So let's start by having the panelists introduce themselves. We'll start with Dr. Victoria Gomez. Hello, everyone. I'm Victoria. I'm an associate professor of medicine at the Mayo Clinic in Jacksonville, Florida. I've been on staff now for seven years. I did all my training there. I'm a therapeutic endoscopist, EUSCRCP, EMR. And I am also director of our bariatric endoscopy program, where we do mainly ESGs and outlet reduction procedures. Like on a personal note, you know, I'm a mother to four little boys. I have a six-year-old and I have two-year-old triplets. That's a set of identical twin boys who are two, and then their adopted brother who's only three months older. They're the three amigos. They go to class together. So life is really busy. When I come to work, this is my break. Thank you. Thank you. Dr. Kaswani? Hi. Raj Kaswani. I am at Northwestern in Chicago, and I'm a therapeutic endoscopist. My areas of interest, as you saw, are healthcare quality beyond just the interest in endoscopy and gastroenterology more broadly. My kids are all older. So whether I'm at work or at home, it's not that hard anymore. I mean, they're not that old. They're like 10 and 11. So that's a vastly different age. So I can't ‑‑ pretty soon they'll be driving me around, I hope. We're almost there. Okay. And Dr. Mergener? Yeah, hello again. I introduced myself to all of you. I'm Klaus Mergener. I'm an interventional endoscopist working part‑time now. Have worked in pretty much any practice setting, initially more academic and hospital‑based than private practice than part‑time. Currently part‑time as a GI hospitalist, have worked with various industries, including many of the companies that are on today, and I'm currently doing part‑time work with Pentax as chief medical officer. All right. Thank you. Our last speaker is Dr. Koala Prabhu, who gave the talk this morning on artificial intelligence, and hopefully she will join us soon. But in the meantime, we'll get started. I'm going to share my screen here. All right. So question one for the panel. What do you see as the biggest change coming to GI in the next ten years? I know we talked on a couple different topics today, particularly AI, EMR health system, maybe colon cancer screening, but let's get everyone's take on this question. So we'll start with Dr. Gomez. Thank you. So for me, I think the biggest change, I think, is in the field of artificial intelligence. But not so much in the sense of just using it during endoscopy, but using it, like, for quicker, faster data acquisition when patients are being seen in the clinic. So, you know, I think it's going to streamline patients' needs by being able to extract, you know, key words and clinic notes in the EHR system. You know, as our population is growing and the life expectancy is elongating, you know, there's going to be a bigger demand to continue to follow patients. with chronic conditions, for example, inflammatory bowel disease. So I think for me, the big question will be how is AI going to be able to be optimized to really implement it, you know, in large electronic health record systems where physicians are able to not be so overworked but still able to provide top quality care. And I think that's gonna be in finding, you know, systems and networks that are gonna allow us to extract the data more quickly and being able to push it through and provide with a treatment plan, you know, much more quickly, so. Okay, Dr. Goswami. Yeah, I still think the fundamental shift will be that the people who are not clinicians and just screening colonoscopies all day will have to find something else that they do besides screening colonoscopies. So I think a small proportion of our workforce barely sees patients. And just, you know, I have patients I see, I only have a half-day clinic a week even, and I still see people who go, they see me for their abdominal pain role at SOD and they say, oh, you're a gastroenterologist, that's done your last 10 colonoscopies. I'm like, no, no, that's just my screening colonoscopist. That's not my gastroenterologist. Like, I think eventually that will have to shift as we potentially find alternative screening modalities and people actually like to manage these patients going forward. But obviously the answer about digital innovation and AI is really the key thing that majority of us will change our practice, I think, which will be sort of, hopefully computers work for the better, although we keep assuming it'll happen every year that the EHR and computers will make our lives better. But I just got an epic update last night and I'm already anxious about how my inbox looks now. All this seems to make it worse for me. Yeah, it's interesting. I mean, that's what Kaswani is mentioning. He thinks that screening colonoscopies are gonna change. I feel like we've probably heard this now for a decade or two. Even as a med student, I thought I heard someone say the days of screening colonoscopy are gone and here I am 10, 15 years later and there still seem to be the same, we're still in the same situation. So maybe Dr. Mergener, can you give us your perspective on this? You've been through this? You've seen some of the changes that have occurred over the last couple of decades? What do you think? This is how you know you're getting old when you're the one being asked, how was it 30 years ago? Exactly. But it's actually an excellent point. When I started my clinical training in the early nineties, I was told that GI was at the end. This was not a smart decision to go into GI because reimbursements are gonna go down, world's coming to a screeching halt. And that was because in 92, the RBRVS, the current Medicare payment system was implemented and everyone was certain that was the end of things. And then came a couple of the really good decades for GI. So the one thing I would say is I am still, I was then and I'm still very optimistic that this field and this is true for the industry side as well. It's gonna be great going forward. Secondly, I agree with Victoria. I think AI is gonna be big. On the clinical side, the other thing I would say is the shift from diagnostic to therapeutic endoscopy. There's still a lot of the kinds of things that Dr. Khashwani does that are not totally optimized in terms of techniques and technology. I think we're gonna see more of a shift towards technology. And lastly, quickly on the structural side, we talked about this in my breakout, as many of you know, the consolidation trend. If I had to name one issue on the practice management sort of structural side, you as industry folks, you're gonna, instead of dealing with a hundred precedents from small practices, you're gonna be dealing with these mega practices and only a handful of decision-makers. So that's a huge trend that I think is gonna continue for at least a few years. Okay. I just wanna make a point. I do not think that colonoscopy is going away. I do assume that people will have to pick up some skillset besides screening colonoscopy, but I could be wrong still. But I think that there are certain people who have literally no other skillset right now besides screening colonoscopy. And I think that's where hearing about bariatric endoscopy and all these other things, people need to understand there's more to GI than screening colonoscopy, right? That's, there's a clinical part of it and there's an interesting, exciting evolution endoscopically as well. Okay. I move to my next question. And I know Dr. Mergener talked about this in his breakout session. How has the COVID pandemic changed your clinical practice and are these changes temporary or here to stay? I wanna start with Dr. Keswani this time. So I would say that it has not as dramatically shifted us now two plus years later, as much as I would have