starting over, training again, things that maybe you worry too much about that you didn't really need to, or something like that. All right, who wants to talk? I think early on you're worried about having enough cases and your co-fellows might look like they're advancing a little faster than you. You know, they're gonna be like, I made the CECM, and you're like, I'm stuck in the rectum. But you'll catch up, and there's plenty of time. I mean, I think some programs, I think the fellows at Einstein were doing like 1,000 colonoscopies and stuff. You don't need 1,000. But it's nice that you're going in. You can kind of seek out extras if you want. If the endoscopy's not your thing, maybe you're more focused towards liver or something else, and then you can tailor what you want kind of in your third year. But you don't worry about what other people are doing. You're gonna catch up. Even if you're a little, even at the end of the first year, you know, it depends on rotations. You might be on service months for three in a row, and they've been on endoscopy, and you feel like, I can't do anything, and they're doing this great stuff. You'll catch up. Everyone does. Yeah, I think that's a really good point. Especially with ERCP, I was an advanced fellow, and there were two of us, and the other one had done 200 ERCPs, and I had done zero. Actually, I'd done a couple with you over at the VA. And that was super intimidating because she was so far ahead of me. But by the end of the year, we were both fine. And it's the same way with colonoscopy. After about 200, everyone can get to the CECM pretty reliably. The more you do, obviously, the better you'll get, but I wouldn't worry about getting 1,000. What I was gonna say, during my fellowship, I went to an institution where research was really important and really stressed, and I didn't enjoy that aspect of my fellowship at all, but I felt like I had to put in the time to do that. And in retrospect, I wish I would have just admitted to myself sooner that that just wasn't my love or passion, and spent less time doing that and more time doing maybe more clinically-related research or less research altogether. So that's what, just be honest with yourself. Try and think early what makes you happy, what don't you like, and try and, it's early, right? You have three years to figure out what you're gonna do ultimately. But just be honest with yourself. Talk to a lot of people in different areas, academics, non-academics, and figure out what's right for you. Don't feel pressured to be who they want you to be. Yeah, I'll add, know what you want, take your time, and have fun. Three years is a pretty long time, so you'll get wherever you wanna get. If you wanna be an academician, if you wanna be a researcher, if you wanna be the busiest private practitioner in the area and make a million dollar, I mean, you'll do that. So take your time, know what you want early on, and work on that. Don't stress too much about endoscopy. I mean, we're talking a lot about endoscopy this course, so you'll all get there. I think everybody graduates being competent with endoscopy. Usually by six months, most of you will complete 90% of your colonoscopies, maybe 80% of your colonoscopies. In one year, you'll complete 95. In two years, if you cannot finish it, your attending probably cannot finish it. So you'll get there with time. So enjoy. And I will also add that, try to use all the resources you have. Specifically, when you work with different attendings, every attending will have something to teach you. So try to get a little bit of this, a little bit of that. At the end, it's one big toolbox for you, and you keep adding skills and knowledge, and you will have your own style at the end. But you'll learn something from this person, something from that person, and it will all help you when you practice on your own. We have said twice, though, that kind of know what you want to do, but that's not, if you don't know if you want to do liver, or your lumen, or if you want to do IBD, that's not something you have to decide yet, and there's plenty of time for that. And if there's IBD clinics where you are, you know, maybe try to get, if that's something you're thinking about, maybe get in there early to see if you like the clinic structure and the patients and things, because patient populations are kind of different characteristics, depending on what you're looking at. Maybe your motility is different, and your liver patients, which aren't necessarily the easiest patients either, but it's more hardcore medical stuff. So it depends on what your interests are going in, but you don't have to decide yet. But I think at some point you do, and it's easier to get a mentor earlier on that can maybe kind of say the same clinical interests and try to get in with them on a project or something, just especially if you're expected to do, and you can't get out of it. So you have to just at least try to find the mentor that you're gonna mesh with, even if it's not maybe your topic that you're interested in. Yeah, I wanted to add, you know, there's fellows that have said, you know, I'm gonna go out, and in their second year they decide what they wanna do, and some are looking for jobs, and they decide they wanna go into private practice or join a hospital. And they say, I went and interviewed for a job, and they told me they love me, they love my training, they like me a lot, but they wanted to make sure I was able to do ERCP. You can substitute whatever you want. I was able to do IBD, I was able to do motility, otherwise they weren't gonna hire me. Strange, right? So I've had fellows that have come back and said, well, you know, I need to learn ERCP during my third year of fellowship, because