Society for Gastrointestinal Endoscopy. We appreciate your participation in tonight's webinar. My name is Ed Dellert. I'm the Chief Publications and Learning Officer for ASGE and I'll be one of your facilitators throughout tonight's presentation. We're very excited about our program tonight entitled GI Hospitalist and the Future of Inpatient Gastroenterology. Please note that this presentation is being recorded and will be posted on GI LEAP, ASGE's online learning management platform. You will have ongoing access to the recording and GI LEAP as part of your registration. I would also like to acknowledge the gracious educational programming support from Olympus for the remainder of the 2021 ASGE Thursday Night Lights programming. Thank you very much for that support. Before we get started, I just want to note that in our platform there's a number of features and rooms and resources that you'll be able to access during and after tonight's program. You all are currently located in the auditorium to access tonight's presentation and you should note that meeting information, other resources, master videos from VideoGIE, access to our guidelines, etc. are all available in various rooms, so please check those all out for us. In the networking lounge, you will find access to a link to complete an evaluation for tonight's webinar, so if you could just take a couple of minutes, it really won't take you that long to complete. Your feedback is very valuable to us. Tonight's objectives are twofold, to understand the evolving role of the GI Hospitalist in modern hospital-based care and two, to provide a practical roadmap for establishing a GI Hospitalist program. I am very excited to introduce tonight our faculty. We have an all-star three. I will start on my left here and ask them to introduce themselves to you. First up is Dr. Melissa Latore, if you'd introduce yourself and a fun fact about yourself real quickly. Good evening, everyone. Thank you for joining us. My name is Melissa Latore. I'm from NYU Langone over in New York. Fun fact, I'm a new dog mom throughout this pandemic, so I've enjoyed honing in on those skills and learning to play fetch with my new dog. Congratulations and nice to meet you. Next up is Dr. Michelle Hughes. Introduce yourself and a fun fact about yourself. All right. My name is Michelle Hughes and I am from Yale School of Medicine. My fun fact is that the good Dr. Latore is my inspiration for becoming a GI Hospitalist. Our connection started before I even became one. I would not be here thanks to her. I will with that step off and pass to Ed. All right. Very good. Thank you. Finally, Dr. Edward Sun. Hi, everyone. Thanks so much, Ed D. I'm Ed Sun. I'm a GI Hospitalist at Stony Brook University Hospital in Long Island, New York. Fun fact, I've been spending my days recently answering COVID-19 vaccine questions, trying to get our employees vaccinated in my role as Assistant Chief Medical Officer given the New York State mandate to get everybody vaccinated by next week. Excellent. Such a fun fact. Well, thank you and welcome to tonight's webinar. We're really looking forward to your presentation. So we're going to kind of go through, we've already gone through our welcoming introductions. Dr. Michelle Hughes will present on the evolution of the GI Hospitalist. Then that'll be followed by Dr. Melissa Latore on building your own GI Hospitalist program. And then finally, tips for success as a GI Hospitalist presented by Dr. Edward Sun. And we'll use the remaining time for questions from you all, the participants. We would encourage you to use the question and answer box to submit your questions. We will try to get to all of your questions tonight. And we may occasionally pop a question into the chat box just to get you to respond by chat. So please look out for that and engage with your faculty member. So without further ado, let me turn the presentation over to Dr. Michelle Hughes. So hi everybody. I'd like to introduce Dr. Michelle Hughes. She's a gastroenterologist specializing in the practice of GI in the inpatient setting. I met Michelle through Vivek Kahl actually, as she completed her GI fellowship at the University of Rochester. She has published multiple papers on GI inpatient care, and she is the vice president of the new ASGE GI Hospitalist Special Interest Group. I'm truly looking forward to her talk titled The Evolution of the GI Hospitalist, Past, Present, and Future. Thank you so much, Ed, for such a kind introduction and to ASGE for having us for such a wonderful talk tonight. So thank you everyone for joining us. So as Ed had mentioned, I'm going to be talking about the evolution of GI hospitalists, really where it started and where we think it's going. I have no relevant financial disclosures. And just a brief overview of what we're going to be talking tonight, really going into the history of the hospitalist movement, defining what exactly is a GI hospitalist for those that are new to the concept tonight, discussing the current state of affairs, and then exploring some of the future directions of the field. So just to level set the playing field a little bit, for those who may not be as familiar as others, I wanted to just go over the basics of what exactly is hospital medicine and a hospitalist. So the definition through the Society of Hospital Medicine is that the hospital medicine is a specialty dedicated to the delivery of comprehensive medical care to hospitalized patients. And therefore, a hospitalist is a physician who engages not just in clinical care. And I think that's where a lot of us thought that their work ended. But really, they've expanded to say that this involves not only care, but teaching, research, and or leadership in the field of general hospital medicine. And they've now taken this a step further, acknowledging that there are this evolution of subspecialty hospitalists, and recognize that there are a minority of hospitalists specializing in fields such as neurology, obstetrics and gynecology, and oncology, amongst others. So it all started back in 1996. There was a landmark opinion piece that came out by Drs. Robert Wachter and Lee Goldman. And basically, what they said was that they thought that the hospitalists were going to be a thing. This wasn't a term that really was well recognized. It wasn't a concept that was understood most of the U.S. medical care. But what they saw was this financial pressure and this pressure for productivity as managed care started to come about. And so they predicted that this was going to be a field in significant evolution in the decades to come. And they were quite right. And so in the first decade of existence for hospitalists, what they found was, you know, hundreds and hundreds of publications were coming out. And they found that there was significant improvement in things like length of stay, costs, charges, time to surgery and ED throughput. And so it led to further growth of the field to the point where we have now reached over 62,000 general hospitalists in the U.S. And that grew exponentially from the dozen or so hospitalists that were in existence when Wachter wrote that article back in 1996. And so it's a field that has really grown exponentially and made significant impacts on the field. So where did GI hospitalists fit in? Well, only a few years after that landmark publication, GI hospitalists were first described by two practices. They were actually private practices, one on the East Coast and one on the West. And basically they described a team-based approach. It involved a gastroenterologist, advanced practice provider, and a nurse coordinator. And they showed that depending on which model you were looking at, there was significant increase in both models, one at 30 and one at 100%. And they both found that there was decrease in costs for upper GI bleed management by over $400 per case. And while it wasn't formally studied, they anecdotally reported that both patients and providers were quite satisfied with this model. So you think, so there's this entire evolution within the general hospital fields that there are exponential growth. So the GI hospitalists must be doing the same. But interestingly enough, there were only about three publications that came out from 1999 during that first paper to 2006. And then the GI hospitalists sort of faded from the literature. And they continue to exist in different forms, but there really wasn't any formal organization. And really there was an entire paucity of publications. And so for years went on that there were these three articles and then that was kind of it. But an interesting thing started to happen in the climate of GI. There was increasing pressure. And I think that financial push, that managed care, the financial constraints and push for productivity all really started to be felt by GI just a couple of decades later. And prediction came true from that original landmark article. It just took a while in the field of GI to really start to ring and speak to us. And basically what they said was that since the inpatient setting involves the most intensive use of resources, it is the place where the ability to respond quickly to changes in a patient's condition and to use resources judiciously will be most highly valued. This should prove to be the hospitalist's forte. And in hearing that context, it really does make sense that as GI providers were getting more and more pushed to be productive as an outpatient, that this really started to become unattainable. And some of those pressures that we're feeling were both on the inpatient and on the outpatient side. Inpatient care over the years has become increasingly challenging. The costs of hospitalizations are increasing. As you can see in the graphic from one of the national groups looking at hospital-based health care research, shows that hospitalization costs have increased thousands of dollars over the last decade. And so everybody feels that when costs become higher. Patients are also increasingly becoming sicker with more