Okay, without further ado, I think we're ready to move on with our program, and I'm going to welcome our faculty that are assigned for the next day in the life, Dr. Falk and Dr. Gonsalves, Dr. Ali, and Dr. Lightdale up to the panel, and Lyle, if you would advance the slides. Let me see. I can probably do that. There we go. These are, as we did yesterday, I want to see a show of hands for the topics that we want to discuss with our panel. So of the following topic areas, which one would you like to hear more information about from our ASGE faculty? Is it A, the role of biologic coordinators in GI practices? Show of hands. Okay. B, the coordination of EOE care with allergists, pathologists, and dieticians. Okay. C, how financial patient preference choices and clinical factors impact EOE treatment decisions. Okay, very good. How advanced practice providers function in GI practices. Very good. And then decision-making regarding endoscopy in patients with EOE. Okay. All right. With that in mind, let's talk about the coordination of EOE care with allergists, pathologists, and dieticians. And we have a couple of our faculty members that are adult gastroenterologists, and Dr. McDowell is a pediatric gastroenterologist who sees patients with EOE. And some of those dynamics may vary from practice to practice. Dr. Ali is, as you remember, an inflammatory bowel disease expert, and he has tremendous experience with biologic coordination and navigation. So we'll be picking his brain when we get to that topic. So we'll start with Jennifer. In terms of what percentage of your patients, and what is the communication chain of command, if you will, when you're dealing with allergists, pathologists, and dieticians in your pediatric or adolescent group of patients with EOE? All right. Well, I would say 100 percent of our patients we deal with our pathologists because we really rely on them to help us make the diagnosis. And actually, the current fellow in pathology is turning over. So we at UMass, we have a GI fellow who we wind up really running our conference with. We have a weekly pathology conference to go over all our pathology. And we're really dependent on them learning well, running that conference well, and frankly, getting good guidance from their attendings. So what you see with EOE is some lack of standardization with how pathologists read their reports. So some pathologists will count up to, I don't know, 30, 50, 100 EOs, and they'll stop counting. And there's a lot of variation with where they'll make that cutoff. So I think what's been nice is over, I've been at UMass now almost 8 and 1⁄2 years, I think we've come up with some standards and what we need to hear from them. And we definitely have this pathology conference happening on a weekly basis. Anybody I scope, I'm telling the patient, I will talk to you after that pathology conference and we'll usually have some conversation. Then dieticians. So we work with our dieticians for many of our kids with EOE, not all of them. A lot of the kids are now, they've had the condition for a while. If you do, if you say to them, can you meet with the dietician, it's really a hardship on the family. They don't really want to meet with the dietician again. So they know that there's exclusion that you're recommending. And I'll be talking more about it, but personally, I'm really at the one food. I'm really asking them to get out milk from their diet. That's really what I focus on. And then finally to the allergist. So allergists for me are all around who gets non-IgE mediated conditions and who doesn't. Who's really interested in EOE and who isn't. I think most allergists have heard of it at this point, but they're not all facile with it. They sort of panic at weird things. They'll do a lot of food testing, which isn't always helpful because they often find the milk is not IgE positive, but for many of my kids, that makes the difference to get milk out of their diet. So I really want an allergist who's working with me, not against me. And one more thing, which is I also need an allergist who communicates to me when they're doing now the immunotherapies because that often makes the EOE flare. And if I wasn't given a heads up that they're doing the immunotherapy, all of a sudden the kid's got something stuck in the middle of the night and I'm not happy that nobody told me they were doing immunotherapy. So I like allergists who are my friends. Can you just clarify for the audience what the immunotherapy involves? Yeah. So actually I'm just a gastroenterologist, but there are increasing ways to try to sensitize people who have significant allergies and a lot of these kids have significant ATP. So not just food allergy, but cat allergy, pollen allergies, seasonal allergies. And I feel like the allergists, some of them are moving to more and more treating for this, offering that option. My understanding is the kids go in and get shots like every week to get this going. And I'm sure adults too, but you may know more about it. I don't know. Yeah. So I mean, this is a thing now for the last like five years or more where it's either oral immunotherapy or subcutaneous immunotherapy for both environmental allergens and now even food allergens where people are getting desensitized to these environmental allergens. One of the things, as Dr. Lachdale was mentioning, is that that increases