PSG Rumblings Newsletter Summer 2020

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Rumblings SUMMER 2020


President’s Message / Ravi K. Ghanta, MD, PSG President

Dear Colleagues, Summer has arrived and with the change of season we have also experienced tremendous changes to our lives and our practices as a result of the COVID-19 global pandemic. As of this writing, the Pennsylvania economy is slowly opening up and medical practices and outpatient endoscopy centers are finding optimal ways to allow patients back into these facilities.


For the past few months, medical practices, whether private or hospital based, have seen drastic reduction in patient volumes to their office and outpatient endoscopy centers. Office visits were significantly reduced, and most endoscopy centers had come to a standstill.

The PSG along with the Pennsylvania Medical Society advocated for the approval of and reimbursement for telemedicine. Although not optimal, telehealth did allow for us to continue taking care



of our patients and at least receive some form of compensation for our needed services. Unfortunately, this was not the case for our endoscopy centers in which many facilities were completely closed and the ones that remained open were seeing only a small fraction of the usual volumes. As a result of the tremendous decline in patient visits at our offices and endoscopy centers, this has resulted in a crippling effect on the finances of these practices. This has led to a situation that most physicians have never seen. Layoffs and furloughs of not just staff members, but also of health care providers including physicians, nurses, and physician assistants. How ironic is it that we are facing perhaps the worst global pandemic of a lifetime, and the very people needed to care for patients are being laid off? Physicians who were not laid off were still impacted in many ways. They may have been forced to take significant pay cuts, lose vacation time, lose benefits, cover other medical services or even worse, they became ill from COVID-19. continued on page 2

2 President’s Message

5 F eatured Apps

10 Personal Finance

3 Physician Burnout

6 Legal Corner

12 Tech Update

4 FIT Update

8 Practice Mgmt Update

15 Free Educational Lectures

President’s Message

continued from page 1

The devastating impact was not limited to physicians in private practices alone. Large hospital systems were also forced to lay off hundreds of staff including doctors. As a procedural based specialty, gastroenterology has likely been impacted more than non-procedural based specialties simply due to the fact that a large portion of revenue is usually derived from endoscopic procedures which had abruptly declined. Healthcare systems and large practices may have the capital to sustain viability for a period of time, but there comes a point that even these entities will collapse under the financial strain. Many small practices have been hit the hardest since they may not have the reserves or resources to keep the business running. Fortunately, there were some government programs to help small businesses and were utilized by many of these practices. The PSG Practice Management team, chaired by past PSG President, Dr. McKibbin, had done a valuable job keeping abreast of all the changes that were impacting practices and worked hard to provide guidance to our members during this pandemic. In the past few weeks, we are now seeing a gradual reopening of practices and endoscopy centers

with the goal of doing this in a safe manner. The mood has also changed and seems more optimistic. However, we must be cautious and not be overzealous in trying to reach our pre-pandemic status too quickly. A terrible thing would be for another outbreak leading to further devastation. As a result of the uncertainty of this pandemic and our goal to keep our members and staff safe, the PSG Board has decided to not go forward with our Annual Scientific Meeting as initially scheduled in September 2020. This year’s course director, Jennifer Maranki, MD from Hershey Medical Center, had planned an exciting lineup planned with thought leaders throughout the state. It was a difficult decision to not have the Annual Meeting which has been a fall tradition for almost forty years. There was only one other time in PSG history that our Annual Meeting had to be cancelled and that was in 2001 in light of the horrific September 11th terrorist attacks. Although disappointing, we are optimistic and will plan to have the conference in 2021 with Dr. Maranki as Course Director. Although the COVID-19 pandemic has created havoc in our lives and

our practices, our experiences during this time were not all negative. For many of us, it has given us time for reflection and appreciation for relationships and to look at life from a renewed perspective. As doctors, we are privileged to be entrusted with patients’ health which is the most valuable thing one can have. This pandemic has strengthened our appreciation for the profession that we have chosen.

