Welcome to ASG Endo Hangouts for GI Fellows. The American Society for Gastrointestinal Endoscopy appreciates your participation in tonight's event entitled Making the Most of Your GI Fellowship. The discussion of this webinar will focus on lessons learned and tips to better navigate your fellowship years. My name is Reddy Akova, and I will be the facilitator for this presentation. Before we get started, just a few housekeeping items. We want to make this session interactive, so feel free to ask questions at any time by clicking the Q&A feature on the bottom of your screen. Once you click on that feature, you can type in your question and hit return to submit the message. Please note that this presentation is being recorded and will be posted within two business days on GI Leap, ASG's online learning platform. You will have ongoing access to the recording in GI Leap as part of your registration. And now it's my pleasure to introduce our host for tonight, Dr. Keith Epstein, who is an Associate Professor of Medicine and Director of GI Fellowship Training Program at Vanderbilt University Medical Center in Nashville, Tennessee. I will now hand the presentation over to Dr. Epstein. Hey, everyone. I'm going to share my screen, and we'll get started. Appreciate everyone joining us tonight. And I first want to thank everybody at the ASGE for organizing this event. This is a great opportunity for us, our panel members, to share hopefully some really good information with you. We appreciate all the panel members as well for taking the invitation. I'll go through and introduce everyone as well. And then you for taking the time out of your schedule and your evening to join us for this session. So thank you very much. And please be sure to ask us questions, because that'll be great. Going through our panelists for tonight, we have Dr. Janice Ju. She is the Program Director of GI Fellowship at OHSU and is a transplant hepatologist. I've known Janice for a long time. She's an outstanding clinician and just a wonderful resource. She has a lot of wealth of information, especially on this topic in particular. And I've also created with Janice the ACGME milestones. So Janice is really a wealth of resource information on curriculum and milestones in that aspect as well. Our next panelist is Dr. Ankita Seisselman. She is our Associate Program Director here at Vanderbilt. She's a graduate of our program, so she's completed her training and is also a member of our Center for Human Nutrition, looking at dietary involvement in our patients both with IBD as well as who don't have IBD but are on parenteral or internal nutrition. And then we have Dr. Audrey Bennett. She's a third-year GI Fellow here at Vanderbilt, and she's interested in IBD and will be pursuing a fourth-year IBD fellowship. And then we have Dr. Walt Coyle, who is the Director of the GI Division and was also the former Program Director at Scripps in San Diego, California, to round out the panel and give additional perspective. So just the agenda tonight so that everybody has it. We're going to be going through the introductions, which we've done, and then we'll do a quick topic overview. I'm going to try to go quick through that so that we can really hone in on the questions and answers and have a good panel discussion. And then we'll just do some summary and take-home points. So I'm going to let you all know, we have a really great mix of fellows tonight. About 40% are first-year fellows, 20% are second-year fellows, and 40% are third-year fellows. And everyone is from the United States North America programs, and there's a variety of concerns, which is great because we'll touch on all those. I would be remiss if I did not show this slide, and this is our most recent graduating class here at Vanderbilt. We're very proud of them. So they've all made it through the program and are successful in there. And so we just want to show that because we're very proud of them. That's Sarah Brown, and Keita Seisselman, and Ashley Spann. And it just happens that they're all staying on at Vanderbilt, so we're very glad about that. I'm going to go in this. Congratulations to you. I've said it before. You're all fellows. You've matched into a competitive subspecialty. Excellent. And be proud of that because this is really what you wanted to do. If you finished your first year and you're one of the 20% on here that's a second year, good job. First year is very challenging. It's a tough clinical year. So excellent work. And if you finish your second year and now your third year, which about 40% of you are, you know, that's an awesome time. You've gained a lot of experience and your career is really starting to take shape. All of the information or a lot of it can be presented. I like to try to present two resource articles for everyone. And so you can see here, these are pretty good manuscripts that have been written about sort of what to look for in fellowship and how to navigate and lessons learned. And then we'll talk about these topics as they relate to first, second, and third years, knowledge, endoscopy, management, career building in your trajectory, scholarly activity, and community. So first year, you know, first year is you're smart, you're well-trained, you are professionals, and you did a great job in internal medicine programs, or you wouldn't be in a competitive subspecialty like GI. So trust your internal medicine training and your skillset. But don't be afraid to ask questions. Nobody expects you to know everything about gastroenterology, hepatology, nutrition, endoscopy, and day one of fellowship. Certainly no one expects you to know everything by the time you're done with fellowship. So ask, you know, what we want you to do is really show up early. That way you can know everything about the people that say that are going to be present that day. And leave when it's appropriate within duty hour, you know, compliance, but make sure that you're there. And when you're there, be present minded, you know, be involved in patients, be involved with faculty, ask questions, get the job done. Try to keep your focus and attention on being there and taking care of patients and learning. You know, your job is to be a sponge and just suck up all that information. And then seek out endoscopic cases, be aggressive, talk with patients, sign them up, you know, and then learn high quality skills. Identify some people in your division or talk with your program director who have really great teaching endoscopic skills and have high quality performance metrics and work with them. Ask for feedback. This is a common thing. And this I think we can all do better. And don't just ask for feedback, how am I doing and accept it was good as an answer. Ask for focused feedback about a particular issue. And don't be afraid to say, what's one area or what is one item that you think I can improve on or read on tonight to get better? I think the more specific you are with your request for feedback, the better feedback you're going to get and you're going to grow from that. And then do your homework. You know, there's a lot of people that you see during a day, there's a lot of experiences that you have. Just take three to five minutes at the end of the day and pick something that you found to be either most interesting or that you found challenging and read about it, look up a question on it, check out the anatomy, do something just a little bit extra to solidify that. And like I said, be a sponge. There's a lot of ways of doing things, but pick up what works for you and what's right and when you want to do it. It's okay to say, I don't know. And then make friends. You know, it's really important, especially in fellowship. You're going through