ACG MAGAZINE | Vol. 5, No. 2 | Summer 2021 by AmCollegeGastro

ACG MAGAZINE Summer 2021

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MEMBERS. MEDICINE. MEANING.

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Emotions

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Emotional Intelligence

An Impactful and Often Overlooked Leadership Skill

CALL for ABSTRACTS ACG 2021

SUBMIT your ABSTRACTS NOW for ACG 2021 in Las Vegas!

Don’t miss this opportunity to showcase your research alongside colleagues from the U.S. and abroad at the premier GI clinical event of the year.

OCTOBER 22–27, 2021 MANDALAY BAY • LAS VEGAS, NV

SUBMISSION DEADLINE MONDAY, JUNE 21, 2021 11:59 P.M., EASTERN TIME

The American College of Gastroenterology invites you to submit abstracts for presentation at the 2021 Annual Scientific Meeting and Postgraduate Course. Abstracts must be clinical or research-oriented, with a focus on gastroenterology or hepatology.

Visit acgmeetings.gi.org for complete rules and to submit your abstract online.

SUMMER 2021 // VOLUME 5, NUMBER 2

FEATURED CONTENTS

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Starting a Family While Becoming a Trainee Dr. Shifa Umar in a Q & A with Dr. Lauren Feld on interviewing for GI fellowship during pregnancy. PAGE 17

Law Mind Ann Bittinger, Esq., reviews changes to the 2021 CMS Medicare Physician Fee Schedule that may increase or decrease pay, depending upon your employer, for physicians whose compensation is tied to wRVUs PAGE 21

COVER STORY

Emotions

EMOTIONAL INTELLIGENCE: An Impactful and Often Overlooked Leadership Skill Discussing emotional intelligence and its role in your practice, Dr. David Hass, Dr. Sara Ancello, Dr. Uchenna Agbim, and Dr. Divya Bhatt review key concepts and introduce a new learning module on the ACG Education Universe

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Attend an upcoming

ACG POSTGRADUATE COURSE 2021 ACG’s Functional GI Disorders School and ACG Midwest Regional Postgraduate Course

ACG Weekly Virtual Grand Rounds REGISTER NOW: GI.ORG/ACGVGR Plus now offering a new monthly webinar series focused on career-based topics!

 Hilton St. Louis at the Ballpark | St. Louis, MO  August 13–15, 2021

ACG’s Hepatology School and ACG / VGS / ODSGNA Regional Postgraduate Course  Williamsburg Lodge | Williamsburg, VA  September 10–12, 2021

ACG’s IBD School and ACG Southern Regional Postgraduate Course  Nashville, TN  December 3–5, 2021

MORE INFO: gi.org/acg-course-calendar

SUMMER 2021 // VOLUME 5, NUMBER 2

CONTENTS

“My father’s story isn’t the quintessential American immigrant story; it is the quintessential American story—full stop. We are a nation of immigrants; to deny this immutable fact is to try to rewrite history.” —William D. Chey, MD, FACG, “American Dreams,” PG 38 6 // MESSAGE FROM THE PRESIDENT

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43 // INSIDE THE JOURNALS

Dr. Greenwald on the imperative of effective physician leadership during extraordinary times.

EMOTIONAL INTELLIGENCE: AN IMPACTFUL AND OFTEN OVERLOOKED LEADERSHIP SKILL A primer on emotional intelligence and why it is key to effective professional and clinical practice

44 AJG ACG issues updated CRC screening guidelines by Shaukat, et al., with an accompanying AJG podcast

7 // NOVEL & NOTEWORTHY

Celebrating the life of Dr. Dawn T. Provenzale; highlights from CRC Awareness Month; ACG Clinical Research Awards & more

13 // PUBLIC POLICY Congress ends the “post-polypectomy surprise” with the passage of the Removing Barriers to Colorectal Cancer Screening Act

17 // TRAINEE HUB Section editor Dr. Shifa Umar shares insights from Dr. Lauren Feld on pregnancy and parenthood while interviewing for GI fellowship

21 // GETTING IT RIGHT LAW MIND Ann Bittinger, Esq., discusses changes to CMS’ Medicare Physician Fee Schedule that may affect take-home pay for those whose compensation is tied to wRVUs

Photo courtesy of Dr. William Chey

33 // ACG PERSPECTIVES 33 CULINARY CONNECTIONS ACG "foodies" reflect on the importance of food and diet, both personally and professionally as GI physicians, and share recipes for ACG members to try 38 AMERICAN DREAMS Dr. William Chey offers a glimpse into his father’s hard-fought resilience and sense of purpose as an immigrant and GI physician

39 // EDUCATION EDGAR ACHKAR VISITING PROFESSORS EAVP continues to provide educational opportunities for GI programs, despite the challenges of distance and travel limitations

44 ACGCRJ The Pillow Sign: Is It Always Benign? By Alvencar, et al. 45 A LOOK BACK Dr. Robert Kravetz shares insights from his new book, featuring medical history and artifacts from past issues of AJG 46 CTG Q&A with new CTG Editor-in-Chief Dr. Brian Jacobson 47 CTG Identification of High-Risk Patients with NAFLD Using Non-invasive Tests from Primary Care and Endocrinology Real World Practices by Younossi, et al.

49 // A LOOK BACK 25 YEARS AGO IN AJG In 1996, Johnston, et al., published an article on clinical characteristics of short segment specialized intestinal metaplasia in the distal esophagus

ACG MAGAZINE MAGAZINE STAFF

CONNECT WITH ACG

Executive Director Bradley C. Stillman, JD

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

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CONTACT

BOARD OF TRUSTEES

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

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

ACGMag@ @gi.org

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

Past President: Sunanda V. Kane, MD, MSPH, FACG Director, ACG Institute: Neena S. Abraham, MD, MSc, 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: Patrick E. Young, MD, FACG Vice Chair, Board of Governors: Dayna S. Early, MD, FACG Trustee for Administrative Affairs: Irving M. Pike, MD, FACG

ACG MAGAZINE Spring 2021

MEMBERS. MEDICINE. MEANING.

Leading the Way in

Advancing Health Equity ACG MAGAZINE Spring 2021

MEMBERS. MEDICINE. MEANING.

Leading the Way in

Advancing Health Equity

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 John R. Saltzman, MD, FACG Nicholas J. Shaheen, MD, MPH, MACG Neil H. Stollman, MD, FACG Renee L. Williams, MD, MHPE, FACG

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American College of Gastroenterology is an international organization with more than 16,000 clinician members representing some 86 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

Uchenna A. Agbim, MD Dr. Agbim is a transplant hepatologist and gastroenterologist and was an ACG Young Physician Leadership Scholar from 2018–2019.

Sara E. Ancello, DO Dr. Ancello is a gastroenterologist at Central Arizona Medical Associates and serves as a Clinical Assistant Professor of Medicine at Midwestern University in Phoenix, AZ. She was an ACG Young Physician Leadership Scholar from 2018–2019.

Divya B. Bhatt, MD Dr. Bhatt is Assistant Professor of Medicine at UT Southwestern Medical Center. She was an ACG Young Physician Leadership Scholar in 2018-2019.

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

William D. Chey, MD, FACG Dr. Chey is the Timothy T. Nostrant Collegiate Professor of Gastroenterology and a Professor of Nutrition Sciences at Michigan Medicine. Since 2015 he has been an ACG Trustee, and was co-Editorin-Chief of The American Journal of Gastroenterology from 2010 to 2015.

Brad Conway, Esq. Mr. Conway is ACG’s Vice President of Public Policy, Coverage & Reimbursement and has been a member of the College’s management team since 2009.

Lauren D. Feld, MD Dr. Feld is a second year GI Fellow at the University of Washington.

David A. Greenwald, MD, FACG Dr. Greenwald is the 2020–2021 ACG President and is Director of Clinical Gastroenterology and Endoscopy at the Mount Sinai Hospital and Professor of Medicine at Icahn School of Medicine at Mount Sinai in New York City.

David J. Hass, MD, FACG Dr. Hass is Director of Endoscopy at Yale-New Haven Hospital, Saint Raphael Campus, Associate Clinical Professor of Medicine at Yale University School of Medicine, and serves as Medical Director of PACT Gastroenterology Center in Hamden, CT. He co-directs the ACG Young Physician Leadership Scholars.

Vani Paleti, MD Dr. Paleti is a gastroenterologist at Baylor Scott & White Health. She is board-certified in gastroenterology, a Diplomate in Lifestyle Medicine from the American Board of Lifestyle Medicine, and a Diplomate in Obesity Medicine from the Obesity Medicine Association.

Alexander Perelman, DO, MS Dr. Perelman practices at Vanguard Gastroenterology in New York, NY. He is a member of the ACG Professionalism Committee.

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

Christina Tennyson, MD Dr. Tennyson is a board-certified gastroenterologist with an interest in nutrition, integrative medicine, culinary medicine, and small bowel diseases. She is a Diplomate of the American Board of Lifestyle Medicine.

Shifa Umar, MD Dr. Umar is a third year GI fellow at the Allegheny Health Network and incoming advanced pancreatology fellow at the Mayo Clinic. She serves on the ACG Digital Communications & Publications Committee.

MESSAGE FROM THE PRESIDEN

PHYSICIANS: LEAD THE WAY! THESE ARE EXTRAORDINARY TIMES,

and I would say there has never been a more important time for physician leadership than right now. Let’s examine the past year. A pandemic, not yet over, but certainly unlike any seen in over a century, with unimaginable horror, sickness, grief and resulting in millions of deaths worldwide. That same pandemic bringing into even sharper focus the clear and deep disparities in health care access and health outcomes both in the United States and abroad. Brutal murders and acts of violence, including the killings of George Floyd, Breonna Taylor and others, led to public outrage, and shined a bright spotlight on injustice in society and systemic racism. The medical profession confronted once again, but maybe more clearly than ever before, that racism is a public health issue. And most recently, acts of violence and hatred directed against the Asian, Asian American and Pacific Islander communities have again shown the need for greater and more sustained efforts to increase understanding and to promote tolerance, as well as the imperative to denounce bigotry and prejudice. I would submit that physicians can and absolutely must have an important leadership role in moving forward from this year of tumult. Why can physicians lead here? As a community, health care providers are trusted sources of information and advice. As COVID-19 ripped through our world, physicians and scientists around the globe rapidly led the way through mountains of data, quickly gaining an understanding of SARS-CoV-2, studied ways to treat infected patients and in short

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“Effective leadership will allow us to continue to develop as a community of healers and better help our patients and our society grow to be more inclusive, equitable and just."

order developed a series of vaccines that have proven to be both highly effective and safe. Yet, despite the unprecedented and remarkable progress and with so many already having been vaccinated, there remains much vaccine hesitancy. Physician leadership to expand vaccine uptake is critical; the voice of that trusted source of information delivering facts and accurate information and dispelling myths can be all it takes to move an individual from being vaccine hesitant to being vaccinated. I was fortunate just this week to spend 15 minutes with a 24 year old who, when I asked about whether he had been vaccinated, told me he “wasn’t worried about COVID.” By the end of our conversation, which started with my asking, “What are your concerns about the COVID vaccines,” he said, “no one had ever taken the time to explain the available vaccines” to him, and he was grateful for the information. I saw him just this morning, and he smiled and said he had gone for his “first vaccine” shortly after our conversation. I urge my physician colleagues to lead here. Ask everyone you meet where they are in terms of COVID vaccination status, and for those who remain unvaccinated, ask them about their concerns and then respond to those worries with facts and understanding. Leading the way here, one person at a time, is our mission and our gift. On issues of racial bias, prejudice and inequity in society and in the health care system, again the times demand great leadership. The challenges of the past year are also great opportunities to reexamine the deep inequities of both the past

and the present, and physicians can and must lead the way towards making substantial change. Call out inequities when you see them, and work for progress at removing bias. Multiple small steps can lead to large leaps, so take the little jumps whenever possible. I am personally grateful to many of our GI colleagues who have stepped forward this past year, willingly and courageously, to tell their very personal stories of bias, hostility and bigotry. By listening to them, and of course to similar stories from our patients, we can all gain a better understanding of injustice and inequity, and then work for change. Effective leadership will allow us to continue to develop as a community of healers and better help our patients and our society grow to be more inclusive, equitable and just. These issues are, in short… Incredible. Important. Intense. Addressing these issues is worth the effort! Leadership is challenging. Leadership is rewarding. Great leadership now is imperative. Outstanding leadership demands an open mind to all pertinent information, thoughtful consideration of all relevant issues, and careful decision-making. As a group, we are so fortunate to be in a position to lead our patients, our colleagues and our communities as we recover, regroup, and push forward. My advice is to choose to lead, and to do so by listening carefully, and always using kindness, compassion, and empathy. Physicians: Lead the way!

—David A. Greenwald, MD, FACG

Note hy wor t A SAD LOSS FOR THE FIELD OF GASTROENTEROLOGY is the death of Dawn T. Provenzale, MD, FACG, whose career and contributions are memorialized in Novel & Noteworthy. One of Dr. Provenzale’s ACG leadership roles was Research Committee Chair, so it is fitting that we celebrate her life and the 2021 Clinical Research Awardees. ACG observed Colorectal Cancer Awareness Month with virtual events that brought the GI community together in new ways; the “Ride or Stride for 45” Challenge and a live webstream “Tune It Up: A Concert to Raise Awareness of Colorectal Cancer” which showcased musical performances by an incredible group of artists. You can access the recording at gi.org/concert. Share recent professional news for yourself or a colleague with ACG MAGAZINE at acgmag@gi.org.

Novel & Noteworthy | 7

// N&N [BLACK IN GASTRO]

INTRODUCING ABGH

Association of Black Gastroenterologists and Hepatologists Renee L. Willliams, MD, MHPE, FACG; Sophie M. Balzora, MD, FACG; Valerie Antoine-Gustave, MD, MPH and Ugonna C. Iroku, MD, MHS.

"Creating an organization dedicated to addressing digestive disease health inequities in the Black community has been a long time in the making. From Dr. Leonidas Berry becoming the first Black gastroenterologist in the United States in 1935, to Dr. Sadye Curry becoming the first Black female gastroenterologist in the United States in 1972, the need to train, promote, and support Black gastroenterologists, hepatologists, and scientists to serve the community has always been a mission in motion. With the arrival of 2020 came reminders of the varied manifestations of health inequities. With the COVID-19 pandemic, Black communities suffered disproportionately higher rates of hospitalization and deaths. With the deaths of George Floyd, Breonna Taylor, and Ahmaud Arbery, we reached for our voices to affirm the value of Black lives. And with the passing of our hero Chadwick Boseman, we felt the painful reminder that Black people have the highest rates of colorectal cancer incidence and mortality. It was in this backdrop that our professional community united to grieve and take the mission another step forward. On February 26, 2021, we launched the Association of Black Gastroenterologists and

Hepatologists (ABGH), a nonprofit organization with the mission to promote health equity in Black communities, advance science, and develop the careers of Black gastroenterologists and hepatologists. On March 23, 2021, we hosted our inaugural community event, a virtual roundtable entitled, “Colorectal Cancer in the COVID-19 Era,” which drew over 200 registered attendees, where ABGH was able to give a platform to colorectal cancer survivors and advocates to share their stories, encourage screening, and discuss community needs. To extend the reach of ABGH, we look forward to collaborating with major medical societies aligned with our mission and vision. Our cofounders include Sophie M. Balzora, MD, FACG (President); Renee L. Williams, MHPE, FACG (Vice President); Ugonna C. Iroku, MD, MHS (Secretary); Valerie AntoineGustave, MD, MPH (Treasurer); and Adjoa N. Anyane-Yeboa, MD, MPH; Rotonya M. Carr, MD; Darrell M. Gray, II, MD, MPH, FACG; Alexandra Guillaume, MD; Rachel Issaka, MD; Folasade P. May, MD, PhD, MPhil; and Pascale M. White, MD.”

 LEARN MORE: For more information about ABGH and to support our cause, please visit blackingastro.org

[AWARDEE]

[MILESTONE]

DR. COSTAS KEFALAS RECEIVES LIFETIME ACHIEVEMENT AWARD

DR. LINDA NGUYEN

Costas H. Kefalas, MD, MMM, FACG received the Lifetime Achievement Award of the Digestive Disease National Coalition (DDNC) at their 31st Annual Public Policy Forum on March 7, 2021. Beginning in 2011, he served as the ACG representative to the DDNC, and from 2014 to 2016, Dr. Kefalas was the DDNC President. He is currently a Trustee of the College and serves as President and Chair of the Board of Directors of the GI Quality Improvement Consortium, Inc. (GIQuIC).

PROMOTED Linda Ahn B. Nguyen, MD, FACG was promoted to Clinical Professor of Medicine at Stanford Medicine Division of Gastroenterology & Hepatology where she serves as Clinic Chief, Digestive Health Center. Upon her promotion, Dr. Nguyen shared this reflection: “This little immigrant girl dared to dream that she would be a doctor. Today, she exceeded that dream & became Professor. To all the little girls, dream big!!!”

