PSG Rumblings Newsletter Winter 2023

The Importance of Mentoring

attending physicians at one’s own training program work very hard to train GI fellows, but this is generally different from a mentoring relationship.

Many of us have benefitted from mentors. Perhaps some of us have suffered for the lack of a mentor during our education or training. Mentors can have a lifelong impact on their trainees, but the relationship does not go in only one direction. Mentors can get as much benefit and satisfaction as their mentees can. Gastroenterology, like other areas of medical training is akin to a “guild”, where the experienced take the novice under their wing to train them in the arts of their chosen field. All GI fellows, including us way back when, had trainers and coaches that typically were staff gastroenterologists at our program. Many medical schools provide for mentor relationships, but this is less common in GI training. Certainly,

I have been lucky enough to have some important mentors in my medical career. The first was assigned to me when I was a firstyear medical student. His name was Eugene “Skip” Felmar, MD and he was a Family Practice attending in the San Fernando Valley area of Southern California. I enjoyed going out to his office and shadowing him closely while he saw outpatients, rounded on inpatients, and did office procedures. Beyond gaining valuable insight into the practice of medicine, I found out why his nickname was “Skip” after he took me out on his sailboat which he kept docked at the Los Angeles harbor. Skip Felmar became a role model for me, and the mentor-mentee relationship was mutually rewarding.

Another highly impactful mentor that I had was someone that I chose myself. Dick Kozarek, MD was (and

The PSG is launching a mentorship program for GI Fellows and early career GI physicians. We will be reaching out to those of you who would like to participate in this project.

@DavidDiehlMD

President’s Message

continued from page 1

is!) one of the most well-known ERCP specialists in the country, working at Virginia Mason Medical Center in Seattle, Washington. I had completed an ERCP fellowship but I realized that there was a lot more for me to learn in the field. During this formative period after my advanced fellowship, I flew up from Los Angeles to Seattle at least 3-4 times per year and hung out with Dick for a week at a time. I stood directly behind him in the fluoroscopy suite, asking a million questions, and picking up many invaluable tips. I am certain that I would not have gotten as far in my career if it wasn’t for Dick Kozarek.

What is a mentor?

A mentor is someone who shares knowledge and serves as an experienced and trusted advisor. While it may at one point have been synonymous with an academic advisor, the role of a mentor has expanded and often includes supervisor, collaborator, professional development coach, advocate, and friend.

“Mentors are:

• Advisors, people with career experience willing to share their knowledge;

• Supporters, people who give emotional and moral encouragement;

• Tutors, people who give specific feedback on one’s performance;

• Masters, in the sense of employers to whom one is apprenticed;

• Sponsors, sources of information about and aid in obtaining opportunities;

• Models, of identity, of the kind of person one should be to be to excel in their field.”

—Morris Zelditch (“Mentor Roles”, Proceedings of the 32nd Annual Meeting of the Western Association of Graduate Schools, Tempe, Arizona, 16-18 March 1990)

“A mentor is an individual with expertise who can help develop the career of a mentee. A mentor often has two primary functions for the mentee. The career-related function establishes the mentor as a coach who provides advice to enhance the mentee’s professional performance and development. The psychosocial function establishes the mentor as a role model and support system for the mentee. Both functions provide explicit and implicit lessons related to professional development as well as general work–life balance”.

American Psychological Association. (2012, January 1). Introduction to mentoring: A guide for mentors and mentees. https://www.apa.org/ education-career/grad/mentoring

“Cultural Capital”

“Becoming successful in any profession requires acquisition and display of the cultural capital that established members of a group or field recognize as indicative of those who “belong” in it. Cultural capital is the ways of knowing and behaving —that family and others pass on to younger generations, often unknowingly. Cultural capital is highly contextual; knowing and behaving appropriately in one setting often does not translate to another setting. Ideally, mentors should make sure all trainees have access to the cultural capital appropriate to their fields”.

Womack VY, et al. The ASPET mentoring network: enhancing diversity and inclusion through career coaching groups within a scientific society. CBE— Life Sciences Education. 2020;19(3):ar29.

What are the roles of a mentor?

“The physician-researcher as mentor has at least seven roles to fill: teacher, sponsor, advisor, agent, role model, coach, and confidante. The mentor needs to customize each role to match the characteristics of the fellow”.

