ACG Magazine | Vol. 6, No. 2 | Summer 2022

ACG MAGAZINE Summer 2022

MEMBERS. MEDICINE. MEANING.

Speaking Out:

Inclusion and Challenges for LGBTQ+

in Gastroenterology

REGISTRATION IS OPEN! 

REGISTER ONLINE: ACGMEETINGS.GI.ORG

THE AMERICAN COLLEGE OF GASTROENTEROLOGY

SUMMER 2022 // VOLUME 6, NUMBER 2

FEATURED CONTENTS

Getting It Right

COVER STORY

Speaking Out: Inclusion & Challenges for LGBTQ+ in Gastroenterology GI faculty and fellows share their experiences as LGBTQ+ physicians and ways the GI community can create a culture of acceptance and support for patients and colleagues

How to respond to a legal summons in a professional, timely manner PAGE 21

ACG Perspectives Dr. Lauren Nephew on barriers to care in liver disease and professional barriers in transplant hepatology PAGE 39

PAGE 24

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Attend an upcoming

ACG POSTGRADUATE COURSE 2022

ACG Weekly Virtual Grand Rounds REGISTER NOW: GI.ORG/ACGVGR

ACG’s IBD School & Midwest Regional Postgraduate Course

Plus now offering VGRs TWICE each Thursday, with a live broadcast at noon (ET) followed by an 8:00pm (ET) rebroadcast!

 JW Marriott | Indianapolis, IN  August 26–28, 2022

ACG’s IBD School & ACG/ VGS/ODSGNA Regional Postgraduate Course  Williamsburg Lodge | Williamsburg, VA  September 9–11, 2022

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

ACG’s Endoscopy School & Southern Regional Postgraduate Course  Grand Hyatt | Nashville, TN  December 2–4, 2022

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

SUMMER 2022 // VOLUME 6, NUMBER 2

CONTENTS

“One thing that has stuck with me over the years is that ‘ally’ is a verb and that being an ally means being willing to act with and for others in pursuit of ending oppression and creating equality.”

—Dr. Lukejohn Day, "Speaking Out: Inclusion and Challenges for LGBTQ+ in Gastroenterology,” PG 24

6 // MESSAGE FROM THE PRESIDENT ACG President Dr. Samir Shah on ACG's role in GI advocacy and advancement

7 // NOVEL & NOTEWORTHY March CRC Month activities, recognizing young GI physician leaders, helpful GI reading & more

17 // PUBLIC POLICY A DAY OF LEGISLATIVE ADVOCACY ACG leaders collaborate with the GI community and members of Congress to advance ACG's public policy priorities

21 // GETTING IT RIGHT PROFESSIONALISM How to respond to a legal summons

24 // COVER STORY

45 // EDUCATION

SPEAKING OUT: INCLUSION & CHALLENGES FOR LGBTQ+ IN GASTROENTEROLOGY GI faculty and fellows share their experiences as LGBTQ+ physicians and how you can be an ally for colleagues and patients

45 EDGAR ACHKAR VISITING PROFESSORSHIP Introducing the new EAVP Visiting Scholar in Equity, Diversity & Ethical Care

33 // ACG PERSPECTIVES 33 CULINARY CONNECTIONS Inspired recipes using fresh, local produce 37 ACG PERSPECTIVES Dr. Justin Brandler empathizes with GI patients by undertaking common at-home GI recommendations 39 CONVERSATIONS WITH WOMEN IN GI Dr. Jill Gaidos interviews Dr. Lauren Nephew on identifying barriers for patients and providers

48 INTERNATIONAL TRAINING GRANT Dr. Giselle Mahoro reflects on her international training in Rwanda

49 // INSIDE THE JOURNALS 50 AJG ACG-CAG Clinical Guidelines on Management of Anticoagulants and Antiplatelets During Acute GI Bleeding by Abraham, et al. & ACG Clinical Guideline on the Diagnosis and Management of Barrett's Esophagus by Shaheen, et al.

51 CTG 5Ms of Geriatrics in Gastroenterology: The Path to Creating Age-Friendly Care for Older Adults with IBD and Cirrhosis by Kochar, et al.

51 ACGCRJ Learning From Highly Effective Teams: What Can We Apply to the GI Endoscopy Unit Team? by Dr. Nicholas McDonald

Cover story illustrations by Davide Bonazzi; Featured Contents photo (see page 1) by Irving M. Pike, MD, FACG

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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

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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

4 | GI.ORG/ACGMAGAZINE

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

Justin G. Brandler, MD Dr. Brandler is a third-year GI fellow at University of Michigan Medicine.

Rebecca A. Burbridge, MD Dr. Burbridge is Associate Professor of Medicine, Director of Advanced Endoscopy, and Director of Advanced Endoscopy Fellowship at Duke University Medical Center.

Lukejohn W. Day, MD, FACG Dr. Day is Professor of Medicine at the University of California, San Francisco, and Chief Medical Officer at Zuckerberg San Francisco General Hospital.

Nikki Duong, MD Dr. Duong is a second-year fellow in GI and hepatology at Virginia Commonwealth University and is a member of the ACG Training Committee.

Andrew D. Feld, MD, JD, FACG Dr. Feld is at Kaiser Permanente Washington and a Clinical Professor of Medicine at the University of Washington. He is a member of the ACG Professionalism Committee.

Aayush Gabrani, MD, FAAP Dr. Gabrani is a pediatric GI fellow at University of Texas Southwestern Medical Center in Dallas, TX.

Giselle Mahoro, MD Dr. Mahoro is a gastroenterology fellow at Thomas Jefferson University Hospital in Philadelphia, PA.

Jill K. J. Gaidos, MD, FACG Dr. Gaidos is Associate Professor at Yale School of Medicine Section of Digestive Diseases and Director of Clinical Research for the Yale IBD Program.

Lauren D. Nephew, MD, MAE, MSc Dr. Nephew is Assistant Professor of Medicine in the Division of Gastroenterology and Hepatology at Indiana University School of Medicine.

James D. Haddad, MD, FACP Dr. Haddad is a GI fellow at University of Texas Southwestern Medical Center.

He is a U.S. Navy veteran and recipient of the Melvin Museles & CAPT Coleen Counihan teaching awards, as well as the 2019-2020 ACP Sparks Award.

Victoria A. Jaeger, DO Dr. Jaeger is a second-year GI fellow at Baylor Scott & White Health in Temple, TX.

Parastoo Jangouk, MD Dr. Jangouk is a gastroenterologist and certified trauma-informed wellness coach who practices at Austin Gastroenterology in Austin, TX.

Kira L. Newman, MD, PhD Dr. Newman is a second-year GI fellow at University of Michigan Medicine.

Sonali Paul, MD, MS Dr. Paul is Assistant Professor of Medicine at The University of Chicago Medicine and serves as an Associate Editor for ACG’s Evidence-Based GI publication.

Irving M. Pike, MD, FACG Dr. Pike is an ACG Past President (2017-2018) and, prior to his retirement in 2021, served as Senior Vice President and Chief Medical Officer at John Muir Health in Walnut Creek, CA.

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.

Douglas A. Simonetto, MD Dr. Simonetto is Program Director of Gastroenterology and Hepatology Fellowship and Associate Professor of Medicine at the Mayo Clinic College of Medicine in Rochester, MN.

Joseph Sleiman, MD Dr. Sleiman is a PGY-4 GI fellow at University of Pittsburgh Medical Center and currently serves as social media editor for ACG’s Evidence-Based GI publication.

Shifa Umar, MD Dr. Umar is Editor of ACG MAGAZINE’s Trainee Hub section and an Advanced Endoscopy fellow at the University of Chicago. Dr. Umar is also member of the ACG Digital Communications & Publications Committee, the ACG Diversity, Equity & Inclusion Committee and is one of the ACG Institute’s Young Physician Leadership Scholars.

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MESSAGE FROM THE PRESIDEN

BEING AT THE TABLE (AND NOT ON THE MENU) DEAR COLLEAGUES: The beginning of April was a busy month for the College with 112 ACG members (104 in person) from 45 states, including 56 Governors (51 in person), 31 Young Physician Leadership Scholars Program (YPLSP) participants and many members of the Board of Trustees gathering in Washington, DC, to represent our profession on important issues facing our membership. Advocacy has been an essential priority for ACG over many decades. I remember being inspired when I first served as a Governor, almost 20 years ago, that I was able to meet with my Senator and discuss the importance of colonoscopy in preventing colon cancer. With all the challenges facing the practice of clinical gastroenterology, advocacy is more critical now than it has ever been.

This year, the Governors/YPLSP focused on the barriers to care that Step Therapy and prior authorizations impose on patients and providers. (See page 20 for an infographic on key challenges.) In addition to discussing local state issues, they reminded Congress about the challenges of providing medical care during the pandemic and increased cost of delivering care while facing staffing shortages and cuts from Medicare — a prescription for disaster for both patients and providers. We were also able to thank many legislators who cosponsored the Removing Barriers to Colorectal Cancer Screening Act which finally passed just over a year ago and was signed into law.

I am so grateful to all the Governors, led by Dr. Patrick Young and Dr. Dayna Early, who took time out from their regular jobs and families to be in DC. There were 197 meetings with congressional leaders and/or staff during the course of the day.

Our seasoned ACG Governors were joined by the ACG Institute’s YPLSP cohort, which helped them see the importance and value of advocacy as part of their leadership training. My thanks to the YPLSP course directors, Dr. Allon Kahn and Dr. Elizabeth Paine (both alumni of YPLSP) who did a fantastic job with these rising stars in our profession from both private practice and academic backgrounds. The first ACG Institute Advanced Leadership Development Program had its launch under the leadership of ACG Institute Director, Dr. Neena Abraham, Past ACG Presidents Dr. Mark Pochapin and Dr. Sunanda Kane, and ACG member (and force behind creating the YPLSP) Dr. David Hass.

Let me also thank Dr. Young and Dr. Hass for pacing me for an inspiring run at 5:15 am in the rain from the hotel along the National Mall to the Lincoln Memorial and back! All kidding aside, I wouldn’t have made it without them. Furthermore, no matter how many times I see the Washington Monument, Lincoln Memorial, White

6 | GI.ORG/ACGMAGAZINE

“We need all our ACG members to be part of the solution.

Be a part of our democracy — it’s our civic duty to engage actively in the process and make sure that our values are represented at the highest levels.”

House, the U.S. Capitol Building, or any part of the National Mall, a sense of awe and gratefulness to be an American fills my heart.

In addition, a delegation of ACG leaders met with the Director of CMS, Dr. Meena Seshamani, and her team to discuss challenges facing our patients/ profession and offer our perspective in improving care, including health equity for all Americans, focusing on improving access to colonoscopy in underserved and minority communities. We proudly outlined our quality initiatives through GIQuIC and improving multidisciplinary care through GI OnDEMAND. We plan to continue these conversations with CMS for the benefit of the patients we serve to deliver high quality, high value care.

A highlight for all of us was hearing directly from congressional leaders, including some members of the GOP Doctors Caucus. These are members of Congress who are health care professionals and who understand the issues we face since they have faced those same issues themselves. Read more about their comments on page 17.

Legislative and Public Policy Council Chair Dr. Louis Wilson was able to attend a breakfast with the GOP Doctors Caucus and further develop working relationships with this important group of legislators.

I am grateful for his energy and vision in growing our connections with physician leaders in Congress. Dr. Wilson is calling on you to join the ACG National Affairs Action Network (NAAN). If you currently have a personal or working relationship with state/ federal policymakers, or are interested in advocating for our patients and profession, then the NAAN is the right group for you.

Sign-up via bit.ly/ACG-NAAN-Signup.

Many challenges remain. We need all our ACG members to be part of the solution.

Be a part of our democracy — it’s our civic duty to engage actively in the process and make sure that our values are represented at the highest levels. To use a sports analogy, advocacy is a team sport and every member’s participation is critical to success: Keep us off the menu and at the table!

­­—Samir A. Shah, MD, FACG

Note hy wor t HIGHLIGHTS OF A BUSY MARCH Colorectal Cancer Awareness Month include concerts, challenges to get physically active, and new patient educational materials. ACG Virtual Grand Rounds included a patient voice when CRC survivor and cancer educator Allison Rosen presented in March.

The ACG Institute will invest a record-setting $2.2 million to fund the 2022 Clinical Research Awards, including two of the new Health Equity Research Awards. The highly selective North American Conference of GI Fellows (NACGF) convened 24 fellows-in-training for a weekend of skills building, networking, and education. Three fellows received Distinguished Achievement Awards.

The N&N Book Review is by Jill K.J. Gaidos, MD, FACG, of “Curbside Consultation in IBD: 49 Clinical Questions, Third Edition 2021,” edited by David T. Rubin, MD, FACG; Sonia Friedman, MD, FACG; and Francis A. Farraye, MD, MSc, MACG.

Novel & Noteworthy | 7

N&N GI EYE: ARTWORK FROM ACG MEMBERS

YOSEMITE VIEWS About the Photos The second week of February 2022 provided special photo opportunities in Yosemite National Park. This year the amazing lighting effect known as Fire Fall occurring at Horsetail Falls along with a full moon created quite a show. My wife and I took full advantage of this unique time and witnessed both events, among the many other amazing sites in the park during the winter.

“Moonrise Over Cloud Rest” My favorite experience was the calm and peace watching the moonrise from the area of Tunnel View looking into Yosemite Valley below. While photographing and after, I spent time just being in this peaceful and beautiful moment. The photograph Moonrise Over Cloud Rest now takes me back to that moment each time I view it.

“Fire Fall (Horsetail Fall)” [see page 1] Fire Fall is the name that has been given to Horsetail Fall during the last two weeks of February when the setting sun shines on a heart-shaped section of El Capitan for just a few minutes to create an awesome phenomenon. The light reflects off the wall through the water in a manner that makes it appear on fire. One can imagine that the first humans who inhabited Yosemite Valley must have seen this phenomenon as a supernatural event.

Technical Aspects Moonrise Over Cloud Rest was taken with a Canon 5D Mark II digital camera. The lens used was a 70-300 Canon Zoom lens set at 135mm, ISO 100, 1/40 sec exposure with f14 setting. A Bogen tripod with a ball head was used. The composition captures the moonrise over Cloud Rest Peak between El Capitan on the left-hand side of the photo and the iconic Half Dome on the right. For Fire Fall (Horsetail Fall) I used the same camera and lens with the lens at 200mm, ISO 100, 5 sec exposure at f11.

Photography as a Hobby My interest in photography was stimulated by my mentor Dr. Gunter Krejs. Dr. Krejs 8 | GI.ORG/ACGMAGAZINE

assigned me to research endoscopic photography for a presentation at the weekly Thursday morning Dallas citywide GI conference during my first year of GI fellowship at UTSW. This was a pre-video endoscopy period and image capture was by attaching either a Polaroid Instamatic Camera or a 35mm camera with an adapter that fit over the eyepiece of the endoscope

which allowed the endoscopist to view the finding of interest and take a picture or slide photograph for documentation in the medical record or for teaching purposes.

I had no education and limited knowledge of photography at the time. Post-training, I found that what I learned during research of my presentation allowed me to overcome a then-existing frustration

of not being able to draw or paint using a perspective of depth, shading, and other aspects of creating an image of interest.

Since then, I have discovered through photography that with good composition and attention to light and shadows, I am able to capture a moment in time that provides, for me, a memory of a day spent relaxing and enjoying

nature. The moment reoccurs each time I view the photograph.

For others it may stimulate other pleasant thoughts. A photo, like a good painting, should draw the viewer into the photo and into the moment. As a lover of nature and wildlife, and an avid fly fisher, the camera is a good tool for me to carry with me during leisure activities.

Irving M. Pike, MD, FACG

Dr. Pike is an ACG Past President (2017-2018) and, prior to his retirement in 2021, served as Senior Vice President and Chief Medical Officer at John Muir Health in Walnut Creek, CA.

Novel & Noteworthy | 9

// N&N

[CRC MONTH HIGHLIGHTS]

RIDE OR STRIDE FOR 45 VIRTUAL CHALLENGE

45 IS THE NEW 50 “45 is the New 50” was ACG’s key theme for 2022 Colorectal Cancer Awareness Month. A new set of educational materials and social media banners were created and shared with the ACG membership and featured prominently the College’s messaging for patients and the public.