something that very few people go through other than your co-fellows and your attendings. So make good friends and strong bonds with those people. And then also reach out. You know, you can make friends with house staff and nurses, et cetera, there. But if you build those relationships, you're going to have a better support structure to get through your fellowship training and then beyond. And then explore the opportunities. You know, when we sit around, we say, you know, residents come in and they want to do one of three things. They either want to do IBD, they want to do transplant hepatology, or they want to do therapeutic endoscopy. Well, GI is more than just those three fields. So even though your heart might have been set on IBD from the get-go, explore nutrition, explore the esophagus and manometry and motility. Explore the pancreas. See if there's something that you really have a passion for, but you just weren't exposed to in a residency program. Use first year as a time to do that. And then find mentors. Some of them are assigned. Some of them are organic. But mentors can be different from champions as well. And champions are somebody who's really going to be in your corner and promote you and, you know, really help foster your development and boost your self-esteem. And then make time for you. It's important to do things for you. Wellness. If there's an activity that you like to do, please keep doing that. You know, if bowling is your thing, go out and bowl. Continue with that league. Make sure that you have time away from work so that you can recharge your battery and decompress. Second years. This is the opportunity to continue to grow and to solidify your relationships with mentors, role models, and champions. And then hone in on what excites you. This is really where you sort of want to navigate that pathway and figure out what kind of career do I want and how do I envision it? And then using the people from the above bullet point, your mentors, role models, and champions, let them help to guide you based on your interests along that path. And then make sure that you tailor either your research or your electives along that narrative to support your goal so that you can really be firmly focused in what you want to do. And then get involved. You know, this is your opportunity to get involved both, you know, at the program level, be in charge of quality, improvement of assignments, help champion diversity, help be a member of your hospital's committee, whether that's an IRB or some other protocol. You know, go to the national meetings, reach out, be a fellow on a national committee like at the ASGE, and really try to be present-minded and involved. And then identify areas for improvement. I can't overemphasize self-reflection, it's key. You know what you do well, and you know what you might struggle with. And also ask your mentors and other individuals what they think you can do to continue to improve. You know, these are also part of your program director and associate program director meetings, but go beyond that. Use other resources like question banks as well to identify knowledge areas. And then identify areas that you might have missed during first year. Let's say that you were really interested in nutrition, but you just never got the opportunity to do that elective. Ask your program director or associate program director to put you on that elective during your second year. That way you get exposed to it and can see if that's something that you really enjoy. And building your portfolio, both in terms of scholarship, and that could be more than just sort of a couple manuscripts or research papers. That can be with teaching and mentoring. That could be outreach and even activism. And then try to refine either a skill set, such as your niche. It's a buzzword that we like to throw around. Or an area that really gives you strength and charges you up so that you're excited to come to work and take care of patients. Be a communicator. Always, it's almost better in a fellowship program to over-communicate and say what's going on and asking about that because people have been there before and can help you through that. So be sure to do that. And then in third year, it's really your opportunity to finalize what you want to do after fellowship. And this is where you're going through the job application process, considering fourth year fellowships, and continuing to expand that portfolio of your scholarship and research and really refining sort of what you want to do as far as your niche. And then ask your providers, your attendings, if you can serve as a pretending. This is a great skill. It's one of those only times that you have left where you have this big, big blanket of people around you to sort of help get you through either clinical activity or endoscopy or other thought process. So use that. Use that safety net there. And ask if you can serve as the attending, let's say, for the consult month. And you run the service, run rounds, try to be the attending. And your attending on there will then give you pointers on that. I think it's a great opportunity, certainly. Please take that. Service role model. This also goes into it. You know, believe it or not, third years have a lot, a lot to offer in terms of serving as mentors and role models. It's who the first years and a lot of the second years go to as they were boots on the ground, you know, initially and have gone through the program or gone through training. So do that. Serve as a role model. Be kind and friendly. Allow them to sort of gain that knowledge that you've already gained through there. You do have a lot to offer. And then refine your skills. So look at electives that you might want to do. Come up with some untraditional electives that might work at your program and do more endoscopy just so that you can feel more comfortable. Building confidence is key in gaining experience. And then just capitalize on that time that you have remaining. Again, it's sort of that only time that you have left to really continue to explore different facets of GI in this protected environment. So use it. Rely on the people that are your champions and mentors to help you. So with that, I am going to open this up to questions. And while we're waiting for our first question to come in, I'm going to pose this to the panel. What would be one piece of advice that you would have given yourself at the start of your GI fellowship or to new fellows? So I'm going to stop sharing so we can see everybody here. Dr. Ju, do you want to answer this? Sure. Obviously, it's the beginning of the year. So maybe some of these things are on my mind. But maybe the piece of advice that I'd give to my July fellows is just to maybe not expect so much of yourself. I mean, I know that maybe seems like we're asking people to kind of undershoot a little bit. But I think it's a bit of a hard transition when you're a third-year resident and you're kind of running the service and you feel very facile with your internal medicine skills to come into a GI fellowship and essentially feel like you know nothing. Like you can maybe comment on somebody's blood glucose or something like that. But you have no idea whether or not that patient is going to be safe for moderate sedation for their urgent EGD. And I think that there's always this pressure that one puts on themselves to just come in and just be like sort of guns a-blazing. And I think from the faculty perspective, we just expect so little in the beginning. We just want someone who is engaged and enthusiastic and willing to learn, willing to ask questions when they don't know what's going on. And so I thought your comment about asking questions with impunity was great. As