Tobin MJ. Am J Resp Crit Care Med. 2004;170:114-117

Identifying a good mentor

“A mentor might be a faculty member, a project leader, a more senior student, a wise friend, or anyone who can provide trustworthy advice. A person needs to possess —several qualities in order to be an effective mentor: 1. Experience with the challenges that the trainee may confront, 2. Ability and willingness to communicate that experience, 3. Interest in helping another person develop into a successful professional, 4. Admirable character traits, 5. Willingness to share time, 6. Professional respect from others (including current and former trainees).”

Adviser, Teacher, Role Model, Friend: On Being a Mentor to Students in Science and Engineering. National Academies of Sciences, Engineering and Medicine, 1997 https://nap.nationalacademies. org/catalog/5789/adviser-teacher-role-modelfriend-on-being-a-mentor-to

Why be a mentor?

“Mentors typically find satisfaction in sharing their knowledge and experience and renew their enthusiasm for the profession. It can help the mentor develop and enhance professional networks, extend their professional contributions, and contribute to the advancement of the field. Mentors can gain the opportunity to learn about new research areas, build a strong research program, gain new friendships, and affect the future by leaving a part of their expertise and values in every trainee.”

National Academies of Sciences, Engineering, and Medicine. 1997. Adviser, Teacher, Role Model, Friend: On Being a Mentor to Students in Science and Engineering. Washington, DC: The National Academies Press. https://doi.org/10.17226/5789.

Sometimes more than a single mentor is needed; this increase the scope of knowledge and expertise being handed down. Similarly, mentors may change or transition as the trainee’s career path evolves

Being a Proactive Mentee

a. Identify goals: Be clear about expectations, meeting plan, and professional development

b. Actively participate in the process of finding a mentor: mentor should be a good match in terms of both personality and experience

c. Being a proactive mentee: Take an active role in identifying and communicating needs, expectations, and opportunities as professionals-in-training

d. Although a mentor can provide a unique and invaluable perspective, the mentor’s advice should not be accepted without reflection

e. Be on the lookout for new mentors. Sometimes more than a single mentor is needed; this increase the scope of knowledge and expertise being handed down. Similarly, mentors may change or transition as the trainee’s career path evolves

Mentoring affects the personal and professional lives of the mentor and trainee. Successful mentoring requires awareness of appropriate practices, social responsibilities, and a sincere commitment from mentors and trainees. The mentoring relationship can clearly be rewarding for all parties involved.

We hope that you will be interested in participating in the new PSG Mentorship Program as it gets underway in 2023! Please look out for further communications from the PSG about this.

Mentors will be sought for the following categories:

Disease specific categories

Inflammatory bowel disease

Hepatology

GI Motility

Functional bowel diseases and GI Psychology

Pancreaticobiliary

Bariatrics and Nutrition

Endobariatric Endoscopy

Interventional Endoscopy

Other categories

Women’s GI Health

Diversity, equity, inclusion

Private Practice GI

Work/Life Integration

Advocacy

Clinical research and trials

Basic Research

Invention and Innovation in GI

Practice Management Update: GI “Supergroups”

By R. Fraser Stokes, MD

PSG

Practice Management Task Force Chairman.

Disclosure: Dr. Stokes’ practice joined U.S. Digestive Health In June 2022.

health care rules and regulations gets more onerous by the year. The future actually projects a worsening of some of these trends. Examples include inflation showing no signs of cooling, Medicare proposing an 8.4% reimbursement cut in January, and GI docs retiring at an increasing rate.

For many GI physicians in small private practices, it’s crunch time. We are facing a multitude of difficult challenges. Overhead costs are up for supplies, payroll and supporting services such as accounting, malpractice coverage, IT support, and employee benefits. Reimbursements from private insurers have been stagnant for many years and have slowly and consistently dropped from Medicare. Due to a national healthcare labor shortage, it’s harder than ever to recruit new staff and retain established team members. In addition, physician recruitment is quite tough in many places, as there’s a shortage of 1500 gastroenterologists in our country. Administrative work to maintain a healthy practice has become quite daunting, requiring physicians to attend more meetings, problemsolve repeatedly with practice managers, as well as other timeconsuming activities. Keeping a small practice compliant with burdensome

This has left physicians in small to medium sized independent GI practices with 3 choices: to continue with the status quo, to become an employee of a hospital system, or to join a GI supergroup. The first option is more viable for those in an area with an excellent payer mix and who have a highly skilled administrative team. A dominant national trend over the past five to seven years has been a decreasing percentage of physicians working in traditional private practice. The COVID pandemic accelerated this shift. Hospital systems obviously want to have GI’s in their community to improve patient care, but also to drive hospital finances through inhospital procedures, test ordering, and referring to hospital-based consultants. If a practice is struggling, a hospital may be motivated to purchase the practice and employ the GI’s in that group. Often, salaries are quite competitive, especially with the initial contract. However, hospital employed physicians often complain of a loss of autonomy and of dealing with red tape and administrative decision makers that have suboptimal understanding of and commitment to our specialty. Colleagues that are hospitalemployed may feel pressure to fulfill production quotas.