In this virtual challenge, the entire GI community was invited to bike, hike, run, walk, or row 45 miles in March (or 45 minutes per day during the month) to show support and enthusiasm for preventing colorectal cancer, beginning at age 45 for all average risk adults.

A highlight was a Peloton group ride on March 12th in which dedicated fans had an intense workout with instructor Alex Toussaint, who shared his personal family history of colorectal cancer and gave ACG a shout out during the ride. Dr. Andrew Moon of UNC Chapel Hill was at the top of the leaderboard after 45 grueling minutes. Well done!

 DOWNLOAD AND SHARE: bit.ly/ACG-CRC-Toolkit

DRESS IN BLUE DAY [PATIENT VOICE]

ALLISON ROSEN FOR ACG VIRTUAL GRAND ROUNDS Stage II colorectal cancer survivor, patient advocate, and cancer educator Allison Rosen presented an outstanding ACG Virtual Grand Rounds on March 17th. Ms. Rosen is currently Director of Project ECHO at the American Cancer Society and previously worked at Dan Duncan Comprehensive Cancer Center at Baylor College of Medicine. In her talk, “The CRC Patient Journey: What GI Clinicians Need to Know Now,” Ms. Rosen shared her personal story and emphasized the challenges of early age onset CRC and the importance of considering all signs or symptoms, regardless of the patient’s age. In a candid and thoughtful presentation, she discussed shared decision making and empathy as a best practice.

A recording is available of the session, which was moderated by Aasma Shaukat, MD, MPH, FACG.

ACG celebrated “Dress in Blue Day” on Friday, March 4th. This national awareness day is an opportunity for the entire GI community to put the spotlight on colorectal cancer prevention. The College used social media and email to share photos from ACG members, amplify their messages, and applaud all the creative ways they are “true blue” for CRC screening.

 WATCH: bit.ly/acg-rosen-virtual-grand-rounds

[BRIDGING MEDICINE AND MUSIC]

ACG Governor for Northern California, Ronald Hsu, MD, FACG, organized a virtual Colon Cancer Prevention Seminar and Concert, “Bridging Medicine & Music” on February 19, 2022. Dr. Hsu invited many physician experts to present at an educational roundtable discussion on colorectal cancer, and for the second part of the program Dr. Hsu was a guest violinist with the Davis Senior High School Baroque Ensemble for a performance that included music by Vivaldi, Marai, Purcell, and Pachelbel, among others.

10 | GI.ORG/ACGMAGAZINE

[PIPELINE]

CONCERT The College is deeply grateful to all the artists who contributed performances to “Tune It Up: A Concert to Raise Colorectal Cancer Awareness” for their support. Artists Hilary Hahn, Rufus Wainwright, Ben Folds, Tim Reynolds, and Aoife O’Donovan headlined a musical program that included rock singer/ songwriter Ben Kweller and operatic baritone Will Liverman, along with a performance by The Knights with violinist Gil Shaham in a special program! So many artists from an incredible array of musical genres donated their time and performances to support colorectal cancer awareness, including the Cincinnati Pops Orchestra and the Toronto Symphony Orchestra.

For the second year, Dr. Benjamin Levy (top) of the ACG Public Relations Committee invited musical guests for this virtual event that brought together the ACG community to focus attention on colorectal cancer screening.

ACG’s goal was to tap the connection and energy that music creates to shine a light on the importance of colorectal cancer prevention!  LISTEN TO THE RECORDING: gi.org/concert

A NEW SCHOLARSHIP of $1,000 for education expenses is now part of ACG’s “Prescription for Success” outreach program to cultivate interest in careers in medicine and science among high school students. Each year since 1999, members of the ACG Committee on Diversity, Equity & Inclusion visit a local high school in the city hosting the College’s Annual Scientific Meeting. The award went to three juniors from Rancho High School in Las Vegas, NV. [Left to Right] Miah Solis, Olivia Fenkell, and Marc Natali are part of the Rancho PreMedical Academy magnet program.

[MUST READ]

[SCRUBS & HEELS]

THOMAS J. MCGARRITY, MD, FACG, published an elegantly written personal reflection in The New England Journal of Medicine which described his piece, “Roulette,” thus: “While facing an ophthalmic cancer diagnosis and treatment of his own, a gastroenterologist refocuses his good eye on his patients, helping them play whatever cards they have been dealt, as his scar is etched in survivor’s guilt.” Dr. McGarrity was ACG’s Governor for Western Pennsylvania from 2000 to 2007 and served on the ACG Credentials Committee and Educational Affairs Committee. Highly recommended reading: McGarrity, TJ. Roulette. N Engl J Med 2022; 386:505-507 DOI: 10.1056/ NEJMp2112743

ALINE CHARABATY, MD, FACG, the College’s Governor for DC, and her collaborator and co-founder Anita Afzali, MD, MPH, FACG, Vice Chair of ACG Educational Affairs Committee, together envisioned and launched an independent new summit for women in gastroenterology, Scrubs & Heels.

The two inspiring leaders convened a weekend program in Miami in March that covered topics such as negotiations skills, professional branding, organization building and management, effective networking, executive and financial coaching, as well as a presentation by ACG President Samir A. Shah, MD, FACG, on ways men can be effective allies to women gastroenterologists. Their goal for the summit was to provide women gastroenterologists with a strong network of women empowering women. scrubsandheels.com

 READ: bit.ly/NEJM-McGarrity

[NEW JOB]

ANITA AFZALI, MD, MPH, FACG, is taking on a new role at the University of Cincinnati College of Medicine as Executive Vice Chair of Internal Medicine & Associate Chief Medical Officer of UC Health. She was previously Professor of Medicine at The Ohio State University Wexner Medical Center where she held the Abercrombie & Fitch Endowed Chair in IBD and served as Medical Director of The OSU IBD Center.

Dr. Afzali and Dr. Charabaty at their Scrubs & Heels Summit

Novel & Noteworthy | 11

// N&N

[RESEARCH FUNDING]

[LEADERSHIP]

FOR 2022, THE ACG INSTITUTE FOR CLINICAL RESEARCH

YOUNG PHYSICIAN LEADERSHIP SCHOLARS

and Education made a record-setting investment of over $2.2 million for clinical research and career development in gastroenterology and hepatology.

This year, the ACG Institute will support four Junior Faculty Development Grants, a three-year award of $450,000 that recognizes and supports junior faculty members of outstanding promise to establish an independent, productive career in gastroenterology or hepatology.

Sarah Lieber, MD, MSCR, University of Texas Southwestern

The ACG Institute’s 2021-2022 cohort of Young Physician Leadership Scholars gathered in Washington, DC, on April 7th to participate in ACG Advocacy Day on Capitol Hill with the ACG Board of Governors and on April 8th had a full day of inspiring leadership training. This program is directed by Allon Kahn, MD, and Elizabeth R. Paine, MD, FACG, both YPSLP alumni, and offers the group meaningful connections while focusing on building aptitude in executive decision-making, critical thinking, and understanding organizational behavior.

Nikhilesh Mazumder, MD, MPH, University of Michigan

ADVANCED LEADERSHIP DEVELOPMENT PROGRAM

Emily Lopes, MD, Massachusetts General Hospital

Amelie Therrien, MD, MSc, Beth Israel Deaconess Medical Center

Two new $50,000 Health Equity Research Awards (HERA) were granted to Maya Balakrishnan, MD, MPH, (below left) of Baylor College of Medicine and Rachel Issaka, MD, MAS, (below right) of Fred Hutchinson Cancer Research Center.

The HERA award was introduced under the auspices of the new ACG Center for Leadership, Ethics & Equity.

The ACG/ASGE Epidemiologic Research Award in Gastrointestinal Endoscopy, which invests up to $50,000 in research projects involving the use and outcomes of gastrointestinal (GI) endoscopy using the GI Quality Improvement Consortium (GIQuIC), went to Seth Crockett, MD, MPH, of the University of North Carolina at Chapel Hill.

LEARN ABOUT all the 2022 ACG Research Awardees including GI fellows, medical residents, and medical student winners. gi.org/research-grant-recipients

12 | GI.ORG/ACGMAGAZINE

Also joining in the Advocacy Day legislative visits were members of the ACG Institute Advanced Leadership Development Program. This new offering provides mid-career physicians (10 to 20 years post-fellowship) with an opportunity to further develop comprehensive leadership skills. The program includes advocacy training, online and in-person learning, as well as one-on-one mentoring.

Mark B. Pochapin, MD, FACG; David J. Hass, MD, FACG; and Sunanda V. Kane, MD, MSPH, FACG, direct this visionary new program.

[KUDOS]

CONGRATULATIONS TO THE 2022 NORTH AMERICAN CONFERENCE OF GI FELLOWS (NACGF) Distinguished Achievement Awardees, Rahul Dalal, MD; Kira Newman, MD, PhD; and Christina Wang, MD. Twenty-four fellows presented at the conference in March and were scored by the faculty on their presentation skills, including confidence while presenting, clear and concise slides, and ample time allowance for Q&A from the audience. The winning presenters received a $1,000 travel stipend to attend ACG 2022 in Charlotte, NC. ACG has sponsored NACGF since 1990. The strengths of this conference include its small size, and the opportunity for GI fellows to present their research to colleagues in a less pressured environment than at L to R: Dr. Rahul Dalal; Dr. Kira Newman & national meetings, while also receiving coaching on Dr. Christina Wang presentation skills from experienced faculty.

BOOK REVIEW

CURBSIDE CONSULTATION IN IBD: 49 CLINICAL QUESTIONS, THIRD EDITION 2021, SLACK BOOKS David T. Rubin, MD, FACG; Sonia Friedman, MD, FACG; Francis A. Farraye, MD, MSc, MACG Reviewed by Jill K. J. Gaidos, MD, FACG Curbside Consultation in IBD, edited by Dr. David T. Rubin, Dr. Sonia Friedman, and Dr. Francis A. Farraye, provides detailed, yet succinct, evidence-based answers to 49 of the most pertinent clinical questions regarding the management of patients with IBD. Each chapter focuses on one clinical question with follow-up questions spanning the range of IBD care from assessing prognosis in Crohn’s disease; an overview of medical treatments, including alternative therapies; prevention and management of infections and malignancy; as well as pre- and postoperative management.

In each chapter, written by different content experts, the authors summarize the currently available evidence to answer each clinical question thoroughly. In addition, each chapter includes important graphics, such as treatment algorithms or summaries of the data in table format for quick and easy review.

One of the highlights of this book for me was the inclusion of chapters on managing some of the more challenging aspects of IBD care. For example, there are chapters covering the management of IBD in special populations, such as patients with concomitant primary sclerosing cholangitis during pregnancy and elderly patients, as well as the management of pouchitis, chronic pain, and mental health evaluation.

This book is an amalgamation of years of research and expert experience providing an excellent overview and guide for the management of IBD. It is a great read to jump start an Advanced IBD Fellowship year or for anyone caring for IBD patients who wants to stay current with IBD management.

JUNE 20 ACG 2022 CALL FOR ABSTRACTS SUBMISSIONS DUE Submit Now: conferenceabstracts.com/acg2022.html

AUGUST

26–28 2022 IBD SCHOOL & MIDWEST REGIONAL POSTGRADUATE COURSE  Indianapolis, IN Register: meetings.gi.org

SEPTEMBER

9–11

2022 HEPATOLOGY SCHOOL AT ACG / VGS / ODSGNA REGIONAL POSTGRADUATE COURSE  Williamsburg, VA

Register: meetings.gi.org

 acgmeetings.gi.org/registration

ACG CALENDAR | 13

ACG PRACTICE MANAGEMENT

Toolbox

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Billing & Coding FORUM

ACG’S

ACG members and GI practices continue to face mounting financial and reimbursement pressures. Complex coding and documentation requirements only add to these burdens. The ACG Practice Management Committee is pleased to announce the new member benefit: professional coding and documentation assistance for ACG members, tailored to your individual practice’s questions and needs.

HAVE A QUESTION? Email coding@gi.org

Arlene Morrow, CPC, CMM, CMSCS, is now available to answer your questions!

ACG members will receive an answer and guidance within a few business days.

Start Building Success Today gi.org/practice-management

14 | GI.ORG/ACGMAGAZINE

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 | 15

!

W! E NEW N

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

• NO SODIUM PHOSPHATE1

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

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

Each dose is followed by actual two additional 16 oz of water

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

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

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

considered severe * Success was primary endpoint and was defined in noninferiority trials as an overall cleaning assessment of 3 (good) or 4 (excellent) by the blinded endoscopist; scores were assigned on withdrawal of colonoscope.

OF PATIENTS IN ONE PIVOTAL TRIAL WOULD REQUEST SUTAB AGAIN FOR A FUTURE COLONOSCOPY2† † Patients completed preference questionnaire following completion of study drug to capture the subject’s perceptions of the preparation experience. This * questionnaire has not undergone formal validation.

Success was primary endpoint and was defined in noninferiority trials as an overall cleaning assessment of 3 (good) or 4 (excellent) by the blinded endoscopist; ‡ scores were assigned on withdrawal of colonoscope.

Patients were queried for selected gastrointestinal adverse reactions of upper abdominal pain, abdominal distension, nausea, and vomiting following completion †of study drug, rating the intensity as mild, moderate, or severe.

Patients completed preference questionnaire following completion of study drug to capture the subject’s perceptions of the preparation experience. This questionnaire has not undergone formal validation.

ACG=American College of Gastroenterology ‡ ® Patients were queried for selected gastrointestinal adverse reactions of upper abdominal pain, abdominal distension, nausea, and vomiting following completion is a registered trademark of Velinor AG. MoviPrep of study drug, rating the intensity as mild, moderate, or severe.

ACG=American College of Gastroenterology MoviPrep® is a registered trademark of Velinor AG. IMPORTANT SAFETY INFORMATION 2‡

78%

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

INTERACTIONS: Drugs that increase risk of fluid and electrolyte imbalance.

Please see Brief Summary of Prescribing Information on reverse side. See Full Prescribing Information and Medication Guide at SUTAB.com.

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

THE #1 MOST PRESCRIBED, BRANDED BOWEL PREP KIT4

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

THE #1 MOST PRESCRIBED, BRANDED BOWEL PREP KIT4

PUBLIC POLICY 2022 ACG Advocacy Day Patrick E. Young, MD, FACG, Chair, ACG Board of Governors and Dayna S. Early, MD, FACG, Vice Chair

B:11.25"B:11.25"

S:9.75" S:9.75"

T:10.75"T:10.75"

A DAY OF LEGISLATIVE ADVOCACY TO ADVANCE ACG'S PUBLIC POLICY PRIORITIES On April 7, 2022, the Board of Governors, Young Physician Leadership Scholars, and members of the Advanced Leadership Development Program joined together to participate in 2022 ACG Advocacy Day in Washington, DC. The critical focus of ACG Advocacy Day was sharing stories and insights with legislators and their staffs to help advance care for gastroenterology patients while educating congressional leaders on the issues that matter in clinical GI practice, particularly step therapy reform, access to quality care for Medicare beneficiaries, and the burdensome challenges of prior authorization.

Public Policy | 17

// PUBLIC POLICY

In a morning briefing, the group heard from a number of congressional leaders, including U.S. Senator Bill Cassidy (R-LA), a gastroenterologist.

An ACG delegation also met with Dr. Meena Seshamani, Director of Medicare at the U.S. Department of Health and Human Services.

KEY MESSAGES AND SPECIFIC LEGISLATIVE REQUESTS • Support The Safe Step Act (S. 464; H.R. 2163) A policy priority for ACG is to urge lawmakers to put patients first by supporting the Safe Step Act (S. 464/HR. 2163) and urge others to become co-sponsors. The bill requires insurers regulated under ERISA to implement a clear and transparent process to request an exception to a step therapy protocol.

• Fix Prior Authorization for Medicare Beneficiaries (S. 3018/H.R. 3173) ACG urged Congress to adopt the "Improving Seniors' Access to Care Act" that protects Medicare Advantage patients from timeconsuming practices and removes barriers to medically necessary care.

