Hello, and welcome to ASGE Endo Hangout 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, Advanced Endoscopy Fellowship. My name is Michael DeLutri, and I will be the facilitator for the 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 that this presentation is being recorded and will be posted to GILeap, ASGE's online learning platform. You will have ongoing access to the recording in GILeap as part of your registration. Now it is my pleasure to turn this over to one of our co-moderators, Dr. Satish from Baylor College of Medicine in Houston, Texas. Hi, everyone. Thank you for joining. So I'm just going to briefly introduce the moderators here. We have Dr. Girapinho, who's a director of Bariatric Endoscopy Fellowship and an assistant professor at the Brigham in Boston. We have Dr. Janka, who's here as an assistant professor of medicine at the Oregon Health and Science University in Portland, Oregon. And I'm Dr. Satish. I'm one of the assistant professors in medicine at Baylor College of Medicine in Houston. Our contact experts today include four excellent advanced endoscopists. We have Dr. Barron. He's the director of Advanced and Therapeutic Endoscopy and Advanced Endoscopy Fellowship. He's a professor of medicine at the University of North Carolina in Chapel Hill. We have Dr. Fukami, who's the director of Therapeutic Endoscopy and Advanced Endoscopy Fellowship, professor of medicine at the Mayo Clinic, Scottsdale, Arizona. Dr. Reem Shariah. She's the director of Endoscopy and Advanced Endoscopy Fellowship, associate professor of medicine at Weill Cornell in New York. And finally, Dr. Chris Thompson, who's the director of Endoscopy and Advanced Endoscopy Fellowship, professor of medicine at the Brigham in Boston as well. At this point, I'm going to hand it over to my co-moderators to go over the match results and a little more data about the advanced endoscopy match. So much, Dr. Satish, and welcome, everyone. We're very excited to have you here. So first, we're just going to go over the match result for the advanced endoscopy fellowship from the most recent year. As you can see, for 2024, in the left column, we had a total of 124 fellows applying for advanced endoscopy fellowship. And the positions, there were a total of 95 positions. So that came down to a matching rate of 62% for the fellows, which was slightly lower than the previous year. From a program standpoint, we have a total of 72 programs with a total of 87 positions for advanced endoscopy fellowship. And the position match for the programs was at 90%. For this year, I think most of you guys are going to be applying for the advanced endoscopy fellowship through the ASGE. So these are the important dates that you want to mark your calendar for. So number one, the application is going to be open on the ASGE website on January 13th. And then the application is due on February 24th. So you have about five weeks to complete the application. And then the interview season is going to be in the spring, starting in March, goes to until about May. And then you have to submit the rank list by June 20th. And then the results should come out in July. And last but not least, I would like to welcome all of you to our advanced endoscopy fellowship course. This is our flagship course. We focus on not just traditional EUS, ERCP. We're going to be having a lot of hands-on on interventional EUS, endobariatrics, third space endoscopy. For this coming year, it's going to be on September 13th to 14th. It's going to be in Chicago. And registration is free. So look out for the website to sign up. It's going to be coming out soon. Wonderful. So I think for the next hour or so, feel free to ask any questions to our experts. The goal here is that we would like this opportunity for you to ask any questions about the upcoming fellowship, application for advanced endoscopy, life during the fellowship, or even beyond fellowship. And we have four truly experts in advanced endoscopy here. I'm going to turn the mic to my co-moderators, Emily and Deepika, who are going to be asking some questions. And also, we're going to be monitoring the chat as well. So if you have any questions, feel free to send along our way. Hello. So should we start with some questions to the faculty? I think that sounds great, Emily. Let's do it. OK. So I have a few that I had sort of curated. So I can try to share that screen. Questions for faculty. These were sort of some open-ended questions that I had come up with, just kind of starting with how do I gauge if advanced endoscopy is a good fit for my lifestyle and for myself personally? So I don't know if one of the senior faculty want to take a stab at this. I'd be happy to start. I mean, I like to think that most people that gravitate toward advanced endoscopy are sort of wired in that direction that probably already have had an affiliation or feel that they're very comfortable with endoscopy, and they want to make that their primary interest. But obviously, part of it is not only doing as much endoscopy as you can when the opportunity arises, but also to shadow people that are doing advanced endoscopy to see as much as you can about the procedures, and if that's something that really lends itself to what you think you would like to do. And I think that's going back, what are the challenges post-fellowship, a lot of challenges post-fellowship, including how do you build a practice, which is probably the subject of several hours of, you know, when you go out, I think one of the biggest challenges, how do you, if you're not into a group, let's say, for example, you're hired as the index advanced endoscopist within a group that's trying to expand and offer advanced endoscopy, you know, one of the big challenges is if you're the only one there doing it, are you going to have the coverage that's available, or are you really going to be responsible for all of what happens with these patients? Because one thing I think people don't appreciate who think they like advanced endoscopy is they don't appreciate how difficult it is to manage complications. So we all see the good side of it. It's all fun and games, I say, until somebody has a severe complication and then their life can be drastically changed. So I think, you know, that's the other thing to think about is it is kind of cool, it's neat procedures, but, you know, do you have the, you know, the patients and do you, you know, how are you going to, how's that going to impact you? Because complications are going to arise. How are they going to be managed? Will you have the support in your group or in your hospital to do the kind of procedures that you may have been taught to do in an academic medical center? And that's just really, you know, my thoughts about touching the surface on these things. So there's some really good points. And I think one of the things that I really appreciate since I graduated fellowship with that transition is having the ownership of the patients. It's a blessing and a curse. You know, there's always going to be ups and downs, and sometimes it's very gratifying when you really help people and you feel this intense ownership, but you also have that responsibility to the patients. And so there is that other side that, again, we're often shielded from in fellowship, that when complications happen, it may be something that, you know, it's going to ruin your Friday night. If you're going out to dinner, if you had dinner plans, you know, having those, that discomfort, those feelings reflecting when things go wrong and having to deal with those complications. Yeah. Very good point. We have a question from Ahmed. Very great questions here. Very, very practical. So to the experts here, what do you look for in the recommendation letters for advanced endoscopy fellowship? And what makes an applicant stand out given that the season, the application season is coming up? I'm going to let Norio take that one. Thanks. That's a tough question. You know, I think if people look at it in different ways, but what I see first is after thinking about advanced endoscopy is endoscopic skill. How do they see you as the endoscopist? The second thing is how they're regarded from the other people. You know, the reputation, what the work ethics, and those are things I really look for. Many recommendation letters list, well, this fellow did a fantastic job, you know, just building up the CVs and did the multiple studies. That's great. I mean, that's sort of things we need to see, but we can see many of them through the CV and the publication itself. So recommendation letter touches on the personality, endoscopic skill, and the relationship with others. We're trying to figure out what the person looks like and how they're regarded in the institution. And you brought up a good point. So are you looking for a letter from like a colleague in advanced endoscopy field? Is that a requirement usually? It's not, but if you see the researcher, we did the research together. I see that his endoscopy is great. I don't take it as a great recommendation from his skills. If you see the advanced endoscopist saying this person has a great skill, I think there's some weight to it. What do you think of the panel, Todd, Emily? Yeah, I mean, honestly, I don't harp as much on purely endoscopic skill, because you've got to remember by the time people apply, they've really been only doing it for about a year, year and a half before they apply. So, you know, unless they really had two left feet, you really don't know what