The emergence of supergroups is a hot button topic in medical economics today. Dermatologists, urologists, orthopedic surgeons, ophthalmologists, and gastroenterologists have been increasingly joining single specialty supergroups over the past three to five years. The keynote speech at this fall’s PSG annual meeting focused on GI supergroups. At this point there is one GI supergroup in Pennsylvania, U.S. Digestive Health, that consists of 130 GI physicians and numerous GI advanced practice providers.

What is the typical process involved in joining a supergroup? For an established practice to merge with a supergroup, a highly detailed analysis is run on the private practice regarding finances, compliance, facilities, physician interest, and other parameters. A practice buy-out offer is then made with physician payment coming in the form of both cash and ownership shares in the supergroup. After the deal is closed, a transition then occurs over the next 3-6 months whereby administrative functions are increasingly done by both local staff and centralized leaders. Ancillary services, such as pathology, billing, infusion, anesthesia, nutrition, research, and breath testing are then managed by a centralized specialized administrative team. Employees of the practice, including providers, then become employees of the supergroup. When a practice joins with a supergroup, the supergroup often buys into a portion of the practice’s ambulatory surgery center.

@fraserstokes

Individual GI’s, such as hospitalemployed physicians or fellowsin-training have also been joining supergroups. They typically work in one of the supergroup practice settings as an associate for one to two years with a competitive salary and signing bonus, before being offered partnership in the supergroup with ownership shares. So, what are the potential advantages of joining a supergroup?

The biggest one might be physicians gaining access to a highly effective administrative talent. This can result in optimized insurance contracts, reduced prices for supplies and equipment, skillfully created compliance programs, knowledgeable and timely IT support, coders and billers that are focused on best practices for revenue cycle management, and access to thought

leaders dedicated to strategic thinking and planning. Delegating numerous tasks to this administrative team can reduce stress and free up physician time – leading to less physician burnout. Most supergroups have a single highly efficient pathology lab processing specimens that are reviewed by dedicated GI pathologists. Supergroups often have a clinical research team that allows providers to enroll their patients in trials, which can both improve patient care and allow for an additional revenue stream. Supergroups also offer high level assistance with practice marketing and provider recruiting. Lastly, joining a supergroup can sometimes lead to a valuable exit strategy for gastroenterologists that are in the late stage of their careers.

In most cases, supergroups are partially owned by private equity (PE) firms. This allows for greater capital resources to invest in key business infrastructure. PE firms are increasingly investing in nearly all aspects of our economy. PE firms can be highly valuable partners in supergroups. That being said, this author believes that it is paramount that physicians have ultimate say in clinical management decisions. Most supergroups allow for this.

For gastroenterologists, the practice landscape is changing rapidly. Maintaining a viable practice is becoming more and more challenging. Many PA GI physicians in the recent past have turned to hospital buy-outs. A new option for many GI’s may be to join a supergroup.

“Venue Shopping” Returns in Pennsylvania: Professional Liability Implications

Richard E. Moses, D.O, J.D.

others. At the same time, physicians, who were strapped with subsequent rising medical malpractice insurance premiums, started to move out of state.

On August 25, 2022, the Pennsylvania Supreme Court enacted a new rule that will cause a major change for Pennsylvania medical healthcare providers. Under the new rule, medical malpractice plaintiffs (the people bringing the lawsuits) will soon be able to sue in various counties throughout the Commonwealth. Legal professionals are concerned that there will be a surge in Pennsylvania medical malpractice verdicts starting in 2023.

