Hello, welcome to a discussion on sustainable practice and specifically the practical actions endoscopy teams can take towards a greener practice as every change in the right direction matters. My name is Eden Essex and I will be the announcer for this session. This session is being recorded and will be available to you in the near future via G.I. Leap, ASG's online learning platform. By registering for this event, the program automatically has populated your G.I. Leap account and in about two weeks you will find a recording of the session there. Contact the ASG office if you need assistance accessing your account. Prior to opening this session, I shared a PDF of one of the presenter's slide decks with you all via email, so you should have that in your inbox. You will be able to submit questions and comments throughout the event via the Q&A box. A panel discussion followed by audience Q&A will be held at the conclusion of the presentations. Now it is my pleasure to introduce our moderator for the session, Dr. Rabia De La Torre. Dr. Rabia De La Torre is a gastroenterologist and therapeutic endoscopist in New York City. She is an assistant professor of medicine at NYU School of Medicine and the director of endoscopy at Bellevue Hospital. Dr. De La Torre currently serves on the G.I. Multisociety Task Force for Environmental and Practice Sustainability. She's the lead author of the next article to be published in the ASG paper series, Practical Steps to Green Your Endoscopy Unit, which addresses appropriate management of endoscopic waste. I will now hand the proverbial floor over to Dr. De La Torre. Thank you, Eden. I'm really looking forward to these wonderful talks that we're going to be discussing today on sustainable endoscopy with two really wonderful experts. Our first talk is presented by Cecil Scheib, who will discuss culture change and how our changes and actions matter. Cecil is NYU New York University's chief sustainability officer. In this role, he oversees the university-wide effort to build a healthier and more sustainable future. Key responsibilities include reducing NYU's carbon emissions, supporting sustainability teaching and learning across NYU's diverse schools and campuses, championing ideas that advance innovation, education, and social justice, and engaging with the community through students, staff, and faculty opportunities. Cecil also co-founded the EcoVillage Dancing Rabbit, which we have lots of questions and we'll talk about later, is a New York State licensed professional engineer and is a certified energy manager and LEED certified accredited professional. He serves on the board of directors of Urban Green Council. Cecil, the virtual floor is yours. Thank you so much for having me. It is an honor to be here. So I'm going to say a few words about this topic and also look forward to the Q&A period and hear what is interesting to people. I'm an engineer, so I'm a professional. I go to these types of meetings of my own, professional societies, and it's really interesting to me to see how another profession does this. So the sort of question set up, and this is a perfect time for it during Earth Month is, is change possible? Can things change? Can they change for the better? And sometimes it seems like change is impossible, but that is a little bit of a psychological construct that we all have, right? So for those of you that have been practicing medicine for 10 years or 20 years or 30 years or even longer, think about it. Do you practice the same way you did when you started out? I mean, obviously not, right? Things have changed, everything from technology. You can go back far enough, doctors didn't wash their hands before they went into the surgical room, right? So changes are possible. I always like to tell students at NYU when they seem to despair that change is possible, there was a time you could stand in New York City and look at the city streets and they would have been filled with horses, filled with horses bringing people all over the city. Of course, also filled with horse poop, but that's a total other story of New York. And you could have told someone back then, you know, someday all these horses will be gone. There'll be no horses. And people would have said, but that's impossible. How will people get around New York City? It can be very difficult to see that that change is coming and yet we know that it is. And so each of us has our own story about how we came to care about the environment and the earth, right? Everyone cares about it in a different way to a different extent. Some people say they don't care. Although when people say they don't care about the environment or sustainability or it's not a priority, I sometimes ask them, do you want your kids to have clean air to breathe? Do you want your kids to have clean water to breathe? You want there to be less traffic. You want healthier environments, right? We want less disease. You want to feel confident that your kids are going to have, and your grandkids have a world they can grow up in and be safe and secure without, you know, various natural climatic disasters. It turns out you do care about it. And while it's easy to view our world as being very polarized, I think this is an area where we really have a lot of common ground. You know, I myself, when I started college, I was a music major. That was what I got into in high school. And I wanted to make the world a better place by playing in a symphony orchestra, making beautiful music and making people happy. And it wasn't until I was a junior in college and I took a class, just a general survey class in the environment, and really started to understand what was going on. I didn't know those things when I entered college. Now I think things are different, right? When I talk to NYU students, they enter, they know about, you know, if I had given this talk to this group 15 years ago, I started NYU in 2007, you know, if I had given the talk to this group back then, I would have said, okay, let me make sure everyone knows about greenhouse gases and how that affects our global temperatures. I'm going to trust that the people on this call know what's going on there, right? I don't have to explain the basic facts. But what I find interesting to observe in our culture is that even though the level of knowledge and of education and awareness has grown, that does not necessarily mean that people are more likely to act. In fact, this knowledge sometimes just brings a sense of hopelessness, either an understanding of how large the problem is may make