So we are at, it seems that we are at the appointed hour, so I welcome the hardy amongst you both to the last day of chess and to the first morning session of the last day of chess. So you've not only stayed long, but you've gotten up early and I assure you, you will be glad that you did so. To my right are five esteemed panel, actually one co-host and four esteemed panelists who will be throwing barbs at each other. Welcome to the show that is the most dangerous show at chess, so dangerous they made us change the name for legal purposes. So we have rebranded to pardon the disruption, but we are still the same flair. I am your host, Dave Shulman, I have few skills other than hosting, so let's get to the crew to my right. Before we pardon the disruption, we're going to pardon the introduction. Each year I have my panelists send me pictures and I ask them to send me embarrassing pictures that would be good for the show. Each sent me pictures, Gerard sent me a wonderful picture that I will be using, the other three sent me okay pictures and I will use them, but because I spent time, because they took so long, I spent time using AI to craft photos of them. I decided I'm going to show the audience, because you've come early, you've stayed for a long meeting, so I'm also going to show you my AI pictures of them, because you deserve it, you're worth it. So on my far right, your far left, I'm going to introduce, bringing the harm from the city of charm, halting maladies from Baltimore's localities, hailing from Johns Hopkins University School of Medicine, your first competitor, Dr. Christine Argen in charge, Argento. Thanks, I love it. It's not bad, right? AI does some good work. It's a true representation. To her left, I will introduce, sitting pretty in the windy city, the real McCoy from Illinois, hailing from Northwestern now, for those of you who did not know, the University School of Medicine, Dr. Mo Money, Mo Problems, Mo Minwahidi. To his left, I will introduce, she's come very far to pop the car, she's bringing the smack down from Beantown, hailing from the Leahy Clinic, Dr. Out of My Dreams, Into My Carla Lamb. You get ready for this. All right. Oh, you brought a cape. I may give you a point for the cape, all right. And last but not least, the final competitor to her left, introducing, nothing could be finer from the state of Carolina, the Dominic Toretto from the state of Palmetto, hailing from the MUSC, ladies and gentlemen, Dr. Judging Gerard Silvestri. And I didn't have to come up with AI Gerard, because that's a super picture. All right. So I'm going to now move to use the pictures that each of them had given me, because they're, you know, I just wanted to show those, but I didn't want to give you the courtesy of using the pictures. Let's pick up where I left off. Okay. So let's go right down there. There are less good pictures, but we'll go right here. So let's just review the rules for the audience and for the competitors. We have 13 topics prepared. We will get to as many as we can. Sometimes we get to all. Sometimes we don't. But I'll jump around if I want to hit certain topics that we don't have time for. For most topics, speakers are going to be selected in a random order. I ask the speakers to keep their comment under one minute. I get bored easily, as most of them know, so we will move on, and I have ways to prod them along, including a buzzer if I need be. Volume, humor, and accuracy are encouraged, and those are the orders that I recommend the speakers prioritize their statements. I reserve the right to cut off speakers for going long, being off topic, being annoying, or unfunny. Four points are available for a topic per contestant, two for actual facts, but two for style and sass. If somebody comes at you aggressively and they are effective, you will lose points for letting yourself get sassed. You are welcome to come at me, but I have been doing this now for seven years. I've gotten pretty good at it, so when you come at the king, you best not miss. Back this year, audience participation, you all have paddles. You get to affect the score. If you hear something you like, either from a data standpoint that corroborates something you do in practice, or somebody had a really good zinger, go ahead and hold that paddle up with a thumbs up, and we can adjust the points. If you hear something that you aggressively disagree with, you're welcome to give me a thumbs down, and we will adjust the points downward, because points don't matter with the exception of for one purpose, and that is to earn this prize. Ladies and gentlemen, there is a prize for winning the competition. I purchased it for $14.95 on Amazon, so you know it's good. It is this glittery red ring, as yet unworn by any human hand. Fits all sizes, which, by the way, means it is large on all sizes, but that's okay, and you can either display it on a case, or you can wear it around your neck if you prefer. It goes with the cake, guys. It goes with the cake. There is an opportunity to earn a prize here, and if those want to Twitter, Dr. Rickman and I will be doing a little bit of a debrief later. We'll try to keep an eye on the Twitters. I'll actually probably help out with him. If you want to tweet at us so you can ask a question later, you can use that chestPTD hashtag. So here's the glittery ring, just so you know it's real. $14.95, folks. You can get your own. Okay. With that said, it's go time. So I will start with the panelist on the far right, Dr. Argento. The first topic is yours to comment on. Do the robot. Is the procedural robot everything it was promised to be? The floor is yours, Dr. Argento. Yes, it is. It is. It is everything that we wanted. It is cool. It is sexy. It is fun to drive. It is, patients love it. You've described basically a fancy car. Cool, sexy, fun to drive. Yeah, just like the robot. It does allow us to go for smaller nodules without a bronchus sign with more precision. We are able, there is, you are able to manipulate the distal end of the scope, which you were not able to do with a traditional scope. It does hold steady. Is it everything that we wanted? Maybe not. We're still working on it. There's a learning curve, and we're figuring out how to deal with some of the challenges and complexities of biopsy. But the sexiness, the fun, it's all there. You know, patients don't really care about sexy, do they? They do. They care about, no, no, they don't. Yes, they do. No, no, they don't. Well, that says something about your patients. They don't care about sexy. They care about results. They care about what the doctor tells them three days later. They care about, do I have to have a salvage procedure? They care about results. They care about that. They don't care about sexy. And I'm glad you care about sexy. That motorcycle picture's pretty cool. But they don't care about sexy. It's my new hobby. Nobody, moment, any thoughts on this? Cool and sexy, but no data yet to say it works better than anything else. We have a bunch of retrospective or registry. And, you know, think about the procedure. There are two things. The first phase is getting from the mouth to the nodule. That has not improved. We're still relying on a CT from a week ago when the patient was in the scanner breathing spontaneously. Lots of CT body diversion. The part that got better is when we get closer to the nodule, we have more steerability. We have more sturdiness. We have a catheter that's not being moved by the instrument. So that part is better. But let's see the data that it's much better. What kind of data do you need? Well, we need to have less heterogeneity in the research, right? Right now there's high variable in operators, patient types, the size of nodules. We have to be data driven and push the urgency for that data drive. So that, you know, look at meta-analysis so far. All the different navigational technologies. None of them have been the clear leader. And I think we have much to learn. But this is encouraging. Clearly we're going for nodules that were not even attainable by any other existing