This is a fun course. I've done the prior aria, which was very complicated because it was like medical school, whereas this is more about pontificating and sort of just thinking about GI as we do as clinicians. We don't think so much, we just sort of sit around and tell stories. So that's what this is about. It's about just sort of explaining what it's like to be a GI physician these days, so you can sort of work and interact with us in the most optimal manner. Let's see if it's advanced. It's perfect. So we're going to go through just a few different things to really give you a flavor of what it's like to be a GI physician today. And from that, obviously, we can sort of build off of that in Q&A later in the afternoon, when we all meet back as a group. So, you know, something that you should just understand, in terms of what it is, what it means to be a gastroenterologist right now, there is a prerequisite training that I think most of you are familiar with, but sometimes the numbers may not hit home, right? So everyone who's a gastroenterologist who's trained in the US has done college, then medical school, internal medicine, residency, and all of that is generally going to be close to 11 years. Then you do another gastroenterology fellowship, which is three years. And then you can, you know, choose to do subspecialty training like some of us on this webinar have done, which is another one to two years. So you're talking about 15 to 16 years after your high school prom until you are a, you know, as your parents would call you a real doctor, right? And so it's a lot of time. You start getting paid, as you know, during residency, but it's a lot of time in training specifically. There is, after that, this idea of board certification, which you can do both in general medicine or internal medicine, as well as your subspecialty, which is the, in our case, GI fellowship. And it's not just, obviously, internal medicine slash GI that we talk about. We work with a lot of other physicians, and you yourself will call on a lot of other physicians, and that includes surgeons who have a longer residency training, although a short fellowship training, usually one year. So it tends to be the same number of years in total. And then if you're in the endoscopy space, or if you're in some of the biologic space, you know, some of your medicines and your procedures will be done by family practitioners and internists, in which case you will, you know, understand that their training is going to be a different composition than what we have, right? So what do I mean by that? They have, you know, there are certain family practitioners and internists out there who actually do endoscopy. This is most common in rural settings. Same with surgeons. They're performing endoscopy in rural settings. And a lot of this is self-taught or through really short courses or short training during their residency itself. So it's something to be aware of that all training is not equivalent, even though we may be doing the same procedures or treating the same patients. And then, as you all know, we work with advanced practice providers. These are people who see patients in the hospital and office independently, or alongside of us. There's PAs, which are physician assistants, or now their sort of nomenclature has changed to physician associates, which is two to three years of a master's program beyond their college and any sort of pre-PA on-the-job training they might have. And nurse practitioners who must have a nursing degree have trained for some time as a nurse and then do this advanced degree with some on-the-job training. So a lot of people you'll work with. And then GI nurses who have a nursing degree plus on-the-job training, as you know. And a lot of them get certified in things to be endoscopy nurses specifically. Finally, there's medical assistants that you all know very well who are three months to a year post-high school on the job. And then we have the endoscopy nurses, endoscopy technicians as well. So a lot of people that we work with, it's not just obviously us in a silo. And then as you well know, there's lots of places now that the modern practice is not sort of a monolith, right? There's people in private practice, which is independent practices, offices, things like ASCs or AECs, in-ventory endoscopy centers, hospital services. And you can be in a variety of private practices too. It doesn't just mean that you're in a solo private practice. There is these gigantic conglomerations of private practitioners that many of you on the call are aware of already. Then there's the employed model, which sort of goes up and down in popularity. This is the idea that you're employed by a hospital or healthcare system. You're not in an academic medical center, but you're employed by the healthcare system to give care. So sometimes on a salaried basis, sometimes still on an incentivized basis, but you're not of course in private practice. And then there's these things called hospital gastroenterologists who are really just working for the hospital. They're not even working for a healthcare system. They're just basically hospital GI physicians who see patients in the hospital and are salaried by the hospital itself. And then of course, the traditional thing you think about when you think about sort of the academic physician is the professor who does teaching, research, and