ACG Magazine | Vol. 7, No. 3 | Fall 2023

ACG MAGAZINE Fall 2023

MEMBERS.

APPLY for an ACG Clinical Research Award

Deadline: Monday, December 4, 2023

ACG Junior Faculty Development Award

$150,000 a year for three years

Established Investigator Bridge Funding Award

Up to $150,000 a year for two years

*NOTE: NEW Eligibility Criteria

Health Equity Research Award

Up to $75,000 (50k year-one, 25k year-two based on progress) for actionable science that will reduce health and/or healthcare disparities

ACG/ASGE Epidemiologic Research Award in Gastrointestinal Endoscopy

Up to $50,000 for research utulizing the GIQuIC database

Learn more about ACG 2024 Clinical Research Opportunities and Submit Your Application:

GI.ORG/GRANT-ANNOUNCEMENTS

Clinical Research Award

Up to $50,000 for clinical research

Clinical Research Pilot Award

Up to $15,000 for pilot projects

Resident Clinical Research Award

Up to $10,000

Medical Student Research Award

Up to $5,000 for 6–10 week summer project

FEATURED CONTENTS

TALES FROM GIQUIC

Leadership, members, and grantees of the GI Quality Improvement Consortium (GIQuIC) discuss the value of the registry for measuring quality and advancing health outcomes. PAGE 28

CONTENTS

6 // MESSAGE FROM THE PRESIDENT

Dr. Daniel Pambianco on the College’s advocacy efforts opposing a new prior authorization policy by UnitedHealthcare

7 // NOVEL & NOTEWORTHY

Memorial tributes to two ACG members, intersociety diversity and global health initiatives, state-level advocacy & more

17 // TRAINEE HUB

THE ESSENTIAL GUIDE FOR NEW GI FELLOWS

Tips from fellows for navigating training as a new GI fellow

23

// GETTING IT RIGHT

Insights on handling medical malpractice claims and legal action

28 // COVER STORY TALES FROM GIQUIC GIQuIC leadership, members, and grantees discuss the value of the registry for GI quality improvement

39 // ACG PERSPECTIVES

39 CULINARY CONNECTIONS Fall flavors inspired by Autumn from the #ACGfoodies

43 ACG INTERNATIONAL TRAINING GRANT Dr. Kartik Natarajan at Mayo Clinic Rochester

45 ACG INTERNATIONAL TRAINING GRANT Dr. Stella-Maris Chinma Egboh at Beth Israel Deaconness Medical Center & Massachusetts General Hospital

47 INTERNATIONAL SPOTLIGHT Endoscopist Dr. Fabian Emura in conversation with Dr. Sarah McGill

51 // INSIDE THE JOURNALS

52 AJG

New ACG acute liver failure guidelines and accompanying podcast with first author Dr. Alexandra Shingina

52 CTG

Clinical Value of Multi-Omics-Based Biomarker Signatures in Inflammatory Bowel Diseases: Challenges and Opportunities by Bourgonje, et al

53 ACGCRJ

Introducing the 2023–2024 ACG Case Reports Journal Editorial Board

54 // REACHING THE CECUM

ABOUT DIVERTICULOSIS/DIVERTICULITIS

A patient infographic about diverticulosis and diverticulitis from ACG's Patient Care Committee

“Photography reminds me to slow down and pause to capture the moment both literally and figuratively...”

—Dr. Linda Nguyen, “GI Eye” PG 8

ACG MAGAZINE

CONNECT WITH ACG MAGAZINE STAFF

youtube.com/ACGastroenterology

Executive Director

Bradley C. Stillman, JD

Editor in Chief; Vice President, Communications

Anne-Louise B. Oliphant

Manager, Communications

Becky Abel

Art Director Emily Garel

Senior Graphic Designer Antonella Iseas

BOARD OF TRUSTEES

President: Daniel J. Pambianco, MD, FACG

President-Elect: Jonathan A. Leighton, MD, FACG

Vice President: Amy S. Oxentenko, MD, FACG

Secretary: Costas H. Kefalas, MD, MMM, FACG

Treasurer: William D. Chey, MD, FACG

Immediate Past President: Samir A. Shah, MD, FACG

Past President: David A. Greenwald, MD, FACG

Director, ACG Institute: Neena S. Abraham, MD, MSc, MACG

Co-Editors, The American Journal of Gastroenterology:

Jasmohan S. Bajaj, MD, MS, FACG

Millie D. Long, MD, MPH, FACG

Chair, Board of Governors: Dayna S. Early, MD, FACG

Vice Chair, Board of Governors: Sita S. Chokhavatia, MD, MACG

Trustee for Administrative Affairs: Irving M. Pike, MD, FACG

TRUSTEES

Jean-Paul Achkar, MD, FACG

Seth A. Gross, MD, FACG

David J. Hass, MD, FACG

Immanuel K. H. Ho, MD, FACG

James C. Hobley, MD, MSc, FACG

Nicholas J. Shaheen, MD, MPH, MACG

Aasma Shaukat, MD, MPH, FACG

Neil H. Stollman, MD, FACG

Renee L. Williams, MD, MHPE, FACG

Patrick E. Young, 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

11333 Woodglen Drive, Suite 100 North Bethesda, MD 20852 (301) 263-9000 | gi.org

DIGITAL EDITIONS

GI.ORG/ACGMAGAZINE

American College of Gastroenterology is an international organization with more than 18,000 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.

Jean-Paul Achkar, MD, FACG

Dr. Achkar is the Rainin Endowed Chair for IBD Research and GI Fellowship Program Director at The Cleveland Clinic. He is a Trustee of the College and serves as Chair of the IBD Measures Subcommittee for GIQuIC.

Douglas G. Adler, MD, FACG

Dr. Adler is Director of the Center for Advanced Therapeutic Endoscopy (CATE) at Centura Health-Porter Adventist Hospital in Denver, CO.

Brett B. Bernstein, MD, MBA, FASGE

Dr. Bernstein is Chief of Gastroenterology and Clinical Associate Professor of Medicine at Mount Sinai Beth Israel Hospital. He serves as Chair of the Measures Steering Committee for GIQuIC.

Seth Crockett, MD, MPH

Dr. Crockett is an Associate Professor at Oregon Health & Science University. He received the ACG/ASGE Epidemiological Research Award in Gastrointestinal Endoscopy in 2022.

Jason A. Dominitz, MD, MHS, FASGE

Dr. Dominitz is National Director for Gastroenterology and Professor of Medicine at the Veterans Health Administration and the University of Washington. He received the ACG/ASGE Epidemiological Research Award in Gastrointestinal Endoscopy in 2021.

Katie A. Dunleavy, MB BCh BAO

Dr. Dunleavy is a second-year GI fellow at Mayo Clinic Rochester. She is editor of the Trainee Hub section of ACG MAGAZINE and is a member of ACG’s Digital Communications and Publications Committee.

Stella-Maris Chinma Egboh, MD

Dr. Egboh is a Consultant Gastroenterologist at the Federal Medical Centre in Yenagoa, Nigeria. She is a 2022 recipient of an ACG International GI Training Grant through which she trained at Beth Israel Deaconess Medical Center and Massachusetts General Hospital.

CONTRIBUTING WRITERS

Tamara Duker Freuman, MS, RD, CDN

Ms. Freuman is a dietitian in gastroenterology practice at New York Gastroenterology Associates and the author of two books on GI health topics for patients.

Hala Fatima, MD, FACG

Dr. Fatima is Professor of Clinical Medicine at Indiana University School of Medicine and Section Chief of Gastroenterology at Eskenazi Health and the Director of Endoscopy. She recently served a term on the ACG Training Committee (2020-2023).

Andrew Feld, MD, JD, FACG

Dr. Feld is Clinical Professor of Medicine at the University of Washington. He served as ACG Governor for Washington from 2016 to 2022 and is currently a member of the ACG Professionalism Committee.

Divyangkumar Gandhi, MD, FACG

Dr. Gandhi is a Board-certified gastroenterologist at Augusta Health in Fishersville, VA, and is a 2023 ACG Institute 2023 Early Career Leadership Scholar.

Prasad Iyer, MD, MSc, FACG

Dr. Iyer is a Professor of Medicine at Mayo Clinic Rochester. He serves as Chair of the GIQuIC Research Committee and is a member of ACG’s Innovation and Technology and Credentials Committees.

Mike G. Kantrowitz, DO, MS

Dr. Kantrowitz is a gastroenterologist at Maimonides Medical Center in Brooklyn, NY. He serves as Vice Chair for Quality and Safety in the Department of Medicine.

Costas H. Kefalas, MD, MMM, FACG, FASGE, AGAF

Dr. Kefalas is Director and President of the GI Quality Improvement Consortium (GIQuIC), as well as Partner and Vice President of Akron Digestive Disease Consultants, Inc. He is currently the Secretary of the ACG Board of Trustees.

Sarah K. McGill, MD, MSc, FACG

Dr. McGill is Associate Professor of Medicine at the University of North Carolina at Chapel Hill and has served as chair of the ACG International Relations Committee since 2021.

Vanessa Méndez, MD

Dr. Méndez is a physician

Board-certified in internal medicine, gastroenterology, and lifestyle medicine, based in Florida. She founded a multi-specialty telemedicine practice, Planted Forward.

Kartik Natarajan, MBBS

Dr. Natarajan is a gastroenterologist at Apollo Main Hospital in Chennai, Tamil Nadu, India. He is a 2022 recipient of an ACG International GI Training Grant through which he trained at Mayo Clinic Rochester.

Linda Anh B. Nguyen, MD, FACG

Dr. Nguyen is Clinical Professor of Medicine and Clinic Chief, Digestive Health Center at Stanford Health Care. She serves on the College’s Public Relations Committee and is a member of the inaugural cohort of the ACG Institute’s new Advanced Leadership Development Program (ALDP).

Aasma Shaukat, MD, MPH, FACG, FASGE

Dr. Shaukat is Robert M. and Mary H. Glickman Professor of Medicine, Professor of Population Health, and Director of GI Outcomes Research at NYU Langone and is a Trustee of the College. She received the ACG/ ASGE Epidemiological Research Award in Gastrointestinal Endoscopy in 2023.

Shelby A. Sullivan, MD, FACG

Dr. Sullivan is Professor of Medicine at the University of Colorado School of Medicine. She serves as Chair of the Bariatrics Subcommittee for GIQuIC.

Sachin B. Wani, MD

Dr. Wani is a Professor of Medicine at the University of Colorado School of Medicine. He currently serves on the ACG Innovation and Technology Committee.

ACG PATIENT ADVOCACY

By Daniel J. Pambianco, MD, FACG

IN THE FACE OF CHALLENGES, leadership within the American College of Gastroenterology shone brightly as we, along with allied organizations, united to protest UnitedHealthcare's new prior authorization policy for gastroenterology endoscopy services. This stand represented not only a defense of patient care but a reaffirmation of the vital doctor-patient relationship.

As the effective date of UnitedHealthcare's policy neared, the ACG, in collaboration with the AGA, ASGE, and 175 other concerned groups, chose to raise their collective voice against what we perceived as a policy that could hinder patient access to care and strain already burdened gastroenterology practices. The policy, slated to start on June 1, 2023, would require prior authorization for almost all gastroenterology endoscopy procedures, potentially leading to delays in care and negatively impacting colorectal cancer prevention, early detection, and patient outcomes.

The rallying cry was led by Dr. Dayna S. Early, the Chair of the ACG Board of Governors, who eloquently highlighted the policy's potential to interfere with the patient-provider relationship and impose additional administrative burdens on gastroenterologists. This rallying sentiment echoed through the joint letter to UnitedHealth Group CEO Andrew Witty, signed by ACG, AGA, ASGE, patient advocacy groups, medical societies, and academic institutions,

all expressing strong opposition to the policy's implementation.

The heart of the opposition lay in the belief that the policy would particularly affect vulnerable patient populations, delay crucial diagnoses, and increase the burden on physicians, potentially leading to diminished patient adherence and treatment abandonment. Driven by our steadfast commitment to patient welfare, the ACG leadership and its allies sought to make a lasting impact on both this policy and the broader landscape of progressive insurance impediments to care.

In response to the insurer's claims of overutilization of endoscopic procedures, as ACG President, I highlighted the need for a databacked approach and called for a genuine partnership that prioritized quality patient care over cost-cutting measures. This request for sharing data of overutilization and offer to study and further educate our members was patently dismissed by United Healthcare as inability to share proprietary information.

Even as our efforts appeared futile, the ACG, led by Brad Conway our Vice President of Public Policy, engaged in continued diplomatic discourse with UnitedHealthcare, aiming to find common ground. An alternative program was proposed by United that required rigorous patient data collection from practices to identify compliant gastroenterologists in exchange for a “gold card program” that would permit

the accepted members a pass from procedure preauthorization. However, the ACG and its partners were – and remain – highly skeptical since no details were provided and the ongoing and progressive practice administrative burden will be more complex.

The pinnacle of this movement was the ACG’s participation with the Crohn’s and Colitis Foundation's planned rally on May 31st outside UnitedHealthcare's headquarters in Minneapolis, in which I represented the College along with Brad Conway. This rally was a powerful symbolic gesture of unity and determination to protect patient wellbeing. On June 1st, United announced postponement of their implementation of the Prior Authorization Plan.

While the outcome of these efforts remains to be seen, the inspirational story of how the ACG and its allies rallied to safeguard the doctor-patient relationship and advocate for accessible, quality care is a testament to the enduring strength of collective action and shared purpose.

As the outgoing President of the ACG, I am immensely proud of how our members, patients, and leaders came together in the face of adversity, demonstrating resilience, compassion, and an unyielding commitment to our mission of patient care. This chapter serves as a reminder that when the medical community unites for the greater good, powerful change is possible, even in the face of daunting challenges.

“If you want something you have never had, you must be willing to do something you have never done.”— Thomas

—DJP

Jefferson

“The inspirational story of how the ACG and its allies rallied to safeguard the doctor-patient relationship and advocate for accessible, quality care is a testament to the enduring strength of collective action and shared purpose.”

Note wor thy Note wor thy

NOVEL & NOTEWORTHY

INCLUDES memorial tributes for distinguished ACG members, Dr. Martin Floch (1928–2023) and Dr. Ashok N. Shah (1939–2023), both of whom leave significant legacies in gastroenterology.

We applaud ACG’s representatives to the Intersociety Group on Diversity in Novel & Noteworthy, Dr. Somaya Albhaisi, Dr. Victor Chedid, and Dr. Darrell Gray. Notable achievements by ACG members include a contribution by Dr. Brennan Spiegel to a World Health Organisation publication on the impact of innovations in science and technology upon global health challenges. Dr. Sita Chokhavatia and colleagues in New Jersey celebrated their 1,000th colonoscopy through their “Fast Track” program at Valley Health System. Two ACG Governors are in the spotlight: Dr. Tauseef Ali for advocacy at the state level in Oklahoma, and Dr. Aline Charabaty for cultivating the pipeline of future GI talent in the Washington, DC area.

PERSPECTIVES

LOCATION: THE TUILERIES GARDENS, AKA THE LOUVRE GARDENS

Linda Anh Bui Nguyen, MD, FACG

About the Photos & Paris: As someone who loves LOVE, I have always wanted to visit Paris, the City of Love, but never got around to it. Then I married the love of my life who planned what was to be the most romantic trip for two to Paris in March of 2020. We never made it to Paris in 2020. Over the next 3 years, life got in the way of rescheduling the trip. There was always something to do or the timing was never just right. It finally took a work-related trip to Belgium that inspired me to detour to Paris. But this time, the excitement and thrill I felt in 2020 was not the same. It was different. I was different.

The trip, like hobbies, had fallen into the “one day, when” bucket. For years, I’ve said, “One day, when the kids are older, I want to take up photography.” I even bought a Nikon DSLR camera with all the bells and whistles when my youngest was 5. He’s now 16 and I have a perfect condition Nikon sitting in a box in my closet. A couple months before I had even finalized my trip to Paris, I was talking to a friend and coach about hobbies and my desire to take up photography “one day.” She encouraged me make today the “one day” by using my iPhone to capture the beauty around me. She pointed out that I didn’t need a fancy camera or formal classes, merely an eye and to be present. So just like that, I became a photographer.

With my iPhone in hand, I found myself drawn to photographing nature. Nature has always been a grounding force for me as I contrast the grandeur of the world to the minutia of my problems. I recently realized that nature was something I admired and appreciated but did not really experience until I saw it through the lens of my camera. I first discovered this on a hike along the California coast at the Terranea Resort. I stopped to take a photo of wildflowers surrounding a cluster of cacti with the Pacific Ocean as the backdrop. The view was breath

taking! After I took the picture, I noticed something glistening in the sun. On closer examination, I found the glimmer had come from spider webs spun between the cacti which I had not previously seen. Delighted by my discovery, I zoomed in and took a picture. I sent that picture to my friend to thank her for helping me find that “Glimmer of Life.”

Fast forward to Paris. We toured the Louvre along with approximately 30,000 other tourists that day, which can only be described as controlled chaos. The experience left me with a feeling of ambivalence. I wanted to love the splendor of the history, admire the beauty of the art, and marvel at the talent of the artists. But there was just too much. Too much of everything to truly appreciate anything. So, as we walked out of the building with a twang of disappointment into the garden, I looked back and experienced that

sense of awe I was in search of during my tour of the museum.

I was so moved by the juxtaposition of billowy cherry blossoms and swaying tulips against the opulent stone palace that it stopped me in my tracks. I needed to get closer. As I approached one of the cherry blossom trees, I felt a sense serenity and renewal knowing that the blossoms have a short life span, and I had the privilege of seeing them bloom in Paris. Then as I turned my attention to the individual tulips, I saw a blend of strength and vulnerability where I previously just

saw a beautiful bed of flowers.

These collections of photos remind me that perspective matters. How we view something depends on distance, angle, lighting, background and so much more. What I saw and how I felt that day changed, despite looking at the same objects but from different vantages individually and collectively. These photos remind me to be curious and ask questions rather than assuming, especially during difficult conversations. Photography reminds me to slow down and pause to capture

the moment both literally and figuratively. I love discovering extraordinary beauty in everyday life.

Equipment: iPhone 13 Pro Max for capturing the moment and wedge heels for getting me there. One day, I WILL dust off my Nikon DSLR and learn how to use the shutter and aperture. Until then, if you see me stopped at a random spot, come check out the view from my perspective.

About Dr. Nguyen

Dr. Linda Anh B. Nguyen is Clinical Professor of Medicine and Clinic Chief, Digestive Health Center at Stanford Health Care where her clinical work and research focus on neurogastroenterology and motility disorders. She serves on the College’s Public Relations Committee and is a member of the inaugural cohort of the ACG Institute’s new Advanced Leadership Development Program (ALDP).

ACG IS PROUD TO BE PART OF THE INTERSOCIETY GROUP ON DIVERSITY (IGD) which includes physician leaders from AASLD, AGA, ASGE and NASPGHAN. Somaya Albhaisi, MD, is in the second year of her term as one of ACG’s two representatives. In July, she was joined by Victor Chedid, MD, who replaced Darrell M. Gray, II, MD, MPH, FACG. Formed in 2020, IGD works collaboratively across the five GI societies to guide, support and advance diversity, equity and inclusion in the GI field. The IGD aims to increase diversity in gastroenterology among the societies’ members, the pipeline of trainees, and leadership; and eradicate health disparities in the patients and populations our members serve. Leadership of the IGD rotates among the GI societies and the current IGD chair is Dennis Spencer, MD, of NASPGHAN.