otherwise, you know, the job's not gonna be pleased with me. And I start laughing. I was like, oh, I'm sorry to hear that. I guess you'll remain jobless. No, I'm just kidding, no, I didn't say that. But I was like, listen, who in their right mind requires somebody to do something that A, they weren't going to do or didn't wanna do for a job? So I'm saying this related to Dr. Jorgensen's point. If you don't want to do it, and you're looking for a job, and they're like, well, I have to live this area, I have to do that, then maybe that's just not the job for you. It's really hard, though, right? You're like, oh, I wanna live in South Florida, and my family's from Miami, and I can't wait to go back there. That's the job I have to have, so I have to learn this. Okay, great, but are you gonna be happy doing it? Really hard. Yeah, that's a really good point. There was a study out, I don't know, maybe 10 years ago that looked at why people chose their first job, and when it was primarily based on location, those people were much more likely to leave within five years. So you do really want to love your job, you want to love your colleagues, and I think that's usually more important than location. It may seem like location is really, really important if you have family and things like that, but there are a lot of other things to consider. You don't want to be miserable working. You'll spend a lot of time doing it. You have to go through a fellowship first, though. We're getting ahead of ourselves. I feel like I'm struggling a lot with engaging a lot of fine motor hand skills, particularly when talking. I feel like I'm having a lot of pain with that. So any advice or tips to share as we learn skills that we should probably not get into bad habits or prevent that or get through that? Yeah, you're not the only one. Everyone is struggling right now with fine motor skills and twerking and using both hands to do something. We don't do a lot of things with both hands, right? So were you a big video game player? I'm guessing not. I want someone to do that study to see if video gamers are better at colonoscopy. But anyway, there are some things that you can do to help prevent injury. Making sure that you have good ergonomics, like we went over in a couple of the lectures is really important. Try not to grip the scope really hard. As you get better with your left hand, using the dials more and twerking less is also gonna be easier on your body. It's hard in the beginning, because it's sort of like all you can do to get around that curve is twerk, twerk, twerk, but it will get better. If you feel like your hands are getting sore, though, make sure that you're taking breaks if you need to. I know that's also hard, because you don't wanna be seen as a wimp or trying to skirt work and things like that. But honestly, just things like ice and rest and NSAIDs can help, too. But don't let it get so bad. If you think you have carpal tunnel syndrome or something like that, you should definitely be evaluated. I think a good point with not gripping the scope or the shaft very hard, I mean, I use extra gauze, because I don't like the, it actually takes less pressure to when you have a bigger grip. So I put a lot of lube on there when I'm doing a colonoscopy and I try to grip it. But for early days, I remember having a kind of sore thumb. Early days, even advanced year, I had like a sore thumb. I was pushing on the L. I was so worried that little wire was gonna come out. I was pushing down on it so hard, but it was just, it was actually probably a faulty scope. It needed to be adjusted, but you did get some pain. And then once you relax and you don't wanna, you're gonna get better. And when you're getting better, you're gonna be more confident that if you slip back, it's not gonna matter. So you don't, just try to grip things a little less. A really hard grip strength can really make you sore. And women are hugely disadvantaged because it's been demonstrated that we have actually 1 8th the grip strength of men on average. So women tend to have more problems with their hands doing endoscopy. So just be very careful. I was gonna say also, if you're just looking for things to like practice and work on your fine motor skills, if you have access to a simulator at your institution, which a lot of people do, and a lot of people have access and don't really know about it because sometimes it lives in a surgical department or somewhere else. If you haven't already used a simulator, definitely ask your program director about that because the simulators can really help you practice on your fine motor skills with endoscopy. It's a nice way to practice without doing endoscopy on a patient. You'll get to practice on one of our mechanical simulators in the lab today, but a lot of institutions will have like virtual simulators to practice on. And I would just say one more thing for technique, actually two tips. One, and it may sound a little silly, but if you have typically smaller hands, if you find faculty that typically have smaller hands, they'll have a lot more techniques than those with larger hands. People tend to scope a little bit differently actually based on the size of their hands. Actually, one of our mentors, Dr. Elta was incredible. Hands were very small and she could do things that no one else could. But she actually spent the latter part, the former part of her career, she's like, you know, my hands actually hurt and I had to change the way I scoped 20 years into my career. She's a master endoscopist, one of the best we've ever seen. And she found that actually using her right hand more for dials rather than her left hand to control everything, even though she could save a lot of things, which gets back to her