We're going to move on to the questions, so guys keep asking, but one thing I'm going to open up to the panel members that are still here is, if you could give one piece of advice to everybody in the audience on how, like we were talking about this before, in regards to how do we get some of our colleagues involved with industry, what would be your best approach to get colleagues at your institutions to work with our industry supporters? Talk to the reps, be nice a little bit, don't slam the door in our faces as much. I'm just being honest. I mean, I've got accounts where it's on purpose, and it's just like, you can't tell us you hate our products, but you don't want to speak to us. How much of that is due to maybe an institutional policy versus just that? Well, I mean, in some of that, it's invest, I mean, you talked earlier, there was a comment when I was talking to them about lunch that you made about doctors wanting best care and best practice, and it's more than a financial, but at the end of the day, there is a huge struggle on that financial side of it, where there's advocates like yourselves that will fight for things, and you're industry leaders, so you can obviously stand up for what you want in your institutions, where you get some of these institutions in rural or regional areas that they might be the smartest person in the room, and they know what's best for the care of the patient, but materials management runs the show, because the almighty dollar is making decisions for patient care, and not the doctors and physicians, and that's something that if you want to see the best care and best product development and industry evolution, you've got to be able to have our advocates from you guys, and preach that message, not allowing material, somebody looking at a spreadsheet making all the calls. Value analysis shouldn't take six to nine months, it shouldn't take a year to get a product through, we're just wasting our time. And if I could just add something, I mean, I'm from Endosoft, and we're on the software side, your ISD departments and large institutions can trump the decision of what clinicians may, excuse me, what clinicians may actually be saying. If ISD says they're going to buy whatever X, Y, and Z technology, whether, it doesn't matter what, I mean, some places ISD drives the decision from a technology standpoint, and I've seen and heard a lot of clinicians say, we didn't know that they were going to buy X, Y, and Z, and so I think if you're selling tangibles and devices, it's materials in that department, but also on the software and the technology side, it could be ISD or Biomed or whatever that's making decisions that clinicians may not necessarily be consulted or talked to about. Male Speaker You're very correct with that. So in those kind of scenarios, it's, even when there's a clinician input, it does not necessarily mean that that's the decision that will be taken, and in that kind of scenario, it's up to the clinician to make any meaningful progress along the lines of which of the products you wanted to call your marketing to the institution. Female Speaker I mean, I agree, and I think that, again, you're always going to meet people that aren't the easiest, especially, I think, as healthcare providers, that we can acknowledge that not every one of our colleagues is going to be open. I think that we can bring home a message. You know, you look at an organization like ASGE and creating this, creating ARIA, this is a step in the right direction. I think that one thing that when providers see that, you know, the organizations that they support are supportive of this type of interaction, that sets the stage that there is some educational value to it. Again, I think there's certain people you'll never quite convince, or, you know, there's people that are always not going to have enough time for it and things like that, but I agree with you. I also do think, like, to your point, that they're in a big level hospital system. There's always going to be things that trump, like, just our conversation, but I, one of the things that, you know, is just trying to, like, my side to you guys is, like, I'll have industry companies that I work with from, like, an IBD perspective that have, like, I'll give you an example. So, one of the places that I work for has a new drug coming out for EOE. I don't do EOE, so they want to meet with one of my colleagues. I know that colleague is not going to be available for a variety of different reasons. So I say, I'll, you know, it's sort of opening up the discussion, like, I know you're not going to necessarily be able to meet with this person, but can you meet with one of my junior colleagues that is willing to meet with you? And then that person may be able to connect you because they're at least in the space. So I think that, you know, that's one way at least I try to navigate it is, and you, if you have one person at the institution, we were talking before, like, you just have to get the one person there. They can usually, if they have the time, lead you in the right direction. And I also give a lot of respect to the, my industry colleagues, like, everybody knows if they text me, if I don't respond back, sometimes it can be a week, sometimes it can be two weeks, and then I'll eventually get back to it. But it's very great for me that sometimes I, there's this understanding that it's not because I'm trying to be