comorbidities and confounding use of things like antiplatelet and anticoagulation. And in a world where GI bleeds can happen spontaneously, this is something that we are well aware affects our ability to care. And there was a study that came out with several hundred people through the VA. And that's an interesting study because as we know, the VA has used the same medical record now for 20 or 30 years. And so it eliminated a lot of confounders thinking about documentation bias. But they found that in 2002, patients on average had about two comorbidities. Fast forward 13 years later, and there are over 20 comorbidities on average for these patients. And so patients are just astoundingly becoming more comorbid and more complicated. And similar trends were seen in the Medicare population as well. And so currently they report about 14% of their patients have at least six comorbidities or more. And so that just makes everything more challenging when we're thinking about inpatients. The electronic medical record has become increasingly time consuming as well, as we all are painfully aware. And treatments have become more complex and more expensive. And similarly, on the outpatient landscape, there's a lot of pressures here as well. So there is an increase in demand for colonoscopy started in 2011 with the Affordable Care Act, which shifted costs away from patients and made it more feasible of a testing strategy. And 80% by 2018 was an initiative that certainly increased demand for colonoscopy. And most recently, the USPSTF decreased the age of screening colonoscopies to 45, meaning that all of these pushes were resulting in more screening tests, not only colonoscopies, but stool-based testing as well, which inevitably will lead to a lot more procedures. And so that, coupled with changes in reimbursement on procedures, sedation, the way office visits are reimbursed, and also the way that ambulatory surgical centers are reimbursed, have all really changed the way that we think about throughput and volume. Documentation burden with EHR, I think on the outpatient side, has quite frankly become even more difficult than on the inpatient side. Now with the advent of the Cures Act, it's only getting to be more challenging and more demanding to answer all of those MyChart messages. And patients' treatment and procedures are increasingly more complex as well. Not only are those comorbidities there, but now we have challenges such as new biologics, the introduction of small molecules and other individualized therapies, endoscopic techniques are rapidly advancing, and equipment is changing all the time. And there's increasing comorbidities with all of our patients, including metabolic syndrome and obesity, which make everything more challenging. And so for the GI practitioner, the GI provider, it's really become incredibly challenging to try to balance your time. The outpatient side alone, your outpatient practice is very difficult to manage a panel, and then you have to step away or try to balance each and straddle both worlds for a while when you take inpatient service. And that really has made it be a very difficult tightrope walk between the two. On one side, you have your outpatients calling you, your results and your requests are building up, you cancel or have to shorten clinic sessions and cancel endoscopy sessions. That means that revenue is lost and productivity is unused. And with the backlog of the pandemic certainly hasn't helped either when we give up those valuable slots. And you're also trying to struggle and cover the consults, that urgent and emergent procedure demand and manage teams and also provide good education if you're in a training institution. And so the reason that the GI hospitalists are really fitting in so well, probably now better than when these were first described in 1999, is that it's a really good solution to help so that both worlds can continue to be productive. And so the outpatient providers can remain in their outpatient practice, not having the disruptions of having to step away for a day or a few hours or a full week at a time, and they can manage their patient calls, their clinic sessions, their endoscopy sessions without the stress of travel time, having to juggle a bunch of things, having reduced availability or cancellations in their schedule. And on the inpatient side too, that means that somebody is dedicated and physically present throughout the day. And that's a very valuable thing to have for the hospitalists, for the hospital, because these are sick patients and they need people to be there and be present. And so improves the ability to have consults and follow-up, you know, emergent procedures. You can run to the OR if there's a situation or up to the ICU. And so you're just physically there and ready at all times. Also providing more continuous supervision, either for your APPs or for your trainees. And so what exactly is a GI hospitalist, right? It sounds great. We can help strike balance in both worlds, but what exactly are we? And so our working definition at this time is that it's a gastroenterologist who has completed an accredited gastroenterology fellowship. They must possess a strong clinical knowledge in both acute and chronic manifestations of GI conditions and in management of the acutely ill patient. The majority of practice for a GI hospitalist is focused on the providing inpatient, excuse me, providing GI care to the hospitalized patient. And they have to have skills in basic upper and lower endoscopy with techniques including hemostasis, foreign body management, and management of all those amongst others. And depending on where you are and where you're practicing, you may have additional training or gain additional training in advanced endoscopic techniques such as ERCP, EOS, stenting, or deep enteroscopy. But that definition is certainly still in evolution. So we have sort of a more practical informal list of questions you can ask yourself to see if you fit in with this cohort. And so I ask people, you know, you might be a GI hospitalist if you find yourself in the hospital more than your partners. You also are probably a GI hospitalist if you're seeing more patients than outpatients. Really start thinking about being a GI hospitalist if you're doing more endoscopic hemostasis than polypectomies. And I would say that it's time to admit you're a GI hospitalist if the only continuity clinic that you have is when you're seeing your patients during readmissions. And so the value of an inpatient specialist, as I alluded to earlier, is that it is a designated provider that is physically stationed in the hospital. This translates to a rapid, reliable access to on-site acute care GI, and basically an acute GI response team. They're familiar with the workflows and operations, providing an opportunity for endoscopy unit throughput improvement, protocol development, and other process improvements. You are there to build interspecialty networks and provide close team supervision. And also, GI hospitalists are experienced in inpatient-related GI issues and knowledgeable in the current guidelines and recommendations as they overlap to these inpatient-focused conditions. That means that there's an opportunity to improve trainee education and standardization of care. And also, these providers are able to increasingly accommodate for this personalized management strategies that are advocated in all of the new guidelines coming out. Accommodating for care plans that take into consideration comorbidities, antithrombotic and antiregulation use, surgically altered anatomy. And also, you have to remain up to date on the evolving hemostatic techniques. And one of the reasons or a good example of why a GI hospitalist may fit in perfectly is that upper GI bleeding, for example, we know that time matters and you have to be sort of perfectly positioned. You don't want to do it too soon. You certainly don't want to do any sort of procedures too late. And so, there is a sweet spot and reaching that sweet spot really does take a lot of effort and presence to be able to resuscitate a patient appropriately and then be able to scope them within that 12 or 24-hour mark. And one really nice study that just got published actually this past month that showed that there is a significant mortality improvement at 30 days when you're scoping within that 12 to 24-hour mark. You reduce your need for repeat EGDs and you also reduce your ICU admissions. And so, the GI hospitalist in being physically present can deal with these issues and really optimize patients for things like GI bleeding and hope to improve outcomes. Now, we all love data. We currently just are still in evolution as a GI hospitalist. And so, the data really is limited. But what we know so far is that we have shown to be increased consult volume and also clinic volume. We have internal data at Yale that showed that clinic volumes were increased by about 45% after the initiation of our GI hospitalist model, which translates to not only revenue but also improved patient care. We can get our patients in sooner and we're preventing delays in important diagnoses. There has been improvement in time to upper endoscopy for urgent indications. It's been shown to the GI hospitalist can reduce length of stay and direct costs. And also, there's been a multitude of quality of care or quality initiatives that have been published showing things like we're better able to follow guideline-based therapy for upper GI ulcers and for H. pylori testing. You can expedite management of suspected small bowel bleeding, create internal access teams with improved outcome, and collaborate with other services to reduce complications for things like ileus and constipation. One thing as we start to think about if you're really looking to introduce the GI hospitalist model, and we'll cover that later in the talk, but having data to show that this is a productive model is very helpful. And what we were able to show at our center here was that we increased total procedures, just by