Hello. Welcome to a discussion titled Your Path to Career Success and Joy. The objective of this session is to explore four distinct practice models and career paths for today's physicians and providers in GI, hearing from members of the ASGE Practice Operations Committee as they share their experiences and career pathways and what has led them to career success and joy. First a few housekeeping items. My name is Eden Essex and I will be the announcer for this session. At the conclusion of Dr. Martin's presentation, there will be a roundtable discussion with panelists, followed by audience Q&A. You will be able to submit questions and comments throughout the session via the Q&A box. A recording of tonight's session will populate your GI LEAP account when it is available next week so you can view the content anew or watch it with others. Now it is my pleasure to introduce Dr. John Martin. Dr. Martin is a full-time practicing gastroenterologist at the Mayo Clinic in Rochester, Minnesota. In addition to his clinical practice, Dr. Martin's interests center on endoscopy unit operations and efficiency, technological innovations in endoscopy, and endoscopic training and simulation in hands-on training and education. He has served on the ASGE Governing Board and currently serves on the ASGE Practice Operations Committee. I will now hand the proverbial floor over to Dr. Martin. Thank you very much, Eden, and good evening to everyone. We sure appreciate you joining us for what we hope will be an extremely spirited hour. As you can see, this evening is all about both career success and joy in your exploring four different employment and practice models as a GI physician or provider. Success is important, but your joy and the joy of your loved ones all figures into all of this. There are more than four practice models, but we're going to try to start with that. Then we have a Q&A and discussion session where we can expound even further. My name again is John Martin. I'm from Mayo Clinic in Rochester, Minnesota, where I practice mostly therapeutic endoscopy. We're joined and supported by our erstwhile leader, Dr. Anessa Kikus, who is from Vanguard Gastroenterology LLP in New York City. We have four expert faculty lead discussants who have tremendous experience in different camps of GI practice, including Dr. Vasu Apalaneni from OneGI in Dayton, Ohio, Dr. Sufian Chowdhury from GastroOne in Germantown, Tennessee, Dr. Larissa Fujii-Lao from Queens Gastroenterology in Honolulu, Hawaii, and Dr. Tarun Rai from the Borland Groover Clinic in Fleming Island, Florida. We've got a great faculty who will talk to you and also not only provide you with information, but lead you in a great discussion. Just a couple of thoughts here. GI and endoscopy truly abound with opportunities. We are truly blessed in GI to be either one of the most sought after specialties in medicine today, or in some surveys, the most sought after subspecialty. That means there's incredible opportunity for you out there. But when there are a lot of opportunities, that also means that you have a big responsibility to choose well. And yet at the same time, not feel that to be too daunting, because our careers thankfully should last a long time. And the demand for our services is likely to be insatiable for the foreseeable future. And as a result, I think it's fair to say that many of us, maybe most of us, will have more than one station in our career. And so you may find yourself practicing in more than one or even several of these practice models, and even in practice models that don't really exist today. So there's a lot to be excited about here, but we want to help you choose well, particularly for whatever chapter this chapter is within your long career. So there are many practice models, not just simply practice versus academia. In today's environment, that's an oversimplification. One of the great opportunities in GI is that you can also super specialize. You can practice in particular niches of GI, and those opportunities can be more available in some practice settings than others. But you might be surprised that some of the practice settings where you can specialize are actually in private practice, not just academia. There are opportunities for you to own practice equity. You can actually own a practice yourself or own a part of your practice. And that means not only the practice of your clinic seeing patients, but ownership in your facility or facilities. And that is something that not all medical specialties afford their practitioners. There are opportunities for passive income as you own elements and businesses within your practice that have to do with other than your own personal clinical activities. There's also the ability to mitigate risk through guaranteed income models if you would like a salary type of position, yet the ability to profit from calculated risk through productivity based practice equity and passive income opportunities. And you're going to hear about some of these from our expert faculty. You have a solid future in GI because we have rapidly advancing technologies to continually put new tools into your hands to help you continue to improve and update your practice throughout your long career. We have minimally invasive therapies, which are in greater and greater demand, not only by patients, but also by practitioners that serve those patients and the institutions and payers who would like to see less expensive opportunities to provide more satisfactory, less injurious care to patients. GI is also full of pharmacotherapeutic innovation in the pharma arena. There are all sorts of biologics in addition to pharmaceuticals that have entered our armamentarium, and there are even new practice models that have arisen even within the last half decade, the decade that you can take advantage of and would like to inform you about those. That insatiable demand for GI-related clinical services is going to continue for years and serve you well. So then high opportunity, as I mentioned, I think does equate with high responsibility. Having great options means considering more than one option and being open-minded because, hey, you never know, right? And we want you to know. Responsibility to understand your options thoroughly for your own good and for the good of your loved ones who will participate in your life at the interface of your career. You'll need to seek out data so that you can compare these opportunities critically and quantitatively, and it's important to understand different work models and practice to assess your fit and your potential for overall happiness because it's about work and life at a critical balance. You need to understand your compensation model because your paycheck is not the only way that you're compensated. You're going to hear a lot about that tonight. Asking the right questions of the right people is important, and getting evidence-based answers is equally important. One person's opinion, if it's just an opinion not backed up by data when there's plenty data out there, is something that you need to