So, Jason, you had a fantastic and very practical talk on colonoscopy prep, and, you know, I think I say that if you haven't heard of a Zempik, you've been living under a rock. So, you know, our whole world's changing. So what do we do with these GLP-1 agonists, and this I think can be extrapolated to the opiate use among our patients. So how do you navigate that? Yeah, it's a great question. Thank you for bringing that up from the audience member who introduced that. Yeah, so, you know, these GLP-1 agonists, they do cause delayed gastric emptying, and we've been hearing more and more from anesthesia colleagues about wanting to hold those medications, maybe have a longer NPO status. I just, you know, was looking to see if there's any literature on this. There's a paper from Brazil where they looked at patients undergoing upper endoscopy, and they do find that there was more retained gastric contents in patients getting EGD who were on semaglutide than patients not on that. They had one case of aspiration pneumonia out of 33 patients or so that they scoped to were on semaglutide. I think it's still largely in the case report, case series, you know, this case series type of literature. I don't know what we should be doing in terms of changing our practice at this point. I think we need to be a little careful. I was asked, I was covering somebody a few months ago, and, you know, they said, well, we need to scope this guy. He's got gastric outlet obstruction, and, you know, we think he has a mass or something. I scoped him and didn't find anything at all, and then later I found out he's been on Ozempic, you know, and I think that that is not that rare of a situation. So in terms of the NPO status, split dose preps, people on semaglutide and similar drugs, I think we need more data. I think we should be cautious getting people to probably hold those drugs for at least a week or two before their endoscopy seems reasonable. They do have a long duration of action, as people know, a long half-life. I'm curious what you do at Mayo Clinic and others if there's anything. I was just going to also put it out to the audience, but from our perspective, I think the answer is obviously we don't know. We need more data, but what's happening in our unit or in general at the hospital is the anesthesia team is actually forming a, has formed a working committee. They're coming up with best practice recommendations and specifically designed on these medications. So they are essentially creating a document, but I think that it's going to be that one week sort of hold, I think, because it's very tough to do that. You know, patients don't really want to come off that, then when they go back on it, do you do a dose escalate? Do you go back on the regular dose? So there are a lot of unknowns, but Samir, Julie, what are you guys doing at your institutions? We've had the same issue as well, and I think we're all in the same boat. So our biggest thing is also driven by our anesthesiologists because there have been instances for major surgeries, not GI surgeries, where there were serious complications that were blamed on Ozempic in terms of significant aspiration and really significant morbidity. So once again, this is driven in our endoscopy unit. We have started tentatively to have patients hold their Ozempic for an EGD. We've had a lot of compliance issues with patients, maybe not, or failing to understand or to do that, but we've noticed that a lot of EGDs are having a lot of food in the stomach. So we're tentatively experimenting with that. I agree. At our institution, our anesthesiologists are really taking the charge regarding this issue. It's a very hot topic right now, and people are rightfully scared and worried about this issue, especially because Ozempic and these drugs are so prevalent at this point. But I think for us as gastroenterologists, we just have to make sure that we're at the table for these discussions, and we do that, again, as a team approach so that all sides are heard. Yeah, no, I think that's important. There was one other question, which is an interesting question. I think, Samer, this goes back to the point you mentioned about the delays and physicians being sort of the, I guess, 71% is the data you showed. I think the question is, is this whole issue of multitasking and sort of going, you know, we are constantly available or meant to be constantly available, and you really are pulled in multiple different directions. So in a busy practice, what practical, and this is for the entire group, what practical sort of recommendations can you give to really sort of streamline that scope in or time to first scope in and what happens in the endoscopy unit? Yeah, so, you know, you're right, this is a whole prevalent problem, not only just for doctors, but just an idea. So I think the first thing we have to recognize, and this is, you know, really big in the literature is that multitasking doesn't work for anybody. I mean, it's very clear in the evidence that doing multiple things at one time does not make you efficient in anything. This is true in business and medicine and everything. So I think we need to, it's hard to get out of this culture of multitasking, but things that you can do, you know, having physician extenders can certainly help out because they are a way for us to help minimize some of the workload that we have. Number two, having clear boundaries of what you're going to do whenever you're in a particular area will help out as well. And then number three, I think more importantly, having systems and processes in place for when a doctor should be notified or when you should be engaged in a particular discussion or decision, because a lot of times it's these small interruptions that just end up, you know, bothering your day. Hey, Dr. Issam, can you just look at this? Or, hey, Dr. Issam, can you manage this? Or things that really don't really need your attention at that point in time that can maybe be batched at a later point in time. But these are all kind of productivity hacks to help out. But I think more importantly, doing things, multitasking just does not work. There's clear evidence for this. Any other thoughts from the panel members or the audience? Well, you