ACG MAGAZINE | Vol. 5, No. 4 | Winter 2021

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ACG MAGAZINE Winter 2021

MEMBERS. MEDICINE. MEANING.

Starting a Conversation for

South Asians LIVING with IBD By Tina Aswani Omprakash


Attend an upcoming

ACG POSTGRADUATE COURSE ACG Weekly Virtual Grand Rounds

2022 ACG’s Functional GI and Motility Disorders School and ACG Board of Governors / ASGE Best Practices Course

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

 The Aria | Las Vegas, NV  January 28–30, 2022

ACG/FGS Spring Symposia  Naples Grande Hotel | Naples, FL  March 11–13, 2022

ACG/LGS Regional Postgraduate Course  Hilton New Orleans Riverside | New Orleans, LA  March 18–20, 2022

Eastern Regional Postgraduate Course  The Seaport Hotel | Boston, MA  April 1–3, 2022

ACG 2022 Annual Scientific Meeting and Postgraduate Course  The Charlotte Convention Center | Charlotte, NC  October 21–26, 2022

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


WINTER 2021 // VOLUME 5, NUMBER 4

FEATURED CONTENTS Law Mind Ann Bittinger, Esq., on negotiating out of a noncompete agreement with a private equity-backed GI practice PAGE 24

ACG Perspectives ACG members share how family memories and the holidays shaped their approach to food and nutrition and suggest recipes for you to try PAGE 33

COVER STORY STARTING A CONVERSATION FOR SOUTH ASIANS LIVING WITH IBD IBD patient and advocate Tina Aswani Omprakash discusses the unique challenges of navigating the diagnosis and management of IBD in the South Asian community and how she is working to break the stigmas

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It’s TIME to

RENEW YOUR MEMBERSHIP! New ACG benefits added for 2022— free to members!  Evidence-Based GI Journal Review, a monthly online publication that highlights important research published in GI journals  ACG’s Billing & Coding Forum, professional coding and documentation assistance tailored to your individual practice’s needs  GI OnDEMAND, a virtual integrated care and support platform now offering genetic testing, free telehealth and access to registered dietitians and GI psychologists

In addition, you’ll continue to benefit from:  Free subscriptions to The American Journal of Gastroenterology, Clinical and Translational Gastroenterology and the unique ACG Case Reports Journal  Free Education from the Education Universe and the ACG Annual Scientific Meeting that keeps you current on treatment, therapy and management of key GI conditions and disorders  Practice management tools that help you improve efficiency and increase profitability in your practice

 Renew today at gi.org/renew


WINTER 2021 // VOLUME 5, NUMBER 4

CONTENTS

“I began to talk not only about my experiences as a minority woman facing delays to care, but also about the cultural stigmas and taboos that had plagued me throughout my journey with IBD.” —Tina Aswani Omprakash, “Starting a Conversation for South Asians Living with IBD,” PG 26

6 // MESSAGE FROM THE PRESIDENT Dr. Samir Shah shares his first message as president, emphasizing gratitude

26 // COVER STORY

Introducing the new LE&E Center, a new ACG member publication, highlights from ACG 2021 & more

STARTING A CONVERSATION FOR SOUTH ASIANS LIVING WITH IBD Tina Aswani Omprakash shares her experiences living with IBD and navigating the nuances of South Asian culture and taboos, and her role as a vocal patient advocate in the South Asian IBD community

15 // TRAINEE HUB

33 // ACG PERSPECTIVES

7 // NOVEL & NOTEWORTHY

GI fellows and faculty share their perspectives on what makes a good endoscopy educator

19 // GETTING IT RIGHT 19 BUILDING SUCCESS Advice on maximizing the benefits of electronic health records in your practice 24 LAW MIND Strategies for negotiating out of a noncompete agreement with a private equitybacked GI practice

CULINARY CONNECTIONS For the holiday season, culinary enthusiasts share how family memories influence their dietary choices and perspectives

37 // EDUCATION EDGAR ACHKAR VISITING PROFESSORSHIP Virtual EAVP visits keep GI fellows engaged and connected with esteemed faculty

41 // INSIDE THE JOURNALS 42 AJG ACG welcomes new Co-Editors-in-Chief Dr. Jasmohan Bajaj and Dr. Millie Long, new ACG Guidelines for Management of Benign Anorectal Disorders, and an ACG Special Issue highlight 43 CTG Impaired Proximal Esophageal Contractility Predicts Pharyngeal Reflux in Patients with Laryngopharyngeal Reflux Symptoms by Sikavi, et al. 43 ACGCRJ Endoscopic Mucosotomy and LumenApposing Metal Stent Placement for the Management of a Closed Colorectal Anastomosis by Sánchez-Luna, et al.

45 // A LOOK BACK 25 YEARS AGO IN AJG In 1997, Tenner, et al., discussed the use of endoscopic ultrasound for the management of pancreatic diseases, a novel technique at the time

Photo above courtesy of Tina Aswani Omprakash Cover photo: Remedy Health Media and Lizzy Sullivan, photographer

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ACG MAGAZINE MAGAZINE STAFF

CONNECT WITH ACG youtube.com/ACGastroenterology

Executive Director Bradley C. Stillman, JD

facebook.com/AmCollegeGastro Editor in Chief; Vice President, Communications Anne-Louise B. Oliphant

Manager, Communications & Member Publications Becky Abel

Art Director Emily Garel

Graphic Designer Antonella Iseas

BOARD OF TRUSTEES President: Samir A. Shah, MD, FACG President-Elect: Daniel J. Pambianco, MD, FACG Vice President: Jonathan A. Leighton, MD, FACG Secretary: William D. Chey, MD, FACG Treasurer: Amy S. Oxentenko, MD, FACG Immediate Past President: David A. Greenwald, MD, FACG

twitter.com/amcollegegastro

instagram.com/amcollegegastro

bit.ly/ACG-Linked-In

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

ACGMag@ @gi.org

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

Past President: Mark B. Pochapin, MD, FACG Director, ACG Institute: Neena S. Abraham, MD, MSc, FACG Co-Editors, The American Journal of Gastroenterology: Jasmohan S. Bajaj, MD, MS, FACG

DIGITAL EDITIONS

GI.ORG/ACGMAGAZINE

Millie D. Long, MD, MPH, 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 Seth A. Gross, MD, FACG Immanuel K. H. Ho, MD, FACG James C. Hobley, MD, MSc, FACG Costas H. Kefalas, MD, MMM, 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 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 on her areas of expertise, including legal relationships between hospital systems and physicians or physician groups. (bittingerlaw.com)

Parakkal Deepak, MBBS, MS, FACG Dr. Deepak is an Assistant Professor of Medicine at Washington University in St. Louis School of Medicine. He currently chairs the ACG Digital Communications & Publications Committee and is a member of the FDA-Related Matters and Research Committees.

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

Richard L. Nemec, MD, FACG Dr. Nemec is a gastroenterologist at Winchester Gastroenterology Associates in Winchester, VA.

Tina Aswani Omprakash Ms. Aswani Omprakash is a Crohn’s patient and award-winning patient leader and health advocate in NYC. She maintains a blog and advocacy platform called Own Your Crohn’s (ownyourcrohns.com) and recently co-founded IBDesis, a community for South Asians living with IBD.

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

Tatiana Policarpo, MD Dr. Policarpo is a first-year gastroenterology fellow at Thomas Jefferson Hospital in Philadelphia, PA.  @drtatieats  @Tati_Policarpo.

Supriya Rao, MD Dr. Rao is a gastroenterologist and obesity medicine specialist at Integrated Gastroenterology Consultants in North Chelmsford, MA.   @GutsyGirlMD

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 past chair of the ACG Archives Committee.

Samir A. Shah, MD, FACG Dr. Shah is the 2021-2022 ACG President, Clinical Professor of Medicine at Alpert Medical School at Brown University, Chief of Gastroenterology at the Miriam Hospital, and is a partner with Gastroenterology Associates, Inc., a private practice GI group affiliated with Brown and Lifespan.

Jordan M. Shapiro, MD Dr. Shapiro is an Assistant Professor of Gastroenterology at Baylor College of Medicine in Houston, TX, where he specializes in the transition from pediatric to adult care. Shifa Umar, MD Dr. Umar is a pancreatology fellow at Mayo Clinic Rochester and incoming advanced endoscopy fellow at the University of Chicago. She is a member of ACG’s Digital Communications & Publications and Diversity, Equity, and Inclusion Committees.

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MESSAGE FROM THE PRESIDEN

AN OUTLOOK OF GRATITUDE DEAR COLLEAGUES: Everyone who attended our Annual Scientific Meeting would agree with me regarding the energy and quality of the meeting and the simple joy of being and learning together. My profound thanks to our talented ACG staff, Board of Trustees, Postgraduate Course co-directors Dr. Millie Long and Dr. David Hass, Educational Affairs Chair Dr. Brooks Cash, committees and speakers for pulling off a live/hybrid meeting with our cherished values of camaraderie, connection and collaboration. This year’s named lectures were phenomenal and I was grateful to all the invited speakers. Dr. Jerome Waye gave the David Sun Lecture, taking us on a captivating journey through the beginnings of endoscopy and polypectomy to the modern era and, finally, his predictions for the future. Dr. David Greenwald, in his Presidential Address, highlighted the work of the College focusing on the exciting launch of The Center for Leadership, Ethics & Equity under the auspices of the ACG Institute. Later, he shared a recorded interview with former CDC director Dr. Tom Frieden focusing on COVID-19, colon cancer prevention and health care in the U.S. and globally. Dr. Amy Oxentenko gave The American Journal of Gastroenterology Lecture on Critical Mass Theory and highlighted women pioneers in medicine. She offered practical advice on allyship to accelerate progress, pinpointing the need for sponsorship and not just mentorship. Dr. Darrell Gray gave the Emily Couric Memorial Lecture on health care disparities in colorectal cancer including incidence, mortality, and age of diagnosis with all these issues being magnified by social drivers of health. He then provided strategies to address these disparities with a focus on building trust, partnerships and proactive policy changes. Dr. William Chey gave the J. Edward Berk Distinguished Lecture on megatrends in GI, explaining how technology with platforms like GI OnDEMAND (free to ACG members) can extend our reach to provide patients with tertiary resources such as cognitive behavioral therapy, genetic counseling and specialized nutritional consultation. Finally, Dr. Marla Dubinsky gave the David Graham Lecture, reviewing ongoing transformative studies examining the microbiome, genetics, environmental factors and serologies to predict and prevent IBD. After the meeting, I returned to Providence, RI, where the leaves were already shades of yellow, orange and red. November is special to me for many reasons including Diwali in India and Thanksgiving in the U.S. As an Indian American, I wanted to share some reflections on both. In Rochester, NY, where I grew up, we always marked November with a Diwali observance in our community and our Indian immigrant version of Thanksgiving. Diwali or “Deepavali” (a Sanskrit word meaning “rows of lighted lamps”) is a Hindu festival marking the new

6 | GI.ORG/ACGMAGAZINE

“So, my simple message is don’t take things for granted and express your gratitude to your loved ones, colleagues and to yourself. I wish you and your families a joyous Diwali, Thanksgiving and health, peace, and success in the coming year.”

year and is celebrated around the world. Also known as the festival of lights, Diwali glorifies the victory of light over darkness, good over evil and knowledge over ignorance. Though celebrated in different ways, common elements including getting together with family/friends in brand new clothes, gift giving, colorful decorations including lights and a rangoli (a decorative, geometric pattern created on the outside entrance of a home), prayers, lighting lamps and wishing everyone peace, joy, health and prosperity in the new year. Given all we have been through, I find this message of hope celebrating light over darkness, good over evil, and knowledge over ignorance particularly meaningful. Thanksgiving to me has always been the four F’s: Family, Friends, Food and Football. As Americans, we have so much to be thankful for: I am for the support of family/friends/colleagues, the blessings of living in America, the ability to help others as a physician and the research leading to effective vaccines to prevent/mitigate COVID-19. As a result, I am looking forward to spending Thanksgiving with extended family. Our Thanksgiving meal is vegetarian Gujarati food (kadhi, bhaat, dhokla, puri, undhiyu) with a few twists like cranberry chutney, pecan, apple and blueberry pies with ice cream, and watching football—a mix of Indian and American culture. I am grateful for my eyesight: last December, I had a spontaneous retinal detachment and was fortunate to get great medical care and have my vision restored so that I can continue to practice endoscopy and gastroenterology. Being a patient can be frightening and reminds us of the incredible trust our patients place in us. I remember the astute advice of Dr. Francis Peabody, “The secret of the care of the patient is in caring for the patient.” My outlook is different as a result: I get to (instead of have to) do another case or help another patient or see another consult. We often take things for granted until taken away or somehow compromised. So, my simple message is don’t take things for granted and express your gratitude to your loved ones, colleagues and to yourself. I wish you and your families a joyous Diwali, Thanksgiving and health, peace, and success in the coming year.

­­—Samir A. Shah, MD, FACG


Note hy wor t The College celebrates the professional accomplishments of our members and others in the GI community. In this issue of Novel & Noteworthy, we highlight prize-winning accomplishments, prestigious research awards, new roles and a marathon run. The ACG Institute is proud of the launch of the new Center for Leadership, Ethics & Equity. Thanks to the leadership of Dr. Philip Schoenfeld, ACG this fall introduced a new monthly member publication, EvidenceBased Gastroenterology. Finally, ACG mourns the loss of gastroenterologist Dr. Dario Sorrentino who was known to many in the global IBD community and whose death this summer in a bicycle accident while vacationing in his native Italy was a shocking loss. ACG MAGAZINE welcomes you to share your professional news or highlights from your colleagues by email at ACGMag@gi.org.

