ACG Magazine | Vol. 7, No. 4 | Winter 2023 by AmCollegeGastro

ACG MAGAZINE Winter 2023

MEMBERS. MEDICINE. MEANING.

Special Issue:

Well-being

It’s TIME to

RENEW YOUR MEMBERSHIP! Member Benefits! Free Education from the Education Universe and the ACG Annual Scientific Meeting that keeps you current on treatment, therapy and management of key GI conditions and disorders Free subscriptions to The American Journal of Gastroenterology, Clinical and Translational Gastroenterology, EvidenceBased GI Journal Review and the unique ACG Case Reports Journal Practice management tools that help you improve efficiency and increase profitability in your practice ACG’s Billing & Coding Forum, professional coding and documentation assistance tailored to your individual practice’s needs GI OnDEMAND, a virtual integrated care and support platform now offering genetic testing, free telehealth and access to registered dietitians and GI psychologists

Renew today at gi.org/renew

WINTER 2023 // VOLUME 7, NUMBER 4

FEATURED CONTENTS COVER STORY

COVER STORY Joy and Well-being in the Practice of Medicine – The Importance of the Human Connection PAGE 28

Faith and Spirituality – Should They be Part of Your Practice and/or Your Life?

PAGE 34 Wellness and Work-Life Integration: What Matters Most

PAGE 37 Gastroenterologist Motility: Inspired Moves for Your Heart, Brain & Endoscopy Ergonomics

PAGE 41 A Firm Foundation: Fitting Footwear for the “EndoAthlete”

PAGE 47

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

WINTER 2023 // VOLUME 7, NUMBER 4

CONTENTS

“There is so much we can do in healthcare to reduce stress and create an environment focused on well-being.” —Cover Story, “Joy and Well-being in the Practice of Medicine – The Importance of the Human Connection” PG 28

6 // MESSAGE FROM THE PRESIDENT

28 // COVER STORY

55 // INSIDE THE JOURNALS

Dr. Jonathan Leighton on strengthening meaning and purpose in medical practice

28 JOY AND WELL-BEING IN THE PRACTICE OF MEDICINE The importance of creating a professional environment focused on well-being

56 AJG Infusing joy and sustainable well-being into your practice by this issue's cover authors

7 // NOVEL & NOTEWORTHY Recognizing Dr. Frank Hamilton's retirement from NIDDK, awards and notable talks from ACG 2023, a new podcast & more

34 FAITH & SPIRITUALITY Dr. Mark Mellow reflects on the role of faith and spirituality in personal and professional lives

56 CTG Clinician’s Toolbox: Understanding Our Tests – Fecal Calprotectin for the Diagnosis and Management of IBD by Kapel, et al.

8 // GI EYE

37 WORK-LIFE INTEGRATION The ACG Professionalism Committee shares practical tips for establishing balance

56 ACGCRJ A fellow's perspective on ergonomics in endoscopy by CRJ Co-EIC Dr. Khushboo Gala

41 GASTROENTEROLOGIST MOTILITY A look at how your colleagues stay inspired to make exercise part of their routines

58 // REACHING THE CECUM

Dr. George Ioannou's photo "Symphony in Blue" of the Ayioi Anargyroi Chapel in his native Cyprus

17 // TRAINEE HUB Dr. Katie Dunleavy on how posture training and coordination can improve your endoscopy ergonomics

23 // GETTING IT RIGHT Incorporating APPs into your practice to enhance GI care

49 // ACG PERSPECTIVES

COLORECTAL CANCER SCREENING A patient handout about colorectal cancer screening: perfect for March Colorectal Cancer Awareness Month!

49 CULINARY CONNECTIONS Stories and recipes from #ACGfoodies to eat well and be well 53 INTERNATIONAL TRAINING Dr. Andrew Moon shares his experience training at Barcelona Clinic Liver Cancer

ABOVE: L to R: Keith W. Jones; Cynthia M. Stonnington, MD; and Jonathan A. Leighton, MD, FACG, Mayo Clinic in Arizona. Photo courtesy of Dr. Leighton

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 Becky Abel

Art Director Emily Garel

Senior Graphic Designer Antonella Iseas

BOARD OF TRUSTEES President: Jonathan A. Leighton, MD, FACG President-Elect: Amy S. Oxentenko, MD, FACG Vice President: William D. Chey, MD, FACG Secretary: Nicholas J. Shaheen, MD, MPH, MACG Treasurer: Costas H. Kefalas, MD, MMM, FACG Immediate Past President: Daniel J. Pambianco, MD, FACG

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

ACGMag@ @gi.org

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

Past President: Samir A. Shah, 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 Brooks D. Cash, MD, FACG Jill K. J. Gaidos, MD, FACG Seth A. Gross, MD, FACG David J. Hass, MD, FACG James C. Hobley, MD, MSc, FACG 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 Richard S. Bloomfeld, MD, FACG Dr. Bloomfeld is a professor of gastroenterology and the director of the inflammatory bowel disease clinic at Wake Forest School of Medicine. He currently serves as chair of the ACG Professionalism Committee.

Katie A. Dunleavy, MB BCh BAO Dr. Dunleavy is a third-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.

Sarah Enslin, PA-C Ms. Enslin is a Physician Assistant at the University of Rochester Medical Center. She currently serves on the ACG Advanced Practice Providers Committee.

George Ioannou, MD, MS Dr. Ioannou is a professor of medicine at the University of Washington and Director of Hepatology in the VA Puget Sound Health Care System.

Lenore Lamanna, EdD, RN, ANP-BC Dr. Lamanna is an associate professor in the School of Nursing at Stony Brook University. She is the director of the Adult Gerontology Primary Care and Acute Care Nurse Practitioner programs and serves on ACG’s Advanced Practice Providers Committee.

Jonathan A. Leighton, MD, FACG ACG President Dr. Leighton is Professor of Medicine at Mayo Clinic Arizona and is the Medical Director of the Office of Mayo Clinic Experience there. He also chairs Mayo Clinic Arizona’s Office of Joy and Well-being.

Mark H. Mellow, MD, FACG Dr. Mellow is a gastroenterologist from Edmond, OK, and the author of “A Case for Faith Sharing Ancient Secrets for Longer Life, Health and Happiness” exploring the impact of faith and spiritual practices on physical and mental health.

Andrew M. Moon, MD, MPH, FACG Dr. Moon is Assistant Professor of Medicine at the University of North Carolina at Chapel Hill. He serves ACG as Deputy Associate Editor of The American Journal of Gastroenterology and chair of the Digital Communications and Publications Committee.

Kimberly Orleck, PA-C Ms. Orleck is the Director of Advanced Practice Providers at Atlanta Gastroenterology. She currently serves on the ACG Advanced Practice Providers Committee.

April Panitz, MS, RDN, CDN Ms. Panitz is a Registered Dietitian Nutritionist, New York Certified Dietitian-Nutritionist, and co-founder of Amenta Nutrition. She is a Monash University low-FODMAP diet-trained dietitian, has a Certificate of Training in Obesity for Pediatrics and Adults from the Commission on Dietetic Registration, and is a member of the Academy of Nutrition and Dietetics.

Laurel Podulke-Smith Ms. Podulke-Smith is an educator and healthcare professional specializing in the Alexander Technique at the Mayo Clinic's Dan Abraham Healthy Living Center. She currently serves on the board of County Commissioners in Olmsted County, MN

Christine Randazzo Kirschner, MS, RDN, CDN Ms. Randazzo Kirschner is a GI-expert dietitian and the co-founder of Amenta Nutrition. She is a member of the Dietitians in Gluten & GI Disorders Dietetic Medical Nutrition Therapy Practice Groups, a Monash University low-FODMAP diet-trained dietitian, and an active member of the Academy of Nutrition and Dietetics.

Trupti S. Shinde, MD Dr. Shinde is a gastroenterologist practicing in Crystal River, FL. She serves as a Director of the Suncoast Endoscopy Center and as a faculty member for the GI fellowship and IM residency program at Citrus Memorial Hospital. She co-founded the Citrus Colorectal Cancer Foundation.

Cynthia M. Stonnington, MD Dr. Stonnington is a consultant and the Interim Chair in the Department of Psychiatry & Psychology at Mayo Clinic Arizona. She serves as Associate Medical Director of Mayo Clinic’s Arizona Office of Joy and Well-Being

Mary Vetter, ANP Ms. Vetter is a Senior Nurse Practitioner at the University of Rochester Medical Center specializing in the care of patients with a wide range of GI, liver, and hepatobiliary disorders. She previously served as chair of the ACG Advanced Practice Providers Committee.

MESSAGE FROM THE PRESIDEN

STRENGTHENING YOUR SENSE OF MEANING AND PURPOSE By Jonathan A. Leighton, MD, FACG

We as gastroenterologists want to create a supportive work setting, where meaning in work can flourish, burdens decrease, we joyfully connect and support each other and prioritize self-care. I do believe that individual self-care supports the collective wellbeing of those we work with. A personal

THE PRACTICE OF MEDICINE HAS

and internal systems and processes have

COME A LONG WAY. As a child, I

taken us away from our fundamental

was fortunate to see medicine from

“Why.” Our frontline teams are feeling

a completely unique perspective. My

less empowered and engaged with the

father was a pediatrician and practiced

mission and purpose of why we are all in

what I have always called “old-fashioned

healthcare. It is my hope that we can re-

medicine” like Marcus Welby. His office

center the narrative and the story of our

was in our home, he had one nurse,

patients to elevate our values, purpose,

one hospital, did house calls, and kept

and connection with each other. We have

his medical records on a large index

an opportunity to listen more to our

card. He worked hard, but he always

patients and our colleagues and create an

valued his service to his patients. One

environment that will sustain us for years

day, I was sitting in my office looking at

to come, similar to what my father had

my electronic medical records and the

many years ago.

thought occurred to me that the way I

We in healthcare understand the value

practice now was light years away from

in teamwork—the importance of highly

the practice that my dad had. When I

functioning teams who support each

started at Mayo Clinic 32 years ago, we

other and as a result, deliver the best

had a considerable amount of “white

care to our patients. Our patients are

space” to work on clinical research

looking beyond the medical care they

projects or other projects. That white

receive—that human connection where

space has evaporated over time. Many

they can have a trusting relationship and

other changes have occurred, including

a sense of belonging—and they want to

declining reimbursement, pressure

feel hope. For those of us in healthcare,

to increase productivity, increased

it is so important that we have meaning

fragmentation of services, and more

and purpose in what we do. Most of us

complex regulatory requirements. This

are looking for a deep human experience

has led to increased burnout, early

that is strengthened by a sense of

retirement for many and a decrease in job

teamwork, as well as belonging and trust,

satisfaction and overall well-being.

just like our patients. To strengthen

I do believe that we are at a crossroads,

meaning and purpose, we must focus on

and we need to make tough decisions

our relationships, which create a sense

about where we go from here. As

of belonging and a shared purpose.

President of ACG, this weighs heavily

Meaningful work challenges and engages

on my mind, and I believe the College

us and helps us grow. Ultimately, we want

can influence our future in a positive

to cultivate a collaborative atmosphere

way. There is a burning platform from

where we feel valued and fulfilled and

which to start. We know that external

are supported to strive for excellence.

well-being practice heightens awareness that working on yourself is your first act. It helps you gain practice in being your best in challenging interactions with co-workers and situations. In that way, we all can contribute to a healthy work environment and create community that leads to personal enrichment, value and meaning. The ACG provides all of its members with the opportunity to network, foster relationships and enhance meaning and purpose in their careers. By building relationships through networking, I believe we can improve our sense of wellbeing and reduce burnout. There are also opportunities at ACG to learn how to be future leaders through our ACG Institute Center for Leadership, Ethics and Equity, and our many committees and Board of Governors also offer ways to get more involved. In closing, I hope you will take this opportunity to get more involved with ACG and grow your community, your relationships, and your sense of joy and well-being. Always be a team player and inspire and empower those on your team and always bring your best self. Think more about what you can give to others than what you can get from them. Think broadly about what you can give to the networking process such as advice, mentorship, access, and resources. Let curiosity lead the way, ask questions and listen. I hope you will allow ACG to be your professional home for networking, career development, and well-being.

“To strengthen meaning and purpose, we must focus on our relationships, which create a sense of belonging and a shared purpose.”

6 | GI.ORG/ACGMAGAZINE

—Jonathan

Note hy wor t READ ON FOR ACG NEWS AND SELECT HIGHLIGHTS of the College’s Annual Scientific Meeting in Vancouver, BC, Canada. Noted with gratitude: Dr. Frank Hamilton retired after a long and distinguished career of service at NIH’s NIDDK. ACG thanks our AMA representatives and those attending WGO’s Train the Trainer on behalf of the College. Kudos all around! Special congratulations to the ACG 2023 GI Jeopardy winners, a team of third-year fellows from the University of Iowa, Dr. Ahmed Elkafrawy and Dr. Estefania Flores. More awards abound in Novel & Noteworthy with ACG’s own SCOPY Awards, the 2023 Healio Disruptive Innovators Awards, and this year’s Sherman Prizes.

Novel & Noteworthy | 7

N&N GI EYE: ARTWORK FROM ACG MEMBERS

Little blue-domed, white chapels grace the coastline of Greece and the Greek islands, blending into the seascape. Most often they face the sea, and in the old days provided space for refuge and prayer for the safe return from the sea of the sailors and fishermen. I grew up near this Ayioi Anargyroi Chapel. When I was a kid, we used to go there to jump from the cliffs behind the chapel into the sea, a 12-meter drop, and instant test of manhood and courage. We would also climb down to the sapphire blue sea just below the Chapel for a swim into a sea cave, which is supposed to have “holy water.” I left Cyprus when I was 20 for medical school and eventually immigrated to the U.S. I visit Cyprus at least annually. When I showed the Ayioi Anargyroi Chapel to my future wife, she wanted us to get married there, but my parents thought it would be impractical to get all the guests there. I now regret not listening to my wife. Only many years later did I realize the medicine connection: the chapel is dedicated to two saints, Kosmas and Damianos, who did not take payment for their services and were named “Anargyroi”, which literally means “no silver”—silver coins being the currency of that era. We need more of them today. Now this little chapel, that used to be somewhat remote and inaccessible, has been “discovered” by the tourists. Influencers and models come by truckload to get their photo taken next to it and post it on social media. I took the picture with a wide-angle lens using my iPhone to maximize the blue sky and even bluer sea and to create the surreal angles of the chapel.

About Dr. Ioannou is physician-scientist at the University of Wahington School of Medicine where he is a Professor of Gastroenterology. He serves as Director of Hepatology at the VA Puget Sound Health Care System. His research interests include epidemiology and outcomes of chronic liver disease, cirrhosis, hepatocellular carcinoma, NAFLD, optimizing outcomes in liver transplantation, antiviral treatment for hepatitis C, and predictive modeling. He was a 2003 recipient of the ACG Junior Faculty Development grant, an award that he credits with helping to start his career in clinical research.

8 | GI.ORG/ACGMAGAZINE

SYMPHONY BLUE AYIOI ANARGYROI CHAPEL, CAVO GRECO, CYPRUS George Ioannou, MD, MS

IN AND WHITE

Novel & Noteworthy | 9

// N&N

[EMERITUS]

FRANK A. HAMILTON, MD, MPH, MACG retired in October 2023 after a long and distinguished career at the NIH National Institute for Diabetes, Digestive & Kidney Diseases (NIDDK). Read more about Dr. Hamilton and his service to NIH in a profile for ACG MAGAZINE’s Spring 2022 cover story: bit.ly/acg-mag-spring-2022

SCOPY AWARDS ACG’s Service Award for Colorectal Cancer Outreach, Prevention & Year-round Excellence (SCOPY) recognizes community education and public awareness efforts to advance colorectal cancer screening and prevention by ACG members and their staffs. See all 2023 winners: bit.ly/scopy-awards-23

[THOUGHT LEADER]

ACG TRUSTEE AASMA SHAUKAT, MD, MPH, FACG of NYU Langone Health was a panelist at The Atlantic Festival in Washington, DC, this September. She spoke about AI in a session of a program, “AI, Technology, and the Future of Health Care” that included Xavier Becerra, Secretary of the U.S. Department of Health and Human Services.

[AMA REPS]

ACG is grateful to our delegates to the American Medical Association, R. Bruce Cameron, MD, MACG and March Seabrook, MD, FACG pictured in November at the AMA's 2023 Interim Meeting in Washington, DC.

Sita S. Chokhavatia, MD, MACG accepts a 2023 SCOPY on behalf of her colleagues at Valley Health System in New Jersey.

GI JEOPARDY And the winner is….the University of Iowa team! Ahmed A. Elkafrawy, MD and Estefania M. Flores, MD who won the intense GI Jeopardy competition at ACG 2023 by more than 1,000 points past the second-place team. Well done!

Dr. Cameron and Dr. Seabrook

[ACG 2023 HIGHLIGHTS]

ACG AWARDS & LEADERSHIP BOOKLET Explore the ACG “Year in Review” and explore the College’s 2023 awards, committee priorities, and achievements. READ: bit.ly/acg-awardsleadership-2023

Dr. Elkafrawy and Dr. Flores

[PATIENT VOICE]

MARCIA CROSS DELIVERS 2023 EMILY COURIC MEMORIAL LECTURE Actress and patient advocate Marcia Cross delivered the Emily Couric Memorial Lecture at ACG 2023, “HPV-Related Cancers – Are Your Patients Being Misdiagnosed?” Ms. Cross is a co-founder of the HPV Cancers Alliance. Her own diagnosis and treatment of anal cancer inspired her to speak out to help destigmatize the shame that too often accompanies this cancer. Watch the 2023 Couric Lecture: bit.ly/23couric-lecture-marcia-cross

10 | GI.ORG/ACGMAGAZINE

Dr. Shaukat and HHS Secretary Becerra

[LISTEN UP]

NEW! BRAINS & GUTS: The GI Innovation Podcast – The ACG Innovation and Technology Committee is excited to bring you a new podcast highlighting the importance of innovation in GI. In each episode, hosts Toufic Kachaamy, MD, FACG, and Vladimir Kushnir, MD, FACG, will interview gastroenterology innovators and inventors to unpack their successes, pitfalls, and learnings. Their goal? To empower individual gastroenterologists with the knowledge and skills to explore ideas and apply the innovator’s mindset to everyday practice. Listen and subscribe wherever you get your podcasts, or find episodes here: gi.org/brainsandguts

[TAKE A BREATH]

[DISRUPTORS]

ACG VIRTUAL GRAND ROUNDS: Breathing Past Burnout – In June, 2023 ACG Virtual Grand Rounds included a program on the SKY Healing Breaths Program, an online, research-based, breath meditation technique. S. Priya Narayanan, MD, and Michael Fischman of the organization Healing Breaths reviewed the experience with SKY for healthcare providers along with panelists Neelima Reddy, MD, FACG; Neeraj Kaushik, MD; and Juan Murua.

HEALIO DISRUPTIVE INNOVATORS AWARDS at ACG 2023 – Now in its sixth year, the Healio Disruptive Innovators Awards celebrate the achievements of exemplary leaders in gastroenterology and hepatology. Winners were selected by readers of Healio Gastroenterology who cast more than 3,000 votes to decide who among an impressive list of nominees was truly disrupting the field. The ceremony is held each year in conjunction with the ACG Annual Scientific Meeting. The College and Healio together sponsor the Clinical Innovation Award which, this year, went to Brennan M. R. Spiegel, MD, MSHS, FACG, of Cedars-Sinai Medical Center in Los Angeles, CA.

Learn More (login required): bit.ly/acgvgrhealing-breaths

[HONOREES]

THE SHERMAN PRIZE – The Bruce and Cynthia Sherman Charitable Foundation established the Sherman Prize in 2016 to provide national recognition and financial prizes to pioneering IBD professionals who exemplify excellence in Crohn’s disease and ulcerative colitis.

