ACG Conversations with Women in GI Collection

CONVERSATIONS with Wome

i GI from the pages of ACG Magazine

CONVERSATIONS with Women in GI from the pages of ACG Magazine

As we celebrate Women’s History Month in March, we are offered a meaningful opportunity to reflect on the progress women have made within the field of gastroenterology (GI) and hepatology. This is especially true for the many women who have played vital roles within the American College of Gastroenterology (ACG), helping to cultivate an enduring path where women are included, valued, and celebrated. Women’s History Month is not only a time to honor achievements of the past, but also a moment to recommit ourselves to shaping a more equitable and sustainable future.

Women across ACG have led change through clinical excellence, research innovation, education, mentorship, and service. Their leadership has strengthened our community and helped redefine what is possible for future generations. Equally important, we recognize the men who have served as allies along the way—advocating for equity, amplifying women’s voices, and working collaboratively to advance our shared mission. Together, let us continue to build momentum as we work to transform the future of healthcare.

Over time, the growth of women within GI and ACG has been both steady and impactful. Through numerous initiatives, programs, and leadership efforts, the College has responded thoughtfully to changing demographics, striving to ensure that voices are heard, needs are addressed, and opportunities are equitably shared. While progress has been made, our work continues, guided by the belief that diversity and inclusion strengthen our profession and improve patient care.

ACG Trustee Jill Gaidos, MD, FACG, has dedicated countless hours to interviewing women within ACG, capturing a rich and meaningful collection of stories that highlight both successes and challenges along the professional journey. These interviews go beyond personal narratives; they have become an integral part of our ACG Women in History celebration, preserving voices and experiences that might otherwise go unheard. We extend our sincere gratitude to Dr. Gaidos for her passion, commitment, and vision, and to all the women who shared their stories with honesty and courage. Their willingness to be vulnerable has enriched our community and strengthened the foundation upon which future leaders will stand.

Amy S . Oxentenko, MD, MACP, MACG Immediate Past President, American College of Gastroenterology

Conversations with Women in GI

An Inflection Point

Retiring After a Long Career at ACG and Looking Ahead to Life as a Painter

Jill K.J. Gaidos, MD, FACG, in conversation with Anne-Louise Bateman Oliphant, MPP, ACG Vice President, Communications (RETIRED)

ANNE-LOUISE BATEMAN OLIPHANT

JOINED THE ACG STAFF IN SEPTEMBER 1995 and retired March 31, 2025. She served as Director of Communications from 1995 to 2001. As Deputy Director for the ACG Institute from 2001 to 2015, Ms. Oliphant collaborated with Institute Directors Dr. Joel Richter, Dr. Edgar Achkar, and Dr. Nicholas Shaheen while at the same time serving as Vice President of Research & Communications, overseeing the Institute’s clinical research grant program. Beginning in 2015, she focused her ACG role as Vice President of Communications, and in 2017 became Editor-in-Chief of ACG MAGAZINE. Her ACG portfolio spanned strategic communications counsel, media relations, publications, partnerships, archival displays of ACG history, social media strategy and engagement, as well as support for the Public Relations Committee and the Digital Communications & Publications Committee, among many other contributions to the life of the College.

JG: What got you interested in joining the ACG?

ALBO: The short answer is that I was so impressed by the integrity and the commitment of the physicians who I met while working on behalf of ACG at its lobbying firm, Patton Boggs, from 1993 to 1995, that they inspired me to come to work for the College. I finished my graduate degree in American Government and Public Policy at Georgetown in 1993. I went to grad school at night and during the day I worked in the United States Senate for the late Senator Frank Lautenberg (D-NJ). After grad school and time on Capitol Hill, I went to work as a legislative paralegal at Patton Boggs, where one of the clients was the American College of Gastroenterology. I worked there during a very intense time in the early Clinton administration when health care reform and health care policy were at the top of the legislative agenda. ACG’s goal was to ensure that any bill that purported

to reform health care in the United States would cover preventive screening services for colorectal cancer. Starting in 1993, Patton Boggs lobbied to amend the Social Security Act. Ultimately, the legislation passed as part of an omnibus budget reconciliation bill in 1997 and became law on January 1, 1998. That was the start of Medicare’s coverage of preventive screening. While at Patton Boggs, I met Tom Fise, ACG’s Executive Director at the time, and I had the good fortune to meet ACG leaders when they came to Washington to visit members of Congress, including Board members Dr. Seymour Katz, Dr. Larry Brandt, Dr. Bill Carey, Dr. Luis Balart, and Dr. Joel Richter. I was deeply impressed by their compassion and their commitment. Health care reform had been really at the top of the political agenda in the first few years of the Clinton administration, but as the issue cooled off, I was looking for a new opportunity and Tom Fise offered me a job, so I went to work for ACG. That was September of 1995. I was 30 years old.

JG: Were you initially involved with lobbying and advocacy?

ALBO: Yes. While I had a communications role from the very beginning and my title was Director of Communications, Tom Fise had a very lean staff and so I did have a handle on the key policy issues, mostly from a communications perspective. I supported ACG’s policy agenda when physicians came to Washington, DC, to visit members of Congress.

JG: What were those early years like?

ALBO: ACG got grant money back in the mid-1990s through the early 2000s from Astra Merck, and then AstraZeneca, to do a major public awareness campaign on gastroesophageal reflux disease (GERD). I was the primary staffer on that campaign that started in March 1996 and lasted until 2003. ACG was doing television advertising about GERD symptoms and multimedia public awareness efforts—really a huge, coordinated communications campaign. We worked with the Washington office of a global PR

firm called Porter Novelli, so I learned a lot from them. Quickly, my role at ACG evolved to include not just the GERD campaign but all external communications for the College, support for the launch of the ACG Institute, and oversight of its first capital campaign that raised $17.2 million. Overall, I always joke that since the very beginning of my time at ACG, I have worked on all the projects that interest me—and there’s not much that doesn’t! I really have had a wonderful opportunity to learn and [have done] work that has fulfilled me.

JG: You mentioned that initially the staff was kind of small, pretty lean. How have you seen ACG grow over your 30 years?

ALBO: In my early years on staff, ACG really did operate with a very lean and loyal staff and needed an “allhands-on-deck” team, one in which everyone pitched in on everything and knew all that was going on. Inevitably, with growth, the staff has become more departmentalized, but we work very, very hard to make sure that everyone who is on our staff feels like they’re part of a family, and that they understand what’s going on across departments. We meet regularly at the senior managers’ level, and we also meet with key staffers as a larger management team, and finally we meet monthly as an entire staff. Brad Stillman, our Executive Director, goes to great effort to make sure that we’re all together and feel connected, since many work remotely some or all of the time. I believe the growth of our staff is good growth. We need to have lots of people to do the work of the College and to fulfill its mission. So, we are no longer very small, and we don’t have that same all-hands-on deck staffing model, but that spirit of being nimble and flexible, that remains.

JG: And too, I imagine, the initiatives within the College have changed, just sort of blown up for lack of a better word. ALBO: Yeah, but in a good way.

JG: Oh, absolutely.

ALBO: I believe that the size of the staff is just right to make sure that we have the capabilities and talents to be thoughtful and intentional about what we do, and to grow in directions that make sense with ACG’s mission. As I look across our organization, I believe that that’s really happening.

JG: Absolutely. And I hope you see it, but I absolutely see it, that any of our initiatives, even though we say they’re sort of physician-driven or memberdriven, they absolutely are. But there’s always the staff that says, “Well, you know, let’s think about that.” The staff share a history that’s known and can help ACG leaders understand feasibility. There’s a lot of experience that I think the members appreciate when they work with the ACG staff. I don’t know if you feel that as well or you see that in your interactions, but hopefully you do.

ALBO: I’m glad to hear that. I believe that Brad Stillman would agree with me if he were at this interview that there are projects when the staff know that they’re “ripe”—meaning there’s a champion, there’s a budget, there’s an interest, there’s a need, and you can tell there’s a good idea. We’ve just gone through a strategic planning process and lots of great ideas came out of that. As I look back, I believe that the projects that have succeeded—those I see that have really flourished within ACG—they were projects that were ripe, and they had a champion who was an ACG leader and a doer. When you have those factors, then the staff can bring its experience to support a project or initiative, but it’s always aligned with the College’s mission and vision. It was Dr. Mark Pochapin, several years ago

in his update to the ACG Strategic Plan before the pandemic in 2019, who really encouraged everyone at the clinician leadership level and the staff level to remain true to the ACG mission and vision. Another great test of whether a project is ripe is also to ask, “Does this align with ACG’s mission and vision?” I’m very proud that there is a collaborative conversation between the staff and leaders in ACG.

JG: Absolutely. So, you have accomplished a lot in your 30 years. Is there anything in particular that was most meaningful to you or something that you’re most proud of?

“My goal is to devote the years ahead to cultivating my creativity, and to seeing how far I can go as an artist.”

ALBO: I am very proud of the College’s leadership role on colorectal cancer education and advocacy. We have worked hard to provide excellent materials for our members to use. ACG staff and our members have been spirited participants in the national observance of Colorectal Cancer Awareness Month. We’ve worked to cultivate relationships with patient advocacy organizations such as Fight Colorectal Cancer, the Colon Cancer Coalition, and the Colorectal Cancer Alliance. I went to the first meeting ever of the National Colorectal Cancer Roundtable (NCCRT) back in 1997 and have rarely missed NCCRT over the years, so I had the opportunity to be the staff representative for the College at NCCRT with leaders from government, academia, public health, and industry. My goal as Vice President of Communications has always been to focus on how ACG can help patients and the public understand the value of colorectal cancer screening, colonoscopy’s role as a screening test, and its quality. I’m very proud of that work. When it’s Dress in Blue Day and everyone puts on their blue finery, that’s fun. But on a deeper level, I look back on the breadth and depth of ACG’s leadership on colorectal cancer education and I like to think of the lives that ACG has touched by sharing the message about the safety, importance, and lifesaving potential of colorectal cancer screening by colonoscopy with polypectomy.

JG: Right, so even though there’s Dress in Blue Day, it’s a 365-days-ayear issue that we face.

JG: You launched the ACG MAGAZINE, tell me about that.

ALBO: The ACG MAGAZINE has been a labor of love for me since 2017. The College for many years published the ACG Update newsletter that came out six times a year. My idea in launching ACG MAGAZINE was to create a publication that fosters a sense of community for our members, shares their stories, and looks beautiful— something our members can be proud of. ACG MAGAZINE is special and unique in GI because we feature our members not only by showcasing their clinical and professional lives, but also by celebrating their personal interests and endeavors. That’s been very fulfilling for me and exciting to see how the publication has unfolded. I’ve had a wonderful creative collaboration with the magazine team, which is small, but mighty, and includes Emily Garel, the College’s Art Director. Emily and I have been partners from the start, and her work is very important to the way that the magazine looks. Becky Abel, who’s the College’s Senior Communications Manager, is a talented copywriter and a creative brainstorming partner for me. I have relied on both their talents to bring ACG MAGAZINE to life. I want to say that it’s such a privilege still to be able to put ink on paper in the digital era. For that I want to recognize our incredible printer, Doyle Printing. Doyle is a family business in Maryland, and the College has done its printing with them for almost 40 years. Dennis Doyle heads the company now, and his father, Arthur Doyle, taught me everything I know about printing. It’s been a real joy to work with them. Brad Stillman has been unfailing in his support for the work of the magazine. There have been so many people who have been incredibly instrumental helping the magazine to publish great stories. There is too little space to name them all, but I appreciate them deeply. I’m very grateful to all the ACG members, GI patients,

and others who’ve helped me publish the magazine by generously sharing their news, interests, expertise, insights, photos, recipes, favorite books and music, passion for their work, and glimpses of their families and colleagues. I’m honored that so many people have shared their successes and triumphs as well as their trials and challenges—all with such candor, grace, and humility.

JG: Many people in health care, physicians especially, don’t know when to call it quits. What about now signaled for you that it’s time to retire? Why now?

ALBO: That’s a wonderful question. I’ve given a lot of thought to the idea that time is a luxury. I’m in a place in my life and in my marriage, fortunately, where I can take advantage of the luxury of time. I’ve always been creative. I started to paint when my daughter Emily Oliphant went away to boarding school at Phillips Exeter in the fall of 2017. She’d always done art classes at a wonderful community art center outside of Washington as a child, and I realized when she left home that I wanted to take art classes too! I started to paint then, and it’s grown into much more than a hobby, it’s really a calling. My goal is to devote the years ahead to cultivating my creativity, and to seeing how far I can go as an artist. To grow as a painter, you have to paint miles of canvas. So, that is my plan. I also want to bolster my relationships with my family and with my friends. I plan to dedicate this time to deepening my inner life and putting my health and wellbeing at the center of my life. I’m an extreme extrovert, and so for me, I believe it’s really important to cultivate quiet. When you were working with me on a book review for ACG MAGAZINE back in 2024 about “The Art of Stopping” by Dr. David Kundtz, you and I talked about the importance of pausing.* This time of my retirement is a critical pause, a real inflection point for my life. I am very grateful for the long and meaningful career that I’ve had at ACG, but I also look forward to a time when the first fruits of my creativity, my singular focus, and my zest will be used to advance projects and priorities that are important to me as a painter and as a person. I love what I do for ACG, I have incredible friends around the world in GI, and I

deeply value those friendships and the collaborations we’ve forged, but it’s time to retire. Why now? It’s because it’s time for me to put the focus on my own creative life and see where that will take me.

JG: Awesome. I’ve seen your Instagram (@aloliphant). You do amazing paintings. Will there be an Etsy page? Will you sell paintings?

ALBO: Yes, this is a goal of mine. I love to paint “en plein air” outside on an easel, so I can observe and paint from life. My husband and I bought a beautiful house in Maine, and so I will be spending a lot of time up there painting the rugged coast of Maine. Our house is on the St. Croix River that is the border with Canada, across from New Brunswick, so I’ll have a dramatic river view and paint in the landscape there.

And yes, I do plan to launch a website with my paintings and news of my artistic adventures. I believe that writing will also play a role in my creative endeavors. I am eager to see what unfolds in my journey, but it’s bittersweet to say goodbye to all my many ACG friends.

*Read Dr. Gaidos’s book review on “The Art of Stopping” by Dr. David Kundtz in ACG MAGAZINE Summer 2024.

Dr. Jill Gaidos is a Trustee of the College and Associate Professor at the Yale School of Medicine Section of Digestive Diseases and Director of Clinical Research for the Yale IBD Program.

Ms. Anne-Louise Bateman Oliphant retired as ACG Vice President of Communications in March 2025, after nearly 30 years of service to the College.

Jill K.J. Gaidos, MD, FACG in Conversation with Rosemarie L. Fisher, MD, FACG

Conversations with Women in GI

Dr. Jill Gaidos talks with Dr. Rosemarie Fisher, the first woman on the ACG Board of Trustees (1988-1992), about her career in medical education and establishing a niche in GI Nutrition. Dr. Fisher is Professor Emerita of Medicine, Yale School of Medicine.

JG: When I think about your career, I think about two major areas of focus: your career in education and your career in GI nutrition. How did you get into nutrition and nutritional support as part of your career?

RF: I got into nutritional support, interestingly enough, because at Yale the only promotion track at that time was the tenure track, which was basically bench research. Bob Donaldson was my Medicine Department Chair at the VA, (former Editor of Gastroenterology and former President of the AGA) where I was GI section chief. Because I had done research on alpha-1-antitrypsin during the year I spent with Sheila Sherlock, Bob suggested that I look at the effect of alcohol on glycoprotein synthesis by the

liver. So, I was decapitating rats and infusing alcohol into portal veins, while being Chief of GI at the VA, teaching fellows, seeing consults, and doing procedures. He and I and Howard Spiro (who was then Section Chief at Yale) realized (not to my surprise) that bench research was not to my liking or where my strengths were. Yale, by chance, had just instituted a Clinical Scholar Track for promotion and that’s where I would focus and develop a niche. Yale-New Haven had just formed a nutritional support team, a TPN/enteral support team, but without a gastroenterologist. I was following a lot of IBD patients who were on home TPN, so Bob and Howard said, “I think this is where you should go.” So, I became the GI physician member and head of the TPN team at the time. We had a surgeon, a part-time endocrinologist, a nurse practitioner, and a pharmacist on the team. Bob Donaldson also said, “we need to get your name out there in different groups.” He said, “I want you to get on the Training Committee

and I want you to give a ‘Meet the Professors’ luncheon on nutrition” and the education part came with that. He was also Editor-in-Chief of Current Opinions in Gastroenterology, so he appointed me to become the Section editor on nutrition for the journal. I was really getting interested in nutrition support, not in nutrition as dietary modification, but more looking at nutrition in disease processes. It was a quarterly journal, and I could pick topics and authors, and the journal would pay for secretarial support. We didn’t have that support from the GI section at that time or from the VA. About six months into it, he said, “How much are they paying you?” and I said, “$200” and he said, “That’s not enough. Tell them after this year you are not going to do this anymore and one year on your CV is enough.” So, that was it. Support, networking, and connections meant everything at that stage of my career. At the same time, I had been active in the ACG. Larry Brandt, Arvey Rogers, and Jamie Barkin had started pushing me to do more things with the ACG. Being more clinical, I felt very welcome in the ACG. I had trained at Montefiore-Einstein for residency right when Larry Brandt came and I got to know him more. As I became more involved, Larry said, “We want to nominate you to become a Trustee.”

Every time someone asked if I would do something, it seemed to involve nutrition support: give a grand rounds lecture, comment on a paper, write an editorial, etc. That is how my niche in GI became nutrition. Marty Floch took over the Red Journal for the ACG and asked me to be an associate editor, so that helped as well.

JG: So, how did you get involved in medical education?

RF: The plan was for me to go from being the chief of GI at the VA and to go back to Yale to oversee the nutrition support team and GI clinical services (although I left ERCP to others). I had always been involved in the fellowship teaching and was always worried about the wellness of fellows and residents. There were several incidents where the Chief Residents had to deal with

serious wellness issues and there was no program director at the time. The Chair of Medicine ran the program with the Chiefs. We were one of the few programs in the country that did not have a program director. At this point, I had just been appointed as Chair of the internship selection committee and a new chair of medicine was just appointed. I told the new chair that he needed to have a program director for internal medicine, and I wanted to do that job. So, that started the educational and administrative roles. I did get promoted.

But nutritional support didn’t have anyone overseeing it and there wasn’t really anyone who knew how to manage it, so I kept on doing that.

JG: I feel like nutritional support is such a small part of GI training and few of us do it regularly in practice. How do we get more training and more interest in nutritional training?

RF: I believe we have to have more down-to-earth case presentations. I have two fellows in clinic with me and we have about six patients on home TPN and they are starting to see some of the lab abnormalities and complications that can arise. These two are getting it because they see the patients, we review the formula prescriptions, we review the laboratory data and review the possible complications. I have also started to compile some articles for them. I think that if we made some of the modules from American Society for Parenteral and Enteral Nutrition (ASPEN) available to the fellows and faculty, it would be helpful. There is just so much to learn that it is difficult to add much more to the present curriculum.

JG: And find more time to complete the additional training! How has medical education changed over the years? I’m sure you have seen several reiterations of medical education but what has been successful and what has not worked as well?

RF: Nobody had any idea about developing a curriculum when I was in fellowship. Being the program director for medicine, we decided that the subspecialties needed to develop a curriculum of what a general internist needed to know from their subspecialty. The problem is that if you didn’t have someone evaluating those topics or how people are learning those topics, people were getting nowhere. We got a little too much into the grass as opposed to looking at the trees. We got too minutiae driven. I was amazed when I went to my first Accreditation Council for Graduate Medical Education (ACGME) visit as program director, what the ACGME was looking at. They reviewed the program and all the subspecialty programs all together and the program director for medicine was responsible for all the other subspecialties. The first time we encountered them in a site visit, they had a little booklet that was like 10 pages of requirements and that was it, but the residents had to fill out a 250-question survey that the program was judged on, and the answers depended on how the residents felt that day. That started my involvement in looking at what both core internal medicine and subspecialty training programs were to be responsible for training their trainees. At that time, both the accrediting bodies for programs [ACGME and their residency review committees (RRCs)] and the certifying bodies for individuals (i.e., American Board of Internal Medicine) looked at the details, but didn’t look at overall competency. Looking at competency now and how

programs are training their residents/ fellows to be competent is where we stand. This has been the biggest change in education. We, as of yet, in my opinion, do not have the final way to really judge the competency of our trainees. We need to incorporate more faculty development into programs so faculty can be better judges of the competency of their trainees.

JG: How do you think work hour restrictions have impacted training?

“I believe you have to do what you feel you need to do to get your work done, and to show your patients that you are responsible for them, and make sure that there is humanism in medicine.”

RF: The Medicine RRC actually had work hour restrictions before the ACGME implemented them for all of the training programs. We always had 80-hour work limitations, one day off a week averaged over four weeks. I was actually on the first RRC committee that wrote those initial work hour restrictions affecting all of the programs. While I believe everyone meant well, I don’t believe there was enough back up support for people to have those work hour restrictions and get rid of the scut work they were doing. The problem I saw was that people were doing the same amount of work with less time and that the residents thought they were supposed to do less work overall so there was a conflict there. Trainees’ attention to what was happening to patients started to go way down. I may not know the latest LA Grade scale for esophagitis, but I have patients that I have been seeing for 40 years and I am teaching trainees how to talk to patients and build relationships that last and attain knowledge about the patients which shows that you are responsible for them. It still amazes me when a woman comes in with constipation and no one has asked if she has had any children and had any complications. I just think that sometimes it’s a matter of “how soon can I get out of here?” and not a dedication to the patient. I’m pleased to say that it hasn’t been as common as it could be. We haven’t done enough though to get rid of the secretarial duties. We (faculty) don’t get enough administrative support, much less the fellows getting administrative support. Looking at the institution of milestones and board

pass rates, only ABIM certification scores showed a difference in clinical outcomes. I think this was just published in JAMA a couple of weeks ago (Gray BM, Vandergrift JL, Stevens JP et al. Associations of Internal Medicine Residency Milestone Ratings and Certification Examination Scores with patient Outcomes. JAMA 2024;332(4):300-309). I believe in duty hours but put the onus on the trainee to get out of there. They need to do things like go to the dentist. They have things to do. It’s the good old times that were bad, but we didn’t realize it. The one thing that we need to get out of this is to make the trainees feel more responsible for and to their patients.