[SPEEDY]

THE VALLEY HEALTH SYSTEM in New Jersey Fast-Track Colonoscopy Program has screened more than 1,000 individuals since its inception. Sita S. Chokhavatia, MD, MACG, and colleagues created this program to streamline the colorectal cancer screening process so that eligible patients can schedule their colonoscopy without having a pre-procedure visit with a gastroenterologist. The Valley Health Team has won several ACG SCOPY Awards over the years for their creative and high impact community education efforts

[FUTURIST]

BRENNAN SPIEGEL, MD, MSHS, FACG contributed to a publication by the World Health Organisation, “Emerging Technologies and Scientific Innovations: A Global Health Perspective,” released in July. The report identifies eight innovation groups that hold great promise for ensuring healthier populations worldwide. Dr. Spiegel was interviewed about medical virtual reality which is part of one innovation group that also includes AI, the Internet of things, wearables, telehealth, and augmented reality.

 Learn more: who.int/publications/i/item/9789240073876

[A-OK ADVOCACY]

A GROUP OF PHYSICIANS MET with Oklahoma Governor Kevin Stitt in August and discussed health-related issues including tort reform, physician shortages, the current status of APPs, as well as colorectal cancer incidence and mortality in Oklahoma. The conversation included the need to improve CRC screening rates through more public awareness and education. Tauseef Ali, MD, FACG, ACG Governor for Oklahoma, reviewed ACG and USPSTF guidelines suggesting screening colonoscopy at age 45.

Dr. Somaya Albhaisi Dr. Victor Chedid Dr. Darrell Gray

Sita S. Chokhavatia, MD, MACG (pictured front row, third from right) and the team at Valley Health System in New Jersey celebrate 1,000 colonoscopies through their “Fast-Track” program.

August 17, 2023 meeting at Governor’s Mansion in Oklahoma. Attendees (healthcare providers from different specialties) Left to Right: Tayyaba Ali, MD; Hooria Suhaib, MA, LPC; Fazal Ali, MD; Jeanette Kelley, DO; Naeem Tahirkheli, MD; Tauseef Ali, MD, FACG; The Honorable Kevin Stitt, Governor of Oklahoma; Saqib Sheikh, MD; Muhammad Sanaullah, MD.

ACG’S GOVERNOR FOR THE DISTRICT OF COLUMBIA, Aline

Charabaty, MD, FACG, in early June convened a special reception for fellows and faculty from the local GI training programs in the Washington, DC area, including George Washington University, Howard University, Georgetown, and Johns Hopkins (Baltimore, MD). The evening of networking, laughter, and connection included special comments from Neena S. Abraham, MD, MSc (Epi), MACG, Director of the ACG Institute for Clinical Research & Education.

[BOOK REVIEW]

WOMEN'S HEALTH IN IBD: THE SPECTRUM OF CARE FROM BIRTH TO ADULTHOOD (SLACK BOOKS, 2022)

Authors: Bincy P. Abraham, MD, MS, FACG; Sunanda V. Kane, MD, MSPH, FACG; Kerri L. Glassner, DO

Reviewer: Jana G. Al Hashash, MD, MSc, FACG, Mayo Clinic, Jacksonville, FL

In this comprehensive textbook “Women’s Health in IBD: The Spectrum of Care from Birth to Adulthood,” editors Dr. Bincy Abraham, Dr. Sunanda Kane, and Dr. Kerri Glassner address all the IBD related issues that a woman with IBD may experience during her lifetime.

MARTIN H. FLOCH, MD, MACG (1928-2023)

With great sadness, the College notes the death of Dr. Martin H. Floch who served with distinction as Editor-in-Chief of The American Journal of Gastroenterology from 1985 to 1991.

Dr. Rowen Zetterman, an ACG Past President and former AJG Editorin-Chief remembered Dr. Floch’s time at helm of the journal: “Dr. Floch was a superb editor of The American Journal of Gastroenterology and very generous with his time and advice during the transition from his tenure as Editor to mine. I spent several days visiting him at his editorial office to learn what my role as editor would be and how to do so effectively. Of the many things he taught me, the one that is still evident was, ‘Don’t change the red cover of the Journal.’ It was good advice.”

A member of the College since 1982, Dr. Floch was also the ACG Governor for Connecticut from 1984 to 1985, and again from 1994 to 1996. His ACG service also included terms on the Membership Committee (1994-1997), Educational Affairs Committee (2002-2008), and Publications Committee (2006-2012).

Martin Herbert Floch was born on July 24, 1928 in New York City. He received his Bachelor of Arts at New York University in 1949; Master of Sciences from the University of New Hampshire in 1950; and Doctor of Medicine from New York Medical College in 1956. He was an Intern at Beth Israel Hospital, New York City from 1956 to 1957; resident in medicine, Beth Israel Hospital, 1957 to 1959; fellow in gastroenterology, Seton Hall College Medicine, South Orange, New Jersey, 1959 to 1960; instructor of medicine, University of Puerto Rico, 1960 to 1962, served with the Medical Corps United States Army from 1960 to 1962, and then as assistant attending physician, Montefiore Hospital, New York City, from 1962 to 1964.

A member of staff of Norwalk Hospital since 1964, he was Chair of Medicine from 1970 to 1994; and Chief of Gastroenterology and Nutrition from 1970 to 1998. Beginning in 1976, he was Clinical Professor of Medicine, Yale University. He wrote five books, including the second edition of the textbook “Netter’s Gastroenterology” and “Probiotics: A Clinical Guide.”

Dr. Floch married Gladys Wisser in 1954 and they have four children, Jeffrey Aaron, Craig Lawrence, Lisa Suzanne, and Neil Robert.

This textbook is a phenomenal resource covering the journey of women in IBD from birth to puberty, to transitional care, then family planning, pregnancy and delivery, breastfeeding, and menopause. There are also chapters addressing very important yet commonly overlooked conditions including mental health and health maintenance issues as well as the role of diet and nutrition in the management of IBD and the role for alternative treatments for women in IBD.

By far, this complete textbook is an essential read and guide for any physician who cares for women with IBD. This book emphasizes the importance of multidisciplinary care between pediatric gastroenterologists, adult gastroenterologists, dietitians, mental health specialists, colorectal surgeons, and other specialists. Written by world renowned experts in the field, high yield topics are discussed and then key clinical pearls and takehome points for each chapter are highlighted for the reader.

I strongly recommend this book to all gastroenterologists as well as internists and family doctors who care for women with IBD.

L to R: Dr. Aline Charabaty; Dr. Geri Keane; Dr. Cynthia Tsay; Dr. Janese Laster; Dr. Neena Abraham; Dr. Hanna Blaney; Dr. Diana Cheung (center); Dr. Philip Oppong-Twene; Dr. Samuel Muench; Dr. Angesom Kibreab; ACG’s Anne-Louise Oliphant.

THREE QUESTIONS FOR SAMEER K. BERRY, MD, MBA

Practicing Community Gastroenterologist and Chief Medical Officer, Oshi Health

1. What do GI clinicals’ need to know about Oshi Health’s integrated approach?

Oshi Health is a virtual gastroenterology clinic that integrates evidence-based care, nutritional support, and behavioral health treatments into a convenient virtual model to support patients between in-person visits. Oshi does not provide in-person care and refers all procedures and infusions to independent GI physician practices.

Oshi was designed to support in-person GI care. The virtual-first approach allows Oshi to see patients every 2-3 weeks and message with patients every day. Oshi provides patients and GI practices with access to multidisciplinary care as a covered benefit through national health plans.

2. What’s your vision of a whole-person multidisciplinary hybrid GI care model?

My goal is to eliminate the unnecessary administrative work we do fighting with insurance companies to get our patients the care they need, while improving access to high-quality GI care.

Today, Oshi works with GI practices to provide their patients with access to multidisciplinary care. Oshi also refers all in-person care to independent GI physician practices. This hybrid care model extends and differentiates GI practices with dietary and psychosocial support, care plan compliance, care coordination, and enhanced operational efficiency.

3. How can ACG members learn more about the Oshi Health platform?

All patients deserve access to multidisciplinary care. Until now, insurance coverage, practice cost, and a lack of GI-specialized dietitians and psychologists have been barriers to patients accessing these services. To discuss ways to partner with Oshi please email partnerships@oshihealth.com or visit oshihealth.com/for-clinicians

[IN MEMORIAM]

ASHOK N. SHAH, MD, MACG (1939-2023)

The College celebrates the life of Dr. Ashok N. Shah, father of ACG Past President Dr. Samir A. Shah. A member of ACG since 1981, Dr. Ashok Shah became a Master (MACG) in 2007. It was meaningful to Dr. Shah and his family that he became a Master of the College in 2007 at the College’s Annual Scientific Meeting in Philadelphia almost exactly 40 years after coming to the U.S.—in the very same city as his training at the University of Pennsylvania.

Dr. Shah was born in Ahmedabad, India, on May 17, 1939 and was spiritual from an early age, going to temple regularly. He was a gold medalist in multiple subjects at B.J. Medical College and was trained as a general surgeon. In 1966, he married Shobhana Shah of Nairobi, Kenya. In 1967, he received a scholarship from the International College of Surgeons to study gastroenterology at the University of Pennsylvania. He stayed in America, retraining in internal medicine and specializing in GI. Following an internship year at the Lahey Clinic in Boston, Dr. Shah returned to Rochester, NY where he completed his fellowship in gastroenterology. He initially worked at Genesee Hospital, followed by two decades at the Strong Memorial Hospital/University of Rochester as Professor of Medicine, before retiring in 2018.

His family honored his memory with this reflection in his obituary: “He was a renaissance gastroenterologist: his colleagues referred the most challenging cases to him. He was recognized for his teaching, clinical acumen, and compassionate patient care…He was loved by his patients, colleagues and trainees to whom he not only imparted medical knowledge but humanism and spirituality.”

Dr. Shah was a leader in the Rochester, NY, Indian community, including the India Community Center and the Hindu Temple of Rochester. As an independent scholar of comparative religions and a deeply devout practitioner of Hinduism and Bhakti Yoga, Dr. Shah led Bhagavad Gita classes in his home for members of the community since the late 1970s.

He is survived by his wife, Shobhana A. Shah; son, Dr. Samir A. Shah; daughter, Sejal A. Shah; daughter-in-law, Dr. Seema V. Byahatti; son-in-law, Rajesh N. Singaravelu; grandsons, Anand B. Shah and Vijay B. Shah; and by his youngest brother, Nitin N. Shah.

Dr. Ashok Shah (right) with his son Dr. Samir Shah and twin grandsons Vijay and Anand.

[EAVP]

The Edgar Achkar Visiting Professor (EAVP) program brings distinguished faculty to GI training programs for clinical education, mentorship, and networking opportunities, and frequently includes grand rounds or other events that are open to GI clinicians in the local community. The Visiting Scholar in Equity, Diversity & Ethical Care is an initiative of the ACG Institute’s Center for Leadership, Equity & Ethics 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 lectures and grand rounds addressing health disparities and health equity in the context of GI and liver disease as an added component to the current structure of the EAVP visit.

LAUREN D. NEPHEW, MD, ACG VISITING SCHOLAR IN EQUITY, DIVERSITY & ETHICAL CARE AT THE UNIVERSITY OF FLORIDA, MAY 16, 2023

Focus on Health Disparities: “I presented grand rounds to all GI faculty and fellows. My presentation included some background didactic information on health equity, health disparities, and the social determinants of health. I then discussed specific liver disease disparities and some of the more recent work exploring the SDOH. Finally, I finished with a description of an intervention to improve disparities in access to treatment for liver cancer that I think can be used as a model for other interventions in GI and cancer.”

—Lauren D. Nephew, MD

DAVID T. RUBIN, MD, FACG, ACG EDGAR ACHKAR VISITING PROFESSOR AT THE UNIVERSITY OF MASSACHUSETTS T.H CHAN SCHOOL OF MEDICINE, MAY 18, 2023

Connecting with the Community: “One of the biggest impacts was the community-based event. We were able to invite numerous local learners and clinicians, ranging from students and our advanced practitioners to seasoned community gastroenterologists…we invited UMass Chan medical students interested in GI; UMass Chan and St. Vincent's Hospital (local community hospital) IM residents; UMass Chan and Baystate GI fellows, attendings, APPs, and nurses from the UMass Chan Gastroenterology, Pediatric Gastroenterology and Colorectal Surgery Divisions; and local clinicians who manage IBD. The event had 60 participants.” —Krunal Patel, MD and Abbas H. Rupawala, MD

FRANCIS A. FARRAYE, MD, MSC, MACG, ACG EDGAR ACHKAR VISITING PROFESSOR AT THE UNIVERSITY OF MISSOURI - KANSAS CITY AND ST. LUKE’S HOSPITAL, MAY 19, 2023

“I visited University of Missouri Kansas City as well as Saint Luke's Hospital. My first talk entitled ‘Health Maintenance for The Patient With Inflammatory Bowel Disease’ was given to GI faculty and fellows. I subsequently met with the fellows to discuss my practice and career course. I then went to Saint Luke's Hospital and gave medical grand rounds to the GI faculty and fellows as well as internal medicine faculty and residents.” —Francis

A. Farraye, MD, MSc, MACG

“The opportunity for Dr. Farraye to lecture was a unique and memorable experience, but the part we enjoyed the most was the one-on-one conversations about tough patient cases, career advice, and personal growth that he provided in between events.” —Feedback from the fellows

Dr. Lauren Nephew at the University of Florida

Dr. David Rubin at UMass

Dr. Frank Farraye at University of Missouri - Kansas City and St. Luke’s Hospital

ACG POSTGRADUATE COURSE Attend an upcoming

2023

2023 ACG’s IBD School & Southern Regional Postgraduate Course

December 1–3, 2023

Renaissance Nashville Hotel, Nashville, TN

2024

2024 ACG’s Endoscopy School & ACG Board of Governors/ASGE Best Practices Course

January 26–28, 2024

Aria Resort, Las Vegas, NV

2024 ACG/LGS Regional Postgraduate Course

March 1–3, 2024

DoubleTree by Hilton, New Orleans, LA

2024 ACG/FGS Annual Spring Symposium

March 8–10, 2024

Naples Grande Beach Resort, Naples, FL

2024 ACG’s IBD School & Eastern Regional Postgraduate Course

June 2024

Washington, DC

2024 ACG’s Hepatology School & Midwest Regional Postgraduate Course

August 23–25, 2024

Radisson Blu Mall of America, Minneapolis, MN

2024 ACG’s Functional GI & Motility Disorders School & ACG/VGS/ODSGNA Regional Postgraduate Course

September 6–8, 2024

Williamsburg Lodge, Williamsburg, VA

ACG VGRs are o ered TWICE each Thursday, with a live broadcast at noon (ET) followed by an 8:00pm (ET) rebroadcast!

ACG Weekly Virtual Grand Rounds

REGISTER NOW: GI.ORG/ACGVGR

Where dysbiosis once left the gut microbiome in ruin,

RISE ABOVE RECURRENT C. DIFFICILE INFECTION and

restore hope with REBYOTA®

The first and only single-dose microbiota-based live biotherapeutic approved to prevent recurrence of C. difficile infection starting at first recurrence.1,2,a

aIn the pivotal phase 3 trial, 32.8% of patients were treated at first recurrence of CDI following antibiotic treatment of CDI.1

INDICATION

REBYOTA (fecal microbiota, live - jslm) is indicated for the prevention of recurrence of Clostridioides difficile infection (CDI) in individuals 18 years of age and older, following antibiotic treatment for recurrent CDI. Limitation of Use

REBYOTA is not indicated for treatment of CDI.

IMPORTANT SAFETY INFORMATION

Contraindications

Do not administer REBYOTA to individuals with a history of a severe allergic reaction (eg, anaphylaxis) to any of the known product components.

Warnings and Precautions

Transmissible infectious agents

Because REBYOTA is manufactured from human fecal matter, it may carry a risk of transmitting infectious agents. Any infection suspected by a physician possibly to have been transmitted by this product should be reported by the physician or other healthcare provider to Ferring Pharmaceuticals Inc.

Management of acute allergic reactions

Appropriate medical treatment must be immediately available in the event an acute anaphylactic reaction occurs following administration of REBYOTA.

Potential presence of food allergens

REBYOTA is manufactured from human fecal material and may contain food allergens. The potential for REBYOTA to cause adverse reactions due to food allergens is unknown.

Adverse Reactions

The most commonly reported (≥3%) adverse reactions occurring in adults following a single dose of REBYOTA were abdominal pain (8.9%), diarrhea (7.2%), abdominal distention (3.9%), flatulence (3.3%), and nausea (3.3%).

Use in Specific Populations

Pediatric Use

Safety and efficacy of REBYOTA in patients below 18 years of age have not been established.

Geriatric Use

Of the 978 adults who received REBYOTA, 48.8% were 65 years of age and over (n=477), and 25.7% were 75 years of age and over (n=251). Data from clinical studies of REBYOTA are not sufficient to determine if adults 65 years of age and older respond differently than younger adults.

You are encouraged to report negative side effects of prescription drugs to FDA. Visit www.FDA.gov/medwatch, or call 1-800-332-1088.

Please see Brief Summary on next page and full Prescribing Information at www.REBYOTAHCP.com.

References

1. REBYOTA. Prescribing Information. Parsippany, NJ: Ferring Pharmaceuticals; 2022.

2. US Food and Drug Administration. FDA Approves First Fecal Microbiota Product. https:// www.fda.gov/news-events/pressannouncements/fda-approves-firstfecal-microbiota-product. Accessed December 1, 2022.

Scan to visit website

Ferring, the Ferring Pharmaceuticals logo and REBYOTA are registered trademarks of Ferring B.V. ©2023 Ferring B.V. All rights reserved. US-REB-2200129-V2 7/23

DEDICATED J-CODE (J1440) EFFECTIVE JULY 1, 2023

REBYOTA® (fecal microbiota, live - jslm) suspension, for rectal use

Brief Summary Please consult package insert for full Prescribing Information

INDICATIONS

REBYOTA is indicated for the prevention of recurrence of Clostridioides dif cile infection (CDI) in individuals 18 years of age and older following antibiotic treatment for recurrent CDI. Limitation of Use: REBYOTA is not indicated for treatment of CDI.

CONTRAINDICATIONS

Do not administer REBYOTA to individuals with a history of a severe allergic reaction (e.g. anaphylaxis) to any of the known product components.

Each 150mL dose of REBYOTA contains between 1x108 and 5x1010 colony forming units (CFU) per mL of fecal microbes including >1x105 CFU/mL of Bacteroides, and contains not greater than 5.97 grams of PEG3350 in saline.

WARNINGS AND PRECAUTIONS

Transmissible infectious agents: Because REBYOTA is manufactured from human fecal matter it may carry a risk of transmitting infectious agents. Any infection suspected by a physician possibly to have been transmitted by this product should be reported by the physician or other healthcare provider to Ferring Pharmaceuticals Inc.

Management of acute allergic reactions: Appropriate medical treatment must be immediately available in the event an acute anaphylactic reaction occurs following administration of REBYOTA.

Potential presence of food allergens: REBYOTA is manufactured from human fecal matter and may contain food allergens. The potential for REBYOTA to cause adverse reactions due to food allergens is unknown.

ADVERSE REACTIONS

The most commonly reported (≥ 3%) adverse reactions occurring in adults following a single dose of REBYOTA were abdominal pain, (8.9%), diarrhea (7.2%), abdominal distention (3.9%), atulence (3.3%), and nausea (3.3%).

Clinical Trials Experience: The safety of REBYOTA was evaluated in 2 randomized, double-blind clinical studies (Study 1 and Study 2) and 3 open-label clinical studies conducted in the United States and Canada. A total of 978 adults 18 years of age and older with a history of 1 or more recurrences of Clostridioides dif cile (CDI) infection and whose symptoms were controlled 24 – 72 hours post-antibiotic treatment were enrolled and received 1 or more doses of REBYOTA; 595 of whom received a single dose of REBYOTA.

