The New Gastroenterologist

Not every physician coming out of medical school wants to go down the path of conducting clinical research. But for those who do, the decision is a rewarding one that can make a real difference in patients’ lives.

I took a nontraditional route to get to my current role as the director of clinical research and education at the largest gastroenterology practice in the United States. I had a business degree coming out of college and worked for years in the business world prior to going to medical school. After graduation, I got an offer to join the pharmaceutical industry in medical affairs. There, I focused on inflammatory bowel disease (IBD), where my role was to share high-level scientific data and liaise with IBD disease state experts. Part of the role was working internally with clinical operations and externally with sites conducting research throughout the United States. In the next 6 years, I had the opportunity to observe how research was run in both the academic and community practice settings, noting those characteristics that allowed some to succeed and far more to stagnate or fail.

In 2014, I joined Texas Digestive Disease Consultants with the goal to ramp up the practice’s clinical research arm and create a department expressly for that purpose. To date, the department has become incredibly successful and ultimately sustainable. If you’re considering joining a practice based on its clinical research program or starting one in your current practice, here is what I’ve learned along the way:

Know the benefit to patients

You have to decide to conduct clinical research because of its benefit to the patient, not because you see it as an alternative revenue stream. It will never be sustainable if viewed as a profit center. Clinical research offers therapeutic advancements that will not be available to most for the next 5-10 years. Additionally, patients do not need insurance in order to participate in a study. The sponsor covers all study visits, procedures, and therapeutics.

Know the value to the practice

Having a clinical trials program brings both direct and indirect enterprise value to the practice. It may come in the form of referrals from other practices that don’t have the same capabilities. Patients may view your practice differently, knowing that it has the added value of research. There is a halo effect from having clinical trials capabilities in how you are viewed by patients and other physicians in the community.

Get the right people in place

First, you will need an enthusiastic primary investigator who can take a bit of time from practice to conduct clinical trials. But just as importantly, you need a knowledgeable clinical research coordinator. Without an effective coordinator, the program is doomed. A good coordinator should be well rounded in all aspects of research (e.g., regulatory, patient recruitment, quality assurance, contracts, budgets, running labs, conducting patient visits) and able to deal with the day-to-day intricacies of running clinical trials, which will allow a doctor to take care of the existing practice. They should also be versed in the requisite equipment (e.g., locking refrigerator, freezer, and ambient cabinet, temperature monitoring devices, EKG machine, and centrifuge) necessary to run a clinical study.

Know how to recruit patients

The database at Texas Digestive Disease Consultants/GI Alliance (TDDC/GIA) is vast, which makes identification of patients who may qualify for a trial an easier task. Many practices will have an electronic medical record that will aid in identification, but if that is not the case at your practice, there are a number of ways you can go about this. First, talk to physicians in your practice and in other practices – internists, family physicians, and other gastroenterologists come to mind – about what you can offer. Send a letter or an email out to physicians in the community with the inclusion/exclusion criteria for your study, and always direct them to https://clinicaltrials.gov/ for additional information. Patient advocacy organizations are another good source of referrals for clinical trials. And of course, pharmaceutical companies have recruitment services that they use and can help steer patients your way.

Understand the ethics

There are numerous ethical and legal considerations when it comes to running clinical trials. The principles of Good Clinical Practice (GCP) and Human Subject Protection (HSP) guide the conduct of clinical trials in the United States. Understanding the concepts and regulations around caring for patients in trials is not only “good practice,” it’s a necessity. There are free Good Clinical Practice training courses available, which are required every few years for everyone conducting clinical research. These courses are quite lengthy (3-6 hours), but provide a great overview of the Food and Drug Administration regulations, ethical considerations, and other advice on successfully operating a clinical trials program. Again, a capable clinical research coordinator will help guide you here.

Adopt standard operating procedures

Every clinical trials sponsor will require standard operating procedures for such facets of research as informed consent, reporting requirements, and safety monitoring. Here again, a seasoned clinical trials coordinator can put you on the right path. You may choose to purchase standardized templates or work with another group that already has them and would be willing to share.

Be smart about spending

While this may depend on the scale you want to grow your research, at TDDC/GIA we knew we wanted to build a sustainable program. We invested a lot of time and money into our infrastructure, as well as adopting a robust Clinical Trials Management System (CTMS). A CTMS system will provide the ability to measure productivity, finances, schedule patient visits, and pay patient stipends. Some systems even automate the regulatory process (E-Regulatory) or source process (E-source), which can cut down on the paper burden on a site.

Seek mentors

Look for someone to emulate who is already established in operating a clinical research program in private practice. Reach out to the practices or physicians that are already doing this work and doing it well. For physicians who are just starting out or still in training, look for opportunities to publish or be involved with the clinical trials program at your institution.

Contacts in the pharmaceutical industry are very important to getting a new program off the ground. Ask the pharma sales representatives who visit your clinic to put you in touch with their medical science liaison (MSL). The MSL can get you information about the clinical trials their company is currently running and those they have in the pipeline.
 

Dr. Chris Fourment, director of clinical research and education, Texas Digestive Disease Consultants/GI Alliance.

Not every physician coming out of medical school wants to go down the path of conducting clinical research. But for those who do, the decision is a rewarding one that can make a real difference in patients’ lives.

I took a nontraditional route to get to my current role as the director of clinical research and education at the largest gastroenterology practice in the United States. I had a business degree coming out of college and worked for years in the business world prior to going to medical school. After graduation, I got an offer to join the pharmaceutical industry in medical affairs. There, I focused on inflammatory bowel disease (IBD), where my role was to share high-level scientific data and liaise with IBD disease state experts. Part of the role was working internally with clinical operations and externally with sites conducting research throughout the United States. In the next 6 years, I had the opportunity to observe how research was run in both the academic and community practice settings, noting those characteristics that allowed some to succeed and far more to stagnate or fail.

In 2014, I joined Texas Digestive Disease Consultants with the goal to ramp up the practice’s clinical research arm and create a department expressly for that purpose. To date, the department has become incredibly successful and ultimately sustainable. If you’re considering joining a practice based on its clinical research program or starting one in your current practice, here is what I’ve learned along the way:

Know the benefit to patients

You have to decide to conduct clinical research because of its benefit to the patient, not because you see it as an alternative revenue stream. It will never be sustainable if viewed as a profit center. Clinical research offers therapeutic advancements that will not be available to most for the next 5-10 years. Additionally, patients do not need insurance in order to participate in a study. The sponsor covers all study visits, procedures, and therapeutics.

Know the value to the practice

Having a clinical trials program brings both direct and indirect enterprise value to the practice. It may come in the form of referrals from other practices that don’t have the same capabilities. Patients may view your practice differently, knowing that it has the added value of research. There is a halo effect from having clinical trials capabilities in how you are viewed by patients and other physicians in the community.

Get the right people in place

First, you will need an enthusiastic primary investigator who can take a bit of time from practice to conduct clinical trials. But just as importantly, you need a knowledgeable clinical research coordinator. Without an effective coordinator, the program is doomed. A good coordinator should be well rounded in all aspects of research (e.g., regulatory, patient recruitment, quality assurance, contracts, budgets, running labs, conducting patient visits) and able to deal with the day-to-day intricacies of running clinical trials, which will allow a doctor to take care of the existing practice. They should also be versed in the requisite equipment (e.g., locking refrigerator, freezer, and ambient cabinet, temperature monitoring devices, EKG machine, and centrifuge) necessary to run a clinical study.

Know how to recruit patients

The database at Texas Digestive Disease Consultants/GI Alliance (TDDC/GIA) is vast, which makes identification of patients who may qualify for a trial an easier task. Many practices will have an electronic medical record that will aid in identification, but if that is not the case at your practice, there are a number of ways you can go about this. First, talk to physicians in your practice and in other practices – internists, family physicians, and other gastroenterologists come to mind – about what you can offer. Send a letter or an email out to physicians in the community with the inclusion/exclusion criteria for your study, and always direct them to https://clinicaltrials.gov/ for additional information. Patient advocacy organizations are another good source of referrals for clinical trials. And of course, pharmaceutical companies have recruitment services that they use and can help steer patients your way.

Understand the ethics

There are numerous ethical and legal considerations when it comes to running clinical trials. The principles of Good Clinical Practice (GCP) and Human Subject Protection (HSP) guide the conduct of clinical trials in the United States. Understanding the concepts and regulations around caring for patients in trials is not only “good practice,” it’s a necessity. There are free Good Clinical Practice training courses available, which are required every few years for everyone conducting clinical research. These courses are quite lengthy (3-6 hours), but provide a great overview of the Food and Drug Administration regulations, ethical considerations, and other advice on successfully operating a clinical trials program. Again, a capable clinical research coordinator will help guide you here.

Adopt standard operating procedures

Every clinical trials sponsor will require standard operating procedures for such facets of research as informed consent, reporting requirements, and safety monitoring. Here again, a seasoned clinical trials coordinator can put you on the right path. You may choose to purchase standardized templates or work with another group that already has them and would be willing to share.

Be smart about spending

While this may depend on the scale you want to grow your research, at TDDC/GIA we knew we wanted to build a sustainable program. We invested a lot of time and money into our infrastructure, as well as adopting a robust Clinical Trials Management System (CTMS). A CTMS system will provide the ability to measure productivity, finances, schedule patient visits, and pay patient stipends. Some systems even automate the regulatory process (E-Regulatory) or source process (E-source), which can cut down on the paper burden on a site.

Seek mentors

Look for someone to emulate who is already established in operating a clinical research program in private practice. Reach out to the practices or physicians that are already doing this work and doing it well. For physicians who are just starting out or still in training, look for opportunities to publish or be involved with the clinical trials program at your institution.

Contacts in the pharmaceutical industry are very important to getting a new program off the ground. Ask the pharma sales representatives who visit your clinic to put you in touch with their medical science liaison (MSL). The MSL can get you information about the clinical trials their company is currently running and those they have in the pipeline.
 

Dr. Chris Fourment, director of clinical research and education, Texas Digestive Disease Consultants/GI Alliance.

Not every physician coming out of medical school wants to go down the path of conducting clinical research. But for those who do, the decision is a rewarding one that can make a real difference in patients’ lives.

I took a nontraditional route to get to my current role as the director of clinical research and education at the largest gastroenterology practice in the United States. I had a business degree coming out of college and worked for years in the business world prior to going to medical school. After graduation, I got an offer to join the pharmaceutical industry in medical affairs. There, I focused on inflammatory bowel disease (IBD), where my role was to share high-level scientific data and liaise with IBD disease state experts. Part of the role was working internally with clinical operations and externally with sites conducting research throughout the United States. In the next 6 years, I had the opportunity to observe how research was run in both the academic and community practice settings, noting those characteristics that allowed some to succeed and far more to stagnate or fail.

In 2014, I joined Texas Digestive Disease Consultants with the goal to ramp up the practice’s clinical research arm and create a department expressly for that purpose. To date, the department has become incredibly successful and ultimately sustainable. If you’re considering joining a practice based on its clinical research program or starting one in your current practice, here is what I’ve learned along the way:

Know the benefit to patients

You have to decide to conduct clinical research because of its benefit to the patient, not because you see it as an alternative revenue stream. It will never be sustainable if viewed as a profit center. Clinical research offers therapeutic advancements that will not be available to most for the next 5-10 years. Additionally, patients do not need insurance in order to participate in a study. The sponsor covers all study visits, procedures, and therapeutics.

Know the value to the practice

Having a clinical trials program brings both direct and indirect enterprise value to the practice. It may come in the form of referrals from other practices that don’t have the same capabilities. Patients may view your practice differently, knowing that it has the added value of research. There is a halo effect from having clinical trials capabilities in how you are viewed by patients and other physicians in the community.

Get the right people in place

First, you will need an enthusiastic primary investigator who can take a bit of time from practice to conduct clinical trials. But just as importantly, you need a knowledgeable clinical research coordinator. Without an effective coordinator, the program is doomed. A good coordinator should be well rounded in all aspects of research (e.g., regulatory, patient recruitment, quality assurance, contracts, budgets, running labs, conducting patient visits) and able to deal with the day-to-day intricacies of running clinical trials, which will allow a doctor to take care of the existing practice. They should also be versed in the requisite equipment (e.g., locking refrigerator, freezer, and ambient cabinet, temperature monitoring devices, EKG machine, and centrifuge) necessary to run a clinical study.

Know how to recruit patients

The database at Texas Digestive Disease Consultants/GI Alliance (TDDC/GIA) is vast, which makes identification of patients who may qualify for a trial an easier task. Many practices will have an electronic medical record that will aid in identification, but if that is not the case at your practice, there are a number of ways you can go about this. First, talk to physicians in your practice and in other practices – internists, family physicians, and other gastroenterologists come to mind – about what you can offer. Send a letter or an email out to physicians in the community with the inclusion/exclusion criteria for your study, and always direct them to https://clinicaltrials.gov/ for additional information. Patient advocacy organizations are another good source of referrals for clinical trials. And of course, pharmaceutical companies have recruitment services that they use and can help steer patients your way.

Understand the ethics

There are numerous ethical and legal considerations when it comes to running clinical trials. The principles of Good Clinical Practice (GCP) and Human Subject Protection (HSP) guide the conduct of clinical trials in the United States. Understanding the concepts and regulations around caring for patients in trials is not only “good practice,” it’s a necessity. There are free Good Clinical Practice training courses available, which are required every few years for everyone conducting clinical research. These courses are quite lengthy (3-6 hours), but provide a great overview of the Food and Drug Administration regulations, ethical considerations, and other advice on successfully operating a clinical trials program. Again, a capable clinical research coordinator will help guide you here.

Adopt standard operating procedures

Every clinical trials sponsor will require standard operating procedures for such facets of research as informed consent, reporting requirements, and safety monitoring. Here again, a seasoned clinical trials coordinator can put you on the right path. You may choose to purchase standardized templates or work with another group that already has them and would be willing to share.

Be smart about spending

While this may depend on the scale you want to grow your research, at TDDC/GIA we knew we wanted to build a sustainable program. We invested a lot of time and money into our infrastructure, as well as adopting a robust Clinical Trials Management System (CTMS). A CTMS system will provide the ability to measure productivity, finances, schedule patient visits, and pay patient stipends. Some systems even automate the regulatory process (E-Regulatory) or source process (E-source), which can cut down on the paper burden on a site.

Seek mentors

Look for someone to emulate who is already established in operating a clinical research program in private practice. Reach out to the practices or physicians that are already doing this work and doing it well. For physicians who are just starting out or still in training, look for opportunities to publish or be involved with the clinical trials program at your institution.

Contacts in the pharmaceutical industry are very important to getting a new program off the ground. Ask the pharma sales representatives who visit your clinic to put you in touch with their medical science liaison (MSL). The MSL can get you information about the clinical trials their company is currently running and those they have in the pipeline.
 

Dr. Chris Fourment, director of clinical research and education, Texas Digestive Disease Consultants/GI Alliance.

Introduction

Despite a global decline in the incidence of gastric cancer over the past 3 decades, it remains the fifth most commonly diagnosed cancer and the third most common cause of cancer deaths worldwide.¹ In the United States it is the fourth most commonly diagnosed GI malignancy, after colorectal, pancreas, and liver cancer. The prevalence remains high in Latin America and Asia, which has implications in the United States because of growing Hispanic and Asian populations.^2,3 In recent years, a change in the trend of gastric cancer among non-Hispanic whites has been observed, particularly in women younger than 50 years old.⁴ Gastric intestinal metaplasia has been recognized worldwide as a premalignant precursor to gastric cancer, but currently, there are limited U.S. guidelines, leading to controversy over management of this condition.⁵

Etiology

Gastric adenocarcinomas are classified into two subcategories based on location (cardia and noncardia) and histology (intestinal and diffuse types).^6,7 Atrophic gastritis and gastric intestinal metaplasia (GIM) are considered precursors of intestinal-type noncardia gastric adenocarcinoma. The Correa cascade is a commonly accepted precancer sequence for noncardia gastric adenocarcinoma that describes mucosal changes from inflammation to atrophy to metaplasia to intraepithelial neoplasia and culminating in carcinoma.^8,9 It has been observed that GIM may be the histologic change prior to the development of dysplasia and over 50% of patients with high-grade dysplasia will progress to adenocarcinoma.^10-12 In the United States, GIM has the highest prevalence in African Americans, Hispanics, and East Asians, with the overall GIM prevalence regardless of ethnicity reported from 3.05% to 19.2%.^5,13

Risk factors and subclassification

Replacement of the foveolar and/or glandular epithelium in the oxyntic and antral mucosa by intestinal epithelium results in GIM. It can be focal when limited to one region of the stomach or extensive when two or more regions are involved.¹⁴ The main risk factors for GIM development are Helicobacter pylori infection, tobacco, alcohol consumption, high salt intake, and chronic bile reflux.^15,16 Additional risks for developing gastric cancer include older age, certain ethnicities, and male sex.¹⁷

CagA strains of H. pylori can promote carcinogenesis by inducing a mitogenic cellular response and downregulating cell adhesion.^18,19 Less carcinogenic risk is associated with H. pylori Cag-A negative strains; however, they also have oncogenic potential mediated by expression of babA2 and vacA genes.²⁰ Hence, the combination of multiple virulent factors encoded in babA2, CagA, and vacA genes has been associated with increased risk of GIM, inflammation, and development of gastric cancer.¹⁵ The clinical usefulness of genotyping H. pylori strains specifically to survey precancerous gastric lesions remains to be seen because of a lack of sufficient clinical studies. In addition, genotyping H. pylori is not commonly performed as part of clinical practice.

The loss of parietal cells seen in atrophic gastritis due to chronic H. pylori infection has been linked to the development of metaplasia due to possible loss of differentiation-promoting factors. As a result, metaplastic cells emerge that express spasmolytic polypeptide (SP or TFF2); hence, this type of metaplasia is referred to as spasmolytic polypeptide–expressing metaplasia (SPEM). The cellular mechanism that may explain a precursor role of SPEM in the development of GIM remains unknown.¹⁴ A second competing theory for the development of GIM is the clonal expansion of stem cells in the gastric isthmus that can lead to dysplasia and cancer development.¹⁴

On the basis of histological similarities with small intestinal or colonic epithelium, GIM can be further classified into complete or incomplete intestinal metaplasia.²¹ Complete intestinal metaplasia most closely resembles small intestinal epithelium with a brush border and goblet cells. Incomplete intestinal metaplasia resembles the colonic epithelium and lacks a brush border. A second classification further classifies GIM into three subtypes: Type I contains nonsecretory absorptive cells and sialomucin secreting goblet cells; type II has few absorptive cells, columnar cells secreting sialomucin, goblet cells secreting mainly sialomucin but some sulphomucin, and presence of Paneth cells; and type III consists of columnar cells secreting predominantly sulphomucin, goblet cells secreting sialomucin or sulphomucin, and absence of Paneth cells.^15,22 In this subclassification, type I GIM is known as complete GIM and types II and III as incomplete GIM.^23-25

Multiple studies performed outside of the United States have shown a higher progression risk to gastric adenocarcinoma in incomplete intestinal metaplasia, or type III intestinal metaplasia.^26-32 Also, the risk of gastric cancer has been demonstrated to be higher among patients with a greater area of metaplasia and extensive intestinal metaplasia, defined as GIM in both the antrum and corpus.^33,34 Hence, the extent of the metaplasia determined with mapping biopsies, regardless of the subtype, should also be incorporated into the risk assessment of the patient. Currently, a major limitation in the United States is a standardized method of pathologic reporting including subclassification of incomplete versus complete intestinal metaplasia.
 

Which patients to screen

Understanding this sequence of carcinogenesis offers a potential window for screening and surveillance. Subsequently, early detection of precancerous mucosal changes would be more amenable for endoscopic submucosal dissection (ESD).^35,36 Currently, U.S. society guidelines do not specifically address the management of GIM. The American Society for Gastrointestinal Endoscopy (ASGE) guidelines for management of premalignant and malignant conditions of the stomach recommend surveillance in individuals with a family history of gastric cancer or of high-risk ethnic background but with no specific optimal surveillance interval.³⁷ Also, H. pylori treatment is recommended if identified, but empiric treatment in GIM was felt to be controversial. The AGA recently sought comments on a proposed new guideline for the management of GIM. This guideline should be released after the comment period and help address management of GIM in the United States. In April of 2019, the European Society of Gastrointestinal Endoscopy (ESGE) updated the management of epithelial precancerous conditions and lesions in the stomach (MAPS II) guideline.³⁸ The MAPS II guideline identifies atrophic gastritis and intestinal metaplasia as precancerous lesions. In patients with moderate to marked atrophy or GIM affecting both antral and body mucosa, ESGE recommends endoscopic surveillance with high-definition chromoendoscopy, mapping, and guided biopsies or at least two biopsies taken separately at the lesser and greater curvature of the antrum and body. H. pylori eradication was recommended if the patient tested positive.

Furthermore, MAPS II proposed replacing atrophic gastritis (AG) in the Operative Link on Gastritis Assessment (OLGA) staging by GIM (OLGIM) as it is considered a more reliable predictor of an individual’s gastric neoplasia risk, based on the interobserver agreement kappa value 0.6 for AG versus 0.9 for GIM.³⁹ Five biopsies (two from the antrum, two from the corpus, and one from the incisura angularis) are needed for the OLGA/OLGIM score system to be considered an accurate predictor of this risk.³⁹ This is supported by the early findings of gastric atrophy and GIM in the incisura angularis.²³ In addition, for patients with GIM only in either the antrum or the body, a family history of gastric cancer, incomplete GIM, autoimmune gastritis, or persistent H. pylori infection was felt to increase the risk to warrant surveillance every 3 years. In those patients with atrophy or GIM in both the antrum and body with a first-degree relative with gastric cancer, surveillance was recommended every 1-2 years. Patients with any dysplasia and a visible lesion should have staging and resection. With no visible lesion, a follow-up endoscopy should be performed in 6 months with high-grade dysplasia and with low-grade dysplasia a repeat in 12 months. Patients with mild to moderate atrophy in the antrum and no intestinal metaplasia were not felt to warrant any further surveillance. (See Figure 1.)

How to screen

Previous studies have found a poor correlation between the endoscopic determination of gastric atrophy and the histologic diagnosis.⁴² Several studies also found that gastric cancer was missed on initial endoscopic examinations. Sensitivity of endoscopy to detect gastric cancer has ranged from 77% to 93%.^43,44 In the United States, there is a lack of standardized quality indicators for upper endoscopy exams. The ESGE has suggested several performance measures to ensure a quality endoscopy exam, including accurate photo documentation, sufficient procedure time of at least 7 minutes, adherence to biopsy protocols, and low complication rates.⁴⁵ In Asia, a systematic screening protocol is used for photo documentation, and simple techniques such as adequate air insufflation and irrigation to remove mucus are routinely used to improve the endoscopy exam.^46,47 The mean time of an endoscopy exam has also been found to increase the detection of neoplastic lesions, as slow endoscopists – with a mean exam duration of 8.6 ± 4.2 min during upper endoscopy – detected threefold more neoplastic lesions than did fast endoscopists.⁴⁸

A standardized biopsy approach is also important when screening patients. The updated Sydney protocol has been suggested for mapping the stomach to screen for atrophy and GIM. This protocol recommends two biopsies from the antrum (at the lesser and greater curvature), two from the body (at the lesser and greater curvature), and one from the incisura.²³ This biopsy protocol was also suggested in the recent MAPS II update, with the biopsy of the incisura felt to be an additional biopsy left to the discretion of the endoscopist. Notably, abnormal appearing mucosal areas should be biopsied separately from the mapping biopsies.

High-definition endoscopy with virtual chromoendoscopy is felt to be better than white-light endoscopy alone at detecting precancerous gastric lesions.³⁸ (See Figure 2.)