At PSG, we are grateful to be on your side and appreciate all of your hard work. If you are already a member, we thank you for your continued support. If you are not a member, please consider joining so we can continue to support the interest of our specialty and our patients. Together, I am confident that we will get through this storm with renewed passion. Respectfully,

Ravi Ghanta, MD President Pennsylvania Society of Gastroenterology


How to Take Action Against Physician Burnout By Lawrence John, MD, President of the Pennsylvania Medical Society Our work as physicians is extremely rewarding. But the demands of today’s health care system can also create stresses that lead to burnout. It’s important that we find a balance. Physicians are constantly asked to perform many demanding tasks without the needed support to accomplish them. Studies have identified a multitude of different factors that contribute to physician burnout. You can certainly relate to some of these factors, such as: • Spending time on the phone with prior authorization peer-to-peer appeals instead of spending time in an exam room with patients. • Losing sleep over paperwork, patient satisfaction ratings, RVU requirements, quality measures, MIPS, and MACRA. • Pajama time at night completing patient notes with your computer instead of quality time with your family. • A sense of loss of control with the demands of an overwhelming workload. How can we achieve wellness and resiliency?

On an Individual Level

On an individual level, burnout is recognizable, reversible, treatable. From a personal perspective, there are steps we can all take to address stress and anxiety, such as: • Be a part of organized medicine, such as the Pennsylvania Medical Society and the Allegheny County Medical Society, so we can stand with a united voice as the government and insurers continue to edge into our exam rooms.

• Identify your stressors and take action to reduce them. As a two-physician family, my wife and I struggled at dinner time – we were tired, hungry, and wanted to connect instead of spending time in the kitchen. So, we hired someone to prepare healthy meals for our family when our children were younger. This enabled us to enjoy meals together without the stress of cooking. • Unplug from technology and connect with loved ones. Keep a good balance between work and home by spending time with family and friends doing things you enjoy. • Get enough sleep. Set a bedtime and honor it, realizing that you can finish what you were working on tomorrow. • Take mindful minutes throughout the day. Doing a few yoga poses, a 10-minute meditation, listening to your favorite music, and taking a few deep breaths can give you a quick reset. Try things out to see what works best for you. • Build physical activity into your daily routine. Movement increases your energy, releases stress, and improves your mood. • Eat healthy food, drink water, and avoid excessive alcohol and caffeine.

On an Organizational Level

Organizational involvement is key in re-engaging physicians and reversing the trend in burnout.

There are many things organizations can do to address burnout, including: Get organized • Educate and increase awareness Assess your needs and prioritize • Designate time for reflection • Identify your organization’s core values • Envision your organization’s culture Anticipate obstacles • What resources do you have? • What’s realistic for your organization? • What do you need to do to foster employee buy-in? Engage leadership • Teach practical skills • Build community • Incentivize physicians to get involved Stay accountable • Improve workplace environment, promote flexibility and work-life integration • Provide resources to promote resilience and self-care • Keep talking about it—Make it a continued priority, not a once-anddone discussion During my presidency, I will continue to work with PAMED leadership and staff to provide resources and education that can help you determine the best ways to mitigate signs of burnout. The solutions will require more than yoga and mindfulness training, although these are effective practices for some of us. I invite you to join in the conversation at “ We are all here to develop a life more beautiful, more concordant, more fully expressive of our own sense of pride and joy than ever before in the world.” —Fronk Lloyd Wright


FIT Update: Life After Fellowship, Finding the Right Job for You Aaron Martin, MD


Most fellowship curricula are

focused on training fellows to manage disease and perform procedures with little guidance regarding career development. After a decade of centralized applications and match algorithms many fellows are lost when it comes to their first job search. I created this guide to provide an action plan and timeline for gastroenterology fellows at all levels preparing for their future careers.

First Year of Fellowship

Find a mentor. You have heard this countless times during your medical training, but when it comes to career planning finding a mentor is a necessity. A career development mentor will help you set goals, form a timeline, make connections, and, not only expose you to various career paths, but also help you identify the best fit for you. Finding a mentor can be challenging, but the inpatient heavy first year allows the opportunity to work side-by-side with multiple faculty members. Identify someone who has experience navigating tough career decisions and with whom you enjoy spending time.

This will allow for comfortable, open communication as your mentor assists you in choosing the career path that is right for you.

must. Talk to your mentor who can provide experience and knowledge regarding career expectations to assist you.