platform or bronchoscopy. But it's got to be driven by data. And there's yet to be proven in peer-reviewed assessments. And how we call diagnostic biopsy, right? Not everyone defines diagnostic the same way. That's critical. Critical. Thank you for mentioning our meta-analysis, which updated patients over 20 years and included 16,000 patients in all different technologies and found that no technology was better than the next. Over two decades, no technology was better than the next. 16,000 patients, 126 studies, right? Like every time new technology comes along, we want to talk about it being sexy. But we have no trials. And you know what the real trial is here? Pardon the interruption. The real trial here is a randomized trial between trans-thoracic needle biopsy and robotic bronchoscopy in the same setting so that we know what we're going after. You know what's crazy about you? I would call you has-beens, but you haven't even been yet. So I can't even call you that. You know, what's really, really crazy about all this is all I hear is we can get these tiny nodules out in the periphery. They're so cool. They're out in the periphery. There are three things I want this group to remember. Technique, technology, and patient selection. Probably patient selection is the most important thing. Why in the world are people going for one centimeter ground glass nodules in the periphery of the lung and bragging about it, Christina Argento? You know, it's madness to me. I am not saying that it might not be better technology. Now, all of a sudden, by the way, they want to protect the robots. So what they're saying is, oh, we can do EBUS at the same time. Well, guess what? We could do that before. They were also saying, oh, you know, we can get out and maybe ablate these lesions. Come on, guys, man. We need a randomized trial. The real thing. But let me caution. Ivory Tower publications don't cross the board of how performance is across the country. How can we make accessible care for our patients in minimally invasive ways and raise the bar of every bronchoscopist with data-driven technology and have clear guidelines on how to utilize that? More to come, fellas. I want to make sure the microphone on the far side is working. And by fellow, she didn't mean to demean the women in the room. It's men and women. Argento, you cannot let this stand. She's like, wait, am I on the right panel? It's like battle. I feel like the Arizona right now. We haven't even gotten to the good part yet. I mean, I do think that we are making strides forward. And I think that's the point, right? Have we gotten everywhere we need to get? No. I do absolutely agree that we need randomized controlled trials. We need real data. We need to have consistent data that we can actually compare studies and trials so that definition of diagnostic yield should be consistent across the board. But I do think that these parameters of being steady, where you don't have to hold the bronchoscope and you're getting fatigue as you're taking your biopsy passes, and this idea of being able to properly maneuver your scope are really key and important. And I think they are showing promise. We just need to get sort of the rest of the challenges out of the way. I'm going to move us along. Dr. Silvestri, I do have to take a point away for using, I don't know that ESPN attorneys are in the audience or not, but you did use the old name of the session. And I'm told that I have to take a point away if you use a branded trademark name. So you're down to three. All right. It's his poor memory. He's a bit old. You might want to give him a second. At the end of the day, the people in the crowd know what's going on here. You are not above the law. All right. Moving on. Dr. Wahidi, I'm going to let you take topic two. Animal magnetism. Is electromagnetic, I can't even speak the English. It's Jersey. I use only small words normally at home. Is electromagnetic bronchoscopy dead? We haven't buried it yet. It's alive and kicking. I mean, we have to have a global view, right? And not everybody can afford the robot. Not even in the U.S. So I think it still has a role. It needs to be improved. It needs to catch up to the robotic improvement. It's not dead, but it's nearing CPR status. Carla, dead? Well, I think I don't disagree with my colleague here. I think that, you know, there's publications utilizing other image-guided adjuncts to any navigational platform. Again, jury's out. But there is some potential promise that some of the radiographic visualization adjuncts in real time may enhance other navigation platforms. Nothing is independent of itself. I think that's what I would take from it. I also don't know that, you know, the affordability of electromagnetic navigation, it's not like it costs 20 bucks. I mean, this is still an extremely expensive system. It's not super affordable and doesn't give universal access. It's interesting that you bring up affordability with magnetic navigation, but you didn't talk about it with the robot. And, you know, it's interesting because that was cool and sexy. You need general anesthesia. There's tons of disposables that cost thousands of dollars. I mean, it's incredible. Look, navigation, electromagnetic navigation is okay if what you want is to get a diagnosis at best 70% of the time. 16,000 patients over 20 years, 126 studies. First 10 years, we published in 2002, 2012. That had a 70% diagnostic yield. 2012 to 2022, 69.5%. And one thing we did in the meta-analysis, we looked at the risk of bias by scoring every study by the risk of bias. The high biased studies had a yield of 65%, so even lower. And they've talked about definitions and everything else. The low bias studies had a yield of 65%. The high bias, 70%. Look, like, is it dead? If 70% is okay with this crowd, great. Seven out of 10, three out of 10 times, you're going to call your patient up and say, I did not make a diagnosis. And one of the endpoints we have to put in these studies that we have to force on people is patient-centered endpoints, such as salvaged procedures. Do I have to go back, right? Do I have to now say, I didn't get it. We're going to watch this for a while so the patient can be more anxious, right? We need better studies. Is it dead? If 70% is alive, then we're 70% alive. That's it. Says the guy who hates bronchoscopy. Yeah. No, I've been accused of hating bronchoscopy. What I like is the truth, you know? You can't handle the truth, Doc. Yeah, exactly. I'm trying to ask the ones who can't handle the truth. It was in everybody's head in the audience. And the question is, do I give them a point for saying what everybody was already thinking? Do I take a point? I'm going to give you a point for that, but it was a little too low-hanging. At this point, I want to remind the audience that your arms do work. So please show us what you like and what you don't. Out of curiosity, thumbs up, thumbs down from the audience. Is electromagnetic bronchoscopy dead? Thumbs up if you think it is dead. Thumbs down if you think it's not. So it's almost 50-50 down the middle. 70%. 