ergonomics. The second thing I would say is, what do you do when you're nervous? What do you do when you're a first year fellow? So relax. I mean, half the time your hands are fine, it has nothing to do with your hand size or strength or skill, it's just you're nervous. And invariably, your left hand grips because you're nervous and scared and you're like, and I'd actually see the veins pop on some of the fellows and I'm like, oh my God, relax. It's okay, they're like, I can. Take a couple deep breaths, relax, and try to hold the scope with your left hand as if it was freely mobile, it's loose in your hand and you're not gripping it so tight. Your left hand grip is actually supposed to be a lot looser than you think. And it'll actually save some of your grip strength and hurt on your left hand. So adding on that point, I think in September to December, a lot of things that you're thinking too much about now will just become second nature. It's really amazing. You'll be thinking about a lot of things now, but just this is how the human body, the muscle memory, this is how it works. It will just become a lot easier for you. Now it varies between one person and another. Some people are more skilled, but 99.9% of people graduate fellowship really competent and doing a lot of discovered procedures. So take your time again. But if you're hurting every day after endoscopy, then something is not right. So you have to, probably the best thing is to work with your attending of that week or that day, look at how they're doing things, tell them, I'm hurting here. And you can probably change something in your technique and the hand size, the grip size, there's a lot of data on that, especially from the surgical literature. Make sure you don't compensate with your back because back injury is more common in women because the strength they have is a little bit less. So they compensate with their backs. So also keep that in mind. So you need to develop early habits, knowing that you will get better at everything like very, very soon. And there are also studies show that people who play instruments have better hand skills. And if people who play video games, actually they have better hand skills and really decreases the pain. If you go one month without scoping and go back to scoping, you will hurt a little bit, but that should go away. And all those ergonomic things are very, very important. There are videos by, I think ASG has some videos for sure. ACG also has some videos on YouTube. I really encourage you to look at, all of you to watch them and look at them. There are certain stretching techniques you can do. I actually do them myself. There are like certain things you can do and where you put the screen and all those stuff, they're very, very important. 10 years ago, I used to be out on Friday with my friends and hanging out. Now I cannot sleep on Fridays because my neck hurts and it's really true thing. I'm only three years out of fellowship. So I'm still up at night, but from the pain. So I really think you should develop early habits early on to prevent injury later. Thank you. What other questions do you guys have? Are you just hungry? Anything really in your mind? I mean, it's very casual and formal. Yes. We cannot hear you now. Can you hear now? Yes. Okay, so I have a question about career choices going back, specifically for advanced endoscopists. To me, it seems like you have to have some sort of hospital support. You have to be in some sort of more complex environment to have the cases, to do the cases, to again, evolve yourself and be able to perform these things. But do you necessarily have to be a grant bringer, like in some way, academician to... I know it's easy to say, choose your own clinical or research, but in real life, I think there's always some kind of involuntary things you have to do to maintain your practice. So I'm interested to be a good, independent, competent clinician, endoscopist, therapeutic endoscopist. So how much research do I have to do to maintain myself in a big hospital, for example? How much resources? How much research? Yeah, do I, again, how can I be a good clinician as therapeutic endoscopist while also not putting too much pressure on myself if I can't bring grants or if I can't do some major research? Is that possible? And I'm sure it's evolving in a way. Is it possible? You can be an excellent clinician and not do research. Absolutely possible. You know, a lot of the advanced endoscopists focus on clinical practice, and most of our research is really what the procedures we do. It's just the nature of it, because you cannot be in the lab and then we have some post-doc fellows doing the lab science. You have to do the procedures, know what you're doing. So most of our, you have to be solid clinically to start with. If you're not solid clinically, I think your research will not be as good, but you don't really need to do a lot of research. So nowadays it's a little different. I think when I was starting my fellowship a few years ago, the late, great John Bailey told me that we're, I told him I'm interested in advanced endoscopy, and he's like, well, we're teaching all those fellows great things, but then they all graduate, and it's very hard to find jobs. And that was like, I don't know, six, seven years ago. So it's hard to find jobs in academia, but I think because the places are limited. But you can definitely now, advanced endoscopy is changing and developing, you can do a lot of things in different settings, in hybrid settings, at VA situation, at a big hospital, at a medium-sized hospital. So yes, you can do a lot of those things, and you don't need to be at an academic place and doing a lot of research. I don't know if that answers your question. Any? Yeah. Can