Welcome back. We're going to get ready to start, I guess, the second portion of the morning. So this part is a really interactive portion and we rely on you actually a lot for just your questions. So the second part is part one of two, day in the life of a gastroenterologist. So we have our faculty here up on stage. In addition, Dr. Gonsalves has joined us online. Can you hear us, Nimmi? She's getting... Yes, I can. Okay, great. We have a big and so large screen. So our faculty here is available to answer your guys' questions. So today's for you. We are just going to open it up to the room to you guys to go ahead and start asking whatever questions you want to us. We do have some slides and questions that we have put on some slides that we can also revert to. But let's go ahead and just open up to the room. When you do ask your questions that we ask, if you can turn on those mics so everyone can hear you. Any questions off the bat from anyone? Come on, guys. Okay. So I've noticed a lot of the GIs will kind of empirically dilate for a patient presenting with dysphagia, even just without, this is their very first EGD. How common is that and why would a physician choose to do that over waiting for some sort of diagnosis? Yeah, great question. Let's go to our panel. Diana, you want to start with that? So there's a few factors related to this. So every practice is probably a little different, so we'll see what the others do. We empirically dilate a lot. Typically what happens is we'll have patients that will come in with dysphagia or difficulty swallowing and all the tests may be normal including imaging, endoscopy, motility studies. For some patients, just passing a physical dilator through, which is the empiric dilation you're talking about, can help symptoms. So it's just something we do. Part of it may be related to sort of microscopic scarring that's going on. For instance, I'll have patients with acid reflux. When we go in, there's no stricture, clear, what we call peptic stricture or ring related to the acid reflux. But there may be some of that microscopically going on that we just can't see endoscopically. And so we'll pass the dilator through. And whatever that microscopic scarring is, it helps the patient. So it's low risk to do. But there may be benefits. So often it's worth it for us to at least try it. What do others do? Yeah, I think pretty much the same approach. I like to at least do a workup. Instead of on my initial endoscopy, I may not, as part of the workup, dilate empirically if I don't see a stricture or reasons to do that. But if workup is unrevealing, moving forward, and they're still complaining, then we definitely can do empiric dilation to see if they respond. If they don't respond, yeah, we don't keep offering things. Because there's always risks with everything that we do. Even though it's low, you don't want that patient to encounter that risk, and you don't have anything to fall back on as to why you did that to them. And so as safe as endoscopy is, risks need to be discussed. So you have an educated patient in front of you who's making a shared decision with you. Yeah, I agree. I probably won't offer it as a chronic treatment. But sometimes when you're doing an endoscopy, the EGD diameter, remember, it's smaller than what the compliance of your esophagus is. So sometimes you may not see that stricture right away. So if you go in, even though you're not encountering anything, but patient's giving you a very good history, then we do tend to offer empiric dilation. And then for upper esophageal symptoms, if other workup has been done, there's some data to support empiric dilation for upper esophageal dysphagia at this level too. So we do offer that. The other important related aspect to this is specifically with eosinophilic esophagitis. So there's clear data that we have that as endoscopists, we are not accurate at diagnosing the width of the esophagus when we're in there visualizing it. So that's why we'll use other modalities like FLIP or esophagram X-rays to try to get a sense of what we're dealing with. So in EOE, sometimes we'll use a balloon pull-through technique where you may not exactly see a stricture, but you inflate the balloon at the bottom of the esophagus, pull it up until the balloon kind of sits at a tight area, and then you say, oh, there it is. So it may start out as empiric because you don't recognize it. And then you find it using the tool itself. Okay. Great. Thank you very much. Any other? Yes. I just wanted to chime in, Laura. Yeah. I can't see anybody there. Go ahead. This is a lot for me. But anyway, I agree with really everything that everyone has said. And I think it really comes down to what your suspicion is on that working diagnosis. I think if you're thinking that this patient has EOE, then it's absolutely appropriate to dilate at that upfront endoscopy because the main thing is that patients are coming in with dysphagia. You want to fix that dysphagia. And as Dr. Snyder said, sometimes you don't have a good sense of that esophageal diameter. So really working to target and open up that lumen is very important. So if someone has EOE and there's a stricture, even if there's inflammation, if they are very symptomatic, I will dilate upfront at that upfront endoscopy. The flip side is that if you have a patient with dysphagia and their esophagus is truly normal, I don't do just an empiric dilation in that setting. What I will do is I'll bring them back to do follow-up esophograms to assess to see if there's something called a cricopharyngeal bar, which is a muscle that pushes on the backside of the upper esophagus. Or if there is a