We sort of plan that the last little bit here is just you guys asking us questions, sort of anything about anything we've talked about, or nothing we've talked about, or whatever. I think the faculty, we can just sort of stay in our same spots, unless you guys want to go up front. I don't know. Whatever you want to do. So we're just sort of going to open it up, so use your microphones and, you know, just ask any questions. The other thing I would say is, you know, that all of us in this room, all the faculty are very heavily involved with ASGE, because we want to be, and we really enjoy taking time out of our day. I think COVID really brought that into focus for me, because suddenly we weren't doing all this stuff, and kind of life and doing my everyday thing got a little boring. So it made me really appreciate how much the ASGE has improved sort of just my world, and, you know, getting to know people, and, you know, I learned a ton this weekend. So I learn every time I do these courses, you know, and it just, I think it's just such a great society to work for. And if you're interested, you know, every year in around November or so, they start October, November, asking if you're interested in committee work, can look at the different committees that there are, and if you're interested to get involved, because really, it's just, you know, I started off on Educational Products Committee back when it was a thing, things have changed a lot. But, you know, you're on one committee, and you do good job, and you get on another one, and, you know, you just sort of, it becomes a real family. And this is how I've met all these people who I now see at DDF, and you guys will see each other when you go to meetings, like, hey, you know, and I remember the people who were in my sort of fellow year, right? So I think it's, the society has been great for my career. It's great for promotion as well. You get to meet people. You've met all these people. A lot of them are full professors, which are letters that you're going to need if you're in academics, and they can't be people who you've trained under, right? So I think it's a great way to network for the women. There's a lot of things we're doing with women in GI, so I would encourage you to look and see how you can get involved if you're interested. So, you know, and also, we want feedback from this course. So I think Marilyn will be sending out an email. It's really important, just, you know, besides saying we want more hands-on, we know you want more hands-on always, but if there's any other comments that you have or things that you think could make it better, we would really appreciate it, because we do look at that when we do the planning for the next year. The other thing we'd love to hear is, you know, you guys are the ones who are at the course, and this course has moved from Cleveland to ASGE, and it's still developing. You know, the first-year fellows course has become more of a staple, and we want to do this for this course, and it was a little bit disappointing to see a lot of people who had registered who didn't show up for the course, that, you know, they don't know what they're missing, but, you know, if you have some suggestions as a fellow, I know there's lots of demands, and there's cases, and your faculty may or may not let you go, and, you know, things are happening, but how do we improve the case, the course? How do we make it more part of fourth year? What can ASGE as a society do to help what we think is useful and helpful for fellows, but how do we get the trainees who weren't there and also give us feedback on, you know, the video education, how can we make that better, how can we improve, because that's how we learn how to continue to evolve the course. And then, you know, right now, just, you know, any questions at all, because you guys, if you're negotiating for a career, if you're negotiating for a job, if you're, you know, this is your time to ask people who've gone through the same thing. So I, actually, I was going to say, that's probably been the biggest conversation in one of us had amongst ourselves the last couple of months is, this is around the time we start looking, is that first job out, how did you look, like, what was your thought when looking for it? Was it the dream one, like, because, like, you have a dream of where your career was going to end up, and, like, how far off was that first job from where you thought the trajectory you were headed? You probably don't want to ask me, ask someone else. I was, I had no idea what I was doing. You only had one job. I only had one job. And it was only because my sister lived in Cincinnati, and I just wanted to get out of New York City. I think the best jobs are not advertised most of the time. And so using your mentors as means to build that network, and even sending cold emails if you are interested in academics, institutions, hey, I'm interested in this job, do you have an opening? Do you foresee an opening in the future? And you will find probably the best jobs that way. I mean, I got my first job at this course by walking up to John Dumas and saying, are you guys looking? And I got my first job with these guys. So just asking. When you're reaching out to a place externally, and you have no real internal anything, what's the, like, what do you find the most successful, because most of the time the accessible email address is some admin, and you never know what the end result there is. Most of us know each other in some web or fashion. So again, using your mentor to say, hey, do you know, like, I really want to live