Hello, everyone. Good morning and welcome again. I'm Anand Kumar. I'm from Philadelphia in Thomas Jefferson Hospital there. I'm an advanced endoscopist. Almost 90-plus percent of my work is in advanced field, and I also train advanced fellows and frequently deal with majority of device companies on a regular basis. Hi, good morning. I'm Neha Mathur. I'm a gastroenterologist in Houston, Texas at Houston Methodist, and I'm more of a general gastroenterologist, so I'm not advanced trained, so everything else that falls into our bucket. I'm also involved with fellowship training and there are outpatient continuity clinics as well. Good morning, everyone. I'm Sush Guha. I'm at the UT Health Science Center in Houston as well, and my practice is a little bit mixed. I do general and also a little bit of interventional as needed. We have quite a few interventional people now in our group, so I don't have to devote too much time. I do train fellows. I'm also the associate program director there, and obviously I interact a lot with the industry folks. I'm Vincy Abraham. I'm the program director for our GI fellowship, trying to get all of our fellows trained to be amazing gastroenterologists out there one day, and I'm also the director of the Inflammatory Bowel Disease Program, so I focus pretty much my career on inflammatory bowel disease. So from an endoscopy perspective, my bread and butter is colonoscopies with tons of biopsies and chromoendoscopy, et cetera, not necessarily a lot of anything therapeutic. If I see a huge polyp that I don't feel comfortable taking out, I'm asking these guys over here, saying, hey, take this out, do ESD, EMR, whatever you need to to prevent a colectomy in a patient or so, but again, for the most part, training has been my passion, trying to get anyone that I actually see to educate them to improve whatever they need to do in their future career as well. All right. So it's all on you, questions that you may have, and if there's some shy people, we may just kind of go through perhaps a day-to-day, like what do you do, you know, how's your life like? Because maybe the therapeutic endoscopist can tell us, like, you know, do you spend all your day in the lab, how much clinic time do you have, you know, how much time you spend with everyone or so. Any burning questions first from the audience? Not yet. You want to know how we're, what our day-to-day is, okay. What time do you wake up? So, I mean, each advanced faculty's practice is going to be a little bit very different depending on what sort of, you know, practice environment you're in. I'll just speak for myself and our group. We are about six advanced endoscopists in our group, and each of us has a very similar schedule. It's like almost a cookie-cutter schedule. We do four days of endoscopy lab, one day, I'm sorry, three days of endoscopy lab and one day in clinic. And one day is our administrative day where we, you know, deal with either meetings with you folks or somebody else, you know, within the hospital system, but that's generally our layout. And, you know, typically our day begins in the endoscopy lab at 7.30. On the days that we are in the clinic, it begins at 8.30, and then we just go through until 4.30 or 5. So, right, a little bit different for me. Since we are more general GI, we're still doing a lot of procedures, and our group is also varied. We have some folks who are tail end of their career, some who are coming on as new faculty, so depending in the beginning, your volume may change and your needs may change with your patient, you know, group. So for me, I do endoscopy about three half days. So usually for us, like we have, I would divide the day in halves, right, in the morning block and afternoon blocks. That's how most of us look at our day. So I have three half days of endoscopy, and you can certainly, I think I've actually stepped back from endoscopy a bit because of training requirements. And then I do clinic in the other half days and have a half now, like one administrative day, excuse me. So it's kind of a mix for me. Days start, like Dr. Anand said, like we start at 7.30 in the morning, endoscopy sometimes 7, just depending on anesthesia support for us, meetings, things like that. Clinic usually starts at 8.30, you know, we go to like lunch if it's a morning day and then try to work through lunch sometimes, depending on how busy the day is. And then the afternoon starts at 1, goes to like 4.30 or so. Well, I'm slightly different, but almost very similar to Anand. I'm mostly in the hospital, so it's almost like a hybrid GI hospital is, but doing procedures mostly. So I do, you know, three, three and a half days sometimes of procedures in the inpatient side, obviously seeing consults and taking care of general and interventional cases if needed. I do have clinic, it's maybe you can say half day or three, fourth day, but I do procedures also before and after the clinic. And then obviously, you know, one day I spend on the admin side. So, but usually we start at 7.30 sharp, so I'm usually there 15, 20 minutes early getting things ready. And you know, we try to finish by 4, that's where we lose anesthesia for us, but the procedures and then do rounds if needed afterwards. But that's the usual day on the clinic side. I do procedures in the morning, then my clinic starts at 9, I like to finish by 2.30, 3, then come back and do some procedures till 5. That's the typical day. I'm feeling they're taking out a lot of other academics' work that we do, but we'll get to that as well. So I have a slightly different kind of schedule. I used to have half days, et cetera, but it never worked out well for me. I just found out that I'm a big separator. So also wearing multiple hats as well. So for example, Mondays and Tuesdays are my clinic days, but in the morning I have it for telemedicine visits, starting at 8, and then about 9 o'clock