their trajectory is. Everybody's trajectory is a little bit different. And I tell the applicants, yes, it would be nice if you had a lot of ERCPs or EUSs before you get here. But, you know, really it's did they get the foundation of endoscopy? I agree with you. That's a nice thing to have in the letter is that this person seems natural with their hands, or they work very good, or they do have good endoscopic skills, but it's all very subjective. Again, you would like to think that if they get as far as they've gotten to this point, they're probably going to be reasonably skilled. You would hope that somebody would say, look, you're terrible at advanced endoscopy, but you want to, I mean, you're bad enough with regular endoscopy. You probably shouldn't do advanced endoscopy, but whether that happens in real life, I don't know. But I do think people self-select themselves for this. But, you know, again, we don't really have a metric that we can standardize endoscopic skill. I think having a letter from somebody that is obviously a common, that's a well-known name in the field, where if I have any hesitation, I feel like I could pick up the phone and talk to that person. That carries weight, having, again, somebody who's a well-known person in the field. I think Norio touched on it was, you know, if somebody is extremely hardworking, goes beyond, you know, the limits to do things and to help, and is a team player, I think, like you said, that's, you know, extremely important. The publications are varied because it depends on where the applicant is coming from and who was the mentor. Obviously, if you're in an institution where, you know, Chris is, people are going to get lots of opportunities for research. And then, so I kind of will look at, I look at the number of publications they have relative where I think, in other words, for some people, five or 10 publications might be monstrous if they're from an institution that has limited resources, right? So I try to take into account where they're coming from and what the opportunities they had and what they did with those opportunities to get to where they are. And then, you know, try to get a sense of how dedicated somebody really is to the field, which is really difficult, you know, and, you know, all, and everybody's going to say they want to do academic medicine. So when I do an interview, I literally say at the beginning of my interview, I'm not going to talk too much about what you want to do in the future. I'm not going to ask you the question because you're probably going to lie to me anyway, right? Because everybody knows, I do, I just tell them that, it's like, there's no other, you know, that's the way the system games it is that people have to say that they say, well, I'm going to go into, you know, private practice with my dad, you know, they're going to put you down there. So it's a game, right? People know what they need to say. For me, when I'm done with the interview, I look at it as, is this somebody that I would like to spend a year of my life with personally and whatever, and I can teach them best I can teach them and they're going to do with their life, what they're going to do with their life. And I can't really influence that. I can just try to make them the best that I think I can make them. But obviously, you know, a lot of things go into the selection process, the pedigree, where they went to college, where they went to medical school. Some of that really matters because if somebody has shown excellence and has been at a high level their entire career, obviously that's going to look better. But there's also people that have had trends where they started out slow and they proven they overcame a lot of really difficult, you know, situations to get to where they are. And that's can be impressive. There's a lot of things we look at, but honestly, part of it for me comes down now to my stage in life is, is this somebody I want to teach endoscopy to day in, day out and spend a year, you know, of my life with that person as well. But that's just my approach. I think it's probably changed over the years and it's probably different than other people's. Yeah, I think it's our fault doesn't make them, it may not be lie, but to force them to say, I want to go to academic. But one thing that I want to chime in is the, the, the experience EOS and ERCP experience is nothing, not impressed me at all. So if you have 150 ERCP during the GI fellowship, that probably would, you require, you acquire already the habit. This habit is so difficult to correct. So I don't want you to have ERCP too many, many opportunity to just do ERCPs, just, but honing the basic skill. That's, that's the most important part and GI fellowship. I agree. I think the, the key thing is not to be good at advanced endoscopy before you've done advanced endoscopy. That's the whole point of the fellowship is to know how to use a scope, know how to deal with complications, be confident with the colonoscopy and endoscopy skills, and use those first two years to really understand the scope itself, how to manipulate it, how to maneuver it and, and all of that. Cause that really, those key things come into play later on. And I agree with both what Todd and Noria were saying is that knowing what you know beforehand doesn't really matter in terms of endoscopy. And then in terms of research, I agree with you, Todd, it depends if they've done a lot of research at an institution where they don't have research, then that's fantastic. And it shows a lot of initiative versus if they're at the Brigham and haven't worked with Cy or Chris, then it's like questionable, whether they really want to do advanced. And then the question that Cy, you asked about whether or not they have an advanced letter, if they are doing advanced, they want to do advanced from the Brigham, but don't have a letter from both of you. It makes us question whether or not they became interested in advanced like two months ago, one month ago, and what happened in the last year and a half. That's my only other thing. Yeah, I would agree that if there are some people that just know, literally, or go into the field knowing they're going to do therapeutic endoscopy, if they've proven that at an early point of view, I agree that's much more impressive than if somebody had a bunch of hepatology or basic science publications, and then at the very end had one advanced endoscopy publication. And you're wondering, is that their true dedication to the field? Or is that, like you said, some people have a very reasonable excuse for that. But to me, that's a red flag, is if they weren't really dedicated to it early on in their training program. Yeah. Coming back to the size point, if you don't have the advanced endoscopist in the recommendation letter, we wonder what happened there. Because if you're interested in, you get to go to see those procedures, you develop the relationship. Naturally, there should be one, at least one letter from the advanced endoscopist. So we look for type of recommendation is mixed in. So it's a plus if you have advanced endoscopist in there. Yeah. Yeah. Thank you. That's very similar to our program as well. And I think that's a really good transition to one of the questions from the audience. Having a background in transplant hepatology while applying for advanced endoscopy, could that be seen as a negative? I'm seeing more and more of that trend. So what does everyone think? I can take it and sort of answer Todd's question again. It depends on how you spin it. So if you spin it in a way that you're interested, your career is going to be transplant hepatology and then do strictures and transplant, and that's your research and that's your ultimate aim in life, then that's a good fit versus if you, you know, if you have a if you did, and this is me being cynical, like a transplant year because you didn't get into advanced endoscopy and then doing that, then that's a little bit different. But I think there are more and more people like I know some of our fellows are interested in both and they've struggled to choose and they've decided to do a transplant this year and then they're going to see if they're still interested in like endo hepatology and transplants, and then they'll come to our side later on. And I think if that's really your interest, then you can create a whole niche for yourself. I mean, advanced endoscopy in a way is an evolving field. When we started, we didn't have bariatric endoscopy. There was no ESD only fellowship. There was no whatever. And now, you know, there are so many iterations of everything out there. So I don't see it as a negative as long as you know how to explain yourself. Yeah. Yeah. If somebody tells you, I'm going to say that's not going to, that's not going to work. Right. I mean, so you also have to know that ultimately what they're going to do if you train them translate to real practice. And we're very fortunate today because we have the true experts in interventional EUS, third space bariatric endoscopy. And we definitely are seeing more and more in the applications where fellows are expressing an interest in doing something in addition to EUS ERCP. So the question is, number one, do they need to know that coming in? And what about people who know that they want to do something extra, maybe third space or bariatric or interventional EUS, what would be your advice for them, given that you have only one year to train that fellow? I mean, I would say that it's really difficult