[MOVE]

DR. JORDAN KARLITZ MOVES TO DENVER HEALTH MEDICAL CENTER Jordan J. Karlitz, MD, FACG, recently became Chief of the Division of Gastroenterology, Denver Health Medical Center, and Associate Professor of Medicine, University of Colorado School of Medicine, CU Anschutz, after moving from Tulane University School of Medicine. With his interest in colorectal cancer screening,

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early-onset colorectal cancer and hereditary colorectal cancer syndromes, he aims to help increase CRC screening rates in the surrounding communities, overcome barriers to screening, and develop protocols to better identify patients with hereditary cancer syndromes, including Lynch Syndrome.

[MILEAGE]

ACG RIDE OR STRIDE FOR 45 ACG Ride or Stride for 45—A Healthy Challenge to Promote Colorectal Cancer Screening Starting at Age 45 for March Colorectal Cancer Awareness Month. In this virtual challenge, Co-Chairs David A. Greenwald, MD, FACG and Seth A. Gross, MD, FACG, invited the entire GI community to bike, hike, run, walk, or row 45

miles in March (or 45 minutes per day during the month) to show support and enthusiasm for preventing colorectal cancer beginning at age 45 for all average risk adults. The outpouring of support and participation by so many ACG members across the country and around the world was gratifying, while the photos of incredible locations for exercise were inspiring. Through social media posts, our members shared strong messages about the importance colorectal cancer screening.

[CONCERT]

TUNE IT UP: A CONCERT TO RAISE AWARENESS OF COLORECTAL CANCER ACG was proud to host a free webstream event, Tune It Up: A Concert to Raise Awareness of Colorectal Cancer, on March 31st featuring dynamic performances by a talented collective of musicians. Concert Director Benjamin H. Levy, III, MD, a member of ACG’s Public Relations Committee, organized an impressive evening of music. ACG’s goal was to tap the connection and energy that music creates to shine a light on the importance of colorectal cancer screening and prevention. The virtual concert included messages from celebrity cancer

[IN MEMORIAM]

DAWN PROVENZALE, MD, FACG (1955-2021) The College celebrates the life of Dawn T. Provenzale, MD, FACG, and recognizes her numerous contributions to clinical research, education, and patient care. She served as a Trustee of the College from 2001 to 2007. Dr. Provenzale

On March 13, a dedicated group of Peloton fans enjoyed a group ride, while a challenge to all the GI training programs for a virtual 5K on March 27 created opportunities for group runs and a sense of excitement and purpose at the end of March Colorectal Cancer Awareness Month. Using #RideOrStrideFor45, so many ACG members used social media to share their enthusiasm, commitment, and willingness to go the distance for colorectal cancer prevention.

advocate Katie Couric and performances by notable stars such as GRAMMY® Award winning singer/ songwriter Lisa Loeb, Rufus Wainwright, Tim Reynolds, violinist Hilary Hahn, jazz trumpeter Kermit Ruffins, the Chicago Symphony Orchestra, and the Cincinnati Pops Orchestra, along with other musicians from a wide range of genres who all donated their time and performances to support colorectal cancer awareness efforts.  LISTEN: Explore vibrant performances and discover new artists when you listen to the recording: gi.org/concert

chaired the College’s Research Committee from 2000 to 2004, and in this role was an At-Large member of the ACG Institute Board. She was an associate editor of The American Journal of Gastroenterology from 1998 to 2003. She served as Chair of the National Comprehensive Cancer Network Guideline Committee for Colorectal Cancer Screening. As Director of the Cooperative Studies Program Epidemiology Center

at the Durham Veterans Affairs Medical Center, she was a respected and admired Professor of Medicine at the Duke University School of Medicine.

[RESEARCH]

2021 CLINICAL RESEARCH AWARDEES ANNOUNCED The ACG Institute for Clinical Research and Education announced the 2021 ACG Clinical Research Awards including two Junior Faculty Development Grants, seven Clinical Research Awards, and five Medical Student and Resident Research Awards. Upon review of a record number of submissions from a competitive group of applicants, the ACG Research Committee recommended funding of $1.9 million for 2021. The ACG Institute granted two new awards, the ACG/ASGE Epidemiologic Research Award in Gastrointestinal Endoscopy to Jason Dominitz, MD, MHS, of the University of Washington, and the ACG MidCareer/Senior Clinical Scientist Bridge Funding Award to Johane Allard, MD, of Toronto General Hospital. ACG Institute will support two Junior Faculty Development Awards, at an overall level of $900,000—an investment in career development which recognizes and supports promising clinical researchers. The 2021 grantees are Eileen Carpenter, MD, PhD, of the University of Michigan, and Nicole Rich, MD, a gastroenterologist and transplant hepatologist of UT Southwestern Medical Center. The ACG Institute’s ability to foster clinical research and patient-care innovation is made possible through the support of our membership and industry partners who have made generous gifts to the ACG Institute G.U.T. Fund. Research Awardees (top to bottom) Dr. Carpenter, Dr. Rich, Dr. Dominitz, Dr. Allard

 LEARN MORE about all this year's research grant recipients: gi.org/research-grant-recipients

Novel & Noteworthy | 9

MAY

AUGUST

ENTER TO WIN A SCOPY Submit your Entry: gi.org/scopy

FUNCTIONAL GI DISORDERS SCHOOL AT MIDWEST REGIONAL  Location: Register: meetings.gi.org

SEPTEMBER

HEPATOLOGY SCHOOL AT ACG/VGS/ ODSGNA REGIONAL  Williamsburg, VA

AUGUST

14–15

SEPTEMBER

11-12

ACG/VGS/ODSGNA REGIONAL POSTGRADUATE COURSE  Williamsburg, VA

MIDWEST REGIONAL POSTGRADUATE COURSE  Location: Register: meetings.gi.org

DECEMBER 3 ACG RESEARCH GRANTS DEADLINE Learn More: gi.org/research-awards

DECEMBER

IBD SCHOOL AT SOUTHERN REGIONAL

 Nashville, TN Register: meetings.gi.org

DECEMBER

4–5

SOUTHERN REGIONAL POSTGRADUATE COURSE

 Nashville, TN Register: meetings.gi.org

10 | GI.ORG/ACGMAGAZINE

SAVE THE DATE FOR ACG 2021

BRIEF SUMMARY: Before prescribing, please see Full Prescribing Information and Medication Guide for SUTAB® (sodium sulfate, magnesium sulfate, potassium chloride) tablets for oral use. INDICATIONS AND USAGE: An osmotic laxative indicated for cleansing of the colon in preparation for colonoscopy in adults. DOSAGE AND ADMINSTRATION: Split Dose (2-Day) Regimen: Dose 1 – On the day prior to colonoscopy: A low residue breakfast may be Packaging and consumed. After breakfast, only clear liquids may be consumed until after the tablets not shown colonoscopy. Early in the evening prior to colonoscopy, open one bottle of actual size. 12 tablets. Fill the provided container with 16 ounces of water (up to the fill line). Swallow each tablet with a sip of water and drink the entire amount over 15 to 20 minutes. Approximately one hour after the last tablet is ingested, fill the provided container a second time with 16 ounces of water (up to the fill line) and drink the entire amount over 30 minutes. Approximately 30 minutes after finishing the second container of water, fill the provided container with 16 ounces of water (up to the fill line) and drink the entire amount over 30 minutes. Dose 2 - Day of colonoscopy: Continue to consume only clear liquids until after the colonoscopy. The morning of colonoscopy (5 to 8 hours prior to the colonoscopy and no sooner than 4 hours from starting Dose 1), open the second bottle of 12 tablets. Fill the provided container with 16 ounces of water (up to the fill line). Swallow each tablet with a sip of water and drink the entire amount over 15 to 20 minutes. Approximately one hour after the last tablet is ingested, fill the provided container a second time with 16 ounces of water (up to the fill line) and drink the entire amount over 30 minutes. Approximately 30 minutes after finishing the second container of water, fill the provided container with 16 ounces of water (up to the fill line) and drink the entire amount over 30 minutes. Complete all SUTAB tablets and required water at least 2 hours before colonoscopy. CONTRAINDICATIONS: Use is contraindicated in the following conditions: gastrointestinal obstruction or ileus, bowel perforation, toxic colitis or toxic megacolon, gastric retention. WARNINGS AND PRECAUTIONS: Serious Fluid and Electrolyte Abnormalities: Advise all patients to hydrate adequately before, during, and after the use of SUTAB. If a patient develops significant vomiting or signs of dehydration after taking SUTAB, consider performing post-colonoscopy lab tests (electrolytes, creatinine, and BUN). Fluid and electrolyte disturbances can lead to serious adverse events including cardiac arrhythmias, seizures and renal impairment. Correct fluid and electrolyte abnormalities before treatment with SUTAB. Use SUTAB with caution in patients with conditions, or who are using medications, that increase the risk for fluid and electrolyte disturbances or may increase the risk of adverse events of seizure, arrhythmias, and renal impairment; Cardiac arrhythmias: Use caution when prescribing SUTAB for patients at increased risk of arrhythmias (e.g., patients with a history of prolonged QT, uncontrolled arrhythmias, recent myocardial infarction, unstable angina, congestive heart failure, or cardiomyopathy). Consider pre-dose and post-colonoscopy ECGs in patients at increased risk of serious cardiac arrhythmias; Seizures: Use caution when prescribing SUTAB for patients with a history of seizures and in patients at increased risk of seizure, such as patients taking medications that lower the seizure threshold (e.g., tricyclic antidepressants), patients withdrawing from alcohol or benzodiazepines, or patients with known or suspected hyponatremia; Use in Patients with Risk of Renal Injury: Use SUTAB with caution in patients with impaired renal function or patients taking concomitant medications that may affect renal function (such as diuretics, angiotensin converting enzyme inhibitors, angiotensin receptor blockers, or non-steroidal anti-inflammatory drugs). These patients may be at risk for renal injury. Advise these patients of the importance of adequate hydration with SUTAB and consider performing baseline and post-colonoscopy laboratory tests (electrolytes, creatinine, and BUN) in these patients; Colonic Mucosal Ulcerations and Ischemic Colitis: Osmotic laxative products may produce colonic mucosal aphthous ulcerations, and there have been reports of more serious cases of ischemic colitis requiring hospitalization. Concurrent use of stimulant laxatives and SUTAB may increase these risks. Consider the potential for mucosal ulcerations resulting from the bowel preparation when interpreting colonoscopy findings in patients with known or suspect inflammatory bowel disease (IBD); Use in Patients with Significant Gastrointestinal Disease: If gastrointestinal obstruction or perforation is suspected, perform appropriate diagnostic studies to rule out these conditions before administering SUTAB. Use with caution in patients with severe active ulcerative colitis. ADVERSE REACTIONS: Most common gastrointestinal adverse reactions are: nausea, abdominal distension, vomiting and upper abdominal pain. POTENTIAL FOR DRUG ABSORPTION: SUTAB can reduce the absorption of other co-administered drugs. Administer oral medications at least one hour before starting each dose of SUTAB. Administer tetracycline and fluoroquinolone antibiotics, iron, digoxin, chlorpromazine, and penicillamine at least 2 hours before and not less than 6 hours after administration of each dose of SUTAB to avoid chelation with magnesium. Pregnancy: There are no available data on SUTAB use in pregnant women to evaluate for a drug-associated risk of major birth defects, miscarriage, or adverse maternal or fetal outcomes. No reproduction or developmental studies in animals have been conducted with sodium sulfate, magnesium sulfate, and potassium chloride (SUTAB). Lactation: There are no available data on the presence of SUTAB in human or animal milk, the effects on the breastfed child, or the effects on milk production. Pediatric Use: Safety and effectiveness in pediatric patients has not been established. Geriatric Use: Of the 471 patients who received SUTAB in pivotal clinical trials, 150 (32%) were 65 years of age or older, and 25 (5%) were 75 years of age or older. No differences in safety or effectiveness of SUTAB were observed between geriatric patients and younger patients. Elderly patients are more likely to have decreased hepatic, renal or cardiac function and may be more susceptible to adverse reactions resulting from fluid and electrolyte abnormalities. STORAGE: Store at 20º to 25°C (68º to 77°F). Excursions permitted between 15º to 30°C (59º to 86°F). See USP controlled room temperature. Rx only. Manufactured by Braintree Laboratories, Inc. Braintree, MA 02185 See Full Prescribing Information and Medication Guide at SUTAB.com. References: 1. SUTAB® [package insert]. Braintree, MA; 2020. 2. Di Palma JA, Bhandari R, Cleveland M, et al. A safety and efficacy comparison of a new sulfate-based tablet bowel preparation versus a PEG and ascorbate comparator in adult subjects undergoing colonoscopy. Am J Gastroenterol. Published online November 6, 2020. doi: 10.14309/ajg.0000000000001020 3. Rex DK, Johnson DA, Anderson JC, Schoenfeld PS, Burke CA, Inadomi JM; ACG. American College of Gastroenterology guidelines for colorectal cancer screening 2009 [corrected]. Am J Gastroenterol. 2009;104(3):739-750. 4. IQVIA. National Prescription Audit Report. November 2020.

201-133-v1-A January 2021

! W! E NEW N

A NEW TABLET CHOICE A BOWEL NEW TABLET CHOICE IN PREPARATION IN BOWEL PREPARATION

• NO SODIUM PHOSPHATE1

• SAFE AND EFFECTIVE1,2 1 • NO SODIUM PHOSPHATE • ACG-RECOMMENDED1,2 SPLIT-DOSE REGIMEN3 • SAFE AND EFFECTIVE 1 – Two SUTAB doses are required for a complete preparation

Dose 1 consists of 12 tablets and 16 oz of water REGIMEN3 • ACG-RECOMMENDED SPLIT-DOSE Dose 2 consists of 12 tablets and 16 oz of water 1 – Two are required for a complete preparation EachSUTAB dose isdoses followed by two additional 16 oz of water Dose 1 consists of 12 tablets and 16 oz of water Dose 2 consists of 12 tablets and 16 oz of water Packaging and tablets not shown size. Each dose is followed by actual two additional 16 oz of water

92% OF PATIENTS IN TWO PIVOTAL TRIALS ACHIEVED SUCCESSFUL BOWEL CLEANSING WITH SUTAB1,2* 91% OF PATIENTS IN ONE PIVOTAL TRIAL RATED SUTAB AS TOLERABLE TO VERY EASY TO CONSUME2† 1,2 ® 1,2‡ 92% OF PATIENTS IN TWO PIVOTAL TRIALSreported ACHIEVED SUCCESSFUL CLEANSING SUTAB * • 52% of all SUTAB and MoviPrep patients at least one selectedBOWEL gastrointestinal adverseWITH reaction • More SUTAB patients reported experiencing nausea and vomiting than competitor, with ≤1%TO of these reports2† 91% OF PATIENTS IN ONE PIVOTAL TRIAL RATED SUTAB AS TOLERABLE TO VERY EASY CONSUME 2‡ Packaging and tablets not shown actual size.

considered severeand MoviPrep® patients reported at least one selected gastrointestinal adverse reaction1,2‡ • 52% of all SUTAB

2† 78% OF PATIENTS ONE reported PIVOTALexperiencing TRIAL WOULD REQUEST SUTAB AGAIN FOR A FUTURE • More SUTAB IN patients nausea and vomiting than competitor, with ≤1% ofCOLONOSCOPY these reports

considered severe * Success was primary endpoint and was defined in noninferiority trials as an overall cleaning assessment of 3 (good) or 4 (excellent) by the blinded endoscopist; scores were assigned on withdrawal of colonoscope. OF PATIENTS IN ONE PIVOTAL TRIAL WOULD REQUEST SUTAB AGAIN FOR A FUTURE COLONOSCOPY2† † Patients completed preference questionnaire following completion of study drug to capture the subject’s perceptions of the preparation experience. This * questionnaire has not undergone formal validation. Success was primary endpoint and was defined in noninferiority trials as an overall cleaning assessment of 3 (good) or 4 (excellent) by the blinded endoscopist; ‡ scores were assigned on withdrawal of colonoscope. Patients were queried for selected gastrointestinal adverse reactions of upper abdominal pain, abdominal distension, nausea, and vomiting following completion †of study drug, rating the intensity as mild, moderate, or severe. Patients completed preference questionnaire following completion of study drug to capture the subject’s perceptions of the preparation experience. This questionnaire has not undergone formal validation. ACG=American College of Gastroenterology ‡ ® Patients were queried for selected gastrointestinal adverse reactions of upper abdominal pain, abdominal distension, nausea, and vomiting following completion is a registered trademark of Velinor AG. MoviPrep of study drug, rating the intensity as mild, moderate, or severe. ACG=American College of Gastroenterology MoviPrep® is a registered trademark of Velinor AG. IMPORTANT SAFETY INFORMATION 2‡