zanker diverticulum, a little pouch in the upper part of the esophagus that's contributing to their dysphagia, I really want to get the lay of the land and know that anatomy before doing that empiric dilation. And partly that's because we are not perfect at assessing that esophageal diameter. So sometimes doing that follow-up testing will be very important. Great. Thank you. Someone else had a question. Go ahead. My question, I hear a lot of chatter about using AI in your use of both of your tools. About how it's more regularly used within the colonoscopy space, like a red blinking light to let you know, you know, look at this. Now not as much chatter with the EGD component of using AI, but there are a few clinics that are starting to use it. Can you talk to me about your experience with AI utilization in some of your tools? Go ahead. I guess on the panel, how many of your guys' institution routinely on colonoscopy use AI? We do at Northwestern. Okay. Go ahead. Sure. Well, we were talking about this outside of the room. AI is more of an adjunct at this point, you know, because we're still trying to understand, you know, what's the extent or what's the breadth of AI that can be incorporated in the procedures that we do. So we're not, you know, as you can see that there's a variation in the routine use of AI. So not every, it's not needed. It's not a prerequisite before doing a procedure, but it aids and we're still as physicians and endoscopists, as proceduralists, still trying to explore more. So it may vary between different endoscopists to the extent of what they're utilizing it as. In a center where we're training our new gastroenterologists, in that population, it's sometimes, you know, it aids, it's a help that, you know, that red light or green light, whatever it is, the genius blinking, but it still hasn't surpassed our eyes or we're definitely looking at the camera like a hawk watching everything, especially for colonoscopy. In my experience, and I'm not sure maybe, you know, other panelists can answer this. In our, in my experience for upper endoscopies, for esophageal, you know, we're using, you know, the NBI and other stuff, like other forms of light to get a better look, but we're not utilizing, even though we do have AI for upper endoscopy, but maybe other panelists could speak for that. I completely agree. I think somebody else brought this up in the hallway when we were on break. So it's a great question. I think this is the frontier of how we can incorporate AI into medicine. This is just one of the areas in medicine that AI is starting to be used. So yeah, the most, you know, utilization is on colonoscopies for colon cancer, because the statistics are high, the stakes are high there, and you want to catch that, you want to have good detection. So you have kind of a tangible measurement with AI to see improvement, whereas sometimes with other, you know, we don't really know what we're measuring, how we're measuring it. I think with AI, what goes in, what is the input to an AI determines how useful the AI is, right? So you also have to put the data into AI to detect and help you. So right now our experience, the more experienced an endoscopist is, you know, may not supersede AI assisting them. So sometimes people feel like it's more of a nuisance, having like two screens on a, you know, two images on a screen or blinking, it detracts from their maybe procedure. But a lot of studies have been shown that that's been disproven, that it doesn't really slow you down. So I think it's adopting AI also, you're willing to adopt AI in your practice and being open to that. So those are very personal things to the endoscopist. We were also talking about resources where people have, you know, it's expensive to buy this type of equipment. So not all facilities can universally have these tools. And right now it's not showing like a need, like Dr. Mishra is saying that you must have it as a prerequisite to perform a good endoscopy and have good outcomes. But we don't know for the upper as well. I know they're looking at it. The same guys that have designed the AI tools for our colon are looking at the esophagus. I'm not fully aware of the extent of the results of that fully yet. Maybe you can speak on that. It's more in the research phase. A couple interesting things that are being looked at. One is I was mentioning Barrett's esophagus, that precancerous condition in the esophagus with our patients with chronic acid reflux. They're looking at different blood vessel patterns and nodular or lumpy bumpy areas to try to identify with AI and target. And then the other interesting thing is one of the pathologists at Mayo is looking at with AI is to detect the eosinophils on the pathology slides for EOE. But this is all in research. And one other important point we were tying to the group in the break about is, as mentioned, AI is to augment our own practice, right? So medicine is a complex endeavor. So the goal is not to put us out of jobs. It's really to make sure that we take care of our patients the best that we can. So it's really a tool to help us not to replace physicians. We still need people that are interpreting these studies. To comment on our experience at Northwestern, so for colonoscopies, we standardly use the GI genius, so the AI detection to detect polyps. So it will detect, you know, there's a library of millions of images in terms of what quote unquote a polyp is. So it's, again, a lump. And so you'll see different things highlighted on the colonoscopy when we do it. And it's sort of this blinking light to draw your attention to an area. But if you, well, even at this point, you