Yeah, I heard a couple of you mention that the surgical team will also take a look before they make their decision in conjunction with your medical opinion as well. Are they looking at just the findings that you came up with in your work, or do they do their own sort of tests? It's mostly the cross-sectional imaging data, and also our endoscopic ultrasound data. We are talking about the pancreatic mass, right? Yes. In that case, then we sit down with the surgical oncologist to decide the next steps. Yeah, a lot of it also with the patient's medical comorbidities. They would have to independently assess the patient. They also look at the social support, and all of that factors into their decision-making as well. I think most larger institutes have a multidisciplinary tumor board that these patients are typically presented if it's not straightforward, where there's oncology, GI, and surgery and radiology involved. And so they discuss each case, and they review it, come up with a consensus, and that's what we do moving forward. So that helps as well. And that goes for a lot of areas in GI, not just pancreatic cancer. Even when we're talking about, like, for example, for IBD patients, sometimes it's a question if they have a complex fistula where small bowel and colons, everything's matted together, and there's inflammation, and there's stenosis. And do we go forward for surgery? Well, if you do, then they have to take a whole bunch of small bowel and colon out where the patient's going to be at risk for short gut syndrome. Or consider doing medical therapy, put them on nothing by mouth, put them on TPN for nutrition, and wait six, eight weeks. So it's like a lot of things that needs to be done with the multidisciplinary care. You don't want to make a decision on your own. I tell this to my fellows all the time. If you have a complicated patient in front of you, you don't need to make that decision alone. It's better not to make that decision alone. Talk to colleagues. Talk to your consultants. Go and look at the image with the radiologist to get a better understanding instead of just going by what the report says. Because often you might get a different understanding by maybe having another radiologist review the case. Or if they understand what the patient's history is a little bit better, then they can actually look for something. And so having a multidisciplinary team can be hugely beneficial. We don't have to do it alone. I think that's one thing I keep telling my fellows, like if it's very complicated, don't go at it alone. Get your team together. And whoever it may be. And you never know. Like you might come up with a better idea after you talk to somebody else. Or with the multidisciplinary management, the patients feel better. Because they just say, oh, I had this, but this is what my decision is. No, no, no. We met together with the entire team. We had everybody look at it. And they feel special because it's not just one person making a decision. We made a decision together, put all of our brains together, figure out what's going to be the best outcome for that patient. And the patients really appreciate that as well. Do you guys deal with pediatric patients? And if so, do you find that you have effective tools to treat them? Yeah. So I used to have a transition clinic for the pediatric patients coming because it's a chronic disease. The majority of these patients get diagnosed young as well. I only see 18 or older. I did attempt to see some 16-year-olds. But when they get admitted, they would have to go back to our Texas Children's Hospital. And I don't have access to their care anymore. And I'm relying on the pediatricians and PDGI. So it just became a mess. And they had to come back and wait for them to come back to a clinic. So I stopped doing that. When I was at my prior institution, Baylor, I had a transition clinic at Texas Children's Hospital, their PDGI. They were 18, though, but I would help transition them over. It was not a very efficient clinic because the PDGI saw them, the PD nurses. It was like a goodbye party and trying to get all their documentation, their history. The parents wanted to know all these questions and answers and all of this and very inefficient. It was great for the patients and the parents. But once I moved over to my current organization, at least I've established the relationship with my PDGIs. So if they have questions, they will contact me. And when I do the multidisciplinary conference, we include them in there as well. They can listen. We have Zoom now. And sometimes we have some patients I've been seeing for several years, and they came from one of my PDGIs. So I like continuity of care. So I do do that, but not very often pediatric, like as far as less than 18, because technically it is more of an issue. Having said that, at least I can be different. I'm curious to see what they say. But from the IBD side, medications get approved for the adults way faster than the pediatric. So they're typically learning from us. I actually saw a cute little meme. You know Mr. Bean? So there was one about him. He was taking a test. And there's one guy there that's actually writing the answers. That's the adult IBD GI. And Mr. Bean is the pediatric IBD GI. And guess what Mr. Bean is doing? Looking over to see what the adult IBD person is doing. And I was cracking up. I was like, oh my gosh, I have to put this on a presentation, because it's exactly what the PDGIs do. Because the medications are already approved