Courtesy Diana Curras-Martin, MD, and Susana Gonzalez, MD

In particular, narrow-band imaging (NBI) has been studied and found to increase the diagnostic yield of GIM and dysplasia compared with white light alone.⁴⁹ Several studies have shown an increased accuracy for the detection of GIM with magnification NBI.^50-52 An unfortunate limitation is the geographic availability of magnification NBI: It is not available in the United States. A multicenter study in Portugal developed a new classification system for the appearance of precancerous lesions with NBI and tested its accuracy in endoscopists with a wide range of NBI experience. An abnormal mucosal pattern that showed light blue crests/regular ridge or a tubulovillous appearance and a regular mucosal pattern was found with GIM. An irregular vascular pattern with a white opaque substance and an absent or irregular mucosal pattern was most often found with dysplasia. Furthermore, the reproducibility of these patterns was high between endoscopists.⁵³ Multiple studies have been performed on additional imaging technologies to enhance the detection of gastric neoplasia; however, these technologies are still investigational and currently not recommended for screening.^54-57

Serum pepsinogens have been studied in Europe and Asia as noninvasive indicators of gastric atrophy to determine who should be screened with endoscopy.⁵⁸ A low serum pepsinogen I level below 70 ng/mL and pepsinogen I/II ratio below 3 has generally been used to detect atrophic gastritis and at-risk populations. However, the studies performed in Europe and Asia used different methods for quantifying pepsinogen levels. Therefore, cutoff values cannot be generalized for all assays and should be validated for the specific tests used.³⁸
 

Summary

Gastric atrophy and gastric intestinal metaplasia are considered precancerous lesions with an increased risk of development of gastric cancer. H. pylori is a major risk factor for the development of GIM. The extent of GIM as well as the presence of incomplete intestinal metaplasia, or type III intestinal metaplasia has been found to have the highest gastric cancer risk. Currently, in the United States, specific guidelines on endoscopic screening and surveillance for noncardia gastric adenocarcinoma based on histological subtype of GIM, location, and extension are lacking. The ESGE recently updated guidelines that recommend surveillance of patients with extensive atrophy and intestinal metaplasia or with a significant family history. Location and extension of intestinal metaplasia plays a role in increased risk. Screening should include a standardized upper endoscopy approach with high-definition white- light endoscopy and NBI, at least a 7-minute examination, adequate insufflation and cleaning, adequate photo documentation, and a standardized biopsy protocol. Further studies are needed to determine an appropriate surveillance interval and standardized pathology reporting approach as well.

Diana Curras-Martin MD, is an internal medicine resident at Hackensack Meridian Jersey Shore University Medical Center. Susana Gonzalez, MD, is assistant professor of medicine in the division of gastroenterology and hepatology (@WCM_GI), Weill Cornell Medicine, New York Presbyterian Hospital–Cornell. 

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46. Uedo N et al. Gastroenterol Clin North Am. 2013;42(2):317-35.

47. Yao K. Ann Gastroenterol. 2013;26(1):11-22.

48. Teh JL et al. Clin Gastroenterol Hepatol. 2015;13(3):480-7 e482.

49. Capelle LG et al. Dig Dis Sci. 2010;55(12):3442-8.

50. Bansal A et al. Gastrointest Endosc. 2008;67(2):210-6.

51. Tahara T et al. Gastrointest Endosc. 2009;70(2):246-53.

52. Uedo N et al. Endoscopy. 2006;38(8):819-24.

53. Pimentel-Nunes P et al. Endoscopy. 2012;44(3):236-46.

54. Kato M et al. Gastrointest Endosc. 2009;70(5):899-906.

55. Nishimura J et al. Gastroenterol Res Pract. 2014;2014:819395.

56. Dohi O et al. Gastrointest Endosc. 2019;89(1):47-57.

57. Osawa H et al. World J Gastrointest Endosc. 2012;4(8):356-61.

58. Pasechnikov V et al. World J Gastroenterol. 2014;20(38):13842-62.

Introduction

Despite a global decline in the incidence of gastric cancer over the past 3 decades, it remains the fifth most commonly diagnosed cancer and the third most common cause of cancer deaths worldwide.¹ In the United States it is the fourth most commonly diagnosed GI malignancy, after colorectal, pancreas, and liver cancer. The prevalence remains high in Latin America and Asia, which has implications in the United States because of growing Hispanic and Asian populations.^2,3 In recent years, a change in the trend of gastric cancer among non-Hispanic whites has been observed, particularly in women younger than 50 years old.⁴ Gastric intestinal metaplasia has been recognized worldwide as a premalignant precursor to gastric cancer, but currently, there are limited U.S. guidelines, leading to controversy over management of this condition.⁵

Etiology

Gastric adenocarcinomas are classified into two subcategories based on location (cardia and noncardia) and histology (intestinal and diffuse types).^6,7 Atrophic gastritis and gastric intestinal metaplasia (GIM) are considered precursors of intestinal-type noncardia gastric adenocarcinoma. The Correa cascade is a commonly accepted precancer sequence for noncardia gastric adenocarcinoma that describes mucosal changes from inflammation to atrophy to metaplasia to intraepithelial neoplasia and culminating in carcinoma.^8,9 It has been observed that GIM may be the histologic change prior to the development of dysplasia and over 50% of patients with high-grade dysplasia will progress to adenocarcinoma.^10-12 In the United States, GIM has the highest prevalence in African Americans, Hispanics, and East Asians, with the overall GIM prevalence regardless of ethnicity reported from 3.05% to 19.2%.^5,13

Risk factors and subclassification

Replacement of the foveolar and/or glandular epithelium in the oxyntic and antral mucosa by intestinal epithelium results in GIM. It can be focal when limited to one region of the stomach or extensive when two or more regions are involved.¹⁴ The main risk factors for GIM development are Helicobacter pylori infection, tobacco, alcohol consumption, high salt intake, and chronic bile reflux.^15,16 Additional risks for developing gastric cancer include older age, certain ethnicities, and male sex.¹⁷

CagA strains of H. pylori can promote carcinogenesis by inducing a mitogenic cellular response and downregulating cell adhesion.^18,19 Less carcinogenic risk is associated with H. pylori Cag-A negative strains; however, they also have oncogenic potential mediated by expression of babA2 and vacA genes.²⁰ Hence, the combination of multiple virulent factors encoded in babA2, CagA, and vacA genes has been associated with increased risk of GIM, inflammation, and development of gastric cancer.¹⁵ The clinical usefulness of genotyping H. pylori strains specifically to survey precancerous gastric lesions remains to be seen because of a lack of sufficient clinical studies. In addition, genotyping H. pylori is not commonly performed as part of clinical practice.

The loss of parietal cells seen in atrophic gastritis due to chronic H. pylori infection has been linked to the development of metaplasia due to possible loss of differentiation-promoting factors. As a result, metaplastic cells emerge that express spasmolytic polypeptide (SP or TFF2); hence, this type of metaplasia is referred to as spasmolytic polypeptide–expressing metaplasia (SPEM). The cellular mechanism that may explain a precursor role of SPEM in the development of GIM remains unknown.¹⁴ A second competing theory for the development of GIM is the clonal expansion of stem cells in the gastric isthmus that can lead to dysplasia and cancer development.¹⁴

On the basis of histological similarities with small intestinal or colonic epithelium, GIM can be further classified into complete or incomplete intestinal metaplasia.²¹ Complete intestinal metaplasia most closely resembles small intestinal epithelium with a brush border and goblet cells. Incomplete intestinal metaplasia resembles the colonic epithelium and lacks a brush border. A second classification further classifies GIM into three subtypes: Type I contains nonsecretory absorptive cells and sialomucin secreting goblet cells; type II has few absorptive cells, columnar cells secreting sialomucin, goblet cells secreting mainly sialomucin but some sulphomucin, and presence of Paneth cells; and type III consists of columnar cells secreting predominantly sulphomucin, goblet cells secreting sialomucin or sulphomucin, and absence of Paneth cells.^15,22 In this subclassification, type I GIM is known as complete GIM and types II and III as incomplete GIM.^23-25

Multiple studies performed outside of the United States have shown a higher progression risk to gastric adenocarcinoma in incomplete intestinal metaplasia, or type III intestinal metaplasia.^26-32 Also, the risk of gastric cancer has been demonstrated to be higher among patients with a greater area of metaplasia and extensive intestinal metaplasia, defined as GIM in both the antrum and corpus.^33,34 Hence, the extent of the metaplasia determined with mapping biopsies, regardless of the subtype, should also be incorporated into the risk assessment of the patient. Currently, a major limitation in the United States is a standardized method of pathologic reporting including subclassification of incomplete versus complete intestinal metaplasia.
 

Which patients to screen

Understanding this sequence of carcinogenesis offers a potential window for screening and surveillance. Subsequently, early detection of precancerous mucosal changes would be more amenable for endoscopic submucosal dissection (ESD).^35,36 Currently, U.S. society guidelines do not specifically address the management of GIM. The American Society for Gastrointestinal Endoscopy (ASGE) guidelines for management of premalignant and malignant conditions of the stomach recommend surveillance in individuals with a family history of gastric cancer or of high-risk ethnic background but with no specific optimal surveillance interval.³⁷ Also, H. pylori treatment is recommended if identified, but empiric treatment in GIM was felt to be controversial. The AGA recently sought comments on a proposed new guideline for the management of GIM. This guideline should be released after the comment period and help address management of GIM in the United States. In April of 2019, the European Society of Gastrointestinal Endoscopy (ESGE) updated the management of epithelial precancerous conditions and lesions in the stomach (MAPS II) guideline.³⁸ The MAPS II guideline identifies atrophic gastritis and intestinal metaplasia as precancerous lesions. In patients with moderate to marked atrophy or GIM affecting both antral and body mucosa, ESGE recommends endoscopic surveillance with high-definition chromoendoscopy, mapping, and guided biopsies or at least two biopsies taken separately at the lesser and greater curvature of the antrum and body. H. pylori eradication was recommended if the patient tested positive.

Furthermore, MAPS II proposed replacing atrophic gastritis (AG) in the Operative Link on Gastritis Assessment (OLGA) staging by GIM (OLGIM) as it is considered a more reliable predictor of an individual’s gastric neoplasia risk, based on the interobserver agreement kappa value 0.6 for AG versus 0.9 for GIM.³⁹ Five biopsies (two from the antrum, two from the corpus, and one from the incisura angularis) are needed for the OLGA/OLGIM score system to be considered an accurate predictor of this risk.³⁹ This is supported by the early findings of gastric atrophy and GIM in the incisura angularis.²³ In addition, for patients with GIM only in either the antrum or the body, a family history of gastric cancer, incomplete GIM, autoimmune gastritis, or persistent H. pylori infection was felt to increase the risk to warrant surveillance every 3 years. In those patients with atrophy or GIM in both the antrum and body with a first-degree relative with gastric cancer, surveillance was recommended every 1-2 years. Patients with any dysplasia and a visible lesion should have staging and resection. With no visible lesion, a follow-up endoscopy should be performed in 6 months with high-grade dysplasia and with low-grade dysplasia a repeat in 12 months. Patients with mild to moderate atrophy in the antrum and no intestinal metaplasia were not felt to warrant any further surveillance. (See Figure 1.)

How to screen

Previous studies have found a poor correlation between the endoscopic determination of gastric atrophy and the histologic diagnosis.⁴² Several studies also found that gastric cancer was missed on initial endoscopic examinations. Sensitivity of endoscopy to detect gastric cancer has ranged from 77% to 93%.^43,44 In the United States, there is a lack of standardized quality indicators for upper endoscopy exams. The ESGE has suggested several performance measures to ensure a quality endoscopy exam, including accurate photo documentation, sufficient procedure time of at least 7 minutes, adherence to biopsy protocols, and low complication rates.⁴⁵ In Asia, a systematic screening protocol is used for photo documentation, and simple techniques such as adequate air insufflation and irrigation to remove mucus are routinely used to improve the endoscopy exam.^46,47 The mean time of an endoscopy exam has also been found to increase the detection of neoplastic lesions, as slow endoscopists – with a mean exam duration of 8.6 ± 4.2 min during upper endoscopy – detected threefold more neoplastic lesions than did fast endoscopists.⁴⁸

A standardized biopsy approach is also important when screening patients. The updated Sydney protocol has been suggested for mapping the stomach to screen for atrophy and GIM. This protocol recommends two biopsies from the antrum (at the lesser and greater curvature), two from the body (at the lesser and greater curvature), and one from the incisura.²³ This biopsy protocol was also suggested in the recent MAPS II update, with the biopsy of the incisura felt to be an additional biopsy left to the discretion of the endoscopist. Notably, abnormal appearing mucosal areas should be biopsied separately from the mapping biopsies.

High-definition endoscopy with virtual chromoendoscopy is felt to be better than white-light endoscopy alone at detecting precancerous gastric lesions.³⁸ (See Figure 2.)

Courtesy Diana Curras-Martin, MD, and Susana Gonzalez, MD

In particular, narrow-band imaging (NBI) has been studied and found to increase the diagnostic yield of GIM and dysplasia compared with white light alone.⁴⁹ Several studies have shown an increased accuracy for the detection of GIM with magnification NBI.^50-52 An unfortunate limitation is the geographic availability of magnification NBI: It is not available in the United States. A multicenter study in Portugal developed a new classification system for the appearance of precancerous lesions with NBI and tested its accuracy in endoscopists with a wide range of NBI experience. An abnormal mucosal pattern that showed light blue crests/regular ridge or a tubulovillous appearance and a regular mucosal pattern was found with GIM. An irregular vascular pattern with a white opaque substance and an absent or irregular mucosal pattern was most often found with dysplasia. Furthermore, the reproducibility of these patterns was high between endoscopists.⁵³ Multiple studies have been performed on additional imaging technologies to enhance the detection of gastric neoplasia; however, these technologies are still investigational and currently not recommended for screening.^54-57

Serum pepsinogens have been studied in Europe and Asia as noninvasive indicators of gastric atrophy to determine who should be screened with endoscopy.⁵⁸ A low serum pepsinogen I level below 70 ng/mL and pepsinogen I/II ratio below 3 has generally been used to detect atrophic gastritis and at-risk populations. However, the studies performed in Europe and Asia used different methods for quantifying pepsinogen levels. Therefore, cutoff values cannot be generalized for all assays and should be validated for the specific tests used.³⁸
 

Summary

Gastric atrophy and gastric intestinal metaplasia are considered precancerous lesions with an increased risk of development of gastric cancer. H. pylori is a major risk factor for the development of GIM. The extent of GIM as well as the presence of incomplete intestinal metaplasia, or type III intestinal metaplasia has been found to have the highest gastric cancer risk. Currently, in the United States, specific guidelines on endoscopic screening and surveillance for noncardia gastric adenocarcinoma based on histological subtype of GIM, location, and extension are lacking. The ESGE recently updated guidelines that recommend surveillance of patients with extensive atrophy and intestinal metaplasia or with a significant family history. Location and extension of intestinal metaplasia plays a role in increased risk. Screening should include a standardized upper endoscopy approach with high-definition white- light endoscopy and NBI, at least a 7-minute examination, adequate insufflation and cleaning, adequate photo documentation, and a standardized biopsy protocol. Further studies are needed to determine an appropriate surveillance interval and standardized pathology reporting approach as well.

Diana Curras-Martin MD, is an internal medicine resident at Hackensack Meridian Jersey Shore University Medical Center. Susana Gonzalez, MD, is assistant professor of medicine in the division of gastroenterology and hepatology (@WCM_GI), Weill Cornell Medicine, New York Presbyterian Hospital–Cornell. 

References

1. Bray F et al. CA Cancer J Clin. 2018;68(6):394-424.

2. Global Burden of Disease Cancer Collaboration et al. JAMA Oncol. 2018;4(11):1553-68.

3. Balakrishnan M et al. Curr Gastroenterol Rep. 2017;19(8):36.

4. Anderson WF et al. J Natl Cancer Inst. 2018;110(6):608-15.

5. Trieu JA et al. Dig Dis Sci. 2019;64(5):1079-88.

6. Lauren P. Acta Pathol Microbiol Scand. 1965;64:31-49.

7. Correa P, Schneider BG. Cancer Epidemiol Biomarkers Prev. 2005;14(8):1865-8.

8. Correa P. Cancer Res. 1992;52(24):6735-40.

9. Correa P, Piazuelo MB. J Dig Dis. 2012;13(1):2-9.

10. Correa P et al. J Natl Cancer Inst. 1970;44(2):297-306.

11. Correa P. Semin Oncol. 1985;12(1):2-10.

12. Rugge M et al. Hum Pathol. 1991;22(10):1002-8.

13. Simko V et al. Bratisl Lek Listy. 2015;116(1):3-8.

14. Giroux V, Rustgi AK. Nat Rev Cancer. 2017;17(10):594-604.

15. Jencks DS et al. Gastroenterol Hepatol (N Y). 2018;14(2):92-101.

16. Amieva M, Peek RM Jr. Gastroenterology. 2016;150(1):64-78.

17. Karimi P et al. Cancer Epidemiol Biomarkers Prev. 2014;23(5):700-13.

18. Hatakeyama M. Proc Jpn Acad Ser B Phys Biol Sci. 2017;93(4):196-219.

19. Tsutsumi R et al. Mol Cell Biol. 2006;26(1):261-76.

20. Kikuchi S et al. Am J Gastroenterol. 1999;94(12):3455-9.

21. Jass JR, Filipe MI. Histopathology. 1980;4(3):271-9.

22. Jass JR, Filipe MI. Histochem J. 1981;13(6):931-9.

23. Dixon MF et al. Am J Surg Pathol. 1996;20(10):1161-81.

24. Kang KP et al. J Gastroenterol Hepatol. 2009;24(1):140-8.

25. Gonzalez CA et al. Int J Cancer. 2010;127(11):2654-60.

26. Filipe MI et al. Gut. 1985;26(12):1319-26.

27. Filipe MI et al. Int J Cancer. 1994;57(3):324-9.

28. Gonzalez CA et al. J Gastroenterol Hepatol. 2016;31(5):953-8.

29. Cassaro M et al. Am J Gastroenterol. 2000;95(6):1431-8.

30. Shao L et al. Int J Cancer. Apr 29. 2018.

31. Stemmermann GN. Cancer. 1994;74(2):556-64.

32. Gonzalez CA et al. Int J Cancer. 2013;133(5):1023-32.

33. Reddy KM et al. Clin Gastroenterol Hepatol. 2016;14(10):1420-5.

34. Tava F et al. Hum Pathol. 2006;37(11):1489-97.

35. Fernandez-Esparrach G et al. Rev Esp Enferm Dig. 2014;106(2):120-32.

36. Ono H et al. Dig Endosc. 2016;28(1):3-15.

37. Evans JA, DeWitt JM. Gastrointest Endosc. 2016;83(1):274.

38. Pimentel-Nunes P et al. Endoscopy. 2019;51(4):365-88.

39. Capelle LG et al. Gastrointest Endosc. 2010;71(7):1150-8.

40. Saumoy M et al. Gastroenterology. 2018;155(3):648-60.

41. Gupta N et al. Gastrointest Endosc. 2011;74(3):610-24 e612.

42. Eshmuratov A et al. Dig Dis Sci. 2010;55(5):1364-75.

43. Nam JH et al. Cancer. 2012;118(20):4953-60.

44. Amin A et al. J R Coll Surg Edinb. 2002;47(5):681-4.

45. Bisschops R et al. United European Gastroenterol J. 2016;4(5):629-56.

46. Uedo N et al. Gastroenterol Clin North Am. 2013;42(2):317-35.

47. Yao K. Ann Gastroenterol. 2013;26(1):11-22.

48. Teh JL et al. Clin Gastroenterol Hepatol. 2015;13(3):480-7 e482.

49. Capelle LG et al. Dig Dis Sci. 2010;55(12):3442-8.

50. Bansal A et al. Gastrointest Endosc. 2008;67(2):210-6.

51. Tahara T et al. Gastrointest Endosc. 2009;70(2):246-53.

52. Uedo N et al. Endoscopy. 2006;38(8):819-24.

53. Pimentel-Nunes P et al. Endoscopy. 2012;44(3):236-46.

54. Kato M et al. Gastrointest Endosc. 2009;70(5):899-906.

55. Nishimura J et al. Gastroenterol Res Pract. 2014;2014:819395.

56. Dohi O et al. Gastrointest Endosc. 2019;89(1):47-57.

57. Osawa H et al. World J Gastrointest Endosc. 2012;4(8):356-61.

58. Pasechnikov V et al. World J Gastroenterol. 2014;20(38):13842-62.

Introduction

Despite a global decline in the incidence of gastric cancer over the past 3 decades, it remains the fifth most commonly diagnosed cancer and the third most common cause of cancer deaths worldwide.¹ In the United States it is the fourth most commonly diagnosed GI malignancy, after colorectal, pancreas, and liver cancer. The prevalence remains high in Latin America and Asia, which has implications in the United States because of growing Hispanic and Asian populations.^2,3 In recent years, a change in the trend of gastric cancer among non-Hispanic whites has been observed, particularly in women younger than 50 years old.⁴ Gastric intestinal metaplasia has been recognized worldwide as a premalignant precursor to gastric cancer, but currently, there are limited U.S. guidelines, leading to controversy over management of this condition.⁵

Etiology

Gastric adenocarcinomas are classified into two subcategories based on location (cardia and noncardia) and histology (intestinal and diffuse types).^6,7 Atrophic gastritis and gastric intestinal metaplasia (GIM) are considered precursors of intestinal-type noncardia gastric adenocarcinoma. The Correa cascade is a commonly accepted precancer sequence for noncardia gastric adenocarcinoma that describes mucosal changes from inflammation to atrophy to metaplasia to intraepithelial neoplasia and culminating in carcinoma.^8,9 It has been observed that GIM may be the histologic change prior to the development of dysplasia and over 50% of patients with high-grade dysplasia will progress to adenocarcinoma.^10-12 In the United States, GIM has the highest prevalence in African Americans, Hispanics, and East Asians, with the overall GIM prevalence regardless of ethnicity reported from 3.05% to 19.2%.^5,13

Risk factors and subclassification

Replacement of the foveolar and/or glandular epithelium in the oxyntic and antral mucosa by intestinal epithelium results in GIM. It can be focal when limited to one region of the stomach or extensive when two or more regions are involved.¹⁴ The main risk factors for GIM development are Helicobacter pylori infection, tobacco, alcohol consumption, high salt intake, and chronic bile reflux.^15,16 Additional risks for developing gastric cancer include older age, certain ethnicities, and male sex.¹⁷

CagA strains of H. pylori can promote carcinogenesis by inducing a mitogenic cellular response and downregulating cell adhesion.^18,19 Less carcinogenic risk is associated with H. pylori Cag-A negative strains; however, they also have oncogenic potential mediated by expression of babA2 and vacA genes.²⁰ Hence, the combination of multiple virulent factors encoded in babA2, CagA, and vacA genes has been associated with increased risk of GIM, inflammation, and development of gastric cancer.¹⁵ The clinical usefulness of genotyping H. pylori strains specifically to survey precancerous gastric lesions remains to be seen because of a lack of sufficient clinical studies. In addition, genotyping H. pylori is not commonly performed as part of clinical practice.

The loss of parietal cells seen in atrophic gastritis due to chronic H. pylori infection has been linked to the development of metaplasia due to possible loss of differentiation-promoting factors. As a result, metaplastic cells emerge that express spasmolytic polypeptide (SP or TFF2); hence, this type of metaplasia is referred to as spasmolytic polypeptide–expressing metaplasia (SPEM). The cellular mechanism that may explain a precursor role of SPEM in the development of GIM remains unknown.¹⁴ A second competing theory for the development of GIM is the clonal expansion of stem cells in the gastric isthmus that can lead to dysplasia and cancer development.¹⁴

On the basis of histological similarities with small intestinal or colonic epithelium, GIM can be further classified into complete or incomplete intestinal metaplasia.²¹ Complete intestinal metaplasia most closely resembles small intestinal epithelium with a brush border and goblet cells. Incomplete intestinal metaplasia resembles the colonic epithelium and lacks a brush border. A second classification further classifies GIM into three subtypes: Type I contains nonsecretory absorptive cells and sialomucin secreting goblet cells; type II has few absorptive cells, columnar cells secreting sialomucin, goblet cells secreting mainly sialomucin but some sulphomucin, and presence of Paneth cells; and type III consists of columnar cells secreting predominantly sulphomucin, goblet cells secreting sialomucin or sulphomucin, and absence of Paneth cells.^15,22 In this subclassification, type I GIM is known as complete GIM and types II and III as incomplete GIM.^23-25

Multiple studies performed outside of the United States have shown a higher progression risk to gastric adenocarcinoma in incomplete intestinal metaplasia, or type III intestinal metaplasia.^26-32 Also, the risk of gastric cancer has been demonstrated to be higher among patients with a greater area of metaplasia and extensive intestinal metaplasia, defined as GIM in both the antrum and corpus.^33,34 Hence, the extent of the metaplasia determined with mapping biopsies, regardless of the subtype, should also be incorporated into the risk assessment of the patient. Currently, a major limitation in the United States is a standardized method of pathologic reporting including subclassification of incomplete versus complete intestinal metaplasia.
 

