All right, welcome back. This is the last part of the program for the day, and I think this is the part that you may all appreciate very, very much. Thank you for all the effort in attending and participating, and thanks to the faculty for the enormous effort, both on the presentation side here in the auditorium and in the hands-on sessions. This is an open Q&A. I know we haven't had the chance to do a specific Q&A for the last stretch of the talk, so if you have a technical question about any of the few talks, feel free to come forward to any of the speakers. But this was conceptually designed to address any and all questions or concerns you have about anything you'd like to know more about, including how you transition to a new practice, what you do beyond fellowship, maybe negotiate or look through your first contract you get, how do you build confidence and bridges with other specialties as you start in a new place. Sai, do you want to add anything? Yeah, I mean, this is basically your opportunity to ask literally anything about your year, your future career. We're so special to get all of our faculty here. As you can see, we have experts of the experts in everything advanced endoscopy. So if you want to ask about training in interventional EOS, third space, bariatric, or how to start a program, ask away. This is your floor. And don't forget to use the mic, so make sure you press the button before you ask questions. I'll start. So I mean, one of the most commonly asked questions, I know a lot of you are interested in third space endoscopy, right? A lot of you are like, how do I learn third space? During fourth year, you're trained to do EOS, ERCP, which is a lot already. You need to get 200, 300 cases, right, to get comfortable. How can you fit in third space endoscopy in your training? We have multiple, I mean, several of the experts here. Do you guys want to hear how they did it and maybe what advice they might have for people who are interested in this? Someone's got to speak here. Oh, okay. She's like, drinking a beer. Drinking immediately. Yes. So advice for how to start a third space training? Yeah. So in the United States, we don't have a formal training yet in third space, but we have two recognized pathways, either as a part of advanced endoscopy fellowship, which most of the time you would be learning EOS and ERCP and extra time for ESD. And to be honest with you, I really don't like this model because I don't feel that one year is enough to learn all these skills in a good manner, especially the EOS skills requires a lot of reading and understanding. And if you want to be good in EOS, you will have to dedicate a lot of time for studying. But a lot of time, what happened that people do 200 EOS procedure or 300, but they don't do some of the basics, like even tumor stagings. And I see this and when I get counsels from outside and I look at the EOS or do it myself again and I find it's totally different. So I'm very concerned about quality of EOS training and how this is affecting all these things we're adding to the fellowship. One unique part about third space compared to any other training is that you really can get good by training in animal model in vivo and ex vivo for a while. So you could be in your practice, you could be acquiring your EOS and ERCP skills, and you can start doing hands-on training and courses, or even on Saturday in your endoscopy unit. And a lot of industry and other now can provide you with training EGD scope, which is animal scope, or in our unit we designated one scope as an animal scope. And my partners would go on Saturday, they would get an animal like explant and they keep practicing. So you don't even need a lot to practice and get better. And then when you do human cases, you can do some preceptorship and with time you'll get better, you select lesion, easier one, and move on. Or later on in few years you might have a dedicated ESD training. There's another mentorship pathway, which you are attending, and while you are attending and practicing EOS and ERCP and getting more comfortable with them, then you add ESD under supervision, which is a model that I have in my institution. So basically I train two physicians, actually three now, with this model. They are practicing, attending one day a week, they will come and watch 3SD and do one. And in one year, just from watching 150 to 200 cases and practicing 50, your learning curve improve rapidly. And when I'm studying now the R0 resection rate, they get to R0 above 90% after 50 cases in their own, which is way much better than my learning curve, which is 250 case. So of course tutor training will be the best, but I highly advise you not to seek ESD, EOS, ERCP in one year. And if you do that, know that one of them will be affected. Dennis, do you want to add anything? I don't want to put you on the spot, but I'm sure you had an answer. Yes, I have to, right? No, so I think we talked about this with the people that were sitting on our lunch table. It was a similar question, and people were saying, well, how did you get started with third space endoscopy? And I told everybody, I didn't do third space endoscopy during my advanced endoscopy fellowship. And I knew I wanted to do third space even before my advanced endoscopy fellowship, but I wanted to focus on being a good endoscopist doing ERCP, EOS. This is something that a lot of programs nowadays are starting to offer you some exposure, which is great, doing an advanced endoscopy fellowship to be exposed to third space, but you should not make that the focus of your advanced endoscopy fellowship. It should still be ERCP, it should still be EOS, and the branches of this. Because in reality is, there's only so many jobs where you can leave as an interventional endoscopist and be specialized in third space endoscopy alone, right? So you need to first take care of ERCP, EOS, and learn that, and on the way, start learning third space. If you go into a program that offers you exposure, great, that's great, but you should not have the expectation that that should supplant adequate, basic advanced endoscopy training. I'm just going to add one thing, so as the most junior person on the table here, I started the third space program at my hospital just around three years ago, and I started off very slow. That was my biggest concern is, you know, how fast should I start? I have