ACG MAGAZINE | Vol. 1, No. 3 | Fall 2017

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ACG MAGAZINE Fall 2017

MEMBERS. MEDICINE. MEANING.


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 sports 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.

Register Now!

GI.ORG/BEST-PRACTICES


FALL 2017 // Volume 1, Number 3

FEATURED CONTENTS COVERSTORY STORY COVER

GASTROENTEROLOGY & GASTRONOMY

Dr. Prem Chattoo is Owner, GI Practice, and Co-Owner, NYC Restaurant Page 20

CONVERSATIONS WITH WOMEN IN GI

Dr. Jill Gaidos interviews Dr. Aasma Shaukat Page 32

LAW MIND: THE INCREDIBLE SHRINKING PAYCHECK Ann Bittinger, JD

Photo courtesy of Dr. Prem Chattoo.

Page 15

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APPLY

for an ACG Clinical

Research Award

Deadline: Friday, December 8, 2017

ACG Junior Faculty Development Award $100,000 a year for three years Clinical Research Awards up to $50,000 for clinical research; up to $15,000 for pilot projects “Smaller Programs” Clinical Research Awards up to $35,000 for programs with 15 or fewer full-time faculty

Learn more about ACG 2018 Clinical Research Opportunities and Submit Your Application:

GI.ORG/GRANT-ANNOUNCEMENTS


FALL 2017 // Volume 1, Number 3

CONTENTS “I have a love for gastroenterology, and I have a love for gastronomy, I suppose.” —Dr. Chattoo, "Gastroenterology & Gastronomy" PG 20

6 // MESSAGE FROM THE PRESIDENT

20 // COVER STORY

41 // INSIDE THE JOURNALS

Dr. Carol Burke reflects on her year as ACG President.

GASTROENTEROLOGY & GASTRONOMY Dr. Prem Chattoo is Owner, GI Practice, and Co-Owner, NYC Restaurant.

42 AJG AUTHOR INSIGHTS Dyspepsia guideline, physician and patient voices on fecal incontinence.

In Memoriam: Dr. Marvin Schuster, Dr. Darrell Gray earns 40 Under 40 Leaders in Health award, and more.

29 // ACG PERSPECTIVES

44 ACGCRJ UPDATES Editor-in-Chief Dr. Parth Parekh on what lies ahead; new editorial board.

13 // PUBLIC POLICY

32 CONVERSATIONS WITH WOMEN IN GI Dr. Jill Gaidos interviews Dr. Aasma Shaukat.

7 // NOVEL & NOTEWORTHY

GOVERNORS' VANTAGE POINT Navigating insurance denials.

15 // GETTING IT RIGHT

29 REMEMBERING DR. LAUREN GERSON The College remembers ACG Trustee Lauren Battat Gerson, MD, MSc, FACG.

35 JUNIOR FACULTY AWARDEES Recipients share their career interests.

15 LAW MIND MACRA and the link between accountability and physician compensation.

36 TRAINING IN TOKYO ACG North American International Training Grant recipient Dr. Gene Ma on learning ESD in Tokyo.

18 HELP! ... I’M ON YELP! Dr. William Palmer has four tips for the era of online patient reviews.

37 // EDUCATION

19 MENTORSHIP Dr. Manish Singla on steps to achieve a successful mentor-mentee relationship.

45 CTG PRIMERS New column: Primers in Clinical and Translational Research.

46 // REACHING THE CECUM A LOOK BACK: SCHINDLER’S GASTROSCOPY MODEL Schindler’s original ceramic model that was made in the 1930s. Cover photo and photo top courtesy of Dr. Prem Chattoo.

EDGAR ACHKAR VISITING PROFESSORS Taking ACG's commitment to GI training on the road.

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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

CONNECT WITH ACG youtube.com/ACGastroenterology

facebook.com/AmCollegeGastro

twitter.com/amcollegegastro

instagram.com/amcollegegastro Copy Editors; Staff Writers Jenny Dunnington, Sarah Richman, Martha Spath, Lindsey Topp

bit.ly/ACG-Linked-In

Art Director 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 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).

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.

Robert E. Kravetz, MD, MACG 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

William C. Palmer, MD Dr. Palmer is Assistant Professor of Medicine, Division of Gastroenterology and Hepatology, Mayo Clinic, Florida. He is a member of the ACG Training Committee.

Parth J. Parekh, MD Dr. Parekh, Carilion Clinic, Roanoke, VA, is the Editor-in-Chief of the ACG Case Reports Journal.

Manish B. Singla, MD Dr. Singla works at Walter Reed National Military Medical Center in Bethesda, MD. He is a member of the ACG Training Committee.

Douglas C. Wolf, MD, FACG Dr. Wolf, Atlanta Gastroenterology Associates, Atlanta, GA, is the ACG Governor for Georgia.

Gene K. Ma, MD Dr. Ma, University of Pennsylvania, Philadelphia, PA, is the 2016 North American International Training Grant recipient.

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MESSAGE FROM THE PRESIDEN

SADLY, MY YEAR AS ACG PRESIDENT IS QUICKLY COMING TO A CLOSE.

It seems as if just yesterday Kenneth R. DeVault, MD, FACG, transitioned the temporary custody of the College to me. The reality is that over the last 85 years, the College continues a strong course under the caring stewardship of the Board of Trustees, the wise guidance of Brad Stillman, JD, the Executive Director and the lean, capable, professional and brilliant ACG staff. As I reminisce about my year at the helm of the College, I recognize that I have developed a deeper appreciation of the organization which has meant so much to me since 1993 when I became a trainee member. The ACG is truly a “College”—not merely a place of bricks and mortar, but a vibrant community of people all committed to creating opportunities and activities to meet the needs of its members and fostering life-long friendships. With sadness, I note we recently lost our friend, colleague and member of the ACG Board of Trustees, Lauren B. Gerson, MD, MSc, FACG. Lauren was an exceptional researcher, author and human being. We will miss her greatly. Some of the greatest highlights of my year include the engagement with trainees and young faculty as I traveled the country. The College has created a myriad of superb programs for trainees. One that I participated in this past spring was the Edgar Achkar Visiting Professorship Program. GI training programs can apply to this program to have a well-known national expert visit their institution to spend time with their fellows, educate colleagues and visit with young faculty for mentoring at no cost.

6 | GI.ORG/ACGMAGAZINE

 Bincy P. Abraham, MD, FACG, ACG President Carol A. Burke, MD, FACG, and ACG Past President Eamonn M. M. Quigley (2008-2009).

Bincy P. Abraham MD, FACG, GI Fellowship Program Director and long-time good friend, Eamonn M.M. Quigley MD, MACG, Chair of Gastroenterology at the Houston Methodist Hospital, invited me to meet their fellows and faculty as the Edgar Achkar Visiting Professor. I participated in conferences, gave a lecture at an evening GUT club, and spent private time with the GI fellows—both young and more-established staff to discuss career options, work-life balance, academic success and opportunities to engage in the ACG. I was honored to participate in the program because Edgar Achkar MD, MACG, has long been a mentor, coach, colleague and friend of mine. He was raison d’être I became involved in the ACG as a trainee member. Therefore, the opportunity for me to give back to other young faculty and trainees as Edgar did for me was most fulfilling. Another highly sought after program for trainees is the North American Conference of GI Fellows. I was invited by Co-Directors Sunanda “Susie” V. Kane, MD, FACG, Philip O. Katz, MD, FACG, and David J. Hass, MD, FACG, to participate this spring in Orlando, FL. It is an opportunity for fellows to present their clinical research in a forum simulating a presentation at a national meeting, and network with other trainees throughout the country while interacting with senior faculty in a busy but fun filled weekend. Universally, trainees expressed their gratitude for the opportunity to participate in the program and said it was wonderful, effective and enjoyable. These are only two of many activities the College offers to trainees. The Education Universe, face-to-face live education offerings including our regional meetings, postgraduate course and Annual Scientific Meeting, and hands-on courses not only disseminate high-quality education, but also provide the professional networking opportunity for trainees and other ACG members. In addition to education, clinical research is another pillar of the mission of the College and is a large boost for the academic success of trainees and young faculty. It is a great source of pride that the College spent over $1.3 million this past year on funding clinical research. You can read about recent increases in the award limits and funding to talented young investigators on page 35. I believe if our profession is to succeed, the College must continue in its unwavering support and provision of resources to the next generation of gastroenterologists. I am looking forward to seeing you all at the World Congress of Gastroenterology at ACG2017, a one-of-a-kind meeting which has not been held in the United States in more than 20 years. Sixty international faculty representing 26 countries will be present. I anticipate we will gain a new perspective and understanding of worldwide digestive health disorders, be able to reunite with old friends, proudly represent the ACG to international visitors, and highlight the benefits of membership to our world community. Ciao,

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


N&N

Darrell M. Gray, II, MD, MPH, and U.S. Representative Joyce Beatty (D-OH) pose with Dr. Gray’s National Minority Quality Forum 40 Under 40 Leaders in Health award at the April 25, 2017, Awards Dinner. Photo courtesy of Dr. Gray.

Marvin M. Schuster, MD, MACG, testifies at the U.S. House of Representatives Committee on Ways & Means in 1997. U.S. Rep. Steny Hoyer (D-MD) with Dr. Schuster on Capitol Hill. U.S. Rep. Ben Cardin (D-MD) with Dr. Schuster and Tom Scully, ACG’s legislative counsel in Washington.

[HONORED]

DARRELL M. GRAY, II, MD, MPH The National Minority Quality Forum (NMQF) recognized Dr. Gray as one of its 2017 “40 Under 40 Leaders in Health” awards winners. The awards, which honor “influential young minority leaders making a difference in health care,” feature leaders across the health care spectrum. The award commends Gray’s civic endeavors in the Columbus, OH area, including the Provider and Community Engagement (PACE) Program, which “provided low-to-no cost colonoscopies and patient navigation services for uninsured and underinsured patients, novel educational experiences for community members and health care providers, and a local media campaign on colorectal cancer prevention.” Awardees were recognized at the 2017 NMQF Leadership Summit and CBC Spring Health Braintrust. The 2016 ACG SCOPY Award, “Best Initiative to Address Health Care Disparities,” was given to Gray for the PACE Program and an annual Cancer Disparities Conference.  READ the full Gray entry on the NMQF website: bit.ly/Gray-40-U-40, and view the full list of 2017 Awardees: bit.ly/40-U-40-List

[RECORD]

ABSTRACT SUBMISSIONS SET NEW RECORD FOR WCOG AT ACG2017 More than 3,000 abstracts were submitted for the World Congress of Gastroenterology at ACG2017 (WCOG at ACG2017), setting a new record. Researchers from nearly 50 countries submitted their research for oral and poster presentation. In late June, Chairs of the Abstract Review Committee met and selected those to be presented, and all oral and poster presentations are listed in the WCOG at ACG2017 Preliminary Program. Members may also search the abstracts via the

8 | GI.ORG/ACGMAGAZINE


[INNOVATION] [NECROLOGY]