Which patients to screen

Understanding this sequence of carcinogenesis offers a potential window for screening and surveillance. Subsequently, early detection of precancerous mucosal changes would be more amenable for endoscopic submucosal dissection (ESD).^35,36 Currently, U.S. society guidelines do not specifically address the management of GIM. The American Society for Gastrointestinal Endoscopy (ASGE) guidelines for management of premalignant and malignant conditions of the stomach recommend surveillance in individuals with a family history of gastric cancer or of high-risk ethnic background but with no specific optimal surveillance interval.³⁷ Also, H. pylori treatment is recommended if identified, but empiric treatment in GIM was felt to be controversial. The AGA recently sought comments on a proposed new guideline for the management of GIM. This guideline should be released after the comment period and help address management of GIM in the United States. In April of 2019, the European Society of Gastrointestinal Endoscopy (ESGE) updated the management of epithelial precancerous conditions and lesions in the stomach (MAPS II) guideline.³⁸ The MAPS II guideline identifies atrophic gastritis and intestinal metaplasia as precancerous lesions. In patients with moderate to marked atrophy or GIM affecting both antral and body mucosa, ESGE recommends endoscopic surveillance with high-definition chromoendoscopy, mapping, and guided biopsies or at least two biopsies taken separately at the lesser and greater curvature of the antrum and body. H. pylori eradication was recommended if the patient tested positive.

Furthermore, MAPS II proposed replacing atrophic gastritis (AG) in the Operative Link on Gastritis Assessment (OLGA) staging by GIM (OLGIM) as it is considered a more reliable predictor of an individual’s gastric neoplasia risk, based on the interobserver agreement kappa value 0.6 for AG versus 0.9 for GIM.³⁹ Five biopsies (two from the antrum, two from the corpus, and one from the incisura angularis) are needed for the OLGA/OLGIM score system to be considered an accurate predictor of this risk.³⁹ This is supported by the early findings of gastric atrophy and GIM in the incisura angularis.²³ In addition, for patients with GIM only in either the antrum or the body, a family history of gastric cancer, incomplete GIM, autoimmune gastritis, or persistent H. pylori infection was felt to increase the risk to warrant surveillance every 3 years. In those patients with atrophy or GIM in both the antrum and body with a first-degree relative with gastric cancer, surveillance was recommended every 1-2 years. Patients with any dysplasia and a visible lesion should have staging and resection. With no visible lesion, a follow-up endoscopy should be performed in 6 months with high-grade dysplasia and with low-grade dysplasia a repeat in 12 months. Patients with mild to moderate atrophy in the antrum and no intestinal metaplasia were not felt to warrant any further surveillance. (See Figure 1.)

How to screen

Previous studies have found a poor correlation between the endoscopic determination of gastric atrophy and the histologic diagnosis.⁴² Several studies also found that gastric cancer was missed on initial endoscopic examinations. Sensitivity of endoscopy to detect gastric cancer has ranged from 77% to 93%.^43,44 In the United States, there is a lack of standardized quality indicators for upper endoscopy exams. The ESGE has suggested several performance measures to ensure a quality endoscopy exam, including accurate photo documentation, sufficient procedure time of at least 7 minutes, adherence to biopsy protocols, and low complication rates.⁴⁵ In Asia, a systematic screening protocol is used for photo documentation, and simple techniques such as adequate air insufflation and irrigation to remove mucus are routinely used to improve the endoscopy exam.^46,47 The mean time of an endoscopy exam has also been found to increase the detection of neoplastic lesions, as slow endoscopists – with a mean exam duration of 8.6 ± 4.2 min during upper endoscopy – detected threefold more neoplastic lesions than did fast endoscopists.⁴⁸

A standardized biopsy approach is also important when screening patients. The updated Sydney protocol has been suggested for mapping the stomach to screen for atrophy and GIM. This protocol recommends two biopsies from the antrum (at the lesser and greater curvature), two from the body (at the lesser and greater curvature), and one from the incisura.²³ This biopsy protocol was also suggested in the recent MAPS II update, with the biopsy of the incisura felt to be an additional biopsy left to the discretion of the endoscopist. Notably, abnormal appearing mucosal areas should be biopsied separately from the mapping biopsies.

High-definition endoscopy with virtual chromoendoscopy is felt to be better than white-light endoscopy alone at detecting precancerous gastric lesions.³⁸ (See Figure 2.)

Courtesy Diana Curras-Martin, MD, and Susana Gonzalez, MD

In particular, narrow-band imaging (NBI) has been studied and found to increase the diagnostic yield of GIM and dysplasia compared with white light alone.⁴⁹ Several studies have shown an increased accuracy for the detection of GIM with magnification NBI.^50-52 An unfortunate limitation is the geographic availability of magnification NBI: It is not available in the United States. A multicenter study in Portugal developed a new classification system for the appearance of precancerous lesions with NBI and tested its accuracy in endoscopists with a wide range of NBI experience. An abnormal mucosal pattern that showed light blue crests/regular ridge or a tubulovillous appearance and a regular mucosal pattern was found with GIM. An irregular vascular pattern with a white opaque substance and an absent or irregular mucosal pattern was most often found with dysplasia. Furthermore, the reproducibility of these patterns was high between endoscopists.⁵³ Multiple studies have been performed on additional imaging technologies to enhance the detection of gastric neoplasia; however, these technologies are still investigational and currently not recommended for screening.^54-57

Serum pepsinogens have been studied in Europe and Asia as noninvasive indicators of gastric atrophy to determine who should be screened with endoscopy.⁵⁸ A low serum pepsinogen I level below 70 ng/mL and pepsinogen I/II ratio below 3 has generally been used to detect atrophic gastritis and at-risk populations. However, the studies performed in Europe and Asia used different methods for quantifying pepsinogen levels. Therefore, cutoff values cannot be generalized for all assays and should be validated for the specific tests used.³⁸
 

Summary

Gastric atrophy and gastric intestinal metaplasia are considered precancerous lesions with an increased risk of development of gastric cancer. H. pylori is a major risk factor for the development of GIM. The extent of GIM as well as the presence of incomplete intestinal metaplasia, or type III intestinal metaplasia has been found to have the highest gastric cancer risk. Currently, in the United States, specific guidelines on endoscopic screening and surveillance for noncardia gastric adenocarcinoma based on histological subtype of GIM, location, and extension are lacking. The ESGE recently updated guidelines that recommend surveillance of patients with extensive atrophy and intestinal metaplasia or with a significant family history. Location and extension of intestinal metaplasia plays a role in increased risk. Screening should include a standardized upper endoscopy approach with high-definition white- light endoscopy and NBI, at least a 7-minute examination, adequate insufflation and cleaning, adequate photo documentation, and a standardized biopsy protocol. Further studies are needed to determine an appropriate surveillance interval and standardized pathology reporting approach as well.

Diana Curras-Martin MD, is an internal medicine resident at Hackensack Meridian Jersey Shore University Medical Center. Susana Gonzalez, MD, is assistant professor of medicine in the division of gastroenterology and hepatology (@WCM_GI), Weill Cornell Medicine, New York Presbyterian Hospital–Cornell. 

References

1. Bray F et al. CA Cancer J Clin. 2018;68(6):394-424.

2. Global Burden of Disease Cancer Collaboration et al. JAMA Oncol. 2018;4(11):1553-68.

3. Balakrishnan M et al. Curr Gastroenterol Rep. 2017;19(8):36.

4. Anderson WF et al. J Natl Cancer Inst. 2018;110(6):608-15.

5. Trieu JA et al. Dig Dis Sci. 2019;64(5):1079-88.

6. Lauren P. Acta Pathol Microbiol Scand. 1965;64:31-49.

7. Correa P, Schneider BG. Cancer Epidemiol Biomarkers Prev. 2005;14(8):1865-8.

8. Correa P. Cancer Res. 1992;52(24):6735-40.

9. Correa P, Piazuelo MB. J Dig Dis. 2012;13(1):2-9.

10. Correa P et al. J Natl Cancer Inst. 1970;44(2):297-306.

11. Correa P. Semin Oncol. 1985;12(1):2-10.

12. Rugge M et al. Hum Pathol. 1991;22(10):1002-8.

13. Simko V et al. Bratisl Lek Listy. 2015;116(1):3-8.

14. Giroux V, Rustgi AK. Nat Rev Cancer. 2017;17(10):594-604.

15. Jencks DS et al. Gastroenterol Hepatol (N Y). 2018;14(2):92-101.

16. Amieva M, Peek RM Jr. Gastroenterology. 2016;150(1):64-78.

17. Karimi P et al. Cancer Epidemiol Biomarkers Prev. 2014;23(5):700-13.

18. Hatakeyama M. Proc Jpn Acad Ser B Phys Biol Sci. 2017;93(4):196-219.

19. Tsutsumi R et al. Mol Cell Biol. 2006;26(1):261-76.

20. Kikuchi S et al. Am J Gastroenterol. 1999;94(12):3455-9.

21. Jass JR, Filipe MI. Histopathology. 1980;4(3):271-9.

22. Jass JR, Filipe MI. Histochem J. 1981;13(6):931-9.

23. Dixon MF et al. Am J Surg Pathol. 1996;20(10):1161-81.

24. Kang KP et al. J Gastroenterol Hepatol. 2009;24(1):140-8.

25. Gonzalez CA et al. Int J Cancer. 2010;127(11):2654-60.

26. Filipe MI et al. Gut. 1985;26(12):1319-26.

27. Filipe MI et al. Int J Cancer. 1994;57(3):324-9.

28. Gonzalez CA et al. J Gastroenterol Hepatol. 2016;31(5):953-8.

29. Cassaro M et al. Am J Gastroenterol. 2000;95(6):1431-8.

30. Shao L et al. Int J Cancer. Apr 29. 2018.

31. Stemmermann GN. Cancer. 1994;74(2):556-64.

32. Gonzalez CA et al. Int J Cancer. 2013;133(5):1023-32.

33. Reddy KM et al. Clin Gastroenterol Hepatol. 2016;14(10):1420-5.

34. Tava F et al. Hum Pathol. 2006;37(11):1489-97.

35. Fernandez-Esparrach G et al. Rev Esp Enferm Dig. 2014;106(2):120-32.

36. Ono H et al. Dig Endosc. 2016;28(1):3-15.

37. Evans JA, DeWitt JM. Gastrointest Endosc. 2016;83(1):274.

38. Pimentel-Nunes P et al. Endoscopy. 2019;51(4):365-88.

39. Capelle LG et al. Gastrointest Endosc. 2010;71(7):1150-8.

40. Saumoy M et al. Gastroenterology. 2018;155(3):648-60.

41. Gupta N et al. Gastrointest Endosc. 2011;74(3):610-24 e612.

42. Eshmuratov A et al. Dig Dis Sci. 2010;55(5):1364-75.

43. Nam JH et al. Cancer. 2012;118(20):4953-60.

44. Amin A et al. J R Coll Surg Edinb. 2002;47(5):681-4.

45. Bisschops R et al. United European Gastroenterol J. 2016;4(5):629-56.

46. Uedo N et al. Gastroenterol Clin North Am. 2013;42(2):317-35.

47. Yao K. Ann Gastroenterol. 2013;26(1):11-22.

48. Teh JL et al. Clin Gastroenterol Hepatol. 2015;13(3):480-7 e482.

49. Capelle LG et al. Dig Dis Sci. 2010;55(12):3442-8.

50. Bansal A et al. Gastrointest Endosc. 2008;67(2):210-6.

51. Tahara T et al. Gastrointest Endosc. 2009;70(2):246-53.

52. Uedo N et al. Endoscopy. 2006;38(8):819-24.

53. Pimentel-Nunes P et al. Endoscopy. 2012;44(3):236-46.

54. Kato M et al. Gastrointest Endosc. 2009;70(5):899-906.

55. Nishimura J et al. Gastroenterol Res Pract. 2014;2014:819395.

56. Dohi O et al. Gastrointest Endosc. 2019;89(1):47-57.

57. Osawa H et al. World J Gastrointest Endosc. 2012;4(8):356-61.

58. Pasechnikov V et al. World J Gastroenterol. 2014;20(38):13842-62.

Dear Colleagues,

It’s hard to believe that The New Gastroenterologist (TNG) is now in its 5th year of publication! Since the inception of TNG, it has been a true honor and pleasure to serve as the inaugural editor in chief (EIC), and it has been an experience that I will never forget. When the idea of TNG was first conceived nearly 5 years ago, the goal of the publication was to provide a dedicated home for content for early-career GIs and trainees, an area that was a clear void in the GI community. Over 4 years later, TNG remains a one-of-a-kind resource for our field, and I hope that you have enjoyed the content published.

As my term is ending soon, it is my pleasure to turn TNG over to the next EIC, Vijaya Rao from the University of Chicago. I have no doubt that Vijaya will do a fantastic job continuing TNG, and I am excited to see how she applies many of her innovative ideas to grow the publication and make it even more valuable to the early-career and trainee GI community. Finally, I would just like to thank all of the people who have made invaluable contributions to make TNG a success including Erin Landis and Ryan Farrell from the AGA; the staff of our publisher Frontline Medical Communications, especially Lora McGlade; and current editor in chief of GI & Hepatology News, John Allen.

As for this issue of TNG, my last issue as EIC, there is a fantastic line-up of content. The “In Focus” article, by Diana Curras-Martin and Susana Gonzalez (Cornell), addresses the controversial topic of gastric intestinal metaplasia, and will no doubt be very helpful for dealing with this condition when it’s encountered in clinical practice. Additionally, Edward Barnes (UNC Chapel Hill) covers the importance of mentoring during the early-career stage, while Josh Sloan (Hopkins) provides an overview of options for extra training in motility, including motility fellowships.

Also in this issue of TNG, Rishi Naik (Vanderbilt) outlines some of the important lessons he learned during his 1-year term as the Gastroenterology editorial fellow, and Latha Alaparthi (Gastroenterology Center of Connecticut) discusses tips for building an effective community practice as part of our “Private Practice Perspectives” section cosponsored by the Digestive Health Physicians Association. Finally, lawyers Matthew D’Emilio and Jeremy Riley cover estate planning, which is a topic that is important for all to be familiar with, regardless of age or current health status.

If you’re interested in contributing or have ideas for TNG, please contact me ([email protected]), incoming editor in chief Vijaya Rao ([email protected]), or Ryan Farrell (rfarrell@gastro.org), managing editor of TNG.

Thank you, this has been a true pleasure.

Sincerely,

Bryson W. Katona, MD, PhD
(outgoing) Editor in Chief

Dr. Katona is an assistant professor of medicine in the division of gastroenterology at the University of Pennsylvania, Philadelphia.

Dear Colleagues,

It’s hard to believe that The New Gastroenterologist (TNG) is now in its 5th year of publication! Since the inception of TNG, it has been a true honor and pleasure to serve as the inaugural editor in chief (EIC), and it has been an experience that I will never forget. When the idea of TNG was first conceived nearly 5 years ago, the goal of the publication was to provide a dedicated home for content for early-career GIs and trainees, an area that was a clear void in the GI community. Over 4 years later, TNG remains a one-of-a-kind resource for our field, and I hope that you have enjoyed the content published.

As my term is ending soon, it is my pleasure to turn TNG over to the next EIC, Vijaya Rao from the University of Chicago. I have no doubt that Vijaya will do a fantastic job continuing TNG, and I am excited to see how she applies many of her innovative ideas to grow the publication and make it even more valuable to the early-career and trainee GI community. Finally, I would just like to thank all of the people who have made invaluable contributions to make TNG a success including Erin Landis and Ryan Farrell from the AGA; the staff of our publisher Frontline Medical Communications, especially Lora McGlade; and current editor in chief of GI & Hepatology News, John Allen.

As for this issue of TNG, my last issue as EIC, there is a fantastic line-up of content. The “In Focus” article, by Diana Curras-Martin and Susana Gonzalez (Cornell), addresses the controversial topic of gastric intestinal metaplasia, and will no doubt be very helpful for dealing with this condition when it’s encountered in clinical practice. Additionally, Edward Barnes (UNC Chapel Hill) covers the importance of mentoring during the early-career stage, while Josh Sloan (Hopkins) provides an overview of options for extra training in motility, including motility fellowships.

Also in this issue of TNG, Rishi Naik (Vanderbilt) outlines some of the important lessons he learned during his 1-year term as the Gastroenterology editorial fellow, and Latha Alaparthi (Gastroenterology Center of Connecticut) discusses tips for building an effective community practice as part of our “Private Practice Perspectives” section cosponsored by the Digestive Health Physicians Association. Finally, lawyers Matthew D’Emilio and Jeremy Riley cover estate planning, which is a topic that is important for all to be familiar with, regardless of age or current health status.

If you’re interested in contributing or have ideas for TNG, please contact me ([email protected]), incoming editor in chief Vijaya Rao ([email protected]), or Ryan Farrell (rfarrell@gastro.org), managing editor of TNG.

Thank you, this has been a true pleasure.

Sincerely,

Bryson W. Katona, MD, PhD
(outgoing) Editor in Chief

Dr. Katona is an assistant professor of medicine in the division of gastroenterology at the University of Pennsylvania, Philadelphia.

Dear Colleagues,

It’s hard to believe that The New Gastroenterologist (TNG) is now in its 5th year of publication! Since the inception of TNG, it has been a true honor and pleasure to serve as the inaugural editor in chief (EIC), and it has been an experience that I will never forget. When the idea of TNG was first conceived nearly 5 years ago, the goal of the publication was to provide a dedicated home for content for early-career GIs and trainees, an area that was a clear void in the GI community. Over 4 years later, TNG remains a one-of-a-kind resource for our field, and I hope that you have enjoyed the content published.

As my term is ending soon, it is my pleasure to turn TNG over to the next EIC, Vijaya Rao from the University of Chicago. I have no doubt that Vijaya will do a fantastic job continuing TNG, and I am excited to see how she applies many of her innovative ideas to grow the publication and make it even more valuable to the early-career and trainee GI community. Finally, I would just like to thank all of the people who have made invaluable contributions to make TNG a success including Erin Landis and Ryan Farrell from the AGA; the staff of our publisher Frontline Medical Communications, especially Lora McGlade; and current editor in chief of GI & Hepatology News, John Allen.

As for this issue of TNG, my last issue as EIC, there is a fantastic line-up of content. The “In Focus” article, by Diana Curras-Martin and Susana Gonzalez (Cornell), addresses the controversial topic of gastric intestinal metaplasia, and will no doubt be very helpful for dealing with this condition when it’s encountered in clinical practice. Additionally, Edward Barnes (UNC Chapel Hill) covers the importance of mentoring during the early-career stage, while Josh Sloan (Hopkins) provides an overview of options for extra training in motility, including motility fellowships.

Also in this issue of TNG, Rishi Naik (Vanderbilt) outlines some of the important lessons he learned during his 1-year term as the Gastroenterology editorial fellow, and Latha Alaparthi (Gastroenterology Center of Connecticut) discusses tips for building an effective community practice as part of our “Private Practice Perspectives” section cosponsored by the Digestive Health Physicians Association. Finally, lawyers Matthew D’Emilio and Jeremy Riley cover estate planning, which is a topic that is important for all to be familiar with, regardless of age or current health status.

If you’re interested in contributing or have ideas for TNG, please contact me ([email protected]), incoming editor in chief Vijaya Rao ([email protected]), or Ryan Farrell (rfarrell@gastro.org), managing editor of TNG.

Thank you, this has been a true pleasure.

Sincerely,

Bryson W. Katona, MD, PhD
(outgoing) Editor in Chief

Dr. Katona is an assistant professor of medicine in the division of gastroenterology at the University of Pennsylvania, Philadelphia.

“So you want to be a gastroenterologist? What do you really want to do?” This is not an uncommon question that a trainee is faced with when progressing through residency and gastroenterology fellowship.

The list of possibilities includes general gastroenterology, advanced endoscopy, transplant hepatology, and neurogastroenterology and motility. From there, each subspecialty can be broken down further into organ system or a specific procedure of interest. Another necessary question is whether to pursue a career in academics or private practice. When it comes to the decision to proceed with a fellowship in neurogastroenterology and motility, there are two pathways that can be taken. The first is for the resident who is interested in gaining experience in gastroenterology prior to starting a general gastroenterology fellowship (there are two programs that currently allow for this pathway). The other track is for those who have completed a general gastroenterology fellowship and are looking to enhance their academic careers by pursuing additional training in neurogastroenterology and motility.

There is currently a need for gastroenterologists interested in neurogastroenterology and motility. Among the most common diagnoses in an ambulatory setting, based on International Classification of Disease (ICD) coding, are abdominal pain, gastroesophageal reflux disease, constipation, nausea and vomiting, irritable bowel syndrome, functional dyspepsia, and dysphagia.^1,2 While many fellows are exposed to a wide range of motility patients during general gastroenterology fellowship, there is typically not a sufficient amount of training to attain “level 2” proficiency.^2,3 In an effort to help standardize training there are recommended thresholds established and advanced training in neurogastroenterology and motility can help fellows to attain that proficiency.^2,3 The extra year can also help you prepare to run a motility lab, train nurses, establish lab protocols and quality standards, and manage referrals, which are important skills as a neurogastroenterology and motility specialist.
 

Types of programs

There are several different types of motility programs available. As mentioned previously, some programs afford individuals an opportunity to gain additional experience in gastroenterology before progressing to general gastroenterology fellowship. There are two programs that offer a 1-year fellowship in neurogastroenterology and motility, both prior to or after a general gastroenterology fellowship. Four programs offer 1-year neurogastroenterology and motility fellowships only after a general gastroenterology fellowship. While the neurogastroenterology and motility fellowships cover esophageal motility, there are four programs that specifically focus solely on the esophagus (Table 1).

Where to find programs

Currently, there is not a singular list of neurogastroenterology and motility programs available for review as you might find with an Accreditation Council for Graduate Medical Education (ACGME) residency or fellowship. At present, the best way to identify the available programs is to search online. Motivation to select a specific program may be related to individual preference and can include geography and department expertise; this ultimately helps to create a focused list. With regard to the ANMS 1-month Clinical Training Program, the list of available programs is available on the society’s website and is for fellows currently in training who wish to incorporate neurogastroenterology and motility into their general GI fellowship.

How to apply

Advanced training in neurogastroenterology and motility is currently a non-ACGME pathway and does not offer a match process for its applicants. After identifying a program of interest, one can find specific instructions on how to apply at the programs’ websites. Typically the process involves reaching out to the program director, writing a letter of interest or personal statement, providing letters of recommendation, and interviewing. Each program has some variability in what is required and attention should be paid to the criteria listed on the specific website.

My experience

I was fortunate to have substantial exposure to esophageal motility in my general gastroenterology fellowship. Gaining this experience was invaluable and laid the foundation for my interest in neurogastroenterology and motility, and, specifically, esophageal dysmotility. My interest in neurogastroenterology and motility then collided with my desire to pursue a career in academics. Knowing the general trajectory for my future career, I began exploring the possibility of undergoing an additional 1-year fellowship early in my second year of GI fellowship. I worked closely with my program director to help define my future goals and to identify available places that would help me attain those goals. While I continued to have an interest in the esophagus, additional training in neurogastroenterology and motility would broaden my understanding and enhance my ability to manage complex patients and perform research at a tertiary care center. I investigated the different neurogastroenterology and motility fellowship programs online and followed the online application instructions. Utilizing national gastroenterology society conferences as networking opportunities, I was able to meet with the program director of my current neurogastroenterology and motility fellowship. In my third year of general gastroenterology fellowship I formally interviewed with the motility group at Johns Hopkins and was later accepted into the neurogastroenterology and motility fellowship program.

Now, nearing the end of my 1-year neurogastroenterology and motility fellowship, I reflect on my extremely positive experience. Throughout the course of the year I have been able to work with multiple GI providers — each with their own area of expertise within the field. There has been a profound exposure to a wide variety of patients with a spectrum of motility conditions covering the entire GI tract. There has been ample opportunity to read motility studies with the guidance and support of the motility faculty to further enhance my skills. The additional year has broadened my exposure to, and the management of, the biopsychosocial aspect of this specific patient population. In line with that, I have had the ability to grow with regard to my use of pharmacology and recognize which symptom might benefit from a particular neuromodulator. An emphasis was also placed on learning the gut-brain axis, and, through multidisciplinary clinics, I worked closely with other disciplines such as psychiatry and GI clinical psychology. Furthermore, the additional year has allowed me to be involved in several research projects within neurogastroenterology and motility that will undoubtedly enhance my future career.

