ACG MAGAZINE | Vol. 1, No. 4 | Winter 2017

ACG MAGAZINE Winter 2017

MEMBERS. MEDICINE. MEANING.

R ole Models

Save the Date

ACG’s ACG’s IBD SCHOOL and 2018 ACG BOARD OF GOVERNORS/ASGE BEST PRACTICES COURSE

ACG IBD SCHOOL

January 26, 2018 ACG BOARD OF GOVERNORS/ ASGE BEST PRACTICES COURSE

January 27-28, 2018

LEARN THE LATEST CLINICAL UPDATES and ways to incorporate them into practice when you attend ACG’s IBD School and the ACG Board of Governors/ASGE Best Practices Course, January 26–28, at Caesars Palace in Las Vegas. Best Practices will be offered during the bye week between the playoffs and the Super Bowl, so you won’t miss any of your favorite sports action.

Caesars Palace is centrally located on the Las Vegas Strip and is considered one of the top luxury hotels in the world with more than 3,000 rooms and dozens of diverse restaurants. The Forum Shops, located on the property, features high-end fashion retailers from around the world.

Register Now!

GI.ORG/BEST-PRACTICES

WINTER 2017 // Volume 1, Number 4

FEATURED CONTENTS COVER STORY

ROLE MODELS

Dr. Sidney Winawer reflects on the importance of mentors Page 22

Hirschowitz Gastroduodenal Fiberscope photo courtesy of UAMS Library Historical Research Center

NOVEL & NOTEWORTHY WCOG at ACG2017: Awardees, special lecturers and more.

Page 7

LAW MIND: USE SMARTPHONES SMARTLY Ann Bittinger, JD Page 19

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ACG MOBILE: ACCESS KEY RESOURCES

at the point of care

STAY ON-THE-GO with ACG’S MOBILE APP An exclusive ACG Member benefit that provides access to valuable resources for your practice and your patients, from your mobile device.

ACG Guidelines GI Anatomical Diagrams IBD Vaccination Guide

Medical Calculators powered by MDCalc and more

DOWNLOAD THE ACG MOBILE APP Download the app via Google Play or Apple App Store.

WINTER 2017 // Volume 1, Number 4

CONTENTS

"He was my mentor.

I wanted to do what he was doing

and be like him.

I became a Gastroenterologist."

—Dr. Winawer, pg. 22 6 // MESSAGE FROM THE PRESIDENT Dr. Irving Pike on supporting the needs of GI practices, employed and independent alike.

21 GI SMALL PRACTICES "CRASH CART" Four steps to avoid the MIPS penalty in 2019.

22 // COVER STORY 7 // NOVEL & NOTEWORTHY 8 WCOG AT ACG2017 RECAP: SCOPY and other awardees, Special Lecturers, GI Jeopardy winners, New MACGs, Twitter posts, and more.

17 // PUBLIC POLICY GOVERNORS' VANTAGE POINT ACG Governor for Northern Ohio Dr. Ashley Faulx on partnering for progress in policy.

ROLE MODELS Dr. Sidney Winawer reflects on the importance of mentors.

41 // INSIDE THE JOURNALS 42 AJG Exploring the Med-diet and living on liquids.

44 ACGCRJ Captivating case report images.

45 CTG Distinguishing Celiac disease from its many mimickers.

31 // ACG PERSPECTIVES 31 ACG-FDA FELLOWSHIP PROGRAM What Dr. Eric Shah learned about drug and device development while at the FDA. 33 TRAIN THE TRAINERS USA Attendees share the most useful tips, lessons and insights from TTT-USA.

46 // REACHING THE CECUM A LOOK BACK: SUPPOSITORY MOLD Suppositories are still a basic tool for gastroenterologists 250 years after their introduction.

19 // GETTING IT RIGHT 19 LAW MIND Ann Bittinger, JD, on what physicians can, can’t, and shouldn’t text on their smartphones.

35 // EDUCATION EDGAR ACHKAR VISITING PROFESSORS Taking ACG's commitment to GI training on the road.

Cover photo courtesy of Dr. Winawer’s personal collection. Above photo courtesy of the ACG archive. Left to right, Dr. Arvey I. Rogers, Dr. Winawer, Dr. Lawrence J. Brandt.

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ACG MAGAZINE MAGAZINE STAFF Executive Director Bradley C. Stillman, JD Editor in Chief; Vice President, Communications Anne-Louise B. Oliphant Managing Editor; Senior Writer Brian C. Davis

CONNECT WITH ACG youtube.com/ACGastroenterology

facebook.com/AmCollegeGastro

twitter.com/amcollegegastro

instagram.com/amcollegegastro Copy Editors; Staff Writers Jenny Dunnington, Sarah Richman, Martha Spath, Lindsey Topp

bit.ly/ACG-Linked-In

Art Director Emily Garel Graphic Designer Antonella Iseas

CONTACT IDEAS & FEEDBACK

BOARD OF TRUSTEES

We'd love to hear from you.

Send us your ideas, stories and comments.

ACGMAG@GI.ORG President: Irving M. Pike, MD, FACG President-Elect: Sunanda V. Kane, MD, MSPH, FACG Vice President: Mark B. Pochapin, MD, FACG Secretary: Samir A. Shah, MD, FACG Treasurer: David A. Greenwald, MD, FACG Immediate Past President: Carol A. Burke, MD, FACG

CONTACT ACG American College of Gastroenterology 6400 Goldsboro Rd., Suite 200 Bethesda, MD 20817 (301) 263-9000 | GI.ORG

Past President: Kenneth R. DeVault, MD, FACG Director, ACG Institute: Nicholas J. Shaheen, MD, MPH, FACG Co-Editors, The American Journal of Gastroenterology: Brian E. Lacy, MD, PhD, FACG Brennan M. R. Spiegel, MD, MSHS, FACG

DIGITAL EDITIONS

GI.ORG/ACGMAGAZINE

Chair, Board of Governors: Costas H. Kefalas, MD, MMM, FACG Vice Chair, Board of Governors: Douglas G. Adler, MD, FACG Trustee for Administrative Affairs: Delbert L. Chumley, MD, FACG TRUSTEES William D. Chey, MD, FACG Immanuel K. H. Ho, MD, FACG Caroll D. Koscheski, MD, FACG Paul Y. Kwo, MD, FACG Jonathan A. Leighton, MD, FACG Amy S. Oxentenko, MD, FACG Daniel J. Pambianco, MD, FACG David T. Rubin, MD, FACG John R. Saltzman, MD, FACG Scott M. Tenner, MD, MPH, JD, FACG

4 | GI.ORG/ACGMAGAZINE

AMERICAN COLLEGE OF GASTROENTEROLOGY is an international organization with more than 14,000 physician members representing some 85 countries. The College's vision is to be the pre-eminent professional organization that champions the evolving needs of clinicians in the delivery of high-quality, evidence-based and compassionate health care to gastroenterology patients. The mission of the College is to advance world-class care for patients with gastrointestinal disorders through excellence, innovation and advocacy in the areas of scientific investigation, education, prevention and treatment.

CONTRIBUTING WRITERS Ann M. Bittinger, JD Ms. Bittinger is health law expert at Bittinger Law Firm in Jacksonville, FL. She is a regular contributor of articles to ACG publications on her areas of expertise, including legal relationships between hospital systems and physicians or physician groups (bittingerlaw.com).

COMMENTS "I am blown away by the ACG Magazine.

This is awesome in its composition, items of interest, graphics…

Of course, I find the tributes to Dr. Gerson to be meaningful and beautifully written. Please, make sure everyone who is working on this publication knows the impact it is having."

—Irving M. Pike, MD, FACG, ACG President

Ashley L. Faulx, MD, FACG Dr. Faulx, of University Hospitals Cleveland Medical Center and the Louis Stokes Cleveland Veterans Affairs Medical Center, is ACG Governor for Northern Ohio and President of the Ohio Gastroenterology Society.

Robert E. Kravetz, MD, MACG Dr. Kravetz is passionate about the history of medicine and the history of the College. He is Past Chair, ACG Archives Committee, and was instrumental in the publication of the ACG 75th Anniversary history in 2007. Read about ACG’s History: gi.org/about-acg/#Anniversary

Eric D. Shah, MD Dr. Shah, of the University of Michigan Medical School, completed the onemonth ACG-FDA Fellowship in 2017.

Sidney J. Winawer, MD, MACG Dr. Winawer is Paul Sherlock Chair in Medicine in Gastroenterology and Nutrition Service, Department of Medicine at Memorial Sloan-Kettering Cancer Center, and Professor of Medicine at Weill Cornell Medical College.

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MESSAGE FROM THE PRESIDEN

MANY OF YOU KNOW ME AS SOMEONE WHO IS PASSIONATE ABOUT QUALITY IMPROVEMENT, and through my involvement in the GI Quality Improvement Consortium, Ltd. (www.giquic.org) In fact, one of my goals this year as ACG President is to remain focused on keeping the College in a position to maintain GIQuIC as an important means for practicing gastroenterologists to lead the way in defining and using quality metrics that are relevant to improving the care our patients receive.

You might not know that my career as a private practice gastroenterologist and then as a physician executive for hospitals, health systems and a developing multi-specialty group practice gives me a unique position to understand the needs and interests of physicians, health systems, insurers and patients. I am especially sensitive to supporting the needs of small and solo GI practices, and helping them to thrive.

The span of my career, first in a private GI practice in Tidewater, VA, later as an executive at Sentara Health System, and currently as Senior Vice President and Chief Medical Officer at the integrated health system, John Muir Health, has kept me in tune with the needs—as well as the trials and tribulations—of the organizations and individuals delivering services in the current health care environment.

LEADING THROUGH CHANGE, NOT FOLLOWING Today, gastroenterologists face significant changes in the structure of clinical practice. As physicians, we will remain a very important part of the aim to promote health and deliver care. We need to stay on the cutting edge—if not one step ahead—of the evolving models of care delivery.

6 | GI.ORG/ACGMAGAZINE

GI SMALL PRACTIC “CRASH CART” ES STEP 1:

CHECK YOUR PARTICIPATION STATUS

To be “eligible” for MIPS, you must first meet certain patient volume and revenue thresholds. If you are excluded from MIPS, you do not have to do anything.  See if you qualify.

Type in your NPI and TINs: qpp.cms.gov This is where being



STEP 2:

IF YOU QUALIFY FOR MIPS

LE

MP

SA

PLEASE PRINT OR

TYPE

APPROVED OMB-0938-1197

AVOID the MIPS penalty in 2019

a small practice can

come in handy!

If you meet MIPS threshold requirements, you may report:

1 Measure for  1 Medicare Fee-forservice Patient on  1 Medicare Claims Form

STEP 3:

ADD THE REPORTING CODE ON MEDICARE CLAIMS FORM

 Pick a quality measure that you can use for any Medicare fee-for-service patient. qpp.cms.gov  Add the “quality code” to the claims form, along with the other charges for services.

For example, most GI clinicians can report Current Medications the “Documentation in the Medical Record” measure during an (Quality ID: 130) quality of evaluation and management (E/M) service.

FORM 1500 (02-12)



Type in Code: "G8427"*

*CODE: "G8427"

—You are attesting to documenting in obtained, updated, the medical record or reviewed the patient's that you you add a nominal current medications. charge ($0.01) in CMS recommends the charge line so reporting a quality that the contractor sees code. that you are

STEP 4:

DON’T WORRY ABOUT MIPS

Spend more time

©2017 AMER ICAN COLLEG E OF GASTRO ENTE

with your patients.

Regulatory requirements are becoming increasingly complex, requiring knowledgeable administrators to make sure practices achieve what is necessary to receive the compensation needed for the sustainability of our practices. In order to maintain such an infrastructure, either practices need to be large enough to do so, or physicians who wish to remain independent and in a small practice need to find ways to come together in a collaborative fashion to achieve the scale necessary to afford such infrastructure. No doubt, more and more physicians—especially those new to practice—will seek employed positions to free themselves from the burden of today’s practice infrastructure requirements.