Novel & Noteworthy | 7


N&N GI EYE: PHOTOGRAPHY FROM ACG MEMBERS

WINGING IT “GI EYE: PHOTOGRAPHY FROM ACG MEMBERS” is a forum for the many GI clinicians whose hobby and passion is photography to share well-composed photos from your life and/or travels of any (non-endoscopic!) subject that captures your imagination.

About the Photo: During the summer of 2020, after caring for COVID patients and seeing all the devastation this pandemic wrought on New York City and the world, we escaped to a small rental home in Westchester. In the backyard there were beautiful flowers, and I was mesmerized by all the flying creatures that would weave in and out of these beautiful thin, vertical purple flowers. These common white lawn moths really captivated me with their playfulness and rapid movements. They would dance around the flowers in pairs, and using an ultra-zoom lens, I recognized that their wing movements were quite different from the up and down wing motion of the butterfly. Surprisingly, these common little moths looked like flying ballerinas whose wings bowed in the air, appearing more graceful than I ever imagined a moth could be. What equipment did you use? I used a Sony RX10 IV set at f4, 1/2000, ISO 800 180 mm lens What captured your attention, and any technical challenges? Keeping a focus on such a fast-moving small object required fixing the focus on the flower, waiting for the moth to enter the focus plane, and then shooting a rapid sequence of burst photos to capture the wings in flight. Lighting was a challenge, and I spot-metered on the brightest area of the plant, set the shutter to 1/2000 sec, and increased the ISO film speed fast enough so I could use a wide open aperture (f4) to create a shallow depth of field. This combination of fast shutter and wide aperture allowed the camera to clearly focus and freeze the wing movement while blurring the background. In addition, since the moth was so bright in the sunlight, the rest of the photo appeared dark, creating a beautiful black background as a contrast to the white moth and purple plants. The long zoom with an open lens at f4 created the very shallow depth of field as described; however, it also made achieving a sharp focus on the rapidly moving moth quite challenging. Fortunately in digital photography, we can take plenty of photos. It took quite a few tries, but this photo was my favorite of the sequence.

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Share your thoughts on the personal significance of this photo or photography in general, reflecting briefly upon why you pursue photography as a hobby and personal passion. Photography allows artistic creativity without drawing or painting. I was never able to draw or paint pictures well, but photography allowed me to be an artist by using the amazing technology of a

camera. As a kid, I used my father’s old Yashica reflex camera, the type you hold at chest level and peer in from above, and developed the black and white photos in our basement. In college, I became the photo editor of our college newspaper and would shoot the varsity games with the school’s massive Nikon and huge telephoto lens. I spent many a night in the darkroom developing and then “veloxing”


the photos into black and white dots so they could be printed the next day in the daily school newspaper called the DP (Daily Pennsylvanian). When digital photography became mainstream, I had trouble making the transition initially, as I always had a love for film. However, with the recent advances in digital technology and the ability to take a photo with high resolution/high megapixel sensors, I can

now do even more then what I was ever able to do with black and white film. And the best part: you can get immediate results by just looking at the camera screen. The joy of looking down and seeing the beautiful photo just created is exhilarating and keeps me going back for more.

Mark B. Pochapin, MD, FACG, Clinical Vice Chair, Department of Medicine, Director, Division of Gastroenterology and Hepatology, Sholtz-Leeds Professor of Gastroenterology and Professor of Medicine, NYU Langone Health

Novel & Noteworthy | 9


// N&N

[BOOK REVIEW]

[LAUNCH]

THE 6 DS OF FECAL MICROBIOTA TRANSPLANTATION: A PRIMER FROM DECISION TO DISCHARGE AND BEYOND

INTRODUCING THE CENTER FOR LEADERSHIP, ETHICS & EQUITY

by Jessica R. Allegretti, MD, MPH, FACG and Zain Kassam, MD, MPH (SLACK Inc., 2021) Reviewer: Parakkal Deepak, MBBS, MS, FACG, Washington University School of Medicine, St. Louis, Missouri The 6 Ds of Fecal Microbiota Transplantation by Dr. Jessica R. Allegretti and Dr. Zain Kassam is a very practically written book edited by two experts in the field of Fecal Microbial Transplantation. There are multiple chapters written by individual experts in FMT, including investigational indications for FMT in inflammatory bowel diseases (IBD), irritable bowel syndrome and liver diseases, to name a few. The “6 Ds” in the title alludes to the ‘Decision’ of doing FMT in the right patient; selecting a ‘Donor’; ‘Discussing’ the risk and benefits of FMT; the best method to ‘Deliver’ the FMT whether oral, colonoscopy or enema; ideal follow-up after ‘Discharge’ and the sixth D of ‘Discovery’ of new indications for FMT. The 6 Ds are discussed over multiple chapters. The highlights of the book for me are the very actionable design of the book where this can be a pocket-sized volume for the gastroenterology fellow as they encounter potential patients for FMT, either in the clinic or on the inpatient floor. This can also be a step-by-step book that can instruct on how to initiate and sustain an FMT program starting from scratch. This starts with a primer on the microbiome from an expert in microbiome-based research. For a history buff, the inclusion of a chapter on the history of FMT was also a nice touch. The practical design of the individual chapters is also highlighted by tables of ‘pearls’ of things ‘To Do’ and ‘Not To Do’ in each chapter. There is also humor infused such as the “CRAP” approach for determining eligibility for FMT. In summary, I recommend this book as an addition to the bookshelves and/or whitecoat pocket of ACG members and trainees, as a reference on a rapidly changing field, for practical selection of patients for FMT in clinical practice, and for those planning to start their own FMT programs.

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ACG Institute Director, Neena S. Abraham, MD, MSc (Epi), FACG invites you to learn more about The Center for Leadership, Ethics & Equity, an entity within the Institute that provides resources and a forum to envision new paradigms for effective clinician-leadership. The catalyst for the The LE&E Center launch is this time of challenge and crisis during the SARS-CoV-2 pandemic, but it has its roots in the longstanding and significant organizational commitment by the College and the ACG Institute to strategies, programs, and committee activities that celebrate and increase diversity in the GI profession; cultivate the potential of GI fellows-in-training, junior faculty and early career clinicians; fund promising clinical research; reach high school students; and elevate the leadership skills of GI clinicians at various stages of their career trajectory. The mission of The LE&E Center is to elevate leadership competencies in GI clinicians, to advance equity in gastroenterology, to educate and cultivate the pipeline of wellprepared clinician-leaders, to promote the practical application of ethical leadership, and to invest in promising research that strengthens equitable health care. READ: The LE&E Center Launch Statement bit.ly/LEE-Center-Booklet WATCH: Video with Dr. Neena Abraham and Dr. David Greenwald bit.ly/LEE-Launch EXPLORE: Mission and vision, programs and priorities of The LE&E Center gi.org/LEECenter

[NEW PUBLICATION]

EVIDENCE-BASED GASTROENTEROLOGY: AN ACG PUBLICATION In this new monthly publication for ACG members, editors summarize noteworthy GI, hepatology, and endoscopy clinical research from general medical journals and European GI journals using evidencebased medicine strategies, structured abstracts and standardized commentaries. The goal of Editor-in-Chief Philip S. Schoenfeld, MD, MSED, MSc (Epi), FACG is to highlight important studies that ACG members may have missed and help apply that data to their practices.

AMERIC AN

COLLE GE

OF GASTR OENTE

ROLOG Y

READ the introductory editorial by Dr. Schoenfeld: bit.ly/ebgi-schoenfeld-2021 Explore: gi.org/EBGI [ACG 2021 HIGHLIGHTS]

ACG 2021: A RESOUNDING SUCCESS The College experienced a triumphant return to in-person clinical education at the ACG 2021 Annual Scientific Meeting & Postgraduate Course. Between the in-person and hybrid options, over 7,400 participants were part of ACG 2021. The College saw a record number of abstract submissions for the Annual Scientific Meeting, of which 74 were presented as oral papers and 3,136 were posters. If you missed the programs, there is still time to register to access on-

demand education sessions and recorded talks at acgmeetings.gi.org until December 31, 2021 and content and recordings will be available via the meeting platform until March 31, 2022.

ACG LEADERSHIP & AWARDS

Read the ACG “Year in Review” and explore the College’s 2021 awards and committees’ priorities and achievements.

READ: bit.ly/2021leadership-and-awards


[IN MEMORIAM]

DARIO R. SORRENTINO, MD The College notes with great sadness the loss this summer of Dr. Dario Sorrentino who from died from injuries he sustained in a bicycle accident while vacationing in his native country, Italy. Dr. Sorrentino was Professor of Medicine at Virginia Tech Carilion School of Medicine and Research Institute in Roanoke, VA, where his clinical expertise was Crohn’s disease. He also had a faculty position at the University of Udine Medical School in Italy. He is survived by his wife and three daughters.

[SHERMAN PRIZES]

EDWARD L. BARNES, MD, MPH Dr. Edward Barnes was awarded this year’s Sherman Foundation Emerging Leaders Prize of $25,000 for applying his expertise in epidemiology and the study of big data to the treatment of pouchitis after J-pouch surgery. Dr. Barnes leads the PROP-RD study (A Prospective Registry for the Study of Outcomes and Predictors in Pouchitis and Pouch-Related Disorders) to investigate real-world outcomes after pouch surgery. Dr. Barnes is Assistant Professor of Medicine and Associate Program Director, Gastroenterology and Hepatology Fellowship Program, University of North Carolina School of Medicine at Chapel Hill, NC.

[BOSS MOVES]

AASMA SHAUKAT, MD, MPH, FACG Dr. Aasma Shaukat has been appointed by NYU Langone Health as the Director of Outcomes Research within the Division of Gastroenterology and Hepatology. She will also serve as Co-Director of Translational Research Education and Careers, within the Clinical and Translational Science Institute, at NYU Grossman School of Medicine. Dr. Shaukat will hold the endowed Robert M. and Mary H. Glickman Professor of Medicine and Gastroenterology as well as the Professor of Population Health faculty appointments at the NYU Grossman School of Medicine. Prior to joining NYU Langone, Dr. Shaukat served on faculty at the University of Minnesota Medical School, where she was a professor of Medicine and Public Health and Section Chief of Gastroenterology Service at the Minneapolis VA Health Care System.

[26 MILES]

PICHAMOL “SIGH” JIRAPINYO, MD, MPH Dr. Sigh Jirapinyo finished the Boston Marathon on October 11, 2021. She is an interventional and bariatric endoscopist who serves as Director of the Bariatric Endoscopy Fellowship at Brigham and Women’s Hospital.

[NIH NIDDK K23]

RENA H. YADLAPATI, MD, MSHS

JUDY H. CHO, MD Dr. Judy Cho was awarded a $100,000 Sherman Prize for her pioneering research on the involvement of IL-23 in the disease cascade, which led to anti-IL-23 therapies that are widely used to treat Crohn’s disease and ulcerative colitis. Dr. Cho is Dean and Ward-Coleman Professor of Translational Genetics, Director, Charles Bronfman Institute for Personalized Medicine at Icahn School of Medicine at Mount Sinai, New York, NY.

PHILLIP R. FLESHNER, MD, FASCRS Dr. Phillip Fleshner is a surgeon whose research focuses on the relationship between biologics and surgery in IBD. His work has set the stage for using biomarkers to predict surgical outcomes. He received a Sherman Prize of $100,000 and is the Shierley, Jesslyne, and Emmeline Widjaja Chair in Colorectal Surgery, Program Director, Colorectal Surgery Residency, at Cedars-Sinai Medical Center, Los Angeles, CA.

Dr. Rena Yadlapati of the University of California San Diego received a prestigious NIH NIDDK K23 Award for her project, “Mechanism Guided Therapy for Laryngopharyngeal Reflux.” Dr. Yadlapati is a member of the ACG Institute Board of Directors and was a 2018 recipient of the ACG Junior Faculty Development Award. She is Associate Professor of Medicine and Director, UCSD Center of Esophageal Diseases.

[INSTITUTE]

ACG INSTITUTE ANNUAL REPORT The ACG E ITUT Institute reports INST ACG 021 2 0 on a year of 202 s vitie accomplishments, Acti and ms rogra P f o its investment in clinical research, and proudly launches The Center for Leadership, Ethics & Equity.

UALRT N AN EPO R

READ: bit.ly/Institute-AR-2021

SCOPY AWARDS SCOPY celebrates excellence in community education and public awareness efforts to advance colorectal cancer screening and prevention by ACG members and their staffs.

#DIVERSITYINGI VIRTUAL 5K The 2021 SCOPY Awardees were honored at event hosted by Dr. Tauseef Ali, Chair, ACG Public Relations Committee. Dr. Benjamin Levy won the 2021 “Grand SCOPY” Award for organizing a virtual concert for March 2021 Colorectal Cancer Awareness Month.

READ: bit.ly/scopy-awards-21

This year’s 2021 #DiversityinGI Virtual 5K raised $30,000 for the ACG Summer Scholars, a mentoring program for medical students from groups under-represented in medicine administered by the ACG Committee on Diversity, Equity & Inclusion.