takes care of patients. And so a variety of compositions of what you can do in an academic medical center. So all of this is a long-winded way to say is that there's a lot of, there's like no one modern practice. Some of us will be in private practice, some of us will be an academic, some will be employed by the VA. There's just a lot of different approaches towards medical practice. So who is the modern gastroenterologist right now? What are the demographics? So as of a few years ago, about 19% of active gastroenterologists are women. This is rapidly changing every year in training. There's a much more even split of men and women going into gastroenterology. So this will obviously become even out once we get some of us older people retiring. But as of right now, women are a minority of gastroenterologists in the U.S. And what do we know about that modern gastroenterologist? Well, you know, obviously it reflects a little bit of the breakdown of what you'd think. But again, both for Asian and Caucasian, predominantly men. Most, but by a small majority are employed. So about 53% are employed. And so most of us still are collecting a salary from someone else and not just a private practice. And that's slowly changing over time, as you saw. This is the average salary for a gastroenterologist. So it is a lucrative profession, which is why it's so difficult to match in during residency. It's one of these specialties after internal medicine that people really try to get into and some people struggle to get into. I would like to think it's because it's rewarding and great procedures and all of that is true. But that doesn't change the fact that it is also lucrative. And when you ask gastroenterologists, you know, what do they what do they find as threats to their income? They think that non-physicians, such as PAs and MPs are a threat to their income. But the biggest thing that they say is that, you know, is competition from other sources, right? Other practices, all these other things, you know, maybe another practice gets bought out by a hospital and then they lose their opportunity to practice at that hospital, all these sort of things. So there is a lot of worry about what competition out there and that's where this consolidation can be challenging for practices, right? So I may have this great relationship with the hospital, but I'm a private practitioner. Once they decide to actually, you know, maybe employ some GI physicians, maybe your sole source of income is going away. So nothing's really transformed the practice of gastroenterology more than the focus on colon cancer screening and ambulatory endoscopy centers, right? So the non-modern gastroenterologist was someone who sat in clinic and basically just took care of patients to understand, you know, their medical problems, give them medications, etc. The modern gastroenterologist does a lot of colonoscopy and that's because colon cancer is a massive problem. So if you look at this, there'll be about 145,000 new cases of colon cancer in the United States. So a football field, plus a baseball field, plus a basketball stadium, all these together is about how many cases of colon cancer there are in the U.S. altogether. And then we know that this is a preventable disease, so it's common and preventable. Common in about 1 in 25 women will get it, 1 in 23 men will get it, so pretty even distribution. But we can arrest the progression of colon cancer, which has really led to colonoscopy being what a lot of gastroenterologists do on their daily basis, because it is reimbursed by insurance. So it's curable if caught early, right? So these are the five-year survival rates of colon cancer. If you catch it early, very high survival rates of 90 plus percent. And we know we can catch it early through colonoscopy, right? So we get people through screening, whether it's stool-based testing or straight to colonoscopy, and then removing any precancerous polyps. So colon cancer can be prevented. And we think that we're doing a good job both through prevention and also treatment. You can see the colon cancer mortality is going down over time, and I think that's largely in part to how our care is changing over time. But I want to sort of make this comment here that, you know, many of you have heard of this article that came out recently in the New York Journal of Medicine, which said that maybe colonoscopy's effects on colon cancer rates isn't as dramatic as we thought. The impact of colonoscopy was limited in this study, much less than we would have expected. And that's in large part to offering people colonoscopy didn't lead them to just jump up and down and say, yes, sign me up. The adherence rates to colonoscopy were actually somewhat blunted compared to what we would have expected. And so this is one of the threats towards the modern gastroenterologists is that colonoscopy isn't a test that people are desperate to sign up for. And so if you don't pivot towards either improving adherence or trying to figure out, you know, is there some sort of progression from stool-based testing to colonoscopy, you know, this is a threat to the modern gastroenterologists. But right now, everyone's still living off of colonoscopy. What about the business practice of endoscopy? You know, the revenue generation for practices is heavily focused on volume, efficiency, and a lot of people owning pathology