I don't know if we have any audience questions at the moment, but Gretchen, I wanted to ask you from your perspective, say for example, the endoscopists in your endoscopy unit want to bring a new robotic endoscopy technology into their endoscopy unit. Allie's very interested in getting this into her unit. I'm picking on her. She's from Cleveland. This is the truth though. She's from Cleveland, so I can do this. Yeah. Is that she has the skill set to do this. She has the will, the mastery, but she's running into roadblocks with budgetary concerns. How do you see, say from your high level perspective, what are some of the issues that need to be taken into account to address Allie's request? It's actually one of my favorite things to talk about. Allie's heard me talk about this probably five times. Whenever we want to do something new, we want to start essentially a new program platform. We want to bring in something robotic in this case. It's really about how you tell your story and you convey your message to the people at the levels where you're going to get the support for funding, resources, training, because any of these, whether you're talking about a capital acquisition for the robot, or you're talking about expanding your disposables that now have to go through your value analysis committee, you have to be able to tell a story very succinctly, but with good data that sells what you're trying to do. Because as we heard Raj say, essentially every place can't be all things to all people. What makes this impactful for this region, this industry, this facility? How does it tie in? To tell the story of it being impactful in a greater platform and performa. When you think about putting that together, who are you trying to address it to? Are you trying to address it to the chief medical officer or the president of the health system? Start with those very basic things. This is the why. These are the patients that we're trying to attract. We're losing them to another system. When we do that, they're taking the rest of their care elsewhere. It's complete leakage. It's more than just the ROI that you're trying to talk about or the subpatient population that you want to care for. You have to think about it and present it in a much bigger picture and talk about the dynamics of what that means for your whole organization and the downstream impact. If we get Allie, her robot, and in that we get funding for the device, and we've got value analysis on page, and we're going to use our quality metrics to track and make sure that we're not upside down in what we're doing and things are going well, we also can tell the story then of how we kept those patients in our system and what their downstream metrics are. Really, you have to talk about and sell people on the whole package. What's your performa? What's your platform look like? Thank you so much for that insight. Allie or Raj, do you have any comments on that? Neil? Yeah, I think some of the nuances that Dr. Keswani touched on between what is privileging and what is credentialing and what is competence and all of these terms, those are really, really important, not only for medical legal issues, but also how your medical staff functions at your individual hospital. Depending on your particular hospital's medical staff bylaws, that is where you're going to find a lot of this information on your privileging and credentialing process. It's really important, I think, to know what that looks like ahead of time before you go to your committee members or your administration or whomever in order to try to request doing new things or request new technology. I think having a sound understanding of that as the operator or on the team of operators before approaching that is a really good step so you can know what that whole journey will look like for you as the physician. The only other thing I would add to what everyone said is we talk a lot about the physician. Allie, Neil, Gerard might just be amazing endoscopists and they do this procedure at their main institution, but now they want to go to a smaller hospital, so they have the competency, but does that hospital have the competency to deal with when things don't go well? It's something you need to think about, so you may get a hotshot physician in there who can do everything, but do their interventional radiology colleagues, are they so hotshot? The surgeons, do they not want to do anything that is pancreatic biliary or complex, anything like that? You need to be really clear about when things don't go well, does the downstream have competency as well? That's something we see, and we have a large healthcare system like many of you do too. That is the limiting factor sometimes of some of us when we go out there to do what we can do downtown without a question. That's part of that discussion that I didn't really touch on, but as you all talk about it, it makes me think about how we all know Allie's great, but put Allie in a place that is a small town USA and may not go so well. Yeah, I totally agree. Also, just something else to add about that is that even if the proceduralist is exceptional and has the skillset that's needed, it's really oftentimes in complex cases about the whole room feeling comfortable. We spend a lot of time teaching our smaller crew of techs who work in just a few