71% to 70%. Dr. Lam, I'm going to let you go first. It's the same as the yield. Stay in your definition. So this is a question that Dr. Rickman was kind of hinting at back in the first topic. Should we define diagnostic yield for pulmonary nodules? Oh, she's pulling up notes. Well, I think it's very important because I think it's quite confusing. And when you look at the literature and dissect it, everyone has a different definition. There's been recent publications in CHEST talking about that very fact as it pertains to lung nodules. So let's talk about three clear, if we want to make it as clear as possible, definitions that can be accepted, right? You've got the strict definition where when you do a biopsy of a nodule, it either comes back malignant or very specifically benign, hematoma, something very specific. If you have an intermediate type of diagnosis, you either have malignancy or you have a benign diagnosis, but also maybe a nonspecific benign, like a granulation tissue, granuloma. If it's going to be more of a liberal definition, which is often used in the literature as a reference point, is either you get a malignancy with the biopsy or you have follow-up, which is variable. I've seen six-month follow-up, one-year follow-up, two-year follow-up, radiographically or any surrogate subsequent biopsy to be deemed true negative or false negative. So we've got to get, as a community, our definitions straight and adhere to them consistently so we can make sense of the literature. Let's go to your right, Dr. Wahidi. So, I mean, we need to really agree on a standard definition. It should be that the numerator is the number of patients who had a specific diagnosis from your biopsy, benign or malignant, specific granuloma, malignancy, and then the denominator is every procedure you've done, right? So we cannot accept inflammation, atypical cells. We cannot accept all these things that Carla said, and we need to all agree on that. Otherwise, we're just doing whatever we want so we can increase that number. And that's what matters to the patient, by the way. It's at the time of the procedure. If you want to wait a year, that's fine for research, but that did not help your patient. The diagnostic yield is at the time of the procedure. I think that's true. We're starting to find, though, that atypical, you know, is that going to end up, you know, we just presented some data here yesterday about our atypical diagnoses end up being malignancy, you know, 80% of the time. And so, you know, I think we're still working on that definition. I agree that we have to be specific. I don't think that patients can wait a year to be like, oh, okay, this is definitively negative, and that's a true negative. But I think there are some nuances. It's not just as easy as we have a very specific diagnosis or not. While Carla was reading her notes and Christine was talking about making a diagnosis 80% of the time, we were actually out writing guidelines. And so what you'll be seeing soon is a guideline on what the definition of diagnostic yield is. It's close to what Momin talked about, right? And we also talk about patient-centered outcomes as well. Atypical cells is atypical cells. It's not a definitive. You don't tell your patient you have cancer. You tell them, well, we got something that's a little suspicious. You might even treat that. You might even, in the right clinical setting, with a growing nodule, hot on PET, do stereotactic body radiotherapy if they can't be operated on. That, I'm not talking about clinical now. I'm talking about how we evaluate new technologies. And I think the strict definition is the only definition that counts. And for me, when we started this project led by Ann Gonzalez, we actually just talked about it among ourselves. And one of the things I said is, what do you tell the patient three days later? Do you tell them I got it? Do you tell them I think this is what it is? Or do you tell them I didn't get it and we're going to have to do something else? That is the critical issue. Now, putting your definitions around that is important. The other thing I would tell you is the literature is really all over the place with the prevalence of malignancy. The higher the prevalence of malignancy, people start talking about sensitivity of malignancy and that's what they want to publish. That is not a diagnostic yield. But the higher prevalence of malignancy, the more likely you are to make a diagnosis. I would agree with that. Who enforces the diagnostic yield definition? I think it has to come from our societies. I think we have to have an agreement and consensus in our societies that maybe the guidelines drive that. Or the editors don't publish the paper unless you have it. Yeah. The editors-in-chief of respiratory journals. But you're always going to have some journals that are willing to publish whatever. And we think all of us have to be responsible for that. So tell me about tool and lesion. Does that matter? I mean, that's like saying scope and mouth. That's a really good thing. That's fine. No, it is. It is. Tool and lesion is meaningless. Tool and lesion is meaningless. This is like me yesterday going to a restaurant. I got there by GPS, but it was on the third floor. I had no idea. I kept going and going and going. I could not know where the restaurant was. And yet we invited him to participate today. We're shocked that he made it here this morning. But the technology has everything. The lesion's not a tool, and it doesn't show up on the path. Yeah, tissue is the issue. If it's not on the biopsy in front of the pathologist, it doesn't really count. I agree. You could have a really pretty picture. We've all seen pretty navigation pictures. It doesn't always equate to diagnostic yield. I think the technology has to be comprised of everything, right? It includes the tools that you're going to use with that navigational tool to get there. So you may get your tool in the lesion, but if there's no lesion in your tool, you're nowhere. The lesion in tool, tool in lesion, is sounding a little risque, so I'm going to move on to the next topic. That's how we like it. Gerard, you're going to be first on this one. Cup or cone, is there a benefit or need to add cone beam CT to robotic bronchoscopies? Yeah. We know it's sexy. We've already heard that. But other than that. Let's talk cost. So again, and probably because I'm the oldest guy on the stage, maybe the oldest guy in the conference room, I've seen it all before, right? We could do this with fluoro. It was this, it was this. Cone beam CT, I think, will give a better view. We don't have it at our institution, but I've seen the pretty pictures that Christine sends around. You've got to get a life, Christine. We don't want to see that stuff anymore. But I would say this. I would say a couple things. Are you then evaluating the robot anymore? Or are you now evaluating image guidance, right? And is it the image guidance that now makes technology available? And could we have gotten it if we used cone beam with peripheral ultrasound, right? I'm not saying it's not good. And then, oh, let's add yet another million dollar toy to the bronch lab. And let's see what happens when in South Carolina, where 2 3rds of the counties are rural and underserved, and it takes 50 miles to get to a pulmonologist. Is this really what, when they have transthoracic needle, and you're looking at a 1 and 1 half centimeter lesion just below the rib cage, is this what we should be doing? I mean, the one problem here is that when you build these interventional pulmonary powerhouses that we see at Lahey and Northwestern and at Hopkins, you've got to feed that beast, right? And that beast just requires you to keep doing these procedures day and night, day and night. I think that cone beam might be good. I think it's probably going to get you closer to lesion, basically, when there's diversity between breath holds and everything like that. Will it increase yield? I don't know. Need a randomized trial. Well, we are going to start a GoFundMe page for Gerard and MUSC. But I think the thing is that having real time guidance, it's what's going to matter, in my opinion. Because again, all these navigation systems, including the robot, is taking you to the nodule based on the CT that was done a few days ago. But the radial EBUS and the cone beam CT are the real deal, are telling you, where are you today? And I think I was not very happy with the fixed cone beam team. Now we have a mobile cone beam CT. So that's, I think, still a little expensive. But it's coming down in price. A little? We're in Chicago. Oh. To Gerard's point, is the incremental benefit worth the cost? You're not talking about adding technology expensive number one, technology expensive number two. And I don't know if we're using quality adjusted life years. I don't know how you measure the effectiveness in that. But the dollar per year of life added, at some point, you're breaking the bank, right? We don't have a single cost effect. Yeah, we don't know. We don't know the