Novel & Noteworthy | 11


DECEMBER 27, 2021 AMERICAN COLLEGE OF GASTRONTEROLOGY'S BIRTHDAY DECEMBER 27, 1932 The College became incorporated as The Society for the Advancement of Gastroenterology

JANUARY

28

2022 FUNCTIONAL GI AND MOTILITY DISORDERS SCHOOL AT ACG BOARD OF GOVERNORS / ASGE BEST PRACTICES COURSE  Las Vegas, NV

Register: meetings.gi.org

YOU CAN STILL REGISTER UNTIL DECEMBER 31, 2021

MARCH

11-13 2022 ACG/FGS ANNUAL SPRING SYMPOSIA

 Naples, FL Register: meetings.gi.org

JANUARY

29-30

2022 ACG BOARD OF GOVERNORS/ ASGE BEST PRACTICES COURSE  Las Vegas, NV

Register: meetings.gi.org

MARCH 2022

MARCH

18–20 2022 ACG/LGS REGIONAL POSTGRADUATE COURSE

 New Orleans, LA Register: meetings.gi.org

COLORECTAL CANCER AWARENESS MONTH

MARCH 31 NORTH AMERICAN INTERNATIONAL GI TRAINING GRANTS More Info: gi.org/gi-training-grants

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MARCH

4–6 NORTH AMERICAN CONFERENCE OF GI FELLOWS (NACGF)  Orlando, FL Learn More: bit.ly/NACGF-2022


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.

For additional information, please call 1-800-874-6756 ©2021 Braintree Laboratories, Inc.

All rights reserved.

201-133-v1-A January 2021

Novel & Noteworthy | 13


! 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— 14 | GI.ORG/ACGMAGAZINE

THE #1 MOST PRESCRIBED, BRANDED BOWEL PREP KIT4


TRAINEE HUB What Makes a

Good Endoscopy Educator Perspectives from Gastroenterology Fellows and Faculty By Shifa Umar, MD

B:11.25"B:11.25"

S:9.75" S:9.75"

T:10.75"T:10.75"

LEARNING GASTROINTESTINAL ENDOSCOPY IS ONE OF THE INTEGRAL ASPECTS of gastroenterology fellowship. Yet, while interacting with my peers at local and national meetings, I always found it interesting how differently we all progressed at learning the various endoscopic skills and maneuvers. Training fellows to perform endoscopy is challenging and has, over the years, evolved from an apprenticeship model to a competencybased model. To bring together perspectives from educators and learners, I invited faculty and fellows from various backgrounds and different career stages and points in their training to share their vision and identify attributes which make for an effective endoscopy educator. During my own gastroenterology fellowship, I identified that we all have our own learning pace. What works for me may not work for someone else and, by the end of three years of fellowship, I adopted a bit of something from everyone I worked with (faculty, technicians and nurses). I discovered that endoscopy, just like with everything in medicine, will be a constant process of learning. —Dr. Shifa Umar

Trainee Hub | 15


// TRAINEE HUB

FELLOW RESPONSES

“A great endoscopy educator enables fellows to develop their own techniques, lets them ask for help, and allows them to ‘struggle’ everso-slightly before intervening at the perfect moment.” ­—Ruchit N. Shah, DO, First Year Fellow, Geisinger Commonwealth School of Medicine “A great endoscopy teacher emphasizes the cognitive aspect of scoping as much as its technical component and challenges the learner to think critically about (1) whether a scope is indicated and, if so, (2) how we can make it as safe as possible.” —Malorie Simons, MD, Advanced Endoscopy Fellow, Weill Cornell Medicine Division of Gastroenterology and Hepatology “A solid endoscopy educator is approachable, patient and honest. Honest when you're doing well (praise) and honest for skill refinement (feedback). Allowing the trainee to struggle and encouraging the trainee to identify 1-2 endoscopy objectives for the day are helpful." —Nikki Duong, MD, Second Year Fellow, Virginia Commonwealth University A great endoscopy educator… “is someone who teaches with patience and positivity, effectively communicates tangible goals while providing real-time feedback, and creates a safe, nonjudgmental environment for trainees.” —Rashmi R. Advani, MD, Third Year Fellow, Stony Brook University Hospital

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“The 4 T's of a good endoscopy educator: • Tips: gives the fellow clear-cut tips on ergonomics, driving the scope, reducing loops, turning flexures, etc. • Time: does not take over the scope for too long but knows when to jump in and help out. It is a fine balance! • Technique: teaches her/his method while accepting that fellows may also incorporate techniques from other educators. • Timely feedback: provides real-time, constructive feedback during the procedure and at the end of each case.” —Daniela Guerrero Vinsard, MD, Second Year Fellow, Mayo Clinic, Rochester, MN

“A good endoscopy teacher fosters a good learning environment, allows for appropriate autonomy, and, most importantly, provides real-time feedback.” —Elizabeth Aby, MD, Third Year Fellow, University of Minnesota “A good endoscopy educator is someone who can patiently walk their fellow through a scope and effectively communicates how to troubleshoot problems without having to take the scope away.” —Mayssan Muftah, MD, Second Year Fellow, Brigham and Women’s Hospital, Harvard Medical School A great endoscopy educator… "understands the current skill level of the trainee. They give the trainee the endoscopic instruction and confidence to expand their skills and comfort zone while maintaining patient safety." —Dean Ehrlich, MD, Third Year Fellow, David Geffen School of Medicine at UCLA “A good endoscopy educator has a passion for teaching and sharing in an accessible way. By this, infects, inspires, motivates, and boosts trainees up in reaching the stars.” —Katarzyna Monika Pawlak, MD, PhD, Final Year Fellow, Hospital of The Ministry of Interior and Administration, Szczecin, Poland “The best teachers allow you to hold the scope and somehow get you to the cecum with just their words. They embody patience and profound procedural expertise.” —Chuma G. Obineme, MD, Second Year Fellow, Emory University School of Medicine


FACULTY RESPONSES “When flexible endoscopy began over 50 years ago, there were no trainers since we had no experience in how best to use the flexible instruments. Many techniques were developed, some were good and some were terrible, and unfortunately, some of the terrible techniques still are being taught today. There is no uniformity in the teaching of endoscopy. Over the years, many of us traveled long distances to train doctors in other countries in the handling of scopes for diagnosis and therapy. Now, with the COVID pandemic, nobody travels to teach endoscopy and a whole new world of innovation has become possible through the internet. Whether close by or far away, the trainer needs to be a knowledgeable and capable endoscopist having dedicated time to stay with the trainee throughout the entire procedure.”

—Jerome D. Waye, MD, MACG, Emeritus Professor of Medicine, Icahn School of Medicine at Mount Sinai “Do not compare yourself to your classmates; everyone learns endoscopy, but at different paces. I was the last to get to the cecum in my class yet here I am today, a skilled endoscopist. Don’t get pre-occupied with the time you take to complete colonoscopy, extremely important to focus on good technique and ergonomics. You will get faster with experience and volume but good technique ensures less work-related injuries later on in your career.”

—Renee L. Williams MD, MHPE, FACG, Associate Professor of Medicine, Division of Gastroenterology, NYU Langone Health, Associate Chair, Saul J. Farber Program in Health Equity, Director GME Education, NYU Institute for Excellence in Health Equity "I think the most important factor in training a GI fellow in endoscopic techniques is giving that fellow access to performing endoscopies on patients. While stimulation training is obviously important, there is no substitute for substantiative time working with live patients. This requires patience on the part of busy attending staff, flexibility and educational prioritization from

“As I tell all my trainees, your endoscopic education is not limited to the time your hands are on the scope. There should be some thought put into why we are doing these procedures, the risks associated with them, and learning how to relay this information to the patients who you have the privilege of caring for each day. In addition, the age of virtual learning has opened up many more avenues for endoscopic teaching than ever before. Endoscopy is not just doing procedures but a way of life for the gastroenterologist, so gathering knowledge from multiple sources will lay the foundation for a successful career.” —Uzma D. Siddiqui, MD, FACG, Professor of Medicine, University of Chicago, Director, Center for Endoscopic Research and Therapeutics (CERT) and Advanced Endoscopy Training

administration, and an appreciation and focus from trainees. Spending an afternoon scoping with an enthusiastic fellow one-on-one in a non-hurried environment is truly one of the great pleasures of being an attending physician."

—Timothy B. Gardner, MD, MS, FACG, Professor of Medicine, Geisel School of Medicine at Dartmouth, Program Director, Gastroenterology and Hepatology Fellowship Program “Don’t go fast and furious to reach the cecum; good endoscopic technique is about a non-forceful journey to the cecum. Go slow and have intentional scope movements and torque, so you can reach the cecum in an adequate time. We all obsessed about reaching the cecum as fellows like it’s the Holy Grail; but the real target should be perfecting how to navigate the sigmoid and reach the splenic flexure with a reduced and straight scope—after that the cecum becomes easy (most of the time). Beyond techniques: the key is to not get frustrated. Frustration leads to forceful pushing, poor technique, and to repeating the same maneuvers while expecting different results that won’t come. All this can lead to injury to the patient and ergonomic injury to the endoscopist. Stop, take a deep breath, pause, relax your shoulders, straighten up your back and start fresh with a different plan, don’t get angry at the colon. #KeepItZen Keep the patient at the center of what you do and always be the patient’s best advocate. Ask yourself: is the endoscopy indicated, can you do something meaningful about the findings on the scope and will that have a positive outcome on the patient (from improving the patient’s quality of life to saving the patient’s life)? Next: be honest with yourself and prepare the team adequately. Do you have the right skill set needed for the expected degree of difficulty of the scope? What do you expect to find and/ or treat and prepare and brief your team about it? It is OK to “give up a scope” to a more senior fellow or to the attending when it is the right thing to do. Remember, you will be that expert endoscopist one day.

Trainee Hub | 17


Finally: Open communication with the patient, the family, the medical and nurse team is a key component to being a good endoscopist!”

—Aline Charabaty, MD, FACG, Assistant Clinical Director of the Division of Gastroenterology, Johns Hopkins School of Medicine, Clinical Director of IBD, Johns Hopkins - Sibley Memorial Hospital, Washington, DC “Learning theory shows that when learning a new skill, we actually get worse (consciously incompetent) before we get better (consciously competent). It is at this point where direct observation of your teacher doing the scoping is highly valuable. Your focus can be more on what they are doing to perform a safe and effective maneuver (think EMR), rather than you trying to figure it out on the fly.”

—Christopher J. DiMaio, MD, FACG, Professor of Medicine, Icahn School of Medicine at Mount Sinai, Director of Interventional Endoscopy, Mount Sinai Health System “Most people who taught endoscopy in the past (including myself) were not trained how to do so. We let trainees handle the scope for a while, made a few comments, and then took over. I would encourage those in charge of fellowship training programs to expose their colleagues to the "train the trainers" paradigm. Taking such a course recently made me realize what a poor job I had done. It is fascinating and effective.”

—Peter B. Cotton, MD, FACG, Professor of Medicine, Medical University of South Carolina “Endoscopy is humbling. Even for the experienced endoscopist there are days when endoscopy feels easy and other days, when even the simplest maneuvers seem impossible! As you are learning endoscopy, have patience with yourself and your endoscopy teacher. Early on, your focus should not be reaching the cecum, but rather on specific skills such as maneuvering the sigmoid colon with a straight scope and fine tip control.

18 | GI.ORG/ACGMAGAZINE

Once you master the basics, reaching your destination will be so much easier!”

—Laura Raffals, MD, FACG, Professor of Medicine, Division of Gastroenterology and Hepatology, Mayo Clinic Rochester “To be successful, I remind the fellows that I work with to always ask themselves 3 questions when performing an endoscopic maneuver: • What do I need to do to be successful? • What will I do after I am successful (in this maneuver)? • What will I do if I am unsuccessful (in the maneuver)? Having these three questions constantly circulating in our minds can provide maximal benefit for patients. These questions allow us to simultaneously think about the present as well as steps ahead. In this way, we can minimize repetitive maneuvers that could introduce harm. By asking these questions we remain cognitive in our approach to endoscopy, thus ensuring we are acting with purpose which, ultimately, improves outcomes and care.”

—Shyam J. Thakkar, MD, Professor of Medicine, Director of Advanced Therapeutic Endoscopy, West Virginia University Medicine “Be open to learning new ways to perform endoscopy. I was a third-year fellow when an attending told me that I was performing colonoscopy incorrectly. While initially frustrating, that modification significantly helped my colonoscopy technique and has stuck with me throughout my career.”

—Vinay Chandrasekhara, MD, Consultant, Division of Gastroenterology & Hepatology, Associate Professor of Medicine, Director, Pancreas Group, Program Director, Advanced Endoscopy Fellowship, Mayo Clinic “The key element fellows need to learn endoscopy is TIME; time to make their own mistakes, and to learn what manipulating a scope feels like. Fellows will learn from many preceptors, each with their own style. Fellows should try all these styles, see what works best for them, and eventually incorporate them into their own unique style. For preceptors, it is often better to tell, than to

show/do; I challenge myself to verbally coach a fellow through a complete procedure and minimize my ‘hands on’ time. Remember, lab nurses make great teachers too.”

