Good evening, the Association for Bariatric Endoscopy, a division of the American Society for Gastrointestinal Endoscopy, welcomes you to this evening's presentation titled Obesity Core Curriculum Enhancing Obesity Training in GI Fellowship. My name is Marty Roth, and I will be the facilitator for this program. Please note that this presentation is being recorded and will be posted on GI LEAP, ASGE's online learning management platform. You will have ongoing access to the recording in GI LEAP as part of your registration. Following Dr. Pinela's presentation, there will be a question and answer session. Questions can be submitted anytime online by using the Q&A icon at the bottom of your screen. Please do not use the chat box for submitting questions. Our presenter for this program is Dr. Rahul Pinela. Dr. Pinela is an associate professor of medicine and a consultant gastroenterologist at the Mayo Clinic in Arizona. He received his medical training at Gandhi Medical College in India. He subsequently earned a master's in public health at the University of Massachusetts Amherst. He did his internal medicine residency at Bridgeport Hospital, Yale University and gastroenterology fellowship at Mayo Clinic Rochester, followed by a therapeutic endoscopy fellowship at Virginia Mason Medical Center in Seattle. He has been on staff at Mayo Arizona for the past 11 years. He is the director of the Pancreas Clinic and the Endoscopic Bariatric Therapeutics Program at the Mayo Clinic in Arizona. His research interests include pancreatic biliary diseases and endoscopic bariatric therapies. He is a member of the ABA Advisory Board and the vice chair of the Education Committee for the World Endoscopy Organization. So Dr. Pinela, I will now turn the presentation over to you. Thank you so much, Marty. I hope everyone can hear me. Thanks again, Marty. And it's a real pleasure to be here and welcome everyone on behalf of the ABE. You know, I think we would like this to be a very interactive session. So please feel free to put your questions, things like that in the chat or in the Q&A section. What we really wanted to focus today on and something that we are trying to really shine a light on is the integration of obesity into the training, into our general gastroenterology fellowship. And I will kind of go over and make a case for why we think it's important and why the time is now. And I hope you would sort of agree with me on that. These are my disclosures. So really the objectives of our talk today are to enumerate the goals of obesity training for GI fellows. And this talk really is sort of designed for program directors, gastroenterology fellows who have an interest in obesity, but even general gastroenterology fellows, core curriculum sort of writers, and then a whole host of other stakeholders. We'll discuss endoscopy in patients with obesity and endoscopy in patients who have undergone bariatric surgery. We'll review the training processes and content areas for evaluation and treatment of patients with obesity in the GI fellowship. So first I'll start out by really making, trying to make a case for why we think we should expand obesity training in gastroenterology. We'll talk about primarily the paper that we put out from the ABE and the ASG training committee on the core curriculum recommendations in terms of goals and content areas. And how do we go about it? What are the modes of training that would be, that should be considered? And what are the resources out there, both within a fellowship structure, but outside of a fellowship structure as well? So really the first question is why, why should we focus on obesity training? And I think these two images really send home the message. The message on the left is the gastroenterology core curriculum, which is the current core curriculum. It was published in 2007, obviously a lot has changed since 2007, both with regards to gastroenterology in general, but especially with regards to the epidemic of obesity in the United States. The chart on the right, as you can see, shows the obesity prevalence trends going all the way from 1960, all the way up to 2018. And both in men and women, we see a substantial increase in the prevalence of obesity such that at least more than 40% of individuals in the United States are people with obesity. So we really, this is something that we really have to take into account. And when we go back and look at the 2007 curriculum, really there is a very limited mention and focus on obesity in the curriculum. In the chapter on the nutrition, this really is the only specific paragraph that is there or I could find. It does really hit upon though, on some of the key concepts in terms of treatment of obesity, both in terms of pathogenesis, complications associated with obesity, principles of weight management, endoscopic and surgical treatments for weight loss, which I thought at least the endoscopic options in 2007 was very forward-thinking, and then managing the adverse events of obesity surgery. And we'll go into all of these in great detail. Now, as our knowledge of obesity increases, we realize that obesity is a chronic disease with multi-system effects. And especially even with regards to gastroenterology, this paper really, I think, encapsulates our knowledge and this is sort of increasing every day. Obesity is a risk factor for several diseases, both from esophagus with gastroesophageal reflux disease, esophageal