(Photo left) 2023 Healio Disruptors L to R: Sonali Paul, MD, MS (Rising Disruptive Innovator); Marla C. Dubinsky, MD (Lifetime Distruptor); Neilanjan Nandi, MD on behalf of South Asian IBD Alliance (The Patient Voice Award); Laurie A. Keefer, PhD (Allied Health Provider of the Year); Brennan M. R. Spiegel, MD, MSHS, FACG (Clinical Innovation); Edward V. Loftus, Jr., MD, FACG (Master of Ceremonies); Folasade P. May, MD, PhD, MPhil (Health Equity); Wendi G. LeBrett, MD (Social Media Inflencer); Urgo Iroku, MD (Presenter); Phil Schallwig on behalf of AbbVie (Industry Breakthrough). Not Pictured: Lubna Kamani, MBBS, MRCP, FRCP, FCPS (Woman Disruptor of the Year). (Photo right) Dr. Spiegel received the Healio-ACG Clinical Innovation Award for 2023

2023 SHERMAN PRIZES ($100,000) Corey A. Siegel, MD, MS, Director of the Center for Digestive Health and CoDirector of the Inflammatory Bowel Disease Program at Dartmouth Health’s Dartmouth Hitchcock Medical Center and Constantine and Joyce Hampers Professor of Medicine at the Geisel School of Medicine at Dartmouth in Hanover, NH

[TTT]

THE “TRAIN THE TRAINERS” PROGRAM of the World Gastroenterology Organisation, convened in Peirera, Colombia, in August 2023, was a unique global educational workshop emphasizing teaching and training skills. ACG sponsored airfare costs for Luis F. Lara, MD, of the University of Cincinnati to serve as TTT faculty, as well as two attendees, Amit Gupta, MD, of UNC Chapel Hill, and Cesar A. Taborda Vidarte, MD, of Emory University School of Medicine.

Thaddeus Stappenbeck, MD, PhD, Sherwick Endowed Chair in Inflammation & Immunity and Chair of Inflammation and Immunity at the Cleveland Clinic in Cleveland, OH SHERMAN EMERGING LEADER PRIZE ($25,000) Andres J. Yarur, MD, FACG, Associate Professor of Medicine at Cedars-Sinai in Los Angeles, CA Visit ShermanPrize.org to view the Honor Roll of past Sherman Prize recipients, watch inspiring short tribute films, and sign up to receive notification of the 2024 nomination cycle.

(Photo left) Dr. Lara & Dr. Gupta. (photo right) Dr. Taborda Vidarte & Dr. Lara

Novel & Noteworthy | 11

// N&N

NOTEWORTHY CLINICAL ALERT Robert D. Richards, Jr., MD, Gastroenterology of Central Virginia, Lynchburg, VA

I practice gastroenterology in Lynchburg, Virginia, surrounded by the Lone Star tick, and studies have consistently shown a prevalence of IgE antibodies to alpha-gal in some 15-25% of residents in this region. A recent survey of healthcare workers in central Virginia noted an IgE sensitization prevalence of 16%, but only 16% of those reported classic allergy and/or GI symptoms thought to be due to alpha-gal syndrome.1 However, our GI clinics are going to be enriched with these patients and we commonly see GI alpha-gal syndrome symptoms superimposed upon other intestinal and medical illnesses. Several studies listed below report on our experience with this.2,3 Our study looking at alpha-gal in patients with suspected pancreatic exocrine insufficiency shows how complicated these patients can be.4 The alpha-gal syndrome story is fascinating, and it provides a wonderful pathway into the study of immunology and allergy. All of us carry high titers of IgA and IgG to alpha-gal, but only some of us will develop IgE antibodies to alpha-gal after the bite of a Lone Star tick. The gut microbiome is covered in alpha-gal, xenograft transplant rejection is hugely driven by alpha-gal, as is Chagas disease, and the list goes on and on.5 In our careers we have seen the understanding and manipulation of the immune system take medicine and gastroenterology to amazing new places. The story of alpha-gal will be a small but fun part of this, so stay tuned, and hang on for the ride.6,7 Lone Star Tick

REFERENCES 1. Longitudinal Alpha-gal IgE Levels in a University of Virginia Employee Cohort. J Allergy Clin Immunol 151(2):AB92. doi: 10.1016/j.jaci.2022.12.293. 2. Richards NE, Richards RD Jr. Alpha-Gal Allergy as a Cause of Intestinal Symptoms in a Gastroenterology Community Practice. South Med J. 2021 Mar;114(3):169-173. doi: 10.14423/ SMJ.0000000000001223. 3. Richards NE, Makin TA, Smith AR, Platts-Mills TAE, Richards RD and Wilson JM (2022) The α-Gal mammalian meat allergy as a cause of isolated gastrointestinal symptoms. Front. Gastroenterol. 1:987713. doi: 10.3389/fgstr.2022.987713. 4. Richards NE, Wilson JM, Platts-Mills TAE and Richards RD (2023) A retrospective review of α-gal syndrome complicating the management of suspected pancreatic exocrine insufficiency in one gastroenterology clinic in central Virginia. Front. Gastroenterol. 2:1162109. doi: 10.3389/fgstr.2023.1162109 5. Galili, Uri. The Natural Anti-Gal Antibody as Foe Turned Friend In Medicine. Elsevier Academic Press, 2018. ISBN: 978-0-12-813362-0 6. McGill SK; Richards RD, Commins SP. Suddenly Steakless: A Gastroenterologist's Guide to Managing Alpha-Gal Allergy. Am J Gastroenterol 117(6)822-826, June 2022. doi: 10.14309/ ajg.0000000000001765. 7. McGill SK, et al. AGA Clinical Practice Update on Alpha-Gal Syndrome for the GI Clinician. McGill et al., Clin Gastroenterol Hepatol. 2023 Apr;21(4):891-896. doi: 10.1016/j. cgh.2022.12.035

12 | GI.ORG/ACGMAGAZINE

2024 ACG EDGAR ACHKAR VISITING PROFESSORSHIPS

*Christopher D. Vélez, MD Atrium Health Carolinas Medical Center January 18–19 Satish S.C. Rao, MD, PhD, FACG Creighton University – St. Joseph Medical Center February 1 *Baharak Moshiree, MD, MSc, FACG University of Miami February 8 Lin Chang, MD, FACG Westchester Medical Center March 6 *Rachel Issaka, MD University of South Florida April 4 Francis A. Farraye, MD, MSc, MACG Texas Tech University – El Paso April 4 Millie D. Long, MD, MPH, FACG UMass Chan Medical School – Baystate Health April 10 *Victor Chedid, MD University of Alabama at Birmingham April 11 Neena S. Abraham, MD, MSc (Epid), MACG Advent Health Orlando April 25–26 Tyler M. Berzin, MD, FACG University of Illinois - Chicago May 28–29 David T. Rubin, MD, FACG Augusta University August 9 *Linda Anh B. Nguyen, MD, FACG Cedars-Sinai Medical Center September 5 John E. Pandolfino, MD, MSCI, FACG Oregon Health & Sciences University October 11–14 Allison R. Schulman, MD, MPH Ascencion St. John’s Adjoa Anyane-Yeboa, MD, MPH Tufts Medical Center *ACG Visiting Scholar in Equity, Diversity, and Ethical Care

[EAVP]

The ACG Institute for Clinical Research & Education sponsors the Edgar Achkar Visiting Professorship (EAVP) program to bring distinguished faculty to GI training programs for clinical education, mentorship, and networking opportunities. Within EAVP, the Visiting Scholar in Equity, Diversity & Ethical Care is an initiative of the ACG Institute’s Center for Leadership, Ethics & Equity that aims to create awareness around the issues and challenges of delivering equitable care, respecting diversity, and instilling ethical decision making.

ADJOA ANYANE-YEBOA, MD, MPH: VISITING SCHOLAR IN EQUITY, DIVERSITY & ETHICAL CARE, COOPER UNIVERSITY HOSPITAL, CAMDEN, NJ, SEPTEMBER 7, 2023 “Dr. Anyane-Yeboa offered some strategies to implement in our personal practice to better address disparities

Dr. Anyane-Yeboa at Cooper University Hospital

and equitability of care, but more importantly, her presentation generated interest and brainstorming, especially with the fellows, for ways we can improve service to our community.” —Tara Lautenslager, MD “The visit consisted of a lunchtime presentation to the GI fellows and faculty, individual meetings with fellows, and a dinner presentation to faculty and fellows. The title of my first talk was, “Promoting Equity in GI: Strategies and Opportunities for Practice,” and the title of the second talk was “Colorectal Cancer Screening in Black Individuals: Leveling the Playing Field.” The audience at lunch and dinner consisted of faculty and fellows. The chief of the division was present at the dinner. I participated in impromptu brainstorming discussions after the talks with different faculty about things that could be done better for their patients, and strategies to increase diversity in trainees and faculty.” —Adjoa Anyane-Yeboa, MD, MPH

SONALI PAUL, MD, MS: VISITING SCHOLAR IN EQUITY, DIVERSITY & ETHICAL CARE TO NYU GROSSMAN SCHOOL OF MEDICINE, NEW YORK CITY, NY, OCTOBER 10, 2023 “One of the most impactful Dr. Paul at NYU Grossman School of Medicine

moments of my visit was meeting with faculty and fellows, and

connecting with residents after, I was able to share that you can have courage and vulnerability and be an effective leader, which was something I learned through the ACG Young Physician [Leadership] Scholars' Program. I was also able to address and emphasize the importance of DEI while sharing that ‘you can't be what you don't see’—stressing the importance of visibility and representation to inspire future trainees. —Sonali Paul, MD, MS “Every aspect of Dr. Paul’s visit was impactful! Her Grand Rounds lecture was informative, endearing, and relatable in many ways. In her presentation and conversations, she talked about her multiple identities as they related to gender, being physician, a daughter of South Asian parents, a gastroenterologist, and a wife and mother.” —Danielle Seabron, NYU Coordinator

Novel & Noteworthy | 13

Attend an upcoming ACG Attend POSTGRADUATE COURSE an upcoming

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2023 ACG’s IBD School & Southern Regional Postgraduate Course December 1–3, 2023 Renaissance Nashville Hotel, Nashville, TN

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2023 ACG’s IBD School & Southern Regional Postgraduate Course

2024

December 1–3, 2023 2024 ACG’s Endoscopy School & Renaissance Nashville Hotel, Nashville, TN

ACG Board of Governors/ASGE Best Practices Course

ACG Weekly Virtual Grand Rounds

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

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

January 26–28, 2024 Aria Resort, Las Vegas, NV

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2024 ACG’s Endoscopy School & 2024 ACG/LGS Regional Postgraduate CourseCourse ACG Board of Governors/ASGE Best Practices 1–3, 20242024 March January 26–28, Aria DoubleTree Resort, by LasHilton, Vegas,New NV Orleans, LA

2024 Annual Spring Symposium 2024 ACG/FGS ACG/LGS Regional Postgraduate Course 2024 March March 8–10, 1–3, 2024 Naples Grande Beach Resort, Naples,LAFL DoubleTree by Hilton, New Orleans,

2024 IBDAnnual School Spring & 2024 ACG’s ACG/FGS Symposium Eastern Regional Postgraduate Course March 8–10, 2024 June 2024 Naples Grande Beach Resort, Naples, FL Washington, DC

2024 ACG’s IBD School & 2024 ACG’s Hepatology School Course & Eastern Regional Postgraduate Midwest Regional Postgraduate Course June 2024

August 23–25, Washington, DC2024 Radisson Blu Mall of America, Minneapolis, MN

2024 ACG’s Hepatology School & 2024 ACG’s Functional GI & Motility Disorders School & Midwest Regional Postgraduate Course ACG/VGS/ODSGNA August 23–25, 2024Regional Postgraduate Course September Radisson Blu6–8, Mall2024 of America, Minneapolis, MN Williamsburg Lodge, Williamsburg, VA

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MORE INFO: gi.org/acg-course-calendar MORE INFO: gi.org/acg-course-calendar 14 | GI.ORG/ACGMAGAZINE

Where dysbiosis once left the gut microbiome in ruin,

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

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

Scan to visit website

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

INDICATION REBYOTA (fecal microbiota, live - jslm) is indicated for the prevention of recurrence of Clostridioides difficile infection (CDI) in individuals 18 years of age and older, following antibiotic treatment for recurrent CDI. Limitation of Use REBYOTA is not indicated for treatment of CDI. IMPORTANT SAFETY INFORMATION Contraindications Do not administer REBYOTA to individuals with a history of a severe allergic reaction (eg, anaphylaxis) to any of the known product components. Warnings and Precautions Transmissible infectious agents Because REBYOTA is manufactured from human fecal matter, it may carry a risk of transmitting infectious agents. Any infection suspected by a physician possibly to have been transmitted by this product should be reported by the physician or other healthcare provider to Ferring Pharmaceuticals Inc. Management of acute allergic reactions Appropriate medical treatment must be immediately available in the event an acute anaphylactic reaction occurs following administration of REBYOTA. Potential presence of food allergens REBYOTA is manufactured from human fecal material and may contain food allergens. The potential for REBYOTA to cause adverse reactions due to food allergens is unknown.

Adverse Reactions The most commonly reported (≥3%) adverse reactions occurring in adults following a single dose of REBYOTA were abdominal pain (8.9%), diarrhea (7.2%), abdominal distention (3.9%), flatulence (3.3%), and nausea (3.3%). Use in Specific Populations Pediatric Use Safety and efficacy of REBYOTA in patients below 18 years of age have not been established. Geriatric Use Of the 978 adults who received REBYOTA, 48.8% were 65 years of age and over (n=477), and 25.7% were 75 years of age and over (n=251). Data from clinical studies of REBYOTA are not sufficient to determine if adults 65 years of age and older respond differently than younger adults. You are encouraged to report negative side effects of prescription drugs to FDA. Visit www.FDA.gov/medwatch, or call 1-800-332-1088. Please see Brief Summary on next page and full Prescribing Information at www.REBYOTAHCP.com. References 1. REBYOTA. Prescribing Information. Parsippany, NJ: Ferring Pharmaceuticals; 2022. 2. US Food and Drug Administration. FDA Approves First Fecal Microbiota Product. https:// www.fda.gov/news-events/pressannouncements/fda-approves-firstfecal-microbiota-product. Accessed December 1, 2022.

RESTORE HOPE

REBYOTA® (fecal microbiota, live - jslm) suspension, for rectal use Brief Summary Please consult package insert for full Prescribing Information INDICATIONS REBYOTA is indicated for the prevention of recurrence of Clostridioides 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, the Ferring Pharmaceuticals logo and REBYOTA are registered trademarks of Ferring B.V. ©2023 Ferring B.V. This brief summary is based on full Rebyota Prescribing Information which can be found at www.RebyotaHCP.com US-REB-2200277-V2

TRAINEE HUB

My Journey to Finding Alexander Technique

Alexander Technique:

Uncovering the Secret for Improved Endoscopy, Wellness and Self-Care Trainee Hub Section Editor Katie Dunleavy, MB, BCh, BAO in conversation with Laurel Podulke-Smith

Before exploring a career in medicine, my first love was singing opera. As a young lyric soprano, I had the opportunity to travel the world singing and learning from masters of their craft. Along the way, I learned about Alexander Technique (AT), a method that explores how you do what you do. As a music major at Middlebury College, my voice teacher often employed techniques from AT to help decrease unnecessary tension and poorly formed habits to allow my natural voice to release. Years later, as a GI fellow at Mayo Clinic, I once again turned to AT when encountering pain and tension when learning to perform endoscopy. Prior to the ASGE guidelines on the “Role of Ergonomics for Prevention of Endoscopy-Related Injury,” I sought help outside of medicine to optimize my body for a long career in endoscopy. The reactions were contrary; in the performing arts world AT was exclaimed on high to

Trainee Hub | 17

// TRAINEE HUB

musicians, dancers, and singers, but in medicine it was a mere murmur. I am very grateful to Dr. Jean Fox, Gastroenterology Consultant at Mayo Clinic, for introducing me to Laurel Podulke-Smith, a seasoned AT instructor living in Rochester, MN. Incredibly, Laurel’s experience as an AT instructor at the Dan Abraham Healthy Living Center (DAHLC) at Mayo Clinic allowed her to observe and improve the health of patients, doctors, and health care providers. I had been exposed to AT throughout my life, but it wasn’t until I began practicing AT principles daily (akin to a daily vocal warm-up) that I saw the true power of this method and the positive impact of feeling better in your body. Since beginning AT lessons, I feel less fatigued, more aware of how my body rests and the habits that place strain, more engaged at work and at home, more agile during endoscopy and most importantly, I have learned to do less. I want to share my secret for learning to better operate the self from within.

Introduction to the Alexander Technique

The Alexander Technique was created by Frederick Matthias Alexander, who was born in 1869 in Tasmania. As a young actor, he developed a hoarse voice and despite medical advice he did not improve. Alexander took his health into his own hands and started observing the mechanics of his speech using two mirrors. He noticed that each time he spoke, he saw his head move back and downward on his neck as his neck thrust forward, and he awkwardly gulped for air. Once he acknowledged this tension-fraught mannerism, he found it difficult to prevent. Through further study he disproved several widely held beliefs: 1) he believed he would know if he was doing harm to his body, 2) he believed his body would function normally without assistance, and 3) he believed he could make his body do what he wanted. The idea of undoing was a term he called ‘inhibition’ driven by thinking opposite thoughts. He later termed ‘directing’ to

18 | GI.ORG/ACGMAGAZINE

describe the new set of verbal instructions he gave himself to maintain a tensionfree movement that takes advantage of gravity. Through self-experimentation and observation, Alexander returned to the stage in London and began a movement to study human reaction.