• Addressing Threat of Significant Medicare Cuts A critical part of the conversation on the Hill for ACG advocates was to address the risk to patient access and quality of care from potential Medicare cuts at a time when GI practices are facing mounting financial pressures.

We are grateful to the College's leadership, to ACG President Dr. Samir A. Shah, and to everyone who dedicated time and effort to the success of ACG Advocacy Day.

Dayna , Dr. Patrick Young, Dr. an, Dr. Mark Pochapin Director Brad Stillm participant Dr. Jannel SP YPL ley, Hob L to R: ACG Executive es Dr. Jam lic Policy Brad Conway, of Health and Human Early, ACG VP of Pub at the U.S. Department ident Dr. Samir Shah Lee-Allen & ACG Pres Services.

L to R: Dr . James Ho bley, Dr. Ne elima Redd y&

U.S. Sena tor Bill Ca ssidy, MD , FACG (R -LA)

 U.S. Senator Bill Cassidy, MD, FACG (R-LA), a gastroenterologist, addressed many of the most pressing issues facing medicine and GI today and spoke with candor and insight, recognizing ACG and its work to advance the interests of patients on Capitol Hill.

U.S. Rep. Kim Schrier, MD, (D-WA)  a pediatrician, and U.S. Rep. Mike Johnson (R-LA), who has a family connection to colorectal cancer, addressed ACG Advocacy Day and shared illuminating perspectives on health care legislative landscape and policy challenges.

 U.S. Rep. Schrier

U.S. Rep. Johnson 

18 | GI.ORG/ACGMAGAZINE

antha riguez, MD; Sam ; Nicolette Rod i Asombang, MD MD, FACG; Akw MD bo, ez, Vel Lem D. J. r y istophe L to R: Anthon ra Chiu, MD; Chr nifer Cai, MD; Lau Zullow, MD; Jen

L to R: Al lon Kahn, MD; Indu Srinivasan, MD; Jona than A. Le ighton, MD , FACG

L to R:

san, Sriniva D; Indu Hang, M MD; Tina , id O av D man, D Yakira er Perel n, MD; Alexand Lee-Alle Jannel k Row); L to R: D (Bac M u, an Lo MD; Sus

Shifa U mar, MD ; Prasad G. Iyer, MD, MSc , FACG ; Susan

Lou, MD ;

John T. Bassett , MD, FA CG

U.S. Rep. Greg Murphy, MD, (R-NC) a urological surgeon who still practices surgery, shared why it is important for physicians to get involved in politics. Rep. Murphy is a member of the House Ways & Means Subcommittee on Health. U.S. Rep. John Joyce, MD, (R-PA) a dermatologist serving on the House Energy & Commerce Committee emphasized step therapy reform in his comments. 

Samir D. Verm ani, MD and Lu is

S. Marsano, MD , FACG

 U.S. Rep. Murphy

U.S. Rep. Joyce 

22 April 7, 20 cacy Day ACG Advo

ton, DC Washing

Public Policy | 19

PRIOR AUTHORIZATION: HARMING PATIENTS & OVERWHELMING PRACTICES. Background: The American College of Gastroenterology’s (ACG) Legislative and Public Policy Council created a survey to gauge the burden of prior authorizations in gastroenterology, as well as the impact on prescribing behavior and clinical care.

Over 150 ACG Members from 43 states and Puerto Rico provided their experiences with prior authorization.

How Does Prior Authorization Impact Patient Care?

OVER

50%

of ACG Members reported that prior authorization led to a

SERIOUS ADVERSE EVENT in patients.

How Does Prior Authorization Impact GI Practices?

OVER 90% of ACG Members

reported a HIGH BURDEN associated with prior authorizations in their practices.

How Does Prior Authorization Impact the Physician-Patient Relationship?

NEARLY

70%

of ACG Members urge their patients to help with getting prior authorization approvals.

14 8 0

Average number of prior authorization requests completed for patients in the past 7 days.

Average number of prior authorization requests completed in the last 7 days, for patients already taking the requested medicine.

Average number of peer-to-peer reviews with a gastroenterologist in the past 7 days.

CONCLUSION: PRIOR AUTHORIZATION IS HARMING PATIENTS AND DEVASTATING PRACTICES  READ: bit.ly/ajg-prior-auth-survey-shah SOURCE: 2021 National Survey on Prior Authorization Burden and Its Impact on Gastroenterology Practice Shah, Eric D. MD, MBA, FACG; Amann, Stephen T. MD; Hobley, James MD; Islam, Sameer MD, MBA; Taunk, Raja MD; Wilson, Louis MD. The American Journal of Gastroenterology: May 2022 - Volume 117 - Issue 5 - p 802-805 doi: 10.14309/ ajg.0000000000001728

20 | GI.ORG/ACGMAGAZINE

GETTING IT

Respond to A Legal Summons How to

By Andrew D. Feld, MD, JD, FACG, ACG Professionalism Committee

 RECEIVING A LEGAL SUMMONS and being involved in a lawsuit can understandably be stressful for physicians.

Most health care providers are unfamiliar with the legal processes. Our uneasiness can be ameliorated by understanding the steps to take when receiving a summons and how to seek help. Our busy medical educational programs, and the demands of continuing medical education, have left little time for legal training, including discussion of a summons. Keeping a few key points in mind can help inform physicians in how to appropriately respond.

ABOUT A LEGAL SUMMONS A summons is a legal form issued by a court that informs the receiver that they are being sued or are required to appear in court. It may be served by a sheriff or another authorized person and will inform the receiver of the number of days they

Getting it Right | 21

// GETTING IT RIGHT

have to respond to the lawsuit or appear in court.

Some state malpractice laws require that a notice letter is served prior to a summons. A notice letter is not legally filed with a court, but rather comes directly from the plaintiff’s attorney indicating intent to file a lawsuit against the receiver of the notice. While the summons and notice letter differ in that regard, the steps taken in response to both a summons and notice letter are very similar. A request to appear before a state medical board may differ from a summons for malpractice action but needs equal serious attention.

WHAT TO REMEMBER IF YOU ARE SERVED A SUMMONS The first thing to remember when served a malpractice summons or notice letter is to act in a timely manner and act immediately, regardless of whether you think the suit has merit. Failing to respond in a timely manner could result in a judgment against you, or at least will not shine a good light on your case. Promptly notify your risk management office and recruit their assistance.

While you may feel intimidated by the legal process, your risk management office is well equipped to assist you and ease the process for you. Additionally, you should promptly notify your insurance carrier if you are covered by your employer or through a personal plan and comply with their processes for responding to a lawsuit.

Swift notification to your insurance carrier ensures that you are in compliance with your insurance and do not jeopardize your coverage during the lawsuit. Very rarely, your interests and that of your institution will not be aligned; in that case you may need to seek your own independent counsel to oversee the legal advice you are receiving from the attorneys your employer has provided.

CAUTIONS You should also practice caution regarding with whom you discuss any pending lawsuit, and how you manage the documentation required in the suit. A protected peer review process should not be discoverable. Avoid discussing the lawsuit with colleagues outside a protected peer review process, despite how tempting that may be.

You will likely be asked with whom you have discussed the case, and those individuals can be subpoenaed to testify about your statements to them. Discussion of the claim should only occur between you, your attorney or risk management department, and your insurance carrier.

Contacting the patient or patient’s attorney yourself after a lawsuit has been filed is also not a good idea. In fact, it is best if you arrange to have your colleagues provide any requested needed

22 | GI.ORG/ACGMAGAZINE

“The legal world can be daunting and stressful for physicians, who may feel largely out of their element.

Seek assistance from your risk management team and take time to sufficiently rest and manage stress.”

care of the patient (to avoid abandonment) given the damage to the relationship a lawsuit creates.

Never change the medical record. Not only is that unethical, but the plaintiff’s attorney has likely already received a copy of the original. Alterations will severely affect your credibility if the action proceeds. Remember that your demeanor and poise during interactions can affect the lawsuit; a plaintiff’s attorney have an easier time turning a jury against a physician who appears arrogant and hostile.

Finally, you should practice good self-care during legal proceedings. The legal world can be daunting and stressful for physicians, who may feel largely out of their element. Seek assistance from your risk management team and take time to sufficiently rest and manage stress.

Some institutions also have peer counselors — fellow physicians who have been through and understand the process. Do not hesitate to ask your attorney and risk management team questions to help your understanding of the process, to practice doing a deposition and quell any anxieties you may have. While receiving a summons or notice letter is certainly stressful, it can be made less so with the assistance of others and proper preparation.

WHAT TO DO IF YOU RECEIVE A SUMMONS 1. Promptly notify your risk manager, insurance carrier, attorney.

2. Do not call the patient or speak with the patient’s attorney.

3. Do not discuss the content of the case with colleagues (unless during a protected peer review process).

4. Never change chart notes.

5. Take a deep breath, and care of yourself.

You will get help and get through it.

WORKS CITED:

1. Murphy JL When Clinicians Are Summoned to Testify in Court: Orientation to the Process and Suggestions on Preparation. (2018) SAGE Open Nursing. 4:2377960818757097, Jan-Dec. 2. Berry DB The Physicians Guide to Medical Malpractice. Proceeding, Baylor University Medical Center (2001) 14(1) 109-112 3. Starr KT You’ve been served: Responding to a malpractice summons (2018) Nursing 48(8) 11-12 4. Feld AD Moses RE Most Doctors Win: What do to if sued for medical malpractice Am Journal Gastroenterol (2009) 104(6): 1346-51

Andrew D. Feld, MD, JD, FACG, ACG Professionalism Committee; Kaiser Permanente Washington and Clinical Professor of Medicine, University of Washington Division of Gastroenterology

EVIDENCE-BASED GI JOURNAL REVIEW Clinical take-aways and evidence-based summaries of articles in GI, Hepatology & Endoscopy.

ACG PUBLICATION EVIDENCE--BASED GI (EBGI) evaluates new research articles published across GI and Hepatology journals using evidence-based criteria.

ACG Editors identify the highest quality studies published on important topics and create structured abstracts summarizing the study for quick reference and provide commentary on how the data is applicable to clinical practice.

Editors record audio summaries for easy listening on the go.

Listen to individual article summaries or stream the entire issue all at once.

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Full issue download available as PDF: gi.org/ebgi

Getting it Right | 23

// COVER STORY

24 | GI.ORG/ACGMAGAZINE

Speaking Out: Inclusion

and Challenges for LGBTQ+ in Gastroenterology

By Shifa Umar, MD and Nikki Duong, MD

Cover Story | 25

A // COVER STORY

AS PHYSICIANS, WE PROVIDE CARE FOR PATIENTS from different backgrounds, including race, ethnicity, socioeconomic status and sexual orientation; hence, it’s important for us to understand and educate ourselves to best care for our patients.

The GI community is a very diverse group but we can do better with increasing representation and inclusiveness for LGBTQ+ physicians.

In this Q&A, I invited Dr. Nikki Duong, a secondyear fellow at Virginia Commonwealth University, to interview fellows at various stages of training with different clinical/research interests and faculty in leadership roles to share their journey in GI. They offer specific strategies and critical actions we can take to improve care for LGBTQ+ patients and reflect on ways to create a culture of inclusion and promote diversity and equity in gastroenterology.

Our goal in amplifying the perspectives of LGBTQ+ fellows and faculty is to take a step towards creating an environment in the GI profession where peoples' differences of thought, belief and experience are appreciated and viewed as an organizational advantage and where physicians and trainees feel adequately equipped to provide sensitive and compassionate care to LGBTQ+ individuals.

– Dr. Shifa Umar

ABOUT SHIFA UMAR, MD Dr. Umar is Editor of ACG MAGAZINE’s Trainee Hub section. She is an Advanced Endoscopy fellow at the University of Chicago. Dr. Umar is also member of the ACG Digital Communications & Publications Committee, the ACG Diversity, Equity & Inclusion Committee and one of the ACG Institute’s Young Physician Leadership Scholars.

ABOUT NIKKI DUONG, MD Dr. Duong is a second-year fellow in gastroenterology and hepatology at Virginia Commonwealth University. He is a member of the ACG Training Committee.

26 | GI.ORG/ACGMAGAZINE

FACULTY PERSPECTIVES LUKEJOHN W. DAY, MD

"An environment where you feel like you must hide your true self is a barrier to success.

Find the places and people who accept you as you are so you can work and learn to your full potential."

- Dr. Newman

(He / Him / His) Professor of Medicine, University of California, San Francisco; Chief Medical Officer, Zuckerberg San Francisco General Hospital Why did you choose GI/hepatology?

I selected gastroenterology as my chosen specialty during medical school. I knew I wanted to be in a field that had a procedural and clinic-based aspect. Also, I wanted to have the flexibility to work in the inpatient, outpatient, and emergent settings; all these dynamic components are what led me to the field of GI. My choice was solidified by doing a third-year GI rotation in medical school; at this time, I met many exceptional mentors who supported me in my research and provided me encouragement in my career choices. The collegiality, kindness, and enthusiasm I noted in the GI faculty affirmed my decision to become a gastroenterologist.

How has being LGBTQ+ affected your practice of medicine and your experiences leading up to your current position?

Identifying as both a gay and American Indian male has impacted many aspects of my practice in medicine. I was born and raised in a small town in Southern California. During the school year I lived with my parents, but each summer I would travel to South Dakota to live on Pine Ridge Indian Reservation with my grandmother and great-grandmother.

These living experiences very much shaped who I am as an individual in terms of not only my values, but what I wanted to do in the future. Even from a young age, I appreciated the disparities and adversity that my relatives faced living on the reservation. Being raised by two very strong, independent women helped to instill in me confidence, ambition, and purpose. Also, observing the poor access and limited healthcare my family experienced on the reservation made me want to pursue a career in healthcare and to work in a setting where my work would focus on reducing disparities and improving access to healthcare for vulnerable patients.

Have you ever felt that your sexual orientation has affected (or impacted) your advancement in the field?

I have been very fortunate during my career that my sexual orientation has not impacted my advancement in GI. I am out regarding my sexual orientation at my current institution, and I have felt incredibly supported by the leadership and staff where I practice medicine as well as within the GI societies.

How could GI attract more LGBTQ+ trainees?

GI is an incredibly exciting, challenging, engaging, and evolving field of medicine.

There are many ways in which we can increase diversity in the field of GI. GI, and medicine as an entire field, must make a commitment to improving and increasing diversity, equity, and inclusion. We must create a welcoming environment for LGBTQ+ trainees; this could take many forms, such as implementing mentoring programs, creating research opportunities within the LGBTQ+ community, offering educational programs for trainees, staff, and patients, and offering networking opportunities for LGBTQ+ trainees.

What advice would you give to junior fellows/residents and medical students about the clinical care of LGBTQ+ patients?

LGBTQ+ patients face many barriers and challenges within healthcare, such as a lack of informed care, research, and access to routine care. Consequently, LGBTQ+ health requires specific attention from healthcare and public health professionals. The more informed healthcare professionals are, the more comfortable LGBTQ+ patients will become. I would encourage all providers and healthcare team members not to make assumptions about their patients, engage in active listening and humble inquiry with your patients and staff, lead with empathy and compassion, and remember that we are always learning and continuously improving.

What advice would you give to your colleagues on being strong allies and supporting an inclusive community in medicine and GI? There are many ways our colleagues can be strong allies. This can be achieved by listening to your colleague’s stories, lending your voice, and speaking up and being willing to learn.

One thing that has stuck with me over the years is that “ally” is a verb and that being

an ally means being willing to act with and for others in pursuit of ending oppression and creating equality. It’s important to remember this when trying to build and advance a diverse and inclusive work environment.

SONALI PAUL, MD, MS (She / Her / Hers) Assistant Professor of Medicine, The University of Chicago Medicine Why did you choose GI/hepatology?

I fell in love with hepatology as a third-year medical student rotating on our inpatient liver service. It was humbling to see how one organ’s failure could cause such devastation. But also, amazing to see how liver transplant could be lifesaving. I really enjoyed taking care of the patients and getting to know their families and knew this is what I wanted to do for my career.