JG: There is a little bit of a learning curve because once they are out of fellowship, they will no longer have these duty hour restrictions. Now is the time for the fellows to learn how to manage their clinical duties, notes, and in-basket messages during work hours so they learn how to avoid taking as much work home to work on after hours.

RF: I tell them, “I’m not the example to follow.”

JG (laughing): Right!

RF: It was interesting even when I became the program director. I had four women in each class of trainees and one of them came up to me and said, “You know you are not a good role model for women in medicine.” I said, “Why?” “You work too hard.” OK, you have to do what you are comfortable doing. To me, it doesn’t look like I’m working too hard because I haven’t stopped it. I believe you have to do what you feel you need to do to get your work done, and to show your patients that you are responsible for them, and make sure that there is humanism in medicine. I enjoy really spending that time talking to my patients about their lives, before the administrative/secretarial work. I just finished charts from a week and a half ago! Oops – I shouldn’t have said that!

JG: You were also the Director of Resident/ Fellow Wellbeing. How did that position come about?

RF: When I stepped down from being the Associate Dean of GME, I, with Steve Huot established the position of Director of Wellness and Resident/Fellow Wellbeing along with continuing my position as one of the Deputy Title IX coordinators for the Medical School. My GME involvement included being an advisor to the resident and fellows’ senate. I also started a peer support group called “Call a Friend” which included trainees who received training to be active listeners and had access to resources for mental health needs. We developed a whole network of therapists who will see trainees for mental health concerns. We got the hospital to agree that the needs of residents and fellows are different from the needs of hospital staff. They needed extra help at times. Paul Desan, a consultation psychiatrist and Program Director of the consult liaison psychiatry fellowship, and I had gone to the hospital and got them to agree to set up a system either through the “Call a Friend” program or directly through me or Paul to get access to mental health practitioners which would be billed to the hospital, not through insurance, and no records would be included in Epic. That has continued and I’m just now in the phase of turning it over to someone else. We also created a Resident/Fellow Appreciation Week.

Resilience recently, however, has gotten a bad reputation because people think it means you need to just toughen up and tolerate bad things. But it’s not that. Medicine is a 24/7 job, and it can be depressing at times but you have got to learn how to deal with those times. Resilience is about learning how to change some of the things you can change in yourself to help deal with these difficult times.

JG: When you were on the Board of Trustees, what was a current focus of ACG and what were some of the issues you had to face?

RF: Some of it was improving fellowships to include more clinical research and less basic science research-oriented training. I remember when I came to interview for

fellowship with Howard Spiro and Henry Binder was a junior attending. Henry said to me, “What do you mean by clinical research?” “Patientoriented research.” We started to talk more about that on the Board. We also started to talk more about involvement with the FDA, looking at new drug development and the problems with some of the drugs. That lead to my position on the FDA GI Drugs Advisory Committee and then I become chair of the GI Drugs Advisory Committee. We (the ACG) also had a committee that wrote articles for the Red Journal that was an FDA-associated committee that put together articles on drug development for different types of therapies for different disease states. So, the ACG really looked at that in depth and built those relationships. Since we had so many people in practice, the Board started looking at what was happening to people in practice – their wellness and their practices. We were also working on getting more women involved in the ACG and getting more fellows involved in research posters and presentations. ACG did have a training and education committee. They focused on things that were more clinically relevant. We saw ACG as being total gastroenterology and hepatology, not separate from each other. The big thing was getting people involved and keeping them involved once they were in practice.

JG: That is still one of our goals!

Dr. Gaidos is a Trustee of the College and Associate Professor at the Yale School of Medicine Section of Digestive Diseases and Director of Clinical Research for the Yale IBD Program.

Dr. Fisher is Professor Emerita of Medicine at Yale School of Medicine. She was the first woman on the ACG Board of Trustees, serving from 1988 to 1992.

“Digital Health in Clinical Practice”

Jill K. J. Gaidos, MD, FACG in Conversation with Sara N. Horst, MD, MPH, FACG

asynchronous care models like eVisits or eConsults. I also want to help with education around how to help people do their daily work a little bit better through the EMR because it’s such a big part of our lives.

JG: One of the challenges for physicians is that IT is not a comfortable space for us. We figure out how we interface with the EMR the least amount possible to get our work done, close the chart, and walk away. So, how do you educate clinicians or get people comfortable making changes to the EMR, opening their eyes that charting and placing orders can be completed more easily?

Conversations with Women in GI

DR. SARA HORST IS THE ASSISTANT VICE CHAIR FOR DIGITAL HEALTH OPERATIONS for the Department of Internal Medicine and Health IT Clinical Director for Vanderbilt University Medical Center.

JG: What are the duties associated with your titles? What are your job responsibilities at Vanderbilt?

SH: For the Department of Medicine Digital Health Operations position, this is really a place where I can work on everything associated with the electronic medical record, both on the patient-facing side and on the clinician-facing side. I am excited our hospital system is supporting administrative infrastructure around health IT implementation. When a physician wants to change something in the EMR, even with a robust health IT infrastructure, it can be difficult sometimes to interface and even understand what to ask for. I am tasked with trying to improve this clinician experience with the EMR. I’m also spending a lot of time trying to think of innovative ways for us to deliver care through telehealth, through

“I believe having physicians involved in health IT decisions is imperative as we understand the operational downstream effects in patient care.”

—Dr. Horst

SH: I definitely do not have all the answers, but I am excited to be in a space to think about how to help. As a busy clinician, you often figure out one way to do something, even though it may not be the easiest way to do something, and habits form. So, I am trying to tackle it in little pieces. We implemented Epic in 2017, and I saw a lot of potential for improvement after the initial implementation, so I became an Epic Physician Builder. This is a program that allows physicians to learn more about the build foundation background of the EMR and even implement some health IT build. Now, when someone comes to me with a problem, I can say, “OK, I see your problem. There is no perfect solution, but here are some ways we can make this a little bit better.” It’s really satisfying to make an EMR improvement that makes things simpler for workflows, and also allows for measurement of outcomes. This is how we can make improvements in system-based patient care as there is so much power in data. I believe having physicians involved in health IT decisions is imperative as we understand the operational downstream effects in patient care.

JG: How did you get interested in this pathway? We all know this is needed, but not all of us are going to volunteer to help implement changes to the EMR.

SH: I take care of IBD patients, and I was in this nice clinical research space and had figured out how to efficiently pull data from our prior EMR. It was fun, and I was working to expand these projects. But when we implemented Epic in 2017, I realized that data extraction was going to be much different and likely more difficult.

JG: Yes, it’s a complex process!

SH: I actually got pretty frustrated and discouraged, but interestingly I also had just taken part in a women in GI leadership course. Something that really resonated with me in the course was the advice: “Don’t just complain. You should come up with a solution.”

JG: (Laughing) Right!

SH: As this is happening, I heard about the Epic Physician Builder program that was starting at my institution and so I volunteered myself. I knew I needed to understand the background of the EMR to see if I could help make changes. At that point, I was just interested in clinical research and data extraction, but then I started to get into the building piece and really enjoyed it. I started to work on improvements for our clinic and I could see the potential for helping clinicians’ daily lives. Because I had gained interest and knowledge, I started to be asked to be on committees around EMR workflows. I said yes a lot because it was interesting to me, and it just kept building. This was definitely not a career path that I was originally planning. If you had asked me 10 years ago if I was going to be a Clinical Health IT Director and Assistant Vice Chair of Digital Health Operations, I would have said, “What are you talking about?” (Laughing)

JG: (Laughing) Exactly!

SH: It kept me going and the passion was there. I would stay up until midnight trying to work something out in Epic. Once you do that, you realize it’s probably a direction you need to keep pushing.

JG: Yes, absolutely. I have been working with our Epic people to try to facilitate some of the health maintenance documentation for my IBD patients and they were more focused on the fact that our notes are already too long as it is and I shouldn’t include that information. There is clearly a disconnect between IT, practitioners, and the billing office.

“It’s not easy, and, in the end, will still require individual and organizational 'buy-in.' However, even these beginning attempts will help others understand the art of the possible.”

—Dr. Horst

SH: There are actually some solutions that I have come up with, but none are perfect. If the “data in” isn’t good, the “data out” is not going to be good for you. We are still very limited by the inability for EMRs to truly share data elements, such as a DEXA scan from an external location that is scanned in. Am I ever going to find that for you easily in our current EMR infrastructure? No. But I’ve worked through some things to more easily gather data into easily accessible locations in Epic—for us, this is called “Synopsis and Snapshot.” Because I am really passionate about this, I currently sit on the National Epic GI Steering Committee, and I am working to try to implement some of these things that could be put into Epic Foundation and allow more organizations with the same EMR to access it. I think these are the kinds of strategies that we as leaders, and maybe even societies, need to be thinking about a little bit more. It’s not easy, and, in the end, will still require individual and organizational “buy-in.” However, even these beginning attempts will help others understand the art of the possible.

JG: There is so much information in the EMR that you just can’t easily tap into. SH: Now, this is where things get tricky. Our current infrastructure often still requires you to click a button or put it in a flow sheet, which is just not easy for a clinician to do in a busy workday. It’s possible that AI or easier access to natural language processing could take a free form note that you write and turn it into an actual standardized data element that we could use for clinical research and data evaluation. But these strategies are time intensive and expensive currently. How institutions are going to weigh the risks and benefits of this, I don’t think we know the answer to that yet. But there is opportunity there.

JG: That is really interesting. There are quite a few studies showing that women spend more time in the EMR in general, including getting more inbasket messages, spending more time on documentation (Rotenstein LS, Fong AS, Jeffery MM, et al., Gender Differences in Time Spent on Documentation and

the Electronic Health Record in a Large Ambulatory Network. JAMA Netw Open. 2022;5(3):e223935. doi:10.1001/ jamanetworkopen.2022.3935). Do you see a gender difference among the people that you help to optimize their Epic use?

SH: That’s a really interesting question and I don’t know the answers to this completely, and I don’t believe it’s just women who struggle with this. There was a really interesting study out of Mayo Clinic recently (Bali AS, Hashash JG, Picco, MF, et al., Electronic Health Record Burden Among Gastroenterology Providers Associated with Subspecialty and Training. Am J Gastroenterol 2023. DOI: 10.14309/ ajg.0000000000002254), where they looked at clinicians in gastroenterology and found that time in the EMR was specialty driven. So, chronic disease state specialists (such as inflammatory bowel disease and hepatology) spent more time in the EMR. Non-physician providers (NPPs) also spent more time in the EHR. In some clinical infrastructures, it may be that these NPPs are required to take on more day-to-day care in patient calls and message baskets. Primary care clinicians in particular are getting overwhelmed by extra-clinical time duties.

JG: Our primary care doctors are struggling with this increased demand as well.

SH: If you want to see the burden across our institution, primary care is really bearing the brunt. Across health care, we have rapidly changed to giving asynchronous care more. When you look during the COVID pandemic, one study showed that EMR in-basket message volume doubled (Holmgren AJ, Downing NL, Tang M, et al., Assessing the Impact of the COVID-19 Pandemic on Clinician Ambulatory Electronic Health Record Use. J Am Med Inform Assoc. 2022 Jan 29;29(3):453-460. doi: 10.1093/jamia/ ocab268). Suddenly, patients were getting onto the portal because they had to; there was no other way for them to get their care. And then there was the 21st Century Cares Act which requires that all results go to the patient immediately. Our institution found that turning this on immediately doubled messages (Steitz BD, Sulieman

“I find when I am asking for something, I set up a meeting to physically show them exactly what is happening and ask them for an idea around what is a better workflow.”

—Dr. Horst

L, Wright A, Rosenbloom ST. Association of Immediate Release of Test Results to Patients With Implications for Clinical Workflow. JAMA Netw Open. 2021;4(10):e2129553. doi:10.1001/ jamanetworkopen.2021.29553). We have a lot of unintended consequences around trying to get better access to care that our clinicians and teams are feeling. We need to right the ship a little bit, and I don’t think we know exactly how to do this yet. There is a lot of interest. For example, one idea is to use AI to generate draft in-basket messages. This typically works best for the less complicated questions and not as well for the more complex questions or concerns.

JG: Such as the messages that end up in our in-baskets.

SH: Right. Also, institutions are increasingly billing for patient portal messages. Our institution implemented this in 2023. I think this is important, as we are providing more asynchronous care, and we need to start framing this better for patients. There is a lot of time and effort for the clinician to give care over the patient portal even if the patient is not directly in front of them in clinic. Also, patients don’t always want to come to clinic, and I understand that completely.

JG: You highlighted a few of the key strategies for setting boundaries around MyChart messaging in your ACG Magazine article, “Embracing Access to Physicians and Establishing Boundaries,” (available at https://issuu.com/amcollegegastro/ docs/23acgmag-summer-web/29) as well as providing specific criteria for billing for MyChart messages. One of the things that I thought was very interesting is that you have to have permission from the patient to bill them for MyChart messaging. When you are rolling this out, do you tell this to patients in clinic or how do you frame it?

SH: It is so key. I do think that for any of these care options, the patients need to say, “Yes, I want this.” Or they can say, “No, I want to come to clinic instead." Or “I’m going to go to a walk-in clinic.” We had to think a lot about this, and nationally people are handling this differently at every institution. We put together a strategy that is consistent across our institution such that when a patient goes into MyChart, they see the possibility of an eVisit as soon as they enter the portal and give consent. When another institution

implemented a similar strategy, they ended up having < 1% of their MyChart messages as billable visits, and decreased the number of messages that came in by 5-10% (Holmgren AJ, Byron ME, Grouse CK, Adler-Milstein J.Association Between Billing Patient Portal Messages as e-Visits and Patient Messaging Volume. JAMA 2023;329(4):339–342. doi:10.1001/ jama.2022.24710).

JG: One of the challenges with managing the in-basket message is that it’s care on top of care that we already providing. Sometimes patients don’t get that. I have patients who send messages saying, “I need to talk to Dr. Gaidos right now.” But I’m scheduled to be in endoscopy or clinic all day and can’t do a telephone visit while simultaneously doing all my other clinical duties.

SH: We have done such a good job of asynchronous care that it is causing a lot of pressure on our clinical teams to try to do this on top of what we are doing all day in clinic. This is creating a very difficult system to sustain.

JG: Absolutely. Patient questions are just one piece of the Epic in-basket and if all I had to do was keep up with that, it would be relatively manageable. But, we also have lab results that come in as the results are available (so 10 labs ordered for one patient may come in as 10 messages), and staff messages that need to be addressed as well.

SH: Yes, patient messages and calls occur in addition to all the prior authorizations, denial letters, peerto-peers, an outside physician is calling you, or infusion centers are calling. We have not enhanced the infrastructure around the support for that to measure up to the volume of messages that physicians are getting. And, as healthcare costs are higher and margins closer, our ancillary teams are getting tighter. There is nowhere for this work to go. And frankly, a lot of EMRs always just push the messages up to the top which may

be the clinician. It would be advantageous to think about how we can get ancillary teams to work to the top of their license and take some of this work so it would not even make it to the physician. These are difficult workflows to implement, and they require a lot of health IT support and operational buy-in. I don’t believe our message baskets are facile enough quite yet to do that, but I’m hopeful that over the next three to five years, this will get better.

JG: Are there resources for people who are interested in learning more about how to optimize their EMR? Any other training you would recommend?

SH: This is a place where it gets tricky because everybody’s EMR is a little bit different. The rules around what is accessible to clinicians to work on at each institution level are a little bit different. I think we need to start from the ground up. Some of the things I have been doing is talking to fellows. “Hey, when you go out to your practice, these are a few EMR workflows that you need to implement right away to make your life easier in five years.” It’s probably not a bad idea to start enhancing this education all across GI. There are things like the “community library” in Epic. If you can get access, it has a lot of great enhancement ideas, but a busy clinician doesn’t always have time. At an institution level, we have customer care support specialists who can work with clinicians and spend an hour of your time trying to improve your daily clinical care. We need to be better about this, but the time investment is difficult to do.

JG: I definitely want to understand Epic a little bit more, not that I want this to be my full-time job. There is a language barrier when I am trying to ask for things from my Epic team which leads to 10 emails back and forth just to get across the specifics of what I want. How would you recommend someone communicate with their health IT team when having issues with the EMR?

SH: A health IT analyst may not understand the clinical workflow enough to best help you. I find when I am asking for something, I set up a meeting to physically show them exactly what is

happening and ask them for an idea around what is a better workflow. Those have usually been the most successful conversations because even screenshots a lot of the time don’t get to the point of “these are the 15 clicks that I am doing for this.” It’s not always easy to make those conversations happen so I would reserve them for really important, bigger obstacles that you are coming upon. Once you have figured out a workflow change that happens in one area, I have realized that I can actually use that in other areas. I think if you are interested in learning more, little pieces can be helpful like “Smartphrases,” “Smartlists,” “Smartlinks," and “Letter Templates” in Epic. Often these can be shared with your teams, and starting here can be an entry into bigger and better things!

Jill K. J. Gaidos, MD, FACG

Dr. Gaidos is Associate Professor of Medicine at the Yale School of Medicine Section of Digestive Diseases and Director of Clinical Research for the Yale IBD Program.

Sara N. Horst, MD, MPH, FACG

Dr. Horst is Assistant Vice Chair for Digital Health Operations for the Department of Internal Medicine and Health IT Clinical Director for Vanderbilt University Medical Center.

Dr. Bincy Abraham on “Innovations in Clinical Care: Incorporating Intestinal Ultrasound in the IBD Clinic”

Jill K. J.

Gaidos, MD, FACG in Conversation with Bincy P. Abraham, MD, MS, FACG

Conversations with Women in GI

BINCY P. ABRAHAM, MD, MS, FACG, is the Fondren Distinguished Professor in Inflammatory Bowel Disease, Department of Medicine; Professor of Clinical Medicine, Academic Institute in the Academic Division of Gastroenterology and Hepatology at Houston Methodist – Weill Cornell, and Program Director of the Gastroenterology Fellowship Program, Lynda K. and David M. Underwood Center for Digestive Disorders, Houston Methodist in Houston, Texas. Dr. Gaidos had the opportunity to interview Dr. Abraham while at Houston Methodist for hands-on intestinal ultrasound training.

Jill Gaidos: You were the first person that I heard in the U.S. who had started using intestinal ultrasound (IUS) in your inflammatory bowel disease (IBD) clinic. What interested you about intestinal ultrasound to want to learn it and begin using it in your clinical practice?

Bincy Abraham: We had a visiting professor from Australia who came to give a talk for our local GI society and he came to visit us at our institution. He was not doing bowel ultrasound, but his colleague was. He was

“The nice thing about IUS is that it’s an adjunct test. If you have any concerns, you can always order a CTE or MRE if needed.”

—Dr. Abraham

more of a functional GI doctor. He found out that my practice is focused on inflammatory bowel disease and he said, “Bincy, you have to learn how to do intestinal ultrasound.” I had heard about it a bit from a presentation by Dr. Kerri Novak in Calgary, but I didn’t know all the details. So, I reached out to Kerri initially and she introduced me to the Intestinal Bowel Ultrasound Group (ibusgroup.org) and told me to submit an application. I applied and I didn’t get in that first round; I initially got waitlisted but then an opening became available and started training. It was Thanksgiving weekend in 2019 when I did Module 1 in Copenhagen. I remember we took the kids because it was their break too. In the application, you had to talk about what equipment you are getting. I learned about the equipment from the visiting doctor from Australia whose colleague raved about his equipment, “You have to get the Canon i800. It’s the best machine in the world.” I reached out to ultrasound reps and had several vendors come in with their equipment, top of the line stuff. Every clinic day I had one or two vendors each and I would compare the images between the machines. I fell in love with the Canon and the GE but ultimately made the decision to get the Canon machine. I ordered it, went to the course, and came back and started practicing in clinic. I then went to Milan in early 2020 and did 99 ultrasounds there for Module 2 and then went to the European Crohn’s and Colitis Organisation meeting for Module 3 in Vienna. This all happened peri-COVID. Literally, I had taken the last train from Italy to Vienna before Italy shut down. I went to the ECCO meeting, passed my test, and got certified. When I got back, everyone was talking about COVID and how Milan was at the epicenter and I was like, “Oh my gosh!” I think I missed the whole thing by just a few days. And, I came back and started doing ultrasounds and it’s really changed how I practice.

JG: One of the challenges with implementing IUS in practice is the cost of the machine. A lot of sites are using donations and philanthropy

funds to pay for the ultrasound machine. How were you able to get your ultrasound machine funded?

BA: I was lucky enough to get department funding for my equipment. It is the best opportunity if you can utilize philanthropic funding because you can actually show value to those who provided the funds and how it is changing the practice of medicine. For centers who don’t have the opportunity to use philanthropic funds or have saved budget to purchase a machine, you can eventually break even with normal reimbursement of performing the exams. In our article “Integrating Intestinal Ultrasound into an Inflammatory Bowel Disease Practice: How to Get Started” published in Crohn’s and Colitis 360 (Abraham BP, Reddy D, Saleh A.Integrating Intestinal Ultrasound into an Inflammatory Bowel Disease Practice: How to Get Started. Crohns Colitis 360. 2023 Aug 7;5(3):otad043. doi: 10.1093/crocol/otad043. PMID: 37719309) we have provided a formula to calculate how long it will take you to pay off your machine. The formula includes the number of ultrasounds you do with the average reimbursement for the insurance companies in your area to calculate how long it would take to recoup the cost of the machine. You can use that information to tell your institution or administrators, “If we get this machine now, we can break even in X number of months.” It will vary depending on the number of procedures that you do and the number of providers who do it at your site. Fortunately, the maintenance of the equipment is of low cost. I’ve had my machine since 2019 and as long as you take good care of it, that is, don’t drop your transducers, do annual maintenance through the manufacturer, it will last you for years and years. And, once you break even, the rest is profit. Some sites bill for a facility fee. We do not bill for a facility fee at our site.

JG: Another challenge is taking the time away from your clinical practice to complete the multiple training sessions.

BA: Practitioners have to spend one month away from their clinical practice to complete the hands-on session which can be a struggle to arrange. The time is typically divided up into two-week blocks. But it’s important to get adequate practice at an expert center to be comfortable obtaining and interpreting these images.