Adverse Reactions: Across the 5 clinical studies, participants recorded solicited adverse events in a diary for the rst 7 days after each dose of REBYOTA or placebo. Participants were monitored for all other adverse events by queries during scheduled visits, with duration of follow-up ranging from 6 to 24 months after the last dose. In an analysis of solicited and unsolicited adverse events reported in Study 1, the most common adverse reactions (de ned as adverse events assessed as de nitely, possibly, or

probably related to Investigational Product by the investigator) reported by ≥3% of REBYOTA recipients, and at a rate greater than that reported by placebo recipients, were abdominal pain, (8.9%), diarrhea (7.2%), abdominal distention (3.9%), atulence (3.3%), and nausea (3.3%).Most adverse reactions occurred during the rst 2 weeks after treatment. After this, the proportion of patients with adverse reactions declined in subsequent 2-week intervals. Beyond 2 weeks after treatment only a few single adverse reactions were reported. Most adverse drug reactions were mild to moderate in severity. No life-threatening adverse reaction was reported.

Serious Adverse Reactions - In a pooled analysis of the 5 clinical studies, 10.1% (60/595) of REBYOTA recipients (1 dose only) and 7.2% (6/83) of placebo recipients reported a serious adverse event within 6 months post last dose of investigational product. None of these events were considered related to the investigational product.

USE IN SPECIFIC POPULATIONS

Pregnancy: REBYOTA is not absorbed systemically following rectal administration, and maternal use is not expected to result in fetal exposure to the drug.

Lactation: REBYOTA is not absorbed systemically by the mother following rectal administration, and breastfeeding is not expected to result in exposure of the child to REBYOTA.

Pediatric Use: Safety and effectiveness of REBYOTA in individuals younger than 18 years of age have not been established.

Geriatric Use: Of the 978 adults who received REBYOTA, 48.8% were 65 years of age and over (n=477), and 25.7% were 75 years of age and over (n=251). Data from clinical studies of REBYOTA are not suf cient to determine if adults 65 years of age and older respond differently than younger adults

For more information, visit www.REBYOTAHCP.com

You are encouraged to report negative side effects of prescription drugs to FDA. Visit www.FDA.gov/medwatch, or call 1-800-332-1088.

Manufactured for Ferring Pharmaceuticals by Rebiotix, Inc. Roseville, MN 55113

US License No. 2112

9009000002

Rx Only

Ferring, the Ferring Pharmaceuticals logo and REBYOTA are registered trademarks of Ferring B.V. ©2023 Ferring B.V.

This brief summary is based on full Rebyota Prescribing Information which can be found at www.RebyotaHCP.com US-REB-2200277-V2

TRAINEE HUB

TRAINEE HUB

Title Title Line 2 Title

By Shifa Umar, MD

The essential Guide New GI Fellows for

Introduction & Goal Setting

Author: Katie Dunleavy, MB BCh BAO

Welcome to the wonderful world of gastroenterology and hepatology! We all remember the mix of excitement and fear of the unknown as we embarked on our GI fellowship. Many of you have moved across the country, found new homes, and migrated from your support systems to dedicate yourself to training in GI and endoscopy. I remember the stress of moving from NYC to MN during COVID, and how isolating it felt in the beginning as I found my way. Over the past two years,

By Katie Dunleavy, MB BCh BAO; Carl Kay, MD; Joseph Sleiman, MD; Aruj Choudhry, MD, MS

I’ve found my footing, fostered incredible friendships and mentorships, all while embracing the winter the Minnesota. Through ACG, I have discovered my GI family, and this network has given me more opportunities than I ever could have imagined. Given this time of transition, I’ve asked some of our #ACGMagazine friends in GI fellowship from across the country to help lend their tips and tricks for thriving during GI fellowship and beyond. Please use this guide to help navigate the transition from resident to fellow, as you learn more about who you are, and the type of gastroenterologist you want to become.

About the Contributors

Aruj Choudhry, MD, MS

Twitter/X: @ArujChoudhry

Dr. Choudhry is a Gastroenterology (GI) fellow at Stony Brook University Hospital in New York. She completed her Internal Medicine training at Temple University Hospital in Pennsylvania, followed by an Advanced Hepatology fellowship at Beth Israel Deaconess Medical Center in Boston. Her clinical interests include general GI with a focus on pre-transplant hepatology and medical education. She most recently spearheaded efforts to design and implement an endoscopy ergonomics curriculum within the GI and Hepatology Division at Stony Brook University Hospital.

Katie A. Dunleavy, MB BCh BAO

Twitter/X: @dunleavy_katie

Dr. Dunleavy is a third-year GI fellow at Mayo Clinic Rochester and is a member of ACG’s Digital Communications and Publications Committee. She is the Editor of ACG MAGAZINE’s Trainee Hub section. Her research interests overlap in IBD and motility disorders. After training she will complete an Advanced Inflammatory Bowel Disease fellowship at Mayo Clinic. On the weekends you can find her at the farmer’s market or singing opera!

Carl Kay, MD

Twitter/X: @CarlKayMD

Dr. Kay is a Captain in the United States Army and Chief Fellow at San Antonio Uniformed Services Health Education Consortium. He is also a social medial ambassador for Evidence-Based GI, a monthly publication by the American College of Gastroenterology. When not playing pickleball, he enjoys medical education and quality improvement - especially within endoscopy. Most importantly, he is a husband and girl dad with a second baby girl on the way!

Joseph Sleiman, MD

Twitter/X: @JosephHabibi_MD

Dr. Sleiman is a gastroenterology fellow at the University of Pittsburgh Medical Center, and an incoming IBD fellow at the Cleveland Clinic. His research interests are in IBD, immunotherapy-induced colitis, and machine learning for GI research purposes. He is the Social Media Associate Editor for Evidence-Based GI, a monthly publication by the American College of Gastroenterology. He is involved in medical #SoMe (social media) education and trainee mentorship and is part of social education platforms, including #MondayNightIBD, #ScopingSundays and #GIJournal Club.

A Guide to Lifelong GI Learning in the Digital Era

Author: Carl Kay, MD

During fellowship, it’s important to foster lifelong learning habits that can transition with you after fellowship. In our rapidly changing field, it is not sufficient to only learn via textbooks. There are a multitude of invaluable resources available to augment your learning and studying. However, it can be overwhelming if you don’t have a framework for your learning. Learning gastroenterology in the digital era can be divided into several different facets – guidelines, eBooks, podcasts, board studying, apps, and social media.

A good PDF organizer is foundational to all these resources. I would recommend one of three top PDF organizers: 1) GoodNotes, 2) Evernote, or 3) Notability. These PDF organizers will allow you to download PDFs, notate documents, and easily synch between other devices (phone, tablet, and laptop). Keeping these PDFs on your devices also allows you to quickly search documents using advanced search features (“Control+F" or "Command+F"). Purchasing a tablet stylus (e.g., Apple Pencil) allows you to maintain tactile learning while adopting more sustainable notetaking.

My first recommendation to GI fellows is to become familiar with all major society guidelines. One of the best ways to do this is by downloading all the guidelines from the ACG, AGA, AASLD, and ASGE on your PDF organizer. You will quickly identify publication year, topics covered, multi-society guidelines, and recent updates. Additionally, you can quickly add new guidelines that are published throughout training. You won’t read them all right away. Instead, you’ll easily be able to track your progress on your PDF organizer with highlighting and notations from your last reading. ACG Virtual Grand Rounds frequently reviews guidelines and essential topics and can be viewed in real time or later (making it

ideal for a hectic schedule).

Even with all the most upto-date guidelines available, textbooks remain an important cornerstone of your education. I would recommend downloading two reference textbooks:

1) Sleisenger & Fordtran's Gastrointestinal and Liver Diseases and 2) Zakim & Boyer's Hepatology. Additionally, I recommend three other eBooks:

1) Gastroenterology Clinical Focus (with integrated QR codes linked to relevant society guidelines),

2) Cotton & William’s Practical Gastrointestinal Endoscopy, and 3) Yamada's Atlas of Gastroenterology. By having these books in electronic form, it allows you to quickly read chapters and search the content for relevant information on your phone.

Podcasts are another useful learning modality that can be used in normal “downtime” during the day, like a commute to the hospital. There are many excellent podcasts that vary in length to fit your learning style and attention span. Some of my favorites include “The Emoroid Digest,” “GI Pearls,” “Liver Talks,” “Listen In: GI Endoscopy,” “Evidence-Based GI,” and AGA’s “Small Talk, Big Topics.” Podcasts offer auditory learners a niche and provide a much needed screen break.

Much of this material is preparing you for the Board exams, but there are some noteworthy resources primarily for board studying. Specifically, Brennan Spiegel’s Acing the GI Board Exam, ACG’s Online Self-Assessment Tests, AGA’s Digestive Diseases Self-Education Program (DDSEP) and William M. Steinberg’s Board Review in Gastroenterology.

No digital era resource list would be complete without highlighting several apps and social media. Any GI trainee knows how vital MDCalc and UpToDate are for everyday practice, but there are a few others worth

mentioning. Specifically, National Comprehensive Cancer Network (NCCN)’s app has updated guidelines for easy access. It is important to be familiar with all GI-relevant NCCN guidelines. Also, ASGE’s “GI Leap” app is a great education hub to watch great lectures and endoscopy videos including SUTAB® “Tips of the Week.” However, Twitter/X remains a powerful resource to any trainee. Get started by searching the tags #GITwitter, #LiverTwitter, or #MedTwitter to access experts in our field and top quality open-access medical education.

In summary, GI fellowship is a marathon – not a sprint. Avoid burnout. And keep mixing it up. The goal of learning in fellowship should not just be the board exam after graduating. You need to keep learning and integrate new resources. If you’re interested in more resources, check out my tweetorial. (bit.ly/3NLYhMC).

*For reference, all my files on GoodNotes are collectively less than 3 GB.

The Who, What, Where, When, Why, and How of Endoscopy…

Author: Aruj Choudhry, MD, MS

Learning and performing endoscopy is exciting and constitutes a significant portion of GI training. All fellows eagerly await their first endoscopy session and cecum sighting. As a first year fellow, it is important to recognize that there is a huge learning curve in endoscopy that includes cognitive, technical, and non-technical skills.

Who?

Who is the patient you considering for a procedure?

A thorough preprocedural assessment of your patient is just as important as your technical skills when performing endoscopy. This typically includes a review of the patient’s presentation, physical exam, hemodynamics, and prior history (e.g., medical, surgical/ prior endoscopic procedures, medications, prior issues with anesthesia). Risk scores, such as

PDF Organizers

LEARNING GI IN DIGITAL ERA MEDICAL EDUCATION

• GoodNotes

• Evernote

• Notability

eBooks

• Sleisenger & Fordtran’s Gastrointestinal and Liver Disease

• Zakim & Boyer’s Hepatology: A Textbook of Liver Disease

• Gastroenterology Clinical Focus

• Cotton & William’s Practical Gastrointestinal Endoscopy: The Fundamentals

• Yamada’s Atlas of Gastroenterology

• ACG Education Universe

Podcasts

• The Emoroid Digest

• GI Pearls Podcast

• Liver Talks: The Liver Network Podcast

• Listen In: GI Endoscopy

• Evidence-Based GI

• The American Journal of Gastroenterology Author Podcasts

• AGA Small Talk, Big Topics

• The Curbsiders

• ACG GastroGirl

Board Study

• Acing the GI Board Exam Series by Brennan Spiegel

• ACG Online Self-Assessment Tests

• ACG Board Review Question of the Week

• Steinberg Board Review

Apps

National Comprehensive Cancer Network (NCCN)

Glasgow-Blatchford score for upper GI bleeding, should be utilized when appropriate. A thorough preprocedural assessment will help to triage the procedure and identify any potential challenges such as, prior complications related to sedation or endoscopy, altered GI anatomy, anticoagulation/antiplatelet agent use, active cardiopulmonary issues, unstable hemodynamics, and mental status changes that may require a healthcare proxy for further discussion and consent. Moreover, this allows for open communication with your patient and/or their family members to address any concerns or questions they have. This is extremely important in alleviating the patient’s procedurerelated anxiety and establishing good rapport.

What?

What are you planning to do?

After evaluating your patient and determining that an endoscopic procedure is warranted, it is helpful to brainstorm which procedure (e.g., esophagogastroduodenoscopy, colonoscopy, etc.) would be most appropriate and be prepared with therapeutic tools that may be needed. As an example: for acute GI bleeding cases, make sure you have a therapeutic upper endoscope along with hemostatic clips, epinephrine with injection needles, electrocautery device, a banding kit, Blakemore, and hemostatic agents (e.g., Hemospray® or PuraStat®).

What do you see during the procedure?

There is something to learn during each case. With each endoscopic procedure, you are building your personal archive of

normal and abnormal findings. Careful attention and reflection on these findings will take you far in improving your endoscopy evaluation and interpretation skills. And please follow up on those biopsies!

Where?

Where will the procedure be done? Logistics play a major role in effectively and safely preparing a patient for endoscopy. The acuity of the clinical scenario, time of day/week, and availability of endoscopy suite space and personnel will help guide where the procedure should be done. You should be familiar with all the potential sites for performing a case. The typical options are your endoscopy suite area, bedside in the intensive care unit, the operating room, and bedside in the emergency department. Additionally, you should evaluate whether you will require assistance from an anesthesiologist for the procedure. Once you have established the appropriate location for the procedure, you are responsible for communicating with the points of contact for each site (e.g., charge nurse in the endoscopy suite, endoscopy support team, the primary critical care team, etc.).

When?

When is the most appropriate time? Timing is everything. In general, it is recommended that patients are adequately resuscitated, their hemodynamics are stabilized, and they have completed adequate bowel prep (if colonoscopy indicated) prior to their GI procedure. These measures are to ensure patient safety during the procedure, improve mucosal visualization, and help increase your chances of successful endoscopic therapy.

Why?

Why are you doing it?—Do the potential benefits outweigh the potential risks?

An endoscopic procedure can help diagnose and treat many conditions (acute and chronic) of the digestive system. While the rate of procedural

complications is relatively low compared to other more invasive measures (e.g., surgery), it is not zero and may be higher in certain patients. The end goal is to improve overall patient outcomes. Therefore, the risks and benefits should be carefully reviewed.

How?

How will you be doing this?

You will learn the technical skills and techniques required to perform endoscopy over the next 3 years under close guidance of your attendings. Describing the complexity and nuance of this skillset is beyond the scope of this article. However, we can take a minute to introduce the concept of ergonomics and the importance of learning good habits early! Performing endoscopy is physically demanding and can lead to work-related musculoskeletal injuries. Several studies demonstrate a high prevalence of endoscopy-related injury (ranging as high as 89% in practicing endoscopists) and this can begin as early as your first year of training. Ergonomics in endoscopy can

help you scope more efficiently and prevent injury during fellowship and beyond. Detailed recommendations can be found in the 2021 ASGE core curriculum for ergonomics in endoscopy document. Some key tenets of ergonomics are maintaining neutral body posture, optimizing room set up, and proper handling of the endoscope to minimize strain and injury risk. Consider implementing the points in the table below before and after each case.

Adapting an ergonomics mindset will help you be effective, efficient, and safe. The path to learning endoscopy is not linear. There will be days and cases that are more challenging than others. Remain consistent in your efforts and patient with yourself. Keep practicing and keep in mind who, what, where, when, why, and how.

ERGONOMIC CHECKLIST

Ergonomic ‘Time-Out’ (before sedation and scope insertion)

Endoscope: know what all buttons and dials do and make sure they are functioning Monitor angle and height: directly in front of you, at resting eye-level or 15-25° below eye height

Bed height and position: at level of hip OR in between elbow height and 10 cm below elbow height. Bed is at a comfortable distance from you and the endoscopy tower

Endoscopy tower: directly in line with insertion site (mouth or anorectum)

Foot pedal: beside foot and functioning

Lead apron (if applicable): 2 piece

Endoscope handling: no external loop, suction fluid at 6 o’clock, ‘pencil grip’ rather than ‘clenched fist grip’, make sure the gloves you use fit you well

Endoscopist position: athletic stance with feet hip-width apart, extremities in neutral position

Ergonomic ‘Reset’ (post-procedure, in between cases)

Neck rolls

Upper trapezius stretch

Shoulder rolls

Wrist flexion and extension stretch

Wrist rolls

Finger stretch

Finding Your Footing and Building Relationships

Author: Joseph Sleiman,

MD

For most trainees, GI training marks another move to a new city, a new hospital, and amidst the uncertainty you must once again find your footing. For a few, this may be the first time you are leaving your home institution or state. This experience, both daunting and exciting, weighs heavier than prior experiences for another reason: you are actually at the end of your training path! Now you can start thinking about the things that matter most including location, family, and work-life integration. In the process you will look both outwards (city specs, job-related features, geopolitical tones of the area, culture of the hospital, etc.) and inwards (way of life, friends/family circles, space to grow a hobby, etc.). Here are some tips to make the best of your first-year fellowship to find your way and build your community.

1. Explore Your City (In ALL Seasons)

The first year of fellowship is busy! It is easy to assume you will be as tired and busy as intern year, but remember you became an expert at time-management during residency and in fellowship you will continue to learn to prioritize. Safe to say, you will have more time to explore your city! Start by subscribing to newsletters that share weekly events, following popular social media accounts that highlight hidden gems, and exploring activities that bring you joy outside of the hospital. It is also important to check out the city in all seasons to see if extreme weathers (winters or summers) bring you joy. Be open to visiting different neighborhoods when dining out and take walks to check out the pace of life, and the overall culture. Travel a bunch: not only will you get to compare other cities in real time, but you will also get to explore the ease of travel through your home airport. And, by all means, save yourself the postACG conference dash to the airport, please get TSA Pre-Check!

2. Make New Friends (Outside of Your Fellowship)

On average, incoming GI fellows have hit their thirties, and more than half of each year’s class is partnered, about to get married, or have enough kids and pets to be preoccupied with life outside of fellowship. Some may be returning to their hometowns near family. For everyone else, this might feel like a lonely first year, where you are far from residency friends, and when it can be difficult to connect with co-fellows who are busy with their families. You can find friends within your institution in other fellowships or through residency, sometimes by joining diversity and inclusion groups, or residency-fellowship support groups. If you have a hobby, you may join a regional interest group (book clubs, bike rider’s group events, museum travelers, etc.). Nextdoor and other apps are also designed to connect you to your neighborhood and find people who share your interest. And finally, do not forget about your GI nurses (more below).

Give yourself #GRACE and have #PATIENCE

Be the consultant others #WANT to consult

3 4 5 6

Stay #FLEXIBLE

#LEARN as much as you can, this is your time to be selfish with education

Find #MENTORS, nourish the relationship frequently and with intent

1 7 2 8 9 10

Find your #GIFAMILY (get involved in GI societies)

Invest in your #EDUCATION by finding your ‘way’ to study

#RESPECT your body and mind. Take time to exercise, perform proper endoscopic ergonomics, and perform self-care

Strengthen #RELATIONSHIPS! Reach out to others in your program, your endoscopy unit, your community

Remember the needs of the #PATIENTS come first, but you must take care of yourself to be present for your patients

3. Befriend Your GI Endoscopy

Team

GI fellowship offers a chance to build strong relationships both inside and outside the hospital. Not only are you taking care of your patients together, but you are also collaborating during technically difficult endoscopies, commiserating over poor bowel preps, and catching up on life outside the hospital almost every day for three years. It’s crucial to start off on the right foot. Fortunately, GI nurses and endoscopy techs are wonderful, but you need to play your part in nurturing these fruitful relationships. Showing your endoscopy techs and nurses that you appreciate them is so important. You can do this by engaging your endoscopy team with your daily endoscopy plans, in a timely, efficient, and clear manner to help reduce stress and get everyone out on time. Endoscopy techs and nurses are gems for providing information both inside and outside the hospital — everything from the best cafeteria food to consultant scope preferences, to best ice cream store and breweries in town. In many cases, GI staff and nurses may become lifelong friends. Above all, remain professional and kind.

