Welcome. The American Society for Gastrointestinal Endoscopy, Women in Endoscopy Special Interest Group appreciates your participation in this endo hangout discussing the pros and cons of pursuing a fourth-year fellowship. My name is Eden Essex, and I will be the announcer for this presentation. Before we get started, a few housekeeping items. First, you can submit a question at any time online via the Q&A button on your Zoom control panel. Following this event, in about a week, you can access a recording of the discussion, which will be posted in the Fellows Corner on GILeap, ASG's online learning platform. Now it is my pleasure to introduce our moderators for this event. Dr. Shabana Pasha is a professor of medicine and vice chair of the Division of Gastroenterology and Hepatology at Mayo Clinic Arizona. Dr. Mihir Wag is an associate professor of medicine and head of endoscopic surgery and tissue opposition in the Division of Gastroenterology at the University of Colorado. He is also chair of the ASG training committee. I will now hand the presentation over to Dr. Pasha. Thank you, Eden. We look forward to an interactive and informative session with our excellent panel this evening. I'd like to begin by introducing Drs. Rashmi Advani and Yakira David. Dr. Advani is a gastroenterology fellow at Stony Brook Medical Center in New York with interests in advanced therapeutic endoscopy and bariatric endoscopy. Dr. David is a chief fellow at the Icahn School of Medicine at Mount Sinai with interests in interventional EUS and bariatric endoscopy. Rashmi and Yakira, please share your thoughts on any gender-specific factors influencing your decision to pursue a fourth-year fellowship. Hi, good evening, everyone. Thank you so much, first of all, for having me speak for this very important topic with ASGE, Dr. Shahal for having the vision for this very important topic. I remember as a resident when I was not only trying to match into general GI fellowship, I was interested in learning more about the fourth-year fellowship, especially advanced endoscopy since it was a major reason why I decided to pursue GI in the first place. I think having all of us today virtually will help prepare future gastroenterologists, the generation of gastroenterologists in making more well-informed decisions about the fourth-year fellowship. I'm Rashmi, I'm a second-year GI fellow. So there are many factors influencing my decision to pursue a fourth-year fellowship in advanced endoscopy. For one, I have a genuine interest in endoscopy and all of the therapeutic possibilities I can offer my patients with the tools that I can learn in advanced endoscopy fellowship and beyond. I also feel that there are also underlying gender-related factors that have further propelled my interest in advanced endoscopy. For one, I truly believe that there is an increased need for representation of women in advanced endoscopy. And although growing currently, there is a noticeable imbalance in representation of women in GI, and especially for those that currently hold leadership roles in both GI and medicine. Dr. David might mention this study soon, but she had basically conducted a study last year where it is clear that we need to increase representation and become mentors ourselves in the hopes of inspiring other women to enter the field of advanced gastroenterology. I hope that through this talk, seeing our journey as early career female gastroenterologists in advanced endoscopy, other women will feel more inspired and empowered to enter this field. Thank you. All right. Hi, good evening, everyone. My name is Yakira. I want to say thank you to the ASG and the Women ASG SIG group for having this event. It's a very progressive discussion that needs to be had, and I'm grateful for the opportunity and the platform to discuss it. I want to echo a lot of Rashmi's sentiments as well with regards to the importance of this discussion. So as Rashmi mentioned, I did a study last year, really looking at some of the gender-specific factors that influence women gastroenterologists to pursue or not pursue a career in advanced endoscopy. In terms of gender-specific reasons that women might pursue advanced endoscopy, there weren't any gender-specific motivating factors. The factors that motivated women to go into advanced endoscopy were largely similar to those for men, which was largely a true interest in the subject area and the field, and also acquiring more skills that would help them in their careers moving forward. What was interesting, however, was that there were some differences in the deterring factors for not pursuing an advanced endoscopy career. A lot of that centered around family planning, around concerns about radiation exposure in pregnancy, and then additional concerns about gender gaps in reimbursement, referrals, promotions, achieving leadership roles. Lastly, there were also a lot of concerns about not having gender-specific mentors or role models in the field that may have otherwise encouraged women to pursue that field. For me specifically, I'm very much in keeping with the cohort that I'm genuinely interested in the subject area. I am really interested in the therapeutic interventions that we can do in the pancreatic and biliary system, so that's what largely motivated me to pursue this field. I'm originally from Trinidad, and we just don't have a lot of gastroenterologists to start with. What's interesting for me is that I never appreciated that there was a gender gap in gastroenterology, because the main gastroenterologist in the country was a woman. She trained in the era of when ERCP was part of your standard GI fellowship, so she did it all. She was the benchmark for me as to what career I wanted to have. I guess in many regards, I had that role model present, so it never presented a deterring factor for me. I just would say that even though I'm not deterred at all, one of the things that did cross my mind as a potential gender-specific concern in pursuing advanced endoscopy was that prospect of radiation exposure in pregnancy, but on doing some additional reading, especially as I was doing that survey, it was really helpful to see what the interventional radiology societies have done in terms of very specifically investigating the radiation exposure associated with different procedures and radiation exposure that women get exposed to during pregnancies and the different mechanisms that can be used to effectively prevent that. Those are the gender-specific factors that I think have been influential. Thank you, Rashmi and Yakira, for those interesting thoughts. I think we'll add some additional voices to our discussion now by having Drs. Paula Adamson and Andy Tao joining us. Dr. Adamson is currently a third-year fellow at the University of Louisville. Upon completion of fellowship, she will be practicing in the academic setting at Morehouse School of Medicine. Dr. Tao is a partner at Austin Gastroenterology in Texas. He has not done an additional fourth year of advanced endoscopy fellowship, and in his third year, he learned ERCP, luminal stenting, endoscopic suturing under the guidance of a noted advanced endoscopist at his institution. Paula and Andy, the question now is to hear the other side. What are the factors that impacted your decision to not pursue a fourth year advanced endoscopy fellowship? We'll start with Paula. Hello, everyone. I also wanted to thank ASG for allowing me to participate in this panel. I guess when I initially decided I wanted to go into GI, of course, I went in with the intent that I would do a fourth year advanced GI fellowship. I guess ultimately what made me decide not to pursue that after entering into fellowship was more from a personal and also kind of some social and logistics standpoint. The prospect of having to move again for an additional year of training weighed in heavily in my decision. Currently, while I'm doing my GI fellowship here in Louisville, I've actually been long distance from my husband who's been in Atlanta, so that was probably the biggest factor that made me decide to hold off and maybe take some time later on down the line to decide if that's something I want to pursue later on down in my career. Good evening, everyone. My name is Andy Tao. I'm a partner at Austin Gastroenterology. I can give you guys a little bit of my perspective why I didn't pursue a fourth year. Part of it was, and this is kind of from the private practice perspective, I had early on in my second and third year, beginning of third year, already considered the prospect of the job that I was interested in. And much like Paula's consideration, you have to consider your family, where you want to live. Like, for example, Paula, I'm just going to presume you want to live with your husband, so you want to look for a job in Atlanta or if that's where you want to stay, so that's a joint decision. So, real life kind of starts to play a role in there. And I love the comments by the two previous speakers about the reasons that they wanted to do the fourth year was that it was the content, it was the people who provide the therapies. And that's just as important as some of the real life considerations, isn't it? It's about where you want to live. And so, my personal issue was that while I like therapeutics, my wife and I I, my wife, who's from Austin, she wanted to move here and her parents are here and we want to have family here. So, I first started off the question about whether or not I should pursue a fourth year, even though I was moderately interested in it, with where did I want to end up in terms of the job market. And it just so happened that Austin Gastroenterology needed a hospitalist. You guys know what a medicine hospital is, but this is GI hospitals. And so, they needed somebody who could do ERCP, but they didn't exactly value EUS. They didn't value EUS because they already had EUS people. They already had these EUS guys and the entire group would refer to them. And EUS, as any one of the senior panelists can attest to, is a procedure in which you want a lot of procedures done by very few people. ERCP, however, not as strict in my opinion. You don't need that level of volume per se. People's opinions may differ. But that job basically told me when I went to my interview, they said, Andy, we need you to do 200 ERCPs if you can. And if you can only get between 100 and 200, we have a proctor. A proctor, a partner, a senior partner who will watch you do the procedures. He'll build them. He'll rescue you if you need help. But he'll proctor you until you get 200 