IN MEMORIAM: MARVIN M. SCHUSTER, MD, MACG

The College lost a great friend with the death of Marvin M. Schuster, MD, MACG, of Baltimore, MD, at age 87 in May 2017. Dr. Schuster served with distinction as ACG President from 1996-1997. During his years in ACG leadership preceding his presidency, the College’s legislative priorities focused on passage of a colorectal cancer screening preventive benefit under Medicare. This goal was realized in 1997. Thanks to Schuster’s deep knowledge of the issues and tireless networking, ACG established a key relationship with legislators, including U.S. Rep. Steny Hoyer (D-MD) and Ben Cardin, a Democratic Member of Congress from Baltimore. Mr. Cardin, who currently serves as U.S. Senator for Maryland, has in the intervening decades been a great friend to ACG and a stalwart champion for public health issues in general, and CRC screening in particular. Schuster was Professor of Medicine at the Johns Hopkins University School of Medicine, the former Director of the Division of Gastroenterology at Johns Hopkins Bayview Medical Center, and the Founding Director of the Marvin M. Schuster Center for Digestive and Motility Disorders at Johns Hopkins Bayview. Schuster is survived by his wife, Dr. Lois Bernstein Schuster, their three daughters, and seven grandchildren.  READ Dr. Schuster's obituary in The Baltimore Sun: bit.ly/Schuster-Obit

Ergonomic Endoscopy Workstation A new ergonomic endoscopy workstation was invented by Dr. Jesse Lachter at Rambam Health Care Campus of the Technion Faculty of Medicine in Israel. Backed by provisional patents, it is in its third prototype phase. This device moves the strain of holding up the endoscope handle from the left hand/wrist/elbow/arm, and distributes the effort onto the shoulders equally, making for a more symmetric stance. The large core muscles are able to take over from the small peripheral muscles which endoscopists use and often over-use. Design features include: • Full maneuverability of the scope while in the harness—with tilt, pitch, yaw and wide range of left/right motions • Comfortable vest with spinal support • Peripheral straps comfortable for male and female chest physiques • Easy cleaning in current endoscope reprocessors • Adjustable for all size bellies, high enough to maintain ideal elbow positions

WCOG at ACG2017 Itinerary Planner. ACG and the World Gastroenterology Organisation thank those who submitted an abstract and congratulate those who are presenting at the WCOG at ACG2017. Attending the WCOG at ACG2017? Pick up your copy of the WCOG at ACG2017 Abstracts on DVD at the Shire booth, #629. The DVD includes a searchable database of the abstracts, as well as a passcode to search

• Smooth, non-threatening design for when patients observe device • Sturdy construction, built to last  FOR MORE INFORMATION, write to

Dr. Lachter: lachter@gmail.com.

online, for those who do not have a DVD drive.

Novel & Noteworthy | 9


ACG CALENDA

ACG/VGS/ODSGNA REGIONAL POSTGRADUATE COURSE

SEPTEMBER

This Williamsburg, VA course offers the latest clinical updates, Breakout Sessions and Hands-on Sessions.

9–10

OCTOBER 2 MACRA DEADLINE LAST DAY to begin submitting 90 continuous days of 2017 data

More info: meetings.gi.org

OCTOBER

OCTOBER

HANDS-ON ENDOSCOPY WORKSHOP CENTER SESSIONS AT WCOG AT ACG2017

15–17

Participate in one of more than 40 Hands-on Endoscopy Workshop Sessions being offered this year.

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

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

13–18 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

NOVEMBER

9–11

DECEMBER

1

ADVANCES IN INFLAMMATORY BOWEL DISEASES (AIBD)

IBD SCHOOL AT SOUTHERN REGIONAL

Walt Disney World Dolphin Hotel, Orlando, FL Gain practice-changing IBD knowledge, which can be implemented immediately at this ACG-endorsed course organized by Imedex.

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.

More info: meetings.gi.org

More info: meetings.gi.org

DECEMBER

2–3

ACG SOUTHERN REGIONAL POSTGRADUATE COURSE Experts will explore dysphagia, EoE, hepatitis C, obesity, IBD, lower functional GI disorders, practice management, and more, in Nashville, TN. More info: meetings.gi.org

DECEMBER 8

DECEMBER 31

2018 ACG INSTITUTE RESEARCH GRANT APPLICATIONS DEADLINE

Final day to earn MOC for 2017

MOC DEADLINE

DECEMBER 31 MACRA DEADLINE

JANUARY 26, 2018 JANUARY 27-28, 2018

10 | GI.ORG/ACGMAGAZINE

IBD SCHOOL AT BEST PRACTICES

Final day for 2017 data

Course Directors Dr. Sunanda V. Kane and Dr. David T. Rubin offer a one-day immersion in IBD management in Las Vegas, NV, at Caesars Palace.

ACG BOG/ASGE BEST PRACTICES COURSE Gain insight from the experts and learn about the latest clinical updates when you attend the Best Practices Course. Register: meetings.gi.org

MARCH 31, 2018 MIPS DEADLINE LAST DAY to submit CY 2017 data


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

MY APPROACH INSURANCE DENIALS OF MEDICATIONS AND TESTS IN INFLAMMATORY BOWEL DISEASE

By Douglas C. Wolf, MD, FACG, Atlanta Gastroenterology Associates, Atlanta, GA ACG Governor for Georgia

PATIENTS WITH CROHN’S DISEASE AND ULCERATIVE COLITIS, the inflammatory bowel diseases (IBD), are increasingly confronted by insurance denials, high co-pays and excessive costs. This pertains primarily to diagnostic tests and medications and makes it difficult for a large number of patients to receive quality care.

LABORATORY TESTS Denials or significant co-pays are uncommon with standard laboratory tests, but have become increasingly common with specialized tests such as the blood measurement of the enzyme activity of thiopurine methyltransferase (TPMT), which must be checked before using azathioprine or 6-mercaptopurine (6-MP). Measurement of thiopurine levels may be covered or may cost $200 to $300, depending on the insurance plan. With personalized medicine in IBD, which is both state of the art and an evolving standard of care, tests for therapeutic blood levels of medications, especially antiTNFs and other biologics, are typically denied or have co-pays ranging from $75 to $2,500. Tests to measure inflammatory biomarkers in the stool, 

Public Policy | 13


PUBLIC POLICY: GOVERNORS' VANTAGE POINT such as calprotectin or lactoferrin, are useful in the evaluation of IBD and uniquely helpful to assess disease states such as clinical response, clinical remission, and deep remission. There are often regional geographic differences in coverage for these tests with no logical explanation. Regarding a TPMT level, I tell the insurer, usually after the patient receives a $300 bill, that this test is mandatory before the use of azathioprine or 6-MP because a patient who is homozygous recessive for this enzyme could die if they receive either of these two medications. Regarding a calprotectin or lactoferrin, I tell them that other insurers cover the test, that it gives less exact but supplemental and alternative information to a colonoscopy, and that one can monitor IBD disease activity and better adjust medications with the stool test results.

SHARED DECISION-MAKING CHALLENGED BY COVERAGE ISSUES Medication denials or excessive co-pays have escalated in recent years. Some of these are for pills and many are for biologics. The practice of shared decision-making, where patients and physicians have dialogue and come to a conclusion, then jointly select the most suitable therapy, is challenged by coverage issues. It is unfortunate when doctor and patient come to the conclusion that Brand A will be the most suitable option, when Brand B is the only agent covered by the plan. At times, if there is good rationale for the choice, the insurer will accept the alternative.

COVERAGE CHALLENGES IN IBD Repeatedly, insurers are denying or substituting enteric release budesonide for colonic release/budesonide MMX®, Uceris®. Enteric release targets the ileum and right colon and is FDA approved for Crohn’s disease, not ulcerative colitis. It comes as three 3mg capsules per day. Budesonide MMX® targets the entire colon, is FDA-approved for ulcerative colitis, not Crohn’s disease, and is a single 9 mg tablet each day. I tell insurers or pharmacy benefit managers that they cannot substitute one for another. Typically, they try substituting enteric release for MMX® (likely because it is cheaper, although at times this may be inadvertent.) Recently, I have had many Canasa® denials or high copays that have required challenges. I add that this is a unique formulation and no one is abusing it. For biologic dose escalation denials, I cite the literature, may use our specialty pharmacy to assist, and reference any therapeutic drug monitoring (TDM) levels.

NAVIGATING COVERAGE OF ANTI-TNFS The biggest challenge with drug denials is with the antiTNFs, where one agent is requested and it is denied, but an alternate is allowed. Some patients prefer subcutaneous dosing: adalimumab (Humira®), certolizumab pegol (Cimzia®), golimumab (Simponi®), or ustekinumab (Stelara®) [one IV dose to start] over intravenous dosing: infliximab (Remicade®) or vedolizumab (Entyvio®), and vice versa. A patient’s intravenous access or fear of needles, as well as many other relevant factors, need to be considered. Recently, I have seen patients who have exclusion of all biologics in their insurance policies.

14 | GI.ORG/ACGMAGAZINE

We increasingly use shared decision-making to determine the best testing and treatment strategies for our patients. Many denials impact quality of care, whether an IBD patient or other patient. We should maintain our convictions and appeal

these denials.

Biosimilars to infliximab and adalimumab have received FDA approval in the past year. There has been some rare reported use of the biosimilar to infliximab. At times, patients have been switched from the brand Remicade® to the biosimilar without physician or patient knowledge, even though interchangeability of these agents has not been approved by the FDA. Such switching is a form of unauthorized substitution and should be prevented. When denials occur, I speak with a medical director. I have my medical assistant call them and if he/she is not available, my cell number is left for a return call. For some insurers, they refuse to speak by phone. In these cases, one needs to dictate a letter challenging the denial. Sound rationale can change the decision in the majority of cases. We increasingly use shared decision-making to determine the best testing and treatment strategies for our patients. Many denials impact quality of care, whether an IBD patient or other patient. We should maintain our convictions and appeal these denials.  HERE are several examples of appeal letters: bit.ly/Sample-Dose-Esc-Letter


GETTING GETTING IT IT

LAW MIND

THE INCREDIBLE SHRINKING PAYCHECK: MACRA AND THE LINK BETWEEN ACCOUNTABILITY AND PHYSICIAN COMPENSATION

By Ann M. Bittinger, JD 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

THE MEDICARE ACCESS AND CHIP REAUTHORIZATION ACT (MACRA) IS THE MOST IMPORTANT HEALTH LAW concerning gastroenterologists at this time. It’s bigger than any legislation aimed at repealing and replacing the Affordable Care Act. MACRA will affect your wallet more directly than current health care reform legislation could. The impact on your paycheck because of MACRA, however, may emerge not from Washington but rather from your own employment agreement. 

Getting it Right | 15


GETTING IT RIGHT: LAW MIND

PICK YOUR PACE IN MIPS:

If you choose the MIPS track of the Quality Payment Program, you have three options.

–%

0

+%

+%

DON’T PARTICIPATE

SUBMIT SOMETHING

SUBMIT PARTIAL YEAR

SUBMIT FULL YEAR

Negative 4% payment adjustment.

Avoid a downward payment adjustment.

Neutral or positive payment adjustment.

Moderate positive payment adjustment.

