The New Gastroenterologist

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

UPCOMING EVENTS

Dec. 10-11, 12-13, 2018; Jan. 16-17, 22-23, 23-24, 2019; Feb. 20-21, 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.
Tampa, FL (12/10-11), Dallas, TX (12/12-13), Houston, TX (1/16-17), New Orleans, LA (1/22-23), Pittsburgh, PA (1/23-24), 2/20 (Hartford, CT)

Jan. 17-19, 2019
2019 GI Cancers Symposium
Join colleagues from across the globe in San Francisco to discover and share groundbreaking research in treating gastrointestinal cancers.
San Francisco, CA

Feb. 7–9, 2019
Crohn’s & Colitis Congress™ (A Partnership of the Crohn’s & Colitis Foundation and American Gastroenterological Association)
Expand your knowledge, network with IBD leaders, spark innovative research and get inspired to improve patient care.
Las Vegas, NV

March 8-9, 2019
2019 Women’s Leadership Conference
The conference is specifically designed for women looking to advance their careers, further professional goals, enhance personal growth and effectively network.
Bethesda, MD

March 8-10, 2019
FORWARD Program
AGA’s Fostering Opportunities Resulting in Workforce and Research Diversity (FORWARD) Program is a new initiative funded by NIH, supporting the career entry and development for underrepresented minority physician scientists in gastroenterology. The program provides concrete leadership and skill development that includes scientific manuscript and grant writing, research development, executive coaching and more.
Bethesda, MD

March 8-10, 2019
Future Leaders Program
The Future Leaders Program provides a pathway within the organization to network, connect with mentors, develop leadership skills and learn about AGA’s governance and operations while advancing your career and supporting the profession.
Bethesda, MD

March 23–24, 2019
2019 Gut Microbiota for Health World Summit
The 2019 program will present the latest evidence on the interaction between diet, nutrition and the gut microbiome. Learn how diet and nutrition are being used in concert with traditional therapies to manage GI disorders.
Miami, FL

May 18-21, 2019
Digestive Disease Week (DDW)®
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. DDW is co-sponsored by AGA, AASLD, ASGE and SSAT.
San Diego, CA

AWARDS APPLICATION DEADLINES

AGA-Rady Children’s Institute for Genomic Medicine Research Scholar Award in Pediatric Genomics
This award provides $90,000 per year for three years (totaling $270,000) to a young investigator, instructor, research associate or equivalent working toward an independent career in gastroenterology, hepatology or related areas. The proposed research may be basic, translational or clinical and must use genomics as an approach to enhance understanding of pediatric digestive diseases toward prevention, treatment and/or cure of such diseases. The funded research must be conducted full-time at the Rady Children’s Institute for Genomic Medicine in San Diego, California, or at Rady Children’s Hospital – San Diego.
Application Deadline: Dec. 14, 2018

AGA-Bern Schwartz Family Fund Research Scholar Award in Pancreatic Cancer
This award provides $100,000 per year for three years (total $300,000) to early career faculty (i.e., investigator, instructor, research associate or equivalent) working toward an independent career in pancreatic cancer research.
Application Deadline: Dec. 14, 2018

AGA Research Scholar Award (RSA)
This award provides $90,000 per year for three years (total $270,000) to a young investigator, instructor, research associate or equivalent working toward an independent career in gastroenterology, hepatology or related areas.
Application Deadline: Dec. 14, 2018

AGA-Shire Research Scholar Award in Functional GI and Motility Disorders
This award provides $90,000 per year for three years (total $270,000) to a young investigator, instructor, research associate or equivalent working toward an independent career in functional GI and motility disorders research.
Application Deadline: Dec. 14, 2018

AGA-Takeda Pharmaceuticals Research Scholar Award in Inflammatory Bowel Disease
This award provides $90,000 per year for three years (total $270,000) to a young investigator, instructor, research associate or equivalent working toward an independent career in inflammatory bowel disease research.
Application Deadline: Dec. 14, 2018

AGA Fellow Abstract Award
This travel award provides nine $500 and one $1,000 prize to recipients who are MD, PhD or equivalent fellows presenting posters/oral sessions at Digestive Disease Week^® (DDW).
Application Deadline: Feb. 15, 2019

AGA Moti L. & Kamla Rustgi International Travel Awards
This travel award provides two $750 prizes to recipients who are young basic, translational or clinical investigators residing outside North America to support travel and related expenses to attend Digestive Disease Week® (DDW).
Application Deadline: Feb. 15, 2019

AGA Student Abstract Award
This travel award provides nine $500 and one $1,000 prize to recipients who are high school, undergraduate, graduate, or medical students or residents (residents up to year three postgraduate) presenting posters/oral sessions at Digestive Disease Week® (DDW).
Application Deadline: Feb. 15, 2019

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

UPCOMING EVENTS

Dec. 10-11, 12-13, 2018; Jan. 16-17, 22-23, 23-24, 2019; Feb. 20-21, 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.
Tampa, FL (12/10-11), Dallas, TX (12/12-13), Houston, TX (1/16-17), New Orleans, LA (1/22-23), Pittsburgh, PA (1/23-24), 2/20 (Hartford, CT)

Jan. 17-19, 2019
2019 GI Cancers Symposium
Join colleagues from across the globe in San Francisco to discover and share groundbreaking research in treating gastrointestinal cancers.
San Francisco, CA

Feb. 7–9, 2019
Crohn’s & Colitis Congress™ (A Partnership of the Crohn’s & Colitis Foundation and American Gastroenterological Association)
Expand your knowledge, network with IBD leaders, spark innovative research and get inspired to improve patient care.
Las Vegas, NV

March 8-9, 2019
2019 Women’s Leadership Conference
The conference is specifically designed for women looking to advance their careers, further professional goals, enhance personal growth and effectively network.
Bethesda, MD

March 8-10, 2019
FORWARD Program
AGA’s Fostering Opportunities Resulting in Workforce and Research Diversity (FORWARD) Program is a new initiative funded by NIH, supporting the career entry and development for underrepresented minority physician scientists in gastroenterology. The program provides concrete leadership and skill development that includes scientific manuscript and grant writing, research development, executive coaching and more.
Bethesda, MD

March 8-10, 2019
Future Leaders Program
The Future Leaders Program provides a pathway within the organization to network, connect with mentors, develop leadership skills and learn about AGA’s governance and operations while advancing your career and supporting the profession.
Bethesda, MD

March 23–24, 2019
2019 Gut Microbiota for Health World Summit
The 2019 program will present the latest evidence on the interaction between diet, nutrition and the gut microbiome. Learn how diet and nutrition are being used in concert with traditional therapies to manage GI disorders.
Miami, FL

May 18-21, 2019
Digestive Disease Week (DDW)®
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. DDW is co-sponsored by AGA, AASLD, ASGE and SSAT.
San Diego, CA

AWARDS APPLICATION DEADLINES

AGA-Rady Children’s Institute for Genomic Medicine Research Scholar Award in Pediatric Genomics
This award provides $90,000 per year for three years (totaling $270,000) to a young investigator, instructor, research associate or equivalent working toward an independent career in gastroenterology, hepatology or related areas. The proposed research may be basic, translational or clinical and must use genomics as an approach to enhance understanding of pediatric digestive diseases toward prevention, treatment and/or cure of such diseases. The funded research must be conducted full-time at the Rady Children’s Institute for Genomic Medicine in San Diego, California, or at Rady Children’s Hospital – San Diego.
Application Deadline: Dec. 14, 2018

AGA-Bern Schwartz Family Fund Research Scholar Award in Pancreatic Cancer
This award provides $100,000 per year for three years (total $300,000) to early career faculty (i.e., investigator, instructor, research associate or equivalent) working toward an independent career in pancreatic cancer research.
Application Deadline: Dec. 14, 2018

AGA Research Scholar Award (RSA)
This award provides $90,000 per year for three years (total $270,000) to a young investigator, instructor, research associate or equivalent working toward an independent career in gastroenterology, hepatology or related areas.
Application Deadline: Dec. 14, 2018

AGA-Shire Research Scholar Award in Functional GI and Motility Disorders
This award provides $90,000 per year for three years (total $270,000) to a young investigator, instructor, research associate or equivalent working toward an independent career in functional GI and motility disorders research.
Application Deadline: Dec. 14, 2018

AGA-Takeda Pharmaceuticals Research Scholar Award in Inflammatory Bowel Disease
This award provides $90,000 per year for three years (total $270,000) to a young investigator, instructor, research associate or equivalent working toward an independent career in inflammatory bowel disease research.
Application Deadline: Dec. 14, 2018

AGA Fellow Abstract Award
This travel award provides nine $500 and one $1,000 prize to recipients who are MD, PhD or equivalent fellows presenting posters/oral sessions at Digestive Disease Week^® (DDW).
Application Deadline: Feb. 15, 2019

AGA Moti L. & Kamla Rustgi International Travel Awards
This travel award provides two $750 prizes to recipients who are young basic, translational or clinical investigators residing outside North America to support travel and related expenses to attend Digestive Disease Week® (DDW).
Application Deadline: Feb. 15, 2019

AGA Student Abstract Award
This travel award provides nine $500 and one $1,000 prize to recipients who are high school, undergraduate, graduate, or medical students or residents (residents up to year three postgraduate) presenting posters/oral sessions at Digestive Disease Week® (DDW).
Application Deadline: Feb. 15, 2019

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

UPCOMING EVENTS

Dec. 10-11, 12-13, 2018; Jan. 16-17, 22-23, 23-24, 2019; Feb. 20-21, 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.
Tampa, FL (12/10-11), Dallas, TX (12/12-13), Houston, TX (1/16-17), New Orleans, LA (1/22-23), Pittsburgh, PA (1/23-24), 2/20 (Hartford, CT)

Jan. 17-19, 2019
2019 GI Cancers Symposium
Join colleagues from across the globe in San Francisco to discover and share groundbreaking research in treating gastrointestinal cancers.
San Francisco, CA

Feb. 7–9, 2019
Crohn’s & Colitis Congress™ (A Partnership of the Crohn’s & Colitis Foundation and American Gastroenterological Association)
Expand your knowledge, network with IBD leaders, spark innovative research and get inspired to improve patient care.
Las Vegas, NV

March 8-9, 2019
2019 Women’s Leadership Conference
The conference is specifically designed for women looking to advance their careers, further professional goals, enhance personal growth and effectively network.
Bethesda, MD

March 8-10, 2019
FORWARD Program
AGA’s Fostering Opportunities Resulting in Workforce and Research Diversity (FORWARD) Program is a new initiative funded by NIH, supporting the career entry and development for underrepresented minority physician scientists in gastroenterology. The program provides concrete leadership and skill development that includes scientific manuscript and grant writing, research development, executive coaching and more.
Bethesda, MD

March 8-10, 2019
Future Leaders Program
The Future Leaders Program provides a pathway within the organization to network, connect with mentors, develop leadership skills and learn about AGA’s governance and operations while advancing your career and supporting the profession.
Bethesda, MD

March 23–24, 2019
2019 Gut Microbiota for Health World Summit
The 2019 program will present the latest evidence on the interaction between diet, nutrition and the gut microbiome. Learn how diet and nutrition are being used in concert with traditional therapies to manage GI disorders.
Miami, FL

May 18-21, 2019
Digestive Disease Week (DDW)®
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. DDW is co-sponsored by AGA, AASLD, ASGE and SSAT.
San Diego, CA

AWARDS APPLICATION DEADLINES

AGA-Rady Children’s Institute for Genomic Medicine Research Scholar Award in Pediatric Genomics
This award provides $90,000 per year for three years (totaling $270,000) to a young investigator, instructor, research associate or equivalent working toward an independent career in gastroenterology, hepatology or related areas. The proposed research may be basic, translational or clinical and must use genomics as an approach to enhance understanding of pediatric digestive diseases toward prevention, treatment and/or cure of such diseases. The funded research must be conducted full-time at the Rady Children’s Institute for Genomic Medicine in San Diego, California, or at Rady Children’s Hospital – San Diego.
Application Deadline: Dec. 14, 2018

AGA-Bern Schwartz Family Fund Research Scholar Award in Pancreatic Cancer
This award provides $100,000 per year for three years (total $300,000) to early career faculty (i.e., investigator, instructor, research associate or equivalent) working toward an independent career in pancreatic cancer research.
Application Deadline: Dec. 14, 2018

AGA Research Scholar Award (RSA)
This award provides $90,000 per year for three years (total $270,000) to a young investigator, instructor, research associate or equivalent working toward an independent career in gastroenterology, hepatology or related areas.
Application Deadline: Dec. 14, 2018

AGA-Shire Research Scholar Award in Functional GI and Motility Disorders
This award provides $90,000 per year for three years (total $270,000) to a young investigator, instructor, research associate or equivalent working toward an independent career in functional GI and motility disorders research.
Application Deadline: Dec. 14, 2018

AGA-Takeda Pharmaceuticals Research Scholar Award in Inflammatory Bowel Disease
This award provides $90,000 per year for three years (total $270,000) to a young investigator, instructor, research associate or equivalent working toward an independent career in inflammatory bowel disease research.
Application Deadline: Dec. 14, 2018

AGA Fellow Abstract Award
This travel award provides nine $500 and one $1,000 prize to recipients who are MD, PhD or equivalent fellows presenting posters/oral sessions at Digestive Disease Week^® (DDW).
Application Deadline: Feb. 15, 2019

AGA Moti L. & Kamla Rustgi International Travel Awards
This travel award provides two $750 prizes to recipients who are young basic, translational or clinical investigators residing outside North America to support travel and related expenses to attend Digestive Disease Week® (DDW).
Application Deadline: Feb. 15, 2019

AGA Student Abstract Award
This travel award provides nine $500 and one $1,000 prize to recipients who are high school, undergraduate, graduate, or medical students or residents (residents up to year three postgraduate) presenting posters/oral sessions at Digestive Disease Week® (DDW).
Application Deadline: Feb. 15, 2019

You are trying to buy your first home. Maybe you have heard stories from family, friends, and colleagues about nightmare scenarios when purchasing a home. There are many facets to the home-financing process, and a little bit of planning can reduce a significant amount of time and stress. Where do you begin? What do lenders look for when preapproving a borrower? What steps do I take to get preapproved for a mortgage loan? This article will help guide you through these initial stages to ultimately guide you to settlement on your new home.

