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GI Doc Aims to Lift Barriers to CRC Screening for Black Patients
In gastroenterology, a good bedside manner is a vital attribute. Visiting with an anxious patient before a colonoscopy, Adjoa Anyane-Yeboa, MD, MPH, knew what to say to calm him down.
“I could tell he was really nervous about the procedure, even though he wasn’t letting on,” said Dr. Anyane-Yeboa, a gastroenterologist with Massachusetts General Hospital in Boston. She put him at ease by cracking jokes and making him smile during the consent process. After it was over, he thanked her for making him feel more comfortable.
“I will have it done again, and I’ll come back to you next time,” said the patient.
GI doctors perform colonoscopies all day, every day, “so we sometimes forget how nervous people are. But it’s nice to be able to connect with people and put them at ease,” she said.
Interacting with patients gives her joy. Addressing health disparities is her long-term goal. Dr. Anyane-Yeboa’s research has focused on the barriers to colorectal cancer screening in the Black population, as well as disparities in inflammatory bowel disease (IBD).
“I think there’s a lot that still needs to be done around colorectal cancer screening,” she said.
In an interview, she talks more in depth about her research and her ongoing work to increase public knowledge and awareness about colorectal cancer screening.
Q: Why did you choose GI?
Dr. Anyane-Yeboa: When I got to residency, GI was the rotation that was the most fun. I was the most excited to read about it, the most excited to go to work the next day.
I remember people saying, “You should look at the people who are in the field and look at their personalities, and then think about which personalities match you best.” In residency I considered hematology, cardiology, and GI. The cardiologists were so serious, so intense, talking about research methods all the time. Whereas, the GI folks were joking, laughing, making fart jokes. I felt like these were my people, lighthearted and easy-going. And I genuinely enjoyed going to work every day and learning about the disorders of the GI tract. I still do to this day.
Q: Let’s discuss your research with IBD in Black populations and colorectal cancer screening.
Dr. Anyane-Yeboa: My two main areas of work are in IBD and minority populations, predominantly Black populations, and in colorectal cancer screening in minority populations, and again, mostly in historically marginalized populations.
With colon cancer, we know that there are disparities with incidence in mortality. Black individuals have had the second highest incidence in mortality from colorectal cancer. For me, being a Black female physician and seeing people who look like me, time and time again, being diagnosed with colorectal cancer and dying is really what drives me, because in GI, colon cancer screening is our bread and butter.
Some of the work that I’m doing now around colorectal cancer is in predominantly Black community health centers, working on increasing colorectal cancer screening rates in this population, and figuring out what the barriers are to screening and how we can address them, and what are some strategies that will work in a health center setting to get people screened.
Q: One study of yours surveyed unscreened Black individuals age ≥ 45 and found age-specific barriers to CRC screening in this population, as well as a lack of targeted messaging to incentivize screening.
Dr. Anyane-Yeboa: That mixed method study was done in partnership with the National Colorectal Cancer Roundtable and American Cancer Society.
In that study, we found that the most common barrier to screening was self-procrastination or delay of screening, meaning, “I’m going to get screened, just not right now.” It’s not a priority. What was unique about this is we looked at it from age breakdown, so 45-49, 50-54, 55-plus. With the younger 45-49 group, we don’t know as much about how to get them screened. We also saw that healthcare providers weren’t starting conversations about screening with these younger newly eligible patients.
We also described effective messages to get people screened in that paper as well.
Q: What changes would you like to see going forward with screening? What still needs to happen?
Dr. Anyane-Yeboa: In some of the other work that I’ve done, particularly with the health centers and younger populations interviewed in focus groups, I’m seeing that those who are younger don’t really know much about colorectal cancer screening. Those who do know about it have seen commercials about popular stool-based testing brands, and that’s how they’ve learned about screening.
What I would like to see is ways to increase the knowledge and awareness about colorectal cancer screening and colorectal cancer on a broad scale, on a more national, public-facing scale. Because I’m realizing that if they’re healthy young folks who aren’t going to the physician, who don’t have a primary care provider, then they might not even really hear about colorectal cancer screening. We need ways to educate the general public so individuals can advocate for themselves around screening.
I also want to see more providers discussing screening with all patients, starting from those 45-49, and younger if they have a family history. Providers should screen every single patient that they see. We know that every single person should be screened at 45 and older, and not all providers, surprisingly, are discussing it with their patients.
Q: When you’re not being a GI, how do you spend your free weekend afternoons?
Dr. Anyane-Yeboa: Saturday morning is my favorite time of the week. I’m either catching up on my TV shows, or I might be on a walk with my dog, particularly in the afternoon. I live near an arboretum, so I usually walk through there on the weekend afternoons. I also might be trying out a new restaurant with my friends. I love traveling, so I might also be sightseeing in another country.
Lightning Round
Texting or talking?
Texting
Favorite junk food?
Cookies
Cat or dog person?
Both; love cats, have a dog
If you weren’t a gastroenterologist, what would you be?
Fashion boutique owner
Best place you’ve traveled to?
Morocco
How many cups of coffee do you drink per day?
Two
Favorite ice cream?
Don’t eat ice cream, only cookies
Favorite sport?
Tennis
Optimist or pessimist?
Optimist (glass half full)
In gastroenterology, a good bedside manner is a vital attribute. Visiting with an anxious patient before a colonoscopy, Adjoa Anyane-Yeboa, MD, MPH, knew what to say to calm him down.
“I could tell he was really nervous about the procedure, even though he wasn’t letting on,” said Dr. Anyane-Yeboa, a gastroenterologist with Massachusetts General Hospital in Boston. She put him at ease by cracking jokes and making him smile during the consent process. After it was over, he thanked her for making him feel more comfortable.
“I will have it done again, and I’ll come back to you next time,” said the patient.
GI doctors perform colonoscopies all day, every day, “so we sometimes forget how nervous people are. But it’s nice to be able to connect with people and put them at ease,” she said.
Interacting with patients gives her joy. Addressing health disparities is her long-term goal. Dr. Anyane-Yeboa’s research has focused on the barriers to colorectal cancer screening in the Black population, as well as disparities in inflammatory bowel disease (IBD).
“I think there’s a lot that still needs to be done around colorectal cancer screening,” she said.
In an interview, she talks more in depth about her research and her ongoing work to increase public knowledge and awareness about colorectal cancer screening.
Q: Why did you choose GI?
Dr. Anyane-Yeboa: When I got to residency, GI was the rotation that was the most fun. I was the most excited to read about it, the most excited to go to work the next day.
I remember people saying, “You should look at the people who are in the field and look at their personalities, and then think about which personalities match you best.” In residency I considered hematology, cardiology, and GI. The cardiologists were so serious, so intense, talking about research methods all the time. Whereas, the GI folks were joking, laughing, making fart jokes. I felt like these were my people, lighthearted and easy-going. And I genuinely enjoyed going to work every day and learning about the disorders of the GI tract. I still do to this day.
Q: Let’s discuss your research with IBD in Black populations and colorectal cancer screening.
Dr. Anyane-Yeboa: My two main areas of work are in IBD and minority populations, predominantly Black populations, and in colorectal cancer screening in minority populations, and again, mostly in historically marginalized populations.
With colon cancer, we know that there are disparities with incidence in mortality. Black individuals have had the second highest incidence in mortality from colorectal cancer. For me, being a Black female physician and seeing people who look like me, time and time again, being diagnosed with colorectal cancer and dying is really what drives me, because in GI, colon cancer screening is our bread and butter.
Some of the work that I’m doing now around colorectal cancer is in predominantly Black community health centers, working on increasing colorectal cancer screening rates in this population, and figuring out what the barriers are to screening and how we can address them, and what are some strategies that will work in a health center setting to get people screened.
Q: One study of yours surveyed unscreened Black individuals age ≥ 45 and found age-specific barriers to CRC screening in this population, as well as a lack of targeted messaging to incentivize screening.
Dr. Anyane-Yeboa: That mixed method study was done in partnership with the National Colorectal Cancer Roundtable and American Cancer Society.
In that study, we found that the most common barrier to screening was self-procrastination or delay of screening, meaning, “I’m going to get screened, just not right now.” It’s not a priority. What was unique about this is we looked at it from age breakdown, so 45-49, 50-54, 55-plus. With the younger 45-49 group, we don’t know as much about how to get them screened. We also saw that healthcare providers weren’t starting conversations about screening with these younger newly eligible patients.
We also described effective messages to get people screened in that paper as well.
Q: What changes would you like to see going forward with screening? What still needs to happen?
Dr. Anyane-Yeboa: In some of the other work that I’ve done, particularly with the health centers and younger populations interviewed in focus groups, I’m seeing that those who are younger don’t really know much about colorectal cancer screening. Those who do know about it have seen commercials about popular stool-based testing brands, and that’s how they’ve learned about screening.
What I would like to see is ways to increase the knowledge and awareness about colorectal cancer screening and colorectal cancer on a broad scale, on a more national, public-facing scale. Because I’m realizing that if they’re healthy young folks who aren’t going to the physician, who don’t have a primary care provider, then they might not even really hear about colorectal cancer screening. We need ways to educate the general public so individuals can advocate for themselves around screening.
I also want to see more providers discussing screening with all patients, starting from those 45-49, and younger if they have a family history. Providers should screen every single patient that they see. We know that every single person should be screened at 45 and older, and not all providers, surprisingly, are discussing it with their patients.
Q: When you’re not being a GI, how do you spend your free weekend afternoons?
Dr. Anyane-Yeboa: Saturday morning is my favorite time of the week. I’m either catching up on my TV shows, or I might be on a walk with my dog, particularly in the afternoon. I live near an arboretum, so I usually walk through there on the weekend afternoons. I also might be trying out a new restaurant with my friends. I love traveling, so I might also be sightseeing in another country.
Lightning Round
Texting or talking?
Texting
Favorite junk food?
Cookies
Cat or dog person?
Both; love cats, have a dog
If you weren’t a gastroenterologist, what would you be?
Fashion boutique owner
Best place you’ve traveled to?
Morocco
How many cups of coffee do you drink per day?
Two
Favorite ice cream?
Don’t eat ice cream, only cookies
Favorite sport?
Tennis
Optimist or pessimist?
Optimist (glass half full)
In gastroenterology, a good bedside manner is a vital attribute. Visiting with an anxious patient before a colonoscopy, Adjoa Anyane-Yeboa, MD, MPH, knew what to say to calm him down.
“I could tell he was really nervous about the procedure, even though he wasn’t letting on,” said Dr. Anyane-Yeboa, a gastroenterologist with Massachusetts General Hospital in Boston. She put him at ease by cracking jokes and making him smile during the consent process. After it was over, he thanked her for making him feel more comfortable.
“I will have it done again, and I’ll come back to you next time,” said the patient.
GI doctors perform colonoscopies all day, every day, “so we sometimes forget how nervous people are. But it’s nice to be able to connect with people and put them at ease,” she said.
Interacting with patients gives her joy. Addressing health disparities is her long-term goal. Dr. Anyane-Yeboa’s research has focused on the barriers to colorectal cancer screening in the Black population, as well as disparities in inflammatory bowel disease (IBD).
“I think there’s a lot that still needs to be done around colorectal cancer screening,” she said.
In an interview, she talks more in depth about her research and her ongoing work to increase public knowledge and awareness about colorectal cancer screening.
Q: Why did you choose GI?
Dr. Anyane-Yeboa: When I got to residency, GI was the rotation that was the most fun. I was the most excited to read about it, the most excited to go to work the next day.
I remember people saying, “You should look at the people who are in the field and look at their personalities, and then think about which personalities match you best.” In residency I considered hematology, cardiology, and GI. The cardiologists were so serious, so intense, talking about research methods all the time. Whereas, the GI folks were joking, laughing, making fart jokes. I felt like these were my people, lighthearted and easy-going. And I genuinely enjoyed going to work every day and learning about the disorders of the GI tract. I still do to this day.
Q: Let’s discuss your research with IBD in Black populations and colorectal cancer screening.
Dr. Anyane-Yeboa: My two main areas of work are in IBD and minority populations, predominantly Black populations, and in colorectal cancer screening in minority populations, and again, mostly in historically marginalized populations.
With colon cancer, we know that there are disparities with incidence in mortality. Black individuals have had the second highest incidence in mortality from colorectal cancer. For me, being a Black female physician and seeing people who look like me, time and time again, being diagnosed with colorectal cancer and dying is really what drives me, because in GI, colon cancer screening is our bread and butter.
Some of the work that I’m doing now around colorectal cancer is in predominantly Black community health centers, working on increasing colorectal cancer screening rates in this population, and figuring out what the barriers are to screening and how we can address them, and what are some strategies that will work in a health center setting to get people screened.
Q: One study of yours surveyed unscreened Black individuals age ≥ 45 and found age-specific barriers to CRC screening in this population, as well as a lack of targeted messaging to incentivize screening.
Dr. Anyane-Yeboa: That mixed method study was done in partnership with the National Colorectal Cancer Roundtable and American Cancer Society.
In that study, we found that the most common barrier to screening was self-procrastination or delay of screening, meaning, “I’m going to get screened, just not right now.” It’s not a priority. What was unique about this is we looked at it from age breakdown, so 45-49, 50-54, 55-plus. With the younger 45-49 group, we don’t know as much about how to get them screened. We also saw that healthcare providers weren’t starting conversations about screening with these younger newly eligible patients.
We also described effective messages to get people screened in that paper as well.
Q: What changes would you like to see going forward with screening? What still needs to happen?
Dr. Anyane-Yeboa: In some of the other work that I’ve done, particularly with the health centers and younger populations interviewed in focus groups, I’m seeing that those who are younger don’t really know much about colorectal cancer screening. Those who do know about it have seen commercials about popular stool-based testing brands, and that’s how they’ve learned about screening.
What I would like to see is ways to increase the knowledge and awareness about colorectal cancer screening and colorectal cancer on a broad scale, on a more national, public-facing scale. Because I’m realizing that if they’re healthy young folks who aren’t going to the physician, who don’t have a primary care provider, then they might not even really hear about colorectal cancer screening. We need ways to educate the general public so individuals can advocate for themselves around screening.
I also want to see more providers discussing screening with all patients, starting from those 45-49, and younger if they have a family history. Providers should screen every single patient that they see. We know that every single person should be screened at 45 and older, and not all providers, surprisingly, are discussing it with their patients.
Q: When you’re not being a GI, how do you spend your free weekend afternoons?
Dr. Anyane-Yeboa: Saturday morning is my favorite time of the week. I’m either catching up on my TV shows, or I might be on a walk with my dog, particularly in the afternoon. I live near an arboretum, so I usually walk through there on the weekend afternoons. I also might be trying out a new restaurant with my friends. I love traveling, so I might also be sightseeing in another country.
Lightning Round
Texting or talking?
Texting
Favorite junk food?
Cookies
Cat or dog person?
Both; love cats, have a dog
If you weren’t a gastroenterologist, what would you be?
Fashion boutique owner
Best place you’ve traveled to?
Morocco
How many cups of coffee do you drink per day?
Two
Favorite ice cream?
Don’t eat ice cream, only cookies
Favorite sport?
Tennis
Optimist or pessimist?
Optimist (glass half full)
GI physician channels humor to incentivize cancer screenings
She watched her father suffer from the complications of Crohn’s disease and her brother struggle with irritable bowel syndrome. “We always needed to know where the nearest bathroom was. I grew up with that around me, and I was always just fascinated by the gut and the digestive system,” said Dr. Haghighat, who just finished up her fellowship at the University of Miami and is now a gastroenterologist at University of California, Los Angeles. She also serves as social media editor for AGA’s Gastro Hep Advances.
As she got to know the personalities of the GI department in the first year of medical school, “I realized that our senses of humor and personalities kind of aligned, and I was like, ‘Oh yeah, this is where I’m supposed to be,’ ” said Dr. Haghighat, who can be found on X @DoctorShida.
Humor is something Dr. Haghighat has reached for throughout her life and career. She eventually channeled her gift for satire onto the stage and the internet, as a stand-up comedian. In an interview with GI & Hepatology News, she spoke about the connection between GI medicine and humor, and the creative ways she has helped promote cancer screening in underserved populations.
Q: What practice challenges have you faced in your career?
Dr. Haghighat: I trained in a county hospital, so I’ve always worked with underserved and vulnerable populations. One of the challenges has been just navigation of care, especially as it pertains to cancer diagnoses or cancer screening. A lot of the time, patients don’t understand why they have to do a test or something invasive like a colonoscopy for symptoms they don’t have.
Q: A focus of yours has been improving uptake of screening in underserved communities. Please talk about the work you’ve done in this area.
Dr. Haghighat: I was at Los Angeles General Medical Center — a county hospital in Los Angeles — for residency, where we treated underserved, uninsured patients. I noticed in our primary care clinics a very low uptake of colon cancer screening. Patients didn’t want to bring the stool tests back or get colonoscopies. I surveyed a bunch of the patients and asked: How can we make colon cancer screening easier for you? About a third of the patients said, “If I can do it in the clinic before I go home, that would be great.”
So, I started this initiative called “Go Before You Go.” We would ask patients, “Hey, do you need to go to the bathroom right now, if you can?” Our nurses handed them the stool test to do in the bathroom before they left the clinic after their doctor visits.
We saw really good results with that. Surprisingly, a lot of people can go on demand. We saw increased screening rates, and that quality improvement project went on to win multiple first place awards in research competitions. So that’s what got me interested, and that’s where I had my beginnings of increasing preventative services in underserved communities on the ground.
Q: Can you discuss some health disparity studies you’ve done in this area?
Dr. Haghighat: As a GI at Jackson Memorial Hospital in Miami, I was seeing cancer disparities firsthand every day. I wanted to approach these disparities from a research funding standpoint on a federal level. I was particularly interested in gastric cancer because it’s not common enough in the United States to warrant universal screening, but it’s very common among certain racial and ethnic minorities, which would warrant targeted screening.
I evaluated cancer funding allocation from the National Cancer Institute among the most common cancers in the United States and found that cancer afflicting a higher proportion of racial and ethnic minorities was receiving lower funding. One of those cancers was stomach cancer. This study basically highlighted that, to decrease these disparities, a top-down policy approach is necessary to distribute cancer research funding equitably across these groups.
A lot of stomach cancer comes from a bacteria called Helicobacter pylori, which can be more prevalent in certain countries. In another study, I looked at country of birth as a risk factor for stomach cancer, specifically for gastric intestinal metaplasia, which is a precursor for gastric cancer .
We found that country of birth is a key risk factor for gastric intestinal metaplasia and that it should be incorporated into risk stratification for targeted screening.
Q: Outside of medicine, you perform as a stand-up comedian. You have a popular satirical alias on social media. How did you get interested in stand-up comedy?
Dr. Haghighat: I gave my medical school’s commencement speech, and I had sprinkled a few jokes in there. Afterward, multiple people approached me and said, “You should really consider stand-up comedy. Your timing and delivery are great.” A few months later, I started my intern year in Los Angeles and simultaneously took stand-up comedy classes. I started performing at local clubs around town throughout residency, and I had two or three good sets that I could rely on. And so that’s how I got into stand-up comedy.
My intern year is also when I started this social media satire account. It was a way to cope with the anxieties and stress of residency. Before I knew it, the account gained multitudes of followers, doctors, and other medical professionals. And I joke that the more hours I work in a week, the more memes I make, the more posts I make. It’s kind of a creative outlet for me after a long day.
Q: What types of things do you talk about during your stand-up act?
Dr. Haghighat: A lot of it is about growing up in an immigrant household as a first-generation Iranian American. One of my favorite jokes is, my parents gave me so many options for a career. They said I could be a family doctor, a surgeon, a plastic surgeon, and if I worked hard, even a wife of a surgeon. But I talk a lot about being a woman in medicine. That always gets a lot of laughs. And now that I’ve graduated GI fellowship, I’m excited to incorporate some GI jokes because it turns out people love poop jokes.
Lightning Round
Texting or talking?
Text
Favorite city in U.S. besides the one you live in?
Denver
Cat or dog person
Dog
Best place you went on vacation
Patagonia
Favorite sport
Basketball
Favorite ice cream
Rocky Road
What song do you have to sing along with when you hear it?
Celine Dion’s My Heart Will Go On
She watched her father suffer from the complications of Crohn’s disease and her brother struggle with irritable bowel syndrome. “We always needed to know where the nearest bathroom was. I grew up with that around me, and I was always just fascinated by the gut and the digestive system,” said Dr. Haghighat, who just finished up her fellowship at the University of Miami and is now a gastroenterologist at University of California, Los Angeles. She also serves as social media editor for AGA’s Gastro Hep Advances.
As she got to know the personalities of the GI department in the first year of medical school, “I realized that our senses of humor and personalities kind of aligned, and I was like, ‘Oh yeah, this is where I’m supposed to be,’ ” said Dr. Haghighat, who can be found on X @DoctorShida.
Humor is something Dr. Haghighat has reached for throughout her life and career. She eventually channeled her gift for satire onto the stage and the internet, as a stand-up comedian. In an interview with GI & Hepatology News, she spoke about the connection between GI medicine and humor, and the creative ways she has helped promote cancer screening in underserved populations.
Q: What practice challenges have you faced in your career?
Dr. Haghighat: I trained in a county hospital, so I’ve always worked with underserved and vulnerable populations. One of the challenges has been just navigation of care, especially as it pertains to cancer diagnoses or cancer screening. A lot of the time, patients don’t understand why they have to do a test or something invasive like a colonoscopy for symptoms they don’t have.
Q: A focus of yours has been improving uptake of screening in underserved communities. Please talk about the work you’ve done in this area.
Dr. Haghighat: I was at Los Angeles General Medical Center — a county hospital in Los Angeles — for residency, where we treated underserved, uninsured patients. I noticed in our primary care clinics a very low uptake of colon cancer screening. Patients didn’t want to bring the stool tests back or get colonoscopies. I surveyed a bunch of the patients and asked: How can we make colon cancer screening easier for you? About a third of the patients said, “If I can do it in the clinic before I go home, that would be great.”
So, I started this initiative called “Go Before You Go.” We would ask patients, “Hey, do you need to go to the bathroom right now, if you can?” Our nurses handed them the stool test to do in the bathroom before they left the clinic after their doctor visits.
We saw really good results with that. Surprisingly, a lot of people can go on demand. We saw increased screening rates, and that quality improvement project went on to win multiple first place awards in research competitions. So that’s what got me interested, and that’s where I had my beginnings of increasing preventative services in underserved communities on the ground.
Q: Can you discuss some health disparity studies you’ve done in this area?
Dr. Haghighat: As a GI at Jackson Memorial Hospital in Miami, I was seeing cancer disparities firsthand every day. I wanted to approach these disparities from a research funding standpoint on a federal level. I was particularly interested in gastric cancer because it’s not common enough in the United States to warrant universal screening, but it’s very common among certain racial and ethnic minorities, which would warrant targeted screening.
I evaluated cancer funding allocation from the National Cancer Institute among the most common cancers in the United States and found that cancer afflicting a higher proportion of racial and ethnic minorities was receiving lower funding. One of those cancers was stomach cancer. This study basically highlighted that, to decrease these disparities, a top-down policy approach is necessary to distribute cancer research funding equitably across these groups.
A lot of stomach cancer comes from a bacteria called Helicobacter pylori, which can be more prevalent in certain countries. In another study, I looked at country of birth as a risk factor for stomach cancer, specifically for gastric intestinal metaplasia, which is a precursor for gastric cancer .
We found that country of birth is a key risk factor for gastric intestinal metaplasia and that it should be incorporated into risk stratification for targeted screening.
Q: Outside of medicine, you perform as a stand-up comedian. You have a popular satirical alias on social media. How did you get interested in stand-up comedy?
Dr. Haghighat: I gave my medical school’s commencement speech, and I had sprinkled a few jokes in there. Afterward, multiple people approached me and said, “You should really consider stand-up comedy. Your timing and delivery are great.” A few months later, I started my intern year in Los Angeles and simultaneously took stand-up comedy classes. I started performing at local clubs around town throughout residency, and I had two or three good sets that I could rely on. And so that’s how I got into stand-up comedy.
