It's time for questions. So you can either scan the QR code, join via the web for pollev.com backslash ASGE 2023, or you can text as it says on the right side of that screen. Thank you for those of you who have already sent in questions. So I think the first question is for you, Dr. Wilder. Someone was asking if you could perhaps comment on the nourish practitioner colonoscopy project being done in Baltimore, if you're familiar with it, and maybe some of the perceived issues associated with it. Sure. I will admit I'm not fully aware of all the details around that project. If it's what I think it is, you know, folks have thought about ways to leverage resources to get resources to various communities. And this is what I think it is. It's where they're trying to leverage APPs trained to do endoscopy to go into certain communities and do endoscopic procedures. You know, some of the best colleagues I have and have learned from have been APPs. We're very lucky to have them in partnership as we provide care to very complex patient populations. And so on the surface, I don't necessarily have a problem with the idea of us leveraging them as a resource when it comes to things like endoscopy. I'd have to think really hard about that as physicians, about how we feel about that and as societies about how we feel about that. And that's a whole other issue. I think around the issue of equity, there's another thing to think about, though. You know, for example, in my clinic, you know, my APP colleagues see people who have decompensated cirrhosis as, you know, returns and as new consults. And I might see those same patients, too. That's sort of a shared thing. If we're saying we're going to use the APPs to do endoscopy in poor communities only and physicians and trainees aren't going there, I do have a problem with that. If we're going to say we're going to leverage this important resource to provide better care for everyone, and so they might be scoping people in a poor community but also scoping the, you know, CEO that comes to, you know, Johns Hopkins for his colonoscopy, well, then I'm down with that. I'm okay with that. But that's an important distinction that needs to be made if we're going to leverage this resource. So the same way we leverage that important resource and their incredible insight and guidance and patient care for all of our liver patients, for just my personal example, you know, we can think about what that looks like in terms of endoscopy. You know, I will say what I do like is the idea of us thinking about how institutions can be very intentional and proactive about placing these resources in communities of need and not doing it in a cheap way or in a way that saves resources, but doing it providing the same level of care that you would get at the main institution when you go to these other communities. I hope that answers that question. That's it. Thank you. I think that's a very good point. If we're going to leverage the APPs, it should be across the board, not just specific communities, and that was a controversy in that study that came out. For Dr. Isaka, thank you again for the wonderful talk. You mentioned advocacy. For someone who's looking to start and just be an advocate, what are ways or which ways can they do that? Because I think it sounds like a very big umbrella term that can be a little bit intimidating. So what can we do as an individual to really push this forward? Thank you. I believe all of the current GI societies, ASGE, AGA, ACG, all have one day a year where there are organized advocacy opportunities. And these will generally go out in email to the members. And so all you have to do is respond to that email if you're interested. That might be a one to two day commitment with travel visiting Washington, D.C., but I found those opportunities to be really meaningful because much of the work in organizing is done for you by the societies. You simply show up and they typically will have a dossier prepared for you on the talking points that are relevant to us right now. And they will schedule all the visits for you to your local representatives and senators. And you simply show up and you come with a group. So I was recently in D.C., I was with AGA, and I was joined by six other colleagues from the state of Washington where we had the opportunity to meet with our state representatives and senators to discuss these issues and recently saw ASGE was on the Hill as well doing something similar. So I think that's a really easy way for people to enter advocacy if they're looking to do so. Can I add to that? Actually, ASLD also has Liver Capital Hill Day, a little liver love. But along the same lines, there's a lot of sort of power when these societies come together around issues, both, you know, like ASLD and ACG and AGA all coming together around issues that were important, has happened in the past, and help move things forward, as well as us in partnership with AMA and so forth, other institutions, with pediatric societies. And so I think leveraging those relationships to combine efforts is also very helpful when trying to affect policy in D.C. Thank you both. Actually, I'm wondering, building off of that, so, and Dr. Wilder, you spoke a little bit about it in your talk, where, how do you utilize your health systems to also leverage this in both spaces, right? So how do you advocate within your health system to make sure the resources that are necessary to have equitable care are there, but also to fight these fights in a more kind of national policy-based ways? I can give an example. So in Seattle, at the University of Washington at the Fred Hutch, I direct our colon cancer screening program. And so, you know, it started with advocating for resources, just to have a population-based program where we can do screening in a meaningful way, but to also ensure that all patients had access to that program. And so, for example, what that meant for us was that our safety net hospital was well represented within that program, and that individuals who might need additional assistance covering out-of-pocket costs, that there was an additional fund available for those individuals. So that was grassroots advocacy with the CEOs and CMOs of the health care system to ensure that that happens. And so then from there, we were able to escalate, you know, up to the state and say, okay, well, what is the Washington state plan around colon cancer? And it turns out that there's a colon cancer state task force. So then we said, okay, well, here are the priority areas we believe that should be prioritized for colon cancer screening. And then we get to be part of that conversation, and that plan is being developed now. And then we're able to, you know, share that information through opportunities and ongoing efforts. Dr. Christie might mention this, but the work that she's doing as ASG president to ensure follow-up colonoscopy around the country. So then we're able to bring our learnings and experiences, you know, from a state level, to a national society, and, you know, having impact nationally, and then the efforts I talked about on the Hill. So I think you can really start local and start small and build up as much as you wish to do. Yeah, I would add to that another, you know, example being hepatitis C eradication. I'm sure many of you have heard about the role that Francis Collins and Rachel Florence have played as part of President Biden's cancer moonshot, which was a beautiful picture in front of that. And so, and it's another example of where we can begin to collate our efforts. And so, you know, a number of us were in the White House last year in March, where we got a chance to meet Francis Collins and Rachel Florence and learn about the fact that a significant amount of that moonshot money is hopefully going to be diverted towards hepatitis C elimination. And so this is an example of going the other direction, where at a national level, it has become our priority, and they are now reaching out to entities, particularly ASLD, and institutions across the country to help address this at a sort of local level, as we begin to think about how we in a grassroots way can be able to engage those communities, particularly those hard to reach communities about, you know, hepatitis C elimination. But I raise this issue because, again, you know, cancer moonshot and what it means to us as gastroenterologists, both with respect to hepatitis C and HCC, as well as colon cancer is another example of where we can become very active and have a significant impact in terms of our legislators, who we do or don't vote for, what we say to them, and how we can encourage and support policies to help affect the things that we do in the patient care we provide. Thank you. In the interest of time, we're going to move on to our keynote. There are some questions around medical education. For those, we will move them to the later section, the med ed section. I think it's the last session for the day we're doing. So we will ask your questions in the medical educator section. And again, my apologies, we can't get to all the questions that we have here.

Nurse Practitioner Colonoscopy Project

Advanced Practice Providers

equity in healthcare

advocacy opportunities

health systems and equitable care