ACG MAGAZINE | Vol. 2, No. 3 | Fall 2018

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ACG MAGAZINE Fall 2018

MEMBERS. MEDICINE. MEANING.

Banishing Banishing

Burnout Resilience Resilience Burnout& Building & Building Resilience


ACG MOBILE: ACCESS KEY RESOURCES

at the point of care

NEW DECISION SUPPORT TOOLS for ACG CLINICAL GUIDELINES

Developed in partnership with EvidenceCare 

Acute Diarrheal Infections

Mark S. Riddle, MD, DrPH, FACG

Anorectal Disorders

Philip O. Katz, MD, MACG

William E. Whitehead, PhD, MACG

C. difficile (Pseudomembranous Colitis) Dyspepsia Paul Moayyedi, MB, ChB, PhD, MPH, FACG

Helicobacter pylori (H. pylori) Infection William D. Chey, MD, FACG

Christina M. Surawicz, MD, MACG

Gastroesophageal Reflux Disease (GERD)

Lower GI Bleeding Lisa L. Strate, MD, MPH, FACG

Small Bowel Bleeding Jonathan A. Leighton, MD, FACG

DOWNLOAD THE ACG MOBILE APP Download the app via Google Play or Apple App Store.


FALL 2018 // VOLUME 2, NUMBER 3

FEATURED CONTENTS

COVER STORY

BANISHING BURNOUT & BUILDING RESILIENCE Dr. Christina Surawicz, Dr. Carol Burke and the ACG Professionalism Committee on physician burnout and wellness, personal and professional prevention strategies, and helpful resources. PAGE 22

GOVERNORS AT WORK

Dr. Tauseef Ali meets with Sen. Jim Inhofe’s staff in Oklahoma. Dr. Wilmer Rodriguez leads on hurricane relief.

Photo courtesy of Richard S. Bloomfeld, MD, FACG.

PAGE 13

GETTING TO YES

Five steps to negotiating alternative payment arrangements from Ann Bittinger, JD. PAGE 20

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Attend an upcoming

ACG POSTGRADUATE COURSE 2018 Hepatology School and ACG Midwest Regional Postgraduate Course Sheraton Indianapolis City Centre Hotel | Indianapolis, IN August 24–26, 2018

2018 IBD School and ACG/VGS/ODSGNA Regional Postgraduate Course Williamsburg Lodge | Williamsburg, VA September 7–9, 2018

ACG 2018 Annual Meeting and Postgraduate Course Pennsylvania Convention Center | Philadelphia, PA October 5–10, 2018 • Practice Management | October 5, 2018 • GI Pharmacology | October 5, 2018 • Pathology and Imaging | October 5, 2018

Regional courses

• ACG’s Postgraduate Course | October 6–7, 2018

• ACG’s Annual Scientific Meeting | October 8–10, 2018

2018 Hepatology School and Southern Regional Postgraduate Course JW Marriott Hotel | Nashville, TN November 30–December 2, 2018

2019 IBD School & Western Regional Postgraduate Course Cosmopolitan Hotel | Las Vegas, NV January 18–20, 2019

2019 ACG/FGS Annual Spring Symposium Naples Grande Beach Resort | Naples, FL March 1–3, 2019

2019 ACG/LGS Regional Postgraduate Course Hilton New Orleans Riverside | New Orleans, LA March 7–10, 2019

North American Conference of GI Fellows (NACGF)* Hyatt Regency Grand Cypress | Orlando, FL March 22–24, 2019 *NACGF is by application only and free to selected participants.

2019 Hepatology School & Eastern Regional Postgraduate Course Marriott Marquis | Washington, DC June 7-9, 2019

FOR MORE INFO, VISIT: GI.ORG/ACG-COURSE-CALENDAR


FALL 2018 // VOLUME 2, NUMBER 3

CONTENTS

“Hiring the right employees, who are engaged to work effectively in your practice culture, is paramount and should be one of the highest priorities.” —Dr. David Limauro and Dr. Louis Wilson, “Human Resource Management and Staff Development in Your Practice: Hiring and Keeping the Best Staff,” PG 17

6 // MESSAGE FROM THE PRESIDENT Dr. Irving Pike offers kudos for some great news involving College programs and priorities.

20 LAW MIND Five steps to negotiating alternative payment arrangements from Ann Bittinger, JD.

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

22 // COVER STORY 7 // NOVEL & NOTEWORTHY Physicians in the news, assuming leadership positions, publishing books, and more.

13 // PUBLIC POLICY 13 GOVERNORS’ VANTAGE POINT Sen. Jim Inhofe’s staff meets with ACG Governor for Oklahoma Dr. Tauseef Ali in Oklahoma City. 15 GOVERNORS’ VANTAGE POINT ACG Governor for Puerto Rico Dr. Wilmer Rodriguez takes the lead on hurricane relief.

17 // GETTING IT RIGHT

BANISHING BURNOUT & BUILDING RESILIENCE Dr. Christina Surawicz, Dr. Carol Burke and the Professionalism Committee take on physician burnout and offer prevention strategies.

35 // ACG PERSPECTIVES 35 A FRESH LOOK AT THE INSIDES Dr. Bhavana Bhagya Rao on the continuing journey of a trainee. 37 CLINICAL RESEARCH Dr. Nicholas Shaheen on funding promising careers in clinical research and an introduction to ACG’s Junior Faculty Development awardees.

17 BUILDING SUCCESS How to hire and retain great staff members.

43 // INSIDE THE JOURNALS 44 AJG Dr. Gary Lichtenstein identifies clinical implications and key points from the new ACG Guideline on Management of Crohn’s Disease. 45 CTG Characteristics of the bacterial microbiome in association with common intestinal parasites in IBS; Brain fogginess, gas and bloating. 46 ACGCRJ Meet the new Editorial Board and hear from its Editor-in-Chief, Dr. Samuel Han.

48 // REACHING THE CECUM A LOOK BACK: PATENT MEDICINE Reviewing the heyday of patents medicine in the 19th century: curative claims, common ingredients and eventual regulation.

Cover illustration and cover story spread courtesy of Davide Bonazzi. Born and raised in Bologna, Italy, Bonazzi is an award-winning illustrator working for major publishers, advertisers, institutions and animation studios.

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ACG MAGAZINE MAGAZINE STAFF

CONNECT WITH ACG

Executive Director Bradley C. Stillman, JD

youtube.com/ACGastroenterology

Editor in Chief; Vice President, Communications Anne-Louise B. Oliphant Managing Editor; Senior Writer Brian C. Davis Copy Editors; Staff Writers Sarah Richman Lindsey Topp

facebook.com/AmCollegeGastro

twitter.com/amcollegegastro

instagram.com/amcollegegastro

bit.ly/ACG-Linked-In

Art Director Emily Garel Graphic Designer Antonella Iseas

BOARD OF TRUSTEES President: Irving M. Pike, MD, FACG President-Elect: Sunanda V. Kane, MD, MSPH, FACG Vice President: Mark B. Pochapin, MD, FACG Secretary: Samir A. Shah, MD, FACG Treasurer: David A. Greenwald, MD, FACG Immediate Past President: Carol A. Burke, MD, FACG

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

ACGMag@gi.org

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

Past President: Kenneth R. DeVault, MD, FACG Director, ACG Institute: Nicholas J. Shaheen, MD, MPH, FACG Co-Editors, The American Journal of Gastroenterology: Brian E. Lacy, MD, PhD, FACG

DIGITAL EDITIONS

GI.ORG/ACGMAGAZINE

Brennan M. R. Spiegel, MD, MSHS, FACG 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 Immanuel K. H. Ho, MD, FACG Caroll D. Koscheski, MD, FACG Paul Y. Kwo, MD, FACG Jonathan A. Leighton, MD, FACG Amy S. Oxentenko, MD, FACG Daniel J. Pambianco, MD, FACG David T. Rubin, MD, FACG John R. Saltzman, MD, 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

Tauseef Ali, MD, FACG

Gary R. Lichtenstein, MD, FACG

Dr. Ali, of Saint Anthony Hospital and the University of Oklahoma, is the ACG Governor for Oklahoma and is a member of the ACG Public Relations Committee.

Dr. Lichtenstein, of the University of Pennsylvania, is an author on the recently published ACG Clinical Guideline on Management of Crohn’s Disease in Adults.

Ann M. Bittinger, JD

David L. Limauro, MD, FACG

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

Dr. Limauro, of Pittsburgh Gastroenterology Associates, is a member of the ACG Practice Management Committee.

Carol A. Burke, MD, FACG Dr. Burke, who is Immediate Past President of the ACG, is of the Cleveland Clinic Foundation in Cleveland, OH.

Bhavana Bhagya Rao, MD Dr. Rao, of the Cleveland Clinic Foundation in Cleveland, OH, writes about the evolving journey of a trainee.

Nicholas J. Shaheen, MD, MPH, FACG Samuel Han, MD Dr. Han, of the University of Colorado, is the new Editorin-Chief of the ACG Case Reports Journal.

Dr. Shaheen, of the University of North Carolina at Chapel Hill, is the Director of the ACG Institute for Clinical Research & Education.

Christina M. Surawicz, MD, MACG 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 about ACG’s History: gi.org/about-acg/#Anniversary

Dr. Surawicz is the Chair of the ACG Professionalism Committee and is a Past President of the College (1998-1999).

Louis J. Wilson, MD, FACG Dr. Wilson is a gastroenterologist and the managing partner of Wichita Falls Gastroenterology Associates, a seven-physician single-specialty group. He is the current Chair of the ACG Practice Management Committee and a frequent author and speaker for ACG on practice management.

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MESSAGE FROM THE PRESIDEN

KUDOS!

Clinical Data Registry (QCDR) under Medicare. Unleashing the research potential of the registry is a major priority for GIQuIC, a joint initiative of ACG and ASGE under the leadership of Dr. Glenn Eisen. Dr. David Greenwald chairs GIQuIC’s Research Committee, and he recently reported that findings from analyses of GIQuIC data generated five DDW abstracts this year, including two oral presentations. Findings based on GIQuIC data will also be presented at ACG in Philadelphia this fall, and I look forward to seeing how researchers are mining this rich dataset for insights applicable to GI endoscopic practice.

It’s an honor to report on some great news involving College programs and priorities so closely aligned to the pillars of our mission: ACG’s journals, education, dedication to quality improvement, and advocacy at the state and federal levels on behalf of you—the members of ACG.

TRACKING THE PULSE OF CRITICAL ISSUES: ACG GOVERNORS

IMPACT FACTORS ON THE RISE FOR AJG AND CTG Reports of the 2017 journal impact factors reveal increases for both The American Journal of Gastroenterology and Clinical and Translational Gastroenterology. At 10.231, AJG holds the top place for journals publishing original clinical GI science. The growing clout of CTG is accompanied by an increase in impact factor to 4.621, up from 3.923 last year. The consistent quality and the usefulness of the College’s journals as a way for GI clinicians to keep abreast of the most timely and relevant research, guidelines, and practice insights is particularly meaningful. Congratulations are in order on the outstanding work by AJG’s Co-Editors-in-Chief Dr. Brian Lacy and Dr. Brennan Spiegel and CTG’s Editor-in-Chief Dr. David Whitcomb, along with the editorial boards they oversee.

RECORD-SETTING ABSTRACTS SUBMITTED Clinical GI investigators submitted a record number of abstracts for the upcoming Annual Scientific Meeting this October in Philadelphia. With total submissions of just under 3,100, this robust showing is a harbinger for a vibrant and well-attended meeting that showcases clinical research impacting GI patient care. The continued upward growth in abstracts is a testament to the excellence of the educational program, developed by the Educational Affairs Committee chaired by Dr. Seth Gross.

GIQUIC HITS MILESTONES AND MATURES AS A DATASET FOR RESEARCHERS Major milestones and meaningful growth are a continued theme for the GI Quality Improvement Consortium (GIQuIC) registry which is implemented in 650 locations representing over 475 entities, and used by more than 4,500 physicians. The registry now boasts data on more than six million colonoscopies and just surpassed the one million mark for EGDs. The exponential growth in procedures tracks the maturation of the registry and the growing usefulness of GIQuIC as a Quality

6 | GI.ORG/ACGMAGAZINE

“As this step

therapy issue bubbled up from the state level thanks to the voices of the Governors, ACG saw an opportunity to play a leading role in this issue.” 

An essential role for the College’s Board of Governors is to identify hot topics in their states and regions impacting the GI profession and bring them to the forefront for action at the national level. The issue of prior authorization requirements by commercial insurers and state-level legislation on step therapy shows just how well attuned and responsive the ACG Governors are. Last year, when the Governors convened in 2017 for their Fly-In visit to Capitol Hill and met to discuss their concerns, and emerging from their reports throughout the year, the issue of insurance denials and the need for prior authorization for medications was becoming more prevalent around the country. At the same time, state legislatures in Minnesota, Massachusetts, Ohio and elsewhere introduced bills limiting insurers’ ability to implement “fail first” drug therapy requirements, in which patients are forced by insurers to try and fail with one or more medications before the cost of the medication their doctor originally prescribed will be covered. As this step therapy issue bubbled up from the state level thanks to the voices of the Governors, ACG saw an opportunity to play a leading role in this issue. Step therapy was a priority agenda item when the Governors returned to Washington in 2018 for their visits with the United States Congress, including support for the "Restoring the Patient's Voice Act of 2017” (H.R. 2077) introduced by U.S. Representative Brad Wenstrup (ROH). The bill would allow for exemptions to be made to the step therapy protocol to remove current barriers and allow patients to gain access to the medication they need at a faster pace. This is just one of many examples of the exemplary work by the Governors, ably shepherded by Chair Dr. Costas Kefalas and Vice Chair Dr. Douglas Adler, who keep a keen focus on the issues that matter most to practicing gastroenterologists and give voice to their interests and priorities at the state and national level.