well, just ask away. But I think that it's just a hard thing to kind of come down those couple of rungs in the beginning. So maybe just to expect a little less of yourself, but just sort of bring the enthusiasm and the energy. Dr. Bennett? Yeah, I think the advice I would give to incoming first-year fellows is to really be, you said, kind of be aggressive in pursuing endoscopies in the beginning. It's a whole new skill to learn. So I remember in the beginning of fellowship, sometimes it seems very daunting and you don't always get very far in your procedure. And it can be easy sometimes to shy away from doing it because it's challenging to start something and really not be good at it. But I think just getting involved in endoscopies whenever you can and being kind to yourself and knowing that in the beginning, you might not get very far and that's OK. And really just the more practice and time you have with different endoscopists and in different types of procedures, you just gain more comfort and skills that will really kind of carry you forward in fellowship. Yeah, I think that those are both awesome comments. You know, they sort of tie into each other, right? Where it's like you have to not expect that you're going to make it to the CCOM all the time and that's OK. You haven't been doing it for 20 years, right? You've just started. You're maybe 20 hours in and that's OK. Nobody expects that. So I think you guys commenting on the fact that sort of what somebody like the fellows expectation is and what the reality is of what the attending expect are sort of two different things. I think, you know, being there, present minded and excited and doing what you can, you know, use that good internal medicine skills of knowing the patients and coming up and be like, hey, you know, Dr. Seisselman, this patient's next on your endoscopy schedule X, Y and Z is going on with them and they're doing a colonoscopy for this. We need to take biopsies for this. That's like, whoa, awesome. And everything else is like, OK, you're going to learn. Not now. Now we set the stage to learn. Dr. Coyle, we're asking, what would be one piece of advice that you would have given yourself many moons ago when you were an incoming fellow? By a two piece of advice, not one. I wish I could say we're endo athletes. If you're going to be endoscopists, it's you need to stretch, you need to train, you need to pay attention to where the bed is. And I wish I had learned proper training. So I would definitely go both AESGE and ACGF websites and talk about proper stretching, ergonometrics, you know, standing with the screen, the proper height. That is so important to get the habits very early on. We have a fellow that came in last time and already has a little bit of tennis elbow, you know, from torquing that skull with that iron grip. So you got to work the good habits now. And no one taught me that. I picked them up as I went. And I have a little chronic overuse injury, but overall, I'm doing OK. The other thing is be willing to change what you came in on. You know, I wanted to be a transplant hepatologist. And now I'm a therapeutic endoscopist, you know, but learn everything you can. I love your idea of the sponge, suck up everything you can. Who are the best subspecialists? They were good internists first. Who are the best subsub subspecialists? Good general gastronomist would be that really good general gastronomist. That'll serve you well as whether you're a transplant person, IBD or, you know, you're a cancer focused doctor, whatever. And Dr. Sieselman, what would have been a piece of advice that you would have given to yourself? I think all of those were great pieces. I think ergonomics was a big one. I wish I had started focusing on early on rather than more as a third year. So I think that's definitely really important to take your time to kind of focus on those things and build those good habits early. And the other thing, overnight call can be really intimidating. So embrace it. That's sometimes when you're going to see your most fascinating cases, a lot of foreign body removals, food impactions, things like that. It can be frustrating getting called at night, but obviously we're there to care for patients. So not getting frustrated with your colleagues, going in early if you're potentially concerned and just kind of knowing that that's part of your learning experience as well. Yeah, I think another excellent point there. A question came through. Thank you, Dr. Sundar. So Dr. Hu, how many colonoscopies, upper endoscopies and let's say pegs, do you recommend that a fellow does or participates in prior to finishing their fellowship where they might begin to feel comfortable or practice confidently? So, I mean, I bet everyone has kind of varying opinions on this. I mean, I guess I would say what I experienced myself as a fellow and have seen in my fellows is I think there are two peaks. There's like the, or plateaus maybe, or two levels you reach one, which is sort of like the, you're no longer lost in the sigmoid all the time and you're actually going to get into the cecum more times than not. But it's not like if nobody could get to the cecum. If I couldn't get to the cecum, nobody could get to the cecum, right? I feel like there are like two levels that I see in the fellows. So I think the first one happens in the somewhere between three to 400 colonoscopy range. I feel like where the fellows seem like they can get there and, you know, the exam's reasonable, but it's not like the most efficient, you know, sort of insertion and withdrawal. And then there's like another one that comes at more of the like 500, 600, 700 sort of plateau, where I feel like then they become much more confident. Their, you know, withdrawal is better. And then to be frank, I think the last bit of learning through endoscopy happens when you cannot hand the scope off to anyone anymore. And then I would say, additionally, as an attending, having to help the fellow, taking the scope from a fellow and having to troubleshoot that taught me so much about loops and sort of the sort of conscious competence that you have to have in order to scope. So if there's a comment that I would make about sort of fellowship and learning to scope is that to take the time to recognize what's working for you as you're learning and to remember those things will be easier to sort of have your conscious competence because you don't have to go back and remember or try and figure out why the things that you're doing are working. So I guess so that's like sort of a side comment then I guess we're saying how many pegs. I mean the, the sort of threshold that everyone seems to use is 15. I think it's kind of hard, you know, now with IR doing as many pegs as they're doing to always get that number but our fellows do but where we are I would say, our fellows have to, you know, they have to get 15 and it's getting harder I feel like, especially post pandemic and we haven't even talked about the pandemic yet. Sorry that to be the first one to do that but it has changed things a lot I'm sure. Dr. Coyle, do you want to do you want to answer that you know it's interesting. I think you know numbers are one of the sort of that we like numbers because it's a, it's a construct right it's a it's a something it's a goal right it's concrete. But we've really gotten away from that which is why I think there's sort of, you know, not like a firm number a good answer. There's a lot of studies of learning curves and stuff like that. And I like how you, you know, you framed it it everybody's different. There are some first years that at the end of first year you're like oh my gosh, you're like, going to rock it out of the park and then there's other