Second Year of Fellowship

Prepare a professional curriculum vitae (CV). A strong CV will be your most effective marketing tool when searching for jobs. Tailor your CV to highlight your strengths, interests, and future aspirations. For example, if you want to make teaching part of your career, make sure to highlight any teaching experiences, awards, or lectures you have given. Ideally, this should be completed in the spring of your second year. Before long, faculty and practices will start to approach you about your plans after fellowship. It is important to have your CV prepared for when the time comes so you do not feel rushed and do not miss any potential opportunities.

Do some soul searching. While some trainees enter fellowship with predefined career goals, many fellows are unsure which career path best fits them. Take the time to evaluate and prioritize your personal and professional goals. Be honest with yourself. You have worked hard to get to this point; your job search should be focused on what you want and what makes you happy. Here are some questions to get the process started: 1. What do you enjoy most about your job? Seeing complex cases in the hospital, developing long-term patient relationships, performing procedures? 2. What motivates you professionally? Patient care, education, research? 3. How much financial and professional success are you willing to sacrifice to have more personal time or more time with family/friends? Use these questions to identify your ideal practice setting and envision a work-life balance that works for you. If you are primarily motivated by patient care, private practice may be a good fit. If you want to make teaching or research part of your career, an academic affiliation is a


Third Year of Fellowship

Gather contacts. Unlike the residency or fellowship match there is no centralized directory containing information and contacts for potential employers in your area of interest. You need to create one. Talk to your mentor, faculty members, and recently graduated fellows to compile a list of practices and institutions. Identify a contact person and contact information for each potential employer. Once you have exhausted the process of making connections through mentors and colleagues, you can explore other channels such as advertisements in medical journals, job fairs at national meetings, or physician recruiters. Write a cover letter. A cover letter is your chance to introduce yourself to potential employers and present your future aspirations. You will send this letter, along with your CV, to all

potential employers. Use the cover letter to highlight important pieces of your CV (i.e. research or a teaching portfolio), explain any gaps in your training, and express your interest in that particular practice or institution. The letter does not need to be tailored for each individual practice, however, if you choose to apply to both private practices and academic institutions you should have a separate letter for each field. Aim to have this completed by the end of June entering your third year. Start contacting potential employers. This process usually starts June/July at the beginning of your third year. Ask a mentor or faculty member to introduce you to or help establish contact with potential employers. If they are hiring, they will ask you to follow-up with your cover letter and CV. If you are unable to connect with employers through colleagues, do not be afraid to “cold-call “or “coldemail.” Although “cold-calling” is challenging and may seem strange, it is effective, and most practices/ institutions are accustomed to it. If you decide to send an email, make sure to attach your cover letter and CV for reference.

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Career development is an essential part of fellowship that is rarely emphasized in training programs. I hope this action plan provides current and future fellows with a basic rubric for the job search process. Fellows please stay tuned for more practical guidance from the PSG Training Task Force lead by Dr. Harshit Khara.


Legal Corner

Telemedicine & Legal Issues Beyond COVID-19

Richard E. Moses, DO, JD

ACOs are established networks that coordinate patient care and become eligible for bonuses when they deliver that care more efficiently, i.e., when they save money. Telemedicine has played a strong role in cost saving under this model with the best example being patients with Inflammatory Bowel Disease. Most private insurers have been reluctant to reimburse, however, for telemedicine delivery. States also had individual restrictions although these have been loosened over time. @therealgidoc

A ccording to the American

Telemedicine Association, telemedicine has existed for approximately 40 years. Telehealth refers to a broad range of technologies and services to provide patient care and improve the healthcare delivery system as a whole. A few telehealth examples include remote patient monitoring of vital signs, ECG, blood pressure, oxygen level, transmission of medical imaging, and educational services. Telemedicine is a form of telehealth. This refers to remote doctor-patient consultations using technology. Telemedicine makes it possible to treat patients whenever and wherever the patient is via electronic media such as a computer or smartphone. The Affordable Care Act (ACA) promoted telemedicine in order to enhance healthcare delivery in rural areas. In an attempt to reduce healthcare costs, the ACA encouraged physicians, hospitals, and other healthcare providers to establish Accountable Care Organizations (ACOs) in the Medicare program.