—Michael M. Babich, MD, GI Fellowship Program Director, Allegheny General Hospital, Pittsburgh, PA, Associate Professor of Medicine, Temple University School of Medicine “Learn the endoscopes and accessories in your unit in detail: materials, lengths, diameters, bending capabilities, how they’re built and how they work. You need this knowledge to perform with optimal effectiveness and safety.”

—Douglas K. Rex, MD, MACG, Distinguished Professor Emeritus of Medicine, Indiana University School of Medicine, Chancellor’s Professor at Indiana University Purdue University Indianapolis, Director of Endoscopy at Indiana University Hospital in Indianapolis, IN


GETTING IT

EXECUTIVE SUMMARY ACG Practice Management Toolbox

Leveraging the EHR to Your Advantage:

Make the Electronic Beast Work for You! By Manoj K. Mehta, MD, FACG and Richard L. Nemec, MD, FACG

This thorough and detailed overview on making the EHR work for you by Dr. Mehta and Dr. Nemec is part of the ACG Practice Management Committee’s “Practice Management Toolbox” article series that offers useful and applicable resources, tips, and insights from peers in the GI community to advance GI practice. Available online is an illustrated version of the article with specific examples from the Epic EHR system, as well as a video by Dr. Mehta with a range of helpful ideas and examples to serve as a supplement to the strategies outlined in this article.

Getting it Right | 19


// GETTING IT RIGHT

What Can This Article Do For You? This article can get you started, provide ideas of what can be accomplished, open your eyes to what can be improved, and point you to resources to achieve what you need. It cannot give you specific, step-by-step instructions. There are simply too many EHRs, and even a single EHR can have multiple versions. You will have to do some research, sit down in front of the computer, and perhaps consult your trainer for advanced tips and setup. However, spending a few hours upfront could save you untold amounts of time in the future.

RESOURCES READ MORE: View the full Practice Management Toolbox article that includes references, as well sample images from the Epic EHR system: bit.ly/ pmtoolbox-ehr-mehta-nemec WATCH: Dr. Mehta created a helpful YouTube video as a supplement to the article: bit.ly/pmtoolbox-ehr-video

BACKGROUND Aside from the COVID-19 pandemic, there is probably no single more difficult hurdle within the last generation of medicine than the implementation of electronic health records (EHR) as mandated by the 2009 HITECH Act. Scanning and destruction of paper records, steep learning curves, IT issues, multiple platforms, difficult to navigate patient encounters, cost, and delayed integration have plagued nearly every practice. Physicians identify their obligations to the EHR as a major source of stress and, therefore, physician burnout. Many more physicians report taking work home with them to complete after hours than during the paper-chart era. The EHR is a template-

“The EHR is a tool. The key to making any tool work appropriately for you is to learn how to

driven system, and the more complex efforts to perform “data entry” become a major impediment to delivery of care. That is not to say that there have not been major benefits and, in the early days of any process, it is easy to focus on the negative. The EHR has clearly helped us with governmental compliance, legibility, record permanency, pre-populating notes, and potentially shorter encounters. This article will explore ways to leverage as much good out of your EHR as possible. By grooming your electronic health record, you might start to see the positives outweigh the negatives. The EHR is a tool. The key to making any tool work appropriately for you is to learn how to use it. Computers have the advantage of being programmable, and therefore malleable to the needs of a number of different users. Unlike most tools, which have only one right way to use them, your EHR can be made to work to your style. The good news is that you don’t need to be a programmer to set up an EHR to work in your favor. TOP 5 EHRs IN THE U.S. BY MARKET SHARE

Epic

30.9%

Cerner

25.1%

MEDITECH

14.7%

Evident

8.1%

Allscripts

5.7%

Epic and Cerner, combined, comprise over 50% of the health information technology market. Bigger healthcare systems appear to favor Epic, and ambulatory centers appear to favor Cerner.

use it.” WHAT CAN YOUR EHR DO FOR YOU? 1. Help you type Yes, actually. Many EHRs have autocorrect functions. If you commonly misspell something, enter it into the autocorrect dictionary. Amytriptiline becomes “amitriptyline” without a second thought. You can also use this as a shortcut. Enter an abbreviation for any string in autocorrect, and every time you enter the shorter string, the entire phrase will be entered. Nonstandard abbreviations can be normalized.

Dr. Mehta created a helpful tutorial video to illustrate the key points of this article. Watch: bit.ly/pmtoolbox-ehr-video

20 | GI.ORG/ACGMAGAZINE

2. Achieve more meaningful communication with patients The 21st Century Cures Act was signed into law in 2016. One of the mandates is increased


transparency for patient access to your notes and tests you have ordered. This means that not only may patients get results before you see them, but they will also be able to read many of your notes just as written. Notwithstanding the lack of medical education in the general public leading to much confusion and perhaps concern, the medical language we use will raise a myriad of questions. Save yourself from the inbox messages and phone calls by cleaning up dialogue. With autocorrect, you can type SOB and have the EHR correctly write out “shortness of breath,” PO to “by mouth,” and BRBPR to “bright red blood per rectum.” These shorthand notations were developed when writing was done by hand, but we are not tied to that now. Patient portals, or your “inbox,” are another common consumer of overall computer time. Answering questions this way has the advantage of permanency in the record but is also a source of after-hours computer time and potentially overall frustration. As with anything, there will be respectful users of your time, and perhaps patients who abuse this system. Use the system at a balance, benefiting you and your patients. If that balance is lopsided, don’t be afraid to ask the patient to make an appointment to address their questions and advise them the portal is not a good place for urgent or detailed dialogue. 3. Reduce your workload For more control, create a smart phrase. In Epic, these are preceded by a dot, so “.PREP” could print out the entire bowel prep regimen stepby-step. Like autocorrect, you need to set these up. That is a little time consuming but will pay dividends in the long run. Please note, you can usually look at others’ smart phrases in Epic, and these are not proprietary to the user, so they can be copied and pasted into your own smart phrases. The EHR gGastro has MACROs that operate similarly. You can create your own drop-down lists. In Epic, these are called “smart lists.” You can give the list a name,

suggest the default, and connection logic (“and/or”). An example of this would be a letter to a patient explaining the number of polyps, type of histology, and years until follow up. Instead of typing this out, the smart phrase contains the various smart lists which show up as numbers to pick or words of explanation in drop-down format. Set this up, and you have a full letter in three or four clicks.  View an example of a smart list, see bit.ly/pmtoolbox-ehr-mehta-nemec 4. Document E/M coding (with a warning) Many EHRs support disease-specific templates. You can create a template for a patient with, say, abnormal liver enzymes, which covers all the historical points that you typically ask, as well as the orders that you would write. Not only will this help you and your patient, but oftentimes the more specific documentation leads to more accurate coding for billing! ACG has spent considerable effort in developing guidelines in the evaluation and management (E/M) of most significant GI conditions. By building a smart phrase (or similar process in other EHR systems), you can incorporate the latest guideline into your note with one smart phrase or “ribbon.”  View an example of a smart phrase or ribbon, see bit.ly/pmtoolbox-ehrmehta-nemec However, you must be careful with templates. You are probably all aware that you can generate almost an entire note with all the past medical history, vitals, and usual note requirements. Do not get too caught up in this. Notes that claim a gastroenterologist examined the optic fundus will be suspicious. Cutting and pasting from your prior note, in part, is fine. Just keep in mind when you are writing it that it is a rolling history and that you will be building on it. You’ve all seen notes that say “awaiting x” even though it’s been done for days. Do not be that person. Copying and pasting others’ notes is not a good idea, as errors get perpetuated. Also know that there is an element

of “note fatigue.” A longer note filled with pre-populated information tends to not get read. Change the font for your impression and plan, bold it, or even put it at the top above the computer-generated information. Still, a properly set-up note template is instrumental in making you efficient. 5. Make you look good Do you find yourself making the same teaching points? Make a smart phrase that encompasses the nature of Ranson’s criteria, the differential diagnosis for post-op hyperbilirubinemia, or a hyperlink to a reference article. One author here uses a smart phrase .STRATE when trying to stop the habitual restriction of nuts in patients with diverticulosis. This phrase inserts “see LL Strate, et al., Nut, corn, and popcorn consumption and the incidence of diverticular disease. JAMA. 300(8):90714, 2008 Aug 27.” By using these short cuts you can provide increased diagnostic accuracy, precision in the care you deliver for your patient, and thoroughness of documentation. Epic has a tool called Synopsis, which allows chronological tracking of interventions and recorded outcomes. For example, in IBD, you would record the patient's past history of interventions and status updates with semi-quantitative scores (e.g., HBI, CDAI, Mayo scores) via your template. Synopsis can generate a report that contains a rolling history of the patient's previous symptoms, treatments, and (most importantly) responses. At a glance, you could see the Mayo score and how it correlated with different biologics, calprotectin, or even seasonality. Think about the power of this tool when evaluating DILI. Every drug used when overlying a graph of LFTs! 6. Order efficiently Admitting diagnoses can be set up to generate order sets (e.g., orders relevant to abnormal liver enzymes, variceal bleeding, or colonoscopy preparation). By creating an order set/smart phrase/ macro (depending on your EHR), you can quickly and rapidly order all necessary tests in the evaluation and management of your patient's condition. Not only does this increase the efficiency of your orders, but it increases the consistency of your orders and the quality of your

Getting it Right | 21


patient care. Finally, it helps you to "remember" all the necessary orders for this condition. Did you “remember” that celiac disease can cause abnormal LFTs? It may or may not be relevant to your case, but there is the order to remind you to consider it.  View examples of an order set in Epic and gGastro for abnormal liver enzymes: bit.ly/ pmtoolbox-ehr-mehta-nemec 7. Remind yourself of something important Use the power of the computer to your advantage: it remembers everything you tell it to. Do you find yourself repeatedly looking up, say, the management of pancreatic cysts? Or perhaps the ascites characteristics of nephrotic syndrome? Create a smart phrase encompassing what you need to know, and you can pull it up in a note and then delete it after you’ve refreshed your thinking on this subject. This will save you from going back and forth to Google. Let the computer remind you (or your staff) of the need for future care for a specific patient. If there is an imaging study that needs a follow-up study in six months, the computer can remind you when that is due. You or your support staff can use the reminder function to warn you when the IBD patient is due for routine labs, levels, vaccines, or if they have a TB evaluation due. Your EHR can be constructed to create appropriate recalls and reminders whether for labs, imaging, endoscopic procedures, vaccinations, etc. It only takes a little time to set this up in your EHR and your patients will benefit from your efforts.  View an example of a self-reminder in Epic: bit.ly/pmtoolbox-ehr-mehta-nemec 8. Separate the wheat from the chaff You can generally modify the EHR start page to show your schedule, notes, patient list, and any number of other factors. Each of these, in turn, can be modified to suit you. Choose the best formats that works for your needs. Are you on rounds in the hospital? Start with your patient list. Endoscopy day? Start with your schedule.  View an example of a brief note in gGastro: bit.ly/pmtoolbox-ehr-mehta-nemec You can change the search function defaults, for example, to display notes from you, your partners, or your specialty first. This lets you hone in on what is probably most relevant to you as a consultant, and bypass those infamous notes from music therapy. 9. Use available metrics You are all probably familiar with the reports you get from your endoscopy report writing system, showing your ADR, how you compare to peers

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“You’ve all seen notes that say “awaiting X” even though it’s been done for days. Do not be that person.”

and the national standards, how many sessile serrated lesions you find, and perhaps your time efficiency in the GI Lab. Did you know there are similar, and even much more robust, resources available to assess how efficiently you use your EHR time? Epic is constantly tracking everything you do. What times are you logged on, how much time you spend in your basket answering messages, how much time writing orders, and how much time in chart review. It tracks how much time you spend writing notes, how many characters are in your average note, and even how much of that note is cut and paste vs original writing. This data is presented in a pathway called Signals. It is overwhelmingly thorough. Be aware the information is not blinded like your ADR data might be. You can see every person’s details in your section, in your hospital, and even across institutions. All centers using Epic are included. At a minimum executives, project directors, and managers qualify for access, so someone at your organization can get this information.  View an example of Epic Signals data on organizational efficiency: bit.ly/pmtoolboxehr-mehta-nemec

CONCLUSIONS Getting the most out of your EHR involves a little bit of setup time. But in the end, it saves you time, makes you look good, and shortens your workload instead of expanding it. This doesn’t just help you; it helps your patients. The EHR is here to stay. You might as well use the power of the computer to remember and organize things for you, help you find information, and help you communicate effectively. As you free up time spent struggling with notes and orders, you can get back to doing what you do best—taking care of patients.

PRACTICAL STEPS TO IMPLEMENT THESE IDEAS: 1. Ask and answer the question: What makes my EHR so painful? (Pick your top three) 2. Ask and answer the question: What do I need to change in my EHR to make it more helpful to me? Use the data from Signals (if you are an Epic user), or just pick your top three.


An example of data summaries of EHR use in Epic.

3. Review some of the specific ideas attached to this article. Do you like any that you see? 4. Decide how much time you want to invest in the process. Do you want someone to set it up, show you how to use it, and just use it in a static fashion moving forward? Or do you want to do a “deep dive” on learning how to create and modify the EHR on the go? The more you invest, the greater the return, but we all know we have limits. 5. Take your preferred ideas from #1 through #3 above to your local EHR expert—those people really do exist! Take an active role in building the structure that addresses YOUR wants: whether it be through templates, smart phrases, short cuts, or different views.