labs, et cetera, right, and then partnering with anesthesia. So you can generate more practice income with a technical fee from endoscopy, pathology reimbursement, anesthesia. And so a lot of it's about business. What can we do to sort of make more money, right? And so I think that's something that you need to understand as a real threat towards the modern gastroenterologists in terms of what can be done going forward. And that's why a lot of these insurance companies are recommending that endoscopy be performed at ASCs because they are somewhat lower costs than getting your endoscopy at a hospital, right? So the modern practice is going to shift endoscopy ultimately outside of a hospital where there's a high cost for performing procedures. So this has been a slow movement, but it's something you need to know as a progression. So what's the daily routine of a gastroenterologist? Like, what do we do on a daily basis? You know, it varies greatly by the type of practice. A hospital GI, we often will have that person with either trainees or APPs or advanced practice providers doing consults, rounds, and procedures. And then you have the office GI who is doing a mix of things, right? They'll be doing some endoscopy in the offices. They'll be doing a lot of consultations, follow-up visits. And then you have the people who are predominantly in ASCs who basically run endoscopy sort of morning and afternoon. So if you look at some people in private practice, there's literally some gastroenterologists who don't see patients. They just do endoscopy day and morning and afternoon into the early evening because that is the most lucrative thing. You know, you could argue that they're not really clinicians, but this is what their practice is. The general practice is probably two endoscopy blocks to one clinic block, if you're someone who does a mix of both. And then obviously, you have the, you know, odd time where you need to be in the hospital seeing consults, things like that. So the daily routine of a typical cover-all practice is you see some patients in the hospital, some office, you might go to the ASC to do some scopes, and you basically do everything, but it's got some inefficiencies. So a lot of what's happening now is subspecialty practice, where you're going to have, you know, focus on one thing, you're going to be the hospital-based physician, you're going to be the one who does all the interventional cases, you're going to be the one who sees all the IBD patients, and really try to sort of focus in on whatever might be most high yield for your practice. So when you ask the modern gastroenterologist, you know, what they do, it's kind of interesting when you see how many hours per week the gastroenterologist spends seeing patients, right? So they will say, you know, the majority of people will say they spend at least 30 hours a week with patients. And some of them say they spend more than 55 hours a week with patients, right? So a lot of patient contact in clinic and endoscopy. But what are they doing besides just seeing patients? So some people are doing, you know, other medical related work, maybe working a second job, medical moonlighting. They're doing some non-medical related work, like legal consulting, etc. So people do things to supplement their income. And that includes consulting with industry, as many of you on this call know, as well. And so, you know, obviously, it's sort of inversely related. The less lucrative the specialty, oftentimes more times they're spending doing non-clinical work. It's sort of quite frustrating. But the gastroenterologist non-clinical work is still about 14 hours a week. So that's just us doing things that are paperwork, you know, prior authorizations, all these things that sort of drag the week down. So gastroenterologists say they spend about 14 hours a week doing that. Anesthesiologists do the least amount of non-clinical work. And when you ask gastroenterologists to choose their specialty, again, a queer majority say yes, they would choose this job again, 95%. So the modern gastroenterologist is very pleased with their job and what they're doing. And so it's an interesting idea of like, you know, this is something positive. This is something that they like doing. But when you sort of think about what they don't want to do, what bothers people, there's still a lot of negatives that people complain about. And we'll talk a little bit about that as well. And so, you know, what are the things that people say that are sort of threats or challenges or things that they find detract from the job when you look at this 5% who wouldn't want to be a gastroenterologist again? You know, the main things are really this electronic health record that people find there. A lot of the time they're spending charting and putting in notes and things of that sort that are unrelated towards, you know, clinical care. As many of you know, the EHR, the electronic health record is mainly made to help for billing. But it's become this sort of difficult beast that we sort of all must be attentive to at all times. And it sometimes has become a bit of a challenge for clinicians to basically get that good work-life balance with the amount of paperwork or computer work that's required to be a physician now. The other thing that, you know, people can find difficult is some of the depersonalization that's come with