third years there. I think what you need to do is make sure you're scoping with the people who are good at assessing endoscopy and making sure that they can pinpoint what some of the challenges that you're having are, and help you to correct those challenges. And by being identified early. If you're having a problem. If, as you get to second and third year if you need some more endoscopy time or more skills to develop, then, then that's a resource to really utilize. I mean I tell all of our fellows that really you don't feel totally comfortable doing endoscopy until the end of your first year as an attending, because I think that's really when you get just volumes of numbers under your belt and we're trying to frame, but you get the experience and while you have your colleagues in the rooms next door to help you in that immediate time and setting, it is you and so you're figuring that out and your learning curve is really exponential. So I think that the practice confidently part is really after your fellowship is done. I think getting the basic skill set like there where you can feel sort of, I can do this without hurting somebody is is should be at the end of your fellowship, but to sort of not get IBS before you drive in to do your morning, you know, cases and stuff that comes after the end of first year sometimes later. Sometimes it doesn't go away if you have some like big case that like you got on your schedule. Walt, do you want to add, change. I agree there's no and every fellow progresses, and it's already started now with our fellows you know the the four years, I got to the seek him in four minutes I got to the seek him in eight minutes you know, let them just wash over you do your own thing, you'll be all become very good endoscopist I think all of us are good endoscopic teachers, but sometimes you're going to be annoyed by some of the attendings they're going to be more torque guys, or the woman will be a you know more of a torque person. You have to master all the skills to become a master and basket. So sometimes I'm using mostly knobs and that's I'm using torque only, you know, so you really have to master all of them and embrace everything every time you get a chance to do an endoscopy ever do it. But don't get frustrated. So there'll be good days, got three scopes in a row you won't get to the second, that's okay. By the end of the second year that shouldn't happen too much and by the end of third year, you still in case you don't get it but I agree with everyone else, I did not become a good endoscopist until I finished my first year of staff, then I at the end of that thousand colonoscopy said okay, I can do this. But our goal is to try to get you close to that feeling at the end of fellowship, and you may or may not, and if you don't that's okay you will get it, but just take your time. Take everyone's techniques that you like and don't like and make them your own. We have a question here as well in the era of rapidly evolving GI. What are some of the best resources that incoming fellows can use to learn on the fly. Dr. Seisman do you want to take this what are some resources that you would recommend fellows use when they're incoming that are sort of quick exchanges. I think all of the societies have really great website so AGA is GE I think are where I go for a lot of guidelines I think is important as an incoming fellow just so you're up to date with current practices with kind of topics that you're going to be as a subspecialist. I'm not as savvy in the Twitter world I know that is an upcoming kind of platform for a lot of, you know, new updates and things that are coming out in the medical field and so I think a lot of us will be headed that way. for some major updates that are coming along as well. Dr. Bennett, what would be some things that that you would recommend sort of on the fly resources that maybe you found helpful. I agree with reading really a lot of the guidelines and updates and sometimes when I'm on consults and I get a question about a topic I'm not as familiar with sometimes it's even just looking at during consult days like a quick up to date kind of search to read just more about a topic and then I guess lately now and into 30 or fellowship. I'm also utilizing more of like DDSF and certain questions so if I'm going on to a certain rotation so I'm going to be going on to hepatology consults I might try to do some of the questions in that area and get a little bit more familiar and with some of the questions and some of the answers and explanations on questions to kind of learn different topics. I started, I'd be curious. I started doing some listening of some podcasts on my commute into work or back home, because I figure it's like 20 to 40 minutes and some of them are really great whether it's about journal articles or past ASGE, or, you know, AGA things like I listened to Dr. on this very similar topic the other day as well so I just find it's a great time that you know you have 20 to 40 minutes to be able to learn something new or get caught up on sort of the literature what other people think are important. I'm curious, is anybody else on our panel or group done that or am I like breaking the new technology and I know it's so old. I used to do that especially when the boards are coming up, you know, there was all sorts of resources including podcasts you know and lectures and stuff like that. But I'll tell you, with COVID, when I'm driving in, I'm listening to books on tape, I'm escaping. I'm sorry, I had, I needed my little getaway, you know, but when I was at that learning curve really steep. I found it very helpful to do those things on because I had about a half hour commute, same thing. I would listen to like our Vanderbilt recorded lectures that we would get as fellows I thought those are really helpful and good review session so maybe a little bit more accessible which is why I went to them but that's good to know that there are other kind of podcasts out there as well that may be a good, good option. I think one is good just to listen to. It's very soothing. Oh, that's good. Yeah, good. Um, that piggybacks on one of the questions that popped up as well which is about boards, and I'm going to send this to Dr. Ju because she maybe writes some questions. What do you think is the best board prep to pass the board GI boards for the first time like if you're taking them. First time, what would you recommend. I think everyone learns a little bit differently I mean I think a lot of people like to do questions, so Dr Bennett was talking about that so I think a lot of people used on, you know, DDS and that as a text. post grad course often has an associated list of questions that comes with that course which is often a really good review. I offer the in training exam, you know sort of print out of subject areas that they may have missed during the training exam as a way to sort of guide their study. When my fellows are preparing for their boards. I mean I would say they're just a lot of different resources and you sort of have to know kind of how you learn best. So, are you a question, sort of question bank kind of person and so there are many question banks, are you more of a well, I'm going to take the blueprint and that's another way to do it is, you know, take the ABI and blueprint and then read about because that's what's tested has to fall in those subject areas. So, you know, you can do that either through, you know, you know the Mayo board review or whatever there's so many ways to go about it but I think some of it's just understanding a little bit about how you learn and what's best for you. And some people actually need a board review course because otherwise they're not going to be