someone's risk for development of eosinophilic esophagitis. We don't know if those people had EOE at baseline because it's not protocol to scope everyone before they do immunotherapy. So there probably is a little bit of unrecognized EOE in that population, but it definitely has been associated with development of EOE with this type of immunotherapy. So it's very important for those allergists to communicate. That's very interesting. People that were getting immunotherapy, say for seasonal rhinitis, might then all of a sudden present with EOE. That's something I wasn't aware of. Yeah. Definitely happening. By the way, you said be very honest, Bill, right? Yeah. Absolutely. Nobody say that I said nasty things about allergists. Okay. How about Nimi and Gary, in terms of your interaction with the pathologist and the allergist and the dieticians within your practice? Yeah. So I'll speak for Northwestern. I mean, we're really very lucky in that we've had this development of our eosinophilic GI program since I was a fellow back in 2002. So it's a very well, like, finally established machine. The gastroenterologists are the main people that manage the patients in terms of making management decisions, therapeutic decisions, follow-up endoscopy. We have a very close relationship with our pathologists. And as Dr. Lightdale mentioned, it's really challenging, even at our center where we have dedicated GI pathologists to get good pathology readings. So we have been in the process of educating and asking nicely for peak eosinophil counts and making that diagnosis. So every biopsy that I send to them has a note on that to rule out eosinophilic GI disease. Please give me the max eosinophils per heart per field. Please give me any additional features. So when they see the biopsies, they're like, oh, it's a Gonsalves biopsy. I have to count. But I mean, I think part of that is—I mean, but let's just say we have a new series of pathologists that come every July. So it's a part of training, and our nurses are like, you want your, you know, phrase on the biopsies? I'm like, yes, I do. They have even—it's laminated in my room so that all the nurses know to put that in the biopsies. But it does help. So for the average gastroenterologist, when you're sending off that pathology, really communicate with that pathologist and write that stuff down. We have a good working relationship with them. If there's a biopsy in question where I think someone really has EOE or eosinophilic gastritis and the biopsies don't show that, I'll go back and I'll call them. I'll look at the biopsies with them. It's a very multidisciplinary approach. In terms of our dieticians, again, we're very lucky. We conned or enticed one of our stars to come over to the Egypt field, and she's our dedicated GI dietician, and she's excellent. So as part of our program, she sees all of our patients essentially for free who want to do dietary therapy. So that's been part of our success with dietary therapy. But I do think that dieticians are very important as part of this disease, especially to make sure people are getting a well-rounded diet if they're doing dietary therapy. In terms of our allergists, I think there is a lot of education that needs to happen in the allergy community. I think most academic allergists know the data. They don't necessarily need your skin test everyone for the food allergens, but they're very mindful about controlling other atopic disease. I think what happens a lot in the community, patients will come to me with a full-on panel of all sorts of testing that they've done and are avoiding 50-plus foods and getting really stressed out because nothing's helping them. So I think there's still a little bit of education that needs to happen there, but it is very multidisciplinary. I don't think we can operate in a vacuum. We're lucky, and hopefully we can try to expand this model to the community setting to show people how this can work. Eric? Let me just add a few things here. Most of it has already been said. First of all, I think it goes without saying that what you're hearing, this is a team sport. And if you approach these diseases in a collegial team way, things work out better for the patient. Unfortunately, that is sometimes an aspirational goal, not what happens. There can be antagonisms that we've heard about. I'll get to that in a moment. So really, it's a team collegiality. Everyone needs to respect each other's territory and expertise. As far as pathologists, the one thing I would add is that as things have changed, we have templated our EOE reports. So we're asking for certain things, peak eosinophil count, basal cell hyperplasia, microabscesses, fibrosis. So we know that it's there because the disease is more than just counting eosinophils, that you need that for the diagnosis. But there are other subtle features that you'd like to have, and there are some other diseases that can cause eosinophils. So it's very simple to have a template. There are very complex things that have been developed. The EOE scoring system that is really for research purposes, not ready for clinical prime time. So a pathology report that just says eosinophils doesn't tell me anything. So we just have it templated to every pathologist. It's standardized. They do it because there was a lot of variability before. That's the pathologist. The allergist, again, what