We're going to move forward to our first one. So we're going to begin today with our day in the life of a gastroenterologist and this is part one of two. So if you have a question in your mind and you don't remember it, you're going to go back and you can remember it later because there will be a part two. So I'm going to open it up to the panel and then we'll get you guys involved and ask some questions. But I'm going to go to the panel here first and ask you guys a little bit about what factors have had the greatest impact on practice for you in the last five years and then how they impacted your practice. I'm going to go to the panel. I know. Should we start off with an easy one? Yeah. Start off with an easy one. How has everything that's happened in the world in the last five years changed your practice? You can go ahead. Good morning, everybody. See, we can't figure it out either way. So I'm going to start off with an easy one. How has everything that's happened in the world in the last five years changed your practice? I'm going to go to the panel. I know. Should we start off with an easy one? Yeah. Start off with an easy one. How has everything that's happened in the world in the last five years changed your practice? You can go ahead. Good morning, everybody. See, we can't figure it out either. Good morning. I don't have a great answer for this, but I think the last five years have been really challenging for all of us, especially four or five years ago with COVID, but I think a big part that has changed, and I don't want to say that this is the greatest impact in my practice, but some of the changes that we've had to deal with have to do with the ability to see patients remotely, to be able to have some of these meetings remotely, and how that's changed our day-to-day practice and ability to take care of patients. Part of my job as a clinician, but also who has an administrative role, I can have a greater balance between my administrative roles and my clinical practice by being able to meet with somebody by Zoom. If I'm meeting even with one of my industry partners, I'm able to do that remotely, not necessarily have to do it face-to-face. I don't want to say it's the greatest impact, but it's kind of just what has come to mind with me as far as something has changed and has impacted my practice of medicine over the past five years. That's a good answer. Thank you. I agree. Hi, everybody. My name is Kajuli. I haven't had five years of practice, but the five years behind me, including my training time, I'll sort of piggyback off of that. The COVID era has definitely changed all of us in a lot of ways, but I do think that in addition to having this beautiful virtual life that we all are living, 50% of our time is virtual most of the day, but I do think it has also highlighted some of the loopholes medicine has and things that we could definitely improve. It has highlighted the disparities that we have while we take care of patients and how we're providing care and how could we do better. That during my training has definitely had a great impact on me to realize it may seem like, oh, we're doing a great job, but we really are not. There's always room to improve in all the fields, but in medicine especially. As physicians, we realize how important it is to have and how blessed we are to have our support staff around and how blessed we are to have the support from the industry. A lot of times to make things happen, to get things possible, to do outreach, to be able to provide certain expertise of care in areas where it may not be certainly available. I think that has definitely changed my outlook towards medicine and has impacted my day to day practice as a gastroenterologist. I didn't. Now is it right? Okay. Those are really great answers. I probably should have tried to go first so that I don't have to follow them. I think one of the... I am maybe late junior faculty. I don't know if I would call myself mid-career yet. In the last five years, I went from being very, very junior in my position to being less junior. I think that the... I don't know what you guys think, but just the volume of patients that we've been seeing over the last little bit has been, maybe like three or four years, I think has made me into a far more efficient practitioner than I could ever have dreamt of being five years ago. I think that's really kind of the big thing. I'm seeing way more people. I'm doing it a lot more efficiently than I would have before. You still have to be good. You still have to have deliverables for every single patient encounter. I think that's been a big challenge, but I think it's also things kind of fun. I will add to that. One of the things for you guys to understand is, depending on where we're at, some of us are in academics, some of us are in honoring community. In academics, if you are trying this career trajectory, which is you typically started as an assistant professor, and then you move on to an associate professor, and then you would move on to a full professor. It's like the typical sort of hierarchy. For five years, that's usually the time for many of us in which we can move up for that next stage. That may be something as you're meeting a junior faculty in comparison to a mid-level and then in comparison to a senior that you may be seeing them go through. In order to get that, every institution's a little bit different, but one of the things, as somebody who just went through promotion, one of the things that you needed to do just to go from an assistant to an associate is you have to demonstrate a regional reputation. That's like the term that they will use. Then if you want to go from an associate to a full, you have to demonstrate a national reputation. That's something that you may see, and part of the ways to engage with, again, some of the young faculty and then even the more senior ones is that I've seen that part of my practice change as I've evolved. You definitely get more confidence, but confidence isn't always good. You find your practice techniques. I'm an IBD-ologist, if that's a word. I practice almost 100% inflammatory bowel disease. I don't see any patients any longer that don't have that, and I direct our inflammatory bowel disease center. If I talk to you about where I was five years ago to where I am today, it's a completely different mindset on it, but then also you start to change because now I've got people under me, which makes me just feel old mostly, but it's an exciting sort of step. I will say, though, and all of us, I