Q&A with Laurel Podulke-Smith:

I sat down with Laurel Podulke-Smith to discuss her experience with AT and how, as gastroenterologists, we can ALL use AT to improve well-being, resilience, and career longevity. Laurel is a 2005 graduate of the Alexander Training Institute of Los Angeles, where she completed her three-year, 1,600hour training. Upon certification, Laurel taught the Alexander Technique for many years in the Los Angeles area in private practice, as well as at numerous colleges, schools, and performing arts academies. Upon moving to Rochester, MN, in 2009, Laurel joined the Mayo Clinic's Dan Abraham Healthy Living Center team as an educator and healthcare professional specializing in the Alexander Technique. Serving students, patients, and staff holistically, her work centers on resiliency, healthy aging, and social well-being. A lifelong advocate for the power of local government, in 2023 Laurel ran for county commissioner and won! She currently serves on the Board of County Commissioners in Olmsted County, MN, and finds that the Alexander Technique was the single best preparation to be an elected official. She attributes her listening skills, enjoyment of public speaking, and unflappability to her AT training. In addition to her AT training, Laurel has a bachelor’s degree in Theater Arts from the University of Minnesota, and a master’s degree in organizational leadership from Saint Mary’s University of Minnesota. Katie Dunleavy: What is Alexander Technique? Laurel Podulke-Smith: The best description of Alexander Technique is that ‘it’s what you always needed, but never knew existed.’ It may sound like a cheeky and confident response, but it is true. In fact, I had this response to AT when I was 21 years old studying theater at the University

of Minnesota. I took a class called "Movement for Actors" that was taught by an AT teacher. I was both intrigued and mystified. I could feel the benefit, but I didn’t understand why. I was determined to learn everything I could about AT. I took all the group classes and private lessons I could find in Minneapolis, until it became clear that my only next step was to train to become a teacher. I moved to California and trained in my early 30s to become a certified Alexander Technique teacher. The path we take to cultivate change can be challenging to understand at first. Teachers will sometimes say the technique is hard to define, but I haven’t found that to be true. I think it’s quite simple, AT is a method for improving the overall postural health, functioning, and coordination of the body. This definition is most closely connected to its origins in early 1900s London. What evolves is how the technique improves postural health, quality of life, well-being, coordination, and functioning. Over time we have developed deep and far-reaching habits and tendencies that interfere with postural health. These habits affect our emotional life, our perceptions, our self-regard, and how we experience the world around us and the life of the interior body. AT is so much more than postural health; it is a whole work of resource, meaning, and wholeness. KD: What are the principles of Alexander Technique? LP-S: The key to AT is that it is a form of education, and not a therapy or treatment. It’s a process of learning self-awareness and applying the principles of AT. Overwhelmingly, people know they are suffering. People know that they feel pain, strain, and tension; they know their habits are connected to their suffering. The piece that is so unique to AT that I have honestly not found anywhere else, is the way we go about cultivating these positive changes. In society, we are strivers, and we are conditioned to think we can fix things through

doing. The trouble is that the ways we struggle posturally are a result of our doings and over-doings. In the process, we often add judgmental corrections to try to fix a condition, which in turn exacerbates our troubles. KD: When I first heard about AT, it was the improved postural health that caught my attention. Some may wonder how this is different from physical therapy? My experience is that this is a learned practice for the whole body, not just focused on painful aspects of living. LP-S: The principle that sets AT apart is that the improvements of interest require stepping back before you can move forward. We use a principle called ‘inhibition’ which is the human capacity for non-reactivity and less habitual reactivity to stimuli. This is a reset, it gives us a chance to not take the usual path, but instead gives us time and space to rethink so that when we take action it’s volitional, conscious, productive, and sustainable. This is a process of sorting, to stop the unhelpful processes and cultivate healthy habits. As you can see, it’s much more than postural health. KD: Why is the Alexander Technique relatively unknown? LP-S: I have pondered this question for 25 years! My answer is two parts: 1) It’s a serious technique that asks us to build honest awareness about what we do and how we do it. We must have a willingness to not do our usual habits. Not everyone is up for that task. Our habits are comforting, familiar, and not being our usual way in the world is disorienting and intimidating. You have to be willing to be wrong, to feel wrong. To be clear, wrong in this practice means different. We override the instinct to go back to the familiar, and we cultivate a willingness to go into the unknown continuously and on purpose. It’s a big, serious task. KD: I wholeheartedly agree that AT is deeply personal work, and very distinct from the quick-fix wellness influencers. In my experience, the undoing takes

longer than I would like because the appeal of the known can be stronger than the desire to change. It helps to believe in AT from the beginning. The enlightening moments that come during a lesson hold both discomfort and relief, and it can be hard to reconcile these cognitive dissonances. LP-S: 2) AT somehow got swept into the highly competitive nature of acting, and this may have contributed to the relative anonymity of AT in the public. It’s no secret that high-level performers are well aware of AT and often AT teachers are on sets with A-list actors and actresses. For some, AT is used to maintain their competitive edge and revealing their secret weapon may not be appealing. KD: That’s so interesting. For me growing up taking voice lessons in NYC, I often heard of AT. It was a tool, just as we were expected to take dance classes for stage presence, those who were serious about opera took AT lessons. Many of my voice teachers used AT language and imagery. I viewed my body as my instrument, and it was culturally expected that we take care of ourselves in every possible way. This feels starkly different from medicine where a culture of wellness is not inherent. In recent years, there’s been a movement for doctors to ‘be well,’ but the weekly wellness emails are not helping. In order to move past the moral injury, the grief from loss, health care providers need something that fills our cup. I love that AT has shown me that saying goodbye to behaviors that are contrary to my health and well-being help me sustainably recharge. This may be opposite to the culture of medicine, but to move forward as humans we can only heal others if we are well and truly non-reactionary. As doctors, we are trained to be calm in urgent situations, but that’s not the same as being nonreactionary because our bodies hold the tension. It’s as simple as starting with awareness: how am I holding space with a colleague, a patient, a friend? The rest will follow.

KD: You are uniquely positioned because you’ve worked with performers, doctors, nurses, and patients. Do you think AT is accessible for people who work in healthcare? LP-S: There is no limit to the degree to which AT can bring anyone benefit. Anyone can learn it and apply it. F.M. Alexander would boast about his best student, who was an elderly lady, but her understanding and alertness far outshone the others. AT is for anyone, at any age and can be used for healthy aging. It’s a highly adaptable and agile technique which can be used to improve balance, resiliency, and agility. The reason AT works is because the body is resilient, including our emotional life, our perceptions, and our thinking life. KD: Do you think it’s harder for healthcare workers to believe in the Alexander Technique? LP-S: There was a time in my clinical practice at the DAHLC when my clients were all doctors. I think this was because the physical stresses of doctoring are unimaginable to most. The doctors who came to see me were experiencing the emotional and physical manifestations of burnout, including chronic headaches, thoracic outlet syndrome, jaw strain, and repetitive musculoskeletal injuries. AT treated their whole being. Sadly, for most doctors it took a personal health crisis for them to take action with their health. KD: Why do you practice Alexander Technique? LP-S: It is purely for my wellness. I was not trying to fix or improve habits based on a crisis. This is a practice of self-care and selflove, and time spent doing AT is the most important time I have in my whole week. My goal is to use AT as an investment in the longevity of my career so I can help people for longer. KD: Can you share a meaningful story of change for a client? LP-S: The people I have helped resolve chronic pain issues see tangible impacts on their daily lives. But a story that stands out is not glamorous, and instead shows the power of AT as a holistic practice. A woman came to AT with a constellation of problems she couldn’t see her way through.

Trainee Hub | 19

// TRAINEE HUB

She felt like she was at the end of her rope. She decided to try AT because it couldn’t hurt. During our first lesson I spent time asking her simple questions about why she was here, and she broke down in tears. She expressed that I was the first person to listen to her in a very long time. The other part about why AT works is because we are trained as teachers to interact with others non-coercively. We present with optimism and hold a positive non-judgmental space the student can join in. Over time the therapeutic relationship starts to heal people socially. The social well-being component is really underestimated. Often people feel alone in their suffering or problems. It’s a clue, just as thirst tells us to drink. The feeling of loneliness that we often get lost in, is actually just an indication to cultivate social connection. AT private instruction and group classes satisfies that basic human need for social connection. Ultimately, my client thought she was coming for health reasons, but she may have been more healed from the social connection. KD: I enthusiastically agree! Just knowing someone like you exists in the world inspires me to be better in my own interactions, and to always come from a place of kindness. If doctors are feeling guilty about taking time for self-care, they should know that AT dramatically improves our ability to interact with others. So, it’s essentially an investment in their patients. KD: Since I’m sure we convinced all our readers to try AT, what are some resources for finding an Alexander Technique teacher locally? LP-S: It would make me so happy to think there are more people interested in improving their lives through AT! There are hundreds of AT teachers, thousands throughout the world. Most major cities have some presence of AT. In places like LA, San Francisco, NYC, London, Sydney, there is a culture of AT that follows the performing art centers. If you are interested, we recommend you only use an official AT certified instructor. (Note: For Laurel to become an AmSAT certified teacher she completed training over three years and 1,600 hours!) Check out AmSATonline.org for more information. Read “How You Stand, How You Move, How You Live” by Missy Vineyard if you are interested in reading more about AT with self-directed exercises.

20 | GI.ORG/ACGMAGAZINE

Laurel Podulke-Smith, certified Alexander Technique instructor, conducts a private lesson with Dr. Katie Dunleavy, third year GI fellow at Mayo Clinic, Rochester, MN. Here you can see Laurel uses light touch and visual imagery to guide Katie into tension-free postures of strength and stability. Lessons are often conducted standing, on a chair, on the floor, or on a working table. Due to Katie’s interest in improving fatigue and strain from endoscopy, lessons often simulate endoscopic procedures and focus on dynamic movements void of tension.



Trainee Hub | 21

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.

22 | GI.ORG/ACGMAGAZINE

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

GETTING IT Incorporating Advanced Practice Providers into GI Practice Enhancing GI Care

By Mary Vetter, ANP, University of Rochester Medical Center, Lenore Lamanna, EdD, RN, ANP-BC, Stony Brook University, Kimberly Orleck, PA-C, Atlanta Gastroenterology Associates, Sarah Enslin, PA-C, University of Rochester Medical Center

ADVANCED PRACTICE PROVIDERS (APPs), INCLUSIVE OF NURSE PRACTITIONERS (NPs) AND PHYSICIAN ASSISTANTS (PAs), REPRESENT A CRITICAL PART OF HEALTH CARE DELIVERY SYSTEMS. The Bureau of Labor Statistics predicts that the NP and PA workforce will grow by greater than 40% and 28% respectively by the year 2031.1,2 As demands for health care increase and physician shortage projections increase, APP utilization in clinical practice settings will be important to improve patient access to care, promote continuity of care, and enhance patient care delivery.3,4 APPs represent an essential part of the health care work force and are able to

provide safe, high quality and cost-effective care to patients.5-8 This article will discuss multiple important aspects of incorporating APPs into a GI practice including APPphysician collaboration, onboarding programs, leadership structures and billing/ reimbursement. BENEFITS OF ADDING APP(S) INTO A GI PRACTICE It is estimated that 60 to 70 million people in the United States are affected by gastrointestinal diseases accounting for 48.3 million ambulatory care visits annually.9 Additionally, there is a projected shortage of 1,630 full-time gastroenterologists.10 Adding APPs to GI practices increases access to care, reduces wait times for consultations and follow-up

visits, enables physicians to focus on endoscopic procedures and complex medical issues, and reduces burnout of the entire healthcare team. The utilization of APP skillsets can enhance value for both patients and practices. There have been several models of health care delivery described which demonstrate effective integration of APPs into various practice settings including ambulatory clinics, inpatient roles, and hybrid (practicing both inpatient and outpatient) roles. Additionally, APPs can develop specialized skillsets which enhance patient care such as performing ancillary procedures and delivering specialized patient education.11-14

Getting it Right | 23

// GETTING IT RIGHT

 KEY components to success in incorporating and optimizing APPs into gastroenterology practices include: • defining the role of the APP • recognizing differences in scopes of practice and credentialing for NPs and PAs at the state and institutional level • encouraging APPs to practice at the top of their licensure according to their scope of practice • understanding physician-APP collaboration and practice agreements, billing and reimbursement • developing a robust orientation and onboarding program for new APPs and encouraging professional development and leadership opportunities These important components promote practice integration, role optimization and professional fulfillment.15-17

APP SCOPE OF PRACTICE Education and clinical experience of APPs varies by degree. NPs are registered nurses who then enroll in graduate programs to receive their advanced degree which allows them to practice as a medical provider. NPs take a national certification examination once and renew their certification every 5 years. PA programs are often master level degrees; no prior clinical experience is necessary to enter these programs. PAs are required to take a national certification examination every 10 years. There are doctoral level programs for NPs and PAs who wish to advance their education further, including Doctor of Nursing Practice (DNP) and Doctor of Medical Science (DMSc) degrees, respectively. Doctorate degrees are not currently required for practice as an APP. The scope of practice for APPs varies from state to state. NPs in some states can practice independently without physician supervision. In other states, NPs are required to document a minimum number of hours collaborating with a physician prior to practicing independently while others

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require physician supervision indefinitely. For example, in New York state, a new NP graduate must complete 3,600 hours of practice post licensure and have an attestation of physician collaboration before they can practice independently. NPs with more than 3,600 hours of experience do not need a formal relationship with a medical doctor to practice, and can “evaluate patients; diagnose, order and interpret diagnostic tests; initiate and manage treatments; and prescribe medications,” according to the American Association of Nurse Practitioners.18 Practice authority varies across states and with the passage of new legislation. Groups should be aware of state rules when incorporating APPs into their practice and for more information on NP practice authority by state visit: aanp.org/advocacy/state/statepractice-environment. PA’s scope of practice also varies from state to state. Some states have a requirement for a certain percentage or number of PA charts be co-signed by a physician while other states have no co-signature regulation. Many states have established limits on the number of PAs a physician can supervise or collaborate with. In New York state, PAs must have ongoing supervision by a physician but this does not require the physical presence of the supervising physician at the time and place where clinical services are performed.19 Additionally, there may be restrictions regarding PA scope of practice in relation to their collaborating physician’s skillset. We encourage you to visit amaassn.org/sites/ama-assn.org/files/corp/ media-browser/public/arc-public/statelaw-physician-assistant-scope-practice.pdf for each state’s practice authority. There are a paucity of formal studies investigating the role of APPs in gastroenterology. In the inpatient setting, APPs can be a part of a primary team or consulting team and can perform new patient evaluation and continuity visits.11 In many health systems, APPs are often the first point of contact for hospitalists and referring physicians.8 APPs may also be trained and credentialed to perform procedures such as percutaneous gastrostomy replacement, large volume paracentesis, percutaneous liver biopsy, and esophageal and/or anorectal motility testing. In the outpatient setting, APPs play a pivotal role in direct patient care and indirect patient care tasks. For direct patient care, one of several models may be used including:

1. APPs see patients independently. b. APPs may see patients for new patient consultation independently and maintain their own panel of patients with physician input as needed. c. Patients may see physicians for their initial consultation and then see APPs in follow-up. 2. APPs see patients both independently and in shared visits with their collaborating physicians. This model supports APP autonomy and encourages ongoing education and mentorship with the collaborating physician. This model is more common in academic centers who see a high volume of complex referrals. 3. APPs perform in a hybrid role with a combination of inpatient service time and outpatient clinic time. In addition to direct patient care, APPs also respond to telephone calls, complete telehealth visits, prescription renewals and pre-procedure visits. In gastroenterology, APPs have an invaluable role in periprocedure management, including engaging in interdisciplinary care to optimize patient’s comorbidities prior to endoscopy and ensuring antithrombotic therapy is appropriately adjusted for endoscopic procedures when warranted. While many APPs see a variety of gastrointestinal complaints, there has been an increase in sub-specialization over the last decade in areas such as inflammatory bowel disease, hepatology, motility, and GI-oncology. A study which evaluated the impact of APPs on cirrhotic patients showed the addition of APPs to the medical team improved patient adherence to screening recommendations and reduced both 3-day readmissions and mortality of cirrhotic patients.20 Studies support that APPs can achieve similar polyp detection rates (PDR) and adenoma detection rates (ADR) as physicians, but to achieve this, extensive training and skill is required.21 Additionally, the scope of practice is regulated by state as mentioned earlier and may differ between NP and PA. Data suggest APPs can increase the colorectal cancer screening rate in the United States at a reduced cost to

taxpayers and other payers with equal safety and effectiveness.22 APP ORIENTATION AND ONBOARDING For successful integration of an APP into a GI practice, a strong and comprehensive orientation and onboarding program is essential. It is key to remember that unlike physicians who have completed a residency and fellowship program, APPs come from a variety of backgrounds with varying patient care and clinical experience. There are limited GI APP fellowship programs available in the United States for APPs who wish to enroll in a formal 12-month post-graduate program. These programs consist of didactic learning, clinical experience, and exposure to clinical research. There are also subspecialty APP fellowships such as the Inflammatory Bowel Disease APP Fellowship at Cleveland Clinic. These require dedicated time and for an individual practice may not be practical.

 KEY Consideration: Due to the limited number of programs around the country, most APPs require on-the-job training and specialty education via their physician colleagues and senior APP colleagues.

The onboarding process may differ based on an individual APP’s past training and experience. Regardless of their background however, a formal orientation and onboarding program, including didactic learning, will set an APP up for success. Upon starting their new position, orientation should include a deeper dive into the practice as a whole and his/her specific role within the group. This should include face-to-face time with their direct supervisor who should again review in detail: • Which physician(s) they will be working with • Roles and specific responsibilities (inpatient, outpatient, call schedule, in basket responsibilities) • Productivity expectations • Expectations for periodic performance reviews Orientation should also include an overview of proper billing and coding, electronic medical record training, an overview of ancillary services offered

by the practice (infusion, imaging, etc.) and meetings with key individuals from each department (coding, compliance, human resources, etc.) It may also be helpful to have APPs shadow with services such as thoracic surgery, colorectal surgery, surgical oncology, and interventional radiology, particularly in large academic practices. GI EDUCATION The onboarding process often lasts for 3 to 6 months, but may vary based on the APPs individual training and experience and the practice expectations. Onboarding should include training with physicians or other APPs. This may be with one or multiple provider mentors, depending on the size and structure of the practice. The APP should also be provided with learning opportunities during onboarding such as textbooks, UpToDate access, national guidelines and any practice specific protocols or algorithms. There are many excellent resources available for APPs starting a career in GI including the American College of Gastroenterology (ACG) APP training series on the ACG Education Universe (education.gi.org) and the many free virtual learning opportunities on the Gastroenterology Hepatology Advanced Practice Provider (GHAPP) website. APPs starting in GI should also be encouraged and supported with CME time and money to attend GI-specific CME courses. While there are many GI CME courses available, some are tailored specifically for APPs in GI including the American Gastroenterological Association’s (AGA) Principles of GI for the NP and PA, American Society of Gastrointestinal Endoscopy’s (ASGE) Annual APP Course and the GHAPP National Conference. Supporting and encouraging APPs to attend these conferences will not only build their clinical knowledge but allow them to network with hundreds of other GI APPs, increasing morale and engagement. Another way to increase APP knowledge and demonstrate support is to include APPs in GI trainee programs such as journal clubs, grand rounds, and morbidity/mortality meetings. In addition to these roles, APPs can also develop leadership roles through clinical research, APP fellowship and residency programs, APP education and nationally through participation in national GI societies. The American College of Gastroenterology has a 40+-member APP committee. Transitioning to a new APP role can be stressful and challenging for both novice

and experienced APPs, but with a structured orientation and onboarding program you can minimize the stress and anxiety not only for the APP but for the practice as a whole.

 KEY for Success: • APPs should have a dedicated Physician leader to act as a liaison for APPs in practice to enhance communication, feedback and open discussion. Regular check-ins with new APPs will ensure they feel supported and encourage success and facilitate an opportunity for constructive feedback. The cadence and formality of these check-ins may vary but it should occur frequently during the first few months and continue periodically throughout the first year. • Senior APPs should have at minimum an annual evaluation to discuss clinical productivity and performance. This is also an excellent opportunity to discuss their career goals and professional development opportunities.

PHYSICIAN-APP COLLABORATION Many institutions and practices require a formal collaborative agreement which outlines regulatory guidelines, policies, and procedures that both parties agree to adhere to. There are several other aspects of collaboration that contribute to a successful partnership. The APP role should be clearly defined with an understanding of each person’s individual roles and responsibilities. A team-based approach, inclusion, and open, honest communication also contribute to the development of a successful collaborative practice. Finally, the physician should serve as a mentor, both for clinical and professional development.23 Mentorship in professional development is crucial to the success of the APP and to their career advancement. As the APP becomes more experienced, increasing their involvement in complex clinical cases, including them in research and scholarly work, and promoting them for leadership opportunities helps to increase their career satisfaction.

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LEADERSHIP STRUCTURES The role of APPs and the idea of team-based practice has evolved over the last several decades with rapid growth in the APP profession. An increasing number of health systems and practices are recognizing the need for and benefit of a defined leadership structure for APPs. In many groups, APPs are appointed to lead a group of colleagues in clinical operations, oversee regulatory and compliance standards, and help develop/support strategic planning. Having dedicated APP leaders increases involvement and may increase retention.24 It is anticipated that over time APP leadership roles will become more formalized and inclusive at the executive level. Example In large health systems, there is a senior leader role either Director, Senior Director, Vice President, Chief of APPs, or similar title. Many leaders in this role play a significant role in the strategic plan for APPs, clinical resource deployment, recruitment and hiring processes, monitoring and reporting of compliance and regulatory measures, and development of system processes. Clinically, there may be APP leaders at the departmental level, overseeing several other divisions and often participating in department operations and leadership meetings, recruitment strategies, onboarding and clinical competency evaluation, and at the divisional level, focused on daily operations and the onboarding, recruitment, and competency of individual APPs. In smaller health systems and private practices, APPs typically report directly to the practice manager and the supervising physician. BILLING/REIMBURSEMENT APPs, similar to physicians, are reimbursed by payers for medical and surgical services provided, although the process for enrollment, extent of physician supervision, documentation, and rates vary based on state of practice and payer. There are three primary ways in which an APP is reimbursed by a payer: independent, incident-to, and shared visits.

