the technology for EUS and I was hoping you would circle back and speak to that a little bit more as to what is it that you feel is lacking in the field in terms of devices for you to propel that type of treatment? I think I'm guilty as charged as the one that said that. I think it's a very good question and one that the technology of GI endoscopy is advancing Most of the devices that we use for EUS guided interventions are actually borrowed from biliary endoscopy. We have some lumen-opposing stents that are available that are designed to drain pancreatic collections, or approved to drain pancreatic collections, but we use them for other things. And what we probably need is better, more specific devices for interventions in the liver when we're accessing bile ducts directly from the stomach into the liver. When you're trying to do that, occasionally there's a lot of resistance of trying to enter the bile duct because you're working so far away, you're in the stomach, you're limited by the stomach and you're trying to access and get into a bile duct. And that can be a challenge sometimes. And so just having devices that are a little bit more steerable and designed to puncture bile ducts are one example of that, where we're often limited. And then the steerability of the lesions when you're, again, working from, say, the stomach, trying to direct something all the way down the bile duct, and then antegrade or forward flowing in the bile duct into the duodenum can also be a challenge because we don't have devices that were designed for that purpose right now. So those are some examples of what I was talking about. I could add a couple of examples, too, in the IBD space. You know, we talked a lot about using anti-inflammatory or immunosuppressive drugs to treat IBD, but one of the spaces that's growing is antifibrotic therapies. And one of our issues when we scope patients with strictures is, you know, we really can't see anything except what's on the inside of the lumen. Sorry, I'm losing my voice probably because you're in my group. So anyways, but one of the things that I've always thought would be helpful is if we had a colonoscope, an EUS through a colonoscope, you know, so that we could use it in the TI or doing a balloon neuroscopy, but actually see to what extent, you know, is this narrowing inflammatory versus fibrotic, how much of this is fat creeping. Sometimes it can be really hard to tell just based on cross-sectional imaging. But again, you know, a lot of people are looking at things like electroincision, you know, and cutting. And, you know, I'm not there yet. I know some people are. But I think if we had better tools to visualize deeper layers, that would be really useful. I think the other space where, you know, we could use it is with perianal fistulas. So, you know, David Schwartz uses it a lot for IBD patients with perianal fistulas at Vanderbilt, but it's not really standardized, and most gastroenterologists don't know how to do that for IBD. However, stem cell injections are in phase three trials right now for perianal fistulas. And I think that's going to really be done by the colorectal surgeons, but I don't see any reason why as GIs we can't do that. Exactly. Yeah, so we know where we're injecting. We can make sure we know if there are other tracks. I mean, if you have an MRI of the pelvis, it's really helpful, but, you know, when you're actually in there and you're doing something therapeutic, you need to see the deeper tissue layers. Yeah, I think that, in general, the majority of what we use for our therapeutic endoscopy has been borrowed. Borrowed from minimally invasive surgery, interventional radiology, cardiology, ERCP, even like a counterpart to within GI. But we have very few actually dedicated EOS therapeutic tools. Personally, I would love a better cyst ablative fluid that we could inject into the cyst to ablate the cyst. We're kind of limited right now, and the technology is a little bit short of perfect. I'm just trying to think. I guess interventional EOS is used a lot at our place for helping to deal with peripancreatic fluid collections, draining, you know, transgastric drainage to help direct that. And also for bypassing malignant gastric outlet obstruction to place a self-expanding stent from the stomach to the jejunum as an alternative to placing a luminal stent. I'm just trying to think of other, I'm not sure what to say is what the improvement might be for you, but it's clearly EOS is developing many more interventional roles. One of the things that we, the ASG has a technology committee that assesses new technologies, and I'm losing my voice too. And I wasn't even in that room very long. But one of the things that we look at in that technology committee is the ease of use of a technology. How easy is it to use? Is it something that requires a tremendous amount of skill and experience to use and or takes a long time to use? Or is it something that, you know, even somebody that can do standard endoscopy is able to apply in their practice and it is easier to use than whatever it's replacing. So whenever new technologies are being developed, that's a really critical issue is the ease of use so that it can be disseminated widely in practice and applied to as most patients as possible, as many patients as possible. And that's not always easy to achieve is trying to anticipate how that, how we can modify or change existing devices to make them easier to use. I have been told in the past by various companies that the volume does not support the amount of money that goes into the research and development for these very, very specialized tools. And that because the field has been changing so much that by the time something has been developed and created and researched, we've already moved on to something else. So that has been the feedback that I have been told in the past, which is frustrating, but probably in some part may be true. We have a limited amount of time left. And one of the things that we usually kind of double back on is the day in the life of the gastroenterologist. And that's really kind of what we're asking questions about. Do you guys have any questions about what the practice of gastroenterology is, how to navigate with endoscopy directors or clinic managers, infusion center managers? Not so much a question about that type of interaction, but