“For centers who don’t have the opportunity to use philanthropic funds or have saved budget to purchase a machine, you can eventually break even with normal reimbursement of performing the exams.” —Dr. Abraham

JG: Did you have support from your hospital leadership to implement IUS or did you have to convince your administration that this would be useful?

BA: In Texas, we are not employed by the hospital, but we are under the physician organization of Houston Methodist. So, our hospital is different from the clinic practice. Our GI section is very big and we are ranked in the top five in the nation for GI and GI surgeries based on this year’s U.S. News & World Report, so there is a reputation to do what is important to advance medicine. I never received any pushback from radiologists or our leadership but, in fact, encouragement to learn this point-of-care imaging. At our referral center, patients can have very complex disease, so I still order MRI Enterographies (MRE) on them if needed. Especially if I am not sure of a finding on IUS. Until my surgeons feel comfortable with just IUS imaging, I don’t prevent them from ordering additional imaging such as CT or MRIs especially if they feel it is needed to obtain cross-sectional assessment prior to a major surgery.

JG: Right, you don’t want to miss anything. BA: I feel better, the patient feels better when there is confirmation with another type of assessment. So, no real pushback. I think everyone has seen the benefit. The other part of it is I’ve been here at my institution for 10 years, so being a bit established and having seen me grow the practice helped a lot. I also applied for an institutional grant that is available for those who want to learn a new technique or skill that is not available at my institution. I received the grant funding to learn IUS with approval from my Chief of GI who was quite supportive of me doing this additional training.

JG: Was it easy to implement IUS into clinic logistically? Did you just watch to see how others did this during your training or was it trial and error?

BA: It was trial and error because no one else in the U.S. was doing it so I didn’t know who to ask. Because I was learning, and I didn’t want patients to be delayed in clinic I set aside one day to do IUS; Tuesdays were my IUS days. I made sure

I had one hour per patient because I was doing the full clinic visit, doing the ultrasound, the report, and the billing. I wanted to make sure I had time to see everything and not feel rushed to find stuff quickly while the next patient is waiting. So, I initially set aside one full hour (30 minutes for clinic visit, and 30 minutes for IUS) to do all of it including documentation and orders. I thought that was great because, even though I was seeing fewer patients, I felt more comfortable and used that as investment time to learn how to implement IUS into clinic correctly. But, once I became more comfortable, I was able to shorten the visits to 45 minutes (15 minutes for IUS), then 40 minutes total. I have my APP help me in clinic too; we tag team. I start the ultrasound, getting the history while she is typing in the note and ordering labs. When I’m done with the ultrasound, I already know the management plan for the patient. Since I know what their disease activity is based on the IUS, I either continue therapy, do therapeutic drug monitoring and adjust the dosing of their therapy, change to new therapy, schedule for additional tests like a colonoscopy, or order additional imaging, if needed. We have a plan in place before they leave, so I don’t have to wait for a calprotectin to come back or wait for an imaging order to be scheduled or wait for the colonoscopy to provide a plan of care. So, it just makes the flow of assessment and management so much quicker. Right then and there, we know what to do and we can schedule the appropriate follow-up based on if they are in remission or if they have active disease. The whole management part of the patient visit is simplified. Now, I do IUS on essentially every IBD patient that comes for an in-person visit.

JG: How long do you think it took you to get comfortable? I know you did 99 cases during your Module 2 training. So, when you came back, were you comfortable with everything you saw on the intestinal ultrasound? BA: Absolutely not. It’s a lot like GI fellowship when you learn

colonoscopies. You may be very good, but if you can’t get through a tight curve or can’t get into the ileocecal valve, you have an attending backing you up. But when you leave fellowship, you don’t have that backup anymore. Similarly, when you are done with your training and you are doing your own ultrasounds, there isn’t anyone there to say, “Oh that’s right,” or, “you measured that correctly.” So, there was a time period for building up of your confidence. The nice thing about IUS is that it’s an adjunct test. If you have any concerns, you can always order a CTE or MRE if needed. I’m not saying I ended up ordering MREs on every patient I did IUS on, but more for those with complex disease. Also, with IUS, you can reassess them at any time; you know your own schedule. You always have the back-up of additional testing if you need to. I can’t give you an exact number that I did before I felt better, but I would say probably another 50 to 100 or so. I think the hardest ones are the normal ones because it’s harder to find normal bowel. The other thing that is more challenging are the patients who have had surgery because their anatomy is different. There are a lot of things that you worry about such as missing any critical findings or especially early on, mixing up the stomach for part of the transverse colon or using the incorrect probe and missing findings deeper in the abdomen. Similar to colonoscopy, when you know to look behind all the folds to try not to miss a small polyp or something. You learn more from experience and learn tips and tricks as you go along. Also, staying involved with IBUS and their meetings definitely helps. Just hearing others talk about how they do ultrasounds, their data, and seeing their images are quite reassuring and you think, “OK, I’m doing it right,” or, “That’s a good tip,” and I’ll keep that in mind when I’m doing my next pouch patient or a patient with a stoma, etc.

JG: So now that more U.S. sites are getting involved in IUS, do you think this will lead to changes in our guidelines for IBD management?

BA: I’m actually excited that most of the IBD centers are learning it because I think IUS is the most amazing tool. I can’t believe we have gone so many years without using it. I think it’s just fantastic. Now,

the question is, could every single gastroenterologist be able to learn this now? Probably not the existing general practice GI doctors. But, since it’s such an impactful tool, I think we are starting out correctly by using this at IBD centers. My hope though, as we are talking about the future, is to train all GI fellows in abdominal and intestinal ultrasound. It’s useful to distinguish IBD from IBS. We would do a colonoscopy for these patients, but there are some patients who are low risk and may not warrant an invasive procedure. We could use adjunct markers such as fecal calprotectin, but for those patients who have more abdominal pain and less diarrhea, the stool marker may not be as useful, whereas the IUS would be beneficial. I have a patient who has IBD in remission but has terrible constipation. We saw her entire colon filled with stool. She wanted me to change her IBD medications when really it was due to delayed transit constipation. We put her on constipation medication, and she improved clinically. But I had to show her that there was no bowel wall thickness. We could actually see her bowel wall beautifully because everything was filled with stool, and we could see all her normal bowel wall layers. She then understood that we needed to treat the constipation. I think it can be hugely beneficial. In the future, I think we should be training our GI fellows in this, starting them really early. Now our internal medicine residents are being trained in pointof-care ultrasound, not just for GI but for heart and lungs and other organs too. Future generations of GI fellows should get trained in ultrasound, not just intestinal but abdominal too. That would be my hope.

Regarding guidelines for IBD, in our STRIDE 2 guidelines we talk about the informal recommendation for transmural healing in Crohn’s disease. I think STRIDE 3 guidelines would need to include that as a formal target. Now that we are doing more IUS, we have more data on the benefit of transmural healing over just endoscopic healing. With endoscopic healing, you are

just looking at the mucosa. But we all know that Crohn’s is a transmural disease, so we need to know about the submucosa and the other layers. We can also look at extramural complications with IUS. I think we are going to change our guidelines for disease assessment and our long-term goals for histological and transmural healing. Especially now that we have more treatment options.

JG: One of the things I commonly find is that women tend to compare themselves to other women, particularly related to their accomplishments. You are someone who does a lot! As the director of your IBD program, the program director for the fellowship program, you are the PI on multiple clinical trials, you give a ton of talks. How do you find time to do all that you do?

BA: It’s all about looking good on the outside (laughing)! Internally though, my brain may be going a little bit crazy. Reading a lot of time management books has helped. Setting up boundaries has also helped. I gave a talk at the ACG Women’s Leadership Conference in 2020 about setting boundaries and no one had really talked about exactly how to do that previously. I found this amazing article that talked about what is your boundary style. If you know that, then you can set the appropriate boundary. That really opened my eyes. We always read articles that suggest you need to manage your time, but how do you do that? Yes, you make to-do lists, but when you get 200–300 emails a day you are never on top of everything. Or “do your priority activities first.” But, in medicine, everything is a priority. So how do you even distinguish what is a priority?

JG: Everything is an emergency.

BA: Everything, it seems. One thing that has really helped was knowing what my boundary style is. There are two major boundary styles: a separator vs. an integrator. When I did the quiz, I found out I’m a huge separator. Meaning, that when I’m at work, I

prefer to focus on work only. When I’m at home, I prefer to focus only on home and family. If anything gets disrupted, I feel out of balance; I feel stressed. What I used to do was work until about 6 p.m. I would take home all the stuff I hadn’t finished. Once my kids were in bed, I would go back to finish the work. But I noticed that 80-90% of the time, I didn’t get that work done because I was exhausted, especially when my kids were little. I don’t know what I was thinking. Unless it was a major deadline, then I drink as much coffee as possible to get it done. But, when I found out I was a separator, I realized why I was feeling so out of control. So what I ended up doing was staying a little bit later at work, finishing the work. Then when I get home, I can spend time at home with the family and not stress out about going back into work mode.

JG: Not thinking about all the things you didn’t finish at work.

BA: Yes! Similarly, when I’m at work and I’m getting a call about home stuff or something about the house, I get so stressed because I’m not there to fix that or help them out. My husband knows not to call me at work unless it’s a true emergency. If there are any home issues, he will wait until I get home and then we can discuss it then. Unless it’s a true emergency, of course, like a kid who is ill and someone needs to pick them up from school/daycare, etc. That happens as a working mom, but I’m always hoping my husband can go pick them up, especially on my scope days when you can’t leave.

JG: Exactly. Nobody get sick today! BA: I just find I do so much better that way compared to someone who is an integrator. They do well integrating work and home life stuff easily. They can schedule an appointment for their kid at the pediatrician or schedule the plumber to come to their house while they are at work. Then when they get home they can do work-related calls or emails and still be there doing their home stuff. I just need to mentally separate.

JG: I can already tell just by what you are saying, I am absolutely a separator. BA: This article was amazing; I think everyone should read it. [Kossek, Ellen E. 2016. Managing work–life boundaries in the

digital age. Organizational Dynamics. 45(3): 258-270.] Finding out that I am a separator really helped, but it was also critical to incorporate the basics of time management. Not everything is a priority; some things can wait. You do as many of the urgent and important things as possible, like putting together the slides for upcoming presentations. I put deadlines on my calendar and block off time to work on those. I tell my administrator not to schedule any meetings during those times. For the most part, I make myself stick to it. Sometimes, it takes me less time than I expected, but 90% of the time it takes longer. I read somewhere that you should allot 50% more time than you think you will need. Delegating as much as possible is also important. We have issues delegating things because we have been doing these things for so long, so we think we are the best at it. But, unless you allow someone else to do something for you, you will never let go. One of the classic examples is letting the kids wash the dishes. Sure, they may leave a few crumbs here and there, but if they never start, and we never delegate, then I will end up doing the dishes for the rest of my life. You also need to know how much time you need for yourself to recharge. Depending on how much time you need, you should schedule it. I am an introvert, so at conferences, I spend a lot of time with other people, but I have to include time to go back to my hotel room, taking time for myself alone so I am recharged for the next day.

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

Bincy P. Abraham, MD, MS, FACG

Dr. Abraham is the Fondren Distinguished Professor in IBD and Professor of Clinical Medicine at Houston Methodist-Weill Cornell and Program Director of the GI Fellowship Program at the Lynda K. and David M. Underwood Center for Digestive Disorders.

The Movement Toward Environmental Sustainability in GI

Jill K. J. Gaidos, MD, FACG in Conversation with Rabia A. De Latour, MD and Swapna Gayam, MD, FACG

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

Conversations with Women in GI

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

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

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

—Dr. Rabia de Latour

JG: I would also recommend reading your Red Section article from 2020 for further background information (Gayam S. Environmental Impact of Endoscopy: “Scope of the Problem”. Am J Gastroenterol 2020;115:19311931). What about for you, Rabia? RDL: I’ve always cared about sustainability and made an effort to be a good “citizen of the world,” but it wasn’t until my first child was born in 2017 that I really started to think about how our actions will impact future generations. I think what they're going to be the angriest about is our degree of waste, how we perpetuated practices that we inherited from previous generations without thorough consideration of the wellbeing of future generations. I want my children and future generations to have the same quality of life that I grew up with—a very happy, carefree childhood and adulthood. I started to think about things we could do at home. My husband actually trades energy, and he has been a great educator in terms of simple things like renewables, non-renewables, how are we going to transition to renewable energy. We are already doing a lot at home. We have minimized our waste, virtually eliminated single use products from our lives; we compost and we recycle. We were already doing everything we could within our household, and so I wanted to cast a larger net to have a bigger impact and I believed the best way to do that is in the workplace. As you know, we can rattle off 100 different statistics to you about how bad healthcare is for the environment as an industry, not only for the U.S. but also globally (for more information see Haddock R, de Latour R, Siau K et al. Climate Change and Gastroenterology: Planetary Primum Non Nocere and How Industry Must Help Am J Gastroenterol 2022;117:394400). So, I figured the best way to do this was through a very measured and directed approach on how to go about this. I started by meeting with the sustainability experts at our hospital. I don’t have any formal training in this; I’m just a concerned citizen. I learned as much as I could from them, and

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

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

RDL: At first, because I started this group a few years ago before sustainability was really en vogue within medicine, back in 2017 or 2018, the support wasn’t as robust as it is now. We started to gain momentum after a few “low-hanging fruit” initiatives that actually saved money and lowered costs, and now I have a ton of support. And I have to say that the sustainability folks at my hospital have been amazing because I'm only helping their bottom line by enlisting clinicians to join their efforts; this has been a seamless marriage, so it’s really been nice for me.

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

JG: Rabia was mentioning having a sustainability group at her hospital. Does your hospital have a sustainability group as well, Swapna? Or are you starting from scratch?

SG: I am starting from scratch. There is a university sustainability office, but they are separate from Health Sciences and Medicine. The university group doesn’t include the hospital in its initiatives because healthcare has always been “exempt” from such undertakings. I am now starting to form my own endoscopy unit sustainability team.

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

—Dr. Swapna Gayam

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

RDL: I applied a lot of pressure. To start with, being a director of endoscopy at my hospital was really helpful because I am allowed to initiate pilots and programs within my unit. This autonomy means that you can do things and show that they work. By establishing a system, showing that it works and saying that I want to take the same system and cast a wider net within the hospital system I was able to make some larger changes. I asked my hospital, Bellevue, to make my role official and I then became the Chief Sustainability Officer. I now have dedicated time to focus on this and maintain a heavy element of clinical duties, which is also my passion. This has been a significant change for me. It’s been a lot harder being someone who is now responsible for a hospital-wide initiative, including how to deal with different departments instead of your own closed unit where you know everybody, you know how it works, it’s a well-oiled machine. That has been really a learning process for me, and it has been amazing. It has been a huge leadership opportunity that I asked for. I wanted this. I don’t think that it’s common for a clinician to get this role. I think there are about eight people in the United States who are MDs or APPs who are doing this type of work within sustainability, and I feel extremely blessed. I think the hospital was interested in this type of work and I am ecstatic that I get to be a part of it!

SG: For me, none. From my discussions with hospital administration, there was not enough interest or importance given to sustainability. There are no leadership opportunities for sustainability at my hospital.

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

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

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

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

RDL: It has been a really wonderful opportunity to work and collaborate with likeminded individuals from different institutions across the U.S. and abroad. It’s been a great group to work with. And, of course, it’s obviously a platform for more opportunities. You will see some of the members of our group at the podium regularly, talking about this important topic and it’s been great to just have them broadcast our message and make sure it gets out there. The opportunity is just about spreading the word. Any single human being I can get this message to, whether it’s through me or through Swapna or through anybody else, that is a blessing and gets us that much closer to the end goal which is trying to gift a planet to the next generation(s) that is better off, not worse off, than how we received it. I just want this work to spread like wildfire, no matter who the messenger is. There is a quote from one of the Lancet articles that says that climate change is the biggest threat to global health at this point, and it is. It’s more than just water levels rising, it's the infections that are associated with that, the mass migration that happens with that, the associated political unrest, the mental health ramifications. It touches health in so many different ways and until we start to take it

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

—Dr. Rabia de Latour

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

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

SG: For me, I want to help get the word out in the GI community so it will hopefully help me influence my hospital leaders. I am working backwards. Many healthcare workers don’t realize how much healthcare is contributing to climate change, which is the biggest public health challenge currently. This is negatively affecting the physical, social and mental health of millions of people. If healthcare were a country, it would be the fifth largest emitter of greenhouse gases. That is huge! Medical education should include this content. We have a small environmental student group that I work with at West Virginia University. I started a two-week elective in climate change and healthcare for MS-4 students. Actually, I was inspired by Emory University’s program. They have a four-week elective for medical students that includes lectures from experts in Canada and the U.S. There are many things that we do without thinking that we can change to help reduce waste and reduce resource use. I think the main motivation is going to be the financial impact. There are great studies out there to show that environmental sustainability is financial sustainability; it’s not the opposite. I think that is going to really help to start these initiatives. Relatability is another key aspect in getting our message out there.

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

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

you; don’t be a disruptor. Don’t veer too far from the path. But things are changing. Having a non-traditional path on a bigger picture, but even on a smaller picture, we should ask more questions. Why don’t we use reusable gowns? Why do we need sterile gauze for every procedure? We're doing colonoscopy; why do they need to be sterile? It doesn’t make any sense. The more questions you ask, the more likely you are to have an impact and make changes in your endoscopy unit. It’s kind of like all of these whispers will eventually reach a scream, a fever pitch. It’s like Horton Hears a Who by Dr. Seuss. I was reading that to my kids and I was like, “Huh. This is really representative.” Once we all start talking about sustainability, it will eventually cause change because that is how change starts. When someone questions the status quo, that will eventually lead to a larger impact, hopefully an avalanche of change. Ask questions in your endoscopy unit and someone else will be like, “Yeah, right, this does need to change. Why aren’t we doing this?”

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

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

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

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

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

RDL: I wrote an ACG Toolbox article (“Going Green: Improving your Endoscopy Unit's Carbon Footprint”) that is available on gi.org. I include a number of simple steps to green your endoscopy unit. I would recommend reading that to start. If you are like me and need some low-hanging fruit, something that is free and that may even save your hospital some money. They are very simple, straightforward, common-sense suggestions. If I just explain things simply to people, I think that’s going to be the biggest bang for your buck. ASGE is putting out a series as well, so there will be other resources available.

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

the computers on. I am not an expert in waste segregation like Rabia, but there is no recycling in my hospital. Waste segregation can help. Bundling procedures can help. I always tell my fellows to think about how a test is going to change patient management. If it’s not going to change your management, then that is a low-value test. There are multiple things that we as gastroenterologists can do and change our mindset. There are some great papers that have been published in the last few years that I would recommend.

RESOURCES

Going Green: Improving your Endoscopy Unit's Carbon Footprint, Rabia de Latour, MD and Seth Gross, MD, FACG; ACG Practice Management Toolbox; November 2020. [bit. ly/ACG-PM-Toolbox-Green-Endo]

Gayam S. Environmental Impact of Endoscopy: "Scope" of the Problem. Am J Gastroenterol. 2020 Dec;115(12):19311932. doi: 10.14309/ajg.0000000000001005. PMID: 33086225. [bit.ly/AJG-Enviro-Endo-Gayam]

Sebastian, et al. Green endoscopy: British Society of Gastroenterology (BSG), Joint Accreditation Group (JAG) and Centre for Sustainable Health (CSH) joint consensus on practical measures for environmental sustainability in endoscopy. Gut. 2023 Jan;72(1):12-26. doi: 10.1136/ gutjnl-2022-328460. Epub 2022 Oct 13. PMID: 36229172; PMCID: PMC9763195.

Siau K., Hayee B, Gayam S. Endoscopy's Current Carbon Footprint Techniques and Innovations in Gastrointestinal Endoscopy. Volume 23, Issue 4, 2021. Donnelly L. Green endoscopy: practical implementation. Frontline Gastroenterol. 2022 Jun 10;13(e1):e7-e12. doi: 10.1136/flgastro-2022-102116. PMID: 35812035; PMCID: PMC9234726.

Clough J, Donnelly L, Leddin D, Hayee B. FGTwitter debate: green gastroenterology - are we nearly there yet? Frontline Gastroenterol. 2022 Sep 16;14(2):158-161. doi: 10.1136/flgastro-2022-102301. PMID: 36818799; PMCID: PMC9933594.

Baddeley R, Aabakken L, Veitch A, Hayee B. Green Endoscopy: Counting the Carbon Cost of Our Practice. Gastroenterology. 2022 May;162(6):1556-1560. doi: 10.1053/j.gastro.2022.01.057. Epub 2022 Feb 17. PMID: 35183550.

Maurice JB, Siau K, Sebastian S, Ahuja N, Wesley E, Stableforth W, Hayee B; Green Endoscopy Network. Green endoscopy: a call for sustainability in the midst of COVID-19. Lancet Gastroenterol Hepatol. 2020 Jul;5(7):636-638. doi: 10.1016/S2468-1253(20)30157-6. PMID: 32553141; PMCID: PMC7295492.

Leddin D, Macrae F. Climate Change: Implications for Gastrointestinal Health and Disease. J Clin Gastroenterol. 2020 May/Jun;54(5):393-397. doi: 10.1097/ MCG.0000000000001336. PMID: 32235149. Setoguchi S, Leddin D, Metz G, Omary MB. Climate Change, Health, and Health Care Systems: A Global Perspective. Gastroenterology. 2022 May;162(6):15491555. doi: 10.1053/j.gastro.2022.02.037. Epub 2022 Mar 2. PMID: 35247463.

Le NNT, Hernandez LV, Vakil N, Guda N, Patnode C, Jolliet O. Environmental and health outcomes of single-use versus reusable duodenoscopes. Gastrointest Endosc 2022 Dec;96(6):1002-1008. doi: 10.1016/j.gie.2022.06.014. Epub 2022 Jun 17. PMID: 35718068. Pohl H. Single-use duodenoscopes: How concerned should we be about the environment? Gastrointest Endosc. 2022 Dec;96(6):1009-1011. doi: 10.1016/j. gie.2022.08.014. Epub 2022 Oct 15. PMID: 36253193.