­­—Irving M. Pike, MD, FACG


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 GI news and innovation. In this issue, ACG MAGAZINE highlights the authors of the recently published IBS Monograph and features physicians in the news, assuming leadership positions, publishing books, and more. Email your news and any ideas for future issues of ACG MAGAZINE to ACGMag@gi.org

Novel & Noteworthy | 7


// N&N

[EVENTS]

PATRICK E. YOUNG, MD, FACG

On May 4, Dr. Young presented on “Common GI Problems in Women” as part of Women’s Health 2018: Translating Research into Clinical Practice, in Arlington, VA. The event featured presentations on interdisciplinary women’s health topics intended for “primary care physicians, nurse practitioners, nurses, physician assistants, and other healthcare professionals focused on women’s health in family practice, internal medicine, and obstetrics and gynecology." Young is ACG’s Governor for the Military and is Director, Digestive Diseases Division, and Professor of Medicine, H. Edward Hebért School of Medicine at the Uniformed Services University of Health Sciences in Bethesda, MD.

[BOOKS]

SAMUEL P. HARRINGTON, MD On February 6 retired gastroenterologist Dr. Sam Harrington published the book, “At Peace: Choosing a Good Death After a Long Life,” which addresses end-of-life decisionmaking and care. The book “outlines active and passive steps that older patients and their health-care proxies can take to ensure loved ones live their last days comfortably at home and/or in hospice when

8 | GI.ORG/ACGMAGAZINE

further aggressive care is inappropriate." In a February 26 piece in The Washington Post titled “Failing to tell patients that nothing will help may only make them suffer more,” Harrington recalls a time he was called to the emergency room late in his career while he was on call for a colleague. The patient, who had metastatic colon cancer, had recently undergone several tests and treatments. “Nobody had looked at him as a whole being. No one had told him that he was terminally ill. No one had told him that his symptoms might be reduced by palliative care but could not be eliminated,” Harrington wrote. Harrington’s website says the book “offers a path and a story that guides the reader through this maze of problems.”  LEARN MORE about the book: bit.ly/Sam-Harrington  READ the piece in The Washington Post: bit.ly/Harrington-WP

[MILESTONES]

CYNTHIA A. MOYLAN, MD, MHS Dr. Moylan, of Duke University Medical Center, was recently promoted to Associate Professor of Medicine. Moylan, who was the recipient of a 2015 ACG Junior Faculty Development Award for Epigenetics and the Development of Nonalcoholic Fatty Liver Disease, was promoted in recognition of her “research program in genomics/epigenetics in liver disease, contributions to the Durham VA practice, and her commitment to education,” according to a tweet from the Duke Division of Gastroenterology.

[MILESTONES]

MARCH E. SEABROOK, MD, FACG In April, Dr. Seabrook became the 157th president of the South Carolina Medical Association (SCMA), an organization founded in 1848. The SCMA counts nearly 6,000 physicians as its members. The organization’s purpose is “to support the

efforts of South Carolina physicians and to advocate for quality medical care and good health for the citizens of South Carolina.” Seabrook, of Consultants in Gastroenterology in Columbia, SC, serves on ACG’s Legislative and Public Policy Council and is the College’s representative to the American Medical Association House of Delegates. “I would like to express my appreciation to my physician partners and staff as well as to my wife and family for their support,” Seabrook said.


[MILESTONES]

MIGUEL D. REGUEIRO, MD, FACG In May, Dr. Regueiro joined Cleveland Clinic as the new Chair of Gastroenterology & Hepatology, Vice Chair, Digestive Disease and Surgery Institute, and Professor of Medicine, Cleveland Clinic Lerner College of Medicine. “I am incredibly honored to be joining the Cleveland Clinic and the wonderful team of physicians and health care providers within the Department of Gastroenterology and Hepatology in the Digestive Disease and Surgery Institute,” Regueiro told ACG MAGAZINE. Before departing in March, Regueiro had worked for the University of Pittsburgh Medical Center (UPMC) since

[IN THE NEWS]

January 2000. He described to ACG MAGAZINE his feelings about joining Cleveland Clinic. “The culture of Cleveland Clinic as a physicianled organization is unique and the plans for population-based medicine innovative. I am eager to work with my colleagues on transformational health care delivery, cutting-edge research, and the advancement of medical education,” he said.

[MONOGRAPHS]

MONOGRAPH PUBLISHED ON MANAGEMENT OF IBS ON JUNE 27, 2018, the updated systematic review on irritable bowel syndrome was published as a Supplement to The American Journal of Gastroenterology. IBS Monograph authors: Alexander C. Ford, MB ChB, MD, FRCP; Paul Moayyedi, BSc, MB ChB, PhD, MPH, FACG, FRCP, FRCPC; William D. Chey, MD, FACG,

At the conclusion of his tenure at UPMC, Regueiro was Medical Director of the Inflammatory Bowel Disease Center and Associate Chief for Education in the Division of Gastroenterology, Hepatology and Nutrition, as well as serving as the Senior Medical Lead of Specialty Medical Homes and Professor of Medicine and Professor of Clinical and Translational Science.

RONALD J. VENDER, MD, FACG AMA Wire published a Q&A with Dr. Vender as part of its “Members Move Medicine” series, which features doctors who are “navigating new courses in American medicine.” Vender answers what "moving medicine" means to him, who

inspires him, and what have been his hardest moments in medicine, among many other questions. Which work means the most to him? “Nothing is more important than caring for our patients. Each day we see human nature at its most trying moments, we hear intimate stories, we are entrusted by our fellow humans, and we have the opportunity to offer comfort, hope and healing.” Vender is an ACG Past President, Professor of Medicine and Associate Dean for Clinical Affairs at Yale School of Medicine, and Chief Medical Officer, Yale Medicine.  READ the full Q&A: bit.ly/Vender-AMA

[MILESTONES]

JOHN M. CARETHERS, MD, FACG Dr. Carethers recently took over as President of the Association of American Physicians (AAP). Carethers, who is the John G. Searle Professor and Chair of the Department of Internal Medicine at the University of Michigan, was selected to become the 2018–2019 President in early 2017. AAP was “founded in 1885 by seven physicians, including Dr. William Osler and Dr. William Henry Welch, for ‘the advancement of scientific and practical medicine,’” according to the organization’s website.

FACP; Lucinda A. Harris, MD, FACG; Brian E. Lacy, MD, PhD, FACG; Yuri A. Saito, MD, MPH, FACG; and Eamonn M. M. Quigley, MD, MACG, FRCP, FACP, FRCPI, for the ACG Task Force on Management of Irritable Bowel Syndrome.  READ the ACG Monograph on Management of Irritable Bowel Syndrome: rdcu.be/2JFv

Novel & Noteworthy | 9


ACG CALENDA

24

25–26

HEPATOLOGY SCHOOL AT MIDWEST REGIONAL

ACG MIDWEST REGIONAL POSTGRADUATE COURSE

 Indianapolis, IN

 Indianapolis, IN

More info: gi.org/regional-meetings

More info: gi.org/regional-meetings

21

ACG 2018

Late-breaking Abstracts DEADLINE Submit your abstract:

AUGUST

AUGUST

AUGUST

conferenceabstracts.com/acg2018.html

ACG 2018

SEPTEMBER

ANNUAL SCIENTIFIC MEETING & POSTGRADUATE COURSE

7–9

October 5–10, 2018

Pennsylvania Convention Center Philadelphia, PA

acgmeetings.gi.org

AC G 2O18 O CTO B E R 5 – 1 O, 2 O 1 8 The Premier GI Clinical Meeting & Postgraduate Course

IBD SCHOOL AND ACG/ VGS/ODSGNA REGIONAL POSTGRADUATE COURSE  Williamsburg, VA More info:

gi.org/regional-meetings

NOVEMBER

30

DECEMBER

1–2

DECEMBER 7 HEPATOLOGY SCHOOL AT SOUTHERN REGIONAL  Nashville, TN

SOUTHERN REGIONAL POSTGRADUATE COURSE  Nashville, TN More info: gi.org/regional-meetings

ACG INSTITUTE

RESEARCH GRANTS DEADLINE More info: gi.org/grant-announcements

DECEMBER 13–15 ADVANCES IN INFLAMMATORY BOWEL DISEASES (AIBD 2018)

 Orlando, FL More info: advancesinibd.com

10 | 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 ECGs 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-U

May 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* †

Aligned with Gastrointestinal Quality Improvement Consortium (GIQuIC) performance target of ≥85% quality cleansing for outpatient colonoscopies.4

*This clinical trial was not included in the product labeling. †Based on investigator grading. References: 1. IMS Health, NPA Weekly, May 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-U

May 2017


PUBLIC

POLICY // GOVERNORS' VANTAGE PINT

INVITATION ACCEPTED

From Capitol Hill to Oklahoma City, Senator Inhofe's Staff Visits Saint Anthony Hospital By Tauseef Ali, MD, FACG, ACG Governor for Oklahoma, Saint Anthony Hospital and the University of Oklahoma

BACK IN APRIL, I joined more than 50 ACG Governors and members of the ACG leadership to advocate on Capitol Hill on your behalf at the 2018 ACG Board of Governors Legislative Fly-In. During the Fly-In, I had the opportunity to meet with Senator Jim Inhofe’s (R-OK) staff, and invited them to come have a personal tour of our endoscopy lab back home in Oklahoma. I recognized the mutual importance in this opportunity for both ACG members and his staff: they could learn more about colonoscopy from our perspective, and meet with the endoscopy nurses and team in order to gain first-hand knowledge and to better understand and advocate for GI-related issues in Washington, DC. In June, Senator Inhofe’s staff graciously toured our facility. During our meeting together at lunch, we sat down and discussed the issues I and other ACG leaders highlighted in April: colon cancer screening awareness, establishing exemptions for insurer step therapy, and the negative impact of prior authorization regulations. We discussed the “Removing Barriers to Colorectal Cancer Screening Act (S. 479/H.R. 1017),” which fixes a Medicare coverage quirk by waiving Medicare beneficiary cost-sharing when screening colonoscopies turn therapeutic. I also addressed the “Restoring the Patient’s Voice Act of 2017 (H.R. 2077),”  Public Policy | 13


// PUBLIC POLICY: GOVERNORS' VANTAGE POINT

Top left: Dr. Tauseef Ali addresses the ACG Governors during the ACG Board of Governors Legislative Fly-In. Photo in the top right and on page 13 courtesy of Dr. Ali.

which allows for exemptions for step therapy requirements in health plans regulated by federal law. Step therapy entails the “fail first” drug therapy requirements, in which patients are forced by insurers to try and fail with one or more medications before the insurer approves the cost of the medication which ACG members originally prescribed. Senator Inhofe’s staff also had the opportunity to meet directly with the staff member of our clinic who is in charge of handling our prior authorization requests, and heard the details of our daily difficulties with this process. ACG Governors and members continue to express their frustration over the amount of time and resources GI practices spend dealing with insurers and prior authorizations, to the detriment of patient care. These policies are not rooted in clinical evidence, and ultimately take valuable time away from treating patients. In a recent study by the American Medical Association (see bit.ly/AMAStudy) surveying 1,000 physicians, 92% of participants stated that prior authorization issues delayed their patients’ access to necessary care, and carried an overall negative impact on patient outcomes. Senator Inhofe’s staff expressed their appreciation for the College, its mission and for the opportunity to be educated on these issues. They plan on visiting again in the near future to sit in on a colonoscopy and to listen to more of these concerns. This is just one example of how my role as an ACG Governor on behalf of the College can 14 | GI.ORG/ACGMAGAZINE

“In a recent study by the American Medical Association surveying 1,000 physicians, 92% of participants stated that prior authorization issues delayed their patients’ access to necessary care, and carried an overall negative impact on patient outcomes.”

be impactful at the federal, state and local level. The ACG Board of Governors is one of the most unique aspects of the American College of Gastroenterology. Governors are ACG Fellows who are elected by the membership of their particular state or region. There are currently 77 Governors across seven different regions in the U.S. and abroad. The Board of Governors acts as a two-way conduit between College leadership and the membership at large. This helps the College make certain it is meeting the evolving needs of the membership. I welcome you to reach out to your ACG Governor to bring to light any other issue at the local and state level that is important to you, your practice and your patients. We recognize the significance and power of advocacy at the local, grassroots level. It not only helps to resolve the issues impacting your state, but also sends a message to representatives on Capitol Hill by creating a larger voice and momentum for federal GI-related legislation and concerns.

 We would like to hear from you. Contact your Governor today: gi.org/governors


 ACG Governor for Puerto Rico Wilmer Rodriguez, MD, FACG, meets with Representative Jenniffer González-Colón (R-PR) on Capitol Hill.