EOS, I have ERCP, I have luminal stenting, that's a lot that you can start as junior faculty and still not be comfortable with. So I was very selective with my cases. My first ESD, I did four to five months after starting because I wanted to get my feet wet with just advanced endoscopy, and then I chose an easy three centimeter rectal ESD, got comfortable with that, and then from there, kind of went to the next step and slowly built the volume. But it's tough because you're anxious with these cases, you want to have a good reputation where you start, the last thing you want is starting a tough case, have a bad outcome, your self-esteem is shaken, people say, oh, is this the right person for ESD? And so you want to build, you want to start an easy step and, you know, take it from there. But it comes with time. I think the learning curve is the steepest when you're junior faculty, actually, your first few years. I still think I'm in that learning curve till now. So it takes time to kind of get very confident. But we're in a place now in the U.S., we're very lucky that we have people like Mohammed and Dennis that, you know, can train us here rather than, you know, have to pursue the avenues of going abroad and training, which was sort of the historical way of getting trained. Let me ask the fellows, how many of you came to the advanced fellowship track expecting to graduate and be somewhat independent with some level of third space endoscopy? Or knowing that the first job you'll take will request you to do some of that work? None. I think this is fair. So this is exactly reflecting what the panel just said. You will not become proficient in this year. You have to focus on the fundamentals of advanced endoscopy. And most programs would want you to spend a lot of U.S. and ERCP time, which is pretty much what, unless you pursue one of these super boutique, only third space fellowships and there are only less than four probably in the country, I think the list is going to grow quickly over the next few years. But those are not going to be your, there's not going to be a full-time job that will only allow you to do third space. So you'll have to do everything else around that. Okay. Other questions from the group? Great. Thank you all for being here and for your time for teaching us. Grace Kim from University of Chicago. Dr. Gramsci's lecture mentioned how we should be proficient at reading MRI or MRCPs. And I was just wondering how you guys got familiar with imaging. I feel like I still have to depend a lot on the arrow sign from the radiologists. And just wondering how you guys got more familiar with it. Mark, you should probably start. And then Linda. Yeah, happy to. So first of all, I think that you're probably not on consult, or you may or may not be on consults all that often. But if you have 20 patients on a consult service, you have 20 examples of scans most likely to see every day. That's number one. Number two is before or during every case, I think a decent expectation of your attending that you're working with is to, if you don't know looking yourself, to go over those scans with you. Because particularly if you're doing the case and they're teaching you, you need to know the game plan going into it. And so that's the other. And then you should have a... It's a little challenging now in the post-COVID era, because not all the radiologists are sitting in the reading room like they used to. And so it used to be very easy to walk down to the reading room and say, hey, I've got two patients I'd like to... With the radiologist that you really respect and know does an excellent job. But pick out one or two radiologists that you or your attendings have a good relationship with and then just take cases that you're not clear on and go over them with them. But every day that you're working, you should be looking at scans. So I've just backed... I think we've heard... So we heard earlier on about the importance of developing relationship with surgeons. And so I would echo that. As therapeutic endoscopists, we want to be part of a multidisciplinary team. And that's being... Having a superb relationship with one or multiple surgeons, plus pathologists, plus radiologists. You're often going to go for your more complex cases, you're going to review them. And so it's a wonderful opportunity as you develop a relationship with often the best pancreatic obility, MRI and CT radiologists. They will teach you. So as you review it and at the MDT, they can teach you and you can ask the question, why are you doing that? What are you looking for? What are the sequences you're looking at? And you have a year to do that. So that's... If you think about all the scans that you're going to see together, and I found that incredibly helpful. I think... I think the most useful way to do that would be if you have like a pancreatic tumor board or a pancreatic clinical conference. Like I trained with like Chris and Linda and we had like Peter Banks going over scans and the pancreatic radiologist going over scans. And whatever case conference tumor board you can sit in on, where there's a radiologist and they're pointing stuff out is the quickest way to do that. I told you. I mean, it's just practice, right? I mean, yeah. Forgive me to the radiologist, but it's not rocket science, right? I mean, it's just practice. And as general GI fellows, you should be doing this, right? You should be forcing yourself to pull up every CAT scan, KUV, MRI, looking at it and trying to see if you can see what the report says. And if you can't, go to the radiologist and be like, hey, where is this? What does it look like? So you should be doing that every single time. And eventually, it will become like second nature to you. And sometimes, like honestly, like at this point, we'll... Myself, my colleagues, we'll pick up on some things that maybe even the radiologist kind of blew by. And you're like, hey, what is this now? And they're like, oh, yeah, okay, maybe, right? So that's critically important to do and a skill to learn. I think it's also important that radiologists may not know all of the types of procedures that you're doing and what is normal and what is not. Like I've gotten all sorts of reports when I started a new place, like for an object traveling from the stomach to the intestine or something like that. And so it's a two-way street. Like working