rooms who do very complex procedures. We make sure that they're comfortable with the instruments so that they can participate and be helpful. We make sure that our staff and our nursing staff and the rest of everyone who may participate in some capacity in the patient care, that everyone is trained accordingly so that you can be more efficient, higher quality, depend on each other. I think that's really important. I can't remember who it was in their talk brought this up earlier, but I think it's very humbling to be oftentimes the proceduralist in these rooms. I think it's so important to lean on the people around you. They bring with them a totally different skillset and neither can function independently. Someone in their talk, it might have been you, Gerard, said, does anyone look at their tech and their nurse and say, does anyone else see a polyp? I do that every time I do a procedure. I depend on people in the room to also look with me and our fellows. Whoever's there, the more eyes on something, the better. I think to be humbled by that is a really important characteristic for anyone who's going into the world of gastroenterology. It can be fun, though. I sometimes go, do you want to extend the sphincterotomy? And then they're like, well, if it bleeds after I extend it, it's a joint decision. Not everyone wants to be as involved, depending on when it comes to a plus minus decision, but that's what a team is. A team is honestly being respectful that we're all doing this together. Sometimes you can have fun with it, but if you really say, listen, what do you think? It really helps because sometimes you want the opinion. Sometimes it helps you appreciate what's happening yourself. You start to think about it as you verbalize it. I think that point is so good, that team approach. Yeah. And someone else to blame for that extended sphincterotomy that bleeds is even better. Exactly. In the procedure note, things were going well, asked nurse to do this. They said, yes, bleeding occurred. Exactly. As an aside regarding this, I don't know how many of you have had situations where you have nurses or technicians, and because of the huge turnover that we've experienced in the last several years, we have new nurses, new technicians who don't have those skills to help us out with some of these more specialized procedures. They're wanting to get more education and training associated with this. The ASG has a wonderful course that was developed by Dr. Raju, who has developed this amazing tech course, tech university, I call it. And yet the resources from the hospital or from the practice just aren't there to help develop that. How do other institutions, how do you get those resources for your nurses and techs? So I would say it starts with knowing that they're available, right? And having it out there and creating the awareness, because you can budget for those things and you can make arguments for those, particularly in the spaces where you have high turnover, right? And you either are reducing your patient volumes because you don't have the staff to care for them, or you're paying a lot in agency or other things, or you're seeing providers leave because they don't have the support that they want. So creating awareness around that. But there's some really neat technology coming to the forefront now too that I think we can all appreciate is the AI and the Google Glasses and training for polyp recognition and running through mock cases. There's not enough that's done from a simulation or sim lab realistically where we could be doing those together as a team. So if you have times where your units are down, if you've got three providers that are left over that aren't going to DDW, and you can instead use that time to do mock scenarios and things like that, that's one of the greatest things that we can do, especially to build up that opportunity. Doing mentorships with the staff, you've got somebody new, pairing them up with somebody who's not as new. But the mentorship too with a provider, if you've got someone who's willing to spend some time reviewing with them, even if it's an hour go through, you know, how I'd like to do my case, you're going to get a long way. But I didn't know that there was an ASG program for techs. I'd fund that. Allie, you've got an in. I love this. Dr. Eisenberg, we do have two questions, and if you'd like me to read any of them. Sure. Okay. So the first one is, how do you find balance of numbers for endosuturing? Some endoscopists are extremely fast learner compared to others. What are basic minimum to make it fair credentialing and approving privileges? So I could probably take some of this because I do a ton of endoscopic suturing and to teach most of the courses that surround it. So this is a challenge. And I think the ASGE in general has gone away from volume based competency measures, which I think is very appropriate. We know that people, you know, we can set threshold numbers that are required, but there's more to just volume than meets the eye with competency. And so I think it's really important now to think of the cognitive components to these sorts of cases as well, and not just based purely on the numbers. With that having been said, it's easiest, obviously, in our field to say, once you do a certain number of cases, now you're established in