During my presidency, ACG will continue to evolve to support the needs of GI practices employed and independent alike, particularly small and solo practices, by following changes proposed by the government and private insurers.

The College has historically been proactive in facing these challenges, and makes it an organizational priority to educate legislators and the Centers for Medicare and Medicaid Services on the impact of potential regulatory changes on our members and our patients. The College’s staff, committees, Governors and Course Directors will continue to keep us informed and educated as changes occur.

As always, our goal will be to continue to lead in this effort, rather than follow.

In that respect, I want to commend the vision and leadership of those involved in the ACG Legislative and Public Policy Council, who worked to develop a helpful infographic, GI Small Practices “Crash Cart,” (on page 21) which provides clear guidance on ways to avoid the Merit-based Incentive Payment System (MIPS) penalty in 2019, along with simple actions your practice can take to navigate MIPS.

R O LO GY • G I .O R G

MY ADVICE: GET INVOLVED WITH ACG As I start my term as President of our College, I want to share some advice with my colleagues: get involved in ACG. The College boasts a wonderfully diverse membership of more than 14,000 individuals. The work done by our committees and our strong Board of Governors is what makes us the premier clinical gastroenterologist society in the country.

Whether you are a GI fellow, private gastroenterologist or an academician, if you wish to make a contribution of your skills, ideas and precious time, make your interest in getting involved known to ACG. Send an email or make a call to our office in Bethesda, MD, or reach out to any of our Trustees, our Officers or your ACG Governor. Your contribution to ACG will be welcome and will make our organization better.

Over my years of involvement in ACG, I have found myself learning along each step of the journey. Those lessons have been significant to me professionally and personally. I invite you to be a part of the team at ACG that is making a difference for gastroenterology.

Irving M. Pike, MD, FACG

N wotoerthy ACG MAGAZINE is a forum for College news—a place to showcase the interests and accomplishments of ACG members, as well as notable innovations in the GI profession. In this issue, we recap the WCOG at ACG2017, highlight ACG advocacy at CMS, feature news sent by readers, and celebrate the professional achievements of ACG members. Send your news and any ideas for future issues of ACG MAGAZINE via email to ACGMag@gi.org

Novel & Noteworthy | 7

N&N [SPECIAL LECTURERS]

JOHN J. VARGO, II, MD, MPH, FACG

THE J. EDWARD BERK DISTINGUISHED LECTURE “Are Our Patients Sleeping Safely and Soundly? The State of Endoscopic Procedural Sedation in 2017”

[ON THE AIR]

COMING TO YOU LIVE FROM THE WCOG AT ACG2017

SiriusXM’s “Doctor Radio” took its show on the road to Orlando and the World Congress of Gastroenterology at ACG2017 (WCOG at ACG2017). ACG Vice President Mark B. Pochapin, MD, FACG, hosted a live two-hour show on Sunday, October 15, from a studio set up in the Exhibit Hall during the Opening Welcome Reception. Interested attendees watched and listened to 15 guests discuss the WCOG at ACG2017, the collaboration between ACG and the World Gastroenterology Organisation, and the great clinical science and historic nature of the meeting. The guest list featured ACG leaders, including Immediate Past President Carol A. Burke, MD, FACG, and President Irving M. Pike, MD, FACG, featured lecturers from the WCOG at ACG2017, and SCOPY Award winners Matthew Paul Mewhorter, the Stage-Two colorectal cancer survivor behind CancerOwl.com, and Amy Doran, MD, representing the University of Virginia Department of Gastroenterology. The College is grateful to SiriusXM and Doctor Radio for broadcasting live from the WCOG at ACG2017.

SiriusXM subscribers can listen to the show via SiriusXM On Demand.

Dr. Vargo reviewed extended physiologic monitoring techniques, optimal GI endoscopy sedation practices, and the pharmacoeconomic landscape of sedation practices.

The J. Edward Berk Distinguished Lecture is awarded to individuals prominent in gastroenterology or a related area, and was established in recognition of the significant contributions made by J. Edward Berk, MD, MACG, to clinical gastroenterology during his long and distinguished clinical and academic career.

[SPECIAL LECTURERS]

MARK B. POCHAPIN, MD, FACG, ACG VICE PRESIDENT

[SPECIAL LECTURERS]

GARY W. FALK, MD, MS, FACG THE DAVID SUN LECTURE “Screening and Surveillance of Barrett’s Esophagus: Where Are We Now and What Does the Future Hold?”

Dr. Falk discussed current best practices and future advancements for Barrett’s Esophagus.

The David Sun Lecture was established by Mrs. Sun in memory of her husband, Dr. David Sun, an outstanding gastroenterologist and investigator who died at the peak of his career.

[SPECIAL LECTURERS]

COREY A. SIEGEL, MD, MS THE AMERICAN JOURNAL OF GASTROENTEROLOGY LECTURE “Refocusing IBD Patient Management: Personalized, Proactive, and Patient-Centered Care” Dr. Siegel discussed ways to improve IBD outcomes by personalizing treatment.

The American Journal of Gastroenterology Lecture was established in 2003 to provide a forum for the Editors of the College’s flagship scientific publication to select a key scientific topic for debate or discussion based on their evaluation of key controversies in clinical gastroenterology.

8 | GI.ORG/ACGMAGAZINE

THE EMILY COURIC MEMORIAL LECTURE “Colon Cancer: Polyps, Prevention, and Progress” Dr. Pochapin shared insights into the latest colon cancer treatment and prevention options.

The Emily Couric Memorial Lecture, developed by the ACG, the Virginia Gastroenterological Society, and the Old Dominion Society of Gastroenterology Nurses and Associates, is given in honor of Virginia State Senator Emily Couric, who died of pancreatic cancer in October of 2001. Senator Couric was a strong advocate for health care issues, particularly in her instrumental work to pass the nation’s first legislation mandating health insurance coverage for colorectal cancer screening.

[AWARDEES]

[AWARDEES]

[AWARDEES]

[AWARDEES]

EAMONN M. M. QUIGLEY, MD, MACG

DARWIN L. CONWELL, MD, MS

JOHN W. POPP, JR., MD, MACG

MARK D. TOPAZIAN, MD, FACG

Dr. Quigley was honored with the Berk/Fise Clinical Achievement Award in recognition of his outstanding contributions to clinical gastroenterology throughout his career. He has served as President of the ACG and the World Gastroenterology Organisation (WGO). The award, formerly the ACG Clinical Achievement Award, is presented to no more than one member of the College in any year, and is made in recognition of distinguished contributions to clinical gastroenterology over a significant period of time.

Quigley is David M. Underwood Chair of Medicine in Digestive Disorders, Chief of the Division of Gastroenterology and Hepatology, Medical Director of the Lynda K. and David M. Underwood Center for Digestive Disorders and Professor of Medicine, Weill Cornell Medical College at Houston Methodist Hospital, Houston, TX.

Darwin L. Conwell, MD, MS, a physician-scientist in gastroenterology specializing in pancreas disorders, was honored with the 2017 Minority Digestive Health Care Award. The Minority Digestive Health Care Award recognizes an ACG Member or Fellow whose work in the areas of clinical investigation or clinical practice has improved the digestive health of minorities or other underserved populations of the United States. Conwell has been an advocate to medically underserved communities throughout his medical school training and academic career.

He is Professor of Medicine at The Ohio State University College of Medicine, where he serves as Director of the Division of Gastroenterology, Hepatology and Nutrition at The Ohio State Wexner Medical Center. He is also the Principle Investigator of The Ohio State Pancreas Disorders Network.

John W. Popp, Jr., MD, MACG, received the Samuel S. Weiss Award for his outstanding contributions to the College. The award was established as a service award in commemoration of the founding father of the ACG, Samuel S. Weiss, whose efforts and initiative resulted in the establishment of the College in 1932. It is presented periodically, and not necessarily annually, to a Fellow of the College in recognition of outstanding career service to the ACG. Popp joined ACG in 1990, and served as the College’s President in 2004. He became a Master of the College in 2009, and continued on the ACG Board as Trustees for Administrative Affairs until 2013, when he received the President’s Recognition Award upon completion of his service. He retired from practice in 2006 and joined Centocor (now Janssen) as a Medical Director, a position he continues to hold.

Mark D. Topazian, MD, FACG, is the recipient of the International Leadership Award, which is given to a Fellow or Master of the ACG in recognition of outstanding and substantial contributions to gastroenterology, to the College, and to the international gastroenterology community.

Topazian has been active in strategic initiatives for the medically underserved in the developing world.

He is currently Professor of Medicine at the Mayo Clinic in Rochester, where he does endoscopy and sees patients in the Mayo Pancreas Clinic.

[SPECIAL LECTURERS]

SUNANDA V. KANE, MD, MSPH, FACG, ACG PRESIDENT-ELECT THE DAVID Y. GRAHAM LECTURE “On Becoming a Successful Leader: An Amazing Journey or the Path to Nowhere?”

Dr. Kane described the attributes and tools necessary to become a successful leader for any scenario.

The David Y. Graham Lecturer is a distinguished individual in the field of gastroenterology. This named lectureship was established in 2004 in recognition of the many contributions to clinical gastroenterology by David Y. Graham, MD, MACG, who gave the inaugural presentation in 2004.

[AWARDEES]

AMAR R. DESHPANDE, MD, FACG

In recognition for his commitment to his community, the Community Service Award was bestowed upon Amar R. Deshpande, MD, FACG. The award is given to an ACG Member who has initiated or has been involved in volunteer programs or has provided extensive volunteer service post training. Deshpande has been a long and passionate advocate for the large and diverse medically underserved population of South Florida.

He is Associate Professor of Medicine in the Division of Gastroenterology at the University of Miami Miller School of Medicine.

Novel & Noteworthy | 9

N&N [ACCOLADES]

[BOOKS]

ERIC ESRAILIAN, MD, MPH

COURAGE TAKES GUTS

The University of California, Los Angeles (UCLA) recognized Dr. Esrailian as one of its “UCLA Optimists,” a distinguished group of notable alumni and faculty.

UCLA Optimists are “...people who take on any challenge and find solutions to any problem. People for whom excellence is a way of life…And every day, our lives are made better by something they have discovered, improved, invented or created.”

The commendation of Dr. Esrailian reads, in part: “Whether he’s working one-on-one with a patient, studying public health to improve the community or using filmmaking for social impact, Dr. Eric Esrailian is committed to helping others.”

Dr. Esrailian shares this distinction with professors, scientists and sports figures, including two of his personal heroes, John Wooden and Jackie Robinson.

Lois Fink is an ostomy patient who was diagnosed with Crohn’s disease in the 1960s and had ostomy surgery more than 30 years ago.

In her book, Courage Takes Guts: Lessons Learned from a Lost Colon, published in April 2017, Fink recounts her medical journey.

“I wrote Courage Takes Guts as a way to share my battle with Crohn's disease, illustrate how full and active my life is as a result of ostomy surgery, and share my father's words,” Fink writes on her website.

In a Q&A with ACG, Fink discusses her life lessons, the biggest epiphany in her journey, and how her lifestyle and perspective have changed.

“In the middle of a crisis, it can be difficult to see what benefits a situation might ultimately bring us, what gifts we could receive if we are willing to see the incident in a different light,” Fink said.

 Read Dr. Esrailian's profile:

bit.ly/17-Esrailian and view the full list of UCLA Optimists: bit.ly/17-Optimists

 Read the full Q&A with Ms.Fink

on the ACG Blog: bit.ly/Fink-17

[POLICY]

ACG TAKES A SEAT AT THE TABLE FOR NEW CMS “PATIENTS OVER PAPERWORK” INITIATIVE

CMS Administrator Seema Verma

In October, the Centers for Medicare and Medicaid Services (CMS) announced a new initiative to reduce the regulatory burdens impacting

10 | GI.ORG/ACGMAGAZINE

patient care and the practice of medicine.