with your radiologist will not only allow you to sort of absorb their language, but also you can impart on them the types of procedures that you're doing. So now, you know, now I see cyst gastrostomy in place as opposed to something like that or free air after poem as expected, you know, something like that. So I think that it's really important to work together so that all the reads are accurate. One additional point is I make a practice of going over scans with the patient in the clinic. And it does a lot with building trust and with having them understand why you're proposing a certain procedure or a course of action. And so it's very important before you see a patient in clinic if they're referred from another GI doctor or another doctor for your office to upload those scans or if you're getting new scans to present those to the patient in clinic, I think, because I think that's a good way for you to efficiently go over the problem and the plan kind of all in one without having to draw necessarily pictures or describe in words. It ends up saving you time and building trust. One additional comment I would like to make is take initiative. Sometimes, you know, a busy council service or a busy endoscopy service, if the attending you're working with is not going over imaging, they quickly looked at it. Stop them. Ask them, can you please go over the images with me? If they don't know how to, then find somebody who does. I would maybe give a slightly contrarian viewpoint, which is I think everyone's mentioned that you can do it yourself. I would just look at the images before you look at the report and then look at the report. I think that's the critical way I tell the fellows to do it on council service at General GI Fellows. Look at the images yourself, then read the answer key, and then go back to the images and see why you didn't get it right. And over time, it's essentially the best way to train is just you're repeatedly finding the answer key and then eventually you do find things that the radiologist doesn't see because you figured out how to do it yourself. So don't look at the report and then look at the images. To me, do it the opposite way. Images, report, back to images. It depends on the radiologist. You don't want the press radiologist in the ER and take their word on what's going on with the pancreas. In my opinion. Or at least at Michigan, you don't. David and Fee, that's a warning to you guys. Next question. Hey, everyone. Thank you so much for being here. I'm Julia. I'm from Dartmouth right now. And so compiling the wisdom that I've been hearing today is that I hear that your first couple years as an attending, the growth is huge, the learning curve is huge, complications happen, you want a good reputation. I would love just some of your thoughts about your reasoning when you're trying to decide if trying something is worth it. Where I know if I'm trying to put a lamb's in the gallbladder neck, maybe not worth it. But if there's something where it's like I have some of the skill, but it's riskier because I'm a first year attending, a second year attending, just like how you think through whether or not to try something. What's really important is having good backup. When you choose your first job, you want to have senior faculty that will have your back and will allow you to push the envelope. And I was very fortunate. I had David Carlock, who was my mentor, and he allowed me to really push the envelope in what I was doing. Probably too far, right? But he would be like, I'd go tell him beforehand. It's not like I shocked him. I think I'm going to try to do this. You think that's a good idea? Yeah, do it. I'm like, okay. I don't think he ever said no. And sometimes I'm in the room, I can't believe he thinks I should do this. But it was great because he could always get me out of that trouble, right? And it's happened more than once, right? And I'm very grateful for that mentorship. But it's good to have that communication and not be surprising people, right? I'd go tell him before the case, I'm thinking about doing this, are you comfortable with me trying this? And he'd be like, yes. I think that was really helpful, and it helped my skills grow tremendously over the first few years that he was giving me that latitude. So I think that's an important relationship to have, and try to figure that out before you even take your first job. I would also say, it's always about patient care, right? It always comes down to what is best for the patient, and not your own ego, your own whatever, right? And so it is a balance, as you said, because especially in the beginning, you haven't necessarily become an expert on all these things, and even throughout our careers, there's new things that are coming up, that certainly weren't there when I was a fellow, right? So it's like, okay, and I'm thankful to have people like Chris, Marvin, all these people at my place where I can be like, hey, can you, let me talk to you about this, is this the right approach? Can you come into the procedure with me? Look at it, proctor me, yada, yada, yada, right? So I'm very grateful to be at a place where I have supportive people like that, but it always comes down to patient care first. And if you're really feeling uncomfortable, if you don't have that support, you're in the middle of a case, I would say do what's right for the patient first and foremost. If you were the patient, if it was your mom or your dad, what would you wanna have happen? Because there's always gonna be more opportunities to take that on. And then I would also say, kind of build your confidence and your skill with a slightly easier cases, right? Don't choose the hardest gastrojejunostomy case to start off with, right? Unless you've done a million in your training and you're very comfortable with it. I would kind of be like, okay, let me do, again, if we're talking about lambs, let me do necrosectomy, got this humongous thing, well walled off, okay, boom. And then you kind of do that, build up your confidence and skills with that. And then you can move on from there to kind of progressively more difficult things at your pace. I think importantly is if you're thinking about doing something that experimental, right? Or pushing the envelope, you're operating outside of theoretically standard of care, right? So you are probably thinking about doing something that