4. Practice Building Your “Consultant Image”

Remember that fellow who scorned you when you were asked to consult GI at 4:50 PM on a Friday? If you remember how that made you feel, you know you don’t ever want to be that person. Now imagine you are the GI consultant in a busy private practice, where your referral basis is largely PCPs asking for colon cancer screening, chronic diarrhea, and abdominal pain. You must practice your consultant ethics from the first day of fellowship, as how you carry yourself and interact with others will be noted. Look to your GI consultants and assess their stylistic differences – not only in how they treat disease, but also how they treat the clerical staff, the patients’ families, the referring providers, and consult services on a busy day. This can be hard and requires practice! Busy days can make anyone disgruntled, but do

not let it affect your behaviors towards others. Never forget that the simplest (and sometimes “inappropriate”) consults are an ask for help. Focus on stewarding a sense of camaraderie and role modeling for others on your team. Remember patients benefit from a truly collaborative multidisciplinary team.

5. Take Advantage of "1-on-1” Moments with Faculty

To the surprise of many fellows, the trainee-faculty interaction during a GI/ hepatology rotation is quite different from your standard internal medicine inpatient service. There is noticeably more one-onone time compared to residency which provides an opportunity for learning and getting to know each other. I encourage new fellows to take this time to enjoy discussing life beyond fellowship while walking the hospital corridors (or getting to the cecum) with your attendings. Their unique stories will help you bond and forge long lasting relationships. Although it may feel uncomfortable for some fellows to engage on a personal level with their attendings, I highly recommend stepping outside your comfort zone.

6.

Join GI Societies Locally, Nationally and Internationally

No matter your future career goal (academics, pharmaceutical/industry, private practice, hybrid), you will find excellent resources and connections from the GI societies. Being an active agent of change within these GI societies during fellowship will allow you to understand the ‘behind the scenes’ processes that govern these large organizations, while also allowing you to build lifelong relationships. For many fellows, myself included, it’s essential to have mentors outside your home institution, and these connections may be career-shaping in unexpected ways. The sky is the limit: journal reviewing groups, committees for learning research design methodology, trainee committees, policy advocacy groups, conference scientific content committees… the list goes on. I encourage you to consider joining all the major GI societies and before long you will find your #GIFamily.

GETTING IT

Practical Strategies when Facing a Malpractice Claim Highlights of ACG Virtual Grand Rounds Career Edition

FACING A

MALPRACTICE

PROCEEDING IS AN UNFORTUNATE REALITY that many physicians in the United States will face at some point in their careers. According to the American Medical Association, about onethird of practicing U.S. physicians have had a medical malpractice lawsuit filed against them, and nearly half of all physicians aged 55 and older have been sued at some point in their careers. The consequences of malpractice proceedings can have professional, financial, and emotional tolls on the involved physicians regardless of the outcome. There are also implications for the quality and cost of care delivery when physicians practice defensively to avoid being sued.

As proceduralists, gastroenterologists have been found to have a higher number of claims but lower indemnity payments than physicians overall. Missed diagnoses and management of complications pose the largest risk. Yet reviews of closed claims

Contributors: Douglas G. Adler, MD, FACG; Hala Fatima, MD, FACG; Andrew D. Feld, MD, JD, FACG; and Michael G. Kantrowitz, DO, MS

across all specialties show that just over two-thirds are either dropped or dismissed. The defendant physician prevails in the vast majority of cases that do go to trial. Ultimately, approximately 25 percent of cases overall result in a payment to the claimant. There are strategies to both prevent and successfully overcome malpractice proceedings, particularly after adverse events. What follows are a series of common questions that arise and some advice for navigating the process. It is important to remember that malpractice cases can take years to resolve. It is critical that physicians work closely with their risk managers, malpractice insurers, and attorney throughout the process.

1. If there is an adverse event and you are worried about getting sued, what can you do to potentially prevent a lawsuit?

Adler: If you are worried about potential legal action, you can do a few things. First, keep lines of communication with the patient and their family open. Schedule follow-up visits and procedures, stay in contact, and let the patient and their family know how to get in touch with you. You should also talk to your Risk Management office and let them know your concerns. They can help you look over the events to date and strategize regarding what to do going forward and how to handle things internally at your job in the event that legal action develops.

Kantrowitz: Communicating with patients and their families clearly is key. Stick to the facts of what occurred and what is being done to support that patient. The relationship can break down and impair communication if patients feel that their physician is avoiding them or being evasive.

Fatima: Immediate and clear communication establishes trust and reduces the chance of being sued. Make sure you document all complications objectively and the steps taken to resolve them. It is also essential to stay professional and avoid statements that could be misconstrued as negligence. Regular follow-up conversations are a major part of effective communication, so continue to address ongoing concerns from patient and family and to provide regular updates. If you feel that a lawsuit is impending, then consult early with your healthcare attorney.

2. What language do you use when informing the patient and their family about the adverse event?

Adler: In general, it is better to be more direct and straightforward. In the face of an adverse event, especially a bad one, the patient and family are likely to be (very) upset and may not be able to have a nuanced discussion. Be upfront about what happened, the implications of the injury, and what you plan to do about it to make it better. Resist the urge to point fingers and deflect blame, especially if you are the one who caused the injury.

Kantrowitz: It is important to recognize that adverse events affect not only patients but physicians and the teams they work with as well. No one intends to cause harm when taking care of patients. Telling a patient that you are sorry for what they are experiencing and the discomfort they may have is a way to express empathy without necessarily admitting fault. This is especially important when the facts and details are not be entirely apparent at the time of the event.

Fatima: It is important to be honest and compassionate with the patient and family. Showing empathy with words and body language is key. Make sure you listen to their concerns, show respect, and validate their feelings. Inform them about the steps you have taken or plan to take to manage the complication. If they ask, tell them clearly about the cause of the adverse event. Address all questions to the best of your ability. Avoid medical terminology so your explanation is easy to understand. Do not speculate about the outcome, but let them know that you will continue to do your best and take all necessary steps to manage the complication. You may consider providing apology and disclosure to the patient and family if your state laws have clear protections from them being used against you in lawsuits. It is crucial though to check with your lawyer regarding these rules.

3. What can you do in the consent process to mitigate risk?

Adler: Consent is a whole topic in and of itself, but, in general, consents should be succinct but clear, e.g., here is why you are here, here is what we plan to do, and here are the risks and benefits of the procedure. Do not sugar-coat or minimize risks. Alternatives can be difficult to discuss in

“If you are worried about potential legal action, you can do a few things.

First, keep lines of communication with the patient and their family open. Schedule follow-up visits and procedures, stay in contact, and let the patient and their family know how to get in touch with you.”

—Douglas G. Adler, MD, FACG

some situations – we generally do not discuss alternatives to colonoscopy when the patient is there and has prepped, or if they have a bile duct stone and are scheduled for ERCP.

Kantrowitz: If possible, obtain consent before the patient enters the procedure room. Patients may feel especially vulnerable and pressured to consent in the immediate period before the procedure. Consider having the informed consent discussion during your office consult. Remember that informed consent involves much more than having a patient sign a document. Ensuring that patients have a complete understanding of the procedure they are consenting to with the ability to ask questions is crucial.

Fatima: Explain the procedure thoroughly, including the risk-benefit ratio and potential adverse events, in simple language. Use pictures and videos, if available. Inform patients about other options of diagnosis or treatment. Allow adequate time for patients to ask you questions. Never appear in a hurry when taking consent and do not get frustrated with questions. The way you present yourself before the procedure can be a deciding factor for patients whether or not they choose to sue. Ask for verbal loop to ensure the patient understands. Document your consent process in detail. Confirm that your consent forms are updated, reflect your discussion, and meet the legal requirements.

4. Do you think the burden of medical malpractice affects how we practice gastroenterology? For example, do we overtest, e.g., is that leading to higher healthcare costs?

Adler: I believe the risk of medicolegal actions affects all physicians, regardless of their specialty. I believe that some people may be overly cautious (e.g., over-ordering tests, not undertaking relatively high-risk, but clearly indicated procedures), but in general these strategies are self-defeating. If the patient needs a risky procedure and you are trained and able to do it, you should not avoid doing the procedure out of fear of a potential lawsuit at an undefined point in the future. Clearly, physicians who have been sued (whether they won, lost, or settled) are often deeply (and negatively) affected by the experience in a durable manner.

Kantrowitz: This likely varies by state due to differing laws, however, tort reform has not been clearly shown to reduce defensive practice.

Fatima: It is difficult to assess the extent to which this affects the practice of gastroenterology, but it is documented that it does lead to increased healthcare costs. Defensive practices, however, do not provide additional clinical benefit. Overall, it depends on individual physician’s experiences whether or not they over-test.

5. Additional dimensions of medical professional liability (MPL) include telemedicine and social media. How can we protect ourselves from lawsuits on these platforms?

Adler: I perform a large number of telemedicine visits as my practice covers a large geographical area. In general, I do not feel that telemedicine confers an increased risk of liability, although others might disagree. Social media, in general, should be used to educate patients and other physicians and should not be a place for political/cultural rants or inappropriate comments/images. Separate your personal social media accounts from your professional ones.

Kantrowitz: Telemedicine should complement but not replace in-person evaluation. It should be used judiciously. A virtual visit may be useful for discussing recent test results but obviously not for encounters requiring a physical exam. Social media should not be used for clinical care. Don’t assume that social media posts will necessarily remain private even if intended to be.

Fatima: First and foremost, we need to familiarize ourselves with the legal requirements for telemedicine and social media. For telemedicine, make sure you or your staff obtain consent from the patient for a virtual visit and inform them of the limitations. Use HIPAA-compliant platforms only. An online presence is needed in this day and age; however, it is imperative that you ensure patient privacy on social media especially when sharing images for educational purposes.

6. Vicarious liability holds that GI clinicians may be liable for the actions of personnel they supervise. In addition to fellows, does this include nurses and technicians?

Adler: For the most part, yes. Anyone under your direct supervision who commits an error may put you in legal

“It is important to be honest and compassionate with the patient and family. Showing empathy with words and body language is key. Make sure you listen to their concerns, show respect, and validate their feelings.”

—Hala Fatima, MD, FACG

jeopardy. As the attending, the burden of responsibility often falls on you. If a nurse makes an error and gives the wrong drug/dose/route/etc., and the patient is injured, you may very well be sued alongside said nurse. You may be dropped from the case or found to be without fault, but you may still be under the gun for a time. If the fellow perforates during an endoscopy and you are the attending, you will likely be named in any subsequent legal action.

Fatima: Yes, it absolutely does. Therefore, it is essential to train the nurses and technicians and support their ongoing education. Correct their mistakes, teach them on the job, and do regular evaluation and feedback as it pertains to patient safety. Having protocols and policies in place for patient safety helps tremendously. Healthcare facilities also have a big role to play in ensuring adequate staffing so burnout does not increase the chance of medical mistakes.

7. What would you suggest as stress-reducing/resilience-building strategies for physicians with malpractice claims?

Adler: Most lawsuits settle or are dismissed, few go to trial. Recognize that the case may take years to get resolved, so do not expect rapid action. Listen to your attorneys, and do not ignore the fact that you may have little to no objectivity about the case in question. Try not to let the case overshadow the rest of your life (easier said than done). If you have a lawsuit and lose at trial or a settlement is made, remember that your life is not over, your career is not finished, and you can live to practice another day.

Kantrowitz: Being sued can shake a physician’s confidence. But studies have of closed claims have not demonstrated a close correlation to healthcare quality. Work closely with an experienced attorney to understand the process and prepare, recognizing that it could take years for a resolution. Keep in mind that while malpractice proceedings must be taken very seriously, many are resolved favorably for the physician.

Fatima: Seek emotional support from friends and family and, if needed, from professionals. Practice self-care and do not be too hard on yourself. Exercise and a healthy diet are big stress reducers in my opinion. Having a robust legal counsel can help alleviate anxiety about the unknown. If you do get sued, use it as a growing experience and learn from it; it will definitely build resilience.

Take-Home Points:

 Clear and empathetic communication is crucial.

 Understand the legal requirements and potential risks associated with telemedicine and social media. Use secure platforms and maintain patient privacy.

 Proper training and maintaining patient safety protocols can mitigate risks of vicarious liability.

 Always consult with legal professionals to guide you through your specific situation and jurisdiction.

 Malpractice claims can take years to resolve. Maintain self-care and seek emotional support for your mental health through the process.

 Having a malpractice claim does not define you. You can navigate through this tough process and continue to practice gastroenterology with resilience and growth.

SUGGESTED READING:

Barry G. Fields, Regulatory, legal, and ethical considerations of telemedicine. Sleep Med Clin. 2020 Sep;15(3):409-416

John Azizian, Camellia Dalai, Megan

A. Adams, Andrew Murcia, James H. Tabibian. Medical professional liability in gastroenterology: definitions, trends, risk factors, provider behaviors, and implications Expert Rev Gastroenterol Hepatol 2021 Aug;15(8):909-918.

Michael G. Kantrowitz. Medical malpractice and gastrointestinal endoscopy Curr Opin Gastroenterol. 2022 Sep 1;38(5):467-471.

ASGE Standards of Practice Committee. American Society for Gastrointestinal Endoscopy guideline on informed consent for GI endoscopic procedures Gastrointest Endosc. 2022 Feb;95(2):207-215.e2

WATCH: ACG Virtual Grand Rounds

Career Edition: “Malpractice/Dealing with Lawsuits,” April 19, 2023

gi.org/past-acg-virtual-grand-rounds

SLIDES: bit.ly/Malpractice-SlidesApril-2023

About Dr. Adler: Dr. Adler is Director of the Center for Advanced Therapeutic Endoscopy (CATE) at Centura Health-Porter Adventist Hospital in Denver, CO. He is Editor-in-Chief of the ASGE journal Gastrointestinal Endoscopy

About Dr. Feld: Dr. Feld, whose training includes medicine and a law degree, is Clinical Professor of Medicine at the University of Washington. He served as ACG Governor for Washington from 2016 to 2022 and is currently a member of the ACG Professionalism Committee. He is Past Chair of the ACG Professional Issues committee (2004-2006).

About Dr. Fatima: Dr. Fatima is Professor of Clinical Medicine at Indiana University School of Medicine and Section Chief of Gastroenterology at Eskenazi Health and the Director of Endoscopy. She recently served a term on the ACG Training Committee (2020-2023).

About Dr. Kantrowitz: Dr. Kantrowitz is a gastroenterologist at Maimonides Medical Center in Brooklyn, NY. He serves as Vice Chair for Quality and Safety in the Department of Medicine and received his Master's in Healthcare Quality and Safety from the College of Population Health at Thomas Jefferson University.

Advance to Fellowship of the AMERICAN COLLEGE OF GASTROENTEROLOGY (FACG)

Criteria

for an ACG Physician Member to Advance to Fellowship:

 Demonstration of scholarly activities, which include continuing education experience, professional leadership, and excellence in the fields of clinical practice and/or academic medicine.

 Current uninterrupted membership or international membership in the College for a period of no less than five years (Post Resident/Trainee Membership).

 Minimum of three distinct* CME programs sponsored by the ACG within the last six years (*Attendance at multiple courses in the same meeting, e.g. PG Course and Annual Meeting, or Regional Meeting plus Hepatology School counts as one program.)

 Evidence of ongoing involvement in ACG activities: Committees, Courses, Annual Meeting attendance, etc.

 Letters of recommendation from two Fellows of the College.

 Documentation of initial certification by one or more of the following specialty boards recognized by the Council on Graduate Medical Education of the American Medical Association: American Board of Internal Medicine, (subspecialty Boards in Gastroenterology), or its equivalent, e.g., American Board of Pediatrics (subspecialty Board in Gastroenterology), American Board of Surgery, American Board of Radiology, American Board of Pathology, the American Osteopathic Board of Internal Medicine or the Canadian equivalent qualifications, Fellow of the Royal College of Physicians and Surgeons.

Benefits of ACG Fellowship:

 You can run for elected office on the Board of Governors

 You can serve as the Chair of an ACG Committee

 You can be nominated for the Board of Trustees

 You can be nominated for a Master Award or the Samuel S. Weiss Award

 Add FACG to your credentials, on business cards, and on your CV

 Recognition at the ACG Annual Meeting and on the ACG website

 Certificate of Advancement to Fellowship signed by the ACG President and Secretary

 Complete the application online: members.gi.org/acgmembership

 Application fee is $50

Tales from GIQuIC

Introduction:

Costas H. Kefalas, MD, MMM, FACG, FASGE, AGAF Director and President, GI Quality Improvement Consortium; Partner and Vice President, Akron Digestive Disease Consultants, Inc.

What is GIQuIC?

GIQuIC is a medical registry, and the acronym stands for the GI Quality Improvement Consortium. the primary functions of GIQuIC include performance benchmarking and improvement, promotion of quality-based research, and use as an approved Qualified Clinical Data Registry. Formed in 2010 as a joint collaboration of the American College of Gastroenterology and the American Society for Gastrointestinal Endoscopy, GIQuIC is a separate entity with its own physician board and Executive Director.

As a clinical quality data registry, GIQuIC collects, organizes, and displays healthcare information. Currently, there are over 4,300 physicians participating in the registry, and this represents approximately one-third of all U.S.based gastroenterologists. there have been more than 18 million colonoscopies and more than 3.5 million EGDs recorded in the registry.

GIQuIC’s Origins & Objectives

the impetus to create GIQuIC stemmed from the Endoscopy Quality Indicators, which were initially published by ACG and ASGE in 2006. these quality indicators were deemed to be both feasible to measure and associated with improved patient outcomes. therefore, the foresight of the ACG and ASGE physician leaders was to create a reliable, consistent way for providers to capture healthcare information, with the ability to analyze and benchmark performance at a provider and group or site level and compare it to the established performance targets and the national cohort. the early leaders of the GIQuIC include founding President Dr. Irving Pike, whose vision brought the registry to life, and Dr. thomas Deas who was a

champion from ASGE. the overarching goal of GIQuIC is to improve endoscopic quality, raise the level of the healthcare provided to patients, and ultimately improve patient outcomes.

GIQuIC currently measures adenoma detection rate, cecal intubation rate, withdrawal time, adequacy of bowel prep, and adherence to CRC screening and surveillance recommendations, to name a few. It provides real-time reports based on up-to-date evidence and recommendations. All participating physicians or practices must submit 100% of each procedure.

GIQuIC has a robust dataset which is an invaluable resource for digestive disease research. GIQuIC is an approved Qualified Clinical Data Registry and participants can submit data to the CMS Quality Payment Program, the Merit-Based Incentive Payment System, otherwise known as MIPS.

The Future of GIQuIC

At present, the registry only measures colonoscopy and upper endoscopy quality metrics, however, I am pleased to report that inflammatory bowel disease quality metrics, ERCP quality metrics, and other endoscopic procedures and digestive disease areas will soon be part of the registry for participants to measure and report.

GIQuIC is working with our technology vendor, Health Catalyst, to automate the data extraction and collection process, thereby enhancing the amount and type of data collected and reducing the time and effort required to collect data. this will be especially valuable as we enhance the registry functionality, add additional endoscopy procedures and digestive disease states, and facilitate patient-reported outcomes.

Conclusion

the work of quality will increasingly advance and become more important as the slow transition from volume to value marches forward. GIQuIC has played a significant role to date in the quality arena and will continue to do so, to improve the care of patients. I hope that you enjoy reading about GIQuIC’s past success and future opportunities in the following pages.

Priorities & Publications

Research Findings from the GIQuIC Endoscopic Quality Data

Repository: Q&A with GIQuIC Champions

Colonoscopy with a Focus on Adenoma Detection Rate and Surveillance

Questions for Aasma Shaukat, MD, MPH, FACG, FASGE and Jason A. Dominitz, MD, MHS, FASGE

What are two or three key papers emerging from GIQuIC in this area and what key takeaways do GI clinicians need to know?