adenocarcinoma, gastric cancer, pancreatic cancer, intestinal dysmotility, gallbladder cancer, and obviously non-alcoholic fatty liver disease and NASH. And especially another big one is colorectal cancer. So I think it really impacts pretty much every aspect of our practice as gastroenterologists. Now, a lot has also changed in terms of our endoscopic practice as the population, the prevalence of obesity is increasing in our population. It stands to reason that a lot of the procedures that we are doing, the endoscopic procedures are in people with obesity. And obviously that comes with specific challenges. We have to factor in the appropriate sedation strategy, anesthesia, are we doing these procedures in the appropriate setting, what kind of equipment do we need, what kind of staff, if any different. And it's our duty to really train our fellows to make appropriate decisions, to take all of these into account as they care for their patients. And then the prevalence of bariatric surgery is also increasing. So we are doing more and more procedures as just this picture I'm showing you, we're doing more and more procedures and more complex and interventional procedures in people who have undergone bariatric surgery. So that has become a really a component of our practice that has developed in the past really, or expanded in the past few years. And it is important again, to take it back to our fellows and the topic of this discussion today to really train our next generation, to train our fellows to be competent in these areas. The other major obvious impact has been both the expansion and the advent of really multiple new technologies in the endoscopic space for the primary treatment of obesity. This includes obviously intergastric balloons, which have really expanded as has been shown in this multi-society guidelines, the gastric placation procedures, such as the POSE procedure and the endoscopic sleeve gastroplasty, the ASPIRE procedure and so on and so forth. And these are increasing every day. So these have all really expanded since the publication of the core curriculum. And especially in the past few years, we're taking several different strategies. Pharmacotherapy for obesity has also really expanded with the availability of multiple new medications. We are combining drugs and devices and using really novel strategies. And so again, to take it back to the gastroenterology fellows, they really need an understanding of the general management of patients who undergo these procedures, medications that are used for obesity, and really again, opens up a brand new avenue for gastroenterology fellows where they may consider specialized training in obesity management. And we have to factor that in into how we structure our fellowships and what opportunities we really give for our fellows. So really to bring all those points together, the case that for incorporating or expanding really the role, expanding the evaluation and management of obesity, we feel that this really needs to become an integral part of GI training, given the prevalence of obesity, the fact that obesity is a risk factor for several GI diseases, many of which are things that we see daily in our clinical practice. It has had a substantial impact on endoscopic practice, both in terms of doing endoscopy in patients with obesity, but also the several other things that we discussed. We now have a lot more endoscopic options for the treatment of obesity, and this is an expanding area for our fellows to get trained in. And then going back to the core curriculum, there is hope that, you know, that this would be revised and a revision may be coming. So putting a spotlight on this topic at this time seems very appropriate and something that, you know, falls in what we should do to really train the next generation. So this is the paper that was put out by the Association of Bariatric Endoscopy, the ABE, and the ASG training committee. This went through a fair, a lot of discussion and really reflects the collective effort of a large number of individuals in both committees to really get this to fruition. So I want to take a moment here to acknowledge everyone that really worked hard on these core curriculum recommendations. Over the next 30 minutes or so, I'll try to sort of delve deep into what we are trying to do and I'd be interested in everyone's thoughts about this. So this is available in GIE. It's available on the ASG website. So really the first thing that is to really define the goals and the structure of training before we delve into the content areas to really focus on what are the goals of training. We need to define specific goals for education in obesity, clinical training, procedural training in obesity, describe the content areas, what is the training matrix, how do fellows go about this, develop a program structure, and also suggest sort of interdisciplinary connections in terms of what are the other specialties that fellows need to interact with, really how to engage faculty with expertise in treatment of obesity, provide training resources for trainees, and then start the discussion on quality and proficiency assessment, which is going to become an important component as this becomes more mainstream. So what we thought it would be easier to look at this, especially in terms of content areas, is to break it down into three sort of big buckets. One is the medical evaluation and treatment of patients with obesity