ACG MAGAZINE | Vol. 4, No. 2 | Summer 2020

ACG MAGAZINE Summer 2020

MEMBERS. MEDICINE. MEANING.

Feeling fine with fear:

Mastering Risk Perception and Decision Making in Medical Practice

Attend an upcoming

ACG POSTGRADUATE COURSE 2020 ACG’s Hepatology School August 22, 2020 |

Now Virtual!

v

ACG 2020 Annual Scientific Meeting & Postgraduate Course

Now ALL VIRTUAL Enhanced Live Programming!

October 23-28, 2020 • GI Pathology and Imaging Course • What’s New in GI Pharmacology Course • Practice Management Summit at ACG: Something for Everyone • ASGE Endoscopy Course October 23, 2020 • Postgraduate Course October 24-25, 2020 • Annual Scientific Meeting October 26-28

ACG’s Functional GI Disorders School December 5, 2020 |

Now Virtual!

v

2021 ACG/FGS Annual Spring Symposium Hyatt Regency Coconut Point | Naples, FL March 13–15, 2021

ACG/LGS Regional Postgraduate Course Hilton New Orleans Riverside | New Orleans, LA March 6–8, 2021

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

SUMMER 2020 // VOLUME 4, NUMBER 2

FEATURED CONTENTS

COVER STORY

FEELING FINE WITH FEAR: MASTERING RISK PERCEPTION AND DECISION MAKING IN MEDICAL PRACTICE

Louis J. Wilson, MD, FACG reflects on how physicians can develop a healthy relationship with risk

PAGE 24

GETTING IT RIGHT: PROVIDING CULTURALLY COMPETENT CARE

Guidance for gastroenterologists on how to best provide care that meets the social, cultural, and linguistic needs of patients PAGE 17

GETTING IT RIGHT: IMPROVING DIVERSITY AND INCLUSION IN GI

A call-to-action with concrete steps to improve diversity and inclusion in GI to reflect society's increasing diversity PAGE 21

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THE AMERICAN COLLEGE OF GASTROENTEROLOGY

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ATTEND THE VIRTUAL ACG 2020 ANNUAL SCIENTIFIC MEETING & POSTGRADUATE COURSE to learn the latest in clinical practice, exchange ideas with colleagues, and gain insight from the experts.

Registration now open:

acgmeetings.gi.org

SUMMER 2020 // VOLUME 4, NUMBER 2

CONTENTS

"Ultimately, we all should be striving for equity, which is different than equality. Equality is giving everyone the same tool(s) or resource(s) and expecting the same result. But as this...graphic shows, if you give everyone the same tool, it definitely will not produce the same result."

—Darrell M. Gray, II, MD, MPH, FACG, "Providing Culturally Competent Care," PG 17

6 // MESSAGE FROM THE PRESIDENT

24 // COVER STORY

Dr. Mark Pochapin on the challenges of the COVID-19 pandemic and ways ACG is supporting its members

FEELING FINE WITH FEAR Dr. Louis J. Wilson on mastering risk perception and decision-making in medicine

7 // NOVEL & NOTEWORTHY Celebrating ACG member achievements; recognizing everyday heroes in your community; and a plant-based diet guide

13 // PUBLIC POLICY GUIDANCE ON SAFELY REOPENING YOUR ENDOSCOPY CENTER A roadmap from ACG's Endoscopy Resumption Task Force

17 // GETTING IT RIGHT 17 CULTURALLY COMPETENT CARE Meeting the social, cultural, and linguistic needs of patients by Dr. Darrell M. Gray 21 DIVERSITY AND INCLUSION IN GI Actionable steps to promote diversity and inclusion in GI by Dr. Adjoa Anyane-Yeboa, Dr. Sophie Balzora, and Dr. Darrell M. Gray, II

Illustration courtesy of the Robert Wood Johnson Foundation

33 // ACG PERSPECTIVES 33 TELEMEDICINE IN VERMONT Dr. Eric Asnis reflects on using GI OnDEMAND during COVID-19 and beyond 35 MEETING NEEDS IN CAMBODIA Dr. Madhan Iyengar and Dr. Adam Snyder on their international service trip to Cambodia 37 CRC AWARENESS MONTH 2020 Celebrating commitment and creativity in promoting CRC screening and prevention

39 // EDUCATION 39 EDGAR ACHKAR VISITING PROFESSORS Reflections from EAVP visits by Dr. Laura Raffals and Dr. Roy Soetikno 43 ACG INTERNATIONAL TRAINING GRANT Dr. Vikrant Sood on his training experience in pediatric transplant hepatology

45 ACG LAUNCHES VIRTUAL GRAND ROUNDS AND #GIHOMESCHOOLING ACG Educational Affairs Committee Chair Dr. Brooks Cash on ACG's Virtual Grand Rounds

49 // INSIDE THE JOURNALS 50 AJG Author insight on ACG’s recent clinical guideline on Chronic Pancreatitis by Dr. Timothy Gardner 51 ACGCRJ Dr. Brett Sadowski discusses Leadership in Gastroenterology: Developing Fellows for Future Responsibility 52 CTG Analysis of SEER data on the rising incidence of CRC in young adults by Hussan, et al.

52 AJG Commentary on the May 2020 Negative Issue

by AJG Co-Editors-in-Chief Dr. Brian Lacy and Dr. Brennan Spiegel

53 // A LOOK BACK 50 YEARS AGO IN AJG In a 1970 report in AJG, Drs. Benner and Tellman publish one of the earliest case-series relating pseudomembranous colitis to lincomycin

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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 Liz Starnes

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: Sunanda V. Kane, MD, MSPH, 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: Irving M. Pike, MD, FACG Director, ACG Institute: Nicholas J. Shaheen, MD, MPH, FACG Co-Editors, The American Journal of Gastroenterology: Brian E. Lacy, MD, PhD, FACG

DIGITAL EDITIONS

GI.ORG/ACGMAGAZINE

Brennan M. R. Spiegel, MD, MSHS, FACG Chair, Board of Governors: Neil H. Stollman, MD, FACG

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

4 | GI.ORG/ACGMAGAZINE

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

CONTRIBUTING WRITERS

Adjoa N. Anyane-Yeboa, MD, MPH Dr. Anyane-Yeboa completed her GI fellowship at the University of Chicago this spring and received her MPH from the T. H. Chan School of Public Health at Harvard. She serves on ACG's Committee on Diversity, Equity & Inclusion.

Brian E. Lacy, MD, PhD, FACG Dr. Lacy is Co-Editor-in-Chief of The American Journal of Gastroenterology and is a gastroenterologist and neurogastroenterologist at Mayo Clinic, Jacksonville, FL

Eric L. Asnis, MD, FACG Dr. Asnis is a gastroenterologist at Mountainview Physicians Center in Berlin, VT.

Mark B. Pochapin, MD, FACG Dr. Pochapin is ACG’s 2019-2020 President, the Sholtz-Leeds Professor of Gastroenterology, and Director, Division of Gastroenterology and Hepatology at NYU Langone Health.

Sophie M. Balzora, MD, FACG Dr. Balzora is Chair of the ACG Public Relations Committee and Clinical Associate Professor, Department of Medicine at NYU Grossman School of Medicine.

Brooks D. Cash, MD, FACG ACG’s Chair of Educational Affairs, Dr. Cash serves as Chief, Division of Gastroenterology, Hepatology, and Nutrition at the University of Texas Health Science Center at Houston, where he is the Dan and Lillie Sterling Professor of Medicine.

Timothy B. Gardner, MD, FACG Dr. Gardner serves as Director, Gastroenterology & Hepatology Fellowship Program; Director, Pancreatic Disorders; Medical Director, Islet Cell Transplant Program; and Associate Professor of Medicine, Geisel School of Medicine, Dartmouth.

Darrell M. Gray, II, MD, MPH, FACG Chair of ACG’s Committee on Diversity, Equity & Inclusion, Dr. Gray is Associate Professor of Medicine, Director of Community Engagement and Equity in Digestive Health, and Deputy Director at the Center for Cancer Health Equity at The Ohio State University Comprehensive Cancer Center, The James.

Madhan S. Iyengar, MD Dr. Iyengar is a gastroenterologist in Lone Tree, Colorado, where he practices with Kaiser Permanente.

Brett W. Sadowski, MD Dr. Sadowski served as an Associate Editor of ACG Case Reports Journal from 2019 to 2020 and serves as a Lieutenant in the United States Navy.

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 the ACG Archives Committee.

Adam J. Snyder, MD Dr. Snyder is in GI practice at Citrus Valley Gastroenterology in Glendora, CA.

Vikrant Sood, MD, DM Dr. Sood is a gastroenterologist in the Department of Pediatric Hepatology at the Institute of Liver and Biliary Sciences in New Delhi, India.

Brennan M. R. Spiegel, MD, MSHS, FACG A Professor of Medicine and Public Health at UCLA and Director, Cedars-Sinai Center for Outcomes Research and Education, Dr. Spiegel serves as Co-Editor-inChief of The American Journal of Gastroenterology.

Louis J. Wilson, MD, FACG Dr. Wilson chairs the ACG Practice Management Committee and is a gastroenterologist at Wichita Falls Gastroenterology Associates in Texas.

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MESSAGE FROM THE PRESIDEN

GETTING THROUGH THIS PANDEMIC, TOGETHER

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

I HOPE THAT EVERYONE IS STAYING SAFE DURING THESE CHALLENGING TIMES. After becoming President of the ACG, I wanted to give frequent updates to keep connected as a way to enhance our GI community with meaningful engagement, and so I started a series of short video blogs or “vlogs.” It was a time when burnout was one of the top issues facing our profession. In my first vlog, I spoke about how being together at meetings was more than just an educational event, but a means of connecting with our colleagues and our friends, both personally and professionally.

Then at Thanksgiving, I spoke about gratitude. During the holidays, I talked about caring for ourselves, perhaps even taking a vacation. Who knew that a few months later, all of these factors would become even more important, but in such radically different ways?

Now, months into the COVID-19 pandemic, connecting with colleagues means something totally different.

It does not mean getting together in person, it means a Zoom meeting. And gratitude is not only about the gratitude we have for our profession and caring for others, but the public’s gratitude to health care workers who have been on the frontline of this pandemic.

Caring for ourselves is no longer about taking that vacation, it’s now about caring for our mental health.

This is a critically important issue that I want you all to think about.

Whether we realize it or not, we are all experiencing tremendous stress from situations that were unimaginable a few months ago. Our endoscopy practice at a standstill? N95 masks? Telehealth visits? Could we ever have imagined acting as hospitalists caring for medical patients during a pandemic?

Meaningful engagement, connections, gratitude, and recognizing our own stress and vulnerability are

6 | GI.ORG/ACGMAGAZINE

all necessary attributes that enhance our roles as authentic leaders for our patients and for our community. They have also been part of the leadership values of the ACG in order to provide the best real-time information and guidance to get through this pandemic.

Now we’re focusing on re-opening our endoscopy practices and the ACG has provided a great roadmap to help you at every turn.

Virtual Grand Rounds held every Thursday afternoon are an amazing new addition to our educational offerings. We have thousands of people joining us each week as we rekindle our passion for gastroenterology.

The special webinars in the evening enhance our ability to learn the best ways to handle the evolving issues that the virus has thrown at us.

In early June, I was proud to work with an amazing interdisciplinary team to present a webinar, “Bolstering Resiliency & Well-Being: Strategies to Reactivate Your Staff and Your Practice During COVID-19,” which I highly recommend for actionable insights to help you, as well as your colleagues and staff. (Free and accessible via ACG Education Universe here: bit.ly/ACGResilience-062020) In July, I was honored to be part of a very open and honest dialogue about racism in medicine with leaders of the College. This issue surfaced during a time when disparities in health care became clearly evident, as

demonstrated by the disproportionate number of patients with COVID-19 who are Black, Hispanic or Latino. The College is focused on diversity, equity, and inclusion, and we are creating actionable steps to better understand and implement strategies to combat systemic racism and social inequities in medicine. (Free and accessible via ACG Education Universe here: bit.ly/ACGRacism-in-Medicine) The purpose of our profession is to care for others, and this is more evident now than ever. This is a long haul with rising COVID-19 incidence rates in certain communities and dropping rates in others. However, we ARE getting through this pandemic.

And, we are learning new information and investigating new ways to treat and prevent COVID-19. Together we are supporting each other and weathering this storm, and the ACG is here for you every step of the way.

So stay strong, resilient, and safe.

A lot of people are counting on us, and we are counting on each other. Please know that you can always count on the ACG. We are working around the clock to bring you the latest and most up-to-date information and recommendations in real time. Together, our dedication to our profession and our patients can overcome any obstacle. I’m absolutely sure of it.

­­—Mark B. Pochapin, MD, FACG

“...[W]e are learning new information and investigating new ways to treat and prevent COVID-19. Together we are supporting each other and weathering this storm, and the ACG is here for you every step of the way.”

—Dr. Mark Pochapin

Note hy wor t WHILE THE LAST FEW MONTHS HAVE BROUGHT MUCH UNCERTAINTY, the GI community continues to rally support for one another.

Join the College in celebrating the achievements of your colleagues, with three promotions, two service awards, and two research award announcements, including the 2020 ACG Institute Clinical Research Awards.

Nominate Your Real Champions, the everyday heroes dedicated to providing necessary services during the COVID-19 pandemic, to be featured on the medical radio talk show Your Radio Doctor.

Learn about a new plant-based diet guide to help support your patients in making healthy lifestyle choices.

Novel & Noteworthy | 7

// N&N [RESEARCH AWARDEES]

ACG AWARDS 20 CLINICAL RESEARCH GRANTS IN 2020 The ACG Institute for Clinical Research and Education is pleased to announce the award of over $1.5 million in support of outstanding clinical research in gastro­enterology. For 2020, the ACG Institute will support four Junior Faculty Development Awards, seven Clinical Research Awards, and nine Medical Resident and Medical Student Awards.

The Medical Resident and Student Awards are new additions to the program.

 VIEW the full list of Clinical Research Grants: gi.org/research-grant-recipients

[ON THE AIRWAVES]

DR. MARIANNE RITCHIE SEEKS “YOUR REAL CHAMPIONS” FOR MEDICAL RADIO PROGRAM HIGHLIGHT Your Radio Doctor, the Philadelphia region’s only medical radio program, is a new hour-long talk show hosted by Marianne T. Ritchie, MD, of Jefferson University Hospital. Dr. Ritchie features guests from a wide range of health specialties, including GI,

8 | GI.ORG/ACGMAGAZINE

cardiology, and psychology.

During the COVID-19 pandemic, Dr. Ritchie has incorporated talks about the effect COVID-19 can have on patients and the public, both physically and mentally. Her latest campaign, Your Real Champions, seeks to highlight

everyday, non-MD community helpers who put their health and lives at risk to provide necessary services to treat COVID-19 patients or ensure that the public has access to essential supplies during shelter-in-place and stay-athome orders.



NOMINATE YOUR REAL CHAMPION to be featured

on Your Radio Doctor: yourradiodoctor.com/ your-real-champions

[AWARDEES]

DR. DENNIS AHNEN AWARDED FIGHT CRC'S 2020 ANDREW GIUSTI MEMORIAL AWARD Dennis J. Ahnen, MD, FACG, is the 2020 recipient of Fight CRC’s Andrew Giusti Memorial Award, which honors advocates who have shown exceptional leadership in advancing the nation’s commitment to colorectal cancer research. A

renowned leader in colorectal cancer screening and prevention, Dr. Ahnen has served on the National Colorectal Cancer Round Table (NCCRT) since 2009, joining the NCCRT Steering Committee in 2014 and pressing for change in

understanding and preventing early-age onset colorectal cancer by advocating on Capitol Hill.

As a GI Fellow in his 30s, Dr. Ahnen underwent a screening colonoscopy which detected an advanced adenoma in his colon, further underscoring his deep personal commitment to leading advancements in early detection.

He served as faculty at the

Department of Veterans Affairs Eastern Colorado Health Care System for over 30 years, retired from the University of Colorado School of Medicine in 2016, and was appointed Professor Emeritus in 2017.

