So, without further ado, this is the day of the live session. We have our esteemed group of panelists here. If you want to just say a quick hi and another introduction so that they just remember who you are and where you are, that would be great. Go ahead. Daryl? Hi. I'm Daryl Pardee. I'm the chair of GI at Mayo Clinic in Rochester. Good morning again. I'm Alexis Calloway. I'm a private practice gastroenterologist in general GI at Digestive Healthcare of Georgia and Atlanta, out of Piedmont, Atlanta system. My name is Namesha Park. I'm with the University of California, Irvine. I am an ibediologist. Hi. I'm Walt Coyle. I'm the head of GI at Scripps Clinic and an advanced endoscopist. Hi. Steve Kim from UCLA, an interventional endoscopist. All right. Here we go. So, you know, of the following areas, usually we have this on a text thing that you can slide into, but we're going to probably talk about all these, but you can shout it out. Which one do you want to hear most of from our crew? Changes in GI practice setting and resources, optimizing work relations between GI physicians and pharmaceutical medical device groups, trends in endoscopy or other GI procedures, and types of GI patient diseases that are being evaluated and managed by GI providers. So I'm going to go through them again. Just raise your hands. Just so we can get a sense of how to tailor it and make sure that we hit the topics that are important to you. All right. Changes in GI practice setting and resources sought by gastroenterologists. Cool. Optimizing work relations between physicians, GI pharmaceutical. I knew it. That would be a big hitter. I'm like Nostradamus. All right. Trends with endoscopy or other GI procedures. Awesome. And then types of GI patient disease states being evaluated and managed by GI people. Perfect. All right. We're going to have some fun. Ready? Here we go. First question. What is a typical clinical schedule for a gastroenterologist? And it's going to be different among everybody because our practice settings are different. So I'm just going to start. Dr. Pardee, you want to tell us? Yeah. So I'm in an academic practice. So for me, my time is divided into buckets. So am I in the clinic? Am I in the hospital? Am I in endoscopy? Or am I in protected time, whether that's admin or research? And that's important for you to know because when I'm in one of the clinical settings, typically very busy with very little downtime. So when we're going to meet, it's almost certainly going to be when I have protected time, whether it's research or admin. Great. Dr. Calloway, you want to give us your scoop from a private setting? Sure. Absolutely. So I'm 100% clinical. We cover a major hospital system. So we do tend to split our time between inpatient clinic and also hospitalization. So it's like procedures, clinic, and hospital consults. We tend to be very busy. We don't have terribly a lot of carved out or protected time. So most of the meetings are either like catching us if someone happens to have a lunch break or arranging like a dinner or something like that after. Dr. Parekh? So I'm like Dr. Pardee. I'm in academics as well. And so I have buckets of time. I would say probably about 40% to 50% of my time is done doing endoscopy, another 30% to 40% in the clinic. And then I have about 25% protected time for administrative work that I do as the IBD director and also in the dean's office. In our practice or in our group, we also have to help cover the hospital services. And so we each take turns doing that as well. So like Dr. Pardee, I try to meet with people during my protected admin time. My schedule is almost exactly the same. We're a hybrid academic practice. But there's always lunch available. So I come in, it'll be five minutes, grab lunch, and then come out. So that's the time you're reaching. But if you really want to sit down and talk to me, it's going to be the protected time, which is three half days. Yeah, so I'm in academics, but I don't have lunch, and I don't have protected time. I think the key for you guys to figure out, it's going to be different for every physician. I think that's what you're hearing. When we're in clinic, it is insane. I can't pick up my phone. I can't answer text messages. I don't check my email. I finish clinic, and basically my phone's blown up. And I think it's hard for some people to understand that. We're in clinic. We're just seeing patient after patient after patient. We're not going to stop until the clinic's over. So that's like four hours of just nonstop patients lined up in a row to see you. It's hard to talk to the physician during clinic. Now, I do a lot of procedures. But because I'm academics, I have a fellow who's helping me dualize procedures. So oftentimes, I'm talking to my reps during procedures, whether it's in between procedures or the fellow is assisting in a procedure and I have more time to talk. And so, again, everyone's going to be a little bit different. I don't have any protected time. Some others here have protected time where you can say, like, well, Monday afternoons work great for me. Then you know that every Monday afternoon with this doctor is going to work if you need to reach that person because that's their time off from clinical work. But for some of us who do clinical work most of the time, it's often hard to find a time that works during the day outside of maybe, say, lunch. I think the point you're hearing is that our time is limited. And I agree completely. It's going to be really different for all the people you