ACG MAGAZINE | Vol. 2, No. 4 | Winter 2018

ACG MAGAZINE Winter 2018

MEMBERS. MEDICINE. MEANING.

l The Essentia ced van Roles of Ad viders o Practice Pr in GI

SUBMIT YOUR APPLICATION for the ACG

2019 International GI Training Grant Awards

The International Relations Commi ee of the American College of Gastroenterology is now accepting applications for the 2019 International GI Training Grants. Each training grant will award one fellowship, with a maximum of $10,000, during 2019. Grants are to be used for travel to and from the training center and to the ACG Annual Meeting, as well as for incidental expenses related to the training. The training must take place between July 1, 2019, and June 30, 2020.

GI Training Grants INTERNATIONAL

GI TRAINING GRANT

This grant provides partial financial support to physicians outside the United States and Canada to receive clinical or clinical research training or education in Gastroenterology and Hepatology in selected medical training centers in North America.

WHO IS ELIGIBLE? Physicians who are not citizens or residents of the United States or Canada, and who are working in gastroenterology or related areas, are eligible to apply together with their training institution.

SUBMISSION DEADLINE March 29, 2019 APPLY HERE gi.org/intl-training-grant

NORTH AMERICAN INTERNATIONAL

GI TRAINING GRANT

This grant provides partial financial support to United States and Canadian GI Fellows in training, or GI Physicians who have completed their training within the last five years, to receive clinical or clinical research training or education in Gastroenterology and Hepatology outside of North America.

WHO IS ELIGIBLE? GI Fellows in training who are enrolled in an accredited gastroenterology fellowship program, or GI Physicians who completed their training within the last five years, and are citizens of the United States or Canada, are eligible to apply together with their training institution.

SUBMISSION DEADLINE March 29, 2019 APPLY HERE gi.org/na-intl-training-grant

WINTER 2018 // VOLUME 2, NUMBER 4

FEATURED CONTENTS

MESSAGE FROM THE PRESIDENT

Dr. Sunanda Kane on ACG's commitment to the wellbeing of the College and the wellbeing of individual GI clinicians.

PAGE 6

COVER STORY

THE INDISPENSABLES

Dr. Paul Kwo, Dr. David Rubin and a series of experts offer insights on the essential roles of Advanced Practice Providers in GI. PAGE 26

SAGE ADVICE

Past President Dr. Arvey Rogers presents aphorisms that improved his and his patients' quality of life during his career.

PAGE 24

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Attend an upcoming

ACG POSTGRADUATE COURSE 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

The 2019 Western IBD School is only $99 for ACG Members!

2019 ACG/LGS Regional Postgraduate Course  Hilton New Orleans Riverside | New Orleans, LA  March 8–10, 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

2019 ACG’s IBD School & Midwest Regional Postgraduate Course  Hyatt Regency Bloomington | Minneapolis, MN  August 16–18, 2019

2019 ACG/VGS/ODSGNA Regional Postgraduate Course  The Williamsburg Lodge | Williamsburg, VA  September 6–8, 2019

ACG 2019 Annual Scientific Meeting and Postgraduate Course  Henry B. Gonzalez Convention Center | San Antonio, TX  October 25–30, 2019 • Practice Management | October 25 • GI Pharmacology | October 25 • GI Pathophysiology | October 25 • ACG’s Postgraduate Course | October 26–27 • ACG’s Annual Meeting | October 28–30

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

WINTER 2018 // VOLUME 2, NUMBER 4

CONTENTS

“There is no doubt that our practices have grown and thrived with the incorporation of these outstanding colleagues, who not only expand the services that would otherwise be provided by gastroenterologists, but they offer unique expertise that we would not have without their partnership.”

— David T. Rubin, MD, FACG, ACG Trustee, “The Indispensables: The Essential Roles of Advanced Practice Providers in GI,” PG 26

6 // MESSAGE FROM THE PRESIDENT Dr. Sunanda Kane on ACG's commitment to the wellbeing of the College and the wellbeing of individual GI clinicians.

7 // NOVEL & NOTEWORTHY

SCOPY and other awardees, special lecturers, GI Jeopardy winners, new MACGs and more.

15 // PUBLIC POLICY GOVERNORS’ VANTAGE POINT How ACG is pushing back against step therapy and what you can do to engage in your state.

19 // GETTING IT RIGHT 19 BUILDING SUCCESS How to add Advanced Practice Providers (APPs) to your practice.

22 LAW MIND How to avoid financial uncertainty when performing experimental treatments.

24 SAGE ADVICE Past President Dr. Arvey Rogers presents aphorisms that improved his and his patients' quality of life during his career.

26 // COVER STORY THE INDISPENSABLES Dr. Paul Kwo, Dr. David Rubin and a series of experts offer insights on the essential roles of APPs in GI: SWOT analyses from physicianAPP teams, resources to conquer the learning curve in GI, and perspective from Mary Vetter, NP.

37 // ACG PERSPECTIVES LEARNING FROM ENDOSCOPIC MASTERS ACG International GI Training Grant recipient Dr. Piyush Somani on learning interventional endoscopy procedures at the Center for Interventional Endoscopy, Florida Hospital, Orlando, FL.

Photo Top: Some of the IBD APPs at the University of Chicago – From left to right: Jennifer Labas, MSN, FNP-BC; Michele Rubin, APN, CNS, CGRN; Janice Colwell, RN, MS, CWON, FAAN; Ashley Perkovic, DNP, FNP-BC; Alexandra Masching, MSN, FNP-BC.

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

43 // INSIDE THE JOURNALS 44 AJG Dr. Sameer Saini and Dr. Hetal Karsan provide perspective on the Journal's “How I Approach It” column.

44 CTG Dr. Douglas Rex and team on how using scribes impacts endoscopist efficiency; Meconium Microbiome Associates with the Development of Neonatal Jaundice.

45 ACGCRJ A Second Attack of Anisakis: Intestinal Anisakiasis Following Gastric Anisakiasis.

46 // REACHING THE CECUM A LOOK BACK: RECTAL DILATORS A brief history of rectal dilators and how the featured set from the 1920s would be just as effective today.

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ACG MAGAZINE MAGAZINE STAFF

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BOARD OF TRUSTEES President: Sunanda V. Kane, MD, MSPH, FACG President-Elect: Mark B. Pochapin, MD, FACG Vice President: David A. Greenwald, MD, FACG Secretary: Daniel J. Pambianco, MD, FACG Treasurer: Samir A. Shah, MD, FACG Immediate Past President: Irving M. Pike, 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: Carol A. Burke, 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: Neil H. Stollman, MD, FACG Vice Chair, Board of Governors: Patrick E. Young, MD, FACG Trustee for Administrative Affairs: Delbert L. Chumley, MD, FACG

TRUSTEES Jean-Paul Achkar, MD, FACG 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 David T. Rubin, MD, FACG John R. Saltzman, MD, FACG Renee L. Williams, MD, MHPE, 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

Jaya R. Agrawal, MD

Richard L. Nemec, MD, FACG

Dr. Agrawal, of Hampshire Gastroenterology Associates, Florence, MA, is a member of the ACG Practice Management Committee.

Dr. Nemec is Chief, Division of Gastroenterology, and Chief, Endoscopy Services, at Winchester Medical Center, Winchester, VA, and practices at Winchester Gastroenterology Associates. He is a member of the ACG Practice Management Committee.

Ann M. Bittinger, Esquire Ms. Bittinger is health law expert at Bittinger Law Firm in Jacksonville, FL. She regularly contributes to ACG's publications on her areas of expertise, including legal relationships between hospital systems and physicians or physician groups (bittingerlaw.com).

Arvey I. Rogers, MD, MACG Dr. Rogers is Past President, ACG (1991–1992) and Professor Emeritus of Internal Medicine and Gastroenterology at the University of Miami Miller School of Medicine.

Wassem Juakiem, MD Dr. Juakiem is of Brooke Army Medical Center, San Antonio, TX.

David T. Rubin, MD, FACG Dr. Rubin is an ACG Trustee and the Joseph B. Kirsner Professor of Medicine at the University of Chicago, Chicago, IL.

Hetal A. Karsan, MD, FACG Dr. Karsan, of Atlanta Gastroenterology Associates and Emory University, is Co-Editor, The Red Section, The American Journal of Gastroenterology.

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

Paul Y. Kwo, MD, FACG Dr. Kwo is an ACG Trustee and Professor of Medicine, Stanford University Medical Center, Palo Alto, CA.

Sameer D. Saini, MD, MS, FACG Dr. Saini, of the University of Michigan in Ann Arbor, MI, is Co-Editor, The Red Section, The American Journal of Gastroenterology.

Piyush Somani, MD Dr. Somani is of Jaswant Rai Speciality Hospital, Saket, Meerut, Uttar Pradesh, India.

Ellena M. Thomas, PA-C Ms. Thomas is in practice with Dr. Richard Nemec at Winchester Gastroenterology Associates, Winchester, VA.

Ralph D. McKibbin, MD, FACG Dr. McKibbin, of Blair Gastroenterology Associates, Altoona, PA, is a member of ACG's Practice Management Committee and Past Co-Director, ACG Practice Management Course.

Mary S. Vetter, NP Ms. Vetter, of the University of Rochester Medical Center, is Chair of ACG’s new Committee on Advanced Practice Providers. She serves on the Women in Gastroenterology and Membership Committees.

Gina Michkofsky, PA-C Ms. Michkofsky is in practice with Dr. Ralph McKibbin at Blair Gastroenterology Associates, Altoona, PA.

Craig M. Womeldorph, DO, FACG, CAPT USN Dr. Womeldorph is of Brooke Army Medical Center in San Antonio, TX. He is a member of the ACG Practice Management Committee.

Joanna M. Myers, PA-C Ms. Myers is in practice with Dr. Richard Nemec at Winchester Gastroenterology Associates, Winchester, VA.

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MESSAGE FROM THE PRESIDEN

THOUGHTS ON WELLBEING

NEW STRATEGIC PLAN MAPS ACG’S ROLE AS A BEACON IN CLINICAL GASTROENTEROLOGY Among the many reasons I am so proud to be your President are ACG’s longstanding and deep dedication to the wellbeing of the College as an organization advancing the GI profession, and our dedication to the wellbeing of individual GI clinicians.

ACG works to create numerous ways to ensure that its members will flourish in gastroenterology.

So much of what I see and read recently, and what I hear in conversations with my colleagues, raises concerns about threats and obstacles to wellbeing—among health care providers in GI and throughout medicine. As clinicians, and as human beings, we are living in times of heightened controversy and facing unprecedented stressors. Decreasing reimbursement rates, unfriendly electronic medical record systems, and significant changes to recertification are just some of the variables that make burnout a real threat to our profession.

I do not pretend to have all the answers. However, I believe we must all be mindful of ways GI clinicians can care not only for our patients, but also for ourselves during these challenging times. We must also re-dedicate ourselves to care for each other—our colleagues and our communities.

NEWLY UPDATED STRATEGIC PLAN: ENSURING ACG’S ORGANIZATIONAL WELLBEING The health and integrity of the College as a nonprofit medical professional society—our organizational wellbeing—and the leadership that ACG needs right now are among my top priorities this year. I see a big part of my presidential role as a guardian of the wellbeing of the College and a steward of its Mission and Vision. In these responsibilities, I am honored to have the Officers and Trustees of the College at my side, as well as the contributions of the Board of Governors, our dedicated journal editors, and all of the many ACG members who participate in the life of the College as volunteers through our educational programs and committee activities.

As my predecessor, Dr. Irving Pike, mentioned in his Presidential Address at ACG 2018, we are in the final phases of an update to the College’s 2014 Strategic Plan. It was an honor to work on this comprehensive review with ACG Past President Carol A. Burke, MD, FACG, and PresidentElect Mark B. Pochapin, MD, FACG. We led a consensus-building process guided by the goal of aligning this roadmap document with the College’s Mission and Vision Statements. In our update, we

6 | GI.ORG/ACGMAGAZINE

looked broadly at the landscape of our profession as well as deeply at our organizational strengths, assets, opportunities and challenges.

We started with a fresh look at ACG’s Vision and Mission Statements. Advocacy was added to the Mission Statement to reflect its importance in the life of the College, whether it be with policymakers, insurance companies or other payers on behalf of patients and the specialty. Throughout the review, we heard loud and clear that ACG’s leadership places the highest priority on evidence-based and compassionate patient care as the driving force behind the College’s Vision Statement, and on a shared commitment to improve the digestive and liver health of the public at large.

The biggest new area of focus in the updated Strategic Plan is the addition of wellness and professionalism as equally important to ACG’s future as research, education, publications, governance and other pillars of our organization. I believe this thorough revision aptly reflects who we are and where we want to go together. This is a living document, and I will look forward to watching the Strategic Plan come to life in the years ahead. More details and the full text will be available soon.

TAKING CARE OF OURSELVES AS ENDOSCOPISTS One very practical way you can help advance wellbeing is to respond to the survey research fielded by the ACG Women in Gastroenterology Committee on musculoskeletal injuries from endoscopy. These findings will help illuminate risks and suggest strategies to improve the physical wellbeing of endoscopists.