each of us feel that our contribution is so small it's hardly worth making, or that it's hopeless, there's nothing we can do, it's forces outside of our control, or it's just so depressing we'd rather think about something else. And I totally get it. This is my job. This is what I do as a career. And sometimes I get depressed and say, I don't know how we're going to address this. And it's for each of us to figure out how to find the levers to feel it's worth it to make a difference. And, you know, my journey in those levers started with right around the time that I was waking up to these concerns, there was, and some of the older people in the audience may remember a large oil spill off the coast of Alaska, the Exxon Valdez ran into a reef on the coast spilled millions of gallons of oil, it was one of the worst ecological disasters the planet had ever seen. There's 1000 miles of Alaska coast coated with oil people wiping off seabirds with paper towels in a vain attempt to try to save them stuff is truly horrible. And that and it happened because the captain, it is said the captain does not agree with this allegation, but was said the captain was drunk and was not following the boat, you know, correctly directing the boat. So it was his fault. And he was, of course, a national scapegoat for being drunk. And again, he says it's not true. But we'll go with this story for for not, you know, drinking at the helm and and causing this disaster. And around that time, Greenpeace, the International Ecological Organization, ran full page ads in a bunch of major media, and had a picture of this guy, this national international villain, the scapegoat. Everyone recognizes picture and in big letters, it said it wasn't his driving to cause the Exxon Valdez oil spill, it was yours. And as a young person, as a college student, that hit me like a ton of bricks, right? It's easy to blame big corporations and say, they should be doing it different, you know, it's their fault. And you'll hear this narrative, right? People say, well, you know, the, you know, the hundred largest companies on the planet are responsible for, you know, 70% of all climate pollution. So don't focus on individual choice. You know, it doesn't matter. It's big corporations. And believe me, those big corporations, they do bear that blame. They are the one influencing our political system, lobbying in order to continue their polluting but very profitable fossil fuel economy. And they do bear that responsibility. And yet it is also true, they don't bring oil around in tankers, because it's fun, or they get paid to ship it around, they get paid because we buy it and we use it. And we do have influence, and the choices we make matter. And it's hard to remember how much the situation we find ourselves in is the result of billions of small decisions made by individuals that have brought us to where we are. And we can get out of it the same way. The billions of little decisions matter, right? And so what I try to help students at NYU is to be climate optimists. Are we facing climate challenges? Yes. I'm not going to deny it. I can't sugarcoat it. We're already seeing the wildfires, the increasing hurricanes, the droughts, the torrential rainfall. I mean, these things are just happening over and over again. And they're not going to stop. They're going to get worse. That's just a fact. But does that mean that we should give up? No. Every little bit matters. There's a very widely shared narrative that says we have so many days or so many years to fix the climate crisis, and then it's too late. And this may have been a very powerful media strategy. It got a lot of people to wake up and think about the climate. But it also has a real downside. There's no one point that happens where all of a sudden it's too late, right? Every little bit matters. Will we keep global temperature rise to 1.5 degrees C as the International Panel on Climate Change has suggested is where we should aim? Probably not. But that doesn't mean there's not a huge difference between 1.5 and 1.6 and 1.6 and 1.7. And again, these little things add up, right? about five years ago, we said we're going to stop buying the single-serve water bottles with our own money, right? New York tap water, some of the best tap water in the world. It's safe. It's healthy to drink. It's basically free. Bring a water bottle, fill up, and do that, right? And since then, we saved millions of water bottles out of the landfill. And part of that discussion, I think, that was really interesting and that got us over the edge, and I enjoy talking to other sort of professionals and people who are used to thinking through problems logically to solve them, is people get on some level that, okay, water bottles are probably bad. It's probably wasteful to make plastic, and then you use it for a couple seconds while you drink the water, and then it just gets thrown away. But a lot of people at NYU said, well, look, that's all well and good for some, but we have guests come and visit our department. We don't have a pantry. We can't wash out water glasses. So what do you expect me to do, serve in a plastic cup? And my answer was yes. And they said, well, that just seems hypocritical. You're telling me not to use a plastic water bottle, but it's okay that I use a plastic cup. That just doesn't make any sense. And we went through the science and the research together to show that most of the environmental impact of plastic water bottles is in the energy to ship the water bottle around, sorry, to ship the water around. Water is heavy. When it comes down to New York City from a reservoir that's a higher elevation and is pumped to our buildings, it's practically energy free, whereas to bring it around on a truck using fossil fuels is incredibly energy intensive. So yes, you are doing better to do that. You are doing most of the right thing, even though it's not perfect. You are making an improvement. And sharing those facts and that narrative with people was just really important. So doctors in our culture are still in a place of respect and a place of seen as figures of authority. I know it's not always the same as it was, but I still think it's very true in a fundamental way. So I encourage everyone to think not just about what you do through your operational actions, and you'll hear from Daniel some amazing tips and suggestions about things you can do in your practice. But also just think about yourself as role models for other people who look up to you. And I say this to NYU faculty all the time. You can