Taking the LEAD

Dr. Wilmer Rodriguez Recognized for Leadership on Hurricane Relief  In the days leading up to the June 2018 American Medical Association (AMA) Annual Meeting of the House of Delegates, AMA Wire published an article— “Physicians helped boost aid for Puerto Rico, U.S. Virgin Islands”—recapping the steadfast efforts of ACG Governor for Puerto Rico Wilmer Rodriguez, MD, FACG, to secure aid for Puerto Rico and the U.S. Virgin Islands in the wake of the 2017 hurricane devastation. The efforts can be traced back to last fall when, at Rodriguez’s suggestion, ACG submitted an emergency resolution to the November 2017 AMA Interim Meeting of the House of Delegates. Resolution 235 urged the AMA, the House of Medicine, and U.S. policymakers to provide more support for hurricane disaster relief efforts for Puerto Rico and the U.S. Virgin Islands. Through the leadership of Rodriguez and ACG Delegates R. Bruce Cameron, MD, FACG, and March E. Seabrook, MD, FACG, the resolution passed with overwhelming support, which made advocating for Medicaid funding and regulatory waivers a part of AMA’s public policy objectives. Ultimately, the Bipartisan Budget Act of 2018 provided $143 million for the U.S. Virgin Islands and $4.8 billion in Medicaid funding for Puerto Rico. Medicaid funding for Puerto Rico was especially important

BIPARTISAN BUDGET ACT OF 2018 BY THE NUMBERS

MEDICAID FUNDING

$143 Million FOR U.S. VIRGIN ISLANDS

$4.8 Billion FOR PUERTO RICO

BEFORE THE HURRICANES...

49%

OF U.S. CITIZENS ON PUERTO RICO ENROLLED IN MEDICAID

because, even before the hurricanes, 49% of U.S. citizens on the island were enrolled in its Medicaid program, 46% of Puerto Ricans were below the federal poverty level, and annual federal funding for Puerto Rico is capped, unlike the 50 states and Washington, DC. In speaking with AMA Wire for the article, Rodriguez expressed his sincere gratitude for the resolution passing, while also cautioning that more will likely need to be done. “‘It solved the problem for now,’’’ he said, “‘But it won’t solve the problem forever.’” During a meeting at the 2018 ACG Board of Governors’ Spring Meeting and Washington, DC Fly-In, Rodriguez presented to the Governors about the devastation in Puerto Rico, the efforts to get the resolution passed, and evolving concerns in Puerto Rico including, among other issues, a physician shortage, as many physicians have moved or plan to move to the mainland United States following the devastation. ACG is grateful to Dr. Rodriguez, Dr. Cameron and Dr. Seabrook for the time and effort they dedicated to this important initiative. This is a pivotal example of the role that the ACG Board of Governors can play in serving as a two-way conduit between College leadership and the membership, quickly acting to meet the evolving needs of the membership. Remember to contact your ACG Governor on important state and local issues impacting you and your practice.

 Contact your ACG Governor: gi.org/governors

 46%

OF PUERTO RICANS WERE BELOW FEDERAL POVERTY LEVEL

READ the AMA Wire story: bit.ly/WRodriguez

Public Policy | 15


Accessible. Relevant. Practical.

The information you need to improve your practice. The ACG Practice Management Committee’s mission is to equip College members with accessible tools to overcome management challenges, improve operations, enhance productivity, and support physician leadership in their private and physician-led clinical practices. Learn from practicing colleagues through monthly articles on topics important to you. Articles include a topic overview, suggestions, examples, and a list of resources or references.

Toolbox topics will include

• Alternative Payment Models (APMs)

• Patient Satisfaction Surveys & Engagement

• Merit-Based Incentive Program Systems (MIPS)

• Reviewing & Updating Informed Consent

• Medicare Compliance & Preparation for RAC Audits

• Developing an Infection Control Plan

• Reviewing & Maximizing Revenue Cycle Efforts

• Professional Society Opportunities & Involvement

• Reviewing & Negotiating Insurance Contracts

• Quality Improvement Projects in Your Practice

"Pressures are high as gastroenterologists make important management decisions that profoundly affect their business future, their private lives, and their ability to provide care to patients." —Louis J. Wilson, MD, FACG

Start Building Success Today. GI.ORG/TOOLBOX


it Right GETTING

GETTING

IT

Hiring & Keeping the BEST STAFF // BUILDING SUCCESS

Human Resource Management and Staff Development in Your Practice David L. Limauro, MD, FACG, Pittsburgh Gastroenterology Associates, Pittsburgh, PA

Louis J. Wilson, MD, FACG, Chair, ACG Practice Management Committee, Wichita Falls Gastroenterology Associates, Wichita Falls, TX

This article is part of a series sponsored by the ACG Practice Management Committee. See more: gi.org/toolbox

 THE STAFF OF A MEDICAL PRACTICE PLAYS A CRITICAL ROLE IN THE HEALTH OF THE BUSINESS and may have dramatic effects on the patient experience. Despite that, many physicians were never trained to properly manage the people they employ or be the best leader for their staff. A happy staff means happy patients. Some of the most crucial elements of this process involve the hiring, training, appraising and compensation of employees. This ACG Practice Management Toolbox article focuses on the important aspect of staff management and development. Creating a strategic plan for your practice involves setting a goal (likely a mission statement stating that goal) and creating the map on how to get to that place. Medical practices that can find and retain great employees who believe in that strategic goal will be crucial in creating success or failure. Hiring the right employees, who are engaged to work effectively in your practice culture, is paramount and should be one of the highest priorities. Excellent employees can accelerate and grow your practice, while poor employees can not only stunt growth and destroy good morale, but also potentially land you in the court house. 

Getting it Right | 17


// GETTING IT RIGHT: BUILDING SUCCESS

ASSESSING MANPOWER A structured assessment of manpower is the first step of properly hiring staff. The principles of a manpower review are listed below:

 Start with a review of the organizational chart. Does everyone have an immediate supervisor? Is the supervisor structure adequate? Do supervisory positions need to be created or enhanced? Is there a clear chain of command?

 Match staff positions to important tasks. Is the number of FTEs adequate to accomplish all necessary tasks? Are there important secondary tasks being neglected due to inadequate staffing?

THE NEEDS ASSESSMENT: THE 360-DEGREE APPROACH

FINDING EMPLOYEES In the past, hiring employees might have involved posting ads in the newspaper and reviewing applicants by mail or in person. Now employees are more likely to be found online. They are searching job websites like monster. com, careerbuilder.com or even your own practice website. When posting for a new position, include the job requirements, expectations, the dates by which the application must be completed, and multiple ways for the applicant to contact you (including online through your website). Do not forget to highlight the benefits of working for your organization, and perhaps something that sets your practice apart from others that might be filling the same or a similar position. Another excellent and cost-effective way to find employees is through your current employees. Consider offering a cash bonus to current employees who refer a friend. Staying in touch with valued former employees who might return—or send new recruits—is also recommended.

18 | GI.ORG/ACGMAGAZINE

Before practices can adequately train employees, there should be a comprehensive needs assessment for the workplace. There has to be recognition of what is needed against what skills your current staff already possesses. HR experts tout a “360-degree” evaluation and feedback process. This 360-degree concept can be applied to both the review and also the evaluation process. It entails more than simply acquiring an in-house manager’s view of employee skills. Rather, ideally feedback is obtained from those who work “above,” “below” and “with” the employees. These reviews would also include input from patients and customers, and would give an assessment to the medical practice trying to design the training programs in order to improve employee skills. Managers can organize 360 feedback using published, standardized assessment tools or customized organizationrelated tools, or hire an outside HR professional or training consultant.

 Adjust the staffing plan to resolve issues in the manpower review. Consider the most costeffective and efficient solutions to manpower needs. This might mean hiring temporary versus permanent employees or unlicensed employees for tasks that do not require a license.

 Cross-training should always be considered as a less disruptive way to meet staffing needs. Each employee can be trained to function in a variety of roles. This increases flexibility and improves communication between staff members who will better understand the critical tasks and work demands of their colleagues.

STAFF TRAINING Once the employee and employer needs are assessed and reviewed, an action plan for training can be developed. Adults learn in different ways. Practices should develop training plans that are both economically feasible and suitable for different learning styles. This might include creating a course in house, buying off-the-shelf training manuals or computer programs, PowerPoint lectures or presentations, identifying an in-house trainer, and hiring outside trainer(s) or even consultants to develop the work staff in the desired direction. Another training method that should not be forgotten is the possibility of mentoring. Frequently physicians or managers are an ideal position for this type of training, which can be formal or informal.

Training Areas Training in important areas should occur periodically. These might include:  Customer service  Telephone call etiquette and protocol  Infection-control practices  Patient confidentiality and the Health Insurance Portability and Accountability Act  Communication and conflict resolution  Electronic record system optimization

INTERVIEWING PROSPECTIVE EMPLOYEES When interviewing job candidates for a new position, save everyone’s time and let the job seeker know the salary range

A

Q

at the beginning of the process. During the interview, to avoid hiring the wrong person for the skills needed, use behavioral interviewing. The behavioral interview is carefully planned and based on the principal that past job performance will predict future behavior and the likelihood of success. Good behavioral interview questions are open ended, for example: tell

me about a time when…; give me an example of when you….; describe for me…; etc. Interview questions should be tailored to the position being filled. Access a list of excellent interview questions for prospective managers on page 13 of the online version of this article: bit.ly/HR-StaffDev


PRACTICAL SUGGESTIONS

PROPER COACHING OF STAFF

ANNUAL PERFORMANCE REVIEWS

According to author Leigh F. Branham, “Lack of feedback is the number one reason for performance problems.” Most employees want to do a good job, but also expect to be told how they are doing within the practice. To be most effective, managers must give not only annual feedback, but rather frequent, ongoing communication to their employees. If this is done correctly, there is feedback throughout the year, and then the formal annual or semiannual performance appraisal offers no significant surprises. There still should be a formal performance evaluation, which for the employee can set guideposts for their work and allow for discussion about future goal setting. For managers (or physician managers in many cases), the assessment helps develop rapport with employees, allows assessment of good and poor performance, and likely identifies employees that should be given raises or further compensation.

Annual performance reviews are a critical part of practice management and staff development. When used properly, these reviews improve morale and productivity, as well as support your practice’s budget, wage structure and organizational structure. Annual performance reviews must be done consistently and documented properly. Performance reviews should be done prior to the end of the year—perhaps in the summer—so that budgetary planning, bonus items and staffing issues can be planned in advance of end-of-year decisions. Many experts recommend semi-annual reviews. There are many types of appraisals: checklist, essay, graphic scale, group order ranking, individual ranking, and pair comparison that can be done and are defined elsewhere. The tone of the review is important. Managers should communicate in a positive

PRINCIPLES OF PROPER COACHING

Principles of Effective Performance Reviews

 Coaching conversations should promote learning. It is best to use words like improve, learn, develop and grow. Doing this will help your staff develop their own insights.  Coaching conversations should start with a statement of your positive intention. You can do this by saying something like “I want to improve how we work together” or “I want to help you think creatively.”  During coaching conversations, always try to put your staff at ease and build trust. Try to make your staff feel competent and capable.  Ask questions of your staff and listen to the answers carefully. Approach staff development conversations as a learning opportunity for yourself.  Rather than immediately stressing details, focus on the result. This is a solutionsoriented approach. Ask questions like “What would success looks like?”

 Performance reviews should be done at least annually, best early in the year or summer. Many experts recommend semi-annual performance reviews.  A budget should be set by your practice leadership for raises.  Raises should always be tied to the performance reviews.

tone while clearly delineating both strengths and weaknesses, including specific examples. Job results should be discussed, and excessive criticism should be avoided. The meeting should not be rushed, and employees should be given ample time to actively participate. At the end of the meeting, ideally both employer and employee would collectively problem solve any issues and would then mutually set goals for the next review period. At the end of the review, employees should sign and date the form. Confidentiality on both sides should be stressed. The employee should be reminded that the evaluation process is continuous throughout the year and that the door is open to discuss employee performance and practice improvement.

 Each employee’s performance review should include an action plan to be accomplished by the next year’s review.  Performance reviews are signed by the employee, manager and physician leadership and added to the employee file.  A copy of the review should be given to the employee.

RESOURCES AND SUGGESTED READING

1. Armstrong S, Mitchell B, The Essential HR Handbook, Career Press, 2008. 2. Branham, L. The 7 Hidden Reasons Employee Leave. New York, AMACOM, 2005. 3. Website for the Society for Resource Management: www.shrm.org. 4. Lozar Glenn, Joanne, Mentor Me: A Guide to Being Your Own Best Advocate in the Workplace. Roanoke, VA: National Business Education Association. 2003. 5. Simon Sinek, How great leaders inspire action: www.ted.com/talks/simon_sinek_ how_great_leaders_inspire_action.

 Do not forget that your employees are your most valuable resource. Treat them as such.  Set a practice strategic plan to know where you are going and how you plan to get there.  Consider an employee referral program. Your current employees will want the new employee choice to reflect well on them personally and will have the opportunity to positively affect the practice culture.  Keep in touch with former employees that you would consider hiring again, particularly if they left for another job or educational opportunity and might come back with new skills.  To make the best hires, prepare an excellent job description. Be a good listener and use behavioral interviewing: a systematic, analytical and objective technique to interview job applicants.  If you want to increase productivity, start with a manpower review and follow with clear job descriptions.  Take a proactive, personal approach to employee development. Endeavor to find ways to mentor the employees with the highest potential.  Use continuous feedback in addition to annual or semi-annual performance reviews.

