ACG MAGAZINE | Vol. 1, No. 2 | Summer 2017

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ACG MAGAZINE Summer 2017

MEMBERS. MEDICINE. MEANING.

FINDING DISCOMFORT THE RACING LIFE OF DR. FRED POORDAD


American College of Gastroenterology & World Gastroenterology Organisation present the

WORLD CONGRESS of GASTROENTEROLOGY @ ACG2017in Orlando, Florida First time in the U.S. in more than 20 years!

Orange County Convention Center October 13–18, 2017 ORL

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COLLABORATE AND ENGAGE at

WORLD CONGRESS of GASTROENTEROLOGY at ACG 2017 Many sessions will be interpreted in Spanish!

CLINICAL UPDATES delivered by international and U.S. experts

CONNECT WITH COLLEAGUES from the Americas and around the world

DISCUSS GLOBAL HEALTH ISSUES and ways to work together to improve outcomes

HONE YOUR TECHNICAL SKILLS at hands-on workshop sessions

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SUMMER 2017 // Volume 1, Number 2

FEATURED CONTENTS COVERSTORY STORY COVER

FINDING DISCOMFORT The Racing Life of Dr. Fred Poordad By Brian C. Davis Page 36

NOVEL & NOTEWORTHY ACG members make a difference in colorectal cancer screening Page 7

PLAN FOR A LIFE OF COMMITMENT TO MEDICINE IN A HEALTHFUL, HARMONIOUS WAY A reflection by Dr. Lawrence J. Brandt

Photo courtesy of Dr. Fred Poordad.

Page 30

CONVERSATIONS WITH WOMEN IN GI Dr. Jill Gaidos interviews Dr. Shivangi T. Kothari Page 52

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A peer-reviewed, open-access journal edited exclusively by gastroenterology and hepatology fellows.

AC G RTS CASE REPO

JOURN L ORTS ACGCASEREP

.GI.ORG

UE VOLUME 3 / ISS

• Indexed on PubMed, Web of Science, and others 4

• No submission, publication, or subscription fees • Cases previously presented as abstracts are welcome • Case reports, image, and video submissions accepted • Learn more at acgcasereports.gi.org • GI fellow, resident interested in GI, or private practice clinician must be lead author

ited by SE REPORTS ed URNAL of CA OWS JO LL e FE in nl GY O An PATOLO ROLOGY & HE GASTROENTE

Editor-in-Chief: Matthew Chin, MD University of California, Irvine

in, MD

f: Matthew Ch Editor-in-Chie

Submit your manuscript at

mc.manuscriptcentral.com/acgcr


SUMMER 2017 // Volume 1, Number 2

CONTENTS

“There’s some level of discomfort, sometimes, when you’re exploring something, or trying to stretch what you can do in a racecar to achieve a goal or a certain outcome. And it’s the same with life.” —Dr. Poordad, "Finding Discomfort: The Racing Life of Dr. Fred Poordad," PG 36

6 // MESSAGE FROM THE PRESIDENT An historic moment for GI & hepatology.

30 SAGE ADVICE FROM DR. BRANDT A life of commitment to medicine in healthful, harmonious ways.

7 // NOVEL & NOTEWORTHY

32 LAW MIND Plan for a wave of physician retirements.

9 Ergonomics, patient artists and a physician author. 12 Making a difference in colorectal cancer screening.

25 // PUBLIC POLICY 25 GOVERNORS' FLY-IN On the Hill with ACG's Governors. 27 GOVERNORS' VANTAGE POINT Tackling ASC taxes in Connecticut.

29 // GETTING IT RIGHT 29 MAKING SENSE OF MACRA Dealing with deadlines and data.

36 // COVER STORY FINDING DISCOMFORT The Racing Life of Dr. Fred Poordad.

47 // ACG PERSPECTIVES

57 // EDUCATION 57 NORTH AMERICAN CONFERENCE OF GI FELLOWS Honing skills and making connections. 60 EDGAR ACHKAR VISITING PROFESSORS Taking ACG's commitment to GI training on the road.

64 // INSIDE THE JOURNALS 66 AJG AUTHOR INSIGHT Dr. Ali Rezaie on breath tests for GI disorders.

47 AT HOME IN A FARAWAY PLACE Dr. Seth Gross travels to Japan for ACG.

68 ACGCRJ AUTHOR PICKS Editor-in-Chief Dr. Matthew Chin's top picks.

50 Q&A WITH DR. DOUGLAS ADLER Writing for varied audiences.

69 THE LATEST FROM CTG New series: Translational Medicine.

52 CONVERSATIONS WITH WOMEN IN GI Dr. Jill Gaidos interviews Dr. Shivangi Kothari.

70 // REACHING THE CECUM A LOOK BACK: ANATOMICAL PLATE Exquisite detail heralds modern medical era.

Cover photo and photo top courtesy of Dr. Fred Poordad.

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ACG MAGAZINE MAGAZINE STAFF Executive Director Bradley C. Stillman, JD Editor in Chief; Vice President, Communications Anne-Louise B. Oliphant Managing Editor; Senior Writer Brian C. Davis Copy Editors; Staff Writers Jenny Dunnington, Sarah Richman, Martha Spath, Lindsey Topp Vice President, Marketing Martha Spath

CONNECT WITH ACG youtube.com/ACGastroenterology

facebook.com/AmCollegeGastro

twitter.com/amcollegegastro

instagram.com/amcollegegastro

linkedin.com

Art Director; Graphic Designer Emily Garel Graphic Designer Antonella Iseas

CONTACT IDEAS & FEEDBACK

BOARD OF TRUSTEES

We'd love to hear from you. Send us your ideas, stories and comments.

ACGMAG@GI.ORG President: Carol A. Burke, MD, FACG President-Elect: Irving M. Pike, MD, FACG Vice President: Sunanda V. Kane, MD, MSPH, FACG Secretary: David A. Greenwald, MD, FACG Treasurer: Mark B. Pochapin, MD, FACG Immediate Past President: Kenneth R. Devault, MD, FACG

CONTACT ACG American College of Gastroenterology 6400 Goldsboro Rd., Suite 200 Bethesda, MD 20817 (301) 263-9000 | GI.ORG

Past President: Stephen B. Hanauer, MD, FACG Director, ACG Institute: Nicholas J. Shaheen, MD, MPH, FACG Co-Editors, The American Journal of Gastroenterology: Brian E. Lacy, MD, PhD, FACG Brennan M. R. Spiegel, MD, MSHS, FACG

DIGITAL EDITIONS

GI.ORG/ACGMAGAZINE

Chair, Board of Governors: Costas H. Kefalas, MD, MMM, FACG Vice Chair, Board of Governors: Douglas G. Adler, MD, FACG Trustee for Administrative Affairs: Delbert L. Chumley, MD, FACG TRUSTEES William D. Chey, MD, FACG Lauren B. Gerson, MD, MSc, FACG Caroll D. Koscheski, MD, FACG Paul Y. Kwo, MD, FACG Jonathan A. Leighton, MD, FACG Daniel J. Pambianco, MD, FACG David T. Rubin, MD, FACG John R. Saltzman, MD, FACG Samir A. Shah, MD, FACG Scott M. Tenner, MD, MPH, JD, FACG

4 | GI.ORG/ACGMAGAZINE

AMERICAN COLLEGE OF GASTROENTEROLOGY is an international organization with more than 14,000 physician members representing some 85 countries. The College's vision is to be the pre-eminent professional organization that champions the evolving needs of clinicians in the delivery of high-quality, evidence-based and compassionate health care to gastroenterology patients. The mission of the College is to advance world-class care for patients with gastrointestinal disorders through excellence, innovation and advocacy in the areas of scientific investigation, education, prevention and treatment.


CONTRIBUTING WRITERS Douglas G. Adler, MD, FACG

Costas H. Kefalas, MD, MMM, FACG

Dr. Adler is Vice Chair of the ACG Board of Governors and is a Professor of Medicine at University of Utah School of Medicine. He has been writing passionately since childhood.

Dr. Kefalas serves as Chair of the ACG Board of Governors and practices with Akron Digestive Disease Consultants. He is affiliated with Summa Health System in Akron, OH.

Lawrence J. Brandt, MD, MACG

Shivangi T. Kothari, MD, FACG

Dr. Brandt is Past President of the American College of Gastroenterology (1992–1993). He is Professor of Medicine and Surgery at Albert Einstein College of Medicine and Emeritus Chief of the Division of Gastroenterology at Montefiore Medical Center in Bronx, NY.

Dr. Kothari serves on the ACG Women in GI Committee and is Associate Director of Endoscopy and Co-Director of Developmental Endoscopy Lab at University of Rochester in New York.

Robert E. Kravetz, MD, MACG Ann M. Bittinger, JD Ms. Bittinger is health law expert at Bittinger Law Firm in Jacksonville, FL. She is a regular contributor of articles to ACG publications on her areas of expertise, including legal relationships between hospital systems and physicians or physician groups (bittingerlaw.com).

Dr. Kravetz is passionate about the history of medicine and the history of the College. He is Past Chair, ACG Archives Committee, and was instrumental in the publication of the ACG 75th Anniversary history in 2007. Read ACG’s History here: gi.org/about-acg/#Anniversary

Jeffry L. Nestler, MD, FACG Matthew A. Chin, MD Dr. Chin is a third-year GI fellow-in-training at the University of California, Irvine in Orange, CA. Dr. Chin received his MD at University of California, San Diego. He completed his internal medicine residency at Santa Clara Valley Medical Center. This year, Dr. Chin is the Editor-in-Chief of the ACG Case Reports Journal (acgcasereports.gi.org).

ACG Governor for Connecticut, Director, Division of Gastroenterology at Hartford Hospital, the President, Connecticut GI, PC, and serves as Clinical Assistant Professor, University of Connecticut Health Center.

Ali Rezaie, MD, MSc Dr. Rezaie serves as Assistant Director of the GI Motility Program at Cedars-Sinai in Los Angeles, CA.

Jill Gaidos, MD, FACG Dr. Gaidos chairs the ACG Women in GI Committee and is a gastroenterologist at the Hunter Holmes McGuire VA Medical Center in Richmond, VA, where she is Director of Inflammatory Bowel Disease and the Director of the GI Clinics.

Patrick E. Young, MD, FACG, Dr. Young is the Director of the Division of Digestive Diseases at the Uniformed Services University of Health Sciences in Bethesda, MD. He currently serves as the Governor of the ACG Military Region.

Seth A. Gross, MD, FACG Dr. Gross serves as Chief of Gastroenterology at Tisch Hospital and is an Associate Professor of Medicine at NYU School of Medicine.

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MESSAGE FROM THE PRESIDEN

AN HISTORIC MOMENT for Gastroenterology and Hepatology

AT DDW 2017, IN CHICAGO, I WAS PROUD TO REPRESENT THE ACG and join the three Presidents of our sister societies to celebrate an historic milestone. At DDW, Dr. Sheila E. Crowe, American Gastroenterological Association (AGA), and Dr. Karen L. Woods, American Society for Gastrointestinal Endoscopy (ASGE), joined Dr. Anna S. Lok, American Association for the Study of Liver Diseases, and me to lead our respective organizations. This is the first time that all four societies are under the simultaneous auspices of female leadership. In Chicago, the excitement in the air was palpable, as many of the current and past female Presidents, society leaders and hundreds of female members of our societies joined together at the sold-out Annual Women in GI Luncheon hosted by AGA. In addition, a standing roomonly crowd attended the ASGE LEAD Fireside Chat with the Presidents for a lovely reception. Both events solidified the respected place that women in GI and hepatology hold in the profession. As a proud participant, I witnessed an incredibly talented pool of young, bright and energetic women currently serving or eager to serve their professional societies. Friendship, networking and heartfelt stories of the challenges and opportunities for personal and professional satisfaction and success were exchanged. Many women were encouraged to witness that all sister societies value and reward the hard work and commitment by members to their society regardless of gender, ethnicity, country of origin or type of practice.

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 L to R: Karen L. Woods, MD, FACG, Sheila E. Crowe, MD, FACG, Carol A. Burke, MD, FACG, and Anna S. Lok, MD.

It was clear that all societies actively encourage and promote the development of women leaders by specific leadership training programs and courses. I reminded the women in the rooms that, in our success, we are standing on the shoulders of many women and men who have come before us. ACG Past Presidents Dr. Christina M. Surawicz (1998–1999) and Dr. Amy E. Foxx-Orenstein (2007–2008) created a foothold for the advancement of female leaders in the College. Currently, Dr. Sunanda V. Kane is ACG Vice President. Women are engaged in the life of the College at many levels. The percentage of female ACG members is currently 21% and has increased steadily over the past decade. Women make up 26% of committee members, 24% of committee Chairs, 9% of our Governors, 16% of our officers and Trustees, and 9% of our FACGs (Fellows of the American College of Gastroenterology). While these trends in women’s participation in the College are hopeful, our work is not done. Female gastroenterologists continue to earn less pay for equal work, bear more brunt of domestic chores and family care, have less tangible career advancement, and, sadly, if not intended, have more childless rates than their male counterparts. Women need to recognize these disparities, determine their fair market value, and demand their worth. The ACG Women in GI Committee has always been active in researching and highlighting gender disparities in our specialty and in medicine (Am J Gastro 2004;100:259-264, Am J Gastroenterology 2008;103:1589-1595). Now more than ever, the College is creating more resources for women in GI. The offerings for women are flourishing under the leadership of Dr. Jill Gaidos, current Chair of the Women in GI Committee. Opportunities for female ACG members to network, mentor, coach and learn by sharing stories, professional and work-life balance tips, salary facts and other resources are available through the College with the new online community, the “Women in GI Circle.” I have been impressed by the inspirational stories in the “Conversations with Women in GI” series that Jill writes for ACG MAGAZINE. I encourage all women in the College to engage in these opportunities, but especially to consider joining the Mentoring Program or attending any of the face-to-face offerings, such as the “Navigating, Networking and Negotiating Your First Job Workshop” and the “Career Opportunities for Women in GI Luncheon” at the ACG Annual Scientific Meeting. Lastly, it would give me and the other female FACGs no greater pleasure than to support applications by female gastroenterologists for advancement to fellowship in ACG. For both women and men, attaining the professional status of FACG affords a pinnacle of professional recognition and opens the way for more leadership opportunities within the College.

Carol A. Burke, MD, FACG @burkegastrodoc


N wotoerthy ACG MAGAZINE is a forum for College news—a place to showcase the interests and accomplishments of ACG members, as well as notable innovations in the GI profession. In this issue, we feature news sent by readers, highlight ways technology and social media are changing medical practice, and celebrate the professional achievements of ACG members. Send your news and any ideas for future issues of ACG MAGAZINE via email to ACGMag@gi.org

Novel & Noteworthy | 7


[ACCOLADES]

IRVING M. PIKE, MD, FACG

Dr. Pike was named one of the “100 hospital and health system CMOs to know | 2017” in a list published by Becker’s Hospital Review. The description notes Pike’s history of leadership in ACG and the GI Quality Improvement Consortium, a joint initiative of ACG and the American Society for Gastrointestinal Endoscopy. Pike, who started as Chief Medical Officer of John Muir Health in 2012, is President-Elect of ACG. Access the full list, in alphabetical order: bit.ly/2017CMOs, including Dr. Pike's description: bit.ly/Pike-bio

[MILESTONES]

[AWARDEES]

STEVEN J. CZINN, MD, FACG

NEERAL L. SHAH, MD, FACG

The University of Maryland Medical Center and the University of Maryland School of Medicine (UMSOM) appointed Dr. Czinn Director of the University of Maryland Children’s Hospital (UMCH). Czinn will focus on UMCH’s research and patient care. The position is intended to “help advance a strategic plan and vision,” the “central tenet” of which is “optimal patient outcomes,” according to a news release. “Under Dr. Czinn’s augmented leadership role, we will advance our expertise as he steers the Children’s Hospital to new and impressive heights as a national leader in pediatric subspecialty research and patient care,” E. Albert Reece, MD, PhD, MBA, Dean of UMSOM and Vice President for Medical Affairs at the University of Maryland, said in the release. Czinn has worked for the University of Maryland since 2006. Czinn has served as an Associate Editor for The American Journal of Gastroenterology and is past Chair of ACG’s Pediatric Gastroenterology Committee. Read the release on the UMMC website: bit.ly/Czinn-news

The Virginia Chapter of the American College of Physicians awarded its 2017 Young Physician Award to Dr. Shah. Shah is Associate Professor of Medicine, Gastroenterology and Hepatology, at the University of Virginia (UVA). Shah earned the distinction for “his work with medical students, internal medicine residents, and GI fellows,” according to a UVA notice. In the notice, Shah expressed gratitude to his family and colleagues “who all have been totally supportive in my endeavors.”