was wondering if you could comment on your relationship with some of your counterparts, for example, colorectal surgeons or others within your hospital systems whom you might have to discuss patient treatment algorithms and how you go about doing that. Yeah, that's a great question. And it gets to the fact that so much of what we do is multidisciplinary now. And I got asked this question a couple weeks ago. What do you think about colorectal surgeons doing colonoscopy? Is there a competition with gastroenterologists and colorectal surgeons doing colonoscopy? And I said, well, it's perhaps one way of viewing it. But we also have to partner a lot when it comes to co-managing patients. And that co-management and the discussions and exchange of ideas is really very important to optimizing the outcome for our patients. So we have a mutual respect for each other. And we each have our strengths and what we can bring to that platform of improving the care for our patients. And we have to keep that in mind, even if there's a concern about, oh, you're stealing some patients from me of doing colonoscopy. I'm not worried about that. I'm really more worried about how we can optimize the patient's care. I don't know what you guys think. I can tell you how we do it at Scripps. So we have weekly surgical pathology case conferences where we discuss cases. And at those meetings, we always have radiology, pathology. And then once a month, there's always the colorectal surgeons presenting. But other weeks, there might be other types of surgeons or other folks there, depending on the case. But that's been really helpful, just from a discussion about the cases, as well as teaching for our fellows. And then last year, we actually started a multidisciplinary IBD conference, as well, with our surgeons, pathologists, and IBD subspecialists. And that's been really nice, because then it sort of gives you an opportunity to discuss cases in real time. Most of the time before that, we would just call or walk down to radiology. And that's fine, too. I think once you've been at an institution for a while and you've been working with folks, you get to know them really well. And pretty soon, you're just kind of calling each other on your cell phones, asking for help. But I think it's really nice when you all have a place to meet and to talk about cases and to share ideas and see what others might do. But yeah, I think building that collegiality is huge. And there's so many ways to do that. Yeah, I would agree with that. In our institution, we have a multidisciplinary forum where we discuss cases. And I would say this, always have your friendly neighborhood colorectal surgeon on speed dial. Because invariably, you're going to need each other. Even if he does scopes, there'll be those difficult scopes that he'll say, hey, would you see this patient for me? And obviously, when you're doing screening colonoscopies, when you do find cancer, you would need to work hand-in-hand with your colorectal surgeons to manage and to treat that patient. So it's critically important. I'll share from my institution. We had one colorectal surgeon who was still doing colonoscopy who has since left the institution. So none of our colorectal surgeons do it on a regular basis. They obviously have the technical abilities to if they had to. They really limit themselves to sigmoidoscopy and clinic as part of their pre-op assessment and post-op follow-up for rectal cancer patients. But nobody's really doing routine screening and surveillance. However, I'll just add to that is the training issue. The colorectal surgery fellows need a certain number of colonoscopies for board certification. And they're not getting it from the surgical side. So are you all running into this at your institutions? So there is a need for training of the surgical fellows to give them colonoscopy cases. So we all, like everyone, I think every institution has, we call them disease management team meetings. We meet weekly. And each organ system has their own, colorectal, thoracic, hepatobiliary. Other institutions are called tumor boards. But it's the same idea. All of the groups work together very well. Everybody's collegial. I don't get that sense of competition for cases. We're all in it together trying to help manage the patient as best as possible. But there is that little issue about colonoscopy training for the surgical fellows. And I just want to echo so everyone knows that at University Hospitals, we also are very collaborative with all of our surgeons. We have multiple multidisciplinary conferences. I cannot stress the importance of good collaboration with multiple team members. Almost everything we do in GI is so multidisciplinary. And so we have a separate IBD multidisciplinary group, a pancreatic biliary, a hepatobiliary, a colorectal. And we actually did, there's a lot of research on it. We've done a few research projects looking at quality improvement. And the patients by far do so much better when you have a collaborative approach to their care. And we also, I just want to point this out, for colorectal surgery, a question had come up about competition and if we were taking cases away from each other. And we actually looked at caseloads prior to a more collaborative approach versus afterwards. And what we found was that we actually fed each other patients. And so volumes for both GI and colorectal surgery went up after we started working together more frequently. Yeah, and I would say the colorectal surgeons look to us more and more from the GI side to assist with the care of their patients. Enteral stenting is a big help to them. Sometimes people that come in with a new primary colon cancer with obstruction, rather than do an emergency diversion and do a stepwise approach, they'll ask us to stent to deal with the acute bowel obstruction issue, then the patient will be prepped properly and have an elective operation. If people have recurrent disease and it's needed for paleation, they much prefer a less invasive endoscopic stent than a paleative diverting colostomy. And the patients, of course, love that as well. They also appreciate the growing area of ESD, endoscopic submucosal dissection, because we're now, you know, people have this expertise in GI, are able to take care of lesions that otherwise would have went for an invasive surgical resection. Also