you hear me okay? So what advice would you give if you run into a situation in which you have a PERF or some other adverse event? How do you bounce back, and what resources would you use for that? Yeah, that's a really great question. I think, so first of all, just know that you're not alone. Everyone in GI will eventually have some sort of complication. It's good to talk to people. So either your attendings or your fellows. Most hospital systems, I think, nowadays have some sort of a program that help providers get through adverse events in our hospital. It's called, I can't remember what it's called, the BESIDE program. And there are actually psychologists available for us for counseling for situations like that, because it is common, and it is hard to get over that. I also find it very helpful when I have a complication to spend a lot of time with the patient and the family, explain what happened, say I'm sorry. You don't necessarily have to say that you made a mistake or that you don't have to blame yourself or flog yourself, but it does help to, makes me feel better to apologize and say I'm sorry this happened. I would just say to that, when you talk about I'm sorry, just because I do a lot of medical legal work for defending, if you say I'm sorry, there was one of the known complications that occurred. I'm very sorry it happened. I know we talked about this before the procedure as a complication. I feel very bad that it occurred. Unfortunately, it's just a complication from the procedure, but I'm sorry it happened to your family member. And obviously, you're gonna feel it. They're gonna feel your honesty coming through and showing as someone who cares, rather than saying, I'm sorry, there shouldn't have been a complication. It's a very fine line, because at the end of the day, we know you're sorry, we know nobody meant to do it, but if you say it one way versus the other, it actually can impact. I think Jen's right, or Dr. Jorgensen's right, talking to your attending, having that discussion early with the patient, even if you haven't settled it, is very important to have that discussion early on. Because if you wait to say, well, I have to be ready mentally to talk to them, doesn't work. Actually, there have been studies to show that patients are less likely to be sad and have any legal ramifications if you talk to them right away and early on, rather than wait. Yeah, patients who like their doctors usually don't sue their doctors. So if you're talking about legal stuff, that connection you have, that physician-patient relationship, which is something kind of changed over the years, that relationship will protect you for sure. I mean, sometimes you have complications and the patient's family will tell you, thank you. And they are kind of feeling your pain. So that's from the legal standpoint. From your development, I think it's painful. You'll probably remember this patient for the rest of your life, most likely. But take that as an opportunity to learn. You can take it as teaching what happened, what went wrong. Sometimes nothing really goes wrong. You just did the same thing like you do every single time. But if there is something you could have done a little bit better, don't talk to anybody about it. Just you're attending your team. But think about it yourself. Try to learn something from that experience. And I wanna take a step back, just one more step back, because we're still learning here. If you're doing something and you're not comfortable with this month, next year, and the third year, don't do it. If you're comfortable, sure, you all wanna be, some people wanna be like really, don't be a cowboy in fellowship, even after, I would say, for a little bit. Or never, I don't know. But don't do things, keep chatting, but don't do things you're not comfortable with. Something is, even if the attending trusts you 100% and they leave the room and you come into something that doesn't sound right, doesn't feel right, wait, call for the attending, just wait. So don't put that on yourself, because you're still learning for the next couple years, three years. I'll just add one thing. I agree that just talking about it with your colleagues does help if you have a CQI-type conference where you can talk about, we've done that with just anything from post-polyvectomy bleeds, which are that uncommon, you see every quarter, and we're talking about them and how the patient was managed. You're out there, especially if you're doing advanced stuff, you're up there more than everybody else. But just, when they were talking earlier in some of the talks about the indication for the procedure, why you're doing it, you wanna make sure every case that there is a good indication, that you're gonna feel much worse if a complication occurs and wasn't even really indicated. Some 20-year-old with some dyspepsia got sent for an EGD, and you did the EGD, and they aspirated massively, and they're in the ICU. It's gonna make you feel much worse than if an 80-year-old with dysphagia and has a bunch of food in there and aspirated. So, you wanna make sure that you're gonna, even though you didn't order it, you can question. We've canceled cases before that didn't really seem high-risk for patients, and really, what are you gonna do with the data? What are you gonna do? What are you expecting to find? You're still gonna feel bad that this happened, but you're gonna feel a lot less guilty, I think, if you at least know it was indicated and that was a good reason that you did it and it's just a complication that's known. If it's kind of this questionable indication, you're gonna feel worse and probably open yourself up to legal stuff, too. I just wanna say one more thing about that, that just make