might potentially help the patient that has little options. You need to establish that point. So it's good idea to have other people involved, not only the patient, their family, have a good understanding of what is the current standard of care and why we're not approaching standard of care in this particular setting. And very important that not just your colleagues, your intervention endoscopist agree with you. This is where you should definitely discuss it whether it's the surgeons in your team or whoever, because you don't wanna run into something thinking that this is the way to go and then have a disagreement with a surgeon or whoever when a complication happens. And this happened to me when I remember a few years back, I wanna do a procedure for a patient who have very little options. And one of my colleagues just said, yeah, just go for it, just do it. And something made me, he said, you don't have to tell the surgeons because if you tell the surgeons, they're gonna oppose it. They're not gonna want you to do this procedure. But I didn't feel comfortable with it. I'd rather just talk to my surgeon and say, hey, listen, this is the situation with this patient. What do you think? Can you offer anything? Or do you think this is a good idea? And he said, I think what you're trying is reasonable. So I documented very well, clearly documented, discussed with the family. It didn't go well. Patient had a complication, but the surgeon had my back, right? So he said, this patient had no options. We did everything we could for this patient. Things didn't go our way. The patient was hospitalized for three weeks, go to nursing home, all this stuff, but they were extremely understanding. They were grateful we tried something. So always have open communication. Don't do it behind doors. If you don't get to do it, don't do it. At the end of the day, it's what's best for the patient. And also- I think the multi-D care is so important, right? This is where Rich was talking about tumor going to pancreas conference and things like that. We will present these tough cases at the conferences where all the experts in radiology, surgery, pathology, yada, yada, yada, are present. And people are talking. And we're like, wait a second, should we do surgery? Should we do this? And that's really what's in the best interest of the patient. And then you can go to the patient and be like, hey, we had this conference with all these people. We talked about all the options. These are the pros and cons. And this is why we're suggesting this kind of more outside the box endoscopic approach, let's say. Yeah. No, I just wanted to say we were discussing this at our table at lunch. And not every one of you leaving from here finding a job may have that setup of having two, three senior partners be in the next door room who will rush and probably save the day. But the communication is key. If you have a tough case and you know it's coming up, talk to your mentors beforehand. Hey, I have this, what would you do? And I've had fellows FaceTime me in the middle of their case. Eski, this is what's going on. What should I do? Literally on 4 p.m. Friday evening, I was driving somewhere and suddenly my FaceTime rings. And it's my fellows now in attending FaceTiming. This is what I EMR'd. Look at the base, what do you think? And I talked her through it. Pulled over. Yes. No, I do not drive a Tesla, but I still pulled over. Long story. Yeah, we don't want another complication happening to the attending, right? Now we have two complications. And that's actually part of my tag. I always say, while fixing a complication, don't create another one. So if you're going down with an over-the-scope clip to heroically close a perf, don't tear up the esophagus. People have done that. So, but long story short, you know, think about the case, especially when you know you're stepping out of your comfort zone, or even if you're in your comfort zone, you're the only endoscopist at 7 p.m. doing it, feel free to reach out, ask for help, and do what's right for the patient. And have that favorite surgeon, favorite IR colleague. As you become an attending, these should be on your speed dial. You not start doing these things in silos. You need them for backup. And calling them is not losing. It's not a war or a battle. They are having your back, truly, for all these complex cases. I just want to make one, I know we belabor this, but one quick comment that I want to emphasize is, I agree with everything everyone said about having backup and, you know, working in a comfort zone, but something as an interventional endoscopist, all of us feel on the stage is, a lot of general GI just does what's called risk transference, right? I've made that term up, right? They're like, they could do this, but they don't want to take the complications of it. And as interventional GI, we want to avoid, we want to be pragmatic, we want to avoid risk transference to say, I don't want this complication on my record, so I'm going to send them to a surgery that's even higher risk, or an IR procedure that's more morbidity. So I think you have to keep the patient centered, but you got to be not where you suddenly say, I just don't want to do it because it's going to make me look bad if something bad happens, because part of that discussion needs to be, an easy example would be malignant cholecystitis, right? Malignant cholecystitis should get a gallbladder LAMS. It should never get a percutaneous gallbladder drain, because they will never lose that drain. So they will have a permanent drain because the cystic duct is permanently occluded. Yes, you want to talk to people at month four of your fellowship, but you don't want to avoid the case because you don't want to look bad, and you'd rather have IR put something in that's worse. And again, that happens a lot for polyps and they go to surgery because GI doesn't want to take them out, simple things. So putting the patient centered doesn't mean not doing the procedures. It just means that you need to understand what the risks are for the thing that you send them to if you decide that it's not good for you to do. Can I make one last comment? I was just gonna say, also you want to set yourself up for success. If this is the first, let's say gallbladder case that you're doing, don't do it Friday at 4 p.m. Do it Monday morning at 8 a.m. when there's gonna