answer to that. Not at all. And I think you're adding more technology. You're adding more personnel. It's really hard to do the cone beam yourself. You need radiology techs that are there and dedicated to your room. And they're not short procedures. You're adding all of this technology that costs a lot of money, that's not going to be accessible or available in a lot of places. However, I will say that intraoperative imaging is certainly helpful. And when you have your patient on the table, and they're trying to get an answer, and you're close, or you're there 70% of the time, can we improve that to get you a better answer for your patient? So if it is available, it's pretty darn nice to have. But otherwise, go fund me for it. That's your next trial, right? Robotic bronchoscopy versus robotic bronchoscopy with cone beam. But what I'm hearing is, see how they're afraid? See how they're so afraid to make it against transthoracic needle aspirate? You're such a baby. Because then we could do the absolute costs. I'm a health services researcher. They miss the part where now we're going to have a rad tech in the room. You know what else we miss? The anesthesiologist who has to be there. You can't do these under conscious sedation anymore. And they're up there reading their Harlequin novels while they're collecting a per minute cost for these procedures, right? Per minute, not per our procedure. And oh, by the way, how many of the pulmonologists practicing in the community have an hour and 20 minutes to sit in the bronch lab fiddling around with a joystick, while there's 14 patients out there with lung masses that need your attention? I'm not sure how many of those there are out there. Certainly not me. I have the attention span of a grape, which is about my attention span for the drivel that's going on over here. And looking at that picture, it should actually sort of look a little bit like a grape if you blur your eyes a little bit. You've got a technical problem. Terrible. All right, let's move on to the next topic. But I think the one other thing, though, is to go back to, even though I am a bronchoscopy lover, unlike Gerard, who's a bronchoscopy hater, but I think it goes back to, do we really need to do these procedures for these really tiny peripheral nodules? Should we be doing EBES, staging the mediastinum, and then sending them for surgery or other things? So I think that's part of that. So y'all let Gerard get away with CT, because nobody's talked about complications. Yeah, and look, our IR, all of us. IR, they cherry pick. We know that. Our IR colleagues, I love them, but they're never going to go after any. Do you know that? Huh? No, I love them. I love them. And Otis is right. There's a higher pneumothorax rate, although they say, oh, it's not important. We'll just watch them for a few hours. But that matters to the patient, too. And there's also some lesions that are not attainable by IR, even though they can be consulted. Things that are really close to vessels, things that are more ominous when there's emphysematous lung, where the risk of pneumothorax is certainly significant. And there's no question that bronchoscopically, if we can get to the lesion, or regardless getting to that place, our risk of pneumothorax, that even those higher risk cases, and even with bleeding, is far less than some of the comparable cases if you match them up with IR and bronchoscopy. Or by the diaphragm. Last comment, Christine. No, no. No, Gerard, go ahead. 90%, 90-plus percent yield look like you can bash the people who are in the room where you can imagine what we could do better if we would actually critically look at our own technology. I mean, that's really the bottom line. Yes, there's a pneumothorax rate. It's actually 16%. Renda, Wiener, and Annals of Internal Medicine. 6% require a chest tube. But you know what? You can tell the patient what they have way more, at least 20% more of the time than we currently can do with the technology we have. And you're absolutely right, man. You've got to talk about vessels and this and that, and patients with emphysema. It does come down to patient selection. I don't hate bronchoscopy. If it's a central lesion and the patient has emphysema and splebs that you have to go through, I'm totally wanting to do a bronchoscopy. But let's be honest, man. Let's be honest. Then they get the IR biopsy. Then I have to do a bronchoscopy to stage them with EBIS. Moving on. Dr. Argento, I'll give this back to you. Who's on first? When doing bronchoscopy? So Gerard, you have to do bronchoscopy on this one. I'm fine. When you're doing bronchoscopy for a nodule, using either robotics or navigation, do you do EBIS first or go after the peripheral nodule first? So my protocol is to do EBIS first, almost exclusively, because you stage the mediastinum. And again, going back to those comments about should we be doing navigational bronchoscopies at all for small nodules, really the important part of the procedure is making sure that the mediastinum is staged and you've done your due diligence in that sense. The one caveat is if you do have patients who they really want a biopsy for whatever reason and the mediastinum really looks negative and that nodules, especially if it's in the lower lobes or close to the diaphragms where you know atelectasis could be a problem and your CT to body divergence is going to be high, then I may start with the nodule first. But by far and away, my protocol is to go for the lymph nodes first. For example, I, moment. Well, I agree with that if you have enlarged lymph nodes on CT or PET-AVID. But if you have a small nodule in the periphery, we know that the mediastinum involvement, if you have normal CT and PET, is about 10%. So it's a smaller yield. You still have to do it, but I'd much rather start with the navigation part, not let the atelectasis settle in and move my nodule, biopsy the nodule, and then go to EBIS for that 10%. Again, if it's enlarged more than, you know, on CT or PET, I'm going there first for sure. But the 10% even, I mean, I think we're going to see some data. It's, you know, 10%. It's around that. It's 10 to 20%. And we're seeing a lot more occult nodal disease and seeing that even in patients with small nodules, whether they're peripheral or central, have that. And so I think it's still important to look at the mediastinum. That's your main job. And that's what we're particularly good at, right? That's where we know the technology shines. We're at over 90% yield when it comes to EBIS for lung cancer, finding it in the lymph nodes. Moment, what's the problem with that logic? What's the problem with what? Why do you disagree with that logic? You're saying you're doing- To start with EBIS on everybody? Yeah. Because you are going to spend a lot of time. I mean, it's depending on your skill, 30 minutes or so, and looking for nodules, sampling some six, seven millimeter lymph nodes, and you're losing time. There's atelectasis that settles in and moves your target. So again, I'm going with the higher likelihood of the finding, and that's how I do the order. Dr. Lam. And depending how you look at it, atelectasis sets in the minute you put your patient under sedation. So I don't know that it's going to make that much of a difference. If you're going to take 30 minutes, or you're going to take three minutes, atelectasis will- If the radiology techs are in the room billing per minute per Gerard's earlier point, it kind of does matter, I would argue, but it's a different issue. Dr. Lam. So do the job you need to do that's going to give you the best, you know, your job done. I think what you're seeing among just this short group of people is that there's variability, and there's thought process that goes behind it. You don't want to get so tunnel vision that you're going to do a navigation that you forget, you know, what's the end game here? Get some type of diagnosis, and be thorough in the examination. So it's, these procedure have now become dual procedures. Whether you do the order is flipped, you're still looking