ACG Magazine | Vol. 7, No. 2 | Summer 2023

ACG MAGAZINE

Summer 2023

MEMBERS. MEDICINE. MEANING.

Collaborative Patient-Centered Care

VANCOUVER  REGISTER

TODAY!

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SUMMER 2023 // VOLUME 7, NUMBER 2

FEATURED CONTENTS COVER STORY

COLLABORATIVE PATIENT-CENTERED CARE Dr. Douglas Drossman and Johannah Ruddy of the Rome Foundation discuss patient collaboration and the biopsychosocial model of care in disorders of gutbrain interaction

PAGE 30

GI EYE Dr. Aline Charabaty reflects on a visit to Egypt and how "documenting" every moment isn't as important as experiencing and feeling it PAGE 8

ACG PERSPECTIVES Dr. Rabia de Latour and Dr. Swapna Gayam in conversation with Dr. Jill Gaidos on environmental sustainability in GI and ways to advocate for and implement change PAGE 51

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REGISTER NOW: GI.ORG/ACGVGR ACG VGRs are offered TWICE each Thursday, with a live broadcast at noon (ET) followed by an 8:00pm (ET) rebroadcast!

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2024 ACG Endoscopy School & ACG Board of Governors/ASGE Best Practices Course Aria Resort | Las Vegas, NV January 26–28, 2024

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

SUMMER 2023 // VOLUME 7, NUMBER 2

CONTENTS

"Patients need evidence-based, scientific information about their condition to be empowered to participate in their care. Good, clear education must begin in the clinical encounter, face to face.”

—Johannah Ruddy, MEd, "Collaborative Patient-Centered Care: The Biopsychosocial Model of Care in Disorders of Gut-Brain Interaction" PG 30

6 // MESSAGE FROM THE PRESIDENT

30 // COVER STORY

55 // INSIDE THE JOURNALS

Dr. Daniel Pambianco on the bright future of ACG's members, advocacy, and patientcentered care

COLLABORATIVE PATIENT-CENTERED CARE Dr. Douglas Drossman and Johannah Ruddy of the Rome Foundation discuss patient collaboration and the biopsychosocial model of care in disorders of gut-brain interaction

56 AJG Joint AGA-ACG Guideline on Chronic Idiopathic Constipation by Chang and Chey, et al., and ACG Guideline on Acute Lower GI Bleeding by Sengupta, et al.

7 // NOVEL & NOTEWORTHY Colorectal Cancer Awareness Month efforts, promising new Summer Scholars, recent member accomplishments, the latest EAVP visits & more

17 // PUBLIC POLICY Highlights from the 2023 ACG Advocacy Day

21 // TRAINEE HUB NACGF REFLECTION Dr. Katie Dunleavy and course directors/ faculty provide an inside look at ACG’s North American Conference for GI Fellows

27 // GETTING IT RIGHT

43 // ACG PERSPECTIVES 43 CULINARY CONNECTIONS ACG foodies provide refreshing summer recipe suggestions to invigorate the season 47 ACG INTERNATIONAL TRAINING GRANT Dr. Artemis Trikola from Athens shares her experience training at Massachusetts General Hospital 48 ACG INSTITUTE Insights from the 1st year of the ACG Institute Clinical Research Leadership Program 51 CONVERSATIONS WITH WOMEN IN GI Dr. Rabia de Latour and Dr. Swapna Gayam on environmental sustainability in GI

Dr. Sara Horst on setting EMR response time expectations with patients

56 CTG Clinician’s Toolbox - Understanding Our Tests: Hydrogen-Methane Breath Testing to Diagnose Small Intestinal Bacterial Overgrowth by Aylin Tansel, MD, MPH & David J. Levinthal, MD, PhD 56 ACGCRJ Editorial by the Co-EICs on 10 years of ACGCRJ & Video: Successful Nonoperative Management of a Sigmoid Colon Perforation Caused by a Migrated Biliary Stent by Kwong, et al.

58 // REACHING THE CECUM ABOUT CHRONIC CONSTIPATION A patient infographic on chronic idiopathic constipation, informed by the new joint AGAACG Guideline by Chang and Chey, et al.

ABOVE: Douglas A. Drossman, MD, MACG & Johannah Ruddy, MEd. FEATURED CONTENTS: photo courtesy of Aline Charabaty, MD, FACG.

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ACG MAGAZINE MAGAZINE STAFF

CONNECT WITH ACG youtube.com/ACGastroenterology

Executive Director Bradley C. Stillman, JD

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

Manager, Communications & Member Publications Becky Abel

Art Director Emily Garel

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

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ACGMag@ @gi.org

CONTACT ACG American College of Gastroenterology 11333 Woodglen Drive, Suite 100 North Bethesda, MD 20852 (301) 263-9000 | gi.org

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

DIGITAL EDITIONS

GI.ORG/ACGMAGAZINE

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

4 | 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.

CONTRIBUTING WRITERS

Rashmi R. Advani, MD Dr. Advani is an Interventional GI Fellow at Cedars-Sinai Medical in Los Angeles, specializing in obesity medicine.

Rabia A. de Latour, MD Dr. de Latour is Director of Endoscopy and Chief Sustainability Officer at Bellevue Hospital Center, Associate Program Director of NYU Gastroenterology Fellowship, and Assistant Professor of Medicine at NYU School of Medicine.

Douglas A. Drossman, MD, MACG Dr. Drossman is Chief Executive Officer and President Emeritus of the Rome Foundation and Professor Emeritus of Medicine and Psychiatry at the University of North Carolina School of Medicine.

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.

Jill K.J. Gaidos, MD, FACG Dr. Gaidos is Associate Professor at Yale School of Medicine Section of Digestive Diseases and Director of Clinical Research for the Yale IBD Program. She is a member of ACG’s Digital Communications and Publications Committee.

Swapna Gayam, MD, FACG Dr. Gayam is Associate Professor at West Virginia University School of Medicine. She is a member of ACG’s Women in GI Committee.

Jennifer Horsley-Silva, MD Dr. Horsley-Silva is Assistant Professor of Medicine and Senior Associate Consultant at Mayo Clinic Scottsdale. She is a member of the 2022-2023 ACG Institute Clinical Research Leadership Program cohort and is a member of ACG’s Research and Educational Affairs Committees.

Sara N. Horst, MD, MPH, FACG Dr. Horst is Associate Professor of Gastroenterology, Hepatology, & Nutrition at Vanderbilt University Medical Center and Associate Vice Chair of Digital Health Operations for the Department of Medicine. She is a member of the ACG Professionalism Committee.

Daniel J. Pambianco, MD, FACG ACG President Dr. Pambianco is a practicing gastroenterologist and managing partner of Gastro Health in Charlottesville, VA. He is also the founder of Charlottesville Medical Research, a local network of community-based physicians in private practice who conduct clinical research studies in the central Virginia area.

Patricia Pringle Bloom, MD Dr. Pringle Bloom is an Assistant Professor and transplant hepatologist at the University of Michigan Medicine. She is a past recipient of an ACG Institute Clinical Research Award and an ACG Junior Faculty Development Grant.

Johannah Ruddy, MEd Ms. Ruddy is Chief Operations Officer and Executive Director of the Rome Foundation. She is a GI patient advocate, educator, and national expert, researcher, and writer on teaching communications skills to patients and providers.

James H. Tabibian, MD, PhD, FACG Dr. Tabibian is Director of Endoscopy at Olive View-UCLA Medical Center and Health Sciences Clinical Professor at David Geffen School of Medicine at UCLA.

Tiffany Taft, PsyD Dr. Taft is a Clinical Health Psychologist and Founder of Oak Park Behavioral Medicine, LLC., near Chicago. She was previously an associate professor and director of psychogastroenterology research at Northwestern University Feinberg School of Medicine.

Artemis Trikola, MD Dr. Trikola is a Consultant Gastroenterologist at the Naval and Veterans Hospital in Athens, Greece. She is a 2022 recipient of an ACG International Training Grant and trained at Massachusetts General Hospital in Boston.

Christopher D. Vélez, MD Dr. Vélez is a gastroenterologist practicing within the Center for Neurointestinal Health of Massachusetts General Hospital Division of GI. He is a member of the 2022-2023 ACG Institute Clinical Research Leadership Program cohort and is a member of the ACG Research Committee.

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MESSAGE FROM THE PRESIDEN

THINGS ARE LOOKING BRIGHT

By Daniel J. Pambianco, MD, FACG

“Here comes the sun, and I say, it’s alright” -George Harrison It is with great pleasure and a deep sense of gratitude that I address you as the President of our esteemed organization with recent highlights of your professional home at work for the advance of our profession, members, and patients, present and future. This edition of the ACG MAGAZINE is particularly apropos as we welcome the summer solstice with progress in the treatment and understanding of patients with functional disorders, more effective liaison with our legislators, closer communication with our ACG Governors, and the auspicious future of our College.

The cover story is an interesting interview with Dr. Douglas Drossman and Johannah Ruddy about “patientcentered collaborative care” and the biopsychosocial model of care for disorders of gut-brain interaction. All the questions for Dr. Drossman were crowdsourced from the ACG Patient Care Committee and Chair Dr. Scott Gabbard.

The Patient-Centered Collaborative Care approach recognizes the importance of involving patients as active participants in their healthcare. It emphasizes effective communication, shared decision-making, and a partnership between healthcare providers and patients. In the context of gut-brain disorders, collaborative care ensures that patients' concerns, preferences, and goals are considered.

It encourages open dialogue, educates patients about their condition, and involves them in developing treatment plans. This approach has been shown to promote patient satisfaction, engagement, and adherence to treatment, leading to improved overall outcomes.

The biopsychosocial model in gut

disorders recognizes the influence of the interplay of biological factors (e.g., gut microbiota, immune system), psychological factors (e.g., stress, mood), and social factors (e.g., support systems, lifestyle) in the development and management of these conditions. It emphasizes a comprehensive assessment that goes beyond physical symptoms, incorporating psychological well-being, social context, and lifestyle factors.

This holistic approach helps healthcare providers understand the unique needs of each patient and develop tailored treatment plans that address multiple aspects of their health. By promoting a comprehensive and multidimensional understanding of the patient's condition, this collaborative model enhances treatment outcomes and empowers individuals to actively participate in their own care.

The ACG is working to bring this multidisciplinary care model to all our practices with GI OnDEMAND, making digestive health expertise, resources, and support accessible to everyone. You can learn more at giondemand.com.

We also highlight our Washington, DC, Advocacy Day lead by Dr. Dayna Early and Dr. Sita Chokhavatia, that took place in April. I had the pleasure of participating with the ACG leadership and Board of Governors in visits to our legislators in the Senate and House of Representatives. Under the auspices of Dr. Louis Wilson and Brad Conway, Vice President of Public Policy & Reimbursement, we all had lunch with the six of the physician legislators from the Doctors Caucus who provided insight as to the current status of the Congress, such as the “Strengthening Medicare for Patients and

“Together, we can drive positive change, expand our knowledge, and further enhance the care we deliver.”

6 | GI.ORG/ACGMAGAZINE

Providers Act” (H.R.2474). This a bipartisan bill introduced by some members of the Doctors Caucus to address payment uncertainty and avoid possible physician shortages for Medicare beneficiaries by providing annual physician payment updates tied to inflation.

Participating in Advocacy Day were members of the ACG Institute’s Early Career Leadership Program under the directorship of Dr. Allon Kahn and Dr. Elizabeth Paine. This was the final experience in their yearlong leadership development program. ECLP is designed to create a pipeline of rising young leaders who applied and were selected to participate in a program of lectures, personality inventory/consultations, and advocacy work. I had the pleasure – and a most inspiring experience – in meeting and speaking to this illustrious group of future leaders about their careers and the potential service of the ACG. Lastly, there is a thoughtful reflection on the North American Conference of Gastroenterology Fellows from Dr. Katie Dunleavy, who was the recipient of one of the Distinguished Achievement Awards for her presentation. I had the distinct honor of participating in NACGF in March and witnessed this small select group of GI fellows give abstract presentations and receive critiques for performance skills and timeliness. NACGF provides a meaningful opportunity for networking and professional development. Fellows benefited from the tutelage of Course Co-Directors Dr. David Hass and Dr. Jill Gaidos and faculty Dr. Shivangi Kothari and Dr. Andrew Moon. Dr. Dunleavy was a standout amongst standouts and is editor of the magazine's Trainee Hub section.

On that final note, I encourage you all to actively participate in our vibrant professional community. Attend our conferences, engage in meaningful discussions, share your expertise, and collaborate with fellow members, albeit in person or through our online Circles.

Together, we can drive positive change, expand our knowledge, and further enhance the care we deliver. I am most pleased to report that, as you can see, our future leadership is bright as the summer sun!

Note hy wor t SPRING IS A BUSY TIME for ACG with March Colorectal Cancer Awareness Month and ACG Advocacy Day in Washington, DC, which this year included the cohort of ACG Institute’s Early Career Leadership Program. To learn about a new Institute program, the Clinical Research Leadership Program, see ACG Perspectives PG 48.

ACG's Summer Scholars are paired with mentors as part of this signature program of the Committee on Diversity, Equity & Inclusion that funds a mentored summer research experience for medical students from groups underrepresented in medicine.

N&N celebrates the accomplishments of the ACG family and recognizes professional achievements and contributions to the College and to the world.

Send your news or story ideas to ACGmag@gi.org.

Novel & Noteworthy | 7

N&N GI EYE: ARTWORK FROM ACG MEMBERS

CONTEMPLATING ETERNITY, THE CAMEL WAY PYRAMIDS OF GIZA, EGYPT

Aline Charabaty, MD, FACG

Share some information about the location.

My father, who is an engineer, told me recently he always wanted to see the Pyramids of Giza. So, almost on a whim, we took a family trip to Egypt this Spring, because the time is always now to share experiences with loved ones and make wishes come true.

Like most people, I had “seen” and learned about the pyramids in history books, documentaries and movies, and read about the many theories of how such monumental structures could have been built in 2500 BC. But nothing had prepared me for the awe that hit me strongly when I actually stood in front of the pyramids and got to truly experience how incredibly monumental and exceptional these structures were. I was simply looking at pure engineering and human greatness: millions of blocks of stones, each weighing several tons, were ferried along the Nile from a distance, and stacked on top of each other to precisely meet at the apex of the Great Pyramid, at more than 400 feet high. The pyramids were built as a passage to the afterlife for the pharaohs, where they would rule as gods, and they have indeed achieved the impossible: immortality and eternity on Earth, still standing for more than 4,500 years, majestic and mysterious in their unrevealed secrets…It was mind blowing, spiritually shaking and elevating, humbling, exhilarating, inspiring, puzzling, all at the same time.

8 | GI.ORG/ACGMAGAZINE

What captured your attention/share your thoughts on the personal significance of this photo.

After visiting one of the pyramids and seeing them up close, like good tourists, we followed the flow of visitors towards the camel rides. That area was busy with noise, music, vendors, and people striking the pose for Instagramworthy pictures before their tour bus departs: holding a pyramid by the tip of their fingers, leaning or pushing on one, spreading their hands wide as if they could embrace an entire civilization sitting high on a camel…It was a bit chaotic, a bit Vegas, a bit Disney…I stepped away from the crowd and as I turned around I saw these camels sitting on an elevation overlooking the pyramids, quietly chewing on their food, unfrazzled by the excitement and the silly busyness of the crowds around them. To me, they seemed to be peacefully absorbed in their contemplation of the familiar pyramids: indeed, who can better appreciate the pyramids than these animals who represent endurance and stamina in difficult environments?

From the camels’ vantage point, the pyramids were all mine to enjoy.

I stopped, took the snapshot, and dropped my phone in my pocket, and for the next few minutes, I channeled that camel attitude, soaking in the view, wondering how close it was to what centuries of travelers, merchants and archeologists saw when they arrived

to Giza. This moment was simply magical, because I was “in” it, not just witnessing it; me, the camels and the pyramids and all they represented.

So, this photo is one of my favorites of the trip: a good reminder that as we are busy “documenting” trips and experiences, building an Instagram or Facebook portfolio worthy of likes and hearts, we are actually missing the moment, and the meaningful impact it can have on our soul. For the rest of

the trip, I did my best to channel that camel attitude and melt in the experiences of the moments instead of obsessing over documenting them for future review.

made it easy to snap the photo without much preparation. I wish I knew how to work a fancy camera with zoom, lenses and such…maybe it will be my next life experience to explore?

Aline Charabaty, MD, FACG Dr. Charabaty is the Assistant Clinical Director of the GI Division at Johns Hopkins School of Medicine and Clinical Director of the Inflammatory Bowel Diseases (IBD) Center at Johns Hopkins-Sibley Memorial Hospital. She serves as the ACG Governor for the District of Columbia and is the creator of #MondayNightIBD and co-founder of Scrubs & Heels.

What equipment did you use? Any technical challenges?

I took this photo with my iPhone, and I have to admit, I don’t even recall which series my iPhone is.

The desert light and the still camels

Novel & Noteworthy | 9

// N&N

[CRC MONTH HIGHLIGHTS]

FIGHT CRC’S “UNITED IN BLUE” INSTALLATION On March 13, 2023, on the National Mall, ACG President Daniel J. Pambianco, MD, FACG, represented ACG in a rally sponsored by advocates from Fight Colorectal Cancer at their “United in Blue” installation. ACG is one of the organizations standing with this group of CRC patients, survivors, and caregivers who gathered in Washington, DC, to visit legislators and bring attention to colorectal

cancer and the trends in young-onset disease. The dramatic installation of 27,400 blue flags near the U.S. Capitol was a visual representation of those younger than 50 who will be diagnosed with colorectal cancer in 2030 unless more is done to screen and educate.  DOWNLOAD AND SHARE: bit.ly/ACG-CRC-Toolkit

DRESS IN BLUE DAY

“RIDE OR STRIDE FOR 45” – OR GLIDE!

ACG celebrated “Dress in Blue Day” on Friday, March 3, 2023. This national awareness day is an opportunity for the entire GI community to put the spotlight on colorectal cancer prevention. The College celebrates all the creative ways our members and their staff express their enthusiasm for and commitment to CRC screening.

