ACG MAGAZINE | Vol. 3, No. 4 | Winter 2019

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ACG MAGAZINE Winter 2019

MEMBERS. MEDICINE. MEANING.

Beyond City Limits:

GI Practice in Rural America


It’s TIME to

RENEW YOUR MEMBERSHIP! When you renew your ACG membership, you’ll continue to benefit from: Free subscriptions to The American Journal of Gastroenterology, Clinical and Translational Gastroenterology and the unique ACG Case Reports Journal Free Education from the Education Universe and the ACG Annual Scientific Meeting that keep you current on treatment, therapy and management of key GI conditions and disorders Practice management tools that help you improve efficiency and increase profitability in your practice And new this year, GI OnDemand – first of its kind GI focused online telehealth platform that can be personalized for your practice, at a deeply reduced ACG members’ only price. ACG is a community of GI clinicians committed to providing quality in patient care.

Renew today at gi.org/renew


WINTER 2019 // VOLUME 3, NUMBER 4

FEATURED CONTENTS BUILDING SUCCESS

Marketing your practice in the digital era PAGE 19

LAW MIND

Ann Bittinger, Esq. offers legal insight on key situations every professional services agreement should address PAGE 23

SAGE ADVICE FROM A SEASONED CLINICIAN

Four take-aways on physician burnout from ACG Past President Christina M. Surawicz, MD, MACG PAGE 27

COVER STORY

Photo courtesy of Justin T. Kupec, MD, FACG

BEYOND CITY LIMITS: GI PRACTICE IN RURAL AMERICA The experiences of GI physicians in rural areas that have left an important imprint on their professional lives and their personal perspectives PAGE 28

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Attend an upcoming

ACG POSTGRADUATE COURSE 2020 ACG/LGS Regional Postgraduate Course  Hilton New Orleans Riverside | New Orleans, LA  March 6–8, 2020

ACG/FGS Annual Spring Symposium  Hyatt Regency Coconut Point | Naples, FL  March 13–15, 2020

ACG’s IBD School & Eastern Regional Postgradaute Course  Renaissance Hotel | Washington, D.C.  June 5–7, 2020

ACG’s Hepatology School & Midwest Regional Postgraduate Course  Hilton St. Louis at the Ballpark | St. Louis, MO  August 21–23, 2020

ACG’s Hepatology School & ACG/VGS/ODSGNA Regional Postgraduate Course  The Williamsburg Lodge | Williamsburg, VA  September 11–13, 2020

ACG’s Functional GI Disorders School & Southern Regional Postgraduate Course  Louisville Marriott | Louisville, KY  December 4–6, 2020

MORE INFO: GI.ORG/ACG-COURSE-CALENDAR


WINTER 2019 // VOLUME 3, NUMBER 4

CONTENTS

"It is humbling to know that a patient has driven three or four, or more, hours, from a corner of West Virginia, to seek your advice or to have a procedure." — Dr. Justin T. Kupec “Beyond City Limits: GI Practice in Rural America” Cover Story PG 28

6 // MESSAGE FROM THE PRESIDENT Dr. Mark Pochapin reflects on finding inspiration for the leadership journey and ACG's Young Physician Leadership Scholars

27 SAGE ADVICE Four take-aways on physician burnout from ACG Past President Christina M. Surawicz, MD, MACG

7 // NOVEL & NOTEWORTHY

28 // COVER STORY

Special Lectures and Awards from ACG 2019; Introducing the EndoTitans competition; In Memoriam for Dr. James Achord and more

17 // PUBLIC POLICY GOVERNORS’ VANTAGE POINT Dr. Najum Méndez-Sánchez, ACG Governor for Mexico, raises awareness of fatty liver disease in his country

19 // GETTING IT RIGHT 19 BUILDING SUCCESS Marketing Your Practice in the Digital Era. Advice from Dr. David Hass, Dr. Austin Chiang and Dr. Manoj Mehta 23 LAW MIND Key situations every professional services agreement should include by Ann Bittinger, Esq.

BEYOND CITY LIMITS: GI PRACTICE IN RURAL AMERICA GI physicians' experiences in rural areas make an important imprint on their professional lives and personal perspectives

39 // ACG PERSPECTIVES 39 GUATEMALA ENDOSCOPY INITIATIVE Dr. Bryan Sauer and colleagues established endoscopy at Hospitalito Atitlán in Sololá, Guatemala

43 // EDUCATION 41 EDGAR ACHKAR VISITING PROFESSORS A signature program of the ACG Institute continues its strong tradition of outreach and engagement at numerous recent visits

46 THE JOURNEY OF FIRST YEAR GI FELLOWSHIP From her perspective as a 2nd year GI fellow, Dr. Shifa Umar offers advice and encouragement to 1st year GI fellows

49 // INSIDE THE JOURNALS 50 AJG Dr. Paul Tarnasky on defining and tracking quality for acute pancreatitis 51 ACGCRJ Introducing "Behind the Case" podcast series with ACGCRJ Editor-in-Chief Dr. Roberto Simons-Linares 52 CTG A Primer on Precision Medicine for Complex Chronic Disorders by CTG Editor-in-Chief Dr. David Whitcomb

53 // A LOOK BACK 25 YEARS AGO IN AJG Endoscopic variceal band ligation compared favorably to sclerotherapy a 1994 study in The American Journal of Gastroenterology

Photo Caption: Cooper’s Rock State Forest, Bruceton Mills, WV. Photo courtesy of Justin T. Kupec, MD, FACG

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ACG MAGAZINE MAGAZINE STAFF

CONNECT WITH ACG

Executive Director Bradley C. Stillman, JD

youtube.com/ACGastroenterology

Editor in Chief; Vice President, Communications Anne-Louise B. Oliphant Manager, Communications & Member Publications Becky Abel

facebook.com/AmCollegeGastro

twitter.com/amcollegegastro

instagram.com/amcollegegastro Copy Editors; Staff Writers Lindsey Topp

bit.ly/ACG-Linked-In Art Director Emily Garel Graphic Designer Antonella Iseas

CONTACT

BOARD OF TRUSTEES

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

President: Mark B. Pochapin, MD, FACG President-Elect: David A. Greenwald, MD, FACG Vice President: Samir A. Shah, MD, FACG Secretary: Jonathan A. Leighton, MD, FACG Treasurer: Daniel J. Pambianco, MD, FACG Immediate Past President: Irving M. Pike, MD, FACG

ACGMag@ @gi.org

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

Past President: Sunanda V. Kane, MD, MSPH, 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

ACG MAGAZINE Winter 2019

MEMBERS. MEDICINE. MEANING.

Vice Chair, Board of Governors: Patrick E. Young, MD, FACG Trustee for Administrative Affairs: Delbert L. Chumley, MD, FACG ACG MAGAZINE Winter 2019

MEMBERS. MEDICINE. MEANING.

TRUSTEES Jean-Paul Achkar, MD, FACG William D. Chey, MD, FACG Immanuel K. H. Ho, MD, FACG Costas H. Kefalas, MD, MMM, FACG Caroll D. Koscheski, MD, FACG Paul Y. Kwo, MD, FACG Amy S. Oxentenko, MD, FACG David T. Rubin, MD, FACG John R. Saltzman, MD, FACG Renee L. Williams, MD, MHPE, FACG

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


CONTRIBUTING WRITERS

Ann M. Bittinger, Esquire

Mark B. Pochapin, MD, FACG

Ms. Bittinger is a 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)

Dr. Pochapin is ACG's 2019–2020 President and the Sholtz-Leeds Professor of Gastroenterology and Director, Division of Gastroenterology and Hepatology, at NYU Langone Health

Bryan G. Sauer, MD, MSc, FACG Austin Chiang, MD, MPH Dr. Chiang directs the Endoscopic Bariatric Program at Thomas Jefferson University Hospital and is Assistant Professor of Medicine. He serves as the hospital's first Chief Medical Social Media Officer

David J. Hass, MD, FACG Dr. Hass is Director of Endoscopy at Yale New Haven Hospital, Saint Raphael Campus and Associate Clinical Professor of Medicine, Yale University School of Medicine. He practices at Gastroenterology Center of CT

Chesley Hines, Jr., MD, MACG Dr. Hines served as ACG President from 1988 to 1989. He practiced gastroenterology for decades in New Orleans, LA until Hurricane Katrina. His career path included time as a locum tenens physician which he describes in this issue

Justin T. Kupec, MD, FACG Dr. Kupec is an Assistant Professor of Medicine at J.W. Ruby Memorial Hospital of the West Virginia University School of Medicine

Manoj Mehta, MD Dr. Mehta practices at the Endoscopy Center of the North Shore in Wilmette, IL and is a member of the ACG Practice Management Committee

Dr. Sauer serves as Associate Professor of Medicine and Medical Director of Endoscopy at the Division of Gastroenterology and Hepatology of the University of Virginia Health System

Lawrence R. Schiller, MD, MACG ACG Past President Dr. Schiller is the Program Director of the Gastroenterology Fellowship at Baylor University Medical Center and Chairs ACG's Archives Committee

Christina M. Surawicz, MD, MACG Dr. Surawicz was ACG’s first woman President (1998–1999). In 2019 she retired from a long career at the University of Washington Harborview Medical Center where she served as Chief of Gastroenterology and Hepatology among many roles.

Paul R. Tarnasky, MD, FACG Dr. Tarnasky is a gastroenterologist at Digestive Health Associates of Texas and serves as Medical Director at Methodist Digestive Institute in Dallas.

Shifa Umar, MD Dr. Umar is a second-year GI fellow at Allegheny Health System in Pittsburgh, PA. She received her M.D. from Shifa College of Medicine in Islamabad, Pakistan

David C. Whitcomb, MD, PhD, FACG Nahum Méndez-Sánchez, MD, MSc, PhD Dr. Méndez-Sánchez is ACG'S Governor for Mexico and is Professor of Medicine at the Liver Research Unit, Médica Sur Clinic & Foundation, Mexico City, Mexico

The Giant Eagle Foundation Professor of Cancer Genetics, Professor of Medicine, Cell Biology & Physiology and Human Genetics at the Division of Gastroenterology, Hepatology and Nutrition at the University of Pittsburgh Medical Center, and Director, UPMC Precision Medicine Service, Dr. Whitcomb is currently Editor-in-Chief of Clinical and Translational Gastroenterology

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By Mark B. Pochapin, MD, FACG, ACG President

SPENDING TIME WITH THE MOTIVATED YOUNG PHYSICIAN LEADERSHIP SCHOLARS PROGRAM (YPLSP) for an intense day-long immersion in leadership skills was one of my top highlights from ACG 2019. Our work together filled me with optimism for the future and reminded me of what I value most about ACG as my professional home. I had the privilege to collaborate with Dr. David Hass to help launch YPLSP in 2018 as an ACG Institute initiative. The goal is to provide young gastroenterologists with a comprehensive skill set to serve as a foundation for the development of leadership and physician advocacy skills, with a focus on building aptitude in executive decision-making, critical thinking, and understanding organizational behavior. Along with the ACG Institute’s investment in clinical research funding to cultivate the next generation of physician investigators, YPLSP is a pillar of the College’s deep commitment to develop potential, identify talent, hone leadership skills, and create opportunities for networking and collegiality among young gastroenterologists. This year’s group includes 33 young physicians who range in experience from third- or fourth-year GI fellows to those who are fewer than five years out of training. The capstone experience for the 2018 YPLSP cohort was joining the Governors at the ACG legislative FlyIn in April 2019 to develop advocacy skills and familiarity with the policymaking process. LEADERSHIP PRINCIPLES It was incredibly rewarding to share lessons from my journey as a leader with the YPLSP group. I outlined leadership principles that have been formally taught to me and choose the lessons that have been most meaningful to me that I use in every aspect of both my personal and professional life. I encouraged the

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group to try new things, allow themselves to be vulnerable, and learn from their mistakes. From my own career, I know how essential it is to seek out role models and to identify the values you want to emulate, and those you want to avoid. One of the quotes that inspires me is from Ralph Waldo Emerson: “Nothing great was ever achieved without enthusiasm.” Another is, “The only place Work comes before Success is in the dictionary.” My advice to the group was to be an enthusiastic, intentional leader who is not afraid of working hard, trying new things, learning from mistakes (which will happen), and always strive to do better. This is a critical point: we can never be afraid of change, because in order to do better, we have to accept change. Intentionality with the goal of always doing better for both ourselves and others will allow us to grow both personally and professionally. DEVELOPING A MODEL FOR INTENTIONAL LEADERSHIP Dave Hass and I introduced an exercise that challenged the YPLSP group to reflect on their core values and develop a personal leadership model. It is not often in our busy lives that we take the time to reflect on our ideals and identify those qualities that matter most. Working with large sheets of paper and colored Post-its, the group visualized their models, finding creative metaphors to offer a framework for leadership qualities that resonated with them. My personal leadership model is in the shape of a rocket built on a frame of trust and integrity, guided with wings of excellence and kindness, always racing to the stars, which represent our greatest aspirations and ambitions (#Reach4TheStars). The flames propelling this leadership rocket represent our desire to always do better and improve ourselves, our patient’s health, and our profession—literally the “fire in the belly.” My model also reflects the value

I place on the rocket’s crew, our team, and the need to navigate according to a strategic plan that allows us to plot a course and adapt to change. Because in space, as in life, there are unexpected obstacles that may require a quick change in course. FINDING INSPIRATION FOR THE LEADERSHIP JOURNEY I was so inspired by the insights and energy of the YPLSP program that I issued a Twitter challenge to my colleagues to share a favorite leadership quote. I shared mine: “There are only two outcomes for any venture: success or learning. The only time you fail is when you stop trying.” Within a matter of hours, I had a number of inspiring quotes, including one from YPLSP participant, Edward Barnes, MD, MPH of the UNC School of Medicine. Dr. Barnes tweeted a quote from a fellow Tar Heel, basketball legend Michael Jordan that is one of my absolute favorites: “I’ve missed more than 9,000 shots in my career. I’ve lost almost 300 games. 26 times I’ve been trusted to take the game winning shot and missed. I’ve failed over and over and over in my life. And that is why I succeed.” It was gratifying to see that Dr. Barnes really took to heart one of my messages about successful leadership— great leaders need to fail and learn from their mistakes to be successful, so don’t be afraid of failure! The YPLSP reminds me of why I am so enthusiastic about ACG's mission and vision. I am inspired and energized by ACG’s commitment to young physicians whose contributions to our profession and to the College will help to define the future of GI. As this program continues to grow, I look forward to working with future generations of enthusiastic and dedicated physicians to unleash their incredible potential and reach the stars.

ACG President Dr. Mark Pochapin (Left) with Young Physician Leadership Scholars and (Back Row Right to Left) course co-director Dr. David J. Hass; ACG Institute Director Dr. Nicholas J. Shaheen; and ACG Past President Dr. Carol A. Burke.

MESSAGE FROM THE PRESIDEN

INSPIRING LEADERS: CULTIVATING THE FUTURE OF GI


Note hy wor t IN THIS ISSUE, ACG MAGAZINE Novel & Noteworthy celebrates the accomplishments of the College’s award winners and distinguished lecturers at the ACG 2019 Annual Scientific Meeting in San Antonio as well as the new cohort of ACG Masters (MACG). Some highlights of this year’s gathering in San Antonio included the fifth annual SCOPY Awards for colorectal cancer prevention and education, as well as the introduction of the EndoTitans competition for second- and third-year fellows, a test of cognitive and procedural skills in endoscopy. SiriusXM’s “Doctor Radio” broadcast returned to ACG for its third year with host Mark B. Pochapin, MD, FACG, the College’s President, and his invited guests discussing impactful clinical science and hot topics from ACG 2019.

Novel & Noteworthy | 7


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2019 SHERMAN PRIZES

[WINNERS]

NEW ENDOTITANS HANDS-ON CHALLENGE SHOWCASES SKILLS ACG 2019 FEATURED A NEW EVENT for fellows-in-training, the EndoTitans HandsOn Challenge! The challenge provides an opportunity for fellows to demonstrate both their knowledge and technical abilities in endoscopy. The competition began in August with a preliminary knowledge round open to all second- and third-year fellows. The top scoring fellows from each year were then invited to participate in a skills challenge. In the event’s inaugural year, Fady Haddad, MD, of Zucker School of Medicine at Hofstra/Northwell at Staten Island University Hospital and Jason Pan, MD, of Brown University emerged victorious. The Winners will each receive a $1,000 grant to the ACG Annual Scientific Meeting in Nashville, TN, October 23–28, 2020.