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

Swapna

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

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

Conversations with Women in GI

Jill K. J. Gaidos, MD, FACG in

Conversation with Anca I. Pop, MD, MBA, Head, Medical Affairs Gastroenterology at Sanofi Genzyme

Dr. Jill Gaidos talks with Dr. Anca Pop about her transition from private practice to a career in the pharmaceutical industry. The two initially met while they were members of the ACG Women in GI Committee and Dr. Pop was on the faculty for the ACG Bridging the Leadership Gap in GI Conference in 2020.

JG: When we were on the ACG Women in GI Committee, you were in private practice. Did you start your career in private practice?

AP: I grew up in Romania and I came here right after I finished medical school. I did my residency and fellowship in Detroit, and I followed that with a one-year liver transplant fellowship in Memphis. I was on a visa so when I finished fellowship, I went to an underserved area. I worked in East Tennessee at the VA for 5 years as the Head of the GI Division until I got my Green Card. I was also an Associate Professor at the local medical school and had the opportunity to teach students and residents. It was an amazing experience. The VA was a great place to work, great people, great patients, and a high need for physicians. I was the only VA GI specialist for a 100-mile radius. I took leadership of the hepatitis C clinic and started doing transplant evaluations in rural East Tennessee and worked closely with Vanderbilt for referrals and post-transplant care. I was also able to be the principal investigator on the PEGASYS (pegylated Interferon for hepatitis C) trials, which has helped me to understand that aspect of drug development and it has been helpful especially now that I am in industry. I learned a lot. It was a very satisfying experience because I didn’t have to deal with the bureaucracy of a practice, issues such as prior authorizations, etc. Then moving to

a private practice, I started to deal with more of the business side of medicine. You have less availability for your patients to get the medications they need due to lack of insurance, lack of money, lack of co-pay money. If you look at my trajectory, I have a lot of points that I can connect but they are not on the same path, it’s not a linear path, it’s a zigzag, but I find that was very useful.

JG: What lead you to consider a transition to a career in the pharmaceutical industry?

“It’s exciting to start from scratch, building a new gastroenterology team in a new therapeutic area for the company and creating relationships between the GI community, the health care providers, and the medical affairs professionals in the company.”

AP: After being in practice for over 20 years, I became interested in the business aspect of medicine. I was in a private practice; I was a partner, so I wanted to learn more. I completed a Master’s in Business of Medicine. I loved it! I loved the aspects that we were never taught in medical school, the least of which was negotiation, conflict resolution, not to mention the financial aspects of business. I said, “This is something new. This is a part of my brain I haven’t used before.” So, I continued at MIT where I completed an executive certificate program in strategy and innovation. I did an entrepreneurship course. All of this I find enriched my thinking and got me out of a box, that box being just patient care. I saw the aspect of medicine from a different angle. After doing that, I wanted to use what I learned. Not necessarily to be the CEO of a hospital or management in my private practice. So I did a stint in an underserved area where I developed a GI service line at a hospital without a gastroenterologist for the previous several years. I decided afterwards that coming to industry would marry the clinical knowledge I had, the experience I had and the business aspect. I entered industry in 2019 at UCB working on Crohn’s disease. Then I started learning exactly what working in industry was really about because it’s a whole world that I didn’t know about. For example, learning about the life cycle of a drug. Working on a drug at the end of life before the loss of exclusivity is totally different than working in a company trying to launch a drug. I realized that you can have another lifetime in the industry and still keep learning. So, that is how I journeyed from clinical practice to industry, which was basically due to a hunger for learning new things.

JG: I hear from many women who are interested in leadership positions, whether that is in academics, private practice or industry, they feel like they need to get a more education such as an MBA or an Master’s of Health Administration to be adequately prepared. Did you feel like you needed a Master’s degree for a leadership position in industry?

AP: For me, a leadership position was never the intent. It was to get me out of my box, if you will, and to do something for myself. And, by the way, having an MBA does not guarantee you are going to get a leadership role in industry. In industry, a lot of people have MBAs, PhDs and PharmDs. MDs are actually less prevalent. So, I think the MD experience actually got me the leadership position in industry, not the MBA.

JG: Would you encourage others to get an MBA? Did you feel like it would be useful for leadership position in a private practice?

AP: It depends on where you are coming from. Our MBA class in Indiana had only physicians. It was the first class that did the business of medicine program and was geared toward physicians. The physicians that came from an academic institution or hospital system and wanted to stay in that hospital system used their MBA to be promoted to leadership positions. So some of my MBA colleagues became CEO of the hospital or service-line leaders and took on more and more responsibilities. Others just used their experience in their own practice and developed more from a business perspective and some joined the industry or became published authors. For me, I used it to think in a different way. I have a different perspective that’s centered on patient care and benefit. I believe it’s tremendously helpful to have physicians who know patient care. Also having a Master’s in Business doesn’t hurt, but I wouldn’t go into it with the idea that this is a guaranteed promotion to a leadership position.

JG: You were the head of medical affairs of gastroenterology at UCB?

AP: Yes, I was the Head of Medical Affairs of Gastroenterology at UCB for two years and now I am at Sanofi.

That experience taught me one side of a drug life cycle management and continued with my current experience in pre-launch and launch of a new asset. Currently I am the U.S. Medical Affairs Head at Sanofi. We successfully launched dupilumab in eosinophilic esophagitis. Launching a new asset, especially in a therapeutic area where there is no FDA-approved drug for a certain disease such as eosinophilic esophagitis in my case, is another new experience where I learned tremendously. It’s exciting to start from scratch, building a new gastroenterology team in a new therapeutic area for the company and creating relationships between the GI community, the health care providers, and the medical affairs professionals in the company.

JG: I imagine your first job at UCB wasn’t Head of Medical Affairs for Gastroenterology, was it?

AP: It was.

JG: It was? Your first position in the pharmaceutical industry was to be in charge?

AP: I entered industry as the UCB Head of GI Medical Affairs for the United States and, again, this is the lesson I learned. The MD experience, the gastroenterology experience, got me the position, not the MBA. They had other very capable MBAs in the company. What I noticed is that clinical or research experience could be the valuable stepping stone on which you build in industry. There are a lot of PharmDs and PhDs in industry, but not as many MDs. We are trying to change that. I have had a goal to recruit on my team more professionals with direct clinical experience including physicians and advanced practice providers. An added MBA or a Public Health degree was not something I was looking for to push them over the line.

JG: It seems intimidating to have your first job in industry to be the lead for a whole team. Did you have any hesitation taking that role or did you feel 100% prepared?

AP: It’s not intimidating if you come in with a strategic mind. One important thing in industry is relationships. I

found that my hiring manager, the head of the unit that hired me, was extremely open and we had a good conversation before I took the job. I asked point blank, “What would my day be like? What do you need from me?” Because obviously, I have a lot of deficiencies; I haven’t worked in the industry, I don’t know standard operating procedures and all that, so I will have a learning curve.” I asked, “Why do you need me?” and “Do you think I can do the job?” He explained that what he needed at that time was the clinical experience. He needed to learn strategically, how do we show value for an asset toward the end of its lifecycle? Strategically and competitively, what would bring value to a physician and his or her patient? Communication is key, knowing who your team is going to be is key, knowing exactly what you are expected to deliver is key. Because you are going to learn more and more every month, but at the basic level the question is, what qualifications will allow you to do the job? I think that his approach made me comfortable with joining industry and that specific role. It took six months to become comfortable in the job, to be honest. I was kind of crying for six months because I was at a crossroads, and I kept wondering if I should go back. Because I worked for 20 years, and I saw patients and I missed my patients. I was afraid I was going to lose everything I built, licensing and credentialing – what is going to happen to that? I never thought I was going to stay, but the longer I stay and the more new things I learn and do, I feel fulfilled here. I’m crying less (laughs)

JG: That’s good to hear (laughing). There is a perception that people understand what a life in industry is like. Can you give me an idea of what your day-to-day schedule looks like?

AP: The day-to-day, if you look at the calendar, consists of a lot of meetings. The working from home situation and Zoom just increased the volume. We were talking to each other more, stopping in the hallway, going to lunch before the pandemic. When the pandemic hit, we were home and we filled the calendar with meetings. So, that is what we still do. But also, now that we are back to in-person interactions, we travel to internal and external face-to-face meetings, congresses, as well as national and in some cases international meetings. Hopefully, in the future, we will do more advisory

boards in person; we have been doing advisory boards virtually. Medical affairs is responsible for synthesizing information about the science, disease state, and available product data, and is a trusted resource internally to functions ranging from research to commercial. It is customarily about two to three years before a new launch to create relationships and educate the community about the unmet needs in that therapeutic area and the science (immunology, in my case) behind the pathophysiology of the disease. The team is comprised of headquarter individuals and field individuals. Field individuals have Medical Science Liaison roles. There is an MSL lead or director who manages the MSLs. Headquarter roles are directors led by section heads and higher management that ranges from country to global. The headquarter roles are mostly strategic and are involved in creating a medical plan each year, including strategy, tactics, and budgetary aspects. That is where the business part helps. In discussing strategic and tactical aspects, we frequently need to align with multiple individuals in large teams. We are very crossfunctional and enjoy being a valuable resource for other teams. Compliant behavior is paramount and we are frequently learning important legal and compliance aspects that are essential to our day to day job.

JG: How does it feel being a woman in industry? Do you feel outnumbered? I’m sure it’s company specific, but do you feel supported?

AP: There are a lot of women in industry, but you are correct that it depends on the company. Both companies I have worked in are global, both are based in Europe, and I feel they are both doing a lot to promote women. Where I work now, at Sanofi, we have a leadership management path where everybody is helped and mentored to grow and move into the next role if they wish to. This upward mobility, including women, is encouraged. It’s actually one of the tasks for manager, such as myself, to have discussions with my MSLs and my directors, and find a way to develop their career so they can go for promotions if they want to.

JG: How is that established? Is there a curriculum or do you have scheduled meetings where you have time to talk about it?

AP: We are mandated by human resources to do a rating for how each of our employees did that year. As a manager, we evaluate them overall on what they do and how, but also their ambition, what do they need to grow and their desired career path. So if an MSL says they want to be a director, there are multiple ways where they can gain the necessary learning and expertise to empower them for the next step. As a manager, one of my jobs is to promote my team members, even if it means they leave my team. I think it’s a great system put in place where leaders have to mentor their team members and give them the tools to advance if they want to. In addition, our company has specific goals for promoting women, especially, towards leadership positions.

JG: Did you have anything like that in your private practice experience?

AP: In private practice, no, I did not have that. When I started, I joined a male-driven group. For the duration of my partnership we had less than 10% women physicians or advanced practice providers in the group. There was no formal mentoring process and no formal path towards a leadership role. Going to business school was my own initiative, not sponsored by the group. I wanted to grow my skills and perhaps get more tools to avoid feeling like an imposter if I go and ask for a promotion inside the group or a leadership job. I wanted to have more in my toolbox.

JG: What advice would you give other women who may be interested in pursuing a career in industry?

AP: I’m looking at the way that industry is changing and what I need to say is you need to have a strong scientific background, plus expertise either in research or clinical practice. So, it would be useful if you have done bench research or have experience as the Principal Investigator on clinical trials. Similarly, it would help if you have deep expertise in a therapeutic area or led a clinic that specializes in a disease state, for example a hepatology clinic focusing on NASH. An MD degree is highly valued with or without added degrees such as an MBA or a Master’s in Public Health. Communication skills are very important because all of

these internally and externally facing relationships need to be maintained, you need to interact with people, and be an effective speaker. Strategic thinking is essential if you intend to have a leadership position. The way to negotiate, the ability to interact and influence people, and especially to function in a team are essential in the industry. See, this is also what we do as gastroenterologists. When you do endoscopy or work in a clinic, you work in a team setting. This is crucial in industry as well. In order to align people who come from different functions, like attorneys, business partners, medical or marketing colleagues, you have to express your opinion on a topic and ideally they have to align with it. In that case, if there is a conflict, how are you going to resolve it, how are you going to negotiate, how are you going to get them to see your way, and how are you going to see their way and the rationale behind their opinions? Conflict resolution is huge. I would like to see it be taught in medical school, residency, and fellowship, much more than finance or budgets. How to talk to people, how to be empathetic, and how to understand what they want to achieve and to be able to find a common ground despite differences, that is harder to achieve.

JG: Absolutely. Those are very important skills to have.

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

Anca I. Pop, MD, MBA, Head, Medical Affairs Gastroenterology at Sanofi Genzyme

Conversations with Women in GI

Jill K. J. Gaidos, MD, FACG in Conversation with Guadalupe Garcia-Tsao, MD, FACG

Dr. Jill Gaidos talks to Dr. Guadalupe Garcia-Tsao, Professor of Medicine in the Section of Digestive Diseases at the Yale School of Medicine, about her incredible journey from medical training in Mexico City to becoming a world-renowned expert in hepatology.

Gaidos: After completing your residency and fellowship in gastroenterology and hepatology in Mexico City, you decided to research liver disease abroad. You accepted a three-year research fellowship position at the West Haven Veteran’s Affairs Medical Center. Was this a repeat of your fellowship training? Garcia-Tsao: No, not at all. The GI fellowship in Mexico was clinical. At that time, research was not part of the curriculum of either medical school or residency/ fellowship. However, in the last year of medical school (the “social service” year), I had the opportunity to do research at the Instituto Nacional de la Nutrición under Dr. David Kershenobich, who had gone abroad and trained with Sheila Sherlock in the U.K. I worked in research on collagen synthesis in cirrhosis and also became involved in a randomized controlled trial of colchicine in the treatment of cirrhosis. I was just a medical student but I was in charge of the randomization of patients (provided sealed envelopes) and data collection. I ended up being a co-author of the New England Journal of Medicine article that resulted from this study! Actually, in the very nice introduction that Dr. Tamar Taddei made for my recent ALF award (Dr. Garcia received the 2021 Distinguished Scientific Achievement Award from the American Liver Foundation on November 19, 2021), she mentioned how I have gone full-circle and am now Associate Editor for the NEJM. I stayed on at the Instituto Nacional de la Nutrición for residency and fellowship, at the end of

which David Kershenobich wrote letters to every hepatologist he knew across the U.S. to see if I could perform research at their institution. Most of them said, “Of course, if she comes with funding, we will be happy to take her.” But there was no money. So, the only two places that would accept me and provide a salary were Northwestern University and Harold Conn at the West Haven VA. Harold was the very first one to respond and said, “Yes, we have a research position for her.” I had met Harold in Mexico when he came to lecture and I liked him a lot. Also, I looked at a U.S. map and thought, “Oh wow! Connecticut is right on the water.” I was thinking it was going to look like the Mexican beaches.

JG: Right! Not quite.

“In a way, my focus has always been to do what I love and to never give up. It would have probably been easier if, early on, I had been more assertive. But assertiveness comes with knowledge and with being more comfortable in your skin.”

GGT: Not quite. But, I came for a visit, met with Harold at the West Haven VA and chose his research fellowship position. It turns out that two weeks before coming to the U.S., Harold calls me and says, “I have some news for you. I am starting a one-year sabbatical in California.” And I’m thinking, “What the hell! Now my mentor is leaving.” And he said, “And you will lead my lab.” So, I come here but my mentor is away. He had started some studies on lactulose and he also had ongoing randomized controlled trials, so I decided to just continue those projects. However, Roberto Groszmann had just returned from his sabbatical in the U.K. so I started working with him as well. That is why I have experience in two different fields; one is portal hypertension with Roberto and the other is ascites and other complications of cirrhosis such as SBP with Harold. So, I was lucky in that way that in my fellowship I had two mentors studying different areas of cirrhosis. As part of the fellowship, I also had to review many charts (in that time, all paper charts) and I learned so much clinical hepatology from doing so, particularly reading the notes from Colin Atterbury who was a brilliant clinician and hepatologist at the VA. After completing my research fellowship, I returned to Mexico to apply what I had learned in the U.S. and continue the lines of research. I returned to the Instituto Nacional de la Nutrición (my alma mater) but it was rough because the salary was very meager and I had to supplement it by doing private practice, which mostly consisted of general GI, which I definitely do not enjoy. Then, as time progressed, I started getting grants including national investigator awards and teaching at private

universities that supplemented my salary so I could dedicate a bit more time to my academic position, rather than to private practice. Then, maybe about a year into this, Harold Conn calls and says, “I want you back.” And I said, “Will I have a faculty position?” And he said, “Come as a fellow and while you are here, we will work on it.” I said no to this. Roberto had another approach and he had discussed with Jim (James Boyer) the possibility of me returning in a junior faculty position. Three years into me being in Mexico, Jim said, “I want you as a faculty member.” I was already quite established in Mexico, so I thought, “Let me give it a try. I’ll give it a year.” That was 30 years ago. (laughs)

JG: In reading your bio (available at medicine.yale.edu/profile/guadalupe_ garcia-tsao), you were interested in hepatology starting in medical school.

GGT: Exactly! During our GI course as a medical student, they provided a little book entitled “The Jaundiced Patient” by a Mexican gastroenterologist (Dr. Horacio Jinich) and it was so didactic and explained the bilirubin pathways and all the entities that could lead to jaundice so simply that I thought I could easily make the diagnosis. And all of my fellow students knew that if a jaundiced patient was admitted, call Lupe (in Mexico, they actually call me Lupita) because she will know, she can figure it out. This led to me discussing cases and interacting with the hepatology attendings and this, together with my medical student experience, led me to a career in hepatology. I loved the liver from very early on.

JG: What got you into medicine?

GGT: That is an interesting question which no one has ever asked me. There are no doctors in my family. My father thought he wanted to be a doctor but he quit after only one semester in medical school. He ended up in advertising. So, entirely different, right?

JG: Yes, right!

GGT: In “preparatoria“ (or preparatory school, which is sort of a combination of high school/college in Mexico), I had an awesome female biology teacher who made me consider biology as a career that I would like

to pursue. But when I looked at the course work for biology, it was all lab work. I thought, “What am I going to do as a biologist?” It wasn’t clear to me what my path would be. I couldn’t see myself just being in a lab because I like people. So, then I said, “So, let me do medicine.” I went to my parents saying, “I think I’m going to do medicine.” And my father was grumbling because he wanted me to do something in advertising. So, that is how I decided to do medicine, because of my love of biology and people.

JG: When you started on this pathway, did you have specific aspirations? For example, did you plan to be the Chief of a GI Section or the president of a national society?

GGT: No, not in the least. Zero. That’s the whole thing, Jill. When I was a medical student, all I wanted to do was complete medical school with the best scores.

JG: Exactly! Just let me finish that first. GGT: Let me just finish this successfully and see then what life brings me and perhaps follow the steps of my mentors who had pursued further training abroad after which they had returned to Mexico and would be in academics in the morning and in their private practice in the afternoons. However, when I came to the U.S. as a fellow, I realized that one could dedicate their whole life to academics and have a practice at the same institution composed of patients that are the subjects of one’s research and I thought this was the ideal world. In fact, before going back to Mexico I remember thinking, “If someone would offer me a position here now, I think I would take it.” But nobody offered me a position, so I went back to Mexico until years later, when Jim Boyer offered me the position. However, let me tell you, Jill, that coming back was brutal. I thought it would be easy. I knew the place and many of the players, I had a bank account, a credit card - I thought I was all set! But it was totally different from being a fellow. A fellow from another country that works hard and does well is very liked and is not threatening. I found out that, in returning as a junior faculty member and an attending,

people who had been nice to me were no longer as nice. Perhaps because I became a threat, a competitor.

JG: Oh, no... Really?

GGT: The fellows were definitely not nice to me, but they didn’t know me, right? Here I am, a young female attending from Mexico. So, they had no respect for me. At that time, we had mostly male fellows. I remember rounding and they were just looking at their watches like, “when is this going to be over?” But it was also bad with other attendings. I remember when I was on a clinical rotation and a male colleague was asked to see a patient because they did not have confidence in my opinion. But this was not the worst part, the worst part is that my colleague consulted on the patient instead of saying, “You know, Dr. Garcia-Tsao is actually the liver attending.” Another attending (a surgeon) also wrote a comment in the chart on how unhelpful my note had been regarding a patient with jaundice (I had recommended supportive care for a very complicated post-op course). I also remember being at a Friday conference with Dr. Howard Spiro sitting in his usual seat in the front row and at one point I am sitting there suffering because I wanted to make a comment but didn’t feel comfortable. I finally raised my hand and made the comment and Dr. Spiro turns to me and says, “And whom may I ask is this young lady?” I suspect he must have known who I was (because he had seen me when I was a fellow) but since no one had introduced me to other faculty, and there was animosity with the liver people, he seized the opportunity. It was very uncomfortable.

JG: How did you break through that lack of respect?

GGT: I just went along and considered that, little by little, I would be able to overcome these challenges by doing a good job, asserting myself by acquiring and demonstrating clinical and research knowledge that would support my opinions and decisions. I always thought that all these microaggressions had to do with me being Mexican; I never thought it was because I was female. Now, I think that it was probably both.

JG: With these experiences, how do you talk to women or foreign medical graduates about microaggressions and handling these kinds of situations?

GGT: I have learned that one has to stand up and not be timid (like I had been). If one feels that something is not correct, one has to speak up even though it may be very difficult. I did speak up to that surgeon who had written in the chart about my consult being unhelpful. But I remember sitting in my office for a long time with the phone in my hand until I finally called him and told him how inappropriate he had been. He apologized. Never got to meet him because he left Yale shortly after. This was one thing I could not let pass and I had to get out of me. I felt like a really little person and I had to grow into this body and then say when things I think are not right and just say it. In a way, this reluctance to speak up, in my case, is cultural. But progressively, people recognized that I was a good clinician, making accurate diagnoses and providing good advice, that I was doing my research and I was publishing important papers. By the nature of my work is how I overcame everything, but not so much by speaking up, which I should have

JG: For people who know you, timid is not the first characteristic that comes to mind (laughing). I think it’s hard to speak up, though, when you are so outnumbered.

GGT: Outnumbered, and probably me feeling that they were doing me a favor by taking me as faculty, like maybe I was not deserving of it. The beginning was hard.

JG: Do you now see yourself as a role model?

GGT: Now I do. Back then, no; but now, yes.

JG: With your amazing career and with your background, do women come to you for mentoring and career advice? Or, foreign medical graduates as well because, as you said, there is still a stigma associated with being a foreign medical graduate.