question. Seek out better answers from people who can back up their opinions with evidence. Finally, taking family, timing, geography, finances, and personal needs into account, I think, is looking at this whole process holistically. Finally, our committee, the ASGE Practice Operations Committee, wants to help you to navigate all of the great opportunities out there for you so that you can make the best choice possible. Excellent. So then, you heard about tonight's panel, and Dr. Apolloneni is going to talk specifically about single-specialty private practice, then followed by Dr. Larissa Fujilow is going to talk about hospital-employed practice, which is her setting, followed by our committee leader, Dr. Anessa Kikus, who's going to talk to you about multi-specialty private practice, and then Drs. Sufian Chowdhury and Tarun Rai will talk to you about academic medical center practice. Dr. Chowdhury is actually going to lead the discussion regarding that, with Dr. Rai performing the formal presentation on that topic, and we'll follow all of that with an interactive question and answer session with you and us, and a discussion and roundtable with all of the speakers. So that concludes my presentation, and now it's my pleasure to introduce the first panelist, who will be Dr. Vasu Apolloneni. She will give you a presentation here without slides, so it's going to be all her. Vasu, take it away. Thank you so much, John. Thank you, everyone, for joining and giving us your valuable time on a Thursday evening. My name is Vasu Apolloneni. I'm a practicing gastroenterologist at Dayton Gastro, part of 1GI in Dayton, Ohio. We are a single-specialty private practice, and that's what I would be concentrating more on tonight. I thought I'll give you a few points why I joined private practice and single-specialty, and this is where I joined soon after my fellowship, and I haven't moved. And sometimes it happens where you go into one practice, and sometimes that may not be the right fit, and we go into a different practice at that point. For me, it worked out this particular practice, and I continued to work here. I did my fellowship and residency at the same place at Wright State University in Dayton, Ohio. While I was moving to Charleston, South Carolina to do my advanced fellowship in endoscopic ultrasound, the group here whom I was trained, they were the faculty for the Wright State GI Fellowship Program, so I was in touch with the private practice group who is also a faculty for the Wright State GI Fellowship. They wanted me to come back, so I already formed a good rapport with them. I felt the group was fair enough, so once I went to MUSC, I came back here because I wanted to be in touch with the fellows, have that little bit of academic feeling, but mostly it's a private practice. So I did some teaching as well as stay in a private practice setting. So I thought I'll give you a few points, like five pros and five cons of what I see with a private practice, single specialty. First and foremost that I see is autonomy, where in private practice there is single, few group of people. It could be two, or it could be five, it could be ten. There are bigger groups up to 60 as well in the country. When you are in your own, obviously as you're growing bigger, you know, the leadership changes, governance changes, but if any projects need to be done, if any schedules need to be changed, or do you have control of your patient schedule, that autonomy is in place. Second one is the ambulatory surgical centers, turnover of the rooms, the efficiency of room turnover. When I came here in 2007 to Dayton, Ohio, after my fellowship, I wanted to do endoscopic ultrasound procedures as an outpatient in an ambulatory surgical setting. If I'm not wrong, we are probably one, first one, or the second one to perform outpatient endoscopic ultrasound at that time in 2007. It worked out so well because most of the times when I was trying to schedule procedure in a hospital setting, they're like, you need to schedule for one and a half hour or two hours. In those days, you know, they did schedule for a longer time, but in an endoscopy center that's private practice, you have control of how things work, what's the room turnover time, and stuff like that. I mean, mostly you would know most of the staff that's working around there. I felt like the respect and the trust between the staff and you is much more. There's easy access to patients, patients allow, you know, there's not like huge parking lots that you need to go, then go to registration, and then come to you. And obviously, it's less expensive to the patient, the ambulatory surgical center of, you know, private practice. Then comes the third one, multiple locations and geography. I mean, if you want to get into private practice, probably there are multiple opportunities in different corners of the city, depending on what our lifestyle is. Do you want urban, rural, stuff like that. Fourth one, you can be part of the owner. Each practice has their own styles. Some could be one-year partnership, some could be two, and there are other complex methodologies some people use where you buy into the practice and become a partner. And the fifth one, I would say, is several of these private practices, they have ancillary service lines. So you can have, as John mentioned earlier, some of these passive incomes coming from these service lines. To cons, I wouldn't say these are completely cons, but things are changing, but this is what I saw when I joined. First comes research. I mean, being an academic area, you get several mentors and get to publish papers, lots of help where you can get research done. In coming to a private practice, because most of the times you are trying to provide care, there's no dedicated research time, so you can't get to do much. Now we are seeing several of the private practices consolidating. I feel like there's a lot of data right now with these huge practices that there are, and there's tremendous opportunity to get research from these. I think that system is changing, so we will see new opportunities there. Number two, management expertise. It's kind of little, it could be lean in some of the private practices, because if it's a two out of three positions group, sometimes it's so hard to hire all this management talent. You cannot have a CEO, CFO, and recruitment, HR, everybody. So you try to run the ship with one practice manager and a few other key personnel, so you may not have access to as much deep bench in a management style. And the next one that I see is recognition, kind of. Probably you would see more academicians being as speakers and so forth, even though there are several talented expert doctors in private practice. But people are coming out, they're trying to network, get to meet people. So there might be some opportunities, but if you want to be more on the research side or on the speaker side, are there more opportunities on the academic side rather than on the private practice? Fourth one, there's no formal mentorship programs in private practice, but we are