Source: qpp.cms.gov/docs/Quality_Payment_Program_Overview_Fact_Sheet.pdf

BACKGROUND

MACRA is the law that did away with the Sustainable Growth Rate (SGR) that required Congress to vote each year on whether to override automatic cuts in the Medicare physician fee schedule. It replaced the SGR with a series of quality and performance requirements that physicians must report to the federal government or their Medicare reimbursement will be subject to automatic percentage-based reductions each year. There are two routes to MACRA compliance: the MeritBased Incentive Payment Systems (MIPS) and the Alternative Payment Models. Most physicians will work through the MIPS option, which requires physicians or physician groups to track performance and quality and report it to the Centers for Medicare and Medicaid Services (CMS). A physician is not removed from Medicare for failure to participate in MACRA; Medicare just lowers physicians’ Medicare reimbursement by a few percentages off of the physician fee schedule. MACRA reporting is already in effect. If you are not already tracking data for MACRA reporting, you are in trouble. The start date that physicians may select ranges from January 1 to October 1, 2017. All data must be submitted by March 31, 2018, for the 2017 reporting year. The first reductions to physicians’ Medicare reimbursement, essentially starting at 4% for the first year, go into effect January 1, 2019.

ACG has resources available to help guide you.

EFFECT ON YOUR PURSE

If you don’t meet MACRA requirements, your employer’s collections for the treatments you perform on Medicare patients will decrease, so long as all other factors stay the same. This may directly or indirectly impact physicians’ take-home pay. The most obvious compensation structure impacted by MACRA is the revenue-minus-collections model. If a physician is paid a salary based on collections attributable to the physician’s work minus expenses attributed to him plus a share of group expenses, and if a MACRA-induced cut in the reimbursement from Medicare decreases the physician’s overall collections, the physician’s paycheck amount will decrease in 2019, without any amendment to the employment agreement or any other action by the entity, physician or the government. The paycheck will, inevitably, decrease.

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Similarly, many groups pay bonuses or dividends to physician owners based on profits. If collections from Medicare decrease, profits likely decrease. The dividend check amounts will shrink. Employment agreement compensation terms that pay a fixed base salary or that include a work relative value unit (wRVU) component – and, as such, have no collections or profits variable – may seem safe but may not be. The agreement could contain hidden language that allows the employer to modify the agreement unilaterally in the event of Medicare compensation changes. If it does not, physicians with a fixed base salary or wRVU component may be asked to sign an amendment to their employment agreement to adjust for MACRA non-compliance. The employers, after all, will have less funds from which to pay physicians if the physician is subject to a MACRAinduced cut in 2019. In other words, employers may give a physician an amendment to the physician’s employment agreement that allows the group to automatically lower the physician’s compensation by an amount representing the impact to the practice. It may be prudent for groups to identify their percentage of Medicare revenue and to amend employment agreements to allow the group to address the compensation of a physician who fails to meet MACRA requirements. The amendment would say that if the physician is hit with a decrease, then the physician’s pay would be decreased by a percentage representing the decrease under MACRA times the practice’s percentage of collections from Medicare. If the physician does not sign the amendment, the physician may receive notice of termination of the employment agreement.

MACRA IS COMPLICATED

That is the simple part. MACRA allows reporting individually by a physician or by all physicians in a group. How a group chooses to report may impact each physician’s compensation. If a group fails to meet MACRA requirements, every physician in the group receives decreases in reimbursement from Medicare. Groups may want to add provisions to their physician employment agreements to encourage or mandate MACRA reporting initiative participation.


Participation itself may be more important than the results reported. For example, a group that takes Medicare reimbursement amounts seriously may consider amending agreements to make failure to participate in MACRA reporting initiatives result in termination of employment or other sanction (like decreased pay), particularly if the group is reporting as a group and one physician’s failure to participate could negatively impact all group members. Another complicating factor is that health care is experiencing an age of consolidation. Groups are changing. If a physician reports as a group now, will the same group be in existence in three years? What if the other parties to the successor group did not meet MACRA requirements? Will you be punished for that? What if one physician complies but the physician’s colleagues do not, and the group chose to report as a group? Each physician would be punished for colleagues’ failure to report. Second, what do you report, and when do you report it? If you fail to report anything, your reimbursement amount from Medicare will automatically decrease by 4% in 2019, and by more in later years. It is important to act now. There is a simple way to report that I call the “uno approach” in the MIPS system: report one measure in the Quality Performance Category, one activity in the Improvement Activities Performance Category, or the required measures of the Advancing Care Information Performance Category, and your Medicare payments will remain the same for 2019—no decrease or increase based on MACRA. If you do this, then at least the status quo Medicare physician fee schedule remains. Be mindful of what activities you choose to report, so as to maximize your opportunities for success. Some activities are easier to track and report for some specialists or for certain practice sizes better than others. Another issue to be mindful of is how the group or individual will “receive” the increase. Recall the Physician Quality Reporting System and Meaningful Use payments. There was much confusion as to who— the group or the physician—receives the payment from the government. With MACRA payments being built in to Medicare reimbursement, it should not be as much of a concern as with the other programs, but it may be prudent to address it in an employment agreement term.

THE INCREDIBLE GROWING PAYCHECK

Physicians are able, indirectly through MACRA, to grow their paychecks based on MACRA-induced increases to Medicare reimbursement. Just as MACRA can decrease compensation under compensation structures described above, it can increase compensation. While the law calls for corresponding increases in reimbursement, if few providers are receiving cuts, opportunities for a real bonus may not be available due to the government having limited

ACG MACRA RESOURCES

MAKING $ENSE OF MACRA: Detailed overview of MACRA: gi.org/macra

WEBINAR: Webinar on the MIPS program held by ACG and the Centers for Medicare and Medicaid Services: gi.org/cms-webinar

QUALITY REPORTING CHECKLIST: A list of each measure in the MIPS Quality, Advancing Care, and Improvement Activities categories: bit.ly/Quality-Checklist

MACRA TIDBIT FOR THE WEEK: A comprehensive list of MACRA tidbits: gi.org/national-affairs

funds to pay providers. If many physicians qualify for increases and few for cuts, it will be interesting to see where the increases come from. Exceptional participation bonuses are also available, but the bar may be set so low that the overall $500 million for exceptional participation may run out or leave for only sparse payments. There are options for MACRA participation levels. With full participation, physicians will receive an increase in 2019. Physicians that the government deems “exceptional performers” can qualify for additional increases. According to CMS, “The best way to earn the largest positive adjustment is to participate fully in the program by submitting information in all the MIPS performance categories. Positive adjustments are based on the performance data on the performance information submitted, not the amount of information or length of time submitted.” There is also an option to “test the system,” if you want to prevent a decrease but do not quite have your MACRA ducks in a row. By reporting minimal data in 2017, such as one quality measure or one improvement activity, physicians can avoid any decrease but not receive an increase.

IMPETUS TO INTEGRATE

Historically, greater government regulation of health care leads to greater consolidation in the medical group industry. Burdened by regulatory burdens and costs, many physicians decide that they can no longer survive as small practices and must integrate. MACRA may be another sign of the consolidation times. On an individual level, physicians may feel that overhead in their smaller groups is so high that it makes sense for them to move to a bigger group. Employment agreement provisions that encourage physicians to stay with their group, or that prevent departure, such as non-competes and tail insurance purchase requirements, may be ripe for review and consideration in light of MACRA. There are efforts to assist small practices with MACRA participation, in order to help practices avoid the need to resort to consolidation, however this may not be sufficient to curb consolidation.

Getting it Right | 17


GETTING IT RIGHT: YOUR PRACTICE As a subspecialty trainee, you may be faced with online patient reviews. CONSIDER THESE TIPS:

KEEP OPEN COMMUNICATION

The biggest pitfall for physicians leading to poor patient satisfaction is ineffective communication. Do your best to spend time with your patients during initial visits and in subsequent encounters, developing a rapport and fostering trust. Follow up with your patients via phone while the treatment plan is implemented and be open to hearing their concerns. Patients are much more likely to respond favorably if they feel you are invested in their care.

HELP! ... I'M ON YELP!

ENCOURAGE SECOND OPINIONS

MANAGING ONLINE PATIENT REVIEWS By William Palmer, MD, Mayo Clinic, Jacksonville, FL

THE ERA OF ONLINE PATIENT REVIEWS HAS ARRIVED. A shift toward value-based care for outcomes and reimbursement has placed an increased emphasis on patient satisfaction, and has opened the floodgates for online reviews of physicians. Physicians are faced with answering for online evaluations submitted to sites such as Vitals, RateMDs, Doximity and Healthgrades. Institutional pressures may be present for physicians to be graded well due to the importance placed on U.S. News and World Report rankings. Doximity is closely tied to the U.S. News rankings; the two have significant financial and corporate ties. Despite the growth of several online rating websites, Yelp has emerged as a titan of physician reviews. Yelp currently holds more than 100 million reviews of everything from restaurants to auto mechanics, with 6% of those falling in the health care category. A study published in Health Affairs in 2016 used natural language processing to evaluate 17,000 Yelp reviews of 1,352 hospitals, and demonstrated similar patient satisfaction scores to those found in the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) Survey, including key categories such as scheduling efficiency, billing and overall cost.1 Yelp recently announced a partnership with ProPublica to expand available ratings to include quality metrics. Several large U.S. health care systems have launched their own online patient review portals to promote transparency. Most sites use the “star rating” adopted by other social media rating platforms. The Centers for Medicare and Medicaid Services has also launched its own Hospital Quality Star Rating. Negative reviews may have an extended impact if the physician becomes engaged in the online discussion. Multiple reports have described providers firing back at disgruntled patients in an online forum, which has led to blatant violations of the Health Insurance Portability and Accountability Act (HIPAA) and erosion of patientprovider trust.2

“A BAD REVIEW IS BOUND TO HAPPEN NO MATTER HOW VIGILANT YOU ARE. THE KEY IS TO NOT RESPOND NEGATIVELY TO A NEGATIVE REVIEW.” 

If you have reached a road block in care, discuss your case with other providers. A fresh set of eyes may identify something that was not initially considered. Just as importantly, tell your patient that you are doing those things. Patients like to know you are going the extra mile to help them, and sometimes that means swallowing your pride and asking for help.

IF YOU RECEIVE A BAD ONLINE REVIEW, LET IT GO

A bad review is bound to happen no matter how vigilant you are. The key is to not respond negatively to a negative review. You could risk exposing key HIPAA information, inciting more ill will from the patient or, worse, instigating a lawsuit. Keep your chin up, learn from any mistakes, and work hard to minimize the risk of a future negative review.

TREAT EVERY PATIENT LIKE FAMILY

The Golden Rule has never been more applicable. You may not always like your patients, but you should still work hard to hear their concerns and help them get better. Your “crazy Aunt” may get on your nerves, but she is still your Aunt, and you still love her. Take this practice into your clinic, and your risk of a bad review will drop. We must adapt in this era of online reviews with a focus placed on patient satisfaction, quality, and outcomes. Trainees starting into gastroenterology should commit to strong communication, empathy and high-value patient care.

1. Raynard BL, Werner RM, Antanavicius T, et al. Yelp reviews of hospital care can supplement and inform traditional surveys of the patient experience of care. Health Aff 2016; 35: 679-705. 2. Ornstein C. Doctors fire back at bad Yelp reviews – and reveal patients’ information online. The Washington Post. May 27, 2016.

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GETTING IT RIGHT: MENTORSHIP

LESSONS LEARNED

SHARE YOUR SUCCESSES AND YOUR SETBACKS

HOW TO TAKE ADVANTAGE OF GREAT MENTORS An earlier version of this article appeared in the ACG Case Reports Journal.

By Manish B. Singla, MD, Walter Reed National Military Medical Center, Bethesda, MD SIGNIFICANT RESOURCES ARE DEDICATED TO TRAINING FACULTY PHYSICIANS to become better mentors. As I reflect on my first years as faculty and my time with the American College of Gastroenterology, I find that mentorship requires significant effort from both the mentor and the mentee.