you're hearing is aspirational. Gastroenterologists have, I can't speak for the pediatric folks, but gastroenterologists, when you look at our core curriculum, which is now many years since it's been updated, when you look at the section for allergy training for gastroenterologists, you will see a blank page because we are not trained in any of that. So gastroenterologists need our allergists to help us in the management of atopic conditions. Not until I entered the EOE space did I really have any appreciation for what allergists did. It was, oh, food allergies. But it's really a big deal. And when you take the time to talk to people, I always ask about things like, do you have itching on your tongue or at the back of your throat when you eat certain foods? Do any foods give you specific symptoms? Do you have anaphylaxis with anything? That's way above my pay grade. I need the help of an allergist for that. Similarly, eczema, asthma, that's where the co-management comes in. And the thing to emphasize, what was said by Drs. Lightdale and Gonzalez, is that when patients get a panel of tests done and then they see us and they say, I'm avoiding all this and I'm not better, then you have to kind of untangle this and unwind and point out to that that the mechanisms of EOE are different than the mechanisms for which traditional food allergies are tested. So all that allergy testing can lead to chaos and confusion for a patient and to a certain extent anger. So it's not ideal. I'm not sure if the two of you encounter that as well. So as far as dietician, the problem with dieticians is that they are the reimbursement aspect for it. So a lot of places don't look favorably upon it. We're fortunate that we have a dedicated GI dietician for this who we do not institute dietary therapy by just sending someone to the website. We have them sit down with the dietician to go over it and also to make sure they're getting adequate calories and adequate trace elements, et cetera, et cetera. So bottom line, it's a team sport. Yeah. Great point. Did you want to say something, Taseef? Yeah. I'm representing the private practice here, the community practice, which is the majority of the practices and some challenges that I will just share with you. I think I attest to the need of more education and coordination. Things are ideal in academic institutions, but when you come to a private practice, if you are practicing in Hutchinson, Kansas, or you're practicing in Ardmore, Oklahoma, it becomes really challenging. There are challenges when you are trying to coordinate the care. So the first challenge comes with the pathologist because in many practices, if you are a multi-specialty practice, if you are in a private practice or a hospital-based practice, your interaction with the pathologist could be very different than having a direct communication. Many specialties in private practices have these national franchise of pathologists where you don't know who the pathologist is. You're just sending it out and you're just getting a report. You don't even know who your pathologist is. So there's some national pathology companies that are reading your reports. They call themselves GI pathologists, but when you look at the report, you realize that there are a lot of issues with that. Then comes the hospital-based practices and private practices. Many times, the pathologist would be rotating off and covering different hospitals. And again, having a direct interaction with those pathologists becomes a challenge in a very busy practice. Trying to find and locate the pathologist who has read your report, it's a challenge. And then the second challenge is having a communication with them and asking them. And it's a huge favor. In academic institution, there is an understanding that we are learning from each other. We will have an interaction. When you come to a private practice, asking these questions like, hey, can you give me a count on the eosinophils? You said there is an eosinophilic esophagitis. Can you give me a count? I mean, that's like climbing a mountain. This conversation can go totally wrong. And there's like, who the hell are you asking me? So there are issues with that. So I think that's where we need some education and some collaboration and teaching of what we are dealing with. Same thing with a lot of community gastroenterologists, the protocol, how you do biopsies, it's a challenge. Many times, we get reports and they have just done biopsies and they were not the appropriate biopsies. For dieticians and allergists, the challenge comes with the insurance and patient's ability to afford going to these specialties. A lot of patients don't have the ability. I mean, I see a lot of patients who are either uninsured or they just don't have resources or means to go and pay for their co-pays and have these extra visits. Many times, you don't have in-house or within campus your allergist or a good dietician, so you have to ask them to go and see them. So these are some of the challenges that we face. I'm relaying most of this information through my experience with IBD, where you need a lot of coordination between a lot of specialties, and I think that kind of like speak to taking care of these EOE patients also. One other thing, too, that we've seen, Nimi and I, as we've done some consulting work with other companies, is that little did we