My intern year is also when I started this social media satire account. It was a way to cope with the anxieties and stress of residency. Before I knew it, the account gained multitudes of followers, doctors, and other medical professionals. And I joke that the more hours I work in a week, the more memes I make, the more posts I make. It’s kind of a creative outlet for me after a long day.
Q: What types of things do you talk about during your stand-up act?
Dr. Haghighat: A lot of it is about growing up in an immigrant household as a first-generation Iranian American. One of my favorite jokes is, my parents gave me so many options for a career. They said I could be a family doctor, a surgeon, a plastic surgeon, and if I worked hard, even a wife of a surgeon. But I talk a lot about being a woman in medicine. That always gets a lot of laughs. And now that I’ve graduated GI fellowship, I’m excited to incorporate some GI jokes because it turns out people love poop jokes.
Lightning Round
Texting or talking?
Text
Favorite city in U.S. besides the one you live in?
Denver
Cat or dog person
Dog
Best place you went on vacation
Patagonia
Favorite sport
Basketball
Favorite ice cream
Rocky Road
What song do you have to sing along with when you hear it?
Celine Dion’s My Heart Will Go On
She watched her father suffer from the complications of Crohn’s disease and her brother struggle with irritable bowel syndrome. “We always needed to know where the nearest bathroom was. I grew up with that around me, and I was always just fascinated by the gut and the digestive system,” said Dr. Haghighat, who just finished up her fellowship at the University of Miami and is now a gastroenterologist at University of California, Los Angeles. She also serves as social media editor for AGA’s Gastro Hep Advances.
As she got to know the personalities of the GI department in the first year of medical school, “I realized that our senses of humor and personalities kind of aligned, and I was like, ‘Oh yeah, this is where I’m supposed to be,’ ” said Dr. Haghighat, who can be found on X @DoctorShida.
Humor is something Dr. Haghighat has reached for throughout her life and career. She eventually channeled her gift for satire onto the stage and the internet, as a stand-up comedian. In an interview with GI & Hepatology News, she spoke about the connection between GI medicine and humor, and the creative ways she has helped promote cancer screening in underserved populations.
Q: What practice challenges have you faced in your career?
Dr. Haghighat: I trained in a county hospital, so I’ve always worked with underserved and vulnerable populations. One of the challenges has been just navigation of care, especially as it pertains to cancer diagnoses or cancer screening. A lot of the time, patients don’t understand why they have to do a test or something invasive like a colonoscopy for symptoms they don’t have.
Q: A focus of yours has been improving uptake of screening in underserved communities. Please talk about the work you’ve done in this area.
Dr. Haghighat: I was at Los Angeles General Medical Center — a county hospital in Los Angeles — for residency, where we treated underserved, uninsured patients. I noticed in our primary care clinics a very low uptake of colon cancer screening. Patients didn’t want to bring the stool tests back or get colonoscopies. I surveyed a bunch of the patients and asked: How can we make colon cancer screening easier for you? About a third of the patients said, “If I can do it in the clinic before I go home, that would be great.”
So, I started this initiative called “Go Before You Go.” We would ask patients, “Hey, do you need to go to the bathroom right now, if you can?” Our nurses handed them the stool test to do in the bathroom before they left the clinic after their doctor visits.
We saw really good results with that. Surprisingly, a lot of people can go on demand. We saw increased screening rates, and that quality improvement project went on to win multiple first place awards in research competitions. So that’s what got me interested, and that’s where I had my beginnings of increasing preventative services in underserved communities on the ground.
Q: Can you discuss some health disparity studies you’ve done in this area?
Dr. Haghighat: As a GI at Jackson Memorial Hospital in Miami, I was seeing cancer disparities firsthand every day. I wanted to approach these disparities from a research funding standpoint on a federal level. I was particularly interested in gastric cancer because it’s not common enough in the United States to warrant universal screening, but it’s very common among certain racial and ethnic minorities, which would warrant targeted screening.
I evaluated cancer funding allocation from the National Cancer Institute among the most common cancers in the United States and found that cancer afflicting a higher proportion of racial and ethnic minorities was receiving lower funding. One of those cancers was stomach cancer. This study basically highlighted that, to decrease these disparities, a top-down policy approach is necessary to distribute cancer research funding equitably across these groups.
A lot of stomach cancer comes from a bacteria called Helicobacter pylori, which can be more prevalent in certain countries. In another study, I looked at country of birth as a risk factor for stomach cancer, specifically for gastric intestinal metaplasia, which is a precursor for gastric cancer .
We found that country of birth is a key risk factor for gastric intestinal metaplasia and that it should be incorporated into risk stratification for targeted screening.
Q: Outside of medicine, you perform as a stand-up comedian. You have a popular satirical alias on social media. How did you get interested in stand-up comedy?
Dr. Haghighat: I gave my medical school’s commencement speech, and I had sprinkled a few jokes in there. Afterward, multiple people approached me and said, “You should really consider stand-up comedy. Your timing and delivery are great.” A few months later, I started my intern year in Los Angeles and simultaneously took stand-up comedy classes. I started performing at local clubs around town throughout residency, and I had two or three good sets that I could rely on. And so that’s how I got into stand-up comedy.
My intern year is also when I started this social media satire account. It was a way to cope with the anxieties and stress of residency. Before I knew it, the account gained multitudes of followers, doctors, and other medical professionals. And I joke that the more hours I work in a week, the more memes I make, the more posts I make. It’s kind of a creative outlet for me after a long day.
Q: What types of things do you talk about during your stand-up act?
Dr. Haghighat: A lot of it is about growing up in an immigrant household as a first-generation Iranian American. One of my favorite jokes is, my parents gave me so many options for a career. They said I could be a family doctor, a surgeon, a plastic surgeon, and if I worked hard, even a wife of a surgeon. But I talk a lot about being a woman in medicine. That always gets a lot of laughs. And now that I’ve graduated GI fellowship, I’m excited to incorporate some GI jokes because it turns out people love poop jokes.
Lightning Round
Texting or talking?
Text
Favorite city in U.S. besides the one you live in?
Denver
Cat or dog person
Dog
Best place you went on vacation
Patagonia
Favorite sport
Basketball
Favorite ice cream
Rocky Road
What song do you have to sing along with when you hear it?
Celine Dion’s My Heart Will Go On
The Gamer Who Became a GI Hospitalist and Dedicated Endoscopist
Reflecting on his career in gastroenterology, Andy Tau, MD, (@DrBloodandGuts on X) claims the discipline chose him, in many ways.
“I love gaming, which my mom said would never pay off. Then one day she nearly died from a peptic ulcer, and endoscopy saved her,” said Dr. Tau, a GI hospitalist who practices with Austin Gastroenterology in Austin, Texas. One of his specialties is endoscopic hemostasis.
Endoscopy functions similarly to a game because the interface between the operator and the patient is a controller and a video screen, he explained. “Movements in my hands translate directly onto the screen. Obviously, endoscopy is serious business, but the tactile feel was very familiar and satisfying to me.”
Advocating for the GI hospitalist and the versatile role they play in hospital medicine, is another passion of his. “The dedicated GI hospitalist indirectly improves the efficiency of an outpatient practice, while directly improving inpatient outcomes, collegiality, and even one’s own skills as an endoscopist,” Dr. Tau wrote in an opinion piece in GI & Hepatology News .
He expounded more on this topic and others in an interview, recalling what he learned from one mentor about maintaining a sense of humor at the bedside.
Q: You’ve said that GI hospitalists are the future of patient care. Can you explain why you feel this way?
Dr. Tau: From a quality perspective, even though it’s hard to put into one word, the care of acute GI pathology and endoscopy can be seen as a specialty in and of itself. These skills include hemostasis, enteral access, percutaneous endoscopic gastrostomy (PEG), balloon-assisted enteroscopy, luminal stenting, advanced tissue closure, and endoscopic retrograde cholangiopancreatography. The greater availability of a GI hospitalist, as opposed to an outpatient GI doctor rounding at the ends of days, likely shortens admissions and improves the logistics of scheduling inpatient cases.
From a financial perspective, the landscape of GI practice is changing because of GI physician shortages relative to increased demand for outpatient procedures. Namely, the outpatient gastroenterologists simply have too much on their plate and inefficiencies abound when they have to juggle inpatient and outpatient work. Thus, two tracks are forming, especially in large busy hospitals. This is the same evolution of the pure outpatient internist and inpatient internist 20 years ago.
Q: What attributes does a GI hospitalist bring to the table?
Dr. Tau: A GI hospitalist is one who can multitask through interruptions, manage end-of-life issues, craves therapeutic endoscopy (even if that’s hemostasis), and can keep more erratic hours based on the number of consults that come in. She/he tends to want immediate gratification and doesn’t mind the lack of continuity of care. Lastly, the GI hospitalist has to be brave and yet careful as the patients are sicker and thus complications may be higher and certainly less well tolerated.
Q: Are there enough of them going into practice right now?
Dr. Tau: Not really! The demand seems to outstrip supply based on what I see. There is a definite financial lure as the market rate for them rises (because more GIs are leaving the hospital for pure outpatient practice), but burnout can be an issue. Interestingly, fellows are typically highly trained and familiar with inpatient work, but once in practice, most choose the outpatient track. I think it’s a combination of work-life balance, inefficiency of inpatient endoscopy, and perhaps the strain of daily, erratic consultation.
Q: You received the 2021 Travis County Medical Society (TCMS) Young Physician of the Year. What achievements led to this honor?
Dr. Tau: I am not sure I am deserving of that award, but I think it was related to personal risk and some long hours as a GI hospitalist during the COVID pandemic. I may have the unfortunate distinction of performing more procedures on COVID patients than any other physician in the city. My hospital was the largest COVID-designated site in the city. There were countless PEG tubes in COVID survivors and a lot of bleeders for some reason. A critical care physician on the front lines and health director of the city of Austin received Physician of the Year, deservedly.
Q: What teacher or mentor had the greatest impact on you?
Dr. Tau: David Y. Graham, MD, MACG, got me into GI as a medical student and taught me to never tolerate any loose ends when it came to patient care as a resident. He trained me at every level — from medical school, residency, and through my fellowship. His advice is often delivered sly and dry, but his humor-laden truths continue to ring true throughout my life. One story: my whole family tested positive for Helicobacter pylori after my mother survived peptic ulcer hemorrhage. I was the only one who tested negative! I asked Dr Graham about it and he quipped, “You’re lucky! It’s because your mother didn’t love (and kiss) you as much!”
Even to this moment I laugh about that. I share that with my patients when they ask about how they contracted H. pylori.
Lightning Round
Favorite junk food?
McDonalds fries
Favorite movie genre?
Psychological thriller
Cat person or dog person?
Dog
What was your favorite Halloween costume?
Ninja turtle
Favorite sport:
Football (played in college)
Introvert or extrovert?
Extrovert unless sleep deprived.
Favorite holiday:
Thanksgiving
The book you read over and over:
Swiss Family Robinson
Favorite travel destination:
Hawaii
Optimist or pessimist?
A happy pessimist.
Reflecting on his career in gastroenterology, Andy Tau, MD, (@DrBloodandGuts on X) claims the discipline chose him, in many ways.
“I love gaming, which my mom said would never pay off. Then one day she nearly died from a peptic ulcer, and endoscopy saved her,” said Dr. Tau, a GI hospitalist who practices with Austin Gastroenterology in Austin, Texas. One of his specialties is endoscopic hemostasis.
Endoscopy functions similarly to a game because the interface between the operator and the patient is a controller and a video screen, he explained. “Movements in my hands translate directly onto the screen. Obviously, endoscopy is serious business, but the tactile feel was very familiar and satisfying to me.”
Advocating for the GI hospitalist and the versatile role they play in hospital medicine, is another passion of his. “The dedicated GI hospitalist indirectly improves the efficiency of an outpatient practice, while directly improving inpatient outcomes, collegiality, and even one’s own skills as an endoscopist,” Dr. Tau wrote in an opinion piece in GI & Hepatology News .
He expounded more on this topic and others in an interview, recalling what he learned from one mentor about maintaining a sense of humor at the bedside.
Q: You’ve said that GI hospitalists are the future of patient care. Can you explain why you feel this way?
Dr. Tau: From a quality perspective, even though it’s hard to put into one word, the care of acute GI pathology and endoscopy can be seen as a specialty in and of itself. These skills include hemostasis, enteral access, percutaneous endoscopic gastrostomy (PEG), balloon-assisted enteroscopy, luminal stenting, advanced tissue closure, and endoscopic retrograde cholangiopancreatography. The greater availability of a GI hospitalist, as opposed to an outpatient GI doctor rounding at the ends of days, likely shortens admissions and improves the logistics of scheduling inpatient cases.
From a financial perspective, the landscape of GI practice is changing because of GI physician shortages relative to increased demand for outpatient procedures. Namely, the outpatient gastroenterologists simply have too much on their plate and inefficiencies abound when they have to juggle inpatient and outpatient work. Thus, two tracks are forming, especially in large busy hospitals. This is the same evolution of the pure outpatient internist and inpatient internist 20 years ago.
Q: What attributes does a GI hospitalist bring to the table?
Dr. Tau: A GI hospitalist is one who can multitask through interruptions, manage end-of-life issues, craves therapeutic endoscopy (even if that’s hemostasis), and can keep more erratic hours based on the number of consults that come in. She/he tends to want immediate gratification and doesn’t mind the lack of continuity of care. Lastly, the GI hospitalist has to be brave and yet careful as the patients are sicker and thus complications may be higher and certainly less well tolerated.
Q: Are there enough of them going into practice right now?
Dr. Tau: Not really! The demand seems to outstrip supply based on what I see. There is a definite financial lure as the market rate for them rises (because more GIs are leaving the hospital for pure outpatient practice), but burnout can be an issue. Interestingly, fellows are typically highly trained and familiar with inpatient work, but once in practice, most choose the outpatient track. I think it’s a combination of work-life balance, inefficiency of inpatient endoscopy, and perhaps the strain of daily, erratic consultation.
Q: You received the 2021 Travis County Medical Society (TCMS) Young Physician of the Year. What achievements led to this honor?
Dr. Tau: I am not sure I am deserving of that award, but I think it was related to personal risk and some long hours as a GI hospitalist during the COVID pandemic. I may have the unfortunate distinction of performing more procedures on COVID patients than any other physician in the city. My hospital was the largest COVID-designated site in the city. There were countless PEG tubes in COVID survivors and a lot of bleeders for some reason. A critical care physician on the front lines and health director of the city of Austin received Physician of the Year, deservedly.
Q: What teacher or mentor had the greatest impact on you?
Dr. Tau: David Y. Graham, MD, MACG, got me into GI as a medical student and taught me to never tolerate any loose ends when it came to patient care as a resident. He trained me at every level — from medical school, residency, and through my fellowship. His advice is often delivered sly and dry, but his humor-laden truths continue to ring true throughout my life. One story: my whole family tested positive for Helicobacter pylori after my mother survived peptic ulcer hemorrhage. I was the only one who tested negative! I asked Dr Graham about it and he quipped, “You’re lucky! It’s because your mother didn’t love (and kiss) you as much!”
Even to this moment I laugh about that. I share that with my patients when they ask about how they contracted H. pylori.
Lightning Round
Favorite junk food?
McDonalds fries
Favorite movie genre?
Psychological thriller
Cat person or dog person?
Dog
What was your favorite Halloween costume?
Ninja turtle
Favorite sport:
Football (played in college)
Introvert or extrovert?
Extrovert unless sleep deprived.
Favorite holiday:
Thanksgiving
The book you read over and over:
Swiss Family Robinson
Favorite travel destination:
Hawaii
Optimist or pessimist?
A happy pessimist.
Reflecting on his career in gastroenterology, Andy Tau, MD, (@DrBloodandGuts on X) claims the discipline chose him, in many ways.
“I love gaming, which my mom said would never pay off. Then one day she nearly died from a peptic ulcer, and endoscopy saved her,” said Dr. Tau, a GI hospitalist who practices with Austin Gastroenterology in Austin, Texas. One of his specialties is endoscopic hemostasis.
Endoscopy functions similarly to a game because the interface between the operator and the patient is a controller and a video screen, he explained. “Movements in my hands translate directly onto the screen. Obviously, endoscopy is serious business, but the tactile feel was very familiar and satisfying to me.”
Advocating for the GI hospitalist and the versatile role they play in hospital medicine, is another passion of his. “The dedicated GI hospitalist indirectly improves the efficiency of an outpatient practice, while directly improving inpatient outcomes, collegiality, and even one’s own skills as an endoscopist,” Dr. Tau wrote in an opinion piece in GI & Hepatology News .
He expounded more on this topic and others in an interview, recalling what he learned from one mentor about maintaining a sense of humor at the bedside.
Q: You’ve said that GI hospitalists are the future of patient care. Can you explain why you feel this way?
Dr. Tau: From a quality perspective, even though it’s hard to put into one word, the care of acute GI pathology and endoscopy can be seen as a specialty in and of itself. These skills include hemostasis, enteral access, percutaneous endoscopic gastrostomy (PEG), balloon-assisted enteroscopy, luminal stenting, advanced tissue closure, and endoscopic retrograde cholangiopancreatography. The greater availability of a GI hospitalist, as opposed to an outpatient GI doctor rounding at the ends of days, likely shortens admissions and improves the logistics of scheduling inpatient cases.
From a financial perspective, the landscape of GI practice is changing because of GI physician shortages relative to increased demand for outpatient procedures. Namely, the outpatient gastroenterologists simply have too much on their plate and inefficiencies abound when they have to juggle inpatient and outpatient work. Thus, two tracks are forming, especially in large busy hospitals. This is the same evolution of the pure outpatient internist and inpatient internist 20 years ago.
Q: What attributes does a GI hospitalist bring to the table?
Dr. Tau: A GI hospitalist is one who can multitask through interruptions, manage end-of-life issues, craves therapeutic endoscopy (even if that’s hemostasis), and can keep more erratic hours based on the number of consults that come in. She/he tends to want immediate gratification and doesn’t mind the lack of continuity of care. Lastly, the GI hospitalist has to be brave and yet careful as the patients are sicker and thus complications may be higher and certainly less well tolerated.
Q: Are there enough of them going into practice right now?
Dr. Tau: Not really! The demand seems to outstrip supply based on what I see. There is a definite financial lure as the market rate for them rises (because more GIs are leaving the hospital for pure outpatient practice), but burnout can be an issue. Interestingly, fellows are typically highly trained and familiar with inpatient work, but once in practice, most choose the outpatient track. I think it’s a combination of work-life balance, inefficiency of inpatient endoscopy, and perhaps the strain of daily, erratic consultation.
Q: You received the 2021 Travis County Medical Society (TCMS) Young Physician of the Year. What achievements led to this honor?
Dr. Tau: I am not sure I am deserving of that award, but I think it was related to personal risk and some long hours as a GI hospitalist during the COVID pandemic. I may have the unfortunate distinction of performing more procedures on COVID patients than any other physician in the city. My hospital was the largest COVID-designated site in the city. There were countless PEG tubes in COVID survivors and a lot of bleeders for some reason. A critical care physician on the front lines and health director of the city of Austin received Physician of the Year, deservedly.
Q: What teacher or mentor had the greatest impact on you?
Dr. Tau: David Y. Graham, MD, MACG, got me into GI as a medical student and taught me to never tolerate any loose ends when it came to patient care as a resident. He trained me at every level — from medical school, residency, and through my fellowship. His advice is often delivered sly and dry, but his humor-laden truths continue to ring true throughout my life. One story: my whole family tested positive for Helicobacter pylori after my mother survived peptic ulcer hemorrhage. I was the only one who tested negative! I asked Dr Graham about it and he quipped, “You’re lucky! It’s because your mother didn’t love (and kiss) you as much!”
Even to this moment I laugh about that. I share that with my patients when they ask about how they contracted H. pylori.
Lightning Round
Favorite junk food?
McDonalds fries
Favorite movie genre?
Psychological thriller
Cat person or dog person?
Dog
What was your favorite Halloween costume?
Ninja turtle
Favorite sport:
Football (played in college)
Introvert or extrovert?
Extrovert unless sleep deprived.
Favorite holiday:
Thanksgiving
The book you read over and over:
Swiss Family Robinson
Favorite travel destination:
Hawaii
Optimist or pessimist?
A happy pessimist.
Gastroenterologist advocates for fair coverage, reduced physician burden
Faced with an opportunity to advocate for patients, Rajeev Jain, MD, AGAF, is never afraid to speak up. He recently spoke out publicly against a major payer’s new advance notification process for colonoscopy and endoscopy procedures, cautioning it was a glidepath toward far-reaching prior authorization requirements.
UnitedHealthcare plans to collect a larger scope of data for this new policy, “which I fear will disrupt and deny patients’ access to lifesaving care,” Dr. Jain, a gastroenterologist with Texas Digestive Disease Consultants and a member of the American Gastroenterological Association’s (AGA) Prior Authorization Reform Task Force, wrote in an opinion piece in the Dallas Morning News.
Insurance coverage should be fair to the end goal of taking good care of patients, said Dr. Jain. “And if they’re putting processes in place, which are solely to be an impediment to excellent care, then that’s not right.”
Through his extensive participation in AGA panels and other influential groups, Dr. Jain has sought to improve clinical practice and reduce physician burnout. As Director and now Chair of the Board of Directors” of the American Board of Internal Medicine, Dr. Jain participated in conversations to make the maintenance of certification (MOC) process more accessible and less burdensome for doctors.
People spent a lot of time studying for ABIM’s 10-year MOC exam, sometimes even taking a course to help them pass. Now, there’s an option in all specialties to take a 30-question exam every quarter.
On average, it takes someone roughly 2 minutes to answer each question on this short exam. “Per quarter, you’re roughly spending an hour to do that instead of taking a big 10-year exam, where people were spending money and missing work,” said Dr. Jain. This modality enables physicians to meet credentialing requirements “in a way that it meets many of the desires of our practitioners,” he added.
Dr. Jain expounded on his work to advocate for patients and physicians in an interview.
Q: I’d like to discuss your opinion piece on UnitedHealthcare’s advanced notification process. Where does that policy stand now? I’m wondering if your opinion piece led to any changes.
Dr. Jain: There’s not a metric I can use to measure its success. But I will tell you this: I’ve had numerous patients mention to me, “Hey, I saw your article in the Dallas Morning News. That was great.” And that would lead to a conversation.
Q: Why do you think UHC’s policy was a tool for prior authorization?
Dr. Jain: Imagine you go to see a gastroenterologist in clinic, and the GI believes you need a procedure for certain symptoms or abnormal laboratory tests or imaging. It’s not a screening procedure. It’s a diagnostic procedure. Now, the insurance company is going to say, “Well, we can’t schedule that until you do a preauthorization.”
That could take a day. It could take a week. It could take longer. And now, the patient has lost that moment where they can get this settled. It’s not just the schedule for the patient. They’re going to get anesthesia, be it conscious sedation or deeper sedation, and they’re going to need a ride home. They have to coordinate things with family members or friends. Those little logistics add up to a lot of times why patients cancel or don’t show up or don’t follow through, because we couldn’t get it scheduled at that moment.
I feel like we are trying to attack this problem from many different angles, and my opinion piece was one of those tactics. The patients and the rank-and-file gastroenterologists appreciate the AGA being at the forefront of this issue.
Q: Your interests range from colon cancer to Barrett’s esophagus and inflammatory bowel disease (IBD). Is there an area of focus you feel passionate about?
Dr. Jain: Through AGA, I was the cochair of the IBD Parenthood Project, which convened subject-matter experts outside of GI, including maternal-fetal medicine, lactation experts, and patients. We came up with a care pathway for women in their reproductive years who have inflammatory bowel disease, including how they should think about family planning and what they should do during pregnancy and then the postpartum. Those kinds of things have really kept me energized. It’s sort of an antidote to burnout.