Photo left: 3rd Year Fellows winner Fady Haddad, MD with the Judges. Left to Right: Seth A. Gross, MD, FACG (2019 Chair of the Educational Affairs Committee and Creator of EndoTitans); Rabia de Latour, MD; Laith H. Jamil, MD, FACG; and Vivek Kaul, MD, FACG (not pictured—Judge Aasma Shaukat, MD, MPH, FACG). Photo right: 2nd Year Fellows winner Jason Pan, MD with the Judges. Left to Right: Seth A. Gross, MD, FACG (2019 Chair of the Educational Affairs Committee and creator of EndoTitans); Rabia de Latour, MD; Laith H. Jamil, MD, FACG; and Vivek Kaul, MD, FACG (not pictured—Judge Aasma Shaukat, MD, MPH, FACG).

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The Bruce and Cynthia Sherman Charitable Foundation announced the 2019 Sherman Prizes for outstanding achievements in the fight to overcome Crohn’s disease and ulcerative colitis. The three recipiences are: Maria T. Abreu, MD, FACG Professor of Medicine and Microbiology and Immunology at the University of Miami Miller School of Medicine. Dr. Abreu, who is also the Director of the University of Miami Health System Crohn’s & Colitis Center. Florian Rieder, MD, FACG, Assistant Professor in the Department of Inflammation and Immunity and part of the Department of Gastroenterology, Hepatology and Nutrition at Cleveland Clinic. Dr. Rieder received the Sherman Emerging Leader Prize. William J. Sandborn, MD, FACG, Chief of the Division of Gastroenterology and Director of the Inflammatory Bowel Disease Center at University of California San Diego Health and Professor of Medicine at UC San Diego School of Medicine.

[ON THE AIR]

LIVE FROM ACG 2019— SIRIUSXM’S “DOCTOR RADIO” SiriusXM’s “Doctor Radio” returned for the third year in a row for a live broadcast during the Opening Welcome Reception at the ACG Annual Scientific Meeting at the Henry B. Convention Center in San Antonio, TX. ACG President Mark B. Pochapin, MD, FACG served as the host of the two-hour show, which featured ACG officers and leaders in an engaging and far-reaching discussion of key clinical science from the meeting with implications for patient care. The College is grateful to SiriusXM and Doctor Radio for broadcasting live from ACG 2019. SiriusXM subscribers can listen to the show via SiriusXM On Demand.

(Photo top) Dr. Pochapin with L to R: David A. Greenwald, MD, FACG; Miguel D. Regueiro, MD, FACG; Sunanda V. Kane, MD, MSPH, FACG, and ACG Executive Director Bradley C. Stillman, Esq. This group covered key themes and significant findings from ACG 2019, as well as Dr. Regueiro’s David Sun Lecture on the concept of an “IBD home.” (Photo middle) Dr. Pochapin was joined by current and formers AJG editors-in-chief L to R: Eamonn M. M. Quigley, MD, MACG; Brennan M. R. Spiegel, MD, MSHS, FACG; William D. Chey, MD, FACG and Brian E. Lacy, MD, PhD, FACG who shared insights on functional GI disorders and research presented at ACG 2019. (Photo bottom) Dr. Pochapin had a lively discussion with L to R: Aasma Shaukat, MD, MPH, FACG; Joseph C. Anderson, MD, MHCDS, FACG; Laurie H. Parker, Executive Director, GIQuIC; and Folasade P. May, MD, PhD, MPhil on colorectal cancer screening, young onset disease, age recommendations for screening, and an update on the GIQuIC registry.

[WINNERS]

STATEN ISLAND LIFTS THE GI JEOPARDY TROPHY The duo of Fady Haddad, MD, and Youssef El Douaihy, MD, claimed the GI Jeopardy title on behalf of Zucker School of Medicine at Hofstra/Northwell at Staten Island University Hospital on Saturday, October 26 at the ACG Annual Scientific Meeting (ACG 2019) in San Antonio, TX. For winning the competition, Haddad and El Douaihy will each receive a $1,000 grant to the ACG Annual Scientific Meeting in Nashville, TN, October 23–28, 2020. The lively GI version of the television classic began over the summer, when GI training programs participated in the preliminary


[MILESTONES]

FOUR MEMBERS HONORED AS MASTERS OF THE AMERICAN COLLEGE OF GASTROENTEROLOGY

MICHAEL CAMILLERI, MD, MACG Mayo Clinic, Rochester, MN

MARTIN L. FREEMAN, MD, MACG University of Minnesota, Minneapolis, MN

G. RICHARD LOCKE, III, MD, MACG (1961 – 2019)* Mayo Clinic, Rochester, MN

HARRY E. SARLES, JR., MD, MACG Digestive Health Associates of Texas, Rockwall, TX

*Dr. Locke earned the distinction of MACG posthumously in October 2019. The College was saddened to learn of his passing on January 10, 2019.

READ about 2019 Masters at gi.org/awards

round, during which groups of GI fellows took an online test on various GI topics and diseases. The live event, hosted by Ronald D. Szyjkowski, MD, FACG, allows the top five teams emerging from the preliminary round to vie for the winning spot. Teams also contended from Brown University, Indiana University School of Medicine, Stanford University, and the University of California San Diego (UCSD) Medical Center. The enthusiastic crowd watched as the field was narrowed to Staten Island, Indiana University, and UCSD, when Staten Island pulled ahead before the final question.

LEARN MORE about GI Jeopardy: bit.ly/GIJeopardy

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ACG 2019 SPECIAL LECTURERS MIGUEL D. REGUEIRO, MD, FACG The David Sun Lecture “The IBD Medical Home and Neighborhood: It Takes a Village” Dr. Regueiro discussed the role of alternative models of care, such as the medical home, for the management of inflammatory bowel disease. The David Sun Lecture was established by Mrs. Sun in memory of her husband, Dr. David Sun, an outstanding gastroenterologist and investigator.

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CIARÁN P. KELLY, MD, FACG The American Journal Of Gastroenterology Lecture “Celiac Disease: Myths and Mysteries?” Dr. Kelly explained how to appreciate the diverse clinical presentations of celiac disease, recognize the challenges and limitations of treatment with a gluten-free diet, and the need for non-dietary adjunctive therapies. 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.

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LINDA RABENECK, MD, MPH, MACG The J. Edward Berk Distinguished Lecture “Post-Colonoscopy Colorectal Cancer: How Are We Doing?” Dr. Rabeneck shared best practices, incidences and causes, and reviewed approaches to reduce the risk of postcolonoscopy colorectal cancer in clinical practice. 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 to clinical gastroenterology by J. Edward Berk, MD, MACG, during his long and distinguished clinical and academic career.

SURESH T. CHARI, MD, FACG The Emily Couric Memorial Lecture “Early Detection of Pancreatic Cancer: Problems, Promise, and Prospects” Dr. Chari explained how to define “early” detection, recognize its benefits, and identify early detection barriers. 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 of 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.

STEPHEN B. HANAUER, MD, FACG The David Y. Graham Lecture “Mentoring Mentors” Dr. Hanauer shared how to gain a better understanding of mentoring towards leadership roles in gastroenterology. 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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[AWARDEES]

ACG 2019 AWARDEES SESHADRI T. CHANDRASEKAR, MD, FACG Dr. Chandrasekar was presented with 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. Dr. Chandrasekar provides free medical camps, health awareness programs, and concessional treatment, and has performed over 23,000 advanced endoscopy procedures in his local community of Chennai, Tamil Nadu, South India. He also created numerous patient materials, including Braille charts and medical cards to expedite treatment in emergencies. Dr. Chandrasekar is the founding chairman and chief gastroenterologist at MedIndia Hospitals, a GI institution affiliated with Tamil Nadu State Dr. MGR Medical University (TNMGRMU) in Chennai, where he is an Adjunct Professor.

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MANOOP BHUTANI, MD, FACG, FACP Professor Manoop Bhutani, MD, FACG, FACP 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 over 20 years, Dr. Bhutani has been instrumental in advancing the field of endoscopic ultrasonography. In addition to his internationally known publications and speaking engagements, Dr. Bhutani has mentored and hosted visiting faculty and fellows from around the world. His long tenure serving on ACG’s International Relations Committee is a testament to his commitment to advancing the gastroenterology community worldwide. He has authored more than 300 publications, acted as PI on many studies at MD Anderson, and served on many editorial boards. Dr. Bhutani is the Walter H. Wriston Distinguished Professor and Director of Endoscopic Research and Development at MD Anderson Cancer Center in Houston, Texas.

2019 Special Lectures and Awardees, many pictured with ACG 2018-2019 President Sunanda V. Kane, MD, MSPH, FACG. (1) Miguel D. Regueiro, MD, FACG; (2) Ciarán P. Kelly, MD, FACG; (3) Linda Rabeneck, MD, MACG; (4) Suresh T. Chari, MD, FACG; (5) Stephen B. Hanauer, MD, FACG; (6) Seshadri T. Chandrasekar, MD, FACG; (7) Manoop Bhutani, MD, FACG; (8) Jamie S. Barkin, MD, MACG; (9) Alvin M. Zfass, MD, MACG

JAMIE S. BARKIN, MD, MACG This year’s Berk/Fise Clinical Achievement awardee is ACG Past President Dr. Jamie S. Barkin, for his significant and distinguished contributions to clinical gastroenterology, particularly teaching and military medicine. 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. He became a Trustee of the College in 1980, served as President from 1989 to 1990, and has been active in numerous ACG committees. Dr. Barkin is an innovator of endoscopic instrumentation and diagnostic techniques and was a pioneer in the development of small bowel enteroscopy and video-capsule endoscopy. In the pancreas, he was a pioneer of diagnostic aspiration of pancreatic lesions. ALVIN M. ZFASS, MD, MACG In recognition of his deep and abiding enthusiasm for the College, consistent and loyal service to ACG, and encouragement of young gastroenterologists to get involved, Dr. Alvin Zfass receives the College’s highest honor—the Samuel S. Weiss Award. This service award in commemoration of ACG’s founding father, Samuel S. Weiss, MD, is presented periodically to a Fellow of the College in recognition of outstanding career service to ACG. As a clinician, educator and mentor to many, Dr. Zfass exemplifies the ideals of service and dedication to ACG that are the hallmarks of the Weiss Award. According to one of his recommenders for this honor, Dr. Zfass has never missed an ACG Annual Scientific Meeting and to this day, “remains invested in the success of the ACG.” He steadfastly encourages his junior faculty at Virginia Commonwealth University to join and participate in the College. He has served on numerous ACG committees, including Educational Affairs, Public Policy, and Archives; served as ACG Governor for Virginia from 1988 to 1994; and was co-chair of the annual ACG Postgraduate Course in 1992.

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// N&N [AWARDS]

SCOPY AWARDS: ACG RECOGNIZES 31 CRC AWARENESS PROJECTS

ACG celebrates the winners among a recordbreaking number of entries. In 2019, a total of 31 SCOPY Awards were presented to an outstanding slate of CRC awareness champions. Their initiatives demonstrated a motivating spirit of collaboration, a dedication to reaching underserved communities, a focus on quality care and public health intervention, and an understanding that patient stories have an impact. The winners were celebrated during the 2019 SCOPY Awards Ceremony and Workshop, Sunday, October 27, 2019, at the ACG Annual Scientific Meeting in San Antonio. The winning projects included international Dress in Blue Day participation, free colonoscopy clinics and university-wide community health events, extensive social media outreach, events

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as tributes to loved ones personally affected by CRC, and several videos—including a gastroenterologist’s own experience of getting a colonoscopy—among many other campaigns. The initiatives “demonstrate sustained engagement with community members, effective collaboration to deliver comprehensive public awareness campaigns, and exemplary commitment to increasing of colorectal cancer screening,” said ACG Public Relations Committee Chair Sophie M. Balzora, MD, FACG, of the NYU School of Medicine in New York, NY.

LEARN MORE about the

2019 SCOPY Award winners: bit.ly/SCOPY19


MARTIN E. GORDON, MD, FACG PUBLISHES A NEW BOOK AT AGE 98 4. At this point in your life, what motivates you as an author? The ongoing interaction of plants, vectors, parasites and ourselves become vibrantly apparent as we delve into the silent world of plants. An example is that these disclose many fascinating “pearls”—such as bananas peels make excellent shoe polishers; the banana’s serotonin helps the post-liquor hangover condition and many other benefits.

1. What are the origins of your interest in healing properties of plants and how long have you studied them? The growth and beauty of plants have always intrigued me, but upon moving to Saint Louis, I was overcome with the voluminous activities of new plant sciences in this area. In fact, this area is becoming the epicenter of global plant sciences. The ongoing need to amalgamate plant knowledge with medicinal practice became a fascinating calling, amplified by my addictive videography and silent photography.

5. As you reflect on the span of your career as a physician, are there insights about medicine or patient care that you would like to impart to your ACG colleagues? By applying newer microscopic and basic genetic discoveries, we strengthen the ongoing connections of awareness of illness culminating in good health. We must constantly be aware of global toxicities that impact on our lives. An example: aiding the patient recall that the old wallpaper remodeling exposure to the arsenicalbased flowers may prevent diagnostic dilemmas. Always recall Soma Weiss’ admonition: “Any diagnosis is easy, once we think of it.”

2. What do gastroenterologists need to know about the world of medicinal plants? The intimate association of the digestive diseases and plant biochemistry grows progressively as each of the sciences expand their own breakthroughs and understanding. Many illnesses are discovered and treated by knowledge of plants’ physiology as the treatment becomes associated with clues from plants. Many acute gastrointestinal illnesses are now amendable to plant substances but may also stimulate new discoveries. These evolving discoveries within the gut microbiome predict diverse interactive beneficial food additives. 3. What was the most surprising or promising knowledge about plants, that you gained while writing this book? How intricate and complex Nature has provided us with subtle but very effective diagnostic and therapeutic aids. The application of ancient skills with the newer sciences often yields practical answers to clinical puzzles. MEDICINE

Cures Martin E. Gordo n, M.D.

U.S. $XX.XX

Plants

Plants R Cures explores the intersection the past—while of plants and also offering medicine—no a practical guide variety of ailmen w and in to the use of ts, from small herbs to treat promote good to a large health and which catastrophic. Dr Gordo n tells us which features anecdo ones you will plants tal be an almanac-style patient cases from his storied wise to avoid. The book also practice and format and world travels an abundance designed to speak to laypeo . With of graphics, ple and academ this engaging book is ics alike. “American Indian s made Chapa creosote bush. This desert shrub rral tea by grinding the leaves of the United States grows in Mexico and has a distinc tive tar-like fragran and the southwestern made tea from the ce. Native Americ diarrhea, menst leaves of this plant to ans treat chicke rual cramps, n pox, rheumatism. pain, snake bites, skin disord colds, Over the years, longer list of it has also been ers and ailments rangin prescribed for g from acne UTI and even an even to dandruff, cancer.” diabetes, ulcers, DR MART IN E. GORD ON is a renown He served on ed gastroenterolo the faculty of gist and expert Yale Medical library for an School for 40 in additional 10 years and headed travel medicine. years. During with mysterious those years, the Yale medica gastrointestin he was asked l al symptoms, diagnoses and often to diagno and he provid cures via educat se patients ed fellow physici scientific publica ional materi als, lectures ans with guides tions—which and exhibits. to practitioners, focus on clinica He has author and patients—and l solutions for ed many the benefit of has received His experiences medical studen awards for his have inspire ts, films and other their applica d him to focus tion to medica efforts. on the often l problems. neglected plant sciences and

Plants R Cure s An Almanac of Plants & Med icine

[IN MEMORIAM]

JAMES L. ACHORD, MD, MACG ACG Past President, James L. Achord, MD, MACG passed away on November 18, 2019 at the age of 88. In addition to serving as ACG President from 1983–1984, Dr. Achord also served as ACG Governor for Mississippi and on various College Committees and as a Mississippi Governor for the American College of Physicians. He was named a Master of the College as well. Dr. Achord was born in Dayton, OH and grew up in Alamo, GA. He attended Emory University and was accepted into the Emory School of Medicine at the end of his Junior year in college. After graduating from the Emory School of Medicine, he went on to serve in the Army Reserves. As a physician leader, he Medical Director and Director of Medical Education at the Medical Center of Central Georgia, in Macon, GA, and was Professor of Medicine and Director of Digestive Diseases at the University of Mississippi Medical Center in Jackson, MS. In 1991, ACG honored Dr. Achord with the Samuel 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. He also was recognized by the Mississippi chapter of the American College of Physicians with their Laureate award. ACG Past President Dr. Sidney J. Winawer offered this remembrance: “I had the pleasure of being a friend and colleague of Jim. He was a very special physician and human being. High integrity and wonderful collegiality. He will be missed.” Dr. Stephen T. Amann, ACG’s Governor for Mississippi, recalls that many who trained under Dr. Achord noted that “his greatest gift was he always put the patient first, and by example taught us to do the same.” Dr. Achord was preceded in death by his wife of 62 years, Pat Moore Achord. He is survived by a sister, his three children and 13 grandchildren.