to learn, you know, just for the audience. By this point, I guess people have realized that there are basically three major spheres of therapeutic endoscopy right now, and more and more to come, right? Sorry about that. Where did you lose me? Sorry about that. Yeah, very early. Oh, okay. All right. So, sorry, let me back up. I'm sorry, I didn't want to hog it, but basically for those out there, there are three major spheres, USCRCP predominant, bariatric predominant, third space slash resection predominant. So you have to figure out which of those major fields really, really speaks to you. Don't choose one because, yeah, that sounded good, or I heard somebody that you can get a better job with that skill, because you're not going to be really good at it. Choose something that really speaks to you that you think you could see yourself doing long term. Now, the chances you get all three of those in a year are almost zero. There are very few people that do all three of those spheres all the time and do it well. There's maybe a couple of people in the United States. So count on that you're going to do predominantly one of those three spheres, and really then you have to tailor where you're going to go based on where that training is predominantly given amongst those three things. Now, Hopkins obviously has a two-year program where you can do more, but I just think it's very difficult to learn all of therapeutic endoscopy in one year and be really good at it. Absolutely. I totally agree with you, Todd. Traditionally, all the fellows didn't want to do two years, and they wanted to finish in one year. They tried to do EUS, ERCP. Traditionally, ERCP only. Now, EUS is added, and they really struggled to get both of them really at the high level. So EUS comes along after you graduate, but it's okay, so they can get it done. When you add third space, bariatric endoscopy, all this complex, it's just almost impossible. I totally agree it's impossible. So you have to choose. I mean, there's no dedicated third space endoscopy fellowship except for, I know the three places, Todd, you guys have one too, right? Yeah, we have one. So about three programs, and the other programs combined, maybe one year, one and a half, or two years program. Johns Hopkins combined research as well. So it's not truly two years of clinical, but they added some research too. So you want to see what's the availability of the teachers in the institution to see where you can get the true education on those things. And EUS, ERCP is really a good training on third space, bariatrics, what kind of teacher you have, what's opportunities, annual labs, what kind of experience you can get. If you're interested, you have to ask for those questions, and you may want to omit one of them. So maybe if you're interested in third space bariatric, maybe just combine those two, or maybe some EUS and luminal EUS, and you may want to just omit ERCP. I mean, those are the possibilities to do in one year, but you really have to think two years program. One year here, second year there, two years would get you really, really far. So I would just recommend thinking about not one year, but two years in some way and sequence. Yeah. I'd also add that sometimes depends on where you go for your next job. If you go to an academic institution, for example, for me, I had one of the senior bariatrics endoscopist come and watch my first tour case. And you have that mentorship in academia. A little harder with, I'd say, third space, because you have to really dedicate time, and you have to probably... The two other people who joined at the same time at Baylor are training in a third space endoscopy, but they're using their admin day to go watch Dr. Othman do third space and get mentored by him. So it is possible, I think, to learn after, and maybe the experts can kind of talk about this, but it's definitely a little harder. You have to really dedicate your own time, which is hard when you're trying to build a practice as well. Yes. I think adopting new skills after fellowship is really difficult because our programs aren't really set up for training people post-training, right? We're used to setting up fellows who already have fellows. And as you said, if they want to do that, then they have to drop something and lose productivity. So it is very difficult to learn that. The other thing I wanted to emphasize is how I think variability... How much variability or how much variation there is amongst advanced endoscopy training programs, at least the way I see it. That's the way I perceive it. Now, can I tell you I've been to every one of these programs? The answer is no, but we've not really standardized anything in terms of how we train in advanced endoscopy. So your volumes are going to vary, the people that do them are going to vary in terms of their aggressiveness or non-aggressiveness. So you really have to try to pin down the place that will offer you what you're really looking for because there are variations. You need to know the numbers of procedures performed, the types of procedures that have been performed, the number of attendings that have performed these procedures, the numbers you're going to get out of these procedures. A lot of things go into where your decision is based on a lot of these things. So you really need to ask the questions about volume. Were the previous fellows happy? What became of the previous fellows when they were done? Doesn't necessarily mean that they have to go into academics, but yes, they got a good job at a good place. These kinds of things you really should ask as an applicant. I agree. And then I tend to also think that looking past our last maybe eight years, our pool of applicants, each applicant sort of excels in when they graduated, they graduated with different skill sets. So some graduated with foreign bariatric endoscopy, some with more third space, some with more EUS guided than others. And I think you'll realize what you're interested in or you know what you're interested in beforehand and that's what you can hone in on. And if you're, you know, blessed with amazing skills, you might graduate with even more than one skill set. And it's definitely possible. But the key thing is everyone's saying is that it never stops at the end of fellowship. I mean, we've all like I can look at all of us. We've learned more stuff out of fellowship than in fellowship because there are new devices, new procedures, new techniques, new disciplines that didn't necessarily exist before. So there's definitely a lot of opportunity out there. I can also say that I tell the fellows that what becomes of them long term is less on what I teach them that year as to what becomes of them after. Meaning, if you have the best fellow you've ever trained and they go to a place that does 50 or 100 of whatever a year, they're really, their skill set is really never going to be maximized, right? So your learning continues. And really it would becomes of you how good you get is what the opportunities you have for the next place that you go or maybe even next place after that that has the right mix of cases, the right volume of cases, the right mentorship, the right support to get you where you want to be long term. Even though the advanced fellowship is really important, it's what really becomes of you is where you go after you're done. Yeah, and that brought up a really good point. Like when you negotiate for your first job, right? Like you can potentially negotiate for protected time or like maybe some small funding so that you can go either at a local place or like at another place to pick up more skills if you did not get that opportunity during the fellowship. Let's see. I think we got a lot of great questions. There are a few questions on J-1. So how does everyone view applicants on a J-1 visa? If not favorably, what would you recommend they do? So maybe we'll start with that's your program. Take J-1 visa applicants. I can say that we don't, but there are. You should definitely look at the programs that do. They're like a bunch. They're probably like 10 or 7 in the country. I think the number keeps changing. So it's really important that you know that number off hand and apply to all of those off the bat. But Cornell, unfortunately, does not. Yeah, I think that's the same here. So not because I had a J-1 before. I'm more pro J-1. But to be fair, J-1 holders, they have worked a lot harder to get to where you are. And a lot of things shine on your CV. So don't be shy to be on J-1. Mayo Clinic accepts J-1. So we don't really look at the status of the citizenship J-1, H-1. It doesn't really matter. Your background, how you accomplish to be who you are is what we want to see. And frequently, the accomplishment is much more with the J-1 holders. Citizens have an excellent background as well. And they accomplish so much as well. So there's nothing inferior. The problem is the institution-wise, probably about 20, 25 maximum that accept J-1. Frequently, they come around. They know the numbers. They know which one accept. I think the information is circulating around. So you have to just look for the institution where they accept J-1. Thank you, Norio. And yes, similarly, like our program, unfortunately, doesn't take J-1. We are seeing more and more applicants who might take a few gap years to kind of like get rid of the J-1, the waiver. So that's a little unfortunate. Here, we're very fortunate to have a few female advanced endoscopists. So we have a question on what are