[MILESTONES]

[MILESTONES]

[MILESTONES]

[AWARDEES]

DR. CHRISTOPHER THOMPSON ADVANCES TO PROFESSOR OF MEDICINE

DR. AMY OXENTENKO APPOINTED CHAIR OF MEDICINE AT MAYO CLINIC ARIZONA

Christopher C. Thompson, MD, MSc, FACG, Director of Endoscopy at Brigham and Women’s Hospital, has been promoted from Associate Professor of Medicine to Professor of Medicine at Harvard Medical School.

Congratulations to Dr. Thompson, an international leader in endoscopy and pioneer in the field of bariatric endoscopy.

ACG Trustee Amy S. Oxentenko, MD, FACG, will be joining Mayo Clinic Arizona after being named Chair of the Department of Medicine. Dr. Oxentenko completed her residency and fellowship at Mayo Clinic Rochester before joining as faculty, most recently serving as Professor of Medicine and Director of the Internal Medicine Residency Program. The College is grateful for all Dr. Oxentenko has done to advance the #FutureofGI and looks forward to her continued success at Mayo Clinic Arizona.

DR. FERNANDO VELAYOS NAMED CHIEF OF GI AT KAISER PERMANENTE SAN FRANCISCO

DR. DARRELL GRAY RECEIVES #BIGHEROES AWARD FROM COLUMBUS FOUNDATION

ACG Research Committee member Fernando S. Velayos, MD, MPH, was named Chief of GI at Kaiser Permanente San Francisco, advancing from his previous role as director of Kaiser Permanente’s Regional Program for Inflammatory Bowel Disease. The College recognizes this achievement, as well as Dr. Velayos’ sustained contributions to IBD research and clinical care.

[RESEARCH AWARDEES]

[PATIENT INFO]

ACG INSTITUTE AWARDEE RECEIVES NIH FUNDING

PLANT-BASED DIET GUIDE FROM VIVER HEALTH

CHRISTOPHER V. ALMARIO, MD, MSHPM, Assistant Professor of Medicine at CedarsSinai Medical Center, was recently awarded an NIH/ NCI K08 Career Development grant. Dr. Almario’s project, Automated Colorectal Cancer Educational Support System (ACCESS): Development and Validation of a Novel Online Decision Aid for Improving Colorectal Cancer Screening Uptake, leverages skills gained during his time as a 2015 ACG Institute Junior Faculty Development Grantee.

An informative laminated patient guide on a whole-food, plant-based diet is offered for bulk purchase by Viver Health. Breast cancer survivor Vicki Barghout relied on her training in public health and professional experience in the pharmaceutical industry when starting a company committed to supporting patients in making healthy lifestyle choices by publishing educational health information that is evidence-based, easyto-understand, and simple to navigate.

Brian E. Lacy, MD, PhD, FACG is one of the scientific advisers to Viver Health.

ACG DIVERSITY, EQUITY, AND INCLUSION COMMITTEE CHAIR DARRELL M. GRAY, II, MD, MPH, FACG, received a #BigHeroes award from The Columbus Foundation for his dedication to serving Columbus, Ohio communities facing higher numbers of health disparities. He was commended for his work in how structural racism, poverty, and systemic inequities impact health outcomes and access to high quality care. As part of the award, a $1,000 grant is provided to Ethiopian Tewahedo Social Services, a communitybased nonprofit that helps new arrivals from all countries establish roots and gain self-sufficiency in Columbus, where Dr. Gray serves as a Board Member.

 Learn More: viverhealth.com

Novel & Noteworthy | 9

THE AMET RH I CEA A N MCEO LE R LII C C AG N EC CO OL LL LE EG GE E TH E AM ER A N OF GASTR O EGNAT SETRROOLEONGTYE R O L O G Y O F OF GASTROENTEROLOGY

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VIRTUAL HEPATOLOGY SCHOOL with Live Q&A and Case Based Presentations

ATTEND THE ATTEND ACG 2020 ATTEND THE THE ACG ACG 2020 2020 ANNUAL SCIENTIFIC MEETING ANNUAL SCIENTIFIC ANNUAL SCIENTIFIC MEETING MEETING & POSTGRADUATE COURSE & & POSTGRADUATE POSTGRADUATE COURSE COURSE to learnNOW: the latest in clinical to REGISTER to learn learn the the latest latest in in clinical clinical practice, exchange ideas with practice, exchange practice, exchange ideas ideas with with acgmeetings.gi.org colleagues, and gain insight gain insight colleagues, colleagues, and and gain insight from the experts.

ACG 2020 from from the the experts. experts. ACG ACG 2020 2020 will be held inwill Nashville, will be be held held in in Nashville, Nashville, Tennessee at the Music Tennessee Tennessee at at the the Music Music City Center. City Center.

City Center.

Register: meetings.gi.org

Continue DECEMBER 27,to visit 2020 Continue Continue to to visit visit

DECEMBER 4, 2020

More Info:

gi.org/research-awards

MARCH 2021 COLORECTAL CANCER AWARENESS MONTH

acgmeetings.gi.org acgmeetings.gi.org acgmeetings.gi.org for updated information. for for updated updated information. information.

AMERICAN COLLEGE OF GASTRONTEROLOGY'S BIRTHDAY DECEMBER 27, 1932 The College became incorporated as The Society for the Advancement of Gastroenterology

MARCH 2021 NORTH AMERICAN TRAINING GRANTS More Info:

gi.org/gi-training-grants

10 | GI.ORG/ACGMAGAZINE

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APRIL 2021 ACG AWARD NOMINATIONS Nominate Your Colleague Learn More: gi.org/award-nominations

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 Guidance on

SAFELY REOPENING Your ENDOSCOPY CENTER The ACG Endoscopy Resumption Task Force

 TO HELP ACG MEMBERS DEVELOP PLANS TO RESUME ENDOSCOPY that were as safe, flexible, and practical as

possible, the “ACG Road Map for Safely Resuming or Ramping Up Endoscopy in the COVID-19 Pandemic” aimed to summarize the current regulatory framework on reopening endoscopy as it stood in May 2020. The authors based their recommendations on available data, and when data were inadequate or evolving, provided expert consensus opinion as to best practices.

FOREWORD BY ACG PRESIDENT DR. MARK POCHAPIN AND ACG PRESIDENT-ELECT DR. DAVID GREENWALD As our profession faces the COVID-19 pandemic, it is critical at this time that all endoscopy units provide a safe environment for patients and staff.

In order to care for our patients, we must resume endoscopic services for our patients and local communities as soon as it is feasible.

In response to the tremendous challenges of resuming or ramping up endoscopy during the pandemic and navigating a deluge of clinical information, regulations, and recommendations by

POST-CO RESUMINVID-19 G E N D OS COPY

The ACG Resumption TaEnskdoscopy Force:

G SAFELY REOPUEIDNANCE ON G YOUR ENDOSCOPY IN C EN T ER

the GI societies, the College’s immediate objective was to provide insight and guidance. In late April, we convened the ACG Endoscopic Resumption Task Force, co-chaired by Dr. Neil Stollman and Dr. Costas Kefalas. On April 27th, this group presented a webinar attended by thousands of your colleagues, “COVID-19: A Roadmap to Safely Resuming Endoscopy.”

Growing out of that invaluable session is this guidance document in which the Task Force provides a practical overview of reopening or ramping up endoscopy including when, who, what, where and how to succeed safely.

Even at a time when so much remains uncertain during the COVID-19 pandemic—and data to support decisions may be limited—the Task Force offers expert consensus opinion based upon the available data. 

Novel & Noteworthy | 13

// PUBLIC POLICY

As a summary, the Task Force noted in early May that: • The impact of the pandemic is substantial, with only one-third of GIs doing endoscopy in their ASC, and less than one-quarter having adequate PPE. • There are patient consequences to delayed care, and this should inform resumption planning.

• Federal guidance is extensive, but local regulations and conditions dominate.

• Every aspect of ASC patient flow and operations needs thoughtful attention.

• PPE recommendations are fluid and dependent on local conditions and availability; we propose a flexible algorithm, the ACG “PPE Decision Tree.”

gastroenterologists performing endoscopy now, and in the days ahead, are practicing during an uncertain time when recommendations are likely to change as this pandemic evolves.

For this reason, the Task Force will continue to monitor and communicate any necessary changes in the coming weeks and months. We are so grateful to the members of the Endoscopic Resumption Task Force for providing a clear roadmap to support ACG members as they formulate plans to reopen or ramp up endoscopy that are as safe, flexible and practical as possible.

Stay safe and thank you for your commitment to the care of our patients.

• Highly sensitive rapid polymerase chain reaction (PCR) tests are recommended when and where available.

It is an understatement that

Mark B. Pochapin, MD, FACG ACG President

David A. Greenwald, MD, FACG ACG President-Elect

ACG ENDOSCOPY RESUMPTION TASK FORCE Costas H. Kefalas, MD, MMM, FACG Co-chair, ACG Endoscopic Resumption Task Force

Neil H. Stollman, MD, FACG Co-chair, ACG Endoscopic Resumption Task Force

Harish K. Gagneja, MD, FACG Member, ACG Endoscopic Resumption Task Force

Whitfield L. Knapple, MD, FACG Member, ACG Endoscopic Resumption Task Force

Melissa Latorre, MD, MS Member, ACG Endoscopic Resumption Task Force

Michael S. Morelli, MD, CPE, FACG Member, ACG Endoscopic Resumption Task Force

Jeffry L. Nestler, MD, FACG Member, ACG Endoscopic Resumption Task Force

PPE DECISION TREE

Low Prevalence Area/ Negative COVID-19 Test/ Negative Symptom Screen

Consider standard precautions (surgical masks, face shields, gloves, gowns)

Low Prevalence Area/ No COVID-19 Test/ Negative Symptom Screen N95 or equivalent mask if available

GI ASC Patient High Prevalence Area/ Negative or No COVID-19 Test/ Negative Symptom Screen

High or Low Prevalence Area/ Positive COVID-19 Test or Positive Symptom Screen

14 | GI.ORG/ACGMAGAZINE

Face shields, gloves, gowns

Delay procedure or perform in hospital setting with N95 or equivalent mask

Vonda G. Reeves, MD, MBA, FACG Member, ACG Endoscopic Resumption Task Force

Sapna V. Thomas, MD, FACG Member, ACG Endoscopic Resumption Task Force

Louis J. Wilson, MD, FACG Member, ACG Endoscopic Resumption Task Force

INTRODUCTION UNPRECEDENTED DISRUPTION IN GI PRACTICES The COVID-19 global pandemic has led to millions of infections worldwide with tragic loss of life. Lockdown measures necessary to mitigate the spread of the infection have also caused extensive economic damage, resulted in millions of lost jobs, and marked disruption of our healthcare system.

A survey done by the American College of Gastroenterology Practice Management Committee in April (Table 1) revealed important changes to practice operations, severe reductions in revenue across all gastroenterology practice models, and a significant impact on patient access to endoscopy.

WEIGHING UNINTENDED CONSEQUENCES OF THE COVID-19 RESPONSE: The profound attention during this crisis to infection control and mitigation efforts has left significant health care needs unmet, with potential negative consequences of prolonged delays to care.

Causes for these delays include widespread closure of medical offices, cancellation of procedures deemed non-emergent and the loss of health insurance by millions. Telemedicine represents a significant change from traditional care and is a partial solution applicable only to cognitive care.

Although colonoscopy for cancer screening has been categorized as ‘elective,’ it is likely that a prolonged delay will result in real harm. The

IQVIA Institute for Human Data Science in April 2020 reported that the pandemic response has resulted in a reduction of mammograms, colonoscopies, and Pap smears by 87%, 90% and 83% respectively since February 2020. Furthermore, if these trends continue in the United States through June 2020, it was estimated to translate to a delay in the diagnosis of over 80,000 cancers.

According to another recent report, a suspension of elective colonoscopy for 6 months will result in the delayed diagnosis of over 2,800 colorectal cancers and 22,000 high-grade adenomatous polyps in the United States alone. The 6-month mortality rate for those eventually diagnosed with colorectal cancer would increase by 6.5%. Although determining how to weigh these issues in decisionmaking about expanding access to endoscopy is problematic, the importance of potential increases in cancer risk cannot be ignored. We believe that recommendations that significantly reduce access to the benefits of endoscopy must be firmly evidence-based and of clear net benefit.

NEED FOR A ROADMAP Resuming endoscopy during this pandemic is a tremendous challenge, with a daily deluge of new information, regulatory guidelines, expert opinions, and society recommendations. The American College of Gastroenterology established the Task Force on Endoscopic Resumption to critically review the available information and offer practical guidance for our members.

To financially succeed in reopening and ramping up endoscopic services, a robust leadership team should be assembled as a priority. Frequency of communication and flexibility of staff

TABLE 1. KEY FINDINGS: ACG PMC COVID-19 CRISIS BUSINESS SURVEY (APRIL 7-21, 2020) – 335 RESPONDENTS 1. Reached a broad cross-section of practice types and communities in 42 states and Puerto Rico 2. Severe revenue reductions in every practice type: 86% reported at least a 50% income reduction and 38% expecting negative income 3. 39% of gastroenterologists were seeing patients face to face 4. 33% of gastroenterologists were performing endoscopy in an ambulatory surgical center (ASC) 5. A dramatic transition to telemedicine (67% doing >75% of encounters) 6. A widespread shortage of facial personal protective equipment (PPE) (only 23.5% reported adequate supply of N95 masks)

and providers is essential. Scheduling the right patient at the right time is critical. Availability of supplies may be a rate-limiting step. Careful attention to the issues described can maximize the chance of success with reopening or ramping up an endoscopy unit or center.

READ THE FULL DOCUMENT: Guidance on Safely Reopening Your Endoscopy Center: Roadmap for Safely Resuming or Ramping-Up Endoscopy in the COVID-19 Pandemic by the ACG Task Force on Endoscopic Resumption May 12, 2020  bit.ly/Resuming-Endo-Guidance

WATCH ACG Webinar: COVID-19: Resuming Endoscopy: Unanswered Questions and Ongoing Controversies An update on the clinical developments and practical tips for your endoscopy center from the ACG Task Force on Endoscopic Resumption under the leadership of Co-Chairs Dr. Neil Stollman and Dr. Costas Kefalas. Watch via ACG Education Universe Login using ACG Single Sign-on or create a free account to view.

June 1, 2020  bit.ly/COVID-Endoscopy-0601 ACG Webinar: COVID-19: A Roadmap to Safely Resuming Endoscopy An update on the clinical developments and practical tips for your endoscopy center from the ACG Task Force on Endoscopic Resumption under the leadership of Co-Chairs Dr. Neil Stollman and Dr. Costas Kefalas. Watch via ACG Education Universe Login using ACG Single Sign-on or create a free account to view.

April 27, 2020  bit.ly/0427-Webinar-View ACG Webinar: COVID “101” for the Clinical Gastroenterologist Clinical pearls needed by any gastroenterologist on the medicine floor treating COVID-19. ACG President Dr. Mark Pochapin, ACG President-Elect Dr. David Greenwald along with experts in pulmonology, hepatology and the hospitalist’s perspective. Watch via ACG Education Universe. Login using ACG Single Sign-on or create a free account to view.

April 17, 2020  bit.ly/COVID-101-0417

Novel & Noteworthy | 15

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GETTING IT

GETTING it Right

Providing

CULTURALLY COMPETENT CARE Image: 2017 Robert Wood Johnson Foundation

By Darrell M. Gray, II, MD, MPH, FACG, Chair, ACG Diversity, Equity and Inclusion Committee

This is an excerpt of the introduction by Dr. Gray to his presentation, “Providing Culturally Competent Care” at ACG Eastern “Virtual” Postgraduate Course on June 6, 2020. Dr. Gray characterizes this talk as a “primer” on a topic that should be covered much more extensively. The entire presentation is fully accessible for free via ACG’s online learning platform, the ACG Education Universe.

Watch: bit.ly/DMGray-Culturally-Competent-Care

WHAT DOES CULTURAL COMPETENCE MEAN ANYWAY? “Cultural competence” does not mean learning about every cultural nuance, norm, language, religious practice. On the other hand, it does not mean being color blind and ignoring those things that foster diversity. Instead, cultural competence refers to recognizing your attitudes—and perhaps biases— toward cultural differences and building cross-cultural skills to help you to function effectively across cultures and to provide high quality patient care.

The U.S. Department of Health and Human Services states that practicing cultural competence means, “understanding the core needs of your target audience and designing services and materials to meet those needs strategically.”