thought. There was a big telehealth evolution obviously during that timeframe, but the hospital started liking it more and more to start to utilize the building, the structure we live in more and more. So we've shifted some of our telehealth volume. I wouldn't say post pandemic, but now we're still, who knows when post pandemic comes? I guess we'll know when it's actually gone, but we've shifted some of that to be more in-person again. And so I wouldn't say that my practice today, it looks so dramatically different as it did three years ago. And certainly not what I expected it to look like when the pandemic started, where I thought that we'd have this sort of massive telemedicine revolution. So I'm curious actually if others have had a different experience than I have. Dr. Gomez? Yeah, I'm still practicing similar to how I practiced a few years ago. I think when I look at it like the big, the more philosophical picture with COVID, I think it's that I think now, hospitals and institutions hopefully now have the tools necessary to deal with another like pandemic crisis. I think that's what I took home from this experience. We do a lot of telemedicine now still, I'm still able, I still see lots of patients within and outside of Florida. And I'm able to do international telemedicine visits as well now because of the pandemic, which I think has helped, I wanna say maybe improve access for patients to make it to their appointments. So I think that's a plus. In terms of just every month, every week, we learned more and more about how to screen patients for COVID, symptomatic versus not symptomatic, doing away with screening now because it led to canceling so many cases in asymptomatic people. I think for me, it was just the whole learning behind it. And hopefully if and when another pandemic comes, that I hope that like the medical infrastructure is gonna be better prepared to act more quickly and take action to not only keep the practice running, but doing what's best for the patient. Okay. And Dr. Mergener who mentioned in our breakout session that he was the ASG president when the pandemic first started. I think COVID has affected the practice of GI in this country. Are you blaming the pandemic on him? I wasn't sure what that is. Is that an association or a causation? Go ahead, Steven. Everyone else does. Yeah. Very good. And no, I would agree with everything Raj and Victoria said. You notice the changes a bit more on the practice side. So if you're working within a hospital setting, of course they were extremely impacted and everything, but they have ways to shift costs that private practices, single specialty don't have. And so if you were a part of that environment, I think you would have a good sense that there is a significant impact and even going forward in the foreseeable future. And it has to do mostly as we talked about in the breakout with the economic side of private practices. So I think there's clearly a realization now that you need professional management. Profits margins have become so small in GI that there's no room for error. And the practices that were well-managed going into the pandemic are the ones that are coming out reasonably unscathed. And the ones that weren't are participating in that consolidation trend that I mentioned. On a sort of an idealistic, if I might add one more 32nd point here on idealistic point, as I mentioned in one breakout, GI is a very procedural specialty. And I think what we're lacking sometimes, and this is true in all practice settings for us, is the communication piece. We've become so procedural and so direct access that sometimes we're scoping because that is where the profitability is. And we haven't always spent enough time communicating. And by communicating, I mean with our patients, with our team members, with everyone. And hopefully the pandemic is a good reminder for us that the way we help our patients most is not by doing some crazy standing on the head, wiggling your toes interventional procedure, but it's actually sitting down and listening to the patient. So hopefully the pandemic provides at least a little bit of a reminder in that direction. Okay, well, kind of related to this, there's a question in the Q&A from Alex who asked, what are some strategies you've implemented to overcome the lack of screening due to the pandemic? How are you preparing for the later stage and increased numbers of diagnoses coming in the following years? And I guess this is more, even not directed at the individual physician, but what your institution has done to tackle the postponement of a lot of screening that was done during the pandemic. Have we moved to non-invasive techniques? And what has your institution done to take care of the population at large? We'll start with Dr. Mergener. Sure, so it goes towards what is the cause for the decrease in screening. So again, we talked about this briefly in the breakout. For many practices anyway, it's staffing level. So what one major challenge is getting enough nurses back into the practice to open the extra rooms. There was an element early on of patient education and patients being afraid to come back to us and this is really safe to have endoscopies and so on and so forth. At least in some environment, I personally see that as now a secondary issue. I think we've done a reasonably good job, but that's one work that has to be done to get the patients back. And part of that is communicating with them and educating. That's not only safe to come back, but it's important to have your screening done. So those are two elements. And the last thing I agree with Raj, I don't think screening is gonna go away for us, but if we're honest, as we're sitting here, we don't know that colonoscopy overall, taking the entire country is the best initial way to screen. Very loud statements from some of our colleagues, not withstanding, right? We'll see what some of the randomized control trials, the confirmed trial and some of the other trials show. So to some degree, what have we done? We've accepted the fact that at least for subgroups of patients, stool testing as an example, may not be the end of the world as the initial screening test. And we've shifted, certainly in my practice, to some degree to accepting that and using colonoscopy as a secondary test. Okay, Dr. Gomez. No, that's great insight, Klaus. I think very similarly, I mean, it goes down to the heart of what is the issue? What are the issues to why patients aren't able to undergo screening? If it's an issue because we have to reduce the resources, reduce the staff and the endoscopy labs, then yes, that's gonna ultimately result in reduced screening per endoscopic methods. I know that we had to close down the labs many times, and we only left them open for urgent or emergent cases. So we had a huge backlog that we had a set ancillary staff that had to keep track of all the patients that had to be canceled and postponed. So there's a lot of scut work that you have to do in order to keep track of these patients. I think it is unfortunate that some patients did miss screening. I mean, just looking at the data around in the nation that people get lost, slip through the cracks, and then you may see an increase in cancer diagnoses. To me, that's not acceptable. That shouldn't happen. But I think if it involves having to switch from, if your practice is traditionally a very pure endoscopy diagnostic method savvy, you may need to switch to an alternate form and really emphasize patients to undergo fit screening, for example. But I think, unfortunately, I don't think there's an amazing gold standard solution because when a crisis like the pandemic hits, everyone's in crisis mode and you have to triage emergent from urgent versus elective cases. But I do think elective cases