gastroenterology and medicine in general, not some of the longitudinal relationships with patients that they used to have. And then, you know, working with insurance companies is a big challenge for gastroenterologists and physicians in general as well. So a lot of reasons that people are happy, clearly the vast majority are happy with their profession. But there is still this issue where gastroenterologists find areas where they wish they could have improvements. So what about the future of GI? And, you know, a lot of it was spoken about earlier through that great talk on artificial intelligence. And that's why, you know, my talk is a little shorter today because, you know, a lot of what the future is, is around this world of how AI is going to change medical care. But what about everything besides AI? So what about the idea that our medical record is all digital now? And again, a lot of you on the call are involved in these sort of things, but the electronic health record is this massive amount of data, right? And so data is really just going to be the key to what allows us to discover insights into patient care and provide more timely care, right? So once we can harness all of the EHR data, patient laboratory values, clinician notes, all this stuff, and merge that with this AI work that you talked about, that was talked about, then we can start to maybe make physician lives easier, right? Oh, your patient appears to be due for their, you know, colonoscopy, would you like us to send a reminder message? When the EHRs can start to do things like that, that'd be great. When the EHRs can interpret laboratory results and send the results to the patients automatically based on everything looks normal, here you go, that's going to sort of be the future. But it's until we can harness that sort of beast that is the electronic health record, we haven't really gotten to the future of digital health. We're just sort of charting on computers as opposed to on paper. I think there's going to be a vast change in the digital communications. Many of you know about this idea of what's called MyChart messaging. This is patients can message their physicians at any time to ask them questions, literally anything that comes to their head. And actually this weekend, I didn't get any MyChart messages and I thought like Epic broke. So I was on a Sunday, I'm like, oh, I didn't get any today. It's kind of odd. But this is constant communication you get back and forth from patients. And so this will be something that patients expect. People expect on-demand, real-time responses to any question they might have. And so this will be, how does the modern GI physician pivot to that? Is it us responding? Is it our advanced practice providers responding? Do we charge for these messages? All these things are coming about. Open notes. This is just the fact that patients can see what is going forward. You'll see all their notes and see there's transparency in what we think and what we write. So we need to be aware of this. A lot of digital health communication. So telemedicine, we've talked a lot about as the pandemic hit. So I'm not gonna belabor that point, but a lot of unique digital health options, like what's called a chatbot, right? A patient goes on to the Northwestern website, says, I have GERD. They're getting asked a series of questions. Based on each question, the computer has a different, based on each response, the computer has a different question until ultimately it's decided, okay, you need to go to clinic. You just need an endoscopy. You're having a heart attack. You need to go to the ER, right? All these things for GERD that might be mistaken or might take a lot of difficulty for a phone room to understand. And then you've already heard a nice talk on social media as well on how that's transforming digital health. We put this in every time on this emphasis on quality, not quantity. And as a person who is interested in quality, I wanna believe it's true, but I do not believe that there's any rapid shift towards quality versus quantity at this point. Everything still seems very based on volume compensation, not outcomes. So this is more aspirational than the present. And then just a lot of novel technology that's coming out there. Robotic endoscopies coming out, which is gonna be very fascinating. Autonomous robotic endoscopy, which is basically swallowing capsules and having it sort of take pictures and make decisions. These things are gonna come out, just the future of personalized medicine, not one biologic for every patient, but understanding, harnessing the EHR data and then saying, this is the medicine your patient should be on. These are the sort of future things gonna be out there. And then really this, again, this comes back to the data that's in the EHR, this idea of predictive analytics. You can get all this data there and you can figure who your at-risk patients are. This is the future of GI. And ultimately the future of GI is not gonna be screening colonoscopy day in and day out. It may be still a vast majority of what we do because it is still the dominant way to remove polyps that are precancerous, but I cannot see that screening colonoscopy will be the, and patients who have never had any other testing is gonna be what we do in 10 years from now. So we need to pivot to this future of GI, which includes AI, digital health, innovation