At the core of what we do as GI providers, whether it is in the management of patients with liver disease, inflammatory bowel disease, a motility disorder, a genetic syndrome that places them at high risk for a GI cancer, a hepato-biliary disease requiring advanced endoscopic intervention—or anything in between—is cultural competence. It intersects with patients, providers, and practice and health systems factors. 

Getting it Right | 17

much you care.” And I find

pea ran ce

the community, in the clinic and in

l ca il ti ogy Po eol Id

Ap

rk Wo ound kgr B ac

that to be true in my interactions in

d

ee Cr

Communication Style/Skills

// GETTING IT RIGHT

Physical Abilities/ Qualities

Edu c

atio n

Parental Status

l rita Ma tus Sta

Age Sexual Orientation/ Identity

Gender

the hospital.

SOCIAL DETERMINANTS OF HEALTH Achievement of health and wellbeing extends far beyond the walls of our clinics and hospitals and only a small portion of health is attributable

Functional Specialty

to direct patient care. It is largely the result of behavioral, social and economic factors. These can be

hic rap n g o Ge catio Lo

Ethnicity

Race

Religious Beliefs

So Eco cionom Stat ic us

n

io

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described as social determinants of health—the conditions in which people are born, live work, pray and play, and the larger forces that influence those things. As we think about cultural differences and differences in the lived experiences of our patients, it is important that we at least have a basic understanding of the relationship between social factors and health outcomes.

HEALTH DISPARITIES AND COVID-19

Data suggest that providing culturally competent care translates into improved

In public health, we often throw around

patient satisfaction, care quality and patient safety, meeting legislative and regulatory standards such as culturally and linguistically appropriate standards (CLAS), and, in some cases, a market advantage.

Cultural competence is particularly important because our world is becoming more diverse.

It’s predicted that by 2045 minorities, by today’s definition, will be the majority. Additionally, there is a growing diversity in sexual orientation, gender identity, religion, disability status, socioeconomic status, preferred language, health literacy, and the list goes on.

It’s important to recognize the intersectionality of all of these things and how these identities may influence the lived experiences and health of people that we see in our clinics and hospitals.

At the center of cultural competence again is understanding a patient and their needs. I am reminded of sage words from Sir William Osler, “It is much more important to know what sort of patient has a disease than what sort of disease a patient has.” I find it to be true that, “people don’t care how much you know until they know how

18 | GI.ORG/ACGMAGAZINE

terms such as “upstream factors” and

“It is much more important

“downstream outcomes” to distinguish those things that are root causes from those that are outcomes, or symptoms of the underlying problem.

to know what

As an example, let’s take what we are

sort of patient

health disparities. Certainly, we have

has a disease than what sort of disease a patient has.”

learning about COVID-19 and existing seen disproportionate deaths from COVID-19 among communities of color—the same communities that have high prevalence of chronic diseases like cancer, heart disease and diabetes.

But these diseases are symptoms of inequities such as food insecurity, poor access to high-quality health care, and unsafe and overcrowded housing conditions, for example. Additionally, these factors are influenced by poverty,

— Sir William Osler

racism and discrimination. So you can see the pathway here. Biology, behaviors such as dietary practices, and environment interact across all

these domains. These factors are also

RECOMMENDATIONS FOR HEALTH EQUITY

important to understand in the context of cultural competence because they

Ultimately, we all should be striving for equity,

give insight into those things that

which is different than equality. Equality is giving

contribute to mistrust of the health

everyone the same tool(s) or resource(s) and

care system and low health literacy,

expecting the same result. But as the Robert

and that influence whether your patient

Wood Johnson Foundation graphic shows, if you

understands and follows through with

give everyone the same tool, it definitely will not

the recommendations you give them.

produce the same result. We have to tailor our practices; we have to tailor our education; we

IDENTIFYING AND MITIGATING IMPLICIT BIAS

have to tailor our resources to those things that our patients need.

Implicit bias refers to unconscious

My hope is that this discussion of cultural

attribution of particular qualities or

competence, implicit bias, and how we can be

stereotypes to a member of a certain

more accommodating to populations—whether

group. It is shaped by experience and

they be those with limited English proficiency,

based on learned associations which

those from the LGBTQ+ population, those

influence decision making, such as what

living with a disability—will help really push the

physicians do in patient care. The good news is that we can consciously identify and mitigate implicit biases. Bringing these unconscious associations to our conscious awareness is critical for helping individuals become self-aware of their biases.

In the remainder of his talk, Dr. Gray offers approaches to identifying and mitigating implicit bias for providers as well as practice/system bias, including recommendations on an implicit association test (implicit. harvard.edu/implicit/takeatest.html) and other approaches.

You can watch the entire presentation which features Dr. Gray offering:

“We have to tailor

needle toward equity and eliminating disparities

our practices; we

communities, and, even more broadly, in our

that occur within our practices, within our states and our nation.

have to tailor our education; we have to tailor our resources to those things that our patients need. ”

RESOURCES 1. ThinkCulturalHealth.hhs.gov 2. Koh HK, et al., National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health and Health Care, N Engl J Med 2014; 371: 198-201. bit.ly/nejm-clas-healthcare 3. Betancourt JR, Green AR, Carillo JE, Cultural Competency in Health Care: Emerging Frameworks and Practical Approaches, Field Report, October 2002, The Commonwealth Fund. bit.ly/cmwf-competency-frameworks 4. Balzora S, Abiri B, Wang X-J, McKeever J, Poles M, Zabar S, Gillespie C, Weinshel E, “Assessing core competency skills in GI fellowship training,” World J Gastroenterol. 2015 Feb 14; 21(6): 1887–1892. bit.ly/wjg-fellow-competency 5. Association of American Medical Colleges, Cultural Competence Education, 2005 bit.ly/aamc-cultural-comp-ed 6. Gregg J, Saha S, Losing culture on the way to competence: the use and misuse of culture in medical education, Academic Medicine 2006; 81: 542-547. bit.ly/ acadmed-losing-culture 7. Smedley BD, Stith AY, Nelson AR, Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care, Institute of Medicine, Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care, Washington, DC: National Academies Press, 2003. bit.ly/nap-unequal-treatment

• Guidance on Working with Patients Requiring an Interpreter • Guidance on Working with Patients Living with a Disability • Guidance on Working with Patients Who Identify as LGBTQ+ • Suggestions on Fostering Foster Cultural Competency Personally and Among Partners and Staff in a Medical Practice • Strategies to Improve Office Practices and Accessibility to Create a Culturally Competent Environment for Patients • Thoughts on Embracing Values That

Darrell M. Gray, II, MD, MPH, FACG, Chair, ACG Diversity, Equity and Inclusion Committee

Foster Diversity and Health Equity Getting it Right | 19

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 monthly articles on topics important to you. Articles include a topic overview, suggestions, examples, and a list of resources or references.

Explore the 2020

PRACTICE MANAGEMENT TOOLBOX and LAW MIND insights!

Download the e-Book: bit.ly/PM20EBOOK

"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 20 | GI.ORG/ACGMAGAZINE

IMPROVING DIVERSITY and INCLUSION in GI Adjoa Anyane-Yeboa, MD1, Sophie Balzora, MD2, and Darrell M. Gray II, MD, MPH3 Am J Gastroenterol 2020;00:1–3. https://doi.org/10.14309/ajg.0000000000000647; published online May 27, 2020

 “IT’S GOOD TO SEE ONE OF US IN THE WHITE COAT. IT’S RARE AND I AM SO PROUD OF YOU.” Such intimate acknowledgments are seemingly commonplace between minority patients and providers and reflect the lack of diversity of our healthcare workforce. Diversity refers to having a workforce that reflects different types of people (such as by race, ethnicity, gender identity, socioeconomic background, and disability status). Inclusion moves beyond satisfying quotas—it speaks to an environment in which those in the workforce feel acknowledged, respected, and valued.

The American Association of Medical Colleges traditionally reports

groups under-represented in medicine as Hispanic, Black, Native Americans, and Alaska Natives. These groups comprise 33.2% of the US population, and yet, there were only 9.1% of gastroenterology (GI) fellows and 10% of GI faculty in 2018–2019 (1–3).

Other under-represented groups in GI that are not reflected in these statistics include lesbian, bisexual, gay, transgender and queer individuals, people living with a disability, and veterans (Figures 1 and 2).

This lack of representation is problematic because diversity in medicine has been shown to improve access to care for underserved communities and positively influence healthcare delivery, patient outcomes,

and public policy (4,5). For example, patient-physician racial concordance has been linked to greater receipt of preventive care services, and gender concordance has been associated with decreased mortality among women with acute myocardial infarction (6,7).

In support of diversity and inclusion in academia, the National Institutes of Health has allocated resources toward diversity supplements for researchers from under-represented groups. In addition, the Accreditation Council for Graduate Medical Education appointed their first Chief Diversity and Inclusion Officer in 2019, recognizing the impact that this role can have on the environment for medical trainees.

Furthermore, many medical subspecialty leaders are embracing the opportunity to support diversity and cultivate cultures of inclusion.

A recent article in the Journal of Infectious Diseases outlines recommendations for achieving equity in the infectious disease workforce (8). Our cardiology colleagues have followed suit. At a national level, the American College of Cardiology has developed a strategic plan around 3 diversity and inclusion objectives: (i) enhancing a culture of inclusion, (ii) implementing programs for accountable execution, and (iii) engaging and leveraging all available talent at the College (9).

On a local level, some cardiology fellowship programs have revised the recruitment process to make diversity a priority, and in the case of The Ohio State University, improvements in diversity with the fellowship classes have been sustained (10).

In a similar fashion, GI professional societies have committees aimed at fostering a culture of diversity and inclusion among their membership.

Some have created programs for under-represented minorities to enrich the pipeline to GI careers including: the American College of Gastroenterology (ACG) Prescriptions for Success program for high school students, the ACG Summer Scholars Program which provides research opportunities for promising medical students, and the American Gastroenterological Association Getting it Right | 21

// GETTING IT RIGHT

FORWARD program which is aimed at bolstering the career advancement of minority physician scientists.

Furthermore, in 2017, for the first time in the history of these organizations, the presidents of the American Gastroenterological Association, the ACG, the American Society of Gastrointestinal Endoscopy, and the American Association for the Study of Liver Diseases were women.

Yet, despite these efforts and successes, the face of GI does not mirror that of our nation. We need a level of gender diversity and minority representation that is better aligned with the demographics seen both domestically and internationally (11,12).

So what does it require to enhance diversity and inclusion in GI? It demands an environment in which all people feel valued and those from minority groups are in roles and spaces in which they can influence practice and policy decision-making.

Such an environment recognizes and mitigates implicit biases, actively addresses racism and the structural forces that produce inequities, and cultivates GI practices and, to a larger extent, health systems that reflect the increasing diversity of the society that we live in today.

Outlined here are critical steps to make sustainable strides in improving diversity and inclusion within the GI field.

1. Create and support pipeline programs at the earliest stages of education. These programs offer mentorship, summer research with potential to publish, and shadowing opportunities. These experiences are pivotal for underrepresented students in medicine— working intimately with and readily seeing a diverse population of clinicians, researchers, and patients is invaluable for many who do not see people who look like them in these professional positions.

2. Incorporate holistic review and implicit bias training in recruitment selection committees.

Individuals involved in the recruitment of fellows and/or faculty should undergo implicit bias training to both confront 22 | GI.ORG/ACGMAGAZINE

prejudices that may impede their ability to select diverse candidates and to allow for candidates to be evaluated wholly. In addition, there should be faculty from underrepresented groups intimately involved in the selection process to create a diverse pool of fellow applicants to interview and to create final program rank lists.

3. Encourage mentorship and sponsorship. Coaches, mentors, and sponsors are pivotal to professional success. Coaches provide basic skill building. Mentors offer career guidance and advice. Sponsors are typically senior leaders who both publicly and privately provide endorsement, recommendations for key positions, promotions, and other appointments. It is imperative that under-represented trainees and faculty, in particular, have mentors guiding them through career choices and sponsors advocating for equal pay, committee appointments, promotions, and their overall career success.

4. Use mandatory implicit bias training for GI faculty, trainees, and staff. Too often minorities are subject to microaggressions, expectations of lesser performance from peers and staff, or racismww.

These experiences can result in imposter syndrome, isolation, and burnout (13). Implicit bias training is paramount to fostering inclusivity.

5. Cultivate a diverse and inclusive cadre of leadership. It is essential for prospective students, postgraduates, and trainees to see people with a shared experience and who look like them in leadership. Furthermore, diversity in leadership and teams within organizations is associated with greater innovation and better financial performance.

Representation matters!

Pediatric Gastroenterology, Hepatology & Nutrition to enhance the campaign’s reach and impact that now has international support from colleagues in Europe and the Middle East.

Nonetheless, although we have made progress toward improving diversity and inclusion in gastroenterology, bigger strides are overdue. In addition, as gastroenterologists from underrepresented groups, we long for the day when there is equity in leadership opportunity, research funding, pay, and academic promotion. We know this day is on the horizon.

CONFLICTS OF INTEREST Guarantor of the Article: Darrell Gray II, MD, MPH, FACG. Specific author contributions: A.A.Y.: drafting of the manuscript and revisions; S.B.: drafting of the manuscript and revisions; D.G.: drafting of the manuscript and revisions.

Financial support: None to report.

Potential competing interests: None to report.

REFERENCES 1. U.S. Census Bureau QuickFacts: United States. US Census Bureau Website. (www.census.gov/quickfacts/fact/table/US/PST045218).

Accessed January 9, 2020.

2. ACGME Data Resource Book 2018–2019. (www.acgme.org/AboutUs/ Publications-andResources/Graduate-Medical-EducationDataResource-Book). Accessed January 9, 2020.

3. AAMC. Diversity in Medicine Facts and Figures 2019. (https://www. aamc.org/data-reports/workforce/report/diversity-medicine-factsandfigures-2019). Accessed January 10, 2020.

4. Marrast L, Zallman L, Woolhandler S. Minority physicians’ role in patient care. JAMA Intern Med 2014;174:289–91.

5. Cohen J, Gabriel B, Terrell C. The case for diversity in the health care workforce. Health Aff 2002;21:90–102.

6. Alsan M, Garrick O, Graziani G. Does diversity matter for health?

Experimental evidence from oakland. Am Econ Rev 2018;109: 4071–111.

7. Greenwood BN, Carnahan S, Huang L. Patient-physician gender concordance and increased mortality among female heart attack patients. Proc Natl Acad Sci USA 2018;115:8569–74.

8. Marcelin J, Manne-Goehler J, Silver J. Supporting inclusion, diversity, access and equity in the infectious disease workforce. J Infect Dis 2019; 220:S50–S61.

9. Douglas P, Miller A, Khandelwal A. Improving diversity and inclusion in cardiology at the state level. J Am Coll Cardiol 2018;72:2265–8.

10. Auseon A, Kolibash A, Capers Q. Successful efforts to increase diversity in a cardiology fellowship training program. J Grad Med Educ 2013;5: 481–5.

There is also a role for social media in promoting diversity and inclusion within gastroenterology. In April 2019, the ACG launched its #DiversityInGI social media campaign to accomplish this. They subsequently partnered with the North American Society of

11. Rabinowitz L, Anandasabapathy S, Sethi A, et al. Addressing gender in gastroenterology: Opportunities for change.

Gastrointest Endosc 2020;91: 155–61.

12. May F, Anandasabapathy S. Globalization and gastroenterology: A role for women in the American gastroenterological association.

Gastroenterology 2019;156:539–41.

13. Malcom S. The Culture of Undergraduate STEM Education Barriers and Opportunities for 2-Year and 4-Year STEM Degrees: Systemic Change to Support Students’ Diverse Pathways. U.S. National Library of Medicine, 2016

Figure 1. Active gastroenterology physicians in the United States by sex. Data adapted from AAMC Diversity in Medicine: Facts and Figures 2019 from AMA Physician Masterfile (ref. [3]).

Figure 2. Active gastroenterology physicians in the United States by race and ethnicity. Data adapted from AAMC Diversity in Medicine: Facts and Figures 2019 from AMA Physician Masterfile (ref. [3]).