Shaukat: The study by Liang, et al. (PMID: 35643172) is an important one, reporting the yield of neoplasia in individuals 18-49 compared to 50-75-year-olds. The study found that the prevalence of advanced neoplasia was 5% for 45-49-year-olds, with higher prevalence in men compared to women, and in whites compared to nonwhites. It adds to our understanding of the risk of neoplasia in younger individuals.

Dominitz: GIQuIC is an unparalleled resource for endoscopy-related research, particularly for quality improvement efforts as well as for understanding the epidemiology of colorectal neoplasia. And many investigators are now leveraging this rich database to answer important clinical questions.

For example, some have questioned the recent recommendations to begin colorectal cancer screening at age 45. However, using GIQuIC data, Bilal, et al (PMID 35169107) and Liang, et al. (PMID 35643172) both explored the prevalence of colorectal neoplasia in individuals aged 45-49 years and found considerable rates of neoplasia in this group to support these recommendations. They also found that the current ADR benchmarks do not need to be lowered to account for younger individuals presenting for screening.

GIQuIC also has provided critically important data to help us understand the epidemiology of sessile serrated lesions (SSLs). Shaukat, et al. (PMID 32833735)

found that SSL detection averaged 6% but was highly variable between endoscopists. Variation of this magnitude is often reflective of quality issues. The fact that the SSL detection rate has been increasing over time is encouraging and highlights the value of colonoscopy quality improvement efforts.

How has your research benefited from access to GIQuIC data and what are the areas of future research you hope to pursue?

Shaukat: GIQuIC is a valuable resource, as an endoscopic procedure repository of over 20 million procedures, representing all geographic regions of the U.S., and both academic and community practices. The data gathered can be used to understand the current practice patterns, yield of endoscopic procedures, and quality indicators for colonoscopy and upper endoscopy. These studies have informed guidelines, led to establishing quality indicators, and set benchmarks for the quality indicators. In the future, the addition of more data fields and modules for other endoscopic procedures such as ERCP and EUS will enhance the research potential of the registry. I would be interested in understanding how computeraided detection technologies impact quality of colonoscopy, polypectomy practices, and complications.

Dominitz: Early in the COVID-19 pandemic, I was interested in better understanding the impact of COVID-19 on endoscopy across the nation and, especially, upon the diagnosis of colorectal cancer. Using GIQuIC data, we found that 30% fewer colorectal cancers were diagnosed early in the pandemic than we would have predicted based upon historical data. Therefore, it was evident that we needed to find ways to prevent an epidemic of delayed cancer diagnoses. This data was helpful for my role as the Executive Director of Gastroenterology for the Veterans Health Administration as we endeavored to mitigate the impact

GIQuIC Leadership, Committee Structure, Vision & Mission

The current GIQuIC seven physician board members are:

• Costas H. Kefalas, MD, MMM, FACG, FASGE, AGAF, President and Director;

• Colleen M. Schmitt, MD, MHS, MASGE, FACG, Vice President and Director;

• Brett Bernstein, MD, MBA, FASGE, Secretary and Director;

• Jay N. Yepuri, MD, MS, FACG, Treasurer and Director;

• Katie F. Farah, MD, FASGE, Director;

• Aasma Shaukat, MD, MPH, FACG, FASGE, Director;

• Joseph J. Vicari, MD, MBA, FACG, FASGE, Director.

Laurie H. Parker, GIQuIC Executive

GIQuIC Committees

• Finance Committee, chaired by Jay Yepuri, MD, MS, FACG

• Research Committee, chaired by Prasad Iyer, MD, FACG

• Measures Steering Committee, chaired by Brett Bernstein, MD, MBA, FASGE

Subcommittees of Measures Steering Committee

• Colonoscopy/CRC

• EGD

• ERC

• EBT (Bariatrics)

Vision & Mission:

• IBD

• WCE

• EUS

The GIQuIC Vision is to improve patient outcomes by establishing standards for defining, measuring, and improving the quality of digestive health care.

The GIQuIC Mission is to drive the highest quality delivery of digestive healthcare.

GIQuIC will:

• Define, measure, and implement metrics

• Enable continuous performance evaluation and feedback

• Deliver data reports, benchmarks, and dashboards

• Promote outcomes-based research

• Provide quality driven education

• Create value for patients, clinicians, and payors

• Improve health equity and healthcare disparities

The GIQuIC Data Collection Process

The GIQuIC process for collecting and reporting data involves:

• Patient information (i.e., demographic information) is entered into EHR and mapped to the endowriter.

• Physician documents procedure information in the endowriter.

• Biopsy or pathology samples are sent to the lab. When results are returned, findings are entered into the endowriter, along with the recommended follow-up interval told to patient; this is often the only manual data entry necessary. The rest of the information required by GIQuIC is collected by the endowriter.

• Once records are complete in the endowriter, multiple records can be selected at a time to be exported into a file that can be read by GIQuIC.

• Data Manager logs into GIQuIC and uploads the file.

• GIQuIC does a sweep of the data to identify any errors and/or warnings.

o Error – a required data element is missing or invalid and must be corrected.

o Warning – a data element may be incorrect and should be investigated for accuracy.

• Data can also be entered manually, directly into the registry.

• Data Manager can run quality measures reports in real-time to look at data in the registry and provide reports to physicians.

of the pandemic for Veterans. Currently, I am using GIQuIC data to explore the association between the indication for colonoscopy and colonoscopy quality indicators, including the detection of neoplasia and providers’ recommendations for follow-up after a negative colonoscopy.

Author Insights - Questions for Authors of Recent Publications Derived from GIQuIC Data

Bilal M, Holub J, Greenwald D, Pochapin MB, Rex DK, Shaukat A. Adenoma Detection Rates in 45-49-YearOld Persons Undergoing Screening Colonoscopy: Analysis From the GIQuIC Registry. Am J Gastroenterol. 2022 May 1;117(5):806-808. DOI: 10.14309/ ajg.0000000000001684. Epub 2022 Feb 15. PMID: 35169107.

Shaukat: In our updated ACG colorectal cancer screening guidelines in 2021, the screening age was lowered to 45 for average risk men and women. It was important to understand the adenoma detection rate in men and women ages 45-49 to assess the impact of the new

guidelines on our practice. We found that with the addition of the younger individuals (45-49) to our screening colonoscopy pool, endoscopists can expect a small drop in ADR of 3-5%, compared to ADR for 50-54-yearolds, and 7-8% lower than ADR for 50-75-year-olds, but overall impact is small.

Q&A with GIQuIC Champions: EGD with a Focus on Barrett’s Esophagus

Questions for Prasad G. Iyer, MD, MSc, FACG and Sachin B. Wani, MD

Reflect on a key paper emerging from GIQuIC in the area of EGD, and what key takeaways do GI clinicians need to know? How has your research benefited from access to GIQuIC data and what are the areas of future research you hope to pursue?

Prasad Iyer, MD, MSc, FACG, Chair, GIQuIC Research Committee, Mayo Clinic, Rochester, MN

Currently, the recommendation for one-time endoscopic screening for Barrett’s esophagus (BE) is based on relatively scant evidence from two studies with short follow up intervals. Using the unique data available from GIQuIC, we assessed the proportion of patients who were diagnosed with BE on their second EGD after an initial negative EGD. In a cohort of over 200,000 patients from GIQuIC who underwent a second EGD, we found that the BE prevalence was 45% of that at baseline endoscopy (4%) and remained relatively stable over time, suggesting that most of these cases were initially missed during their baseline endoscopy. This reinforces the need for a high-quality initial endoscopic assessment in those with risk factors for BE. This paper is accepted for publication in CGH (PMID

“GIQuIC is an unparalleled resource for endoscopy-related research, particularly for quality improvement efforts as well as for understanding the epidemiology of colorectal neoplasia..” —Dr. Dominitz

FIGURE 1: GIQuIC Drives Quality Improvement: ADR on the Rise

One of the hallmarks of the GIQuIC experience is that the adenoma detection rate of participants in the registry has significantly increased over time.

is pending).

The large size of the cohort allowed us to perform subgroup analyses and assess trends over time and identify a subgroup of patients (with two or more risk factors) who could be a candidate for a repeat evaluation, particularly with less expensive non-endoscopic BE screening tools. These findings may have an impact on GI society guidelines and reveal the substantial impact of data that can be gleaned from GIQuIC.

With recent modifications (completed and planned) in data collection forms for EGD, the GIQuIC EGD database has the potential to become an even more powerful tool to answer important clinically impactful questions in diseases such as Barrett’s esophagus, eosinophilic esophagitis, and GERD. The GIQuIC Research Committee looks forward to receiving additional proposals to harness the power of data collected from EGD data to favorably impact patient care.

Sachin B. Wani, MD, University of Colorado School of Medicine

It has been an absolute honor and privilege to have collaborated with the GIQuIC research team over the last five years; a collaboration that has resulted in the conceptualization and implementation of several critical research projects in the field of Barrett’s esophagus and esophageal adenocarcinoma.

Our initial research addressed a fundamental question: how well do we as a community of endoscopists adhere to the established quality measures in Barrett’s esophagus? These measures focus on appropriate endoscopic surveillance intervals in patients diagnosed with nondysplastic Barrett’s esophagus (3-to-5-year intervals) and appropriate

sampling in patients with suspected or established Barrett’s esophagus (Seattle biopsy protocol, biopsies obtained every 2 cm in a four-quadrant fashion plus targeted biopsies from any visible lesions).

Our analysis, using the GIQuIC registry, demonstrated that approximately 30% of patients with non-dysplastic Barrett’s esophagus are recommended to undergo surveillance endoscopy too soon and nearly 20% of endoscopies performed in Barrett’s esophagus patients are not adherent to the Seattle biopsy protocol with worsening adherence rates in patients with longer segments of Barrett’s esophagus (PMID: 30865017, 31085185). Contemporary guidelines for Barrett’s esophagus recommend against sampling of a normal or an irregular appearing squamocolumnar junction (irregular Z-line), in the absence of any visible lesions. Analyzing data within the GIQuIC registry demonstrated that a significant proportion of these patients undergo sampling are wrongly diagnosed with Barrett’s esophagus and recommended to undergo surveillance endoscopies (PMID 33156106).

ACG/ASGE

Epidemiologic Research Award in Gastrointestinal Endoscopy

Investigators Share Insights from Their Projects

The joint ACG/ASGE Epidemiologic Research Award in Gastrointestinal Endoscopy supports up to $50,000 for research projects involving the use and outcomes of gastrointestinal (GI) endoscopy using the GI Quality Improvement Consortium (GIQuIC). The three funded investigators whose projects have been funded through this award share the rationale and some of the key questions/findings for their projects and reflect on how their findings will help shape endoscopic practice and/or help clinical practitioners.

GIQuIC Measures Subcommittees

Colonoscopy

Chair: Dr. Aasma Shaukat

Subcommittee: Dr. Jason Dominitz, Dr. Carol Burke, Dr. Philip Schoenfeld, Dr. Douglas Rex

EGD

Chair: Dr. Reem Sharaiha

Subcommittee: Dr. Prateek

Sharma, Dr. Kenneth Wang, Dr. Nicholas Shaheen, Dr. Rahul Shimpi

ERCP

Chair: Dr. Douglas Adler

Subcommittee: Dr. Anna Duloy, Dr. Betsy Rodriguez, Dr. Paul Tarnasky, Dr. Jeffrey Tokar

Bariatrics

Chair: Dr. Shelby A. Sullivan

Subcommittee: Dr. Blake Jones, Dr. Nitin Kumar, Dr. Vladimir Kushnir

IBD

Chair: Dr. Jean-Paul Achkar

Subcommittee: Dr. Anita Afzali, Dr. Frank Farraye, Dr. David Rubin, Dr. Anne Tuskey, Dr. Colleen Schmitt, Ex Officio

Wireless Capsule Endoscopy/Deep Enteroscopy

Chair: Dr. David Hass

Subcommittee: Dr. Jodie Barkin, Dr. Glenn Eisen, Dr. Jonathan Leighton, Dr. Daniel Raines

Endoscopic Ultrasound

Chair: Dr. Sachin Wani

Subcommittee: Dr. Benjamin Bick, Dr. Vivek Kaul, Dr. Jennifer Maranki, Dr. Vanessa Shami

“the GIQuIC EGD database has the potential to become an even more powerful tool to answer important clinically impactful questions in diseases such as Barrett’s esophagus, eosinophilic esophagitis, and GERD.” —Dr. Iyer

Aasma Shaukat, MD, MPH, FACG, FASGE of NYU Langone Health was granted the ACG/ASGE award in 2023 for her project, “Association of quality indicators for colonoscopy and risk of metachronous advanced neoplasia at surveillance colonoscopy: Results from a national colonoscopy registry.”

Shaukat: Surveillance colonoscopy is a large part of our practices, and we need to understand the factors that are associated with risk of metachronous neoplasia (i.e., finding adenomas, advanced adenomas, sessile serrated lesions, and colorectal cancer) at surveillance colonoscopy. We know that the quality of the baseline colonoscopy is important. In this study, we plan to evaluate the contribution of endoscopist quality indicators such as ADR, withdrawal time, patient level factors, such as age, and findings on the baseline colonoscopy, on the risk of colorectal neoplasia at the follow up colonoscopy. We hope to find factors that we can improve upon and reduce the risk of future neoplasia and render our colonoscopy practice more effective at cancer prevention.

Seth D. Crockett, MD, MPH of Oregon Health & Science University was granted the ACG/ASGE award in 2022 for his project, “Assessing variability in polypectomy practices and postpolypectomy complications among U.S. endoscopists.”

Crockett: The nidus of this study was a conversation with my two talented collaborators (Dr. Rajesh Keswani from Northwestern and Dr. Audrey Calderwood from Dartmouth) about the importance of polypectomy technique in high quality colonoscopy. There has been a lot of focus on polyp detection in the past few decades, and the Adenoma Detection Rate (ADR) has been established as the key metric for colonoscopy quality. However, there has been comparatively little study on polypectomy technique, which is arguably just as important as detection: If a polyp is detected, but incompletely resected, this

diminishes the cancer preventive effect of colonoscopy. Additionally, we know that certain polypectomy techniques such as hot biopsy or hot snare polypectomy are more dangerous than others in terms of causing colonic injury or postpolypectomy bleeding. We now have guidelines from the U.S. Multisociety Task Force that recommend the safest and most efficacious methods for removal of <10mm polyps. But we know very little about polypectomy practices in the U.S. and how much variability there is.

This study was designed to leverage the large size and representativeness of the GIQuIC registry to determine how U.S. endoscopists are currently performing polypectomy for small polyps, to see how an endoscopist’s polypectomy practice correlates with existing quality metrics (e.g., ADR) and to determine whether an endoscopist’s polypectomy technique is associated with certain endoscopy complications.

One goal of this project is to establish whether and how we can reliably use the GIQuIC database to measure a usage of cold snare, cold biopsy, and hot snare polypectomy rates for small polyps removed during screening and surveillance colonoscopies. If we can do this, and if we can establish that these polypectomy practices correlate with important outcomes, this could lead to a new frontier in quality improvement for colonoscopy. Essentially, this project represents the beginning of a line of investigation into whether measuring, tracking, and improving one’s polypectomy practice could help further refine the quality and safety of screening colonoscopy.

Jason A. Dominitz, MD, MHS, FASGE of the Veterans Health Administration and the University of Washington was granted the ACG/ASGE award in 2021 for his project, “Comparison of colonoscopy quality metrics among individuals

undergoing diagnostic colonoscopy for an abnormal fecal occult blood test, abnormal FIT-DNA test or average risk screening colonoscopy in a national colonoscopy registry.”

Dominitz: We were curious how the indication for colonoscopy might impact various aspects of colonoscopy performance and findings, specifically with regard to screening vs. abnormal occult blood testing (FOBT, including FIT) vs. abnormal FIT-DNA (AKA Cologuard®). Using GIQuIC data, we identified over 1.8 million colonoscopies, including approximately 26,000 colonoscopies for abnormal FOBT and 23,000 for abnormal FIT-DNA. We hypothesized the endoscopists may be more concerned about missing pathology when performing colonoscopy for abnormal FIT-DNA, leading to changes in their behavior. In fact, we found that when the colonoscopy was negative for polyps or cancer, endoscopists spent an average of 9% more time on withdrawal for FIT-DNA+ colonoscopies than for screening and FOBT+ colonoscopies. In addition, while guidelines recommend repeating colonoscopy in 10 years after a negative exam, earlier colonoscopy was recommended for 20% of FITDNA+ patients versus about 13% of screening and FOBT+ patients. This suggests that the endoscopists were more concerned about the risk for missed pathology and has implications for the overall cost-effectiveness of the various screening strategies.

Also, while it has been previously shown that the ADR is strongly correlated with the risk of postcolonoscopy colorectal cancer, we

“GIQuIC is a valuable resource, as an endoscopic procedure repository of over 20 million procedures, representing all geographic regions of the U.S., and both academic and community practices.” —Dr. Shaukat

have found that the ADR is also associated with the risk of finding adenocarcinoma on the initial exam. This suggests that many post-colonoscopy cancers were actually present as cancers at the time of the colonoscopy (but were missed.) These findings reinforce the importance of ongoing quality assurance efforts within individual practices as we strive to reduce colorectal cancer incidence and mortality.

Looking to the Future of GIQuIC

Q&A with Brett B. Bernstein, MD,

MBA,

FASGE, Mount Sinai Beth Israel Hospital, Chair of the GIQuIC Measures Steering Committee

What is the work of the Measures Steering Committee?

We have a GIQuIC Measures Committee which is comprised of a Steering Committee and several Subcommittees. The GIQuIC Measures Committee as a whole is focused on advancing the mission of the GIQuIC Registry which is to promote the highest quality of digestive care. The Steering Committee focuses on the registry’s scope and direction and is responsible for helping to identify those essential clinical quality, research, and educational priorities and making the organizational decisions to ensure those priorities are met.

The Measures Subcommittees focus on specific clinical topics in gastroenterology. Subcommittees review, make recommendations, and develop clinical quality measures and other quality, educational and research initiatives included in the GIQuIC modules. Currently,

we have six procedure-specific subcommittees including Colonoscopy, EGD, Capsule Endoscopy/Deep Enteroscopy, ERCP, EUS, and Endoscopic Bariatric Therapies (EBT). We have one disease-specific subcommittee focused on quality of care for patients with inflammatory bowel disease (IBD). We are keenly focused on expanding quality improvement opportunities within the GIQuIC Registry and plan to release the modules for the other five clinical topics starting in 2024.

How does expanding into these particular new areas enhance the relevance and usefulness of the registry?

The role of clinical registries has never been more significant. Registries help us bring into focus large volumes of data to measurably improve care, identify educational opportunities, and advance research. This is done with the singular goal of improving patient care across all aspects of gastroenterology practice. Expanding the GIQuIC modules to include ERCP, EUS, CE/ DE, EBT and IBD is essential to provide physicians with a comprehensive picture of the care they provide and help identify areas of improvement. We want to provide a broad range of quality improvement opportunities to address a complex myriad of digestive procedures and conditions. We will continue to expand the offering of the GIQuIC Registry to provide clinicians with the tools they need in their clinical practice to care for their patients. How will the new measures benefit GI clinicians and their patients? Through increasing the depth and breadth of quality measures, both clinicians and patients may benefit in the following ways:

 Standardization of Care: GIQuIC has been fortunate to recruit

renowned experts to develop measures for routine and advanced endoscopic procedures. Many of these experts have helped create standardized protocols and guidelines for the ACG and ASGE. Such standardization can lead to consistency in care across different practices and practitioners, reducing the variability in patient outcomes. This also reduces the chances of procedure-related complications, enhancing patient safety.

 Evidence-Based Practice: The involvement of thought leaders who have directly participated in guideline development ensures measures will be evidence-based, integrating the best available research with clinical expertise. These measures can guide clinicians in adopting practices that are backed by strong evidence, improving the quality of care provided.