know, I think some of it has to do with, you know, setting expectations. And, you know, if we say we start endoscopy at 730 in the morning, does that mean that the attending physician shows up at 730? Or does that mean that the scope gets dropped at 730 or sedation starts at 730? And it's interesting because when you ask people, like in my endoscopy unit, I get three, you know, I get different answers from different people. Some people think 730 is when the doctor walks in the room and meets the patient. And so if you really expect, you know, sedation starting at 730, you got to show up earlier than 730, of course. And then there's the issue of where do you do your note writing? Do you have space to write your note while you're there in the room? Or do you go somewhere else to your office? If you go to your office, you're going to get distracted by something else. You know, I spent some time watching Virginia Mason do endoscopy. Virginia Mason is a hospital in Seattle, a very efficient type, high quality endoscopy unit. And, you know, the doctor finishes the case, goes over, starts working on their note. And I watched this army of people come in, take the patient out, clean the room and everything. When the doctor's done with their note, they turn around the next patients that are ready to go. And I think if you have a setup like that, you can be very efficient. But if the doctor walks out, goes down the hall, goes to the room, they open their email, they're doing their note, you know, writing their probation report or whatever. And then they're, but they check their email, they get a phone call, they're knocking me back at that next patient going on time. Yeah, great point. I trained there. I know exactly how it works there. I think the audience is very, very perceptive. I think we may have missed it. The American Society of Anesthesiologists have already put out the guidelines for the GLP-1 agonist. So we should all look at it. So thank you to, thank you for appointing that as, appointing that. Thank you. Yeah, I appreciate it. The other aspect is academic. The question is about teaching facility in, you know, for the fellowship program and things like that. But I'll extrapolate that a little bit to an overall academic practice and efficiency in the academic practice. So Julie, Jason, and Jenny work at three different academic centers. So how do you handle efficiency sort of in the context of fellows, teaching, and that kind of stuff? So maybe Jenny, I'll start with you. What do you do at MUSC? Yeah, happy to answer that. So we have a fellowship program. We do not have a therapeutic advanced fellowship. We have a general fellowship program. It's usually a multitude of both in-house and people that have come from other organizations. And they take turns rotating between our pink belly and our GI luminal. We do three-year fellowship programs. So we have four first years, four second year, and four third years. And we've really tried developing more of a mentorship fellowship program where there's kind of like a lead fellow, if you would, that really kind of takes under the wing. I meet with all of the fellows, the first-year fellows, the first week that they come. And I say, get ready to drink from a fire hydrant, not a fire hose. I provide them with really just the kind of the down and dirty nitty gritty that they need to know for important phone numbers, workflows, efficiencies, and really just kind of team them up to be successful to say, when you're rounding and you're on this service or this service, I need you to be prepared and make the charge nurse your best friend. Because if you communicate with them, you know, with the attending, of course, with the direction for the day, that the charge nurse will wildly make you very successful. So you have to communicate with them very clearly a plan. And then we do daily huddles that includes our anesthesia staff, our attendings, the fellow and the charge nurse to talk about any concerns or complex patients for the day for our inpatient add-ons or outpatient therapeutic patients coming in that just have a lot of, you know, comorbidities. And so I really just emphasize the importance of the huddles and being prepared and the communication. And then I just kind of serve as a resource with them. So I'll kind of check in with them. Even though our workflows are very different, I'll check in with them and say, do you, how's it going? Do you need any support? And then, of course, we have two attendings that run the fellowship program, so they meet monthly with the fellows. Julie, any thoughts on that from your perspective? Yes, I mean, I agree with what Jenny said. I think one of the really significant tools that are valuable is huddling. I think no matter what your level of trainee is, I think it's good as a faculty member to huddle before the case and after. And if it's a particularly complicated case and you know that it might take some time and it may go against your efficiency that day, it might be good to just focus on one particular aspect of the case. So, for instance, if it's an ERCP in a new trainee, you might want to say, OK, this is going to be a high layer case. It's going to be difficult. Why don't you focus on the cannulation? And once that's achieved, I'll walk you through the rest of the case and then we can huddle about it afterwards. So that's a kind of good way to focus your attention if you are running out of time or you think that efficiency is going to be an issue that day. Yeah, well, that's a good point. Jason, any other pearls of wisdom? Yeah, I agree with those comments. I think setting expectations with the fellows up front helps. I mean, I always want to give the fellows the chance, you know, during colonoscopy to get to the secant and then do the withdrawal. But you know, that's not always realistic, and especially early on in their training. So with a first-year fellow, I might say, OK, today we're going to have you focus on trying to get through the sigmoid colon. And we're going to give you up to 10 minutes to work on the intubation. If they get to the cecum in five minutes, I'll give them time to start the withdrawal. But if they get through the sigmoid in under 10 minutes, which sometimes is a