Mary Vetter, ANP, University of Rochester Medical Center

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A. Independent (this pertains to outpatient and hospital care) APPs can bill and be reimbursed for both new patient evaluations and follow-up visits, both inpatient and outpatient. Independent visits are billed for using the APPs National Provider Identifier (NPI). Medicare reimburses these visits at 85% of the Medicare Physician Fee schedule, while many independent payers reimburse generally 9095% of physician rate. B. Incident-To (this pertains to outpatient care) Billing for this visit type occurs only after the physician has seen the patient for the initial consultation, outlined diagnosis and treatment recommendations, and initiated the course of treatment. The APP can then see the patient in a subsequent visit for the same medical issue but cannot adjust the treatment plan as needed. The APP cannot see the patient for new medical issues and bill incident-to. Additionally, the physician needs to maintain an active role in the management of this patient. They do not need to see the patient directly but must be available for immediate discussion if needed. (Note: physician must be in the same clinical practice setting for this to apply which has led to less use of this.) C. Shared Visits (typically for hospital care or site of service) Shared visits are when an APP and a physician see the patient on the same date. The physician must document their extent of involvement in the patient’s evaluation and management, as well as portions of the history, physical and/or plan of care. These visits can be performed inpatient or outpatient but exclude surgery and critical care. Shared visits are reimbursed at a rate of 100% of the Medicare Physician fee schedule. There are anticipated changes to the CMS billing requirements for shared visits which will be effective in January 2024.

Lenore Lamanna, EdD, RN, ANP-BC, Stony Brook University

REFERENCES

1. Bureau of Labor Statistics, U.S. Department of Labor, Occupational Outlook Handbook, Nurse Anesthetists, Nurse Midwives and Nurse Practitioners https://www.bls.gov/ooh/healthcare/nurseanesthetists-nurse-midwives-and-nurse-practitioners.htm. Published 2022. Updated September 8, 2022. Accessed January 3, 2023. 2. Bureau of Labor Statistics, U.S. Department of Labor, Occupational Outlook Handbook, Physician Assistants. https://www.bls.gov/ooh/ healthcare/physician-assistants.htm. Published 2022. Updated September 15, 2022. Accessed January 3, 2023. 3. Lang L. Physician shortage predicted through 2020. Gastroenterology News 2004;127(6):1657. 4. IHS Markit Ltd. The Complexities of Physician Supply and Demand: Projections From 2019 to 2034. Washington, DC: AAMC; 2021. In. 5. Ammi M, Ambrose S, Hogg B, Wong S. The influence of registered nurses and nurse practitioners on patient experience with primary care: results from the Canadian QUALICO-PC study. Health Policy. 2017;121(12):1215-1224. 6. Kartha A, Restuccia JD, Burgess JF, Jr., et al. Nurse practitioner and physician assistant scope of practice in 118 acute care hospitals. J Hosp Med. 2014;9(10):615-620. 7. Donovan AL, Aldrich JM, Gross AK, et al. Interprofessional Care and Teamwork in the ICU. Crit Care Med. 2018;46(6):980-990. 8. Allen JI, Aldrich L, Moote M. Building a Team-Based Gastroenterology Practice With Advanced Practice Providers. Gastroenterol Hepatol (N Y). 2019;15(4):213-220. 9. National Institute of Diabetes and Digestive and Kidney Diseases, Digestive Diseases Statistics for the United States. https://www. niddk.nih.gov/health-information/health-statistics/digestivediseases. Updated November 2014. Accessed. 10. U.S. Department of Health and Human Services HRaSA, National Center for Health Workforce Analysis. National and Regional Projections of Supply and Demand for Internal Medicine Subspecialty Practitioners: 2013-2025. https://bhw.hrsa.gov/sites/default/ files/bureau-health-workforce/data-research/internal-medicinesubspecialty-report.pdf. Published 2016. Accessed April 1, 2023. 11. Thurler AH, Waghmarae P, Staller K, Burke KE. How to Incorporate Advanced Practice Providers Into GI Practice. Gastroenterology. 2021;160(3):645-648. 12. Sun E, Hughes ML, Enslin S, Bull-Henry K, Kaul V, Littenberg GD. The Role of the Gastrointestinal Hospitalist in Optimizing Endoscopic Operations. Gastrointest Endosc Clin N Am. 2021;31(4):681-693. 13. Nandwani MCR, Clarke JO. Incorporating Advanced Practice Providers Into Gastroenterology Practice. Clin Gastroenterol Hepatol. 2019;17(3):365-369. 14. Kuriakose C, Stringer M, Ziegler A, et al. Optimizing Care Teams by Leveraging Advanced Practice Providers Through Strategic Workforce Planning. J Nurs Adm. 2022;52(9):474-478. 15. Nandwani M, Blacker A, Shanafelt TD, Harshman J, Kuriakose C. Promoting Professional Fulfillment for Advanced Practice Providers. NEJM Catalyst. 2022;3(10):CAT.22.0183. 16. Proulx B. Advance Practice Provider Transformational Leadership Structure: A Model for Change. J Nurs Adm. 2021;51(6):340-346. 17. Chaney A, Beliles G, Keimig A, Porter I. Advanced Practice Provider Care Team Models: Best Practices From an Academic Medical Center. J Ambul Care Manage. 2022;45(2):126-134. 18. American Association of Nurse Practitioners’, State of New York Grants Full and Direct Access to Nurse Practitioners. https://www. aanp.org/news-feed/state-of-new-york-grants-full-and-directaccess-to-nurse-practitioners. Published April 11, 2022. Accessed January 3, 2023. 19. American Medical Association (2018). Advocacy Resource Center: Physician assistant scope of practice. https://www.ama-assn.org/ sites/ama-assn.org/files/corp/media-browser/public/arc-public/ state-law-physician-assistant-scope-practice.pdf. In. 20.Tapper EB, Hao S, Lin M, et al. The Quality and Outcomes of Care Provided to Patients with Cirrhosis by Advanced Practice Providers. Hepatology. 2020;71(1):225-234. 21. Riegert M, Nandwani M, Thul B, et al. Experience of nurse practitioners performing colonoscopy after endoscopic training in more than 1,000 patients. Endosc Int Open. 2020;8(10):E1423-E1428. 22. Hutfless S, Kalloo AN. Screening colonoscopy: a new frontier for nurse practitioners. Clin Gastroenterol Hepatol. 2013;11(2):106-108. 23. Enslin S, Kaul V. GI Physician–APP Collaboration In Modern Gastroenterology Practice. Gastroenterology & Endoscopy News. GI APP Corner Web site. https://www.gastroendonews.com/ PRN/Article/03-22/GI-Physician%E2%80%93APP-CollaborationIn-Modern-Gastroenterology-Practice/66317. Published 2022. Accessed April 17, 2023. 24. Mahoney M, Beatty D, Kuriakose C, Anen T, Hartsell Z. The Key Role of Advanced Practice Providers in Today’s New Normal. https:// www.physicianleaders.org/articles/key-role-advanced-practiceproviders-todays-new-normal. Accessed April 17, 2023.

Kimberly Orleck, PA-C, Atlanta Gastroenterology Associates

Sarah Enslin, PA-C, University of Rochester Medical Center

SUBMIT YOUR APPLICATION for the ACG

2024 International GI Training Grant Awards The International Relations Commi ee of the American College of Gastroenterology is now accepting applications for the 2024 International GI Training Grants. Each training grant will award one fellowship, with a maximum of $10,000, during 2024. Grants are to be used for travel to and from the training center and to the ACG Annual Meeting, as well as for incidental expenses related to the training. The training must take place between July 1, 2024, and June 30, 2025.

INTERNATIONAL GI TRAINING GRANT

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

SUBMISSION DEADLINE March 31, 2024 APPLY HERE gi.org/gi-training-grants

NORTH AMERICAN INTERNATIONAL GI TRAINING GRANT

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

SUBMISSION DEADLINE March 31, 2024 APPLY HERE gi.org/gi-training-grants

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Special Issue:

Well-being

Joy and Well-being in the Practice of Medicine – The Importance of the Human Connection By Keith W. Jones; Cynthia M. Stonnington, MD; and Jonathan A. Leighton, MD, FACG

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Community Garden, Mayo Clinic in Arizona

OUR WORLD IS BECOMING MORE COMPLEX AND COMPLICATED. The healthcare sector, like other communities, has been struggling with burnout and disengagement due to factors such as declining reimbursement, pressure to increase productivity, stricter regulatory requirements, growing patient expectations, and yes, social media. If that is not bad enough, we have also been burdened with increased administrative and logistical burdens, unintended consequences of the electronic health record, people working in silos, and ineffective care teams. This has led to our frontline teams feeling disempowered, less engaged with their mission and purpose and, in turn, a decrease in retention. Gastroenterology and Hepatology, as medical disciplines, are no different. To reduce burnout and infuse joy and well-being into our daily routines, we need to be more intentional and use practice innovation and technology to enable more opportunity for human connections and time to think or recharge. We also need to cultivate leaders who listen effectively and create an environment where individuals are motivated to excel and foster a sense of community and authentic peer support. Across the nation, wellness programs have been steadily added to the list of offerings companies provide to their employees. Healthcare organizations are no exception. In many cases, the programs are ancillary benefits aimed at boosting staff resiliency and bolstering joy. While potentially beneficial, these interventions can be met

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“To reduce burnout

and infuse joy and well-being into our daily routines, we need to be more intentional and use practice innovation and technology to enable more opportunity for human connections and time to think or recharge. We also need to cultivate leaders who listen effectively and create an environment where individuals are motivated to excel and foster a sense of community and authentic peer support.”

with skepticism if not integrated into organizational culture and if the problems caused by the system itself are not recognized. With the growing complexity of challenges that affect healthcare delivery systems, we believe well-being efforts can be designed and utilized in a more effective and integrated way to solve problems. At Mayo Clinic, our secret sauce has always been our rich culture of working in collaborative teams for our patients. However, we too have seen trends similar to those across the nation with respect to burnout and well-being. Our Office of Joy and Well-being has thus been focused on inspiring change to reverse those trends.1 In this article, we seek to explore how making well-being the center of all decision-making in healthcare can help individuals and organizations, large and small, thrive better. Service Organizations Should be Generous in Investing in their Staff It is time to re-center the narrative and story of medical care to elevate our values, purpose, and connection to each other. This is critical if we expect our colleagues and allied health staff to treat each other with kindness and respect and deliver great care and connect compassionately with our patients. Generosity can be defined as being kind to our staff and providing them with the resources they need to be successful. We believe that practices, small and large, need to be generous to their employees if they are going to excel. Examples include delegating specific “joy” funds out of their budget for joy and wellbeing activities, providing space in the day for team huddles, and enabling flexibility in scheduling and enough time to complete necessary tasks. This generosity strengthens staff’s sense of community, security, and loyalty.2 It also leads to trust and inspires them to go the extra mile to serve others. Leaders can achieve this by developing a culture of well-being through wellness-centered leadership training, promoting belonging and inclusion, enhancing the human connection, and developing highly functioning care teams.

Well-being Should be Adopted as an Institutional and Practice Value Well-being should be adopted by healthcare practices as a core value, and each member of the health workforce should feel valued. We are all familiar with the Triple Aim which focuses on patient care, patient experience, and the cost of care. The current standard is the Quadruple Aim, which also addresses the issue of burnout and well-being in health care professionals.3 All practices, large and small, should “authentically” listen to their staff and truly understand the challenges they face. In addition to addressing the “pebbles in the shoe”4 and tackling systemic drivers of burnout, every administrative decision or change must factor into the impact on the staff’s well-being, ideally using a triad leadership model where physicians, nurses, and administrators partner together to accomplish this goal. Leaders need to engage their staff in meaningful dialogue and exercise active listening to gain their trust and valuable insights. This is not only critical for the health of our staff but also because we know that an engaged and empowered workforce is necessary for our patients to have a great experience as well. If done properly, this will also improve employee retention. If done exceptionally, it can lead to highly functioning care teams that support each other, take excellent care of patients, and naturally inspire change for the better. There Should be a Priority on Creating Psychological Safety and Developing Highly Functioning Care Teams Wellness-centered leadership is critical for gastroenterology practices to be successful in reducing burnout and improving the well-being of their staff.5 It starts with modeling the foundation of caring for people always, which leads to cultivating relationships with individuals and teams with the intent to inspire change that again improves the current environment. Leaders are not always trained in a way that promotes staff well-being, but it is

“It’s important that

organizations create an environment committed to a compassionate workforce that acknowledges, listens, empathizes, and makes that human connection. It is about each person bringing their best self to work because they feel valued, empowered, and accountable.”

necessary in our current environment. Wellness-centered leadership cultivates a sense of community, a deeper connection to meaning and purpose in the work we do every day, and emphasizes choice and autonomy. It fosters one’s intrinsic motivation to engage and do the right thing for each other and for patients. A leader’s willingness to be vulnerable, open, curious, and accepting of views different from one’s own are some of the traits that foster psychological safety among team members. Expert teams, as opposed to a team of experts, require good leadership behaviors, psychological safety, role clarity, peer support, emotional intelligence, trust, task interdependence, regular debriefs, and celebration of wins and recognition of contributions.6 High-functioning care teams produce high quality patient care, greater efficiencies, and reduced burnout among team members. We Should Focus on Individual and Collective Well-being Well-being interventions need not be complicated or costly to be effective. When leaders both prioritize their own well-being and integrate well-being initiatives within the normal workday, they can make a powerful impact. At Mayo Clinic in Arizona, we introduced a 12-week, voluntary, 15-minute daily well-being intervention called “The Practice.” Individuals performed a short gratitude exercise, read one page from The Mayo Clinic Guide to Stress-free Living book, engaged in at least 5 minutes of exercise and stretching, listened to an inspiring podcast or faith-based talk, and recorded the completed practice in an accountability group text with other

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throughout the work day, and noted stronger relationships with colleagues.

Above: Keith W. Jones; Cynthia M. Stonnington, MD; and Jonathan A. Leighton, MD, FACG

participants. The individual’s efforts were complemented by bi-weekly group well-being meetings integrated into an existing meeting structure with coworkers in the program. The groups included physicians and allied health staff on a first name basis. Individuals shared how their professional and personal lives were positively affected by applying principles from “The Practice,” including gratitude, compassion, acceptance, higher meaning, and forgiveness. These meetings encouraged vulnerability and provided a psychologically safe space to share challenges in their lives and obtain wellness-oriented feedback from their peers. With individual well-being consistently supported, employees had expanded capacity to contribute to patients, each other, and the organization. After the completion of the initial 12 weeks, “The Practice” participants reported an improvement in their attitude toward work. Specifically, they were able to handle change better, were more optimistic

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“There is so much we

can do in healthcare to reduce stress and create an environment focused on well-being. We know that an engaged and healthy workforce is paramount to delivering the best care to our patients and also treating each other well.”

Practices Need to Promote Belonging, Inclusion, and a Diverse Workforce Collective well-being can aid diversity, equity, and inclusion efforts and vice versa. An example of this is where practices set measurable hiring and promotion targets aimed at increasing overall diversity. Too often we see well-meaning individuals working against each other instead of working together to produce positive change for all. If one side is unwilling to consider the other side’s perspective, their positions only serve to build walls between them. Individuals who contribute to collective well-being are focused on building bridges. They move away from an “us” versus “them” mentality in which one group has exclusive rights on how to improve inclusivity and diversity, while the other group is made to feel defensive and left out. It’s important that organizations create an environment committed to a compassionate workforce that acknowledges, listens, empathizes, and makes that human connection. It is about each person bringing their best self to work because they feel valued, empowered, and accountable. A diverse workforce benefits all. To reap the benefits, practices and organizations must first recognize that underrepresented minorities disproportionately face dayto-day experiences, whether small or large, that increase stress and burnout, undermine well-being, and diminish a sense of belonging. In addition, leaders need to communicate their commitment to creating a diverse workforce to staff in a way that inspires everyone to actively participate in building an inclusive organization. In efforts to make good on the commitment through diversity-inspired strategies and tactics, it is important that organizations and their staff support each other by both acknowledging and constructively addressing experiences of marginalization, and giving grace and, if necessary, coaching, to those who unintentionally say or do something hurtful.7 In this way, all have an opportunity to feel supported and to learn and grow from the experience while continue to cultivate a culture of respect and inclusion.

Lastly, organizations and practices should regularly measure the effects of diversity initiatives and document best practices that can be applied throughout to ensure sustainability in an ever-changing world. Intentionally Enhance the Human Connection through Peer and Community Support Medicine is stressful and stressful clinical events are inevitable. Healthcare professionals also notoriously are reluctant to ask for help due to stigma and a culture that historically glamorizes those who “suck it up.” Yet the reality is that suffering in silence increases the risk of burnout, depression, or even leaving the profession entirely. Peer support and community connections are the first line of defense. Peer support programs that don’t rely on an individual asking for help themselves can effectively reduce the negative consequences of stressful clinical events.8 Trained peer supporters can reach out to the affected colleague and offer support and, if necessary, encourage them to seek out mental health counseling, etc. In addition, support groups and repeated opportunities to connect as a community provide a way for staff to support each other. Examples include Schwartz rounds, hiking groups, community action groups, narrative medicine groups, journal clubs, parenting support groups, and even a community garden. In 2022, a staff community garden was started at Mayo Clinic in Arizona to help reduce stress, promote wellness, and help colleagues connect with each other in new ways. Thus far, it has accomplished those goals. Some teams even did their meetings in the garden. As one person commented, “Having the support to cultivate relationships away from the bedside and to reduce stress and increase well-being is great both from a personal standpoint as well as a team standpoint.”

We Need To Reduce the Burden through Effective Technology and Addressing Regulatory Issues Finally, leadership must recognize the importance of reducing the burdens and barriers in healthcare that directly lead to burnout and commit to effectively addressing them in sustainable ways. Resolving the inefficiencies of the electronic health record and regulatory issues are key. Barriers to being successful must be identified and addressed. We must fix systems and processes that are either broken or do not make sense. Again, this is where we must engage and listen to frontline employees who know what is wrong. For example, through participation in a wellness-centered leadership program at Mayo Clinic, Community Internal Medicine is currently doing a pilot to address staff burnout with cross-team communications breakdowns and inbasket overload. They are focused on addressing inbasket inefficiencies and team communication workflows to improve the functionality of the care team and transform the delivery of care. It is critical to acknowledge that many issues have to do with systems and processes that have not been updated.

References 1. Stonnington CM, Jones K, Leighton JA. How to Infuse Joy in Your Practice: Our Journey to Sustainable Well-Being. Am J Gastro 2022;117:1723-27. 2. Berry LL, Awdish RLA. Health Care Organizations Should Be as Generous as Their Workers. Ann Intern Med. 2021 Jan;174(1):103-104. 3. Bodenheimer T, Sinsky C. From Triple to Quadruple Aim: Care of the Patient Requires Care of the Provider. Ann Fam Med. 2014;12(6):573–576. 4. Institute for Healthcare Improvement, IHI Tool: “What Matters to You?” Conversation Guide for Improving Joy in Work, 2017. https://www.ihi.org/resources/tools 5. Shanafelt T, et al. Wellness-Centered Leadership: Equipping Health Care Leaders to Cultivate Physician Well-Being and Professional Fulfillment. Acad Med. 2021; 96:641-651. 6. Tannenbaum S and Salas E. Teams That Work: The Seven Drivers of Team Effectiveness. Oxford University Press, 2020. 7. Torres MB, Salles A, Cochran A. Recognizing and Reacting to Microaggessions in Medicine and Surgery. JAMA Surg. 2019;154:868-872. 8. Finney RE, Jacob A, Johnson J et al. Implementation of a

The Bottom Line There is so much we can do in healthcare to reduce stress and create an environment focused on well-being. We know that an engaged and healthy workforce is paramount to delivering the best care to our patients and also treating each other well. It is time to create supportive work settings for all of us in healthcare where we prioritize self-care, enable meaning and purpose to flourish, and we joyfully connect and support each other. We must always keep the “why” ahead of the “what.” We can never let the things we do replace the reasons that we do them—the meaning and purpose in our work to keep our patients safe, ensure the best outcomes, and deliver great service. We invite all of you to think of ways to innovate in your practice, inspire change, and promote an environment where we prioritize wellbeing and the human connection.

second victim peer support program in a large anesthesia department. AANA J 2021;89:235-44.