GGT: Totally. I feel very connected to female trainees and I have mentored more women, in proportion to males, in our GI program. As a trainee,

attending the Liver Meeting (and realizing that there were incredible women in the field, such as Dame Sheila Sherlock) was instrumental in me continuing to pursue a career in hepatology. When I was President of the AASLD, I started the Emerging Liver Scholar program that selects residents who may be interested in hepatology to attend the Liver Meeting. They get a guided tour of the meeting. And one of the slots is for someone from Latin America. I am very proud of this program. I still find that foreign medical graduates are more timid than American fellows. Although it may be a language issue, I speak Spanish to those from Latin America and they are still not as open and outspoken. They are like I was when I came to the U.S.

JG: As part of our GI LEADER program at Yale, we have had some discussions about microaggressions and inequality in medicine, particularly in GI, which is still male-dominated, and in some of those discussions your perspective on gender issues and microaggressions was sometimes more of a “get over it” and “just push through” kind of attitude. GGT: (Laughs) Yes, yes it was. I hate to say this but that’s what it was. In a way, my focus has always been to do what I love and to never give up. It would have probably been easier if, early on, I had been more assertive. But assertiveness comes with knowledge and with being more comfortable in your skin.

JG: Do you think your “get over it” attitude is from the male-dominated training or from growing up in Mexico?

GGT: When I was in medical school in Mexico it was actually 90 percent male. I was the only woman in my class for internship, residency, and fellowship. All my buddies were male. I met my very first female medical friend at the end of my internal medicine residency. Unlike me, she is very tall and outspoken and she became a surgeon in Mexico. As such, and as you can imagine, she has had a very difficult time and she has somehow overcome all these difficulties. She is an outstanding physician and surgeon, despite which she has, to this day, been unable to gain the respect of many of her male peers. I cannot compare my environment to hers but, while I have tried to navigate my way, she just says what she feels without any thought of the consequences, which I think generates even more animosity. So,

I am not sure but I think it may be a bit of both. It is the “macho” attitude. I have to say, I have clearly had very good mentors and they have all been men. I have learned good things and bad things from these mentors. I have learned that when something is truly unfair, one has to speak up. I have also learned that seeking advice from other people (men or women) is very important in determining actions to take when one considers they are being treated unfairly. When I was a fellow, there were none of these mentoring committees that exist now where one can discuss these issues without fear of retaliation. Hearing someone’s story, as in this interview, is important for young people to understand that we all have confronted obstacles and that it is on us to decide how to overcome them and move forward. At the end, it is the love and passion of what one does that drives everything.

JG: It’s definitely helpful to hear other people’s stories to recognize that others have had similar struggles, but equally as important to have people to discuss these situations with. GGT: Yes, and I did. At important points in my career, I have asked for help. I don’t think it has anything to do with being a man or woman. It has to do with being a professor and a mentor. As a professor now, I know that the success of a mentee is my success and, therefore, it is not a competition; it is in my best interest to ensure that my mentees succeed.

JG: Exactly! That is what makes you such a great mentor.

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

Guadalupe Garcia-Tsao, MD, FACG, is Chief of Digestive Diseases at the VA-Connecticut Healthcare System and Professor of Medicine at Yale University School of Medicine.

Conversations with Women in GI

Identifying Barriers for Patients and Providers

Jill K. J.

Gaidos, MD, FACG in Conversation with Lauren D. Nephew, MD, MAE, MSc

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

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

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

“I knew I wanted to do something people-facing and I knew I liked science. I knew doctors ask questions and interact with people, and that I could help people.”

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

JG: You go to a restaurant hungry, and you come out full. You’re better! LN: You’re better, right? And they do a good job at it and they work with people. And I like people. I knew I wanted to do something peoplefacing and I knew I liked science. I knew doctors ask questions and interact with people, and that I could help people. And I had a grasp of that in the third grade. By high school, I knew medicine and science were related and that there were three things that I could do in medicine: work with people, be a scientist, and help people.

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

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

JG: But why? Right?

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

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

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

LN: When I started medical school, I did my first rotation in colorectal surgery, and I was lucky enough to work with Dr. Tracy Hull. She is a colorectal surgeon who I think is amazing and who gave me the idea, “I’m going to be a colorectal surgeon.” I’m very easily inspired, right (laughs). And she said, “Why do you want to be a colorectal surgeon?,” and I listed for her all of these reasons I wanted to be a colorectal surgeon. And she said, “You never once mentioned the operating room. Lauren, there is one thing I can tell you about colorectal surgery, about being a woman in medicine, being a woman in surgery — it is a fulfilling role, but it is a challenging role. If you want to do it, I want you to do it, but I want you to love the OR because there are many sacrifices you will make as a woman in surgery and you have got to love every moment of being in the operating room and it has to be the number one reason you want to be a colorectal surgeon. Everything you named about why you like what I do, you can do as a gastroenterologist. I think you should do a GI rotation. If you don’t have that on your elective list, I think you should add that.” So, I added a GI rotation to my elective list and she was right. I absolutely loved GI. While I was on GI, I did two weeks on luminal and two weeks on liver. While I was on the liver rotation, someone said to me, “Why don’t you go to the liver transplant selection meeting?” And, I said, “Sure.” I was a medical student and they were trying to find some activities for me to do (laughs)

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

LN: Fill my time with meaningful experiences, right?

JG: Exactly.

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

“I absolutely loved GI. While I was on GI, I did two weeks on luminal and two weeks on liver. While I was on the liver rotation, someone said to me, 'Why don’t you go to the liver transplant selection meeting?' And, I said, 'Sure.'”

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

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

LN: Right! And these are life and death decisions. And I kept asking the resident who was in the meeting with me, “Is there a computer algorithm?” I kept thinking there must be some big screen somewhere or somewhere there is something spitting out some objective that is going to tell us, “Yes, we transplant this person, or no we don’t.” And he said, “No, what are you talking about? They are going to discuss it and they are going to make a decision.” And I said, “Today? They are going to make it today? On this person?” And I really had a hard time coming to terms with how these decisions are made and these are the people who are making these decisions. And so I said, “I have to learn more about this.” And that really started my journey into transplant hepatology and to researching barriers to access and barriers to care and scarce resource allocation. And my love for sick patients with liver disease also developed on that rotation because there were so many sick people and I love taking care of that patient population. So, it really all came to a beautiful head during those two weeks. During that time, I got a Master’s in bioethics because I said, “Certainly there’s got to be some ways to think about these things and talk about these principles in some formal way.” Case Western has a very strong bioethics program, so I got a Master’s in bioethics and really sat around and got to read. I wish had that time now.

JG: I know! I think about that all the time. Having time to read and think about things. LN: Yes, to think and to write critically about these issues for no other reason than just the joy of doing it. It was a great time to just think

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

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

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

JG: (laughing) You’re like, “Yeah, I got this! It’s not that hard.”

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

JG: You also talk about diversity, equity, and inclusion and easily throw around terms like “URMs” (underrepresented minorities). Do you feel like a lot of your colleagues understand that language or are you having to teach other people what that means and how to incorporate that type of thinking into today’s academic practice?

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

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

JG: Definitely.

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

JG: Exactly.

LN: People are open to it and I am doing a lot more discussions around that. People of color in this space talk of a “minority tax.” This is a term that describes the real phenomenon of underrepresented minorities being called on to participate in institutional diversity efforts. These are efforts that we often feel a real responsibility to participate in for the greater good of our communities and the patients we serve. However, these efforts are often labor-intensive and not valued as highly for promotion and tenure; and, while meaningful, don’t always end in the academic currency of publication. And if you are a Black woman, you may be “doubly taxed” to participate in both gender and race inclusion efforts! It can be hard to find the balance between achieving enough career success to change the system that allowed this to become an issue and participating in these efforts. And you may choose to support equity through your community and may not have the interest or expertise in institutional efforts and that should be okay. For me, because I do this work and I’m passionate about it, I do find that I’m talking about it more, but I’m happy to do it.

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

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

get. I can only spend so much time mentoring because I want to get to a place where I can be a good mentor, where I can be in those positions where I can really advocate and I can be at a table where I can make change. It’s a challenging balance to know when to say perhaps I can’t take on another mentee. So, I try to redirect people to other mentors who may be more senior than me at other institutions or let people know right from the jump what type of mentorship I can provide.

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

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

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

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

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

how not wearing my white coat had really changed the tone of the microaggressions I was experiencing. I was on an all-female team when I experienced a really significant microaggression. I would call this a macroaggression because this was very overt. Our team talked about it after that person left. And I regretted not acting in the moment.

JG: Was it a patient?

LN: No, this was a consulting physician. And I regretted that I didn’t respond in the moment. And I would say, sometimes you have to forgive yourself. Even with all of the training I have about how to respond to these microaggressions, I am still sometimes shocked, taken aback, and not sure what to do. I really was just stunned. I did debrief my team and we talked about it and if I had to do it again and how could I have redirected this situation. I give myself some grace if I don’t have that snappy and appropriate comeback.

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

LN: Yes, this is how I could have handled it. It just doesn’t always happen the way you hoped.

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

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

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

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

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

JG: Oh, absolutely!

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

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

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

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

LN: Getting your time protected as early

“...[I]t takes a lot of effort on the part of the person who has to address these [microagressions]. It takes a lot of effort on my part to have to confront every microaggression; it’s draining, exhausting. So, for me, I have to decide which battles to fight. And, for me, it’s a risk/ benefit ratio. And only the ones that I think people may actually be willing to change and if I’m going to have to interact with that person on a regular basis and it’s happened on multiple occasions are really worth the effort.”

as you can is probably the most important piece of advice. It is critical if you want to do mostly research because it’s really, really hard to have five clinics per week, two endoscopy sessions, attempt to write a grant and have a full family life at home. So, trying to get your time protected, negotiating for that, and asking for it, whether you have funding or not. If this is what you want to do and you have some publications from fellowship that show you have some track record in science, ask for protected time for at least a year and ask for money for statistical support, or whatever it is you need to get yourself started. Some people don’t ask because they assume they won’t get it, and you might not, but it’s worth asking to situate yourself, to get your program going. If you are going to do bench research, that is a whole other beast, in terms of money, because you need a lot more money to do that, but the spirit of asking for what you need upfront is still the same.

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

LN: In terms of finding mentorship, in this world of Zoom, three years ago we may not have realized just how cross-institutional we could be. It was always here, but I don’t think we realized how much we could collaborate. Even to the NIH, you can much more reasonably say, “I’m going to have this mentor and we are going to meet quarterly by Zoom and will meet in person annually,” and it will fly.

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

Lauren

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

Conversations with Women in GI

Christina M. Surawicz, MD, MACG on “A Career of Firsts”

In conversation with Jill Gaidos, MD, FACG

MORE THAN A YEAR AFTER WE WERE LAST TOGETHER at the “ACG Bridging the Leadership Gap in GI” Conference in January 2020, Dr. Surawicz and I finally have a chance to catch up over Zoom to talk about mentoring, coping during the pandemic, and her amazing career of firsts.

Dr. Jill Gaidos: In preparation for our conversation, I found a biography of you published in 1981 where I learned that you were the first female faculty member in the University of Washington Gastroenterology division, you were initially the Director of GI Endoscopy at Harborview Medical Center (the county hospital) then, you were the Section Chief of Gastroenterology there for 20 years and the first Assistant Dean for Faculty Development. You were the first female president of the American College of Gastroenterology from 1998 to 1999. Did you strive for these leadership positions? Were these leadership positions part of your 5-year or 10-year career plans?

Dr. Christina Surawicz: No, it just happened organically. I never planned more than one or two years ahead and had not really thought about doing academic medicine. It was always, “Well, let’s just give it a try and if it doesn’t work out, I can always go into private practice.” But I did end up staying. When I took that first job, I did not negotiate for anything, though I did at least get an office.

I learned some leadership on the fly in my job, but the most important was becoming involved in the College. I met Dr. David Graham when he was a visiting professor at UW. He introduced me to the College and gave me opportunities such as speaking at the annual postgraduate course, and later serving as the course director. Being on ACG committees was important too. You know the saying that committees are the little hands and feet of an organization? Committees are a great way to get involved in ACG: you have tangible products, you meet people, many of whom become colleagues and friends. If you are in academics, committee members can write letters for your promotion because they know you but have not worked with you academically.

I want to highlight the ACG Women in GI Committee that you have also chaired. It was started by Dr. Jamie Barkin when he was president, and the first chair was Dr. Robyn Karlstadt. It was an exciting committee as it was high energy with lots of new projects. We were the first to ensure the College offered free childcare at the Annual Scientific Meeting, even if only one child showed up. We did white papers addressing issues like leave policies for pregnant fellows and radiation exposure. We organized symposia for the Annual Meeting on topics relevant to women. But, of course, these topics are relevant to men as well. I am so proud of the work this committee has continued with new ideas – such as these interviews which were your idea. I also learned a lot serving on the Board of Trustees, watching other leaders. Sometimes, I felt more positive feedback from my College work than I did in my job. You know the saying, “You’re never a prophet in your own land.”

JG: Exactly!

CS: Some of my leadership opportunities at UW started with our Women in Medicine committee, which was very embryonic. A survey at that time showed that women were not

getting as much mentoring as men and were less satisfied at work. That committee, which I ended up chairing, started doing workshops for women faculty on various topics as well as networking events. We sent women to leadership programs, like AAMC and ELAM programs. Then in 2002, I was appointed as the first Assistant Dean for Faculty Development.

JG: You mentioned the survey results showing that women were less likely to have mentors. What were your steps to improve mentoring for women?

CS: A lot was focused on supporting mentoring in departments and divisions, and on learning about mentoring. We stressed the need for multiple mentors. In my experience as a junior faculty, I could not look to the men in my division to advise me on combining work and family when I had twins. We also emphasized that your mentor should not be your boss, as each of your goals may be different. Workshops on topics such as promotions, giving presentations, and unconscious bias, among others, were open to all faculty and were very popular, especially having half day or all-day programs at a nice site off campus with free breakfast, lunch, and parking. We started a Women Faculty day that was very popular. I felt it was also important to find speakers from outside of medicine, such as from the business school, to teach topics like negotiating skills and conflict resolution.

JG: Right! What do you think about sponsors compared with mentors? In talking with other women, many have not heard of the term sponsor.

CS: I only heard of this concept a few years ago. It comes from business, right, from the whole idea of the C-suite?

JG: Yes. The business world is way ahead of medicine in regard to leadership training.

CS: Having a sponsor is important. Originally the mentor was supposed

to do it all, but the sponsor’s job is to promote someone without necessarily having that intense mentoring relationship but just providing opportunities. Tell me your thoughts on sponsorship.

JG: There is a book called Forget a Mentor, Find a Sponsor: The New Way to Fast-Track Your Career that talks about the importance of having a sponsor. It is great to have a mentor to help you with your career goals, but you really need someone who is going to open doors including being first author on reviews and book chapters, speaking opportunities, helping to get you on committees, etc. I agree that it seems like a mentor should be able to do both, but I do not think that happens very often, at least in my experience. It is hard to get promoted without a national reputation and you need those opportunities, you need those doors to be opened. Speaking of opportunities, did you face any major obstacles as the first female President for the ACG?

CS: Not at all. I had a great year. I am proud of the things we accomplished. It was satisfying to be involved in the Annual Scientific Meeting.

One thing I am especially proud of resulted from our recognition that if we wanted disadvantaged young people to consider a career in medicine, we needed to reach out to them before college. So, we started the first “Prescription for Success: Careers in Medicine and Science” program by choosing a high school with many minority students. Anne-Louise Oliphant organized our first visit to Alhambra High School when the ACG Annual Scientific Meeting was in Phoenix, Arizona in 1999 during my ACG presidential year. A group of us went to make our presentations. I remember Dr. Yvonne Romero (from Mayo Clinic) telling the students that if she, as a Latina teen from an underprivileged background in Las Vegas, could end up at Harvard for undergrad and then go to medical school, that they could too. I am happy that this program continues to this day.

In my Presidential address, I spoke on women in medicine, and addressed my tips for combining work and family— maybe the best advice I gave was to lower

your standards at home—I had 3 young boys at home and after being fired by the Maid Brigade cleaning service for having a house too messy to clean I bought an ugly brown couch so that if one of my children spilled milk or juice on it the next day I wouldn’t care. I am proud to have been part of the College, but even more proud of those who have followed me, and their incredible contributions over the decades.

JG: In addition, to your research career on recurrent infection with Clostridioides difficile, you took an early interest in burnout, including raising awareness of physician burnout in gastroenterology. Was there a particular incident to lead to your interest in burnout?

CS: I did not know much about burnout at the time when then-ACG president Dr. Ron Vender asked me to give the Berk/Fise Lecture on burnout at the Annual Meeting. As I read and prepared the talk, I realized I had survived burnout. As a midcareer faculty, I felt like I had a lack of control at work. I became the section chief then, realizing that if I was going to be happy, I was going to have to be in charge and not feel like a victim.

[Dr. Surawicz’s 2018 lecture, “Recognizing Burnout” is available at bit.ly/SurawiczBurnout-2018]

JG: During the pandemic, there have been essentially two movements on how to handle the changes brought on by COVID: one group was promoting the idea that we should be trying to finish everything you have been putting off and/or learning some new skills. I heard that the GI journals were flooded with submissions because people were trying to finish up projects now that they were seeing fewer patients and endoscopy centers were closed. The other group was pushing for us to just give ourselves time to deal with the changes in our society and our lifestyles due to COVID. Which camp would you be in?

CS: Those are two different approaches. It has got to be individual, and maybe a mix of the two approaches works for some. But I have the luxury of being retired and free of patient care responsibilities. It has been a really tough year and I am in awe of the work you have all been doing.

“...when an opportunity comes up, assume that you CAN do it because the tendency may be more to think, ‘Oh, I don’t know if I’m ready for that.’ You would not have been asked if they did not think that you could do it. Just believing in yourself as much as others believe in you, that is the main thing.”

—Dr. Christina Surawicz

JG: You gave an amazing talk at the ACG “Bridging the Leadership Gap” conference called “Tips on Breaking the Glass Ceiling” where you discussed lessons you have learned on how women can reach their highest potential. From someone with a lot of firsts in her professional bio, what advice do you give women who can be a first at something or have an opportunity to do something new?

CS: A few things: First, when an opportunity comes up, assume that you CAN do it because the tendency may be more to think, “Oh, I don’t know if I’m ready for that.” You would not have been asked if they did not think that you could do it. Just believing in yourself as much as others believe in you, that is the main thing. Second, make sure it is something you really want to do. Finally, if you do not fail sometimes, you are probably not taking enough risks. Twice I applied for positions that I didn’t get. I felt bad about not being chosen. Yet in both cases, those chosen were better suited, did a better job, and were happier in those roles than I would have been. Other opportunities came up for me, such as the Assistant Dean position. As Helen Keller said, “when one door of happiness closes, another opens but often we look so long at the closed door that we do not see the one which has been opened for us.”

Helping to advance women and groups underrepresented in medicine and GI has been a passion for me. There are still fewer in leadership (for a variety of reasons), but I am gratified to see that it is heading in the right direction and that the College members and leaders remain at the forefront of the work that needs to be done.

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

Christina M. Surawicz, MD, MACG Dr. Surawicz was ACG’s first woman president (1998–1999). In 2019 she retired from a long career at the University of Washington Harborview Medical Center where she served as Chief of Gastroenterology and Hepatology, among many roles.

Conversations with Women in GI

Dr. Jill Gaidos talks to Dr. Jessica Allegretti on

“Being Your Own Best Advocate”

I HAD THE OPPORTUNITY TO MEET DR. JESSICA ALLEGRETTI at the ACG IBD School in Williamsburg, VA in 2018. I had contacted her several months ago about being interviewed for this series, however, due to COVID, the interview was postponed. We were finally able catch up this summer to complete the interview over the phone.

For those who don’t know you and aren’t familiar with your work, you are the Associate Director of the Brigham and Women’s Hospital Crohn’s and Colitis Center, the Center’s Director of Clinical Trials and the Director of the Fecal Transplant Program for recurrent Clostridioides difficile at Brigham and Women’s Hospital. What got you interested in fecal microbiota transplantation (FMT) as an area of research?

It’s interesting, as with most things, it started with a patient. I was actually in residency. I was already interested in inflammatory bowel disease and was GI fellowship bound and was rotating at the IBD center during an elective. We had a patient who had refractory ulcerative colitis and we were recommending colectomy. And the patient said, “I won’t even meet with the surgeon until you consider this treatment that I’ve been reading about called fecal transplantation.” At the time, I had never heard of it and knew nothing about it. And so, I went on a journey investigating what had been done in the space. And really, at the time, there was almost nothing in IBD, really only small case series in C. difficile. This was before any randomized controlled trials. So unfortunately, we couldn’t offer the patient this therapy at that time. But it really started me thinking about this therapy and the potentials of it. 

So, when I transitioned to my fellowship at the Brigham, I really had this still in my mind and I wanted to work with whoever was doing work in this area. So, I asked, “Who is doing FMT? I would love to get involved.” The answer was nobody. So, I asked my program leadership and the endoscopy leadership if they would be ok if I started a program at Brigham during my 1st year of fellowship. And they said, “Go for it. Whatever you need support with, we are happy to help.” And so, at the time, C. diff wasn’t a big clinical interest of mine. It really evolved out of my interest in FMT as a potential therapy for IBD and C. diff was the obvious place to start. So, I built it from there, I met with infection control, infectious disease, and the billing department to figure out how to put together this program. We did the first fecal transplant at Brigham the spring of my 1st year of fellowship and it really just sort of took off from there. Naturally, C. diff became a really big focus of my clinical practice and really became this other passion of mine. There was a nice link between my interest in C. diff and IBD and the emergence of microbial therapeutics. So, that’s really where it all started.

You also have a Master’s in Public Health (MPH). Did you do that during fellowship or after you completed fellowship training?

I did that during fellowship. I was really lucky because the Brigham has a big focus on clinical research. As part of my fellowship I was able to do a program called the Program for Clinical Effectiveness at the Harvard School of Public Health which is a summer program that serves as a primer for an MPH with an introduction to statistics and methodology. For those interested, we were able to apply for an MPH through the fellowship program and they select up to 2 people every year to pursue an MPH. I was selected so I was able to build the remaining MPH requirements into my 3 years of fellowship. So, I was very lucky because I really did learn to become self-sufficient from a research standpoint through that experience.

For people who are interested in research and are unable to get a Master’s degree during fellowship, do you think getting a Master’s in Public Health is something they should ask for early in their academic career? Do you think it’s really a game changer having that educational background?