You can complete the survey instrument in just a few minutes online: bit.ly/EndoInjurySurvey Finally, on a lighter note, I want to report that the giant inflatable colon stolen from the Colon Cancer Coalition and The University of Kansas Cancer Center was recovered on October 29 by the Kansas City Police after the College offered a $1,000 reward for tips leading to its safe return. If you have not followed news about the #StolenColon on social media, you will enjoy learning how this dastardly colectomy without consent became the butt of many jokes and was featured in The New York Times and on The Late Show with Stephen Colbert. ACG has divided the reward between four nonprofit colorectal cancer advocacy organizations in honor of their good work. All’s well that “ends” well!

­­—Sunanda V. Kane, MD, MSPH, FACG

Note thy wor 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 recaps ACG 2018, from award winners to new MACGs, special lecturers and featured events. Email your professional news and any ideas for future issues of ACG MAGAZINE to ACGMag@gi.org

Novel & Noteworthy | 7

// N&N [MILESTONES]

SIX MEMBERS HONORED AS MASTERS OF THE AMERICAN COLLEGE OF GASTROENTEROLOGY John Baillie, MB CHB, MACG (1953-2018)* Virginia Commonwealth University, Richmond, VA

Sita S. Chokhavatia, MD, MACG The Valley Hospital, Ridgewood, NJ

Grace H. Elta, MD, MACG University of Michigan, Ann Arbor, MI

Wasim Jafri, MD, MACG Aga Khan University, Karachi, Pakistan

Frank L. Lanza, MD, MACG Baylor College of Medicine, Houston, TX

Ronald J. Vender, MD, MACG Yale University School of Medicine, New Haven, CT

[ON THE AIR]

LIVE FROM ACG 2018—SIRIUSXM’S DOCTOR RADIO For the second consecutive year, SiriusXM’s “Doctor Radio” show held a live broadcast during the Opening Welcome Reception at the ACG Annual Scientific Meeting, this time at the Pennsylvania Convention Center in Philadelphia, PA. ACG President-Elect Mark B. Pochapin, MD, FACG, served as the host of the two-hour show, which featured ACG officers and leaders including President Sunanda V. Kane, MD, MSPH, FACG, and Immediate Past President Irving M. Pike, MD, FACG. The two leaders emphasized ACG's commitment to advancing digestive and liver health and gave a preview of ACG 2018.

Past President David A. Johnson, MD, MACG, reviewed key takeaways from his David Sun Lecture, such as how diet, prebiotic/microbiome changes, sleep/ behavioral, and non-prescription medication use can act as pathways for optimizing disease management.

Three guests—Vice President David A. Greenwald, MD, FACG, Past President Carol A. Burke, MD, FACG, and Aasma Shaukat, MD, MPH, FACG—then sat down to discuss colorectal cancer (CRC) including, among other topics, hereditary colorectal syndromes and a reflection on the 80% by 2018 initiative. Following that,

8 | GI.ORG/ACGMAGAZINE

Public Relations Committee Chair Sophie M. Balzora, MD, FACG, Minority Affairs and Cultural Diversity Committee Chair Darrell M. Gray, II, MD, MPH, and ACG Trustee Renee L. Williams, MD, MHPE, FACG, focused on important CRC awareness messages for underserved populations and recapped the 2018 SCOPY Awards Ceremony & Workshop, including the group’s amazement at Victor J. Colon, MD, FACG, who won the “SCOPY Fighting Colorectal Cancer in the Face of Disaster Award” for his practice’s efforts to main CRC awareness efforts while rebuilding after Hurricane Maria.

In the final segment, Nicholas J. Talley, AC, MD, MBBS, PhD, MMedSci, MACG, and Eamonn M. M. Quigley, MD, MACG, joined Brennan M. R. Spiegel, MD, MSHS, FACG, and Brian E. Lacy, MD, PhD, FACG, the Co-Editors of The American Journal of Gastroenterology (AJG), to discuss the AJG Lecture and the recently published ACG Monograph on Management of Irritable Bowel Syndrome.

The College is grateful to SiriusXM and Doctor Radio for broadcasting live from ACG 2018. SiriusXM subscribers can listen to the show via SiriusXM On Demand.

*Dr. Baillie earned the distinction of MACG in October 2018. The College was deeply saddened to learn of his passing on October 29, 2018.

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READ the tribute to Dr. Baillie: bit.ly/DrBaillieTribute; READ the obituary: bit.ly/DrBaillieObit

[AWARDS]

SCOPY AWARDS: ACG RECOGNIZES 24 CRC AWARENESS PROJECTS “Wallop the Polyp.” “Owls for Bowels.” “Butt Seriously. Get Screened.” “#NoButtsAboutIt.”

These catchy, motivating taglines and calls to action headlined a few of the 24 winning colorectal cancer (CRC) initiatives celebrated during the 2018 SCOPY Awards Ceremony and Workshop, Sunday, October 7 at the ACG Annual Scientific Meeting in Philadelphia.

The winning projects featured Dress in Blue Day enthusiasm and creativity, “True or Poo,” an aptly labeled CRC quiz game for patients, an emphasis on shopping and cooking healthy and high-fiber foods, a virtual reality experience to increase understanding of colonoscopy, a human CRC awareness ribbon, and several campaigns providing free or low-cost colonoscopies, among many other efforts.

The initiatives “demonstrated a relentless commitment to community service, a penchant for witty taglines, a focus on quality and public health intervention, a clear commitment to the power of partnership, and dedication to awareness even in the wake of disaster,” said ACG Public Relations Committee Chair Sophie M. Balzora, MD, FACG, of the NYU School of Medicine in New York, NY. Speakers representing four award-winning projects presented about their efforts and, in some instances, explained how others might replicate these efforts in their own communities: Best Bowel Prep Video Adewale B. Ajumobi, MD, Rancho Mirage, CA “Instructive Video on How to Use Bowel Cleansing Agents” Best Public Health Intervention for a Targeted Community Koosh Desai, MD, Medical College of Georgia, Augusta, GA; Minesh Mehta, MD, Geisinger Medical Center, Danville, PA “Georgia Colon Cancer Prevention Project” Most Far-Reaching and Impactful Initiative Douglas J. Robertson, MD, MPH, VA New England Health Care System, White River Junction, VT; and in absentia Jason A. Dominitz, MD, MHS, VA Puget Sound Health Care System, Seattle, WA “Radio Tour Reaches Nearly 25 Million Listeners”

The SCOPY Awards (Service Award for Colorectal Cancer Outreach, Prevention and Year-Round Excellence) recognize the achievements of ACG members in their community engagement, education and awareness efforts for CRC prevention.

SCOPY Fighting Colorectal Cancer in the Face of Disaster Award Victor J. Colon, MD, FACG, Instituto Digestivo de Puerto Rico, Caguas, PR “Maintaining the Spirit of CRC Awareness”

 Award winners:

LEARN MORE about the 2018 SCOPY bit.ly/SCOPY18

[WINNERS]

GEORGETOWN LIFTS THE GI JEOPARDY TROPHY The duo of Joseph J. Jennings, MD, and Rohan Mandaliya, MD, claimed the GI Jeopardy title on behalf of Georgetown University Hospital on Saturday, October 6 at the ACG Annual Scientific Meeting (ACG 2018) in Philadelphia.

For winning the competition, Jennings and Mandaliya will each receive a $1,000 grant to travel to the ACG Annual Scientific Meeting in San Antonio, TX, October 25–30, 2019.

The spirited GI version of the television classic began over the summer, when GI training programs participated in the preliminary round, during which groups of GI fellows took an online test on a variety of GI topics and diseases.

The live event, hosted again this year by Ronald D. Szyjkowski, MD, FACG, pits the top five teams emerging from the preliminary round. Teams also contended from the National Capital Consortium/ Walter Reed, University of California San Diego (UCSD) Medical Center, University of Iowa Hospitals & Clinics, and the University of Nebraska Medical Center College of Medicine. The energetic crowd watched as Georgetown, UCSD and Iowa advanced to the second round before the Hoyas pulled away from the pack.

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LEARN MORE about GI Jeopardy: bit.ly/GIJeopardy

Novel & Noteworthy | 9

[LECTURERS]

ACG 2018 SPECIAL LECTURERS DAVID A. JOHNSON, MD, MACG The David Sun Lecture “Translational Approaches to Common GI Diseases…Thinking Out of the Box…The Future is Now!” Dr. Johnson discussed how diet, prebiotic/microbiome changes, sleep/behavioral, and non-prescription medication use can act as pathways for optimizing disease management.

The David Sun Lecture was established by Mrs. Sun in memory of her husband, Dr. David Sun, an outstanding gastroenterologist and investigator.

NICHOLAS J. TALLEY, AC, MD, MBBS, PHD, MMEDSCI, MACG The American Journal Of Gastroenterology Lecture “What Causes Functional GI Disorders? The Latest Data and Insights” Dr. Talley explained how to recognize known and emerging risk factors for functional GI disorders including infections, foods and alterations in the microbiome.

The American Journal of Gastroenterology Lecture was established in 2003 to provide a forum for the Editors of the College’s flagship scientific publication to select a key scientific topic for debate or discussion based on their evaluation of key controversies in clinical gastroenterology.

STEPHEN B. HANAUER, MD, FACG The J. Edward Berk Distinguished Lecture “Fake News and Alternative Facts on Personalized Medicine in IBD” Dr. Hanauer discussed best practices in IBD and how to differentiate the supporting evidence from the current misinformation and misunderstandings that detract from optimal patient care.

The J. Edward Berk Distinguished Lecture is awarded to individuals prominent in gastroenterology or a related area, and was established in recognition of the significant contributions made by J. Edward Berk, MD, MACG, to clinical gastroenterology during his long and distinguished clinical and academic career.

DAVID A. GREENWALD, MD, FACG The Emily Couric Memorial Lecture “80% Colorectal Cancer Screening by 2018: How Did We Do and Where Do We Go From Here?”

Dr. Greenwald discussed the goals, successes and future plans of the “80% by 2018” campaign for colorectal cancer screening.

The Emily Couric Memorial Lecture, developed by the ACG, the Virginia Gastroenterological Society, and the Old Dominion Society of Gastroenterology Nurses and Associates, is given in honor of Virginia State Senator Emily Couric, who died of pancreatic cancer in October 2001. Senator Couric was a strong advocate for health care issues, particularly in her instrumental work to pass the nation’s first legislation mandating health insurance coverage for colorectal cancer screening.

CAROL A. BURKE, MD, FACG The David Y. Graham Lecture “Management of Patients With Colorectal Polyps: A Personalized Approach Based on Etiology” Dr. Burke discussed the roles lifestyle, genetics and polyp characteristics play in the management of patients with colorectal polyps.

The David Y. Graham Lecturer is a distinguished individual in the field of gastroenterology. This named lectureship was established in 2004 in recognition of the many contributions to clinical gastroenterology by David Y. Graham, MD, MACG, who gave the inaugural presentation in 2004.

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[AWARDS]

ACG 2018 AWARDEES LOUIS J. WILSON, MD, FACG Dr. Wilson was presented the Community Service Award, which is given to an ACG Member who has initiated or has been involved in volunteer programs or has provided extensive volunteer service post training. In the wake of Hurricane Harvey, Dr. Wilson temporarily closed his practice, filled his truck with gas cans and medical supplies, and drove to Houston with his wife, Julie, to assist first responders and the public alike. He is recognized for this and other efforts over 20 years.

Dr. Wilson is Managing Partner of Wichita Falls Gastroenterology Associates in Wichita Falls, TX, and is Chair of the ACG Practice Management Committee.

READ more about Dr. Wilson’s career: bit.ly/LJWilson

FRANCIS KA-LEUNG CHAN, MD, FACG Professor Chan is the recipient of the International Leadership Award, which is given to a Fellow or Master of the ACG in recognition of outstanding and substantial contributions to gastroenterology, to the College, and to the international gastroenterology community. For the past 20 years, Professor Chan has made extraordinary contributions to international gastroenterology. He has used research to inform revisions to national and international practice guidelines, nurtured leaders in the field, led patientcare improvements in the Asia-Pacific region, and participated in humanitarian efforts.

He has published more than 500 scientific papers in leading medical journals and has served as an associate editor or editorial board member to multiple journals, including AJG. Professor Chan is Dean and Professor, Division of Gastroenterology & Hepatology, Department of Medicine and Therapeutics, The Chinese University of Hong Kong.

READ more about Professor Chan’s career: bit.ly/FKLChan

STEPHEN B. HANAUER, MD, FACG This year’s Berk/Fise Clinical Achievement awardee is ACG Past President Dr. Stephen B. Hanauer, who embodies the spirit of the award. Dr. Hanauer is honored for his significant and distinguished contributions to clinical gastroenterology. This annual award recognizes not only clinical excellence, but also contributions in patient care, clinical science, clinical education, technological innovation, and public and community service.

Dr. Hanauer was ACG President from 2014 to 2015, and has been Chair of the College’s Finance & Budget Committee and a member of the Board of Trustees.

Additionally, he served as a member of the Credentials Committee, Publications Committee and Research Committee. In 1999, Dr. Hanauer delivered the David Sun Lecture at the ACG Postgraduate Course.

Dr. Hanauer is the Clifford Joseph Barborka Professor of Medicine and the Medical Director of the Digestive Health Center at the Northwestern University Feinberg School of Medicine.