Where to begin?

• Start by drafting a budget. How much of a monthly housing payment can you afford? Planning a budget is an extremely valuable exercise at any point in life, not just when buying a home. Often, borrowers will ask the question “How much can I afford?” The better question to ask is “Can I qualify for a home that meets the maximum monthly payment I have budgeted for?”
• What funds would I use for purchasing a home? Down payments and closing costs can add up quickly. Do you have funds readily available in an account you hold? Will you be obtaining a gift from a family member? Generally, funds for down payment are not allowed to be borrowed, unless the money is coming from an account secured by your own assets (for instance, borrowing from your own retirement account). Don’t think you necessarily need to put 20% down. Some loan programs offer little or no down payment options, while other programs may offer down payment assistance options.
• If you are not aware of your credit standing, run a free credit report to verify accurate information. Federal law allows consumers to access one free credit report annually with each of the three credit bureaus (Equifax, Experian, TransUnion). Knowing your credit history and data on your credit report is very important. If there are known or unknown issues on your credit report, it’s always best to at least be informed. You can access your free report at www.annualcreditreport.com.
• Start planning ahead with some of the documentation you will need for a loan approval. Lenders will request items such as tax returns and W-2s from the past 2 years, your recent pay stubs covering a 30-day period, most recent 2 months asset account statements (bank accounts, investment accounts, retirement accounts, etc.), as well as other documentation, depending on your specific scenario.

What are lenders looking at when preapproving an applicant?

Many people will often start to search for homes without having prepared for the preapproval process. This is not necessarily an issue and it doesn’t mean you will not be preapproved. Planning ahead could help you avoid any unforeseen problems and avoid rushing into the mortgage application process when trying to place an offer on a home.

In addition to supplying information on residence and employment/student history for the past 2 years, there are three primary components to a borrower’s credit portfolio:

1) Debt-to-income ratio: What monthly expenses will show on your credit report (car loans/leases, student loans, credit card payments, personal loans/lines of credit, and mortgages for other properties owned)? Do you own any other real estate? Do you have other required obligations, such as alimony or child support payments? To calculate, first combine these liabilities on a monthly expense basis along with the new proposed monthly housing payment. Take these monthly liabilities and divide by monthly income. Gross income (pretax) for employees of a company they do not own is typically utilized (bonus or commission income can have some alternate rules to be allowed as qualifying income); for self-employed borrowers, tax returns will be required to be reviewed; tax write offs could reduce qualifying income. Self-employed individuals will typically need to show a 2-year income history via personal tax returns (as well as business tax returns if applicable). See Figure 1 for an example of a debt-to-income ratio calculation. Many loan programs will require a debt-to-income ratio of 45% or less. There are various loan programs that will be more or less restrictive than this percentage. A lender will be able to guide you to the proper program for your scenario.

You are now ready to be preapproved for mortgage financing. What should you do next?

• Talk to a trusted lender. Ask your real estate agent, family, friends, or colleagues for local lender recommendations. Real estate agents will want to make sure you have spoken with a lender and completed a preapproval application to ensure that you can be preapproved for financing before showing you homes. If you need a loan to purchase a home, a preapproval letter will be required to submit with an offer letter. The application contains questions such as your address and employment history for the past 2 years, income and asset information, as well as a series of other financial information. A hard credit inquiry will need to be performed in order for the lender to issue a preapproval. What should you expect from a lender in addition to competitive rates and an array of programs? Some people prefer more of a hands-on approach. Working with a lender who provides regular status updates and makes him/herself easily accessible for all of your questions can certainly be an attractive feature. Working with a local lender also may be reassuring, as he or she should have plenty of experience with the market in which you are purchasing.
• Search for homes. Upon being given the green light for your preapproval and a price range within your comfort zone, connect with your local real estate professional to search for homes. Plan to spend time with your agent discussing all your needs for your new home.
• Submit an offer. Your lender will be able to provide an estimate of closing costs and monthly payments for homes that you are considering buying before you make an offer. You will want to be sure you are comfortable with the financial obligation prior to making your offer. With your offer, an initial good faith deposit (earnest money deposit) will be required. Your real estate agent will guide you on the proper amount of the deposit.

Conclusion

Once you and the seller have come to terms, you will look to discuss with your lender the rate and program options to secure (locking in an interest rate and program), as well as to complete the formal mortgage application. The lender will request additional documentation, if you have not already provided documents, in order for you to obtain a conditional mortgage commitment. The lender also will order an appraisal to ensure the property value supports the price you have agreed to pay for it. Your real estate agent will guide you through the various deadlines and requirements in the contract for items like home inspections, ordering a title search to obtain title insurance, and other nonfinancing contingencies. Some areas may require attorneys for contract review and closing, which your agent will discuss with you. As you can see, buying a home is not an instant process. Taking the appropriate steps to prepare for your mortgage preapproval could save you a lot of time and stress.

Mr. Wishnick is a 15-year mortgage industry veteran, vice president of mortgage lending with Guaranteed Rate (NMLS #2611) and was ranked as a Top 1% mortgage originator by Mortgage Executive Magazine. He can be reached at [email protected].

All information provided in this publication is for informational and educational purposes only, and in no way is any of the content contained herein to be construed as financial, investment, or legal advice or instruction. Guaranteed Rate does not guarantee the quality, accuracy, completeness or timelines of the information in this publication.

You are trying to buy your first home. Maybe you have heard stories from family, friends, and colleagues about nightmare scenarios when purchasing a home. There are many facets to the home-financing process, and a little bit of planning can reduce a significant amount of time and stress. Where do you begin? What do lenders look for when preapproving a borrower? What steps do I take to get preapproved for a mortgage loan? This article will help guide you through these initial stages to ultimately guide you to settlement on your new home.

Where to begin?

• Start by drafting a budget. How much of a monthly housing payment can you afford? Planning a budget is an extremely valuable exercise at any point in life, not just when buying a home. Often, borrowers will ask the question “How much can I afford?” The better question to ask is “Can I qualify for a home that meets the maximum monthly payment I have budgeted for?”
• What funds would I use for purchasing a home? Down payments and closing costs can add up quickly. Do you have funds readily available in an account you hold? Will you be obtaining a gift from a family member? Generally, funds for down payment are not allowed to be borrowed, unless the money is coming from an account secured by your own assets (for instance, borrowing from your own retirement account). Don’t think you necessarily need to put 20% down. Some loan programs offer little or no down payment options, while other programs may offer down payment assistance options.
• If you are not aware of your credit standing, run a free credit report to verify accurate information. Federal law allows consumers to access one free credit report annually with each of the three credit bureaus (Equifax, Experian, TransUnion). Knowing your credit history and data on your credit report is very important. If there are known or unknown issues on your credit report, it’s always best to at least be informed. You can access your free report at www.annualcreditreport.com.
• Start planning ahead with some of the documentation you will need for a loan approval. Lenders will request items such as tax returns and W-2s from the past 2 years, your recent pay stubs covering a 30-day period, most recent 2 months asset account statements (bank accounts, investment accounts, retirement accounts, etc.), as well as other documentation, depending on your specific scenario.

What are lenders looking at when preapproving an applicant?

Many people will often start to search for homes without having prepared for the preapproval process. This is not necessarily an issue and it doesn’t mean you will not be preapproved. Planning ahead could help you avoid any unforeseen problems and avoid rushing into the mortgage application process when trying to place an offer on a home.

In addition to supplying information on residence and employment/student history for the past 2 years, there are three primary components to a borrower’s credit portfolio:

1) Debt-to-income ratio: What monthly expenses will show on your credit report (car loans/leases, student loans, credit card payments, personal loans/lines of credit, and mortgages for other properties owned)? Do you own any other real estate? Do you have other required obligations, such as alimony or child support payments? To calculate, first combine these liabilities on a monthly expense basis along with the new proposed monthly housing payment. Take these monthly liabilities and divide by monthly income. Gross income (pretax) for employees of a company they do not own is typically utilized (bonus or commission income can have some alternate rules to be allowed as qualifying income); for self-employed borrowers, tax returns will be required to be reviewed; tax write offs could reduce qualifying income. Self-employed individuals will typically need to show a 2-year income history via personal tax returns (as well as business tax returns if applicable). See Figure 1 for an example of a debt-to-income ratio calculation. Many loan programs will require a debt-to-income ratio of 45% or less. There are various loan programs that will be more or less restrictive than this percentage. A lender will be able to guide you to the proper program for your scenario.

You are now ready to be preapproved for mortgage financing. What should you do next?

• Talk to a trusted lender. Ask your real estate agent, family, friends, or colleagues for local lender recommendations. Real estate agents will want to make sure you have spoken with a lender and completed a preapproval application to ensure that you can be preapproved for financing before showing you homes. If you need a loan to purchase a home, a preapproval letter will be required to submit with an offer letter. The application contains questions such as your address and employment history for the past 2 years, income and asset information, as well as a series of other financial information. A hard credit inquiry will need to be performed in order for the lender to issue a preapproval. What should you expect from a lender in addition to competitive rates and an array of programs? Some people prefer more of a hands-on approach. Working with a lender who provides regular status updates and makes him/herself easily accessible for all of your questions can certainly be an attractive feature. Working with a local lender also may be reassuring, as he or she should have plenty of experience with the market in which you are purchasing.
• Search for homes. Upon being given the green light for your preapproval and a price range within your comfort zone, connect with your local real estate professional to search for homes. Plan to spend time with your agent discussing all your needs for your new home.
• Submit an offer. Your lender will be able to provide an estimate of closing costs and monthly payments for homes that you are considering buying before you make an offer. You will want to be sure you are comfortable with the financial obligation prior to making your offer. With your offer, an initial good faith deposit (earnest money deposit) will be required. Your real estate agent will guide you on the proper amount of the deposit.

Conclusion

Once you and the seller have come to terms, you will look to discuss with your lender the rate and program options to secure (locking in an interest rate and program), as well as to complete the formal mortgage application. The lender will request additional documentation, if you have not already provided documents, in order for you to obtain a conditional mortgage commitment. The lender also will order an appraisal to ensure the property value supports the price you have agreed to pay for it. Your real estate agent will guide you through the various deadlines and requirements in the contract for items like home inspections, ordering a title search to obtain title insurance, and other nonfinancing contingencies. Some areas may require attorneys for contract review and closing, which your agent will discuss with you. As you can see, buying a home is not an instant process. Taking the appropriate steps to prepare for your mortgage preapproval could save you a lot of time and stress.

Mr. Wishnick is a 15-year mortgage industry veteran, vice president of mortgage lending with Guaranteed Rate (NMLS #2611) and was ranked as a Top 1% mortgage originator by Mortgage Executive Magazine. He can be reached at [email protected].

All information provided in this publication is for informational and educational purposes only, and in no way is any of the content contained herein to be construed as financial, investment, or legal advice or instruction. Guaranteed Rate does not guarantee the quality, accuracy, completeness or timelines of the information in this publication.

You are trying to buy your first home. Maybe you have heard stories from family, friends, and colleagues about nightmare scenarios when purchasing a home. There are many facets to the home-financing process, and a little bit of planning can reduce a significant amount of time and stress. Where do you begin? What do lenders look for when preapproving a borrower? What steps do I take to get preapproved for a mortgage loan? This article will help guide you through these initial stages to ultimately guide you to settlement on your new home.

Where to begin?

• Start by drafting a budget. How much of a monthly housing payment can you afford? Planning a budget is an extremely valuable exercise at any point in life, not just when buying a home. Often, borrowers will ask the question “How much can I afford?” The better question to ask is “Can I qualify for a home that meets the maximum monthly payment I have budgeted for?”
• What funds would I use for purchasing a home? Down payments and closing costs can add up quickly. Do you have funds readily available in an account you hold? Will you be obtaining a gift from a family member? Generally, funds for down payment are not allowed to be borrowed, unless the money is coming from an account secured by your own assets (for instance, borrowing from your own retirement account). Don’t think you necessarily need to put 20% down. Some loan programs offer little or no down payment options, while other programs may offer down payment assistance options.
• If you are not aware of your credit standing, run a free credit report to verify accurate information. Federal law allows consumers to access one free credit report annually with each of the three credit bureaus (Equifax, Experian, TransUnion). Knowing your credit history and data on your credit report is very important. If there are known or unknown issues on your credit report, it’s always best to at least be informed. You can access your free report at www.annualcreditreport.com.
• Start planning ahead with some of the documentation you will need for a loan approval. Lenders will request items such as tax returns and W-2s from the past 2 years, your recent pay stubs covering a 30-day period, most recent 2 months asset account statements (bank accounts, investment accounts, retirement accounts, etc.), as well as other documentation, depending on your specific scenario.