Telemedicine has grown exponentially over the past 5-10 years in some specialties of medicine and geographic areas of the United States. The COVID-19 pandemic imperiled our country and the world. As the pandemic spread in the US from SARS-CoV-2, the Centers for Disease Control and Prevention (CDC), public health agencies, and health insurers recognized telemedicine could be utilized to help prevent a surge, by allowing patients continued access to care, with minimal exposure. COVID-19 has rapidly and drastically elevated telemedicine as a care delivery platform due to the need to take care of patients despite the universal lock down of our country. Telemedicine platforms were ideally situated to help patients during the pandemic. The Coronavirus Aid, Relief, and Economic Security (CARES) Act significantly loosened the federal restrictions on telemedicine temporarily. This included the Office of Civil Rights temporarily pulling back some of the HIPAA restrictions during the COVID-19 pandemic. The Coronavirus Preparedness and Response Supplemental


Appropriations Act of 2020 (CPRSAA) is an emergency aid package that, among other things, expanded access to telemedicine for Medicare beneficiaries during the coronavirus public health emergency. CPRSAA permitted the U.S. Department of Health & Human Services (HHS) Secretary to take action broadening the circumstances under which Medicare will reimburse healthcare services provided via telemedicine. Many states and many insurers also liberalized their policies on telemedicine due to the COVID-19 pandemic. There are a number of medicallegal issues regarding telemedicine delivery. Although the COVID-19 pandemic “bent the rules,� once the pandemic measures have been lifted, we will likely return to the former laws and issues controlling telemedicine.

State Laws and Licensure

The telemedicine visit is defined by the originating site (location) of the patient. If the patient is in Pennsylvania, that is the state where the televisit took place. This means that the healthcare practitioner must have a valid medical license in Pennsylvania. Physicians practicing telemedicine across state lines will need a valid medical license in the state in which the patient is located.

State laws dictate whether physician assistants and nurse practitioners can practice telemedicine in a particular state. In addition to state licensing requirements, practitioners must also comply with state and federal laws regarding telemedicine. Consultation with a health law attorney is mandatory as state and federal telemedicine laws and licensing requirements vary and continue to evolve.

Privacy and Security

Privacy and security risks are a major concern. The HIPAA Privacy Rule provides federal protections for personal health information (PHI) held by covered entities and gives patients an array of rights with respect to that information. The Privacy and HIPAA Security Rule need to be followed. Telemedicine creates potential vulnerability for providers with regard to malware and hacks. Passwordprotected screensavers, encryption, and other safety measures can help keep information safe, while unsecured devices and systems such as cellphones, laptops, and email can result in security breaches.

Informed Consent

Informed consent must be obtained prior to the telemedicine visit. Many states require physicians to obtain informed consent from patients before a virtual visit begins. The discussion must include disclosure of information about the telemedicine system, the potential risks and benefits of telemedicine, and equipment and technology limitations. The provider who is ultimately responsible for care should obtain and document the patient’s oral or written informed consent prior to the telemedicine encounter. The patient should agree that telemedicine is appropriate for that particular visit and understand that he or she may stop the televisit at any time.

General Thoughts

Telemedicine has its limitations. For example, healthcare providers are unable to listen to a patient’s lungs without specialized equipment.


You need to have a plan in place regarding which medical conditions practitioners are comfortable treating remotely, and which require in-person visits. There should be processes for when and how to escalate treatment to a face-to-face visit or send the patient to the ED. It is also important to develop a comfort level with the telemedicine equipment and platform before communicating with the patient. There are certification and training programs that have developed for telemedicine delivery.

Although there is little debate about the value of telemedicine visits to patients, the community, healthcare organizations, and healthcare practitioners during the COVID-19 pandemic such that many of the restrictions and rules have been relaxed, realizing the key areas of exposure is essential to mitigate risk. It is unclear at this time where and how telemedicine will fit into healthcare once the COVID-19 pandemic is under better control and we are back in our offices with patients full time. Until then, we are fortunate that telemedicine has been available during the pandemic.