The “Patients over Paperwork” initiative formalizes CMS’ ongoing review of the unnecessary and burdensome challenges to patient care and physician practices.

ACG was invited to participate in this dialogue, continuing our advocacy on behalf of clinical GI and ACG members.

ACG has been at the forefront of these efforts, advocating for reducing clinician burdens since MACRA was initially passed in 2015, finalized in 2016, and began in 2017. ACG has also successfully urged CMS to exclude those GI practices located in areas hit by this year’s devastating hurricanes from 2017 MIPS requirements.  LEARN MORE: bit.ly/MACRA-Exempt

[AWARDEES]

TAKE THE STAGE

Twenty-One Projects Earn SCOPY Awards In front of a packed room at the Orange County Convention Center, 21 colorectal cancer (CRC) awareness projects were recognized during the SCOPY Awards Ceremony & Workshop, Sunday, October 15, at the World Congress of Gastroenterology at ACG2017.

From lighting up different cities in blue, donating screenings to those in need, advising the public on shopping for healthy foods, telling CRC survivor stories through a comic, and more, this year’s slate of SCOPY Award winners met the high bar established in the previous years.  READ MORE about the SCOPY winners: bit.ly/17-SCOPYS Left to Right: Harish K. Gagneja, MD, FACG; Leo C. Katz, MD, FACG, Marianne T. Ritchie, MD, (center) and additional representatives from Thomas Jefferson University Hospital, Division of Gastroenterology & Hepatology; Hongha T. Vu-James, MD, Nancy S. Schlossberg, BSN, RN, CGRN, and ACG President Irving M. Pike, MD, FACG; Danielle Burgess and Emily Butler Bell; Darrell M. Gray, II, MD, MPH; Matthew Paul Mewhorter and family.

[MACG]

Five Members Honored as

MASTERS OF THE AMERICAN COLLEGE OF GASTROENTEROLOGY (MACG)

AMY E. FOXX-ORENSTEIN, DO, MACG Mayo Clinic Arizona, Arizona State University, Scottsdale, AZ

LAUREN B. GERSON, MD, MSc, MACG (1964–2017)* California Pacific Medical Center, University of California, San Francisco, San Francisco, CA

PHILIP O. KATZ, MD, MACG Weill Cornell Medicine, New York, NY

LAWRENCE R. SCHILLER, MD, MACG [WINNERS]

GI JEOPARDY COMES DOWN TO THE WIRE

In a surprise comeback, the University of California, San Francisco Medical Center (UCSF) edged out the Indiana University School of Medicine (IU) on the final question in the live GI Jeopardy competition on Saturday, October 14, at the World Congress of Gastroenterology at ACG2017 (WCOG at ACG2017).

UCSF’s two-person team (at left) was comprised of Giuseppe Cullaro, MD, and Vivek Rudrapatna, MD, who each receive a $1,000 grant to the ACG Annual Scientific Meeting in Philadelphia, PA, October 5–10, 2018, for winning the competition.

The spirited GI version of the television classic began over the summer, when GI training programs participated in the preliminary round, during which groups of GI fellows took an online test on a variety of GI topics and diseases.

The live event, hosted by Ronald D. Szyjkowski, MD, FACG, pits the top five teams emerging from the preliminary round. In addition to UCSF and IU, teams contended from Duke University Hospital, University of Iowa Hospitals & Clinics, and the University of Nebraska Medical Center. The animated, standing room-only crowd witnessed UCSF, IU, and Iowa survive the first round, before UCSF triumphed on the final question.  LEARN MORE about GI Jeopardy: bit.ly/GIJeopardy

Baylor University Medical Center, Texas A&M University College of Medicine, Dallas, Dallas, TX

NICHOLAS J. TALLEY, MD, PhD, MACG University of Newcastle, Australia

*In recognition of Dr. Gerson’s stature and achievement in clinical gastroenterology, teaching, and because of her contribution to the College in service, leadership, and education, the College is proud to bestow to Lauren B. Gerson, MD, MSc, the posthumous honor of Master of the American College of Gastroenterology.

Novel & Noteworthy | 11

Tweets from # WCOG AT ACG2017 N&N: SEEN ON TWITTER

THE GLOBAL GI COMMUNITY CONNECTED THROUGH #WCOGATACG2017. Attendees and non-attendees alike. Those who drove to Orlando and large international groups who flew thousands of miles. They shared special moments, from action shots during the Hands-on Endoscopy sessions, to poses in front of the WCOG at ACG2017 globe, to insightful guidance and clinical pearls during lectures, to reuniting moments with old friends and colleagues, and many more.

Below is a selection of featured tweets from #WCOGatACG2017.

#Cuba

#WCOGat 12 | GI.ORG/ACGMAGAZINE

#WCOGatACG2017 #CANCER

#Gastroenterology

#WCOGatACG2017

tACG2017

Novel & Noteworthy | 13

ACG CALENDA

JANUARY

JANUARY

SECOND YEAR FELLOWS COURSE

JANUARY

12–14 More info: gi.org/trainee-events-and-meetings

MARCH

9–10

26

27–28

IBD SCHOOL AT BEST PRACTICES Course Directors Dr. Sunanda V. Kane and Dr. David T. Rubin offer a one-day immersion in IBD management in Las Vegas, NV, at Caesars Palace.

ACG BOG/ASGE BEST PRACTICES COURSE Gain insight from the experts and learn about the latest clinical updates when you attend the Best Practices Course.

Register: meetings.gi.org

ACG/LGS REGIONAL POSTGRADUATE COURSE  New Orleans, LA Experts will discuss portal hypertension, NASH, hepatitis C, IBD, foregut surgical complications, EMR, and more.

More info: gi.org/regional-meetings

APRIL

13

IBD SCHOOL AT EASTERN REGIONAL



MARCH

16–18 ACG/FGS ANNUAL SPRING SYMPOSIUM

MARCH 23–25 NORTH AMERICAN CONFERENCE OF GI FELLOWS (NACGF) More info: gi.org/trainee-events-and-meetings

Boston, MA

More info: gi.org/regional-meetings

APRIL

14–15

 Bonita Springs, FL Topics covered will include colon cancer screening, therapeutic endoscopy, esophageal conditions, functional and GI motility, hepatology, and IBD.

MARCH 31 MIPS DEADLINE LAST DAY to submit CY 2017 data

Register: meetings.gi.org

EASTERN REGIONAL POSTGRADUATE COURSE

 Boston, MA

More info: gi.org/regional-meetings

AUGUST

AUGUST

24

25–26

HEPATOLOGY SCHOOL AT MIDWEST REGIONAL

ACG MIDWEST REGIONAL POSTGRADUATE COURSE





Indianapolis, IN

Indianapolis, IN

More info: gi.org/regional-meetings

More info: gi.org/regional-meetings

AC G 2O18 O CTO B E R 5 – 1 O, 2 O 1 8 The Premier GI Clinical Meeting & Postgraduate Course

ACG 2018

SEPTEMBER

8–9

14 | GI.ORG/ACGMAGAZINE

ACG/VGS/ODSGNA REGIONAL POSTGRADUATE COURSE  Williamsburg, VA More info: gi.org/regional-meetings

ANNUAL SCIENTIFIC MEETING & POSTGRADUATE COURSE Pennsylvania Convention Center Philadelphia, PA acgmeetings.gi.org

IMPORTANT SAFETY INFORMATION SUPREP® Bowel Prep Kit (sodium sulfate, potassium sulfate and magnesium sulfate) Oral Solution is an osmotic laxative indicated for cleansing of the colon as a preparation for colonoscopy in adults. Most common adverse reactions (>2%) are overall discomfort, abdominal distention, abdominal pain, nausea, vomiting and headache.

Use is contraindicated in the following conditions: gastrointestinal (GI) obstruction, bowel perforation, toxic colitis and toxic megacolon, gastric retention, ileus, known allergies to components of the kit. Use caution when prescribing for patients with a history of seizures, arrhythmias, impaired gag reflex, regurgitation or aspiration, severe active ulcerative colitis, impaired renal function or patients taking medications that may affect renal function or electrolytes. Use can cause temporary elevations in uric acid. Uric acid fluctuations in patients with gout may precipitate an acute flare. Administration of osmotic laxative products may produce mucosal aphthous ulcerations, and there have been reports of more serious cases of ischemic colitis requiring hospitalization. Patients with impaired water handling who experience severe vomiting should be closely monitored including measurement of electrolytes. Advise all patients to hydrate adequately before, during, and after use. Each bottle must be diluted with water to a final volume of 16 ounces and ingestion of additional water as recommended is important to patient tolerance.

BRIEF SUMMARY: Before prescribing, please see Full Prescribing Information and Medication Guide for SUPREP® Bowel Prep Kit (sodium sulfate, potassium sulfate and magnesium sulfate) Oral Solution.

INDICATIONS AND USAGE: An osmotic laxative indicated for cleansing of the colon as a preparation for colonoscopy in adults. CONTRAINDICATIONS: Use is contraindicated in the following conditions: gastrointestinal (GI) obstruction, bowel perforation, toxic colitis and toxic megacolon, gastric retention, ileus, known allergies to components of the kit. WARNINGS AND PRECAUTIONS: SUPREP Bowel Prep Kit is an osmotic laxative indicated for cleansing of the colon as a preparation for colonoscopy in adults. Use is contraindicated in the following conditions: gastrointestinal (GI) obstruction, bowel perforation, toxic colitis and toxic megacolon, gastric retention, ileus, known allergies to components of the kit. Use caution when prescribing for patients with a history of seizures, arrhythmias, impaired gag reflex, regurgitation or aspiration, severe active ulcerative colitis, impaired renal function or patients taking medications that may affect renal function or electrolytes. Pre-dose and post-colonoscopy ECGs should be considered in patients at increased risk of serious cardiac arrhythmias. Use can cause temporary elevations in uric acid. Uric acid fluctuations in patients with gout may precipitate an acute flare.

Administration of osmotic laxative products may produce mucosal aphthous ulcerations, and there have been reports of more serious cases of ischemic colitis requiring hospitalization. Patients with impaired water handling who experience severe vomiting should be closely monitored including measurement of electrolytes. Advise all patients to hydrate adequately before, during, and after use. Each bottle must be diluted with water to a final volume of 16 ounces and ingestion of additional water as recommended is important to patient tolerance. Pregnancy: Pregnancy Category C. Animal reproduction studies have not been conducted. It is not known whether this product can cause fetal harm or can affect reproductive capacity. Pediatric Use: Safety and effectiveness in pediatric patients has not been established.

Geriatric Use: Of the 375 patients who took SUPREP Bowel Prep Kit in clinical trials, 94 (25%) were 65 years of age or older, while 25 (7%) were 75 years of age or older. No overall differences in safety or effectiveness of SUPREP Bowel Prep Kit administered as a split-dose (2-day) regimen were observed between geriatric patients and younger patients. DRUG INTERACTIONS: Oral medication administered within one hour of the start of administration of SUPREP may not be absorbed completely. ADVERSE REACTIONS: Most common adverse reactions (>2%) are overall discomfort, abdominal distention, abdominal pain, nausea, vomiting and headache. Oral Administration: Split-Dose (Two-Day) Regimen: Early in the evening prior to the colonoscopy: Pour the contents of one bottle of SUPREP Bowel Prep Kit into the mixing container provided. Fill the container with water to the 16 ounce fill line, and drink the entire amount. Drink two additional containers filled to the 16 ounce line with water over the next hour. Consume only a light breakfast or have only clear liquids on the day before colonoscopy. Day of Colonoscopy (10 to 12 hours after the evening dose): Pour the contents of the second SUPREP Bowel Prep Kit into the mixing container provided. Fill the container with water to the 16 ounce fill line, and drink the entire amount. Drink two additional containers filled to the 16 ounce line with water over the next hour. Complete all SUPREP Bowel Prep Kit and required water at least two hours prior to colonoscopy. Consume only clear liquids until after the colonoscopy.

