Welcome to ASG Endo Hangouts for GI Fellows. These webinars feature expert physicians in their field, and I'm very excited for today's presentation. The American Society for Gastrointestinal Endoscopy appreciates your participation in tonight's event, Approaching Your First Job. My name is Marilyn Amador, and I will be the facilitator for this presentation. Before we get started, just a few housekeeping items. We want to make this session interactive, so feel free to ask questions at any time by clicking the Q&A feature on the bottom of your screen. Once you click on that feature, you can type in your question and hit return to submit the message. Please note this presentation is being recorded and will be posted within two business days on GI Leap, ASGE's online learning platform. You will have ongoing access to the recording in GI Leap as part of your registration. Now it is my pleasure to hand over this presentation to our GI Fellow moderator, Dr. Daniela Guerrero-VinSart from the Mayo Clinic in Rochester, Minnesota. Thank you. Thank you so much, Marilyn, and hello, everyone. Welcome to this Endo Hangout session. My name is Daniela Guerrero-VinSart, and today I have the tremendous pleasure to facilitate several super high-yield questions to our outstanding team of early career GI consultants joining us today. And the goal is for us GI Fellows to learn from their experiences as junior faculty and hopefully be able to apply the advice that they will provide to us today once we transition to our very own first job, which can be very exciting, but also quite intimidating. I want to thank the American Society for Gastrointestinal Endoscopy for this space dedicated to Fellows, to our education. And so let's begin by introducing our faculty moderator and panelists. First we have our faculty moderator, Mohamed Bilal. He is an assistant professor of medicine at the University of Minnesota and an advanced endoscopist at the Minneapolis VA Medical Center. He is extremely passionate about endoscopic innovation and medical education, as many of us know. Our panelists today are three outstanding faculty members. First we have Joy Chang. She is a clinical instructor at the Division of GI at the University of Michigan, and she completed both GI training and esophageal fellowship at the University of Michigan. And then she remained on faculty where her clinical research interests focus on eosinophilic esophagitis. Her current research focuses on understanding patient and provider drivers in treatment decisions, shared decision making, and health technology interventions for EOE care. We have then Joshua Steinberg. He is a native of Miami, and he completed his gastroenterology training at Georgetown University in Washington, D.C. And then he completed successfully his IBD fellowship at the University of Chicago. He is now the director of IBD at Gastroenterology of the Rockies, which is a large practice serving patients both in Denver and Boulder, Colorado. And Dr. Steinberg is a fierce advocate for his patients who suffer from Crohn's disease and ulcerative colitis. Thank you so much for joining us. And last but not least, we have Maureen Whitsett. She is a first-year transplant hepatology attending at the Cleveland Clinic with a clinical focus on hepatocellular carcinoma and other liver-related cancers, as well as transplant oncology, and she also enjoys working in medical education. She completed transplant hepatology fellowship at the University of Pennsylvania and GI fellowship at NYU. And that being said, thank you so much for joining us today. We will be first opening the floor for a discussion for several high-yield questions that I received from many of my colleagues in GI fellowship. And so let's start with the first question. The first question is, for how many years have you been already a GI consultant? And what was the hardest part to adjust to when transitioning from fellowship to faculty? Feel free to please just jump in, and whoever wants to participate first, just begin. I'm happy to start, I guess, because my Zoom video box is next to yours. So thank you, Danielle, for the very kind introduction. Thank you, ASG, for hosting this for all of our trainees. So I actually started work as an attending in mid-September. I finished my IBD fellowship in June at Chicago last year. So I've been in practice for a little less than a year. I would say for me, which might differ from some of my colleagues on here, but for me, probably the hardest kind of transition, I would say, would honestly just be the volume. Particularly for me, because I was in an IBD fellowship where, obviously, it's very super specialized. And a big chunk of my time was spent with research, education, admin, where now I'm very, very much doing clinical work. So I think adjusting to that initial change in volume, which maybe in general, from an academic to a private setting, regardless, is going to be probably busier overall, most likely. But I think just really, it took probably, honestly, six months to really feel comfortable and finding my efficiencies and inefficiencies, right, to really get the work done and just be able to feel comfortable with the number of patients, number of procedures. But it's still a work in progress. But I think so far, that transition-wise has been, for me, kind of like the biggest, biggest one. That is wonderful. And Josh, just to, on the same note, is there any specific tip that you have to become more efficient with that volume or transition to that volume? Yeah, I mean, it just takes time, right? For me, I felt like with all these transitions we have in our medical training, for me, I feel like six months, for whatever reason, is like that magic timeline. For everyone, it's going to be different to really just feel like a little more at ease. I think initially, try not to be too hard on yourself, right, and just kind of like embrace the chaos, which I know sounds a little cliche, but like it's just going to be crazy, right? Right? Maybe you're moving to a new location, maybe you're married and you have two children, and you're a new homeowner, and all other things going on at the same time. But I would say at first, just kind of like give yourself a little bit of slack, give yourself some grace, and then don't try to hyperfixate in the very beginning on like what you should or could be doing better. I will say with my practice, and hopefully with many practices, like academic and private, you get a little bit of like a ramp-up period, which certainly helps, right? So it's not like you're booked fully like from day one. So that was nice. I had a nice period of like shadowing for a little more than a week, which was really nice just to like get the feel of things, the flow of things, and how kind of from a systems perspective things operate. Um, so that would be my advice, just like kind of like embrace the chaos. Don't, you know, be too hard on yourself in the beginning. And then, you know, after a few months, try and like find where your inefficiencies might be while working with, you know, mentors or senior colleagues to suss that all out. Perfect. Thank you so much for that very thorough answer. Anybody else who has any other thoughts, something different, perhaps besides the volume of patients? Sure. Hi. Thanks again. Oh, sorry. It looks like I'm frozen. You can see me, right? We can hear you. So very good answer, right? I'm also kind of a new attending. I started in August and I was shocked by the volume. Even in just, you know, you're kind of like a hybrid private practice. I was in a big like academic practice and it's still a lot different than when you're a fellow. And I think one of the things that I struggled with initially was still being in fellow mode and trying to do as much as I could. Everyone comes from different fellowship programs that had different like varying levels of support. And in our like continuity clinic, when I was a GI fellow, we kind of just did everything a lot of stuff on our own. Or maybe I just wasn't good at delegating, but I learned that, you know, learning how to delegate very early on. Who do I call? Who can communicate this to the patient? Can I have this person call and relay a message? Like things that simple. Can you help me please with this prayer off? Like you can learn who very, very early can help you with these things. And it makes such a tremendous difference because for a while I was like feeling the weight of, I felt like I had to get all this done. I had to call all these patients. I had no time for it. So delegation, I think is exceptionally important. And if you can figure that out early, it's going to, it will make such a big difference in your state of mind, quality of life, the amount of time that you're able to like spend at home on, you know, on distracted by all the other things you have to do. So delegation, I think is key. Great. Thank you. Thank you, Maureen. And actually we have a follow-up question from our chat to that. They say, I think it's coming from Susan. Hi, Susan. How are you? To dovetail on Maureen's sentiment, wondering if you all have advice for how not to be seen as the fellow anymore and more as an attending, particularly if someone ends up staying in the same institution. Hi everyone. I'm Joy. I am three years into my faculty appointment and I did my GI fellowship, my Sapojo fellowship and all of the same place. So I'm still in the same area, the same division rather. And so I think in the beginning, definitely I wondered even during, as I was leaving fellowship, like how am I going to set myself apart to these people who are my colleagues, who my attendings. And honestly, I still think of a lot of people as my attendings and it's not going to be comfortable initially, of course. But definitely kind of for myself, it's been, I have a particular kind of clinical niche and an area of expertise. So it's been a little bit easier in that I've done more esophageal things. And so people will come to me just for those esophageal questions. But even if you're not, if you stay on as a general GI, I think the advantage is actually that when I need help, I know exactly who to ask for. And I'm like, oh, I was your fellow, please help. And I still have difficult colonoscopy, I don't do that much colonoscopy anymore. And so that's still an advantage where I can reach for, I can say, okay, who's in the endo unit, ask that person, not this person. But I think it's something that comes with time, just like getting comfortable with your own decision making. Just at some point realizing there's not an absolute right answer, I'm just going to make this decision has helped me to identify myself as more of an attending and not just looking to someone to answer the question. And I think I observed that in other junior people, like the people who