PICK THE RIGHT MENTOR Selecting a mentor can be difficult. While some lucky fellows find their first attending on the inpatient service is the best mentor imaginable, most have to put some time into searching for a good fit. Importantly, good mentors do not have to be in your specialty or maintain the same interests, but they should have qualities that you aspire to possess. Find someone whom you can trust with your concerns and with whom you feel comfortable being honest. Multiple mentors in different places and career stages will ideally take an interest in your future and give you career-long guidance.

MAKE YOUR GOALS CLEAR Mentors will find it difficult to help you if you are vague about your interests; they need guidance. Start a relationship with your mentor by discussing what you like and do not like. If you are interested in private practice gastroenterology, tell your mentors so that they do not guide you toward a career in academics. Likewise, if you want a career in research, give your mentors an idea of your study interests so that they can help you develop protocols.

CHECK IN EARLY AND OFTEN You are not bothering your mentors when you have questions and need help. Although physicians are inundated with burdensome paperwork and clinical requirements, strong mentors find working with mentees to be refreshing and energizing. Your mentors want to hear from you! When writing a manuscript, let them know about your progress e.g., “I just finished the results, and I am working on the discussion and tables,” so that they can block out appropriate time to give you the guidance you need.

“GOOD MENTORS ARE TRYING TO IMPROVE AT MENTORING; BY TELLING THEM HOW THEY HELPED YOU ACHIEVE YOUR GOALS, YOU PROVIDE THEM WITH POSITIVE FEEDBACK AND REINFORCE THEIR VALUABLE SKILLS.” 

Your mentors enjoy hearing about your achievements e.g., “My paper just got accepted to the New England Journal of Medicine,” or “I just got offered that job in New York City.” They have invested valuable time in you, so let them share in your joy. When plans go awry, discuss your obstacles. Let your mentor be your advocate and take the opportunity to learn different ways to respond to disappointment. Good mentors are trying to improve at mentoring; by telling them how they helped you achieve your goals, you provide them with positive feedback and reinforce their valuable skills.

TAKE RESPONSIBILITY FOR YOUR GOALS Manage the time you have with your mentors. Come prepared with thoughtful descriptions of your problems and possible solutions that your mentor can provide. Do your best not to overpromise; while it is hard to say that you do not have time to write that review article, it is better to be honest than to agree to do it and then not follow through.

CHANGE MENTORS If you are dissatisfied with your relationship with a mentor, find another one. Mentorship relationships can change due to your evolving goals. Your mentoring relationship might not be mutually beneficial. If discussing such issues does not solve problems, reach out to someone else who may be able to provide you the help and guidance you desire. As physicians and trainees, it can be difficult to admit that we need help. Learning from a mentor is a rewarding journey in professional development, and can help mentees be better mentors in the future. ACG has a mentorship program to help trainees find mentors across the country.

 LEARN MORE about the ACG Mentoring Program: gi.org/mentoring-program

Getting it Right | 19


By Brian C. Davis

THREE-QUARTERS OF DR. PREM CHATTOO’S GI FELLOWSHIP INTERVIEW WAS NOT ABOUT GI. “Forty-five minutes of it was about food and dining and wine,” Chattoo, DO, 46, said of his interview with Nicholas M. Gualtieri, MD. “He’s an avid foodie,” said Chattoo, who refers to himself by the same moniker. The GI office windows at St. Vincent’s Medical Center in New York City overlooked the James Beard House, Gualtieri told ACG, referring to the historic house owned by the James Beard Foundation, the mission of which is to “celebrate, nurture, and honor chefs…”1

20 | GI.ORG/ACGMAGAZINE


Cover Story | 21


COVER STORY

“Looking out at [the James Beard House] helped inspire the conversation,” he said. For as long as Chattoo has been in GI, he has also maintained a passion for food, founded and rooted in his childhood. He avidly watches the Food Network, has taken classes at a culinary institute, has been known to cook for parties of 20-30 people, and visits high-end restaurants. “I have a love for gastroenterology, and I have a love for gastronomy, I suppose,” Chattoo told ACG in an interview. Chattoo forged a way to make both passions part of his daily life. He owns his GI practice, Hudson River Gastroenterology, which he opened in 2010 in Lower Manhattan. Then, a year and a half ago, Chattoo opened a second business in the West Village—a restaurant named The Warren. He is now Owner, GI practice, and Co-Owner, New York City restaurant.

Background in GI and Cooking Chattoo began experimenting in the kitchen when he was six years old, alongside his mother. He remembers earning an “A” in Home Economics class. During medical school, residency and parts of fellowship, he catered. One day, he even found himself on The Rachael Ray Show, although it was to talk about pill cams and general GI—not to cook.2 Chattoo most likes cooking Indian and Italian food, drawing on his Indian heritage and the Italian neighborhood in Queens where he grew up. “I make pizza...I don’t want to say daily, because daily is difficult, but at least three or four times a week,” he said. An entrepreneurial streak has long driven Chattoo. While in medical school at the New York College of Osteopathic Medicine and during his residency at Winthrop University Hospital, he operated his own event marketing and production company to help pay the bills. He rented space, hosted events, bartended and catered, and said he learned the business aspects of operating a restaurant. The idea of opening a restaurant ran through Chattoo’s head throughout medical school, residency and fellowship. During his fellowship interview, Chattoo opened up to Gualtieri, who was Associate Program Director for the GI section. Between musing about what they enjoyed cooking and the restaurants they haunted, Chattoo shared his non-GI goal. “Hopefully one day I’ll be able to open my own restaurant,” Chattoo told Gualtieri. It was 2000. “I did always want to be an owner/operator of a place,” said Chattoo, who, during those years, would do the math and explore financing options when he saw restaurants go up for sale.

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 Photos on page 20-27 are courtesy of Dr. Prem Chattoo and Dr. Nicholas Gualtieri. At right, The Bombay Palace Cookbook and the inscription Dr. Chattoo wrote in his copy before giving it to Dr. Gualtieri. Photo on bottom left of page 24: Luiz Ribeiro for the New York Daily News.


How Did The Warren Come About? In 2012, Chattoo hosted a holiday dinner for his practice at an Asian fusion restaurant. The General Manager commended Chattoo on the event, pointing out that the guests seemed really pleased. Hosting one event turned into frequenting that same restaurant and more events there. Chattoo and the General Manager, Dimitri Liberis, developed a friendship. The idea of opening a restaurant came up. “Listen, if you ever opened a restaurant one day, I would definitely invest with you,” Chattoo told Liberis. Six months later, Liberis approached Chattoo with an opportunity to open a restaurant roughly 150 feet from where Liberis worked, and they had met. “I would like to think I’m entrepreneurial,” Chattoo told ACG. He reviewed the numbers and lease agreement, consulted with his accountant and financial advisor, and then accepted.

Who Does What? When Chattoo found out he had gotten his GI fellowship, he wanted to express his gratitude to Gualtieri. Like Chattoo, Gualtieri loved Indian and Italian food. Chattoo had just the gift—an Indian food cookbook. “I brought that cookbook— that was tremendously dear to my heart—and gave it to him as a token of paying it forward,” Chattoo said. Gualtieri has not forgotten about the cookbook. “The Bombay Palace Cookbook,” he said. “I still have it and refer to it.” When Chattoo would eventually open his restaurant, the cuisine was neither Indian nor Italian. A gastropub named The Warren, located at 131 Christopher St., New York, NY, was born on March 4, 2016. The food served at the

Cover Story | 23


COVER STORY restaurant is “Nouveau American” or “gourmet pub food,” as Chattoo describes it. When Liberis suggested they open a gastropub, the gastroenterologist found it fitting. “We are technically a gastropub, I guess pun intended,” joked Chattoo, who said that the limited liability company is named “GastroPub.” Liberis runs the day-to-day operation, from scheduling and ordering to serving as the restaurant’s mixologist. Chattoo heads the business side, including financial and marketing decisions. He speaks with Liberis daily and visits the restaurant at least three or four times a week. This is not to say that Chattoo is uninvolved or unconcerned with the restaurant’s culinary direction. “I’m very particular about food and service,” Chattoo said. He helped pick the chef, Hesham Darwish, who previously worked at New York University and as a sous chef in many restaurants. The menu changes seasonably. Chattoo says they aim to be “farm to table,” as best they can. In December 2016, The New York Daily News3 wrote an article about Chattoo and The Warren which emphasized the menu’s heartier dishes, referring to them as “gut busting” food. Chattoo submits that while there are “lavish,” “decadent” or “cheat” dishes on the menu—like poutine and burgers—healthy choices abound. The restaurant tries to keep a “balance,” Chattoo said, and it takes a Mediterranean diet-type

approach to certain entrées which are, for example, accompanied by a grain and a vegetable—not a carbohydrate. He readily cites examples like the salmon, steak, lamb chop and brick chicken, and mentions that the restaurant offers vegetarian and vegan options. Dishes “that people can eat and not feel like… ‘I’ve just gained a ton of weight,’” Chattoo said. Paying attention to the dietary habits of people in the neighborhood is an important practice. The Warren keeps “minimalistic desserts” because patrons generally avoid the sweeter options. “People stay away from high-sugar, high-fat stuff. They move away from that,” Chattoo said. The restaurant seems to be an outlet for Chattoo entrepreneurially and as a venue to, at select times, fulfill his culinary passion. Chattoo pings Darwish with questions about cooking techniques; Darwish regularly answers them in the form of cooking demonstrations. “He taught me fine dining techniques that I don’t learn on The Food Network,” said Chattoo, who has also learned about mixology from Liberis. The Warren has benefited. Chattoo himself has, to varying degrees, inspired several dishes that have made the menu. There is a collaborative process to how this happens. “I’m not the head chef, obviously,” Chattoo said. Chattoo either generates a new idea for a dish or emulates a dish he has enjoyed elsewhere, often times at high-end restaurants. He attempts to recreate the dish at home. Then, he will make the dish for Darwish and consult with him about its potential and changes to consider. Darwish will create his own rendition, which will account for the cost and service of executing the dish in the restaurant. “In the middle of the busiest time of the restaurant, you have to be able to make dishes that can be readily and time efficiently produced for service,” whether one person or 20 people order the dish, Chattoo said.

A concept typically makes the menu when Chattoo, Darwish and Liberis come to a consensus that it belongs. Chattoo recalled how the trio looked at one another in approval about the brick chicken, the original idea for which came from Chattoo. The brick chicken, gulf shrimp and the flatbread menu items in particular are at least partially inspired by Chattoo. Chattoo said this process of creating a dish and seeing how people receive it is the most fun part of being a restaurateur. In addition to cooking to develop new concepts, Chattoo sometimes cooks family meals for his partners and the staff. “It’s a form of relaxation for me,” he said.