Q: Who are your mentors?
Dr. Jain: I would say the late Dan Foster, MD, who was the chair of medicine at UT Southwestern, and Mark Feldman, MD, AGAF, who held leadership roles at the Dallas VA Medical Center and then Texas Health Dallas. He retired a few years ago. They both expected physicians to understand the knowledge of how we were taking care of the patient and our professionalism. There’s also my senior partner, Peter Loeb, MD, AGAF, who’s now retired. He had an insatiable appetite for knowledge. Every time I’d come back from a meeting, he’d say, “Rajeev, tell me three things you learned.” He always kept patients as the primary North Star; that whatever we did, we were thinking, “Is it best for the patient?”
Lightning Round:
Favorite type of music?
1980s alternative
Favorite movie genre?
Comedy
Cat person or dog person?
Dog
Favorite sport:
College football
What song do you have to sing along with when you hear it?
“I Ran,” by a Flock of Seagulls
Faced with an opportunity to advocate for patients, Rajeev Jain, MD, AGAF, is never afraid to speak up. He recently spoke out publicly against a major payer’s new advance notification process for colonoscopy and endoscopy procedures, cautioning it was a glidepath toward far-reaching prior authorization requirements.
UnitedHealthcare plans to collect a larger scope of data for this new policy, “which I fear will disrupt and deny patients’ access to lifesaving care,” Dr. Jain, a gastroenterologist with Texas Digestive Disease Consultants and a member of the American Gastroenterological Association’s (AGA) Prior Authorization Reform Task Force, wrote in an opinion piece in the Dallas Morning News.
Insurance coverage should be fair to the end goal of taking good care of patients, said Dr. Jain. “And if they’re putting processes in place, which are solely to be an impediment to excellent care, then that’s not right.”
Through his extensive participation in AGA panels and other influential groups, Dr. Jain has sought to improve clinical practice and reduce physician burnout. As Director and now Chair of the Board of Directors” of the American Board of Internal Medicine, Dr. Jain participated in conversations to make the maintenance of certification (MOC) process more accessible and less burdensome for doctors.
People spent a lot of time studying for ABIM’s 10-year MOC exam, sometimes even taking a course to help them pass. Now, there’s an option in all specialties to take a 30-question exam every quarter.
On average, it takes someone roughly 2 minutes to answer each question on this short exam. “Per quarter, you’re roughly spending an hour to do that instead of taking a big 10-year exam, where people were spending money and missing work,” said Dr. Jain. This modality enables physicians to meet credentialing requirements “in a way that it meets many of the desires of our practitioners,” he added.
Dr. Jain expounded on his work to advocate for patients and physicians in an interview.
Q: I’d like to discuss your opinion piece on UnitedHealthcare’s advanced notification process. Where does that policy stand now? I’m wondering if your opinion piece led to any changes.
Dr. Jain: There’s not a metric I can use to measure its success. But I will tell you this: I’ve had numerous patients mention to me, “Hey, I saw your article in the Dallas Morning News. That was great.” And that would lead to a conversation.
Q: Why do you think UHC’s policy was a tool for prior authorization?
Dr. Jain: Imagine you go to see a gastroenterologist in clinic, and the GI believes you need a procedure for certain symptoms or abnormal laboratory tests or imaging. It’s not a screening procedure. It’s a diagnostic procedure. Now, the insurance company is going to say, “Well, we can’t schedule that until you do a preauthorization.”
That could take a day. It could take a week. It could take longer. And now, the patient has lost that moment where they can get this settled. It’s not just the schedule for the patient. They’re going to get anesthesia, be it conscious sedation or deeper sedation, and they’re going to need a ride home. They have to coordinate things with family members or friends. Those little logistics add up to a lot of times why patients cancel or don’t show up or don’t follow through, because we couldn’t get it scheduled at that moment.
I feel like we are trying to attack this problem from many different angles, and my opinion piece was one of those tactics. The patients and the rank-and-file gastroenterologists appreciate the AGA being at the forefront of this issue.
Q: Your interests range from colon cancer to Barrett’s esophagus and inflammatory bowel disease (IBD). Is there an area of focus you feel passionate about?
Dr. Jain: Through AGA, I was the cochair of the IBD Parenthood Project, which convened subject-matter experts outside of GI, including maternal-fetal medicine, lactation experts, and patients. We came up with a care pathway for women in their reproductive years who have inflammatory bowel disease, including how they should think about family planning and what they should do during pregnancy and then the postpartum. Those kinds of things have really kept me energized. It’s sort of an antidote to burnout.
Q: Who are your mentors?
Dr. Jain: I would say the late Dan Foster, MD, who was the chair of medicine at UT Southwestern, and Mark Feldman, MD, AGAF, who held leadership roles at the Dallas VA Medical Center and then Texas Health Dallas. He retired a few years ago. They both expected physicians to understand the knowledge of how we were taking care of the patient and our professionalism. There’s also my senior partner, Peter Loeb, MD, AGAF, who’s now retired. He had an insatiable appetite for knowledge. Every time I’d come back from a meeting, he’d say, “Rajeev, tell me three things you learned.” He always kept patients as the primary North Star; that whatever we did, we were thinking, “Is it best for the patient?”
Lightning Round:
Favorite type of music?
1980s alternative
Favorite movie genre?
Comedy
Cat person or dog person?
Dog
Favorite sport:
College football
What song do you have to sing along with when you hear it?
“I Ran,” by a Flock of Seagulls
Faced with an opportunity to advocate for patients, Rajeev Jain, MD, AGAF, is never afraid to speak up. He recently spoke out publicly against a major payer’s new advance notification process for colonoscopy and endoscopy procedures, cautioning it was a glidepath toward far-reaching prior authorization requirements.
UnitedHealthcare plans to collect a larger scope of data for this new policy, “which I fear will disrupt and deny patients’ access to lifesaving care,” Dr. Jain, a gastroenterologist with Texas Digestive Disease Consultants and a member of the American Gastroenterological Association’s (AGA) Prior Authorization Reform Task Force, wrote in an opinion piece in the Dallas Morning News.
Insurance coverage should be fair to the end goal of taking good care of patients, said Dr. Jain. “And if they’re putting processes in place, which are solely to be an impediment to excellent care, then that’s not right.”
Through his extensive participation in AGA panels and other influential groups, Dr. Jain has sought to improve clinical practice and reduce physician burnout. As Director and now Chair of the Board of Directors” of the American Board of Internal Medicine, Dr. Jain participated in conversations to make the maintenance of certification (MOC) process more accessible and less burdensome for doctors.
People spent a lot of time studying for ABIM’s 10-year MOC exam, sometimes even taking a course to help them pass. Now, there’s an option in all specialties to take a 30-question exam every quarter.
On average, it takes someone roughly 2 minutes to answer each question on this short exam. “Per quarter, you’re roughly spending an hour to do that instead of taking a big 10-year exam, where people were spending money and missing work,” said Dr. Jain. This modality enables physicians to meet credentialing requirements “in a way that it meets many of the desires of our practitioners,” he added.
Dr. Jain expounded on his work to advocate for patients and physicians in an interview.
Q: I’d like to discuss your opinion piece on UnitedHealthcare’s advanced notification process. Where does that policy stand now? I’m wondering if your opinion piece led to any changes.
Dr. Jain: There’s not a metric I can use to measure its success. But I will tell you this: I’ve had numerous patients mention to me, “Hey, I saw your article in the Dallas Morning News. That was great.” And that would lead to a conversation.
Q: Why do you think UHC’s policy was a tool for prior authorization?
Dr. Jain: Imagine you go to see a gastroenterologist in clinic, and the GI believes you need a procedure for certain symptoms or abnormal laboratory tests or imaging. It’s not a screening procedure. It’s a diagnostic procedure. Now, the insurance company is going to say, “Well, we can’t schedule that until you do a preauthorization.”
That could take a day. It could take a week. It could take longer. And now, the patient has lost that moment where they can get this settled. It’s not just the schedule for the patient. They’re going to get anesthesia, be it conscious sedation or deeper sedation, and they’re going to need a ride home. They have to coordinate things with family members or friends. Those little logistics add up to a lot of times why patients cancel or don’t show up or don’t follow through, because we couldn’t get it scheduled at that moment.
I feel like we are trying to attack this problem from many different angles, and my opinion piece was one of those tactics. The patients and the rank-and-file gastroenterologists appreciate the AGA being at the forefront of this issue.
Q: Your interests range from colon cancer to Barrett’s esophagus and inflammatory bowel disease (IBD). Is there an area of focus you feel passionate about?
Dr. Jain: Through AGA, I was the cochair of the IBD Parenthood Project, which convened subject-matter experts outside of GI, including maternal-fetal medicine, lactation experts, and patients. We came up with a care pathway for women in their reproductive years who have inflammatory bowel disease, including how they should think about family planning and what they should do during pregnancy and then the postpartum. Those kinds of things have really kept me energized. It’s sort of an antidote to burnout.
Q: Who are your mentors?
Dr. Jain: I would say the late Dan Foster, MD, who was the chair of medicine at UT Southwestern, and Mark Feldman, MD, AGAF, who held leadership roles at the Dallas VA Medical Center and then Texas Health Dallas. He retired a few years ago. They both expected physicians to understand the knowledge of how we were taking care of the patient and our professionalism. There’s also my senior partner, Peter Loeb, MD, AGAF, who’s now retired. He had an insatiable appetite for knowledge. Every time I’d come back from a meeting, he’d say, “Rajeev, tell me three things you learned.” He always kept patients as the primary North Star; that whatever we did, we were thinking, “Is it best for the patient?”
Lightning Round:
Favorite type of music?
1980s alternative
Favorite movie genre?
Comedy
Cat person or dog person?
Dog
Favorite sport:
College football
What song do you have to sing along with when you hear it?
“I Ran,” by a Flock of Seagulls
Best Practices for Hiring, Training, Retaining Rheumatology Advanced Practice Providers
Once considered a luxury, hiring a nurse, nurse practitioner, or physician assistant is becoming a necessity in many rheumatology practices.
Seeing the wait lists pile up in her Florida practice, Stacy Yonker, MBA, chief executive officer of Sarasota Arthritis Center, knew she had to make some changes. “Everyone’s aging in the boomer generations. Particularly in Florida, we have a lot of people who retire here. In the more southern demographics, it is a very difficult challenge for practices to get new patients in,” she said.
Ms. Yonker is in the process of hiring several nurse practitioners (NPs) to assist in the clinics and infusion suites, lightening the load for the practice’s 11 rheumatologists.
Hiring an advanced practice provider (APP) to support the practice is just a first step. Getting these additional personnel up to speed means an investment in education and fostering good working relationships with NPs, PAs, and the staff’s physicians. Even more importantly, practices need to set realistic expectations on workload for these new hires.
“I tried to hire them, but I couldn’t keep them,” is a statement Christine A. Stamatos, DNP, ANP-C, hears all the time from rheumatologists. Oftentimes it’s because the practice saddles the new hire with 20 patients a day, said Dr. Stamatos, director of the Fibromyalgia Wellness Center within the division of rheumatology at Northwell Health in Huntington, New York. She is also an assistant professor at Hofstra Northwell School of Graduate Nursing and Physician Assistant Studies in Hempstead, New York.
“Twenty patients a day is too much,” Dr. Stamatos said. Overload someone, and they won’t stay. Offer them the support, mentoring, and tools they need to practice in their setting — and they will.
Why the Profession Needs APPs
Rheumatology is a much smaller specialty than most, with only a set number of rheumatologists in the field that can provide care to patients. A growing shortage is also looming. Reports from the American College of Rheumatology have projected troubling shortfalls in rheumatologists over the next decade in all regions of the United States.
Many of them aging into retirement “poses a significant issue on being able to continue providing care for the population that experiences the rheumatic disease,” said Ms. Yonker, a director of the National Organization of Rheumatology Management (NORM), a forum that promotes education and advocacy for rheumatology practice managers. People are also living longer, which means more patients are developing arthritis and autoimmune diseases.
Julia M. Swafford, PA-C, a rheumatology physician assistant in Battle Creek, Michigan, sees many advantages of hiring NPs and PAs, and not just from a financial perspective.
Salaries for PAs and NPs aren’t as high and they’re also more accessible than a rheumatologist. “You could train an NP or PA a lot quicker during that same time frame it would take to find a new rheumatology provider,” she offered. And while they may not be as experienced as rheumatologists, “you can kind of mold me on how you like to practice, what medications you may like to use, how you like to treat your patients,” Ms. Swafford said.
Hiring Someone With Experience
Recruiting and retaining APPs is not without its challenges.
Finding individuals compatible with this specialty isn’t easy, noted Mark Box, MD, medical director of Carondelet Rheumatology in Kansas City, Missouri. Ideally, APPs should be inquisitive, compassionate, and ready to learn. “Rheumatology is a cognitive specialty where you have to fit many pieces together. You need an APP who wants to embrace that,” he said.
The profession isn’t that “sexy” either, noted Katie Taylor, Carondelet’s practice manager. Patients are often in head-to-toe pain, and miserable. Many have been to other specialists without answers to their questions. For these reasons, rheumatology can be a hard sell for some PAs and NPs.
Nurse practitioners aren’t always comfortable with administering things such as controlled medications, for example. “It’s a hard patient population, and it’s a specialty of exclusion. You’ve got to be really smart to understand our diseases and our processes and our drugs,” Ms. Taylor said. In other words, it’s a difficult environment for an NP to walk into if their previous experience has been limited to upper respiratory issues and urinary tract infections in the primary care setting.
When hiring an APP, rheumatologists should look for someone who demonstrates an interest in lifelong learning, because the field is changing every day. They should exhibit good scores in educational training and have experience working in an emergency department or another field that translates well into rheumatology such as critical care, immunology, hematology, and orthopedics, she said.
Carondelet Rheumatology was specifically looking for an NP with rheumatology experience to support Dr. Box’s solo practice.
He was facing enormous pressure to be in the office every single day of the week. The practice had to cancel patients for its infusion suite on a regular basis when he was out of the office, Ms. Taylor said. “We couldn’t see new patients, and he wasn’t able to touch as many patients as he wanted to. The doctor takes the oath of touching as many in your community as possible, and you’re limited when you’re a one-man show.”
The practice eventually found an NP who already knew how to do joint injections. “We started her with easier diagnoses for things like osteoporosis and gout. She had an orthopedic background, so she was familiar with some of those diseases,” she said.
Even so, she often leaves with questions every day. “It’s a commitment for her to understand and learn so much,” Ms. Taylor said.
New hires will need support from the practice to get comfortable with rheumatology, Dr. Stamatos said. Responsibility should come in gradual steps.
Instead of loading an NP with 20 patients a day, 2 or 3 patients in the first quarter, eventually graduating to 6-8 patients is a more realistic expectation, Dr. Stamatos advised.
Shadowing the Physician
Partnerships with physicians is a critical component to this onboarding process.
A nurse practitioner recently hired at Dr. Stamatos’ practice works alongside a physician to manage a panel of 25 patients. “We make sure she gets her training, the resources she needs. I personally meet with her to make sure her education is moving forward, connecting her with radiology, pulmonary, hematology,” and other areas of the practice relevant to her training, she added.
The NP also attends weekly grand rounds and case conferences with the fellows. This is the type of well-rounded support any APP needs, she stressed. “Without proper training, you lose people.”
At Sarasota Arthritis Center, NPs help cover the suites but also get assigned to specific physicians so that they can familiarize themselves with that physician’s panel of patients.
“When we start an APP, they shadow for about twice as long as a new physician would. Usually, they’re shadowing for about 6 weeks, just kind of learning the space. There’s a lot of nurse practitioners or PAs who may not have prior rheumatology experience, so we’re essentially training them from the ground up on rheumatology,” Ms. Yonker said.
Pairing them with one provider often directs what type of disease state they focus on, she continued. This dynamic relationship helps guide decisions on whether to include these NPs in the care of patients with more complex diseases.
At least in her practice, the NPs do not see any new patients. They are simply part of the larger care team. “That’s kind of how we present it to our patients, and it makes them feel more comfortable just because they know that they’re not necessarily being handed off to somebody — that the doctor is still overseeing their care,” Ms. Yonker said.
At the same time, the NPs know that they’re supported, that they too have access to tools and mentorship if they need it, she added.
The new NP at Carondelet Rheumatology piggybacked on the doctor’s schedule for 3 months, slowly taking on infusion patients so she could get familiar with their diseases and respective drugs. Eventually, she got her own schedule and was able to take on new patients.
It’s a team effort, Ms. Taylor noted. The NP does the preliminary workup and then the physician comes in and greets the new patient. Together, they develop a follow-up plan for the patient.
Education Resources for Practices
In the case of Dr. Box’s one-physician practice, he was looking for an NP who was willing to be independent and cover things in his absence. “The training has to be there to accomplish that,” said Dr. Box, who likened the training of APPs to a medical residency.
Encouraging them to ask questions, do continuing medical education online and outside reading, are important steps, he added.
In a recent editorial, rheumatologists Eli M. Miloslavsky, MD, and Bethany Marston, MD, offered some strategies for better prepping the APP workforce to meet the demands of rheumatology practices. “Consideration should be given to formal curricula or training programs to help APPs achieve both competence and confidence in treating rheumatologic conditions,” they offered, suggesting an online curriculum developed by the ACR for such a purpose. Fellowship training should also focus on working effectively with APPs, they added.
“Finally, incorporating APPs more effectively into rheumatology professional societies and supporting practices in hiring and training APPs will all be important steps in addressing the rheumatology workforce shortage,” Dr. Miloslavsky and Dr. Marston wrote.
Ms. Yonker said all her APPs take various courses that the ACR and other organizations provide for rheumatology-specific, midlevel positions. “We provide as much training as possible for them to feel comfortable in this space. They are set directly with a physician for a long time and then eventually go into their own space.”
In addition to ACR, the Rheumatology Nurses Society and the Association of Women in Rheumatology offer excellent online training resources for APPs, Ms. Yonker said. “Also, the Bone Health and Osteoporosis Foundation offers an osteoporosis fracture liaison certification which we put APPs through as well,” she added.
Rheumatology practices should also look into an important clinical training grant program from the Rheumatology Research Foundation, Dr. Stamatos advised.
To date, they have “funded almost everyone that applies,” she said. Each grantee receives $25,000 to support training and education involved in onboarding an APP to a rheumatology practice. The money covers attendance at a live rheumatology conference, online educational programs, textbooks, and any society memberships while defraying the cost of training this employee. To increase awareness of the program, the foundation has since expanded the number of available submission dates and the number of grant awardees per year. Currently, the application deadlines for the grants are December 1 and March 1.
For her own health system, Dr. Stamatos has been working on a rheumatology fellowship program for APPs. Through simulation labs, leadership exercises, and other activities, these APPs will learn how to transition from being a new provider to someone who can become part of a practice, she said.
APPs themselves can also get proactive in this learning cycle, Ms. Swafford said. In her view, both APPs and rheumatologists should be conducting didactic lectures and organizing elective rotations with medical students to get them excited about the field. This would establish a good education base that would encourage PAs and NPs to choose rheumatology.
“That’s a huge thing that’s probably missing,” Ms. Swafford said.
Buy-in From the Doctor
No recruitment effort is going to work if the rheumatologists in the practice aren’t committed to the model of having an APP, Ms. Yonker said. “Everybody wants to know their purpose in their company and that they’re valued and they’re needed. And so, I think a pitfall would be if your rheumatologist is not sold on the model of expanding the care team. Because this takes work on behalf of the doctor.”
Rheumatologists are very busy, so it’s a hard sell for them to take time out of their busy clinics to train somebody to do a good job taking care of their patients, Ms. Taylor agreed. “I think that we need the physicians that have had success with this and allow them to coach the physicians that are still resistant.”
In his small practice, Dr. Box has encouraged his NP to assist with practice improvements, working with the office manager. These workers are providers and need to be treated as such, he said. “They need to feel like they contribute to the practice more than just grinding through patients.”
Peer support is another successful ingredient for these workers. Ms. Taylor’s NP finds the time to commiserate with her fellow nurse practitioners — other rheumatology nurses who are also learning the ropes. Rheumatologists are smart, and they can be very intimidating, Ms. Taylor said. In their small office, the rheumatologist is her only peer.
“She likes to get out and sort of integrate with other nurse practitioners that are learning too.”
When APPs Make a Difference
Practices that take on APPs are reporting positive metrics — mainly, shorter wait times for patients. Ms. Yonker’s physicians have been able to add on one to two new patients a day. Wait times have since dwindled from a 5-month to a 3-month wait with the addition of the NPs. “Three months is still long, but we’re working on getting it to that ideal 6-week wait period, which we’re hoping we can accomplish. So we’re able to get more new patients in for sure,” she said.
Prior to hiring an NP, Ms. Taylor’s practice had to defer acceptances for new patients by at least a year. Now, they’re able to accept about half of all new patient referrals. With the NP on board, “We can get them in within 30 days,” she said.
Sometimes, an APP will go beyond their scope of work to make a difference and better support patients.
Patients with rheumatic and osteopathic conditions are often underdiagnosed in the primary care space. As a result, they are not treated as often as they should be. Seeing a need for specialty care, Ms. Swafford took action.
She currently runs the only bone health clinic in southwest Michigan, coordinating with rheumatologists, NPs, urgent care, hospitalists, and interventional radiologists to attend to these patients more quickly and reduce wait times for care. Specialists will flag things such as nontraumatic hip fractures and vertebral fractures and refer them to Ms. Swafford’s clinic, which is part of Bronson Rheumatology Specialists.
The clinic gets quite a few referrals, and the practice is growing. “Usually, they don’t take as long as a rheumatology referral for a workup, so we can see them a little bit quicker,” usually within 3 weeks, she added.
APPs have an opportunity to make their mark in rheumatology at a time when the profession is experiencing significant gaps in care, Ms. Swafford continued. “Unless we find a way to fill that niche, we’re going to be in a world of trouble in the next 10, 20 years.”
None of the sources reported any disclosures or conflicts of interest.
Once considered a luxury, hiring a nurse, nurse practitioner, or physician assistant is becoming a necessity in many rheumatology practices.
Seeing the wait lists pile up in her Florida practice, Stacy Yonker, MBA, chief executive officer of Sarasota Arthritis Center, knew she had to make some changes. “Everyone’s aging in the boomer generations. Particularly in Florida, we have a lot of people who retire here. In the more southern demographics, it is a very difficult challenge for practices to get new patients in,” she said.
Ms. Yonker is in the process of hiring several nurse practitioners (NPs) to assist in the clinics and infusion suites, lightening the load for the practice’s 11 rheumatologists.
Hiring an advanced practice provider (APP) to support the practice is just a first step. Getting these additional personnel up to speed means an investment in education and fostering good working relationships with NPs, PAs, and the staff’s physicians. Even more importantly, practices need to set realistic expectations on workload for these new hires.
“I tried to hire them, but I couldn’t keep them,” is a statement Christine A. Stamatos, DNP, ANP-C, hears all the time from rheumatologists. Oftentimes it’s because the practice saddles the new hire with 20 patients a day, said Dr. Stamatos, director of the Fibromyalgia Wellness Center within the division of rheumatology at Northwell Health in Huntington, New York. She is also an assistant professor at Hofstra Northwell School of Graduate Nursing and Physician Assistant Studies in Hempstead, New York.
“Twenty patients a day is too much,” Dr. Stamatos said. Overload someone, and they won’t stay. Offer them the support, mentoring, and tools they need to practice in their setting — and they will.
Why the Profession Needs APPs
Rheumatology is a much smaller specialty than most, with only a set number of rheumatologists in the field that can provide care to patients. A growing shortage is also looming. Reports from the American College of Rheumatology have projected troubling shortfalls in rheumatologists over the next decade in all regions of the United States.