Practice Management Update

Time to Update your Practice Insurance Contracts Ralph D. McKibbin, MD, FACP, FACG, AGAF


“ You don’t get paid for the hour. You get paid for the value you bring to the hour.” — Jim Rohn, American entrepreneur, author, and motivational speaker

The COVID-19 worldwide crisis is

fundamentally changing how we conduct business. In the private sector, online shopping and work from home are becoming much more common. In office practice, telemedicine, for example, is common and likely to remain. As we emerge from the initial crisis stages and work to restart our practices, we often hear comments such as “I can’t wait to get back to normal.” This is likely never going to happen. What is coming is the “next normal” which will not be identical to the old days. Periods of crisis are known to accelerate disruptive change and we can expect that

over the coming years there will be progressive changes to both our personal and professional lives. Our clinical practices will change with such things as more telehealth, PPE, handwashing, and patient screening. On the practice management side, we can expect such things as employee temperature screening and required sick time utilization. We should also expect regulatory and legislative changes designed to raise money for strained governments, increase insurance carrier reserves, expand employee paid time off and FMLA issues. Patient access to care limitations are also accelerating. We need to manage these practice overhead issues, but it is, perhaps, more important to remember that we also need to change our relationship with our payers and insurance carriers to keep our contracts from becoming outdated. Automatic contract renewals can leave us unaware that we are leaving money on the table. Contracts also contain important provisions covering claims payments terms, medical necessity, appeal processes, notification for policy changes, credentialing requirements, termination, etc. Static payments and rising overhead leads to thin margins. A continuous or scheduled review of existing contracts is best to stay on top of our payer contracts to minimize restrictions and to keep our payments up to date but a review at this time is needed. The process of contract negotiation can be summarized as 1) review of existing data 2) analysis to determine goals and leverage and 3) the negotiation.


The Review:

It is important to invest time and energy in proper preparation. The team that will be involved should become familiar with the definitions of terms and state contract requirements and gain understanding of the position of each health plan and its place in the regional market. Information gathering should be approached with the use of checklists. The core areas include contract basics, carrier data, financial data and practice service and quality data. The American College of Gastroenterology (ACG) has toolbox articles which identify core areas for review. Other sources include the PAMED, AMA and practice management groups such as Medical Group Management Association (MGMA) and the American Association for Physician Leadership (AAPL).

The Analysis:

A focused review of the data and a detailed discussion should be done with the intent of answering two questions: What do we want to negotiate? What is our leverage? Choose several concrete goals and prioritize which is most important. Reviewing existing contracts for such items as days the payer has to pay the claim, claim denial dispute procedures, the fee schedule, notice periods and contract renewal options will identify contract provisions and clauses that need to be negotiated. Determining your leverage is necessary to determine your value in different areas. As noted in the quote from Jim Rohn, this is how

PSG SoMe Update you can negotiate for the best rates and terms. You must differentiate yourself and show your value to the carrier, the patients, and the community if you wish to be fully compensated. Examples of leverage are caring for a large percentage of the carrier’s patients, high quality, and low costs. Contract negotiating guides will expand on these concepts.

PSG Social Media Ambassador’s have been working hard to generate meaningful content on our Facebook, Twitter and Instagram. Since the launch of our Social Media Ambassador program in March, the Ambassador’s have covered content on COVID-19, Telehealth, IBS and Celiac Disease Awareness, and more! Engagement on our social channels have increased exponentially since the launch of the Ambassador program, and we are excited to continue that forward momentum with the advent of some new features you will start to see on our social channels very soon. In the meantime, remember to follow @PAGastroSoc on Facebook, Twitter and Instagram to see what our Ambassador’s are up to! #PAGastro

The Negotiation:

It is important to realize that negotiation is a process. Many negotiation guides exist but basic principles are similar. Several meetings between you and the carrier are necessary so that each side can listen to the issues on the table and build a relationship. pre-established goals facilitate the needed give and take which result in final agreement. Contract acceptance in your practice may require a group approval, so this concrete list of prioritized goals developed at the time of review can help prevent stalemates. After agreement, a careful review of the contract for accuracy is needed. All terms should be defined in an appendix. A debriefing with the team helps define ways to improve the process for the next cycle. And finally, you should try your best to build a longterm relationship to facilitate future negotiations. It is expected that major changes are coming soon and we need to move now to successfully adapt to this next normal.

‘Celiac Update’ by Keerthi Kesavarapu, DO


$/Personal Finance Ravi Ghanta, MD, PSG President @RAVIGHANTA5

this has actually exposed many of the financial weaknesses prevalent amongst highly paid doctors.