6. See medical.gppcpa.com/enewsletters/ article/staff_engagement_leads_to_staff_ loyalty/. 7. See avvartes.com/in-every-person-there-isa-sun/. 8. Buckingham, M., Clifton D., Now, DiscoverYour-Strengths, Gallup Press, 2001.

READ the online version of this ACG Practice Management Toolbox chapter to access a sample performance review form and a list of sample interview questions for prospective managers: bit.ly/HR-StaffDev

Getting it Right | 19


GETTING to YES // LAW MIND

FIVE STEPS to Negotiating Alternative Payment Arrangements By Ann M. Bittinger, JD, a health care attorney with physician group clients across the country. Questions? Email ann@bittingerlaw.com

 WARNINGS THAT THE CENTERS FOR MEDICARE AND MEDICAID SERVICES

will do away with fee-forservice reimbursement to physicians has been a` bit like the boy who cried wolf. Although much has been said and written on forecasted reforms to the Medicare Physician Fee Schedule—to pay package rates per episodes of care or to expand global fees—gastroenterologists have not seen those ideas implemented nationally. The warnings that “If your

20 | GI.ORG/ACGMAGAZINE

practice doesn’t restructure itself to provide services other than fee-for-service, it will become bankrupt” haven’t materialized. That being said, many physicians and private payers heeded the warnings. They did not wait for Medicare to dismantle the Fee Schedule. The change is happening faster in the private sector in some markets than with Medicare. Innovative payers and physician groups are collaborating to creatively address payment regardless of when the Medicare-mandated changes may occur. Just as politics makes strange bedfellows, otherwise-

non-aligned payers are meeting physician groups at the drawing board to develop ways to align payment with quality of care. How can a GI practice execute this type of negotiation?

INVESTIGATE THE PAYER AND ITS INNOVATION LEADERS First, do your research about the payer. Identify the right person handling gastroenterology global or bundled reimbursement modeling. Most payers have departments in charge of physician

group “innovation.” These are people whom the payer has given the task of thinking outside the box on physician reimbursement structures. You probably do not want to be talking with the people you have always worked with on contracting, as they are tasked with maintenance of contracts and relationships. Similarly, you do not want to be talking with someone on the hospital side of payer operations or innovations if you are a physician group. Depending on the payer size, you may find someone in charge of gastroenterology innovation in specific, but in my experience, the payers break down the roles by hospital payment and physician payment innovations. Research what this payer’s physician innovations department is doing. Follow key personnel on LinkedIn. See if they have written papers or made presentations. Reach out to colleagues in your specialty to see whether they have been approached by— or themselves have approached—the payer with an innovative payment plan.

PICK THE TEAM AND STRUCTURE A GAME PLAN Next, identify your area of focus in your practice. Are you looking to collaborate with a hospital, surgery


// GETTING IT RIGHT

center and other specialists to coordinate one price for everyone’s participation in an episode of care—a bundled payment? Or are you looking only at payments for services within your practice—a global fee? The former is, of course, more difficult to achieve outside of a sophisticated system, multi-specialty practice, loosely-aligned clinically integrated network (CIN), or accountable care organization (ACO). One baby step toward developing a more-formal CIN or ACO is to try a bundled payment model first. The gastroenterology practice, the facility and related specialists agree contractually (not via the more-permanent merger or development of a CIN or ACO) to approach a payer with a proposal to work together on certain services by way of protocols, standards and measures. If the measures are reached, then each of the separate companies gets a bonus payment from the payer. Many payers are focusing on bundled payments involving multiple providers. For example, a gastroenterology practice that controls its own surgery center may be able to negotiate one fee for all aspects of colonoscopy— evaluation, the procedure, anesthesia, surgery center facility fee and follow-up. Another bundled payment type across providers could be a bundled payment for gastrointestinal hemorrhage. Others may include gastrointestinal cancer, inflammatory bowel disease or gastroesophageal reflux disease.

FOCUS ON CODES HOW TO IMPLEMENT A NEW PAYMENT SYSTEM

TALK to the payer’s innovation department

RESEARCH the types of innovations the department is promoting

IDENTIFY the providers and facilities to team up with and develop a structure

CONSIDER structures to facilitate the innovation (CIN/ACO) among the team

ANALYZE existing bundled payment structure ideas in the industry

Once you have identified an episode of care, start by identifying exactly which CPT codes should be bundled. You will be speaking in the same language as the payer if you talk in terms of CPT codes and their scope. They know the codes. And more importantly, understand the reimbursement rates for those codes by Medicare and the payer with which you are collaborating. This ACG-provided list provided is a helpful place to start: bit.ly/18MPFSRates. Also analyze associated surgery center codes (bit.ly/ASCPayment) and anesthesia (bit.ly/CMS-Anesthesia).

APPEAL TO THE PAYER’S NEEDS To get to “yes” with the payer, the alternative payment model (APM) has to be about more than just the payer paying the physician more. Keep the reimbursement rates in mind, but focus on more than just the numbers. Be prepared to answer these questions: • Why would bundling these services benefit the payer other than simply saving the payer money? • How will you keep costs down? • How will you measure your actions for quality? • What protocols will you implement and why? • Will post-procedure admissions or repeat procedures drop due to the collaboration model with the other associated providers or facilities? • Will detection and screening improve due to the collaboration with pathology, for example?

If you propose to be paid more under the bundled approach, there has to be something else in it for the payer. This U.S. Department of Health and Human Services source may be helpful in identifying benefits to all parties: bit.ly/HHSASPE. The payer is not simply going to raise the rate under an APM over the fee-for-service price. To be successful in the negotiation, the provider has to convince the payer that the model will produce overall, long-term cost savings for the payer for a certain population of insureds. Payers and providers may reach agreement on models in concept but, to seal the deal, the parties have to develop standards and measures to prove the payer that they achieved the agreed-upon goals. How will outcomes be measured? GIQulC and ACG clinical guidelines offer excellent starting points for standards and metrics to use with payers.

 CONTINUE READING this installment of LAW MIND on the ACG BLOG for several more negotiating tips, including advice on outside experts who can help: bit.ly/LawMind818

ACG IS WORKING ON STARK LAW REFORM: WE NEED YOUR HELP

PROPOSE a practical, operational solution for the payer

CMS stepped up its emphasis on value-based reimbursement in June when it issued a formal request to the health care community for information about new alternative payment systems. With an August 24 response deadline, CMS wants recommendations to lift regulatory walls that block implementation of care coordination and arrangements to incent improvements in outcomes and cost reductions.  Learn More about how you can help: bit.ly/ACGStark

Getting it Right | 21


// COVER STORY

BANISHING Banishing Banishing

BURNOUT Burnout Burnout & Building

& & Building BUILDING

Resilience RESILIENCE Resilience 22 | GI.ORG/ACGMAGAZINE


Cover Story | 23


// COVER STORY

Physician Burnout & Wellness: A Cause for Pause Carol A. Burke, MD, FACG, ACG Immediate Past President, Cleveland Clinic Foundation, Cleveland, OH

Burnout is an epidemic in health care workers and threatens the health and medical workforce of our nation. Innumerable studies from the United States and abroad have documented burnout rates of over 50% in primary care and subspecialty physicians and surgeons. I believe this crisis has resulted from health care reform and specifically the “Triple Aim” introduced in 2007 by the Institute for Healthcare Improvement (IHI). 24 | GI.ORG/ACGMAGAZINE

The three main tenets of the Triple Aim include optimizing the health of populations, enhancing the patient experience, and decreasing the cost of care. Unfortunately, the impact of the alteration of health delivery on one of the most integral constituents in the system—the physician—was not considered within the IHI framework. Physicians are under ever-increasing and tremendous stress including production pressures, changing reimbursement and delivery-of-care models, quality metrics reporting and government regulation, the electronic medical record (EMR), loss of autonomy, sleep deprivation, patient, employee and spouse (dis)satisfaction, managing disruptive colleagues, and maintenance of board certification, to name a few. Stress induces a biologic cascade of events that can change the sympathetic-adrenal-medullary and hypothalamic-pituitary-adrenal axes. Excessive and sustained cortisol secretion can lead to acute and chronic diseases including anxiety, burnout and death. In medicine, burnout is a work-related syndrome characterized by a low sense of personal accomplishment, emotional exhaustion and depersonalization (cynicism and a lack of compassion for others). Burnout leads to detrimental effects on both the personal and professional aspects of a physician’s life. This includes broken relationships, alcohol and substance abuse, depression, suicide, unprofessionalism, decreases in patient satisfaction, quality of care, and productivity, and increases in medical errors, litigation, early retirement, and physician turnover. Some specific drivers of burnout in medicine include the health care organization and systems, excessive workload, unreasonable clerical burdens and inefficient work processes, lack of input or control on issues in practice, loss of autonomy, and a leadership culture which does not visibly support physicians.

Making Physician Well-being a Priority: The ACG Experience

Under ACG Past President Ronald J. Vender, MD, FACG, the College undertook a wellness and professionalism initiative. To increase our members’ awareness of burnout and the importance of professionalism, ACG offered a number of keynote lectures at our Annual Scientific Meetings and regional postgraduate courses. Importantly, the College developed and fielded a survey of members to assess the prevalence of burnout and factors associated with


high levels of burnout according to a validated inventory called the Maslach Burnout Inventory. The 60-item survey was emailed to our members. I presented the results of the ACG burnout survey at the World Congress of Gastroenterology at ACG 2017 Annual Scientific Meeting. The response rate was 9.2%. Burnout as measured by emotional exhaustion or depersonalization was noted in 49.3% of the gastroenterologists who responded. Interestingly— and much to my surprise— burnout was not related to the type of practice setting, full- or part-time status, location of practice, or compensation type. Rather, it was reported more

often in individuals who stated that the EMR was not user friendly. The ACG survey revealed that burnout was more commonly impacted by issues surrounding work-life balance. Among female survey respondents, 64% met criteria for burnout, significantly higher than in our male respondents. It was also noted in younger gastroenterologists and respondents who reported spending more time performing domestic chores, caring for children, working on patient-related tasks at home, and having an employed spouse or partner who spends more time at work or in work-related tasks at home. Retiring earlier than anticipated was planned by 46% of respondents, and higher rates of burnout were noted in those respondents.

The College recognizes that burnout has serious implications on the GI workforce and will continue to raise awareness of burnout and work in areas such as Maintenance of Certification reform to mitigate it. Personal interventions (mindfulness, small group sessions, meditation, etc.) are known to reduce burnout, but organizational interventions have been shown to be more effective than individually focused efforts.

The 20% Rule: Meaningful Work

Let’s start moving the needle with the 20% rule. Physicians who spend 20% of their professional effort on meaningful work have dramatically lower rates of burnout. I recommend further reading for organizational cultural change: Shanafelt TD, Noseworthy JH. Executive Leadership and Physician Well-being: Nine Organizational Strategies to Promote Engagement and Reduce Burnout. Mayo Clin Proc. 2017;92(1):129-146 bit.ly/MayoProJan17

Carol A. Burke, MD, FACG Cleveland Clinic Foundation

“In medicine, burnout is a workrelated syndrome characterized by a low sense of personal accomplishment, emotional exhaustion and depersonalization (cynicism and a Cover art and illustration on pages 22-23: Davide Bonazzi

lack of compassion for others). Burnout leads to detrimental effects on both the personal and professional aspects of a physician’s life.” Cover Story | 25


// COVER STORY

BANISHING BURNOUT:

PREVENTION STRATEGIES

from the ACG Professionalism Committee

 The recognition that the epidemic of physician and provider burnout is a top concern for ACG members prompted us to share our tips on burnout prevention. While the level of burnout for gastroenterologists is lower than many other specialties, such as primary care and emergency medicine,1 rates of 40% or higher are still unacceptable and worrisome and should not be ignored. Furthermore, due to the increasing prevalence of factors associated with burnout such as loss of autonomy,2,3 the burnout rate for gastroenterologists could rise, as observed nationally for all physicians.4 Our institutions may be recognizing the impact of burnout in light of the high cost of replacing physicians who quit, as well as the high cost of complaints or lawsuits which may be more common with burnedout physicians.2, 5-9 It is very important to distinguish between GI or medicine, and the practice itself. The good news for gastroenterologists is that the burnout does not seem to be related to gastroenterology itself. We are fortunate that we like our discipline, our patients and patient care. But we do not enjoy the increase in administrative tasks associated with that patient care, such as documentation requirements that take time and do not add to quality of care. One estimate is that many physicians spend a quarter of their patient care time on administrative tasks. At the invitation of Christina M. Surawicz, MD, MACG, Chair of

26 | GI.ORG/ACGMAGAZINE

the ACG Professionalism Committee, many Committee members offered their top strategies for burnout prevention and treatment for a white paper. The Committee

generated so many heartfelt, hard-won and evidence-based recommendations that not all of them could be included in the 2017 publication by Joseph C. Anderson, MD, MHCDS, FACG, Sheryl A. Pfeil, MD, and Dr. Surawicz in The American Journal of Gastroenterology, “Strategies to Combat Physician Burnout in Gastroenterology.” Read this paper: rdcu.be/Yx3l For ACG MAGAZINE, the Committee shares more of these burnout-banishing approaches that can be broken down into two broad categories: the practice of medicine and the practice of ourselves. It is important to remember that 80% of the cause of burnout among physicians is due to system changes—like the electronic health record—and only 20% is due to personal reasons. The former will take much work on the local and national levels to change.

