Now, okay, I'm going to move to the next slide. Okay, so we'll begin with a polling question to kick things off here. And again, I do want to emphasize the importance of interaction here. This is, I know it's early and we're all just getting warmed up, but we really want to interact with you. This is a great opportunity for us to hear more about what your interests are and for us to be able to respond and to get a conversation going. So to kick things off, here are some questions. And the question is, what would you like to hear more information about from the faculty? The options are changes in GI practice settings and resources being sought by GI physicians, enhanced with endoscopy and other GI procedures, optimizing working relationships. The questions even move up and down as we answer. Optimizing working relationships between GI physicians and pharmaceutical medical device companies and the types of GI patient disease states being evaluated and managed by gastroenterologists. So, although there is a little movement back and forth, it looks like the top two are top choices. So, why don't we begin with discussing some responses to the top two choices. Would one of, Bill, would you like to kick things off? One of the issues that we often play as faculty up here as we go through this polling is we try to anticipate what you guys are going to want to hear about, and this was the opposite of what I thought you were going to want to hear about, so that's why we do it. A lot is changing in the field of GI, particularly over the last, obviously with the pandemic, there was a lot of changes, and we were talking about some of the strains on our system because of the pandemic, but aside from the pandemic, there's a lot of changes happening in gastroenterology and the resources that we need as endoscopists and as physicians. I think that one of the biggest changes that we're seeing is the sub-sub-sub-specialization of our field. We are approaching a time when some gastroenterologists are going to be more like surgeons and doing things that surgeons traditionally have done, and we have other gastroenterologists who are really more almost like hematology oncology physicians, where they're seeing patients with chronic diseases or debilitating diseases that really require intricate pharmacology knowledge and medical treatment, and then we've got a whole bunch in between that wide spectrum. So I think the resources that gastroenterologists need varies tremendously based on what their sub-sub-specialization is turning to, and when I was in training a long time ago, most gastroenterologists were pretty similar in their skillset. There was always some difference, but that discrepancy and that differentiation is becoming wider and wider as years go on. I could add to that. I think that there is a lot of sub-specialization, but it's also amazing to me to see how the individual fields continue to evolve. So I'll give you an example. My focus is inflammatory bowel disease, so I do focus a lot on medical therapies. But I think what's really exciting is that we're, you know, we do stricture dilations and things like that, but I find that there's more and more data on the use of stents. And when I trained, I didn't train on using stents, and so one of the things that I love are when our reps come and they teach me about that, because then it makes me realize the ways in which I could use that. But I think there's a lot of things, you know, there's fistula injections. So it's rapidly changing, I think, across the sub-specialties as well, but, yeah, sometimes I look at my colleagues who do ERCPs or, you know, advanced endoscopic procedures, and, you know, sometimes we look at each other like, how are we both gastroenterologists? So... Can I ask a question based on what you saw? Good morning. Thanks for having us. It was interesting. So the traditional... Excuse me. Would you mind... If it's not too much, would you mind introducing, tell us who you're from, so we can... Yes, no problem. My name's Dan Woods. I'm with Boston Scientific. I've actually been with BSC now for almost 11 years. I was a rep in Chicago, actually, about five or six years ago before moving into our home office. So it's good to be back at the ASG Center. With the training, the first through the third year fellowship, and then the advanced fourth year... You know, 11 years ago, the advanced fourth year was primarily ERCP with a little bit of EUS. Now with the subspecialty, do you see the fellowship having to adopt and change to accommodate the subspecialties? Yes, absolutely. In fact, as you point out, first of all, just as a background, to become a gastroenterologist, you go through medical school. You then do three years of internal medicine training, and then you subspecialize and do a three-year, typically a three-year fellowship in gastroenterology. And then if you subspecialize, then you would go on to what we call a fourth year or an advanced fellowship. And there are now advanced fellowships in numerous areas. In the past, it was primarily in advanced endoscopy and some in hepatology, but now there's IBD advanced training programs, there's motility advanced training programs, there's even a few that are specialized just on the pancreas. But even within the advanced endoscopy training subspecialty fellowship fourth year training programs, there is now becoming a differentiation there. Some that are just focused on EUS and ERCP, and others are focused in an area we call third space endoscopy, or perhaps in bariatric endoscopy, where they're focused on performing procedures to treat patients with obesity and or needs for bariatric interventions. And so that training experience has had to evolve, and centers and faculty have had to evolve to produce physicians and gastroenterologists that will be able to serve