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

Learn more and see more photos from 2023: bit.ly/ACGRideOrStride45 (Photo top) ACG President Daniel J. Pambianco, MD, FACG, and his daughter opted to “glide” down the ski slopes for 45,000 vertical feet. (Photo center) ACG Governor for Washington, DC, Aline Charabaty, MD, FACG, gathered an early morning crowd at the Washington Monument for a walk and chance to support the Fight CRC United in Blue installation on Sunday, March 12, 2023. (Photo bottom) Jassimran Singh, MD, PGY-1 Internal Medicine at Saint Vincent Hospital, Worcester, MA, is going the distance for CRC awareness.

10 | GI.ORG/ACGMAGAZINE

“The Blue MD” is secretly ACG Trustee Seth A. Gross, MD, FACG, of NYU Langone Health. Dr. Gross went all in for March CRC Month to bring attention to colorectal cancer prevention.

[EMERITUS]

TUNE IT UP: A CONCERT TO RAISE AWARENESS OF COLORECTAL CANCER

DAVID C. WHITCOMB, MD, PHD, FACG announced his retirement from the University of Pittsburgh where he served as Chief of the Division of GI, Hepatology & Nutrition from 1999 to 2016 and held the Giant Eagle Foundation Professor of Cancer Genetics.

Dr. Whitcomb was Professor of Medicine, as well Professor of Cell Biology & Molecular Physiology and Professor of Human Genetics. A pioneering physicianscientist recognized for his “leadership and groundbreaking scientific contributions” to the understanding of pancreatico-biliary diseases, Dr. Whitcomb served with distinction as Editor-in-Chief of ACG’s journal Clinical and Translational Gastroenterology from October 2015 to January 2021.

Dr. Whitcomb authored a thoughtful piece for ACG Magazine in 2021, “Perspectives and Advice to Trainees and the Next Generation of Physicians and Scientists.” READ: bit.ly/acg-mag-2021-whitcomb

So many artists from an incredible array of musical genres donated their time and performances to support colorectal cancer awareness including Jon Baptiste, Rufus Wainwright, the Cincinnati Pops Orchestra and the Knights Chamber Orchestra. A duet with veteran blues singer Buddy Guy and newcomer Ally Venable was a treasure in a year which also featured virtuoso performances by violinists Hilary Hahn and Rachel Barton Pine. Dr. Benjamin Levy of the ACG Public Relations Committee invited musical guests for this virtual event that brought together the ACG community to focus attention on colorectal cancer screening.

[NEW VENTURE]

CONGRATULATIONS to Lauren

 LISTEN TO THE RECORDING: gi.org/concert

Feld, MD, for establishing “The Feld Lab” at the University of Massachusetts Chan School of Medicine. Her work focuses on the intersection of workforce equity, patient care, and medical ethics. Specifically, she will conduct clinical research on women’s health in liver disease. She is interested in exploring the impact of provider characteristics on patient outcomes and improving work environments through structural, evidence-based solutions to allow faculty to achieve personal and professional well-being and provide higher quality patient care.

Photo above: Dr. Benjamin Levy, Concertmaster, Cellist, and Gastroenterologist

[NACGF WINNERS]

(Top left photo) Consistently creative and enthusiastic, Connecticut GI outdoes itself each year. “Surrender Your Booty!

Get Your Colon Checked Today!”

(Center photo) ACG Board of Governors Vice Chair Dr. Sita Chokhavatia and colleagues at Valley Health System in New Jersey. (Bottom photo) ACG Governor for South Texas Harish K. Gagneja, MD, FACG and his staff at Austin Gastroenterology bring the fun and help to “Keep Austin Screened.” (Top right photo) Reezwana Chowdhury, MD, at Johns Hopkins is an instigator of their blue brilliance during March CRC Month.

CONGRATULATIONS to the winners of the North American Conference of GI Fellows Distinguished Achievement Awards! L to R: Katie A. Dunleavy, MB BCh BAO, Mayo Clinic Rochester; Yuying Luo, MD, Icahn School of Medicine at Mount Sinai; and Achintya D. Singh, MD, Case Western Reserve University.

These rising stars demonstrated exceptional presentation skills at NACGF 2023 in Washington, DC, in early March. Read more about the 2023 NACGF experience with a reflection by Dr. Katie Dunleavy in the Trainee Hub section on PG 21.

Novel & Noteworthy | 11

// N&N

[#EBGIVSCRC]

THE SOCIAL MEDIA AMBASSADORS for ACG’s newest publication, Evidence-Based GI, took to Twitter and Instagram this year in a monthlong multifaceted campaign #EBGIvsCRC to bring attention to the lifesaving importance of colorectal cancer.

Among their many creative strategies, the Instagram filter photo frame and their pictures of pets stand out for overall impact. In a highly scientific poll on Twitter measuring the impact of Pets vs. Ambassadors, the pets were deemed to show more “True Blue For CRC” spirit by 75.5% of respondents. Follow EBGI on Twitter @ACG_EBGI and read the publication: gi.org/EBGI.

[KUDOS]

SAMIR A. SHAH, MD, FACG: DDNC LIFETIME ACHIEVEMENT AWARD Dr. Shah was honored with the Lifetime Achievement Award of the Digestive Disease National Coalition (DDNC) at their 33rd Annual Public Policy Forum in March, 2023. Dr. Shah has been very active as ACG’s representative to this coalition of GI patient and physician organizations and industry partners dedicated to improving public policy surrounding digestive diseases. He served as DDNC President from 2019 to 2020, and was the College’s President 2021 to 2022.

KENNETH R. DEVAULT, MD, MACG, CHAIR OF ABIM GI SPECIALTY BOARD ACG Past President Dr. Ken DeVault will assume the chair of the GI Specialty board of the American Board of Internal Medicine. In this role he will also be a member of the ABIM Council.

[GLOBAL GI]

THE COLLEGE WAS SADDENED TO LEARN of American gastroenterologist Dr. Bushra Sulieman's death in April due to violence in Sudan. Dr. Sulieman taught at the University of Khartoum’s faculty of medicine and was killed outside his home taking his father to a medical appointment.

Dr. Mohamed Eisa of Allegheny Health Network in Pittsburgh, a gastroenterologist and friend of Dr. Sulieman who was visiting his family in Sudan, escaped Khartoum after a harrowing journey. Dr. Eisa is the Secretary General of the Sudanese American Physicians Association.

Read more in this April 28, 2023 National Public Radio story: n.pr/3LQqRgg 12 | GI.ORG/ACGMAGAZINE

[REPORT FROM DC]

“FROM THE DAYS OF MY YOUTH, growing up in New York City, I’ve frequently thought about how positive changes are made in the world. How we leave things better than we found them.

How we solve the biggest problems and, recently, how as a gastroenterologist, I can help even people I may never see one on one.

Well, on March 10, 2023, my visit to Washington, DC, for the Congressional Black Caucus’s Health Equity Braintrust chaired by U.S. Representative Robin Kelly (D-IL) was one of the ways in which I was able to actively answer some of my contemplations. This visit was at the invitation of ACG and with the support of my awesome private practice group, Digestive Health Institute of Pinnacle GI in Lansing, Michigan. During the event, I had the privilege of being an active participant in change outside the clinic and outside of the endoscopy suite. I was able to sit with other health industry leaders and highlight the biggest Health Equity challenges our country faces: from health disparities in CRC, to food insecurity, to declining healthcare reimbursements.

Specifically, I was able to offer ACG as a partner to the Congressional Black Caucus in educating constituents on the importance of eliminating Health Inequity in colorectal cancer screening rates in Black and Brown communities as compared to their Caucasian and Asian cohorts, as well as Rural and Urban communities as compared to Suburban cohorts. The event was fantastic and only the beginning of this beautiful partnership with Congresswoman Kelly and the Congressional Black Caucus.”

—Jannel Lee-Allen, MD, MUP Jannel Lee-Allen, MD, MUP is a gastroenterologist in Lansing, MI, and is an alumnus of the ACG Institute’s Young Physician Leadership Scholars Program.

[EARLY CAREER LEADERS]

[SUMMER SCHOLARS SPOTLIGHT]

THE EXTRAORDINARILY TALENTED COHORT of the ACG Institute’s Early Career Leadership Program (ECLP) culminated their experience by participating in ACG Advocacy Day with the ACG Board of Governors in April. The ECLP program evolved to replace the Young Physician Leadership Program (YPLSP) as an immersion in leadership skills and policy advocacy training for physicians 1 to 5 years out of fellowship. The program directors are Allon Kahn, MD, and Elizabeth R. Paine, MD, FACG—both of whom are YPLSP alumni. Joining the group for their meeting in Washington, DC, were ACG President Daniel J. Pambianco, MD, FACG (center front) and ACG Trustee Patrick E. Young, MD, FACG (far right).

Front Row L to R: Dr. Diana Snyder, Dr. Tanya Bruckel, Dr. Xiao Jing (Iris) Wang, Dr. Ariela Holmer, Dr. Allon Kahn (Course Director), Dr. Elizabeth Paine (Course Director), Dr. Daniel Pambianco (ACG President), Dr. Swathi Paleti, Dr. Ayanna Lewis, Dr. Sonja Dawsey, Dr. Akshata Moghe. Back Row L to R: Dr. Divyangkumar Gandhi, Dr. Vishant Ramadorai, Dr. Jasna Beard, Dr. Adam Faye, Dr. George Salem, Dr. Drew Triplett, Dr. Dany Raad, Dr. Ramzi Mulki, Dr. Janice Cheong, Dr. Alexander Kuo, Dr. Victor Chedid, Dr. Jianhua (Andy) Tau, Dr. Patrick Young (ACG Trustee)

THE SUMMER SCHOLARS PROGRAM is an initiative of the ACG Committee on Diversity, Equity & Inclusion that pairs medical students from groups underrepresented in medicine with mentors for a research project and provides a stipend of $5,000.

The Committee believes that a formalized mentorship and clinical research program is one pipeline to increase representation of underrepresented groups in medicine in academic gastroenterology careers. The program is an 8- to 10-week structured clinical research experience for medical students in the U.S. who are paired with research mentors sharing similar clinical research interests in the fields of gastroenterology and hepatology. At the end of the program, the students are required to submit a progress report and an abstract to a local, regional, or national conference Here are the three current medical students who are ACG Summer Scholars and their faculty mentors:

[EAVP]

AMY S. OXENTENKO, MD, FACG (Mayo Clinic Rochester) Visits University of Connecticut (March 1, 2023) Dr. Oxentenko presented hospital grand rounds on “Celiac Mimickers” and GI grand rounds during her visit to UConn. She met with fellows for an engaging case conference and career advising sessions, and did a dinner talk on the “Top 10 Things All Clinicians Should Know About Celiac Disease” which included UConn chief residents interested in GI along with GI fellows and faculty.

Bethlehem Michael, David Geffen School of Medicine at UCLA— her mentor will be Helen Burton Murray, PhD, Massachusetts General Hospital

SUNANDA V. KANE, MD, MSPH, FACG (Mayo Clinic Rochester) Virtual Visit with University of Nebraska (March 2, 2023) Dr. Kane was an EAVP Visiting Scholar in Equity, Diversity & Ethical Care and presented a virtual Internal Medicine Grand Rounds on “IBD for the Non-Gastroenterologist” with 168 participants as well as a gut club talk to over 50 people on Pregnancy in IBD.

Cynthia Okafor, University of Texas Medical Branch—her mentor will be Danny Issa, MD, UCLA

CHRISTOPHER VÉLEZ, MD (Massachusetts General Hospital) Visits Thomas Jefferson University (April 13, 2023) When the Jefferson Department of Medicine learned of Dr. Vélez’s planned Medicine Grand Rounds on LGBTQ Digestive Health Considerations, they used it as anchor to have an entire week of didactic content focused on diversity, equity, and inclusion. As an ACG Visiting Scholar in Equity, Diversity & Ethical Care, he addressed topics including reducing electronically medical record bias, how to assist in transitions out of incarceration, and bias towards transgender individuals.

He also presented GI Grand Rounds on Cystic Fibrosis-related GI disorders.

Elias Arellano Villanueva, MS, University of Texas at Rio Grande Valley—his mentor will be Prasad G. Iyer, MD, MSc, FACG, Mayo Clinic Rochester

Novel & Noteworthy | 13

Advance to Fellowship

of the AMERICAN COLLEGE OF

GASTROENTEROLOGY (FACG)

Criteria for an ACG Physician

Member to Advance to Fellowship:

Benefits of ACG Fellowship: You can run for elected office on the Board of Governors

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

You can serve as the Chair of an ACG Committee

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

You can be nominated for a Master Award or

You can be nominated for the Board of Trustees the Samuel S. Weiss Award

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.)

Add FACG to your credentials, on business

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

Certificate of Advancement to Fellowship signed

cards, and on your CV Recognition at the ACG Annual Meeting and on the ACG website by the ACG President and Secretary

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.

14 | GI.ORG/ACGMAGAZINE

 Complete the application online: members.gi.org/acgmembership  Application fee is $50

Where dysbiosis once left the gut microbiome in ruin,

RISE ABOVE RECURRENT C. DIFFICILE INFECTION and restore hope with REBYOTA

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The first and only FDA-approved microbiota-based live biotherapeutic to prevent recurrence of C. difficile infection starting at first recurrence.1,2,a In the pivotal phase 3 trial, 32.8% of patients were treated at first recurrence of CDI following antibiotic treatment of CDI.1

a

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 and the Ferring Pharmaceuticals logo are registered trademarks of Ferring B.V. REBYOTA is a trademark of Ferring B.V. ©2022 Ferring B.V. All rights reserved. US-REB-2200129 1/23

RESTORE HOPE

REBYOTATM (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 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. 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%), flatulence (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 difficile (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 first 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 (defined as adverse events assessed as definitely, 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%), flatulence (3.3%), and nausea (3.3%).Most adverse reactions occurred during the first 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 sufficient 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 and the Ferring Pharmaceuticals logo are registered trademarks of Ferring B.V. REBYOTA is a trademark of Ferring B.V. ©2022 Ferring B.V. This brief summary is based on full Rebyota Prescribing Information which can be found at www.RebyotaHCP.com US-REB-2200277

PUBLIC POLICY Advocacy Day Highlights 2023 Dayna S. Early, MD, FACG & Sita S. Chokhavatia, MD, MACG

NEARLY ONE HUNDRED ACG ADVOCATES FROM OVER 40 STATES canvased Capitol Hill on April 20, 2023, representing clinical gastroenterology and GI patients. Members of the ACG Board of Governors and ACG Institute’s Early Career Leadership Program participated in over 175 meetings with legislators and staff in Washington, DC. A highlight of the powerful slate of legislative visits was a “Political Grand Rounds” luncheon moderated by ACG Legislative & Public Policy Council Chair, Louis J. Wilson, MD, FACG. The group heard a wide array of perspectives from 8 Members of Congress, many of whom were practicing physicians prior to getting into politics.

They shared about their personal journey into politics and what prompted them to run for office while offering tips on how to effectively advocate for the GI profession on Capitol Hill. Following these remarks, Dr. Wilson organized a chance for Governors and advocates from the legislator’s state or district to connect for a photo and a chance to chat briefly.

The special lunch event included a wide array of perspectives from legislators including U.S. Senator Bill Cassidy (R-LA), a hepatologist. Other physicians serving in Congress who spoke to ACG included

Public Policy | 17

// PUBLIC POLICY

U.S. Rep. Larry Bucshon (R-ID); U.S. Rep. Michael Burgess (R-TX); U.S. Rep. Ronny Jackson (R-TX); and U.S. Rep. Kim Schrier (D-WA). The session kicked off with comments from U.S. Rep. Carol Miller (R-WV) and remarks by U.S. Rep. Lori ChavezDeRemer (R-OR) and Rep. Lloyd Doggett (D-TX).

In the afternoon, ACG leaders had a meeting to brief senior staff of the HHS Secretary Xavier Becerra.

There is continued frustration in the GI field about prior authorization policies and a general sense that GI practices are stretched and stressed. The focus of ACG Advocacy Day was representing the interests of GI patients while educating congressional leaders on the issues that matter in clinical GI practice, including reforming Medicare reimbursement and addressing the obstacles of prior authorization.

ACG’S KEY MESSAGES AND SPECIFIC LEGISLATIVE REQUESTS:

C and A (R-ID) on shon y Buc is Wils rr u a o L L . p Dr. Dr. Re Chair Policy Public

sh Gagneja ernor for Texas Dr. Hari (R-TX) and ACG Gov Rep. Michael Burgess

• Support The Safe Step Act (S.652/H.R.2630) A policy priority for ACG is to urge lawmakers to put patients first by supporting the Safe Step Act and urge others to become co-sponsors.

The bill requires insurers regulated under ERISA to implement a clear and transparent process to request an exception to a step therapy protocol.

• Enact Inflationary Update to Medicare Physician Payments (H.R.2474) This legislation provides an annual update to the Medicare physician fee schedule, tied to inflation, and as measured by the Medicare Economic Index (MEI). The bill puts in place an annual physician conversion factor (CF) update starting in 2024 based on the MEI, which reflects physician practice cost inflation.

The 2022 -2023 AC G Board of in front of Governor the Capito s and Early l Building and physici Career Le before mee adership ans. ting with Program legislator participan s to advo ts gather cate on be half of GI patients

• Champion Efforts to Reform/Restrict Prior Authorization The day was also a great opportunity to share examples of the worsening burden prior authorization requirements present for GI practices.

We are grateful to the College's leadership, to ACG President Dr. Daniel Pambianco, to Dr. Louis Wilson, Chair of the College’s Legislative & Public Policy Council, as well as everyone who dedicated time and effort to the success of ACG Advocacy Day 2023!

Kunjali Padhya Washington Dr. G Governor for (D-WA) and AC Rep. Kim Schrier

—Dr. Dayna S. Early, Chair, ACG Board of Governors & Dr. Sita Chokhavatia, Vice Chair

The 2022-20 23

18 | GI.ORG/ACGMAGAZINE

ACG Board of Governors and Early

Career Lead ership

Program.