Physician Resilience Resources— Tips from Dr. Ed Levine Edward J. Levine, MD, FACG, Chair, Professionalism Committee at The Ohio State University Wexner Medical Center

Stanford Medicine WellMD Center

The WellMD website includes a library of peer-reviewed articles on physician wellness and personal resilience, as well as links to anonymous online self-tests. In 2017, Dr. Tait Shanafelt was named the Center’s Director and Stanford Medicine’s Chief Wellness Officer. wellmd.stanford.edu

Wayne M. Sotile, PhD, Sotile Center for Physician Resilience

Dr. Sotile is a speaker and consultant who offers a range of resilience services to physicians, medical

families and medical organizations. sotile.com

Crew Resource Management Applications in Health Care

Crew resource management is based on the safety culture of aviation, and when applied to medicine is about providing quality care and creating a culture of safety. "Joint Commission, Patient Safety Systems Chapter, Sentinel Event Policy," Issue 40, July 9, 2008: bit.ly/TJC2008

What Medicine Can Learn from Improv

Yes, and … The basic tenet of improv is the phrase “Yes, and …” I think Crew

Resource Management is the medical equivalent of improv. We need to engage the people that we work with and acknowledge their input, even if we do not adopt their suggestions. Medicine is a team sport, and quality care and safety are directly linked to optimal team functioning. Amy Poehler, the former SNL comedian, says that improv needs to have a philosophy similar to the military and “leave no man (woman) behind.” You need to bring people along with you in order to have the team function at its best. “What Improv Can Teach Tomorrow's Doctors,” Anu Atluru, The Atlantic, August 24, 2016: bit.ly/TheAtlanticAug16 “The most important single ingredient in the formula of success is knowing how to get along with people.” —Teddy Roosevelt


Table 1. Factors contributing to Physician Burnout From the ACG Professionalism Committee

INSTITUTIONAL FACTORS

Table 2. Areas for education and research in prevention of provider burnout

Suggestions provided by the ACG Professionalism Committee

SUPPORTING DATA

SUGGESTION

Leadership impacts the well-being and satisfaction of clinicians

 Evaluate leaders regularly  Remove ineffective leaders, especially when there is high turnover of staff or faculty

Administrative tasks and lack of support are associated with burnout

 Develop teams of support staff who function to their maximal ability to decrease non-direct patient care tasks for physicians

The electronic health record (EHR) is the biggest driver of dissatisfaction in several studies.

 More efficient use of EHR  Scribes

Lack of control over workflow and scheduling

 Flexibility and control in scheduling

Longer work hours

 Reducing clinical hours i.e., part-time FTE

Peer support and professional relationships

 Peer support for adverse events  Regular meetings with colleagues to problem solve

1. Leadership  What

is the role of the institution in providing programs to promote wellness?

 What

are the responsibilities of clinical leaders?

 How

often should leaders be evaluated and with what metrics?

Should leaders have enough clinical FTE themselves to align goals with their staff and physicians?

INDIVIDUAL FACTORS SUPPORTING DATA

SUGGESTION  Align personal and professional values  Diversify activities  Become involved in professional societies, nationally and locally

Lack of self-care contributes to burnout

   

Plan and prioritize Have a healthy life style Take all your vacations Find non-medical activities and friends

3. Electronic Health Record (EHR) 

A National Survey of Burnout in Gastroenterologists

World Congress of Gastroenterology at ACG2017 Carol A. Burke, MD, FACG, ACG Immediate Past President

2016 ACG Practice Management Course Christina M. Surawicz, MD, MACG WATCH the video: bit.ly/Surawicz16

DOWNLOAD the slides: bit.ly/Burke17Slides

J. Edward Berk Distinguished Lecture: Avoiding Burnout: Finding Balance Between Work and Everything Else 2013 ACG Annual Scientific Meeting, The American Journal of Gastroenterology Christina M. Surawicz, MD, MACG READ the AJG article: rdcu.be/Mzow

appropriate level of support for physicians in clinical work, both in patient care and administrative tasks?  What

are the optimal roles of mid-level providers?

 Are

scribes feasible in practice and how are they best trained and utilized?

How I Approach It: Strategies to Combat Physician Burnout in Gastroenterology

The American Journal of Gastroenterology Joseph C. Anderson MD, MHCDS, FACG, Sheryl Pfeil, MD, Christina M. Surawicz, MD, MACG READ the AJG article: rdcu.be/Mzpb

physicianmandated administrative tasks can be done by others, like order entry?

Can an EHR be user friendly?

 Can

an EHR contribute to better patient care such as with use of incorporated guidelines?

 Can

Avoiding Professional Burnout

 What is the

 What

Shaping career path: spending less than 20% of time on most meaningful activities was associated with burnout

Burnout Resources

2. Support for clinical work

better typing skills and/or dictation software be useful?

4. Work Hours/ environment  Is

full-time work feasible for younger physicians with family and financial responsibilities such as loans?

 What

is a reasonable call load?

 Will

5. Self-care  Can

mindfulness activities be incorporated into a busy day?

 How

can physicians start programs that include exercise and good dietary habits?

institutions support the idea of part-time physicians?

 Are

employed physicians at higher risk than self employed?

Tables from Anderson, et al., "How I Approach It: Strategies to Combat Physician Burnout in Gastroenterology" Am J Gastroenterol 2017; 112:1356–1359.

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PRACTICE OF MEDICINE: PROFESSIONAL STRATEGIES DELEGATE non-clinical tasks, use of teams

WHAT IS KNOWN: Non-clinical tasks can be associated with burnout.

Stephen J. Utts, MD, MHCDS, FACG Austin Gastroenterology

“Practices should prioritize care coordination with referring physicians and other specialists. This is especially important in transition of care from inpatient to outpatient and in timely sharing of health care information.” “Examine practice operations for efficiencies that support physicians working at top of their license. These are the most expensive and valuable resource in a practice. Mundane or clerical tasks should be delegated down the chain. Care coordination can be enhanced by freeing up time for team huddles and emphasizing team approach to patient care.” “Practices need robust information technology resources that can continuously work with EHR vendors to improve end-user experience. The EHR should support and enhance the physician-patient encounter, not hinder it.”

BALANCE & DIVERSIFICATION

Edward J. Levine, MD, FACG

Mitchell A. Mah'moud, MD, FACG

The Ohio State University Wexner Medical Center

Duke University/Boice-Willis Clinic

“Delegate as much to staff as possible so that you are doing physician work, not clerical work. Delegate to our MAs/RNs if the issue does not need my particular attention.” 28 | GI.ORG/ACGMAGAZINE

“I have found the use of scribes to be very reassuring and less tedious or stressful. With scribes, I am able to see so many patients without having to spend time after clinic hours getting my consults or notes done. Furthermore in my liver clinic, we are able to populate some of the routine labs when we go into the exam room even before the patients walk out with the help of my scribe. The services of a resource nurse who helps with some of the patients’ phone calls also helps to relieve the burden on the physician.”

WHAT IS KNOWN: Physicians who spend at least 20% (or potentially one day) of their total effort in an activity that they find most meaningful are at a lower risk for burnout than those who spend a lower proportion.10 Allowing physicians more flexibility in their schedule might reduce risk for burnout.2, 11-17


Lawrence J. Brandt, MD, MACG Montefiore Medical Center

“Find the right work/life balance, evaluate what specifically it is about the burnout phenomenon that is triggering that feeling; it is not the same for all. Once identified, remove it (reconfigure your responsibilities); dilute it (spend more time doing something you really enjoy so that you can be better prepared for when the stress and frustration level builds); or see how it can be modified to become more acceptable or less onerous.”

Joseph C. Anderson, MD, MHCDS, FACG Geisel School of Medicine at Dartmouth College

“A potent step in decreasing MD burnout for an employed MD is the diversification of the work week. I believe that a job description that is diverse allows for job satisfaction to be obtained through other means besides patient care, which can be mercurial.” Cover Story | 29


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AUTONOMY

WHAT IS KNOWN: Leadership has a great impact on physician burnout.19 Leaders can facilitate changes that support their colleagues in regaining their autonomy.

Sasha Taleban, MD University of Arizona Medical Center

“I believe that physicians can be divided into employed and self-employed. I personally feel that physicians who are not selfemployed are at higher risk of burnout due to loss of autonomy.”

30 | GI.ORG/ACGMAGAZINE

COLLEGIALITY & PROFESSIONAL RELATIONSHIPS

Sheryl A. Pfeil, MD

Christina M. Surawicz, MD, MACG

The Ohio State University Wexner Medical Center

Harborview Medical Center, University of Washington

“Mentoring and teaching: It is very rewarding to guide and inspire learners!" "Collegiality and professional relationships can be a lifesaver and can bring much enjoyment to our professional lives. Isolation is something that is a real risk in GI—when we are rotating to different outpatient endoscopy centers, rounding at different hospitals, often as the sole gastroenterologist of our group. Finding an antidote to isolation requires intentional effort, although it does not need to be extremely time consuming. Sometimes five minutes in the physician lounge can bring muchneeded connectivity. Intentionally engaging in conversation with GI colleagues can help emphasize shared experiences.”

“Finding the right colleagues is so important since we may spend more time with them than with our families.”

WORK HOURS

WHAT IS KNOWN: Reducing clinical hours can help physicians recover from burnout and may also reduce risk for burnout.2, 11-17, 18

Steven J. Bernick, MD Madigan Army Medical Center Division of Gastroenterology/ Endoscopy

“I love my job. I love being a physician. But I also love my family, my free time, and the things I do away from medicine. I will now only work part-time to allow myself the free time to pursue those other things.”


PRACTICE OF OURSELVES: PERSONAL STRATEGIES SELF CARE

WHAT IS KNOWN: Work-life aspect, including sleep, rest, exercise, eating habits, personal relationships and past time activities, can help reduce the risk for burnout.22-24 Alcohol consumption in the setting of poor coping skills can be associated with risk for burnout in gastroenterologists. Richard S. Bloomfeld, MD, FACG

Sita S. Chokhavatia, MD, FACG Valley Medical Group

“My short list of strategies: 1. Take the family vacation at least once a year. 2. Do not keep things pent up, reach out and vent to close friend(s). 3. Along the same lines as #2, reach out to your mentor.”

Wake Forest University Baptist Medical Center

“Running provides a great outlet for me to release physical and mental stress after a long day at the hospital. I love being out in the fresh air.”

Jeffrey T. Laczek, MD Walter Reed National Military Medical Center

“Take care of yourself. Make eating well a priority, schedule time to exercise, get enough sleep, limit alcohol to moderate use, and make sure that you keep time to do something that you find relaxing.” Cover Story | 31


// COVER STORY

PLANNING & PRIORITIES

WHAT IS KNOWN: physicians who have control of their work environment are less prone to burnout.

Jeffrey T. Laczek, MD Walter Reed National Military Medical Center

“Before scheduling work obligations e.g., signing up for weeks of call, talk to your significant other or family, identify significant upcoming events e.g., weddings, birthdays, school events, and discuss plans for holidays/ trips/vacations. Protect the time that you need for these personal events before scheduling work obligations. Use your planning as a springboard for arranging the logistics for these events i.e., looking for an airline flight or researching vacation ideas. This helps prevent your work from overwhelming your personal life, gives you something to look forward to, and nudges you to make the most of your personal time.” 32 | GI.ORG/ACGMAGAZINE

MINDFULNESS & GRATITUDE

WHAT IS KNOWN: activities that can increase self-awareness have been shown to decrease burnout.20, 21

Christina M. Surawicz, MD, MACG Harborview Medical Center, University of Washington

“We are our best support when things go wrong and/or when we need help; the value of peer mentoring cannot be overstated. There should also be no shame in admitting to burnout, nor to errors, being named in suits or complaints. We have difficult jobs, mistakes are inevitable, and forgiving ourselves is necessary.”

Somasundaram Bharath, MD, FACG Altru Health System

“Live for the moment enjoying when and what you can. Never worry about things one cannot change. Ignore bad elements (persons, places, etc.) from your radar. In computer terms: ‘delete.’”


Sheryl A. Pfeil, MD The Ohio State University Wexner Medical Center

“Gratitude, humor, humility and not taking oneself too seriously.”

Richard S. Bloomfeld, MD, FACG Wake Forest University Baptist Medical Center

“For me, having active interests outside of medicine and having a social network of nonmedical people is so important.”

Edward J. Levine, MD, FACG The Ohio State University Wexner Medical Center

“The best way to battle burnout is to develop resiliency techniques and have positive aspects of your life, generally outside of medicine, that help one deal with the frustrations that we all have with the practice of medicine, and that will undoubtedly continue. For many people it is their family, spouses and children; for others it may be something different in their life that gives them joy and helps them be resilient.”

Christina M. Surawicz, MD, MACG

Daniel J. Pambianco, MD, FACG

Harborview Medical Center, University of Washington

Charlottesville Gastroenterology Associates

“A gratitude journal was shown to be as effective as an antidepressant for up to three months: check out ‘three good things and why.’”