come in and tell students what to do. But if they see you coming in, let's just go back to the water bottle example, with the plastic water bottle, and see you throw it in the trash and not even in the recycling at the end of the class, that's what they're going to see. People watch each other. We're social animals. We're really observant. So think about what you're doing. Think about the little things that you can affect, because everything you do has a multiplicative effect. We are social animals. So yes, if you change your practice to reduce waste, that helps. But also other people say, well, they're doing it, I guess it is something I should do too, or think about, or it makes it more normal, or they're accepting of more changes. Those changes multiply, they snowball, and you can have a virtuous cycle that ends up with positive change that we all need to be part of. So yes, these things are difficult. Change is hard. It is not always easy. It's a lot of responsibility, and it can be tiring. But I encourage people to, instead of thinking of just about the challenge, think about the opportunity. Think about how satisfying it is to, at the end of the day, to say, you know, the world's not perfect, but today I did something that made the world a little bit better, a little bit better for me, a little bit better for ecosystems and non-human parts of the world, better for my kids, my country, my family, my relationship network, their grandkids. I made the world a little bit better. I feel good about myself today. I look forward to Daniel's presentation and your questions, and thank you so much for having me. Thank you, Cecil. That was really wonderful. What you were saying really resonated with me, and I often think of Horton hears a who as all these whispers eventually reach fever pitch, if enough people are saying the same thing. So next, we welcome Professor Daniel von Renteln, is the Research Program Director in the Gastroenterology Division and Associate Professor at University of Montreal, where he speaks French mostly. And so that's why we're giving a French twist to his name. He has a special interest in the assessment of emerging technologies related to quality and procedural performance in gastrointestinal endoscopy and advanced endoscopy procedures. Professor von Renteln currently serves on the ASGE Sustainable Endoscopy Task Force and is the lead author of an article in progress that is to be published in the ASGE paper series Practical Steps to Green Your Endoscopy Unit. His presentation this evening addresses how to decrease our carbon footprint in the endoscopy room with easy, implementable steps. We are really looking forward to hear what you have to teach us. Thank you so much. Thank you so much for the kind introduction. Thank you. It's fun being here. And yeah, I want to present a bit the work we did recently with the Green Endoscopy Task Force. And so we're currently working on a manuscript for GIE. We just wanted to show easy steps, how we can green our endoscopy unit, and then how we can do little things that are implementable for us right now. So all of you know that healthcare is a huge contributor to greenhouse gas emissions. And within healthcare settings, GI, and especially endoscopy, is a huge contributor to the waste we create and also to the greenhouse gas emissions that we create. And each and every endoscopy procedure contributes quite a bit. And so what can we do in our day-to-day lives to make that burden a little bit less on the planet? And so we came up with this next paper that we discussed in our group. And what kind of practical steps can we give people to say, better to start small than not to start at all, and find something that is easy implementable? So the ideas or the suggestions that we have and that we came up with, the points that are important is reducing low-value procedures, reducing items we consume by patients, reducing instrument use, and also reducing wastes related to the inventory we have and we manage for each and every procedure, reducing the use of pathology jars, and reducing paper and waste usage in our endoscopy practice. We wanted to make sure that the recommendations are practical and feasible and straightforward to implement for everyone, that they're impactful, and that they result in some meaningful changes, that they have an impact, and that they're balanced, and they should keep high-value care happening, but they also should, within keeping high-value care happening, they should reduce as much as we can our CO2 footprint. And they should be scalable, so we should be able to recommend that to everyone and expand beyond local context. So this is how we came up with these recommendations that we chose, and the first one was really to reduce low-value procedures, and I think this is also one of the things where you get the biggest bang for the buck, like you can really, if you see the amount of CO2 footprint of each procedure that we have, the travel of the patient to the hospital, the travel of the personnel to the hospital, all the materials we use, if we really started that, looking at, does this procedure have to be done? Is it maybe a patient scheduled too early for a follow-up endoscopy? Is that endoscopy recommended by the guideline? Can we replace it, for example, can we replace a screening colonoscopy with a fit test? These are the things where we can have a huge impact. They're relatively easy to implement and easy to execute and give us really, will have a huge impact on our yearly CO2 footprint that we create in our units. A good place to go to is this Choosing Wisely initiative, and there's a lot of recommendation or things we do commonly that we might could reduce, for example, the overuse of endoscopy on dyspepsia patients, patients with IBS, patients with abdominal pain that we often have them undergo routine colonoscopy, or patients with constipation. So there are many indications where we could critically look at them, and this Choosing Wisely publication is a good place to look at to see where we kind of overscreen and over-treat and where we could maybe implement this. Same as here in the recommendation for Barrett's esophagus, if we have no dysplasia, really go for a three-year interval, and then when we have patients in surveillance, to really stick to the changing surveillance intervals that move towards 10 years, and I think we still find in a lot of places that patients are routinely surveyed in five years, despite the newer USMFT guidelines going to seven to 10 years for the low-risk