RENEE L. WILLIAMS, MD, MHPE, FACG Dr. Williams was presented with the 2018 Minority Digestive Health Care Award, which recognizes an ACG Member or Fellow whose work in the areas of clinical investigation or clinical practice has improved the digestive health of minorities or other underserved populations of the United States. She is honored for her commitment to mentorship, eliminating health care disparities, and diversity and inclusion in medicine and GI. Dr. Williams’ committee service with ACG includes serving on the Abstract Review Committee, a temporary membership on the Professional Issues Committee, and a long-standing role on the Minority Affairs and Cultural Diversity Committee, including as Chair for the past two years.

Dr. Williams is an ACG Trustee and is currently Assistant Professor of Medicine at the New York University School of Medicine, where she serves as the Program Director for the gastroenterology training program.

READ more about Dr. Williams’ career: bit.ly/RLWilliams

PETER ALAN BANKS, MD, MACG In recognition of more than 30 years of service to the College, his reputation as an expert in pancreatology, and an unwavering dedication to compassion, science and excellence, Peter Banks, MD, MACG, receives the College’s highest honor—the Samuel S. Weiss Award. This service award in commemoration of ACG’s founding father, Samuel S. Weiss, is presented periodically, and not necessarily annually, to a Fellow of the College in recognition of outstanding career service to ACG. Dr. Banks is an internationally known icon in gastroenterology with particular expertise in pancreatology. He has served patients and his peers for over 50 years. His ability to teach at all levels of knowledge, including patients, students, trainees and colleagues, knows no limits. Dr. Banks is humble and gracious with his time and efforts.

Dr. Banks’ curriculum vitae reports outstanding accomplishments in academia, community engagement and, most importantly, service to the College. Dr. Banks was elected to the ACG Board of Governors and served two terms on the Board of Trustees, 1989 to 1992 and 1995 to 2000. Of his time as a Trustee, one ACG Past President commented, “he could be counted on to always think of what was best for the College, during what were two somewhat tumultuous years.”

READ more about Dr. Banks’ service to the College, examples of his leadership, and other career honors: bit.ly/PABanks

READ more about Dr. Hanauer’s academic career and honors: bit.ly/SBHanauer

Novel & Noteworthy | 11

ACG CALENDA

MARCH

JANUARY

1–3

18–20

ACG/FGS ANNUAL SPRING SYMPOSIUM

 Naples, FL Register: meetings.gi.org

MARCH 29

IBD SCHOOL & WESTERN REGIONAL POSTGRADUATE COURSE

MARCH

8–10

NORTH AMERICAN INTERNATIONAL GI TRAINING GRANT AWARD DEADLINE

ACG/LGS REGIONAL POSTGRADUATE COURSE

MARCH 29

 New Orleans, LA

INTERNATIONAL GI TRAINING GRANT AWARD DEADLINE

 Las Vegas, NV

More Info: gi.org/na-intl-training-grant

Register: meetings.gi.org

MARCH 22-24 NORTH AMERICAN CONFERENCE OF GI FELLOWS (NACGF)

Register: meetings.gi.org

More Info: gi.org/intl-training-grant

 Orlando, FL More Info: members.gi.org/nacgf

JUNE

7

8–9

IBD SCHOOL AT EASTERN REGIONAL

EASTERN REGIONAL POSTGRADUATE COURSE

 Washington, DC

 Washington, DC

More info: gi.org/regional-meetings

More info: gi.org/regional-meetings

APRIL 15 AWARDS NOMINATIONS DEADLINE More Info: gi.org/awardees-and-special-lecturers

AUGUST

16

AUGUST

17–18 12 | GI.ORG/ACGMAGAZINE

JUNE

IBD SCHOOL AT MIDWEST REGIONAL

 Minneapolis, MN More info: gi.org/regional-meetings

MIDWEST REGIONAL POSTGRADUATE COURSE

 Minneapolis, MN More info: gi.org/regional-meetings

Learn More: acgmeetings.gi.org

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

©2018 Braintree Laboratories, Inc.

HH25901

August 2018

Braintree—committed to expanding the universe of quality bowel prep products

1991

1984

NuLYTELY®

GoLYTELY®

(PEG-3350, sodium chloride, sodium bicarbonate and potassium chloride for oral solution)1

(PEG-3350 and electrolytes for oral solution)2

2004

HalfLytely ® and Bisacodyl Tablets Bowel Prep Kit (PEG-3350, sodium chloride, sodium bicarbonate and potassium chloride for oral solution and bisacodyl delayed - release tablets)*

2010

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

The #1 most prescribed, branded bowel prep kit with more than 15 million kits dispensed since 20103,4

References: 1. NuLYTELY [package insert]. Braintree, MA: Braintree Laboratories, Inc; 2013. 2. GoLYTELY [package insert]. Braintree, MA: Braintree Laboratories, Inc; 2013.

3. SUPREP Bowel Prep Kit [package insert]. Braintree, MA: Braintree Laboratories, Inc; 2017. 4. IQVIA. National Prescription Audit Report. August 2018. *This product has been discontinued.

PUBLIC

POLICY PUSHING BACK AGAINST STEP THERAPY // GOVERNORS' VANTAGE PINT

The College’s Efforts, How You Can Engage at the State Level Brad Conway, Esq., ACG Vice President of Public Policy, Coverage & Reimbursement and Jil Staszewski, Manager, Public Policy and Government Affairs, contributed to this article. They support the ACG Board of Governors in its advocacy work.

ADVOCATING FOR ISSUES that impact your practice and your patients has always been one of ACG’s top priorities.

Among the top concerns ACG hears from members year-round is insurer “step therapy” requirements, and the unfortunate effects they have on both the physician and patient. This year, pushing back against step therapy has been at the forefront of the College’s efforts. Here are some of the many ways the College and its members have been involved in various strategies attempting to override these destructive policies.

ACG’S VIEW 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. This process damages the patient-physician relationship, as it not only undermines the fact that the physician knows the patient’s condition most intimately and should be trusted with defining the best course of treatment, but it also wastes valuable time in the patient’s treatment. 

Public Policy | 15

// PUBLIC POLICY: GOVERNORS' VANTAGE POINT

MAKING THE CASE ON CAPITOL HILL In April, over 50 ACG Governors, officers and members advocated on your behalf on Capitol Hill during the 2018 ACG Board of Governors Legislative Fly-In. Struggles with step therapy requirements were among the key issues ACG members brought to the attention of elected officials in Washington, DC. ACG Governors and leaders discussed the federal “Restoring the Patient’s Voice Act of 2017” (H.R.2077), introduced by Representative Brad Wenstrup (R-OH), which allows for exemptions for step therapy requirements in health plans regulated by federal law. As of this writing, the bill has 78 cosponsors, including fairly balanced bipartisan support. The College is making a last ditched effort to get the bill passed before the end of the 115th Congress.

CMS PROPOSALS ADD COMPLEXITIES TO PRIOR AUTHORIZATION IN MEDICARE This summer, the Centers for Medicare and Medicaid Services (CMS) announced several important updates to the Medicare Advantage (MA) program. Beginning January 1, 2019, MA plans will have the opportunity to impose step therapy rules for Part B drugs for new prescriptions. Although CMS claims that the imposition of this rule will save money for Medicare beneficiaries and the program as a whole, it will force ACG members to spend more time dealing with insurers and prior authorizations, at a detriment to patient care.

These policies are not rooted in clinical evidence, and ultimately take valuable time

16 | GI.ORG/ACGMAGAZINE

“In addition to working with state societies and like-minded physician groups, collaborating with other ACG Governors is imperative. ACG Governors from states which have proposed or passed similar legislation can assist other ACG Governors by recommending language changes or assisting in the draft process.”

—Christopher D. South, MD, FACG

away from treating patients. That’s why ACG worked with Representatives Phil Roe, MD (R-TN) and Ami Bera, MD (DCA) to garner support for a letter to CMS Administrator Seema Verma, requesting that CMS review these proposed changes to the MA program in order to “help increase transparency, streamline prior authorizations, and minimize impact on patients.” Many of you made your voices heard by reaching out out to your members of Congress on ACG’s behalf. Working with like-minded organizations, in August ACG joined nearly 100 societies in a letter urging CMS not to go through with the MA proposals.

STATE-LEVEL LEGISLATIVE EFFORTS In addition to efforts at the federal level, several state step therapy bills have been introduced and advocated for nationwide.

In December 2017, ACG, along with the Massachusetts Gastroenterology Association and several patient advocacy organizations, participated in the Pharmacy and Medical Malpractice hearing before the Massachusetts Joint Committee on Financial Services in support of the “Acts to Reduce Health Care Costs Through Improved Medication Management (S.551/H.492).” Similar legislation exists in Minnesota, with the “Step Therapy Override” bills (SF.2897/HF.3196), as well as in Ohio (SB.56/H.72), Washington (SB.6233) and several other states.

 Far Left: ACG Governor for Southern Ohio Christopher D. South, MD, FACG, ACG Legislative and Public Policy Council Member R. Bruce Cameron, MD, FACG, Senator Rob Portman (R-OH), and ACG Regional Councilor and Governor for Northern Ohio Ashley L. Faulx, MD, FACG. Immediate Left: Dr. Christopher D. South.

HOW TO GET INVOLVED AT THE STATE LEVEL It is important to build on these efforts and to generate more momentum. ACG recognizes that the more legislation introduced at the state level, the greater the chance the federal bill has to gain additional traction. If no step therapyrelated legislation has been introduced in your state, you can help bring it to the table, with the assistance of your respective ACG Governors. ACG Governor for Southern Ohio Christopher D. South, MD, FACG, commented, “In addition to working with state societies and like-minded physician groups, collaborating with other ACG Governors is imperative. ACG Governors from states which have proposed or passed similar legislation can assist other ACG Governors by recommending language changes or assisting in the draft process.”

The College is grateful for the passion and dedicated activism demonstrated nationwide by so many ACG Governors and College members at the federal, state and local levels.

With your continued support, ACG can continue to push to end these policies and place the power back into the hands of the physician and patient.

 CONTACT your Governor today: gi.org/governors

TAKE ACTION: Visit ACG’s Legislative Action Center to contact your members of Congress about important bills affecting your practice and your patients: bit.ly/ACGActionCenter

Share your

experience and

Help your

colleagues Participate in a musculoskeletal injuries in endoscopy survey Help us identify and prevent musculoskeletal injuries among GI endoscopists Looking at all types of injuries among women and men, interventionalists and non-interventionalists and GI trainees and those in practice Developed by the ACG Women in GI Committee

PARTICIPATE NOW: gi.org/endo-injury-survey

Public Policy | 17

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

GETTING IT

GETTING it Right

 THE TERM ADVANCED PRACTICE PROVIDER (APP) IS DEFINED AS a licensed non-physician health care professional and applies to nurse practitioners (NPs) and physician assistants (PAs). Over the past two decades, APPs have increasingly provided care in a variety of practice settings, including gastroenterology. APPs can benefit health care delivery by increasing access to care, improving the efficiency of practices in the hospital and office settings, improving patient satisfaction, engagement and education, and reducing physician burnout. Because services provided by APPs are reimbursable, the economics of adding APPs are usually favorable, or at least break even. The shortage of physicians in many markets is propelling APPs into increasingly important roles in health care. While integrating APPs into the practice offers multiple benefits, it may also add liability and risks. For successful integration of an APP into a practice, an atmosphere of collegiality, respect and appropriate oversight and teaching is essential.

ADDING PROVIDERS to Your Practice // BUILDING SUCCESS

ADVANCED PRACTICE

Jaya R. Agrawal, MD, Hampshire Gastroenterology Associates, Florence, MA Wassem Juakiem, MD, Brooke Army Medical Center, San Antonio, TX Craig M. Womeldorph, DO, FACG, CAPT USN, Brooke Army Medical Center, San Antonio, TX

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

THE INCREASING DEMANDS ON PHYSICIANS

Multiple factors have escalated the increased demand for gastroenterology services. There is a projected shortfall of at least 1,050 gastroenterologists by 2020 (bit.ly/AAMC1018).

The Patient Protection and Affordable Care Act of 2010 (ACA) has improved access and universal coverage for millions of people who now need evaluation of acute and chronic medical problems. In addition, the ACA moved the health system from a fee-for-service to a value-based reimbursement system and pushed for electronic health care records (EHRs), which subsequently resulted in evaluating fewer patients per office session to improve the patient experience and meet the increased data input burden. In addition, the Medicare Access and CHIP Reauthorization Act (bit.ly/MACRAText) has created alternative and moreburdensome payment reporting requirements. According to the 2016 Physicians Foundation Biennial Physician Survey Report (bit.ly/PFReport16), 49% of providers often or always experience feelings of burnout, 80% of physicians are overextended or at capacity, 72% feel that external factors such as third-party authorizations significantly detract from the quality of care they provide, and 48% of physicians plan to cut back on hours, retire, take a non-clinical job, switch to “concierge” medicine, or take other steps limiting patient access to their practices.

These forces have propelled APPs into increasingly important roles in health care delivery to fill the physician-provider gap. APPs are often able to spend more time facing patients than physicians, thus improving the health care experience for patients and decreasing burnout for physicians. 