for us and adults for pediatric. They're like, ooh, can we use it? And it's not FDA approved yet. It takes like a decade almost. So they have to go off-label. And they ask us often, what are you doing? So we can do that too and try to get it approved that way. Yeah. I agree. I mean, I think there's multiple gastrointestinal disorders that require transition. And Dr. Abraham sees a lot of IBD, so do I. But then there's also, you know, synophilic disease, there's gastroparesis, there's reflux even. So lots of disorders continue from a young age on to adulthood. So I would say tools-wise, no. I think what Dr. Abraham said is accurate. Like, we have more tools. Rather, we are putting them on, you know, first-line agents rather than these supportive drugs because they weren't approved in those age ranges when they were younger. So they actually do a lot better when they transition to us and become 18. But we also found there was logistical issues, like taking on like younger patients, we're not PALS-trained, most of us are not. You know, if there's an emergency in endoscopy, we were not able to be, you know, actually able to resuscitate actively because we are not certified in those things. So we as a group decided 18 and above was our kind of more legally safe realm to stay in. From the interventional point of view, so we actually do see occasionally pediatric, but when I say pediatric, it's 12 and above. We do have pediatric upper endoscopy, pediatric colonoscopes, you know, and then there are also 5-millimeter, you know, scope available for the pediatric patients. The tools are a little difficult. We don't have all the tools available to do all kinds of therapies that we do in the adults, but we can manage. For the pancreatic biliary, simple sphincter atomies and gallstone extractions, we do have those tools for the pediatric people. But again, our experience is 12 and above. We haven't done anything below the 12. In Philadelphia, we have two big pediatric hospitals, and they do not provide any advanced services there. It's like doing ERCPs, EUSs are rarely needed, but doing ERCPs or deep endoscopies, they are not offered. So we do get referrals from those folks to come to our place, and we have done procedures in folks as young as 11 months old. And unfortunately, for doing ERCPs, we still have to use the adult endoscopes, adult ERCP scopes. There used to be Olympus, used to have a thinner diagnostic ERCP scope available, which they no longer make. So if you're lucky to have it in your inventory, you can use it, which most of us don't. So we end up using adult devices and adult endoscopes in even kids as young as that age. So it's not ideal, it's not optimal, but we can still get by and do those procedures in those folks. In terms of the anesthesia-wise, in such young individuals, we bring in the pediatric anesthesiologist along with the patient to come here. So it's a big enterprise to do that. But the reason the services are not offered in the pediatric hospitals is the conditions are rare. Those pancreatic ability conditions are rare. So even if somebody gets trained in it, they just don't have enough volume to be able to do it efficiently and effectively. So that's how they end up coming into the adult hospital for that. So when you say that it's not ideal using the adult scopes in the children, in what way? Is it that it's just the passageways are too small? Or is it just you feel uncomfortable using such a large scope in a smaller person? Sort of both. The esophageal lumen is pretty small to pass such a big endoscope through it. And remember we talked about the ERCP scope being a side-viewing scope. So there is not a direct view. You're kind of guessing where your lumen is to be able to advance those scopes. So there is a bit of comfort level as well to it. But also the endoscope's a little bit larger for those bodies. Plus you end up in a position, because they're really small, you don't end up in the same position as you normally end up where you're visualizing the ampulla in a certain way in the adults. Here you're looking at it differently. More advanced endoscopy question, but do you guys ever do stuff with EBUS, like endobronchial scopes as well? Or is that the role of someone else in the hospital? Those are usually done by interventional pulmonologists, the EBUS. They sometimes use the same processors that we use, but the scopes are different. So besides the EBUS when we all die, what's one thing you do for fun outside of the ER? Do you have any family, or something, like pick a wall, or something like, what do you do for fun outside of the ER? I have a miserable life outside, beyond the hospital to be honest. Most days, by the time, I have about an hour commute from the hospital to home as well. So by the time I go home, it's usually around six or seven. So my goal when I go home is to be able to spend some time with my little one. I have a four-year-old in the house. So that's sort of priority. Before, I used to play tennis. That was one of the things that used to keep me active outside. But now it's just spending time with my little one and wife at home. Right. So I think we can all probably attest to that. Because as you learned, our days start early and end late at times. And we have emergencies that we come in for, depending on our call coverage. So personally, I have two little kids. So I am trying to get home as quickly as possible. But also trying to balance that closing your charts, and trying to not carry work home is