and obesity as a chronic disease, and then the endoscopic impact, like what we talked about briefly, and then the surgical aspect of it, which I'll go into great detail. For example, the medical part would be evaluation of patients with obesity and related comorbidities. What should fellows be taught about the pathophysiology of obesity? What should they be taught about what lifestyle therapy is, what pharmacotherapy is? We talked about endoscopic. Surgical is how do or what do we need to train our fellows in terms of pre- and post-procedure evaluation of patients who are going to undergo bariatric surgery, or once they've undergone bariatric surgery, how we manage their nutritional deficiencies, what are the common post-surgical adverse events, and what endoscopic evaluation and treatments can we offer, and then an expanding area of really advanced endoscopic management of post-surgical adverse events that we'll look at, such as fistulas and things like that. So the next phase of the talk, really, I'll sort of break it down along these specific lines. So to first start with, what are the recommended content areas for training, especially in the medical management of patients with obesity, and what we should really train our fellows in? So this is, I'm not going to go through this table in this slide, but I'm going to delve into each of these. But just this slide is there to sort of indicate to you that we have a detailed matrix in the paper that kind of goes over each of these components. And really, the entire structure is broken down into what should be taught, or what should be the content for general gastroenterology fellows, and a separate tier or separate recommendations for patients or for trainees who want additional training in obesity or want to actually take on the treatment of patients with obesity. So the first content area would be the pathophysiology of obesity. We suggest that, really, all GI trainees should understand the complexity of the pathophysiology of obesity itself, the contribution of genetic, physiologic, environmental, and psychosocial factors, understand, really, the central role of gut in nutrient sensing, gut-brain neurohormonal pathways for hunger and satiety and signaling, and really understand the role of the pancreas, the liver, the gut microbiome, and non-GI organ systems in overall appetite and energy regulation. Now, I just put one representative model or a flowchart here from one of the cardiology journals, but there are a whole host of this, and our knowledge about this is really evolving. And it's really important for GI trainees to understand the complexity, understand the various factors that go into causing obesity. Next, I think it's also important about for fellows to really understand the epidemiology of obesity. What are the trends? Where, you know, I showed you that graph going from the 60s to 2018 and how obesity prevalence has been increasing rapidly. So I think it's important for fellows to recognize that, understand the trends. This also leads to understanding the environmental factors, the cultural, genetic, and behavioral factors that determine energy balance and the risk of having obesity. Now, for fellows who really want to treat patients with obesity and offer treatment, we felt that they need to have a very detailed understanding of what are the true impact of demographic factors in terms of sex, race, ethnicity, on the severity and the causation of obesity, and what are the genetic and epigenetic influences in terms of the prevalence of obesity in these populations. Now, in terms of clinical evaluation of patients with obesity, again, reverting back to general gastroenterology fellows, we suggested that fellows really should recognize obesity and related comorbidities in the general GI and cognitive clinic. Fellows should really be able to take a comprehensive history, physical examination, and laboratory evaluation to assess obesity-related comorbidities. They should be able to do a broad medication and lifestyle review, and we'll go into that in a little bit more detail, and then should be able to care for these patients in a multidisciplinary framework, and when they recognize comorbidities that require interdisciplinary care, to be able to make those appropriate referrals to the other specialties. Now, the other point, which is not on the slide, but which is very important and that bears mention, is that, you know, patients with obesity, when they're evaluated in the clinic or in healthcare settings in general, sort of deal with a significant amount of implicit and explicit bias, and I think it's important to train our next generation to not have that or, you know, be able to approach this as a chronic disease and really help our patients address this as a chronic disease. Now, in terms of the overall medical treatment of obesity for general GI trainees, when they are really having that discussion with the patient in terms of addressing obesity as a disease and treating them medically, I think one of the important aspects is to assess readiness to change, because this is a huge undertaking for a patient to address. It's obviously not easy, and I think that, you know, for a trainee to be able to assess that and to then make the further steps in terms of treatment, assessing the readiness to change is a very important component of it. Trainees should recognize the foundational aspect and components of comprehensive