virtue of a GI hospitalist model with two of us being hired and nothing else changed, increased total procedures by 20%. And that is a significant increase both on outpatient and inpatient side. So, you know, certainly just having their providers dedicated to one space can help translate to productivity. And also, you know, ultimately, we're showing quality of care as well. Unfortunately, the full impact of the GI hospitalist is not yet known, we need more robust studies and things like quality, patient outcomes related to morbidity, mortality, things like length of stay and cost, long term productivity data, still is just not out there yet. And we aren't really sure how this is going to be affecting burnout and patient satisfaction. And also, not a lot of data yet on operations and endoscopy unit throughput. But what we can do is learn from some of our subspecialty hospitalist colleagues. And across the board, both medical and surgical, there have been substantial improvements with introduction of this model. Things like consults, not just from the GI side of things, but both acute care surgery or general surgery and ENT have shown significant improvement in consult volumes, as well as clinic volumes with this model. Costs have been reduced. Importantly, on the acute care surgery service, it can get quite expensive, and they showed a 31% reduction in one model. Neurology has also seen cost decrease. Time to procedures also reduced for common things like appendectomies, length of stay down across the board, and also the complication rates have gone down significantly in both surgery and OBGYN. One interesting thing that we learned from our pediatric colleagues is something, as a medical resident, I used with the I-PASS system for handoffs, and that actually originated out of the hospitalist movement in their system. So certainly, it translates not just to cost and to procedures, but it really can shape the way that we're taking care of patients as well. So it's certainly a subspecialty or a field in evolution. The subspecialty of inpatient-based or GI hospitalist care is still newly being developed. I will say that while there have been GI hospitalists out for now several decades, we really haven't written a lot of this down or really helped outline for the rest of our colleagues. And so that's something that's really starting to pick up momentum. It's certainly growing as a viable career path. There are very different appeals, whether you're coming at this as a new graduate, mid-career, or later in your career. And interestingly, the on and off nature of this schedule really does permit exploration into other interests, both as an academician and also as a private practice partner. And so there's a lot of opportunity for people to grow into their own niche in this field. Certainly, as I mentioned before, we need a lot more research, both on the practice level and national level as well. So certainly more to come on that. I think one of the strongest appeals, certainly one of the reasons that got me into this career path is that the GI hospitalists being physically based in the hospital really uniquely positions us to be involved in academic or scholarship throughout the hospital. That might be clinical research, medical education, administration or leadership, industry operations. Or for me, it was quality and safety. But really, your network is not just your own section, your own department, but really the whole hospital. And so it allows for you to network with people who you may not otherwise interact with and grow, not only as a gastroenterologist, but grow professionally as well. There are a few pitfalls to be aware of when we're talking about the GI hospitalist model. You have to be careful as we start thinking about developing these programs about fractionating care between inpatient and outpatient providers. These are patients who are very well cared for. As an outpatient, they end up in the hospital. We certainly don't want to lose things in handoff. And so it's really imperative to have open lines of communication between your inpatient and outpatient providers. You have to be cautious about burnout and stress mitigation. The unpredictable volume and the frequent emergencies that come with this job are both very exciting, but long term can certainly lead to emotional exhaustion and stress. And so there's certainly things that need to be taken into consideration. Kind of going along with that provider retention, you want to make sure that this is something that is sustainable as you build your model. The reimbursement strategies, they think, are something that are going to be evolving here as well. Our view-based payments or reimbursements or incentives probably aren't as telling of our value to a practice. So that has to be investigated. And then also just be cognizant about the impact to your colleagues and to your other GI providers. You certainly don't want them to have skill set atrophy because they're going to be taking call too. And you don't want them to come in and not remember how to take care of a bleed or not feel comfortable. And also just being aware as well that trainee education is a balance. Certainly being present and knowing the guidelines for inpatient-based presentations and diseases is very important, but you want to make sure that they're getting different styles and knowledge sets and exposure to different providers elsewhere because you certainly don't want to lose that valuable opportunity for your trainees if you're an academic center. Just a quick note on the future of the GI hospitalists. Right now, we're in an evolving step. We're outreaching. We're identifying GI hospitalists across the country. Currently, we have over 25 connected virtually every month. This ASGE SIG is new, and it's going to be an amazing opportunity to bring a lot more content forward. And increasing presence at regional and national meetings to network and to bring content that is inpatient-based forward for everyone. And then really promoting the GI hospitalist as a career path, I think, is also something that we're looking forward to doing. And so just a few key takeaways that reiterating the hospitalists have now been around for a couple of decades, and the GI hospitalists are pretty rapidly increasing in number now as specialists and acute GI condition or acute care GI. There's potential for professional growth as a GI hospitalist, but that future research is really needed to understand the long-term impacts on quality outcomes and practice. All right. So next, I am very excited to introduce Dr. Melissa Torre. She is the Director of Inpatient GI Services, Assistant Professor of Medicine at the NYU Linguin Health. And she is, like I said earlier, the reason that I became a GI hospitalist. So very honored to have her come and talk to everyone today. So thank you for having me. Thank you so much, Dr. Hughes. And thank you everyone for attending and the ASGE for helping us to establish the SIG and to bring this presentation to you. And let me just advance. There we go. These are my disclosures. Okay. So the objectives of my talk are to demonstrate how to evaluate the inpatient GI service at your own institution, to provide a practical framework for creating a GI hospitalist position, and to discuss how to initiate culture change in preparation for a GI hospitalist service model. So just starting off with the goals of a GI hospitalist model and a GI hospitalist program. So the goal is to have onsite availability for multidisciplinary care, to be able to provide timely endoscopy, to have improved hospital metrics and outcomes as it relates to quality, safety, efficiency, and costs, to practice evidence-based medicine and provide evidence-based education to GI trainees, residents, medical students, and physician extenders, and to increase efficiency of both inpatient and outpatient care. So first to begin with, assessing your inpatient service. So how to get started. The key to getting started is to identify a multidisciplinary group of key players who are invested in the current operations of the inpatient GI service. So who might these people be? It could be your GI hospital or endoscopy leadership, the physicians that frequently rotate on the inpatient service, trainees, physician extenders, nurse leadership, other consultants that might be in your endoscopy units such as anesthesiologists. This is even, again, before having a GI hospitalist program. The key here is just to understand what is going on at present. So define your starting point and current environment in order to understand what's going on and what changes need to occur. So a GI hospitalist program should be created to meet the needs of your local environment. So you need to assess what's going on first and then realize where you need to be, and then discuss how, as a group and through your leadership, you might be able to bridge that gap with the GI hospitalist model. Important things to know are your metrics, such as readmissions or rebleeding, and this can be considered something akin to an ADR. How are you performing as an inpatient service? It's important to be honest about the changes that need to occur within your program, and through this process, you might realize that, you know, akin to a remodeling, you might just need a fresh coat of paint or you might need to have a complete overhaul and to rebuild something from the ground up. Next is to look at your community environment. Where is your hospital located? Because that's going to dictate a lot as to the patients you see and the way that you practice medicine. Are you located in an urban setting or rural setting? What's your catchment area? What kind of community do you serve? Who are your patients? Is it a patient population that has easy access to care, that's educated with good insurance, or is it a patient population comprised of immigrants who are uninsured? So what are the kind of patients that you see? Because that may help to dictate not only the kinds of pathology that you see, but