 

Conclusion

Deciding to pursue an additional year in neurogastroenterology and motility has been one that has helped to give a solid direction to my budding career. It has left me confident in managing this diverse and complex patient population and has helped prepare me for a career in academic gastroenterology. For those who are interested in academic neurogastroenterology and motility, an additional fellowship can help define you as a gastroenterologist and help you to pursue the career of your dreams.

Dr. Sloan is a clinical instructor in the division of gastroenterology at Johns Hopkins in Baltimore.

References

1. Peery A. et al. Burden of gastrointestinal, liver, and pancreatic disease in the United States. Gastroenterology 2015;149:1731-41.e3.

2. Rao S., Parkman H. Advanced training in neurogastroenterology and gastrointestinal motility. Gastroenterology 2015;148:881-5.

3. American Association for the Study of Liver Diseases, American College of Gastroenterology, American Gastroenterological Association (AGA) Institute, and American Society for Gastrointestinal Endoscopy. The gastroenterology core curriculum, third edition. Gastroenterology 2007;132:2012-18.

“So you want to be a gastroenterologist? What do you really want to do?” This is not an uncommon question that a trainee is faced with when progressing through residency and gastroenterology fellowship.

The list of possibilities includes general gastroenterology, advanced endoscopy, transplant hepatology, and neurogastroenterology and motility. From there, each subspecialty can be broken down further into organ system or a specific procedure of interest. Another necessary question is whether to pursue a career in academics or private practice. When it comes to the decision to proceed with a fellowship in neurogastroenterology and motility, there are two pathways that can be taken. The first is for the resident who is interested in gaining experience in gastroenterology prior to starting a general gastroenterology fellowship (there are two programs that currently allow for this pathway). The other track is for those who have completed a general gastroenterology fellowship and are looking to enhance their academic careers by pursuing additional training in neurogastroenterology and motility.

There is currently a need for gastroenterologists interested in neurogastroenterology and motility. Among the most common diagnoses in an ambulatory setting, based on International Classification of Disease (ICD) coding, are abdominal pain, gastroesophageal reflux disease, constipation, nausea and vomiting, irritable bowel syndrome, functional dyspepsia, and dysphagia.^1,2 While many fellows are exposed to a wide range of motility patients during general gastroenterology fellowship, there is typically not a sufficient amount of training to attain “level 2” proficiency.^2,3 In an effort to help standardize training there are recommended thresholds established and advanced training in neurogastroenterology and motility can help fellows to attain that proficiency.^2,3 The extra year can also help you prepare to run a motility lab, train nurses, establish lab protocols and quality standards, and manage referrals, which are important skills as a neurogastroenterology and motility specialist.
 

Types of programs

There are several different types of motility programs available. As mentioned previously, some programs afford individuals an opportunity to gain additional experience in gastroenterology before progressing to general gastroenterology fellowship. There are two programs that offer a 1-year fellowship in neurogastroenterology and motility, both prior to or after a general gastroenterology fellowship. Four programs offer 1-year neurogastroenterology and motility fellowships only after a general gastroenterology fellowship. While the neurogastroenterology and motility fellowships cover esophageal motility, there are four programs that specifically focus solely on the esophagus (Table 1).

Where to find programs

Currently, there is not a singular list of neurogastroenterology and motility programs available for review as you might find with an Accreditation Council for Graduate Medical Education (ACGME) residency or fellowship. At present, the best way to identify the available programs is to search online. Motivation to select a specific program may be related to individual preference and can include geography and department expertise; this ultimately helps to create a focused list. With regard to the ANMS 1-month Clinical Training Program, the list of available programs is available on the society’s website and is for fellows currently in training who wish to incorporate neurogastroenterology and motility into their general GI fellowship.

How to apply

Advanced training in neurogastroenterology and motility is currently a non-ACGME pathway and does not offer a match process for its applicants. After identifying a program of interest, one can find specific instructions on how to apply at the programs’ websites. Typically the process involves reaching out to the program director, writing a letter of interest or personal statement, providing letters of recommendation, and interviewing. Each program has some variability in what is required and attention should be paid to the criteria listed on the specific website.

My experience

I was fortunate to have substantial exposure to esophageal motility in my general gastroenterology fellowship. Gaining this experience was invaluable and laid the foundation for my interest in neurogastroenterology and motility, and, specifically, esophageal dysmotility. My interest in neurogastroenterology and motility then collided with my desire to pursue a career in academics. Knowing the general trajectory for my future career, I began exploring the possibility of undergoing an additional 1-year fellowship early in my second year of GI fellowship. I worked closely with my program director to help define my future goals and to identify available places that would help me attain those goals. While I continued to have an interest in the esophagus, additional training in neurogastroenterology and motility would broaden my understanding and enhance my ability to manage complex patients and perform research at a tertiary care center. I investigated the different neurogastroenterology and motility fellowship programs online and followed the online application instructions. Utilizing national gastroenterology society conferences as networking opportunities, I was able to meet with the program director of my current neurogastroenterology and motility fellowship. In my third year of general gastroenterology fellowship I formally interviewed with the motility group at Johns Hopkins and was later accepted into the neurogastroenterology and motility fellowship program.

Now, nearing the end of my 1-year neurogastroenterology and motility fellowship, I reflect on my extremely positive experience. Throughout the course of the year I have been able to work with multiple GI providers — each with their own area of expertise within the field. There has been a profound exposure to a wide variety of patients with a spectrum of motility conditions covering the entire GI tract. There has been ample opportunity to read motility studies with the guidance and support of the motility faculty to further enhance my skills. The additional year has broadened my exposure to, and the management of, the biopsychosocial aspect of this specific patient population. In line with that, I have had the ability to grow with regard to my use of pharmacology and recognize which symptom might benefit from a particular neuromodulator. An emphasis was also placed on learning the gut-brain axis, and, through multidisciplinary clinics, I worked closely with other disciplines such as psychiatry and GI clinical psychology. Furthermore, the additional year has allowed me to be involved in several research projects within neurogastroenterology and motility that will undoubtedly enhance my future career.

 

Conclusion

Deciding to pursue an additional year in neurogastroenterology and motility has been one that has helped to give a solid direction to my budding career. It has left me confident in managing this diverse and complex patient population and has helped prepare me for a career in academic gastroenterology. For those who are interested in academic neurogastroenterology and motility, an additional fellowship can help define you as a gastroenterologist and help you to pursue the career of your dreams.

Dr. Sloan is a clinical instructor in the division of gastroenterology at Johns Hopkins in Baltimore.

References

1. Peery A. et al. Burden of gastrointestinal, liver, and pancreatic disease in the United States. Gastroenterology 2015;149:1731-41.e3.

2. Rao S., Parkman H. Advanced training in neurogastroenterology and gastrointestinal motility. Gastroenterology 2015;148:881-5.

3. American Association for the Study of Liver Diseases, American College of Gastroenterology, American Gastroenterological Association (AGA) Institute, and American Society for Gastrointestinal Endoscopy. The gastroenterology core curriculum, third edition. Gastroenterology 2007;132:2012-18.

“So you want to be a gastroenterologist? What do you really want to do?” This is not an uncommon question that a trainee is faced with when progressing through residency and gastroenterology fellowship.

The list of possibilities includes general gastroenterology, advanced endoscopy, transplant hepatology, and neurogastroenterology and motility. From there, each subspecialty can be broken down further into organ system or a specific procedure of interest. Another necessary question is whether to pursue a career in academics or private practice. When it comes to the decision to proceed with a fellowship in neurogastroenterology and motility, there are two pathways that can be taken. The first is for the resident who is interested in gaining experience in gastroenterology prior to starting a general gastroenterology fellowship (there are two programs that currently allow for this pathway). The other track is for those who have completed a general gastroenterology fellowship and are looking to enhance their academic careers by pursuing additional training in neurogastroenterology and motility.

There is currently a need for gastroenterologists interested in neurogastroenterology and motility. Among the most common diagnoses in an ambulatory setting, based on International Classification of Disease (ICD) coding, are abdominal pain, gastroesophageal reflux disease, constipation, nausea and vomiting, irritable bowel syndrome, functional dyspepsia, and dysphagia.^1,2 While many fellows are exposed to a wide range of motility patients during general gastroenterology fellowship, there is typically not a sufficient amount of training to attain “level 2” proficiency.^2,3 In an effort to help standardize training there are recommended thresholds established and advanced training in neurogastroenterology and motility can help fellows to attain that proficiency.^2,3 The extra year can also help you prepare to run a motility lab, train nurses, establish lab protocols and quality standards, and manage referrals, which are important skills as a neurogastroenterology and motility specialist.
 

Types of programs

There are several different types of motility programs available. As mentioned previously, some programs afford individuals an opportunity to gain additional experience in gastroenterology before progressing to general gastroenterology fellowship. There are two programs that offer a 1-year fellowship in neurogastroenterology and motility, both prior to or after a general gastroenterology fellowship. Four programs offer 1-year neurogastroenterology and motility fellowships only after a general gastroenterology fellowship. While the neurogastroenterology and motility fellowships cover esophageal motility, there are four programs that specifically focus solely on the esophagus (Table 1).

Where to find programs

Currently, there is not a singular list of neurogastroenterology and motility programs available for review as you might find with an Accreditation Council for Graduate Medical Education (ACGME) residency or fellowship. At present, the best way to identify the available programs is to search online. Motivation to select a specific program may be related to individual preference and can include geography and department expertise; this ultimately helps to create a focused list. With regard to the ANMS 1-month Clinical Training Program, the list of available programs is available on the society’s website and is for fellows currently in training who wish to incorporate neurogastroenterology and motility into their general GI fellowship.

How to apply

Advanced training in neurogastroenterology and motility is currently a non-ACGME pathway and does not offer a match process for its applicants. After identifying a program of interest, one can find specific instructions on how to apply at the programs’ websites. Typically the process involves reaching out to the program director, writing a letter of interest or personal statement, providing letters of recommendation, and interviewing. Each program has some variability in what is required and attention should be paid to the criteria listed on the specific website.

My experience

I was fortunate to have substantial exposure to esophageal motility in my general gastroenterology fellowship. Gaining this experience was invaluable and laid the foundation for my interest in neurogastroenterology and motility, and, specifically, esophageal dysmotility. My interest in neurogastroenterology and motility then collided with my desire to pursue a career in academics. Knowing the general trajectory for my future career, I began exploring the possibility of undergoing an additional 1-year fellowship early in my second year of GI fellowship. I worked closely with my program director to help define my future goals and to identify available places that would help me attain those goals. While I continued to have an interest in the esophagus, additional training in neurogastroenterology and motility would broaden my understanding and enhance my ability to manage complex patients and perform research at a tertiary care center. I investigated the different neurogastroenterology and motility fellowship programs online and followed the online application instructions. Utilizing national gastroenterology society conferences as networking opportunities, I was able to meet with the program director of my current neurogastroenterology and motility fellowship. In my third year of general gastroenterology fellowship I formally interviewed with the motility group at Johns Hopkins and was later accepted into the neurogastroenterology and motility fellowship program.

Now, nearing the end of my 1-year neurogastroenterology and motility fellowship, I reflect on my extremely positive experience. Throughout the course of the year I have been able to work with multiple GI providers — each with their own area of expertise within the field. There has been a profound exposure to a wide variety of patients with a spectrum of motility conditions covering the entire GI tract. There has been ample opportunity to read motility studies with the guidance and support of the motility faculty to further enhance my skills. The additional year has broadened my exposure to, and the management of, the biopsychosocial aspect of this specific patient population. In line with that, I have had the ability to grow with regard to my use of pharmacology and recognize which symptom might benefit from a particular neuromodulator. An emphasis was also placed on learning the gut-brain axis, and, through multidisciplinary clinics, I worked closely with other disciplines such as psychiatry and GI clinical psychology. Furthermore, the additional year has allowed me to be involved in several research projects within neurogastroenterology and motility that will undoubtedly enhance my future career.

 

Conclusion

Deciding to pursue an additional year in neurogastroenterology and motility has been one that has helped to give a solid direction to my budding career. It has left me confident in managing this diverse and complex patient population and has helped prepare me for a career in academic gastroenterology. For those who are interested in academic neurogastroenterology and motility, an additional fellowship can help define you as a gastroenterologist and help you to pursue the career of your dreams.

Dr. Sloan is a clinical instructor in the division of gastroenterology at Johns Hopkins in Baltimore.

References

1. Peery A. et al. Burden of gastrointestinal, liver, and pancreatic disease in the United States. Gastroenterology 2015;149:1731-41.e3.

2. Rao S., Parkman H. Advanced training in neurogastroenterology and gastrointestinal motility. Gastroenterology 2015;148:881-5.

3. American Association for the Study of Liver Diseases, American College of Gastroenterology, American Gastroenterological Association (AGA) Institute, and American Society for Gastrointestinal Endoscopy. The gastroenterology core curriculum, third edition. Gastroenterology 2007;132:2012-18.

As a first-year gastroenterology fellow, banding my first patient with a variceal bleed was an exciting – but also stress-provoking – event. What if I banded incorrectly and caused more bleeding? With a successful band, a patient’s hemorrhagic shock is now controlled, hemodynamics improved, and euphoria takes over. Now, in my third year of a gastroenterology fellowship but my first year of the American Gastroenterological Association (AGA) Editorial Fellowship, preparing to present the first manuscript that I handled to the Board of Editors at our weekly meeting has now induced the same excitement and need for the same level of dedication. Have I researched the foundational literature that this current manuscript was built on? What is the trajectory of this research and will this project be interesting to our readers and lead to breakthroughs in the field?

Gastroenterology is the premier flagship journal of the AGA and, in this Editorial Fellowship, I was selected to spend a fully immersive 1-year experience working on all aspects of this journal. In its second year of inception, I echo Dr. Eric Shah’s insight into the transformative and immersive nature of this fellowship.¹ In this role, I have made three developments, and each one has left me with a valuable lesson.

Mentorship

My first development was as a direct mentee under the leadership of the two editors in chief Richard Peek, MD, and Douglas Corley, MD, and associate editor John Inadomi, MD. In this role, I reviewed submitted manuscripts regarding outcome data of oncologic studies in the fields of colon, esophageal, and gastric cancer. I served as a reviewer for submitted manuscripts and discussed the impact, novelty, and decision for publication with the Board of Editors. In our weekly meetings, the associate editors discussed manuscripts that needed further review prior to acceptance, revision, or rejection. A few themes underpinned the discussion of these manuscripts:

• Is this science reproducible and is there scientific rigor for study design, validity, and analysis?
• How does this manuscript add to the current state of the literature?
• What is the trajectory of this research field?
• How will this manuscript lead to breakthroughs in this field?
• Are the advancements in this manuscript likely to lead to paradigm shifts in the field in its approach, design, or findings?

I also was fortunate to meet leaders in the field, including working daily in person with multiple members of the Board of Editors at Vanderbilt University Medical Center, Nashville, Tenn., as well as visiting professors, including Dr. Corley, Linda Rabeneck, MD, and T. Jake Liang, MD, who not only spoke on their scientific inquiries but also about their transitional path from gastroenterology fellows to pioneers in their respective fields. From these lessons, I have learned the scientific rigor of manuscript review for Gastroenterology and how to approach modern challenges in our field to directly improve patient care.
 

AGA’s commitment to early-career investigators

The Editorial Fellowship allowed me to expand a traditional third-year gastroenterology fellowship to dive deep into the intense path to get a manuscript published in Gastroenterology. Whereas 1 year prior, I had found dilating a complete esophageal stricture difficult, I now found myself learning to master clinical trial design, applying modern techniques of artificial intelligence, understanding organoid development, and navigating the impact of the microbiome. I was fortunate to be selected for Vanderbilt’s Master’s in Science in Clinical Investigation, which allowed me to apply my education not only to my own research but also to synergistically understand and deconstruct new submissions ranging from modern statistics with Bayesian modeling to analysis of large genetic data. All of this was built in the supportive framework of my mentoring committee.

As a fellow, I am inspired to see the multicenter, international collaboration to answer important questions in our field. Leveraging large databases and the expertise of multiple investigators, breakthroughs were made because of the collaborative nature of the science. This also was felt in the review process, where experts generously reviewed manuscripts to enhance the quality of the submission in order to advance knowledge in the field. Reading hundreds of these reviews this year has allowed me to refocus my current research studies and improve the way I write my current reviews. In the spirit of reproducible science and challenging the precision of study design, I was impressed by the time, effort, and dedication reviewers from our field spent to help improve the literature. Dr. Peek and Dr. Corley, our editors in chief, committed their time in discussing my innovations and critiques and displayed their level of interest in the opinions of early-career investigators and fostering the next generation of scientists and practitioners. In this lesson, I was invigorated by the depth of AGA opportunities for fellows and junior faculty in education, research, and involvement.
 

Self-reflection

Having the honor and privilege to review manuscripts upon submission also increased my critical view of my current practices. I now question the level of evidence for which current patient care practices are based, which allows me to better understand the research areas that need increased attention to improve the quality of our guidelines and evidence. For motivated fellows interested in a path of academic medicine, I would strongly advise applying for this prestigious fellowship. In no other training process could I have learned such a breadth of scientific skills and directly apply them to my patient care, my research, and my role as an educator. Furthermore, I was able to contribute to the reviewing and editing process, which allowed me to directly contribute to the field at an early stage of my career. In this final lesson, I exit this impactful Editorial Fellowship in self-reflection. I leave this fellowship humbled – by you – the reader who continues to learn to improve your patient care, the scientist as she works tirelessly to answer questions and contribute to the literature, the gastroenterology community for their willingness to teach and mentor fellows and early-career investigators and practitioners, and the patients who remind us that we all have a shared mission to advance scientific knowledge to improve patient care.

Dr. Naik is a gastroenterology fellow in the department of gastroenterology and hepatology at Vanderbilt University Medical Center in Nashville, Tenn.

Reference

1. Shah ED. Skills acquired during my 1-year AGA Editorial Fellowship. Gastroenterology. 2018;154(6):1563.

As a first-year gastroenterology fellow, banding my first patient with a variceal bleed was an exciting – but also stress-provoking – event. What if I banded incorrectly and caused more bleeding? With a successful band, a patient’s hemorrhagic shock is now controlled, hemodynamics improved, and euphoria takes over. Now, in my third year of a gastroenterology fellowship but my first year of the American Gastroenterological Association (AGA) Editorial Fellowship, preparing to present the first manuscript that I handled to the Board of Editors at our weekly meeting has now induced the same excitement and need for the same level of dedication. Have I researched the foundational literature that this current manuscript was built on? What is the trajectory of this research and will this project be interesting to our readers and lead to breakthroughs in the field?

Gastroenterology is the premier flagship journal of the AGA and, in this Editorial Fellowship, I was selected to spend a fully immersive 1-year experience working on all aspects of this journal. In its second year of inception, I echo Dr. Eric Shah’s insight into the transformative and immersive nature of this fellowship.¹ In this role, I have made three developments, and each one has left me with a valuable lesson.

Mentorship

My first development was as a direct mentee under the leadership of the two editors in chief Richard Peek, MD, and Douglas Corley, MD, and associate editor John Inadomi, MD. In this role, I reviewed submitted manuscripts regarding outcome data of oncologic studies in the fields of colon, esophageal, and gastric cancer. I served as a reviewer for submitted manuscripts and discussed the impact, novelty, and decision for publication with the Board of Editors. In our weekly meetings, the associate editors discussed manuscripts that needed further review prior to acceptance, revision, or rejection. A few themes underpinned the discussion of these manuscripts:

• Is this science reproducible and is there scientific rigor for study design, validity, and analysis?
• How does this manuscript add to the current state of the literature?
• What is the trajectory of this research field?
• How will this manuscript lead to breakthroughs in this field?
• Are the advancements in this manuscript likely to lead to paradigm shifts in the field in its approach, design, or findings?

I also was fortunate to meet leaders in the field, including working daily in person with multiple members of the Board of Editors at Vanderbilt University Medical Center, Nashville, Tenn., as well as visiting professors, including Dr. Corley, Linda Rabeneck, MD, and T. Jake Liang, MD, who not only spoke on their scientific inquiries but also about their transitional path from gastroenterology fellows to pioneers in their respective fields. From these lessons, I have learned the scientific rigor of manuscript review for Gastroenterology and how to approach modern challenges in our field to directly improve patient care.
 

AGA’s commitment to early-career investigators

The Editorial Fellowship allowed me to expand a traditional third-year gastroenterology fellowship to dive deep into the intense path to get a manuscript published in Gastroenterology. Whereas 1 year prior, I had found dilating a complete esophageal stricture difficult, I now found myself learning to master clinical trial design, applying modern techniques of artificial intelligence, understanding organoid development, and navigating the impact of the microbiome. I was fortunate to be selected for Vanderbilt’s Master’s in Science in Clinical Investigation, which allowed me to apply my education not only to my own research but also to synergistically understand and deconstruct new submissions ranging from modern statistics with Bayesian modeling to analysis of large genetic data. All of this was built in the supportive framework of my mentoring committee.

As a fellow, I am inspired to see the multicenter, international collaboration to answer important questions in our field. Leveraging large databases and the expertise of multiple investigators, breakthroughs were made because of the collaborative nature of the science. This also was felt in the review process, where experts generously reviewed manuscripts to enhance the quality of the submission in order to advance knowledge in the field. Reading hundreds of these reviews this year has allowed me to refocus my current research studies and improve the way I write my current reviews. In the spirit of reproducible science and challenging the precision of study design, I was impressed by the time, effort, and dedication reviewers from our field spent to help improve the literature. Dr. Peek and Dr. Corley, our editors in chief, committed their time in discussing my innovations and critiques and displayed their level of interest in the opinions of early-career investigators and fostering the next generation of scientists and practitioners. In this lesson, I was invigorated by the depth of AGA opportunities for fellows and junior faculty in education, research, and involvement.
 

Self-reflection

Having the honor and privilege to review manuscripts upon submission also increased my critical view of my current practices. I now question the level of evidence for which current patient care practices are based, which allows me to better understand the research areas that need increased attention to improve the quality of our guidelines and evidence. For motivated fellows interested in a path of academic medicine, I would strongly advise applying for this prestigious fellowship. In no other training process could I have learned such a breadth of scientific skills and directly apply them to my patient care, my research, and my role as an educator. Furthermore, I was able to contribute to the reviewing and editing process, which allowed me to directly contribute to the field at an early stage of my career. In this final lesson, I exit this impactful Editorial Fellowship in self-reflection. I leave this fellowship humbled – by you – the reader who continues to learn to improve your patient care, the scientist as she works tirelessly to answer questions and contribute to the literature, the gastroenterology community for their willingness to teach and mentor fellows and early-career investigators and practitioners, and the patients who remind us that we all have a shared mission to advance scientific knowledge to improve patient care.

Dr. Naik is a gastroenterology fellow in the department of gastroenterology and hepatology at Vanderbilt University Medical Center in Nashville, Tenn.

Reference

1. Shah ED. Skills acquired during my 1-year AGA Editorial Fellowship. Gastroenterology. 2018;154(6):1563.

As a first-year gastroenterology fellow, banding my first patient with a variceal bleed was an exciting – but also stress-provoking – event. What if I banded incorrectly and caused more bleeding? With a successful band, a patient’s hemorrhagic shock is now controlled, hemodynamics improved, and euphoria takes over. Now, in my third year of a gastroenterology fellowship but my first year of the American Gastroenterological Association (AGA) Editorial Fellowship, preparing to present the first manuscript that I handled to the Board of Editors at our weekly meeting has now induced the same excitement and need for the same level of dedication. Have I researched the foundational literature that this current manuscript was built on? What is the trajectory of this research and will this project be interesting to our readers and lead to breakthroughs in the field?

Gastroenterology is the premier flagship journal of the AGA and, in this Editorial Fellowship, I was selected to spend a fully immersive 1-year experience working on all aspects of this journal. In its second year of inception, I echo Dr. Eric Shah’s insight into the transformative and immersive nature of this fellowship.¹ In this role, I have made three developments, and each one has left me with a valuable lesson.

Mentorship

My first development was as a direct mentee under the leadership of the two editors in chief Richard Peek, MD, and Douglas Corley, MD, and associate editor John Inadomi, MD. In this role, I reviewed submitted manuscripts regarding outcome data of oncologic studies in the fields of colon, esophageal, and gastric cancer. I served as a reviewer for submitted manuscripts and discussed the impact, novelty, and decision for publication with the Board of Editors. In our weekly meetings, the associate editors discussed manuscripts that needed further review prior to acceptance, revision, or rejection. A few themes underpinned the discussion of these manuscripts:

• Is this science reproducible and is there scientific rigor for study design, validity, and analysis?
• How does this manuscript add to the current state of the literature?
• What is the trajectory of this research field?
• How will this manuscript lead to breakthroughs in this field?
• Are the advancements in this manuscript likely to lead to paradigm shifts in the field in its approach, design, or findings?