Many of them aging into retirement “poses a significant issue on being able to continue providing care for the population that experiences the rheumatic disease,” said Ms. Yonker, a director of the National Organization of Rheumatology Management (NORM), a forum that promotes education and advocacy for rheumatology practice managers. People are also living longer, which means more patients are developing arthritis and autoimmune diseases.
Julia M. Swafford, PA-C, a rheumatology physician assistant in Battle Creek, Michigan, sees many advantages of hiring NPs and PAs, and not just from a financial perspective.
Salaries for PAs and NPs aren’t as high and they’re also more accessible than a rheumatologist. “You could train an NP or PA a lot quicker during that same time frame it would take to find a new rheumatology provider,” she offered. And while they may not be as experienced as rheumatologists, “you can kind of mold me on how you like to practice, what medications you may like to use, how you like to treat your patients,” Ms. Swafford said.
Hiring Someone With Experience
Recruiting and retaining APPs is not without its challenges.
Finding individuals compatible with this specialty isn’t easy, noted Mark Box, MD, medical director of Carondelet Rheumatology in Kansas City, Missouri. Ideally, APPs should be inquisitive, compassionate, and ready to learn. “Rheumatology is a cognitive specialty where you have to fit many pieces together. You need an APP who wants to embrace that,” he said.
The profession isn’t that “sexy” either, noted Katie Taylor, Carondelet’s practice manager. Patients are often in head-to-toe pain, and miserable. Many have been to other specialists without answers to their questions. For these reasons, rheumatology can be a hard sell for some PAs and NPs.
Nurse practitioners aren’t always comfortable with administering things such as controlled medications, for example. “It’s a hard patient population, and it’s a specialty of exclusion. You’ve got to be really smart to understand our diseases and our processes and our drugs,” Ms. Taylor said. In other words, it’s a difficult environment for an NP to walk into if their previous experience has been limited to upper respiratory issues and urinary tract infections in the primary care setting.
When hiring an APP, rheumatologists should look for someone who demonstrates an interest in lifelong learning, because the field is changing every day. They should exhibit good scores in educational training and have experience working in an emergency department or another field that translates well into rheumatology such as critical care, immunology, hematology, and orthopedics, she said.
Carondelet Rheumatology was specifically looking for an NP with rheumatology experience to support Dr. Box’s solo practice.
He was facing enormous pressure to be in the office every single day of the week. The practice had to cancel patients for its infusion suite on a regular basis when he was out of the office, Ms. Taylor said. “We couldn’t see new patients, and he wasn’t able to touch as many patients as he wanted to. The doctor takes the oath of touching as many in your community as possible, and you’re limited when you’re a one-man show.”
The practice eventually found an NP who already knew how to do joint injections. “We started her with easier diagnoses for things like osteoporosis and gout. She had an orthopedic background, so she was familiar with some of those diseases,” she said.
Even so, she often leaves with questions every day. “It’s a commitment for her to understand and learn so much,” Ms. Taylor said.
New hires will need support from the practice to get comfortable with rheumatology, Dr. Stamatos said. Responsibility should come in gradual steps.
Instead of loading an NP with 20 patients a day, 2 or 3 patients in the first quarter, eventually graduating to 6-8 patients is a more realistic expectation, Dr. Stamatos advised.
Shadowing the Physician
Partnerships with physicians is a critical component to this onboarding process.
A nurse practitioner recently hired at Dr. Stamatos’ practice works alongside a physician to manage a panel of 25 patients. “We make sure she gets her training, the resources she needs. I personally meet with her to make sure her education is moving forward, connecting her with radiology, pulmonary, hematology,” and other areas of the practice relevant to her training, she added.
The NP also attends weekly grand rounds and case conferences with the fellows. This is the type of well-rounded support any APP needs, she stressed. “Without proper training, you lose people.”
At Sarasota Arthritis Center, NPs help cover the suites but also get assigned to specific physicians so that they can familiarize themselves with that physician’s panel of patients.
“When we start an APP, they shadow for about twice as long as a new physician would. Usually, they’re shadowing for about 6 weeks, just kind of learning the space. There’s a lot of nurse practitioners or PAs who may not have prior rheumatology experience, so we’re essentially training them from the ground up on rheumatology,” Ms. Yonker said.
Pairing them with one provider often directs what type of disease state they focus on, she continued. This dynamic relationship helps guide decisions on whether to include these NPs in the care of patients with more complex diseases.
At least in her practice, the NPs do not see any new patients. They are simply part of the larger care team. “That’s kind of how we present it to our patients, and it makes them feel more comfortable just because they know that they’re not necessarily being handed off to somebody — that the doctor is still overseeing their care,” Ms. Yonker said.
At the same time, the NPs know that they’re supported, that they too have access to tools and mentorship if they need it, she added.
The new NP at Carondelet Rheumatology piggybacked on the doctor’s schedule for 3 months, slowly taking on infusion patients so she could get familiar with their diseases and respective drugs. Eventually, she got her own schedule and was able to take on new patients.
It’s a team effort, Ms. Taylor noted. The NP does the preliminary workup and then the physician comes in and greets the new patient. Together, they develop a follow-up plan for the patient.
Education Resources for Practices
In the case of Dr. Box’s one-physician practice, he was looking for an NP who was willing to be independent and cover things in his absence. “The training has to be there to accomplish that,” said Dr. Box, who likened the training of APPs to a medical residency.
Encouraging them to ask questions, do continuing medical education online and outside reading, are important steps, he added.
In a recent editorial, rheumatologists Eli M. Miloslavsky, MD, and Bethany Marston, MD, offered some strategies for better prepping the APP workforce to meet the demands of rheumatology practices. “Consideration should be given to formal curricula or training programs to help APPs achieve both competence and confidence in treating rheumatologic conditions,” they offered, suggesting an online curriculum developed by the ACR for such a purpose. Fellowship training should also focus on working effectively with APPs, they added.
“Finally, incorporating APPs more effectively into rheumatology professional societies and supporting practices in hiring and training APPs will all be important steps in addressing the rheumatology workforce shortage,” Dr. Miloslavsky and Dr. Marston wrote.
Ms. Yonker said all her APPs take various courses that the ACR and other organizations provide for rheumatology-specific, midlevel positions. “We provide as much training as possible for them to feel comfortable in this space. They are set directly with a physician for a long time and then eventually go into their own space.”
In addition to ACR, the Rheumatology Nurses Society and the Association of Women in Rheumatology offer excellent online training resources for APPs, Ms. Yonker said. “Also, the Bone Health and Osteoporosis Foundation offers an osteoporosis fracture liaison certification which we put APPs through as well,” she added.
Rheumatology practices should also look into an important clinical training grant program from the Rheumatology Research Foundation, Dr. Stamatos advised.
To date, they have “funded almost everyone that applies,” she said. Each grantee receives $25,000 to support training and education involved in onboarding an APP to a rheumatology practice. The money covers attendance at a live rheumatology conference, online educational programs, textbooks, and any society memberships while defraying the cost of training this employee. To increase awareness of the program, the foundation has since expanded the number of available submission dates and the number of grant awardees per year. Currently, the application deadlines for the grants are December 1 and March 1.
For her own health system, Dr. Stamatos has been working on a rheumatology fellowship program for APPs. Through simulation labs, leadership exercises, and other activities, these APPs will learn how to transition from being a new provider to someone who can become part of a practice, she said.
APPs themselves can also get proactive in this learning cycle, Ms. Swafford said. In her view, both APPs and rheumatologists should be conducting didactic lectures and organizing elective rotations with medical students to get them excited about the field. This would establish a good education base that would encourage PAs and NPs to choose rheumatology.
“That’s a huge thing that’s probably missing,” Ms. Swafford said.
Buy-in From the Doctor
No recruitment effort is going to work if the rheumatologists in the practice aren’t committed to the model of having an APP, Ms. Yonker said. “Everybody wants to know their purpose in their company and that they’re valued and they’re needed. And so, I think a pitfall would be if your rheumatologist is not sold on the model of expanding the care team. Because this takes work on behalf of the doctor.”
Rheumatologists are very busy, so it’s a hard sell for them to take time out of their busy clinics to train somebody to do a good job taking care of their patients, Ms. Taylor agreed. “I think that we need the physicians that have had success with this and allow them to coach the physicians that are still resistant.”
In his small practice, Dr. Box has encouraged his NP to assist with practice improvements, working with the office manager. These workers are providers and need to be treated as such, he said. “They need to feel like they contribute to the practice more than just grinding through patients.”
Peer support is another successful ingredient for these workers. Ms. Taylor’s NP finds the time to commiserate with her fellow nurse practitioners — other rheumatology nurses who are also learning the ropes. Rheumatologists are smart, and they can be very intimidating, Ms. Taylor said. In their small office, the rheumatologist is her only peer.
“She likes to get out and sort of integrate with other nurse practitioners that are learning too.”
When APPs Make a Difference
Practices that take on APPs are reporting positive metrics — mainly, shorter wait times for patients. Ms. Yonker’s physicians have been able to add on one to two new patients a day. Wait times have since dwindled from a 5-month to a 3-month wait with the addition of the NPs. “Three months is still long, but we’re working on getting it to that ideal 6-week wait period, which we’re hoping we can accomplish. So we’re able to get more new patients in for sure,” she said.
Prior to hiring an NP, Ms. Taylor’s practice had to defer acceptances for new patients by at least a year. Now, they’re able to accept about half of all new patient referrals. With the NP on board, “We can get them in within 30 days,” she said.
Sometimes, an APP will go beyond their scope of work to make a difference and better support patients.
Patients with rheumatic and osteopathic conditions are often underdiagnosed in the primary care space. As a result, they are not treated as often as they should be. Seeing a need for specialty care, Ms. Swafford took action.
She currently runs the only bone health clinic in southwest Michigan, coordinating with rheumatologists, NPs, urgent care, hospitalists, and interventional radiologists to attend to these patients more quickly and reduce wait times for care. Specialists will flag things such as nontraumatic hip fractures and vertebral fractures and refer them to Ms. Swafford’s clinic, which is part of Bronson Rheumatology Specialists.
The clinic gets quite a few referrals, and the practice is growing. “Usually, they don’t take as long as a rheumatology referral for a workup, so we can see them a little bit quicker,” usually within 3 weeks, she added.
APPs have an opportunity to make their mark in rheumatology at a time when the profession is experiencing significant gaps in care, Ms. Swafford continued. “Unless we find a way to fill that niche, we’re going to be in a world of trouble in the next 10, 20 years.”
None of the sources reported any disclosures or conflicts of interest.
Once considered a luxury, hiring a nurse, nurse practitioner, or physician assistant is becoming a necessity in many rheumatology practices.
Seeing the wait lists pile up in her Florida practice, Stacy Yonker, MBA, chief executive officer of Sarasota Arthritis Center, knew she had to make some changes. “Everyone’s aging in the boomer generations. Particularly in Florida, we have a lot of people who retire here. In the more southern demographics, it is a very difficult challenge for practices to get new patients in,” she said.
Ms. Yonker is in the process of hiring several nurse practitioners (NPs) to assist in the clinics and infusion suites, lightening the load for the practice’s 11 rheumatologists.
Hiring an advanced practice provider (APP) to support the practice is just a first step. Getting these additional personnel up to speed means an investment in education and fostering good working relationships with NPs, PAs, and the staff’s physicians. Even more importantly, practices need to set realistic expectations on workload for these new hires.
“I tried to hire them, but I couldn’t keep them,” is a statement Christine A. Stamatos, DNP, ANP-C, hears all the time from rheumatologists. Oftentimes it’s because the practice saddles the new hire with 20 patients a day, said Dr. Stamatos, director of the Fibromyalgia Wellness Center within the division of rheumatology at Northwell Health in Huntington, New York. She is also an assistant professor at Hofstra Northwell School of Graduate Nursing and Physician Assistant Studies in Hempstead, New York.
“Twenty patients a day is too much,” Dr. Stamatos said. Overload someone, and they won’t stay. Offer them the support, mentoring, and tools they need to practice in their setting — and they will.
Why the Profession Needs APPs
Rheumatology is a much smaller specialty than most, with only a set number of rheumatologists in the field that can provide care to patients. A growing shortage is also looming. Reports from the American College of Rheumatology have projected troubling shortfalls in rheumatologists over the next decade in all regions of the United States.
Many of them aging into retirement “poses a significant issue on being able to continue providing care for the population that experiences the rheumatic disease,” said Ms. Yonker, a director of the National Organization of Rheumatology Management (NORM), a forum that promotes education and advocacy for rheumatology practice managers. People are also living longer, which means more patients are developing arthritis and autoimmune diseases.
Julia M. Swafford, PA-C, a rheumatology physician assistant in Battle Creek, Michigan, sees many advantages of hiring NPs and PAs, and not just from a financial perspective.
Salaries for PAs and NPs aren’t as high and they’re also more accessible than a rheumatologist. “You could train an NP or PA a lot quicker during that same time frame it would take to find a new rheumatology provider,” she offered. And while they may not be as experienced as rheumatologists, “you can kind of mold me on how you like to practice, what medications you may like to use, how you like to treat your patients,” Ms. Swafford said.
Hiring Someone With Experience
Recruiting and retaining APPs is not without its challenges.
Finding individuals compatible with this specialty isn’t easy, noted Mark Box, MD, medical director of Carondelet Rheumatology in Kansas City, Missouri. Ideally, APPs should be inquisitive, compassionate, and ready to learn. “Rheumatology is a cognitive specialty where you have to fit many pieces together. You need an APP who wants to embrace that,” he said.
The profession isn’t that “sexy” either, noted Katie Taylor, Carondelet’s practice manager. Patients are often in head-to-toe pain, and miserable. Many have been to other specialists without answers to their questions. For these reasons, rheumatology can be a hard sell for some PAs and NPs.
Nurse practitioners aren’t always comfortable with administering things such as controlled medications, for example. “It’s a hard patient population, and it’s a specialty of exclusion. You’ve got to be really smart to understand our diseases and our processes and our drugs,” Ms. Taylor said. In other words, it’s a difficult environment for an NP to walk into if their previous experience has been limited to upper respiratory issues and urinary tract infections in the primary care setting.
When hiring an APP, rheumatologists should look for someone who demonstrates an interest in lifelong learning, because the field is changing every day. They should exhibit good scores in educational training and have experience working in an emergency department or another field that translates well into rheumatology such as critical care, immunology, hematology, and orthopedics, she said.
Carondelet Rheumatology was specifically looking for an NP with rheumatology experience to support Dr. Box’s solo practice.
He was facing enormous pressure to be in the office every single day of the week. The practice had to cancel patients for its infusion suite on a regular basis when he was out of the office, Ms. Taylor said. “We couldn’t see new patients, and he wasn’t able to touch as many patients as he wanted to. The doctor takes the oath of touching as many in your community as possible, and you’re limited when you’re a one-man show.”
The practice eventually found an NP who already knew how to do joint injections. “We started her with easier diagnoses for things like osteoporosis and gout. She had an orthopedic background, so she was familiar with some of those diseases,” she said.
Even so, she often leaves with questions every day. “It’s a commitment for her to understand and learn so much,” Ms. Taylor said.
New hires will need support from the practice to get comfortable with rheumatology, Dr. Stamatos said. Responsibility should come in gradual steps.
Instead of loading an NP with 20 patients a day, 2 or 3 patients in the first quarter, eventually graduating to 6-8 patients is a more realistic expectation, Dr. Stamatos advised.
Shadowing the Physician
Partnerships with physicians is a critical component to this onboarding process.
A nurse practitioner recently hired at Dr. Stamatos’ practice works alongside a physician to manage a panel of 25 patients. “We make sure she gets her training, the resources she needs. I personally meet with her to make sure her education is moving forward, connecting her with radiology, pulmonary, hematology,” and other areas of the practice relevant to her training, she added.
The NP also attends weekly grand rounds and case conferences with the fellows. This is the type of well-rounded support any APP needs, she stressed. “Without proper training, you lose people.”
At Sarasota Arthritis Center, NPs help cover the suites but also get assigned to specific physicians so that they can familiarize themselves with that physician’s panel of patients.
“When we start an APP, they shadow for about twice as long as a new physician would. Usually, they’re shadowing for about 6 weeks, just kind of learning the space. There’s a lot of nurse practitioners or PAs who may not have prior rheumatology experience, so we’re essentially training them from the ground up on rheumatology,” Ms. Yonker said.
Pairing them with one provider often directs what type of disease state they focus on, she continued. This dynamic relationship helps guide decisions on whether to include these NPs in the care of patients with more complex diseases.
At least in her practice, the NPs do not see any new patients. They are simply part of the larger care team. “That’s kind of how we present it to our patients, and it makes them feel more comfortable just because they know that they’re not necessarily being handed off to somebody — that the doctor is still overseeing their care,” Ms. Yonker said.
At the same time, the NPs know that they’re supported, that they too have access to tools and mentorship if they need it, she added.
The new NP at Carondelet Rheumatology piggybacked on the doctor’s schedule for 3 months, slowly taking on infusion patients so she could get familiar with their diseases and respective drugs. Eventually, she got her own schedule and was able to take on new patients.
It’s a team effort, Ms. Taylor noted. The NP does the preliminary workup and then the physician comes in and greets the new patient. Together, they develop a follow-up plan for the patient.
Education Resources for Practices
In the case of Dr. Box’s one-physician practice, he was looking for an NP who was willing to be independent and cover things in his absence. “The training has to be there to accomplish that,” said Dr. Box, who likened the training of APPs to a medical residency.
Encouraging them to ask questions, do continuing medical education online and outside reading, are important steps, he added.
In a recent editorial, rheumatologists Eli M. Miloslavsky, MD, and Bethany Marston, MD, offered some strategies for better prepping the APP workforce to meet the demands of rheumatology practices. “Consideration should be given to formal curricula or training programs to help APPs achieve both competence and confidence in treating rheumatologic conditions,” they offered, suggesting an online curriculum developed by the ACR for such a purpose. Fellowship training should also focus on working effectively with APPs, they added.
“Finally, incorporating APPs more effectively into rheumatology professional societies and supporting practices in hiring and training APPs will all be important steps in addressing the rheumatology workforce shortage,” Dr. Miloslavsky and Dr. Marston wrote.
Ms. Yonker said all her APPs take various courses that the ACR and other organizations provide for rheumatology-specific, midlevel positions. “We provide as much training as possible for them to feel comfortable in this space. They are set directly with a physician for a long time and then eventually go into their own space.”
In addition to ACR, the Rheumatology Nurses Society and the Association of Women in Rheumatology offer excellent online training resources for APPs, Ms. Yonker said. “Also, the Bone Health and Osteoporosis Foundation offers an osteoporosis fracture liaison certification which we put APPs through as well,” she added.
Rheumatology practices should also look into an important clinical training grant program from the Rheumatology Research Foundation, Dr. Stamatos advised.
To date, they have “funded almost everyone that applies,” she said. Each grantee receives $25,000 to support training and education involved in onboarding an APP to a rheumatology practice. The money covers attendance at a live rheumatology conference, online educational programs, textbooks, and any society memberships while defraying the cost of training this employee. To increase awareness of the program, the foundation has since expanded the number of available submission dates and the number of grant awardees per year. Currently, the application deadlines for the grants are December 1 and March 1.
For her own health system, Dr. Stamatos has been working on a rheumatology fellowship program for APPs. Through simulation labs, leadership exercises, and other activities, these APPs will learn how to transition from being a new provider to someone who can become part of a practice, she said.
APPs themselves can also get proactive in this learning cycle, Ms. Swafford said. In her view, both APPs and rheumatologists should be conducting didactic lectures and organizing elective rotations with medical students to get them excited about the field. This would establish a good education base that would encourage PAs and NPs to choose rheumatology.
“That’s a huge thing that’s probably missing,” Ms. Swafford said.
Buy-in From the Doctor
No recruitment effort is going to work if the rheumatologists in the practice aren’t committed to the model of having an APP, Ms. Yonker said. “Everybody wants to know their purpose in their company and that they’re valued and they’re needed. And so, I think a pitfall would be if your rheumatologist is not sold on the model of expanding the care team. Because this takes work on behalf of the doctor.”
Rheumatologists are very busy, so it’s a hard sell for them to take time out of their busy clinics to train somebody to do a good job taking care of their patients, Ms. Taylor agreed. “I think that we need the physicians that have had success with this and allow them to coach the physicians that are still resistant.”
In his small practice, Dr. Box has encouraged his NP to assist with practice improvements, working with the office manager. These workers are providers and need to be treated as such, he said. “They need to feel like they contribute to the practice more than just grinding through patients.”
Peer support is another successful ingredient for these workers. Ms. Taylor’s NP finds the time to commiserate with her fellow nurse practitioners — other rheumatology nurses who are also learning the ropes. Rheumatologists are smart, and they can be very intimidating, Ms. Taylor said. In their small office, the rheumatologist is her only peer.
“She likes to get out and sort of integrate with other nurse practitioners that are learning too.”
When APPs Make a Difference
Practices that take on APPs are reporting positive metrics — mainly, shorter wait times for patients. Ms. Yonker’s physicians have been able to add on one to two new patients a day. Wait times have since dwindled from a 5-month to a 3-month wait with the addition of the NPs. “Three months is still long, but we’re working on getting it to that ideal 6-week wait period, which we’re hoping we can accomplish. So we’re able to get more new patients in for sure,” she said.
Prior to hiring an NP, Ms. Taylor’s practice had to defer acceptances for new patients by at least a year. Now, they’re able to accept about half of all new patient referrals. With the NP on board, “We can get them in within 30 days,” she said.
Sometimes, an APP will go beyond their scope of work to make a difference and better support patients.
Patients with rheumatic and osteopathic conditions are often underdiagnosed in the primary care space. As a result, they are not treated as often as they should be. Seeing a need for specialty care, Ms. Swafford took action.
She currently runs the only bone health clinic in southwest Michigan, coordinating with rheumatologists, NPs, urgent care, hospitalists, and interventional radiologists to attend to these patients more quickly and reduce wait times for care. Specialists will flag things such as nontraumatic hip fractures and vertebral fractures and refer them to Ms. Swafford’s clinic, which is part of Bronson Rheumatology Specialists.
The clinic gets quite a few referrals, and the practice is growing. “Usually, they don’t take as long as a rheumatology referral for a workup, so we can see them a little bit quicker,” usually within 3 weeks, she added.
APPs have an opportunity to make their mark in rheumatology at a time when the profession is experiencing significant gaps in care, Ms. Swafford continued. “Unless we find a way to fill that niche, we’re going to be in a world of trouble in the next 10, 20 years.”
None of the sources reported any disclosures or conflicts of interest.
Hepatologist finds purpose as health equity advocate for LGBTQI+
Sonali Paul, MD, once thought she was an anomaly in the world of medicine. “As I was going through training, I didn’t think others like me existed, a gay South Asian transplant hepatologist. I certainly didn’t have mentors that looked like me. I didn’t have anyone to look up to,” she said.
Fighting to promote health care equity in the LGBTQI+ population has been a cornerstone of her career. As cofounder and an executive board member of Rainbows in Gastro, a sexual and gender minorities affinity group that builds community among LGBTQI+ medical trainees and physicians in gastroenterology, Dr. Paul often goes into the community to promote open discussions about health equity in sexual and gender minority populations.
“Our mission is CHARM: community, healing, advocacy, research, and mentorship,” said Dr. Paul, a transplant hepatologist with the University of Chicago Medicine with a specific niche within fatty liver disease and obesity medicine. She serves as an associate program director for the Internal Medicine Residency Program specifically for diversity, equity, and inclusion.
In 2022 she received the University of Chicago’s Department of Medicine Diversity Award.
Rainbows in Gastro has shown trainees they can be open about their sexual orientation and gender identity without fear of retribution. “I’ve had medical students and residents come to me and say they were going to go into endocrine or some other field because they thought it was more gay friendly, until they saw our group and the work we’re doing,” Dr. Paul said.
In an interview, she talks more about her two key passions: reducing disparities and promoting health equity.