“I had the pleasure of being a friend and colleague of Jim. He was a very special physician and human being. High integrity and wonderful collegiality. He will be missed.” – Dr. Winawer

Martin E. Gor don, M.D.

Novel & Noteworthy | 13

ACG CALENDAR

[READING]


MARCH

MARCH

6–8

13–15

ACG/LGS REGIONAL POSTGRADUATE COURSE

ACG/FGS ANNUAL SPRING SYMPOSIUM

 New Orleans, LA

 Naples, FL

Register: meetings.gi.org

Register: meetings.gi.org

MARCH

20–22 NORTH AMERICAN CONFERENCE OF GI FELLOWS (NACGF)  Orlando, FL Learn More: www.abstractscorecard.com/ cfp/submit/login.asp?EventKey=YCFOFAJN

JUNE

5

ACG'S IBD SCHOOL AT EASTERN REGIONAL

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JUNE

6–7

MARCH 31

 Washington, DC

2020 GI TRAINING GRANTS DEADLINE

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EASTERN REGIONAL POSTGRADUATE COURSE

APRIL 15

 San Diego, CA

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2020 AWARDS NOMINATIONS DEADLINE More Info:

gi.org/awards

MAY

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ENTER TO WIN A SCOPY

THE AMET RH I CEA A N MCEO LE R LI C AG N EC O L L E G E OF GASTR OO F EGNAT SETRROOLEONGTYE R O L O G Y

 St. Louis, MO

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Register: meetings.gi.org

14 | GI.ORG/ACGMAGAZINE

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ATTEND THE ATTEND ACG 2020 THE ACG 2020 ANNUAL SCIENTIFIC ANNUALMEETING SCIENTIFIC MEETING & POSTGRADUATE COURSE & POSTGRADUATE COURSE to learn the latest in clinical to learn the latest in clinical practice, exchange ideas with practice, exchange ideas with colleagues, and gain insight colleagues, and gain insight from the experts. ACG 2020 from the experts. ACG 2020 will be held inwill Nashville, be held in Nashville, Tennessee at the Music at the Music Tennessee City Center. City Center.

LEARN MORE: acgmeetings.gi.org

Continue to visit Continue to visit acgmeetings.gi.org acgmeetings.gi.org for updated information. for updated information.


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. All rights reserved.

HH27314B

September 2018


THE ORIGINAL 1 LITER PRESCRIPTION BOWEL PREP SOLUTION

1 MOST PRESCRIBED,

#

BRANDED BOWEL PREP KIT1 WITH MORE THAN 15 MILLION KITS DISPENSED SINCE 20101

A CLEAN SWEEP

EFFECTIVE RESULTS IN ALL COLON SEGMENTS2 · SUPREP® Bowel Prep Kit has been FDA-approved as a split-dose oral regimen3 · >90% of patients had no residual stool in all colon segments2* †

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

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

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

*This clinical trial was not included in the product labeling. †Based on investigator grading. References: 1. IQVIA. National Prescription Audit Report. September 2018. 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; 2017. 4. Rex DK, Schoenfeld PS, Cohen J, et al. Quality indicators for colonoscopy. Gastrointest Endosc. 2015;81(1):31-53.

©2018 Braintree Laboratories, Inc. All rights reserved.

HH27314B

September 2018


PUBLIC POLICY

// GOVERNORS' VANTAGE POINT

SPREADING AWARENESS of

Nonalcoholic Fatty Liver Disease By Nahum Méndez-Sánchez, MD, MSc, PhD, FACG

 PREVENTING LIVER DISEASES IN MEXICO: A PRIORITY

One of the most satisfying aspects of my work in recent years is the opportunity to participate in different campaigns about the prevention of liver diseases. In my country, and specifically in my hometown, Mexico City, I organize and lead several long walks and run races in favor of a healthy liver. These events help to warn the general population about the effects of NAFLD, especially because Mexico has a serious problem of obesity and diabetes which currently are the main risk factors to developing NAFLD and, ultimately, cirrhosis. We must take into account that 50% of patients with diabetes have steatosis and 100% of patients with obesity and diabetes have steatosis. In fact, liver cirrhosis is the fourth cause of death in Mexico. Moreover, our research team investigated the current etiologies of cirrhosis in Mexico and we conclude that NAFLD, together with alcohol, will soon become one of the most frequent causes of liver cirrhosis.

A CHANCE TO DO MORE Nevertheless, my activities at my place of work in Médica Sur Clinic & Foundation were limited to Mexico City and I felt that I could do more. So, I was excited last year when I received an invitation to participate in a TV show quite famous in all the country, called “Hoy” (which means “Today”), that has been on the air since 1994. I took the opportunity to spread awareness on national TV about NAFLD. In that very moment, it was something special since I diagnosed, just few days earlier, a patient with cirrhosis, and unfortunately the etiology was NASH. The day of the interview finally came. I arrived early at the studio where the members of the staff kindly received me. Immediately they prepared 

Nahum Méndez-Sánchez, MD, MSc, PhD, FACG ACG Governor for Mexico, Médica Sur Clinic & Foundation, Mexico City

Public Policy | 17


// PUBLIC POLICY: GOVERNORS' VANTAGE POINT

18 | GI.ORG/ACGMAGAZINE

1

2

consider going to a gastroenterologist or hepatologist if their physician told them the diagnosis of NAFLD. I would like to say that the interview was a great experience. The influence of media in health is always important; now with the social media is easier to reach a lot of people, but I cannot deny that TV still has a lot of impact on the public. In fact, I believe that in Mexico the impact of TV is higher than in the United States, and the opportunity to use that tool in order to talk about a health problem that is not enough covered, even by the national health system propaganda. For me, experiences like this are an example of the passion I feel for my specialty, also represented in being a member of ACG that at the same time encourages me to continue my labor, and that is why I am glad to share this with all of you. I am sure that there are more stories like this or even better examples of the work of my colleagues in Mexico. I welcome all gastroenterologists in my country, and also those in the international regions, to share with our colleagues in other countries the

3

stories of the great work that an ACG member can do for people. Finally, I am proud of my involvement with ACG and congratulate the College for their continuous work improving people’s health.

ABOUT DR. MÉNDEZ-SÁNCHEZ A member of the ACG since 2005, Dr. MéndezSánchez considers it an honor to serve as ACG Governor for Mexico. During his last year in this role, one of his goals is to encourage Mexican gastroenterologists to join ACG and/or to participate in the College’s academic activities. He was pleased when one of his youngest colleagues, Dr. Luis R. Valdovinos, applied and was selected for the ACG International GI Training Grant and trained at the Mayo Clinic.

NEWLY ELECTED AND APPOINTED ACG GOVERNORS The following individuals were newly elected or appointed to terms on the ACG Board of Governors beginning October 2019:

 Ronald K. Hsu, MD, FACG (Northern California)

 Mohammad Al-Haddad, MD, MSC, FACG (Indiana)

 Vonda G. Reeves, MD, MBA, FACG (Mississippi)

 Wilson R. Catapani, MD, FACG (Brazil)

 Sapna V. Thomas, MD, FACG (Northern Ohio)

 Silvio W. de Melo Jr., MD, FACG (Oregon)  Nalini M. Guda, MD, FACG (Wisconsin)

 Baharak Moshiree, MD, FACG (North Carolina)

Learn More about the ACG Board of Governors & Connect with Your Governor: gi.org/acg-board-of-governors

(3) Dr. Méndez-Sánchez in a TV appearance on Mexico’s “Hoy”; (1)(2) Run race to promote the Liver health; Awareness on non alcoholic fatty liver disease

me for the interview. At eleven a.m. we were on-air. The presenters introduced me to the public and after some introductions, questions began. The first one was about the definition of fatty liver. I tried to explain it clearly, emphasizing that from 5% of accumulation of fat in the liver we can call it fatty liver; it results from the different causes such as diabetes, obesity, and metabolic syndrome; and explaining also that triglycerides are synthesized in the liver from excess carbohydrates that are then esterified to storage for future energy needs. Surprisingly, the presenters did not know that triglycerides come from carbohydrates. The second question was about the effects of alcohol on the liver. Of course, I explained that it is the main cause of fatty liver and there are other causes such as viral hepatitis and less-common hepatic autoimmune diseases, but again, given the high prevalence of metabolic risk factors such as obesity, metabolic syndrome, and type 2 diabetes, the prevalence of NAFLD will be higher. Following the interview, we talked about diagnostic methods of NAFLD. Since Mexico has a huge public health program, I focused on non-invasive tests that most of the population can afford. First, emphasizing the importance of assessing metabolic risk, for example, if a patient has an increased body mass index. Second, the importance of liver function tests, and third, evidence that hepatic ultrasounds can give. Moreover, we talked about the complications of NAFLD and its progression from fibrosis and cirrhosis to hepatocellular carcinoma. Finally, prevention was the last topic we discussed, and I basically explained that the best strategy is lifestyle interventions, of which diet and exercise are primary prevention by avoiding not just food with high concentrations of fats, but also those with carbohydrates. About weight loss, I repeatedly explained the importance to achieve at least a 10% loss of body weight. Finally, I said to the public that a medical assessment is also important and to


GETTING IT

GETTING it Right

MARKETING YOUR PRACTICE DIGITAL ERA // BUILDING SUCCESS

By Austin Chiang, MD, MPH; David J. Hass, MD, FACG & Manoj Mehta, MD

in the

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

 THE CONCEPT OF BUILDING A PRACTICE in today’s era of medicine is vastly different than just a few years ago. Gone are the days of simply doing good work and building a grateful and faithful following of patients. The landscape of how patients find doctors, share their experiences, communicate their satisfaction, and the permanency of these perceptions is so quickly and constantly changing that it is a difficult concept to even understand. Many doctors don’t bother to develop a competitive website, market their practice electronically, engage in social media, or work towards reputation management at all. As these have been emerging technologies, and fall outside the realm of traditional medical training, it is easy to simply look the other way or wait and see what happens. But being overly cautious can be risky in itself. Rapid change does not just imply risk, however, but also opportunity.  Getting it Right | 19


// GETTING IT RIGHT: BUILDING SUCCESS

http:// www.

TRADITIONAL METHODS OF MARKETING

SOCIAL MEDIA

Professional loyalty from referring doctors can be optimized by developing personal relationships, calling with important results, and helping doctors out with urgent issues. Periodic visits to referring providers’ offices are a helpful means by which to check in and provide updated clinical guidelines or to introduce a newly hired associate. Most importantly, periodic visits allow for providers to inquire about the quality of care they are providing. This provides your practice with invaluable feedback necessary to improve the service you provide, and allows the referring doctors know your practice cares about their patients. Sending holiday cards or gift baskets to referring offices is an excellent way to remind them of your practice and a means to simply say “thank you.” This can especially endear you to an unrecognized gatekeeper of referrals, the front office staff. Mailers, newsletters, or notices focusing on new technology or services in your practice can help to keep you ahead of competitors. Purchasing ad space in a local periodical is an option. Being interviewed regarding a newsworthy story highlights you as a local expert. Lectures and seminars are opportunities that showcase your practice and present your physicians as valuable resources. An example of this is organizing a course that offers CME credit, while showcasing the talents of the members of your practice1 as local experts. The face-to-face contact at such events is tremendously beneficial. Good work is still its own reward. Remember that patients and their families can be good sources for ongoing referrals. Also, medical discussions don’t have to be peer-to-peer. A great number of patients appreciate being included in workshops or support groups that have an expert present.

The electronic age is here, social media is here to stay, and whether you know about it or not, people are talking about you online. “One of the greatest risks of social media is ignoring social media,” said Don Sinko, chief integrity officer of Cleveland Clinic. “It’s out there, and people are using it whether you like it or not. You don’t know what you don’t know.”2 By embracing social media, physicians can increase their visibility among patients and colleagues, highlight accomplishments, and develop an online presence to reach the next generation of colleagues and prospective patients. Furthermore, education from trained professionals may help dispel misconceptions, combat inaccuracies, and preserve trust in the medical profession. This allows them to boost their local, regional, and national reputation as problem solvers and valuable resources to patients and colleagues.

20 | GI.ORG/ACGMAGAZINE

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C#

WEBSITE DEVELOPMENT There is essentially no practice that can get by in today’s age without a functioning website. A website that is easy to navigate can help patients locate a practice in their area that suits their needs. Search engine optimization can help improve the visibility of a practice among search results. Even a “mature practice” will include technology savvy patients who will want to see your picture, find your location on a mobile app, or simply gauge the professionalism of the practice. You can leverage this interest to engage in marketing, answer frequently asked questions, provide a map and listing of your hours, and have educational content available. If you believe nothing else, know that it will save you and your office staff countless hours of telephone time. A good website will be easy to understand, easy to navigate, and provide valuable resources for patients. Beyond the basics, your website can include secure registration, appointment making, and direct contact information. Despite the option of communicating completely online, a phone number to a live person ready to address questions is high yield. Experience suggests that live staff result in more confirmed patient appointments, and generate higher patient satisfaction scores. Having an actual human being answer one’s questions provides warmth and reassurance for patients that is worth the additional expense to the practice. The website can still be a gateway to the direct human experience, just as your office staff are a gateway for the patient to ultimately see you.

 Blogging Writing a blog about health care issues, professional experiences, or disease states is a terrific way to deliver your thoughts to a larger audience. You can keep this strictly medical, you can delve into health care reform or other topical interests, or you can be personal and insightful. You should come up with a goal for your blog and keep that in mind whenever writing. Do you want the most number of readers, to augment your professional reputation, to bring in new patients, or to deliver medical news to a more select community?  Twitter Twitter has seen an explosion of growth as a source for medical information and a forum for professional dialogue. There’s a tremendous amount of peer-to-peer networking that occurs via Twitter, a kind of connectivity that is hard to find anywhere else. Articles and abstracts are often released here first. In fact, published articles in the field of gastroenterology and hepatology that were discussed on Twitter were independently associated with higher citation rates compared with those that were not, as recently published in GIE3. In 2016, a hashtag ontology was developed to create a standardized list of hashtags for academic discussion on social media as published in AJG. This list of hashtags was agreed upon by various GI societies including ACG, AGA, ASGE, AASLD,


http:// www.