,

Adjoa Anyane-Yeboa, MD ACG Diversity, Equity & Inclusion Committee

Sophie Balzora, MD, Chair, ACG Public Relations Committee

,

Darrell M. Gray II, MD, MPH Chair, ACG Diversity, Equity & Inclusion Committee

Getting it Right | 23

// COVER STORY

Feeling fine with fear:

Mastering Risk Perception and Decision Making in Medical Practice

By Louis J. Wilson, MD, FACG, Wichita Falls, Texas, Chair, ACG Practice Management Committee

T

“The heart of risk is ignorance, and ignorance is ubiquitous.”

– Peter Bernstein, American financial historian, economist, writer and educator

INTRODUCTION The process of consolidation among medical practices and hospitals the past several years is undeniable. Physicians who have valued autonomy have been seeking scale as a solution for a variety of difficulties maintaining and managing independent medical practices of all types. Even highly successful private practice single-specialty gastroenterology groups have recapitalized or sold medical practices to hospitals and private equity investment groups.

Although there are a variety of reasons for these transactions, many of them involve a perception that increased scale decreases risk or that recapitalizing successful medical practices takes some of the risk out of uncertain futures.

Are the decisions the physicians are making in these transactions beneficial to them? Are the doctors involved in these decisions seeing and weighing the risks appropriately? Unfortunately, when outside of the practice of medicine, and as will be discussed here, a variety of factors make doctors vulnerable to poor decision-making. What are those factors and what strategies can physicians employ to more effectively manage risk in these uncertain times?

RISK VERSUS RISK PERCEPTION Risk is everywhere. Possibly more importantly, the idea of risk is everywhere. Every day the headlines are full of relevant stories. The vastness of the subject is staggering. Exploring risk involves psychology, mathematics, statistics, history, law, business, insurance, science, and—of course— medicine. Similarly, the idea of “risk management” pervades businesses and medical practices alike.

Risk has, in fact, become a commodity to be managed, bartered, traded, and sold. Physicians have become accustomed to viewing risk predominantly in the form of legal liability, managed through defensive clinical strategies and liability insurance. The truth, however, is that legal liability only scratches the surface of truly managing risk in our lives and medical practices.

RISK PERCEPTION IS A HIGHLY SUBJECTIVE, FOGGY, COMPLICATED, AND CONFUSING SUBJECT What does someone mean when they say, “taking a risk,” “reducing risk,” or call something “risky”? The answer that question is probably not as obvious as it seems. Generally, those phrases relate more to risk perception than risk itself. This is especially true in the daily struggles of life—trial and error, dealing with the ambiguity of facts and information, or with the power of emotions.

To illustrate the complexity of this, envision yourself as a gastroenterologist “taking call” at your local hospital. There are three consultations waiting to be seen, each with a different clinical story, of which you’ve only heard a small portion. You are also about to start a colonoscopy in an 80-year-old patient with hematochezia in the setting of chronic anticoagulation, which you ordered discontinued two days ago. There are

“

Research demonstrated that people are more risk-averse in negative frames than opportunity-seeking in positive frames.

In other words, our behavior shows we are not strictly rational.”

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“

Risk has, in fact, become a commodity to be managed, bartered, traded, and sold.

Physicians have become accustomed to viewing risk predominantly in the form of legal liability, managed through defensive clinical strategies and liability insurance. The truth, however, is that legal liability only scratches the surface of truly managing risk in our lives and medical practices.”

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also several laboratory results awaiting your review including a patient with a creatinine level of 2.6 but about whom you can’t remember the details of the clinical history. Meanwhile, at home you have a teenage daughter going to the high school prom with a boy you don’t know, and your husband has been suffering from a headache for two days.

Finally, you’ve heard on the news there is a Category 4 hurricane approaching the Bahamas that may impact the East Coast tomorrow. None of this is farfetched.

Which of the obvious risks in this scenario do you choose to perceive at that moment, and how do you prioritize them? Weather, political unrest, infection, medical error, accidents, engineering failures, business risks, even terrorist activity all represent options on which to focus and act upon at any given time.

Managing risk perception is a critical part of decision-making. Moreover, each of us has a different relationship with risk. However, risk-taking and decision-making are skills that can be learned and improved.

A BRIEF HISTORY OF RISK We live in a society almost obsessed with risk, but this was not always the case. The word risk comes from the old Italian word riscare, which means “to dare.” Surprisingly, an equivalent word does not even exist in many ancient languages. It is an intellectual concept so rooted in the modern mind that it’s difficult for us to imagine that it was not always so.

According to Peter Bernstein in Against the Gods: The Remarkable Story of Risk, the idea of predicting the future, or measuring and modifying its outcome, was absent for most of human history. Ancient philosophers such as Socrates and Plato, who pondered almost all the essential questions, seem to have ignored or failed to recognize the uniquely modern idea of risk.

The modern definition is usually stated, “exposing oneself to the possibility of loss or injury.” In his book Taking Smart Risks: How Sharp Leaders Win when Stakes are High,

Doug Sundheim suggests that a better definition adds the phrase “in hopes of achieving a gain or reward.” Modern business plans invariably include discussions of risk management, insurance, balancing portfolios, and risk tolerance.

How and why did all this begin?

The answer, not surprisingly, begins with one of mankind’s most ancient diversions, that of gambling. In 1494, a Franciscan monk and mathematician named Luca Pacioli published Summa de Arithmetic, Geometria et Proportiomatica, “in praise of the great abstraction and subtlety of mathematics.” Among the book’s remarkable achievements was the first presentation of double-entry bookkeeping. Perhaps its greatest contribution, however, has become known as “Pacioli’s Puzzle.” With it, Pacioli poses this problem: if players A and B are playing a fair game of balla and agree to continue until one of them has won six rounds, how would the stakes be divided if the game was interrupted early? This seems like a simple question. Attempts to solve this puzzle, however, resulted in heated debates among mathematicians for hundreds of years.

Pacioli’s Puzzle was resurrected in 1650 when a French aristocrat, the Chevalier de Méré, posed it to famed mathematician Blaise Pascal. In 1654, Pascal sought the help of prominent mathematician and polymath Pierre de Fermat. The two of them then worked on it together for several months. Working this out began with recognition that the player who is winning when the game is interrupted had a greater probability of winning in the end, assuming a fair game. The problem is determining how much greater that is.

This was the first known attempt to construct a systematic approach to probability. They realized the solution required quantifying the number of potential options or outcomes that could occur at any point in the game. The subsequent solution became known as Pascal’s Triangle (Figure 1). While the solution of Pascal’s triangle certainly

Meanwhile, in 1687, Lloyd’s of London coffeehouse became a major gathering place for tradesmen on the wharf. While potentially very profitable, investing

does not apply to all probabilities, it had tremendous implications to the future of business, insurance, economics, and risk management.

FIGURE 1. PASCAL’S TRIANGLE AND BINOMIAL FORMULA

1 1 1 1

1 2

3

1 3

1

1 4 6 4 1 1 5 10 10 5 1 1 6 15 20 15 6 1 1 7 21 35 35 21 7 1

(x+y) 0 =1

0th row

(x+y)1 =1x+1y

1st row

(x+y)2 =1x2+2xy+1y 2

2nd row

(x+y)3 =1x3+3x2y+3xy 2+1y 2

3rd row

(x+y)4 =1x 4+4x3y+6x2y 2+4xy 3+1y4

4th row

(x+y)5 =1x5+5x 4y+10x3y 2+10x2y 3+5xy4+1y5

5th row

FROM PASCAL TO PROBABILITY Another great advance was the development of the critical concepts of statistics, statistical inference, and sampling. Decisions and forecasts are always made with limited data. John Graunt was a haberdasher, buying and selling clothing, who enjoyed dabbling in mathematics. In 1662, he published Natural and Political Observations made upon the Bills of Mortuary. In this book, he used mortuary records of deaths to extrapolate a variety of population statistics. It was the first example of using statistical inference from sampling. In 1690, famed astronomer Sir Edmund Haley took the idea much further to create the first actuary tables.

in merchant shipping was financially hazardous. In 1696, Lloyd’s List was created to help investors in merchant marine shipments. By 1771, the merchants of the Society of Lloyd’s had developed standardized underwriting rules that set the foundation for the entire insurance industry.

THE BIRTH OF DECISION THEORY The beginnings of modern decision theory can be traced to the work of Daniel Bernoulli who, in 1738, published the important article, “New Theory.”

Bernoulli was a physician, botanist, and mathematician who had a special interest in probability. His article was the first description of rational decision-making.

In his article, Bernoulli asserts that decisions are made by an evaluation of 1) observable facts, and 2) the desirability of what can be gained or lost.

Importantly, Bernoulli stated that the value of any increase in wealth is inversely proportional to the wealth already possessed.

He therefore introduced a novel idea that many consider is the driving force in economic activity.

This is the value of human capital.

Human capital is not always measured in monetary terms, but instead as anything that can satisfy a need or want. Such capital could include education, talent, training, experience, or physical effort.

Bernoulli’s “utility theory” was the jumping off point for modern economics and a modern understanding of supply and demand. It was also a powerful insight into the concept of risk-taking. This idea of rational decision-making based on human capital subsequently influenced economists, such as Adam Smith, in developing traditional economic theory. Traditional economics was then based on the idea of homo economicus, as a rational decision maker operating in his own best interest and relying on rational judgments for economic decisions.

The Rev. Thomas Bayes made important additional contributions to these ideas when, in 1768, he published, “An Essay Towards Solving a Problem in the Doctrine of Chances.” Bayes’ rule or theorem attempts to quantify the relationship between the probability of any event, given the knowledge of prior events. This was the introduction of the critical modern concepts of sensitivity, specificity, and positive or negative predictive values. The further development of empirical statistics and analysis based on sampling is critical to the modern practice of business and medicine.

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CHOICES, RISKS, AND FRAMES During the 20th century, modern economists recognized that homo economicus does not operate rationally and attempted to discover new principles in human decision-making. In a presentation by Dr. Daniel Kahneman and Amos Tversky at the 1983 American Psychological Association Annual Meeting titled, “Choices, Risks, and Frames,” these researchers summarized findings and concepts that would eventually be published in a book by the same name in 2000. These psychologists were awarded the Nobel Prize in Economics in 2002 and laid the foundation for the field of “behavioral economics.” Their work demonstrated the behavioral relationship between value and cost. This research demonstrated that people are more risk-averse in negative frames than opportunity-seeking in positive frames. In other words, our behavior shows we are not strictly rational. Their research demonstrated that the framing of risks is more important to decision-making than any rational measurement of benefit and cost.

BEHAVIORAL ECONOMICS

“Where all think alike, no one thinks very much” -Walter Lippmann, editor of the New Republic and Pulitzer Prize winning American writer and political commentator The modern study of the psychological, social, and cultural factors that impact decision-making and how they are subsequently reflected in economic outcomes is known as behavioral economics. “Decision Theory” emerged as the scientific study of how people make decisions in the face of uncertainty.

Richard Thaler, who received the Nobel Prize in Economics in 2017, suggested that choices are built on an architecture of options. The decisions that are made navigating those options seem to demonstrate a variety of irrational

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“

Along with a high aspiration for success, physicians often possess an equally high fear of failure and a tendency to feel shame or guilt when they do not meet their own high standards. Whether physicians admit it or not, they usually fear failure.”

tendencies. These behavioral tendencies are often called theories, fallacies, or principles.

Many of these are very important to decision-making by physicians. Some of them are described below.

• Nudge Theory proposes that positive reinforcement and indirect suggestion influence behavior in predictable ways called “nudges.” A nudge is defined as any aspect of the “choice architecture” that predictably changes people’s decisions without forbidding the other options or altering incentives.

• Loss Aversion and Prospect Theory proposes that people value gains and losses differently, and that human decision suggests there is more pain from loss than pleasure from an equal gain.

• Sunk Cost Fallacy proposes that people behave as if additional investment is justified based on previous investment.

This is related to the “commitment consistency principle” which results in irrational escalation of commitment based on an instinctive desire to favor consistency.

“There is no expedient to which a man will not resort to avoid the real labor of thinking.”

-Sir Joshua Reynolds, British painter • Availability Heuristics (also known as Availability Bias) proposes that people will overvalue recently learned facts and details more heavily than less recent or non-recalled facts.

• Herding Phenomenon proposes that people will follow crowds or groups in favoring highlighted or recently released information.

• Endowment Effect proposes that people will overvalue objects or resources that are already controlled or

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•

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owned. This can be demonstrated by unwillingness to sell owned resources for actual value.

Bounded Rationality proposes that choices will be limited due to the availability of information, cognitive abilities, critical thinking skills, or finite time available to make decisions.

Reciprocity proposes that people have a deeply ingrained bias to return payment in kind and follow rules of mutual concessions.

The Contrast Principle proposes the psychological tendency to misperceive value when compared with strongly contrasting objects.

Stereotyped Behaviors proposes decision-making through shortcuts, repetitive behavior, and rules of thumb. The error of these stereotyped behaviors increases in the presence of overstimulation and distraction.

Status Quo Bias proposes a perceived increase in value of familiar, rather than unknown, information. This bias may increase the degree of loss aversion.

Social-Proof Effect proposes that people will make choices based on the decisions of others, and that choices seem more appropriate when others are making the same choice. When this effect is combined with Availability Heuristics, the Herding Phenomenon can be accentuated.

DOCTORS AND DECISIONMAKING In May 1991, Harvard business theorist and Professor Emeritus Chris Argyris published an article titled, “Teaching Smart People How to Learn,” which has profound implications about decisionmaking problems experienced by physicians and other highly educated professionals. He points out that many people define learning too narrowly as “problem solving” which involves identifying and correcting problems from the external environment.

While this type of problem solving is important, effective learning also requires internal focus, including

critical reflection on ways our own thought processes or behavior contribute to problems.

Professor Argyris coined the terms “single loop” and” double loop” learning to label this critical distinction. Physicians are often exceptional problem solvers, and spend years mastering the intellectual discipline of medicine and applying it to solve clinical issues. Ironically, that same education and experience helps to explain why physicians are often bad at doubleloop learning. Virtually all physicians were highly successful during their long and arduous education. Many are, therefore, unaccustomed to failure and unprepared to navigate it.

and impersonal standards. Open competition is discouraged.

Physicians usually dislike or reject any requirement to compete openly with others. They often avoid open confrontation or competition and avoid difficult conversations with peers. Pay is also a factor. Physicians are well paid, and generally believe the compensation is justified.

Professor Argyris notes that highly paid professionals feel increased embarrassment for any mistakes they make at work. These factors accentuate the defensiveness that many physicians exhibit when forced into self-reflection.

MOTIVATION IS NOT THE ISSUE

THEORIES OF ACTION

Physicians embody the learning dilemma.

They are typically very enthusiastic about continuous improvement, and yet are often an obstacle to its success. If improvement efforts focus on external organizational factors such as job design, training, performance reviews, or compensation programs, physicians are usually enthusiastic participants. However, when the effort turns to the physician’s own performance, something often goes wrong. Along with a high aspiration for success, physicians often possess an equally high fear of failure and a tendency to feel shame or guilt when they do not meet their own high standards. Whether physicians admit it or not, they usually fear failure.

When faced with a situation they cannot immediately handle, they tend to fall apart.

They also cover up the distress in front of patients and colleagues. In fact, these conversations often divert blame to other members of the team, the system itself, or even patients. This tendency is often categorized as a “brittle personality.”

It is impossible to evaluate and reason through every new situation. Everybody needs “shortcuts.” In medicine, these shortcuts often involve peer-reviewed literature, guidelines, and best practices.

Outside of clinical decision-making, the availability of similar shortcuts is severely limited. This brings us back to behavioral economics.

Physicians and non-physicians alike are forced to design and adopt sets of rules to govern everyday behavior and decision-making. Professor Argyris calls these sets of rules “Theories of Action.” Much of this is unconscious.

In fact, these theories of action may become so taken for granted that many people do not even realize they are using them. Moreover, when people are asked to articulate the rules they use to govern their actions, they will give an “espoused theory of actions” that often contradicts their actual behavior. It turns out that the master program people use in day-to-day life is rarely the one they believe they use.

Theories of action in use will typically involve some variation on four rules: 1. To remain in unilateral control 2. To maximize winning and minimize losing 3. To suppress negative feelings 4. To be as “rational” as possible.

Rational in this context is defined as stating clear objectives and making choices best suited to achieve them.