How has being LGBTQ+ affected your experiences leading up to your current position?

I was fairly closeted growing up and during most of training – only a handful of people knew that I was gay. However, when interviewing for my first job, I knew that I needed to be “out” on the interview trail as I didn’t want to work somewhere that was uncomfortable with who I am and my family (I was married with a oneand-a-half-year-old son at the time). And while I knew medicine was quite heteronormative, it was only when I had my son that I intensely felt that heteronormativity in our lives, from hospital experiences to paperwork asking for “mother/ father” instead of “parent.” My goal now is to educate and increase awareness of the important healthcare needs of the LGBTQ+ population.

How has being LGBTQ+ affected your practice of medicine?

Overall, I think it has made me a more compassionate person and physician. Coming from a fairly conservative South Asian family, I struggled coming out and that affected so many facets of my life and health. I realize my patients are more than just their livers – they have stories and lives that affect so much of their health and healthcare. And I am privileged to know and learn these stories so that I can better take care of themselves.

"Represent: Your voice matters to the LGBTQ+ community, whether you are in a diversity and inclusion committee, performing research on healthcare disparities or simply being a great clinician."

- Dr. Sleiman

Have you ever felt that your sexual orientation has affected (or impacted) your advancement in the field?

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// COVER STORY I don’t think so, at least not to my knowledge. And to be honest, if I do not get a position or award because of my sexual orientation, it is something I don’t want or need in my life.

How could GI attract more LGBTQ+ trainees?

GI and hepatology need increased awareness and education surrounding the needs of LGBTQ+ patients. Trainees need to see mentors that “look like them.” I was dismayed when a trainee once told me that they felt the [GI] field was “tone deaf” to the needs of the LGBTQ+ population. I think this is starting to change, but much more work is to be done.

What advice would you give to junior fellows/ residents and medical students about the clinical care of LGBTQ+ patients?

Cultural humility. Culture and terminology change so often and we all are going to make mistakes, even if we identify as LGBTQ+. I sometimes will misgender someone. I feel terrible. But the most important thing I can do is to acknowledge it and apologize. That not only shows respect for the patient, but also gently shifts the power differential in the sometimes intimidating doctorpatient relationship.

What advice would you give to your colleagues on being strong allies and supporting an inclusive community in medicine and GI? Educating oneself on key historical moments that have impacted the relationship between medicine and the LGBTQ+ community and health disparities that continue to affect the community is important. Using appropriate personal pronouns, recognizing important LGBTQ+ events and displaying small tokens of support (such as the rainbow or progress flag) are other steps that can be taken to demonstrate inclusivity and a welcoming environment. Allyship is also vitally important to the LGBTQ+ community’s freedom of expression and helps identity discrimination on both institutional and personal levels. Many institutions have self-designated faculty allies identified on their webpages to show, not only patients but also trainees, that they foster an inclusive environment.

Why did you choose GI/hepatology?

I got inspired to pursue GI/hepatology by an amazing professor in medical school. He was a phenomenal clinician and educator, who instilled in me a passion for hepatology and research.

"One thing that has stuck with me over the years is that 'ally' is a verb and that being an ally means being willing to act with and for others in pursuit of ending oppression and creating equality."

-Dr. Day

How has being LGBTQ+ affected your experiences leading up to your current position?

I had never given much thought to how my sexual orientation affected my professional experiences until I decided to become more open about it. I then realized the huge effort it was, trying to keep my personal and professional lives completely separate. Unfortunately, this wall I had built around me created a sense of fear and isolation at work which was definitely holding me back.

Breaking free of this social heteronormative construct has allowed me to flourish both personally and professionally.

How has being LGBTQ+ affected your practice of medicine?

As I believe is the case for all underrepresented minorities in medicine, being a member of the LGBTQ+ community (and consequently a victim of bullying during formative years) has made me a more empathic clinician. These experiences not only affected my practice of medicine but were also the reason I chose to pursue medicine as a career.

Have you ever felt that your sexual orientation has affected (or impacted) your advancement in the field?

As I mentioned above, not my sexual orientation but the fact that I chose to actively hide it negatively impacted me. For example, I would have never considered applying for leadership positions in the past due to the increased visibility/exposure it entailed. I know that I am very lucky though to live and work in an environment that accepts and promotes diversity, which is unfortunately still not the case in some parts of the country and the world.

How could GI attract more LGBTQ+ trainees?

We need more role models and LGBTQ+ mentors in GI. We need to show trainees that GI is a welcoming specialty to LGBTQ+ and diversity.

DOUGLAS A. SIMONETTO, MD (He / Him / His) Program Director, Gastroenterology and Hepatology Fellowship Associate Professor of Medicine, Mayo Clinic College of Medicine, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN

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What advice would you give to junior fellows/ residents and medical students about the clinical care of LGBTQ+ patients?

Be attuned to the unique needs of your patients and create a safe space for them to share their concerns.

What advice would you give to your colleagues on being strong allies and supporting an inclusive community in medicine and GI? Be aware of potential implicit biases and microaggressions. Create a welcoming learning and working environment for LGBTQ+ trainees and colleagues and always be an upstander!

REBECCA A. BURBRIDGE, MD (She / Her / Hers) Associate Professor of Medicine, Division of Gastroenterology Director of Advanced Endoscopy, Director of Advanced Endoscopy Fellowship, Duke University Medical Center Why did you choose GI/hepatology?

I always found myself drawn to the procedure-oriented fields during my internal medicine residency. GI was intriguing to me, given the many different types of procedures that were performed. Growing up, I always liked to be challenged both physically and intellectually. Each procedure offers its own unique set of challenges to conquer in order to be successful.

These challenges keep me on my toes and interested in what I am doing.

How has being LGBTQ+ affected your experiences leading up to your current position?

I pride myself in being open and honest with who I am. My institution is very supportive and progressive with regards to inclusion. I guess I am lucky. I have never felt that my sexuality was a deterrent or distractor to progressing my career. This is a testament to the people I work with and the institution I work for. I have been judged by the care I provide to my patients and the colleague I am to my peers, and not by my sexuality.

How has being LGBTQ+ affected your practice of medicine?

In caring for patients, I focus solely on providing the best care for their situation. The focus is on them

and their situation and not me and my sexuality. If they ask for me to pray with them prior to a procedure, I am happy to oblige to make them feel comfortable and confident in the care I am providing. Being part of the LGBTQ+ community has taught me to be a good listener because every patient’s story is important.

KIRA NEWMAN, MD, PHD

Have you ever felt that your sexual orientation has affected (or impacted) your advancement in the field?

No. I feel like I have always been judged by my clinical performance rather than my personal preferences.

Why did you choose GI/hepatology?

GI was a good fit for my clinical and research interest because I am interested in the role of gut microbes in human health and wanted to be in a subspecialty with both clinic and procedures.

How could GI attract more LGBTQ+ trainees?

I believe exposure is important.

Recognizing leaders in the field who are open with their sexuality makes it more acceptable and commonplace, rather than a novelty. Initiatives, such as this one through the societies, provide role models and contacts within the field who the LGBTQ+ community will feel comfortable reaching out to for advice.

How has being LGBTQ+ affected your experiences leading up to your current position?

Being LGBTQ+ did not directly affect my decision to go into GI/hepatology.

However, I am proud to be a gay woman in a traditionally maledominated subspecialty and know that my diverse experiences are an important contribution to the field.

What advice would you give to junior fellows/residents and medical students about the clinical care of LGBTQ+ patients?

We all have inherent biases that we hope do not impact patient care. Symposia and workshops directed towards care of the LGBTQ+ community are prevalent at academic institutions. I would encourage attendance at these programs to gain insight into the challenges faced by the LGBTQ+ community. Most importantly, being a good listener goes a long way.

What advice would you give to your colleagues on being strong allies and supporting an inclusive community in medicine and GI? I would encourage all colleagues to speak up if you see an injustice. Show support for your colleagues by addressing disparaging comments by patients or peers on the spot. If you are not comfortable with or do not understand the LGBTQ+ community, avoidance is not an effective strategy.

Instead, reach out to your LGBTQ+ colleagues to chat or attend an inclusion workshop/symposium to gain further insight.

FELLOWS’ PERSPECTIVES (She / Her / Hers / Dr.) Gastroenterology Fellow University of Michigan

How has being LGBTQ+ affected your practice of medicine?

It has made me work to be more inclusive and thoughtful when communicating with patients. Implicit assumptions and "standard" language we use can be alienating or offensive to patients. I know that when I feel unseen because of an assumption someone has made about me, I am less likely to trust that person or value their opinion. The same is true for our patients.

Have you ever felt that your sexual orientation has affected (or impacted) your advancement in the field?

I have been open throughout medical training about my sexual orientation, and I do not feel that it has impacted my advancement in the field. This may in part be because I have had and continue to have the support of excellent mentors who value the perspective I bring as an LGBTQ+ person.

Why do you think some LGBTQ+ trainees do not choose GI/ hepatology as a specialty?

There is a perception of GI/hepatology

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// COVER STORY as a conservative subspecialty, which may discourage some trainees from considering it.

"I definitely feel that I owe patients from the LGBTQ+ community a responsibility to pay more attention to their voice, their needs, and the way

What unique challenges do LGBTQ+ patients experience when they seek GI/hepatology care and how do you face these challenges in your clinic/practice, if at all?

The challenges LGBTQ+ patients experience when they seek GI/hepatology are likely similar to those they encounter in accessing medical care more generally, but there are very few data on this subject. The most common ones [challenges] my LGBTQ+ patients report are biases from other medical providers and medical documentation that assumes patients are heterosexual and cisgender. While there are some issues related to sexual practices and GI diseases that may be more likely to impact LGBTQ+ patients, focusing exclusively on sex ignores the many other ways that sexual orientation and gender identity impact our patients' lives. Within GI/hepatology, there is a need to better understand how chronic GI/ liver disease and LGBTQ+-specific experiences intersect so we can develop targeted approaches to addressing barriers to care for our LGBTQ+ patients.

What advice would you give to junior fellows/residents and medical students?

An environment where you feel like you must hide your true self is a barrier to success. Find the places and people who accept you as you are so you can work and learn to your full potential.

that healthcare systems treat (or sometimes mistreat) them, knowingly or unknowingly."

-Dr. Sleiman

AAYUSH GABRANI, MD, FAAP (He / Him / His) Pediatric GI Fellow, University of Texas Southwestern Medical Center, Dallas, TX Why did you choose GI/hepatology?

Pediatric GI/hepatology is an optimal balance of outpatient, inpatient, and procedures, which I wanted in a specialty. I wanted a sub-specialty where I can provide longitudinal care for my patients. In my opinion, Peds GI is the best fit for me with a combination of clinical, educational, and research work.

How has being LGBTQ+ affected your experiences leading up to your current position?

My identity as a gay, immigrant person of color (POC) had a significant impact on my experiences thus far. While completing medical school in India, I was always in the

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closet but having a supportive boyfriend (and LGBTQ+-friendly peers) helped me get through that time. I moved to the U.S. right after graduating medical school, but I wasn’t living as an openly gay physician for the first year in this country. Often LGBTQ+ people face a lot of discrimination from the beginning; some even suffer from various forms of abuse. These instances definitely contribute to/ affect their long-term development. I have had many such instances in the past (minor and major, both) which certainly made me resilient and gave me strength to live as an openly gay physician in U.S. I was also able to be a part of the diversity group at my residency program to help create resources for improving LGBTQ+ patient care for the medical students.

Another unique incident that I experienced as an openly gay physician was facing homophobic comments by one of my patient’s mothers during my residency. By publishing that instance as a letter to the editor, I was able to raise awareness on the issue of physician safety at the workplace for gay physicians.

How has being LGBTQ+ affected your practice of medicine?

My identity as a gay pediatric gastroenterology fellow has definitely made me more empathetic towards my LGBTQ+ patients, especially in understanding their struggles. Pediatric patients are vulnerable to begin with, and then not having family support (for LGBTQ+ patients) makes it even more challenging. I often try to support my LGBTQ+ teenage patients by sharing my experiences with them. This acknowledges their concerns and also provides them a support system. Also, I did my residency at a center caring for an extremely vulnerable and underserved population in Newark, New Jersey (Rutgers New Jersey Medical School) where I would routinely refer my LGBTQ+ teen patients to local queerfriendly resource centers. They didn’t have family support but found community support at these centers. Currently, during my fellowship, I manage a few LGBTQ+ patients, who often express how the lack of family support worsens their GI symptoms, thus I try to do my best by actively listening to their stories and connecting them to appropriate resources when available.

Have you ever felt that your sexual orientation has affected (or impacted) your advancement in the field?

It is hard to answer for me at this point in my career. In India (where I wasn’t out), my sexual orientation would certainly have affected my advancement—I saw it myself during medical school in India happening to my residents

and attendings who were treated differently (inferior as compared to others.) Maybe this subconsciously also affected my decision to stay in the closet during medical school in India. Since I have been living in the U.S. as an out and proud physician, I haven’t felt similarly (at least not when I was on the East Coast.) Things might be slightly different since I moved for fellowship (maybe because of the geographical location), where I have felt at times that being LGBTQ+ might be a hindrance to my advancement in career.

Why do you think some LGBTQ+ trainees do not choose GI/hepatology as a specialty?

Not sure of the reason for this particular question, but I know from the recent paper in JAMA that sexual and gender minority trainees tend to choose psychiatry, pathology and IM/peds. So, certainly a lot of trainees do choose IM/Peds, however unsure of GI/Hepatology. Particularly for MSM trainees, it could be possibly linked to concerns of stigmatization associated with anal sex. There have been many instances I can recall during my peds GI fellowship when jokes about anal sex have been made casually (which have the potential to make LGBTQ+ trainees uncomfortable.)

What unique challenges do LGBTQ+ patients experience when they seek GI/hepatology care; and how do you face these challenges in your clinic/practice, if at all?

One of the unique challenges I can personally relate to is the ability to discuss the sexual history (or the lack of this discussion during clinical encounters.) When I had to seek GI care for my symptoms, I had a lot of reservations on how I would disclose my sexual practices to a physician who is a part of GI group comprised of all straight doctors. This was never brought up during my visit and I had to initiate this conversation and my GI handled it well. But this is not the case with every LGBTQ+ patient, so I can definitely consider this a potential challenge for many LGBTQ+ patients. Secondly, the stigma of being judged for their sexual or lifestyle practices in case of infectious hepatitis, anal infections, etc., is definitely another barrier preventing LGBTQ+ patients from getting the best care they deserve.

In pediatric GI practice, it is slightly different because parents are the primarily responsible for the patients, which often included history and decision making too. It can be challenging sometimes to make a management plan for the patients with brain-gut disconnect where the issues associated with their LGBTQ+ identity is a contributing factor because of refusal of families (or lack of support) to even accept the LGBTQ+ identity of their children.

"I would encourage all providers and healthcare team members not to make assumptions about their patients, engage in active listening and humble inquiry with your patients and staff, lead with empathy and compassion, and remember that we are always learning and continuously improving."

- Dr. Day

What advice would you give to junior fellows/residents and medical students?

No matter what specialty you chose, make sure to take care of the most vulnerable since they need medical professionals the most! Also, they are the most appreciative of the care provided to them. Always approach a patient/family without any preconceptions because medical care provided with prejudices and biases in mind can harm the patients, instead of helping them. Lastly, never be afraid to speak up for yourself and for others who cannot do it for themselves. I cannot tell you how many times during residency one of my favorite seniors had our backs and would never let anyone treat us badly as interns. This also inspired me to make sure I do the same for my interns too when I was a senior. Change begins with you, no matter how small it is.

JOSEPH SLEIMAN, MD (He / Him / His) Gastroenterology Fellow, PGY-4, University of Pittsburgh Medical Center Why did you choose GI/hepatology?

I had an interest in IBD as a complex disease with multiorgan interactions that surpass the GI tract; this provides ample space for research and innovation. It also runs in my family, especially those who traveled from Lebanon to Australia.

My grandmother used special herbal concoctions for treating this disorder, and I found that quite intriguing as I learned more about IBD. By caring for patients with IBD, I feel I am connecting with my grandmother on some level, as she was a true source of inspiration for me on how to be both compassionate and ambitious.