[MILESTONES]

[TECH]

COSTAS H. KEFALAS, MD, MMM, FACG

BRENNAN M.R. SPIEGEL, MD, MSHS, FACG

In late March, Summa Health announced the addition of three members to its Board of Directors, one of whom was Dr. Kefalas, of Akron Digestive Diseases Consultants Inc., Akron, OH. Summa Health appointed Kefalas a Physician Director, for a three-year team. Kefalas has worked on-staff at Summa Health since 2003. Kefalas is Chair, ACG Board of Governors. Read the announcement in the Cleveland Plain Dealer: bit.ly/Kefalas-Summa

In March, a Fast Company article considered the merits and benefits of scientists engaging on social media. Embedded in the article, “Why We Need Scientists on Social Media, Now More Than Ever,” is a list of “10 Scientists to Follow on Social Media (As Recommended by Scientists).” Spiegel, of Cedars-Sinai Medical Center, makes the list, which recommends following Spiegel for “musings about medical technology, wearables, and the future of medical education.” Spiegel is Co-Editor-in-Chief of The American Journal of Gastroenterology. Read the Fast Company article and recommended scientists to follow on social media: bit.ly/Spiegel-FC @BrennanSpiegel 

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[TECH]

RELIEVE THE PAIN, REDUCE THE INJURIES Optimize the Ergonomics of Your Endoscopy Environment

Patrick E. Young, MD, FACG, Uniformed Services University of Health Sciences, Bethesda, MD

As clinical faculty for a gastroenterology fellowship, we frequently observe and guide novice endoscopists. While we spend a considerable amount of time teaching fundamental principles such as careful mucosal examination, loop reduction and polypectomy techniques, we have traditionally devoted less energy to ensuring our fellows develop

habits designed to prevent overuse injuries. After successfully adding a more intentional focus on ergonomics to our fellowship, we realized that our experience might be useful to the broader GI community. An instructional video demonstrating good techniques and appropriate positioning seemed a particularly suitable method for delivering this

content. We wanted to provide a tool that would help educators teach fellows, provide endoscopy unit managers with a guide on how to construct ergonomically optimized endoscopy suites, and give experienced endoscopists some ways to tweak their techniques. Ultimately, we hope this video helps reduce the burden of chronic pain and disability from overuse injuries in endoscopists. Watch the six-minute video: bit.ly/ErgoEndo

 Novel & Noteworthy | 9


[BOOKS]

PROCESSING NEWBORN DIGESTIVE HEALTH

Bryan S. Vartabedian, MD, aims to help parents make sense of digestive issues their newborns may encounter in a new book, Looking Out for Number Two: A Slightly Irreverent Guide to Poo, Gas, and Other Things That Come Out of Your Baby, released on May 23. The book takes an “irreverent” approach to the ins and outs of both age-old questions and more recent newborn digestive health topics. Vartabedian derives his knowledge and guidance from being both a parent and a pediatric gastroenterologist. He is Assistant Professor, PediatricsGastroenterology, at the Baylor College of Medicine, The Woodlands, TX. This book is not the first or only venue for Vartabedian’s writings. Since 2009, he has written 33charts, a blog “exploring the edges of medicine and technology.” Read Vartabedian’s blog: 33charts.com @Doctor_V 

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[AWARENESS]

“PICTURE MY IBS” WINNER ANNOUNCED ACG, IN COLLABORATION WITH ALLERGAN AND IRONWOOD PHARMACEUTICALS, INC., recently announced that Kimberly P. of Pennsylvania is the winner of the Picture My IBS competition, an initiative aimed at encouraging individuals to express their experience with irritable bowel syndrome (IBS) and to share their journey—and the symptoms that affect them—through art and narrative. According to a recent physician survey, when asked what was lacking most in IBS treatment, communication between patients and their doctors was one of the most common answers. As a result, the Picture My IBS competition was developed to engage, connect, inspire and motivate the IBS community to share their personal experiences, with the goal of improving patient-physician communication and, ultimately, patient care. “There were many powerful images submitted by the entrants, and aside from artistic merit, the ACG also recognized the winning artwork for its creativity and motivational impact in expressing a personal journey with IBS,” said Brian E. Lacy, MD, PhD, FACG, Co-Editor-in-Chief of The American Journal of Gastroenterology, and one of


VOLUME 112 NUMBER 4 APRIL 2017 www.nature.com/ajg

official publication of the american college of gastroenterology

LEADING ARTICLES OF THE MONTH Clinical and Systematic Reviews 537

A Multidisciplinary Approach to Pancreas Cancer in 2016: A Review CME

E.L. Fogel, S. Shahda, K. Sandrasegaran, J. DeWitt, J.J. Easler, D.M. Agarwal, M. Eagleson, N.J. Zyromski, M.G. House, S. Ellsworth, I. El Hajj, B.H. O’Neil, A. Nakeeb and S. Sherman

Esophagus 556

Recurrence of Barrett’s Esophagus is Rare Following Endoscopic Eradication Therapy Coupled With Effective Reflux Control S. Komanduri, P.J. Kahrilas, K. Krishnan, T. McGorisk, K. Bidari, D. Grande, L. Keefer and J. Pandolfino

Endoscopy 568

Water Exchange Method Significantly Improves Adenoma Detection Rate: A Multicenter, Randomized Controlled Trial CME H. Jia, Y. Pan, X. Guo, L. Zhao, X. Wang, L. Zhang, T. Dong, H. Luo, Z. Ge, J. Liu, J. Hao, P. Yao, Y. Zhang, H. Ren, W. Zhou, Y. Guo, W. Zhang, X. Chen, D. Sun, X. Yang, X. Kang, N. Liu, Z. Liu, F. Leung, K. Wu and D. Fan

Liver 581

Prevalence of Nonalcoholic Steatohepatitis-Associated Cirrhosis in the United States: An Analysis of National Health and Nutrition Examination Survey Data M.N. Kabbany, P.K. Conjeevaram Selvakumar, K. Watt, R. Lopez, Z. Akras, N. Zein, W. Carey and N. Alkhouri SEE ACCOMPANYING EDITORIAL

Functional GI Disorders 613

A Randomized Phase III Clinical Trial of Plecanatide, a Uroguanylin

Analog, in Patients With Chronic Idiopathic Constipation OPEN P.B. Miner Jr, W.D. Koltun, G.. Wiener, M. De La Portilla, B. Prieto, K. Shailubhai, M. Layton, L. Barrow, L. Magnus and P.H. Griffin

Colon/Small Bowel 622

Do Primary Care Provider Strategies Improve Patient Participation in Colorectal Cancer Screening? N.N. Baxter, R. Sutradhar, Q. Li, C. Daly, G.N. Honein-AbouHaidar, D.P. Richardson, L. Del Giudice, J. Tinmouth, L. Paszat and L. Rabeneck

Picture My IBS Art, L to R, top to bottom: Picture My IBS competition winner “Darkest of Days,” Kimberly P.’s Story; “My New Normal,” Amber’s

Pancreas and Biliary Tract 643

Long-Term Glycemic Control in Adult Patients Undergoing Remote vs. Local Total Pancreatectomy With Islet Autotransplantation S.J. Kesseli, M. Wagar, M. K. Jung, K. D. Smith, Y.K. Lin, R.M. Walsh, B. Hatipoglu, M.L. Freeman, T.L. Pruett, G.J. Beilman, D.E.R. Sutherland, T.B. Dunn, D.A. Axelrod, S.S. Chaidarun, T.K. Stevens, M. Bellin and T.B. Gardner

FULL TABLE OF CONTENTS INSIDE

EDITORS: Brian E. Lacy, PhD, MD, FACG and Brennan Spiegel, MD, MSHS, FACG

Story; “Finding the Good,” Hess’ Story; “Ah ha!,” Jeff’s Story; “Trapped,” Ali’s Story.

the judges for the Picture My IBS competition. Eamonn M.M. Quigley, MD, MACG, ACG Past President (2008-2009) also served as a physician judge. The winning artwork, titled “Darkest of Days,” chronicles Kimberly P.’s experience living with IBS: “How alone we feel when suffering from IBS. I feel so alone at times, afraid to go out and enjoy myself because a flare-up may happen. When I do make plans, I often cancel, making me feel like a bad friend. The gray bleak skyscape is my life and the red represents the pain I experience.”

“I feel so alone at times, afraid to go out and enjoy myself because a flare-up may happen. When I do make plans, I often cancel, making me feel like a bad friend. The gray bleak skyscape is my life and the red represents the pain I experience.” — Kimberly P.

Read about the Picture My IBS campaign: PictureMyIBS.org, and view the photo album: bit.ly/PictureMyIBS

The “Picture My IBS” campaign highlights the importance of communication skills in enhancing the patientdoctor relationship. Earlier this year in the Red Section of The American Journal of Gastroenterology, Douglas A. Drossman, MD, MACG, an expert on the psychosocial and behavioral aspects of patient care, outlined an approach to treating patients with difficultto-diagnose and -manage GI disorders of gut-brain interaction that is “humanistic, patient-centered…[and] linked with trust, respect and mutual engagement in the plan of care.” He also invited his patient, Katie Errico, to share her perspective in an accompanying Red Section piece.

Read “Katie: The Physician’s Perspective of a Young Woman’s Illness Experience,” by Dr. Drossman: rdcu.be/tiWh “Katie: A Patient’s Perspective,” by Katie Errico: rdcu.be/tiWe

Novel & Noteworthy | 11


MAKING A DIFFERENCE IN COLORECTAL CANCER SCREENING 12 | GI.ORG/ACGMAGAZINE

JUST ONE DAY BEFORE THE ANNUAL MARCH OBSERVANCE OF COLORECTAL CANCER AWARENESS MONTH, THE NEW YORK TIMES RAN A STORY, “COLON AND RECTAL CANCERS RISING IN YOUNG PEOPLE,”


featuring research from the American Cancer Society published in the Journal of the National Cancer Institute revealing that even as the overall incidence of colorectal cancer in the United States has been declining, CRC incidence in patients younger than 50 is on the rise in the past two decades. The article featured ACG’s published recommendation about screening for African Americans starting at age 45. Publication of these data on youngonset CRC generated a number of media stories that dominated press coverage on colorectal cancer during March 2017. The news of this trend prompted a follow-up article, and The Times reached out to ACG for an expert to comment. On March 16, 2017, a second article, “What Young People Need to Know

About Colon Cancer,” ran in The Times in which ACG Treasurer Mark B. Pochapin, MD, FACG, commented that, “[t]he new data raise the flag to be vigilant.” Pochapin put the young-onset CRC findings in perspective: “We don’t want to create a panic, and the frequency in younger adults is still relatively low, but we are seeing an increase…We need doctors to realize that colorectal cancer is possible in younger patients, and if they are having something like rectal bleeding, this could be something more serious. Young people’s symptoms should not be dismissed.” The fact that ACG’s screening guidelines are covered in high-profile national stories on colorectal cancer and that a major newspaper of record reaches out to ACG for comment on breaking news is a testament to the College’s reputation and longstanding commitment to advancing understanding of colorectal cancer prevention. ACG’s consistent messaging over the years, and the many significant contributions of ACG physician leaders to the fight against colorectal cancer, have contributed to a widening public

understanding of the importance of screening tests. Since the year 2000, when President Bill Clinton designated March as Colorectal Cancer Awareness Month in a White House Proclamation, overall public awareness of colorectal cancer screening has increased, and attention to the disparities experienced by African Americans and other racial and ethnic groups in terms of incidence and mortality is on the rise. The news of young-onset data came in stark contrast to evidence suggesting that overall colorectal incidence and mortality are down in the past decade, thanks to increasing use of colonoscopy. Against this backdrop, ACG’s public awareness activities for Colorectal Cancer Awareness Month in March 2017 reflected the College’s significant, longstanding commitment to preventing colorectal cancer. Here are some selected highlights which showcase the diverse talents and deep commitment of many ACG members, as well as the work of the ACG Public Relations Committee, participation by the College’s leadership, and efforts by the ACG Board of Governors. Novel & Noteworthy | 13


Blue Notes from

MARCH CRC MONTH ntial

Preside

ACGBLOG What can Gastroenterologists & Endoscopists Do to Advance 80% by 2018? Colorectal cancer is the second leading cause of cancer death in the United States among men and women combined, yet it’s one of the most preventable. Join the national effort to get 80% of age-appropriate adults regularly screened for colorectal cancer by 2018. (Starting screening before age 50 may be appropriate for people with certain risk factors). If we can achieve 80% by 2018, 277,000 cases and 203,000 colon cancer deaths would be prevented by 2030.

The number of colorectal cancer cases is dropping, thanks to screening. We are helping save lives. We can save more.

Dr. Burke’s Call-to-Action for March 2017 CRC Month At the start of March Colorectal Cancer Awareness Month, ACG President Carol A. Burke, MD, FACG, set the tone for ACG’s observance by devoting her Presidential Blog to encouraging ACG members to spread the message of the lifesaving benefits of colorectal cancer screening through active participation in education and public awareness efforts in their local communities and by highlighting the College’s patient education resources. “80% by 2018” A Shared

14 | GI.ORG/ACGMAGAZINE

National Goal ACG is a strong supporter of a national coalition of organizations committed to eliminating colorectal cancer as a major health problem. With the American Cancer Society and the National Colorectal Cancer Roundtable (NCCRT), the College is working toward the shared goal of reaching 80% of eligible adults screened for colorectal cancer by 2018. As we look to the year ahead, ACG remains a champion of this ambitious national public health goal.

Joining NCCRT for “Countdown to 2018” in NYC Dr. Mark Pochapin had a chance to join advocates from the American Cancer Society and the National Colorectal Cancer Roundtable at their March 1, 2017, kick-off event, “Countdown to 2018.” Pochapin was interviewed by Katie Couric during a presentation that was webcast live from the Hard Rock Café in Times Square, New York, NY. Couric added her experience as a national colorectal cancer advocate and shared a personal and moving conversation with Pochapin, who was part of the team that cared for Ms. Couric’s late husband, Jay Monahan, who died of colorectal cancer at age 42 in 1998.


Dress in Blue Day: Friday, March 3, 2017 The College participated in a day of awareness and fun, sponsored by the Colon Cancer Alliance, to raise awareness about colorectal cancer and the importance of screening by inviting people to wear blue. ACG shared photos via Twitter and Facebook from around the United States of the many creative, engaging and sometimes wacky ways GI practices showed off their blue.

ACG Goes Blue In Bethesda, MD, the ACG staff showed their true colors for 2017 Dress in Blue Day.

Novel & Noteworthy | 15


PHYSICIANS SUPPORT ACG RADIO TOUR W. Timothy Denton Gerardo S. Lanes Aasma Shaukat Jeffry L. Nestler James C. Hobley Tonya R. Kaltenbach Keith L. Obstein Carol A. Burke Costas H. Kefalas Jordan J. Karlitz Wilmer Rodriguez Darrell D. Wadas

**

Reached

25.5 MILLION LISTENERS Participated in

40 RADIO INTERVIEWS

Addressed challenges to

REACHING 80% BY 2018

ACG Radio Tour Reaches 25.5 Million Listeners Radio has been a mainstay of ACG’s outreach for March Colorectal Cancer Awareness Month over the years because it reaches such a broad audience so effectively and key demographics can be targeted. This year, leaders from the College took to the airwaves during the first week of March for a national radio tour. Physicians from the ACG Board of Governors and ACG Public Relations Committee participated in 40 radio interviews that addressed the challenges for our nation to reach 80% of eligible U.S. adults screened for colorectal cancer by 2018. These interviews reached a record number of listeners, with more than 25.5 million media impressions. ACG Trustee Caroll D. Koscheski, MD, FACG, on WHKY1290 AM.

Social Media Outreach: Twitter Chat The College co-sponsored a Twitter chat with the American Gastroenterological Association in March that was masterminded by then-ABC News Chief Health and Medical Editor Dr. Richard Besser. Besser moderated the hour-long online session in which advocates and experts contributed insights in fewer than 140 characters. ACG pitched this idea to Besser and then joined forces with a sister GI society, paving the way for a varied, interesting and important conversation about colorectal cancer prevention. On Capitol

Hill with CRC Survivors and Advocates On March 13, 2017, ACG Public Relations Chair Jordan J. Karlitz, MD, FACG, addressed a group of more than 150 colorectal cancer survivors, patients and advocates for “Call on Congress” in Washington, DC with patient advocacy group Fight Colorectal Cancer. For several years, Fight CRC has invited ACG to provide a speaker for their Capitol Hill lobby day. Karlitz was part of a panel of speakers that included several members of Congress with personal ties to colorectal cancer. Also on the Hill that day was March Seabrook, MD, FACG, of Columbia, SC, who came to Washington as a CRC screening advocate and met with legislators, including Senator Tim Scott (R-SC). Dr. Seabrook has been active in the South Carolina State House and brought his passion for colorectal cancer prevention to Washington, DC at the invitation of Fight Colorectal Cancer.

16 | GI.ORG/ACGMAGAZINE


Sirius XM Radio Show with Dr. Mark Pochapin at NYU Renee L. Williams, MD, FACG, David A. Greenwald, MD, FACG, ACG Secretary, Dr. Mark Pochapin, and Seth A. Gross, MD, FACG, who were joined on the air via telephone by Dr. Carol Burke and Dr. Jordan Karlitz for a SiriusXM “Doctor Radio” show devoted to colorectal cancer prevention on March 30, 2017.

CRC Month Observed with State-Level Proclamations B. Indrakrishnan, MD, FACG, second from left, with Georgia Governor Nathan Deal (R). Indrakrishnan, a Clinical Professor at Emory University School of Medicine who has a private practice in Gwinnett County, met with Deal to receive the proclamation declaring March as Colorectal Cancer Awareness Month in the state.

Dr. Burke’s Message on Lynch Syndrome Awareness Day In a March 22, 2017, post on the ACG Blog, ACG President Dr. Carol Burke shared her perspective on Lynch Syndrome Awareness Day. She wrote to ACG members, “Patients with Lynch syndrome have a substantially increased lifetime cumulative risk of colorectal cancer and other LS-associated cancers including endometrial, ovarian, gastric, small bowel and urothelial tract. Prevention of the occurrence and death from some of these cancers due to Lynch syndrome is possible with recognition of the syndrome and preventive strategies, such as colonoscopy and prophylactic surgery.” In the photo above, Dr. Burke and Kim Chang hold a proclamation by Ohio Governor John Kasich (R) designating March 22nd as Lynch Syndrome Awareness Day.

Walter J. Coyle, MD, FACG, of Scripps Clinic, was interviewed about colorectal cancer prevention on KUSI in San Diego, CA.

Novel & Noteworthy | 17


In Rhode Island, Dr. Samir Shah Takes Action on CRC Proclamation ACG Trustee Samir A. Shah, MD, FACG, of Rhode Island, worked with state legislator Representative Mary Messier (D) to have a proclamation read at the Rhode Island State House.

Little Rock Arkansas Goes Blue Bridges over the Arkansas River were illuminated in blue thanks to the efforts of Whitfield L. Knapple, MD, FACG, who serves as ACG’s Governor for Arkansas and chairs ACG’s National Affairs Committee. Through a connection to a city official in Little Rock, Knapple helped light the bridges and the Union National Plaza building. He coordinated his efforts with the local office of the American Cancer Society and advocates organizing a 5K run/walk for colorectal cancer awareness known as “Get Your Rear in Gear.”