are just as important. But we need to have a system in place so that these patients don't fall through the cracks and they can still come back for their screening tests. I guess, Juan, you want to comment on this? I'll just make two comments. One is that we've had such a backlog. We've done things like Saturday endoscopy to try to catch up because we have a limited number of workforce and limited number of rooms during the week. And we are several months behind like many of those on the call. So we've done Saturday endoscopy, but people don't want to work Saturdays. And I'm surprised some patients still no show on a Saturday. People just no show no matter what day of the week it is. So that's one solution. We've also had providers pivot towards stool-based testing, but we've had the anxiety about positive tests getting lost to follow-up. So we've spent some effort on EHR solutions on making sure that anyone with a positive test gets followed and make sure that they get through to a colonoscopy because no one here is opposed to stool-based testing in any way. And at a population level, I tend to think the confirmed study is going to show that they're at least equivalent. That's just without any insider data, just my guess. And so I think we've been planning on how we can sort of better manage those patients going forward. But I think the pandemic solution is, pandemic was essentially the same issue we have in general, which is we have way too many patients to screen. If everyone actually who was due for screening showed up, we'd be inundated. It's just that we have a backlog, a little bit of a backlog from the pandemic that's over, or it's really sort of hypercharged the problem. Yeah, I think it sounds like different institutions have different ways of combating this issue of this backlog. Some are doing more endoscopies, some have moved to stool-based testing. I think it just becomes very institution dependent and how big that backlog is. I'm gonna move to my next question, and Dr. Coelho probably has joined us now. So I'll pose the next question to her first. If you could change or improve one aspect of the way you practice medicine now, what would it be and why? Boy, that's a deep question, Steven. I don't know. What would I change? I think in general, so this is speaking from the perspective of a woman physician and I have three boys. I think potentially having a little bit more control, if you will, of your schedule and your day would be helpful. I work at an institution which is incredible. Mayo Clinic, we have a lot of freedom in what we do. We each have the ability to have very niche practices, which I think is very helpful. But more and more medicine is controlled by a hospital administrator. So I think that's a big change. Medicine is controlled by hospital administrators, as you all are aware of. And so I think that would be something that I think, if we had a little bit sort of more control over potentially schedule, that might help a little bit. I think the other thing is really having some way to have patients have easier access and getting rid of some of that administrative burden. I would rather spend more time talking to the patient and understanding then, and I understand the need to document. I'm still kind of old school in that I don't type my note while the patient's in the room with me. I write stuff out and then I dictate it later. But it does take time. And a lot of the administrative, a lot of the patients I see in clinic, which I do mostly procedures, but little clinic I have is IBD. And so there's a lot of angst for patients. And then I think for myself too, to make sure that they get the adequate medicine. So it's prior authorizations and it's dealing with insurance companies. And this year, especially a huge influx of insurance companies randomly stopping coverage in the middle of a patient's course, leaving the patients scrambling. And then as a result, you as their provider, I feel terrible. And so we're trying to send letters, et cetera. So I think that part of the administrative burden and we have great support system. I mean, where I practice, I'm incredibly lucky, but it still takes time and effort. And I think there's effort taken away from your own development as a physician, as well as from patient care. So I think that would be a big, if there was a way to decrease the administrative burden, that would be huge. Okay. Dr. Mergener. I was hoping you would ask the other colleagues first, so I can play off what Victoria and Raj say, but. We can come back to you if you like. No, that's all right. So I agree with all of that. I personally, I'm in the lucky situation that I can pick and choose and not work full time if I don't like to. So that's not a unique, but somewhat unusual situation. I think by and large, most of our problems are first world problems. When we talk about all the challenges we have and all the complaints we have, many of them would generally be in our own control to some degree. No one forces us to pick a certain job over another one necessarily. But I think the common theme that we're going to hear is administrative time spent away from the patient. Essentially, if I could, for the time that I am working clinically, I didn't have to fill out as many chart clicks and I could spend a little bit more time with a patient's family, explain the cancer diagnosis. Ideally, that's where I would want to be spending more one-on-one time, less in the procedure room, less definitely with an electronic medical record, more with patients because that's where we're helping most. Dr. Gomez? Yeah, I was reviewing these questions yesterday and I thought about this one. In the realm of DEI and trying to retain staff, especially people who are primary caregivers, not necessarily mothers, but even employees who have to take care of elderly parents, for example, that oftentimes I find that unless the employee seeks help or goes out of the way and try to accommodate a better, more feasible schedule, that it's not going to happen. So what I'm getting at is I would love it if in the medical culture that when human resources is hiring staff, I mean, I don't know, I feel like something should be built into their schedule where the employee may have the option up front to accept the position with the caveat of being able to reduce even just a few hours in the beginning to be able to accommodate family life. I reduced my hours a little bit, about three or four years into my practice for lots of personal reasons. And one of them was because I wanted to be more present at home as a mother, as a therapeutic endoscopist is very difficult. But unless I was proactive and I had, and again, just like Dr. Coelho says, I'm incredibly lucky to work in the Mayo Clinic system and particularly my GI division where they value you, they trained me, I'm a product of their program and they knew that family life was important. So they allowed me to reduce my hours and it's made a world of a difference and I'm much happier now. But I also have colleagues in other departments who don't have that same luxury to be able to approach their chief and request to reduce hours. And so, again, I don't know the financial part of it. I'm kind of, I'm not really savvy in that. But with all the administrative burden of have to keep up with the FTEs and the full workload, I understand that that's important because you've got to keep your operation running. But wouldn't it be nice to have the ability to hire staff and give them the option to join the team with reducing their hours if needed, so that they can actually have better balance in their work and home life, rather than having them to be more proactive when you see people struggling or dragging behind or you have employee surveys with a lot of