know that there can be an antagonistic relationship between allergists and gastroenterologists out in the community, and the patient then is in a tug-of-war, and the allergist views us as simply brainstem preparations to obtain biopsies. The gastroenterologist doesn't necessarily have the passion to take care of the EOE patient, and the patient is left holding the bag. So again, as I said, it's a team sport, but sometimes people are not rolling in the same direction, and we always have to remember, no matter how you slice it, I tell this to generations of students, residents, and fellows, everybody that we take care of is someone's mother, father, brother, sister, grandparent, son or daughter, and I have my bad hair days, too. But it's always important to remember that that human being that we take care of is somebody's family member, and if you use that as a guiding principle, good things usually happen. Again, it sounds aspirational, but that's kind of my touchstone of how I approach things every day. Those are all great points. I think we've heard about a lot of very practical obstacles that can get in the way of that team sport that is so essential in almost anything we do in medicine, and efforts of communication are really what's necessary to break down those barriers, and education, and educating both other specialists and our specialists within our own gastroenterology specialty. We've mentioned that now a number of times, that we need better education, better coordination and communication between specialties, but there certainly are a lot of obstacles, and as Dr. Ali pointed out, what happens in community settings is not always the same that happens in academic settings, and as you guys go into the field, you'll probably get a sense of that very quickly, and many of you have been in the industry for a while and already probably have a sense of that. Interestingly, we talk about diet therapy for EOE, and the dieticians are a very important resource for us to call upon, yet the healthcare system gets in the way, because I think it was Jennifer, you mentioned they see them for free. Is that right? Whoa. I do. Oh, you did. Yeah. I got a grant for our program so that we cover our dietician's time, so for the EOE patients, she sees all of them for free. That's not the way that it works in the real world. Yeah, it's a little unusual for that, and so dietician care and consulting is something that is very much underappreciated, not just in EOE, but in a lot of things that we see in gastroenterology, and unfortunately, it's not always available because of reimbursement issues. Okay. I want to move on to another topic here, and that is what kind of financial patient personal choices and clinical factors really impact your decision and your shared decision-making with your patients for EOE, and I think that dynamic also may be very different in the pediatric versus the adult realm, so I'll start again with Jennifer. What sort of factors sort of flow into those decisions? Well, first off, I do feel like I threw my poor dieticians under the bus, but there is a financial ... They pay a co-pay to come see our dieticians, and frankly, our dieticians don't get very much for most visits, so it's very hard to support dieticians, and that is a dynamic going on in the background, which I think it's hard to be a dietician these days, bottom line. At least in the healthcare system, perhaps private practice works better, so that's a little bit of finance. I mean, a lot of it for us is around quality of life and the age of the patient and just how much they're failing to grow, so I'm going to do some cases later, but a two-year-old, three-year-old who is thin and not growing, that's a kid who I am all full-court press, putting in an NG tube, starting them on an elemental formula, excluding everything, and I'm getting them back on the bus of growing. As you get into the older kids, the teenagers, and you're telling them, gee, I kind of need you to exclude a bunch of foods. I know you went to the allergist and they told you you're not allergic to anything, but I actually do need you to exclude some foods. I've already alluded to this, but I think the number of foods you're seeing many of us have really started to drop in terms of what we think is the highly effective way to ask them to do some exclusion. And then a lot of the treatment for me, I mean, I'm trying to cover this whole question here, but a lot of the treatment decisions for me that I'm doing in a shared way for them is that we've moved away from perfection. I'm no longer looking for mucosal healing, which is, unfortunately, it's not great, and I know I'm going to be handing patients over to my adult colleagues who are much more on that road to fibrosis than we want them to be in pediatrics. And this is why it's very exciting to hear there's a biologic coming. We knew we needed one. They tried different ones. It wasn't working, whatever. But I think a little bit of the decision-making is around diet, certainly the suspensions. You're trying to teach them how to make budesonide into a suspension, or the inhalers. So I'll go through all that in my cases. But a lot of it is around quality of life, what's going to work for that family, recognizing this is a chronic condition, lifelong. It's going to be something you have to deal with. You need to know about it. Try