call in. So you'll learn their tendencies. But I think the key for you, or at least for me, is for your message to be honed. So when you come in, I don't really have a half hour to go through a whole bunch of slides. I want to know, what is your main message? Maybe 15, 20 minutes, a couple minutes for me to ask questions. And the key will be the office manager, whoever runs, like, I don't run my own life. Someone else runs my life. She's very good. That's the person you need to contact and say, when will he be here? And then, again, same thing. I don't want to see a slide presentation. I really like, if I've missed an article, here's a reprint of an article, and I'll read this later, and give me one or two points. That's how I want you to know and move on. Sorry. That's usually what it is. I concur with that as well, in the private practice setting. Like, catching us in between a patient, you might have 30 seconds, like an elevator. Yeah. You know, and then there's call schedules and other stuff that you wouldn't have privy to, but that manager, whoever runs the schedule, is going to be helpful. So, if you know one of us is on call that week, seeing patients, that's probably not the best week to sort of come in and even do a quick elevator pitch, just because it is insane there. So, working, getting close with the admin people, getting close with the managers is going to be important. Developing rapport with your provider. Like, we're here, we love teaching, right, whether it's to colleagues, whether it's to trainees or other people. So, if there's something that you could learn from us, or that you could teach us about on a, you know, high level, because essentially you're the experts in what you do, and we're the experts in what we do, that's always a beneficial relationship, and we're, you know, happy to make time or to understand that. But really trying to work with the team to catch us when our stress level and patient load is lower, or potentially is going to be key. Next question. The relationship between the primary care provider and the gastroenterologist. Tell us, Dr. Kim, when does a patient transition from a primary care provider to a GI, to an adult GI, or let's say, when do they transition back, and how does that relationship work? Yeah, I mean, again, I think it's going to be different per physician. So, I'm an interventionalist. Most of my referrals come from other GI doctors, surgeons, oncologists. I very rarely communicate with primary care doctors, because the patient has seen a primary care doctor, who's then referred the patient to a, say, a GI doctor or surgeon, who then needs help with something that gets referred to me, and I see the patient, and I send them back to their GI or surgeon oncologist. But in all cases, you know, it's this, if you have a chronic disease that requires constant attention from a subspecialist, then you'll continue seeing that subspecialist until the treatment is essentially cured or resolved, and it maybe needs that person less often. But oftentimes, a primary care doctor has to send some sort of referral for the patient to see a specialist, right? I'm trying to think, you know, more specifically to you guys, you know, the patient may see the primary care doctor, say, a difficulty swallowing, gets referred to the GI doctor. The GI doctor might say, oh, this is a very, very complicated case to be aware of. Make the diagnosis. You might get referred to someone even more subspecialized in GI that does esophageal motilities or esophageal diseases, and that person may manage the patient, right? It may not be necessarily corresponding with PCP, but maybe corresponding with the GI doctor that referred the patient. So it might differ depending on the scenario. Dr. Callaway, how do you work with the primary care doctors? So obviously in a private practice setting, a fair amount of my referrals are coming from the primary care physicians, and so, you know, you develop a relationship. You want to obviously have open lines of communication, but generally when patients are sent to me for a workup, for example, for anemia or abdominal pain or what have you, once we've kind of completed the lion's share of the workup, I tend to send recommendations along the way to the provider, but I give them, you know, kind of like my major recommendations with a note, and then they can decide if they feel comfortable managing something, if it's benign. Generally if they're stable on something, a disease is quite simple. They're not on a medication that requires a lot of therapeutic monitoring, like my Crohn's patients. Like I'll keep an eye on them at an interval, and I'll try to have the PCP space in between. So it's kind of like a tag team, if you will, in terms of management. But some folks who are completely stable with like reflux, that's doing great. They just need medication refills. If the provider's comfortable, I'll send them back to them and just say, you know, follow up with me as needed. Others on the panel? So my practice, I take care of patients with a lot of chronic diseases, with Crohn's and ulcerative colitis. So a lot of those patients do stay with me for their disease course because it's a lifelong disease, but I work really closely with the primary care doctors because I need their help in case the patient gets an infection. I need them to get caught up on their healthcare maintenance, like getting their vaccines and cancer screening. So in our practice, we work really closely with them, but a lot of it's a partnership. They take