PRODUCTIVE LONERS Although physicians loosely work as members of a team, many of the decisions they make in clinical practice are done in isolation. In this aspect, they tend to be “productive loners,” gathering information, making conclusions, solving problems, and determining the course of action alone. In addition, although they frequently compare themselves to peers, it is usually through the buffer of guidelines, best practices,

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before or are known. As the terrorist attack of September 2001 or the COVID-19 Pandemic of 2020 have clearly demonstrated, the most disruptive events of our lives are unexpected! In the book The Black Swan: The Impact of the Highly Improbable, Nassim Nicholas Taleb explains how these events were highly disruptive precisely because they were not predicted. Real risk mitigation must involve behaviors or skills not contained in the hazard vulnerability analysis (HVA) tables.

with an assessment performed by safety experts. The hazards listed usually include severe weather, external disaster, fire, chemical spills, cyber-attack, loss of power, or an unexpected surge in patient volume.

While these risk assessment processes are undoubtedly valuable, they may create a false sense of security for physicians.

The scoring systems, risk-impact criteria, priority tables, and vulnerability plans fill pages often quickly passed over in board meetings (Figure 2).

Overreliance on bureaucratic processes can lead to dangerous inattention.

Physicians are vulnerable to these errors by excess constraints on their time and the limited availability of their attention.

Moreover, doctors often limit discussions on risk mitigation to the narrow topics of medical liability and insurance. Meanwhile, they may use poorly understood shortcuts to hastily make career-altering decisions that have a lasting impact on their lives.

These administrative processes also overemphasize risks that have been experienced

None of these rules support selfreflection or learning, and we have already discussed that most decisionmaking is not a rational process.

RISK-HAZARD ASSESSMENT Another important type of shortcut used in decision-making and risk-taking are administrative or bureaucratic risk mitigation processes.

Structured “risk-assessment” has become part of every business, and the medical profession is no different.

These structured assessments are usually performed by administrators and carefully created by the bureaucracy of health systems, medical facilities, and practices. Pre-made templates are available for many of them. One example is the “risk-hazard analysis.” This RHA includes strategies for mitigation of risk as well as goals to preparation, response, and recovery.

Policies and procedures are reviewed

Priority (based on total impact factors)

Patient Care Service

Support Services

Severe Weather (tornado)

4

4

4

4

Severe Weather (storms)

4

3

4

Communication Failure

4

4

Utility System Failure

3

Fire or Explosion (internal)

A SETUP FOR BAD DECISIONS In summary, physicians are set up for bad decision-making outside of clinical practice. In business, we often relegate risk assessment to administrators and lawyers.

Many are accustomed to academic success, productive loners, afraid of failure, defensive, and externally focused, who also avoid

Utility Services

Public Service

Commercial Resources

Staff Family Members

Scoring Total

3

4

4

4

4

124

4

2

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3

3

3

104

3

3

3

4

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100

4

4

3

4

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3

87

3

4

4

4

4

4

2

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2

78

Data Loss/ Loss of IS capabilities

4

4

3

2

1

1

3

3

1

72

HAZMAT Situation

3

3

3

3

2

2

3

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63

Flood

3

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51

Patient Surge

0

4

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0

Emergency

RISK IMPACT CRITERIA USED 0

Virtually No Risk

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Minimal Risk

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Moderate Risk

3

High Risk

4

Severe Risk w/ History

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Staffing Structure

FIGURE 2. HVA TABLE AND RISK IMPACT FACTORS from ASC Board Meeting January 2020, Wichita Falls, Texas. Note absence of any mention of viral pandemic and zero (virtually no risk) priority score for patient surge.

confrontation and specialize in singleloop learning that makes heavy use of behavioral short cuts. Furthermore, we are often tired, stressed, distracted, and overworked. Finally, we are paid too much to make mistakes and fear failure. If even half of these factors apply, care must be taken for doctors to seek to improve the skill of risk perception and decision-making.

HAVING A RELATIONSHIP WITH RISK

“A half-person… is not someone who does not have an opinion, just someone who does not take risks for it.”

–Nassim Nicholas Taleb, LebaneseAmerican essayist, scholar, statistician, and former option trader and risk analyst, whose work concerns problems of randomness, probability, and uncertainty With all this in mind, it is no wonder physicians are often defensive and risk-averse. Furthermore, in clinical practice the failures of risk-taking are obvious and everywhere. We experience them firsthand in the emergency rooms, surgical suites, and medical offices every day. What is less obvious are the failures that come from avoiding risk. It is critical for personal and professional success that physicians develop a healthy relationship with risk.

In his book Taking Smart Risks: How Sharp Leaders Win When Stakes are High, author Doug Sundheim explains that risk perception can be viewed on a continuum. On one end of the continuum is the “power perception” that focuses on opportunity taking and on the other end is the paralysis perception that focuses on risk avoidance. The paralysis

perception asks, “what might I lose if I try this?” The power perception asks, “what might I lose if I don’t try this?” Kahneman and Tversky would call viewing risk through these or other perspectives “applying frames.”

Carefully choosing the frames applied to any risk or decision is critical to a healthy relationship with risk-taking.

TIME FRAMES In addition to framing risk in both the positive and negative frames, no discussion of framing risk can ignore the effect of time. Time, after all, both creates and transforms risk. If there were no tomorrow, there would be no risk. The nature of risk is shaped entirely by the time horizon in which it is viewed. There is a kinetic moment during any decision-making process in which the effort turns from consideration into action. Certainly, action is required for progress, but time is also required to bring necessary information.

Procrastination has value. A helpful maxim is that, “time matters most when a decision is irreversible.”

“Perfection is the enemy of creation.”

-John Updike, American author

THE PREVENT DEFENSE During the 2012 AFC division playoff game between the Denver Broncos and the Baltimore Ravens, the Broncos coaches made a critical decision to change their defensive strategy during the last minute of the game. The Ravens were on their own 30-yard line, needed a touchdown to tie the game, and had only 40 seconds left to do so.

The Broncos deployed five defensive backs, conceding any short yardage situation, and attempted to prevent the completion of any long pass plays. This was a classic example of the “Prevent Defense.” Unfortunately for Denver fans, defensive back Rahim Moore allowed receiver Jacoby Jones to get behind him which allowed quarterback Joe Flacco to complete a 70-yard touchdown pass to tie the game. The Ravens would go on to win the game in overtime.

THE DANGERS OF PLAYING IT SAFE Comfort is always temporary. A focus on safety, rather than opportunity, often results in failure in business.

In an all-too-common scenario, opportunity is lost due to risk avoidance. Inspiration never comes with a guarantee. Entrepreneurs will usually follow inspiration with gathering of information and developing a plan of action. After making small steps toward the goal, difficulties are realized that are more than anticipated. The process of advancement is then halted for better evaluation of any pitfalls.

Rationalizations follow. Although a commitment may occur to re-engage at a time that is less risky, that time never arises, and the opportunity is abandoned. Starting in independent medical practice or forming a new independent physician group is an example of such an opportunity.

Initiating a new ancillary service for a medical practice is another example.

Sundheim summarizes actions that typify “playing it safe” as: 1. Disengaging from meaningful challenge 2. Reducing creative endeavors 3. Failure to push yourself in new directions 4. Exchanging creative activities for something more predictable 5. Moving from an active to a passive mindset 6. Exchanging independence for group thinking On the other hand, rewards of “risktaking” hand are summarized as: 1. Innovation and creation 2. Learning and personal growth 3. Achieving true potential 4. Feeling more vital and alive 5. Increased sense of passion and purpose 6. Winning

BEYOND BURNOUT A great deal of attention has been paid in recent years to the phenomenon of “physician burnout.” Many of the symptoms attributed to burnout are

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closely tied to those of risk avoidance.

Avoiding burnout is not enough for a successful and rewarding professional career. Peak professional performance and strong decision-making require cycles of stress and recovery, risk and reward. A healthy relationship with risk-taking is essential to better performance and more rewarding lives.

None of this can happen without an ability to embrace failure.

Learning to live with failure is an essential part of achieving full potential. Physicians must be prepared to live with failure, worstcase scenarios, partial failures, and incomplete successes. They must be prepared to pivot, adjust, and redirect their efforts. In fact, without failures it is impossible to make progress.

START WITH PURPOSE: THE ULTIMATE FRAME All healthy risk-taking starts with the purpose. Without carefully defining and prioritizing the purpose, any risk-taking must be seen as foolish.

Sundheim calls this “something worth fighting for.” Almost any risk can be justified when dared for the appropriate purpose. If the purpose does not meet scrutiny, then the risk will also surely fail to do so. Once again, time horizon may come into play. Many risks are best taken in small steps.

This is the logic behind developing a so-called “minimum viable product” by inventors and entrepreneurs. The sooner such a product is produced and the smaller and less expensive it’s scale, the lower the risk and the faster the learning process for eventual success.

The maxim here is, “start fast, fail small.”

COMMUNICATION IS INSURANCE AGAINST RISK

Risk rarely is taken alone, and communication is critical in reducing it. First, clearly defining and communicating purpose is essential.

Refining that purpose involves gathering a variety of viewpoints.

New ideas start off with hints and guesses before we explore them in detail. It is essential to take the

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appropriate amount of time to review these ideas with others before action.

Second, having difficult conversations is an essential part of reducing risk. Often, the more difficult the conversation, the more necessary. When those involved are poor communicators, the risk is enhanced.

If there is a lack of trust between those involved, communication is the best way to improve it. Structuring and preparing for these tough conversations is vital.

STEPS TO A HEALTHIER RELATIONSHIP WITH RISK

“Medice, cura te ipsum [physician, heal thyself]” - Luke 4:23

8. Approach all risk with humility.

Balance conviction with doubt.

9. Be comfortable with failure.

Without failure, there is no improvement.

10. Purpose is paramount. Begin all risk-taking by defining the purpose for it.

Physicians are in a unique position to impact lives positively and contribute meaningfully to their communities.

Avoiding burnout is not enough for them. They deserve truly successful and rewarding careers. Healthy risktaking is a critical part of those things and is vital for a life of passion and purpose.

RESOURCES AND SUGGESTED READING 1. Argyris, Chris “Teaching Smart People to Learn” Harvard Business Review May-Jun 1991 2. Bernstein, Peter L. “Against the Gods: The Remarkable Story of Risk” John Wiley & Sons, Copyright 1996

Risk-taking is essential for success but risk perception and decision-making are irrational. This paradox increases the urgency to view risk-taking as a skill that can be studied, practiced, and improved.

Physicians embody the learning dilemma because while they are highly motivated to seek improvements, they are highly paid, unaccustomed with failure, externally focused, and defensive. In this context, they can be set up for poor decision-making.

The following are some steps for a healthier relationship with risk. While none of these removes uncertainty, adopting them will improve chances for successful risk-taking and decision-making: 1. Don’t pass the buck. Avoid overreliance on structured risk assessment.

2. Avoid the “Prevent Defense.” Playing it safe guarantees long-term failure.

3. Maintain structured and open communication. Don’t avoid the tough conversations.

4. View all risks in both positive and negative frames.

5. Start fast, fail small with new ideas.

6. View gains and losses in terms of human capital, rather than money alone.

7. View all risks by several time frames.

Time of is most critical when a decision is irreversible.

3. Cialdini Ph.D., Robert B “Influence: The Psychology of Persuasion” Pearson Education, Copyright 1984 4. Kahneman, Daniel and Tversky, Amos, “Choices, Values and Frames,” 1983 American Psychological Association Awards Address, American Psychologist 1984, Vol39(4); 341-50.

5. Kahneman, Daniel “Thinking Fast and Slow” Farrar, Straus and Giroux, Copyright 2011 6. Sundheim, Doug “Taking Smart Risks: How Sharp Leaders Win When Stakes are High” McGraw Hill Education 2012 7. Taleb, Nassim Nicholas “The Black Swan: The Impact of the Highly Improbable” Random House, 2007 8. Thaler, Richard “Misbehaving: The Making of Behavioral Economics” W.W. Norton and Company Copyright 2015

Louis J. Wilson, MD, FACG. Dr. Wilson chairs the ACG Practice Management Committee and is a gastroenterologist at Wichita Falls Gastroenterology Associates in Texas.

 MY PRACTICE IN CENTRAL VERMONT IS AN INDEPENDENT PRACTICE serving a largely rural community. Well before

TELEMEDICINE in Vermont: Using GI OnDEMAND during

COVID-19 AND BEYOND

BY Eric L. Asnis, MD, FACG

we had even heard of coronavirus, I began thinking of how telemedicine might be of value to our practice and our patients. Our practice is small; we have only two physicians, so it is critical to practice in the most efficient manner in order to maintain our independent status. We intentionally do not use an office EHR. We do not have an IT department to manage technology issues. In the Vermont winter, it can be difficult sometimes for patients to get to see us and, at times, they end up canceling office visits or simply not showing up. Some patients travel 30 or 40 miles for a 15- to 30-minute visit. Some patients can’t get rides.

We also have some patients who require frequent visits several times per week, which often involve lengthy phone calls which are unreimbursed.

When I heard about GI OnDEMAND, I began to see that telemedicine could address these issues.

They provided a cost effective, HIPAA-compliant option with IT support. The decision to start using telemedicine was a no-brainer, but I had no clue that telemedicine would soon become such a critical component of our practice, and medicine in general.

In March, when the coronavirus pandemic hit the U.S. hard, we were prepared, having just setup our

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telemedicine system. Fortunately, we were not in a hotspot, but our practice was immediately shut down when my partner and a staff member contracted COVID-19. There was a fear amongst the staff of coming to work. I did not panic, as I was able to continue seeing patients and generate some revenue through the telemedicine system, despite being the only person physically in our office, the remainder working remotely at home.

THE PATIENT EXPERIENCE Most patients embraced the technology, though some have had issues. Some low-income patients and some of the elderly may not have a computer or a smartphone. Others who live in rural parts of the state don’t have broadband coverage. Some patients have the technology but don’t know how to use it. We continued to offer telephone-only visits for these patients.

Fortunately, and thanks to the advocacy provided by our GI societies, some insurers have started providing payment parity for these services. The IT support provided by GI OnDEMAND has been instrumental in guiding the patients, as well as our staff, through the nuances of connecting to the platform.

The limitations of telemedicine were also clear. When a physical exam is needed to evaluate certain complaints, a telemedicine visit was of limited value—but being able to see patients visually definitely provides an advantage over voice-only visits. I have come to realize that there is information to be gained from facial expression and body language that can be gathered by telemedicine. We have also been able to exchange information on patient education materials through the platform.

Through the use of the telemedicine platform, my staff has been able to feel comfortable returning to the office. Our practice started to reopen to elective procedures at the hospital in early May. We decided to continue, for the time being, to see office patients only through telemedicine to ensure the safety of our staff. Eventually this will change, and we will see patients in person, but the value of telemedicine has become clear to us and will continue to play a part in our practice going forward.

known them for many years. I have some patients who travel extensively and will have the option of being seen urgently when they are anywhere in the world.

I have one patient who is a medical student with IBD who is currently studying in Poland. I have another patient who developed colitis and is an Olympic athlete training in Florida. For these patients we can now offer office visits without the need to seek medical attention in an unfamiliar environment and they can avoid the difficulty of having to find a specialist when they don’t have a primary care provider.

Working with my colleagues at the Dartmouth Hitchcock Medical Center IBD department, we will be taking part in a study to determine the role of telemedicine for complex IBD patients that I hope will help others understand the potential of telemedicine to benefit patients in rural areas like mine.

THE ROLE OF TELEMEDICINE AFTER COVID-19 I predict that after using telemedicine, some patients will likely request telemedicine appointments instead of in-person visits. We have a number of patients who go south for the winter but prefer to manage their medical problems with their local doctors, who have 34 | GI.ORG/ACGMAGAZINE

Eric L. Asnis, MD, FACG, Mountainview Physicians Center, Berlin, Vermont

Meeting Needs in CAMBODIA: ENDOSCOPY TRAINING and Technology

By Madhan S. Iyengar, MD and Adam J. Snyder, MD

With advancing health technology and knowledge transfer across the globe, the world

has seen the average lifespan increase in proportion. However, there are areas where the slope of this curve has failed to maintain this mark.