ERCPs, at which time, as many societies dictate, you can be assessed for independent practice of ERCP. And so, that was what drove me to just hustle and get those ERCPs in my third year. And I was lucky because I had good mentors and very, very high volume ERCP centers in the Texas Medical Center all in one fellowship. And the last thing I have to say, not to be too private practice oriented, but there's an opportunity cost measured in dollars with pursuing an additional year. Now, you may say, oh, it's just an additional year of your first year of practice. Or maybe you'd say it's the additional year of the end of your practice. But if you really think about it, in the beginning of your practice, you're ramping up. And at the end of your career, you're ramping down. And no matter how long your career is, those ramp up times will probably be the same. So, in fact, the additional year that you take will be at max salary, at your most productive years. And so, you do have to consider that. Gosh, I don't want to be that private practice guy, but I feel like I have to speak the truth about real life. And there it is. Thanks. Thank you, Andy. So, I think I'll chime in here a few comments that come to my mind. I think this is a personal decision. We are hearing this from all our panelists. There's no right and there's no wrong. It's a personal decision. And I'll give this, I'll say the same thing what I say to college students when they're asking me, should I go into medicine? And the answer is, you should not go into something because someone else wants you to do it. You should do it if you want to do it, because this is going to be the next, I would say, 30 years of your life, or maybe 40 years, depending on what you do. So, if that's what you're going to do, you better like what you do, because otherwise, you're going to be frustrated and you're going to regret every day that you're doing ERCPs or whatever that you decide to do. So, I think I'm hearing, and my own experience was that it has to be your personal decision, maybe with your family and make that choice, but you should think about it. There's pros and cons, and we're going to go through the rest of this webinar, talking about all of that. And Andy, you bring up a good point about the prime of your career when you're earning potential and so on. The other side to that is that some people would think that my earning potential actually will go up if I do something, or it may not go up. So, I think there's a lot of factors that come into this, and we'll keep going, but I think that's my personal take on it, that it should be your decision with the people around you and make that choice. And we'll talk about whether it's necessary to do a fourth year and so on as we go along. But Shabana, any thoughts you have about this? Thank you, Mir. Yeah, it was really interesting to hear all the different perspectives. So, speaking from a standpoint of someone who hasn't done an additional fourth year, I would say the ultimate decision whether or not to pursue a fourth year, I think, depends on what your interests are and also some of the opportunities that are available to you during your fellowship. So, in my case, I think I realized very early on that my primary interests were IBD, colorectal neoplasia, and small bowel enteroscopy. And I was very fortunate to have mentors and resources to pursue some of that required training during my three fellowship years. So, I purposefully chose electives that allowed me to develop my skills in deep enteroscopy and therapeutics. I did a dedicated three-month off-site rotation in IBD where I worked with several IBD experts. So, I think my advice that I have for fellows is try and identify your interests early on if you can during fellowship. And I think communicating with your program director, your mentors is key. And then trying to, you know, seek out and availing of any opportunities both within the institution as well as, you know, I know ASGE, several other GI societies offer excellent courses. So, kind of learning through that. And then if your passion is advanced endoscopy and if the right opportunities are not available during your three years, my thought would be I think pursuing a fourth year is certainly worth the time and investment in the long run. So, now I think we'll move on to the next section. So, I'm going to welcome Drs. Shalini Suklal and Dr. Thomas Rangia. Dr. Suklal is an advanced endoscopist at Kaiser Permanente in Seattle. She completed a gastroenterology fellowship at Drexel University in 2018 where she served as chief fellow and then served, she stayed on at Drexel University in a combined gastroenterology faculty position and as a fourth-year advanced endoscopy trainee. She then completed a formal fourth-year advanced endoscopy fellowship at Cleveland Clinic. Dr. Rangia is a therapeutic endoscopist and assistant professor of medicine at the Ohio State University Wexner Medical Center. He's gained significant training and expertise in emerging endoscopic therapies through extended fellowships at Johns Hopkins and UNC Medical Center at Chapel Hill. So, please share with the audience the factors that impacted your decision to pursue a fourth year. And Shalini, please start us off. Good evening, everyone. Thanks to USG for having me. So, I feel, you know, my sentiments pretty much, you know, matched the main reason that, you know, the guys who did pursue a fourth-year mentioned, which is just passion. You know, it was something I always loved, biliary pathology, even from, you know, first year of fellowship. It was a biliary pathology that really got me. And then as I started to do procedures, I noticed the things that really excited me was finding like a massive polyp in the colon. That was like the highlight of my day, you know, and just kind of seeing, you know, how you're going to tackle it. And then when we moved on to doing underwater, I'm like, oh, this is so, this is amazing. This is really cool stuff, you know. So, I think it's just really that that interest started really early on. And then kind of, you know, when I found myself just, you know, sneaking off at lunchtime instead of eating your lunch to try to get into an ERCP and see if they'll let you touch the tome, you know, or let you see if you can get close to the papilla, you know, those are the kind of things I was like, you know, this is really, this is really my passion and really what excites me, you know, and definitely something that I feel like this is what gets you up in the morning every day and makes you want, you know, to do this more. I also like that, you know, these cases are challenging, yes, from a procedural perspective, but also I feel that there is a cognitive competence to this, which we don't always think about, which is, you know, a lot of these times, these cases are complex, they're failed cases that come to you, and you always have to think about how am I going to approach this differently compared to the last person if it's a failed case or what other devices am I going to use? What techniques am I going to try? What am I going to do to make this successful? And I feel kind of like, what's your plan B and your plan C if plan A doesn't work? So I kind of like that kind of cognitive aspect to it too, which I feel, you know, we don't always think about. You know, variety is a big thing, you know, not every case is the same, you know, it's not always going to be small polyps or, you know, an easy papilla or a simple, you know, pancreatic lesion that, you know, it's always different. You don't know what you're going to find when you get down there. And I feel like, you know, just the kind of the excitement and the unknown is really, really interesting. The instant gratification factor, I feel is huge too, you know, so, you know, you have a patient in severe abdominal pain, fever, and, you know, you have cholangitis and you remove the stone and boom, like within, they wake up from the procedure and they're like, well, I don't know what you did, but I feel amazing, you know, or you drain a huge pseudocyst and they wake up and they're like, you know, it's night and day in the weighted field. So I feel, you know, there's really that feeling that you made a difference. You really did something good today, you know, which I feel is a huge thing. And I mean, you know, from the practical side too, this gives you an additional skill that, you know, not everyone has. So, you know, it kind of helps you tackle, you know, a little bit more confidently, whatever shows up on your doorstep and, you know, potentially could make you a little bit, you know, more marketable in maybe a large city or, you know, oversaturated market. So, yeah, I think those are kind of the main reasons that I chose this. And mentorship was huge as well. You know, although there were no female advanced endoscopists in my program, my program director in my GF fellowship was a woman and she was very supportive. When I told her I wanted to advance endoscopy, she was like, well, there is no reason why you should not, like, why is that even a question? If you should, you should, obviously. And, you know, she really helped, you know, to, you know, kind of tweak my rotation schedules. I kind of have that flexibility to get in as many cases as I can, to kind of present at two more boards, to, you know, really interact with the advanced faculty. And I think, you know, that kind of support and backing is everything, you know, when you're trying to, especially as a female, do something a little bit unconventional. Okay. So I will tag along there with my perspective also. And thanks to everybody for tuning in tonight. Why do a fourth year fellowship? I think you could do it either way. And I think it's great that we have Andy's perspective on here as well as everybody on this panel, because we'll all look at it in a similar way. And I think everybody is having some of the similar, the same thought processes as they go through this. Why did I do it? I thought that if there were more things that I could do, that I would have more, I had a more wide open playbook, if you will. If there was an endoscopic solution for a patient's problem, I wanted to be able to offer them that. I didn't know early on that there was such thing as doing it all in advanced endoscopy, but I discovered there were some superhuman people, not me, in the world who can come close. And I thought that I wanted to shoot for that and see what I could get accomplished in an advanced fellowship that I couldn't get accomplished necessarily in a