situations, and the European guidelines say you can send the patient back to FIT testing, which would even have a bigger impact on our waste generated with the procedures and CO2 footprint. And the other thing is, again, if you have normal findings, no family history, also consider sending patients back to FIT testing. This would save a lot of resource use for the screening programs. And one thing that is, I think, important to keep in mind is this waste management hierarchy, like just sometimes when we're at conferences and we now discuss single-use endoscopes, and so then it's often like, oh, we're just going to recycle and everything's going to be fine. The problem with recycling is that often the recycling remains theoretical, and a lot of these instruments that are recyclable will just end up in landfill and never get recycled. So the source reduction is a really important thing. So this is where critically looking at indications for procedures really kick in, because it does this source reduction, which has a much bigger impact than just saying, okay, let's use everything, and we just try to recycle, and then we end up still having a lot of things ending in the landfill. And we discuss other small things we can do on a daily basis, reduce items consumed by patients. I mean, it was a good example, just these water bottles, we still use at our unit, also we give patient little plastic containers with drinks, and we're trying to move away from that. So these are all things where we can really do small steps, but over the years, it would have a big impact and also can ask patients to bring their own material so we don't need to supply everything from the hospital, especially if it creates plastic waste. Then instrument usage, like a smart use of instrument, look at what is more waste-heavy in instrument, what can we use that we have all polyps removed with cold snares, it's a relatively waste-free intervention compared to having several snares and electrocautery and electrocautery pads. So these are little things that really add up because we do so many of these standard polypectomy procedures, and really be careful of not opening up instruments that then will just get discarded if that doesn't have to be used. Then checking also the inventory, I'm always surprised given also the price of many of the instruments we use that so many instruments expire in our inventory, and to really monitor that well and avoid overnight ordering and really earmark supplies. Sometimes we see that the new orders get put in the front, and then we discover things that have expired sitting around in the back, and they get just thrown away in the end. I think another idea of what can be done for these things that have expired is to donate them for a research lab or also for trainings. I see at the conferences we have a lot of endoscopy trainings happening, and what typically happens we use brand new supplies for these trainings, they end up in the waste, and we can also try to identify them. In the paper it was mentioned also donating them for second use, but I think that's still something up in discussion, because if something expired I think it should go to the research lab or training use, and not then be donated away for use somewhere else. Then pathology, that's a very interesting thing, there are different ways how we can with pathology reduce our waste that is generated. One suggestion was to collect multiple small polyps in one pathology jar whenever that's appropriate and you think it does not impact the surveillance interval assignment for that patient, and the other quite clear recommendation is to use smaller pathology jars and not always use the biggest pathology jar for the tiniest polyp. The resect and discard didn't make it in, I want to talk a little bit to that. A lot of members of the group felt this is not practical enough for most people, but I think also with regard to pathology that would be a huge transition to reducing our waste. Then when we do our documentation, transition to digital documents, trying to go paperless in the hospitals, I think most hospitals are implementing that and using recycled paper and printing double-sided. These are easy things to just do and to just implement to reduce a bit the environmental burden of our practice. I want to speak a little bit about this resect and discard strategy because this is something I'm really trying to work on, that we implement that into our practice. It means that we would, as an endoscopist, we would diagnose a polyp during the procedure and we would just then, based on certain criteria, optical or artificial intelligence-guided, say this is an adenoma or non-adenomatous polyp, and then we throw that polyp away. We never use a jar. We never transport this to pathology. We don't have to wait for the report. We don't print out these reports. There's a lot of cost and also environmental savings that we could implement, but the group felt right now it is not really feasible and straightforward to implement for most people. I think that's going to hopefully change over the next years because we have computer-aided diagnosis, AI-based, and this is really where I feel like the link between technology development and our hope to reduce a bit the environmental burden of our practice can really connect and we can be really helped. We have these models that can look at a polyp and can just say what kind of polyp that is, and we basically can predict the pathology of a polyp so we don't have to send this polyp to pathology. And this is how it looks. So you just look at a polyp switch on these models and then they will tell you this is a hyperplastic and a neoplastic polyp. You can resect this polyp, document these findings in your report, and then apply the recommendations for the surveillance interval right away. You don't have to wait for pathology reports and you don't have to use a pathology jar at all and send the polyp out for an investigation. So this is, for most people, not fully practical yet because in the U.S. it's just about that the first CAT-X models get approved. And then the other big question was always, will patients actually accept that? And there are kind of survey studies where patients were theoretically asked if they would participate, and they said 50% of patients said no, they wouldn't participate, and so but we are really trying to push for using that at my institution. We just said we're going to do a pilot study. We really want to use that, and we said that our interest is now if we really ask patients, are you