disciplined enough to do it so you sort of have to know yourself right. So there's lots of different ways, but I would say those are many of those different ways I would say are the most accessed. And then actually what Dr. Sizeman was talking about is reading the guidelines, I mean I think the questions are often guidelines based and so I often will point my fellows in that direction to get started with their board review as well. Dr. Bennett, they're coming up for you. What are you, what are you, what are you, what are you doing. So I have been doing DD set questions and then I am a person who learns a lot from like flashcards and repetition so I have two windows open on my computer when I do DD set questions I use a website that's called cram.com and there's a free app you can download onto your phone and so you can make flashcards for yourself and you can put them into kind of a memorize mode where you can say whether you got it right or wrong and it puts all the ones you got wrong into a separate pile and just keeps having you repeat them until you get them right. And so as I'm taking DD set questions, whether I, you know, get them right or wrong or I maybe just guessed and got it right. I read all the explanations for the answers, and then I make flashcards and then I can study those at later times if you're just waiting between consults, I have the app on my phone and so I can just run through questions during the day. That explains why you're on your phone. I love it. Very good. This, this is a great question I'm going to put this to Dr. Coyle, when starting out as an attending as as the division chief. When starting out as an attending, how many procedures, or what do you think a fresh sort of attending a new attending just out of the third year fellowship would sort of put on their schedule to make sure that they can get through the day and not cause a lot of delays in care and then how do you sort of look at ramping them up to certain numbers or is there a time that you put on it, how do you know that. What do you do. I hope that the group you join understands where you're coming from, because that's really where it should be driven from you shouldn't walk in and say, you're doing 20 minute colons for six hours straight that's, that's not possible for persons coming out, and even that's not sustainable for a lifetime of doing endoscopy if they're going to drive you like that so we usually give our starting attendings for the first you know six to eight weeks, an hour for colonoscopy half hour for endoscopy because remember there's the paperwork side of it there's doing the procedure. There's a lot. And then we decided as a group we were every half hour and now we're 45 minutes for everything. So, whether it's a, it's a double, you know, Koga we call it up or lower, it's an endo or colon it's 45 minutes, and it just works out nice it's a nice place other places are half hour, you know, and you really have to stay on top of things if you're in the half hour pace, but absolutely I think I would ask for the beginning, you know, give me an hour, you know, for my morning per case, maybe for a colon, and a half hour for an endo, and then after about a month to six weeks, you can start to pick the pace up faster than that you just get a panic and actually have your IBS attack going into. What is your sort of schedule look like starting out here. Yeah, that's exactly what I'm starting with so an hour for colons and 30 minutes for EGD and then just based on how things go we'll start to ramp up from there. I'm waiting on my credentialing so I actually haven't started doing any endoscopy yet, but my colleagues who have started who just graduated with me. I think that pace seems appropriate and they seem to be doing well with that so have to follow in their Yeah, I think that that you made a great comment Walt it's it's not just the endoscopy scope in the scope out time, it's all the other stuff that can take just as much if not more time. So like if you're doing moderate sedation, and not as sometimes that takes longer to get the patients you know they didn't that could take 20 of your 30 minutes sometimes. So I think, you know, framing it in context of really looking at globally not just sort of your component and understanding that there's a lot more that goes into it than just you and don't put that. Oh my god, I'm going to be sort of the cornerstone or why the whole day is delayed there's a lot that goes on in the endoscopy lab even before you get there, and between cases that can make cases go extra long in there so I think putting any additional pressure like you're responsible for the entire flow of your room or the unit is unfair and you're going to start at a disadvantage. And, you know, everybody recognizes that there's all these other factors involved and it just takes experience to be able to understand that and sort of come to terms with it. It doesn't mean that it gets any better. I know that like we still get, you know, a little bit sort of frustrated when rooms are running slow or turnover times are like 20 minutes. Yeah, I mean we have sort of similar scheduling, and I think it is a discussion that you have to have before you start, you know, what are the expectations for what I need to do and honestly when you're interviewing, you know, ask them, you know, and speak to people who are junior in that group or in that faculty practice. What was it like for you did you feel supported like how did they ramp you up I think that gives you a sense of what the culture of the program is and so yeah I think it's pretty similar in, in that Yeah, like some places are going to give you not a lot of time and you might already know that up front and so you should just go into that eyes wide open. There's a there's a good question here. I'm going to put this to Dr. Coyle see that he's our therapeutic endoscopist. He's going into, you know, a lot of our fellows are doing fourth years therapeutic endoscopy fellowships but don't have the opportunity within their program to do ERCP or EUS, and they're nervous. Thankfully, so is there any way that they can prepare during let's say their third year or second year when they sort of decide this is what they want to do to do a therapeutic endoscopy fellowship any any words of wisdom that you give them for sort of that next jump from third year to that fourth year. Yeah, exactly. That's why one of the pros I give for our program we don't have a therapeutic endoscopy fellowship. So you know our third years are doing us is in the ERCPs and the ones who really want to focus on it get a chance to do it. So for a program where it's very heavy driven at that next generation at fourth year fellow. It can be hard. But I think it's important to really, if you're interested in therapeutics, you need to be in the suite in the room, do some rotations and ask. And a lot of times when I was in my, my program, we'd let the third year fellow say hey pass the you know get us in position. You know, and do that. But also like for us, it's just as important as interpretation. You know it's important to know the stations but okay, oh this is now this is the portal vein here's where the SMA is and stuff like that so be in there doing it. And if you like watching. If you get excited about watching them do it, you will like it when you can actually do it yourself. I'm not impressed with the models, I'm not impressed with so far, you know what the simulators for advanced endoscopy, they're just not very good yet they don't give the same feel. You can try them but I've been disappointed with that. So I think you need to be in there with these people say hey I really want to do advanced endoscopy. If I'm an attending, I'll say hey, get