“I am mindful of my desire to be a physician, especially my commitment to provide the best care for my patients. I frequently revisit this commitment and remind myself of the vital elements of that sacrosanct relationship, and the privilege that is entrusted to me. I am deeply grateful for that opportunity.”

Cover Story | 33


References 1. Shanafelt TD, Boone S, Tan L, et al. Burnout and satisfaction with work-life balance among US physicians relative to the general US population. Arch Intern Med 2012;172:1377-85. 2. Shanafelt TD, Noseworthy JH. Executive Leadership and Physician Well-being: Nine Organizational Strategies to Promote Engagement and Reduce Burnout. Mayo Clin Proc 2017;92:129-146.

APPLY

for an ACG Clinical

Research Award

Deadline: Friday, December 7, 2018

3. Wallace JE, Lemaire JB, Ghali WA. Physician wellness: a missing quality indicator. Lancet 2009;374:1714-21. 4. Shanafelt TD, Hasan O, Dyrbye LN, et al. Changes in Burnout and Satisfaction With Work-Life Balance in Physicians and the General US Working Population Between 2011 and 2014. Mayo Clin Proc 2015;90:1600-13. 5. Shanafelt T, Sloan J, Satele D, et al. Why do surgeons consider leaving practice? J Am Coll Surg 2011;212:421-2. 6. Shanafelt TD, Raymond M, Kosty M, et al. Satisfaction with work-life balance and the career and retirement plans of US oncologists. J Clin Oncol 2014;32:1127-35. 7. Williams ES, Konrad TR, Linzer M, et al. Physician, practice, and patient characteristics related to primary care physician physical and mental health: results from the Physician Worklife Study. Health Serv Res 2002;37:121-43. 8. Williams ES, Konrad TR, Scheckler WE, et al. Understanding physicians' intentions to withdraw from practice: the role of job satisfaction, job stress, mental and physical health. 2001. Health Care Manage Rev 2010;35:105-15. 9. Dewa CS, Loong D, Bonato S, et al. How does burnout affect physician productivity? A systematic literature review. BMC Health Serv Res 2014;14:325. 10. Shanafelt TD, West CP, Sloan JA, et al. Career fit and burnout among academic faculty. Arch Intern Med 2009;169:990-5.

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

11. Shanafelt TD, Mungo M, Schmitgen J, et al. Longitudinal Study Evaluating the Association Between Physician Burnout and Changes in Professional Work Effort. Mayo Clin Proc 2016;91:422-31. 12. Shanafelt TD, West CP, Poland GA, et al. Principles to promote physician satisfaction and work-life balance. Minn Med 2008;91:41-3. 13. McMurray JE, Heiligers PJ, Shugerman RP, et al. Part-time medical practice: where is it headed? Am J Med 2005;118:87-92. 14. Mechaber HF, Levine RB, Manwell LB, et al. Part-time physicians... prevalent, connected, and satisfied. J Gen Intern Med 2008;23:300-3. 15. Murray A, Safran DG, Rogers WH, et al. Part-time physicians. Physician workload and patient-based assessments of primary care performance. Arch Fam Med 2000;9:327-32. 16. Panattoni L, Stone A, Chung S, et al. Patients report better satisfaction with part-time primary care physicians, despite less continuity of care and access. J Gen Intern Med 2015;30:327-33. 17. Parkerton PH, Wagner EH, Smith DG, et al. Effect of part-time practice on patient outcomes. J Gen Intern Med 2003;18:717-24. 18. Shanafelt TD, Dyrbye LN, West CP, et al. Potential Impact of Burnout on the US Physician Workforce. Mayo Clin Proc 2016;91:1667-1668. 19. Shanafelt TD, Gorringe G, Menaker R, et al. Impact of organizational leadership on physician burnout and satisfaction. Mayo Clin Proc 2015;90:432-40.

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

GI.ORG/GRANT-ANNOUNCEMENTS

34 | GI.ORG/ACGMAGAZINE

20. Shanafelt TD, Dyrbye LN, West CP. Addressing Physician Burnout: The Way Forward. JAMA 2017;317:901-902. 21. West CP, Dyrbye LN, Rabatin JT, et al. Intervention to promote physician well-being, job satisfaction, and professionalism: a randomized clinical trial. JAMA Intern Med 2014;174:527-33. 22. Hlubocky FJ, Back AL, Shanafelt TD. Addressing Burnout in Oncology: Why Cancer Care Clinicians Are At Risk, What Individuals Can Do, and How Organizations Can Respond. Am Soc Clin Oncol Educ Book 2016;35:271-9. 23. Linzer M, Levine R, Meltzer D, et al. 10 bold steps to prevent burnout in general internal medicine. J Gen Intern Med 2014;29:18-20. 24. Quill TE, Williamson PR. Healthy approaches to physician stress. Arch Intern Med 1990;150:1857-61.


A FRESH LOOK at the INSIDES THE CONTINUING JOURNEY OF A TRAINEE Bhavana Bhagya Rao, MD Cleveland Clinic Foundation, Cleveland, OH

IT HAS BEEN AN EXCITING 16 MONTHS AS A GASTROENTEROLOGY FELLOW. While at first training seemed daunting I have since

slowly familiarized myself with and befriended all the cool gadgets and techniques that embellish the armamentarium of an endoscopist. Now, more than a year in as of the time of this writing, I dared to claim that I had a fair idea of what I was doing and felt under control during a procedure. But did I really know the inside scoop of performing a scope? Recently, I had a unique opportunity to gain additional perspective on the actual impact of an endoscopic procedure on a human body. A middle-aged female patient with a new diagnosis of Peutz-Jegher’s syndrome was evaluated at our hereditary colon cancer clinic with the complaint of recurrent small bowel obstructions. Her history included a single abdominal surgery, performed when she was two years old, but she was unaware of further details. Abdominal computerized tomographic enterography was notable for multiple dilated small bowel polyps with scattered foci of intussusception,

ACG Perspectives | 35


// ACG PERSPECTIVES  Images courtesy of Dr. Bhavana Bhagya Rao.

which were suspected to be the etiology of her recurrent blockages. A push enteroscopy was pursued for polyp removal, which turned out to be technically challenging due to marked abdominal distension during the procedure. The scope could not be safely advanced beyond the mid-duodenum. To ensure a complete “clean sweep of her small bowel,” the patient was scheduled for a laparoscopyassisted enteroscopy. This procedure would entail a joint collaboration by endoscopists and surgeons, who would help in advancing our intra-orally passed endoscope into the most distal regions of the small bowel, otherwise beyond reach, and there we would perform extensive polyp resection. As it turned out, during the laparoscopy the patient was noted to have extensive intra-abdominal adhesions and the surgeons switched from a laparoscopic approach to exploratory laparotomy and performed adhesiolysis while at the same time we proceeded with the push enteroscopy. At this point in my training, I may well have performed upwards of 900 endoscopic procedures, but if I were being honest with myself, this felt as if it was my first because I saw the process in an entirely new light and discovered a whole new meaning. How fragile the intestinal tract seemed and how intrusive and foreign our five-foot-long scope appeared, invading her entrails through her mouth. How different this was from our routine outpatient cases, where often during colonoscopies some patients are comfortably awake and talkative and even watch images of their insides along with us. Seeing her bowels quiver in the hands of the surgeon while our scope snaked through them was unnerving. It was anxiety provoking for me as we

36 | GI.ORG/ACGMAGAZINE

“At this point in my training, I may well have performed upwards of 900 endoscopic procedures, but if I were being honest with myself, this felt as if it was my first because I saw the process in an entirely new light and discovered a whole new meaning.” 

insufflated air into her bowels, and they ominously distended and glistened in the harsh operating room lights. The most nerve-wracking aspect of all was watching the sparks and glow within the bowel lumen as we cauterized more than 40 giant polyps from her jejunum and ileum. I realized how easy it is to forget in the operating room that the shiny bowels that spilled out of the gaping wound in her abdomen, the innumerable tubes and catheters that poked out from multiple sites, the scope that was jammed between three other tubes in the mouth, were all part of a whole, single, alive human being. She seemed so remote and distant— lost under all those layers of drape. The next day, we went to check on her and, lo and behold, she was whole again, sitting up in a chair, beaming at us and profusely thankful. I had a quick flashback to the image I had of her from the previous day, and could not help but be impressed at the striking contrast in her circumstances. It was then time to move on to our scheduled procedures of the day, none of which was as exciting as her case or involved any operating room action. Yet something profound had changed for me: I looked at every patient and every esophagus and colon I examined in a new light. The screen still accurately displayed what the camera was seeing but, in the back of my mind, there was an added visual impression, a more holistic and comprehensive view of both the inside and outside milieu of the patient, that served to guide and caution me as an endoscopist. It is easy for GI training to seem long and arduous, but medicine has provided me with several such experiences of clarity that have encouraged me to pause for introspection on even the so-called routine procedures we perform. Moments, often humbling, in which I am revitalized to continue seeking the “inside scoop” in all that we say and do, and to revel in the healing and care that we have the honor of being a part of everyday!


Clinical Research Awards & Pilot Awards Our smaller awards, including ACG’s Clinical Research Awards and Pilot Awards, provide investigators not only external validation of the quality of their work, but also the seed money which often spurs other awards and further investigation. Given that the vast majority of our awards result in one or more peer-reviewed publications, members of the College can be proud of the performance of this program.

THIS YEAR, AS ALWAYS, the ACG Institute has invested in the future by having a large portion of the Institute’s research dollars go to promising young investigators whose Junior Faculty Development Awards are listed below. This three-year award of $100,000 per year protects time for clinical research.

Funding Promising Careers in CLINICAL RESEARCH Nicholas J. Shaheen, MD, MPH, FACG, Director, ACG Institute for Clinical Research & Education

THE COLLEGE IS COMMITTED TO ADVANCING THE FIELD OF GI through the support of clinical research. This commitment is manifest in many ways, the most obvious being the clinical grants program of the ACG Institute. Through this program, the College annually awards substantial funds to promising researchers and projects, last year totaling $1,512,145. These awards are especially instrumental in the development of young clinical investigators.

2018 Junior Faculty Development Grants Our Junior Faculty Development program has proven itself to be a significant incubator of young research talent in our field and, as it passes its 20th birthday, numbers multiple division chiefs, department chairs, deans and other significant contributors to academic medicine amongst its alumni. These research awards, which currently protect a substantial amount of time for research early in the careers of these recipients, are the “rocket fuel” that allows these careers to take off.

Megan Adams, MD, JD, MSc University of Michigan Promoting High-Value Use of Endoscopic Sedation “Balancing tests” are commonplace in American law, where the outcomes of legal disputes are often dependent on weighing counter-balanced interests, such as an inmate’s liberty interest versus the government’s interest in public safety. In my prior career as an attorney working for a state appeals court, it was my job to help the judges for whom I worked wrestle with these challenging balancing exercises across a range of legal contexts. I saw both the importance and difficulty in deciding questions regarding what values and interests should be taken into account and how these interests should be weighted. Indeed, I have continued to wrestle with these questions, albeit in a different context, since transitioning to a career in medicine. As the US medical system shifts to valuebased health care delivery, we must learn how to balance complex and competing factors, including medical appropriateness, patient preferences, cost and access in a meaningful and equitable manner. This is particularly important in procedural fields such as GI in which the use of expensive, invasive interventions of sometimes marginal benefit is common. Now a general gastroenterologist,

ACG Perspectives | 37


// ACG PERSPECTIVES

attorney and health services researcher, my long-term goal is to build a successful career focused on improving the quality and delivery of health care for patients with gastrointestinal conditions by helping to define, measure and implement high-value care that effectively reconciles the inherent tradeoffs in health care delivery. The support provided through the 2018 ACG Junior Faculty Development Award will help me maximize the impact of my work and realize my goal of federal funding through an Agency for Healthcare Research and Quality or National Institutes of Health award.

Parakkal Deepak, MBBS, MS Washington University School of Medicine in St. Louis Triangular Phenotyping and Response Assessment in Small Bowel Crohn’s Disease Using MRE and Novel Proteomic Biomarkers The small bowel is involved in ~70% of patients with Crohn’s disease. The assessment of Small Bowel Crohn’s Disease (SBCD) activity and response to therapy remains a major challenge in clinical management. Current serum biomarkers are inadequate for SBCD, and mucosal healing visualized during repeated ileocolonoscopies as a “treat-to-target” strategy is burdensome for the patient and carries inherent risks. Thus, there is an unmet need for accurate and clinically meaningful methods to measure SBCD activity. This is particularly relevant as the field moves toward “treat-to-target” management strategies. Compared to colonoscopy, patients have reported greater preference for serial assessment of disease activity magnetic resonance enterography (MRE) and non-invasive serologic biomarkers. We recently demonstrated that treating to a target of radiological transmural response (TR) on CT enterography (CTE) or MRE was associated with reduction in hospitalization, surgery and corticosteroid use in a retrospective cohort study of SBCD patients. In this study, TR was assessed using a method that accounts for aggregated transmural inflammation and longitudinal disease burden. The overall objective of this project is to establish that radiologic transmural response and a novel proteomic biomarker are accurate and clinically meaningful predictors of SBCD inflammatory activity and response to biologic therapy. To address this objective, we will establish a prospectively

38 | GI.ORG/ACGMAGAZINE

followed cohort of SBCD patients starting a new biologic therapy. These patients will be comprehensively phenotyped using state-of-the-art MRE imaging, proteomic profiling and clinical disease activity indices. We will use this innovative approach of triangular phenotyping to address our central hypothesis that “Corticosteroidfree remission at 52 weeks after biologic therapy initiation is predicted by short-term radiologic TR or early changes in serum proteomic biomarker profiles.”