kind of waffle and they say, oh, I'm not really sure. And they kind of ask the fellows what to do, kind of just exerting yourself and telling yourself, I'm the attending. I know that's like a weird transition because you're like, yesterday I was a fellow, today I'm an attending. But I think it comes with time and it's just the more things you'll see, you'll just notice, wow, I actually know this. And I feel like sometimes on call that happens to me. I'm like, oh my gosh, I'm so nervous on call. But then when I'm in it and holding a Minnesota team, I'm like, oh, I'm doing this. And just realizing I'm the attending and that you do have so much training and so much experience under your belt, but also nobody knows all the answers. I'm hoping I don't have to play as many Minnesota films during my career. I hope not every day. Yeah, sorry. Go ahead, Maureen. Oh, I was just going to say one thing also, I bounced around. So I was new here and got to start over new. But when you're an attending, you can call other attendings. So when you're on service and you're running into roadblocks or you really don't understand a consultant's recommendation, you just call them. And that's one of the ways I would imagine you can start establishing yourself as I am now in the attending role and I can do this and I can communicate directly with the attending. So I thought that was really a cool thing. I just would cold call people and they would answer. So just a thought. No, that's wonderful. And I think, sorry, just just to add to that, that some of us may have this feeling of, oh, I don't want to bother or I don't want to ask too many questions because people will feel like I don't know enough. But I guess it's the opposite, right? We should have the opposite mindset and just ask for help. Yeah. Yeah. All about the patient. Is that what you said, Maureen? Yeah. Keep the patient in the car. At the end of the day, you're trying to provide like the highest level of care for your patient. And you have to put your ego and your kind of like anxiety or whatever, which is normal to have all these things aside. And really, it's like you reach out to this person or that person because you're trying to do the best thing for the patient in front of you. So, Bilal, you had something else. No, I mean, I think I think this is so great. I mean, I think I think the really key takeaway that take from Josh, Maureen and Joy is that, you know, none of us really know the answers or there's no real like all these sessions are just really share mainly that that the feeling of vulnerability, the feeling of like uncertainty, that's going to be normal. And if you're the one who's feeling that on July 1st or July 15th or August, whenever you start, remember that every single person that you has ever been you're attending, you know, including the four of us have been through the exact same feelings, right? Like not knowing the uncertainty, feeling overwhelmed, feeling like, you know, do I really belong here? But then, you know, like what Joy said, you have to just and all of a sudden, you realize that you're actually doing all those things. Even when you're feeling all those things, you're still doing all those things. So, you know, I've now been attending for about, you know, 18, 19 months, or just over a year and a half. I started a little bit late. And, you know, the funny story I always tell my and I'm kind of an interesting model where, you know, I have I'm the only person who does advanced endoscopy at the VA. So I remember I always tell the story to our fellows that when I finished my first, you know, ERCP, you know, if for people who do it, you know, usually to clean out the bile duct from stones, you do like, you know, five or six balloon sweeps. I don't know, I done like 15. And then I kept doing it. And then after I was done, I looked at look behind the nurses was like, so are we done? And they all were like, looked at me and they're like, I don't know, are we? And I was like, oh, man, I have to make this decision. Because, you know, in fellowship, there's always someone telling you, I think we're good, even though you know the answer. But you have that always constant validation of someone behind you, even if, you know, there are attendings who don't say much or don't. But there's just knowing that if they're not saying something, it means I'm good. You know, you always have that. And all of a sudden, you don't have that. But to me, I would say that was like the biggest. And honestly, like part of me is still, you know, still still try to find that validation. And sometimes I ask my fellows a lot of times. And, you know, and there's no there's no no, I don't think there's any any shame in that. I think like all of us, you know, probably told you in different ways. So I think so I think that's still it's still a it's still a it's still a process in, you know. But then all of a sudden, when I was seven, eight months old, you know, into my job, I had two other, you know, partners joined who were banning me out of fellowship. And also, they're asking me a question. And I remember saying the first time and I felt so weird. I was like, oh, in my practice. And I was like, oh, really? I already have a smile because I was the person, you know, I remember my first week and the fellows were like, do you like a cap for your colonoscopy? I was like, I don't know. I've just been doing whatever my headings have been doing, you know, for all these last even though I did an advanced fellowship. And, you know, maybe I'm supposed to know the answers. But I you know, I didn't really know them. I don't know if I still know them. So I think that would be that sort of my, you know, a long winded answer to this starting question. That's wonderful. Thank you so much. And let's move on to the next question that we have here then. Very different from the previous one. How did you manage to prepare for boards while fulfilling your new job duties? Are there any tips for studying in those first few months? What was your trick to actually get very well prepared for boards? It's tough. I'll just say so I took my board during my IBD year. So I moved like peak pandemic to Chicago. We had our second kid in September. And then like boards were in November, early November. So it was tough. I think, you know, for me, I found like a structured like I did, like the Steinberg course, no affiliation. But I found that to be really helpful. I don't it's hard. I don't know what you just have to find the time and really like incorporate into your schedule. And everyone obviously has a different learning style. But I would not kind of just like flake on your boards. I think you should prepare, do the QBanks, you know, the DDSCP and the ACG and all these things. But like just do what's realistic if it's like just blocking out, you know, a couple hours on the weekend consistently. If that works for you, great. But not like delaying it until the end. I think that would be the best advice is like trying to have some sort of general structure of like at least when are you going to dedicate the time to study? Yeah, OK. And I think all of the panelists actually did some sort of advanced fellowship. So you had probably a little bit more time during your advanced year. But what do you think about in case you had to give the boards just right after your third year of fellowship, you know, jumping into your consultant role? No, I would say that I gave my boards during the advanced endoscopy fellowship. And I would say that it was probably harder to give the boards during that fellowship than it would be as an attending. You know, one of the things I would say that, you know, it's also like, you know, if you guys are starting jobs right away, unless, you know, but everybody has different reasons, family issues, financial. But really, if you can take time off in between your job and your fellowship and jobs, that would be great because you're never, ever going to have an empty in basket, you know, ever in your life after a vacation that you will have like you would when you're starting, you know, so take time between off, you know, study for your boards. And, you know, this is an important time and now you're an attending. So don't feel, you know, be upfront with your partners and be like, I want to take my boards. Can I have two weeks off before my boards? Like, you don't need to, like, you know, be finishing cases at 5 p.m. and then going on to do, you know, stuff the next day. We have our whole lives to do clinical work. And, you know, I feel like boards are an important part of our sort of journey makes us officially done with our training. And it's like a nice, so I think it's important to not overstress ourselves, even though over the three years, we're all hopefully prepared for the boards, but not to like, feel like, you know, we can't, we don't have time. So just feel pretty, you know, you'll be pleasantly surprised. I think most of your partners, colleagues, you know, jobs are going to be very receptive to you guys taking some time off or preparing for your boards. And, you know, eventually I'll want you to succeed. Thank you. Joy or Maureen, any other tips in terms of boards prep? Just question banks. That's, I found that to be really helpful. But I, like Josh, I took my GI during transplant and then my transplant pathology boards I have coming up in November. I have not started studying for those yet. I have a plan. I was going to say, how would you plan on studying? I'm thinking about, so pre-covid, I'm thinking about, so pre-contemplative. Yeah. Yeah. I had an easier year to study for it. But honestly, like, I felt like this is the smartest I'm going to be at GI, you know, like all things GI when I finished GI fellowship. And I don't know. I felt like I did all the Q bank things. The ACG question, I did it. And I thought that were really helpful. At least there were hidden answers. But I did find, maybe you guys can echo. I was like doing scoring really poorly on those. And I was getting very, very discouraged. So my takeaway is that do the Q bank, like get terrible, terrible scores, but then know you're still going to pass. You know, like, I think the pass rate is insanely high though. But that doesn't mean just slack off. But just as you're doing the Q bank and failing epically, just remember that. The real test will feel like that, but you'll pass. Okay. Thank you. That's very reassuring. Thank you, Joy. Next question is, we all have different job aspirations, right? Some people are more clinical and endoscopic oriented, some more research and academic oriented, and some more education and administrative oriented. And these all come with different learning curves. So how was your learning curve based on the role that you had to fulfill as a junior faculty? And when did you start