working on it in the last five years, I would say. There are several programs where within the practices itself, they're trying to formulate a local mentorship kind of program, like the younger recruits when they join, trying to find one with compatible fit and culture where they can confidently share and train and get knowledge share. The fifth one, I would say, is the call schedule. It could be variable because depending on number of people in the practice, it could be every other week call or depending on how many are in the practice itself. So there's no fellows help on call compared to academics, you know, where you may have GI fellows that could help in the call. That's what I have for the private practice single speciality-wide. Vasu, we greatly appreciate that wonderful presentation, particularly as someone who comes from an academic background and an advanced endoscopy fellowship and has done research, but then entered a career focused on what one might consider the traditional version of private practice as we have known it. That's a wonderful perspective. So thank you so much for sharing that. We're going to shift gears. I'm going to introduce to you Dr. Larissa Fuji, who is Assistant Professor of Medicine at the University of Hawaii. She completed her GI and hepatology fellowship at Mayo Clinic and then undertook an advanced endoscopy fellowship at Washington University in St. Louis. So her focus is actually in interventional endoscopy, and she has been employed for over seven years by the same hospital-based medical group, which is Queen's Medical Center, since she completed her interventional fellowship. Dr. Fuji-Lao's focus is still in interventional endoscopy, and I'm sure always will be. Larissa, if you can share our experience or your experience with us, this audience is yours. Thank you, John, for that introduction, and thank you everybody for allowing me to participate in this interesting topic. So like Dr. Martin said, I'll be talking about a hospital employee practice. So I've been with the hospital called Queen's Medical Center for the past almost eight years. Just to give a background on this hospital, it does have two main hospitals that employ 17 different specialties and over 400 physicians. In GI and hepatology itself, we have 11 physicians. To give a brief overview of our compensation plan, because every hospital employee practice will have some form or another of a compensation plan, but just realize that there is a whole variety of different compensation plans. But as an example, I'm giving you ours. So we have a base salary. Our base salary is based off of the MGMA salaries, and we go by the 50 percent or the median. So the median base salary of everybody across the nation that MGMA has, sorry, owes, we have at the 50th percentile, that's our base salary. As long as if we meet certain quality measures, which everybody is supposed to meet the quality measures. So basically we get 50 percent of the 50th percentile based off of MGMA salaries throughout the entire United States. However, we do have additional incentive bonuses that we can get every quarter. For our example, if we make at least 50, the 50th percentile of the median work RVUs, again based off of the MGMA, in our case it's a three-year average, then we get compensated per work RVU that we make over that median RVU. It's kind of confusing, but you do get an incentive if you do work harder and you make more than the 50th percentile of the median work RVUs, then you do get an extra incentive paid every quarter. And then at our hospital we also get call pay. There's a difference if you do general call versus ERCP call or both. And again, just realize that there's a whole other variety of compensation models. When I was interviewing, I know there are some that only had base salary for a certain amount of years, and then they could do a buy-in to the hospital, and then they were based off of what they brought into the hospital. Other places didn't have call pay when I was interviewing there, so it's important for you to understand all the different types of compensation plans that each hospital has. So I'm going to go into the pros and cons of a hospital employee practice, starting off with the pros. The main pro of the hospital employee practice is that you get a salary, and so that's stable pay. And we especially saw this over the past couple of years when COVID hit, because as you guys all know, our work RVUs and our work significantly decreased during the time of COVID. But despite this, our pay stayed the same, despite us working much less. In addition, usually when you first join a hospital employee practice, you have initial incentives, like you have the moving expenses paid for or any signing bonuses. Again, those are all different with the different hospitals that you might be interviewing at. And then you also get retirement benefits. Like at our hospital, they match our 401k up to a certain point, and as long as we max out our 401k withdrawals from our paychecks. And then you have the educational fund. So they pay for you to go to conferences, and then you also have a stipend if you want to do other things. And so again, every hospital is going to be different. One of the main reasons why I stay at a hospital employee practice is the malpractice insurance. And so as we know, majority of us will get sued at some point. But with being a hospital employee, if and hopefully, well, if not hopefully when I get sued, the lawsuit will be against the hospital rather than myself. And so if you're in private practice, and say, if you get sued and you lose a lawsuit, then it could potentially more than likely be your name that is mentioned in regards to losing the lawsuit as compared to if I get sued and potentially lose the lawsuit or have to settle, it's underneath my hospital, Queens Medical Center rather than my name itself. Another important aspect of a hospital employee practice is the mentorship with senior partners. Especially when you're coming out as a fellow, it's important to have that mentorship because your main job once you come out is to gain the trust of everybody that you're working with. And you don't want to go out there and be a cowboy and start doing all these crazy things and getting to have a lot of complications. And so it's good to have senior partners there helping you either with endoscopies or helping you to make any sort of clinical decisions decisions because you're not going to see everything while you're a fellow. And it's when you have that mentorship and all that responsibility on your shoulders, it's good to have somebody that you can talk to and run things by. Another pro about a hospital in play practice is the opportunity to continue medical education. At our hospital, although we don't have a GI fellowship, we are associated with internal medicine residency. So we do have a lot of residents that rotate through and so we can still provide education to medical residents. And then you also have the opportunity to have leadership positions within the hospital itself. Another