at the media, starting with low threshold, irrespective of the PET or the CT findings, because we know now that there's microscopic disease. So I think the tricky patients are the ones who have the diaphragm, lower lobe, they're a bigger BMI patient. Those patients are probably the highest risk for atelectasis, or you couch that by having a really clear protocol with your anesthesiologist about re-recruitment, so that you don't lose a lot of ground on nodule movement. So there's variability. I think the take home here, it's gray as can be, and I think there's room for variability. I think everyone's fine with things being gray. The problem is that, everyone's going to say you should always use judgment, right? But what I'm hearing, though, is that even in the context of using judgment, there are significant differences amongst experts in the field, which leaves those who are potentially a little less expert completely unclear as to exactly how to proceed. You're calling these guys experts in the field? I said amongst experts in the field. I didn't say amongst the experts present here. Okay, I just wanted to make sure I understood this. First of all, we would put these patients on Adapeep, at least Adapeep, during the procedure to prevent atelectasis. Secondly, I do EBIS first. It has a 90% yield. And one thing that my non-cancer doctors haven't mentioned is that if we have rows on site and if we get cancer, then one really important thing now in early stage disease, 1B through 3A, is that they have options that weren't there before. So we want to do molecular markers in these patients. And so we want EGFR because if they get EGFR positive, they could get resected and get osimertinib for EGFR positive, second generation TKI. The second thing is if they're positive and they're not EGFR positive, if they're positive for cancer in the mediastinum, then they're eligible for Checkmate 816, which is chemoimmunotherapy, followed by surgery. So in those instances, I think that 10% is probably worth doing EBIS first because you can also stop the procedure at that time and get enough for molecular markers if you're going to find it. And why is that, why do? Yeah, I think that's a little bit on the, I believe that's a little bit on the controversial side. We do PD-L1 on every one of our advanced lung cancers and if you get something greater than 1%, I think you can go ahead and use that for something like chemoimmuno followed by surgery. They're stage 3A disease. Actually, let's get the rest of the panel's take on that question. Agreed. Yeah, no, I agree with that. I agree with that. But we haven't practiced. Do you agree with Gerard or do you agree with the commentator? Well, I think that the comment is an important point to be raised. But I think that in our practice, at least we actually do low threshold, we do markers on all patients who have advanced disease because they often are candidates for other therapies that are much more specific than what we would do otherwise. So, but I think the bulk of the markers we take are from the primary lesion. Yeah. Moving on to the next topic. Let's start with Dr. Lamb here. Oh, that's cold. Is cryobiopsy necessary to sample peripheral lesions reached with either robotics or navigation in order to obtain sufficient tissue for molecular markers? Well, I think some interesting shifts in the last couple of years is the small probe, the 1.1 millimeter probe. And we're talking little data, single center, a little over 100 patients published just in the last couple of years. And they looked at their robotic experience with different types of biopsy for peripheral nodules. And specifically, they looked at using a needle biopsy, needle aspirate. And they did transbronchial biopsy the traditional way with the robot guidance. And then they did cryobiopsies using the 1.1 millimeter probe. And they, again, very built in with their diagnostic yield. But they quoted that they had a 90% diagnostic yield, but cautioned with the diagnostic yield regarding malignancy or specific benign diagnoses. And they had a complication rate in that context. And some of the lesions were certainly small. And they were somewhat near the pleura, within 0 to 15 millimeters, I believe, is what they quoted in their study. And they had a 5.4% pneumothorax rate. And they had a bleeding rate that was less than 2%, but nothing untoward. I think about 2.7 needed chest tubes, but ultimately recovered. But the bottom line is the miniature cryoprobe, the stats that were quoted with the larger probes with high risk of bleeding as high as 30%, 34%, that's not translating so far. But again, a lot of this is more anecdotal, single centers, word of mouth, more publications on a broader scale. The frostbite study, I think some things are coming out. But I think the bottom line is, I think it's shifting how we think about biopsies. They also did something interesting. They did digital analysis of the quantity and the quality of the cryobiopsy specifically. And that had a signal, a positive signal for quality and quantity. So it's just interesting to know. Dr. Argento, can you actually answer the question? Is it necessary to sample lesions? So I got data. Data are good. The answer, I would say, yes. OK, now you're saying yes. So is it necessary to sample peripheral lesions with cryobiopsy? So it's not necessary. It depends on whether you have ROSE or not. So it's really going to be about your feedback. Do you think you have enough? You need to have enough material to get a diagnosis and to have your molecular markers. So is it necessary? No. If you get all of that with a needle, and ROSE is particularly good at looking at samples from needles, they're not going to give you great feedback for the most part. If you're going to give them a cryobiopsy and you smear it on a slide and then put it in a cup, they're not going to be as good at looking at that. So you're going to get feedback for your sample from a needle. If you get enough of a cell block from your needle, you do not need cryobiopsy. However, if you are getting sort of scant cells, you do have a diagnosis of malignancy, and you want to build up your cell block and make sure you have enough, then I think cryobiopsy is certainly a great adjunct to have. Just as Carlo was saying, that 1.1 millimeter probe is the way to go. The complication risk is much lower than we had seen before. You can keep your scope in the airway, and it's easy to use. Moment looks a little unhappy with your answer. No, the answer is no. Come on. I mean, we're like kids in a candy store. They make something, and we want to use it. And now we're excited, jumping up and down. And you know, the cryoprobe is close to $1,000. Let me remind you. And you know, we have no data that you're not getting enough molecular markers with a biopsy or a needle. I disagree with that. I've been told it's not $1,000 from aggressive members on the panel. $500. What is it? $500? I think he's buying his on eBay. We don't negotiate well. But I think we don't know. We don't know. I don't want to use cryoprobe right now, because I don't know if they're going to get me more markers or not. So why am I going to use? But we have a trial, right? There's a Frostbite 2 trial that's comparing forceps to cryoprobe in ILD, in transplant, and in lung cancer. So let's wait for the trial. But I know we're not going to wait. And I know half of you are going to go use it. Gerard, anything to add? Well, I mean, I don't even know where to start. Moments like Trump, he overvalues things when he wants to, and he undervalues things when he wants to. It's incredible. One point for the Insomniac. It's like, robots aren't that expensive. But oh, that $1,000 probe, I mean, look, let's talk data. Let's talk data, for God's sake. There's already been some really cool animal studies that compared needle to forceps to cryoprobe. And if you look at the histology from those, cryoprobe is much better. I can tell you, I've come around on cryoprobe over a 30-year career. I started with really thinking it was a technology in