Okay, so for the next 20 minutes or so we'll have a Q&A session, and I guess I'll start us off. This is a question primarily for Olaya, but also a comment about aspirin use in endoscopic practice. I think it is important to reinforce that cessation of aspirin in most patients is not necessary and not worthwhile. And we looked at this at MUSC, and this is actually a much bigger problem than just sort of at the provider level. There's a cultural enterprise change around aspirin that's a big problem. So often administrators and nursing staff and schedulers still have that sort of embedded in their mind, and it takes a lot of active work to reverse that. And beyond this, we found that patients often do this under their own volition because of that sort of misconception that aspirin and endospirin, any interventional procedure, is problematic. So there needs to be an active education against cessation of aspirin in most of these patients. Olaya, in your practice, have you noticed that people have stopped aspirin on their own or that sort of non-medical providers have done that? Yes, and a lot of the times their primary care actually has asked them to stop the aspirin. And we need to really change this culture, and we need to start with ourselves because we already know that stopping cardioprotective aspirin increases the risk of either stent thrombosis and all-cause mortality in high-risk individuals. And we already also know that the risk of bleeding from endoscopy, except those four conditions I mentioned, is very, very low. And in the high-risk conditions like cavity or ampulectomy or any ESD, you again need to weigh risk and benefit of stopping the aspirin. But current recommendations do say that in these four scenarios, it will be indicated to stop the aspirin and resume it as soon as feasible, and of course within seven days because that's where the highest risk happens. That was wonderful. Thank you. Dr. May, may I ask you a question? What advice do you have for us gastroenterologists who are practicing? What can we do to address the concerns that our underrepresented patients have, and how can we help them? Absolutely. Thank you for that question. You know, I really think that we need to listen to patients more. I think that, and part of it is not our fault. We have very short time with patients, and we recognize that that's the reality of patient care now. But every patient's concern is different. I think sometimes I even make assumptions. I look at a patient and I say, I know why this patient doesn't want to do this. But if I stop myself and I say, what is really going on? What is the reason why you're so hesitant about this clinically indicated evidence-based recommendation that I'm giving you? I'm kind of surprised sometimes the things that they'll say. So it's about correcting that misinformation. And there's a lot of parallels to COVID-19 and the COVID vaccine. But I think we can learn from that that we can build trust with patients when we listen, and we can many times correct some of the misinformation or misunderstandings they have about these clinically indicated interventions that can be lifesaving. Thank you. And some of this, in all honesty, comes back to a concept that I'm going to ask Megan about, which is this sort of concept of being really nice to patients. And so I know, Megan, I hope you are on with us. But you had discussed the importance of clear communication with patients. And of course, that's critical. But are there any data? Because as somebody who does a reasonable amount of medical malpractice defense, my observation has been that it's that human element of interacting and being really kind and empathetic with patients that seems, at least in my observation, to be the most protective against medical legal action. So Megan, are there any data around sort of those human elements of how physicians interact with patients? And is it something that is intrinsic? Or is it something that can be either learned or at the very least faked? Thanks, Joe. Yeah, I can hear you. So I don't know about any studies that I can, you know, cite specifically in that area. I'm sure that there have been some kind of more broadly in terms of, you know, the importance of kind of bedside manner in communicating with physician, I mean, with patients, excuse me. You know, one of the things that I think is challenging for us as endoscopists is, you know, particularly with open access endoscopy, we're really meeting the patient for the first time on the day of the endoscopy. And because of the way in which our sort of endoscopy units are set up, often we as the endoscopist are sort of meeting the patient in the endoscopy room for the first time. And so there's a whole part of that interaction that would normally happen, for instance, if they were our patients that we saw individually in clinic, that's just not there. And so I think we need to make sure that we kind of really understand that context. And, you know, from the patient perspective, the importance of really kind of taking time to develop that rapport in terms of outlining the risks of the procedure, making sure that the patient understands, you know, why they're undergoing the procedure and the benefits of it, and, you know, really kind of making that distinction between sort of expected risks or known risks of the procedure versus, you know, actual sort of malpractice. I think patients have a very difficult time kind of distinguishing between the two. And the more that we can educate patients before the procedure about what to expect, the better, you know, we are both in terms of the way in which we, you know, take care of the patients and kind of patient-physician relationship. And then, as I said, sort of secondarily reducing medical legal risk through that process. Thank you. Wonderful. And we have a question for Dr. Shergel from the audience. Again, I hope you're here with us. And can you comment on the volume of