the patient's needs. Great, thank you. No, I just I did want to just go back to that first question, though, real quick, and just not to minimize and not to kind of focus on how things have changed during the pandemic, but they have really changed our practice quite a bit. And I think it might be fair to say, I'm not sure, but I know at least where I work, we still have a bunch of, you know, a lot of our support staff are still kind of working from home at least multiple days during the week. And so that really changes our interaction with our own team, as well as then just working with anyone else in industry. And so I don't want to minimize that, because I think that that might be here to stay. And I think that we need to I know that we've been trying to work over the past two years how to make that work for our office, for our patients, for you guys. I think that we still need to do a little bit more work on that in order to make it a little bit more of a smooth transition. In the past, just as an example, like if I had a problem with getting a medication approved, you know, it was very easy to just go to my nurse and kind of work out to get to work it through together. And now we're kind of trying to do it through email or through phone calls, and it's in between procedures. And it's really changed, I would say, the pace of kind of what we do on a day to day basis. So. Great. I might, I might ask our whole panel just to comment about how the pandemic evolved and how it's how it is now, in particular, how it's altered the industry physician relationship. Obviously, early in the pandemic, industry was shut out. I mean, you couldn't get in anywhere. You could not really communicate with your health care team that you usually are working with. And then as it ebbed and waned, there were opportunities to get back in and then they shut it down and get back in. Our place was shut down early in the pandemic, but now it's as open as it's ever been for industry partners to get into the facility. In fact, we used to have a policy where industry, especially in the endoscopy lab, where industry partners could not be present unless they were invited and accompanied by one of our physicians as a host. Now they're standing in our supply room and re-inventorying things and checking out supply. So it's it is very liberal at our place, but I'm wondering how it is in some other centers. So at Loyola, we don't really have that much interaction with the industry and similar to what Dr. Cheney has said earlier in that they had to be invited and have to have a faculty member to invite them to come in. So that's been policy because of the way the health care system runs. And so it's really limited for us. Yeah, for us, it was I mean, I'll say actually Scripps was a big change for me compared to Fellowship where I had no interaction with industry or pharma. So actually coming to Scripps pre-pandemic, I felt like, you know, at first I didn't even really know how to interact with industry or pharma and sort of what was the utility. And then I saw the value, which was really helpful, you know, as far as getting drugs approved, how to use these devices. Here's how this compares to this. Here's data to support, you know, if you want to bring this into your practice, here's what you need to talk to the health administration about or here's how much it would cost relative to this. I actually found it really helpful. And then with the pandemic, it did, you know, kind of just shut everything down. But, you know, everything shut down. Right. We were really just focusing on urgent things. We weren't really focusing on moving the needle with how we practice or trying to change it right away because I don't think we knew how we were going to change things in the context of the pandemic. Nowadays, you know, it's it's a hybrid. Are we require industry reps to have an appointment, whether that's coordinated through our schedulers or with a physician or with our endoscopy team? So sort of just coming in and doing things isn't isn't allowed and it's actually frowned upon. But I think it's it's also sort of the the reason for the visit, you know, sometimes when we're learning about new techniques, it's actually really helpful to have like our fellows and any interested faculty there to learn, whereas, you know, sometimes it's just sort of a routine supply stock issue or just education on existing technologies or drugs. So I guess I would just say that, you know, I think it really depends on the purpose. And and then when when folks are coming, being aware of, you know, well, what's going to be helpful to me as a provider and, you know, should I show up to that session or not? I'll just add in from my perspective as well, when when we bring in a new device or technology, particularly to the endoscopy unit, it's very helpful to have industry come in to in-service us and not only the physicians, but the entire team, you know, the attendings, the fellows, as well as the nurses and technicians. And I think they really appreciate the expertise of the industry representatives who know the devices extremely well and are able to give give them insight, you know, everything from the most simplest, you know, how do you plug it in and turn it on to how do you how do you utilize the equipment? And and then also it gives you the opportunity to get to know each other so that you can reach, you know, so that the team at the hospital can reach back to you if there are questions that come up or supply issues and things like that. Could I could I say one more thing? Thanks. I also like I trained in Minnesota, which has I don't know if anyone works in Minnesota, but like there's very, very strict regulations as far as your interaction with industry and pharma. And then I moved to Cleveland and it was a lot more relaxed and