to, and I think Josh already mentioned that for him, it was kind of like the six month timeline to feel sort of comfortable, at least with the volume. For the rest of the panelists, when did you truly start feeling comfortable and competent in your new role? So my role is a little bit different. I'm in like a purely academic setting. And my job is largely research. So I do a lot of clinical research. I'll do a lot of health services research. And so what that looks like for me is that I'm still super struggling. Because a lot of times I just wanna be a clinician and I wanna do the things that make me feel good, take care of patients and make a huge difference and hear that patients are doing well. And I wanna do that and I love that. And that's what fuels me to do research. But I'm still, I'm three years in and I'm still very uncomfortable with my research career because that's kind of the new thing, right? Like I feel like I've been practicing to be a doctor since medical school but the research thing is something that I've been only working on for probably, I don't know, since my fellowship. So by no means am I expert at that. And so it's taking me a really long time to navigate how to write grants and what it means to get grants or all the logistical nonsense that goes with that. I think even as a clinician in a subspecialty, for example, esophagus, it probably still took me like a year to feel really comfortable with, this is why I'm doing this. Yeah, that's why I said. Even when I go back to like some notes or patients that I saw during my first year out, I'm like, oh, that was not a good idea. Or it took me about almost a year to really be able to say, oh, this is 100% what I would do for this patient again and again. It's a while. Oh, that's great. Thank you for acknowledging that it's not easy. Even three years into practice, I mean, there's a lot of things to still figure out, right? Anybody else? I think, no, I think for me, it was not 100% opposite from Joy. But my fellowship career was all built on medical education and working on scholarship and research. And then I went to Advanced Endoscopy Fellowship. And like I said earlier, I came and our VA, I'm the only one who does advanced endoscopy. So all of a sudden, it was like a burden of clinical responsibilities, right? Every single procedure that came to me, I was like, would this person be better served if you went to an expert? And I would be like, because like Maureen said, you're all of a sudden, I'm like, this is a patient's life depend on me, what I'm going to do, what I'm going to biopsy, what I'm going to stand, I'm going to put in, what I'm going to resect, what everything I'm going to do is like, am I the right person for this, right? Am I, you know, I don't know. I just graduated a fellowship. I, you know, in the fellowship, even till the very last day, some things are humbling. In endoscopy, some things are humbling every day. I mean, everything we do in life is humbling, right? So it was like the biggest, I think for me was like, okay, I have to now provide a clinical expertise where I have to be, go to bed knowing that this person was served, is being served as good as it is by me, as it would be by someone else who does this. And I think that, you know, I think Joy said it like early, like all of a sudden you have to like believe in yourself. You know that you've been training, you know, you went to med school, you went to residency, you went to fellowship, you went to advanced fellowship. You know, I still feel like a fellow sometimes. I think the first three months I kept introducing myself as a fellow every single meeting or every single time I talked to someone. And then I think it was just that, you know, that slowly you just start realizing and understanding that you've done all this training. And then, you know, one of the biggest things that I think helps me is like, every time I have a meeting with a medical student or someone rotates with me, they leave. And I'm like, man, I'm like eight, nine years ahead of them, you know, because part of me still feels like I'm a medic. So you kind of have to remember that all that training that you've had has prepared you for this role. And yes, you are feeling like uncertain, but also, you know, what it is, how to back yourself. And I would say prepare. Like, I don't think I prepared as much as I ever did in my career that I did. Like, I, you know, I watched, if I'm doing a simple, you know, like EMR, which I've done like, I don't know, like so many of them in my fellowship, but I would review videos the night before, review equipment, you know, review all the settings, review all the troubleshooting tips. You know, there is, you know, talk to, if I had something that was relatively new, I would talk to peer mentors and my own mentors and be like, hey, you know, I'm doing this thing tomorrow. Talk to radiology, talk to surgery, talk to my nurses, you know, who are going to be with me. Like they know all the equipment review, like even a small thing, like you're putting an endo loop on a large polyp, you know, something that all of us have done and will do. And just making sure you review all those little things. It's nothing about your skill. It's just about knowing that little interests, little small thing about an equipment. So I think I still, I feel like a lot of times as I build on new techniques into my practice and my endoscopy practice, I still feel like, and I always like, you know, you kind of have to like believe in yourself, but also prepare. So I think that helped me a lot is like, I always prepared the day before, reviewed all my procedures, you know, what challenges I could run into. And I think that I went in with a plan. So I think same if you are, you know, I would assume if you have like a busy clinic, if you review them a little bit ahead of time, so you're going with a plan. So like you're trying to set yourself up to six. So yes, you're trained, but just a little bit extra prep because eventually it'll become like a habit, right? Like I'm sure like Josh, like was saying earlier, like, you know, and now he feels like doing 15 colonoscopies in a day is becoming a habit, but just like a little extra prep in the first few months will keep you on par and, you know, help with just navigating, you know, day and just take it one day at a time, you know, you know, just take one day, one week at a time. Don't overthink it. Don't think about the law, you know, just to kind of, you know, and remember at the end of the day, whatever we're doing, you know, especially as we're doing it, yes, we want to focus on our careers, but also for the patients and whatever is best. And sometimes asking someone else is best. Sometime knowing that this person, you know, getting an opinion from someone and asking like, hey, you know, this is, I've just encountered a scenario, not enough. What would you do? You know, and asking all that. And being honest with their patients, I tell my patients sometimes, I'm like, hey, you know, I'm gonna ask, reach out a mentor and an expert and I'll get back to you. You know, I really have not encountered this scenario before and I think they respect you more and they trust you more because they know you're the person and your colleagues trust you more. If a surgeon asks me and I've never dealt with it, I'll be like, you know, let me ask some colleagues, let me ask on social media and I'll get back to you, you know, and I'm just like, I think you get more respect from your colleagues and your patients if you do that. Thank you, that's wonderful. We have a couple of questions coming in the chat. The first one is, how comfortable were you actually scoping with fellows from the beginning of your faculty years? Or when is the appropriate timing to actually start teaching and not only doing procedures by yourself? I think it's reasonable. In transplant fellowship, we did scope, but not as much. And I felt like pretty rusty. So it's definitely reasonable to ask, you know, can I have the first couple of months just to scope alone, just because I need to like get my feet back, you know, wet again and kind of feel more comfortable. And then, you know, six months I think is when I started saying, you know, okay to let fellows in. Can't really say I'm very comfortable yet teaching endoscopy, that's a whole other skillset. But I think if you, you know, especially if you are rusty or you just want to work on building your confidence, I think that's a reasonable ask that I was easily accommodated. Perfect. What about you, Josh, in private? I don't think you can necessarily, you don't work with fellows. Not with fellows. I have residents and medical students, but not fellows. So I don't have to worry about that yet. But I think what Maria is saying makes total sense. Like give yourself a little time. And I mean, I would imagine, yeah, that is a pretty fair ask, right? You just want to like hone your skills, get used to the flow, you know, and just get your bearings and then, you know, can start kind of focusing on training, right? So. Right. Yep. And the next question is actually coming for Josh as well. And they say, hello, what are some ways to look for a private practice job, private practice job opportunities? And how long before graduation should we be looking into this? Yeah, great question. Sorry, one more thing. What are some important things to be aware to ask when looking for private practice jobs? Good question. So I think to answer the question about when should you start, I think it's never too early to start looking, you know, loosely and kind of making those connections, planting those seeds with kind of like practices in areas geographically of interest, right? So, you know, as like a, even as an early second year fellow, if you're fairly confident that your goal is to join a group in the Midwest, I think it's more than appropriate for you to either send kind of like introductory emails out to, you know, CEOs or chiefs of departments, or, you know, the leaders of practices, or have, you know, a mentor sponsor for you to reach out on your behalf. Hey, you know, Josh is a third year fellow and he's gonna be doing IBD, but he's interested in coming to wherever, Chicago, and making those connections early. I think if you're focusing on private practice, some important things to think about is certainly call, right? Call and private practice can be Q2, like week. It could be Q10 week. It could be Q15 week. It really depends on the number of providers, the number of hospitals you're affiliated or associated with. So that can make a big difference. You know, I interviewed at private academic on a hybrid hospital base and the call varied, you know, some private practices, it was every third week, you're on call for the week and weekend, covering multiple, very