I also was fortunate to meet leaders in the field, including working daily in person with multiple members of the Board of Editors at Vanderbilt University Medical Center, Nashville, Tenn., as well as visiting professors, including Dr. Corley, Linda Rabeneck, MD, and T. Jake Liang, MD, who not only spoke on their scientific inquiries but also about their transitional path from gastroenterology fellows to pioneers in their respective fields. From these lessons, I have learned the scientific rigor of manuscript review for Gastroenterology and how to approach modern challenges in our field to directly improve patient care.
 

AGA’s commitment to early-career investigators

The Editorial Fellowship allowed me to expand a traditional third-year gastroenterology fellowship to dive deep into the intense path to get a manuscript published in Gastroenterology. Whereas 1 year prior, I had found dilating a complete esophageal stricture difficult, I now found myself learning to master clinical trial design, applying modern techniques of artificial intelligence, understanding organoid development, and navigating the impact of the microbiome. I was fortunate to be selected for Vanderbilt’s Master’s in Science in Clinical Investigation, which allowed me to apply my education not only to my own research but also to synergistically understand and deconstruct new submissions ranging from modern statistics with Bayesian modeling to analysis of large genetic data. All of this was built in the supportive framework of my mentoring committee.

As a fellow, I am inspired to see the multicenter, international collaboration to answer important questions in our field. Leveraging large databases and the expertise of multiple investigators, breakthroughs were made because of the collaborative nature of the science. This also was felt in the review process, where experts generously reviewed manuscripts to enhance the quality of the submission in order to advance knowledge in the field. Reading hundreds of these reviews this year has allowed me to refocus my current research studies and improve the way I write my current reviews. In the spirit of reproducible science and challenging the precision of study design, I was impressed by the time, effort, and dedication reviewers from our field spent to help improve the literature. Dr. Peek and Dr. Corley, our editors in chief, committed their time in discussing my innovations and critiques and displayed their level of interest in the opinions of early-career investigators and fostering the next generation of scientists and practitioners. In this lesson, I was invigorated by the depth of AGA opportunities for fellows and junior faculty in education, research, and involvement.
 

Self-reflection

Having the honor and privilege to review manuscripts upon submission also increased my critical view of my current practices. I now question the level of evidence for which current patient care practices are based, which allows me to better understand the research areas that need increased attention to improve the quality of our guidelines and evidence. For motivated fellows interested in a path of academic medicine, I would strongly advise applying for this prestigious fellowship. In no other training process could I have learned such a breadth of scientific skills and directly apply them to my patient care, my research, and my role as an educator. Furthermore, I was able to contribute to the reviewing and editing process, which allowed me to directly contribute to the field at an early stage of my career. In this final lesson, I exit this impactful Editorial Fellowship in self-reflection. I leave this fellowship humbled – by you – the reader who continues to learn to improve your patient care, the scientist as she works tirelessly to answer questions and contribute to the literature, the gastroenterology community for their willingness to teach and mentor fellows and early-career investigators and practitioners, and the patients who remind us that we all have a shared mission to advance scientific knowledge to improve patient care.

Dr. Naik is a gastroenterology fellow in the department of gastroenterology and hepatology at Vanderbilt University Medical Center in Nashville, Tenn.

Reference

1. Shah ED. Skills acquired during my 1-year AGA Editorial Fellowship. Gastroenterology. 2018;154(6):1563.

As medical professionals, you may have encountered patients with serious illnesses and asked yourself the following questions: What if I was in that situation? Where will my assets go when I die? What will happen to my loved ones, and will they be taken care of? Who would handle my affairs if I became ill? These important questions can only be addressed through effective estate planning.

Everyone needs an estate plan regardless of age, health, and financial or family situation. An effective estate plan provides for the orderly management and disposition of your assets upon your death. In addition, as medical professionals may appreciate, an effective estate plan appoints individuals to manage your financial affairs and make health care decisions for you in the event that you become physically or mentally incapacitated.

The most common estate planning tool is a will, which dictates how your assets pass at death. In addition, a will identifies the personal representative of your estate (that is, the person who will see that your assets pass in accordance with your wishes) and, in many states, identifies the guardian of any minor children. Although a court will make the ultimate determination of who is appointed as the guardian, courts typically give significant weight to the person named in a will.

If you die “intestate,” meaning that you died without a valid will, your assets will be distributed in accordance with your state’s intestacy statutes, and any interested person (as opposed to the individual of your choice) may be appointed as the personal representative of your estate. Therefore, to ensure that your property goes to the individuals of your choice and that your final affairs are handled by the person you trust, a will is essential.

In many states, a revocable living trust can be equally beneficial. Like a will, a revocable living trust will dictate how your property passes at death and appoints a trustee to see that the property is distributed in accordance with your wishes. Revocable living trusts can be great tools for incapacity planning and, unlike a will, are not required to be recorded, so the trust agreement can remain private. The assets that are held in a revocable living trust also avoid the often lengthy and expensive probate process, which generally includes the preparation and filing of a petition to open the estate, an inventory identifying the assets of the estate, and an accounting that details all assets received and distributed, followed by the payment of fees based upon the value of the probate estate.

In many situations, leaving assets to young, disabled, or troubled children would result in catastrophic consequences, such as disqualification for government benefits, dissipation of assets for inappropriate uses, or attachment by creditors. Further, for wealthy individuals, outright distributions to spouses could lead to unnecessary estate tax. Wills and revocable trusts can protect against these issues by requiring that, at death, the decedent’s assets are held in further trust for these individuals.

There are various types of trusts that can help ensure that your assets are used for the benefit of your loved one while avoiding any unintended consequences, some of which include the following:

• Special needs trusts, which allow the trustee to use the trust funds for the benefit of the disabled beneficiary without disqualifying the beneficiary from important government benefits.
• Spendthrift trusts, which can protect the trust assets from claims of creditors or property division in a divorce action.
• Marital trusts, which can be used to reduce taxes and ensure that property will be distributed pursuant to your wishes upon the death of your spouse.
• Dynasty trusts, which can be used to protect assets for many generations and, in doing so, reduce the amount of federal and state transfer taxes.

Whether you use a will or revocable living trust, it is critical to coordinate the beneficiary designations of assets such as retirement accounts and life insurance policies, as well as any other account that passes by beneficiary designation. These beneficiary designations trump the provisions of your will and revocable living trust. Likewise, property owned jointly with another person as joint tenants with the right of survivorship, or with a spouse as tenants by the entirety, will pass directly to the joint owner and not pursuant to the terms of your will or revocable trust.

An effective estate plan involves not just planning for death, but also for your incapacity. A durable power of attorney allows you to select an agent or agents to manage your property during your lifetime. The power of attorney can become effective immediately so that the agent can act on your behalf upon execution of the document or the power of attorney can become effective only if and when you become incapacitated.

A durable power of attorney for health care (or advance health care directive) permits you to appoint an agent to make health care decisions on your behalf in the event that you cannot make your own decisions. In addition, should you become permanently unconscious or in a terminal condition, it permits you to appoint an agent who can withhold or withdraw life-sustaining treatment. With a living will, you can express in writing the circumstances under which you do or do not want artificial life-sustaining measures.

With respect to these powers of attorney, the persons that you appoint as your agents should be people that you trust. It is also important to have conversations with your designated agents to ensure that they understand their responsibilities and your wishes. Without these powers of attorney, in the event of your incapacitation, a court will appoint a guardian. The guardian may not be the person you would have appointed, and it will result in annual, and burdensome, court filings.

As busy medical professionals, it may be difficult to find time to develop an estate plan and you may believe that there is plenty of time to do it in the future. It is important to begin thinking about your estate-planning goals and to speak with an attorney to help develop and draft your estate-planning documents. If you already have estate-planning documents, it is important to review those documents periodically to ensure that your estate-planning objectives have remained the same and, if they have changed, to update your documents.

No one knows what the future will hold, so it is important to consult with a local attorney to establish or review your estate plan now. If you do, you will be comforted by the fact that you and your loved ones will be taken care of in accordance with your wishes if you are unable to do so in the future.
 

Mr. D’Emilio is a managing member and Mr. Riley is an associate at McCollom D’Emilio Smith Uebler, Wilmington, Del.

As medical professionals, you may have encountered patients with serious illnesses and asked yourself the following questions: What if I was in that situation? Where will my assets go when I die? What will happen to my loved ones, and will they be taken care of? Who would handle my affairs if I became ill? These important questions can only be addressed through effective estate planning.

Everyone needs an estate plan regardless of age, health, and financial or family situation. An effective estate plan provides for the orderly management and disposition of your assets upon your death. In addition, as medical professionals may appreciate, an effective estate plan appoints individuals to manage your financial affairs and make health care decisions for you in the event that you become physically or mentally incapacitated.

The most common estate planning tool is a will, which dictates how your assets pass at death. In addition, a will identifies the personal representative of your estate (that is, the person who will see that your assets pass in accordance with your wishes) and, in many states, identifies the guardian of any minor children. Although a court will make the ultimate determination of who is appointed as the guardian, courts typically give significant weight to the person named in a will.

If you die “intestate,” meaning that you died without a valid will, your assets will be distributed in accordance with your state’s intestacy statutes, and any interested person (as opposed to the individual of your choice) may be appointed as the personal representative of your estate. Therefore, to ensure that your property goes to the individuals of your choice and that your final affairs are handled by the person you trust, a will is essential.

In many states, a revocable living trust can be equally beneficial. Like a will, a revocable living trust will dictate how your property passes at death and appoints a trustee to see that the property is distributed in accordance with your wishes. Revocable living trusts can be great tools for incapacity planning and, unlike a will, are not required to be recorded, so the trust agreement can remain private. The assets that are held in a revocable living trust also avoid the often lengthy and expensive probate process, which generally includes the preparation and filing of a petition to open the estate, an inventory identifying the assets of the estate, and an accounting that details all assets received and distributed, followed by the payment of fees based upon the value of the probate estate.

In many situations, leaving assets to young, disabled, or troubled children would result in catastrophic consequences, such as disqualification for government benefits, dissipation of assets for inappropriate uses, or attachment by creditors. Further, for wealthy individuals, outright distributions to spouses could lead to unnecessary estate tax. Wills and revocable trusts can protect against these issues by requiring that, at death, the decedent’s assets are held in further trust for these individuals.

There are various types of trusts that can help ensure that your assets are used for the benefit of your loved one while avoiding any unintended consequences, some of which include the following:

• Special needs trusts, which allow the trustee to use the trust funds for the benefit of the disabled beneficiary without disqualifying the beneficiary from important government benefits.
• Spendthrift trusts, which can protect the trust assets from claims of creditors or property division in a divorce action.
• Marital trusts, which can be used to reduce taxes and ensure that property will be distributed pursuant to your wishes upon the death of your spouse.
• Dynasty trusts, which can be used to protect assets for many generations and, in doing so, reduce the amount of federal and state transfer taxes.

Whether you use a will or revocable living trust, it is critical to coordinate the beneficiary designations of assets such as retirement accounts and life insurance policies, as well as any other account that passes by beneficiary designation. These beneficiary designations trump the provisions of your will and revocable living trust. Likewise, property owned jointly with another person as joint tenants with the right of survivorship, or with a spouse as tenants by the entirety, will pass directly to the joint owner and not pursuant to the terms of your will or revocable trust.

An effective estate plan involves not just planning for death, but also for your incapacity. A durable power of attorney allows you to select an agent or agents to manage your property during your lifetime. The power of attorney can become effective immediately so that the agent can act on your behalf upon execution of the document or the power of attorney can become effective only if and when you become incapacitated.

A durable power of attorney for health care (or advance health care directive) permits you to appoint an agent to make health care decisions on your behalf in the event that you cannot make your own decisions. In addition, should you become permanently unconscious or in a terminal condition, it permits you to appoint an agent who can withhold or withdraw life-sustaining treatment. With a living will, you can express in writing the circumstances under which you do or do not want artificial life-sustaining measures.

With respect to these powers of attorney, the persons that you appoint as your agents should be people that you trust. It is also important to have conversations with your designated agents to ensure that they understand their responsibilities and your wishes. Without these powers of attorney, in the event of your incapacitation, a court will appoint a guardian. The guardian may not be the person you would have appointed, and it will result in annual, and burdensome, court filings.

As busy medical professionals, it may be difficult to find time to develop an estate plan and you may believe that there is plenty of time to do it in the future. It is important to begin thinking about your estate-planning goals and to speak with an attorney to help develop and draft your estate-planning documents. If you already have estate-planning documents, it is important to review those documents periodically to ensure that your estate-planning objectives have remained the same and, if they have changed, to update your documents.

No one knows what the future will hold, so it is important to consult with a local attorney to establish or review your estate plan now. If you do, you will be comforted by the fact that you and your loved ones will be taken care of in accordance with your wishes if you are unable to do so in the future.
 

Mr. D’Emilio is a managing member and Mr. Riley is an associate at McCollom D’Emilio Smith Uebler, Wilmington, Del.

As medical professionals, you may have encountered patients with serious illnesses and asked yourself the following questions: What if I was in that situation? Where will my assets go when I die? What will happen to my loved ones, and will they be taken care of? Who would handle my affairs if I became ill? These important questions can only be addressed through effective estate planning.

Everyone needs an estate plan regardless of age, health, and financial or family situation. An effective estate plan provides for the orderly management and disposition of your assets upon your death. In addition, as medical professionals may appreciate, an effective estate plan appoints individuals to manage your financial affairs and make health care decisions for you in the event that you become physically or mentally incapacitated.

The most common estate planning tool is a will, which dictates how your assets pass at death. In addition, a will identifies the personal representative of your estate (that is, the person who will see that your assets pass in accordance with your wishes) and, in many states, identifies the guardian of any minor children. Although a court will make the ultimate determination of who is appointed as the guardian, courts typically give significant weight to the person named in a will.

If you die “intestate,” meaning that you died without a valid will, your assets will be distributed in accordance with your state’s intestacy statutes, and any interested person (as opposed to the individual of your choice) may be appointed as the personal representative of your estate. Therefore, to ensure that your property goes to the individuals of your choice and that your final affairs are handled by the person you trust, a will is essential.

In many states, a revocable living trust can be equally beneficial. Like a will, a revocable living trust will dictate how your property passes at death and appoints a trustee to see that the property is distributed in accordance with your wishes. Revocable living trusts can be great tools for incapacity planning and, unlike a will, are not required to be recorded, so the trust agreement can remain private. The assets that are held in a revocable living trust also avoid the often lengthy and expensive probate process, which generally includes the preparation and filing of a petition to open the estate, an inventory identifying the assets of the estate, and an accounting that details all assets received and distributed, followed by the payment of fees based upon the value of the probate estate.

In many situations, leaving assets to young, disabled, or troubled children would result in catastrophic consequences, such as disqualification for government benefits, dissipation of assets for inappropriate uses, or attachment by creditors. Further, for wealthy individuals, outright distributions to spouses could lead to unnecessary estate tax. Wills and revocable trusts can protect against these issues by requiring that, at death, the decedent’s assets are held in further trust for these individuals.

There are various types of trusts that can help ensure that your assets are used for the benefit of your loved one while avoiding any unintended consequences, some of which include the following:

• Special needs trusts, which allow the trustee to use the trust funds for the benefit of the disabled beneficiary without disqualifying the beneficiary from important government benefits.
• Spendthrift trusts, which can protect the trust assets from claims of creditors or property division in a divorce action.
• Marital trusts, which can be used to reduce taxes and ensure that property will be distributed pursuant to your wishes upon the death of your spouse.
• Dynasty trusts, which can be used to protect assets for many generations and, in doing so, reduce the amount of federal and state transfer taxes.

Whether you use a will or revocable living trust, it is critical to coordinate the beneficiary designations of assets such as retirement accounts and life insurance policies, as well as any other account that passes by beneficiary designation. These beneficiary designations trump the provisions of your will and revocable living trust. Likewise, property owned jointly with another person as joint tenants with the right of survivorship, or with a spouse as tenants by the entirety, will pass directly to the joint owner and not pursuant to the terms of your will or revocable trust.

An effective estate plan involves not just planning for death, but also for your incapacity. A durable power of attorney allows you to select an agent or agents to manage your property during your lifetime. The power of attorney can become effective immediately so that the agent can act on your behalf upon execution of the document or the power of attorney can become effective only if and when you become incapacitated.

A durable power of attorney for health care (or advance health care directive) permits you to appoint an agent to make health care decisions on your behalf in the event that you cannot make your own decisions. In addition, should you become permanently unconscious or in a terminal condition, it permits you to appoint an agent who can withhold or withdraw life-sustaining treatment. With a living will, you can express in writing the circumstances under which you do or do not want artificial life-sustaining measures.

With respect to these powers of attorney, the persons that you appoint as your agents should be people that you trust. It is also important to have conversations with your designated agents to ensure that they understand their responsibilities and your wishes. Without these powers of attorney, in the event of your incapacitation, a court will appoint a guardian. The guardian may not be the person you would have appointed, and it will result in annual, and burdensome, court filings.

As busy medical professionals, it may be difficult to find time to develop an estate plan and you may believe that there is plenty of time to do it in the future. It is important to begin thinking about your estate-planning goals and to speak with an attorney to help develop and draft your estate-planning documents. If you already have estate-planning documents, it is important to review those documents periodically to ensure that your estate-planning objectives have remained the same and, if they have changed, to update your documents.

No one knows what the future will hold, so it is important to consult with a local attorney to establish or review your estate plan now. If you do, you will be comforted by the fact that you and your loved ones will be taken care of in accordance with your wishes if you are unable to do so in the future.
 

Mr. D’Emilio is a managing member and Mr. Riley is an associate at McCollom D’Emilio Smith Uebler, Wilmington, Del.

During my medical training and fellowship, I often heard that my education was not preparing me for the real world. After 3 years of internal medicine training with limited exposure to the outpatient arena and 3-4 years of specialty gastroenterology, hepatology, and advanced procedure training, you’ve probably heard the same thing. If you’ve chosen private practice, the thought of building a practice and establishing referrals probably seems daunting. It doesn’t have to be. Most gastroenterologists who enter private practice have felt this way early on, and our experiences can help you navigate some of the major factors that influence clinical practice to build a thriving career in gastroenterology.

Conduct research on referrals

Once you’ve decided to join a practice, do some research about local dynamics between large hospital systems and private practice. Community clinical practice is unique and varies by region, location, and how the practice is set up. GIs working in rural, low-access areas face different challenges than those working in urban areas near major health care systems. In rural, low-access areas, some physicians have long wait lists for office appointments and procedures.

In urban settings, there may be a larger population of patients but more competition from hospital systems and other practices. In this case, you’ll have to figure out where most of the referrals come from and why – is it the group’s overall reputation or are there physicians in the practice with a highly needed specialty?

Determine if your specialty training can be a differentiator in your market. If you are multilingual and there is a large patient population that speaks the language(s) in which you are fluent, this can be a great way to bring new patients into a practice. This is especially true if there aren’t many (or any) physicians in the practice who are multilingual.

Meet with local physicians in health care systems. Make a connection with hospitalists, referring physicians, ED physicians, advanced practitioners, and surgeons while covering inpatient service. Volunteer for teaching activities – including for nursing staff, who are a great referral source.

Figure out what opportunities exist to have direct interactions with patients, such as health fairs. If possible, it might be smart to invest in marketing directly to patients in your community as well. Leverage opportunities provided by awareness months – such as providing patients with information about cancer screening – to establish a referral basis.

Medical practice is complex and at times can be confusing until you’ve practiced in a given location for some time. Look internally to learn about the community. It’s always a good idea to learn from those who have been practicing in the community for a long time. Don’t hesitate to ask questions and make suggestions, even if they seem naive. Develop relationships with staff members and gain their trust. Establishing a clear understanding of your specialty with your colleagues and staff also can be a good way to find referrals.

Learn the internal process

Schedules during early months are usually filled with urgent patients. Make yourself available for overflow referrals to other established physicians within the practice and for hospital discharge follow-ups. Reading through the charts of these patients can help you understand the various styles of other doctors and can help you familiarize yourself with referring physicians.

This also will help to clarify the process of how a patient moves through the system – from the time patients call the office to when they check out. This includes navigating through procedures, results reporting, and the recall system. While it will be hard to master all aspects of a practice right away, processes within practices are well established, and it is important for you to have a good understanding of how they function.

Focus on patient care and satisfaction

Learning internal processes also can be useful in increasing patient satisfaction, an important quality outcome indicator. As you’re starting out, keep the following things in mind that can help put your patients at ease and increase satisfaction.

• Understand how to communicate what a patient should expect when being seen. Being at ease with the process helps garner trust and confidence.
• Call patients the next day to check on their symptoms.
• Relay results personally. Make connections with family member(s).
• Remember that cultural competency is important. Do everything you can to ensure you’re meeting the social, cultural, and linguistic needs of patients in your community.
• Above all – continue to provide personalized and thorough care. Word of mouth is the best form of referral and is time tested.

Continue to grow

As you begin to understand the dynamics of local practice, it’s important to establish where you fit into the practice and start differentiating your expertise. Here are some ideas and suggestions for how you can continue to expand your patient base.

• Differentiate and establish a subspecialty within your practice: Motility, inflammatory bowel disease, Clostridium difficile/fecal microbiota transplantation, liver diseases, Celiac disease, and medical weight-loss programs are just a few.
• Establish connections with local medical societies as well as hospital and state committees. This is a great way to connect with other physicians of various specialties. If you have a specialty unique to the area, it may help establish a clear referral line.
• Establish a consistent conversation with referring physicians – get to know them and keep direct lines of communication, such as having their cell phone numbers.
• Look for public speaking engagements that reach patients directly. These are organized mostly through patient-based organization and foundations.
• Increase your reach through the local media and through social media platforms like Facebook, Instagram, and Twitter.

At this point, you should have plenty of patients to keep you busy, which could lead to other challenges in managing your various responsibilities and obligations. A key factor at this stage to help reduce stress is to lean on the effective and efficient support system your practice should have in place. Educating medical assistants or nurses on the most common GI diseases and conditions can help reduce the time involved in communicating results. Practice management software and patient portals can help create efficiencies to handle the increasing number of patient visits.

Remember, creating a referral process and patient base as a new gastroenterologist doesn’t have to be daunting. If you follow these tips, you’ll be on your way to establishing yourself within the community. No doubt you will have the same success as many physicians in my group and in the groups of my colleagues in the Digestive Health Physicians Association. And once you’re established, it will be your turn to help the next generation of physicians who want to enter private practice and thrive – so that independent community GI care remains strong well into the future.

Dr. Alaparthi is the director of committee operations at the Gastroenterology Center of Connecticut and serves as chair of the communications committee for the Digestive Health Physicians Association.

During my medical training and fellowship, I often heard that my education was not preparing me for the real world. After 3 years of internal medicine training with limited exposure to the outpatient arena and 3-4 years of specialty gastroenterology, hepatology, and advanced procedure training, you’ve probably heard the same thing. If you’ve chosen private practice, the thought of building a practice and establishing referrals probably seems daunting. It doesn’t have to be. Most gastroenterologists who enter private practice have felt this way early on, and our experiences can help you navigate some of the major factors that influence clinical practice to build a thriving career in gastroenterology.

Conduct research on referrals

Once you’ve decided to join a practice, do some research about local dynamics between large hospital systems and private practice. Community clinical practice is unique and varies by region, location, and how the practice is set up. GIs working in rural, low-access areas face different challenges than those working in urban areas near major health care systems. In rural, low-access areas, some physicians have long wait lists for office appointments and procedures.

In urban settings, there may be a larger population of patients but more competition from hospital systems and other practices. In this case, you’ll have to figure out where most of the referrals come from and why – is it the group’s overall reputation or are there physicians in the practice with a highly needed specialty?

Determine if your specialty training can be a differentiator in your market. If you are multilingual and there is a large patient population that speaks the language(s) in which you are fluent, this can be a great way to bring new patients into a practice. This is especially true if there aren’t many (or any) physicians in the practice who are multilingual.

Meet with local physicians in health care systems. Make a connection with hospitalists, referring physicians, ED physicians, advanced practitioners, and surgeons while covering inpatient service. Volunteer for teaching activities – including for nursing staff, who are a great referral source.

Figure out what opportunities exist to have direct interactions with patients, such as health fairs. If possible, it might be smart to invest in marketing directly to patients in your community as well. Leverage opportunities provided by awareness months – such as providing patients with information about cancer screening – to establish a referral basis.