reason why I stay employed is because I do not have any business sense and a lack of money sense. And so keeping track of everything that I need to in order to fill out my taxes and all of that, that would give me a headache. And so not needing to focus on the business aspect of a practice, not only compensation and monetary wise, but also hiring and firing a staff is also one thing that you don't necessarily have to worry about as a hospital employee, which can be a pro or a con depending on how your office functions. And then finally, the cons of a hospital employee practice, you basically have a lot less autonomy than a private practice. Your hospital will tell you when, like how many work hours you have to do in a week, how many patients you should be seeing within a clinic. They tell you, well, they tell you how many staff you can have in your office that helps you with everything. And so there is a lot of lack of autonomy with being employed by a hospital. There's also lots of bureaucracy that you have to go through. You know, like for example, here at Queens, in order to even get one new equipment, I have to go through so many different layers of management in order to even try and get something, some form of new medical equipment, medical device into here. You likely, as a hospital employee practice, have less total compensation, as well as higher taxes than private practice. For example, your incentive payment is not a guarantee, especially if you don't meet the certain amount of, say, work hours we use, or compensation, or however your hospital calculates it. For example, in my practice, probably only one or two of us actually get incentive pay per quarter. Most times people, the other people in their group, don't meet that 50th percentile for work hours we use, and so they don't get any incentive pay, and they're only getting salaries. Another, in regards to the higher taxes, so you're a W-2 employee, so you basically don't have any tax write-offs, very minimal tax write-offs that you can do. And then, I don't think this is supposed to be, oh, so the lack of control over changes to the model that pertains to your specialty. So we've been arguing, because our compensation plan is over 10 years old, we've been trying to argue for a while to try and update that compensation plan and compensation model, but you don't really have much control over that, both when you first start off, and also when you're trying to make any changes to the model. And then insurance-wise, so this is here because in private practice, a lot of times people can say that they don't take certain insurances, but if you're employed by a hospital, then usually that hospital, other than the Kaiser system, of course, but usually a hospital will take all sorts of insurance, and so you get all sorts of patients in your patient panel that you're gonna have to follow up with, which is good and bad. Just realize that in some instances, some patients that have certain types of insurances may be less likely to listen to all your instructions or follow up or actually show up to the endoscopy area. We do notice those types of things based off of the hospital taking any insurance. And then finally, inpatient coverage. You know, this comes kind of hand-in-hand with insurance because when patients are hospitalized, they can have any insurance. I don't even pay attention to insurance being a hospital employee, but usually in private practice, people just see the patients, their own patients potentially, at least here in Hawaii, and they don't necessarily have to do inpatient coverage, but here as a hospital employee, we have to do inpatient coverage, and so that's essentially being like a fellow for the rest of your life because you're doing all the inpatient calls. Hopefully you have some fellows to help you with that, but you're doing coverage and call for the hospital, and so that can also be seen as a con. I like it because you have the acuity of the patients and you keep up to date with, you know, the higher risk inpatient practice, but it can, that's probably one of the main reasons why most of the people that were previously part of our practice have now left is because of the inpatient call coverage. Thank you. Larissa, that was great. Really appreciate the specific details and the numbers that you provided for us. Next, we welcome Dr. Anessa Kajkis, who is our erstwhile leader of the ASGE Practice Operations Committee and one of our faculty this evening. Dr. Kajkis is Clinical Assistant Professor of Medicine at New York University School of Medicine and a managing partner with Vanguard Gastroenterology in New York City. She's been a member of the Kips Bay Endoscopy Center for eight years and is an alumnus of the ASGE LEAD Program, which is Leadership, Education, and Development, and she currently serves as chair of the ASGE Practice Operations Committee. So Anessa, we look forward to your perspectives and experience with multi-specialty private practice. Thank you, John. Thank you, everyone, for joining us this evening. Thank you for giving the opportunity to share my experience. So imagine if you could create a dream team of doctors from experts in different specialty areas and have them all work in one place where you can quickly share knowledge with one another and provide this advanced, improved patient care. So for me, it wasn't a dream. When I graduated fellowship, there was one dominating force, a group that dominated the hospital at that time. So when I got invited to join, I felt flattered because much like Larissa, I thought I have no business sense and this group appeared to be doing something very right because not only they were on the cutting edge of patient care, they were heavily involved, members of the group in the hospital life, in national societies. So, and it seemed like that was an incredible opportunity to join a very established, esteemed colleagues. And I accepted the offer. So I joined the team. So that was like a dream come true. And that was a multi-specialty group practice. And while incentive of having many great minds come together in one place is incredible, this is not the only perk of a group practice. In fact, those environments support the physician who work in them economically and logistically, making the practice management seamless. So you have that instant access to the consultants, to your colleagues that you know and trust. And while smaller practices or smaller private offices might not have the funding for state-of-the-art technology, the group practices are likely to have the digital imaging, machinery, the equipment, the access to all the latest innovation that helps doctors to make their practices stand out. And you can also design very individualized approach to a patient care with the multidisciplinary offering in your practice. So we had a very difficult patient when I just started practicing year one, typical Munchausen syndrome patient. She was in and out of the hospital every week or every other week, undergoing a battery of unnecessary expensive tests from CAT scans to MRIs