busy hospitals. Where I'm at now, I think it's like every eight weeks, roughly, for a week at a time, which is pretty reasonable, I think, for a private group. So call is one thing. Certainly, you know, when you're talking about private, it's like the route to partnership and kind of what other setup there is for you to become partner, what other incentives there are. For me specifically, you know, I was looking for an IBD specific role, right? So if you have a clinical interest, right? And if you asked me two years ago, I wouldn't have told you I would have joined private practice, but I was presented a very kind of unique and exciting opportunity, but part of my contract very explicitly included my role as the Director of Inflammatory Bowel Disease for this private group, right? So if you have a particular niche, if you're doing an advanced year in liver, we have a transplant hepatologist who just finished at University of Colorado who joined us, and he has a very clear role that was explicitly written in his contract. You know, I think those are important things to consider. There's a lot of stuff, but I'm happy to also talk offline about private practice stuff. Yeah, so many details to talk about private practice-wise, RVU, et cetera, it's like an obscure science that you kind of need to learn about to learn how to negotiate with private practice jobs as well. Yeah, totally. So our next question is actually very interesting here. What do you wish you had known before starting your job? Looking back, what could better prepare a third year or a four-year fellow prior to the starting date? I think just to really quickly circle back on what I said about, it's never too early to kind of make those connections, make those introductions. You know, I'm currently helping current fellows that are in their second and third years kind of make some connections in the places I've trained. So again, I don't think anyone's going to hold it against you for inquiring about a potential job and asking to learn more. And the more you talk to people, like when I was in the interview or like just before the interview process, I literally talked to someone on the phone every day, like a friend, a colleague, a mentor, you know, some friend of a friend who's on staff here. I think the more people you talk to, the more perspective you get, and it kind of just helps you, you know, hone your own interview path and like experience. So get as much advice as you can and perspective as you can. And the only thing I would add to that, what Josh said is that basically that, you know, what I've seen when majority of the fellows is that they undersell themselves when looking for jobs, because we're all still in fellow mode. We're like, oh my God, someone wants to recruit me. You know, or this person that I looked up to, my attending or mentor or someone else at a big institution or a big private group, oh, they're going to recruit me or they're going to pay me X amount of money. And, you know, in private practice, and you're like used to living on a resident and fellow salary for the last six, seven years and a medical student. So I think we tend to undersell ourselves. So I think it's really just it's, and there's no real way to train yourself for that, but just remember that all these years of training you've done is now that you are an asset, you're in a really important, valuable member to some team you will be, you know, whether it's academics, private practice, hybrid models, you know, staying on in the same institution that you are. And one of the things I tell our fellows is that, you know, try to identify what your mission is going to be. And is your mission, like Josh said, is like, you know, I want to provide the most state-of-the-art IBD care, the most complex IBD care in the region. Is your mission like I want to build a career on education? Is my primary, and you can have all missions, right? Like, but some missions are going to be like, is your mission like for me as an advanced endoscopist, like the first five years I want to focus my mission is like primary mission is advanced endoscopy. I'm so passionate about education and research, but that's my primary mission for the first few years because I want to, you know, be good at my skills, advance my skills and refine more the things I've learned. And according to that, you can negotiate, right? Because a lot of it is like you're overwhelmed. Someone's like, you know, I'm going to give you the protected time. I'm going to give you this. You're going to have, and you get overwhelmed by what's being offered. And there are so many little things to try to figure out what, like someone gave me good advice is like, write down a list of like four or five things that are, you know, absolute essentials to you, right? Is that like, is that like having a research assistant? Is that having protected time? Is that having, you know, more clinic or less clinic or more scoping or less scoping? And then ask, negotiate for those specific things. Like these are the three or four things I'm not going to settle for. And then these are the things that I'm open. You know, of course you have to be flexible because, you know, you're also demonstrating to your partners. This is a partner I want to be with, right? Working in medicine is all about compromising, helping each other, you know, we're all have days, long days, someone helps each other out, call coverage, urgent leaves comes. So you don't want to be an unflexible person, but also sharing your, how passionate you are about some things and how, you know, how that would be important. And in academic jobs, you know, salaries are hard to negotiate, but support can. You can negotiate how you're going to value your time. You know, what is, and that really helps in figuring out what am I going to really happy? And then the last thing is, your first job is not your last job. And you always have it, you know, as you three years in, you're like, I don't know, I thought I was going to enjoy research a lot more, but now I want to go back more to clinical or vice versa. There's always a chance. So don't feel like what you did is like the end. It's a learning opportunity in our, you know, when I talk to my mentors who've done this for 30 years, 40 years, you know, the first job is a distant past. So just, this is another learning opportunity. And like I said, I don't know, I don't know the answer, but that's what I'm still learning about, about this first job that I have. Right. There's a lot of people who keep reinventing themselves, right, along the way. Totally. So we have the next question. Maybe Joy can help us with. For those interested in research and career development, as well as grant writing, what is your advice regarding timeline to successfully apply for such opportunities early during your faculty years? Yeah, so I think, I mean, it's funny because like, depending on what fellowship you went to, or what, you know, depending on where you train and what like kind of your path, like where your breakdown kind of ends up being, you end up with different exposures and that's kind of pushed me towards different things. So I'm kind of in this like very pure academic model where maybe the rest of my life will be dependent on me writing grants and then keeping myself afloat. So that's where I am now. I think if that's what your calling is and that was your passion, awesome, go for it. You know, I will say that with like, I'm never really sure if that's like the best thing for me. So I don't know if that's what I'm gonna end up doing for the rest of my life, but I'm trying it now. I think that if that's something you're interested in doing, awesome, it's so fun. But kind of being cognizant of the timeline is gonna be key for sure. Realizing how long it actually takes to assemble a grant. So the kind of grants we're talking about are like these early career development grants. The first big grant that's gonna float you so you get that street cred, so you get that prelim data so you can go for your R01 down the line. So these are called your K grants or your kind of society career development grants. These are long grants to write in that the actual science part is very short. It's like maybe like 15 pages, but then there's like about 60, 70 other pages of other stuff. Now, the parts of the grants that are important because these are career development grants are having a solid mentorship team. You got your science, but even having the, you have to assemble a mentorship team to even put the grant together, these training grants. And so that actually takes a lot of time to assemble your Avengers and together write this grant. So for scope, I've been working on my career development grant for three years now. So I kind of started during my fourth year multiple rejections and I think I'm at this place where I'm getting my first career development grant. But so it takes about probably three years is the runway you're looking at. Some people get really lucky and they get in immediately or you start out by getting maybe a society career development grant that kind of floats you before you get your federal funding. But definitely start, if that's something you're passionate about, assemble that mentorship team of people who can get you there. And when I say that, I kind of mean like find someone who has the gig that you want, who has the life, who has the career that you want and ask them how they got it, how they got to that place, how the process because they don't teach you that in fellowship, unfortunately, but know that it will take a couple of years. So start early and get ready for a lot of discomfort. A lot of resilience for sure. Yeah. Thank you so much for sharing that experience. We have a question in the chat now. Let me just open this up here real quick. Did the geographic location of your fellowship have any impact on where you were able to find the job? For example, I am training in the South, but trying to find a job in the Midwest. So location matters for your job, location for your fellowship. Personally for me, it did not. I was physically in Chicago. I was looking here in Colorado. I was looking in Miami, like South Florida where I'm from and also the tri-state area. Obviously, just regionally, your attendings, your faculty, most likely are going to know the regional people and help you make those connections, but it shouldn't be a hindrance. You should not box yourself in like, oh, because I'm training in Atlanta, I should only really focus on the Southeast, but I really wanna be in Boston. I think obviously expressing that interest to those programs or groups is important. And if you have any faculty that have connections with those people, whether they've trained with those people or previously on faculty with those people in