Before 2002, Pennsylvania plaintiffs were allowed to sue for medical malpractice in any county where there was a somewhat reasonable connection between the defendant (the person or entity being sued, i.e., the medical provider or the hospital) and the county where the lawsuit was brought. As the litigation climate continued to change, it became clear to plaintiff lawyers that certain counties were more plaintiff friendly, and often had larger verdicts than

To deal with the “physician crisis” that developed, in 2002, Pennsylvania passed the Medical Care Availability and Reduction of Error Act (“MCARE”). In conjunction with the passage of MCARE, the Pennsylvania Supreme Court changed the “venue” (location where the lawsuit could be filed) rule for Pennsylvania medical malpractice plaintiffs, so they could sue only in the county where the cause of action (“the injury”) occurred. The goal was to eliminate venue shopping to obtain high medical malpractice case verdicts. From 2003 until the new rule was enacted, Pennsylvania plaintiffs had to file their medical malpractice lawsuits in the county where they received the medical care that led to the injury.

However, that has now changed again. As of January 1, 2023, plaintiffs will be able to pursue cases in any county where the care occurred, where the defendant can be served, or where any transaction or occurrence giving rise to the suit took place. So effective in 2023, defendants can be sued in many counties, including counties where juries are more likely to issue plaintiff verdicts and larger awards, such as Philadelphia and Allegheny counties. This in essence allows “venue shopping” since the plaintiffs now may sue in more counties throughout Pennsylvania.

Even with the new rule, defendants will still be allowed to challenge venue through the use of Preliminary Objections or a motion to dismiss for “forum non conveniens,” arguing that the place where the lawsuit was filed is not convenient for the defendant and that another court is better suited to hear the case.

Although the new rule is now “the law,” there is a move underway for the Pennsylvania legislature to reinstate the prior venue restrictions. However, it is unlikely that there will be a return to the 2002-2022 restrictive venue requirements.

However, if as a result of the new rule the size of medical malpractice verdicts increase as expected, the likelihood is that the physicians and health institutions will face larger medical malpractice insurance premiums and more physicians will be inclined to move to more “defense-favored” states, which will result in an increasing healthcare provider shortage and Pennsylvania patients having less access to healthcare in our Commonwealth.

@richardmoses

Oh! Diarrhea, & The Bladder Wink

Oh diarrhea, diarrhea, when will you be done? Ask the bladder, you inquisitive one.

For years ago were the connections made the sympathetic, to give you aid.

Without a brain, they work quite well to satisfy the urge, to quiet the spell.

How they combine? That is the question –to quiet the flow, that is its unction.

The empty colon . . . but who knows when? the Bladder knows, again and again.

But we don’t give it credit, we GI guys, for urine and flow we often despise.

But the answer is there just beyond the nose, and the bladder wink “winks” because it knows.

That the excitatory half of that sympathetic fraction now stimulates the bladder to come into action.

So the bladder wink “wink” may produce just a squirt to give you relief, no need to exert.

You are finished, through, great relief has been won! And the bladder knew best that finally we are done.

By David M. Weston, M.D., F.A.C.G. (retired)

Founder, Lancaster Gastroenterology, Inc. Co-Founder with Frank Jackson, M.D., Central Pennsylvania Society of Gastrointestinal Endoscopy

Endoscopic Mucosal Resection (EMR) or Endoscopic Submucosal Dissection (ESD):

when and how to choose?

Alexander Schlachterman, MD Associate Professor of Medicine Director, Third Space Endoscopy, Section of Advanced Endoscopy Thomas Jefferson University Hospital

ESD can be curative. EMR can deliver en bloc resection only with smaller lesions, and larger lesions have to be removed in a piecemeal fashion.

New and improved technologies and techniques in endoscopy have allowed management of complex mucosal lesions without needing to resort to surgery. These are termed “organ-sparing” procedures and can lead to outstanding curative results while in many cases avoiding surgical intervention. There is an impressive safety record of the procedures as well.

Advanced mucosal resection techniques include endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD). The general difference is that ESD is typically done to ensure an en bloc resection of the mucosal lesion. With an en bloc technique, resection margins can be accurately determined, so it is ideal for early mucosal cancers for which successful

Both EMR and ESD started in Japan to manage early gastric cancers. Development of techniques and devices to accomplish EMR and ESD was soon applied to mucosal lesions throughout the GI tract. Expansion of ESD in the West has been considerably slower than in Asia, mainly because of the much lower incidence of early superficial spreading gastric cancer. In the West, the colon is most often the target of EMR and ESD procedures. In the United States, ESD is now performed at major tertiary medical centers.

A brief review of GI applications for esophageal, gastric and colorectal ESD is timely as more United States centers are offering these services.