Girish Hiremath, MD, MPH Vanderbilt University Medical Center Label Free Determination of Biomolecular and Biochemical Signatures in Eosinophilic Esophagitis: Bench to Bedside Application of Raman Spectroscopy The long-term goal of this research is to develop an innovative, real-time, clinically applicable, minimally invasive approach to identify Eosinophilic Esophagitis (EoE) with molecular specificity. At present, in the compatible clinical setting, identification of cellular, microstructural and tissue markers with hematoxylin and eosin staining (goldstandard) and immuno-histochemical analysis of esophageal biopsies is essential for identification of EoE and to distinguish it from overlapping conditions such as gastroesophageal reflux disease (GERD) and proton pump inhibitor (PPI) therapy responsive esophageal eosinophilia. This approach is expensive, time consuming, clinically burdensome and prone to subjective variability. Additionally, it allows identification of EoE only after tissue damage, oftentimes irreversible, has already set in. Therefore, a minimally invasive, efficient and real-time approach to identify EoE holds promise to advance the field, impact clinical care and promote patient outcomes. Raman spectroscopy-based applications are capable of providing labelfree, minimally invasive tools to discriminate tissue pathology in real-time with molecular specificity. We have previously validated these applications in IBD. Our novel preliminary data suggest that Raman spectroscopy can precisely determine in vitro biochemical and molecular composition of the esophageal tissue affected by EoE and can distinguish EoE from GERD with 96% accuracy. Also, for the first time in the pediatric age group we have demonstrated the

safety and feasibility of a pediatric upper endoscope compatible fiberoptic Raman spectroscopy probe to acquire real-time, in vivo esophageal Raman spectra during esophagogastroduodenoscopy. Under the auspices of the ACG Junior Faculty Development Award, I propose to leverage our exciting preliminary results to test the hypothesis that identification of EoE-specific biochemical and molecular signatures will facilitate development of innovative and clinically applicable diagnostic strategies to identify EoE in children.

Rena Yadlapati, MD, MSHS University of Colorado Anschutz Medical Campus Determining Best Practices for Reflux Associated Laryngeal Symptoms Inappropriate use of diagnostic and therapeutic strategies for Reflux Associated Laryngeal Symptoms (RALS) is a major problem, contributing to a high economic burden, increased patient risk, and failure to deliver effective personalized care. Identification of patient-centered and cost-effective clinical practices for RALS is a high priority. This study will address three crucial gaps impacting the clinical approach to RALS: (1) Paucity of diagnostic tests that predict clinically relevant outcomes; (2) Undefined clinical role of UES augmentation; and (3) Deficiency of personalized and costeffective approaches. Central hypothesis: In a personalized, costeffective approach to RALS, a diagnostic screen (e.g., salivary pepsin) will guide a PPI trial. In the case of PPI non-response, physiologic testing (e.g., the multi-channel intraluminal impedance Z/2pH system, high-resolution impedance manometry) will elucidate mechanisms and personalize treatment. This project leverages my background in health services research and esophageal physiology, and examines state-of-the-art clinical tools for a critically important and understudied field. The anticipated impact of this research is to lay the groundwork for future NIH K23 and R01 proposals aiming to: (1) Refine the diagnostic criteria for RALS; (2) Assess best practice strategies in a multicenter placebo- and shamcontrolled clinical trial; and (3) Implement and disseminate effective interventions. My long-term goal is to lead the national effort to improve the care of RALS through standardized implementation of guidelines.


EDUCATION “Besides gaining the medical knowledge from [Dr. Syngal’s] excellent talks, I think they really appreciated the mentoring and question-answer session they had with her. Some of the comments that I received were: ‘It is nice to hear it from an expert's perspective’; ‘Inspiring to hear how she followed her passion and ended up creating a sub-specialty in GI’; ‘Her advice on work-life balance was really helpful.’”—Saurabh Chawla, MD, Emory University School of Medicine

Photo top: Sapna Syngal, MD, MPH, FACG, during her visit to the Emory University School of Medicine.

THE ACG EDGAR ACHKAR

VISITING PROFESSORSHIP PROVIDING NOTEWORTHY SPEAKERS FOR TRAINING IN YOUR COMMUNITIES THE GOAL OF THE ACG EDGAR ACHKAR VISITING PROFESSORSHIP PROGRAM is to enable GI

fellowship programs to have high-quality visiting professors to bolster the training program by providing lectures, small group discussions, and one-on-one visits with trainees and faculty. This issue of ACG MAGAZINE provides the full schedule of dates for this year's visiting professors and features four 2018 visits: Sapna Syngal, MD, MPH, FACG, at the Emory University School of Medicine; Sachin B. Wani, MD, at the University of Nebraska; David T. Rubin, MD, FACG, at UConn Health; and Christopher C. Thompson, MD, MSc, FACG, at the University of Alberta.

Education | 39


// EDUCATION

“For three hours during dinner, the fellows were engaged in lively discussions regarding difficult IBD cases fellows have seen and struggled with during fellowship. It was refreshing to hear [Dr. Rubin’s] practical perspective on managing complex IBD topics…” —John W. Birk, MD, FACG, Brian T. Moy, DO, Haleh Vaziri, MD, UConn Health

40 | GI.ORG/ACGMAGAZINE


“I will change my management of Barrett's as a result of his talk. Dr. Wani is a very good example of an all-around modern physician scientist. He is a great role model of future gastroenterologists.” —University of Nebraska Medical Center fellow

2018

ACG EDGAR ACHKAR VISITING PROFESSORSHIPS NICHOLAS J. SHAHEEN, MD, MPH, FACG University of Minnesota FEBRUARY 1–2 PETER D.R. HIGGINS, MD, PHD, MSC UCLA David Geffen School of Medicine FEBRUARY 21–23 SATISH S.C. RAO, MD, PHD, FACG Virginia Commonwealth University FEBRUARY 22–23 KRIS V. KOWDLEY, MD, FACG University of Arizona College of Medicine Phoenix MARCH 1–2 STEPHEN B. HANAUER, MD, FACG Cleveland Clinic Florida MARCH 5–6 SAPNA SYNGAL, MD, MPH, FACG Emory University School of Medicine MARCH 26–27 SACHIN B. WANI, MD University of Nebraska APRIL 12–13 DAVID T. RUBIN, MD, FACG UConn Health MAY 2

“The biggest impact of his lecture was his approach to develop a clinical solution for a medical challenge…he analyzes the pathophysiology of any given disease and meticulously studies the impact endoscopy can have on the outcome.” —Daniel C. Baumgart, MD, PhD, MBA

CHRISTOPHER C. THOMPSON, MD, MSC, FACG University of Alberta JUNE 12 JOHN J. VARGO, II, MD, MPH, FACG Vanderbilt University JUNE 21 SUNANDA V. KANE, MD, MSPH, FACG SUNY Downstate SEPTEMBER 13 MILLIE D. LONG, MD, MPH, FACG Beaumont Hospital – Farmington Hills SEPTEMBER 26 JOHN E. PANDOLFINO, MD, MSCI, FACG Genesys Regional Medical Center NOVEMBER 6–7 COREY A. SIEGEL, MD, MS The National Institutes of Health NOVEMBER 16

Education | 41


ACG ���� ANNUAL SCIENTIFIC MEETING & POSTGRADUATE COURSE PENNSYLVANIA CONVENTION CENTER OCTOBER 5–10, 2018

REGISTER NOW! Learn the latest in clinical practice, exchange ideas with colleagues, and gain insight from the experts at ACG 2018.

AC G 2O18 O CTO B E R 5 – 1 O, 2 O 1 8 The Premier GI Clinical Meeting & Postgraduate Course

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THE AMERICAN COLLEGE OF GASTROENTEROLOGY 42 | GI.ORG/ACGMAGAZINE


Inside the

JOURNALS GREAT NEWS FOR ALL THREE ACG JOURNALS: The College is rightly proud of the success of all its journals, but is especially gratified that The American Journal of Gastroenterology (AJG) and Clinical & Translational Gastroenterology (CTG) saw their Impact Factors rise compared to last year based upon data compiled by Clarivate Analytics. This impressive growth for both journals underscores the quality and relevance of these publications, and reflects the vision and leadership of their editorial teams. The American Journal of Gastroenterology Ranked as Top Clinical GI Journal: With an Impact Factor of 10.231, AJG is ranked as the top journal publishing original clinical C Gmaintains GI science.AAJG its position as number six out ORTSoverall in gastroenterology and SE REPjournals of C 80Ascientific L N R JOU hepatology on this quantitative measure of a journal’s importance and standing within its field. Impact Factor is a measure of the number of citations the journal received in 2017 for papers published in 2015 and 2016. The College recognizes with thanks Co-Editors-inChief Brian E. Lacy, MD, PhD, FACG, and Brennan M. R. Spiegel, MD, MSHS, FACG. AJG is published by Springer Nature. The College recently announced a new publishing partnership with Wolters Kluwer which will commence with the January 2018 issue. nature.com/ajg G PORTS.GI.OR

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n, Anthony G. Hashash, Regueiro, Brian Mahesh Gajendra E. Koutroubakis, Jana J. Cruz, Miguel Janet Harrison, R. Watson, Ioannis Kenneth K. Lee, Ruy Arthur Barrie, Shah, , Jason Swoger, Rivers, Nilesh Benjamin Click, Marc Schwartz William M. Rivers, Babichenko, Zuckerbraun, Javier Salgado, Umapathy, Dmitriy Douglas J. Hartman, , Chandraprakash Alyce M. Andersonand David G. Binion Michael A. Dunn

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CTG Grows Its Impact as an Open-Access GI Journal: Clinical and Translational Gastroenterology rose to a 2017 Impact Factor of 4.621, up from 3.923 last year. Launched in 2010 as a peer-reviewed open access journal published by Springer Nature, CTG made a strong showing, ranking 15 out of 80 among gastroenterology and hepatology journals. In 2018, Wolters Kluwer will become the publisher of CTG. CTG welcomes novel cohort studies, early-phase clinical trials, qualitative and quantitative epidemiologic research, hypothesis-generating research, studies of novel mechanisms and methodologies including public health interventions, and integration of approaches across organs and disciplines. The Editor-in-Chief is David C. Whitcomb, MD, PhD, FACG. nature.com/ctg New Editor-in-Chief for ACG Case Reports Journal: The beginning of the academic year in GI training programs marks the turnover for the Editorial Board for ACGCRJ. The new Editor-in-Chief is Samuel Han, MD, of the University of Colorado. ACGCRJ is a peer-reviewed, open-access publication that provides GI fellows, private practice clinicians, and other members of the health care team an opportunity to share interesting case reports with their peers and with leaders in the field.

Inside the Journals | 43


// INSIDE THE JOURNALS

INSIDE THE JOURNALS [THE AMERICAN JOURNAL OF GASTROENTEROLOGY]

NEW CROHN'S GUIDELINE Clinical Implications & Key Points By Gary R. Lichtenstein, MD, FACG, University of Pennsylvania

 The American College of Gastroenterology, in March 2018, updated clinical guidelines on the management of Crohn’s disease in adults. This new guideline represents an update for practitioners, since the prior guideline published in 2009. The diagnosis and management of patients with Crohn’s disease has evolved substantially since the last-published ACG practice guideline on Crohn’s disease. In this update there are a total of 60 position statements and 53 summary statements noted. To evaluate the level of evidence and strength of recommendations, the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system was used for each statement (accessible at gradepro. org). In areas reviewed, when there were not available clinical trial data, these areas are discussed as summary statements rather than GRADE statements. A SUBSTANTIAL EVOLUTION Many different areas have changed since the last guidelines were published nearly a decade ago. When treating patients with Crohn’s disease, we attempt to maximize long-term health-related quality of life by means of controlling their disease-related symptoms, while attempting to prevent structural damage. In so doing, we facilitate patients’ normalization of function and participation in social and work-related activities. In these updated guidelines, we have incorporated a large amount of change which has been made possible from our education from clinical studies and clinical practice in gastroenterology and in other subspecialties. There has been substantial “cross fertilization” between our different specialties, which has enhanced our knowledge and enabled us to assimilate these guidelines. These guidelines should enable the practitioner to make educated and evidence-based treatment decisions with the Crohn’s disease patient as the central focus. KEY CLINICAL TAKEAWAYS  Out of Vogue: A “Step-Up” Approach: In the prior guideline, treatment was based upon a “step-up” approach. The traditional treatment paradigm in Crohn's disease had previously been based on a step-up approach