the geographic area of your interest, it's okay to ask for your attending or faculty to make that connection for you. So I wouldn't box yourself in. So, yeah, Maureen. Yeah, I was gonna say Maureen. Yeah, you also changed geographically. I've been everywhere. I bounced back and forth and now I'm back in the Midwest. So geography is not, the transplant and hepatology job market every year seems to be different. I was interviewing when the year before there had been financial freezes and there weren't jobs available. And so I do think because it's a smaller world, I think every year the amount of positions available are just so variable. So I just kind of put feelers out to places geographically where I feel like I could have moved with my husband. And I don't really think that, like if you really, I got bites from everyone. It wasn't really like very hard. I don't know how many people were applying that year. So it wasn't really hard to connect with these programs. And again, in the transplant world, it's such a small world that even if there are some, like regional, there's like the New York people and the different kind of like factions almost, like everybody knows everyone. And I think that even if you're trying to break through to a new, from the South to the Midwest, if you have people in your, that you've trained with, whether in medical school, during GI fellowship, who could reach out in your favor and kind of help you out. And you might not even really need that if you have a good enough reason to be at a program and you can, you're really like believe that you, this would be a good fit and the program really likes you. Even if you don't have connections. I think like when you're on like our side, when we're interviewing for a job, people like applicants, we're trying to figure out like how do they really want to come here? Like, what is it about this program? So if you're from the South, but you know, you're kind of unencumbered and you can move wherever you want to move. Or if you have family in the Midwest, like we're kind of on our end looking for, does the person really want to come here? I kind of am jumping all over with my answers, but I think geography is less of a barrier. Use your mentors, use your connections. And then, you know, if you really are interested in a place and feel strongly about a place, like make sure you communicate that interest. Like when you're looking for your jobs and you know, if it means making an extra site visit or reaching out and talking to someone, you know, after an interview, you know, just to kind of show them that you're really serious about coming up, you know, north of the Mason Dixon line. So don't let it be a barrier, I guess. Thank you, Marie. Super on point answer. What tips do you have to build your practice? For example, referrals, clinical practice or academic niche and any tips to build your brand. And I know it might be a little early, you know, kind of like as an early career, you may not have a set brand already, but any tips to build your practice and your brand that you might be able to share? I'll say, you know, luckily my group has like an internal marketing person, which is wonderful. Like not every group or, you know, institution will have that, but if you have that to your advantage, it's wonderful, especially like regionally, right? So what you want to do is get the referrals from referral providers in your region, in your community, right, whether you're a general practitioner, GI practitioner, or an IBD specialist, right? So just really, you know, in the first few months, you're going to be inundated with just getting used to everything and being busy, but taking the time to go out and meet people in the community, obviously COVID, right, has made that a little more cumbersome, but I have plenty of Zoom meetings with referral providers where I put my best face forward. I introduce myself, explain what services I offer, and just, you know, introduce myself and a little bit about my background. So regionally getting yourself out there, you know, going to hospital events, or, you know, if you're in private practice, right, there's like radiology groups or surgical groups or all these things. There's all these opportunities for you to like meet and network with your local community. You know, all of us here, I think use social media to our advantage professionally as a way to get our names out there, to interact with others, to network with others. You know, I wouldn't use social media as like an only tool, particularly in an academic field, if that's what you're trying to achieve, right? You don't want to focus all your time on social media and not have kind of like the clinical or research or societal kind of involvement to back it up. But even if you're just a casual social media user, just to have a profile, it's just another way to interact with people. I mean, Twitter, I think we all could agree for GI is probably, you know, the social media platform of choice that most of us kind of use professionally. So I've found a lot of, you know, personal and professional gratification in using it, not just to like, you know, post like personal pictures of myself and what I'm doing as we all have our personal Instagrams for, but, you know, we've done Scoping Sundays, Bilal and I, Monday Night FBD, which is, you know, stuff I got involved in. And obviously we're all sharing information, we're sharing journal articles, and I think it's a good way to kind of put yourself out there and build your brand. I think that's one of the tips, yeah. Anybody else? Yeah, I think I can answer, I'm not great with the social media. I just try to like a lot of things and read deep. We need that perspective too, because if you don't have social media, you don't necessarily have to. I find it very overwhelming. Yeah, I take breaks every now and then, like so often, I have to like step away, it gets too much. Yeah. Me, me too. Yeah. You're right. Oh, seriously? Bilal. I think, so one, when you're a new faculty, you will get asked to do lots of things. Can you give this talk? Can you fill in for this person? Can you do this? Can you do that? So you have these competing interests, like people asking you, you know, to help fill a need. And then you kind of wanting to build your niche, so to speak, and not really like throw yourself into projects that you, or give talks that you might not really, might not like help further your interests or get you to like the point where you become that person, you know, like that, whatever, that fatty liver specialist or X, Y, Z. It's always great if you, right away, when you come in, you kind of have a clinical interest and a niche that you can fill. And so it makes it a little bit easier, you know, say yes to talking engagements, you know, within your institution, regionally, et cetera. If you don't have a niche, which I didn't really, everyone will ask you if you want to do this and do that. And you'd have to try and figure out, like, is it a smart idea to kind of engage or, you know, commit myself to a clinic that I'm not a hundred percent sure I could like see myself doing. So I now am like liver tumor. I am the liver tumor person, but I just kind of like fell into that role. But I was, I thought about it and it kind of helps me to, I have an interest in palliative hepatology. And I thought, oh, this is actually great for me because it aligns some of my other interests. And so I like jumped at the opportunity and took it when the spot was filled. But if you're lucky and you have like an interest, a clinical niche or something, you know, you can even make that known, you know, you make that known in your interview. And, you know, if you're lucky enough, you can sign on and that could be part of your contract. Like I will be this person for the clinic, et cetera. Yeah, those are my thoughts. Great. One piece of advice that someone gave me is that in the beginning, try and say yes to the opportunities upfront, if you can, you know, time withstanding, because ideally you're gonna want to do those things later on. And if you don't say yes upfront, you might not be thought of as that person to go to, whether it's giving a talk for grand rounds or, you know, writing a paper. So all these things, especially in the beginning of starting a new job, I've said yes to a lot of things, which is good and it keeps you very busy, but I wouldn't be doing those things if I didn't want to be doing. But the advice I had was, you know, if you really are just saying no to everything upfront, it might do you a disservice in the longterm because whether it's pharmaceutical opportunities or speaking opportunities or research collaboration opportunities, you know, if you're saying no, no, no upfront, then you might not be thought of again in the future. I don't know if everyone has different- That is a good point. I haven't said no to anything yet. I'm like not practicing what I preach. I have, I've said a maybe to one thing, but I don't know that I've said no to many things. I think there's like, I think you would take that with a grain of salt, where you say yes to some like things in the beginning and then at some point, but if they align with your values, right? Like- Yes, yeah. Josh, if someone was like, hey, do you want to do this panel on GI bleeding specifically? I'd probably say no. Yeah, does that serve me, right? If it serves your purpose. Yeah, at some point you have to start fiercely saying no to absolutely like many, many things. Now, and I'm still super at risk of this because I want to do things, you know, like I want to do this talk and then I say yes. And then later on, like two weeks later, I'm like, oh God. So, you know, number one, I think just make sure it aligns with your values and you're like your mission, like philosophy. Totally, I should have used that. I should have said that, yeah, agreed, 100%. I'm super niche. I mean, I'm doing eosinophilic esophagitis within the esophagus and I do mainly that. I think building your brand, I don't do the social media thing well either. I kind of like, I'm one of these lurkers and then sometimes I, you know, reach out to people. I think if you're interested in a specific disease as well, like some, there are some national patient advocacy, there's international and national patient advocacy groups who really want to get behind a physician as well. Yeah. That's, they're so helpful. They just like, the ground swells underneath you, you know, kind of contacting local practices, super instrumental, because they kind of want your expertise as well. And then for me, because I do EOE, just even in my own center, kind of reaching out, talking to allergists, even though, you know, as GI, I manage it by myself, but kind of getting their perspectives, like, who are you here getting EOE referrals