also how they're going to have access both on the inpatient and outpatient side. So how does this patient population and your community impact the care that you're able to provide? Next, looking at the hospital environment. What is your hospital setting? Are you in an academic facility? Is it a tertiary, quaternary care facility with multiple transplants that are unique? For example, at my institution in the last few years, we've rapidly developed cardiac transplant, face transplant, gender reassignment, all of which have brought a large population of GI consults to our center, and unique pathologies, such as for the bone marrow transplants, all those diarrheas associated with immunosuppression. Are you located in a community setting? Is it a VA or some other type of hospital setting, or is it a hybrid? What is the geographical footprint of your inpatient team? Is it one building, two hospital facilities, three hospital facilities, or more? What is the actual size of your institution? So over here in New York, the footprint of NYU's academic hospital is about four city blocks, so maybe three from the endoscopy unit to the furthest patient care room. Is there an electronic medical system? Because that will help to impact your efficiency. And what are your institution's expectations? What is the culture in your institution regarding procedures? Is it okay to delay a case 24-48 hours? Is it expected that things happen immediately? Because that also dictates the resources that you're going to need. Now looking at your consult service and the service type, there's a couple of concepts. Is it an open or a closed service? An open service being where the primary outpatient or GI attending can choose to be the consulting physician while the patient is in the hospital, therefore allowing for continuity of care. A closed service is where all care is relinquished to the inpatient or covering hospital-based team. Or is it perhaps a hybrid, where some people choose to follow their own patients and others choose to delegate? Is the service functioning as a primary service or a consulting service? And a primary service being that the GI providers are in charge of all aspects of care, including discharge planning and social work papers and coordination and reinstating home services, that type of work, which usually most often medicine hospitalists are responsible for. Or is the GI service a consulting service, where they're solely responsible for GI care in a consultative manner? Next, look at who is on your inpatient team. So this is a photo of my inpatient team a few years ago. And here we have me as the GI hospitalist. We have three fellows. We have two physician assistants and one co-attending at a given time. So who's your inpatient team? Is it physicians? Is it one physician, two, three? Is it fellows and trainees like residents or students who rotate? Physician assistants, nurse practitioners, nurses, or others such as medical assistants? Each one of these potential team members has a different limitation in terms of their abilities and their ability to participate in procedures versus doing more of a consultative role. And there's changes that have occurred with respect to the level of documentation that they can do. So it's important to know who's on your team and what are the responsibilities that they're capable of and what are their limitations. Additionally, are there other GI specialty services? And here we have a cute comic of the gallbladder and the liver fighting about who's responsible or who's caused the problem. But the point being that there are nuances in GI that are best managed by certain services. And how is your hospital organized? And how is your GI service organized? So for example, this could be one setup where the general GI team takes all initial consults and then distributes to general hepatology or transplant hepatology or advanced endoscopy or motility service or an IBD service. Or alternatively, where the general GI is responsible for everyone with general GI conditions in addition to inflammatory bowel disease, general hepatology issues, and or mortality issues. And then we'll delegate only transplant hepatology versus advanced endoscopy patients. So whatever the setup is, how is your inpatient service organized? Next, it's important to assess the consult volume. So knowing your numbers at this point. So how many consults are seen per day and per week? And understanding how many consults, how many follow-ups and the trends in your service. Is it towards the beginning of the day, the week, or the end of the week where things pick up? Do the consults come in in the morning? Do the consults come in bimodal as they do at my institution, which is in the morning and right after that, that sugar high from lunch is when we get our second wave. That can help you to staff your service appropriately on the days when you need help the most. And how about how many consults convert into inpatient endoscopic procedures? At our institution, it's anywhere from 30 to 50% of the inpatient consults that we see end up having an endoscopic procedure. So knowing that conversion rate can help you to allocate the appropriate amount of endoscopy time and resources to accommodate that volume. Next, looking at physician coverage, how many attendings are in the coverage pool for inpatient consult at any given time? And how is call divided? Is it divided evenly amongst the faculty? So you have 365 days, 52 weeks. How do you divide that amongst your faculty pool? Is there a seniority factor or is there some other way as to how call and responsibilities are divided? Not only during the week, but also weekends and emergencies and holidays. And how often does handoff or coverage occur between attending providers? So is it that one attending is responsible for a week at a time or a month at a time? Or is it Monday is this person's day and Tuesday is this person's day and Wednesday, et cetera. So understanding that can help to to have you understand if there is hiccups in the care that patients are receiving and the continuity of care, or maybe an opportunity for where a GI hospitalist might help to make the service run more smoothly. So moving on to the next part is assessing your endoscopy unit. So endoscopy unit of operation. So what is the availability of the endoscopy unit for your inpatients? Is it open on weekdays? Is it nine to five? Is it seven to seven? Whatever it is, know those hours of operation. Is it a hard stop or is it kind of an overtime offered so that you can continue to go if it's necessary to add on procedures? What about weekends and holidays? How much time is allocated for inpatient procedures on a given day? And again, does your volume of conversion to endoscopic procedures match the amount of time that you have allotted? Is time lost due to certain factors like colonoscopy prep, et cetera? These are important things to really look at microscopically to understand how to best optimize endoscopy unit operations for your inpatient service. How many inpatient procedures are performed per day or even per week? At our unit, we can accomplish about five to six procedures on an average day, sometimes more, sometimes less, but that's basically what we aim for on a given day for our inpatients. And how are inpatients scheduled? I've seen this, you know, at different places and heard different things from everyone, but sometimes it's a dedicated block time. Sometimes it's in between outpatient. Sometimes there is no time. Sometimes it's just unused time where, you know, somebody is on vacation and that's where you fill them in. But how is that scheduled? How does that impact your throughput at your hospital? Is the block time in the morning or is it best in the afternoon giving time for inpatients to finish their preparation or get the procedures that they need in order to be able to execute an endoscopy safely? Where are endoscopic procedures performed, including at bedside? So is it solely an endoscopy unit? Is it an operating room where it's shared with other services such as surgeons? Do you have to compete for urgency? Is a gunshot wound going to go into the same operating room as an endoscopy? Because those obviously have very different levels of urgency for competing resources. Can things be done safely in an emergency room or an intensive care unit or a step-down unit? So know what the limitations are of your institution and of your inpatient service and endoscopy unit. Next, how is GI, is sedation administered for GI's procedures? Is a conscious sedation administered by the gastroenterologist or is it monitored anesthesia care where it requires the input of a consulting service because more hands in the pot also means more help, but at the same time, it's another opinion that can lead to pickups in workflow. So working with anesthesiologists means collaborating, discussing some of these issues that might arise and areas for quality improvement to improve your throughput and to minimize the possibility of cases being canceled. What is your process workflow? And I'll go through this in a minute, but what are the steps from when you see a patient to when they leave your endoscopy unit? What must happen in order for that patient to execute a procedure? And where are the potential opportunities for hiccups? And are there any other operational nuances within your endoscopy units where, for example, fluoroscopy can be only performed in a certain room or a certain machine is only available on a given day or time? What are the limitations that you need to be aware of when scheduling? So this is an example of the workflow at my institution and in order to bring a patient through our endoscopy unit. So we're solely anesthesia-based, but for the GI team, we must obtain GI procedure consent, call the anesthesia consult, order the procedure in the EMR, document a full consult note before bringing the patient, complete a pre-procedure checklist where we make sure that everything's been done, a COVID test, a pregnancy test, an