78%

SUTAB® (sodium sulfate, magnesium sulfate, potassium chloride) tablets for oral use is an osmotic laxative indicated for cleansing of the colon in preparation for colonoscopy in adults. DOSAGE AND ADMINSTRATION: A low residue breakfast may be consumed. After IMPORTANT SAFETY INFORMATION breakfast, only clear liquids may be consumed until after the colonoscopy. Administration of two doses of SUTAB (24 tablets) are required ® SUTAB (sodium sulfate, magnesium sulfate, potassium chloride) tablets for oral use is an osmotic laxative indicated for cleansing of the for a complete preparation for colonoscopy. Twelve (12) tablets are equivalent to one dose. Water must be consumed with each dose colon in preparation for colonoscopy in adults. DOSAGE AND ADMINSTRATION: A low residue breakfast may be consumed. After of SUTAB and additional water must be consumed after each dose. Complete all SUTAB tablets and required water at least 2 hours breakfast, only clear liquids may be consumed until after the colonoscopy. Administration of two doses of SUTAB (24 tablets) are required before colonoscopy. CONTRAINDICATIONS: Use is contraindicated in the following conditions: gastrointestinal obstruction or ileus, for a complete preparation for colonoscopy. Twelve (12) tablets are equivalent to one dose. Water must be consumed with each dose bowel perforation, toxic colitis or toxic megacolon, gastric retention. WARNINGS AND PRECAUTIONS: Risk of fluid and electrolyte of SUTAB and additional water must be consumed after each dose. Complete all SUTAB tablets and required water at least 2 hours abnormalities: Encourage adequate hydration, assess concurrent medications and consider laboratory assessments prior to and after each before colonoscopy. CONTRAINDICATIONS: Use is contraindicated in the following conditions: gastrointestinal obstruction or ileus, use; Cardiac arrhythmias: Consider pre-dose and post-colonoscopy ECGs in patients at increased risk; Seizures: Use caution in patients bowel perforation, toxic colitis or toxic megacolon, gastric retention. WARNINGS AND PRECAUTIONS: Risk of fluid and electrolyte with a history of seizures and patients at increased risk of seizures, including medications that lower the seizure threshold; Patients with abnormalities: Encourage adequate hydration, assess concurrent medications and consider laboratory assessments prior to and after each renal impairment or taking concomitant medications that affect renal function: Use caution, ensure adequate hydration and consider use; Cardiac arrhythmias: Consider pre-dose and post-colonoscopy ECGs in patients at increased risk; Seizures: Use caution in patients laboratory testing; Suspected GI obstruction or perforation: Rule out the diagnosis before administration. ADVERSE REACTIONS: with a history of seizures and patients at increased risk of seizures, including medications that lower the seizure threshold; Patients with Most common gastrointestinal adverse reactions are: nausea, abdominal distension, vomiting and upper abdominal pain. DRUG renal impairment or taking concomitant medications that affect renal function: Use caution, ensure adequate hydration and consider INTERACTIONS: Drugs that increase risk of fluid and electrolyte imbalance. laboratory testing; Suspected GI obstruction or perforation: Rule out the diagnosis before administration. ADVERSE REACTIONS: Please see Brief Summary of Prescribing Information on reverse side. See Full Prescribing Information and Medication Guide at Most common gastrointestinal adverse reactions are: nausea, abdominal distension, vomiting and upper abdominal pain. DRUG SUTAB.com. INTERACTIONS: Drugs that increase risk of fluid and electrolyte imbalance. Please see Brief Summary of Prescribing Information on reverse side. See Full Prescribing Information and Medication Guide at SUTAB.com. From the makers of SUPREP® Bowel Prep Kit (sodium sulfate, potassium sulfate and magnesium sulfate) Oral Solution for adults—

THE #1 MOST PRESCRIBED, BRANDED BOWEL PREP KIT4

From the makers of SUPREP® Bowel Prep Kit (sodium sulfate, potassium sulfate and magnesium sulfate) Oral Solution for adults—

THE #1 MOST PRESCRIBED, BRANDED BOWEL PREP KIT4

PUBLIC POLICY Congress Passes

the Removing Barriers to Colorectal Cancer Screening Act B:11.25"B:11.25"

S:9.75" S:9.75"

T:10.75"T:10.75"

Ending “Post-polypectomy surprise” included in larger COVID-19 stimulus package By Brad Conway, Esq., Vice President, Public Policy, Coverage & Reimbursement

THE AMERICAN COLLEGE OF GASTROENTEROLOGY (ACG) IS GRATEFUL TO CONGRESS for passing a long-overdue resolution to a problem that has been impacting GI patients for decades. The Removing Barriers to Colorectal Cancer Screening Act was included in the $900 billion COVID-19 relief and stimulus agreement, and $1.4 trillion omnibus federal government spending bill cleared by Congress on December 21, 2020.

Public Policy | 13

// PUBLIC POLICY The legislation was championed in the U.S. House of Representatives by Rep. Donald Payne, Jr. (D-NJ), who introduced the bill upon losing his father, former Rep. Donald Payne (D-NJ) to colorectal cancer in 2012. The bill fixes an unintended coverage quirk impacting Medicare coverage of screening colonoscopy that was enacted as part of the Patient Protection and Affordable Care Act, now known as the “ACA.” THE POST-POLYPECTOMY SURPRISE The ACA led to an unintended quirk in Medicare that ACG referred to as the “post-polypectomy surprise”— when a polyp is removed during screening colonoscopy and the procedure is billed, the procedure switches from a screening to a therapeutic intervention. Under the ACA, colonoscopy with polypectomy was not considered a “screening” for Medicare cost-sharing purposes. Thus the surprise—Medicare beneficiaries were left with unexpected bills. Notwithstanding the fact that finding and removing polyps is the purpose of screening, for years policymakers failed to resolve this issue.

ADVOCACY YEARS IN THE MAKING: TIMELINE The College has long advocated for Medicare coverage for colorectal cancer screening, removing patient cost-sharing, and accurate Medicare reimbursement for screening colonoscopy.

REDUCING COST SHARING FOR MEDICARE BENEFICIARIES The College worked closely with thenRepresentative Ben Cardin and former Senator Joseph I. Lieberman (I-CT) as they first introduced the Screen for Life Act in 2002. The bill was designed to remove Medicare beneficiary cost-sharing for colorectal cancer screening.

Various iterations of the SCREEN Act were introduced since 2002. Congress partially waived patient cost-sharing for colorectal cancer screening in 2010 when passing the ACA. Medicare eliminated certain cost-sharing for recommended colorectal cancer screenings, but the perplexing out-of-pocket costs coverage quirk remained.

AN EXPANSION OF BENEFITS In July 2001, Medicare began colorectal cancer screening for average risk beneficiaries. Congress amended the statute, again on legislation introduced by Rep. Cardin, which created the 10-year average risk colonoscopy screening. Once again, in addition to Rep. Cardin, the Chair of the House Ways & Means Committee, Rep. Bill Thomas (R-CA) played a key role and announced to a group of gastroenterologists that he would include the average risk colonoscopy benefit for approval in a year-end bill.

A LEGISLATIVE VEHICLE In the first days of the 105th Congress in 1997, then Representative Ben Cardin (D-MD) introduced H.R. 15, a bipartisan bill providing a preventive benefits package for Medicare beneficiaries, including CRC screening. The provisions of H.R. 15 were the basis for language ultimately enacted into law as part of the Balance Budget Act of 1997. 2

14 | GI.ORG/ACGMAGAZINE

ORGANIZATIONS AND CONGRESS RALLY AROUND THE “REMOVING BARRIERS TO COLORECTAL CANCER SCREENING ACT” AND REP. DONALD PAYNE, JR. The College joined a coalition of like-minded organizations and patient advocacy groups in 2012 to advance the “Removing Barriers to Colorectal Cancer Screening” Act. The bill eliminated the Medicare beneficiary’s coinsurance portion of cost-sharing when a polyp was removed during a screening examination.

THANK YOU, ACG MEMBERS The College recognizes with thanks the countless ACG members, Governors, and leaders whose unstinting efforts over the years to communicate with legislators, visit Capitol Hill, write to their members of Congress, engage with patient advocates and allies of colorectal cancer screening, and champion colorectal cancer screening at the national level all helped move this issue forward, and ultimately contributed to passage of this important legislation.

THE NEXT CHALLENGE TO ADVANCE COVERAGE OF COLORECTAL CANCER SCREENING UNDER MEDICARE The American College of Gastroenterology thanks all members of Congress who championed the postpolypectomy surprise issue over the years on behalf of our patients. However, ACG’s work is not done; the next step is to make sure that cost-sharing and deductible waivers are extended throughout the entire “continuum of care” for colorectal cancer screening for Medicare beneficiaries. That is, regardless of which colorectal cancer screening test a patient receives—since all positive tests must result in colonoscopy and, in some cases, to surgery—the cost-sharing should be waived until the process is completed.

12 13

(1) U.S. Rep. Donald M. Payne, Sr. (D-NJ) died of colorectal cancer in 2012 and inspired the SCREEN Act introduced by his son, U.S. Rep. Donald M. Payne, Jr. (2) ACG Past President Marvin M. Schuster, MD, MACG (center) in March 1997 testifying before the House Ways & Means Committee. (3) U.S. Rep. Ben Cardin (D-MD) served on the House Ways & Means Committee and gave ACG an opportunity to have a voice on the Hill to champion important screening benefits for Medicare patients. (4) Former U.S. Sen. Joseph I. Lieberman (I-CT) partnered with (5) former U.S. Rep. and current U.S. Sen. Ben Cardin in championing legislation to expand Medicare coverage for colorectal cancer screening. ACG thanks the champions of the SCREEN Act and Members of Congress who supported the bill: (6) U.S. Sen. Lindsey Graham (R-SC), and (7) U.S. Rep. Richard Neal (D-MA). (8) U.S. Rep. Donald Payne, Jr. (D-NJ) championed the Removing Barriers to Colorectal Cancer Screening Act that was first introduced by (9) former U.S. Rep. Charles Dent (R-PA). The Senate version was introduced by (10) U.S. Sen. Sherrod Brown (D-OH). (11) Whitfield L. Knapple, MD, FACG and Sen. Cardin. (12) ACG Governors Legislative Fly-In to Washington, DC April, 2018. (13) L to R: David Mangels, MD, FACG; Sen. Brown; Ashley L. Faulx, MD, FACG; and Costas H. Kefalas, MD, MMM, FACG. (14) L to R: Ramona Rajapakse, MD, FACG; Rep. Payne; and Sita S. Chokhavatia, MD, MACG. (15) ACG Governors Legislative Fly-In to Washington, DC April, 2019.

Public Policy | 15

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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.

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TRAINEE HUB

Notes from the Journey: Pregnancy and Parenthood During

GI Training

Introducing ACG MAGAZINE Trainee Hub

By Shifa Umar, MD

AS THE INAUGURAL OFFERING IN ACG MAGAZINE’S NEW TRAINEE HUB SECTION, in this Q&A I asked Dr. Lauren Feld how she navigated through chief year, interviewing and preparing for GI fellowship during her pregnancy. My questions explore her reasons for writing a recent article in the March 2021 issue of The American Journal of Gastroenterology, “Baby Steps in the Right Direction: Toward a Parental Leave Policy for Gastroenterology Fellows.” 

Trainee Hub | 17

// TRAINEE HUB

Umar (Cont.)

The decision to have a child and its influence on your career is a decision female trainees struggle with, considering that medical training is long and spans the main childbearing years. For many, it can be daunting to consider parenthood during fellowship training, bonding with the infant, trying to recover physically, and then resuming such a demanding schedule and there is no standard approach to how medical training deals with pregnancy. I am grateful to Dr. Feld for sharing her insights and experience. —Dr. Umar ABOUT NEW ACG MAGAZINE “TRAINEE HUB” SECTION Dr. Shifa Umar is currently a GI fellow at the Allegheny Health Network and incoming Advanced Pancreatology fellow at the Mayo Clinic, and serves as a member of the ACG Digital Communications & Publication Committee. She suggested this new Trainee Hub section as a way to focus on issues pertaining to GI fellows and is serving as the 2021 section editor. Readers can share story ideas for this section with Dr. Umar at ACGMag@gi.org

Shifa Umar, MD, Allegheny Health Network

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“My advice to fellows is to have a child when you are ready to be a parent, and know that we all have to work to make the system better to support you.” Advice & Insights on Starting a Family While Becoming a GI Trainee By Lauren D. Feld, MD

Dr. Umar: What was the impetus for writing “Interviewing for Two” and why do you believe it was important for you to share your experience? Dr. Feld: As I moved through the interview trail, I wrote notes about programs to help with my final rank list. With other program details, I began noting experiences related to my pregnancy (good and bad). When I went through my notes while making rank list decisions with my husband, he was surprised by some of the things people had said about my pregnancy and suggested I form the experiences into an article. I had not previously shared a personal experience for publication, and had concerns that some readers may view these ideas negatively as promoting excessive accommodation, but my hope is that this article will contribute to the conversation about next steps for gender equity in GI. What is some specific practical advice you can offer to women considering starting a family during GI fellowship? Ideally, advice should be directed to fellowship programs about how to support and accommodate parenthood in training (please see my recent Red Journal article for the extensive evidence base supporting this under References below). Fellows are asked to balance multiple concerns on top of their own readiness for parenthood, including limited access to parental leave and obscure policies about potential impacts on their career. This often leads women, in particular, to delay child-rearing. Nearly a quarter of female physicians who attempted conception report infertility, and, in gastroenterology specifically, after 5 and 10 years as an attending, female

gastroenterologists still have fewer children than their male colleagues (please see excellent work by Dr. Carol Burke, Dr. Aparajita Singh and colleagues through the ACG Women in Gastroenterology Committee in 2005 and 2008 under References below). My advice to fellows is to have a child when you are ready to be a parent, and know that we all have to work to make the system better to support you. Take comfort in the fact that there are many incredible physician parents who have paved the way before you. Try to make it a little easier for the people who come after you, by sharing your experience and advocating for what you need. How do you break the news to your program director, and why is it important (in terms of scheduling, etc.)? A program director likely wants to know as early as you feel comfortable, in order to arrange schedules. This must be balanced with personal comfort, and I know that I waited until after my first trimester to disclose. I was the first chief resident at my institution that I knew of who had gotten pregnant, and was worried about responses. However, I think many people had guessed I was pregnant before I publicly disclosed. One beloved attending saw me walking out of OB clinic with my husband. I sheepishly said, “Well, I guess you know my secret.” To which she replied: “Secret? Lauren, I’m old, not blind.” I burst out laughing, then realized it was time to start telling people. GI fellowship is about both service and education, and in my opinion, if sufficient weight is being given to your education, then there should be enough coverage and flexibility within the system to allow parental leave without overburdening colleagues. Ideally, increased involvement from

advanced practice providers can be recruited as well. Indeed, fellowship is likely an easier time, logistically, to plan for parental leave than early attending years. And it is my hope that parental leave will become an expectation for all genders, and fellowship programs should be built with systems in place to support this leave. What are the most important lessons learned about specific interview strategies that you share in the article? Importantly, we need to improve anti-bias training for all interviewers (please see excellent article by Dr. Joshua Ellis, et al. on bias experienced by Black interviewees in References below.) If you are asked an offensive question, I could not say with confidence the best way to handle it. In my article, I describe that I shied away from pointing out sexism on the interview trail. Fellowship interviewees are in a vulnerable position, and it is hard to address these issues in the moment. However, it is also likely true that if interviewees pointed out microand macro-aggressions with regularity, then they would occur less frequently in subsequent years. But rather than putting the onus on interviewees, I believe we should have anti-bias training for interviewers. Additionally, whether interviewing for fellowship or a job, I believe representing yourself honestly is the best way to find a good fit. That will mean some programs view you more favorably and others less so, but you are more likely to end up in a program with similar values and goals. I personally find it helpful to anticipate hard questions and rehearse answers with friends and family, to ensure that I have an honest and polished answer at the ready. But each interview always has surprises, and proceeding with flexibility and humility is necessary.