from? Dietitians, psychologists, and things like that. I think the more people, I mean, it's like very counter-cultural, but the more people you tell about yourself, you know, is helpful. And then you just, to get your name on people's lips is uncomfortable. Yeah, I think that's great advice, Joy, because I think that's one of the things I would say, you know, sort of like practice building sort of technique as well, right? Like depending on whatever your niche may be, right? And it doesn't always have to be a clinical niche, right? Like even if it's a research niche, you're doing a trial to get enrolled patients. Like, I think one of the cultural shifts, you know, I've never met a fellow who came to me or a resident, or even when I was there, who was like, oh my gosh, I'm so excited I got 21 consults today, right? Like there's never been, or like came like, oh my, this is like a dream come true. Like this is the maximum number of consults I've ever seen, right? And that's because we're doing too many things in fellowship and, you know, it's training and it's just a cycle. But it's a little bit of, once you're an attending or a faculty, whether you're in academics or prior practice, you know, any call that you get is an opportunity to build your brand. So building brand doesn't always mean like necessarily that it's on social media. It's like, it's building like who you are. Are you the person? Because if you're building, even if it's a general GI practice, right? A primary care doctor calls you, hey, this person's having abdominal pain and just being available and telling them you'll take care of it, your practice is gonna get, you're gonna get more referrals because they know that you're the consultant that they can trust, that you're the doctor, you're the IBDologist, you're the hepatologist, you're the advanced endoscopist. So if a colleague calls me and they're like, you know what, they're like, hey, you know, this is, I have this really complicated endoscopic procedure resection they need. It's not like, oh gosh, I have to figure this out. It's like, oh, thank you so much. You know, let me take a look. I'll take whatever I can do to make it easier for them. So they continue to call me. Like you want to be their go-to person, right? Versus in fellowship, you're like, I hope that nobody faces me right now because, but it's a different, you know? So yes, you know, being an attending isn't easy as you guys heard, but we do all acknowledge that everything is better than fellowship, right? Like fellowship is busy, it's tough. You're balancing multiple hats, like, you know? So I think you have more levy. So being available for your, whoever your referring base would be. And that's your brand, that you're the one who's always easy to talk to. If you want to be, build your career in education, you know, are you going to be available to the residents and medical students and people who come to you for advice because education is not just gonna be about, it's gonna be being available. So that's your building your brand. The name will get around locally and your institution will go regionally. And I think what Josh said has some value, right? Because sometimes if you're, some people have opportunities laid out for them, right? Like you're at an institution where someone just aligned, goals aligned. There was an opportunity, like someone retired and all of a sudden you're the director of IBD. But some places you might have to create some opportunities in that situation. It's okay to say yes, because getting yourself out there eventually will be a stepping stone to get the opportunities that you really, really want. But of course we don't want, you don't wanna burn yourself out and you don't wanna, doing all those things. But it's kind of like that approach where I think, I think no matter what specialty or academic or clinical niche you are, is that mindset that really helps you become a successful. Like, if I know like Maureen's address is liver cancer and I call her and I'm like, hey, this patient has, and you're like, she's like, that's great. Thank you so much. You know, I'll take care of it. I'll see the patient. She's gonna get more likely to get a lot of these referrals from the, you know, and being in the big center like Cleveland and she's gonna get from the community because you're like, oh, you know, this is a complicated patient. We don't have the resources. We have a person for that. And then you actually are spending time seeing those patients that you wanted to see. Versus if you did not wanna see an X, Y, or Z category, those will filter out to someone who is more passionate about those diseases. That's great. Yeah, and I think that even during fellowship, your brand is something that you can start building and saying yes and saying no to things. It's completely okay. I remember just in DDW, they approached me for a research collaboration that had nothing to do with the type of research that I actually like. And I just decided to kind of connect that person with another colleague that I knew was very passionate about that. So I think that's always something important to consider. I'm just gonna add to that. That's actually building your brand, right? Because even if you didn't wanna do something, but providing someone that you think would be good, that's establishing relationship, sponsoring people, mentoring, and then there's no, you know, you can be a fellow and start doing it. You could be a resident. You know, it could be early career. There's never too late. You could be peer sponsoring. Like, I'd be like, oh, this is an IBD opportunity. That's great for Joy. Oh, sorry, great for Josh or esophagology. That's great for Joy. So that's also building your brand as someone who would help create opportunities for others. So people will start looking up. So every little thing is part of building your brand as how people will see who you are. That's true. Thank you so much. We have a question in the chat. How do you deal with procedural complications? And this one goes for Bilal, particularly in advanced endoscopy where complication rates are higher? Yeah, I think it's a great question. I think, you know, what I would say is that it's hard because, you know, serious complications are not as common and fellowship, you don't get a lot of exposure to them. So one of my advice to what I give to our fellows is that if you ever, even if you're on consult service, you see a post-polypectomy bleed get admitted, you see someone, you know, perforation, even if you weren't involved in the procedure, you know, go with your attendings, talk to the patients as if they were your complications, right? Because you're representing the department or division and see and navigate those challenges with someone, right? Like the emotional challenges of it, the guilt that comes with it, the feeling of like, oh man, maybe I could have done something differently. Maybe it was me, you know, maybe my, you know, that expert person had done it. But the truth is it can happen to the best of us and remembering that we're in a special, if you're in a procedural specialty, that will happen. But it's like, how are you gonna deal with it? And, you know, it never gets easy, right? Like, I don't think that I have a certain number of complications, but understanding what things are under your control, learning from it and having a group of peers, like, you know, feeling open to it. Like I strongly and big advocate for departments and divisions, whether you're chiropractors, academics, having meetings to discuss complications where you're not, where you learn from it, not necessarily where it's like, why did you do this? And why didn't you do this? Like, I would have done this versus just like, you know, and then finding your persons in your job, like peers outside your job who you can just call and be like, like, if I have a complication, I call some friends, I'm like, you know what, I had this. And they're like, yeah, this happened to me so many times. You just, you know, having a went in group where you can feel, be vulnerable about it, you know, about how you're feeling. And then just, you know, and take ownership of the complication. I think you will realize if you take ownership of the complication and don't shy away from it, you will feel much better. So, you know, admitting to the, there's a, you know, whole different legal aspects to it as well. But more importantly, you know, if someone needs surgery, you will be the one to call the surgeon, coordinate it, talk to the patient, talk to the family, tell them this happened. I'm sorry, this happened to you. And this is what I'm gonna do to help coordinate your care. And I think, honestly, the two or three complications that I've had, I have a better relationship with those patients than I have with those that I had successful procedures with, because I just, you know, took so much follow-up with them, saw them in the clinic, had after visit, that I have a better relationship with those patients than those that I did a great job on. So don't be shy away, take ownership of it. You know, just like people will respect you for being honest and things. And there will obviously be certain instances where you will have difficult encounters and things that are beyond your control, but that's, but there's nothing you can do about it. So as long as you, and you learn, each, you know, and you learn and you go from there. So I don't think it ever gets easy, but I think in fellowship, if you ever have an opportunity, go with your attendings and see how they, how they talk to those patients, how they deliver that news. Just even saying, hey, I'm, you know, this, it's not, you know, in your mind, you have all this way, but then you actually have to articulate it. And that's not always easy. So that would be my two cents on this. Thank you. Thank you, Vilel. And we have a question regarding billing and coding, and this can be taken by Josh. How did you prepare for billing and coding and any other administrative tasks that you were asked to do when becoming a consultant, but rarely had to worry about during fellowship? It's a great question. Honestly, quite frankly, unless your fellowship or institution has any sort of billing training, you're really just going to learn on the fly. Luckily, my practice, we had like a billing orientation and session, but really you're not going to figure it out until you're actually doing it. And I'm still figuring it out, to be honest with you. Luckily, we have like billing auditors that look at our notes and our charges and all these things that many practices and institutions have that kind of help you learn and optimize your billing so that it's appropriate and correct. But honestly, I wouldn't waste too much time or energy before starting. Obviously, it's