CCF, DDW, UEG, SAGES, as well as journals including AJG, Gastroenterology, CGH, GIE, Gut, Journal of Hepatology, and Nature Reviews Gastroenterology & Hepatology. As an example of how Twitter can be useful from the medical perspective, we discussed #MondayNightIBD with Aline Charabaty, MD. Dr. Charabaty, a national expert in IBD at Johns Hopkins, created this hashtag as a simple means for professionals to communicate with one another about interesting cases. Dr. Charabaty told us, “I am an educator; techs, fellows, anyone who will listen. But there are questions for which there may be no published answers. This is a realm where we can extend our usual clinical questions to a broader audience and ideas that are not addressed in the publications. We can ask clinical questions, take polls, and learn the nuances of others’ practices.” Additionally, Dr. Charabaty emphasizes, “it’s completely fluid. You can catch up anytime if you are busy and can’t be there, and just read through the discussions.” Dr. Charabaty’s initially small-group discussion recently hit over 200,000 impressions on Twitter. It has grown to become, as she says, “a little journal club.” Twitter is also frequently used to amplify discourse at GI conferences through live tweeting. Communication and connections forged online can translate into real-life networks and collaborations, as apparent during in-person social gatherings that are a staple at many national conferences. This type of activity benefits everyone. All participants gain exposure. This allows for everyone to be heard, and expand and grow their individual professional and personal networks.  Facebook Facebook is the prototype for social media engagement. In fact, it may be eclipsed by newer, and “purer” forms of communication. However, it is still a very powerful tool. Whether organic readership or paid advertising is used, this is a mechanism

to reach a vast numbers of patients. Targeted ads can be directed to certain age groups, demographics, and even ZIP Codes. Facebook groups can also be used to target specific audiences. Facebook has become a medium for the masses, and virtually every age group is extremely engaged in this social media platform. If you want to generate raw numbers of views, Facebook might still be the best digital place to market.  Instagram Instagram is the fastest growing major social media platform, now exceeding over 1 billion active users. Each visual post is uniquely organized on one’s personal page in a “grid,” though new posts accounts followed by the user will show up in a similar news feed. The structure and visual nature of the platform typically requires posting with less frequency. Owned by Facebook, some of the advertising functionality translates across both platforms. Furthermore, other industries have capitalized on “influencers” on Instagram to promote a variety of products. The influencer phenomenon has coincided with a surge in medical professionals and trainees joining Instagram to promote their practices and share personal experiences. As a highly visual platform, many users find the platform engaging. Without the character restrictions of Twitter, individuals can post longer captions and expound on their material. Instagram has adopted functionality seen on most other popular platforms, namely the temporary 24-hour video posts of Instagram stories. Within these stories, users can post polls, Q&A sessions, and livestreams. Similar to Twitter, hashtags are critical for amplification of material on Instagram, and likewise engagement with others on the platform. Searching these GI-related hashtags will reveal who is utilizing these hashtags and potentially identify a target audience or influencers in that topic.  YouTube YouTube has been cited as the second largest search engine and is the fastest growing video sharing website in the

world. Each month the site sees 5 billion views per day and 300 hours of video uploaded every minute. Video is an effective medium of conveying information, but requires a different skill set of filming and editing.

ASSOCIATION FOR HEALTHCARE SOCIAL MEDIA The Association for Healthcare Social Media (ahsm.org) is the first 501(c) (3) professional society devoted to health professional social media use. The new organization aims to provide resources to help health professionals build a health-related social media presence and to define best practices to encourage responsible social media use. By doing so, physicians can avoid missteps and potential professional pitfalls, as well as inadvertent harm toward public health. Part of the resources will also be for patients to better interpret health-related social media posts for accuracy. These best practices are currently in development.

REPUTATION MANAGEMENT It’s wonderful when something meaningful and insightful you write becomes a sensation, but it’s similarly tragic if something taken out of context or misconstrued goes viral.

Getting it Right | 21


// GETTING IT RIGHT: LAW MIND

You must keep this in mind whenever posting anything online. You should assume that anything you write anywhere online is visible to anyone, could be taken in the worst possible way, is not subject to separation of personal and professional, and is available permanently. These facts likely keep a lot of people off-line, but they should not dissuade you completely from engaging in social media. You should just do so cautiously. Whether you have taken charge of your professional digital presence or not, you have one. You may as well own it and drive it in the direction you want. A good exercise is to Google yourself and check the various doctor rating sites to see what people write about you. But be prepared, there will be negative comments. Experience has shown that often times, despite the initial disappointment that might result from seeing negative reviews, you can get valuable feedback regarding your overall practice. If the comments always focus on the front office staff being rude, your waiting room is dirty, or that you seem dismissive, these can be tangible action points for meaningful and positive change. Even a negative comment itself can be spun into something positive. A response along the lines of an apology for some misunderstanding or delay, and a reaffirmation of your practices commitment to provide the highest level of care, can win over readers. People will respond to, “I am as disappointed as you are to hear this. Thank you for bringing it to my attention, and I hope you return so we can start over after I have made some very necessary changes.” A negative review that goes unanswered, on the other hand, can be seen as an acknowledgment of the comments as

Austin Chiang, MD, MPH, Director of Endoscopic Bariatric Program, Asst. Prof. of Medicine, Thomas Jefferson Hospital, Philadelphia, PA

22 | GI.ORG/ACGMAGAZINE

fact or disinterest on your part. Whatever you do, do not be inflammatory or engage in any kind of hostile back and forth. The Internet loves for these David and Goliath type stories to go viral. Most of the doctor rating sites have the option for you as the healthcare provider to take ownership of that account. This allows you to put your picture and a written introduction in place. You may be able to direct people to your website from there. This looks more professional and polished, and less anonymous—anonymity being a key driver of negativity online. There’s also the risk that if you do not take ownership, someone else may lay claim to it. Although most of the sites have some type of paid membership available, be wary of sites that suggest they can improve your ratings for pay.

people can have a tremendous number of fickle followers, or a few very dedicated and professional followers. Take charge of your online reputation, because people are talking about you whether you know it or not. And remember, at the end of the day, maintain a human touch for your office and your own individual practice. People may find you and talk about you electronically, but it still all comes down to your face-to-face meeting.

FURTHER READING For further information, there are a number of professional discussions on these topics that take place during the national society events such as the practice management conferences, regional conferences, or the Annual Meeting of the ACG.

CONCLUSION How doctors communicate with the rest of the world, and how our own patients find and rate us, is a game that has entered a new season. We must play in the current field conditions. Websites, electronic advertising, and social media are all extremely useful tools to augment the time-honored and more traditional approaches. Define your goals clearly when using social media and stick to them. Be cautious in your approach, particularly if you venture outside of the strictly medical with social media. Remember that

David J. Hass, MD, FACG, Director of Endoscopy – Yale New Haven Hospital, Associate Clinical Professor of Medicine, Yale University; Gastroenterology Center of Connecticut, Hamden, CT

1. Clinical Pearls Brochure, Gastroenterology Center of CT, 2019. 2. Social media “likes” healthcare: From marketing to social business. PricewaterhouseCoopers Health Research Institute, April 2012. 3. Longitudinal relationship between social media activity and article citations in the journal Gastrointestinal Endoscopy, Smith, Zachary L. et al., Gastrointestinal Endoscopy, Volume 90, Issue 1, 77 - 83 4. https://journals.lww.com/ajg/ Citation/2016/08000/Harnessing_the_ Hashtag__A_Standard_Approach_to_ GI.2.aspx

Manoj Mehta, MD, Endoscopy Center of the North Shore, Wilmette, IL


// LAW MIND

PROFESSIONAL SERVICE AGREEMENTS: PERFECT SOLUTIONS to AFFILIATIONS? Key Situations Every PSA Should Address The College commissioned Ann Bittinger, Esq., to draft a white paper on Professional Services Agreements (PSA) as a resource for our members. In addition to guidance and perspective, Ms. Bittinger also provides template legal contract language that will be helpful to ACG members negotiating a PSA with a health system. • As you read the white paper, the legal template language can be viewed online by scanning this QR code with your smartphone • View and download the template language: bit.ly/ACG-PSA-LegalTemplates

By Ann Bittinger, Esq.

 THE RAINSTORM THAT STARTED AROUND 2010 IN FAVOR OF CONSOLIDATION IN THE HEALTHCARE INDUSTRY CONTINUES TO FLOOD THE MARKET, with creative, mutuallybeneficial arrangements between hospitals and physicians taking the form of every color of the post-storm rainbow. One form, Professional Services Agreements (“PSAs”), continue to be quite common among hospitals and gastroenterology groups where the system has not yet employed the gastroenterologists. Background. A PSA is simply a contract by which physicians in a physician group provide services to a hospital or health system. They take many shapes and sizes. One physician can enter into a PSA with a system for a few hours of defined work. Or, on the other end of the spectrum, a GI group with dozens

of gastroenterologists can contract through a PSA to manage the GI service line at a system, much like what we used to call a co-management agreement. There is no one-size-fits-all PSA, but there are key terms that should appear in any PSA, and those terms should be tailored to the specific facts and circumstances following negotiation of a robust letter of intent. When a group sells its practice to a system, the group’s company is usually dissolved. The physicians no longer own the company for which they work, and they become W-2 employees of the hospital system, usually of its physician enterprise subsidiary. The closeness of the affiliation in a PSA, however, is one or more steps shy of full employment; how close is up to the terms of the PSA. For most PSAs, the gastroenterologists typically still bill and collect for clinical services. As such, the health system is paying the group for administrative and management services only. In other PSAs, however, all of 

Getting it Right | 23


the gastroenterologists work under the tax ID number and payer contracts of the health system. (In other words, the GI group still employs all the physicians and assigns all of them via a PSA to work under the hospital system’s payer contracts). In those situations, the payment to the group compensates it not only for administrative services but also for the costs of salaries the group incurs in providing a full spectrum of gastroenterologists to provide services to the hospital. Because the hospital bills and collects for physician services, the hospital pays the group to pay the physicians’ salaries and benefits. The Law. It is illegal for a hospital to pay a physician group other than fair market value. The hospital can only pay physicians rates that do not vary based on the volume or value of referrals, for commercially reasonable services. Payments above fair market value or for work that is not commercially reasonable can be construed by prosecutors as kickbacks that violate the Federal AntiKickback Statute. This is a criminal law, so if violated, the physicians and system executives who offered, solicited, paid, or received payment can face prison time. Fair market value is a range, not a number. And the range should not be based solely on third-party data. To use third party data properly, the facts surrounding the proposed relationship have to be shared with the consultant. That way, the consultant can ensure that he or she is comparing the industry information correctly to the facts at hand. Although it’s not advisable to blatantly negotiate what is considered fair market value, there is absolutely nothing wrong with providing supporting documentation about the facts at hand in response to a draft report from a valuation consultant. Typically, in a fair process, the consultant will interview both the physician group and the hospital and ask for non-biased, fair information relating to the valuation job. A consultant may share the draft report with both parties, soliciting feedback, before finalizing it, to insure the integrity of the assumptions and conclusions the consultant makes.

24 | GI.ORG/ACGMAGAZINE

Sample Agreement Terms. Although every PSA must be tailored to the specific facts and circumstances, groups should pay particular attention to these terms: 1. Duties 2. Term 3. Exclusivity 4. Non-compete (Confidentiality)

DUTIES What are you doing? Because the most important compliance issue in a PSA is to demonstrate commercial reasonableness and fair market value, it is essential that the contract accurately and robustly describe the work that is being performed by the physician group for the benefit of the system. Is it specifically for call coverage, for example, or only for endoscopy coverage for the hospital? Valuation consultants, not lawyers, opine on fair market value, but before you call a valuation consultant you need an accurate description of services that will be provided. Sometimes PSAs are casually referred to as “medical director agreements on steroids.” Some level of medical direction or administrative oversight is part of all PSAs (other than agreements for call coverage only), but what else are you doing? Need more help? View and download examples of contract language when negotiating duties related to your PSA: bit.ly/ACG-PSA-Legal-Templates

As to the schedule containing the metrics and targets, a model is beyond the scope of this paper, but be sure that the targets and metrics are tailored to your service. Do they make sense from a cooperative standpoint as items that both the hospital and group want to improve upon? Is there a fair way to track and document progress on those targets? Does the group get to review the documentation before

it is finalized? Metrics should be flexible or provide multiple options. The practice will change over time, so the effectiveness of the measures needs to change in tandem. As to physician recruitment, consider including in the PSA that if the staffing of the group falls below X number of physicians, then the hospital will agree to subsidize the income of a new hire subject to a recruiting agreement that complies with the Stark Law and Anti-Kickback Statute. This agreement typically mandates that the recruit stay in the community for 2–3 years in addition to a subsidy paid to the group to allow the group to pay him regardless of his collections or productivity. The recruiting agreement is separate from the PSA, but a provision in the PSA that would mandate a subsidy, under to-be-determined terms, is helpful to physician groups. Another option is to mandate a needs assessment periodically, so that at a minimum a discussion about recruiting is built in to the PSA. As to call coverage obligations, be wary of how heavy the beeper is. By this, I mean incorporate a cap or some other limit on the extend of your call obligations per shift. It’s not reasonable for a gastroenterologist to have to manage 30 inpatient and emergency department patients a night. Also, as to call obligations, explore the medical staff bylaws and PSA terms to ascertain whether an extender can be used in addition to, or in lieu of, a physician on call. For example, a call coverage provision might say that the group will provide call coverage 10 nights a month for $1000 a night, but in the event that the census for patients seen by the group on call in the hospital (inpatient and ED)


in the last six weeks exceeds 20, then the fee will increase going forward to $1750 a night to support a second provider on the shift or an extender. The heaviness of the beeper should definitely be considered by the valuation consultant to determine the fair market value of the pay for call coverage.

TERM One of the pros of a PSA as opposed to an acquisition/employment model is that PSAs are easy to unwind, as the physician group entity remains in place. (That being said, an unwind can be difficult if the PSA includes the hospital hiring the non-physician staff and administration. In those cases, the PSA should allow for the re-hire of staff upon an unwind). But easy termination can also be one of the cons. It is not uncommon for a PSA to have a longerthan-normal term, of three to five years for example, with no without-cause termination provision by either party. They are, in a way, a short-term marriage between group and hospital. Locking in a longer term may be more valuable than negotiating higher compensation. It’s hard to get things done if you know the agreement is subject to expire in year term. If you negotiate favorable control rights and exclusivity, you want to lock that in for a while. Additionally, PSAs usually have minimal for-cause termination provisions. Need more help? View and download contract language examples related to terminations: bit.ly/ACG-PSA-Legal-Templates

EXCLUSIVITY When negotiating PSAs with hospitals, groups sometimes focus on the compensation and duties without paying attention to the value of intangibles, like exclusivity. An exclusive agreement means that you are the only entity or person providing the services defined in the agreement. If your group has an exclusive contract to handle call coverage, then only your group can take call (so long as there’s no conflict with the medical staff bylaws). If your group has an exclusive contract to manage the GI service line at the hospital and to oversee GI quality assurance and utilization review, then your group and your group alone maintains control of that. Having this intangible in your pocket prevents other groups from taking control of the department. An exclusivity term also makes clear the line of demarcation between what the hospital’s administrators do and what the physician group does. Need more help? View and download sample contract provisions related to exclusivity: bit.ly/ACG-PSA-Legal-Templates

NON-COMPETE (CONFIDENTIALITY) One remnant topic from employment agreement drafting that hospital systems like to make a part of a PSA is a noncompete. Hospital counsel argues that if the hospital is going to associate so closely with the GI Group, sharing information and collaborating so closely and perhaps exclusively, then the group has to agree not to take that information and use it competitively. Non-competes lock groups in, preventing them from leaving and associating with a system that competes with the system. Agreeing to a non-compete sacrifices significant leverage. The point of pursuing a PSA rather than an employment model is to

allow for an easy out if the Group is not happy. That easy out isn’t much of an out if the PSA includes a non-compete. If the hospital system is sincerely worried about a group taking the system’s confidential information and using it elsewhere, then the group should argue that a Non-Disclosure or Confidentiality Agreement (not a non-compete) is the more appropriate contractual tool to protect the hospital’s interests. After all, the physician group has its own intellectual property and experience that it is bringing to the PSA. Any restrictions on use of information should be mutual. It’s not like the group is an employee who is being trained to work for an employer and who should, therefore, be subject to a non-compete post-termination. Need more help? If the system suggests a non-compete in its letter of intent or PSA, view and download suggested language that you can counter with during your negotiation: bit.ly/ACG-PSA-Legal-Templates

When negotiating your letter of intent before entering into the PSA, don’t focus on compensation to the detriment of other important provisions. Be sure to keep in mind topics that could carry great intangible value: termination and term, confidentiality-versus-non-compete, and exclusivity. Doing so could help your group more strategically align its future course and help it survive well into the 2020s. Spend significant time outlining exactly what duties the group will provide, as there’s no better way to assure a group’s demise than to come under the scrutiny of a United States Attorney who things a hospital is paying a group a kickback for referrals. Careful counsel and detail-oriented executives for the group and hospital system should negotiate at arm’s length a PSA that reflects the true nature of services and protects what is important to each side.

By Ann M. Bittinger, Esq., a health care attorney with physician group clients across the country. Questions? Email ann@bittingerlaw.com

Getting it Right | 25


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// GETTING IT RIGHT: SAGE ADVICE

FOUR TAKE-AWAYS on PHYSICIAN

BURNOUT

By Christina M. Surawicz, MD, MACG

WE DIDN’T TALK ABOUT BURNOUT WHEN I WAS IN MEDICAL TRAINING, or

afterwards at work—we didn’t even recognize it, as we lived in a culture of endurance. So when I was preparing to give the 2013 Berk Lecture on this topic at the invitation of Ron Vender, then ACG President, I recognized that I had survived burnout, as a junior faculty at a busy county hospital—when I felt I had no control at work. Anyone in medicine reading this now has heard about the epidemic of burnout: how it is increasing and is a huge risk for our profession. Fortunately, the new generation of physicians aren’t accepting the old culture of medicine and want it to be better. Let’s not criticize them if they want to improve worklife integration and have better boundaries in their professional lives.