What are lenders looking at when preapproving an applicant?

Many people will often start to search for homes without having prepared for the preapproval process. This is not necessarily an issue and it doesn’t mean you will not be preapproved. Planning ahead could help you avoid any unforeseen problems and avoid rushing into the mortgage application process when trying to place an offer on a home.

In addition to supplying information on residence and employment/student history for the past 2 years, there are three primary components to a borrower’s credit portfolio:

1) Debt-to-income ratio: What monthly expenses will show on your credit report (car loans/leases, student loans, credit card payments, personal loans/lines of credit, and mortgages for other properties owned)? Do you own any other real estate? Do you have other required obligations, such as alimony or child support payments? To calculate, first combine these liabilities on a monthly expense basis along with the new proposed monthly housing payment. Take these monthly liabilities and divide by monthly income. Gross income (pretax) for employees of a company they do not own is typically utilized (bonus or commission income can have some alternate rules to be allowed as qualifying income); for self-employed borrowers, tax returns will be required to be reviewed; tax write offs could reduce qualifying income. Self-employed individuals will typically need to show a 2-year income history via personal tax returns (as well as business tax returns if applicable). See Figure 1 for an example of a debt-to-income ratio calculation. Many loan programs will require a debt-to-income ratio of 45% or less. There are various loan programs that will be more or less restrictive than this percentage. A lender will be able to guide you to the proper program for your scenario.

You are now ready to be preapproved for mortgage financing. What should you do next?

• Talk to a trusted lender. Ask your real estate agent, family, friends, or colleagues for local lender recommendations. Real estate agents will want to make sure you have spoken with a lender and completed a preapproval application to ensure that you can be preapproved for financing before showing you homes. If you need a loan to purchase a home, a preapproval letter will be required to submit with an offer letter. The application contains questions such as your address and employment history for the past 2 years, income and asset information, as well as a series of other financial information. A hard credit inquiry will need to be performed in order for the lender to issue a preapproval. What should you expect from a lender in addition to competitive rates and an array of programs? Some people prefer more of a hands-on approach. Working with a lender who provides regular status updates and makes him/herself easily accessible for all of your questions can certainly be an attractive feature. Working with a local lender also may be reassuring, as he or she should have plenty of experience with the market in which you are purchasing.
• Search for homes. Upon being given the green light for your preapproval and a price range within your comfort zone, connect with your local real estate professional to search for homes. Plan to spend time with your agent discussing all your needs for your new home.
• Submit an offer. Your lender will be able to provide an estimate of closing costs and monthly payments for homes that you are considering buying before you make an offer. You will want to be sure you are comfortable with the financial obligation prior to making your offer. With your offer, an initial good faith deposit (earnest money deposit) will be required. Your real estate agent will guide you on the proper amount of the deposit.

Conclusion

Once you and the seller have come to terms, you will look to discuss with your lender the rate and program options to secure (locking in an interest rate and program), as well as to complete the formal mortgage application. The lender will request additional documentation, if you have not already provided documents, in order for you to obtain a conditional mortgage commitment. The lender also will order an appraisal to ensure the property value supports the price you have agreed to pay for it. Your real estate agent will guide you through the various deadlines and requirements in the contract for items like home inspections, ordering a title search to obtain title insurance, and other nonfinancing contingencies. Some areas may require attorneys for contract review and closing, which your agent will discuss with you. As you can see, buying a home is not an instant process. Taking the appropriate steps to prepare for your mortgage preapproval could save you a lot of time and stress.

Mr. Wishnick is a 15-year mortgage industry veteran, vice president of mortgage lending with Guaranteed Rate (NMLS #2611) and was ranked as a Top 1% mortgage originator by Mortgage Executive Magazine. He can be reached at [email protected].

All information provided in this publication is for informational and educational purposes only, and in no way is any of the content contained herein to be construed as financial, investment, or legal advice or instruction. Guaranteed Rate does not guarantee the quality, accuracy, completeness or timelines of the information in this publication.

The global incidence and prevalence of inflammatory bowel disease (IBD) is rising, and it is estimated that by 2025, approximately 2.2 million Americans will be living with this disease. At the same time, there have been several paradigm-changing scientific and medical advances in the understanding and management of IBD. As the diagnostic, therapeutic, and monitoring armamentarium in the management of IBD increases, so is the complexity of the decision making. Advanced concepts and training are often not covered adequately during a general gastroenterology fellowship. In a survey of 160 trainees, more than one-third of fellows did not feel “confident” or “mostly comfortable” with their level of IBD training. Yet, efficient dissemination, effective translation and integration of these advances into clinical practice is paramount to improving quality of care. To facilitate multiple goals as listed in Table 1, advanced training in the field of IBD is increasingly important. In this article, I review different training options available for young gastroenterologists.

Readers are also directed to an excellent article by David Rubin, MD, published in Gastroenterology in 2015.

Advanced fellowship training in IBD

The most rigorous training in IBD is offered through dedicated advanced fellowships. Currently, there are more than 20 such fellowships in North America, most of them offered at large academic centers with nationally and internationally renowned faculty. These training positions are generally 1 year long, offered after completion of gastroenterology fellowship. The Accreditation Council of the Graduate Medical Education (ACGME) does not accredit these advanced training programs, and there is not a separate American Board of Internal Medicine (ABIM) certification for IBD. Funding of such programs comes from different sources including endowments, private foundations, institutional funds, pharmaceutical company grants, and even limited faculty appointments of the trainees. Though there is currently no official regulatory oversight and requirements, most programs have well-defined curricula covering diverse aspects of IBD care. This core curriculum has been nicely summarized in a recent article by Uma Mahadevan, MD, in Gastroenterology.

Clinical training in these programs is offered through a mix of outpatient IBD clinics (generally three to five clinics/week, with one or more senior IBD-focused faculty member), supervising general gastroenterology fellows for inpatient IBD care, dedicated IBD-focused endoscopy sessions (generally one or two sessions/week) including chromoendoscopy and stricture dilation, as well as formal and informal mentorship by one or more senior faculty members, time and mentorship for scholarly activities, and appropriate evaluation and feedback systems. In addition, most programs offer multidisciplinary training through dedicated clinics with colorectal surgeons (such as pouch clinics, etc.), opportunities for observing and interacting with radiologists, pathologists, psychologists, and dietitians.

Visiting IBD Fellow Program: Clinical observership, through the Crohn’s and Colitis Foundation

The Visiting IBD Fellow Program – with the support of the Crohn’s and Colitis Foundation – which launched in 2006, arose from the need for immersive training in IBD, especially for fellows for whom IBD exposure may be limited. In this 1-month “observership,” interested 2nd and 3rd year fellows get the opportunity to observe faculty at a high-volume, multidisciplinary IBD Center of Excellence. Besides providing additional knowledge and expertise in the field, this also allows fellows the chance to understand how IBD Centers are set up, so they may seek to replicate similar models as local or regional IBD experts. Currently, 12 centers participate in this program. There is no cost to the fellows who are selected to participate, and all travel expenses and lodging are covered. The program significantly improved the fellows’ knowledge, skills, and attitudes toward IBD and has steadily gained in popularity, with more than 60-80 applicants for 10-20 positions per year (depending on funding). In addition to the clinical exposure, this experience also facilitates networking with faculty and other fellows at participating institutions. Full details of this program can be accessed from the Crohn’s and Colitis Foundation website.

A similar, expenses-paid, abbreviated 3-day program of IBD preceptorship has been launched for advanced practice providers (qualified advanced-practice nurses, nurse practitioners, and physician assistants). This program provides preceptee exposure to medical, surgical, outpatient, and inpatient experiences with patients at a leading academic IBD center.

Visiting IBD Research Fellowship Program, through the Crohn’s and Colitis Foundation

The Crohn’s and Colitis Foundation recently launched a new, short-term, mentored research initiative designed to promote career advancement for talented junior investigators dedicated to IBD research, and to enable knowledge-sharing among leaders in the IBD field. The Foundation encourages outstanding young scientists (postdoctoral studies in the first 3 years of their fellowship), who would like to expand their expertise in IBD research to participate in this short-term research training, carried out in a cutting-edge, NIH-funded laboratory under the mentorship of a leader in IBD research. This all-expense covered 3-12 week rotation provides mentorship and technical training in a state-of-the-art research lab relevant to IBD, with an emphasis on preclinical research most closely relevant to human disease. Details of the program can be found on the Crohn’s and Colitis Foundation website.

IBD Xcel

In 2013, Cornerstones Health, a nonprofit medical education organization, launched a 2-day program dedicated to advances in the field of IBD for junior gastroenterologists within 5 years of completion of their fellowship training. The program includes a didactic component as well as close interaction with a number of IBD experts, small-group discussions about difficult cases, and recent journal articles, as well as career-development advice. The education component is free of cost to selected participants, though travel and housing expenses are not covered.

Besides these dedicated advanced training opportunities, there are major conferences that cover IBD extensively and exclusively. These include the annual Crohn’s and Colitis Congress® conducted jointly by the Crohn’s and Colitis Foundation and the American Gastroenterological Association, the annual Advances in Inflammatory Bowel Diseases through Imedex, the annual European Crohn’s and Colitis Congress, the American College of Gastroenterology’s IBD School, as well as several regional courses conducted throughout the country. In terms of networking opportunities for gastroenterology fellows interested in IBD and junior faculty, REACH-IBD (Rising Educators, Academicians and Clinicians Helping Inflammatory Bowel Disease), founded under the auspices of the Crohn’s and Colitis Foundation in 2013, provides a unique resource. This group is open to all clinical fellows, postdoctoral scientists, and junior faculty (pediatric and adult; medical and surgical specialties, as well as PhDs) less than 7 years out of training with a rank not higher than assistant professor. The mission is to facilitate networking and career development for clinical fellows, postdoctoral scientists, and junior faculty with an interest in IBD; increase active participation of our members in the clinical, educational, scientific, and research programs within the Crohn’s and Colitis Foundation; and foster collaborative research among our members within the Foundation. The group organizes specific breakout events at the Digestive Disease Week® and the annual Crohn’s and Colitis Congress, covering diverse topics such as setting up an IBD practice, funding opportunities, paper and grant writing, career advancement guidance. More information on this can be found on the Crohn’s and Colitis Foundation website.

To summarize, there are numerous opportunities of varying lengths to receive training in inflammatory bowel diseases. This exciting field is expanding at a rapid pace, and instead of limiting management to dedicated IBD Centers of Excellence, there is clear need for effective dissemination of new management approaches and incorporation of quality measures will likely raise the bar for all patients and physicians who care for them.

AGA offers IBD education

Check out AGA’s on-demand IBD education available in AGA University.
 

Dr. Singh is assistant professor of medicine, division of gastroenterology, University of California, San Diego. He is supported by the American College of Gastroenterology and Crohn’s and Colitis Foundation, has received research grants from Pfizer and AbbVie, and consulting fees from AbbVie, Takeda, and AMAG Pharmaceuticals.
 

The global incidence and prevalence of inflammatory bowel disease (IBD) is rising, and it is estimated that by 2025, approximately 2.2 million Americans will be living with this disease. At the same time, there have been several paradigm-changing scientific and medical advances in the understanding and management of IBD. As the diagnostic, therapeutic, and monitoring armamentarium in the management of IBD increases, so is the complexity of the decision making. Advanced concepts and training are often not covered adequately during a general gastroenterology fellowship. In a survey of 160 trainees, more than one-third of fellows did not feel “confident” or “mostly comfortable” with their level of IBD training. Yet, efficient dissemination, effective translation and integration of these advances into clinical practice is paramount to improving quality of care. To facilitate multiple goals as listed in Table 1, advanced training in the field of IBD is increasingly important. In this article, I review different training options available for young gastroenterologists.

Readers are also directed to an excellent article by David Rubin, MD, published in Gastroenterology in 2015.

Advanced fellowship training in IBD

The most rigorous training in IBD is offered through dedicated advanced fellowships. Currently, there are more than 20 such fellowships in North America, most of them offered at large academic centers with nationally and internationally renowned faculty. These training positions are generally 1 year long, offered after completion of gastroenterology fellowship. The Accreditation Council of the Graduate Medical Education (ACGME) does not accredit these advanced training programs, and there is not a separate American Board of Internal Medicine (ABIM) certification for IBD. Funding of such programs comes from different sources including endowments, private foundations, institutional funds, pharmaceutical company grants, and even limited faculty appointments of the trainees. Though there is currently no official regulatory oversight and requirements, most programs have well-defined curricula covering diverse aspects of IBD care. This core curriculum has been nicely summarized in a recent article by Uma Mahadevan, MD, in Gastroenterology.

Clinical training in these programs is offered through a mix of outpatient IBD clinics (generally three to five clinics/week, with one or more senior IBD-focused faculty member), supervising general gastroenterology fellows for inpatient IBD care, dedicated IBD-focused endoscopy sessions (generally one or two sessions/week) including chromoendoscopy and stricture dilation, as well as formal and informal mentorship by one or more senior faculty members, time and mentorship for scholarly activities, and appropriate evaluation and feedback systems. In addition, most programs offer multidisciplinary training through dedicated clinics with colorectal surgeons (such as pouch clinics, etc.), opportunities for observing and interacting with radiologists, pathologists, psychologists, and dietitians.