lifestyle and behavior intervention, and recognize everything that goes into what we say lifestyle and behavior intervention, which incorporates a lot of disciplines and inputs. Trainees should have a general overview of pharmacotherapy or medications that are available currently, that are FDA approved for the treatment of weight gain, and also the trainee should be able to look at the medication list that the patient is on for other diseases, and recognize those that may be associated with weight gain, and maybe explore alternative treatments. They may not be the ones prescribing those, but I think recognizing that those medications and then seeking out alternatives would be very appropriate for our trainees to learn. Now for trainees who really want to treat obesity from a medical perspective, I think it goes without saying they should really be able to delve deep into the medical history, the weight history, what has really worked in terms of previous interventions, what has not worked, and why. Really identify the barriers to treatment of which there are many, exercise, psychological comorbidities, etc. Then understand the impact of intensity and the mode of delivery of lifestyle interventions. What I mean by that is when they prescribe patients to undergo lifestyle and behavior, are they getting high intensity, moderate intensity, low intensity? How does that work, and how are patients able to sustain that? And then how are these being delivered to the patient, and what has really worked for that individual patient? And they should be able to liaise with other disciplines to really develop a comprehensive lifestyle program in their practice setting to be able to deliver that to their patients, to effectively treat patients with obesity. And these trainees who are going to offer medical treatment should really be comfortable with offering pharmacotherapy for obesity. They should be able to evaluate the concurrent weight promoting medications like we talked about and really explore alternative treatments. If they so desire, they should really be able to prescribe weight loss medications. They should know what's available, what are the indications, the contraindications, and what would really be appropriate for an individual patient. We feel that trainees who will treat obesity should be comfortable with combining pharmacotherapy with other modalities, whether it's endoscopic bariatric metabolic therapies like EBMTs, as noted here, weight regain after bariatric surgery. So the combination therapy, they should really be familiar with. So that was sort of an overview of what we had recommended in terms of medical treatment of obesity. Now changing gears to endoscopy and evaluation of the post-bariatric surgical patients and dealing with post-bariatric surgical adverse events, this is again a very similar table to what I showed you in terms of the matrix of endoscopic training, and then we'll go into these in greater detail over the course of the next few slides. So as we talked about, the prevalence of obesity is increasing and more and more we're doing endoscopic procedures in patients with obesity. So I think it behooves us and to teach our trainees to think differently, think appropriately of how we are approaching this, recognize the specific challenges in this patient population. For example, you're doing a screening colonoscopy in a patient with a BMI 50. Is it appropriate to do it in an ambulatory surgery center with maybe moderate sedation or does that need to be done in the hospital? So there's obviously several factors going to that calculation in terms of both the type of the procedure, the complexity of the procedure, the complexity of the patient and their health. The other aspect to also recognize is equipment or is the equipment both in terms of, let's say just to take an example, do we have bariatric stretchers available? Where are they available? Are they available mostly in the hospital or are they available in the ambulatory surgery center? Are we providing appropriate equipment for patients with obesity? I think those are factors that in general we have to recognize more and more in gastroenterology and teach our next generation, teach our trainees to do this effectively. Patients with obesity have multiple comorbidities. For example, just to take an example, obstructive sleep apnea. So the cardiopulmonary assessment becomes very, very important. Looking at the airway, the sedation and making decisions about sedation both in terms of can this be done with moderate sedation or does this need anesthesia assistance? So those are several of those questions, but in general, I think recognizing obesity as a risk factor for cardiopulmonary complications or increased risk of cardiopulmonary complications in patients undergoing general endoscopy is a very important component that we wanted to convey. The other aspect of this is when we do endoscopy, let's say upper endoscopy, especially in patients who have undergone bariatric surgery, then it becomes very important to be able to accurately evaluate the anatomy, recognize the anatomy, accurately report it, and to document it. For example, just I put a few pictures up here, let's say we were doing an endoscopy in a patient with, who's undergone a Roux-en-Y gastric bypass, it would be really important for the endoscopist to document the size of the gastric pouch, the orientation, the size of the gastrojejunal