to endoscopic procedures. And it was happening over and over and over again. And those patients notoriously difficult to manage and diagnose. So while we all talked to one another and recognized that that what was going on, we partnered with a psychiatrist, an infectious disease person, and I was involved in her care as a gastroenterologist. And we started scheduling appointments, just the quick visits, like 10 minute clinic visit. Every two, every three weeks for five years, that person did not have any more tests, hospitalizations or ER visits. So that was very unusual case, but I really appreciate the team coming together, generated that sort of in that unique clinical scenario, that team approach that actually prevented that patient from probably being harmed eventually from all these unnecessary tests. And when you join the practice, you obviously have the networking potential maximized when you team up with other doctors. Not only you will get referrals, but you also reap the benefits of your group marketing. And you will have to participate in it, but the group supporting usually the junior additions to the group, you get the referrals. And just because of the groups standing in the community, you get that automatic branding. So just because you join Concord Medical Group at that time, you are being regarded as a doctor that worthy of joining that practice. So that was, that meant a lot to me. At the beginning that really helped to build my practice, just leaning on my colleagues, enjoying that interactive multidisciplinary approach. And we had a wonderful time. And that certainly enabled me to build the practice in a very competitive environment of New York City. But when you find a bunch of pros, there is always, always you can find some cons. And that setup is definitely not perfect for everyone. And while multi-specialty group practice definitely comes with lots of benefits, there are some obvious pitfalls. The practice culture might not necessarily be the one that you will enjoy. It's still a smaller environment. You might find that, that might not be the cardiologist that you want to refer to. You might not be satisfied with the answers that you're getting for your patient. So it becomes very individual and in nuance, like the dynamic of a practice, just as simple as the colleagues might not be getting along. And also the negative of the multi-specialty group practice, the individual doctor might not realize their full earning potential as if they were in the solo practice. Just because physician compensation is already set, there are certain formulas that are already in place. And the larger the group is, the more it's beginning to look like what Larissa described in the hospital, because it's already established that the senior or founding fathers of the group created that type of a financial environment. And you come as a rank and file, and you have to establish yourself within a group. And for you to become one of the leads of the group, it's a process. It might be sometimes as difficult of a process as you would face in a hospital employment. And obviously what Vasu shared with us, how much he enjoyed the autonomy, the larger the group is, the more players in a group, the more limited your autonomy will be to make that decision. So there are pros and cons to these types of practice setting. And I'll be happy to address more in the Q&A session. I think it's a wonderful environment to practice in. Certainly the pluses for me outweigh the minuses. Thank you very much for your attention. Vanessa, thank you very much. We really look forward to digging into some of these themes that you touched on. It really is heartening to know that we have so many great choices available. Now we have to pick, right? So then next, let's hear some perspectives on the Academic Medical Center. And to do so, it's my pleasure to introduce to you Drs. Tarun Rai and Sufian Chaudhry. Dr. Chaudhry has been a partner at Gastro One, which is a large gastroenterology group in Tennessee for the past seven years. But before joining Gastro One, he was an interventional endoscopist on the full-time faculty of the University of Tennessee. He obtained an MBA from the University of Massachusetts at Amherst, and he's a longstanding, highly contributive member of our ASGE Practice Operations Committee. Dr. Tarun Rai currently works in a single specialty GI practice in Jacksonville, Florida. Previously, he was assistant professor at the University of Kansas in Kansas City and the affiliated VA hospital for three years prior. Dr. Rai also served as director of Fellows Education and Motility Division at the VA hospital, and also participated in a number of research projects under the mentorship of the well-known and stellar Dr. Prateek Sharma. So, Sufian and Tarun, the audience is yours. And just to clarify, Dr. Chaudhry will actually be leading the Q&A and discussion portion of this topic. And so, Dr. Rai, please start us off with your presentation. Hello, everyone. So, I appreciate everyone joining us this evening. So, I'm going to talk about the academic practice. And I think that is an easy choice, partly because everyone, we have been trained during our GI practice and we have our mentors, and we have done our training at academic places so we definitely know what is expected. So, I think the biggest reason one should join academic place is for the teaching. So, we have to give back what we have been trained. So, I think the most of the people, based on my experience who have stayed in academic jobs or at academic places for longer, they're the one who are definitely passionate about teaching and education. And they want that, and they feel that they should train a new generation who can take this GI field into, they will make this go up and up. Second reason I think some people choose to stay in academics is for the research. And the research could be either in basic science or clinical, but majority of places in my experience on the university places, they are doing research and clinical research. And that was, I was also involved. And the third reason which people stay in academics could be they want to advance their career in GI. They want to be on the speaker. They want to go into ACG or ASGE. They want to be, and then some people would also want to stay in academic to progress, to be into the leadership. For example, they want to be the chief of medicine or they want to be the dean of the hospital. Some people may want, they may stay into academic for a long time and they eventually move to the pharmaceuticals. Pharmaceuticals. So I think we all have a good reason. And then people, so, but I think all of, all the four or five reasons that I studied, the strongest reason is the people who have the passion for the teaching. As far as the people why do leave and what are the short and the pitfalls of being into an academic job, which could be the benefit of the private practice, that the biggest issue that I have faced or I've seen is we don't have like autonomy or the control on this as well. And there is much less