know, AI is in the beginning stages. It's getting further refined. If there's a ball of poop there, it could light that up, okay? So it's, again, not the end all be all yet. And I'm sort of waiting for that next generation where it can give us histology, which I think is key. Because, again, it's detecting these lumps and bumps in the colon, but not everything you see is a true sort of precancerous pop that we want to take out. In the IBD space, I know they're also looking at that, too, because when we look at scopes in terms of determining the severity of inflammation, there is AI technology that is being developed to grade severity. So we grade it on a male scoring system, one, two, and three, but you can imagine, right, what I see, again, what someone else defines as mild or moderate may not be the same thing. So I think AI levels the playing field for everyone in terms of standardizing sort of what we're seeing. So I think we're at the beginning stages, and you're going to see that continue to advance and develop in the future. Nimi, go ahead. Thanks. Thanks, Laura. So the two things. I think you've heard that in the colon and using the GI genius and detecting polyps and other things, it can be very mainstream. In the esophagus specifically with EOE, it is not yet. I think the two main areas where this can really make a difference is with endoscopic features of EOE. So a lot of times, there's publications that talk about a normal esophagus in EOE, and in theory, if you're really good at looking at EOE features and endoscopic features of EOE, no one has that normal esophagus, but if you can train that AI program to pick up on things like the linear furrows, the white exudates, the edema, the rings and strictures, that's where I think it'll really be helpful in helping people target those areas of abnormality to target those biopsies. Someone had asked a question about numbers of biopsies, and we'll talk about that a lot more tomorrow, but targeting those areas of abnormalities really helps to increase that diagnostic yield. So having that tool will be really important, and I know there's work in progress on that. The second thing that Dr. Snyder also brought up is in terms of pathology. So there are a lot of people looking into not only just assessing the eosinophil count, but also assessing some of the other histologic parameters and histologic features of EOE and some of the degranulation, some of the epithelial hyperplasia, basal cell hyperplasia, other things, and basically, it's really what has already been said, things that you want to train the AI program to be able to pick up on, but those are the two key areas that I think will be in development for EOE. Other questions? Yes. I guess when it comes to, like, any new technology, like, when you talk about our therapies or treatment modalities, like, what is your guys' protocol in terms of, like, you know, how long do you kind of, like, look into things before you decide to adopt something new? I can take that. It's a very good question, because, you know, after a new thing comes in the market and there's evidence behind it and the evidence supports that, every division across the United States is going to be different in adapting that technology. Now, a lot depends on how much resource the institution has and how much is the institution focused in developing certain things. So if it's something that's coming for advanced procedures, like interventional procedures, you know, if the center is developed to do that and they have the ability to incorporate that and they have the resource to do that, again, kind of bringing you back to the point that everything depends on how much money we're getting. So if the institution is ready to pour in that money to buy that product and start using it, the providers will get comfortable using it. But at the same time, this is a very good opportunity for the industry to interact with endoscopists, because sometimes, you know, the industry is coming up with new technologies or new ways of doing a certain thing, even like simple things like polypectomy, there are newer methods coming out every day and industry is also looking into better ways of tackling the problems that we face. So I think the interaction has to also, this is a great opportunity where the providers can interact with the industry to create that association where you all feel comfortable reaching out to us, like, you know, advertising what you got and then we get to, you know, maybe try it in our endoscopy world and see how we feel about it or could give you some feedback. So that's another learning opportunity that I see, which often leads to more development because you get that one-on-one interaction with the providers. And you know, that could range from different instruments to different things on the scope to medications and a lot of, there's, you know, just so many things that could be explored in that dimension. Just to talk about our experience at Northwestern and incorporating that GI Genius. So we did, you know, I think Northwestern has been pretty good in the endoscopy area in terms of, you know, if there's something that physicians show an interest in, we work with industry, we bring it in for a trial. So that was for GI Genius. You know, we trialed it out and every physician had a time where they could use it and just, you know, see how it felt, seeing this blinking screen, is it disturbing, is it, does it enhance the detection rate? They actually did a trial looking at it at Northwestern and we found that we did increase polyprotection rate with this. And then subsequently we have incorporated it in the system. So