to really be prepared. So I hope I left a couple of minutes for questions. And once again, thanks for the opportunity to talk about where we are now and where we're going. All right, thank you very much, Dr. Goswami. Would you mind just going back one slide there? All right. So I'll touch on a couple of things here in terms of the questions. And you mentioned this thing on emphasis on quality, not quantity, which again, you said was aspirational. I know you're giving a talk later in the breakout sessions on quality metrics in GI. There was a question earlier today when we discussed AI about why it's become so, why it's been so hard for GI to adopt AI. For example, you know, colon polyp detection devices. We know that it improves colon polyp detection, adenoma detection rates. You know, it's better for patients to take out polyps, right, and prevent colon cancer that you discussed. So why is it so hard to get people to do it? Yeah, great question. Part of it's gonna be always based on cost, right? So there is no increased reimbursement for taking my ADR from 45% to 50%. So now is there, I mean, in terms of a quality perspective, but is there gonna be a improved reimbursement just based on the fact that I'm converting more procedures into polypectomy-based procedures and so my collections will be greater? That's gonna help improve the use of AI. If you can deliver more value-based care for the individual practitioner, I'm getting paid more and it's better for the patient. That's the ideal scenario. But just asking people to pay more for quality is difficult. It's sad, but that's just the reality right now. I mean, you may have some insights in this, your own healthcare system, but if you say, I wanna spend, I'm not talking about any proprietary system, I wanna just spend $5,000 per room, let's just say a year, because it's gonna make us, who we've been saying we're great forever, we're gonna be even greater. That's a big cost. That's an annual cost for your healthcare system. And where is that reimbursement, where is that money coming from? It's gotta come from somewhere. And so unless the payers incentivize it, you're taking really just asking for the healthcare system to be completely noble on this. So I think the real pivot's gonna be on how this gets reimbursed. And just get your perspective on this, where do you think it'll be reimbursed? I mean, do you think insurance companies will pay for a longer colonoscopy with more pulse being removed? Is that realistic to think that that's gonna be the case? Or again, is that just aspirational? Is there another way to get at this? You're paying doctors more or less for their ADR, but that means we have to track ADRs to physicians. What does it look like in the real life? I mean, I think, well, the real life is tough, but you and I can say, let's say in five to 10 years in the future, this will be standard of care, right? You won't be able to have a scope without AI, right? Whether it's a commodity product AI or one of the more expensive or whether, like almost everyone has a car, right? You're obviously probably driving like three Teslas over there. I'm driving a very, you know, beat up Jeep Cherokee, but we still drive, right? And so I think everyone will have AI and you'll be picking sort of which software works best for you, because it's impossible to think that it won't be standard of care based on the quality of data. But I just think that the movement is slow because of the cost right now. That said, we've done some work and others have done work too to show that probably installing AI actually pays for itself by just, if I turn me into someone who removes polyps in 46% of my procedures to 52%, that extra 6%, those stack collections probably pays for the AI itself. So I think it's those cost analyses that can make it easier to get in sooner, but ultimately we're all getting there. It's just a question of, if you're one of the companies that makes AI, you're wondering why you're not there faster. Okay. You mentioned earlier about, there's been about a 50-50 split as opposed to self-employed versus employed physicians, like 53 to 47. Where do you see this going in terms of you moving towards more employed or self-employed? And how does that affect the way industry interacts with the physician? Yeah, it's a great question. So I think it's going in two directions and we sort of maybe glossed over this a little bit. It's going just away from, Raj is a GI practice in Chicago and he sees patients and does everything. That's just becoming, or Raj and his three buddies. That's just going smaller and smaller and smaller. So it's either I'm employed by a healthcare system or a hospital or a VA or whatever, or Raj and his five buddies and Steven and his 10 buddies and Mohammed and his 10 buddies and Nina and her 10 buddies, we all get together and we're gonna develop this gigantic consortium and we're all called buddy gastroenterologists, right? And we're all gonna work together because you can't compete as a small practice, right? So I believe that it's really gonna go those two ways. And I didn't believe that before. I thought everyone was gonna be employed before, but we've seen the power of private equity and these mega GI groups. I don't see how they would dissolve anytime soon. They have extreme amount of power and that's good because you need some sort of competition to keep the