Q: You presented “Embrace the Rainbow: Creating Inclusive LGBTQ+ Spaces in Medicine” at the University of Chicago Medicine Grand Rounds. What were some of the key takeaways of that presentation?
Dr. Paul: One is education. Knowing the history of the LGBT community and how marginalization and discrimination affects the individual coming into that clinic is important. Having little things like pronoun badges or a rainbow flag, having nondiscrimination policies that include sexual orientation, gender identity that are displayed in the clinics, are very small things that seem almost trivial to some people. But I can tell you for myself, it matters if I walk into a door and there’s a rainbow flag there. I feel immediately safer.
Q: What are your hopes and aspirations for the field of GI moving forward?
Dr. Paul: I didn’t learn about social determinants of health in medical school, but more and more I think we’re starting to pivot and really look at those things. I hope GI and hepatology continues to do that.
For me, it’s looking at everything through a health disparities lens, seeing the health disparities across communities and finding solutions to mitigate them. How do we get people access to transplant for all our patients, and really examining the social determinants of health in the health care we provide?
Q: Your clinical focus has been on nonalcoholic fatty liver disease. Can you tell me how you got interested in that area of medicine?
Dr. Paul: There’s been a name change for the disease itself. It’s now metabolic dysfunction-associated steatotic liver disease (MASLD). I got interested from an obesity medicine perspective. I thought the liver pathology was interesting but I wanted to approach it from a different kind of perspective and not just focus on the liver, but also the metabolic factors.
I practice from that kind of lens: Looking at a lot of the metabolic comorbidities that happen with fatty liver disease to help patients with weight loss.
Q: What do you think about the new weight loss drugs?
Dr. Paul: I think they’re very effective. They’re obviously very popular. Weight loss is a really hard thing and I think they are really changing the game. A newer one that was just approved, tirzepatide (Zepbound, Lilly) resulted in up to 20% body weight loss. I think if there’s a medicine that we can give to avoid surgery for some people, I think that’s great. I think what is quite disheartening is insurance access to the medications.
Q: Is there any type of research you’re doing in this area right now?
Dr. Paul: I’m interested in the changes in fatty liver with gender-affirming hormone therapy with estrogen and testosterone, an area that’s never been studied.
Q: Describe how you would spend a free Saturday afternoon.
Dr. Paul: With my wife, my 9-year-old son, and two dogs. One of our favorite places to go is the Lincoln Park Zoo. We go there, especially over the summer, sometimes every week just to walk around. And, my son loves animals. Or, play with our dogs.
LIGHTNING ROUND
What is your favorite junk food?
Doritos
What is your favorite holiday?
Thanksgiving
Is there a book that you reread often?
“Interpreter of Maladies” by Jhumpa Lahiri
What is your favorite movie genre?
Comedy
Are you an introvert or extrovert?
Somewhere in the middle.
Sonali Paul, MD, once thought she was an anomaly in the world of medicine. “As I was going through training, I didn’t think others like me existed, a gay South Asian transplant hepatologist. I certainly didn’t have mentors that looked like me. I didn’t have anyone to look up to,” she said.
Fighting to promote health care equity in the LGBTQI+ population has been a cornerstone of her career. As cofounder and an executive board member of Rainbows in Gastro, a sexual and gender minorities affinity group that builds community among LGBTQI+ medical trainees and physicians in gastroenterology, Dr. Paul often goes into the community to promote open discussions about health equity in sexual and gender minority populations.
“Our mission is CHARM: community, healing, advocacy, research, and mentorship,” said Dr. Paul, a transplant hepatologist with the University of Chicago Medicine with a specific niche within fatty liver disease and obesity medicine. She serves as an associate program director for the Internal Medicine Residency Program specifically for diversity, equity, and inclusion.
In 2022 she received the University of Chicago’s Department of Medicine Diversity Award.
Rainbows in Gastro has shown trainees they can be open about their sexual orientation and gender identity without fear of retribution. “I’ve had medical students and residents come to me and say they were going to go into endocrine or some other field because they thought it was more gay friendly, until they saw our group and the work we’re doing,” Dr. Paul said.
In an interview, she talks more about her two key passions: reducing disparities and promoting health equity.
Q: You presented “Embrace the Rainbow: Creating Inclusive LGBTQ+ Spaces in Medicine” at the University of Chicago Medicine Grand Rounds. What were some of the key takeaways of that presentation?
Dr. Paul: One is education. Knowing the history of the LGBT community and how marginalization and discrimination affects the individual coming into that clinic is important. Having little things like pronoun badges or a rainbow flag, having nondiscrimination policies that include sexual orientation, gender identity that are displayed in the clinics, are very small things that seem almost trivial to some people. But I can tell you for myself, it matters if I walk into a door and there’s a rainbow flag there. I feel immediately safer.
Q: What are your hopes and aspirations for the field of GI moving forward?
Dr. Paul: I didn’t learn about social determinants of health in medical school, but more and more I think we’re starting to pivot and really look at those things. I hope GI and hepatology continues to do that.
For me, it’s looking at everything through a health disparities lens, seeing the health disparities across communities and finding solutions to mitigate them. How do we get people access to transplant for all our patients, and really examining the social determinants of health in the health care we provide?
Q: Your clinical focus has been on nonalcoholic fatty liver disease. Can you tell me how you got interested in that area of medicine?
Dr. Paul: There’s been a name change for the disease itself. It’s now metabolic dysfunction-associated steatotic liver disease (MASLD). I got interested from an obesity medicine perspective. I thought the liver pathology was interesting but I wanted to approach it from a different kind of perspective and not just focus on the liver, but also the metabolic factors.
I practice from that kind of lens: Looking at a lot of the metabolic comorbidities that happen with fatty liver disease to help patients with weight loss.
Q: What do you think about the new weight loss drugs?
Dr. Paul: I think they’re very effective. They’re obviously very popular. Weight loss is a really hard thing and I think they are really changing the game. A newer one that was just approved, tirzepatide (Zepbound, Lilly) resulted in up to 20% body weight loss. I think if there’s a medicine that we can give to avoid surgery for some people, I think that’s great. I think what is quite disheartening is insurance access to the medications.
Q: Is there any type of research you’re doing in this area right now?
Dr. Paul: I’m interested in the changes in fatty liver with gender-affirming hormone therapy with estrogen and testosterone, an area that’s never been studied.
Q: Describe how you would spend a free Saturday afternoon.
Dr. Paul: With my wife, my 9-year-old son, and two dogs. One of our favorite places to go is the Lincoln Park Zoo. We go there, especially over the summer, sometimes every week just to walk around. And, my son loves animals. Or, play with our dogs.
LIGHTNING ROUND
What is your favorite junk food?
Doritos
What is your favorite holiday?
Thanksgiving
Is there a book that you reread often?
“Interpreter of Maladies” by Jhumpa Lahiri
What is your favorite movie genre?
Comedy
Are you an introvert or extrovert?
Somewhere in the middle.
Sonali Paul, MD, once thought she was an anomaly in the world of medicine. “As I was going through training, I didn’t think others like me existed, a gay South Asian transplant hepatologist. I certainly didn’t have mentors that looked like me. I didn’t have anyone to look up to,” she said.
Fighting to promote health care equity in the LGBTQI+ population has been a cornerstone of her career. As cofounder and an executive board member of Rainbows in Gastro, a sexual and gender minorities affinity group that builds community among LGBTQI+ medical trainees and physicians in gastroenterology, Dr. Paul often goes into the community to promote open discussions about health equity in sexual and gender minority populations.
“Our mission is CHARM: community, healing, advocacy, research, and mentorship,” said Dr. Paul, a transplant hepatologist with the University of Chicago Medicine with a specific niche within fatty liver disease and obesity medicine. She serves as an associate program director for the Internal Medicine Residency Program specifically for diversity, equity, and inclusion.
In 2022 she received the University of Chicago’s Department of Medicine Diversity Award.
Rainbows in Gastro has shown trainees they can be open about their sexual orientation and gender identity without fear of retribution. “I’ve had medical students and residents come to me and say they were going to go into endocrine or some other field because they thought it was more gay friendly, until they saw our group and the work we’re doing,” Dr. Paul said.
In an interview, she talks more about her two key passions: reducing disparities and promoting health equity.
Q: You presented “Embrace the Rainbow: Creating Inclusive LGBTQ+ Spaces in Medicine” at the University of Chicago Medicine Grand Rounds. What were some of the key takeaways of that presentation?
Dr. Paul: One is education. Knowing the history of the LGBT community and how marginalization and discrimination affects the individual coming into that clinic is important. Having little things like pronoun badges or a rainbow flag, having nondiscrimination policies that include sexual orientation, gender identity that are displayed in the clinics, are very small things that seem almost trivial to some people. But I can tell you for myself, it matters if I walk into a door and there’s a rainbow flag there. I feel immediately safer.
Q: What are your hopes and aspirations for the field of GI moving forward?
Dr. Paul: I didn’t learn about social determinants of health in medical school, but more and more I think we’re starting to pivot and really look at those things. I hope GI and hepatology continues to do that.
For me, it’s looking at everything through a health disparities lens, seeing the health disparities across communities and finding solutions to mitigate them. How do we get people access to transplant for all our patients, and really examining the social determinants of health in the health care we provide?
Q: Your clinical focus has been on nonalcoholic fatty liver disease. Can you tell me how you got interested in that area of medicine?
Dr. Paul: There’s been a name change for the disease itself. It’s now metabolic dysfunction-associated steatotic liver disease (MASLD). I got interested from an obesity medicine perspective. I thought the liver pathology was interesting but I wanted to approach it from a different kind of perspective and not just focus on the liver, but also the metabolic factors.
I practice from that kind of lens: Looking at a lot of the metabolic comorbidities that happen with fatty liver disease to help patients with weight loss.
Q: What do you think about the new weight loss drugs?
Dr. Paul: I think they’re very effective. They’re obviously very popular. Weight loss is a really hard thing and I think they are really changing the game. A newer one that was just approved, tirzepatide (Zepbound, Lilly) resulted in up to 20% body weight loss. I think if there’s a medicine that we can give to avoid surgery for some people, I think that’s great. I think what is quite disheartening is insurance access to the medications.
Q: Is there any type of research you’re doing in this area right now?
Dr. Paul: I’m interested in the changes in fatty liver with gender-affirming hormone therapy with estrogen and testosterone, an area that’s never been studied.
Q: Describe how you would spend a free Saturday afternoon.
Dr. Paul: With my wife, my 9-year-old son, and two dogs. One of our favorite places to go is the Lincoln Park Zoo. We go there, especially over the summer, sometimes every week just to walk around. And, my son loves animals. Or, play with our dogs.
LIGHTNING ROUND
What is your favorite junk food?
Doritos
What is your favorite holiday?
Thanksgiving
Is there a book that you reread often?
“Interpreter of Maladies” by Jhumpa Lahiri
What is your favorite movie genre?
Comedy
Are you an introvert or extrovert?
Somewhere in the middle.
Narrative medicine: Physician advocacy on the ground
In 2021, when Eric Esrailian, MD, MPH, was awarded the Benemerenti Medal from Pope Francis for his humanitarian work, he recognized other people worldwide who save lives daily – but without recognition. They’re motivated for “the right reasons. To be clear, I do not deserve this honor. It is honestly overwhelming and humbling,” he said in 2021 when news of the award reached him in Los Angeles where he holds the Lincy Foundation Chair in Clinical Gastroenterology at the University of California, Los Angeles. He also serves as chief of the Vatche and Tamar Manoukian Division of Digestive Diseases, and director of the Melvin and Bren Simon Digestive Diseases Center.
Dr. Esrailian, the son of Armenian immigrants, says that humanitarian work has been ingrained in him since childhood. His great-grandparents were Armenian genocide survivors and their struggles have never left him. He’s devoted his life not only to medicine, but to documenting the history of the Armenian genocide and leading, or supporting, efforts to resolve humanitarian crises in Armenia and around the world. Earlier this year, he, with Kim Kardashian and singer/actor Cher, published op-eds that addressed a humanitarian crisis building as a result of Azerbaijan’s blockade of the Lachin corridor – which is the only road that links Armenia to the ethnic Armenian–populated sections of Nagorno-Karabakh. In September, Armenia and Azerbaijan reached a tentative agreement to end the blockade, but more needs to be done, he says. Tragedies continue to unfold, and he is redoubling his efforts to bring more attention to this humanitarian crisis, he said.
The first film was “The Promise,” a historical war drama set in the Ottoman Empire and released in 2016. In 2017, he and partners released “Intent to Destroy: Death, Denial, & Depiction,” a documentary about the Armenian genocide. The documentary received an Emmy nomination for Outstanding Historical Documentary. And, in 2020, he produced “Francesco,” a film about Pope Francis that documented his pilgrimage to Armenia in 2016.
“The Promise” had such an impact on viewers that in 2017 Dr. Esrailian and the UCLA School of Law created The Promise Institute for Human Rights as a center of human rights education, research, and advocacy. In 2019, Dr. Esrailian and UCLA followed up with The Promise Armenian Institute as a place for academic research and teaching of Armenian studies, language, and culture. “The impact from building these two institutes has been transformational, and they will be part of UCLA forever,” he said.
His philanthropic efforts connecting health, human rights, education, and the arts has had an impact worldwide. One person can make a difference, Dr. Esrailian said: “I’ve learned along the way that an individual can have more of an impact than ever imagined, but you have to dream big and never give up.”
In this interview, he tells us more about his work.
Q: Not many doctors wear hats in medicine and filmmaking. Describe your journey as a filmmaker.
Dr. Esrailian: I’ve always been interested in storytelling. I was an English minor at Berkeley. My late mentor, Kirk Kerkorian, a legendary philanthropist, businessman, and entrepreneur, pushed me to take storytelling and do something that would potentially help secure Armenian Genocide recognition by the United States. Because of genocide denialists and geopolitical pressure, he felt the United States government was reluctant to recognize the Armenian Genocide. He thought having some visual materials for educational and outreach efforts would be transformational, and as it turns out, they were.
If you talk to any advocacy organization that tried for years to get Armenian Genocide recognition, they’d say that both films, “The Promise” (a feature film) and “Intent to Destroy” (a documentary), and the social impact media campaign we launched around them, were influential in moving the needle with legislators in the United States who, 3 years after “The Promise” was released, recognized the genocide. This was followed by the Library of Congress in 2020 and President Biden’s executive branch in 2021.
Q: What has been your most rewarding accomplishment?
Dr. Esrailian: Giving a voice to people who don’t have a voice is something that I’m proud of. Sometimes, it’s questionable what impact it may have because we still see atrocities committed all over the world. In September, Azerbaijan completed an ethnic cleansing campaign of Armenians from a region called Artsakh, officially the Republic of Nagorno-Karabakh.
Despite having so many relationships with powerful people in government and in high-profile media, and despite our documentaries, op-eds, and interactions with influential leaders on a regular basis, it always feels like it’s not enough. Obviously, the perpetrators are still able to abuse human rights and conduct these campaigns. Nevertheless, I don’t think we should be deterred. Allowing human rights violations to occur with impunity only emboldens perpetrators even more. It takes a long time to bring people to justice through international courts, but it does happen – eventually. That’s something I’m going to continue to work on.
Q: What should be the role of physicians in supporting human rights?
Dr. Esrailian: Physicians and health care providers play an important role in human rights. If you look back throughout history, whether it’s the International Committee of the Red Cross, or Doctors Without Borders, or other organizations, physicians and health care professionals are often on the front lines, helping people. Unfortunately, physicians have also been part of human rights violations, like the Holocaust or other genocides. But I do think that in this day and age, with the reputation that physicians have, we can be policy advocates and upstanders in addition to taking care of patients. Telling our stories to the world is important so that people know what’s actually happening on the ground.
Lightning round
Do you prefer texting or talking?
Talking
How many cups of coffee do you drink each day?
Two
What was the last movie you watched?
Mission Impossible
If you weren’t a gastroenterologist, what would you be?
Entrepreneur
Who inspires you?
My family
In 2021, when Eric Esrailian, MD, MPH, was awarded the Benemerenti Medal from Pope Francis for his humanitarian work, he recognized other people worldwide who save lives daily – but without recognition. They’re motivated for “the right reasons. To be clear, I do not deserve this honor. It is honestly overwhelming and humbling,” he said in 2021 when news of the award reached him in Los Angeles where he holds the Lincy Foundation Chair in Clinical Gastroenterology at the University of California, Los Angeles. He also serves as chief of the Vatche and Tamar Manoukian Division of Digestive Diseases, and director of the Melvin and Bren Simon Digestive Diseases Center.
Dr. Esrailian, the son of Armenian immigrants, says that humanitarian work has been ingrained in him since childhood. His great-grandparents were Armenian genocide survivors and their struggles have never left him. He’s devoted his life not only to medicine, but to documenting the history of the Armenian genocide and leading, or supporting, efforts to resolve humanitarian crises in Armenia and around the world. Earlier this year, he, with Kim Kardashian and singer/actor Cher, published op-eds that addressed a humanitarian crisis building as a result of Azerbaijan’s blockade of the Lachin corridor – which is the only road that links Armenia to the ethnic Armenian–populated sections of Nagorno-Karabakh. In September, Armenia and Azerbaijan reached a tentative agreement to end the blockade, but more needs to be done, he says. Tragedies continue to unfold, and he is redoubling his efforts to bring more attention to this humanitarian crisis, he said.
The first film was “The Promise,” a historical war drama set in the Ottoman Empire and released in 2016. In 2017, he and partners released “Intent to Destroy: Death, Denial, & Depiction,” a documentary about the Armenian genocide. The documentary received an Emmy nomination for Outstanding Historical Documentary. And, in 2020, he produced “Francesco,” a film about Pope Francis that documented his pilgrimage to Armenia in 2016.
“The Promise” had such an impact on viewers that in 2017 Dr. Esrailian and the UCLA School of Law created The Promise Institute for Human Rights as a center of human rights education, research, and advocacy. In 2019, Dr. Esrailian and UCLA followed up with The Promise Armenian Institute as a place for academic research and teaching of Armenian studies, language, and culture. “The impact from building these two institutes has been transformational, and they will be part of UCLA forever,” he said.
His philanthropic efforts connecting health, human rights, education, and the arts has had an impact worldwide. One person can make a difference, Dr. Esrailian said: “I’ve learned along the way that an individual can have more of an impact than ever imagined, but you have to dream big and never give up.”
In this interview, he tells us more about his work.
Q: Not many doctors wear hats in medicine and filmmaking. Describe your journey as a filmmaker.
Dr. Esrailian: I’ve always been interested in storytelling. I was an English minor at Berkeley. My late mentor, Kirk Kerkorian, a legendary philanthropist, businessman, and entrepreneur, pushed me to take storytelling and do something that would potentially help secure Armenian Genocide recognition by the United States. Because of genocide denialists and geopolitical pressure, he felt the United States government was reluctant to recognize the Armenian Genocide. He thought having some visual materials for educational and outreach efforts would be transformational, and as it turns out, they were.
If you talk to any advocacy organization that tried for years to get Armenian Genocide recognition, they’d say that both films, “The Promise” (a feature film) and “Intent to Destroy” (a documentary), and the social impact media campaign we launched around them, were influential in moving the needle with legislators in the United States who, 3 years after “The Promise” was released, recognized the genocide. This was followed by the Library of Congress in 2020 and President Biden’s executive branch in 2021.
Q: What has been your most rewarding accomplishment?
Dr. Esrailian: Giving a voice to people who don’t have a voice is something that I’m proud of. Sometimes, it’s questionable what impact it may have because we still see atrocities committed all over the world. In September, Azerbaijan completed an ethnic cleansing campaign of Armenians from a region called Artsakh, officially the Republic of Nagorno-Karabakh.
Despite having so many relationships with powerful people in government and in high-profile media, and despite our documentaries, op-eds, and interactions with influential leaders on a regular basis, it always feels like it’s not enough. Obviously, the perpetrators are still able to abuse human rights and conduct these campaigns. Nevertheless, I don’t think we should be deterred. Allowing human rights violations to occur with impunity only emboldens perpetrators even more. It takes a long time to bring people to justice through international courts, but it does happen – eventually. That’s something I’m going to continue to work on.
Q: What should be the role of physicians in supporting human rights?
Dr. Esrailian: Physicians and health care providers play an important role in human rights. If you look back throughout history, whether it’s the International Committee of the Red Cross, or Doctors Without Borders, or other organizations, physicians and health care professionals are often on the front lines, helping people. Unfortunately, physicians have also been part of human rights violations, like the Holocaust or other genocides. But I do think that in this day and age, with the reputation that physicians have, we can be policy advocates and upstanders in addition to taking care of patients. Telling our stories to the world is important so that people know what’s actually happening on the ground.
Lightning round
Do you prefer texting or talking?
Talking
How many cups of coffee do you drink each day?
Two
What was the last movie you watched?
Mission Impossible
If you weren’t a gastroenterologist, what would you be?
Entrepreneur
Who inspires you?
My family
In 2021, when Eric Esrailian, MD, MPH, was awarded the Benemerenti Medal from Pope Francis for his humanitarian work, he recognized other people worldwide who save lives daily – but without recognition. They’re motivated for “the right reasons. To be clear, I do not deserve this honor. It is honestly overwhelming and humbling,” he said in 2021 when news of the award reached him in Los Angeles where he holds the Lincy Foundation Chair in Clinical Gastroenterology at the University of California, Los Angeles. He also serves as chief of the Vatche and Tamar Manoukian Division of Digestive Diseases, and director of the Melvin and Bren Simon Digestive Diseases Center.
Dr. Esrailian, the son of Armenian immigrants, says that humanitarian work has been ingrained in him since childhood. His great-grandparents were Armenian genocide survivors and their struggles have never left him. He’s devoted his life not only to medicine, but to documenting the history of the Armenian genocide and leading, or supporting, efforts to resolve humanitarian crises in Armenia and around the world. Earlier this year, he, with Kim Kardashian and singer/actor Cher, published op-eds that addressed a humanitarian crisis building as a result of Azerbaijan’s blockade of the Lachin corridor – which is the only road that links Armenia to the ethnic Armenian–populated sections of Nagorno-Karabakh. In September, Armenia and Azerbaijan reached a tentative agreement to end the blockade, but more needs to be done, he says. Tragedies continue to unfold, and he is redoubling his efforts to bring more attention to this humanitarian crisis, he said.
The first film was “The Promise,” a historical war drama set in the Ottoman Empire and released in 2016. In 2017, he and partners released “Intent to Destroy: Death, Denial, & Depiction,” a documentary about the Armenian genocide. The documentary received an Emmy nomination for Outstanding Historical Documentary. And, in 2020, he produced “Francesco,” a film about Pope Francis that documented his pilgrimage to Armenia in 2016.
“The Promise” had such an impact on viewers that in 2017 Dr. Esrailian and the UCLA School of Law created The Promise Institute for Human Rights as a center of human rights education, research, and advocacy. In 2019, Dr. Esrailian and UCLA followed up with The Promise Armenian Institute as a place for academic research and teaching of Armenian studies, language, and culture. “The impact from building these two institutes has been transformational, and they will be part of UCLA forever,” he said.
His philanthropic efforts connecting health, human rights, education, and the arts has had an impact worldwide. One person can make a difference, Dr. Esrailian said: “I’ve learned along the way that an individual can have more of an impact than ever imagined, but you have to dream big and never give up.”
In this interview, he tells us more about his work.
Q: Not many doctors wear hats in medicine and filmmaking. Describe your journey as a filmmaker.
Dr. Esrailian: I’ve always been interested in storytelling. I was an English minor at Berkeley. My late mentor, Kirk Kerkorian, a legendary philanthropist, businessman, and entrepreneur, pushed me to take storytelling and do something that would potentially help secure Armenian Genocide recognition by the United States. Because of genocide denialists and geopolitical pressure, he felt the United States government was reluctant to recognize the Armenian Genocide. He thought having some visual materials for educational and outreach efforts would be transformational, and as it turns out, they were.