Web Access to ACG’s Colorectal Cancer Educational Resources To enhance the efforts of gastroenterologists and others dedicated to colorectal cancer education in the clinic and community setting, the College offers a wide array of tools and resources along with tips and templates for media outreach and social media promotion. Fliers, posters, a fact sheet, podcasts, a video and downloadable graphics form a suite of tools to support gastroenterologists and their colleagues in their community engagement and colorectal cancer education. Visit ACG’s patientoriented Colorectal Cancer Awareness page to access the best of the College’s CRC resources: gi.org/coloncancer

PHYSICIANS from the AMERICAN COLLEGE OF GASTROENTEROLOGY

RECOMMEND COLONOSCOPY as the PREFERRED COLORECTAL CANCER

PREVENTION TEST

Colorectal Cancer: YOU CAN PREVENT IT gi.org/ColonCancer

PHYSICIANS FROM THE AMERICAN COLLEGE OF GASTROENTEROLOGY WANT YOU TO KNOW that SCREENING TESTS CAN FIND PRECANCEROUS COLON POLYPS so they can be REMOVED BEFORE THEY TURN INTO COLORECTAL CANCER

COLORECTAL CANCER: YOU CAN PREVENT IT

gi.org/ColonCancer

The Uplifted In honor of Dress in Blue Day, in a portrait by photographer Kenaro Yamada for his project, The Uplifted, is ACG Trustee David T. Rubin, MD, FACG, Chief, Section of Gastroenterology, Hepatology and Nutrition, University of Chicago Medicine. According the artist, The Uplifted project “highlights joy, accomplishment and success through a collection of portraits of everyday leaders and visionaries with their most prized possessions levitating right before their eyes.” Learn more: theuplifted.net

18 | GI.ORG/ACGMAGAZINE


Novel & Noteworthy | 19


Who to Follow on

TWITTER MORE AND MORE PHYSICIANS ARE ENGAGING ON SOCIAL MEDIA to stay abreast of trends, news and research in the medical profession. Some ACG members are leading the way when it comes to sharing links to clinical resources and interesting news. Many use Twitter to network with others physicians and establish collaborative relationships while keeping abreast of conference news, such as the World Congress of Gastroenterology at ACG 2017, #WCOGatACG2017.

#womeninstem @SophieBalzoraMD  Sophie Balzora, MD, FACG, NYU Langone Medical Center, New York, NY

So so excited to see our visit to @RanchoRamsLV highlighted in @AmCollegeGastro's newsletter!! @NYULMC's #womeninstem

#acgflyin @dagreenwald

@burkegastrodoc  Carol A. Burke, MD, FACG, ACG President, Cleveland Clinic, Cleveland, OH

ACG Governors enlightened legislators #ACGflyin breaking barriers to #coloncancer @amcollegegastro

David A. Greenwald, MD, FACG, Secretary, ACG Board of Trustees, Mount Sinai Hospital, New York, NY

American College of Gastroenterology. Advocating for colon cancer screening. Meeting at Corey Booker's office #acgflyin

#coloncancer 20 | GI.ORG/ACGMAGAZINE


#coloncancer #crc

@MarkPochapin  Mark B. Pochapin, MD, FACG, Treasurer, ACG Board of Trustees, NYU Langone Medical Center, New York, NY

@MikeWallaceMD

Staying alive! We're talking live #coloncancer @SIRIUSXM @NYUDocs with Dr Bernstein, Dr Cohen, Dr Smith and @MarthaRaymondMA.

Michael B. Wallace, MD, MPH, FACG, Mayo Clinic, Jacksonville, FL

Colon Cancer Awareness: Dr. Gomez & Dr. Wallace

 #ulcers @DrMullin  Gerard E. Mullin, MD, MS, FACG The Johns Hopkins Hospital, Baltimore, MD

#Ulcers are more common than you think. #pepticulcer #gastric ulcer #healing #gut #stress #hpylori #dysbiosis

#meded @RyanMadanickMD  Ryan D. Madanick, MD, ACG Public Relations Committee, University of North Carolina School of Medicine, Chapel Hill, NC

T2 Yes. I’ve done this for several years now (in my email signature and on my CV) #meded

@myheroistrane Paul Haidet

Does anyone include their twitter handle in their signature line on email, letterhead, or business card? #meded

VIEW THE ORIGINAL BLOG POST: ACGBLOG.ORG

Novel & Noteworthy | 21


ACG CALENDA

JULY

21

AUGUST

IBD SCHOOL AT MIDWEST REGIONAL

AUGUST

Gain insight from the experts and learn about the latest clinical updates when you attend the Midwest Regional Course.

25

ACG MIDWEST REGIONAL POSTGRADUATE COURSE

ACG Edgar Achkar Visiting Professorship Program Applications DEADLINE

26-27

GI.ORG/EAVP

9–10

13–18

ACG/VGS/ODSGNA REGIONAL POSTGRADUATE COURSE This Williamsburg, VA course offers the latest clinical updates, Breakout Sessions and Hands-on Sessions. More info: meetings.gi.org

DECEMBER

WORLD CONGRESS OF GASTROENTEROLOGY AT ACG2017 For the first time in more than 20 years, the World Congress of Gastroenterology returns to the U.S. Join us in sunny Orlando, where you’ll have the chance to connect with colleagues and learn the latest in GI and hepatology from global experts. Register:

worldcongressacg2017.org

15–17

Register: meetings.gi.org

SEPTEMBER

OCTOBER

OCTOBER

Course Directors Dr. Sunanda V. Kane and Dr. David T. Rubin offer a one-day immersion in IBD management in St. Louis, Missouri, at Hilton at the Ballpark.

1

DECEMBER

2–3

IBD SCHOOL AT SOUTHERN REGIONAL

ACG SOUTHERN REGIONAL POSTGRADUATE COURSE

Course Directors Dr. Sunanda V. Kane and Dr. David T. Rubin offer a one-day course to improve clinical judgment and to address the art and science of IBD management.

Experts will explore dysphagia, EoE, hepatitis C, obesity, IBD, lower functional GI disorders, practice management, and more, in Nashville, Tennessee.

More info: meetings.gi.org

More info: meetings.gi.org

HANDS-ON ENDOSCOPY WORKSHOP CENTER SESSIONS AT WCOG AT ACG2017 Participate in one of more than 40 Hands-on Endoscopy Workshop Sessions being offered this year.

DECEMBER 8 2018 Institute Research Grant Applications DEADLINE

 SUNDAY, OCT 15 | 3:30 PM – 7:00 PM  MONDAY, OCT 16 | 7:45 AM – 9:30 (Fellows-in-Training Only)

 MONDAY, OCT 16 | 10:00 AM – 4:45 PM  TUESDAY, OCT 17 | 10:00 AM – 4:30 PM

22 | GI.ORG/ACGMAGAZINE

DECEMBER 31 FINAL DAY to earn MOC for 2017


IMPORTANT SAFETY INFORMATION SUPREP® Bowel Prep Kit (sodium sulfate, potassium sulfate and magnesium sulfate) Oral Solution is an osmotic laxative indicated for cleansing of the colon as a preparation for colonoscopy in adults. Most common adverse reactions (>2%) are overall discomfort, abdominal distention, abdominal pain, nausea, vomiting and headache. Use is contraindicated in the following conditions: gastrointestinal (GI) obstruction, bowel perforation, toxic colitis and toxic megacolon, gastric retention, ileus, known allergies to components of the kit. Use caution when prescribing for patients with a history of seizures, arrhythmias, impaired gag reflex, regurgitation or aspiration, severe active ulcerative colitis, impaired renal function or patients taking medications that may affect renal function or electrolytes. Use can cause temporary elevations in uric acid. Uric acid fluctuations in patients with gout may precipitate an acute flare. Administration of osmotic laxative products may produce mucosal aphthous ulcerations, and there have been reports of more serious cases of ischemic colitis requiring hospitalization. Patients with impaired water handling who experience severe vomiting should be closely monitored including measurement of electrolytes. Advise all patients to hydrate adequately before, during, and after use. Each bottle must be diluted with water to a final volume of 16 ounces and ingestion of additional water as recommended is important to patient tolerance.

BRIEF SUMMARY: Before prescribing, please see full Prescribing Information and Medication Guide for SUPREP® Bowel Prep Kit (sodium sulfate, potassium sulfate and magnesium sulfate) Oral Solution. INDICATIONS AND USAGE: An osmotic laxative indicated for cleansing of the colon as a preparation for colonoscopy in adults. CONTRAINDICATIONS: Use is contraindicated in the following conditions: gastrointestinal (GI) obstruction, bowel perforation, toxic colitis and toxic megacolon, gastric retention, ileus, known allergies to components of the kit. WARNINGS AND PRECAUTIONS: SUPREP Bowel Prep Kit is an osmotic laxative indicated for cleansing of the colon as a preparation for colonoscopy in adults. Use is contraindicated in the following conditions: gastrointestinal (GI) obstruction, bowel perforation, toxic colitis and toxic megacolon, gastric retention, ileus, known allergies to components of the kit. Use caution when prescribing for patients with a history of seizures, arrhythmias, impaired gag reflex, regurgitation or aspiration, severe active ulcerative colitis, impaired renal function or patients taking medications that may affect renal function or electrolytes. Pre-dose and post-colonoscopy ECG’s should be considered in patients at increased risk of serious cardiac arrhythmias. Use can cause temporary elevations in uric acid. Uric acid fluctuations in patients with gout may precipitate an acute flare. Administration of osmotic laxative products may produce mucosal aphthous ulcerations, and there have been reports of more serious cases of ischemic colitis requiring hospitalization. Patients with impaired water handling who experience severe vomiting should be closely monitored including measurement of electrolytes. Advise all patients to hydrate adequately before, during, and after use. Each bottle must be diluted with water to a final volume of 16 ounces and ingestion of additional water as recommended is important to patient tolerance. Pregnancy: Pregnancy Category C. Animal reproduction studies have not been conducted. It is not known whether this product can cause fetal harm or can affect reproductive capacity. Pediatric Use: Safety and effectiveness in pediatric patients has not been established. Geriatric Use: Of the 375 patients who took SUPREP Bowel Prep Kit in clinical trials, 94 (25%) were 65 years of age or older, while 25 (7%) were 75 years of age or older. No overall differences in safety or effectiveness of SUPREP Bowel Prep Kit administered as a split-dose (2-day) regimen were observed between geriatric patients and younger patients. DRUG INTERACTIONS: Oral medication administered within one hour of the start of administration of SUPREP may not be absorbed completely. ADVERSE REACTIONS: Most common adverse reactions (>2%) are overall discomfort, abdominal distention, abdominal pain, nausea, vomiting and headache. Oral Administration: Split-Dose (Two-Day) Regimen: Early in the evening prior to the colonoscopy: Pour the contents of one bottle of SUPREP Bowel Prep Kit into the mixing container provided. Fill the container with water to the 16 ounce fill line, and drink the entire amount. Drink two additional containers filled to the 16 ounce line with water over the next hour. Consume only a light breakfast or have only clear liquids on the day before colonoscopy. Day of Colonoscopy (10 to 12 hours after the evening dose): Pour the contents of the second SUPREP Bowel Prep Kit into the mixing container provided. Fill the container with water to the 16 ounce fill line, and drink the entire amount. Drink two additional containers filled to the 16 ounce line with water over the next hour. Complete all SUPREP Bowel Prep Kit and required water at least two hours prior to colonoscopy. Consume only clear liquids until after the colonoscopy. STORAGE: Store at 20°-25°C (68°-77°F). Excursions permitted between 15°-30°C (59°-86°F). Rx only. Distributed by Braintree Laboratories, Inc. Braintree, MA 02185

For additional information, please call 1-800-874-6756 or visit www.suprepkit.com

©2017 Braintree Laboratories, Inc.

HH13276B

March 2017


1 MOST PRESCRIBED,

#

BRANDED BOWEL PREP KIT1

A CLEAN SWEEP

EFFECTIVE RESULTS IN ALL COLON SEGMENTS2

· SUPREP® Bowel Prep Kit has been FDA-approved as a split-dose oral regimen3 · >90% of patients had no residual stool in all colon segments2* †

These cleansing results for the cecum included 91% of patients2*

SUPREP Bowel Prep Kit also achieved ≥64% no residual fluid in 4 out of 5 colon segments (ascending, transverse, descending, and sigmoid/rectum)2* †

Help meet the Gastrointestinal Quality Improvement Consortium (GIQuIC) benchmark for ≥85% quality cleansing with the split-dose efficacy of SUPREP Bowel Prep Kit.3,4

*This clinical trial was not included in the product labeling. †Based on investigator grading. References: 1. IMS Health, NPA Weekly, March 2017. 2. Rex DK, DiPalma JA, Rodriguez R, McGowan J, Cleveland M. A randomized clinical study comparing reduced-volume oral sulfate solution with standard 4-liter sulfate-free electrolyte lavage solution as preparation for colonoscopy. Gastrointest Endosc. 2010;72(2):328-336. 3. SUPREP Bowel Prep Kit [package insert]. Braintree, MA: Braintree Laboratories, Inc; 2012. 4. Rex DK, Schoenfeld PS, Cohen J, et al. Quality indicators for colonoscopy. Gastrointest Endosc. 2015;81(1):31-53.

©2017 Braintree Laboratories, Inc.

HH13276B

March 2017


PUBLIC POLICY

Governors' Vantage Point

ACG GOVERNORS VOICE

LEGISLATIVE PRIORITIES

ACG Governors, officers and leaders stand in front of the US Capitol on Thursday, April 6, 2017.

ON CAPITOL HILL

I WANT TO RECOGNIZE the commitment of the many ACG Governors and officers who took time away from their families and practices to advocate on behalf of ACG members and patients on Capitol Hill during this year’s legislative fly-in, which took place on Thursday, April 6, in Washington, DC. I am pleased to report that roughly 50 ACG Governors and other College officers attended the fly-in, which involved more than 230 unique meetings with members of the US House of Representatives and US Senate. The Governors carried a strong, clear message to legislators, representing the interests of practicing gastroenterologists. In taking ACG’s legislative priorities to Capitol Hill, the ACG Governors had several key messages for Congress: →

Public Policy | 25


Support Legislation that Improves Colorectal Cancer Screening Access for Medicare Beneficiaries The Governors asked members of Congress to co-sponsor the “Removing Barriers to Colorectal Cancer Screening Act of 2017” (S. 479; H.R. 1017). This bill corrects a quirk in the law and removes cost-sharing for a screening colonoscopy if polyps are removed. Reduce Burdens on Private Practice Physicians Under MIPS While in Washington, the Governors educated congressional leaders and health policy staff about the administrative and regulatory burdens faced by practicing gastroenterologists. Specifically, ACG Governors urged Congress to simplify the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) by delaying the Resource Use category of the Merit-based Incentive Payment System (MIPS) until the Centers for Medicare & Medicaid Services can accurately attribute costs of providing services to patients. By emphasizing quality of care, and keeping the quality component of MIPS the most significant weight of total MIPS scores, ACG believes that GI physicians may have more direct control over their quality reporting, thus having greater influence over defining their MIPS scores and, ultimately, Medicare reimbursement. Adequately Fund the National Institutes of Health The Trump administration proposed significant cuts to the National Institutes of Health (NIH) in the Fiscal Year (FY) 2018 draft budget plan. NIH research funding is also under threat for the remaining FY 2017 spending packages that Congress must pass by April 28 of this year. Thank you, ACG Governors! The Board of Governors is one of the most unique aspects of the American College of Gastroenterology. I am so proud of the thoughtful way that so many physicians came to Washington to give voice to the concerns that we hear over and over from ACG members. The fly-in exemplifies the important role the Board of Governors plays in serving as a twoway conduit between College leadership and the membership at large—a critical role that helps the College make certain it is meeting the evolving needs of the membership. Contact your ACG Governor today. —Costas H. Kefalas, MD, MMM, FACG Chair, ACG Board of Governors

26 | GI.ORG/ACGMAGAZINE


A Cautionary Tale:

Governors' Vantage Point

PROPOSED TAX ON ASCs in Connecticut Jeffry L. Nestler, MD, FACG; ACG Governor for Connecticut, President, Connecticut GI, PC

M

ARK TWAIN ONCE ASKED, “What is the difference between a taxidermist and a tax collector?” The answer, he wittily said, is “The taxidermist takes only your skin.”