us get my fellow in position, and then the advanced fellow can take over from there. And then also we can also assess how good your hands are in your skill set. Yeah, I think it's very similar in my opinion, in a way to the transition between resident and fellowship where you've never held the scope only the difference is now you've had three years to hold the scope. So I think if your basic endoscopy skills are solid, especially upper endoscopy, and you have good fine tip control. Then the recommendation, you know that that I would have would be so much of it isn't just the mechanics, but it's the images and its interpretation. You certainly have the opportunity to understand the indications. The adverse events that happened from these procedures and how to manage them and that you should really focus in on your three years in fellowship so that you are you are the go to person for that. Make sure that your skills, technically with basic endoscopy is great, and then get involved in really understanding how to interpret the images, whether it be collagen grams or whether it be the fuzzy salt and pepper gray stuff that people I swear makeup is like oh yeah there's the bile duct I see it. You know, so, so if you, if you, if you spend time learning that you've already done so much. Then, you know, the expectation coming in a fourth year is that you have those basic skills, and what is a fourth year for, again, to use the analogy you're the sponge, only this time your skill set that you're trying to pick up is a little different. And so you can build on that I think if you present the building block just like the good building blocks in a GI fellowship are a strong internal medicine resident. You're going to be successful. And it can be intimidating but that's the advice that I would have. Anything that you tell your fellows there differently or. No, I mean I think, you know, obviously this, you know, trainee is being recruited to do this fellowship and it's going to be taught right to do it, and everyone knows that they're going to have varying degrees of exposure. And so I think it goes back to maybe the first bit of advice I gave which is, you know, there probably are going to be very little expectations of yourself yourself when you come in and so ride that for a while, right, and then get your feet wet and get settled, and then you know the skills will come. You know, I think that as fellows and I did this too you know I think I was like, you know, I was told in fellowship that musicians, athletes, and gamers are good endoscopists, and so I was a musician and I was an athlete, and I sort of expected that I was going to be this amazing endoscopist. And I was pretty average for the first couple years and I was like gosh my hand eye coordination supposed to be good like I don't know what's going on, and it really took me a little while to really figure out what was working for people and what wasn't and what was working for me and that has made me a much better endoscopist and that's made me a much better teacher but we expect so much for ourselves and we expect that it's all going to come so quickly and serve as we talked about before it comes in varying times, and sometimes it is what your exposure has been and who has been teaching you and and sort of what you're seeing and so I think no one expects someone coming into training to already know it all because then why would you come to fellowship, right, you wouldn't need one. I think these things happen much more organically I think. Yeah. Um, it's sort of a piggyback question I'll open this one up to everyone. If you're not taught conscious sedation. Do you look for practices where it's only anesthesia, or, you know, is there some expectation that you should be trained in conscious sedation and this, I think this is a great question, because so many and, you know, endoscopic practices are falling to, you know, anesthesia supported sedation. So I'll open it up to everyone, what do you guys think, how do you, how do you learn conscious sedation anymore. It's amazing to me you know we're heavy heavy moderate sedation practice you know for our advanced stuff we have anesthesia. But I just recruited a gentleman who doesn't do a lot of moderate sedation so we had to have a little talk about that but he has done very good in basket this, but it's a problem. You know, and if you've never done any moderate sedation it's another level of stress you would carry to the practice, but if you love the practice and they love you. Don't let it be a barrier, but you tell them, I may need a little help feeling comfortable giving births and fentanyl and you know and stuff like that. But really, my experience is that nurses really run the show. You know the nurses are my end of nurses are extremely good. You know, and they really help take you through it. But if you've not done it, it's an added stress I would try to get moderate sedation experience, even as 1020 cases, you know what you should think, but there are some programs now where the fellows never do monetization which is amazing to me. As someone who does quite a lot of moderate sedation. I mean maybe I'm making it seem too easy but I don't find it to be particularly difficult if you just look at their vital signs you know breathing not breathing. You know like talking to me needs more I mean, I, you know, I think it's more just maybe just talking to someone about it like, you know, sort of Dr. experience with it and really pay attention to and ask, you know, the attending like what do you look for and how do you decide how much you give and I think you generally have some kind of constructs in your mind like I never start someone who's over 75 to 250. I mean like just that's a recipe for disaster I mean there's like things like that that are just sort of practices that you have that you can get from people if you just ask the question. So I agree I don't think it should be a barrier. And after you have several cases under your belt, you should be comfortable. Dr. Seisman or Dr. Bennett we, you know, comment on our on our groups. Yeah, we get a lot of moderate sedation exposure at the VA. Most of our cases are about half are done with moderate half with anesthesia so we really start first year, kind of getting comfortable with that I don't think it takes a lot of cases I would say probably in the realm of, you know, 15 to 30 where you start kind of building some of those constructs as well and getting an idea of what you're looking for. So it would be nice to have some exposure but I don't think it's a hard skill set to learn that you could add to your tool belt. I think, you know, if your endoscopy group that you just have there is just pure anesthesia, and you just want to get some exposure to moderate sedation, it might also be worthwhile if you know ask potentially there's opportunities to do, you know, cases without anesthesia under the guidance of sort of when I say that without propofol and ask if you can administer you know midazolam and fentanyl so you can always, you know, check out that there's also potential that your anesthesia team you might do a rotation or a day or so with them, where they're doing moderate sedation for other reasons so that you can see it being done and gain some experience that way right. Just because you're doing moderate sedation doesn't necessarily have to be endoscopy it's learning sort of which medicines work how a patient responds to that, and their level of sort of sedation as well so I think there's, there's opportunities as well to gain exposure even if it's sort of zero offered at your program. I'm seeing here as well. So, you know, how do you, how does one, you know, learn to sort of stay focused in