challenge, often is a challenge, especially with first-year fellows, I don't feel bad about taking the scope away because I set the expectations up front. But if they think they're going to the cecum, even if it takes an hour, we're all going to be unhappy. So you've got to be clear about those expectations. Some of our attendings even put a stopwatch on the monitor so they can see when their time is running out. And then they're not going to be disappointed that we were taking the scope away unfairly. Yeah, those are great points. I think we have about 10 minutes. So I would really like to move towards sort of interactive case discussions because I think we have some very important topics to talk about, especially about staffing and things like that. So yeah, so I think let's talk about this. I think this sort of brings together a lot of, and maybe else, this one. I'll start with you, Jenny, and then I would be interested in what others think. I can read it out for the audience, and then I'd like to kind of get everybody's input. So the nurse manager has been receiving more feedback from her staff regarding frustrations with long work hours, increased inpatient add-on cases, and the endoscopy staff vacancy rate has increased by 15% due to travel assignments. And the nurse manager recognizes the increased workload of her staff given the longer hours and current staffing vacancies. What should the nurse manager do to help the nurse or staff feel supported? And I'll sort of extend that to all stakeholders in the endoscopy unit leadership, but Jenny, maybe you can kind of get this. Yeah, this is very applicable. This is definitely something that we have encountered in the past. You know, as we all know, the days can run very long if you have a high patient add-on or if you have subsequent delays that are unforeseen. And so this is definitely something we have. My department specifically, we actually have not had a high turnover rate, and we've always had a pretty high retention rate. But there's been twice in my four and a half years there that we've just had a wave of exit. And so what I have done is that I, you know, have worked with leadership and I really have gotten some travelers agencies in real time to help mitigate some of those holes and help offload that. I have worked with, you know, my nursing director, administrator, if there's anybody, you know, that's like maybe a nurse or tech that's on light duty from other units that couldn't fulfill and maybe have cross-trained them just to help maybe, you know, with workflows or efficiencies or helping turnover bays. For my particular unit, we do not have a tech in our prep and recovery that somebody highlighted earlier. So for my prep and recovery, it's all nursing staff that they do all of the turnover. But I've just, you know, trying to be creative in those instances, acknowledge my staff that are having to be late. I have worked with, you know, my physician group just to, you know, so they're aware of the frustrations of what's going on. I think it's important for the providers to know, you know, is there anything that we could do differently? I've worked with the coordinators. There's been some physicians that, you know, we've worked maybe with their templates or, you know what I mean? So I just think really collaboration and communication has been key. And something else I've done financially, you know, is really working with my HR and compensation team when I had a large number of my tech vacancies is I've instituted retention bonuses. Not that money makes everything better, but I think that the care team members appreciate it if you're advocating, acknowledging, you know, their increased workload and, you know, rewarding them in some capacity. Yeah, no, that's a great point. I think, Subir, what's your perspective as both, you straddle both worlds, sort of the private world and also the academic world. So sort of what's your physician sort of big picture perspective on how your unit has handled staffing and, you know, the challenges with that in the post-pandemic era? So I think it's a good point. So I think there's two things I would say that we do. So in the non-inpatient setting, we have done something a little bit radical. We've moved to a four-day work week where we're kind of just maximizing Monday through Thursday and just eliminate all outpatients on Friday. We'll do a Friday on the occasional time, depending on staff volume, but we've tried to, we've actually done this for the past two months and actually has been, we've had really good feedback from our staff for doing that. Now, obviously there's a lot of contingencies, you know, some patients want Fridays and things like that, but at least in terms of staff morale, that has helped out a lot. On the inpatient service, I think Jenny hit the nail on the coffin for talking to your doctors about this, because we had this issue in the hospital service for a long, for quite some time, and the physicians were not aware that they were adding so many cases on, or that some of these cases may not need to be added on at that time. And so I think having that conversation with the physicians and letting them know, hey, this is the issue, can we either adjust block volume, block time, or maybe if it's possible to add these cases early on or work around things that has helped out with retention on the inpatient side. Yeah, that's a great point. And Julie, any thoughts from your perspective and in big city practice? Yeah, I mean, I think everyone's brought up some really great points. And I think we've all had to deal with this around the country, particularly after the wake of the pandemic and shifting workforce. But I would echo what everyone has said. I think communication is key, being partners with the staff and the physicians with what cases that really need to go and what doesn't or can wait when maybe staffing can be a little bit more flexible. I think those things are key. And obviously, you're just recognizing the hard work, recognizing the frustration, acknowledging that. I think little things goes a long way. So all of the efforts that Jenny particularly highlighted in her talk was really, really important, I think. Any perspectives from the VA, Jason? Well, I