More than a century after his death, Twain’s words continue to elicit a laugh. But for those of us contending with ambulatory surgery center (ASC) taxes, they also get more than a few knowing nods. On October 1, 2015—without any prior discussion —a 6% ASC provider tax was imposed on Connecticut’s ASCs. The sole purpose of this 11th-hour tax was to close the deficit gap in the Fiscal Year 2016–2017 budget. There was no forethought about the economic impact of the tax, the legality of the tax, the impact on patient care, or the ultimate cost to the consumer. As the nation is driving toward high-quality, costeffective care, this ill-conceived tax will increase the cost of health care. With higher deductibles becoming more prevalent, the patient will incur greater individual costs, thereby decreasing compliance with colonoscopy and upper endoscopy. It just doesn’t make sense. In addition, the ASC tax is on total gross revenues, which will reduce the centers’ ability to hire more staff and reinvest in their capital needs. Unlike hospitals, ASCs pay federal and state income taxes as well as sales and local property taxes. Therefore, this equates to double taxation on Connecticut’s ASCs. Some ASCs may be driven out of business, resulting in the loss of more skilled jobs in the state and the loss of access for patients. This is very concerning for health care providers in our state, but also those in other states who may face the same type of unnecessary taxation. Thanks to the collaborative efforts of ASCs, physicians, patients and many other concerned citizens, a full-scale effort is now underway across Connecticut to seek the tax’s repeal or restructuring. Through our outstanding lobbyists, we have been successful in encouraging an economic impact study through the Governor’s office. We have also been successful in our legislators introducing 27 bills this session to address this unfair tax. Legislative Lobbying Blitz in CT Our exceptional team of lobbyists has been blanketing the capitol in Hartford, where they are conducting frequent meetings with legislators and committees. This

BE PROACTIVE. BE DILIGENT and make sure your state associations are ACTIVELY MONITORING your legislature. BE READY to act at a moment’s notice. Develop strong ADVOCACY groups and SUPPORT your local legislators.

effort has been strengthened by a robust grassroots campaign, hundreds of phone calls and emails, and all-important visits by concerned lawmakers to ASCs in their legislative districts. Our activities also include many other important strategies, including spreading our message far and wide, pressing for public hearings, delivering formal testimony, physicians and ASC staff conducting capitol visits, polling voters to measure their opposition to the tax, and coordinating with all impacted medical specialties across our state. It is a lot of work, to be sure, but the cost of inaction is too great. Like ASCs across the country, those centers serving Connecticut communities—our patients— are delivering superb clinical results at a fraction of the cost charged by hospitals. We are meeting the needs of our patients, reducing their health care costs, and supporting high-quality jobs in a state that has been no stranger to tough economic times and bare-bones budgets. By June 30, at the latest, we will know for sure the outcome of this uphill battle. We will continue this effort until the very end. In doing so, I hope we will not only prevail over this counterproductive tax but will be able to provide advocacy strategies to other states. My Advice for GI Colleagues in Other States My advice to gastroenterologists in other states is to be proactive. Be diligent and make sure your state associations are actively monitoring your legislature. Be ready to act at a moment’s notice. Develop strong advocacy groups and support your local legislators. Working together and tirelessly, we can protect ASCs and the patients they serve from unfair taxation. In the state where Mark Twain lived for 17 years, we need to be able to fear tax collectors less than taxidermists.

Public Policy | 27


GO BEYOND

the PAGES of AJG

Podcasts, Videos, and Digital Issues! VOLUME 111 NUMBER 1 JANUARY 2016 www.nature.com/ajg

AJG offers readers

MORE THAN just their print subscription!

official publicati on of the american college of gastroen terology

LEADING ARTICLES OF

THE MONTH

The Red Section: EndoTech Update

6

Just Clip It: Endoscopic Clipping in the 21st Century

B. Joseph Elmunzer

Practice Guidelines 30

ACG Clinical Guideline: Diagnosis and Managemen t of Barrett’s Esophagus CME

N.J. Shaheen, G.W. Falk,

P.G. Iyer and L.B. Gerson

Clinical and Systematic Reviews

53

Diagnosis and Managemen t of Functional Heartburn

C. Hachem and N.J. Shaheen

CME

Endoscopy 63

Effect of Dynamic Position Changes on Adenoma Detection during Colonoscope Withdrawal: A Randomized Controlled Multicenter Trial J.-S.

S.-W. Lee, J.H. Chang,

Ji et al.

Liver 78

Diagnosis of Minimal Hepatic Encephalopathy Using EncephalApp: A Multicenter Stroop US-Based, Norm-Base d Study

S. Allampati, A. Duarte-Rojo,

Functional GI Disorders 93

L.R. Thacker et al.

The Epidemiology of Irritable Bowel Syndrome in the Findings from the Millennium US Military: Cohort Study Open

M.S. Riddle, M. Welsh,

Colon/Small Bowel

C.K. Porter et al.

105

Adherence to Competing Strategies for Colorectal Cancer Screening over 3 Years

115

Prevalence of Adult Celiac Disease in India: Regional Associations Variations and

P.S. Liang, C.L. Wheat,

A. Abhat et al.

B.S. Ramakrishna, G.K.

Pediatrics 124

Makharia, K. Chetri et al.

A Prospective Study on the Usefulness of Duodenal Bulb Biopsies in Celiac Disease Diagnosis in Children: Urging Caution

J. Taavela, A. Popp, I.R.

FULL TABLE OF CONTENTS

Korponay-Szabo et al.

INSIDE

EDITORS: Brian E. Lacy, PHD, MD, FACG and Brennan Spiegel, MD, MSHS, FACG

VIDEO OF THE MONTH • Watch fascinating findings and novel techniques in action nature.com/ajg/votm

PODCASTS

DIGITAL ISSUES

• Learn more from authors of important articles

• Compatible with Apple and Android devices

• Available on iTunes, Android, and gi.org

• Save a PDF for offline mobile reading

gi.org/ajgpodcasts

• Free for member subscribers! • Fully linked and interactive gi.org/ajgdigital

28 | GI.ORG/ACGMAGAZINE


GETTING IT MAKING $ENSE OF

MACRA

  THE IMPORTANT DATES    

2017 IS A “TRANSITION YEAR” to ease Medicare providers into MIPS. Any quality reporting effort in CY 2017 means you will avoid a downward payment adjustment in 2019.

JANUARY 1, 2017 MIPS BEGINS

 DON’T SUBMIT

DEADLINE to register if reporting as a “Group Practice” and using the CMS website to submit your practice’s 2017 data

any 2017 data = negative 4% payment adjustment in 2019

 SUBMIT A MINIMUM

amount of 2017 data = avoid negative payment adjustment

 SUBMIT 90 CONSECUTIVE DAYS of 2017 data = neutral or positive payment adjustment

OCTOBER 2, 2017

LAST DAY to begin submitting 90 continuous days of 2017 data 

DECEMBER 31, 2017 LAST DAY for 2017 data

 SUBMIT A FULL YEAR

of 2017 data = possible positive payment adjustment

JUNE 30, 2017

MARCH 31, 2018

DEADLINE for submitting CY 2017 MIPS data 

JANUARY 1, 2019

Medicare payment adjustments begin for Part B fee-for-service claims

Getting it Right | 29


PRACTICAL ADVICE FROM A SEASONED CLINICIAN

PLAN FOR A LIFE OF COMMITMENT TO MEDICINE

IN A HEALTHFUL, HARMONIOUS WAY

AT THE TIME OF THIS WRITING, THE 50TH ANNIVERSARY OF MY GRADUATION FROM MEDICAL SCHOOL IS FAST APPROACHING and I have sent approximately 150 fellows out into gastroenterologic practice or academia. It is with the perspectives gained over this time that I offer the following thoughts, as yet another June 30th is soon to roll around and another group of fledglings leave the nest to enter the harsher and more challenging world of real life. Medicine has changed greatly in the past five decades: our independence and status in society have been eroded; governmental regulation of our work has increased; our work load and the need for its documentation have grown such that we have moved from the luxury of having the time to look a patient in the eye and hold their hand during an untimed office visit, to staring at a computer screen and typing furiously to keep pace with the now-average 17-minute office visit—and all of this at a lower reimbursement rate than in decades past. Those in academic medicine have seen increasingly severe competition for a more restricted pool of research funding. The bottom line: medicine is still a calling, but it has become a business, and it is addressing the consequences of this evolution that forms the basis of my advice. To practice medicine and be trusted with a patient’s most intimate secrets is an honor and a privilege. But these gifts come at a cost—especially to those of us who are idealists, perfectionistic and who feel a pervasive sense of responsibility for our actions. The cost is that of feeling stressed, and stress over time has a deleterious effect that may lead to what is now referred to as “burnout.”

30 | GI.ORG/ACGMAGAZINE

“…ONE MUST PLAN FOR A LIFE OF COMMITMENT TO ONE’S DISCIPLINE, BUT THIS MUST BE ACHIEVED IN A HEALTHFUL AND HARMONIOUS WAY.”

1

healthful and harmonious way. Young physicians are at the greatest risk of burnout, fueled by emotional exhaustion, long work hours, and work-home conflicts that necessarily arise because of conflicting commitments. Start your career by structuring your professional and personal life to avoid—or more accurately—reduce the stresses that lead to burnout.

2

IN YOUR WORKPLACE, SURROUND YOURSELF WITH PEOPLE WHO SUPPORT YOU, WHO CARE FOR YOU AS A PERSON, AND DON’T JUST SEE YOU AS A COG IN THE WHEEL OF PRODUCTION. Ask yourself if these are the kind

of people with whom you want to spend the majority of your time away from home. They are the ones who need to be kind and supportive when your grant is not renewed; when you have an endoscopic complication and are in the midst of a malpractice suit; or when one of life’s many crises appears.

3

— Dr. Lawrence J. Brandt

 Lawrence J. Brandt, MD, MACG

FROM THE MOMENT OF GRADUATING FELLOWSHIP, ONE MUST PLAN FOR A LIFE OF COMMITMENT TO ONE’S DISCIPLINE, but this must be achieved in a

4

SURROUNDING YOURSELF WITH GOOD PEOPLE IS KEY, BUT IT ALSO IS CRITICAL THAT YOU FIND A GOOD WORK-LIFE BALANCE. One cannot practice

good medicine if one is troubled. Find your life’s passions inside and outside of medicine, and practice them. Schedule the time to care for yourself. Be sure to sleep a sufficient amount of hours. Enjoy your personal recipe for maintaining good mental health—be it exercise, reading, watching TV, cooking, traveling or anything else you enjoy.

FINALLY, DON’T NEGLECT YOUR FAMILY OR YOUR FRIENDS, FOR THEY ARE THE ONES WHO CARE THE MOST FOR YOU. Easy to say, difficult to do. It is imperative that we, as physicians, take care of ourselves first; if we don’t, we will not be able to take care of others.

Anton Chekhov said that medicine was his lawful wife and literature his mistress, and when he tired of one he spent the night with the other. That balance worked for him. Find your balance.


Save the Date

ACG’s IBD SCHOOL and 2018 ACG BOARD OF GOVERNORS/ASGE BEST PRACTICES COURSE

ACG IBD SCHOOL

January 26, 2018 ACG BOARD OF GOVERNORS/ ASGE BEST PRACTICES COURSE

January 27-28, 2018

LEARN THE LATEST CLINICAL UPDATES and ways to incorporate them into practice when you attend ACG’s IBD School and the ACG Board of Governors/ ASGE Best Practices Course, January 26–28, at Caesars Palace in Las Vegas. Best Practices will be offered during the bye week between the playoffs and the Super Bowl so you won’t miss any of your favorite sport’s action. Caesars Palace is centrally located on the Las Vegas Strip and is considered one of the top luxury hotels in the world with more than 3,000 rooms and dozens of diverse restaurants. The Forum Shops, located on the property, features high-end fashion retailers from around the world.

Registration will open soon.

GI.ORG/REGIONAL-MEETINGS Getting it Right | 31


Law Mind

BYE BYE BABY BOOMERS: PLAN NOW for a Wave of Physician Retirements

Ann M. Bittinger, JD, represents physicians and physician groups in transactions with other entities and with compliance with federal health care laws and in structuring their independent practices. Questions? Email ann@bittingerlaw.com

INTERESTING EMPLOYMENT ISSUES ARE ARISING for physician groups and enterprises as large segments of their employed, baby-boomer physician workforce reach retirement age. Reviewing group agreements and policies on how retiring physicians—as well as those not eager to retire—are to be treated is essential at this time. Failure to do so could have a devastating effect on the employer in the form of a large payout to buy back retiring physicians’ shares in the practice. And deviation from federal employment laws on age, disability and illness could expose the group to extensive litigation and judgments. Retirements on the Rise

Although many factors contribute to the projected physician shortage, physician retirements will have the greatest impact on supply, for all specialty categories.1 More than one-third of all currently active physicians will be 65 or older within the next decade.2 Eleven percent of the active workforce consists of physicians between ages 65 and 75; those between ages 55 and 64 make up nearly 26% of the active workforce.3 Fourteen percent of physicians plan to retire in the next one to three years.4 Indeed, almost one half of all respondents to a recent survey of physicians indicated that they planned to accelerate their retirement plans due to the changes in medicine and health care.5 Approximately 75% of pulmonologists are 55 or older, as are 67% of oncologists, 60% of psychiatrists, 55% of cardiologists, and 53% of orthopedic surgeons.6 Impact on Collections

From the perspective of the physician employer that is managing aging physician employees, practices should take steps now to ensure their continued financial success after the physicians retire. Abrupt retirements

32 | GI.ORG/ACGMAGAZINE

TACKLE RETIREMENT ISSUE LANGUAGE IN KEY AGREEMENTS AS PART OF A MORE COMPREHENSIVE AND GENERATIONNEUTRAL PROJECT OF REVIEWING ALL EMPLOYMENTRELATED AGREEMENTS AND POLICIES FOR ALL TYPES OF ISSUES...

from practices can send patients looking for new doctors, costing tens of thousands of dollars in recruitment and opportunity costs.7 Likewise a last-minute departure can have a negative impact on the practice’s bottom line because some overhead costs, such as rent and support staff, will continue while productivity and collections slow.8 A practice is less likely to retain its patients if the retirement of a physician overburdens the group’s physicians such that patients cannot be seen soon enough.9 Thus, as a physician approaches retirement, it is imperative to have in place a succession plan to ensure a smooth transition. One approach to this is to amend the group’s shareholder agreement to require one year’s notice of retirement. This long-term notice is becoming common. Impact on Practice Reserves

Physician-owned groups can be devastated financially if their corporate documents do not plan for a large number of doctors retiring at once. If the termination of employment triggers a buy-back of the physician’s stock, and if the buy-back provisions value the shares with formulas that produce a six-figure purchase price that the practice pays the physician, and a number of physicians retire within the same year, the practice’s reserves can be depleted. I am revising a number of practices’ buy-back documents to allow for longer periods of time for the group to pay the retired physician for his or her stock in the event a certain number of physicians retire in the same, short timeframe. Other practices are revising their shareholder agreements’ provisions as to how the purchase price is valued. Finally, some are paying the physician only his or her accounts receivable that are collected after his last day of work, eliminating a big payout in the stock price that physicians had counted on in their retirement planning. Any physician who is


considering retiring in the next few years should have these documents reviewed by health care counsel. In many that I review, I find that a number of agreements that interplay (employment agreement, accounts receivable agreement, shareholder agreement, deferred compensation agreement) were drafted by different lawyers at different times, and their pieces do not fit together. Groups that have not reviewed their agreements or had a physician retire in a while should ask their attorney to explain in plain English how the buy-back and retirement processes work, and what would happen if three or more physicians retired in the same 12-month period. Collaboration with the group’s CPA may be required if stock value is based on tangible assets of the practice or an Earnings before interest, tax, depreciation and amortization multiple. Forced Retirement and Age Discrimination

At one time, forced physician retirements from a practice based simply on age were commonplace. Employment and shareholder agreements often stated that the employment relationship would terminate upon the physician employee’s 60th birthday. Shareholder agreements stated that the physician must sell back his or her shares in the practice to the employer upon termination of employment, so the physician’s ownership of the practice ended on that birthday as well. Federal law makes it illegal to discriminate in employment on the basis of age. The federal Age Discrimination in Employment Act of 1967 (ADEA) applies to employees who are at least 40 years of age— very young in this day and age. In sum, it states that: It shall be unlawful for an employer to fail or refuse to hire or to discharge any individual or otherwise discriminate against any individual with respect to his or her compensation, terms, conditions, or privileges of employment, because of such individual’s age.10 In other words, an employer cannot fire an employee based on age. Enforcement of a mandatory retirement age is illegal. Arguably, earlier versions of the ADEA permitted a forced retirement at age 70. The ADEA was amended in 1978 to make absolutely clear that the exceptions do not authorize an employer to permit the involuntary retirement of any individual specified because of the age of such individual.11 Additionally, the 1986 amendment to the ADEA removed the 70-year age cap. Accordingly, unless a specific exception applies, an employer can no longer force retirement or otherwise discriminate on the basis of age against an employee because he or she is 70 or older.

The ADEA contains certain exceptions to this general prohibition. When an employer claims such an exception, the burden of proof is on the employer to prove that its actions are lawful. The exceptions to the ADEA most applicable to physicians are set out below. 1. Bona Fide Occupational Qualifications. It is not unlawful for an employer to take action that would otherwise be prohibited by the ADEA where age is a bona fide occupational qualification reasonably necessary to the normal operation of the particular business.12 2. Differentiation. It is not unlawful for an employer to take action that would otherwise be prohibited by the ADEA where the differentiation is based on reasonable factors other than age.13 3. Bona Fide Seniority Systems. It is not unlawful for an employer to observe the terms of a bona fide seniority system that is not intended to evade the ADEA regulations.14 Applying these exceptions to the various practice specialties is tricky. Under the general prohibitions of the ADEA and the Fair Credit Reporting Act, an employer cannot legally discharge employed physicians when they reach a certain age. The employer’s decision to discharge an employee would have to fit squarely within an exception to be permissible. Exception for Bona Fide Occupational Qualifications and Application to Company

In Trans World Airlines, Inc. v. Thurston Air Line Pilots Association, the U.S. Supreme Court held that Trans World Airlines (TWA) could not force pilots to retire at age 60. The Court held that TWA’s bona fide occupational qualification defense to an unlawful employment practice claim under the ADEA was meritless because age is not a bona fide occupational qualification for the position of flight engineer. The Court further held that TWA’s discriminatory transfer policy permitted the forced retirement of captains on the basis of age,

BEST PRACTICES: Properly Handling

PHYSICIAN RETIREMENT

1

Review all employment and shareholder documents, focusing on what the provisions say would happen when a physician becomes disabled or wants to retire.

2

Make sure that the company’s leaders clearly understand the financial impact of retirement: How is the purchase price for shares calculated? Determine that amount every six months if it is based on a formula.

3

Allow for longer payment plans for the practice to buy back the shares if multiple physicians decide to retire in the same, short time.

4

Make clear that after a defined period of disability (90 days, perhaps), the physician’s shares are automatically sold back to the practice.

5

Create and implement a succession plan as to physician workforce and physician leadership roles to ensure you have enough physicians to treat patients, and prepared leaders to lead the practice.

6

Make retirement appealing psychologically and financially, such as through a diminished work schedule followed by retirement, and through removing barriers like tail coverage purchase obligations.