Getting it Right | 19

// GETTING IT RIGHT: BUILDING SUCCESS

ADVANTAGES OF ADDING ADVANCED PRACTICE PROVIDERS Integrating APPs into the gastrointestinal practice offers multiple benefits, including improved patient access, increased provider face time, improved patient education, which leads to greater patient satisfaction, improved physician work-life balance, and increased practice efficiency and revenue.2-3 Evidence shows improved health care outcomes and patient satisfaction with NPs and primary care physicians.2

 Gives Physicians More Time for Procedures: APPs can reduce the physician’s time seeing patients in the clinic and can increase procedure volume.

 Increases Practice Efficiency: For most practices, the revenue generated by the clinical work of the APP generally exceeds salary and benefits.

CONSIDERATIONS WHEN CHOOSING AN APP  New Graduate Versus Experience: New PA/NP graduates have a base of medical knowledge but need time/supervision to learn common GI problems and approaches to evaluation and work-up, including indications/ contraindications for procedures.

Teaching the rhythm of patient assessments will take time e.g., may take months to accomplish.

As mutual confidence and trust grow, APPs become proficient at assessing, triaging and managing common GI disorders.

APPs with previous experience in surgical practices or emergency departments may be disappointed with the exclusively office and consult work that is the usual scope of practice in GI groups. Therefore, setting expectations up front is critical.

Ideal candidates will have one to two years of experience in family medicine, internal medicine, hospitalist medicine or medical subspecialties that involve inpatient and outpatient care.

 NP Versus PA: Both can see patients in hospital and office settings and either can be billed independently or incident-to with physician supervision. NPs have a prior work history of an RN, particularly for hospitaloriented work, which can be an asset. Most APPs work defined hours; however, some take call and work flexible hours depending on the volume of work.

APPs taking call and working longer hours are compensated accordingly compared with those working fixed hours. PAs receive training that more closely resembles medical training. Regardless, both NPs and PAs can become integral to a GI practice, and the individual and supervision are more critical than whether it is an NP or PA.

CONTRACT NEGOTIATION WITH AN ADVANCED PRACTICE PROVIDER The Medical Group Management Association (MGMA) will give you the salary ranges for APPs in your region. In general, salaries for APPs in GI are similar to those in primary care, but lower than salaries for APPs in dermatology, surgery, emergency medicine, etc. It is not uncommon for contracts to have a base salary plus bonus for productivity based on revenue generated or relative value units (RVUs), similar to physician contracts. Contracts will also often contain an expectation as to number of patient encounters performed or RVUs generated a week. As with physicians, CME time and stipend in addition to vacation time is often offered. In addition, employment contracts for APPs often contain a “scope of practice” describing the range of services the provider will provide and the extent of the supervision in place.

20 | GI.ORG/ACGMAGAZINE

 Reduces Physician Competition: APPs do not increase the supply of gastroenterologists in the market the same way bringing in another gastroenterologist does.

 Easier Exit Strategy: Adding physician partners results in some loss of autonomy and ownership with every new partner and can result in difficult separations when the partnership ends. APPs are employees, and the issues inherent with partnership/ownership are not in play.

SCOPE OF PRACTICE FOR ADVANCED PRACTICE PROVIDERS The scope of practice for APPs is not clearly defined but the common roles are to see new and established followup patients in both the outpatient and inpatient setting. In the outpatient setting, APPs may perform patient history and physical examinations, formulate differential diagnosis and treatment plans, order laboratory and radiographic studies, and prescribe medication. APPs may also oversee counseling and education programs for chronic conditions, such as non-alcoholic fatty liver disease, hepatitis C treatment, liver cirrhosis pre- and post-transplant, irritable bowel syndrome and inflammatory bowel disease. In some states, APPs have been trained and credentialed to perform diagnostic and therapeutic procedures, such as paracentesis, liver biopsies, manometry, and assisting providers in PEG tube placements. APPs may coordinate post-hospital discharge follow-up and manage clinical trials. Incorporating APPs into a practice may increase the practice’s exposure to some liability risks. Three methods commonly used to attach liability for errors of APPs and which should be reviewed are vicarious liability, negligent supervision and negligent hiring.3-6 APPs are incorporated into gastroenterology using one [or a combination of] four general strategies:

 Limited Office-Based Practice: This means the mid-level provider’s primary function is to see patients in the office, but with a limited range— screening consults who require an office visit, low complexity (rectal bleeding, iron deficiency anemia), and hepatitis C. APPs often manage their own panels of patients, sometimes concentrated in an area of focus like hepatitis C. Downside: it may be more challenging for office staff to distinguish between APP and MD/DO patients for scheduling, and it concentrates difficult or complex patients onto the physician’s schedule. Physicians may feel like they are supervising the care of patients they never see.

 Full Office-Based Practice: This allows APPs practicing primarily in the outpatient setting to see the same range of patients that the physician sees. While this makes scheduling easier and reduces patient backlog, referring providers and patients may feel they are not getting the appropriate level of care for a subspecialty practice. This is often overcome as the patients and referring providers gain confidence in the APP and/or have confidence in the group employing the APP to provide appropriate and adequate supervision.

BILLING COMPLIANCE Many practices experience difficulty incorporating APPs due to problems with billing compliance. Each payer has a different policy as it relates to APPs, and a few will not credential APPs at all. Most have specific criteria that will need to be met in order for the APP to bill under the physician’s name. The criteria used by the Centers for Medicare and Medicaid Services (CMS) is referred to as “Incident to.” It is beyond the scope of this document to provide billing and coding advice, but in general CMS allows a practice to bill a patient seen by a mid-level under a physician’s name if they are continuing a plan of care established by a physician. This means that new consults or new problems assessed by an APP should always be billed under that APP’s NPI and not the physician’s NPI. For patient follow-up visits billed under the physician, a physician should be on site, and it is prudent practice to demonstrate some supervision by the attending physician (co-sign note, etc.) It is good practice to review billing guidelines for each payer with your billing staff or billing company every one to two years to ensure compliance.

STATE-BY-STATE VARIATIONS

 Hospital-Based Practice: Many practices have their APPs based in the hospital part or all of the time. Most commonly, they will see hospital follow-up patients after the initial consultation.

Some practices have APPs see simple inpatient consults, such as to screen for contraindications for requested procedures. In this role they also manage communication with inpatient providers, increasing efficiency of patient care in the hospital setting. This also frees up more time for the gastroenterologist to perform add-on procedures.

 Physician Extender: In some models, APPs work alongside physicians as assistants, without independently seeing their own patients. In this setting, they respond to patient phone calls, assist with triage, and compose notes while physicians see patients. This can be an expensive option because much of this work can be done by lessexpensive staff.

Your practice should review all credentials and references and take into account the specific state’s supervision requirements. Be sure to properly train and supervise APPs and review work regularly. One of the challenges is different styles/approaches of different physicians that supervise and work with the APPs. Planning for those differences and emphasizing evidence-based best practices and using resources available from the GI societies to help train and integrate APPs is crucial. Subspecialty work by APPs requires an environment that encourages regular interaction with physicians, sets high standards of care, and stresses documentation and compliance monitoring.4

CONCLUSION

REFERENCES

1. Moses RE, McKibbin RD. Non-physician clinicians in GI practice part 1: current status and utilization.

Am J Gastroenterol 2017; 112: 409 – 1.

2. Dorn SD. Mid-level providers in gastroenterology.

Am J Gastroenterol 2010; 105: 246 – 51.

3. Wilson LJ, Yepuri JN, Moses RE. The advantages and challenges of measuring patient experience in outpatient clinical practice. Part 4: acting on patient satisfaction results. Am J Gastroenterol 2016; 111: 916 – 7.

4. Moses RE, McKibbin RD. Non-physician clinicians in GI practice part 2: current status and utilization. Am J Gastroenterol 2017; 112: 530 – 31.

5. Moses RE, Feld AD. Legal risks of clinical practice guidelines. Am J Gastroenterol 2008; 103: 7 – 11.

6. Moses RE, Feld AD. Physician liability for medical errors of nonphysician clinicians: nurse practitioners and physician assistants. Am J Gastroenterol 2007; 102: 6 – 9.

7. Moses RE, Jones DS. Physician assistants in health care fraud: vicarious liability. J Health Care Compliance 2011; 13: 51 – 6.

The use of APPs in practice can provide many tangible benefits, including an increase in patient access and satisfaction, improving physician quality of life, and increasing practice productivity.

Clearly delineating the role of the APP, understanding the state licensure requirements, implementing a supervision policy, and establishing a welldefined standard of practice will help avoid the pitfalls of working with these valuable professionals.

Getting it Right | 21

// GETTING IT RIGHT: LAW MIND

AVOIDING // LAW MIND

Financial

UNCERTAINTY

When Performing Experimental Treatments

By Ann M. Bittinger, Esq., a health care attorney with physician group clients across the country.

Questions? Email ann@bittingerlaw.com

 THERE ARE FEW THINGS MORE VEXING FROM A MEDICAL-ADMINISTRATIVE STANDPOINT than

performing cutting-edge treatments to help patients only to have insurers deny claims on the basis that those services are “investigational.” Equally frustrating is the payer second-guessing the treatment you prescribe, saying the patient should be on one drug prior to another drug—commonly called step therapy.

22 | GI.ORG/ACGMAGAZINE

Your GI colleagues experience denials for the following, among other items: • Capsule endoscopies; • Various drugs, particularly inflammatory bowel disease biologics and direct-acting antivirals; and • Motility studies (viewed as experimental).

Take these steps to prevent medical-based denials.

PAYER RELATIONSHIPS As big insurance companies get bigger, it may be more difficult for gastroenterologists and practice administrators to develop mutually beneficial relationships with payer representatives, yet these relationships are more important than ever. Successful GI groups meet at least quarterly with major private payers in their markets. They talk strategically, educating each other on issues and working on solutions.

Cultivate a relationship with the payers’ medical directors in charge of GI and endoscopy. Volunteer to serve where physicians can help (focus groups, guidance drafting, speaking services, etc.)

Gastroenterologists can fight denials by putting themselves in the payers’ positions and proactively making their cases to payers before services are rendered. A payer’s main objective is to pay for services at the lowest-reasonable cost to their insured.

Embrace that objective. Explain that while a therapy may be more expensive in the first six months, if it works it avoids later treatments that are more expensive. In other words, when negotiating with payers, the argument that emphasizes that your plan of care is, indeed, the most costeffective one (in the long term or big picture, considering other diagnostic tests, specialists visits, drugs and other procedures) is an argument with which payers will most likely agree.

Pay attention to the different payer service lines and which one each payer favors. Some payers may be more lenient in allowing experimental treatment for health maintenance organization (HMO) contracts, over which they have more control of specialists. Be sure your contract does not have “all products” language, meaning your group has to participate in all types of contracts the insurer has to provide to patients.

CONTRACT The key to legal enforcement of payer payment obligations is the GI grouppayer contract.

Contract Terms The definitions sections of these contracts are typically most important in clarifying what the payer will and will not pay. Negotiating on the front end will make payment more likely and improve chances of winning legal disputes. Key terms to negotiate include:

Medical Necessity This term is the holy grail of payment enforcement disputes. The payer has to pay for services that are “medically necessary.” How that term is defined is crucial. Who decides what is medically necessary? If you see a phrase like “in Payer’s sole discretion,” you will likely never win a dispute on the medically necessary basis. The broader the language, the more likely you can win a dispute.

• Experts: Benign definitions of medically necessary like “services or supplies needed to prevent, diagnose or treat an illness, injury, condition, disease or its symptoms,” require a physician expert to decide if something is medically necessary. This involves an expert witness or the use of peer-reviewed journal articles to establish medical necessity. You can add that if there’s a question on medical necessity, the dispute will be decided as follows: • Each party chooses one expert, board certified in gastroenterology, who has no financial relationship with either party, and those two experts choose a third. The panel of three experts reviews the cases of each side and determines if the procedure is, indeed, medically necessary.

This process allows for a focused, prompt resolution by individuals with medical (not business administration) backgrounds. A provision that allows the payer’s medical director to decide what is medically necessary is usually a Trojan Horse and should be avoided.

• It is also important to use guidance issued by the payers. Payers often publish guidelines similar to Medicare’s local and national coverage determinations.

Often that guidance contains citations to peer-reviewed journals. If the payer used an article or study in support of its position on one procedure, use it and its rationale to support the procedure they are questioning, as applicable. Don’t reinvent the wheel by finding sources they have never cited as credible. Use their sources, and the associated authors and investigators, as your experts—to support your position.

• Third-party sources like the InterQual Guidelines may also be helpful.

Experimental Often the definition includes exceptions like “services…that meet accepted standards of medicine” or “except for services that are experimental in nature.” Consider citing ACG clinical guidelines and studies to help demonstrate that the service or procedure is considered the “standard of care.” Use the definitions to cut off denials of arguably experimental treatments. Use language to establish how things are determined to meet “accepted standards” of medicine. The challenge lies in that there may be no bright line as to evolving procedural effectiveness.

Many payers include a process by which they will judge if something experimental warrants reimbursement.

Learn these processes. Often that process includes testing the new procedure against three to five other established procedures to determine effectiveness. The fewer existing procedures the experimental procedure must beat, the better.