a challenge. It's because you're always at home. Some ER doctor has your cell phone. Even though you're not on call, you get a call. Or somebody wants some advice. Or some family member is like, I have abdominal pain. So you're always kind of on. And you have to create boundaries. And sometimes that's really hard. And that's a learning. I'm still learning. I think Dr. Abrahams figured it out. But I like to 10 more years, right? You've got to figure it out rapidly, though. So I also have a husband who's a physician. And I think that's also hard to balance work-life between both of our work schedules. So we've kind of started figuring things out. And I like music. My husband and I are trying to get more fit. So we have exercises that we try to do. And sometimes that's when you do things together, to spend more time with your families, do an activity. And then I have a husband who's a doctor. So I like to spend more time with your families, do an activity. And then I like cultural Indian dancing. So I do that on the side. So just something to enjoy for yourself. Well, I think you already heard. For me, it's almost the same miserable life that Dr. Kumar was mentioning about. But I used to be, actually, let me go back. I've been doing this for almost 25 years. So my kids are out. We are empty nesters for a long time. But now, actually, I've tried to balance work and life. So I try to come home. And I love attending music festivals and different other festivals that we have. So pretty much busy on those. I do love sports. So I go and watch different sports events. In Houston, we have quite a few of them. And that's mostly on the weekend, though, and travel. So like this and others. And so hopefully I can get coverage. And my junior people now take care of those. Obviously, it was just like what Kumar was saying. I mean, yeah, I used to come pretty late, actually, 7, 8, starting the day at 7. I also have a long commute, close to 45 minutes or so. So that adds to it. I guess I'm glad I didn't become a therapeutic endoscopist. It was part of my career path at one point in time, but I'm glad I did IBD now. So now my kids are older. I feel like I can breathe a little bit. They're in their teens now, so they kind of keep to themselves, which is quite nice, although they are missing me because I've been on the road for the past three weeks everywhere. So a couple of things I like to do. I'm a big avid reader. Took me a while to actually get back to reading, but I stopped reading novels. A lot more self-help books than anything else. I think it took the 100th month in 10 years to get to where I am. I feel like I'm always learning something. Yeah, so reading a lot of books and different aspects of that because I feel like I need to get away from just GI knowledge and all of that. So reading books is one of my favorite pastimes. Secondly, I play badminton. We have a little group in our church, so they're always bugging me. They know to not bug me on the weekdays. There's no way I'm this exhausted after work. The weekends, I'm like, usually they just think I was always up in the air because every time they ask me on the weekend, I'm at a conference. But badminton, when I get a chance over the weekends, I love to play. It's also good to get some exercise in. When we have events at our church too, we'll do some classical dance as well, anything that's always fun. But those are the main things. So badminton is my go-to. But my other little vice is I don't take anything to go to sleep when you're really stressed. I play Candy Crush. That's my little vice, but it helps me go to sleep and relax. I'll let you guys guess which level I'm on, but that's for later. She's competitive. She's probably high. She's competitive with herself. We're also human. We have the same vices as anybody else, or patients, just because we're doctors doesn't mean we don't do that. Binging on Netflix, so that's another thing I do. I'm sure everyone does that, but I can tell you if I have a weekend, I'm at home, I'm not at a conference, I'm not on call. Sometimes I lay on the couch, and I get frustrated when the TV goes, Am I still watching this? I'm like, yes. Let me keep watching this series. It's been five hours, but I don't care. So another vice, Netflix. So I think you touched upon this this morning, and we hear this almost in every ARIA course, and I think it's always good to end the day on this note. But if you were to each think about what your ideal relationship with a rep is, what is that and why? I think it would be good for the group to kind of hear your perspective on what's your ideal. Think about your ideal rep that you've had in your career, past or current, and what made that such an impactful relationship for you? Let me start. Like my impact, well, my main relationships would typically with my pharmaceutical reps because IBD is more, you know, like, yes, my Boston Scientific, they're there, and I work with them closely for like our training of our fellows and setting those things up as well for endoscopy training. However, I can tell you more from my relationship with my pharmaceutical reps, I know the bad ones from the good ones essentially, but I think it's also like learning that relationship over time. So the ones that, the bad rep, I mean, they're not really bad, but you know, like the worst relationship are the ones that expect you to see them anytime they come in and you're running behind in clinic and they wanna talk to you for five, 10 minutes to explain, oh, how