willing? We will not send diminutive polyps to pathology anymore. Are you willing? We're using AI to diagnose them during the procedure. We're going to throw them away. So we explained them. I had a consent where we explained what this is and what we do, and 95% of patients accepted. So that was the first pilot study that we just completed with that. And when we ask patients who say, I don't want to participate that, we find most often they just say, well, I don't want to participate in research at all. One patient said, I'm not trusting this AI thing, and one said, I don't trust if you throw polyps away. But overall, most patients are absolutely willing to follow that, and that would have a huge impact on environmental impact of our procedures and also cost effectiveness of what we do. And then when we do this now and we're trying to expand these cohorts and implement that, so what we do is we diagnose them during the procedure, and then the right-sided polyps that will be resected and would just be discarded, and the left-side erectosigmoid polyps that will be diagnosed, and if they're hyperplastic, then they will be left in place, and we document that. And the next thing we're going to try out is expanding that. We had a larger trial using AI autonomously, meaning the endoscopist gets no say in the diagnosis in the end. And we had one where we checked if the endoscopist then interferes with the diagnosis or makes the final decision, and we found overall it's pretty similar. If you use these AI models that are autonomous and they are just the final decision maker, you get pretty good results, and that are equivalent at least with human AI combination decision in accuracy, and the surveillance interval agreement was even higher when compared to pathology. So the next study we're doing here now is we're going to do another cohort where we use this AI, these CADx models autonomously, and we again will ask and see what patients say, and because it will make implementation even easier, because you're not depending on some, okay, there's some expert that in combination with AI has really good results. If you can use these systems autonomously, then everybody can just use that and implement that, and that's where we hope to go in a few years, and I think this would have a huge impact. It's for me something that gets me excited to implement in the future, but right now not fully practical, but we can start with all these other steps of looking at low-quality procedures and these smaller steps to implement, which will be published in GIE soon. So thank you very much. Thank you, Daniel. That was a very thoughtful presentation, and I think just really gave us practical solutions and ideas about how we can all work on improving our carbon footprint as an endosc unit, which I know a lot of people want to do, but they lack the tools, education, and resources on how to, and also oftentimes support the administration of their hospital. So I really appreciate that. So like Eden just messaged to everyone, the Q&A box is open if you have any questions for our wonderful presenters. Those were two very informative lectures. So I have a bunch of questions, so I'm going to ask you guys my questions. I guess we'll start with Cecil. So you are by trade an engineer. What got you into the sustainability world? And maybe explain to the listeners, the viewers, and also myself, how does somebody become a chief sustainability officer of a major organization like NYU? Well, a few took my route, which is to start an off-grid eco-village first. So I can't necessarily suggest others follow in my footsteps, but I told that story about the Greenpeace ad, and at that time, my friends and I that I had gone to college with really believed this was a solution, conscious consumerism, let people make decisions and collectively we can influence society. And so we worked on building this village, which is still there, Dancing Rabbit. You could go visit it. It's a lovely place to live, to demonstrate that people could live a sustainable life that was much less impactful. And it is. The people live there on 90% less impact than the average North American in terms of miles driven, climate impact, trash and waste impact, fossil fuels, all these things. We built houses there out of local materials. Everything was recycled. People didn't own their private cars. We had car sharing, things like that, and it was great. And it was a good example. But I also think I was interested in getting involved with the part of societal change that does come through institutions and governments. And I was also excited to live in New York and people sometimes say, well, so you went straight from the rural eco village where you were like growing your own food and building your own houses to living in Manhattan. But what those two things have in common is they're maybe the two places in North America where it's more common to not own a car than it is to own one. And so in some ways there was some real continuity for me there. And coming to NYU and I was sort of the inaugural position and NYU's sustainability function came because students demanded it. Students did research reports and collected all sorts of data that NYU had never collected before about itself and its environmental impact, its energy use, its water use, what classes were taken and were being taught, what students clubs were there. And they advocated to the administration to start a sustainability program. And actually one of the first recommendations was hire full-time staff, which was me. So I always tell students, thank you for your activism. It really does make a difference in people's lives because it certainly made a difference in mine. And that ended up at 99% of NYU's onsite impact is from the energy used in buildings. We don't have large extensive campuses here in New York. We don't have large vehicle fleets. We're a city of buildings. And so that's where my beginning of my journey, which is a lot about building engineering really came on. But since then, I've spent a lot of time on food as well. And food is a quarter of global emissions and also so close to our daily lives and so close to our health as the people on this call very well know, the relationship between what we eat and those kinds of health. And people may vaguely understand, but have a hard time maybe getting their hands on a solar panel or a building insulation or things like that. But everyone understands food and everyone's got an opinion on food. So it's a fascinating topic to discuss. Where is Dancing