flexibility. And I've also seen, let's say in the 10 years before or 20 years before people were getting more academic time, more protected time for the research, but more and more the university places, they are going towards the RVU, which is the typical. So you will have a base salary. And then above, if you make, then you will get a bonus. So with this RVU model built in, so there is more incentive to do clinical, and to see patients and you don't get as much incentive to do research. And then overall, if you compare the academic salary, is it much low as compared to, again, it could be variable. For example, the Cleveland Clinic and the Mayo Clinic salary could be comparable to many private places. It could be, but if you go to the top tier universities, for example, University of Pittsburgh or Harvard, your salary may not be as compared to the private practices. And some of those top tier universities will expect the faculty to do some research in addition to the clinical practice. So for me, I was in academic practice for two and a half years or so. I had a great work, you know, the balance. I was mainly in the VA. I would be done by 2.30 and 3 p.m., but the reason I chose to move to private practice for those issues, so I wanted more flexibility, plus I wanted an autonomy. So at the end, you know, no job. Everyone has told, you know, what could be the practice models be? Is it a private practice, hospital? So my two cents on it, there is no job that is perfect. So if we have, let's say, if we see a patient in our practice as a typical IBS patient with multiple of symptoms, bloating, nausea, change in bowel habits, constipation, then I typically ask the patient, what are the most bothersome symptoms? So same way I approach the job, and that would be my advice to everyone, participant who is trying to look for a job, that what is the one thing or the two things that you are going to look for in a job? And look for those. You may not get everything, but look for the most important aspect that gives you happiness and choose that one. So we'll go back to, we'll go on. Thank you very much. Sure, appreciate your insights, Tarun. Now, before we move into our Q&A session, let's do a quick poll. Does that sound good, Eden? It sure does. Love the polls. Here we go. All right. I'll launch it for you. Thank you. So what is the most important factor to you choosing a job? Is it work-life balance? Is it location? or is it earnings, or is it, in GI, our great ability to super specialize within a segment of GI, whether that's hepatology, advanced endoscopy, oncology, esophagology, nutrition, whatever. So, which is it? Is it work-life balance, location, earnings, or the ability to focus within a segment of GI and hepatology? What's the most important factor to you in choosing your job? Please answer. And we've got a clear winner here. Really? Yep, there's the results. Wow. Okay. And, you know, I think that that speaks to life today, and what we value. That probably would have been a very different poll answer and unanimity, as little as a decade or two ago. Work-life balance is important, and you have many practice choices that I think is clear from what you've heard from our faculty that can influence that and help you achieve success in that and other goals. You probably, to some extent, can have it all, although there's always, as many of our faculty mentioned, all of them, actually, there's always some compromise that one needs to make. Now, Eden, I'm kind of looking at the time here. Shall we go with some Q&A here, or shall we do a discussion with all of the faculty? I think we could go either way here. We could go either way here. I'm kind of curious as to how the faculty would respond to that question. When they first started out, did they have that same goal of work-life balance? And if they didn't, how did they, how did they, if it is now, how did they come to that? That's a great question. Should we start with Dr. Heikes? Sure. Work-life balance was not in my cards, but location was. So I really didn't want to move out of the city, and I really valued tremendously the opportunity to stay within associated, affiliated with our academic center. That was a priority. So back then, as John mentioned, joining the private practice, you would not expect work-life balance. Having said that, over the years, I clearly see the change, because the new generation, our associate physicians, we see how priorities are changing. And we were discussing that with my senior partners, that it becomes irrelevant how we've come to our positions in the group, because the times have changed, and we have to acknowledge the fact, especially in the post-pandemic world, that those were the days of the of course, that they can continue to talk about what we cannot expect the generation that coming out of a fellowship to continue carry on the values that's already clearly outdated, as witnessed by this poll. Thank you, Inessa. Sufian, some thoughts on that from you? Absolutely. Right after fellowship, the most important thing for me was the location, as Inessa alluded to, because of the family reason, my wife was doing residency and all, and it was a no brainer for me to just go and join the faculty at the University of Tennessee, because as Tarun said, we all have seen how it works, what is expected of you, you're comfortable with the setting, and I just joined the faculty. And I actually loved it. I mean, the fulfillment you get by teaching, interacting with the fellows, it's amazing. It takes time to realize there are some shortcomings and cons and problems. But yeah, I mean, for me at that time, that was the most important reason to choose a practice. But looking at the poll, it's really interesting. I think this is the Gen Z expression of what they want from their work is the lifestyle and, you know, the balance between work and life. But I see it every day. I mean, this pattern is changing. And I think this is actually kind of changing the way practices are as well. I couldn't agree more. And I think, you know, too, don't you all agree that much of this is just as dependent, if anything, on the fact that we have so many different practice models now that you actually have these choices that you can make. Many of us have been doing this for a few decades, didn't have some of these practice model choices. They didn't really exist in the form that they exist in now. And work-life balance was really difficult to find, regardless of which practice model one was in, you know, back in the last decade of the 90s and the early 2000s. It's changed immensely. We really have choices now. I'd like to shift the discussion a little bit to understanding the compensation and the specifics that one probably needs to be aware of, questions one needs to ask when you are discussing compensation, which is not an easy thing to do when you're looking at different practices, different practice models, centers, hospitals, etc. Because your salary isn't your only paycheck, as we heard. Any insights into how to ask questions about what your total