search of an indication to clear airways. I don't think it's great, because you end up having to wait days for it to really clear the airway. But I actually do think it's good at getting tissue, and really good quality tissue. I agree with the panel that if you can get it on needle, great. And remember that for next-generation sequencing, we're looking at DNA, at cells. We don't need even large needles for that. But in general, I think we also have to look at the indications. And the Frostbite 2, of which we're a site, because we actually do prospective trials at our place, is looking at ILD, at cancer, and comparing these technologies. Why is that so important? For ILD, it may make a huge difference, because you want a lot of lung architecture. For lung cancer, you may only need some cells. So I think the prospective trial is necessary. But if I had to put my money down right now, I actually think cryo, with the lower side effect profile and the smaller probe, is going to be what we're using in the next 10 years. Wow, Gerard is getting excited about something with that data. I did say with data alone. Animal data. I'm going to go back to Dr. Argento. Home improvement, are we any better at diagnostic bronchoscopy than we were 10 years ago? So we spent all this time talking about technology. Has it made a difference? Well, I think we've already kind of answered that. I think in the published literature right now, the meta-analysis, we're saying we're shooting at best 65%, 73%. But again, there's high variability in diagnostic yield. I keep saying that over and over, because I think that's how we have to, in a different lens, look at these studies in terms of what really was diagnostic. So I think more to come. Let the technology evolve. Let's push the science. Let's do prospective, randomized trial, multi-center. And then come away with some take-homes that we can share for our whole medical community, and most importantly, for our patients. But I'm not hearing a yes. I mean, so I'm hearing, let's go down. Are we better? We are better, yes. We are better. But we could be even better. Dr. Argento, are we better than we were 10 years ago? Meaningfully better. Meaningfully better. I do think we are better. But if we do look at the data, again, it's heterogeneous. It's going to show that we are exactly the same, based on that meta-analysis. Everyone is saying we're better, and then saying the data do not show we're better. Can you people give a yes or no answer? It's a yes or no. Are we better, yes or no? No. We are better. I think we're better. For God's sake, I haven't mentioned one trial. One trial. I do need to mention one trial. The only randomized trial, and our site was involved in this trial, as was the great Johns Hopkins University, and Washington University in St. Louis, and Washington Hospital Medical Center, and the University of Florida. Five IB programs, and we looked at transbronchial biopsy, randomized controlled trial, transbronchial biopsy versus radioprobe EBIS. And do you know what the yields were? Prospective. You couldn't fake it. You couldn't lie. It wasn't retrospective. It wasn't single center. The yields were 37% for transbronchial biopsy, and 47% for radioprobe EBIS. That's in a prospective trial, as opposed to the 70%, even the 65% that we just talked about. We've got to be realistic here, guys. We've got to be realistic. Whenever you see prospective randomized trials, then you can know that you have ground truth. The answer is no. Wait, I'm going to hear from the audience, then I'm going to go to Dr. Moe. So audience, thumbs up, thumbs down. Are we better at bronchoscopy than we were 10 years ago? Diagnostic bronchoscopy. Wait, which is thumbs up or thumbs down? Thumbs up is we are better. Thumbs down is we are not better. So maybe a slight majority. So why is the audience saying yes when the data are not supporting that statement? Well, the audience just said no. Can you guys go up again, please, for God's sake? The audience said yes with a slight predominance. No, they didn't. Thumbs up. Yes, there are more thumbs up. Gerard, look, you're good at many things, but if you can't tell thumbs up, thumbs down, we're going to have a good conversation. It was at best 50-50. Moeman, why is there a discrepancy here? Because we lie to him all the time. Let me respond to Gerard. That trial they did, it was OK. They did not use a needle. They only used forceps. Oh, here we go. So a needle would have added a lot, maybe 5%, 10%. I don't know. But I didn't like that trial. But anyway, so, and I was not invited. That's why I'm bitter about it. But anyway, I mean, we are better. But let me brag for Gerard, since he's been bragging nonstop. His center did the meta-analysis 10 years ago, and now, last year. And yes, the yield is still around 70. I think we're not publishing well. It feels like we're doing better. I'm definitely getting after more nodule these days. Linear IBIS has gone great, and we sample with confidence. But we're not able to show it. And I'm not sure why. I think we suck at reporting. We just like retrospective stuff, and look at me. I'm so good. And we don't publish the good stuff. Or we don't design good stuff. I'm really glad that you feel like we're better. The literature, again, 16,000 patients, two different decades, and we got the same exact result. We can quibble about whether we're using needles or no needles. We can quibble about that. 16,000 patients tell us there's no improvement. How much more data do you need? How much more data do you need? I would love us to be better, which it's not. But I feel like we're going after different patients now than we were before. Oh, more excuses. So in the last 10 years, we were going after harder patients. Is that the new one? That's the new one. Oh, now we're going. No, actually. No, easier patients before, harder patients now. We're doing things now that we weren't. But wait a second. We did that analysis, Christine. We did that analysis. Lesions less than 2 centimeters versus lesions greater than 2 centimeters, no difference. 10, 20 years ago, no difference now. So you can't say we're going after more lesions. Now we're going to go, we're going after more lesions. They're tougher lesions. The definitions are different. No, man, like 16,000. Give us another decade, Gerard. We'll be there. Can you really redo it, please? And we'll have better, sexier toys then, too. All right, Gerard, I'm going to let you go first on this one. Friends without benefits, what are the real bronchoscopic lung volume reduction outcomes? Do we have another bronchial thermoplasty on our hands? Yeah, so I'm a cancer guy who, like the mafia, I got sucked into the world of IP, and now I can't get out. You know, I have never, ever bought into this technology. And to be fair, I don't do them. You know, if you look at the national emphysema treatment trial, it was an incredibly small subgroup of patients that benefited. The risks were really high. Patients died. You guys, a lot of people in this room aren't old enough to even remember that trial. And then we found this little subgroup, and we said, OK, well, if we just take these guys and you use any of the technologies, you know, suddenly these patients are going to do better. I think a lot of people take care of these patients sort of off protocol. They don't evaluate them the same way as the trials were done. They don't put them all through pulmonary rehab first. I'm not a real friend without benefits. You just ignored all the data. We have a LIBERATE trial that showed 55% of the patient had an FEV1 of 15% or more. They all had rehab. It works. It's all about selection. Putting the valve is, you know, a lot of people want to put the valve, but select the right patient, and those patients will get better. But it's all about selection. And obviously, we need to reduce the pneumothorax rate of 26%, and we're trying to do more research to reduce it. But this is a valid option for severe emphysema patients who don't have any other option. He was OK with 26% pneumothorax rate, when