That’s a really good question. I would say, ultimately, no. When you think of everything that an MPH encompasses, there’s a lot of aspects to it. Unless you are really interested in a career in public health, I don’t think that it’s absolutely necessary. I think if you have a focus in clinical research, I do think asking for classes in statistics

and being able to understand how to perform your own statistics and to have the vocabulary to be able to communicate effectively with statisticians is important. I remember in residency trying to design studies and not understanding how the analyses are actually performed. It makes it very difficult to design an effective study without having that background and you need to be able to ask the statistician the appropriate questions. Now, I’m lucky that I’m at a point where I don’t have to do all my own statistics anymore, but I can have informed conversations with statisticians about design. So, I do think that is what I would ask for above all else.

“[At the beginning of my career]...I really felt like I had to advocate for myself and I had to put myself out there in many regards. I had to network as much as I could at meetings to let people know about the work I was doing…”

Too, understanding the statistical analysis is important for designing the data collection. If you have a spreadsheet with a bunch of words on it and send that to the statistician, they are going to look at you like you're crazy. Absolutely. Understanding how the statistics are done, how to clean the data, how to code the data even so that, again, you are all speaking the same language. I do think that is incredibly helpful. Let’s say you are designing something as simple as a survey study, you need to know how to design the questions in a way so that the output makes sense to a statistician and actually answers the questions you set out to study. I do think those are some of the most important lessons that I took away from the MPH and that is the critical aspect of it.

We were talking, I think it was at the last ACG Annual Meeting, and you made a comment about how you are now finally being taking seriously for your research. What was it that made you feel you weren’t being taken seriously? And what changed that made you feel you are now finally being taken seriously as a scientist and researcher? For me, I struggled a bit in the beginning as I was getting started. I started a program when I was a fellow. So, I really felt like from the get-go that I had expertise in an area that no one else in my division, even my hospital, had. But because of my age and because of my junior status, it felt very much like I still I had to “pay my dues” in order to be taken seriously. In training, it’s always assumed you are working underneath someone else. So, I did experience a lot of frustrations in the beginning of my career when I transitioned to an attending as I already truly felt like I was an expert in this space, but because of my age and, in some ways my gender, I really wasn’t being taken seriously or considered a leader. I really felt like I had to advocate for myself and I had to put myself out there in many regards. I had to network as much as I could at meetings to let people know about the work I was doing and what I had done

at the Brigham, that I would be happy to give talks, happy to come help set up FMT programs, and share what I knew. I also focused on doing really good work and publishing as much as I could. Really, it was just a lot of hustle. I wanted to be taken seriously and I wanted a seat at the grown-ups' table and I really felt like it took a while. My husband even laughs at me when I say this now. He says, “It took a while, Jessica? You’ve only been an attending for six years” (laughs). So ultimately, I do think I was able to lift myself up quickly, but I was quite frustrated when I was getting started. Now I have a seat at the table and people consider me a leader in this space. I’m grateful for that because that is where I always wanted to be. I really felt like I had to advocate for myself and put my work out there and really network and meet people like you and many others to explain what I was doing and get my name out there. So, my advice to people when they ask me “How do you get to that place?” A lot of it is not expecting other people to lift you up. Some people have great people in their corner who do that for them, but in some ways, you still have to be your own best advocate. I found, often, more senior people don’t want to give talks. I was like, “I’ll fly anywhere, I’ll do anything. If you want me to give a talk, I will be there.” I never said no to those opportunities so I could get my work out there. I think that is really what helped.

Do you feel like you had to do more to advocate for yourself to become recognized as a thought leader in this area than a man six years out of fellowship would have had to do?

My answer is always yes. I do think that, even though I work with many amazing women, even my division is equal parts women and men now, I do think that it’s still a maledominated profession and I am at a disadvantage in that I look like a very young woman. Even still to this day, I still often get the “you’re the doctor?” comments.

Exactly!

I don’t feel like I should have to alter my appearance or try to look older to try to be taken seriously. I feel that the science and the work should speak for itself. I did feel that in the beginning people were kind of eying me up and down, going “You? This is you?” (laughing). I wish that the answer was no, but I do think that the answer is yes.

Also, at the last ACG annual meeting, you had co-chaired the Women in GI Luncheon. Yes, I’m doing it again this year.

You were really excited about the experience you had co-chairing that session. There’s an impression that after training, you don’t need to that type of networking and social connection anymore, but really we need that throughout our careers. What did you get out of that experience as the co-chair organizing and moderating that session?

It’s such a fabulous session and I’m very excited that I’m co-chairing it again this year with Dr. Jami Kinnucan. I think one of the biggest take-aways is it wasn’t just fellows or women who are about to graduate who attended, it was anyone who was interested in either a career change or looking for that type of networking. And this year, because it’s virtual, it’s open to all woman. For me, the biggest takeaway is that we all have a lot of the same concerns. For women in GI, there’s a lot of fear and uncertainty with regards to navigating careers. How do you balance wanting to have a family and a career and still be taken seriously by your male colleagues? That was a big theme that a lot of women expressed concerns about. How do you choose which path you are going into? Is there a path that will be easier with all of the other aspects that we have to take into consideration? One of the pieces of advice I was trying to share with attendees and also one of the things that I have learned along the way is that some of the best networking I have done was well after fellowship. A lot of the important female colleagues that I have met along the way was

while traveling and speaking at meetings like you and Aline (Dr. Aline Charabaty). Really just this huge network of women in IBD, specifically, that I would have never known otherwise. I think, as attendings and academics, we have been able to really support each other in ways that I didn’t really know was possible even as a fellow. I think a lot of the more important and supportive relationships were created once I became an attending. I think we as women like to think that other women, especially where you work, will be our best allies but that’s not always the case.

That’s true.

There is sometimes a feeling of competition among other women specifically in your division or in your space that can be unfortunate. So, having allies and advocates at other institutions, for me, has been career-making. In the very beginning, when I was trying to get the FMT program going, one of the best things that happened to me was I met a bunch of other women who were doing FMT around the country and they became my network. If I hadn’t met Dr. Colleen Kelly and Dr. Monika Fischer early in my career, I don’t know where I would be right now. And, I didn’t have anyone to turn to within my local space, so that was one of the big talking points that came out of that lunch.

Exactly. Another issue that women face is feeling less respected by the clinic and endoscopy staff as an attending when they stay at the institution where they trained for fellowship. Did you experience that? And, if so, how did you handle that?

It is really interesting. When you are transitioning to attending from a fellow, the staff knows you as a fellow, and sometime garnering respect as the attending can be challenging. I do think that, as women, this is something that we particularly face. For me, I would say that I have been fortunate. Because I was running my own program, even as a fellow, I had sort of earned some of that clout, if you will, as I transitioned, because there was no one else to go to if you wanted an FMT, you had to come to me. I felt like I had a bit of an advantage and why I was quite happy to stay at the Brigham and didn’t have a lot of the

same concerns that I know some of my female colleagues have had. For me, the thing that benefited me and the advice I give is, if you treat the endoscopy staff and clinic staff with respect, they will return that respect. I have befriended a lot of the clinic and endoscopy staff and have tried to create a collegial environment. They would never disrespect me because I wouldn’t disrespect them. That has really been helpful. Out of the gate, I always introduce myself if there is someone I don’t know on the endoscopy floor. I say, “Hi, I’m Jessica. I’m the attending today.” It’s easy to get defensive and say, “Well, I’m the attending.” If that is your attitude, people are going to mirror that back to you. So, I think that has helped me along the way. Being on time, showing up, and being responsible, I haven’t had a lot of those issues.

One of the things that you do really well is that you are a physician, a researcher, a scientist, but you are also not afraid to be a woman. You and I have talked about your love of make-up and spending time at Sephora and you have shared a picture of your shoe room on Twitter (available at bit.ly/2Zoh2gh).

(Laughs) I’m very proud of it!

In this field and in other male-dominated fields, women sometimes feel that they need to be more "manly" to be taken seriously or respected. Do you ever get push back from that?

It sort of goes back to the fact that I look like a young woman and I’m also 4’ 10." I have very blond hair and I wear hot pink lipstick most days. It’s a balance between wanting to be taken seriously but also wanting to be myself. I actually started really dressing up towards the end of fellowship as I felt that that type of appearance allowed patients to take me more seriously. It really worked and it sort of blossomed from there. I got very into the artistry of make-up which is how I de-stress. That is my creative outlet. Some people paint or write music. My husband is a saxophone player and that is what he does to unwind. For me, doing make-up is how I unwind and how I clear my head. I do think that it is an interesting balance in that I do get a lot of comments whether it’s from colleagues or from patients about my appearance. I don’t ever want it to be about my appearance but you have to learn this balance between wanting to be yourself and dressing how you can be comfortable—but also shielding yourself from some of the sexist and, quite frankly, offensive comments that you get day in and day out. I do think it is a balance. I think if I didn’t do that, if I didn’t put myself together in a way that I’m

“I don’t ever want it to be about my appearance but you have to learn this balance between wanting to be yourself and dressing how you can be comfortable—but also shielding yourself from some of the sexist and quite frankly offensive comments that you get day in and day out.”

comfortable with, I don’t think I would perform in the way that I want to perform because I just wouldn’t feel like myself. We all have the right to dress how we want, to wear as much make-up and to be as feminine or as non-feminine as you want to be. The fact that colleagues feel they can freely comment on your appearance is something I’ve never quite gotten used to though. This never happens to men. One example, I was on service in the hospital about two weeks ago and my fellow, another female, and I and we were about to go see a patient when a female nurse on the floor walked up to us and said, “What are you two children doctors doing here? You are too pretty, you’re too this, you're too that” and I was literally like, “What is going on right now?”

(Laughs) That is crazy!

I’m an attending gastroenterologist and this is my fellow and we are about to go see a patient and we are being riddled with critiques about our appearance. It was so off-putting. Even though I do think that sometimes people think they are being complimentary. I don’t put on make-up or dress a certain way because I want people’s comments on it. I do it because that is how I feel my best. It is a bit of a balance. This is something we talked about at the luncheon because you kind of have to have a set series of retorts on how you respond to microaggressions when people say X, Y or Z. I don’t tolerate it.

In that scenario, it’s really important for that fellow to hear how you respond to that and, really, you are supporting her by sticking up for both of you. Absolutely. This was a senior female nurse and before we walked into the patient’s room, I said to her, “What you just said was extremely offensive and incredibly inappropriate and negates our years and years of combined training.” It was so off-putting. She apologized, but we shouldn’t have to deal with that not only from men but from other women.

You are so right!

Jill J.K. Gaidos, MD, FACG Yale School of Medicine New Haven, CT

Jessica R. Allegretti, MD, MPH, FACG

Brigham & Women’s Hospital

Crohn’s & Colitis Center

Chestnut Hill, MA

Conversations with Women in GI

Dr. Jill Gaidos talks to Dr. Colleen Schmitt on

“Leadership for Women in GI”

I HAD THE OPPORTUNITY TO MEET DR. COLLEEN SCHMITT at the ACG “Bridging the Leadership Gap in GI” conference in January 2020. Dr. Schmitt was one of our amazing faculty members for the conference and presented a talk on “Developing Your 5-Year Plan in Academics and Private Practice.” We had planned to meet up at the next GI society meeting for her interview, however, due to COVID, the interview was postponed. We were finally able to catch up this summer and talk about her experience being a leader in GI.

You were previously the Chief of the Gastroenterology division and the Director of Clinical Research at the University of Tennessee College of Medicine Chattanooga Unit. You are now the President of the Galen Medical Group which is a multi-specialty private practice group in Chattanooga, Tennessee. You have leadership experience in both academic and private practice settings. What lead to you to transition from academics to private practice?

My first academic position was at Duke after finishing my fellowships. The move to Chattanooga was a deeply personal decision. My husband and I wanted our children to grow up near their grandparents, as we are both originally from this area. We both looked at a lot of opportunities. Clint is a musician and I’m in medicine. We looked at both academic and private practice positions in different cities that we had enjoyed and loved living in, like Boston and Durham as well. But what took us back home, if you will, was this personal decision. And we both had to give up something to do that, but in the end that was the wisest, best decision I think we could have made for ourselves and our family.

You know, you don’t have a perfect crystal ball, but my career has been very satisfying and enriching. The nice thing about the move to Chattanooga was that I was able to take on a hybrid position, where our group straddled both private practice and academics. For individuals who still want to have an opportunity to teach while working out of a private practice setting, those opportunities do exist. Our group eventually had to leave the teaching hospital behind due to system changes, so we made the decision to give up our faculty positions there. The decision to close that door was a decision I made jointly with the rest of my partners.

You also have quite extensive research experience. You were the Director of Clinical Research at the University of Tennessee College of Medicine Chattanooga Unit and then the founding Medical Director for Chattanooga’s first multispecialty clinical trials unit.

So, this is one of those situations where you just take what you have and use it and see what kind of doors and opportunities will open for you. When I was at Duke, my mentors there, Scott Brazer, and Jack Feussner, who was the chief at the Durham VA, encouraged me to do a joint fellowship in health services research. During that experience, I had accumulated enough academic hours to complete a Master’s degree in Biometry and Informatics. So, when I came to Chattanooga, there were a couple of single-specialty clinical trials groups. I became friends with them, and with folks in industry and asked about starting to do clinical trials. I went to my partners and asked if they had interest in doing clinical trials I believe this is a kind of situation where if you enjoy the work, you can make what you want to out of the job. It’s been a job that has allowed us to continue to be cutting edge, has crossed several different clinical areas, has been tremendously rewarding, and really just plain fun.

With all of your leadership experience, did you ever have any formal leadership training through leadership conferences or classes?

Never. It was a real eye opener to me. I can tell you exactly how and when it happened. I remember when Sheryl Sandberg’s book Lean In was published, and there was a lot of pushback against that book. I don’t know if you remember it. But I thought, “I’m going to read this just because she’s gotten so much flack. Judge for yourself about who she is as a person or her personal wealth, whatever you want, but I want to know what this says so I can be part of that conversation.” At the same time, I read a book called Women Don’t Ask by Linda Babcock. I think I read them both the same month. I found Linda Babcock’s research to be so compelling and then juxtaposed that with the personal experience and observations

that Sheryl Sandberg made.

“What we have seen happen over the last few years is considerable education and thought around how to develop professional leadership skills. We have had to borrow from the business community, to do that effectively because they were so far ahead of academia in terms of what kind of resources brought to bear on this problem.”

We knew then how many women were going into our field and yet really were not rising to the level of leadership positions that you would naturally think that they would be getting to by that point. And this is 20 years into women going into GI as a specialty. It’s not an original observation, by any means, but I think all of our societies were looking internally at ourselves and wondering what is going on and what can we do to change it.

I believe what differentiated the experience of someone my age or anyone around the time we trained is that we felt very fortunate to actually be in an era where there was a serious focus on the development of clinical research skills in training. And what we have seen happen over the last few years is considerable education and thought around how to develop professional leadership skills. We have had to borrow from the business community, to do that effectively because they were so far ahead of academia in terms of what kind of resources brought to bear on this problem. So, that is what we did. I was very lucky. I don’t think it would have happened, Jill, if I didn’t have a Board who all had daughters in the 18–25-year old range and women leadership in the society administrative staff who were completely behind at the idea. They all arrived at the same conclusion I did. So, no, no formal training. I went through the Leadership, Education and Development (LEAD) program with the LEAD classes for the first three years. I actually attended all of those.

The hard part is that our GI societies seem so siloed. I have met with women on different committees or task forces for various GI societies and all the women are saying, “We need leadership training.” That is one of the reasons that Dr. Amy Oxentenko and I worked so hard to develop the “Bridging the Leadership Gap in GI” conference — because of this need for leadership training for women in GI. Do you see any way we can expand these training opportunities? First of all, it was a really good course. My observation is that it’s an expensive endeavor. The people who really teach well these topics teach it professionally at places like the Kellogg School of Business or Stanford and they are expensive. The other thing that I believe is very different is, in medicine in particular, we are taught to learn in bitesize lectures. In fact, that has gotten more obvious over time. When was the last time you sat through a 45-minute lecture at the postgraduate course? They are usually 15 or 20 minutes with Q & A, at most. Leadership training can’t be taught in bite-size snippets. These are deep dives. So you have to be invested for coming in for more than a day and be willing to spend two days with a speaker and come out on the other side of that tangibly and functionally changed. Minimum for some of these lectures is going

to be four hours. And there are so many nuances to what we are talking about that are still going to be impactful for the development of one skill set. We learned that before we launched LEAD at ASGE, and incorporated that model into the development program. Pooled resources and opportunities to share that kind of substantive content would be of benefit to women in all of these groups.

When we were developing the curriculum for the conference, I had several conversations about this with Jean Gasen, the executive leadership coach who gave the keynote speech at the conference. She looked at the agenda and said, “How can you process this information in 20 minutes? When do you reflect on what you’ve learned?” But when you look at a business school leadership course, these topics are covered over hours, not minutes.

Yes, and there is a lot of role playing that occurs and the commitment to developing these skills is time consuming. You have to allow time for introspection and feedback. Any of us are smart enough to go sit and learn something about a biopsy protocol or diagnostic criteria for certain disorders. That’s memorization work and something you can write down and put in your back pocket. But practicing, I’ll pull this out, practicing an elevator speech is not something that comes naturally to us, by any means, much less the opportunity to use it. It’s important to really be still, and sit, and think. I think my talk at your course was developing your career path. To really have time to ponder that, and then think about where your gaps are, and where you want to invest time and learning—this is not a 20-minute thought process by any stretch.

Right! Back to your talk at the ACG “Bridging the Leadership Gap in GI” conference, you spoke on developing a 5-year career plan to identify steps to take to develop and achieve future career plans. Throughout your career, did you have a career plan? Do you encourage others that you mentor to create a plan?

Yes, although I did not have the pointby-point plan that I outlined in my talk. I don’t know if that was even a thing back then. I’m not sure if you remember, but one of the points I made for me personally was that mine was more of

a crooked path and part of that was because there were two people to think about—I believe that’s true for many women. We did not set out for our family to say, “Okay, we’re going to take turns,” but that’s basically what we did. One would make a decision to help put the other one forward for education or for whatever purpose and then the other person would put that person forward.

It’s easier to see that in retrospect, but in real life if you’re not willing to do that, I don’t think the end result is going to be happy. I believe, first of all, leadership is about creating opportunity for other people. Truly, that has been the best part of any leadership position I’ve been in. Of course, the downstream benefit of that is that I get to surround myself with people who are extremely talented and gifted. I would say that our career plan was maximum 5 years. When we came to Chattanooga, it was not my career plan to be a division chief or lead a clinical trials group. I kind of looked around and thought, “You know, there is an opportunity to do this and I’ve got this person who works with me that would be really good at this,” and we would explore that and more opportunities would come from that. I hate to tell you that’s what I did, but in truth it is. So, if my partners read this article and saw anything else, they’d start laughing. (Laughing).

In reality, I don’t think I’ve ever made a 5-year career plan. I hadn’t ever really considered it until I listened to your talk. It’s funny because I’ve just moved to Yale University for the Director of Clinical Research in IBD position and my husband asked me, “So, is this it or are we going to be moving again for a Chair position?” And I said, “You know what, I haven’t even thought about that.”

I think that’s an honest question and an honest answer.

It’s certainly not in the 5-year plan. I would be interested to hear what your 5-year plan is.

I’ll let you know when I come up with it. (Laughing) (Laughing) Oh, that’s funny! I think the next most important point from my talk is for folks not just to “give and get” but the “try, rinse, and repeat.” Understanding that the trajectory is not going to be just a straight arrow. It’s going to wind, it’s going to curve and may require iterations of your plan. Honestly, it’s taking advantage of those curves, taking advantage of those unexpected opportunities, that’s where the magic happens. And I’m sure the same thing is true for people who do research primarily. It’s the accidental discoveries. It’s not just the deliberate, intentional discoveries, it’s the ones that you take advantage of that you didn’t expect are really the amazing part of that.

That’s something that is hard for women to do. I listen to a podcast called, “The Brave Enough Show” (www. becomebraveenough.com/podcast) by Dr. Sasha Shillcutt. On the podcast she talks about how women get on these trajectories and we continue to do what we are good at, but not necessarily what we love. And it becomes hard to switch from the things that we are good at to the things that we love but we may not be as good at yet.

That takes courage and it also takes a significant amount of insight. That is the big decision maker for someone who is leaving one type of position and going to another type of position, like leaving academics. You are taught certain things about what that means, but for everyone in a position like yours where you have to juggle or balance the administrative responsibilities, which, let’s face it, some people love, and the research responsibilities, teaching and clinical responsibilities, it may even be a moving target. You may love the clinical part of it for a period of time or the research part and want to maximize something else. There may be no door that you want to close. But if you do have the insight and then the courage to say, “Okay, I’m committed to this path,” you do realize that you may close doors. It’s not a small decision.

Jill K. J. Gaidos, MD, FACG Yale School of Medicine New Haven, CT

Colleen M. Schmitt, MD, MHS, FACG

Galen Medical Group Chattanooga, TN

CONVERSATIONS with WOMEN IN GI

Aline

Charabaty, MD

on “transitions: Changing Institutions and Building a Social

Media

Presence”

By Jill Gaidos, MD, FACG

“For me, when I tweet, I tweet with a purpose —the purpose of educating, promoting women and minorities, promoting my colleagues’ work, lifting up others, and advocating for my patients.”

AFTER HER PRESENTATION AT THE ACG/VGS/ ODSGNA REGIONAL COURSE in williamsburg, vA, Dr. Charabaty and I sat down to talk about how her role as an IBD doctor and educator has been expanded through her use of social media. Since our conversation, she was awarded a healio Disruptive Innovator “Social Media Influencer” Award during the 2019 ACG Annual Scientific Meeting. 

I recently searched for you on the internet and saw that you moved from MedStar Georgetown to Johns Hopkins School of Medicine. What triggered you to move to another academic center?