How Does He Do It? One might wonder how Chattoo makes it through the day and the week, operating separate enterprises in different industries. In talking to him, it is evident that he deliberately makes decisions that increase his personal efficiency. “It’s having two loves professionally that you’re really trying to manage,” he said. “The hardest part is being able to manage my time with both of them, and do a good job with both of them.” Chattoo is keenly aware of other challenges he encounters

“I brought that cookbook— that was tremendously dear to my heart—and gave it to him as a token of paying it forward,” “The Bombay Palace Cookbook I still have it and refer to it.” 24 | GI.ORG/ACGMAGAZINE


TwiCe FrIed CHicKen red cabbage slaw spicy aioli

SteelHeAd Salmon

Warren Burger

baby bok choy

Roquefort, cheddar or gruyere cheese

harissa yogurt espelette

onion jam

SHiSHito PepperS garlic aioli sea salt

Flank SteAk salt & vinegar fingerlings

bearnaise sauce

SeA sCallops sugar snap peas english peas pickled enoki miso brown butter emulsion

Cover Story | 25


COVER STORY

“It’s having two loves professionally that you’re really trying to manage...The hardest part is being able to manage my time with both of them, and do a good job with both of them.” and quickly dispenses them in conversation. For example, the restaurant opened in March 2016, but did not have its grand opening until it first acquired its liquor license in mid-October 2016. Chattoo, Liberis and Darwish also are also performing their specific roles for the first time. “It was new for my partner; it was new for myself; and it was new for the head chef,” Chattoo said. “He was a sous chef in many restaurants, but he’d never been an executive chef before. Dimitri was a GM, but he’d never been an owner before. And I was a sole owner of a business, but I’d never been a restaurant owner before.” Initially, the economics of the restaurant business were a challenge. “Being able to translate medical economics into restaurant economics,” Chattoo said. “…To be able to find that niche of finding quality and being able to make it profitable.” While these are significant obstacles, Chattoo asserts that administering his time is his biggest hurdle. Then, he jumps into proactive steps he takes to streamline his time. Chattoo employs people to perform functions at both establishments, including marketing, accounting and financial advisement services. This allows him to hold fewer conversations and still get a grasp on the latest from both establishments. Chattoo’s schedule reflects a focus on properly allocating time between his practice, restaurant, and his three kids, ages three, six and seven. He takes his kids to school in the morning, thereby leaving for work later and dodging rush hour traffic on the way from his New Jersey home to his New York City office. After leaving his practice in the evening, he often pit stops at the restaurant— which is on his route home—so he can make use of this time rather than sit in traffic. Chattoo spends his weekends at home with his kids. Cake Wars and Chopped Junior play on the

26 | GI.ORG/ACGMAGAZINE


TV. They make pizza together. “I try to involve them in [cooking],” Chattoo said. “I feel like that is something that I love to do, and something that I try to share with them.” Chattoo maintains what he calls “really a good, harmonious” relationship with Liberis, who oversees the restaurant on the weekends. On partnerships, Chattoo said, “You have to see the same vision. You have to have the same understandings, beliefs and commonalities.” In sourcing what is at the core of his and Liberis’ relationship, Chattoo said that Liberis’ father is also a doctor, although he cannot say whether this plays a role. “I think that he understands me and he respects what I do; I understand him and I respect what he did, because I kind of did some of what he did as well,” Chattoo said.

Goals Realized Chattoo tries to keep his careers separate. He does not advertise the restaurant to his patients, saying it is “serendipitous” when a patient visits the restaurant. “Patients have coincidentally had dinner there, unbeknownst to me, and heard about it, and then they realize after the fact that I was Co-Owner,” said Chattoo, who said patients may have found out from his office staff or by reading the Daily News story. In mid-December 2016, his careers briefly came together. A St. Vincent’s reunion was held at The Warren. Gualtieri, who attended, liked the food very much and appreciated the "welcoming feel” of the restaurant. “It was made even more enjoyable by having many of the Attendings and past Fellows come and be together again,” Gualtieri said. He reflected on Chattoo realizing both of his goals—to be a gastroenterologist and to open his own restaurant. “Each has gone on like Dr. Chattoo to be an excellent doctor and like Prem to be leaders in their communities,” Gualtieri said. “To see the joy in his eyes with all of us enjoying his food and being united again in his restaurant brought joy to my heart.”

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Related ResourCes 1. READ about the James Beard Foundation website: jamesbeard.org/about 2. WATCH the video of Dr. Chattoo on the Rachael Ray Show, December 9, 2014: bit.ly/Chattoo-Ray 3. READ the full New York Daily News article, “New York Gastroenterologist opens restaurant with gut-busting foods like fried chicken, mac and cheese,” December 15, 2016: bit.ly/Chattoo-Daily-News

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Attend an upcoming

2017–2018 ACG Regional Postgraduate Course 2017 IBD School and ACG Southern Regional Postgraduate Course Omni Nashville Hotel | Nashville, TN

December 1 – 3, 2017 2018 IBD School and ACG Governors/ASGE Best Practices Course Caesars Palace | Las Vegas, NV

January 26 – 28, 2018 2018 ACG/LGS Regional Postgraduate Course Hyatt French Quarter | New Orleans, LA

March 9 – 10, 2018 2018 ACG/FGS Annual Spring Symposium Hyatt Regency Coconut Point Resort & Spa | Bonita Springs, FL

March 16 – 18, 2018 2018 IBD School and ACG Eastern Regional Postgraduate Course Seaport Hotel | Boston, MA

April 13 – 15, 2018 2018 Hepatology School and ACG Midwest Regional Postgraduate Course Sheraton Indianapolis City Centre Hotel | Indianapolis, IN

August 24 – 26, 2018 2018 ACG/VGS/ODSGNA Regional Postgraduate Course Williamsburg Lodge | Williamsburg, VA

September 8 – 9, 2018 2018 IBD School and ACG Southern Regional Postgraduate Course December 2018

For more info, visit: GI.ORG/REGIONAL-MEETINGS 28 | GI.ORG/ACGMAGAZINE


REMEMBERING DR. LAUREN BATTAT GERSON (1964-2017) THE OFFICERS AND TRUSTEES OF THE COLLEGE MOURN THE DEATH OF A VIBRANT, TALENTED AND WELLRESPECTED ACG TRUSTEE, DR. LAUREN B. GERSON. She will long be remembered for her radiant enthusiasm, and especially for the “grace, professionalism, collegiality, and uncommon good sense,” noted by one of her many friends. Dr. Gerson passed away on July 21, 2017, after battling metastatic melanoma. She was a gastroenterologist at Sutter Health California Pacific Medical Center in San Francisco, CA, who was elected to the ACG Board of Trustees in 2015. An Exceptional Human Being “Lauren was an exceptional researcher, author, and human being. We will miss her greatly,” reflected ACG President Carol A. Burke, MD, FACG. ACG President-Elect Irving M. Pike, MD, FACG, and his wife, Randy, attended Dr. Gerson’s funeral on July 26, 2017, in Burlingame, CA. Dr. Pike shared, “Not surprisingly it was standing room only. There were beautiful tributes to Lauren the person, the wife, the mother, the scholar, the researcher, the caring physician, the figure skater, the musician, the skier, the loyal friend and more. We found that we only knew some of Lauren, and I am sad that I did not have time to know more about this wonderful person.” Lauren Gerson received her undergraduate degree from Princeton University and her medical degree at SUNY - Buffalo School of Medicine. She completed her internship and residency at California Pacific Medical Center, and her gastroenterology fellowship at Stanford University Medical Center. She served as a fellow and faculty member at Stanford Hospital for over 15 years. In recent years, she practiced at California Pacific Medical Center in San Francisco. Dr. Gerson was a highly respected and accomplished clinician and researcher who led the ACG Practice Parameters Committee from 2011-2015. During her tenure, she oversaw the publication of numerous ACG clinical guidelines. Nicholas J. Shaheen, MD, MPH, FACG, preceded Dr. Gerson as Chair of Practice Parameters, and remembers her impact: “In the key roles she held for the College over the years, as chair of the Practice Parameters Committee and as a member of the Board of Trustees, she inspired many young scholarly physicians, and motivated them to be future leaders of our profession. She instilled a new degree of rigor in the development of ACG’s guidelines, making these documents even more useful to the clinician.” Among her significant and noteworthy contributions to the educational excellence of ACG’s programs, she served as Co-Director of the ACG Postgraduate Course in 2014. Seth A. Gross, MD, FACG, had the opportunity to work with Dr. Gerson when they planned the course. He recalled, “I remember thinking after our first phone call, I am working with someone who is passionate, driven, and who loves what she does. Lauren was smart, well-rounded, and her energy was contagious—inspiring everyone around her to continue to advance our field.”

 Lauren B. Gerson, MD, MSc, FACG

Dr. Gerson also made noteworthy contributions in many roles for the American Society for Gastrointestinal Endoscopy, where she was active as a Senior Associate Editor of the journal Gastrointestinal Endoscopy. ASGE President Dr. Karen L. Woods noted, “She has accomplished so very much in her short life and has touched many with her knowledge, teaching skills and warm personality.” As her many friends in gastroenterology carry on her legacy of clinical excellence and dedication to the GI profession, they will continue to be inspired not only by Dr. Gerson’s professional accomplishments, but also by her joy in her family and her graceful courage while facing adversity. As her friend Dr. Pearl Yee of San Francisco said, “Lauren was the best of us. She excelled at everything with a fierce intellect and unwavering smile.” Dr. Gerson is survived by her husband, Bill, a lawyer at Apple, Inc., her children, Stephanie, Jackie and Andrew, her parents, and siblings.  READ Dr. Gerson’s obituary: goo.gl/3cqwwd

ACG Perspectives | 29


“Lauren was the quintessential academic gastroenterologist who consistently contributed to the field, all the while with a ready smile, and a sincere warmth for trainees as well as her peers. We all learned from her honest erudition. She will, however, always be missed by those who knew her and by those who never had that privilege.” —Lawrence J. Brandt, MD, MACG, Montefiore Hospital, Bronx, NY

“My main recollection of Lauren will always be her irrepressible enthusiasm for our field and the College. If nine-tenths of success in life is attitude, it was easy to see why Lauren was successful. She was so supportive of others and their ideas, and so constructive in her suggestions for improvement for the work, that it elevated everyone around her.”

“A bright spot in our field has been lost, but Lauren’s contributions and spirit will live on for years to come. —Seth A. Gross, MD, FACG, NYU Langone Medical Center, New York, NY

—Nicholas J. Shaheen, MD, FACG, University of North Carolina, Chapel Hill

“Lauren was an amazing woman, who inspired me every time I interacted with her. She always had a smile on her face, and that ‘can do’ attitude. I was so impressed with everything that she accomplished in her time as a committee chair, and I know she could have achieved anything that she set her mind to.” —Amy S. Oxentenko, MD, FACG, Mayo Clinic, Rochester, MN

“Lauren was a very positive individual and always wanted to do clinical research or write a paper. She was persistent with everything she did. I never understood where she got all of her energy from. She touched many lives and will be remembered for her energy and passion for her family, for life and for medicine.” —Jonathan A. Leighton, MD, FACG, Mayo Clinic, Scottsdale, AZ

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“Lauren challenged me, taught me and made me laugh whenever we worked together. I will miss her enthusiasm for discovery and desire to find new ways to help patients. I’m grateful she was a part of my life.” —Philip O. Katz, MD, FACG, Jay Monahan Center for Gastrointestinal Health, Weill Cornell Medical Center, New York, NY


“A RENAISSANCE CLINICIAN” YEARS AGO, I DID MAKE AN IMPORTANT DECISION.