Here are my 4 take-aways: 1. It’s not our fault. 80% of burnout is due to systems factors, like the EHR (maybe the biggest one), increasing regulations (MOC, are you listening ABIM?), and more administrative demands for us to do things that others may be able to do (CPOE? Meaningful use?) It’s estimated that you spend a quarter of your time in patient-related tasks, in addition to your time with patients. Fixing these dysfunctional systems will take a coordinated effort; the health care systems, government agencies, our professional societies, and physicians must all be at the table and work together for change. In the meantime, what else can we do?

2. Don’t forget to look at the big picture. When you look back on your career, what do you wish to have accomplished? When I was a junior faculty with children at home and a husband busy with his internal medicine practice, I did an exercise called “write your own obituary.” It sounds morbid but was helpful for me to feel less guilty about working and whether I had the right balance between work and family and everything else—I never felt the balance was right, but decided that this was normal, since balance was not achievable. At any rate, consider doing this, and I can guarantee that you won’t be putting meeting your RVU targets into your obituary.

3. Peer support is essential—have the right colleagues. Peer support is so important. Especially when things go wrong, as they will since we are human and mistakes are inevitable. I still carry the memory of my mistakes with me and forgiving myself was harder than forgiving my peers when they had made mistakes or had bad outcomes. We need to support each other, in ways that those who don’t walk in our shoes cannot do. 4. My best advice. Finally, I have gotten feedback that the best advice I have given recently is to take a day off after you travel, either for work or vacation. DR. SURAWICZ was ACG’s first woman President (1998– 1999). Starting in 1981, she served as Director of the GI Department at the University of Washington and Director of GI Endoscopy at Harborview Medical Center, and from 1993 to 2013 was Chief of Gastroenterology and Hepatology. In 2002, she was appointed to the newly created Assistant Dean for Faculty Development at the University of Washington School of Medicine, a position responsible for job skills and teaching, research, and clinical requirements, as well as career growth. She retired in 2019 from a career where she was widely recognized as a clinician, researcher, educator, and administrator, and as a role model and mentor for medical students, residents, and faculty.

“We need to support each other, in ways that those who don’t walk in our shoes cannot do.” Getting it Right | 27


Beyond City // COVER STORY

GI Practic Rural A


Limits:

ce in America

t

The theme for this issue, Beyond City Limits: GI Practice in Rural America emerged from two submissions to ACG MAGAZINE from College members whose experiences as GI physicians in rural locations have left an important imprint on their professional lives and their personal perspectives. ACG’s Past President Dr. Chesley Hines, a vivid and descriptive writer, shares his first-person account of his experiences as locum tenens after Hurricane Katrina swept away his well-established private practice in New Orleans and his plans for retirement. The aftermath of a devastating turn in his professional life led him to many satisfying opportunities to be of service as locum tenens in a number of rural communities. Through his assignments, he developed an acute appreciation for our country’s beauty and history. Through his experiences, Dr. Hines says he was reminded of “the lesson that I had learned while serving in Vietnam as a young physician, namely that difficult situations can often lead to enriching experiences.” For Dr. Justin Kupec, working with patients and training young gastroenterologists in West Virginia has been a profound experience and a source of pride to serve the state where he was raised and educated. In his personal reflection for ACG MAGAZINE, Dr. Kupec captures the vital role played by West Virginia University’s H.W. Ruby Memorial Hospital in his state and his sense of purpose there. Through his photographs which accompany the text, he also conveys the rugged beauty of West Virginia and its impact on his quality of life. Also dovetailing with the theme of this issue is a profile of Dr. Son Nguyen and his work with Vietnamese patients from rural Louisiana to screen and treat for Hepatitis B in a community clinic he established while a GI fellow-in-training at Tulane. One of his mentors, Dr. Jordan B. Karlitz, chairs ACG’s Digital Communications and Publications Committee and recommended this inspiring story for ACG MAGAZINE. Brian C. Davis interviewed Dr. Nguyen and made a significant contribution to this profile. Cover Story | 29


// COVER STORY

LOCUM TENENS: THE ONE WHO REPLACES ANOTHER By Chesley Hines, Jr., MD, MACG

“Sweet are the uses of adversity... And this our life… Finds tongues in trees, books in the running brooks, Sermons in stones, and good in everything.” —As You Like It, William Shakespeare

Standing on a slightly elevated bed of gravel in the middle of the headwaters of the Kennebec River—just below its origin at Moosehead Lake in northern Maine—in light snow with the temperature somewhere below freezing, I cast my fly into the moving water, where the ripples formed a line. With almost every cast, a landlocked salmon would take the fly. The fish were not big, averaging only 10 to 12 inches in length, but they were hungry and fought vigorously. From time to time, the guide would stop me long enough to knock off the ice that had gathered at the tip of the rod. We had waded from the opposite side of the river where I was casting. The water came up to the waist of our waders and was so rapid that we had to hold each other by the sleeves of our jackets to keep from falling into the icy water. As long as we remained on the gravel bed, the water reached only to the level of our knees. Never in my dreams did I think that I would ever be able to fish for landlocked salmon while on assignment as a locum tenens gastroenterologist at the main hospital in northern Maine, the Eastern Maine Medical Center. For various reasons, the hospital had recently lost all but one of its gastroenterologists, and he was only part-time. I had been recruited via one of many companies that recruit physicians for hospitals and clinics at times of sudden need, such as death, illness, or retirement of a physician. 30 | GI.ORG/ACGMAGAZINE

Hurricane Katrina, which struck New Orleans on the last day of August and the first few days of September of 2005, had destroyed my office, hospital, and brand-new endoscopy center, creating havoc for my practice. After several futile attempts to resurrect my practice, because of the widespread destruction, I decided to try locum tenens at the ripe old age of 69. I had considered this possibility while living in exile in Houston after Hurricane Katrina, when the mayor forbade citizens to return to New Orleans for two months. Hurricane Katrina had done such damage to my income that I felt the need to continue to work. I still enjoyed practicing medicine, felt young, and assumed that I would probably live a long time and might run out of money if I did not continue to work. In addition, Hurricane Katrina had destroyed the beautiful 150-yearold cottage in the historic community of Pass Christian, Mississippi, 60 miles east of New Orleans, where we had planned to retire. My duties as a temporary gastroenterologist were basically the same as that of a permanent one, namely doing upper gastrointestinal endoscopy and colonoscopy, and seeing patients in consultation in the hospital, with a few in the office. Each location used a different computer system, so each new location was a new learning experience. On most nights, I was on call for the emergency room, hospital patients, and phone calls. This assignment in Bangor, Maine was my third. My first was a 10-day assignment in Marquette, Michigan, the only city of any size in the Upper Peninsula of Michigan, called “UP.” The town of Marquette is perched on the side of a tall hill, with streets at a 25-degree angle in the main part of town. The client had arranged for my wife and me to stay in the penthouse suite in the


old Landmark Hotel, which had recently been renovated. The view from our room encompassed Lake Superior, the harbor and lighthouse, and the town. Two or three excellent restaurants were located just down the hill from the hotel, which contained an excellent bar and beautiful dining room. The hospital, Marquette General, was only a short trip from the hotel, passing near the university. Before beginning my assignment, we had taken a cruise out to Pictured Rocks National Monument, along the shore of Lake Superior. I had always wanted to catch a steelhead trout and thought that working in Michigan gave me a grand opportunity, which, indeed, it did. My first encounter with a steelhead occurred late on my first afternoon, after arriving at noon. The fish took my fly and began to run downriver. All that I could do was watch the line roll off my reel. Finally, before losing all my line, the fish went around a branch of a fallen tree and snapped the line. Early the next morning, the guide and I waded across the river to a special pool known to the guide. There, I hooked and landed two large steelheads, which were photographed and released. After my assignment in Marquette, I spent one month at a large hospital in Jackson, Michigan. The hospital took care of the prisoners at a large Michigan state prison, where I regularly had to remove swallowed objects from their stomachs, such as batteries and razor blades. The countryside between Jackson and Ann Arbor was beautiful, with numerous shallow ponds, marshes, and vineyards. My assignment in Bangor began in mid-September of 2009 and lasted until March of 2010. During the period between Marquette and the beginning of this assignment, much time was spent securing a temporary Maine medical license and going through the credentialing process at the Eastern Maine Medical Center. There was a young gastroenterologist who had just finished his training working there as a locum tenens. His father was a practicing accountant who had told him about the SEP-IRA, which permits locums tenens, who are considered consultants by the IRS, to participate. Additionally, two other gastroenterologists worked there irregularly as locums.

“My experience as a locum tenens physician reminded me of the lesson that I had learned while serving in Vietnam as a young physician, namely that difficult situations can often lead to enriching experiences. The trauma of Hurricane Katrina held such a blessing as well. Despite the loneliness from being away from home, and the trials and tribulations of travel, being a locum tenens physician provided the opportunity to see parts of the country that I had never seen, and to meet and work with some wonderful people.”

During the first five days of my assignment in Bangor, I heard constant conversations about hiking, mountain climbing, and fly fishing. Therefore, on my first free weekend there I determined that I would find out what all the fuss was about. That Saturday, I drove north for 60 miles to Baxter State Park and climbed Sentinel Mountain, which looks across the headwaters of the Penobscot River at Mount Katahdin, the 5,000-foot northern terminus of the Appalachian Trail. I had never climbed up such a mountain; what’s more, I had never climbed down such a mountain. Despite traumatized knees, I was able to make my first fly fishing trip the next day, which was one of many. Fall and winter are beautiful in Maine. During the magnificent fall leaf season, I took off a week to tour Maine with my wife, much of it almost wilderness except for privately-held wild blueberry patches clearly marked with no trespassing signs, from the border with New Brunswick to Portland, and from the ski resort at Sugarloaf Mountain to the Acadia National Park at Bar Harbor, and exquisite little towns such as Camden and Casteine, established by Samuel de Champlain. In the winter, the snow would be so heavy at times that the manager of the hotel where I stayed would have the maintenance crew cut a trench in the deep snow and reserve it for me, to allow me to come and go from the hospital with ease. Because the snow and ice were very confining at night, I found the time to finish a novel I had been working on for four years. The assignment in Bangor ended in March of 2010. At that time, I began an assignment in Sioux Falls, South Dakota, followed by two brief assignments in Kinston and Goldsboro, two small towns in North Carolina. The assignment in Sioux Falls was unique because most of the population was Native American Sioux, and the remainder of the population was Dutch in ancestry, for the most part. It was located not far from important parts of the route of the Lewis and Clark Expedition up the Missouri River.

Cover Story | 31


// COVER STORY

Subsequent assignments over the next two years, usually three to six months long, were at the Salem VA, next door to Roanoke, Virginia; twice in Southhaven, Mississippi near Memphis; Wausau, Wisconsin; La Crosse, Wisconsin; and Temple, Texas. Living in Roanoke, at the southern end of the Shenandoah Valley was particularly enjoyable. The entrance/ exit to the Skyline Drive along the crest of the Appalachian Mountains made the area beautiful, especially during the fall color change. My last assignment was in the beautiful, historic town of New Bern, North Carolina. Prior to that, my two favorite assignments were in Bennington, Vermont and Petoskey, Michigan. The assignment in Bennington lasted for a year and a half, and the one in Petoskey for over three years. Petoskey, Michigan is beautiful. Situated at the apex of Little Traverse Bay, near the upper end of Lake Michigan, it is surrounded by low mountains and numerous lakes and rivers. For well over a century, it has been a vacation site for wealthy people of the Midwest, including the family of Ernest Hemingway. The hospital is the significant referral hospital for most of the northern part of the lower peninsula of Michigan. Snow skiing, water sports, hiking and bicycling along a paved path along the bay, golfing, and fishing provide outdoor entertainment throughout the year. The fall colors are equally as beautiful as those in Maine and Vermont. Plus, the spring flowers are amazing, especially the Edelweiss and the blossoms on the cherry and apple trees. These color changes make hiking and bicycling especially pleasurable. My experience as a locum tenens physician reminded me of the lesson that I had learned while serving in Vietnam as a young physician, namely that difficult situations can often lead to enriching experiences. The trauma of Hurricane Katrina held such a blessing as well. Despite the loneliness from being away from home, and the trials and tribulations of travel, being a locum tenens physician provided the opportunity to see parts of the country that I had never seen, and to meet and work with some wonderful people. Although I had traveled to all seven continents, I had not been to many of the beautiful, exciting places in the United States. 32 | GI.ORG/ACGMAGAZINE

“There is one special activity in the Petoskey, MI area that is uniquely popular—searching for “Petoskey stones,” the fossils of corals who lived 350 million years ago. I became obsessed with looking for these stones along the shore of the bay. They were then polished by an old Marine veteran of Vietnam, who made a living by doing this. Now, I have a huge collection of these beautiful stones.” 

ABOUT DR. HINES

Dr. Hines served as President of the ACG from 1988 to 1989. Prior to that, he had served as Chairman of the Education Committee, Secretary for three years, President-Elect, and then President and Past President. During his tenure as ACG President, the Board of Governors was reorganized so that every state and Canadian province was represented, the regional meetings of the ACG were established, and the title of Master of the ACG (MACG) was created. He is the author of numerous scientific papers as well as a novel, Sixty-Four Degrees, based on his adventures while canoeing the Yukon River with his son, and during a voyage on a working vessel between Chile and a research station in Antarctica.


ON A MISSION TO SCREEN FOR HEPATITIS B Dr. Son Nguyen described for ACG MAGAZINE how during GI fellowship he built a Hepatitis B screening program for the Vietnamese community in southeastern Louisiana that screened more than 2,500 patients.

Son Nguyen, MD, was a firstyear fellow in 2010 rotating

in a transplant unit at Tulane University in New Orleans when a Vietnamese woman in her 50s was transferred from Baton Rouge, LA—approximately an hour and a half away—to Tulane for liver failure. Why? She spoke no English, Dr. Nguyen says. “Luckily for me, and them, I speak fluent Vietnamese,” says Nguyen, who was born in Vietnam before moving to Pensacola, FL at age five. The two communicated. Tests were run, and it was determined the woman had chronic hepatitis B in addition to liver cancer, leading to decompensated liver failure. “She was sick,” Dr. Nguyen explains in an interview with ACG MAGAZINE. The woman had a MELD score of 30, within hours of her arrival required intubation, and, while she needed a liver transplant, it was too late. “She was too far gone,” Dr. Nguyen recalls. He informed the woman’s 21-year-old daughter that her mother was dying from liver failure secondary to undiagnosed Hepatitis B, and now she had liver cancer. When the daughter asked what they would do to treat her mother, Dr. Nguyen explained that there was nothing that could be done. After the conversation, Dr. Nguyen went into the stairwell and cried.

"[HBV is] kind of a silent killer. These communities don't know they have it until it's too late.” —Dr. Nguyen

“It just took everything out of me,” he said. “That was when it really hit me pretty hard.” Within a few days, the woman died. Dr. Nguyen thought about the many Vietnamese-speaking patients he had been called in to see thanks to his fluency with the language. He would often see elevated liver enzymes, jaundice, and Hepatitis B in these patients. “That’s when it just clicked,” Dr. Nguyen says. He knew there was something to this. “I guess when people get down that low, it’s how they rise,” Dr. Nguyen said. “That was when I went on a mission.”

ON A MISSION

Dr. Nguyen began researching and was wowed by Hepatitis B’s prevalence in the foreignborn community and, in particular, Vietnamese immigrants. There are an estimated 28,000 Vietnamese residents in the southeast Louisiana area, Dr. Nguyen says, many of whom do not speak English and go to the emergency room for care. Many assume Hepatitis B is most often transmitted through sexual activity and sharing of needles.