I did my training at Georgetown University hospital and I was asked to stay on faculty to build the IBD service line. I was very excited to build something new within the program that trained me, and my first job was like a “first baby.” I put in a lot of planning, learning, effort, and endless hours of work, because Georgetown didn’t have a formal IBD center, and I spent several months at the hopkins IBD clinic in my third year of fellowship. Several years later, hopkins asked me to build the IBD service line in their DC hospital, Sibley Memorial hospital. So, in some way, I came full circle. I was very proud of the work I did at Georgetown. I had established a good team of medicine, surgery, and radiology faculty with interest in IBD, and had made great friends there. I just loved my fellows and had patients I was following for years; they were like family to me. So it was really a long process to reach the decision to leave and start something new, but at the same time it was very liberating and something I knew I needed to do if I wanted my professional and personal life to move in the direction I wanted it to.

I think reassessing now my first job out of fellowship, there are a lot of positive things that came out of it, and several mistakes I have learned from. what I absolutely don’t regret and what carried me forward were the relationships I built with fellows, colleagues, nurses, staff, and my GI/IBD patients. Connecting with people, having a sense of community, is my saving grace from burnout. the reason I love IBD is that it really gives me the opportunity to connect with my patients on so many levels. to be able to improve the health and quality of life of someone is so rewarding, but it's really beyond that. For me, it’s really making sure my patients’ concerns are heard and understanding what goes through their mind when we're talking about disease, plans of care, procedures, but also what is going on in their lives outside of their disease. working with patients at all stages of life, understanding how IBD affects their lives, and how life affects their IBD care, doing my best to make a difference and teach that to

“It was like a mix of a professional and personal midlife awakening: who am I as a woman, as a mother, as a person, and as a physician; what do I want for my life and how can I get it; and what are my priorities?”

my GI fellows and nurses, these are really the best experiences and where I find joy at work.

what I regret about the early part of my career is how much I allowed work to take precedence over other things in life, and the lack of direction for my professional growth. I was over-working, but not necessarily in a smart way. I wanted to prove that, as a young woman, I could do it all and do it as well as my male and senior colleagues. I was putting in long hours, and completely ignoring myself and my family needs, missing some of my kids’ events at school. with my first child, I had struggled to get pregnant, did IvF, and had complications from IvF. After that, I had more miscarriages and struggles before my second pregnancy. So, you would think in that situation I would be prioritizing more personal time and working reasonable hours, but I think there was so much pressure on me to prove that even as a young mom and a young faculty member I could see a high volume of patients, scope, and meet high rvU targets, work late, and never stop. I was even on call the week before my due date, and it never occurred to me to say “No, this is ridiculous, I can't do that!” I wish someone had said, “Stop; you need to work smart, and you need to ask for what is important for you, and do what is right for you—at work and outside of work—and take care of yourself and your family.” And when someone said it—my Chief at that time, Stan Benjamin—I didn’t listen because I didn’t think he shared the same experience!

this is one of the reasons why women mentors are so important, to be available, and to advocate for and mentor junior female faculty—and you, Jill, sharing the experiences of women in GI with others is so critical. receiving mentoring and advice from someone who understands what is going on in our head and life has such great impact and value. what I also wish I had was guidance on how to build a career outside of clinical work; get protected research and admin time, join national societies, work with hospital or national committees, etc. I discovered the importance of all of this much later; that is why when I mentor fellows or young faculty, I ask them first to define their interests and plan their time accordingly and get involved early in professional societies like ACG.

So, at some point, despite the professional and clinical successes I had at work and all the good opportunities Georgetown had

given me in my early career, I felt I had plateaued and my mind started nagging me, “So what’s next? where do we go from here? what are your goals? how can you get there? what are your values and your vision? Are they aligned with your institution?” It was like a mix of a professional and personal midlife awakening: who am I as a woman, as a mother, as a person, and as a physician; what do I want for my life and how can I get it; and what are my priorities?

So, it was a slow process to get to that decision point. Interestingly, it came with a self-rediscovery on a personal level, redefining my interests, prioritizing kids and family time, exercising again, doing things I enjoyed, having the time to think, and discovering meditation. So, from a personal awakening came a professional one. I realized that the value I bring to my patients is within me; it’s my knowledge, my compassion, my ethics, and this is something I carry with me everywhere. My value is not linked to a title; it is what I give as a physician, as a mother, as a friend, as a mentor, and finding joy in all that. And now, I was in a place in my life where I knew what I wanted from my work life, what leadership path I wanted to take, what to negotiate for in a contract.

In addition, at Sibley/Johns hopkins Medicine, I found the culture, the schedule, the support I needed at this point of my career. the Chief of GI who hired me, tony Kalloo, is a strong advocate and sponsor of women and minorities in medicine, building a division with a large number of women in advanced endoscopy and in leadership roles. our new Chief of GI is an accomplished female researcher and clinician, Anne-Marie lennon. It is very empowering to have women colleagues and be offered a leadership position when you feel you are ready for the next step in your career.

As the clinical director of the hopkins GI Division at Sibley hospital, I am tackling new challenges like growing the division, recruiting faculty, and shaping a positive culture in the division that aligns with the values I want to live by. I want everyone to feel part of the team, their opinion heard, their work valued, and for my team to enjoy coming to work, at least most of the time! (laughs) I think that is key to fighting burnout, to continue finding joy in healthcare, and to give incentive and space for everyone to thrive.

“So, from a personal awakening came a professional one. I realized that the value I bring to my patients is within me; it’s my knowledge, my compassion, my ethics, and this is something I carry with me everywhere.”

I don’t know what it means to lead like a woman or lead like a man; all I know is that as women leaders, we bring something different to the table, and it’s good! the way we approach problems and offer solutions, our understanding of people’s needs, and the importance of achieving a healthy work-life balance. I believe we can be assertive and empathetic at the same time. we can be team builders and we can make decisions on our own when we need to.

So, another thing that popped up when I was looking you up online was your personal Twitter page (@DCharabaty), but also your Monday Night IBD (MNIBD) Twitter page (@MondayNightIBD). yes. I’m very excited about this new adventure!

You have more than 4,600 followers on your handle and more than 3,000 followers on MNIBD. Tell me about @MondayNightIBD. What is it and how did that get started?

So, I joined twitter under peer pressure, I admit. one of my fellows said, “If you’re not on twitter, you are nowhere and you’re nobody.” I was like, “oh! that’s harsh!”

That’s mean!

the way I wanted to use it is kind of an extension of what I love doing: educating and advocating for my patients, my fellows, my colleagues. So, when I joined twitter, I would post summaries of IBD articles I read or things I learned at GI conferences. But then, since I really like to have conversations and connect with people, I started asking questions about IBD management.

In March, after an experience with a hospitalized UC patient who got partially better on steroids and infliximab, but much better after adding Cipro and metronidazole (despite lack of an active infection), I put out a tweet, “If you have a patient with acute severe UC, do you use antibiotics in addition to steroids?” with a poll: yes, never, only if evidence of sepsis. A great discussion started and different IBD experts and gastroenterologists shared their opinions. there was a spontaneous enthusiasm to have these conversations regularly, so, I said we should turn “Monday Bingo Night”—I don’t know why I thought about Bingo Night; I guess I keep thinking that when I’m old, I’m going to be playing Bingo on Monday night— into “Monday Night IBD.” I thought it would

be a great opportunity to use this platform to highlight the expertise of everyone caring for patients with IBD and learn from everyone; so, I started asking IBD colleagues to lead a conversation and poll every Monday on a topic of their choice, based off of a clinical vignette.

the question @MondayNightIBD asks is, “how would you manage a real life IBD situation?” And the conversation comes easily, because the beauty of twitter is that you can follow a discussion and tweet at anytime, anywhere, without the constraints of time and space. And for some reason, it is less intimidating to comment or ask a question on twitter than in a large conference room. I also wanted the platform to be inclusive of everyone involved in IBD care, like a virtual multidisciplinary team from all around the USA and the world. I wanted everyone represented and to keep it diverse: IBD experts, up-and-coming IBDologists, private and academic GI doctors, researchers, GI fellows, colorectal surgeons, women, minorities, dietitians, psychologists, clinicians from different parts of the world with different challenges and experience in caring for IBD patients. we can all learn from each other and lift each other up!

And finally, the inclusiveness means also bringing in the patient voice the online patient advocacy world was new to me and I’ve seen, on twitter, IBD advocates doing amazing work promoting good science to other IBD patients, providing support to patients, and actively advocating for IBD care. And we need that, clinicians and IBD advocates bringing the good science to our patients where they are, on social media. I really wanted to bring the patient perspective to @MondayNightIBD because we often think that physicians and patients are speaking the same language, but we are not. I think that is one of the things that makes @MondayNightIBD special: clinicians and patients learning from each other.

How did you overcome the technical barrier of using social media? There are a lot of women who haven’t joined Twitter because they just don’t know how or the concern that it will take up too much of their time.

you need to make the conscious effort to limit the time you spend on twitter, because it can take up all your time if you let it! But you

“I really wanted to bring the patient perspective to @MondayNightIBD because we often think that physicians and patients are speaking the same language, but we are not.”

have to enjoy it to do it. Initially, I didn’t think I was going to like twitter. I thought twitter was for politicians and for the Kardashians (laughs). then, for me, it turned out to be an extension of who I am and what I like doing; I’m an extrovert and I love talking to people and getting to know them, teach and learn, explore new ideas.

I encourage women in GI to build their social media presence. one, it gives you visibility and exposure to promote your work and your research. two, it connects you with people you wouldn’t have connected with. three, it does build your “brand,” if you want, letting the world know who you are, what you stand for, what your interests are, not just as a physician but as a whole person, independent from your institution or organization. Four, you can make a wider impact for the things you advocate for. For me, when I tweet, I tweet with a purpose—the purpose of educating, promoting women and minorities, promoting my colleagues’ work, lifting up others, and advocating for my patients. Advocacy is a very important aspect of a physician mission and social media is a very powerful tool to advocate for change, for physicians, and our patients’ access to care. one thing that is great about twitter is the connection with non-GI physicians, writers, psychologists, sociologists; it opens up horizons beyond the confines of an institution and your circle of friends. twitter gives you the quick opportunity to see what other people are doing in their work and life. I often bring back the knowledge I gather to my personal life and my professional life. there was one post by a gentleman who does a lot of disaster relief work and he was talking about his approach to disaster victims. And I was thinking, for my patients with a new diagnosis of IBD or complicated IBD, this is a trauma, this can be experienced as a disaster in someone’s life. I took some of the wisdom he shared and I applied it in my practice. other tweets with a great personal impact are the tweets from psychologists, free advice and wisdom—we all need that in our lives and when raising kids. that is priceless!

Jill Gaidos, MD, FACG, McGuire VA Medical Center, Richmond, VA; Virginia Commonwealth University, Richmond, VA

Aline Charabaty, MD, Sibley Memorial Hospital, Washington, DC; Johns Hopkins Medicine, Washington, DC

Aasma Shaukat, MD, MPH, FACG, on “Being a VA GI Section Chief”

By Jill Gaidos, MD, FACG

AAFTER PARTICIPATING IN THE PANEL DISCUSSION FOR THE “CAREER OPPORTUNITIES FOR WOMEN IN GI” LUNCHEON

at the ACG 2016 Annual Scientific Meeting, Dr. Shaukat and I sat down to talk about her road to becoming a Veterans Affairs Gastroenterology Section Chief and her responsibilities in that position.

How long have you been Section Chief for the Division of Gastroenterology and Hepatology at the Minneapolis VA Medical Center?

AS: For the last four years.

How big is your GI section?

AS: Our section grew. It went from four physicians to 10.

Do you have a lot of nurse practitioners?

AS: There are 10 physicians and five Advanced Practice Providers.

Prior to becoming the Section Chief, were you full-time at the VA with an academic appointment at the University of Minnesota or part-time at both?

AS: I started as full-time VA, and then the university contracted the VA for my time. The university and VA do different things in different places in terms of how they share FTE because of the way the benefits are structured. The university doesn’t give benefits to anybody who’s not full-time. So, it’s beneficial to be full-time in one place. I did clinic and endoscopy at the university, also have a university appointment, and was also involved with Fellows’ training and education. I went back and forth between the University and VA, but was still full-time VA. That was beneficial because I could apply for a VA career development award and I could also apply for the University’s K award. So, that opened up more opportunities for research funding.

Was that beneficial for your career, to have some academic time and some VA time?

AS: It was, because I see different populations and that gives me a really good perspective. In terms of outpatient clinic, the university has a different kind of population, so I see a more complex patient population who has been referred to a tertiary care facility. And, I got an opportunity to work with fellows in both settings, where I could teach them a lot about system-based practice, how to apply the same evidence, or do the same kinds of things for patients in different settings based on resources. So I think it is beneficial. 

You had clinic and endoscopy at the University of Minnesota. What were your responsibilities at the VA?

AS: I had clinic and endoscopy at the VA as well. I also served as the Associate Program Director for the GI fellowship for four years. The Program Director was very busy, so I pretty much ran the fellowship. That’s something that I had an interest in and got involved when I first got there. You always can benefit from a fresh pair of eyes. I said, “So, you guys don’t really do a journal club? How about I do a series of small talks on critical appraisal of literature, of RCTs, comparative studies, systematic reviews, cost-effectiveness analysis, and then we go through a critical appraisal?” They said, “Absolutely. Go for it” So, I restructured that. I set up a Core Curriculum committee, in charge of what topics are discussed in our core lectures, in our grand rounds and mapped them to ACGME requirements. Did a lot of the fellowship nuts and bolts of education, and journal club. We survived a site visit for fellowship by ACGME. Now they do NAS, Next Accreditation System, so it’s a constant, ongoing process.

When Dr. John Bond retired in 2012, the section was down to three people. They chose me to lead the section. It was a tough year because I was still running the fellowship program and I had just had my first child. Not knowing very much about the section, and having people who were much older and far more senior than me, was very challenging.

IalsohadaVAcareerdevelopmentaward. So,technically,75%ofmytimewassupposed tobeprotectedforresearch,butwewere short-staffed,andclinicalneedshadtobe met.Eventually,Icutbackonmytimefrom theuniversity,andIstoppeddoing endoscopy there.Then,Itransitionedthe Associate ProgramDirectorpositionto someoneelse.I stillremainheavilyinvolved, eventoday,Istill runthejournalclubandthe corecurriculum, butatleastIcouldgetaway fromsomeofthe tediousandmore administrativetasks.

Itookonawholenewsetofadministrative responsibilitiesasDivisionChief.Thefirst goalwasrecruitmentbecausewewereso shortstaffed.Thesecondgoalwas,ofcourse, makingtheendoscopyunitmoreeffective in termsofdoingmorecases,havingfewer noshowsandcancellations,andassisting patientswhohavetransportationissuesor needanaccompanyingadult.

“ ...You should let your Section Chief and the Chief of Medicine know about your interest so they will groom you for the position, if it’s a good section and they are invested in your success. ”

I remain very close with my university counterparts. Most of my research is at the university. My VA career development award is using data from a private practice here in Minneapolis, because I needed a large database of colonoscopies. For career development, I got a VA Merit grant to look at long-term outcomes after colon cancer screening, and I wanted to use the Minnesota Fecal Occult Blood trial data, which was the original colon cancer screening trial done at the university. I finished the CDA, which resulted in a highimpact publication in Gastroenterology (Gastroenterology 2015;149:952-957). I finished the Merit Study, which was published in The New England Journal of Medicine (N Engl J Med 2013;369:1106-1114).

As a Section Chief, who now has two children, how do you balance your research time, clinical responsibilities and administrative time?

AS: Clinical responsibilities always trump everything. Being the Section Chief, I actually end up doing more of it. So it’s never a neat ratio where I can say, every week, two days I do this, two days I do this. If it averages to 50/20/30 ratio—50 research, 20 clinical, 30 administration, that would be a good week. That is what I strive for. But, there are some weeks where it’s all clinical. Close to grant deadlines, I try to carve out a lot of time to work on grants. Then, when you have JAHCO visits, or other directives come down, or some other issue happens in the endoscopy lab that consumes your time. Unfortunately, a lot of stuff trickles into home time. If I didn’t get through all my alerts, then I am logging in at night. Or if I didn’t get to all of my emails, or some academic or administrative stuff I have to do, review a grant or something, then I will do it from home. There are only so many hours, so that work typically happens after you put the kids to bed. I do try not to do that. I try to plan my week ahead of time. But, then, I expect the unexpected.

Absolutely, and the older the kids get, the later their bedtime, so the shorter the amount of time you have to get work done before you go to bed.

AS: Yeah, exactly.

For other ACG members who may be interested in taking on a leadership position, such as being a Section Chief or Chair position, do you have any recommendations on how to prep for this type of leadership position?

AS: If you have an interest and an aptitude, those are the two things that have to match up. That’s pretty much all you need, and then you have to let your interest be known. It may be intuitive to you, but it’s not intuitive to your Section Chief that you could be the next Section Chief or Associate Chief. Then people notice you for your thoughtful comments at staff meetings. You need to take ownership of the section and say, “I see this as a way we can make things better.” If you think you truly want that kind of a role, you should let your Section Chief and the Chief of Medicine know about your interest so they will groom you for the position, if it’s a good section and they are invested in your success.

Women Conversationsin

Shivangi T. Kothari, MD, FACG, on

DAILY LIFE IN ADVANCED ENDOSCOPY

By Jill Gaidos, MD, FACG

withGI

A AFTER ANOTHER SUCCESSFUL CAREER OPPORTUNITIES FOR WOMEN IN GI LUNCHEON

at the 2016 ACG Annual Scientific Meeting in Las Vegas, which was organized and moderated by Shivangi T. Kothari, MD, FACG and Anca I. Pop, MD, I met with Dr. Kothari to talk about her career as an advanced endoscopist.

You are the Associate Director of Endoscopy and Co-Director of the Developmental Endoscopy Lab at the University of Rochester (U of R) in New York. What are your responsibilities as the Associate Director of Endoscopy?

SK: As the Associate Director of Endoscopy, I contribute to the overall growth and smooth operation of our extremely busy tertiary care endoscopy unit. I work closely with the Division Chief, Director of Endoscopy, and the nursing leadership in the implementation, growth and success of our unit. In this role, I am primarily responsible for helping troubleshoot certain operational issues and identifying opportunities for improvement. These include, but are not limited to, upgrading the endoscopy reporting software, being involved with the endoscopy unit expansion planning and execution, new technology acquisition and endoscope reprocessing updates, and the drafting and implementation of recommendations. My key areas of focus have been implementation of new initiatives and technologies and providing leadership and support for the Nurse Manager and Nurse Leaders, especially around nursing education and training.

For the last three years, I have also been a Course Co-Director of our annual University of Rochester Medical Center (URMC) Advanced Endoscopy Nurses Course. This role involves strategic planning and execution in developing and implementing the course and bringing the entire endoscopy unit staff together to put together this one-of-a-kind, comprehensive nurses training course. I took the initiative on this course three years ago, and it has grown very rapidly and is attended by nurses from all over the country.

One of the things I’ve seen in academic center endoscopy centers is that the nurses and physicians are employees of different entities, so the endoscopy nurses do not report to the Director of Endoscopy, which can make it hard to implement changes to speed up room turnover, etc. Do you have similar problems?

SK: We work closely with the Nurse Manager and the Nurse Leaders to discuss any endoscopy unit work-flow issues, staffing issues, and to address and fix any road blocks in the smooth running of the unit. We have periodic leadership and staff meetings with the endoscopy unit →

leadership and also with the staff to, in an open forum, discuss projects and their outcomes and any areas that need improvement, as well as to plan future activities. When our Advanced Endoscopy Nurses Course takes place, the entire unit staff comes together, from the techs to the nurses to the Nurse Leaders, to work hard together and to make the course a success. From the daily endoscopy work to academics, unit progress and clinical studies, we are all in it together.

What is the Developmental Endoscopy Lab, and what is your role as the Co-Director?

SK: Under the direction of our Division Chief, our interventional group started the Developmental Endoscopy Lab two years ago when my husband, Truptesh H.Kothari, MD, MS, joined URMC as an Interventional Endoscopist. It’s a fully functional animal lab at U of R where we utilize the live animal platform for endoscopy teaching and training, clinical research, and device and technique development. It’s a very good educational and training platform. There are not too many such units in academic centers in New York or around the country.

As the Co-Director of the lab, I am involved with the planning, organizing and execution of all training courses that we hold at the lab, and also am the CoInvestigator for all device evaluations and efficacy trials that we perform at the lab.

Was this something that was in place when you started, or did you help create it?

SK: The lab facility has existed for a number of years and is a part of the Center for Experiential Learning at U of R. Many other departments of the hospital were using it, but it was Truptesh’s initiative at the time of his recruitment to help establish this aspect of our program along with our interventional group. It involved a lot of paperwork, training, certification and staff education to enable all of us to work in the animal lab, and we all went through it. It took us a good eight to nine months to get all of the paperwork and training ironed out before we had our first training workshop at the lab, which was a hands-on training course for GI fellows.

entire upstate New York area. It was a hands-on workshop on a Saturday morning. They could do Endoscopic ultrasound (EUS)/Endoscopic Retrograde Cholangiopancreatogram (ERCP) on live pigs, and there were explants as well. There were different hands-on stations for endoscopic mucosal resection (EMR), overthe-scope clips, luminal stenting, ERCP, EUS, foreign body removal, etc.

for advanced endoscopy nurses. It’s a day-and-a-half course with a day of live case transmissions and didactics and the next half-day is in the lab. There are two live animal stations for hands-on ERCP and EUS training. Furthermore, there are eight explant stations and two model-based stations for participants to practice advanced techniques first hand. The stations utilize various devices for foreign body retrieval, EMR, ERCP, EUSfine needle aspiration (EUS-FNA), intraluminal stenting, hemostasis advances, and fistula closure. Each station is staffed by a physician and expert technical assistants. The course has been very well received and is growing rapidly because it is a unique learning opportunity for advanced endoscopy nurses and techs.

For those of us interested in career timelines, how many years have you been out of fellowship?

SK: I graduated from my interventional endoscopy fellowship in 2012, so I am four years out.

Was your position as the Associate Director of Endoscopy a promotion or part of your position when you started?

SK: It was a part of the offer/position when I started working at URMC.

Was that something that you negotiated for?

SK: Yes, I did. I did negotiate, but it was not that difficult, at least in my case.

How do you handle the administrative duties in addition to your clinical duties, because you have to keep up your number of procedures? Do you have administrative time set aside?

Do you keep that open to just the fellows in your program, or is it open to all fellows?

SK: No, we had fellows attend from the

Is it for first-year fellows, second-year fellows? Who do you include?