—Joseph A. Murray, MD, FACG, Mayo Clinic, Rochester, MN

A WOMAN TO REMEMBER AND HONOR

“Her grace, professionalism, collegiality and uncommon good sense were such an asset to the gastroenterology community.”

this blend of excitement about everything that drove her and all of us around her to go beyond preconceived borders and fences—practically and intellectually— looking after patients, clinical problems and research questions. And in her honor and memory many of us, touched by her, will continue her course. She was relentless in the pursuit of knowledge, properly acquired and implemented. Every clinical decision was destined to be supported by evidence either already available or soon to be generated. Bias was condemned, true value to the patient defended. One would have to literally go on a journey to the center of the evidence and, if not encountered, grab the opportunity to find it. Everything was a question in search of one answer, or more. We played this intellectual game with Lauren a lot, myself as a mentor, she as budding academic and clinician. And patients benefited, science moved forward. A physician, wife, mother, musician, athlete, friend has departed and will be missed, but not forgotten. A special energy, her smile, her ideas, wit and thoughts will inspire and bless many to come…

I accepted Lauren Gerson to work in my lab at the Palo Alto VA. She quickly became a passionate clinical researcher and the rest is history. She eventually became a GI fellow, an outcomes researcher, an accomplished gastroenterologist, and a faculty of our Division at Stanford where she spent the next 15 years as a renaissance clinician with her hands on the pulse of the patient and her heart on doing what is best, what is right. She rose to become an Associate Professor at the university, a Trustee of our College, an internationally known authority in gastroenterology, an Editor, a Researcher. Having grown older in the field of academic gastroenterology over the past 30 years, continuously aiming at fermenting the next generation of clinician-researchers and educators, I look back at my own successes and failures, my surprises and regrets. Doing so, I have come across some people who I feel blessed of working with and inspired by and one of them is Lauren Gerson. Her premature departure marked me indelibly, her place in the field of gastroenterology will remain difficult to fill, her star will shine in our memories, her inspiration a path to pursue. Having studied romance languages at Princeton, Lauren was a “francophone” and “francophile.” Hence, she impersonated and epitomized what the French call “joie de vivre,” liberally translated as “exuberant enjoyment of life,” describing her cheerfulness, vivacity and zest. And she did this not only in her personal and family life, but also professionally. It was

D, Gerson, M Lauren B.

MSc, FACG

À bientôt, Lauren… George Triadafilopoulos, MD, FACG Clinical Professor of Medicine (Gastroenterology), Stanford University School of Medicine

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ACG Perspectives | 31


ACG PERSPECTIVES

Aasma Shaukat, MD, MPH, FACG, on “Being a VA GI Section Chief” By Jill Gaidos, MD, FACG

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A

AFTER PARTICIPATING IN THE PANEL DISCUSSION FOR THE “CAREER OPPORTUNITIES FOR WOMEN IN GI” LUNCHEON at the ACG 2016 Annual Scientific Meeting, Dr. Shaukat and I sat down to talk about her road to becoming a Veterans Affairs Gastroenterology Section Chief and her responsibilities in that position. How long have you been Section Chief for the Division of Gastroenterology and Hepatology at the Minneapolis VA Medical Center? AS: For the last four years. How big is your GI section? AS: Our section grew. It went from four physicians to 10. Do you have a lot of nurse practitioners? AS: There are 10 physicians and five Advanced Practice Providers. Prior to becoming the Section Chief, were you full-time at the VA with an academic appointment at the University of Minnesota or part-time at both? AS: I started as full-time VA, and then the university contracted the VA for my time. The university and VA do different things in different places in terms of how they share FTE because of the way the benefits are structured. The university doesn’t give benefits to anybody who’s not full-time. So, it’s beneficial to be full-time in one place. I did clinic and endoscopy at the university, also have a university appointment, and was also involved with Fellows’ training and education. I went back and forth between the University and VA, but was still full-time VA. That was beneficial because I could apply for a VA career development award and I could also apply for the University’s K award. So, that opened up more opportunities for research funding. Was that beneficial for your career, to have some academic time and some VA time? AS: It was, because I see different populations and that gives me a really good perspective. In terms of outpatient clinic, the university has a different kind of population, so I see a more complex patient population who has been referred to a tertiary care facility. And, I got an opportunity to work with fellows in both settings, where I could teach them a lot about system-based practice, how to apply the same evidence, or do the same kinds of things for patients in different settings based on resources. So I think it is beneficial. 

ACG Perspectives | 33


ACG PERSPECTIVES You had clinic and endoscopy at the University of Minnesota. What were your responsibilities at the VA? AS: I had clinic and endoscopy at the VA as well. I also served as the Associate Program Director for the GI fellowship for four years. The Program Director was very busy, so I pretty much ran the fellowship. That’s something that I had an interest in and got involved when I first got there. You always can benefit from a fresh pair of eyes. I said, “So, you guys don’t really do a journal club? How about I do a series of small talks on critical appraisal of literature, of RCTs, comparative studies, systematic reviews, cost-effectiveness analysis, and then we go through a critical appraisal?” They said, “Absolutely. Go for it.” So, I restructured that. I set up a Core Curriculum committee, in charge of what topics are discussed in our core lectures, in our grand rounds and mapped them to ACGME requirements. Did a lot of the fellowship nuts and bolts of education, and journal club. We survived a site visit for fellowship by ACGME. Now they do NAS, Next Accreditation System, so it’s a constant, ongoing process. When Dr. John Bond retired in 2012, the section was down to three people. They chose me to lead the section. It was a tough year because I was still running the fellowship program and I had just had my first child. Not knowing very much about the section, and having people who were much older and far more senior than me, was very challenging. I also had a VA career development award. So, technically, 75% of my time was supposed to be protected for research, but we were short-staffed, and clinical needs had to be met. Eventually, I cut back on my time from the university, and I stopped doing endoscopy there. Then, I transitioned the Associate Program Director position to someone else. I still remain heavily involved, even today, I still run the journal club and the core curriculum, but at least I could get away from some of the tedious and more administrative tasks. I took on a whole new set of administrative responsibilities as Division Chief. The first goal was recruitment because we were so short staffed. The second goal was, of course, making the endoscopy unit more effective in terms of doing more cases, having fewer no-shows and cancellations, and assisting patients who have transportation issues or need an accompanying adult.

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...You should let your Section

Chief and the Chief of Medicine know about your interest so they will groom you for the position, if it’s a good section and they are invested in your

success.

I remain very close with my university counterparts. Most of my research is at the university. My VA career development award is using data from a private practice here in Minneapolis, because I needed a large database of colonoscopies. For career development, I got a VA Merit grant to look at long-term outcomes after colon cancer screening, and I wanted to use the Minnesota Fecal Occult Blood trial data, which was the original colon cancer screening trial done at the university. I finished the CDA, which resulted in a highimpact publication in Gastroenterology (Gastroenterology 2015;149:952-957). I finished the Merit Study, which was published in The New England Journal of Medicine (N Engl J Med 2013;369:1106-1114). As a Section Chief, who now has two children, how do you balance your research time, clinical responsibilities and administrative time? AS: Clinical responsibilities always trump everything. Being the Section Chief, I actually end up doing more of it. So it’s never a neat ratio where I can say, every week, two days I do this, two days I do this. If it averages to 50/20/30 ratio—50 research, 20 clinical, 30 administration, that would be a good week. That is what I strive for. But, there are some weeks where it’s all clinical. Close to grant deadlines, I try to carve out a lot of time to work on grants. Then, when you have JAHCO visits, or other directives come down, or some other issue happens in the endoscopy lab that consumes your time. Unfortunately, a lot of stuff trickles into home time. If I didn’t get through all my alerts, then I am logging in at night. Or if I didn’t get to all of my emails, or some academic or administrative stuff I have to do, review a grant or something, then I will do it from home. There are only so many hours, so that work typically happens after you put the kids to bed. I do try not to do that. I try to plan my week ahead of time. But, then, I expect the unexpected. Absolutely, and the older the kids get, the later their bedtime, so the shorter the amount of time you have to get work done before you go to bed. AS: Yeah, exactly. For other ACG members who may be interested in taking on a leadership position, such as being a Section Chief or Chair position, do you have any recommendations on how to prep for this type of leadership position? AS: If you have an interest and an aptitude, those are the two things that have to match up. That’s pretty much all you need, and then you have to let your interest be known. It may be intuitive to you, but it’s not intuitive to your Section Chief that you could be the next Section Chief or Associate Chief. Then people notice you for your thoughtful comments at staff meetings. You need to take ownership of the section and say, “I see this as a way we can make things better.” If you think you truly want that kind of a role, you should let your Section Chief and the Chief of Medicine know about your interest so they will groom you for the position, if it’s a good section and they are invested in your success.


ACG’s INVESTMENT in CLINICAL RESEARCH 2017 JUNIOR FACULTY DEVELOPMENT AWARDEES' RESEARCH & CAREER FOCUS THIS YEAR, THE ACG INSTITUTE INVESTED $1.3 MILLION IN CLINICAL GI RESEARCH GRANTS, and increased award limits to $15,000 for pilot programs, $35,000 for grants to investigators from “smaller” GI programs, and $50,000 for clinical research projects. Learn more about the 2017 research awardees: goo.gl/y9Cxrx. Supporting the work of promising young investigators and positioning them to go on to secure other sources of funding is the goal of the ACG Junior Faculty Development Grant of $300,000 over three years. The three 2017 Junior Faculty Development Award recipients share their thoughts on their career interests and the directions of their research. ALINA M. ALLEN, MD Mayo Clinic

RENUMATHY DHANASEKARAN, MD Stanford University

Noninvasive Diagnosis of NASH by Magnetic Resonance Elastogram (MRE)

Plasma Glycoproteomic Biomarkers for Invasive Human Hepatocellular Carcinoma (HCC)

Dr. Allen is a second-year as gastroenterology and hepatology fellow at Mayo Clinic with an interest in nonalcoholic fatty liver disease (NAFLD). Her near-term goal is to improve the means to diagnose and monitor NASH, which will enable identification of those at risk of disease progression, timely prevention and treatment. “The focus of my research is to determine and validate the role of magnetic resonance elastography (MRE) in the diagnosis and monitoring of NASH. I believe that this innovative application of an imaging biomarker will provide novel diagnostic options that will circumvent the invasiveness of liver biopsy and have a major impact in the clinical care and therapeutic trials of NASH.”

Dr. Dhanasekaran is an early career physician scientist committed to pursuing a career in academic medicine who currently works as an Instructor at Stanford University. She is pursuing basic and translational research in the field of hepatobiliary malignancies whose overall research goal is to identify biologically relevant prognostic biomarkers and molecular targets for drug therapy and consequently improve the clinical outcome of patients with hepatocellular carcinoma (HCC). Her long-term career goal is to build an independent translational research program to identify biomarkers for HCC. “Hepatocellular carcinoma is a lethal malignancy with an incidence that is on the rise. Vascular invasion is a key event during cancer progression, which is associated with recurrence, hematogenous dissemination, metastases and poor survival. Currently, there are no accurate prognostic plasma biomarkers that can detect invasive HCC and thus stratify clinical outcomes and guide treatment selection. My study proposes to use a translational mouse-to-human approach for proteomic biomarker discovery for human HCC. The central hypothesis is that specific plasma proteomic and glycoproteomic signatures are associated with invasive HCC.”

REENA KHANNA, MD University of Western Ontario

Efficient Early Drug Development in Inflammatory Bowel Disease

 Alina M. Allen, MD, Renumathy Dhanasekaran, MD, Reena Khanna, MD.