6. Preview with partners and list “shortcuts” or EHR efficiencies that they have found or developed for various tasks or documentation, list them, and disperse to others to improve group efficiency. This can also be done on a staff level and revisit biannually to update ideas. We all have different skill sets and can empower others in the group.

8. Show others how you have improved the generic EHR at your hospital or practice. This will not only help your colleagues, but as you instruct others, you will become a local expert.

7. As you learn how to make your EHR work for you, you can identify other areas for improvement and efficiency.

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

Richard L. Nemec, MD, FACG Winchester Gastroenterology Associates, Winchester, VA

Getting it Right | 23


Help Me Out! LAW MIND

By Ann M. Bittinger, Esq.

Approaches to Negotiate Out of a Non-Compete with a Private Equity-Backed GI Practice

With the increased market share of private equity-backed gastroenterology practices (“PE groups”) in the United States, I am often asked if PE groups’ non-compete agreements differ from other groups’ restrictions on post-termination competitive work. The answer is, as it often is to legal questions, “maybe.” Non-compete agreements, also called restrictive covenants, are found in almost all physician employment agreements that I review. There are five components to most non-competes: 1) a time frame, 2) a geographic area, 3) a description of prohibited activity, 4) triggering events and 5) exceptions. Many attorneys focus on just the first three elements, but in many cases the final two can be the most important to negotiate prior to signing the employment agreement. A typical prohibition might read like this: “Physician agrees not to practice gastroenterology within a 20-mile radius of any Employer location during the term of this Agreement and for two years following termination; provided, however, this prohibition will not apply if Physician is terminated without cause or Physician terminates for cause, and it will not prohibit Physician from working for a company that is wholly-owned by individual physicians.” Where PE groups’ non-competes tend to differ is the geographic area. The PE groups want to protect their intellectual property. They are perhaps less concerned about the physician luring patients away than about the departing physician

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“Can an employer with a gigantic geographic footprint ban a physician from working anywhere within that footprint if the physician’s employment terminates? Again, maybe.”

sharing with a new employer information about how the PE group is structured, who they deal with, pending acquisitions, practice purchase information, how scheduling is done, pricing and payment relationships with systems and payers, and other intellectual property matters. For that reason, they may ask physicians to sign non-competes that bar the physician from working for any competitor of the PE group. For a national PE group, the prohibited geographic area could, therefore, be vast. Even a prohibition against working within 20 miles of any of the PE group’s offices could be extremely expansive. Would this type of contractual provision be enforceable? Again, maybe. While not specifically addressing PE groups, many state courts have in the last decade reviewed the fairness of non-competes in the greater context of the postconsolidation mega-group that is often a physician enterprise of a regional health system. Can an employer with a gigantic geographic footprint ban a physician from working anywhere within that footprint if the physician’s employment terminates? Again, maybe. State law is very important on this issue. Some states like Connecticut have laws that limit the geographic area


and timeframe components. When negotiating a national-template physician employment agreement with a PE group, considerations may not have been made as to the enforceability in that state of that generic, template non-compete section that all physicians employed by the PE group anywhere sign. The challenge is that a physician does not know if a non-compete is enforceable until he or she asks for it not to be enforced. There are two ways to ask that a signed non-compete not be enforced. Of course, going straight to court is an option, although an expensive and indirect one. In most states, a physician can’t just ask a judge to read a term of his or her contract and ask if it is legal before taking a new job based on what the judge says about the existing non-compete. Instead, what usually happens is the former employer files for an injunction­—like a restraining order—in which the court would tell the physician he or she must stop working in violation of the non-compete. The problem with this, though, is that the physician must have already taken another job—perhaps committing to a term of employment and perhaps maybe even another non-compete. Additionally, in that new employment agreement the physician might promise that he or she is not subject to a non-compete from the previous job, so that if indeed the previous employer tries to enforce the non-compete, the new employer could fire the physician for breaking that promise that no non-compete exists. That for-cause termination could carry additional penalties, like having to repay a signing bonus or having to buy tail insurance.

HOW CAN THIS BE AVOIDED? THE OFFBOARDING NEGOTIATION OPPORTUNITY In the stress surrounding an imminent termination of employment, physicians often overlook another option: asking that the non-compete be revised

upon termination as departure terms are discussed. Just as things are negotiable when onboarding a new job, the terms under which a physician departs may also be negotiable. This can be especially true with nimble and business savvy PE groups. Many physicians ignore the offboarding negotiation opportunity and call me only after they have submitted notice of termination. It’s often too late. Offboardings should be planned months in advance, if possible. The key is to determine what matters to the employer. Does the employer need you to stay for six months when you only have to give 90 days’ notice of termination? Can you give something to assist the employer—like agreeing to stay 4 additional months—in exchange for some exception or tweak to your non-compete that would allow you to take the job you want?

IDENTIFYING A NARROW EXCEPTION TO AN EXISTING NON-COMPETE Once you identify and establish your offboarding leverage, the next step is to try to identify a narrow exception to the existing non-compete that will allow you to take your desired job. The key is to elucidate how the new job will not be competitive with the existing job. Explain why the new job should not be threatening to the existing employer. For example, is the new job in an area that falls within the generic, template non-compete language but is really far away from any group site such that no patients will follow the physician to the new job? Is the new employer somehow different from the existing employer such that the existing employer has nothing to lose from the physician working for that employer? Is the market different? Is the patient different? Are the procedures that the physician will do different? In an interesting Florida non-compete case, the exiting physician refused to see any of his prior employer’s patients at his new job, and the court sided with the physician. Would the existing employer waive the geographic area prohibition if the physician agreed not to see any of its patients? Essentially, what the physician is doing is gently explaining to the employer that the non-compete that the employer

mandated is overly expansive, that the physician’s new job will not be competitive with the existing employer and, therefore, that a judge won’t enforce the prohibition. Rather than spend tens of thousands of dollars on litigation, the parties should aim to sign a separation agreement that leaves the non-compete in place for some situations (let the employer keep the restrictions that really matter) but that allows the physician to continue to earn a living. The irony is that although PE groups’ non-competes can be brutal and generic, PE groups’ nimbleness often enables an offboarding negotiation that might allow the physician to evade the non-compete in a non-threatening way.

WHAT TO ASK WHEN NEGOTIATING OUT OF A SIGNED NON-COMPETE: Is there anything you can give to the current employer in exchange for a tweaked non-compete? • Work longer than required so the employer can onboard a replacement? • Agree to a more expansive non-compete in ways that matter to the employer? • How would the potential job not threaten the current employer? • Is the work you would do different? • Is the employer’s market or patient base different? • Could you agree not to see any patients that had been treated at the current practice?

Ann Bittinger, Esq. is an attorney with The Bittinger Law Firm and helps physicians onboard and offboard from their jobs. She can be reached at ann@bittingerlaw.com.

Getting it Right | 25


Starting a Conversation for

SOUTH ASIANS LIVING WITH IBD By Tina Aswani Omprakash

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Cover Story | 27


// COVER STORY

It was June of 2006, 5 months after I was diagnosed with inflammatory bowel disease (IBD). I was 22 years old and had graduated with dual degrees in Finance and Spanish just the prior year. I was getting off the train from New Jersey into the World Trade Center, with the sweltering summer sun beating on me. I felt faint and nearly fell over as I walked into the Merrill Lynch tower in the World Financial Center where I had been working for several months. I couldn’t concentrate and was running to the ladies’ room throughout the day. My mother picked me up from work soon thereafter and took me straight to the emergency room at a local hospital near her home in New Jersey where my gastroenterologist was at the time. My hemoglobin was apparently 6 and I was becoming severely anemic from bleeding for several months without even realizing it. As I was being admitted into the hospital and waiting for a colonoscopy and imaging studies, it began to dawn on me that my IBD diagnosis could interrupt all that I had accomplished as a 4.0 student who had grown up into a young, successful woman with many hopes, dreams and aspirations. Over the next decade, I tried to work on and off, in spite of trying many different medications available at the time to treat IBD and undergoing more than 20 surgeries. I had tried every form of complementary and alternative therapy my family could dream of—as many South Asian families, including mine, tend to look to dietary factors first and some have fears around taking medications due to side effect profiles. My family believed in being “all natural” and “side effect free” and there was a guilt and shame associated with contracting this illness as something I had done to myself with a poor diet and lifestyle choices. I was pushed and pushed by extended family and friends not to go on biologics and not to have ostomy surgery; I was worried that if I went against them, I would not have anyone at all to care for me. All of these challenges and medical choices were set against the backdrop of my family history, with my father and aunt, both of whom had IBD, passing from colorectal cancer in the early ‘90s. NOT JUST “A TINA PROBLEM”

As I went through my arduous battle playing tug of war with my family and with my doctor, my disease continued to worsen and I began to realize that this couldn’t just be a “Tina

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“From the labeling of IBD as a diet and lifestyle disease, to fearfulness of the medical system and traditional medicine, to IBD being a bleeding bowel disease that can result in an ostomy, I felt mired in stigma and desperately wanted to break out of the clutches of sociocultural taboos and give justice to the suffering of my father, my aunt and myself.”

problem.” These same challenges of navigating IBD had to be affecting others within the South Asian community. I was concerned that others could be impacted, given the mistrust I had sensed among some in my family and in my community since childhood towards modern medicine, and particularly reluctance about ostomy surgery. Over the years as I developed fistula after fistula, needed surgery after surgery, and fought for my life day in and day out, something inside me kept telling me I had to do something about the sociocultural taboos—that it couldn’t just be me suffering in silence and in shame. When I finally came into remission 10 years and more than 20 surgeries later thanks to a clinical trial, I knew it was time to take action on what I suspected to be a larger issue. My husband and I had discussed patient advocacy at length since 2014 and when I started volunteering for the Crohn’s & Colitis Foundation in New York City, it became a reality. In 2018, the Foundation named me their “Adult Honored Hero” for all the volunteer work I had done in running support groups and raising funds. And that’s when my story hit social media for the first time and led to reporters contacting me, and publishers wanting me to write for them, which led to the birth of my blog and social media advocacy platform, Own Your Crohn’s [ownyourcrohns.com].


FACING CULTURAL STIGMAS AND TABOOS

I began to talk not only about my experiences as a minority woman facing delays to care but also about the cultural stigmas and taboos that had plagued me throughout my journey with IBD. From the labeling of IBD as a diet and lifestyle disease, to fearfulness of the medical system and traditional medicine, to IBD being a bleeding bowel disease that can result in an ostomy, I felt mired in stigma and desperately wanted to break out of the clutches of sociocultural taboos and give justice to the suffering of my father, my aunt and myself. I wouldn’t be exaggerating when I say coming out as an outspoken patient advocate felt like social suicide to me in so many ways. Many extended family members and many of my friends disappeared once they realized the nature of the work I was doing. And as much as I sometimes wanted to hide under the covers, I was determined not to let this life-altering experience die of attrition without helping people in my community with IBD. So I kept speaking out. But I didn’t just want this effort to be about me; I wanted all minorities (racial, ethnic, cultural, sexual and gender minorities) to start sharing

their marginalized experiences with IBD so we could create awareness and education to allow the GI space to hear the patient side and what we needed most in our care. To complement my advocacy work, I wrestled with the decision to go back to graduate school, worrying if I would be well enough to do so but knowing it was time to start owning my Crohn’s and fulfilling my dreams. I started at Mount Sinai’s Icahn School of Medicine as a part-time certificate student and transferred into their Master of Public Health program in fall 2019. This program has opened up my mind to depths I had never imagined. You see, I already had the patient experience; what I didn’t have was the researcher or clinician experience and pursuing my MPH made me feel like the world was my oyster to learn from and explore. A DREAM TAKES SHAPE

Over time, my dreams began to expand. On my own, I could only do so much and representation of the experiences of South Asians living with IBD wasn’t just about me. It was about

the community. I started a Facebook community for South Asians living with IBD (facebook.com/groups/ibdesis) during the pandemic and invited a few brilliant ladies from around the world to help me moderate the space: Sharan Khela and Surakhsha Soond from the United Kingdom, and Madhura Balasubramaniam from India. I had gotten to know them throughout the pandemic via social media and all three had a joie de vivre similar to mine, and also a real passion for advocacy and deep knowledge and experience living with IBD and/or ostomies like myself. Within a few months, that Facebook community also became an externalfacing platform called “IBDesis” (a term we coined to refer to those with IBD of South Asian descent who are known as “desis”). The four of us started talking about the South Asian experience, as we could all relate to one another about experiences with the deep stigma about bowel disease and/or ostomy we all faced. Even though our platform was just born in mid-April 2021, within just a couple of months, it had already become wildly successful as many patients and clinicians from around the world could recognize and identify with the challenges we were shedding light upon and discussing. In June 2021, I decided it was high time we expanded. I remember at DDW 2019, Dr. Neil Nandi, Neha Shah and I had met during the cocktail hour and were talking about how much the prevalence and incidence of IBD in South Asians had grown in their practices. I shared with them my sense of how awful the state of Indian, Pakistani, Bangladeshi and Nepalese IBD patients is and how difficult medication access is for them in their respective countries. I remember Neha saying she would love to work towards an organization that could address these challenges in care for South Asian IBD patients. With that in mind, I reached out to several South Asian clinicians around the world asking that we come together to form an organization to do exactly that: create resources, research and education for IBD patients and healthcare providers of South Asian

Cover Story | 29


// COVER STORY

origin to minimize disparities, dispel stigma, promote early diagnosis and improve access to treatment. And that was the birth of the South Asian IBD Alliance (SAIA). Today, I am joined by Dr. Parakkal Deepak, Dr. Shrinivas Bishu, Neha Shah, RD at the helm of the organization, with an Executive Council including Dr. Shaji Sebastian, Dr. Neil Nandi, Dr. Vishal Sharma, and Dr. Sumit Bhatia alongside patient advocate, Madhura Balasubramaniam. We have begun to push forward our mission as the first patient-clinician initiative in the IBD space. We are currently working together on various projects and are in planning stages with regard to research and conferences. We have recently kicked off a slew of patient education sessions with both clinicians and patients delivering credible information to patients, caregivers and even other clinicians to learn from and spread the word. As SAIA moves into 2022, we have high hopes that it can set a precedent for minimizing disparities in the minority health space for the future of public health and well-being for all. Doing so will fulfill a dream I have had for many years now: to recognize that disease can affect anyone and everyone, regardless of race, culture, ethnicity, age or sexual orientation. I firmly believe we have to be the change we wish to see in the world. SAIA accomplishing its mission will be the future of change for patients and clinicians alike.