general GI fellowship. And it really does depend on what you're exposed to in general GI fellowship too. I was lucky to get about 150 ERCPs in my general GI fellowship. But of course, there are places, we had an advanced fellow, but we had relative, a higher number of advanced docs compared to the fellows who could do those procedures. So there was always stuff available. There are some places also that don't have an advanced fellow at all. In those places, you can really get pretty impressive numbers. Wake Forest comes to mind, but there are some out there. A lot of things, I mean, people who you work with shape you. And so, and faculty that you learn from shaped me. You know, one of the doctors I trained with was Todd Barron and he had a real thing about not being a one trick pony. And I think he sort of, I sort of assimilated some of that into my thinking as to trying to, I wanted to make sure that I wasn't just someone who could just do one or two things and just to be able to sort of offer as many things that, you know, however many that would turn out to be, I didn't know, but it seemed like the Advanced Fellowship was gonna be where I could pick those things up. Things I learned over time that sort of, I think can affect this decision for people, hopefully are helpful in some way. Hepatobiliary GI is just an interesting topic area, as many people have said. ERCP is a hell of fun procedure and it's satisfying and gratifying as others have said also. With EUS, which I did not feel like you could accomplish or you could get good training in a single, or sorry, in a GI fellowship without an advanced year, you can really do a lot. You can sample, you can drain, you can divert, a lot more applications for that than I first realized. And then of course there's what I call, or what you can call the non-hepatobiliary category of therapeutic endoscopy. So that's like third space endoscopy, bariatric endoscopy, other areas that are emerging and things that I felt very little exposure to in general GI fellowship for the most part. But I think all those things are sort of the academic, or compose the academic compartment of it. And the sort of, those are in some ways made in elements that are part of a vacuum based decision. And again, Andy's perspective on making decisions on real life is important to remember. And Dr. Wagh alluded to this also, that it's just a decision. We have to weigh all those things and it's not, you don't get to just have one basket of stuff and forget about the other basket. You have to be happy with the mix that you end up with in the end. Thank you both for sharing your experiences, perspectives and how mentors have shaped your decisions. Yakira, can I loop you in on this discussion now? So I wanna echo a lot of what Shalini and Thomas said before. Again, a lot has to do with interest in the subject matter itself. And as Shalini alluded to, I really appreciate the cognitive aspects as well that a lot of these cases bring with it and the interdisciplinary discussions that you end up having. And what particularly fascinates me is the innovation that goes into a lot of these procedures. Oftentimes there's no standard playbook that exists already for a particular problem. And you have to sort of figure it out and innovate on how to solve the problem sometimes on the fly. And I think that's a particularly, I like that, I really appreciate that challenge. And that's a big driving factor for me. In addition to that, I have a little bit of a atypical career sort of anticipates that I'm hoping for. As I mentioned, I'm from Trinidad. The English speaking Caribbean does not have advanced endoscopy as a thing at all. There are some older endoscopists who are grandfathered into ERCPs, but EUS is non-existent and there's a huge need for that. So I'm hoping to ultimately grow that aspect of advanced endoscopy in the Caribbean and bring that service there. Because at this point in time, a lot of things that are pretty routine for us go to surgery or you just die. And a lot needs to be better in terms of the care of those patients. So I'm really hoping to do that. And particularly as I'll be going into a space where there isn't much experience there, I need to be very, very competent when I go back there because there's no backup, there's no one to prop to me. So for me, doing a fourth way seems like a really important investment for the career that I have planned ahead of me. In terms of mentorship, our advanced endoscopy team, we have five advanced endoscopists at our hospital, four of which are men. And I have to say that they've been incredibly supportive of my career and anything and everything that they can do to help me along that career trajectory, they've been there for me. Great discussion. I'll just add a few thoughts that came to my mind in listening to this most recent discussion. The reason some of us do an advanced endoscopy, and at least that was true in my case, is that doing advanced procedures not just allows you to do those procedures, but your comfort level to do general procedures goes up dramatically. And I just noticed that in my fourth year itself, and I'll give you this example. I say this all the time when we have interviewees and candidates asking similar questions about how much of their advanced endoscopy training are they doing general endoscopy? Because some fellowships require you to do that. And I used to spend one day a week doing general endoscopy and then doing interventional cases as a fellow for the rest of the four days. And I found that as the months went on, when I was doing general cases, I mean, my threshold to take out all these big polyps and do all the stuff started becoming... Threshold went down and I would start doing it all by myself. And I knew there was no one with me at that time. So that's one thing that comes from doing an advanced year that you can start, you do things even general, EGDs and colonoscopies, you're a lot more comfortable. You can do small, fine movements. Sometimes there's like a sharp angulation somewhere and you can make those movements because you've learned those kinds of maneuvers doing other procedures. That is one. Hemostasis, GI bleeding, that's the bread and butter of what gastroenterologists do. And I'm now in a little different situation. I do third space endoscopy where bleeding is part of the procedure. When you do a POEM or ESD, there will be bleeding. It is not considered as an adverse event if you stop the bleeding, right? Because when a surgeon cuts, there will be bleeding the same way as an endoscopist, when we cut, there will be bleeding. So if there's bleeding, you'll have an arterial spurt and we'll be able to say, yeah, we can stop this. We know how to do this, right? And we'll control that bleeding. And when I look back as a general gastroenterologist or as a GI fellow, your heart rate goes up when you see that arterial spurt from an ulcer, right? So that kind of comfort level starts coming once you start doing some of the more complicated cases as well. I'll also add one last thing and then we'll move on. I know that Eden might be looking at the clock here since I'm just going off on a tangent here. So the last thing is, yeah, you can always stop me by the way, Eden. So what I was saying is the other thing is you can use tools that are used in the interventional world to do general GI procedures. And I'll use food impaction as an example. All of us as gastroenterologists, we hate it coming in the middle of the night, taking some food bowl out and sometimes it's jammed and we don't know exactly the best tool to do it. But as an interventionalist, you've dealt with baskets, you've dealt with stone retrieval balloons, guide wires. There's so many different things that you can start using. So I think those are other reasons that I consider when I started doing this is like, oh, now I can use this. I don't, I'm not stuck. And hopefully you'll be able to bail yourself out of that situation. So that was some of that, those were some of the reasons I went into this field, but we'll move on. Shaleen and Thomas, let me ask you our next discussion question. What do you find are the challenges working as a new advanced endoscopist staff? And are there any gender specific challenges? Thomas, why don't we start with you? Sure, yes. So this is a great question and what's rolled into it is of course, just starting as a new attending. Plenty of steep learning going on as a new attending. And I can say that myself, but everybody who I talk to, just like I sort of, the way I phrase it to GI fellows or residents interested in GI is that every year that I've been like a first year of whatever it was, fellow, advanced fellow of resident around the middle point of the year, you're like, who am I gonna make it through this year? December, January, it's like getting dark, like four o'clock and you're like, this is like sort of the dog days of it. And it feels like more of a grind than it does the rest of the year. And that's been the same for me. Like there's a steep learning curve with any new job. And as an attending, there's some special considerations for me that come up, but I think it's common to a lot of people. People question you as an advanced attending more so that maybe possibly than a general GI doc who you might be doing EGDs, colons, pegs, as an academic GI, general GI doc in endoscopy at least. And for me, I was doing things, I am doing some things where people weren't doing them before. So nurses maybe are using the endoscopic suturing device for the first time in a procedure that we're doing. And it's a little stressful, more stressful than if someone is with you or two people are with you who've used it before, then everything's going smoothly. Or same thing with a U.S. gastrointestinal ostomy. For example, I answered a question the first time I did one of those about five times about whether it was a replacement or a new GJ tube, like a pig J. And I was just getting people, trying to get people to the same level of familiarity with things that were just running like smooth as could be in fellowship. And then you go to a place where it's less familiar and that's a challenge and adds some stress. And some of it too is whether you stay at the place where you are for your job and there's synergies with that or do you go to a new place and then you got to learn like all the new job stuff, where do you get a coffee? Where do you pee? Where do you park? All those things add to it. And there's the commonly cited one, which is no one's behind you and gonna bail