EKG, medicine clearance. And then the team will start a multidisciplinary chat with the charge nurse and the anesthesia attending to make sure that the patient is appropriately ready for their procedure, that they've been MPO, that they've completed their prep, et cetera. The nurse will confirm the GI and anesthesia consents are complete. They'll call for nursing handoff. They'll enter the transfer order for the patient to be transported. They'll confirm that documentation is signed by the attending physicians, and then put the order for the patient to be transported from the pre-op into the room. The anesthesiologist, they have an NP to assess the patient and that NP will obtain the consent at bedside. The anesthesia attending will review the chart and provide clearance. The anesthesia attending will sign documentation and then assess the patient in person. And then ultimately this patient gets their procedure. But at any step along the way, there could be a hiccup and figuring out what you need, what resources are necessary, where these hiccups can occur, allows you to improve your through foot and to prevent issues from arising. So putting it all together, using all the information that you gather about your service, you can begin to identify the resources that you may need and the role that a GI hospice can play in your particular system and where they could potentially smooth things out. It's important to be realistic about the work volume, the resources and the expectations when you create this position. If your volume is to be extreme, like 50 consults a day, that doesn't seem like a reasonable number of consults to have one person be responsible for. So again, it's important to be realistic. Maybe you need two people, maybe you need three people, maybe you need a PA. So set what you think might be a realistic expectation for the amount of work that's identified. Also identify areas of inefficiency and redundancy and bottlenecking to see if you can create many quality improvement opportunities around that. And then set your GI hospice up for success. And as Dr. Hughes mentioned, creating a successful GI hospice program can help to benefit everyone. So it's not an opportunity for someone to have a scapegoat. The GI hospice shouldn't be the scapegoat to a busy call system or busy hospital. They should be a colleague that can help in making this whole unit, both inpatient and outpatient, a bit more fluid. So designing your GI hospice position. Flexibility is the key to success here. Again, this is an opportunity to create something like everything that we're saying is a little bit from our experience and a lot from trial and error. And you'll get that sense from every GI hospice that you speak to. But to pick up on a few key points. So when it comes to scheduling, it's important to define the inpatient and outpatient roles if there is going to be an outpatient role. My suggestion is it's sometimes easier just to start with one, such as the inpatient, which is the focus here, and add the outpatient role at a later time. That's always going to be available, but to really understand the inpatient operations as a GI hospice, you want to be able to just be there and by osmosis, pick up what's going on. Sense those areas of frustration. Oh, my procedure was canceled because of this or that or this was delayed. And just think about how you can tackle those and optimize those issues that arise. So starting, my suggestion would be to start with the inpatient, add the outpatient, if that's something that's really important to you and that you want to make sure you preserve. Define time commitments, whether, again, for an outpatient opportunity or for an alternative administrative role, such as clinical education, research, et cetera. Identify how many physicians are needed to accomplish the work. At our institution, we decided that about one and a half physicians would be necessary to make everything happen, to make sure that all the patients are seen, the procedures are done in a reasonable amount of time on a given workday. And so we have a second attending that comes in the afternoon to help clean up the afternoon day. So whatever works for your institution. Anticipate areas of burnout and build in layers of protection. And the hospital is a 24-hour environment, seven days a week, 365 days. So it's important to make sure that the GI hospitalist does not live in the hospital, but that they have their start time, their end time, and that they can maintain a relatively comparable quality of life to their outpatient colleagues. It's important to discuss a coverage model for weekends, emergencies, and vacations. And also to make sure that the GI hospitalist has that flexibility, that they're not beholden to the hospital because they can't find coverage. So to that point, incorporate your faculty pool and backup plans and contingency planning and scheduling. Compensation, this is a little bit more challenging, but it's in general dictated by your PGY status and local salary rates. But there is an argument for incentivizing the starting salary of a GI hospitalist. When new physicians start on the outpatient side, they often spend a year or two building a practice and spend a couple of their sessions, perhaps not as occupied, which sometimes when they come into the inpatient setting. But the GI hospitalist is gonna be productive from the day they walk in. There's not gonna be a lead time into building a practice. They're just gonna have their practice from the day they walk in and will be as productive as the hospital dictates. To that point, they have little control over their productivity. But when you think about it, depending on what's being done, the volume, et cetera, the reimbursement for inpatient consults can sometimes be greater for a new consultation than for an outpatient new consultation. There's also a higher proportion of new consultations on the inpatient side, which have higher RVU reimbursements. The procedures performed for hemostasis and variceal bleeding and things of that sort can also have higher reimbursements than a diagnostic, UGD, et cetera. So something to consider when you're looking at the volume, you're looking at the numbers and you're looking at the reimbursement. And as I mentioned before, there's minimal time to productivity based on the volume of the hospital and of the service. It is unclear, as Dr. Hughes mentioned, what the optimal salary model is, whether it's someone should be salaried, whether they should be RVU based or collections based, given that there is limited control over that. But in the GI milieu, we still are very much RVU based or productivity based in terms of salary models. It's unclear whether salary support should be from the hospital or the GI practice or both. And it's important to ask ourselves who really benefits from having a GI hospitalist and who should be contributing to that salary. And while starting salary may be easy to define, the salary growth with time is what's a little bit more challenging. And the thought is the GI hospitalist is gonna be an integral part of your team and they're gonna help the outpatient team to be productive. They're gonna help the inpatient team to be efficient, inpatient side to be efficient. And so they shouldn't be penalized for that. So just a thought is to make sure that that's somewhat at par with their PGY status as time goes on or their promotion level, whether it's a assistant or associate or full professor. The other thought is when creating a new GI hospitalist position, to refrain from offering that standard cookie cutter template for an outpatient position to an inpatient position. And really to think about what needs to be incorporated in that contract and maybe create something new. One thing that's often found in contracts these days are these restrictive covenants. And when you think about it, is it really fair to have a restrictive covenant on someone who has no control over their patient panel? And most likely people are not gonna be coming to look for that GI hospitalist at another institution were they to switch locations. Typically it doesn't seem like medicine hospitalists or other hospitalists within the field have similar restrictive covenants. So it would make sense for the GI team not to have that also. But that's often found on the private practice side or the academic side for reasons I mentioned. So on the private practice side, it might be interesting to consider a separate buy-in model for GI hospitalists that are contributing to the group. Expected clinical expertise. So what does the GI hospitalist need to be capable in? And basic hemostasis for sure, standard clips, bipolar, cautery, epinephrine injection, advanced hemostasis such as over the scope clips, Doppler probes and hemostatic sprays. So here's an example of the bread and butter that we have at our institution, which we treated with an over the scope clip. Also variceal banding and glue, percutaneous gastrostomy tube placements and troubleshooting, small bowel video capsule and deep enteroscopy, EUS, ERCP, things of advanced training, stenting, definitely food impactions in foreign bodies. Those are all expected clinical expertise of the GI hospitalist. There are also opportunities for professional development in the clinical education realm, research, hospital administration, GI administration, quality improvement. The GI hospitalist is gonna be spending a lot of time in the hospital and really becomes a familiar face. And someone that is someone you can go to for issues that arise within the hospital. Last but not least, tips for changing culture. So changing institutional culture, and this can be challenging regardless of where you are, whether you're in medicine or whether you're in business, but a change in culture is best executed from the top down. So making sure that there's true hospital support and GI leadership support to demonstrate why this is gonna be mutually beneficial for everyone. It's important to weigh the dilemma of continuity