be a lot of people around to help you. Same thing, like don't do it with a staff in the room who's never deployed a LAMS before, who may be learning or interning. I've said many times when I have someone training in the room with me, this is not the case for you to learn how to work the wire. I want the person who's training you is gonna do this part of the case and then you can take back over when we're in a less complicated part. So you wanna, in addition to what everyone else has been saying, make sure that you set yourself up for success in the ways that you can control. I think that's such an important point, right? To set yourself up for success with the team and have the vendor present too, right? Our vendors are fabulous and just come in. You text them, they're right there. So they're there for a resource for you guys and wanna be there, because obviously they want their product to do well, right? They don't want all these horrible things happening because people have misdeployed LAMS, yadda yadda yadda. And the more experienced reps are really, really good. Now they're not physicians, but they are there to support and help you. And it's nice to hear that it's not just us who have the risk transference in general GI, because that is rampant at our institution where people are like, oh, I can't dilate. You know, when it's like, oh my gosh, this is general GI. I can't put a peg in. Oh my lord, that's general GI, right? But I tend to think that therapeutic endoscopists, for the most part, don't have that kind of mentality. I haven't noticed that as much with the therapeutic endoscopists, but it's a very valid point. Yeah, I just wanna echo that. Like definitely, I feel like during the first five years out from your fellowship, you're almost protected. So ask for help because patients come first. And I remember Linda told me as I was graduating, she was like, you don't wanna have a negative diagnostic EUS during your first two years. So ask for help. So Linda was like my first call for like almost every EUS case. So definitely ask for help. I think one of the, oh, sorry. Yeah. I would like to say, so I think just something similar to what Raj was saying. You know, Chris said he had David Carlock, but you know, highly competent. He got out of the trouble. If somebody's getting in trouble, voice of reason. But the flip side is also true. You know, when you're reaching out to somebody, you don't want to be reaching out to somebody who's highly conservative and they would find a reason for you to not do the procedure. Good point. Good point. I didn't know what you were talking about. No, you shouldn't do it. That was amazing. Thank you all. So one of the questions that came up at my lunch table, which I thought was really good, and it might be applicable to most of you, is that most of you or half of you are looking for a job now and obviously you're being trained for EUS ERCP, but you're thinking ahead that, hey, for the next first one to two years, you might want to get extra hands on training on bariatric endoscopy or a third space endoscopy. So how do you integrate that into your negotiation for your first job to get that extra time protected or how do you get maybe some support to learn extra skills that you may not have sufficient time to learn during your fourth year? So any advice for the fellows? Especially the chief. The chair. The chair. We start with the chair. We have chief and chair. Yeah, this is a very common question for everybody who's looking for a job, which FYI, we are hiring. But yes, as an advanced endoscopist in that position, I absolutely understand how critical it is in terms of skill building and how critical it is that you get that sort of support early on in your years. So yes, we have had candidates where they requested that they have some mentorship. Somebody fly in and then they are watching them do the procedure, do that two or three times a year and have the senior mentor available, just like what Mohammad was saying, have one day dedicated where the senior person is doing the procedure and the other person is just observing for half a day and doing the other half a day. So as a chief, I have to make that allowance that I'll have one of my faculty not making any productivity revenue, the finest part of my job, but I'm just dedicating that time so they get trained into being competent, taking care of the patient, give a high quality care. So as a chief, I'm willing to do that because for me, I'm looking long term. Three years, five years from now, that's a service time I'm creating for my patient, for my community, when none of that is existing for 120 miles or so. Yes, you have to talk that the jobs that you're looking at, make sure they agree to providing you that kind of a support and probably get that in writing. I totally agree with you, Praveen, and this is the time when you get the most leverage is before you sign. Once you sign, you will lose a lot of that power. So before you sign, as you negotiate your first job, what does that entail? Get guarantees about a certain amount of time, also financial resources in the first two to three years that you can use for travel. I'll use an example. Mark is actually here. Mark, you spent some time out in Colorado during your fellowship to learn bariatric endoscopy, for example, because at the time, we had not had a program that was busy enough to do that. The best time to do that is to do it before you make the commitment. Bundle this as part of your startup, basically. And if you're joining an academic institution and they want this skillset, they will do whatever it takes to make sure that you get it. Also, you're not suffering financially because you're spending months away learning something new. You're typically on guarantee for the first two years. So that's not going to hurt you financially, but it should be part of your negotiations. And I would say a very sensible division chief or chair would absolutely agree to that. It's a good long-term retention tool as well. If you know your team is vested in having you up to speed on a new skillset and you building a new program, they will do whatever it takes to make sure that you get that. And then the rest becomes history. You come and you build it and it grows. But Ken, do you want to add something? Yeah. Yeah, so as division chiefs for 23 years and now institute director for