How has being LGBTQ+ affected your experiences leading up to your current position?

I used to live a double life, growing up in Lebanon, with a very limited number of friends who are aware of my LGBTQ+ identity. I would say my internal medicine residency at the Cleveland Clinic is truly where I saw a chance to "start over" and be honest about my identity without fear of judgment or risk of jeopardizing my career. I remember opening up to my close co-residents at first, then my program director, then the entire class during an icebreaker meeting, and it felt truly liberating. I've been partnered for two years now and feel that my fellowship and future academic positions need to be in institutes that are clearly accepting of LGBTQ+ communities because I am not willing to go back to a double life anymore.

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// COVER STORY

How has being LGBTQ+ affected your practice of medicine?

I definitely feel that I owe patients from the LGBTQ+ community a responsibility to pay more attention to their voice, their needs, and the way that healthcare systems treat (or sometimes mistreat) them, knowingly or unknowingly. It's empowering to some patients to know that they are represented in healthcare. It's also made me more aware of other communities that suffer from discrimination and healthcare disparities, and to realize that we need each other to push the agenda of equality and equity in medicine.

Have you ever felt that your sexual orientation has affected (or impacted) your advancement in the field?

Luckily no, but I do constantly still worry about being honest about my LGBTQ+ identity with new mentors and program leadership and take time to gauge their perceptions and opinions before I discuss this topic in a professional setting.

Why do you think some LGBTQ+ trainees do not choose GI/hepatology as a specialty?

I recall asking many mentors and even GI/hepatology physicians about divulging my sexual orientation during the Match interviews or in the personal statement, and I had a 50/50 split on the matter. Although the end result was, "do what you are comfortable with," it still left an eerie feeling that GI/hepatology, as a specialty, is not ready to have un-prejudiced representation by an LGBTQ+ physician. Still, I've seen many role models in GI/hepatology (perhaps most significantly to me was when Dr. Doug Simonetto became the most recent Mayo Clinic GI program director), and that gives me hope.

What unique challenges do LGBTQ+ patients experience when they seek GI/hepatology care and how do you face these challenges in your clinic/ practice, if at all?

Stigma remains a challenge for LGBTQ+ patients in the 21st century. This may

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be more pronounced if they need care for hepatitis B or C, but less likely if they have Crohn's disease. I often wonder if LGBTQ+ patients who need a liver transplant have a harder time procuring the needed social support for the transplant process compared to non-LGBTQ+ patients. I also wonder if LGBTQ+ patients who practice receptive intercourse have some pelvic floor complaints that are difficult to speak about to their primary care doctors, let alone a specialist. It certainly did not help to have the term "gay bowel syndrome" coined in the 1970s to describe various sexually transmitted rectal infections observed in men who have sex with men. We've come a long way since, but we still have to work hard on changing the rhetoric.

In my practice, I do the following: 1. Ask all patients about their sexual practices in an unbiased, judgmentfree manner: I ask everyone about their sexual orientation and give a blank face when asking "Do you have sex with men, women, or both (important to mention this)?" My blank face tells the patients that I am not judging and that this is as routine as asking if they have diabetes. It also helps to say that I ask this to everyone I see, and it is standard in my practice.

2. Listen and observe their body language carefully while discussing bowel habits: No one likes to talk about their bowel habits. It simply is not tea-time material, so we have to be vigilant, especially with LGBTQ+ patients who have receptive intercourse. I listen carefully and observe body language to get cues about possible anorectal concerns that the patient might want to talk about but is too afraid to mention. I may ask about safe sex practices, anorectal bleeding, peri-intercourse instruments used for cleaning, dilation, and so on.

3. Respectfully ask to perform an anorectal exam, when necessary: With luminal GI complaints, I feel that a good anorectal exam can help rule out fissures, hemorrhoids, and STI-related skin findings. If unsafe sexual practices are mentioned, I may have a quick look at the genital organs. Patients often develop more trust when I show that I care about their health holistically and may mention more medical history during this particular part of the exam.

4. Offer STI testing: We often create a sharp line between the role of a specialist and that of a PCP, but we fail to realize that LGBTQ+ patients may not be comfortable with their PCP. STI testing is important for overall health, but also GI pathologies (hepatitis, proctitis, differential diagnosis of dysphagia, or chronic diarrhea), so I always have it on my to-do checklist.

5. Say thank you: To many patients, talking about sexual practices is quite a hoop to jump over. I finish my visit by thanking my patients for showing courage and trust in discussing these matters and asking them to make sure to discuss other topics that may come up (for example, mental health, drug use, social stressors) with their PCP just as they did with me.

What advice would you give to junior fellows/residents and medical students?

• Being open about your LGBTQ+ identity is quite empowering for you and others in your shoes, but never feel pressured to open up if you are not ready. This is a personal decision, first and foremost.

• Ask about workspace measures that guarantee nondiscrimination during your training. If they don't know, chances are this isn't a topic that is being addressed or monitored in an active manner.

• When searching for training or job opportunities, check the current list of trainees/employees to get a feel of representation.

• Represent: Your voice matters to the LGBTQ+ community, whether you are in a diversity and inclusion committee, performing research on healthcare disparities, or simply being a great clinician. Stand up against hidden agendas that may affect LGBTQ+ patients or healthcare workers and strive to be a role model for future LGBTQ+ leaders in medicine.

Culinary Connections:

Farm Fresh from the Farmer’s Market

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

IN THE SUMMER, COLORFUL PRODUCE FILLS GARDENS, farms, and markets. Fruits and vegetables at the peak of ripeness are bursting with flavors and provide vitamins, phytonutrients, and, importantly, fiber. The delicious culinary possibilities are endless! Unfortunately, the diets of most Americans are markedly deficient in fiber and do not contain a wide variety of plants.

As gastroenterologists, we regularly advise our patients to increase fiber intake. Importantly, consuming a wide variety of plants also has been associated with diversity of the microbiome.

In this edition of Culinary Connections, “Farm Fresh from the Farmer’s Market,” we are excited to feature the personal journeys and recipes of three more #ACGfoodies from different backgrounds. Enjoy their stories and tips on bringing more produce to the plate. We hope this serves as inspiration shopping in your local famer’s market, cooking in your kitchen, and counseling patients in the clinic.

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// PERSPECTIVES

JAMES HADDAD, MD, FACP

UT Southwestern Medical Center Dallas, TX

I grew up in an Italian-Lebanese family and no matter where you turned, someone was always trying to feed you. At a young age, I began helping in the kitchen, learning not just recipes, but discipline, focus, and a healthy respect for tools; skills which—little did I know—would translate well into the world of endoscopy years later.

As gastroenterologists, patients naturally expect us to be knowledgeable about nutrition, which is unfortunately, as we know, under-represented in medical education. This is an enormous, missed opportunity, because an astounding amount of illness and chronic disease is directly influenced by what we put—or don’t put—into our bodies. The good news is that it is literally never too early (or too late) to begin to learn cooking. As with any other habit (such as exercise), I recommend patients gradually ease into the practice rather than overwhelm themselves by trying to transition directly from a convenience food diet to entirely self-prepared meals.

My wife and I are voracious travelers, typically booking walking food tours of the cities we visit, and often bringing home a recipe or two as keepsakes; when we later prepare one of these dishes, it helps us relive our travel experiences. Cooking a variety of foods regularly allows me to better connect with patients from diverse cultural backgrounds and help

“Cooking a variety of foods regularly allows me to better connect with patients from diverse cultural backgrounds and help patients make healthier choices that work for them (rather than issue blanket recommendations).”

—James Haddad, MD, FACP

OVEN ROASTED ZUCCHINI WITH HALOUMI [SERVES 3-4]  Ingredients

• 3 medium zucchinis, topped & halved lengthwise • 2 Tbsp olive oil (or cooking spray) • 8oz. Haloumi cheese, grated (can substitute Havarti, mozzarella, or Swiss cheese according to your taste) • 6-8 cherry tomatoes, quartered (or grape tomatoes, halved) • 1 tsp smoked paprika • Fresh cracked pepper, to taste • Salt, to taste • ¼ cup of fresh basil, chopped • Juice of half a lemon

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 Steps

1. Preheat oven to 450°F and line a medium-sized baking sheet with parchment paper.

2. Arrange the zucchini cut side up on the parchment paper and brush or spray with olive oil.

3. Sprinkle each zucchini half with a small amount of salt and fresh cracked pepper.

4. Roast for 30-35 minutes until cooked through and golden brown before removing.

5. Top each zucchini section with cheese, arrange tomatoes along each section, and sprinkle with smoked paprika.

6. Return to the oven under the broiler (if not available, use the highest heat setting) for 3-5 minutes to melt and brown the cheese and blister the tomatoes. This step requires supervision as there is a thin line between browning and burning!

7. Sprinkle with chopped basil and drizzle with lemon juice prior to serving.

patients make healthier choices that work for them (rather than issue blanket recommendations). On a personal level, I have come to see cooking as a rewarding experience, rather than a chore, and I enjoy it even after a long day at work. Cooking is an expression of love through nourishment, whether it’s a weeknight dinner with my wife, a meal with visiting friends, or a special holiday with family.

I chose the following recipe to share because it’s the perfect showcase for summer vegetables you might find at a farmer’s market, while being simple enough for a beginner and requiring only a few ingredients you can find at your local grocery store year-round. Inspired by elements of Mediterranean cuisine, it also happens to be plant-forward and uses low-FODMAP ingredients that can be easily substituted, so it can fit into just about any diet. This recipe is customizable and versatile, and can be served as an appetizer, side dish to a lean protein or fish, or you can replace the zucchini with meatier eggplants for a main course. I served these roasted zucchinis on a beautiful platter alongside some homemade lamb kofta, and it was a home run.

VICTORIA JAEGER, MD Baylor Scott & White Health Temple, TX

One month into my intern year, I was a firsttime mom. I was struggling to learn how to be a physician and a mom at the same time. I knew that I needed to start putting an emphasis on my own health and wellbeing before I burned out. My role as a mother and a physician was to set the best example of healthy living. Despite the overwhelming fatigue, I started exercising regularly and focusing on my own health.

In medicine, I found myself using the term “lifestyle changes” when counseling patients for a vast number of chronic health conditions.

It was so easy to say, but what did that really mean? If I didn’t have all the answers, how would my patients know what to do? The diet industry is full of contradictory information and patients often floundered in what to do. I read books on lifestyle changes, delved into the evidence, listened to podcasts, and became passionate about what healthy living really meant. Two key themes were woven through the information—exercise and nutrition. I was determined to put the information I had learned into practice. I needed to “practice what I preach,” right? If I was going to make an impact on my patients’ lives and educate them about “lifestyle changes” I needed to do these

“Figuring out what ‘lifestyle changes’ meant and felt like, I became passionate about emphasizing, educating, and counseling patients on how they, too, could make these changes in the most simple, effective way.”

—Victoria Jaeger, MD

things myself. At home, my daughter was growing, and I didn’t want her to live the standard American life and end up with the standard American diseases. As a mom and a physician, I wanted to set an example.

Movement was my first step towards health, and nutrition quickly became my next focus. We started by eliminating processed foods. We emphasized eating whole, real food in our home. By the end of residency, my three-year-old daughter, my ultramarathon running husband, and I were all thriving on a whole food plant-based diet. The symptoms of reflux, heartburn, and restless legs my husband had perpetually complained about were gone. My daughter eliminated her constipation woes (and chose to become an ethical vegan). My overall energy level drastically improved. We embraced our new lifestyle together and never looked back. Finally figuring out what “lifestyle changes” meant and felt like, I became passionate about emphasizing, educating, and counseling patients on how they, too, could make these changes in the most simple, effective way.

Since the beginning of my health journey, meal time has become an important time for us to be together as a family. With busy schedules, sitting down each evening and enjoying our food together is a highlight of the day. As a physician mom, there is little time for meal planning, grocery shopping, and cooking.

Over the past three years, I have discovered budgetfriendly, kid-approved, healthful, quick meals that are my go-to. This recipe is one of my favorites because it can be customized for taste preferences, is full of fiber and nutrients, and is super simple. If you are wanting to eat more plant-forward, try starting with this recipe.

Tray bakes are one of the easiest and most delicious meals for the whole family.

ROASTED VEGGIE TRAY BAKE  Ingredients (choose 4-6) • Broccoli • Cauliflower • Butternut squash • Acorn squash • Potatoes (russet, sweet, purple, red) • Brussels sprouts • Carrots • Asparagus • Bell peppers • Beets • Zucchini • Corn (canned or fresh from the cob) • Onions (red, yellow, or white) • Chickpeas • Tempeh

 Steps 1. Pick 4-6 veggies from the ingredient

list and chop into bite size pieces.

2. Add a can of chickpeas (drained and rinsed) or cut up some tempeh.

3. Place the veggies and beans on bakin g sheets lined with baking paper.

4. Spray with a light dusting of olive oil.

5. Season with whatever spices you’d like (salt, pepper, garlic powder, turmeric, red pepper flakes, cayenne pepper, nutritional yeast, etc.). Our favor ites are garlic powder, onion powder, turmeric, salt and pepper.

6. Bake at 400°F for about 25 minu tes.

7. Enjoy the bake alone or with som e kale

or mixed greens. Add some lemon juice or vineg ar (apple cider, red wine, malt vinegar) for extra flavor.

ACG Perspectives | 35

// PERSPECTIVES

PARASTOO JANGOUK, MD

“My goal is to help people understand that, despite everything going on in the outer and inner world, we still have a lot of control over our health.

And the biggest changes always start with us.”

Austin Gastroenterology Austin, TX

You cannot be Persian or have Persian friends and not love “Tahdig.” Tahdig is the famous Persian crispy rice. One of my Persian friends recently posted the picture of a greeting card saying, “You’re the Tahdig to my rice.” This alone shows you the significance of Tahdig in Persian cuisine.

As a kid growing up in Iran, we had access to fresh food on daily basis. I remember I would go to the local grocery store with my mom every day to buy the ingredients she needed to cook. The local grocery store was a hole-in-thewall selling organic natural produce.

Persian main dishes consist of cooked meat and vegetables served with rice. The key part of the meal, however, is the side dish. You can always find a platter of fresh herbs, a bowl of pickled vegetables (called Turshi), or Greek yogurt served with cucumber and dill.

I remember during my childhood I developed a conflicted relationship with our food. I found it boring, heavy, and not delicious. Like a lot of kids my age, I was craving the greasy Western food. It wasn’t

LOUBIA POLO (GR



—Parastoo Jangouk, MD

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 good health and great meals from our culinary connections #ACGfoodies team.

DIG AND A SIDE OF FRESH EEN BEAN RICE) WITH CRISPY TAH

 Ingredients • 2 cups basmati rice • 2 cups green beans • 4 Tbsp tomato paste • 1 large potato • 1 medium onion • 2 cloves garlic

• 1-2 Tbsp cinnamon powder • 2 Tbsp turmeric • ½ Tbsp saffron • ½ Tbsp salt and pepper • Vegetable oil

 Steps Sauce lic and sauté in vegetable oil 1. Finely chop onion and gar 2. Add the tomato paste er; season with turmeric, 3. Add 2 cups of boiled wat n salt, pepper, and cinnamo 1-inch pieces and sauté into ns 4. Chop the green bea le oil until nicely browned them separately in vegetab 2 Tbsp of boiled water and 5. Add minced saffron to add it to the sautéed beans

ron 6. Add the beans and saff and garlic sauce

36 | GI.ORG/ACGMAGAZINE

until the recent years when I started my plantbased journey that I started to reconnect with Persian food and appreciate the myriad of health benefits it provides. Today in my practice as a gastroenterologist, I deal with the consequences of poor dietary choices on my patients’ health, and I always encourage them to kickstart their healthy lifestyle by adding more plants to their diet.