distant or anything, I just might have something going on, and I'll eventually get back to it. And then I could say to, like, to this person, like, hey, I know it's been a few days, but let me connect you with this person. So sometimes that helps. But I think there are, there are little ways that we can navigate this, but there's always going to be those providers that I, that we, that we just know are not going to necessarily meet. Sure. I was the first one who came out earlier, but I don't think it's one person. And it's a layer in these institutions, because it's not medical professionals making decisions for your patients. We all know that. It's the almighty dollar, it's the bottom line. And that's where I, okay, I like get adamant about this, because I've been in this business for over 30 years. And I've been from sales to marketing, and now I'm in advocacy, and I've seen a lot of it. And the problem is, is, and I'm not saying it's a physician thing, but the physicians need to say, I want this for my patients. It's called patient choice. We're all about health equity here. Everything is about health equity. We all talk about educating patients, things like that. And we sit here and we, we try to bring, industry tries to bring product, good products, and we get shut out. Oh, well, we got to see your utilization. We got to see this, we got to see that. And the thing is, is we don't get physicians saying that they're willing to support our drugs a lot. Like, I know that these guys are all salespeople, and I can't tell you how many times they've said, oh, well, we can't do it. We can't do it. We can't do it. So I'm not saying that it's one entity, the physician, or one entity, the payer, the person, the business decision, the, you know, in that position in the hospital, or the rep. It's all of us coming together. You know, we have to work together. We're, we're working together. The thing is, is we need the physicians to bridge the gap to get to those, those payers that make the decision in the institution. That is the hardest gap to bridge. And if we can't get to those people, it, we, it, we're done. I mean, and I know that these, this team over here, they do, they do, you know, key account management, and they deal with big institutions. Takes, sometimes it takes a year to get an appointment. That's ridiculous. And they're right. By that time, you realize that your drug's been out, you lose your exclusivity, that kind of thing. So it is frustrating. And I know it's not a single physician or a single institution, but it's just been getting worse and not better. And with COVID, completely understand, everybody's got, yeah, take care of patients. It's about patient care. That's what you do for a living. That's what you're all about. I get it. But we're here not to make your practice, not to like, oh my gosh, you know, I got to go see the rep. We're here to try to make the situation better for the patient. And I think we forget that we're all, we're all working for the common goal, which is making it better for the patient. Patient care, health equity. We all know that those are going to be looked at, that everybody has to look at those patient points. So, I mean, I know it's frustrating and it's, it's just a statement, but something's got to change at that level in the institution or there's not going to be any industry in 10 years. It's going to be a couple generic houses making crap and there's going to be no drug innovation. So, I don't know. I mean, I hate to say that, but it's very frustrating. But over the years, you've seen those payers come in, the PBMs, which are completely unnecessary. And if you work for a PBM, I'm sorry, but, so I think I'll get off my soapbox. No, I mean, I think that we, we appreciate that. And, you know, you know, I think I want to open this up to, we're doing a different style of panel, Michelle. We're doing everybody's on the panel. Everybody here, doctors and industry, where, like to, to your point, you know, where do we see GI going in the next 10 years? And do we, do we see these, these innovations declining? Do we see, you know, research and investigation dropping? Or do we see us getting to a point where the innovation is too high and we can't get people to pay for it? So, we'll, we'll start with the physicians. Can you hear me? You guys know me in technology. So, where do we think GI is going to be in 10 years? I don't know, but what I can say is just in the last 10 years, I think that there are some things that I knew very well as a fellow that if you were to ask me to speak intelligently about it now, it's not that I've forgotten things, but it's that things have changed so much in such a short period of time. I think IBD is an excellent example of that. There are some medications that I have never used. There are some that I have barely even heard of that are now kind of commonplace for management. It's not that I'm out of the loop. I go to like three or four national conferences a year. It's that the innovation has been so rapid and so impressive in such a short span of time. I think Hep C is another example. Even EOE, like when I was first learning about EOE as a, as a resident, there were two things that we had, or two, two medications that we had that were approved or that weren't approved, but were used. Now we have one that's FDA approved. I just actually, not while we were talking right now, but earlier today, made