STORAGE: Store at 20°-25°C (68°-77°F). Excursions permitted between 15°-30°C (59°-86°F). Rx only. Distributed by Braintree Laboratories, Inc. Braintree, MA 02185

For additional information, please call 1-800-874-6756 or visit www.suprepkit.com

©2017 Braintree Laboratories, Inc.

HH13276B-U

May 2017

1 MOST PRESCRIBED,

#

BRANDED BOWEL PREP KIT1

A CLEAN SWEEP

EFFECTIVE RESULTS IN ALL COLON SEGMENTS2

· SUPREP® Bowel Prep Kit has been FDA-approved as a split-dose oral regimen3 · >90% of patients had no residual stool in all colon segments2* †

These cleansing results for the cecum included 91% of patients2*

†

SUPREP Bowel Prep Kit also achieved ≥64% no residual fluid in 4 out of 5 colon segments (ascending, transverse, descending, and sigmoid/rectum)2* †

Aligned with Gastrointestinal Quality Improvement Consortium (GIQuIC) performance target of ≥85% quality cleansing for outpatient colonoscopies.4

*This clinical trial was not included in the product labeling. †Based on investigator grading.

References: 1. IMS Health, NPA Weekly, May 2017. 2. Rex DK, DiPalma JA, Rodriguez R, McGowan J, Cleveland M. A randomized clinical study comparing reduced-volume oral sulfate solution with standard 4-liter sulfate-free electrolyte lavage solution as preparation for colonoscopy. Gastrointest Endosc. 2010;72(2):328-336. 3. SUPREP Bowel Prep Kit [package insert].

Braintree, MA: Braintree Laboratories, Inc; 2012. 4. Rex DK, Schoenfeld PS, Cohen J, et al. Quality indicators for colonoscopy. Gastrointest Endosc. 2015;81(1):31-53.

©2017 Braintree Laboratories, Inc.

HH13276B-U

May 2017

PUBLIC

POLICY Ohio Gastroenterology Society Governing Board at 2015 Annual Meeting, left to right: Rami Abbass, MD, FACG, OGS Education Chair; Ashley L. Faulx, MD, FACG, OGS President and ACG Governor for Northern Ohio; Arjun Venkataramani, MD, OGS Membership Chair; Sapna V. Thomas, MD, FACG, OGS Treasurer; Victor J. Jochem, MD, OGS Vice President; Alan V. Safdi, MD, FACG, OGS Nominations Chair.

PARTNERS for PROGRESS Governors' Vantage Point

OHIO GASTROENTEROLOGY SOCIETY AND OHIO STATE MEDICAL ASSOCIATION

By Ashley L. Faulx, MD, FACG, ACG Governor for Northern Ohio, President, Ohio Gastroenterology Society

HEALTH POLICY IS DEVELOPED IN THE UNITED STATES THROUGH a complicated interplay of governmental and private agencies and businesses, physician organizations and societies, as well as a variety of other private ventures. There are many pathways to influence policy development within this system, and many of these are influenced by physicians as individuals and through organized medical societies.

Norman H. Gilinsky, MD, FACG, and Costas H. Kefalas, MD, MMM, FACG, appreciated the important role a state GI society could play in affecting health care policy both on the state and national levels, and thus co-founded the Ohio Gastroenterology Society (OGS) in 2009. The OGS, in conjunction with the Ohio State Medical Association (OSMA), has advocated for gastroenterologists throughout Ohio ever since. I have had the honor of serving in many capacities for the OGS, including as Chair of the Education Committee, Vice President, and President for the past two years.  Public Policy | 17

PUBLIC POLICY: GOVERNORS' VANTAGE POINT

CURRENT CHALLENGES IN OHIO: NEW STATEHOUSE BILL TAKES AIM AT MOC REQUIREMENTS

ADVANCING PRIORITIES AT THE STATE LEVEL In addition to an Annual Meeting with educational sessions and a Members’ Forum, the OGS is very active in legislative issues that impact Ohio gastroenterologists. In conjunction with the OSMA, we participate in an Annual Legislative Day in the state capital, Columbus, OH, to discuss important issues with State Senators and Representatives. Like most state medical associations, the OSMA has an effective advocacy arm, the OSMA Government Relations Group, which exerts significant political influence in the state capitol on important health-related legislation.

Over the past few years, the OGS and OSMA, with additional guidance from the ACG, have addressed the following key issues:

MEDICAID REIMBURSEMENT RESTORED In 2015, the Ohio Department of Medicaid (ODM) decided to reduce the physician fee schedule for colonoscopy and other upper and lower endoscopy codes. In early 2015, gastroenterology representatives from OGS, ACG and other local and national experts met with ODM Director John McCarthy. At the conclusion of this meeting, McCarthy stated that ODM would be willing to re-examine the rate reduction. After that meeting, a group of dedicated gastroenterologists worked with both national and local experts to evaluate the impact the rate reduction would have on Ohio gastroenterologists, Ohio hospitals, and their patients. Following months of evaluating data, the stakeholder group sent a letter to McCarthy in May 2015 asking him to reinstate the 2013 rates for the services that had been drastically reduced. Their advocacy and effort paid off, when after an extensive rulemaking process in the last quarter of 2015, Medicaid restored the prior rates.

PRIOR AUTHORIZATION LAW CHANGES In the Spring of both 2015 and 2016, members of the OGS Governing Board traveled to Columbus for the our OGS Annual Legislative Day. The events were again organized by the OSMA, which administers the OGS, and one of the legislative priorities was changing the Prior Authorization Law. In June 2016, Governor John Kasich (R) signed Senate Bill 129, the Prior Authorization Reform Act, aimed at ensuring that patients receive the quality care they need and that their insurance carriers will provide the necessary coverage.

To learn more about the provisions of the bill, the first part of which became effective in January 2017, read this ACG Blog post I wrote with David G. Mangels, MD, FACG: bit.ly/Good-NewsOH. Additional provisions will become effective in January 2018.

18 | GI.ORG/ACGMAGAZINE

“

Over the past seven years, through my involvement in the OGS I have appreciated the important role a state GI society can have in changing legislation on the local level, as well as influence changes nationally.

By partnering with the OSMA, we have formed an important alliance to help make positive changes for all Ohio gastroenterologists.

”

As of this writing, a bill pending in the Ohio legislature would prohibit the requirement of Maintenance of Certification (MOC) before a physician can be employed by a health care organization or be contracted to provide medical services under certain plans.

House Bill 273 was introduced in June 2017 by state Rep. Theresa Gavarone (R) and has been referred to the Ohio House Health Committee for deliberation. The bill has several co-sponsors.

H.B. 273 would not remove the initial board certification requirement or the need to participate in CME, with which physicians must already comply to maintain and renew their state license to practice medicine in Ohio.

The OGS supports passage of H.B. 273 and will participate in a House of Medicine meeting with other statewide medical specialty organizations, convened by the OSMA, and at which an advocacy plan for H.B. 273 will be discussed.

The MOC issue has become a hot topic in recent years, as many physicians have grown weary of the time-consuming and costly requirement, pushed by the ABIM, that many physicians feel does little to add to their ability to provide proper patient care.

To date, 12 other states have addressed the requirement with most either outright barring the requirement as a condition of employment or contracting, and others introducing some limits or restrictions on those stipulations.

More than a dozen other states, including Ohio, now have bills or regulations pending to take on the issue.

Update: In October, Immediate Past President Dr. Carol A. Burke and Dr. Christopher D. South testified before the Committee in support of the bill.

Left to Right: Terrance M. O’Toole, DO, OGS Insurance Chair; Christopher D. South, MD, FACG, ACG Governor for Southern Ohio; Ohio State Representative Terry Johnson (R); and Dr. Faulx.

GETTING IT GETTING IT

LAW MIND

USE SMARTPHONES

SMARTLY

WHAT HIPAA ALLOWS YOU TO TEXT ABOUT PATIENTS

By Ann M. Bittinger, JD

Ann M. Bittinger, JD, represents physicians and physician groups in transactions with other entities and with compliance with federal health care laws and in structuring their independent practices. Questions?

Email ann@bittingerlaw.com

WE HAD A ROBUST DISCUSSION DURING THE 2017 ACG GOVERNORS’ FLY-IN and Meeting about

patients’ medical information. What can, can’t and shouldn’t physicians text on their smartphones?

HIPAA APPLIES TO TEXTS? Yes, the Health Insurance Portability and Accountability Act (HIPAA) applies to any electronic Protected Health Information (PHI)—whether that information is in your electronic medical record (EMR) system appearing on a monitor in your treatment room, in a database on the cloud, or on the smartphone in your lapel pocket. If the message you text to your colleague relates to the past, present or future physical or mental health or condition of a patient, or the provision of health care to a patient, if it identifies the individual or if there’s a reasonable basis to believe the information can identify the individual, that text is PHI. If it’s PHI, it’s subject to HIPAA. 

Getting it Right | 19

GETTING IT RIGHT: LAW MIND

IS IT WRONG TO TEXT PHI? Nothing in HIPAA outright prohibits physicians from texting PHI. Physicians can text PHI on their smartphones, but the texts essentially need to be as secure as entries in their EMR systems. If you are texting using basic texting or messaging apps that come with your smartphone, make sure that—at a minimum—two levels of authentication protect your messages. Most people have a password that engages and locks the screen after a few seconds of non-use. That’s one step.

How long is it before your phone locks? How curious or difficult to crack is your password to your smartphone? Then there’s step two: once you enter the password, is another password or bio-authentication required before the messaging app can be accessed?

The US Department of Health and Human Services has not stated that texts sent after two levels of access are permissible, but two levels of access is a rule of thumb as to PCs and laptops (screen saver locks, plus a password to enter the EMR itself), so it makes sense to apply that rule to smartphones.

In assessing your HIPAA compliance, think about what would happen if you lost your smartphone. Could the thief access the texts?

Just as you need a password or other unique identifier to access not only your computer but also your EMR, the same is needed for a smartphone. If your teenager picked up your phone, could he access your messages and see information about your patients?

If that image identifies the patient­—within the image or with accompanying text—it is PHI just like an X-ray or CT scan image.

DO TEXTS HAVE TO BE ENCRYPTED?

CHECKLIST

FOR MOBILE DEVICE POLICIES AND PROCEDURES

 UNIQUENESS Does each user have a unique user identification?

 AUTO-LOCK Does the device automatically lock (requiring a password) upon 30 seconds of non-use?

 PASSWORD Are two levels of complex passwords required?

 ENCRYPTION Is the data encrypted at rest and in motion?

WHAT ARE YOU TEXTING? Do you name patients in your texts to your colleagues and other providers? If there’s a way to communicate about the patient without naming the patient, that’s good. However, that may be extremely risky under professional liability actions if, for example, the parties are not talking about the same individual. Using a code or another identifier may be helpful.

What about initials? For example, say you get this text: “B.W.’s oxygen saturation point is at 80 percent; come back to office ASAP.” Is this PHI? Not if there’s no reasonable basis to believe “B.W.” and the information that follows can identify the individual.

Photos, videos and other images also qualify as PHI if they are identifiable or if there’s a reasonable basis to identify the patient from the information as a whole. You might reach to pull out your iPhone to snap a photo of something involving the patient’s appearance.

20 | GI.ORG/ACGMAGAZINE

 SWIPING Can the data be swiped clean, remotely, in the event the physician loses his phone?

 LOCATION Can you find the lost device?

There’s nothing in HIPAA that explicitly mandates that texts be encrypted.