Specifically, as a pregnant interviewee, a few programs highlighted pictures of fellows with their children in their introductory presentation, which was a good way to know that the program valued the families of their fellows. Additionally, many interviewers shared with me information about childcare resources and what it was like to raise a family in their city, which helped me visualize being a fellow at their institution. There is an excellent study by Dr. Freda Arlow and colleagues from 2002 which found that training programs with a parental leave policy had more female fellows. It is hard to know the direction of causality, but I recommend fellowship programs create a policy and highlight it in the information provided to all applicants—many will want to know but not want to ask. Additionally, program directors should ask each of their fellows what would make the program more inclusive for them. How best to prepare to return to work? Returning to work will be tough, regardless of your preparation. I recommend finding someone at your institution who has returned from parental leave and asking them for detailed logistics. I had coffee with a kind resident at my institution and she showed me a map of pumping

rooms, discussed where she stored her breastmilk, and recommended time-saving essentials like a hands-free pumping bra and a Nalgene for storing milk more conveniently. After I returned to work, I paid it forward by grabbing coffee with the pregnant residents and sharing what I had learned. Also, if you may be interested in daycare, sign up early! As in, right after you find out you are expecting a child (or even before)! I am still on the waitlist for the University of Washington daycare near the hospital, two years later. Personally, I started with a nanny when my daughter was very young, with plans to transition to daycare when she was around 1 (which was, of course, disrupted by COVID.) Each family will need to decide what works for them financially and logistically, but know that if your partner is also a physician the hours that daycare is open may not be sufficient. I also recently heard that Brown University’s Women in Radiology group will fund portable breast pumps for their residents returning from maternity leave—I highly encourage more programs do this! It is a very important piece of medical equipment to balance busy clinical duties and pumping, but the $500+ price tag makes it difficult to afford on a fellow salary. I did not have one, and at the beginning of my fellowship I needed to disappear

How can GI training programs ensure that their interview process is inclusive and offers opportunities for women who wish to start a family? Training programs that support a diverse faculty and fellowship class will attract more diverse fellows. Trainee Hub | 19

// TRAINEE HUB

“Becoming a mother has been my greatest joy and has given all aspects of my life, including my career, new fuel and purpose.” every few hours to sit in a closet (er, “pumping room”), losing precious time. I was told by an attending that I would need to choose between extra procedural experience and continuing pumping, and eventually stopped pumping. In hindsight, I wish I had set myself up for success by finding a pumping space with a computer, which is easier with a portable pump. What are the ergonomic challenges for females performing endoscopy during pregnancy and what can they do to overcome that? This is an important consideration that deserves more attention, but is unfortunately understudied. I highly recommend this as a research project for anyone reading, or as a focus of attention for those who are currently experts in endoscopy ergonomics. Until we have more data specific to pregnancy, I would suggest paying extra close attention to general ergonomic recommendations, including appropriate screen and bed height, and sufficient break time. I am also a fan of compression stockings! Beyond endoscopy, however, what we know from studies in the surgical literature is that frequent overnight calls (more than 6 per month) and greater number of hours in the operating room were correlated with significantly higher obstetrical complications. I believe, as a specialty, we need to offer appropriate accommodations to our pregnant colleagues, and build this into the system so that accommodations do not require overburdening already busy colleagues. How is life as a gastroenterologist with a young family going, and what are some of the joys and challenges? Becoming a mother has been my greatest joy and has given all aspects of my life, including my career, new fuel and purpose. Above all else, I’m grateful for an incredible, supportive

20 | GI.ORG/ACGMAGAZINE

partner who values my career and works hard to support it. Having family in the area is also very helpful as a fellow. There are days where I leave before my daughter wakes up and get home after she goes to bed—those are tough. I was advised in medical training to not disclose that I am asking for accommodations for my daughter, that it would make me look as if I’m not dedicated to my career. For example, I was told if I have to bring her to a pediatrician appointment that I should tell my attending I have to leave for my own medical appointment. I have chosen to disregard that advice and opt for openness and honesty. Indeed, I work hard and organize tasks with efficiency, and I believe this has helped me be a happier person and better physician. For example, prior to my daughter’s birth, I would stay late in clinic and finish notes immediately after. Now, I leave clinic after seeing the last patient and finish my clinic notes after she goes to bed, which does not adversely affect patient care. She also motivates me to be more efficient. For example, if I complete a research project during her nap time then I’ll have more time to spend with her, so it is easier to focus and be productive. I also maximize extra educational opportunities in a way that works, such as watching the weekly ACG Virtual Grand Rounds recording while folding laundry. When I was on a busy call weekend and didn’t see my daughter much, my husband explained to her that I was busy “at the hospital, helping people by fixing booboos” and that I would always come back. She now tells our nanny “mama’s helping people!” and when I leave for work in the

morning, she asks if I am going to fix boo-boos. She’s in for a rude surprise when she learns that I do this via colonoscopy!

References Baby Steps in the Right Direction: Toward a Parental Leave Policy for Gastroenterology Fellows Lauren Deborah Feld Am J Gastroenterol. 2021 Mar 1;116(3):505-508. doi: 10.14309/ajg.0000000000001145.

 bit.ly/AJG-Feld-Baby-Steps Gender Disparity in the Practice of Gastroenterology: The First 5 Years of a Career Carol A. Burke, Suriya V. Sastri, Gordon Jacobsen, Freda L. Arlow, Robyn G. Karlstadt, Patricia Raymond Am J Gastroenterol. 2005 Feb;100(2):259-64. doi: 10.1111/j.1572-0241.2005.41005.x.

 bit.ly/AJG-2005-Gender-Disparities-GI Do Gender Disparities Persist in Gastroenterology After 10 Years of Practice? Aparajita Singh, Carol A. Burke, Brett Larive, Suriya V. Sastri, Women in Gastroenterology Committee of American College of Gastroenterology Am J Gastroenterol. 2008 Jul;103(7):1589-95. doi: 10.1111/j.1572-0241.2008.01976.x.

 bit.ly/AJG-2008-Gender-Disparities-GI Interviewed while Black Josh Ellis, Onyeka Otugo, Alden Landry, Adaira Landry N Engl J Med. 2020 Dec 17;383(25):2401-2404. doi: 10.1056/NEJMp2023999. Epub 2020 Nov 11.

 bit.ly/NEJM-2020-Ellis

Lauren D. Feld, MD, Second Year GI Fellow, Division of Gastroenterology and Hepatology, University of Washington

“Fellows are asked to balance multiple concerns on top of their own readiness for parenthood, including limited access to parental leave and obscure policies about potential impacts on their career. This often leads women, in particular, to delay child-rearing.”

GETTING IT

GETTING it Right Thank Uncle Sam for your Pay Increase in 2021 A Bureaucratic Rule Change May Impact Your Wallet

By Ann Bittinger, Esq.

WILL YOUR TAKE HOME PAY CHANGE THIS YEAR WITHOUT NEGOTIATING AN AMENDMENT TO YOUR EMPLOYMENT AGREEMENT OR ALTERING YOUR PRODUCTIVITY? If so, CMS may be the one to thank. Many employers, however, are taking steps to make sure CMS’ change does not increase physician pay.

WHAT HAPPENED? Effective January 1 each year, the Centers for Medicare and Medicaid Services (CMS) publishes its Medicare Physician Fee Schedule (MPFS). Among other things, this administrative rule sets values for wRVUs (work relative value units) for each CPT code. Typically, the changes are not dramatic, but this year, CMS decided to recognize the increased work effort involved in office visits. CMS increased the wRVU values for evaluation and management codes and other office-related codes by a substantial amount. For example, a 99212 was worth .48 wRVUs in 2020, but it increased by 46 percent to .7 in 2021. It does not take a mathematician to understand that a physician who bills 120 E&M codes like 99212s each week could see a fairly substantial increase.

Getting it Right | 21

// GETTING IT RIGHT: LAW MIND

“On a microeconomic level, gastroenterologists whose practices rely largely on office visits as opposed to procedures may see an increase in pay.”

While CMS’ change was designed to impact reimbursement to employers for services to Medicare patients, physicians whose compensation is tied to wRVU productivity may see a big increase or decrease. CMS’ action impacted not only the value per CPT code but also the total amount of reimbursement per CPT code. On a macroeconomic level, leading organizations estimate the impact for gastroenterology services generally to decrease 4 to 5 percent (largely due to the specialty being more procedure-heavy than other officebased specialties). Yet, on a microeconomic level, gastroenterologists whose practices rely largely on office visits as opposed to procedures may see an increase in pay.

THIS IMPACTS MY WALLET? How does a federal administrative rule increase your pay? If you are paid a flat salary, it won’t. If you are on a collections minus expenses / “eat what you kill” compensation model, if overall Medicare payments go down 4 percent for GI generally then, all other things stable, you might see a 4 percent drop in your pay. But if your base compensation or bonus is in any way tied to how many wRVUs you bill, then you will see a direct correlation between the CMS wRVU value changes and your compensation. Your pay will fluctuate based on the wRVU values CMS gives to the CPT codes you bill. If your employment agreement provides for a bonus of $40 per wRVU and the code you most frequently bill was worth .48 but is now worth .7, what had paid you $19.20 is now paying you $28. A 20 percent increase on average in your CPT code values will result in a 20 percent increase in this component of your compensation.

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THE FINE PRINT As always with physician employment agreements though, the precise wording of each physician’s contract matters. A contract might define “wRVU” as “the value assigned by the then current Medicare Physician Fee Schedule.” Under that definition, the value changes in step with each new year’s MPFS values. Other contracts, however, lock the definition into a specific year’s MPFS: “the value assigned by the 2020 MPFS.” (Trust me, most new contracts I am reviewing now specifically state the 2020 MPFS). Others are silent as to year: “the value assigned by CMS.” Others have expansive language that might suggest the most recent publication governs. Many physician enterprises, particularly those that employ many internal medicine physicians, family practitioners, hematologists, oncologists, and endocrinologists are going to exceed budgets for physician compensation simply due to the MPFS increase for E&M codes. Many are desperately trying to stop that from happening by making the 2020 values apply to their physician compensation models for another year. While the changes are not dramatic for gastroenterology codes and, therefore, the desperation may not be dramatic by leaders in GI specialty practices, that’s not the case in multispecialty practices. Generally, many physician enterprises want to use the same wRVU compensation formulas for all of their employed physicians. If the enterprise

leaders need to use the 2020 value to retain the status quo for pay for general practitioners, they are going to do the same for all employed physicians. That could be a good thing for proceduralists. Generally, this change is impacting proceduralists the worst. Due to the changes in the 2021 MPFS, this is a good time to be in internal medicine, endocrinology and hepatology; it’s a bad time to be a surgeon, radiologist or other proceduralist. Gastroenterology falls about in the middle, with the impact largely dependent on the heaviness in the practice of procedures versus E&M codes. For proceduralists, locking in the 2020 rates for another year might be good. Gastroenterologists may get caught in their physician enterprise’s broadlytossed net, though, being asked—along with all the employed physicians in the group or enterprise—to sign amendments to their employment agreements to freeze the definition of wRVU in their employment agreements to the 2020 value. I have been telling clients that if your employer is asking you to sign an amendment to your employment agreement to keep the 2020 MPFS, then it’s pretty likely that your contract says they are supposed to pay you based on the (probably higher) 2021 MPFS. They wouldn’t ask you to sign an amendment if they didn’t need to. Other employers are being a bit more brash. Some employers are simply retaining the 2020 MPFS whether the physician employment agreements allow it or not. They do so at much legal risk. If the contract clearly mandates use of the 2021 MPFS, and the employer paid based on the 2020 MPFS, the employer could

“While the changes are not dramatic for gastroenterology codes and, therefore, the desperation may not be dramatic by leaders in GI specialty practices, that’s not the case in multispecialty practices”.

“It does not take a mathematician to understand that a physician who bills 120 E&M codes like 99212s each week could see a fairly substantial increase.”

LET’S TALK Some leaders of physician enterprises are spending a lot of time and energy explaining the impact to physicians and asking them to be team players and to sign the amendment. Some of my clients in those situations are agreeing to a limited freeze on the MPFS values but asking for other things like higher call pay or more paid time off. When you are asked to come to the table, it is smart to place your order.

be liable for breach of contract. In that case, a court could order the employer to pay the physician the difference between what was paid based on the 2020 MPFS versus what the employee should have been paid using the 2021 MPFS. For a physician enterprise employing hundreds of physicians who, as a whole, could have a very large increase in pay between the two years, that’s a large financial exposure for the employer to face.

DUE DILIGENCE I have been telling physician clients in this situation to be sure to retain documentation of actual CPT codes billed in 2020 and in 2021. It’s not enough to simply track your wRVUs. A court will want to see exactly what you should have been paid versus what you were, and in a wRVU based compensation model that depends on each CPT code billed. While reports on CPT codes billed would likely be available upon subpoena, and maybe even upon request, it’s valuable for physicians to be able to do their own calculations (and share them with the employer) to work in good faith to remedy the breach by the employer prior to filing suit.

CHANGE IT Once a physician determines if the contract requires the use of a certain year’s MPFS, it is important to determine whether the employer can change the employment agreement without the physician’s consent. For example, if the agreement says the “then current” or “most recently published” MPFS must be used, is there something else in the employment agreement that allows the employer to change that? Most contracts do not allow the employer to unilaterally amend the contract. This amendment issue due to wRVUs is déjà vu of last year’s COVID lockdown’s impact on physician pay. This time last year, physicians whose compensation was based on wRVUs were unable to generate wRVUS when elective procedures were stopped. The employers whose physicians were paid based on wRVUs were the lucky ones; physician compensation expenses decreased as physician productivity decreased. The same is true for physicians on revenue minus expenses models. Administrators saw income from procedures decrease during lockdown, but at least physician compensation expenses were going down too. Contrast that to employers who paid physicians flat salaries. Many

of them simply docked physicians’ pay by 20 or so percent. The lucky few had force majeure or “act of God” clauses that might have allowed that. Many, though, had to ask physicians to sign amendments to their contracts or pressure them to take a hit for the team and volunteer to lower pay. I have heard some argue that the provisions allowing employers to make changes to reflect fair market value would allow the employer to freeze the physician’s pay if the physician is slated to receive a big increase under the 2021 MPFS. I disagree that this is a fair market value issue. To the contrary, if anything is indicative of measure or standard for a fair value of a service, I would argue that the government’s published rate, applicable to all physicians everywhere per CPT code, fits the bill. Frankly, if the government says that office visits have been under-valued in the past, then employers should worry that their argument can be used against them to say that family practitioners have been paid less than fair market value in the past and that reparations are due based on the increase in 2021. Be careful what you argue for, employers. In short, I’ve seen nothing that impacts physician pay more dramatically in 22 years of practice than the publication of the 2021 MPFS, coupled with the impact of decreased procedures for a short time during COVID. Never before have physicians needed to really understand the means by which the calculations on which they are paid are made.

Ann Bittinger, Esq., is a healthcare attorney with The Bittinger Law Firm and can be reached at ann@bittingerlaw.com

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l e b a

Emotions

regu l a t

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Emotional Intelligence An Impactful and Often Overlooked Leadership Skill Overview by David J. Hass, MD, FACG with Insights from Uchenna A. Agbim MD, Sara E. Ancello, DO & Divya B. Bhatt, MD

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It is March 2020. It’s 6:30 pm on Thursday evening and you are sitting in the middle of a Department meeting being held on Zoom. You watch as colleagues become more and more impatient, discussing who will be covering extra teaching attending and overnight call responsibilities due to concerns about attempts to minimize COVID exposure to those colleagues with risk factors that may portend a poor prognosis. The conversation becomes somewhat heated and you feel your impatience beginning to surface as there are other things that you feel could be more productive and efficient for you to be focusing on. —Dr. Hass 26 | GI.ORG/ACGMAGAZINE

Suddenly, you unmute yourself and blurt out, “I’ve got to go, this conversation is truly a waste of time.” You press the “leave meeting” button. Initially, you feel empowered and satisfied. I showed “them” how inefficient they are. My time is too valuable to waste on aimless conversations, you think to yourself. However, after a minute, you begin to reflect. What might the conversation on the call be focusing on now? Me? My actions? What is the emotional wake that I have just left behind? Did my frustration lead me to behave in a way that did not reflect the best version of myself? Maybe if I had paused, taken a deep breath, analyzed how I was feeling and why I was feeling that way, I could have moderated and expressed my response more effectively. "Gosh, now I may have to do some damage control," you think. As you reflect, you realize that these types of actions or, more accurately, “reactions” will not help me accomplish my goals of making my colleagues function more efficiently and having my input viewed as collaborative and effective. The concept of “feelings” is one that we don’t address often in medicine. Emotions play an integral role into what makes all of us human. However, emotions often cloud our judgment, expose our vulnerabilities in ways we may not want them to, and ultimately lead us to express ourselves or act in ways we wish we hadn’t. The field of Emotional Intelligence (EI) has blossomed in recent years and is applicable to everyone and every industry. Originally defined by psychologists Peter Salovey and John Mayer in 1990, EI is “the ability to monitor one’s own and others’ feelings and emotions to discriminate among them and to use this information to guide one’s thinking and actions.” Why EI? Often, suppressing or ignoring our emotions or feelings leads to unwanted outcomes and situations. A recent Gallup poll revealed that over 50% of employees are unengaged at work, and 13% report they are “miserable.” From 2016–2017, one in three students at U.S. college campuses surveyed reported diagnosed mental health conditions. The goal of EI is to allow us to accept our emotions, understand and regulate them so as to live healthier, more productive lives, and to make smarter choices and more impactful and constructive decisions.