As the saying goes, “when the tide pulls back, we can now see who is swimming naked.”

The COVID-19 pandemic has caused devastation not just from a health care point of view, but also economically. The global economy had come to a screeching halt as a result of the quarantine that has led to the downturn of most businesses including medical practices and endoscopy centers. Only now, after a few months of the economy being shut down, are we starting to observe an increasing volume of patients returning to our practices. The economic impact of the pandemic is not limited to private practice doctors alone but also to employed doctors in hospital systems. No one could have anticipated this in one of the most “stable” and “secure” professions. Physicians have now been experiencing significant pay cuts and, paradoxically, even layoffs. Financial security as a doctor is not guaranteed and not as certain as once perceived. As a result of the economic decline in the economy,

Consistently, gastroenterology as a specialty tends to rank in the top five to ten specialties with the highest salaries. However, this does not mean that GI specialists are immune to financial injury. It is highly unlikely that any bailout will come to the assistance of physicians and medical practices. Most GI doctors are unlikely to qualify for stimulus payments that many other Americans will receive. The public who perceive physicians as “rich” will unlikely be sympathetic to the economic woes that many doctors are facing. Gastroenterologists along with other procedural based specialists may have had the greatest financial hit due to the temporary shutdown of elective and non-urgent procedures which tend to be a disproportionate portion of their income. Unfortunately, doctors are in a mindset of trading time for money. In essence, most doctors can only make money when they are seeing patients. If there are no patients to be seen, they have no income. This is what is happening currently which has led to layoffs or substantially reduced salary. The doctors who are “weathering the storm” are those who have been very deliberate with saving and investing in assets that provide ancillary income. In this


for Physicians during the COVID-19 Pandemic scenario, they are still receiving different streams of income even if they are not getting their full pay in their usual physician job. The reality is that many doctors have a high salary, but sadly have low financial net worth. In fact, a large percentage of doctors have a negative net worth meaning their liabilities (debts) are more than their assets. To add insult to injury, doctors tend to be in the higher tax brackets giving up almost half of their income to tax. Doctors may have nice material things like fancy cars, primary residence, clothes, vacations, etc., but these things are liabilities, not assets. Oftentimes, you will hear that one’s primary home is one’s largest asset. Many experts believe that your home is actually a liability since it is more of an expense and does not produce income. Most people don’t have a net gain in value after calculating years of expenses that are incurred with a home. If your highest percentage of your assets are invested in your primary home, you may want to reconsider this. Unless, you live in one of the highest appreciating regions for real estate, the likelihood of growing wealth to a significant degree is unlikely with just your primary home. With a decline in income and even decline in retirement and other investment accounts, this has led to panic amongst many doctors, young and old. So, what should a

doctor do in this situation?

Most importantly, one should focus on the basics. Oftentimes, doctors are lured into complicated investments and insurance products without first doing the basic steps.

Many doctors are duped into investing in things that are heavily promoted as great investments with high returns. They are often taken advantage of due to their limited knowledge in financial products. I myself have been fooled on many occasions and now look at the financial industry with skepticism. In fact, I had invested in something that sounded so legitimate. However, I later realized that I had actually invested in a Ponzi scheme and lost my investment. My humble advice is to not believe everything that is being sold to you. You may receive fancy proformas and even legal documents that seem to bolster legitimacy. However, always be cautious and never over concentrate your funds too much in any one sector. Fortunately, the loss of my investment won’t impact me to a significant degree, but certainly leaves me a bit disappointed and paranoid at the same time. This is not to say that everyone in the financial industry is untrustworthy. However, it is imperative to do your own due diligence and to not simply chase the next “hot” investment just because a colleague or friend is doing so. During this pandemic, cash flow had been drastically reduced for many doctors. As a result, many had to sell investments in a panic just to maintain enough money to support their day to day needs. This brings me to the concept of “liquidity” which was especially important during this period when cash flow had gone down. Standard teaching says you should have 3-6 months of cash reserves. Much of

the advice one hears is from the mainstream media and targeting people with incomes far less than most doctors. The information is well intentioned but may not be pertinent to high income professionals. It is my personal opinion that doctors should have far more in cash reserves, perhaps at least a year’s worth at the minimum. This will result in less panic selling of assets in an inopportune time. It would be a “double whammy” to have to sell assets at lower values while income has also declined at the same time. Check your recurring expenses and see if there is anything that you could cut or lower. Put any major purchase on hold unless you absolutely need it. This is not the time to splurge on discretionary items like furniture, home improvements, expensive vacations, etc. Make sure that every dollar spent has an important purpose especially during these uncertain times. I have often found many statements by Warren Buffett to be quite inspiring and profound. As he states,

“if you buy things you do not need, soon you will have to sell things that you do need.”