there is a process. We've done this with various things or new devices that come out. So you know, we have to embrace technology and what it has to offer. There's various aspects, physician use, comfort, data behind it, right, and then resources. So a lot goes into determining if it's appropriate for us to pick it up. And just I'll echo the same thing because I think it highlights the key thing that Dr. Mishra said, it's the interaction between industry and the doctors, right? Because we are the end user, whether it's medical therapy with drugs or, you know, technology. And there is a, you know, adoption phase that we have to feel comfortable, we have to feel we understand how to fix any complications that come with that and how to respond to that. So it's a learning curve for us, but I think the key is like feedback, right? So for example, there are tools that were developed in, as far as technology and endoscopy to help like, for example, there was a company that came out with a better suctioning device for like a poor clean out of a colon. So the data showed that, okay, well, we're missing these colonoscopy patients who are coming in having bad bowel preparation. So instead of saying goodbye, come back, you know, six months later, we lose, potentially lose that patient. They're disheartened by the process, they don't come back, and then we have a bad outcome, you know, a year later or more. So how do we recapture that patient? So that was a need. So this company created, you know, a better like cleaning device where if we identified the problem early on into that procedure, we could maybe utilize or add that tool into our, onto our day and make the best of it. And maybe we don't bring them back in three to six months, but we bring them back in like five years potentially, which is still better for the patient. So the first iteration of that tool was okay, it was cumbersome, it was not user friendly. And then with the feedback of the physicians using it, working with industry, they have developed like a newer generation and same thing goes to AI. So I think if you don't have the users, you know, you coming, you coming to us and encouraging us to use it or providing it on a trial basis, it, you know, very few people will reach out for it themselves because we already have other technology or they'll design it themselves. So I think the industry doctor relationship is kind of a symbiotic relationship for everybody's advancement. So I think that's where we have to, the angle we have to look at. I agree. One more thing I'll say, you know, since I'm at, I'm at Stroger, which is like, it's a sort of a community hospital, tertiary care, but amongst like larger center, UChicago, Northwestern, Rush. so sometimes what happens is that the industry may feel that this center may not be interested, but you'll be surprised smaller community center are still, the providers are still, they're skilled enough to try new products. So bigger centers may have more resources to incorporate in form of a clinical trial. That may not happen at a smaller community center, but newer products can still be introduced to the endoscopic at smaller centers and at community centers. So reaching out to them and kind of showing what you have and then if they do need special training for that, they could always go to tertiary center for like a day and kind of like shadow and do stuff like that. That's always a possibility and you guys know more about that than I do, but just don't shy away. I think don't target your audience at the tertiary or major centers, like your folk endoscopists everywhere need your help. So we really look forward to that interaction with you all. Great, any other questions from the audience? Yes, go ahead. Yeah, I got one. It's a little bit off gear of where this has been flowing, but I have a question of how you guys or ladies coach through patient uncertainty. Like let's say for example, you have somebody that's diagnosed with EOE and they're used to taking steroids and PPIs, but they tell you that they don't want to take an injection, but when you look at the scope and you listen to their symptoms, they definitely need it and just kind of what your word track sounds to encourage them to take the medication. Is there something? Go ahead. Okay, so I'll go first. So great question. I think that's the art of medicine. It's how I would look at it and that's how you, your relationship with that patient. That is the key to not forcing the patient because you don't want to be paternalistic. The patient needs to come to their own conclusion of what's best for them. Otherwise you won't have compliance long term if you force something down anybody's, you know, for anything in life. So I think you have to work at it. Sometimes patients are very smart. I think most patients can understand data. You just have to present it in a simplified manner instead of clinical trial, big words sometimes, where they feel overwhelmed with that kind of decision right away. So sometimes it takes not the first conversation to encourage them to step up their therapy to the right drug, but repetitive conversations. I do present data. I'm not afraid to present data to my patients because I think you should give them benefit of the doubt and have an ongoing conversation. And I try to, you know, show the long term benefit if a data, or if their disease process requires the next, you know, therapy. And present like, look, you've been on this therapy for X amount of time. We have objective proof that you're still having inflammation or complications like a stricture or something else. You know, the data behind this new drug, just