do you position their medication, the whole treatment of IBD, which could be an entire, you know, day's lecture on all the complications of that. Like, I don't have time for that, I feel bad, but I don't wanna feel bad because that patient's waiting, you know, that type of thing, versus someone who sees me running around and they know they wanna talk to me, but they already know I'm busy, it's like, oh, they're gonna come back another day or just say wave, hi, and I'm like, hi, okay, bye, you know, that sort of thing. But I think the ones that, at least from the pharmaceutical side of things, the ones I have are the ones that are there for you when you need them and take a step back when you don't necessarily need it, in the sense that if there's something new for their product I've been prescribing for the past 10 years, then sure, come and let me know about that, but don't tell me data about their drug that I've done the studies for five years ago. So I think knowing where you are in your field of space, I think it's important, or when there's a new drug and it's for an IBS drug and I don't know anything about it because I don't really treat that, but sometimes I have patients that have IBD and IBS, I wanna learn about it, I'll actually go ahead and if they're coming in for an in-service or something, I'll actually go, okay, tell me about it because I wanna know, but that may be all the interaction I need with that rep because if I have more questions, I can reach out to them later or talk to my colleagues that are experts in IBS for other things. So it really, it's depending on what you need from them and what they need from you and making sure it connects, but also knowing when to approach, like you were talking about, how do we get to you when you're behind an endoscopy, you're setting up a time, if there's something really important that you wanna discuss with us, say, hey, when would be a good time to meet with you type of thing, yeah. Yeah, I mean, we have a little different but almost similar ideas. As I mentioned before, we have dedicated days. For me, I'm spending most of the time in the hospital doing procedures, I just only have one day or three fourth of a day maybe of a clinic. So the second and fourth Fridays in the morning from seven to eight, the reps come and do the in-situation, the reps come and do the in-service, but also at the same time talking to me, going over different products, different things. On the other days also in between procedures, they usually reach out because I guess I know them now quite well enough over the years and the time that I'll tell them that, okay, come so and so, and I'll have a gap in between procedures where I can sit down and go over. But as Dr. Epnam was mentioning that, I think the key is that we need to, it's a two-way road. I mean, we actually ask them what devices or what products you have and then we go over the data critically, but I give my honest feedback though and that's very important for them also to learn what are the pros and cons of these different devices because then they can take that back to their office and discuss it further. But I mean, that's the way usually I function and as I said, normally we have kind of a little strict rules like we do have a program where the industry representatives can come and watch cases, but we actually ask them to make appointments beforehand so that the nurses and everyone else know that they are coming in and watching. And also it's important for the patients to know that there'll be someone else in the room watching the procedure. So that's the way our function goes. So I'm more like Dr. Abraham where I'm less advanced therapeutics and more general gastroenterology. And so dealing more with pharmaceutical representatives, but I still do like stent placements and snares and other tools, basic tools. So for me, it's important to learn about what's coming down the pipeline, what's the best. I mean, there's been new innovations even in old technology. So you're never immune to like meeting new, learning about new things. But that being said, you need space, breathing space, because we're always like running around. So if today's not a good day, I think a respectful rep or a good rep, quote unquote, would be somebody who sees that, acknowledges that and finds another time to still relay their information or it's a symbiotic relationship I think we were talking about. So we also need to learn and sometimes that's the best way is one-on-one instead of a large meeting. So sometimes that's good. And then also to give feedback. So if something is not working the way you had hoped or you have a recommendation, it's important for us to also communicate that not everything has to be a perfect review of everything. And I think for a representative to be able to take that negative feedback also is important, not to like judge you specifically directly about that. And sometimes you can tell that they don't take negative critical feedback well. So that I think also allows your relationship to grow if you have room to give that kind of feedback or somebody like really pushing, like I actually had a patient who came to see me and she was a rep for something else, but not in GI. It was a cardiology rep for a Watchman actually device. But she was just the whole time, like the whole interaction was like, you have to come to my dinner talk. I will give you a dinner talk. And I said, so I finally had to create boundaries. I said, I'm here to take care of