six, the two magic words are professional development and financial alignment. Okay? Those are key words. So when you're being recruited, you say, okay, I'd like to talk about professional development. How am I going to grow? I'm just starting my career. And if they say, well, nights and weekends, then run, right? So there needs to be, whether it's one day, one and a half, two full days, in that range, that's within range of an ask. And then you want to talk about alignment, right? So it's one thing to say, okay, we're going to give you X amount of time that you don't have to do clinical, but you're going to be compensated by only your clinical. So then you're non-clinical, it's kind of on your own, but they want you to publish. They want you to bring in new technology. They want you to do research. They want you to direct things. Then you're asking for, where's the alignment, right? How's that getting funded? And so that's when the chiefs and the chairs need to come up with a solution. Okay, we're going to create RVU equivalents. When you do academic work, we're going to give you RVUs that are equivalent so that you're not going to be punished for doing something we're asking you to do as you're shifting from clinical to non-clinical. Suddenly you're punished, but you're doing what you were recruited to do. So alignment, professional development. I think one of the things that we haven't mentioned about this is you need to sell the dream, right? So it's not about, yeah, it's about when you're applying for a job, you want to ask for these things. So on this side of the table, you got to understand, they're going to say, well, what is in it for me? Why do I have to invest in you? We have a lot of candidates. You say you want to do third space. How is that going to benefit us, right? So that's what you need to think about when you think about professional development. It's not about you, it's about what they get out of you. So when you go into these type of interviews, when you go job searching, that's the key. Don't think about how things benefit you. Think about how it's going to benefit the place you're going to apply for, right? And you say, well, I need this professional development because these resources, this skill that I'm going to bring is going to pay off in X, Y, and Z manner, right? So if you're doing a poem, you want to learn third space, talk about motility. Talk about how that's going to bring business to radiology, right, or imaging studies. Surgeons, they do laparoscopic heller, so you need to figure out ways of selling the dream, not just about asking, because if you're just asking, you don't have a good plan, they're gonna not do it, yeah. The key word there is downstream revenue, for that, what you're talking about. Yeah, you know, advanced endoscopy is becoming the new orthopedic surgery. A lot of institutions understand that with, as you grow and develop the program, the financial downstream is huge. They may never say, oh, you know, yeah, we're gonna count every downstream effect, we're gonna count every imaging and every blood test, and we're gonna credit that, that'll likely never happen, but they see it, right? And so the bottom line does speak, and if you say, okay, we can take it from here to here, but this is what it's gonna take for me to do that. I think also understand what you're asking for, understand what it costs, so if you're asking for a day a week, two days a week as a therapeutic endoscopist, and you want to cover that cost, you should understand what you're asking for, it's a very large ask, but I would say exactly that, you need to sell the dream, you need to explain to them why, what you're going to do is going to benefit the group, it's how it's going to increase their national, international reputation, how it's going to draw in more patients, how ultimately this investment in you is going to benefit the group, and you also need to obviously, if they're going to invest in you, they need to see commitment for you, that you're going to stay with them long term, otherwise why would they invest in you? And then I would say very clearly, make sure you get it documented, and not by email, but in your contract, I would have it specifically written into your contract, not in your contract. It's a gentleman's agreement. Just don't tell them the increased downstream revenue is for more adverse events, that's not how to accomplish that. All right, we have a few minutes for last minute questions, yeah. I noticed that a lot of GI units, the director of endoscopy is a therapeutic endoscopist, what does that mean, and what role does that put responsibilities for how you maximize your position in that role? Is that a desirable position? Many of our faculty have served as, so I'll let- Actually, this one, the director of endoscopy is one of the jobs that brings you a lot of headache, and no- No financial return. Just to let you know, everybody will come complaining to you, starting from the technician, from the janitor, from the nurses, and from your chief, and from the chair, and everyone goes home late, or the turnover is late, they're gonna blame it on you, and they would not appreciate what you're doing to do, leave the job. You don't have to show them your ADRs. I'm sorry for that experience, because I have to admit, I have the exact opposite experience. I love my job, and I feel very fortunate and blessed to be able to help run endoscopy where I am, and yes, there are obviously lots of headaches, and yes, there are faculty email you coming into your office, yadda, yadda, yadda. I'm like, oh my Lord, okay, we'll try to deal with that, but I think, for me, and it depends on the kind of person you are, and I think this is hard. I think in lunchtime, we were talking with some people about this, that you should be trying to figure out what your passion is, and what really brings you joy, and what you're good at, because those things have to kind of match up. If you're a horrible endoscopist, and you think, oh my God, this is awesome, well, that doesn't really match up too well, I mean, even if you love the idea of your CP in the US. So I think both of those things kind of have to match up, and not everybody, so being director of endoscopy, lots of meetings, lots of details about operations, how do we make the unit run better, from stem to stern, from the moment that an order goes