However, HIPAA requires that physicians take steps to promote HIPAA compliance within their means to do so. HIPAA is scalable, meaning that the government will require what it thinks the group should have been doing, based on its size and resources. If you can afford an app— particularly one that interfaces with your group’s EMR (so as to store the texts—read more at the below link to the ACG Blog) —that encrypts texts, by all means buy it.

Many knowledgeable HIPAA attorneys and consultants advise that texts should not be sent unless they are encrypted both in transit and at rest. This prohibition is ideal from a compliance standpoint, but it could preclude innovation and fast action and be unfair to smaller groups. There are HIPAA-compliant ways to text information about patients without implementing an encryption texting app: • Communicate without identifying the patient or use another identifier to identify the patient such that if a stranger saw the texts, the patient would not be reasonably identifiable. “The first patient we saw today: lab results back show X.” Remember, though, that vagueness could give risk to error.

• Text on your smartphone to get your colleague’s attention, but use a phone for verbal conversation or another method (messaging via the EMR) to communicate PHI with your colleague.

For example, the text: “Call me ASAP to discuss Jenny Jones” would not likely, alone, constitute PHI. Contrast that text to: “Call me to discuss Jenny Jones’ positive STD test results.” That is definitely PHI.

 CONTINUE READING

this installment of LAW MIND on the ACG BLOG. Ms. Bittinger addresses provider communication via smartphone apps, topics to include in your mobile device policy, and texting with patients:

bit.ly/LawMind



GI SMALL PRACTICES

AVOID the MIPS penalty in 2019

“CRASH CART” STEP 1:

To be “eligible” for MIPS, you must first meet certain patient volume and revenue thresholds. If you are excluded from MIPS, you do not have to do anything.

CHECK YOUR PARTICIPATION STATUS

 See if you qualify. Type in your NPI and TINs: qpp.cms.gov This is where being a small practice can come in handy!

STEP 2:



If you meet MIPS threshold requirements, you may report:

IF YOU QUALIFY FOR MIPS

1 Measure for  1 Medicare Fee-forservice Patient on

S

E L P

AM

PLEASE PRINT OR TYPE

STEP 3: ADD THE REPORTING CODE ON MEDICARE CLAIMS FORM

 1 Medicare Claims Form  Pick a quality measure that you can use for any Medicare fee-for-service patient. qpp.cms.gov

 Add the “quality code” to the claims form, along with the other charges for services.

For example, most GI clinicians can report the “Documentation of Current Medications in the Medical Record” (Quality ID: 130) quality measure during an evaluation and management (E/M) service.

APPROVED OMB-0938-1197 FORM 1500 (02-12)

*CODE: "G8427"—You are attesting to documenting in the medical record that you obtained, updated, or reviewed the patient's current medications. CMS recommends that you add a nominal charge ($0.01) in the charge line so the contractor sees that you are reporting a quality code.



Type in Code: "G8427"*

STEP 4: DON’T WORRY ABOUT MIPS

Spend more time with your patients.

© 2 01 7 A M E R I C A N CO L L E G E O F G AST R O E N T E R O LO GY • G I .O R G Getting it Right | 21

Role Models COVER STORY

Written by: Sidney J. Winawer, MD, MACG

22 | GI.ORG/ACGMAGAZINE

Cover Story | 23

COVER STORY

She lay on the bed, curled up in a fetal position with a heated pot cover pressed against her right ear to ease the pain: a remedy from the old country. The pain did not ease.

In desperation, my mother called our family doctor.

She was especially anxious since her first child, my sister, died many years ago of meningitis that started as an ear infection. Antibiotics were not widely available then. Finally Dr. Mandel arrived, with his little black bag and big smile, and we all immediately felt better. He was calm and reassuring. He took an otoscope out and looked into her ears. Both drums were inflamed. Her pain began to subside as soon as he instilled the drops. I was sent running to the corner drugstore with a prescription for antibiotics after he checked my ears too. Five dollars for the house call, anytime, day or night. He always checked out all of the kids and the grown-ups, if necessary, for the same $5. In later years, I did small chores and errands in his office, crowded with loyal patients.

Always a smile. Always warm. Always a kind word.

And always available for that multi-generational house call. I liked him a lot. In reality, I wanted to be him. My mother was wise, and she picked that up.

Whenever company came she would shove a little black bag into my hand and say, “Look, he wants to be a doctor.” She was right.

It was a miracle that he didn’t get killed. Driving somewhat recklessly from home to the office every morning, Dr. Kramer wore his infra-red goggles to accommodate his eyes to the dark fluoroscopy room so that he could start the first barium enema case on arrival. The problem was that he couldn’t see the red traffic lights; he just stopped when other cars stopped. I got a bit anxious when driving with him. I wondered if absorbing his teaching was worth putting my life on the line. Apart from the life-threatening daily commutes, I admired Dr.

24 | GI.ORG/ACGMAGAZINE

 Image at right courtesy of The New York Times.

Photos for this story are courtesy of Dr. Winawer's personal collection and the ACG archive.

"Always a smile. Always warm. Always a kind word. And always available for that multi-generational house call. I liked him a lot. In reality, I wanted to be him. My mother was wise, and she picked that up."

Cover Story | 25

COVER STORY Kramer. As a medical resident, I spent a GI elective with him, making rounds in the hospital, seeing patients with him in the GI clinic, and observing him perform x-ray and endoscopic procedures. We only had rigid scopes in those days. It was before the explosion of the fiberoptic era, and X-ray was king. The barium enema was the way to make a diagnosis in the colon then, later to be trumped by the colonoscope.

He was meticulous in his examinations, conservative in his recommendations, and compassionate in his explanations to patients of the findings and plan of treatment.

He was a different person clinically than when driving: self-assured, warm and even careful! He was up on the literature and had intellectual curiosity. He was my mentor.

I wanted to do what he was doing and be like him. I became a Gastroenterologist.

I was in Boston doing a GI fellowship, having arrived via a circuitous route. As a medical resident in Brooklyn, I reached out to the Chief of GI at a prestigious New York hospital across the river. After an hour

26 | GI.ORG/ACGMAGAZINE

"He was excited by my passion, talked with me at the end of the day—often for hours—about medicine, research and life, looked through the microscope with me, sat and edited papers with me word by word, and had an unbridled enthusiasm for new observations."

of hearing how great his program was, my high hopes got popped like a balloon. He informed me that he didn’t have an open spot— but he was generous and suggested that I contact the Chief at Yale. It was a thoughtful gesture. I called and mentioned that a New York hospital Chief recommended I meet him. “Of course! He’s a good friend.” I was impressed with his program, but alas, he was going on sabbatical and couldn’t take me on either. Nevertheless, he too was generous and recommended that I call Dr. G, as everyone affectionately called him, at the Harvard Medical Division of the Boston City Hospital (BCH). Wow! Harvard Division! That would be a great leap from Brooklyn, indeed!

I called. He was greatly impressed with my “recommendations” from two giants in the field. “Come on up!” After a lengthy and very warm chat, during which he probed my interests and motivation, he said, “All I want is someone to roll up their sleeves and work.” So I rolled up my sleeves. I was in!

A few days later in my mailbox was a distinguished looking letter from the Chair of the Harvard Medical Division at BCH. “I beg to inform you that at a meeting of the President and Fellows of Harvard College, you were appointed Instructor in Medicine— This entitles you to dining room privileges.” At the very least, I would be fed. Thankfully, Dr. G provided a modest stipend in

Cover Story | 27

COVER STORY

addition. And so began my amazing GI Fellowship in Boston with my new mentor.

Academia or private practice? My next fork in the road in medicine.

“Take it!” Yogi Berra would say. I was uncertain. In private practice I would be more independent, and my income would probably better support a future family. But I so enjoyed the intellectual stimulation of the Boston academic environment, clinical rounds at BCH, my budding research, and scientific discourses over dinner at the big round tables in the hospital dining room with professors from Harvard, Tufts and Boston University. A dilemma.

The game changer was my mentor, Dr. G. He was excited by my passion, talked with me at the end of the day—often for hours—about medicine, research and life, looked through the microscope with me, sat and edited papers with me word by word, and had an unbridled enthusiasm for new observations. He

"As we marched through the Boston City Hospital wards, patients called us the Boston City Orchestra.

It was an affectionate label. They loved us because we listened and tried to help. It came from Dr. G." Photos for this story are courtesy of Dr. Winawer's personal collection and the ACG archive.

"He was meticulous in his examinations, conservative in his recommendations, and compassionate in his explanations to patients of the findings and plan of treatment."

28 | GI.ORG/ACGMAGAZINE

was an insightful thinker. When CEA was introduced as a screening test for colorectal cancer, he questioned it: “But how good is it for early stage curable disease?” He initiated a study that showed that it wasn’t. It had poor sensitivity for early stage cancer. So that was the end of CEA as a screening test, although it still had value for treatment follow-up. Thus was introduced the concept of evaluating new screening tests based on performance in earlystage cancer rather than cancer in general.

Dr. G encouraged me in a study of massive small bowel resection, reviewing with me the nuances of clinical investigation day after day. He also envisioned the potential of fiberoptic endoscopy when we introduced it at BCH. We began our fiberoptic endoscopy experience with the new Hirschowitz gastroduodenoscope at the patient’s bedside.

No sedation, just a little local anesthetic throat spray and a dozen curious resident, student and fellow onlookers. Of course, the patient froze. A failure, but he later taught us how to do it with compassion, and impressed upon us the importance of photodocumenting the endoscopic pathology, which was cumbersome compared with the current videoscopes. We had many different types of scopes then, all in different-sized black boxes.

As we marched through the BCH wards, patients called us the “Boston City Orchestra.”

It was an affectionate label. They loved us because we listened and tried to help. It came from Dr. G. He had another, interesting, side to him. When we complained that we could not use the fluoroscopy room at BCH, which was under the jurisdiction of another medical school, he instructed us to put a sign on the door one evening—it said, “to be used only on Tuesday and Thursday by the Harvard division,” and told us to show up on Wednesday. It worked! We were kicked out and told to come back the next day. He knew how to navigate the system.

He supported his fellows passionately. I remember when I wanted to join an “invitation only,” longstanding journal club run by the head of another GI division and was told that we were welcome only if our “boss” came and reviewed papers. He came week after week, presenting along with the first-year fellows. I was proud of him. I was very fond of my Dr. G. I admired his keen mind, warmth and vision.

And so I decided: academia it was!

I will always remember my mentors. My role models. And of course there was my mother. With her—my—little black bag.

Cover Story | 29

Accessible. Relevant. Practical.

The information you need to improve your practice.

The ACG Practice Management Committee’s mission is to equip College members with accessible tools to overcome management challenges, improve operations, enhance productivity, and support physician leadership in their private and physician-lead clinical practices.

Learn from practicing colleagues through monthly articles on topics important to you. Articles include a topic overview, suggestions, examples, and a list of resources or references.

Toolbox topics will include

• Alternative Payment Models (APMs)

• Patient Satisfaction Surveys & Engagement

• Merit-Based Incentive Program Systems (MIPS)

• Reviewing & Updating Informed Consent

• Medicare Compliance & Preparation for RAC Audits

• Developing an Infection Control Plan

• Reviewing & Maximizing Revenue Cycle Efforts

• Professional Society Opportunities & Involvement

• Reviewing & Negotiating Insurance Contracts

• Quality Improvement Projects in Your Practice

"Pressures are high as gastroenterologists make important management decisions that profoundly affect their business future, their private lives, and their ability to provide care to patients." —Louis J. Wilson, MD, FACG

Start Building Success Today.

GI.ORG/TOOLBOX 30 | GI.ORG/ACGMAGAZINE

“

I WOULD HIGHLY RECOMMEND THIS FELLOWSHIP PROGRAM TO GASTROENTEROLOGY FELLOWS TO COMPLEMENT THEIR RESEARCH AND CLINICAL TRAINING WITH THIS VERY DIFFERENT AND EXTREMELY INSIGHTFUL OPPORTUNITY.