Getting it Right | 33


and could not be viewed as part of a bona fide seniority system.15 In this case, TWA’s retirement policy required pilots to, upon reaching age 60, apply for a status it called “flight engineer status” by entering a “bid” into a pool of other flight engineers. If there was no vacancy in the pool of flight engineers, or if the pilot lacked sufficient seniority to bid successfully for the vacancies, the captain had to retire. Although there were some caveats, essentially the pilots’ jobs were made very hard to continue based solely on them reaching age 60. Applying this exception and decision to physicians in their 60s, the employer would have to prove that its decision to terminate a physician was not on the basis of age alone. The employer would not successfully defend itself in a lawsuit under federal law without presenting additional evidence demonstrating how age affected that particular employee’s ability to perform his or her duties e.g., hands shaking during surgery. If age is not a bona fide occupational qualification for the position of flight engineer as discussed above, it may likewise not be considered a bona fide occupational qualification for the position of physician. The fact of turning a certain age in and of itself does not render the physician unable to perform his job. Other Exceptions and Application to Company

The ADEA references exceptions to the general prohibition for bona fide seniority systems, employee benefit plans, or systems measuring earnings by quantity or quality of production. Physician group employers may want to further examine the development of one of these bona fide systems, but must remember that the ADEA makes clear that the exceptions do not authorize an employer to permit the involuntary retirement of any individual because of the age of such individual.16 There may be legal ways to address employers’ intentions by meeting one of the federal ADEA exemptions: (1) a bona fide seniority system; (2) a bona fide employee benefit plan such as retirement, pension or insurance plan; or (3) a system that measures earnings by quantity or quality of production, which is not designed, intended or used to evade the purposes of the law. Possible Approaches

Astute employers provide a pathway for physicians to phase into retirement. Although there is little that an employer can legally do to keep an able physician who wants to continue to treat patients full time well into his 70s to retire from doing so, the Company can provide incentives in the form of money, parttime work, paid tail insurance, continuation pay after

34 | GI.ORG/ACGMAGAZINE

TURNING A CERTAIN AGE IN AND OF ITSELF DOES NOT RENDER THE PHYSICIAN UNABLE TO PERFORM HIS JOB.

working, and so forth. Removing barriers to retiring, like allowing for some post-retirement consulting work despite a non-compete, waiving the non-compete entirely after a certain age, or other pathways have proven to be useful incentives. The ADEA prohibits forced termination, but if the physician consents to being treated differently based on his or her age, that is fine. The goal of a pre-retirement/transition policy is to make it lucrative enough that the employee agrees to it. Addressing not only the financial but the psychological/lifetransition effects of retirement is important. Many physicians self-identify based on their role as a physician, such that physicians sometimes feel they have lost their purpose upon retirement. It may be helpful to allow the physician to do some outside work with other companies despite a non-compete, or to keep the physician on in an advisory role. Make sure, however, that there is a clear contractual demarcation of the point in time when the high salary of a full-time working physician ends and the new role of consultant or advisor starts. Exceptions to non-competes should be documented in an amendment to the noncompete agreement. An Appealing Downturn in Work Time

Some practices find success in policies I have drafted that allow employed older physicians to elect to transition to a finite two-thirds work schedule. The physicians understood that once they got that benefit and chose the two-thirds work time, it was finite after a period of three years. In other words, when they consent to the election and policy and receive the benefit of essentially more paid time off, they in effect are giving three years notice of their retirement. Physicians could take the two-thirds work time only if they agree that at the expiration of a three-year period of working two-thirds time, their employment ends completely. This is typically a “win-win” alternative. The employer can transition older employees over the course of a few years, allowing the employer time to find a replacement and rebuild leadership. The employee receives the benefit of whatever he or she is paid at the time he elects to go to the two-thirds time. Of course, this arrangement could be altered in a number of ways in terms


of how much time the work-week is reduced (twothirds, three-fourths, etc.), how long the physician gets the benefit of the reduced work time (three years, two years, etc.), and how much the physician’s pay is lowered, if at all, during the reduced work period. Plans should be tailored to each practice. Productivity-Based Minimums

Another approach that works in avoiding the mandatory retirement prohibition yet encouraging retirement is to institute mandatory minimum productivity requirements, such as those based on work-relative value units. The standard would have to be applied uniformly, to all employees. If, indeed, older physicians should retire due to the fact that they cannot keep up with work requirements, then a productivity-based basis—as opposed to an age-based basis—would be a legal reason to terminate employment.

 Practices must plan now for the incoming wave of baby boomer retirements.

 Failure to do so can have devastating effects on the practice’s reserves and collections.

Without-Cause Termination

If an employment agreement contains without-cause notice-of-termination provisions, the employer may terminate the agreement and therefore the employment relationship without cause. However, if challenged, the employer would have to defend itself that the reason was really for no cause and was not really based on age. If a company routinely sends without-cause notice of termination to physicians when they reach a certain age, that could be used as evidence of illegal age discrimination. Disability and FMLA

The same facts that give rise to issues under the ADEA expose employers to legal risk under other federal laws: the Americans with Disabilities Act (ADA) and the Family and Medical Leave Act (FMLA). Put simply, these federal laws prohibit employers of a certain size (15 or more employees for ADA; 50 or more for FMLA) from terminating physicians based on their disability or the need to be absent from work for certain periods to seek medical treatment or care for family members who need treatment. In my experience, applying these laws to the aging physician situation is quite difficult. Ailments related to age often reveal themselves slowly and affect the ability to work for short, distinct periods that occur over time. For example, a physician in his 50s may need radiation treatment for cancer over the course of many months, but may be fine to return to practice thereafter. He may exhaust his FMLA benefits and therefore the practice could, subject to state law, terminate him—but his condition could be a disability under the ADA, giving rise to the need to make a meaningful accommodation

 Failure to properly address retirement and related issues, like disability, can expose the practice to legal liability.

 Practices can prepare for the wave of retirements by reviewing and updating the documents that govern employment and shareholder rights and obligations.

of his need for treatment. The practice’s employment agreement and disability policy should address the sporadic but prolonged-yet-finite need for time away from work for treatment. Early planning with comprehensive physician buy-in to the process is important. Because of the generational dynamic, practices often experience great angst in addressing these issues to the extent that their anxiety breeds stagnation. To mitigate emotion, address this issue in a bigger contest. Tackle retirement issue language in key agreements as part of a more comprehensive and generation-neutral project of reviewing all employment-related agreements and policies for all types of issues (noncompete scope and duration, for example). A routine check-up for legal issues in these documents may be just what the practice needs. 1 IHS, Inc., 2016 Update: The Complexities of Physician Supply and Demand: Projections from 2014 to 2025, Final Report, available at: www.aamc.org/download/458082/data/2016_ complexities_of_supply_and_demand_projections.pdf. 2 Id. 3 Id. 4 Id. 5 Id. 6 Id. 7 Id. 8 Id. 9 Id. 10 29 C.F.R. §1625.2(a) (1987). 11 29 C.F.R. §1625.9. 12 29 C.F.R. §1625.6. 13 29 C.F.R. §1625.7. 14 29 C.F.R. §1625.8. 15 Trans World Airlines, Inc. v. Thurston Air Line Pilots Association, International v. Thurston, 469 U.S. 111 (1985). 16 29 C.F.R. §1625.9(a)(2).

 Smart practices create successions that make retirement appealing, both financially and psychologically, and that provide for well-timed physician recruitment and leadership development.

Getting it Right | 35


FINDING DISCO 36 | GI.ORG/ACGMAGAZINE


THE RACING LIFE OF DR. FRED POORDAD

OMFORT By Brian C. Davis

Finding Discomfort | 37


CAR RACING IS NOT FOR THE TIMID. THAT’S WHY DR. FRED POORDAD KNEW THE NEXT TIME HE SLID INTO HIS RACECAR WOULD BE TELLING AND, PERHAPS, DETERMINATIVE. He would not continue racing if he felt apprehensive when he drove his racecar for the first time after his accident. “I thought that if I had any trepidation, I wouldn’t be able to do it,” said Poordad, who quipped, “Fortunately, the concussion probably helped me forget a little bit.” Poordad, who began racing in 2009, suffered a broken back and a severe concussion in the accident. But he otherwise accepts—even embraces—the demands of racing. “It’s incredibly challenging both physically as well as mentally. When people ask me why I do it, that’s really the reason,” Poordad said. He expects racing to push him to new and unfamiliar places. “There’s some level of discomfort, sometimes, when you’re exploring something, or trying to stretch what you can do in a racecar to achieve a goal or a certain outcome. And it’s the same with life."

 Photo courtesy of Dr. Fred Poordad.

Breaking New Ground The accident happened in 2012, as Poordad and his family were making the transition from California to Texas. He preferred the idea of raising his children in Texas—where he had grown up—rather than in Los Angeles.

2007: Learns to race shifter karts

38 | GI.ORG/ACGMAGAZINE

2009: Begins racing in Porsche Racing Club

Wins Rookie of the Year


In moving to San Antonio, Poordad undertook a professional challenge in starting a new concept—the freestanding liver institute—which he and Eric Lawitz, MD, opened in early 2013. “We only practice liver disease. We actually don’t do any gastroenterology,” said Poordad of the Texas Liver Institute, which partners with the University of Texas Health Science Center at San Antonio and the University hospital system. This is not what Poordad expected when he chose gastroenterology. He pursued GI because there was history of colon cancer in his family. “Once I got into the field, I realized that liver was my true passion and my true calling,” Poordad said. Poordad has leapt from coast to coast throughout his career. He completed a gastroenterology fellowship at the University of South Carolina and a liver transplant fellowship at Johns Hopkins University. After finishing at Johns Hopkins, he moved to northern California to work at California Pacific Medical Center, before deciding to return to Baltimore and Johns Hopkins to serve as CoDirector of Liver Transplantation. “I literally couldn’t afford to live there,” said Poordad, of living in California during the “Dot-com Bubble.” Johns Hopkins is where Poordad says his career took shape. After a couple of years there, he moved back

2010: Races in the Porsche POC, Modified 911 Class

Multiple Top-10 Finishes

 Photo courtesy of Dr. Fred Poordad.

“When I’m racing I really can’t think about anything else, so I’m incredibly focused on the task at hand. That has allowed me to actually grow in many ways and remain focused.” 2011: Races in the Pirelli GT3 Cup Trophy USA

Multiple Top-10 Finishes

Finding Discomfort | 39


ACE DAY OUTFI

Balaclava

Fireproof head cover

40 | GI.ORG/ACGMAGAZINE

Race Helmet

Features air blower, and is outfitted with radio communication system to race team

Head and neck restraint system (HANS device)

FIREPROOF RACE SUIT

Fireproof underwear and shirt

Race Gloves

Fireproof Socks

Race Shoes

2011: Competes in 24 hours of Daytona, in Ferrari GT

Finishes 14th in class


to California, but this time to southern California and, specifically, to Cedars-Sinai Medical Center. He stayed at Cedars-Sinai for 11 years, ultimately becoming Chief of Hepatology and Liver Transplantation. Of course starting a new job—let alone launching a new concept—does not come without obstacles. Management of a large staff, the regulatory challenges that come with performing lots of clinical research, and the uncertain future of health care in the United States are among the more significant issues Poordad perceives, though he says they are not unique. “The problem is we don’t have a clear path of where health care is going. It’s always difficult—when you don’t know where you’re eventually going to end up— how to plan for it,” Poordad said. “It really requires a lot of nimbleness and some forethought and planning.” Not Slight Poordad’s 2012 accident took place at Road America, in Elkhart Lake, WI. He was competing in the International Motor Sports Association (IMSA) Porsche GT3 Cup Challenge USA by Yokohama, one of the two series in which he was racing. The collision took place in the first lap, as he and his car exited the third corner. “Another car had spun off and back onto the track,” Poordad said. “I was drafting behind another car and pulled out to pass, and hit the disabled car, destroying both cars.”

It took weeks for Poordad to recover from the concussion. He wore a brace for three months and endured six months of rehab, through physical therapy, to recover from his injuries and regain his flexibility. “I don’t ever want to go through that again,” he said. “This is not a sport you can participate in if you have anxiety or nervousness,” Poordad said. Accidents are “just one of those things that can happen with racing,” he said, but he considers himself fortunate to have been able to recover. Poordad did not quit racing after his accident. This was likely his most trying time in racing, but the sport had tested him previously, and he had not relented. In 2007, before the accident—before Poordad even began racing cars—he had learned to race shifter karts, an aggressive type of open-wheel racing, while he was living in southern California. “I decided my body couldn’t handle it,” Poordad said of shifter kart racing. Rather than abandoning racing altogether, he determined instead “I better get into a car,” which would have a more substantial platform and body.

“I’ll hang up the racing gloves when the passion is no longer there and the drive to compete at this level is no longer there.” 2012: Races in the International Motor Sports Association (IMSA) Porsche GT3 Cup Challenge. He gets into a bad accident at Road America, in Elkhart Lake, WI, resulting in a broken back, severe concussion, and an end to his season.

Finding Discomfort | 41


From there, he began racing in the Porsche Racing Club. He hired a professional driver who worked with him for a year and acquired his racing license. He won the Rookie of the Year Award in his first year, 2009. The physical demands remained a constant, irrespective of the vehicle type. The cars are extremely hot. Drivers have to maintain cardiovascular fitness and a degree of flexibility, in order to enter and exit the car through the roll cage. “The physical demands of these cars are not slight,” Poordad said. “It is physically much more grueling than people think.” Escaping Comfort Poordad had ample time to recover from the accident, as his workload was still light when he first moved to San Antonio. He was back racing the next season, resuming competition in both the IMSA Porsche GT3 Cup Challenge, an East-Coast racing series, and the Pirelli GT3 Cup Trophy USA, a West-Coast series. In 2014—a year after he returned to racing—Poordad competed in the IMSA Porsche GT3 Cup Challenge Gold Championship, finishing in third place. His success has not subsided. In 2015, Poordad won the Pirelli GT3 Cup Trophy Championship. In 2016, he finished second in the IMSA Porsche GT3 Cup Challenge Platinum Masters Championship, and he continues to race in both series. Pushing himself inside the car has benefitted Poordad outside of the car. His personal health has improved due to the physical demands of car racing. “It’s forced me to get into much better shape than I otherwise would have been in,” Poordad said. “I’m more fit than I have been in the past 30 years.” Racing is a “learned behavior. It’s definitely not agile,” Poordad said. Data engineers and team members help drivers focus. As a result, he has improved his focus in other areas of his life. “When I’m racing, I really can’t think about anything else, so I’m incredibly focused on the task at hand. That has

Bottom: Dr. Fred Poordad with his daughter, Riley, and son, Austin. Top right: Dr. Fred Poordad with his daughter, Riley, and wife, Judy Kim, MD, who is an internist. Courtesy of Dr. Fred Poordad.

2013: Returns to IMSA Porsche GT3 Cup Challenge - Gold Class

MULTIPLE TOP-10 FINISHES

42 | GI.ORG/ACGMAGAZINE

2014: IMSA Porsche GT3 Cup Challenge - Gold Class Championship

3rd Place


“You have to get into uncharted territories and tolerate a little bit of discomfort, whether that’s doing something that you’ve not done, negotiating various deals you were unable to do before, or setting up a new program...”

DO YOU HAVE A RACE DAY GOOD LUCK CHARM OR SUPERSTITION?

Text to my kids and silent prayer to keep all racers safe WHAT'S THE COOLEST PIECE OF RACING TECH YOU USE?

The computerized data acquisition system in the race car that allows the race engineer to assess all facets of what the car is doing on track. The data collected is the best way to assess car and driver and is both learning tool, but also a set up tool to allow the team to make set up changes to the car, and allow the driver to adapt and change technique when needed.

2015: Pirelli GT3 Cup Trophy Championship

1st Place

2016: IMSA Porsche GT3 Cup Challenge - Platinum Masters Championship

2nd Place

Finding Discomfort | 43


allowed me to actually grow in many ways and remain focused,” Poordad said. Being in a racecar might not seem, to an outsider, like the ideal setting for sustaining one’s focus, but Poordad advises otherwise. “It’s not an adrenaline rush, as people might think. It’s a very controlled environment.” Racing has taught him that commitment and perseverance—to the point of discomfort—will be required at times to “get things done.” “You have to get into uncharted territories and tolerate a little bit of discomfort, whether that’s doing something that you’ve not done, negotiating various deals you were unable to do before, or setting up a new program,” Poordad said. Big Challenges Are the Best Challenges Starting a new program also has begun to bear fruit. The Texas Liver Institute now maintains more than 100 employees and eight liver doctors. According to Poordad, it is the busiest clinical liver research facility in the United States. The Institute has done lots of work in viral hepatitis, and it is now focusing its attention and resources on fatty liver disease, anti-fibrotics and liver cancer. Poordad, who says he wakes up every day enjoying what he does, welcomes the imminent, unavoidable challenges in his field. He says the sheer volume of people with advanced fibrosis and fatty liver disease requires that advances take place. “We can’t ignore it. We really have to take this head on and dedicate a lot of research to these areas,” Poordad said. “I see that happening, so it’s very exciting for me.” Poordad is optimistic about the treatment prospects for fatty liver disease, cirrhosis and liver cancer.

“I’m very excited for the patient with these conditions because I think over the next 10 years we’re going to have viable therapies,” Poordad said. “That really is amazing when you think about it. I mean, we’re all impressed by what happened with the Hepatitis C world, but I actually think the next 10 years will even dwarf what’s happened in Hepatitis C.” Do not expect Poordad to give up racing during that time period. “Well, you know, Paul Newman raced until he was in his early 70s, so I think I’ve got some time still,” Poordad said. “I’ll hang up the racing gloves when the passion is no longer there and the drive to compete at this level is no longer there.”