in Nashville, Tennessee. Do you know anybody in Nashville, Tennessee? Probably not. And if so, can I have their contact information? And if not, they can probably direct you to somebody else. It's like start somewhere. Yeah. But use your mentors as a good step, foot in the door. Actually, if you log into ASG website, then the membership, go under membership, and then go into search. Everybody's name and email is there. And even DDW, too, will have a directory of people through all the societies as well. That's another way to do it. ASG also has a career center, which has postings of jobs. I think your mentors are a great starting point. And I will say, my mentor, to Ashvi's point, my mentor, Subhash Banerjee, knew Dr. Vivek Kaul through the tech committee. And Dr. Kaul was a chief at U of R. And I was headed to New York City. And Subhash is like, well, Rochester is licking. You want to swing by, you know, go for a casual interview. I literally had never been to Rochester, went for a casual interview. And now I've been there 11 years. So and it was a complete leap of faith. It was an amazing division, a great platform that I would have never known about, wasn't on my even radar. So it's good to explore early. I think now is the right time. I know somebody was asking, well, we're just two months in, you're in survival mode right now. How do I even start looking for jobs or advertise yourself? But the thing is, you want to start now. So you have a headway. And you know where you want to go at least. These hiring cycles are, what, six months, probably? Minimum. Beginning to... So Sagarika just did this. So we could get some. So I think the mentors are probably the most helpful because they have direct connections. So both Drs. Chuck and Pho connected me to people in Texas that they knew. Because what I found was these job postings that are listed, like to fill the applications, they go into some black hole where you cannot reach an actual person. And then you cannot wait. You have to try to get in touch with an actual person. And then I think for me, I think just writing down what you value in your career, which is for me, it was like family was the number one. And then being in academics. And then the third thing was having a senior person just to help me. And so I found all three of those things. But you have to have some clarity about what you're looking for. And I think advanced endoscopy in the academic world, I think, is getting a bit saturated. So I do worry a little bit about that. And I think that that's where having the connections through your mentors is very, very helpful. Because there are a lot of jobs that exist that are not even posted. Or maybe they'll create one for you because your reputation is very good, coming from your mentor. So I think try to find a way to directly talk to people, but via your mentor. How about the industry reps? Do they help out? Yeah. Yes. They usually know better than some other people do about jobs around the United States. Just like nurses know who are the good endoscopists, who are the bad endoscopists. If you ever want to get your mother to an endoscopist, ask the nurse in that hospital. Similarly, industry knows where the really good jobs are. Because they go there every week. And they see that there is a lack of services. So for example, they may go to Dr. Chak's unit this week. And next week they go to some rinky-dink place where patients are there and they hear stories and this and that. But there's nobody like Dr. Chak to take care of them. So then that's their reference point. Then they come back and keep telling you, go over there, they will pay you double the salary and will triple the patients, then you go check it out. And most of the time you'll find it correct. So industry reps are a very big source. The other point Sagarika mentioned is the saturation in the market. About six years ago, I think Shivangi and I published on that topic. We did a national survey and found that 80% of graduating advanced fellows said that basically job market was saturated. And that is still true. Not only is that true, but I think in the post-COVID era, capacity has gone down. So academic centers have suffered the most because they are the most inefficient at healthcare. So they have major investments, huge business plan. We are paying actually, there was a surgical business plan for $20 million that generated $1 million. Our department is paying for that surgeon, okay. So that's how academic centers are mostly. What that means is that there is more opportunity on the private side. Now the private side does not mean that you are the solo person in boondock. Nowadays the hybrid private systems are very emancipated. They have a platform very similar to quasi-academics, the residents rotating, creating their fellowships. So don't discount that and only, I mean, it's a great cause that if you join our academic pool, but the community needs you one way or the other. So wherever you go, the platform robustness is more important than the label of academic versus private. There is a 50% chance that you may leave your first job for all physicians. So always have a lawyer review your contract. If the people that are trying to hire you does not want you to do that, that is a red flag. And remember to get out of the fellow mindset of please accept me, please accept me. They want you more than you want them, trust me. And everything is negotiable, everything. There's a couple of two cents from my end about this. I think as an advanced fellow, probably shouldn't have to worry too much about job saturation. Let