negative comments or people who are feeling burnt out. You know, maybe we can address the problem from the very beginning at the time of hiring, so. Yeah, certainly, you know, we, Jimmy's Star Institution, they offered, called it, what do they call it, retention hours or something along those lines. But the idea of being cut back a few hours a week, you got to get it approved. It's helpful, hopefully, to prevent burnout of physicians. But we've also found a lot of physicians don't take on that opportunity because you cut back on salary, right? I mean, it comes at a cost. It's not like you get free hours per week where you don't, you're not expected to make any money and still get paid the same. So everything's a cost-benefit. But I think, Aswani, what would be one thing you would change in your practice? Yeah, I needed all that prep time to think of something and I still think I'm very brilliant. But I would say that, you know, in industry, you might hear this phrase a lot, which is, you know, working to your license and all these phrases that you hear, which is that everyone seems to be doing something that is a task that perhaps someone else could be doing. So physicians are often doing tasks that the APPs or nurses could be doing. Our nurses are often doing tasks that our medical liaisons could be doing. Our liaisons are often doing tasks that no one should be doing. So it's like this idea that everyone's sort of doing work that isn't quite what they signed up for. Our nurses are rarely giving nursing advice anymore. They're just scheduling and triaging a lot of things. And so if I could change maybe my own practice slash I think the larger Northwestern healthcare system and maybe other places have done a better job of it, I would have people actually work, you know, at their license, right? What they're meant to be doing, everyone's sort of working there because we've been inundated with paperwork and sort of clicks that I feel like people are not doing what they are capable of anymore. And that translates into this EHR burden that is just so much stuff. Can I make one more quick comment, Steve? Yeah, of course, please. I want to make sure our audience doesn't misunderstand. We're very aware that we're talking to you all as one of the most pressurized professions, right? You on the industry side, every year are under more and more pressure to produce your bonus is related to it. You know, when we talk about, oh yeah, hey, it's great. We've reduced our hours a little bit. You know, you may not have an easy way of doing that. But I think where this question really might be important for you is to go out into your territories or have your team members go out and understand for your individual physicians, what are their pain points? Ask that same question. You know, if you could change one thing, Dr. So-and-so, what would it be? And you might just find some doctors where you feel like you and your company and your products might be able to help by providing better service, by, you know, I don't know, changing some things around where you can assist your doctors in making their life a little bit easier. And in turn, that's gonna help you in the field. So I think it's an important question for you all to take home and ask your respective doctors. All right. Move on to the next question. And this goes back to Dr. Goswami's talk on quality metrics and GI. What quality metrics are being measured in your GI practice? Who is doing it and how? And I bring this up particularly in light of the fact that we know that ADRs are important, right? Additive detection rates are important. They can be predictors of your risk of developing a colon cancer after having had a colonoscopy. We know these things. I think the question becomes, are we measuring these outcomes? They're not always easy to do. There's not always someone there to do it. Physicians don't have time. I have no idea what my ADR is right now. I'll be quite honest with you. So what are your institutions doing in terms of quality metrics and GI? Let's go back to Dr. Coelho. Thanks, Stephen. So in terms of colonoscopy quality metrics, we do have a team that measures this for us. And so every quarter you get your own report for your ADR and it's benchmarked against the entire division. So you get a report and you know who you are, but you don't know who anyone else is. And so you are given a quarterly update on your ADR. It used to be PDR and then it was this complicated formula to calculate the ADR from it. I don't think we've quite yet mastered how to link a pathology report to it, to actually get your true ADR. It's more of a formulaic measurement as of now, but we do do that. We have an IT analyst that does it for us. So we don't really have any physician involvement in this, but I think it's also important as you think about endoscopy for all these other quality metrics, right? So we do have fellows that do a quality improvement project every year. And so whether it's in the IBD clinic, are you checking bone density on people and immunizations? In the liver clinic, are you ordering appropriate hepatocellular cancer screening? In colonoscopy, we do have a project where we're looking at, are you making sure that you give the appropriate post colonoscopy recommendation for follow-up so that you're not just leaving the referring provider hanging? And so those are all of the various, I mean, there's endless quality improvement that we could do, but essentially in terms of colonoscopy in the reportable metrics, that's what we do at our institution. The colon is curious. So the ADR, PDR, which is polyp detection rate for those people in the audience. So adenoma is a precancerous polyp just because you take out a polyp doesn't necessarily mean that you've removed an adenoma or a precancerous polyp. So the ADR is actually defined as taking out a precancerous polyp on a screening colonoscopy. Just curious, is that information available to patients, to the public, or is it just internal data for you guys to look at and say, oh, I need to do better or I'm really good already, I just need to keep this up? It's internal data. That's a great question. It's not made publicly available. It's mostly for our own quality improvement. I'm just curious, have any patients ever asked you what your ADR is or how you compare to your colleagues? They don't. They usually ask. Well, now that I'm so great, they don't ask how many of these I've done, but I used to get that quite a bit when I was younger. But yeah, we don't really display that and it's not public knowledge. And I suppose it's a Midwest practice. I don't know. We don't have as many people ask about that here. Okay. Dr. Gomez, you're in the same type of institution. Are you in Jacksonville? What's being measured at your institution? Yeah. I mean, we have like a quality committee run by a quality chair, one of our colleagues, and they oversee our adenoma detection rate as well. We track many metrics, including your procedural time, product waste. That one's always a little controversial. And then we also look at our adverse events as well, which is overseen by our quality committee as well. So we have nurses who send out cards to patients after procedures. They have like a 30 day event reporting. So we encourage patients to provide information because they come from all outside of Jacksonville. But I wanna talk a little bit about the adverse events because that is something that we do monitor. We have a more formalized system. So if a patient comes back, post polypectomy bleeding, bleeding after an endoscopic mucosal resection, our fellows are the ones who take the calls at night because it's usually at nighttime that they call and they send us a message. So if a nurse or the fellow doesn't report to the quality