"That's hardly the case," says Dr. Nguyen. His experience is that there is a lack of screening and vaccination in the community, and most who contract Hepatitis B do so through vertical transmission. "It's kind of a silent killer. These communities don't know they have it until it's too late," Dr. Nguyen says. At this point the wheels started turning in his mind. Word spread that Dr. Nguyen was doing this research, and he began talking with Gilead representative Chantelle Jabbia. Ms. Jabbia gave him the opportunity to join a speakers program, where he was trained to be a speaker and began traveling to talk to primary care physicians. Dr. Nguyen used the skills he learned through the program to go directly to the Vietnamese community to tell that they have higher rates of Hepatitis B and that it’s silent—they may have it and not know about it. Audience members were surprised and maybe unconvinced at times. “You see these are the things people don’t know they have until it’s too late,” Dr. Nguyen would caution. For around one year from 2011 to 2012, Dr. Nguyen gave these talks to “anyone

Cover Story | 33


who would listen” at existing Vietnamese community events, typically gatherings of 30 to 40 people. “There’s something missing in this whole formula. We could educate people, but there’s no real screening” if their primary care physician did not screen them, he said. “How am I really helping these people?” if they don’t get screened, Dr. Nguyen thought.

COMMUNITY SCREENING & ACCESS TO CARE

During his GI fellowship, Dr. Nguyen wrote two grant requests and received support from Gilead and Vertex Pharmaceuticals. The money went toward covering screening tests. He contracted with local labs to have their services covered at cost. Just like that, they began screening community members. As the test results came in, Dr. Nguyen was “blown away” at the Hepatitis B rates. “How are we going to help these people? It’s great they know about [Hepatitis B]. It’s great now they know they have it.” Yet, Dr. Nguyen explains “We have done them no good until we provide them some sort of linkage to care.” To address this issue of treatment, Dr. Nguyen created and ran an indigent clinic in New Orleans east each Saturday for several years. He had approached a Federally Qualified Health Center (FQHC), told them he would like to run a free clinic for Hepatitis B, and said he only needed one nurse—and that he would take care of the rest. A social worker helped patients apply for Medicaid or Medicare; surprisingly to Nguyen, some patients had insurance. “For people who qualified for treatment, we got them treatment,” whether funded through government programs or their own insurance, said Dr. Nguyen. For those who didn’t have coverage, Dr.

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Nguyen and the team worked to get them patient assistance. “This concept of education, screening, and access to care—that was my motto…that is the formula to how to truly help these people, but it came to me one at a time.” “I did all of that as a fellow, but not by myself by any means,” said Nguyen, who explained that it was somewhat of a one-person show during the speaking stage at the beginning, but Dr. Nguyen brought in local medical students through two local chapters of Asian Pacific American Medical Student Association (APAMSA) to help. The program grew thanks to community outreach and word of mouth. A local Vietnamese language newspaper donated a free advertisement for the screening program and Dr. Nguyen was interviewed on a Vietnamese radio station, speaking in language and taking calls to answer questions. At one point, 30 to 40 volunteers would assist with screening between 200 and 300 people at community screening events. “We had a show on the road,” Dr. Nguyen remembers. Everyone covered their own lunch and their own gas. “No one was paid for their time, all we got was a sense of doing something for your community,” Dr. Nguyen said. Ultimately, over the course of his involvement with screening

for Hepatitis B in the Vietnamese community, Dr. Nguyen and his team screened about 2,500 people over a dozen or so events. Around 18% of patients were positive for Hepatitis B, which “blew me out of the water,” Dr. Nguyen said. He continued to run the clinic each Saturday two to three years after he finished his GI fellowship and went into private practice ending his active involvement in 2016 since he was now living more than 130 miles away from New Orleans in New Iberia, LA. By this time, he and his wife had three kids (they now have five), which made the weekly trips to the clinic all the more challenging. He would rise early on Saturday mornings, drive two hours and 45 minutes, spend the day at the clinic, drive the same distance home on Saturday nights, and be back at work at his increasingly busy practice on Monday. Ultimately, Dr. Nguyen transitioned away from his work at the clinic took a different approach. He worked to train local Vietnamese primary care colleagues, educating them about Hep B, and encouraging them to take over following the clinic patients. Looking back on the intensity of this experience during and immediately after his fellowship, Dr. Nguyen recalled that “having the right people with same vision was fun and rewarding.”

Dr. Nguyen and his volunteer team at a educational event in tee-shirts created as “walking billboards” for Hepatitis B screening in the Vietnamese community in Louisiana.

// COVER STORY


PRIDE OF PLACE: A GASTROENTEROLOGIST IN WEST VIRGINIA By Justin T. Kupec, MD, FACG; West Virginia University Medicine, Morgantown, WV

Pride. It is the first thing you learn as a Mountaineer.

Pride in who you are, pride in where you come from, pride in the quality of work that you do. Some of us lucky ones are born into Mountaineer Nation. Some become part of the Mountaineer family when they choose to provide world class medical care at West Virginia University Medicine. As the flagship institution in West Virginia, a state with unrivaled natural beauty in the heart of Appalachia, WVU Medicine’s H.W. Ruby Memorial Hospital consists of nearly 700 beds, soon to be expanding with the addition of WVU Medicine Children’s Hospital. Hundreds of physicians and thousands of healthcare providers deliver tertiary and quaternary care to the region that encompasses the entire state of West Virginia, southwestern Pennsylvania, western Maryland, and eastern Ohio. With the sprawling mountains, winding country roads, and four distinct seasons that define West Virginia’s natural beauty, access to this care has historically been less than easy to obtain. Over the past five years, WVU Medicine has become a “spokeand-hub” organization with significant growth in infrastructure and collaboration with dozens of smaller hospitals throughout the state, thus streamlining patient transfers and expediting treatment. With the backing of WVU Medicine, it has become more straightforward to support the mission of providing care to West Virginians. Growth in the health system has led to growth in opportunities within the section of Digestive Diseases. More referring providers and facilities mean a substantial increase in requests for outpatient procedures, screening and diagnostic, as well as inpatient consults on patients transferred specifically for specialized care. Working with administration, patients in need of access to an advanced procedure (for example, ERCP for biliary obstruction or biliary leak) are transferred as a priority, often having their procedure within hours of arrival. Thousands of endoscopic procedures—many of them advanced—are performed each year at the main campus, and with the addition of two new state-ofthe-art endoscopy rooms, we are able to efficiently schedule EGD, colonoscopy, capsule endoscopy, RFA, ERCP, EDGE, EUS, EMR, ESD, and more.

“With the sprawling mountains, winding country roads, and four distinct seasons that define West Virginia’s natural beauty, access to [health] care has historically been less than easy to obtain.” Cover Story | 35


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“It is humbling to know that a patient has driven three or four, or more, hours, from a corner of West Virginia, to seek your advice or to have a procedure.”

driven three or four, or more, hours, from a corner of West Virginia, to seek your advice or to have a procedure. Expanding our section will allow us to bolster our statewide presence by adding satellite clinics, offering care to patients closer to where they call home, and continuing to strengthen the mission of WVU. A state hit hard by the opioid crisis and high rates of hepatitis C, the institution has partnered with physicians on the front lines in an attempt to screen, diagnose, and treat patients. The WVU emergency department has pioneered point-ofcare testing (for HCV) for patients as they arrive for care. Once diagnosed, patients are directly referred for treatment evaluation, thus bypassing unnecessary steps that can complicate access. This process has been replicated throughout the health system and, combined with telemedicine, significant strides have been made in the distribution of resources.

PRIORITIZING KNOWLEDGE AND COMPASSION

A focus on the education of both patients and providers shows WVU Medicine’s commitment to sustaining wellness throughout the state. Pride

Photos courtesy of Dr. Kupec.

We are tirelessly providing aroundthe-clock care supported by a fellowship with unmatched clinical experiences and exposure. In addition to the cutting-edge advanced endoscopic procedures and care we offer, our constantly evolving inpatient consult services capably manage any and all pathology that is encountered. A full complement of dedicated endoscopy nurses, advance practice providers, and nurses make the difficult seem routine. Additional physician resources, such as thoracic surgery, surgical oncology, and interventional radiology, offer our patients procedures that are otherwise inaccessible throughout the state. A collaborative approach ensures that when patients come to see us, they are treated with the standard of care. Community presence throughout the state is an institutional goal, a goal that our section shares. Outreach clinics serve many purposes, not the least of which is prioritizing care for patients with insufficient resources to make it to Morgantown. The vast majority of West Virginia is rural, with a population density that is in the bottom quarter of the country. For many of the 1.8 million West Virginians, to be treated at WVUH requires significant planning, a potential overnight stay, and often a financial challenge. A state known for natural resources, jobs are no longer as plentiful as in decades past. For providers living close to the “hub” hospital, we often take it for granted that advanced care is nearby and accessible. It is humbling to know that a patient has


can often be a barrier for our patients to receive care. Patients without a medical background may feel fear or worry about seeming ignorant when they seek medical advice. Often this can delay treatment, if they venture from their comfort zone at all. Outreach programs and community events are meaningful, yet individualized patient education involves everyone from the fellows to the nurses, nurse practitioners, and physicians. Training our fellows to be outstanding clinicians while emphasizing research, education, and compassion are longstanding goals of the gastroenterology fellowship at WVU. Clinically, fellows are exposed to a myriad of pathologies during their training, both common and complex disease processes alike. Upon completion of their training, having been exposed to these conditions and understanding the geographical challenges to providing care in West Virginia, our fellows are uniquely qualified to practice gastroenterology in our traditionally underserved state,

“Serving the state in which I was raised and educated has given me more pride than I could have ever imagined.”

and have an advantage if they choose to practice anywhere. This type of integrated education creates empathetic physicians who understand the complexity of caring for patients. Providing medical care to proud, truly appreciative West Virginians is rewarding beyond description. Serving the state in which I was raised and educated has given me more pride than I could have ever imagined. Besides, where else can you find a career that is as demanding and challenging as it is satisfying, set amongst the backdrop of mountains, streams, wildlife, rhododendrons, country roads, and the beauty that is West Virginia?

ABOUT DR. KUPEC

Dr. Kupec is an Assistant Professor of Medicine at J.W. Ruby Memorial Hospital of the West Virginia University School of Medicine.

Cover Story | 37


OVER 10 MILLION CASES AND GROWING GIQulC Reaches New Milestone for colonoscopy cases and approaches 2 million EGD cases.

GIQulC, the leader in GI registries, continues to experience unprecedented growth with 700 facilities representing 4,700 racticing endoscopists using the platform. With nearly 10 million colonoscopy procedures now part of the registry, the GIQulC success story continues.

MIPS—avoid the negative, achieve the positive The GIQuIC Registry is an approved Qualified Clinical Data Registry (QCDR) for reporting to the Merit-based Incentive Payment System (MIPS). GIQuIC’s QCDR status allows providers to report on measures that are meaningful to their specialty practice and foster improvement in the quality of care provided to patients, while facilitating compliance with public reporting requirements. The GIQuIC QCDR supports reporting to the Quality, Promoting Interoperability, and Improvement Activities performance categories, so that providers can, at minimum, avoid the negative payment adjustment and have the potential to earn a positive payment adjustment.

For more information on the Medicare Quality Payment Program, visit: • CMS’ Quality Payment Program website: qpp.cms.gov • The American College of Gastroenterology’s National Affairs webpage: gi.org/national-affairs • The American Society for Gastrointestinal Endoscopy MACRA Implementation Resource Center: asge.org/macra • The GI Quality Improvement Consortium website: giquic.gi.org

The GIQulC 2020 QCDR and FIGmd MIPS Dashboard One of the many strengths and innovations GIQuIC and its registry vendor, FIGmd, bring is an interactive dashboard to help registry users navigate Medicare’s MIPS requirements. The GIQuIC 2019 QCDR supports reporting to these categories: Quality, Promoting Interoperability, and Improvement Activities. This could allow providers to avoid the negative payment adjustment, with the potential to earn a positive payment adjustment.

About FIGmd FIGmd, Inc. is an experienced industry leader in the development of clinical data registries, and provides analytics and data reporting solutions to medical practices, specialty societies, medical professional associations, hospitals, and health systems, and is the trusted partner of a number of specialty societies, including organizations that serve cardiology, ophthalmology, urology and neurology. FIGmd’s technologies, solutions and customization capabilities allow organizations to massively scale their projects in a timely and cost-effective manner. For more information on how FIGmd’s solutions can result in productive and actionable data, visit www.figmd.com

Learn more: GIQuIC.org Contact us: info@giquic.org

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GIQuIC is a joint initiative of ACG and ASGE.


GUATEMALA ENDOSCOPY INITIATIVE:

Hospitalito Atitlán, Santiago, Sololá Region, Guatemala By Bryan G. Sauer, MD, MSc, FACG

IN FEBRUARY 2019, I was part of a group of gastroenterologists, endoscopy nurses, and a nurse anesthetist who traveled to Santiago Atitlán, Sololá, Guatemala to the Hospitalito Atitlán to provide endoscopy care. The trip was the culmination of work and planning that started several years in advance. My wife is from El Salvador and I speak Spanish and I had been looking for an opportunity to serve others in Central America. I meet Dr. Michael Dougherty when he applied for GI fellowship at UVA and he shared about his experience as an internist at the Hospitalito Atitlán in 2015-2016 as part of Penn’s Global Health Program, so that helped move things along. I visited in April 2016 to evaluate the facilities and to connect with local physicians to understand the endoscopy needs in the region and began fundraising and seeking donations of endoscopic equipment. 

ACG Perspectives | 39


// ACG PERSPECTIVES

ADDRESSING AN UNMET NEED Endoscopy in the Sololá region of Guatemala is limited. Most patients are referred to Guatemala City for endoscopy services. For most individuals in the region, a day-long travel to Guatemala City for an expensive procedure is not feasible and many forgo endoscopic evaluation. In 2016, an endoscopy needs assessment was conducted in the Sololá, Totonicapán, and Quetzaltenango regions of Guatemala and concluded that there was a significant need for endoscopy services. In 2017, I partnered with Americares and Olympus to provide endoscopy equipment to be stationed at Hospitalito Atitlán to allow endoscopy services to be provided in the Sololá region. In 2018, I set up the equipment at Hospitalito Atitlán. Then in February 2019, the first clinical care team performed a week of endoscopies with the help of Dr. Dougherty (a fourth year fellow at UVA), Dr. Nicolas J. Nickl, MD, (retired from the University of Kentucky), nurses Farren Dodson, Terri Rodee, and Sarah Schumacher, as well as nurse anesthetist Dixie Mills. During four days in February, forty-three endoscopic procedures were performed including upper endoscopies and colonoscopies. The team was able to diagnose conditions including H. pylori-associated gastritis, erosive esophagitis, gastric ulcers, gastric cancers, colon polyps. One older gentleman was seen in the outpatient clinic on Tuesday with issues of chronic vomiting and weight loss. He underwent upper endoscopy on Thursday and was diagnosed with a cancer of the stomach causing gastric outlet obstruction. He will be referred for further cancer treatment. The family expressed their gratitude for the excellent and efficient care that was provided at the Hospitalito Atitlán, particularly made possible by the presence of endoscopy services. Patients were universally thankful for the medical care they received and appreciative of the endoscopy care team.

MAKING AN IMPACT When asked about the impact of the trip, Lyn Dickey, Director of Development at the Hospitalito Atitlán responded, “It is difficult to do justice in expressing the tremendous impact that the equipment and services provided by Dr. Sauer and his team had for the community of Santiago Atitlán. We live in a place where previously there had been virtually no access to endoscopy and colonoscopy services, leaving many gastrointestinal illnesses and problems undiagnosed and unsolvable.” She added, “Dr. Sauer and his team worked with great organization, kindness and professionalism, and our patients were overwhelmingly grateful

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“It is difficult to do justice in expressing the tremendous impact that the equipment and services provided by Dr. Sauer and his team had for the community of Santiago Atitlán.”

for the services they received. On behalf of the people of Santiago Atitlán and its surrounding communities, we thank them immensely for their work and hope to continue working together in providing more of these procedures in the future here in Atitlán.”

PLANS FOR THE FUTURE With endoscopy equipment now available at the Hospitalito Atitlán, clinical endoscopy team trips are being planned several times per year. Furthermore, foundations have begun to understand the patient population and disease entities encountered through research projects so that care and services can be best tailored to the population. Finally, training of local staff and physicians will continue to be a priority so that the endoscopy services can be used year-round to enable access to care at all times.

­—Lyn Dickey (1) First Endoscopic Procedure, February 25, 2019 (used with permission); (2) Guatemala Medical Team L to R: Bryan G. Sauer, MD, MSc, FACG; Sarah Schumacher, RN; Terri Rodee, RN; Farren Dodson, RN; Michael Dougherty, MD; Dixie Mills, CRNA, and Nicholas J. Nickl, MD; (3) Guatemala Endoscopy Team and Hospitalito Atitlán Staff; (3) Hospitalito Atitlán.