 Enhanced Clinical DecisionMaking: In complex areas like IBD, these measures could be of significant help. They can provide a roadmap for managing complex and challenging cases, supporting clinicians in making effective clinical decisions. This can lead to more accurate diagnoses, appropriate and effective treatments, and overall improved patient outcomes.

 Benchmarking and Performance Evaluation: Measures developed by GIQuIC provide a standard against which individual clinicians, or entire practices, can evaluate their performance. This allows for identification of areas of excellence and areas needing improvement, contributing to the overall enhancement of healthcare quality.

 Patient-Centered Care: With standardized and evidence-based measures in place, patients receive care that is not only clinically effective but also centered around their specific needs and conditions. This can lead to improved patient satisfaction and better health outcomes.

“The role of clinical registries has never been more significant. Registries help us bring into focus large volumes of data to measurably improve care, identify educational opportunities, and advance research.” —Dr. Bernstein

 Professional Development:

For clinicians, such measures represent opportunities for learning and professional growth. They offer insights into best practices and emerging trends in gastroenterology, helping clinicians stay updated in their field.

What is their research potential for clinical investigators?

GIQuIC is a unique opportunity for investigators interested in gastroenterology research. The large, robust dataset provides investigators with the ability to analyze outcomes, trends, risk factors, and other key interests in the field of gastroenterology. GIQuIC users will be able to monitor their performance as new quality measures are released and readily available for review after logging into the GIQuIC website. Using the aggregate data stored in the registry, clinical researchers will be able to study “real world” adoption and adherence to new quality measures. Investigators can also study and identify factors that are associated with adherence both initially and over time as well as other areas based on their research interests.

Q&A with Jean-Paul Achkar, MD, FACG, The Cleveland Clinic Foundation, Chair of the GIQuIC IBD Measures Subcommittee

What is the work of the IBD Subcommittee?

GIQuIC has been a leader in defining and measuring quality in GI patient care with a focus to date on upper endoscopy and colonoscopy related measures. GIQuIC’s leadership had the vision to expand to other fields in GI and chose IBD as an area that would bring the added value of defining both procedural and non-procedural based quality metrics. This is particularly important as it is estimated that up to 3 million Americans have IBD, a chronic illness which requires long term, multi-disciplinary and high-

quality care. The overall goal of the IBD Subcommittee has been to establish well-defined and reliable measures that will enhance care for IBD patients over their disease course which often can last 20 or more years.

Describe the vision and plans to expand GIQuIC’s mission in this new clinical area and why it matters for clinical GI.

Since IBD is a chronic illness that often begins at a young age and can last a lifetime, the quality of care can vary over the continuum of disease as patients move through various transitions including those from pediatric to adult GI care, to different practices or geographic areas, and as they require different levels of care including surgical intervention. The IBD Subcommittee has worked to develop well-defined and reliable measures to enhance overall care for IBD patients and to allow the ability to measure performance and outcomes against internal and national benchmarks. This has been a unique opportunity to develop and define what quality in IBD patient care really means particularly in the growing area of setting standards for nonprocedural based measures.

What measures are you working on and how do you see this data benefiting those seeking to benchmark their practice, clinical investigators, and even payors?

Since IBD requires high-quality medical and endoscopic care, we have focused on developing both non-procedural and procedural based measures; a list of the measures is listed below. For non-procedural care we focused on the importance of health care maintenance and reducing risk of infections, as many IBD patients are immunocompromised due to their disease and associated medications used to control inflammation. We therefore wanted to highlight defined standards for patients receiving appropriate vaccinations and being tested for hepatitis B and latent tuberculosis prior to initiating certain therapies.

From a procedural perspective, we

GIQUIC BY THE NUMBERS

15 PUBLISHED RESEARCH ARTICLES

OVER 18 MILLION COLONOSCOPIES

recognized that standardization of performing a complete examination and reporting of endoscopic findings is important in the continuum of care. We thus highlighted the importance of documentation of factors such as extent of disease and terminal ileal involvement as well as using scoring systems such as the Mayo endoscopic score, the Rutgeerts score, and the SES-CD. Colonoscopy also plays an important role in dysplasia detection among patients with longstanding colonic disease and we included measures related to recommendations for follow-up examinations if no dysplasia is detected.

The overarching goal of these efforts is to standardize and improve the care of IBD patients and to help practitioners measure performance and outcomes against internal and national benchmarks. In addition, these measures could set the stage for improved performance reimbursements from Medicare and insurance companies.

Non-Procedural Based Measures:

• Appropriate Vaccination Against Influenza in Adult Patients with IBD

• Appropriate Vaccination Against Herpes Zoster Infection in Adult Patients with IBD

• Appropriate Vaccination Against Pneumococcal Pneumonia in Adult Patients with IBD

• Testing for Hepatitis B (HBV) and Latent Tuberculosis (TB) Before Initiating Anti-Tumor Necrosis Factor (TNF), Interleukin (IL) 12/23 Inhibitor or Janus kinase (JAK) Inhibitor Therapy

Procedural-Based Measures:

• Use of the Rutgeerts Score to Grade Post-operative Crohn’s Recurrence in Neo-terminal Ileum

• Use of a Validated Endoscopic Scoring System to Grade UC Severity

• Use of SES-CD Endoscopic Scoring System to Evaluate CD Severity and Disease Distribution

• Documentation of Extent of Colitis

• Photodocumentation of the Ileum in Patients Undergoing Diagnostic

Colonoscopy

• Photodocumentation of the Ileum in Patients with Crohn’s Disease Undergoing Subsequent Colonoscopy

• Appropriate Recommendation for Follow-Up Colonoscopy Interval for Ulcerative/Indeterminate Colitis Patients Undergoing Dysplasia Screening Without Dysplasia Detected

• Appropriate Recommendation for Follow-Up Colonoscopy Interval for Ulcerative/Indeterminate Colitis Patients with Primary Sclerosing Cholangitis (PSC) Without Dysplasia Detected

Q&A with Shelby A. Sullivan, MD, FACG, University of Colorado School of Medicine, Chair of the GIQuIC Bariatrics Subcommittee

Q. What is the work of the Bariatrics Subcommittee?

This is such an exciting area of expansion for the GIQuIC registry given the advancements that have been made in endoscopic bariatric therapies (EBT). The initial work of this subcommittee is to develop key data fields that play a role in the efficacy and safety of EBT, including important data related to both mild and serious adverse events, patient reported outcomes, and quality of life. There are no established quality measures in this area, therefore having the ability to capture data related to EBT and management of these patients will result in an opportunity to develop these quality measures and to improve patient outcomes. Currently, there is no reimbursement for these procedures, therefore we envision involving stakeholders such as the FDA, CMS and other payors, patients, and industry in order to achieve reimbursement and at the same time work towards heightening the efficacy and safety of EBT and management of these affected patients.

Q. What measures are you working on and how do you see this data benefiting those seeking to benchmark their practice, clinical investigators and even payors?

The key aspects for this EBT module are extremely patient-centric: quality of

life, patient reported outcomes, and adverse events. With the prevalence of these procedures increasing, the GIQuIC registry platform will provide a mechanism to capture clinically relevant and valuable information to further this field of treating patients endoscopically, in a manner that is both efficacious and safe.

Learn More About GIQuIC & Research Opportunities

 Access information on participation in GIQuIC at giquic.org

 Learn more about the opportunities for clinical research at giquic.org/research

 Epidemiologic Research Award in Gastrointestinal Endoscopy: This award, offered jointly by ACG and ASGE supports one- or two-year awards of up to $50,000 for projects involving the use and outcomes of gastrointestinal (GI) endoscopy using the GI Quality Improvement Consortium (GIQuIC). This award type is for physicians (MD, DO or PhD) in the U.S. or Canada. Applicants must be an ACG or ASGE member at the time of submission. Grant submission will be open in September 2023 with deadline of Monday, December 4, 2023 at 11:59 pm EDT. Apply: gi.org/research-awards

ORAL PRESENTATIONS OF GIQUIC DATA AT NATIONAL GI MEETINGS

2018 DDW Sachin Wani

Over-utilization of Repeat Upper Endoscopy in Patients with Nondysplastic Barrett’s Esophagus: A Population-based Study Using a National Benchmarking Registry

2018 DDW Sachin Wani

Endoscopists Biopsy The Least Those Who Need It The Most: An Analysis of Barrett’s Esophagus Biopsy Practices from a National Quality Benchmarking Registry

2018 DDW Audrey Calderwood

Practice Patterns and Yield of Surveillance Colonoscopy Among Older Adults: An Analysis from the GI Quality Improvement Consortium (GIQuIC)

2018 DDW David Greenwald

Recommendations for follow up interval after colonoscopy with inadequate bowel preparation: An analysis from the GI Quality Improvement Consortium

2018 ACG Sachin Wani

Factors Associated with Over-utilization of Repeat Upper Endoscopy in Patients with Non-dysplastic Barrett's Esophagus (NDBE): A Study Using the GI Quality Improvement Consortium (GIQuIC) National Registry

2019 DDW Sachin Wani

Adherence to Appropriate Surveillance Intervals in Barrett’s Esophagus Has Improved Over Time but Adherence to the Seattle Biopsy Protocol Has Not: An Analysis Using the GIQuIC National Quality Benchmarking Registry

2019 DDW Sachin Wani

Racial Disparities in the Care of Patients with Barrett’s Esophagus: An Analysis Using the GIQuIC National Benchmarking Registry

Prevalence and Predictors of Advanced Neoplasia in Adults Younger Than 50 Years Undergoing Screening Colonoscopy in the GIQuIC National Registry

Patients Commonly Undergo Biopsy of a Normal or Irregular Z-Line and Are Recommended Endoscopic Surveillance Despite the Absence of Barrett’s Esophagus: A Population-based Analysis Using the GIQuIC National Quality Benchmarking Registry

Significant Reduction in the Diagnosis of Barrett’s Esophagus and Related Dysplasia During the COVID-19 Pandemic: An Analysis of the GIQuIC National Benchmarking Registry

ACG VIRTUAL GRAND ROUNDS

Weekly on Thursdays at 12 pm and 8 pm ET

Live Presentation by an ACG Expert Plus Q & A

#GIhomeschooling

Even as all aspects of practice have changed due to COVID-19, your need to stay up to date on clinical GI does not stop. ACG is committed to your professional education. Our goal is to help the GI community embrace #GIhomeschooling with quality speakers and presentations.

ACG has launched Virtual Grand Rounds weekly on Thursdays at 12 pm and 8 pm ET. Each week an expert faculty member will present live on a key topic followed by Q & A.

Learn More and Register: GI.ORG/ACGVGR

Culinary Connections:

Flavorful Fall

Editors: Vani Paleti, MD; Alexander Perelman, DO; and Christina Tennyson, MD

AS THE DAYS BECOME SHORTER AND THE WEATHER COOLER, it is an opportunity to experience the bountiful flavors found in the Fall. Farmers markets and local shops are filled with colorful and tasty produce. A nourishing home-cooked meal incorporating vegetables, herbs, and spices can be both delicious and easy to make. Our contributors this month share their unique stories and savory inspiration for the season. Bon appétit!

—Christina, Alex, and Vani

DIVYANGKUMAR GANDHI, MD, FACG

Gastroenterologist, Augusta Health, Fishersville, VA

Growing up in the western state of India, Gujarat, vegetarianism is deeply rooted for centuries through the principle of non-violence. Although there are various spiritual and holistic reasons to be vegetarian, I chose to be vegetarian due to a simple belief that I do not want to harm any other life to feed myself. While growing up in India, I used to go with my mom to a fresh produce market, which is where I learned how to select ripe fruits and vegetables. We didn’t have a refrigerator or reliable electricity for several years. Everything was bought fresh and finished, with no leftovers, which kept us in good health. At school, we used to exchange lunch among friends, so everyone got to try different varieties. This helped us bond with each other while developing new tastes. Interestingly, many of my childhood memories are forgotten now, but food-related memories are still vivid!

Hospital and school cafeterias are filled with processed foods and often extremely limited vegetarian options. My family

INSTANT POT HORSEGRAM AND LENTIL SOUP

 Ingredients:

• 1/2 cup small brown lentils

• 1/2 cup horsegram

• 1/4 cup crushed tomatoes

• 1/4 cup carrots

• 1/4 cup green peas

• 2 Tbsp ghee (clarified butter)

• 1 Tbsp cumin seeds

• 2 Tbsp cumin powder

• 1 Tbsp salt as per taste

• 1 tsp lemon juice

• 1 tsp paprika

• Cilantro for garnish

makes home-cooked meals a priority. Like me, my wife is also fond of trying new recipes, but she adds a hint of health consciousness on top of that. We like to simplify complex Indian recipes, as traditional recipes could be time consuming and laborious. I strongly believe that if plant-based diets with minimal processing are adopted from childhood, we can bend the curve of various autoimmune GI conditions and fatty liver.

Horsegram (Macrotyloma uniflorum) is a pulse crop native to the southeast Asian subcontinent and tropical Africa. Horsegram has been widely cultivated and consumed in India since ancient times. Traditionally, it is supposed to have been fed to racehorses because it is a powerful source of immediate energy and protein. Surprisingly, 100 grams of cooked horsegram contains approximately 22 grams of protein, the highest among plant-derived food sources! It might be hard to find this legume at a local grocery store but easy at any Indian grocery store. Besides these benefits, horsegram is a draught resistant crop with minimal water irrigation requirement so good for mother nature, too!

VANESSA MÉNDEZ, MD

Founder, Planted Forward, Pembroke Pines, FL Instagram @plantbasedgutdoc and drvanessamendez.com

Studies have shown that we lose microbiome diversity as we immigrate to western societies. There are a lot of potentially protective foods in various cultures that may be forgotten as patients immigrate to a new country, whether because of a lack of access to appropriate ingredients, or the desire to assimilate into a new environment. As a gastroenterologist and a Latina, I try to put cultural sensitivities at the forefront of my health and nutrition discussions with my patients. I strive to create awareness that our cultural foods are an important part of our health, identity, and in many ways, are protective for our microbes.

Even as a child growing up in Cuba, I was aware of the importance of prioritizing nutrition. Food insecurity was a big issue, and we didn’t actually have the diversity that we see in the United States. My food staples were white rice and beans, some sort of animal protein, and fruit. In terms of a complete meal, there was not a lot of

 Steps & Tips:

1. Wash horsegram and brown lentils in water twice.

2. Soak horsegram and brown lentils overnight in 2.5 cups of water. Discard the water before cooking.

3. Turn on Instant Pot in sauté mode.

4. Add ghee, let it get warm, then add cumin seeds and paprika. Sauté for a few seconds.

5. Add crushed tomatoes, sauté for 1-2 minutes.

6. Add soaked horsegram and brown lentils, carrots, and peas.

7. Add 2-3 cups of water. Add salt to taste.

8. Cancel sauté mode, press pressure cook or manual mode for 8 minutes.

9. Wait for natural pressure release then add cumin powder (the more the merrier!), lemon juice, and salt

10. Garnish with cilantro and enjoy!

access to vegetables, grains, or nuts.

We were grateful for the food we did have but knew that we were missing something vital. That all changed when we came to the U.S. where we found the opposite: we had access to all sorts of foods, both nutritious and overly processed. But we were new here, and we had neither the time nor the knowledge to navigate this new and abundant nutritional world. So instead of adding diversity to our meal, we supplemented the old stapes with highly processed food; instead of adding grains and vegetables, we added cakes and fries.

As gastroenterologists, our traditional medical training shows us only the basics of nutrition. It does not, however, go beyond those basics to manage cultural sensitivities, food scarcity, or address the complexity of diseases due to lifestyle choices – or more commonly those that are due to societal choices that are made for us depending on the environment we grew up in.

My third board certification in Lifestyle Medicine through ABLM has helped bridge some of the gaps my traditional IM and GI medicine training left behind. My most important education has come outside of these formal platforms through my

VEGAN PICADILLO

 Ingredients:

• 2 Tbsp olive oil

• 1 large sweet onion, diced

• 1/2 medium red bell pepper, diced

• 1 cup mushrooms, roughly chopped (shiitake mushrooms work best)

• 6 cloves of garlic, diced (or less if you find it too strong)

• 1 1/2 Tbsp soy sauce

• 2 cans brown lentils, rinsed and drained

• 1 tsp dried oregano

• 1/2 tsp ground cumin

• 1 1/2 Tbsp tomato paste

• 1/2 cup water

• 1/2 cup green olives (chopped or whole)

• Salt and black pepper to taste

interactions with patients and my community. These give me an insight into the day-to-day limitations they struggle with: knowledge, access, and marketing forces targeting lower income families and starting from a young age.

My experiences have led me to the conclusions that 1) we need better and broader food programs to bridge these gaps in food access in our communities, and 2) that we need to do a much better job in training our future doctors in nutrition, barriers to access, food scarcity, and cultural sensitivities.

As for my family, we have adopted a more whole food plant-forward lifestyle, with wide access to a variety of unprocessed and whole foods. We haven’t forgotten our Cuban roots and are able to supplement the best of these with the access we have to a wider variety of foods in our community. We’ve kept the beans, but substituted white rice for brown, or sometimes mashed potatoes for a change, and we’ve decreased our animal protein intake. We love our plantains, but we’ve traded the deep fryer for an airfryer, and we’ve added a panoply of veggies on the side for more flavor and variety.

When we miss that picadillo (ground beef), we make this recipe!

Eating this way not only provides

for my nutritional needs but also helps me maintain a strong connection to my Cuban heritage and culture. I believe that the act of eating is a powerful way to build and nurture relationships, and this applies both on an individual level and within the broader community.

TAMARA DUKER FREUMAN, MS, RD, CDN

Dietitian, New York

Gastroenterology Associates. Author of The Bloated Belly Whisperer and REGULAR. Instagram @tamarafreuman and on Twitter/X @tamaraduker

Dietetics is my second career, which I was drawn to on the eve of my thirtieth birthday. At the time, I was feeling burnt out from a travel-intensive corporate job and wanting to get serious about taking better care of my own health through exercise and diet. I began reading a lot about nutrition in my free time when an epiphany struck: I enjoyed thinking about food and nutrition a heck of a lot more than I enjoyed thinking about ‘work stuff.’ The rest, as they say, is history.

I’ve now worked as a GI dietitian in gastroenterology practices for thirteen years and counting, and there is something uniquely rewarding about helping people navigate their food choices while trying to manage digestive symptoms or disorders.

 Steps:

1. Over medium heat, heat the oil in a large skillet.

2. Add mushrooms and sauté until they release their water and it has evaporated, ~3-5 minutes.

3. Add onions and bell peppers and sauté until browned, ~4 minutes

4. Add garlic, oregano, and cumin and sauté until fragrant, ~1 minute.

5. Add tomato paste and stir well, and sauté 1-2 minutes.

6. Add drained lentils, olives, soy sauce, and water. Stir well to combine all the ingredients and allow to cook over medium heat ~10 minutes, or until the mixture has started to thicken.

7. Add salt and pepper to taste.

When people ask how I developed my expertise in digestive nutrition, I joke that as a Jewish mother, I am very experienced in telling other people what to eat! But in all seriousness, I am driven to keep learning more so that I can help improve quality of life for my patients, who often view food as the enemy and eating as something to be feared. When I can steer a patient toward a dietary pattern, food choices and/or a supportive supplement regimen that enables them to eat more freely without negative consequences, I know I’m making a difference.

Being a foodie and home cook myself helps me help my patients identify meal ideas and food/ingredient swaps that allow them to enjoy the maximum amount of variety within the context of whatever dietary restrictions they may have. As someone with celiac disease, I am well-versed in adapting recipes to meet my own dietary needs, and I honestly find that constraints can inspire delicious innovation and

diagnosed with celiac disease, I never would have thought to make granola with puffed millet, to make pancakes with almond flour, or to use mashed plantains as a dough for empanadas. Necessity can truly be the mother of invention!