The best way for gastroenterologists to prove experimental processes are working is to participate in studies and publish findings. This establishes a reference base that can be used to promote reimbursement. It’s not enough to show results in your own practice; you need to show that the specialty is finding results. Network with colleagues, develop protocols about new procedures, test them, and publish results. Those publications are the roots for establishing the reimbursement requirements for those procedures.

FIGHTING THE FIGHT Most payer agreements allow for informal internal appeals processes.

Another option is to file a complaint with the appropriate state agency.

I encourage practices, however, to consider filing for arbitration. Most payer contracts have arbitration provisions, meaning disputes are handled privately (and usually less formally and less expensively) by an arbitrator. If you cannot work your

relationships with payers, as described above, or if you are stuck with contract definitions, evaluate your arguments, experts and peer-reviewed data and make a case for arbitration. Often, invoking arbitration is as easy as sending a letter to the payer and paying a filing fee with an arbitration service. You will need an experienced health care attorney to prepare the claim.

Invoking arbitration gets your argument out of the payer’s claims administration department and into the hands of the plan’s lawyers—typically in-house counsel who are not paid by the hour. Discovery is streamlined in arbitration as opposed to litigation.

To arbitrate, claims must already have been denied. It’s not possible to ask an arbitrator to require payment prospectively. Be mindful of attorney’s fees provisions. You may have to pay for the payer’s attorney’s fees if you lose; if you win, the payer may have to reimburse you for yours.

These cases generally settle, with an agreement about how the procedure will be performed (or not) going forward. Arbitration can be a last resort to educate the payer about the science behind new procedures. Invoking arbitration can be a way to have the aforementioned dialogue with the payer.

A good health care attorney will not, however, take your case unless you have done your homework.

The gastroenterologist is typically in a better position than an attorney to scour medical literature to find and evaluate journal articles that support the group’s position.

The gastroenterologist may be the best person to identify experts to retain and to explain the nuances of why current payer guidance is outdated or inaccurate.

Getting it Right | 23

// GETTING IT RIGHT: SAGE ADVICE

Sage Advice On Being

A PHYSICIAN

Eight years have passed since I addressed the class of 2014 at the University of Miami Miller School of Medicine’s Annual Pinning (White Coat) ceremony. A portion of my talk was devoted to presenting a list of aphorisms that had contributed to making my long journey as a physician a daily joy; enabled me to contribute in many ways to improving the quality of life of my patients and my own as well; and inspired within me a culture of professionalism. Those aphorisms intended then to guide students on their way to BECOMING a physician apply still now to all of us who BECAME gastroenterologists:

BE for Your Patient By sharpening or acquiring skills facilitating your ability to bond quickly; By being an active, undistracted listener, absorbing your patient’s unique narrative; By listening with the third ear, learning to sense what the patient is feeling; By being an effective communicator; By exhibiting a sense of humor when appropriate; By expanding your knowledge base every day, but never being arrogant displaying it; By being truthful, inspiring trust and confidence; By recognizing your limitations and being able to say, “I don’t know” when you don’t; By feeling compassion and empathy yet not allowing either to compromise your objectivity; By understanding the importance of the quality of life being lived and of life’s limits; By remembering: “Holding a hand is often as important as examining one” (Lawrence J. Brandt, MD, MACG, 1993); By being able to comfort the seriously ill and dying; By letting your patients see and know your human side; By being able to cry with and for your patients; And by remembering the words of Dr. Francis Weld Peabody written in his inspiring essay, “The Care of the Patient,” JAMA, 1927:

“One of the essential qualities of the clinician

is interest in humanity, for the secret of the care of the patient is in caring for the patient.”

24 | GI.ORG/ACGMAGAZINE

BE Zealous about Your Profession BE for Your Colleagues BE Mindful of Societal Needs in Health Care and Assist in Meeting Them

ACG MOBILE

ACCESS KEY RESOURCES at the point of care

BE for Yourself By being mindful of your feelings and how you affect and influence others around you; By keeping low your titer of self-deception; By learning to become comfortable with uncertainty; By acknowledging that you will never know everything or remember everything you learned and once knew; By enjoying spending time with loved ones, family and friends; By learning to set priorities; By being able to separate yourself as a person from your profession as a physician; By developing a passion for something in addition to medicine; By recognizing and acknowledging personal imperfections, being self-compassionate; And, finally, by taking care of yourself (we are not immortal).

“We will have to reconcile ourselves to the fact that the Hippocratic physicians

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were no demigods but just humble mortals,

seeking the truth, erring, rejoicing, and suffering like ourselves.”

—Hippocratic aphorism

Arvey I. Rogers, MD, MACG, of Miami, FL, is Past President of the American College of Gastroenterology (1991 to 1992) and Professor Emeritus of Internal Medicine and Gastroenterology at the University of Miami Miller School of Medicine. He joined the faculty in 1962 and served as Chief of the Division of Gastroenterology from 1994 until 2001, when he retired in order to spend more time with his wife, Susan, who had been diagnosed with a recurrence of breast cancer. She passed away in 2008, after which he rejoined the medical school as Assistant Dean of Continuing Medical Education. Dr. Rogers is remarried and living happily with his wife, Joan Rosenberg-Rogers.

DOWNLOAD THE ACG MOBILE APP Download the app via the Apple or Android Store.

Getting it Right | 25

// COVER STORY

26 | GI.ORG/ACGMAGAZINE

Cover Story | 27

// COVER STORY

THE INDISPENSABLES

Paul Y. Kwo, MD, FACG. Dr. Kwo is an ACG Trustee and Professor of Medicine, Stanford University Medical Center.

Gastroenterologists who care for patients in 2018 have more diagnostic and therapeutic tools and options than ever before to help better care for their patients. These advances have occurred in the setting of rapid change in the delivery of health care that has occurred both in the inpatient and outpatient settings. One key addition to the health care team to care for these patients has been the introduction of the Advanced Practice Provider (APP).

APPs play an indispensable role in the care of patients in general gastroenterology and hepatology clinics, specialized service lines (such as the care of motility liver and transplant patients), as well as inpatient gastroenterology/hepatology services. APPs are often found in gastroenterology outpatient clinics, where they can evaluate patients with routine problems such as occult blood in the stool, gastroesophageal reflux or elevated liver tests, and more-complicated problems, including the evaluation of decompensated cirrhosis. Moreover, APPs can provide longitudinal care to patients who require ongoing monitoring.

LESSONS LEARNED FROM HEPATOLOGY EXPERIENCE In our hepatology practice, APPs can evaluate patients with chronic hepatitis C, chronic hepatitis B and

28 | GI.ORG/ACGMAGAZINE

nonalcoholic fatty liver disease (NAFLD), determine what therapy is appropriate in consultation with our liver group, and guide patients through therapy and lifestyle modifications. This has become essential with the large number of individuals who are diagnosed with NAFLD who need to be assessed to determine whether or not they have findings that warrant an evaluation for non-alcoholic steatohepatitis, in addition to the still large number of individuals who have chronic viral hepatitis.

The strength of this model is that it allows greater capacity for practice, and patients appreciate the extra time that our APPs can spend with them. We also have APPs who work closely in our liver transplant practice, including with patients who have been recently transplanted.

These nurses receive specialized training in immunosuppression and monitoring of transplant complications, can serve as a vital link as patients transition from their immediate post-operative transplant course to being followed in the outpatient post-transplant clinic, and can help accommodate the patient who requires frequent and/or urgent visits to the clinic during their immediate posttransplant course. Finally, our inpatient APPs offer ongoing care to our inpatients, including patients awaiting orthotopic liver transplant who are admitted with complications of cirrhosis, including variceal bleeding or infections, as well as care of our post-transplant patients who require admission. Not only can they provide day-to-day care of inpatients, but they can help perform procedures such as paracentesis, both in the inpatient and outpatient settings.

In setting up an APP program, it is important to define the roles of the APPs as well as the populations that they will care for to ensure they will have the best opportunity to improve overall practice quality. With the rapid changes in how health care is delivered, these models of delivery will need to be highly flexible.

Well-trained APPs will allow practices to adapt in this environment.

Photo Right: Some of the IBD APPs at the University of Chicago – From left to right: Jennifer Labas, MSN, FNP-BC; Michele Rubin, APN, CNS, CGRN; Janice Colwell, RN, MS, CWON, FAAN; Ashley Perkovic, DNP, FNP-BC; Alexandra Masching, MSN, FNP-BC.

The Essential Roles of Advanced Practice Providers in GI David T. Rubin, MD, FACG. Dr. Rubin is an ACG Trustee and the Joseph B. Kirsner Professor of Medicine at the University of Chicago.

The essential roles of Advanced Practice Providers (APPs) in GI practices have expanded, and their significant value for patient care is growing. In the last few years, the number of APPs in GI practices has grown, in part out of necessity and in part because of their unique skillsets. Gastroenterologists recognize the benefit of APPs, who can bill for services and act independently while also providing a much needed expansion of specialty services for practices, so that the physicians are able to see additional patients and, importantly, perform endoscopic procedures.

In the subspecialty of inflammatory bowel disease (IBD), the shift from acute, crisis management to a chronic care, monitoring and prevention model is a perfect match for the APP role. In our practice at the University of Chicago, we work with four talented Advanced Practice Nurses (APNs) on the medical side, and several more on the surgical side.

Our IBD medical APNs see return patients for their "healthy" monitoring visits, and also run a post-op clinic which occurs in conjunction with the surgical APN. We also have an additional APN who works with our dedicated inpatient IBD service and also sees all postop IBD patients. This position—and the outstanding person who works in it—has literally transformed our practice, providing seamless care for our patients as they transition from inpatient IBD medical service to

the IBD surgery service. She also provides up-to-date communication to the primary gastroenterologists and makes sure that our patients have discharge plans for their condition for follow-up monitoring and treatments. We also count among our wonderful APP team our three APP ostomy specialists, who are indispensable and extremely appreciated.

Separate from the IBD practice, our liver team has two outstanding APNs who assist with management of hepatitis C therapies, but also perform fibrosis assessments and paracenteses, and our nutrition team works with a wonderful APN who runs a gastrostomy tube clinic. There is no doubt that our practices have grown and thrived with the incorporation of these outstanding colleagues, who not only expand the services that would otherwise be provided by gastroenterologists, but they offer unique expertise that we would not have without their partnership.

A BUSINESS MODEL TO SUPPORT ADVANCED PRACTICE PROVIDERS IN GI PRACTICE Important to the incorporation of APNs in a gastroenterology practice is a business model that can accommodate their salaries and benefits. In order to achieve this, we have developed individualized productivity targets for our APNs. In addition, we have educated our faculty and fellows that APNs are independent providers, and should not be asked to fulfill fellow, nursing or scheduling roles. Each of our APNs has a nurse associate and medical assistant to help with their patient management.

By supporting our APPs in this manner, we have seen their productivity flourish, and we are very proud of our great team!

Some of our APPs are now leading educational programs for others and have become ACG members.

The College welcomes this important group of colleagues to our ranks!

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// COVER STORY

SWOT ANALYSIS OF ADVANCED PRACTICE PROVIDERS IN GI PRACTICE A Thoughtful Approach to Adding Advanced Practice Providers to GI Practices Ralph D. McKibbin, MD, FACG. Blair Gastroenterology Associates, Altoona, PA. Dr. McKibbin serves as Director of Strategic Planning and Business for his practice and is a Past Co-Director, ACG Practice Management Course.

My practice has utilized Advanced Practiced Providers (APPs) for many years and, in fact, recently has had two retire. Their scope of practice has evolved since the early days and allows for more-expansive clinical roles. APPs are now broadly accepted in primary care, and specialists are increasing their use of APPs to help meet practice demands. If you are thinking of adding to or growing the number of APPs in your practice, I recommend a thoughtful approach.

The addition of APPs should be done only after detailed consideration of the role to be filled by the practitioner. A proper job description is absolutely necessary to realistically outline duties and responsibilities, define expectations for the employee, coworkers and supervisors, and to protect patients.

An organizational life cycle analysis can be helpful here. Metaphorically speaking, practices, departments and employees can be viewed as having a life cycle just as living organisms do. Smaller practices and departments tend to have a less complicated structure and less-formal policies. Conversely, larger departments or those dealing with complex matters such as the revenue cycle or human resources usually have more clearly defined roles and policies as well as standardized performance metrics.

Individual employees also have a similar growth and development cycle. New employees in the billing department or new registered nurses would not be expected to have the same level of insight, experience and maturity as more-tenured employees. It is important to recognize that while APPs can perform many of their required duties right out of training, an ongoing training and education program is needed to ensure a complete fit into a specialty medical practice. The concept of a care team should be developed.

Differences in training should be recognized. Physician assistants and nurse practitioners generally have about 2,000 hours of clinical training, family practitioners 16,000 to 20,000 clinical hours, and 26,000+ clinical hours for gastroenterologists. A failure to actively supervise APPs can lead to a patient perception of a lower level of care. Diagnostic test utilization and prescribing habits will need to be monitored to avoid quality and outcome

30 | GI.ORG/ACGMAGAZINE

“Higher levels of APP training allow both the APP and the physician to work at the top of their training, with lower system costs of care and improved productivity.”