“There’s some level of discomfort, sometimes, when you’re exploring something, or trying to stretch what you can do in a racecar to achieve a goal or a certain outcome. And it’s the same with life.” 44 | GI.ORG/ACGMAGAZINE


CAREER MOVES 1990 | EDMONTON, ALBERTA, CANADA University of Alberta, Medical Doctorate, to

1990–1993 | AKRON, OHIO Northeastern Ohio College of Medicine, Internal Medicine Residency, to

1993–1995 | COLUMBIA, SOUTH CAROLINA University of South Carolina, Gastroenterology Fellowship, to

Bottom: Dr. Fred Poordad finishes in second place in the 2016 IMSA Porsche GT3 Cup Challenge – Platinum Masters. Photos courtesy of Dr. Fred Poordad.

1995–1996 | BALTIMORE, MARYLAND Johns Hopkins University, Hepatology/Liver Transplantation Fellowship, to

1996–1999 | SAN FRANCISCO, CALIFORNIA California Pacific Medical Center, to

1999–2001 | BALTIMORE, MARYLAND Johns Hopkins University, Co-Director of Liver Transplantation, to

2001–2012 | LOS ANGELES, CALIFORNIA Cedars-Sinai Medical Center, Chief of Hepatology and Liver Transplantation, to

2012–PRESENT | SAN ANTONIO, TEXAS Texas Liver Institute, Co-Founder, Vice President, Academic and Clinical Affairs. Joined the faculty of The University of Texas Health Science Center San Antonio.

Finding Discomfort | 45


Attend an

ACG Regional Postgraduate Course close to where you work and live

2017–2018 ACG REGIONAL POSTGRADUATE COURSE CALENDAR 2017 IBD School and ACG Midwest Regional Postgraduate Course August 25–27, 2017 Hilton at the Ballpark St. Louis, MO

2017 ACG/VGS/ODSGNA Regional Postgraduate Course September 9–10, 2017 Williamsburg Lodge Williamsburg, VA

2017 IBD School and ACG Southern Regional Postgraduate Course December 1–3, 2017 Omni Nashville Hotel Nashville, TN

2018 IBD School and ACG Governors/ASGE Best Practices Course January 26–28, 2018 Caesars Palace Las Vegas, NV

For more info, visit: GI.ORG/REGIONAL-MEETINGS 46 | GI.ORG/ACGMAGAZINE


Right at Home in a Faraway Place

Page 11: Dr. Katz gives the David Y. Graham Lecture at the 2016 ACG Annual Scientific Meeting.

 Golden Pavilion, Kyoto, Japan.

Seth A. Gross, MD, FACG, on His Trip to Japan and Representing ACG at the JGA Annual Meeting

K

onnichiwa…

I recently had the opportunity to represent the American College of Gastroenterology (ACG) at the Annual Meeting for the Japanese Gastroenterological Association (JGA). Attending the conference touched me both professionally and personally. I was honored to be invited by ACG President Carol A. Burke, MD, FACG, to give a talk on new technology for GI disease at an international GI meeting endorsed by the College. This was the first time my family joined me at a conference.

Making an ACG Connection After a long flight followed by a high-speed train ride, I arrived in Nagoya, where the conference was taking place. Once we settled in, I attended the presidential dinner with my wife, Stacy. The first person I met is current ACG Governor for Japan Shin’ichi Takahashi, MD, FACG, of Kosei General Hospital. Shin’ichi was a wonderful host, introducing me to several members of the JGA. He made Stacy and me feel right at home. It was a wonderful evening with fabulous food, exciting entertainment and, most importantly, good company. →

ACG Perspectives | 47


L to R, top to bottom, Dr. Seth Gross, his wife, Stacy, and his kids; ACG Governor for Japan Shin’ichi Takahashi, MD, FACG, of Kosei General Hospital; Gross speaking at the Annual Meeting of the Japanese Gastroenterological Association; standing in the bamboo forest; taking in sumo wrestling practice in Tokyo; visiting with the monkeys at Arashiyama Monkey Park. Photos in this story are courtesy of Dr. Seth Gross.

Shin’ichi shared with me the strong bond the College has with the JGA and our Japanese colleagues. JGA is one of four ACG international affiliate GI societies. Each year, the College graciously sponsors a speaker at the JGA Annual Meeting. JGA reciprocates and sends faculty to the ACG Annual Scientific Meeting for a special hands-on workshop session with Asian experts. A Special Trip: Work and Family During our stay, Stacy and I visited two other cities: Kyoto and Tokyo. Kyoto, known as the “Imperial Capital,” is home to many beautiful temples and shrines set against the backdrop of a spectacular mountain range. Kyoto has an “old world” feel, but like the rest of Japan, has an excellent subway system. We explored the bamboo forest, made new friends at the Arashiyama Monkey Park, and visited the Golden Pavilion while the snow was falling. We even saw a Geisha roaming at night in the streets of Kyoto. From there we hopped the bullet train, leaving a city reminiscent of Japan’s past to the bright lights and

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fast pace of Tokyo. A word of advice: do not travel to your hotel by subway with your wife, three kids, mother-in-law, and luggage at rush hour. It is packed! Tokyo is similar to other big cities, with tall skyscrapers, museums and great shopping, but you will not find a sumo wrestling stable in any other city. My kids always viewed me as a pretty big guy—until I took a photo with a sumo wrestler. We had the chance to watch these guys practice, and the level of intensity was at its peak for three straight hours. And no, I was not asked to participate in the scrimmage. Despite the language barrier, the people of Japan were friendly and helpful in guiding us throughout our journey. Everyone in my family was excited to see the different parts of Japan. Stacy was thrilled to absorb the culture and visit the museums and shrines, a true tourist soaking up everything this beautiful country has to offer. My daughter was able to participate in an official tea ceremony and was overjoyed to see all the Hello Kitty gear. Let’s not forget my two boys: no trip to Japan would be complete without a visit to Disney Sea (only in Japan), followed by a jaunt to the official Pokemon store. I will remember this trip for years to come, since it is not often I have the honor to represent my specialty abroad, visit an amazing country, share the experience with my family, and speak to international colleagues as part of the ACG family. Lastly, yes it’s true, the toilets are amazing in Japan. Go buy a Toto… Sayounara!


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ACG Perspectives | 49


Writing for New& Familiar Audiences Douglas G. Adler, MD, FACG, Vice Chair, ACG Board of Governors

Q&A WITH DR. ADLER

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DR. DOUGLAS G. ADLER HAS A HISTORY OF MEDICAL WRITING, but his passion for writing and publishing extends far beyond medical writing and began long before his medical career. Adler started writing when he was a child, and he continues to spend time writing every day, usually working on several pieces at once. He not only writes medical papers, articles, book chapters, and even textbooks, but he has now published six articles for the general public.


In March, Discover magazine published “A Gusty Call,” in which Adler recounts the story of his patient, Albert, and the unconventional approach he took to isolate and fix Albert’s mysterious bleeding condition. ACG corresponded with Adler about his zeal for writing, the differences in medical writing and writing for the lay reader, and why he decided to share Albert’s story. When and how did you become interested in publishing? I have always been interested in writing in general and publishing specifically. As a child, I wrote lengthy adventure stories and have pretty much been writing in one format or another ever since. As an adult, I became very interested in the mechanics of publishing. Medical and scientific publishing, book publishing and magazine publishing are all vastly different worlds that are organized under different business and organizational models. I have written about 300 medical papers, articles, and book chapters, and my sixth textbook of gastroenterology will be published in 2017. Writing an article for gastroenterologists is totally different than writing an article for the lay reader in a popular science magazine you can buy at a supermarket or an airport. In a medical paper, it is assumed that the reader has—at the very least—a significant understanding of the topic at hand and the specific technical terminology. When writing for the lay reader, you have to assume they are completely new to the topic and you have to lay out the information in a way that they can easily grasp complex concepts. How do your writing ideas come to you? Do you try to find time in your schedule to write? Most ideas come from daily experiences. Ideas for studies almost always come out of patient interactions or procedures: you see something unusual that sheds light on a problem or suggests a solution to an existing problem, prompting you to undergo some kind of formal investigation that [hopefully] leads to a meaningful change in practice. For articles to the lay reader, if I see a patient who has an interesting case or something that presents a medical illness or disease in a novel or exciting way, I look to find a route to write about it. What moved you to share this story with a broad audience? The patient in question was deeply frustrated by his recurrent GI bleeding, and we were able to find an answer to his problem by taking a bit of a risky approach—administering him heparin to provoke a bleeding event so we could “catch him in the act.” It took some time to trigger the bleed but ultimately this is exactly what happened, and we were able to finally identify a source of his troubles and fix it. The personality of Albert, your patient and the subject of the article, comes through clearly. His desperation, courage and sense of humor endear him to the reader. Did Albert’s courage play a role in you deciding to tell this story? It was certainly brave of him to risk going on the blood thinners given his prior history of having multiple large GI bleeds. I think it took a lot of courage on his part to go ahead with the plan. We were standing by with a lot of resources, but it was still a scary thing for the patient.

 March 2017 cover of Discover.

In writing the article, were you focused on how to articulate complex topics and procedures in a way that would be easy for readers to understand and envision? When you go to medical school or nursing school or PA school, a lot of what we do is learn the language of medicine. Nonmedical people don’t speak this language, but it is a manner of communicating to people in the same field quickly, just as two fighter pilots or two roofers could meet and speak to each other in their own very technical languages. In a scientific or medical paper, you use references to fill in the gaps. When writing for the public, you can’t do this and need to define everything as you go so they can easily follow the story and understand the picture you are painting. What do you hope readers learn in reading the article? On reading the article, I hope people get a sense that medicine is not cut-and-dry. Some patients have complex problems that require novel solutions, and that sometimes treatment entails risk. The story is also good in that we had a good outcome and a happy ending for the patient.

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Conversations Women in Shivangi T. Kothari, MD, FACG, on DAILY LIFE IN ADVANCED ENDOSCOPY By Jill Gaidos, MD, FACG

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A n GI with

AFTER ANOTHER SUCCESSFUL CAREER OPPORTUNITIES FOR WOMEN IN GI LUNCHEON at the 2016 ACG Annual Scientific Meeting in Las Vegas, which was organized and moderated by Shivangi T. Kothari, MD, FACG and Anca I. Pop, MD, I met with Dr. Kothari to talk about her career as an advanced endoscopist. You are the Associate Director of Endoscopy and Co-Director of the Developmental Endoscopy Lab at the University of Rochester (U of R) in New York. What are your responsibilities as the Associate Director of Endoscopy? SK: As the Associate Director of Endoscopy, I contribute to the overall growth and smooth operation of our extremely busy tertiary care endoscopy unit. I work closely with the Division Chief, Director of Endoscopy, and the nursing leadership in the implementation, growth and success of our unit. In this role, I am primarily responsible for helping troubleshoot certain operational issues and identifying opportunities for improvement. These include, but are not limited to, upgrading the endoscopy reporting software, being involved with the endoscopy unit expansion planning and execution, new technology acquisition and endoscope reprocessing updates, and the drafting and implementation of recommendations. My key areas of focus have been implementation of new initiatives and technologies and providing leadership and support for the Nurse Manager and Nurse Leaders, especially around nursing education and training. For the last three years, I have also been a Course Co-Director of our annual University of Rochester Medical Center (URMC) Advanced Endoscopy Nurses Course. This role involves strategic planning and execution in developing and implementing the course and bringing the entire endoscopy unit staff together to put together this one-of-a-kind, comprehensive nurses training course. I took the initiative on this course three years ago, and it has grown very rapidly and is attended by nurses from all over the country. One of the things I’ve seen in academic center endoscopy centers is that the nurses and physicians are employees of different entities, so the endoscopy nurses do not report to the Director of Endoscopy, which can make it hard to implement changes to speed up room turnover, etc. Do you have similar problems? SK: We work closely with the Nurse Manager and the Nurse Leaders to discuss any endoscopy unit work-flow issues, staffing issues, and to address and fix any road blocks in the smooth running of the unit. We have periodic leadership and staff meetings with the endoscopy unit →

ACG Perspectives | 53


leadership and also with the staff to, in an open forum, discuss projects and their outcomes and any areas that need improvement, as well as to plan future activities. When our Advanced Endoscopy Nurses Course takes place, the entire unit staff comes together, from the techs to the nurses to the Nurse Leaders, to work hard together and to make the course a success. From the daily endoscopy work to academics, unit progress and clinical studies, we are all in it together.

for advanced endoscopy nurses. It’s a day-and-a-half course with a day of live case transmissions and didactics and the next half-day is in the lab. There are two live animal stations for hands-on ERCP and EUS training. Furthermore, there are eight explant stations and two model-based stations for participants to practice advanced techniques first hand. The stations utilize various devices for foreign body retrieval, EMR, ERCP, EUSfine needle aspiration (EUS-FNA), intraluminal stenting, hemostasis advances, and fistula closure. Each station is staffed by a physician and expert technical assistants. The course has been very well received and is growing rapidly because it is a unique learning opportunity for advanced endoscopy nurses and techs.

What is the Developmental Endoscopy Lab, and what is your role as the Co-Director? SK: Under the direction of our Division Chief, our interventional group started the Developmental Endoscopy Lab two years ago when my husband, Truptesh H. Kothari, MD, MS, joined URMC as an Interventional Endoscopist. It’s a fully functional animal lab at U of R where we utilize the live animal platform for endoscopy teaching and training, clinical research, and device and technique development. It’s a very good educational and training platform. There are not too many such units in academic centers in New York or around the country. As the Co-Director of the lab, I am involved with the planning, organizing and execution of all training courses that we hold at the lab, and also am the CoInvestigator for all device evaluations and efficacy trials that we perform at the lab. Was this something that was in place when you started, or did you help create it? SK: The lab facility has existed for a number of years and is a part of the Center for Experiential Learning at U of R. Many other departments of the hospital were using it, but it was Truptesh’s initiative at the time of his recruitment to help establish this aspect of our program along with our interventional group. It involved a lot of paperwork, training, certification and staff education to enable all of us to work in the animal lab, and we all went through it. It took us a good eight to nine months to get all of the paperwork and training ironed out before we had our first training workshop at the lab, which was a hands-on training course for GI fellows. Do you keep that open to just the fellows in your program, or is it open to all fellows? SK: No, we had fellows attend from the

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For those of us interested in career timelines, how many years have you been out of fellowship? SK: I graduated from my interventional endoscopy fellowship in 2012, so I am four years out. Was your position as the Associate Director of Endoscopy a promotion or part of your position when you started? SK: It was a part of the offer/position when I started working at URMC. Was that something that you negotiated for? SK: Yes, I did. I did negotiate, but it was not that difficult, at least in my case. entire upstate New York area. It was a hands-on workshop on a Saturday morning. They could do Endoscopic ultrasound (EUS)/Endoscopic Retrograde Cholangiopancreatogram (ERCP) on live pigs, and there were explants as well. There were different hands-on stations for endoscopic mucosal resection (EMR), overthe-scope clips, luminal stenting, ERCP, EUS, foreign body removal, etc. Is it for first-year fellows, second-year fellows? Who do you include? SK: Upstate GI fellows from all three years of training were invited to participate in the course. That’s the same platform we use for the nurses when we do our course annually

How do you handle the administrative duties in addition to your clinical duties, because you have to keep up your number of procedures? Do you have administrative time set aside? SK: The balance is very tough. I have one half-day of administrative time during which I try to schedule all my meetings and any conference calls that need to happen. Administrative time as an interventional endoscopist is extremely hard to protect because there are always urgent ERCP or EUS procedures that need to be done, and you always want to help the patient and gets things done quickly for them. It’s extremely difficult to draw a hard line protecting your administrative time, at least for me. I try to work around my


meeting schedules and do any urgent cases in between the meetings. The staff understands that and plans accordingly. What is a typical week or month like for you, including endoscopy days (general and advanced), number of clinics (all related to advanced endoscopy or any general GI clinics), call, and inpatient responsibilities and consults? SK: I am one of four interventional endoscopists at URMC, thus my schedule mainly consists of interventional procedures. I have one half-day of administrative time, one half-day of clinic, and one half-day of general GI procedures that we do at our outpatient setting. There are also urgent EUSs and ERCPs that get squeezed in, and the four of us take turns in taking care of the inpatient advanced procedures volume. We also do about seven to eight weeks of inpatient GI consult service during which we manage the inpatient consults as well as inpatient advanced and general GI procedures. During the consult service weeks, I limit my outpatient schedule to just one to two urgent advanced procedures and no office hours. What about call? Do you only take call when you are on the inpatient service? SK: Our call schedule is separate from our inpatient consult service schedule. We do about six weeks and weekends of call—that is just your general GI call—and now we have a separate biliary call schedule as well. So, the four of us are on biliary call, one in four, in addition to our regular GI call. When you take biliary call, how often do you have to come in? SK: We started the biliary call because the on-call ERCP volume has increased over the past two to three years and now, with four ERCP attendings on staff, it just made sense to have an official person on call in place. When you are on biliary call, pretty much every time we have had to go in for ERCPs, mainly on the weekend. Also, with the University acquiring more hospitals, the volume of urgent on-call ERCPs has increased, making the biliary call relatively busier compared with in the past. You mentioned that there are four advanced endoscopists at your center. Do you evenly share all of the advanced cases? Or, is it dependent on who you see as an outpatient?