Rabbit located? Dancing Rabbit is in Northeast Missouri. Sort of if you made a big circle between St. Louis, Kansas City and Chicago, it's somewhere in the middle there. All right. I'm going to have to make a trip out there. Check it out. Daniel, how about your journey? How did you go from a gastroenterologist like myself and advanced endoscopist like myself and kind of venture into the world and take the plunge into sustainability work? Good, good question. So I was always since I started endoscopy, I love the technology and the things we can do. I just find it totally fascinating. But I was always pained a bit by the waste we were creating. Like I was always looking at, you know, like when these garbage bags were filling up every day and every day. And then there was always kind of like, I don't like that about my practice. And then I was sitting with Heiko Pohl a few years, like it was, I think it was, as we went out UGW somewhere in Europe or so, and then we were discussed, we were discussing this, yeah, we had both the same feeling, right, that we do this, and we have this part that we really love, and then this other part, which is just really painful to watch how much garbage is created during our practice. Yeah, it's cited that U.S. hospitals, which are by far the worst, we're way worse than you guys, so, you know, you have that going for you, but our patients on average produce over 29 pounds of trash per day in the inpatient setting, and that's for each patient. And I think a lot of that is driven by our desire to fulfill this need of infection control, and it's driven this like single-use item, basically economy now, and it's a vicious cycle because, you know, the people who are selling them to us are incentivized to keep on selling more, and there's a little bit of fear-mongering too that is, a lot of it is residual from the AIDS epidemic and, you know, needing things to be single-use, and so we really need to raise alarm, like the students did at NYU, bring things to attention, not accept the status quo like we're trained to do in medicine, and start to ask questions and question why some rules are in place, and I think that's been one of my favorite things, much to the dismay of the administrators at the hospital to do at NYU, at the hospital, and at Bellevue, so it's been really great. In your guys' work, and I'll start with Cecil, what's one of the biggest challenges you faced? I mean, you're working and operating in a city that is very much in tune and wanting to improve, but there's a lot of people who work in hospitals in cities where they, unfortunately, whether it's due to politics or whatever the reason is, they're not as supportive, but despite, in terms of improving sustainability efforts, but despite the fact that we live in New York and people here are really trying their best to be more green in general, what's one of the biggest challenges you faced in your role? Well, you know, it's interesting what you said about, you know, going against the mold, right, and I like to joke that when I first came to NYU in 2007, I would show up to the luncheon or the meeting where food was served or whatever, and I would carry along my little silverware, reusable silverware, and even like a little glass and things like that, so I wouldn't have to throw things out, and people, it was novel, and people would sort of comment, but you know, and I was the only person doing it, and but after a few years of being at NYU, I would go to the luncheon stuff, and I was still the only person doing it, so you know, just because you set a good example doesn't mean that everyone follows it, and actually it does, since I'm on this call, occurred to me that when I turned 50 and got my first colonoscopy and research and find out that I could do it without anesthesia, and that sounded really good to me, and I have done it, and I've done it twice now and thought it was a great experience, because I could just get up after it was done and bike back to work, and didn't lose a day of work, and didn't need someone to come pick me up on the subway, and it was fantastic, but do I expect everyone to follow this example? Maybe not. You know, I should start using this as my inspirational talk. It's like, which would you rather do? Bring reusable silverware or do a colonoscopy without anesthesia? See, the silverware doesn't seem so hard now, does it? So I think the biggest challenge is that, you know, we're an advanced culture that's been doing these things for a long time now. Like, yes, there's change, but sort of our industrialized processes that were set in place after World War II, or going back farther, a lot of modern medicine sort of came after the Civil War, right, the period between 1870 and 1900 is where we traced a lot of modern medicine, or going back to the Industrial Revolution is where a lot of things. We have almost 200 years of ruthlessly cutting costs out of the system. The highest good has been saving costs, and we are good at it, but every other value almost has been left to the side. In fact, interestingly, medicine is one of the areas where people will spend more if it's perceived as safer, right, whereas most areas, you know, there's a couple areas like that, aviation, medicine is one, you know, building, construction is another, but most things people care about just make a one penny cheaper. And so I think one of my biggest challenges is getting people out of the mindset that's not just, okay, how can we save a dollar today, but to think something that everyone gets the concept, yes, but what's it costing you over time, right? Yes, you save a dollar today, but then you're, well, this goes into the into the reused items thing, right? Look, I can't speak to the hygiene and the safety, and of course, as a patient, I want to know that the sanitation is paramount, right, but I'll trust the expert to take care of that. Well, why should we get a pipette tip washer? You know, the pipette tips, you know, cost a tenth of a cent apiece, you know, we buy a box of a thousand, you know, for 20 bucks or whatever. So it's like, yeah, but how many times do you buy that? And over how long and how long would the washer last and how much the reusable pipette tips? And, you know, you have to start to do these calculations. And so I've worked and since I started with a snarky negative comment, I'll end with a positive story. You know, when I work with partners at NYU, the first time they're asked to do that calculation, I mean, it's like a foreign language to them. Wait, I'm supposed to add