hospitals honest as well. I don't know if you have any different thoughts on that. No, I mean, I think it's interesting perspective. I mean, so how does that affect the way industry interacts with us, right? Interacts with the academic physician or the one that's employed and potentially is now likely salaried versus these big power groups that are really for profit, right? I think they interact the same way for both of them, but they interact differently than we used to, right? It used to be even 10 years ago, industry could come to GI lab. It was like, Raj, I want you to try this device. I'm like, I wanna try this device. And then we just try the device. And then I'm like, tell someone Raj wants the device. I'm like, okay, we'll get the device. Now it's like, okay, we'll try all the device. Let's see, we have eight hospitals under our healthcare system. We have to make sure everyone wants to switch from this clip to this clip. What's the cost analysis, all this stuff. So industry's relationship with the individual physician to me becomes less important over time. And it's more the sophistication of how you provide the value analysis of the product you're delivering to the people who crunch the numbers. And I think that goes obviously for the healthcare employed physicians, but I think it goes for these large groups as well, right? They want to understand sophisticated analyses on cost and benefit rather than just, oh, wow, this is a cool delivery system on this debt. Oh, I think you're muted, Stephen. Yes, there's a comment in the Q&A section here from Stacey. The shift to more therapeutic colonoscopies and fewer screening colonoscopies covers the cost of the technology, maybe more meaningful to a physician who owns an ASC as opposed to the physician in the hospital, but still beneficial to hospital reimbursement. Yeah, I mean, Stacey's not really asking a question. She's making a comment that sort of reinforces the comment I made, but it's a good case example, which is this is obviously industry has to promote that statement and provide the data. We've seen this for a variety of companies out there that say why we should use disposable scopes or why we should use AI, why you should use this biologic. And cost analyses are sophisticated out there now, right? They're not just like somewhere on the back of a paper napkin. And this discussion is, okay, we need to make it so that the GI practice is not on the hook for the cost for this technology. Either the payer's gonna have to pay or it becomes something that pays for itself. And for AI, it seems like it'll pay for itself based on a lot of the early analyses, but you have to convince the people who are purchasing, right? And that's part of the work of industry. Great. Let's see any other questions here. I just wanna touch on this impact of digital health. I'm with you, Dr. Goswami, on the fact that right now our EHR system is a bear and there's a ton of data in there. There's so much data to the point where I think patients come in and they've been at three different hospitals and they assume you have access to all the data, can review all the data, and be able to make a medical decision. And I spend half the time trying to dig out from thousands of notes what's pertinent from these other hospitalizations. And it makes my job way more difficult. I can imagine a world without digital records. I don't have access to any of that. And I say, look, I don't know what happened to you in the hospital last month or last year. All I have is the paper chart in front of me and I can only deal with what I have, what I know about you for what you're telling me. It's so much simpler. It may not be better, but it's also very difficult to dig through all those medical records. How do you see that changing for the future for physicians, not just GI, but for all physicians? Because it is a huge time suck. It takes time away from our patient care, from our families, from our opportunities to talk to industry about whatever else they need to talk to us about during the day. So how do you see that changing? Yeah, I mean, a lot of this is such a good question and it's such an important area. I have not personally seen a solution that is great about this. Some solutions you've seen yourself, but I'll just sort of highlight for the audience as well. One is patients can actually provide data upfront, right? So there are some solutions out there where patients like, you're coming to see me for pancreatitis and instead of me digging through all the records, before the visit, you're answering a series of questions about your hospitalizations, what was done, where the CTs were, and it's sort of creating a skeleton note for me to say, so-and-so had his first attack of pancreatitis in 2020, was hospitalized in the ICU, then had a CT scan three months later, and it can sort of put the piece through that. People have done that for irritable bowel syndrome and things of that sort. The other options are out there, which is just the computer does everything autonomously. And companies have been out there trying to do that. I personally have not seen a solution that does it, but that would be just like AI essentially, but it's kind of like this where AI digital health hybrid, which is basically doing what you'd be doing on your free time and trying to pull it together for you, right? But the problem with that