care of certain things. We take care of certain things. Yeah, I would say it's co-management, which has been easier with Epic. You know, because I take care of fundamental EOE patients, and obviously there's no cure for that disease. It's a chronic one, but it's not quite as serious as some of the implications of Crohn's in UC. So a lot of times it can be on the primary care doctor, but with guidelines. Hey, you want to taper off this, use this, let's try this, and obviously then they flag me up. Hey, his swallowing is worse again. He's noncompliant and stuff like that. But we also have the allergist to be involved too because they help a lot. Great. All right. Question three. How do you effectively communicate with GI healthcare professionals? So give us some of the potentially do's and don'ts that you would make for recommendations on how you can effectively communicate with, let's say, your representatives from either device or pharma. I'll open it. Whoever wants to start. You're like, yeah, this is a good one. All right, I'll start. Oh, go ahead. I was just going to say, I think, as you heard earlier, be brief. Like, bring it to the point because everyone is very time limited. So bring your key points, like two, maybe two to three points, that you want to cover in that few minutes. I'll say, admittedly, my message basket probably has, like, over 1,000 emails at any given moment. So contacting me by email, there is a very high probability that I did not see it and I don't know what you're talking about and I don't know who you are. So if you pass by the office, even if it's just to pop your head in, drop your business card, you know, with an article, then I'll at least have that kind of memory for that. I'll add, to be careful with your messaging. So I do mostly inflammatory bowel disease, and oftentimes we've participated in the major trials of the drugs that are approved, and it's just a little bit irritating when a sales rep comes into my office and treats me like an idiot. I know you would never do that. So just know your audience. If they're a key opinion leader in EOE, they're probably going to have a certain baseline information that you don't need to go over. Whereas if you're calling on maybe a general GI doctor who doesn't specialize in EOE, they might need more of that basic information. So just know your audience and tailor your message to the person you're talking to. Yeah. I'm going to add on that. I think that's a great point, and we tell our fellows when they're applying for fellowship the same thing, do your homework, right? And when we say do your homework, what does that mean? It means look up the people that you're calling on in advance. Our CVs are posted online. Papers are there. Know who we are and what we do first before you come, because then you'll understand at what level you should gauge that conversation at, and maybe it's going to be more beneficial to you to just stop by and be like, hey, you know, I'm here. Whatever you need, happy to help. Versus somebody that needs education on how the heck do I make an EOE diagnosis? Right? There's variable levels, because we'll shut down with limited time depending on your engagement, or you could be really excited about that. So I think do your homework in advance is going to be a huge help, and that's what Dr. Pardee was commenting on. The other thing is don't try to stop me in the hall and say, hey, just watch this 10-minute video. It's really good. I'll tell you, that's not going to work. And the other one is a pet peeve. This just happened like a couple months ago. You know, you don't prescribe any so-and-so. It bugs me that my prescribing information is available to everyone out there, and don't tell me you're underperforming with this drug of ours. Don't flag me with that. I think it's become harder for reps to get in to clinics, to hospitals. Okay? I mean, I'm not even that old. I remember a time when lunches were provided by pharmaceutical reps and everyone sat around the table. We all ate lunch together as a staff, all the doctors and nurses. You know, the rep was standing in the corner waiting for the doctor to show up, and everyone's having a great time eating all the food, right? I can't remember the last time I've done that. I feel like I think a lot of academic institutions have moved away from that. They don't allow a lot of reps to come in unless you are here for a reason, for a patient, for a procedure. You can't come in. We certainly had reps get blacklisted because they did something wrong, and then they can't come to the hospital ever again. So you need to be very careful now in terms of your time is very limited with the providers. Everyone's different, so different personalities. You may find someone who's willing to talk to you for ten minutes. Others are like, I don't have time for you today. Go away. Don't take that personally. It's just how the day is going. You know, Dr. Callaway said, you know, don't email her. I prefer email because if you text me, which some reps do, I can't flag it. I can't unread it or whatever you want to do with your phone. So if I get 20 text messages, I have to click on it, and I read your text message, I can't go back and remember it. And maybe some of you guys go back on your phone and look at all your old text messages, but I want to be the last one that was sent to me. And I reply to that one, and that's it. I move on to the next text message because there's more coming in. With email, I can flag it. And at the end of the day, when my work is