endoscopy procedures and ergonomics during endoscopy and its impact? Hi, everybody. It really was such a great session this morning, very practical. So in terms of volume of endoscopy, certainly volume contributes to overall loads. And I don't think that we know enough in terms of what the threshold for volume is for individual endoscopists, and it's going to vary for the particular endoscopy. So this is sort of an unmet need. And I think every endoscopist needs to determine for themselves at this point sort of how many procedures can they do without having that pain that might persist for over two hours after a day of endoscopy, and then making sure that they're building in enough time both for breaks within the day and breaks between sessions to ensure they're fully recovered from a session of endoscopy before starting another one. So one thing to consider is, you know, half day of endoscopies instead of a full day schedule. Thank you, Amandeep. I'm going to stick with you. So at the provider level, right? So, and I'm sure many of us face this, is, you know, we walk into one of our many rooms, endoscopy rooms, and it is an ergonomic nightmare. And this sort of speaks to the engineering controls that you referenced. As an individual endoscopist gastroenterologist within a complex healthcare system, if I were to identify a situation that's ergonomically suboptimal, what is in your experience my pathway to make a meaningful change in that space? Because it's a big undertaking. It requires, you know, physical structure changes and so forth. Is it just advocacy? Is it people don't want to disrupt? So have you seen examples? And what advice can you give us to actually be able to affect meaningful change that hopefully will prolong our careers? Yeah, Joe, that's a great question. And I think that it kind of speaks to this really would need to be a systems approach that you can apply that hierarchy of control to the endoscopy unit. So as an individual, if you especially are in a complex healthcare system, that might work to your benefit in the sense that you may have ergonomists or physical therapists on staff for your hospital system that you could invite into your endoscopy suite to help facilitate those changes. I think it's hardest when you're maybe in an ASC or in private practice by yourself where you're trying to figure out how to implement changes. And in those cases, again, I think a team approach and sort of using as a quality, using this as a quality marker for a unit, developing a team really to come together and evaluate issues that need to be addressed in the unit and implement changes in the unit. And all of these changes will require admin support because it is going to require money to sort of develop a unit that has adjustability built in. So with the booms or the adjustable monitors. So anything that an endoscopist does themselves will be less effective than if they can get the administration support to develop and implement engineering and administrative controls. Thank you. Wonderful. Well, we have some questions from the audience for people. We're going to run through them. Dr. Brewer, do you typically delay high-risk endoscopic procedures, for example, in ERCP with sphincterotomy in hospitalized patients who have received DVT prophylaxis with low molecular weight heparin? Well, that's an excellent question. So if the patient is in the hospital and the patient is on low molecular weight heparin and the patient is not cholangitic, you could potentially wait 24 hours in order to do the procedure. If the patient is on unfractionated heparin, very short half-life, two to six hours, you are going to actually proceed and do the procedure same day. But unless the patient, and again, this at the end, you will weight benefit and risks. It's always easier to treat a GI bleeding and the risk of mortality is always less than a cardioembolic event of stopping that anticoagulant longer than it should. But if the patient is not cholangitic, wait 24 hours before doing the sphincterotomy. I don't know, Joe, you're very... My practice is actually is to just, even if they've received a dose, as long as it's a prophylaxis dose, even if they received it that morning, I typically don't, I wouldn't delay the procedure on that basis. Prophylactic dose, no, but if they are being actively treated for venous thromboembolism, it's not prophylactic. Yeah, different story. Yeah, I think if it is just for prophylaxis, typically it would not affect our practice. But along those lines, and sorry just to sort of stick with you really quickly, can you comment on an elevated INR in a patient with cirrhosis as opposed to in a patient who's anticoagulated? In other words, do you in your practice change your approach to endoscopic therapy if a cirrhotic has an elevated INR? Well, we already know they are not producing the vitamin K dependent clotting factors. So yes, these are very high risk patients for bleeding. And typically, as long as the INR, they are not going to be usually on anticoagulants. If this patient's INR is less than 1.5, right now actually 1.7 is currently towards acceptable, I will go ahead and do the procedure. If it's greater than 1.7, 1.5, then these patients will require some support before doing the procedure. Either platelets, or you will discuss with the hepatology group, obviously, to support. And you could give also vitamin K in these patients, or fresh frozen plasma as well. Wonderful. Thank you very much. We are getting a lot of questions. We appreciate all the questions coming in from the audience. So a question for Dr. Adams. Is it common to get a lawsuit despite an informed consent if the patient claims they didn't understand the risks? And very importantly, what can we do to prevent this? Well, you know, I think that, you know, cases in which, you know, the patient states they didn't understand the risk, but there's sort of documentation of the conversation and all of that are