chair, then they really ask for us to try and remember to send them a message, just a quick one-liner with a medical record number and just say patient came to the ER for X, Y, Z. So they do track that. And if for example, someone were having a higher rate of adverse events than what would be normally quoted like in the literature, for example, then the quality committee and the chair would pause and maybe talk to that individual one-on-one and have some type of a formal system to like review the particular cases and see what could have been done differently or room for improvement. So we do track everything. And it is also in a blinded fashion, just like Dr. Coelho, that we do get our reports and everyone's assigned like a number, an identification number so you can look at your own data. I have yet to have a patient ask me what my ADR is, but they do ask me if I'm old enough to be a doctor sometimes and that's fine. But I mean, the patients, they ask really good questions. They've done their research. They look at the videos on YouTube on all the different therapeutic procedures. And so they do their research and wanna go to a place that has good patient outcomes and good patient stories. Of course. Dr. Bergener? Yes, for some reason, patients don't ask me if I'm old enough to be a doctor. I'm not quite sure why that is. My answer to your question, Steven, would have been we're not doing nearly enough in terms of measuring quality metrics, as we all know. So I work as a GI hospitalist. I don't do any screenings. I just do hospital-based interventional stuff. So I essentially have no quality metric that is being measured on me in any way. The outpatient piece of our practice, we track ADRs, as was said. We track patient satisfaction scores. We link none of this stuff, unfortunately, to any incentives that would be in any way meaningful in terms of changing behavior, other than shaming people into seeing some statistic where you're not the top ADR performer. 15 years ago, we thought that would happen very quickly, that quality metrics would be extremely important because we thought the payment system would change to a place where that is being rewarded by insurance companies. And it is, to some degree, in bits and pieces, but not in a meaningful enough way to really make a difference. So very little is being done, unfortunately. Okay. Dr. Kaswani, before I go to you about what's being measured at your institution and who's doing it, there's a comment here in the Q&A box saying some ASCs post their ADR on their websites. And while we were having this panel discussion, I quickly went online. I could find a bunch of private practitioners who say, my ADR is 56%, it's the best in the region. How do you know that that person is measuring this correctly? How do they know that this is even done properly? It's just posted on the website. I could create a website that says, my ADR is 75%. I'm the best endoscopist in the country. How am I gonna prove it? You should do that. I mean, you can't, no one, there's, you know, Doug Rex did a survey on ADR and how people measure it and everyone measured it incorrectly. Well, that's not fair. A lot of people measure it incorrectly. So I've read some of these websites where they say their ADR is such and such, and they're using all colonoscopies, not just screening. They're using screening and surveillance, which obviously will make your ADR go up. The problem, sort of as Klaus alluded to, is it isn't the, we don't have good metrics to measure. We don't have the feasible way to measure most of these things. And so, you know, even the idea of adverse events, you know, it's self-reported. If you create a system like we have, which measures seven-day returns, and we actually screen every patient who comes back to the hospital within, for us now, we do two weeks with any adverse event code for perforation or bleeding or any sort of need for like, you know, something that's related to a GI procedure. We screen them, we put them in, but that gets rid of all the people who go to their own local hospitals. You could also do the system, which I know Mayo Rochester does, which is like gives them a postcard and says, send us a postcard in if you have an adverse event, which I'm sure when they're, you know, going to the ICU, not that anything bad ever happens after an endoscopy at Mayo Rochester, but when they're going to the ICU with their, you know, post-palpitory bleed, they're not like, honey, remember the postcard. We got to tell them this has happened. So we have such a fragmented healthcare system. We have so many metrics to measure, and most of them could be measured reasonably well if you had one full-time, you know, nurse to track that one thing. But short of that, none of our, none of what we care about is so important that the government mandates it be measured. And so the best way to do it, in my opinion, is to have some sort of EHR data dump solution, like a GI quick registry, or the EHR has its own registry, like some of the new EHR solutions might have, because otherwise people just pick the one or two metrics that they care about, that they can measure, and then a lot of other stuff gets left behind. We measure a lot of things, you know, like you said, through the disease states for hepatitis stuff, for IBD, for all the colonoscopy metrics, but then who's also tracking it? Like we measure stuff, and is anyone actually doing anything with the information? That's the existential question. If you measure it and no one looks at it, does it really exist? But the questioner brings up a good point. Oftentimes these quality metrics are used as a marketing tool by practices, by essentially posting it. Now, I'm naive enough to want to give doctors a little bit, cut them a little bit of slack, and assume that if you're posting this, I don't know a person who's making up an ADR of 80%, and you would think that they're more likely the ones that actually care about ADR, and are not just fabricating some numbers, but we don't know that, of course. So it is a problem, and it costs money, by the way, right? Especially for private practices where it hits home to the bottom line. So measuring it takes some effort, and it takes some resources. And so the ones that are posting it, the ones that are doing at least something, as a patient, I would hope, I would recognize that they're at least wanting to do the right thing, even if they measure it incorrectly. Yeah, Stacy, the same person who mentioned that comment about the ASCs posting their ADR, has also mentioned that it's never below 50%. If they're advertising, they're marketing it, it's because they are so good at screening colonoscopies, or their ADRs are very high, and people should come see that doctor for that reason. So Stephen, but this goes back to the talk that I gave earlier in the day, which is, can we automate a lot of this? Sure. Can we have artificial intelligence slash NLP mechanisms that will detect your appendiceal orifice, that will give you an automated withdrawal time, that will link to your pathology database, so that you get an accurate ADR? And I think as the field moves forward, this may not be for five years, it may be 10 or 15 or 20 years, but I do think that quality will eventually, that reimbursement will eventually be linked to quality. And quality will have to be standardized, and will have to be accessible across the board. And so, it's already happening in surgery, right? There are platforms where you put them into your ORs, and at the end of the week or the end of the day, you will get a statistic on your cholecystectomies, for example. And it'll tell you of the last 50 cholecystectomies you did, these were all the specific checkpoints that you hit. And so, this is being done real time in the