Visiting IBD Fellow Program: Clinical observership, through the Crohn’s and Colitis Foundation

The Visiting IBD Fellow Program – with the support of the Crohn’s and Colitis Foundation – which launched in 2006, arose from the need for immersive training in IBD, especially for fellows for whom IBD exposure may be limited. In this 1-month “observership,” interested 2nd and 3rd year fellows get the opportunity to observe faculty at a high-volume, multidisciplinary IBD Center of Excellence. Besides providing additional knowledge and expertise in the field, this also allows fellows the chance to understand how IBD Centers are set up, so they may seek to replicate similar models as local or regional IBD experts. Currently, 12 centers participate in this program. There is no cost to the fellows who are selected to participate, and all travel expenses and lodging are covered. The program significantly improved the fellows’ knowledge, skills, and attitudes toward IBD and has steadily gained in popularity, with more than 60-80 applicants for 10-20 positions per year (depending on funding). In addition to the clinical exposure, this experience also facilitates networking with faculty and other fellows at participating institutions. Full details of this program can be accessed from the Crohn’s and Colitis Foundation website.

A similar, expenses-paid, abbreviated 3-day program of IBD preceptorship has been launched for advanced practice providers (qualified advanced-practice nurses, nurse practitioners, and physician assistants). This program provides preceptee exposure to medical, surgical, outpatient, and inpatient experiences with patients at a leading academic IBD center.

Visiting IBD Research Fellowship Program, through the Crohn’s and Colitis Foundation

The Crohn’s and Colitis Foundation recently launched a new, short-term, mentored research initiative designed to promote career advancement for talented junior investigators dedicated to IBD research, and to enable knowledge-sharing among leaders in the IBD field. The Foundation encourages outstanding young scientists (postdoctoral studies in the first 3 years of their fellowship), who would like to expand their expertise in IBD research to participate in this short-term research training, carried out in a cutting-edge, NIH-funded laboratory under the mentorship of a leader in IBD research. This all-expense covered 3-12 week rotation provides mentorship and technical training in a state-of-the-art research lab relevant to IBD, with an emphasis on preclinical research most closely relevant to human disease. Details of the program can be found on the Crohn’s and Colitis Foundation website.

IBD Xcel

In 2013, Cornerstones Health, a nonprofit medical education organization, launched a 2-day program dedicated to advances in the field of IBD for junior gastroenterologists within 5 years of completion of their fellowship training. The program includes a didactic component as well as close interaction with a number of IBD experts, small-group discussions about difficult cases, and recent journal articles, as well as career-development advice. The education component is free of cost to selected participants, though travel and housing expenses are not covered.

Besides these dedicated advanced training opportunities, there are major conferences that cover IBD extensively and exclusively. These include the annual Crohn’s and Colitis Congress® conducted jointly by the Crohn’s and Colitis Foundation and the American Gastroenterological Association, the annual Advances in Inflammatory Bowel Diseases through Imedex, the annual European Crohn’s and Colitis Congress, the American College of Gastroenterology’s IBD School, as well as several regional courses conducted throughout the country. In terms of networking opportunities for gastroenterology fellows interested in IBD and junior faculty, REACH-IBD (Rising Educators, Academicians and Clinicians Helping Inflammatory Bowel Disease), founded under the auspices of the Crohn’s and Colitis Foundation in 2013, provides a unique resource. This group is open to all clinical fellows, postdoctoral scientists, and junior faculty (pediatric and adult; medical and surgical specialties, as well as PhDs) less than 7 years out of training with a rank not higher than assistant professor. The mission is to facilitate networking and career development for clinical fellows, postdoctoral scientists, and junior faculty with an interest in IBD; increase active participation of our members in the clinical, educational, scientific, and research programs within the Crohn’s and Colitis Foundation; and foster collaborative research among our members within the Foundation. The group organizes specific breakout events at the Digestive Disease Week® and the annual Crohn’s and Colitis Congress, covering diverse topics such as setting up an IBD practice, funding opportunities, paper and grant writing, career advancement guidance. More information on this can be found on the Crohn’s and Colitis Foundation website.

To summarize, there are numerous opportunities of varying lengths to receive training in inflammatory bowel diseases. This exciting field is expanding at a rapid pace, and instead of limiting management to dedicated IBD Centers of Excellence, there is clear need for effective dissemination of new management approaches and incorporation of quality measures will likely raise the bar for all patients and physicians who care for them.

AGA offers IBD education

Check out AGA’s on-demand IBD education available in AGA University.
 

Dr. Singh is assistant professor of medicine, division of gastroenterology, University of California, San Diego. He is supported by the American College of Gastroenterology and Crohn’s and Colitis Foundation, has received research grants from Pfizer and AbbVie, and consulting fees from AbbVie, Takeda, and AMAG Pharmaceuticals.
 

The global incidence and prevalence of inflammatory bowel disease (IBD) is rising, and it is estimated that by 2025, approximately 2.2 million Americans will be living with this disease. At the same time, there have been several paradigm-changing scientific and medical advances in the understanding and management of IBD. As the diagnostic, therapeutic, and monitoring armamentarium in the management of IBD increases, so is the complexity of the decision making. Advanced concepts and training are often not covered adequately during a general gastroenterology fellowship. In a survey of 160 trainees, more than one-third of fellows did not feel “confident” or “mostly comfortable” with their level of IBD training. Yet, efficient dissemination, effective translation and integration of these advances into clinical practice is paramount to improving quality of care. To facilitate multiple goals as listed in Table 1, advanced training in the field of IBD is increasingly important. In this article, I review different training options available for young gastroenterologists.

Readers are also directed to an excellent article by David Rubin, MD, published in Gastroenterology in 2015.

Advanced fellowship training in IBD

The most rigorous training in IBD is offered through dedicated advanced fellowships. Currently, there are more than 20 such fellowships in North America, most of them offered at large academic centers with nationally and internationally renowned faculty. These training positions are generally 1 year long, offered after completion of gastroenterology fellowship. The Accreditation Council of the Graduate Medical Education (ACGME) does not accredit these advanced training programs, and there is not a separate American Board of Internal Medicine (ABIM) certification for IBD. Funding of such programs comes from different sources including endowments, private foundations, institutional funds, pharmaceutical company grants, and even limited faculty appointments of the trainees. Though there is currently no official regulatory oversight and requirements, most programs have well-defined curricula covering diverse aspects of IBD care. This core curriculum has been nicely summarized in a recent article by Uma Mahadevan, MD, in Gastroenterology.

Clinical training in these programs is offered through a mix of outpatient IBD clinics (generally three to five clinics/week, with one or more senior IBD-focused faculty member), supervising general gastroenterology fellows for inpatient IBD care, dedicated IBD-focused endoscopy sessions (generally one or two sessions/week) including chromoendoscopy and stricture dilation, as well as formal and informal mentorship by one or more senior faculty members, time and mentorship for scholarly activities, and appropriate evaluation and feedback systems. In addition, most programs offer multidisciplinary training through dedicated clinics with colorectal surgeons (such as pouch clinics, etc.), opportunities for observing and interacting with radiologists, pathologists, psychologists, and dietitians.

Visiting IBD Fellow Program: Clinical observership, through the Crohn’s and Colitis Foundation

The Visiting IBD Fellow Program – with the support of the Crohn’s and Colitis Foundation – which launched in 2006, arose from the need for immersive training in IBD, especially for fellows for whom IBD exposure may be limited. In this 1-month “observership,” interested 2nd and 3rd year fellows get the opportunity to observe faculty at a high-volume, multidisciplinary IBD Center of Excellence. Besides providing additional knowledge and expertise in the field, this also allows fellows the chance to understand how IBD Centers are set up, so they may seek to replicate similar models as local or regional IBD experts. Currently, 12 centers participate in this program. There is no cost to the fellows who are selected to participate, and all travel expenses and lodging are covered. The program significantly improved the fellows’ knowledge, skills, and attitudes toward IBD and has steadily gained in popularity, with more than 60-80 applicants for 10-20 positions per year (depending on funding). In addition to the clinical exposure, this experience also facilitates networking with faculty and other fellows at participating institutions. Full details of this program can be accessed from the Crohn’s and Colitis Foundation website.

A similar, expenses-paid, abbreviated 3-day program of IBD preceptorship has been launched for advanced practice providers (qualified advanced-practice nurses, nurse practitioners, and physician assistants). This program provides preceptee exposure to medical, surgical, outpatient, and inpatient experiences with patients at a leading academic IBD center.

Visiting IBD Research Fellowship Program, through the Crohn’s and Colitis Foundation

The Crohn’s and Colitis Foundation recently launched a new, short-term, mentored research initiative designed to promote career advancement for talented junior investigators dedicated to IBD research, and to enable knowledge-sharing among leaders in the IBD field. The Foundation encourages outstanding young scientists (postdoctoral studies in the first 3 years of their fellowship), who would like to expand their expertise in IBD research to participate in this short-term research training, carried out in a cutting-edge, NIH-funded laboratory under the mentorship of a leader in IBD research. This all-expense covered 3-12 week rotation provides mentorship and technical training in a state-of-the-art research lab relevant to IBD, with an emphasis on preclinical research most closely relevant to human disease. Details of the program can be found on the Crohn’s and Colitis Foundation website.

IBD Xcel

In 2013, Cornerstones Health, a nonprofit medical education organization, launched a 2-day program dedicated to advances in the field of IBD for junior gastroenterologists within 5 years of completion of their fellowship training. The program includes a didactic component as well as close interaction with a number of IBD experts, small-group discussions about difficult cases, and recent journal articles, as well as career-development advice. The education component is free of cost to selected participants, though travel and housing expenses are not covered.

Besides these dedicated advanced training opportunities, there are major conferences that cover IBD extensively and exclusively. These include the annual Crohn’s and Colitis Congress® conducted jointly by the Crohn’s and Colitis Foundation and the American Gastroenterological Association, the annual Advances in Inflammatory Bowel Diseases through Imedex, the annual European Crohn’s and Colitis Congress, the American College of Gastroenterology’s IBD School, as well as several regional courses conducted throughout the country. In terms of networking opportunities for gastroenterology fellows interested in IBD and junior faculty, REACH-IBD (Rising Educators, Academicians and Clinicians Helping Inflammatory Bowel Disease), founded under the auspices of the Crohn’s and Colitis Foundation in 2013, provides a unique resource. This group is open to all clinical fellows, postdoctoral scientists, and junior faculty (pediatric and adult; medical and surgical specialties, as well as PhDs) less than 7 years out of training with a rank not higher than assistant professor. The mission is to facilitate networking and career development for clinical fellows, postdoctoral scientists, and junior faculty with an interest in IBD; increase active participation of our members in the clinical, educational, scientific, and research programs within the Crohn’s and Colitis Foundation; and foster collaborative research among our members within the Foundation. The group organizes specific breakout events at the Digestive Disease Week® and the annual Crohn’s and Colitis Congress, covering diverse topics such as setting up an IBD practice, funding opportunities, paper and grant writing, career advancement guidance. More information on this can be found on the Crohn’s and Colitis Foundation website.

To summarize, there are numerous opportunities of varying lengths to receive training in inflammatory bowel diseases. This exciting field is expanding at a rapid pace, and instead of limiting management to dedicated IBD Centers of Excellence, there is clear need for effective dissemination of new management approaches and incorporation of quality measures will likely raise the bar for all patients and physicians who care for them.

AGA offers IBD education

Check out AGA’s on-demand IBD education available in AGA University.
 

Dr. Singh is assistant professor of medicine, division of gastroenterology, University of California, San Diego. He is supported by the American College of Gastroenterology and Crohn’s and Colitis Foundation, has received research grants from Pfizer and AbbVie, and consulting fees from AbbVie, Takeda, and AMAG Pharmaceuticals.
 

Authors of manuscripts typically receive one of three responses from journals: 1. Accepted as submitted; 2. Accepted pending revisions (major or minor); and 3. Rejected. Receiving an unconditional acceptance is an unusual fate worth documenting and celebrating. On the other hand, irreversible rejections are so common that authors need to get accustomed to them. Upon receiving an unqualified editorial rejection without a formal review (usually described as priority-related rejection), send the same manuscript out the next day to another journal (with electronic submissions you can do this on the same day).

If your manuscript is rejected after being reviewed, consider seriously the comments given and try to learn from them. Was your study design flawed? Do you need additional data? Were your analyses incomplete or did you employ suboptimal statistical methods? Was your interpretation of the findings far reaching and out of proportion to the actual data? Use this experience and feedback, revise your manuscript, and submit it to a different journal. It is not uncommon to encounter the same reviewer at the next journal; fixing major issues seems responsive and gets you in the door.

To receive a “conditional acceptance” or “rejection with hope” is the most likely “good” editorial response. Avoid a very quick response, because it may be hasty or create an impression of a hasty response. Because most manuscripts with substantial reviews are sent back to the reviewers, the turnaround time in most journals is several weeks and, therefore, there is little to be gained by sending the revised manuscript in 1 day rather than 1 week. The best course of action is to cool down for 1-2 days and then decide and draft responses in 1 week, including planned additional analyses. In the case of seemingly contradictory or numerous requests from reviewers, it is best to carefully examine clues from the editors or associate editors as to the nature and extent of the revision needed. In most instances, we draft the response letter before revising the manuscript. We use the draft letter to obtain specific input from other authors and ‘brainstorm’ about additional analyses that can best address reviewers concerns.