probably part of that sort of 75% that are either, you know, decided in favor of the physician or are ultimately settled. I think, you know, that's sort of the importance of documentation, you know, accurate documentation about the conversation that you've had with the patient. But, I mean, I think the documentation part of this is separate from, I mean, the responsibility that we have as physicians to really kind of, you know, explain things well and make sure that the patient is digesting and understanding. And as long as we have done that and, you know, documented that appropriately, then, you know, I think that's where you minimize risk. I mean, it's a difficult, you know, situation. I think where most people get into trouble is if, for instance, you know, a certain aspect of the procedure wasn't captured in the informed consent, right? And, for instance, you explained the risks of the upper endoscopy, but didn't explain the risks of dilation, right, the increased, slightly increased risk of perforation. And then the patient suffers a complication and said, I didn't know about that risk, right? So, I think that is more where you open yourself up to liability risk is when you, you know, it's sort of incomplete information that you're providing the patient and incomplete documentation. Thanks, Megan. This next question is for Fola and to you to some extent. This is a long question, so I hope I do it just as paraphrasing. But it's actually an audience member in Hawaii who has brought up a question that sort of pertains a little bit to some of the populations you were discussing in your talk where there's a large immigrant community, particularly Micronesian or newly immigrated Filipinos, who are obviously very different to their physicians. And their common answer during informed consent is whatever you think is best, doctor. And so, it can be difficult to truly understand or to truly get a sense of whether they've fundamentally understood the consent. And often, they don't even want to discuss the risk because they're too afraid to do so. And so, any tips as to how best to provide informed consent, make sure they understand without sort of freaking them out. And at the same time, protecting yourself medical legally. So, Megan, if you're still there, I'll start and then maybe you can jump in. It's nice to hear your voice. I think that's actually a really interesting question. And I didn't touch on migrant populations very much in my talk. But it's very interesting because what you find is that the sentiments of many of these populations mirror the sentiments of their home countries. So, if they're coming from a place where no one does cancer prevention or cancer screening, and they suddenly are in the United States and everyone's recommending all these preventive strategies, that can be very foreign to them. So, I think we need to recognize that that in itself is a very large barrier. And that some people are going to be hesitant in thinking that we're taking advantage of them, potentially that there's financial gain and are recommending that they have procedures done. I think my advice about the patients who don't want to hear about their risk, obviously, we have a requirement to tell them about all the benefits and the risks of the procedure. And just kindly telling them that, that I know that you don't want to hear, but I actually have to share this with you and I have to answer your questions, is something that we just have to do. I think Megan would agree medical legally that we need to do, but also just ethically. And I think when patients are deferring to our opinions, I think it's very challenging. I think everyone addresses that differently. I tend to give people a couple scenarios. Like, if I'm feeling this way, I might do this. And if I'm feeling this way, I might do that. But I tend to not direct what their decisions are and have them talk to their family or their elders or their children to help make these decisions, potentially giving them more time to do that. Megan, do you want to comment on the legal side? Sure. Yeah, I'd be happy to. So I think that there are a couple of comments I have. The first is that for sort of unique patient populations or that may, I was really interested in Fola's comment about the idea of sort of cancer not even being sort of a term that sort of understood or appreciated in certain populations. I think that you could do things like tailoring. You could create videos that present or some sort of a video for the patients to watch that presents the risk information in a slightly different manner, right? And again, this idea of sort of tailoring that presentation to the patient. You know, I think also there is going back to something that I raised in my talk, which is sometimes, you know, you can overwhelm the patient with too many details, right? And so in a patient that says, you know, I don't even want to know about the risks, you know, you may start by saying something like, look, you know, overall, this is a very safe procedure. You know, there are a few things that we need to, you know, tell you about, right? And then speaking more in sort of big picture terms and kind of putting that into context rather than giving them, you know, percentages and, you know, overwhelming them with data. And that's the approach that I take. I practice primarily actually at the VA here in Ann Arbor. And, you know, I find that that approach works very well for, you know, the veteran population. So those are my comments on that topic. DR. EISENACHER. Thank you so much, Megan. And thanks to all our wonderful speakers. Unfortunately, we're out of time. If there are any additional questions, please email them. I promise we'll do our very, very best to get you responses back. It's been a wonderful session. Hopefully all of them today will be just as informative and educational.

endoscopic practice

aspirin use

patient concerns

communication

patient safety