he's doing it. But when the IR guys are doing a needle biopsy, he's not OK. That's not OK. But I think even with strict patient selection, you're putting the valves in perfectly. You're not getting pneumothorax at 26%. The benefits are incremental, and they're so small. I would say your patients, like, we're purporting this as this big, amazing thing. Honestly, they can walk 50 meters more on a six-minute walk test. They're, you know, it's horrible. I feel like they're. So nice of you to feel that that's not significant. That is significant for your emphysema patients. It is not. It is. That, you know, FAD1 improvement, exercise, quality of life, it's all been proven recently. Randomized controlled trials showed benefit. Why are we denying it? You got to select the right patient. Yeah, but let me try to interfere a bit. Even selecting the right patients, it's minimal benefit. I think, you know, the thing is that, look at these patients. Where are they coming from? They're the patients who are completely limited. They cannot live their lives. That's why they're seeking this intervention. And so when you think about patient-facing, this was presented at the meeting this year. There's three-year data, post-placing valves on patients, tracking them to look at their St. George's respiratory questionnaire, which is a subjective quality of life and other quality of life measures. And interestingly enough, three years out from the valves, they have sustained benefit. They may start declining with natural progression of disease, but they are getting their lives back on some meaningful level. And that's as judged by the patients. And there's even a signal that there may be some mortality reduction. And again, the outcome endpoints that we look for in the original trials reduce severity of exacerbation, reduced hospitalization, gain back, move the dial for this quality of life for patients when there's really no option, when they can't have a transplant, when they can't have a surgical lung volume reduction, but they want to live their lives not defined by the handicap of their disease. So I'm a proponent in this data to back that up. What's wrong with that? I think it's just like bronchial thermoplasty. Yeah, you had a patient or two. Oh, yes, I did. All right, let her finish. Let her finish. It's just like bronchial thermoplasty, where you had a handful of patients that did better. They felt amazing. You were encouraged by that. And the studies, there were studies for bronchial thermoplasty also showing benefits that you could also pull out. The bronchial thermoplasty trial primary outcome was a questionnaire. This is an FEV1 improvement of 15%, 15% or more. Are you seriously comparing BT, who's probably, by the way, is dying, apparently it's going to be pulled out of the market next year, with valves? No way. Look, I actually want to congratulate Carla. She presented a cogent argument. And I do. It's the first one she's presented today. And no, I'm actually saying, please give Carla an extra point on my behalf. Take a few points off of her. So I think everything she said is true, absolutely true. I just think it's a very, very small population that we're talking about. Everything she said is true. And then the one last thing I would say is we're quibbling over what meaningful differences are. There's actually something called a minimum clinical difference. And we should look up those things. Because a six-minute walk test of 50 meters in some studies is not a clinically meaningful improvement. And FEV1 of 10% or 15% maybe. So I think we have to be really thoughtful. And Carla, you are really thoughtful about this population. So I changed my tune a little bit. It's worthwhile. But I think the population, at least that we see, is very, very small. We have time for one more topic. I'm going to take host prerogative and go to one that affects the non-IP trained folks. How will ACGME-accredited IP training affect PCCM procedural competency? I'm going to start with Dr. Lamb. Yeah, I like this quote that I use for many different things. A rising tide lifts all boats. And so I think it's our responsibility as educators to create standardized curriculum across the board because we are all serving patients. And the true north for us is to protect our trainees, to give them quality education, a standardized way of looking at things, and procedural training as part of the whole canvas of the curriculum should be no different. And so I look at when we are looking more carefully and more thoughtfully about how we train others and how we standardize that so it's not kind of a wild west of variability, there's a reason for that. Because history has shown that standardization of curriculum and education with the Flexner report back in the early 1900s showed that we needed some measure. Otherwise, physicians do a very poor measure of ourselves and how good we're doing and how we assess ourselves. So I think that it raises the tide, lifts all boats, including our pulmonary care fellows. You do not think it will detract from procedural competency? Absolutely not. OK. OK. Yeah, absolutely not. No, I don't think it's going to detract at all from pulmonary critical care fellows. Actually, I think it's going to improve their procedural skills. They have an extra point of contact, an extra person to look to, to commiserate with, who is going to help to teach them. Whenever I've been at a program that has an IP fellowship, when I was an IP fellow, and even when I was a pulmonary fellow, having that IP fellow with the pulmonary fellows only improves your procedural skills. It gives them more access to procedures. It means more procedures are being done at their institutions by qualified people who do them with quality metrics. And I think it's only going to improve their skills and give them more access and exposure. Dr. Wahidi. Well, I agree with both of you. I think there is a bit of risk of just everything shifted to the IP fellow. And I think the program director of the general pulmonary fellowship and the IP fellowship need to have concerted effort to ensure that everybody is getting the education they need and that there is this collaboration. It is much easier if you have a skilled IP fellow to just let him or her do everything, right? It's just easier for us. But we need to make that concerted effort and not forget about the pulmonary training, for sure. Gerard. So it's necessary, but not sufficient. It's necessary to continue to have skills and training and competency among these IP fellowships. But make no mistake. They are absolutely lying up here. Pulmonary fellows at IP programs will not get the number of procedures they need to be competent. Because they will end up. And listen, Christine. I sent one of my pulmonary fellows, because we don't have an IP program, to Hopkins this last year. He did like 1,000 thoracentesis. The residents at Hopkins aren't even doing thoracentesis. Certainly not the vast majority of your pulmonary fellows. That's a fact. And the reality is I want, at MUSC, every one of my fellows leave with more than 100 EBIS in their hands. We need to train general pulmonologists to do advanced diagnostics to be able to be competent in those procedures. So while I agree with Moeman when he says, oh, we're going to protect the pulmonary fellows out there, I haven't seen evidence for that. And I've seen some really poorly trained pulmonologists who come out of programs with IP training that didn't do an IP fellowship. And I'm going to call up the last comment. I think that there is an impetus on the trainees, as well as the program directors, to give their trainees time to spend with us. And honestly, the trainees, no, they vote with their feet. Do they show up? We give them every opportunity at Hopkins. So if you want to use Hopkins as an example, they are absolutely, if they call for a consult for a thoracentesis, we will go and supervise them to do it 100% of the time. 100% of the time, they are not there. So they need to vote with their feet. And the program directors, if