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Dr. Patrick Yo ung provides instruction on ergonomics in endoscopy.

inia), Dr. G Governor for Virg Anne Tuskey (AC Sen. G President), Dr. with the office of iel Pambianco (AC e before meeting Dan ven Dr. con , ents LP) stitu (EC Virginia con Ramadorai ant Vish Dr. and , dhi (ECLP) Divyangkumar Gan Tim Kaine (D-VA).

s and e Governor dresses th havatia ad . Sita Chok Dr air t). lef Ch Early, rnors Vice Dr. Dayna d of Gove ram (Chair ACG Boar ship Prog er Leader Early Care

ACG Gove rnor for Illi nois Dr.  Russell Co hen (far rig ht) with Sen. Tamm y Duckwo rth (D-IL) and Sen. Dick Durb in (D-IL).

Public Policy | 19

ACG PRACTICE MANAGEMENT

Toolbox

NEW! Members Only

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

HAVE A QUESTION? Email coding@gi.org

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

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

Start Building Success Today gi.org/practice-management

TRAINEE HUB Title

Title Line 2 Title

By Shifa Umar, MD

An Insider Look at the

North American Conference for Gastroenterology Fellows (NACGF)

By Katie Dunleavy, MB BCh BAO

THE AMERICAN COLLEGE OF GASTROENTEROLOGY is committed to supporting the growth of GI fellows. Recently, I was chosen to attend the 31st Annual North American Conference for Gastroenterology Fellows (NACGF) sponsored

by ACG and held at the Ritz-Carlton in Pentagon City, VA. I expected to make new friends, interact with senior faculty, and use the opportunity to practice the much-anticipated art of public speaking without a Zoom background.

I was immediately impressed by the authenticity and welcoming culture of this intimate conference led by course directors Dr. Jill Gaidos and Dr. David Hass. The care and compassion for mentorship is at the heart of this unique experience, which is why it was even more thrilling to spend time with current ACG President, Dr. Daniel Pambianco, and

esteemed faculty including Dr. Shivangi Kothari and Dr. Andrew Moon. Although the competition is tough for fellows to present their abstracts, the twenty-five GI fellows from across the country who were lucky to attend an all-expense paid trip were more than deserving of this honor. I left this weekend knowing this shared experience would forever connect me with my colleagues no matter where our journeys lead.

Front Row (L to R): Dr. David Hass, Dr. Aruj Choudhry, Dr. Aileen Bui, Dr. Babu Mohan.

Middle Row (L to R): Dr. Daniel Pambianco, Dr. Daryl Ramai, Dr. Tomoki Sempokuya, Dr. Siri Urquhart, Dr. Katie Dunleavy, Dr. Yuying Luo, Dr. Nghiem Ha, Dr. Taylor Geisman, Dr. Nakia Chung, Dr. Jill Gaidos, Dr. Muhammad Yousaf, Dr. Amanda Krause, Dr. Shivangi Kothari Back Row (L to R): Dr. Achintya Singh, Dr. Sachin Srinivasan, Dr. Harsh Patel, Dr. Ryan Flanagan, Dr. Brent Hiramoto, Dr. Andrew Moon, Dr. Mahmoud Rahal, Dr. Elie Al Kazzi, Dr. Omar Jamil, Dr. John George

Trainee Hub | 21

// TRAINEE HUB

Q&A with Faculty Panel: Dr. David Hass, Dr. Jill Gaidos, Dr. Kothari & Dr. Pambianco

Our Friday evening began with an open and truthful conversation about career planning and leadership skills often overlooked in medicine. I left with more than one book recommendation after Dr. David Hass’ poignant discussion on how to value emotional intelligence as a leadership tool.

Check out some pearls from this discussion on forging a career in GI. What is the best professional advice you have received?

Answers: • Join GI Society Committees. (Gaidos) • Focus on one project and give it your full honesty. Be present. (Kothari) • Always remember medicine is a ministry. It is a privilege to be witness to your patients’ lives, never lose sight of that. (Pambianco) • Put the important on par with the necessary. Keep long-term goals at the forefront of your mind. (Hass) • Take 24 hours before responding to emotionally charged situations.

(Pambianco) What is the worst professional advice you have received?

Answers: • You can’t negotiate your academic job. (Kothari) • Say yes to everything. (Pambianco) • Avoid taking risks. Put your head down and do the job. (Hass)

Can you share tips on work-life balance?

Answers: • Always make room for what’s important. I work hard to have a flexible schedule and I ask my family for feedback. How am I doing? Make your health a priority. (Hass) • Don’t take yourself too seriously. As William Shakespeare said, “We are all actors on the stage of life.” (Pambianco) • Enjoy your job, you’ve worked your whole life for this! (Kothari) • The days are long, but the years are short. Don’t compare yourself to others. You don’t know what’s going on in someone else’s life. (Gaidos)

Perfect equation for a great presentation. Source: David J. Hass, MD, FACG

Presentation Pearls of Wisdom The anticipation and nervous energy were palpable over breakfast on Saturday morning. As we all amicably greeted each other in preparation for our presentations, I took note of other routines. Some were chatty, others quiet, and all of us eager to have this day behind us. I was enthralled by the research presented by my colleagues. I learned about ergonomics curriculums at GI fellowship programs, intricate meta-analysis and systematic reviews, creation of new clinical criteria for GERD, and how diversity is portrayed in GI Board review questions. I walked away richer in knowledge and inspired by this group. We all enjoyed exploring Washington, DC, and mingling with faculty once the day was over.

“I would be remiss if I did not comment that in recent years with virtual conferences, standing up in front of an audience has become more daunting and less practiced in many GI fellowship programs. I cannot emphasize the importance of in-person presentations for professional development.”

What have you learned from failures?

Answers: • You can always reinvent yourself, in fact, you should be doing it every 10 years. (Hass) • Never make the mistake of not putting family first. (Pambianco) • It’s OK to do the unconventional or to change paths. It’s OK to leave academic medicine. It’s OK to leave your dream job when it’s no longer your dream. It’s all OK. (Gaidos) • Be vulnerable, we all have failures, don’t create a perfect facade. (Kothari) Some of the NACGF group take in the sights in Washington, DC (at the World War II Memorial).

22 | GI.ORG/ACGMAGAZINE

It was a rewarding Sunday morning as the faculty presented dedicated feedback for improving our presentations. I would be remiss if I did not comment that in recent years with virtual conferences, standing up in front of an audience has become more daunting and less practiced in many GI fellowship programs. I cannot emphasize the importance of inperson presentations for professional development. NACGF is the ideal opportunity, due to its small size, GI fellows were given space to present our research to faculty in a low-stakes environment. In the future, it may be beneficial to consider ways to increase the pressure to help prepare seasoned GI fellows for national/international speaking engagements.

Presentation Stages of Development 1. Assessing & Accepting an Invitation to Speak • Evaluate if this presentation is the right time, the right content, and the right audience. Don’t be afraid to ask background questions to ensure this is right for you.

• If it’s a match, use your response as an opportunity to engage with faculty, begin networking, and most importantly, thank the sponsoring institution.

2. Know Thy Audience: Create Structured and Interesting Content • Knowing the background of your audience, the size of the room, and the format of the conference will help build confidence. This can help you frame your mindset and meet the expectations of those who have invited you to speak.

• You must keep a basic structure in mind for a research vs. nonresearch presentation.

• Comparing the “Summary” and “Conclusion” slide • The summary should restate your data in 3 succinct bullet points.

• The conclusion should analyze data, suggest future directions, and clinical applications for findings. This is your opportunity to engage both researchers and clinicians in the purpose of your research.

• Confusing these slides can be a major pet peeve for judges and audience members!

• Creating slides should be a constant editing process. When in doubt, simple and concise is always better.

• Remember, you can create backup slides to reference to during your Q&A session.

3. Practice. Practice. Practice. Feedback is Essential • In Michelle Obama’s book, “The Light We Carry,” she shares her personal and professional journey to becoming an engaging public speaker. The preparation and refinement of her speeches has won accolades from bipartisan supporters. She inspires all young people, especially women, to use every opportunity for public speaking as a chance to connect with the light in yourself to help bring out the light in others. Of course, this process could not become a reality without the critical role of exhaustive practice, and thoughtful feedback.

Comparing the “Summary” and “Conclusion” Slides

• The summary should restate your data in 3 succinct bullet points.

• The conclusion should analyze data, suggest future directions, and clinical applications for findings.

This is your opportunity to engage both researchers and clinicians in the purpose of your research.

• Confusing these slides can be a major pet peeve for judges and audience members!

Research Structure

• Title • Background • Hypothesis • Aim(s) • Methods • Results • Summary • Conclusion • Limitations (self-aware) • Future steps (thoughtful) • Acknowledgements (photo)

Non-research Structure

• Title • Relevant conflicts of interest • List of topics, goals, objectives for talk • Slides of actual talk • Summary • Acknowledgements

Slides 101

• 1 minute per slide • Simple backgrounds • Avoid red font • Text size 24+ • Easy to read tables/charts • Phrases, not sentences • Avoid line orphans • Judicious use of pictures • Only use videos if they are embedded/work • Turn off PowerPoint autotimer • Don’t insert text box over valuable data, create a text box below

Trainee Hub | 23

// TRAINEE HUB

• This stage of presentation development can often be overlooked as there is relief that comes from creating finished content. Do not be fooled, as this step of reflection and enhancement is key to calming nerves and ensuring success.

• When asking for feedback, start with someone you trust. If you can’t, consider recording yourself as a first step. Reflect on this to identify your body language, stage presence, and filler words to actively avoid (um… ok…but…really….so…). Use statistics to tell stories, make it interesting.

Once you have practiced the difficult transitions and complicated data, challenge yourself by asking a mentor who you know will be tough.

This step, while daunting, will push you to become your best!

• Remember, practice can be done anywhere – at the gym, walking to the car, on your commute home – so don’t make excuses! The goal is to be genuine, not perfect.

4. Delivery & Mastering the Question/ Answer Session • Once the day has arrived, you may feel mixed emotions, but that is normal! I try to keep the power of vulnerability in mind, reminding myself that I am allowed to be authentic, and my willingness to connect with the audience will only benefit us all.

• Understanding the logistics will help you appear like a pro – and the AV team should be your first stop of the day. Take the time you need to make sure the correct slides are uploaded, the videos can play seamlessly, and you are comfortable standing at the podium and adjusting the microphone. Figure out the laser pointer and slide advancement so there’s no fumbling on stage. These 10 minutes can be a game changer!

• Introduce yourself to the moderators. Thank them for their time and help them with the pronunciation of your name.

• We wouldn’t be doctors without a back-up plan, and technology can crash. Instead of resorting to giving

24 | GI.ORG/ACGMAGAZINE

your presentation by candlelight, have a USB with your slides and a printed hard copy in case all else fails.

• Before stepping on stage, center yourself, give yourself the pep talk your best friend would give to you.

Remember you are the expert of your research, and everyone wants you to thrive!

• Stage presence starts simply with posture. Face your audience and try to divide your attention between the three sections of the room (left, center, right). There’s no need to repeat your title and qualifications after being announced, so don’t waste time. Similarly, don’t apologize for the timing of your talk, it’s out of your control. Enunciate and speak slowly, it will never be too slow. As Dr. Hass says, “you don’t need gimmicks to be impactful.” Be respectful of your audience by finishing early.

How to answer audience questions?

• Breathe!

• View every question as a compliment of audience engagement, even if they raise difficult points.

• If they go low, you go high.

• Each time say, “Thank you for your question…” to avoid creating a dichotomy among audience questions.

• Be truthful and brief. Admit if you don’t know something and ask to follow-up after the presentation.

• Prepare supplemental slides to anticipate questions. Keep these at the end of your presentation following a blank slide.

How to ask questions?

• Introduce yourself and your institution.

• Always thank the presenter for their research.

• Use time judiciously; don’t hog the mic.

• If you have criticism, deliver it with grace, not aggression.

• Don’t ask patient specific questions.

• Be brave! This can help forge collaborations.

5. The After: Growing & Networking • Congrats, you’ve developed, rehearsed, and delivered a great presentation! Even if you’re feeling confident about the outcome, your work is not over yet.

• Immediately following the presentation, make sure those who have stayed behind have your email address for further follow up. This can generate new collaborations or help spark new research questions.

• Take 15 minutes to decompress and write down your thoughts.

1. Gut feeling.

2. What went well?

3. What did not go well?

4. Right audience? Right content?

5. Any major questions to follow up?

• The journey home can provide precious opportunities for growth.

My mentor, Dr. Laura Raffals, encourages me to use this time in the airport to start editing the first draft of the manuscript.

Prior to attending a major GI conference, she requires that I submit a completed first draft manuscript. Although challenging, I am grateful that her mentor, Dr. Stephen Hanauer, taught her that momentum is key in research.

• In the week following the presentation, send thank you notes to the moderators, faculty, and sponsoring institution. Take a few minutes to reach out to colleagues or trainees you may have met, consider connecting on Twitter. In all interactions, be personal and persistent – send an article, opportunity, or resource the recipient might appreciate.

Relationships are built on small moments of trust.

Katie 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.

Brief History of NACGF

It wasn’t until I returned to Rochester, MN, and ran into Sunanda Kane, MD, MSPH, FACG, that I learned the rich history of this unique and not-to-be missed GI fellows conference.

NACGF was originated 31 years ago to provide GI fellows with an opportunity to present their research in a mentoring environment. The program has been kept deliberately small to prioritize individual attention and mentoring, and to foster a sense of collegiality. Dr. Kane shared with me that as a fellow she participated in the NACGF and made lifelong friends. Before long she was asked to participate as faculty, before transitioning to co-chair of the conference with Dr. Philip O. Katz, MD, MACG. Learning of Dr. Kane’s involvement as a champion of NACGF made me reflect on the importance of protecting this GI fellows conference to provide an invaluable chance for coaching, camaraderie, and genuine investment in the future of ACG fellows.

COURSE DIRECTORS: David J. Hass, MD, FACG Associate Clinical Professor, Yale University School of Medicine Jill K.J. Gaidos, MD, FACG Associate Professor of Medicine, Yale University School of Medicine

FACULTY: Shivangi T. Kothari, MD, FACG Associate Professor of Medicine, University of Rochester Medical Center Andrew M. Moon, MD, MPH Assistant Professor of Medicine, University of North Carolina School of Medicine Daniel J. Pambianco, MD, FACG Managing Partner Gastro Health Charlottesville

for Former NACGFs  Call-to-Action

I task all former NACGF participants to dig up your photos, memories and share them with us on Twitter tagging @AmCollegeGastro and #NACGF!

Acknowledgements

Thank you to the American College of Gastroenterology, to the course directors Dr. David Hass and Dr. Jill Gaidos for inviting me to this event, the 25 incredible GI fellows from across the country, the fantastic faculty, and ACG staff member Robyn Graff who went above and beyond to make every detail perfect.

Trainee Hub | 25

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GETTING IT

Embracing Access to Physicians and Establishing Boundaries Sara N. Horst, MD, MPH, FACG, ACG Professionalism Committee

INCREASINGLY, HEALTH CARE IS OCCURRING ASYNCHRONOUSLY THROUGH THE ELECTRONIC MEDICAL RECORD (EMR). While this may help with patient access to health care teams, several factors have increased the rates of patient use dramatically over the past 5 to 10 years. Practices and hospital systems have implemented EMRs that give increased access to patients through patient portals. The COVID pandemic dramatically shifted health care into telecare. Studies have shown that this has increased the number of messages in the EMR.1 The 21st Century Cares Act was implemented which requires all results be immediately accessible to the patient. One study showed that when this was released in a large tertiary care academic center, the number of patient advice messages doubled within 6 hours of a test release.2

Getting it Right | 27

// GETTING IT RIGHT

This asynchronous care is causing a significant and increasing burden on physicians, advanced practice providers, and nursing staff. Physicians with the highest quartile of messages experience 6 times higher levels of exhaustion.3 While there is no simple answer for this increasingly complex issue, here are some practical considerations for your practice.

It is important to set expectations for patients about when patient portal messages will be answered. Often, 2 to 4 business days is a reasonable expectation, and this should be communicated uniformly to patients.

For instance, we have a new patient handbook with a section: “What to expect from our practice.” I show this to every new patient and discuss expectations about when to expect a response from myself or my staff.

It is also important to detail the types of problems that can be dealt with in a patient portal message.

We communicate that complex EMR questions may require clinic or telehealth visit. It is not unreasonable to set clear limits for yourself and your staff. For instance, if a message contains more than 2 to 3 questions, it could be routed to scheduling for an acute visit.

While not a viable option for all practices, one way to improve message burden is to have an appropriate triage system in place.

If a “Triage Basket” can be set up with staff to work through the messages before they go directly to the provider, it can allow for team members to work at the top of their license. This can also cut down on delayed responses to patients. It is important to consider protocols for staff members working in message baskets. For instance, I have a practice that cares for patients with IBD. We have medication refill protocols in place for immunosuppressive and biologic medications. If a patient meets criteria (i.e., up to date on labs

“If a 'Triage Basket' can be set up with staff to work through the messages before they go directly to the provider, it can allow for team members to work at the top of their license.

This can also cut down on delayed responses to patients.” and clinic visits), these medications can be automatically refilled. Also, if a patient with IBD calls in with symptoms, the nurse has a list of questions in a pre-defined EMR phrase and sends this to the patient.

Only when the patient answers these questions is the provider sent the message to evaluate for response.

Increasingly, hospital systems and practices are exploring options to bill for asynchronous care. This provides an opportunity to capture revenue and allows for productivity to be measured for this increasing work.

CMS has 3 codes that can be used for non-face-to-face patient-initiated communications through an online portal.

These are time-based codes (99421 for 5-10 minutes, 99422 for 11-20 minutes, and 99423 for > 20 minutes) for care over a period of 7 days. Details for using these codes is detailed below: 1. These can only be used for established patients.

2. You must provide evaluation and management and appropriate documentation.

3. You must get and document patient consent.

4. This cannot be provider-initiated communication (i.e., follow up of provider-ordered labs, radiology, pathology, or endoscopy).

5. You cannot have seen the patient in the prior 7 days or have a plan to see the patient in the next 7 days for the same problem.

6. Your patient will likely incur a copay or coinsurance cost.

A large medical center recently reported their experience with patient portal message billing at a system level. Over a

“Increasingly, hospital systems and practices are exploring options to bill for asynchronous care.”

28 | GI.ORG/ACGMAGAZINE

period of a year, approximately 1.4% of all patient advice messages were billed using these codes. There was a significant drop in the number of patient advice messages when this billing was implemented, and it did not lead to an increase in telephone communication messages or scheduled visits.4 In conclusion, clinicians and medical staff are facing a new and unprecedented way of delivering care, with consequences of increasing EMR burden. Practices and health care systems need to continue to consider innovative ways to provide and triage care for patients in the future.