FUNDING: A STRUGGLE One struggle that I have had is finding ways to fund the medical trips. For our first trip, the nurses/ CRNA agreed to pay their own way for the trip (and take vacation time, etc.) We were able though to raise a fair amount of support with a GoFundMe page to at least pay for the flights, although this is not feasible for more trips. So, my next venture will be to find grants/ donations that will help fund the medical team trips to at least pay for the flights for each trip.

AN INVIGORATING AND REWARDING EXPERIENCE FOR THE GI TEAM Besides being able to provide much needed endoscopy to a region of Guatemala, the team members found the week invigorating. Farren Dodson, RN, commented, “The trip was rewarding personally and professionally. The Hospitalito Atitlán graciously welcomed us and provided an excellent facility to provide services. It was great to

be immersed in Guatemalan culture, provide needed endoscopy care, and collaborate with the Hospitalito nurses and staff.” The healthcare team left having gained insight into the greater health landscape in Latin America and learning valuable insights into Guatemalan culture. The week in Guatemala can be summed up with their adopted motto, “Work hard, serve others, and have fun.” The group did this in their week and look forward to a return.

 For more information, please feel free to email Dr. Bryan Sauer: bryansauer@virginia.edu

Bryan G. Sauer, MD, MSc, FACG Associate Professor of Medicine, Medical Director of Endoscopy; Division of Gastroenterology and Hepatology, University of Virginia Health System

ACG Perspectives | 41


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-lead clinical practices. Learn from practicing colleagues, through articles and podcasts on topics important to you. Articles include a topic overview, suggestions, examples, and a list of resources or references.

Explore the Podcast

Alignment but NOT Employment: Professional Service Agreements with a Hospital System Listen as Dr. Louis J. Wilson, Chair of ACG’s Practice Management Committee, goes deeper into the topic with authors Stephen T. Amann, MD, FACG, and James C. DiLorenzo, MD.

Listen Now: bit.ly/PMToolboxPodcastPSAs

"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 42 | GI.ORG/ACGMAGAZINE


EDUCATION

THE ACG EDGAR ACHKAR VISITING PROFESSORSHIP Providing Noteworthy Speakers for Training in Your Communities

Dr. Abreu at Mountain Vista Medical Center.

SINCE THE INCEPTION OF THE EDGAR ACHKAR VISITING PROFESSORSHIP PROGRAM (EAVP) in 2014, more than 60 institutions have been matched with GI leaders to provide unique educational experiences for GI fellows-in-training. The program supports GI programs by providing access to enriching presentations and discussions that foster a collegial learning environment. Past visiting professors also comment that the experience is rewarding and insightful for them, as it provides perspective from the future of GI. Here ACG MAGAZINE shares visits from David Hass, MD, FACG, to Cooper University Hospital; Ashwani K. Singal, MD, MS, FACG, to University of Iowa Hospitals & Clinics; and Maria T. Abreu, MD, to Mountain Vista Medical Center/Midwestern University.

Education | 43


// EDUCATION

“The Edgar Achkar Visiting Professorship Program gives smaller programs a chance to get a lot of personalized time with an expert in an area. That intimacy leads to lifelong relationships, which are priceless.” —Maria T. Abreu, MD

“The grand rounds was very well organized with over a dozen interesting questions from the audience…which is not only satisfying to me as a speaker, but also gave me new ideas for potential research and collaboration.” —Ashwani K. Singal, MD, MS, FACG

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2019

ACG EDGAR ACHKAR VISITING PROFESSORSHIPS EAMONN M. M. QUIGLEY, MD, MACG Mount Sinai Beth Israel, St. Luke and West FEBRUARY 26–27 AMY S. OXENTENKO, MD, FACG NYU School of Medicine APRIL 2 STEPHEN B. HANAUER, MD, FACG Lehigh Valley Health Network APRIL 3–4 DAVID T. RUBIN, MD, FACG Brown University MAY 8–9 BRIAN E. LACY, MD, PHD, FACG New York Presbyterian/Weill Cornell MAY 9 NICHOLAS J. SHAHEEN, MD, MPH, FACG Wayne State University/ Detroit Medical Center MAY 9–10

“Our fellows enjoyed learning from an expert in the field, as well as the interactive nature of the ACG Visiting Professorship. Dr. Hass graciously offered to serve as a resource for future challenging cases in small bowel disorders, a gesture that I know the fellows truly appreciate.”­­ —Tara Lautenslager, MD

WILLIAM D. CHEY, MD, FACG University of Colorado JUNE 6–7 DAVID J. HASS, MD, FACG Cooper University Hospital JUNE 13 DOUGLAS K. REX, MD, MACG Texas Tech University Health Sciences Center El Paso JUNE 14 ASHWANI K. SINGAL, MD, MS, FACG University of Iowa Hospitals & Clinics JULY 25 EDWARD V. LOFTUS JR., MD, FACG University of California, Davis SEPTEMBER 19 MARIA T. ABREU, MD Mountain Vista Medical Center/ Midwestern University NOVEMBER 12-13 LAURA E. RAFFALS, MD, MS, FACG Creighton University FEBRUARY 12, 2020

Education | 45


Journey of FIRST YEAR of

GI FELLOWSHIP

Is It the Cecum Yet?

By Shifa Umar, MD, Allegheny Health Network

in the power of PPI and MiraLAX® daily, and, your mantra will become: “patients avoid NSAIDs, you avoid NSAIDs, everyone AVOID NSAIDS!”

THE TRANSITION TO GI FELLOWSHIP FROM RESIDENCY

WELCOME TO THE FIRST YEAR OF FELLOWSHIP! You have finally made

it here. Congratulations, you are on your journey to becoming a Gastroenterologist. For some of you it may have been a lifelong goal, and for others of you it may have been a pursuit you started during your residency. It is exciting and thrilling, and you are going through mixed emotions. You are proud of what you have accomplished, and you are nervous about what lies ahead (“I have never scoped anyone!”) As you transition from a knowledgeable third-year resident (medicine attending) to a firstyear fellow, you will learn that this year may be daunting, but your

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three years of residency training have prepared you to be a good physician, triage patients, gather information and effectively provide care. Remember those skills and have confidence in your training – it will be the foundation of your fellowship training and future role as a consultant. In most fellowship programs, the first-year GI fellows are mostly assigned to the consult service. The most common consult will be “GI bleed.” The golden rule to evaluating a GI bleed is to “always have your finger, nose and jelly ready.” You will learn to know your patients with cirrhosis and obscure GI bleeders better than your family, following hemoglobins will become the bane of your existence, you will believe

The most challenging part of the transition from medicine to GI is holding yourself back from addressing those high blood sugars—while it is important to see the patient as a whole, it is also important to gather information that is more GI-centric (that is why the primary team consulted you.) A wise man once said, “don’t be so focused on the trees that you can’t see the forest.” As you take on your new role as a consultant, introduce yourself clearly to patients, as they see many faces in the hospital. When interacting with house staff, strike a collaborative tone, acknowledge their efforts in taking care of the patients, verbally communicate recommendations, and embrace your role as an educator. In return, they will


be thankful for your teaching and make your job easier. Become part of national societies, stay up-to-date on guidelines, and build up your GI knowledge by reviewing GI journals monthly.1

TIPS FOR ENDOSCOPIC TRAINING Along with being an effective consultant, you will be expected to acquire procedural skills. As you embark on exploring the landscape of the GI tract, a million thoughts may cross your mind: Your best friend got married, had her first baby, and you are still in the sigmoid colon…. your hand is too small…you are the first fellow of the century to drop the scope..…what is the attending thinking….is it the cecum yet? Remember, nobody in the room knows everything, and nobody expects you to know everything either. Everyone, including the procedure veterans, went through the same feeling when they started to learn endoscopy— “Experts are made, not born.”2 Be patient with yourself, practice, self-reflect, and do not be afraid to ask for help. A good textbook is definitely a good investment.3 Most centers have endoscopy simulator devices which you may have access to during residency—a good way to start practicing scope control. In the beginning of fellowship, many fellows are dismayed at having to observe rather than having their hands on the scope. This is inevitable. Take this opportunity to observe the endoscopist— their body positioning, hand maneuvering, communication with the technician – and if you are not performing the procedure, ask to perform the GI technician’s duties. Establish a rapport with the endoscopy nurses! Many of them have been working in the endoscopy suite longer than you have and are well-versed with the equipment. They can teach you tips and tricks to be more efficient. During your first year, as someone who has successfully navigated through residency and matched into GI fellowship, medical students and residents will be looking up to you for guidance. Embrace the opportunity to become a mentor. While it may take some extra effort and time, this role is gratifying and a great learning experience for you. Become the ‘middle author’ of every research project to encourage medical students and junior residents to take ownership as lead investigators, and acknowledge their efforts. Lastly, you have worked hard to get to your first year of GI fellowship and you deserve to be here. There will be days when you will “hit the

Photo pg 44: GI Fellows at Allegheny Health Network, Pittsburgh, PA, L to R: Pamela Kim, MD (PGY4); Thayer Nasereddin (PGY4); Shifa Umar, MD (PGY5); and Vincent M. Pronesti, MD (PGY4). Photo pg 45 Allegheny Health Network GI Training Program Associate Program Director, Dr. Suzanne K. Morrissey (left) with first year fellow Dr. Pamela Kim in the GI lab.

“Be patient with yourself, practice, self-reflect, and do not be afraid to ask for help.” —Dr. Umar 

cecum,” and days when you will be flailing. Enjoy it all—especially the camaraderie of fellowship and the security of having senior mentors to fall back on— because before you know it you will be venturing into the next stage of your GI career by yourself. Remember these words by Robert M. Pirsig: “Sometimes it’s a little better to travel than to arrive.”

RESOURCES & TOOLS: JOIN ACG, READ, LEARN • A subscription to The American Journal of Gastroenterology is free when you become an ACG Trainee member for annual dues of $25 during your fellowship. Trainee members are also eligible to attend the ACG postgraduate course for free. Learn more and apply online: gi.org/membership/join-acg • Explore more ACG offerings for GI Fellows-inTraining: gi.org/trainees

REFERENCES: 1. The American Journal of Gastroenterology www.amjgastro.com 2. K. Anders Ericsson (July-August 2007) The Making of an Expert. Retrieved from hbr.org/2007/07/the-making-of-an-expert 3. Adam Haycock, et al., Cotton and Williams' Practical Gastrointestinal Endoscopy: The Fundamentals, 7th Edition. New York, New York, Wiley, 2014.

Education | 47


SUBMIT YOUR APPLICATION for the ACG

2020 International GI Training Grant Awards The International Relations Committee of the American College of Gastroenterology is now accepting applications for the 2020 International GI Training Grants. Each training grant will award one fellowship, with a maximum of $10,000, during 2020. 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, 2020, and June 30, 2021.

2020

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.

2020

SUBMISSION DEADLINE: March 31, 2020 APPLY HERE: gi.org/gi-training-grants

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.

48 | GI.ORG/ACGMAGAZINE

SUBMISSION DEADLINE: March 31, 2020 APPLY HERE: gi.org/gi-training-grants


Inside the

JOURNALS

G

AC RTS EPO CASE RO J URN L

an of the Americ Official Journal enterology College of Gastro

Volume 114

| Number 7

G OM I.OR TS.C TS.G POR POR ERE ERE CAS CAS ACG ACG

| July 2019

The GUT E MICROBIOuM Iss e EDITORS: Brian

E. Lacy, MD, PhD,

VOLUME 6

n Spiegel, MD,

FACG and Brenna

MSHS, FACG

ed by orts edit e Rep ed by nal of CasRep orts edit ne Jour ows An Onli nal of Case atology Fell ne Jour ows An Onli ology & Hep atology Fell Gastroenter ology & Hep Gastroenter

ACG MAGAZINE invited Dr. Paul Tarnasky to provide insights about the College’s new Quality Indicators for Acute Pancreatitis Management published in The American Journal of Gastroenterology. Developed under his leadership by a multi-disciplinary physicianlead work group convened by the ACG Institute for Clinical Research and Education, the new validated quality indicators provide a dependable quantitative framework for health systems to monitor the quality of care provided to patients with known or suspected acute pancreatitis. Dr. David Whitcomb, Editor-in-Chief of Clinical and Translational Gastroenterology, has introduced a series of primers for this publication, including one he authored on “Precision Medicine for Complex Chronic Disorders.” Dr. Whitcomb elucidates the differences between the Western medicine paradigm and precision medicine which he characterizes as “a bottom-up approach that identifies predisease disorders using genetics, biomarkers, and modeling to prevent disease.” The Editorial Board of ACG Case Reports Journal, under the energetic leadership of Dr. Roberto Simons-Linares, is helping that publication evolve as a forum for interesting cases and an opportunity for fellows to gain editorial and publication experience. The ACGCRJ team have expanded the journal’s reach by launching a new podcast series, “Behind the Case” and by sharing notable cases and podcast conversations via social media.

 LISTEN: gi.org/acgcrpodcasts Inside the Journals | 49


// INSIDE THE JOURNALS

INSIDE THE JOURNALS [THE AMERICAN JOURNAL OF GASTROENTEROLOGY]

Author Insight: Defining and Tracking Quality for Acute Pancreatitis—Insights on New Quality Indicators Paul R. Tarnasky, MD, FACG, Digestive Health Associates of Texas, Dallas, TX. Dr. Tarnasky chaired the ACG Task Force on Quality Indicators in Acute Pancreatitis

 “QUALITY MEANS DOING IT RIGHT WHEN NO ONE IS LOOKING.” —Henry Ford

In a perfect world, the above quote is valid. When applied to the practice of medicine, however, there are two challenging issues. First, how do we define the “right” way to do it and second, someone is and should be looking. Recent progress has helped to address both in the setting of acute pancreatitis (AP) with its inherent complexity due to a variety of causes, variable course, and the potential for devastating outcomes. Defining and tracking quality is increasingly important for acute pancreatitis. The incidence of AP is rising and potential for severe AP and the burden of complications can be expected. The Institute of Medicine in 2006 declared, “the only way to know whether quality of care is improving is to measure performance.” Califf, RM et al. (2002) described integrating quality into a cycle; hypotheses from clinical observations lead to high-quality clinical research from which clinical practice guidelines are derived. Ultimately, quality indicators (QIs) and performance measures are developed to document outcomes and close the loop. Evidence-based metrics were needed in order to optimize outcomes and enable a way to rate the quality of AP care. Detailed recommendations and guidelines for AP diagnosis, treatment, and follow-up already existed, so the next step in the cycle was to develop QIs. Beginning in 2017, the American College of Gastroenterology and

50 | GI.ORG/ACGMAGAZINE

“The validated Acute Pancreatitis Quality Indicators developed by the ACG Task Force provide a dependable quantitative framework for health systems to monitor the quality of care. They also serve as the precursor for specified performance measures.”

ACG Institute for Clinical Research & Education convened the Acute Pancreatitis Task Force on Quality. This multidisciplinary expert panel included 21 gastroenterologists, hospitalists, and surgeons who are acknowledged leaders in their specialties and who represent geographic and practice setting diversity. A Delphi process, a modified version of the RAND/UCLA Appropriateness Methodology (RAM), was then utilized to develop validated QIs. This process included conducting a literature review and developing a list of proposed QIs. Then in three rounds, panelists reviewed literature, modified QIs, and rated them on the basis of scientific evidence, bias, interpretability, validity, necessity, and proposed performance targets. Ultimately, 40 QIs for AP were developed which were found to be both valid and necessary. These QIs were organized into ten domains, outlining the plan of care for a patient with typical AP, from diagnosis to disposition. These included Diagnosis, Etiology, Initial Assessment and Risk Stratification, Initial Management, etc. The AP QIs developed were related to: • Processes of care (e.g., fluid resuscitation should be titrated according to interval assessment of vital signs, urine output, BUN, and hematocrit during the first 48 hours)

• Efficiency (e.g., if a patient has AP with cholangitis, then they should undergo ERCP with appropriate endotherapy within 24 hours of diagnosis) • Appropriateness (e.g., the preferred choice of enteral feeding is a low-fat solid diet as tolerated) • Outcomes (e.g., if a patient is diagnosed with AP and has persistent organ failure [>48 hours], then the severity should be classified and documented as severe AP) • Structure of Care (e.g., the hospital should have EUS/ERCP services available, or a transfer agreement with a facility that has those capabilities) The ACG Task Force also suggested performance thresholds that reflect the rate at which panelists recommend providers or healthcare systems should fulfill the QIs in clinical practice. Indicators that recommended against a practice had a low suggested threshold (i.e., rate between 0 and 40%), suggesting that the practice should be avoided. For example, if a patient is diagnosed with AP, then prophylactic antibiotics should not be prescribed (performance threshold equals 10%). Additionally, quality of evidence and strength of recommendations were derived for each QI. The validated Acute Pancreatitis Quality Indicators developed by the ACG Task Force provide a dependable quantitative framework for health systems to monitor the quality of care. They also serve as the precursor for specified performance measures (with inclusion/exclusion criteria). There continues to be a shift in payment models from traditional feefor-service to pay-for-performance and value-based healthcare models. Ultimately, AP outcomes may be mapped to treatment costs and the resources used, enabling value-based healthcare models to track quality of care provided and aid in identifying opportunities for reduction of cost and resources.