Cambodia, located between Vietnam and Thailand, has a population of approximately 16 million people, about 2 million of which reside in the capital city of Phnom Penh [1]. Although only separated by a few hundred kilometers, the average Cambodian lifespan of 69 years trails behind both its neighbors— Vietnam at 75 years and Thailand at 76 years [2]. The cause of this disparity is complex and impacted by geographic, economic, and political factors. But there is also a sinister element to this disparity—driven by the actions of the

Khmer Rouge, an extremist socialist group that seized power in 1975. At the direction of their leader, Pol Pot, the Khmer Rouge orchestrated a cultural genocide responsible for the death of nearly 2 million Cambodians.

Especially targeted was the intellectual class, which included physicians, dentists, lawyers, and teachers. By some estimates, when the Khmer Rouge were finally toppled in 1979, there were fewer than 20 doctors still alive in the country [3].

Cambodia has been slow to recover from the Khmer Rouge revolution.

To this day, the country suffers from a severe physician and medical equipment shortage. It is estimated that Cambodia has 1.7 physicians per 10,000 people, compared to 8 physicians per 10,000 people for both

of its direct neighbors, Vietnam and Thailand. Even more striking is the comparison to fully modernized nations such as the United States, which has 25 physicians per 10,000 people, or Russia at 40 physicians per 10,000 people [4].

It is even murkier determining what specialties are available to Cambodians.

Based on conversations with local physicians, there are approximately 100 gastroenterologists in the entire country of 16 million people. Of these, only about 50% are trained in endoscopy and the vast majority of endoscopy is restricted to diagnostic maneuvers. ERCP availability is very sparse. There simply have not been enough opportunities for medical training or equipment for this metric to improve.

In the summer of 2019, Dr. Adam Snyder and I heard about a group of cardiologists from Denver, CO who organize and operate an annual trip each February to provide specialty care to Cambodians. They work with an organization called Jeremiah’s Hope.

We reached out to this organization and decided to tag along and assess the GI situation in Cambodia.

Prior to the trip, we spoke with two gastroenterologists in Florida, Dr. Hong Tek and Dr. Kyle Etzkorn, who have volunteered in Cambodia in the past. These two gastroenterologists performed the first ERCP in the history of Cambodia in 2015. Through our conversations, it became clear that there was a pressing need for new equipment, as the original duodenoscope and processor they donated had vanished. There was also a need for re-training of physicians and nurses on proper maintenance of the equipment they do have. At this point, we reached out to the Pentax Corporation to see if they could help and they encouraged us to apply for a medical mission grant. This grant request was accepted and a new duodenoscope and processor were shipped directly to Sihanouk Hospital Center of Hope (SHCH). SHCH is a public hospital in the capital city of Phnom Penh, and primarily focuses on treating the city’s poor.

ACG Perspectives | 35

// ACG PERSPECTIVES

When we arrived, we knew we still had some challenges ahead of us.

The first step was, of course, getting everything to work. While both of our fellowship programs were quite rigorous and thorough, setting up a brand new duodenoscope and processor was certainly not part of it. Add to this that the processor and scope were brand new, but that the remaining Cambodian components (monitor, power supply, water, and cautery) were all at least 20 years old.

Yet, we ended up with a functioning endoscopy apparatus, albeit at times held together by sheer force of will (and the odd Cambodian nurse holding wires and plugs in place).

The next step was identifying appropriate patients for endoscopy.

Imaging is not readily available in Cambodia. MRCP is not available at all and CT scans are not easily obtained.

The pre-procedure diagnostics are often limited to laboratories, clinical history, physical examination, and the occasional ultrasound report. For instance, we were asked to evaluate a young male with jaundice, elevated transaminases, and an elevated INR for ERCP. There were no imaging tests available, but we were able to make the diagnosis of acute alcoholic hepatitis after the patient admitted to a long history of daily alcohol abuse, and thus avoided an unnecessary procedure. On the other end of the spectrum, we saw a middle-aged woman with normal transaminases, an unremarkable 36 | GI.ORG/ACGMAGAZINE

special in Phnom Penh, and that SHCH may develop the capability of performing both diagnostic and therapeutic ERCP independently. Of course, this hope is predicated on both of us returning and continuing the training at SHCH, and possibly expanding to other nearby hospitals. We also hope to convince other gastroenterologists to join us, and to bring even more valuable experience and knowledge to this country that desperately needs it.

REFERENCES 1. www.nis.gov.kh/nis/Census2019/Provisional%20Population%20

ultrasound, but with persistent biliary-type right upper quadrant pain. We decided to go forward with her ERCP and swept out several biliary stones from the common bile duct.

In total we were able to do four ERCPs over three days and were able to provide hands-on teaching to three local gastroenterologists and a number of nurses.

While we were delighted to end our stint at the Sihanouk Hospital Center of Hope by leaving a functioning duodenoscope, processor, and monitor with the hospital, we both believe that the Cambodian gastroenterologists and surgeons will need a fair amount of further training in order to become proficient with this equipment.

We hope that we have started something

Census%202019_English_FINAL.pdf 2. www.who.int/gho/countries/khm/en 3. www.the-rheumatologist.org/article/inside-cambodias-strugglespoverty-dearth-trained-rheumatologists 4. www.who.int/gho/health_workforce/physicians_density/en

images of polyps to raise awareness of colonoscopy and polypectomy via social media.

WATCH A SUMMARY VIDEO of highlights from Dress in Blue Day: bit.ly/acg-dressinblue-video-2020

COLORECTAL CANCER AWARENESS Month 2020

It’s Never Too Late to CELEBRATE

By Sophie M. Balzora, MD, FACG, Chair, ACG Public Relations Committee

The College’s observance of March Colorectal Cancer (CRC) Awareness Month started strong

with new graphics for use on social media featuring the #POLYPalooza theme, as well as outreach to ACG members offering support and resources for public education and social media engagement.

However, by the end of the second week of March, the tenor of the national conversation about health turned to SARS-CoV-2 and ACG’s public and physician communications and outreach efforts pivoted to a response to COVID-19.

The PR Committee recognizes and appreciates the energy, commitment, and creativity of those who joined the #POLYPalooza campaign and posted photos for “Dress in Blue Day” in early March. We believe it’s never too late to celebrate the work of ACG members

and their staffs during March and offer these highlights with gratitude for all you do to educate about colorectal cancer and prevention.

#POLYPALOOZA SOCIAL MEDIA CAMPAIGN Over the years, the PR Committee’s aim is to create messages and public education campaigns based on clinical evidence that clarify the role of colorectal cancer screening in health and highlight the potential to prevent colorectal cancer via polypectomy. This year, to bring attention to the role of polyps in the natural history of CRC and the role of gastroenterologists and colonoscopy in colorectal cancer prevention, ACG embraced a lighthearted theme of “POLYPalooza” with new social media graphics shared via the College’s CRC Community Education Toolkit. The call-to-action: Share your (HIPAA-compliant)

DRESS IN BLUE DAY MARCH 6, 2020 The PR Committee was very proud of ACG members and their staffs who celebrated Dress in Blue Day on Friday, March 6, 2020, with such spirit and dedication to prevent colorectal cancer.

A selection of Dress in Blue Day photos shared with the College is on Flickr,[bit. ly/acg-dressinblue-photos-2020] an online photo platform.

The evolution of Dress in Blue Day over the past few years to a national observance has made this day an important focus for social media sharing and engagement. ACG’s social media strategy is to provide encouragement, graphics, messaging, and patient information, and to amplify and extend the reach of social media posts by our members. In 2020, Dress in Blue Day engagement via Twitter was most active, although Facebook and Instagram are also channels our members use to share photos and information with patients and the public.

CRC MONTH RADIO MEDIA TOUR WITH ACG BOARD OF GOVERNORS The Committee continued its annual radio media tour on colorectal cancer screening in partnership with the ACG Board of Governors and with support from ACG President Dr. Mark Pochapin. The Committee invited ACG Governors from U.S. regions with lower-than-average CRC screening rates, according to data from the CDC, as well as Dr. Nieto, a Spanish speaker.

ACG Perspectives | 37

// ACG PERSPECTIVES

ACG CRC MONTH RADIO TOUR BY-THE-NUMBERS TOTAL LISTENERSHIP:

2,016,700

TOTAL NUMBER OF AIRINGS:

ACG 2020 MARCH CRC MONTH RADIO MEDIA TOUR PARTICIPANTS  Mark Pochapin, MD, FACG, ACG President, NYU Langone Health, New York, NY

 Sophie Balzora, MD, FACG, ACG PR Chair, NYU Langone Health, New York, NY

 Patrick E. Young, MD, FACG, Vice Chair, Board of Governors, National Military Medical Center, Walter Reed, Bethesda, MD

357

 Jay N. Yepuri, MD, MS, FACG, Governor

TOTAL NUMBER OF STATIONS AIRING:

 Michael Bay, MD, FACG, Governor New

344

including statewide networks in Mississippi, North Carolina, and Virginia, as well as metroarea networks in Washington, D.C. (Hagerstown), San FranciscoOakland-San Jose, Tampa-St. Petersburg (Sarasota), and El Paso (Las Cruces)

38 | GI.ORG/ACGMAGAZINE

Northern Texas, Digestive Health Associates of Texas, P.A., Bedford, TX Mexico, Southwest GI Associates, P.C., Albuquerque, NM

 Vonda G. Reeves, MD, MBA, FACG, Governor Mississippi, GI Associates Endoscopy Center, Flowood, MS

 Tauseef Ali, MD, FACG, Governor Oklahoma & PR Committee, Saint Anthony Hospital, Oklahoma City, OK

 Jose Nieto, DO, FACG, Governor Northern Florida & PR Committee, Borland-Grover Clinic (Spanish Speaker), Jacksonville, FL

SCOPY MOVES FORWARD FOR 2020: COLORECTAL CANCER AWARENESS IN A CHALLENGING YEAR In a year marked by the uncertainties and challenges of the COVID-19 pandemic, the PR Committee weighed carefully going forward with our tradition of the SCOPY Awards. When it comes to ACG's longstanding and deep commitment to colorectal cancer prevention, “the show must go on.” Nevertheless, the Committee and staff were mindful that this is a difficult year and allowed practices extended time to submit their applications.

This year, it is especially important to carry on SCOPY's mission of recognizing great work by the GI community in promoting colorectal cancer awareness, even as ACG aims to help practices resume or ramp up endoscopy through the ACG Endoscopy Resumption Task Force.

Sophie Balzora, MD, Chair, ACG Public Relations Committee

EDUCATION

THE ACG EDGAR ACHKAR VISITING PROFESSORSHIP Providing Noteworthy Speakers for Training in Your Communities THE EDGAR ACHKAR VISITING PROFESSORSHIP PROGRAM (EAVP) provides opportunities for highly regarded GI leaders to visit institutions, spend time with fellows, educate colleagues, and visit with young faculty to enhance the educational experience for GI fellowsin-training and provide objective, timely, and clinically-relevant presentations to GI practitioners in the community.

Institutions, in conjunction with

the visiting professor, select topics to best address areas of clinical interest and meet the needs of the fellowship program. These educational opportunities provide flexibility in their format and have included lectures, small group discussions, one-on-one visits, community events, hands-on courses, and online courses in advance of the visit, creating opportunities to engage both the GI program and their local GI community.

This issue of ACG MAGAZINE shares visits from Laura E. Raffals, MD, FACG, to Creighton University and Roy M. Soetikno, MD, FACG, to the University of North Carolina at Chapel Hill. To date, more than 60 institutions have hosted 48 speakers from coast to coast in the United States, as well as Canada, thanks to the ACG Institute for Clinical Research & Education and charitable support to its G.U.T. Fund.

Education | 39

// EDUCATION

“The fellows were inspired by [Dr. Raffals'] mentorship, advice, and personal examples... particularly in regards to gaining leadership skills and finding enjoyment and passion in work.”

—Erin T. Jenkins, MD, Creighton University

40 | GI.ORG/ACGMAGAZINE

2020

ACG EDGAR ACHKAR VISITING PROFESSORSHIPS ROY SOETIKNO, MD, FACG University of North Carolina at Chapel Hill JANUARY 9-11 STEPHEN B. HANAUER, MD, FACG Geisinger AUGUST 7 (VIRTUAL) JOHN E. PANDOLFINO, MD, MSCI, FACG Providence-Providence Park Hospital SEPTEMBER 9-10 (VIRTUAL) PAUL Y. KWO, MD, FACG UC Irvine SEPTEMBER 16 (VIRTUAL) DAVID A. JOHNSON, MD, MACG Rutgers Robert Wood Johnson School of Medicine POSTPONED MILLIE D. LONG, MD, MPH, FACG Tufts Medical Center POSTPONED BRUCE E. SANDS, MD, MS, FACG University of Kansas Medical Center POSTPONED

“The biggest impact of the visit was that almost all of our fellows and most of our luminal GI faculty learned a new endoscopic skillset—the use of over-the-scope clips in GI bleeding.”

BRIAN E. LACY, MD, PHD, FACG Allegheny General Hospital POSTPONED DAVID T. RUBIN, MD, FACG Methodist Dallas Medical Center POSTPONED

CAROL A. BURKE, MD, FACG Atrium Health in Charlotte, North Carolina POSTPONED CHRISTINA HA, MD University of New Mexico POSTPONED

—Sarah K. McGill, MD, University of North Carolina at Chapel Hill

The Edgar Achkar Visiting Professorship program is a project of the ACG Institute and is supported by charitable contributions to the G.U.T. Fund.

Education | 41

OBSERVERSHIP @ UPMC CHILDREN’S HOSPITAL OF PITTSBURGH

By Dr. Vikrant Sood

The Indian subcontinent, accounting for almost one-fourth of the world’s population, has an expectedly high

burden of liver diseases, especially chronic viral hepatitis. As per conservative estimates, less than 5% of the patients requiring liver transplant for various illnesses actually undergo this procedure annually in India, mainly due to financial constraints and donor availability (programs being predominantly living-donor-related).

Unlike the developed countries where medical expenses are taken care by personal insurance policies, the majority of the population in this part of the world depend on the out-of-thepocket expenditure for the same. As is the current scenario in the Indian subcontinent, liver transplant facilities are restricted to only the large private sector hospitals. This lack of affordable access to liver transplantation is the

42 | GI.ORG/ACGMAGAZINE

major hindrance to goal of universal healthcare. This happened because previously there were no governmentsponsored liver transplant programs.

At my present institution, the Institute of Liver and Biliary Sciences, the state government established the first state-sponsored governmentrun public sector liver transplant program in the entire region which subsequently succeeded in allowing even the marginalised sections of the society access to quality healthcare including Liver Transplantation at nominal prices. With a long term aim of working in a academic setup, I wished to steer my career path in a way that has a balanced mix of research and clinical work.

Thus, it was a dream come true when I was selected by the ACG for a sixmonth training in pediatric transplant hepatology in the Liver Transplant Unit at the prestigious UPMC Children’s

Hospital of Pittsburgh (CHP), Pittsburgh, which is one of the foremost and premier units in the entire world, and their forefathers were the pioneers in building up the concept of the field of Pediatric Liver Transplantation. With experience spanning more than four decades, the unit has performed >1,800 pediatric liver transplants and is the largest living donor transplant program in the entire country with long term post transplant survival rates exceeding 95%.

During the observership, I attended the daily inpatient and outpatient units where pre- and post-transplant patients (including cases of both liver and multivisceral transplants) were being managed; detailed discussions involving difficult post transplant situations like recurrent malignancies, PTLD, recurrent or refractory rejections, etc. were real eye-openers. I also attended the weekly transplant pathology and multispeciality transplant board meetings where various

aspects of pediatric liver transplant would be discussed in detail. During the interaction with the transplant unit, I was exposed to various novel transplant concepts, including immunogenetic basis (including biomarker development) for rejection after transplant. I was also kindly allowed to take part in some of the ongoing projects in the department including study of genetic variants in subjects with rejection vs. tolerance in liver transplantation using whole exome analysis, and review of living related liver transplantation in metabolic liver diseases in children.

Simultaneously, I was also given the opportunity to gain some clinical experience in the management of metabolic liver diseases in children in the division of medical genetics including pre-, peri- and post-livertransplant management. In this regard, I was exposed to the huge variety of

these disorders including diseases like urea cycle defects, mitochondrial hepatopathies, etc. I also spent some time in the metabolic lab where I observed the lab techniques of metabolic testing (amino-acid/organic acid/carnitine-acylcarnitine analysis) including their interpretation. Also, I learnt the basics of genetic testing and genetic counselling which was really helpful in the learning the diagnostic aspect of metabolic diseases.