compensation is? What does it mean? And how do you compare? Because, you know, sometimes the benefits, including deferred compensation opportunities and retirement pay plans and so forth, can be worth as much and sometimes more than just your salary. Feel free, any of the faculty, please, to chime in on that. I think one aspect that's important is the flexibility. Because when you first start off, you know, your work hour reuse, however many patients you're seeing, is going to be much lower as you continue to build your practice and build your patient panel. So I think the flexibility and the ability to see the growth in both your compensation, as well as any other aspects of it is an important part. I wish I had asked more about things when I had first started in regards to the ability to grow as I increase my patient panel. Thank you, Dr. Fujilow. Anyone else? Yeah, let me just add a few words here. And I have no hesitancy in accepting that when I started my job, I was not educated about asking these questions about the compensation. Because it's, as you said, it's much more than just the paycheck you get. And coming back to the hospital based or even academic centers, they can offer a lot of higher deferred money, which can go to these 403 plans and 401 plans, which can be more than the private practices. And that can, in the end, in the long run, actually can contribute a lot to your retirement, more than what you can get as a private practitioner. So these are some of the things you should get educated on, like what type of retirement plans they are offering. As I said, there are a slew of these things that can be offered, like 403B, 401K, and there are a bunch of others. And they can help in increasing your overall compensation over time. So these are some of the questions you should be asking, rather than just, you know, what is the RVU rate and, you know, what is your take home salary. I'm also going to pick on you again, Sufjan, because you have an MBA. You know, and also I'm going to pick on Dr. Fujii Lau because she actually put this in her slide about more than W-2 compensation. So W-2 compensation, obviously, is your salary. It's your paycheck. But there are advantages to getting income that's not W-2 income. And there are things that you can deduct from that kind of income and so forth. Can you tell us a little about what is and isn't W-2 income, and how can having at least some of your income be non-W-2 be financially advantageous? Sure. So W-2, as you know, this is the post-tax income, which you usually get. It is basically salary, which is a fixed salary most of the time, which you get your taxes deducted from there. And mostly, I would expect, as a gastroenterologist, you're going to be in the higher bracket, the highest bracket of tax in the tax bracket. So you'll be paying a lot of tax on that. On the other hand, if you get money, which is tax deferred, as I said, these plans of, you know, 405, 430, then 401s, a lot of that money can be sent over there. And especially 405, I think, has a limit of some $60,000 a year. So a lot of that money will be pre-taxed, and it can be deferred and sent into your retirement account. Now, in a private practice, the distribution of the money can be varied. It can be non-W-2, which can come as a profit-sharing base, and that can also be deferred from the tax. There are different ways of doing that. And then you can deduct a lot of your expenses pre-tax from your income as well. So, you know, every dollar counts. So a lot of these things you can, as a private practitioner, you can put in there, and that can help you to defer some of those costs. These are the benefits of having a private practice. But as I said, I mean, if you are in a non-profit hospital employment situation, or you're an academic center, you can have a lot of tax deferred money sent into your retirement account. So, you know, you just have to weigh what is good for you and what is your goal there. Any other faculty want to contribute to the compensation discussion? This is Vasu. Probably I would add for the private practices, you know, as you said, there is a salary that we talk about. You don't get any bonus after you hit certain RUs being an employee until you become the owner. And how do you become an owner? Owner means partner. How do you get into, buy into the partnership? Nowadays, we were part of a single specialty private practice, and now we partnered with private equity. So the partnership differs. Right now there is no buy-in into the practice, and then there are profits interest, like equity, that is given to the new owners that come in place. So ask questions and learn how to get into the ownership, which might be different in different practices. You could ask for moving allowances, educational allowances like CME. Few stuff like that. Thank you very much. Yes, Inessa, thank you for contributing. I noticed also, so that the expectation at this time that we're trying to meet that the compensation package almost supposed to mirror what the hospital is offering. So, the expectation from our associate physicians that we provide paid vacation, CME, 401k, also opportunity to defer money into the retirement accounts. Plus the opportunity to eventually become a partner and a shareholder and have that income from the ancillary services, just being phased into the practice on the senior level. So there are numerous opportunities in a private practice that the composition of those packages oftentimes are very similar, just because, again, the expectation and the reality of nowadays driving the supply. Thank you so much. Larissa, anything else to add on the compensation topic or practice buy-in topic? Things that have to do with finances? Yeah, definitely. I can give my two cents on the academic, the model. So, you know, I've been seeing this trend that many centers and the hospitals, especially if they're RVU based, so they will employ new people with a higher base salary. But then they don't look into their contract, like how many RVUs they have to make after their fixed salary is over. Like sometimes they can have fixed salary for one year or two years or maybe four years. But then beyond that, they don't look on the hospitals, don't give them a data, like what their RVU rate is going to be, number one. And number two, how many RVUs they are going to make to make that minimum base salary. And the third thing is that, and they also need to look into what is the average or what is the median number of RVUs that each doctor is making. So I want everyone who is newly joining an academic center to don't get a sticker shock. Like once they complete or they're into after one year or two year of salary, when it's actually RVU based. So initially they can have a higher base salary and they get tempted to join an academic center or a hospital employed job. But then they get a sticker shock that they are not meeting certain RVUs and they will have the meeting just because if the hospital or system is not very efficient to make those minimum RVUs. Thank you very much. I guess going back to