REFERENCES 1. Nath B, Williams B, Jeffery MM, et al. Trends in Electronic Health Record Inbox Messaging During the COVID-19 Pandemic in an Ambulatory Practice Network in New England. JAMA Netw Open. 2021;4(10):e2131490. doi:10.1001/ jamanetworkopen.2021.31490 2. Steitz BD, Sulieman L, Wright A, Rosenbloom ST. Association of Immediate Release of Test Results to Patients With Implications for Clinical Workflow. JAMA Netw Open.

2021;4(10):e2129553. doi:10.1001/jamanetworkopen.2021.29553 3. Julia Adler-Milstein, Wendi Zhao, Rachel Willard-Grace, Margae Knox, Kevin Grumbach, Electronic health records and burnout: Time spent on the electronic health record after hours and message volume associated with exhaustion but not with cynicism among primary care clinicians, Journal of the American Medical Informatics Association, Volume 27, Issue 4, April 2020, Pages 531–538, https://doi.org/10.1093/ jamia/ocz220 4. Holmgren AJ, Byron ME, Grouse CK, Adler-Milstein J. Association Between Billing Patient Portal Messages as e-Visits and Patient Messaging Volume. JAMA. 2023;329(4):339–342. doi:10.1001/jama.2022.24710

Sara N. Horst, MD, MPH, FACG Associate Professor Gastroenterology, Hepatology, & Nutrition, Vanderbilt University Medical Center; Associate Vice Chair Digital Health Operations for Department of Medicine. Dr. Horst is a member of the ACG Professionalism Committee.

ACG MEMBERS CONNECT AND COLLABORATE WITHIN GI

ACG’s Online Professional Networking Communities Login or sign-up now at: acg-gi-circle. acg-gi-circle.within3.com within3.com

Getting it Right | 29

// COVER STORY

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Collaborative Patient-Centered Care

The Biopsychosocial Model of Care in Disorders of Gut-Brain Interaction: Q&A with Douglas A. Drossman, MD, MACG and Johannah Ruddy, MEd of the Rome Foundation

AT THE INVITATION OF THE ACG PATIENT CARE COMMITTEE, Dr. Douglas Drossman and Ms. Johannah Ruddy of the Rome Foundation each answered ten questions about their work together and the biopsychosocial model of care for disorders of gut-brain interaction (DGBI).

In a wide-ranging Q&A, they both reflect on strategies to improve communication between physicians and patients to advance patient care. Dr. Scott Gabbard, Chair of the Patient Care Committee, also reviews their latest book, “Gut Feelings: The Patient’s Story.”

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Ten Questions for Dr. Drossman

from the ACG Patient Care Committee

a parent or spouse died with having the same symptoms. Once the patient articulates their concern, then I can adequately address them. Finally, at the end of the visit, I will ask: "Have I answered all your questions?"

Q

Q

If a patient says they are not having their symptoms heard, they may feel the doctor is not listening effectively to what they say or possibly the patient is not clearly expressing their symptoms. One simple approach for the provider to remedy this is to ask questions in an open-ended fashion and without interruption initially (studies show that the provider interrupts the opening statement of symptoms in 12 seconds!), and actively listen to the patient's symptom presentation with full attention. The provider can then summarize the patient's symptom presentation to check for errors and validate the symptoms, which makes it clear that they are listening. Also, I always find it essential to ask, "What concerns do you have about your symptoms."

Sometimes we learn that after 10 years of pain, the patient is still concerned about having underlying undiagnosed cancer or that the pain began when

When you say "holistic," I believe you are referring to patients who want to be treated solely with herbals, OTC supplements, or other complementary or nontraditional treatments rather than pharmaceuticals. In that situation, I clarify with the patient that my practice's treatments are scientific and evidence-based. I prescribe medications approved by the FDA or recommended for use off-label by credible scientific agencies like ACG, AGA, or the Rome Foundation. If they want to try a supplement or herbal product, I will agree if they inform me what they are taking so, I can be sure it is safe to use. With the patient's permission, I may sometimes need to communicate with other providers to clarify my treatment approach and try to reach a consensus in our care with the patient.

In a generic sense treating patients with Disorders of Gut-Brain Interaction (formerly called functional

Patients with DGBI often feel like they make it through many appointments without having their symptoms heard. How do you validate patient concerns and address barriers to care?

32 | GI.ORG/ACGMAGAZINE

Do you have any strategies for getting therapy buy-in for patients that prefer a more holistic approach to their care? Similarly, do you have any other allied health professionals you reach out to?

GI disorders) is "holistic" as it should adhere to a biopsychosocial model of care.

Treatments can involve pharmaceuticals targeted to the gut or brain-gut axis and other integrative methods like dietary consultation and brain-gut therapies like CBT or hypnosis. I keep lists of braingut therapists (often relying on the Rome Foundations Gastropsych group (https://theromefoundation.org/romegastropsych), dietitians, and physical therapists (for patients with pelvic floor disorders) that I can refer to.

Q

How do you address/co-manage diseases that overlap with DGBI with more tangible symptoms (i.e., rectal bleeding)? Do you have strategies for educating/guiding patients through two disease processes (e.g., IBD with endoscopic remission and IBS)?

It's not uncommon for patients to have comorbid structural disorders like IBD and a DGBI like IBS. When patients have overlapping diagnoses, the provider must be skilled in treating both conditions and be able to determine priorities. I frequently see patients with IBD taking a biologic agent but are in clinical remission with a relatively normal endoscopy but continue to have abdominal pain – postinflammatory IBS. Here, the provider must shift from treating the disease (objective structural evidence) to addressing illness (the patient's experience of ill health).

I might explain to the patient that the symptoms and the disease state don't always correlate. So, for example, many patients with severe active colitis or Crohn's disease may have minimal symptoms but still require treatment for the inflammation.

Conversely in this case, having persistent pain and minimal disease, the patient will likely benefit from using a neuromodulator like a tricyclic antidepressant or SNRI. So the provider must be vigilant to markers of disease (rectal bleeding) and illness (e.g., chronic pain with a negative evaluation) to help educate the patient on the proper diagnosis and treatment approach. At times I will co-manage a patient with complex IBD with an IBD colleague or a patient with severe psychiatric difficulties with their treating psychiatrist, especially given the overlap in neuromodulator

treatments. In my experience, patients are open to, and quite welcoming of, a provider who addresses all aspects of their illness-disease spectrum, including comorbidities, and who communicate with other providers.

“It's not uncommon for patients to have comorbid structural disorders like IBD and a DGBI like IBS. When patients have overlapping diagnoses, the provider must be skilled in treating both conditions and be able to determine priorities.” ­— Dr. Douglas Drossman

Q

For those who believe in the hype of probiotics for the gut, what is the best way to explain that we don't have strong evidence that they work in IBS, and in fact, at times, can worsen symptoms of IBS? The internet has become the dominant influence in educating patients about various medical conditions and treatments, which is a challenge for us as providers. Because patients may obtain most probiotics without a prescription, the suppliers also do a great deal of marketing. So I try to provide a scientific perspective to their use. While I usually don't recommend probiotics, if patients ask me about them, I say they are generally safe but minimally effective and may cause side effects like gaseousness, bloating or diarrhea. If patients choose to take them, I work with them to monitor their effects, for better or worse, and we decide whether to continue them. If patients are already taking probiotics, I ask if they have seen any benefit. If they have, I permit it; if not, I ask them to consider stopping it to see if it makes a difference.

Q

Do you often have your IBS patient with numerous non-specific GI complaints see a psychologist/ psychiatrist? If so, what would you suggest are some tips to do that without making the patients feel you think "it is all in their head"? How do you decide if the patient would benefit from seeing a psychiatrist vs. a behavioral psychologist?

Because of my combined GI and psychiatric training, I take more licenses to prescribe neuromodulators for psychiatric and GI problems or manage multiple non-specific symptoms. So let me respond by offering recommendations to the practicing gastroenterologist.

A psychiatrist should be consulted if the patient has complex or severe comorbid psychiatric problems like major depression or severe anxiety that require psychopharmacological treatments

beyond the neuromodulators that the gastroenterologist might prescribe.

Generally, psychiatrists do not routinely do psychotherapy. However, over time, we see more and more patients referred to psychologists (what we now call brain-gut behavioral therapists) to provide complementary integrated care.

For further information on brain-gut therapies and to find a provider go to the Rome Foundation Gastropsych website: theromefoundation.org/ rome-gastropsych.

For information on the rationale and types of brain-gut behavioral treatments (BGBT) that can be used, see the video: romedross.video/Q_ AGIPsychology.

There are several considerations regarding whether or when a patient might benefit from a BGBT. First, the patient should have a diagnosis such as a DGBI or Inflammatory Bowel Disease where the data supports the benefit of such treatment (although, empirically, patients with most GI disorders might benefit). Next, patients should be open to making

behavioral changes to alleviate their symptoms. Finally, it helps if the patient can connect their thoughts and feelings to their symptoms.

Patients who have a personality disorder or who lack insight or resist the concept of a brain-gut disorder may not benefit. The GI provider then needs to explain the rationale for the referral. I find it helpful to explain the brain-gut axis (see response in the next question). I indicate that emotional distress or maladaptive coping that occurs in response to the illness (rather than the emotional state causing the symptoms) will respond to BGBT leading to emotional and symptomatic benefits. I also indicate that BGBT is safe and has long-lasting benefits that extend over months to years, even after completing treatment. To see how patients can understand the rationale for CBT or hypnosis, go to the video: romedross. video/KinsingerCBT.

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Q

How do you describe the pathophysiology, natural history, and treatment options for DGBIs in a way that patients can understand?

First, I might engage the patient in a dialogue about their beliefs about what they have and what they have learned from media, family, friends, and providers. Frequently I hear that patients sense that others feel their problem is psychiatric or that nothing has been found. That provides a segue for me to clarify that their symptoms are real but not explained by structural findings like with IBD. I tell them their diagnosis with confidence and show the Rome Criteria to validate it. Then I explain that DGBI occurs because of dysregulation of the brain-gut axis, which can produce pain, and other GI symptoms even without endoscopic or histopathologic findings.

Here is a video: romedross. video/3b8jcVz explaining the brain-gut axis. This information can be downloaded as a product card romedross.video/B-GAxisCard to demonstrate or give to patients. Then, I discuss treatments available to reset these dysregulated systems. There are peripherally acting treatments

like diet, antibiotics, and motility agents for symptoms like bloating, diarrhea or constipation. There are also central neuromodulators and BGBT (see above) for symptoms like pain, nausea and vomiting, and emotional distress resulting from DGBI.

Q

What is your approach to patients who continue to obtain multiple medical opinions after your encounter, or who act against your medical advice?

For example, if a patient goes to another facility and starts a medication or has a surgery you previously recommended against?

My practice receives many patients also treated by other gastroenterologists, psychiatrists, and psychologists, so routinely I will communicate with other treating providers to be sure we are "on the same page." Usually, I send them a copy of my evaluation and plan of care and invite them to email or call if they have questions or concerns. When I believe there may be differing views on the management, I set up a call to discuss any differences to give my perspective and hopefully reach a consensus. This can occur with psychiatrists who co-

“Over the last 5 years, I have collaborated with Johannah Ruddy to cofacilitate educational programs. Our latest interest is to publish books to help providers and patients learn communication skills and establish patient-centered collaborative care.” ­—Dr. Douglas Drossman 34 | GI.ORG/ACGMAGAZINE

manage the patient and may use different central neuromodulators.

Psychiatrists are not always familiar with how gastroenterologists use central neuromodulators for GI symptoms. I will also set up a call with gastroenterologists or surgeons who may be planning an interventional procedure that I believe may be better managed through pharmacological treatments or a "watch and wait" and re-evaluate approach.

I have occasionally had patients who go to unscrupulous providers who charge them high fees to use useless or potentially harmful products. In that situation, I inform the patient they need to stop seeing them. I cannot continue their care if they see providers who prescribe potentially harmful treatments.

See this video of a patient seeing providers who use illogical diagnostic methods and ineffective and possibly harmful treatments: romedross.video/ Comm1015BadDiagnosis.

Q

There is a very active young community on social media (Instagram, TikTok) of patients (primarily young women) with digestive symptoms who share their diagnoses, work ups, and home remedies. Some of these viral trends are evidence-based and others less so (such as the chia seed internal shower trend on TikTok). How do you handle patient messages/questions about using these trends in place of or in conjunction with traditional medical therapies?

A patient gave me a coffee mug that says: "Don't confuse my medical degree with your Google search."

Unfortunately, the healthcare field is competing with Google searches and social media, where anyone who chooses to post treatment may do so.

The only quality control for patients who adopt these recommendations is their provider. I feel obligated to ask my patients (and this is not often done) what treatments they use that are recommended by social media, or friends and family. Once I have this information, I give my best judgment.

Using the ingestion of chia seeds

"Unfortunately, the healthcare field is competing with Google searches and social media, where anyone who chooses to post treatment may do so. The only quality control for patients who adopt these recommendations is their provider.” ­—Dr. Douglas Drossman

as an example, I might say that the promotors say that the benefit is from their antioxidants and fiber but for patients with DGBI it may cause bloating and gaseousness. I suggest these products are also in other, more traditional products. Because the seeds absorb so much water, they may cause side effects, even a bowel obstruction in larger quantities.

Q

How do you set realistic expectations for patients on how much improvement they should expect in their symptoms, and the timeline for that improvement? And how do you communicate those expectations to patients so they are not frustrated (and send messages frequently) while waiting for their response to therapy?

Many patients, even with years of symptoms, may go to a new provider with the belief that they will get rapid and substantial relief with proper treatment. Especially with a chronic GI disorder like DGBI, setting treatment expectations on the first visit is vital. I always ask, "What are your expectations about what we can do?"

By saying "we" I am clarifying that the patient and provider collaborate.

That helps to offset the patient saying weeks or months later, "I'm not any better. What will you do for me now?" I can then readdress what we initially decided to do and review other options for them to select. I will also address their response to this question. So if they say, "I want you to fix me" or "I want to be pain-free," I will say, "This may take time because the longer the symptoms are present, the longer it takes to respond. What if we could get you 25% better in 6 months?" In this way, I am indicating the possibility of some relief. It's then essential to say, "We can't always predict how fast improvement will occur but what's important is that I'm here to work with you whatever the outcome; there are always other treatment options." So I'm promising to work with them on the process of care rather than a timeframe for improvement.

When treating chronic abdominal

pain with a central neuromodulator, I will also mention that it may take 6 to 8 weeks to get a response. If they benefit, we will keep them on the neuromodulator for 6 to 12 months to induce remission. Then when they are better we may be able to taper them off the medication.

Q

You have emphasized in your teaching the importance of communication skills to improve the patient-provider relationship to optimize the treatment benefit. Can you tell us how you developed this perspective, why you think it's important, and what you are doing now with this work?

Before I went into gastroenterology, I was fortunate to have been trained in psychiatry and biopsychosocial medicine by my mentor George Engel, MD. He was an internist and psychiatrist who originally coined the term "Biopsychosocial Model."

I have practiced, investigated, and taught this model throughout my career. It is intrinsic to obtain psychosocial and medical information and integrate it via effective communication skills. Dr. Engel

was a master communicator. Later my work as a faculty facilitator with the Academy of Communication in Health Care (ACH) honed my skills in training others on communication skills and introduced me to the importance of patient-centered care. I made it an integral part of all my work within gastroenterology. I gave lectures and workshops and over the last two decades, this work has become more recognized within gastroenterology.

I created a "Center for the Education and Practice of Biopsychosocial Care (DrossmanCare)," and I collaborated with the Rome Foundation to develop various educational programs.

See theromefoundation.org/ programs-projects/rome-foundationcommunication-program.

I have produced workshops, seminars, research studies, one-on-one training, educational videos, and Train the Trainer programs of over 30 key opinion leaders in the field on how to teach others these effective skills. Our Rome Working Team Report published in Gastroenterology last year includes

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“...[S]etting treatment expectations on the first visit is vital. I always ask, 'What are your expectations about what we can do?' By saying 'we' I am clarifying that the patient and provider collaborate.” ­—Dr. Douglas Drossman

Ten Questions for Ms. Ruddy from ACG MAGAZINE

Q

Please share details of your career trajectory and your current role as COO and Executive Director of the Rome Foundation.

How did you reach this point in your professional journey?

an evidence-based review to show the importance of effective communication skills on the outcome. It increases patient and provider satisfaction, improves symptoms, reduces psychological distress, improves treatment adherence, and reduces burnout, unnecessary tests and health care costs.

Over the last 5 years, I have collaborated with Johannah Ruddy, also featured in this magazine, to co-facilitate educational programs.

Our latest interest is to publish books to help providers and patients learn communication skills and establish patient-centered collaborative care.

In the first book, "Gut Feelings: Disorders of Gut-Brain Interaction and the Patient-Doctor Relationship" (romedross.video/ GutFeelingsWebsite), we review the underlying concept of the biopsychosocial model and braingut interactions. We then provide information on the pathophysiology, diagnosis, and treatment of the DGBIs

36 | GI.ORG/ACGMAGAZINE

in an easy-to-read format. Following this, we focus on communication skills and techniques for patients and providers.

Johannah tells the story of her medical illness, the poor care she received and the stigmatization she experienced. Then she discusses the insights she learned from the collaborative care of her illness, which led her to become a skilled patient advocate.

The second book, "Gut Feelings: The Patient's Story" (romedross.video/ patient-story), includes narratives from eight patients (including Johannah) about their complex DGBI, and the factors that helped them improve or adapt to their illness. Johannah and I are working on a third book: "Gut Feelings: Doctors Achieving Patient-Centered Care" where 12 key opinion leaders in DGBI provide perspective on their work and their impact on the field. This book will help many others choosing to work in Neurogastroenterology. Please see Johannah's Q&A for further information on our collaboration and our work on the second book.

I have 23 years of experience in executive leadership positions for health-related non-profits at the state and national levels. My previous roles included Executive Director for the American Heart Association, and for the Muscular Dystrophy Association. I was the State Director of the American Academy of Pediatrics for New Mexico for over a decade. I have a BS in History and an MEd in Educational Leadership, and I have been active in patient advocacy, education, and healthcare provider support for most of my career.