My goal is to help people understand that, despite everything going on in the outer and inner world, we still have a lot of control over our health. And the biggest changes always start with us. Becoming plant-based is one of the best gifts one can give themselves. It requires curiosity and openness. Reminiscing on those good old days, I’m grateful that I was raised in a country where healthy eating was engrained in the culture. I hope the footprints of those healthy days are still alive somewhere within my gut microbiome.

to the tomato, onion,

HERB PLATTER (SERVES 2-4)

Rice 1. Wash the rice

add salt 2. Bring water to boil and er wat ing boil the 3. Add rice to r after 3-5 minutes when nde cola a in rice 4. Drain the

soft on the outside and firm

in the center

Layering and Tahdig ium-thick slices 1. Chop the potato into med

pan to coat the bottom of the 2. Add 1-2 Tbsp of butter s slice ato pot with pan 3. Cover the bottom of the — cover with a layer of sauce 4. Add a layer of rice and repeat until done n kitchen towel 5. Line the lid with a clea

r low temperature with the

ove 6. Steam for 45 minutes lid on

Herb Platter • Radish • Basil • Spring onion • Mint ned, and chopped as All washed in cold water, clea needed. al with 12 plant points.

Voila! Enjoy this healthy me

My professional focus is to transform the stigma surrounding “functional” GI disorders through entertaining and evidence-based education. The drivers of prejudice towards these patients are historic and complex.1 Currently, the harsh reality is that many providers of all types are burnt-out to a crisp. And as a husband and father to two young children finishing 11 years of medical training at the tail end of a pandemic…I get it. Providers are doing their best amidst an industrialized system that incentivizes profit margins over missions.

Therefore, my job is not to insult but to inspire. Enter the #GIEmpathyInitiative.

The GI Empathy Initiative

By Justin G. Brandler, MD Third Year GI Fellow, Michigan Medicine “I can’t trust a fart.”

“It’s so embarrassing being THAT person at the restaurant.”

“Is this enema even going in right?”

“All I see in the grocery store are red flags saying, ‘Nope…no…not that either.’”

Thoughts I never thought would cross my mind, but ones my patients face every day.

“DOCTOR” COMES FROM THE LATIN WORD “DOCERE” – “TO TEACH.” “Physician” is connected to the concept “to heal.” My mission in medicine is to become a master teacher and healer. Western medicine traditionally leans on testing and treatment algorithms to transport a patient from disease to health. While I love snaring polyps and achieving objective remission of Crohn’s disease, for me formulaic frameworks handicap physicians’ unique quality, one that artificial intelligence will never replace: authentic empathy for fellow human beings.

“Now nearing the starting line of my career, I will order thousands of tests, pills, and preps. What better time to take a stroll down the digestive aisle and figuratively step foot into my patient’s bathroom? Thus the #GIEmpathyInitiative was born.”

A Social Media Challenge to Appreciate GI Patients’ Experiences Now nearing the starting line of my career, I will order thousands of tests, pills, and preps. What better time to take a stroll down the digestive aisle and figuratively step foot into my patient’s bathroom? Thus the #GIEmpathyInitiative was born (Figure 1). As a belated New Year’s resolution, I challenged myself to experience firsthand what it is like to undergo some of the common things we prescribe or recommend to patients with disorders of GI function.

I invited others to join me on Twitter and posted my findings. The points meant nothing, but the experiences will last a lifetime.

Do as They Do While I cannot walk a mile in my patient’s J-pouch, I sure as heck can give myself an enema like she does every year before her flex sig. A lot of frustrations with patients surround the concept of “nonadherence” (the artist formerly known as “non-compliance”). But I realized that since I have never had to take a medication 30 minutes before eating or guzzled four liters of salty water, how could I feel frustrated with them for having persistent GERD or an inadequate prep on their colonoscopy?

Thus, I felt a powerful way to build therapeutic alliances was to prescribe myself some of the recommendations I ask my patients to adhere to. Even if I couldn’t always take away the unpleasantness of the experiences, at least they would know that they were not alone.

ACG Perspectives | 37

// PERSPECTIVES

Some Key Take-Aways from My Experience  Fiber: • Didn’t “start low or go slow” enough and faced the wrath of the “quiet toots” to my four-year-old’s delight • Important to warn household members about said potential wrath  Clear Liquid Diet 36h + >6L Go-Lytely Prep: • Worst part was fullness/nausea before the floodgates opened • I have prescriptive powers for more prep, but as a patient I would freak out if I was not clear by the last liter and have to re-schedule (especially if had to take day off work) • Doing a prep while watching a toddler = cautionary tale

Reflections on the GI Empathy Initiative Though this challenge clearly “brought work home,” I am a zealous advocate of healthy work/life boundaries. I recognize that endlessly bleeding hearts do eventually bleed out. However, this challenge starkly revealed to me how our patients might also be wounded as collateral damage from interacting with providers facing burn-out or moral injuries in the midst of a pandemic.

38 | GI.ORG/ACGMAGAZINE

 Low-FODMAP Diet: • If I had a history of an eating disorder, this would completely re-trigger me • Easy to restrict to <10 safe foods just to stop thinking • Separate meal preps & limited ingredient options can put strain on family if not on board • Shopping is confusing in areas of store you’re not used to + incredibly stressful if doing with small children • Beautiful online recipes abound but is expensive to get different foods + need family support  Enemas/Suppositories: • Stressful to decide if should hold longer, versus running to the bathroom • Hard to tell % of enema going into rectum, versus down the leg Based upon the reactions to my experiences posted by patients on social media, apparently just seeing a doctor feebly attempt to understand their invisible illnesses by trying a suppository has been validating to patients who may feel abandoned in the labyrinth of modern healthcare. One even described it as “invaluable.”

I believe empathetic patient care and sustainable provider wellness can be

synergistic, instead of mutually exclusive. Sometimes pushing into our patients’ challenges can actually remind us of why we went into medicine in the first place.

In a world where both providers and patients feel increasingly depersonalized, these occasional reminders can slowly shift the needle on our burnt out fuel tanks from surviving to thriving.

While your #GIEmpathyInitiative may look different than fiber and Febreze®, my hope is that we can more fully live into our professional identities as teachers and healers, one empathetic act at a time. , Further Reading: An inspirational book proving compassionate care makes a difference in hard outcomes: Trzeciak S, Mazzarelli A. “Compassionomics.” Pensacola, Fl, Studer Group, 2019.

Reference 1. Feingold JH, Drossman DA. Deconstructing stigma as a barrier to treating DGBI: Lessons for clinicians.

Neurogastroenterol Motil. 2021 Feb;33(2):e14080.

Epub 2021 Jan 23. PMID: 33484225.

Conversations with Women in GI Identifying Barriers for Patients and Providers Jill K. J. Gaidos, MD, FACG in Conversation with Lauren D. Nephew, MD, MAE, MSc

DR. LAUREN NEPHEW IS AN ASSISTANT PROFESSOR OF MEDICINE in the Division of Gastroenterology and Hepatology at Indiana University School of Medicine.

While she was in medical school, she completed a Master’s program in Bioethics and during her GI fellowship obtained a Master’s of Science degree in Clinical Epidemiology. She is a transplant hepatologist who focuses her research on understanding disparities in access to transplant among vulnerable populations and racial disparities in hepatocellular carcinoma outcomes. I was first introduced to Dr. Lauren Nephew and her work when I heard her speak about the importance of mentorship in her career. We were able to connect via Zoom to talk about building her career in hepatology, the importance of having mentors, and her drive to continue to each about the importance of diversity in medicine.

JG: I read that you have wanted to be a doctor ever since you were in the third grade. What got you interested in medicine?

LN: That’s an interesting question because both of my parents are creative folks, so not in the science sphere. So, my exposure to medicine was not really until medical school. But there was a pediatrician

“I knew I wanted to do something people-facing and I knew I liked science.

I knew doctors ask questions and interact with people, and that I could help people.”

that I was close to who I thought was really amazing and I said, “This seems like a cool job and he is really helping people.” So, I thought this would be interesting work. And I really enjoyed science early in school and I’m not quite sure how I made the connection between my Mars science project and medicine. We certainly weren’t learning about biology. But I loved asking questions and I loved inquiry, but I am not sure I knew that that translated into a job. My mom tells a story that the first job I wanted to do was to be a waitress. She asked me why I wanted to be a waitress and it was because I wanted to help people.

I told her in kindergarten that I wanted to be a waitress because I wanted to help people. And I thought, waitresses certainly help people.

JG: You go to a restaurant hungry, and you come out full. You’re better!

LN: You’re better, right? And they do a good job at it and they work with people. And I like people. I knew I wanted to do something peoplefacing and I knew I liked science.

I knew doctors ask questions and interact with people, and that I could help people. And I had a grasp of that in the third grade. By high school, I knew medicine and science were related and that there were three things that I could do in medicine: work with people, be a scientist, and help people.

JG: So, were you initially interested in pediatrics because of that experience?

LN: I was. I initially thought I would be a pediatrician because of my pediatrician. He was amazing. I didn’t want to transition. When he told me I needed to find an adult doctor, I was very devastated. When I started to hit puberty and was becoming a woman, he told me, “It’s probably time for you to find an adult doctor.” And I said, “Really?”

JG: But why? Right?

LN: Exactly, but why? So, yes, I initially thought that I would be a pediatrician and that’s what I told people for a

ACG Perspectives | 39

// PERSPECTIVES

long time: that I would be a doctor and I would be a pediatrician. I send him thank you cards sometimes. He retired recently. But he was a big inspiration as to why I went into medicine.

JG: You have since transitioned into transplant hepatology. What got you interested in studying barriers to liver transplantation and disparities in the care of patients with liver disease?

LN: When I started medical school, I did my first rotation in colorectal surgery, and I was lucky enough to work with Dr. Tracy Hull. She is a colorectal surgeon who I think is amazing and who gave me the idea, “I’m going to be a colorectal surgeon.” I’m very easily inspired, right (laughs). And she said, “Why do you want to be a colorectal surgeon?,” and I listed for her all of these reasons I wanted to be a colorectal surgeon. And she said, “You never once mentioned the operating room.

Lauren, there is one thing I can tell you about colorectal surgery, about being a woman in medicine, being a woman in surgery — it is a fulfilling role, but it is a challenging role. If you want to do it, I want you to do it, but I want you to love the OR because there are many sacrifices you will make as a woman in surgery and you have got to love every moment of being in the operating room and it has to be the number one reason you want to be a colorectal surgeon. Everything you named about why you like what I do, you can do as a gastroenterologist. I think you should do a GI rotation. If you don’t have that on your elective list, I think you should add that.” So, I added a GI rotation to my elective list and she was right. I absolutely loved GI. While I was on GI, I did two weeks on luminal and two weeks on liver. While I was on the liver rotation, someone said to me, “Why don’t you go to the liver transplant selection meeting?” And, I said, “Sure.” I was a medical student and they were trying to find some activities for me to do (laughs).

people’s lives were and how critical these decisions are, and yet how subjective they can be. And I was shocked by who was at the table making these decisions and how few of the people at the table I thought reflected and looked like the patients who actually have the diseases and need these transplants. And I said, “Wow! This is incredible. There were a bunch of mostly white men sitting around the table with sandwiches making decisions about people’s lives while they are getting pages.” And I was really shocked as a medical student by this.

JG: Some activities to fill your time (laughing).

LN: Fill my time with meaningful experiences, right?

JG: And sometimes the people making this decision have only met the patient once and are making this crucial decision based on that one interaction with the person.

LN: Right! And these are life and death decisions. And I kept asking the resident who was in the meeting with me, “Is there a computer algorithm?” I kept thinking there must be some big screen somewhere or somewhere there is something spitting out some objective that is going to tell us, “Yes, we transplant this person, or no we don’t.”

And he said, “No, what are you talking about?

They are going to discuss it and they are going to make a decision.” And I said, “Today?

They are going to make it today? On this person?” And I really had a hard time coming to terms with how these decisions are made and these are the people who are making these decisions. And so I said, “I have to learn more about this.” And that really started my journey into transplant hepatology and to researching barriers to access and barriers to care and scarce resource allocation. And my love for sick patients with liver disease also developed on that rotation because there were so many sick people and I love taking care of that patient population. So, it really all came to a beautiful head during those two weeks. During that time, I got a Master’s in bioethics because I said, “Certainly there’s got to be some ways to think about these things and talk about these principles in some formal way.” Case Western has a very strong bioethics program, so I got a Master’s in bioethics and really sat around and got to read. I wish had that time now.

JG: Exactly.

LN: So, I went and I was forever changed by that experience. Because I was really shocked by how subjective, in some ways, the decisions that were being made about

JG: I know! I think about that all the time.

Having time to read and think about things.

LN: Yes, to think and to write critically about these issues for no other reason than just the joy of doing it. It was a great time to just think

40 | GI.ORG/ACGMAGAZINE

“I absolutely loved GI. While I was on GI, I did two weeks on luminal and two weeks on liver.

While I was on the liver rotation, someone said to me, 'Why don’t you go to the liver transplant selection meeting?' And, I said, 'Sure.'”

and write about scarce resource allocation and social justice. So, that is where it was born, as a third-year medical student in a conference room on a liver rotation.

JG: You have what many consider a traditional academic career with 25% clinical duties and 75% research. Having an academic research career relies heavily on grant funding, which can be a major barrier for many who are initially interested in research. How did you establish a researchfunded career?

LN: A lot of practice. I wrote my first grant as a fellow. For me, I learn by doing. Everyone’s learning style is different. I think I’ve taken a grant writing course here or there, but for me it was learn by doing. I wrote an F32 grant as a fellow. I wrote an AASLD award as a fellow. And, I had really good mentors along the way who helped me. I also looked at a lot of examples of good grants and grants that didn’t score as well. And so, I got lucky that my first grant that I wrote got funded and that gave me a false sense of success (laughing).

JG: (laughing) You’re like, “Yeah, I got this!

It’s not that hard.”

LN: Right! It’s not been that easy since that time. But I do think, the more you do it, the better you get. At least for me, because that’s my learning style. Having good mentors, having lots of people read it, reading lots of other people’s grants, funded or not funded, so you can get an idea of what is getting funded. If people let you see their reviews about what needed to be changed, that is even more helpful. I have written a lot of grants and they have not all been funded.

JG: You also talk about diversity, equity, and inclusion and easily throw around terms like “URMs” (underrepresented minorities).

Do you feel like a lot of your colleagues understand that language or are you having to teach other people what that means and how to incorporate that type of thinking into today’s academic practice?

LN: There is a lot of teaching that I am doing and people who do this work are doing now. I think people are more open to learning about issues around disparities from a patient perspective, as well as around underrepresented minorities in academic medicine and in gastroenterology.

JG: Definitely.

LN: There is more discussion now about underrepresented minorities being missing from our physician workforce, and how this impacts the patients we care for, and how it even impacts our science. And how all of these factors interact to change, or not change, quite frankly.

“I really had a hard time coming to terms with how these decisions are made and these are the people who are making these decisions. And so I said, 'I have to learn more about this.' And that really started my journey into transplant hepatology and to researching barriers to access and barriers to care and scarce resource allocation.”

JG: Exactly.

LN: People are open to it and I am doing a lot more discussions around that. People of color in this space talk of a “minority tax.” This is a term that describes the real phenomenon of underrepresented minorities being called on to participate in institutional diversity efforts.

These are efforts that we often feel a real responsibility to participate in for the greater good of our communities and the patients we serve. However, these efforts are often labor-intensive and not valued as highly for promotion and tenure; and, while meaningful, don’t always end in the academic currency of publication. And if you are a Black woman, you may be “doubly taxed” to participate in both gender and race inclusion efforts!

It can be hard to find the balance between achieving enough career success to change the system that allowed this to become an issue and participating in these efforts. And you may choose to support equity through your community and may not have the interest or expertise in institutional efforts and that should be okay. For me, because I do this work and I’m passionate about it, I do find that I’m talking about it more, but I’m happy to do it.

JG: Because of your experience and background, do you feel that there are more people coming to you for mentorship and help establishing their career?

LN: I can’t say that there are more because I’m still fairly junior. I do certainly have a number of people who reach out to me from underrepresented minority backgrounds who are looking for someone who is from a similar background who has navigated this space because there are unique challenges for women, unique challenges for minorities, and, if you are a minority woman, then that can be even more challenging. So, there certainly can be people who reach out and you want to do as much as you can. I want to do as much as I can to help mentor but I have to be careful because I am fairly early in my career. I can only pull people up as far as I

ACG Perspectives | 41

// PERSPECTIVES

get. I can only spend so much time mentoring because I want to get to a place where I can be a good mentor, where I can be in those positions where I can really advocate and I can be at a table where I can make change.