the ASGE worry about that. I think ASGE carefully considers how many advanced fellows go through the match every year and that sort of thing. And there is attrition even in academic centers and whatnot. As long as you're reasonably good and don't have a personality disorder, you should be able to make yourself pretty attractive based off of where you guys are training, based off the fact that you guys took the initiative to come to this course. It shows a lot that you guys came to this course and took the initiative to do so. And I think that already kind of puts you guys ahead of the curve. The other thing I want to mention is that, you know, the year is short and it's very easy to let the year run away from you, especially early on, you're kind of freaking out about like every native cannulation. You want to absorb every case possible, which may account for why some of your counterparts may not have come to this course, right, because they are still in the mindset of, I got to rack like a thousand cases in this year and, you know, being here this last day, I might have missed out on eight cases. But I think it's important to have like some free time to yourself for some very honest reflection about what you want in life. You know, to be where you are now, you've obviously kind of had to have been at the top of the curve in every step along the way, right? So you're kind of easily in this mindset of, I have to be the overachiever, I have to be the A plus student. But now is the time to actually sit down and think about what do you honestly, honestly want for yourself that's going to make you happy. And that's a very difficult reflection to have, and it's a very difficult reflection because you have to also cast aside your own ego to have that reflection. But it's a very worthwhile reflection to have, because you should not be ashamed of what your values are, and you should not be ashamed to say, you know what, maybe I don't want to do academics. You know, maybe I want to be a really good clinician. Maybe I want to be a really good educator. Maybe like publishing in science is not for me. Maybe I'd rather just publish in IGAE every month, but you don't want to make those goals known to yourself. The third thing that I'll mention that I'm really glad Amitabh talked about promotions. So I recently went through the promotions myself, and it never occurred to me the value of service to your institution. That's one of those things that you don't quite realize because you start your academic job and you start thinking to yourself, I gotta publish, I gotta crank out cases, I gotta research, etc. You kind of forgot that there's like another component that's a committee service or service to your own institution. I think to myself, why the hell did my chair put me on this BS committee of nonsense, waste my time attending these like nonsense meetings or whatever? Well guess what? It came up during promotions that actually being the BS member of your faculty Senate and contributing nothing except obstructing the president of your institution actually counted as committee service or counted as service to your institution which I never thought. So just a couple a couple cents from my end. So how to choose between how much you want to do as an advanced guy, what's the general GI in your future practice? Is it like a, you know, the question probably, you know, the future emperor asks how much you want to do. Talk in the microphone because no one can hear you. His question is how much ratio of advanced versus general should you accept in your first job, right? That's totally up to you. That depends on what you came into advanced endoscopy for. My recommendation is if everything else is good, don't worry about the caseload. Because if you are good and you're so inclined and you deliver and don't kill people, slowly, actually probably very quickly, your case mix will turn into what you want it to turn. Yeah, if you build it, they will come. Yeah, because at the end of the day, if you sign up for a $850,000 job and you do three and a half cases a day, complex cases, that is a very short-term relationship. You know, so there is really no free lunch out there. So if you want a million dollars, you will have to do that level of caseload. It doesn't matter where you are in which system. You could be at the Mayo Clinic. But you want top salary. Salaries and productivity have to be in the similar range of percentile. You cannot have a 90th percentile salary and 35th percentile productivity. So a bunch of colonoscopies in your work, they actually help you get there. But the rest of it, the work will speak for itself. With regards to promotion, just one comment, and I learned this also from somebody that I took advice from. I think for serious promotions like from associate professor to professor, assistant to associate may not matter that much. But getting a professorship, and Amitabh can comment on that, is a pretty big deal even in today's academic world where tenure is kind of out of the question mostly. But professorship is not just dished out even in B and C grade institutions. Most professorship promotions require you to get at least 12 to 16 letters. And the common mistake people do is they try to gravitate within the institution to get those letters. It's easier. Everybody knows you there. And therein is the pitfall because most of the time, your peers who are not getting promoted and that you are asking for letters, they are not very happy in helping you promote. So you need to get the letters from outside. So you get the letter from your division