someone who can actually perform the procedures. But we've tried to go away a little bit from volume based numbers in that regard. We have a whole slew of different courses that are available to teach endoscopic suturing. There's also different levels of endoscopic suturing. So it's very different to be able to, let's just say, suture in a stent, which can, you know, is one suture and doesn't require maybe the cognitive capacity of performing a full endoscopic sleeve gastroplasty, which can take hours and be, you know, 10 to 15 sutures, depending how you perform it. And so it's really, it's a very interesting and intriguing question. In order to, you know, to get into some of the advanced courses, you have to have either participated in one of the beginner courses, participated in one of the industry courses, or participated in at least 10 of your own cases, because then we think you at least have the foundation to then launch more aggressive endoscopic suturing techniques. So this is definitely a work in progress, and especially with the actual, you know, device getting approval for the treatment of obesity and coming to fruition in January 2026 is going to be, you know, first level, category one code for this. And we're going to see a lot of people very interested in using this who may not be fully competent in doing so yet. The other thing I would say about the device, and, you know, you think about kind of which practice you're using the device in. It's very different, again, to suture in a stent than from maybe to perform a procedure for obesity management, where it's not just about the procedure, but it's about the full, you know, year of therapy and other interventions that come with the procedure to help patients lose weight. So it's a very challenging perspective. I would say that this is one area, and I almost highlighted this when I spoke just before, about kind of making sure that your team is trained well. This is one area where that's exceptionally important. So having your tech and your nurse involved in the learning with these types of nuanced devices can make any procedure much more efficient and much safer. And knowing when to, you know, immediately cinch if you run into bleeding or those sorts of things, it's really a team effort. And I think something like suturing really highlights that. If I can squeeze, I think Dr. Schulman just addressed this question, but I don't know if there's any additional spin to put on it with this question. Any insights on minimum procedure volumes for maintaining privileges? These volumes are easy to reach for full-time clinical faculty, but not so easy for part-time or research-focused individuals. Would you extend your comments any further based on that question, Dr. Schulman? Yeah, I would say this is a challenge. We go through this every year with credentialing our faculty and different endoscopic approaches. And I think there's a few things that Raj mentioned that I just want to highlight, which are that sometimes if you're credentialed to, let's just say, do an ERCP, there's some inherent knowledge that you should be credentialed to take that ERCP to the next level, like a needle-knife sphincterotomy. Even if you don't do 10 needle-knife sphincterotomies a year, you're still capable of doing it because you're performing the other high volume complex procedure that's involved. So I think there is a threshold, and that threshold is not set in stone. It's not universal. I think it's very institutionally dependent. But my suspicion is that if we compared numbers and benchmarked between institutions, it's probably similar. So you have to be able to perform a certain number of ERCPs. I think Peter Cotton always said 150 was kind of the threshold for how to say that you're high volume enough to continue your own cases. And I would say that I think there is probably a minimum with some of the complex procedures that you need to be doing annually to be considered competent. But again, competency is so complex and not just numbers-based anymore. And it kind of depends on your skill acquisition, your learning patterns, what your experiences have been before you're taking on a new procedure. If you can do very complex ERCP, maybe it makes it more likely that you could do very complex therapeutic endoscopic ultrasounds or very complex suturing, as opposed to someone who maybe just finished fellowship who's new at performing EGDs and colons and then trying to learn a new skill. So I think there's a lot to it, and it's a very complex and very intriguing topic. The ASGE did put together a small group of people that's specifically interested in this exact question and how to basically define competence in the advanced world, as the advanced world no longer is pancreatic obiliary and people are branching off into ESD and into bariatrics and into all these kind of nuanced aspects of advanced endoscopy. And I think this will shed light, I know it was developed into a white paper, I expect it to be hopefully coming through the governing board and coming out in the coming months, but I think this will shed light on some of these really nuanced questions. The interesting thing about this particular topic is that the leaders of the small group of which I was a part, brought in people from all different kind of professions who had gone