—Dr. McKibbin

drops. APPs are eligible providers in the Centers for Medicare and Medicaid Services’ Quality Payment Program. ACG guidelines are one useful tool to simultaneously educate and guide patient care.

THE BENEFITS OF ADVANCED PRACTICE PROVIDERS IN GI The benefits of adding APPs can be immediate. Adding a provider can relieve an overburdened physician, cover for vacationing partners, broaden practice diversity, and allow for a “higher touch” practice at a friendlier cost profile than hiring an additional physician/ partner. Less-complicated patients can be seen by the APP to allow more procedure time for the physician, resulting in a higher level of productivity.

Additional benefits can accrue with ongoing training or the hiring of more highly trained APPs. The expansion of clinical roles for APPs has grown tremendously. Hospital inpatients in many systems can be seen daily by APPs with physician supervision. Advanced uses for APPs now include performing invasive GI procedures such as liver biopsies, paracentesis, hemorrhoid banding, etc.

Higher levels of APP training allow both the APP and the physician to work at the top of their training, with lower system costs of care and improved productivity.

In recognition of this trend, physician assistant and nurse practitioner residency and fellowship programs are developing. Many are in surgical specialties, but hepatology, dermatology, emergency medicine, family practice, internal medicine, cardiology, oncology and critical care programs also exist. APPs are an accepted part of the health care team and their use is expected to continue growing. Your practice should do an assessment to see how and where APPs can help you and your patients now and in the future.

Gina Michkofsky, PA-C. Blair Gastroenterology Associates, Altoona, PA. Ms. Michkofsky is a PA in practice with Dr. Ralph McKibbin.

STRENGTHS Advanced Practice Providers (APPs) are diversely trained in the different facets of medicine without requiring specialization, which allows them to adapt to whichever field piques their interest upon graduation. When choosing a career, APPs pursue the fields of medicine that are of greatest interest to them, which gives specialty practices APPs who are motivated to excel. From a business perspective, APPs provide the opportunity for high-quality medical care at a lesser cost in comparison with physician providers. Furthermore, with the rapidly growing need for health care providers, APPs improve access to care by increasing same-day visits and allowing more-timely routine follow-up appointments—both factors that increase patient satisfaction with the practice.

WEAKNESSES Perhaps one of the most observable weaknesses attached to APPs is the stigma some patients see regarding not being treated by a physician. APPs combat this stigma by putting their medical training to work. By often giving patients more time during a visit, APPs help patients feel comforted by giving in-depth explanations, which in turn leads to better patient compliance. From a business standpoint, having supportive staff in each practice who understand how to properly utilize APPs to their full capacity is of the utmost importance. By integrating APPs into practice in an efficient way, the access to care for patients blossoms, along with the financial success of the practice.

OPPORTUNITIES By looking beyond the exam rooms, one can see the opportunities to utilize APPs for community outreach projects and charitable work. From medical mission trips to third-world countries to a presentation at a local community building, APPs can utilize their talents for the betterment of those around them.

S H T G N E R T S

WEAKN

ES S ES

O P P O RT U N I T I ES

THREATS While diverse training and adaptability are often seen as strengths, these traits can also be perceived as threats to our practices. Because APPs are an increasingly integral part of the medical community, they can choose to leave a practice and have easy access to other employment options. This can result in high turnover rates, which reduce availability in patient schedules and also require frequent training of new APPs. It is ideal to have a stable group of APPs because it allows the practice to grow in experience and for APPs to develop rapport with patients.

THREATS

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// COVER STORY

Our Experience with Six Advanced Practice Providers in a Rural GI Practice with Six Physicians Richard L. Nemec, MD, FACG. Dr. Nemec is Chief, Division of Gastroenterology, and Chief, Endoscopy Services, at Winchester Medical Center, Winchester, VA, and practices at Winchester Gastroenterology Associates. He is a member of the ACG Practice Management Committee.

Our history: Winchester Gastroenterology Associates is a group of six GI physicians providing inpatient and outpatient GI care supporting a local 400-bed hospital and a 140,000-person catchment area. The group had one Advanced Practice Provider (APP) in 2010 and slowly transitioned to having six APPs who provide the vast majority of the outpatient GI care, as well as providing consultative support for inpatient service.

STRENGTHS • The vast majority of outpatients seen in gastroenterology clinic have functional bowel disease (including reflux, functional dyspepsia, irritable bowel syndrome, etc.), the management of which requires time, listening and frequent non-pharmaceutical support. This is generally more available from APPs. • Therapy for viral hepatitis B and viral hepatitis C lends itself to treatment protocols that can be easily approved by medical staff for use by APPs. • Even complex conditions such as IBD and cirrhosis are typically managed with attention to detail, ensuring that patients have robust and complete follow-up as suggested by guidelines and other documents.

• With training and experience, single-specialty APPs provide a level of outpatient care similar to the gastroenterologist.

• The APPs can provide excellent support to an in inpatient call gastroenterologist by triaging and initiating consultations for priority for endoscopic and/or bedside evaluation.

WEAKNESSES • Acceptance by the Local Community: Especially in a smaller/rural-type community, the expectation by both the patients and the medical staff is to "see the doctor."

We spent considerable time and effort emphasizing to both our referral base as well as to our patient population that our APPs were highly qualified to provide inpatient and outpatient care under physician supervision.

• Training and Experience: In order to have a highly qualified APP, time and effort need to be expended.

This must be done by the local practice, which obviously is time-consuming. As we were initiating our APP program, the physician in our clinic had no direct 32 | GI.ORG/ACGMAGAZINE

patient care visits but would evaluate every patient with an APP, providing direction and support. It was tiresome and exhausting. However, after six months our APPs’ skill sets increased to the point that we no longer needed to provide such intensive, direct supervision.

• Variations—A Weakness Becomes a Strength: There are clearly variations of practice style and method between GI providers. There are also different levels of skill and ability between APPs. These variations may make it somewhat difficult for the APP under training to grasp what is essential to patient care and what might be more style and method.

This can be easily solved by having one APP work for one GI provider, but we found that different GI physicians challenged APPs differently, making all the APPs more competent.

OPPORTUNITIES • Formalized Training for GI/ Hepatology APPs: We currently expect graduates in medical school to train six to seven years after graduation to become a fully qualified GI physician.

If there was a postgraduate training program for APPs to be "GI-certified APPs," then many of the potential weaknesses and threats might be drastically reduced.

• Procedures: Gastroenterology is a procedure-intensive specialty.

Currently, APPs serve as first surgical assistants and oftentimes may even "close" a case. Many APPs have the proper hand-eye coordination and visual acuity necessary to perform GI procedures. Potential procedures for APPs (going from probable to less likely) might include paracentesis, PEG tube maintenance and changes, hemorrhoid banding procedures, and even screening colonoscopies. Outside the United States, ongoing privileges for screeningsurveillance colonoscopy are based more upon the performance of the provider (i.e., adenoma detection rate (ADR), three-year post colonoscopy colorectal cancer incidence, etc.) It might be that your APP could do a higher quality colonoscopy than you with a better ADR. If you feel threatened, see the “Turf Wars” section on the next page!

THREATS • Regulatory: External agencies, particularly governmental agencies, may by the power of regulation or accreditation, purely by fiat, restrict or modify APP practice (who otherwise would be very competent in a certain role.)

• Inconsistencies: There are currently a great many inconsistencies between what different licensing bodies may permit and the rules of what insurance companies will financially support. These all hinge on the exact supervisory role that the physician provides to the APP(s). Due to the vagueness of rule interpretations, the multiple insurance carriers, and the aforementioned differences, practices have to step through a minefield of potential insurance fraud threats that may appear as insurance billing rules and requirements are clarified and applied ex post facto. This threat impedes full use of otherwisequalified APPs. • Turf Wars: Some gastroenterologists already have turf battles with surgeons, internists and family practitioners regarding care of GI patients, both in the office and in the endoscopy suite. As APPs assume a larger role in supporting GI care to our patients, might there be a backlash from the GI physicians to restrict APP practice? Will that backlash come from outside the GI community, as other physicians attempt through referral patterns or legislation to restrict the use of our APPs? As long as the demand for services is strong, then APPs may be able to expand roles, but if there is a change in supply-demand for GI care, will APPs be cast off?

Joanna M. Myers, PA-C, and Ellena M. Thomas, PA-C, Winchester Gastroenterology Associates. Ms. Myers and Ms. Thomas are in practice with Dr. Richard Nemec.

STRENGTHS As in any specialty, physician assistants (PAs) who work in gastroenterology have the advantage of being able to focus on learning one body system extensively. There are rarely life-threatening illnesses in the outpatient setting, which helps with the day-to-day stress level. With hospital privileges, GI PAs are often able to handle acutely ill patients. This variance of acuity helps to keep monotony at bay. Any lack of excitement is typically more than rectified by the work-life balance afforded by working in GI, however. PAs in this specialty are rarely expected to work nights, weekends or holidays, or take call.

WEAKNESSES In addition to a lack of variety in outpatient care complaints, often the GI patient population can be difficult. Many GI patients have psychological issues or external stressors that contribute to their symptoms. In our society, it is often difficult for patients to accept or acknowledge these factors as contributory. The diseases we treat typically are chronic and difficult to manage. These factors can certainly make day-to-day interactions with patients potentially frustrating at times.

OPPORTUNITIES There are limited opportunities for expanding our skill sets in our specific practice; however, some PAs are able to perform procedures. One of the most rewarding parts of PA practice in GI is the opportunity to get to know patients well. Many patients return to the clinic multiple times per year, and this builds trust and camaraderie in the patient-PA relationship.

THREATS In a semi-rural patient population like ours, however, there is sometimes a mistrust of non-physician providers. This does sometimes threaten our ability to adequately care for our patients. An unintended consequence of this is overly cautious ordering of diagnostic studies, which burdens the entire health care system. Another threat is a potential interruption in continuity of care, because physicians perform the procedures ordered by PAs.

OUR ADVICE FOR ADVANCED PRACTICE PROVIDERS CONSIDERING CAREERS WITH GI PRACTICES Overall, a career as a PA in GI is fulfilling and provides excellent quality of life. Our advice for PAs who are looking to do well in a GI position is: • Cultivate a good working relationship with your supervising physician(s).

• Take advantage of the work-life balance: if you are starting a family or have young children, GI is a great specialty, as PAs are rarely expected to work weekends, holidays or nights.

• Be cognizant that many of your patients may have external stressors contributing to their symptoms.

• A good background in nutrition and/or psychology may be helpful to your patients and your practice.

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// COVER STORY

CONQUERING THE LEARNING CURVE FOR GI Advanced practice providers Jaya R. Agrawal, MD. Hampshire Gastroenterology Associates, Florence, MA. Dr. Agrawal is a member of the ACG Practice Management Committee.

Our practice utilizes Advanced Practice Providers (APPs) in the office setting. In this setting they are able to generate higher relative value units than in the hospital and work more independently due to the low complexity nature of most GI outpatient care. This improves physician satisfaction by producing a more favorable procedure-to-office visit ratio for the gastroenterologist.

We have found that because most APPs do not have specialist training, there is a learning curve, in particular with learning chronic disease management in liver disease and inflammatory bowel disease. An upfront investment in training and education is required, as well as retention strategies, so that the practice continues to accrue the benefits of GI-trained PAs for years to come.

In addition to having a physician present in the office for supervision and questions, we try to alternate patients' office visits between a PA and an MD (ideally the same PA and MD), to produce a team approach to patients who require long-term care and to ensure that a physician is continuously involved in the care plan.

We consider the incorporation of PAs in our practice to be a success on all fronts. There is the rare patient or referring physician who prefers physician-only care, but we find this is the exception rather than the rule. Our plan moving forward is to improve our advance practice clinician (APC) retention strategies— by providing adequate staff support for patient care activities and ensuring salaries are competitive—and expanding both the role and number of APCs in our practice.

Editor’s Note: You can read Dr. Agrawal’s contribution to the ACG Practice Management Toolbox, “Adding Advanced Practice Providers to Your Practice,” on page 19.

34 | GI.ORG/ACGMAGAZINE

The College is committed to helping all health care professionals on the GI care team stay up-to-date on emerging strategies for the management of GI and liver diseases, including Nurse Practitioners and Physician Assistants. The Editors of the ACG Education Universe have identified a number of “Must See” sessions for Advanced Practice Providers working in GI practices. The ACG Education Universe offers the option of CME credit through this easy online portal, where members can access lectures by expert faculty presented at ACG’s national Postgraduate Course and Regional Courses. Learn more at universe.gi.org.

Goals of Caring for the IBD Patient Raymond K. Cross, Jr., MD, MS universe.gi.org/vow/15107.htm Immunizations and Health Maintenance in Chronic GI Disorders James H. Lewis, MD, FACG universe.gi.org/vow/11353.htm Approach to Patients With Continued Symptoms on a PPI Philip O. Katz, MD, MACG universe.gi.org/vow/13849.htm Diagnosing and Treating GERD, NERD and Atypical Chest Pain Lauren B. Gerson MD, MSc, MACG universe.gi.org/vow/13545.htm Hereditary Colon Cancer: How Not to Miss It in Your Patients Carol A. Burke, MD, FACG universe.gi.org/vow/13623.htm Mechanistic Underpinnings for the Management of Refractory Constipation Darren M. Brenner, MD universe.gi.org/vow/14939.htm The Diarrhea Persists: What to Do Next?