of care versus access to care. So again, having that physician that knows and loves you, see you both on the inpatient side and outpatient side can be really comforting. But having a doctor that's available the minute you have some kind of emergency is also important. So how do you balance these two? And today I had a very similar experience where a patient came in for a post-polypectomy bleed and said, my doctor, he told me I should come in and I thought I was gonna see him here. And so at which point I had to reinforce with the patient and reiterate, I have spoken to him, he's well aware, he knows, and we're in constant communication. And that was the truth, the patient was satisfied and we were able to maintain that closed loop communication with the GI physician from the outpatient side involved in the care plan and the decision-making. So that's the next important thing is to always incorporate that outpatient physician and to reassure the patient and the outpatient physician that the care will be returned to them once the patient leaves the hospital. And last but not least, it's important to reinforce this workflow with consultants and colleagues. There's always gonna be that person that says, but I want doctor so-and-so to do this person's procedure or I want that person. And it's kind of, you have to change the culture with your team. And in situations that I've encountered like that, my colleagues now will say, we have a really great inpatient team and they're gonna take care of that person and they kindly relinquish care back to the GI hospitalist and reinforce with both the patient or the other consultants that this is now the structure that we're implementing. So it has to come from all around. So last but not least, the take-home points. So building a GI hospitalist program requires a review of the current volume and operations of your current program before you can bring in a new person. So finding out where you are, where you wanna be, and using the GI hospitalist as an opportunity to bring on resources to bridge that gap. Flexibility is the key to success and be willing to design a program and position that meets the needs of your hospital, physicians, patients, and practice, and be willing to do this trial and error, again, with frequent reassessment to see what's working, what needs to be changed, but to build a program that fits your institution. And then finally, before hiring a GI hospitalist, engage your current faculty pool and set expectations for how a GI hospitalist model can be mutually beneficial for everyone. With that said, it is my pleasure to introduce Dr. Edward Sun, who is the Assistant Chief Medical Officer, Secretary-Treasurer of the Medical Board, and a GI hospitalist over at Stony Brook University Hospital. I'd like to just highlight Dr. Sun for all of his hard work and effort in helping us to bring this GI hospitalist special interest group to life. And he is such a gracious colleague. And when we created this group, he said, I would love for the face of this GI hospitalist group to be two women, which I will never forget and eternally grateful for. And so with that said, I present to you, Dr. Sun. Dr. LaTorre, thank you very much. Dr. LaTorre and Dr. Hugh, thank you very much for inviting me to participate in this webinar. And thank you very much ASGE for supporting and really pushing the frontier of GI educational material, supporting these venues. And I'm very excited for the success of the GI hospitalist special interest group in building these discussions around inpatient GI care. I have no financial disclosures, and I wanna thank the audience for staying with us. I know it's late. My goal with this talk is to build upon the skills and tools you've already developed in successfully managing the inpatient GI service. We'll start with a discussion about success as a GI hospitalist. We'll talk about how really we're in the service industry and how important the customer service mindset is to doing well in this role. I'll introduce the concept of the situational matrix and navigating professional relationships. And finally, we'll look at how building trust and understanding the prisoner's dilemma can help us be more effective on the GI inpatient service. I think we'd all agree that technical skill and competence and sound medical decision-making are fundamental to success on the inpatient GI service. These really are prerequisites for good patient outcomes. But why is it that on some inpatient weeks, you'll thrive and flourish? Others, even when patients have done well, you can end up in the week frustrated, angry, and even feeling defeated. Well, there's great value in discussing time management skills, building resilience and grit, building a capacity for dealing with the unexpected, and developing strategies for avoiding burnout. This, however, is not that talk. Dr. LaTorre and Dr. Hughes, I look forward to when you do have that webinar because I'll be the first to sign up as an attendee, especially for the talk on strategies for avoiding burnout. Instead, tonight, I'm gonna focus on the challenges of personal interaction on the GI inpatient service, even when patients have good outcomes. I'm talking about that call from patient advocacy, but when the primary service is attending, their documentation doesn't accurately reflect the time, effort, and good GI care being delivered. I'm going to make the argument that the GI hospitalist actually has two customers, the patient and the primary team calling the consult, and that success as a GI hospitalist really comes from providing great customer service to both. Now, we're used to the concept of patient satisfaction, you know, it's been ingrained in us to sit down at the bedside, to use patient-centered communication techniques, to ask open-ended questions, to use the teach-back method and shared decision-making, and to avoid jargon. We invite questions. We really involve the patient in sort of that decision-making and discussion. But I'd argue that success as a GI hospitalist comes not only from having a healthy relationship with our patients, but in successfully managing our interactions with consulting physicians. You know, going through this list of tips for providing excellent customer service, being available, being prompt and timely, being responsive, being proactive, these are all things that we already do with our patients. Listening to our patients, knowing them, following up, and even asking them for feedback. But what we're not used to is thinking about the consulting physician or the primary team as a customer. Once you start thinking of them as a customer, your approach really starts to change. When's the last time you've asked a consulting physician or team for feedback? And that's a very powerful tool because it's a signal that you appreciate them and value their opinion. And as we'll see in just a bit, building that personal relationship is key to overcoming times of conflict. I'm going to describe a framework that does a great job of characterizing the types of conflicts that we're likely to encounter and the most effective strategies in negotiating each scenario. Richard Schell is the Chair of Wharton's Legal Studies and Business Ethics Department. He also teaches the wildly popular course Success at the Wharton School of Business. In a truly excellent book titled Bargaining for Advantage, Schell articulates so much of what we'd otherwise have to learn the hard way through trial and error and through experience. This is what he calls the situational matrix, which characterizes types of interactions or situations based on the stakes involved and the importance of future relationships between negotiating parties. Let's start with quadrant four, classic consistent coordination. This is probably the most basic of negotiation situation. There's low conflict over stakes and a limited future relationship with both parties. The classic example is that of two drivers meeting at an intersection. Let's say there aren't any stop signs. Both parties, hopefully, would wanna avoid a collision and there's little need for conflict here. The drivers are unlikely to see each other again, so it doesn't really matter who goes first. In these situations, the best strategy is just to move on, accommodate when conflict can't be avoided and if accommodation isn't possible, then compromise in a genuine and helpful way. Almost daily, some hospital employee comes up to me asking a question about their GERD, their constipation or their family member's GI condition. When you're stuck riding the elevator with that person, it's hard to avoid it, so I'll typically entertain their question and then just move on. Yes, as a GI hospitalist, you'll soon realize that you're the personal gastroenterologist for every single person in the entire hospital. In quadrant two, relationships, the stakes are low, but there's a high importance for future relationships. This is the most common situation in a healthy marriage or friendship. Your best strategies really are accommodation, problem solving and compromise. And I've learned in my own marriage that the only strategy here is accommodation. So for our GI fellows, this may be a call from a team to help place an NG tube or perform a bedside paracentesis. It might be that consult from cardiology for TEE clearance in a patient who had a remote history of an H. pylori ulcer that was fully treated at the time, now with a hemoglobin of 14 and no GI complaint. Because it's important to maintain a good relationship with the consulting physician, the best strategy is just to accommodate their needs. However, it's important to find out what the other party really wants, even if they don't know it. For the TEE consult, it's easy to get stuck in a position where you feel like the cardiology service is pressuring you to perform an unnecessary EGD. However, you may find that a chart review and a five-line summary would suffice. Find out what the party actually wants and then give it to them. This is because the relationship