because it's new doesn't mean it's scary. There's a lot of safety. For example, the drug you're talking about, Dupixan, has been around much longer than the GI space. So we have to show that, also safety data, and encourage them that this is not, you know, scary. And we always keep it open ended. Say, look, try it for a little bit of time. If you're open to it, and if you don't like it, let's have another conversation. So you keep an open communication with your patient. Completely agree with everything that you talked about with shared decision making. We'll mention that in some of the lectures too, and how important that is. Because as you all know, there isn't necessarily one treatment at any given time for EOE that's correct, right, so a lot of it is understanding the risks and benefits and discussing that in detail with the patient. I'm fortunate the way our practice is structured at Mayo that we get a little bit more time with the patients when they're new to us than maybe some other institutions, including academic. So I can sit and help them with that education piece until they feel very comfortable. And then we also have dedicated, for dedicated esophageal nurses in our esophagus clinic that come in afterward, and they have different pamphlets on dupilumab, they also have the example kit of how the actual pen is used. So having patients be able to visualize that directly with some interaction with me and the nurse I think helps a lot too to quell any fears. The other resources I've used are the videos that you all have told me about that I send them links to through the portal, in the patient portal, so that they can see exactly how the medication is used. And so different touch points really help people feel more comfortable. Yeah, I agree, I don't really manage as much EOE, but for IBD, we do have kind of a similar situation. The best medication is the medication the patient's gonna take. So a lot of that goes into convincing. One other thing I would say in terms of the risk factor, kind of the way you're counseling. So you tell them there's risk for cancer or lymphoma, but when you tell them the relative risk that the chance of dying with a lymphoma with this medication is way lower than your chances of dying in a car accident, which you're driving every single day. So that kind of changes their perspective. So a lot of onus falls on the provider for that. And then I would also give a lot of credit to the industry for providing patient support programs and support groups, and especially for the population that I cater to, poor health literacy, uninsured population. Sometimes it's a struggle to get them the right medication. So we do take a lot of pride in our connections with the industry and their efforts in supporting us with the assistance program. So we do leverage a lot from those, and those have excellent nurses and who are available to the patients in different ways, virtual, live, and whatnot. So I think there's a lot of room for us to grow, but we do appreciate the partnership with the industry for helping our patients too. Great, Dr. Gonzalez, do you have anything else to add to that? Yeah, I mean, I agree with everything that has been said already. I think it really comes down to that patient relationship and patient education and patient trust. And I'm very fortunate in that I have an EOE and agent dedicated clinic. So that's really 95% of the patients that I see. So I can, just like Dr. Snyder, spend a little bit more time with that education in terms of the different types of therapies, the different rates of effectiveness, and then try to really meld what that patient's goals of care are with what their disease state is and what available therapies there are. Because I can't stress enough that, we never tell patients like, hey, this is the right medication, this is what you should be on, this is what you should take, because it's really not fair for them. They need to kind of come to this discussion and this decision together based on what is important to them. So for instance, you brought up the situation of someone that's really fearful of needles. I mean, if that's something that they're willing to overcome, there are ways that we have had our nurses do like more education and training and have them come in to do that with the patient and then kind of get them over the hump. But some patients are just really averse to that. And so that's not the person that you want to kind of push in that direction. But it's really a conversation. We have a lot of patient education materials that we've developed for our new patients so that they can spend a little bit more time learning about their disease and options and all the pamphlets that industry has provided too about their various products are there as well. But it is definitely a conversation. Right, any other questions? Hi there again. So my question again, it's one of those controversial ones within my territory where if I were to pull 10 different GIs, they'll give me 10 different answers. And it's around the elimination diet and allergy testing. Some doctors are on one end where they're like, you know what, I'm gonna do elimination diet because I can isolate what the trigger is and I can treat EOE early upfront. Where others are saying, you know what, it's not IgE mediated. So they can go and target the interleukin pathways. They can get better success that way. Some are sending them to the allergist for testing. They never see the patient back. It's just everywhere. We have others who believe that, you know, some patients are predisposed to EOE and an allergen is just a trigger that starts it even if you