The recipe I’ve chosen exemplifies what a little creativity can do when adapting recipes for people with GERD, who often default to bland food so as not to trigger their reflux. It’s a Moroccan-style vegetable stew—or tajine—that’s perfect for fall, and it was developed for my first book with Kristine Kidd, the former Bon Appétit food editor, specifically for people who are acidreflux prone. Unlike traditional tajines which can be heavy on the tomatoes and onions, this version offers loads of fragrant and flavorful North African spices with just a tiny smidge of onion and no garlic, tomato, or heat. Pair it with a box of plain instant couscous, or use gluten-free alternatives such as brown rice, couscous, or quinoa for a delicious, satisfying, vegetarian dinner without a side of dyspepsia.

Divyangkumar Gandhi, MD, FACG, is a Board-certified gastroenterologist at Augusta Health in Fishersville, VA, and one of the ACG Institute 2023 Early Career Leadership Program scholars.

Vanessa Méndez, MD, is a Board-certified internal medicine, gastroenterology, and lifestyle medicine physician based in Florida. She founded a multispecialty telemedicine practice, Planted Forward.

Tamara Duker Freuman, MS, RD, CDN, is a dietitian in gastroenterology practice at New York Gastroenterology Associates and the author of two books on GI health topics for patients.

 We would like to hear from you if you have personal connections with GI & gastronomy. Contact ACG magazine staff by email at acgmag@gi.org to share your story with the ACG community. You can also tweet using #ACGfoodies to connect with the community.

VEGETARIAN COUSCOUS

From The Bloated Belly Whisperer by Tamara Duker Freuman (St. Martin’s Press, 2018).

 Ingredients:

• 2 Tbsp extra-virgin olive oil

• 1/4 onion, finely chopped

• 2 tsp paprika

• 1 tsp ground cumin

• 1/2 tsp ground cinnamon

• 1/2 tsp ground ginger

• 1 15.5-ounce can organic garbanzo beans, with liquid

• 3 cups vegetable broth

• 1 lb. yams, peeled, cut into 1-inch pieces (~3 cups)

• 1/4 cup raisins, minced

• 1/2 lb. carrots, cut into 1⁄2-inch-thick rounds (~2 cups)

• 1 lb. zucchini, halved lengthwise, cut crosswise into 1/2-inch-thick pieces (~3 1/2 cups)

• 8 oz. green beans, trimmed, cut into 2-inch lengths (~2 cups)

• Coarse kosher salt

• Freshly ground pepper

To serve:

• Freshly cooked instant couscous or, for gluten free, brown rice “couscous” or quinoa

• Chopped fresh cilantro

 Steps:

1. Heat the oil in a heavy, large pot over medium heat.

2. Add onion and sauté until beginning to soften, ~5 minutes.

3. Add paprika, cumin, cinnamon, and ginger and stir until fragrant, ~30 seconds.

4. Add garbanzo beans with their liquid. Simmer for 5 minutes.

5. Mash garbanzos with a spoon.

6. Add vegetable broth, yams, and raisins.

7. Increase heat and bring to a boil.

8. Reduce heat, cover, and simmer for 5 minutes.

9. Add carrots and zucchini, cover, and simmer for 5 minutes.

10. Add green beans.

11. Cover and simmer until vegetables are tender, stirring occasionally, ~20 minutes.

12. Season to taste with salt and pepper.

13. Spoon cooked couscous or quinoa onto 4 plates.

14. Spoon vegetables and their liquid over.

15. Sprinkle with cilantro and serve.

ACG International Training Grant to Mayo Clinic Rochester

GASTROENTEROLOGY HAS BEEN SEEING DYNAMIC CHANGES with a paradigm shift in the management of many conditions especially through endoscopy. The critical need for advanced endoscopies has been increasing. One of the hurdles that is faced is the learning curve and the infrastructure necessary to set up an advanced endoscopy unit.

Procedures for common problems have seen an increasing trend such as Endoscopic Balloon Dilation, Mucosal Resection, Transluminal Drainage of Pseudocysts and Per Oral Endoscopic Myotomy (POEM). With the diversity in culture and food habits in the Tropical Subcontinent, there is bound to be an increasing need to attend to many gastroenterological conditions and advanced endoscopy is definitely a step forward for the same. The patients are often required to go to specialised hospitals which are far too few. Again, they are not easily affordable unlike in developed countries where people have complete insurance coverage and can easily afford specialised treatment. This need prompted me to get trained in such areas with the prestigious Mayo Clinic at Rochester. When I received the ACG International Training opportunity with Mayo Clinic, I was only overwhelmed that my interest in training and observership

in such a hospital in advanced scopes under senior specialists along with clinical work would go a long way.

It was indeed a pleasure in working along with the senior professionals specialised in such advanced procedures. Right from my day of arrival, I was enamoured by the history and rich culture of this institution, which was provided as part of a two-day induction tour programme. The chief mentor and host was Dr. Prasad Iyer. Dr. Iyer is an authority in disorders of the esophagus with a special interest in Barrett’s esophagus and various endoscopic treatment modalities. He is also trained in endoscopic ultrasound as well as advanced endoscopic procedures. Hence, he guided me perfectly with a good balance of these procedures. As part of my keen interest in third space endoscopy, I was introduced to Dr. L. M. Wong Kee Song who performs all the advanced third space procedures including POEM and Gastric POEM, endoscopic submucosal dissection and endoscopic mucosal resections, and full thickness resections. I was even allowed to be a part of the ongoing research in full thickness resection. I also had the privilege of being introduced to Dr. Barham Abu Dayyeh

and Dr. Andrew Storm who perform most of the advanced bariatric procedures once a week in turns and learned a lot from them. Dr. Andrew Storm, along with Dr. Iyer, introduced me to the animal lab facility at Mayo where I was taught endoscopic suturing techniques for bariatric and troubleshooting purposes. I was also introduced to Dr. Elizabeth Rajan and Dr. Ferga Gleeson who perform and teach endoscopic ultrasounds. This provided a step wise learning of the station approach in endo ultrasound.

I also had the opportunity to interact and learn from some stalwarts like Dr. Bret Petersen who is a master in ERCP and was kind enough to demonstrate and teach me short exchange of the guidewire in ERCP as well as narrow band image guided papilla access. I also spent time with the legendary late Dr. Michael Levy again an expert in ERCP and master of endoscopic ultrasound. He taught and demonstrated advanced endoscopic ultrasound-guided procedures.

Dr. Iyer also introduced me to Dr.

Kartik Natarajan, MBBS, Apollo Main Hospital, Chennai, Tamil Nadu, India

Kartik Natarajan, MBBS, Apollo Main Hospital, Chennai, Tamil Nadu, India

Nayanthara Coelho-Prabhu (advanced endoscopist and IBD expert), Dr. Ryan Law, and Dr. Vinay Chandrasekhara (advanced endoscopists – EUS and ERCP). I was also introduced to Dr. Navtej Buttar who is an expert in the endoscopic management of leaks and fistulas. He taught well through a wide exposure to complicated cases.

During this tenure, I was fortunate to attend daily sessions of outpatient clinics as well. I was allowed to observe minute procedural nittygritties and take some notes accordingly of many of the ongoing endoscopies and reporting techniques. I visited the patients pre- and postprocedures being effectively managed along with the co-medicos nursing team. Special thanks to the entire nursing team and endoscopic technical team, especially Laura and Kristen.

Apart from this, I had an opportunity to interact with the fellows in advanced endoscopy as well as hepatology. I also was allowed to participate in the IBD clinic and grand

rounds which took place periodically. I am very grateful to the team of doctors mentioned above and a special thanks to all of them with whom I interacted so very well, and they were always kind enough to carry me through with any sort of queries which were clarified to the end point of closure. It was really a pleasant learning experience and a great way to experience the observership with a hands-on feel.

I will always be thankful and much obliged for the excellent mentorship, willingness to go out of the way towards clarifications, and commitment which is par excellence. I will cherish this learning experience from these veterans who were guiding at every stage throughout the tenure. I am fairly confident that this will keep me in good stead and positively shape my future, and I wish to continue to stay in touch with them for future collaborations as well.

Special thanks are vastly due to Dr. K. R. Palaniswamy who has been a mentor in every aspect right from the time of concept of the idea and to get this golden opportunity for me. I would also like to

thank Dr. Bharath Somasundaram who guided me all along and was instrumental in driving me to train abroad and my family who were very supportive and encouraging throughout. Lastly, I am grateful to be part of an institution which has supported me all along and keeps motivating me to do better for myself and for the patients – our charismatic and encouraging Chairman Dr. Prathap C. Reddy as well as Vice Chairperson Mrs. Preetha Reddy have been encouraging throughout and Dr. Venkatasalam, the Director of Medical Services at Apollo Hospitals, Chennai, who has been a pillar of support for me throughout this process.

Clockwise from upper left: Dr. Natarajan with Nayantara Coelho-Prabhu, MD, FACG; with Prasad G. Iyer, MD, FACG; with Louis M. Wong Kee Song, MD; again with Dr. Iyer, ACG Governor for Minnesota with Navtej S. Buttar, MD.

ACG International Training Grant

GASTROINTESTINAL DISEASES IMPOSE A SUBSTANTIAL BURDEN on global health, thereby constituting considerable health care utilization and spending. In Africa, there is an upward trend in the burden of GI cancers with early onset being the predominant mode of presentation and outcome worsened by advanced stages of disease at diagnosis, attributed to poor availability and utilization of endoscopic services for early diagnosis and management of these cancers. In Nigeria, the poor annual health budgetary allocation has significantly affected adoption of best practices in the health care system, thereby negatively impacting the quality of health care delivered to patients. There is currently no state-of-the-art national digestive disease center serving as a referral center for gastrointestinal tract diseases, and WGO's Lagos Training Centre, which is a training hub for gastroenterologists in Nigeria, cannot accommodate the number of aspiring trainees. ERCP is at its early stage of development, while facilities are still lacking for most of the advanced endoscopic procedures and motility testing. It was an actualized aspiration when I was selected for a 6-month split-site ACG International Training Grant at Harvard Medical School-affiliated hospital Beth Israel Deaconess Medical Center (BIDMC) and Massachusetts General Hospital (MGH)

in the United States. The objective of this training was to acquire the knowledge and skills required for the diagnosis and management of gastrointestinal cancers in Nigeria. My training at MGH was for four months, mainly at the GI Oncology Unit, where I shadowed clinic visits three times weekly to understand the multidisciplinary approach in the management, care, and support of GI cancer patients. I participated in the GI Tumor Board, which involves discussion of clinical cases and review of radiological images in a multidisciplinary meeting to ascertain the appropriate treatment for the patients. In the course of the training, I was a panelist on a webinar focused on creating awareness on colorectal cancer in Africa. I also had some research experience on protocols for systematic reviews with the area of interest as the impact of Helicobacter pylori on the epidemiology of gastric cancer in Africa. At the neuro-intestinal health unit of MGH, I attended clinics once weekly to learn the current concepts in the management of various gastrointestinal motility disorders and interpretation of high-resolution manometry. I also participated in

the weekly neurogastroenterology meetings aimed at discussing novel and evidenced based treatment of various gut brain disorders. Additionally, I observed advanced endoscopic procedures once every week and appreciated the inflow, procedural and post-procedural care of patients.

I spent two months at BIDMC, observing endoscopic procedures daily and attended the weekly virtual conferences including pancreatobiliary multidisciplinary meetings, a liver pathology conference, combined conferences, and a GI journal club. I had the opportunity to observe computer-assisted detection of colon polyps, which ignited my interest in artificial intelligence in the health care system in Africa, which I am collaboratively reviewing with some of my mentors.

Stella-Maris Chinma Egboh, MD, Federal Medical Centre, Yenagoa, Nigeria

Stella-Maris Chinma Egboh, MD, Federal Medical Centre, Yenagoa, Nigeria

Clockwise from left: Dr. Brenna Casey, Dr. Egboh & Dr. Kumar Krishnan at the MGH GI Advanced Endoscopy Unit; BIDMC Advanced Endoscopy Fellows Dr. Sultan Mahmood, Dr. Samuel Igbinedion & Dr. Eric Holzwanger with Dr. Egboh; Dr. Akwi Asombang & Dr. Egboh

The knowledge obtained during the period of this training will enable me to optimize the utilization of endoscopic services in screening, diagnosis, and surveillance of gastrointestinal cancers in order to reduce the burden of gastrointestinal cancers in Africa. I also appreciated the role of a multidisciplinary team in the management of diverse GI disorders.

My appreciation to ACG for this wonderful opportunity and to Dr. Akwi Asombang for her supervision, guidance, and mentorship. To Dr. Brenna Casey, Dr. Brian Jacobson, Dr. Jonah Cohen, Dr. Kumar Krishnan, and Dr. Brad Kuo for being so impactful. I am very grateful to my wonderful teachers and mentors at BIDMC, Dr. Douglas Pleskow, Dr. Tyler

Berzin, Dr. Moahmen Gabr, and Dr. Mandeep Shawney along with other advanced fellows, including Dr. Sultan Mahmood, Dr. Igbinedion Samuel, and Dr. Eric Holzwanger for contributing significantly to the success of the training.

I acknowledge my amazing trainers at the GI oncology unit of MGH, Dr. Samuel Klempner, Dr. Matthew Strickland, Dr. Aparna Parikh, Dr. Kelsey Lau-Min, Dr. Elizabeth Walsh, Dr. David Ryan, and Dr. Colin Weekes for their tutelage and continual guidance. My gratitude also goes to the nurses and the staff of the various hospitals for being supportive and creating an enabling environment for the training.

“The knowledge obtained during the period of this training will enable me to optimize the utilization of endoscopic services in screening, diagnosis, and surveillance of GI cancers in order to reduce the burden of gastrointestinal cancers in Africa.”

Photos below (clockwise): Dr. Douglas Pleskow & Dr. Egboh at BIDMC Advanced Endoscopy. GI Oncology Center Team at MGH; (L-R) Dr. Matthew Strickland, Dr. Samuel Klempner, Dr. Egboh, Dr. Aparna Parikh & Dr. Priya Pathak. Dr. Akwi Asombang & Dr. Egboh at MGH. Dr. Egboh, Dr. Tyler Berzin & Dr. Angelo Kum at Beth Israel Deaconess Medical Center. Berenson Scholar Dr. Dave Nkengeh, Dr. Moahmen Gabr & Dr. Egboh at BIDMC. Dr. Micaela Atkins, Dr. Brad Kuo & Dr. Egboh at the MGH GI Motility Unit

Twenty Questions for Dr. Fabian Emura

FABIAN EMURA, MD, PHD, FACG, is an International ACG member from Colombia, a pioneer in endoscopic imaging and endoscopic submucosal dissection, and a past president of the World Endoscopy Organisation. Sarah McGill, MD, MSc, FACG, ACG’s International Relations Committee Chair, sat down to speak with Dr. Emura for ACG Magazine.

Tell me about where you grew up. I was born in Cali, Colombia. I was a street kid. I was playing football outside, baseball. As a street kid, I had lot of friends. I was aware of my surroundings, I was independent. It’s very different, compared to today. That generation of Colombia is special.

Colombia is an incredibly diverse country, but I don’t know too many JapaneseColombians. How did your family end up there?

Colombia was the third most popular Latin American destination for Japanese immigration after Brazil and Peru. My father’s parents immigrated to Colombia from Japan in the late '20s. My mother’s family is Colombian. Growing up, people saw me as different, and I saw myself as different. But when I went to study endoscopy in Japan, I was shocked

to discover that people there also viewed me as a foreigner. By now, I’ve digested it. I’ve learned to take the best of the two cultures.

You started your career as a surgeon. How did you end up in endoscopy?

In my case, I did general surgery for four years. One of my mentors said, “Why don’t you go to Japan to learn to do gastric cancer surgery with lymphatic dissection?” That was the standard for gastric cancer. I went to Japan with that in mind, but instead the University of Tsukuba offered me a basic science PhD on tumor biology in an animal lab. I was already there, and accepted the challenge. I studied Japanese day and night. At the end of the doctorate program, I decided to go for the GI fellowship in Tokyo.

What was your GI training like?

In 2003, when I began my advanced training at the National Cancer Center in Tokyo, narrow band imaging (NBI) and endoscopic submucosal dissection (ESD) were unproven concepts. We gathered clinical data and drafted the first papers. In 2005, I co-authored the first major manuscripts on gastric and colorectal ESD followed by the first

reports of effectiveness of NBI and image-enhanced endoscopy. In 2006, I did my first gastric ESDs in Tokyo. Perhaps I was in the right place at the right moment.

Many who leave their homes to train in developed countries remain in those locations, but you returned to Colombia. Was that an intentional decision on your part?

I didn’t want to leave Tokyo as this was my comfort zone. My supervisor advised me to leave since there were numerous ESD practitioners in Tokyo, but none in Latin America. He encouraged me to teach others and help cancer patients. Looking back, it was the greatest decision I’ve ever made. In 2015, we published what was the largest Western gastric ESD series with outcomes identical to Japanese referral institutions. In recent years, I’ve taught diagnostic and ESD techniques during live courses in Argentina, Brazil, Ecuador, Chile, Bolivia, Panama, Mexico, the U.S, India, Japan, and China. In all, I've conducted educational courses in more than 23 countries.

Sarah K. McGill, MD, MSc, FACG, Chair, ACG International Relations Committee

You leave Japan, which has the world’s highest gastric cancer rate, for Colombia, where gastric cancer is also quite prevalent. Tell me what you did then.

I founded my private endoscopy center, the EmuraCenter LatinoAmérica, in Bogotá. We developed a routine protocol for endoscopic screening of early upper GI tract malignancies. Our team started stomach cancer prevention campaigns announced by radio and television. We screened thousands of low-socioeconomic class people with upper endoscopy, for free, with private funding. We started finding early gastric cancer and did the first ESD case in Colombia in 2007. Then gradually the community became aware of prevention and the importance of endoscopic screening for GI cancers.

Who gets the screening?

We screen general population adults with a one-time upper endoscopy starting around age 40-45, and this is, in general, covered by health systems. In Colombia, the access to screening endoscopy in public institutions is challenging.

There’s a huge GI physician shortage here in the U.S., but certainly in many developing countries. One idea is for private practices to start training fellows. You did that, right?

I partnered with Universidad de la Sabana, which is a large Colombian university that lacked a GI program, 15 years ago. I developed the curricula, and the Ministry of Education endorsed our GI fellow training program. We’ve graduated three classes of fellows. Fellows are also trained at large hospitals, but we train in high-quality upper and lower endoscopy, resection of lesions, and advanced endoscopy.

Colombia was in a civil war for much of your life, with most of the fighting outside the cities, but there was also violence related to the drug trade in Bogotá, where you live now. How did this affect you?

I would say it is a fight against terrorism, not a civil war. Colombians have learned to be resilient. In the medical field, I learned to work with a shortage of equipment and accessories and take the best of that and get good results in terms of cancer cure. We remove lesions, but don’t have many resources to do surveillance. We’ve trained

a lot of endoscopists through the years—over 300 in-person, and more via Zoom. I keep teaching, scoping, and writing despite not having the best conditions. I’ve enjoyed the ride.

Favorite place?

On top of Mount Fuji. It is possible to be above the clouds near the stars. But my favorite place to be is on my knees beside my bed. My faith in God has driven me. There’s no way I could have done what I have without my relationship with God.

What is the innovation in GI now that is most exciting for you?

The innovation is still ESD. We’re expanding the use of ESD from the stomach and colon to remove tumors in the small intestine, the anal canal, the EG junction, the hypopharynx.

Artificial intelligence is on the road to making huge changes in how we image, diagnose, and resect lesions in endoscopy. Are you excited about letting an algorithm do what you’ve been teaching for years, wary, or both?

Cancer cure is what has driven my research and work for the past 20 years, and we’re not there yet with AI. Also, you have to realize that AI is based on tons of images recorded and labeled by endoscopists. There, human contributions to AI come into play.