is the EHR is so fragmented, right? So you have your healthcare system, then you have the ones that are linked through other EHR vendors. You have people who are still not on an EHR at all that we can link to. And so how do you consolidate all that together? It's just not clear to me. I think that what I do know is that a reliance on the EHR has probably made us worse sort of clinicians in terms of acting in interpersonal manner with patients. We sort of don't even try to ask, we just try to figure out the plan, to figure out the whole history through the EHR. But I would say that if I were to say the most easy solution coming forward is just with the EHR asking the patients prior to their visit, did they work, et cetera? And then having that sort of auto-populate or EHR. Okay. Yeah, I certainly think it's gonna evolve over time and I'm curious to see how they make it, how they make our lives easier hopefully in the future. But I think everyone would agree that it's not been easier. But that's the bad part. Agreed. I'll leave you with this because you mentioned colon cancer. It's certainly the bread and butter of GI for most practices out there, screening colonoscopies. But you mentioned at the very end here that in terms of technologies, personalized medicine, robotics, better predictive tools, you don't think that screening colonoscopy is necessarily gonna be the way that we do screening for colon cancer. If it is, there's better ways to do it. If we do colonoscopy, there are better ways to do it. Just give us your take in the next few minutes or so. What do you see colon cancer screening look like in the future, right? Sometime in our lifetime, what does it look like 10, 20 years from now that's gonna be dramatically different than what you see today? So I think we all agree, well, almost everyone agrees that the person who's asymptomatic, who's never had any other tests for colon cancer is not gonna come for screening colonoscopy in 10 years. So I think that the big thing that the audience may not know, obviously all the GI physicians know, the big disruptor to the US healthcare system will probably be the VA study that's comparing FIT versus colonoscopy for upfront colonoscopy or upfront colon cancer screening. So the VA group and Jason Dominic, who's one of our ASG members, is one of the leaders of this. It basically randomizing people to either getting a FIT first, which is a stool-based test or colonoscopy first. And many of us believe it's probably gonna show equivalence that if you get FIT first versus colonoscopy first, the outcomes on things like colon cancer death will be similar in both groups. You'll find it will maybe prevent more colon cancers in the colonoscopy group, but for a lot more costs. And so this is probably gonna fundamentally shift us towards payers wanting to do stool-based testing or some sort of testing, whether it's blood or stool, et cetera, as first line. Then it comes to be what you do with that information and what the modern practice is. I don't see the sort of robotic endoscopy and the autonomous colonoscopy and all that sort of stuff changing in that next decade or so. I think that I'll be retired and hopefully, happily living on an island somewhere by the time the massive shift happens in how we perform the colonoscopy itself. But again, I think it's gonna change us into a largely therapeutic profession, which is finding polyps, including big polyps and removing them as opposed to just doing a bunch of screening colonoscopies with people who had no problem to begin with. Okay. I mean, it's almost like the evolution of ERCP to some extent. Yeah. And MRIs and how that's changed the way we perform ERCP. I still do diagnostics. Oh, I'm just kidding. Okay, keep your numbers up. You gotta respond to the threats. You gotta just go out there and do more cases. No, I think everyone's gonna be busy. There's not enough gastroenterologists right now anyway. So it's not this sort of massive threat to our future, but it's something that we should all be aware of is to remember that we're still clinicians. Okay. Well, thank you very much for that perspective. And thank you very much for your talk. For the people in the course, for the audience, there's one more Q&A. Let's see, no, this week took care of this. And yeah, there's one more comment. As we become more streamlined in EHR, reducing the questions needed at the initial visit with the patient, it will be interesting to see the impact on rapport with patients. Older patients love talking for a long time with their physicians and equate that to care. I mean, just to highlight that point, the modern physician is gonna have to figure out how to balance what you talked about, Stephen, which is the fact that you have to pull together just volumes of data with the fact that patients just wanna be talked to as well. And it's very hard to do both of those. And so I think these solutions will help with that, but we are not necessarily doing the care that patients want. We're trying to give good medical care, but the patient, like was noted here, patients want someone who cares about, acts like, shows that they care about them, like in a physical manner, actually looks at them. People like eye contact, apparently. That's right.

gastrointestinal physician

training

practice models

demographics

colon cancer screening

endoscopy

future of GI medicine