44 | GI.ORG/ACGMAGAZINE

in which therapies with the least toxicity are used initially, and subsequent therapies are then added as a consequence of a patient having had a lack of response or related to medication toxicity. When patients follow this treatment paradigm, the use of agents which are the least effective, such as aminosalicylates, are used for prolonged periods of time while uncontrolled inflammation results in tissue damage. Patients who fail to respond to aminosalicylates are then treated with corticosteroids in the form of prednisone, or alternatively with budesonide when disease is limited to the ileum or right colon. Immunosuppressant therapy is reserved for those patients with steroid-refractory or steroid-dependent disease. Many patients may stay on therapies to which they are not responding for a prolonged duration because clinicians may be reluctant to step up to therapy that is perceived as more "toxic." This approach is no longer in vogue.  Patient Prognosis: In the past, treatment was based upon symptoms and we did not take into account the individual patient’s prognosis. We currently, however, can determine individual patient prognosis and use appropriately aggressive medical therapy at the time of their diagnosis.  Treat-to-Target: A treat-to-target approach has been adapted into routine clinical practice. This approach entails measurement of both clinical and endoscopic targets. From the clinical standpoint, patientreported outcomes measure the patient’s experience of the disease and impact of treatment. Objective measures, such as endoscopic findings, measure the biological expression of the disease. When using a treat-to-target approach, it is important to measure comprehensive disease and risk factor assessment at diagnosis and at regular intervals in the disease course. This approach permits health care deliverers to perform risk stratification and implementation of a treat-to-target strategy, after detailed patient consultation.  Surveillance Colonoscopy: The guidelines also stress that for Crohn’s disease patients undergoing surveillance colonoscopy there is

insufficient evidence to recommend universal chromoendoscopy for IBD colorectal neoplasia surveillance, if the endoscopist has access to high-definition white light endoscopy. In patients at particularly high risk for colorectal neoplasia (e.g., personal history of dysplasia, primary sclerosing cholangitis), chromoendoscopy should be used during colonoscopy, as it may increase the diagnostic yield for detection of colorectal dysplasia, especially compared with standard-definition white light endoscopy.  Therapeutic Drug Monitoring (TDM): TDM has become better established in the management of patients with Crohn’s disease, particularly in patients with a secondary loss of response. The use of TDM has enabled us to better treat our patients and have a better understanding of the pharmacokinetics as it relates to their care. TDM has also been shown to be a cost-effective measure. In an effort to give patients the best treatments available for their disease state—and to modify them according to their response or lack thereof—a precision medicine approach has ensued.  Current Medical Therapy: A comprehensive update on the current medical therapy for treatment of patients with Crohn’s disease (including patients with luminal, fistulizing and postoperative Crohn’s Disease) is in the guidelines, with an up-to-date on the evidence supporting or refuting the use of certain agents such as mesalamine and corticosteroids. The evidence on the anti-TNF agents, vedolizumab and ustekinumab, are presented, and discussion regarding their appropriate use is emphasized in the guidelines.  Biomarkers: The use of biomarkers is now advocated in certain clinical scenarios. When it comes to diagnosis, we now advocate use of biomarkers such as fecal calprotectin in helping with the differential diagnosis in patients for whom it is unclear whether they have inflammatory bowel disease or irritable bowel syndrome. In addition, C-reactive protein is a good predictive biomarker when assessing response to biologic agents, particularly anti-TNF therapy.

 Read the Guideline rdcu.be/JXy5 Listen to the AJG Author Podcast gi.org/ajgpodcasts/Lichtenstein


Krogsgaard et al. Clinical and Translational Gastroenterology (2018)9:161

Page 8 of 11

[CLINICAL & TRANSLATIONAL GASTROENTEROLOGY]

Characteristics of the Bacterial Microbiome in Association with Common Intestinal Parasites in Irritable Bowel Syndrome Laura Rindom Krogsgaard, Lee O ‘Brien Andersen, Thor Bech Johannesen, Anne Line Engsbro, Christen Rune Stensvold, Henrik Vedel Nielsen, Peter Bytzer

 This Danish study of more than 400 people investigated whether the composition of the bacterial microbiome was altered by a low prevalence of intestinal parasites in people with irritable bowel syndrome (IBS). The group explored whether parasite colonization was associated with differences in the diversity and richness of the bacterial microbiome in healthy controls, people with unspecific GI symptoms, and people with IBS.

 Read the full article bit.ly/CTGJune1

[CLINICAL & TRANSLATIONAL GASTROENTEROLOGY]

Brain Fogginess, Gas and Bloating: A Link between SIBO, Probiotics and Metabolic Acidosis Satish S. C. Rao MD, PhD, FRCP (LON), FACG, Abdul Rehman, MD, Siegfried Yu, MD, Nicole Martinez de Andino, ARNP

 It is understood that D-lactic acidosis occurs in short bowel syndrome. What is not known—and what this study aimed to uncover—is whether D-lactic acidosis, which is “characterized by brain fogginess (BF) and elevated D-lactate,” occurs in patients with an “intact gut” and with “unexplained gas and bloating.” Dr. Rao et al. “aimed to determine if BF, gas and bloating is associated with D-lactic acidosis and small intestinal bacterial overgrowth (SIBO).” Find out what the authors learned, and whether and how probiotic use and SIBO affected these patients.

Fig. 3 Relative abundance of the ten most abundant bacterial genera found in each of the three symptom groups. Each bar illustrates the bacterial abundance in one3stool sample from an individual. Samples are ordered according to a hierarchical clustering, grouping samples with a similar FIGURE Relative abundance of the ten most abundant bacterial genera bacterial composition. Plot a includes samples from individuals with irritable bowel syndrome (IBS), plot b includes samples from individuals with foundand in plot each of the three symptomcontrols. groups. unspecific GI symptoms, c includes samples from asymptomatic The two horizontal bars below plot a show the IBS subtype and time since onset of symptoms of each sample. Additionally, the four horizontal bars below each of the three plots indicate the presence or absence of *, any parasite; **, Dientamoeba fragilis; ***, Blastocystis; and ****, multiple parasites. Notable clusters of samples with low prevalence of parasites are highlighted with a black box

Limitations to the present study include the limited effect of interperson variability is larger than effect of characterization of the study population. Information on storage methods on bacterial composition53,54. demographics and characterization of GI symptoms Numerous studies of the bacterial microbiome in IBS according to the Rome III criteria were available, but we have not been able to identify distinct reproducible had no information on possible diagnoses not related to changes in relation to IBS which questions a possible the GI tract, medication use and diet, which are all factors significant and causal relation. However, many factors Duodenal that could influence the composition of the gutaspirate/culture micro- have the potential to affect data on the microbiome; both biome. Stool samples were returned by postal mail in factors unrelated to the study setting and factors tubes with no additives, which could affect the composi- embedded in the study design leading to variance in tion of the microbiome compared with immediate freez- findings between studies. Even so, a distinct feature of the ing at −80 °C52. However, studies have shown that the bacterial gut microbiome directly involved in the

With brain

Without brain fogginess n=8

Official journal of the Americanfogginess College of Gastroenterology

n=28

Positive culture

Negative culture

Positive culture

Negative culture

n=14

n=14

n=2

n=6

Lactic acidosis Present

Lactic acidosis Absent

Lactic acidosis Present

Lactic acidosis Absent

Lactic acidosis Present

Lactic acidosis Absent

Lactic acidosis Present

Lactic acidosis Absent

n=8

n=6

n=14

n=0

n=0

n=2

n=2

n=4

FIGURE 2 Flow diagram describing the correlation between duodenal aspirate/culture results in both

Read the full article: bit.ly/CTGJune2

Inside the Journals | 45


// INSIDE THE JOURNALS

[ACG CASE REPORTS JOURNAL]

MEET THE 2018–2019 ACGCRJ EDITORIAL BOARD Samuel Han, MD Editor-in-Chief University of Colorado, Denver, CO

 The ACG Case Reports Journal provides not only a forum for fascinating case reports, but also represents the College’s commitment to supporting academic and professional growth in trainees. Getting involved in research as a trainee at any level presents a challenge given the difficulty of finding the right mentor and the right project, not to mention having to carve out time from the clinical duty requirements of their training program. From that standpoint, case reports offer the perfect starting point for trainees, particularly fellows, to produce scholarly work. The act of writing a report, conducting a literature search, and becoming familiar with the topic matter are crucial skills for academic medicine, and cases that arise within the context of clinical training provide the ideal substrate for original work. The experience of serving as an Associate Editor this past year struck me in terms of how reading case reports of rare and unusual conditions first hand greatly expanded my differential diagnoses for gastrointestinal conditions. Furthermore, reviewing these case reports significantly improved my critical appraisal ability, giving me exposure to a significant, yet seldom practiced skill within medicine. I am humbled and honored to serve with such a productive and talented Editorial Board this year. They are critical in the review process of the many submissions we receive. I am excited to work with them to move and shape the Journal to become not only the premier case reports journal in this field, but also to educate trainees and provide the supportive environment for their academic growth.

 View all published cases without a subscription: acgcasereports.gi.org

46 | GI.ORG/ACGMAGAZINE

Shawn Shah, MD Associate Editor New York-Presbyterian/Weill Cornell Medical Center New York, NY

Sasan Mosadeghi, MD Associate Editor University of Arizona Tucson, AZ

Darrick Li, MD Associate Editor Massachusetts General Hospital Boston, MA

C. Roberto Simons-Linares, MD Associate Editor Cleveland Clinic Cleveland, OH

Brett Sadowski, MD Associate Editor Walter Reed National Military Medical Center Bethesda, MD

Zachary Junga, MD Associate Editor Walter Reed National Military Medical Center Bethesda, MD

Alexander Podboy, MD Associate Editor Stanford University Palo Alto, CA

Vineet Rolston, MD Associate Editor New York University School of Medicine New York, NY

Thank you to the outgoing ACGCRJ Editorial Board members for their outstanding service to the Journal. We wish them continued success in their careers. Erica R. Cohen, MD Shirley Cohen-Mekelburg, MD Tossapol Kerdsirichairat, MD

Parth J. Parekh, MD Ali Raza, MD M. Anthony Sofia, MD


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

AC G RTS CASE REPO

JOURN L ORTS ACGCASEREP

.GI.ORG

VOLUME 4

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

ports edited by nal of Case Re An Online Jour y Fellows gy & Hepatolog Gastroenterolo

Editor-in-Chief: Samuel Han, MD University of Colorado

Submit your manuscript at

mc.manuscriptcentral.com/acgcr Inside the Journals | 47


M CECUM THE CECU HING THE REACHING REAC By Robert E. Kravetz, MD, MACG Scottsdale, AZ

A LOOK BACK

PATENT MEDICINE

This archival reflection originally appeared in The American Journal of Gastroenterology in May 2001.

T

he 19th century was the age of patent medicines because patients viewed physicians with suspicion and the working class could ill afford to pay for doctors’ services. They were not patented, in the legal sense, as the composition and method of preparation were not registered, only the name. The charlatans who marketed these ineffective nostrums could change anything related to the “medicine” but retained proprietary rights to the name and the implied false curative claims.

48 | GI.ORG/ACGMAGAZINE

Initially these medicines were peddled by traveling salesmen, but after the Civil War printing and mail services became more widespread and advertising became the main marketing method. They were exceedingly popular and did produce a temporary benefit, as most of them contained large amounts of alcohol and opium. In 1906, the government passed the Pure Food and Drug Act to protect the public and bring an end to the sale of these quack nostrums. Illustrated here is a typical patent medicine that dates to the 1800s. It claims to cure liver disease, jaundice, reflux, dyspepsia, and kidney disease, as well as headache and nervousness.


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 ECGs 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-U

May 2017


1 MOST PRESCRIBED, BRANDED BOWEL PREP KIT1 #

2

FIVE-STAR EFF1CACY WITH SUPREP ® Distinctive results in all colon segments • SUPREP Bowel Prep Kit has been FDA-approved as a split-dose oral regimen3 • 98% of patients receiving SUPREP Bowel Prep Kit had “good” or “excellent” bowel cleansing2* †

• >90% of patients had no residual stool in all colon segments2*

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

Aligned with Gastrointestinal Quality Improvement Consortium (GIQuIC) performance target of ≥85% quality cleansing for outpatient colonoscopies.4 *This clinical trial was not included in the product labeling. †Based on investigator grading. References: 1. IMS Health, NPA Weekly, May 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. All rights reserved.

HH13276A-U

May 2017


ACG MAGAZINE ARCHIVE 2018 ACG MAGAZINE Spring 2018

MEMBERS. MEDICINE. MEANING.

ACG MAGAZINE Summer 2018

MEMBERS. MEDICINE. MEANING.

GIVING RISE to

Resolved to

BEAT

COLON

GI in RWANDA

CANCER

Vol. 2 No. 1 // Spring 2018

Vol. 2 No. 2 // Summer 2018

2017 Volume 1, Number 1

ACG MAGAZINE Members. Medicine. Meaning.

Striking

Gold

ACG MAGAZINE Summer 2017

MEMBERS. MEDICINE. MEANING.

FINDING DISCOMFORT

ACG MAGAZINE Fall 2017

MEMBERS. MEDICINE. MEANING.

ACG MAGAZINE Winter 2017

MEMBERS. MEDICINE. MEANING.

THE RACING LIFE OF DR. FRED POORDAD

R ole Models

gi.org/acgmagazine

Vol. 1 No. 1 // Spring 2017

Vol. 1 No. 2 // Summer 2017

Vol. 1 No. 3 // Fall 2017

Vol. 1 No. 4 // Winter 2017


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