I had a lot of interaction and I really enjoyed it. It was kind of my first time working closely with with everyone. And then during the pandemic, I didn't realize how much I miss this. I didn't realize how much I really did value that educational aspect that you guys all bring to my practice. And so, like Bill, we've really opened things up. So our hospitals, we still have to have an appointment and have some accepting faculty. But other than that, it's actually been pretty wide open. And what I'd say is I now I'm an assistant for the fellowship program and I have fellows right now that are in their third year. They're about ready to graduate and they've had literally no interaction with reps or with pharma. And I think it's a really it's a big disservice because as they go on into their practice, they are not going to know exactly how to how to navigate that interaction in that relationship. And so I've been trying to encourage all of our local reps to get in there and to meet the fellows and just have that interaction. I really do think that's important, no matter where they end up in their in their career, to at least know what value is added by having that good relationship. I'll just add to what Arnie was saying earlier, the you know, as physicians, as providers, there's a lot of science that we have to track and keep up with to provide the optimal care for our patients. And what our industry partners can bring to us is really the technical details or the ability to navigate pharmacologic agents to get to our patients. As well as perhaps some of the, you know, up to date literature or knowledge and science that's out there. But for us to be able to really focus on the science and focus on the clinical outcomes of our patients, we do really do rely on our industry partners. And I know many of you are managers and upper level corporate executives. But your boots on the ground folks that are out on the field, they need to know that they need to know that they are really providing an amazing, amazingly powerful resource to the docs and or the advanced practice providers that they're interacting with, or the nurse managers or the endoscopy nurse managers, that those resources are valuable and they're welcome. Unfortunately, there are also a lot of obstacles to those relationships. Sometimes hospitals have policies. Brooke was just talking about the trainee policy. I'm actually the fellowship program director for our training program. And there's a policy within our College of Medicine that precludes industry interaction with trainees because they're concerned about, you know, the influence and the bias information they might get. And it's some of the trying to navigate around those policies, both in terms of access to physicians and providers and to trainees in this example, is something we all have to work with. Can I invite some questions? Yes. Have you noticed a difference over the last few years within the pandemic of more of a movement from the larger conferences that have been virtual to more of the regional conferences since you all work at larger institutions? I've found from the industry side in managing a wide area is our resources are better spent at Case Western is partnering like in teachings with actually with ASGE versus the national meetings and the virtual. I think the national virtual meetings have really diluted education from the product point of view. I'm curious to see if you all have seen that as well. Well, I mean, I'll just say we all miss in-person meetings, period, and, you know, we've started some of our big national meetings are starting to come back online in person. There's still some that are happening virtual. I just attended one last week. That's more. It's not a meeting, but it's a national education meeting that was all virtual. But, you know, our big meeting DDW next month will be in-person meetings. Big meeting DDW next month will be in person with a virtual option. But I think we miss that. There's a lot of educational experiences that you cannot replicate virtually as hard as we try. And I know there's some folks listening and participating in this virtually. But the the hands on sessions that are really part and integral part of GI training and education is hard to replicate virtually. And just the networking and the relationship building, talking to a computer screen just doesn't cut it for me. I don't know about you guys, but it just doesn't cut it. And and so the more we can do that in person, the better. And I think perhaps the regional meetings just are more because of travel issues and travel constraints. It may be an easier way to facilitate those in-person meetings. I agree. I think there's going to I think people are starting to relax a little bit and we'll see what happens with DDW in May. But I think I know I signed up and some of my colleagues signed up. You know, the past couple of years have been so up in the air. I think everybody was afraid to, you know, to try to travel. And so everything was pretty virtual. But I think things are going to start heading back in the more in-person direction. As Bill just mentioned, he was at a recent meeting. I was at a meeting on Saturday just a couple of days ago in Denver, and there were 400 people in person with with industry sponsors there. And I don't know if it was Denver, but it felt like it was barely COVID there. I think I saw like 10 people wearing a mask. So it might be a regional thing about where some places are still much more tighter and other place more relaxed. But I think over the past couple of years, clearly things were much more virtual, both national and probably even regional. But I think that'll open up more now as long as we don't have another surge. And I was just going to say, to your point, I mean, I think that as far as research allocation