you out. If you get yourself into a pickle, everybody's looking to you and it's like, okay, well, I guess it's time to buckle down. The other thing I'll say is that everybody's experience and sort of, I mean, I think of people's aggressiveness, if you will, on a spectrum, even an advanced group, there could be a very wide range within the group as to people's aggressiveness or conservativeness. And so you have to sort of mesh like a family and that is not, no one really tells you how to do it. There's no real rules. You sort of have these discussions about what to do with complex cases and you identify where you are in that spectrum. And for me, I'm on the more aggressive side, but then there's people who have been doing it a long time who are on the other end of the spectrum and you sort of have to find this happy medium. So those are some challenges for both genders. From the standpoint of gender, of course, and I'm not gonna be the best one to speak on this without personal experience, but I can say that this is an exciting time for women to enter this field and lead this field. Divisions are looking for that across the country and it's definitely a transformative time in medicine generally, in advanced endoscopy as well for these issues where inequities and gender-related issues are being explored time and time again and only going to get more and more important. Thank you. Shalini, you wanna comment on this? Yeah, so I would say, I guess one of the biggest challenges is gaining your confidence. I felt very well-trained coming out of a fourth year fellowship, but then reality hits and you're on your own and you're expected to do this. So I felt like the what-ifs, the what-ifs get you. What if I'm not able to cannulate? What if the axios misdeploys? What if this case takes three hours and the end of staff labels me as one of those who keeps them late every night? What if I ask a colleague to help me and then they think I'm not good enough? So I feel it's just combating all the what-ifs and really just kind of having successes and building on that and really just gaining your confidence as the months go by, I would say is really the biggest challenge. And in practical challenges, I felt like just adjusting to new equipment was a little bit of a challenge. Like for example, all my training thus far was on Olympus devices and then they use the Fuji equipment here. And so it's just differences in the equipment, you're just getting used to different, the EOS views and switching from like a short wire to a long wire system and getting used to, you probably had a favorite stent before and they don't stop that here and you have to find a new favorite. So just kind of adjusting to differences in equipment that you've gotten used to, that you were comfortable with and hey, now suddenly you have to find a new one and a new way to do things and be comfortable with that. And then regarding, I guess, gender specific challenges, to be honest, I cannot think of any that just being a female advanced endoscopist was more challenging. I don't think so. I would say definitely though, there was a lot of curiosity when I started, both by male advanced endoscopist and the endo staff. Sometimes the staff told me, I never knew there were female advanced endoscopist. I didn't know women did advanced endoscopy and I remember one of my first ERCP procedures, I'm just doing my case and then I look up and there's like a line of people in the back of the room and I was like, hey, where did this crowd come from? They're just kind of curious. They wanna see what you're doing and kind of what your skillset is like. But I feel like after, as time went on and you just continue doing what you do, the excitement kind of died down and it went back to business as usual. Thank you. I'll just say one thing that always comes up when you have a new faculty member or new staff endoscopist and they ask you, I'm nervous and that is normal, that is natural that now you are on your own. And what I tell a new person joining our group is that, or if they're going elsewhere, to remember two things. One is you don't want to really have any major adverse events in your first six months or one year in the new place because people are watching you and they say, oh, so-and-so is an intervention endoscopist or so-and-so is coming from this place and they say he can do this and or she can do that. And they're watching. And I think it is better to be careful and cautious and choose the right patients with the right indication. It may mean you do one less ERCP, but that's okay. If you choose the right patients and you do it carefully for the first six months or a year or maybe even a little more than that, people start trusting you after that. And then you can start taking on some of the more difficult ones. Now, often we think that when I was a fellow, we would do this all the time, but it's different as a fellow because you have that senior person with you who signs that note and who takes responsibility for everything. So I think that is one thing that I tell fellows. And often I will also tell them when they're getting their first job, often look for a place where you're not really the only one who can do that. Because no matter what, even after many years of doing this, we still ask each other for help and we'll get a senior person or sometimes not a senior person, just someone else, a second pair of eyes to come in and say, hey, what do you think this is? Should I take this out? Should I cut more? Should I stop? And it's always good to have that one other person who can help you, guide you and mentor you through your first few years. And I would just add to that too, whether it's advanced endoscopy or general GI, I think when there's a new faculty joining, I think just the senior or the more experienced endoscopy is just popping their head into the room and saying, hey, I'm here. If you have any questions, I think that makes such a big difference and it's such a confidence booster. So I think in the interest of time, we move on to the next question. I'd like to ask Andy and Thomas for their thoughts on the necessity of a fourth year training to be competent in ERCP and EUS. And Andy, would you mind going first? I think Thomas touched on this earlier. I think EUS requires a full year, hands down, no questions asked. I know ASGE has efforts to teach people to do EUS in an extended course. I think that is a nice endeavor, but for the most part, for the average person, I think it requires a full year. And particularly, particularly, if you're planning on doing therapeutic EUS. And remember, so much of gastroenterology is the doing part, is to be able to land the target, cut the polyp, but it's almost more, especially at the advanced level, about training your eyes, about being able to recognize what you're seeing on EUS and what you're not seeing. And I don't do EUS, but I know that that is where the limitation is. And I tried in my third year when I was hustling to get those 200 ERCPs. I thought about splitting my time when I was running around for ERCPs to maybe get some EUS, but I quickly realized that that skill is gonna take a lot longer. It's gonna take a lot longer. And so personally, no, I don't think EUS for the average individual can be learned in the third year, unless you do not also learn ERCP. I don't think both can be done. Not by, some can do it, but by the average person, no. I'll give you one example of someone who did break that rule that I just mentioned. And it was my mentor. His name is Kalpesh Patel at Baylor St. Luke's Medical Center. He trained at Mount Sinai. And his third year, much like mine, none of his colleagues, none of his third year fellows were at all interested in advanced endoscopy. And there was a whole year for him to do EUS and ERCP. And there was plenty to go around. And so he actually managed to do it, but he honestly told me that he didn't really get that good at it until a few years into practice. And so the bottom line is, no, I don't think EUS can be done ERCP, I think yes. Many more people will show that they've learned it. And as you guys have mentioned, back in the heyday, people were learning EUS, I'm sorry, ERCP as a standard practice. I do believe though, that you need to be the right person in order to pull that off. You have to be a very enterprising person. You have to be someone who thinks a lot about the procedure before and after you begin. You have to do, you have to have the right mentors that you can ask questions to very readily. You cannot be, in my opinion, you cannot do an ERCP, you cannot do ERCP unless you have resources around you that you can kind of debrief with and think about afterwards. You have to be contemplative about the procedure. It's not just a do, do, do procedure. And if you don't have that on the front end in your third year, and you don't have that when you go to practice, like in my private practice, I had someone who was there for me so I can debrief and discuss. Sometimes he'd even come into the room, which in private practice, you don't try to like have two doctors in the same room, it's a waste of money, right? But he would come in and he would watch and he would say, yeah, that's good technique. Or, hey, you know, I do this different. So I had a mentor there. And if you don't have that, and you don't have the personality to think carefully about the procedure before and after, then I think it's not the right choice. I think you should be careful because you can really hurt somebody. And so it takes the right personality and it also takes the right external resources. Thomas, what do you think? Yeah, I think you're dead on. By some token, we're all sort of a, like I think I alluded to this and Andy did as well, we're a function of the environment that we're exposed to. And so if you go to a place, and there was a co-fellow of mine in advanced fellowship who the deal was they had two advanced fellows in his GI fellowship and you don't get in touch with scope, you don't get any real exposure to advanced stuff because it's all gobbled up. And then you come into advanced fellowship and that's where we start, which is even a hard place to start advanced fellowship, but it can be done. The more you can get your hands on the better. And I think by definition, you don't have to do advanced fellowship to be competent in the US and ERCP because there are opportunities outside the US, but it's just like how logistically complicated can you make it for yourself? The ERCP is more sort of intuitively understandable because it's