My introduction to the Rome Foundation was serendipitous. In early 2017, my family and I moved from Albuquerque, NM, to Raleigh, NC. This was a big move for us and meant that I was starting over in my career. I recall taking a preliminary call about the new position from a quiet aisle full of riding lawnmowers at the Home Depot, but I was anxious to find a job! I had yet to learn what Rome Foundation and "functional GI disorders" were, but after speaking with Dr. Drossman and other board members further into the vetting process, I knew I was well prepared for this role and felt enthusiastic about taking it. Little did I know that this new association would also positively impact my life and health.

As I approach my sixth anniversary with Rome Foundation, I am proud to have evolved into the new COO and Executive Director role in 2022.

Working alongside Dr. Jan Tack, now President and Board Chair, and Dr. Drossman, CEO, I am responsible for most of the Foundation's operational aspects. Rome Foundation has evolved tremendously in the past six years,

adding to our accreditated clinical education, we now have a vibrant research institute (Rome Foundation Research Institute), and we address gaps in the field by creating the Rome GI Psych Section, the Rome Pediatric GI Section, the Rome/Drossman Care Communication and Patient-Centered Care Section and the new Rome Food and Diet Section. We are also building our new Rome Partners Program, designed to increase awareness of neurogastroenterology to primary care residents and GI fellows and provide collaboration and mentoring opportunities to build up the pipeline of providers skilled at treating patients with Disorders of Gut-Brain Interactions. This has required us to expand our leadership in this manner. I am honored to take over the day-today management of Rome and our team, and I look forward to continuing to lead in this field.

“Patients need evidence-based, scientific information about their condition to be empowered to participate in their care. Good, clear education must begin in the clinical encounter, face to face.” ­—Johannah Ruddy

Q

Your professional life is deeply grounded in your personal experience as a patient with a chronic GI condition; what are some of the lessons and insights from this important confluence in your life's work?

Isn't it great when your personal life and professional life align? Most readers of our book, "Gut Feelings: Disorders of Gut-Brain Interaction and the Patient-Provider Relationship," or those who read my illness journey published in Gastroenterology in 2018 know that I suffered from debilitating IBS symptoms for over ten years after an acute infection that hospitalized me for several days. Despite seeing both primary care and gastroenterology providers, I was told that my testing was normal and that I should use OTC treatments. I did that for many years but found no benefit and worsening symptoms.

Over time, I lost significant weight, struggled with anemia and other nutritional deficiencies, and maintained an overly restricted diet to treat my worsening symptoms.

I struggled with symptom-based anxieties and altered my life around my illness, missing a tremendous

amount of time with my children and husband and working as hard as possible to keep up with my job and life responsibilities. I recall visiting a new healthcare provider with severe pain about six years into my illness who told me that, as a woman, I may exaggerate my symptoms a bit, as many women could do. He felt that if I were as ill as I claimed, something would be evident in my blood work or some other testing. I left crying, feeling defeated, stigmatized, and hopeless. After that encounter, I stopped seeking health care and thought this would be my life from now on, mourning the life I had left behind when I first became ill.

After beginning to work with Rome in 2017 and ten years after the onset of these symptoms, I saw Dr. Drossman as my provider. He diagnosed me with post-infection IBS and offered validation, support, and management options. It was life-altering, and I now have my life back. I still have IBS, but I am 90% better and 100% in control of how I manage my flare-ups when they do occur. I credit the medications and the therapy of being heard, understood, and receiving empathy

and support from my healthcare provider. I also credit the education I received about why this occurred, the role of stress on health and illness, and my role in managing the illness, both physically and emotionally.

Since then, I can look back and see things I did not do correctly in my selfadvocacy and communication with my former healthcare providers that contributed to my negative clinical experiences. I have seen patients who feel timid and embarrassed about communicating their bowel habits and pain issues. Some of this is generational or even cultural, believing the physician to be the revered expert and not feeling they can ask questions or be forthcoming about the impact of the illness on their life. In my work as a patient advocate, I encourage the patients I work with to see the relationship with their physician as a partnership. In a partnership, both patient and provider are honest, working together to achieve desired outcomes, and share in the decisionmaking around testing and treatments.

This type of relationship takes time

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“Every patient I know has felt stigma to some degree or another. We are learning to understand why one patient chooses to believe the stigma and fall prey to the maladaptive behaviors around it, or if they choose to fight against it and redefine the narrative.” ­—Johannah Ruddy

to build trust but will improve clinical outcomes and patient satisfaction, improve physician satisfaction, and reduce burnout.

I also teach patients that IBS is a multi-factorial, heterogeneous, chronic condition. No magic pill exists to treat it; patients respond differently to current management options. Because of this, it is vital that patients are given scientific education about their condition and provided the rationale for a fully integrated management approach – including dietary, behavioral, and CAM therapies. It is my experience that patients desire scientific education about their illness, not a watered-down brochure that provides limited information and no data. More information about the integrated care process that addresses a fully biopsychosocial approach will improve patients' ability to manage their expectations for overall treatment response and their understanding of their role in the management process.

My position within the Rome Foundation and the GI community is very personal to me. I live with IBS every day. In previous professional

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roles, I advocated and taught about conditions and situations to which I had no personal connection. This work is different, and that link gives a level of validation to my education and advocacy work.

Q

You are a doctoral candidate in Health Science with a focus on Population Health. How does your research and writing intersect with your role as a patient advocate and your work for the Rome Foundation?

Growing up in the early '80s in a multigenerational, conservative household, post-secondary education was not accessible or acceptable to the women in my family. However, I always thought I would be capable of anything if given the educational opportunities that others around me had. That is why I defied my family's standards and went to college, achieving my master's degree in education. Now, in my mid-40s, I am rediscovering what impact I want to have on the world and have launched into a doctorate degree. Improving population health is not a simple concept and relates to my work in GI. It ultimately requires dismantling systems that have historically prevented access to quality health care

and education, healthy foods, safe housing, and jobs with incomes that raise people out of poverty.

Approaching these issues from a public health aspect, examining the social determinants of health that drive our decision-making, behaviors, and ultimately our health, is very important to me. My experiences as a woman with IBS and other chronic health conditions have also given me firsthand knowledge of genderbased discrimination in health care and the stigma attached to chronic conditions like IBS and chronic pain.

That is why I have made this topic the area of research and writing. I also raised a child who needed over a dozen reconstructive orthopedic surgeries since birth, so I have intimate experience with access to quality care, dealing with constant insurance denials for necessary care, and cultural stigmas driving decision-making and medical options. I harness my experiences into my research and look forward to addressing the systemic issues impacting patients daily in meaningful ways.

Q

You have a unique collaborative relationship with Dr. Drossman; what is your working partnership like and what are the most meaningful or formative lessons have you learned from him? What is he like as a mentor and a boss?

Given Dr. Drossman's contributions to gastroenterology and psychiatry, it is no surprise that he can be intimidating for many new to the field. I fondly remember my first encounter with him in my interview, and within 15 minutes, I felt as if I had known him my entire life. He was impressive in his knowledge, expertise, and experiences, which were overwhelming. However, his enthusiasm and passion for the work and the Rome Foundation were infectious. I found myself excited and motivated, despite how daunting it all seemed at the time.

Early on, I, too, was intimidated working with him. I had intense "imposter syndrome" and was afraid to admit that I did not know

everything. I felt devastated when I made a mistake and was sure he was deciding early on that I was not the right person for the job. Thankfully that was not the case. I do not think he knew initially how to handle an empath who could be far more critical of herself than anyone else could ever be. Over the past six years, we have evolved into a very close working relationship, and I think of him more paternally. Certainly we have had our disagreements over the years, but we always find common ground, and with some honest conversation and a few jokes, we are back on track. We learn from each other daily and bring similar attitudes and work ethics to our collaboration. Some days we joke that we communicate telepathically!

Dr. Drossman has taught me the importance of investing in one's protégés and staff and allowing them room to grow. I recall a year or so into our working together, we were on a flight home from a meeting, and he asked me what I would love to do in the job that I still had not done. I replied that I wanted to educate patients, and we began to discuss patients with IBS. I shared my experiences with the health care system as a patient, parent, and woman and my perspective on how things could be different with improved patient communication and education.

This conversation sparked an intensive collaboration to build on his work in teaching communication skills to healthcare providers while bringing in the patient's perspective and voice.

This work has been significant to me, and I have incorporated much of it into my research.

I feel incredibly fortunate to have Dr. Drossman as a mentor. Not many people can say that! He is a brutal editor but has taught me the complexities of academic writing, encouraged my research and studies, and served as a sounding board for personal and professional issues. Of course, he is always up on the latest streaming shows or British crime series we bond over in our free time.

Q

Your new book with Dr. Drossman, "Gut Feelings: The Patient's Story", puts the spotlight on the importance of patients' personal narratives. Why are patient stories so powerful? Why did you and Dr. Drossman write the book and what are your hopes for your readers?

After completing our first book, "Gut Feelings: Disorders of Gut-Brain Interactions and the Patient-Provider Relationship," we began receiving messages from patients and providers who resonated with my illness narrative described in the book.

From a patient's perspective, it validated their illness experiences and gave them hope that they could find a proper diagnosis and treatment options.

We knew that patient narratives had value and meaning, so we asked patients with complex DGBI and other illnesses to provide their narratives in a guided format.

Many themes in these stories extend to most or all of the patients in this book, so we added an epilogue describing the commonalities we observed. This included an acute illness or infection precipitating these conditions, having high-achieving personalities and being personally

motivated to succeed, and a history of trauma (personal or medical). Finally, all the patients shared an innate drive to continue their search for proper care, despite the dismissiveness or stigmatization they experienced. In addition, for the patients who shared their stories, writing about their experiences provided a therapeutic quality that benefited their long-term care.

When providers read this new book, we hope they better understand the impact of the illness before and after diagnosis and management.

Many of these patients struggled for decades with worsening symptoms, misdiagnosis, and even detrimental management, but all eventually found their way to effective and appropriate care. For providers, understanding that you might have the answers for a patient struggling should provide a renewed sense of purpose. We hope patients come away with a sense of hope and a better understanding of how these conditions are diagnosed and managed.

“I harness my experiences into my research and look forward to addressing the systemic issues impacting patients daily in meaningful ways.” ­—Johannah Ruddy Cover Story | 39

// COVER STORY

“I feel strongly that patients who are armed with scientific and evidencebased education can bring information to their providers and start the conversation about treatments or diagnostics that might be beneficial and be empowered to participate in their own care.” ­—Johannah Ruddy

checklist. Some providers may think that a narrative history takes up too much time for a 15-20 minute clinical encounter. However, the studies show that patients will speak uninterrupted for only 3-4 minutes and provide clues and information that never could have been gathered through rapid closedended questions. Optimal patientcentered care occurs by allowing the patient to tell their story in their own words and with guided facilitation from the provider.

Q

Your work with Dr. Drossman puts the spotlight squarely on the physician-patient relationship and "patient-centered collaborative care."

Why this is such a powerful lens to approach the care of patients with DGBI?

Q

You are an expert on the impact of communications skills on health care. From your perspective, what are the most important ways patients with DGBI and other GI disorders can take responsibility in their care?

Our early life experiences and cultural or religious backgrounds often shape our communication abilities, behaviors, and attitudes. These factors can influence our communication styles as adults, sometimes without us even realizing it. Emotions can also impact our communication, leading us to focus solely on our intent without considering how we deliver our message. Patients may have difficulty communicating their symptoms and feelings in a clinical setting due to distractions such as pain or discomfort. Compund that with other factors that can include limited training of providers about DGBI, adhering to a dualistic or doctor-centered model rather than biopsychosocial model of care and time constraints, you are undoubtedly going to experience some miscommunication!

I encourage patients to enter a

40 | GI.ORG/ACGMAGAZINE

clinical visit with realistic expectations and, in particular, to understand that chronic illness does not go away overnight. I also encourage patients to "ditch the shame" they may feel about their condition. Their provider needs to hear everything they may consider embarrassing to get a clear picture of what testing might be warranted to lead to a diagnosis or treatment, and to understand the true impact of the disorder on their life. Many patients find it helpful to bring a written list of questions, medications, doses, a brief diary when symptoms are at their worst, and even a trusted friend or family member as support.

Dr. Drossman and I love to promote the idea of narrative history taking in the clinical encounter. This type of history gathering can unveil information that will guide the diagnostic process and ultimately save time while improving patient and provider satisfaction. These disorders are multi-factorial and must be approached from a biopsychosocial model.

That involves considering not only the physical symptoms (chronicity, duration, onset, red flags, etc.), but also the patients' understanding of their illness, and their emotional and psychological well-being.

This is more than using a symptom-based

Patient-centered care began in 2001 with the National Academy of Medicine's landmark report on health care, “Crossing the Quality Chasm: A New Health System for the 21st Century.” Before that, however, in 1988, the Picker Commonwealth Program for Patient-Centered Care conducted a national qualitative research study to identify which elements of care were most valued by patients. Patientcenteredness was defined as: "Health care that establishes a partnership among practitioners, patients, and their families…to ensure that decisions respect patients' wants, needs, and preferences and that patients have the education and support they need to make decisions and participate in their own care." This comes as no surprise as this is what any patient would still want in their health care. The issue is that patient-centered, collaborative care is typically not what patients receive when seeking health care today. Sadly, the burdens of the health care system at large, added stressors on providers' time, and additional administrative tasks have eroded this model of care.

Dr. Drossman and I have been teaching gastroenterologists and other providers that this type of patient care can be provided, despite the limitations and burdens of the system.

Providing patient-centered care while

working within the current system of EHR and other requirements does not require any more time and will save time in the end because you will have more satisfied patients who do not need to see you as often.

How do we make it a reality?

1) Patients need evidence-based, scientific information about their condition to be empowered to participate in their care. Good, clear education must begin in the clinical encounter, face to face. Some providers may assume that what they enter into the discharge notes is sufficient to provide the diagnosis and management education. This is not enough. If the patient does not hear it firsthand in the clinical encounter, being allowed to ask questions about things they do not understand, they will not remember it, leading to a diminished quality of care and the declining clinical outcomes.

The patient will leave frustrated, be convinced the provider is wrong, and seek additional care elsewhere.

2) The provider and the patient must work as an equal partnership. This allows the patient to feel empowered to ask questions, participate in the decision-making around testing and management options, and feel comfortable communicating when things might change. This also alleviates the burden of responsibility solely from the provider to one that is mutually beneficial, with each person sharing the responsibility for the management process. When a management option does not work in a shared decision-making model, the patient is not looking to the provider to "fix" it but collaborating in the discussion about what to do next. This model improves patient and provider satisfaction and reduces physician burnout.

Q

One of the topics you tackle in this latest book with Dr. Drossman is stigmatization due to lack of knowledge of DBGI. What strategies are essential for patients to address any stigmas they may perceive?

Stigma is a problem in chronic health conditions, especially with "functional"

disorders where symptoms exist without the structural abnormalities to explain them. That is why the Rome Foundation changed the name from “functional” to Disorders of Gut-Brain Interaction, which better describes their pathophysiology and legitimatizes it for patients. We can trace the beginnings of stigma back to the 17th century when Descartes’ philosophy birthed the biomedical model with the separation of the mind from the body.

When we look at illness through the lens of the biomedical model, we cannot assess the impact of symptoms on the whole person. We are are blind to other issues that might be playing a role in the generation of symptoms, such as genetics, previous life experiences, previous infection, trauma, and other factors. This sets the stage for us to dismiss symptoms without a structural cause as feigned or psychological and dismiss the patient without any answers or help. Stigma highly impacts patients' behaviors, attitudes, and overall clinical outcomes.

Every patient I know has felt stigma to some degree or another. We are learning to understand why one patient chooses to believe the stigma and fall prey to the maladaptive behaviors around it, or if they choose to fight against it and redefine the narrative. The latter approach is more adaptive as the patient can then appropriately find a health care provider, friends, and others who will provide empathy, validation, and support.

The most effective way to reduce stigma is to provide empathy, not sympathy. Providers should not say to a patient with DGBI, based on negative diagnostic testing, "at least you don't have XYZ." A negative diagnostic workup does not help the patient suffering from severe symptoms as it provides no solution and can be delegitimizing. Patients need to be given knowledge as to why they have their symptoms, wrapped up in empathy.

For example, "The good news is that all of your testing came back in normal ranges, so we know that XYZ does not cause your symptoms. Your symptoms are better explained by a dysregulation of the braingut axis which is……. However, I know how debilitating and impactful these symptoms have been on your life and how much you have been suffering. You meet the criteria for irritable bowel syndrome, and that is good news because now we can move to

treatment options and work together on a plan to get you feeling better.”

Statements that provide empathy, validation and a clear diagnosis help move collaboratively towards management, reduce stigma, and build the connection for an effective patient-provider relationship.

Q

In light of your own health history, you have a unique perspective on the journey for patients with DGBI. For those who may be feeling frustrated or hopeless, what encouragement and advice can you offer and what recommendations do you have to make the most of their relationships with their clinicians?

Sadly, most patients I hear from have stories similar to mine, with decades of worsening symptoms, no diagnosis or management, and feeling hopeless.

We know that DGBI makes up 50% of a gastroenterologist practice and 70% of GI patients seen in primary care practice, so why are so few providers confident caring for these patients, and why are patients left struggling to find good care?

Over the last several decades, there has been a decline in patient and clinician satisfaction with clinical care and ultimately increased health care costs. We find this most often within patients with disorders of gutbrain interaction (DGBI). The reasons include: clinicians who are not well trained to diagnose these disorders using gold standards such as the Rome Criteria, and instead order tests to “rule out disease,” and third-party payers who readily reimburse for procedures over face-to-face patient care.