endoscopy as you know during fellowship depending on what room you're in sometimes there's loud music on. Sometimes there's attending conversations with the nurses, or the techs. Sometimes, you know, fellows don't want to speak up for fear that either they're not part of the conversation that something you know that's not pertinent. So, you know, what do you think about the endoscopy room, how can the environment, be such that might be more beneficial to a trainee. Audrey. Dr Bennett. Yes. I mean I think some of that also changes throughout fellowship and your comfort level so I think that now in third year fellowship you know if if the attending has kind of music on or they're having other conversations I know that they're, you know, I feel more you know just have gotten to know the attendings better to know kind of feel comfortable reaching out and asking someone to when I can meet them to maybe focus and have a question. I think certainly though in the first year when you're trying to learn I think that I don't know I was someone who likes to have usually kind of more of a quiet focused room when I need a lot of questions answered, but I think it's a little bit different kind of across across different years of fellowship. What do you think. I mean, I think there is a comfort level that comes kind of as you're doing more endoscopy and getting comfortable with that but I think it's always okay to ask to I mean the environment like if there's a lot of conversation going on or music and you're not really focused just kind of asking you know you're in that environment you're learning it's important for you. And so, you know, having that open relationship and the faculty are there to teach you and so I don't think it's unreasonable to kind of have that conversation or if you feel uncomfortable in that, you know, setting, just waiting till in between procedures and, you know, just just letting them know hey I was I was having a really hard time focusing. You know, do you think it would be okay if we, we asked the nurses to you know quiet down the music or, you know, whatever kind of the distraction is so that you can kind of focus on the skill set that you're working on. This is a great, a great question here. Dr. Chu, what is the single best piece of advice that a faculty member gave you when you were in training that sort of you still carry with you today. Um, it's hard. Um, one, so it's a good question. I was actually thinking about that. I think I learned, I'm kind of at like one of the, you know, sort of academic skills workshop kind of type conferences was the idea of mentorship and what makes a good mentor. And it's seeking someone a mentor or sponsor whoever who's willing to give you their time. And, you know, time is something that is worth more than money. And in this sort of current state that we're all in and we all feel like we have even less time like someone who is willing to sit down and give you time is probably the most valuable thing that they can give you. I remember reflecting on my own mentor in fellowship, and how during my, I was a T32 fellow and I was doing research, and we just had a weekly meeting, no matter what regardless of whether or not I had anything to say, and we just met and I remember reflecting on that thinking like what a tremendous gift that was to me that he gave me that time. And when I try to mentor I try to do the same in that if you know someone's on their research block, and I'm mentoring them in research then I'm checking in with them every week to make sure there aren't any barriers in their way and so we haven't really talked about mentorship yet but that is something that I think that was really valuable and at the time it was really simple to kind of sort of think about like just this giving of your time, but I think I value that even more so now that you know I'm sort of feeling more and more taxed for my own time. So, just a reflection. Others. Well, I think you were doing a clinical obligation that the question that we had was, you know, what is the single best piece of advice that you heard from someone when you were going through training that you might still carry with you today. You know, because I still there's, I came across a syndrome that the days and oh my god I never even heard of this, you know, and it was exciting you know and then also I get excitement, teaching so you got to find what your love is I like a lot of you. I, you know, although it was very painful we just finished our first year fellows first month, that was, that's an act that's a gift that's, that's really an act of love. But after that, it's so much sun, because you'll get I forgotten all about this syndrome you know and, and, you know, and then all of a sudden you get excited again about learning and teaching and it keeps you young, you got to find it's not always I love advanced endoscopy, I love doing this, you know, so you got to find your passion, and then that's where it's nice to find a mentor, it shares your passion, and that really helps, you know, and that's how you can really, you know, never stop learning, which I think the ones who burn out who are not happy you're getting out of medicine, they lost that love that's that's why to be that love of life and love of learning and to keep that it's going to be a good career. I think to echo a lot of that my biggest thing is, you know, explore everything this is your time during training to really absorb everything explore every subspecialty so do motility do nutrition advanced hepatology I did everything that was offered at Vanderbilt to gain exposure to become a well versed gastroenterologist because this is your time that you're building your foundation, and then kind of take it from there what you're passionate about and go forward but I'm just taking everything that you can and explore it. We have one, it looks like I have one other question that just popped up this might be a quick one if somebody is interested in therapeutic endoscopy we talked about resources. What is there a book or resource that you would recommend that they take a look at to learn cholangiograms and ultras how to interpret ultrasound. I think it's up to third edition now and then I think you should get an us book to any there's houses has one and Falcons has another one and so just find one, and just go through it. But I'll tell you, and I this is a, my fellows know this and they never come to my office I said did you look at the x ray yourself. I'll say you know never trust the radiologist, because I've looked at 10,000 pancreas is, and I know what a pancreas should look like. So you should get in the habit, and basically it's sent to you and we're trying to look at a cat scan the first thing I look is the pancreas we're in the tail way back and that filed up in getting that habit of doing it. And that's if you can be advanced or not it could be IVD it doesn't matter know how to read your own studies, and that goes a long long way. It doesn't matter what resource you do as long as you go to that resource and use it, you know, buying the book it sits on the shelf doesn't really help you very much. So, well, we're importing on the hour, I'm going to go and share my screen. We'll do some just brief take home points and then I'll open it up to panelists with any sort of final thoughts as well. So, you know, the take home points I think to summarize a lot is, you know, be that sponge. Just learn absorb everything that you can be involved. Be there. You know, never underestimate the power of teamwork teamwork applies here as well. Right, there is no I in gastroenterology or hepatology or endoscopy. It's all about the team so working with your colleagues your co fellows your attendings the