chief, you need that, you need a couple of peers from the division, that's it. The rest of the letters you should get from outside because the outside people are not competing with you. They are happy to see you promoted because they don't really care. They are not competing in your system. So they write an objective letter that is favorable. Inside, you cannot predict. They may be friendly to your face, but they may not necessarily like that you have been promoted. First point. Second point is when the chair of medicine in the promotions committee see that you are getting letters from Northwestern, Cleveland Case Western, all that stuff, they think, oh, you are somebody of some reckoning, that some person outside the building is giving you letters. So automatically it adds multiple layers of positivity to your promotion process. As opposed to getting only from inside, like nobody knows this guy. Who is this guy? He is getting from ID, from renal, you know. So promotion is a tricky thing. Get counseling before you apply the thing because you are not allowed to apply repeatedly. We have some online questions for the experts in the room, Dr. Chuck. So first one is about teaching. And, you know, initial part of the fellowship, the fellows may feel they are just holding the scope or how do they get more involved or enhance their learning? No, like how can they? What we try to do and hopefully your method would do it. We are now at the stage where you can teach the regular fellows and having you be their teacher and the go-to setting up that system. And at least we try when there is regular endoscopy, colonoscopy cases, have the advanced fellow go in and become the teacher, sort of transition and teach that to the first-year fellows or second-year fellows. That does take a while to learn how to teach. Like I said, I used to go in and listen to Mike teaching his fellows and just how he verbalized what he did himself. It is an art how you communicate that. So I think if you can, when you get the opportunity, start teaching your first-years and second-years, not just about the clinical case but also how to do endoscopy if you are not doing the endoscopy yourself. Yes, you also have to train the trainer course. But, yeah, it is hard when you are suddenly, because you are so focused when someone is helping training you, you don't really think about what they are telling you. You go in and then you are trying to tell them what to do. And you are not going to be like, turn right, turn left. Think about the stuff that helps you, right? Not be like, go there, go there, but maybe more broader things. I think it takes a long time to learn how to. And I would say stay engaged. Even if you lose the scope or something, as I said yesterday, be involved in what the tech is doing, what is happening, how to run your fluro. There have been times where we traditionally always have a fluro tech, but there have been times where we don't have a fluro tech. And I'm running the fluro at the C-arm, so make sure you are in the know of everything happening in that unit, from your Irving machines to your fluro to the wire to the endoscopy portion. You should be the expert in this one year and be the quarterback for that room. The other thing that's going to happen, now you're getting all these cases handed to you, you're at the forefront. It's sort of a unique year. Next year, you're the lowest person on the totem pole. And like I said, it's going to take time for you to prove yourself before people start referring to you, before other patients. Once you show that you can do it, only then will the – so when you're starting out, you're not going to get the same things. You know, you can negotiate from whatever type of practice, et cetera, but you're going to get a certain limited number of things and you're going to have to show that you can do it before people start trusting you and referring cases to you. That's a very good point. I think, you know, you think you're in the academic ivory tower and the other people referring to you are fools. They're not stupid people. They actually cherish and value their patient very much. And especially difficult to break referral pathways, you know, if you have senior colleagues in the community and you want to do this fancy stuff, it's not just going to happen just like that. So you have to prove yourself. And I think the other thing is that with salary versus productivity, the higher you go with salary, the more burden will be there on you to produce during the workday. So try to balance it out. Negotiation came up earlier. It was good, but to a point. You know, it has to be a win-win for both the organization and you. It cannot be just, you know, you build in the contract that you will deliver the New York Times in the morning with a cup of coffee. That doesn't happen, you know. You have to be realistic. And the more pressure you put on yourself salary-wise, the more pressure they will put on you for producing. The other thing you could think about if you know where you want to go, like say I want to go to this certain place, you could look to see what their needs are, right? So maybe you don't have a niche idea, but you're sort of open or whatever, and they need some third space, or they need someone who does whatever it is, and you have the ability during your fourth year to, you know, kind of glom on to someone who does something. Because we all have our different areas of interest, right? So not everybody – advanced adoption is huge now. It's not like it used to be where it was EOS and ERCP. So if there's – or you want