Keith W. Jones Mr. Jones is a Well-being Program Manager in the Office of Joy & Well-being at Mayo Clinic Arizona, where he also chairs the African Descendants MERG (Medical Education Resource Group). Jonathan A. Leighton, MD, FACG ACG President Dr. Leighton is Professor of Medicine at Mayo Clinic Arizona and is the Medical Director of the Office of Mayo Clinic Experience there. He also chairs Mayo Clinic Arizona’s Office of Joy and Well-being. Cynthia M. Stonnington, MD Dr. Stonnington is a consultant and the Interim Chair in the Department of Psychiatry & Psychology at Mayo Clinic Arizona. She serves as Associate Medical Director of Mayo Clinic’s Arizona Office of Joy and Well-Being.

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Faith and Spirituality – Should They be Part of Your Practice and/or Your Life? Mark H. Mellow, MD, FACG, Edmond, OK

Faith and science are often viewed as antagonistic or, at best, separate/ unrelated. It is of interest, however, that Sir William Osler, the father of Western medicine, published an article over 100 years ago entitled, “The Faith that Heals.”1 Let’s define terms: faith is belief, trust, and obedience to a higher power. Spirituality involves meditation, prayer, and oneness with nature (thus, one can be spiritual without being a person of faith, but not vice versa). Certain spiritual practices, also known as mind body practices (MBP) are being recognized as helpful in a variety of health-related settings. In America, the more popular MBP—meditation, mindfulness, and yoga—have been beneficial in the management of chronic pain (including migraine headaches), and the management of anxiety and depression, especially in the setting of a new cancer diagnosis or in chronic pain. Importantly, a few recent studies found that mindfulness and/or meditation have significant physiological effects, including lowering the expression of proinflammatory genes.2,3 Additionally, a study from China reported a decrease in age-related thinning of the frontal lobe in seniors who regularly practiced tai chi vs. age-related controls. Mind-body practices also appear to be of value in the management of irritable bowel syndrome. Years ago, researchers from Manchester, England, found that hypnotherapy reduced symptoms in IBS, especially pain.4 Recent studies found that both mindfulness and cognitive behavioral therapy produced moderate improvement in IBS symptoms, as well as anxiety.5,6 Mindfulness has been conducted in group sessions, both in-person and remotely. There is

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“Certain spiritual

practices, also known as mind body practices (MBP), are being recognized as helpful in a variety of healthrelated settings.”

less experience with MBP in inflammatory bowel disease. In a study of 43 patients with inactive ulcerative colitis, 8-week mindfulness training decreased the likelihood of a flare in the ensuing 12 months.7 An RCT from Spain found that levels of inflammatory biomarkers (fecal calprotectin and C-reactive protein) were decreased in Crohn’s disease patients who underwent MBP compared to standard care alone.8 However, a recent metanalysis concluded that while stress and depression in IBD improved after MBPs, there was no consistent decrease in disease activity.9 It might surprise you to know that there are well over a thousand studies in peer-reviewed journals demonstrating that faith membership and participation in faith-community activities are associated with significant reductions in age-related incidences of hypertension, coronary disease (even recovery from major cardiac surgery), several common cancers, and, most impressively, age-related mortality.10 Several large longitudinal studies demonstrate that faith participation is associated with increased survival compared with survival of non-attendees and some studies demonstrate this in a “dose-response” manner, e.g., nonattendees fared worse than infrequent attendees, who fared worse than frequent attendees).11 One important caveat in this and several other longitudinal studies— the nature of one’s relationship with their higher power is of importance: a loving relationship is key; positive effects are not seen if the relationship is motivated by fear of punishment. A positive effect of faith on incidence of mental illnesses is even more profound— depression, mind-altering substance abuse, adolescent sexual promiscuity and suicides are significantly less in faith practitioners.10 What mechanisms play a role in the beneficial health effects of spirituality and faith? From the new science of epigenetics, we know that while gene structure generally remains stable through life, gene FUNCTION can be altered dramatically by

a variety of factors, mainly social. Pessimism, anger, revenge, and depression are associated with an increase in harmful pro-inflammatory gene expression, increasing the likelihood of hypertension, coronary disease, cancers, and inhibiting the response to viral and bacterial infections; the reverse is true for optimism, gratitude, happiness and, interestingly, the performance of compassionate acts.12 These emotions and actions also have a profound effect on cellular aging. Telomeres are structures on the ends of chromosomes in the cells in our bodies. They shorten over time with cell divisions; an enzyme, telomerase, acts as a homeostatic mechanism to keep telomeres long. Once telomeres become short, cell division cannot occur, and cell death results. Optimism and gratitude are linked to faith participation and, in turn, linked physiologically to a decrease in proinflammatory gene expression and increased telomere length. In fact, the psychological trait most strongly linked to telomere length is optimism!13,14 If faith and spirituality have health benefits, how can we incorporate them into the practice of gastroenterology? I believe a spiritual history is appropriate in those patients in whom we are likely to become their “subspecialty PCPs”—patients with IBD, chronic liver disease, complex IBS, and short bowel syndrome. Dr. Christina Puchalski (George Washington University School of Medicine) has written extensively on the subject of spiritual history.15,16 A spiritual history takes approximately 5 minutes. The focus is on what the patient thinks gives meaning to their life. In this way, faith can be addressed if the patient addresses it, but if the patient focuses on non-religious spirituality, then that becomes the focus. Several keys: don’t proselytize and don’t impose your views of faith—positive OR negative—on the patient. Studies show that well over 85% of patients viewed the spiritual history interaction as strongly positive— “humanizing" the doctor-patient encounter. Once this information is known, and is part of the patient’s chart, should a catastrophe arise (e.g., ICU admission or end-of life discussions with patient and family), you will be comfortable knowing their views.

“…the most

predominant faith teaching, compassion, is well worth reflecting on.”

Recent Harvard studies showed that families of patients who had discussions with the spiritual care staff rated their opinion of overall care significantly higher than those who had not had spiritual care interaction. While many staff avoided such conversations because they felt uncomfortable having them and feared that patients/families would feel awkward also, the families felt this was rarely the case. Your hospital CEOs would be happy to know that cost of care in the final week of life was 2 to 3 times higher in those patients in whom no spiritual care consultation was received.17 You may not realize how important your patient views their interaction with you and your staff. In a study from the British healthcare system, one factor predicted a 40% difference in 10-year mortality in patients with type 2 diabetes: whether, after the initial visit with their healthcare team, the patient considered the team to be empathetic or not!18 At last year’s ACG Annual Scientific Meeting, it was reported that after an initial in-person visit, two factors determined whether the patient preferred a remote rather than in person re-visit: long distance from their home AND healthcare team deemed to be noncompassionate! Should you make faith and spirituality part of your and your children’s lives? As a society, we are becoming less and less associated with faith; this is especially true in our younger generations. You are well aware that survey after survey shows that the incidences of depression, addiction, anxiety, suicides—the deaths of despair—are increasing nearly exponentially, especially in our youth. While other factors (especially social media-related) are in play, let’s look at the disparate world views: a person of faith believes in a higher power who loves us and forgives us of our imperfections; an atheist believes that we are the latest in the line of hunter-gatherers—kill or be killed, with a finite life expectancy, whose body decomposes at the end of life—end of story! Not very comforting to young people, who tend to exaggerate the

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importance of negative inputs. Is this “higher power thing” just a big placebo? While placebos can be of significant value, in my book, "A Case for Faith," I present evidence (indirect, but hopefully convincing) for the existence of an omniscient benevolent higher power.… Would love to get your feedback. Are there significant problems with the actions of some faith community members and faith leaders? Absolutely, as there are with secular leaders. Human behavior is distressingly flawed. I devote the final chapter of my book to many of these concerns. However, the most predominant faith TEACHING, compassion, is well worth reflecting on. Peace! —Mark H. Mellow, MD, FACG

REFERENCES 1. Osler W. The Faith That Heals Br Med J 1910;1:1470 doi:10.1136/ bmj.1.2581.1470. 2. Buric I, Farias M, Jong J, Mee C and Brazil IA (2017) What Is the Molecular Signature of Mind–Body Interventions? A Systematic Review of Gene Expression Changes Induced by Meditation and Related Practices. Front. Immunol. 8:670. doi: 10.3389/ fimmu.2017.00670.

FIGURE 1. Anger, depression, anxiety, pessimism, isolation

3. Tang Y-Y, Fan Y, Lu Q, Tan L-H, Tang R, Kaplan RM, Pinho MC, Thomas BP, Chen K, Friston KJ and Reiman EM. (2020) Long-Term Physical Exercise and Mindfulness Practice in an Aging Population. Front. Psychol. 11:358. doi: 10.3389/fpsyg.2020.00358. 4. Whorwell PJ. Controlled Trial of Hypnotherapy in the Treatment of Severe Refractory Irritable Bowel Syndrome. Lancet 1984;324:8414;1232-1234. 5. Naliboff BD, Smith SR, Serpa JG, Laird KT, Stains J, Connolly LS, Labus JS, Tillisch K. Mindfulness-based stress reduction improves irritable bowel syndrome (IBS) symptoms via specific aspects of

Increased CTRA gene expression

mindfulness. Neurogastroenterol Motil. 2020 Sep;32(9):e13828. doi: 10.1111/nmo.13828. 6. Henrich JF, Gjelsvik B, Surawy C, Evans E, Martin M. A randomized clinical trial of mindfulness-based cognitive therapy for women

Decreased telomerase activity

with irritable bowel syndrome-Effects and mechanisms. J Consult Clin Psychol. 2020 Apr;88(4):295-310. doi: 10.1037/ccp0000483. 7. Jedel S, Beck T, Swanson G, Hood MM, Voigt RM, Gorenz A, Jakate S, Raeisi S, Hobfoll S, Keshavarzian A. Mindfulness Intervention Decreases Frequency and Severity of Flares in Inactive Ulcerative Colitis Patients: Results of a Phase II, Randomized, Placebo-

Increased age-related heart disease, hypertension, cancers, decreased resistance to infections

Controlled Trial. Inflamm Bowel Dis. 2022 Dec 1;28(12):1872-1892. doi: 10.1093/ibd/izac036. 8. Goren G, Schwartz D, Friger M, Banai H, Sergienko R, Regev S, Abu-Kaf H, Greenberg D, Nemirovsky A, Ilan K, Lerner L, Monsonego A, Dotan I, Yanai H, Eliakim, Horin SB, SlonimNevo V, Odes S, Sarid O, on behalf of the Israeli IBD Research Nucleus. Randomized Controlled Trial of Cognitive-Behavioral

ABOUT Mellow Mark H. Mellow, MD, FACG is a gastroenterologist from Edmond, Oklahoma, who has been a member of ACG since 1988. He is the author of “A Case for Faith Sharing Ancient Secrets for Longer Life, Health and Happiness” (Covenant Books 2022) exploring the impact of faith and spiritual practices on physical and mental health.

Shorter telomeres

and Mindfulness-Based Stress Reduction on the Quality of Life of Patients With Crohn’s Disease, Inflammatory Bowel Diseases, Volume 28, Issue 3, March 2022, Pages 393–408, doi: 10.1093/ibd/ izab083. 9. Ewais T, Begun J, Kenny M, Rickett K, Hay K, Ajilchi B, Kisely S. A systematic review and meta-analysis of mindfulness

Shorter, Unhealthier Life

based interventions and yoga in inflammatory bowel disease. J Psychosom Res. 2019 Jan;116:44-53. doi: 10.1016/j. jpsychores.2018.11.010. 10. Koenig HG. Religion, spirituality, and health: the research and clinical implications. ISRN Psychiatry. 2012 Dec 16;2012:278730. doi: 10.5402/2012/278730. 11. Li S, Stampfer MJ, Williams DR, VanderWeele TJ. Association of Religious Service Attendance With Mortality Among Women.

FIGURE 2. Optimism, meditation, prayer, community, acts of compassion

JAMA Intern Med. 2016 Jun 1;176(6):777-85. doi: 10.1001/ jamainternmed.2016.1615. 12. Nelson-Coffey SK, Fritz MM, Lyubomirsky S, Cole SW. Kindness in the blood: A randomized controlled trial of the gene regulatory impact of prosocial behavior. Psychoneuroendocrinology. 2017 Jul;81:8-13. doi: 10.1016/j.psyneuen.2017.03.025. 13. Rode L, Nordestgaard BG, Bojesen SE. Peripheral blood leukocyte telomere length and mortality among 64,637 individuals from the general population. J Natl Cancer Inst. 2015 Apr 10;107(6):djv074.

Decreased CTRA gene expression

doi: 10.1093/jnci/djv074. 14. Schutte NS, Palanisamy SK, McFarlane JR. The relationship between positive psychological characteristics and longer telomeres. Psychol Health. 2016 Dec;31(12):1466-1480. doi:

Longer telomeres

10.1080/08870446.2016.1226308. 15. Puchalski C, Romer AL. Taking a spiritual history allows clinicians to understand patients more fully. J Palliat Med. 2000 Spring;3(1):129-37. doi: 10.1089/jpm.2000.3.129. 16. Sajja A, Puchalski C. Training Physicians as Healers. AMA J Ethics. 2018 Jul 1;20(7):E655-663. doi: 10.1001/amajethics.2018.655.

Longer, Healthier Life

17. Balboni T, Balboni M, Paulk ME, Phelps A, Wright A, Peteet J, Block S, Lathan C, Vanderweele T, Prigerson H. Support of cancer patients' spiritual needs and associations with medical care costs at the end of life. Cancer. 2011 Dec 1;117(23):5383-91. doi: 10.1002/ cncr.26221. 18. Dambha-Miller H, Feldman AL, Kinmonth AL, Griffin SJ. Association Between Primary Care Practitioner Empathy and Risk of Cardiovascular Events and All-Cause Mortality Among Patients With Type 2 Diabetes: A Population-Based Prospective Cohort Study. Ann Fam Med. 2019 Jul;17(4):311-318. doi: 10.1370/afm.2421.

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Wellness and Work-Life Integration: What Matters Most Insights from the ACG Professionalism Committee

INTRODUCTION Richard S. Bloomfeld, MD, FACG Chair, ACG Professionalism Committee Young physicians are taught about the great responsibility that comes with caring for patients, and this often comes with great personal sacrifice. Indeed, during my internal medicine residency, I was taught the words of Dr. Eugene Stead that “the sick never inconvenience the well.” While a strong work ethic is important to what we do, over my career I have also observed the effects of burnout on many healthcare providers. Burnout is a work-related syndrome that is characterized by a low sense of personal accomplishment, emotional exhaustion, and a lack of compassion. It can result in severe consequences for a person’s personal and professional lives. This includes broken relationships, alcohol and substance abuse, depression, unprofessionalism, decrease in patient satisfaction, poor quality of care, early retirement, and suicide. Over time, medical organizations have recognized the effects of physician burnout and have offered resources to help those who experience burnout to recover. Indeed, the ACG has provided materials, including articles and lectures, to help our members recognize and mitigate burnout. But this approach has shortcomings. Physicians must recognize burnout, they must seek resources, and they must face the added burden that this is their problem to fix. An ACG survey showed that about half of the members who responded experienced symptoms of burnout. We need to improve our approach to wellness, and this is a primary goal of our 2023-2024 ACG president

Dr. Jonathan Leighton. The ACG will strive to promote wellness for all its members to prevent burnout. We all face significant pressures that may be related to patient care, technology, RVU production, medical records, quality metrics, governmental regulations, administrative duties, and myriad other job responsibilities. We also face time constraints, financial pressures, and personal and family issues that all people face. To overcome these pressures, we must promote wellness as part of our lives. We must take the time and effort to focus on keeping ourselves well, so that we are able to satisfy the requirements of our job and the needs of our friends and families. Toward this goal, the ACG has now established “ACG Wellness Central.” This will be an online resource that is always available to ACG members to provide guidance on maintaining wellness. It will provide articles, lectures, and multimedia resources to promote wellness and mitigate burnout. It covers topics related to home life and work life. It will also provide resources for members in leadership positions who seek to promote wellness at their workplace. In this issue of the ACG MAGAZINE, you will see what members of the ACG Professionalism Committee think about wellness and what they do to maintain wellness in their own lives. INSIGHTS FROM THE ACG PROFESSIONALISM COMMITTEE Aparajita Singh, MD, MPH Associate Clinical Professor; Medical Director of Quality and Safety, Division of Gastroenterology; University of California, San Francisco, CA As life responsibilities increase and stressors accumulate, maintaining a balance becomes increasingly

challenging. The growing demands of childcare responsibilities and the constant effort to excel both at work and as a parent create an unending cycle. On days when you give your best at work, you may feel inadequate as a mother or wife. Likewise, dedicating time to your family can give the impression that your work is suffering. To address these challenges, I have found it beneficial to allocate time for brainstorming sessions with my husband for planning the entire year’s vacation calendar in advance. We ensure that we reserve specific dates for mandatory vacations periodically. While this approach is still a work in progress, we aim to plan and take a day off on our birthdays and our children's birthdays to celebrate together. There have been instances when work emergencies have kept me late at work, resulting in my children falling asleep before I could even come home to cut the cake. While I cherish many aspects of my work and interacting with my patients, the task of writing notes is not enjoyable for me. Fortunately, having scribe support has been invaluable. They assist in pre-charting my notes and scribing in real-time, allowing me to focus on building relationships and connecting with my patients rather than constantly staring at my screen. Another strategy I intend to implement in the upcoming year is to have a lighter schedule for a day after an extended on-call week. This lighter workday will help me catch up on the non-urgent email backlog of work or spend quality time with my family to decompress. Sara Horst MD, MPH, FACG Associate Professor, Division of Gastroenterology, Hepatology, & Nutrition; Medical Director, VUMC Ambulatory Telehealth and VUMC Specialty Pharmacy; Associate Vice Chair, Digital Health Operations of Department of Medicine, Vanderbilt University Medical Center About 5 years ago, I had a friend ask me, “How are you taking care of yourself?” I couldn’t really answer the question. Once I realized I needed to do something different,

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I talked to my spouse, and he was very supportive in making sure I got dedicated time. I went through a Health Coaching course which pushed me to try a lot of new things (meditation, yoga, exercise classes, retreats). I learned that while a lot of things don’t resonate for me, it was important (and fun) to go on the journey to find what does. Currently, daily exercise is what I need to stay less stressed and grounded. While that should seem easy, with two young children and two full-time jobs in our household, it took me almost a year to get into a rhythm. It had always been easier to forego my self-care when someone or something else I cared about needed my attention. To combat that habit, I planned out and blocked time on my calendar, and it took about 6 months before I could do it without a prompt. If I could give any advice for others about work/life balance, I think the first step is to realize it is not a failure to need help, and this is not something you can just “turn on.” It may take a coach or a therapist to start the process, and you need family and work support to give you time and space. Patrick A. Twohig, MD Gastroenterology & Transplant Hepatology Fellow, University of Nebraska Medical Center Work-life balance is a flawed term which suggests that there is an ideal ratio of work to life, when in fact, the optimal mix of these two things vary significantly from person to person, and often changes significantly over the course of one’s career. It is important to consider re-wording the phrase work-life balance to work-life engagement. We are most effective when we are engaged and energized in both our personal and professional lives. Spending more time focusing on the balance of energy, rather than time, can provide a healthier lens through which to find the right balance between different commitments in life. When we are emotionally or physically