something you're going to need to learn and focus on, but it's, in my opinion, something you're going to learn on the fly unless you have some established billing session, right, in your institution, especially if you're staying at the same institution, that would probably be helpful. Sorry, the sun's like getting my face, but- In my learning on the fly, Josh, do you mean just asking maybe your colleagues who are sitting next to you? Totally, and exactly. The person sitting next to you, you know, it's a lot. It's just like a completely foreign language that we just don't think about as fellows. If you do an advanced fellowship and you kind of like act as a pseudo-attending, you might get that opportunity, which is helpful. But yeah, just reaching out to your colleagues and again, asking for help. They were there once, like they know it's like a completely new and foreign experience, this coding and billing situation. But again, beforehand, before starting, I don't know that I would spend too much time or energy on that personally. And for Joy and Maureen, do you have to worry at all about billing and coding in your practices? To a certain extent, yes, but you will have someone kind of sit with you. You should have someone go over billing. It's pretty standard. Okay. Yeah, and you can bill by the time spent, which is like awesome as a hepatologist because our patients do spend a lot of time with them. And sometimes it's, so you'll learn like there are different ways to bill are, you know, problem-based, time spent. But I think overall it's, don't stress about it. Yeah. It'll be fine. Realistically, a lot of it changes on the fly. Like even in the pandemic, all that virtual care stuff, those are completely new billing codes. But usually like there'll be like a short orientation on like basically what to do, how to bill procedures, how to build notes. And then, you know, you'll learn things like how to bill based on time, how to bill if you're with a fellow or a resident, things like that. So you should get that at your job. Wonderful. Okay. I think we're coming to an end being 8, 10 PM. And I know Bilal, you had some slides that you wanted to share with us, but maybe that's, it's going to be a little late for that. And we will- I was going to say there's, it looks like there's still some Q&A. So, you know. Oh, there are? Okay. Let me open those then. Might be- I know there's some on the chat and there are some in the Q&A, yeah. Oh, okay. We have many in the Q&A. Yeah. Okay. Let's, just one person per question so that we can just like, you know, kind of answer as many as we have here. Do you find it's hard to take vacation as new staff? One person, one line. Do it. My answer is no. Make it hell. That's practice dependent, you know? Many first year associates, whether you're in private practice or academics, it just varies. But for me, no. Okay. Yeah. Awesome. And I think that's also, you'll negotiate with your job as well. Like how much vacation you're going to have, et cetera, when you start interviewing for jobs. To piggyback on this question, which I'm not sure what it was, how long did it take you to feel comfortable scoping independently? We did this one already. Kind of. But just for the endoscopy part, independently. One, two months, three months. Nothing? You were already all set after fellowship, probably. Still. Still, still learning. Yeah, I mean, I think there's some things you feel more comfortable than others, the things you see more commonly in your practice, and the others that you're still evolving. I think the important thing about endoscopy, I would say learning, is that you have to remember that there's basics to it, right? Then everything else is a supplement to it. Like either it's putting on a new device, like over the scope clip. Like it's just a device. You know, your movements and the scope skills, there's not an additional technical skill to learn. It's more of like understanding the cognitive part of it. So a lot of the learning in, which is the hardest thing, right? As fellows, we're all worried about scoping, right? Like everybody's like worried about like endoscopy education. But like whenever someone becomes an attending, the most challenges they face are always not endoscopic. It's all cognitive. So the additional growth that you have to your basic armamentarium that you learn as a fellow, I think is all cognitive skills. It's like talking about people, like how would you navigate a challenge? It's usually like, oh, maybe I changed my position. It didn't, not necessarily someone had better, you know, in my opinion, technical or hand skills. It's just, they have a different idea of how they would have navigated that situation, right? Someone's bleeding and blood's pooling in the fundus. Someone's like, I'm gonna change your position. That's what comes from the experience, right? Like, because when the moment you're just like, you know, anxiety, something anxious, stressful, a lot of those things are, you know, somebody like a food impaction, try to use a cap with it. Or, you know, how do you dilate a EOE, you know, stricture. So it's gonna be like those little subtle additions to those things, which are not necessarily technical, you know, more cognitive. Because, you know, you guys are all graduating from fellowship programs where you do enough upper endoscopies and colonoscopies and then everything else will. And then remember that you can take a lot of skills. You can learn a lot of skills on the job, right? Like there's, whatever you learned is not the end. I'm just now specifically talking about endoscopy. But like, if you learned, if you didn't learn how to do, you know, complex spec dupes, you can shadow a colleague for three or four days and, you know, you'll figure it out or have a peer mentor. And that can be in prior practice, you know, in academics, you know, always have the luxury, like Joy said, you can always, you know, call someone in and ask who's in the endoscopy suite. But even in prior practice, you have senior partners and colleagues. And then also the things that you learn in your fellowship. There are a lot of newer things that have come by in the last, you know, two, three years, hemo spray over the scope clips and different dilation tools. And those are things that you can also introduce to your senior partners, you know, who are a little bit out of, and didn't get a lot of experience with those things. So it's always a give and take. And you're just, you know, you're never alone. So don't ever feel like in any situation, like I think all of us will tell you that we've called someone for a device in a procedure and clinic and in life. Never stop learning. And the next question is, I think a very loaded question, but great question. How do you split your time between clinical research, educational, admin work percentage wise? And I know all the panelists have probably very different percentages, but why did you choose to split it this way? And do you plan for this to change as you progress in your career? And I think Joy shared with us a little bit about her case. She's a very research oriented person and it may change. We don't know. It may definitely change as her career progresses. Anybody else who wants to tell us about their experience, deciding how clinical or research oriented you want it to be? I don't know, Maureen. I'm curious, or Joy, I'm curious. So being in private practice, right? By nature, I'm going to be clinical based, but because of my subspecialty focus and kind of my director role that was kind of created, you know, I'm pursuing a typical kind of interest, right? So, you know, my time, if you're looking at it from like an eight to five, it's mostly clinical. I do have some admin time, but I'm really spending time during lunch and sometimes after hours, not like inundating all my personal life, but I'm going, you know, out of my way to reach out to the residency program director at the hospital that I cover to get involved with GI education. You know, I'm seeking these opportunities to collaborate, you know, in research and review articles and, you know, this, right? These opportunities. So I just, from my perspective, I would say if your interests are like somewhat academic in a private practice, you can make those opportunities if your practice supports it. So when you're interviewing, ask those questions and kind of make that apparent that you have kind of those interests. And as long as they support it, then it's a win-win because I love doing all the things, you know, that I'm doing. Multitasker. Multitasker. Maureen, any other perspectives in terms of this? Yeah, so for me, it was easy. I don't enjoy research that much. So I knew I was, I'm just going to be honest, that I wanted to do clinical. I have like a master's in ed and I also really like medical education, but it is very hard to get protected time right off the bat for medical education. So I think, you know, as you, if you decide to, you know, you want to pursue advanced or like an APD position or a PD position, eventually you, you know, you can't start that right away from right out of fellowship but that's something that kind of, you could potentially get protected time for down the line. When you're first starting out and you're mostly clinical like myself, it's really just, you get your admin time and then you get endoscopy time and then the rest is clinical. And, you know, you kind of like my time that I'm using to kind of develop my med ed portfolio is usually just like either on my admin day or I'll, you know, block off stuff from time in clinic. So now it's kind of like you get a set schedule and I'm trying to like, you know, add things here and there. But I would imagine as you progress in your training, if you're someone who's medical education interested, that could change, but I don't know. Okay. No, that's great. So basically you negotiate your time depending on what your passions and dreams and, you know, objectives are early during your interview trail when you're looking for a job. Is that what everyone agrees on? Okay, wonderful. We have for everyone, when do you think the salary should play a role in your job selection? Just one person though, so that we can keep it coming, keep the questions coming. I think I would say that it depends on your goals, right? Like I said earlier, like identify if you're like, my mission is like, you know, I want to be in a big academic center where I can do specific research on this topic or build this very specific clinical niche. It's hard because, you know, you might be limited in terms of salary negotiations. You're like, you know, like, you know, I have, you know, whatever reasons you are, salary is important for you. I think it's an, I think it is an important factor. It should always be in, you know, don't