goes for you, you know, I do think the national platform will still be really important. And I think hopefully it's here to stay again. But I do think that, to your point, probably over the past couple of years, you've been spending more time on the regional conferences. And I think that that's important to continue as we move forward to not ignore those smaller, more regional conferences as, you know, not as important as a national conference, because as you know, these national conferences, it's so overwhelming and it's like, you know, sensory overload. And you might not get as much, well, you'll get a lot of activity there, too, but you might not get as great one-on-one personal activity as you would with some of these regional conferences that you participate in. Yeah, I mean, to that point, we as an organization have cut back a little bit on the larger shows because of the uncertainty and have put more into the regional and even individual facilities because of the interaction. So it's been it's been a conscious decision based on risk. So it's interesting. Yes. Thank you. Good morning. I'm Maria Miller with WL Gore and I'm very new to the industry, so my questions are out of ignorance. I'm talking about trends with endoscopy and other GI procedures. While I'm trying to get my toes wet on interviewing doctors, I realize that some are saying that ERCP is here to stay. Others are talking about endoscopic ultrasound, like for biliary drainage, another type of procedures are moving into the future. How do you see these trends? Is this really something that is going to be a shifting or it will maintain as is? What are your views and what would make the endoscopic ultrasound move faster? What are the needs of the industry? I'm going to try to tackle that. So I would personally say that ERCP is here to stay. I think maybe what you're what you're referring to is just the speed at which maybe different parts of the advanced endoscopy world is changing. And to what Bill was kind of saying earlier, that there has been just leaps and bounds advances in the endoscopic ultrasound therapeutic world. And then moving on to some of the other parts of advanced endoscopy that kind of, I guess, would be part of that. But in addition, you know, like third space endoscopy and whatnot. So I think, you know, we see these trends in GI where, you know, there will be a lot of excitement about one particular part of a subspecialty and a lot of resources and a lot of education and a lot of, you know, everything's kind of focused on that one part. And then five, six, ten years, you know, something else will be developed in another part of the advanced world and then everything will be focused over there. So at one point, there was a whole lot of excitement about small bowel evaluation. There was a ton of different scopes that were being created and developed into the third eye and spirus. And there's so many different technologies and those really had their day and then they kind of fizzled. And then now right now, a lot of effort has been focused on interventional endoscopy US. And at some point, I think we might hand back to the ERCPs, but. Yeah, I think it's interesting because 15 years ago, I was chair of the ASG Technology Committee and we wrote a paper on sort of a exploratory paper on therapeutic US. And our conclusion was we need more US specific devices to really make the field of therapeutic US take off. And yet, when we look around 15 years later, there's really not there's really hardly any US specific devices. We're still using devices that were meant to be used during ERCP or biliary endoscopy or for biliary interventions on US. And similarly, back even further back, maybe 25 years ago, many of us or not me, but some people were concerned that US would become obsolete because back then it was just a diagnostic modality and MRI and MRI imaging and CT imaging was becoming so much better and more accurate at defining anatomy that we said, oh, well, you know, it's going to at some point it's going to outpace the US. But it turns out, just like many other aspects of endoscopy, once it becomes more therapeutic, it becomes more valuable. And that's really what's happening with the US. But we still answer your question for US therapies to take off. We need US specific devices. And right now they're not they're not there. Probably need to move on. OK, Dan, did you have one more question or before I was just going back to DDW, I was curious in talking to your colleagues, do you expect attendance to be back to historic norms 2019 or later? I'd just be curious to get your thoughts. Well, it's hard to say whether attendance will be back to what it was before the pandemic. But what I can say is that a lot of people are excited to meet in person. And so I can expect that there'll be a great turnout, at least based on my colleagues have spoken to everyone seems to want to get together. National attendance will be pretty good. I don't know about international presence. Yeah, just just my gut sense is people are making plans to go. People have definitely bought their tickets and registered. So I think this year will be a bellwether of how things you know, which which direction things are going. OK, I think we need to move on to the talks. So thank you very much. And there'll be plenty of opportunity for us to continue to interact, including during breaks and lunch. So thank you to the panel for that lively discussion. We're now going to move on to our didactic session. And as mentioned earlier, we're going to begin with GI track and health. So the first series of talks will be about normal GI track anatomy and physiology. And then after the break, we'll go on to the disease state.

gastroenterology

subspecialization

pandemic impact

industry partnerships

endoscopy trends

DDW conference