I'll start the actual clinic. I've actually learned how to do intestinal ultrasound, so I'm doing intestinal ultrasound in my clinic patients with inflammatory bowel disease. So I'm incorporating that into my clinic visit. So I'm actually be able to do point-of-care testing, assessing the patient, making decisions right then and there. So Mondays and Tuesdays are my full clinic days doing intestinal ultrasound. Wednesday is my full day of endoscopy. Thursdays and Fridays are my admin day, taking care of the fellowship program, doing IBD research, traveling to conferences. It seems like there's a conference every other weekend for IBD now. So it's like Fridays are now becoming my travel days, trying to work on the plane and writing the next manuscript or the next presentation. So that's kind of how typically it's been. But again, that's our typical clinic day, but with all of us being in academia, we're also required or we have this passion to do research or publications and teach as well. So somewhere in between all of that, it could be on a plane, it could be before we start work or procedures, or even after we're done and after other meetings, we're then trying to finish off a paper or think about a research idea or try to meet with our fellows to kind of say what they want to do and make me write the next abstract for our next national meeting like DDW, ACG, et cetera. So we kind of try to incorporate that as well. It's hard to incorporate it because in our routine, like, I don't know, 7.30 to 4.00, 5.00 day workday, I used to bring a lot of work home. And I realized that when I'm at home, I just can't do it with kids, I don't want to spend time with them. So I end up staying a little bit later in work just to get that stuff done. So even if it's an hour later, and usually by then people have left work, so no one's really bugging you in between, I get that done. And then I go home and I can actually say, okay, no more work, I can focus on family. That's kind of how I've structured it. It took me, I don't know, 10 years to figure this out, but it works a little bit better now than I was trying to figure it out for the past 10 years or something, yeah. Okay, you guys are really shy. Oh, there's, oh, wait, that's Ed, he's asking other questions. Well, let me help kickstart the coffee a little bit for everybody. You know, we, I think, routinely hear about how staffing changes within the healthcare system and in endoscopy units, gastroenterology, general clinics, have impacted your practices. Can you describe a little bit about what that is like for you all or amongst your colleagues and has that had any impact on your day-to-day working relationships with industry, your local industry reps? I'll start again. I'll take that. It's significantly impacted in terms of what we do on a day-to-day basis. Not so much the interactions with the industry, but indirectly, yes. So every health system, especially in the area that I'm working in, in Philadelphia area, and I'm sure you guys also will support that, is experiencing significant staff shortages. We actually have lost our dedicated MA, who rooms our patients, dedicated nurse practitioner who takes the phone calls for our patient, and dedicated scheduler. So the three people who have gone in the last six months. And then we're kind of, you know, working with temporary people filling in those positions. And when that happens, you know, the usual flow indirectly from industry reps or whatever who are trying to make appointments to come see us, et cetera, that gets affected because everybody is overburdened with the clinical work that they are, you know, bridging from the staff that have left. So it adds burden for, has added burden for us in terms of making sure our patients get seen in an appropriate, you know, time frame, get scheduled appropriately, et cetera. But it also does interfere with our ability to interact with industry. We had a period of time, actually, where we had a shortage of nursing staff in endoscopy. And at a certain point, too, endoscopy techs. And so it was stuff like we would schedule patients, but we wouldn't have rooms to put our patients in. And that would delay our day, and especially in our inpatient rounds, which is not the typical stuff that we talked about. Those, at least, we're now getting to 50 or 60. Last week was like our, we had 65 patients on our general GI inpatient service to see. And typically, that means like about 10 to 13 cases of endoscopy that we have to do, and then go around, and the other 50 patients are in the hospital. And so we can imagine our day starts at 7 and ends at 10 p.m. or so in those days. And after that week, we're like, I need a vacation from work. But you're just back on again, you know. But during that time, if we didn't, if we were, you know, if we had one less room to accommodate these patients, then we're just waiting. And sometimes, we would start our last case at 4 p.m. or even 5 p.m., and sometimes we lose anesthesia. And it's like, it's been, it was a huge impact to our day-to-day practice at that time. Things have gotten significantly better, but, you know, people get sick, and there's always some something going on, or anesthesia leaves, and it's like, oh my gosh, everything, all hell is breaking loose, because we got to, they got to find somebody. And then if they, you know, and of course, most of the patients that we see in our tertiary referral center, like, they're like ASA-4s, meaning, you know, I don't know if you know the ASA gradient of, like, ASA-1 is American Society of Anesthesia, like, one is like someone who's completely healthy, you're 18, 19-year-old with no symptoms, and, you know, we're doing an endoscopy because of reflux or something, and they're healthy. And ASA-4 is someone who's on hemodialysis, has an echo, you know, like, has a, sorry, you know, a heart pump, you know, and, you