Professor Marc Brackett, Director of the Yale University Center for Emotional Intelligence, is a pioneer in this field. The Center for Emotional Intelligence has a distinct goal: “to use the power of emotions to create a healthier and more equitable, innovative and compassionate society,” states Dr. Brackett in his new thought provoking book Permission to Feel. Imagine if all of us were able to give ourselves the permission to feel any way we did, but then used that information in constructive ways to create better solutions to problems, and become more effective resources for our patients, our colleagues, and ourselves. Data supports that this will lead to more personal and professional satisfaction, less job stress, less fatigue and burnout, and better quality care delivered. It is difficult to accurately and specifically describe how one “feels” at any given moment. Often we respond when asked with words like “fine” or “good” or “OK.” EI challenges individuals to dive deeper and try to recognize, understand, and label more specifically how one feels in response to any given stimulus or situation. By doing this, we learn to express ourselves more clearly to others while regulating our responses. This will ultimately lead to better professional and personal relationships and better collaboration, teamwork, and quality in our home lives and professional settings. The RULER Methodology The tenets of the “RULER” Method developed by Dr. Brackett are detailed in Figure 1. It aims to help individuals recognize, understand, and label his/her emotions. By incorporating these reflective practices, one will hopefully be able to better express and regulate one’s response. This RULER methodology has been validated in many settings and is currently being implemented into school systems nationwide as part of a core curricular endeavor. The hope and goal of this implementation is that students, educators, and administrators will all subscribe to this methodology to create an environment that optimizes learning while recognizing individual challenges faced by teachers and students alike. There is one simple question that many of us ask each other in passing every day. “How are you? How are you doing?” Paradoxically, we inquire with one another, but most times don’t ever expect or desire an honest answer. We expect the reflexive, “Fine, how are you?”

“

“The goal of EI is to allow us to accept our emotions,

understand, and regulate them so as to live healthier, more productive lives, and to make smarter choices and more impactful and constructive decisions.” —Dr. Hass

or “Great, thanks and you?” This is normal as we have an instinct not to show our vulnerability and admit that all might NOT be OK or great, as if it would reflect weakness or ineptitude. EI turns this notion on its head. Though it might be risky or inconvenient to share how we are truly feeling when asked, suppression of those feelings only makes them stronger and build up and affect all of our interactions and relationships. If we don’t express our emotions, “they pile up like a debt that will eventually come due,” states Dr. Brackett. Why Feelings Matter Our feelings matter most in the following ways. Our emotional state determines what we remember and how we learn. Emotions affect our decision making, as we perceive the world differently depending on the mood that we are in. A study evaluating teachers asked to recall a positive memory and then grade an exam compared with teachers asked to recall a negative memory asked to grade the same exam revealed that those who recalled negative memories graded the same test a full grade level lower. When these same educators were asked if they felt that their mood affected their evaluation of the papers, 87% said no. This suggests that emotions subjectively affect our decision making and analytical skills. Emotions affect our social relations and our mood, words, and non-verbal cues signal others to approach or avoid. Those with robust social networks enjoy better physical and mental health and data also suggests that those with more enhanced networks live longer. Emotions modulate our health through endorphin release and neurotransmitter release. Finally, emotions impact our creativity and performance levels. Positive

Figure 1. The RULER Methodology as described by Marc Brackett, PhD. Permission to Feel, 2019

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

PRESENTATIONS: ACG Education Universe Emotional Intelligence Module The ACG Education Universe offers an Emotional Intelligence Learning Module, developed by Dr. Ancello, Dr. Bhatt and Dr. Agbim. To maximize this activity, participants are encouraged to review all 8 lectures in order. Lecture 1 is an Introduction to EI. Lectures 2 to 5 cover the 4 domains of EI. Lectures 6 to 8 offer recommendations on how to incorporate EI into practice, leadership roles, and everyday life. • Lecture 1 EI Introduction Sara Ancello, DO • Lecture 2 Self-Awareness Uchenna A. Agbim, MD • Lecture 3 Self-Management Divya B. Bhatt, MD • Lecture 4 Social Awareness Meir Mizrahi, MD • Lecture 5 Relationship Management Elizabeth R. Paine, MD, FACG • Lecture 6 Communication Calvin Chou, MD, PhD • Lecture 7 Implicit Bias Mitigation Michelle Guy, MD • Lecture 8 Maximize Your Performance Aasma Shaukat, MD, MPH, FACG  WATCH: universe.gi.org/modulelist.asp



Resource List for Further Reading on Emotional Intelligence • Bradberry T, Greaves J. Emotional Intelligence 2.0. Talent Smart. San Diego, CA; 2009. • Goleman, Daniel. Emotional Intelligence. Bantam Dell. New York, NY; 2005. • True MW, Folaron I, Colburn JA, Wardian JL, Hawley-Molloy JS, Hartzell JD. Leadership Training in Graduate Medical Education: Time for a Requirement? Mil Med. 2019. • Mintz LJ, Stoller JK. A Systematic Review of Physician Leadership and Emotional intelligence. J Grad Med Educ. 2014;6(1):21-31. • Holliday EB, Bonner JA, Formenti SC, et al. Emotional Intelligence and Burnout in Academic Radiation Oncology Chairs. J Healthc Manag. 2017;62(5):302-313. • Hollis RH, Theiss LM, Gullick AA, et al. Emotional intelligence in Surgery is Associated with Resident Job Satisfaction. The Journal of Surgical Research. 2017;209:178-183.

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emotions help to promote divergent thinking and creative problem solving, which yields a positive feedback loop to promote happiness and feeling good. EI in Your Leadership Toolbox Emotional intelligence enables individuals to think more honestly, creatively, and critically self-reflect in order to get better results from ourselves and our colleagues. It doesn’t allow feelings to impair that process; in fact, it restores balance to our thought processes and prevents emotions from having excessive influence over our actions. Thus, if EI were part of one’s leadership toolbox, the vignette at the beginning of this piece may have had a very different outcome. The physician described could have recognized and understood how s/he was feeling, labeled those emotions so as to disempower them and their ability to impair for proper communication, and in turn allowed for productive expression of one’s opinion in a more tactful way. If medicine were to implement EI as part of a medical school or postgraduate training curricular pillar, this very well could help all colleagues enjoy more personal and professional satisfaction and assist with combatting the other pandemic we are presently facing, professional burnout.

About Dr. Hass Director of Endoscopy, Yale-New Haven Hospital-Saint Raphael Campus; Associate Clinical Professor of Medicine, Yale University School of Medicine; Medical Director, PACT Gastroenterology Center, Hamden, CT

Introduction to Emotional Intelligence Sara E. Ancello, DO

Determination leads to success, but what determines who will succeed? It is undeniable that qualities like

knowledge, education, and power play a role, but there is something else that society does not account for. While there are many reasons that highly skilled people struggle and others with seemingly fewer skills flourish, let us consider the role of Emotional Intelligence (EI). In short, Emotional Intelligence is the ability to identify our own emotions and the emotions of others, and use them to guide our thinking and behavior to better manage relationships. In practice, however, EI is much more than just a simple sentence. How to Avoid “Emotional Hijacking” Did you know that only about onethird of people are able to accurately identify their own emotions? In other words, two-thirds of people are missing the opportunity to understand their emotions and guide their own behavior. In lacking this understanding, there is a higher likelihood of falling victim to something called “emotional hijacking.” This is when high-intensity emotions intrude and shape a person’s actions. Imagine you are driving down the highway, when suddenly another driver cuts you off. You quickly swerve into the shoulder to avoid hitting other drivers and just miss taking out a road sign. Your heart is pounding in your chest and your adrenaline is rushing through your body. You are feeling terrified and furious at the same time. Now, pause for a minute to consider what you would do next. Are you the type of driver who would take a deep breath, shake it off, and continue along to your destination? Or are you the type of driver that would step on the gas, follow the person who cut you off, and signal to them to express how enraged you are? If your reaction is the latter, it is a classic example of “emotional hijacking,” and many would call it “road rage.” It is here that we must consider Aristotle’s words, “anyone can become angry—that is easy. But to be angry with the right person, to the right degree, at the right time, for the right purpose, and in the right way—that is not easy.” EI calls for an understanding of our own tendencies across situations. This “road rage”

scenario is one way to consider our own tendencies across similar scenarios, and once we are able to recognize this, we can use it to control our behavior in the future. Why EI Matters for GI High-proficiency EI has been linked to improved job satisfaction, physician wellness, and may even reduce burnout. It can improve communication, peer and patient relationships, and encourage successful professional interactions. EI is an essential component for organizational and leadership development, negotiation, and conflict resolution– skills that are necessary for medical directors, division chiefs, department chairs, and other leadership roles. However, even as EI has continued to gain a foothold in popular and business culture, the professional development of EI in medicine continues to be lacking. This is why the American College of Gastroenterology has decided to shine a spotlight on this important topic. The Major Domains of Emotional Intelligence EI is composed of four major domains: SelfAwareness, Self-Management, Social Awareness and Relationship Management. Self-Awareness is the ability to understand yourself and your tendencies across many different situations. SelfManagement focuses on using the awareness of your own emotions to direct your own behavior. Social Awareness is the ability to pick up accurately on the emotions of others and Relationship Management is using your awareness of your own and others’ emotions to manage interactions successfully. By analyzing the principles of EI, we can implement a series of techniques and strategies within these domains that address our own areas for improvement and strengthen the skills we already have. As physicians, high Emotional Intelligence is a key tool that will undoubtedly help us to achieve better relationships with our peers, our patients, and drive us toward success.

“By analyzing the principles of EI, we can implement a series of techniques and strategies within these domains that address our own areas for improvement and strengthen the skills we already

About Dr. Ancello Dr. Ancello is a gastroenterologist at Central Arizona Medical Associates. She received her medical degree from Nova Southeastern University, College of Osteopathic Medicine in Florida. She completed her internal medicine residency as Chief Resident at Rowan University in New Jersey. She then moved to Arizona to complete her fellowship in gastroenterology through Midwestern University at Mountain Vista Medical Center, where she led her colleagues as Chief Fellow for two years. Dr. Ancello also serves as a Clinical Assistant Professor of Medicine at Midwestern University in Phoenix, Arizona.

have.” —Dr. Ancello



Emotional Intelligence: Self-Awareness Uchenna A. Agbim, MD Do you recall the last time you procrastinated on a project for clinic? How about you when you said “Yes” to serving on a hospital committee that your boss suggested, but you really wanted to respond with, “Thank you for considering me, but I am not able to commit to the committee at this time” (in essence, “No”) because you are already overextended. Or, more simply put, what was occurring in your mind when you engaged in an action (or perhaps, inaction) that eventually you regretted. What thoughts and feelings did you have during those times? Exploring these thoughts and subsequent feelings on a routine basis are fundamentals of Self-Awareness. Self-Awareness: The Bedrock of Emotional Intelligence Self-Awareness refers to the intrinsic ability to recognize one’s thoughts, feelings, and responses to situations. It serves as the bedrock upon which the other emotional intelligence (EI) domains rely, as (1) controlling one’s emotions (Self-Management) requires good Self-Awareness; (2) recognizing the pulse of group settings (Social Awareness) rests on having sufficient appreciation of one’s own awareness; and (3) navigating the world of social connections (Social Management) mandates sufficient Self-Awareness. Developing Self-Awareness assists in leveraging other key features of EI. Becoming more self aware sounds easy, but in reality it requires considerable patience

WATCH all 8 Learning Modules on Emotional Intelligence on the ACG Education Universe: universe.gi.org/modulelist.asp

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and curiosity to explore one’s mindset, values, strengths, and limitations. In general, life consists of numerous neutral situations or circumstances in which we develop thoughts about these circumstances. Subsequently, these thoughts engender specific feelings or emotions. From these feelings and emotions, we engage in an action or inaction. SelfAwareness relies on continuous appraisal of self, requiring considerable inward observation and reflection. Being a Passive Observer of Your Own Behavior One method to heighten Self-Awareness is acting as a passive observer of your own behavior. This method requires mindfulness. Ultimately, you must step back from the situation at hand and note—with curiosity and compassion—the feelings, patterns, and reasons behind your behavior. Labeling the feelings can be powerful, and some people even note the associated physical sensations experienced. Then, it may help to ask yourself why you felt this way and responded in the manner you did. Essentially, it means pondering what thoughts ignited the feelings that were perceived. How you think about a situation dictates the feeling experienced. If you want to change the way you feel, a change in the underlying thought is necessary. This requires doing a deep dive into your thoughts and questioning whether those thoughts benefit you. This type of metacognition and evaluation is a crucial component of developing Self-Awareness. Similarly, journaling serves as one strategy to capture these thoughts, feelings, and emotions, as well as a method to commit to thought work and your mindset. Others employ meditation or even coaching. Nevertheless, finding some type of avenue in which you can ponder, reflect, and work on

“Self-evaluation does not entail being hard on yourself but recognizing your successes, as well as acknowledging your limitations. It consists of reflecting on your values and if you are being true to them.” —Dr. Agbim

your thoughts and subsequent feelings will assist with developing increased Self-Awareness. Another approach to increase Self-Awareness is self-evaluation and eliciting feedback from others. Self-evaluation does not entail being hard on yourself but recognizing your successes as well as acknowledging your limitations. It consists of reflecting on your values and if you are being true to them. Because we all have degrees of bias, seeking feedback or an evaluative assessment from individuals whom you interact with and populate your social and professional world can broaden your perspective. These approaches, along with many others, remain critical to enhancing Self-Awareness. Ultimately, successful and noteworthy leadership rests on how an individual leads and comports oneself. This starts with Self-Awareness.

About Dr. Agbim Dr. Uchenna Agbim works as a transplant hepatologist and gastroenterologist. Dr. Agbim is a graduate of Baylor College of Medicine. She completed her internal medicine residency at UCSF Department of Medicine in San Francisco, CA and her gastroenterology and transplant hepatology fellowships at New York Presbyterian—Columbia University in New York, NY.

Emotional Intelligence: Self-Management Divya B. Bhatt, MD

Self-Management is the second domain of Emotional Intelligence and builds on SelfAwareness. Self-Management is the ability to use Self-Awareness techniques to understand one’s emotional response, and subsequently use that understanding to determine the most effective course of action. Once a person understands what they feel, and why, they can subsequently begin to identify their triggers and redirect their behavior patterns in a more productive way. The First Tenet of Self-Management is Impulse Control Impulse control means to think before you act or react. Most of us have sent an angry email or said something that we later regretted. In SelfManagement, it is critical to distinguish between another person’s actions, and your reaction. However, impulse control does not mean allowing others to take advantage of you. For example, it is normal to feel irritation when dealing with a

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rude patient or a frustrated staff member. Impulse control dictates that you respond in a calm, yet authoritative, manner regardless of your inner emotions. How do we control our impulses? Start by watching your own behaviors closely, and ask yourself, “Why do I act, or react, in this way?” Try to analyze your actions, especially while under stress. That way, you will begin to determine how certain stimuli activates your responses. Then, use that awareness to “retrain your brain.” Adaptability & Flexibility Another tenet of Self-Management is being able to adapt to changing circumstances. No one could have predicted the changes we have endured over the last year, and the challenges we continue to face. Being able to assess our emotions, in response to an unforeseen event, allows us to adapt our behavior more easily. Furthermore, the ability to be flexible gives us the space to take more risks and try something new, even if we may not succeed. Being more adaptable allows us to emotionally bounce back from failure, seeing it instead as redirection. How do we become more adaptable? Learn to see obstacles as opportunities for growth. Most people, especially high-achieving professionals, prefer a structured and stable routine. However, if you train yourself to view uncertainty as “full of possibility” instead, you will start to think of creative solutions. For example, a research article addressing colorectal cancer screening could be rejected from the gastroenterology journal of your dreams, but might become the featured article in a preventive healthcare journal. Don’t let setbacks undermine the pursuit of your goals. Taking Responsibility for Emotional Growth Another technique of Self-Management is taking personal responsibility. This means taking initiative, following through on commitments, and taking responsibility for your emotional growth. Part of this process is recognizing that your actions may have unintended negative effects on others. For example, if you typically “suffer in silence” until you become overwhelmed, your colleagues may avoid asking you to participate in an important project because of fears about adding to your workload. Instead, start to learn your limitations and remember that collaboration can open more avenues in the future. Ask for help and feedback often. How do we take personal responsibility? First, understand that harnessing your emotions effectively and learning to manage your tendencies

“No one could have predicted the changes we have endured over the last year, and the challenges we continue to face. Being able to assess our emotions, in

takes time and effort. Take a step back from the moment and think about achieving your long-term vision. Your emotional growth is your responsibility. It is hard work, but only you can do it.