surgical world. And so, there's no doubt it's gonna extend to GI. And then once you have something like this, where you can pull up your own ADR on your phone, and do that, then I think that's when there'll be a democratization, you're gonna have an equality, and then reimbursement will be linked to, well, did you do an exam where you examined 50% of the colon, or did you achieve 80%? Whatever that target is. And I think that's where the ASGE will come up. The ASGE is gonna have to be as the leading endoscopy society, someone that sets the thresholds and sets those bars to define what a good quality exam is. Okay. All right. We'll move on to our next question. So, how many on the panel are actively engaged on social media for work? And I'm talking about your personal lives, for work, actively engaged social media. If not, why? If you are, do you think that being active on social media is essential and or important for the future of medicine and our industry partners? So, are you on social media for work? If not, why not? If so, do you think it's important? Dr. Gomez. Yes, I am active on social media for work. Not as intense as some of my other colleagues who are the social media gurus, but I do use it. I do have a little YouTube channel that I created several years ago where we had a social media expert that helped me. And so that's where I post like my interviews with GIE, some endoscopic videos. I like editing. I do video editing and just general videos on bariatric endoscopy. And what I find, the age of social media, the digital age, I mean, patients are smart. I mean, I have patients who pull up my YouTube channel, like from California. Sorry. And they're like, I saw your video. I'm gonna fly in for my bariatric endoscopic procedure, for example. And so I always ask them, I'm like, well, how did you find out that I'm doing these? And they're like, social media. I think it's here to stay. I think that's how a lot of people get their information. I just barely started delving into TikTok and it's very overwhelming because I was like in the first generation when Facebook came out and that's probably as much as I know how to do, but I have a few videos on TikTok and I find out that people, that's where they get all their news updates is through TikTok. It's not even the TV anymore. So I hear these comments and I realize that for me, it's important for me to stay on somewhat of a social, the level of a social platform because it helps not only, you know, bring in patients, but it also helps get the word out with what your passions and your expertises are. So I use it. And on Facebook, you know, when I have new videos with the ASGE or courses or interviews that are recorded offline, I always post them because you'll be surprised. You always end up getting the few questions afterwards that perk people's interests and they seek medical care. Okay. Dr. Keswani? I have a up and down relationship with social media. I think that, you know, everything Dr. Gomez said is the great part of social media. And I think specifically with the outreach, I do find there's a lot of bravado on social media and look at me, I'm amazing and I never have a complication, which I find very nauseating. And so I don't really enjoy that part of it. But I do enjoy the, it's a accessible way to educate. I think some people are using it very intelligently for educating patients. Most people are using it to educate peers, but I think educating patients. If I did a dance on TikTok, I don't think it would educate any patients, but I think for some people it works well. And so I think there's a lot of benefits to it, but it's, you have to really use it well. And some people use it poorly and it makes it difficult to be in the ecosystem occasionally. I think from an industry perspective, really helpful to have that presence there. You can always count an industry like high-fiving you after, you know, you say something and saying you're great, being your friend there when you say something on social media. But I think just having a presence from industry of understanding what the pulse is out there, what people are talking about, it's very interesting. So now I've turned into more of a lurker than a participator. Interesting. Atikwala. So I, my feelings are exactly the same as Raj's. A, I don't have too much time to do it. And so I, you know, I, I will sometimes ride a bus somewhere between campuses and watch what other people are posting, but I agree with Victoria. It does, it is powerful if it's used correctly. I enjoy reading posts from people that post academic articles that I otherwise may have missed. Like, you know, Dr. Muhammad talked about earlier today. There are certain people that post that there's a lot of chest pumping and in my opinion, a fair amount of inflated achievement, which I don't really enjoy. And so I, I would rather not, you know, but, but you can choose what you want to look at, I suppose, and just go past that. And so I, I am on social media and I do utilize it, but it's kind of more a question of reading as opposed to active self-promotion. So. Okay. Dr. Moerner. Yeah, I think all the important stuff has been said. I don't currently use it. I used it extensively during my ASG presidency because one of the foci of that presidency was on GI fellows and you can find a lot of them there. So that was very helpful. Currently it's not necessary for, for my currently, for my current practice. Will it be important going forward and for you all from industry? I think absolutely in some shape or form details to be determined. One of the companies with some of the participants here today hired a CMO in part because he's one of the major influences on social media. And I think it was a great move to do that. So definitely I, you know, social media is a little bit of a hodgepodge for me. I think if I was on the industry side, I would say for the next few years foreseeable future, I think the IT infrastructure to be able to walk into an office with an iPad and show some product and show some videos and, and pull stuff digitally to show your, your customers is going to be important. Is it as important now to have some sexy lap dance on, on YouTube? I'm not a hundred percent convinced. And last thing I might say is the quality, just like in politics, right? I think what we're going to find out, I suspect over the next few years is the quality check of what is being posted is very problematic for patients. You know, if I see a Mayo Clinic logo behind YouTube posting, that's great. But most of the time I don't. And how do I know that what is being shown and what is said it's really accurate and it's going to help me. I'd rather be in Dr. Khashwani's office and get a personal sense for the kind of doctor he is, but that's the old guy speaking. Well, I'm a, I feel like I'm a young guy, but I'm already old. I mean, I don't do any social media. I'm not on TikTok, Instagram, Twitter. I don't even follow these things. I'm usually getting my alerts from my younger colleagues or the fellows who are texting me updates on this and that that's happened in the GI world. I count on them more than I do on myself to look these things up. But I get the sense more and more that if I'm going to have a career in academic medicine at some point, I'm going to have to at least follow on social media, if not post myself to be in the know of what's going on. At least that's my sense from hearing from you guys and from Dr. Bilal's talk earlier today. It's essentially aggregation. There's other things that do this sort of aggregating data for you and information for you, but we don't sign up for those as much. ASG does some great stuff that aggregates, like did you miss this in the journal clubs, all these sort of things. But people have gotten used