you as a patient. We can talk about that in a professional manner other time, but frankly, I'm not interested, period. And that was the line. And so that needed to be drawn because they were not reading the potty language and every other way to say, look, we're not interested in this. So I think that's what makes a good rep is it's to understand each other, understand the niche that that provider is practicing in and how to educate them or promote your tool that's specific to their practice also, not just generally. So my interactions are more on line with Dr. Guha, but in terms of from a rep standpoint, representing your particular companies, I think it depends on like what your motivation is, right? To come see us. If you're in the beginner level, like some of you are here, your goal is to try to learn everything about this new person that you're gonna be meeting. What sort of, what their practice looks like and what their procedures look like, what sort of devices they use and try to identify and you're trying to identify where the gap is that you could fill with your devices if you're not the person, the devices that are being used. So as a beginner level, what I would like to see from a rep is to reach out to us, introduce yourself, make appointments on a day that you can, especially for folks like us who are doing procedures, you would come in and just shadow and observe procedures without necessarily marketing or giving any input from your end. You're just watching and understanding how this practice runs, how these procedures go, what this person specializes in and what kind of patients they see. And on the other hand, a more mid-level person, somebody who's been doing this for a while, but then now you're trying to, you have a new device that you're trying to promote or you have a new technology that you're trying to promote. Those folks, you want to set up an appointment where you can come see us in the office where we are not busy doing something else, but you're coming and setting up an appointment in the office you're demonstrating your new technology to us, explaining everything. And if you're doing that, you have to really know everything about your device. You have to be taking it somewhere and you have to know who have experimented it with, who have done all the studies, and you need to know that information to be able to provide to us. And if that's been so new that it's not being studied well, then you are giving it to us to say that, okay, I want you to try it and give me some feedback. Then you're putting it into the procedure room and observing and getting that feedback. So from the qualities of a rep that I would like to see is somebody who understands what their need is and accordingly tailors how they would benefit from our interaction. Being flexible, following the unit protocols as well and being able to observe cases when they need to. And if there's a device that you're promoting, then try to talk to us in person. I just want to conclude perhaps in that sense of using that 80-20 rule. There are some providers that you may not need to see or you do, they're not gonna be very great relationship because maybe they don't use or not gonna do that type of procedure ever. But if you find out about that person and what they do in practice, you can figure out, oh, this person's really worth setting up the appointment, trying to reach out to versus another provider. Well, it's great if you see them, but if not, it's not really gonna be worth your time or it's not necessarily worth it for you to really work on trying to get to know that person. So I think it's important to know who you're working with so that you can actually put your most effort in establish the relationship with that provider. I think that's huge. And then I was actually thinking of, there was one interaction, it was actually more recent, where I had what not to do, like this is in the pharma world, but it could be the same thing in a device world where they said, oh, we have this new drug out, I want you to consider this in your next patient with ulcerative colitis. And I mean, I'm typically a very laid back person, but my, I was like, you do not need to tell me to use your product on the next patient I'm gonna see. Well, how do you know my next patient? My next person could be completely in remission. Why would I use your drug and change something from a person that's doing well? Or my next person probably failed a different, similar medication with similar mechanism of action. I'm not gonna put this person on this medication. So it's like offended, like, really? Do you know the type of patients I see? I can make a decision on an IBD medication that I've been doing the research with or known the mechanism. Just don't tell the provider, use this product or use this for the next patient you're gonna scope. Like, it makes no sense. Like, I was actually flabbergasted that they said, I want you to use my drug on this. And it wasn't even a rep, it was a different level. So they didn't maybe know me compared to my local rep who apologized, profuse, like, oh my gosh, I'm so sorry. They said that and I can't believe they said it. I would never do that. I'm like, I know you wouldn't, but yeah. And they didn't know me because they came in, you know, trying to meet all the providers and it was the wrong thing to do. But that was just a funny story. I was like, I can't believe she told me how to practice medicine, but okay. But I had to like, again, put boundaries