Medical practice is complex and at times can be confusing until you’ve practiced in a given location for some time. Look internally to learn about the community. It’s always a good idea to learn from those who have been practicing in the community for a long time. Don’t hesitate to ask questions and make suggestions, even if they seem naive. Develop relationships with staff members and gain their trust. Establishing a clear understanding of your specialty with your colleagues and staff also can be a good way to find referrals.

Learn the internal process

Schedules during early months are usually filled with urgent patients. Make yourself available for overflow referrals to other established physicians within the practice and for hospital discharge follow-ups. Reading through the charts of these patients can help you understand the various styles of other doctors and can help you familiarize yourself with referring physicians.

This also will help to clarify the process of how a patient moves through the system – from the time patients call the office to when they check out. This includes navigating through procedures, results reporting, and the recall system. While it will be hard to master all aspects of a practice right away, processes within practices are well established, and it is important for you to have a good understanding of how they function.

Focus on patient care and satisfaction

Learning internal processes also can be useful in increasing patient satisfaction, an important quality outcome indicator. As you’re starting out, keep the following things in mind that can help put your patients at ease and increase satisfaction.

• Understand how to communicate what a patient should expect when being seen. Being at ease with the process helps garner trust and confidence.
• Call patients the next day to check on their symptoms.
• Relay results personally. Make connections with family member(s).
• Remember that cultural competency is important. Do everything you can to ensure you’re meeting the social, cultural, and linguistic needs of patients in your community.
• Above all – continue to provide personalized and thorough care. Word of mouth is the best form of referral and is time tested.

Continue to grow

As you begin to understand the dynamics of local practice, it’s important to establish where you fit into the practice and start differentiating your expertise. Here are some ideas and suggestions for how you can continue to expand your patient base.

• Differentiate and establish a subspecialty within your practice: Motility, inflammatory bowel disease, Clostridium difficile/fecal microbiota transplantation, liver diseases, Celiac disease, and medical weight-loss programs are just a few.
• Establish connections with local medical societies as well as hospital and state committees. This is a great way to connect with other physicians of various specialties. If you have a specialty unique to the area, it may help establish a clear referral line.
• Establish a consistent conversation with referring physicians – get to know them and keep direct lines of communication, such as having their cell phone numbers.
• Look for public speaking engagements that reach patients directly. These are organized mostly through patient-based organization and foundations.
• Increase your reach through the local media and through social media platforms like Facebook, Instagram, and Twitter.

At this point, you should have plenty of patients to keep you busy, which could lead to other challenges in managing your various responsibilities and obligations. A key factor at this stage to help reduce stress is to lean on the effective and efficient support system your practice should have in place. Educating medical assistants or nurses on the most common GI diseases and conditions can help reduce the time involved in communicating results. Practice management software and patient portals can help create efficiencies to handle the increasing number of patient visits.

Remember, creating a referral process and patient base as a new gastroenterologist doesn’t have to be daunting. If you follow these tips, you’ll be on your way to establishing yourself within the community. No doubt you will have the same success as many physicians in my group and in the groups of my colleagues in the Digestive Health Physicians Association. And once you’re established, it will be your turn to help the next generation of physicians who want to enter private practice and thrive – so that independent community GI care remains strong well into the future.

Dr. Alaparthi is the director of committee operations at the Gastroenterology Center of Connecticut and serves as chair of the communications committee for the Digestive Health Physicians Association.

During my medical training and fellowship, I often heard that my education was not preparing me for the real world. After 3 years of internal medicine training with limited exposure to the outpatient arena and 3-4 years of specialty gastroenterology, hepatology, and advanced procedure training, you’ve probably heard the same thing. If you’ve chosen private practice, the thought of building a practice and establishing referrals probably seems daunting. It doesn’t have to be. Most gastroenterologists who enter private practice have felt this way early on, and our experiences can help you navigate some of the major factors that influence clinical practice to build a thriving career in gastroenterology.

Conduct research on referrals

Once you’ve decided to join a practice, do some research about local dynamics between large hospital systems and private practice. Community clinical practice is unique and varies by region, location, and how the practice is set up. GIs working in rural, low-access areas face different challenges than those working in urban areas near major health care systems. In rural, low-access areas, some physicians have long wait lists for office appointments and procedures.

In urban settings, there may be a larger population of patients but more competition from hospital systems and other practices. In this case, you’ll have to figure out where most of the referrals come from and why – is it the group’s overall reputation or are there physicians in the practice with a highly needed specialty?

Determine if your specialty training can be a differentiator in your market. If you are multilingual and there is a large patient population that speaks the language(s) in which you are fluent, this can be a great way to bring new patients into a practice. This is especially true if there aren’t many (or any) physicians in the practice who are multilingual.

Meet with local physicians in health care systems. Make a connection with hospitalists, referring physicians, ED physicians, advanced practitioners, and surgeons while covering inpatient service. Volunteer for teaching activities – including for nursing staff, who are a great referral source.

Figure out what opportunities exist to have direct interactions with patients, such as health fairs. If possible, it might be smart to invest in marketing directly to patients in your community as well. Leverage opportunities provided by awareness months – such as providing patients with information about cancer screening – to establish a referral basis.

Medical practice is complex and at times can be confusing until you’ve practiced in a given location for some time. Look internally to learn about the community. It’s always a good idea to learn from those who have been practicing in the community for a long time. Don’t hesitate to ask questions and make suggestions, even if they seem naive. Develop relationships with staff members and gain their trust. Establishing a clear understanding of your specialty with your colleagues and staff also can be a good way to find referrals.

Learn the internal process

Schedules during early months are usually filled with urgent patients. Make yourself available for overflow referrals to other established physicians within the practice and for hospital discharge follow-ups. Reading through the charts of these patients can help you understand the various styles of other doctors and can help you familiarize yourself with referring physicians.

This also will help to clarify the process of how a patient moves through the system – from the time patients call the office to when they check out. This includes navigating through procedures, results reporting, and the recall system. While it will be hard to master all aspects of a practice right away, processes within practices are well established, and it is important for you to have a good understanding of how they function.

Focus on patient care and satisfaction

Learning internal processes also can be useful in increasing patient satisfaction, an important quality outcome indicator. As you’re starting out, keep the following things in mind that can help put your patients at ease and increase satisfaction.

• Understand how to communicate what a patient should expect when being seen. Being at ease with the process helps garner trust and confidence.
• Call patients the next day to check on their symptoms.
• Relay results personally. Make connections with family member(s).
• Remember that cultural competency is important. Do everything you can to ensure you’re meeting the social, cultural, and linguistic needs of patients in your community.
• Above all – continue to provide personalized and thorough care. Word of mouth is the best form of referral and is time tested.

Continue to grow

As you begin to understand the dynamics of local practice, it’s important to establish where you fit into the practice and start differentiating your expertise. Here are some ideas and suggestions for how you can continue to expand your patient base.

• Differentiate and establish a subspecialty within your practice: Motility, inflammatory bowel disease, Clostridium difficile/fecal microbiota transplantation, liver diseases, Celiac disease, and medical weight-loss programs are just a few.
• Establish connections with local medical societies as well as hospital and state committees. This is a great way to connect with other physicians of various specialties. If you have a specialty unique to the area, it may help establish a clear referral line.
• Establish a consistent conversation with referring physicians – get to know them and keep direct lines of communication, such as having their cell phone numbers.
• Look for public speaking engagements that reach patients directly. These are organized mostly through patient-based organization and foundations.
• Increase your reach through the local media and through social media platforms like Facebook, Instagram, and Twitter.

At this point, you should have plenty of patients to keep you busy, which could lead to other challenges in managing your various responsibilities and obligations. A key factor at this stage to help reduce stress is to lean on the effective and efficient support system your practice should have in place. Educating medical assistants or nurses on the most common GI diseases and conditions can help reduce the time involved in communicating results. Practice management software and patient portals can help create efficiencies to handle the increasing number of patient visits.

Remember, creating a referral process and patient base as a new gastroenterologist doesn’t have to be daunting. If you follow these tips, you’ll be on your way to establishing yourself within the community. No doubt you will have the same success as many physicians in my group and in the groups of my colleagues in the Digestive Health Physicians Association. And once you’re established, it will be your turn to help the next generation of physicians who want to enter private practice and thrive – so that independent community GI care remains strong well into the future.

Dr. Alaparthi is the director of committee operations at the Gastroenterology Center of Connecticut and serves as chair of the communications committee for the Digestive Health Physicians Association.

Introduction

Burnout in physicians has received significant attention within the past several years, particularly among trainees and early-career physicians. The subspecialties of gastroenterology and hepatology are not immune to burnout, with multiple studies indicating that early career gastroenterologists may be disproportionately affected, compared with their more-established counterparts.^1-4 Although the drivers of depersonalization, emotional exhaustion, and a reduced sense of personal accomplishment among trainees and early-career gastroenterologists are not fully understood, maximizing career fit during the transition from fellowship into the first posttraining position has been promoted as a potential method to decrease burnout in this population.^4,5

While most trainees enter gastroenterology fellowships with a set of predefined career goals, mentorship during fellowship can provide critical guidance along with exposure to new areas and career tracks that were not previously considered. In a survey of gastroenterology and transplant hepatology fellows, 94% of participants with a mentor reported that the mentor significantly influenced their career decision.⁶ Effective mentoring also has been identified as one possible method to decrease burnout among trainees.^7,8

Formal mentoring in gastroenterology fellowship programs might decrease burnout through effectively identifying risk factors such as work hour violations or a lack of social support. Additionally, when fellows are being prepared for transition to their first positions as attending gastroenterologists, there is a critical opportunity to improve career fit and decrease burnout rates among early-career gastroenterologists. Making the correct choice of subsequent career path after fellowship might be a source of stress, but this should allow early-career gastroenterologists to maximize the time spent doing those activities they feel are the most rewarding. A formal mentoring system and an accessible career mentor can be invaluable in allowing the mentee to identify and select that position.
 

Career fit

The concept of career fit has been described as the ability of individuals to focus their effort on the aspect or aspects of their work that they find most meaningful.⁵ Multiple specialties have recognized the importance of career fit and the need to choose appropriately when selecting a position and career path upon completing fellowship. In one evaluation of faculty members from the department of medicine at a large academic medical center, those individuals who spent less than 20% of their time working on the activity that they found most meaningful were significantly more likely to demonstrate burnout.⁵

In a relatively short time period, gastroenterology fellows are required to gather multiple new skill sets, including functioning as a consultant, performing endoscopic procedures, and potentially gaining formal training in clinical, basic, or translational research methods. During this same period, an intense phase of self-assessment should begin, with one critical aim of training being to identify those factors most likely to lead to a long, satisfying career. The growth that occurs during fellowship may allow for the identification of a career track that is likely to be the most rewarding, such as a career as a clinical investigator, clinician educator, or in clinical practice. Importantly, the trainee must decide which career track will most likely lead to self-fulfillment, even if the chosen path does not align with a mentor or advisor. Additionally, self-assessment also may aid in the identification of a niche that an individual finds most intellectually stimulating, which may lead to an area of research or clinical expertise.

While the demonstrated relationship between career fit and burnout is only an association without demonstrated causation, this does merit further consideration. For the first time in most trainees’ careers, the position after fellowship represents an opportunity to choose a job as opposed to going through a “match” process. Therefore, the trainee must strongly consider the factors that will ultimately lead to career satisfaction. If a large disconnect is present between self-identified career goals and the actual tasks required within daily workflow, this may lead to burnout relatively early in a career. Perhaps more importantly, if an individual did not perform adequate self-reflection when choosing a career path or did not receive effective guidance from career mentors, this also might lead to decreased career satisfaction, poor career fit, and an increased risk for burnout as an early-career gastroenterologist.
 

The mentor’s role

Although a structured career mentoring program is in place within many gastroenterology training programs, other fellowships encourage the mentee to select from a pool of potential mentors. In many cases, trainees and early career gastroenterologists will benefit from building a mentorship team, including career mentor or mentors, research mentors, and other advisors.⁹

While the mentor-mentee relationship can be an extremely rewarding experience for both parties, the effective mentor must meet a high standard. Several qualities have been identified that will maximize the benefit of the mentor-mentee relationship for the trainee, including the mentor taking a selfless approach to the relationship, working to assist the mentee in choosing a career path that will be the most rewarding, and then aiding the mentee in making helpful connections to promote growth along that chosen path.⁹ A good mentors should inspire a mentees, but also should be willing to provide honest and at times critical feedback to ensure that mentees maximizes their potential and ultimately assume the appropriate career trajectory. Unbiased mentorship, as well as continued reevaluations of strengths, weaknesses, and career goals by the mentor and mentee, will ultimately offer an opportunity to ensure the best combination of career fit,⁵ work-life balance,¹⁰ and satisfaction with career choice.¹¹
 

The mentor-mentee relationship after training is complete

Once a trainee has completed gastroenterology fellowship, another stressful transition to the role of an attending physician commences. It is critical that early-career gastroenterologists not only have confidence in the guidance that their mentor has provided to ensure appropriate career fit in their new role but also maintain these critical mentor-mentee relationships during this transition. A good mentor does not disappear because one phase of training is complete. The need for effective mentoring at the junior faculty level also is well recognized,¹² and early-career gastroenterologists should continue to rely on established mentoring relationships when new decision points are encountered.

Depending on the career track of an early-career gastroenterologist, formal mentoring also may be offered in the new role as a junior faculty member.¹² Additionally, external mentoring can exist within foundations or other subspecialty groups. One example of extramural mentoring is the Career Connection Program offered through the Crohn’s & Colitis Foundation’s Rising Educators Academics and Clinicians Helping IBD (REACH-IBD) platform. In this program, early-career gastroenterologists are selected and paired with national opinion leaders for one-on-one mentoring relationships. Such a program offers further opportunities for career growth, establishing connections within a smaller subspecialty of gastroenterology, and maximizing career fit.
 

Conclusion

In an era where the toll of burnout and other influences on early-career gastroenterologists are increasingly being recognized, the importance of career fit during the transition into the role of an attending should not be underestimated. In conjunction with appropriate self-reflection, unbiased and critical mentorship during fellowship can promote significant growth among trainees and allow for the ultimate selection of a career track or career path that will promote happiness, work-life balance, and long-term success as defined by the mentee.

Edward L. Barnes, MD, MPH, is with the Multidisciplinary Center for Inflammatory Bowel Diseases and the Center for Gastrointestinal Biology and Disease in the division of gastroenterology and hepatology at the University of North Carolina at Chapel Hill. Dr. Barnes reports no relevant disclosures.

References

1. Keswani RN et al. Am J Gastroenterol. 2011;106(10):1734-40.

2. Burke C et al. Am J Gastroenterol. 2017;112:S593-4.

3. DeCross AJ. AGA Perspectives. 2017.

4. Barnes EL et al. Dig Dis Sci. 2019;64(2):302-6.

5. Shanafelt TD et al. Arch Intern Med. 2009;169(10):990-5.

6. Ordway SM et al. Hepatol Commun. 2017;1(4):347-53.

7. Janko MR, Smeds MR. J Vasc Surg. 2019;69(4):1233-42.

8. Eckleberry-Hunt J et al. Acad Med. 2009;84(2):269-77.

9. Lieberman D. Gastroenterology. 2016;151(1):17-9.

10. Shanafelt TD et al. Mayo Clin Proc. 2015;90(12):1600-13.

11. Shanafelt TD et al. Ann Surg. 2009;250(3):463-71.

12. Shaheen NJ, Sandler RS. Gastroenterology. 2018;155(5):1293-7.

Introduction

Burnout in physicians has received significant attention within the past several years, particularly among trainees and early-career physicians. The subspecialties of gastroenterology and hepatology are not immune to burnout, with multiple studies indicating that early career gastroenterologists may be disproportionately affected, compared with their more-established counterparts.^1-4 Although the drivers of depersonalization, emotional exhaustion, and a reduced sense of personal accomplishment among trainees and early-career gastroenterologists are not fully understood, maximizing career fit during the transition from fellowship into the first posttraining position has been promoted as a potential method to decrease burnout in this population.^4,5

While most trainees enter gastroenterology fellowships with a set of predefined career goals, mentorship during fellowship can provide critical guidance along with exposure to new areas and career tracks that were not previously considered. In a survey of gastroenterology and transplant hepatology fellows, 94% of participants with a mentor reported that the mentor significantly influenced their career decision.⁶ Effective mentoring also has been identified as one possible method to decrease burnout among trainees.^7,8

Formal mentoring in gastroenterology fellowship programs might decrease burnout through effectively identifying risk factors such as work hour violations or a lack of social support. Additionally, when fellows are being prepared for transition to their first positions as attending gastroenterologists, there is a critical opportunity to improve career fit and decrease burnout rates among early-career gastroenterologists. Making the correct choice of subsequent career path after fellowship might be a source of stress, but this should allow early-career gastroenterologists to maximize the time spent doing those activities they feel are the most rewarding. A formal mentoring system and an accessible career mentor can be invaluable in allowing the mentee to identify and select that position.
 

Career fit

The concept of career fit has been described as the ability of individuals to focus their effort on the aspect or aspects of their work that they find most meaningful.⁵ Multiple specialties have recognized the importance of career fit and the need to choose appropriately when selecting a position and career path upon completing fellowship. In one evaluation of faculty members from the department of medicine at a large academic medical center, those individuals who spent less than 20% of their time working on the activity that they found most meaningful were significantly more likely to demonstrate burnout.⁵

In a relatively short time period, gastroenterology fellows are required to gather multiple new skill sets, including functioning as a consultant, performing endoscopic procedures, and potentially gaining formal training in clinical, basic, or translational research methods. During this same period, an intense phase of self-assessment should begin, with one critical aim of training being to identify those factors most likely to lead to a long, satisfying career. The growth that occurs during fellowship may allow for the identification of a career track that is likely to be the most rewarding, such as a career as a clinical investigator, clinician educator, or in clinical practice. Importantly, the trainee must decide which career track will most likely lead to self-fulfillment, even if the chosen path does not align with a mentor or advisor. Additionally, self-assessment also may aid in the identification of a niche that an individual finds most intellectually stimulating, which may lead to an area of research or clinical expertise.

While the demonstrated relationship between career fit and burnout is only an association without demonstrated causation, this does merit further consideration. For the first time in most trainees’ careers, the position after fellowship represents an opportunity to choose a job as opposed to going through a “match” process. Therefore, the trainee must strongly consider the factors that will ultimately lead to career satisfaction. If a large disconnect is present between self-identified career goals and the actual tasks required within daily workflow, this may lead to burnout relatively early in a career. Perhaps more importantly, if an individual did not perform adequate self-reflection when choosing a career path or did not receive effective guidance from career mentors, this also might lead to decreased career satisfaction, poor career fit, and an increased risk for burnout as an early-career gastroenterologist.
 

The mentor’s role

Although a structured career mentoring program is in place within many gastroenterology training programs, other fellowships encourage the mentee to select from a pool of potential mentors. In many cases, trainees and early career gastroenterologists will benefit from building a mentorship team, including career mentor or mentors, research mentors, and other advisors.⁹

While the mentor-mentee relationship can be an extremely rewarding experience for both parties, the effective mentor must meet a high standard. Several qualities have been identified that will maximize the benefit of the mentor-mentee relationship for the trainee, including the mentor taking a selfless approach to the relationship, working to assist the mentee in choosing a career path that will be the most rewarding, and then aiding the mentee in making helpful connections to promote growth along that chosen path.⁹ A good mentors should inspire a mentees, but also should be willing to provide honest and at times critical feedback to ensure that mentees maximizes their potential and ultimately assume the appropriate career trajectory. Unbiased mentorship, as well as continued reevaluations of strengths, weaknesses, and career goals by the mentor and mentee, will ultimately offer an opportunity to ensure the best combination of career fit,⁵ work-life balance,¹⁰ and satisfaction with career choice.¹¹
 

The mentor-mentee relationship after training is complete

Once a trainee has completed gastroenterology fellowship, another stressful transition to the role of an attending physician commences. It is critical that early-career gastroenterologists not only have confidence in the guidance that their mentor has provided to ensure appropriate career fit in their new role but also maintain these critical mentor-mentee relationships during this transition. A good mentor does not disappear because one phase of training is complete. The need for effective mentoring at the junior faculty level also is well recognized,¹² and early-career gastroenterologists should continue to rely on established mentoring relationships when new decision points are encountered.

Depending on the career track of an early-career gastroenterologist, formal mentoring also may be offered in the new role as a junior faculty member.¹² Additionally, external mentoring can exist within foundations or other subspecialty groups. One example of extramural mentoring is the Career Connection Program offered through the Crohn’s & Colitis Foundation’s Rising Educators Academics and Clinicians Helping IBD (REACH-IBD) platform. In this program, early-career gastroenterologists are selected and paired with national opinion leaders for one-on-one mentoring relationships. Such a program offers further opportunities for career growth, establishing connections within a smaller subspecialty of gastroenterology, and maximizing career fit.
 

Conclusion

In an era where the toll of burnout and other influences on early-career gastroenterologists are increasingly being recognized, the importance of career fit during the transition into the role of an attending should not be underestimated. In conjunction with appropriate self-reflection, unbiased and critical mentorship during fellowship can promote significant growth among trainees and allow for the ultimate selection of a career track or career path that will promote happiness, work-life balance, and long-term success as defined by the mentee.

Edward L. Barnes, MD, MPH, is with the Multidisciplinary Center for Inflammatory Bowel Diseases and the Center for Gastrointestinal Biology and Disease in the division of gastroenterology and hepatology at the University of North Carolina at Chapel Hill. Dr. Barnes reports no relevant disclosures.

References

1. Keswani RN et al. Am J Gastroenterol. 2011;106(10):1734-40.

2. Burke C et al. Am J Gastroenterol. 2017;112:S593-4.

3. DeCross AJ. AGA Perspectives. 2017.

4. Barnes EL et al. Dig Dis Sci. 2019;64(2):302-6.

5. Shanafelt TD et al. Arch Intern Med. 2009;169(10):990-5.

6. Ordway SM et al. Hepatol Commun. 2017;1(4):347-53.

7. Janko MR, Smeds MR. J Vasc Surg. 2019;69(4):1233-42.

8. Eckleberry-Hunt J et al. Acad Med. 2009;84(2):269-77.

9. Lieberman D. Gastroenterology. 2016;151(1):17-9.

10. Shanafelt TD et al. Mayo Clin Proc. 2015;90(12):1600-13.

11. Shanafelt TD et al. Ann Surg. 2009;250(3):463-71.

12. Shaheen NJ, Sandler RS. Gastroenterology. 2018;155(5):1293-7.

Introduction

Burnout in physicians has received significant attention within the past several years, particularly among trainees and early-career physicians. The subspecialties of gastroenterology and hepatology are not immune to burnout, with multiple studies indicating that early career gastroenterologists may be disproportionately affected, compared with their more-established counterparts.^1-4 Although the drivers of depersonalization, emotional exhaustion, and a reduced sense of personal accomplishment among trainees and early-career gastroenterologists are not fully understood, maximizing career fit during the transition from fellowship into the first posttraining position has been promoted as a potential method to decrease burnout in this population.^4,5

While most trainees enter gastroenterology fellowships with a set of predefined career goals, mentorship during fellowship can provide critical guidance along with exposure to new areas and career tracks that were not previously considered. In a survey of gastroenterology and transplant hepatology fellows, 94% of participants with a mentor reported that the mentor significantly influenced their career decision.⁶ Effective mentoring also has been identified as one possible method to decrease burnout among trainees.^7,8

Formal mentoring in gastroenterology fellowship programs might decrease burnout through effectively identifying risk factors such as work hour violations or a lack of social support. Additionally, when fellows are being prepared for transition to their first positions as attending gastroenterologists, there is a critical opportunity to improve career fit and decrease burnout rates among early-career gastroenterologists. Making the correct choice of subsequent career path after fellowship might be a source of stress, but this should allow early-career gastroenterologists to maximize the time spent doing those activities they feel are the most rewarding. A formal mentoring system and an accessible career mentor can be invaluable in allowing the mentee to identify and select that position.
 