to this digestible, that's an email. People have gotten used to avoiding email and then reading posts. But there are other ways to get it. So we can sign up for old school. These are called journals, they come on paper. Yeah. I love paper. I still love paper journals. I still love the emails. I don't like the blast. Yeah. The trouble is even the young folks here in this group are old, right? When you talk to our kids, some of us who have kids in that range. So you wait another 10 years for sure, some of these platforms are going to be more important. One of the things though there is that you're only getting in these tweets that you get a high level overview of your study, for example. But you're not actually understanding the science behind it, the nuances of the study. And so I think as you progress towards, science gets more complicated. It almost is a disservice to have a three line synopsis of an entire study when there's no understanding of the nuances. So I prefer to have a link to the article so that I can go there and read it myself, which I'm otherwise may have missed if I wasn't looking for it. And so it draws your attention to it, but it's not kind of giving you all the information in three lines when you don't quite understand how that applies then. That's my thought on it. Raj, I'm sorry. I think I cut you off. No, no. I think you're sort of saying the same thing, which is that in many ways, social media is sort of like analogous to our EHR. There's just so much information. You're not sure how to process it. It comes in at all angles and you may come up with the wrong idea of what's going on, right? So people post back, 60 cases I did of this. I'm amazing. The other person's like, oh, I do this for that. And then did you see this new article? That's a retrospective study of three patients. This definitively shows the answer. It's just like so much information as opposed to like, you know, the non-ADHD way to approach things or sit down thoughtfully and read it. Just like you get the EHR and someone gives you like, you know, I've been at 16 hospitalizations. I have 75 CT scans and it's just coming at you at all angles and you can't figure out how to process it. So it can be overwhelming. So I think from a marked industry perspective, you want to sort of build a brand and post useful educational material. What I don't think, I don't see, you know, I'm not as big on social media. I don't know any industry partner in GI that does a really good job of posting educational information that is sort of digested and understood by the gastroenterologist. So if that's out there, I apologize, but you know, I don't see a lot of, I see it on their personal websites, but I don't see them putting it on social media platforms. Interesting take. All right, let's move on. All right. My next question is going back to AI. The people on the panel, are you more excited or concerned about the role of AI on your clinical practice? And what do you foresee as the biggest challenges to incorporating AI into your practice? So are you more excited or concerned? And what do you see as the biggest challenges to actually incorporating the AI in your practice? All right, Dr. Gomez. I'm an optimist. I'm glass half full. So I'm more excited than concerned or worried. I think you can, you know, there's, you can propose both, you know, but I think, you know, with the way medicine is being practiced with having to see more patients, again, with a growing aging population, we're seeing chronic diseases that are going to need long-term management. It's impossible, I think, for a clinician to be able to manage that many patients in their practice. Again, the AI that I'm referring to more, you know, I think there's definitely a place for it in endoscopy. I mean, if you can help improve polyadenoma detection, improve real-time histological assessment with endocytoscopy for patients with IBD, absolutely. The question is, in which setting is it going to be optimum to use it? You know, you can install these AI systems in your entire endoscopy suite. But for me, the main question is, when is it really going to change the pendulum? When is it really going to make a difference in practice and with better outcomes for patient care? Because I think that's what it really comes down to. And it also has to be cost effective. Okay. But digging deeper, I mean, I think AI is very exciting because, again, being able to have better systems in place that can extract clinical data, you know, clinical notes, link clinical notes with the procedures, with the pathology, be able to streamline a treatment plan for a patient. And then that leaves the physician with more time to talk to a patient in the clinic. I mean, yeah, I mean, that's prime. I think that's really what I would want to see out of artificial intelligence. Not so much helping, you know, plumbers do procedures, but really going above and beyond to improve patient outcomes and really be able to reestablish like the art of medicine where physicians can actually sit down and talk to patients rather than feeling rushed to have to document everything and having to, you know, put out a report. So. Okay. Interesting. Dr. Goswami? Yeah, I think that, as always, the correct thing has been said, right? I think that there's, there's, it's excitement, but it's a little bit of fear that the important things aren't going to get the focus they need to make, to fundamentally transform medical care. And if they are, that they'll be more difficult to produce in my lifetime of practicing gastroenterology, which is still pretty good. Yeah. Great. But you know, I got, still got, still got a lot of kids to pay for. So the really, really fundamentally shifting stuff where it helps us assimilate complex information, identify high risk patients early, all those sorts of things. That's the stuff that gets us very excited. Although I'm super into AI for endoscopy. I think it's very important. I think it's going to end up having a more limited impact than these other AI advancements ultimately. So I'm excited, but worried that we're going to not get to the most important stuff soon enough. Okay. Dr. Merzner? Whoops. Yeah. Thank you. No, I'm, I'm excited about the innovation for sure. I'm curious where, where this is going to go. And in this country and this health system, the reality is a lot of it is going to be cost and reimbursement driven. And if, if you've been around long enough, it's, it's, it's very hard when there's a hype around a new innovation, like there currently is about AI. You cannot go to a meeting and not talk about AI. Everyone is excited about it. Everyone wants to understand it better, wants to start utilizing it. The reality is no one's going to pay for it. Right. And so I, I wouldn't be so sure that companies that are sitting there trying to figure out how to make a return on investment on developing more AI tools for practices are going to rush into this. Even the current applications, which are extremely limited, are very difficult to get out. For colonoscopy, eventually it'll be in the processor box, like NBI and iScan is on our endoscopes now, but no one's making extra money of it. The reality is that is the driver in this country. And so I wouldn't be so sure that there's going to be a quick and widespread sort of adoption of all kinds of AI applications. So I'm excited, but skeptical. Interesting. It's a different perspective and I'll let Dr. Coelho end since it's her talk. Yeah. Thanks. I agree with everyone and what's been said so far to, to kind of give an example of what Dr. Mugner was talking about. You know, our current algorithms, for example, our polyp detection was relatively meaningless unless they're meaningful polyps or you change the patient's outcome in some way, shape