If you talk to any advocacy organization that tried for years to get Armenian Genocide recognition, they’d say that both films, “The Promise” (a feature film) and “Intent to Destroy” (a documentary), and the social impact media campaign we launched around them, were influential in moving the needle with legislators in the United States who, 3 years after “The Promise” was released, recognized the genocide. This was followed by the Library of Congress in 2020 and President Biden’s executive branch in 2021.
Q: What has been your most rewarding accomplishment?
Dr. Esrailian: Giving a voice to people who don’t have a voice is something that I’m proud of. Sometimes, it’s questionable what impact it may have because we still see atrocities committed all over the world. In September, Azerbaijan completed an ethnic cleansing campaign of Armenians from a region called Artsakh, officially the Republic of Nagorno-Karabakh.
Despite having so many relationships with powerful people in government and in high-profile media, and despite our documentaries, op-eds, and interactions with influential leaders on a regular basis, it always feels like it’s not enough. Obviously, the perpetrators are still able to abuse human rights and conduct these campaigns. Nevertheless, I don’t think we should be deterred. Allowing human rights violations to occur with impunity only emboldens perpetrators even more. It takes a long time to bring people to justice through international courts, but it does happen – eventually. That’s something I’m going to continue to work on.
Q: What should be the role of physicians in supporting human rights?
Dr. Esrailian: Physicians and health care providers play an important role in human rights. If you look back throughout history, whether it’s the International Committee of the Red Cross, or Doctors Without Borders, or other organizations, physicians and health care professionals are often on the front lines, helping people. Unfortunately, physicians have also been part of human rights violations, like the Holocaust or other genocides. But I do think that in this day and age, with the reputation that physicians have, we can be policy advocates and upstanders in addition to taking care of patients. Telling our stories to the world is important so that people know what’s actually happening on the ground.
Lightning round
Do you prefer texting or talking?
Talking
How many cups of coffee do you drink each day?
Two
What was the last movie you watched?
Mission Impossible
If you weren’t a gastroenterologist, what would you be?
Entrepreneur
Who inspires you?
My family
Advancing personalized medicine in IBD
Gastroenterologists have more treatments at their disposal today than ever before, particularly in the last decade. “We have had tremendous advances in many areas of understanding contributors to disease,” said Dr. Melia, an assistant professor of medicine at Johns Hopkins Medicine in Baltimore who specializes in inflammatory bowel disease (IBD). But the hurdle is in translating the science to clinical care that is individualized to each patient based on condition and stage of the condition.
“That still remains a bit of a dream,” she said. Much of her career has been devoted to chasing down a particular genetic variant that contributes to IBD, with the goal of reaching more precise treatments for patients.
In an interview, she shared how she entered this line of work, and what her research has revealed about Crohn’s disease, manganese, and a common genetic variant known as ZIP8.
Q: Your expertise is in inflammatory bowel disease and manganese deficiency. Why did you choose these two areas as your focus in GI?
Dr. Melia: In talking to many patients with IBD, I was always struck by the questions around nutritional factors related to disease. As a fellow, I was embedded in a lab that focused on genetics of IBD. A micronutrient transporter, ZIP8, has a mutation in it that increases the risk of Crohn’s disease.
I’ve dedicated the last 8 years to understanding how this mutation can increase risk. It initially started out as a project focused on zinc, because that’s what the transporter was thought to regulate. However, it’s evolved as we’ve learned more about it, underscoring the importance of manganese, another micronutrient that we derive from food.
We have established that having this mutation changes how the body handles manganese and affects downstream processes that involve manganese. What I’m doing now is trying to connect those dots on why those processes are important in Crohn’s disease and whether we can target them for treatment.
Q: How does manganese deficiency lead to chronic IBD?
Dr. Melia: In individuals with this mutation, their blood manganese levels are lower than people who don’t have this mutation. When we talk about manganese deficiency or insufficiency, what we’re really talking about is lower blood levels. But it’s more complicated than that at the tissue level.
What we and other groups are working on right now is trying to understand if the manganese levels change in the gut and what happens in inflammation. The gut is a particularly interesting area for manganese, in that much of the manganese that we eat is excreted. We only absorb a small amount of it. And so, manganese levels within the gut lumen may actually be quite high – and may be even higher in inflammation. But there are things we don’t understand about that and how it relates to mucosal levels of manganese and Crohn’s disease. The ileum, the site of the Crohn’s disease that’s specifically associated with this mutation, might be particularly sensitive to changes in the manganese levels or the downstream processes that changing manganese availability affects.
One of those processes is glycosylation. Manganese is important to properly glycosylate your proteins. Many enzymes help cells put sugars on proteins, and many of those enzymes need manganese to do it. Glycosylation of proteins is important so cells know where those proteins should go, and the sugars help them stay where they need to be. When you change protein glycosylation, you can stress the cells. We know individuals who carry this mutation have changes in the glycosylation of their proteins. What we’re working on right now is understanding which key proteins might change when that happens, and why that’s a potential problem, especially in the ileum.
Q: How might your research inform clinical practice?
Dr. Melia: We’ve seen significant progress in new medications and new pathways that have emerged. We still have this fundamental problem that our immune-targeting medicines are only helping about 50% of the patients.
It’s critical that we begin to identify new pathways. And my hope is that in studying genes like the ZIP8 (SLC39A8), which is associated with the dysregulated processing of manganese, we can understand different pathways and mechanisms to target.
As an example, if we could help correct the glycosylation problem, that would help to boost the barrier function of the gut and perhaps decrease the activation of those immune cells, because you’re just reinforcing the barrier integrity of the gut.
We want to target that glycosylation problem as we would treat patients with congenital disorders of glycosylation by giving supplemental sugars. We think this problem of glycosylation extends beyond patients with the ZIP8 mutation, but it is also really important for patients with the mutation. So, the goal would be to use ZIP8 genetics to help prioritize patients for therapy targeting this problem.
Q: You’re involved in the American Gastroenterological Association Future Leaders Program. What is your role in this program? Why is it important?
Dr. Melia: I was very grateful for the opportunity to participate in the AGA’s Future Leaders Program. I think it was exceedingly valuable for two main reasons. One, it really offered an insight into the role of the AGA and the important role that the AGA plays in the careers of gastroenterologists. Two, it was such a unique opportunity to work with colleagues nationwide and to build a network of individuals who are all at a similar stage in their careers. It was a very inspiring group to meet and to have the opportunity to work with as part of that program, and I thank the AGA for supporting such an initiative.
Q: What teacher or mentor had the greatest impact on you?
Dr. Melia: I have been blessed by many clinical and research mentors through my career. I was inspired to do science at the lab of Ramnik Xavier, MD, at Massachusetts General Hospital. At Johns Hopkins, I credit Cindy Sears, MD, and Anne Marie O’Broin Lennon, MBBCh, PhD, as two physician scientists who have really shaped how I have tried to integrate my clinical and research career.
LIGHTNING ROUND
Do you prefer texting or talking?
Texting
If you weren’t a gastroenterologist, what would you be?
Teacher
What was the last movie you watched?
Great Bear Rainforest
What is your most favorite city in the U.S.?
Surry, Maine
What song do you absolutely have to sing along with when you hear it?
Any song by Whitney Houston.
Are you an introvert or extrovert?
Introvert
How many cups of coffee do you drink per day?
One
Gastroenterologists have more treatments at their disposal today than ever before, particularly in the last decade. “We have had tremendous advances in many areas of understanding contributors to disease,” said Dr. Melia, an assistant professor of medicine at Johns Hopkins Medicine in Baltimore who specializes in inflammatory bowel disease (IBD). But the hurdle is in translating the science to clinical care that is individualized to each patient based on condition and stage of the condition.
“That still remains a bit of a dream,” she said. Much of her career has been devoted to chasing down a particular genetic variant that contributes to IBD, with the goal of reaching more precise treatments for patients.
In an interview, she shared how she entered this line of work, and what her research has revealed about Crohn’s disease, manganese, and a common genetic variant known as ZIP8.
Q: Your expertise is in inflammatory bowel disease and manganese deficiency. Why did you choose these two areas as your focus in GI?
Dr. Melia: In talking to many patients with IBD, I was always struck by the questions around nutritional factors related to disease. As a fellow, I was embedded in a lab that focused on genetics of IBD. A micronutrient transporter, ZIP8, has a mutation in it that increases the risk of Crohn’s disease.
I’ve dedicated the last 8 years to understanding how this mutation can increase risk. It initially started out as a project focused on zinc, because that’s what the transporter was thought to regulate. However, it’s evolved as we’ve learned more about it, underscoring the importance of manganese, another micronutrient that we derive from food.
We have established that having this mutation changes how the body handles manganese and affects downstream processes that involve manganese. What I’m doing now is trying to connect those dots on why those processes are important in Crohn’s disease and whether we can target them for treatment.
Q: How does manganese deficiency lead to chronic IBD?
Dr. Melia: In individuals with this mutation, their blood manganese levels are lower than people who don’t have this mutation. When we talk about manganese deficiency or insufficiency, what we’re really talking about is lower blood levels. But it’s more complicated than that at the tissue level.
What we and other groups are working on right now is trying to understand if the manganese levels change in the gut and what happens in inflammation. The gut is a particularly interesting area for manganese, in that much of the manganese that we eat is excreted. We only absorb a small amount of it. And so, manganese levels within the gut lumen may actually be quite high – and may be even higher in inflammation. But there are things we don’t understand about that and how it relates to mucosal levels of manganese and Crohn’s disease. The ileum, the site of the Crohn’s disease that’s specifically associated with this mutation, might be particularly sensitive to changes in the manganese levels or the downstream processes that changing manganese availability affects.
One of those processes is glycosylation. Manganese is important to properly glycosylate your proteins. Many enzymes help cells put sugars on proteins, and many of those enzymes need manganese to do it. Glycosylation of proteins is important so cells know where those proteins should go, and the sugars help them stay where they need to be. When you change protein glycosylation, you can stress the cells. We know individuals who carry this mutation have changes in the glycosylation of their proteins. What we’re working on right now is understanding which key proteins might change when that happens, and why that’s a potential problem, especially in the ileum.
Q: How might your research inform clinical practice?
Dr. Melia: We’ve seen significant progress in new medications and new pathways that have emerged. We still have this fundamental problem that our immune-targeting medicines are only helping about 50% of the patients.
It’s critical that we begin to identify new pathways. And my hope is that in studying genes like the ZIP8 (SLC39A8), which is associated with the dysregulated processing of manganese, we can understand different pathways and mechanisms to target.
As an example, if we could help correct the glycosylation problem, that would help to boost the barrier function of the gut and perhaps decrease the activation of those immune cells, because you’re just reinforcing the barrier integrity of the gut.
We want to target that glycosylation problem as we would treat patients with congenital disorders of glycosylation by giving supplemental sugars. We think this problem of glycosylation extends beyond patients with the ZIP8 mutation, but it is also really important for patients with the mutation. So, the goal would be to use ZIP8 genetics to help prioritize patients for therapy targeting this problem.
Q: You’re involved in the American Gastroenterological Association Future Leaders Program. What is your role in this program? Why is it important?
Dr. Melia: I was very grateful for the opportunity to participate in the AGA’s Future Leaders Program. I think it was exceedingly valuable for two main reasons. One, it really offered an insight into the role of the AGA and the important role that the AGA plays in the careers of gastroenterologists. Two, it was such a unique opportunity to work with colleagues nationwide and to build a network of individuals who are all at a similar stage in their careers. It was a very inspiring group to meet and to have the opportunity to work with as part of that program, and I thank the AGA for supporting such an initiative.
Q: What teacher or mentor had the greatest impact on you?
Dr. Melia: I have been blessed by many clinical and research mentors through my career. I was inspired to do science at the lab of Ramnik Xavier, MD, at Massachusetts General Hospital. At Johns Hopkins, I credit Cindy Sears, MD, and Anne Marie O’Broin Lennon, MBBCh, PhD, as two physician scientists who have really shaped how I have tried to integrate my clinical and research career.
LIGHTNING ROUND
Do you prefer texting or talking?
Texting
If you weren’t a gastroenterologist, what would you be?
Teacher
What was the last movie you watched?
Great Bear Rainforest
What is your most favorite city in the U.S.?
Surry, Maine
What song do you absolutely have to sing along with when you hear it?
Any song by Whitney Houston.
Are you an introvert or extrovert?
Introvert
How many cups of coffee do you drink per day?
One
Gastroenterologists have more treatments at their disposal today than ever before, particularly in the last decade. “We have had tremendous advances in many areas of understanding contributors to disease,” said Dr. Melia, an assistant professor of medicine at Johns Hopkins Medicine in Baltimore who specializes in inflammatory bowel disease (IBD). But the hurdle is in translating the science to clinical care that is individualized to each patient based on condition and stage of the condition.
“That still remains a bit of a dream,” she said. Much of her career has been devoted to chasing down a particular genetic variant that contributes to IBD, with the goal of reaching more precise treatments for patients.
In an interview, she shared how she entered this line of work, and what her research has revealed about Crohn’s disease, manganese, and a common genetic variant known as ZIP8.
Q: Your expertise is in inflammatory bowel disease and manganese deficiency. Why did you choose these two areas as your focus in GI?
Dr. Melia: In talking to many patients with IBD, I was always struck by the questions around nutritional factors related to disease. As a fellow, I was embedded in a lab that focused on genetics of IBD. A micronutrient transporter, ZIP8, has a mutation in it that increases the risk of Crohn’s disease.
I’ve dedicated the last 8 years to understanding how this mutation can increase risk. It initially started out as a project focused on zinc, because that’s what the transporter was thought to regulate. However, it’s evolved as we’ve learned more about it, underscoring the importance of manganese, another micronutrient that we derive from food.
We have established that having this mutation changes how the body handles manganese and affects downstream processes that involve manganese. What I’m doing now is trying to connect those dots on why those processes are important in Crohn’s disease and whether we can target them for treatment.
Q: How does manganese deficiency lead to chronic IBD?
Dr. Melia: In individuals with this mutation, their blood manganese levels are lower than people who don’t have this mutation. When we talk about manganese deficiency or insufficiency, what we’re really talking about is lower blood levels. But it’s more complicated than that at the tissue level.
What we and other groups are working on right now is trying to understand if the manganese levels change in the gut and what happens in inflammation. The gut is a particularly interesting area for manganese, in that much of the manganese that we eat is excreted. We only absorb a small amount of it. And so, manganese levels within the gut lumen may actually be quite high – and may be even higher in inflammation. But there are things we don’t understand about that and how it relates to mucosal levels of manganese and Crohn’s disease. The ileum, the site of the Crohn’s disease that’s specifically associated with this mutation, might be particularly sensitive to changes in the manganese levels or the downstream processes that changing manganese availability affects.
One of those processes is glycosylation. Manganese is important to properly glycosylate your proteins. Many enzymes help cells put sugars on proteins, and many of those enzymes need manganese to do it. Glycosylation of proteins is important so cells know where those proteins should go, and the sugars help them stay where they need to be. When you change protein glycosylation, you can stress the cells. We know individuals who carry this mutation have changes in the glycosylation of their proteins. What we’re working on right now is understanding which key proteins might change when that happens, and why that’s a potential problem, especially in the ileum.
Q: How might your research inform clinical practice?
Dr. Melia: We’ve seen significant progress in new medications and new pathways that have emerged. We still have this fundamental problem that our immune-targeting medicines are only helping about 50% of the patients.
It’s critical that we begin to identify new pathways. And my hope is that in studying genes like the ZIP8 (SLC39A8), which is associated with the dysregulated processing of manganese, we can understand different pathways and mechanisms to target.
As an example, if we could help correct the glycosylation problem, that would help to boost the barrier function of the gut and perhaps decrease the activation of those immune cells, because you’re just reinforcing the barrier integrity of the gut.
We want to target that glycosylation problem as we would treat patients with congenital disorders of glycosylation by giving supplemental sugars. We think this problem of glycosylation extends beyond patients with the ZIP8 mutation, but it is also really important for patients with the mutation. So, the goal would be to use ZIP8 genetics to help prioritize patients for therapy targeting this problem.
Q: You’re involved in the American Gastroenterological Association Future Leaders Program. What is your role in this program? Why is it important?
Dr. Melia: I was very grateful for the opportunity to participate in the AGA’s Future Leaders Program. I think it was exceedingly valuable for two main reasons. One, it really offered an insight into the role of the AGA and the important role that the AGA plays in the careers of gastroenterologists. Two, it was such a unique opportunity to work with colleagues nationwide and to build a network of individuals who are all at a similar stage in their careers. It was a very inspiring group to meet and to have the opportunity to work with as part of that program, and I thank the AGA for supporting such an initiative.
Q: What teacher or mentor had the greatest impact on you?
Dr. Melia: I have been blessed by many clinical and research mentors through my career. I was inspired to do science at the lab of Ramnik Xavier, MD, at Massachusetts General Hospital. At Johns Hopkins, I credit Cindy Sears, MD, and Anne Marie O’Broin Lennon, MBBCh, PhD, as two physician scientists who have really shaped how I have tried to integrate my clinical and research career.
LIGHTNING ROUND
Do you prefer texting or talking?
Texting
If you weren’t a gastroenterologist, what would you be?
Teacher
What was the last movie you watched?
Great Bear Rainforest
What is your most favorite city in the U.S.?
Surry, Maine
What song do you absolutely have to sing along with when you hear it?
Any song by Whitney Houston.
Are you an introvert or extrovert?
Introvert
How many cups of coffee do you drink per day?
One
New initiative aims to test investigational OA treatments in high-risk patients after knee injury
David Felson, MD, MPH, often steps out of his physician’s role to help patients with osteoarthritis (OA). “I have one now who needed me to write to her landlord to get her to a ground floor apartment because she’s unable to navigate the stairs,” said Dr. Felson, a professor of medicine and epidemiology at Boston University.
Rheumatologists don’t have a lot of options to treat patients with OA, Dr. Felson said. The most effective treatments are NSAIDs. While reasonably effective, they have a lot of side effects and are not always safe to use, he said.
Exercise also works, but people don’t adhere to it after a while. “Another useful strategy is getting cortisone injections into the affected joint, but that doesn’t last for very long, and I think we’re all reluctant to do it over and over again,” Dr. Felson said.
Some might say, “Well, why can’t they just get a knee replacement?” Many patients don’t want the surgery, and others are too frail to qualify. They’re also not 100% successful. Patients after the surgery sometimes say that they’re still in pain.
There’s an urgent need for more effective therapies, said Dr. Felson, who’s been working on a unique approach to target patients at high risk for OA by studying two specific populations who sustain knee injury.
Previous clinical trials have failed
Clinical trials to test OA treatments have run into some roadblocks. The market for this is enormous, with the potential to benefit millions of patients, Dr. Felson continued.
However, very few large pharmaceutical companies or even biotech companies are pursuing treatment development in osteoarthritis because there have been a lot of expensive failures. “It’s made them gun shy,” Dr. Felson noted.
One issue is OA has a long disease course, taking decades to progress and see changes, said Jason Kim, PhD, vice president for osteoarthritis research at the Arthritis Foundation in Atlanta.
The typical clinical trial window runs just 2-5 years, which is insufficient to see adequate results in a disease like OA. Longer trials are prohibitively costly, especially for corporations with near-term pressures, Dr. Kim said.
Many of these trials also apply disease-modifying drugs to participants with OA who are “too far gone” and beyond repair. By the time older people present with OA to the doctor, their disease is far advanced, and it may not be reversible or even stoppable, Dr. Felson said.
Finding patients with ACL reconstruction with ‘bad outcomes’
Dr. Kim and Dr. Felson have joined other researchers to test a new approach, using people with anterior cruciate ligament (ACL) reconstruction as a starting block to sleuth out OA tendencies years before it even begins.
When someone gets an ACL or meniscal tear, the knee in many cases begins the process of developing OA. However, that process can take 10-20 years, or sometimes even longer.
“We can’t do trials that last that long,” Dr. Felson said. But there are a few people who do quickly develop OA when they sustain those injuries. “If we can grab those people and get them involved in a study where we test treatments, we could probably figure out what kinds of treatments would be effective,” Dr. Felson explained.
The challenge is finding enough patients with ACL reconstruction with bad outcomes to effectively study OA prevention and treatment. While that sounds unfortunate, “it’s what we needed,” Dr. Felson said.
A longitudinal study known as the MOON trial that tracked 2,340 ACL reconstruction cases offered some initial clues, providing a foundation for future research. Dr. Felson and Dr. Kim joined lead researcher Kurt Spindler, MD, to create the “MOON” cohort for people who underwent surgery after an ACL tear, following them for a decade.
Through the MOON trial, Spindler et al. were able to assess how many people developed OA over 2, 6, and 10 years of follow-up, and how many experienced pain.
“It allowed us to guesstimate whether we were going to have enough numbers of people getting bad outcomes to see if we could get enough numbers to treat,” Dr. Felson said.
Clinical trial to test FastOA criteria
The Arthritis Foundation, which funded the MOON trial along with the National Institutes of Health and The American Orthopaedic Society for Sports Medicine, launched the FastOA initiative, based on its findings.
FastOA is defined as “the rapid development of OA in those who have sustained a major joint injury.” One criterion for FastOA is older age. Eighteen- to 25-year-olds generally don’t have high risk for injury or OA. “It’s only when you get to your late 20s and 30s where your risk really starts to increase substantially, just like the risk of osteoarthritis does,” Dr. Felson said.
The other major risk factor for FastOA is pain. Pain after ACL reconstruction usually takes a long time to surface. Many people never experience pain. However, for a subgroup of people who get ACL reconstruction, their pain never goes away. “What the MOON data told us was that those are the people who continue to have pain later and who get osteoarthritis quicker,” he added.
The MOON results also informed researchers on the types of patients they should seek out for a future trial. “We wouldn’t just take everybody with ACL reconstructions. We’d take selected people who we knew based on the MOON data were at really high likelihood of developing FastOA,” Dr. Felson said .
Armed with these risk factors, Dr. Felson and colleagues plan to apply FastOA to a new clinical trial, Post-Injury Knee Arthritis Severity Outcomes (PIKASO), that will test the use of metformin, a well-known diabetes drug, in 500 patients at high risk of developing post-traumatic OA in the knee following ACL reconstruction.
Two groups will participate in the PIKASO trial, an initiative of the Arthritis Foundation’s Osteoarthritis Clinical Trials Network (OA-CTN).
“If you have pain at the time of ACL reconstruction, we are interested in you. And if even you don’t have pain, if you’re among older people who need ACL reconstruction, we’re also interested in you,” Dr. Felson said.
People aged 25-40 are eligible for the older category and those 18-40 are eligible for the pain group. It’s important to include younger people in the study, Dr. Felson said. One of his colleagues, a physical therapist, was disabled by a sports injury in her late teens. Now in her 30s, she’s disabled by OA and will have to wait up to 15 years to qualify for a knee replacement.
“It’s a good idea for us to focus in on the younger folks who develop osteoarthritis at a very early age where there’s nothing we can do for them in terms of surgical options for a few years,” he said.
Targeting specific groups means fewer patients will need to be followed over the period of the study, which will lower costs, Dr. Kim said.
Metformin, a popular diabetes drug with a good safety profile, is an ideal treatment for this trial, Dr. Felson said. It’s been tested in multiple animal models and has been shown to protect against OA in all those models.
Researchers will employ imaging and biomechanics measurements to assess changes in joint structure. Eight institutions will participate, including Mass General Brigham, the trial’s clinical coordinating center, and the Cleveland Clinic and University of North Carolina at Chapel Hill, which will coordinate the collection and analysis of MRI data and biomechanical and function assessments, respectively.
“Positive results from this trial would have the potential to enable surgeons to immediately prescribe the drug before a patient undergoes surgery to slow the disease progression, or even fully prevent” post-traumatic OA, according to a statement from the Arthritis Foundation.