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exhausted, it is natural to become less effective and feel more disconnected, resulting in burnout. However, when engagement is achieved, positive energy can improve physical health, mental and emotional well-being, and increase satisfaction in both personal and professional lives. To improve engagement, I dedicate times of the day to different activities, including spending time with family, exercising, working, reading, and spending time outside. When doing these activities, I try to prioritize what projects are most important so that I can derive the most satisfaction from my time spent during the day. My family tries to maintain a healthy diet and continuously stay connected to family and friends around the world, which helps improve wellness too. Amy S. Oxentenko, MD, FACG Professor of Medicine; Vice Dean of Practice, Mayo Clinic Rochester, MN Trying to maintain balance in one’s personal and professional life is a challenge that we all are faced with. The one thing that is in our control is a personal commitment to our own wellness. Many things around us may slowly drain our body battery, and I try to find any way that I can to continually recharge my battery to allow me to have the focus, commitment, and energy to do all of the things I need and want to do. For me, there are several things that I do to maintain wellness. First, I prioritize family above all else. This is my North Star and allows me to feel good about the decisions I make. Second, intentionally connecting with friends in whatever means possible (phone call, coffee, after-work meet-up, etc.) fills up my cup and allows me to feel connected in this world which is often viewed through a computer screen. Next, exercising is absolutely fundamental to my wellness, and nothing allows me to reduce stress and clear my mind better than an early morning or late day run. It is essential to find the activity that does this for each individual, because it feels like the pop-off valve for the daily pressure cooker. This needs to be built into an already busy schedule, because if not, it is often neglected. Finally, while I likely overlooked the benefits of sleep

earlier in my career (and when my children were little and in control of my sleep), it is clear that I function much better with a minimum of 7.5 hours of sleep a night, and my goal is 8-9 hours of sleep nightly. That allows me to be more alert throughout the day and be much more efficient in getting work done so I have time to enjoy all of the other great things in life! While we continue to focus on initiatives that improve wellness in our professional lives, it is essential to prioritize it in our personal lives as well! Richard S. Bloomfeld, MD, FACG Professor of Medicine, Director of Inflammatory Bowel Disease Services, Atrium Wake Forest Baptist Health, Winston Salem, NC While we are all so busy with our careers, it is important to focus on wellness. Each of us must find something that we enjoy that contributes to our well-being. I run several days a week. When running, I find that I can turn my brain down and exert myself and spend time outdoors in fresh air and this provides the perfect balance to all the time I spend inside at the clinic or in the endoscopy unit. Divya B. Bhatt, MD Assistant Professor of Medicine, UT Southwestern Medical Center and VA North Texas Healthcare System, Dallas, TX Movement and exercise help me achieve moments of calm, especially when my stress levels are high. Dance, yoga, and high-intensity interval training allow my brain to focus, rather than worrying about my entire to-do list. Reading, journaling, spending time with loved ones, and actively practicing empathy (especially when I don’t feel like it!) also help me fight against burnout.

Karolina Siniakowicz, MD Gulf Comprehensive Gastroenterology, Sarasota, FL Over the years, I have discovered that taking time to speak with my family has been a great way to relieve stress, and to recharge after a challenging week. When not able to see them in person, I try to make a call to them from the car after work. Working in GI is challenging, it takes a physical and emotional toll, and staying connected to my roots helps me gain perspective and respite from the inevitable stress. Leo C. Katz, MD, FACG Associate Chief, Division of Gastroenterology and Hepatology; Medical Director, Office of Patient and Family Experience; Clinical Associate Professor of Medicine; Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA As Associate Chief, we started a program at Jefferson GI of “Wellness Wednesdays.” Every other Wednesday or so, we have a snack, treat, or other item during lunch where the entire staff can take a break and enjoy a few treats. This week: Root Beer Floats. We create a free hour in everyone’s schedule to accommodate this. Has been very popular with faculty and staff. We also have periodic faculty meetings without any Chiefs present to allow faculty to voice their concerns, this is done by our “Wellness Officer.” Meena A. Prasad, MD Assistant Chief of Gastroenterology, Atlanta VA Medical Center; Emory GI Fellowship Site Director, Atlanta VA Medical Center; Associate Professor of Medicine, Emory University, Atlanta, GA To promote my own wellness, I make sure to keep up with my routine medical/dental appointments and do something nice for myself on those days off. I will usually volunteer at my kid’s school or in my community, meet a friend for lunch, get my nails

done, or treat myself to something new. Besides these “me days,” I also have a lot of joy in playing tennis, participating on year-round tennis teams, traveling, baking, and tending to my flowers. I am mindful about prioritizing time for my hobbies, family, friends, and making memories. At work, these happy moments and having something to look forward to help me pull through frustrations and conflict. Ahmad M. Al-Taee, MD Assistant Professor of Medicine, Carle Illinois College of Medicine, The University of Illinois In Urbana-Champaign I prefer the term work-life integration (over work-life balance) as the aim is to find a way for both aspects to complement each other without sacrificing one for the other. This starts with visualizing what your ideal life looks like and then working deliberately to align your actual life with it. The life aspect involves nourishing the physical, spiritual, emotional, and intellectual facets of our lives on a regular basis. There are many ways to achieve this, which vary based on the individual’s values, interests, and skills. When it comes to the work aspect, I believe this starts with finding the right practice setting that aligns with your values and career goals. Starting as junior faculty last year, the learning curve can be steep while working towards streamlining clinic and endoscopy workflows. A few tips have helped me during this process: pre-charting the day before clinic/endoscopy; utilizing templates in electronic medical record and endoscopy dictation software; having proper support staff (e.g., to triage patient calls/portal messages and answer those that do not require physician input); taking a lunch break; daily huddle with clinic nurse and procedure scheduler; not bringing work home; and taking all vacation time (in addition to CME time). We spend most of our waking time at work and a fulfilling career goes a long way toward achieving wellness and work-life integration.

Mohammad Bilal, MD "As physicians, we always put patients first, as we should, but we are also humans. Therefore, it is essential to maintain a healthy work-life balance, because if we are happy in our personal lives, this will translate into our professional lives and vice versa."

INTRODUCING ACG WELLNESS CENTRAL Curated Resources to Cultivate Wellness in the Professional and Personal Lives of ACG Members The ACG Professionalism Committee and its collaborators created ACG Wellness Central, hoping to bring about a significant positive impact on ACG members by providing specific resources to improve wellness. Explore an extensive collection of multimedia resources designed to provide general burnout information, recommendations for things you can do at home to promote wellness, recommendations for things you can do at work to promote wellness, and resources for organizations seeking to improve wellness.  Explore Wellness Central: gi.org/acg-wellness-central

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DREAM THE IMPOSSIBLE DREAM: ACHIEVING WORK-LIFE BALANCE AS A PHYSICIAN Ali Mir Ahmed, MD

AS A NEW YORK CITY (MANHATTAN) HIGH SCHOOL STUDENT I had access, often standing room only tickets, to discounted Broadway productions. Perhaps, that may explain why I pilfered the title “Dream the Impossible Dream” from the iconic Man of La Mancha1, but work-life balance is truly elusive and essential to maintain well-being and achieve happiness. I have listed below a few areas that I am trying to work on myself. 1. Just Say No! As physicians we are always solving, treating, researching, reviewing, and willing to assist in any situation, even at the detriment of ourselves. This quality is part of what makes us excel in the healthcare environment. However, imbalance and overcommitting are not healthy practices. Know your limitations and focus your projects on those that align with your work/life priorities. 2. Identify Your Priorities. This is for both work and home. At work, focus your efforts on the tasks that drive you. Collaborate and initiate research efforts in those areas. At home, set your goals so that time is allocated efficiently. 3. Set Boundaries. Clearly delineate the boundaries between your professional and personal life. It is important to be consistent as much as possible. For example, if you are having dinner with the family, try not to check work email/answer phone calls during this time unless it is an emergency, or you are on call. 4. Automate and Outsource Tasks. Leverage technology and personnel to follow up patient questions through an online portal. Consider an automated reply for pathology results that are normal. 5. Screen Time Limits. Recently, the

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Cyberspace Administration of China2,3 legislated specific screen time limits for minors. There may be an opportunity to implement technology-free time during the day to enable other activities or meaningful connection with family. 6. Schedule “Me” Time. These should be firm commitments just as your work schedule. The focus here would be to identify activities that provide enjoyment or relaxation. These can be alone or with family and friends and include sports, dining, travel, self-care. Maintaining fixed non-work activities gives you something to look forward to and helps keep you centered. 7. Stop and Smell The Roses. Mindfulness. Consider incorporating mindfulness activities into your work/home routine. These include meditation, breathing exercises or taking time to recognize and be present in your environment. 8. Healthy Habits. Incorporate regular exercise and a healthy diet into your life. This includes a healthy sleep schedule. As a physician it is always easier to give recommendations than to accept them. Personally, I try to take my kids to their sports practices and games during the season. On weekends, I try to schedule a family hiking excursion at a nearby mountain or trail. I will also play basketball or swim with my family at least once a week. We also try to ban media at dinnertime, but that remains a work in progress for both the adults and kids at the table! Lastly, I read about Morris Panner4, CEO of DICOM Grid, who called his mother every day to start his workday. So, I have tried to incorporate this as part of my routine to incorporate mindfulness. This gives me the opportunity to stay grounded to where I come from and give thanks for all the sacrifices my family has made to help me achieve success. I try to call my parents daily, even if for a few minutes, and if the kids are available and cooperating, incorporate the always popular grandchildren FaceTime! Professionally, I am limiting my research and journal reviews to areas within my specific discipline of advanced endoscopy and leveraging our physician extenders to respond to inbox messages in our patient

portal. I’m still bad at saying no and try to do too much at work, but that is something I can improve. It is most important to recognize that wellness is an ambitious and life-long process. Strategies change as your work-life situation changes or with the stage of your career/life. Wellness is a dynamic process; so, frequently assess how you and those around you feel and prioritize what works for you and alter what can be improved. “And the world will be better for this… To reach the unreachable star.”1 —Man of La Mancha SOURCES: 1. Lyrics to The Impossible Dream – Man of La Mancha ST Lyrics, 2023, https://www.stlyrics.com/lyrics/ bestofbroadway-americanmusical/theimpossibledream.htm. 2. http://www.cac.gov.cn/2023-08/02/c_1692541991073784. htm. 3. Yang Ziyi. China is escalating its war on kids’ screentime. MIT Technology Review. Aug. 9, 2023. Accessed online: https://www.technologyreview.com/2023/08/09/1077567/ china-children-screen-time-regulation. 4. Walters, Natalie. What this CEO does everyday will make you want to pick up your phone and call your mom. Business Insider. Feb 29,2016. Accessed online: https:// www.businessinsider.com/ceo-calls-his-mom-everyday-2016-2555.

Gastroenterologist Motility: Inspired Moves for Your Heart, Brain & Endoscopy Ergonomics Andrew M. Moon, MD, MPH, Assistant Professor of Medicine, Division of Gastroenterology and Hepatology, The University of North Carolina at Chapel Hill; Deputy Associate Editor, The American Journal of Gastroenterology

HAVE YOU SEEN THE HEADLINES? A wonder medication that has been around for ages with the ability to improve cognition, sleep, and muscle strength. A remedy with such profound neurologic and cardiometabolic benefits that, if bottled up, could be sold for thousands of dollars per ounce. A therapy with close to zero side effects that has just as many benefits for doctors as it has for patients. Despite being well-versed in the multitude of positive effects of this wonder drug called exercise, you might find it challenging to find time in your daily schedule for a run, cycle, or lift. To help provide some inspiration, we invited a panel of ACG athletes to share their workout routines, tips for working it in to the daily schedule, and tunes for the workout and endoscopy playlists. Answers from this panel were inspiring and enlightening. Most of the ACG athletes wake up early to workout, which helps avoid excuses and boosts work productivity with an early morning dose of endorphins. Many of these GI athletes focus on stretching and core exercises to stave off endoscopy-related injuries. Lastly, all jam out on runs or in endoscopy suites to upbeat hits ranging from Diana Ross to Pitbull. So sit back, pop on those running shoes, and get inspired to make physical activity a never-miss part of your day. Invited Athletes: A gender balanced and diverse group of GI physicians from all career stages who have participated in ACG’s #RideOrStrideFor45 and/or #DiversityinGI virtual challenges, many are known for showing up for group Peloton rides or are up before the sun for early morning “fun runs” at the ACG Annual Scientific Meeting; some

are serious marathoners. Everyone graciously shared their personal routines, photos, and favorite tunes! Here are the questions: 1. What does your exercise routine look like throughout the week? 2. When do you fit exercise into your busy life, and how do you psych yourself up for your workouts? 3. What is your favorite piece of exercise equipment or favorite workout, and why? 4. What moves do you emphasize in your workout to stay strong and injury-free in the endoscopy suite? Are there specific muscle groups that deserve more focus for good ergonomics? 5. Do you listen to music and what’s your playlist like?

ACG ATHLETES Neena S. Abraham, MD, MSc (Epi), MACG Carol A. Burke, MD, FACG Aline Charabaty, MD, FACG Reezwana Chowdhury, MD, FACG Seth A. Gross, MD, FACG David J. Hass, MD, FACG Alexander Jow, MD Justin T. Kupec, MD, FACG Jonathan A. Leighton, MD, FACG Amy S. Oxentenko, MD, FACG Joseph W. Rinaldi, MD Samir A. Shah, MD, FACG Aasma Shaukat, MD, MPH, FACG Neil H. Stollman, MD, FACG Judy A. Trieu, MD Alexa R. Weingarden, MD, PhD Patrick E. Young, MD, FACG

GASTROENTEROLOGISTS SHARE THEIR WORKOUTS Neena S. Abraham, MD, MSc (Epi), MACG, ACG Institute Director, Mayo Clinic, Scottsdale, AZ 1. Routine? I walk 3-5 miles a day with my fur-baby, Obi, and lift heavy weights to failure twice a week. When the weather is nice in Arizona (fall through spring), I enjoy hiking on the weekend with my two- and four-legged friends! 2. Fit it in? Get psyched? My JackChi (Jack Russell Terrier-Chihuahua) loves to walk many miles daily and is kind enough to take his Momma. 3. Favorite equipment/workout? A nopull harness and leash for Obi and my sneakers—I go through many pairs a year as we put in our daily miles. 4. Moves to stay strong for endoscopy? After a shoulder injury in 2015, I focused on strengthening my shoulders, back, hands, wrists, and core muscles to remain injury-free. I have learned that the best defense against endoscopic repetitive use injury is proactive strengthening and being mindful of ergonomic principles when scoping. 5. Music? For me, endoscopy is a form of moving meditation, so I scope without music. I have been known to crank reggae, classic rock from the ’70s and ‘80s, or ‘90s boy bands when completing my charting at the end of the day. 6. Song(s) for GI playlist? “Another One Bites the Dust” by Queen—this refrain plays in my head when removing a polyp! Alternatively, “Bye Bye Bye” by N’Sync or “Taking Care of Business” by Bachman-Turner Overdrive.

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Carol A. Burke, MD, FACG, ACG Past President, Cleveland Clinic Foundation, Cleveland, OH 1. 4-5 mile walk 3 x per week, sun, rain or snow. Zoom yoga classes 3-5 days per week; biking 20 miles 1-3x per week summer in the Cuyahoga Valley National Park in Ohio (Spring-Fall) 2. Exercise is life, so life needs to fit it! No greater feeling of wellness than after physical activity. If we could bottle the feeling, people would pay a lot per dose. 3. My yoga mat for power vinyasa yoga. Life is breath, breath is yoga. Perfect practice for building equanimity, strength and flexibility, and gratitude. 4. Posture, balance, core and breathing. Yoga is perfect for ergonomics. 5. Pandora in endoscopy suite: Allman Brothers, Sia, Earth Wind and Fire, Genesis, Led Zeppelin, Imagine Dragons, Santana, Chris Isaak, Fleetwood Mac, Pink Martini, Devo, the Cars, Adele, Luke Combs, Boccelli, The Weeknd, Gypsy Kings, to name a few of very many! 6. “Carry on My Wayward Son” by Kansas.

Aline Charabaty, MD, FACG, Johns Hopkins Medicine at Sibley Memorial Hospital, Washington, DC 1. I am a "jungle gym” type of person, which makes my exercise routine not so routine-ish: During the weekdays I alternate days of HIIT cardio, weightlifting, with “recovery days” of Pilates, barre, or yoga. Because I like to exercise in the morning but cannot make it to a gym and back on time, I pull a 30-minute YouTube video of my choice; my fav channels are Popsugar Fitness, Fitbymik, Juice & Toya, Move with Nicole, Boho Beautiful Yoga, and Action Jacquelyn. On the weekend, I go for an hour morning run, when it is not too hot outside, I melt above 75˚F and I 42 | GI.ORG/ACGMAGAZINE

am at my best at 50-60˚F and love running under a light snow. I also bike, hike, and try different studio classes on the weekends (recently got into aerial yoga) when I have the luxury of more wellness time. 2. I actually feel the need to workout in the morning before I head for work. If I don’t exercise for a couple of days for whatever reason, my physical, emotional, and intellectual energies dip down! Those small workout wins at the start of the day (like being able to do few more pushups, lift a heavier weight, run a bit lighter, or get more flexible in my yoga pose) pump up my mindset for the rest of the day and get me excited and ready for the challenges ahead! 3. Maybe it doesn’t qualify as “equipment” but picking a fun and colorful outfit for each type of activity makes me look forward to sweating it out. My fav workouts are outdoor yoga and running: it is like an active meditation, focusing on my breathing and slow strong movement or repetitive movement, while soaking in the sounds and the smells of nature, the breeze, the sun… I feel a peaceful joy in that. 4. Weightlifting, yoga, and Pilates for a strong upper body and core! Exercises that work the large and small muscles of the shoulders and back are key. Core exercises (like abs, planks, “Superman”) really help with posture and several yoga movements (like down-dog, warrior poses) are a great stretch for the hard-working upper body muscles 5. I recently started listening to standup comedy recordings when I am running (one of my fav channels is Dry Comedy Bar), laughter is an awesome energy booster! Sometimes I go for 70’s-80’s music, with The BeeGee’s “Staying Alive” and ABBA’s “Dancing Queen” pushing me to the next mile. 6. I often play music and love singing while scoping. A favorite is “Ain’t No Mountain High Enough” when facing a technically “difficult” colon or a TI challenging to intubate; “I’m Coming Out” after a TI touch down and on my way out. I guess Diana Ross is with me in endo a lot of the time!

Reezwana Chowdhury, MD, FACG, Johns Hopkins Medicine, Baltimore, MD 1. My exercise routine includes running a total of 10 miles per week, most of the time on my Peloton treadmill with my favorite instructors, along with at least 1 treadmill bootcamp per week. 2. I fit in runs or workouts by telling myself that if I don't move, my gut doesn't move and most folks can tell I get cranky. I tell myself, there is no excuse not to go downstairs for just 20 minutes, just to move. And, most often, that 20 minutes increases to 30 minutes and more. 3. My favorite workout is running, and I look forward to some cool weather to run outside. My favorite equipment is my Peloton treadmill and my selfcompetition to continue streaks or PR when working out with others, etc. 4. I make an effort to move my legs, i.e., running, and make sure to do stretches and foam rolling to help my lower back. I also try to lift light weights to gain strength in my arms because our arms and back are very important for endoscopy and standing on our feet all day. 5. Music is an absolute must. I have a workout playlist with some boy bands, current top hits, and some oldies.