Dr. Khanna is a physician scientist and Assistant Professor at the Schulich School of Medicine and Dentistry, The University of Western Ontario, Canada whose training includes gastroenterology, IBD, clinical trials research, and outcome measure development. She has completed a master’s degree in clinical epidemiology and is now engaged in IBD clinical trials with a focus on outcome measure validation to increase the efficiency of trials. “Since current therapies for IBD are sub-optimal, development of new treatments is a research priority. My research seeks to find ways to improve the efficiency of early drug development given that current trial endpoints have not been fully validated and are statistically inefficient...I chose a career in IBD because it enables long-term relationships with patients, and is an area that requires additional discovery that will change within my career.”

ACG Perspectives | 35


ACG PERSPECTIVES

ACG GRANT RECIPIENT RECEIVES ADVANCED TRAINING IN ENDOSCOPIC SUBMUCOSAL DISSECTION IN TOKYO By Gene K. Ma, MD, University of Pennsylvania, Philadelphia, PA

WITH THE GENEROUS SUPPORT OF THE 2016 ACG NORTH AMERICAN INTERNATIONAL TRAINING GRANT, I had the honor of learning endoscopic submucosal dissection (ESD) from the endoscopic masters at Jikei University School of Medicine in Tokyo, Japan. After my general gastroenterology fellowship, I will be completing a fellowship in therapeutic endoscopy, as the field provides an array of techniques that allow for both early detection of malignancy and curative interventions. I have developed a keen interest in ESD, as it is a technique that may provide an ideal method for en bloc resection of early colorectal and other gastrointestinal neoplasms. While I wish I could have stayed for a longer period at Jikei, the weeks that I spent there were incredibly educational and inspirational. While I initially felt trepidation about training in another country where I was unable to speak the language, my fears were allayed immediately once I met the individuals who would serve as my primary mentors during the experience. Drs. Hisao Tajiri, Kazuki Sumiyama, Tomohiko Ohya, and Naoto Tamai were the architects of my experience at Jikei University. They immediately set out to make me feel welcome and developed an engaging schedule for each day. Every person I encountered—from faculty to trainees to the endoscopy staff—was extremely helpful and eager to ensure that I achieved the objectives of my trip. During my time at Jikei University, I learned about the performance of ESD through didactics, observation of procedures, and practice in porcine models with direct guidance from one of the ESD masters at Jikei. The Jikei endoscopists relied heavily on visual diagnosis using advanced imaging techniques and, with their guidance, I have incorporated many of these principles into my own

36 | GI.ORG/ACGMAGAZINE

“I LEARNED THE NUANCES OF ESD INDICATIONS, PRE-PROCEDURAL ASSESSMENT, COMPLICATIONS, AND THE IMPORTANCE OF A STRONG COLLABORATION WITH SURGICAL COLLEAGUES.” 

practice. One of the most valuable conferences was the weekly multi-disciplinary conference during which time providers would discuss the following week’s scheduled ESD cases and follow up on previously performed ESD cases. During these sessions, I learned the nuances of ESD indications, pre-procedural assessment, complications, and the importance of a strong collaboration with surgical colleagues. I cannot adequately express my gratitude to the American College of Gastroenterology for providing me the support for this opportunity, my hosts at Jikei University for making me feel like a part of the Jikei family, and my mentors at the University of Pennsylvania for encouraging my pursuit of this unique opportunity. Not only have I gained an invaluable skill, but I am also proud to have gained many lifelong friends and colleagues at Jikei University. Domo arigato gozaimasu! Photos courtesy of Dr. Gene Ma (center). 


EDUCATION

VISITING PROFESSORSHIP ACG President Dr. Carol A. Burke, with Dr. Eamonn M. M. Quigley and Dr. Bincy P. Abraham, during her visit.

The ACG Edgar Achkar

PROVIDING NOTEWORTHY SPEAKERS FOR TRAINING IN YOUR COMMUNITIES

ACG President and national experts bring expertise to institutions across the U.S. ACG PRESIDENT CAROL A. BURKE, MD, FACG, VISITED HOUSTON METHODIST HOSPITAL ON APRIL 20–21. Invited for her expertise on hereditary colon cancer by Bincy P. Abraham, MD, FACG, and Eamonn M. M. Quigley, MD, MACG. The visit included a well-attended dinner conference with the Texas Gulf Coast Gastroenterology Society, where Dr. Burke presented “Enhancing the Effectiveness of Colonoscopy.” The presentation was attended by two past ACG presidents, David Y. Graham, MD, MACG, and Dr. Quigley, and was beneficial for both GI fellows as well as seasoned gastroenterologists. The GI fellows benefited from Dr. Burke’s mentorship, career advice, and general work-balance insight, and learned more about how to participate in ACG committees and get involved in the life

of the College. Furthermore, the fellows obtained direct feedback on issues facing the practice and what the College is doing to help support gastroenterologists. The visit included a multi-disciplinary clinical case conference attended by gastroenterologists, GI fellows, surgeons, pathologists, radiologists, and oncologists, as well as residents and medical students. The conference included a great discussion of some hereditary cancer syndrome cases presented by the GI fellows. Houston Methodist received expert advice on the management of these patients based on Dr. Burke’s analysis of the polyps, and pathology readings. 

Education | 37


EDUCATION

Photos from top (left to right): Drs. Burke and Quigley (seated) with Dr. Abraham and Houston Methodist GI Fellows. Dr. Gerson speaks from the podium. Dr. Lacy at the University of Oklahoma. Dr. Gerson receiving ACG Edgar Achkar Visiting Professorship plaque from Dr. Baseer Qazi.

38 | GI.ORG/ACGMAGAZINE

BRIAN E. LACY, MD, PHD, FACG, CO-EDITOR-IN-CHIEF, THE AMERICAN JOURNAL OF GASTROENTEROLOGY, VISITED THE UNIVERSITY OF OKLAHOMA ON APRIL 25–26. Invited by William M. Tierney, MD, he presented “Clinical Dilemma in Functional Bowel Disease,” an interactive dinner program, to over 40 physicians at the Oklahoma City Golf and Country Club. The visit included many individual meetings with faculty to discuss research, mentoring, faculty development, fellowship training, and changes in GI, both locally and nationally. Dr. Lacy presented “Functional Dyspepsia and Gastroparesis: One Disease or Two?” at GI grand rounds, followed by lunch with the fellows. The fellows and faculty were impressed with the wonderful program. The University of Oklahoma found Dr. Lacy to be an inspirational educator, and one of the best speakers they have had, particularly in reaching both the faculty and fellows.


LAUREN B. GERSON, MD, MSC, FACG, ACG TRUSTEE, VISITED ADVOCATE LUTHERAN HOSPITAL IN CHICAGO ON APRIL 26. Requested by Alan B. Shapiro, MD, FACG, and Baseer Qazi, MD. The visit began with a dinner during which faculty discussed small bowel pathology. At the morning GI pathophysiology conference, Dr. Gerson presented “Evaluation of Small Bowel Bleeding,” followed by case-based presentations. For the fellows, it was valuable to have the chance to ask an expert questions in a more-intimate format. At medical grand rounds, Dr. Gerson covered “Updates in GERD and Barrett’s Esophagus,” followed by lunch with the fellows where they shared research ideas and thoughts on clinical scenarios, including small bowel bleeding. Dr. Gerson valued the fantastic experience of interacting with the fellows and providing feedback on patient management.

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 Visiting Professorships:

FEBRUARY 2–3 CHRISTINA M. SURAWICZ, MD, MACG Saint Louis University, presenting on Clostridium difficile. APRIL 20–21 CAROL A. BURKE, MD, FACG Houston Methodist Hospital, presenting on colon cancer screening, genetics of colon cancer, and hereditary polyp syndromes. 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 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 30–31 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 | 39


GI QUALITY IMPROVEMENT CONSORTIUM, LTD.

P P P P P P P

Setting the standard in quality improvement initiatives in GI. Improving clinical practice and patient outcomes. Providing real-time peer-based performance evaluation. Upload data directly from a number of endowriters—saving staff time. Generate reports in real-time, at the physician and facility level. Submit GI-specific measures to PQRS via the GIQuIC registry. Join the 4,000 U.S. gastroenterologists who have made GIQuIC their quality improvement benchmarking registry.

To contact GIQuIC, email info@giquic.org

Visit giquic.org for more info

GIQuIC is a joint initiative of ACG and ASGE

40 | GI.ORG/ACGMAGAZINE


Inside the

JOURNALS

G

AC RTS EPO CASE RO J URN L G PORTS.GI.OR

ACGCASERE

VOLUME 4

THE SCIENTIFIC LIFE OF THE COLLEGE IS THRIVING in the pages of its journals. “Inside the Journals'” features a joint guideline on dyspepsia published in The American Journal of Gastroenterology (AJG) by ACG in partnership with the Canadian Association of Gastroenterology. In a related podcast, lead author Dr. Paul Moayyedi shares clinical insights with AJG Co-Editor-in-Chief Dr. Brennan Spiegel. Patient voices also find a prominent place in the pages of AJG’s Red Section, with a candid personal reflection by Sigrid LaFata, a patient with fecal incontinence, treated by Dr. Stacy Menees of the University of Michigan, who authored the accompanying “How I Approach It” piece. Clinical and Translational Gastroenterology (CTG) has launched a series of primers which are attracting attention in the GI community thanks to the leadership of Dr. David Whitcomb, CTG’s Editor-in-Chief. A new editorial team has taken the helm at ACG Case Reports Journal (ACGCRJ) as of July 2017. Dr. Parth Parekh, ACGCRJ Editor-in-Chief, shares what lies ahead for this case reports outlet edited by GI fellows-in-training. orts edited by nal of Case Rep ows An Online Jour atology Fell ology & Hep Gastroenter

Inside the Journals | 41


INSIDE THE JOURNALS: ACG CLINICAL GUIDELINE

MANAGEMENT OF DYSPEPSIA Paul Moayyedi, MB ChB, PhD, MPH, FACG; Brian E. Lacy, MD, PhD, FACG; Christopher N. Andrews, MD; Robert A. Enns, MD; Colin W. Howden, MD, FACG; and Nimish Vakil, MD, FACG.

IN THE FIRST UPDATE IN MORE THAN 10 YEARS, the American College of Gastroenterology and the Canadian Association of Gastroenterology joined forces on an updated systematic review and clinical guideline on dyspepsia management. The focus of the guideline is on initial investigations for dyspepsia, such as Helicobacter pylori testing and endoscopy, as well as pharmacological therapies such as H. pylori treatment, PPIs and prokinetic therapy. The authors do not address the management of organic pathology that may present with dyspepsia identified at endoscopy, such as esophagitis or peptic ulcer disease, as there are other ACG guidelines for these specific diseases. Further, when H. pylori testing or treatment is recommended, we do not specify which investigation or which therapy to use, as this will be addressed in an ACG Guideline on H. pylori and other recent guidelines that have been published.

Listen to the AJG Podcast Paul Moayyedi, MB ChB, PhD, MPH, FACG, discusses the evolving definition and diagnosis of dyspepsia, when and when not to use endoscopy, and how H. pylori factors into dyspepsia treatment in a conversation with AJG Co-Editorin-Chief, Brennan M.R. Spiegel MD, MSHS, FACG.  LISTEN Here: goo.gl/9gd835

42 | GI.ORG/ACGMAGAZINE

Figure 1. Algorithm for the management of undiagnosed dyspepsia.