remove the allergen, that it just still continues. So it's, so I wanna know like what your thought is on the allergy and, you know, elimination diet. So I'll take this one. This is the, I'm the leader in this. But so again, I think you bring up some very valid things that happen out in the community and even in, you know, some other large centers. I mean, I think what we know about EOE in terms of mechanisms, it is a clinical pathologic diagnosis. It is a food antigen driven disease. We know that that's irrefutable. There are additional like air allergens and allergic pathways that contribute, but the primary kind of trigger are food allergens. Now diet therapy isn't the right choice for everybody, for sure. But if you have a patient that's willing to embark on diet therapy, that is something that absolutely is very reasonable path for that person. In terms of your question about the allergy tested directed diet versus empirical elimination, I think it is now the stance of every single GI society as well as the allergy society. And there's lots of studies that have shown very poor correlation between allergy testing and actual food antigens. So it is no longer recommended for patients to go for allergy testing to figure out their food antigens. It's really the favorite choice is empiric elimination diet. So that's really something that as a GI community, allergy community, we're trying to stress at every education conference. The one caveat for that is that the studies that have shown some benefit for allergy testing ends up being in younger children who have combined allergy patch testing and skin prick testing, that has shown a slightly higher link to those food antigens. But even the pediatric gastroenterologist and allergist typically don't do allergy testing in EOE patients to help guide diet therapy. If you have children who have a higher risk of that anaphylactic type reaction, that's when those IgE mediated testing can be helpful. Or the other time it's really helpful is if you've had a patient who's been eliminating something for years and years and years, there's some data that in children, they can get resensitized to that food and they can develop an anaphylactic type reaction. So if someone comes to me and says, hey, I've been avoiding milk, wheat and soy for six years, but I wanna reintroduce it back, that's when I will send them to the allergist to get that skin prick testing to assess for that IgE reaction and sensitization. We haven't seen it in adults, but it has been reported in case reports in children. Great. We do have a part two of the day in the life specifically for EOE. So we may save more EOE questions for tomorrow just because we are a little bit behind on schedule. Any other sort of general sort of questions about day in the life? I have one. So I have in the community doctor and community clinics, our GIs who spend probably about 80% of their time in the endoscopy suite and the other like 15, 20 in clinic, but they rely heavily on their APPs, nurse practitioners and PAs. What I've noticed the dynamic in their relationship is say like IBD-UC, anything that was related to starting a biologic historically was that is the doctor's patient and that is maintained and followed by the doctor. A lot of that has to do with kind of the nuances of the biologics or the different treatment options available for those. And so when we introduced Dupixen, a new biologic, it kind of, because it's a biologic, went that route. Do you have a similar setup with your APPs in your groups where that biologics are managed by the doctors and not necessarily the APPs? Or and how has that changed? Or it hasn't changed since Dupixen has come out? We have two esophageal and PPAs in our group that work with us. And so they see new patients and return patients. And with the new patients, we're physically there as the MD staff that also sees the patient. And so our nurse practitioners are prescribing dupilumab. So it hasn't been a limiting step. We're kind of following behind the IBD specialists that are here, right? So their biologic therapies, as you all know, are a little bit different where there's prebiologic testing and there are certain risks involved. Whereas dupilumab working through the Th2 pathway, as you all know, those risks are a bit lower. So we don't have to worry about some of those things, but certainly our NPPAs are prescribing them. In that situation, do they prescribe any other biologics or is it just dupilumab? It's our esophageal clinic. So that's really the only one we have. But there are NPPAs in the inflammatory bowel disease clinics at our institution as well that are prescribing biologic therapies for IBD. Okay, thank you. What are you all doing? Yeah, for IBD, we do have trained NPs and PAs in our clinic. And we heavily rely on them for caring for our patients because sometimes our top of the license for gastroenterologist work is endoscopy. And as you said, we're dedicated more towards doing the tasks that only we could provide. And so for our clinic patients, we have to rely on them. There are special training tracks and a lot of pharma companies are coming out with APP tracks for training in certain specialty and advanced therapy. So we encourage our support, our APP staff to go to these trainings and the biologic coming out for IBD in the last five years have been just an enormous load. So they have to keep up with the training. And I'm sure like in any other space in GI as the number of biologics increase and number of medications increase, like that training, but that's true for even for the providers. We have to attend more CMEs to get that fresh knowledge. We