stoma, look, you know, the jejunal margin, the overall health of the gastrojejunal anastomosis, and so on and so forth. And really the general gastroenterology trainee, we suggest that they should be able to assess and treat basic pathology in the post-bariatric surgical anatomy. So any marginal ulcer, bleeding with a marginal ulcer, things like that. The other aspect of this is to recognize more complex issues in the post-bariatric surgical patient and to make the appropriate referrals. It could either be to surgery or to therapeutic endoscopy for endoscopic treatment of those adverse events. Then the next sort of component of this really, which requires additional training is the evaluation of complex bariatric surgeries and the variations of several bariatric surgeries. Obviously there's multiple variations on the theme, for example, even with gastric bypass and then, or even with sleeve to recognize for these complex situations, which may not always be very easy to recognize, for example, sleeve stenosis or sleeve torsion. And then really to perform complex interventions, whether it be treatment of post-bariatric surgical adverse events, for example, in this picture where we're doing pneumatic dilation of a gastric sleeve or other general endoscopic procedures in the post-bariatric surgical settings, such as deep endoscopy, interventional US procedures, such as EDGE and so on and so forth. Obviously those require significant additional training and trainees who have interest in that or therapeutic endoscopist should get specific expertise and training in those more complex interventions. Now, shifting gears to the primary endoscopic bariatric and metabolic therapies, which are obviously a really new frontier and have really expanded in the past few years and the gastroenterology core curriculum obviously predates these by many years. So we wanted to focus on how trainees should be exposed, what should they be trained in this arena? And for trainees who want to actually do these procedures, what kind of content areas should they focus on? So for general trainees, we suggest that the general trainees should really have a basic knowledge of all the approved endoscopic bariatric and metabolic therapies that are FDA approved. What are the indications for each of these devices or procedures? What are the typical patient selection criteria and what are the common adverse events? Because they may be seeing patients who've undergone the procedure and they're on call and they have to take care of this patient or at least triage this patient. And they have to recognize situations that require consultation with an EBMT specialist or a surgeon to take care of complications. Now, for trainees who really want to do these procedures and offer these procedures, these trainees should have a really comprehensive knowledge of the medical aspects of treatment of obesity as well. And especially what we talked about. So that these procedures are not offered in a vacuum and that these fit into the profile of the overall sort of the spectrum of treatment of obesity. We strongly suggest that the physicians who really want to offer this, consider developing core competencies in medical management. For example, maybe be certified or consider certification in obesity medicine, be comfortable with prescribing medications or at least have an endocrinology or an obesity medicine partner in their practice who they have access to. And obviously if they're going to offer these procedures, they need to have cognitive and technical proficiency in the devices or techniques that they're offering. And they should be comfortable and proficient in the management of the adverse events related to the devices or the procedures. There is again, this sort of breaks down into the regular procedures, which sort of are an extension of general gastroenterology or general endoscopic training. And then the more complex therapies, the terminology can be variable and can be used differently. But for the purposes of this discussion, I'll say complex therapies, which really require dedicated training and mentoring. Example of this would be endoscopic placation techniques, suturing techniques. These really require dedicated training, transoral outlet reduction, fistula closure, and then really endoscopic interventions for complex bariatrics adverse events, refractory ulcers, strictures, leaks. For example, if trainees want to offer septotomy or other complex procedures, they really need to be trained in those specific procedures or devices. So that was about what we felt should be included in the core curriculum from an endoscopic or from a medical and endoscopic and a surgical aspect, both for general trainees and for trainees who want to offer these procedures. Then the question of, then we shift gears a little bit and talk more of how to go about it. What are the modes of training? How do we deliver this to our fellows and trainees? So I think this is one of the most important concepts, and I think this is universally recognized, but I think it bears sort of some mention, especially in the context or from the perspective of a GI fellowship and incorporating obesity training into the GI fellowship, we felt that this needs to be in sort of an interdisciplinary framework. So a GI fellow, both the general GI fellow, but especially fellows who are going to go on to offer treatment, obesity should have exposure to all of these specialties, both