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“I kept speaking out. But I didn’t just want this effort to be about me; I wanted all minorities (racial, ethnic, cultural, sexual and gender minorities) to start sharing their marginalized experiences with IBD so we could create awareness and education.”

RESOURCES

For more information on South Asian IBD Alliance, please visit southasianibd.org Follow South Asian IBD Alliance

on Facebook, Instagram & Twitter: @southasianibd

Follow IBDesis on Facebook, Instagram

& Twitter: @ibdesis

Join our private Facebook community:

facebook.com/groups/ibdesis

View SAIA’s November 2021 publication in The Lancet Gastroenterology & Hepatology, “Addressing unmet needs from a new frontier of IBD: the South Asian IBD Alliance:” doi.org/10.1016/S24681253(21)00336-8 Check out SAIA & IBDesis’ feature in Crohn’s & Colitis UK’s Connect Magazine: crohnsandcolitis.org.uk/connect-now/ october-2021/a-great-team

All photos courtesy of Tina Aswani Omprakash. Cover spread photo: Health Remedy Media and Lizzy Sullivan, photographer.


ABOUT TINA ASWANI OMPRAKASH

Tina Aswani Omprakash is a Crohn’s patient and award-winning patient leader and health advocate based out of New York City. She has had Crohn’s Disease for 16 years and has had numerous surgeries. Tina maintains a blog and advocacy platform called Own Your Crohn’s (ownyourcrohns.com) and recently co-founded IBDesis, a community for South Asians living with inflammatory bowel disease (IBD). She has now merged IBDesis into a patient-clinician non-profit initiative called South Asian IBD Alliance (SAIA). Her overarching aim is to normalize the rhetoric around chronic illnesses and disabilities in order to help diverse groups of patients own their ailments to live fuller, happier lives. Via her writing, lobbying, social media advocacy and speaking engagements, she spearheads public health causes, including those proposing research for and creating awareness for IBD, life-saving ostomy surgery, gastroparesis, fistulizing disease and initiatives supporting health equity for women and racial, ethnic & sexual minorities. Tina is pursuing her Master’s degree in Public Health at Mount Sinai’s Icahn School of Medicine. Additionally, she has spoken at many premier GI conferences and has co-authored three research papers and two guidebooks on IBD care. Tina does freelance work as a patient advisor for non-profits, as well as ostomy manufacturers, in addition to pharmaceutical and digital health companies. Her aim is to help companies recognize disparities and unmet needs in minority health populations. The Crohn’s & Colitis Foundation recognized Tina in 2021 for her phenomenal leadership and powerful impact on the IBD community with the Above & Beyond Volunteer Award. Tina’s blog was also recognized as a 2020 Best Blog by Healthline and she was awarded the 2019 Healio Gastroenterology Disruptive Innovator Award for moving the needle on GI care for patients. Learn more about Tina:

 ownyourcrohns.com  health.mountsinai.org/blog/tina-aswaniomprakash-a-journey-from-inflammatorybowel-disease-patient-to-patient-advocateto-master-of-public-health-student  healthcentral.com/experience/my-storycrohns-tina-aswani-omprakash

“Dr. Neil Nandi, Neha Shah and I had met... and were talking about how much the prevalence and incidence of IBD in South Asians had grown in their practices. I shared with them my sense of how awful the state of Indian, Pakistani, Bangladeshi and Nepalese IBD patients is and how difficult medication access is for them.”

Tina’s Authorships:

Aswani Omprakash, Tina, et al., Addressing Unmet Needs from a New Frontier of IBD: The South Asian IBD Alliance, The Lancet Gastroenterology & Hepatology, Volume 6, Issue 11, 884 – 885. (DOI:https://doi.org/10.1016/ S2468-1253(21)00336-8) Sedano, Rocio Hogan, Malcolm Mcdonald, Cassandra Aswani-Omprakash, Tina Ma, Christopher Jairath, Vipul, et al., Underrepresentation of Minorities and Underreporting of Race and Ethnicity in Crohn’s Disease Clinical Trials, Gastroenterology, In Press. (DOI:https:// doi.org/10.1053/j.gastro.2021.09.054) Tina Aswani Omprakash, Norelle Reilly, Jan Bhagwakar, Jeanette Carrell, Kristina Woodburn, Abby Breyer, Frances Close, Gabriel Wong, Patients’ Journey Through Inflammatory Bowel Disease (IBD): A Qualitative Study, Inflammatory Bowel Diseases, Volume 27, Issue Supplement 1, January 2021, Pages S53–S54. (DOI:https://doi. org/10.1093/ibd/izaa347.127) The Circle of Care Guidebook for Caregivers of Children and Adolescents Managing Crohn’s Disease ©2021 National Alliance for Caregiving (caregiving.org/ wp-content/uploads/2021/05/NAC_ ManagingCrohnsGuidebook_051721. pdf) Defining, Caring & Treating Crohn’s Disease & Ulcerative Colitis, United Ostomy Associations of America (ostomy.org/what-is-crohns-disease)

Cover Story | 31


// COVER STORY

A Gastroenterologist’s Perspective on South Asians Living with IBD Parakkal Deepak, MBBS, MS, FACG

Recent studies have informed us about the accelerating trend in new diagnoses of inflammatory bowel diseases in countries in South Asia and immigrants of South Asian origin in the Western world. Having completed my medical school training in India, this was not the case back then and this change from those days suggests a trend likely primarily driven by urbanization, changes in lifestyle, and westernization of diet. This surge in South Asia, and among South Asians, brings forth unique challenges due to a spectrum of factors, including resources in South Asia and attitudes towards medical and surgical therapies shaped in the Western world. I had been following the amazing advocacy work started by Tina Aswani Omprakash across the various social media platforms, culminating in the formation of the IBDesis along with Sharan, Suraksha and Madhura. I had also realized in my own clinical practice in IBD that patients of South Asian origin had a different

32 | GI.ORG/ACGMAGAZINE

“I had also realized in my own clinical practice in IBD that patients of South Asian origin had a different approach to managing IBD when presented with similar medical, dietary and surgical options, often shaped by cultural attitudes.”

approach to managing IBD when presented with similar medical, dietary and surgical options, often shaped by cultural attitudes and their perspectives on complementary and alternative medicine. Hence, when Tina and the IBDesis approached me along with a group of GIs of South Asian origin and invited us to join forces on the first patient and provider coled group focused on addressing the challenges on managing IBD in South Asia and among South Asians, I could immediately see the potential to make a difference through the South Asian IBD Alliance. Over the past few months, Tina and the other patient advocates in the IBDesis have driven the group to start new initiatives in improving access to medical therapies in South Asia, improving patient and provider education in IBD, and setting up research collaborations across the US, UK and South Asian countries. I admire Tina’s passion in disease advocacy that has been the impetus to start the IBDesis and now SAIA, that will positively impact the overall care of South Asians living with IBD. About Dr. Deepak

Dr. Deepak is Assistant Professor of Medicine at Washington University School of Medicine in St. Louis and serves as Chair, ACG Digital Communications & Publications Committee. His research focuses on utilizing non-invasive methodologies for assessment of disease activity and response to medical therapy in Crohn's disease.


Culinary Connections:

warm and wonderful

WHAT STARTED AS A COMMON LOVE FOR FOOD ON #GITWITTER by Dr. Vani Paleti, Dr. Alexander Perelman, and Dr. Christina Tennyson during the start of the COVID pandemic is now into its third series of #ACGfoodies culinary connections, with immense support from our ACG team. We are very excited to bring you “Warm & Wonderful” as we look forward to gathering with family and friends during this holiday season. Holidays are filled with love, joy, and memories-in-the-making. Let’s come together to celebrate safely (yay for vaccines!). We thank Dr. Supriya Rao, Dr. Jordan Shapiro, and Dr. Tatiana Policarpo for sharing their culinary connection journeys and recipes for dishes that speak to their souls and bring a smile to their faces.

ACG Perspectives | 33


// PERSPECTIVES

SUPRIYA RAO, MD

Integrated Gastroenterology Consultants, North Chelmsford, MA

Growing up in a South Indian family, food was not just an important part of life, it was an expression of love. I would watch my mom exchange recipes with her friends and family members like she exchanged hugs. Family gatherings and dinner parties were synonymous with culinary adventures. Like in most cultures, coming together over food was a social and cultural celebration. I was raised a vegetarian and was introduced to a variety of plants at a young age. Leafy greens, okra, brassicas, squashes, root vegetables, beans, and lentils were in common rotation at the dinner table. Over the years, I became my mother’s apprentice and learned everything I could about Indian cooking, mixing turmeric and cumin with ginger and chili powder and eating highly flavorful food that was healthy and nourishing. I must admit, I wasn’t the healthiest during my college and training years. Away from my mother’s cooking, I fell into a highly processed vegetarian diet. Late nights studying and on-call nights in the hospital led to poor eating choices—something very common for my peers, myself, and anyone at that stage in training. I watched colleagues start antihypertensives and statins, and I knew that my lifestyle had to change. After becoming a gastroenterologist and seeing patients full time, I got a firsthand glimpse into how our lifestyle, especially our diet, affects our health. We know that food can affect how we feel

“We know that food can affect how we feel and that there is a strong connection between the brain, gut, and microbiome.” —Dr. Supriya Rao

and that there is a strong connection between the brain, gut, and microbiome. Highly processed and palatable foods wreak havoc on our microbiome and our moods. I saw this not only in patients with functional GI disorders, but also in patients with GERD and NAFLD. Even colon cancer is linked with diet. I wanted to be able to provide the necessary toolkit for patients to improve their lives with small, sustainable changes. This desire led me to seek further education. I became board certified in obesity medicine and am pursuing further training in lifestyle medicine. I wanted to make changes in my patients’ lives and ended up making some in my own life, as well. I currently am plant-based and raise my children this way. I have involved them in preparing meals from a young age. I’ve learned that kids are excited to learn where their food comes from and want to partake in cooking. We aim for a high-fiber diet that is full of vegetables and fruits, whole grains, and plant-based protein. Our goal is to have a wide range of colors in our meals, and we often count the number of plants present. We aim for at least 30 unique plants per week to improve microbiome diversity. As we enter the colder months, I find myself making a lot of soups and stews. It’s an easy way to get in a lot of vegetables and have leftovers for later in the week. This lentil soup is a family favorite—warm and hearty and even better with a hunk of crusty bread. Over the last several years, I’ve rediscovered the habits that I had growing up in a plant-based household. I want to teach my

NOURISHING LENTIL VEGETABLE SOUP  Ingredients

• ¼ cup olive oil • 1 onion, diced • 2 cloves garlic, minced • 2 carrots, chopped • 2 stalks celery, chopped • 1 potato, diced • 1 cup French or brown lentils • Couple of handfuls baby spinach • 4 cups vegetable broth • 2 cups water

Spices • 2 tsp cumin • 1 tsp coriander • 1 tsp thyme • 1 tsp turmeric • ½ Tbsp salt • 1 tsp freshly ground black pepper, to taste 34 | GI.ORG/ACGMAGAZINE

 Steps

7. Add in the baby spinach and let it 1. Heat up the olive oil in a Dutch wilt in the soup. over pot oven or other heavy-based medium heat. 8. Add more salt and pepper to taste. soft are they until onions the Sauté 2. and translucent, about 5 minutes If you have an Instant Pot, you can do steps 1–5 in the Instant Pot and cook at 3. Add in the garlic along with the c, turmeri er, coriand , spices (cumin high pressure for 15 min. thyme) and stir for about 1 minute 4. Add in the carrots, celery, potato and lentils. Stir until well combined, about 2 minutes. 5. Pour in the broth and water, add in salt and pepper. Bring to boil, then cover and turn the heat down to medium to allow for a gentle simmer. 6. Cook for about 25 minutes until the lentils are soft but hold their shape.


kids how to eat so that they will carry these habits forward and make good choices for their health and wellness.