Esophagus

The European Society for Gastrointestinal Endoscopy (ESGE) recommends endoscopic en bloc resection for superficial esophageal squamous cell cancers (SCCs), excluding those with obvious submucosal involvement. Although SCC is seen in other parts of the world more than the United States, it can be treated with en bloc EMR if the lesion is smaller than 10 mm.

However, the ESGE recommends ESD as the first option, mainly to provide an en bloc resection with accurate pathology staging and to avoid missing important histological features. The American Gastroenterology Association (AGA) recommends ESD as the primary modality for treatment of squamous cell dysplasia and cancer confined to the superficial esophageal mucosa. Any degree of submucosal invasion caries an increased risk of lymph node metastasis and alternative/additional therapy should be considered.

The ESGE recommends endoscopic resection with a curative intent for visible lesions in Barrett’s esophagus. ESD has not been shown to be superior to EMR for excision of mucosal cancer, and for that reason EMR should be preferred for smaller lesions. ESD may be considered for en bloc resection in selected cases, such as larger lesions, poorly lifting tumors, and lesions at risk for submucosal invasion. Recent AGA best practice guidelines state that ESD may be considered in selected patients with Barrett’s esophagus with the following features: large or bulky area of nodularity, lesions with a high likelihood of superficial submucosal invasion, recurrent dysplasia, endoscopic mucosal resection specimen showing invasive carcinoma with positive margins, equivocal preprocedural histology, and intramucosal carcinoma.

The ESGE recommends endoscopic resection for the treatment of gastric superficial neoplastic lesions that possess a very low risk of lymph node metastasis. EMR is an acceptable option for lesions smaller than 10 – 15 mm with a very low probability of advanced histology (Paris 0-IIa). However, the ESGE recommends ESD as treatment of choice for most gastric superficial neoplastic lesions larger then 10-15mm. The safety and feasibility of ESD for early gastric cancer is well established. The absolute indications for curative endoscopic resection include moderately or well-differentiated nonulcerated mucosal lesions that are ≤2 cm in size. Recent expanded indications for gastric ESD include moderately and well-differentiated superficial cancers that are >2 cm, lesions ≤3 cm with ulceration or that contain early submucosal invasion, and poorly differentiated superficial cancers ≤2 cm in size. The risk of lymph node metastasis for these extended indications is higher but remains acceptably low. Many of the patients undergoing ESD with expanded indications have comorbid conditions precluding surgical intervention.

Colorectal

The majority of colonic and rectal superficial lesions can be effectively managed with curative intent by standard polypectomy and/or by EMR. ESD can be considered for removal of colonic and rectal lesions with high suspicion of limited submucosal invasion. Submucosal invasion is suggested by depressed morphology and irregular or nongranular surface pattern, particularly if the lesions are larger than 20 mm. ESD can be

considered for colorectal lesions that otherwise cannot be optimally and radically removed by snarebased techniques.. Accumulating evidence has shown that the majority of colorectal neoplasms without signs of deep submucosal invasion or advanced cancer can be treated by advanced endoscopic resection techniques. Colorectal neoplasms containing dysplasia confined to the mucosa have no risk for lymph node metastasis and endoscopic resection should be considered as the criterion standard.

Large (>2 cm) colorectal lesions frequently require piecemeal removal when EMR is performed, and this can be associated with rates of recurrent neoplasia up to 20%. ESD enables higher rates of en bloc resection and lower recurrence rates for these lesions. Patients with large complex colorectal polyps should be referred to a high-volume, specialized center for endoscopic removal by either EMR or ESD.

Duodenum

ESD in the duodenum is associated with an increased risk of intraprocedural perforation and delayed adverse events even in the hands of experts. It has been strongly suggested that endoscopists in the United States refrain from performing duodenal ESD during the early phase of their ESD practice. EMR is the preferred treatment of adenomatous lesions of the duodenum. Duodenal EMR requires particular expertise in mucosal resection due to anatomic factors and increased risk of perforation and post-polypectomy bleeding, which can be as high as 15%.

General knowledge for EMR and ESD referral

Avoid practices that may induce submucosal fibrosis which can prevent complete removal by EMR and/or ESD. These include tattooing in close proximity or beneath a lesion for marking as the tattoo can induce significant submucosal fibrosis and make future resection very difficult. It is impressive how far tattoo can track, so the tattoo should ideally be on the opposite wall of the colon. In addition, aggressive biopsy or partial snare resection of a portion of a lesion can make subsequent resection complex. If the lesion will be referred to an advanced endoscopist for management, biopsy may not be needed at all. However, if biopsies are done, they should be limited and not very deep.