‘We’re taking a leap’
PIKASO doesn’t come without its challenges. “There’s a lot of dangers here,” Dr. Felson acknowledged.
Even with the application of the FastOA risk factors, not enough people may end up getting OA. “We could do an expensive study with 500 people and not get enough people with OA to be able to test a treatment,” he said.
Another risk is metformin might not work in these participants to prevent disease. “We’re taking a leap and we’re hoping that leap works out,” Dr. Felson added.
Physicians outside of this project are hopeful that FastOA will facilitate the development of new OA therapeutic strategies.
“We all intuitively understand that a joint injury will increase our risk of arthritis in 5, 10 years, even 20 years if we’re lucky,” said Dominik R. Haudenschild, PhD, professor and director of translational orthopaedic research at Houston Methodist Academic Institute.
Most patients with a painful joint can recall when an injury took place. Focusing on treatments closer to the time of injury before irreversible disease sets in makes sense, he added.
The MOON researchers found that pain is not uncommon in patients with ACL reconstruction, making them an excellent choice for analysis, Dr. Haudenschild continued.
PIKASO could face some limitations, specifically with respect to the effect size – how big of a difference a treatment can make the moment a measurement is taken.
“If we’re looking at earlier disease, the intensity of pain is likely lower, or pain isn’t felt as frequently, or the extent of structural damage in the joint is smaller,” he explained. Even a perfect treatment would only make a smaller difference at the moment measurements are taken, which can be harder to measure.
“But I expect that many of the limitations can likely be overcome by making sure the appropriate outcomes are chosen,” he said.
Nancy E. Lane, MD, professor of medicine and rheumatology at UC Davis Health System, is hoping the research will better inform physicians and patients about ACL tears. They should be aware “that within a few months of an ACL injury, the bone structure around the joint changes and there are cartilage changes,” Dr. Lane said.
While early changes may not necessarily lead to OA, patients who develop joint pain with activity or joint swelling would benefit from education, additional imaging, and modifying their activities to prevent progression, she said.
“Hopefully, within a few years we will have effective treatments to slow or reverse the development of knee OA,” Dr. Lane said.
The PIKASO trial is scheduled to begin enrollment at the end of this year or in early 2024.
Dr. Felson is a board member and past and current awardee of the Arthritis Foundation. Dr. Kim is a staff member of the Arthritis Foundation. Dr. Haudenschild received a grant from the Arthritis Foundation and participates in local, regional, and national activities with the Arthritis Foundation. Dr. Lane had no disclosures.
David Felson, MD, MPH, often steps out of his physician’s role to help patients with osteoarthritis (OA). “I have one now who needed me to write to her landlord to get her to a ground floor apartment because she’s unable to navigate the stairs,” said Dr. Felson, a professor of medicine and epidemiology at Boston University.
Rheumatologists don’t have a lot of options to treat patients with OA, Dr. Felson said. The most effective treatments are NSAIDs. While reasonably effective, they have a lot of side effects and are not always safe to use, he said.
Exercise also works, but people don’t adhere to it after a while. “Another useful strategy is getting cortisone injections into the affected joint, but that doesn’t last for very long, and I think we’re all reluctant to do it over and over again,” Dr. Felson said.
Some might say, “Well, why can’t they just get a knee replacement?” Many patients don’t want the surgery, and others are too frail to qualify. They’re also not 100% successful. Patients after the surgery sometimes say that they’re still in pain.
There’s an urgent need for more effective therapies, said Dr. Felson, who’s been working on a unique approach to target patients at high risk for OA by studying two specific populations who sustain knee injury.
Previous clinical trials have failed
Clinical trials to test OA treatments have run into some roadblocks. The market for this is enormous, with the potential to benefit millions of patients, Dr. Felson continued.
However, very few large pharmaceutical companies or even biotech companies are pursuing treatment development in osteoarthritis because there have been a lot of expensive failures. “It’s made them gun shy,” Dr. Felson noted.
One issue is OA has a long disease course, taking decades to progress and see changes, said Jason Kim, PhD, vice president for osteoarthritis research at the Arthritis Foundation in Atlanta.
The typical clinical trial window runs just 2-5 years, which is insufficient to see adequate results in a disease like OA. Longer trials are prohibitively costly, especially for corporations with near-term pressures, Dr. Kim said.
Many of these trials also apply disease-modifying drugs to participants with OA who are “too far gone” and beyond repair. By the time older people present with OA to the doctor, their disease is far advanced, and it may not be reversible or even stoppable, Dr. Felson said.
Finding patients with ACL reconstruction with ‘bad outcomes’
Dr. Kim and Dr. Felson have joined other researchers to test a new approach, using people with anterior cruciate ligament (ACL) reconstruction as a starting block to sleuth out OA tendencies years before it even begins.
When someone gets an ACL or meniscal tear, the knee in many cases begins the process of developing OA. However, that process can take 10-20 years, or sometimes even longer.
“We can’t do trials that last that long,” Dr. Felson said. But there are a few people who do quickly develop OA when they sustain those injuries. “If we can grab those people and get them involved in a study where we test treatments, we could probably figure out what kinds of treatments would be effective,” Dr. Felson explained.
The challenge is finding enough patients with ACL reconstruction with bad outcomes to effectively study OA prevention and treatment. While that sounds unfortunate, “it’s what we needed,” Dr. Felson said.
A longitudinal study known as the MOON trial that tracked 2,340 ACL reconstruction cases offered some initial clues, providing a foundation for future research. Dr. Felson and Dr. Kim joined lead researcher Kurt Spindler, MD, to create the “MOON” cohort for people who underwent surgery after an ACL tear, following them for a decade.
Through the MOON trial, Spindler et al. were able to assess how many people developed OA over 2, 6, and 10 years of follow-up, and how many experienced pain.
“It allowed us to guesstimate whether we were going to have enough numbers of people getting bad outcomes to see if we could get enough numbers to treat,” Dr. Felson said.
Clinical trial to test FastOA criteria
The Arthritis Foundation, which funded the MOON trial along with the National Institutes of Health and The American Orthopaedic Society for Sports Medicine, launched the FastOA initiative, based on its findings.
FastOA is defined as “the rapid development of OA in those who have sustained a major joint injury.” One criterion for FastOA is older age. Eighteen- to 25-year-olds generally don’t have high risk for injury or OA. “It’s only when you get to your late 20s and 30s where your risk really starts to increase substantially, just like the risk of osteoarthritis does,” Dr. Felson said.
The other major risk factor for FastOA is pain. Pain after ACL reconstruction usually takes a long time to surface. Many people never experience pain. However, for a subgroup of people who get ACL reconstruction, their pain never goes away. “What the MOON data told us was that those are the people who continue to have pain later and who get osteoarthritis quicker,” he added.
The MOON results also informed researchers on the types of patients they should seek out for a future trial. “We wouldn’t just take everybody with ACL reconstructions. We’d take selected people who we knew based on the MOON data were at really high likelihood of developing FastOA,” Dr. Felson said .
Armed with these risk factors, Dr. Felson and colleagues plan to apply FastOA to a new clinical trial, Post-Injury Knee Arthritis Severity Outcomes (PIKASO), that will test the use of metformin, a well-known diabetes drug, in 500 patients at high risk of developing post-traumatic OA in the knee following ACL reconstruction.
Two groups will participate in the PIKASO trial, an initiative of the Arthritis Foundation’s Osteoarthritis Clinical Trials Network (OA-CTN).
“If you have pain at the time of ACL reconstruction, we are interested in you. And if even you don’t have pain, if you’re among older people who need ACL reconstruction, we’re also interested in you,” Dr. Felson said.
People aged 25-40 are eligible for the older category and those 18-40 are eligible for the pain group. It’s important to include younger people in the study, Dr. Felson said. One of his colleagues, a physical therapist, was disabled by a sports injury in her late teens. Now in her 30s, she’s disabled by OA and will have to wait up to 15 years to qualify for a knee replacement.
“It’s a good idea for us to focus in on the younger folks who develop osteoarthritis at a very early age where there’s nothing we can do for them in terms of surgical options for a few years,” he said.
Targeting specific groups means fewer patients will need to be followed over the period of the study, which will lower costs, Dr. Kim said.
Metformin, a popular diabetes drug with a good safety profile, is an ideal treatment for this trial, Dr. Felson said. It’s been tested in multiple animal models and has been shown to protect against OA in all those models.
Researchers will employ imaging and biomechanics measurements to assess changes in joint structure. Eight institutions will participate, including Mass General Brigham, the trial’s clinical coordinating center, and the Cleveland Clinic and University of North Carolina at Chapel Hill, which will coordinate the collection and analysis of MRI data and biomechanical and function assessments, respectively.
“Positive results from this trial would have the potential to enable surgeons to immediately prescribe the drug before a patient undergoes surgery to slow the disease progression, or even fully prevent” post-traumatic OA, according to a statement from the Arthritis Foundation.
‘We’re taking a leap’
PIKASO doesn’t come without its challenges. “There’s a lot of dangers here,” Dr. Felson acknowledged.
Even with the application of the FastOA risk factors, not enough people may end up getting OA. “We could do an expensive study with 500 people and not get enough people with OA to be able to test a treatment,” he said.
Another risk is metformin might not work in these participants to prevent disease. “We’re taking a leap and we’re hoping that leap works out,” Dr. Felson added.
Physicians outside of this project are hopeful that FastOA will facilitate the development of new OA therapeutic strategies.
“We all intuitively understand that a joint injury will increase our risk of arthritis in 5, 10 years, even 20 years if we’re lucky,” said Dominik R. Haudenschild, PhD, professor and director of translational orthopaedic research at Houston Methodist Academic Institute.
Most patients with a painful joint can recall when an injury took place. Focusing on treatments closer to the time of injury before irreversible disease sets in makes sense, he added.
The MOON researchers found that pain is not uncommon in patients with ACL reconstruction, making them an excellent choice for analysis, Dr. Haudenschild continued.
PIKASO could face some limitations, specifically with respect to the effect size – how big of a difference a treatment can make the moment a measurement is taken.
“If we’re looking at earlier disease, the intensity of pain is likely lower, or pain isn’t felt as frequently, or the extent of structural damage in the joint is smaller,” he explained. Even a perfect treatment would only make a smaller difference at the moment measurements are taken, which can be harder to measure.
“But I expect that many of the limitations can likely be overcome by making sure the appropriate outcomes are chosen,” he said.
Nancy E. Lane, MD, professor of medicine and rheumatology at UC Davis Health System, is hoping the research will better inform physicians and patients about ACL tears. They should be aware “that within a few months of an ACL injury, the bone structure around the joint changes and there are cartilage changes,” Dr. Lane said.
While early changes may not necessarily lead to OA, patients who develop joint pain with activity or joint swelling would benefit from education, additional imaging, and modifying their activities to prevent progression, she said.
“Hopefully, within a few years we will have effective treatments to slow or reverse the development of knee OA,” Dr. Lane said.
The PIKASO trial is scheduled to begin enrollment at the end of this year or in early 2024.
Dr. Felson is a board member and past and current awardee of the Arthritis Foundation. Dr. Kim is a staff member of the Arthritis Foundation. Dr. Haudenschild received a grant from the Arthritis Foundation and participates in local, regional, and national activities with the Arthritis Foundation. Dr. Lane had no disclosures.
David Felson, MD, MPH, often steps out of his physician’s role to help patients with osteoarthritis (OA). “I have one now who needed me to write to her landlord to get her to a ground floor apartment because she’s unable to navigate the stairs,” said Dr. Felson, a professor of medicine and epidemiology at Boston University.
Rheumatologists don’t have a lot of options to treat patients with OA, Dr. Felson said. The most effective treatments are NSAIDs. While reasonably effective, they have a lot of side effects and are not always safe to use, he said.
Exercise also works, but people don’t adhere to it after a while. “Another useful strategy is getting cortisone injections into the affected joint, but that doesn’t last for very long, and I think we’re all reluctant to do it over and over again,” Dr. Felson said.
Some might say, “Well, why can’t they just get a knee replacement?” Many patients don’t want the surgery, and others are too frail to qualify. They’re also not 100% successful. Patients after the surgery sometimes say that they’re still in pain.
There’s an urgent need for more effective therapies, said Dr. Felson, who’s been working on a unique approach to target patients at high risk for OA by studying two specific populations who sustain knee injury.
Previous clinical trials have failed
Clinical trials to test OA treatments have run into some roadblocks. The market for this is enormous, with the potential to benefit millions of patients, Dr. Felson continued.
However, very few large pharmaceutical companies or even biotech companies are pursuing treatment development in osteoarthritis because there have been a lot of expensive failures. “It’s made them gun shy,” Dr. Felson noted.
One issue is OA has a long disease course, taking decades to progress and see changes, said Jason Kim, PhD, vice president for osteoarthritis research at the Arthritis Foundation in Atlanta.
The typical clinical trial window runs just 2-5 years, which is insufficient to see adequate results in a disease like OA. Longer trials are prohibitively costly, especially for corporations with near-term pressures, Dr. Kim said.
Many of these trials also apply disease-modifying drugs to participants with OA who are “too far gone” and beyond repair. By the time older people present with OA to the doctor, their disease is far advanced, and it may not be reversible or even stoppable, Dr. Felson said.
Finding patients with ACL reconstruction with ‘bad outcomes’
Dr. Kim and Dr. Felson have joined other researchers to test a new approach, using people with anterior cruciate ligament (ACL) reconstruction as a starting block to sleuth out OA tendencies years before it even begins.
When someone gets an ACL or meniscal tear, the knee in many cases begins the process of developing OA. However, that process can take 10-20 years, or sometimes even longer.
“We can’t do trials that last that long,” Dr. Felson said. But there are a few people who do quickly develop OA when they sustain those injuries. “If we can grab those people and get them involved in a study where we test treatments, we could probably figure out what kinds of treatments would be effective,” Dr. Felson explained.
The challenge is finding enough patients with ACL reconstruction with bad outcomes to effectively study OA prevention and treatment. While that sounds unfortunate, “it’s what we needed,” Dr. Felson said.
A longitudinal study known as the MOON trial that tracked 2,340 ACL reconstruction cases offered some initial clues, providing a foundation for future research. Dr. Felson and Dr. Kim joined lead researcher Kurt Spindler, MD, to create the “MOON” cohort for people who underwent surgery after an ACL tear, following them for a decade.
Through the MOON trial, Spindler et al. were able to assess how many people developed OA over 2, 6, and 10 years of follow-up, and how many experienced pain.
“It allowed us to guesstimate whether we were going to have enough numbers of people getting bad outcomes to see if we could get enough numbers to treat,” Dr. Felson said.
Clinical trial to test FastOA criteria
The Arthritis Foundation, which funded the MOON trial along with the National Institutes of Health and The American Orthopaedic Society for Sports Medicine, launched the FastOA initiative, based on its findings.
FastOA is defined as “the rapid development of OA in those who have sustained a major joint injury.” One criterion for FastOA is older age. Eighteen- to 25-year-olds generally don’t have high risk for injury or OA. “It’s only when you get to your late 20s and 30s where your risk really starts to increase substantially, just like the risk of osteoarthritis does,” Dr. Felson said.
The other major risk factor for FastOA is pain. Pain after ACL reconstruction usually takes a long time to surface. Many people never experience pain. However, for a subgroup of people who get ACL reconstruction, their pain never goes away. “What the MOON data told us was that those are the people who continue to have pain later and who get osteoarthritis quicker,” he added.
The MOON results also informed researchers on the types of patients they should seek out for a future trial. “We wouldn’t just take everybody with ACL reconstructions. We’d take selected people who we knew based on the MOON data were at really high likelihood of developing FastOA,” Dr. Felson said .
Armed with these risk factors, Dr. Felson and colleagues plan to apply FastOA to a new clinical trial, Post-Injury Knee Arthritis Severity Outcomes (PIKASO), that will test the use of metformin, a well-known diabetes drug, in 500 patients at high risk of developing post-traumatic OA in the knee following ACL reconstruction.
Two groups will participate in the PIKASO trial, an initiative of the Arthritis Foundation’s Osteoarthritis Clinical Trials Network (OA-CTN).
“If you have pain at the time of ACL reconstruction, we are interested in you. And if even you don’t have pain, if you’re among older people who need ACL reconstruction, we’re also interested in you,” Dr. Felson said.
People aged 25-40 are eligible for the older category and those 18-40 are eligible for the pain group. It’s important to include younger people in the study, Dr. Felson said. One of his colleagues, a physical therapist, was disabled by a sports injury in her late teens. Now in her 30s, she’s disabled by OA and will have to wait up to 15 years to qualify for a knee replacement.
“It’s a good idea for us to focus in on the younger folks who develop osteoarthritis at a very early age where there’s nothing we can do for them in terms of surgical options for a few years,” he said.
Targeting specific groups means fewer patients will need to be followed over the period of the study, which will lower costs, Dr. Kim said.
Metformin, a popular diabetes drug with a good safety profile, is an ideal treatment for this trial, Dr. Felson said. It’s been tested in multiple animal models and has been shown to protect against OA in all those models.
Researchers will employ imaging and biomechanics measurements to assess changes in joint structure. Eight institutions will participate, including Mass General Brigham, the trial’s clinical coordinating center, and the Cleveland Clinic and University of North Carolina at Chapel Hill, which will coordinate the collection and analysis of MRI data and biomechanical and function assessments, respectively.
“Positive results from this trial would have the potential to enable surgeons to immediately prescribe the drug before a patient undergoes surgery to slow the disease progression, or even fully prevent” post-traumatic OA, according to a statement from the Arthritis Foundation.
‘We’re taking a leap’
PIKASO doesn’t come without its challenges. “There’s a lot of dangers here,” Dr. Felson acknowledged.
Even with the application of the FastOA risk factors, not enough people may end up getting OA. “We could do an expensive study with 500 people and not get enough people with OA to be able to test a treatment,” he said.
Another risk is metformin might not work in these participants to prevent disease. “We’re taking a leap and we’re hoping that leap works out,” Dr. Felson added.
Physicians outside of this project are hopeful that FastOA will facilitate the development of new OA therapeutic strategies.
“We all intuitively understand that a joint injury will increase our risk of arthritis in 5, 10 years, even 20 years if we’re lucky,” said Dominik R. Haudenschild, PhD, professor and director of translational orthopaedic research at Houston Methodist Academic Institute.
Most patients with a painful joint can recall when an injury took place. Focusing on treatments closer to the time of injury before irreversible disease sets in makes sense, he added.
The MOON researchers found that pain is not uncommon in patients with ACL reconstruction, making them an excellent choice for analysis, Dr. Haudenschild continued.
PIKASO could face some limitations, specifically with respect to the effect size – how big of a difference a treatment can make the moment a measurement is taken.
“If we’re looking at earlier disease, the intensity of pain is likely lower, or pain isn’t felt as frequently, or the extent of structural damage in the joint is smaller,” he explained. Even a perfect treatment would only make a smaller difference at the moment measurements are taken, which can be harder to measure.
“But I expect that many of the limitations can likely be overcome by making sure the appropriate outcomes are chosen,” he said.
Nancy E. Lane, MD, professor of medicine and rheumatology at UC Davis Health System, is hoping the research will better inform physicians and patients about ACL tears. They should be aware “that within a few months of an ACL injury, the bone structure around the joint changes and there are cartilage changes,” Dr. Lane said.
While early changes may not necessarily lead to OA, patients who develop joint pain with activity or joint swelling would benefit from education, additional imaging, and modifying their activities to prevent progression, she said.
“Hopefully, within a few years we will have effective treatments to slow or reverse the development of knee OA,” Dr. Lane said.
The PIKASO trial is scheduled to begin enrollment at the end of this year or in early 2024.
Dr. Felson is a board member and past and current awardee of the Arthritis Foundation. Dr. Kim is a staff member of the Arthritis Foundation. Dr. Haudenschild received a grant from the Arthritis Foundation and participates in local, regional, and national activities with the Arthritis Foundation. Dr. Lane had no disclosures.
GI docs’ nutrition education deficit may shortchange patients
Yevgenia Pashinsky, MD, has seen her share of patients who have bounced from one gastroenterologist to the next after becoming frustrated when food elimination, supplements, or medications don’t alleviate their gastrointestinal symptoms.
In most cases, their decision to switch gastroenterologists comes down to a simple fact: No one dissected their diets.
The situation underscores how essential it is for gastroenterologists to be comfortable with nutrition concepts, said Dr. Pashinsky, a gastroenterologist with New York Gastroenterology Associates and affiliated with Mount Sinai Hospital in New York.
“There should be a focus in recognizing patterns that will help the physician pinpoint triggers, thereby helping identify the underlying disorder and guide further diagnostic and treatment options,” she said.
Although many common digestive diseases and their corresponding outcomes are linked to dietary quality and are complicated by poor nutrition and/or obesity, nutrition often gets pushed to the wayside in GI education, write Carolyn Newberry, MD, Brandon Sprung, MD, and Octavia Pickett-Blakely, MD, MHS, in a recent analysis.
“Gastroenterology fellows report limited exposure to nutrition topics leading to knowledge deficit on assessment,” they add.
One 2022 studybased on a survey of 279 GI clinicians treating patients with irritable bowel syndrome (IBS) reported that only 56% felt that they were trained to provide nutrition education, and 46% said that they sometimes, rarely, or never offered to help patients with their menu planning, label reading, or grocery shopping. And 77% said that they spent 10 minutes or less counseling patients on nutrition. Though almost all respondents (91%) said that having access to a dietitian would help them better manage patients with IBS, 42% said that they lack access to one.
But some gastroenterology professors are working to incorporate nutrition into GI training and integrating dietitians in their work with fellows as well as collaborating with dietitians to improve care in their own practices.
Nutrition overlooked in procedure-heavy specialty
In 1985, the National Academies of Sciences, Engineering, and Medicine made recommendations to upgrade nutrition education programs in U.S. medical schools.
Still, medical schools often don’t have the faculty or infrastructure to integrate and teach foundational nutrition concepts. These topics include clinical concepts, such as protein, carbohydrate and fat digestion/absorption, weight loss/gain, and symptoms related to food intake, as well as physical examination, which can help identify nutritional risks, said Dr. Pickett-Blakely, an associate professor of clinical medicine at the University of Pennsylvania and director of the Penn Center for GI Nutrition, both in Philadelphia.
Standardized medical exams include only about five questions on nutrition, and they’re all geared toward pathology, Dr. Pashinsky noted.
GI training, which includes 3 years of internal medicine residency and 3 years of GI fellowship, typically doesn’t focus on nutrition beyond total and peripheral parenteral nutrition and nutritional deficiencies, Dr. Pashinsky said. Instead, it focuses on the recognition, diagnosis, and medical management of GI diseases.
The Accreditation Council for Graduate Medical Education requires that fellows demonstrate core competency in nutrition and in the prevention, evaluation, and management of disorders of nutrient assimilation. The council also has incorporated the opportunity to interact with and learn from dietitians in its requirements for GI fellowship programs. Fellows in the dual GI/transplant hepatology pathway, created in 2021, must show competency in nutritional support for patients with chronic liver disease and in the factors involved in nutrition and malnutrition and their management.
Despite these requirements, the education that fellows receive often falls short for several reasons, said Dr. Sprung, an associate professor of medicine at the University of Rochester Medical Center’s gastroenterology and hepatology division in New York.
Gastroenterology faculties have generally shown a lack of interest in nutrition, translating into fewer faculty members able to train the future generations of physicians, he said. Training institutions have limited nutrition and obesity resources, staff, and support.
Gastroenterology is also a very procedure-focused specialty, and many students and trainees come to fellowships for procedural training, Dr. Sprung noted. Nutrition and obesity training don’t fit as well into what is traditionally an organ- or disease-specific style of education and training and, as a result, are superseded, he added.
It is possible that some fellowships are just not teaching these core concepts, Dr. Pickett-Blakely said. “The depth and breath of coverage of these concepts varies from program to program,” she added.