This could be a golden opportunity to refinance student loans or your home mortgage. Indeed, mortgage rates have been hitting all-time lows. Reevaluate your investments and review your asset allocation. If you have lost sleep because of your investments, perhaps you need to adjust your investments based on your risk tolerance. If you are well capitalized and have


some “dry powder”, this may be a good opportunity to consider increasing your funds toward certain investments which may be at bargain prices. As they say, cash is king, and this may be ever more valid now. However, make sure that your emergency fund is well funded as discussed above. There are many people who have viewed the downturn in the economy as an opportunity. As Warren Buffett taught investors in the past,

“Be fearful when others are greedy and be greedy when others are fearful.”

The COVID-19 pandemic has had a tremendous impact on the personal finance of many people, including highly paid doctors. However, this has also exposed some weaknesses in the financial health of many. If one can weather this period of time and rebound with minimal financial and emotional damage, this may end up making one stronger and more prepared for the next “black swan” event. The content in this article is purely for informational purposes only and should not be construed as personal financial advice. Please seek assistance from your own financial professional.

Bariatric Endoscopy Tech Update: Revision of Endoscopic Sleeve Gastroplasty

Austin L Chiang, MD MPH, Director of Endoscopic Bariatric Program, Thomas Jefferson University Hospital Assistant Professor of Medicine, Sidney Kimmel Medical College of Thomas Jefferson University into question in recent months, and repeat procedures have also been undertaken to sustain gastric restriction.


Mirroring the rising prevalence

of obesity year after year, Gastrointestinal Endoscopy has included endoscopic bariatric therapies as one of the top ten advancements in endoscopy for the past few years.1 A variety of novel endoscopic treatments for obesity and metabolic disease have been developed for primary weight loss, such as a number of FDAapproved intragastric balloons or the endoscopic sleeve gastroplasty (ESG) which describes an endoscopic suturing procedure to reduce gastric volume. While the former offers no alteration to the anatomy, many patients opt for the latter procedure in hopes of more durable weight loss with endosuturing. The only study comparing the intragastric balloon to ESG showed that weight loss outcomes with the balloon were significantly lower the entire post-procedural follow-up period out to 18 months (when total body weight loss was 13.9% vs. 21.3%, p = 0.005).2 However, the long-term durability of ESG has been called

Weight loss outcomes of the ESG procedure have been demonstrated at a mean 18.6% total body weight loss (%TBWL) after 24 months, with 84.2% of patients achieving at least 10% TBWL according to a study of a study of 248 patients in 2017.3 One study examined the endoscopic appearance of the stomach after 6 and 12 months post-ESG.4 After 6 months, 6 (6.9%) were open, 38 (43.7%) were partially intact, and 43 (49.4%) were fully intact. Among those who underwent repeat endoscopy at 12 months (n=31), 10 (24.4%) had an intact ESG. As one may expect, weight loss outcomes differed by how intact the ESG remained. However, another case series also showed persistent reduction in gastric volume despite suture dehiscence even 2 years after ESG.5 The paucity of data in regards to revision after ESG is somewhat expected given how experience with the procedure has been limited to only the past few years. Out of 120 patients who underwent primary ESG (initial 44.4% excess weight loss [%EWL] and 18.3% TBWL), Boskoski, et al reported revision ESG in 4 patients for weight regain or insufficient weight loss. These patients achieved a mean additional 20.4% total body weight loss 6 months after revision.6 Lopez-Nava and colleagues also investigated 482 patients who