Do the best that you can to fully address all reviewers’ comments. Adequate time should be spent making real changes, including adding additional data or analyses to the manuscript, and taking utmost care in describing and highlighting these changes. If you believe that the reviewers missed a point that was already included in the paper, then point this out as politely as possible as part of the response letter (see below).

In addition to revising your manuscript, you will be asked to prepare a point-by-point response to each of the reviewers’ comments you receive. Thank the editors and reviewers sincerely for their comments and explain how changes based on the comments have made the paper better; they did spend time reviewing your manuscript, and they have not rejected it yet. Reviewers are usually recognized experts, or their apprentices, in the content or method of research employed in your paper. Reviewers are also likely to be authors on papers cited in your manuscript. Avoid unnecessary arguments when possible, especially about noncore issues or about changes that you already conceded. If you are compelled to contest any of the reviewers’ comments, provide substantial evidence that supports your position and be respectful with your responses. Address each comment separately, beginning with the comments raised by the editors followed by those from reviewer one, two, and so on. After each response, clearly point the reviewers and the editors to the revised sections in the manuscript. In case of similar comments, it is acceptable to direct the second (or the third) reviewer to your previous response. Provide new tables, figures, data elements, and references as part of the response letter to make it a stand-alone document. It can be difficult (and annoying) if the reviewer has to flip back and forth between documents to understand the full story.

Appealing editorial decisions consumes a lot of energy, annoys editors and reviewers, and is generally futile. If it is needed, then write a polite, brief appeal letter that summarizes the reasons for the appeal. The most common editorial response to an appeal, which usually follows a several-week delay, is an equally polite affirmation of the original decision. The second and arguably worse outcome is for the manuscript to be sent to two to three new reviewers with another rejection after a several-month delay.

Have colleagues read and comment on your revised paper and use these comments to improve the draft. There is evidence that writing groups are effective in providing suggestions for improving papers: A writing group also keeps the momentum going during the revision process. Setting realistic time lines with the coauthors of the paper is a useful strategy to maintain momentum during revisions.

Writing (and revising) papers can be a highly rewarding activity. Start early, plan carefully, and do not delay the process. Reviewers’ comments are mostly geared toward enhancing the manuscript. Take them seriously, address them fully, and you will have an improved (and we hope, an accepted) manuscript.

Additional reading

El-Serag HB. Writing and publishing scientific papers. Gastroenterology. 2012 Feb;142(2):197-200. doi: 10.1053/j.gastro.2011.12.021. Epub 2011 Dec 16.

Downey SMet al. Manuscript development and publishing: A 5-step approach. Am J Med Sci. 2017 Feb;353(2):132-6. doi: 10.1016/j.amjms.2016.12.005. Epub 2016 Dec 9.

Sullivan GM. What to do when your paper is rejected. J Grad Med Educ. 2015;7:1-3. doi: 10.4300/JGME-D-14-00686.1

Kotz Det al. Effective writing and publishing scientific papers, part XII: responding to reviewers. J Clin Epidemiol. 2014;67:243. doi: 10.1016/j.jclinepi.2013.10.003. Epub 2014 Jan 9.
 

Dr. El-Serag is chairman of the Margaret M. and Albert B. Alkek department of medicine, Baylor College of Medicine, Houston; incoming president of the American Gastroenterological Association Institute; and past Editor in Chief, Clinical Gastroenterology and Hepatology. Dr. Kanwal is professor of medicine and chief of the section of gastroenterology and hepatology, department of medicine, Baylor College of Medicine and Michael E. DeBakey Veterans Affairs Medical Center, Houston, and Editor in Chief, Clinical Gastroenterology and Hepatology. This material is based on work supported by Cancer Prevention & Research Institute of Texas grant (RP150587). The work is also supported in part by the Center for Gastrointestinal Development, Infection and Injury (NIDDK P30 DK 56338).

Authors of manuscripts typically receive one of three responses from journals: 1. Accepted as submitted; 2. Accepted pending revisions (major or minor); and 3. Rejected. Receiving an unconditional acceptance is an unusual fate worth documenting and celebrating. On the other hand, irreversible rejections are so common that authors need to get accustomed to them. Upon receiving an unqualified editorial rejection without a formal review (usually described as priority-related rejection), send the same manuscript out the next day to another journal (with electronic submissions you can do this on the same day).

If your manuscript is rejected after being reviewed, consider seriously the comments given and try to learn from them. Was your study design flawed? Do you need additional data? Were your analyses incomplete or did you employ suboptimal statistical methods? Was your interpretation of the findings far reaching and out of proportion to the actual data? Use this experience and feedback, revise your manuscript, and submit it to a different journal. It is not uncommon to encounter the same reviewer at the next journal; fixing major issues seems responsive and gets you in the door.

To receive a “conditional acceptance” or “rejection with hope” is the most likely “good” editorial response. Avoid a very quick response, because it may be hasty or create an impression of a hasty response. Because most manuscripts with substantial reviews are sent back to the reviewers, the turnaround time in most journals is several weeks and, therefore, there is little to be gained by sending the revised manuscript in 1 day rather than 1 week. The best course of action is to cool down for 1-2 days and then decide and draft responses in 1 week, including planned additional analyses. In the case of seemingly contradictory or numerous requests from reviewers, it is best to carefully examine clues from the editors or associate editors as to the nature and extent of the revision needed. In most instances, we draft the response letter before revising the manuscript. We use the draft letter to obtain specific input from other authors and ‘brainstorm’ about additional analyses that can best address reviewers concerns.

Do the best that you can to fully address all reviewers’ comments. Adequate time should be spent making real changes, including adding additional data or analyses to the manuscript, and taking utmost care in describing and highlighting these changes. If you believe that the reviewers missed a point that was already included in the paper, then point this out as politely as possible as part of the response letter (see below).

In addition to revising your manuscript, you will be asked to prepare a point-by-point response to each of the reviewers’ comments you receive. Thank the editors and reviewers sincerely for their comments and explain how changes based on the comments have made the paper better; they did spend time reviewing your manuscript, and they have not rejected it yet. Reviewers are usually recognized experts, or their apprentices, in the content or method of research employed in your paper. Reviewers are also likely to be authors on papers cited in your manuscript. Avoid unnecessary arguments when possible, especially about noncore issues or about changes that you already conceded. If you are compelled to contest any of the reviewers’ comments, provide substantial evidence that supports your position and be respectful with your responses. Address each comment separately, beginning with the comments raised by the editors followed by those from reviewer one, two, and so on. After each response, clearly point the reviewers and the editors to the revised sections in the manuscript. In case of similar comments, it is acceptable to direct the second (or the third) reviewer to your previous response. Provide new tables, figures, data elements, and references as part of the response letter to make it a stand-alone document. It can be difficult (and annoying) if the reviewer has to flip back and forth between documents to understand the full story.

Appealing editorial decisions consumes a lot of energy, annoys editors and reviewers, and is generally futile. If it is needed, then write a polite, brief appeal letter that summarizes the reasons for the appeal. The most common editorial response to an appeal, which usually follows a several-week delay, is an equally polite affirmation of the original decision. The second and arguably worse outcome is for the manuscript to be sent to two to three new reviewers with another rejection after a several-month delay.

Have colleagues read and comment on your revised paper and use these comments to improve the draft. There is evidence that writing groups are effective in providing suggestions for improving papers: A writing group also keeps the momentum going during the revision process. Setting realistic time lines with the coauthors of the paper is a useful strategy to maintain momentum during revisions.

Writing (and revising) papers can be a highly rewarding activity. Start early, plan carefully, and do not delay the process. Reviewers’ comments are mostly geared toward enhancing the manuscript. Take them seriously, address them fully, and you will have an improved (and we hope, an accepted) manuscript.

Additional reading

El-Serag HB. Writing and publishing scientific papers. Gastroenterology. 2012 Feb;142(2):197-200. doi: 10.1053/j.gastro.2011.12.021. Epub 2011 Dec 16.

Downey SMet al. Manuscript development and publishing: A 5-step approach. Am J Med Sci. 2017 Feb;353(2):132-6. doi: 10.1016/j.amjms.2016.12.005. Epub 2016 Dec 9.

Sullivan GM. What to do when your paper is rejected. J Grad Med Educ. 2015;7:1-3. doi: 10.4300/JGME-D-14-00686.1

Kotz Det al. Effective writing and publishing scientific papers, part XII: responding to reviewers. J Clin Epidemiol. 2014;67:243. doi: 10.1016/j.jclinepi.2013.10.003. Epub 2014 Jan 9.
 

Dr. El-Serag is chairman of the Margaret M. and Albert B. Alkek department of medicine, Baylor College of Medicine, Houston; incoming president of the American Gastroenterological Association Institute; and past Editor in Chief, Clinical Gastroenterology and Hepatology. Dr. Kanwal is professor of medicine and chief of the section of gastroenterology and hepatology, department of medicine, Baylor College of Medicine and Michael E. DeBakey Veterans Affairs Medical Center, Houston, and Editor in Chief, Clinical Gastroenterology and Hepatology. This material is based on work supported by Cancer Prevention & Research Institute of Texas grant (RP150587). The work is also supported in part by the Center for Gastrointestinal Development, Infection and Injury (NIDDK P30 DK 56338).

Authors of manuscripts typically receive one of three responses from journals: 1. Accepted as submitted; 2. Accepted pending revisions (major or minor); and 3. Rejected. Receiving an unconditional acceptance is an unusual fate worth documenting and celebrating. On the other hand, irreversible rejections are so common that authors need to get accustomed to them. Upon receiving an unqualified editorial rejection without a formal review (usually described as priority-related rejection), send the same manuscript out the next day to another journal (with electronic submissions you can do this on the same day).

If your manuscript is rejected after being reviewed, consider seriously the comments given and try to learn from them. Was your study design flawed? Do you need additional data? Were your analyses incomplete or did you employ suboptimal statistical methods? Was your interpretation of the findings far reaching and out of proportion to the actual data? Use this experience and feedback, revise your manuscript, and submit it to a different journal. It is not uncommon to encounter the same reviewer at the next journal; fixing major issues seems responsive and gets you in the door.

To receive a “conditional acceptance” or “rejection with hope” is the most likely “good” editorial response. Avoid a very quick response, because it may be hasty or create an impression of a hasty response. Because most manuscripts with substantial reviews are sent back to the reviewers, the turnaround time in most journals is several weeks and, therefore, there is little to be gained by sending the revised manuscript in 1 day rather than 1 week. The best course of action is to cool down for 1-2 days and then decide and draft responses in 1 week, including planned additional analyses. In the case of seemingly contradictory or numerous requests from reviewers, it is best to carefully examine clues from the editors or associate editors as to the nature and extent of the revision needed. In most instances, we draft the response letter before revising the manuscript. We use the draft letter to obtain specific input from other authors and ‘brainstorm’ about additional analyses that can best address reviewers concerns.

Do the best that you can to fully address all reviewers’ comments. Adequate time should be spent making real changes, including adding additional data or analyses to the manuscript, and taking utmost care in describing and highlighting these changes. If you believe that the reviewers missed a point that was already included in the paper, then point this out as politely as possible as part of the response letter (see below).

In addition to revising your manuscript, you will be asked to prepare a point-by-point response to each of the reviewers’ comments you receive. Thank the editors and reviewers sincerely for their comments and explain how changes based on the comments have made the paper better; they did spend time reviewing your manuscript, and they have not rejected it yet. Reviewers are usually recognized experts, or their apprentices, in the content or method of research employed in your paper. Reviewers are also likely to be authors on papers cited in your manuscript. Avoid unnecessary arguments when possible, especially about noncore issues or about changes that you already conceded. If you are compelled to contest any of the reviewers’ comments, provide substantial evidence that supports your position and be respectful with your responses. Address each comment separately, beginning with the comments raised by the editors followed by those from reviewer one, two, and so on. After each response, clearly point the reviewers and the editors to the revised sections in the manuscript. In case of similar comments, it is acceptable to direct the second (or the third) reviewer to your previous response. Provide new tables, figures, data elements, and references as part of the response letter to make it a stand-alone document. It can be difficult (and annoying) if the reviewer has to flip back and forth between documents to understand the full story.

Appealing editorial decisions consumes a lot of energy, annoys editors and reviewers, and is generally futile. If it is needed, then write a polite, brief appeal letter that summarizes the reasons for the appeal. The most common editorial response to an appeal, which usually follows a several-week delay, is an equally polite affirmation of the original decision. The second and arguably worse outcome is for the manuscript to be sent to two to three new reviewers with another rejection after a several-month delay.

Have colleagues read and comment on your revised paper and use these comments to improve the draft. There is evidence that writing groups are effective in providing suggestions for improving papers: A writing group also keeps the momentum going during the revision process. Setting realistic time lines with the coauthors of the paper is a useful strategy to maintain momentum during revisions.

Writing (and revising) papers can be a highly rewarding activity. Start early, plan carefully, and do not delay the process. Reviewers’ comments are mostly geared toward enhancing the manuscript. Take them seriously, address them fully, and you will have an improved (and we hope, an accepted) manuscript.