in nutrition, bariatric surgery, endocrine, therapeutic endoscopies, psychiatry, and obesity medicine. And we'll talk about how to go about this for various different settings and where all of these specialties may or may not be easily accessible within the fellowship itself. But the ideal situation would be that these are all available within the institution or readily accessible for the fellows at outside institutions that collaborate and that fellows are really exposed to all these disciplines. So depending on local expertise, what's available at a fellowship program, and depending on the trainee interest of where they fall in that spectrum of offering obesity treatment, some of the strategies would be to do away electives. For example, they could go and do an away elective in obesity medicine and spend some time with an obesity medicine specialist if that's not easily accessible, or if that's accessible in the institution, really developing some of those opportunities for our fellows. The other strategy is interdisciplinary case conferences where really discussion of how to approach treatment of patients with obesity and maybe the involvement of the fellows in some of those case conferences, which are likely already going on in the other specialties. The other really important aspect that we wanted to spotlight is the availability of several resources from national societies, several large academic institutions, both in terms of workshops and courses, and also the companies themselves that manufacture these devices offer a lot of these workshops. So for trainees who really want to be trained in this aspect, there are a lot of resources that are easily or that are accessible, and we should encourage really our trainees to pursue these resources. There are also a whole host of electronic resources, videos, lectures that we put some examples at the end of the paper, and I would welcome you to take a look there, but we really wanted to highlight the fact that I think the take-home point of these two slides really is to say that within a program itself, I think we should really establish a structure and encourage our trainees to have that interdisciplinary framework so they understand the complexity and that it really takes a village to treat these patients and also to reach out and make maximum use of all these other resources that are available through various national societies. The other aspect is the faculty, and really there should be core faculty with expertise in treating patients with obesity and related comorbidities, or at least fellows should have exposure to such faculty in other rotations, especially with clinical rotations and related disciplines like we talked about. We also felt strongly that core curriculum lectures should include evaluation of patients with obesity, training, treatment of patients with obesity, the interdisciplinary care, and also the endoscopy in patients with obesity. And if a fellowship program does have an endoscopic bariatric program, then fellows really should be offered exposure in both the evaluation of patients, taking care of these patients, both before and after these procedures in terms of endoscopic rotations and whatnot, and clinic. So then the focus really is we have this whole host of endoscopic bariatric and metabolic therapies that are becoming more and more available. How do we go about training our fellows? We don't have all the answers, but here are thoughts that we, and recommendations that we put out. For the majority of endoscopic bariatric procedures, these could be integrated into a three-year fellowship because many of these can be extensions of the regular training or the regular skills that they learn in general endoscopy. Many of these will require, obviously, additional training with specific devices and learning about these devices. And the devices that they choose to offer, really, they have to be trained to proficiency in those devices, whether it be within the fellowship or them seeking additional training either within the fellowship or after. For example, an intragastric balloon, one could make the argument that this sort of overlaps with general GI skills and with some amount of training that's integrated within the fellowship, graduating fellows should be able to offer these and to be trained to proficiency. And as we talked about before, advanced skills such as plication and suturing really need a lot of training and both mentoring and hand-holding by experienced trainers or experienced endoscopists. Now, that could be within a three-year fellowship, depending on the structure of the fellowship, could be within a fourth-year advanced therapeutic endoscopy fellowship, a dedicated post-fellowship rotation, or a dedicated bariatric endoscopy year. I think that is still a work in progress, but I think that the key take-home point that we wanted to convey is for some of these more complex procedures, that mentoring by an experienced endoscopist is very, very critical to good outcomes. There's obviously extensive additional resources. In the paper, we talk about simulators a little bit. There's really no good simulators out there. The best sort of animal model is an ex vivo porcine stomach. So this is a common model for endoscopic bariatric training. I think if fellowship programs have access to an animal lab or can do bench-top sort of ex vivo work, this can be an excellent sort of avenue to do that. There's