done, I can go back and read my emails and go through all the flagged emails and reply to the ones that are appropriate and I feel like I need to. So some people, email is going to work better. Some people, showing up in clinic and giving them something physically may be better. But I think you're hearing is that it's hard to get access. It's hard and hard to get access for you guys. And certainly, you want to be useful. So while you guys think EOE is the top diagnosis, I mean, most of you guys are seeing hundreds of diagnoses every day, and EOE might be once a week or once a month. But when they find someone that may need your drug and they call on you, you want to be available and be ready to help the doctor prescribe this medication, talk about the side effects, all those types of things. There's Rob, so I don't talk to him because I don't need him. Frank called? Isle? Do you need to extend your service contract? I think we didn't make a payment. Isle's in the booth. He didn't pay his bill. Did you hear that? I get that same one. All right, anyway. Dr. Epstein's hearing voices again. Yeah. Do you guys have a medication for that? Is it injectable? No? I think you get my message. There are reps I don't talk to unless I need them for something, right, and it sounds terrible, but I can't have them around all the time for patients that are not relevant to what I'm doing. But then the patient comes along where I need them, and I call on them and say, look, I have your phone number. You have your business card. You're on my cell phone. You have my e-mail address. I find the e-mail address, and then I contact that person. The person comes running and says, here you go. Here's everything you need. Let's go, right? And then you build that relationship, and then next time they need you for something else, they'll come back. They'll call on you again, all right? So I think that's how you build some of these relationships. It takes time. You didn't answer them. I know. I'm done. I love it. Yeah, you know, every institution, every practice, every group is different as far as the rules of coming into the building and engagement. So part of also doing your homework, we talked about provider, we talked about institution, is do the institutional stuff. Understand, get on their list if you have to be on a list of providers, which most do. Understand what the rules of engagement are and regulations are in advance. If you have to be invited in, make sure that you have that invite, right? You don't want to be the rep that's sort of in there and gets a demerit, and then the whole thing is shut down. So if you know the rules better than anybody else and you follow them, that's like half the battle. Yeah. Other comments? Namesha, what's the best way to contact you if somebody wanted to come in? For me, it's email. I prefer email as well. I'm like Steven, so I manage my entire calendar via email. And actually, for me, with our IBD team, what we're going to do is we're just going to set aside a half-hour block once a month to meet with the different reps, because our whole team needs to meet them. We've been getting a lot. Just like you guys have a new drug, we have a lot of new drugs in IBD. We need to know how to prescribe them, what pharmacies are covered, how to get them patient assistance programs. And so instead of meeting individually with each member of the team, we figured it would be better for everyone to just meet all at once. And so that may be another strategy to do as well. It's important the team, like the nurse, the health coach, the medical assistant, they need all the information just as much as we do. And the other thing we haven't talked about is I just went to a dinner the other night. I don't go to that many, but it is sort of nice. It's usually something I'm interested in, and then you will have my attention. I'll sit there and have probably a good scotch, although I have to buy that myself now. Now listen, and again, I don't mind listening. I want to see the scientific data. I want to hear about it, and then I'll make a decision. So that's helpful, but not all of us can do that, and I usually limit myself to about once or twice a month tops. There was a hand up I saw. Yeah, go ahead. So as many of these things have changed since, just in general, with institutions not necessarily allowing us in, but you might not necessarily agree with the institution's choice, how do you propose that we access you, that you reach out to us? Because that's becoming the challenge with access right now, is that your institution might say, so for instance, I'm in the D.C. area, so we have an institution, you know, MedStar, and it's like, no, you cannot come in. It's that dark in our doorstep, you know, but you might not agree with that. So how do you propose that we may or may not get a hold of you, or how would you reach out to us? Well, I can speak to that. I'm in a hospital system. It's Piedmont, Atlanta, and we definitely have some major kind of barriers set in place for patient safety. We have our infusion clinic there, so immunosuppressed patients, but our waiting room, the front desk, does have schedulers and people who are like really as such where you can easily drop your information and say, could you please pass this along to, if you've done your research, whichever physician you'd like to get in contact with. And generally, they're good about saying, hey, someone stopped by and this. And that leaves it, of course, in the power of that physician and their availability. And now you've