It’s a challenging balance to know when to say perhaps I can’t take on another mentee.

So, I try to redirect people to other mentors who may be more senior than me at other institutions or let people know right from the jump what type of mentorship I can provide.

JG: One of the things that I’ve heard you mention that seems very simple but I don’t think many people do is to try to figure out what each mentee needs from the start. Not every mentee is going to want to have the same career as you or have the same needs as each other.

LN: That has been something that I had to figure out early on — not everyone is trying to be me. Once I figured that out, it’s much easier to meet people’s needs and set those goals early on. What is it that you need, what do I have time to give and then where can we meet in between? Sometimes it can be tough because I have had people reach out to me and I’ve had to say I can’t mentor you because I don’t have the time to give what you need. But I’ve had another mentee, and what she is looking for, I do have time to give. On the surface, if they were to see each other in a bar, the one person could say, “Dr. Nephew says she didn’t have time to mentor me.” But when we talked about what it was she was looking for, I couldn’t offer that at the moment, but the other mentee, what she needed, I could give. Just because a mentor turns you down, they may not turn down the next person but it may just be that they can’t give what you need right now.

JG: You have talked about microaggressions you have experienced in your career, including the increase in microaggressions when you don’t wear your white coat on rounds. I have certainly experienced this and I’m sure a lot of other women experience this in medicine.

LN: I always rounded with my white coat.

I’m not sure if COVID prompted me to leave off the white coat because I wanted to be able to wash everything and wanted to be a little bit more clean. And so I tried to round without my white coat and I noticed just a real increase in microagressions, and I was like, “Wow.” I was really shocked by

42 | GI.ORG/ACGMAGAZINE

how not wearing my white coat had really changed the tone of the microaggressions I was experiencing. I was on an all-female team when I experienced a really significant microaggression. I would call this a macroaggression because this was very overt.

Our team talked about it after that person left. And I regretted not acting in the moment.

“There is more discussion now about underrepresented minorities being missing from our physician workforce, and how this impacts the patients we care for, and how it even impacts our science. And how all of these factors interact to change, or not change, quite frankly.”

JG: Was it a patient?

LN: No, this was a consulting physician.

And I regretted that I didn’t respond in the moment. And I would say, sometimes you have to forgive yourself. Even with all of the training I have about how to respond to these microaggressions, I am still sometimes shocked, taken aback, and not sure what to do. I really was just stunned. I did debrief my team and we talked about it and if I had to do it again and how could I have redirected this situation. I give myself some grace if I don’t have that snappy and appropriate comeback.

JG: Thirty minutes later, you think, “I should have said this”.

LN: Yes, this is how I could have handled it.

It just doesn’t always happen the way you hoped.

JG: Right, because you have to process the situation. At first, all you’re thinking is, “Did that really just happen?”

LN: Yes, with all the training I’ve had, I still sometimes have a hard time responding in the moment. I gave myself some grace that I didn’t. And I debated whether or not to say something to that colleague afterwards and circle back. I ultimately decided not to. This is a tough situation.

JG: It’s hard. You want to do it because you think it’s going to make you feel better but in reality you could walk away feeling worse and they may not have learned anything from the situation.

LN: It’s hard to navigate. In an ideal world, you experience a microaggression, you deal with it right then so that person can, in the moment, see what they did. You point it out, you redirect, you move on. Or shortly thereafter, you can bring it up to them and say, “This is what happened. This is how it made me feel. This is how it could have been handled better.” In reality, these are our colleagues that we have to work with frequently, we are in a COVID pandemic, people are stressed, people are behaving in

ways that they may not normally. You have to decide, is this is a frequent occurrence, is this something that has happened many times with this colleague, what is the risk/benefit ratio for this? And I think that’s where I am with these microaggressions. If it’s someone I need to interact with a lot, if it’s someone in my division, if it’s someone in my research group, has it happened multiple times? Then I think it’s worth dealing with because you are going to have to work with this person and so you can’t continue to feel or have that person do that to you and put you in that space. For someone you may not see again until you round together again three years from now, then it may not be worth it. And, it takes a lot of effort on the part of the person who has to address these. It takes a lot of effort on my part to have to confront every microaggression; it’s draining, exhausting. So, for me, I have to decide which battles to fight.

And, for me, it’s a risk/benefit ratio. And only the ones that I think people may actually be willing to change and if I’m going to have to interact with that person on a regular basis and it’s happened on multiple occasions are really worth the effort. It was definitely worth talking to my team about.

JG: Oh, absolutely!

LN: And helping them as women to understand that these things happen. “Did you all see this? We all saw this. We were all a part of this.” I wished that I had handled it differently and we talked about some of the things I could have done so we all learn from the experience.

JG: Sometimes we get into the situation where the microaggression is directed at one of our trainees, which we handle very differently. We may be more likely to brush off a comment directed at ourselves, however we feel much more obligated to speak up for someone on our team.

LN: Right, you feel some sense that you need to protect your team. Whereas, if it’s you, you spend the first three minutes trying to figure out, did this happen? Then you spend the next few minutes wondering if you are being overly sensitive.

“...[I]t takes a lot of effort on the part of the person who has to address these [microagressions].

It takes a lot of effort on my part to have to confront every microaggression; it’s draining, exhausting. So, for me, I have to decide which battles to fight.

And, for me, it’s a risk/ benefit ratio. And only the ones that I think people may actually be willing to change and

as you can is probably the most important piece of advice. It is critical if you want to do mostly research because it’s really, really hard to have five clinics per week, two endoscopy sessions, attempt to write a grant and have a full family life at home. So, trying to get your time protected, negotiating for that, and asking for it, whether you have funding or not.

If this is what you want to do and you have some publications from fellowship that show you have some track record in science, ask for protected time for at least a year and ask for money for statistical support, or whatever it is you need to get yourself started. Some people don’t ask because they assume they won’t get it, and you might not, but it’s worth asking to situate yourself, to get your program going. If you are going to do bench research, that is a whole other beast, in terms of money, because you need a lot more money to do that, but the spirit of asking for what you need upfront is still the same.

JG: I think it’s also important to think about mentors outside of your institution because there are still a lot of places where there aren’t many women in academics in gastroenterology and hepatology.

LN: In terms of finding mentorship, in this world of Zoom, three years ago we may not have realized just how cross-institutional we could be. It was always here, but I don’t think we realized how much we could collaborate.

Even to the NIH, you can much more reasonably say, “I’m going to have this mentor and we are going to meet quarterly by Zoom and will meet in person annually,” and it will fly.

if I’m going to have to interact with that person on a regular basis

Jill K. J. Gaidos, MD, FACG, Dr. Gaidos is Associate Professor at Yale School of Medicine Section of Digestive Diseases and Director of Clinical Research for the Yale IBD Program.

and it’s happened on multiple occasions are really worth the effort.”

Lauren D. Nephew, MD, MAE, MSc, Dr. Nephew is Assistant Professor of Medicine in the Division of Gastroenterology and Hepatology at Indiana University School of Medicine.

JG: Exactly! What advice do you have for women who are interested in a career in academic research, particularly related to obtaining grant funding and finding a mentor?

LN: Getting your time protected as early

ACG Perspectives | 43

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Introducing The New ACG Visiting Scholar in Equity, Diversity & Ethical Care THE ACG VISITING SCHOLAR IN EQUITY, DIVERSITY & ETHICAL CARE is a new initiative of The ACG Institute’s Center for Leadership, Ethics & Equity that aims to create awareness around the issues and challenges of delivering equitable care, respecting diversity, and instilling ethical decision making. This unique opportunity allows the Visiting Scholar to provide onsite lectures and grand rounds as an added

component to the current structure of the well-respected ACG Edgar Achkar Visiting Professorship (EAVP) program that brings distinguished faculty to GI training programs. Of the 12 EAVP visits scheduled for 2022, six institutions opted to invite speakers as part of this new program. Their DEI talks are often delivered in conjunction with a disease state topic and a key goal is to bring attention to health disparities and health equity. The ACG Institute created the Visiting Scholar in Equity, Diversity & Ethical Care to help promote these values to institutions so that they can provide sensitive

care to patients of many different backgrounds. The more comfortable patients feel, the more likely they are to seek care to improve their health outcomes.

­ CG’S FIRST VISITING A SCHOLAR IN EQUITY, DIVERSITY & ETHICAL CARE: DR. FOLASADE MAY On March 11, 2022, Geisinger Medical Center welcomed Folasade P. May, MD, PhD, MPhil, as ACG’s first Visiting Scholar in Equity, Diversity & Ethical Care.

She presented virtually to an

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// EDUCATION

audience of GI fellows, GI faculty, department of medicine faculty, and health system leadership on “Pursuing Equity in Colorectal Cancer Screening and Outcomes” and addressed issues of diversity, equity, and inclusion. Dr. May held a few one-on-one meetings with faculty where they were able to have deeper discussions on promoting health equity. Dr. May also met with GI fellows for continued conversation. After her lecture, she participated in a roundtable discussion with Geisinger GI leadership, health system leadership, and members of the Health Equity Committee at Geisinger.

“The fellows were inspired by Dr. May and her accomplishments, got practical academic and career advice, and had answers to specific clinical questions related to colorectal cancer screening/ surveillance. The fellows also learned how gastroenterologists can promote health equity in GI and in medicine in general.” —Benyam D. Addissie, MD, Geisinger Medical Center 2022 EAVP VISITS UNDERWAY

“This program is a unique opportunity for experts and thought leaders in DEI to share their research nationally and also to develop relationships with other professionals who are interested in or working in DEI. I have already had one follow-up meeting with a member of the Geisinger Health System leadership to discuss DEI efforts and projects.” —Dr. May

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The EAVP Program benefits the hosting institution, as well as the visiting professors. Institutions report on the exciting opportunity to host high-quality visiting professors to bolster their training program by providing lectures, small group discussions, and one-on-one visits with trainees and faculty. The visiting professors also report how rewarding it is to engage with fellows and share their experience.

The ACG Institute is grateful to all the programs that have hosted visiting professors so far in 2022 and recognizes with great thanks the faculty featured in this issue of ACG MAGAZINE. Mark B. Pochapin, MD, FACG, visited University of Virginia and Rachel Issaka, MD, MAS, visited Mount Sinai Hospital in New York City.

Mark B. Pochapin, MD, FACG, Visit to University of Virginia - March 18, 2022 Dr. Pochapin of NYU Langone Health presented on colorectal cancer disparities and the future of CRC screening with enhanced colonoscopy (cuffs, AI, and robots), blood, breath, and stool testing.

“Dr. Pochapin tied in the screening rates within our state and some of the history of the bills passed by the Virginia state legislature. I think the broad implications of this GI topic to all of internal medicine was very clear from Dr. Pochapin’s visit.” —Neeral Shah, MD, University of Virginia

Rachel Issaka, MD, MAS, Visit to Mount Sinai Hospital, New York City - March 25, 2022 Dr. Issaka of Fred Hutchinson Cancer Center gave two talks as a Visiting Scholar in Equity, Diversity & Ethical Care: “Disparities in Care, Fellows Clinics, Outpatient GI” and “Racial, Ethnic and Socioeconomic Disparities in Colorectal Cancer Outcomes.”

“Meeting with the fellows was absolutely energizing!

They were engaged and had thoughtful questions about their next career steps! They were such a fun group and I’m honored I had the opportunity to meet with them!” —Dr. Issaka “Dr. Issaka’s grand rounds provided listeners with a framework to think about the impact of the social determinants of health on colorectal cancer outcomes and ideas on how to combat such disparities with the goal of achieving health equity in outcomes… Hearing Dr. Issaka speak on her own career trajectory from trainee to junior faculty and how she navigated career decisions and negotiations was very much appreciated by the fellows.” —Christina Wang, MD, Mount Sinai Hospital

2022

ACG EDGAR ACHKAR VISITING PROFESSORSHIPS *Visiting Scholar in Equity, Diversity, and Ethical Care

FOLASADE P. MAY, MD, PHD, MPHIL* Geisinger Medical Center MARCH 11 MARK B. POCHAPIN, MD, FACG* University of Virginia MARCH 18 RACHEL ISSAKA, MD, MAS* Mount Sinai Hospital MARCH 25 DAVID T. RUBIN, MD, FACG The University of Texas Health Science Center at Houston APRIL 14 NICOLE E. RICH, MD* University of Miami APRIL 21 TYLER BERZIN, MD Cleveland Clinic APRIL 27 MARCELO F. VELA, MD, MSCR, FACG Tufts Medical Center MAY 12-13 SATISH S.C. RAO, MD, PHD, FACG The Wright Center for GME MAY 31 SOPHIE M. BALZORA, MD, FACG* Mayo Clinic Arizona JUNE 9 RENEE L. WILLIAMS, MD, MHPE, FACG* Loma Linda University Medical Center JUNE 22 ALLISON R. SCHULMAN, MD, MPH University of Pittsburgh School of Medicine SEPTEMBER 14-15 BRIAN E. LACY, MD, PHD, FACG University of South Alabama SEPTEMBER 21-22 EDWARD V. LOFTUS, JR., MD, FACG UC Riverside SEPTEMBER 22-23

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.

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2021 ACG North American International GI Training Grant Giselle Mahoro, MD, Gastroenterology Fellow, Thomas Jefferson University Hospital

“My days were very busy, with 20 to 25

In 2021, Giselle Mahoro, MD, was selected as the recipient of the ACG North American International GI Training Grant, which provides financial support to early career U.S. and Canadian fellows or physicians to receive training in GI and hepatology outside of North America to gain new knowledge or technical skills. Dr. Mahoro’s background as a refugee immigrant from Rwanda and experience at a teaching hospital in Uganda during her medical residency inspired a lifelong commitment to global health and advancing access to GI care. Dr. Mahoro, a GI fellow at Thomas Jefferson University Hospital, reflects on her experience training internationally in Rwanda at University Teaching Hospital of Kigali.

I had the honor of being awarded the 2021 ACG North American International GI Training Grant. This grant allowed me to spend six weeks at University Teaching Hospital of Kigali (CHUK).

Access to endoscopy services is very limited in Rwanda. Endoscopy is performed by general medicine providers, some of whom were taught

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procedures per day — mostly diagnostic upper endoscopy. The majority of patients had complications from H. pylori-related peptic ulcer disease.”

Top photo: Dr. Mahoro and endoscopy nurse Francine Bottom photo: (L-R) Dr. Steve Bensen, Dr. Vincent Dusabijambo, Dr. Giselle Mahoro

by visiting GI faculty. I spent my time in the endoscopy suite working alongside an amazing team of dedicated physicians who run the unit, including Dr. Eric Rutanganda, Dr. Francois Ngabonziza, Dr. Vincent Dusabijambo, and Dr. Benoit Seminega, who also served as my teachers and mentors.

My days were very busy, with 20 to 25 procedures per day — mostly diagnostic upper endoscopy. The majority of patients had complications from H. pylori-related peptic ulcer disease. I saw a lot of gastric cancer, with most patients presenting at late stage with gastric outlet obstruction and gastrointestinal bleeding. I have since developed a special interest in gastric cancer and I plan to pursue clinical research in the near future. Anesthesia was available on most days, but not every day. With help from my mentors, I learned how to perform upper endoscopy without sedation.

My favorite part of the trip was the relationships and connections I made with the faculty and staff at CHUK. I spent countless hours with endoscopy nurses, many of whom became dear friends. I also had the opportunity to teach and interact with medical students and residents who were rotating on endoscopy. I am hoping to return to CHUK this fall, and I am excited to continue building relationships and collaborating with the team at CHUK. I am so grateful to the American College of Gastroenterology for providing support for this trip; my mentors and program leadership at Thomas Jefferson University for allowing me to pursue this non-traditional path during fellowship training; Dr. Damascene Kabakambira, the head of Internal Medicine at CHUK, for coordinating and connecting me with the right people to figure out logistics; Dr. Akwi Asombang, my mentor in global health; and my co-fellows for being flexible so that I could pursue this unique opportunity.