”

UNDERSTANDING THE DRUG AND DEVICE DEVELOPMENT AND REGULATION PROCESS Reflecting on the ACG-FDA Visiting Fellowship Program Eric Shah, MD, University of Michigan

THE AMERICAN COLLEGE OF GASTROENTEROLOGY (ACG) PARTNERED with the Division of Gastroenterology and Inborn Errors Products (DGIEP) of the U.S. Food and Drug Administration (FDA) to offer a one-month joint fellowship program designed to expose gastroenterology fellows to the role of the FDA in regulating the design and conduct of development programs for treatment of patients with gastroenterological conditions, and for fellows to understand the exchanges between regulators and industry. I am honored to have been able to participate in this program, which is housed within the FDA’s Center for Drug Evaluation and Research (CDER). 

ACG Perspectives | 31

ACG PERSPECTIVES

“

WITNESSING THESE PROFESSIONAL EXCHANGES ACROSS THE TABLE HELPED ME UNDERSTAND THE PERSPECTIVE OF WELL-INFORMED REGULATORS IN PROTECTING THE PUBLIC AND ENSURING QUALITY DEVELOPMENT EFFORTS, WHILE ALSO PROMOTING THE DEVELOPMENT OF NOVEL GASTROENTEROLOGICAL TECHNOLOGIES IN ACHIEVING MEANINGFUL OUTCOMES FOR PATIENTS.

”



When I arrived on my first day, I was immediately welcomed and immersed into a highly motivated and trained team of medical reviewers within DGIEP. I was given access to the medical reviewer training program and mentored by my DGIEP team leader. This helped me understand the language and perspective of the FDA in the drug development lifecycle, from the preinvestigational new drug stage, to the new drug application process, and post-marketing activities to monitor the safety of approved drugs. To complement this structured curriculum with an experiential learning component, I had daily opportunities to attend meetings between program sponsors and the FDA in which they discussed critical aspects of ongoing drug development programs.

Witnessing these professional exchanges across the table helped me understand the perspective of well-informed regulators in protecting the public and ensuring quality development efforts, while also promoting the development of novel gastroenterological technologies in achieving meaningful outcomes for patients.

During my month, my team leader organized a significant number of opportunities to meet one-on-one with key FDA personnel from relevant divisions around the campus. These meetings allowed me to understand the incredibly nuanced and welloutlined processes involved in regulating the nascent stages of drug and device development all the way from pharmacology, toxicology, clinical trial outcomes assessment, and trial monitoring activities toward regulatory approval, labeling development, and postmarketing monitoring and surveillance. I also had an opportunity to meet personnel involved in regulating over-the-counter drugs, biosimilar therapies, and cuttingedge therapies that do not yet cleanly fit into a specific regulatory pathway. I spent a day understanding differences in device development regulation compared with drug development within the GI division of the Center for Devices and Radiological Health. Overall, it was inspiring to see how professionals trained in a variety of educational backgrounds and experiences, ranging from PhDs in pharmacology to biostatisticians, pharmacists and gastroenterologists,

coordinated their focused efforts together on strict timelines to develop a unified and consistent regulatory position on drug development programs at each and every stage in the development process in an evidence-based and proactive manner.

There were numerous and varied opportunities to take advantage of across the FDA campus. For example, I was able to attend a public Advisory Committee meeting involving relevant academic thought leaders brought to the FDA from across the country to advise the FDA on drug approval based on recent clinical trial results for an adjuvant cancer therapy.

These meetings enable the medical community and public to have a critical voice in weighing the availability of potentially life-changing novel therapies, weighed against the safety of these novel drugs and available alternatives for patients.

Given my interest in evaluating meaningful clinical outcomes, I completed a project to systematically identify known cases of hepatosplenic T-cell lymphoma in patients with inflammatory bowel disease.

This culminated in a presentation of my findings to DGIEP in a division-wide meeting, as well as an abstract submission to the World Congress of Gastroenterology at ACG2017.

I want to thank both the FDA and the ACG for this wonderful opportunity. I am elated to have met such a wonderful group of professionals at the FDA. There is an incredible amount of proactive effort that goes into drug and device development and regulation, and a wealth of information is available to clinicians on the FDA website (Drugs@FDA) at bit.ly/DrugsAtFDA. I would highly recommend this fellowship program to gastroenterology fellows to complement their research and clinical training with this very different and extremely insightful opportunity. This fellowship certainly will help me shape my career aspirations. I look forward to opportunities for collaboration with both the FDA and ACG in the future.

 LEARN MORE about the ACG-FDA Visiting Fellowship Program: gi.org/acg-fda-visiting-fellowship-program

32 | GI.ORG/ACGMAGAZINE

TRAIN THE TRAINERS-USA: THEORY AND PRACTICE OF ADULT EDUCATION PRINCIPLES OF ADULT EDUCATION WERE BOTH ON THE SYLLABUS AND BROUGHT TO LIFE BY EXPERT FACULTY at ACG Train the TrainersUSA last June in Washington, DC. Course Co-Directors Ronald D. Szyjkowski, MD, FACG, and Francisco C. Ramirez, MD, FACG, developed a program to meet the needs of junior faculty members on topics such as educational concepts and common problems encountered in GI training programs, while offering a toolbox of strategies and techniques to improve their clinical teaching skills and enhance their professional lives.

Beyond the didactic content, each session demonstrated adult learner teaching techniques and provided examples of technologies, handouts and original materials, all of which the attendee could use immediately on arrival home to meet their center's educational needs. ACG’s TTT-USA curriculum is adapted for U.S. faculty from a program pioneered by the World Gastroenterology Organisation.

The TTT topics ranged from procedural training, writing test questions, and giving evaluation and feedback to trainees, to career development talks on negotiation, research funding, manuscript preparation, and keys to work-life balance. Several ACG Past Presidents were featured lecturers, including: Ronald J. Vender, MD, FACG, on leadership qualities and traits, Jack A. Di Palma, MD, MACG, on “The Difficult

Colleague and the Difficult Trainee,” and Eamonn M. M. Quigley, MD, MACG, on effective communication.

“Scholarship courses such as this TTT demonstrate the College's commitment to its members on many levels, but specifically underline the recognition that support of junior faculty promotes the next generation of leaders. In this year's course, we had new faculty who were previous TTT attendees!” commented Dr. Szyjkowski.

Overall, the feedback from participants reflected their high level of engagement and enjoyment in networking with peers. Pooja Singhal, MD, shared her impressions: “The ACG TTT is by far the most important career and professional development course that I have attended since fellowship. I valued specific advice on how to become a

(Photo Bottom) L to R Front: Laura E. Raffals, MD, Rochester, MN; Meridith Phillips, ACG Vice President of Education, Bethesda, MD; Sarah B. Umar, MD, Scottsdale, AZ; Stacie A.F. Vela, MD, Paradise Valley, AZ; Jack A. Di Palma, MD, MACG, Mobile, AL. L to R Rear: David J. Bjorkman, MD, MSPH, FACG, Sandy, UT; Francisco C. Ramirez, MD, FACG, Scottsdale, AZ; Ronald D. Szyjkowski, MD, FACG, Syracuse, NY; Eamonn M. M. Quigley, MD, MACG, Houston, TX; Ronald J. Vender, MD, FACG, New Haven, CT. 

better teacher, not only in terms of teaching clinical skills, but how to give proper feedback for endoscopic skills.”

The opportunity to network with peers was a highlight for many at TTT-USA, including David A. Leiman, MD, who noted, “There was an instant camaraderie between attendees and it was particularly nice to be among others with similar interests. The chance to network among both attendees and teachers was a highlight of the course for all of us.”

In reflecting on the value of TTT-USA, Dr. Szyjkowski offered this advice to attendees: “The advice I would give is to maintain that fire and passion for both learning and teaching, and continue to be generous with your skills and talents to advance the learning and careers of others.”

ACG Perspectives | 33

ACG PERSPECTIVES

BEST TIPS FROM TTT-USA

Because only a limited number of participants were selected for TTT-USA, ACG MAGAZINE invited them to share their insights for the broader benefit of the ACG membership. We asked for their most useful tips, lessons that they applied immediately in their teaching and mentoring of fellows, as well as deeper insights about the TTT-USA experience that might benefit others involved in GI training.

ACG MAGAZINE: What was your favorite tip from TTT? We want your favorite small, useful, relevant nugget.

For me the best tip from TTT was the idea of creating “Teaching Scripts” which include a few key characteristics about common diseases that can be easily and repeatedly used for bedside teaching.

—Jill Gaidos, MD, FACG, Hunter Holmes McGuire VA Medical Center, Richmond, VA Avoid emails for sensitive topics, instead rely on direct communication over phone or in person.

—Virendra Tewari, MD, New York Medical College, Valhalla, NY Schedule in time for reflection and planning. This time can be used for a variety of different purposes but it allows you to think ahead and organize your lesson plans, thoughts or expectations so that you can be a better teacher and leader.

—Jeffrey M. Baumgardner, MD, University of California, San Francisco, San Francisco, CA Teachable clinical moments and opportunities to mentor occur throughout the day, seizing on them is the key.

—David A. Leiman, MD, Duke University Medical Center, Durham, NC The “One Minute Preceptor” tool is a quick method to give feedback to any level of trainee in real time after a procedure, by bedside rounds or after a presentation.

Despite being obvious, a lot of us wait till the end of the month to give feedback. Using the One Minute Preceptor tool is an opportunity to give feedback instantly, and gives trainee an opportunity to improve on a daily basis.

—Pooja Singhal, MD, St. Anthony Hospital, Oklahoma City, OK A NEW APPROACH ACG MAGAZINE: After TTT-USA, what did you do differently in terms of your approach to fellows-intraining and helping to mentor and train them?

The sessions on creating good exam questions and course objectives were incredibly important. I have been asked to do these things since I started my faculty

34 | GI.ORG/ACGMAGAZINE

position six years ago, and this is the first time anyone has actually taught me how.

—Dr. Gaidos Always review expectations with fellows at the beginning of rotation, provide feedback more often, and provide a summative review at the end of the rotation.

—Dr. Tewari Feedback requires preparation through identifying objectives, evaluating effectively, and fostering a healthy learning environment...Another easy tool to remember for feedback is the “Ask-Tell-Ask-Act” method: Ask how things are going (be specific). Tell what I observed. Ask how they can improve.

Act or follow-up.

—Dr. Singhal

I was most moved by a video showing inappropriate comments going on while a patient was undergoing a procedure. We should remain sensitive and maintain utmost professionalism regardless of whether a patient is under anesthesia, and eliminate all casual conversation in the endoscopy room.

—Dr. Tewari One of the good takeaways was that you need to schedule in time for yourself. I have personally taken the time for myself on an ad hoc basis, but I recognize the importance of scheduling the time and holding myself to it. This strategy will help with integration of my outside life with work and also force me to step back and assess my needs and wants.

—Dr. Baumgardner

ACG MAGAZINE: What, if anything, did you do differently right away when you got back to work after TTT?

My approach to teaching endoscopy changed right away. My fellows and I now set a learning agenda for the day before we start our procedures. The goals are realistic, learner appropriate and emphasized throughout the session. Feedback is given both in the moment and reiterated in summary at the conclusion of the day.

—Dr. Leiman I found that the lectures on organizing feedback were very instructional and I have been able to put those lessons into practice already. I used to do feedback haphazardly, but now have been able to work it into every endoscopy session with trainees —Dr. Baumgardner LESSONS LEARNED

Within the context of a larger discussion about strategies for managing work-life balance, we were encouraged to reflect on our own balance and given strategies to acknowledge priorities, including the dictum, “be stubborn about your goals but flexible about your methods.”