Careful assessment of the “pit pattern” of a lesion can be useful in determine the optimal approach for resection of a mucosal lesion. Contrast or reaction chromoscopy along with high definition and magnification endoscopy is prevalent in Asia. However, most US endoscopists are not trained in this technique, and in addition, less than perfect interobserver agreement in pit pattern evaluation can be a limitation of its use. It is hoped that artificial intelligence assessment of these features will be useful for endoscopists to make a more accurate assessment at the time of initial endoscopy. When in doubt for larger lesions, it is probably best to not attempt resection, and instead refer the patient to an expert.

Endoscopic Mucosal Resection (EMR) or Endoscopic submucosal dissection (ESD): when and how to choose?

continued from page 9

Risks of EMR and ESD, and technical considerations

The risks of EMR are well known, and include perforation (which is very rare), and delayed bleeding. ESD has a higher perforation rate; however, most of these perforations, when they occur, are seen immediately usually during the dissection, and can be successfully managed without serious sequelae.

ESD requires special training and should be done by a practitioner who subspecializes in complex mucosal resection. ESD can be extremely time consuming, with procedure lengths not uncommonly more than 2 hours. It can be hard to block time on an endoscopy schedule to accommodate these procedures! In general, it is usually sufficient to have one ESD specialist on staff at a major medical center. This contributes to better outcomes and shorter procedure times as that individual grows in their skill set. Clearly, ESD is not something that can be picked up with a weekend course.

As expertise with ESD grows in the West, more mucosal lesions will be managed with this approach. However, the EMR technique is still adequate for the majority of colonic lesions. An exception might be for larger rectal lesions, because en bloc resection allows the best T staging as well as resection margin evaluation. For example, if a large rectal polyp is removed with piecemeal EMR, and then later found to have cancer on histology, the completeness of resection cannot be easily

determined. An ESD approach, on the other hand can allow an accurate determination of completeness of resection. As one can see, the stakes of incomplete resection of an early cancer of the rectum are much higher than higher in the colon, as a proctectomy is a much more complex and morbid procedure than a hemicolectomy.

REFERENCES:

Pimentel-Nunes P, Libânio D, Bastiaansen BA, Bhandari P, Bisschops R, Bourke MJ, Esposito G, Lemmers A, Maselli R, Messmann H, Pech O. Endoscopic submucosal dissection for superficial gastrointestinal lesions: European Society of Gastrointestinal Endoscopy (ESGE) Guideline–Update 2022. Endoscopy. 2022 May 6.

Draganov PV, Wang AY, Othman MO, Fukami N. AGA institute clinical practice update: endoscopic submucosal dissection in the United States. Clinical Gastroenterology and Hepatology. 2019 Jan 1;17(1):16-25.

Ishihara R, Arima M, Iizuka T, Oyama T, Katada C, Kato M, Goda K, Goto O, Tanaka K, Yano T, Yoshinaga S. Endoscopic submucosal dissection/endoscopic mucosal resection guidelines for esophageal cancer. Digestive Endoscopy. 2020 May;32(4):452-93.

Roulette

Thomas J. McGarrity, M.D.

This past year, I was double-booked, for my eye exam and the endoscopy suite. I chose endoscopy and canceled ophthalmology. Saving me from myself, my secretary rebooked my appointment.

Then I raced to the commuter train bound for Philadelphia.

had this spot. A freckle, which for me is not unusual. When I was young and the sun was shining, my freckles would blossom, erupting across the bridge of my nose. Every year in grade school, I was in the running to win the Freckle King contest. I had a pretty good shot. This one freckle was in my right eye.

“Has anyone ever mentioned this to you before?” asked the ophthalmologist.

“No,” I said, not confessing that this was my first eye exam. Ever.

“Rarely, rarely these turn into something bad.”

So began my multidecade oph-thalmology surveillance dance. My attendance was laissez-faire. The ophthalmologist’s office had no recall system. The pupillary dilation wrecked my day — I was unable to work or read. Each almost-annual exam concluded with “No change.” My eye exams fell in December, a busy time of year for my gastroenterology practice. Patients get caught up in the holiday rush securing colonoscopies before their deductibles are reset in the new year.