your thoughts about women in advanced endoscopy? Do you think it's more difficult to manage having a family as an interventionalist versus a generalist? Why did you choose advanced endoscopy? I can maybe take a stab at part of this question. The family part of it is still a little bit too early. I need a couple more years before I start a family. So I can't really comment on that. In terms of why I chose advanced endoscopy, I mean, we kind of touched on a lot of these themes earlier. But just I really love the challenges, you know, the complexity of these cases. That was a big drawing point for me. And then in terms of the hours and difficulty, the perceived difficulty, maybe I'm just in a little bit of a bubble because I am at an academic institution. But I actually don't feel like it's much different in terms of work-life balance compared to my colleagues in general GI. You know, I think, you know, if you go to a place where they separate the call, they separate it so that therapeutics is different from general GI. You know, we don't go in overnight for the bleeders unless it's like, you know, an interventional related bleed. We're not going in overnight for routine food impactions or variceal bleeds. So I actually feel like the actual impact of call is much better compared to, you know, when I was a general GI fellow and seeing what the general GI colleagues are dealing with. So, and again, it's probably more relatable at an academic institution where you really have more faculty to divide the call. So we have a group of six of us in therapeutic GI. So we just, we don't take as much call. We do mostly outpatient and it's, to me, you know, we're done by five or six every day for the most part. On the West Coast, you know, maybe our hours are a little bit different than on the East Coast, but anesthesia won't let us start an inpatient after 3.30 p.m. So we're often done by five or six. So it's really, you know, in my experience, it's not that much different than general GI. I get to sleep, you know, 99% of the nights without getting paged in the middle of the night. I would, I would agree with almost everything you said, and not to sound particularly old, but I will, because it's the right time to be a therapeutic endoscopist. Because early on, if you were a therapeutic endoscopist 30 years ago, you took care of everything, right? Every bleeder and you worked frequently. It was difficult, but I agree with you 100% that you have the support, at least in academic, that there are levels that you almost know over the phone who needs a procedure, who doesn't, right? It's not like you have to go to the emergency room or that sort of thing. And then same as your place. Hepatology does a lot of their own. The luminal service does their own. And we just come in for advanced, like ERCP emergencies, which are really pretty uncommon. I always say the, there's the one word for work-life balance, and that's called anesthesia. Because when we used to give our own medication, we could work all day and all night without. A little bit, but yes, unless you're at a place where everything is so incentive-driven that everybody has revenue-driven and you do cases like some places do that are semi-hybrid sort of, you know, tertiary care, private practice, where that's their main drive is financial. Then they go later, but most places don't. Yeah. I can say that. Oh, sorry. Oh, I'm sorry. And just having now observed, like, obviously, you know, Kelly Hathorne joined our faculty. So I've been able to observe her to go through, you know, her two children and the time off and that sort of thing. I think the biggest thing is having, what I can see was when she had children early on, she was just getting her practice going. And then she had to sort of step back, obviously, to take care of her children before she came back. So it kind of interrupts the pattern of your work life, obviously. And it really depends on who your support partner is on the other side, if that person's really there to help you, that you're not feeling stressed both at work. But I think it clearly is more difficult, I think, for women in general, you know, certainly who want children. But I think the field is, we see more and more women in endoscopy, and we should. And I think there's, it's a really good trend that a lot of the people that we're training are women endoscopists. I will say the caveat is that our procedures, there is more at stake compared to our general GI colleagues. So for them, it's probably more predictable. You know, their 4 p.m. case usually is not going to run late. But for us, if we encounter, you know, a complication and we have to tie up, discharge the patient and talk in more detail about what we found in the procedure, I do sometimes feel like it's not quite as predictable. And we may end up dragging a little bit longer. But in general, I think it's a little blown out of proportion in terms of worrying about impact on work-life balance. And I think most people feel that radiation is, as long as you're safe with radiation exposure as a woman, and certainly also as a man or anybody should be radiation safe. But that it's, there's also, I've heard hesitation about, you know, having children and having the radiation exposure. But I think if that's all done in accordance with, you know, correctly, that's not a danger or risk. But I can certainly see how that would be a concern for some people. Yeah, and I kind of want to agree with what everyone else has said. I think really work-life balance is work-life balance with anything. It doesn't really have to do with advanced endoscopy, generally being a GI doctor or just generally being a working mom, so to speak. So I think what Todd said is important, sort of having a spouse on the other side that is very supportive. And then you'll know that there are weeks where you're going to be a good mom. And there are weeks when you're not going to be a good mom and you're going to miss other things, being on the field or being, missing like certain events at school. But overall, you'll manage to get the best out of both worlds. So I think I don't think there's any going to be any profession that's going to have the perfect mix. But I think as long as you love what you're doing, then it's all worth it. And that's kind of where I'm at with that, because at least I enjoy going to work and I'm not bored and every day is something different. And it's definitely very, very interesting. And some days I'm like, oh, my God, what am I doing? But it's always going to be a little bit of both. Yeah, it's yeah, it's less predictable for sure. The other the other thing, and every field has their own stress. I don't want to minimize that. Right. And everybody has their own stressors. But all of us that do advanced endoscopy know how stressful it can be, depending on, obviously, how the case is going. And you're dealing with intraprocedural difficulties and you're on your feet all day. And fortunately, thank goodness I've not had any repetitive injuries. But those are things to consider. The people who do high volumes of endoscopies, that it is it is physically and it can be mentally extremely stressful, especially when things don't go well or when you, again, cause complications. And, you know, those things can really weigh on you that I think people should at least consider that part of your life because that is going to be part of your life. In fact, I sat down with a surgeon I hadn't seen in a while. He came to our office. We talked about some cases. And I said, how's life? And he said, you know, it's pretty good. It'd be really good if I didn't have any complications. And that was coming from a surgeon. So he said, you know, he said to me, you appreciate that. And I said, of course, I appreciate it because we are in some ways who do very, very advanced therapeutic endoscopy are in a surgical field in a way. Right. And so a lot of those things, you don't really like surgeons, but then overall you realize that you become more and more like a surgeon over time. And the survey on the surgeon, they said about 30% get affected emotionally with the complications, about 5% stop doing the surgery. Once you have complication, we feel the same way. It's a lot of pressure on us. Yeah, absolutely. Yeah. I think, Todd, you're the most tolerable to the complications. You're very, very sturdy. Well, I mean, that has been my, I mean, that probably has more to do with my personality and me being in some ways a risk taker, but it doesn't mean that when things don't go well, it doesn't affect me as much. I just guess I'm, I'm always, it's all about risk benefit ratio. Right. And then I still try, even though some things can be really high risk, there still can be less overall better for the patient as crazy as that sounds. Right. And so I guess I've always pushed the envelope and I've things have worked out. Okay. You always, you know, centered for the best for the patient. So I appreciate that. I'd like to touch one more point about just women in endoscopy, the whole fluoro thing. I think it's totally up to you, what you'd like to do, you know, when that time comes about. So I know many women who have continued fluoro, double edded, gotten lead shields, whatever institution you join should be able to provide you, you know, the proper protective equipment. And then me personally, I decided to stop fluoro for my pregnancies. But, you know, it's totally a personal choice. And that's something you should ask when you're interviewing for