through the credentialing process for their own profession. So we had people from nursing who had gone through the whole credentialing process for nursing and people from social work and other areas that have been through this before, that we could kind of lean on and learn what was challenging and what wasn't challenging and how to address this moving forward and how do you kind of set thresholds for these types of things. So it's a very intriguing question, I don't have a great answer for it. But there's a lot of work and interests that surround this, especially in the world of advanced endoscopy. If I could just add to those important comments, which are a lot about the sort of complex endoscopy, and I'm going to bring it back to part of what the question was about, which was the sort of the non-advanced endoscopy, the bread and butter, which is an equally important question. I'm going to give an unfair philosophical approach to the question. Figure out why these part-time research-focused individuals are doing these procedures. So for example, I trained in a fellowship where the research faculty didn't scope during the week, but took call at night. And that's to help sort of make their commitment clinically a horrible idea, right? It doesn't make sense, and you have to figure out why you're doing this. If it's to get your research faculty to have some clinical effort, you're doing the wrong way and you need to figure out whether they should be doing any clinical time at all. If your research faculty actually want to do endoscopy, then this minimum volume needs to be a volume that everyone feels comfortable with. So I guess I'm diverting it into two different ways. So the example here would be, we have people who are so focused on the esophagus, they stopped doing colonoscopy, including my chief, who was an excellent colonoscopist, but now just does so much upper endoscopy, doesn't do any colonoscopy at all. We have some more hepatologists who don't do any colonoscopy at all anymore. They just do variceal banding, all the AGDs that they need to do. That's okay, because they've decided this is what their clinical practice is. If they want to, and we've talked to our hepatologists about that, if you want to do colonoscopy, okay, let's shift now to how much you need to do. So what problem are you trying to solve for? Are you trying to just basically make sure you have enough volume just to keep them credentialed? That's not the right reason to do it. If they want to make this as part of their practice, then the key for us is to get them enough volume. If someone's a research faculty, but they love taking call, then they need to be doing enough urgent cases during the day as well to feel comfortable to do that at 3 a.m. in the morning. And I know it's easier said than done. Our faculty is gigantic, so we can do weird things like this, which is not have people do like, you know, I only scope the esophagus, but don't go blow the lower esophageal sphincter. But I think a lot of places need to sort of have a north star, which is patient care, which I think all of us on this call do, and figure out what that answer is. And so hopefully that also sort of adds to what Allie was talking about. These are great comments, and I'm sure that people in the audience run into situations like this. Let's put you on the hot seat, Raj, let's say we're at a community academic practice that has private practitioners and academicians. One of the people in the academic practice has a threefold higher incidence of adverse events with colonoscopies than everybody else. When do you talk about proctoring? When do you talk about revoking their privileges? How do you address that situation? Yeah, so I would love to get everyone's opinion on this, because I want to learn from everyone else. I'll tell you very briefly what we do here at our institution is we monitor adverse event rates. So we have an automated report that tracks every single person that comes back to the hospital after a procedure. Every time it's an adverse event, it's reviewed by a very small committee, and it's basically marked as, you know, that's life kind of adverse event, like this happens, pancreatitis after ERCP happens, or maybe there's a deviation in care that needs to be escalated further. So we track everyone's adverse events. We also track all their outcome metrics, right? So things like, you know, ADRR, whatever we talked about. If everyone gets an ongoing professional practice evaluation, as I think may have been touched on before, which is basically how you've done over the past year. And for someone who is an outlier, that's when you move to that focused professional practice evaluation, where you actually have to watch someone do procedures, super awkward, and then basically see if they are exhibiting any concerns for competency. It'll be a plug for why I think video recording is so important. As everyone knows, you can pretty much watch someone do a procedure. I mean, the times I've had to do, you know, watch procedures to someone says, you know, is there any issues of competency, all that, like you can tell within a couple of procedures, right? Like, okay, I know what's going on, right? We've all done this at training courses, right? We're watching someone try to learn a new procedure. Pretty quickly, you can