Additional reading

El-Serag HB. Writing and publishing scientific papers. Gastroenterology. 2012 Feb;142(2):197-200. doi: 10.1053/j.gastro.2011.12.021. Epub 2011 Dec 16.

Downey SMet al. Manuscript development and publishing: A 5-step approach. Am J Med Sci. 2017 Feb;353(2):132-6. doi: 10.1016/j.amjms.2016.12.005. Epub 2016 Dec 9.

Sullivan GM. What to do when your paper is rejected. J Grad Med Educ. 2015;7:1-3. doi: 10.4300/JGME-D-14-00686.1

Kotz Det al. Effective writing and publishing scientific papers, part XII: responding to reviewers. J Clin Epidemiol. 2014;67:243. doi: 10.1016/j.jclinepi.2013.10.003. Epub 2014 Jan 9.
 

Dr. El-Serag is chairman of the Margaret M. and Albert B. Alkek department of medicine, Baylor College of Medicine, Houston; incoming president of the American Gastroenterological Association Institute; and past Editor in Chief, Clinical Gastroenterology and Hepatology. Dr. Kanwal is professor of medicine and chief of the section of gastroenterology and hepatology, department of medicine, Baylor College of Medicine and Michael E. DeBakey Veterans Affairs Medical Center, Houston, and Editor in Chief, Clinical Gastroenterology and Hepatology. This material is based on work supported by Cancer Prevention & Research Institute of Texas grant (RP150587). The work is also supported in part by the Center for Gastrointestinal Development, Infection and Injury (NIDDK P30 DK 56338).

A wise person once said, “Research is a marathon and not a sprint.” Grant writing is the training for the marathon, and it requires discipline and fortitude to succeed. We are junior faculty members with mentored career development awards who are transitioning to independence. Below, we provide for our junior faculty colleagues some tips that have helped us train for our marathon in research.

Identify great mentors

We all understand that outstanding mentorship is critical to success. With that said, we often struggle to understand what a good mentor is. In regard to grant writing, you need someone who is willing to use red ink. While positive reinforcement may be good for your self-esteem, your mentor needs to be critical so that you can learn how to present the best possible product. In return, you must be an invested mentee who is respectful of the mentor’s time, is prepared for meetings, and responds appropriately to feedback.

Attend workshops

Your home institution and professional societies hold outstanding workshops that provide didactic lessons on both the logistics and mechanics of grant writing and allow you to network with like-minded peers, potential mentors, and staff from the funding organization. One excellent example is the American Gastroenterological Association/American Association for the Study of Liver Diseases (AGA/AASLD) Academic Skills workshop.

Decide on a grant mechanism

There are many different grants available through the government, industry, foundations, and your institution. Each grantor may have a variety of mechanisms from pilot awards to larger multiprovider and institution grants. Deciding which grants to apply for can be more of an art than it is a science. Research the opportunities available to you and develop a long-term plan with your mentors.

Start early and have a plan

An effective grant application is prepared in steps, and every step takes longer than anticipated. About 6 months prior to the deadline, read the instructions and consider using something like a Gantt chart to identify all required sections, special requirements (font, spacing, page limits), and anticipated time of completion. Then, structure a reasonable timeline – and stick to it! Remember to allow ample time for all sections, including the career development plan and research environment. Your institution will probably request the documents early, anywhere from 1 to 2 weeks prior to the deadline so that it can be circulated for institutional signatures. Steady progress wins most races.

Specific aims

There is no grant without a great idea, but not all great ideas are funded. So, the first step is to polish your idea, which must be clearly described on the Specific Aims page, which is a one-page summary that lays the framework for the rest of the grant. For the primary reviewers, it should entice them to read the proposal. For others on the review panel, it may be the only section of your grant that they read. Make sure it is clear and concise. If possible, construct a visually pleasing and easy-to-follow figure that encapsulates your proposal.

Circulate

Ideally, every section of the grant will be circulated but it is critical to have others review the Specific Aims at the very least. Ask not only your mentors and those in the field to critique but also those outside of your area and even your friends and unsuspecting family members; they may not know (or care) about the content but should be able to follow the flow and identify grammatical errors. Remember that everyone is busy, so give ample time for people to review the documents.

Read other proposals

Practice makes perfect. So you can either apply for many grants and make the mistakes yourself or read and review as many proposals as you can to learn from your colleagues’ successes and mistakes. Many institutions, mentors, and colleagues will provide copies of prior applications if you ask. Make sure you know which were successful and try to understand why the others were not successful.

When reading the aims and research strategy, pay close attention to how significance and innovation are detailed. Also, some things like the research environment, which is especially important for career development grants, may be directly applicable to your grant.
 

Help the reviewer

In general, reviewing grants is a voluntary undertaking. Imagine the reviewer reading your grant at a home filled with screaming children or, alternatively, flying in cramped quarters. Neither situation is stress-free, so put yourself in those positions and decide what you can do to make the reviewer’s job easier.

Use figures and tables to summarize the text, and consider coming back to the figure from your Specific Aims to refer to the specific parts of the proposal. You can decrease reviewer fatigue by using line breaks and fonts to break up sections and highlight important details. This will also be helpful to the reviewers on the panel who were not assigned to your grant and possibly first seeing it during the session.
 

Learn from rejection

You are either a savant or have not applied for enough grants if you have not received a rejection letter. Often, reviewers provide you with constructive comments, which (after a session of crying in the corner in a fetal position), you can use to improve your grant. Resubmission works!

Apply widely

Identify different possible grants, and work with your mentors on a strategy that allows you to make your idea versatile and package it for various funding mechanisms. Once you have a grant, you can tailor it to other grants as needed. However, remember that quantity does not replace quality, so many poor grants that are not funded will not replace one good one that is funded.

There are multiple approaches to training for the marathon of research, so these tips are not a comprehensive list or mandatory commandments. They have, however, proven invaluable to our mentors and us. Our institutions, societies and government agencies have identified the decline of young scientists and physician-scientists as a major leak in the research pipeline, so there are excellent funding mechanisms that are available to you. Good luck!

We would like to acknowledge Jennifer Weiss, MD, and Sumera Rizvi, MD, for their constructive comments.
 

Dr. Beyder is with the enteric neuroscience program, a consultant for the department of gastroenterology and hepatology, and an assistant professor of biomedical engineering and physiology at the Mayo Clinic School of Medicine, Rochester, Minn.; Dr. Twyman-Saint Victor is an assistant professor of medicine in the division of gastroenterology at the University of Pennsylvania, Philadelphia.

A wise person once said, “Research is a marathon and not a sprint.” Grant writing is the training for the marathon, and it requires discipline and fortitude to succeed. We are junior faculty members with mentored career development awards who are transitioning to independence. Below, we provide for our junior faculty colleagues some tips that have helped us train for our marathon in research.

Identify great mentors

We all understand that outstanding mentorship is critical to success. With that said, we often struggle to understand what a good mentor is. In regard to grant writing, you need someone who is willing to use red ink. While positive reinforcement may be good for your self-esteem, your mentor needs to be critical so that you can learn how to present the best possible product. In return, you must be an invested mentee who is respectful of the mentor’s time, is prepared for meetings, and responds appropriately to feedback.

Attend workshops

Your home institution and professional societies hold outstanding workshops that provide didactic lessons on both the logistics and mechanics of grant writing and allow you to network with like-minded peers, potential mentors, and staff from the funding organization. One excellent example is the American Gastroenterological Association/American Association for the Study of Liver Diseases (AGA/AASLD) Academic Skills workshop.

Decide on a grant mechanism

There are many different grants available through the government, industry, foundations, and your institution. Each grantor may have a variety of mechanisms from pilot awards to larger multiprovider and institution grants. Deciding which grants to apply for can be more of an art than it is a science. Research the opportunities available to you and develop a long-term plan with your mentors.

Start early and have a plan

An effective grant application is prepared in steps, and every step takes longer than anticipated. About 6 months prior to the deadline, read the instructions and consider using something like a Gantt chart to identify all required sections, special requirements (font, spacing, page limits), and anticipated time of completion. Then, structure a reasonable timeline – and stick to it! Remember to allow ample time for all sections, including the career development plan and research environment. Your institution will probably request the documents early, anywhere from 1 to 2 weeks prior to the deadline so that it can be circulated for institutional signatures. Steady progress wins most races.

Specific aims

There is no grant without a great idea, but not all great ideas are funded. So, the first step is to polish your idea, which must be clearly described on the Specific Aims page, which is a one-page summary that lays the framework for the rest of the grant. For the primary reviewers, it should entice them to read the proposal. For others on the review panel, it may be the only section of your grant that they read. Make sure it is clear and concise. If possible, construct a visually pleasing and easy-to-follow figure that encapsulates your proposal.

Circulate

Ideally, every section of the grant will be circulated but it is critical to have others review the Specific Aims at the very least. Ask not only your mentors and those in the field to critique but also those outside of your area and even your friends and unsuspecting family members; they may not know (or care) about the content but should be able to follow the flow and identify grammatical errors. Remember that everyone is busy, so give ample time for people to review the documents.

Read other proposals

Practice makes perfect. So you can either apply for many grants and make the mistakes yourself or read and review as many proposals as you can to learn from your colleagues’ successes and mistakes. Many institutions, mentors, and colleagues will provide copies of prior applications if you ask. Make sure you know which were successful and try to understand why the others were not successful.

When reading the aims and research strategy, pay close attention to how significance and innovation are detailed. Also, some things like the research environment, which is especially important for career development grants, may be directly applicable to your grant.
 

Help the reviewer

In general, reviewing grants is a voluntary undertaking. Imagine the reviewer reading your grant at a home filled with screaming children or, alternatively, flying in cramped quarters. Neither situation is stress-free, so put yourself in those positions and decide what you can do to make the reviewer’s job easier.

Use figures and tables to summarize the text, and consider coming back to the figure from your Specific Aims to refer to the specific parts of the proposal. You can decrease reviewer fatigue by using line breaks and fonts to break up sections and highlight important details. This will also be helpful to the reviewers on the panel who were not assigned to your grant and possibly first seeing it during the session.
 

Learn from rejection

You are either a savant or have not applied for enough grants if you have not received a rejection letter. Often, reviewers provide you with constructive comments, which (after a session of crying in the corner in a fetal position), you can use to improve your grant. Resubmission works!

Apply widely

Identify different possible grants, and work with your mentors on a strategy that allows you to make your idea versatile and package it for various funding mechanisms. Once you have a grant, you can tailor it to other grants as needed. However, remember that quantity does not replace quality, so many poor grants that are not funded will not replace one good one that is funded.

There are multiple approaches to training for the marathon of research, so these tips are not a comprehensive list or mandatory commandments. They have, however, proven invaluable to our mentors and us. Our institutions, societies and government agencies have identified the decline of young scientists and physician-scientists as a major leak in the research pipeline, so there are excellent funding mechanisms that are available to you. Good luck!

We would like to acknowledge Jennifer Weiss, MD, and Sumera Rizvi, MD, for their constructive comments.
 

Dr. Beyder is with the enteric neuroscience program, a consultant for the department of gastroenterology and hepatology, and an assistant professor of biomedical engineering and physiology at the Mayo Clinic School of Medicine, Rochester, Minn.; Dr. Twyman-Saint Victor is an assistant professor of medicine in the division of gastroenterology at the University of Pennsylvania, Philadelphia.

A wise person once said, “Research is a marathon and not a sprint.” Grant writing is the training for the marathon, and it requires discipline and fortitude to succeed. We are junior faculty members with mentored career development awards who are transitioning to independence. Below, we provide for our junior faculty colleagues some tips that have helped us train for our marathon in research.

Identify great mentors

We all understand that outstanding mentorship is critical to success. With that said, we often struggle to understand what a good mentor is. In regard to grant writing, you need someone who is willing to use red ink. While positive reinforcement may be good for your self-esteem, your mentor needs to be critical so that you can learn how to present the best possible product. In return, you must be an invested mentee who is respectful of the mentor’s time, is prepared for meetings, and responds appropriately to feedback.

Attend workshops

Your home institution and professional societies hold outstanding workshops that provide didactic lessons on both the logistics and mechanics of grant writing and allow you to network with like-minded peers, potential mentors, and staff from the funding organization. One excellent example is the American Gastroenterological Association/American Association for the Study of Liver Diseases (AGA/AASLD) Academic Skills workshop.

Decide on a grant mechanism

There are many different grants available through the government, industry, foundations, and your institution. Each grantor may have a variety of mechanisms from pilot awards to larger multiprovider and institution grants. Deciding which grants to apply for can be more of an art than it is a science. Research the opportunities available to you and develop a long-term plan with your mentors.

Start early and have a plan

An effective grant application is prepared in steps, and every step takes longer than anticipated. About 6 months prior to the deadline, read the instructions and consider using something like a Gantt chart to identify all required sections, special requirements (font, spacing, page limits), and anticipated time of completion. Then, structure a reasonable timeline – and stick to it! Remember to allow ample time for all sections, including the career development plan and research environment. Your institution will probably request the documents early, anywhere from 1 to 2 weeks prior to the deadline so that it can be circulated for institutional signatures. Steady progress wins most races.