The slit-lamp exam took longer than usual. “Look up, right, down, left,” the ophthalmologist commanded. The blinding white light made my eyes water. Tears ran down my cheeks. There was less free conversation between us, then silence. “Let’s get another look with optical coherence tomography, a second opinion at Philadelphia Eye. I see some activity in this lesion that wasn’t there before.”

My freckle had become a lesion.

My last case the day before my Philly eye appointment was an endoscopic ultrasound. On the gurney was a cheery 74-year-old woman with a meticulously made-up face, vague abdominal pain, and a CT scan suggesting a “fullness” in the head of the pancreas. As I explained the consent form, she mentioned, “Finally I am going to be a grandmother come March.” Her two daughters, she stressed, were “not getting younger!”

The fullness was an irregular 2.8-cm mass with a loss of interface with the portal vein. The on-site preliminary cytology report said “likely malignant.” I told the woman I saw a tumor, a cancer. My words stunned her like a sedative. However, she quickly recovered. “I have a lot to do,” she reminded me; “I am going to be a grandmother” — revealing an insulation of innocence that I dared not disrupt.

I had danced with this devil before, in college. My right testicle had grown painlessly. Surgical excision. Teratocarcinoma — not the type to have. Chemotherapy. Abdominal aortic lymph node dissection. More chemotherapy. Bald as a cue ball on my 21st birthday. But I was younger then, more confident of my strength and stamina. I felt less sure today. I contemplated my long and happy marriage, two strong sons, gratifying 40-year career. Had I made my Faustian bargain way back then? My roulette wheel was in spin.

The train lurched to a stop, floors below street level and my hotel. The next morning, I walked through a wet snow to the eye hospital, oncology, 8th floor.

The waiting room overflowed with people bundled in winter coats, like wet sheep sheltered in a barn. Registration, insurance cards. Then the long, slow wait. Sit, wait, name called, wait, test, have a seat, wait. Visual acuity, formal visual fields, a slit-lamp exam, ultrasound, optical coher-ence tomography, fluorescein an-giogram. My urine flowed a psychedelic yellow. I munched on power bars, sipped tepid tea. All tests completed, results pending. Melancholy squeezed my temples like a vise. My train had left the station, my ticket was punched.

Late in the afternoon, I was placed in a small, narrow exam room. Soon I would hear the results and learn my fate. The slit lamp’s metal frame caged me off from the rest of the room. A disassembled model of an

Roulette

eye lay on the desk. Silently, nurses, aides, fellows filed in and positioned iPads on the desk, each showing a different test result for efficient viewing.

One iPad showed a picture of my right eye, a fiery red background impaled by a dark brown-black hulking mass like a Death Star from Star Wars. The attending came in with an entourage. “Sit forward.” My chin and forehead pressed against the plastic harness. The searing white light blinded me. “Look up, right, down, left.” She then sat at the desk dictating with precision the result of each test. “Impression: 62-year-old male with choroidal melanoma, right eye.” Pause. “Comma, early stage.”

She faced me. I remained seated behind the cage. “We don’t need a biopsy, we know what it is. We don’t need to remove your eye. We treat this with plaque brachytherapy. You’ll lose some vision and might develop a cataract from the radiation. When we take the plaque out, we can biopsy for abnormalities in three chromosomes, which will determine your prognosis. The biopsy is $1,200, not covered by insurance.” She left, having answered all my questions without asking if I had any.

The next week is melanoma treatment day. After surgery, four of us patients are bundled together and shuttled to a hotel. Like disabled war veterans at a parade, we line up to register with our bulging eye patches. We’re quarantined for 72 hours. Three days later, we return for a second surgery. The plaque is removed.

Six weeks pass. I am at work and the phone rings. Cancer genetics counselor calling. She explains that my tumor was analyzed for abnormalities in chromosomes 3, 6, and 8. If all three are abnormal, I have a high risk for metastasis. Like a seasoned game show host, she teasingly goes through each test result. “Chromosome 3, no abnormality. Chromosome 6, no abnormality. Chromosome 8, no abnormality.” I exhale. In the blink of an eye. For me, for now, the roulette wheel is no longer in spin.

I get to live.

Blind luck or blessed from above?

In my right eye where my freckle was, I have a visual field defect. If I am in a hurry when I’m driving, I make mistakes. When I am careful, I stop before making a left turn. Look left once. Then turn to my right, look once, then twice, and then a third time, each turn in a widening arc to compensate for my blind spot.