a whole host of society-related hands-on workshops and didactic sessions. From an ASG perspective, I put a few here. One is the Bariatric STAR program that's going to be focused on specific devices. There's already the Suturing STAR course, which is very popular. There's a whole host of hands-on workshops at ACG, DDW, and many other conferences. And then in the paper, we also talk about the familiarity and using guidelines, both from RGI societies. For example, I put the AGA white paper here in the top graphic, but also several resources available from other societies. I put the ABOM here. There's a whole host of other societies, the surgical societies, IFSO, ASMBS, TOSS, and really, there's a wealth of resources that are available that can be incorporated and leveraged in training our fellows. Then the question comes up is how about quality? As our trainees tend to do more of this, as we do more of this, there's really no guidelines or competency thresholds that have been suggested. Learning curve data is limited. There is some data for ESG, but in general, across the broad spectrum of devices and techniques, the overall learning curve data is limited. And I think we need to develop those competency thresholds. For fellows or trainees who are interested in board certification, the ABOM offers a board certification in obesity medicine. And that can be something that's very valuable. And a lot of, I know my colleagues have done that. The other aspect of it, I think given that we have a sort of a dearth of objective competency thresholds, the trainer or the endoscopist or the physician who's training the fellow really needs to provide very constructive and regular feedback, both during clinical rotations and during the endoscopic mentoring. This becomes much, much more important in complex procedures. And many times for these complex procedures, it is really helpful or invaluable really to have a senior endoscopist proctoring for the first few cases. So those are sort of the recommendations and suggestions that our committee sort of put together, but obviously many challenges exist. GI fellowship, there's a lot crammed into those three years. So I think the biggest challenge is not that program directors and the multi-society committees recognize the importance of obesity, but how to incorporate really within the limited time. You know, and a similar expansion of scope is happening in all the specialties with the rapid advances in science. So this will require a lot of thought, a lot of multi-society effort to incorporate, but we feel that this is really important and we need to train the next generation adequately. I think the interdisciplinary expertise, the availability of multiple other specialties is gonna be a challenge in where it may only be easily accessible in specialty centers. But like I said, and we're trying to make this point in a sense is that these can be done outside of the traditional fellowship program with away rotations, case conferences, things like that. And then the concept of endoscopic bariatric therapies, while there are several programs doing this and doing this very well, in general, they're not widely available. And insurance coverage, unfortunately, is limited to non-existent. Hopefully that'll change, but that can also be a barrier for our trainees, for our interest amongst our trainees to train in these procedures if they feel like they're not going to be able to offer it once they go into independent practice. And then the whole landscape is changing rapidly. This is one of the areas of very rapid innovation. So keeping up and incorporating this into the core curriculum can be challenging. So in summary, we feel that the treatment of obesity and related GI comorbidities should become an integral part of the GI core curriculum. We provide some recommendations for training for both general gastroenterology fellows and those fellows who really want to take on treating obesity, which we feel that gastroenterologists have a very important role to play given the importance or the increasing prevalence of obesity, the very important GI-related comorbidities. And then the availability of exciting new interventions, both in terms of endobariatrics, complex therapeutic interventions in patients with obesity, who have proposed some general guidelines on training and developing training structures. Competency thresholds need to be developed. There's no data is limited on competency thresholds in this sense, but I think we would need to develop these and really utilize the various resources, even if local expertise is limited. So thank you very much for your attention. And I will now turn it over to Marty to start the Q&A and hopefully we'll have a good discussion. Thank you. Dr. Pinola, thank you very much for that insightful and informative presentation. You know, it was very well done, very well organized. So at this time, Dr. Pinola will address questions received from the audience. As a reminder, you could submit questions through the Q&A icon at the bottom of your screen. So let me see what we have here. The first question I have for you, Dr. Pinola, is what process would you suggest for setting up interdisciplinary training for GI fellows in the setting of a busy clinical practice? Yeah, no, that is the key question. I think that it's definitely challenging, but the processes I would suggest are maybe twofold. One is focusing really on our GI