jobs, like how to go about that, like how maybe you can take general GI call instead of advanced endoscopy call, you know, you can kind of negotiate that. But that shouldn't be a limitation in you doing advanced endoscopy, that's something you really like, I really wanted to do it. I enjoyed that and advanced in my general GI fellowship, which is why I applied for it. And you can always make it work, you know, there are opportunities everywhere. And one advice I remember getting as I graduated from fellowship was that for the first one to two years, you definitely do not want to be a hero, you don't want to be Chris Thompson or Todd Barron, you know, because you don't want to have that complication, that one that is going to scar you. And that's going to affect your advanced endoscopy career. So you took that advice pretty seriously. And then after two years, that's when you started doing more and more invasive procedures. Along the injury theme. So one question come from the attendees. Thank you all for the insights. What do you think is the average length of an advanced endoscopy business career given the risk of endoscopy related injuries with aging? I mean, I'm certainly wearing lead continuously for this many years is probably, I mean, I've fortunately, I've taken care of myself and I work out, I think that's important is you have to be in good physical shape to have a long endoscopic career and probably a long life as well. But I mean, unfortunately, the lead is also getting a little bit lighter, but there's neck injuries and things like that. But I mean, I've been doing it now for 30 something years, and I still love doing it, you know. Yeah, I recently had this spine surgery as well, and they don't know exactly whether it is related to the endoscopic posture, but you know, they speculate that it is. So the lead, the knee is going to be hurting, back is hurting. It's similar to all the surgeons, they do the same posture for hours. So it's really important to think about ergonomics. And many of the EST persons start doing the EST in a sitting position. I'm not getting used to it, but I think those, the modifications are important. As Todd said, if you're really being careful, proactive, exercising, staying in a healthy lifestyle, the longevity is really long. But, you know, I don't know how long. It's an interesting thing, though, because at some point you do realize, and this is a totally separate discussion, right, that just like you, eventually I won't be able to drive, right? So at what point is it that you sort of start to plateau and you go the other way and you hear stories about surgeons who operated too long in their last two or three years, or their worst years and things like that. And that's the discussion that's way beyond where the fellows are right now, but it's something to, I think, I think that certainly my point is, I think you can have a long career doing this and not be injured, but it's, it is certainly a risk of, you know, hands risk. I know people have had all kinds of wrist injuries and thumb injuries and things like that. And it's something we probably have, but don't emphasize enough in training. Like I don't think about and tell people, oh, you should do this, that, or the other, but I mean, it's out there. It's just, we don't necessarily follow it, I think. Totally. We have this question. I think this is a good one for Reem. I have my personal opinion as well, but for applicants interested in both bariatric endoscopy and advanced endoscopy, what pathway would you recommend? Handful of programs have dedicated bariatric endoscopy exposure. Do you suggest advanced training before bariatric or vice versa? I think that's a good question. And I think it continues to evolve. Obviously, certain institutions have a purely dedicated bariatric fellowship. And I think it's important when you're doing bariatric fellowship is not just to do bariatric endoscopy, but to learn the obesity parts. And that's where a dedicated fellowship is important because you work with the endocrine people, you learn the medications, you learn the intricacies of medications, which is not just ozempic. And I think that's where that comes into play. There are some bariatric endoscopists who don't do advanced endoscopy. Having said that, it'll be interesting to see where the field might take us because there are more and more devices that may need some interventional type skill sets. And so, I think that's important. And then also, so I think that's still changing. At the moment, it doesn't. But maybe in the future, it would be advantageous. Sai, what do you think? No, I totally agree. I mean, I am advocating for both bariatric plus advanced endoscopy mainly due to that reason where I feel like we're going to have more procedures that are fluoroscopy based in terms of sequence. I have a feeling that if you can choose, sometimes you cannot choose. Doing bariatric first before advanced endoscopy seems to work well because I feel like for suturing, once you get to like 50, 100 suturing cases, you kind of like get above that huge threshold based on your paper and from my personal experience. But for ERCP, I feel like your number needs to be much higher. And then during the first year, one-year fellowship, you're not going to get over that hump yet. So, if you do bariatric first, get that number in and then do EUS-ERCP and then keep doing ERCP during your first year faculty, I feel like that's a nice progression in terms of technical skills. Yeah. Awesome. Maybe we'll change gears and go back to application-based questions because I think a lot of people are anxious about the upcoming application. So, when you look at the CV, what are the key components of the CV? Where do your eyes go first? I can say it goes through the hobbies. Because you've read so many CVs, a lot of them by the time they get to you, I mean, are you talking at the time of the interview or before when you're trying to sift through them? I think sifting through them and then interview is very different. Sifting through them, you're looking at what Todd was saying, the pedigree, the letters of recommendation, who the letters are from, what you've done in your fellowship, do you have a good story that gets you there? And a lot of them come from... And then I, maybe like Norio, have a bias against just pure good pedigree because sometimes you've worked really hard to get in but just don't have the opportunity or an FMG and then it's just been that much harder, but you've worked your way, you've gotten like 300 publications because you've done really well in wherever you've had the opportunity. So I would give that person, again, you can tell from the CV. From an interview perspective, like Todd and Norio both said, people lie or people not necessarily lie, but you have the general like, I am interested in academic medicine, I am interested... The new thing, I think, for General GI Fellowship was education. And it's funny because everyone says the same thing. So then I try and see a little bit something different. And so I go to the hobbies and sometimes there are weird and wonderful hobbies like making flowers out of Lego. And because everything is Zoom, I'm like, oh, show me. And so it just depends because you also want that interaction because you know you're going to spend a year with them. So they have to be able to understand that like my sense of humor might not appeal to everyone, but they're going to spend like three days a week with me, so they better also like me as much. So I don't know, that's my... What you put on your CV is fair game, basically. Yeah. I mean, we've all seen like the... It's just like any other personal statement, whether it's your personal statement for medical school residency or anything else. I mean, as long as you don't really say something just totally egregious and embarrassing, it's probably not going to make a huge difference, right? Unless there's something just amazing in their life that's true and unbelievable that you really need to hear, right? But most of the letters, that part of it, the personal statement, I mean, be honest, be thoughtful. What is it that really drove you to this? And most people will obviously do that. But again, it's going to be come down to what did you do? How did you get there? Personal story. So there's not a one size fits all for a lot of these. I mean, for any of these. And in a way, it's sort of a crapshoot, right? I mean, you don't know and they don't know exactly what they're getting. You don't know what you're getting until you get them, right? And vice versa. And all you can hope is that the delta between what they think and that delta to what you think are not too far apart. And then it's a good year. It's so funny to really look at the interest, but I look at it in a regular way, to look at the picture, actually, to see who they look like. But at the same time, what the dress looks like, the arrangement. If I see the picture with, you know, went to the vacation, that's kind of, oh, this is kind of relaxed person, but it may not be just too formal, appropriately formal. Having said that, I just want to say something. I think Sai's current fellow, and I kept bringing it up, his interview, he was wearing a bow tie. His picture on the application was a bow tie. And it's so memorable that I remember it to this day, because he was just wearing a bow tie. And I was like, what are you doing? But it's... Yeah. Maybe bow tie is the way to go then. That's awesome. Yeah. Usually