Blind spots at screening colonoscopy and upper endoscopy are a big problem that can lead to missed lesions. Tell me about your work trying to minimize them.

I developed a method to systematically visualize the upper GI anatomy at endoscopy called SACE, or Systematic Alphanumeric Coded Endoscopy. It includes looking at and photodocumenting with overlapping images 28 areas of the GI tract. For example, the antrum has four areas, the lesser and greater curvature and the anterior and posterior walls, which are also coded with numbers. I've patented the method but am not seeking royalties from it.

You’re one of thousands of ACG International members. What do you value most about your membership?

I absolutely enjoy how the ACG Postgraduate Course is run. It’s amazing that ACG can make such a valuable clinical input for practitioners in not a huge venue, and combine it with the scientific input. I also think that private practices are growing and are important. They should be supported and acknowledged, which ACG does.

You served as president of the World Endoscopy Organisation. For those readers who don’t know much about it, sum up its purpose and its activities. The WEO is the umbrella organization for the Interamerican Society, Intereuropean Society and AsianPacific Society. WEO promotes high quality and safe endoscopy worldwide. It focuses on underserved areas like Latin America, Africa, the Middle East, and some parts of Asia. WEO has several platforms for practitioners to serve in underserved areas. WEO provides practitioners with numerous platforms to help in underserved communities. For example, it organizes advanced imaging, EUS, and ERCP training throughout Africa.

What was your biggest accomplishment as president of the World Endoscopy Organization?

My presidency ran from 2020 to 2022, during the pandemic. I was the society's leader during its most difficult period. Despite this, we increased our educational initiatives and the organization's global visibility.

We taught and reached out to many people through virtual activities and webinars.

Barry Marshall and Robin Warren discovered that H. pylori caused peptic ulcers in the 1980s, and we eventually understood it as a precursor to gastric cancer. Have we used that knowledge to its full potential?

The H. pylori discovery was one of the biggest medical accomplishments in history—like Fleming discovering penicillin. The evidence supports H. pylori eradication as a primary prevention strategy worldwide. The evidence is overwhelmingly in favor of eradication at the population level. We don’t have that in Colombia, but it should be done.

What brings you joy?

Time with family and my children. I have two kids, ages 5 and 3. I married my wife, who is Colombian-born Japanese, in 2017. Since having kids, I’ve reduced my working time by a lot.

Let’s do a lightning round.

Favorite food?

Tonkatsu curry, a Japanese rice curry with crispy pork cutlets

Site in Colombia you'd recommend visiting?

Cartagena, on the coast. It’s a fascinating place.

Favorite song?

Amazing Grace; it tells my life story.

Favorite musician or musical group? Hillsong United (Australian worship group)

Most influential people in your life? My parents, Arturo and Eyder, they have been there for me throughout my life.

Anything else you would like to share with ACG Magazine readers?

Besides endoscopy, there are many fascinating things to do.

About Sarah K. McGill, MD, MSc, FACG – Dr. McGill is Associate Professor of Medicine at the University of North Carolina at Chapel Hill and has served as chair of the ACG International Relations Committee since 2021. She studies alpha-gal syndrome's GI manifestations and artificial intelligence in colonoscopy.

About Fabian Emura, MD, FACG – Dr. Emura is Associate Professor of Medicine at Universidad de La Sabana, Bogotá D.C., Colombia. In 2006, he founded the EmuraCenter LatinoAmérica, an international reference facility which also provides training in advanced endoscopic techniques.

EVIDENCE-BASED GI

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take-aways and evidence-based summaries of articles in GI, Hepatology & Endoscopy.

EVIDENCE-BASED GI (EBGI) evaluates new research articles published across leading general medicine, GI and Hepatology journals.

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Watch for the eTOC delivered in your inbox monthly!

EBGI has Podcasts Too! Read. Listen. Learn. Stay up to date on notable studies in major medical journals with ACG’s latest publication, Evidence-Based GI edited by Philip S. Schoenfeld, MD, MSEd, MScEpi, FACG.

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

Inside the JOURNALS

EVIDENCE-BASED RECOMMENDATIONS to the assessment of patients with acute liver failure including evaluation for liver transplantation published in The American Journal of Gastroenterology in June. Explore the guideline and listen to an author podcast with Dr. Alexandra Shingina in conversation with AJG CoEIC Dr. Jasmohan Bajaj.

In CTG, authors explore the clinical value of multi-omics-based biomarker signatures in IBD.

The College welcomes the new Editorial Board of ACG Case Reports Journal, an open access online journal of interesting cases edited by GI fellows-in-training. This year the CoEICs are Khushboo Gala, MBBS, and Vibhu Chittajallu, MD.

[THE

AMERICAN JOURNAL OF GASTROENTEROLOGY]

New Guideline: Acute Liver Failure Guidelines

Alexandra Shingina, MD, MSc; Nizar Mukhtar, MD; Jamilé Wakim-Fleming, MD, FACG; Saleh Alqahtani, MBChB, MS; Robert J. Wong, MD, MS, FACG; Berkeley N. Limketkai, MD, PhD, FACG; Anne M. Larson, MD & Lafaine Grant, MD. The American Journal of Gastroenterology 118(7):p 1128-1153, July 2023. | DOI: 10.14309/ajg.0000000000002340

 Acute liver failure (ALF) is a life-threatening condition that occurs in patients with no preexisting liver disease and is characterized by liver injury (abnormal liver tests), coagulopathy (international normalized ratio [INR] >1.5), and hepatic encephalopathy. It has a multitude of etiologies and a variety of clinical presentations that can affect virtually every organ system. It is imperative for clinicians to recognize ALF early in patient presentation because initiation of treatment and transplant considerations could be lifesaving. The current guideline represents the summary of existing data on diagnosis and management of patients with ALF.

 READ bit.ly/ajg-acute-liver-failure-shingina

 LISTEN bit.ly/podcast-acute-liver-failure-guidelines

Red Section: How I Approach It

Use of the Stethoscope to Diagnose Gastrointestinal and Hepatic Disorders

Lawrence J.

Brandt, MD, MACG

The American Journal of Gastroenterology 118(7):p 1113-1116, July 2023. | DOI: 10.14309/ ajg.0000000000002233

 A must-read in the Red Journal: “In recent years, the stethoscope has ceased to be used during physical examination. In addition to its use as a tool for auscultation, however, the stethoscope also is an extension of the human hand and, therefore, enables touching, which has healing qualities and can transmit the magic of caring,” writes ACG Past President Dr. Lawrence Brandt in the AJG Red Section. In his inimitable style, Dr. Brandt reviews “auscultatory findings (clicks, splashes, peristaltic sounds, peels, arterial bruits, friction rubs, and venous hums) that the stethoscope can detect to reveal clues that just might increase our appreciation of pathophysiology, allow prediction of radiologic findings, or perhaps just enable us return to a basic tenet in caring for the patient: a complete examination.”

 READ bit.ly/Red-Section-Stethoscope

[CLINICAL & TRANSLATIONAL GASTROENTEROLOGY]

Clinical Value of Multi-Omics-Based Biomarker Signatures in Inflammatory Bowel Diseases: Challenges and Opportunities

Arno R. Bourgonje, MD, PhD; Harry van Goor, PhD; Klaas Nico Faber, PhD & Gerard Dijkstra, MD, PhD. Clinical and Translational Gastroenterology, 14(7):p e00579, July 2023. | DOI: 10.14309/ctg.0000000000000579

 Multi-omics is a fairly new approach where the data sets of different omic groups (genome, proteome, transcriptome, epigenome, and microbiome) are considered together. Multi-omics profiling technologies are beginning to emerge and may improve disease classification, identify disease biomarkers, and support drug discovery. In this review, the authors note that, “theory-driven disease classifications and predictions are still governing clinical practice, while this could be improved by adopting an unbiased, data-driven approach relying on molecular data structures integrated with patient and disease characteristics.” They acknowledge that implementing multi-omics-based signatures into clinical practice is currently difficult and that the development of practical tools and execution of longitudinal clinical trials could aid in clinical adoption.

 READ bit.ly/CTG-Multiomics-Biomarkers-IBD

Timeline of acute liver failure presentation and investigations. ED, emergency department; HE, hepatic encephalopathy; ICU, intensive care unit; INR, international normalized ratio.

Meet the 20 23 – 2024 ACGCRJ EDITORIAL BOARD

ACGCRJ IS A FULLY OPEN ACCESS JOURNAL. VIEW ALL PUBLISHED CASE REPORTS FOR FREE. ACGCASEREPORTS.COM

Thanks to outgoing ACGCRJ Editorial Board members!

We thank the outgoing members of the Editorial Board for their outstanding service to the Journal and wish them continued success in their careers.

Vibhu Chittajallu, MD Editor-in-Chief University Hospitals Cleveland Medical Center Cleveland, OH

Khushboo Gala, MBBS Editor-in-Chief Mayo Clinic Rochester, MN

Nicholas McDonald, MD

Tomoki Sempokuya, MD

Yvette Achuo-Egbe, MD, MPH, MS

Michael Beattie, DO

Divya Chalikonda, MD

Erik Holzwanger, MD

Anand Kumar, MBBS, MD

Jennifer Onwochei MD, MPH, MS

Eric Swei, MD

Vaishnavi Boppana, MD Associate Editor University of New Mexico Albuquerque, NM

Smit Deliwala, MD Associate Editor Emory University Atlanta, GA

Banreet Dhindsa, MD Associate Editor New York University Langone Health New York, NY

Yue-Sai Jao, MD Associate Editor University of Puerto Rico San Juan, PR

Robert J. Pattison, MD, MPH Associate Editor HCA Healthcare Las Vegas, NV

Nicholas Placone, MD Associate Editor University of Southern California Los Angeles, CA

Shazia Rashid, MD Associate Editor Louisiana State University Health Sciences Center Shreveport, LA

Achintya Singh, MD Associate Editor Metrohealth Medical Center Case Western Reserve University Cleveland, OH

Gianna Stoleru, MD Associate Editor University of Virginia Medical Center Charlottesville, VA

Muhammad Nadeem Yousaf, MD Associate Editor University of Missouri School of Medicine Columbia, MO

Information for Patients and Caregivers from the American College of Gastroenterology Patient Care Committee

What is Diverticulosis?

Diverticulosis is a fairly common condition of the intestinal tract (gut). Diverticulosis refers to the presence of small out-pouchings (called diverticula) or sacs that can develop in the wall of the intestine. They resemble “pot holes” in the intestinal tract lining. The condition is uncommon in people under the age of 30 and is most common in those over 60.

KEY TAKEAWAYS

• Causes: The exact reason diverticulosis occurs is not 100% certain but we do know it may bleed or become infected.

• Symptoms: Most people with diverticulosis have no problems. It is unclear whether diverticulosis alone can cause symptoms such as pain or discomfort in the left lower abdomen, a gassy feeling, and/or a change in bowel habits.

• Diagnosis: Your doctor can discover diverticulosis with colonoscopy, barium enema, or CT scan, an X-ray test.

• Prevention: It is not known whether diverticulosis can be prevented. People who are overweight are more likely to have diverticulosis. Smoking may also increase the chance of developing diverticulosis. Maintaining a healthy weight and not smoking may prevent diverticulosis.

What are the complications of diverticulosis?

Diverticulitis is inflammation of one or a few diverticula in the colon. Diverticulitis occurs in fewer than 5 out of 100 people who have diverticulosis. People with diverticulitis typically have pain in the abdomen, usually on the lower left side. Other symptoms include fever, diarrhea and/or constipation, decreased appetite, nausea, and fatigue.

Complications of diverticulitis include:

• Abscess – a collection of infected fluid outside or within the intestine wall.

• Stricture – a narrowing of the colon in the area of diverticulitis.

• Fistula – a connection between the bowel and nearby organs including the bladder.

• Perforation – a hole in the colon that allows bowel contents, such as stool, to leak into the abdomen. This is the most serious complication of diverticulitis.

How is diverticulitis treated?

Typical treatment of diverticulitis may include antibiotics and a liquid diet or light diet until symptoms improve. Some studies suggest that patients with mild diverticulitis who do not have complications, and who are otherwise healthy, can be managed without antibiotics. People with severe diverticulitis (high fever and/or signs of severe infection) or with complications, require antibiotics and are usually treated in the hospital.

REBYOTA® (fecal microbiota, live - jslm) suspension, for rectal use

Brief Summary Please consult package insert for full Prescribing Information

INDICATIONS

REBYOTA is indicated for the prevention of recurrence of Clostridioides dif cile infection (CDI) in individuals 18 years of age and older following antibiotic treatment for recurrent CDI. Limitation of Use: REBYOTA is not indicated for treatment of CDI.

CONTRAINDICATIONS

Do not administer REBYOTA to individuals with a history of a severe allergic reaction (e.g. anaphylaxis) to any of the known product components.

Each 150mL dose of REBYOTA contains between 1x108 and 5x1010 colony forming units (CFU) per mL of fecal microbes including >1x105 CFU/mL of Bacteroides, and contains not greater than 5.97 grams of PEG3350 in saline.

WARNINGS AND PRECAUTIONS

Transmissible infectious agents: Because REBYOTA is manufactured from human fecal matter it may carry a risk of transmitting infectious agents. Any infection suspected by a physician possibly to have been transmitted by this product should be reported by the physician or other healthcare provider to Ferring Pharmaceuticals Inc.

Management of acute allergic reactions: Appropriate medical treatment must be immediately available in the event an acute anaphylactic reaction occurs following administration of REBYOTA.

Potential presence of food allergens: REBYOTA is manufactured from human fecal matter and may contain food allergens. The potential for REBYOTA to cause adverse reactions due to food allergens is unknown.

ADVERSE REACTIONS

The most commonly reported (≥ 3%) adverse reactions occurring in adults following a single dose of REBYOTA were abdominal pain, (8.9%), diarrhea (7.2%), abdominal distention (3.9%), atulence (3.3%), and nausea (3.3%).

Clinical Trials Experience: The safety of REBYOTA was evaluated in 2 randomized, double-blind clinical studies (Study 1 and Study 2) and 3 open-label clinical studies conducted in the United States and Canada. A total of 978 adults 18 years of age and older with a history of 1 or more recurrences of Clostridioides dif cile (CDI) infection and whose symptoms were controlled 24 – 72 hours post-antibiotic treatment were enrolled and received 1 or more doses of REBYOTA; 595 of whom received a single dose of REBYOTA.

Adverse Reactions: Across the 5 clinical studies, participants recorded solicited adverse events in a diary for the rst 7 days after each dose of REBYOTA or placebo. Participants were monitored for all other adverse events by queries during scheduled visits, with duration of follow-up ranging from 6 to 24 months after the last dose. In an analysis of solicited and unsolicited adverse events reported in Study 1, the most common adverse reactions (de ned as adverse events assessed as de nitely, possibly, or

probably related to Investigational Product by the investigator) reported by ≥3% of REBYOTA recipients, and at a rate greater than that reported by placebo recipients, were abdominal pain, (8.9%), diarrhea (7.2%), abdominal distention (3.9%), atulence (3.3%), and nausea (3.3%).Most adverse reactions occurred during the rst 2 weeks after treatment. After this, the proportion of patients with adverse reactions declined in subsequent 2-week intervals. Beyond 2 weeks after treatment only a few single adverse reactions were reported. Most adverse drug reactions were mild to moderate in severity. No life-threatening adverse reaction was reported.

Serious Adverse Reactions - In a pooled analysis of the 5 clinical studies, 10.1% (60/595) of REBYOTA recipients (1 dose only) and 7.2% (6/83) of placebo recipients reported a serious adverse event within 6 months post last dose of investigational product. None of these events were considered related to the investigational product.

USE IN SPECIFIC POPULATIONS

Pregnancy: REBYOTA is not absorbed systemically following rectal administration, and maternal use is not expected to result in fetal exposure to the drug.

Lactation: REBYOTA is not absorbed systemically by the mother following rectal administration, and breastfeeding is not expected to result in exposure of the child to REBYOTA.

Pediatric Use: Safety and effectiveness of REBYOTA in individuals younger than 18 years of age have not been established.

Geriatric Use: Of the 978 adults who received REBYOTA, 48.8% were 65 years of age and over (n=477), and 25.7% were 75 years of age and over (n=251). Data from clinical studies of REBYOTA are not suf cient to determine if adults 65 years of age and older respond differently than younger adults

For more information, visit www.REBYOTAHCP.com

You are encouraged to report negative side effects of prescription drugs to FDA. Visit www.FDA.gov/medwatch, or call 1-800-332-1088.

Manufactured for Ferring Pharmaceuticals by Rebiotix, Inc. Roseville, MN 55113

US License No. 2112

9009000002

Rx Only

Ferring, the Ferring Pharmaceuticals logo and REBYOTA are registered trademarks of Ferring B.V. ©2023 Ferring B.V.

This brief summary is based on full Rebyota Prescribing Information which can be found at www.RebyotaHCP.com US-REB-2200277-V2

Where dysbiosis once left the gut microbiome in ruin,

RISE ABOVE RECURRENT C. DIFFICILE INFECTION

and restore hope with REBYOTA®

aIn the pivotal phase 3 trial, 32.8% of patients were treated at first recurrence of CDI following antibiotic treatment of CDI.1

INDICATION

REBYOTA (fecal microbiota, live - jslm) is indicated for the prevention of recurrence of Clostridioides difficile infection (CDI) in individuals 18 years of age and older, following antibiotic treatment for recurrent CDI.

Limitation of Use

REBYOTA is not indicated for treatment of CDI.

IMPORTANT SAFETY INFORMATION

Contraindications

Do not administer REBYOTA to individuals with a history of a severe allergic reaction (eg, anaphylaxis) to any of the known product components.

Warnings and Precautions

Transmissible infectious agents

Because REBYOTA is manufactured from human fecal matter, it may carry a risk of transmitting infectious agents. Any infection suspected by a physician possibly to have been transmitted by this product should be reported by the physician or other healthcare provider to Ferring Pharmaceuticals Inc.

Management of acute allergic reactions

Appropriate medical treatment must be immediately available in the event an acute anaphylactic reaction occurs following administration of REBYOTA.

Potential presence of food allergens

REBYOTA is manufactured from human fecal material and may contain food allergens. The potential for REBYOTA to cause adverse reactions due to food allergens is unknown.

Adverse Reactions

The most commonly reported (≥3%) adverse reactions occurring in adults following a single dose of REBYOTA were abdominal pain (8.9%), diarrhea (7.2%), abdominal distention (3.9%), flatulence (3.3%), and nausea (3.3%).

Use in Specific Populations

Pediatric Use

Safety and efficacy of REBYOTA in patients below 18 years of age have not been established.

Geriatric Use

Of the 978 adults who received REBYOTA, 48.8% were 65 years of age and over (n=477), and 25.7% were 75 years of age and over (n=251). Data from clinical studies of REBYOTA are not sufficient to determine if adults 65 years of age and older respond differently than younger adults.

You are encouraged to report negative side effects of prescription drugs to FDA. Visit www.FDA.gov/medwatch, or call 1-800-332-1088.

Please see Brief Summary on next page and full Prescribing Information at www.REBYOTAHCP.com.

References

1. REBYOTA. Prescribing Information. Parsippany, NJ: Ferring Pharmaceuticals; 2022. 2. US Food and Drug Administration. FDA Approves First Fecal Microbiota Product. https:// www.fda.gov/news-events/pressannouncements/fda-approves-firstfecal-microbiota-product. Accessed December 1, 2022.

Ferring, the Ferring Pharmaceuticals logo and REBYOTA are registered trademarks of Ferring B.V. ©2023 Ferring B.V. All rights reserved. US-REB-2200129-V2 7/23

The first and only single-dose microbiota-based live biotherapeutic approved to prevent recurrence of C. difficile infection starting at first recurrence.1,2,a

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DEDICATED J-CODE (J1440) EFFECTIVE JULY 1, 2023