Lawrence R. Schiller, MD, MACG universe.gi.org/vow/13631.htm CME: universe.gi.org/contentitem. asp?c=13631 Management of Functional Dyspepsia Paul Moayyedi, MBChB, PhD, MPH, FACG universe.gi.org/vow/14948.htm CME: universe.gi.org/contentitem. asp?c=14948

Probiotics and Alternative Approaches to Managing Irritable Bowel Syndrome Anthony J. Lembo, MD, FACG universe.gi.org/vow/13895.htm Tried and True Treatments for IBS-C and IBS-D Charlene M. Prather, MD, MPH universe.gi.org/vow/13550.htm Current and Emerging Management for Celiac Disease Peter H.R. Green, MD, FACG universe.gi.org/vow/14988.htm Food: The Main Course to Disease and Wellness William D. Chey, MD, FACG universe.gi.org/vow/13860.htm CME: universe.gi.org/contentitem. asp?c=13860 Approach to Pelvic Floor Dysfunction Amy E. Foxx-Orenstein, DO, MACG universe.gi.org/vow/13544.htm Managing Antiplatelet and Antithrombotic Medications in the Setting of GI Bleeding and Endoscopic Procedures Neena S. Abraham, MD, MSc (Epid), FACG universe.gi.org/vow/13538.htm Non-Celiac Gluten Sensitivity Julio C. Bai, MD universe.gi.org/vow/14989.htm

My Professional Experience as a Nurse Practitioner in Gastroenterology Mary S. Vetter, NP, University of Rochester (UR) Medical Center. Ms. Vetter is Chair of ACG's new Committee on Advanced Practice Providers. She serves on the Women in Gastroenterology and Membership Committees and contributed to the Annual Scientific Meeting Planning Subcommittee for 2018 and 2019.

I have been a Nurse Practitioner in GI since 2013. Prior to this, I worked in the Solid Organ Transplant Program at UR since 2001, specifically in liver transplant surgery and hepatology.

Hepatology drew me to GI. I became interested in the GI needs of pre- and post-liver transplant patients. I also liked closely following the patients prior to getting a liver transplant. When I came to GI, I was initially humbled by the enormity of it, as I had focused on hepatology for so long. Gastroenterology is an exciting field that continues to grow and expand, with so many therapeutic and interventional opportunities. This is one of the great things I love about working in GI.

“A WEEK IN THE LIFE” I work in an outpatient tertiary care setting in mainly a clinical role, where I also precept NP students and am involved with the UR School of Nursing, where I educate NP students in the area of liver disease. In addition, I am a sub-investigator for multiple clinical trials. In the clinical area, I spend a portion of my week following patients collaboratively with Shivangi T. Kothari, MD, FACG, an Advanced Endoscopist and specialist for patients with hepatopancreatobiliary needs. Together, we see patients with hepatobiliary and pancreatic abnormalities, develop plans of care, and schedule the complex interventional procedures.

This is an exciting practice area that is expanding.

It requires identifying appropriate patients for procedures, thorough history and physical exams, education, and preparation and follow-up.

Typically my week starts in our hepatology clinic, seeing a range of patients from those with elevated liver function tests and hepatic lesions to acute and chronic liver disease, as well as those who need a liver transplant. From here, I transition to see new and follow-up patients with general GI, hepatology and hepatopancreatobiliary needs in independent clinics.

Clinics are structured in a couple of ways.

Collaborative attending clinics are sub-specialized to follow patients with specific needs e.g., IBD, hepatopancreatobiliary, hepatology and general GI. Independent APP clinics allow patients with a variety of GI needs to be seen. Overall, this configuration allows me to focus and gain specialty knowledge. This really helps when needing to "change your hat" from one focus to another in the same day.

“It can be challenging to remain current with so many issues in GI, therefore it is helpful to have an organization that offers updates to guidelines and state-of-the-art therapies. I also wanted an avenue to collaborate with other NPs and PAs who work in GI. I strongly believe we can learn so much from each other to improve and strengthen our practices and provide the highest level of care to our patients.”

ACG AS A PROFESSIONAL HOME FOR GI ADVANCED PRACTICE PROVIDERS & WAYS TO GET INVOLVED

I joined ACG in 2015 at the recommendation of Dr. Kothari. Together, we wrote a case study, "Isolated enteric mastocytosis causing recurrent small bowel obstruction," which was accepted as a poster presentation at the 2015 ACG Annual Scientific Meeting. This was a great experience!

I believe it is really important to belong to a national organization that supports clinicians with opportunities for education, research, academic growth and exposure to legislative and financial issues that affect our patients and practice. It can be challenging to remain current with so many issues in GI, therefore it is helpful to have an organization that offers updates to guidelines and stateof-the-art therapies. I also wanted an avenue to collaborate with other NPs and PAs who work in GI. I strongly believe we can learn so much from each other to improve and strengthen our practices and provide the highest level of care to our patients. One main barrier for APPs to join GI societies may be a lack of awareness of what the organizations can offer to the NP or PA. The cost of maintaining membership may also be an issue for some. As NPs and PAs comprise a growing part of the GI and hepatology community, there has never been a better time than now to join ACG. A recent ACG survey showed that there are many new NPs/ PAs in GI practice, including a large base who plan to remain in GI long term. This growing number of NPs/PAs in GI creates an environment to increase the NP/PA base, as well as opportunities within the College.

ACG offers a wide variety of resources and benefits that range from promoting quality in patient care, to education, and ways to remain current on issues, including legislative issues.

The yearly membership fee is reasonable.

Resources, education opportunities and clinical guidelines are among the online tools and are easy to navigate. ACG’s online professional networking forums, such as the IBD Circle and the Women in GI Circle, are current and interactive.

One way to increase membership and involvement by NPs and PAs in the College is for attending GI providers to encourage and create an atmosphere for NP and PA providers in their office to join and get involved in ACG, just like I was supported and encouraged by Dr. Kothari.

This is an exciting time to join ACG and get involved. Membership and involvement with ACG will help shape the path forward for GI physicians and their APP colleagues. Together we can create opportunities that improve and maintain professional standards and promote education, new ideas and programs.

Cover Story | 35

7 MILLION CASES

AND GROWING

GI Quality Improvement Consortium, Ltd.

 Setting the standard in quality improvement initiatives in GI.  Improving clinical practice and patient outcomes.  Providing real-time peer-based performance evaluation.  Upload data directly from a number of endowriters—saving staff time.  Generate reports in real-time, at the physician and facility level.  Submit GI-specific measures to MIPS via the GIQuIC registry.  Join the 4,500 U.S. gastroenterologists who have made GIQuIC their quality improvement benchmarking registry.

To contact GIQuIC, email info@giquic.org

Visit giquic.org for more info

GIQuIC is a joint initiative of ACG and ASGE

36 | GI.ORG/ACGMAGAZINE

My Professional Experience as a Nurse Practitioner in Gastroenterology Mary S. Vetter, NP, University of Rochester (UR) Medical Center. Ms. Vetter is Chair of ACG's new Committee on Advanced Practice Providers. She serves on the Women in Gastroenterology and Membership Committees and contributed to the Annual Scientific Meeting Planning Subcommittee for 2018 and 2019.

I have been a Nurse Practitioner in GI or hepatology since 2001. Initially, I worked in the Solid Organ Transplant Program at UR, specifically in liver transplant surgery and hepatology. The GI needs of pre- and post-liver transplant patients became increasingly interesting to me in this time. I transitioned to a pancreaticobiliary, general GI and non-transplant hepatology position in 2013. Initially I was humbled by the enormity of the broader practice of gastroenterology, as I had focused on transplant hepatology for so long. GI is an exciting field that continues to grow and expand, with so many therapeutic and interventional opportunities. This is one of the great things I love about working in GI.

“A WEEK IN THE LIFE” I work in an outpatient tertiary care setting in mainly a clinical role, precept NP students, and am involved with the UR School of Nursing, where I teach NP students in the area of hepatology/liver disease. In addition, I am involved as a sub-investigator for multiple clinical trials. In the clinical area, I spend a portion of my week following patients collaboratively with Shivangi T. Kothari, MD, FACG. Together, we see patients with hepatobiliary and pancreatic abnormalities, develop plans of care, and schedule the complex interventional procedures. We often must carefully and compassionately guide patients through the initial diagnosis and treatment stages of cancer. It requires identifying appropriate patients for procedures, thorough history and physical exams, education, preparation and follow-up.

Typically, my week starts in our hepatology clinic, seeing a range of patients from those with elevated liver function tests and hepatic lesions to acute and chronic liver disease, as well as those who need a liver transplant. From here, I transition to see new and follow-up patients with general GI, hepatology and pancreatobiliary needs.

Clinics are structured in a couple of ways.

Collaborative attending clinics are sub-specialized to follow patients with specific needs e.g., IBD, pancreatobiliary, hepatology and general GI. Independent APP clinics allow patients with a variety of GI needs to be seen. This configuration allows me to focus and gain specialty knowledge. This really helps when you need to "change your hat" from one focus to another in the same day.

“It can be challenging to remain current with so many issues in GI, therefore it is helpful to have an organization that offers updates to guidelines and state-of-the-art therapies. I also wanted an avenue to collaborate with other NPs and PAs who work in GI. I strongly believe we can learn so much from each other to improve and strengthen our practices and provide the highest level of care to our patients.”

ACG AS A PROFESSIONAL HOME FOR GI ADVANCED PRACTICE PROVIDERS & WAYS TO GET INVOLVED

At the recommendation of Dr. Kothari, I joined ACG in 2015. Together, we wrote a case study, "Isolated enteric mastocytosis causing recurrent small bowel obstruction," which was accepted as a poster presentation at the 2015 ACG Annual Scientific Meeting.

This was a great experience!

I believe it is really important to belong to a national organization that supports clinicians with opportunities for education, research, academic growth and exposure to legislative and financial issues that affect our patients and practice. It can be challenging to remain current with so many issues in GI, therefore it is helpful to have an organization that offers updates to guidelines and stateof-the-art therapies. I also wanted an avenue to collaborate with other NPs and PAs who work in GI. I strongly believe we can learn so much from each other to improve and strengthen our practices and provide the highest level of care to our patients. One main barrier for APPs to join GI societies may be a lack of awareness of what the organizations can offer to the APP. The cost of maintaining membership may also be an issue for some. As APPs comprise a growing part of the GI and hepatology community, there has never been a better time than now to join ACG. A recent ACG survey showed that there are many new APPs in GI practice, including a large base who plan to remain long term. This growing number represents a need to offer GI APPs opportunities for professional growth and leadership.

ACG offers a wide variety of resources and benefits that range from promoting quality in patient care, to education, and ways to remain current on issues, including legislative issues.

The yearly membership fee is reasonable.

Resources, education opportunities and clinical guidelines are among the online tools and are easy to navigate. ACG’s online professional networking forums, such as the IBD Circle and the Women in GI Circle, are current and interactive.

One way to increase membership and involvement in the College is for attending GI providers and APP members to encourage and create an atmosphere to join and get involved in ACG, just like I was supported and encouraged by Dr. Kothari.

This is an exciting time to join ACG and get involved. Membership and involvement with ACG will help shape the path forward for GI physicians and their APP colleagues. Together we can create opportunities that improve and maintain professional standards and promote education, new ideas and programs.

Cover Story | 35

LEARNING

from

“ENDOSCOPIC MASTERS”

WITH THE GENEROUS SUPPORT OF THE 2015 ACG INTERNATIONAL GI TRAINING GRANT, I had the honor of learning interventional

Piyush Somani, MD Jaswant Rai Speciality Hospital, Saket, Meerut, Uttar Pradesh, India

endoscopy procedures from the endoscopic masters at the Center for Interventional Endoscopy (CIE), Florida Hospital, Orlando, FL. After my general gastroenterology fellowship, I developed a keen interest in advanced endoscopic procedures, particularly endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography (ERCP). My clinical supervisor and guide in Mumbai, India, Professor Dr. Pravin Rathi, taught me ERCP. It was a privilege to learn EUS from two world leaders—Professor Sun Siyu of Shenjing Hospital, China, and Malay Sharma, MD, of Jaswant Rai Speciality Hospital, India.

To obtain a Western perspective and learn more about interventional EUS, endoscopic mucosal resection and cholangioscopy, I applied for the ACG International GI Training Grant backed by the immense support of Shyam S. Varadarajulu, MD, and Udayakumar Navaneethan, MD, FACG. 

ACG Perspectives | 37

// ACG PERSPECTIVES

 Dr. Somani and Dr. Navaneethan posing in front of Dr. Navaneethan's poster abstract, titled "Does Preoperative Endoscopic Ultrasound - guided Fine Needle Aspiration have an Impact on Survival in Cholangiocarcinoma" at Digestive Disease Week 2016 in San Diego.

I arrived at the CIE at Florida Hospital in January 2016. The purpose of my stay was to learn the necessary skills to perform EUSguided pancreatic fluid collections drainage and interventional procedures, and then develop this particular area in India.