Career fit

The concept of career fit has been described as the ability of individuals to focus their effort on the aspect or aspects of their work that they find most meaningful.⁵ Multiple specialties have recognized the importance of career fit and the need to choose appropriately when selecting a position and career path upon completing fellowship. In one evaluation of faculty members from the department of medicine at a large academic medical center, those individuals who spent less than 20% of their time working on the activity that they found most meaningful were significantly more likely to demonstrate burnout.⁵

In a relatively short time period, gastroenterology fellows are required to gather multiple new skill sets, including functioning as a consultant, performing endoscopic procedures, and potentially gaining formal training in clinical, basic, or translational research methods. During this same period, an intense phase of self-assessment should begin, with one critical aim of training being to identify those factors most likely to lead to a long, satisfying career. The growth that occurs during fellowship may allow for the identification of a career track that is likely to be the most rewarding, such as a career as a clinical investigator, clinician educator, or in clinical practice. Importantly, the trainee must decide which career track will most likely lead to self-fulfillment, even if the chosen path does not align with a mentor or advisor. Additionally, self-assessment also may aid in the identification of a niche that an individual finds most intellectually stimulating, which may lead to an area of research or clinical expertise.

While the demonstrated relationship between career fit and burnout is only an association without demonstrated causation, this does merit further consideration. For the first time in most trainees’ careers, the position after fellowship represents an opportunity to choose a job as opposed to going through a “match” process. Therefore, the trainee must strongly consider the factors that will ultimately lead to career satisfaction. If a large disconnect is present between self-identified career goals and the actual tasks required within daily workflow, this may lead to burnout relatively early in a career. Perhaps more importantly, if an individual did not perform adequate self-reflection when choosing a career path or did not receive effective guidance from career mentors, this also might lead to decreased career satisfaction, poor career fit, and an increased risk for burnout as an early-career gastroenterologist.
 

The mentor’s role

Although a structured career mentoring program is in place within many gastroenterology training programs, other fellowships encourage the mentee to select from a pool of potential mentors. In many cases, trainees and early career gastroenterologists will benefit from building a mentorship team, including career mentor or mentors, research mentors, and other advisors.⁹

While the mentor-mentee relationship can be an extremely rewarding experience for both parties, the effective mentor must meet a high standard. Several qualities have been identified that will maximize the benefit of the mentor-mentee relationship for the trainee, including the mentor taking a selfless approach to the relationship, working to assist the mentee in choosing a career path that will be the most rewarding, and then aiding the mentee in making helpful connections to promote growth along that chosen path.⁹ A good mentors should inspire a mentees, but also should be willing to provide honest and at times critical feedback to ensure that mentees maximizes their potential and ultimately assume the appropriate career trajectory. Unbiased mentorship, as well as continued reevaluations of strengths, weaknesses, and career goals by the mentor and mentee, will ultimately offer an opportunity to ensure the best combination of career fit,⁵ work-life balance,¹⁰ and satisfaction with career choice.¹¹
 

The mentor-mentee relationship after training is complete

Once a trainee has completed gastroenterology fellowship, another stressful transition to the role of an attending physician commences. It is critical that early-career gastroenterologists not only have confidence in the guidance that their mentor has provided to ensure appropriate career fit in their new role but also maintain these critical mentor-mentee relationships during this transition. A good mentor does not disappear because one phase of training is complete. The need for effective mentoring at the junior faculty level also is well recognized,¹² and early-career gastroenterologists should continue to rely on established mentoring relationships when new decision points are encountered.

Depending on the career track of an early-career gastroenterologist, formal mentoring also may be offered in the new role as a junior faculty member.¹² Additionally, external mentoring can exist within foundations or other subspecialty groups. One example of extramural mentoring is the Career Connection Program offered through the Crohn’s & Colitis Foundation’s Rising Educators Academics and Clinicians Helping IBD (REACH-IBD) platform. In this program, early-career gastroenterologists are selected and paired with national opinion leaders for one-on-one mentoring relationships. Such a program offers further opportunities for career growth, establishing connections within a smaller subspecialty of gastroenterology, and maximizing career fit.
 

Conclusion

In an era where the toll of burnout and other influences on early-career gastroenterologists are increasingly being recognized, the importance of career fit during the transition into the role of an attending should not be underestimated. In conjunction with appropriate self-reflection, unbiased and critical mentorship during fellowship can promote significant growth among trainees and allow for the ultimate selection of a career track or career path that will promote happiness, work-life balance, and long-term success as defined by the mentee.

Edward L. Barnes, MD, MPH, is with the Multidisciplinary Center for Inflammatory Bowel Diseases and the Center for Gastrointestinal Biology and Disease in the division of gastroenterology and hepatology at the University of North Carolina at Chapel Hill. Dr. Barnes reports no relevant disclosures.

References

1. Keswani RN et al. Am J Gastroenterol. 2011;106(10):1734-40.

2. Burke C et al. Am J Gastroenterol. 2017;112:S593-4.

3. DeCross AJ. AGA Perspectives. 2017.

4. Barnes EL et al. Dig Dis Sci. 2019;64(2):302-6.

5. Shanafelt TD et al. Arch Intern Med. 2009;169(10):990-5.

6. Ordway SM et al. Hepatol Commun. 2017;1(4):347-53.

7. Janko MR, Smeds MR. J Vasc Surg. 2019;69(4):1233-42.

8. Eckleberry-Hunt J et al. Acad Med. 2009;84(2):269-77.

9. Lieberman D. Gastroenterology. 2016;151(1):17-9.

10. Shanafelt TD et al. Mayo Clin Proc. 2015;90(12):1600-13.

11. Shanafelt TD et al. Ann Surg. 2009;250(3):463-71.

12. Shaheen NJ, Sandler RS. Gastroenterology. 2018;155(5):1293-7.

AGA journals select new editorial fellows

Congrats to the six GIs selected for this competitive program.

The AGA journals – Gastroenterology, Clinical Gastroenterology and Hepatology (CGH), and Cellular and Molecular Gastroenterology and Hepatology (CMGH) – are pleased to announce their 2019-2020 editorial fellows.



Gastroenterology
Feng Su, MD
University of Washington, Seattle

Victoria Weis, PhD
Wake Forest University, Winston-Salem, N.C.


CGH
Austin Chiang, MD, MPH
Jefferson Medical College, Philadelphia, Penn.

Jennifer Kolb, MD
University of Colorado at Denver, Aurora



CMGH
Cambrian Liu, PhD
The Saban Research Institute, Children’s Hospital Los Angeles, Calif.

Tirthadipa Pradhan-Sundd, PhD
University of Pittsburgh, Penn.

The editorial fellows will be mentored on their respective journals’ editorial processes, including peer review and the publication process from manuscript submission to acceptance. They will participate in discussions and conferences with the boards of editors and work closely with the AGA editorial staff. Additionally, the fellows will participate in AGA’s new reviewer education program and will also be offered the opportunity to contribute content to their respective journals. The newly expanded program builds on the success of the previous 2 years when Gastroenterology had an editorial fellow.

The journals’ board of editors and editorial staff congratulate the fellows and are excited to work with them over the next year.

Get to know this rock star IBS researcher and mom

AGA Research Foundation pilot awards are an invaluable tool for investigators – they provide seed funding to explore promising new lines of research and generate preliminary data for larger grants. So, when Meenakshi Rao, MD, PhD, received the 2016 AGA–Takeda Pharmaceuticals International Research Scholar Award in Neurogastroenterology, she was able to double down on a project to identify why men and women with irritable bowel syndrome (IBS), the most common but least understood of all digestive disorders, report different symptoms and respond differently to treatment. Based on her recent accomplishments, we’re excited for you to get to know Dr. Rao, assistant professor of pediatrics at Harvard Medical School, Boston, and our AGA Research Foundation researcher of the month.

The Rao lab AGA-funded project focused on building upon Dr. Rao’s previous findings, which showed that disrupting nerves in the bowel had vastly different effects on males and females. These surprising results led Dr. Rao to explore whether sex hormones, such as testosterone and estrogen, might regulate how well things move through the bowel. Dr. Rao believes that identifying the underlying causes for sex differences in bowel function could lead to more effective and personalized treatments for patients with IBS. You can read the specifics of Dr. Rao’s research in the October 2017 issue of Gastroenterology and the October 2018 issue of Journal of Neuroscience.

IBS symptoms in women more typically involve constipation while young men with IBS more commonly report diarrhea. Over time, as men age, however, they tend to experience more constipation, Dr. Rao said. “Sex hormones might be signaling directly to the nerves in our gut and playing a role in these sex differences,” Dr. Rao said. “It might mean we can’t think of this as one disorder. IBS in a male may be different than IBS in a female, and that could change how we approach diagnosis and treatment.”

The AGA grant laid the groundwork for Dr. Rao’s findings, which led to a new understanding of how different types of cells in the gut nervous system regulate bowel functions – and how this regulation is different in males and females. The AGA grant helped Dr. Rao secure funding from the National Institutes of Health to launch new projects focused on how disruption of the gut nervous system causes disease.

Dr. Rao received the AGA award in 2015, when her son, Avinash, was aged 2 years. She acknowledged the delicate balancing act of raising a family and advancing her research.

“A lot of things were happening at once,” she said. “As a young parent, having the support of this award and having a technician (made possible by the award) made a big difference.”

Her son, now 5 years old, is growing up in a science-centric household because Dr. Rao’s husband is also a scientist. Not surprisingly, Dr. Rao says, her son is becoming a budding scientist.

“He talks about experiments all the time,” she says. “He even articulated to me the other day why we work on mice to learn how to help people. I never taught him that. I was floored.”
 

Five new GI technologies to know

The AGA Tech Summit Shark Tank is our annual reminder that the field of GI is ripe for innovation. Continue reading for an overview of the five new technologies pitched to our panel of sharks.

The smart toilet seat. A toilet seat developed by Toi Labs, called TrueLoo, is equipped with lighting and cameras that capture images of bowel movements and urination for subsequent analysis. The company describes TrueLoo as a low-cost disease-screening tool that has major potential for early detection of conditions ranging from dehydration to gastrointestinal cancer.

AI to aid screening endoscopy. A new tool called Ultivision, being developed by the startup Docbot, was described as a strategy to employ artificial intelligence (AI) to aid endoscopists in screening for dysplasia in either screening colonoscopy or in surveillance of Barrett’s esophagus. The tool integrates with existing endoscopic tools. As tissue is visualized, the AI is programmed to highlight suspected dysplasia with a colored box to alert the endoscopist.

Obesity phenotyping tool. The Pheno Test, developed by Phenomix Sciences, applies “multi-omics” to a blood-based test to separate patients with obesity into four phenotypes: hungry brain (satiation signal is impaired), hungry gut (signals to eat are upregulated), emotional hunger (psychological reasons drive eating behavior), and slow metabolism (failure to burn fat at normal rates). With this knowledge, treatment can be tailored appropriately leading to better outcomes.

Capsule diagnostic tool. The Atmo Gas Capsule from Atmo Biosciences is an ingestible capsule that measures gases at the source, which can accelerate the diagnosis of diseases such as IBS and inflammatory bowel disease (IBD). According to the company, this technique is highly accurate and offers an alternative to more invasive and expensive diagnostic tools.

Winner: “all-in-one” IBD app. Our Shark Tank winner by both popular vote from AGA Tech Summit attendees and the six-member Shark Tank panel was Oshi Health, selected for its IBD app. The app allows patients to track symptoms, a first step in understanding personalized flare pattern, as well as find resources to learn about their disease and communicate with other patients about their experiences. In a future iteration, information gathered by the app will be made available to physicians to provide current information about disease status to better individualize therapy.
 

2020 Crohn’s & Colitis Congress now open for registration

Join the Crohn’s & Colitis Foundation and AGA next January in Austin, Tex., for the premier conference on IBD.

The Crohn’s & Colitis Congress combines the strengths of the nation’s leading IBD patient organization, the Crohn’s & Colitis Foundation, and the premier GI professional organization, AGA, to bring together IBD professionals, across all disciplines, to transform IBD care.

The 2020 Congress Committee Chair David T. Rubin, MD, AGAF, University of Chicago, and Cochair Uma Mahadevan, MD, AGAF, University of California, San Francisco, lead a faculty that includes thought leaders in the fields of GI, research investigation, surgery, pediatrics, advanced practice, IBD nursing, diet and nutrition, mental health, radiology, and pathology.

The congress’s agenda includes main sessions that will emphasize case studies and panel discussions. There will also be parallel sessions on basic and translational science for senior and junior investigators. In addition, opening breakout sessions, taking place Jan. 23, will be available for selection free of charge.

Attendees of the 2020 congress will be able to meet with IBD leaders, discover different perspectives, leave with practical information they can immediately implement to take care of their next IBD patient and hear what’s on the horizon in potential treatment.

There will also be plenty of social events and plenty of time to build a strong network, including a Friday night Welcome Reception that should not be missed.

In addition, the 2020 congress is taking place in Austin, Tex. The capital of Texas and the Live Music Capital of the World, Austin is famous for its inspiring and enticing entertainment, culture, cuisine, and outdoor settings. Make a week of it and enjoy all Austin has to offer.

Early-bird registration ends Sept. 18. General abstract submissions for basic, translational, and clinical research begin Aug. 28 and end Oct. 23. To learn more and register, visit www.crohnscolitiscongress.org.
 

AGA welcomes new president, Hashem B. El-Serag, MD, MPH, AGAF

Hashem B. El-Serag, MD, MPH, AGAF, began his term as the 114th president of the AGA Institute at Digestive Disease Week® (DDW 2019).

Dr. El-Serag is former editor in chief of Clinical Gastroenterology and Hepatology. He currently serves as chair of the department of medicine at Baylor College of Medicine, Houston, following a decade leading and expanding Baylor’s gastroenterology and hepatology section. He is one of the few academic gastroenterologists serving as a chair of a department of medicine in the United States.

Originally Palestinian, Dr. El-Serag became a U.S. citizen in the early 2000s after medical school in Libya. He completed his training at community hospitals in the United States. His path from Benghazi to Baylor is described in the May issue of Gastroenterology by Baylor colleague Dr. Fasiha Kanwal.

“I firmly believe that the success I achieved in the United States would not have been possible anywhere else in the world, and it is as much a testament to the accepting society and medical system as to whatever intrinsic ability or skill I have,” noted Dr. El-Serag.

The major focus of Dr. El-Serag’s scholarly work is the epidemiology and clinical outcomes of hepatocellular carcinoma. Much of the modern literature on this topic includes his more than 100 publications. Since 2014, Dr. El-Serag has been named by Thomson Reuter as among the top 1% of clinical scientists.

Dr. El-Serag “is an innovative scientist, a compassionate physician, and a gifted educator. He is a relentless advocate of science and training, with an astute political sense — all key to influencing and shaping policy,” said Dr. Kanwal.

Dr. El-Serag’s term as AGA president concludes May 2020. Follow him on twitter at @SeragHashem.

AGA journals select new editorial fellows

Congrats to the six GIs selected for this competitive program.

The AGA journals – Gastroenterology, Clinical Gastroenterology and Hepatology (CGH), and Cellular and Molecular Gastroenterology and Hepatology (CMGH) – are pleased to announce their 2019-2020 editorial fellows.



Gastroenterology
Feng Su, MD
University of Washington, Seattle

Victoria Weis, PhD
Wake Forest University, Winston-Salem, N.C.


CGH
Austin Chiang, MD, MPH
Jefferson Medical College, Philadelphia, Penn.

Jennifer Kolb, MD
University of Colorado at Denver, Aurora



CMGH
Cambrian Liu, PhD
The Saban Research Institute, Children’s Hospital Los Angeles, Calif.

Tirthadipa Pradhan-Sundd, PhD
University of Pittsburgh, Penn.

The editorial fellows will be mentored on their respective journals’ editorial processes, including peer review and the publication process from manuscript submission to acceptance. They will participate in discussions and conferences with the boards of editors and work closely with the AGA editorial staff. Additionally, the fellows will participate in AGA’s new reviewer education program and will also be offered the opportunity to contribute content to their respective journals. The newly expanded program builds on the success of the previous 2 years when Gastroenterology had an editorial fellow.

The journals’ board of editors and editorial staff congratulate the fellows and are excited to work with them over the next year.

Get to know this rock star IBS researcher and mom

AGA Research Foundation pilot awards are an invaluable tool for investigators – they provide seed funding to explore promising new lines of research and generate preliminary data for larger grants. So, when Meenakshi Rao, MD, PhD, received the 2016 AGA–Takeda Pharmaceuticals International Research Scholar Award in Neurogastroenterology, she was able to double down on a project to identify why men and women with irritable bowel syndrome (IBS), the most common but least understood of all digestive disorders, report different symptoms and respond differently to treatment. Based on her recent accomplishments, we’re excited for you to get to know Dr. Rao, assistant professor of pediatrics at Harvard Medical School, Boston, and our AGA Research Foundation researcher of the month.

The Rao lab AGA-funded project focused on building upon Dr. Rao’s previous findings, which showed that disrupting nerves in the bowel had vastly different effects on males and females. These surprising results led Dr. Rao to explore whether sex hormones, such as testosterone and estrogen, might regulate how well things move through the bowel. Dr. Rao believes that identifying the underlying causes for sex differences in bowel function could lead to more effective and personalized treatments for patients with IBS. You can read the specifics of Dr. Rao’s research in the October 2017 issue of Gastroenterology and the October 2018 issue of Journal of Neuroscience.

IBS symptoms in women more typically involve constipation while young men with IBS more commonly report diarrhea. Over time, as men age, however, they tend to experience more constipation, Dr. Rao said. “Sex hormones might be signaling directly to the nerves in our gut and playing a role in these sex differences,” Dr. Rao said. “It might mean we can’t think of this as one disorder. IBS in a male may be different than IBS in a female, and that could change how we approach diagnosis and treatment.”

The AGA grant laid the groundwork for Dr. Rao’s findings, which led to a new understanding of how different types of cells in the gut nervous system regulate bowel functions – and how this regulation is different in males and females. The AGA grant helped Dr. Rao secure funding from the National Institutes of Health to launch new projects focused on how disruption of the gut nervous system causes disease.

Dr. Rao received the AGA award in 2015, when her son, Avinash, was aged 2 years. She acknowledged the delicate balancing act of raising a family and advancing her research.

“A lot of things were happening at once,” she said. “As a young parent, having the support of this award and having a technician (made possible by the award) made a big difference.”

Her son, now 5 years old, is growing up in a science-centric household because Dr. Rao’s husband is also a scientist. Not surprisingly, Dr. Rao says, her son is becoming a budding scientist.

“He talks about experiments all the time,” she says. “He even articulated to me the other day why we work on mice to learn how to help people. I never taught him that. I was floored.”
 

Five new GI technologies to know

The AGA Tech Summit Shark Tank is our annual reminder that the field of GI is ripe for innovation. Continue reading for an overview of the five new technologies pitched to our panel of sharks.

The smart toilet seat. A toilet seat developed by Toi Labs, called TrueLoo, is equipped with lighting and cameras that capture images of bowel movements and urination for subsequent analysis. The company describes TrueLoo as a low-cost disease-screening tool that has major potential for early detection of conditions ranging from dehydration to gastrointestinal cancer.

AI to aid screening endoscopy. A new tool called Ultivision, being developed by the startup Docbot, was described as a strategy to employ artificial intelligence (AI) to aid endoscopists in screening for dysplasia in either screening colonoscopy or in surveillance of Barrett’s esophagus. The tool integrates with existing endoscopic tools. As tissue is visualized, the AI is programmed to highlight suspected dysplasia with a colored box to alert the endoscopist.

Obesity phenotyping tool. The Pheno Test, developed by Phenomix Sciences, applies “multi-omics” to a blood-based test to separate patients with obesity into four phenotypes: hungry brain (satiation signal is impaired), hungry gut (signals to eat are upregulated), emotional hunger (psychological reasons drive eating behavior), and slow metabolism (failure to burn fat at normal rates). With this knowledge, treatment can be tailored appropriately leading to better outcomes.

Capsule diagnostic tool. The Atmo Gas Capsule from Atmo Biosciences is an ingestible capsule that measures gases at the source, which can accelerate the diagnosis of diseases such as IBS and inflammatory bowel disease (IBD). According to the company, this technique is highly accurate and offers an alternative to more invasive and expensive diagnostic tools.

Winner: “all-in-one” IBD app. Our Shark Tank winner by both popular vote from AGA Tech Summit attendees and the six-member Shark Tank panel was Oshi Health, selected for its IBD app. The app allows patients to track symptoms, a first step in understanding personalized flare pattern, as well as find resources to learn about their disease and communicate with other patients about their experiences. In a future iteration, information gathered by the app will be made available to physicians to provide current information about disease status to better individualize therapy.
 

2020 Crohn’s & Colitis Congress now open for registration

Join the Crohn’s & Colitis Foundation and AGA next January in Austin, Tex., for the premier conference on IBD.

The Crohn’s & Colitis Congress combines the strengths of the nation’s leading IBD patient organization, the Crohn’s & Colitis Foundation, and the premier GI professional organization, AGA, to bring together IBD professionals, across all disciplines, to transform IBD care.

The 2020 Congress Committee Chair David T. Rubin, MD, AGAF, University of Chicago, and Cochair Uma Mahadevan, MD, AGAF, University of California, San Francisco, lead a faculty that includes thought leaders in the fields of GI, research investigation, surgery, pediatrics, advanced practice, IBD nursing, diet and nutrition, mental health, radiology, and pathology.

The congress’s agenda includes main sessions that will emphasize case studies and panel discussions. There will also be parallel sessions on basic and translational science for senior and junior investigators. In addition, opening breakout sessions, taking place Jan. 23, will be available for selection free of charge.

Attendees of the 2020 congress will be able to meet with IBD leaders, discover different perspectives, leave with practical information they can immediately implement to take care of their next IBD patient and hear what’s on the horizon in potential treatment.

There will also be plenty of social events and plenty of time to build a strong network, including a Friday night Welcome Reception that should not be missed.

In addition, the 2020 congress is taking place in Austin, Tex. The capital of Texas and the Live Music Capital of the World, Austin is famous for its inspiring and enticing entertainment, culture, cuisine, and outdoor settings. Make a week of it and enjoy all Austin has to offer.

Early-bird registration ends Sept. 18. General abstract submissions for basic, translational, and clinical research begin Aug. 28 and end Oct. 23. To learn more and register, visit www.crohnscolitiscongress.org.
 

AGA welcomes new president, Hashem B. El-Serag, MD, MPH, AGAF

Hashem B. El-Serag, MD, MPH, AGAF, began his term as the 114th president of the AGA Institute at Digestive Disease Week® (DDW 2019).

Dr. El-Serag is former editor in chief of Clinical Gastroenterology and Hepatology. He currently serves as chair of the department of medicine at Baylor College of Medicine, Houston, following a decade leading and expanding Baylor’s gastroenterology and hepatology section. He is one of the few academic gastroenterologists serving as a chair of a department of medicine in the United States.

Originally Palestinian, Dr. El-Serag became a U.S. citizen in the early 2000s after medical school in Libya. He completed his training at community hospitals in the United States. His path from Benghazi to Baylor is described in the May issue of Gastroenterology by Baylor colleague Dr. Fasiha Kanwal.

“I firmly believe that the success I achieved in the United States would not have been possible anywhere else in the world, and it is as much a testament to the accepting society and medical system as to whatever intrinsic ability or skill I have,” noted Dr. El-Serag.

The major focus of Dr. El-Serag’s scholarly work is the epidemiology and clinical outcomes of hepatocellular carcinoma. Much of the modern literature on this topic includes his more than 100 publications. Since 2014, Dr. El-Serag has been named by Thomson Reuter as among the top 1% of clinical scientists.

Dr. El-Serag “is an innovative scientist, a compassionate physician, and a gifted educator. He is a relentless advocate of science and training, with an astute political sense — all key to influencing and shaping policy,” said Dr. Kanwal.

Dr. El-Serag’s term as AGA president concludes May 2020. Follow him on twitter at @SeragHashem.

AGA journals select new editorial fellows

Congrats to the six GIs selected for this competitive program.

The AGA journals – Gastroenterology, Clinical Gastroenterology and Hepatology (CGH), and Cellular and Molecular Gastroenterology and Hepatology (CMGH) – are pleased to announce their 2019-2020 editorial fellows.



Gastroenterology
Feng Su, MD
University of Washington, Seattle

Victoria Weis, PhD
Wake Forest University, Winston-Salem, N.C.


CGH
Austin Chiang, MD, MPH
Jefferson Medical College, Philadelphia, Penn.

Jennifer Kolb, MD
University of Colorado at Denver, Aurora



CMGH
Cambrian Liu, PhD
The Saban Research Institute, Children’s Hospital Los Angeles, Calif.

Tirthadipa Pradhan-Sundd, PhD
University of Pittsburgh, Penn.