not to get food stuck in the middle of the night at some barbecue. It does not make your gastroenterologist happy. And you won't be happy in the ER. So really trying to teach them what they need to do. And them is initially the parents and the child. But increasingly in the teenage years, it's really the teenagers themselves who need to be a part of that shared decision-making. So I don't know if I've totally covered all that, but okay. What about the parents? You have to deal with the parents more than we do. Yeah, I mean, so I was talking about this with my group yesterday a little bit, or somebody yesterday. But one thing that's tricky with EOE is the kids are often atopic, so they have seasonal allergies and asthma, but they've been relatively healthy kids. And you're telling them, your child has a chronic disease that I cannot cure, and this is going to affect them forever. And so you're telling parents that, and it's very hard. It definitely changes the way they look at their child. And again, a lot of them are, I take care of a lot of athletes. A lot of kids are out there with pollens all around them. And this is actually EOE season that we're in the middle of right now. They present in baseball and soccer, sort of my two seasons that all of a sudden get a lot of impactions. And it's not by accident, it's just the way New England is in terms of pollens. But I'm taking these healthy kids and telling parents, this child is gonna have to deal with something forever. Okay, Gary, we'll kind of change the order a little bit. How about from adult perspective? How do you go through the shared decision making? What factors tend to be the most important? So we see patients beginning on the transition from pediatrics to adulthood. So we see people anywhere from 18 to, my phone call yesterday with a 60 plus year old colleague from medical school who told me about his EOE pathway. So it really is variable. And we also see people who are de novo who haven't been treated and people who have had other treatments before. So the bottom line, I don't have to give my lecture later, I guess, is the following is that number one, one size doesn't fit all. Number two, there are pros and cons to each treatment. Number three, despite the excitement about dupilumab, either dupilumab or any other approach has 100% efficacy on other and the closest that gets to that is an elemental diet, which most people are not gonna wanna do. So I will go through in order with people go through the Ds. So I go through pros and cons of diet and the response rate. I agree with Jennifer, I give people the option of a six food versus one, two, three or four food. But I also am encouraging people more towards the bottom up versus the top down approach of keeping it simpler. I'll be here, you should see what Nimi has to say. Nimi is one of the giants in the field of dietary intervention. PPIs, which if you ask most gastroenterologists, they'll, if a patient will ask, what do you think I should do in someone with not severe disease? It's the simplest, easiest, least expensive way to treat someone. You can have a free diet, you're not gonna have any expense issues with it. And if it works, you're in pretty good shape and then you can go from there. Topical steroids, also an excellent option, pros and cons of that. People start worrying about steroids, bad bones, am I gonna start looking funny cosmetically and we have to emphasize, this is not like the systemic steroids that you take for other diseases. These are very low doses, it's like topical steroids on your skin. And we go through the mixes with that. And then we, before, four weeks ago came up the other option we would give patients as clinical trials. And we tell people that you have skin in the game, we have skin in the game, and it's in everyone's interest to try to get new compounds out. And we tell people that all these studies are randomized to either placebo or real drug, but everyone, for most of the studies, will get real drug at some point. Your care is all free of charge and you will potentially help yourself and others. There is sometimes a stipend for it. And when you go through all of these options, and now of course dupilumab, when you go through all these options, at first glance you don't know what someone is gonna say other than I always say that the college student or the someone as a graduate school student is usually gonna be very unenthusiastic about a dietary approach because they want pizza, cheeseburgers, hamburgers, and ice cream. And there's no negotiations. So, how much do, in your experience, how much do, for both of you, Mimi and Gary, how much do financial factors play into this? They're huge because, and we go through that. You know, when we talk about them, PPIs are inexpensive, topical steroids may or may not be approved because it's off-label, even though there's best practice guidance that say it works, and dupilumab is, we're all in this journey together and we're gonna see what happens. The same thing with diet as far as the dietician. So, sorry about that. So, it's highly, highly variable. But yes, you know, I think you have to be upfront in the discussions that it may cost this or it may cost that because patients are proud. They will not tell you upfront if there is gonna be, they do not want to admit they can't afford something, and for obvious reasons. Mimi, your