actually given them the opportunity to reach out to you in their preferred means of communication as well. Okay. I can add to that a little bit. So we're seeing that now with some of these new IBD drugs, where there's certain, we allow reps on campus, but certain things they can talk about, certain things they can't. So what they'll do, and I'm sure you've had the same thing, is set up an evening symposium, all right? So a dinner, and then maybe an hour presentation to get their message across, and then a Q&A. And then you have a bunch of faculty and fellows in the audience. So sort of a captured audience, one shot, you can cover 10 different people. The second would be, if it's allowed, you know, Zoom. One of the good things to come out of the pandemic is we're now pretty comfortable with electronic meetings. So if you can't come on campus, can you do a Zoom meeting with the people you wanna reach out to? I think, you know, dinners are here and there. So like at our institution, dinners are like even off. So like you're reported on like the thing list and everything. But I'll tell you, one of the things that you could do is if you drop those cards, it's important because like in our clinic, or you can have, we have boxes and stuff. So if I know I'm looking at an EOE thing, these are all my reps for these things, so these are my constipation and diarrhea agent things. Because really where we need the help is I think Nimisha said it earlier, is if a patient has a problem with the prescription or we need to know how to order it, I want sort of a quick hit, who do I call that can help? Or who can my nurse reach out to to help us? And it's gonna be you. If your business card is on that thing there, then we know who it is. And we get, there's such an influx of new people in clinic, MAs, nurses, et cetera, that the old ones who just used to know and remember everybody's phone number is low. Yeah, I remember Dana was our rep for this, let's call her. That doesn't happen anymore. And people are changing. Even in your field, there's so much turnover and changes that if you do stuff like that so we know exactly who to contact, you're gonna be up on that board or in that area or in that drawer that the nurses or we go into to look for help. Because if we're gonna reach out, we're gonna reach out. We need help in like an hour ago kind of a thing. And that's really important. I think it's all what I said to you at the beginning, which is look at it as we're all partners in trying to take better care of people, right? That's what you're doing. I mean, there's other things, right? The money and everything else, fine. But at the end of the day, it comes down to patient care. And so if you can partner with us on how to better take care of people in an efficient, safe manner, that's gonna be a win rather than selling something, providing that service of how can we make this easier for everybody, easier for the patient, easier for you as a prescriber, easier for my office staff, because guess where all those messages go from my office staff? To me. So if we can cut down on all that because we're working together, that's gonna be a win. Okay, yeah, one more. The change on both sides for access, et cetera, how has that impacted your ability to get information that you do want to get? Like how are you, in the old days, you just mentioned you remember sitting around the lunch table talking. I'm sure that's how you got some of the clinical updates on the drug. So how are you getting those updates now? I don't know if there's like certain websites or groups or, I'm just curious. I can talk to that. So for me, it's a combination of attending different conferences and also a lot of the IBD companies work through other organizations to get us information. So we have advances in IBD, we have cornerstones, we have different venues where there are more webinars. And so that's, with the pandemic, I find webinars and certain Zoom meetings a very useful way to get information because sometimes you can multitask. We're all doing charting, but we're also listening at the same time and learning. Another way is proactively reaching out to our MSL. So with the new drugs coming out, I'm proactively reaching out to the MSL and our rep. I'm like, let's have a joint meeting. We need to know how to do the prescribing and what's the data and present it to us. We'll give you 25 minutes, give us what we need. And so we're proactively doing it as well as another way. But that's for me, I don't know what the others do. We still have access. So reps can come in. And I'm selective about that though, because some reps, not many, some waste my time or put spin on data I already know the answer to. So I don't really invite them back. But many of them are very helpful because there's so many IBD meetings, I can't go to all of them. So they say, hey, did you go to ACG? No, well, we had a couple of posters here. Let me 10 minutes update you on what was presented on our drug at this most recent meeting. So it keeps me up to date as a specialist. But we're seeing a lot in IBD of these webcasts. So that might be something you think about if you're having trouble reaching a significant proportion of your audience, putting together a webinar, email it out to the gastroenterology community. And if they're interested, they'll watch it. If it's not relevant to their practice, they won't. The other thing that gets tremendous street cred for us is like, it's so hard to get some drugs to some people. It's always hard for the Medicare