—Dr. Leiman

RELATED RESOURCES FROM THE TTT READING LIST “Leadership in Medicine: Do We Need a New Approach?”

Eamonn M. M. Quigley, MD, MACG: rdcu.be/zKT6

PRINCIPLES OF ADULT EDUCATION Adult learners are most successful when:

 The learning is purposeful, meaningful and relevant

 The learner is actively involved

 Objectives are identified

 Positive feedback is given

 The learner is reflective

EDUCATION

ACG Trustee David T. Rubin, MD, FACG, during his July 2017 visit to The Ohio State University Wexner Medical Center.

“Dr. Rubin is so gracious, and his lectures were both home runs.”

—Marty M. Meyer, MD, OSU Wexner Medical Center.

The ACG Edgar Achkar

VISITING PROFESSORSHIP PROVIDING NOTEWORTHY SPEAKERS FOR TRAINING IN YOUR COMMUNITIES

THE GOAL OF THE ACG EDGAR ACHKAR VISITING PROFESSORSHIP PROGRAM is to enable GI fellowship programs to have high-quality visiting professors to bolster the training program by providing lectures, small group discussions, and one-onone visits with trainees and faculty. This issue of ACG MAGAZINE spotlights four visiting professors: Prateek Sharma, MD, FACG, at NorthShore University Health System; Maria T. Abreu, MD, at Augusta University Medical College of Georgia; ACG Trustee David T. Rubin, MD, FACG, at the Ohio State University Wexner Medical Center; and ACG Past President Stephen B. Hanauer, MD, FACG, at the University of Virginia. 

Education | 35

EDUCATION

“It is very meaningful to have this program named for Dr. Achkar, whose long and distinguished career focused on training the next generation of gastroenterologists.” —Dr. Abreu

“In today’s academic climate we have very limited time to interact with fellows in an informal way. My favorite part of the visit is the chance to meet my future colleagues.

Dr. Rao has a talented, energetic diverse group of trainees.” —Dr. Abreu

Read More

about Visiting Professorships in the ACG Institute Annual Report: GI.ORG/AR2017

36 | GI.ORG/ACGMAGAZINE

2017 ACG EDGAR ACHKAR VISITING PROFESSORSHIPS The ACG Institute for Clinical Research and Education, and Director Nicholas J. Shaheen, MD, MPH, FACG, are pleased to present the selected 2017 Visiting Professorships:

FEBRUARY 2–3 CHRISTINA M. SURAWICZ, MD, MACG Saint Louis University, presenting on Clostridium difficile.

APRIL 20–21 CAROL A. BURKE, MD, FACG Houston Methodist Hospital, presenting on colon cancer screening, genetics of colon cancer, and hereditary polyp syndromes.

APRIL 25–26 BRIAN E. LACY, MD, PHD, FACG University of Oklahoma, presenting on IBS and motility.

“This was truly an outstanding event, and it will go down in the books as one of the best educational events we have had at NorthShore.”

— Jay L. Goldstein, MD

APRIL 26 LAUREN B. GERSON, MD, MSC, FACG Advocate Lutheran General Hospital, presenting on diverticular disease, colonoscopy quality, GI bleeding, and refractory GERD. MAY 18–19 PRATEEK SHARMA, MD, FACG NorthShore University Health System, presenting on esophageal disease.

MAY 22–23 MARIA T. ABREU, MD Augusta University Medical College of Georgia, presenting on IBD. JULY 18 DAVID T. RUBIN, MD, FACG The Ohio State University Wexner Medical Center, presenting on IBD.

“The fellows appreciated having access to an expert who was there mainly for them to visit with. In that way this program seems unique, as the speaker is identified and events are set that are centered on the fellows. Not on attendings or the Department, but rather all centered around the fellows.”

—Neeral L. Shah, MD, FACG

AUGUST 15–16 STEPHEN B. HANAUER, MD, FACG University of Virginia, presenting on IBD. AUGUST 30–31 AASMA SHAUKAT, MD, MPH, FACG Northwestern University, presenting on colon cancer.

SEPTEMBER 11–13 ANDREW Y. WANG, MD, FACG University of Michigan, presenting on endoscopic submucosal dissection.

SEPTEMBER 13–14 NICHOLAS J. SHAHEEN, MD, MPH, FACG California Pacific Medical Center, presenting on refractory GERD and complicated GERD patients (ablation).

DECEMBER 5–6 MIGUEL D. REGUEIRO, MD, FACG UT Southwestern Medical Center, presenting on IBD.

Education | 37

give Why I r

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Ways to Give

mission of the research and education e th t or pp su d an n llo Join Dr. Evan De gi.org/donate. deductible gift online: xta a er id ns co se ea Pl ACG Institute.

cation is to promote nical Research and Edu in erology Institute for Cli ent stro Ga of e research and innovation leg l Col ica an public, to support clin the The mission of the Americ and t ien pat the n, education of the clinicia estive disease. about prevention of dig digestive health through raise public awareness to and y, log ato hep and gastroenterology

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Be Par t of the Next

AJG SPECIAL ISSUE! 80% by 2018 Colorectal Cancer Initiative: DID WE MAKE IT?

In 2014, the National Colorectal Cancer Roundtable, together with leadership from the ACG, proposed an ambitious national goal: to screen 80% of all eligible U.S. adults for colorectal cancer (CRC) by 2018.

Well, 2018 is just about here. Did we make it? Where did we succeed and what can we still improve?

The American Journal of Gastroenterology requests your original research and insightful reviews about the current state of colorectal cancer screening and prevention.

Eligible topics include:  Facilitators and barriers to CRC screening

Submit Your t!

Manuscr ip Submit manuscripts here:

mc.manuscriptcentral.com/ajg

DEADLINE: JANUARY 15, 2018

 Racial and ethnic disparities in CRC screening  Health economic consequences of CRC screening  Best practices to increase CRC screening rates  Or your creative interpretation of this topic SUBMIT YOUR RESEARCH AND BE PART OF AJG’S SPECIAL ISSUE CELEBRATING THIS IMPORTANT MILESTONE! Please clearly state in your cover letter that your manuscript is intended for the special 80% by 2018 issue of AJG. Depending upon the response to this request, some accepted manuscripts may be published in other upcoming issues of AJG.

40 | GI.ORG/ACGMAGAZINE

Please address questions to Lindsey Topp, Managing Editor: ltopp@gi.org www.nature.com/ajg

Inside the

JOURNALS

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2017 SEPTEMBER NUMBER 9 VOLUME 112 /ajg www.nature.com

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Associate Bowel Disease Birth Early Life is Inflammatory Inception and Residence During

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in the Colonoscopy After Negative l Cancer Incidence Long-Term ColorectaEffect of Family History Hanson, A. Fraser, The K.R. Smith, H. State of Utah: K.M. Boucherr,

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1

DIET PLAYS A STARRING ROLE IN RECENT RED JOURNAL ARTICLES. GI dietitian Kelly Issokson shares her experience with a 30-day trial of exclusive enteral nutrition in the Red Section. Her podcast with AJG’s Dr. Brennan Spiegel offers more insights on using EEN in patients with Crohn’s disease.

The Mediterranean diet takes center stage in two recent AJG publications. An analysis of diet and lifestyle among French women showed a positive effect of a diet rich in olive oil, legumes, fruits and vegetables on reducing rates of cholecystectomy, while in another study both NAFLD prevalence and insulin resistance were lower in patients who adhered to a Mediterranean diet, according to findings from Italian investigators.

Ensuring that patients are correctly diagnosed and avoid an unnecessary gluten-free diet is one objective of a review article in ACG’s Clinical and Translational Gastroenterology by Dr. Amrit K. Kamboj and ACG Trustee Dr. Amy Oxentenko, “Clinical and Histologic Mimickers of Celiac Disease.”

Inside the ACG Case Reports Journal readers will find noteworthy clinical observations selected for publication by an Editorial Board of GI fellows-intraining. Visit acgcasereports.gi.org. orts edited by nal of Case Rep ows An Online Jour atology Fell ology & Hep Gastroenter

Adults With

Inside the Journals | 41

INSIDE THE JOURNALS

WEIGHING THE BENEFITS OF

THE MEDITERRANEAN DIET

The American Journal of Gastroenterology published two studies in the second half of 2017 which explore the potential health benefits of adherence to a Mediterranean diet (Med-diet).

Prior to the first-published study, while diet and lifestyle were known factors in gallstone disease, there was no prospective study that analyzed diet and cholecystectomy risk. In a populationbased, prospective study of more than 64,000 French women and nearly 2,800 cholecystectomy cases, adhering to a diet rich in olive oil, legumes, fruits and vegetables was associated with reduced cholecystectomy risk.

TABLE 4

TABLE 6

 READ MORE Diet and Risk of Cholecystectomy: A Prospective Study Based on the French E3N Cohort Barré, et al.

Am J Gastroenterol 2017;112:1448–1456. doi: 10.1038/ajg.2017.216.

Read the full article: bit.ly/Med-Diet1

The second paper, published online October 24, looked into the relationship between the Med-diet and non-alcoholic fatty liver disease (NAFLD). As with cardiometabolic disorders more broadly, the prevalence of NAFLD is increasing in Western countries. Although the Meddiet is effective in preventing certain cardiometabolic disorders, investigation was needed to determine the Meddiet’s relationship with NAFLD. The study determined that “adherence to [Mediterranean diet] is associated with a lower prevalence of NALFD in patients with cardiometabolic disorders,” among other findings.  READ MORE Adherence to Mediterranean Diet and Non-Alcoholic Fatty Liver Disease: Effect on Insulin Resistance Baratta, et al.

Am J Gastroenterol 2017;112(12):1832–1839. doi:10.1038/ajg.2017.371.

Read the full article: bit.ly/Med-Diet2

42 | GI.ORG/ACGMAGAZINE

TABLE 3

LIVING ON LIQUIDS GI dietitian Kelly Issokson says the primary question patients ask her is “How can I use diet to help my IBD?” To answer that question, Issokson often recommends Exclusive Enteral Nutrition (EEN), a formula-based diet, to patients with Crohn’s disease.

While Issokson does not have IBD, she underwent a 30-day EEN trial to increase awareness of EEN and to gain greater perspective on patients’ challenges with the diet.

In the October 2017 Red Journal, Issokson reflects on her EEN trial: the foreseen and unforeseen emotional and physical challenges, the acclimation process, and even the perks of the diet. She makes the following recommendations in “Living on Liquids: Surviving and Kelly Issokson MS, RD, CNSC, Thriving on Exclusive Enteral Nutrition.”

Cedars-Sinai Medical Center,  READ MORE Read the full article: bit.ly/LivingOnLiquids

ESTABLISH CLEAR EXPECTATIONS Discuss the duration of therapy, time frames for remission, expected symptoms, and what to do in case of weight loss or lack of response to EEN—these are all key to shared decision-making.

BE ENTHUSIASTIC Using EEN to induce remission is a low-risk and safe therapy that allows patients more control over their disease. This is cool!

Los Angeles, CA

PROVIDE SUPPORT A drastic diet change is scary, and support can make the difference between EEN success and failure. Dietitians help support patients through their EEN and ensure they are getting enough nutrition for healing and weight maintenance.

CELEBRATE ACHIEVEMENTS Every day on EEN is an accomplishment.

At the end of the EEN trial, splurge on something fun with all the money saved from not buying food.

 REINTRODUCE FOOD SLOWLY Remind your patients that solids require more digestive effort than liquids and the body needs time to acclimate.

Lower-fiber and lower-fat foods may be tolerated best initially.