SK: The patients that get referred to the advanced endoscopy practice get evenly distributed amongst the four of us. The patients that get referred to a particular provider get scheduled with that provider. URMC has a huge catchment area, so volume is not an issue. For people interested in a career in advanced endoscopy, do you have any recommendations? For example, what is a realistic patient load when you are first starting out? SK: We recently wrote a paper on this exact topic1—career prospects and professional landscape after advanced endoscopy training. It was a survey that we did of advanced endoscopy-trained fellows who graduated from 2009–2013. We surveyed them to determine what trouble they had finding an advanced endoscopy job after their training, whether they were doing the same complexity of procedures in their practice as in their training, and if they encountered and felt that the advanced endoscopy job market is saturated. We are all talking about it, everybody is saying, “Where are the jobs for advanced endoscopists?” But there was no literature— there are no numbers out there. We found that more than 80% of the respondents feel that the advanced endoscopy job market is saturated. A majority of the respondents had a hard time finding a job, and the ones that are training advanced endoscopy fellows are finding it hard to place their fellows in a good advanced endoscopy practice. I think our overall impression is, especially if you pick big institutions who already have three, four, five or more faculty who are doing advanced endoscopy (our institution already has four advanced endoscopists), then you

may not get the volume or complexity that you should have after a good advanced endoscopy training; volume is a must to keep up your complex procedure skills. The fact is that there is still a need for people really interested in advanced endoscopy, but these people should focus on locating themselves in the areas that truly need these services. That is the only way to keep up your skills and volume in performing these complex procedures. When you are first starting out, only bite off as much as you can chew. Do the procedures that you are trained and proficient in and avoid complications. Make sure the procedure is truly indicated. Currently at our center we annually perform approximately 2,500–3000 advanced endoscopic procedures among four therapeutic endoscopists. Currently there is no recommendation in the United States for the minimum number of procedures to maintain proficiency in EUS or ERCP but I feel, just like in any other procedure-related field, that the greater number of procedures you perform the better. Do you think that will change the number of programs that are training advanced endoscopy fellows? SK: I don’t know if our study will change the number of programs, but I do feel that we need to train the advanced endoscopy fellows that have a defined plan as to where and how they are going to use their newly acquired skills. Where are they going to go? SK: The thing is, most people want to stay in the already-oversaturated big cities and big programs. Then the frustration comes as to where are the patients and procedures and how are they going to keep up their skills. Identifying national and international

Administrative time as an interventional endoscopist is extremely hard to protect because there are always urgent ERCP or EUS procedures that need to be done...

ACG Perspectives | 55


“advanced endoscopy underserved” markets is a first step, and to accept trainees who would then commit to serving these regions more meaningfully, as opposed to oversaturating already-advanced endoscopyheavy markets. This will help redistribute the advanced endoscopy skills to moremeaningful and -needy areas. Any particular things to ask for when negotiating a contract for an advanced endoscopy position? SK: I would first say to join a practice or hospital that you feel has enough volume, infrastructure and multidisciplinary surgical and oncology teams to support your advanced endoscopy practice. Negotiation depends on what your expectations are from the practice and how you want to shape your career. Overall, I would say discuss your relative value unit (RVU) expectations, secretarial support, mid-level support, if available, and the last thing would be the reimbursement. Your RVU requirement will certainly be higher than the general GI guys in the practice, but keep a realistic goal. Negotiate your time off. How many days are you going to be doing interventional procedures? How much administrative time are you going to have? How much clinic time, and how much general GI you are going to do? The key is to try to be a part of a high-volume center, especially if you want to continue doing the complex work for which you are trained. Discuss how you want your practice shaped. What do you want to do? Do you want to focus on EUS or ERCP, Barrett’s, bariatrics—that’s a big one now—if you want to pick a sub-sub niche in endoscopy, or do you want to do all things therapeutic? Discuss how will you build your practice—what is the group’s plans for outreach and getting a word out in the community to help get you the referrals? Meet with the surgical and oncology teams to discuss your expectations and plans for partnering with them. This wasn’t on my list of questions, but now that I see you and know that you are six months pregnant, how is that impacting your practice? SK: All of my referring providers know that I’m not doing ERCPs right now. Even if the ERCP gets referred to me, I send it to one of my three interventional partners. I continue to do EUS-FNA,

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The fact is

that there is still a need for people really interested in advanced endoscopy, but these people should focus on locating themselves in

Barrett’s endotherapies and enteroscopies. It was a personal decision, and I just chose not to do any fluoroscopic procedures during my pregnancy. I am not even taking biliary call right now, which increased my three interventional partners’ biliary call volume, but they have been extremely understanding and supportive. As a women in interventional endoscopy, I can say that getting that balance and expanding your family is difficult, but you have to get your priorities right. For me, right now, it is my kid, and I had to slow down a little bit. When I go on my two-month maternity leave, they have to block off my schedule, which is so hard for my secretary to plan right now because of my busy interventional practice. But, that is something that the entire staff is extremely supportive of, and we are working together to make it happen. It all falls in place, you just have to voice it. The show will go on, the work will always be there—that is one thing I have realized. You think, “What is going to happen with the schedule and the procedures?” But, it all works out and falls into place. And I will be back. The patients will still be there. SK: The patients will still be there. Knowing our volume there will probably be more patients. But, I will have had my baby and, for me, that is the most important thing right now. You have to prioritize and balance your work and life. Decide what’s important at the moment. After I am back from my maternity leave, I return to my full-time advanced endoscopy job, our advanced endoscopy nurses course that will happen in April 2017, my role as Co-Director of the ACG Regional Hands-on Workshops, and all of my other commitments to the endoscopy unit as well as nationally. The efforts at achieving a work-life balance will continue on a daily basis. 1 Granato CM et al. Career prospects and professional landscape after advanced endoscopy fellowship training: a survey assessing graduates from 2009 to 2013. Gastrointest Endosc 2016; 84:266-71.

the areas that truly need these

services.

 READ MORE INTERVIEWS in the Conversations with Women in GI series: acgblog.org


Top, ACG President Carol A. Burke, MD, FACG, Philip O. Katz, MD, FACG, Past President (2009-2010), and GI fellows.

EDUCATION

Focus & Feedback for GI Fellows

27TH ANNUAL NORTH AMERICAN CONFERENCE OF GI FELLOWS GETS

HIGH MARKS

AS NETWORKING EVENT

BUILDING PRESENTATION SKILLS AND CULTIVATING AN INTEREST IN CLINICAL RESEARCH among GI fellows-in-training was the goal of ACG’s 27th annual North American Conference of Gastroenterology Fellows (NACGF). Sponsored by the American College of Gastroenterology and endorsed by the Canadian Association of Gastroenterology, NACGF creates an opportunity for GI fellows to present their research, interact with senior faculty, and attend excellent educational programs and breakout sessions. Co-Chairs of the Educational Advisory Committee Sunanda V. Kane, MD, MSPH, FACG, ACG Vice President, and Philip O. Katz, MD, FACG, Past President (2009–2010) have been involved in this course for many years. This year, David J. Hass, MD, FACG, joined them as a Co-Chair. The 2017 faculty also included ACG President Carol A. Burke, MD, FACG. →

Education | 57


Mentoring and feedback from a distinguished faculty of gastroenterologists is at the heart of this experience. The competition is tough and fellows must submit their projects for consideration. Only 25 fellows are selected to attend and their expenses are covered. This year's conference took place in sunny Orlando, FL, at the Hyatt Regency Grand Cypress Resort, from March 17–19, 2017. From the perspective of the fellow, the conference's strengths include its small size, the opportunity to present their research to colleagues in a less pressured environment than at national meetings, and receiving coaching on presentation skills from experienced faculty. Learn more about the NACGF application process: nacgf.org

NAVIN L. KUMAR, MD Brigham & Women’s Hospital, Boston, MA

What were the highlights of this experience for you? The NACGF conference is a wonderful opportunity to meet fellows from across the United States and Canada, gain valuable experience in delivering an oral presentation, and interact with faculty members who are leaders in the field of gastroenterology and hepatology. One of the unique aspects of this program is its focus on personal development, as the faculty provide detailed feedback on each fellow’s presentation as well as discuss key principles of becoming a leader during the welcome dinner. The intimate setting allows for all participating fellows and faculty to get to know each other. I actually met a few fellows who would like to expand my project to their training site as well, which was a very humbling and exciting experience. What project/abstract did you present? I presented my educational innovation entitled “The SAFE-T Assessment Tool: A Validated Web-based Application for Evaluation of Gastroenterology Fellow Performance in Colonoscopy.” The tool allows for pointof-care, continuous assessment of fellow colonoscopic skills and is optimized for smartphone use to improve the user experience. We showed this tool to be concise, valid and reliable in a prospective study done at our institution, and are currently in the process of making the tool available for all interested fellowship programs. What two or three key takeaways from NACGF will help you as you move ahead in your career? From my experience at the NACGF, I gained confidence in my ability to present my research in an effective manner, developed important collaborative relationships that will enrich my future academic pursuits, and was inspired by the faculty members who were all excellent role-models. What advice would you give a potential applicant for 2018? My advice to a potential applicant is to apply! As described above, there are so many wonderful aspects of this program. I hope all interested fellows have the opportunity to participate. The leaders of the program have made the application process very easy and so please don’t hesitate to submit your abstract for consideration—it will absolutely be worth your time.

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FIRST-HAND EXPERIENCES from NACGF 2017

TOSSAPOL KERDSIRICHAIRAT, MD

Laura Ulmer, DO

University of Michigan School of Medicine, Ann Arbor, MI

University of Nebraska Medical Center, Omaha, NE

What were the highlights of this experience for you? The NACGF experience offered wonderful input on how to build presentations slides and present your works from experienced faculty. For me, the best part was getting to know fellow colleagues from many programs. What project/abstract did you present? My project was, “Development and validation of walled off necrosis scoring system for patients undergoing endoscopic step-up approach.” What two or three key takeaways from NACGF will help you as you move ahead in your career? For me, NACGF was an opportunity to strengthen presentation skills and get a chance to ask questions in a meeting. I came away from NACGF with a better appreciation for how to develop collaborations and network among institutions. What advice would you give a potential applicant for 2018? This is one of the best meetings dedicated for GI fellows. Experienced faculty will guide you how to effectively and professionally present your works in national meetings. To my knowledge, this might be the only one conference that can help improve your skillsets from this perspective.

What were the highlights of this experience for you? Having the opportunity to present an oral presentation in a more low-key setting than a national meeting, as well as the feedback received. We were taught not only about how to give our presentation in a more effective manner, but also about presentation and question-answering etiquette—valuable things that are not often taught. Given that this is a small conference, the fellows also had the ability to mingle with the faculty throughout the weekend. What project/abstract did you present? I presented a project entitled: "Fecal Microbiota Transplant for Clostridium difficile Colitis From Thawed Frozen Stool: Two-Year Real-Life Experience In A Community Hospital." What two or three key takeaways from NACGF will help you as you move ahead in your career? It’s important to continue to attend conferences such as NACGF in the future, as these opportunities are key for networking in our field. Also, the constructive criticism received will be very helpful in preparing for future presentations with confidence. What advice would you give a potential applicant for 2018? Don’t be afraid to apply! This was one of the most enjoyable educational experiences I have had the opportunity to participate in.

Education | 59


The ACG VISITING Edgar Achkar PROFESSORSHIP Providing Noteworthy Speakers for Training in Your Communities ACG Institute educational opportunities aim to reach fellows and community physicians with national experts.

CHRISTINA M. SURAWICZ, MD, MACG ACG Past President Dr. Christina Surawicz visited Saint Louis University, on February 2–3, 2017, at the request of Christine Y. Hachem, MD, FACG, and Charlene Prather, MD, MPH. The fellows presented Clostridium difficile infection cases, demonstrating appropriate management of challenging cases, and excellent presentation skills. The case presentations were attended by the infectious disease specialist and included probing questions by the fellows.

Surawicz presented “FMT: Use and Misuse” at the GI Grand Rounds, followed by an evening community roundtable dinner on chronic diarrhea challenging cases, with the GI fellows and private practice docs. A talk for the internal medical grand rounds on difficult Clostridium difficile cases was attended by faculty, including the head of transplant, residents and fellows. One of the visit highlights was interacting with senior, mid-career and junior faculty (in this case all women faculty) at breakfast, and individual meetings. St. Louis also learned of Surawicz's involvement with the ACG, and hopes to continue this tradition of engagement in the life of the College.

“We learned so much about Clostridium difficile infections, role of fecal transplant and chronic diarrhea management. Plus, many of our junior and senior faculty got to meet and talk with Dr. Surawicz, which has already been invaluable in establishing what I am sure will be longlasting relationships.” —Dr. Christine Y. Hachem

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2017 ACG EDGAR ACHKAR VISITING PROFESSORSHIPS The ACG Institute for Clinical Research and Education, and Director Nicholas J. Shaheen MD, MPH, FACG, are pleased to present the selected 2017 ACG Edgar Achkar Visiting Professorships:

FEBRUARY 2–3 CHRISTINA M. SURAWICZ, MD, MACG Saint Louis University, presenting on Clostridium difficile.

60: ACG Past President Dr. Christina Surawicz (1998-1999) presents at Saint Louis University; 61: Dr. Martin Freeman with Dr. Alok Jain; Dr. Freeman (center) and fellows.

APRIL 20–21 CAROL A. BURKE, MD, FACG Houston Methodist Hospital, presenting on colon cancer screening, genetics of colon cancer, and hereditary polyp syndromes.

MARTIN L. FREEMAN, MD, FACG visited MetroHealth Medical Center in Cleveland, OH, on October 18–19. Freeman was requested by GI Fellowship Program Director Alok K. Jain, MD, for his expertise in pancreatobiliary diseases and interventional endoscopy. Freeman provided an evening talk on the evidence-based management of necrotizing pancreatitis, attended by fellows and staff, including one of his former fellows, Brooke Glessing, MD, at Case Western. The next day, grand rounds had the largest audience of the academic year, with attendees from internal medicine, family medicine and surgery. The visit also included one-on-one time with the fellows and a discussion of total pancreatectomy and islet autotransplantation.

“I have to say, of all my years doing visiting professorships and lectures, this Edgar Achkar invited professorship through the ACG at MetroHealth in Cleveland was about the most enjoyable.” —Dr. Martin Freeman

APRIL 25–26 BRIAN E. LACY, MD, PHD, FACG University of Oklahoma, presenting on IBS and motility. APRIL 26 LAUREN B. GERSON, MD, MSC, FACG Advocate Lutheran General Hospital, presenting on diverticular disease, colonoscopy quality, GI bleeding, and refractory GERD. MAY 18–19 PRATEEK SHARMA, MD, FACG NorthShore University Health System, presenting on esophageal disease. MAY 22–23 MARIA T. ABREU, MD, FACG Augusta University Medical College of Georgia, presenting on IBD. JULY 18 DAVID T. RUBIN, MD, FACG The Ohio State University Wexner Medical Center, presenting on IBD. AUGUST 15–16 STEPHEN B. HANAUER, MD, FACG University of Virginia, presenting on IBD. AUGUST 31 AASMA SHAUKAT, MD, MPH, FACG Northwestern University, presenting on colon cancer. SEPTEMBER 11–13 ANDREW Y. WANG, MD, FACG University of Michigan, presenting on endoscopic submucosal dissection. SEPTEMBER 13–14 NICHOLAS J. SHAHEEN, MD, MPH, FACG California Pacific Medical Center, presenting on refractory GERD and complicated GERD patients (ablation). DECEMBER 5–6 MIGUEL D. REGUEIRO, MD, FACG UT Southwestern Medical Center, presenting on IBD.

Education | 61


give Why I r

e to mind. Since e, so many thoughts cam tut sti In G AC the to e giv ed why I nities in the When I was recently ask vided me service opportu pro s ha G AC the o, ag n 30 years the research aspects my fellowship more tha the practical as well as t ou ab rn lea to me for nal haven it provided me the College and a professio lished over 22 years ago, ab est s wa e tut sti In G hen the AC of gastroenterology. W

zation which has been in ni ga or an to ck ba opportunity to give opportunities ch ar se re d an re ca t en ti pa g the forefront of improvin ers. embarking on their care s n ia sic hy p ge ta -s for early

to see first e, I have been fortunate tut sti In G AC the of ard mote public Having served on the bo of ACG Institute to pro ff sta d an ers mb me of the er health hand the commitment on of physicians and oth ati uc ed as ll we as h alt he st make a awareness of digestive mission, I feel that I mu e’s tut sti In the e iev ach to the care providers. In order ve that each member of G Institute. I truly belie AC the to e giv to t en nt, to commitm less of the dollar amou on to give back, regard ati lig ob an s ha ity un GI comm the Institute.

ort n we count on to supp ca o wh n, ow r ou t If we do not suppor l? u sf es cc su be to s u of y an m d we lo al s organization which ha

an

MACG Frank A. Hamilton, MD, MPH, Directors, 2010–2016 ACG Institute Board of & Cultural Diversity tee on Minority Affairs mit Com Past Chair, ACG es Committee Past Chair, ACG Archiv

the ACG Institute. Please WAYS TO GIVE d education mission of an ch ear res the rt po n and sup make a taxJoin Dr. Frank Hamilto MAGAZINE, or you can G AC of ue iss s thi in envelope inserted consider a gift using the gi.org/donate. deductible gift online at

Education is to promote for Clinical Research and te titu Ins y log ovation in ero ent an College of Gastro t clinical research and inn The mission of the Americ t and the public, to suppor ien pat the n, icia clin education of the of digestive disease. digestive health through areness about prevention y, and to raise public aw log ato hep and y log ero gastroent


s i y p o r h t n a l Phi

l a n o s er pL Make a tax-deductible gift today: gi.org/donate


64 | GI.ORG/ACGMAGAZINE


Inside the

JOURNALS In keeping with the clinical mission of the College, ACG MAGAZINE offers a glimpse “Inside the Journals” at recent publications that impact patient care. In The American Journal of Gastroenterology this spring, Dr. Ali Rezaie and colleagues from the United States, Canada and Mexico published a North American consensus document providing guidance on hydrogen and methane-based breath testing in GI disorders. As a tool for clinicians and researchers, Dr. Rezaie and his co-authors aimed to develop a uniform approach to breath testing for small intestinal bacterial overgrowth and carbohydrate maldigestion syndromes, and to identify gaps in knowledge and technology. ACG MAGAZINE invited Rezaie to provide insights and clinical pearls from these evidence-based recommendations on indications, preparation, performance and interpretation of methane and hydrogen-based breath testing. The Editors of Clinical and Translational Gastroenterology (CTG) have developed a noteworthy “Translational Medicine: Bench to Bedside” series, and now all the articles are available in one accessible place online. CTG’s Editors hand-pick experts to summarize and interpret recent basic science with promising clinical implications—experts who stay abreast of the basic science literature, so you don’t have to. All of these articles have been organized on a “Translational Medicine” webpage and, because CTG is an open-access journal, the entire series is free online at nature.com/ctg/transmed.html If you have not yet explored the ACG Case Reports Journal, an open-access, peer-reviewed journal edited by GI fellows-in-training, some recent highlights are featured for your perusal. Visit acgcasereports.gi.org to explore recent cases and consider a submission.