tell that they've not done this procedure before. So it doesn't take forever to figure that out. The question is when to pull the, you know, the trigger of, okay, this is someone who's unsafe care. Jordan, I think no one knows that answer. And especially in a murky area where there's no real hard outcome metrics. But I'd be curious, you know, maybe Neil can give his perspective too, because, you know, he's wearing scrubs. So he, I feel like he looks more authoritative than I am. This is just business schedule for me, really. No, those are all good points that you brought up. And I was actually in this situation in my previous institution. I was the chairman of medicine and there was a aging general surgeon who did everything from freezing skin lesions in his clinics to gallbladders here and there to colonoscopies here and there. And as he got older and his skills declined, his colonoscopy practice really started to have an increase in adverse patient outcomes. So I was the one who was kind of had to lead the charge on his OPPE and FPPE. And like you said, Raj, it gets really murky. And knowing your hospital policies and your hospital bylaws is the most important suggestion I can give to anyone who finds themselves in this unfortunate position. Because this surgeon, in my experience, he basically chose to lawyer up and went all the way with it. And then the hospital lawyered up and went all the way with it. So it was a year and a half worth of med staff hearings at seven, eight o'clock at night with an interdisciplinary panel of physicians, you know, hearing arguments. It was like a trial, basically. But that really shows the lengths that this could go to. And all of these themes came into play of how do we define competence? How do we define volume? And at what point do we privilege and credential someone? And at what point do we call that into question? And having really robust hospital bylaws and policies is just really important in order to maintain that level of standard. And yes, sometimes you do have to have difficult conversations and be in difficult situations. Like I was one of the people who had to proctor this person doing colonoscopy, for example. And then he sort of filed a motion saying that I have a bias because I'm a gastroenterologist and he's a general surgeon and it's in my financial interest to sort of torpedo his practice. And, you know, it really got very granular into how far it goes. And then an independent proctor had to be called in from another institution. So anyway, a lot of gory details. But all that to say that knowing your hospital policies, bylaws, and having clear definitions of these terms, which are oftentimes moving targets, is going to be the best kind of North Star in order to navigate these tricky situations. Yeah, I will say, we also were in a similar situation with one of our faculty more recently. And it's very awkward. It's very sensitive, especially as people, you know, age out in their career, and they're still trying to maintain the same volume of care. And we had a very different experience or reaction from this faculty member than you're describing. And I think in several ways, she recognized the awkwardness. And she was very grateful that this far along in her career, she was, you know, having numerous perforations and we knew it was time to intervene. We started with kind of the proctoring and then we had further discussions with her as other things came to light that it was probably time to stop endoscopy altogether. And then there was the question of, should she still be able to do endoscopy on call and to cover service endoscopy? And we really felt that that would be unacceptable and inappropriate. If you can't maintain your skills and kind of the outpatient world, then you shouldn't be necessarily on the front line on the inpatient side. And she was very, while very sensitive, we kept it very closed within our, you know, only our leadership team. But she was very grateful and she felt like it was kind of a weight off her shoulders that she could recognize that this was not the way she had previously practiced. And she's such a well-respected physician that she was kind of grateful that we had intervened. So just wanted to put that kind of opposite extreme out there. Yeah. I mean, Neil's story is about as bad as it gets, which is what hospitals are nervous about. Your best bet, even if it's contentious, is to convince the person that it's not in their best interest to fight it because then it gets reported to the medical board. And if they're younger, they will have difficulty going somewhere else. So your best bet is for them to recognize that they should voluntarily recuse their clinical privileges. But you know, if you're at the end of your career, you know, you might not be finding a new job. So you're going to maybe fight tooth and nail to hang on to the one you have. But it's just such an emotionally laden thing that you just hope, whoever asked the question, you hope you never have to get into this, but you kind of owe it to your patients if you think there's an issue to do it because, you know, no one else is going to fight for it otherwise. Yeah. I'm glad you touched on what's reportable, too, because that really plays into a lot of what we're talking about here. And if a physician is under investigation, they