on, said, actually I can't do that because of whatever reason. And she ended up sending me a thank you card for meeting with her later. But I guess sometimes you don't know, right? But you just assume that's the right thing to say or do, but it's often not because there's, as you can see, like there's so many intricacies in medicine. It's never like someone falls into, okay, this person's gonna be the best for this procedure or medication. There's a whole practice of medicine aspect that every patient's so different and we have to use that art of medicine to figure out what's the best for them. Yeah, we have about five more minutes, four more minutes. Well, I have half of a question to what you just said and then another question on top of that, so I'll keep it short. So basically, would your preferred conversation with that person have been to say, you know, we have this drug, which patient do you think this medicine might be ideal for? Or what would you have preferred to go differently with that? Yeah, so they would say, what would you see this fit into your practice or general of managing these patients? And I would say, well, if this person had failed this medicine or had severe disease or this location, I can explain that rather than use it for this next patient that you have. So, and often, you know, we get, our brains get picked because we're like experts in our fields, right, of whatever we do. So that's a valid question. So they can take that back and get that information. So, well, I talked to so-and-so and they're using in this field or, you know, whatnot. And I think that's reasonable, but not to say, you use it for this because they, you know, you guys know our patients really well. Like, well, not really. So yeah, yeah, that's what I would, that's true. Okay, great. Now, and then my second question would be, it's kind of going more about GI bleeds. So say you're doing a poem and you see a bleed in that case and there's in-servicing going on with the rep, typically it can be sometimes a tense environment based on what you're seeing. So if there's newer technicians in the room, kind of what type of support would you be looking for with training or any type of like, you know, guidance or support from the rep or from the company with that? Yeah, so, yeah, it's a very good point. So for doing all these interventional procedures, I mean, you mentioned poem, we tend to use obviously trained person. That's why we like to consolidate all these procedures in few locations. We don't do it in every hospitals. Unfortunately, we don't have a training program for the endoscopy techs for every procedures, but we do have, say again, specializing in interventional. We do have techs who are familiar with these. So I will then, from the industry perspective, I prefer that if you all can come and also help with the training part. So that'll be very, very, very helpful. And again, in not all hospitals, but few. That's what we like to consolidate. So at our hospital, we do have in-service. I think it's once every few, once a week, right? Yeah, and even if it's like an older tool, we'll still do an in-service if there's been an incident, you know, that week that a provider has complained about an issue, we'll try to address that with that. It doesn't always happen, but that's the idea behind that. And because sometimes there's varying degree of expertise from each tech as sometimes some technicians are only in certain rooms with certain providers who are doing just black and white, those kind of techniques. And so sometimes they have to float into another room and then now they're out of their element and they don't know, they've forgotten how to use, say, a device that they should have been educated on before. So those in-services, I think, are meant to hit those weaknesses or refresh. And it is helpful to have the industry rep there to speak, you know, the pros and cons or the niche to use that device in or the pitfalls. You know, you guys go around multiple centers. So you've heard from everybody's viewpoints, you can say like, oh, you know, we've noticed and so-and-so provider who does this a lot uses a special other, you know, suction and then deploy or something like that. Like these little, you know, pearls that sometimes can make a big difference and then our techs can pass that knowledge down to us when we're doing it, you know, at that time. So whenever I'm doing a procedure that, say, I haven't done in a while, so I would like run through a mental checklist of how to do it. I actually talk to my tech ahead of time, like, this is what I'm gonna plan on doing. This is what I'm anticipating planning on doing. Do we have all these, you know, things ready? And do you feel comfortable with it? And if they kind of waiver, I immediately try to eject them out of the room if possible and get another tech because I don't have time to do it wrong, you know, and we shouldn't do that to the patient. We should have the right team put together or they can use that as a learning tool and shadow a senior tech. This will conclude our program for the day. So thanks for coming actually. And I wanna thank all of our faculty for all their knowledge and expertise in training you. Hopefully you enjoyed it. And of course, give us feedback. And remember that you have to do the post-test to pass, okay? 80%.

decision-making process

gastrointestinal conditions

multidisciplinary team

collaboration

pediatric patients

building relationships

pharmaceutical representatives