broad-based premalignant lesions, or some lesions that had high-grade dysplasia, the surgeons appreciate us being able to do that. Also there's some patients that might not be optimal surgical candidates. They might be more medically frail, older, or have significant comorbidities. And if something could be done endoscopically, they're happy for that. So we're all working together and helping, you know, share caring for the patients, and I think they're appreciating how we can help complement them. So I think some of these advances from the colon standpoint with ESD is, I think, looked at very favorably by the colorectal surgeons. I have to say, I think this extends beyond just cancer and even IBD. Within IBD, there's really a need to have inputs from nutritionists, psychologists, other people with other expertise. The same is true for patients with irritable bowel syndrome. Having that nutrition and psychology expertise handy really comes as indispensable when you're managing these patients in a multidisciplinary format. We all have the luxury of coming from relatively large institutions where all of these specialties work together. That's not always the case. There's a lot of, you know, still a lot of practices where it's separate silos of practice and trying to coordinate that care, and that multidisciplinary care is not always as easy as it is in a larger institution where they're all under the same umbrella. Yes? Let's say that you have been using product X for 10 years in your place, and then another company shows you product Y, and you find it to be intriguing, better in certain way, right? And what support do you need from us, industry, for you to go back and give the battle for a new product while the other one is on contract and has been on contract and used, you know? I can start. So whether it's a new drug or a new device, I think many institutions and many facilities and even insurance plans have gotten into the habit of what's the cost-benefit here? How much is, am I going to reduce my cost and provide the same benefit? Am I going to reduce my cost and increase the benefit in terms of outcomes for the patient? Then that's a no-brainer. Then we've got some, we've got a possibility of pushing it through. If it's a very expensive item that's not necessarily clearly, it's more expensive than item X, and it's not clearly going to improve outcomes, it's going to be a harder sell to the people that will approve that. And then in the device world, we often have what's called VACs or value-added committees, and that's the hurdle you have to get over because I have to pitch it to an orthopedic surgeon and a neurosurgeon and a hospital administrator and the chief of nursing staff and a number of other people on the committee and tell them why this is going to save us money and improve patient outcomes because ultimately they have to approve it before our institution will invest in it and buy it. So from the device side, that's the way it works. There's something similar with the P&T committee in terms of improving new pharmacologic agents. Again, what's the value added for the cost if there's an incremental cost to the product? And I just want to add that sometimes you need to talk to your physicians and ask them what about product X is working for them? And sometimes you might not know as a physician that with product X, I'm actually using two or three of them in a case because they're breaking where I could use product Y and maybe only use one product. And in my head, even though the cost is a little bit different, if it's not outstaying insanely different, then it might be actually the cost benefit might be there. But I think that's huge. I would also say that in this day and age, now is the time. We're having so many supply chain and product inventory issues that a lot of times we've been, at least lately, been looking at what other products are out there. And there sometimes isn't a reason. There isn't a clearly better product. It's just a different product and maybe the price is similar, but we just haven't switched because we haven't had a need. And this is the time when we're actually looking at new products and availability. I could speak as someone who's not involved in bringing devices to our institution or clinic, but more as someone who's served as a guinea pig for it. And the way it works there is I find that the reps work a lot with our techs because our techs are the most heavily involved in those devices. They work with our endoscopy director. And then essentially we start with samples. And what they'll do is they'll have the different docs try it out and literally just kind of get a poll for which one did you like better. And that's resulted in a lot of decisions, to be honest. And granted, these are for maybe a cuff for screening colonoscopy. I mean, not necessarily the super advanced cases that I couldn't speak to, but that's one process that I think has worked. It's like, OK, you know, if there's any training, let me learn and then let me try it and see how it goes. I think that's kind of the best way for me to make a decision as well. Same experience as Bill described. You know, institutions have value added committees, back committees that do meet. And as described, you know, if there's a physician that has an interest in a product, talking about devices here, and may have tried it and thinks there might be some filling, some niche, some way better than the products that are being used. I think the initial thought to using it might not necessarily be the cost, like a benefit and cost. I think the first thing that triggers them to want to try it is that it's some improvement in clinical care. You know, a better mousetrap or, you know, easier to use, less complicated, quicker to use, stronger, you know, causes less adverse effects after. You know, maybe the patient wakes up with less pain or whatever. That's usually what triggers it. And then if there's an interest in it, then as described, it would have to be presented to the back committee and then go through a trial period before, you know, before being considered for adding on. And when it's formally assessed, everything comes into play, people's opinions about it, what's the benefit over what's already being used. And then the cost analysis comes into play as well, which obviously, from an institutional