I would always be grateful to my teachers at the CHP (UPMC): Prof. Robert Squires, Prof. Patrick McKiernan, Dr. James Squires, Dr. Veena Venkat (Pediatric Hepatology), Prof. George Mazareigos, Prof. Rakesh Sindhi, Prof. Ajai Khanna, Dr. Kyle Soltys, Dr. Armando Ganoza (Transplant Surgery), Prof. Gerard Vockley, Prof. Uta Lichter-Konecki, Dr. Lina Ghaloul Gonzalez (Medical Genetics) and Dr. Steve Dobrowolski (Clinical Biochemical Genetics Laboratory) for their

wonderful mentorship, commitment and willingness to go the extra mile just for me. Also, a special thanks to fellows (Dr. Sarah Henkel, Dr. Arpit Amin and Dr. Laura Duque Lasio) and nurses/coordinators (including Ms. Terry Trimble) I worked with for their constant support and guidance. All this would not have been possible without the encouragement and support of my mentors at my parent institution, Prof.

S.K Sarin and Prof. Seema Alam.

It was a life-changing experience, indeed, which I am sure would positively shape all my future endeavours. Thank you ACG for this wonderful opportunity.

Photo top left: Dr Chen (Observer, Transplant Surgery), Dr Arpit Amin (Fellow, Transplant Surgery), Prof. Ajai Khanna (Tranplant Surgery), Prof. Patrick McKiernan (Hepatology), Dr. Yu-Tang Chang (Observer, Transplant Surgery), Dr Sarah Henkel (Fellow, Transplant Hepatology), Myself, Dr James Squires (Hepatology), and Prof. George Mazareigos (Transplant Surgery). Photo top right: Ms. Beverly Kosmach (Clinical Nurse Specialist, Transplant Services), Dr Arpit Amin (Fellow, Transplant Surgery), Dr Armando Ganoza (Transplant Surgery), Prof.

Robert Squires (Hepatology), Myself, and Ms. Tamara Fazzolare (Physician Assistant, Transplant Services)

Education | 43

APPLY

for an ACG Clinical

Research Award

Deadline: Friday, December 4, 2020 NEW!

Mid-Career/Senior Clinical Scientist Bridge Funding Award $150,000 a year for two years ACG Junior Faculty Development Award $150,000 a year for three years Clinical Research Award up to $50,000; pilot data required Clinical Research Pilot Award up to $15,000 for pilot projects “Smaller Programs” Clinical Research Awards up to $35,000 for programs with 15 or fewer full-time faculty Resident Clinical Research Award up to $10,000 Medical Student Research Award up to $5,000 for 6–10 week summer project

Learn more about ACG 2021 Clinical Research Opportunities and Submit Your Application:

GI.ORG/GRANT-ANNOUNCEMENTS 44 | GI.ORG/ACGMAGAZINE

https://gi.org/acgvgr

https://gi.org/acgvgr

https://gi.org/acgvgr

ACG LAUNCHES

VIRTUAL GRAND ROUNDS and Embraces #GIHOMESCHOOLING During COVID-19

By Brooks D. Cash, MD, FACG, Chair, Educational Affairs Committee

In March, 2020 as most of the

country began to shut down due to the COVID-19 pandemic, ACG was busy at work creating our now familiar Virtual Grand Rounds webinar series.

ACG’s leadership and the Educational Affairs Committee recognized that with the implementation of social distancing, opportunities for face-toface education were rapidly shrinking.

Our members and trainees were going to need a way to stay current on general GI education as well as the COVID-19 pandemic and its impact on clinical practice.

In response, ACG quickly created a weekly series of lectures on general GI topics convened each Thursday at Noon EDT to fill a void left by the demise of live lectures. Topics

have ranged from “Small Intestinal Bacterial Overgrowth: Fact or Fiction” and “Update on Managing Your Pregnant IBD Patient” and the College has tapped an incredible number of powerhouse faculty who have been gracious with their time and expertise to deliver world-class lectures and continuing education.

SPECIAL EVENING SESSIONS TACKLE COVID-19 CHALLENGES FOR GASTROENTEROLOGISTS & ENDOSCOPISTS

brought together the clinical expertise of physicians from different specialties whose experience at institutions in New York City facing the surge of SARS-CoV-2 patients offered invaluable insights to help the entire GI community address the emergency.

Later, as the practical challenges of endoscopy loomed large for so many in GI, these special evening webinars tackled topics such as “COVID-19: A Roadmap to Safely Resuming Endoscopy” and “Bolstering Resiliency & Well-Being: Strategies to Reactivate Your Staff and Your Practice During COVID-19.” Each of these 60-90-minute sessions included a live presentation by one or more thought leaders followed by an expert moderated Q&A session.

Since the launch of ACG Virtual Grand Rounds, the College has now offered dozens of distinct topics and featured content developed with leadership and input from a range of experts within the College, including the ACG Endoscopic Resumption Taskforce, the ACG Resiliency and Wellbeing Taskforce, the ACG Diversity, Equity, & Inclusion Committee, and the ACG Training Committee. Key talks in partnership with the Crohn's & Colitis Foundation, the American Neurogastroenterology and Motility Society, and GI OnDEMAND have made it possible for ACG to address pressing concerns including the care of IBD patients on immunotherapies, the unique challenges of resuming or ramping up motility testing during the pandemic, as well as the essential role of telehealth in these unprecedented times.

The weekly and special Grand Rounds are accredited for CME and ABIM MOC points and recordings of past webinars can be found on the ACG’ Online learning platform, the ACG Education Universe universe.gi.org. Upcoming topics as well as past lecture information and handouts for each talk can be found at gi.org/ACGVGR.

Additional special grand rounds were offered as evening webinars addressing the key issues gastroenterologists would need to understand as they were called to the front lines of the pandemic, often as internists on the COVID floors. A notable early session

Education | 45

ACG VIRTUAL GRAND ROUNDS BY THE NUMBERS TOTAL NUMBER OF PARTICIPANTS

NUMBER OF SESSIONS

30+

MORE THAN

25,000*

22 webinars with 23,650 attendees for live webinars

AVERAGE NUMBER OF PARTICIPANTS

AVERAGE LIVE ATTENDANCE

1075

RECORD-SETTING SESSION WITH HIGHEST NUMBER OF LOGINS

1849

Special Grand Rounds Webinar on March 22: “COVID-19 and Impact on Clinical GI”

ACG VIRTUAL GRAND ROUNDS (AS OF JUNE 2020) Week 1: SIBO: Challenges in Diagnosis and Treatment Thursday, March 26, 2020 Presenter: William D. Chey, MD, FACG Week 2: Chronic Abdominal Pain and Bloating Thursday, April 2, 2020 Presenter: Brian E. Lacy, MD, PhD, FACG Week 3: Update on Managing Your Pregnant IBD Patient Thursday, April 9, 2020 Presenter: Sunanda V. Kane, MD, MSPH, FACG

1466

Weekly Grand Rounds Lecture on April 30: “Celiac Disease...

Or Not? A Guide to Celiac Mimickers” Dr. Amy Oxentenko

Week 7: C. difficile and Fecal Microbiota Transplant: The Beginnings of Microbiome Therapy Thursday, May 7, 2020 Presenter: Neil H. Stollman, MD, FACG Week 8: Serrated Polyps and Serrated Polyposis Syndrome Thursday, May 14, 2020 Presenter: Carol A. Burke, MD, FACG Week 9: Positioning of Old and New Therapies in IBD Thursday, May 21, 2020 Presenter: David T. Rubin, MD, FACG

Week 4: Hepatitis B: An Update Thursday, April 16, 2020 Presenter: Nancy S. Reau, MD, FACG

Week 10: Colorectal Cancer Screening in a Post-COVID World Thursday, May 28, 2020 Presenter: Renee L. Williams, MD, MHPE, FACG

Week 5: Refractory GERD: New Options for Treatment 2020 Thursday, April 23, 2020 Presenter: Philip O. Katz, MD, MACG

Week 6: Celiac Disease…Or Not? A Guide to Celiac Mimickers Thursday, April 30, 2020 Presenter: Amy S. Oxentenko, MD, FACG

46 | GI.ORG/ACGMAGAZINE

Week 11: Non-Alcoholic Steatohepatitis: Disease Burden, Diagnosis, and Treatment Thursday, June 4, 2020 Presenter: Zobair M. Younossi, MD, MPH, FACG

Week 12: Gastroparesis: Then, Now, and the Future Thursday, June 11, 2020 Presenter: Henry P. Parkman, MD, FACG Week 13: Health Maintenance for the Patient with IBD Thursday, June 18, 2020 Presenter: Francis A. Farraye, MD, MSc, FACG

ACG SPECIAL EDITION GRAND ROUNDS (AS OF JUNE 2020) SPECIAL EDITION — COVID-19: Surviving the Impact to GI Practices Monday, April 13, 2020 Hosted by: ACG President Mark Pochapin, MD, FACG; ACG President-Elect David Greenwald, MD, FACG; and The ACG Board of Governors SPECIAL EDITION — COVID “101” for the Clinical Gastroenterologist Friday, April 17, 2020 Hosted by: ACG President Mark Pochapin, MD, FACG, and ACG President-Elect David Greenwald, MD, FACG SPECIAL EDITION — COVID-19: A Roadmap to Safely Resuming Endoscopy Monday April 27, 2020 Hosted by: ACG Trustee Costas H. Kefalas, MD, MMM, FACG; ACG Chair of the Board of Governors Neil Stollman, MD, FACG; and the ACG Endoscopy Resumption Task Force SPECIAL EDITION — IBD Circle Virtual Grand Rounds: IBD in the COVID-19 Era: Update for the Busy Clinician Tuesday, May 12, 2020 Hosted by: The ACG / CCF IBD Circle

NUMBER OF HOURS OF CME

7854 CME CREDITS claimed in March/April/May

MOC 3483 ABIM POINTS claimed in March/April/May

NUMBER OF FACULTY

50*

NUMBER OF MODERATORS

30*

MODERATORS WITH THE MOST ACGVGR SESSIONS Weekly: Dr. Brooks D. Cash, Chair of Educational Affairs has moderated five sessions Special: Dr. Mark B. Pochapin, ACG President, and Dr. David A. Greenwald, ACG President-Elect, have each moderated four sessions

* As of 6/22

SPECIAL EDITION — Gastrointestinal Manifestations of COVID-19: Latest Data on Symptoms, Stool Testing, and Clinical Outcomes Monday, May 18, 2020 Presenters: Brennan M. Spiegel, MD, MSHS, FACG; Paul Y. Kwo, MD, FACG; Millie D. Long, MD, MPH, FACG; and Jordan E. Axelrad, MD, MPH SPECIAL EDITION — COVID-19: Resuming Endoscopy: Unanswered Questions and Ongoing Controversies Monday, June 1, 2020 Hosted by: ACG Trustee Costas H. Kefalas, MD, MMM, FACG; ACG Chair of the Board of Governors Neil Stollman, MD, FACG; and the ACG Endoscopy Resumption Task Force SPECIAL EDITION — Bolstering Resiliency & Well-Being: Strategies to Reactivate Your Staff and Your Practice During COVID-19 Monday, June 8, 2020 Faculty: Mark B. Pochapin, MD, FACG; Renee L. Williams, MD, MHPE, FACG; Cynthia M. Stonnington, MD; Patrick E. Young, MD, FACG; Dona E. Locke, PhD; and Jonathan A. Leighton, MD, FACG SPECIAL EDITION — Joint ACG/ ANMS Webinar – Restarting Your Motility Practice Monday, June 15, 2020 Speakers: Mark B. Pochapin, MD, FACG; Jason Baker, PhD; C. Prakash Gyawali, MD, MRCP, FACG; Baharak Moshiree, MD, FACG; William D. Chey, MD, FACG; Satish S.C. Rao, MD, PhD, FACG; Abraham R. Khan; MD, FACG

Education | 47

NEW! ACG VIRTUAL GRAND ROUNDS Weekly on Thursdays at Noon EDT Live Presentation by an ACG Expert Plus Q & A #GIhomeschooling

https://gi.org/acgvgr

https://gi.org/acgvgr

https://gi.org/acgvgr

Even as all aspects of practice have changed due to COVID-19, your need to stay up to date on clinical GI does not stop. ACG is committed to your professional education and—until we can be together in person again—our goal is to help the GI community embrace #GIhomeschooling at this time.

ACG has launched Virtual Grand Rounds weekly on Thursdays at Noon EDT. Each week an expert faculty member will present live on a key topic followed by Q & A.

Learn More and Register: GI.ORG/ACGVGR

48 | GI.ORG/ACGMAGAZINE

Inside the

JOURNALS

G

AC RTS EPO CASE RO J URN L G OM I.OR TS.C TS.G POR POR ERE ERE CAS CAS ACG ACG

VOLUME 6

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

AS THE MAY 2020 ISSUE OF THE AMERICAN JOURNAL OF GASTROENTEROLOGY PROVES, negative is positive—at least when it comes to a special issue dedicated to negative studies, according to Co-Editors-in-Chief Dr. Brian Lacy and Dr. Brennan Spiegel.

In AJG Author Insights, Dr. Timothy Gardner offers a practical clinical approach to chronic pancreatitis and summarizes key take-aways from the College’s new guideline. He presents a diagnostic algorithm based on the new mechanistic definition of chronic pancreatitis.

Dr. Gardner offers further insights in the AJG Podcast he recorded with Dr. Spiegel.

From the steady flow of new papers published in Clinical and Translational Gastroenterology, we feature an analysis of SEER data by Hussan, et al., “Rising Incidence of Colorectal Cancer in Young Adults Corresponds with Increasing Surgical Resections in Obese Patients.”

Dr. Brett Sadowski makes a persuasive case for using fellowship training as a “leadership laboratory” in his reflection, “Leadership in Gastroenterology: Developing Fellows for Future Responsibility” in ACG Case Reports Journal, an open access journal edited by fellows-intraining.

Inside the Journals | 49

// INSIDE THE JOURNALS

INSIDE THE JOURNALS [THE AMERICAN JOURNAL OF GASTROENTEROLOGY]

ACG Clinical Guideline: Chronic Pancreatitis Timothy B. Gardner, MD, MS, FACG

 THE ACG CLINICAL GUIDELINES ON CHRONIC PANCREATITIS SERVE TO EDUCATE ON HOW TO DIAGNOSE AND MANAGE this often very debilitating disease.

These guidelines are the first the ACG has commissioned on the topic. They highlight the new mechanistic definition of disease, which is defined as a pathologic fibroinflammatory syndrome of the pancreas in individuals with genetic, environmental, and/or other risk factors, who develop persistent pathologic responses to parenchymal injury or stress. The features of the disease include pancreatic atrophy, fibrosis, pain syndromes, duct distortion and strictures, calcifications, pancreatic exocrine dysfunction, and dysplasia.

DIAGNOSIS

The mainstay of diagnosing chronic pancreatitis is using cross-sectional imaging with CT scan or MRI. If these tests do not demonstrate the classic morphologic findings of chronic pancreatitis, an endoscopic ultrasound should then be performed.

Due to the lack of evidence inherent in published EUS scoring systems to date, no particular scoring system is recommended.

If standard cross-sectional imaging and/or EUS does not all allow a diagnosis to be made, secretin-enhanced MRCP followed by obtaining pancreatic histology is equivocal. At this time, pancreatic histology represents the diagnostic gold standard for the diagnosis of chronic pancreatitis. Of note, pancreatic function testing only serves to diagnosis pancreatic exocrine insufficiency and this is an ancillary test for the diagnosis of chronic pancreatitis.

50 | GI.ORG/ACGMAGAZINE

DETERMINING ETIOLOGY

A comprehensive evaluation for all modifiable risk factors should be undertaken in every patient with chronic pancreatitis to determine the etiology.

If a standard evaluation of the TIGAR-O criteria does not produce a diagnosis, genetic testing should then be performed.

The hallmark clinical symptom of chronic pancreatitis is severe pain with varying degrees of exocrine and endocrine insufficiency. In general, a particular etiology of chronic pancreatitis, with the exception of autoimmune pancreatitis, does not determine important clinical outcomes.