counts more than the dispute, and you never know when you're gonna need their help. Quadrant three, transactions. So transactions, this quadrant seems to be the situation with the most conflict. These are situations where the stakes matter substantially more than any future relationship. Selling a house or car or negotiating a divorce fall into this category. Here, the best strategy is one in which, the best strategy is to bargain, and bargain hard. Distributive bargaining is a strategy in which one party gains only if the other party loses something. It's the most common strategy when distributing fixed resources. The classic process is to be aggressive with your opening offer. Hold for a bit and then show willingness to bargain, then make a series of progressively smaller concessions as you close in on the expectation level. The smaller or the declining size of your concession sends a powerful signal that you're getting close to a resistance point. So you wanna set your expectations and be consistent. Don't give in. We just had an example of this the other day. 45-year-old man with quote-unquote Crohn's disease, was never proven, presented with 10 out of 10 epigastric pain, no nausea or vomiting, vital signs were normal, no leukocytosis, no anemia, normal CRP and ESR, normal imaging. He was demanding to get that IV pain medication that started with a D. We very clearly told him that we wouldn't be giving him any narcotic medication, but that we'd see how he did with IV Tylenol, and that if he was in that much pain, we recommended that he stay NPO. My fellow came up to me 10 minutes later and said he left AMA. Quadrant one, balance concerns. This is probably the most common quadrant for us to be in. Here, both future relationships and stakes are equal in importance for both sides. Your best strategies involve problem solving or compromise, and the goal is to address as many priorities as possible, and make sure each side gets its fair share while maintaining good working relationships moving forward. Aggressive hardball tactics do not work well because they're too bruising to personal feelings. I'll never forget one PEG consult I had last year for a patient with advanced dementia. The hospitalist kept insisting that the patient needed a PEG. And despite all the data that we showed them, that PEG tubes have no mortality benefit or morbidity benefit in patients with advanced dementia, and insisted that the patient needed a PEG. After several discussions, turns out that the hospital's main concern was that they couldn't discharge the patient to long-term care without a means of feeding. And at that point, we really thought about it and thought of a solution and suggested calling palliative care, and that the patient, palliative care came and saw the patient, and the patient actually qualified for hospice and was discharged the next day without a PEG. When stakes are high and the importance of future relationships is high, it's crucial to exchange as much information to get to the real underlying needs or issues. You wanna focus on the interest, not on the physician. My interest in this example was to do no harm, to avoid the risk of placing a PEG in someone who really wouldn't benefit from it, and who could potentially be harmed by getting a PEG tube. The interest of the hospitalist in this case was to be able to discharge the patient safely. It was only after probing and asking questions, sometimes the tough questions, that these interests became clear. Otherwise, the conversation would have been stuck about placing the PEG. So sometimes you'll realize that you're in the wrong quadrant, that you yourself are in the wrong quadrant. Let's say that you're in quadrant three, you feel that the importance of the future relationship is really low, but that your stakes are high and so there's high conflict. I would challenge you to see if there's a way that you can move into quadrant one, where there is a value in maintaining that relationship between both sides, and then working with them, probing, finding the interests and not focusing on the physician, to be able to then come up with creative solutions. But these conversations where information can be exchanged to get at the underlying interest, can only be had if the parties trust each other. The prisoner's dilemma is a great way of understanding how trust can result in mutual benefit. Imagine you have two prisoners, prisoner A and prisoner B. They get caught after committing a crime. And the rules are basically that if they both confess to the crime, they'll both serve five years. If neither of them rat on each other and they remain silent, they don't sell each other out, both of them will only get one year. But if one person trusts the other, let's say prisoner B trusts prisoner A and decides to stay quiet, but prisoner A sells out prisoner B and confesses to the crime. Prisoner A gets set free and prisoner B has to spend 20 years behind bars. Over time, what you realize after many, many iterations of this sort of experiment, if it all depends on that relationship between prisoner A and prisoner B. And the key to the behavior lies in whether the game is iterative. If prisoner A and prisoner B feel that they have no relationship to each other and there's no trust, both of them are likely to think or to confess to the crime and to sell each other out, both suffering then for five years. But there's a mutual benefit if you can convince both prisoner A and prisoner B that there's a mutual benefit to their relationship and to a continued relationship. That if they have to play this game over and over and over again successively, then it makes sense for them to cooperate. Success as a GI hospitalist when the stakes are high comes from emphasizing the importance of future relationships, of repeated interactions and consults. So in other words, if you have a hospitalist who is treating you very poorly and really insisting on demands and things that are not reasonable, there has to be a way to try to change the way they think about your relationship with them. And as a GI hospitalist, it becomes even more important because they will be consulting you over and over in successive consults. So focusing on the relationship and getting them to realize that there's a benefit to cooperating may actually help your cause and help to open up that dialogue and discussion to actually get them at the true interest that they're concerned about and not just being rooted in the position. So again, moving from that quadrant three into quadrant one of the situational matrix. A word about trust. People who inspire the most trust are those who exhibit two distinct traits, warmth and competence. We trust competent people because they're credible, effective, and efficient. We trust warm people because we know that they care about us and cold people pose a threat. So really in order to build strong relationships, it's important to project both warmth and competence. It's important that what we say and do match each other, that we build credibility when our deeds match our words. However, it's not just about what we say, but how we say it. And warmth in our tone can convey powerful signals that encourage cooperation. We see this daily when we talk to our anesthesia colleagues in determining which patients are too sick to be able to perform in the endoscopy suite and which ones need an actual cardiac anesthesiologist in the OR. In terms of communication, we know that communication is key, but how we communicate is of vital importance. On the GI inpatient service, there are really four means, right, in person, over the phone, by email, or through the electronic medical record. Communicating in person and phone decreases barriers. It allows people to read between the lines of what is said and to ask follow-up questions, to get feedback, and to develop genuine relationships that can ease the negotiation. It allows for nonverbal communication, but however, the downside is that these forms of communication take significant time and effort. Just this past week, I had a patient who has ulcerative colitis, came in with a flare, but it really wasn't clear how he was doing because he was telling my fellow one thing about how many bowel movements he had, how much blood he had, and telling the medicine hospitalist something completely different. So what we did was we got together with the medicine hospitalist, and I suggested that we go to the room together and that the two of us actually just talk to the patient together. And at that point, we were all able to speak and understand in one setting what the patient was actually experiencing. And therefore, we were able to tailor medication treatment to that shared conversation and the shared information. Communicating by email and electronic medical record, it allows you time to consider your next steps carefully. There exists a clear record of the discussion. However, these forms of communication are prone to misinterpretation and delay. There are downsides to every form of communication. You really have to choose which form to use wisely. All right, so that being said, the success as a GI hospitalist, I believe really there are so many factors, but tonight I focused on understanding that customer service is key, understanding that negotiations depend on this particular type of situation, understanding the situational matrix, and tailoring your strategies to negotiating those conflicts and those situations based on the stakes involved, as well as the future relationship with both parties, that success really depends on building trust and emphasizing the importance of maintaining a professional relationship, and finally, choosing how you communicate in each of these situations. So with that, I really want to thank the audience for participating, for staying this late, and thank you very much, ASGE, for sponsoring this webinar. All right, so I think as we kind of transition to our question and answer, we have a question. Maybe, Melissa, you can take a stab at this one