endoscopic visualization, whereas the US is a whole different sort of ball game and grasping it takes a while. So it's harder to pick up and I sort of agree with that idea. I was 250 or 300 EUSs deep before I even sort of became able to grasp it and Dr. Wogg and Dr. Wani over at Colorado have a nice study on that, where just getting competent in EUS just takes a lot. And there's all sorts of different, EUS is not a uniform thing. There's all sorts of different areas of the body and staging and all this things you need to know that are, it's not just the procedure. It's the why and what are we going to do with this information as well. The, you know, again, like places where you can get your hands on stuff earlier, it helps, I think. Like I said, I was fortunate to be able to do that and I was trying to wedge myself in. I mean, I basically, I was thinking back as we were talking about, Andy and others were talking about the exposure they had to the mentors earlier in their training. And I remember basically begging Todd Barron, like just, I was like working on the confidence to ask him one day, like, please just teach me how to pass the duty, let's go to the papilla. And then one day I was like, can you just show me what your approach is? And he drew it out and he explained it to me. And then after that, I was trying to master it and I was like, damn, I couldn't get past the EUS. Okay. Next time, try to go get into the stomach. And then next time try to get, you know, to the papilla and just, just one thing after another and, and all those steps just take time. And it's really more of the time and the reps that you need. And I totally agree with the idea that it's not just the procedure. And sometimes that is not, that's not uniformly understood by folks. It's the whole thing is what are we doing for the patient and why. And with EUS, it's just such a broad thing. So it's, with ERCPs, some people will stick to say, you know, biliary ERCP, or you can say, okay, biliary. You can do both biliary and pancreas and, and live in that world. And much, it's much easier to do if you have, like more people can do ERCP, so you can find a proctor easier than someone, you know, who's trying to EUS on the fly, which it can be done. And the more well connected you are, especially with, you know, people at your institution, you can have, you can go to India, you can go to Asia, South America and have exposure. It's not as much of a pressure cooker environment. You're going to get a lot of stuff rammed into the fourth year that you would not otherwise be doing in your life. Like it's hard to, you know, it's hard to up and leave the country for a while, but you know, it can be done. Thank you. So I, I'll just say that I have a little different take on, you know, some of what we heard. And so the question was, do you need to do a fourth year to be competent in ERCP and EUS? And I think the question or the answer to that is not whether you need a third year or fourth year, whether you need to go overseas. The answer to that is you need to be trained to competency. It doesn't matter how it's done. It's training to competency. And that's the big change in the culture that's happening in, in endoscopic training, even in, in, in medicine, you know, it's all about competency now. It's not about the numbers that, you know, everyone says you need to do 200, 300 of this and that, that is actually not how we should be thinking about it now. So the question is, if someone wants to do ERCPs, it's not whether they need to do a fourth year to be able to do ERCPs. The question is, will they be able to do enough, whatever that number is for that person to be competent. And that means someone senior has to evaluate them on an ongoing basis with continuous feedback. It's not like you just do so many ERCPs and at the end of it, you know, your advanced director signs off on the certificate. It's not that. It's about every, you know, we do it at our institution, every five or 10 ERCPs and EUSs, you get evaluated and there is a TSAT score that we have, and you keep doing it till we think, yes, you can address the papilla, you can cannulate, you can do a sphinctrotomy, you can identify EUS structure. So I think that's the message I would like to get across to, you know, people listening in that it's not about when to do it, where to do it. It's about, if you want to learn a skill, then you need to learn to competency to be able to successfully do it independently. So that's the first point, you know, I'd make. And from the training committee, we recently, you know, we have a paper coming out in GIE. It should come out pretty soon. So I encourage you to read it. And we looked at advanced fellowship training, what experiences advanced fellows have about their training, their job prospects, and so on. And one of the things we found there is that fellows felt that they were more comfortable with ERCP during their advanced training, but were a little less with EUS. And I don't think it's a technical or non-technical, I think it's a cognitive side to it. But with EUS, you can miss cancer, and that's what fellows and trainees are afraid of. They're afraid that they're going to not see something on EUS. And I think, again, that comes to the same competency. And someone mentioned on this panel right now, that you really don't learn the procedure or get good at it, even during your training. It's the first two, three years on your own. That's when you learn a lot. So I think it's a learning process. We're still learning as we start independently doing it after training. And we get more and more competent even after hundreds and thousands of these cases. And the last thing I would say is that if you need to learn something, it's not a 12-month period or a one-year or six-month. I think people go to various places and do a short, quick course of 200 cases in one month or something like that, and they come back. I also think there is some truth and some value to having a one-year training period where it's not just ERCP and EUS. You're dealing with different attendings, with different pathology over and over again. You're dealing with surgeons. You're dealing with pathologists and interpreting that. And all that, you're dealing with fistula closures, which is not really ERCP and EUS. And all that kind of shapes your interventional career. It's not just, I want to learn one procedure, and I'm going to learn it in one month, get competent and be done. It's okay to do that, but there is some value to that 12-month period or six-month, whatever that time is where you're part of this program, there's a lot of people, and that's what you do day in and day out, and your mind starts thinking like that. And I think just knowing how to talk to referring physicians, how to talk to surgeons, and dealing with all of that, I think comes from a longer period than just hammering out a certain number of cases. So I think I'll stop here, and we'll move on. Next I'll move on to Yakira and Shalini. As women advanced trainees, what did your CV look like? What did you do to match at a program? And Yakira, you can start first. I'd like to think that my CV looks just similar to anyone else's CV applying for advanced endoscopy. I don't think there's anything gender-specific that was different about my CV. Again, as I mentioned, I have a lot of interest in the pancreas system and therapeutic interventions for that, so my CV highlighted research that I had done in that area, so a couple abstracts and manuscripts in progress, as well as a couple of different presentations at some of the societies like NISGE as well. I guess the other things that may or may not have influenced my CV for advanced endoscopy specifically is that I highlighted the other interests that I have. I have an interest in health disparities both at the patient as well as the provider level, hence that paper that I did with the gender-specific factors for advanced endoscopy. So my CV really just highlighted a lot of the research, the presentations that I had done, and I think a huge component, which was not my CV specifically, but the lessons of recommendations that I got from all of my advanced endoscopy faculty at my program, and I think that was pretty helpful in making me a more competitive candidate. I think that's interesting because I think my approach was probably a little bit different. You know, I looked at it as if I have to try to be competitive, I have to try to stand out somehow, you know. I didn't have 100 research papers, you know, and I felt like in terms of research, I felt everyone has research, you know, everyone has a couple of publications and does DDW presentations and everyone is a chief fellow. You know, my approach was, you know, how could I highlight other things, you know, to try to, you know, stand out from the crowd, you know. And you know what, it kind of goes back to just, I feel, trying to be very involved in anything that comes my way or anything that came my way during GI fellowship, I wanted to be a part of it, you know. So, I mean, I feel the first thing was I tried to highlight any kind of society involvement that I was, you know, anything that I was involved in society-wise or any kind of awards that I got. So, I was part of the ASG LEAD program, which is, you know, a leadership program for women. So, I included that and I really like, you know, making videos and I had won the ASG community outreach award for a colorectal cancer award for a video I had done, just a patient information video about colorectal cancer awareness. I got a video GIE award to just cover publication, you know, grant fees and all that because one of the videos I did, you know, was the editor's choice video. So, I highlighted all of those things. I won an ASG SCOPE award because I was just really involved, you know, we had undertaken some outreach in Philadelphia in a Jehovah's Witness population, just really spreading colorectal cancer awareness and in a kind of a marginalized population. So, you know, that resulted in a SCOPE award. So, I kind of highlighted those things. Other things I highlighted, again, not necessarily related to advanced endoscopy, just trying to show that I have a genuine interest in GIE, you know, quality improvement projects. I felt that, you know, quality improvement is a huge thing and I noticed in the interviews as well for advanced endoscopy fellowship interviews, anything QI I felt was a great talking point and they asked a lot of questions. So, we had done, you know, a QI project and I kind of led that project where we