thoughts on financial obstacles for patients? Yeah, so, I mean, to follow up on what Gary was saying, when I approach a patient for the first time, I will first off ask them what their understanding of EOE is, and just kind of get their sense for where they're at with that education. And then I'll go through a little mini symposia almost in terms of that clinical visit and go through what EOE is. And then I'll break down the different types of treatments and the pros and cons. And then I'll ask them what their goals of care are. Because I think that's really important in terms of trying to figure out which bucket of treatment this patient's gonna want. And as part of that, when we talk about dietary therapy, we talk about the follow-up endoscopies. When we talk about the medication, we talk about the cost. And oftentimes, and we have the advantage of dealing with adults that can make decisions for themselves as opposed to another human, they will tell me pretty straight off the bat, like, I just can't afford those endoscopies. Or, wow, I just don't wanna be on this medication. I wanna do this or that. So financial definitely plays a huge role in that decision-making. And sometimes, so most of the time, I'll say 90% of the time, I won't make any decisions for the patient. They'll say, what should I do? And I'll say, well, really, what's important to you? What do you wanna do? But there are some circumstances where maybe someone's traveling a lot for work or they're about to go away to college. And I'll say, maybe diet's not the best choice for you right now. You're not gonna be successful at it with all these other variables. Let's choose X or Y. So it's very individualized. I don't think there's one best treatment that fits everybody. That's great. I think Gary's patient had a meat impaction, so that's why he had to go now. We talked about the urgency of the gastroenterologist's schedule, and it's nonstop. And so I wanna transition, leading off of the finances, to the role of biologic coordinators in GI practices, because from you guys, you'll have to get an understanding of that. And that's really where Taseev has a fair amount of experience. Taseev, can you sort of share with folks what the infrastructure is in your practice to help to get biologic agents approved? What's the timeline? What is the percentage of time where it gets approved or not approved, et cetera? Yeah, I think that's a very complicated process. With all our healthcare system, the way it's working, that's an added expense to a practice, having a biologic coordinator. If you're looking for private practices, where we are already, so I'm not talking about myself, because I belong to a healthcare system, so I'm blessed with having a lot of resources available through the healthcare system. But if you look at the community practices, especially if you're just looking purely gastroenterology practices, you'll see that the expenses are going up from simple as like rent, your bills, and the other FTEs. You are competing your staff with Amazon now, because they're just, the per hour rate that you are offering in the practices are way lower the wages as compared to what Amazon is offering. So a lot of the staff, the front desk, the back staff, they're just leaving. So there's a lot of expense as compared to the reimbursements for all the services that we provide. So adding a biologic coordinator, adding a person, a full-time FTE, is a big challenge. But then we are handicapped, because we all know that when you are dispensing these drugs, prescribing these drugs, you need a person who can coordinate the care. Otherwise, you're just lost. I mean, it's gone are those days when I will just write a prescription, send it to the pharmacy or specialty pharmacy, and that's it. And rarely I would get like a prior authorization is required or a step therapy is required. Those days are gone. Now you even for a CAT scan, even for an upper endoscopy, there are a lot of hurdles. And when it comes to the prescription of medications, especially biologics, your medical assistant cannot handle that, because you need to have a trained, dedicated person who can do all these things in a timely fashion, because the clock is ticking when it comes to IBD, when you're having a flare. And even for other diseases, even EOE, if you are symptomatic and you need something. So most of my experience will be applicable to other diseases also, but I'm specifically talking about IBD, because biologics historically have been used in IBD care. So these patients need. So the clock is ticking, they are symptomatic, and you need a dedicated person. So even if you get a dedicated person, you have to have a training for that person. That person needs to be aware that this biologic is going through medical benefits or a pharmacy benefits. So that becomes the first understanding, and that's where the education would come. That okay, well, if this drug is going through the pharmacy benefits or medical benefits, because the processes are totally different, how you get an approval for both of these. So if it's a subcutaneous, mostly it's a pharmacy benefits, and now you have to find out, okay, what's gonna get covered, and that's here where the PBMs come, where here comes the processes, here comes the knowledge of which specialty pharmacy you are going to send that prescription to. So