My scar is etched in survivor’s guilt. What I do know is that I get to sit on the edge of my patient’s bed. I lean toward him into that space with everything I know and have experienced. It is my duty to help him play his cards, whatever they may be.

In my peripheral vision, I glimpse his wife, standing sentry, beseeching with watery eyes. I turn to face them eye-to-eye. I say we will all do our best to get him better, and if we cannot make him better, we will make him feel better. Then I sit for a while in their silence. I focus directly on my patient’s eyes. I look once, then again, and then a third time in an ever-widening arc to see what I need to see.

Disclosure forms provided by the author are available at NEJM.org.

From the Departments of Gastroenterology and Hepatology, Penn State Health Milton S. Hershey Medical Center, Hershey, PA. This article was published on February 5, 2022, at NEJM.org. Reprinted with permission from the Massachusetts Medical Society.

PSG Annual Meeting a Huge Success!

For the first time since 2019, the PSG held an in-person Annual Scientific Meeting which took place at the Hershey Hotel on September 9th to 11th, 2022. A wonderful agenda was developed by the Program Chairman, Shyam Thakkar, MD with valuable input from the Education and Training Task Force. The topics and speakers were truly exceptional. Speakers ranged from seasoned veterans such as Dr. Gary Lichtenstein from the University of Pennsylvania, to young and upcoming junior faculty such as Dr. Rouenne Seeley from Geisinger Medical Center. Dr. Michael Weinstein was the Keynote Speaker and gave an outstanding and timely presentation on “Consolidation Trends in GI”.

We had solid representation among the faculty from West Virginia as well, further solidifying the PSG’s effort to reach out to Gastroenterologists in that state. Overall, the speakers came from 10 different academic programs from around the Commonwealth. There was a GI Jeopardy competition for the GI fellows from 4 different programs, with the St. Luke’s program winning in a tight and entertaining matchup emceed by Dr. Harshit Khara.

The meeting was well attended, with 58 physicians, 23 GI fellows, 24 nurses/techs/practice personnel being present. We would also like to thank all our exhibitors for supporting the PSG; we had a full house in the exhibit room with 35 exhibit tables! The in-person meeting gave an opportunity for us to catch up with each other in “real-time”, and to also to make new personal connections.

As usual, the Hershey Hotel was a wonderful venue for the meeting. The central location is hard to beat for convenience for drawing attendance from the whole state, and there are certainly a lot of things to do in the area! We had our traditional Family Fun Night, and this was again a success as well.

Thanks to everyone for turning out and making our meeting a complete success! Please make a note of the date and location of the meeting for 2023: It will be September 9-10, 2023 at the Wyndham Hotel in Pittsburgh.

Meeting attendees view Fellow Posters

Khara, Diehl, and Thakkar with the winners of Fellows GI Jeopardy tournament from St. Luke’s.

Drs.

President Dr. Diehl and 2022 Program Chair Dr. Thakkar

GI Fellows Abstract competition

Umair Iqbal, MD

GI Fellows Abstract competition 2nd Place Poster Winner

Brittney Shupp, DO

Families enjoy face painting, games and much more at our Annual Family Fun Night Dinner!

BOARD&STAFF

PRESIDENT

David L. Diehl, MD

Geisinger Medical Center Gastroenterology/Nutrition 570-271-6856 dldiehl@geisinger.edu

@DavidDiehlMD

1st Vice-President

Karen Krok, MD Penn State Hershey Gastroenterology (717) 531-4950 kkrok@pennstatehealth.psu.edu @klkrok

SECRETARY

Manish Thapar, MD Thomas Jefferson University Hospital (215) 955-8900 manishthapar@yahoo.com

TREASURER

Neilanjan Nandi, MD, FACP University of Pennsylvania 215-662-8900 Neilanjan.Nandi@pennmedicine.upenn.edu @fitwitmd

EDITOR

David L. Diehl, MD

Geisinger Medical Center Gastroenterology/Nutrition 570-271-6856 dldiehl@geisinger.edu

@DavidDiehlMD

ADMINISTRATIVE OFFICE ASSOCIATION EXECUTIVE

Audrey Dean (717) 909-2633 info@pasg.org

STAFF Cindy Warren Marketing Coordinator

Jessica Winger Meeting Manager

Tom Notarangelo Design Manager