sure that you see those patients every day in the hospital while they're there, also. I think that's really important when you're a fellow and also when you're out in practice and just kind of make a habit of personally going by and seeing that patient every day, even if you kind of rotate it off to a different service or someone else is seeing that patient, also make sure you're physically going in there and seeing that patient every day in the hospital. Yeah, and then final point. So if I do, for example, cyst gastrosomy, patient's fine, they get admissed, post-op for some pain, next day is the weekend and the general GI or liver tending or someone else is rounding because there was nothing wrong, the patient was staying for other reasons, and all of a sudden, a complication occurs, I wanna know about it. Like, you're not calling me and saying, oh, Dr. Taylor, there was a complication and I'm feeling bad about it. I do wanna know. And I would say the vast majority of us all want to know. If we wanna know there was something wrong that happened to our patient, even if we weren't on call. So you're actually doing a favor and a service and I'm eternally grateful for every fellow that calls me on a patient that I had a complication on because then I can go see the patient myself. They're like, yeah, but you're not on call. I'm like, I don't care. I go in, they're like, yeah, but you're not on service. I was like, I don't care, that's my patient. I go in, now that's my own pathology. But I think it's the right thing to do. So I encourage you actually to call in attending until the point they say, I don't wanna know. Somebody says that, well, that's their prerogative. But most of us, I don't know how the panel feels, we all wanna know. So please call us, please. Oh, I just wanted to ask you guys about bariatrics. Is that something new in the field of advanced endoscopy? Is this something you just learn in a course over the weekend or something? Because it's just something I've seen about that, actually. Have I attended and said, yeah, there's really no fellowships. I'm advanced trained, and I went to this course, now I can play with balloons in people's stomachs. I don't know anything about that, I'm just curious. There's a lot of discussion. As the things that we were able to do expands, I mean, they're talking ERCP US, and do you do extra, like a six-month thing for bariatrics? Do you do one for ESD? I mean, you don't wanna be in fellowship forever, right? You wanna... And things like the bariatrics, too, there's a lot of support that go into it. So they have to have the hospital support, they do nutritionists. There's a lot of things that go into it that you have to make sure the hospital... I mean, you would say, I can do this, but then if the hospital's not behind you, it's gonna be impossible, probably. There's places, if you wanna learn it, because the place is wanting to get into it, and they'll support it, they may send you to some courses. You had to learn suturing and stuff like that, for other reasons. And you'll have the skills to do it, so it's just another technique, using the same tools we have. But I think it's a lot of the... Doing the people that do it already regularly, I mean, they've already paved the way of a good technique. You wanna probably watch videos, and go visit them, and maybe they mentor and proctor you during the first case or two. You wanna make sure that's all set up, and not just try it yourself, because you can suture, probably. Yeah, I totally agree. And I do bariatrics. I was lucky to train in my advanced year for that, but I picked that fellowship specifically, because I wanted to work with one person, and my mentor, she did a lot of bariatric stuff, so it's been a passion for me for a long time. So I kind of tailored my match towards it, and luckily I got in, and I think it's a great field. I think it will be around, and it will be better, because once we have insurance to cover it, we will do a lot more. We are still trying to figure out how to train people for it. So one of the biggest questions, do we train fellows in their fourth year, or do we have a special year? There are only two programs right now that do a dedicated one year for bariatric endoscopy, and one in Boston, one in New York, only two programs. So it's not very clear, and I don't think you need a full year for that, my personal opinion. I think if you have the advanced endoscopy skills, you can just add on some skills and learn it. So those skills, this skill set will help you to learn a lot of things. Balloons are very easy to place. Removing them are a little bit harder. You gotta be comfortable with stuff like that. So we're still trying to figure out how to train people, but for you, as you're starting, I would see who's doing it around you. If there's nobody in your program doing it, maybe start emailing some programs and some mentors outside and try to reach out. Actually, I'm just gonna shout out to ASGE, because they have a new ASGE Beyond the Scope mentorship program. So that's one way to kind of figure out if there is a mentor you can reach out to, and it's a two-years mentorship, and you can connect with them, and they will help you with those stuff, put you on some trials or studies or do some research with them. So if you get involved early on, it helps you to get later. And then I agree with all things to start a program. It's a whole different hustle. It's a whole different thing. It's a lot of politics. That comes later. But I would encourage everybody to really try to learn it. But I think, as in general, we need to do a better job incorporating that in fellowship trainings. Most places don't yet do that.

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