people. That's a different story. But even the insured, and there's all sorts of programs that are available. So know about that. And I love that. Oh, here's this for that. And I said, did you give this to Mary? Did you give that to Mary? Because Mary does everything for me. If I need to get a medication, she's gonna do it. She's gonna fight for the prior authorization, stuff like that. So that's very helpful if you train the staff for that. And just by street cred, because then when I need a drug or something like that, and Mary and I'll talk, say, well, we have this program, we could use this. And okay, and that may be enough for me to choose which drug. The patient doesn't care whether it's an oral or an infusion or a shot. But this program, she has no money to cover. I said, okay, that's a good choice. So I hate to be driven that way. But sometimes with these drugs that are thousands of dollars, tens of thousands of dollars per year, I have to be thinking, what can the patient afford? Yeah, in the corner. In regards to, I guess, a good or great elevator pitch, what do you think are some good components to that? How much time should we talk about maybe disease state? How much time should we talk about maybe painting that picture of that patient type? Or how much time should we just go straight to indication, safety profile, and just leave it alone for that quick 30 seconds? So I guess my question is, what does a good elevator pitch look like to you guys? That's gonna be something, a message that you guys can hold on to in that quick 30 seconds. Well, I guess since I'm the one that brought it up, I can start. I will say personally for me, in private practice, like we all, whether you're in academics or private, we have a certain level of baseline scientific research, knowledge, and understanding. So I don't need you to describe to me how a randomized, blinded study works. What I wanna know are the primary endpoints, where you presented it, how you prescribe it, and what's the access to get it for patients? Because those are gonna be the things that my MA is gonna need for the patient trying to get prior authorization. That's what I'm gonna need, like there's not gonna be a head-to-head yet. I don't necessarily need to hear, and it was so much better than placebo, and then I don't, I know. That's why you're here. That's why you're selling it. So I wanna know where it was presented so I can collect for myself, because I do use the webinars quite a bit. So I have my own little catalog of like studies that I'm able to go, okay, well, I'm seeing that this one does this, or that one does that, and then the next time I'm on AIBD or something else, because I do a fair amount of IBD, admittedly. That's where I kind of put that information together. And then we still have to consider like what the patient can afford. In the private practice setting in particular, like we don't have that funding where it's just like whatever you like is gonna happen. Like we have to work through those channels. Like they have to fail Humira first, or something like that. So knowing where it fits in that lineup does help. Yeah, I'd like to add to that, because a lot of the commercial payers have like a certain profile or certain drugs. They have to fail first before we can prescribe a certain drug. So if you can share that information with us, if you guys know that information from the payers, that's super, super helpful, because otherwise we're stumbling through and just waiting. So it just delays care. So I think just as Heath and everybody has said, everyone's goal is to take better care of the patient. So whatever information you can give us to help the patient, and as Alexis mentioned about the studies, a lot of times why we need the study data is we have to write appeal letters. So if you could give us that blurb with the reference, we can put it in the appeal letter that we send out to the payers to get it approved. Maybe I'll just add- I'll make it a little bit simpler than that. I just wanna know who you are, what you got, and how we can get it, to be honest with you. Because I can read the data and the stuff there, so giving me the sound bite on we're better than placebo or this study showed me that, I mean, great. I just wanna know, hey, this is me. This is what I do. This is what we got. I'm happy to help your patients get this met however I can, and I'm happy to help you with prior authorization or whatever if you need it. This is my card. You know? I'm like, amen, you are the greatest thing ever. Can I just add for your elevator speech, again, it depends who your audience is. If you're calling on primary care, then they may wanna know background about EOE. Most GI regardless is gonna know about EOE, so you don't need that background information. For those of us who aren't EOE experts, maybe the basic clinical stuff, like how well does it work? What are the major side effects you need to watch for? Maybe how do you get access to the drug? If you're calling on an expert, they may wanna know mechanistic data, cellular, biochemical information that I really wouldn't care about, but as a key opinion leader in the area, they may wanna know some of that really deep scientific information. So knowing your audience and tailoring your message to the audience. And they might already know it, so be prepared that you're going in there because they're gonna check your credibility. So when you go in there, if you're with a key opinion leader or an expert, they might ask you these questions to see, are