in, to the time the patient leaves, and even beyond, after the patient leaves the unit. So it's all of that, and depending on the kind of unit you're in, like I don't oversee our nurses and techs, and but I have some degree of say, over our nurses and techs, and work in partnership with my nursing and administrative colleagues, and so yes, all of that is kind of under your purview, in a sense, and I think that it has to be, those are the things that have to really excite you, and interest you, if you can't stand the idea of more meetings, and talking about this or that, if you can't stand the idea of, oh my gosh, I have to look at the schedules, and try to figure out, and then that's not the job for you, and I feel very strongly that you should never take a job, just because it, I don't know, sounds good, or you think it's gonna look good, I mean, this is all about you and your life now, and what you want to make of it, and it takes all shapes and forms, right? Like some people are phenomenal clinicians, master clinicians, master educators, and that's wonderful, that that's what you're meant to be, and what you're meant to do, right? Other people do totally administrative stuff, run hospitals, right? I mean, it's a whole gamut, and it's about what you really enjoy doing, and I think that if you're interested in one thing, that may be helpful, is you go to your director of endo, and say, hey, I'd love to help out with this project, because it's always about, what can you do to help, right? I mean, there's always a million problems, but what I don't like, is when people just complain, complain, complain, with no solution, right? But what I really appreciate, is when people come to me like, well, this isn't happening, can we try this, right? Then it's like, okay, you see an issue, and you're like, okay, and you're also trying to think of a solution. It may or may not be the right solution, because they usually don't have insight over all the different parts that's moving, but that's very valuable to someone like me, when people come to me with those kind of suggestions. So yeah, so if you're interested, and then you see an issue, then you can say, hey, I'm thinking maybe we can try this, right, and see if they can, or maybe, oh, I want to, I don't know, there's some issue going on, and say, hey, can I take this on? I'm happy to be project lead on blah, blah, blah, right? And then you get invited to meetings, and you start working on those projects, and see if that interests you, because if it doesn't, and you're like, oh my gosh, this is such a drain, I can't stand, you know, thinking about this next meeting, that's not for you, right? But if on the other hand, you're like, oh, this is really cool, then that may be an avenue for you. But there are a lot of frustrations, especially at a big institution. Things move at a glacial speed, and you have to kind of, depending on the institution, but at our institution, things tend to move at a glacial speed, and you have to learn to prioritize, and understand how to kind of work the system. So anyways, long-winded answer. Right. Maybe just specifically to your question, which I think may be most relevant as you're transitioning to your first job, there's only a few reasons to take a job. I think it was very well-established. Take a job if you care about it, but you're not gonna get offered directive endo in your first year, right? What you're gonna get offered is director of rectal third space, or some fake job, right? Why do you take that, right? So why do you take, it's like, no, no, I'm, I'm sorry. It's like, it's like, distal rectal third space. Exactly. Distal rectal. Exactly. There is a reason to take that job. One is if they offer you FTE, right? They may offer you FTE for a real job. Like they say, hey, we want you to build that third space program. We're gonna give you 0.2 FTE. That means they mean it for real. Oftentimes, they're gonna say, we'll make you director of EUS, or something like that, right? They're not gonna give you FTE. The advantage of that job is you could, it's almost embarrassing, but you say, you're having a meeting, you're like, the reason I'm here at this meeting is because I'm the director of the EUS program. So when we bring in EUS equipment, this is my title. I get 0% effort for it, but it allows me to help make decisions in that. If you wanna be part of that, so you can put any job, I mean, literally, the chiefs will give anyone any job, but they'll give them no FTE for it, right? That's okay if you really are passionate about it. If you're moderately passionate about it, like, I love being director of endoscopy, but I also get an FTE for it, right? I get like, you know, 0.2 FTE for it, right? So I have to like it. I don't have to, you know, be obsessed with it. And so I think it's really helpful to get that job title if you wanna build a program. So if you're taking a new job and you want to build a third space program and it doesn't exist, get that director of third space endoscopy because even though you got no FTE, it looks good when you're calling a meeting to have talk about the third space program. Sorry, go ahead. Just a comment on what you just said about these fake jobs. So, because all of us start with some sort of a fake job someday when you are in your third year of, once you are two years in academia and your third year, one of two thing, you have to move on, but you don't have a space and to give you a real job for administration. So they always find the director of something. So you can make it a real thing. You can really work in a plan. You can create your own job description. And you can make it something beneficial and put it in your CV for promotion and you can become associate faster if you prove that you are an administrative. So even fake jobs can pay off if you really start to do that. Thank you. I think Andrew has one more question, so that's going to be the last question and then we have a few things to wrap up. I think I would have told myself during my advanced year that your first job, and I've said this to some of you at the lunch table and who we've been talking to today, your first job does not have to be your perfect forever job. It's too much pressure to put on yourself that when you're looking for your job that you have to have everything perfect and you're going to be there forever. I wish I could go