think, in this room would agree, the single greatest thing that changed in the last five years was COVID. It changed the entire dynamic of the way we practiced medicine to the point that we have telemedicine at a part of our institutions as commonplace now. We regularly engage with different people through webinars and electronic methods, and a lot of things aren't as in-person, and I think that there are benefits to that, and I think that that is also limiting a little bit about that. I think that those are some of the things that really come to my mind when I think about what's changed. I want to open up the floor. Does anybody have any questions? It doesn't have to be about how our lives have changed before I go to the next thing, but does anybody have any questions that you would want to know about sort of the way that we practice and the things that happen in our daily experiences? As you guys are contemplating questions, I wanted to piggyback a little bit about some of the things that were said earlier, and you had mentioned in academia how you have the promotion process and also coming together. One of the things that changed for us also in the last five years to be able to have some of those faculty meetings, not going back to the remote portion, but to be able to get a wider group of specialists in the same room rather than being in person. So I'll give you an example. We have, in my health system, we have 22 hospitals, but we meet weekly with representation from all of those hospitals to go over every, I'm an advanced endoscopist, take care of patients with pancreatic cancer. So now all of a sudden you have expert representation from 22 hospitals on this one call for two hours to go over every individual patient's care, look at their CTs, look at their MRIs, look at their biopsy results with a pathologist who might be 20 miles away from you and somebody who might be two floors down below you, but you never get to see each other except for this weekly meeting where we're able to do that. So another way how things have changed, but as you guys are thinking of questions, I just wanted to throw that in there. Okay. Do you feel like some of the patients during COVID kind of slipped through the cracks because they didn't go to the doctor, they didn't leave the house? Did you see an influx of patients that had colon cancer or adenomas because these patients decided not to go or couldn't go to the doctor? Did you see that right after COVID? Yeah, I can take that one. I work at a county hospital and absolutely yes, we have seen more late stage diagnoses of cancer, more diagnoses of cancer in general, late diagnoses of a lot of chronic conditions, including inflammatory bowel disease. Due to COVID and inability to interact with the healthcare system or the worries that COVID came with, and then I think the reaction of the healthcare system to not even know how to navigate, I think gastroenterology as a field really got hit because we have a one-to-one interaction, especially upper endoscopy is a high risk procedure if we are dealing with a patient who is COVID positive or if there's any clinical concern of COVID. There are times when I was partly in training and partly in our practice when we noted that the patients are really, the follow-ups are not happening, the screenings were not done on time, patients were not showing up. We were not able to reach out to them. We were not able to offer those number of procedures per day sort of services. So, yeah, that really created a gap and now we are seeing a majority of patients as late stage diagnoses are missed. Yeah? What do you think about the idea of having NPs and PAs starting to help you guys out with procedures or seeing these patients? Because we know there's not a gastroenterologist. Actually, we talked about this this morning. So what is the future? We've been in gastroenterology. We don't have enough gastroenterologists, period. So do you guys see a future in using the NPs and the PAs for that type of usage? In training? We, I rely very heavily on the APPs in our group. They, actually the majority, maybe 60% of the patients that I am performing procedures on are patients that are coming out of our, like from a pathway where they'll come and they'll see the APPs, whether it's for GERD or dysphagia or colon cancer screening is a big one. So a lot of our screening population is initially being seen by our NPs and PAs and they're getting them into the lab a lot faster than they would have been able to get in if they were waiting around for an appointment with a gastroenterologist. So they've made a huge difference in my practice. I mean, I'm sure all of us. I'd say the same. I mean, the impact has been huge as far as the access that we're able to provide. Disclosure, my wife is a PA. So I'm very pro-APPs and the practice that they're able, and what they're able to provide. I think that as long as we're using them to the top of their license to what they're able, they're able to see patients, they're able to take care of patients, do a lot of the follow-ups that some of us might not have time during our procedures. The ASG just last weekend had, or Friday, Saturday, had a course specifically, a GI course specifically for APPs. And it was fantastic. I mean, it was a really, it was a home run with the information that was provided for them in order to make sure that they're getting the appropriate care. In our health system, we've actually recently started a fellowship for APPs where they are shadowing or working with other physicians, with physicians that are in the GI space but with other APPs so we can develop their practice. So somebody who might be one or two years out of their training, then they can spend some time with us and learn a little bit more about GI. And to be really experts in the field. Yeah, I will let you guys know. So the thing about APPs and nurse practitioners is the same thing as it is about DOs and MDs, right? It's all about how well we are educating the people that are in this practice. Like, are they going to play a role? Absolutely. I think as somebody in IBD, I will tell you one of my concerns in my field is I have two of the best nurse practitioners I will I will defend them to anybody in the country and but they are solid 100% IBD nurse practitioners I think where we have to really think about our field in its future is when we think about it in a community setting Right, so IBD is getting harder and harder and harder with more and more meds on the line So we just have to do things like dr. Kobo