have to be on top of our game to know what's the latest evidence and what's out there and what's the risk and benefit for it. So we feel very comfortable in training. And I think the pattern is more towards getting comfortable with them ordering stuff and MD assistance or supervision is required for more complex patients. Certainly someone just a post-hospitalization acute patient visit, those we try to capture those, and more stable patients are taken care of by our APP. And if at any point, I mean, we have a very good relationship where if they feel like, no, I think it's getting out of my scope, like at what point should I connect with the provider, the doctor, they're usually very comfortable just kind of walking up to us or texting us like, hey, I just wanted to run this by you. And that comfort gives them the ability to fall back upon us and ask questions comfortably. I think that is the major key. So yeah, I think now with the changing pattern, most APPs are comfortable. I would echo the same at our institute. We have a PA in our IBD clinic and we have an NP in our esophagus clinic and motility clinic. So they are very comfortable, but they're also, they go to like national conferences to keep up with their CME. And we have grand rounds, other things on topics that they're locally going to. So I think making the APP feel comfortable is important, but part of that's education and mentorship and like seeing it, right? So if you have a community-based practice, which is I think where you're maybe set up, that may be very different. I was in private practice before going back into academics. So I kind of understand where you're coming from. And we are blessed in academic where we have other resources that private practice or community-based clinics don't always have and their volume and the type of diseases that are coming through their door is very broad. And they're trying to capture as best they can for their patient and do whatever they can, but it's sometimes difficult. So you need that APP to be trained. But if that APP, excuse me, if that APP is just really busy in work and never getting education, dinner conversations, conferences, whatever other resources, and that doctor is in endoscopy and not able to oversee, they're probably not gonna feel comfortable and they're gonna outsource that to the physician or to a larger referral center like we work at. So we see that kind of referral to our center all the time from the community because they're just choosing not to put the effort in that sometimes because they have other things that they have to focus on. So sometimes it's a decision of what you wanna be, what your interests are and how far you wanna go. There are a lot of community doctors who have a lot of interest in eosinophilic disease and they're champions, but it's a patchy interest that you have to find. Got it. You see what I did? You see what I did? If any of your APPs specialized in EGID and EOE wanna come out to California, you just let me know. I have a place for them. That is true. So doing more like these types of networking, finding a speaker that could, as feels comfortable presenting and reassuring even the physicians on how to use it and the safety is very important to reaching out and educating the community. Thank you all. Yeah, there's no legal prohibit, that prohibits an NP from prescribing it. It really is just on the patient NPPA relationship and practice patterns and changing practice patterns is tough. Yeah, and I've noticed that going, listening to all of your experiences in the community centers, they're all just general APPs. They don't have a specialty. And so I think that's when the specifics of something that is specialized like the IBD-UC stuff gets kicked over to, and I say kicked over, but like retained by the GI. EOE used to be managed and still is managed by the NPs because that kind of fell in originally before Dupixent came out, was in that low risk sort of realm. And so that's where the uptick or any sort of uptake of Dupixent stalled a little bit because it's a biologic. These general APPs are not familiar with prescribing biologics. They're waiting on the GIs and the GIs are like, no, EOE is your thing. I'm the IBD person. And they're like, well, biologics are your thing. I'm the non-biologic person. And so there's this disconnect there. And so educating them has been something that we've been focusing on for the last, I would say year, but I've been in the territory for two and a half years. It took me a while for me to understand that this was like an inner working of the dynamics in the community center. I just thought everybody knew, did like they had autonomy to do everything. I've walked doctors to the nurse practitioners and said, tell her that she has permission to do this, right? So I just wanted to see is this a unique to me situation or my territory or is this community in all community area kind of scenario playing out here, but it's very good to know. Thank you. Yeah, and in California, and this is a universal thing as you're pointing out across the US, but in California, as you know, it's a large state. There's a lot of good academic centers that have esophageal specialists. So it may be useful for you to collaborate with them and they can help you to be the medical liaisons to educate the community practitioners too. Absolutely, yeah. Okay, great. I do think we wanna get things moving forward. So let's switch gears. Thank you, panelists. You can have a seat. Thank you.

gastroenterologist

empiric dilation

endoscopies

dysphagia

artificial intelligence

polyp detection

eosinophilic esophagitis

biologic treatments