you real? Or are you wasting my time? And if you prove that you're good and real in our education, they're gonna call on you because now you have your credit. And then they're gonna be like, hey, you know what, I got these fellows that need to hear about EOE, or hey, there's this other audience. That's how you get your way in the door. So know more about the product or medication than somebody else do. I shouldn't know more about the electrics on my car and how to fix it than the auto mechanic from three YouTube videos. I would do that, be really specialized, do your background, do your homework, you're gonna be winning. Yeah. I think there's two things that are really fascinating here. First of all is, I think it's gonna be GIs that start this medication. It's not gonna be primary care doctors. We're the ones diagnosing it. And it is the only FDA approved agent right now. And we've been using all these other ones for decades now. So it's interesting to see how that's gonna play out when the insurance company says, we're not gonna pay for that. They say, well, you want me to use this non-FDA approved medication for that? I mean, just curious to see how that plays. Yeah, Jen, we have Jen over here in the corner who's gonna add something. I actually, so I did the Sanofi course two weeks ago. I then saw a kid last week, I counseled, and we're gonna start, I'm gonna work through the insurance process, I'll let y'all know. But we're gonna start your drug. And I counseled, like I counseled for infliximab. So a very interesting thing you may wanna get across to GIs is it's actually not as, it's safer than infliximab. So I talked to this mom about cancer, this is a kid I followed for eight years, and she's ready, but, and I have a way of talking about cancer. But I didn't have to talk about cancer. So just saying that in your elevator speech would get you smiles. I think, you know, it's safe, so. All right, let's go next one. If you could give one piece of advice to the audience, we've sort of done this, this is a little bit of there, let's move on. Ah, predict the future. What do you see as the most important change in gastroenterology over the next five to 10 years? All right, who wants it? Don't all jump in at once. I think we're gonna see an evolution of our endoscopy practice. So Dr. Quill talked about screening colonoscopy being sort of the foundation of our practice. That's gonna go away, and probably in the next five to 10 years. There'll be adequate non-invasive tests to diagnose at least a high risk for cancer. So more of our colonoscopies will be diagnostic or following up on a positive test. And what we're seeing now is a blurring between GI and surgery, right? So we're doing more and more of these amazing things with the scopes that used to require a big surgery. Now we do a day outpatient procedure and the patient's good to go. So I think there'll be further blurring of the boundary between GI and surgery. I think a diminution of screening colonoscopy. And the field is becoming more and more and more specialized. So I'm an IBDologist, I'm pretty comfortable with that. I don't really know a lot about EOE. And I think those distinctions are gonna grow deeper as we get more drugs and understand diseases better. You're gonna see a bunch of specialized silos in GI rather than one homogeneous field. I wanted to add, I also think we're gonna see, we are already seeing it, the use of more advanced practice providers in GI practices. And so that would be another group of healthcare professionals to work with. They have a little bit more time than the rest of us. So, and they're hungry for knowledge. And so working with the advanced practice providers is another avenue as well. I definitely echo the advanced providers piece. I think on the community slash private side is the actual structural formation of what a practice looks like. So with the onset of private equity in these healthcare systems, having hospital-employed physicians, just the avenue in which you operate on a day-to-day basis and who's making the decisions about that. Like there is a switch by insurance to certain biosimilars. There's a switch by negotiation contract based on what type of other medications you can give or where you can perform a procedure or if you work with a specific drug company. So having your finger on the pulse of your potential like demographic that you're working with and understanding that shift will obviously be to your benefit. In my, I think we're gonna, we already are starting to see, artificial intelligence is a huge box that's being thrown around everywhere. And it's really sort of taken commercially hold over the last, let's say two years, one to two years, but it's already flourishing. I mean, at all the meetings going up. We're an imaging based society, right? We take pictures, we take videos, we have endoscopes, we go there, but even in clinic, right? Somebody shows you something physical exam. And so the world of image recognition and software processing, I mean, we all hold the supercomputer now in our pocket. I don't have mine, it's over there, but you have it there. And so how that technology continues to be incorporated in medical practice to the point that maybe diagnosis is made or partially made independent or outside of a traditional office setting. And then a clinician or somebody is responsible with the team for the cognitive function, the decision-making, the choice algorithms, but the diagnosis is made in there. So I'm sort of predicting the five or even 10 or 15 