is talking about where we're educating people properly and we're not as Gastroenterologists leaving our nurse practitioners to just see very complicated patients wherein we're doing colonoscopies And nobody really knows what best practices are so I think that as long as you have some sort of a standard and that's again why this is so important and why Outreach in the community is so important is this long as there's a standard towards Education and we are doing what's in the best interest of patients and not in the best interest of business I I think that absolutely, you know, we can all work together Mm-hmm What what challenges and pressures that put on like your practice your staff and even yourself when you're trying to deal with this that growing Denominator of patients that need to get screened that leads to potential leakage in the system Burnout and things like that. So, how are you guys? What are those pressures and how are you dealing with that? I'll take that one. That's a great question. And that it's an it's an ongoing challenge and You know, it's in in our my hospital setting where I work being a county hospital There is you know, we're sort of like the safety net. So we're really not being able to Deny care and I think we the biggest change that we did was for example for colon cancer One things that they did in the very beginning of post kovat era is they changed? To you know to give preference to patients who have had like a stool test to you know screen for colon cancer So we sort of have one thing to go off of okay You're just you know people are at risk for colon cancer But these people have gone through a stool test and they're positive so they will get streamlined them first So, you know to risk stratifying those patient risk stratifying population. We've done that You know because we're our target population is huge the Cook County, you know, the community that we're serving is is huge and humongous. So We've we've done that well, obviously, you know in that to achieve a goal of providing care to all we have stretched ourselves thin and that You know and that there is that role of the support staff and we do rely heavily on the APB's We're training them not to be, you know focused on one condition because GI is also becoming subspecialized. We're training them to be You know be overall educated to at least be sort of the frontline people to triage because If we're doing the procedural aspect of it, they are really helping us with the clinical aspect and then Also sort of Educating, you know and and in addition to that our nursing or you know tax in our school in our endoscopy suite We're we're educating them as well. Because if we're dealing if you're risk stratifying these patients Obviously the patients are gonna come are gonna be more complex or if they are fit positive We're you know, the procedures are gonna be longer. We're definitely gonna find something When we risk stratify we also sort of, you know put ourselves again Like we put ourselves in a situation where even though we're doing same number of procedures Or maybe thrusting ourselves tend to do more procedures our time for procedures also going up So those challenges are all upcoming and we you know, figure out one and then we run into another so it's a vicious cycle But we're we're dealing with it. Yes. I I Don't think I don't think there's one there's one great answer to it Like you're speaking to a larger problem and we talked about that. We need more people in our field This I'll roll your question into the how industry so I I have a very close relationship with with industry and find it to be ultra important in in you know The way that I practice but I think that one of the things to sort of mitigate we were joking about this I have two nurse practitioners that are honestly more of the boss of me than and than anything But like they will constantly tell me like no is a complete sentence Like that's something that we have to have talks about I think life is peaks and valleys, right and you may have a time where you know The peak is like when we talk about work-life balance, right? It's not just that you're 50% Life and 50% work there are times where work makes up more of that, you know That percentile and then there are times where life has to so I think that for me like Understanding that that there are moments where work is all-encompassing and there's gonna be weeks where work is is representing everything It's important and then I think Being able to say no and that's something that I've had to transition from as you talk about things that have happened in the last five Years early on when you're building your career up you learn never say no to anything If somebody asks you to do something you say yes And then you sort of reach this point where you start to say, okay, does this fit in? And that has been a very difficult learning tool not only with just our clinical practices But with the things that we do outside of our clinical practices and continuing to build our name so I think that that is something that that is important and so sometimes when Well, it's how we say no like even as I engage with industry if I say this isn't good guys I need a little bit of time. It's not because I don't want to work with them It's not because I don't care about you know, what's gonna happen in the future It's just because that's a moment where I have to say right now. I need to focus on either the part of my Institution or the my family and all of that, but I I don't think that any of us does it well And I think it's just acknowledging that there's sort of a constant You know battle with that And I know that we're sort of moving towards the end of this But I just wanted to ask you guys because it's important. How do you guys see your role with industry and in practice? I'll start off. I love this question because it came up just the other day from one of our Reps in the area and she asked me she said, you know I just was curious as we were having a conversation. She texted me and I said, let me quiet I said hold on. Let me text something to you and inside your folders everybody has The Answer to this question and this is what I referred to her I said the answer is what is the role of the industry representative in the practice of gastroenterology and GI endoscopy and she read and she's like wow now I know what your role what your stance is on the role of of Industry, but it's so there's so many parts of this in my view. It's a partnership We're all looking for the common good for our