up, how long do I add up? But how do I know those costs? But how do I compare costs in the future to costs now? And it's all new to them. But after time, like people get it. And now people come to me and my role and say, hey, you know, I'm thinking of doing this thing and I sort of want to buy the more expensive option because I think it's going to save NYU money over time. And here's my reasoning and here's my Excel spreadsheet. Will you help me go to the administration and explain why this is a good idea and help me advocate for this? I say, absolutely. I'm, you know, I'm there. And so people can learn that skill. I think that's one of the challenges a lot of people within the sustainability world face is that it's hard to measure someone's carbon footprint as an individual, as an organization, it's really hard to also find data that feels truly exact because your carbon footprint changes every single day. And it doesn't necessarily have to do with your waste production and, you know, the gas you're burning in your vehicle, whether it's a bus or a car, whatever it is. It also has to do with the energy it takes to manufacture the goods that you're using every single day. And that's almost impossible for us. Even people who are doing like intense LCAs, like myself, like life cycle assessments on the goods that we're using, it's really challenging. Even using the software is challenging. So dedicated to it. It's really hard. I think for me, that's one of the biggest challenges I face is getting stakeholders to understand the dent that they're putting in their carbon footprint, basically, because a lot of people, they don't, we live in a society where everything is instant gratification. Like we swipe and we get likes and we just, everything is, we get our Amazon prime in a day, but it's hard to measure the long-term looming impact, right? Same thing with preventative care. Like I I'm just having one donut a day, but when I have cardiovascular disease at a young age, it's, you know, you weren't thinking about that when you were getting that instant gratification. So. But I think that's a great example. And maybe that's a great way to make a bridge between the sustainability and, and medicine, you know, people want easy answers, right? Like, can this plastic bottle I just used be recycled? And the answer is, well, it depends, you know, what type of plastic is it? What was it contaminated with? What, what are the rules in your city? Who is the hauler? What's the destination it's going to? What's the global market like for plastic on the day that it leaves the, and people don't like that uncertainty, but I think doctors do. If you ask your doc, doctor, oh, you know, you found this polyp, does that mean I'm going to get cancer? It's like, I can't tell you for sure what's going to happen to you in the future. I can tell you about the probability about the probabilities and the statistics. I can tell you overall the general causality. And I can tell you that for plastic, this much percent gets plastic. This is why reusables are better than disposables. I can tell you that on the grand sense, and maybe we need to stop people. You see people stress over the, the smallest things. I mean, you can have, you can say someone who just like, oh, I flew to London for the weekend and flew back. And then they stress over whether like the sticker on their banana that they peel off should go in the recycling or their trash. It's like people like focus on the big stuff and maybe there's a bridge there. Absolutely. So Daniel, if somebody is in an endoscopy unit and they don't have any support or any stakeholders who are encouraging them to do this work, what would you say is the lowest hanging fruit, the easiest item that they should potentially start with to try to get stakeholders on board to the sustainability work? I find just, I mean, looking at, at endoscopy lists and indication, I find this is, this is really the, the, one of the easiest way it's for us also a little bit easier because we have quite a backlog in, in, in cases, especially after the pandemic and to really look who, you know, how can we, can we prioritize patients? I think that is one of the, the easiest and fastest way and everybody wins from that. Right. And other than that, implementing for the, also the small things, I mean, there's some of them are easy to implement, but I think also on the, on the ground level of people doing the daily task, we have complex days and demanding days. And, and so I think like building a, building a committee in the endoscopy units that starts, you know, directing that. I think other to just, it's hard to tell people who are, you know, rushing through the day, trying to get everything done. Okay. Now, please do more of this and that and increase the complexities of their day. So, so that is kind of really more institution, no, or a committee within to, to help with that. I'm going to play a little bit of devil's advocate. What do we say as a group and believe me, I'm on the same page as you, I, I obviously work in the sustainability front within healthcare. What do we say to the private practice provider who is already fighting insurance companies for the reimbursements for colonoscopy and endoscopy? As you know, we have a bit of a tiny issue with healthcare in the United States that you may not be dealing with, but what do you say to that provider? Who's like, I'm just trying to make ends meet. I can't be focused on doing the to make ends meet. I can't be focused on doing what you might deem to be non-essential procedures. My patient wants a colonoscopy after five years, they're worried, their great grandmother had colon cancer. What do you say to that person? I would say to that person, when it's hard to change, and when you do it in, in five to 10 years, you will experience your practice to be more meaningful. We had this experience here, the, basically the, the, the provinces in Canada, including our province, they're switching to fit based screening. So they're really discouraging from doing a colonoscopy as a, as a screening for, for average risk population. And 10 years ago, when I started here in Montreal, I had, I was seeing a lot of average risk patients and which are easier scopes, less complex, less time consuming. And, and, and the transition wasn't easy, but I feel now that the cases I see, they make much more sense. You know, I don't have at the end of the day, this feeling like, oh my God, I also did a lot of cases. I don't know how much it helped the patient, you know, but it