undersell yourself, but some institutions have a fixed salaries, right? Like they, it's not like they're not being fair to you. They're just like, that's what it is. So if the salary is really important, that's not, that might not be the right fit for you because then you're not gonna be happy. But what I would say is that as long as you're willing to move, there is a right fit for you somewhere, right? That might not be where you are. It might not be where you're geographically, you know, you are, but there is the right job, the right salary, whatever exactly things you want, as long as you're open. But if you're, when you're geographically limited, then you have to be a little bit more, you know, then you kind of have to, I go back to what I said, identify your primary mission and then try to figure out you wanna get that. And if your primary mission is that, you know, like for whatever reason, salary is really a number one thing for you. Like it has to be a half a million or whatever, then that's fine. Then you negotiate that. And then, you know, you might get down, maybe you'll do a little bit extra clinical work than some of us and that's okay because you already identified. So it's kind of like, you know, there's, just like there's no perfect fellowship program, there is no perfect job. It doesn't exist, right? It's like eventually it's the perspective that we have. And as long as we're, I feel, I like to think about it. Am I happy 70% of the time what I'm doing? If that's the case, then that's the perfect fit for me because, you know, there's always gonna be small things and there's a room for improvement per se in anything you do in life. That's great. We have a couple of questions here. The last one that I saw, it was related, sorry, I just lost the question, but it was related for those, oh, I just found it. For those starting advanced endoscopy fellowship, when should the job search start? I think just like anything. That's what an academic center works. I think like anything. I think, again, like the sort of things we've, I think we've covered it intermittently. I know this is such an extensive topic about job search, but I think Josh said never too early. Identify what you really want, right? And for, I would say for advanced endoscopy, you know, if you have a niche in advanced endoscopy, like you really, really want to do third space, you really want to do bariatric endoscopy. You know, do they have the ability to support them? Are there bariatric surgeons willing for you to start a bariatric endoscopy program? You know, are your colorectal surgeons willing for you to start an ESD program? Are your thoracic surgeons willing to start a POM program? So making sure that you're going to a place which does spot your, meets the most premier niche that you have, right? Like I said earlier, there's, you know, no place is going to have everything. And then there's a little bit of a give and take. And slowly you, with time, you'll build it. And don't be in a rush to build any, like things take time. You know, people who've built big IBD careers or big esophagus or advanced, they have to spend their careers doing that, right? So it's a, the career is like a, it's a marathon. It's not a sprint. So pace yourself, you know, things go up and down. Sometimes you have better, you know, other things. So don't feel like it's, it's what, you know, that what you're, if you decided on niche today, you can't, can't change. I think as we discussed earlier. Awesome. There are very relevant questions here for academic people. Please comment on the initial job clinical instructor versus associate, assistant professor. Just curious, what's the actual difference? Thank you. I'll keep this super brief because it is very nuanced and annoying. Some places will have you run into a role of clinical instructor, clinical lecturer. It means absolutely nothing. I have the same salary and the same, I think, clinical respect. But the reason is to give some research people a little bit more runway time to get your first grants, at least where my center is. Once I get my first, once I get promoted assistant professor, I have X amount of years. And if I don't get the things like the metrics, I cannot be promoted or I have to leave or something dramatic. So it's to extend the time so you can get your grant and things like that. But it like reputation wise, it only confuses people. It actually doesn't mean anything in terms of pay or respect, I think. Wonderful. What is a good research time to ask if you have a research interest, especially when you don't have yet funding? If you're, I'll keep this short too. If your goal is to like write, like be federally funded NIH grants, the whole bit, you need a significant amount of protected research time to like write grants and things like that and do your research. So at least 50% research. So my institution for three years, I am 50% research, 50% clinical with the promise that I will deliver a federally funded grant. Once you have a federally funded grant or you become 75% research, 25% clinical. Some of the like ACG, AGA, some of those pre-development awards are like 50 to 75% research. So you need like a chunk of time. I miss clinical work still, but you have to ask for that. And so to kind of piggyback on the salary thing, at some certain jobs, you will have to be able to take a little bit less money because you're bringing less clinical revenue into that practice. You're completely unprotected. They're just floating on your dream. Fair enough. And we have two last questions because it's 825 and we will wrap this up at 830. Tips for managing your new income or salary, which is quite different from the fellow salary. A little different. I'll just say you can find a financial advisor. Luckily, one of my very close friends is one and I have no idea what I'm doing and he's helping me. Or if you have a significant other that has been making a healthy income for a longer time, obviously they'll be able to guide you or a parent or sibling, someone, but finding either an actual financial advisor or a financial advisor mentor, I think would be super helpful. Okay. Anybody else? Any other thoughts? Financial advisor, any other tips? Definitely a good one. I've heard that if you continue living within your means, like a trainee, you'll be super rich. You can find clothes on Amazon and Target. That's my two cents. Thank you. And then last question, and we always leave this for the last discussion, but I think we should start prioritizing these questions. How difficult was it to adjust your time for job and academic duties while also giving attention to your personal life and family duties when you became a faculty? So hard to not bring work home. It's okay. But if you really make it your point, like I don't, I finish my clinic, I give myself maybe an hour for inbox and I go home and I'm home. And if you, you know, you could check your inbox forever, give up the dream of inbox zero if you're comfortable with that. I love that. I love that advice. Because it's never, if you get it, it's a fleeting moment in time. And then you wake up to 40 results. You just, it's gonna happen. So I, you know, I started, we have like LPNs that kind of help with like patient messages just so that I don't miss anything. You know, if I'm like finishing clinic late and all of a sudden I see a message, a phone message from the day that was like, help, I'm having melanoma. And you're like, nobody called me about this patient. So you tell your support people, whether it's your assistant and RN and LPN, anything urgent, tell me in the day, call me, let me know because I've got a big inbox. I'm trying to get through it, but I might not get to the message till the end of the day. So that was like key for me. And just being efficient with notes. I used to pre-chart and then that, I felt like that was kind of a waste of time. So I even stopped doing that. So I'm like, really like try to be as focused as you can, spend as much time as you can with the patient. Dictate, dragging dictation, a godsend, I think. And that, and the inbox, because it'll haunt you. You'll wake up in the middle of the night trying to remember if you answered the last patient's message, but you have to set boundaries. Otherwise you're gonna be just on your computer and on Epic on your phone forever. Four hours. Yeah. Absolutely, absolutely. We have one more minute left. I just want to take some time to say thank you to all of you. This advice has been incredible, incredible. And we will be recorded on the ASG website. So fellows can still access this talk and follow your advice. Thank you so much. Any closing remarks from anyone, anything else that you want to share last minute? I'll just say thank you to ASG and thanks Danielle again for hosting. Good to see my colleagues on here. And I'd encourage anyone, please feel free to reach out to me if you have interest in private practice, if you have interest in IBD, happy to connect. And yeah, good luck with the job search. And again, ask for help. Thank you. You're not alone. That's all I'll say is you're not alone. Find peer mentors, friends, and talk to them. Everybody's going through the same questions, uncertainties. Always ask for help, always. And be humble. And thank you everyone for this opportunity to chat. It was great. It was. Thank you guys. Yeah, feel free to reach out anytime. Cold emails are actually scary to write, but you get answers. Thank you. Thank you so much. Thank you to the ASG as well. Have a good one. Bye bye. Thank you again to all our moderators and panelists for tonight's presentation. Before we close out, I just want to let the audience know to make sure to check out our upcoming ASG educational events. Registration is open. And a lot of these programs are available complimentary to our ASG training members. The next ASG Endo Hangout session will take place on Thursday, July 7th from 7 p.m. central time. At the conclusion of this webinar, you will receive a short survey and we would appreciate your feedback. Your experience with these learning events is important to ASGE. And we want to make sure we are offering interactive sessions that fit your educational needs. As a final reminder, ASG membership is only $25 for fellows. If you haven't joined yet, please contact our membership team and make sure to sign up. In closing, thank you again to all our panelists and moderators for making this excellent presentation. We hope this information has been useful. And with that, I conclude our presentation. Have a good night. Thank you.

junior faculty members

GI fellows

first job

comfort in new roles

board exams preparation

job opportunities

research and career development

mentorship

clinical preparedness

work-life balance

financial challenges

transition to a faculty position