There are four interventional endoscopists at CIE, including Professor Robert H. Hawes, MD, FACG, Professor Varadarajulu, Muhammad K. Hasan, MD, FACG, and Dr. Navaneethan. All are stalwarts in their respective fields of interest. The training program included a broad spectrum of interventional endoscopic procedures including EUS-FNA, advanced ERCP, ERCP with sphincter of oddi manometry, EUSguided interventional procedures, digital cholangioscopy, and a significant number of other techniques, such as endoscopic closure of gastrointestinal defects, resection of large colonic polyps, and endoscopic therapy of subepithelial lesions.

With his years of experience, Professor Hawes gave insights on how to become a successful advanced endoscopist. He gave me many tips on how to avoid complications. Dr. Varadarajulu, being one of the world leaders in EUS, gave insight on how to do research in EUS. Many EUS-guided pancreatic fluid collections drainage were performed in the center with relative ease. Dr. Hasan, who was trained by Professor Peter Cotton and Professor Hawes, performed and taught

38 | GI.ORG/ACGMAGAZINE

“I developed a keen interest in advanced endoscopic procedures, particularly endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography (ERCP). My clinical supervisor and guide in Mumbai, India, Professor Dr. Pravin Rathi, taught me ERCP. It was a privilege to learn EUS from two world leaders...” 

me most advanced ERCPs, like minor papillotomy, ERCP in altered GI anatomy, double balloon enteroscopy-guided ERCP, and more. He offered practical tips for large, laterally spreading polyp resection.

Dr. Navaneethan, with special interest in inflammatory bowel disease research, gave me an opportunity to write a review paper on the “Role of ERCP in Patients with Idiopathic Recurrent Acute Pancreatitis,” which was published in Current Treatment Options in Gastroenterology.

Special thanks to Jason, Jose, Craig, Brittany, Renay, Sameer, Wesam and the technicians and nurses at CIE for making me comfortable in a new country.

I cannot adequately express my gratitude to the American College of Gastroenterology for providing me the support for this opportunity, to the doctors and staff at CIE for making me feel like a part of the CIE family, and to Dr. Sharma for encouraging me to pursue this unique opportunity. I hope to come again to learn new skills and make new friends at CIE. Namaste!

EDUCATION

Photo Top: Millie D. Long, MD, MPH, FACG, during her visit to Beaumont Hospital – Farmington Hills.

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 the 2018 visiting professors and features three 2018 visits: Millie D. Long, MD, MPH, FACG, at Beaumont Hospital – Farmington Hills; John J. Vargo, II, MD, MPH, FACG, at Vanderbilt University; and ACG President Sunanda V. Kane, MD, MSPH, FACG, at SUNY Downstate Medical Center. 

Education | 39

// EDUCATION

“…The ability to ask questions [of] an IBD expert throughout the day…the chance to speak with Dr. Long on a more intimate scale and discuss putting new therapies into clinical practice.” —Beaumont Hospital, Farmington Hills Fellows on what they valued most about Dr. Long’s visit.

40 | GI.ORG/ACGMAGAZINE

“…The inspiration to take principles we are learning in our didactics and lectures and apply them to our field to advance patient care was great to both listen to but also to strive to work on in the coming years in my own research environments.”

—Rishi D. Naik, MD, Vanderbilt University, on Dr. Vargo's visit.

“The entire day with Dr. Kane was wonderful. She was extremely approachable and engaging. The highlight of the visit was watching how passionate she was about the management of the case presentation patients…This shows what a remarkable and caring physician she truly is in addition to her expertise.”­­ —Savanna Thor, DO, MPH, SUNY Downstate Medical Center

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 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 AWARD NOMINATIONS

Honor Your Colleague with an£ACG Award Nomination

T ACG A C           ﹒ B/F C A A The intent of the Berk/Fise Clinical Achievement Award is to recognize an individual who has provided distinguished contributions to clinical gastroenterology, which could include: (a) clinical medicine, (b) technology application, (c) health care delivery, and (d) related factors such as humanism and ethical concern. It is not intended that this award be given in honor of one’s laboratory research accomplishments.

C S A The Community Service Award is bestowed upon an ACG Member who has initiated or has been involved in numerous volunteer programs/activities or has provided significant volunteer service post-training. The service must have been performed on a completely voluntary basis and not for the completion of training or position requirements.

I L A The International Leadership Award is given to a Fellow or Master of the ACG in recognition of outstanding and substantial contributions to gastroenterology, to the College, and to the international gastroenterology community.

M   A C  G Masters of the American College of Gastroenterology shall have been Fellows who, because of their recognized stature and achievement in clinical gastroenterology and because of their contribution to the College in service, leadership, and education, have been recommended for designation as Masters.

M D H C A The ACG Minority Digestive Health Care Award is an achievement award that will recognize an ACG Member or Fellow whose work in the areas of clinical investigation or clinical practice has improved the digestive health of minorities or other underserved populations of the United States. These efforts can be shown by community outreach activities through clinical or educational programs, or research in an area of digestive disease that negatively impacts minority populations such as colorectal cancer, hepatitis B and C, cirrhosis and other GI cancers.

S S﹒ W A The Samuel S. Weiss Award is granted in recognition of outstanding service to the American College of Gastroenterology over the course of an individual’s career.

   ﹕ A ﹐

Nominations for all awards must:

Nominations should be sent to:

• • • •

John W. Popp, Jr., MD, MACG Chair, ACG Awards Commi ee 6400 Goldsboro Road, Suite 200 • Bethesda, MD 20817-5842 Email: awards@gi.org

Be accompanied by two le ers of recommendation Include the nominee’s CV Conform to the specific requirements listed Be unsolicited by the nominee

£﹒﹒/--- ££﹒ 42 | GI.ORG/ACGMAGAZINE

Inside the

JOURNALS

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Point Office-Based Celiac Disease

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

FULL TABLE

INSIDE CONTENTS

Inside the Journals | 43

// INSIDE THE JOURNALS

INSIDE THE JOURNALS [THE AMERICAN JOURNAL OF GASTROENTEROLOGY]

“HOW I APPROACH IT” IN AJG’S RED SECTION: A Dedicated Space for the Voices of Clinical Experts and Opinion Leaders Hetal A. Karsan, MD, FACG, and Sameer D. Saini, MD, MS, FACG Co-Editors, The Red Section, The American Journal of Gastroenterology

 SCIENTIFIC JOURNALS PLAY A CRUCIAL ROLE IN MODERN MEDICINE. But we all know that the practice of medicine requires more than science alone. Indeed, high-quality care requires a combination of scientific knowledge, wisdom and compassion. This is particularly true in our specialty, where we are frequently challenged by complex diagnostic dilemmas and disease management, often for uncommon conditions.

The modern gastroenterologist must also have strong technical endoscopic skills and be willing to occasionally step outside his or her “comfort zone” to care for sick patients in urgent and unexpected situations. In this context, we often turn to experts and opinion leaders in our specialty for guidance.

Traditionally, this occurs informally at the local level—how many of us have more

than once called on a wise, sage clinician in our local clinic or hospital for advice on a difficult case? But what if we could harness and disseminate the vast knowledge of our clinical experts and opinion leaders on a broader scale?

The Red Section of The American Journal of Gastroenterology seeks to address this gap, complementing the academic and scientific missions of the journal with dedicated space for the voices of clinical experts and opinion leaders through a variety of new columns that cover topics ranging from new endoscopic technologies to health care policy. Of these columns, "How I Approach It" is perhaps the most emblematic. Written by a notable clinical expert in the field, How I Approach It describes the practical approach for a particular clinical problem. Topics have

included “Beyond Low Flow: How I Manage Ischemic Colitis” (Lawrence J. Brandt, MD, MACG), “How I Approach Retroflexion and Prevention of Right-Sided Colon Cancer Following Colonoscopy” (Douglas K. Rex, MD, MACG), and many others. These columns have been incredibly well received by AJG’s readership, and we hope to continue to expand the list of topics in the coming year.  Using Ergonomics to Prevent Injuries for the Endoscopist Kimberly Zibert, DO, Manish B. Singla MD, Patrick E. Young, MD, FACG, Vice Chair, ACG Board of Governors READ the article: rdcu.be/bbgXq

 When to Refer for Liver Transplantation Andres F. Carrion, MD, and Paul Martin MD, FACG READ the article: rdcu.be/bawI2

 Improving Nutritional Status in Patients With Cirrhosis Jennifer C. Lai MD, MBA, and Puneeta Tandon MD, MSc (Epi) READ the article: rdcu.be/bawJn

 Diagnosis and Treatment of Definitive Diverticular Hemorrhage (DDH) Dennis M. Jensen, MD, FACG READ the article: rdcu.be/bawJE

[CLINICAL & TRANSLATIONAL GASTROENTEROLOGY]

Impact of Scribing History and Physical Notes and Procedure Reports on Endoscopist Efficiency During Routine Procedures: A Proof-of-Concept Study Margaret E. MacPhail, Samuel A. Main, William W. Tippins, Andrew W. Sullivan, Douglas K. Rex, MD, MACG

WHAT IS CURRENT KNOWLEDGE?  Efficient endoscopy has value to practitioners and society.  The impact of scribing history and physical examinations and procedure reports on endoscopy efficiency is unknown.

WHAT IS NEW HERE?  Scribes reduced the time to record history and physical examinations by 34% and procedure reports by 71%, compared to completion by a colonoscopist.  Over a 6.5-hour session, note scribing saved the endoscopist an average of 41 minutes—enough time to schedule an additional procedure or complete other tasks.

 Read the full article: bit.ly/CTGAug18

44 | GI.ORG/ACGMAGAZINE

Members of Dr. Rex’s scribing team. Back row—Douglas K. Rex, MD, MACG, at left and members of his research team, who helped with the paper, L to R: Margaret E. MacPhail, Meghan Searight, Rachel Lahr and Andrew Sullivan. MacPhail is the first author of the paper and a first-year medical student at Indiana University. Front row—three registered nurses in the endoscopy unit who have learned to scribe procedure notes, L to R: Deb Strong, Patsy Bedford and Angela Mott.

[CLINICAL & TRANSLATIONAL GASTROENTEROLOGY]

[ACG CASE REPORTS JOURNAL]

Meconium Microbiome Associates with the Development of Neonatal Jaundice

A Second Attack of Anisakis: Intestinal Anisakiasis Following Gastric Anisakiasis

Tianyu Dong, PhD, Ting Chen, PhD, Richard Allen White III, PhD, Xu Wang, PhD, Weiyue Hu, PhD, Yali Liang, MS, Yuqing Zhang, PhD, Chuncheng Lu, PhD, Minjian Chen, PhD, Heidi Aase, PhD, Yankai Xia, PhD

Naoto Mizumura, MD, Satoshi Okumura, MD, Hiroshi Tsuchihashi, MD, PhD, Masao Ogawa, MD, PhD, and Masayasu Kawasaki, MD, PhD

WHAT IS CURRENT KNOWLEDGE?  Neonatal jaundice is a commonly found disease in newborns.

WHAT IS NEW HERE?  Gut microbiome is associated with the development of neonatal jaundice especially in C-section babies.

 Gut bacteria mediates the bilirubin metabolism.

 Higher relative abundance of B. pseudolongum is associated with lower risk of jaundice.

 READ the full article: bit.ly/CTGSep18

A 50-YEAR-OLD MAN PRESENTED with epigastric pain after eating raw mackerel. Abdominal computed tomography revealed submucosal edema of the gastric antrum and pelvic ileum. Gastroscopy revealed an Anisakis simplex in the gastric antrum. His epigastric pain resolved after endoscopic removal of the Anisakis; however, he developed right lower quadrant pain the following day. Abdominal computed tomography showed submucosal edema of the terminal ileum involving different ileal loops, which was not present on admission.

The patient developed delayed intestinal anisakiasis. A serving of raw fish may contain more than one Anisakis.

After gastric anisakiasis, a second Anisakis may cause intestinal anisakiasis.  READ the full case: bit.ly/CRJSep18

FIG. 1: Variability and diversity of the meconium microbiome.

FIG. 3: Bar plot of the LDA Score (log10) between control and case groups in cesarean infants.

Inside the Journals | 45

M CECUM THE CECU HING THE REACHING REAC

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

A LOOK BACK

RECTAL DILATORS

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

R

ectal diseases have plagued mankind for millennia. The earliest mention of them is found in the Code of Hammurabi, about 2200 BC. Instructions for the patient state “pay the doctor five shekels for curing a diseased bowel.” The famous Egyptian “Ebers Papyrus,” about 1500 BC, mentions hemorrhoids. Hippocrates, 400 BC, used a rectal speculum. For the next 1500 years, rectal diseases, hemorrhoids, fistulae, prolapse, etc. were treated with cautery, ligatures and caustics.

Aside from rectal strictures related to disease, these therapies resulted in additional structures. Many were

46 | GI.ORG/ACGMAGAZINE

treated with a variety of rectal dilators, which was preferable to surgical intervention. Various forms of instrumentation were used. It is surprising to note that the opening of a stricture, although extremely small, could maintain adequate bowel function.

Graded dilators of various sizes have been used for the past 100 years with great success. This set of Dr. Young’s Improved Rectal Dilators was sold by prescription in drugstores for $3.75 in the 1920s. They are no different from current dilators and would be equally effective today.

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.

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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.

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