TATIANA POLICARPO, MD Thomas Jefferson Hospital, Philadelphia, PA

Sharing a meal is a great way to bring people together. For me, I grew up in a Brazilian household, and food was central to our life. I have fond memories of coming together for weeknight dinners with my family and Sunday afternoon barbecues with family and friends. Our traditional dinners were always accompanied by rice and black beans with a side salad. When I reminisce about the Brazilian foods I grew up with, I’m reminded of rich, flavorful comfort dishes. Some of my favorites were feijoada (black bean stew), Brazilian stroganoff (a creamier twist on the traditional Russian dish served over rice and topped with potato sticks), and desserts that prominently featured sweetened condensed milk such as brigadeiro (fudge balls) and pudim de leite condensado (Brazilian style

“Through my own research and an inspiring social media community of doctors interested in culinary medicine, I’m learning more about nutrition and trying to incorporate more plants and fewer processed foods into my own diet.” —Dr. Tatiana Policarpo

flan). My Brazilian background has influenced my cooking style, particularly my love of beans and my soft spot for sweetened condensed milk desserts. As a first-year gastroenterology fellow, I’m learning more about how food is such an important part of digestive health. I think it’s important for gastroenterologists to be comfortable discussing diet and nutrition with our patients. Through my own research and an inspiring social media community of doctors interested in culinary medicine, I’m learning more about nutrition and trying to incorporate more plants and fewer processed foods into my own diet. I love learning new recipes that highlight fruits, veggies, whole grains, and legumes. Although I love to cook, as a busy GI fellow and mom to a small child, I often struggle to find time to cook healthy meals for myself and my family. I try to prioritize meals that are quick to assemble and can be prepared ahead of time. Here is one of my go-to recipes in the fall and winter—the harvest bowl. I like that it’s a warm and filling meal that I can prep in advance (make a big batch of rice early in the week, roast veggies ahead of time). The harvest bowl is very versatile—I often swap out ingredients for whatever I have on hand.

HARVEST BOWL  Ingredients

• 1 butternut squash, cubed (can buy pre-cubed for faster prep) • 1 cup cooked chickpeas (I used cann ed chickpeas to save time. Could also use any bean or cooked lentils) • 4 Tbsp extra virgin olive oil • salt and pepper • 3 cloves garlic, minced • 2 bunch of kale (any variety), chop ped • juice of 1 small lemon • 2 cups cooked brown rice (or anot her whole grain like quinoa) • 1 apple, thinly sliced • 1/4 cup roasted almonds, chopped (for topping, other good options include any chop ped nuts, dried cranberries, pomegranate seeds, pepit as) Tahini sauce • 1/2 cup tahini • juice of 1 small lemon • 1/3 cup water • 2 garlic cloves, minced • 1/2 tsp salt • 1 tsp maple syrup or honey (optional)

 Steps 1. Preheat the oven to 400°F and line baking sheet with parchment paper. 2. Toss the butternut squash and chick peas with 2 tablespoons of olive oil and 1/2 teaspoon salt. Roast for 30–40 minu tes, until squash is soft. 3. While the squash and chickpeas are roasting, heat 2 tablespoons olive oil in a large sauté pan over medium heat until shimmering, then add garlic and cook 1 minute until fragrant. 4. Add kale to the pan and stir, cook ing until kale is wilted (~5 min), then stir in the lemon juice and add salt and pepp er, to taste. 5. Mix all tahini sauce ingredients in a small bowl until combined. Add additional water to thin if necessary. 6. Assemble individual bowls with brow n rice, squash, chickpeas, kale, apple slices, and chopped almonds. Drizzle tahini sauce on top, to taste.

ACG Perspectives | 35


// PERSPECTIVES

to the need for a different SIM card than the one I’d used in Mumbai. I started wondering which of the four venomous snakes of the area (common krait, banded krait, king cobra, and Russell’s viper) I would run into first. I sat down to rest and a group of people surrounded me. A man named Vinod stepped forward and said, “Sir, you seem to have a problem. Is it language?” Vinod was a local English teacher. He took me to a tea stand, bought me a cup of chai, and waited to help me onto the last bus of the evening. I was dropped off on the side of the highway and walked into the jungle with cup of chai in-hand for half a kilometer until I reached my destination—where I was welcomed with another cup of chai! In many ways, making chai is a spiritual practice. I approach the stove with intention to nourish myself so I can nourish others. I prepare the offerings for the pot. As I add to the pot, I mumble old Sanskrit verses meant to acknowledge that our food can be medicine. And as I strain the tea, there is a newness that emerges out of the ancient culture from which chai originates. Chai is a refreshing way to take the best of old with us into the new day.

JORDAN M. SHAPIRO, MD

Baylor College of Medicine, Houston, TX

Chai means “tea” in Hindi. While the term chai can refer to any tea, it most often refers to tea taken with milk and spices. Chai is the national beverage of India and is much more than a tasty, caffeinated beverage. Chai is a shared cultural experience of all of humanity throughout the Indian subcontinent. No two cups or chaiwalas (chai vendors) are the same. One has a bit more ginger. Another is sweeter. And the man on the corner uses more elaichi (cardamom). Chai may be served in glass cups, metal cups, or traditional clay cups. Despite the variations on the national beverage of India, chai brings together people of all walks of life. All are welcome. I have made homemade chai nearly daily since my first trip to India at age 19 and have countless chai memories. In the mountains, tea stands broke up long hikes and helped slow the ascent to reduce the risk of ascending too quickly. I would wake up in the mornings to the chaiwalas yelling, “Chai ready!” outside of my door. My favorite tea stand was “India’s Last Tea Shop” in Mana Village, just 20 kilometers from the Tibetan border. Years later in medical school I lived and worked for several months in a remote village in Gadchiroli, Maharashtra. I arrived at the local bus station with the sun setting and my phone rendered useless due

MASALA CHAI – MAKES 2 CUPS  Ingredients

• 1 cup water • 1 cup milk er root • 1 inch peeled fresh ging black tea leaf e • 2 tsp Red Label loos s pod m amo • 10 green card • 2 threads saffron • 4 tsp sugar

—Dr. Jordan Shapiro  We would love to hear from you if you have personal connections with GI and gastronomy. Contact ACG MAGAZINE staff at acgmag@gi.org to share your story with the ACG community. You can also tweet using #ACGfoodies to connect with the community. Wishing you all a very safe and happy holidays from our culinary connections #ACGfoodies team.

s 8. Strain and pour into cup

 Tips

1) boiling • Speed the process up by and/or 2) water with an electric kettle m milk war ly using two pots to slow er, and ging er, wat the g while preparin s of tent con the ng bini com tea, then the two pots. buffalo • Traditional chai is made with is ncy siste con al ition milk. The trad  Steps or 2% with ined atta y ilarl sim most and bring to a boil 1. Grate ginger into water chai can whole cow’s milk. However, minutes 3–5 p stee let and tea k 2. Add blac h as soy, suc ives rnat be made with alte to medium to 3. Add milk and turn heat water The . milk p hem and almond, oat, bring to a slow boil and I er high n ofte is e thes of content into powder with 4. Crush cardamom pods to 1 ratio of would recommend using 2 pot to add tle, pes and a mortar er. wat milk alternatives to and pestle, add 5. Grind saffron in a mortar t into a pot • Straining the final produc to pot es it mak lip ring pou d goo a with 6. Add sugar narrower with easier to fill travel mugs boil 7. Stir and bring to a slow openings. 36 | GI.ORG/ACGMAGAZINE

“Despite the variations on the national beverage of India, chai brings together people of all walks of life. All are welcome.”


EDUCATION

Edgar Achkar Visiting Professorship Staying connected, INSPIRING GI TRAINEES BRINGING WELL-REGARDED FACULTY TO CONNECT WITH GI FELLOWS IS THE HALLMARK OF THE EDGAR ACHKAR VISITING PROFESSORSHIP which continued to thrive despite travel restrictions during COVID-19. By necessity, the 2021 EAVP experience featured virtual visits, but nevertheless these small and tailored sessions provided a meaningful way for GI training programs to engage with distinguished educators in gastroenterology.

The benefits of the EAVP Program flow both ways, as the faculty also reported how rewarding it is to engage with fellows and share their experience. The ACG Institute is grateful to all the programs that hosted visiting professors in 2021 and recognizes with great thanks the faculty featured in this issue of ACG MAGAZINE. Dr. Brian E. Lacy visited Allegheny General Hospital; Dr. Corey Siegel visited William Beaumont Hospital; Dr. Douglas Rex visited Westchester Medical Center; and Dr. Satish Rao visited the University of Rochester.

ACG Perspectives | 37


// EDUCATION

“We really enjoyed the time that Dr. Rao was able to spend [with us virtually] going through case presentations with the fellows. The fellows were able to see a unique perspective from a master clinician within the field of neurogastreonterology and motility. We only wish we had more time together!” —Danielle E. Marino, MD, University of Rochester Medical Center

“The faculty and fellows had a real interest in colonoscopy and colorectal cancer screening. I really enjoyed the Q&A sessions and the small group interaction with the fellows. The Westchester program is an outstanding clinical program, and I was very honored to spend time with the group.” —Douglas K. Rex, MD, MACG

38 | GI.ORG/ACGMAGAZINE


"This continues to be an exceptional opportunity for training programs to request national and international experts to discuss educational topics and areas of interest that might not be available locally. This program highlights the American College of Gastroenterology’s dedication to education." —Brian E. Lacy, MD, PhD, FACG

2021

ACG EDGAR ACHKAR VISITING PROFESSORSHIPS CAROL A. BURKE, MD, FACG* Atrium Health MARCH 11, 2021 MOHAMED O. OTHMAN, MD University of Miami ON MARCH 24, 2021 SATISH S.C. RAO, MD, PHD, FACG University of Rochester Medical Center APRIL 27-28, 2021 DOUGLAS K. REX, MD, PHD, MACG Westchester Medical Center MAY 19, 2021 BRIAN E. LACY, MD, PHD, FACG Allegheny General Hospital MAY 27, 2021 COREY A. SIEGEL, MD, MS William Beaumont Hospital JUNE 2 AND JULY 20, 2021 JOHN E. PANDOLFINO, MD, MSCI, FACG Virginia Tech Carilion School of Medicine AUGUST 19-20, 2021

“[Dr. Siegel] was very illustrative with his case presentations and gave great insight regarding the other cases that were presented. We especially appreciated how he incorporated information regarding the guidelines,

ALINE CHARABATY, MD, FACG VA Caribbean Healthcare System SEPTEMBER 22, 2021 EDWARD V. LOFTUS, JR., MD, FACG* Brooke Army Medical Center OCTOBER 14, 2021 SUNANDA V. KANE, MD, MSPH, FACG at St. Luke’s University Hospital NOVEMBER 2, 2021 MILLIE D. LONG MD, MPH, FACG UT Southwestern NOVEMBER 10, 2021 CHRISTINA Y. HA, MD, FACG* University of New Mexico NOVEMBER 18, 2021 *Received funding in 2019, visit scheduled in 2020 **Received funding in 2020, visit scheduled in 2021

as well as how things are carried out in actual practice.”—Laith H. Jamil, MD, FACG

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.

ACG Perspectives | 39


Take Advantage of This ACG Member Benefit

Bringing Multidisciplinary Tertiary Care to Your Practice

GI Care Made Easy GI OnDEMAND provides access to multidisciplinary GI expertise and educational resources.

LEARN MORE About GI OnDEMAND!

giondemand.com 40 | GI.ORG/ACGMAGAZINE


Inside the

JOURNALS

G

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

VOLUME 6

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

THE RED JOURNAL ENTERS AN

IMPORTANT NEW ERA of its history as it welcomes new Co-Editors-in-Chief Dr. Jasmohan Bajaj and Dr. Millie Long with the January 2022 issue, and thanks Dr. Brian Lacy and Dr. Brennan Spiegel for their 6-year tenure at the helm of The American Journal of Gastroenterology. Read more about the vision of the new Co-EICS. Dr. Lacy and Dr. Spiegel also deserve special recognition for their role envisioning and bringing to life the AJG October Special Issue, “Changing Landscape in GI Practice” which also included new ACG Clinical Guidelines on the Management of Benign Anorectal Disorders by Wald, et al. Recent publications in Clinical and Translational Gastroenterology and ACG Case Reports Journal that received attention and spurred discussion on social media are the picks for “Inside the Journals.” Follow CTG on Twitter @ACG_CTG and follow ACG Case Reports Journal @ACGCRJ. For the Red Journal on Twitter, follow @AmJGastro.

Inside the Journals | 41


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

ACG Clinical Guidelines: Management of Benign Anorectal Disorders Wald, Arnold MD, MACG; Bharucha, Adil E. MBBS, MD; Limketkai, Berkeley MD, PhD, FACG; Malcolm, Allison MBBS, FRACP; Remes-Troche, Jose M. MD, MsC; Whitehead, William E. PhD; Zutshi, Massarat MD The American Journal of Gastroenterology: October 2021 - Volume 116 - Issue 10 - p 1987-2008 DOI: 10.14309/ajg.0000000000001507

These updated guidelines summarize the definitions, diagnostic criteria, evaluation, and management of a group of benign disorders of anorectal function and/or structure. Disorders of defecation, proctalgia syndromes, and fecal incontinence are primarily regarded as disorders of function; some patients also have structural abnormalities. The structural disorders include acute and chronic anal fissures and hemorrhoids. The guidelines consist of individual sections that cover the definitions, epidemiology and/or pathophysiology, diagnostic testing, and treatment recommendations.