pulmonary fellowships want their pulmonary fellows to be procedurally trained, then they need to offer them time to rotate specifically and to have time to go and be with the procedural services. Because most of the pulmonary faculty are no longer competent in a lot of the pulmonary procedures. Dr. Lamb, I'm going to give you 15 seconds on the issue. Moeman, 15, and then Gerard, five. Then we're closing it. I walk the walk. And I can tell you, the last decade in our program, our PCCM fellows all have met all the prerequisites, which are very standardized, and the procedural to graduate with a Certificate of Accomplishment for EBUS. We've done a survey that we published as an abstract at ABAP, showing that those folks who get their training from our center go out and start programs for EBUS and are applying EBUS in high-volume centers. So let me show you, it can be done. Just email me, I'll show you our program. I'm going to call you there. Moeman, 15 seconds. I think, I still say I think it's needed. Accreditation is needed. I think we need to deal with the consequences, not put our head in the sand. And we need program directors to come together from both disciplines and collaborate. Gerard, you wanted the last word. Christine, I'm really glad Hopkins is so egalitarian that they allow their fellows to come to procedures whenever they want. If my fellows see a patient on the consult service or in my clinic, they are responsible for that patient and do the procedure for that patient. It's called making sure that they get full training. I'm going to call it there. I will say our observations, at least in the deep south, have suggested that there are decreased procedural volumes. Now whether they correlate with procedural competency is a completely separate question, but I would opine that they probably do to some degree. Hard to know for sure. Before we get into the next of the debrief, a bit of a round of applause for these fine folks for entertaining us the last 50 minutes. All right, I have one final task as I bring up my co-moderator to sum up some things. You have five minutes, maybe one final task. The final task is everyone has a piece of paper, everyone has a pencil. You all have to write a haiku. The haiku, just to remind everybody, is the first line is five syllables, the second line is seven syllables, the third line is five. So five, seven, five syllables, not words. Audience, give me an IP-related topic that they should write a haiku about. Is it five, seven, one? Bleeding. Okay, so let's say intrapulmonary bleeding. Okay, so that's the topic. I will bring up my co-host who has submitted this wonderful picture of himself, which is the best picture I think I've seen in all the years I've done this. Ladies and gentlemen, Dr. Otis Rickman, just to kind of walk us through for the next five minutes. After this talk, this is how I feel about the state of pulmonary, it sounds like, about interventional pulmonary. It's like, oh my gosh, we've come so far, but it seems like we've got so far to go. And you've heard over the past hour, I'm just gonna like maybe a couple of, a few like take-home pearls or teaching points that I wrote down is that yes, we do have sexy new equipment, robots, that sort of thing, that potentially we are going after smaller nodules. We still have more to go, right? And then it's, the thing that I wanna like leave all you with is, and we heard Dr. Silvestri talk about, Who pays for that? You know, so we need, yes, we do need randomized controlled data, but we don't have somebody like Sanofi or, you know, whoever it is out there that's doing the inhaler stuff that's paying for these trials because they're expensive. And so we as a society need to do that. We need to come to common ground on a definition of diagnostic yield. And the last thing, and what I also wanna comment on is who defined diagnostic yield for the radiologist? I don't know. I say, are they using the same metrics that we are? Because we tap them as being awesome and great, but we just don't know. And then finally, it's getting more and more expensive to do bronchoscopy, and at some point, we are gonna need to do cost-effective analysis of all this technology that we're bringing in, and it needs to be compared against CT-guided biopsy, that sort of thing. And then I think finally, are we better than we were 10 years ago? I think as a specialty, yes, we are better than we were 10 years ago. I mean, just the fact that we're having this discussion at this meeting, we didn't have those before because we didn't have enough stuff to talk about 10 years ago. Are you guys seeing this? These guys can't even write a freaking haiku. I am having to give a surprise to my crew. They're having to do this surprise. My haiku's done, done, man. Don't laugh because you will get to vote in the polls. Don't ask what a syllable is. This is not going to last. Since we need a little bit more time. Do you want these people bronching your patience? Okay, I'm doing it over. Bronchoscopy. I'm doing it over. What are syllables? She's doing it over like the way she does non-diagnostic bronchs. I'm doing it over. I've been doing this for six years. I haven't done a lot of the, but this has been the- The haiku? Not the haiku, but this, are you asking me if that's the right? I don't know. I'm a good student. I will look and see if it's the right number of syllables. I bet you it's not. It looks like too many words. I know. What's that last one? I can't even read that last one. Gerard. Oh, that's good. So the second, all right, so. Help out with that, that second line needs a couple more syllables. Seven syllables in that second line. The first and third are good. All right, you got something? Gerard's good. You copied me. Can I just say it? Yes, but you can't say it because I anonymized it. Okay. Let me, okay, I'm just kidding. You are not gonna get any points for this. I'm just gonna, I'm not gonna tell them who's is who's, but I will tell you the audience is gonna thumbs down the hell out of this thing. I could be wrong. All right, let's see what we got. All right, thanks. Ladies and gentlemen, Otis Rickman. A quick round of applause for him. All right. All right. All right, I'm gonna read them. Not gonna tell you who's they are because I want to be anonymous about it, but so thumbs up if you think it's a better than average haiku. Thumbs down if you think it's a worse than average haiku. Get your thumbs down ready for this one. I'm gonna read it as it's written. Don't judge the reader. Hakuna mata, hakuna matata, hakuna mata. Oh wow, that's. Where's the bleeding? Where is the bleeding? Maybe that's bleeding in Hawaiian. All right, we're passing on that one, all right. Next, it starts with a bit. The kids freak out. Oh no, no, dad takes the scope, fixed. Hmm. Actually, that's pretty good. Lots of thumbs up on that one. I'll give that one to you. That's pretty good. All right, so that's gonna get nine points. All right, next one. Blood is very bad. Gerard has experienced, Gerard has experienced, okay, so much that he's sad. Ooh, it rhymes. Blood is very bad. Gerard has experienced so much that he's sad. Thumbs up or thumbs down. All right, that's close. That's probably eight out of 10, 80% of giving for that. And the last one. If you bleed with me, you will survive and thrive and die with Gerard. That's gonna get, that's gonna get, that's gonna get the full 10, all right. By the way, that was really anonymous, huh, folks? All right, well, I hate to say it, Carla, you get zero points for your hakuna tata, tata, tata. It was good. It ain't no problem. Momin got nine for his. Nine, all right. Christine got eight for hers. Ladies and gentlemen, your winner, actually, I think Christine got nine, but Gerard got eight, but it is enough to give him the win. Ladies and gentlemen, your champion, Dr. Gerard Silvestri.

bronchoscopy procedures

robotics

electromagnetic bronchoscopy

cone beam CT

diagnostic yield

order of performing

robotic bronchoscopy

standardized definitions

interventional pulmonology

patient outcomes