The good news is that through continued education from leaders in the field of Neurogastroenterology, as well as through continued research efforts to improve the diagnostic and management process, patients with IBS or other DGBI have more options than ever before to find good treatment for their symptoms and regain an improved quality of life. We are now understanding the critical role that diet and behavioral health can have in symptom control. Patients are

Cover Story | 41

seeing access to hybrid virtual health specialists through digital platforms who are providing expanded access to quality GI care. The emerging market of digital therapeutics that are FDA cleared for IBS offering gutdirected hypnotherapy and cognitive behavioral therapy, that we know can benefit many patients with DGBI, is also meeting the need of patients who lack access to health psychologists trained in GI. Expanded access to evidence-based trained providers, gastroenterologists, GI dietitians, GItrained health psychologists, and even CAM therapy providers, is changing the way patients can access quality medical care and will reduce health care costs overall in time. There are so many good tools in the symptom management toolbox for patients to take advantage of and I am confident that the field will continue to evolve, advancing the science of how we diagnose and manage IBS. An area that I think will be highly impactful is changing the reimbursement model to favor the therapeutic aspects of face-toface time with patients in a clinical visit over performing unneeded

procedures. This would provide providers appropriate compensation to spend time with patients to build the trust needed to care for this patient population. The evolution and early adoption of valuebased care over fee-for-service model, which promises healthier patients, reduced costs, and a better understanding between providers and patients, will dramatically influence patient care in the coming years.

We will see how this influences long-term outcomes for patients with DGBI. The work that Rome Foundation, ACG, GIOnDEMAND/Gastro Girl, and many others are doing to provide education and resources on these conditions is also critical for providers and for patients alike. I feel strongly that patients who are armed with scientific and evidencebased education can bring information to their providers and start the conversation about treatments or diagnostics that might be beneficial and be empowered to participate in their own care. My platform, which I started three years ago with friends and colleagues Jeffrey Roberts, MEd, and Kate Scarlata, MPH, RD, called “Tuesday Night IBS,” was also born from the desire to fill the gap need for evidence-based education in a variety of formats geared to both patients and

providers around IBS and associated disorders. We now offer monthly topical webinars led by the leading key opinion leaders in the field, live Twitter chats, and a growing podcast to reach as many audiences as possible. We have seen tremendous growth and patients reporting feeling validated and provided with new information that is improving their communication with their providers around management options that they were unaware of previously.

Finally, the work Dr. Drossman and I have been doing to teach effective communication skills and train the next generation of neurogastroenterologists to continue this work is vital to patient care for the next generation.

Our curriculum of programming, our video series, and our books all provide support for providers and education and hope to patients. We have heard from patients who purchased a copy of our books and brought them to their providers to help start the conversation around diagnosis or management options that the provider may have not yet been aware of. This is collaborative care and how we improve health care, one provider and one patient at a time.

Book Review: Gut Feelings: The Patient's Story

by Douglas A. Drossman, MD, MACG and Johannah Ruddy, MEd | Reviewer: Scott L. Gabbard, MD, FACG, Chair, ACG Patient Care Committee

In Gut Feelings: The Patient’s Story, Ms. Johannah Ruddy and Dr. Douglas Drossman highlight the patient-provider relationship through 8 clinical vignettes – each one a Dr. Drossman patient who is struggling with a disorder of gut-brain interaction (DGBI). In each vignette, three perspectives are presented: 1) a point-of-view written by the patient, focusing on history of his/her illness, and often discussing pitfalls encountered with previous providers; 2) a discussion of the case by Dr. Drossman, describing his thought process for an individualized approach to management of the DGBI; and 3), an overview from Ms. Ruddy showcasing the dynamics of that specific patient-provider relationship.

This book is a wonderful resource for both patients and providers.

Each case offers numerous clinical pearls regarding the treatment of difficult DGBIs. I was greatly impressed by the overview provided

by Ms. Ruddy—reading her words lead to a reflection on my own practice, I hope to use some of these examples to improve my communication with patients. I suspect that most other practicing gastroenterology providers can apply teachings from this book to all

42 | GI.ORG/ACGMAGAZINE

patient interactions, not just those with DGBIs. Lastly, I also believe that this book would benefit many DGBI patients, especially those with “medical savvy,” who are seeking to improve communication with their providers. In fact, I have started to recommend this book to my own patients.

Highlights “Gut Feelings: Video The Patient’s Story”

WATCH: romedross.video/patient-story

Refreshing Summer Vibes Culinary Connections:

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

SUMMER IS A SEASON OF BRIGHTNESS & CHEER and along with summer comes long days, early mornings, summer picnics, late evenings and starry nights.

As we gather outdoors over food and laughter, let’s be intentional and be present with our family and friends. In this summer edition of #ACGfoodies, our gastroenterologists and a GI psychologist share their culinary journey. Let’s enjoy summer contributions from James H. Tabibian, MD, PhD, FACG; Rashmi Advani, MD; and Tiffany Taft, PsyD. —The #ACGFoodies (Vani, Alex, Christina)

ACG Perspectives | 43

// PERSPECTIVES

JAMES H. TABIBIAN, MD, PHD, FACG

Director of Endoscopy, Olive View-UCLA Medical Center Health Sciences Clinical Professor, David Geffen School of Medicine at UCLA

I was born in Texas but didn’t necessarily have the most typical Texan upbringing.

I'm a son of immigrants who coincidentally happened to meet in Spain; in the early 1970s my mother had gone there on vacation (from Syria, where she was born and worked as a French-Arabic interpreter [and also spoke Armenian and Turkish]), and the rest is history. In addition to language, international food, and the art and of preparing it were integral parts of my childhood…and remain so to this day.

For the first decade or so of my life, I had the opportunity to enjoy not only my mother's cooking, but also that of our Queen Bee—my maternal grandmother. To my mother's credit, her cooking was nearly as fabulous as my grandmother's, but the Queen Bee had a wider repertoire of menu

TABBOULEH SALAD  Ingredients:

• Two bunches of curly parsley (or 1:1 ratio of curly and Italian parsley) • Chopped Persian cucumbers (if unavailable, English or Armenian cucumbers) • Chopped tomatoes (Dr. Tabibian’s pick: cherry tomatoes) • Bulgur (cracked wheat), either #2 (medium coarseness, good for serving later) or #1 (fine, good for serving right away)

44 | GI.ORG/ACGMAGAZINE

items, all in her head...no notes, no books, and certainly no computers.

My father would also periodically cook, his specialty being Paella Valenciana (and many variations of it, at that). In addition, there was influence from our surroundings, in particular the sizable Mexican community around us in Texas and subsequently Central California (our having moved in the late 1980s). Because of this influence, my father became what I'd refer to as a "Grillmaster."

With this background in mind, some might say it'd be only proper for me to also become a chef extraordinaire.

For better or worse, I wouldn't consider myself one. But then again what is or is not "extraordinary" might be subjective. For me, cooking fundamentally needs to be efficient, both in terms of time and cost.

Whereas my grandmother seemed to be able to spend hours in the kitchen, this hasn't been a viable option for me,

• Olive oil (preferably extra virgin—Dr. Tabibian’s pick: Spanish, or any other that is high in Picual olive content) • Lemon juice (Dr. Tabibian’s pick: Eureka lemons, avoid prepackaged lemon juice) • Salt • Aleppo red pepper (for color and flavor, very mild) • Dried mint flakes, sparingly • Chopped green onions or a dash of garlic powder • Optional: sumac and other spices/garnishes

and I imagine it's not for many readers of the ACG MAGAZINE. But efficiency isn't enough; I also want food to be fresh, tasty, and generally simple, e.g., without what I'd consider an excess number of flavors and/or spices. Indeed, most of the foods I prepare have a short list of ingredients, something for which my wife sometimes pokes fun at me ("He's a salt, pepper, and maybe garlic kinda guy.") But this modus operandi does have its benefits – it means I grow many of the fruits and vegetables we eat, I meticulously select the most flavorful and fitting crops for our USDA plant hardiness zone (10A) and can more readily avail myself to help with other tasks.

As for what recipe to contribute to this issue of ACG MAGAZINE, I decided to go with something I've prepared quite a bit earlier this year.

During Lent, or the "Great Fast," I've historically found different ways to make lifestyle changes to observe

 Steps & Tips: 1. Chop parsley and place it in a large bowl. Many folks spend a long time on this, both to chop it down very finely as well as to remove the stems; I don't do either, in the spirit of efficiency and including more rather than less dietary fiber.

2. Chop and add the cucumbers and tomatoes; how much to add is a matter of preference.

3. The bulgur step merits critical consideration: if preparing the Tabbouleh quickly and serving it promptly, add #1 bulgur; if taking your time or planning to let the Tabbouleh sit for a bit prior to serving, #2 is probably better, as the grains are less likely to become soggy.

4. Next, olive oil and lemon iteratively—without fixed amounts or proportions, per se, if nothing else because not all olive oil or lemons taste the same. Approximately 3 Tbsp of each per two bunches of parsley is a good start, with fine tuning there from, per gusto.

5. Add salt, Aleppo pepper, or mint, to taste; experiment and see what tastes best.

6. Lastly, and analogous to various other salads, Tabbouleh isn't something that can sit around for prolonged periods; next-day (or older) Tabbouleh doesn't do the dish justice and is all too often what's available in stores and restaurants.

what many would consider a spiritually unique period of time. For instance, I've gone vegan for 40 days, made various non-food modifications and sacrifices, and so forth. This year, I wanted to emphasize plant-based and humble foods; this said, one of the foods I found myself preparing often was "Tabbouleh," a Middle Eastern (primarily Levantine) parsley-based salad.

Of note, for those who wish to pronounce the word properly, the emphasis is on the middle syllable, which should sound like the "oo" in "cool", and this follows a geminated "b" sound, as denoted by the double b). Interestingly, I learned to make tabbouleh from my father, as he became quite plant-based and health food oriented over the years.

Now, without further ado, here's my Tabbouleh recipe, which can be modified to fit dietary preferences and needs (and I'm here to help provide pointers...feel free to reach me via LinkedIn or on Twitter [@TabibianMDPhD], among other means). !

T'is all folks...to health and

RASHMI ADVANI, MD

Interventional Gastroenterology Fellow, Cedars Sinai Medical Center, Los Angeles, CA

“Ethically they had arrived at the conclusion that man's supremacy over lower animals meant not that the former should prey upon the latter, but that the higher should protect the lower, and that there should be mutual aid between the two as between man and man. They had also brought out the truth that man eats not for enjoyment but to live.”

—Mahatma Gandhi As a first-generation South Asian girl growing up in New York City, my diet has primarily been vegetarian.

My mother, being the amazing cook that she is, has been a vital influence on how my palate and food preference developed over time.

Her dishes perfectly exemplified the discipline of how one could obtain a wholesome diet using a plant-based

CHIA SEED PUDDING WITH MARKET FRUIT AND NUT

Preparation Time: 5 to 10 minutes  Ingredients: • 1/4 cup chia seeds • 1/2 cup coconut milk • 1/4 cup coconut cream • 2 Cara Cara oranges • Almonds (raw) • Strawberries, raspberries, blackberries • 1/2 apple • Passion fruit seeds • Honey (organic preferred)

approach. This influence is a large reason why I exclusively feel satiated by, and actively seek, dishes that are vegetarian and/or plant-forward.

My own personal journey with being more plant-forward is spiritual, practical, and logical. It has created the ability for me to feel more connected with my body, my health, and with the shared responsibility of maintaining the health of our world.

As a medical trainee with very limited time to sit down for meals, I am constantly looking for ways to incorporate dishes that are nutritious, satiating, and wholesome. I also enjoy making quick and easy meals in bulk that are healthy and can satisfy a craving while keeping me full during the day. The Chia Seed Pudding with Market Fruits and Nuts is a simple recipe that requires little to no prep the night before. What attracts me to this dish is the effortless way you can assimilate a variety of delicious plant-forward items that satisfy every taste bud and texture craving you could have.

S

 Steps: 1. Place chia seeds in a medium -sized bowl and add coconut milk.

2. Let sit for two minutes, then stir from the bottom up to catch seeds that stick to the bottom.

3. Add coconut cream and mix again in similar fashion.

4. After a few minutes, stir the mixt ure and refrigerate for a few hours to overnight.

5. In the morning (or 4+ hours later ) add sliced/peeled orange, berries of your choosing, apples, raw almonds, and passion fruit seeds to the mix (on top) 6. Drizzle organic honey at the end, as desired.

ACG Perspectives | 45

// PERSPECTIVES

TIFFANY TAFT, PSYD

Clinical Health Psychologist and Researcher; Founder and Practice Director, Oak Park Behavioral Medicine, LLC.,

Oak Park, IL

This recipe is from a cookbook I received from family living in Denver, Colorado, and is one of my absolute favorite soups that works in any season. Even better, it allows for modifications based on your tastes (I tend to use more curry), and if you have dietary limitations. I follow a wheat-free diet since wheat is one of the triggers for the eosinophilic esophagitis (EoE) I’ve been living with since around 2016. I find substituting gluten-free flour works just as well as regular flour. I’ve also lived with Crohn’s disease since 2002, and pureed vegetable soups are a great way to still get fiber and nutrients in a gut-friendly way. While I don’t live in

Colorado, one of my happiest places is out on a hiking trail and I try to work in time in nature as much as possible for self-care and mental well-being.

 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.

SOUP BUTTERNUT SQUASH AND APPLElect Rockies ion of Fresh Recipes from the Source: Colorado Classique:

A Col

 Ingredients: • 2 yellow onions, chopped te • 3 Tbsp butter (can substitu ter) but vegan ash • 2 ½ cups diced butternut squ le, app th Smi nny Gra • 1 large peeled and chopped • 3 Tbsp all-purpose flour (can d) substitute GF all-purpose blen to e mor (or der pow y curr • 1 ½ tsp e) your tast • Pinch of grated nutmeg • 3 cups vegetable broth • 1 cup milk al for • ½ cup heavy cream (option lts) resu richer • Zest and juice of 1 orange • Salt and pepper to taste

46 | GI.ORG/ACGMAGAZINE

 Steps: the onions 1. In a large saucepan, sauté in butter until soft. sauté 2. Add squash and apples and y. ~3 minutes, stirring occasionall meg; nut 3. Add flour, curry powder, and cook for 2 minutes. m, and orange 4. Add broth, milk, heavy crea zest and juice.

0 minutes or 5. Simmer uncovered for 15-2 er. until the vegetables are tend l. coo let and t hea from ove 6. Rem or food processor.

7. Puree the soup in a blender 8. Season with salt and pepper. , so it’s best to prep a day This soup improves with time in the refrigerator. Serve or two in advance and keep m if you’d like. hot with a dollop of sour crea

ACG International Training Grant to Massachusetts General Hospital

By Artemis Trikola, MD

Inspiration and perspective. These two pillars could best describe my six-month training period in Massachusetts General Hospital.

If ACG aims to inspire and give a new perspective to young physicians from other countries, the International GI Training Grant accomplishes this goal.

Gut-brain interaction is nowadays an established pathway that is commonly encountered between patients presenting with GI complaints. Understanding the diseases of gut-brain interaction and the mechanisms that drive symptoms is the cornerstone to effectively treat patients with these chronic diseases that have a substantial burden in their quality of life.

As motility and neurogastroenterology is not as well established in the Greek healthcare system as other subspecialties of gastroenterology, visiting the Center of Neurointestinal Health of Massachusetts General Hospital, served as an outstanding value for my country and my home institute.

ACG's International Training Grant was an invaluable opportunity to have a six-month training experience in a tertiary center which focuses in functional and gastrointestinal motility diseases. When I was honored to be selected for the ACG grant, a new perspective regarding clinical care was deployed and as this experience lacks in Greek daily practice, the training period at the Center of Neurointestinal Health of

MGH has proven to be a life-changing opportunity.

Outpatient clinic was based on a holistic approach to the patient.

Multidisciplinary meetings that included surgeons, radiologists, specific oriented GI psychologists and GI psychiatrists were organized on a weekly basis aiming to establish a therapeutic plan that aimed to improve patients' quality of life. Endoscopic procedures, carried out by the latest technological equipment, covered all the spectrum of gastroenterology and motility including advanced endoscopic techniques for both diagnostic (such as functional luminal imaging probe, Endoflip) and therapeutic purposes. All-important principles surrounding functional and motility disorders were transmitted via an interactive way, that made this sixmonth period a fruitful, unforgettable experience.

Apart from daily clinical activities, the Center organized educational activities and weekly clinical research meetings.

I had the privilege to be exposed to the basic principles of good clinical practice and to actively participate in the department's meetings and research activities. Moreover, I was encouraged to start clinical research projects on my own and guided by experienced

Dr. Trikola's 2022 ACG International Training Grant and experience at Massachussetts General Hospital proved to be a "life-changing opportunity."

mentors through every step.

I am grateful to all members of the Center of Neurointestinal Health for teaching, inspiring, guiding me and showing their hospitality: Dr. Braden Kuo; Dr. Kyle Staller; Dr. Christopher Vélez; Dr. Barbara Nath; Dr. Vlaicu A. Botoman; and Assistant Professor of Psychology Dr. Helen Burton Murray; as well as Dr. Hamed Khalili (IBD Unit) and Dr. Francis Scholz (Radiology Department) for their willingness to transmit their clinical experience with me; the fellows who were like family to me; and all the nurses in the motility lab. All this would not have been accomplished without the support of my mentors in Athens, Gerassimos Mantzaris, MD, and Nikos Viazis, MD. It was a thrilling experience that will definitely change my perspective of how medicine should be practiced. I thank ACG for this life-changing opportunity that broadened my horizons.

Artemis Trikola, MD, Evangelismos General Hospital of Athens

ACG Perspectives | 47

Reflections on the New Clinical Research Leadership Program

Participants in the new Clinical Research Leadership Program convened March 4, 2023 in Pentagon City, VA. Front Row (L to R): Marcia Cruz-Correa, MD, PhD, FACG; Brennan M. R. Spiegel, MD, MSHS, FACG; Neena S. Abraham, MD, MSc(Epid), MACG; Daniel J. Pambianco, MD, FACG; Aasma Shaukat, MD, MPH, FACG; Nicholas J. Shaheen, MD, MPH, MACG; Lisa L. Strate, MD, MPH, FACG. Back Row (L to R): Po-Hung (Victor) Chen, MD, FACG; Ravy K. Vajravelu, MD, MSCE; Elham Afghani, MD, MPH; Afrin Nahar Kamal, MD, MS; Guru Trikudanathan, MD; Leila Neshatian, MD, MSc; Christopher D. Vélez, MD; Jennifer L. Horsley-Silva, MD; Patricia Pringle Bloom, MD; Sarah Rosanna Lieber, MD, MSCR; Vu Quang Nguyen, MD.