the RV, the W-2 aspect of things. When we're talking about taxes and stuff like that, you know, basically tax season hurts for everybody. We expect like 50% of our paychecks to go away in taxes and it's very, very disheartening every single year. But for the tax write-off aspect of thing, if you're a W-2 participant, and again, this is what my tax person said, I don't know how true it is. But you have to contribute at least 10% of your salary in order for it to be significant from a W-2 standpoint. And so I don't know how many people like donate up to 10% of their salary in order for them to be able to write off something if they're a W-2 employee. Again, I'm not a tax person. I don't know if that's 100% correct, but that's what I've been told in the past. So essentially, if you're a W-2 employee, even though I donate, all of my donations are from the kindness of your heart rather than it being a tax deductible thing. That is an interesting statistic. I must profess I know nothing about that. But I'm going to try to do what you do, Larissa, and know that I'm contributing from the bottom of my heart in spite of the fact that I'm also a 100% W-2 earner. And so I guess I'm not getting a deduction out of that. Just to watch the clock here, we have about five minutes left because of a spirited discussion here. We've been given permission to keep the transmission going till quarter after eight. So I'm going to ask to shift gears now to the academic medical center type of role for the GI physician and provider. What is the proportion, you're going to like this, of clinical and academic work in an average academic GI job? That is the question that is being pitched to us. I'm going to repeat it. What's the proportion of clinical and academic work in an average academic GI job? Gosh, I'd love to answer that one, but I'm not going to do it. Who on the faculty would like to take that one on? Whether you're in academic practice now or were before, you can give us great pointers. I can take on that one. So I did my training at the University of Kansas. So from that experience, so basically four days of clinical and one day of academic time off. So that means 80% clinical and 20% academic. But I've interviewed at other places as well, and they sometimes get 0.5 or one half day per week. So that means 90% clinical and 10% academic. Sometimes it may not be even that much time for the new faculty. But if you go to a top tier place or if you are doing bench research, so you can have 60% academic or you may have only 30 to 40% clinical. So I think it varies. So it all depends on what place you are in and what is the focus of the place you are in. So before joining the job, I think one need to ask these and need to think, is that the right fit for that person? Thank you very much, Tarun. That's very insightful. Others have any thoughts about that? Sure. I can tell from my personal experience, like all the type of jobs, all academic jobs are not the same. When I joined the University of Tennessee Health Science Center, I had about half a day to one day, depending upon the schedule, which was dedicated for academic work. But the clinical work is also academic most of the time because you are training the fellows and you're training them for the procedures, you're rounding with them. So most of the time you spend, even the clinical time is also spent teaching. But I think the sticking point most of the time here is many academic centers now have some RVU requirements for their faculties as well, because they want them to generate some revenue, especially because in medicine, Department of Medicine, GI and cardiology are most lucrative for any hospital system. So they want the faculty to generate some revenue. So they have some RVU in the end, RVU requirement from even from the faculty. So if you are, or anyone is thinking about joining an academic center, this is one of the most important things to ask, how much dedicated clinical time or dedicated academic time they can have. Because compensation could be made, could depend on that. And also, will there be any mandatory RVU generation because that can jeopardize some of the time which you will have for your academic work. And then you have to go those more two or three or five or more colonoscopies every session just to get to that. So that is one of the most important discussions in an academic jobs needed to be done. I couldn't agree more and really appreciate those insights Sufian. I can add that, you know, I've worked in an academic medical center my entire career. I've been here at Mayo Clinic for eight years. I was at Northwestern for over a dozen years before that started my career at UPMC in Pittsburgh. And while the models have differed in those three centers in terms of detail, the bottom line is that academic time that is not clinical, but it's sort of office time to write your papers or time to spend in the lab. You generally get some degree of startup when you're a younger faculty. And those are years where you're paid less. And so the opportunity cost to your practice for giving you a little bit of desk time to start up your academic career is less. So you're still paying for it in a sense. And then after your first couple or a few years, you generally have to pay for that time. And that means either you're going to earn less because you're going to do less clinical billing, or you're going to receive external or internal grant funding to pay for your time. Or you are going to have a clinical operations or other administrative role or academic administrative role that's going to buy you some time. But that's not really time to do research. There are deliverables administratively that come with that time. So generally, there's no free lunch. I think that's fair to say. And that's true whether you're an academic practice or in private practice. I think that is the bottom line. Any final comments as we wrap up? I really can't thank the faculty enough for an incredibly spirited and educational discussion to really help our attendees and our membership make the best decisions they can in their own situations and for their own success and joy. I would say, love what you do, do what you love. Thank you, Vasu. Couldn't imagine a better message than that. Anyone else on our esteemed faculty here? Any final messages? We end on a high note, Dr. Martin. That's a high note. I want to say thank you to all the faculty and also to you, Eden Essex, Michelle Akers, and Eric Boghossian from ASGE. Eden, if you want to wrap it up for us, please go ahead. Thank you so much. Thank you, Dr. Martin, and to all of our panelists and to you, our audience, our future. As a reminder, a recording of this session will populate your GI LEAP account when it's available. This concludes the presentation, Your Path to Career Success and Joy. We hope this information is useful to you and your practice. Have a good night.

practice models

career paths

physicians

providers

GI

ASGE Practice Operations Committee

pros and cons

compensation

specialization

academic practice

work arrangements