to do something and your institution doesn't have that and the place that you're looking does, could you spend a month with someone? I mean, you know, these are things that if you're really focused on an area or a place you want to go and you find out their needs, then maybe you can, you know, become more of an expert during your fourth year. So that's another thing to just think about if you don't already say, I definitely want to do this or I definitely want to do that. So just something to think about. The other thing is, especially kind of going back to like looking for a job, make sure – I think probably to me the most important was enjoying your future colleagues. And I think there's really no better advice that I can give. Far more valuable than your salary, far more valuable than your future promotions is the enjoyment of your future colleagues. I remember one of my UCLA attendings, Ali Setarat, once told me that it's very lonely to join as a junior faculty, as a junior advanced endoscopist. Because, you know, for the first time you're not in a class, right? You're not in like a class of fellows or whatnot. You're by yourself. And you can possibly be many years younger than the next most junior person in your group. You could possibly be joining a practice where you're junior by quite a bit. And it can be very, very lonely. But make sure that you join a group where you genuinely enjoy the people that you're going to be working with, your colleagues and whatnot. You know, Raju recruited me to MD Anderson, and we used to go out for lunch very routinely before COVID happened. We used to call it the father-son lunch. And he would give all sorts of fatherly advice for which I would just not listen to. But, you know, I miss that. One advice I was given is you only get one chance at the first impression. So to the point where you're building your practice, my mentor was very clear that in your first year, stay away from SODs. Stay away from things which, you know, come with a low satisfaction, high complication rates while you're honing in on your skills, building your practice, and creating a name. And then once you are kind of a two-, three-year expert, you could start expanding your portfolios. Actually, Amitabh showed the beautiful slides on Mike Sivak. So, Amitabh, you may or may not know, Mark trained me. So Mark was, I think, his first US fellow maybe? Catalano? And his big thing was from Sivak's hands to mine and from mine to you. And one of the things Mark left me with on June 30th of that year was the fastest way to kill your practice is to generate complications and kill people. And because, you know, people don't like that. That came up earlier when you said the failed procedure is much better because the family will be disappointed, but they won't sue you. They won't, you know, badmouth you. You won't feel like crap. You kill somebody, you know, the first thing they'll say is, why didn't you stop? Why didn't you think something else? So that was a big thing for Mike, I believe, and also for Mark. And that's big. Now, realistically, in your job market, most of you will have to contend with this dilemma. Should you be the seventh person at Case Western or should you be the first person about 150 miles away where they're giving you everything? That is a very difficult question. That depends on who you are, how well you're trained, what your confidence levels are, you know, and all of those things. But I think an important thing looking at that is if there are seven people, where are they in their career? So, like, I, you know, with my partner who came on at the VA, I told him, whatever you want to do, I don't care. If I don't do any more EOSARCP. But if it were 10 years ago, I think I would feel differently, right? So look to see, are they going to be generous with you? Yeah, there are a bunch of therapeutic people, but they're kind of like they're happy to bring someone in to start, you know, doing some of the cases because you get tired. Like, you know, there's just a natural progression. I also have a friend that joined, I'm sorry to interrupt you, joined a practice of all people that were senior to him, like verge of retirement, and they all retired at the same time. So there's that. Three hospitals on call always to make that survive. So it's a rare thing. It's hard to predict, hard to predict. But I think looking to see if there are a lot of junior people are just out, there may be less willing to share. Absolutely. Whereas, you know, in our group, yeah, we have a lot of us, but I think we're all kind of like, we're fine, whatever. I do think that psychologically, actually, I think one of the things they'll welcome the comments, but I think the first three years out of fellowship, you're really hungry for cases. And whereas there may be a timeline for the senior folks to retire at some point, will you be able to survive that timeline? We've had many fellows who've trained in EUS over the years, even in a three-year fellowship, five, six hundred cases in their third year, and many of them went to practices where the platform wasn't necessarily robust and or whatever choices they made. And then a couple, three years, they stopped doing EUS. And this is 600 EUSs in their third year, and they stopped doing it. That's criminal. But that does happen. So I think the first three years need to be solid to set you up. If the timeline for older folks retiring is long or some other variables are there, you may be vulnerable to not become the practitioner that you envisioned.

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