About Dr. Bhatt Dr. Bhatt is Assistant Professor of Medicine, UT Southwestern Medical Center, VA North Texas Healthcare System. She grew up in San Diego, California and completed medical school and internal medicine residency at the University of Illinois College of Medicine in Chicago, Illinois. She completed gastroenterology fellowship at the University of Arizona College of Medicine in Phoenix, Arizona in 2018. Her areas of interest include colorectal cancer screening and outcomes, process improvement, health disparities, and medical education. Currently, her clinical practice emphasizes patient-centered care for veterans at the Dallas Veterans Affairs Medical Center. In addition to medicine, Dr. Bhatt enjoys traveling, reading, dancing, and spending time with family and friends.

response to an unforeseen event, allows us to adapt our behavior more easily.” —Dr. Bhatt

references 1. Salovey P and Mayer JD (1990). Emotional Intelligence. Imagination, Cognition and Personality, 9(3), 185-211. 2. Kelland K, (October 9, 2018). Mental health crisis could cost the world $16 trillion by 2030. Reuters. 3. Lipson SK, Lattie EG, and Eisenberg D. (2018). Increased rates of mental health service utilization by US college student: 10-year population–level trends (2007-2017). Psychiatric Services, 70(1), 60-63. 4. Brackett, M et al. Emotional intelligence: The Influence of Teacher Emotion on Grading Practices: A Preliminary Look at the Evaluation of Student Writing. Teachers and Teaching, 19(6); 634-646.

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

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

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Culinary Connections:

Good for the and the Gut Soul

By Vani Paleti, MD, Alexander Perelman, DO, Christina A. Tennyson, MD

 FOOD IS EMOTIONAL; FOR SOME, IT'S AN AMALGAM OF VARYING EMOTIONS. From the time we are born, our life’s journey and experiences are intricately connected to food. What we eat and how we eat influences our physical health, mental health (gutbrain connection), and general well-being. Food has also provided a way to connect with others and develop a community. During the pandemic, as a community of gastroenterologists, we have been able to celebrate and support each other through our love of food.

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// PERSPECTIVES

VANI PALETI, MD

Baylor Scott & White Health, Killeen, TX

All of my childhood happy memories revolve around food and fresh produce. I have vivid memories of walking the bustling streets of Kothaval Chavadi, one of the largest fresh fruit and vegetable markets in Chennai, India. Bargaining with vendors for fresh fruits and vegetables was second nature. I started learning basic cooking and knife skills, helping my full-time, working mother of four. It started with cleaning and the simple chopping of vegetables in third grade to weekly meal prep by middle school. During summer holidays, we were assigned a small patch to grow vegetables and herbs. This laid the foundation for my love for gardening vegetables and herbs at home. Like all mothers and grandmothers, my mom taught me her home remedies, including those for a simple cough or a starchy fermented broth after a bout of viral gastroenteritis. Family and friends gathered around home-cooked meals and shared whatever food we had at home. We connected and bonded over the dinner table at the end of the day and during festivals.

As a medical resident, a GI fellow asked why I wanted to study gastroenterology. I explained my interest in several organs working in harmony with the sole purpose of digesting food, eliminating toxins, and nourishing our bodies. A disease affecting any of one of these processes can cause a myriad of gut health issues. An optimally functioning GI tract goes a long way in disease prevention and recovery from illnesses. This, in addition to the procedural aspect of the field, sparked my interest. Our changing world and fast-paced culture are fueled by highly processed and refined foods. This contributes to increasing numbers of preventable chronic medical illnesses, a leading cause of morbidity and mortality. As physicians, we need to be more involved and lead the change towards healthier lifestyle choices. I am certified in obesity medicine, lifestyle medicine, plant-based nutrition, and am currently completing culinary medicine certification to focus on integrative approaches to meet the needs of our patients. I want to bring awareness to healthy food choices and how to best incorporate sustainable, cost-effective foods, particularly for patients affected by food deserts and food insecurity. Social media has offered me a platform

SUMMERY SALAD – 1 servin  Ingredients

• 1 cup baby kale • ½ cup cooked or canned chickpeas

into • 1 medium cucumber, cut es cub ½ inch half • 7 cherry tomatoes, sliced in led • 1 small sweet orange, pee • ½ green or red bell pepper, cut into ½ inch cubes

d • 10 pitted green olives, slice in half • ½ tablespoon lime juice • Salt and pepper, to taste

34 | GI.ORG/ACGMAGAZINE

 Steps

minutes 1. Massage baby kale for 1-2 erness) bitt s ove (rem s ertip with fing e for 1 rins as, 2. If using canned chickpe salt ss exce minute to remove in a large 3. Combine all ingredients salad bowl, toss gently juice 4. Mix in ½ tablespoon of lime flavors) y tang like you if e mor d (ad nd 5. Add salt and freshly grou mill, to per pep a from peppercorn e tast

I eat it) or Note: Can be served as-is (how ice (be cho r served with dressing of you ) ries mindful of added calo

to express my love for gardening, sharing healthy recipes and educating communities with evidence-based gut health information. In 2020 during the pandemic, I shared on Instagram (@gastromom_md), 50 simple and healthy #planter2table recipes using herbs, vegetables, and greens from my backyard planter garden. I was warmly surprised to meet a like-minded GI Twitter family involved in evidence-based, integrative, and holistic approaches to GI practice, alongside a neverending love for food and the nuances of cultural aspects connected to food. Enjoy This “Plant-Forward” Salad I would like to share one of my favorite simple, plant-forward salads loaded with plant protein and prebiotics, just in time for summer. I usually use kale, cucumber, tomatoes, and bell pepper from the backyard planter garden.

ALEXANDER PERELMAN, DO

Vanguard Gastroenterology, New York, NY

I’m sure we have all at some point lived this moment: during a long shift, the attending opened the door to “paradise,” also known as the attending lounge. As the K-cups poured and the over-processed snacks filled our bellies, the air was filled with stories of life outside of the hospital. It was never about the bad coffee or snacks; it was about community. Breaking bread has always been about the duality of food; it serves the nutritional needs of the body while nurturing the relationships built around the table. From the ancient Qesem Cave near Tel Aviv to the schoolyard snack exchanges, food continues to connect us. When I started sharing my food with the world on social media, I found so many who share my love of cooking. On social media there is a wonderful niche community of physicians and clinicians that

enjoy spending time in the kitchen and garden, exploring the culinary arts while building bonds with their kids, partners, and friends. Before We Break Bread, We Must Bake Bread One of the relationships I formed through the online community of physicians and clinicians who cook started when, just before the pandemic, I expressed a desire to learn breadmaking. I was inspired by beautiful artisanal breads and an episode of Michael Pollan’s Cooked. I tried my hand with a sourdough starter, without success. After it failed to take hold, Dr. Dmitriy Kedrin (@GI_Pearls) offered to send me some of his, and the rest was history. I spent the last year working on my recipe for sourdough bread, kneading it to perfection, folding and resting it. I woke to feed it early and make sure the temperature was just right. Yet, with my recent move, the starter died. I began again, with a

goal to share the journey with you to contribute to our cooking community, by nurturing the spirit and providing sustenance. After all, before we break bread, we must bake bread. My bread started with the leavening agent; in regular bread, this is commercially available yeast, while in sourdough we utilize naturally occurring yeast. Typically, this is done by combining flour and water, allowing the natural yeast in flour to take hold. I prefer sourdough with its tangy flavor and more natural feel. It takes about a week to cultivate a starter and bring it to baking shape. If you’re not in the mood or are short for time, a local bakery will often gladly share some of its active starter. The good part is that once it is active, it is resilient and can last for years and even generations; just remember to feed it! Since food is for sharing, when baking I always make two loaves: one for home and one for loved ones. The process, as you’ll see in the recipe, takes about a day but the end result

SOURDOUGH BREAD – 1 loaf (for 2  Ingredients

• 3 cups + 2 Tbsp (500 g) allpurpose/bread flour

• 1 ½ cups (375g) water • ½ Tbsp (10g) salt • ½ cup (125 g) starter

 Steps 1. Combine water and starter in a bowl, mix, then add flour

is incredibly worth it. The bread doesn’t always rise as high and the holes are not always perfect, but the reward is a chance to sit down at the table with family and fresh bread and share a moment. Take a look at the recipe and give it a try. When it cools, slice, break, share, and most of all, enjoy! Let me know how it comes out (@ PerelmansPearls).

CHRISTINA A. TENNYSON, MD

Indiana University Health, Muncie, IN (locum tenens)

I grew up in a primarily Italian-American family where food is of the utmost importance. Food is a way for our family to connect, care for each other, and to celebrate. It has also been a way for me to do all of these things with my patients and my family of gastroenterology colleagues, particularly during the pandemic. My interest in food and nutrition led me to a career in gastroenterology. During

loaves, double amounts) 6. After the 6 rests, allow dough to proof at room temperature for 90 minutes. 7. Place the dough on a floured surface and knead a bit to “knock back” the air inside. 8. If making two loaves, this is the time to divide the dough.

4. Dissolve salt in a small amount of water and add to dough, kneading for 5-10 minutes

9. Make a final fold to shape the dough and place in a well-floured proofing basket. Cover with a towel or parchment paper and place in the fridge. If you don’t have a proofing basket, you can line a large bowl with a towel and flour it generously. 10. Proof for around 12 hours in the fridge, less if at a higher temperature 11. Remove bread from the refrigerato r, allowing it to come closer to room temperature

5. Rest the dough for 5-6 30-minute intervals, folding the dough on itself each 30 minutes. Pull the dough up and fold over, rotate the bowl 90°, and repeat for each corner

12. While bread comes to temperature, preheat the oven to 450°F, placing a pot of water on the lower shelf, and the vessel you plan to bake in inside on the shelf above the pot of water

2. Once combined, slowly mix by hand or use a mixer with a bread hook for ~10 minutes until you reach a smooth, stretchy consistency 3. Cover bowl with a damp towel and rest for 30 minutes, covered by a moist towel (Autolyse)

13. After the oven is preheated, transfer the dough to the baking pan (I use parchment paper to line it, but you can use cornstarch as well) 14. Score the dough lightly with a knife and place in the pan in the oven 15. Bake at 450°F for 30 minutes, then decrease to 425°F and cook for 20-30 minutes longer. Avoid opening the oven to check on the bread 16. Once cooked, rest for 1 hour and enjoy. Feel free to preslice and freeze; toasting lightly will bring it back to a “fresh-baked” state  Remember to feed the starter! 1 cup flour and ⅔ cup water weekly if kept in the fridge. Remove from fridge the day before baking and feed as just instructed.

ACG Perspectives | 35

// PERSPECTIVES

fellowship, I incorporated rotations on the nutrition support service and intestinal transplant team, later receiving certification as a physician nutrition specialist. After fellowship, I found treating and educating patients with celiac disease highly rewarding, especially working at a center as part of a team with experienced registered dietitian Suzanne Simpson. She taught me about the struggles of living with celiac disease, how it impacted my patients’ lives, and the importance of having patients learn to cook nutritious food. I subsequently worked in a New York City community gastroenterology practice and later performed locum tenens work in rural locations. These experiences gave me a deeper understanding of food, food systems, and introduced me to delicious foods across the country. At the same time, as my own family enjoyed food (and often lots of it) we experienced heart disease, diabetes, cancers, and obesity, like many other families. As a working mom to three young children, I’ve also struggled cooking healthy meals, particularly ones that everyone would eat! I developed

POLENTA WITH GREENS, BEANS,  Ingredients

• 4 cloves garlic, minced • 2 cloves garlic, thinly sliced • 1 medium onion, finely chopped • 2 cans (28 oz.) crushed tomatoes

an interest in lifestyle, integrative, and culinary medicine, eventually completing additional training and certification in these areas. We need to not only take care of our patients but also ourselves and our families. There are numerous advantages to eating fewer processed foods and more diverse whole plant foods. This can be achieved without spending a lot of money, being overly restrictive, or having to adopt a completely vegan or vegetarian diet. This benefits our microbiota and decreases the risks of other common diseases, including colon cancer and fatty liver disease. We have a small amount of time with our patients and we need to empower them to make significant lifestyle changes. This can start with small steps, support, and developing healthy, delicious alternatives. As gastroenterologists, we are best equipped to help patients when we make positive changes and learn to cook for ourselves. During the pandemic, we have connected with like-minded gastroenterology colleagues, registered dietitians, and patient

 Sauce

1. Add 3 tablespoons olive oil to a saucepan over medium heat and add the onion. Cook until translucent, approximately 5 minutes. Add 2 cloves of thinly sliced garlic and cook for another 3 minutes 2. Add 2 cans crushed tomatoes and 2 teaspoons of basil, then stir

• 2 heads Tuscan kale, stems removed, chopped

3. Bring to a simmer and then reduce heat to low

• 1 cup polenta • Olive oil, basil, salt, pepper, crushed red

4. Stir occasionally until thickened, approximately 45-60 minutes

36 | GI.ORG/ACGMAGAZINE

CONNECTING, CARING, AND CELEBRATING During the COVID-19 pandemic, food has provided a way to connect, care for each other, and celebrate in an otherwise bleak time. Thank you to ACG for giving the three of us the opportunity and platform to share our love for food and all things gastronomical with our gastroenterology community. We look forward to bringing delicious and healthy foods from all parts of the world and invite you to connect with us! #ACGfoodies Have a personal connection with GI and gastronomy? Contact ACG at acgmag@ gi.org to share your story with the ACG community.

AND SAUCE – 2 servings

• 2 cups cooked cannellini white beans (or 16 oz. can, rinsed)

pepper

advocates virtually, particularly with the use of #GITwitter. As a global community, we have shared healthy recipes, conducted challenges to eat at least 30 plants per week, encouraged each others’ indoor and outdoor gardens, and—most importantly— had fun! Like in my Italian-American family, food is of the utmost importance for our GI family and can improve our own health and the health of our patients.

 Polenta

1. Place 4 cups water and 1 teaspoon salt in a heavy-bottomed pot over medium-high heat 2. Once boiling, slowly whisk in the polenta 3. Reduce heat to low, stirring frequently until the mixture thickens, approximately 15 minutes 4. Remove from heat. If desired, whisk in 2 tablespoons of plantbased milk or olive oil for added creaminess

 Greens and Beans

1. Saute 4 cloves of minced garlic with 2 tablespoons of olive oil over medium heat 2. Add chopped kale and ½ teaspoon salt. If desired, add a ¼ cup of water while cooking 3. Cook for another 5-8 minutes until softened 4. Add beans (and crushed red pepper to taste, if desired)

Divide polenta among plates, top with marinara sauce, and arrange greens and beans around the polenta. Top with grated pepper and fresh basil. Optional: Top with another cooked protein, if desired

AmericanDreams Foreword to My Father’s Autobiography

Wi llia m Y Ch ey, M. D., D.S c.

AMERICAN DREA Still Alive. MS,

My father’s story isn’t the quintessential American immigrant story; it is the quintessential American story—full stop. By William D. Chey, MD, FACG Memo

I m m I g r a n tir of an Dreamer

THERE IS AN OLD ADAGE THAT STATES, “LIKE FATHER, LIKE SON.” My father and I do indeed share many similarities; for example, our physical characteristics are eerily similar—same height, same shoe size. Fortunately for me, my father had impeccable taste in clothing. Over the years, I “borrowed” quite a few of my father’s sport jackets; each one holds a special place in my heart. Every time I see, touch, or wear one of them, I wonder what my father was doing or whom he met while wearing them. We also both chose to devote our professional lives to gastroenterology. In 2015, I was honored with an invitation to deliver the David Sun Memorial Lecture at the Annual Scientific Meeting of the American College of Gastroenterology. As I reviewed the list of distinguished gastroenterologists who had spoken before me, I was surprised and humbled to see that my father had also given the David Sun Lecture in 1987. It was fun to share this story with the audience at the start of the talk, though I didn’t tell them the origin of the perfectly fitting sport coat I was wearing. Though reading my father’s story made me reflect on our similarities, it also provided me with a much more textured understanding of who he was and who he

has become. He has so many stories of humiliation, loss, and sacrifice from the 36 years of tumultuous Japanese occupation, including WWII, followed by the fear and uncertainty propagated by the Korean War. Knowing that love of family is the salve that heals a thousand paper cuts makes clear how hard it must have been for my father to immigrate to the United States. Like so many immigrants before him, he left his beloved family in the hopes of finding the American dream. It certainly wasn’t easy to learn a new language, struggle to build a career in academic gastroenterology, and raise a family as an Asian immigrant—but he embraced, even relished, each of these challenges. Learning of those events has helped me to better understand the sense of urgency that my father imposed upon and instilled within my siblings and me: “Do your homework, cut the lawn, go to the laboratory to help with an experiment, go on rounds to see

patients with me. Don’t waste time on things that don’t have a clear purpose; do what needs to be done better than anyone else.” While I was growing up, I resented this and, at times, even disliked him for it. The roller-coaster ride that my father—and, indeed, all Koreans—was forced to endure no doubt infused this feeling of “now or never,” this sense of urgency. Growing up, I always wondered why my father worked so hard and seemed so hardened. I now realize he didn’t have the luxury of leaving anything to chance. The only way for him to

ACG Perspectives | 37

// PERSPECTIVES

“Knowing that love of family is the salve that heals a thousand paper cuts makes clear how hard it must have been for my father to immigrate to the United States. Like so many immigrants before him, he left his beloved family in the hopes of finding the American dream.” increase his chances of success were to work so hard that he determined the outcome. He had to earn everything, even if it meant having to work twice as hard as the next person. In my original writing of this foreword, I wrote that my father’s story is the quintessential American immigrant story. This statement is all the more important at a time when the American zeitgeist views immigrants as a problem, rather than a critical part of the solution to many of our nation’s problems. One need only consider the repeated scapegoating of immigrants for everything from “taking” American jobs; to causing the COVID-19 pandemic to hear echoes of the American Party, which openly discriminated against Irish Catholics in the 1850s; the Ku Klux Klan, which terrorized African Americans and Jews over centuries; and the “yellow peril,” a racist term describing the existential threat posed by Asians to Western culture. All that said, my original statement misses a very important point. My father’s story isn’t the quintessential American immigrant story; it is the quintessential American story—full stop. We are a nation of immigrants; to deny this immutable fact is to try to rewrite history. The richness of my father’s story, and the stories of millions of others like him, adds to the complexity and depth of the American tapestry. American exceptionalism has been forged from the intelligence, empathy, sweat equity, sacrifice, and suffering of countless immigrants who wanted nothing more than a chance for a better life. As a nation, we overtly and implicitly benefit from the collective experiences and the resulting wisdom of people of diverse backgrounds. They have so much to teach us if we will only give them a chance and listen. For much of our nation’s

38 | GI.ORG/ACGMAGAZINE

history, we have done just that. My father could not have left his mark on the American dream as a researcher, mentor, and doctor without the generosity and assistance of countless Americans and a system that offers the possibility of success based upon merit rather than only birthright. While we are “making America great again,” let’s not lose sight of what made America great in the first place.