think, you know, nursing staffing is one of our greatest challenges in the VA. When we look at our endoscopic throughput, we have we decreased dramatically, of course, at the start of the pandemic, and we have not been able to recover. And when we poll people, why the most common reason it's pretty much universal is due to shortages of nurses. And, you know, it is a challenge. I don't know quite how to resolve it. There's been significant pay increases for nurses. And in a federal institution like the VA, we have slow processes for making change to adapt to that. But, you know, we're talking about more than just money. And so, you know, how you get the staff to be satisfied to recruit and retain is very difficult. I mean, I agree with what's been said by the other speakers today. There's only so much we can do to shape the demand for inpatient work, right? We really can't change that very much. But I think it's important for the physicians, especially to be mindful of the stresses that have been put on our support staff throughout the pandemic, especially, but in general, even before the pandemic, there are a lot of stresses on those staff. Yeah. And then to sort of underscore that, I think it's also important to highlight that physicians, but also leaders in general, need to be cognizant of the impact on all staff and, you know, not just nurses, techs, but really even the, you know, the endoscope reprocessing unit and things like that. So it's really sometimes people are forgotten in the, in the daily shuffle. So we have about three minutes, any thoughts from the audience? Otherwise we can, let's see if there are any other questions. Should we do one more quick case study? Before we get to that case, I had a question for you, Jason, you brought up a really good, helpful tip about patients who are not prepped and possibly if they're flexible enough can drink more prep during the day in your unit and have them be done in the afternoon. Have you noticed, or, you know, are there ways that you can get around or get accepted for insurance for that second procedure same day to happen? Well, I work in the VA, so we don't worry about that. But like the, the, yeah, I can't answer that. The Kansas city VA actually has people prep in their endoscopy. And I think in Japan, it's fairly common that they drink the prep. And when the nurse sees that the prep is clear, they're good to go to get, get assigned to our procedure room. So it's interesting approach. So I've learned a lot today. I'm going to work with Samir to work four days, and then I'm going to work with the VA so that all my dirty preps can happen without any extra phone calls. A four day work week has been awesome. I'm telling you, like my staff and me, we've been, it's been a game changer in terms of quality of life. That's wonderful. Is Friday your day off? Yeah, I chose Friday because I just want Fridays off, but I have other friends of mine who take Mondays off, but so it's just Monday through Thursday and we take all Fridays off. That's nice. So it's a great weekend for everybody. That's amazing. So we're going to run short of time. So maybe we'll do one or two questions. Jason, I wanted to ask you, there are a lot of apps and things like that, which help patients prep for their colonoscopies. What do you all, what's the data behind that and what do you all, do you guys use that in your practice? Yeah, we're not using it in our practice. There is this thing that the VA developed called Annie, that's a smartphone app that we actually had a presentation at DDW that Detroit VA used it and it made a significant difference in bowel prep. I think it's got a lot of utility to do these apps. There are a lot of companies marketing this as well. If you think about what the cost is to your practice, if somebody's showing up with a poor prep, and as Julie was just talking about, the phone calls to the insurance company to get approval for another one, it may be worth investing some money in partnering with one of these companies. I think the AGA has some company they've been working with as well to do these reminders. There's quite a bit of literature on this. It does help. It doesn't make a huge difference and of course it depends on your population. You have patients who have smartphone apps. Probably most of you have, I mean almost everyone has a smartphone, but it's not universal. When you think about DEI issues, again, you've got to be mindful of that because that's a real risk. If you start going down this path of using these things that have smartphones, you are going to be leaving some of your patients behind. You need to think of ways how to help those patients achieve the same results. Great point. Any other thoughts from the panel? Otherwise, Julie? I would say that probably a simple thing that maybe we overlook is really spending the quality time to educate for the prep. I mean, I know it's easy for when we check out and say, okay, this prep on this day and please schedule, but really to reinforce and re-educate your staff to say, you know, what are we really saying to patients when we prep them and spending the extra time to educate them to say, you know, if this doesn't work out great for whatever reason it may be, we're going to have to bring it back in a year and redo it. Once you tell patients that, they start to listen and perk up. And, you know, again, in our practice, I've noticed that spending that time and re-educating the staff to really go over those important factors has made a difference. So maybe you don't need a fancy app, but you're right. It does go into DEI issues that, you know, we don't want to go down that slippery slope. But, you know, like if you want your patient to stop their warfarin five days before the procedure, go to a low-residue diet three days before the procedure, start clear liquids, whatever, you know, having an app that sends them a text that says, don't forget, you've got your procedure in five days. Today, you stopped your warfarin. That can help avoid some of the problems we have with canceled procedures. And that's what the Annie app does for us.

colonoscopy preparation

endoscopy unit challenges

GLP-1 agonists

workflow streamlining

staffing challenges

patient education