 READ the article: bit.ly/ACG-Acute-Pancreatitis-QI


[ACG CASE REPORTS JOURNAL]

Introducing Behind the Case: An ACG Case Reports Journal Podcast By C. Roberto Simons-Linares, MD, MSc; Gastroenterology and Hepatology Department, Digestive Diseases Institute, Cleveland Clinic Foundation; Cleveland, OH; Editor-in-Chief & Podcaster, ACG Case Reports Journal

TODAY’S SOCIETY IS MORE MOBILE THAN EVER, and we expect to access a world of information wherever we are.1 Podcasts are audio-media files that can be accessed on-demand via the internet and played on any hand-held devices or computer at any time and in any place.2 Multiple medical journals have begun creating their own podcasts, many of which are successful and sustainable. Medical journal podcasts can reach different audiences who may not be able to read the journal every month, and an interview-based podcast can attract the peer group or following of the interviewee as well.3,4 Behind the Case: An ACG Case Reports Journal Podcast was created to expand the reach and impact of the journal, and to give our trainee editors and trainee interviewees an opportunity to develop their podcasting and interview skills. Moreover, we hope that the podcast will increase the journal’s value to its readers because it provides another platform for learning interesting cases. Podcasts are an important communication and education platform that continues to grow. For example, Apple Podcasts had 2 billion reproductions in 2005, a number that increased tremendously to 50 billion in 2018. There are over 750,000 podcast series, comprising more than 30 million episodes. There is no surprise that over 50% of the U.S. population has listened to at least one podcast. Interestingly, 50% of listening is done at home, 25% is done while driving a car, and 70% of podcast listening is done from a smartphone. In medical education, podcasts are effective in promoting learning and retention of the listeners.

There is scientific evidence on this effectiveness; for example, a randomized controlled trial found that medical students in groups listening to podcasts earned higher scores on their tests compared with a control group who just used a traditional textbook.5 Episodes of Behind the Case will feature interviews with authors of noteworthy cases published in ACG Case Reports Journal, who will discuss in-depth details of the case. We hope to stimulate you to read the article, and we will do our best to cover interesting teaching points during our conversations. We are confident that our podcast will not only teach you something new about a case or topic but will also entertain you! We hope you enjoy the Behind the Case podcast, and we welcome you to tune in, learn, and be entertained, all while supporting GI trainees.

Featured Case: Esophageal Leukoplakia

 READ: bit.ly/Case-Esophageal-Leukoplakia

Patricia V. Hernandez, MD; Diana Snyder, MD; Allon Kahn, MD; Kenneth K. Wang, MD, FACG; David A. Katzka, MD, FACG; Jennifer L. Horsley-Silva, MD

 LISTEN: gi.org/acgcrpodcasts or subscribe on iTunes, Google Podcasts, Stitcher, Pocket Casts, or Spotify. REFERENCES 1. Choi AR, Tamblyn R, Stringer MD. Electronic resources for surgical anatomy. ANZ J Surg. 2008;78(12):1082–91. 2. Chen Z, Melon J, Evolution of social media: Review of the role of podcasts in gynaecology. Int Urogynecol J. 2018;29(4):477–80. 3. Min AA, Morley EJ, Rezaie SR, Fox SM, Grock A. Academic life in emergencymedicine blog and podcast watch: Respiratory emergencies. Cureus. 2018;10(6):e2812. 4. Wilson P, Petticrew M, Booth A, After the gold rush? A systematic and critical review of general medical podcasts. J R Soc Med. 2009;102(2):69–74. 5. Back DA, von Malotky J, Sostmann K, Hube R, Peters H, Hoff E. Superior gain in knowledge by podcasts versus text-based learning in teaching orthopedics: A randomized controlled trial. J Surg Educ. 2017;74(1):154–60.

 LISTEN: bit.ly/ACGCRJ-Podcast-Snyder Dr. Diana Snyder in conversation with ACGCRJ Editor-in-Chief Dr. Roberto Simons-Linares.

ACG MOBILE ACG MOBILE ACCESS KEY RESOURCES

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STAY ON-THE-GO with ACG’S MOBILE APP STAY ON-THE-GO ACG’S MOBILE Anwith exclusive ACG Member benefit APP that provides access to valuable resources for practice and your patients, An your exclusive ACG Member benefit all that from your mobile device. provides access to valuable resources

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Inside the Journals | 51


Precision Medicine for Complex Chron

[CLINICAL & TRANSLATIONAL GASTROENTEROLOGY]

Primer on Precision Medicine for Complex Chronic Disorders David C. Whitcomb, MD, PhD, FACG, University of Pittsburgh

 PRECISION MEDICINE PROMISES PATIENTS with complex disorders the right treatment for the right patient at the right dose at the right time with expectation of better health at a lower cost. The demand for precision medicine highlights the limitations of modern Western medicine. Modern Western medicine is a population-based, top-down approach that uses pathology to define disease. Precision medicine is a bottom-up approach that identifies predisease disorders using genetics, biomarkers, and modeling to prevent disease. In this primer, Dr. David Whitcomb, Editor-in-Chief of Clinical and Translational Gastroenterology, demonstrates the contrasting strengths and limitations of each paradigm and why precision Therapeutic trials using clinicopathologic disease criteria. (a) Randomized clinical trials attempt to reduce medicine will eventually deliver on the promises. Figure 1. Therapeutic trials using clinicopathologic disease criteria. (a) Randomized clinical trials attempt to reduce heterogeneity heterogeneity by selecting the maximum number of patients with the least variability in disease features using

the maximum number of patients with thecriteria. least variability disease features usingwith inclusion–exclusion criteria. CCDs, the treatm inclusion–exclusion In CCDs, the in treatment response is mixed the NNT>>1. The patients with theInhighest burden disease with and inthe need of effective treatment are excluded clinical drug trials. The samefrom traditiona is mixed with the NNT ..1. The of patients highest burden of disease and in from needtraditional of effective treatment are(b)excluded disease population seen a function of of multiple multiple underlying disorders (colored curves)curves) that maythat be amay function trials. (b) The same disease population seen as as a function underlying disorders (colored be aoffunction of a sing a single or multiple factors. A RCT targeting a low-severity mechanism (blue curve) will have “strong evidence” of  READ the full article: bit.ly/CTG-Whitcombfactors. A RCT targeting a effectiveness low-severityinmechanism (blue curve) will have “strong evidence” of effectiveness in the RCT, but will be of no v the RCT, but will be of no value in more severe disease mechanisms (yellow, orange, and red curves). Precision-Primer severe disease mechanisms (yellow, orange, and red curves). Newtoapproaches are needed to apply drug trials to mechanisms rather th New approaches are needed to apply drug trials mechanisms rather than common symptoms. CCD, complex diseases; NNT, number to needed treat; RCT,to randomized controlled trial. symptoms. CCD, complexchronic chronic diseases; NNT, needed number treat; RCT, randomized controlled trial.

2

Whitcomb

therapeutics). It also differs from Mendelian genetics by considering multiple variants simultaneously, rather than limiting analysis to rare, highly pathogenic variants in a single gene as provided by traditional genetic reports that are nearly useless in complex disease management. Table 1. Comparison of Western medicine and precisions medicine Use of disease models Past Interpretation of the impact of hundreds of potential genetic

primary function) (5) allows useful disease models Furthermore, the international pancreatology com pushing the field forward by reaching consensus Mechanistic Definition of chronic pancreatitis (1 gressive disease models (5,15), and use of consensus r lists (17–19). From a clinical standpoint, consensus from authoritative groups that genetic testing is me essary as a part Future of the evaluation of recurrent acute (20,21) and chronic pancreatitis (22,23) mean that Precision testingmedicine with a precision medicine report (genetics clinical guidancewith for decompensation the individual patient) should be System dysfunction reasonable health insurance plans.

Paradigm

variants medicine in a single patient requires highly structured, progressive Western

Basis

Germ theory within the context of active, specialized cells, within cific proteins

Disease definition

the structure pathology and context of an syndrome organ. These models must be Pathogenic responses to injury or stress Characteristic or clinical

Etiology

One primary factor causes the disease in risk factors. Although the Multiple factors specialized cell fluence of metabolic and environmental Diagnosis ofcause medical disorders aability normaltoperson a person with underlying genetic completely integrate all relevant factors remains in dysfunction Precisionin medicine focuses on diagnosing a disor the future, significant progress is being made in critical pieces of susceptibility signs and symptoms, often years before the disorder

Diagnosis

Demonstration of a pathologic agent, Demonstration of mechanistic dysfunction in (8–10), liver diseases (11–13), and other noncancerous gastroorder in precision medicine includes (i) recognizing cl a pathognomonic syndrome, or biomarkersa of a system in a subject with characteristic signs intestinal diseases (14). However, this knowledge has not yet been symptoms, or abnormal biomarkers, (ii) identifying symptoms usually caused 3 and (iii) testi disease integrated into patient-specific, dynamic, mechanistic models andgenetic variants linked to by thegene disease, interactions Based on these evidences, earl that predict disease etiology, progression, complications, and environment system dysfunction.

Time from Sx to Dx

optimal may be indicated. The advantage of a positive geneti 5–10 yrb interventions. In contrast, rapid progress is being made 1 mo

Use of genetics

Not to defining the underlying disorder titis.necessary The simplicity of the organ (2 cell types that each have one Central abnormal biomarkers (Figure 2), (ii) it limits th

Treatment goals

Relief of symptoms

Prevention of disease

Effectiveness

American College of Gastroenterology Generally poor

Hopefully outstanding

Costs

Unaffordable and rising in price

Affordable and dropping in price

disease models that define the effects of genetic variants on spe-

placed in the context of larger biological systems, with the in-

the puzzle for many CCDs including inflammatory bowel disease

in precision medicine for recurrent acute and chronic pancrea-

irreversible disease. The approach to diagnosis of a m

(i) it adds both specificity and accuracy to the inter

Clinical and Translational Gas

a

Biomarkers are characteristics of a person that are objectively measured as indicators of normal or pathogenic processes (2,31). Thus, they reflect the subject’s responses to etiologies that are driving pathogenic processes. The threshold between normal and pathogenic is arbitrary—typically defined as “outside the normal range” and highly dependent on the population being tested. b Early disease diagnosis using biomarkers is also limited by the diagnostic criteria requiring combinations of biomarkers, advanced features, or significant levels of disease pathology/irreversible damage to make the diagnosis (16).

analogy), although the actual disease mechanisms remained obscure (6). These criteria remain useful for public health, but 52 | GI.ORG/ACGMAGAZINE do not determine which patient will develop a disease or how

HOW PRECISION MEDICINE WORKS Approach to patients

Precision medicine for CCDs is a cell dysfunction, “bottom-up”


Lawrence R. Schiller, MD, MACG, for the ACG Archives Committee

25 YEARS AGO...

A A LO LOOK OK BA BACK CK

from the pages of The American Journal of Gastroenterology By Lawrence R. Schiller, MD, MACG for the ACG Archives Committee

E

ndoscopic sclerotherapy was initially reported in 1939 by Crafoord and Frenckner, two Swedish surgeons. It was rediscovered after the introduction of flexible upper endoscopy and was used widely for control of variceal hemorrhage in the 1980s. Complications of endoscopic variceal sclerosis (EVS) occurred in up to 20% of patients, and new technology was developed to ligate varices with rubber bands (EVL). This study was designed to compare short term risks of EVS and EVL and contributed to the replacement of EVS by EVL in the 1990s. “Esophageal variceal ligation is a new approach to the treatment of esophageal varices that does not result in transmural tissue injury and inflammation, and therefore might produce fewer sequelae and symptoms than sclerotherapy… Patient acceptance of ligation was much greater than that for sclerotherapy. Our data define the advantages of ligation over sclerotherapy.” —Berner JS, Gaing AA, Sharma R, Almenoff PL, Muhlfelder T, Korsten MA. Sequelae after esophageal variceal ligation and sclerotherapy: a prospective randomized study. Am J Gastroenterol 1994;89(6):852-8.

Figure 1: Esophageal varix with nipple sign (fibrin plug) at 5 o'clock position (a) targeted for banding (b). (c) Precipitation of bleeding during initial contact. (d) Suction of varix into banding cap. (e) Postbanding appearance of varix with hemostasis. Images in Figure 1 are from Baron TH, Song LMWK. Endoscopic variceal band ligation. Am J Gastroenterol 2009;104(5):1083–1085.

Inside the Journals | 53


2020 ACG AWARD NOMINATIONS Honor Your Colleague with an ACG Award Nomination The ACG Awards Committee is seeking nominations from all members for the following distinguished awards. Berk/Fise Clinical Achievement Award 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.

Community Service Award 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.

International Leadership Award 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.

Master of the American College of Gastroenterology 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.

Minority Digestive Health Care Award 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.

Samuel S. Weiss Award 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.

deadline for all nominations: April 15, 2020 Submit your nomination: gi.org/acg-award-nomination-form Nominations for all awards must: • • • •

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

54 | GI.ORG/ACGMAGAZINE

Nominations must be submitted online: gi.org/acg-award-nomination-form Nomination requirements: gi.org/awardees-and-special-lecturers


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. All rights reserved.

HH27314A

September 2018


THE ORIGINAL 1 LITER PRESCRIPTION BOWEL PREP SOLUTION

1 MOST PRESCRIBED,

#

BRANDED BOWEL PREP KIT1 WITH MORE THAN 15 MILLION KITS DISPENSED SINCE 20101 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. IQVIA. National Prescription Audit Report. September 2018. 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; 2017. 4. Rex DK, Schoenfeld PS, Cohen J, et al. Quality indicators for colonoscopy. Gastrointest Endosc. 2015;81(1):31-53.

©2018 Braintree Laboratories, Inc. All rights reserved.

HH27314A

September 2018


ACG MAGAZINE ARCHIVE 2019 ACG MAGAZINE Spring 2019

MEMBERS. MEDICINE. MEANING.

Profiles in Courage IN The Fight Against Colorectal Cancer

Vol. 3 No. 1 // Spring 2019 Vol. 3 No. 2 // Summer 2019

Vol. 3 No. 3 // Fall 2019

2018 ACG MAGAZINE Fall 2018

ACG MAGAZINE Spring 2018

MEMBERS. MEDICINE. MEANING.

ACG MAGAZINE Summer 2018

MEMBERS. MEDICINE. MEANING.

MEMBERS. MEDICINE. MEANING.

GIVING RISE to

Winter 2018

MEMBERS. MEDICINE. MEANING.

Banishing

Burnout& Building Resilience The Essential ed anc Roles of Adv viders Practice Pro in GI

Resolved to

ACG MAGAZINE

BEAT

COLON

GI in RWANDA

CANCER

Vol. 2 No. 1 // Spring 2018 Vol. 2 No. 2 // Summer 2018

Vol. 2 No. 3 // Fall 2018

Vol. 2 No. 4 // Winter 2018

2017 Volume 1, Number 1

ACG MAGAZINE Members. Medicine. Meaning.

Striking

Gold

ACG MAGAZINE Summer 2017

MEMBERS. MEDICINE. MEANING.

FINDING DISCOMFORT

ACG MAGAZINE Fall 2017

MEMBERS. MEDICINE. MEANING.

ACG MAGAZINE Winter 2017

MEMBERS. MEDICINE. MEANING.

THE RACING LIFE OF DR. FRED POORDAD

R ole Models

gi.org/acgmagazine

Vol. 1 No. 1 // Spring 2017 Vol. 1 No. 2 // Summer 2017

Vol. 1 No. 3 // Fall 2017

Vol. 1 No. 4 // Winter 2017


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