Specific aims

There is no grant without a great idea, but not all great ideas are funded. So, the first step is to polish your idea, which must be clearly described on the Specific Aims page, which is a one-page summary that lays the framework for the rest of the grant. For the primary reviewers, it should entice them to read the proposal. For others on the review panel, it may be the only section of your grant that they read. Make sure it is clear and concise. If possible, construct a visually pleasing and easy-to-follow figure that encapsulates your proposal.

Circulate

Ideally, every section of the grant will be circulated but it is critical to have others review the Specific Aims at the very least. Ask not only your mentors and those in the field to critique but also those outside of your area and even your friends and unsuspecting family members; they may not know (or care) about the content but should be able to follow the flow and identify grammatical errors. Remember that everyone is busy, so give ample time for people to review the documents.

Read other proposals

Practice makes perfect. So you can either apply for many grants and make the mistakes yourself or read and review as many proposals as you can to learn from your colleagues’ successes and mistakes. Many institutions, mentors, and colleagues will provide copies of prior applications if you ask. Make sure you know which were successful and try to understand why the others were not successful.

When reading the aims and research strategy, pay close attention to how significance and innovation are detailed. Also, some things like the research environment, which is especially important for career development grants, may be directly applicable to your grant.
 

Help the reviewer

In general, reviewing grants is a voluntary undertaking. Imagine the reviewer reading your grant at a home filled with screaming children or, alternatively, flying in cramped quarters. Neither situation is stress-free, so put yourself in those positions and decide what you can do to make the reviewer’s job easier.

Use figures and tables to summarize the text, and consider coming back to the figure from your Specific Aims to refer to the specific parts of the proposal. You can decrease reviewer fatigue by using line breaks and fonts to break up sections and highlight important details. This will also be helpful to the reviewers on the panel who were not assigned to your grant and possibly first seeing it during the session.
 

Learn from rejection

You are either a savant or have not applied for enough grants if you have not received a rejection letter. Often, reviewers provide you with constructive comments, which (after a session of crying in the corner in a fetal position), you can use to improve your grant. Resubmission works!

Apply widely

Identify different possible grants, and work with your mentors on a strategy that allows you to make your idea versatile and package it for various funding mechanisms. Once you have a grant, you can tailor it to other grants as needed. However, remember that quantity does not replace quality, so many poor grants that are not funded will not replace one good one that is funded.

There are multiple approaches to training for the marathon of research, so these tips are not a comprehensive list or mandatory commandments. They have, however, proven invaluable to our mentors and us. Our institutions, societies and government agencies have identified the decline of young scientists and physician-scientists as a major leak in the research pipeline, so there are excellent funding mechanisms that are available to you. Good luck!

We would like to acknowledge Jennifer Weiss, MD, and Sumera Rizvi, MD, for their constructive comments.
 

Dr. Beyder is with the enteric neuroscience program, a consultant for the department of gastroenterology and hepatology, and an assistant professor of biomedical engineering and physiology at the Mayo Clinic School of Medicine, Rochester, Minn.; Dr. Twyman-Saint Victor is an assistant professor of medicine in the division of gastroenterology at the University of Pennsylvania, Philadelphia.

Gastroenterology

How and when to consider genetic testing for colon cancer? Ballester V; Cruz-Correa M. 2018 Oct;155(4):955-9. doi: 10.1053/j.gastro.2018.08.031.

How to approach a patient with eosinophilic esophagitis. Hirano I. 2018 Sept;155(3):601-6. doi: 10.1053/j.gastro.2018.08.001.

How to ensure patient adherence to colorectal cancer screening and surveillance in your practice. Hassan C; Kaminski MF; Repici A. 2018 Aug;155(2):252-7. doi: 10.1053/j.gastro.2018.06.051.

How to approach difficult patient encounters: ROAR. McCarthy JG; Cheatham JG; Singla M. 2018 Aug;155(2):258-61. doi: 10.1053/j.gastro.2018.06.052.

An inside view: AGA advocacy priorities. Jain R. 2018 Aug;155(2):572-3. doi: 10.1053/j.gastro.2018.06.028.

Clin Gastro Hepatol

Adding value to the conversation about colorectal cancer screening: Practical pearls for gastroenterologists. Maratt JK; Naylor K; Saini SD. 2018 Oct;16(10):1545–8. doi: 10.1016/j.cgh.2018.07.002.

Credentialing for endoscopic practice: The Mayo Clinic model. Kane SV; Chandrasekhara V; Sedlack RE; Buttar NS. 2018 Sept;16(9):1370–3.e1 doi: 10.1016/j.cgh.2018.06.020.

Gastroenterology

How and when to consider genetic testing for colon cancer? Ballester V; Cruz-Correa M. 2018 Oct;155(4):955-9. doi: 10.1053/j.gastro.2018.08.031.

How to approach a patient with eosinophilic esophagitis. Hirano I. 2018 Sept;155(3):601-6. doi: 10.1053/j.gastro.2018.08.001.

How to ensure patient adherence to colorectal cancer screening and surveillance in your practice. Hassan C; Kaminski MF; Repici A. 2018 Aug;155(2):252-7. doi: 10.1053/j.gastro.2018.06.051.

How to approach difficult patient encounters: ROAR. McCarthy JG; Cheatham JG; Singla M. 2018 Aug;155(2):258-61. doi: 10.1053/j.gastro.2018.06.052.

An inside view: AGA advocacy priorities. Jain R. 2018 Aug;155(2):572-3. doi: 10.1053/j.gastro.2018.06.028.

Clin Gastro Hepatol

Adding value to the conversation about colorectal cancer screening: Practical pearls for gastroenterologists. Maratt JK; Naylor K; Saini SD. 2018 Oct;16(10):1545–8. doi: 10.1016/j.cgh.2018.07.002.

Credentialing for endoscopic practice: The Mayo Clinic model. Kane SV; Chandrasekhara V; Sedlack RE; Buttar NS. 2018 Sept;16(9):1370–3.e1 doi: 10.1016/j.cgh.2018.06.020.

Gastroenterology

How and when to consider genetic testing for colon cancer? Ballester V; Cruz-Correa M. 2018 Oct;155(4):955-9. doi: 10.1053/j.gastro.2018.08.031.

How to approach a patient with eosinophilic esophagitis. Hirano I. 2018 Sept;155(3):601-6. doi: 10.1053/j.gastro.2018.08.001.

How to ensure patient adherence to colorectal cancer screening and surveillance in your practice. Hassan C; Kaminski MF; Repici A. 2018 Aug;155(2):252-7. doi: 10.1053/j.gastro.2018.06.051.

How to approach difficult patient encounters: ROAR. McCarthy JG; Cheatham JG; Singla M. 2018 Aug;155(2):258-61. doi: 10.1053/j.gastro.2018.06.052.

An inside view: AGA advocacy priorities. Jain R. 2018 Aug;155(2):572-3. doi: 10.1053/j.gastro.2018.06.028.

Clin Gastro Hepatol

Adding value to the conversation about colorectal cancer screening: Practical pearls for gastroenterologists. Maratt JK; Naylor K; Saini SD. 2018 Oct;16(10):1545–8. doi: 10.1016/j.cgh.2018.07.002.

Credentialing for endoscopic practice: The Mayo Clinic model. Kane SV; Chandrasekhara V; Sedlack RE; Buttar NS. 2018 Sept;16(9):1370–3.e1 doi: 10.1016/j.cgh.2018.06.020.

Editor's Note: 

As quality metrics are becoming increasingly significant throughout all of medicine, our field is no exception. Recent evidence has demonstrated the importance of quality measures in colonoscopy; understanding, reporting, and improving these metrics has become a hot topic of discussion.

In this month’s In Focus article, brought to you by The New Gastroenterologist, Nabiha Shamsi, Ashish Malhotra, and Aasma Shaukat (University of Minnesota/Minneapolis VAMC) provide an outstanding overview of the evidence as well as recommended goals for important quality metrics in colonoscopy. Ultimately, improving colonoscopy quality amongst all gastroenterologists will increase colonoscopy value and lead to further decreases in the incidence and mortality of colorectal cancer.

Bryson W. Katona, MD, PhD
Editor in Chief, The New Gastroenterologist

Introduction

Colonoscopy is a widely used modality to evaluate colorectal cancer because it allows for both identification of early malignancies and removal of precancerous lesions. The increased use of colonoscopy in the last 20 years has been associated with a decline in the incidence and mortality from colorectal cancer.^1,2 However, colonoscopy has its limitations. It is an invasive test with inherent risks. Additionally, studies have reported rates of post-colonoscopy cancers, also referred to as interval cancers, of 2%-7%, and miss-rates for adenomas by tandem colonoscopy of 2%-26%.^3-5

High-quality exams can maximize the value of colonoscopy, and it is important to consider the factors that contribute to high-quality colonoscopies. While there are many metrics proposed,^6,7 here we discuss the most evidence-based ones, outlined in Table 1, along with their goal values.
 

Cecal intubation rate

A high-quality colonoscopy should include a complete examination of the colon. To achieve this, it is necessary to fully intubate the cecum, passing the colonoscope past the ileocecal valve to examine the medial wall of the cecum.⁸

There are several factors that may contribute to an incomplete colonoscopy, including bowel preparation, anatomy, body habitus, and endoscopist’s skill. To calculate cecal intubation rate as a quality measure, colonoscopies that are incomplete because of poor bowel preparation, severe colitis, or known obstructing lesion are usually excluded.

The U.S. Multi-Society Task Force on Colorectal Cancer recommends a cecal intubation rate of at least 95% for screening colonoscopy and 90% for all colonoscopies.⁶ There is an expectation of photodocumentation of the ileocecal valve and appendiceal orifice to establish completion of the colonoscopy.⁶

Some methods used to assist with cecal intubation include changing patient position, applying abdominal pressure, stiffening the colonoscope, and alternating between adult or pediatric colonoscopes.
 

Adenoma detection rate

Adenoma detection rate (ADR), is defined as the proportion of patients over the age of 50 years undergoing first-time screening colonoscopies in which at least one adenomatous polyp is detected for a given endoscopist in a given time period.

Adenomas are tracked because clearing the colon of neoplasm is the goal of screening colonoscopies; adenomas are tracked instead of more advanced lesions because the higher frequency of adenomas allows for better tracking of variation between endoscopists. Tracking ADR also utilizes the assumption that, if small lesions are identified, larger ones will be as well.

ADR is the only current quality indicator reported to be significantly associated with the risk of interval cancers. In 2010, a study of 45,000 screening colonoscopies by 186 endoscopists validated the use of ADR, finding that patients who underwent colonoscopy by physicians with ADRs below 20% had hazard ratios for development of postcolonoscopy cancer greater than 10 times higher than patients of physicians with ADRs above 20%.⁹ However, this study had limited power to establish that cancer protection continues to improve when ADRs rise above 20%. Another study, which evaluated the association of ADR in 224,000 patients undergoing colonoscopies by 136 gastroenterologists, showed each 1% increase in ADR is associated with 3% decrease in the risk of interval CRC and 5% decrease in the risk of fatal interval cancers.¹⁰

Most recent guidelines propose an adequate ADR for asymptomatic individuals aged 50 years or older undergoing screening colonoscopy should be greater than 30% in men and greater than 20% in women.⁶ It remains unknown whether there is a threshold for maximum benefit of ADR, in which a very high ADR is not associated with further protective benefit. The answer to this question may depend on why a low ADR is associated with a higher rate of interval cancers and whether every missed polyp, independent of size, is a potential interval cancer or whether hasty, inadequate, or incomplete examinations of the colon are the underlying concern.

Withdrawal time

Optimizing identification of colonic lesions requires a careful and thorough exam of the colon on withdrawal. While this may seem obvious, there is often little focus on the approach to withdrawal. In four chapters on colonoscopy technique from textbooks, the number of pages describing insertion ranged from 20 to 38, while the number of pages focused on withdrawal ranged from 0.5 to 1.5.^11-14

A study examining the difference in withdrawal technique between two endoscopists who were known to differ in adenoma miss rates by tandem colonoscopy proposed the scoring system listed in Table 2 that can assess quality of examination on withdrawal. There was a statistically significant difference in quality scores for the two endoscopists, as assessed by expert review of video recordings of their colonoscopies.¹⁵

The endoscopist with the lower adenoma miss rate was also found to have an average withdrawal time of 8 minutes and 55 seconds versus 6 minutes and 41 seconds for the endoscopist with the higher adenoma miss rate. A large, community-based study with over 76,000 colonoscopies found a statistically significant correlation between interval colorectal cancer and withdrawal times shorter than 6 minutes.¹⁶ However, there was no association between ADR and colorectal cancer, suggesting that, for practices with optimal ADRs (that is, rates greater than 25%), withdrawal time may be a more sensitive marker of quality of colonoscopy than ADR is.¹⁶Intuitively, adequate examination of the colon that includes examining the proximal side of folds, washing and suctioning stool, and even repositioning the patient would likely increase withdrawal time. In a 2008 study examining 2,000 screening colonoscopies of 12 endoscopists, those with withdrawal times greater than 6 minutes had significantly higher rates of detecting adenomas and advanced neoplasia, compared with those with faster withdrawal times.¹⁷ The average ADR in this group was 28.3%, compared with 11.8% for physicians who had a withdrawal time less than 6 minutes.¹⁷ An evaluation of nearly 11,000 colonoscopies done by 43 endoscopists also identified an increase polyp yield with increased withdrawal time.¹⁸ These data drive the recommendation for a minimum withdrawal time of 6 minutes, with 2 minutes spent examining each colonic segment.