staff, other people really solidify your knowledge and don't be afraid to rely on the team. Create goals, I think it's really important to do this you know sit down with a sheet of paper there and write you know short term ones, you know, what do you want to do in the next month. What do you think you want to do in the next six months, rely on the people around you to help create those goals if you're sort of at a loss, and then think long term goals meaning longer than six months do 12 months do years, and that'll help you put everything into perspective. And then enjoy. You know this is an awesome time. You're a fellow, you're doing exactly. Finally, what you wanted to do right. You've gone through medical school you've gone through internal medicine. Now you're doing gastroenterology you selected it for a reason. And you love it so enjoy it. Be there, do all these things, and just have a have a wonderful experience. So, you know, my final sort of thought would be, you know, good luck. Learn a lot, and just have a have a have a great time have a great experience. I'm going to open it up to our panelists for any other sort of final thoughts or comments. Words of wisdom. It's now the most in demand subspecialty right now. It's fun. Have fun, find out what really turns you on and do it. I totally agree with that like just finding your passion, finding what makes you want to go to work and figure out what that is what is that x factor the special sauce it's going to make you want to go in every day. And, you know, when you're sort of thinking about your fellowship like I sort of think about it. There's like you know when in medical school right you have different threads like there's the microbiology thread and the whatever you sort of like the clinical exposure thread which is like you need to see everything right so Dr. Quill mentioned that as well. And then you're sort of thinking about well what do I want to do as my subspecialty and we talked about like it's not just IBD transplant hepatology therapeutics but it's motility or functional GI or whatever you want to do that sort of like the subject area. And then there's sort of like, what is the actual like sort of job description that you want one day right or the track that you're going to be on so are you going to be a clinical educator are you going to be a physician scientist, are you going to be. Do you want to be in hospital admin do you want to be in policy are you someone who's, you know, implementation science already I don't know, maybe, but if I didn't. You can do that as well. But you can have mentors and all of these different areas right and so you have to kind of seek these people out because maybe someone does have like the absolute like, you know, from every single sort of variable has the right but often it's multiple people right that are that have the job that you want, or, you know, like myself as a woman in GI now has children like I really looked up to the women in GI who had children at the time and I was trying to see how they made it work. And so there's going to be so many different people that you're learning from and so sort of thinking about these different buckets and what you're doing to seek out who you can learn from and kind of cobbled together. This mentoring team and it really does kind of take a village, and it's really again those people who are willing to spend time with you and you sort of asking them for what you need sort of getting back to what we're talking about the loud music need like you'd be surprised what you'd get if you ask nicely for it right and so I think that you want to be able to sort of empower yourself in that way so sort of just take advantage of everything that you have at your disposal. During your fellowship. Dr Bennett. Yeah, I think, you know, trying to just be really a sponge and kind of take as much as you can in through fellowship I know sometimes, especially, I think in first year was, you know, a lot of, a lot of months on consoles lot of weekend calls and night calls sometimes you can just kind of get bogged down in the, in the long days of fellowship and we have to sometimes take a step back and realize it's a, it is an amazing time you're having the chance to work with, you know, experts across all different areas you're getting a chance to learn all new skills and have amazing patients to learn from as well and so really it's, it's three years to to absorb as much as you can and connect our system was saying, you know, sometimes you're when you're on night calls, kind of pray to have a quiet call but at the same time that's probably one of the most interesting cases are coming in and and now as approaching kind of the end of fellowship, you're just like thankful to have those moments where you've, you've had, you know, variceal bleeders and food impactions and foreign bodies and you feel a little more comfortable because you've, you've had those and so really just absorbing all that you can in the three years and taking the time to learn with all the different experts that you're, you're center. And Dr. Seisman, final comment. Yeah, I mean enjoy it. It's an awesome three years yeah you're busy learn a lot, but it flies by. So, so taking that time taking those moments, enjoy time with your co fellows outside of work, your colleagues, this is going to be your new GI family. They're there to teach you and are invested in you so you know appreciate that and, and, you know, know that that's your network going forward. I want to thank everybody again. All of our panelists, thank you so much for, you know, being here and giving these excellent tips and suggestions. Thank all the attendings appreciate your time as well for attending this this session here and the endo hangout. It's awesome that you made this a priority of your evening, and we hope you learn stuff. I think all of our emails are available through the SG and there so if you have any questions or anything comes up. I know we're all happy to answer those for you. And I just want to thank the SG and the SG staff for putting this together and this awesome opportunity for all of us. So, with that, I'll say goodnight to everyone, and have a have a great rest of your fellowship. Enjoy. Good night. Thank you again Dr. Epstein, Dr. Ju, Dr. Sisselman, Dr. Bennett and Dr. Cole for tonight's excellent presentation and all of the tips and guidance and how to make the most of your GI fellowship. Before we close out I just want to let the audience know to be on the lookout for the next endo hangout, which will take place the first week of October, we're still confirming the details but it will likely take place right after endoscopy live event on October 8, we will confirm the topic and open registration, just in a few days. Also, check out the quality of the presentation we have added a very short survey to the networking lounge or the virtual platform, your experience with this learning events is important to a SG and we want to make sure we are offering interactive sessions that fit your educational needs. And the conclusion of this webinar if you could just go to the networking lounge and take the survey, we would greatly appreciate it. As a final reminder, is G membership for fellows is only $25 per year. If you haven't joined yet please contact our membership team, or go to our website to make sure to sign up. In closing, thank you again to our panelists and moderators for this excellent presentation and thank you to all our audience for making this session interactive. We hope this information has been useful to you. And good night. Thank you.

Making the Most of Your GI Fellowship

Reddy Akova

Dr. Keith Epstein

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