Seth A. Gross, MD, FACG, ACG Trustee, NYU Langone Health, New York, NY 1. Five to six days per week; a mix of cardio, strength, and tennis. 2. Usually after work and on weekends in the morning! Remind myself to try and do something most days! No excuses! 3. Enjoy the Peleton rides to get a good burn and listen to some great music. 4. I do a lot of core body work. For “endo sports” I work on back and shoulders. 5. I listen to Pitbull Radio on Sirius! 6. “Can’t Stop Us Now” by Pitbull and Zac Brown

David J. Hass, MD, FACG, ACG Trustee, Yale University School of Medicine/PACT Gastroenterology Center, New Haven, CT 1. Exercise 6 days/week – tennis for 90 min twice/week or 45-min run and core weight lifting other 4 days 2. Start my mornings at 5:30am. Best way to start my day! 3. 5-mile run early in the morning 4. Core and back strength training 5. Ask patients what kind of music THEY would like to hear. I love classic rock (Allman Brothers, Chris Stapleton) 6. “Starting Over” by Chris Stapleton – Each day is a new day!

Justin T. Kupec, MD, FACG, ACG Governor for West Virginia; West Virginia University Medicine, Morgantown, WV

Dr. Hass with Dr. Aasma Shaukat and Dr. Millie Long for a morning run at ACG Board of Trustees Meeting

Alexander Jow, MD, MidAtlantic Permanente Medical Group, Falls Church, VA 1. Three days of strength training exercises (weightlifting) for about 45-60 minutes. Three days of cardio workout with jogging (30 minutes) or biking (1-2 hours). 2. I try to start my workouts early mornings before 6 AM. It’s a great way to wake up and get the day started. 3. My favorite workout is getting on my road bike on the weekends. There are great trails in Northern Virginia and it’s a great way to enjoy the outdoors. The view of the Washington Monument from the Mount Vernon Trail never gets old! 4. Stretching, warm up exercises, and giving yourself recovery time in between workout days are very important in preventing injuries in both the gym and the endoscopy suite. Posture is very important for good ergonomics, so I do focus my workouts on building good core, leg, and back strength and stability. I also have been incorporating more pull-ups in my workouts to improve hand and wrist strength. 5. I definitely listen to music during my workouts. I love a good beat, so I currently have a lot of Trap Latino music on my workout playlist. 6. “Push It” by Salt-N-Pepa

1. As someone who runs marathons, my weekly routine consists of running 5 days a week with a long run on Sundays. When I am training for a marathon, I may run 50 miles a week or more but only 25 to 30 miles a week when I don't have a race planned. During the week, most of my runs are in the evening and at night while the weekend runs are earlier. 2. Motivating yourself to run after a day of endoscopy or clinic can be a challenge, but isn't that half the reason we do it? 3. As a runner, my favorite piece of equipment is new shoes. My Garmin watch is a close second. 4. Running is great for leg strength and core strength, both of which are important to gastroenterology. 5. I am somewhat weird in that I don't listen to music when I run (I use the time to get away from the chaos of the day), but you can't go wrong with some indie alternative or the timelessness of the Grateful Dead.

Jonathan Leighton, MD, FACG, ACG President, Mayo Clinic, Scottsdale, AZ 1. I wake up early, between 4 and 4:30am and do my well-being “Practice” before getting out of bed. It consists of mindfulness focused on gratitude, compassion, acceptance and forgiveness. I then

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do stretching and core exercises at home followed by a trip to the gym to do aerobics and weight lifting. On the weekend, I try to do a hike with my wife and two dogs and maybe a game of golf! 2. As I mentioned above, I like to do it early in the morning. I am usually home by 5:30am and then into work at 6:30am. It sets me up for the rest of the day and no matter what else happens, I know that I accomplished my mindfulness exercises and morning workout. 3. The mountain bike is by far my favorite piece of exercise equipment. I love getting out in the desert on a single track trail and riding up and down the mountain. It is like skiing. Although one gets a great workout, it doesn’t really feel like exercise… it just feels like fun! When I have the time, my other favorite piece of equipment is my backpack. There is nothing like a good backpacking trip into the wilderness to let your mind rest and wander. 4. I like to do core exercises and stretching every morning to strengthen my lower back and abdominal muscles. I think this is really important in addressing ergonomic issues in the endoscopy suite. When doing endoscopy, I try to stay loose, have good posture, and grasp the scope as lightly as possible. The same thing with my golf swing! 5. I love music! I mostly listen to rock ’n roll mixed with a little bit of country and a few older songs from such greats as Louis Armstrong and Frank Sinatra. 6. “Your Song” and “Rocket Man” by Elton John, my all-time favorite!

Dr. Jamie Bering, Dr. Neena Abraham with Obi, and Dr. Jonathan Leighton on the #DiversityinGI walk at Mayo Scottsdale

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Amy S. Oxentenko, MD, FACG, ACG PresidentElect, Mayo Clinic, Rochester, MN 1. I typically run 4-5 days per week. On weekdays, I will either run at 5:30 am or do it in the evening after dinner, all dependent on the schedule of the day and weather. On weekends, I get up, fuel with coffee, and head out for a longer run. I try to weight train with some regularity, but am pretty pathetic to sticking to that routine (shame on me, but runners just wanna run!) 2. I just plan on it and schedule in into my life, otherwise it will never happen. I know how good it makes me feel during and after a run, so that is the motivation that gets me psyched up. However, the 5:15 am weekday wake-up call to go run is REALLY hard some days – not gonna lie! 3. My running shoes are my favorite (and only) equipment needed, and are portable! My favorite workouts are 1) a run on a drizzly, rainy day; 2) a run on a nice flat beach; and 3) a run on a new path. My least favorite workout is the missed one or the one on a treadmill = dreadmill. 4. I stretch every night before bed, and focus on hips and both upper and lower back – makes such a difference in all aspects of work ergonomics (like being on a Zoom screen for 10 hours a day!) 5. Almost always listen to music (longer runs = podcasts). I have a marathon playlist that my friend created for me for my 2022 marathon, only to have my Aftershoks die on mile 8 – I still listen to the same playlist today since I never heard it all that day! 6. “Stronger (What Does Not Kill You)” by Kelly Clarkson; “Wake Me Up” by Avicii; “I Lived” by OneRepublic

Joseph W. Rinaldi, MD, Montefiore Medical Center, Bronx, NY 1. Running has become central to my weekly exercise and I try to get in around 5 runs a week. I’ll supplement that with 4 days of strength training and always give myself at least 1 full rest day. 2. I try (somewhat successfully) to go for a run in the morning before I leave for work which can be mentally challenging because who doesn’t love an extra hour of sleep? I remind myself that I always feel better after a run and so the mental acrobatics are usually short lived. 3. On non-running days, I’ve grown to love my gym’s Peloton because the classes are fun and you get a great workout while feeling connected to those in the virtual workout space. 4. During my second year of fellowship, I started to notice that my shoulders, particularly my left, was tight. I tried to keep up with my regular strength training, thinking that I could strengthen the rotator cuff muscles, but I ultimately found that full-range stretching was key for me. I use a series of bands and yoga straps to stretch out the shoulders almost daily now, especially on endoscopy days. 5. As strange as it sounds to most people, I don’t listen to music when I run. I almost exclusively listen to podcasts of varying sorts. I like the idea that someone is talking to me about something interesting that is mentally stimulating because it diverts my mind from running. On strength training days, I tend to nerd out to Broadway tunes. 6. “Ain’t No Mountain High Enough” with Marvin Gaye and Tammi Terrell

Dr. Rinaldi with Dr. Alicia Philippou

Samir A. Shah, MD, FACG, ACG Past President, Brown University The Miriam Hospital, Providence, RI 1. Swimming 40 laps 3-4 times per week and running 3-4 miles 2-3 times per week 2. Spotify playlists and swim buddies, occasionally drag our golden doodle to run 3. Portable speaker-blasting the music while I swim makes it more enjoyable and takes me back to high school swim team days 4. Not really, stretching pre- and post-workouts and doing some of the stretches that Dr. Patrick Young taught me about in his ergonomics lecture (he's also my musical guru!) 5. '80s all the way! Police, U2, Genesis, Dire Straits, etc.

Aasma Shaukat, MD, MPH, FACG, ACG Trustee, NYU Langone Health, New York, NY 1. Outdoor run or HIIT workout early in the morning 2. First thing in the morning works best for me, around 5 or 5:30 am. The good thing about that time is that the brain hasn’t had time to process and come up with excuses! 3. Nature, always available right out your door! 4. Really important to warm up and stretch. I try to keep my back straight and shoulders back to counter the rest of the day at work of sitting or standing.

5. I listen to audiobooks that are inspiring or interesting, or music if I'm slogging through, such as "Inspirational Pop" playlist on Spotify. 6. “Keep Your Head Up” by Andy Grammer

Neil H. Stollman, MD, FACG, ACG Trustee, East Bay Center for Digestive Health, Oakland, CA 1. I walk to and from work every day (about a mile each way) and I usually walk up the stairs to my 8th floor apartment. 2. No choice, need to go to work and need to get home! But my leisure exercise, taken as often as possible, is hiking. 3. My hiking shoes, duh. 4. Not really, just try not to trip! 5. I don’t listen to music; see #4 above and need to focus on that! 6. “Walk of Life” by Dire Straits “Walking on Sunshine” by Katrina and the Waves

Judy A. Trieu, MD, MPH, Washington University School of Medicine in St. Louis 1. I have had the same work out plan for nearly 1 year. Each week’s plan is consistent to help take out any “guessing” that may deter me from completing a workout. I learned this “2-day Rule” from my husband, Adam Booth, who used to body build and be a personal trainer – never skip more than 2 days, and work out at least 2 days in a row. This helps me be consistent! • Monday: 30-45 minute Peloton bike class; 10-15 minute Peloton core class (sometimes a Rest Day) • Tuesday: 20-30 minute treadmill run; 30 minute lifting (Back/ Bi’s) • Wednesday: 30-45 minute Peloton bike class; 10-15 minute Peloton core class • Thursday: 20-30 minute treadmill run; 30 minute lifting (Legs) • Friday: Rest Day • Saturday: 45-60 minute Peloton bike class; 30 minute lifting (Chest/Tri’s); 10-15 minute Peloton core class • Sunday: 45-60 minute outdoor run 2. I am an evening workout person. What has been the most successful for me is to change into gym clothes as soon as I get home and go straight into my workout. No sitting on the couch or scrolling through social media on my phone until after the workout! 3. The lat pulldown with row cable machine! I love building muscle and this machine makes me feel so strong and an overall bad@$$ when I can go up to the next level of weights! 4. CORE! CORE! CORE! Ever since I have incorporated core into my weekly plan (at least 3 times a week), I have had zero back pain or body fatigue after standing for a whole day. When I started my

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advanced endoscopy year, wearing lead for a full day was no problem! I never felt the back/shoulder pain that I have heard of with heavy lead aprons, and I think that it’s thanks to consistent core exercises. 5. I listen to primarily Hip Hop and R&B when I run. However, when I lift, I need more OOOMF, so I listen to Trap music. 6. “Like a Girl” by Lizzo. Before the first few times of scoping by myself, I listened to this song to pump myself up to scope confidently “like a girl”!

DR. JUDY TRIEU’S APPLE PLAYLISTS  2000s Hip-Hop/R&B Essentials  2010s Hip-Hop/R&B Essentials  The Trap

Alexa R. Weingarden, MD, PhD, Stanford Gastroenterology & Hepatology, Stanford, CA 1. I typically run 4-5 times per week, usually with a short weightlifting session at home afterwards. 2. I run and work out first thing in the morning. It can definitely be hard to get out when it’s cold and dark, but I know I’ll feel so much better during the day if I’ve been out for a run! 3. I live about 1.5 miles from a regional park, so on days when I have a little more time I love to run through there. There’s even a trail that goes out into the SF bay! 4. I try to avoid exercises that put a lot of strain on my wrists while they’re in extension. For example, if I’m doing planks, I’ll rest my weight on my forearms instead of hands, and for push-ups I’ll use free weights as

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“handles” rather than put my hands flat on the ground. 5. I think having a strong core is important for limiting back strain when you’re standing for a long time (like during endoscopy), so keeping my core strong is a priority for me! 6. I usually don’t listen to music, but when I do it’s usually late '90s/early 2000s pop! 7. “Hold Me Now” by Nanne Grönvall is a great pump-up song for me.

Patrick E. Young, MD, FACG, ACG Trustee, National Military Medical Center, Bethesda, MD 1. Unless I am training for a specific event, I like to mix it up. This decreases the risk of both injury and boredom. I typically work out 6 to 7 days per week with a mix of trail running, road and mountain biking, weightlifting, calisthenics, and flexibility training. I switch the program up every 8 weeks or so to create muscle confusion and enhance the metabolic benefits. 2. This depends on the season (both of the year and of my life) and the activity. When my kids were younger, I worked out early in the morning before they were awake. Now that they are grown, I generally select the timing of outdoor workouts based on the weather and indoor workout based on where I think they fit best. While I generally look forward to my workouts, I have times of low motivation like everybody. On those days, I tell myself, “You only have to do this for 10 minutes. If you want

to quit after that, so be it.” This little trick works to get me going, and once I am going, I essentially always complete the workout – though I am usually not setting personal records on those days! 3. That’s like asking me which child is my favorite! If I had to choose, I would say mountain biking. I love the beauty of flying through the woods or over the mountains, the amount of focus required, the whole-body aspect of the workout, and the fact that it helps you to face fear and practice pushing forward the edge of what is possible. 4. A question which is near and dear to my heart! As a taller guy, I make sure to do exercises which enhance core strength and protect me from back injuries. These include yoga sessions, animal flow, numerous core-focused calisthenics, and gym exercises like deadlifts, singlelegged roman chairs, face pulls, etc. To target grip strength, I also do farmer’s walks, dumbbell “suitcase carries” and climbing grip exercises with a “rock ring.” 5. For aerobic activity, I only listen to music if I am running on a treadmill (or riding on a trainer) for long periods of time. If I am outside, I just listen to the world around me and focus on enjoying the moment. When I am lifting weights, I love to listen to songs that inspire me to push hard. That ends up being an eclectic list for me. Funk, punk, metal, rap, you name it! 6. As a certified funk-o-phile and adherent to the Hippocratic principle of first doing no harm, I suggest “Ain’t Gonna Hurt Nobody” by Brick.

A Firm Foundation: Fitting Footwear for the "EndoAthlete” A special feature in which two distinguished gastroenterologists review the importance of supportive footwear for the endoscopy suite, take on the Crocs vs. Dansko debate, and generally comment on footwear facts, fads, and fashion for the scoping gastroenterologist. I was historically a dedicated Dansko guy….a pair in black and a pair in brown (like it mattered?) I felt taller and sort of cooler, but then a) rolled my ankle a couple of times in them, and b) slid on a wet patch and decided no more Danskos for me! I switched over to Merrell “Jungle Mocs” (cool name, dorky look, in fact my kids insist they remain outside and are referred to as Dad’s "work tools") which I maintain are the most comfortable standing shoes on the planet (kids’ embarrassment be damned). – Neil Stollman, MD, FACG, ACG Trustee

Dr. Neil Stollman

Dr. Stollman’s Merrell Jungle Mocs

As an interventional gastroenterologist, my primary footwear concerns are comfort and ease of cleaning. For years, I wore a well-supported pair of leather slip on shoes which served me well, though it took work to keep the leather looking good. Recently, I decided to move to function over fashion and began wearing Crocs "Bistro Clogs." They are comfortable, supportive, and incredibly easy to clean. I would not wear them in my daily life, but I am certainly enjoying them at work. If I did not do biliary work, I would wear a nice pair of supportive running shoes and also use a cushioned mat in the endoscopy rooms. For those with lower extremity edema from pregnancy or other causes, I would add a pair of compression socks, which are also handy for keeping you feeling fresh on long airline flights! – Patrick E. Young, MD, FACG, ACG Trustee

Dr. Patrick Young

Dr. Young’s Crocs Bistro Clogs

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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

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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

48 | GI.ORG/ACGMAGAZINE

Wellness Culinary Connections:

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

FOOD IS AND HAS ALWAYS BEEN THE GREAT UNIFIER. Over the years it has been so enjoyable for all of us to watch the foodie and medical communities meet and find common ground. The addition of “ACG Foodies” to the ACG MAGAZINE has created the space for many clinicians to share a part of their story and their food culture. We have all recognized that food can be medicine, but this view can be too scientific and calculated, and miss the unspoken, soul-nourishing parts of the kitchen and eating experience. The smell of food that can transport us back to childhood, the taste that connects us across generations. Often, we take these for granted in the hustle of day-to-day life. So, as we head into the holidays this special edition is another opportunity to slow down, reset, reconnect with our friends, families, and ourselves — Alex, Christina, and Vani

ACG Perspectives | 49

// PERSPECTIVES

TRUPTI S. SHINDE, MD

Gastroenterologist, Citrus Memorial Hospital, Inverness, FL

In the heart of Maharashtra, India, amidst the vibrant tapestry of traditions, flavors, and family bonds, I embarked on a culinary and professional journey that has woven together the essence of my upbringing with my passion for gastroenterology. My roots trace back to a family where every meal was a celebration of culture and togetherness, and where the enchanting aroma of spices filled our home. My mother was an incredible cook, specializing in seafood from our coastal region. However, Maharashtra also offers a plethora of mouthwatering plant-based dishes. I still remember those chilly mornings when I stood by our stove, inhaling the wonderful aromas wafting from the pot of Indian tea. Our tea was unique, filled with ginger, cardamom, cloves, and loose tea powder. These fragrances filled our home every morning, creating precious memories

of family togetherness over delicious tea and breakfast. Those moments marked the beginning of my love for food. Food nourishes our bodies and bonds us with others. I believe in the healing power of wholesome food in moderation. This passion for food and my curiosity about digestion inspired me to become a gastroenterologist. I'm deeply dedicated to this field, as it holds the promise of future breakthroughs in disease treatment through the mysterious gut microbiome, which our food can positively impact. Artificial, highly processed foods are a major cause of preventable lifestylerelated diseases in the U.S. Four years ago, I saw my patients struggling with these illnesses, which prompted me to act. I felt a strong urge to educate both our patients and the community about the positive impact of wholesome food. So, I launched a series in a local newspaper called "Eating with Purpose" where I discussed the

advantages of foods like chia seeds, coconut oil, ground flax seeds, and more—all of which can boost our digestive health and overall well-being. Additionally, I conducted a series of community lectures, emphasizing the importance of changing dietary habits and acquiring basic cooking skills. I strongly advocate that every middle school and high school student should acquire basic cooking skills to prepare delicious, wholesome recipes, reducing their dependence on processed foods. We must equip the next generation with the knowledge and habits needed to combat the obesity epidemic. In the pages of this magazine, I am delighted to share a cherished recipe from my family's repertoire: Vegetable Pulao. This dish, with its aromatic spices and hearty vegetables, embodies the essence of Maharashtra's culinary heritage. It's a dish that has transcended generations, filling our homes with warmth and comfort on countless occasions.