I go through what people went through, the college, what they measured in, and then they went, just all this sequence. And I tried to see any of the gaps, to see what the sequence happened. If there's a gap, I want to know what happened. And then I want to see if it explains the personal statement. Sometimes there's a gap here, right? For some reason. It could be explained. So I want to know. Yeah. I want to know if they've been in jail for a couple of years. Sure. So, the other thing we look at, which I look at in faculty right away, is their abstract to publication ratio, right? Because it's very easy to write an abstract, even at this stage. And did you actually get that from abstract to publication is an important step, or are you working on publications? And if it is, what did you actually do? Were you just somebody that got the day together and everybody else had the idea, or was it really your idea for your project? It's going to be obviously much more impressive if... It's impressive enough if I give somebody a huge project and they run with it. I'll say in my letter, they are working on this project, I gave them the idea, but they've done all the background, they've done the first draft, they've done blah, blah, blah, blah. And I will do that in my letter if they really did a really good job in research. And likewise, they should be able to demonstrate that they were really involved with these papers and not, oh, their name was fourth on it because their dog came in and did something on the paper form or whatever, I don't know. I mean, did they substantially contribute to these papers? And if so, how so? And can they talk about it? And during the interview in a way that you say, yes, they actually understood what they were doing and they did the work. That's more important than showing me that your name was on 30 papers, but you're always in the middle somewhere, which means you probably didn't do a whole lot versus you were the first author of the paper. Those things I think are more important. And along that line, one thing that some fellows do that I think is a red flag is when they put abstracts under the publication section. When you present it at DDW, you might get like GIE AB 301 or whatever, and then you kind of like hide that within your true publication. We don't like that. So separate those two from each other. Yeah. As Todd said, we talk about many times about abstract to paper ratio, how many of the abstract actually went to the publication as academic achievement. So that's an important thing. And then if they have a first author paper, we always ask question about, so how did it came about? What's the contribution? What you think about? What you take out of it? Yeah. If you do research, you really should be as involved as you possibly can. Try to work in where you can work with somebody where you're the first author, meaning you did really all the work and you really can present that as something you truly worked on, were a part of substantially, and you can interact and talk the lingo of what it is that you're doing. There's another question, a good one, and I know pretty popular question as well. So good evening, what pathway the panel would suggest for someone who wants to learn and practice third space endoscopy? There are very few dedicated third space or tissue recession fellowship programs. Would the panel suggest doing a third space fellowship program after pancreatobiliary fellowship? Well, again, it depends on what you're really going to do with your life when you're done. And do you think you're going to have enough volume to do those and be good enough at both of those when you're done? So you don't just add degrees just to show that you can do that so you can get a better job. It's can you A, can you pull it off and B, are you really going to be able to do that for volume of cases for both fields? Because I don't see a lot of people that do pancreaticobiliary ERCP US and third space, although it's becoming more and more common just because we're getting more third space. There may not be, I think if you're interested in doing third space and you can't match, and that's something you want to do, then you're really going to have to go to probably to another country. You're going to have to do lots of animal labs. You're going to have to have a proctorship. You're going to have a lot of things to overcome if you don't do specifically a training in third space endoscopy and successfully do that. It's a field unto itself that I basically don't do and my colleagues do, and I'm okay with that. And they don't do ERCP US and they're okay with that. So it depends on, again, where you're going and are you going to be able to conquer and do all those things when you get there? It's nice to say you can do everything, but all of us have really learned that it's okay to say you can't do everything because really what you want to do, you want to do it well. You don't want to just say you do everything. You want to do whatever you're going to do to the highest ability that you can do. And it's hard to do that with so many different, again, the field is just now so wide open that you can't really know everything. So, yeah, we have a dedicated Illumina fellowship. We don't really mind having a fresh out of GF fellowship to come into the fellowship. We don't require ERCP US training beforehand. That would be plus because they know how to maneuver a little more carefully and very skillfully, but you can learn that over the time. So it's not a must to do ERCP US first. It would be nice to do if you want to, if you're interested in, and many people feel like ERCP is the needed skill to be marketable, to get the job. However, I'm seeing so many requests to have somebody who has a third space endoscopy skill. So that can be your niche and it can be a selling point. You have to be able to love what you do. As everybody's alluding to, you have to love what you're doing. So you have to be dedicated to third space all the time, then being happy. That's great. If you learn US ERCP third space, if you don't do ERCP, you don't need to do ERCP. If you don't do ERCP, you get, you feel like you're missing something and that's going to be a kind of challenge. So you may want to dedicate to third space. If you love taking care of the tumors, diagnosing early cancers, helping those patients, I think you should just dedicate to that pathway. The dedicated program has its benefit. We have a background of training people as well as we have access to animal lab. We have industry supports. We have industry relationship. We know how to build the program. We have those know-how, you know, billing part to just have a little tweak you can do. And eventually third space is going to be more standardized, billable service. And the market's going to open much wider. So think about what you like to do, what kind of disease process you like to do. I frequently tell people that I get so many appreciation letter, thank you letter from third space patients. I never get the patient from where, when I removed the stones, maybe Todd, you deal with the really difficult stones, but SOD patient, they never thank you. I get bombs put in my mailbox. And Nouriel, for your third space fellowship, do you teach diagnostic endoscopy as part of that fellowship too? Absolutely. I mean, that is the basic skill. So I emphasize the basic skill, diagnostic endoscopy and the polypectomy as well. So our program include a luminal intervention, including a high quality EMR and also the stents and we're incorporating a luminal EOS as well. And remind me, I believe that your third space endoscopy fellowship right now is within the ASGE match and that might be the only program right now. I think most other programs are outside the ASGE match and similar to our bariatric fellowship. Maybe. I mean, I know that Juha took, he was planning to take his own fellow as a second year advanced fellow. I don't know, Todd, your institution is not participating in match? Well, we've only had two and so far they've been out of the match, yeah. I think it can be a trend as well, unfortunately, because you have to know who you're going to train. And I don't want to sound negative, but if you apply both, I tend to feel like, okay, you don't know what you're doing. You don't know what you want to do. So I tend to just get off, put it by that. Yeah, I agree. There's a few questions here about how many years applying post-fellowship does the application count against you? If you take three gap years, does that count against you? Quite a few questions. I mean, again, it depends on what you did in those three years and what you can account for, and then why did you come back to where you are and what have you done since you made that transition to demonstrate that you're really sincere about pursuing that, not just, well, I need it for my practice that I came from so I can go back to my practice and do it. You know, what is the real story, how dedicated are you? When you're done, now what are you going to do? Are you going to go back to where you were? And if you do, that's fine. How many are you going to do? Because you should know by now, you know, that kind of thing. So I really think it just really depends on the whole package of what the story is and why they took the time off or what made them decide that this was the better place to be and do. So what are the current job market trends for advanced endoscopists and what's the future? Really, that's mine? Okay, for