patients to do better for patients We all understand that industry has their business side of it. We understand that health care has Hospitals have bottom lines and they have their business side But ultimately we're looking for to do better for our patients and without the support of industry At least this is how I see it. And I think a lot of my colleagues feel the same We won't get to that next place. We won't get to that innovation whether it's in endoscopy whether it's in medications Whether it's in the services that we're providing to our patients without Sorry Without that partnership. So that's that's my view. But if anybody wants any more information, it's right here. It's in print. I Know we're running a little over and there's it's break next right or are we moving on to the lectures? What electric okay, we'll move on to lecture. Yeah, I think the same thing guys and I think industry Helps us not only with sponsorship and like I said community outreach, but research And you know with with what we deal with in the country with the NIH and funding and governmental funding I think that we rely heavily on the cooperation of industry to get some of these trials supported and write grants and you know move the field forward and and one of the things that I've been I personally very Humbled by is In my field and I can honestly say this in IBD A lot of the times my industry reps aren't out there trying to just say well just use our drug or use our thing It's really how do we help the IBD population? So I think that that it is just such a great partnership Okay, that is going to end our day in the life oh Oh one more, okay. Yes, please. No, no, no. No, we're good I know post Covid things have changed and all all that But there's a lot of people a lot of gastroenterologists out there that will not see us And I understand because of the schedule and things like that. So it you know, she says just as a note It's like if you don't if the physicians don't want to see us we as a partner It's a two-way street and that's the only thing I see is sometimes it doesn't always go two ways And I just say that I don't want to be pointed out, but I see it a lot and I'm not in sales I'm an advocacy now, but I was in marketing for you know, 25 years I was in sales a long long time ago but I just hear that's the case and The other thing is is when we support meetings a lot of times the physicians don't want to talk to us there as well I know they're busy and things like that. So on the other side on the flip side It's like we want to support all the physicians out there and at all the activities We can't do it unless if unless we can turn to our superiors and say look this is this was beneficial because of XYZ So those are the I just wanted to throw that out there because I don't know if anybody's gonna say that but I know that Happens quite a bit and I see that from our side of it because I hear it from our salespeople I think that's a very valid point. I think we've all been in that situation where You're overbooked you have 30 patients In the afternoon and you're running two hours behind and somebody wants to speak to you Even if you set up that time because what I often they'll do is I'll ask Often my industry partners will text me. I don't mind that cook on me or they'll show up and I don't mind that but what? I prefer is hey, let's set up some time so we can talk and we could set aside some time You brought up something very important meetings as a course director of having led several courses It's our job as course directors to figure out what's gonna be the best way to maximize that partnership to make sure that The physicians are even if it's a raffle or a scavenger hunt There's something to make sure that they spend time coming by the booth and and not only to collect a little trinket But to speak to you to get the latest to get the innovation to understand why you're there why you're supporting this course I think these are very important Points and I think it's something that we need to work on better to be able to recognize that piece So I think that's a very important point. I Agree with I agree with you and I also want to add as a very early career physician that There is definitely a cultural change, you know as in the last decade or so and you know one of the things that as a trainee I learned from my mentors and was it was highlighted again and again is is Industry and it's importance and you know, I'm sure it's important in other fields too but for gastroenterologist like I was is sort of like hammered in me as a trainee that you know, you have these people are Helping our field develop. So you really cannot the things go hand in hand and you have to You know, you have to take an extra effort and obviously there are times when the physician is is, you know, it's busy So those are situations too and but industry does a very good job in being understanding of if our life as a Gastroenterologist and I want to take a moment to thank you all to you know to come to this, you know meeting and Interact with us and it also this feedback really helps us learn and you know to help kind of highlight the deficit that we may Have as physicians and where we could do better. So, thank you Yeah, and I was gonna say even as us on the ARIA committee, I mean, yes, you guys are here for a conference We're we're teaching you but I think the other part of it is how do we get more? How do we make that bridge easier, right? I don't think you have to convince us to meet within three hours We wouldn't be on this committee in the first place, but we like to hear these things about you know Where where we see that gap is it at a community level? Sometimes I know at the community level you can bring in lunch whereas at an academic level I know that there are sometimes barriers to getting through the door And so it is how do you how do you do that? Is it how do you engage there are always going to be certain physicians that are on? Come I can think of one in my head right now that is on so many committees that are on You know writing of guidelines and just cannot it's not allowed to have any in but those should be very very rare and few And things like that So I think that those are really helpful for us as we go back as a committee and say this is one of the things That was brought up. How do we engage others to be better better advocates and better? better communicators with industry

gastroenterologists

practice changes

COVID-19 impact

remote patient care

work-life balance

industry partnerships