VEGETABLE PULAO  Ingredients: • 1 cup basmati rice (or any long-grain rice) • 2 cups water • 2 Tbsp ghee (clarified butter) • 1 medium onion, thinly sliced • 1 green chili, chopped (to taste) • 1-inch piece ginger, finely chopped or grated • 2-3 cloves garlic, minced • 1 bay leaf • 1-2 cloves • 2-3 green cardamom pods • 1-inch cinnamon stick • 1/2 tsp cumin seeds

 Steps & Tips: 1. Wash the rice and soak in water for 15-20 minutes; drain and set aside. 2. Warm ghee in a pan and put whole spices in (bay leaf, cardamom, cloves, cinnamon, and cumin cheese) seeds); sauté until aromatic. • 1/4 cup fresh coriander leaves, 3. Add sliced onion, green/dried red chilies, ginger, chopped (for garnish) and garlic, sautéing until onions turn golden brown. • Salt, to taste r powde ic • 1/2 tsp turmer 4. Add the vegetables mentioned above and cook r powde masala garam • 1 tsp until they start to soften. • 1 tsp red chili powder (to taste) 5. Put in the soaked rice and sauté for a few minutes • 1 cup yogurt (curd) until coated with the spices and ghee. • 5-8 cashews (for garnish, if desired) 6. Add the other spices: turmeric, saffron, garam • Pinch of saffron masala, red chili powder, mixing well. • Lemon wedges (for garnish) 7. Add yogurt; mix until everything combines well, and cook until the yogurt is well incorporated. 8. Add 2 cups of water and salt according to taste and bring it to a boil. 9. Make the heat medium to low, cover the pan with a lid, and let the pulao simmer for about 15 minutes until the whole water is absorbed. 10. Fluff the pulao with a fork, and garnish with finely chopped fresh coriander leaves and fried cashews. 11. Serve the vegetable pulao with lemon wedges on

• 1/2 cup mixed vegetables (carrots, peas, beans, bell peppers, etc.), chopped • 1/4 cup paneer (Indian cottage

the side. 12. Enjoy your delicious homemade Vegetable Pulao!

50 | GI.ORG/ACGMAGAZINE

CHRISTINE RANDAZZO KIRSCHNER, MS, RDN, CDN

Registered Dietitian Nutritionist and Co-Founder, Amenta Nutrition

With the holidays approaching, two things come to mind: family and food. Cooking for others is something I truly enjoy and hold close to my heart. The feelings I get from watching my friends and family members savor each morsel are both joyful and satisfying. This is especially true when the dish is something that they have never tried before or are not particularly fond of (or so they think). For me, one vegetable group in particular comes to mind—bitter greens—and I, for one, always appreciate a challenge. How can I get them to like this new food?! As a child, this type of vegetable was not something that would have ever landed on my plate. The first time I ate bitter greens was at my second job in New York City at Morandi, restaurateur Keith McNally’s Italian restaurant in the quaint West Village. Each late afternoon before service, two things would happen: the entire staff would eat the convivial

“family meal” and the waitstaff would speak to the chef about that evening’s specials. We would taste many of these additions which often consisted of beans, vegetables, and ancient grains or pastas. Chef Jody Williams would speak to each dish’s regional and historical significance and then describe its flavor profile. With the pressure of impressing the chef and my fellow waiters, I tasted everything, and it changed my life. Sounds dramatic? Well, I not only loved all the exciting new flavors, but I realized that I had less discomfort in my belly (and intestines, of course). I wanted to know why and spread that wealth of knowledge so others could also feel good while eating great food. This led me to enroll in Hunter College’s Master of Nutrition graduate program and eventually become a dietitian who specializes in gastrointestinal disorders. As a nutrition scientist, I learned the many benefits of fiber and, in particular, bitter greens. In ancient times, bitterness intensity was a way

to determine which plants were used for food and which for medicine. In modern times, we have learned that there are not only bitter taste receptors (T2Rs) in the mouth, but also lining the gastrointestinal tract, with effects on glucose control, satiety, microbiota composition, and regulation of immune response. Some of the vegetables and bitter greens introduced to me during this period were radicchio, endive, frisée, fennel, radish, arugula, and lacinato kale. I especially fell in love with radicchio and it has been a frequent star in my offerings at dinner parties and holidays throughout the years. Often, people are surprised to ﬁnd that they enjoyed it so much. I wonder—have they only tried a raw piece of radicchio? Have they never eaten it with some acid, fat, fresh herbs, tartness, or a garnish of salty gems like pungent, sharp cheese? The below recipe, Radicchio, Frisée, and Fennel Salad, is one I hold dear to my heart, a winter salad that is crisp, nutty, and fresh. A perfect accompaniment for holiday meals and colder evenings that is delicious, complex, and comforting. It also consists of 8 plant foods—a great start to consuming at least 30 different plant foods a week to optimize your microbiome. I hope you enjoy!

WINTER BITTER GREEN SALAD  Ingredients: For Vinaigrette • 3 Tbsp sherry vinegar • 3 Tbsp extra virgin olive oil 1 tsp Dijon mustard • 1 small shallot (about 1 1/2 Tbsp ) • Salt & pepper to taste For Salad • 1 grapefruit (or 1 large or 2 sma ll oranges), segmented • 1 medium fennel bulb, thinly slice d; stalks & fronds removed & tough oute r leaves discarded • 4 cups torn radicchio leaves, core discarded 2 cups of frisée, cut into 2-inch piec es • 1/4 cup Marcona almonds • 8 oz Parmigiano, thinly sliced • 1/4 cup fresh mint • 1/4 cup fresh basil

 Steps: 1. Cut the segmented grapefruit pieces in half (or thirds if very larg e). Set aside. 2. Using a mandolin, thinly slice half the fennel bulb crosswise (use the remaining bulb for another time ). 3. Toss the fennel, radicchio, frisé e, mint, basil and Marcona almo nds. 4. Whisk together vinegar, olive oil, Dijon mustard, salt, and pep per in a bowl or simply mix together in a mason jar. 5. Toss the salad with vinaigrette, Parmigiano, and half the grapefru it slices, reserving the other half to place on top of the salad afterward. You can add an additional few slices of cheese on top as well for presentation. 6. Taste and add more salt and pepper, if necessary. 7. Serve and enjoy!

ACG Perspectives | 51

// PERSPECTIVES

APRIL PANITZ, MS, RDN, CDN

Registered Dietitian Nutritionist and CoFounder, Amenta Nutrition

I grew up in the 1980s—a time when packaged foods were in their heyday. Commercials for colorful cereals with funny characters, kids laughing with their latest lunchbox treat, and ads for chewing gum were on a constant rotation during Saturday morning cartoons. These foods weren’t allowed in my house. My parents baked everything from scratch: cookies, birthday cakes— they even ground wheat to use for sandwich bread. But I didn’t care, I wanted crustless, white sandwich bread, grocery store cakes, and individually wrapped desserts that came from a box, even if they tasted faintly of plastic. While I couldn’t have these storebought treats, I was free to make any

dessert from scratch. I’d bake chocolate brownies when my parents were out, oatmeal cookies to bring to friends, and pecan pies for the holidays. As I got older, I realized my parents weren’t trying to be cruel by not letting me have these pre-made treats. Instead, they were getting me in the kitchen and cooking. As a result, I learned about taste and texture, gained confidence in my skills, and felt rewarded upon seeing others enjoy my homemade desserts. Now as a dietitian, many of my patients come to me with fear and anxiety around food, particularly treats and baked goods. Some are afraid of triggering symptoms; others feel guilty about eating sweets or are worried about the effects of ultraprocessed foods (especially when they thought these were “healthy” foods). For those who feel guilty about eating treats, I counsel them as a dietitian while also imparting my parents’ philosophy: get in the kitchen, start baking, and enjoy time with family and friends during the holidays, special occasions, and other moments of bonding. These types of foods

ORANGE GINGER POLENTA CAKE  Ingredients: Wet Ingredients • 2/3 cup orange juice • 3 large eggs • 1/3 cup milk (2% or plant milk) • 1/4 cup extra virgin olive oil • 2/3 cup (125 g) sugar • 2 tsp orange zest • 1 tsp vanilla extract • 1 Tbsp fresh grated ginger (from ~2-inch knob) Dry Ingredients • 2 cups (205 g) almond flour • 3/4 cups (110 g) cornmeal • 1 1/2 tsp baking powder • 1/2 tsp Kosher salt • 2 tsp baking soda • 1 tsp cinnamon • 2 tsp ground ginger For the Glaze • 1/2 cup confectioner’s sugar • 1 1/2 Tbsp orange juice For the Dried Orange • 2 Clementines, sliced 1/4 inch slices (optional) 52 | GI.ORG/ACGMAGAZINE

 Steps: 1. Preheat the oven to 350° F. Oil a 9-inch springform or a regular 9-inch pan and line the bottom with parchment paper. 2. Bring the orange juice to a boil in a small pot over medium-high heat. Turn off the heat and let sit for 5 minutes (will reduce to about 1/2 cup). 3. In a large bowl, whisk the almond flour, cornmeal, baking powder, ground ginger, cinnamon, and salt together. 4. In another large bowl, mix the eggs, milk, olive oil, sugar, orange zest, fresh ginger, 1/4 cup of the concentrated orange juice, and vanilla extract. Pour the wet ingredients into the dry and mix until smooth. 5. Pour the batter into the pan and bake on the center rack until golden brown on top and a knife inserted comes out clean, about 28 to 30 minutes.

(especially homemade) absolutely fit into a healthy eating pattern. It is when they are taken away completely that an unnecessary, negative relationship with foods ensues. To this day, I still love to bake. My taste tends to skew less sweet than when I was younger and I often favor desserts with more acid like this delightful gluten-free orange ginger polenta cake. It’s citrusy, and the cornmeal adds a lovely texture while the olive oil and almond flour ensure that it stays moist. It’s a cake that I love and is perfect for a holiday table or with a cup of coffee!

 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.

6. Transfer the cake to a wire rack. Let cool for 10 minutes, then remove the springform sides and let cool completely. 7. Transfer the cool cake to a plate or cake tray. In a small bowl, mix 1 Tbsp of the remaining orange juice with the confectioner’s sugar. 8. Spread the glaze over the top of the cake in a thin, even layer. Let the cake sit for 15 minutes to 4 hours to let the glaze harden. 9. Decorate with zest or dehydrated orange slices. 10. Serve & enjoy!

ACG International Training Grant

Barcelona Clinic Liver Cancer: Més que un clínic Andrew M. Moon, MD, MPH, FACG

THE CULTURE, ART, AND URBAN DESIGN OF BARCELONA SETS IT APART FROM ANY OTHER CITY. Even the great Barcelona Football Club has a motto of "Més que un club" which means “More than a club.” It is therefore fitting that the Barcelona Clinic Liver Cancer (BCLC) has taken on significance beyond itself and served as the standard bearer of liver cancer care for nearly four decades. As a young clinician-scientist with an interest in hepatocellular carcinoma (HCC), I aspired to work with the BCLC. With the support of Dr. Maria Reig, head of the BCLC, and Ferran Torres of Universitat Autònoma de Barcelona, this aspiration has been realized. Over the past year and a half, I have experienced multidisciplinary liver cancer care at the BCLC, learned innovative research methods, and collaborated with giants in the field. The American College of Gastroenterology North American International GI Training Grant helped bring me to BCLC, the epicenter of liver cancer care. The BCLC was established in 1986 by Dr. Jordi Bruix who assembled investigators and trainees from around the world to establish a truly multidisciplinary team. During my stay, Dr. Bruix reinforced that the BCLC “is about the people.” This

“This experience imparted lessons that will last a career, and friendships that will last a lifetime.” —Dr. Moon

remarkable group, assembled by Dr. Bruix, improved our understanding of the epidemiology, diagnosis, and treatment of liver disease. Dr. Maria Reig now leads the BCLC and was first author on the recently updated 2022 BCLC strategy for prognosis prediction and treatment recommendation. This document was widely acclaimed. But its omission of external beam radiation therapy (EBRT) prompted discussion and some consternation, particularly in the radiation oncology community. Dr. Reig identified the opportunity to address the gap in evidence for EBRT. She proposed that I work with her and Ferran Torres to perform an individual patient data (IPD) meta-analysis aiming to better characterize the role of EBRT for HCC. Support from the ACG North American International GI Training Grant turned this remote research opportunity into an unforgettable training experience. This funding allowed me to attend the 2022 BCLC Update Conference, an interactive experience that provided clinical pearls and inspiration that I brought back to my clinic. Following the conference, I continued to meet with

ACG Perspectives | 53

Dr. Reig and Dr. Torres remotely as we worked through research planning and execution. In the spring, I returned to Barcelona for a 3-week stay. During my stay, Dr. Reig demonstrated the importance of managerial skills, in addition to clinical, educational, and research expertise, to lead a clinical group. Dr. Torres provided training on the execution of IPD meta-analyses. Dr. Bruix shared pearls from a legendary career and how he built and maintained the BCLC through its succession plan. Working alongside BCLC faculty, fellows, nurses, and research coordinators demonstrated how this team continues to push the field forward. This visit accelerated progress on our IPD meta-analysis. With the help of co-investigators including Ted Yanagihara, Laura Dawson, and Joel Tepper, the project has made great headway and now involves more than 30 centers from 14 different countries. This immersive training experience, made possible by the ACG Training Grant, provided firsthand knowledge of why BCLC will always be “Més que un clinic.”

“BCLC ‘is about the people.’ This remarkable group, assembled by Dr. Bruix, improved our understanding of the epidemiology, diagnosis, and treatment of liver disease.” — Dr. Moon

Andrew M. Moon, MD, MPH, FACG Assistant Professor of Medicine at the University of North Carolina at Chapel Hill. He serves ACG as Deputy Associate Editor of The American Journal of Gastroenterology and chair of the Digital Communications and Publications Committee.

Page 51: Dr. Ferran Torres and Dr. Maria Reig in a research meeting with Dr. Moon at the BCLC. Clockwise from top: Dr. Moon and Dr. Reig at the 2022 BCLC Update Conference. Dr. Moon at the Barcelona FC match. The entrance to the Barcelona Clinic Liver Cancer

54 | GI.ORG/ACGMAGAZINE

Inside the

JOURNALS

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

VOLUME 6

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

WITH JOY AND WELL-BEING as the focus of this special issue of ACG MAGAZINE, this is the ideal opportunity for Inside the Journals to feature AJG Red Section article, “How to Infuse Joy in Your Practice: Our Journey to Sustainable Well-Being.” Mayo Clinic colleagues Dr. Cynthia Stonnington, Keith Jones, and Dr. Jonathan Leighton report on their experience with workplace strategies to address burnout, elevate joy, and increase professional satisfaction. Inside CTG, the Clinician’s Toolbox series continues with Fecal Calprotectin in IBD by Kapel, et al. A fellow’s perspective on ergonomics in endoscopy is the topic of an editorial by Dr. Khushboo Gala in ACG Case Reports Journal.

Inside the Journals | 55

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

[CLINICAL & TRANSLATIONAL GASTROENTEROLOGY]

How to Infuse Joy in Your Practice: Our Journey to Sustainable Well-Being

Clinician’s Toolbox: Understanding Our Tests Fecal Calprotectin for the Diagnosis and Management of Inflammatory Bowel Diseases

Cynthia M. Stonnington, Keith Jones, Jonathan A. Leighton, MD, FACG. Am J Gastro 2022 Nov 1;117(11):1723-1727. doi: 10.14309/ajg.0000000000001892

 “For our staff to go above and beyond for patients, each other, and themselves, medical practices must develop the infrastructure to address burnout, practice self-care, and infuse joy and well-being. Sustaining these efforts is even more important. Progress depends on enlightened leadership and grassroots efforts from our staff. The intent is to ensure that we evolve from a transactional healthcare environment to a relational environment where we help each other practice and experience stress-free living. Our efforts to address burnout, elevate joy, and increase professional satisfaction led to the creation of the Office of Joy and Well-being at Mayo Clinic in Arizona. We offer our experience as a roadmap to foster and sustain wellbeing in your practice.”  READ bit.ly/ajg-infuse-joy

Nathalie Kapel, PharmD, PhD; Hamza Ouni, PharmD; Nacer Adam Benahmed, PharmD; Laurence Barbot-Trystram, PharmD, PhD. Clinical and Translational Gastroenterology 14(9):p e00617, September 2023. doi: 10.14309/ ctg.0000000000000617

 “The measurement of fecal calprotectin has thus been recognized as a useful surrogate marker to distinguish patients with IBD from those with IBS. Moreover, it allows the monitoring of intestinal inflammation with a high negative predictive value, making it possible to exclude the diagnosis of IBD for symptomatic patients. It also shows high sensitivity for the identification of patients requiring additional examinations for diagnosis, such as colonoscopy, and the evaluation of therapeutic responses, providing evidence of relapse or mucosal healing, which can lead to the intensification or reduction of treatment.”  READ bit.ly/ctg-fecal-calprotectin

[ACG CASE REPORTS JOURNAL]

Ergonomics in Endoscopy: A Fellow's Perspective Khushboo Gala, MBBS. ACG Case Reports Journal. 2023 May; 10(5): e00984. doi: 10.14309/ crj.0000000000000984

 “For most of us, endoscopy is the longest marathon we

will ever run, probably spanning your entire career of a few decades. We are the generation of physicians who will likely see exciting endoscopic innovation during our lifetime—endoscopes designed keeping in mind the wide variety of operators, improved hand-tool interaction, and involvement of robotic tools. In the meantime, we must learn how to do our best with the tools we have—hence, during fellowship, we should be learning not just how to perform endoscopy but how to perform it such that we minimize the injury to ourselves.” – Khushboo Gala, MBBS, Third Year GI Fellow, Mayo Clinic, Rochester, MN  READ bit.ly/acgcrj-gala-endo-ergonomics

56 | GI.ORG/ACGMAGAZINE

EVIDENCE-BASED GI Clinical take-aways and evidence-based summaries of articles in GI, Hepatology & Endoscopy. EVIDENCE-BASED GI (EBGI) evaluates new research articles published across leading general medicine, GI and Hepatology journals. ACG Editors identify the highest quality studies published on important topics and create structured abstracts summarizing the study for quick reference and provide commentary on how the data is applicable to clinical practice. Editors record audio summaries for easy listening on the go. Follow EBGI on Twitter for weekly tweetorials @ACG_EBGI

Member benefit!

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

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

Inside the Journals | 57

COLORECTAL eCANCER: vent It You Can Pr

COLORECTAL CANCER PREVENTION by the Numbers from the AMERICAN COLLEGE OF GASTROENTEROLOGY

3RD

In the United States, colorectal cancer is the third most common cancer in both men and women, yet it is one of the most preventable types of cancer.

1 in 23

1 in 25

Lifetime risk of colorectal cancer for men

1990

Lifetime risk of colorectal cancer for women

Estimated new cases of colorectal cancer this year

50,000+

People will die from colorectal cancer this year

It has been estimated that people born around 1990 have twice the risk of colon cancer and four times the risk of rectal cancer than those born around 1950. While the reasons for these trends are complex, experts suggest unhealthy diet and sedentary lifestyle may contribute.

SCREENING Saves Lives

AGE 45 TO 75

Adults at average risk for colorectal

cancer should get screened

AGE 75+

The decision to continue screening should be personalized

10 VS. 1

In general, colonoscopy every 10 years starting at age 45 for average risk adults is recommended as a screening test as compared to the alternate stool FIT test which you have to undergo every 1 year.

in adults over age 75

POLYPS

150,000+

Removing polyps reduces the risk of colorectal cancer and saves lives. The power of prevention!

Learn More: gi.org/coloncancer Find a gastroenterologist near you: gi.org/find-a-gastroenterologist Read ACG 2021 Colorectal Cancer Screening Guidelines: bit.ly/ACG2021-CRC-Guideline Access translations of this infographic in ten different languages: bit.ly/CRC-Infographic-Translations

1-Step Test

2-Step Test

COLONOSCOPY Your doctor can see and remove pre-cancers called polyps and preventor detect or confirm colorectal cancer ALL IN 1 STEP.

Stool-Based Test FIT Test (Fecal Immunochemical Test) Multitarget Stool DNA

1-STEP TEST Colonoscopy is a one-step test that looks for growths called polyps in your entire colon (large intestine) and rectum using a colonoscope. Your doctor can remove polyps during colonoscopy and prevent colorectal cancer.

Flexible Sigmoidoscopy

2-STEP TESTS If tests such as Fecal Immunochemical Tests (FIT) or multitarget stool DNA are positive, a follow up colonoscopy would be required to as a second test.

POSITIVE TEST?

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

58 | GI.ORG/ACGMAGAZINE

1ST STEP

Imaging Test CT Colonography Colon Capsule

2ND STEP

Colonoscopy

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