anyone. The current advanced endoscopist, I think that continues to change. I think there are less positions in academic places, although having said that, people keep changing every year. In New York, we've had a lot of change in the last year and I think it keeps changing. I think you think you're going to one institution to work with a certain person and that may not necessarily be that way. Again, it's really knowing, I think the key take home is not to look at the current market because your next job might not be your final job. And so if you don't land it where you want to, you'll get that job later on. And most people move at least three times in their throughout their career before settling down. And so it's never one and done. And so I wouldn't look at that market trajectory as a way of sort of saying, should I go into advanced or not? Because you can go into advanced and may not do advanced, or you can go into advanced and then find your niche in a certain particular field in that. I'm changing the question slightly. No, I agree with you 100%. I think none of us really know where the future is other than the future is really, there's no reason to believe the expansion we've seen in the last 30 years is going to continue. A lot of us, other than Norio, didn't see third space coming the way it did. I mean, so that was a brand new field and now it's mainstream, right? So we can't, there's something, there's things that are coming. We just, you know, if we knew we'd probably already have won the lottery and done something else, but I can tell you that I think there's nothing but positive things. It's not like if you go into advanced endoscopy, you're going to be out of a job. I don't see that as happening. I don't think AI is going to take over what you're doing, not in your lifetime until we get robots to do ERCP and things like that. So, you know, I think there's, the field is really growing. I can't, I don't, I haven't been out in the marketplace. I don't really know what it is. I do know that more and more we're trickling, we're trickling out from programs up here into the community. And that's just the way it goes. For example, you know, most places do percutaneous work and they should, but that wasn't always the case. And I think at some point, almost every hospital is going to have an endoscopist who does some form of US or ERCP. And I think, you know, resection, all those things I think will be spreading into the community at some point if they haven't already in a lot of ways. So I think it's, it's, it's, it's, it's a field that's still very, you know, much worth going into. Again, I can't tell you the exact marketplaces. I don't really deal with that. Should we move on to what questions should we ask from the program during interviews? And this could be either to the fellows, the current fellows, or to the, the people interviewing you, the faculty. Well, you should definitely get some alone time or people should be very happy to have you speak to their current fellow in terms of what their experience was. And without any interference with that conversation, that's something that we do. And we don't want to know what they ask. We tell them it's to just be honest with what they like. And so I think that's, you know, obviously a really big thing. You can expect all the questions that you normally think you're going to get as to what got you here, what makes you different? What are your, you know, hobbies? What do you like? What do you don't like? I mean, pretty much, you know, any, any, any normal conversation is going to come up. What do you see yourself five years from now as a common one? What are you going to do when you're done? You know, tell me about such and such a project. Were you on it? What did you do? What do you know about it? I mean, any of those questions are certainly, you know, common and fair game. But are there particular questions that applicants should be asking the current fellows? Yeah. You know, you know, did you have opportunities to do research or video publications if that's something you really wanted to do? You know, are the faculty supportive of you? Do you feel like if you have questions, you always get answers that are people are open and available to help you? I think those are things. What are the numbers that you're doing? You know, do you anticipate any changes in the program in the next, by the time I get here? So you may have heard a rumor, you know, Todd Barron's retiring. You may want to say, are you retiring? Are you still going to be here by the time I'm done? The answer is yes for right now. No, I mean, those are, those are things like, no, but other things you might've heard. Somebody is going to get recruited and go to another place, whether young, old, or whatever it is, you know, you want to know that the, that there's going to be stability in the program. Are there any internal conflicts with, I mean, it's hard to ask this question. I think it's important is, is, you know, how do people get along within the group? Because there are some places where you don't know until you get there that three attendings can't stand each other and they hate each other. And nobody told you that. And then you're in the middle of something that's uncomfortable. I've heard those things. So, you know, try to talk to as many former, not only the fellow that's there, the former fellows, if you can. The other thing that's always impressive as an applicant is to know when you get an interview, who it is you're talking to and what they've done. And you don't have to do it like in a, in a kiss ass sort of way. You can be very genuine about it. But it always impresses me that people will pull out something from 25 years ago that I did, you know, it's just like, if I know something about them, it makes an impact the same way it does if they know something about me. So I think that's, that's an important thing that I, that I've, I don't, I'm not saying I always look for it, but I'm always pleasantly surprised when people either say something or I'm like, wow, they really did their homework and they know something about this or that, that, that they wouldn't have known. So that puts in, they put in the effort to know the people they're talking to, you know, I think that's important. We have one question here. What advice do you have for a fellow who's trying to match into a competitive program from a rural program with limited research experience? I would, if that person can, can somehow engage with somebody in academics, I think that'd be really, really helpful. I've helped a couple people. I was in Rochester and I had at least two people that were in a small place in Iowa that were foreign grads that had to go and do rural medicine. And they drove to Mayo, they'd spend weekends, they'd spend days going through data that I would give them. And I would write that they, they were very passionate and I wrote them really, really good letters. And they, they, they showed, you know, they would drive three hours in the snow to get there and stay a week. And so there are ways that you can do it and connect if you can find the right people that are in academics that can also help you from, from a place where there aren't people that are well known. It doesn't always work out, but I think a lot of us are there that can help people that, that, you know, or have work of people that can mean work, meaning we have some data, we have things we, we can get them involved with, but that's something we want to do. And we have the opportunity to help other people. Yeah, I'm totally echoing that. I remember like this one fellow actually came from a very small program, but actually he had publications with both of you, Todd and Reem. So I just gave him like extra points. So I think that shows. I think it's exactly what you said is true. You have to reach out to some other areas because you have limited resources. The effort reflect on, on what you did in CV, you know, working with the more bigger centers, just collaborate or seek out the opportunity to work with Dr. Barron Reem and all these things would add up. So just seek out to see if you can do that way elective work with other centers, you know, do the collaborative multi-center studied. That'll be probably the, the best way to handle the situation, the limited resources. I think that might be a good segue to one of the questions somebody asked about letters of rec and how important it is to get a letter of rec from somebody who's very well known across the country versus someone that you've worked with, maybe just research, how you guys recommend distributing your letters of rec? Like if you're an applicant asking the faculty. Well, I mean, you know, it's, it's obvious that, that, that the more the person you're asking is more, more, the most, you know, more and more notable in the field and people know their reputation. So that when they say something about an individual, you know, that, you know, what they're talking about and you can relate to it. It's always better to have a letter from somebody, you know, than somebody you don't know. So I think that people should try to get a letter if they can with somebody, certainly that does advanced endoscopy in the field, then you can only ask people that you're exposed to. Now you can always, you know, there are some places where you can, if you can take a month out during your fellowship, you can visit a program and do nothing but observe, ask questions. Let's say you wanted to work with Norio