an appointment with one of the, or set up a meeting with one of the reps for one of the other medications that's kind of coming down the pipeline. So, I think that things are totally different than they were 10 years ago, and I'm kind of excited to see where the next 10 years are going to go. Yeah, I'll sort of take off from where she left, looking more to the future. I think there's still abundant opportunity for innovation, especially in technology and drug development. So, there's still a lot of conditions in GI that we don't really have excellent medication for. For example, gastroparesis. So, there's ample opportunity for drug development, for innovation, and I don't think that's going to be limited by issues regarding payment. I think there's a need out there, and if the industry actually take the lead in terms of research and development for those products, we'll still continue to see newer things coming to the market. The way things may change actually is the adoption of AI in medicine and GI, but really I see that more as a step, or I mean, if you're very optimistic, a leap into looking at the way things are done in a more efficient and at a broader scale. So, there must be a role. That's my take-home message, and innovation is, there's no limit to it. We'll find newer ways, more efficient ways of doing things. Your companies will find newer ways of effectively providing excellent tools that we, in the GI field, can use to make our patients feel better. I think that's great, and you know, I think this is, okay. These questions are all sort of relatively, can roll into one another, like what is the, where do we see this field going in the next 10 years? What are some of the challenges we're facing, and what sort of value does ARIA hold? For me, one of the challenges, and some of you have heard me say this, is that sometimes you're split in so many different directions that it can be hard to do it all, to do everything that you want to do that's best for all parties involved, and there's not enough of us out there doing it. So, I think that that is certainly a limitation. I think closer to home, I think you're going to see more and more separation of certain parts of every field, not just GI, but we're here talking about GI today. Hepatology, and what's going on with hepatitis C, and other autoimmune diseases within the hep space, what we're going to see with with Seattle hepatitis in the future, is going to be so far from what, you know, is going on in another space like EOE, and so far from what's going on in another space like gastroparesis. So, I think that a challenge, and what I see for the next 10 years, is this ongoing separation because of innovation, because of advancements, and then maybe not enough, you know, experts in the field to really be able to do this, and meet the needs of the community, and where does the general GI community doctor fit in 10 years? I think that'll be one of our challenges as a field, is how to do what's best practice for the patients. So, I think that things like ARIA at least allow us, in some level, to communicate with you guys because sometimes you guys are more of, you know, feet on the ground. You're going to different offices on a daily basis, you're going to different places, and you can convey messages, and so I think that we're at one way ARIA helps, right, is it helps bridge a gap, and the more that we can empower you guys with knowledge, and you can bring that knowledge out, even if it's just as simple as, hey, did you know that there's a center over at Rush that you can go to, and you can get expert level care on motility, right? So, sometimes it's just getting that message out to people who maybe didn't know it, APPs, MDs, DOs, all of that. So, I think it's a combination of a lot of things, and this doesn't have one great answer. Yeah? That you just, like, don't have the tools that you need, you know what I mean? Like, is there, like, any gap, like, from the med device standpoint? It's kind of like the million-dollar question, like, you know, what's the biggest innovation? Do you guys know what a Hager dilator is? So, a Hager dilator is a dilator that you can put through the anus, and it has, like, a little tip on it. I've long since, I wish that there was a better way to deal with ileal structures, right? We don't have an antifibrotic on the market. Our biologics are largely preventative, and not necessarily proactive. We've talked about stents, but they're not really great in the lower GI tract. So, if you're asking for my opinion, the single greatest area of innovation in IBD exists in the field of ileal structures and perianal fisheyes and Crohn's disease. That's a very small portion of the population. That's a really good answer. Endoscopically, kind of speaking of strictures again, I think some of the strictures that we see with EOE can be very nasty and difficult to treat, but within the last several months, there have been a couple of new agents that have come out that have some promise for, I guess, controlling the disease a little bit better, and also kind of helping with the remodeling process. So, I actually think that in the next few years, it's going to be a lot easier to treat, and up until now, those have been kind of, like, the bane of my existence. So, I think it's actually going to get better. That was a treatment for gastroparesis.

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