underwent primary ESG, 35 (7%) of whom either failed to lose at least 10% of their total body weight at 6 months, suffered a 3-month plateau in weight loss after losing at least 10% of total body weight, or regained a significant amount of weight after 1 year (≼10% total body weight lost with regain of 50% of maximal weight loss).7 The overall percentage of weight loss was greater among those patients who had suffered weight plateau (26%) compared to weight loss failure (11.2%) or weight regain (12%). The authors noted that the gastric luminal volume was near normal in those with either weight loss failure or weight regain, as opposed to retained restriction in those with weight plateau. How endoscopic revision of the ESG is performed appears to be variable. Boskoski, et al describe removal of old stitches with 4-5 new sutures placed in a triangular pattern in the revision procedure. No peri-procedural complications were reported with the revision procedure. On the other hand, Lopez Nava, et al describe avoiding removal of dehisced sutures and avoiding established mucosal bridges. Likely endoscopic revision of ESG, endoscopic suturing has been recently used in weight regain or plateau after laparoscopic sleeve gastrectomy. The laparoscopic sleeve gastrectomy has replaced Roux-en-Y gastric bypass as the most commonly performed primary bariatric surgery since 2013, accounting for a greater proportion of surgeries with each successive year. This proportion now exceeds 60% of all bariatric surgeries

according to estimates by the American Society for Metabolic and Bariatric Surgery (ASMBS) in 2018.8 ESG has also been used for revision of laparoscopic sleeve gastrectomy. Growing experience with endoscopic revision of surgical anatomy may further inform how to approach post-ESG revision. The high prevalence of obesity at 42.4% of the American adults reflects the challenging nature of disease management. Like other ailments in medicine, focusing on a single therapy is often insufficient. Close follow-up after ESG at regular intervals with a dietitian and other specialists is important to achieving a comprehensive treatment strategy. Likewise, offering adjunctive pharmacotherapy and paying attention to other obesity-related co-morbid illness help to ensure optimal outcomes.


1. H wang JH, Jamidar P, Kyanam Kabir Baig KR, et al. GIE Editorial Board top 10 topics: advances in GI endoscopy in 2019 [published online ahead of print, 2020 May 26]. Gastrointest Endosc. 2020;S00165107(20)34356-X. doi:10.1016/ j .gie.2020.05.021

5. R unge TM, Yang J, Fayad L, et al. Anatomical Configuration of the Stomach PostEndoscopic Sleeve Gastroplasty (ESG)What Are the Sutures Doing? [published correction appears in Obes Surg. 2020 Mar 10;:]. Obes Surg. 2020;30(5):2056-2060. doi:10.1007/s11695-019-04311-7

2. F ayad L, Cheskin LJ, Adam A, et al. Endoscopic sleeve gastroplasty versus intragastric balloon insertion: efficacy, durability, and safety. Endoscopy. 2019;51(6):532-539. doi:10.1055/a-0852-3441

6. B oškoski I, Pontecorvi V, Gallo C, Bove V, Laterza L, Costamagna G. Redo endoscopic sleeve gastroplasty: technical aspects and short-term outcomes. Therap Adv Gastroenterol. 2020;13:1756284819896179. Published 2020 Jan 20. doi:10.1177/1756284819896179

3. L opez-Nava G, Sharaiha RZ, Vargas EJ, et al. Endoscopic Sleeve Gastroplasty for Obesity: a Multicenter Study of 248 Patients with 24 Months Follow-Up. Obes Surg. 2017;27(10):2649-2655. doi:10.1007/ s11695-017-2693-7 4. P izzicannella M, Lapergola A, Fiorillo C, et al. Does endoscopic sleeve gastroplasty stand the test of time? Objective assessment of endoscopic ESG appearance and its relation to weight loss in a large group of consecutive patients. Surg Endosc. 2020;34(8):3696-3705. doi:10.1007/s00464019-07329-1


7. L opez-Nava G, Asokkumar R, Negi A, Normand E, Bautista I. Re-suturing after primary endoscopic sleeve gastroplasty (ESG) for obesity. Surg Endosc. 2020. Online ahead of print. DOI: 10.1007/s00464-02007666-6 8. “ Estimate of Bariatric Surgery Numbers, 2011-2018.” American Society for Metabolic and Bariatric Surgery, 21 Nov. 2019, asmbs. org/resources/estimate-of-bariatric-surgerynumbers.

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