really, it really, you know, created a lot of waste and, you know, a lot of used up a lot of resources for everyone. Great points. I, since we have a few minutes here, I will just share for those listening, my experience as well. I was a gastroenterologist like Daniel and advanced endoscopist. And after having my two kids, I really started to ponder about what kind of world we're leaving for them and how selfish it felt to continue as we were. And so our family, my husband, myself, and our two kids, we decided to make some very serious changes. And again, perhaps it won't put a dent in the overall carbon footprint of our country, but we knew that we couldn't continue to do the things we did. So within our apartment in New York city, I mean, we're growing our own vegetables. We compost, we do as much as we can above, you know, what I think should be standard for everyone, right? Even the low ticket items and things that have the least impact like recycling, right? Because we don't know if they're actually getting recycled these items, but we try our best. We take public transportation, we bike. And it's, I think it's just been again, really rewarding for us to try to not only do that, but also to teach our children about how to be responsible stewards of this earth, which is a gift to us. So after that, I started working within improving the sustainability efforts at NYU Langone through just an organization that we, that I created with the help of the people who are dedicated, like MBA experts on sustainability. So I partnered with them and our goal was to try to create easy, straightforward clinician-based initiatives because unlike Cecil, I'm not an engineer, right? I can't try to get this building to be LEED certified. Like I don't have the background to do that. And I knew my limitations, but I knew that the people who are doing the work behind the scenes and sustainability, who are making sure that, you know, all of these light bulbs are LED and all this stuff that they're also not the boots in the ground. They don't know what's happening in the OR and the endoscopy unit and the IR suite and this, the cardiac cath lab. And there's a lot of waste there. And so I was like, how can we partner with you to improve that? And from that group, which grew, we just got a lot of great attention and support from the administration. And then I became the chief sustainability officer at Bellevue hospital. And that has been really rewarding because it's oldest public hospital in the country. And I'm the first ever chief sustainability officer, much like Cecil. So we have the same title, but your organization is definitely bigger. So it's been great and an incredibly rewarding experience. And I'm just happy to do it. And the amount of students I've seen who have reached out to me to ask, can we do research together? Can we work together in any capacity has been wonderful because it gives me a lot of hope that the next generation, I'm not going to age myself here, but the next generation is really going to take the bull by the horns and make sure that they do this right and do whatever they can to slow down what, what previous generations have got the ball rolling. So anyhow, I want to, I don't think there's any questions from the audience, but I wanted to ask you guys, if you have any last words or final words of wisdom to share before we close out our session, I'll say, and then I'll let Daniel have the, have the last word. And he's got the expertise here, but going back to your question about like, what do you say to someone, you know, who's very busy? It's like, look, we get it. You know, there's never enough hours in the day and there's tons of financial pressures and we're all trying to make it and make ends meet. But I think you said it when you talked about your kids, it's like you spend time on what you value. And, and at some point it's a matter of values and you have to be smart and you have to make decisions. And, you know, Daniel gave that amazing presentation that's got a couple dozen things that people can do. Well, you're right. No, one's going to start doing all dozen tomorrow. You know, you pick something and you start doing it. And after a while it actually doesn't take any more time because it just becomes natural. It's easy. You don't even think about it. And then maybe you take on something else and those things grow and, and you, you get better at them. You find the efficiencies and, and things like that. But at the end of the day, we all spend our time on, on what we value. And if we're going to value that, yeah, it does take some time and attention. And as Daniel said, the, the, the rewards that come are something we tend to undervalue, right? There are rewards in our lives that are not just financial and that rewards of looking at your kids and being like, when you grow up and you say, what did you do? You said, I did the best I could. And here's what I did. Like, you can not put a price on that. Thank you. That's really wonderful. Final words, Daniel, any words of wisdom for people out there? I really appreciate what you guys guys said. And, and one thing that resonated with me from, from the discussion earlier is also to measure and, and to show people, look, this is what we did last year. Like you implement things and then you really like, I mean, it is so much waste that we can, that we can save there every year and just say, look, we, we did, we started with one thing and look, this is the amount of waste we reduce and carbon footprint and show that to people to just get the ball rolling. Yeah. I think that, that is maybe one way to convince and get people on board. Well, thank you both so much for your wonderful presentations and educating us on everything that you're doing. And thank you for doing these things because it's just such an important work. I'm going to pass it back to Eden from ASGE. Thank you so much. Thank you to our presenters, to our moderator and to you, our audience. As a reminder, a recording of this session will populate your GI LEAP account when it's available. On screen is a view of the ASGE sustainable endoscopy webpage. We encourage you to bookmark this page as we will be updating it regularly with resources for you. This concludes the presentation on sustainable endoscopy, small changes matter. We hope this information is useful to you and your practice.

sustainable endoscopy

Eden Essex

Dr. Rabia De La Torre

green practice

low-value procedures

sustainability initiatives

patient screenings

healthcare providers

eco-friendly future