kind of revamped our entire bowel prep process. We retrained the staff, you know, standardized our prep and redid our handouts and we were able to show by numbers how we really improved our, you know, numbers in terms of good preps. And I just try to highlight any kind of unusual or kind of quirky and interesting things I did too. So, like I had done some work on cannabis and its effect on esophageal manometry. And again, this has nothing to do with advanced endoscopy, but advanced endoscopist did ask about this during interviews because they just thought it was really cool, you know, and it was underreported. And another, you know, unique thing, we kind of partnered with the psychology department and, you know, we kind of, you know, managed unusual conditions together. Like, for example, rumination syndrome. So, we had a rumination pathway and managed patients that way. So, I kind of tried to highlight those things on my CV. So, to kind of stand out from the crowd in a unique way. Thank you. That was wonderful. And I think there's a question on the Q&A which pertains to this. So, I'll take that. And the question was, what am I looking for in a candidate when they're applying? So, I'll give you my thoughts on that. And, you know, as you said, most of the applicants have all those boxes checked off that we are, you know, that the panelists mentioned right now. You know, they have, they come from good institutions. They have good letters of recommendation. They have research publications, DDW, you know, posters or oral presentations and so on. So, what is it that, you know, sets someone apart? And in my mind, one of the things I look for is how reliable is this person from a work standpoint? And I think reliability for me and for many of my colleagues, you know, we often, as faculty, when we're evaluating our fellows, this reliability question comes up all the time. And, you know, what we're looking for is the fellows are our eyes and ears, right? Because they're doing all the work and helping us manage these patients. And if we tell a fellow that, you know, I'm a little concerned about this one, can you make sure he gets an x-ray or a CAT scan? If I have to go back in the afternoon and say, hey, what happened to that? That's not the way we want it to function. We want it where, you know, we say, and the fellow follows up and comes and tells us, you know, I made sure the CT is done. There's no perforation. It's a reassurance for us. It's the right thing for the patient. So, I think reliability is one thing. And making sure that you follow up and close the loops is very important. And we get that from, you know, just talking to the fellow, reading the letters of recommendation. And most often in the world of endoscopy, we know each other across the country, right? So, if we really have any questions, we will often talk to their mentors, the ones that have written the letters. And you'd be surprised. Sometimes you get some very different opinions when we talk to them, as opposed to what's written in their letter of recommendation. So, I think all of that factors into deciding, you know, who's the right fit for that position for that program. Shabana, do you have any thoughts about the right applicant? Yeah, I would absolutely agree with you on that, Mihir. I think, you know, you mentioned commitment, dependability. I think they should have shown some track record, obviously, in research publications. And also, I think leadership skills, right? It doesn't have to be anything formal, but some commitment towards leading towards change. I think since we are kind of running out of time, I'm going to move on to the next question, because I want to make sure we sort of hear this next segment, which is going to be really key. So, I'm going to turn it over to Rashmi and then Paula. So, basically, why don't you share some of your thoughts on the barriers that you've either considered or experienced while contemplating a fourth year of training? And then after that, we'll go over to Andy and Thomas. Sure. This is an excellent question that I hope will help clear up some questions regarding the perceived cons or barriers of pursuing a fourth year fellowship. So, in my mind, I like to separate them into general barriers and then gender-specific barriers. Gender-related, I mean, general-related barriers, I think everyone kind of touched upon, you know, aspects of this. You know, it's an extra year of training. You know, it's an extra year where you're being compensated as a trainee. So, people who do have financial responsibilities definitely have to think about this a little bit further. You know, there is a learning curve, you know, having enough cases to, you know, EUS, ERCP, feeling confident enough to go out there and, you know, do these procedures. That's something that definitely crosses my mind. You know, and this is something that I've heard kind of, you know, through the grapevine, but, you know, there's a... I mean, I'm currently applying, so I'm a second year, so I don't really know too much beyond this stage. But I, you know, there are concerns whether there would be the optimal job market, where you could practice your expertise, you know, what your patient volume will be like, what will you be able to have the tools at your disposal that you need to perform these procedures. So, and the support staff, I think, you know, these are all parts of potential thought, like barriers that one can consider, and whether you'd be able to perform those procedures in your ideal geographic setting. I think from a woman's perspective, from a female perspective, there are several perceived barriers, but I think as the landscape and advanced GI is changing, so are these perceived barriers. But, you know, one of them that Yakira spoke about earlier was, you know, the exposure to radiation, and how that affects overall fertility and or childbearing during fellowship. I think this really is an interesting concept, because I was actually just part of a discussion on an Instagram Live earlier this week, where I had the opportunity to speak with brilliant gastroenterologists who actually contributed on some of the data behind this. And it turns out that with the right protection, the degree of exposure to radiation is not significant, and even while pregnant. This ends up being, you know, something that we do need to study further and on a larger scale with more definitive data. But I think, you know, that's something that we are overcoming in terms of a barrier. The following points, I wouldn't say this is a particular barrier per se, but it does pop up in discussions. It is being recognized as the advanced gastroenterologist who is competent and skilled enough to perform these procedures on patients who are very critically ill with relatively higher risk, higher complication profiles. You know, I think this kind of originates from the fact that many patients haven't seen many female gastroenterologists, let alone advanced gastroenterologists, advanced female gastroenterologists. And sometimes this can also translate to our own colleagues. Inside and outside of GI. And I think this goes back to basically increasing representation in the field itself, like everyone has mentioned. I am going to bring up another topic and maybe this resonates with some of you or not, but from my discussions with very early career female medicine and GI physicians, there's a very real reality of this concept called imposter syndrome. And, you know, for those of you who haven't really heard of this term, it really mainly affects higher achieving people who find it difficult to accept their own accomplishments and have a feeling of like not belonging where they are. And it's usually characterized by self-doubt. And usually, you know, people cannot realistically assess their own competence and skills, even though they receive all the praise supporting their competency. And this actually happens in both men and women physicians, but does through data has been shown to occur more in women physicians. So I think that's something that we have to address over time and be comfortable expressing this with our colleagues and have open discussions regarding this. And I think the last part that I do want to mention is, you know, eco-compensation does also cross my mind. And to me, what is compensation? The way I look at it is, it's an objective monetary measure of how our skill and competency are perceived. And we know from countless data that even including the 2017 JAMA study, that women physicians have excellent patient outcomes. So, you know, maybe some of you have some thoughts on how we address this head on, but a thought that I have is that there definitely needs to be more transparency between men and women at the same career stage and position with equal caseload who are compensated and what tangibles are being accounted for. And I think it's important to be treated with the same respect and confidence in our abilities. And if that translates to, in addition to so many other factors, but equal compensation, that's similar to male colleagues, then that is crucial in my eyes. Thank you. I would just agree with a lot of the things you just mentioned there. I think some of the barriers that, or at least things that I definitely considered when I was trying to make my final decision about pursuing the fourth year, not, you know, the time commitment that an additional year, as well as the financial component that you mentioned, especially if you have, you know, personal or family issues or things that, you know, you have to be financially in support of. And then from a woman perspective, I agree, I think some things that perhaps maybe for women become a little bit more difficult or more things that you'd have to consider as far as family planning and things like that. I don't personally have any children now, but I do hope to have some in the near future. And those are things that I definitely had to consider as far as pursuing an additional year because I've done a lot of exploring in my own training in medicine. And even before med school, so I've taken a lot of additional time to do things. So now it's kind of like, you got to figure out what's the best approach as far as where you are in your life in order to find a nice balance between achieving all the goals that you want professionally, but all the goals that you want in your personal life as well. So that you have a nice balance where you're happy with where you're at down the line. And that's what kind of was the main contributing factor for