LISTEN TO THE PODCAST

Listen to Kelly Issokson’s conversation with AJG Co-Editor-in-Chief Brennan M. R. Spiegel, MD, MSHS, FACG. LISTEN HERE: gi.org/ajgpodcasts

Inside the Journals | 43

INSIDE THE JOURNALS

CATCHING YOUR EYE

Gastroparesis As The Sole Presenting Feature Of Neuromyelitis Optica Ahmed Salahudeen, MD, Tejal Mistry, MD ACG Case Rep J 2017;4:e109.

 Read the case report:

bit.ly/Gastroparesis-0917

Fibroblastic Polyps: A Novel Polyp Subtype In Cowden Syndrome

Editor-in-Chief, ACG Case Reports Journal Parth J. Parekh, MD Carilion Clinic Roanoke, VA

Common Variable Immunodeficiency With Several Gastrointestinal Manifestations

Bradley Anderson, MD, Thomas Smyrk, MD, Seth Sweester, MD ACG Case Rep J 2017;4:e113.

Catarina Atalaia-Martins, MD, Sandra Barbeiro, MD, Pedro Marcos, MD, Isabel Cotrim, MD, Helena Vasconcelos, MD ACG Case Rep J 2017;4:e106.

 Read the case report: bit.ly/Fibro-Polyps-1017

 Read the case report: bit.ly/CVID-0817

Hair Growth In Two Alopecia Patients After Fecal Microbiota Transplant

Restoration Of Completely Transected Common Bile Duct Continuity Using Single Operator Cholangioscopy

Dionne Rebello, MD, Elaina Wang, BS, Eugene Yen, MD, Peter A. Lio, MD, Colleen R. Kelly, MD, FACG ACG Case Rep J 2017;4:e107.

Saad Emhmed Ali, MD, Houssam Mardini, MD, Mohsin Salih, MD, Steven J. Krohmer, MD, Wesam M. Frandah, MD ACG Case Rep J 2017;4:e111.

 Read the case report: bit.ly/Alopecia-0917

 Read the case report: bit.ly/CBD-1017

 View more images and all published cases without a subscription: acgcasereports.gi.org 44 | GI.ORG/ACGMAGAZINE

CTG MIMICKERS OF CELIAC DISEASE CLINICAL AND HISTOLOGIC

Amrit K. Kamboj, MD, Amy S. Oxentenko, MD, FACG, ACG Board of Trustees, Mayo Clinic, Rochester, MN

IT IS IMPORTANT TO RECOGNIZE WHAT IS—AND IS NOT—CELIAC DISEASE. In “Clinical and Histologic Mimickers of Celiac Disease,” published in Clinical and Translational Gastroenterology, Dr. Amrit Kamboj and ACG Trustee Dr. Amy Oxentenko detail the importance of accurately diagnosing and treating celiac disease, as well as its many mimickers.

Patients correctly diagnosed with celiac disease can follow a strictly gluten-free diet, which can resolve manifestations of the disease.

However, it is also vital to understand the many mimickers of celiac disease, which can be identified by heeding clues.

“It is necessary to provide patients with a correct

Figure 4. Proposed algorithm for work-up of seronegative enteropathies.

diagnosis rather than subject them to a lifetime of an unnecessary gluten-free diet,” say the authors, who explain that many mimickers have a targeted therapy.

Figure 4. Proposed algorithm for work-up of seronegative enteropathies.

 READ the full article in CTG: bit.ly/CMimickers. CTG is a free, fully open-access journal, available to all readers worldwide. Read the journal: nature.com/ctg

Innovative

Figure 4. Proposed algorithm for work-up of seronegative enteropathies.

INNOVATIVE GI and HEPATOLOGY RESEARCH Published by ACG

2016 IMPACT Figure 5. Proposed algorithm for management of seronegative enteropathies after other etiologies have FACTOR: been excluded.

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Editor-in-Chief: David C. Whitcomb, MD, PhD, FACG

Figure 5. Proposed algorithm for management of seronegative enteropathies after other etiologies have been excluded.

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Inside the Journals | 45

M CECUM THE CECU HING THE REACHING REAC

By Robert E. Kravetz, MD, MACG Scottsdale, AZ

A Look Back

SUPPOSITORY MOLD This archival reflection originally appeared in The American Journal of Gastroenterology in November 2000.

S

uppositories have been used for several centuries to administer medications via the rectum, vagina and urethra. The first known suppositories were made by hand in the 18th century, and some were molded in paper cones.

Metal suppository molds were made from pewter and tin and were introduced in 1860. The tin mold pictured above dates from that time. The oval tray held ice to chill and harden the suppository; the lid contained holes that supported individual molds for each suppository.

46 | GI.ORG/ACGMAGAZINE

Later models were composed of a two-piece metal mold, which simplified the process. By 1875, there were over 20 different molds in use. Suppository machines were widely used by 1895. Unlike the molds, which were filled with melted material, they compressed the suppository from a solid mass of cocoa butter.

Two hundred and fifty years after their introduction, suppositories are still a basic part of the gastroenterologist's therapeutic armamentarium.

IMPORTANT SAFETY INFORMATION SUPREP® Bowel Prep Kit (sodium sulfate, potassium sulfate and magnesium sulfate) Oral Solution is an osmotic laxative indicated for cleansing of the colon as a preparation for colonoscopy in adults. Most common adverse reactions (>2%) are overall discomfort, abdominal distention, abdominal pain, nausea, vomiting and headache.

Use is contraindicated in the following conditions: gastrointestinal (GI) obstruction, bowel perforation, toxic colitis and toxic megacolon, gastric retention, ileus, known allergies to components of the kit. Use caution when prescribing for patients with a history of seizures, arrhythmias, impaired gag reflex, regurgitation or aspiration, severe active ulcerative colitis, impaired renal function or patients taking medications that may affect renal function or electrolytes. Use can cause temporary elevations in uric acid. Uric acid fluctuations in patients with gout may precipitate an acute flare. Administration of osmotic laxative products may produce mucosal aphthous ulcerations, and there have been reports of more serious cases of ischemic colitis requiring hospitalization. Patients with impaired water handling who experience severe vomiting should be closely monitored including measurement of electrolytes. Advise all patients to hydrate adequately before, during, and after use. Each bottle must be diluted with water to a final volume of 16 ounces and ingestion of additional water as recommended is important to patient tolerance.

BRIEF SUMMARY: Before prescribing, please see Full Prescribing Information and Medication Guide for SUPREP® Bowel Prep Kit (sodium sulfate, potassium sulfate and magnesium sulfate) Oral Solution.

INDICATIONS AND USAGE: An osmotic laxative indicated for cleansing of the colon as a preparation for colonoscopy in adults. CONTRAINDICATIONS: Use is contraindicated in the following conditions: gastrointestinal (GI) obstruction, bowel perforation, toxic colitis and toxic megacolon, gastric retention, ileus, known allergies to components of the kit. WARNINGS AND PRECAUTIONS: SUPREP Bowel Prep Kit is an osmotic laxative indicated for cleansing of the colon as a preparation for colonoscopy in adults. Use is contraindicated in the following conditions: gastrointestinal (GI) obstruction, bowel perforation, toxic colitis and toxic megacolon, gastric retention, ileus, known allergies to components of the kit. Use caution when prescribing for patients with a history of seizures, arrhythmias, impaired gag reflex, regurgitation or aspiration, severe active ulcerative colitis, impaired renal function or patients taking medications that may affect renal function or electrolytes. Pre-dose and post-colonoscopy ECGs should be considered in patients at increased risk of serious cardiac arrhythmias. Use can cause temporary elevations in uric acid. Uric acid fluctuations in patients with gout may precipitate an acute flare.

Administration of osmotic laxative products may produce mucosal aphthous ulcerations, and there have been reports of more serious cases of ischemic colitis requiring hospitalization. Patients with impaired water handling who experience severe vomiting should be closely monitored including measurement of electrolytes. Advise all patients to hydrate adequately before, during, and after use. Each bottle must be diluted with water to a final volume of 16 ounces and ingestion of additional water as recommended is important to patient tolerance. Pregnancy: Pregnancy Category C. Animal reproduction studies have not been conducted. It is not known whether this product can cause fetal harm or can affect reproductive capacity. Pediatric Use: Safety and effectiveness in pediatric patients has not been established.

Geriatric Use: Of the 375 patients who took SUPREP Bowel Prep Kit in clinical trials, 94 (25%) were 65 years of age or older, while 25 (7%) were 75 years of age or older. No overall differences in safety or effectiveness of SUPREP Bowel Prep Kit administered as a split-dose (2-day) regimen were observed between geriatric patients and younger patients. DRUG INTERACTIONS: Oral medication administered within one hour of the start of administration of SUPREP may not be absorbed completely. ADVERSE REACTIONS: Most common adverse reactions (>2%) are overall discomfort, abdominal distention, abdominal pain, nausea, vomiting and headache. Oral Administration: Split-Dose (Two-Day) Regimen: Early in the evening prior to the colonoscopy: Pour the contents of one bottle of SUPREP Bowel Prep Kit into the mixing container provided. Fill the container with water to the 16 ounce fill line, and drink the entire amount. Drink two additional containers filled to the 16 ounce line with water over the next hour. Consume only a light breakfast or have only clear liquids on the day before colonoscopy. Day of Colonoscopy (10 to 12 hours after the evening dose): Pour the contents of the second SUPREP Bowel Prep Kit into the mixing container provided. Fill the container with water to the 16 ounce fill line, and drink the entire amount. Drink two additional containers filled to the 16 ounce line with water over the next hour. Complete all SUPREP Bowel Prep Kit and required water at least two hours prior to colonoscopy. Consume only clear liquids until after the colonoscopy.

STORAGE: Store at 20°-25°C (68°-77°F). Excursions permitted between 15°-30°C (59°-86°F). Rx only. Distributed by Braintree Laboratories, Inc. Braintree, MA 02185

For additional information, please call 1-800-874-6756 or visit www.suprepkit.com

©2017 Braintree Laboratories, Inc.

HH13276B-U

May 2017

1 MOST PRESCRIBED, BRANDED BOWEL PREP KIT1 #

2

FIVE-STAR EFF1CACY WITH SUPREP ® Distinctive results in all colon segments • SUPREP Bowel Prep Kit has been FDA-approved as a split-dose oral regimen3 • 98% of patients receiving SUPREP Bowel Prep Kit had “good” or “excellent” bowel cleansing2* †

• >90% of patients had no residual stool in all colon segments2*

†

These cleansing results for the cecum included 91% of patients2*

†

Aligned with Gastrointestinal Quality Improvement Consortium (GIQuIC) performance target of ≥85% quality cleansing for outpatient colonoscopies.4 *This clinical trial was not included in the product labeling. †Based on investigator grading.

References: 1. IMS Health, NPA Weekly, May 2017. 2. Rex DK, DiPalma JA, Rodriguez R, McGowan J, Cleveland M. A randomized clinical study comparing reduced-volume oral sulfate solution with standard 4-liter sulfate-free electrolyte lavage solution as preparation for colonoscopy. Gastrointest Endosc.

2010;72(2):328-336. 3. SUPREP Bowel Prep Kit [package insert]. Braintree, MA: Braintree Laboratories, Inc; 2012. 4. Rex DK, Schoenfeld PS, Cohen J, et al.

Quality indicators for colonoscopy. Gastrointest Endosc. 2015;81(1):31-53.

©2017 Braintree Laboratories, Inc. All rights reserved.

HH13276A-U

May 2017

ACG MAGAZINE ARCHIVE 2017 Volume 1, Number 1

ACG MAGAZINE Members. Medicine. Meaning.

Striking

Gold

ACG MAGAZINE Summer 2017

MEMBERS. MEDICINE. MEANING.

FINDING DISCOMFORT

ACG MAGAZINE Fall 2017

MEMBERS. MEDICINE. MEANING.

THE RACING LIFE OF DR. FRED POORDAD

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Vol. 1 No. 1 // Spring 2017

Vol. 1 No. 2 // Summer 2017

Vol. 1 No. 3 // Fall 2017