Exacerbating the problem is the growth of numerous subspecialties, including inflammatory bowel diseases, hepatobiliary disease, neurogastroenterology, and gastrointestinal motility, Dr. Pickett-Blakely said. Emphasis has dwindled over time on an in-depth understanding of core gastrointestinal functions, like digestion and absorption, and how these functions can be supported for optimal wellness and are affected by diseases.
“With the loss of those with the ability to educate trainees, nutrition sort of falls out of curricula, and trainees aren’t able to be exposed to those educational concepts,” she said.
It would be ideal if foundational concepts of nutrition were integrated into the subspecialty GI fellowships, which are 1-year fellowships that take place before or after the 3-year traditional fellowship, Dr. Pickett-Blakely said.
GI fellows interested in incorporating nutrition and obesity in their clinical practice on a routine basis could investigate getting board certified in nutrition, Dr. Sprung said. The National Board of Physician Nutrition Specialists, the National Board for Nutrition Support, and several other organizations offer certifications in nutrition.
If more physicians became board certified in nutritional or obesity specialties, teaching faculty numbers would increase, and that could help training grow, he noted.
Weaving more nutrition into training
To further increase knowledge, Dr. Sprung and Dr. Newberry, who is an assistant professor and director of GI nutrition at Weill Cornell Medicine’s Innovative Center for Health and Nutrition in Gastroenterology in New York, have created a free online resource covering core nutrition and obesity concepts that is available to GI fellowship programs.
Key components of the curriculum include online pre- and postlearning tests, self-directed reading materials, virtual recorded lectures, and case-based learning modules. It also provides a section on care coordination with a GI dietitian.
“Because the curriculum spans all facets of gastroenterology practice, the information can enhance clinical care experiences on general rotations,” write Dr. Newberry and colleagues in their recent analysis in Gastroenterology.
GI fellows can look at the content at their own pace and complete the curriculum as part of a formal elective.
The developers can see who’s taken the tests, and test participation indicates that several GI programs across the country are already using the program, Dr. Sprung said.
But it hasn’t been as widely adopted as hoped, he said.
“We’re trying to put some spotlight on it through articles, presentations during Digestive Disease Week, and emails to program directors, things like that,” Dr. Sprung said. “So it’s great to spread the word and get the message out there.”
Collaboration in practice
Ultimately, helping a patient with functional GI problems takes a village, and many practices are now including multidisciplinary teams.
Having these dietitians available to them, as well as seeing the benefit to their patients first-hand, has helped encourage the attending gastroenterologists’ interest, said Nancee Jaffe, RD, MS, who is senior supervisor for the GI nutrition program at UCLA Health’s Vatche & Tamar Manoukian Division of Digestive Diseases in Beverly Hills, Calif.
“We all subspecialize, which allows both doctors and patients access to the best nutrition information for a myriad of GI conditions,” Ms. Jaffe said.
In the spirit of teamwork, the university also has an integrative digestive health and wellness program, which is inclusive of doctors, dietitians, and psychologists. These teams meet monthly to discuss cases involving disorders of gut-brain interaction using a multicentered approach, she said.
In New York, one of the first things Dr. Newberry, who is also a clinical gastroenterologist with advanced training in nutrition and obesity sciences, did when she accepted her job at Weill Cornell was to advocate for a multidisciplinary team. At the Innovative Center for Health and Nutrition in Gastroenterology, she works with a group of dietitians, a hepatologist, an endocrinologist, and a team of surgeons to take care of patients. The focus is on treating patients’ GI issues while helping them lose weight.
The clinic sees a lot of patients with reflux disease and fatty liver disease. When patients come in, they’ll see the gastroenterologist, the dietitian, the endocrinologist, and possibly the bariatric surgeon. The team approach, which calls for constant communication among the physicians, improves outcomes, Dr. Newberry said.
It has been shown in the literature that multidisciplinary teams are effective for chronic diseases like nonalcoholic fatty liver disease (now known as metabolic dysfunction-associated steatotic liver disease) and inflammatory bowel disease, she added.
At the University of Rochester, Dr. Sprung and his fellow gastroenterologists coordinate with dietitians and nutrition experts for nutrition support services, as well as liver and transplant nutritional services.
We have nurse practitioners and physician assistants who run our nutritional support services for people who need such specialized care, such as total parenteral nutrition or tube feeds, or for those who need advanced therapies, like for short-gut syndrome, he said.
At NYGA, Dr. Pashinsky works with a team of registered dietitians who have specialized in gastroenterology. The dietitians help with identifying which foods in a patient’s diet are problematic and making recommendations to replace them with nutritionally equivalent staples to avoid dietary gaps, she said.
Dietitians inform patient care because they’re trained in food compounds and how foods pass through the GI tract, said Tamara Duker Freuman, RD, MS, CDN, who leads the group of registered dietitians at NYGA. Ms. Freuman comanages many patients with Dr. Pashinsky.
Oftentimes, the patient provides insights they never tell the doctor, and the dietitian gets a better idea of the patient’s life and eating habits, she said. “We’re able to spend more time with patients than physicians are, and we ask different questions.”
“Any detective work I do informs any future diagnostics [Dr. Pashinsky] does. It’s a team sport,” Ms. Freuman said.Dr. Pickett-Blakely has been a consultant for Novo Nordisk and WebMD. Dr. Newberry has received a speaking honorarium for Baxter and InBody. Dr. Sprung, Dr. Pashinsky, Ms. Freuman, and Ms. Jaffe reported no disclosures.
A version of this article first appeared on Medscape.com.
Yevgenia Pashinsky, MD, has seen her share of patients who have bounced from one gastroenterologist to the next after becoming frustrated when food elimination, supplements, or medications don’t alleviate their gastrointestinal symptoms.
In most cases, their decision to switch gastroenterologists comes down to a simple fact: No one dissected their diets.
The situation underscores how essential it is for gastroenterologists to be comfortable with nutrition concepts, said Dr. Pashinsky, a gastroenterologist with New York Gastroenterology Associates and affiliated with Mount Sinai Hospital in New York.
“There should be a focus in recognizing patterns that will help the physician pinpoint triggers, thereby helping identify the underlying disorder and guide further diagnostic and treatment options,” she said.
Although many common digestive diseases and their corresponding outcomes are linked to dietary quality and are complicated by poor nutrition and/or obesity, nutrition often gets pushed to the wayside in GI education, write Carolyn Newberry, MD, Brandon Sprung, MD, and Octavia Pickett-Blakely, MD, MHS, in a recent analysis.
“Gastroenterology fellows report limited exposure to nutrition topics leading to knowledge deficit on assessment,” they add.
One 2022 studybased on a survey of 279 GI clinicians treating patients with irritable bowel syndrome (IBS) reported that only 56% felt that they were trained to provide nutrition education, and 46% said that they sometimes, rarely, or never offered to help patients with their menu planning, label reading, or grocery shopping. And 77% said that they spent 10 minutes or less counseling patients on nutrition. Though almost all respondents (91%) said that having access to a dietitian would help them better manage patients with IBS, 42% said that they lack access to one.
But some gastroenterology professors are working to incorporate nutrition into GI training and integrating dietitians in their work with fellows as well as collaborating with dietitians to improve care in their own practices.
Nutrition overlooked in procedure-heavy specialty
In 1985, the National Academies of Sciences, Engineering, and Medicine made recommendations to upgrade nutrition education programs in U.S. medical schools.
Still, medical schools often don’t have the faculty or infrastructure to integrate and teach foundational nutrition concepts. These topics include clinical concepts, such as protein, carbohydrate and fat digestion/absorption, weight loss/gain, and symptoms related to food intake, as well as physical examination, which can help identify nutritional risks, said Dr. Pickett-Blakely, an associate professor of clinical medicine at the University of Pennsylvania and director of the Penn Center for GI Nutrition, both in Philadelphia.
Standardized medical exams include only about five questions on nutrition, and they’re all geared toward pathology, Dr. Pashinsky noted.
GI training, which includes 3 years of internal medicine residency and 3 years of GI fellowship, typically doesn’t focus on nutrition beyond total and peripheral parenteral nutrition and nutritional deficiencies, Dr. Pashinsky said. Instead, it focuses on the recognition, diagnosis, and medical management of GI diseases.
The Accreditation Council for Graduate Medical Education requires that fellows demonstrate core competency in nutrition and in the prevention, evaluation, and management of disorders of nutrient assimilation. The council also has incorporated the opportunity to interact with and learn from dietitians in its requirements for GI fellowship programs. Fellows in the dual GI/transplant hepatology pathway, created in 2021, must show competency in nutritional support for patients with chronic liver disease and in the factors involved in nutrition and malnutrition and their management.
Despite these requirements, the education that fellows receive often falls short for several reasons, said Dr. Sprung, an associate professor of medicine at the University of Rochester Medical Center’s gastroenterology and hepatology division in New York.
Gastroenterology faculties have generally shown a lack of interest in nutrition, translating into fewer faculty members able to train the future generations of physicians, he said. Training institutions have limited nutrition and obesity resources, staff, and support.
Gastroenterology is also a very procedure-focused specialty, and many students and trainees come to fellowships for procedural training, Dr. Sprung noted. Nutrition and obesity training don’t fit as well into what is traditionally an organ- or disease-specific style of education and training and, as a result, are superseded, he added.
It is possible that some fellowships are just not teaching these core concepts, Dr. Pickett-Blakely said. “The depth and breath of coverage of these concepts varies from program to program,” she added.
Exacerbating the problem is the growth of numerous subspecialties, including inflammatory bowel diseases, hepatobiliary disease, neurogastroenterology, and gastrointestinal motility, Dr. Pickett-Blakely said. Emphasis has dwindled over time on an in-depth understanding of core gastrointestinal functions, like digestion and absorption, and how these functions can be supported for optimal wellness and are affected by diseases.
“With the loss of those with the ability to educate trainees, nutrition sort of falls out of curricula, and trainees aren’t able to be exposed to those educational concepts,” she said.
It would be ideal if foundational concepts of nutrition were integrated into the subspecialty GI fellowships, which are 1-year fellowships that take place before or after the 3-year traditional fellowship, Dr. Pickett-Blakely said.
GI fellows interested in incorporating nutrition and obesity in their clinical practice on a routine basis could investigate getting board certified in nutrition, Dr. Sprung said. The National Board of Physician Nutrition Specialists, the National Board for Nutrition Support, and several other organizations offer certifications in nutrition.
If more physicians became board certified in nutritional or obesity specialties, teaching faculty numbers would increase, and that could help training grow, he noted.
Weaving more nutrition into training
To further increase knowledge, Dr. Sprung and Dr. Newberry, who is an assistant professor and director of GI nutrition at Weill Cornell Medicine’s Innovative Center for Health and Nutrition in Gastroenterology in New York, have created a free online resource covering core nutrition and obesity concepts that is available to GI fellowship programs.
Key components of the curriculum include online pre- and postlearning tests, self-directed reading materials, virtual recorded lectures, and case-based learning modules. It also provides a section on care coordination with a GI dietitian.
“Because the curriculum spans all facets of gastroenterology practice, the information can enhance clinical care experiences on general rotations,” write Dr. Newberry and colleagues in their recent analysis in Gastroenterology.
GI fellows can look at the content at their own pace and complete the curriculum as part of a formal elective.
The developers can see who’s taken the tests, and test participation indicates that several GI programs across the country are already using the program, Dr. Sprung said.
But it hasn’t been as widely adopted as hoped, he said.
“We’re trying to put some spotlight on it through articles, presentations during Digestive Disease Week, and emails to program directors, things like that,” Dr. Sprung said. “So it’s great to spread the word and get the message out there.”
Collaboration in practice
Ultimately, helping a patient with functional GI problems takes a village, and many practices are now including multidisciplinary teams.
Having these dietitians available to them, as well as seeing the benefit to their patients first-hand, has helped encourage the attending gastroenterologists’ interest, said Nancee Jaffe, RD, MS, who is senior supervisor for the GI nutrition program at UCLA Health’s Vatche & Tamar Manoukian Division of Digestive Diseases in Beverly Hills, Calif.
“We all subspecialize, which allows both doctors and patients access to the best nutrition information for a myriad of GI conditions,” Ms. Jaffe said.
In the spirit of teamwork, the university also has an integrative digestive health and wellness program, which is inclusive of doctors, dietitians, and psychologists. These teams meet monthly to discuss cases involving disorders of gut-brain interaction using a multicentered approach, she said.
In New York, one of the first things Dr. Newberry, who is also a clinical gastroenterologist with advanced training in nutrition and obesity sciences, did when she accepted her job at Weill Cornell was to advocate for a multidisciplinary team. At the Innovative Center for Health and Nutrition in Gastroenterology, she works with a group of dietitians, a hepatologist, an endocrinologist, and a team of surgeons to take care of patients. The focus is on treating patients’ GI issues while helping them lose weight.
The clinic sees a lot of patients with reflux disease and fatty liver disease. When patients come in, they’ll see the gastroenterologist, the dietitian, the endocrinologist, and possibly the bariatric surgeon. The team approach, which calls for constant communication among the physicians, improves outcomes, Dr. Newberry said.
It has been shown in the literature that multidisciplinary teams are effective for chronic diseases like nonalcoholic fatty liver disease (now known as metabolic dysfunction-associated steatotic liver disease) and inflammatory bowel disease, she added.
At the University of Rochester, Dr. Sprung and his fellow gastroenterologists coordinate with dietitians and nutrition experts for nutrition support services, as well as liver and transplant nutritional services.
We have nurse practitioners and physician assistants who run our nutritional support services for people who need such specialized care, such as total parenteral nutrition or tube feeds, or for those who need advanced therapies, like for short-gut syndrome, he said.
At NYGA, Dr. Pashinsky works with a team of registered dietitians who have specialized in gastroenterology. The dietitians help with identifying which foods in a patient’s diet are problematic and making recommendations to replace them with nutritionally equivalent staples to avoid dietary gaps, she said.
Dietitians inform patient care because they’re trained in food compounds and how foods pass through the GI tract, said Tamara Duker Freuman, RD, MS, CDN, who leads the group of registered dietitians at NYGA. Ms. Freuman comanages many patients with Dr. Pashinsky.
Oftentimes, the patient provides insights they never tell the doctor, and the dietitian gets a better idea of the patient’s life and eating habits, she said. “We’re able to spend more time with patients than physicians are, and we ask different questions.”
“Any detective work I do informs any future diagnostics [Dr. Pashinsky] does. It’s a team sport,” Ms. Freuman said.Dr. Pickett-Blakely has been a consultant for Novo Nordisk and WebMD. Dr. Newberry has received a speaking honorarium for Baxter and InBody. Dr. Sprung, Dr. Pashinsky, Ms. Freuman, and Ms. Jaffe reported no disclosures.
A version of this article first appeared on Medscape.com.
Yevgenia Pashinsky, MD, has seen her share of patients who have bounced from one gastroenterologist to the next after becoming frustrated when food elimination, supplements, or medications don’t alleviate their gastrointestinal symptoms.
In most cases, their decision to switch gastroenterologists comes down to a simple fact: No one dissected their diets.
The situation underscores how essential it is for gastroenterologists to be comfortable with nutrition concepts, said Dr. Pashinsky, a gastroenterologist with New York Gastroenterology Associates and affiliated with Mount Sinai Hospital in New York.
“There should be a focus in recognizing patterns that will help the physician pinpoint triggers, thereby helping identify the underlying disorder and guide further diagnostic and treatment options,” she said.
Although many common digestive diseases and their corresponding outcomes are linked to dietary quality and are complicated by poor nutrition and/or obesity, nutrition often gets pushed to the wayside in GI education, write Carolyn Newberry, MD, Brandon Sprung, MD, and Octavia Pickett-Blakely, MD, MHS, in a recent analysis.
“Gastroenterology fellows report limited exposure to nutrition topics leading to knowledge deficit on assessment,” they add.
One 2022 studybased on a survey of 279 GI clinicians treating patients with irritable bowel syndrome (IBS) reported that only 56% felt that they were trained to provide nutrition education, and 46% said that they sometimes, rarely, or never offered to help patients with their menu planning, label reading, or grocery shopping. And 77% said that they spent 10 minutes or less counseling patients on nutrition. Though almost all respondents (91%) said that having access to a dietitian would help them better manage patients with IBS, 42% said that they lack access to one.
But some gastroenterology professors are working to incorporate nutrition into GI training and integrating dietitians in their work with fellows as well as collaborating with dietitians to improve care in their own practices.
Nutrition overlooked in procedure-heavy specialty
In 1985, the National Academies of Sciences, Engineering, and Medicine made recommendations to upgrade nutrition education programs in U.S. medical schools.
Still, medical schools often don’t have the faculty or infrastructure to integrate and teach foundational nutrition concepts. These topics include clinical concepts, such as protein, carbohydrate and fat digestion/absorption, weight loss/gain, and symptoms related to food intake, as well as physical examination, which can help identify nutritional risks, said Dr. Pickett-Blakely, an associate professor of clinical medicine at the University of Pennsylvania and director of the Penn Center for GI Nutrition, both in Philadelphia.
Standardized medical exams include only about five questions on nutrition, and they’re all geared toward pathology, Dr. Pashinsky noted.
GI training, which includes 3 years of internal medicine residency and 3 years of GI fellowship, typically doesn’t focus on nutrition beyond total and peripheral parenteral nutrition and nutritional deficiencies, Dr. Pashinsky said. Instead, it focuses on the recognition, diagnosis, and medical management of GI diseases.
The Accreditation Council for Graduate Medical Education requires that fellows demonstrate core competency in nutrition and in the prevention, evaluation, and management of disorders of nutrient assimilation. The council also has incorporated the opportunity to interact with and learn from dietitians in its requirements for GI fellowship programs. Fellows in the dual GI/transplant hepatology pathway, created in 2021, must show competency in nutritional support for patients with chronic liver disease and in the factors involved in nutrition and malnutrition and their management.
Despite these requirements, the education that fellows receive often falls short for several reasons, said Dr. Sprung, an associate professor of medicine at the University of Rochester Medical Center’s gastroenterology and hepatology division in New York.
Gastroenterology faculties have generally shown a lack of interest in nutrition, translating into fewer faculty members able to train the future generations of physicians, he said. Training institutions have limited nutrition and obesity resources, staff, and support.
Gastroenterology is also a very procedure-focused specialty, and many students and trainees come to fellowships for procedural training, Dr. Sprung noted. Nutrition and obesity training don’t fit as well into what is traditionally an organ- or disease-specific style of education and training and, as a result, are superseded, he added.
It is possible that some fellowships are just not teaching these core concepts, Dr. Pickett-Blakely said. “The depth and breath of coverage of these concepts varies from program to program,” she added.
Exacerbating the problem is the growth of numerous subspecialties, including inflammatory bowel diseases, hepatobiliary disease, neurogastroenterology, and gastrointestinal motility, Dr. Pickett-Blakely said. Emphasis has dwindled over time on an in-depth understanding of core gastrointestinal functions, like digestion and absorption, and how these functions can be supported for optimal wellness and are affected by diseases.
“With the loss of those with the ability to educate trainees, nutrition sort of falls out of curricula, and trainees aren’t able to be exposed to those educational concepts,” she said.
It would be ideal if foundational concepts of nutrition were integrated into the subspecialty GI fellowships, which are 1-year fellowships that take place before or after the 3-year traditional fellowship, Dr. Pickett-Blakely said.
GI fellows interested in incorporating nutrition and obesity in their clinical practice on a routine basis could investigate getting board certified in nutrition, Dr. Sprung said. The National Board of Physician Nutrition Specialists, the National Board for Nutrition Support, and several other organizations offer certifications in nutrition.
If more physicians became board certified in nutritional or obesity specialties, teaching faculty numbers would increase, and that could help training grow, he noted.
Weaving more nutrition into training
To further increase knowledge, Dr. Sprung and Dr. Newberry, who is an assistant professor and director of GI nutrition at Weill Cornell Medicine’s Innovative Center for Health and Nutrition in Gastroenterology in New York, have created a free online resource covering core nutrition and obesity concepts that is available to GI fellowship programs.
Key components of the curriculum include online pre- and postlearning tests, self-directed reading materials, virtual recorded lectures, and case-based learning modules. It also provides a section on care coordination with a GI dietitian.
“Because the curriculum spans all facets of gastroenterology practice, the information can enhance clinical care experiences on general rotations,” write Dr. Newberry and colleagues in their recent analysis in Gastroenterology.
GI fellows can look at the content at their own pace and complete the curriculum as part of a formal elective.
The developers can see who’s taken the tests, and test participation indicates that several GI programs across the country are already using the program, Dr. Sprung said.
But it hasn’t been as widely adopted as hoped, he said.
“We’re trying to put some spotlight on it through articles, presentations during Digestive Disease Week, and emails to program directors, things like that,” Dr. Sprung said. “So it’s great to spread the word and get the message out there.”
Collaboration in practice
Ultimately, helping a patient with functional GI problems takes a village, and many practices are now including multidisciplinary teams.
Having these dietitians available to them, as well as seeing the benefit to their patients first-hand, has helped encourage the attending gastroenterologists’ interest, said Nancee Jaffe, RD, MS, who is senior supervisor for the GI nutrition program at UCLA Health’s Vatche & Tamar Manoukian Division of Digestive Diseases in Beverly Hills, Calif.
“We all subspecialize, which allows both doctors and patients access to the best nutrition information for a myriad of GI conditions,” Ms. Jaffe said.
In the spirit of teamwork, the university also has an integrative digestive health and wellness program, which is inclusive of doctors, dietitians, and psychologists. These teams meet monthly to discuss cases involving disorders of gut-brain interaction using a multicentered approach, she said.
In New York, one of the first things Dr. Newberry, who is also a clinical gastroenterologist with advanced training in nutrition and obesity sciences, did when she accepted her job at Weill Cornell was to advocate for a multidisciplinary team. At the Innovative Center for Health and Nutrition in Gastroenterology, she works with a group of dietitians, a hepatologist, an endocrinologist, and a team of surgeons to take care of patients. The focus is on treating patients’ GI issues while helping them lose weight.
The clinic sees a lot of patients with reflux disease and fatty liver disease. When patients come in, they’ll see the gastroenterologist, the dietitian, the endocrinologist, and possibly the bariatric surgeon. The team approach, which calls for constant communication among the physicians, improves outcomes, Dr. Newberry said.
It has been shown in the literature that multidisciplinary teams are effective for chronic diseases like nonalcoholic fatty liver disease (now known as metabolic dysfunction-associated steatotic liver disease) and inflammatory bowel disease, she added.
At the University of Rochester, Dr. Sprung and his fellow gastroenterologists coordinate with dietitians and nutrition experts for nutrition support services, as well as liver and transplant nutritional services.
We have nurse practitioners and physician assistants who run our nutritional support services for people who need such specialized care, such as total parenteral nutrition or tube feeds, or for those who need advanced therapies, like for short-gut syndrome, he said.
At NYGA, Dr. Pashinsky works with a team of registered dietitians who have specialized in gastroenterology. The dietitians help with identifying which foods in a patient’s diet are problematic and making recommendations to replace them with nutritionally equivalent staples to avoid dietary gaps, she said.
Dietitians inform patient care because they’re trained in food compounds and how foods pass through the GI tract, said Tamara Duker Freuman, RD, MS, CDN, who leads the group of registered dietitians at NYGA. Ms. Freuman comanages many patients with Dr. Pashinsky.
Oftentimes, the patient provides insights they never tell the doctor, and the dietitian gets a better idea of the patient’s life and eating habits, she said. “We’re able to spend more time with patients than physicians are, and we ask different questions.”
“Any detective work I do informs any future diagnostics [Dr. Pashinsky] does. It’s a team sport,” Ms. Freuman said.Dr. Pickett-Blakely has been a consultant for Novo Nordisk and WebMD. Dr. Newberry has received a speaking honorarium for Baxter and InBody. Dr. Sprung, Dr. Pashinsky, Ms. Freuman, and Ms. Jaffe reported no disclosures.
A version of this article first appeared on Medscape.com.