have a 14 day kind of grace period, which is a temporary suspension of privileges. And then it can be reported to the medical board after that. And conversely, if a physician resigns while under investigation, that is also technically reportable, too. And then there is the coercion where if a physician says, well, I was coerced into voluntarily giving up my privileges, then they have there's a case to be made for that, too. So I'm really understanding that actually it's worth doing a leadership course just in this. There's a few that I can recommend offline to anybody who might be interested in. But I went out of the way and took a full retreat on this because I was in these situations a lot. And it can be really helpful. Now, these are difficult conversations, obviously. I don't know. We're towards the end of our time. I can't believe how fast it went. Eden, I don't know if we should close shop here or address any further questions or go to a case study. What do you suggest? You know what? We have one question in the queue. So why don't we let one person respond to it, and then maybe we'll wrap for the day. How does that sound? Sounds great. Go ahead. So I'll read it, and then you tell me who it goes to. I was recently asked to review credentialing for someone for EUS without formal advanced training. However, the endoscopist has performed more than 300 EUS in the last year with their prior hospital. How would faculty, one faculty member, approach this scenario? Give privileges and observe? Is there anybody who'd like to take it, or who do you want to send that to, Gerard? Well, I mean, that's very challenging, obviously. There's a lot of factors that play a role in this privileging. One suggestion would be proctor that person to see if they actually can do what they can do. Raj, one answer? No, I've already said Gretchen has to answer it, so that's my answer. Go ahead. Go for it. It's proctoring. Gretchen's going to say defer to Allie. Well, I mean, from a medical bylaw standpoint, if you're part of a large organization, they generally have guidelines that are on this. But if you look at what's practical in most applications, it's exactly that. Well, with that, I think we will defer to our course directors to go ahead and wrap us up for the day. Well, so I really want to thank each and every one of you for participating in this course. I'm so grateful to my course co-directors, Allie and Neil, and to our all-star faculty. I hope you're able to bring home some of your ideas that you've gained, some strategies to make your teams better through the lens of leading effectively through accountability and development. Your participation has been invaluable and has made this course, I think, one of the best that ASG has offered yet. Allie and Neil, any additional words? This was so much fun to be a part of, and thank you to Gerard, and it goes without saying, but I'm going to say it anyways, Eden, who is always our rock and our rock star in putting together our course materials and being our team mom and everything in between. So, Eden, thank you so much, and thank you to the audience for your very interactive participation. Feel free to reach out even after the course is concluded. We learn from all of you, and it's a two-way street, so look forward to continuing to interact with you all. And, Allie, any last comments? Yeah. I mean, I would, of course, echo what both of you said, nothing more to add, but thank you for everyone's participation. Thank you to the faculty. Thank you to Eden. And I think, just like we had said in most of our slides, leadership is not necessarily something that you're born into, but something that you can learn from, and I feel like I've learned so much throughout this course from my co-directors and from the faculty and from all of your questions. So, thank you to everyone. Well, thank you. To borrow a new term, a term that's new to me from Dr. Kashal, this was probably the bomb diggity course, most bomb diggity course ever. And so, I just want to congratulate everyone, from our faculty to our attendees. This was a really wonderful day. As a reminder, each of you will have ongoing access to the recordings from the course via GI Leap, ASG's online learning management system. You can just go to the word learn.asge.org. So, go ahead and email quality.asge.org if you're having any trouble getting in on that. We may get back to you next week, just because it's the weekend, but we are just so glad you were here. But when the recordings are available in roughly three to four weeks, I'll send out an email to everybody to let you know that that is there. The course evaluation, as we said earlier, is now available, and once you complete it, you can download your certificate. So, for the positions, it'll be at CME. For anyone else, it will be a certificate of participation that you can convert to any kind of continuing education credit that you need. So, again, if you need assistance logging into the GI Leap, you email quality.asge.org. And this concludes the ASGE course, GI Unit Leadership, Optimizing Endoscopic Operations Through Leadership. We hope this information is useful to you and your team. Thanks, everybody.

endoscopy

robotic technology

credentialing challenges

competency assessment

team dynamics

hospital policies

performance issues