my decisions. I think we'll quickly turn it over to Andy and Thomas just for a few quick male perspectives. Just from my perspective with barriers to fourth year training, I do from the private practice perspective, it has to be stated that sometimes learning EUS and wanting to get into a situation where you get enough volume for EUS can sometimes make you less marketable. I would argue that the most marketable person is someone coming out of fourth year fellowship is someone who may be willing to give up EUS as one of their skills. That sometimes happens where you have a job that requires ERCP, but there's already an established EUS person and there's not enough business to go around. And I think that is a reality. I don't know what the study Dr. Wong mentioned that there was a survey that was done. I feel like in the real world that that comes up not infrequently. And so I want to reinforce one of the theses that I had mentioned earlier. And in fact, perhaps Dr. David said it the best or exemplified it the best, which is that I think you need to start thinking about the job that you want to have, your future, what it looks like. Like for Dr. David was going back to her home country and pioneering therapeutic endoscopy. If your purpose is to live in a certain city, Atlanta, Austin, so on and so forth, it behooves you to explore what the job market is and do they need an EUS person in particular? And if they don't, then are you willing to give it up? Just do ERSV and then give up EUS. If you're not, then you have to consider the possibility that learning EUS and wanting to maintain that skill may make you less marketable. Just putting that out there. Maybe not everyone agrees with that, but at least from my perspective, many have come to Austin Gastro and said, I learned ERSP, I learned EUS to competency. I want to practice. And we had to turn them away because we already had that position filled. Yeah. Yeah, I would agree with that. The truth is from where I was before when I was coming out of advanced fellowship, it does depend on what you envision for yourself. Well, it depends on the combination of what you envision for yourself and what you think is out there. There aren't, there's a finite amount of places where you can go in and try to do advanced endoscopy, including ERSP, EUS, yada, yada. Places tend to have something they're looking for. In academics, you will be expected to do both. In private practice, there was a job I interviewed at where they, just like Andy said, they were looking for ERSP, they had an EUS person. And so you either have to say bye-bye to EUS or look elsewhere. And it's how does that fit in with your life vision? But definitely a barrier is, in my view, if you spend the time to do a fourth-year fellowship and you match and you go somewhere for a year, you may have to turn around and do that again wherever the job is, because you may not be able to get that job that you envisioned for yourself in that place where you are. That's a very real, and I was in that situation. I went away from where I was doing general fellowship and then did it again. So it's just a quick turnaround. And that's a difficult thing to do, independent of the other challenges of doing it or the opportunity costs and all those other things is what do you do with your life and your husband or wife or significant other and or kids? It's a barrier for sure. I'll just say that we shouldn't use EUS as in not marketable or marketable. I think that's an example of a certain procedure that may or may not be in line with the kind of job that you're using. I don't think our audience should feel that EUS or any one thing is more or less marketable. I think it's variable depending on where you're looking. And some practices have senior people who do ERCP. In fact, they have more people doing ERCP and they're actually looking for someone who can do EUS. So it just depends where you're looking and what kind of practice you want to join. So that's the first thing I would want to clarify. And there have been some other Q&A on the Q&A box. I'm seeing some questions about the job market. And I think we should just take a brief minute to talk about that and then move on. And so the job market for advanced endoscopists after finishing a fourth-year fellowship is variable. And I say this based on the same study that I just mentioned. Most fellows reported in this study survey that it was not easy to find an interventional job after finishing a fourth-year fellowship. Having said that, 99% of them said, given a chance again, they would still do a fourth-year fellowship. So that's important, right? Because they're saying that it's not easy to get a job, which means that they're probably compromising on some of the things we've talked about, as in some practices might say, no, you can't do ERCP or we don't need you to do that. And they're giving up on some of those skills. The other thing is majority of graduating fellows were spending 50% or less of their time doing interventional procedures in their first job. So which means that is also something to consider that if you're the kind of person who says, I'm only going to do a fourth-year extra year, if I'm going to do 100% of my time when I finish doing interventional procedures, then that's going to be harder than if someone says, no, I don't mind doing EGDs and colonoscopies and also doing these procedures as well. So it depends what you're looking for, but that's what we found, that fellows were not able to find pure interventional positions. But having said that, they all said, we would still do this fourth year again. So I think it's that personal satisfaction, learning a higher set of procedural skills and so on that adds to some of that process of making that decision. So I think we've covered a lot and I'll put out a general question to all panelists. Please share what you would see as at least one pro and one con of pursuing a fourth year. Rashmi, do you want to start? Sure. I think I've mentioned basically on both sides already, but the one major pro is that, the possibilities are endless and advanced gastroenterology is at the forefront of innovation. So that makes me very excited about the field. And I think having that skillset can really help me tackle anything in the future. I would say one con is the, it is an additional year of training and it is, the compensation is a training compensation. For me, that was something that I had to really think about and decide whether I should pursue the fourth year or not. But I am because I can't see myself doing anything else. So. Andy. The pro is that it's fun, exciting. You don't have to call a partner for help. You can take care of a lot of things yourself and you learn skills that help you in general, like Dr. Watt said. That's so true. The cons, I would still say that if your algorithm to approach whether or not you want to do a fourth year, first and foremost begins at where you want to live or where your family needs to be. Then in that case, pursuing a fourth year may be a slight barrier if that job is not available in that location. So look there first, look to see in that area, do some research. It doesn't hurt. It doesn't hurt. Paula. I guess I would say the pros are probably the additional skills and confidence that I imagine anyone would get from that additional amount of time. And the cons again would just be just some of the logistic factors of applying and moving and how that might impact your own personal life. Yeah. Thomas. Okay, so I've mentioned and Paula's dead on with, I'll start with the con because it was fresh out of her mouth. The logistics that I mentioned that too, but I'm gonna skip that for a second. Say, I will say the, not necessarily generating more money or yielding an increased salary with the training that you will have had to sacrifice to get and that depends, like everything else depends. But a con is that EUS is not a high reimbursing procedure. So it can take an hour, it can be difficult. And that is a con compared to, someone doing multiple philosophies during that time. Sometimes. The pro is it's fun, it's gratifying. The field is exploding and it's fun to be on that spectrum somewhere. Delaney. So I would say the pro definitely is variety. Variety, you'll never be bored. You'll never be doing the same old thing every day. And you'll always be at the forefront of innovation. And the one con that I could think of that was not mentioned so far was that you may end up actually taking more call than a general GI person. Because in any faculty or any group, generally speaking, they have more general GIs to share call versus advanced endoscopist to share biliary call. So yeah, you may be end up taking more call than your partners because someone has to cover the biliary patients 365 days of the year. Big second. I second that statement. And I'm gonna go to Yakeera next, but I'll just say that you might have to take more call, but your call, if you do only intervention call, might be a little less needing you to go to the hospital in the middle of the night. So you have to be available, but you might be able to do that ERCP in the morning. So it just depends on the kind of place that you're in. But anyway, Yakeera, one pro, one call. Make that a nationwide standard, only interventional call. Only interventional call. Anyone working on that? I mean, in terms of pros, like everyone has mentioned, all of the pros, innovation, exciting. And I think it really does arm you with a toolkit of skills for managing complications that come up in general GI. Like you can close your own perforation if it happens, God forbid. And then as the field is continuously innovating, it gives you like a good, solid foundation to learn the new skills that will be coming up pretty easily. The other thing is that if you have other interests in GI or other interests in your career, like for instance, you might be interested in medical education or other aspects, it allows you to have, before there's a dedicated year and you can work on the rest of those skills in a third year, during your third year in fellowship, if that's what you're so inclined to. And I guess in terms of cons, it's really just the extra time and then having attempts to compromise any kind of job that you get right out of fellowship. And so I can just going back to the point about the call, I think depending on where you work, for the most part, I think the general GI colleagues are the ones that are supporting the practice. So I guess, again, that's a pro to being an advanced endoscopist. So