point, you know, the institutional standpoint also has an important amount of weight to the decision-making process. So maybe it's a little bit better, but it costs a lot more. You know, all of this has to be considered. And sometimes a device is so unique and it's the only real option to provide for whatever interest. So the Hema spray, for example, when it first came out, that was really the only product that was like that. And because of its uniqueness, it's a tool that you have to have in your toolbox to provide care that can sometimes go a long way if there's something extremely unique about it. Yes. So I wanted to talk a little bit about industry and physician or relationships and, like, questions kind of broad. And I just want to throw it out there. When do you consider someone from industry, you know, a trusted partner? What does that mean to you? And what does it take? I'm not very trusting. So my, well, I'll just talk of my limited involvement with industry. It's in the realm of industry-sponsored clinical trials. And so I've recently gotten involved with that and based on one initial trial, which is a multi-center, multinational trial. And subsequently, we've been approached to participate in other trials. And my experience within that space has shown that they've been very dedicated partners. They have been well funded. And they've been sort of done the due diligence regarding all the things that were required to make the trial a success. So from that perspective, which is I know it is limited and may not fully explain your question, I found that relationship to work. I can speak more maybe on the drug side of things. But there's a lot of drugs coming out for IVD. So I would say that, let's turn it the other way around. What makes for a trusted partner is someone who's communicating with me, like, X drug was just approved. Here's what you need to know. Connecting them to my staff. So my nurses, especially our prior op team. So how do we get this drug approved if we want to use it? How do we get samples if that's relevant? What do my staff need to know about the co-pay program and the support? So it's essentially education and logistics. When they have a medical science liaison who reaches out, who's smart, who's well-informed, who's up to speed on the literature, and who I can call on when I have questions or I want to use more of this drug than people normally do or that is FDA approved, here's all the information you need to justify it to the insurance company. That saves me a lot of work. And when I find that there's follow-through on this, that's really helpful. When I find that there's follow-through on those things, that makes a huge difference. What is really difficult are when people are really pushy. And I realize, like, they're enthusiastic about their drug or, you know, they really want us to use it or incorporate it into practice. But, you know, the bottom line, like Arne's saying, for us, it's patient care. You know, what makes the most sense for this patient in front of me? Having an industry partner who, I guess, is more interested in pushing the drug or even a device than kind of what my needs are, what our division's needs are, it just puts me off, you know? And then I'm just much less likely to offer that person more meetings, because in what way is it going to be productive for our practice? And I know that seems really intuitive, but even to this day, it still happens. And so, yeah, I find trusted partners are ones that educate, that communicate well, that keep us informed, you know, when there are changes to the FDA label, things like that. Yeah, I go exactly what Gauri just said. Like, it's someone who is accessible, who is communicative. I think someone knows my practice, understands what it is that I actually do for my patients and what maybe our division does. And I think, you know, I just had a really, it was kind of funny encounter with a rep who waited an hour to see me and was really excited to see me because he noticed that I don't prescribe any of his medication and was wondering what he could do to get me to prescribe his medication. And it was an IBD medication. And my response was, I try really hard not to prescribe your medication. I try really hard not to see any of those patients. And it kind of, I was a little bit rusty. I haven't, you know, been with reps a lot lately, but it went, it was funny. But I kind of was a little bit put off. Like you waited an hour for someone that does, I see, I can count on my both hands how many IBD patients I really manage. And so, you know, it wasn't, it was not beneficial for him and it wasn't beneficial for me. And so I think to know who you're working with and what's going to work with them. And I think I have, I feel like I do have a lot of trusted partners in industry and pharma. And it's because, you know, they've got, they've taken the time to know me as a person, to know my patient population, to know what I like to use and what works best for them. Yeah. And I think, you know, that's why we titled this the day in the life of the gastroenterologist, because part of the challenge of an industry partner is to understand what a life of a gastroenterologist is so that they can respectfully interact and help to serve the needs of our patients, partner with us to serve the needs of our patients. But if they have an agenda that they're pushing that's their own, that's where it gets hard to form trusted relationships. And on the other hand, if you're able to build that trust over repeated communications and in a way that's understanding of what's going on in our day and the time pressure of our day, finding mutual times that are beneficial to exchange that information and communicate goes a long way in terms of building that trust and building those relationships. And I know you guys, most of the people here, a lot of the people here are managers and territory leaders. When the, you know, the frontline boots on the ground folks are trying to do that, coming to sessions like this, where they learn that skill and learn the whole aspect of what goes into a practice of gastroenterology can go a long way to help them effectively interact with our members, with our ASG members as they're in the field.

advancements

devices

endoscopic ultrasound

gastrointestinal endoscopy

bile ducts

collaboration

patient care