or form. And so I think the second step, which is CADx, where you can actually differentiate, and then you can say what the reasonable amount of certainty, well, this polyp you can just leave in situ or these polyps you can resect and discard. Well, now you're able to actually show benefits in terms of monetary changes, right? So you're going to decrease the amount of polyps that you have to send to pathology. You can improve the patient's, the cost of the procedure. You can improve efficiency. So just from an endoscopic example, I agree that where we are right now is very exciting, maybe not clinically meaningful. But at least in the endoscopy space, there is a way to get that better. I think there are other applications, for example, quality of exam and EUS applications that I think will have wider applicability only because you may be someone who hasn't had the opportunity to train at a super, you know, at a big institution, or you do an EUS for pancreatic cancer, but it's not that often. You know, you're not at a center where you see a lot. Well, now if you have a system that allows you to have the same quality of exam every time, that is improving care. Is that, how is that going to be paid for? Again, it comes back to reimbursement for quality. If you're going to reimburse based on the quality of exam, now suddenly you have a reason to invest in that system. But otherwise, at the current cost levels, it's prohibitive without really any enhancement to your own bottom line, which at the end of the day is how things are measured, especially in this country. So I think if you think about it in a slightly different framework, that might help. I think as you improve AI to improve documentation, to improve clinical decision support tools, so are you able to compile various sources of data and then spit out a result? And it is being done in the emergency room, for example. If you go to an emergency room, you can say, I have this constellation of symptoms, and it's going to tell you, well, your chance of a heart attack is 75%. You need to go in. Or as a patient, you can say, I have this constellation, but it's actually heartburn based on, you know, so many thousands of data inputs that we've had in the past. That would be really meaningful. You know, if you go in with the GI bleed and it can tell you automatically without the need to calculate a GBS what your risk of a high risk bleed is, that again is meaningful. So to me, some of those, and I think it might come down to a hospital saying we're going to improve, you know, efficiency, bed utilization, all of these things, but all of it has to be linked to an economic outcome. And I think that'll be what makes sense. Yeah, well, thank you for your perspectives on reimbursement and the adoption of AI. I have a different type of question for you from Dr. Tierney, who's the chief of our committee here on the ARIA committee. His question is, what is the medical legal implications of AI, particularly for CADX or DL algorithms that predict the diagnosis? Are you aware of any precedents from radiology or other areas where AI is more mature? Thank you. Yeah, this analogy is like the Tesla self-driving car that crashes. I mean, is it the driver's fault or is it the car's fault? So Mercedes, I think, is the company that assumed all liability for their crashes and said, from now on, if you use our automated driving, we take responsibility. And the idea here is, are you using that AI? I think the way to think about it is that AI a replacement for your own decision-making or is it augmenting your decision making? So for example, there is ophthalmological technology, which you can run at primary care offices that will scan your eyes and tell you how much retinal pressure is and whether you're at risk for detachment, et cetera. That company took on its own liability. And Raj and I were at the AI symposium where this was discussed and was really thought-provoking, where the liability is actually the manufacturer of the device who says, we're so confident in this and we can tell you with such high certainty that we're going to take on that liability. So as a provider, you don't care, right? You put it in your office, you buy the machine, and now that's taken care of. CADEX is not that easy because what if you haven't had it? It's not clean enough or you're not looking at it appropriately, et cetera. So I think as it pertains to GI, it's going to be at this point, liability is still covered by the provider. And so the chances, and that's where it's really interesting in that how much there was a single study done prior to AI on the PIVI thresholds of leave-in site to intersect and discard where patients were surveyed and providers were surveyed for what degree of confidence they would have. And I forget the exact numbers, but it was quite high in that how much of a risk as a patient would you be willing to undertake if you knew that your provider had a certain percentage of certainty that this was a benign problem? And they did some monetary calculations for that. So I think it would be really interesting to now apply that to AI. There's no acceptability data at all, but how much would a patient be willing to say, well, my physician thinks that it's 95% benign. AI has added 3% and now they're 98% benign. How much are we willing to take? And I think that will be large volume data. You'll require thousands if not millions of images that are corresponding to the gold standard of histopathology and go from there. But in short, liability is yours. That's the short answer. In short, yeah. Until it gets better or until the companies say this is so good that we can rely on it. But it has to be black and white, right? I mean, the problem with colonoscopy and some of these things you mentioned is the bowel prep, the cleanliness, how much time you spend cleaning the colon, how well a look you're getting of the actual colon mucosa, because maybe you're not seeing 100% of the mucosa. If you miss a polyp because you didn't look at it, how can AI see it, right? If it's behind the fold and you didn't look behind the fold, you can't blame the AI machine, right? Because the AI couldn't see it because you didn't visualize it. I would look for low-hanging fruits. Right now, when you look at endoscope makers, for example, they're developing this because it's a nice add-on to help them sell a few more scopes. They're not getting more money for the AI piece. So what they want to do from their perspective is minimize their costs, but provide something that gets attention to company X. And therefore, those endoscopes will be bought. In general terms, I would not bet my money that in this country, the payment system will change quickly enough that quality is really what drives AI. I would be looking towards efficiency applications. So anything AI can do to make your practice run better in a fee-for-service world, right? That's where the winners are. That's where the winning proposition is in radiology for AI. Help me read my CAT scan quicker because you can point out where some of the major problems are. So it's more efficiency than the quality aspects, I think, in the near term. I agree. And it's been shown in capsule endoscopy to significantly decrease your time if you run an AI algorithm. And anyone who reads capsules knows how incredibly monotonous and mind-numbing it is. And so this will be a significant improvement. Again, easily reimbursed and a quick addition. Okay. Well, thank you very much, guys. It's 4 p.m. So we're going to end this session. Thank you very much for the panelists today. And I'll let you guys go. But thank you again for your talks today as well as your participation on today's panel. Thank you. Thank you.

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