know, has like a creatinine of five and hemoglobin of two, and, you know, like, it's just, it's just crazy, just, you know, the sickest of the sickest. And sometimes we don't feel comfortable doing moderate sedation for these patients, because they need a lot of monitoring. And so if we don't get them done, then forget it, either we have to wait until the next day or, you know, whatnot, or if we're in the ICU, have to be very closely monitored. So it can be very disruptive to our day to day and just delays our patient's care and also our day to day life as well. For a while, we were having a lot of like, you know, through the pandemic, a lot of traveling nurses and substitutes because of the staffing shortages. And so you didn't have well trained people either. And they were just kind of didn't know as much about the GI world and kind of just trying to jump in and fill in where they could. But that significantly impedes your efficiency, not just an endoscopy, but clinic or rounds, like a bedside nurse who doesn't know how to manage a GI bleed, for example, has never done that. So you know, those things all in turn just led to not as good or efficient rounds and not good patient care. So yeah, it absolutely impacts us. And then if somebody, you know, comes in and wants an appointment with us to meet that, that's how the indirect, you know, we are, our bucket is full. And so then it's hard to make time. But I think it's gotten better since then. Yeah, no, I echo the same thing. I mean, at UT Houston, we face the same in our hospital system, which is a Memorial Hermann hospital system. We had a lot of travel nurses in the pandemic time, and then some of them are not well trained. And it was very hard for us to manage cases, especially for me doing inpatients, a very large volume. And post-pandemic also now we are getting a little better, but still we keep losing, as Anand was mentioning, good trained, well-trained people, either they move on or they get a, you know, different idea. And then some of them actually, one of our, two of our techs moved to industry, believe it or not, as territory manager for sales and all the things. So then again, we had to train them and it's a long process. And then the, there's a question, I mean, what happens like now, we work a lot with the industry associates and partners and they come and sometimes, you know, like to see some procedures, but a lot of times what happened, we are in a rush or just the timing doesn't work out. So it's a little bit frustrating for us, but I think they understood over the last two to three years how things went and hopefully it'll get a little better in the next, in the next few months or so, you know, and hopefully we can, we can partner much better. Obviously our hospital system has now new policies when the industry folks come, how to interact and, you know, how much time we can devote and things like that. But it's definitely going to be a very smooth, hopefully. The silver lining is that because of the fast turnover of staff in the endoscopy unit especially, we've been having a lot more in-services for the staff. And that is, you know, not you guys from the industry devices especially, or it could be, you know, other things that we use routinely in the endoscopy lab. Coming in to train our staff more frequently than what we have, you know, previously encountered just because of the rapid turnover of staff. So that's definitely, you know, opened up more doors for the staff to interact with you folks. Not necessarily for physicians, but, you know, once the staff is trained, then it opens up, you know, door back into the lab for industry. So you hit the nail right on the head. I'm starting out, you know, I'm going to learn, you know, GI and, you know, I'm hearing all of you guys start at 7 o'clock in the morning every day and you're till 3.30. Where's there time for a rep to come in and speak with you guys? Because I am seeing, I'm in Los Angeles. And you see them at 7 o'clock in the morning, 6.30 at times. And they're doing 15, 20 procedures, especially when you're talking about the hospital. You're constantly, and I'm sitting here saying, okay, where am I going to find time to speak with you to get to know a Pentax rep, you know, even if you're using Olympus or you use Infusionon. And it's like, I'm trying a lot to find where's time that I can meet with you because the staff, your short staff too, a lot of staff is the, we don't want a sales rep here. We don't want time, you know, just you to spend. And I'm trying to do, let me sit in and see cases so I can sit with you. But some doctors are very standoffish on that. But then there are a lot of doctors that are willing to give their time to say, hey, come on in and, you know, sit in with us. So my question to you guys is, I know you guys are so busy. When is a good time for us to actually, you know, come in to speak with you about our? I'll start off. Actually, it's a good point. That's what I kind of raised. So now in our health system, we basically have a devoted time. So actually for me, it's a Friday because I do less procedures on that day. That's the time I interact with the industry folks. So we kind of, you know, every one of us have developed a day in the week that we can now interact with the industry reps. As you know, we deal with different devices, different scopes. So Friday is my day. So for others, I think there are different days. And we just make an appointment and we just tell our charge nurse that the industry people will be coming in and this is a devoted time for us to interact, yeah. It's probably best in the sense that because we don't know how endoscopy is going to be if we're running behind or in the rare case that we're actually running ahead, which I don't know that, I don't, extremely rare case that, yeah, extremely rare that happens. But and I see, I do see my device reps and