before we move on to the last question, I wanted to make, or the last section, I wanted to make sure that we address a couple of questions. I think there are a lot of questions about non-traditional fourth years. So not necessarily US ERCP, but hepatology, IBD, esophageal. So I'm just going to share my perspective and then I'd be interested to hear Mihir's thoughts on that as well. I think, again, it depends on where you train, what resources you have and what your sort of your ultimate goals are. So if you want to have an overall general practice, I think you should be able to get most of the training during your three years. But again, if you're very passionate about, say, doing just a very dedicated esophageal, having a dedicated esophageal career or transplant hepatology, I think in that case, it really makes sense to do a fourth year. There are several successful programs now which do have a third year. So it's a transplant hepatology pilot that's available. So that's sort of another track you can pursue. Mihir, what are your thoughts about that? Right, so I won't be able to comment on the hepatology and the IBD, the fourth year fellowships or the third year pilot program for the hepatology program, but I will comment on these specific fellowships. I think there was a question about an esophagus fellowship or an esophagologist. And I think the two may be a little different. So there are motility fellowships where you can train in esophageal motility or basic GI motility. And then there's some places, very few, that might be able to train you as an esophagus interventionalist. And we've had some discussions with people at the institutions that I've worked at where someone comes and says, I want to be a barotologist and I want to do EMR and ESD and RFA and esophageal complex dilations and so on. And the question that comes to mind is that it's not about doing just one of that. I think learning interventional procedures gives you that extra backup in case something were to happen. So if you are a barotologist and you do EMR and you do RFA, if there were to be significant bleeding or a perforation while doing that, I would think it would be useful to know how to stent the esophagus or to be able to do over the scope clips or do suturing or something more, which I think comes with being an interventionist. So I think there are these subspecialties now and GI endoscopy has exploded now with so many different things that may be very difficult to learn in a short period of a fourth year, but there are avenues. I think you need to decide how and what exactly you want to train in and then be able to deal with that. I don't think it's useful to be saying, oh, I can do RFA, but I don't do EMR because you're not doing your barot's patients a favor by saying, oh, I only do RFA, but then I have to send them somewhere or to a colleague or something like that. There was also a question about a bariatric or a suturing training, do you need to have a fourth year? And I think that's a little different. And I think you could be a bariatric endoscopist doing endoscopic bariatric therapies and you may not need to know how to do an ERCP. So I think there are, each field has its own plus and minuses. I think you need to identify what you're interested in and be able to do that competently, independently and be able to bail yourself out of sticky situations. So anything that you do, make sure that you're sufficiently competent and have all the skills that you need to sort of work with that subspecialty. I think we have just a couple of minutes more. We've spoken a lot about advanced endoscopy and the pros and the cons. I want to make sure I share the perspective of a general GI standpoint. So I think the question is, this is not only going to impact your professional and your personal life, they wanted me here and me to share my perspectives. So I'm going to say from a professional standpoint, I really enjoy the variations in my practice. I think I get the instant gratification that Shalini was mentioning, and that comes with my endoscopic practice because I also do deep endoscopy and therapies, but I also have the gratification of following our patients. So developing long-term professional relationships with IBD patients who require complex care, maintaining critical thinking, not only in GI, but also internal medicine. And I sort of really enjoyed that aspect of my practice. I think working in an academic setting, again, you want to decide where you want to work, right? Academics versus private practice. I think working in an academic setting also allows you to pursue the other things that give you purpose. So research, education, being part of medical school or teaching the residents and the fellows. And I think coming to personal work-life balance, I think that's a moving target, whether you do advanced endoscopy or general GI, there's never a time in life where you think you've sort of achieved that perfect balance. But I think when we have the right priorities, it's feasible in general GI to dedicate time to family, career goals, and kind of to have the best of both worlds. So Mihir, what do you think from an advanced endoscopy standpoint, professional and personal impacts? Right, so I'm glad you spoke about the general, the GI practice that you're familiar with. And I think I'm a little different doing interventional procedures where we often will see our patient once before, do the procedure, and if everything's fine, we're done. We don't have a long-term follow-up. And for some physicians, that's the best thing they can do, while others, no, they want that continuity of care. So that's a little different. I would say that professionally, I'm in an academic setting where I have, I would say the luxury and the privilege that I do intervention endoscopy. I don't do IBD and general GI procedures and don't see general GI patients. So I'm happy in that setting because that's what I chose to do, and I like doing it. It also means that I have long cases, third space cases and complex US and ERCPs, that I come home seven, eight o'clock tired. And the humbling part is I come home and my wife sees me tired. And the question she asks me is, did you reach the C-cup? And it just brings you back to your first year fellowship days because she knew that we're all struggling with the sigmoid first and reaching the C-cup. So no matter where you are, you'd always be humbled. And I think that's part of life. So I think that's my take. It's a lot of fun. I enjoy these long procedures, but it's quite tiring and takes a toll on you at the end of the day. So anyway, I think we are running out of time. So I will just move on to a few things that I'd like to share with the listeners about the role of ASGE and trainees and advanced and even regular endoscopy, general endoscopy. And there's a lot of offerings that the ASG has and specifically for trainees. So you're probably familiar with the first year fellows course, which is the flagship course that almost all fellows in the country attend. But now we have a second year fellows course, which is a more clinical practice oriented course. And that does not focus much on the medical side, but it focuses on contract negotiation, malpractice, finding your first job and so on. So I think it's all of this ASG offers. There's a senior fellows course that goes beyond the basics that are taught in the first year fellows course. We have DDW offerings. Unfortunately, last year with the pandemic, we weren't able to do any of that, but hopefully we'll get back to normalcy and there are didactic fellow oriented sessions. There's hands-on sessions that we do at DDW. Then there's InScope, which is the new video module that gets sent to fellows every month. We started as a pilot, I think about two years ago, starting with first year fellows with every month they get an email with the link to go to GILeap. By the way, GILeap is something that I would say all of us should be visiting as often as we can. There's a lot of educational content out there. There's videos, there's lectures, postgraduate courses and so on. So I would encourage all the fellows to make use of all of that which ASG offers. So pretty much, I think that if you're interested in endoscopy, I think there's a lot that ASG can offer. And when I was a first year fellow, I didn't know much about ASG. My mentor at that time said, hey, we paid the $25. I don't know what it was at that time. And there's no reason you should not be a member. And I've been a member since. I do consider ASG as family now. It's a very small world. We know everyone in this field. So that's my take on it. And Shabana, anything else you want to add? No, I think excellent training resources. Mir, you highlighted all of them. And then I think for faculty, there's opportunity to serve on different committees. I've served on the standards of practice committee, writing guidelines. And I think that really keeps you in touch with sort of innovations and evolving things. And I talked, speaking of committees, I think there are fellow opportunities to be on ASG committees as well. So I think that's another thing we get asked a lot. Fellows say, I want to be working with the ASG. What can I do? So there are fellow specific positions that committees have as well. So please apply, make use of that opportunity as well. All right, I think that's all the time we have. I think I'd like to thank on behalf of Shabana and myself, this excellent stellar panel that we have here today. I think everyone did a wonderful job. I think we heard different sides of the story. And as I said up front, there's nothing one way, there's no one way to do it. There's no right and wrong. It's a personal choice. And I'm very happy to have everyone join us for this wonderful discussion. And again, thanks to the organizers, from Lean and ASG to have us join in as well. So thank you. Wonderful, thank you all. In closing, thank you for your participation in this discussion on the pros and cons of pursuing a fourth year fellowship. Mark your calendar for the next Endo Hangout taking place on Thursday, May 6th at 7 p.m. Central. The topic will be EUS-Guided Transluminal Interventions for Pancreatobiliary and Luminal Obstruction. This concludes our presentation. We hope this information is useful to you and your practice.

panel discussion

fourth-year fellowship

gastroenterology

endoscopy

women in advanced endoscopy

challenges and benefits

ERCP

EUS

learning curve

mentorship

financial considerations

radiation exposure

non-traditional fellowships