years, but I think we're talking about personalized care. You hear that on advertisements, I'm sure when you turn on the radio about health systems, but I think that's where we're headed, right? We know where you are, we know what you do, you can take a picture, you can take a video, we can analyze that against data and then come back with a treatment plan or regimen. I think we're starting to continue to go that way and you'll see more of it. One thing that bothers me, I think we are going this way, particularly in the private sector and also at academics where the GI doctor is being forced to do more endoscopy, less clinic. So like a lot of my people now I'm hiring, I'm hiring a six scope to three clinic and one guy came and wanted to do eight scope, two clinic. And I'm thinking, I still think we provide the best care in the clinic. APCs are great, we're expanding our APCs, but I think that's a dangerous trend where we're not gonna be connected to the patients, we'll just be scope jockeys. And I think it's a very, I don't like that at all. I don't like that, it's the way I train my fellows. So I don't know how that's gonna affect our practice. We'll essentially, we'll all clinic be seen by APC in 20 years and we're just doing scopes. I don't want that to happen, but I'm not sure. Or will you not be doing scopes? That's true. He has this little thing, he drives through with magnets through the body, right? So when's that coming out? I don't know, when do you want? I'll take the beta version. Yeah, but I mean, we've all said, right? Less and less invasive stuff as it goes on and where does everything fit into the mix? And it's a partnership, so I think healthcare is an evolution, it's gonna continually evolve. But if you know your product, you know your background, more and more about less and less until you know everything about nothing at all, you're gonna be on the forefront, you're gonna be successful. What do you see the role of industry as it relates to your practice? Oh, we have a question, I'm so sorry. You guys touched on something very vital with the APPs, right? And you're doing the scopes. How do you bridge the gap between, because you're seeing the physical changes as it relates to certain diseases, right? When you're scoping, whereas the APPs may be seeing and maintaining, right? In treating from a symptomology standpoint, how do you bridge that gap? Because you may be the one that's seeing, right? That change in progression, whereas they don't necessarily see it from the scoping aspect. So I work with one APP, so for my situation, it's a little different because I've trained her, she's worked with me for eight years and we've gone through very rigorous education so she understands what the differences are and I send her to conferences. If I can't teach her, if I don't have the time, I outsource the teaching. And so that's where all of you come in and can help supplement the education as well. But I think it's being proactive because there is a rise in APPs and there are some really, really good APPs and there are some not so good APPs. And so, and their education is not standardized. And so really relying some, I work with my industry partners on that to fill in some of the gaps. Perfect. Yeah, yeah. When it comes to APPs, biologic prescribing, do they have autonomy? I can tell you in our practice, so our APP specialized just like we do. So we have two APPs in our IBD practice and they're experts at Crohn's and colitis. But they don't see new patients on their own. So they see a new patient with us like a fellow, but they'll see a lot of established patients on their own. So when a plan is already executed or established, they make sure it's executed. If someone's not responding or flaring or having side effects, then they get us back involved. But in terms of prescribing biologics, they can do that. And I'll say like every private practice setting is unique, but in my particular practice, they do not see new patients. They do not prescribe biologics. They do prescribe iron. I guess that would be like the one infusion they could potentially recommend independently. But every single note that they sign, I only use them as like a filler when I don't have space to see the patient myself. Some of my other partners spend more time scoping, but I do like to see patients in clinic and have that relationship. Because I see a lot of chronic disease, mainly like IBD, small bowel, diarrhea, et cetera, where I read their note and I generally respond back to them with recommendations. And I also have a close relation with our infusion center nurse as well. So it's kind of more of a collaborative effort to make sure that those things are happening. They just kind of follow up on the kind of surveillance type things like close blood work monitoring, making sure that symptom control is where we want it to be after tapering something or something like that. Perfect. Thank you all so much. Thank you everybody for participating. We're gonna close the panel right now. We're gonna go back to our lecture show. If you guys have any questions, we have another panel coming up tomorrow or find us during the breaks and stuff. Always happy to answer questions. If you need to stand up and do a quick shake, that's fine, but we're gonna get started right away with the lecture series, okay? Thank you so much. Thank you.

gastroenterologists

GI practice setting

work relations

endoscopy

GI procedures

GI patient diseases

primary care doctors

communication with GI healthcare professionals