clinic initially, which would be our GI continuity clinic for trainees or general GI clinic when they're shadowing as in the general GI clinic or subspecialty clinics, really taking, you know, understanding the contribution of obesity to their overall health. What are the associated GI comorbidities? For example, if you're someone seeing a patient with NASH, really, you know, focusing on the treatment of obesity and recognizing that as a component of treating the overall NASH picture, same with Barrett's or same with pancreatitis and the impact of obesity on outcomes in pancreatitis and so on and so forth. So really focusing, taking that extra minute in the clinic to really focus on some of those aspects. And then in terms of the interdisciplinary framework and what we propose, it's gonna be a little bit of tailoring to an individual program, I think. It's hard to make a general prescription, but if you're fortunate to be a program that has access to these specialties and a fellow is really interested in gaining additional advantage in a training, maybe they can rotate in endocrinology, they can rotate in bariatric surgery, or even for the general GI trainees, maybe within the core curriculum structure to invite the endocrinologist to maybe give a lecture on medications for obesity or inviting the bariatric surgeon. Like for example, in our program, we invited the bariatric surgeon to really talk to our fellows to go over the anatomy of the various bariatric procedures and what could be the potential complications from a surgical perspective. So those are some of the concepts. I think aware rotations we talked about, society resources and thinking of things like incorporating in their nutrition rotation, maybe they spend some time in the bariatric surgery, nutrition clinic, things like that, but whatever is relevant to an individual program. All right, thank you very much. You mentioned that many of these devices are not covered by insurance, they're not reimbursable at this point. So the question would be how receptive are institutions to incorporate obesity programs into their fellows training programs? Yeah, I think it's a two-pronged question from a purely endoscopic perspective. I think that obviously there's several barriers in terms of insurance to the uptake of these devices, but it is a rapidly changing field. There are a lot of efforts to get insurance coverage. And I think the reality is that despite the lack of insurance coverage, given the need for it, many of us are doing it in our practice. It's been, you know, we're doing it routinely. So fellows have that opportunity. I think the acceptance rate to incorporate some of these into general GI training is only going to increase because fellows are gonna see more and more of these patients who have undergone these procedures. That's from an endoscopic perspective, but I think it also has to be reinforced that that is only one component of obesity training for general GI fellows. So that's still, you know, several other factors that I think that doesn't cover. For example, training our fellows in dealing, you know, evaluating patients with obesity, taking care of the post-bariatric surgical patient. For example, they're seeing a patient in their clinic with extensive iron deficiency anemia after bariatric, after ruined by gastric bypass to be able to evaluate those patients appropriately, so on and so forth. All right, very good. Thank you so much. So the next question I have for you is how much time would you allocate for obesity rotation in relation to other subspecialties? Yeah, that's a great question. I think that we don't know the exact answer to that. I think that, you know, different, it would probably depend a little bit on the structure of the program, would depend on the interest of the trainees, things like that. Time is gonna be the critical component because we have a limited amount of time to work with. And if you wanna add something, something else has to go. But to give a general sense, I feel like fellows should have, you know, at least a month of rotations in other specialties, bariatric surgery, endocrinology, especially patient trainees who wanna go on to treat obesity. And then really core curriculum lectures, things like that. So in the big picture, it doesn't take a lot of time to do it effectively and maybe can do it in small increments in the three years of their fellowship. And fellows who are really interested in either the medical treatment of obesity or endoscopic treatment then do use their electives and, you know, to focus on that. All right, well, thank you very much. It does not look like we have any more questions. So it looks like this does conclude our presentation for this evening. We hope this information is useful to you and your practice. And also we would like to hear from you. Following this webinar, you will receive an email with a link to a survey for feedback about this webinar. We appreciate your participation in this survey. As a reminder, you can access a recording of this webinar by logging on to GILeap by going to learn.asge.org. Thank you again for your participation and have a good evening. Thank you.

Obesity Core Curriculum

Enhancing Obesity Training

GI Fellowship

Prevalence of Obesity

Endoscopic Bariatric and Metabolic Therapies

Pathophysiology of Obesity

Medical Evaluation and Treatment

Surgical Aspects of Obesity Treatment

Interdisciplinary Collaboration