Figure 2. Algorithm for the treatment of functional dyspepsia.


TABLE 1 . SUMMARY AND STRENGTH OF RECOMMENDATIONS

IN MY OWN VOICE

1. We suggest dyspepsia patients aged 60 or over have an endoscopy to exclude upper gastrointestinal neoplasia. Conditional recommendation, very low quality evidence. 2. We do not suggest endoscopy to investigate alarm features for dyspepsia patients under the age of 60 to exclude upper GI neoplasia. Conditional recommendation, moderate quality evidence. 3. We recommend dyspepsia patients under the age of 60 should have a non-invasive test for H. pylori, and therapy for H. pylori infection if positive. Strong recommendation, high quality evidence. 4. We recommend dyspepsia patients under the age of 60 should have empirical PPI therapy if they are H. pylori negative or who remain symptomatic after H. pylori eradication therapy. Strong recommendation, high quality evidence. 5. We suggest dyspepsia patients under the age of 60 not responding to PPI or H. pylori eradication therapy should be offered prokinetic therapy. Conditional recommendation, very low quality evidence. 6. We suggest dyspepsia patients under the age of 60 not responding to PPI or H. pylori eradication therapy should be offered TCA therapy. Conditional recommendation, low quality evidence. 7. We recommend FD patients that are H. pylori positive should be prescribed therapy to treat the infection. Strong recommendation, high quality evidence. 8. We recommend FD patients who are H. pylori negative or who remain symptomatic despite eradication of the infection should be treated with PPI therapy. Strong recommendation, moderate quality evidence. 9. We recommend FD patients not responding to PPI or H. pylori eradication therapy (if appropriate) should be offered TCA therapy. Conditional recommendation, moderate quality evidence. 10. We suggest FD patients not responding to PPI, H. pylori eradication therapy or tricyclic antidepressant therapy should be offered prokinetic therapy. Conditional recommendation, very low quality evidence. 11. We suggest FD patients not responding to drug therapy should be offered psychological therapies. Conditional recommendation, very low quality evidence. 12. We do not recommend the routine use of complementary and alternative medicines for FD. Conditional Recommendation, very low quality evidence. 13. We recommend against routine motility studies for patients with FD. Conditional recommendation, very low quality evidence. 14. We suggest motility studies for selected patients with FD where gastroparesis is strongly suspected. Conditional recommendation, very low quality evidence. FD, functional dyspepsia; H. pylori, Helicobacter pylori; PPI, proton pump inhibitor; TCA, tricyclic antidepressant.

Finding Freedom from Fecal Incontinence with my Orange Tote Sigrid LaFata and Stacy B. Menees, MD, MS

A former beauty pageant contestant and registered nurse, Sigrid LaFata shares her experience of living with fecal incontinence after the removal of her sigmoid colon following colon cancer. In a personal and heartfelt reflection published in the Red

Section of The American Journal of Gastroenterology, Ms. LaFata describes how bowel incontinence made her lose her freedom. She writes, “I felt like I had to stop living. It was exhausting and isolating. I could never leave the house.” Faced with frequent episodes of stool leakage, she took to carrying around a large orange tote with extra clothes and supplies to handle emergencies. After consulting with Dr. Stacy Menees at the University of Michigan, Ms. LaFata’s symptoms improved with changes in diet, including a low FODMAP approach, as well as physical therapy for her pelvic floor. She reports, “Things were coming under control, and I was back to work, slowly getting my life back.” Dr. Menees encouraged Ms. LaFata to tell her story in the pages of the Red Section where the editors, Dr. Sameer Saini and Dr. Hetal Karsan, have created a special feature for patient voices. Thanks to Ms. LaFata’s courage and candor, and her partnership with Dr. Menees, other patients can benefit from her experience.  READ the full piece in the Red Journal: rdcu.be/uEUM

RELATED ITEM

My Approach to Fecal Incontinence: It’s all about Consistency (Stool, that is) Stacy B. Menees MD, MS, University of Michigan

DR. STACY MENEES RECOMMENDS that fecal incontinence “needs to be sought out as patients suffer in silence.” She notes that, “Patients are embarrassed to discuss this problem and are unlikely to volunteer this complaint freely.” In a clinical overview to accompany the testimonial by her patient Sigrid LaFata in AJG’s Red Section, Dr. Menees offers a concise definition of fecal incontinence (FI), and an overview of evaluation and treatment, including an algorithm. She distinguishes between fecal soiling and FI, and notes the importance of subtyping the disorder as active or

passive, and working with patients to identify consistency using the Bristol Stool Scale.  READ about Dr. Menees’ approach to Fecal Incontinence, and view the Algorithm for Evaluation and Treatment of FI: rdcu.be/uFrF

Inside the Journals | 43


INSIDE THE JOURNALS: ACG CASE REPORTS JOURNAL

Meet the ACGCRJ EDITORIAL BOARD Editor-in-Chief Parth J. Parekh, MD Carilion Clinic Roanoke, VA

THE OPEN-ACCESS ACG CASE REPORTS JOURNAL OFFERS A UNIQUE OPPORTUNITY for trainees to engage in every aspect of the publication process, including manuscript writing and editing. The Journal has given me insight into the depth and breadth of pathology across the United States and worldwide, as we attract manuscripts internationally. Personally, this has really opened my eyes to expand my clinical horizons. So many times I have read a manuscript that describes a unique presentation of an everyday diagnosis or an extremely rare diagnosis and then see it clinically in my own practice shortly thereafter. I, like other practitioners, would have likely missed the diagnosis had I not been able to read similar experiences in the ACG Case Reports Journal. In addition, reading different cases has definitely lit a light bulb for me in terms of research ventures. The Journal is still in its infancy. I have been fortunate enough to be involved with the Journal for three years, serving both as Associate Editor and now as Editor-in-Chief. I have had a chance to see it really grow. The talent that we recruit for the Editorial Board continues to amaze me, and this year is no different! I am very excited to see the direction we take the Journal this year and how we can really put our stamp on it as it makes tremendous strides in educating and connecting trainees from around the globe.

ASSOCIATE EDITORS

Erica R. Cohen, MD Cedars-Sinai Medical Center, Los Angeles, CA

Sasan Mosadeghi, MD, MS University of Arizona, Tucson, AZ

Shirley Cohen-Mekelburg, MD New York Presbyterian Weill Cornell Medical Center, New York, NY

Ali Raza, MD Houston Methodist Hospital, Houston, TX

Samuel Y. Han, MD University of Colorado, Denver, CO

Shawn L. Shah, MD New York Presbyterian Weill Cornell Medical Center, New York, NY

Tossapol Kerdsirichairat, MD Johns Hopkins University, Baltimore, MD

Anthony Sofia, MD University of Chicago Medicine, Chicago, IL

Thanks to outgoing ACGCRJ Editorial Board Members We thank the outgoing members of the Editorial Board for their outstanding service to the Journal and wish them continued success in their careers.

44 | GI.ORG/ACGMAGAZINE

Matthew Chin, MD Rowena Almeida, MD Benjamin Click, MD Zane Gallinger, MD Jorge Machicado, MD


CTG

INSIDE THE JOURNALS: CLINICAL & TRANSLATIONAL GASTROENTEROLOGY

PRIMERS IN CLINICAL AND ONLINE JOURNAL TRANSLATIONAL RESEARCH of CASE REPORTS EDITED by GI FELLOWS

CLINICAL AND TRANSLATIONAL GASTROENTEROLOGY

AC G

(CTG) IS PROUD TO ANNOUNCE ITS NEWEST COLUMN

Adventures in Developing an App for Covert Hepatic Encephalopathy Jasmohan S. Bajaj, MD, FACG

Advantages and Some Remaining Challenges in Hereditary CASE REPORTS in Clinical and • Indexed on PubMedCancer and PubMed Central Gastrointestinal Panel Testing research community. The CTG Primers L N R U O J Tara Maga, publication, PhD, MS, CGC, or Larasubscription Balay, MS Ed, MS, • No submission, feesCGC, Translational Research series will identify true experts

in service to the gastroenterology and hepatology ACGCASEREPORTS.GI.ORG

VOLUME 3 / ISSUE 4

Barbara Jung, MD

in specific yet critically important areas of study who • Cases presented as meeting abstracts are welcome How to Conduct and Interpret Systematic Reviews and Meta-Analyses can translate their knowledge into clear, step-wise and

Case reports, images, and video submissions accepted

Learn more at acgcasereports.gi.org

practical guidance for non-experts. These Primers will

Siddharth Singh, MD, MS

serve as a research design introduction series, explaining

A Primer on Effectiveness and Efficacy Trials

• GI fellow, GI,Higgins, or private practice Amitresident G. Singal, interested MD, MS, PeterinD.R. MD, PhD, MSc, best practices for how to conduct and interpret research techniques both new and old, including commonly

clinician must be leadMD, author Akbar K. Waljee, MS

observed mistakes. The Editorial Board hopes that

A Primer on Predictive Models

Akbar K.Matthew Waljee, MD, MS, Peter Higgins MD, MSc, these brief summaries will ultimately help non-research Editor-in-Chief: Chin, MD |D.R. University of PhD, California, Irvine Amit G. Singal, MD, MS

clinicians better interpret studies, help researchers write better papers, and even help peer reviewers more by TS edited An Online JOURNAL of CASE REPOR Y & HEPATOLOGY FELLOWS

 READ all currently published Primers:at nature.com/ctg/primers.html. Submit your manuscript

ROLOG GASTROENTE confidently assess manuscripts in process. We hope to Chin, MD Editor-in-Chief: Matthew

add many more in the coming years.

CTG is a free, fully open-access journal, available to all readers mc.manuscriptcentral.com/acgcr 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 | 45


M CECUM THE CECU HING THE REACHING REAC

A Look Back

Schindler’s Gastroscopy Model This archival reflection originally appeared in The American Journal of Gastroenterology in November 2000.

R

udolf Schindler (1888–1968) has been called “The Father of Gastroscopy.” His name is held in reverence by every gastroenterologist who practiced in the early and mid-20th century. Schindler’s life-long devotion to successful gastroscopic visualization of the stomach, combined with his energy and clinical skills, resulted in the establishment of gastroenterology as a major specialty. By the late 19th century, rigid gastroscopes, which poorly illuminated the stomach, had been developed. They were inefficient, dangerous and not particularly useful. Schindler realized that a flexible instrument that provided excellent lighting was needed. In 1932, in collaboration with George Wolf in Germany, he developed an instrument

that overcame these problems. It was widely used into the mid-1960s when the fiber optic gastroscope was introduced. Illustrated here is Schindler’s original ceramic model that was made in the 1930s and was used to teach numerous gastroenterologists the art of gastroscopy. It now resides in the archives of the ASGE in Cleveland at the Dittrick Museum (courtesy of Eric Lee, MD, MACG). Schindler’s adherence to the idea of gastroscopy as an important diagnostic and therapeutic tool led to the establishment of the American Gastroscopic Club in 1941, which later became the ASGE.

By Robert E. Kravetz, MD, MACG Scottsdale, AZ 46 | GI.ORG/ACGMAGAZINE


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

ACG MAGAZINE Summer 2017

MEMBERS. MEDICINE. MEANING.

FINDING DISCOMFORT THE RACING LIFE OF DR. FRED POORDAD

gi.org/acgmagazine

Vol. 1 No. 1 // Spring 2017

Vol. 1 No. 2 // Summer 2017


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