The editorial fellows will be mentored on their respective journals’ editorial processes, including peer review and the publication process from manuscript submission to acceptance. They will participate in discussions and conferences with the boards of editors and work closely with the AGA editorial staff. Additionally, the fellows will participate in AGA’s new reviewer education program and will also be offered the opportunity to contribute content to their respective journals. The newly expanded program builds on the success of the previous 2 years when Gastroenterology had an editorial fellow.

The journals’ board of editors and editorial staff congratulate the fellows and are excited to work with them over the next year.

Get to know this rock star IBS researcher and mom

AGA Research Foundation pilot awards are an invaluable tool for investigators – they provide seed funding to explore promising new lines of research and generate preliminary data for larger grants. So, when Meenakshi Rao, MD, PhD, received the 2016 AGA–Takeda Pharmaceuticals International Research Scholar Award in Neurogastroenterology, she was able to double down on a project to identify why men and women with irritable bowel syndrome (IBS), the most common but least understood of all digestive disorders, report different symptoms and respond differently to treatment. Based on her recent accomplishments, we’re excited for you to get to know Dr. Rao, assistant professor of pediatrics at Harvard Medical School, Boston, and our AGA Research Foundation researcher of the month.

The Rao lab AGA-funded project focused on building upon Dr. Rao’s previous findings, which showed that disrupting nerves in the bowel had vastly different effects on males and females. These surprising results led Dr. Rao to explore whether sex hormones, such as testosterone and estrogen, might regulate how well things move through the bowel. Dr. Rao believes that identifying the underlying causes for sex differences in bowel function could lead to more effective and personalized treatments for patients with IBS. You can read the specifics of Dr. Rao’s research in the October 2017 issue of Gastroenterology and the October 2018 issue of Journal of Neuroscience.

IBS symptoms in women more typically involve constipation while young men with IBS more commonly report diarrhea. Over time, as men age, however, they tend to experience more constipation, Dr. Rao said. “Sex hormones might be signaling directly to the nerves in our gut and playing a role in these sex differences,” Dr. Rao said. “It might mean we can’t think of this as one disorder. IBS in a male may be different than IBS in a female, and that could change how we approach diagnosis and treatment.”

The AGA grant laid the groundwork for Dr. Rao’s findings, which led to a new understanding of how different types of cells in the gut nervous system regulate bowel functions – and how this regulation is different in males and females. The AGA grant helped Dr. Rao secure funding from the National Institutes of Health to launch new projects focused on how disruption of the gut nervous system causes disease.

Dr. Rao received the AGA award in 2015, when her son, Avinash, was aged 2 years. She acknowledged the delicate balancing act of raising a family and advancing her research.

“A lot of things were happening at once,” she said. “As a young parent, having the support of this award and having a technician (made possible by the award) made a big difference.”

Her son, now 5 years old, is growing up in a science-centric household because Dr. Rao’s husband is also a scientist. Not surprisingly, Dr. Rao says, her son is becoming a budding scientist.

“He talks about experiments all the time,” she says. “He even articulated to me the other day why we work on mice to learn how to help people. I never taught him that. I was floored.”
 

Five new GI technologies to know

The AGA Tech Summit Shark Tank is our annual reminder that the field of GI is ripe for innovation. Continue reading for an overview of the five new technologies pitched to our panel of sharks.

The smart toilet seat. A toilet seat developed by Toi Labs, called TrueLoo, is equipped with lighting and cameras that capture images of bowel movements and urination for subsequent analysis. The company describes TrueLoo as a low-cost disease-screening tool that has major potential for early detection of conditions ranging from dehydration to gastrointestinal cancer.

AI to aid screening endoscopy. A new tool called Ultivision, being developed by the startup Docbot, was described as a strategy to employ artificial intelligence (AI) to aid endoscopists in screening for dysplasia in either screening colonoscopy or in surveillance of Barrett’s esophagus. The tool integrates with existing endoscopic tools. As tissue is visualized, the AI is programmed to highlight suspected dysplasia with a colored box to alert the endoscopist.

Obesity phenotyping tool. The Pheno Test, developed by Phenomix Sciences, applies “multi-omics” to a blood-based test to separate patients with obesity into four phenotypes: hungry brain (satiation signal is impaired), hungry gut (signals to eat are upregulated), emotional hunger (psychological reasons drive eating behavior), and slow metabolism (failure to burn fat at normal rates). With this knowledge, treatment can be tailored appropriately leading to better outcomes.

Capsule diagnostic tool. The Atmo Gas Capsule from Atmo Biosciences is an ingestible capsule that measures gases at the source, which can accelerate the diagnosis of diseases such as IBS and inflammatory bowel disease (IBD). According to the company, this technique is highly accurate and offers an alternative to more invasive and expensive diagnostic tools.

Winner: “all-in-one” IBD app. Our Shark Tank winner by both popular vote from AGA Tech Summit attendees and the six-member Shark Tank panel was Oshi Health, selected for its IBD app. The app allows patients to track symptoms, a first step in understanding personalized flare pattern, as well as find resources to learn about their disease and communicate with other patients about their experiences. In a future iteration, information gathered by the app will be made available to physicians to provide current information about disease status to better individualize therapy.
 

2020 Crohn’s & Colitis Congress now open for registration

Join the Crohn’s & Colitis Foundation and AGA next January in Austin, Tex., for the premier conference on IBD.

The Crohn’s & Colitis Congress combines the strengths of the nation’s leading IBD patient organization, the Crohn’s & Colitis Foundation, and the premier GI professional organization, AGA, to bring together IBD professionals, across all disciplines, to transform IBD care.

The 2020 Congress Committee Chair David T. Rubin, MD, AGAF, University of Chicago, and Cochair Uma Mahadevan, MD, AGAF, University of California, San Francisco, lead a faculty that includes thought leaders in the fields of GI, research investigation, surgery, pediatrics, advanced practice, IBD nursing, diet and nutrition, mental health, radiology, and pathology.

The congress’s agenda includes main sessions that will emphasize case studies and panel discussions. There will also be parallel sessions on basic and translational science for senior and junior investigators. In addition, opening breakout sessions, taking place Jan. 23, will be available for selection free of charge.

Attendees of the 2020 congress will be able to meet with IBD leaders, discover different perspectives, leave with practical information they can immediately implement to take care of their next IBD patient and hear what’s on the horizon in potential treatment.

There will also be plenty of social events and plenty of time to build a strong network, including a Friday night Welcome Reception that should not be missed.

In addition, the 2020 congress is taking place in Austin, Tex. The capital of Texas and the Live Music Capital of the World, Austin is famous for its inspiring and enticing entertainment, culture, cuisine, and outdoor settings. Make a week of it and enjoy all Austin has to offer.

Early-bird registration ends Sept. 18. General abstract submissions for basic, translational, and clinical research begin Aug. 28 and end Oct. 23. To learn more and register, visit www.crohnscolitiscongress.org.
 

AGA welcomes new president, Hashem B. El-Serag, MD, MPH, AGAF

Hashem B. El-Serag, MD, MPH, AGAF, began his term as the 114th president of the AGA Institute at Digestive Disease Week® (DDW 2019).

Dr. El-Serag is former editor in chief of Clinical Gastroenterology and Hepatology. He currently serves as chair of the department of medicine at Baylor College of Medicine, Houston, following a decade leading and expanding Baylor’s gastroenterology and hepatology section. He is one of the few academic gastroenterologists serving as a chair of a department of medicine in the United States.

Originally Palestinian, Dr. El-Serag became a U.S. citizen in the early 2000s after medical school in Libya. He completed his training at community hospitals in the United States. His path from Benghazi to Baylor is described in the May issue of Gastroenterology by Baylor colleague Dr. Fasiha Kanwal.

“I firmly believe that the success I achieved in the United States would not have been possible anywhere else in the world, and it is as much a testament to the accepting society and medical system as to whatever intrinsic ability or skill I have,” noted Dr. El-Serag.

The major focus of Dr. El-Serag’s scholarly work is the epidemiology and clinical outcomes of hepatocellular carcinoma. Much of the modern literature on this topic includes his more than 100 publications. Since 2014, Dr. El-Serag has been named by Thomson Reuter as among the top 1% of clinical scientists.

Dr. El-Serag “is an innovative scientist, a compassionate physician, and a gifted educator. He is a relentless advocate of science and training, with an astute political sense — all key to influencing and shaping policy,” said Dr. Kanwal.

Dr. El-Serag’s term as AGA president concludes May 2020. Follow him on twitter at @SeragHashem.

For more information about upcoming events and award deadlines, please visit http://agau.gastro.org and http://www.gastro.org/research-funding.

UPCOMING EVENTS

Aug. 9-10, 2019
2019 Freston Conference: Food at the Intersection of Gut Health and Disease
GI clinicians and allied health professionals are increasingly focused on how nutrients influence GI physiology and how diet can promote sound gut health. In response to this growing body of knowledge, the 2019 James W. Freston Conference — Food at the Intersection of Gut Health and Disease, Aug. 9-10, 2019, in Chicago — will examine how nutrition management therapies can combat GI disorders such as irritable bowel syndrome (IBS), inflammatory bowel disease (IBD), and celiac disease and how diet supports improvement across the care continuum.
Chicago, Illinois

Aug. 9–11, 2019
2019 Principles of GI for the NP and PA
The Principles of Gastroenterology for the Nurse Practitioner and Physician Assistant (NPPA) is the medical industry’s premiere course guiding and enabling nurse practitioners and physician assistants with the intricacies of identifying, treating, and managing GI disorders. Designed and taught by expert clinicians and advanced practice providers, NPPA provides the latest insights, knowledge, and research on how to improve GI patient care. Attendees will leave with stronger diagnostic and therapeutic skills, a more robust professional network, and an enhanced value for their practices.
Chicago, Illinois

Sept. 18-19, 2019; Oct. 9-10. 2019
Two-Day, In-Depth Coding Seminar by McVey Associates, Inc.
Become a certified GI coder with a two-day, in-depth training course provided by McVey Associates, Inc.
Atlanta, GA (9/18-19); Las Vegas, NV (10/9-10)

Oct. 4, 2019
2019 AGA Partners in Value
Join GI trailblazers and leaders from AGA and DHPA to network and discuss strategies that will help your practice succeed in the changing business of health care. Leave equipped to make better decisions for the future.
Chicago, Illinois

May 2-5, 2020
Digestive Disease Week® (DDW)
Digestive Disease Week® (DDW) is the world’s leading educational forum for academicians, clinicians, researchers, students, and trainees working in gastroenterology, hepatology, GI endoscopy, gastrointestinal surgery, and related fields. Whether you work in patient care, research, education, or administration, the DDW program offers something for you. Abstract submissions will be due on Dec. 1, and registration will open in January 2020.
Chicago, Illinois

AWARDS APPLICATION DEADLINES

AGA-Elsevier Pilot Research Award
This award provides $30,000 for 1 year to a recipient at any career stage performing research in gastroenterology- or hepatology-related areas.
Application Deadline: Sept. 4, 2019

AGA-Allergan Foundation Pilot Research Award in Inflammatory Bowel Disease
This award provides $30,000 for 1 year to an investigator at any career stage researching the pathophysiology and/or treatment of inflammatory bowel disease (IBD).
Application Deadline: Sept. 4, 2019

AGA-Allergan Foundation Pilot Research Award in Nonalcoholic Fatty Liver Disease
This award provides $30,000 for 1 year to an investigator at any career stage researching the pathophysiology and/or treatment of nonalcoholic fatty liver disease (NAFLD).
Application Deadline: Sept. 4, 2019

AGA-Pfizer Pilot Research Award in Inflammatory Bowel Disease
This award provides $30,000 for 1 year to recipients at any career stage researching new directions focused on improving the diagnosis and treatment of inflammatory bowel disease.
Application Deadline: Sept. 4, 2019

AGA-Rome Foundation Functional GI and Motility Disorders Pilot Research Award
This award provides $30,000 for 1 year to a recipient at any career stage performing clinical or translational research pertaining to functional GI and motility disorders.
Application Deadline: Sept. 4, 2019

AGA Research Scholar Award (RSA)
This award provides $100,000 per year for 3 years (total $300,000) to early career faculty (i.e., investigator, instructor, research associate or equivalent) working toward an independent career in digestive disease research.
Application Deadline: Nov. 13, 2019

AGA-Gastric Cancer Foundation Ben Feinstein Memorial Research Scholar Award in Gastric Cancer
This award provides $100,000 per year for 3 years (total $300,000) to early career faculty (i.e., investigator, instructor, research associate or equivalent) working toward an independent career in gastric cancer research. Research involving precancerous lesions will be considered if relevance to gastric cancer is explicitly outlined.
Application Deadline: Nov. 13, 2019

AGA-Takeda Pharmaceuticals Research Scholar Award in Inflammatory Bowel Disease
This award provides $100,000 per year for 3 years (total $300,000) to a young investigator, instructor, research associate or equivalent working toward an independent career in inflammatory bowel disease research.
Application Deadline: Nov. 13, 2019
 

AGA Fellow Abstract Award
This $500 travel award supports recipients who are MD, PhD or equivalent fellows giving abstract-based oral or poster presentations at Digestive Disease Week® (DDW). The top-scoring abstract will be designated the Fellow Abstract of the Year and receive a $1,000 award.
Application Deadline: Feb. 26, 2020

AGA Student Abstract Award
This $500 travel award supports recipients who are graduate students, medical students, or medical residents (residents up to postgraduate year three) giving abstract-based oral or poster presentations at Digestive Disease Week® (DDW).
Application Deadline: Feb. 26, 2020

AGA-Moti L. & Kamla Rustgi International Travel Awards
This $750 travel award supports recipients who are young (i.e., 35 years of age or younger at the time of DDW) basic, translational, or clinical investigators residing outside North America to support travel and related expenses to attend Digestive Disease Week® (DDW).
Application Deadline: Feb. 26, 2020

For more information about upcoming events and award deadlines, please visit http://agau.gastro.org and http://www.gastro.org/research-funding.

UPCOMING EVENTS

Aug. 9-10, 2019
2019 Freston Conference: Food at the Intersection of Gut Health and Disease
GI clinicians and allied health professionals are increasingly focused on how nutrients influence GI physiology and how diet can promote sound gut health. In response to this growing body of knowledge, the 2019 James W. Freston Conference — Food at the Intersection of Gut Health and Disease, Aug. 9-10, 2019, in Chicago — will examine how nutrition management therapies can combat GI disorders such as irritable bowel syndrome (IBS), inflammatory bowel disease (IBD), and celiac disease and how diet supports improvement across the care continuum.
Chicago, Illinois

Aug. 9–11, 2019
2019 Principles of GI for the NP and PA
The Principles of Gastroenterology for the Nurse Practitioner and Physician Assistant (NPPA) is the medical industry’s premiere course guiding and enabling nurse practitioners and physician assistants with the intricacies of identifying, treating, and managing GI disorders. Designed and taught by expert clinicians and advanced practice providers, NPPA provides the latest insights, knowledge, and research on how to improve GI patient care. Attendees will leave with stronger diagnostic and therapeutic skills, a more robust professional network, and an enhanced value for their practices.
Chicago, Illinois

Sept. 18-19, 2019; Oct. 9-10. 2019
Two-Day, In-Depth Coding Seminar by McVey Associates, Inc.
Become a certified GI coder with a two-day, in-depth training course provided by McVey Associates, Inc.
Atlanta, GA (9/18-19); Las Vegas, NV (10/9-10)

Oct. 4, 2019
2019 AGA Partners in Value
Join GI trailblazers and leaders from AGA and DHPA to network and discuss strategies that will help your practice succeed in the changing business of health care. Leave equipped to make better decisions for the future.
Chicago, Illinois

May 2-5, 2020
Digestive Disease Week® (DDW)
Digestive Disease Week® (DDW) is the world’s leading educational forum for academicians, clinicians, researchers, students, and trainees working in gastroenterology, hepatology, GI endoscopy, gastrointestinal surgery, and related fields. Whether you work in patient care, research, education, or administration, the DDW program offers something for you. Abstract submissions will be due on Dec. 1, and registration will open in January 2020.
Chicago, Illinois

AWARDS APPLICATION DEADLINES

AGA-Elsevier Pilot Research Award
This award provides $30,000 for 1 year to a recipient at any career stage performing research in gastroenterology- or hepatology-related areas.
Application Deadline: Sept. 4, 2019

AGA-Allergan Foundation Pilot Research Award in Inflammatory Bowel Disease
This award provides $30,000 for 1 year to an investigator at any career stage researching the pathophysiology and/or treatment of inflammatory bowel disease (IBD).
Application Deadline: Sept. 4, 2019

AGA-Allergan Foundation Pilot Research Award in Nonalcoholic Fatty Liver Disease
This award provides $30,000 for 1 year to an investigator at any career stage researching the pathophysiology and/or treatment of nonalcoholic fatty liver disease (NAFLD).
Application Deadline: Sept. 4, 2019

AGA-Pfizer Pilot Research Award in Inflammatory Bowel Disease
This award provides $30,000 for 1 year to recipients at any career stage researching new directions focused on improving the diagnosis and treatment of inflammatory bowel disease.
Application Deadline: Sept. 4, 2019

AGA-Rome Foundation Functional GI and Motility Disorders Pilot Research Award
This award provides $30,000 for 1 year to a recipient at any career stage performing clinical or translational research pertaining to functional GI and motility disorders.
Application Deadline: Sept. 4, 2019

AGA Research Scholar Award (RSA)
This award provides $100,000 per year for 3 years (total $300,000) to early career faculty (i.e., investigator, instructor, research associate or equivalent) working toward an independent career in digestive disease research.
Application Deadline: Nov. 13, 2019

AGA-Gastric Cancer Foundation Ben Feinstein Memorial Research Scholar Award in Gastric Cancer
This award provides $100,000 per year for 3 years (total $300,000) to early career faculty (i.e., investigator, instructor, research associate or equivalent) working toward an independent career in gastric cancer research. Research involving precancerous lesions will be considered if relevance to gastric cancer is explicitly outlined.
Application Deadline: Nov. 13, 2019

AGA-Takeda Pharmaceuticals Research Scholar Award in Inflammatory Bowel Disease
This award provides $100,000 per year for 3 years (total $300,000) to a young investigator, instructor, research associate or equivalent working toward an independent career in inflammatory bowel disease research.
Application Deadline: Nov. 13, 2019
 

AGA Fellow Abstract Award
This $500 travel award supports recipients who are MD, PhD or equivalent fellows giving abstract-based oral or poster presentations at Digestive Disease Week® (DDW). The top-scoring abstract will be designated the Fellow Abstract of the Year and receive a $1,000 award.
Application Deadline: Feb. 26, 2020

AGA Student Abstract Award
This $500 travel award supports recipients who are graduate students, medical students, or medical residents (residents up to postgraduate year three) giving abstract-based oral or poster presentations at Digestive Disease Week® (DDW).
Application Deadline: Feb. 26, 2020

AGA-Moti L. & Kamla Rustgi International Travel Awards
This $750 travel award supports recipients who are young (i.e., 35 years of age or younger at the time of DDW) basic, translational, or clinical investigators residing outside North America to support travel and related expenses to attend Digestive Disease Week® (DDW).
Application Deadline: Feb. 26, 2020

For more information about upcoming events and award deadlines, please visit http://agau.gastro.org and http://www.gastro.org/research-funding.

UPCOMING EVENTS

Aug. 9-10, 2019
2019 Freston Conference: Food at the Intersection of Gut Health and Disease
GI clinicians and allied health professionals are increasingly focused on how nutrients influence GI physiology and how diet can promote sound gut health. In response to this growing body of knowledge, the 2019 James W. Freston Conference — Food at the Intersection of Gut Health and Disease, Aug. 9-10, 2019, in Chicago — will examine how nutrition management therapies can combat GI disorders such as irritable bowel syndrome (IBS), inflammatory bowel disease (IBD), and celiac disease and how diet supports improvement across the care continuum.
Chicago, Illinois

Aug. 9–11, 2019
2019 Principles of GI for the NP and PA
The Principles of Gastroenterology for the Nurse Practitioner and Physician Assistant (NPPA) is the medical industry’s premiere course guiding and enabling nurse practitioners and physician assistants with the intricacies of identifying, treating, and managing GI disorders. Designed and taught by expert clinicians and advanced practice providers, NPPA provides the latest insights, knowledge, and research on how to improve GI patient care. Attendees will leave with stronger diagnostic and therapeutic skills, a more robust professional network, and an enhanced value for their practices.
Chicago, Illinois

Sept. 18-19, 2019; Oct. 9-10. 2019
Two-Day, In-Depth Coding Seminar by McVey Associates, Inc.
Become a certified GI coder with a two-day, in-depth training course provided by McVey Associates, Inc.
Atlanta, GA (9/18-19); Las Vegas, NV (10/9-10)

Oct. 4, 2019
2019 AGA Partners in Value
Join GI trailblazers and leaders from AGA and DHPA to network and discuss strategies that will help your practice succeed in the changing business of health care. Leave equipped to make better decisions for the future.
Chicago, Illinois

May 2-5, 2020
Digestive Disease Week® (DDW)
Digestive Disease Week® (DDW) is the world’s leading educational forum for academicians, clinicians, researchers, students, and trainees working in gastroenterology, hepatology, GI endoscopy, gastrointestinal surgery, and related fields. Whether you work in patient care, research, education, or administration, the DDW program offers something for you. Abstract submissions will be due on Dec. 1, and registration will open in January 2020.
Chicago, Illinois

AWARDS APPLICATION DEADLINES

AGA-Elsevier Pilot Research Award
This award provides $30,000 for 1 year to a recipient at any career stage performing research in gastroenterology- or hepatology-related areas.
Application Deadline: Sept. 4, 2019

AGA-Allergan Foundation Pilot Research Award in Inflammatory Bowel Disease
This award provides $30,000 for 1 year to an investigator at any career stage researching the pathophysiology and/or treatment of inflammatory bowel disease (IBD).
Application Deadline: Sept. 4, 2019

AGA-Allergan Foundation Pilot Research Award in Nonalcoholic Fatty Liver Disease
This award provides $30,000 for 1 year to an investigator at any career stage researching the pathophysiology and/or treatment of nonalcoholic fatty liver disease (NAFLD).
Application Deadline: Sept. 4, 2019

AGA-Pfizer Pilot Research Award in Inflammatory Bowel Disease
This award provides $30,000 for 1 year to recipients at any career stage researching new directions focused on improving the diagnosis and treatment of inflammatory bowel disease.
Application Deadline: Sept. 4, 2019

AGA-Rome Foundation Functional GI and Motility Disorders Pilot Research Award
This award provides $30,000 for 1 year to a recipient at any career stage performing clinical or translational research pertaining to functional GI and motility disorders.
Application Deadline: Sept. 4, 2019

AGA Research Scholar Award (RSA)
This award provides $100,000 per year for 3 years (total $300,000) to early career faculty (i.e., investigator, instructor, research associate or equivalent) working toward an independent career in digestive disease research.
Application Deadline: Nov. 13, 2019

AGA-Gastric Cancer Foundation Ben Feinstein Memorial Research Scholar Award in Gastric Cancer
This award provides $100,000 per year for 3 years (total $300,000) to early career faculty (i.e., investigator, instructor, research associate or equivalent) working toward an independent career in gastric cancer research. Research involving precancerous lesions will be considered if relevance to gastric cancer is explicitly outlined.
Application Deadline: Nov. 13, 2019

AGA-Takeda Pharmaceuticals Research Scholar Award in Inflammatory Bowel Disease
This award provides $100,000 per year for 3 years (total $300,000) to a young investigator, instructor, research associate or equivalent working toward an independent career in inflammatory bowel disease research.
Application Deadline: Nov. 13, 2019
 

AGA Fellow Abstract Award
This $500 travel award supports recipients who are MD, PhD or equivalent fellows giving abstract-based oral or poster presentations at Digestive Disease Week® (DDW). The top-scoring abstract will be designated the Fellow Abstract of the Year and receive a $1,000 award.
Application Deadline: Feb. 26, 2020

AGA Student Abstract Award
This $500 travel award supports recipients who are graduate students, medical students, or medical residents (residents up to postgraduate year three) giving abstract-based oral or poster presentations at Digestive Disease Week® (DDW).
Application Deadline: Feb. 26, 2020

AGA-Moti L. & Kamla Rustgi International Travel Awards
This $750 travel award supports recipients who are young (i.e., 35 years of age or younger at the time of DDW) basic, translational, or clinical investigators residing outside North America to support travel and related expenses to attend Digestive Disease Week® (DDW).
Application Deadline: Feb. 26, 2020