you need that coordinator. And then you have to educate the patient, because the patient's patience is boiling here. Like they are frustrated that, I just had that discussion with Dr. Ali two weeks ago, and where's my medication? Where's the prescription? How is it gonna be prescribed? They don't even know about concepts of PBMs and specialty pharmacy. They feel like that Dr. Ali is gonna send a prescription to my Walgreens. And the next thing is I'm gonna just go to Walgreens and pick it up. So there's a lot of challenges that comes where you need to educate a biologic coordinator so that he or she can then coordinate that care with the patients. So in my practice, so I have a biologic coordinator, and then I have a pharmacy tech, and I have a pharmacist now. Because even one biologic coordinator is unable to handle these things. Because now not only there's a prior authorization process, now not only there's a benefit verification process, now there is a step therapy process, and then there's denials, and there are appeals, and then there's a coordination of peer-to-peer. It's a challenge to find a peer-to-peer. I mean, that's a whole different discussion about who is your peer. I mean, when we say peer-to-peer, it means a gastroenterologist to a gastroenterologist. But that is not the case. So the coordinator has to coordinate that. And how many times my biologic coordinator will be texting me like, are you available at 4 p.m.? No, I have a patient. Are you available at 8 a.m.? No, I have a procedure. And what times I provide, my other peer or the other side does not have an availability. And then when you have the availability, I have to have a very tough discussion. And most of the time, I fail. And then my biologic coordinator, or now my pharmacy tech, or my pharmacist, we all have to go back to the drawing room and say, what can we do now? And now the patient is getting even more frustrated. So this whole system is going through a lot of challenges. And now you can imagine, in the many practices, you don't even have the luxury of carrying these supporting staff. And it's only the physician and their medical staff. And what would they do? They would either, they hate to refer their patient out to someone else. They want to keep the patient. That's a patient life that they're taking care of. For many reasons, they want to provide care. And then there's financial impact of losing a patient. So there's a lot of things in prior practices that are going through the challenge. And then having this coordination. The role of a coordinator is extremely important. And that's where, yesterday I made a comment that when you go to a clinic, make sure you know who's your point of contact. And most of the time, it's the biologic coordinator. Because it's the biologic coordinator who's going to educate me also. Like, well, Dr. Ali, this is not getting approved. But hey, this X company has this bridge program that we can enroll our patient to a bridge program and can get them a drug for free for six months to one year. And now there are many companies who are offering for two years free. So the bridge program is expanding from, I used to see three month free supply to six month, one year. And now there are many companies are expanding it to two years. Because we ask the companies that, well, what's gonna happen after one year? The payer are not gonna come back and say, oh, this drug was working for you for free for one year. So now we can continue that. That doesn't work. It does not exist in their eyes. So that becomes a challenge. So these are some of the challenges that where you very deeply coordinate with your biologic coordinator. So that also speaks, one last word I would say, the education of a biologic coordinator, where that's where you guys come in. You educate biologic coordinator, give information, how this drug work. Because more than me, it's the biologic coordinator who's talking to the patient. She's my eyes, she's my hands. She's the one who is talking directly to the patient, delivering the message. So educating them by all means is extremely critical. So that's kind of like my. Yeah, thank you, that was very helpful. So in many ways, IBD is a bit ahead of the game for EOE as biologics become part of the therapeutic armamentarium for EOE. Our IBD colleagues have sort of lived this for several years now. It may not be to the same extent because we won't necessarily be dealing with, at least for Dupixent and infusion centers, but there are certainly a lot of dynamics. And what you did hear in there are some of the obstacles and frustrations of care. Namely, the peer-to-peer, for example, that he mentioned. Sometimes as a gastroenterologist, when I'm thinking I've got to talk peer-to-peer, it's to another gastroenterologist. But sometimes it's a family doctor, a family medicine doc that's hired by the insurance company to provide opinions and they'll deny it, even though me, as a gastroenterologist, feel that this is important for my patient, they will then deny it. And Garrett, go ahead, Garrett. Perhaps that, peer-to-peer is a saying I try to avoid like the plague because of everything you've heard and it's a time sink. But I used to take a very hostile, antagonistic, New York type of approach to this and get really, really hoity-toity with them. And now I approach it like a police officer. Yes, sir, yes, ma'am, I