SK: Upstate GI fellows from all three years of training were invited to participate in the course. That’s the same platform we use for the nurses when we do our course annually

SK: The balance is very tough. I have one half-day of administrative time during which I try to schedule all my meetings and any conference calls that need to happen. Administrative time as an interventional endoscopist is extremely hard to protect because there are always urgent ERCP or EUS procedures that need to be done, and you always want to help the patient and gets things done quickly for them. It’s extremely difficult to draw a hard line protecting your administrative time, at least for me. I try to work around my

meeting schedules and do any urgent cases in between the meetings. The staff understands that and plans accordingly.

What is a typical week or month like for you, including endoscopy days (general and advanced), number of clinics (all related to advanced endoscopy or any general GI clinics), call, and inpatient responsibilities and consults?

SK: I am one of four interventional endoscopists at URMC, thus my schedule mainly consists of interventional procedures. I have one half-day of administrative time, one half-day of clinic, and one half-day of general GI procedures that we do at our outpatient setting. There are also urgent EUSs and ERCPs that get squeezed in, and the four of us take turns in taking care of the inpatient advanced procedures volume. We also do about seven to eight weeks of inpatient GI consult service during which we manage the inpatient consults as well as inpatient advanced and general GI procedures. During the consult service weeks, I limit my outpatient schedule to just one to two urgent advanced procedures and no office hours.

What about call? Do you only take call when you are on the inpatient service?

SK: Our call schedule is separate from our inpatient consult service schedule. We do about six weeks and weekends of call—that is just your general GI call—and now we have a separate biliary call schedule as well. So, the four of us are on biliary call, one in four, in addition to our regular GI call.

When you take biliary call, how often do you have to come in?

SK: We started the biliary call because the on-call ERCP volume has increased over the past two to three years and now, with four ERCP attendings on staff, it just made sense to have an official person on call in place. When you are on biliary call, pretty much every time we have had to go in for ERCPs, mainly on the weekend. Also, with the University acquiring more hospitals, the volume of urgent on-call ERCPs has increased, making the biliary call relatively busier compared with in the past.

You mentioned that there are four advanced endoscopists at your center. Do you evenly share all of the advanced cases? Or, is it dependent on who you see as an outpatient?

SK: The patients that get referred to the advanced endoscopy practice get evenly distributed amongst the four of us. The patients that get referred to a particular provider get scheduled with that provider. URMC has a huge catchment area, so volume is not an issue.

For people interested in a career in advanced endoscopy, do you have any recommendations? For example, what is a realistic patient load when you are first starting out?

SK: We recently wrote a paper on this exact topic1—career prospects and professional landscape after advanced endoscopy training. It was a survey that we did of advanced endoscopy-trained fellows who graduated from 2009–2013. We surveyed them to determine what trouble they had finding an advanced endoscopy job after their training, whether they were doing the same complexity of procedures in their practice as in their training, and if they encountered and felt that the advanced endoscopy job market is saturated. We are all talking about it, everybody is saying, “Where are the jobs for advanced endoscopists?” But there was no literature— there are no numbers out there.

We found that more than 80% of the respondents feel that the advanced endoscopy job market is saturated. A majority of the respondents had a hard time finding a job, and the ones that are training advanced endoscopy fellows are finding it hard to place their fellows in a good advanced endoscopy practice. I think our overall impression is, especially if you pick big institutions who already have three, four, five or more faculty who are doing advanced endoscopy (our institution already has four advanced endoscopists), then you

may not get the volume or complexity that you should have after a good advanced endoscopy training; volume is a must to keep up your complex procedure skills.

The fact is that there is still a need for people really interested in advanced endoscopy, but these people should focus on locating themselves in the areas that truly need these services. That is the only way to keep up your skills and volume in performing these complex procedures. When you are first starting out, only bite off as much as you can chew. Do the procedures that you are trained and proficient in and avoid complications. Make sure the procedure is truly indicated. Currently at our center we annually perform approximately 2,500–3000 advanced endoscopic procedures among four therapeutic endoscopists. Currently there is no recommendation in the United States for the minimum number of procedures to maintain proficiency in EUS or ERCP but I feel, just like in any other procedure-related field, that the greater number of procedures you perform the better.

Do you think that will change the number of programs that are training advanced endoscopy fellows?

SK: I don’t know if our study will change the number of programs, but I do feel that we need to train the advanced endoscopy fellows that have a defined plan as to where and how they are going to use their newly acquired skills.

Where are they going to go?

SK: The thing is, most people want to stay in the already-oversaturated big cities and big programs. Then the frustration comes as to where are the patients and procedures and how are they going to keep up their skills. Identifying national and international

“Administrative time as an interventional endoscopist is extremely hard to protect because there are always urgent ERCP or EUS procedures that need to be

“advanced endoscopy underserved” markets is a first step, and to accept trainees who would then commit to serving these regions more meaningfully, as opposed to oversaturating already-advanced endoscopyheavy markets. This will help redistribute the advanced endoscopy skills to moremeaningful and -needy areas.

Any particular things to ask for when negotiating a contract for an advanced endoscopy position?

SK: I would first say to join a practice or hospital that you feel has enough volume, infrastructure and multidisciplinary surgical and oncology teams to support your advanced endoscopy practice. Negotiation depends on what your expectations are from the practice and how you want to shape your career. Overall, I would say discuss your relative value unit (RVU) expectations, secretarial support, mid-level support, if available, and the last thing would be the reimbursement. Your RVU requirement will certainly be higher than the general GI guys in the practice, but keep a realistic goal. Negotiate your time off. How many days are you going to be doing interventional procedures? How much administrative time are you going to have? How much clinic time, and how much general GI you are going to do? The key is to try to be a part of a high-volume center, especially if you want to continue doing the complex work for which you are trained. Discuss how you want your practice shaped. What do you want to do? Do you want to focus on EUS or ERCP, Barrett’s, bariatrics—that’s a big one now—if you want to pick a sub-sub niche in endoscopy, or do you want to do all things therapeutic? Discuss how will you build your practice—what is the group’s plans for outreach and getting a word out in the community to help get you the referrals? Meet with the surgical and oncology teams to discuss your expectations and plans for partnering with them.

This wasn’t on my list of questions, but now that I see you and know that you are six months pregnant, how is that impacting your practice?

SK: All of my referring providers know that I’m not doing ERCPs right now. Even if the ERCP gets referred to me, I send it to one of my three interventional partners. I continue to do EUS-FNA,

Barrett’s endotherapies and enteroscopies. It was a personal decision, and I just chose not to do any fluoroscopic procedures during my pregnancy. I am not even taking biliary call right now, which increased my three interventional partners’ biliary call volume, but they have been extremely understanding and supportive.

“ The fact is that there is still a need for people really interested in advanced endoscopy, but these people should focus on locating themselves in the areas that truly need these services.

”

As a women in interventional endoscopy, I can say that getting that balance and expanding your family is difficult, but you have to get your priorities right. For me, right now, it is my kid, and I had to slow down a little bit. When I go on my two-month maternity leave, they have to block off my schedule, which is so hard for my secretary to plan right now because of my busy interventional practice. But, that is something that the entire staff is extremely supportive of, and we are working together to make it happen. It all falls in place, you just have to voice it. The show will go on, the work will always be there—that is one thing I have realized. You think, “What is going to happen with the schedule and the procedures?” But, it all works out and falls into place. And I will be back.

The patients will still be there.

SK: The patients will still be there. Knowing our volume there will probably be more patients. But, I will have had my baby and, for me, that is the most important thing right now. You have to prioritize and balance your work and life. Decide what’s important at the moment. After I am back from my maternity leave, I return to my full-time advanced endoscopy job, our advanced endoscopy nurses course that will happen in April 2017, my role as Co-Director of the ACG Regional Hands-on Workshops, and all of my other commitments to the endoscopy unit as well as nationally. The efforts at achieving a work-life balance will continue on a daily basis.

1 Granato CM et al. Career prospects and professional landscape after advanced endoscopy fellowship training: a survey assessing graduates from 2009 to 2013. Gastrointest Endosc 2016; 84:266-71.

 READ MORE INTERVIEWS in the Conversations with Women in GI series: acgblog.org

Millie D. Long,

MD, MPH, FACG,

on Building a Successful Career in Clinical Research

By Jill Gaidos, MD, FACG

WWHEN DR. MILLIE LONG came to the Virginia Commonwealth University to lecture at our Division of Gastroenterology and Hepatology Grand Rounds, she and I took time to sit in the faculty lounge and discuss her career in clinical research.

You completed your gastroenterology fellowship at The University of North Carolina at Chapel Hill (UNC) and while you were there, you also completed a fellowship in preventive medicine and obtained a Master’s of Public Health (MPH) in epidemiology. What was the timeline of your training? Were these overlapping with your GI fellowship training?

ML: So, it was overlapping. I actually went to UNC for the specific intention of joining their clinical research track so that I would get my MPH during my fellowship training. When I started, I started out on research when I first arrived and was able to get my MPH in the first 18 months of my fellowship. I still did some clinical work during that 18 months and then finished out my clinical fellowship over a three-year time span. My research at that point was in inflammatory bowel diseases, of course, and I was very interested in prevention. At UNC, they also offer a preventive medicine fellowship, which is typically a two-year fellowship but, because I already had my MPH, it could be shortened to a oneyear fellowship. At that point, I wanted to do advanced inflammatory bowel diseases.

I was actually the first to do that at UNC, believe it or not, as we didn’t actually have funding for a fourthyear fellowship at that time. By doing the preventive medicine fellowship and focusing all my research in inflammatory bowel disease (IBD) on prevention, I could also do an advanced IBD year. It worked out very well for me because I did have protected research time during both my fellowship while I was getting my MPH and during my fourth year. This allowed me to focus on writing, publishing and preparing my career development award in anticipation of becoming faculty. At the start of my fourth year, with my mentors, I decided that I wanted to apply for a position at UNC, and I ended up staying on faculty.

Were you on a National Institutes of Health (NIH) T32 grant? Is that how you were able to get funding for your research time?

ML: I was. I was on a T32 grant during my GI fellowship and that allowed me to get my MPH during that time and also do clinical research. Once I was in my fourth year, I was actually funded by our Division of Preventive Medicine. It’s primarily a research year, so there’s some practicum involved. It was actually a really interesting experience. The VA’s National Center for Health Promotion and Disease Prevention is located in Durham. I had a joint appointment that year where I did some practical work with the VA and I did some research. We published a paper looking at modalities of colorectal cancer screening. At that point, they were doing some of the guideline development for various screening and preventive testing, and I focused on those that were GI-related. I was able to work at the VA, not in a clinical position, but rather doing all research, administrative and policy-type work. I was there for a few months during that year, which allowed me to meet some of the requirements for the preventive medicine fellowship, working on policy, but also was pertinent to my career from a GI standpoint. It was a nice collaboration. I really enjoyed it, actually. It was fun to work with the VA. We don’t have a VA at UNC.

So, you miss those patients?

ML: Yes, I miss those times.

What drove you to complete these additional training degrees? How has this additional training helped your career? Or, do you think it has helped?

ML: I think it really has. I went into gastroenterology with the heart of an internist, I believe. When I recognized that I wanted to do inflammatory bowel diseases, I really wanted to focus on, not just the GI tract, but all of the complications that can arise. Focusing on prevention really became a way for me to take a holistic approach to the patients and offered a way for me to focus on what I loved about internal medicine.

I saw that IBD prevention was an arena where there was not as much research at that time. The focus was very much more toward managing the GI manifestations of the disease. This allowed me to have an arena where there was not a lot of prior literature, where I could focus on the complications of some therapies, and the means by which we could prevent those. For example, we did work delineating the skin cancer risks of medications that we use in the treatment of inflammatory bowel diseases. This allowed us to start to move toward policy recommendations to help with prevention of those complications. Other work we did focused on risks of infectious complications and vaccinations. I believe that where the preventive medicine fellowship was very helpful was in recognizing that we really have to have the right level of evidence to be able to apply preventive recommendations and truly understand the policy behind those. It is

important to know what evidence base is needed to implement preventive recommendations and move the field toward eventually preventing complications. That has been valuable for me.

I don’t see myself practicing as a preventive medicine specialist, but I do see that these themes have helped with both my research and my clinical care. We have actually implemented several different quality improvement mechanisms within our own IBD center that lend themselves toward improving the prevention of complications.

Your publications range from looking at the role of nonsteroidal anti-inflammatory drugs (NSAIDs) in IBD flares (J Clin Gastroenterol 2016;50(2):152-6), to hormonal contraception use and the risk of DVT in IBD patients (Inflamm Bowel Dis 2016;22:1631-8), to the risk of IBD flares with avoidance of dietary fiber (Clin Gastroenterol Hepatol 2016;14(8):1130-6). How would you describe your research focus, or do you define your research in any way?

ML: I do. I focus it on prevention. One theme is studying the modifiable risk factors for relapse of disease. For example, the use of NSAIDs is a modifiable risk factor to help to prevent relapse of underlying Crohn’s disease. Dietary management could be considered in the same fashion. This is similar to the work I’ve done in vaccinations and skin cancer and infectious complications of therapies—I look at all of those as potentially preventable complications. And so, that’s where the theme lies. It’s very different because it’s crosscutting in terms of a theme. You’ve also mentioned a paper we did looking at DVT risk factors. By recognizing those risk factors and modifying the form of contraception for those women, we could potentially prevent pretty significant complications down the road. It has been fun to work epidemiologically on all angles of prevention.

“In many instances, it takes small steps to get to your ultimate goal… This is the role of good mentorship—to help, no matter where you are in your career, to kind of ground you. A mentor can say, ‘OK, if that is where you ultimately want to get, here is what we need to do to get there.’”

How do you get your fellows to ask questions about contraception and Pap testing? We see about a quarter of women in our IBD clinic at our VA hospital, and getting fellows to ask about Pap smears has been a challenge.

ML: It doesn’t really cross their mind. But I think that once they’ve been through the clinic, they do understand the importance of that. I think that the EMR is an avenue toward helping us with reminders to ask those things. I know that each EMR is different, but within each structure there are opportunities to build smart forms or reminders therein. Now, of course, if you are seeing a patient who is in the midst of a terrible flare, you are concerned for an abscess, you are scanning them, your admitting them, you’re making pretty significant medication changes. That’s not the time where I address those factors. But I do emphasize to patients that I really want them to follow regularly even when they are feeling well because it’s during those times that I focus on the health maintenance. It’s not that it needs to add to every visit, but I think it does need to be on our radar once a year to review those factors just so we can help to optimize their therapies and potentially prevent either an intestinal or extraintestinal complication such as a malignancy or a flare of disease, an infection, any of those factors.

You are among a group of IBD providers who recently published on the obstacles to investigatorinitiated studies in IBD (Inflamm Bowel Dis 2016 Sep 2 epub). What obstacles have you personally faced in your research career, and how did you overcome them?

ML: I believe that there are a number of obstacles. Some of the hardest ones include the fact that all research comes out of a clinical scenario. You see a patient, and you think to yourself, “How could I help this patient?” or, “How could I have helped this patient earlier to prevent what is going on now?” In many instances, there are

some great ideas, but the feasibility and costs play a huge role. Particularly at a junior stage in your career, but really any time in your career, if a study is not feasible because of the cost infrastructure, then you are not going to be able to complete it. And so, I believe that understanding those limitations is very important. In many instances, it takes small steps to get to your ultimate goal. In looking at a five- or a ten-year view, even a simple study using claims data to look at the incidence or prevalence of a condition can be valuable. This can be pilot data before launching into that expensive prospective cohort or eventually a randomized controlled trial. Each smaller study is a step on the ladder to get there. I think that reaching too high at first can be a real obstacle. This is the role of good mentorship—to help, no matter where you are in your career, to kind of ground you. A mentor can say, “OK, if that is where you ultimately want to get, here is what we need to do to get there.” Another obstacle is time, of course. I think many of us are very busy clinically, and we have other responsibilities as well, whether that be teaching or many of us are involved in the medical school curriculum, and so really being able to set that time aside and focus on what your ultimate goal is to move those small projects forward is very important.

What advice, recommendations or tips for success would you give to either new fellow graduates or junior faculty who are interested in a career in clinical research?

ML: I believe the first thing I would recommend is that education and training are key. Not everyone has the opportunity to get an MPH, but I think it’s a very valuable degree. Certainly, there are often short courses and other ways to help with understanding the methodology in clinical research that can be very valuable. The one thing that helped me a great deal was not only having the clinical epidemiology skills, but also some biostatistics training early. You don’t always have access to a biostatistician who can do

all of your analysis for you when you are early in your career. Luckily, I had the training to be able to do that myself, which allowed me to have sort of a leg up, and the rest follows.

Even if you don’t have the ability to obtain those skills personally, I think joining forces with another faculty member can be valuable, whether that’s a colleague or a faculty member more senior to you who has these skills. For example, we have a junior faculty member at UNC who had a great idea for a project but didn’t have that training himself. I have worked with him to develop the aims and the data source for this project and, in this instance, I did the analysis for him and then he has taken it from there. Really the collaborative aspect of research is that you can find collaborators with those necessary skills, so you do not have to be the expert in everything. This leads to the discussion of mentorship, which is incredibly important and identifying a mentor early can really help you with career, life balance, all of those recommendations, but also help to track out a path toward an ultimate goal that may be clinical research funding through foundations or the NIH. A mentor can also make sure that you stay on a timeline to get where you want to be.

In addition to your research, you also serve on the ACG Research Committee. What are your responsibilities as a member of the Research Committee?

ML: I love this committee. I’m in my sixth year on the ACG Research Committee, so I’m about to leave this committee. We review all of the grant applications for ACG. We review them in a way similar to the NIH in a study section with content reviewers, methodology reviewers, we score these applications accordingly. The most fun part is we get to hand out a lot of money every year to really deserving faculty members. Some of the favorite grants I review are the junior faculty career development awards which,

based on the recommendations from our committee over the past five to six years, have really increased in the amount of funding. These are now three-year grants, where previously they were two-year grants, and they are now $100,000 per year, to really allow the junior faculty recipients to buy back their own protected time, but still have the necessary funds they may need from a research standpoint. This has been incredibly valuable.

The ACG has actually published the impact of these grants on the recipients over the years, and it’s demonstrated that many recipients have gone on to quite successful research careers. I believe it’s really wonderful to be a part of that process. The other aspect of the ACG Research Committee I love is that it’s multidisciplinary. And, so that’s how I know the pancreatobiliary folks around the country and that’s how I know the hepatologists. It’s a great way to get to know people that you wouldn’t normally get to know in your specific content field. I would strongly encourage anyone who is interested to reach out and apply to be a member of an ACG committee, whether the Research Committee or another, just because of this ability to network and meet wonderful people and learn a lot. I learn a lot from all the grants I review each year, and I’ve found it to be very valuable.

What is the most important thing in the grant that you are looking for? Is it the clinical question, or the feasibility or the support? What are you looking for?

ML: It depends a little bit on what the grant is for. I would say for the career development awards, it’s actually much more about the applicant and the environment than it is about the specific scientific project. If we, based on the application, see someone with a lot of potential and a great mentorship and the project is good and feasible, then that’s the person we are going to go with because it helps so much to build that career, and we have so much confidence in a great environment, someone who’s put together a good mentorship team.

The clinical research grants, on the other hand, are actually all about the research, of course. I believe a key aspect there is having pilot data to show us that you can do this work, and having a well-developed clinical question with good methodology, measurable outcomes and, importantly, that it’s feasible. Sometimes the idea is extraordinary, but it’s just not going to be feasible on the small amount of money that we have available, which makes it very hard for reviewers to give that grant a high priority. So, anyone thinking of applying for an ACG research award should focus on those aspects.

For someone who doesn’t have a lot of research experience, there is some hesitancy to join the Research Committee because how can you review these protocols if you don’t have that background. Would you discourage someone from joining this committee in this setting?

ML: It would be good to have some publications under your belt, and to understand the content area. Even writing systematic reviews of a content area and becoming a content expert can be very helpful in terms of reviewing those grants. The other thing is that there are a large number of committees through the ACG and, really, being involved on any committee can be a valuable experience. I think that the support and camaraderie are amazing. I’ve actually had collaborative research projects arise out of working with people that have been on the Research Committee with me. I believe that all of those aspects are true of every ACG committee. I wouldn’t limit yourself to any one area, I guess is what I’d say. If you feel that you are not yet ready to be on a certain committee, then aim for another committee and try to gain the skills necessary to put yourself on other committees in the future, if that’s ultimately what you are interested in.

You are also the Associate Editor for the IBD section of The American Journal of Gastroenterology. What

special training, if any, do you need to be an editor? Is this a position you applied for or were you nominated/ appointed?

ML: You are invited by the editors to be involved in a journal editorial board. And generally, that is based on content expertise, prior publications in the arena, but probably most importantly on reviewing manuscripts and how well you do reviewing

for a decision on that manuscript. The Board determines whether the manuscript needs further revisions, whether we would like to publish it, or perhaps it might not be the right fit for the Journal. From this process, in and of itself, I feel like I’ve learned a lot. In the same setting, as with the ACG Research Committee, it’s a multidisciplinary board, and I’ve met a lot of people from the colon cancer

“The most fun part [of the ACG Research Committee] is we get to hand out a lot of money every year to really deserving faculty members.”

manuscripts. I believe many people are asked to review manuscripts for various journals, and I would strongly encourage you to do that because, not only can you learn from the process, but you can provide a valuable service for the authors in terms of improving their manuscript.

Just in the act of reviewing, you do a literature search, you really try to understand where that paper fits in the field and then write a detailed review. This can also help you, as your literature search may inspire you to look at a different factor and do your own systematic review based on an idea you generate from your review preparation. Prior to being an Associate Editor for the Journal, I did a lot of reviewing for the Journal and for other journals. I think that experience makes you a better editor. And now, I get to do the fun work, which is reading a lot of really interesting papers that are sent my way, sending them out for review, and then using the reviewers’ expert opinions to present back to the board

world, from the hepatology world, and from other silos. What is really interesting is that we share a lot of the same opinions in regards to the methodology of the papers. So, even though I’m not a content expert in hepatitis C, I can certainly add my opinions based on reading a paper from a methodologic standpoint, the outcomes they used, whether or not I thought those were valid. It’s nice to be able to have that cross-disciplinary conversation about a paper.

 MORE INFORMATION on ACG's Committees is available at gi.org/committees