This year the ACG Institute for Clinical Research & Education introduced a new signature program, the Clinical Research Leadership Program (CRLP). Offered as a program of the Institute’s Center for Leadership, Ethics & Equity, this unique interactive program provides funded GI clinician investigators with the skill set to start, grow, and maintain success as research leaders.

Course Directors Neena S. Abraham, MD, MSc (Epid), MACG (Director of the ACG Institute); Aasma Shaukat, MD, MPH, FACG; and Rena H. Yadlapati, MD, MSHS, FACG envisioned a daylong program covering practical topics on operations, strategy, and financial success, as well as core leadership skills. Faculty, who are themselves clinical investigator leaders, included Lisa L. Strate, MD, MPH, FACG; Brennan M. R. Spiegel, MD, MSHS, FACG; Marcia R. Cruz-Correa, MD, PhD; and Nicholas J. Shaheen, MD, MPH, MACG, former Director of the ACG Institute.

ACG MAGAZINE invited a few of the participants to share their experiences and take-aways:

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CHRISTOPHER D. VÉLEZ, MD

#1 Please give your title and institution, tell us about your research interests and the major projects you are working on now.

I am Associate Program Director, Advanced Fellowship in Functional and Gastrointestinal Motility Disorders and an attending gastroenterologist in the Center for Neurointestinal Health of Massachusetts General Hospital's Division of Gastroenterology. My research interests include: cystic fibrosis-related gastrointestinal disorders; digestive health in sexual and gender minority populations; and disordered gut-brain interaction management, including post-COVID DGBIs and patient perceptions of DGBI management. #2 What were the 2 or 3 most critical takeaways from this program and why did they resonate with you? a. When establishing a research career, you are going to not get every grant you apply for. A rejection is not a failure, perhaps the same application to a different foundation or funding agency will be successful.

b. While federal grants are enormously helpful, they are not the be-all/endall of successful research funding. If you apply in one Institute and you do not succeed, perhaps another Institute’s mission better fits with your proposal. c. Investing cognitively in a research team is just as important as securing funding to create it. #3 How will you apply the lessons/ insights to your work going forward?

We received practical tips on how to negotiate institutional support, making those first steps towards independent funding, and how to consider building a sustainable team. #4 This program had powerhouse faculty; what was the most surprising/intriguing advice you heard at CRLP? I was particularly astounded by Dr. Marcia Cruz-Correa’s efforts in clinical research in Puerto Rico.

Research in Puerto Rico is exceedingly difficult (due in large part to a lack of prioritization of federal efforts) which results in a brain-drain for

the mainland U.S. Anyone who can not only survive, but thrive, in this environment can offer some key tips to an early career clinical researcher.

She detailed a continued career and research evolution that remained true to her core principles. Often, we feel pressure to perform in research based on metrics—how many papers, how many grants, etc. We can lose sight of the bigger picture for the minutiae.

She showed that it is possible to advance your career in different directions, and what may seem like distraction ends up becoming an entirely new avenue to be explored. #5 What advice do you now have for younger clinical investigators, especially fellows-in-training, who might benefit from what you learned at CRLP as they consider their futures as clinical investigators?

Throughout medical school and training, I never thought that I could become a researcher. It seemed unattainable, it was for people who were smarter than me or who had “better” pedigrees. Now, I recognize how wrong I was. All it takes is finding that mentor and sponsor who believes in you, who helps you become the clinical researcher you want to be (versus becoming said mentor’s/ sponsor’s clone): this makes a world of difference. Find a mentor/sponsor who encourages you to explore your own clinical research passions, even if they may be outside current mainstream cookie-cutter research pathways. In my current faculty colleagues (and continued mentors/sponsors, like Dr. Braden Kuo and Dr. Kyle Staller), I have been able to begin the first steps in establishing a clinical research career as an independently funded investigator. While it sounds trite, I do

“Investing cognitively in a research team is just as important as securing funding to create it.” —Christopher D. Vélez, MD mean it—if I can do it, you can too! #6 Anything else to add—insights, gratitudes, “ah-ha” moments to share?

“Time is a commodity” and “prioritize yourself.” We as physicians often overextend ourselves as we wish to be helpful. This is not necessarily wrong, but, you need to recognize that that may come at a cost for one of your priorities. If you cannot ensure that you are fulfilled, it is hard to help others. This does not mean to not help others, not to collaborate with colleagues, to not to be someone’s sponsor or mentor—it means you need to be targeted in your efforts. By recognizing that time is a commodity and that you need to prioritize yourself, this means that you can sustainably impact the most people possible with your research career.

PATRICIA PRINGLE BLOOM, MD

#1 Please give your title and institution, tell us about your research interests and the major projects you are working on now.

I am an Assistant Professor and transplant hepatologist at the University of Michigan.

The overarching goal of my research is to improve the lives and care of patients with decompensated cirrhosis. In particular, I study the efficacy of microbiometargeted therapeutics to treat hepatic encephalopathy, as well as biomarkers of hepatic encephalopathy. I am conducting a trial of VE303, a living biotherapeutic, to treat hepatic encephalopathy. I am also doing two prospective studies, one to study speech as a biomarker of hepatic encephalopathy, and the other to investigate the role of mucosal bacteria and intestinal permeability in the pathogenesis

“It always surprises me how many failures very successful people have had. It was surprising and reassuring to hear that not every grant or manuscript comes easily, even for the most successful people in our field.”

—Patricia Pringle Bloom, MD

of hepatic encephalopathy. #2 What were the 2 or 3 most critical take-aways from this program and why did they resonate with you?

You always have time for the things you put first. After CRLP I did an audit of how I spend my time. I found myself spending a lot of my "high energy hours" early in the day accomplishing urgent but less important tasks that did not need as much creativity and brain power. I now block out at least 2 mornings per week to focus on ONLY my most important projects.

This is manuscript or grant writing tasks that will move my key projects forward. In just a short period of time, this re-allocation of time has made a huge impact. #3 How will you apply the lessons/ insights to your work going forward?

I have discovered that I am most motivated, creative, and clear-headed in the morning. I need to match that energy with the things that will be most important to advancing my career trajectory. #4 This program had powerhouse faculty; what was the most surprising/ intriguing advice you heard at CRLP? It always surprises me how many failures very successful people have had. It was surprising and reassuring to hear that not every grant or manuscript comes easily, even for the most successful people in our field. #5 What advice do you now have for younger clinical investigators, especially fellows-in-training, who might benefit from what you learned at CRLP as they consider their futures as clinical investigators?

Listen to your gut. If you find yourself spending more time on something, reflect on that. If you find yourself forcing yourself to do something, reflect on that. You only get one life. Try to align what you do professionally with the things that actually bring you joy.

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“Research is a marathon. Never stop learning from those around you, and continually write proposals, open trials, and write manuscripts in a steady fashion.” — Jennifer Horsley-Silva, MD

#6 Anything else to add – insights, gratitudes, “ah-ha” moments to share?

Another excellent insight I got from CRLP was about how to manage your research team. Team members have different strengths. Sometimes an underperforming team member may actually be someone who is currently performing tasks that don't match their strengths.

JENNIFER HORSLEY-SILVA, MD

#1 Please give your title and institution, tell us about your research interests and the major projects you are working on now.

I am Senior Associated Consultant in the Division of Gastroenterology at Mayo Clinic Arizona, Assistant Professor of Medicine, Assistant Program Director of the Advanced Esophageal Diseases Fellowship, Chair of Division Research Disease Oriented Group. My research interests are in eosinophilic esophagitis looking at testing alternatives to EGD with biopsies and genetic aspects of the disease. Current projects include looking at mucosal impedance and manometry in EoE, evaluating AI on biopsies, building a shared bio bank to answer research questions, and evaluating EoE patients in the tapestry study where we are trying to understand the impact of genetic testing in EoE. #2 What were the 2 or 3 most critical take-aways from this program and why did they resonate with you?

• Diversify your portfolio with studies but also funding streams to continue progress.

• Network both with colleagues and within industry. These connections will allow ideas to marinate and develop, will help you learn from others, and will identify opportunities.

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• Create a winning team and invest in your team’s personal and professional development. I thought it was insightful that others mastering research create a team with multiple experts. This could include an implementation scientist, psychologist, informatics experts, AND data managers—all team members that are separate from the usual coordinator or biostatistician.

These other professionals can help elevate the research you are performing, and the quality of the work being performed. #3 How will you apply the lessons/ insights to your work going forward?

I plan to layer my team with more diversity, meaning both low and senior staff, other experts, and mentors.

Networking takes time, and I plan to continue to meet and learn from others conducting research. I plan to outline my trajectory in a more meaningful way.

Caption: Seen on social media: these photos were posted by participants and faculty.

#4 This program had powerhouse faculty; what was the most surprising/intriguing advice you heard at CRLP? Maybe most surprising was the advice to rest and let go of the unicorn of “worklife balance.” It’s so important, but most advice would focus on “getting jobs done” rather than taking care of mental health and relationships. It’s something we know deep down inside, but don’t hear often. #5 What advice do you now have for younger clinical investigators, especially fellows-in-training, who might benefit from what you learned at CRLP as they consider their futures as clinical investigators?

Research is a marathon. Never stop learning from those around you, and continually write proposals, open trials, and write manuscripts in a steady fashion. #6 Anything else to add – insights, gratitudes, “ah-ha” moments to share?

No Money = No Mission Protect your time! Time management is very important to actually advance in research. Don’t feel bad about delegating the unimportant and non-urgent tasks.

Master your calendar!

The Movement Toward Environmental Sustainability in GI Jill K. J. Gaidos, MD, FACG in Conversation with Rabia A. De Latour, MD and Swapna Gayam, MD, FACG

Dr. Jill Gaidos talks to Dr. Rabia de Latour, Assistant Professor at NYU Langone and Director of Endoscopy at Bellevue Hospital, and Dr. Swapna Gayam, Associate Professor at West Virginia University, on the movement toward environmental sustainability in GI.

Conversations with Women in GI JG: What got each of you interested in environmental sustainability as it relates to healthcare and GI endoscopy?

SG: For me, at home we had been doing a lot of things—recycling, reducing and composting. Also, I grew up in India where nothing went to waste, or you didn’t buy what you didn’t need. And one day I noticed at work one of our endoscopy nurses dumping everything into a trashcan and that appalled me. When I looked through that can there were a lot of things that could be recycled or were not even used. The amount of waste after every procedure and at the end of the day was shocking. That's what got me started. And around the same time, I came across a paper in Gastroenterology by Williams, Kao and Omary (Williams JA, Kao JY, Omary MB. How can individuals and the GI community reduce climate change. Gastroenterology 2020;158(1):14-7). It's a fantastic paper and there is a great editorial in response to the article by Kevin Skole at Penn Med. Those two articles are great for starters to know about our personal and professional carbon footprint. That is where it started for me.

“We started to gain momentum after a few 'low-hanging fruit' initiatives that actually saved money and lowered costs, and now I have a ton of support. And I have to say that the sustainability folks at my hospital have been amazing because I'm only helping their bottom line by enlisting clinicians to join their efforts.”

—Dr. Rabia de Latour

JG: I would also recommend reading your Red Section article from 2020 for further background information (Gayam S. Environmental Impact of Endoscopy: “Scope of the Problem”.

Am J Gastroenterol 2020;115:19311931). What about for you, Rabia?

RDL: I’ve always cared about sustainability and made an effort to be a good “citizen of the world,” but it wasn’t until my first child was born in 2017 that I really started to think about how our actions will impact future generations. I think what they're going to be the angriest about is our degree of waste, how we perpetuated practices that we inherited from previous generations without thorough consideration of the wellbeing of future generations. I want my children and future generations to have the same quality of life that I grew up with—a very happy, carefree childhood and adulthood. I started to think about things we could do at home. My husband actually trades energy, and he has been a great educator in terms of simple things like renewables, non-renewables, how are we going to transition to renewable energy. We are already doing a lot at home. We have minimized our waste, virtually eliminated single use products from our lives; we compost and we recycle. We were already doing everything we could within our household, and so I wanted to cast a larger net to have a bigger impact and I believed the best way to do that is in the workplace. As you know, we can rattle off 100 different statistics to you about how bad healthcare is for the environment as an industry, not only for the U.S. but also globally (for more information see Haddock R, de Latour R, Siau K et al. Climate Change and Gastroenterology: Planetary Primum Non Nocere and How Industry Must Help Am J Gastroenterol 2022;117:394400). So, I figured the best way to do this was through a very measured and directed approach on how to go about this. I started by meeting with the sustainability experts at our hospital. I don’t have any formal training in this; I’m just a concerned citizen. I learned as much as I could from them, and

ACG Perspectives | 51

then we formed a group together. Now we have a very large functioning group, blending sustainability experts and clinicians who would like to enact change. That’s basically how it started, and it’s expanded from there.

JG: Has this interest been supported by your hospitals and your GI sections or have there been some roadblocks?

RDL: At first, because I started this group a few years ago before sustainability was really en vogue within medicine, back in 2017 or 2018, the support wasn’t as robust as it is now.

We started to gain momentum after a few “low-hanging fruit” initiatives that actually saved money and lowered costs, and now I have a ton of support. And I have to say that the sustainability folks at my hospital have been amazing because I'm only helping their bottom line by enlisting clinicians to join their efforts; this has been a seamless marriage, so it’s really been nice for me.

SG: For me, it has not been a success at all.

I emailed a lot of hospital leaders; a few people did meet with me, but it’s just been roadblock after roadblock in my hospital.

That is when I decided to focus my efforts on the GI community and work with people who are more passionate about this. I’m not going to say the people at my hospital don’t want this. They might, but they have many other things to worry about too. From a hospital standpoint, even simple things like changing Styrofoam products in our cafeteria to something more sustainable was met with roadblocks. So, I have to say I have been very unsuccessful in my facility. There are a lot more things coming out of GI societies, so hopefully I can go back and show them the guidelines we came up with and then see what they say.

JG: Rabia was mentioning having a sustainability group at her hospital.

Does your hospital have a sustainability group as well, Swapna? Or are you starting from scratch?

SG: I am starting from scratch. There is a university sustainability office, but they are separate from Health Sciences and Medicine.

The university group doesn’t include the hospital in its initiatives because healthcare has always been “exempt” from such undertakings. I am now starting to form my own endoscopy unit sustainability team.

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“We don’t want people to think of this as another thing doctors have to keep track of, like quality indicators and RVUs. It’s a huge culture change and we want to start slowly with education, acknowledgement and awareness—and we are hoping GI societies will help us spread the message.”

—Dr. Swapna Gayam

JG: Has your interest and passion for sustainability lead to any additional leadership positions or a pivot in your career that you hadn’t anticipated?

RDL: I applied a lot of pressure. To start with, being a director of endoscopy at my hospital was really helpful because I am allowed to initiate pilots and programs within my unit.

This autonomy means that you can do things and show that they work. By establishing a system, showing that it works and saying that I want to take the same system and cast a wider net within the hospital system I was able to make some larger changes. I asked my hospital, Bellevue, to make my role official and I then became the Chief Sustainability Officer. I now have dedicated time to focus on this and maintain a heavy element of clinical duties, which is also my passion. This has been a significant change for me. It’s been a lot harder being someone who is now responsible for a hospital-wide initiative, including how to deal with different departments instead of your own closed unit where you know everybody, you know how it works, it’s a well-oiled machine.

That has been really a learning process for me, and it has been amazing. It has been a huge leadership opportunity that I asked for. I wanted this. I don’t think that it’s common for a clinician to get this role. I think there are about eight people in the United States who are MDs or APPs who are doing this type of work within sustainability, and I feel extremely blessed. I think the hospital was interested in this type of work and I am ecstatic that I get to be a part of it!

SG: For me, none. From my discussions with hospital administration, there was not enough interest or importance given to sustainability.

There are no leadership opportunities for sustainability at my hospital.

RDL: But it’s not from a lack of effort. Swapna is one of the most passionate people you will ever meet!

JG: With each of you serving as the ACG representatives on the GI Multi-Society Strategic Plan on Environmental Sustainability (Pohl H, de Latour R, Reuben A et al. GI Multisociety Strategic Plan on Environmental Sustainability. Am J Gastroenterol 2022;00:16), what are you hoping will change with the release of these guidelines?

SG: Our hope is that it really takes off. I think it’s basically a lack of awareness and acknowledgement about this issue that is preventing sustainability from taking off.

As doctors, we are not taught this in our training. Medical textbooks don’t include environmental sustainability or how we are harming the environment with our healthcare practices and negatively impacting human health. It’s that lack of awareness that we need to tackle first. That is where we are hoping that GI societies will help. Also, there is a big knowledge gap. We don’t have enough evidence-based data because we don’t have much research support in this area. Carbon footprinting of different processes and tools can help us understand the impact of gastroenterology and where we could do better. We need buy-in and support from GI societies to fund research and include this information in educational materials. Even after the strategic plan came out, we have a lot of roadblocks to pushing it forward because it’s a huge undertaking.

We don’t want people to think of this as another thing doctors have to keep track of, like quality indicators and RVUs. It’s a huge culture change and we want to start slowly with education, acknowledgement and awareness—and we are hoping GI societies will help us spread the message.

RDL: It has been a really wonderful opportunity to work and collaborate with likeminded individuals from different institutions across the U.S. and abroad.

It’s been a great group to work with. And, of course, it’s obviously a platform for more opportunities. You will see some of the members of our group at the podium regularly, talking about this important topic and it’s been great to just have them broadcast our message and make sure it gets out there. The opportunity is just about spreading the word. Any single human being I can get this message to, whether it’s through me or through Swapna or through anybody else, that is a blessing and gets us that much closer to the end goal which is trying to gift a planet to the next generation(s) that is better off, not worse off, than how we received it.

I just want this work to spread like wildfire, no matter who the messenger is. There is a quote from one of the Lancet articles that says that climate change is the biggest threat to global health at this point, and it is. It’s more than just water levels rising, it's the infections that are associated with that, the mass migration that happens with that, the associated political unrest, the mental health ramifications. It touches health in so many different ways and until we start to take it

seriously, which, unfortunately, humankind tends to wait until the 25th hour to do, we are playing with fire. We are all about preventative care; why are we not doing it here? So, for me, it’s about getting the word out any way we can because this is a time-sensitive issue. Plus, I have my hands full at my hospital (laughing).