TREATMENT

Patients should be advised to avoid alcohol and tobacco if they have chronic pancreatitis. There is no evidence that performing screening examinations to evaluate for the risk of chronic pancreatitis is beneficial.

To clear the pancreatic duct of stones, endoscopic therapy is first line; however, if this is not successful, surgical therapy has been demonstrated to have

a more efficacious and durable success rate. Antioxidants can be used to treat chronic pancreatitis; opiates can be used but should only be tried if all other options have been exhausted. Pancreatic enzyme therapy specifically for the treatment of pain has not shown to be successful in alleviating pain and is not recommended. Celiac plexus blockade can be attempted, but the success of this intervention is often disappointing. Total pancreatectomy with islet autotransplant should be saved only for those patients who can be evaluated at an expert care center.

MANAGEMENT OF EXOCRINE PANCREATIC INSUFFICIENCY

Patients should be treated with pancreatic enzyme replacement therapy if they are found to have pancreatic exocrine insufficiency.

Fat-soluble vitamins, zinc, and bone density levels should be screened regularly.

These guidelines will hopefully prove to be beneficial to the practicing clinician by providing a standardized, evidence-based approach to treating patients with this disease.

 READ the article: bit.ly/ACGGuideline-Chronic-Pancreatitis  LISTEN to the podcast: bit.ly/AJGPodcast-Chronic-Pancreatitis

[ACG CASE REPORTS JOURNAL]

Leadership in Gastroenterology: Developing Fellows for Future Responsibility Brett W. Sadowski, MD, Walter Reed National Military Medical Center, Bethesda, MD, Medstar Georgetown University Hospital, Washington, DC

THE TIME TO PREPARE TO LEAD OUR FIELD IS NOW Physicians represent some of the most highly trained professionals in the United States, dedicating more than a decade of their lives to imbuing themselves with a sense of duty to those they serve and developing the expertise required to treat complex patients. Despite their crucial position in health care delivery, their potential as leaders within the nation's health system is often unrealized. Be it leading and managing multi-disciplinary divisions, engaging in intradepartmental, large scale quality improvement initiatives, or inspiring others as representatives in national organizations, physicians are positioned to have a broad impact far beyond direct patient care. As frontline clinicians, trainees have a unique perspective, which allows them to observe and make improvements on policies that affect their patients on a day-to-day basis. Fresh ideas that disrupt practices can optimize care in an age different from the one in which older policies were crafted. In a system that mainly focuses on medical knowledge and patient care domains, it is easy for fellows to neglect the fact that they are the leaders who will take on the mantle of responsibility within years, if not already during

training. Although we often ask whether we are doing enough research or board preparation outside our direct clinical time, how often do we reflect on our preparation to lead? Is that any less important?

CONCEPTS TO CONSIDER Although just being on the job can allow physicians to “accidentally” gain leadership experience, dedicating time to formally develop and assess your abilities can help consolidate these skills. For instance, reflecting on common occurrences, including your communication with colleagues and ability to give feedback, may enhance your team's performance. You can also use these skills managing conflict more efficiently so that your group's goals can be met. Assessing your comfort with different leadership styles outside of your comfort zone is also something to think about because varying them between authoritarian, paternalistic, hands-off, or democratic strategies can increase situational versatility and also allow for better followership. Although these only scratch the surface of what leadership can mean to you, your departments, and your patients, they can open the door to countless discussions and reflections that can ready you for the next opportunities.

USING FELLOWSHIP AS A LEADERSHIP LABORATORY There are several specialties that you can consider when reflecting on your own readiness to lead, both locally and through the national organizations, some with titles and some without. Within your own institution, leading quality improvement efforts can be a gateway to enhancing your own ability to manage multidisciplinary teams. For instance, developing systemsbased solutions to problems such as inadequate hepatitis C screening or follow up after positive fecal immunochemical tests would allow for experiential learning

Podcast: Achieving Competence in Endoscopy Dr. Samuel Han discusses ways to get the most out of your endoscopy fellowship training with former ACGCRJ Editor-inChief, Roberto C. Simons-Linares, MD  Listen: bit.ly/ACGCRJ-Han-Podcast

BEHIND THE CASE: An ACG Case Reports Journal Podcast

of clinical leadership skills while improving health care delivery. Beyond leading these efforts, fellows are also ideally positioned to mentor and coach residents and students in practicing these quality improvement and clinical leadership skills. Another opportunity to gain experience in some programs includes serving as a chief fellow in your final year of training.

Formal curricula exist to help programs develop dedicated sessions to teach concepts related to leadership in health care, although outcomesbased research related to these is generally lacking. Finally, opportunities to engage in the national organizations related to our specialty provide extraordinary opportunities to learn from and interact with seasoned leaders in the field. All of the national organizations in our field (ACG, AGA, AASLD, and ASGE) offer committees and special interest groups for which trainees can apply to be exposed to the governance of the organizations early in their training. In addition, the ACG offers an opportunity through its Young Physician Leadership Scholars Program, providing an opportunity for senior fellows and early faculty to engage in leadership and advocacy skill development while focusing on organizational behavior and executive decision-making.

There is no doubt that our generation of physicians will need to lead a transformative change of our nation's complex and constantly evolving health care system. Spending time reflecting on this fact, using fellowship as a leadership laboratory, and readying a versatile and malleable skill set will improve our community and the care of our patients.  Read: bit.ly/ACGCRJ-Sadowski

ACGCRJ PODCASTS Each month the editors of the ACG Case Reports Journal interview authors of key gastroenterology and hepatology case reports and discuss essential teaching points.

You can subscribe and download episodes via Apple, Google, Spotify, Stitcher, and Pocket Casts.

Inside the Journals | 51

[CLINICAL & TRANSLATIONAL GASTROENTEROLOGY]

[THE AMERICAN JOURNAL OF GASTROENTEROLOGY]

Rising Incidence of Colorectal Cancer in Young Adults Corresponds With Increasing Surgical Resections in Obese Patients

Negative is Positive

Hisham Hussan, MD, FACG; Arsheya Patel, MD; Melissa Le Roux, MS; Zobeida CruzMonserrate, PhD; Kyle Porter, MAS; Steven K. Clinton, MD, PhD; John M. Carethers, MD, FACG; Kerry S. Courneya, PhD. Despite a temporal rise in young-onset CRC, GC, and PC, Hussan, et al. only identify a corresponding increase in young adults with obesity undergoing CRC resections. These data support a hypothesis that the early onset of obesity may be shifting the risk of CRC to a younger age.

of young adults with obesity who underwent surgical resections for CRC. Interestingly, this trend was not observed in young obese adults with GC and PC. These findings strengthen the role of obesity in the early-onset CRC pathogenesis.

Previous studies identify an increase in rectal cancer incidence that has driven the rise in early-onset CRC (26–29) . Similarly, our data from the National Inpatient Sample show an increasing number of obese patients undergoing CRC resections, especially for young adults with rectal cancer.

Interestingly, however, obesity was thought to be more related to proximal colon cancers as opposed to rectal cancers, and further data are needed to delineate the role of obesity in the pathogenesis of earlyonset rectal cancer.”  READ: bit.ly/CTG-Hussan-CRC

COLON

6

 INCREASING INCIDENCE OF YOUNG ONSET CRC “The rates of obesity have risen in previous decades, making it a major health burden. In this study, we hypothesized that obesity is the driving force for a previously observed increase in CRC incidence in younger adults. We also investigated the incidence and surgical resections for other obesity-related gastrointestinal cancers divided by age groups. To the best of our knowledge, this study is the largest to address this question by simultaneously querying the SEER and NIS databases. Similar to previous studies, we demonstrate an increase in the incidence of youngonset CRC in the United States in 2002–2013. We also report a novel finding of increased young-onset GC and PC incidence.

Using the National Inpatient Sample, our data are the first to show Hussan et al. an increasing number

Figure 3. Number of adults who underwent colorectal and gastric cancer resections with AAPC stratified by age group and obesity: NIS 2002–2013. AAPC, average annual percent change. *When P , 0.05.

FigureP 3. of adults underwent colorectal and cancers, and further datagastric are neededcancer to delineateresections the role of obesity in 125.7%, , Number 0.001). Although resectionswho tended to increase the pathogenesis of early-onset rectal canceraverage (30). One possible exover time for nonobese patients by with age EC, the trends were with AAPC stratified group andmore obesity: NIS 2002–2013.

AAPC, modest when compared with patients with obesity. planation would be the collective contribution of poor lifestyle diannual percent change. *When P < 0.05 etary and exercise patterns to the pathogenesis of early-onset CRC, in part, by also increasing body fatness. In particular, diets rich in DISCUSSION processed foods, red meats, added sugars, and refined grains have The rates of obesity have risen in previous decades, making it been strongly linked to the development of CRC (5). Specifically, a major health burden. In this study, we hypothesized that obesity is such “Western diets” have been associated with an increased inthe driving force for a previously observed increase in CRC incidence of distal colon and rectal tumors, more so than proximal cidence in younger adults. We also investigated the incidence and colon tumors (31,32). Notably, the association between obesity and surgical resections for other obesity-related gastrointestinal cancers early-onset CRC remained significant after adjusting for diet and divided by age groups. To the best of our knowledge, this study is physical activity in a previous study, suggesting an independent role the largest to address this question by simultaneously querying the of increased body fatness in the early-onset CRC carcinogenesis (12).

SEER and NIS databases. Similar to previous studies, we demonWe also observe an increasing number of obese patients 50 years or strate an increase in the incidence of young-onset CRC in the older with CRC resections, which is likely masked in the SEER data United States in 2002–2013. We also report a novel finding of by the larger decline in resections seen among nonobese patients 50 increased young-onset GC and PC incidence. Using the National

52 | GI.ORG/ACGMAGAZINE

Special AJG Negative Issue May 2020 Brian E. Lacy, MD, PhD, FACG & Brennan M. R. Spiegel, MD, MSHS, FACG, Co-Editors-in-Chief

The field of medicine is constantly evolving. New diagnostic tests, innovative therapeutics and groundbreaking surgical techniques are announced on nearly a daily basis. Advances in medicine, and in all aspects of health care delivery, depend upon rigorous and innovative research programs. Research can take place in any number of different settings (e.g., a basic laboratory, the community, an outpatient clinic, the endoscopy suite) and be categorized as basic science, epidemiologic, translational or clinical in nature.

Scientific advances frequently develop in a series of slow, methodical steps that build upon each other, an incremental process that often takes years and occasionally decades.

Less commonly, a major scientific advance develops within a short period of time, surprising the medical community. These advances, whether rapid or slow to evolve, are typically announced to the scientific community in peer-reviewed journals, such as The American Journal of Gastroenterology.

Traditionally, only research studies that produced a positive result were published. The rationale behind this was that it was believed that only a positive result could be used to change medical care. Thus, the demonstration that a new medication was statistically better than placebo, or that a new diagnostic test was better than an older test, would both be considered a positive finding and thus considered eligible for publication.

However, we believe that significant information can also be learned from studies that do not produce positive results; these are often referred to as “negative” studies. Consider a study comparing a new, expensive medical test to an older, but inexpensive medical test. The study would be considered negative if there was no difference between the two tests, and thus might not get published.

However, that information would be invaluable to the health care system, as the older test could be preferentially used while saving valuable health care dollars. A host of other examples could be provided involving medications, endoscopic and surgical techniques, and other diagnostic tests.

Although once considered unpublishable, we strongly believe that a methodologically sound, wellcrafted study with negative results

is just as valuable, and sometimes even more valuable, than a scientific study with positive results. For that reason, we were proud to offer a special issue of The American Journal of Gastroenterology in May 2020 which focuses on negative studies.

Following the success of our first “negative issue” published in 2016, the AJG May 2020 negative issue features a wide range of informative articles that will appeal to our readers regardless of specialty. A few highlights include: • A systematic review providing up to date information demonstrating that proton pump inhibitors do not cause dementia by Khan, et al.

• The potential association of PPI therapy in a number of gastrointestinal malignancies is investigated and reported by Lee and colleagues.

• An interesting survey by Kurlander, et al. provides information about common misconceptions regarding PPI safety, which is clinically relevant as some clinicians inappropriately stop PPI use in patients who truly need therapy.

• The role of serum ammonia in predicting clinical outcomes is reviewed in a timely article by Rockey and colleagues.

• The results of a large study investigating a novel agent for Crohn’s disease are presented by Sands, et al.

• An important study by Forbes, et al. showing that prophylactic clipping does not prevent delayed postpolypectomy bleeding will be of interest to all who perform endoscopy.

This special issue has a number of other important “negative” studies in addition to several essential review articles, unique images and videos, very educational editorials, and interesting correspondence. We hope that you find reading the “negative” issue as informative and interesting as we did when we assembled these innovative articles. We are sure that the information provided will help you better care for your patients.

Remember, “negative is positive.”  READ the AJG Negative Issue: bit.ly/AJG-Negative-2020

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

A A LO LOOK OK BA BACK CK

50 YEARS AGO...

from the pages of The American Journal of Gastroenterology

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

Pseudomembranous Colitis: From Mysterious Rarity to All-Too-Common Menace

F

ifty years ago, Benner and Tellman published one of the first case-series relating pseudomembranous colitis to ingestion of the antibiotic lincomycin in The American Journal of Gastroenterology.1 The condition was first described in 1893 by Finney, a surgeon at Johns Hopkins Hospital, in a patient recovering from gastric surgery.2 He called it “pseudodiphtheritic enteritis” because of the presence of pseudomembranes in the intestines, similar to those seen in the throat with diphtheria.

(The patient was hypotensive postoperatively and may have had colonic ischemia.)

With the proliferation of antibiotic use in the 1950s, “antibiotic-associated diarrhea” was increasingly recognized. Most were self-limited episodes of watery diarrhea and only occasionally involved pseudomembranes. Some of the more serious cases were attributed to “staphylococcal enterocolitis,” but this association later proved to be spurious.

After lincomycin and its daughter drug, clindamycin, were introduced in the 1960s and early 1970s, reports of pseudomembranous colitis increased. This led to the development of a hamster model of clindamycin-induced colitis by John Bartlett in 1975 and the discovery that a toxin produced by Clostridioides difficile was responsible for most cases of pseudomembranous colitis.3 Despite understanding the pathogenesis of the disorder and the rapid development of oral vancomycin as a treatment, pseudomembranous colitis has become a common nosocomial and community infection due to more intense antibiotic therapy. We have come to recognize that the fundamental disorder is a disturbed microbial flora

Figure 1.

Barium en ema from pseudom patient w embranou ith s colitis re ported by Benner & Tellman.1

that is exploited by C. difficile, not just infection by the organism. Salvage therapy with fecal microbial transplantation for patients with recurrent disease after vancomycin has been used to correct the underlying disturbance with great success.4, 5 References:

1. Benner EJ, Tellman WH. Pseudomembranous colitis as a sequel to oral lincomycin therapy. Am J Gastroenterol 1970 Jul; 54(1): 55-8.

2. Finney JMT. Gastroenterostomy for cicatrizing ulcer of the pylorus. Bull Johns Hopkins Hosp 1893; 4: 53-5.

3. Gorbach SL. John G. Bartlett: Contributions to the discovery of Clostridium difficile antibiotic-associated diarrhea. Clin Infect Dis 2014; 59(Supple 2): S66-70.

4. Surawicz C, Brandt LJ, Binion DG, et al. Guidelines for diagnosis, treatment, and prevention of Clostridium difficile infections. Am J Gastroenterol 2013 Apr; 108(4): 478-498.

5. McDonald LC, Gerding DN, Johnson S, et al. Clinical Practice Guidelines for Clostridium difficile Infection in Adults and Children: 2017 Update by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA). Clin Infect Dis 2018; 66(7): 987-994.

Inside the Journals | 53

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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.

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September 2018

ACG MAGAZINE ARCHIVE ACG MAGAZINE Spring 2020

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The Discoverers: development of the Colon Prep

Vol. 4 No. 1 // Spring 2019

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Spring 2019

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Profiles in Courage IN The Fight Against Colorectal Cancer

Beyond City Limits:

GI Practice in Rural America

Vol. 3 No. 1 // Spring 2019

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The Essential ed anc Roles of Adv viders Practice Pro in GI

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