William D. Chey, MD, FACG, Timothy T. Nostrant Collegiate Professor of Gastroenterology, Professor of Nutrition Sciences, Michigan Medicine

“My father could not have left his mark on the American dream as a researcher, mentor, and doctor without the generosity and assistance of countless Americans and a system that offers the possibility of success based upon merit rather than only birthright.”  READ MORE & SHARE YOUR STORY Read the Book American Dreams, Still Alive: Memoir of an Immigrant Dreamer is available for purchase from Amazon. Do You Have a Story to Share? If you have an inspiring story of your own experience or that of your family, ACG MAGAZINE would love to review and possibly publish, as space permits. The College recognizes the incredible journeys of so many physicians who came to this country, and how their hard work has made all of us, and our country better. If you want to share the story of your American Dream, please reach out to ACGMag@gi.org

EDUCATION Edgar Achkar Visiting Professorship Staying connected, INSPIRING GI TRAINEES IN KEEPING WITH MOST ASPECTS OF LIFE during the COVID-19 pandemic, the past year brought major challenges to GI fellowship training, but the Edgar Achkar Visiting Professorship Program (EAVP) of the ACG Institute for Clinical Research and Education was able to adapt to continue its mission and meet the needs of GI training programs and GI trainees. While travel limitations made it nearly impossible for the program to follow its usual

format of in-person lectures and discussion, nevertheless EAVP was able to enrich the experience of GI fellows-intraining through exposure to experts and leaders in the field, remotely. This included informal social gatherings, Grand Rounds lectures, small group and one-onone connections, and discussions with trainees about both clinical GI science and career guidance. Even from a distance, participants were able to forge connections with respected educators and garner wisdom and advice from their experiences. This issue of ACG MAGAZINE features visits from David A. Johnson, MD, MACG (ACG

President, 2006–2007) to Rutgers University; Carol A. Burke, MD, FACG (ACG President, 2016–2017) to Atrium Health; Sunanda V. Kane, MD, MSPH, FACG (ACG President, 2018–2019) to Washington University in St. Louis; and Mohamed O. Othman, MD to the University of Miami. It is a significant source of pride for the College and the ACG Institute that this program has been able to adapt and thrive this past year. To date, 68 institutions have hosted 70 visits in 28 U.S. states, Washington, DC, and two Canadian Provinces since the program’s inception in 2014.

Education | 39

// EDUCATION

“Being able to visit remotely opens doors for faculty to visit places that would not have otherwise been feasible. The flexibility of visiting remotely versus taking time away with physical travel makes it easier to say yes to invitations.” —Sunanda V. Kane, MD, MSPH, FACG

“The ability to connect through the overwhelming restrictions was awesome. ACG’s resilient, effective ability to provide this connection to continue education…priceless!” —David A. Johnson, MD, MACG

40 | GI.ORG/ACGMAGAZINE

"The lectureship is an honor and provides a great opportunity to network and mingle with the current and next generation of gastroenterologists." —Carol A. Burke, MD, FACG

2021

ACG EDGAR ACHKAR VISITING PROFESSORSHIPS DAVID A. JOHNSON, MD, MACG Rutgers University NOVEMBER 13, 2020 SUNANDA V. KANE, MD, MSPH, FACG Washington University in St. Louis NOVEMBER 18-19, 2020 CAROL A. BURKE, MD, FACG Atrium Health MARCH 11 MOHAMED O. OTHMAN, MD University of Miami MARCH 24 SATISH RAO, MD, PHD, FACG University of Rochester Medical Center in Rochester APRIL 27-28

In recognition of his contribution to knowledge and development of GI fellows in training and continued learning and scholarship by GI practitioners, the American College of Gastroenterology bestows upon

DOUGLAS REX, MD, MACP, MACG Westchester Medical Center MAY 19

Carol A. Burke, MD, FACG the title of

ACG Edgar Achkar Visiting Professor at Atrium Health March 11, 2021

Mark B. Pochapin, MD, FACG ACG President

Neena S. Abraham, MD, MS, FACG Director ACG Institute for Research & Education

BRIAN E. LACY, MD, PHD, FACG Allegheny General Hospital MAY 27-28

“The Edgar Achkar Visiting Professorship

JOHN E. PANDOLFINO, MD, MSCI, FACG Virginia Tech Carilion School of Medicine AUGUST 17-18

program promotes

ALINE CHARABATY, MD, FACG VA Caribbean Healthcare System SEPTEMBER 22

collaborations among institutions and fosters information exchange. This program is a great

CHRISTINA HA, MD University of New Mexico POSTPONED UNTIL LATER IN 2021 SUNANDA V. KANE, MD, MSPH, FACG St. Luke’s University Hospital POSTPONED UNTIL LATER IN 2021

success and a testimony of how ACG is supporting its trainee members.” —Mohamed O. Othman, MD

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

ACG MOBILE: ACCESS KEY RESOURCES at the point of care

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

Medical Calculators powered by MDCalc and more

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

42 | GI.ORG/ACGMAGAZINE

Inside the

JOURNALS

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

BRIAN C. JACOBSON, MD, MPH, FACG, THE NEW EDITOR-IN-CHIEF OF CLINICAL AND TRANSLATIONAL GASTROENTEROLOGY, SHARES HIS VISION FOR THIS OPEN ACCESS PUBLICATION. Featured CTG research includes a study by Zobair M. Younossi, MD, MPH, FACG, of an algorithm to identify high-risk NAFLD patients using non-invasive tests. ACG’s updated colorectal cancer screening guidelines published in The American Journal of Gastroenterology in March. Explore highlights of new evidence-based recommendations and a podcast with lead author Aasma Shaukat, MD, MPH, FACG. The Red Journal is the source for a very special new book by Robert E. Kravetz, MD, MACG, A Look Back: Reflections on Medical History & Artifacts from the Pages of The American Journal of Gastroenterology. Dr. Kravetz shares his thoughts on publishing a new book at age 87, as well as his philosophy on the history of medicine and its relevance today. ACG Case Reports Journal continues to thrive under Co-Editors-in-Chief, Ahmad N. Bazarbashi, MD, and Isabel A. Hujoel, MD.

Inside the Journals | 43

// INSIDE THE JOURNALS [THE AMERICAN JOURNAL OF GASTROENTEROLOGY]

ACG Issues Updated Colorectal Cancer Screening Guidelines New recommendation to begin colorectal cancer screening at age 45 for average risk adults Aasma Shaukat, MD, MPH, FACG; Charles J. Kahi, MD, MSc, FACG; Carol A. Burke, MD, FACG; Linda Rabeneck, MD, MPH, MACG; Bryan G. Sauer, MD, MSc, FACG (GRADE Methodologist); and Douglas K. Rex, MD, MACG

 THE COLLEGE ISSUED

UPDATED EVIDENCEBASED SCREENING GUIDELINES FOR COLORECTAL CANCER in the March issue of The American Journal of Gastroenterology that recommend all average risk individuals begin screening at age 45. ACG has recommended that African Americans begin screening at age 45 since 2005. One-Step vs. Two-Step Screening Tests An important clinical development is the distinction the new guidelines make between one-step screening tests and two-step screening tests. The authors write: “One approach to CRC screening tests is to divide them as one-step (direct) tests (i.e., colonoscopy, which is diagnostic and therapeutic) or two-step tests that require colonoscopy, if positive, in order to complete the screening process. All of the screening tests other than colonoscopy are twostep tests. A major limitation of non-colonoscopy-based CRC screening tests (stool-based, flexible sigmoidoscopy, CT colonography or colon capsule) is that a positive test requires a follow-up colonoscopy. This two-step testing approach represents a continuum of screening,

[ACG CASE REPORTS JOURNAL]

The Pillow Sign: Is It Always Benign? Sujay Alvencar, MD; Erik Holzwanger, MD; Rohit Dhingra, MD; Raffi Karagozian, MD; Lori Olans, MD; Nikola S. Natov, MD, Tufts Medical Center, Boston, MA

In most cases, the pillow sign has been associated with benign lipomas. It is argued that conventional biopsies of these lesions are of little utility because they are superficial, limited to the surface mucosa, and rarely diagnostic. Therefore,

44 | GI.ORG/ACGMAGAZINE

requires strong systems-based support to complete the screening cascade, and is more effectively applied in organized screening.” Helpful Highlights: Updated 2021 ACG CRC Guidelines In Appendix 2, the authors note changes in the 2021 ACG Clinical Guidelines on Colorectal Cancer Screening from the previous 2009 ACG guidelines recommendations: 1. Age to initiate CRC screening in average risk men and women is lowered to 45 2. Decision to offer CRC screening beyond age 75 should be individualized 3. Screening should be considered a multistep process: For example, a one-step process, such as colonoscopy, or twostep, such as a stool-based test followed by colonoscopy, if positive 4. African Americans should start screening at age 45, and special efforts are required to improve screening rates and reduce disparities in treatment and outcomes 5. Colon capsule is added as an option for CRC screening for individuals unwilling or unable to undergo colonoscopy or a FIT. If negative, screening may be repeated in five years 6. Suggestion to initiate CRC screening at age 40 or 10 years before the youngest affected relative, then resume averagerisk screening recommendations for

individuals with CRC or advanced polyp in one First Degree Relative at age >=60. Colonoscopy or FIT are reasonable options 7. Endoscopist should measure quality indicators for screening colonoscopy and achieve minimum benchmarks for cecal intubation (>=95%), adenoma detection rate (>=25%) and withdrawal time (>=6 minutes) 8. Suggestion to use low dose aspirin, in addition to CRC screening, in individuals between the ages of 50 and 69 with a cardiovascular disease risk of =>10% over the next 10 years, who are not an increased risk for bleeding and willing to take aspirin for at least 10 years to reduce the risk of CRC 9. Organized screening programs should be developed to improve adherence to CRC screening and follow-up of a two-stage screening test if positive 10. The following strategies may be implemented to improve organized screening: patient navigation, patient reminders, clinician interventions, provider recommendations, and clinical decision support tools 11. A positive multitarget stool DNA test followed by a colonoscopy with no findings should not prompt any further work up, and repeat screening should be offered at 10 years

 READ: bit.ly/ACG2021-CRC-Guideline  LISTEN: bit.ly/Shaukat-Podcast-CRC  DOWNLOAD: Patient CRC Infographic

bit.ly/ACG-CRC-Infographic-2021

most of these lesions are not biopsied and managed expectantly. Although colonic MALT lymphomas are rare, this is the first case to the best of our knowledge presenting as a lesion exhibiting the pillow sign.

Read the Case: bit.ly/ACGCRJ-Pillow-Sign

Figure 1. The 6-mm subepithelial lesion exhibiting the pillow sign at the hepatic flexure shows (A) the original lesion at hepatic flexure before intervention, (B) a closed forceps-induced indentation, and (C) reversion of the indentation with the lesion returning to its original shape.

Robert E. Kravetz, MD, MACG

on His New Book

A Look Back: Reflections on Medical History & Artifacts from the Pages of The American Journal of Gastroenterology

What was your vision for this book to the field of medicine and gastroenterology? My vision for the book was to preserve the individual articles that had been printed in The American Journal of Gastroenterology over a 10 year period. The articles would be lost in the future if not preserved and published in a single volume. Each article provides an insight into the history of medicine as practiced in the past. The emphasis is on items used by gastroenterologists but also covers broad aspects of medicine in general. I wanted to publish a “coffee table” type book that could also be enjoyed by the general public as well as individuals in the medical field who would like to learn about the history of medicine. Why is it important for physicians to reflect on the history of medicine? My philosophy as a clinician, historian, and teacher is to instill in all physicians an appreciation of the history of medicine. It puts our current knowledge into perspective. We learn from the mistakes, sacrifices, and advances of bygone eras. History also teaches us to pay homage to our

predecessors in the medical profession who paved the way for us. We should not take all of the credit for where we are now. This applies to all fields of medicine and not just gastroenterology. A good example of this is illustrated from when I was a fellow in GI at Yale with Howard Spiro, MD, MACG, in the early 1960’s. He wrote: “Watching gastroenterology over five decades, one sees the rise and fall of many theories.” At that time of the theories for the treatment of ulcers was “Gastric Freezing.” There was a cumbersome, very large machine with a freezing mechanism. A balloon was passed into the stomach, blown up, and the freezing solution run into it. This resulted in the parietal cells necrosing. At that time, acid from parietal cells was thought to be the cause of ulcers. Therapy was successful, but short-lived, as the mucosa regenerated to make new parietal cells and more acid. The technique was discarded, as were many other diagnostic and therapeutic modalities which proved not to be useful.

What are a few of the artifacts you find most unique or interesting in the book? Leech Jar: Leeching was a very popular treatment for a variety of illnesses in years past. The leeches were kept in a jar with water and holes in the top for air. When a physician would make house calls, he would carry his supply of leeches in a small water-filled leech cage. They were applied to almost every part of the body, both external and internal! Leech jars are one of the most highly soughtafter antiques by collectors. I purchased this one for $500 about 40 years ago and sold it at auction last year for $6,700. Revolutionary War Physicians Drug Chest: A similar one was used by Dr. Benjamin Rush, a signer of the Declaration of Independence. This was basically the equivalent of the doctor’s bag used in more contemporary times for house calls. It contained mainly herbal medications and the tools to prepare them. It is an interesting glimpse into what medications these physicians had available when making these calls. Complete drug chests of this type are extremely rare and difficult to obtain! Apothecary Jar: This is my oldest antique and dates from circa 1770. It was being used as a pencil holder when it was given to me because it had a piece missing that was easily and inexpensively repaired. Current value $2,000. I also gained an appreciation of the type earthenware which is called Delft that was made in both England and the Netherlands. It afforded me the opportunity to learn about the technique of tin-glazing and the beauty of this type of item. What are the origins of “A Look Back” section in the Red Journal and what did you learn from the series? Special thanks goes to Eamonn M. M. Quigley, MD, MACG, who in 1999 was editor of The American Journal of Gastroenterology. At that time, I approached him with a proposal for a history page in the journal. Dr. Quigley was most receptive to the concept of dedicating a page in the journal to medical history and artifacts. The page, “A Look Back,” became a regular feature until December 2009 when we commemorated the 75th anniversary of the journal. The items contained in this book were originally published between the years 1999 and 2009 in the Journal. Each month, a special Inside the Journals | 45

// INSIDE THE JOURNALS

“We learn from the mistakes, sacrifices, and advances of bygone eras. History also teaches us to pay homage to our predecessors in the medical profession who paved the way for us.” section was dedicated to “A Look Back” in which each page featured a photo of a specific artifact and text with its historical significance. The photo of the antique for that month was also placed on the cover of the journal. The readership was interested in learning about the artifacts of gastroenterology from prior years and were most receptive to the series and the information it provided. You are a collector of medical antiques; when did you start this collection and why is it so meaningful to you? I started to collect antiques in 1970. My wife, Nancy, came from an old New England whaling town, Newburyport, Massachusetts. At that time, I purchased my first antique for $.25, which was a porcelain toothpaste jar, and sold it to a dentist for $50 years later. I repurchased it, as I was nostalgic about this antique. The following year, I purchased the entire stored contents of a drugstore in the same town. The contents dated back to 1860 and included pharmacy and medical items. As new items became popular, the older ones were placed in storage. It was a treasure trove. I opened an antique shop in Phoenix for a short while with the items. Since that time, I have been collecting medical antiques when I would visit Europe, online, at garage sales, and many items were given to me because people know of my interest. At this point in my career, I have a large, varied collection with medical antiques from the various specialties. Currently, I am completing the installation of a comprehensive medical history museum at The University of Arizona College of Medicine in Phoenix where I am a faculty member. It will be the only medical museum in the state of Arizona. I am the oldest member of the faculty in the entire University system. Any advice for those interested in collecting medical antiques? Absolutely! It is so much easier to do so these days. Just go on eBay and type in

“Medical Antiques.” There are a wide variety of items for purchase at very reasonable prices if someone wants to start their own collection. If one is interested in a specific specialty, then just type that in for example: “Radiology Medical Antiques.” Let your patients and colleagues know of your interest. Retiring physicians are happy to donate items from their practice from past years to you. There are also a number of other sites online that sell medical antiques and they should be accessed. It is a wonderful hobby and I always had the antiques displayed in my office, which patients enjoyed. I recommend that every physician start their own collection, as it is a most rewarding avocation. You are a prolific author. As you reflect on writing this book at age 87, what was your inspiration and motivation? My mentor, Dr. Howard Spiro at Yale, said that if you have something worthwhile to share for future generations, then see that it gets into print. These articles were written over a 10 year period and I always wanted to preserve them together in a separate publication. “If we do not know where we came from, we do not know where we are going.” I might also say that publishing this book at my age is an example that older individuals can be alert, active, and contribute to society! For some strange reason, I do not feel old, but perhaps, that is a good delusion.