and they let you do some sort of elective and you went and followed them around for a month. I'm sure it wouldn't hurt your chances of getting in and at least working with Norio. So I think that's another, you know, potential opportunity. Not everybody's open-minded or has an open door policy, but the worst they can do is say no. And you can reach out to people. If you can make yourself available a week, two weeks, whatever, that's also can be extremely helpful because when you apply, you have a name and a face and somebody you've known, it's just like doing when you were doing sub-eyes, you know, trying to get in an internal medicine, you want a way to work. You can do similar, people don't realize you can do that, I think in endoscopy. I'm not sure if you can share this, but there's a question on how do you rank your applicants when it comes to a rank list? What criteria do you look at? Is there any scoring system that you use for your program? So you know those things they have in the lottery? We take all their names and we just jump, no. Do you look at the hobbies or pictures? No, so obviously not one person makes the decision in our group. We have six or seven, we used to have more than almost 10 people. And a lot of them were not anything to do with advanced endoscopy. Nick Shaheen, who was our division director, would still interview them. Our fellowship director who didn't do advanced endoscopy would interview them. And yes, we had a scoring system that was based on their overall, I guess what we were talking about earlier was their pedigree. I think we had questions about, you know, what's their future potential in academic medicine? You know, I can't, now I'm trying to remember, but there's like categories of things. You rate people from one to five, and then you generate a number. Nobody else can see what you did. Then you get a mean, it gets splayed out. And then everybody that, the main people that are involved in our program, the therapeutic endoscopists have then cleaned down everybody else's numbers. And we sit down and we say, okay, we all agree that person's number one, they have the highest scores. If somebody else says, yeah, but I heard this and the other. So you may jostle the positions based on just sitting around and talking about it and going back over their CVs because the first time you were too lazy when you interviewed them to actually look at everything. Did I say that out loud? Then you have to go back, actually figure out and to ask some of the same questions. And then you may call somebody up and say, hey, we're really thinking about this person. Did you, when you said this on that, did you really mean it? You know, blah, blah, blah. So we go through a process, you know, somebody gets a huge number, then gets them to a reasonable number. Then we pair them down to the number we interview. Then we do what you said and have a numerical thing. And then we talk it out and figure out who we're going to take. We did it pretty much similar way. We just collective thoughts. We share the information that some information we don't get, the other person will get it out from the applicant. So we put all this information, discuss how we want to rank. And then, of course, there's some part of this, how much you want to support to the goal that the applicant expressed. I want to achieve this. And some people will feel really compelled to support that cause. So that may be another point as well. Yeah. And then sometimes we get a phone call from people like Chris Thompson, right? Who says, hey, you know, so-and-so interviewed and I don't know where you're going to put him, but I thought he was the best person. So that'll influence what you end up doing. If somebody reaches out to me directly that I respect and know, and then says, really, you really should take this person, we may change where we rank them based on that too. That doesn't always happen. Yeah. That part, it happens to the interview list, but it doesn't affect the ranking list though. Right. So we, we do something similar, but we do have a field for, you know, so we're trying to be as objective as possible. So all of those are very objective one to five scale, you know, how many publications they have, how many, how much exposure to advanced endoscopy do they have, you know, stuff like that. And then we do have that one that's more subjective is kind of, you know, how the interview go and then the quality of the letters. And I think in the quality of letters, that spectrum includes if people actually reach out proactively, it gets an extra point for that. So I think it's important to encourage your, your mentors and the people that are supporting you to reach out. If you're really interested in that particular program, you don't want them calling all the programs that wouldn't, that wouldn't be good. Yeah. That's the other thing, by the way, do not tell every place you're going to rank that you're going to rank them number one. That's the pet peeve of everybody that's in this room, whether they want to tell you or not. And we've all seen it where they tell every program, you're the place I want to go. If you're interested, you can say, I'm going to rank you very highly. And we say the same thing. If you really think you're going to go there and you can look yourself in the mirror and say, that's the place I really want to go. You can say it, but don't, you know, it comes around. It's a small world, people talk and that stuff, believe it or not, it can stick in your career. Cause I know I've, there's some people I don't even talk to anymore. It is a very small world, you know, having gone through this process three years ago or so. I remember after I did a zoom interview, one of my mentors would tell me, oh, someone so reached out to me and said, you interviewed, it was like super random that it was like, oh, I didn't know they would have spoken with you. So it's a very small world. Interventional in particular. Yes. I think we're almost out of time here, but a couple of questions just regarding, is this going to be in-person virtual or hybrid interviews this year? We, since the pandemic, we've gone all virtual. I personally offer, and I think I'm the only one that does it, even in anybody in our group that if they want to come and visit that I will host them for one or two days and they can see what they're going to get themselves into. If they think it's going to clearly make a difference, but we've really gone purely virtual otherwise. Yeah, same. We've done virtual, but we've offered, people are interested and they they're more than welcome to come. I know that university of Chicago has done it in person, at least last year. I don't know if they've changed, but all general GI has been virtual. So I don't know if we'll end up ever changing to fully in person. The virtual in-person, they have both benefits and shortcomings. The virtual, you can get really a lot of good candidates because the schedule is flexible, but at the same time, we don't get the feel and they don't get the feel of the institution as well. So we're debating, Mayo Clinic is open to going either, or you can choose full in person or full virtual. You cannot mix match. And the site visits are only offered after the ranking is done because we don't want to influence that. If they want to know the location, you can come after the interview, after we rank them because that shouldn't be affecting the candidates. So I think we went over a lot of topics from preparing for the application to life after advanced endoscopy fellowship. I'd like to take this opportunity to thank all of our experts and co-moderators. It's been a wonderful experience. Hopefully most of you get a lot of your questions answered. A few things to remind you, January, the application is open and then it's closed in February. We look forward to seeing most of you during the interviews. If you have further questions, feel free to email Michael, and then we'll try to get those questions answered offline. So now I just want to basically send it back to Michael, who's going to close the program tonight. Thank you very much. I want to thank all of our co-directors and co-moderators and to our content experts for tonight's amazing presentation. Before we close out, I want to let the audience know, please go check out our upcoming ASGE educational events and to register. Visit the ASGE website and check out our lineup for the 2025 ASGE events. Our next endo hangout, Can GI Do That? Understanding Interventional EUS Third Space Endoscopy will take place on Thursday, February 20th, 2025 from 7 to 8 30 p.m. Central Time. Registration is open. 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. We want to make sure we offer interactive sessions that fit your educational needs. As a final reminder, ASGE trainee membership for fellows is only $25 per year. If you haven't joined yet, please contact our membership team or go to our website and sign up today. In closing, thank you again to our presenters for this excellent webinar and thank you to our audience for making this session interactive. We hope this information has been useful to you. And with that, I will conclude our presentation. Have a wonderful night.

Advanced Endoscopy Fellowship

GI Fellows

ASGE Endo Hangout

Dr. Michael DeLutri

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match results

endoscopic skill

work-life balance

ergonomics

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virtual interviews

third-space endoscopy