back and tell myself your first job is your first job and it's the job that's right for you right now. It may end up being your forever job and that's amazing if it is, but it also may be the job that's right for you for the time being and in a couple of years things may change either at the job or personally that make it no longer the best job for you and that's okay and then you can find your next job. I think you've been in training for so many years and I remember feeling a huge amount of pressure when I was trying to figure out what my first job was going to be. I wish if someone had said to me, listen, find the job that's right for you right now and that's going to be the best option for you. I would have said run away, no I'm just kidding. That's a long story, but no what I would have done is gotten an MBA earlier. I think it's important to do something like that. You have to diversify a little bit and I think that there are not enough people with real business experience in our field and I think we get taken advantage of because of that. Even in our own hospitals we get taken advantage of. I think for me personally an MBA for what I do now would have been helpful in negotiating with the hospital and for faculty and what not. I just think having that perspective would have been great. I think do something like that. Don't just be just a great doctor, that's wonderful, but think about also kind of other things that might help out. If you want to do a lot of research, an MPH might be helpful, et cetera. I'm still thinking about my fake job. Me too, wonderful. Thank you so much to all of our faculty. I feel like we can keep going all day, I mean all the questions are very insightful and all the answers, so thank you so much. Wonderful, so next, Bernie, do you mind putting up the next slide please? We are asking the current advanced fellow to please scan the QR code and we have a very short survey. Basically as a committee, advanced endoscopy committee, we're trying to understand the current landscape of advanced endoscopy training. It's very short, but it will be helpful in shaping the curriculum and training for the next generation. And then everyone scan on the QR code already? Then Bernie, do you mind going to the next slide please? So for the third years who match into advanced endoscopy, so you're starting it in July, do you mind also scanning this QR code and fill out a very short survey for us please? Thank you so much, and it should take you three to five minutes. And then at the end, I can just talk about some logistics stuff first for tonight and tomorrow, and then at the end we're going to announce the top five video submitters who are going to be competing tomorrow. So after we're done here, we're going to go into the reception in the main lobby, and we can mingle a little bit and get to know and learn from the faculty and also from your colleagues. So we're going to be there until 6.15. Then there's going to be a shuttle that's going to bring you back to the hotel. Tomorrow there are going to be two shuttles leaving the hotel at 6.30 or 7 a.m. to bring you back here. And then tomorrow, similar to today, we're going to divide you into two groups, the red group and the blue group. One's going to start with the lectures, the other one's going to start in the hands-on, and then we switch. And then at the end of the morning, we're all going to meet here. And then the five fellows are going to be presenting the video live to all of our faculty here. You have eight minutes to present your video. You're going to get some feedback from the faculty. And then at the end, basically the top three winners are going to be announced, and then you're also going to get an award at the end. I saw some blank faces when we did not mean to surprise you with this presentation ask, but we will let you finish your survey first. I think we bombarded you with it before you... You have a perfect audio in your video, but tomorrow you're presenting live. So we had 11 of you submit videos. All 11 of them are phenomenal. We could probably spend three hours tomorrow going through all 11 of them. But since we have a finite amount of time, we had to narrow them down to only five. And tomorrow, we'll tell you who the five are now. And we ask that you present tomorrow and get feedback from the faculty about how you can improve that. And this would be your next submission too. And we'll talk about what things you can get if you submit those and what are the benefits of being the top video of the course. But if you guys finish the survey, I know we don't distract you from that. But also, we will announce that the five finalists, if you have some time tonight to rehearse that, I know many of you probably had done this a million times because your submissions were flawless. And you don't need to rehearse any of that. But if you feel like you need to just get up on your presentation tonight so you can have your eight minutes tomorrow, that would be absolutely fine. Do you want to go ahead and announce the five top finalists, Sai? That sounds wonderful. And this is in no particular order. So the five fellows, it was a very hard decision, but the five fellows who are going to be presenting your video live tomorrow are Clement Wu, Faisal Nimri, I hope all of you are here. Perfect. It's very possible not everyone's here. Kush Bukala, Grace Kim, and Muthasem Alkayan. Here. I would like to recognize the other six fellows who submitted excellent videos. And again, the decision was hard. We just had to really come up with five. Rishad Khan, Othman Darier, Alyssa Grosin, Diego Rodriguez, Firas Badi, and Lauren Branch. Thank you so much for the wonderful work. We would encourage all of you, because your videos are excellent, and actually the format fits perfectly for the video plenary for the DDW submission, so you can go back, maybe make some adjustments if you want to, but this is a good opportunity for you to submit to DDW so that you get to present hopefully at the plenary session in May. Questions? Last minute, last comments before we close? Wonderful. Thank you all so much. Time for some reception now. We'll see you all bright and early tomorrow. Thank you so much.

Q&A session

technical issues

career development

mentorship

advanced endoscopy

negotiating contracts

professional development

networking opportunities

skill acquisition