the practice pearls, endoscopy, GI, hepatology, all our subspecialties are highly highly subspecialized and is a different product now than it was 25 years ago. The role of the GI APP is extremely well established and recognized, it needs to be optimized further especially when we get away from the ivory towers and the big practices but are disseminated in the community so that needs some work. Endoscopic interventions have had a rapid and dramatic evolution and that will continue along with disruptive technology both on the procedure side but also on the practice operations side. Value will be emphasized over volume and that will be a work in progress. We have now recognized wellness and work-life integration as major priorities for our workforce and DEI is being emphasized at all levels in our society from top to bottom. However, I do believe that progressive systems that will prioritize the patient experience, the patient experience really sums it up. Once you prioritize the patient experience, the rest should fall in place. Thank you very much and I think I have a polling question or two. All right, so which of the following have been positively positively impacted in the post-pandemic GI practice setting? Single choice, positive impact, access to care, backlog for screening colonoscopy, innovation and disruptive technology or workforce availability. So we have innovation and disruptive technology which I thought was the correct answer which seems to be the predominant response. Access to care for emergent and urgent indications has improved for sure so I'll give you that but of course we've taken a hit in the backlog department as well as in the workforce attrition. Next question please. So which of the following is not a benefit associated with a GI hospitalist program? Not a benefit, decreased LOS or length of stay, increased physician salary, improved communication between teams and improved patient satisfaction scores. So this is an accept question. A GI hospitalist program is great at everything except. All right, accept question. Increased physician salary, I think I always advise people to negotiate that but I think that's not the goal of the hospitalist program. Thank you very much for that excellent response. I think with that, I'll turn it over to Sarah for the final Q&A. There's still a lot of folks online and we appreciate that very much. Thank you.

GI hepatology

COVID-19 impact

GI endoscopy

innovation in GI practice

advanced practice providers

disruptive technologies in GI