Inside the

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NEW GUIDELINES ARE A PERENNIAL FAVORITE in The American Journal of Gastroenterology and two have published recently. Neena S. Abraham, MD, MSc, (Epi), FACG, and co-authors developed new joint ACG-CAG Guidelines on the Management of Anticoagulants and Antiplatelets During Acute Gastrointestinal Bleeding and the Periendoscopic Period. Nicholas J. Shaheen, MD, MPH, MACG, led the group updating ACG’s Clinical Guidelines for the Diagnosis and Management of Patients with Barrett’s Esophagus.

In Clinical and Translational Gastroenterology, Kochar, et al., address an urgent need for evidence-based and systematic methods to guide treatment decision-making in older adults with chronic GI conditions.

Nicholas M. McDonald, MD, a third-year GI fellow at the University of Minnesota and member of the Editorial Board of ACG Case Reports Journal, authored a “Letter from the Editor” on highly effective teams in the endoscopy unit.

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

AJG: NEW GUIDELINES New Joint ACG-CAG Guidelines on the Management of Anticoagulants and Antiplatelets During Acute Gastrointestinal Bleeding and the Periendoscopic Period  In the first update since 2016 to

clinical guidelines on the management of patients on common anticoagulant and antiplatelet therapies during gastrointestinal (GI) bleeding or undergoing elective endoscopy, authors from the American College of Gastroenterology (ACG) and the Canadian Association of Gastroenterology (CAG) implemented rigorous systematic reviews of predefined clinical questions and used the GRADE approach to develop recommendations for challenging clinical scenarios faced by endoscopists.

The joint ACG-CAG guidelines propose evidence-based recommendations for the periendoscopic management of anticoagulant and antiplatelet drugs during acute GI bleeding and the elective endoscopic period. An international, multisociety, and multidisciplinary working group addressed clinical questions related to 1) temporary interruption of anticoagulant and antiplatelet drugs; 2) reversal of anticoagulant and antiplatelet drugs; 3) periprocedural heparin bridging; and, 4) postprocedural resumption of anticoagulant and antiplatelet drugs.

Read the Guidelines, Abraham, et al.

American College of GastroenterologyCanadian Association of Gastroenterology Clinical Practice Guideline: Management of Anticoagulants and Antiplatelets During Acute Gastrointestinal Bleeding and the Periendoscopic Period. Neena S. Abraham, MD, MSc (Epi), FACG; Alan N. Barkun, MD, MSc (Epi), FACG, CAGF; Bryan G. Sauer, MD, MSc (Clin Res), FACG; James Douketis, MD; Loren Laine, MD, FACG; Peter A. Noseworthy, MD; Jennifer J. Telford, MD, MPH, FACG, CAGF; and Grigorios I. Leontiadis, MD, PhD, CAGF. Am J Gastroenterol 2022;00:1–17.  READ bit.ly/ACG-CAG-Abraham-etal 50 | GI.ORG/ACGMAGAZINE

Clinical Practice Guideline Dissemination Tool Aids Patient Management As a reference and companion to the guidelines, the authors developed a separate publication for clinicians to operationalize their recommendations including practical algorithms and contextual guidance, including where evidence is sparse, weighing the patients’ risk of thromboembolic event versus the procedural risk of GI bleeding.

This dissemination tool published in the AJG Red Section.

Clinical Practice Guideline Dissemination Tool (Barkun, et al.)

Management of Patients on Anticoagulants and Antiplatelets During Acute Gastrointestinal Bleeding and the

Periendoscopic Period: A Clinical Practice Guideline Dissemination Tool. Alan N. Barkun, MD, MSc (Epi), FACG, CAGF, James Douketis, MD, Peter A. Noseworthy, MD, Loren Laine, MD, FACG, Jennifer J. Telford, MD, MPH, FACG, CAGF and Neena S. Abraham, MD, MSc (Epi), FACG Am J Gastroenterol 2022;00:1–7.  READ bit.ly/ajg-red-section-

antithrombotics-tool  LISTEN bit.ly/ajg-abraham-podcast Dr. Neena Abraham in conversation with AJG Co-EIC Dr. Millie Long on the newly updated ACG-CAG guidelines.

Figure 1. Management of patients on anticoagulants in the setting of acute gastrointestinal bleeding.

Revised ACG Clinical Guidelines for the Diagnosis and Management of Patients with Barrett’s Esophagus  Guidelines by Shaheen, et al., published in

The American Journal of Gastroenterology in April implement GRADE methodology to propose 21 recommendations for the definition and diagnosis of BE, screening for BE and esophageal adenocarcinoma, surveillance of patients with known BE, and the medical and endoscopic treatment of BE and its associated early neoplasia. Important changes since the previous iteration of this guideline include a broadening of acceptable screening modalities for BE to include nonendoscopic methods, liberalized intervals for surveillance of short-segment BE, and volume criteria for endoscopic therapy centers for BE. The authors recommend endoscopic eradication therapy for patients with BE and high-grade dysplasia and those with BE and low-grade dysplasia.

They propose structured surveillance intervals for patients with dysplastic BE after successful ablation based on the baseline degree of dysplasia. The guidelines do not make recommendations regarding chemoprevention or use of biomarkers in routine practice due to insufficient data.

Read the Guidelines, Shaheen, et al.

Diagnosis and Management of Barrett's Esophagus: An Updated ACG Guideline Nicholas J. Shaheen, MD, MPH, MACG; Gary W. Falk, MD, MS, FACG; Prasad G. Iyer, MD, MSc, FACG; Rhonda F. Souza, MD; Rena H. Yadlapati, MD, MHS, FACG (GRADE Methodologist); Bryan G. Sauer, MD, MSc, FACG (GRADE Methodologist); Sachin B. Wani, MD, The American Journal of Gastroenterology: April 2022 - Volume 117 - Issue 4 - p 559-587 doi: 10.14309/ ajg.0000000000001680  READ bit.ly/acg-barretts-guideline

Guideline to Practice: Diagnosis and Management of Barrett’s Esophagus: An Updated ACG Guideline In a separate publication in the AJG Red Section, the guideline authors recognize that “…implementation of information in guidelines can be fraught with difficulty. While guideline recommendations generally provide straightforward pronouncements, given the complexities of patient care, in practice, implementing recommendations can be difficult.”

They present three clinical vignettes that demonstrate application of guidance to the bedside in commonlyencountered situations as a way to demonstrate implementation of information in the updated ACG Barrett’s esophagus guideline.  READ bit.ly/ajg-barretts-red-section  LISTEN bit.ly/ajg-shaheen-podcast

[CLINICAL & TRANSLATIONAL GASTROENTEROLOGY]

The 5Ms of Geriatrics in Gastroenterology: The Path to Creating Age-Friendly Care for Older Adults with Inflammatory Bowel Diseases and Cirrhosis Bharati Kochar, MD, MS; Nneka N. Ufere, MD, MSCE; Christine S. Ritchie, MD, MSPH; Jennifer C. Lai, MD, MBA Clinical and Translational Gastroenterology: January 2022 - Volume 13 - Issue 1 - p e00445 doi:10.14309/ctg.0000000000000445

“There is an urgent need for evidence-based and systematic methods to guide treatment decisionmaking in older adults with chronic GI conditions.”  “THE NUMBER OF AMERICANS 65 YEARS OR OLDER in 2060 will be more than double what it was in 2014.

Approximately 40% of patients seen in gastroenterology and hepatology practices in the United States are 60 years or older. Adapting care delivery models, curating data on shifting risk-benefit decisions with geriatric syndromes, understanding appropriate assessments, and focusing on tailored implementation strategies are challenges that are actively confronting us as we provide care for a burgeoning population of older adults.

Limited availability of geriatric specialists results in an onus of specialists caring for older adults, such as gastroenterologists, to innovate and develop tailored, comprehensive, and evidence-based care for adults in later life stages.

In this article, we present the 5M framework from geriatrics to achieve age-friendly healthcare. The 5Ms are

medications, mind, mobility, multicomplexity, and what matters most. We apply the 5M framework to 2 chronic conditions commonly encountered in clinical GI practice: inflammatory bowel diseases and cirrhosis. We highlight knowledge gaps and outline future directions to expand evidence-based care and advance the creation of age-friendly GI care.”  READ: bit.ly/ctg-kochar-geriatric

Figure 1. Screenshots of the RxWell app: (a) RxWell home page, (b) task selection interface, (c) platform for health coach interactions.

Image Source: Mayo Clinic

Figure 6. Suggested algorithm for post-CEIM surveillance in patients treated endoscopically for dysplastic BE. Panel a demonstrates the patient's pretreatment long-segment BE, with a maximal extent of 9 cm and a circumferential extent of 7 cm. Panel b demonstrates the posttreatment esophagus, with previous areas of BE demonstrating neosquamous epithelium.

[ACG CASE REPORTS JOURNAL]

Learning From Highly Effective Teams: What Can We Apply to the Gastrointestinal Endoscopy Unit Team?

Nicholas M. McDonald, MD, Division of Gastroenterology and Hepatology, University of Minnesota Medical Center, Minneapolis, MN ACG Case Reports Journal: February 2022 - Volume 9 - Issue 2 - p e00745 doi: 10.14309/ crj.0000000000000745

Dr. McDonald, a member of the ACG Case Reports Journal 2021-2022 Editorial Board, reflects on lessons from sports and the business world and applies them to the experience of the endoscopy unit in this

letter published in February 2022.

“In sports, transparent and effective leadership is essential for a highly effective team. It is also imperative to have clear and effective leadership in the endoscopy unit. The role of the endoscopist may be seen similarly to the role of team captain in cricket—role modeling best practices and motivating team members. Many traits of an exceptional endoscopic leader have been previously reported, including a recent article about scopesmanship. One area where endoscopic units differ from highly effective teams in sports is the lack of a coach. In this regard, endoscopy unit teams may stand to learn from athletics. Although the captain (endoscopist) provides leadership within the case, it is the coach's role to provide high-level oversight and guidance. Atul Gawande

wrote, “No matter how well prepared people are in their formative years, few can achieve and maintain their best performance on their own.” Gawande wrote about the benefits of coaching for elite performers, including surgeons to achieve their personal best. It may be beneficial for endoscopists to consider having a senior or effective colleague play the role of coach by watching the endoscopist perform procedures and giving advice or guidance on improving team effectiveness.”  Listen: bit.ly/acgcrj-podcast-mcdonald Dr. McDonald in conversation with ACGCRJ CoEICs Dr. Katie Falloon and Dr. Judy Trieu

 Read: bit.ly/acgcrj-mcdonald-2022

Table 1. HIghly Effective Qualities Applied to Endoscopy Highly Effective Team Quality

Application to Endoscopy

Effective Communication

Ensure closed loop communication with endoscopy unit staff and solicit deedback on how to communicate more effectively.

Leadership

Endoscopist role modeling best practices and motication of team members. Consider designating an ecperiences "coach" to observe interations and recomment tips to improve teamwork.

Task Analysis

Identify skills of staff members and determine what knowledge, skills, and abilities will be required for an endoscopy unit. Ensure team members have the appropriate skills or recieve training.

Team Composition

Identify the number of staff and roles needed to preform required tasks. Ensure tasks are staffed with the appropriate amount of people to be successful.

Inside the Journals | 51

About About Inflammatory Inflammatory Bowel Bowel Disease Disease (IBD) (IBD) Information from the American College of Gastroenterology on Ulcerative Colitis and Crohn’s Disease Information from the American College of Gastroenterology on Ulcerative Colitis and Crohn’s Disease

an umbrella term for the chronic gastrointestinal inflammatory INFLAMMATORY BOWEL DISEASE (IBD) isconditions and Crohn’s disease. inflammatory is an umbrella term forcolitis the chronic gastrointestinal INFLAMMATORY BOWEL DISEASE (IBD) conditions ulcerative ulcerative colitis and Crohn’s disease.

ABOUT 7 MILLION PEOPLE WORLDWIDE ARE LIVING WITH IBD, ABOUT MILLIONFEMALES PEOPLEandWORLDWIDE AREMALES. LIVING WITH IBD, nearly 3.97MILLION nearly 3.0 MILLION nearly 3.9 MILLION FEMALES and nearly 3.0 MILLION MALES.

AGE 15 TO 35

The mostAGE common age35 of onset of 15 TO IBDmost is between 15 age and of 35onset years.of The common IBD is between 15 and 35 years.

25% BY AGE 20

Environment

WHAT CAUSES Ulcerative WHAT Ulcerative Colitis CAUSES and Crohn’s Disease?

Colitis and Crohn’s Disease?

Causes are poorly understood but Causes are poorly but may include genes,understood immune system, may include genes, immune system, environment, and gut microbiome. environment, and gut microbiome.

25%25% of people with IBD

BY AGE 20 are diagnosed ageIBD 20.are 25% of peopleby with diagnosed by age 20.

HEALTHY DIET HEALTHY DIET

Immune System Immune

IBD IBD

System

Genes Genes

Gut Microbiome Gut Microbiome

 Maintain a diverse and nutrient-rich diet.

Consult with your doctor or dietitian diet. before making any changes to your diet.  Maintain a diverse and nutrient-rich  Consult with your doctor or dietitian before making any changes to your diet.

PREVENTIVE Health & Vaccines PREVENTIVE & Vaccines  It is importantHealth for people with IBD to receive a vaccine be fully COVID-19 It is important forand people withvaccinated.

IBD to receive a COVID-19 vaccine and be fully vaccinated.

Talk to your doctor about  safety and appropriate Talk to your doctor about timing of vaccinations for:  safety and appropriate •timing influenza of vaccinations for: pneumococcal •• influenza pneumonia • pneumococcal • herpes zoster pneumonia other vaccine•• herpes zoster preventable diseases • other vaccinepreventable diseases

Environment

 screening for: osteoporosis  •screening for: cervical cancer •• osteoporosis •• melanoma and cervical cancer non-melanoma • melanoma and skin cancer non-melanoma • colorectal skin cancercancer  •identification of colorectal cancer depression and  identification of anxiety  smoking cessation depression and anxiety  smoking cessation

TIPS to Make the Most of TIPS MakeVisit the Most of Your to Doctor Your Doctor Visit Before the visit

• Do some research before you go Before the visit Write down questions andyou answers •• Do some research before go Bring along trusted family member •• Write down aquestions and answers friend • or Bring along a trusted family member or Duringfriend the visit

• Be specific During the visitwhen describing how you feel Don’t be afraid todescribing ask questions—even a lot of questions!

•• Be specific when how you feel Speakbe upafraid if something is confusing—your doctor wants •• Don’t to ask questions—even a lot of questions! to up understand • you Speak if something is confusing—your doctor wants you to understand Remember: IBD may vary among patients, so discuss goals and

options for treatment and among monitoring strategies suitable forand you.

Remember: IBD may vary patients, so discuss goals options for treatment and monitoring strategies suitable for you.

ACG supports The Crohn’s & Colitis Foundation Open Restrooms Movement to make moresupports restrooms available with urgentOpen bathroom needs Movement (whatever the cause).

ACG The Crohn’sto&patients Colitis Foundation Restrooms to make www.crohnscolitisfoundation.org/openrestrooms more restrooms available to patients with urgent bathroom needs (whatever the cause). www.crohnscolitisfoundation.org/openrestrooms  Download “We Can’t Wait: Restroom Access App” via Apple App Store or Google Play  Download “We Can’t Wait: Restroom Access App” via Apple App Store or Google Play

YOU ARE NOT ALONE! Gastroenterologists know about IBD and can YOU ARE NOT ALONE! help you find treatments work.

Gastroenterologists knowthat about IBD and can help you find treatments that work.

 Learn More: gi.org/patients/IBD  gi.org/patients/IBD  Learn Find aMore: gastroenterologist near you: gi.org/FindaGI  Find a gastroenterologist near you: gi.org/FindaGI

American College of Gastroenterology | gi.org | Follow ACG on Twitter @AmCollegeGastro American College of Gastroenterology | gi.org | Follow ACG on Twitter @AmCollegeGastro

52 | GI.ORG/ACGMAGAZINE

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

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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