they don't have too much to interact with me because I'm just like, I just need a biopsy for this and I'm happy. You know, I need my methylene blue and I miss my spray pump and they're like, so I don't think they mind too much. I don't see them, you know, very often, but you know, 30 minute cases, all these stuff like you, you have literally like minus two minutes to go and say bye to the first path and come back, et cetera. So I see them and I'm like, you know, I'm like usually running early down the hallway. I'm like, oh, hey, hey, you know, so, and so, so, and so I'm like, oh, it's good to see you. It's good to see you too. Okay, bye. You know, type of thing. I think that it, you know, if you really need to, especially, especially for your therapeutic endoscopy faculty, I think it's very important or if there's something new that's there that you want a general GI to be aware of. I think I learn more when, you know, there's like an in-service, for example, and it's an in-service, not just for the text, but we can come in and go, oh, that's a cool new device. Okay. I can, and if I, you know, have time or I'll just make the time to come in and go, oh, that's okay. You know, it's like a two-second version of the, you know, 10-minute talk or a two-minute version of the 10-minute, you know, presentation you did. And I feel like I can learn more because I'm also interested because if it's something that I'm not going to be doing on a day-to-day basis, then, you know, it's not very, you know, useful. So, I guess, you know, dedicated time, especially if something that's going to be specific for a therapeutic endoscopy that you know is going to be beneficial. If you can't see them on a routine, like you show up in endoscopy, it may be actually good for you to reach out to their nurse or their staff to see when they could be available. And if they're not available that day, maybe they can, you know, find another time specifically to meet with them. Yeah. Yeah. I'll just echo that as well. So, I think for me, I'm general, unlike these guys here. So device, a few devices come along that really are pertinent to us, you know, because it's kind of established endoscopy, colonoscopy, but we're having a lot of advancements like in Barrett's and polypectomies and, I mean, lots of devices are still affecting general gastroenterologists. So, I do like to interact with industry because I want to know, I mean, I may not hit every conference to go check out the industry floor for tools, you know, so I would like to know ahead of time if something is coming down the pipeline. So, I've had two different interactions. Some people just show up and then they're there for like a couple hours in the morning, depending on their day, you know, all the different hospitals they may have to hit. So mornings are generally the best because a lot of people are in the morning and the afternoons, you know, a lot of folks are doing clinics, depending on our varied schedule. But you'll definitely see somebody in the afternoon if that's your time to go to that institute. But some people just show up, so they just bank on like, you know, hit or miss type of interactions. And then I think what he's, Dr. Guha mentioned about having dedicated an appointment base. So I've had industry apps just like text me and say, hey, I'm going to be in this area, you know, if you wanted to just stop by and let me know your needs or I had one more thing I wanted to tell you about. Okay. And then I let them know, well, I have schedule, like this is my schedule for that day. And maybe we can find like a 10-minute block between this, you know, hour. And so, you know, we also have to make time if we want to interact. So it's a two-way street. And then also the in-service is very helpful. Our hospital, it doesn't always work, but sometimes we like to put the in-service on our faculty calendar. And that helps me because, you know, somebody told me three months ago there's going to be this device rep coming three months later when the tool, you know, hits the market and everything. Okay. Well, I don't remember that three months ago. So now that it's on my calendar, I know to show up and check it out. And I think that does help. You know, it's a lot for our fellows and our techs and our nurses, but we're also listening and learning and troubleshooting with them. So I think that's neat. And then the last thing I'm going to say is if I am doing a procedure and I find that something I don't have, and maybe there's some innovation or something, I'll reach out to that particular industry person and say, you know what? This tool doesn't work very well for what I need. Do you have any other suggestions? So we also reach out and that also starts the conversation, I think. We have time for one more comment. One more comment? Okay. So I'll just, you know, add a couple of things to that because, you know, I do advanced procedures and this could be a little bit different depending on, you know, which place you're contacting and which people you're working with. But I generally tend to get folks on my advanced procedure days because our procedures tend to go a little bit longer than normal. So we do have time to kind of, you know, chat while the procedure is happening. I do ESDs as well and those take, you know, sometimes up to four hours. So we do have industry reps coming in. I ask them to come in at that time. If there is a specific product that they, you know, I need to kind of have a focused attention on, then I would just bring them, you know, in my lunchtime on my office day on my day that I'm seeing patients in the clinic. So there we have a little bit more sit down discussion about something more specific. But usually, you know, it kind of works that way with the advanced procedures.

gastroenterologists

schedules

staffing shortages

industry representatives

interactions

advancements