“Once we all start talking about sustainability, it will eventually cause change because that is how change starts. When someone questions the status quo, that will eventually lead to a larger impact, hopefully an avalanche of change.”

—Dr. Rabia de Latour

JG: (Laughs) You don’t need any more to do, right? Spread the word and share the responsibility.

SG: For me, I want to help get the word out in the GI community so it will hopefully help me influence my hospital leaders. I am working backwards. Many healthcare workers don’t realize how much healthcare is contributing to climate change, which is the biggest public health challenge currently. This is negatively affecting the physical, social and mental health of millions of people. If healthcare were a country, it would be the fifth largest emitter of greenhouse gases. That is huge!

Medical education should include this content. We have a small environmental student group that I work with at West Virginia University. I started a two-week elective in climate change and healthcare for MS-4 students. Actually, I was inspired

by Emory University’s program. They have a four-week elective for medical students that includes lectures from experts in Canada and the U.S. There are many things that we do without thinking that we can change to help reduce waste and reduce resource use. I think the main motivation is going to be the financial impact. There are great studies out there to show that environmental sustainability is financial sustainability; it’s not the opposite. I think that is going to really help to start these initiatives. Relatability is another key aspect in getting our message out there.

JG: One of the things I want to highlight again is the lack of awareness. Once I started reading articles about environmental sustainability in healthcare, I started looking around and realized we don’t have any recycling in our endoscopy suites. I then started asking other colleagues and it is unclear to many of us what we use in endoscopy that is even recyclable.

RDL: You hit the nail on the head. We are trained, almost brainwashed, to follow the rules and follow what was done before

ACG Perspectives | 53

// PERSPECTIVES you; don’t be a disruptor. Don’t veer too far from the path. But things are changing. Having a non-traditional path on a bigger picture, but even on a smaller picture, we should ask more questions. Why don’t we use reusable gowns? Why do we need sterile gauze for every procedure? We're doing colonoscopy; why do they need to be sterile? It doesn’t make any sense.

The more questions you ask, the more likely you are to have an impact and make changes in your endoscopy unit.

It’s kind of like all of these whispers will eventually reach a scream, a fever pitch. It’s like Horton Hears a Who

by Dr. Seuss. I was reading that to my kids and I was like, “Huh. This is really representative.” Once we all start talking about sustainability, it will eventually cause change because that is how change starts. When someone questions the status quo, that will eventually lead to a larger impact, hopefully an avalanche of change. Ask questions in your endoscopy unit and someone else will be like, “Yeah, right, this does need to change. Why aren’t we doing this?”

SG: Where GI societies can really help is disseminating this information. Give us some visibility because unless we share this information, people won’t know. The first talk I did was for the Pennsylvania Gastroenterology Society and a lot of people came up to me afterwards and said, “I never thought about this.” Unless we talk about it, nobody will know how we can improve.

DDW this year is having two symposia on this topic; I hope we have in-person talks at ACG and AASLD meetings too where we can address private and academic GI’s thoughts and concerns.

RDL: Some of these interventions are so simple. This isn't rocket science. I’m not presenting some research from my lab of 20 years. Sometimes I'm

Jill K. J. Gaidos, MD, FACG Associate Professor, Yale School of Medicine; Director of Clinical Research for the Yale IBD Program

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presenting, sitting there thinking, “This is so simple. How is anyone interested in this simple idea?” In medicine, a lot of times, when there are big positive social movements or changes, we tend to be 10-20 years behind other sectors because we are focused on our primary goal, which is patient care. And that’s OK. But we need to play catch-up here. So, if we can spread that word, we are so happy to do it. So as simple or as common sensical as it may be, it’s important to still talk about it and spread the word.

JG: So, piggybacking on that, this does feel big. It feels too big for one person or one institution. Where is a good place to get started?

RDL: I wrote an ACG Toolbox article (“Going Green: Improving your Endoscopy Unit's Carbon Footprint”) that is available on gi.org. I include a number of simple steps to green your endoscopy unit.

I would recommend reading that to start. If you are like me and need some low-hanging fruit, something that is free and that may even save your hospital some money. They are very simple, straightforward, common-sense suggestions. If I just explain things simply to people, I think that’s going to be the biggest bang for your buck. ASGE is putting out a series as well, so there will be other resources available.

SG: I live in the heart of coal country, so I can’t start pushing for solar energy yet.

The low-hanging fruit for me would be to switch lights off when not needed. When I was doing my first project, I went to the hospital on a weekend to look at lights and calculate their energy use. There are lights that don’t even have switches; that means they are on 24/7. There is no way to turn them off. Switching all lights to LED and turning them off at night is a simple, yet very effective first step to save energy. I get roadblocks for suggesting we switch computers off at the end of the day because of updates that happen in the middle of the night. But those updates will happen in the morning when you switch

Swapna Gayam, MD, FACG Associate Professor at West Virginia University School of Medicine

the computers on. I am not an expert in waste segregation like Rabia, but there is no recycling in my hospital.

Waste segregation can help. Bundling procedures can help. I always tell my fellows to think about how a test is going to change patient management.

If it’s not going to change your management, then that is a low-value test. There are multiple things that we as gastroenterologists can do and change our mindset. There are some great papers that have been published in the last few years that I would recommend.

RESOURCES

Going Green: Improving your Endoscopy Unit's Carbon Footprint, Rabia de Latour, MD and Seth Gross, MD, FACG; ACG Practice Management Toolbox; November 2020. [bit. ly/ACG-PM-Toolbox-Green-Endo] Gayam S. Environmental Impact of Endoscopy: "Scope" of the Problem. Am J Gastroenterol. 2020 Dec;115(12):19311932. doi: 10.14309/ajg.0000000000001005. PMID: 33086225. [bit.ly/AJG-Enviro-Endo-Gayam] Sebastian, et al. Green endoscopy: British Society of Gastroenterology (BSG), Joint Accreditation Group (JAG) and Centre for Sustainable Health (CSH) joint consensus on practical measures for environmental sustainability in endoscopy. Gut. 2023 Jan;72(1):12-26. doi: 10.1136/ gutjnl-2022-328460. Epub 2022 Oct 13. PMID: 36229172; PMCID: PMC9763195.

Siau K., Hayee B, Gayam S. Endoscopy's Current Carbon Footprint Techniques and Innovations in Gastrointestinal Endoscopy. Volume 23, Issue 4, 2021.

Donnelly L. Green endoscopy: practical implementation.

Frontline Gastroenterol. 2022 Jun 10;13(e1):e7-e12. doi: 10.1136/flgastro-2022-102116. PMID: 35812035; PMCID: PMC9234726.

Clough J, Donnelly L, Leddin D, Hayee B. FGTwitter debate: green gastroenterology - are we nearly there yet?

Frontline Gastroenterol. 2022 Sep 16;14(2):158-161. doi: 10.1136/flgastro-2022-102301. PMID: 36818799; PMCID: PMC9933594.

Baddeley R, Aabakken L, Veitch A, Hayee B. Green Endoscopy: Counting the Carbon Cost of Our Practice.

Gastroenterology. 2022 May;162(6):1556-1560. doi: 10.1053/j.gastro.2022.01.057. Epub 2022 Feb 17. PMID: 35183550.

Maurice JB, Siau K, Sebastian S, Ahuja N, Wesley E, Stableforth W, Hayee B; Green Endoscopy Network.

Green endoscopy: a call for sustainability in the midst of COVID-19. Lancet Gastroenterol Hepatol. 2020 Jul;5(7):636-638. doi: 10.1016/S2468-1253(20)30157-6.

PMID: 32553141; PMCID: PMC7295492.

Leddin D, Macrae F. Climate Change: Implications for Gastrointestinal Health and Disease. J Clin Gastroenterol. 2020 May/Jun;54(5):393-397. doi: 10.1097/ MCG.0000000000001336. PMID: 32235149.

Setoguchi S, Leddin D, Metz G, Omary MB. Climate Change, Health, and Health Care Systems: A Global Perspective. Gastroenterology. 2022 May;162(6):15491555. doi: 10.1053/j.gastro.2022.02.037. Epub 2022 Mar 2.

PMID: 35247463.

Le NNT, Hernandez LV, Vakil N, Guda N, Patnode C, Jolliet O. Environmental and health outcomes of single-use versus reusable duodenoscopes. Gastrointest Endosc.

2022 Dec;96(6):1002-1008. doi: 10.1016/j.gie.2022.06.014.

Epub 2022 Jun 17. PMID: 35718068.

Pohl H. Single-use duodenoscopes: How concerned should we be about the environment? Gastrointest Endosc. 2022 Dec;96(6):1009-1011. doi: 10.1016/j. gie.2022.08.014. Epub 2022 Oct 15. PMID: 36253193.

Rabia A. de Latour, MD Director of Endoscopy and Chief Sustainability Officer at Bellevue Hospital; Assistant Professor of Medicine, NYU

Inside the

JOURNALS

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Volume XXX

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LIFESPAN OF GI orts edited by Case Rep rnal of orts edited by ine Jou Case Rep An Onl logy Fellows rnal of ine Jou gy & Hepato An Onl logy Fellows nterolo Gastroe gy & Hepato rolo nte troe Gas

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EDITORS: Jasmo

MS, FACG, and

Millie D. Long,

MD, MPH, FACG

IN THE SPOTLIGHT for The American Journal of Gastroenterology are new guidelines from ACG in partnership with AGA on Chronic Idiopathic Constipation (CIC). Dr. Lin Chang, for AGA, and Dr. William Chey, for ACG, were co-first authors on a systematic review of OTC and prescription therapies. The ACGAGA CIC guidelines are the first to offer evidence-based recommendations on the supplements senna and magnesium oxide.

Dr. Neil Sengupta and colleagues published updated ACG Clinical Guidelines on the Management of Patients with Acute Lower Gastrointestinal Bleeding that provide a framework for the management of a hospitalized patient.

In Clinical and Translational Gastroenterology, a new entry in the Clinician’s Toolbox “Understanding Our Tests” series examines hydrogen-methane breath testing to diagnose Small Intestinal Bacterial Overgrowth with insights from Dr. Aylin Tansel and Dr. David J. Levinthal.

Inside the Journals | 55

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

[ACG CASE REPORTS JOURNAL]

American Gastroenterological Association-American College of Gastroenterology Clinical Practice Guideline: Pharmacological Management of Chronic Idiopathic Constipation

Where Are We Now and Where Are We Going?

Lin Chang, MD, AGAF, FACG; William D. MD, Chey, AGAF, FACG; Aamer Imdad, MBBS, MPH; Christopher V. Almario, MD, MSHPM, FACG; Adil E. Bharucha, MD; Susan Diem, MD, MPH; Katarina B. Greer, MD, MS Epi; Brian Hanson, MD; Lucinda A. Harris, MD, FACG; Cynthia Ko, MD; M. Hassan Murad, MD; Amit Patel, MD, FACG; Eric D. Shah, MD, MBA, FACG; Anthony J. Lembo, MD, FACG; Shahnaz Sultan, MD, MHSc, FACG. The American Journal of Gastroenterology May 2023 DOI: 10.14309/ajg.0000000000002227

 Nonpharmacological therapies often represent the initial steps in management of Chronic Idiopathic Constipation (CIC) and may include dietary recommendations (such as increased fluid intake and increased dietary fiber) and behavioral changes (such as exercise).

Pharmacological treatment may include the use of over-the-counter or prescription medications, such as polyethylene glycol (PEG), secretagogues, or prokinetic agents. This joint evidence-based guideline from the American Gastroenterological Association and the American College of Gastroenterology aims to provide recommendations for the pharmacological management of CIC in adults.

Tomoki Sepokuya, MD & Nicholas McDonald, MD. ACG Case Reports Journal 10(5):p e00952, May 2023. | DOI: 10.14309/crj.0000000000000952

For the 10th anniversary of ACG Case Reports Journal, the Co-Editors-in-Chief reflect on the past, present, and future of the journal.  READ bit.ly/ACGCRJ-at-10

Successful Nonoperative Management of a Sigmoid Colon Perforation Caused by a Migrated Biliary Stent Eric Kwong, MD, PhD; Katherine Jones, MS; Steven Park, MD; Karl Kwok, MD. ACG Case Reports Journal 10(1):p e00972, January 2023. DOI: 10.14309/ crj.0000000000000972

 READ bit.ly/ACG-AGA-Chronic-Constipation-Guideline

ACG Guidelines: Management of Patients with Acute Lower Gastrointestinal Bleeding: An Updated ACG Guideline Neil Sengupta, MD; Joseph D. Feuerstein, MD; Vipul Jairath, MD, PhD; Amandeep K. Shergill, MD; Lisa L. Strate, MD, MPH; Robert J. Wong, MD, MS (GRADE Methodologist); David Wan, MD. The American Journal of Gastroenterology 118(2):p 208-231, February 2023. DOI: 10.14309/ajg.0000000000002130

 These guidelines provide an evidence-based framework for the management of a hospitalized patient with Lower GI Bleeding (LGIB). The authors include recommendations for the use of risk stratification tools, thresholds for red blood cell transfusion, reversal agents for patients on anticoagulants, diagnostic testing including colonoscopy and computed tomography angiography (CTA), endoscopic therapeutic options, and management of antithrombotic medications after hospital discharge.

 READ bit.ly/ACGCRJ-Kwong-Stent  WATCH Video of flexible sigmoidoscopy stent retrieval and endoscopic clip closure: links.lww.com/ACGCR/A33 and links.lww.com/ACGCR/A34

 READ bit.ly/ACG-Guideline-LGIB  LISTEN bit.ly/LGIB-Sengupta-podcast

[CLINICAL & TRANSLATIONAL GASTROENTEROLOGY]

Clinician’s Toolbox: Understanding Our Tests: HydrogenMethane Breath Testing to Diagnose Small Intestinal Bacterial Overgrowth Aylin Tansel, MD, MPH and David J. Levinthal, MD, PhD. Clinical and Translational Gastroenterology 14(4):p e00567, April 2023. DOI: 10.14309/ctg.0000000000000567 Possible patterns of glucose breath test results and their interpretation

 Breath testing via measurement of exhaled hydrogen and methane gases following ingestion of a readily metabolized carbohydrate has become an important noninvasive testing paradigm to help diagnose SIBO. However, because of a number of physiological and technical considerations, how and when to use breath testing in the diagnosis of SIBO remains a nuanced clinical decision. This narrative review provides a comprehensive overview of breath testing paradigms

56 | GI.ORG/ACGMAGAZINE

including the indications for testing, how to administer the test, and how patient factors influence breath testing results. Additionally, the authors describe complementary and alternative tests for diagnosing SIBO.  READ bit.ly/CTG-Breath-Test-SIBO

ACG VIRTUAL GRAND ROUNDS Weekly on Thursdays at 12 pm and 8 pm ET Live Presentation by an ACG Expert Plus Q & A #GIhomeschooling https://gi.org/acgvgr

https://gi.org/acgvgr

https://gi.org/acgvgr

Even as all aspects of practice have changed due to COVID-19, your need to stay up to date on clinical GI does not stop. ACG is committed to your professional education. 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

Inside the Journals | 57

About

CHRONIC IDIOPATHIC CONSTIPATION Information for Patients and Caregivers: Understanding the ACG-AGA Guideline on Pharmacologic Management of Chronic Constipation

What is Chronic Constipation?

Chronic constipation refers to problems with infrequent bowel movements, hard or lumpy stools, and/or difficult or incomplete bowel movements. Chronic constipation is a common problem affecting 1 in 10 people – that’s over 30 million people in the U.S. Chronic constipation reduces quality of life, makes it difficult for affected persons to carry out their personal or professional activities, and accounts for billions of dollars in medical and work-related costs.

Questions You Should Ask Your Physician About Chronic Constipation • What are the over-the-counter treatment options for chronic constipation?

KEY TAKEAWAYS • Patients should not be embarrassed to

talk to their health care providers about constipation.

• When should I consider a prescription option?

• What are the main side effects of the medications?

• While it may be embarrassing to you, it isn’t embarrassing to your health care provider.

• What is the best option for me?

• If I don’t get better with medications, what is the next step and what should I be concerned about?

• There are diet, lifestyle changes, and overthe-counter and prescription medications that can significantly improve symptoms, quality of life, and daily functioning for patients with chronic constipation.

Warning Signs or Alarming Symptoms A careful work up should be considered in constipated patients who develop new symptoms after age 45 and have:

• The ACG-AGA guidelines provide scientific evidence of the efficacy and safety and implementation remarks to help guide the use of over-the-counter and prescription treatments for chronic constipation in clinical practice.

• unintended weight loss,

• evidence of GI bleeding (like red blood in the stool or black, tarry stools), • unexplained iron deficiency, or • a person has a family history of colon polyps or colon cancer.

LEARN MORE

ACG Patient Information: Scan QR Code or visit gi.org/topics/constipation-and-defection-problems

Find a gastroenterologist near you: gi.org/FindaGI

Read the Guideline bit.ly/ACG-AGA-Chronic-Constipation-Guideline

American College of Gastroenterology | gi.org | Follow ACG on Twitter @AmCollegeGastro 58 | GI.ORG/ACGMAGAZINE

REBYOTATM (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 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. 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%), flatulence (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 difficile (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 first 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 (defined as adverse events assessed as definitely, 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%), flatulence (3.3%), and nausea (3.3%).Most adverse reactions occurred during the first 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 sufficient 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 and the Ferring Pharmaceuticals logo are registered trademarks of Ferring B.V. REBYOTA is a trademark of Ferring B.V. ©2022 Ferring B.V. This brief summary is based on full Rebyota Prescribing Information which can be found at www.RebyotaHCP.com US-REB-2200277

Where dysbiosis once left the gut microbiome in ruin,

RISE ABOVE RECURRENT C. DIFFICILE INFECTION and restore hope with REBYOTA

TM

Scan to visit website

The first and only FDA-approved microbiota-based live biotherapeutic to prevent recurrence of C. difficile infection starting at first recurrence.1,2,a In the pivotal phase 3 trial, 32.8% of patients were treated at first recurrence of CDI following antibiotic treatment of CDI.1

a

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 and the Ferring Pharmaceuticals logo are registered trademarks of Ferring B.V. REBYOTA is a trademark of Ferring B.V. ©2022 Ferring B.V. All rights reserved. US-REB-2200129 1/23

RESTORE HOPE