HOW TO ORDER THE BOOK

 ORDER ONLINE

members.gi.org/store The book has a retail value of $60 and is available for purchase through the ACG website to current ACG members at the special price of $25. This cost covers shipments to addresses in the United States only. For information on ordering outside the U.S., please contact info@gi.org

JOIN THE ACG ARCHIVES COMMITTEE! The Archives Committee preserves and displays the history of the ACG and the practice of clinical gastroenterology. Upcoming projects include planning for the ACG’s 90th Anniversary, producing historical videos, designing historical museum quality displays, and more. Members or fellows with an interest in medical history and creative arts who want to serve, please email: info@gi.org

46 | GI.ORG/ACGMAGAZINE

[CLINICAL & TRANSLATIONAL GASTROENTEROLOGY]

5 QUESTIONS

with Brian C. Jacobson, MD, MPH, the New Editor-in-Chief of Clinical & Translational Gastroenterology The American College of Gastroenterology welcomes Brian Jacobson, MD, MPH, as the new Editor-in-Chief of Clinical & Translational Gastroenterology. Dr. Jacobson answered five questions to give ACG members the opportunity to better get to know him.

Over the course of your research career, what subject area did you most enjoy investigating? This question is akin to asking, “which of your children do you love the most?” I’ve studied a range of topics from “how best to feed patients after acute pancreatitis?” to “does weight gain have an association with gastroesophageal reflux and Barrett’s esophagus, even if you’re not obese?” to “does it really matter what people eat the day before their colonoscopy?” Currently, I’m working on a project to develop a more accurate diagnostic coding system for predicting future healthcare utilization. Throughout my career, I’ve always gravitated toward questions that ultimately have a direct impact on patient care. While I cherish my one-to-one interactions with patients, I realized early on in my career that I could magnify my impact as a physician, and help more people in a positive way, by finding answers to important clinical questions. I think research is a way for investigators, regardless of whether they are healthcare providers or basic scientists, to help others on a large scale. What first attracted you to the field of gastroenterology? During medical school at the Albert Einstein College of Medicine, I had the great fortune to work with both Larry Brandt

and Les Bernstein, not to mention a promising junior attending named David Greenwald! Larry and Les were the two most consummate clinicians I had met as an impressionable medical student. They had amazing bedside manners, were incredible public speakers, and knew more internal medicine—not just gastroenterology—than anyone else I had encountered. I thought, “if these two people are BOTH in GI, there must be something really special about this field.” Our specialty requires extensive knowledge of medicine in general, and when you throw in the interesting variety of conditions we treat, along with the ability to perform endoscopic procedures, there was no chance I was going to land anywhere else. What are you most excited about in research right now? I think I’m most excited about the growing awareness that science needs to do more to help everyone, not just some populations. Today there is greater recognition that societal and cultural biases can adulterate science and that social determinants are vital confounding variables to consider in nearly all aspects of research. As we enter a new age of investigation that relies on big data and artificial intelligence, it is vital that we understand how data can be misinterpreted if viewed through only one or two specific contexts. Is there a mentor who really made a difference in your career? During my fellowship at Brigham and Women’s Hospital in the late ’90s, I worked closely with Peter Banks, a renowned pancreatologist and visionary. He made it possible for me to obtain my Master of Public Health degree and inspired me to devote considerable efforts to research. Throughout his career, he has demonstrated the importance of selfless promotion of trainees and colleagues and serves as a reminder that there is no greater joy than helping others succeed.

What do you think sets CTG apart from other GI-related journals? I’m very excited about the openaccess, web-based format. I think free, readily available access to knowledge by clinicians and researchers worldwide is so important for improving patient care and advancing our field. We will be exploring ways to capitalize on the web-based format, with greater use of hyperlinks to make it easy for readers to jump to additional relevant information in other journals and on the ACG website. Not having a print version of the journal opens up other potentially exciting ways to share online content, including through social media platforms. I also think our translational research focus provides a forum for investigators to share research inclusive of public health dimensions that impact the human experience, including poverty, access to education and healthcare, and all forms of inequality.

[CLINICAL & TRANSLATIONAL GASTROENTEROLOGY]

Younossi, et al., Identification of High-Risk Patients with Non-alcoholic Fatty Liver Disease (NAFLD) using Non-invasive Tests from Primary Care and Endocrinology Real World Practices Authors: Zobair M. Younossi,MD, MPH; Huong Pham, BS; Sean Felix, BS; Maria Stepanova, PhD; Thomas Jeffers, BS; Elena Younossi, BS; Hussain Allawi, MD; Brian Lam, PA-C; Rebecca Cable, BS; Mariam Afendy, BS; Zahra Younoszai, MPH; Arian Afendy, BS; Nila Rafiq, MD; Nahrain Alzubaidi, MD; Yasser Ousman, MD; Marc Bailey, MD; Zik Chris, MD; Maria Castillo-Catoni, MD; Pratima Fozdar, MD; Maria Ramirez, MD; Mehreen Husain, MD; Evis Hudson, MD; Ingrid Schneider, MD; Pegah Golabi, MD; Fatema Nader, MSBM Clinical and Translational Gastroenterology: April 2021 - Volume 12 - Issue 4 - p e00340 doi: 10.14309/ctg.0000000000000340

 DR. YOUNOSSI AND CO-AUTHORS REPORT ON THEIR STUDY demonstrating that a stepwise prospective application of an algorithm using noninvasive tests (NITs) and transient elastography in a clinical practice setting can lead to identification of patients with high risk of NAFLD. Table 2. Distribution of patients based on fibrosis severity by transient elastography All N

103

Liver stiffness < 6 kPa

62 (60.2%)

The CTG Editorial Board comprises Dr. Jacobson and six Associate Editors:

Liver stiffness 6–8 kPa

23 (22.3%)

Liver stiffness 8–10 kPa

6 (5.8%)

Liver stiffness 10-12 kPa

4 (3.9%)

John J. Kim, MD, FACG Loma Linda University

Liver stiffness ≥ 12 kPa

8 (7.8%)

David J. Levinthal, MD, PhD University of Pittsburgh Medical Center Violeta B. Popov, MD, PhD, FACG NYU Langone Health Eugenia Shmidt, MD University of Minnesota Medical School Elena M. Stoffel, MD, MPH University of Michigan Medical School Andrew W. Tai, MD, PhD University of Michigan Medical School

kPa, kilopascal.

"Despite the evidence supporting the growing burden of NAFLD, identification of these patients and linking those who are at high risk of adverse outcomes to preventative care and treatment are lacking. This is especially important for patients with metabolic syndrome who are commonly managed by primary care and endocrinology practices,” write the authors. Their aim was to identify high-risk patients with NAFLD through the development of efficient and easily applicable algorithms that can be used by clinicians in their daily practice. The study prospectively implemented a simple algorithm using easily available non-invasive tests (FIB-4 Index, NAFLD Fibrosis Score, and AST-to-platelet ratio index [APRI]) for linking these patients with a potentially higher risk of progression to further specialty care, including clinical assessment and transient elastography.

 READ: bit.ly/CTG-Younossi-NAFLD-2021

Inside the Journals | 47

// INSIDE THE JOURNALS

New Book Reflects on

(History of Medicine) from the Pages of The American Journal of Gastroenterology

he latest book by Robert E. Kravetz, MD, MACG, “A Look Back – Reflections on Medical History & Artifacts from the Pages of The American Journal of Gastroenterology” is available for purchase at a special rate of $25 for College members. With a keen eye for fascinating images and a gift for vivid and erudite descriptions, Dr. Robert Kravetz reflects on artifacts and trends in the evolution of modern medicine and finds lessons and insights from medical antiques that remain fascinating and relevant today. His appreciation for the past and his curiosity are both evident in each essay in “A Look Back: Reflections on Medical History & Artifacts from the Pages of The American Journal of Gastroenterology.”

learn from the mistakes, sacrifices and advances of bygone eras. “ We History also teaches us to pay homage to our predecessors in the medical profession who paved the way for us. ” – Dr. Kravetz Dr. Kravetz is a healer and historian whose humanistic sensibility shines through in this elegant volume. Illustrated with vivid color photographs and short reflections by Dr. Kravetz, this curated selection of medical antiquities and rare objects, many from his personal collection, comes to life. As a champion of medical history, an avid collector of medical antiques and artifacts, and a consummate educator, Dr. Kravetz shares his passion with readers interested in gastroenterology and medicine.

Order Online ( (members.gi.org/store The book has a retail value of $60 and is available for purchase through the ACG website to current ACG members at the special price of $25. This cost covers shipments to addresses in the United States only. For information on ordering outside the U.S., please contact info@gi.org. 48 | GI.ORG/ACGMAGAZINE

A Look Back

25 YEARS AGO... from the pages

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

Short Segment Specialized Intestinal Metaplasia in the Distal Esophagus: Then & Now

orman Barrett (1903– 1971) was an Australianborn British thoracic surgeon whose fame today rests largely on his description of what has come to be known as “Barrett’s esophagus.” In a seminal paper published in 1950, he introduced the term “reflux oesophagitis” and defined the esophagus as being the part of the foregut “distal to the cricopharyngeal sphincter, which is lined by squamous epithelium.”1 In that same paper he described a patient with columnar epithelium in the intrathoracic esophagus, which—as would be consistent with his definition—he felt represented a congenitally shortened esophagus and an oddly shaped intrathoracic stomach. In time, other investigators realized that the columnar epithelium in such cases represented metaplasia of the esophageal epithelium and that this condition was a complication of gastroesophageal reflux disease that

was associated with development of esophageal adenocarcinoma. In 1994, Stuart Spechler, Raj Goyal and others at Beth Israel Hospital in Boston described their study of specialized columnar epithelium at the gastroesophageal junction in patients having elective upper gastrointestinal endoscopy.2 Among 142 patients not known to have Barrett’s esophagus, two were found to have typical Barrett’s esophagus and 18% of the others had histological evidence of specialized columnar epithelium at the gastroesophageal junction. About two-thirds of this last group of patients had irregular Z-lines extending up to 3 cm from the gastroesophageal junction. These patients had what has come to be known as “short segment Barrett’s esophagus.” Spechler and Goyal summarized the definitional, technical, and clinical conundrums of this condition two years later.3 Twenty-five years ago, Mark

Johnston and colleagues from the National Naval Medical Center in Bethesda published their study of this issue in The American Journal of Gastroenterology.4 They found a prevalence of specialized intestinal metaplasia of 9.4% in their sample and that pyrosis and regurgitation were significantly more common in patients with specialized intestinal metaplasia involving the distal 2 cm of the esophagus. Johnston and colleagues raised several questions about this condition: Is it due to reflux? Does is predispose to the development of adenocarcinoma? Does it need a different surveillance program than longer segments of Barrett’s esophagus? Since that time, some answers to those questions have been advanced. Gastroesophageal reflux may predispose to short segment Barrett’s esophagus, but about half of patients with short segment involvement have no overt reflux symptoms. Short segment metaplasia is associated with development of esophageal adenocarcinoma, but progression to high grade dysplasia or adenocarcinoma from non-dysplastic metaplasia may be slower than in those with more extensive Barrett’s esophagus.5 None of this has impacted guidelines for surveillance of Barrett’s esophagus yet, and so short segment Barrett’s esophagus should be managed just like its more extensive cousin. References: 1. Barrett NR. Chronic peptic ulcer of the oesophagus and 'oesophagitis'. Br J Surg. 1950;38(150):175–

82.

2. Spechler SJ, Zeroogian JM, Antonioli DA, Wanf HH, Goyal RK. Prevalence of metaplasia at the gastro-oesophageal junction. The Lancet 1994;344:1533—36. 3. Spechler SJ, Goyal RK. The columnar-lined esophagus, intestinal metaplasia, and Norman Barrett. Gastroenterol 1996;110:614—21. 4. Johnston MH, Hammond AS, Laskin W, Jones DM. The prevalence

Clockwise from left: Mark H. Johnston, MD, FACG. Stuart J. Spechler, MD, FACG. Raj K. Goyal, MD. Histology of Barrett’s Esophagus – Goblet cells. From: Nandurkar, Sanjay FRACP1; Talley, Nicholas J MD, PhD FRACP, FACG1, * Barrett's Esophagus: the Long and the Short of It, American Journal of Gastroenterology: January 1999 - Volume 94 - Issue 1 - p 30-40 doi: 10.1111/j.1572-0241.1999.00768. Endoscopic view of short segment Barrett’s esophagus. From: Prateek Sharma, MD, FACG, University of Kansas School of Medicine. Barrett’s Esophagus and Intramucosal Esophageal Cancer: Dye, Ablate or Resect? Presentation from the 2014 ACG Governors/ASGE Best Practices Course. gi.org/2017/04/10/prateek-sharma-md-facg-onbarretts-esophagus-and-intramucosal-esophageal-cancer-dyeablate-or-resect.

and clinical characteristics of short segments of specialized intestinal metaplasia in the distal esophagus on routine endoscopy Am J Gastroenterol 1996;91(8):1507—11. 5. Anaparthy R, Gaddam S, Kanakadandi V, Alsop BR, Gupta N, Higbee AD, Wani SB, Singh M, Rastogi A, Bansal A, Cash BD, Young PE, Lieberman DA, Falk GW, Vargo JJ, Thota P, Sampliner RE, Sharma P. Association between length of Barrett's esophagus and risk of high-grade dysplasia or adenocarcinoma in patients without dysplasia. Clin Gastroenterol Hepatol. 2013 Nov;11(11):1430-6.

Inside the Journals | 49

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50 | GI.ORG/ACGMAGAZINE

1ST STEP

Stool-Based Test FIT Test (Fecal Stool-Based Test STEP FIT1ST Test (FecalTest) Immunochemical FIT Test (Fecal Stool-Based Test Immunochemical Test) Multitarget Stool DNA Immunochemical Test) FIT 1ST TestSTEP (FecalDNA Multitarget Stool Multitarget Stool DNA Immunochemical Test) OR Test Stool-Based Multitarget Stool DNA FIT TestOR (Fecal OR Flexible Sigmoidoscopy Immunochemical Test) OR Flexible Sigmoidoscopy Multitarget Stool DNA Flexible Sigmoidoscopy OR Flexible Sigmoidoscopy OR OR Test OR Imaging

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! W! E NEW N

A NEW TABLET CHOICE A BOWEL NEW TABLET CHOICE IN PREPARATION IN BOWEL PREPARATION

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• SAFE AND EFFECTIVE1,2 1 • NO SODIUM PHOSPHATE • ACG-RECOMMENDED1,2 SPLIT-DOSE REGIMEN3 • SAFE AND EFFECTIVE 1 – Two SUTAB doses are required for a complete preparation

considered severeand MoviPrep® patients reported at least one selected gastrointestinal adverse reaction1,2‡ • 52% of all SUTAB

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ACG MAGAZINE ARCHIVE 2021

Vol. 5 No. 1 // Spring 2021

2020

Vol. 4 No. 1 // Spring 2020

Vol. 4 No. 2 // Summer 2020

Vol. 4 No. 3 // Fall 2020

Vol. 4 No. 4 // Winter 2020

2019

Vol. 3 No. 1 // Spring 2019

Vol. 3 No. 2 // Summer 2019

Vol. 3 No. 3 // Fall 2019

Vol. 3 No. 4 // Winter 2019