 READ: bit.ly/ajg-wald-anorectal  LISTEN: bit.ly/ajg-wald-podcast

AJG Special Issue: Changing Landscape in GI Practice, October 2021 As the final issue of The American Journal of Gastroenterology published under the leadership of outgoing Co-Editors-in-Chief, Brian E. Lacy, MD, PhD, FACG and Brennan M. R. Spiegel, MD, MSHS, FACG, the October 2021 Red Journal special edition was dedicated to the changing landscape in gastroenterology. In their accompanying editorial, Dr. Lacy and Dr. Spiegel wrote: “We have witnessed striking advances in our field that are improving quality of life and prolonging survival among patients with digestive disorders. Although some of these innovations might have been envisioned when we were clinical trainees, many were nearly inconceivable at the time. These types of massive advances were an impetus for designing this special edition of The American Journal of Gastroenterology, which focuses on the changing landscape of gastroenterology and hepatology. The advent of new techniques, new therapies, and even new disorders (e.g., COVID-19–associated gastrointestinal and liver pathology) that are changing the everyday landscape of daily practice warrant dissemination to the scientific community.”

 READ: bit.ly/ACG-Oct-2021-Landscape

Origins and location of internal and external hemorrhoids.

42 | GI.ORG/ACGMAGAZINE

Welcome New AJG Co-EICs Dr. Bajaj and Dr. Long The American College of Gastroenterology announced new Co-Editors-in-Chief of The American Journal of Gastroenterology in July 2021. The team of Jasmohan S. Bajaj, MBBS, MD, MS, FACG and Millie D. Long, MD, MPH, FACG were approved by the ACG Board of Trustees thanks to their deep experience as AJG Associate Editors, their individual reputations as clinician-scientists, and their national leadership in the fields of gastroenterology and hepatology. They assume their new roles with the January 2022 issue. Together Dr. Long and Dr. Bajaj will continue AJG’s tradition of clinical and educational excellence, along with ensuring diversity, prompt decisions, and focus on prospective experiences and randomized trials across the field of gastroenterology. They will be partners in leading ACG’s flagship journal into its next era. “I believe that AJG is the premier clinical journal in the field of gastroenterology and hepatology and its strength is in its clinical relevance and applicability,” said Dr. Long. “As Co-Editors-in-Chief, Dr. Bajaj and I will continue to foster that key strength and aim to publish clinically applicable manuscripts of interest to practicing clinicians that will improve the care of patients with gastrointestinal disorders,” she added. “The overall ethos is for the Red Journal to bolster the standing it currently holds as a ‘one-stop shop’ where our clinical readership can enhance their practice and patient management skills,” Dr. Bajaj said. “The overall vision for the journal is to ensure it continues to further the mission of the College and expands its reach, ensuring inclusivity while threading the needle between novelty, innovation, and education.” The new Co-Editors-in-Chief view the clinical guidelines developed by College members as practical, important, useful, and highly relevant to patient care. Guidelines will continue to be a centerpiece of the Red Journal, along with clinically relevant manuscripts and initiatives, pertinent clinical review articles, a continuation of the “How I Approach It” series, and an enhanced focus on clinical education. Shared Leadership: An AJG Tradition Sharing editorial responsibilities has been a successful model for The American Journal of Gastroenterology since 2004 with the team of Joel E. Richter, MD, MACG and Nicholas J. Talley, MD, PhD, MACG, who, in 2010, were


succeeded by Paul Moayyedi, MB ChB, PhD, MPH, FACG and William D. Chey, MD, FACG. Most recently, since 2016, the journal has moved to new levels of excellence during the tenure of Co-Editors-in-Chief Brian E. Lacy, MD, PhD, FACG, of Mayo Clinic Jacksonville, and Brennan M. R. Spiegel, MD, MSHS, FACG, of Cedars-Sinai Health System. “Dr. Brian Lacy and Dr. Brennan Spiegel have been amazing leaders of AJG. They have published outstanding work, including leading coverage of GI complications of COVID-19, and a revitalized Red Section of the journal.

Thank You, Dr. Lacy and Dr. Spiegel, for Service to The Red Journal

The College recognizes with deep thanks the editorial leadership and vision of Dr. Brian Lacy and Dr. Brennan Spiegel who have served with distinction as Co-Editors-in-Chief of The American Journal of Gastroenterology since 2016. The individual strengths and unique perspectives they bring to the editorial board have elevated the journal and enhanced its reputation. Dr. Spiegel and Dr. Lacy are not just thoughtful leaders; they really worked well as a team. They brought to the Red Journal an innovative, inclusive, and pragmatic approach that elevated its reach and impact, engaged members of the GI academic and practice community, and enhanced its scientific quality. They did so while maintaining a highly collaborative and engaged editorial board, a testament to their

They have enhanced the digital footprint and the journal’s presence on social media. Through their leadership, the journal has reached new heights. They have also served as outstanding role models within the field of gastroenterology,” commented Dr. Long.

Endoscopic Mucosotomy and Lumen-Apposing Metal Stent Placement for the Management of a Closed Colorectal Anastomosis Sánchez-Luna, Sergio A. MD; Sobani, Zain A. MD; Rustagi, Tarun MD. ACG Case Reports Journal: July 2021 - Volume 8 - Issue 7 - p e00616 DOI:10.14309/ crj.0000000000000616

Impaired Proximal Esophageal Contractility Predicts Pharyngeal Reflux in Patients with Laryngopharyngeal Reflux Symptoms Sikavi, Daniel R. MD; Cai, Jennifer X. MD, MPH; Leung, Ryan; Carroll, Thomas L. MD, MPH; Chan, Walter W. MD, MPH Clinical and Translational Gastroenterology: October 2021 - Volume 12 - Issue 10 - p e00408 DOI:10.14309/ctg.0000000000000408

Jasmohan S. Bajaj, MBBS, MD, MS, FACG

Millie D. Long, MD, MPH, FACG

ability to organize high functioning teams and delegate effectively. Examples of the innovations they brought to the journal included a new Red Section, laser-focused on the practitioner audience, with columns such as “How I Approach It” and the patient-centered “In My Own Voice,” a renewed focus on scientificallyfocused special editions such as “The Negative Issue,” and an expanded focus on important clinical areas such as hepatology and international health. Additionally, when the world was swept up by the COVID-19 pandemic, they led the way in the GI world, publishing key articles about ground-breaking work on GI COVID.

 IN OUR COHORT OF PATIENTS WITH LARYNGOPHARYNGEAL REFLUX (LPR) symptoms who were prospectively enrolled and systematically evaluated with high-resolution manometry (HRM) and hypopharyngeal-esophageal multichannel intraluminal impedance-pH testing (HEMIIpH), we found that impaired contractility of the proximal esophagus was independently associated with increased pharyngeal reflux events. This observed risk of increased pharyngeal reflux associated with impaired proximal contractility was particularly elevated among patients without a primary esophageal motility disorder per Chicago classification on HRM. Together, our findings suggest a role for proximal esophageal contractile dysfunction in LPR which may be independent of distal esophageal motility.  READ: bit.ly/ctg-sikavi-etal

Measurement of the PCI on highresolution manometry Brian E. Lacy, MD, PhD, FACG

[ACG CASE REPORTS JOURNAL]

[CLINICAL & TRANSLATIONAL GASTROENTEROLOGY]

 BARIUM ENEMA SHOWED complete obstruction of the colonic anastomosis. Sigmoidoscopy revealed a scar at the site of anastomosis (5 cm from the anal verge), suggesting a complete obstruction of the anastomosis with overlying epithelialization. Endoscopic mucosotomy was performed with puncturing of the overlying mucosa using an injection needle, followed by endoincision using a needle knife. An ultrathin endoscope was passed

Brennan M. R. Spiegel, MD, MSHS, FACG

through the mucosotomy with visualization and confirmation of the upstream colonic lumen. A 20 × 10 mm lumen-apposing metal stent (LAMS; Boston Scientific, Marlborough, MA) was then placed across the anastomotic stricture to reestablish the luminal continuity and effectively dilate the stricture to 20 mm (image right). Read the Case: bit.ly/acgcrj-sanchez-luna

Lumen-apposing metal stent was placed across the anastomotic stricture.

Inside the Journals | 43


// INSIDE THE JOURNALS

SUBMIT YOUR APPLICATION for the ACG

2022 International GI Training Grant Awards The International Relations Commi ee of the American College of Gastroenterology is now accepting applications for the 2022 International GI Training Grants. Each training grant will award one fellowship, with a maximum of $10,000, during 2022. Grants are to be used for travel to and from the training center and to the ACG Annual Meeting, as well as for incidental expenses related to the training. The training must take place between July 1, 2023, and June 30, 2023.

INTERNATIONAL

GI TRAINING GRANT

This grant provides partial financial support to physicians outside the United States and Canada to receive clinical or clinical research training or education in Gastroenterology and Hepatology in selected medical training centers in North America. WHO IS ELIGIBLE? Physicians who are not citizens or residents of the United States or Canada, and who are working in gastroenterology or related areas, are eligible to apply together with their training institution.

SUBMISSION DEADLINE March 31, 2022 APPLY HERE gi.org/gi-training-grants

NORTH AMERICAN INTERNATIONAL

GI TRAINING GRANT

This grant provides partial financial support to United States and Canadian GI Fellows in training, or GI Physicians who have completed their training within the last five years, to receive clinical or clinical research training or education in Gastroenterology and Hepatology outside of North America. WHO IS ELIGIBLE? GI Fellows in training who are enrolled in an accredited gastroenterology fellowship program, or GI Physicians who completed their training within the last five years, and are citizens of the United States or Canada, are eligible to apply together with their training institution. 44 | GI.ORG/ACGMAGAZINE

SUBMISSION DEADLINE March 31, 2022 APPLY HERE gi.org/gi-training-grants


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

Endoscopic Ultrasound

I

n January 1997, Dr. Scott Tenner, Dr. Peter Banks, Dr. Maurits Wiersema, and Dr. Jacques Van Dam of Brigham and Women’s Hospital in Boston reviewed the published experience with the then novel technology of endoscopic ultrasound in the pages of The American Journal of Gastroenterology (1). Medical use of ultrasound for diagnostic purposes dates back to 1942 when Karl Dussik, a neurologist at the University of Vienna, attempted to locate brain tumors and the cerebral ventricles with a primitive ultrasound probe (2). Further development occurred in the next two decades, pioneered by Dr. John Julian Wild then working in Minnesota (3). By the mid-1970s, technological advances permitted use of ultrasound imaging in obstetrics, cardiology, and gastroenterology, where it became the standard way to image the gallbladder and its contents.

Whereas transabdominal ultrasound imaging remains the method of choice for visualizing the gallbladder to this day, imaging of the pancreas with transabdominal ultrasound has remained challenging because of the depth of the pancreas within the body and overlying bowel gas. Resolution of ultrasound images depends on the frequency of the sound waves generated by the probe, and the depth of penetration is inversely related to frequency; to make better images, higher frequency, shorter wavelengths must be used closer to the target organ. Endoscopy provided a straightforward way to position the ultrasound transducer within the gastrointestinal tract adjacent to the pancreas. Technological advances led to miniaturized transducers and improved image reconstruction, and they permitted clinical use of what came to be known as endoscopic ultrasound (EUS). Prototypes of EUS scopes

were described in the early 1980s (4), and commercial EUS scopes were available by the early 1990s (5). The review by Tenner, et al. (1) highlighted the emerging use of EUS for the management of many pancreatic disorders in the 1990s. It focused on diagnosis, and EUS still is used for most of these problems to delineate and evaluate pancreatic diseases. Description of therapeutic uses was limited to EUS-guided celiac plexus neurolysis. Nowadays, EUS has become central to the management of pancreatic disorders, including cysts, tumors, and complications of acute and chronic pancreatitis. One can only marvel how EUS has impacted the therapy of pancreatic diseases in the last 25 years, providing safe and effective management alternatives to surgical interventions (6).

References: 1. Tenner SM, Banks PA, Wiersema MJ, Van Dam J. Evaluation of pancreatic disease by endoscopic ultrasonography. Am J Gastroenterol. 1997 Jan;92(1):18-26. 2. Dussik KT. On the possibility of using ultrasound waves as a diagnostic aid. Z Neurol Psychiatr 1942;174:153–68. 3. Shampo MA, Kyle RA. John Julian Wild — pioneer in ultrasonography. Mayo Clin Proc 1997;72:234. 4. DiMagno EP, Buxton JL, Regan PT, Hattery RR, Wilson DA, Suarez JR, Green PS. Ultrasonic endoscope. Lancet. 1980 Mar 22;1(8169):629-31. 5. Gilbert DA, DiMarino AJ, Jensen DM, Katon RM, Kimmey MB, Laine LA, MacFadyen BV, Michaletz PA, Zuckerman G. Status evaluation: endoscopic ultrasonography. American Society for Gastroenterology Endoscopy. Technology Assessment Committee. Gastrointest Endosc. 1992 Nov-Dec;38(6):747-9. 6. Dietrich CF, Braden B, Jenssen C. Interventional endoscopic ultrasound. Curr Opin Gastroenterol. 2021 Sep 1;37(5):449-461.

L-R: Scott M. Tenner, MD, MS, MPH, JD, FACG; Peter A. Banks, MD, MACG; Maurits J. Wiersema, MD, FACG; Jacques Van Dam, MD, PhD, FACG

Inside the Journals | 45


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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.

For additional information, please call 1-800-874-6756 ©2021 Braintree Laboratories, Inc.

All rights reserved.

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


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