Inside the Journals | 65


BREATH TESTING IN GASTROINTESTINAL DISORDERS Ali Rezaie, MD, MSc, Cedars-Sinai, Los Angeles, CA | @AliRezaieMD

THE NORTH AMERICAN CONSENSUS ON STANDARDIZATION OF BREATH TESTING IN RESEARCH AND CLINICAL PRACTICE Gut microbiota is the sole source of exhaled breath hydrogen and methane gases. Systematic and accurate measurement of these gases can provide invaluable information regarding the microbiome. The number of breath tests performed by health care providers is exponentially increasing; however, these tests are conducted and interpreted with significant inconsistency, which has led to a cumulative ambiguity in clinical practice and research trials.1 The North American consensus was a collaborative work by experts from Canada, Mexico and the United States to provide easyto-follow recommendations on indications, preparation, performance, interpretations of results, and future research directions of breath testing for small intestinal bacterial overgrowth (SIBO) and carbohydrate intolerances. This consensus was developed using an evidence-based approach, and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system was used to assess the quality of evidence.2 Selected key points from the consensus statement are presented in this summary.

66 | GI.ORG/ACGMAGAZINE


PREPARATION OF PATIENTS FOR BREATH TESTING The following recommendations on test preparation are aimed to decrease the false positivity and negativity rates of breath testing: We suggest that patients fast eight to 12 hours prior to breath testing. If tolerated by the patient, we suggest that promotility drugs and laxatives be stopped at least one week prior to breath testing. We suggest avoiding fermentable foods such as complex carbohydrates on the day prior to breath testing.

APPROPRIATE INDICATIONS FOR METHANEAND HYDROGEN-BASED BREATH TESTING While the current small bowel aspiration techniques remain unsatisfactory, small bowel aspiration remains the gold standard to diagnose SIBO with a cut-off of more than 103 colonyforming bacterial units per milliliter present. Lactulose and glucose breath testing can be used to diagnose SIBO as a useful, inexpensive and non-invasive test. We suggest evaluating for excessive methane excretion on the breath test in association with clinical constipation and slowing of gastrointestinal transit. We recommend against the use of breath testing for assessment of orocecal transit time. We suggest breath testing for the diagnosis of carbohydrate maldigestion syndromes such as fructose and lactose intolerance. To decrease the false positivity rate, bacterial overgrowth should be ruled out before performing lactose or fructose breath testing.

Although anti-acids may be associated with increased risk of SIBO, it is not necessary to stop anti-acids prior to breath testing. We recommend avoiding antibiotics for four weeks prior to the breath test. This recommendation does not apply if the breath test is being performed to assess the response to antibiotics.

PERFORMING THE BREATH TEST We suggest that the correct doses of lactulose, glucose, lactose and fructose for breath testing are 10g, 75g, 25g and 25g, respectively. We recommend measuring hydrogen, methane and carbon dioxide simultaneously during breath testing.

INTERPRETATION OF THE RESULTS A rise of ≥20 parts per million (ppm) from baseline in hydrogen levels during the test, which should be at least three hours, should be considered positive for fructose and lactose breath testing. A rise of ≥20 ppm from baseline in hydrogen levels by 90 minutes should be considered a positive test for SIBO. Presence of two peaks on a breath test is not required for the diagnosis. An absolute methane level of ≥10 ppm during the test should be considered positive for excessive methane production.

Photos in this story are courtesy of Dr. Ali Rezaie.

We hope these statements will lead to a uniform approach in breath testing and ultimately the optimization of patient care and research. Access the full consensus and complete set of 26 recommendations3

 Hydrogen and Methane-Based Breath Testing in Gastrointestinal Disorders: The North American Consensus: rdcu.be/qgCh

1 Rezaie A, Pimentel M, Rao SS. How to Test and Treat Small Intestinal Bacterial Overgrowth: an Evidence-Based Approach. Curr Gastroenterol Rep 2016;18:8. 2 Guyatt G, Oxman AD, Akl EA, et al. GRADE guidelines: 1. Introduction-GRADE evidence profiles and summary of findings tables. Journal of clinical epidemiology 2011;64:383-94. 3 Rezaie A, Pimentel M, Cohen E. Autoimmunity as a Potential Cause of Post-Infectious Gut Dysmotility: A Longitudinal Observation. The American journal of gastroenterology 2017;112:656-7.

Inside the Journals | 67


CATCHING YOUR EYE

Matthew A. Chin, MD, 2016–2017 Editor-in-Chief University of California, Irvine, Orange, CA

Images from ACG Case Reports Journal

THE CAPTIVATING CASE REPORTS PUBLISHED IN ACG CASE REPORTS JOURNAL are complemented by telling and revealing images that help readers further appreciate the condition of the subjects described in these case reports. This issue of ACG MAGAZINE features a selection of compelling images recently published in the Journal.

MIDGUT VOLVULUS AFTER PERCUTANEOUS ENDOSCOPIC GASTROSTOMY

PANCREATIC FUNGAL BALL PRESENTING AS PSEUDOMASS Naomi Chou, BS, Rebecca Burbridge, MD, Sarah Karram, MD ACG Case Rep J 2017;4:e55.

 Read the case report: bit.ly/FungalBall

HETEROTROPHIC OSSIFICATION OF INTERCOSTAL MUSCLE FLAP CAUSING REFRACTORY ESOPHAGEAL STRICTURE

Diana Martins, MD, Paula Sousa, MD, Juliana Pinho, MD, Joana Ruivo, MD, Ricardo Araújo, MD, Eugénia Cancela, MD, António Castanheira, MD, Paula Ministro, MD, Américo Silva, MD ACG Case Rep J 2017;4:e59.

 Read the case report: bit.ly/MidgutVolvulus

INTUSSUSCEPTION AFTER ROUTINE COLONOSCOPY: A RARE COMPLICATION

Ali Alali, MBBCh, BAO, Kevin Waschke, MD, CM ACG Case Rep J 2017;4:e50.

Michael X. Min, MD, Bradford Sklow, MD, Byron P. Vaughn, MD ACG Case Rep J 2017;4:e63.

 Read the case report: bit.ly/Heterotrophic

 Read the case report: bit.ly/Intuss

 View more images and all published cases without a subscription: acgcasereports.gi.org 68 | GI.ORG/ACGMAGAZINE


CTG

TRANSLATIONAL MEDICINE: ONLINE JOURNAL BENCH TO BEDSIDE of CASE REPORTS EDITED by GI FELLOWS

IN ADDITION TO CUTTING-EDGE TRANSLATIONAL RESEARCH in gastroenterology and hepatology,

Stem Cell Therapy for Inflammatory Bowel Disease Amy L. Lightner, MD

Clinical and Translational Gastroenterology (CTG)

Harnessing the Power of Posttranscriptional Gene Silencing

AC G

in Crohn’s Disease SE REPORTS CA • Indexed on PubMed Central Maisa Abdalla,and MD, PubMed and Shehzad Z. Sheikh, MD, PhD and clinical practice through the Translational Medicine: JOURN L Bench to Bedside article series. In each installment, a • No submission, publication, or subscription fees

further bridges the gap between basic science research ACGCASEREPORTS.GI.ORG

VOLUME 3 / ISSUE 4

New Pathways, New Targets: Visceral Hypersensitivity Pathogenesis

leading translational researcher summarizes a selection • Cases presented meeting abstracts are welcome in Irritableas Bowel Syndrome of recent basic science articles that have the potential

Kenneth G. Barshop, MD, and Kyle D. Staller, MD, MPH

Case reports, images, and video submissions accepted

to influence clinical medicine in the years to come. “We

Quelling Inflammation with Ketosis and Steric Chemistry • Learn more at acgcasereports.gi.org hope that this column becomes a useful and succinct Michael W. Gleeson, MD, PhD, and Rolland C. Dickson, MD

summary of current discoveries valuable to clinical•

GI fellow, resident interested in GI, or private practice beAssociations lead author Genetic of Obesity: The Fat-Mass and Obesitygastroenterology researchers and practitioners alike,” clinician must says CTG Editor-in-Chief David C. Whitcomb, MD, PhD,

Associated (FTO) Gene Adam C. Ehrlich, MD, MPH, and Frank K. Friedenberg, MD

FACG. Recent summaries highlight use of stem cells in Editor-in-Chief: Matthew Chin, MD | University of California, Irvine inflammatory bowel disease, post-transcriptional gene silencing in Crohn’s disease, visceral hypersensitivity AL of CASE REPORTS edited by An Online JOURN

WS

Y & HEPATOLOGY FELLO OENTEROLOG pathogenesisGASTR in irritable bowel syndrome, genetic Editor-in-Chief: Matthew Chin, MD

associations in obesity, and many more. Read the whole series at nature.com/ctg/transmed

Mechanisms of Fructose Absorption Jessica Noelting, MD, and John K. DiBaise, MD, FACG

SubmitCapturing yourIslet manuscript at Stem Cells for a Bio-Artificial Pancreas

Avin P. Pothuloori, MD, and Sushela S. Chaidarun, MD, PhD mc.manuscriptcentral.com/acgcr

 CTG is a free, fully open-access journal, available to all readers worldwide. Read the journal: nature.com/ctg

WE NEED REVIEWERS!

CTGCME IMPACT FACTOR: CREDIT

AVAILABLE! 3.923

274.3 :ROTCAF TCAPMI TNERRUC

CTG Needs Experienced Reviewers with Basic Science, Genetics, or Translational Expertise to Peer Review Manuscripts! Sign up today by emailing ltopp@gi.org with your areas of interest.

Inside the Journals | 69


M CECUM THE CECU HING THE REACHING REAC

A Look Back

Anatomical Plate This archival reflection originally appeared in The American Journal of Gastroenterology in July 2001.

A

natomy was the first discipline to be useful to physicians in the field of medicine because its accuracy could be verified by careful anatomical dissection. For 1,400 years, the anatomical writings of Galen were never challenged, although they were full of errors because his opinions were based upon dissection of animals. Anatomists were freed from the fetters of Galenism in 1543. Andreas Versalius, age 29, published his masterpiece, De Humani Corporis Fabrici, which has been called by Sir William Osler the greatest medical text ever written. It was a significant contribution to the study of human anatomy and Western civilization. He openly broke with tradition and initiated the beginnings

70 | GI.ORG/ACGMAGAZINE

of modern medical science. Over the ensuing centuries, great strides have been made in anatomy and other medical disciplines, but the renaissance in medicine can be traced to Versalius. This anatomical plate was photographed from an early Italian text on anatomy entitled Compendium Anatomicum, published in Venice in 1764. Original, leatherbound texts such as this one are highly prized by medical historians and bibliophiles, especially when they are illustrated. Note the exquisite anatomical detail of the plate.

By Robert E. Kravetz, MD, MACG Scottsdale, Arizona


IMPORTANT SAFETY INFORMATION SUPREP® Bowel Prep Kit (sodium sulfate, potassium sulfate and magnesium sulfate) Oral Solution is an osmotic laxative indicated for cleansing of the colon as a preparation for colonoscopy in adults. Most common adverse reactions (>2%) are overall discomfort, abdominal distention, abdominal pain, nausea, vomiting and headache. Use is contraindicated in the following conditions: gastrointestinal (GI) obstruction, bowel perforation, toxic colitis and toxic megacolon, gastric retention, ileus, known allergies to components of the kit. Use caution when prescribing for patients with a history of seizures, arrhythmias, impaired gag reflex, regurgitation or aspiration, severe active ulcerative colitis, impaired renal function or patients taking medications that may affect renal function or electrolytes. Use can cause temporary elevations in uric acid. Uric acid fluctuations in patients with gout may precipitate an acute flare. Administration of osmotic laxative products may produce mucosal aphthous ulcerations, and there have been reports of more serious cases of ischemic colitis requiring hospitalization. Patients with impaired water handling who experience severe vomiting should be closely monitored including measurement of electrolytes. Advise all patients to hydrate adequately before, during, and after use. Each bottle must be diluted with water to a final volume of 16 ounces and ingestion of additional water as recommended is important to patient tolerance.

BRIEF SUMMARY: Before prescribing, please see full Prescribing Information and Medication Guide for SUPREP® Bowel Prep Kit (sodium sulfate, potassium sulfate and magnesium sulfate) Oral Solution. INDICATIONS AND USAGE: An osmotic laxative indicated for cleansing of the colon as a preparation for colonoscopy in adults. CONTRAINDICATIONS: Use is contraindicated in the following conditions: gastrointestinal (GI) obstruction, bowel perforation, toxic colitis and toxic megacolon, gastric retention, ileus, known allergies to components of the kit. WARNINGS AND PRECAUTIONS: SUPREP Bowel Prep Kit is an osmotic laxative indicated for cleansing of the colon as a preparation for colonoscopy in adults. Use is contraindicated in the following conditions: gastrointestinal (GI) obstruction, bowel perforation, toxic colitis and toxic megacolon, gastric retention, ileus, known allergies to components of the kit. Use caution when prescribing for patients with a history of seizures, arrhythmias, impaired gag reflex, regurgitation or aspiration, severe active ulcerative colitis, impaired renal function or patients taking medications that may affect renal function or electrolytes. Pre-dose and post-colonoscopy ECG’s should be considered in patients at increased risk of serious cardiac arrhythmias. Use can cause temporary elevations in uric acid. Uric acid fluctuations in patients with gout may precipitate an acute flare. Administration of osmotic laxative products may produce mucosal aphthous ulcerations, and there have been reports of more serious cases of ischemic colitis requiring hospitalization. Patients with impaired water handling who experience severe vomiting should be closely monitored including measurement of electrolytes. Advise all patients to hydrate adequately before, during, and after use. Each bottle must be diluted with water to a final volume of 16 ounces and ingestion of additional water as recommended is important to patient tolerance. Pregnancy: Pregnancy Category C. Animal reproduction studies have not been conducted. It is not known whether this product can cause fetal harm or can affect reproductive capacity. Pediatric Use: Safety and effectiveness in pediatric patients has not been established. Geriatric Use: Of the 375 patients who took SUPREP Bowel Prep Kit in clinical trials, 94 (25%) were 65 years of age or older, while 25 (7%) were 75 years of age or older. No overall differences in safety or effectiveness of SUPREP Bowel Prep Kit administered as a split-dose (2-day) regimen were observed between geriatric patients and younger patients. DRUG INTERACTIONS: Oral medication administered within one hour of the start of administration of SUPREP may not be absorbed completely. ADVERSE REACTIONS: Most common adverse reactions (>2%) are overall discomfort, abdominal distention, abdominal pain, nausea, vomiting and headache. Oral Administration: Split-Dose (Two-Day) Regimen: Early in the evening prior to the colonoscopy: Pour the contents of one bottle of SUPREP Bowel Prep Kit into the mixing container provided. Fill the container with water to the 16 ounce fill line, and drink the entire amount. Drink two additional containers filled to the 16 ounce line with water over the next hour. Consume only a light breakfast or have only clear liquids on the day before colonoscopy. Day of Colonoscopy (10 to 12 hours after the evening dose): Pour the contents of the second SUPREP Bowel Prep Kit into the mixing container provided. Fill the container with water to the 16 ounce fill line, and drink the entire amount. Drink two additional containers filled to the 16 ounce line with water over the next hour. Complete all SUPREP Bowel Prep Kit and required water at least two hours prior to colonoscopy. Consume only clear liquids until after the colonoscopy. STORAGE: Store at 20°-25°C (68°-77°F). Excursions permitted between 15°-30°C (59°-86°F). Rx only. Distributed by Braintree Laboratories, Inc. Braintree, MA 02185

For additional information, please call 1-800-874-6756 or visit www.suprepkit.com

©2017 Braintree Laboratories, Inc.

HH13276B

March 2017


1 MOST PRESCRIBED,

#

BRANDED BOWEL PREP KIT1

A CLEAN SWEEP

EFFECTIVE RESULTS IN ALL COLON SEGMENTS2

· SUPREP® Bowel Prep Kit has been FDA-approved as a split-dose oral regimen3 · >90% of patients had no residual stool in all colon segments2*

These cleansing results for the cecum included 91% of patients2*

SUPREP Bowel Prep Kit also achieved ≥64% no residual fluid in 4 out of 5 colon segments (ascending, transverse, descending, and sigmoid/rectum)2* †

Help meet the Gastrointestinal Quality Improvement Consortium (GIQuIC) benchmark for ≥85% quality cleansing with the split-dose efficacy of SUPREP Bowel Prep Kit.3,4

*This clinical trial was not included in the product labeling. †Based on investigator grading. References: 1. IMS Health, NPA Weekly, March 2017. 2. Rex DK, DiPalma JA, Rodriguez R, McGowan J, Cleveland M. A randomized clinical study comparing reduced-volume oral sulfate solution with standard 4-liter sulfate-free electrolyte lavage solution as preparation for colonoscopy. Gastrointest Endosc. 2010;72(2):328-336. 3. SUPREP Bowel Prep Kit [package insert]. Braintree, MA: Braintree Laboratories, Inc; 2012. 4. Rex DK, Schoenfeld PS, Cohen J, et al. Quality indicators for colonoscopy. Gastrointest Endosc. 2015;81(1):31-53.

©2017 Braintree Laboratories, Inc.

HH13276B

March 2017


ACG MAGAZINE ARCHIVE 2017 Volume 1, Number 1

ACG MAGAZINE Members. Medicine. Meaning.

Striking

Gold gi.org/acgmagazine

Vol. 1 No. 1 // Spring 2017


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