hear what you're saying. You're in a very difficult position. But let me kind of go over this with you instead of saying, who the heck do you think you are telling me what to do? That doesn't work. So I find now that if you take a very submissive type approach to just not antagonize them and then you can kind of circle around, I found that to be more effective. A little hard for someone who grew up in New York City to approach things that way, but it works. Having that disarming approach for a lot of things actually is helpful in getting things done for your patients. But also what Taseef touched on is that patients are upset about this and their anger is gonna be directed to Taseef or whoever the provider is. And we as physicians, as you know, have patient satisfaction surveys and we're judged on those patient satisfaction surveys. And in some cases, our compensation may be related to those patient satisfaction surveys. So it's in our interest to try to get the patients in a good situation from their care, but also make sure they're happy and satisfied with the care they're getting. And the resources required to do that sometimes can be overwhelming in terms of the infrastructure. Go ahead, Jen. I just wanna add, so I was asked to try to say what's the difference between peds and adults? And the one difference could be, yes, this is where it's often Blue Cross Blue Shield of Massachusetts. I wind up doing peer-to-peers often with this adult nephrologist who is very kind to me. So maybe I'm able to get the tearjerkers with the kids that need what they need. But what I will tell you is it does feel to us in the physician world, and I think this is so common now in medicine, that the entire system is designed to not give the medicine. That's the bottom line. The insurance companies do not want to pay for the medicine. So they are gonna go out of their way, putting in lots and lots of steps. And then the other thing I guess I'd impart to you, they change it every year. So you know, your biologic coordinator, in my practice, it's my nurses really that have become the experts, but they know by February or March, we know now how each of the big players for us are now dealing with the biologics that year. So, and it's every January, it's gonna change. You won't know it till you start to play the game. I'm gonna send it my prior off. Oh, we got denied. What are they denying it for now? And it changes every year. So the more you guys can get ahead of that, I will tell you the AbbVie reps who are calling us by January 31st to say, okay, this is what Blue Cross Blue Shield is doing this year. This is how you have to change your approach. That's really helpful for my nurses. They take that information, suck it up. You know, Bill, I'd be curious what Nina has to say about this. But one thing in the EOE world is that we truly work very much hand in hand with our patient advocacy groups. They are part of the Seeger Consortium. We have learned tremendous from them. They are very, very powerful in many ways, in a good way. They are truly partners. And I think it's gonna be important for Sanofi to partner with them as well. I'm not sure how that would work, but they are very sophisticated. They are very patient advocacy oriented, and they are very tight. They're tight with the physician community in the EOE world, and they're tight with the patient community. And they know how to use social media, which I will sometimes tell patients, if you're getting denied, just start blasting it out on social media. Disclaimer, I don't use social media. But, Nima, I don't know what you think about the PAGS. Yeah, Gary has an excellent point. I mean, one of the wonderful things about the EOE community is this partnership with our patient advocacy groups. And there's four, two, which are very, very active. And they have been crucial in terms of raising awareness about EOE, getting laws passed about EOE, getting formula coverage for EOE, getting EOE ICD-9 codes for coverage, and even developing this National ESNFL Awareness Week, which was just a few weeks ago. So they are going to be very critical to partner with for you all. And I think they will have mechanisms to be able to kind of put a spotlight on this. APFED and CURED, those are the two groups. And if you go to the Segar website, they'll be part of it too. And the Segar website is a shameless plug, is where we're all plugged into. But so are the patient advocacy groups. Every patient that I see with EOE or any esophageal disease, I give them that website as a resource. And it's really, really a very powerful and good resource. And so as Gary mentioned, they're on the Segar website. APFED is American Partnership for ESNFL-like Disorders. CURED is the Campaign Urging Research for ESNFL-like Disorders. There is an ESNFL Family Coalition, EFC. And there's a larger organization out of the UK as well. Great. Well, I was hoping to get to one last point about decision making in endoscopy and EOE, but I think Gary's gonna cover some of that later in his lecture, for those of you that haven't heard that. So we are gonna move on. And please join me in thanking our panel for a wonderful discussion. Thank you.

eosinophilic esophagitis

gastroenterologists

biologic medications

treatment options

insurance coverage

shared decision-making

patient advocacy groups

collaborative approach