first, so then see if Ed has anything to add. How are research and clinical education compensation funded with a GI hospitalist? Perhaps some examples, if either of you have them, would be great. So Dr. LaTorre, do you want to take a first attempt at that one? Yeah, so I think the easier one of those is the clinical education component, because there are designated roles, such as program director or associate program director that usually come with protected time or salary lines. So that's one way to incorporate that is through a job title and a discrete title. So with the research side, it can be a little bit more ambiguous, but typically, unless there is grant-funded research, but a lot of the research happens on your own time, and there are wide varieties of grants available. There's pilot funds and all these other things to help to buy out and protect part of your salary. So it just depends on the resources that you have related to that. Great. And Dr. Sun, any thoughts from your MVA side of things? Yeah, you know, Will, I think you touched upon really the core of being a GI hospitalist or a hospitalist in general. The medicine hospitalists at our institution at Stony Brook, they work seven days on, seven days off, but their seven days off are completely off, right? So this is a model that is commonly accepted across the United States for medicine hospitalists. GI hospitalists, however, despite the position actually existing for quite a while, is still, I believe, in its infancy. And we don't have a dominant model for how a GI hospitalist should, their workflow should be defined. Because of that, what you've touched upon is, the institution is going to ask, is going to invariably ask, what are you doing with that time when you're not taking care of inpatients? And if you have a passion for research or for clinical education, and you can show that and demonstrate that passion to the institution and to your practice, I certainly think you'd be able to make a very good argument for creating a GI hospitalist position that allows you to care for the inpatients when you're on the inpatient GI service, and then do your clinical research or clinical education and satisfy those missions, which are in line with the educational missions of the hospital and the institution and your department, to create that position for you. So I think that's very powerful and good insight. Thank you, Dr. LaTorre and Son. We have some great questions coming in. We have another one. What do we think is the long-term academic impact for training? That is a really fantastic question. Do either of you have thoughts, or do you want me to take this one? Yes, I can start. For sure. Okay, thanks. We struggled with this quite a bit, right? When I designed this GI hospital position at Stony Brook, we invited the fellows into the discussion and we asked them how would they feel if there was only one person teaching them the entire first year, and they balked at the idea because there's so much that you can learn from every single attending here. Because of that, when I'm not on service, my colleagues actually share service and they divide up service, and in that sense, the fellows really benefit from that varied experience and from the varied experiences and specialties of my colleagues. But every institution is different. So even if another institution only has one or two GI hospitalists, there have to be ways to expose the fellows to the other attendings in that division. And I'd ask Dr. LaTorre and Dr. Hughes to chime in at their experiences from their institutions. Yeah, I definitely agree with that, that having exposure to different attendings and faculty members and styles is critical. So it's important to balance that also with meeting the needs of the hospital and having a GI hospitalist who's familiar with throughput. So at our institution, we kind of merged the two. We have a hospitalist there myself. We've even brought on a halftime hospitalist as well. And we still have our faculty pool rotating through. And usually it's a rotating faculty member and one of the GI hospitalists together tackling the consult service. So we work together. The fellows get exposed to different educational styles. What I find interesting or what I appreciate is the things that we do together in terms of these advanced hemostasis techniques, sometimes they bring that to the other sites that they rotate through. And my fellows come back and tell me, I put a cap on the scope because I wanted to see the bottom better or they're training their hepatology attendings to use hemo spray. And I really feel like there is that value of having someone who's really familiar with these techniques, but then they also get the expertise from their IBD attendings, et cetera. So they get the best of all worlds. And I can, I echo sort of all of that. I think it's definitely a trade-off. There's pros and cons and we don't yet know the long-term data on it. I think it's very much a institution dependent. Ours is our fellows rotate and get inpatient experience at three different hospitals. Only one of which has a hospitalist system. And so, yes, they lose a little bit of exposure there, but at times the supervision wasn't, or the opportunities for teaching and learning weren't as good. The endoscopic skills weren't always as, those providers aren't doing hemostasis cases every day. So they were less likely to have the fellows hold on to the scope. And so, we've kind of anecdotally proven over the last three years is we've had our model that fellows are self-selecting to come back onto our service because they really have enjoyed having that consistent attending core. Granted, we do have three hospitalists, so there's a variety of their exposure, but we have second and third years. We have an additional fellow almost every rotation now because they enjoy that added exposure. The other kind of balancing measure that we're doing is that we're also stationed in the hospital in such a way that we're connecting the fellows to other opportunities. So I have worked on building an endoscopic curriculum for the fellows. I've also built a quality improvement curriculum and I'm connecting them with hospital-based improvement projects. And so, having that consistency within one hospital also has a benefit. So yes, they're losing out on a little bit of clinical experience from different voices and different exposures, but in our system where there's already different attendings at different sites, certainly I think it's outweighed because we're able to offer these other things. But again, we don't yet know. The hope is that we'll continue to study this going forward, but absolutely a consideration as you look to build models because that's not something that you want to take away educational experience from the trainees. Okay, well, it's almost 9.30, so if there are no other- So, yeah, I was gonna kind of help you out here. I think maybe one key point or resource that each of you would leave the audience with, I'll start with Dr. Sun. So, I think the most important resource and exciting resource right now is if you're interested in GI hospitals work, is to join the ASGE GI Hospital Special Interest Group. Dr. Hughes, any last one-pointer or resource that you would like to share? Oh, gosh, so many. I learned a lot from these talks, but I think my takeaway is that it's a position that I think people should consider, and it has an opportunity, not just for the clinical exposure, but for opportunities to grow professionally in other directions as well. And so I think it's an exciting opportunity that's starting to come about at a lot of different centers. Very good, thank you. And Dr. LaTorre. I think in moving this GI hospitalist model forward, it's important to just observe how other inpatient type models, such as the medicine hospitalist, or if you have a dermatology hospitalist, or whatever similar structure. I recently found we have a cardiologist hospitalist at our institution. So just observe and learn from their workflows and how their field is structuring things. And again, just observe all of that and bring it back to this GI realm. And together, I think we can help create the position that our specialty needs. And I think that's one of the most exciting things about being at the forefront. And in addition for us having this opportunity through the ASGE to develop this special interest group. So the future is bright. Very good. And thank you to all three of you. Just a round of applause, virtual applause for these three. They were awesome presentations and the discussions. In closing, I wanna thank everybody for their participation in tonight's presentation. Just a reminder though, but before you log off, we would really appreciate your feedback on tonight's webinar by going to that networking lounge and completing our evaluation. It only takes a minute or two to do. Thank you for doing that. And also just as another reminder, you can access a recording of this webinar by logging on to GILeap by going to learn.asge.org. We plan to have that probably up tomorrow afternoon sometime. You do not have to be an ASGE member to access this content as our goal is to provide information and education from these Thursday webinar topics as an open source resource to assist gastroenterologists globally in improving their practices. And finally, this is the conclusion. Our next webinar is next Thursday, September 30th at 7 p.m., which will focus on endoscopy and the management of a malignant hyaluronabstruction. That's one of our guidelines that was just published by our committee. We look forward to your participation with that. So with that, thank you again and have a wonderful evening. Thank you.

GI hospitalist program

assessing inpatient GI service

evaluating inpatient GI service

institutional needs

community needs

successful program

challenges faced by GI hospitalists

inefficiency in patient care

realistic expectations

staffing needs

flexibility in GI hospitalist position

building relationships