Bowel preparation

Diagnosis of colonic lesions is dependent on adequate visualization of the colon. Poor bowel preparation can limit the yield of colonoscopy and lead to missed lesions. It also leads to canceled and rescheduled procedures that reduce efficiency, increase cost, and pose an undue burden on the patient.

The quality of bowel preparation should be assessed after washing and suctioning of colonic mucosa has been completed. Adequate preparation is that which allows identification of lesions greater than 5 mm in size.¹⁹

Quality of preparation is assessed subjectively by the endoscopists and often listed as excellent, good, fair, or poor. An alternative method of reporting bowel preparation quality is the Boston Bowel Preparation Score (BBPS) (Table 3).²⁰ This scoring system allows for a more descriptive assessment of each colonic segment by assigning a score from 0 to 3 for the right, transverse, and left colon, leading to a total score between 0 and 9. The BBPS also helps standardize reporting of bowel preparation. The polyp detection rate associated with a BBPS of 5 or greater was 40%, compared with 24% associated with BBPS less than 5.¹⁹ A split-dose bowel preparation regimen with at least half of the preparation ingested on the day of the procedure is recommended to optimize quality of bowel preparation.⁶

The American Society for Gastrointestinal Endoscopy and American College of Gastroenterology task force on quality assurance in endoscopy recommends that bowel preparation should be adequate in 85% of all colonoscopy exams on a per-provider basis.⁷ One study of completed colonoscopy with inadequate preparation showed an adenoma miss rate of 48%.²¹ In the setting of inadequate bowel preparation, another study reported 42% of all adenomas detected were only found on repeat colonoscopy. When considering advanced adenomas, there was a 27% miss rate, a relatively high percentage.²²
 

When poor bowel preparation precludes the exam, colonoscopy is appropriately aborted, and the patient asked to return. However, there are situations in which the exam can be completed but the bowel preparation is still inadequate to identify polyps larger than 5 mm. In this setting, the colonoscopy should be repeated with a more aggressive bowel preparation regimen within 1 year.¹⁹ Shorter intervals are recommended if advanced neoplasm is detected within an inadequate bowel preparation.¹⁹

The appropriate surveillance interval can be unclear when bowel preparation is considered adequate to identify polyps greater than or equal to 5 mm, yet still suboptimal. “Adequate” or “fair” bowel preparation often leads to shorter-than-recommended surveillance intervals because of the concern for small missed lesions. For example, patients with normal colonoscopy results and a fair prep were recommended to undergo a screening colonoscopy in 5 years at 57.4%, while only 23.1% received a 10-year recommendation.²³ This increased frequency of colonoscopy leads to increased costs and procedural risks for the patient. Furthermore, a meta-analysis evaluating the effects of bowel preparation reported no significant difference in ADR between adequate and excellent prep.²⁴ These findings suggest that patients with adequate bowel preparation may be followed at guideline-recommended surveillance intervals without significantly affecting colonoscopy quality as measured by ADR.

Endoscopist feedback and report cards

Awareness of quality metrics among individuals and endoscopy practices is crucial to ensuring adequate performance. Several studies have shown improvement with feedback and monitoring of endoscopists.^25,26 Some strategies to improve colonoscopy technique and efficiency include having recorded or observed procedures, computer software that measures image resolution/velocity, and scorecards with quality measures. A representation of the scorecards used in our practice is shown in Table 4. Feedback measures both make endoscopists aware of how their performance compares with recommended goals for colonoscopy and help track their improvement. We recommend such feedback should be provided quarterly for most providers and more frequently for providers not meeting benchmarks.

Conclusion

Given we rely on colonoscopy to identify and clear the colon of potential malignancy, it is imperative that we provide high-value exams for our patients. The basis for a quality colonoscopy is complete intubation and careful inspection of the mucosa on withdrawal. Several quality measures are used as surrogates of a good exam such that endoscopists can assess themselves in relation to their peers. These metrics can help us in our goal of remaining mindful during each procedure we are completing and providing the best exam possible.

Dr. Shamsi is a third-year GI fellow. Dr. Malhotra is an assistant professor in the division of gastroenterology at the University of Minnesota, Minneapolis. Dr. Shaukat is a professor of medicine in the division of gastroenterology at the University of Minnesota, Minneapolis, and the GI Section Chief at the Minneapolis VA Medical Center.

References

1. Siegel R et al. CA Cancer J Clin. 2012 Jan-Feb;62(1):10-29.

2. Edwards BK et al. Cancer. 2010 Feb 1;116(3):544-73.

3. Hosokawa O et al. Endoscopy. 2003 Jun;35(6):506-10.

4. Morris EJ et al. Gut. 2015(Aug);64(2):1248-56.

5. Bressler B et al. Gastroenterology. 2004 Aug;127(2):452-6.

6. Rex DK et al. Am J Gastroenterol. 2017 July;12(7):1016-30.

7. Rex DK et al. Gastrointest Endosc. 2015 Jan;81(1):31-53.

8. Anderson J et al. Clin Transl Gastroenterol. 2015 Feb 26;6:e77.

9. Kaminski M et al. N Engl J Med. 2010 May 13;362(19):1795-803.

10. Corley DA et al. N Engl J Med. 2014 Apr 3;370(4):1298-306.

11. Hunt RH. Colonoscopy intubation techniques without fluoroscopy. In: Colonoscopy techniques clinical practice and color atlas. Edited by Hunt RH, Waye JD. London: Chapman and Hall; 1981. p. 109-46.

12. Waye JD. Colonoscopy intubation techniques without fluoroscopy. In: Colonoscopy techniques clinical practice and color atlas. Edited by Hunt RH, Waye JD. London: Chapman and Hall; 1981. p. 147-78.

13. Williams CB et al. In: Colonoscopy principles & techniques. Edited by Raskin J, Juergen NH. New York: Igaku-Shoin Medical Publishers; 1995. p. 121-42.

14. Baillie J. Colonoscopy. In: Gastrointestinal endoscopy basic principles and practice. Oxford (UK): Butterworth-Heinemann; 1992. p. 63-92.

15. Rex DK. Gastrointest Endosc. 2000 Jan;51(1):33-6.

16. Shaukat A et al. Gastroenterol. 2015;149(4):952-7.

17. Barclay R et al. N Engl J Med. 2006 Dec 14;355(24):2533-41.

18. Simmons DT et al. Gastrointest Endosc. 2007;65(5):AB94.

19. Johnson DA et al. Gastrointest Endosc. 2014;80(4):543-62.

20. Calderwood A et al. Gastrointest Endosc. 2010 Oct;72(4):686-92.

21. Chokshi R et al. Gastrointest Endosc. 2012 Jun;75(6):1197-203.

22. Lebwohl B et al. Gastrointest Endosc. 2011 Jun;73(6):1207-14.

23. Menees SB et al. Gastrointest Endosc. 2013 Sep;78(3): 510-6.

24. Clark B et al. Am J Gastroenterol. 2014 Nov;109(11):1714-23.

25. Nielson A et al. BMJ Open Gastro. 2017 Jun. doi: 10.1136/bmjgast-2017-000142.

26. Gurudu S et al. J Gastroenterol Hepatol. 2018 Mar;33(3):645-9.

Editor's Note: 

As quality metrics are becoming increasingly significant throughout all of medicine, our field is no exception. Recent evidence has demonstrated the importance of quality measures in colonoscopy; understanding, reporting, and improving these metrics has become a hot topic of discussion.

In this month’s In Focus article, brought to you by The New Gastroenterologist, Nabiha Shamsi, Ashish Malhotra, and Aasma Shaukat (University of Minnesota/Minneapolis VAMC) provide an outstanding overview of the evidence as well as recommended goals for important quality metrics in colonoscopy. Ultimately, improving colonoscopy quality amongst all gastroenterologists will increase colonoscopy value and lead to further decreases in the incidence and mortality of colorectal cancer.

Bryson W. Katona, MD, PhD
Editor in Chief, The New Gastroenterologist

Introduction

Colonoscopy is a widely used modality to evaluate colorectal cancer because it allows for both identification of early malignancies and removal of precancerous lesions. The increased use of colonoscopy in the last 20 years has been associated with a decline in the incidence and mortality from colorectal cancer.^1,2 However, colonoscopy has its limitations. It is an invasive test with inherent risks. Additionally, studies have reported rates of post-colonoscopy cancers, also referred to as interval cancers, of 2%-7%, and miss-rates for adenomas by tandem colonoscopy of 2%-26%.^3-5

High-quality exams can maximize the value of colonoscopy, and it is important to consider the factors that contribute to high-quality colonoscopies. While there are many metrics proposed,^6,7 here we discuss the most evidence-based ones, outlined in Table 1, along with their goal values.
 

Cecal intubation rate

A high-quality colonoscopy should include a complete examination of the colon. To achieve this, it is necessary to fully intubate the cecum, passing the colonoscope past the ileocecal valve to examine the medial wall of the cecum.⁸

There are several factors that may contribute to an incomplete colonoscopy, including bowel preparation, anatomy, body habitus, and endoscopist’s skill. To calculate cecal intubation rate as a quality measure, colonoscopies that are incomplete because of poor bowel preparation, severe colitis, or known obstructing lesion are usually excluded.

The U.S. Multi-Society Task Force on Colorectal Cancer recommends a cecal intubation rate of at least 95% for screening colonoscopy and 90% for all colonoscopies.⁶ There is an expectation of photodocumentation of the ileocecal valve and appendiceal orifice to establish completion of the colonoscopy.⁶

Some methods used to assist with cecal intubation include changing patient position, applying abdominal pressure, stiffening the colonoscope, and alternating between adult or pediatric colonoscopes.
 

Adenoma detection rate

Adenoma detection rate (ADR), is defined as the proportion of patients over the age of 50 years undergoing first-time screening colonoscopies in which at least one adenomatous polyp is detected for a given endoscopist in a given time period.

Adenomas are tracked because clearing the colon of neoplasm is the goal of screening colonoscopies; adenomas are tracked instead of more advanced lesions because the higher frequency of adenomas allows for better tracking of variation between endoscopists. Tracking ADR also utilizes the assumption that, if small lesions are identified, larger ones will be as well.

ADR is the only current quality indicator reported to be significantly associated with the risk of interval cancers. In 2010, a study of 45,000 screening colonoscopies by 186 endoscopists validated the use of ADR, finding that patients who underwent colonoscopy by physicians with ADRs below 20% had hazard ratios for development of postcolonoscopy cancer greater than 10 times higher than patients of physicians with ADRs above 20%.⁹ However, this study had limited power to establish that cancer protection continues to improve when ADRs rise above 20%. Another study, which evaluated the association of ADR in 224,000 patients undergoing colonoscopies by 136 gastroenterologists, showed each 1% increase in ADR is associated with 3% decrease in the risk of interval CRC and 5% decrease in the risk of fatal interval cancers.¹⁰

Most recent guidelines propose an adequate ADR for asymptomatic individuals aged 50 years or older undergoing screening colonoscopy should be greater than 30% in men and greater than 20% in women.⁶ It remains unknown whether there is a threshold for maximum benefit of ADR, in which a very high ADR is not associated with further protective benefit. The answer to this question may depend on why a low ADR is associated with a higher rate of interval cancers and whether every missed polyp, independent of size, is a potential interval cancer or whether hasty, inadequate, or incomplete examinations of the colon are the underlying concern.

Withdrawal time

Optimizing identification of colonic lesions requires a careful and thorough exam of the colon on withdrawal. While this may seem obvious, there is often little focus on the approach to withdrawal. In four chapters on colonoscopy technique from textbooks, the number of pages describing insertion ranged from 20 to 38, while the number of pages focused on withdrawal ranged from 0.5 to 1.5.^11-14

A study examining the difference in withdrawal technique between two endoscopists who were known to differ in adenoma miss rates by tandem colonoscopy proposed the scoring system listed in Table 2 that can assess quality of examination on withdrawal. There was a statistically significant difference in quality scores for the two endoscopists, as assessed by expert review of video recordings of their colonoscopies.¹⁵

The endoscopist with the lower adenoma miss rate was also found to have an average withdrawal time of 8 minutes and 55 seconds versus 6 minutes and 41 seconds for the endoscopist with the higher adenoma miss rate. A large, community-based study with over 76,000 colonoscopies found a statistically significant correlation between interval colorectal cancer and withdrawal times shorter than 6 minutes.¹⁶ However, there was no association between ADR and colorectal cancer, suggesting that, for practices with optimal ADRs (that is, rates greater than 25%), withdrawal time may be a more sensitive marker of quality of colonoscopy than ADR is.¹⁶Intuitively, adequate examination of the colon that includes examining the proximal side of folds, washing and suctioning stool, and even repositioning the patient would likely increase withdrawal time. In a 2008 study examining 2,000 screening colonoscopies of 12 endoscopists, those with withdrawal times greater than 6 minutes had significantly higher rates of detecting adenomas and advanced neoplasia, compared with those with faster withdrawal times.¹⁷ The average ADR in this group was 28.3%, compared with 11.8% for physicians who had a withdrawal time less than 6 minutes.¹⁷ An evaluation of nearly 11,000 colonoscopies done by 43 endoscopists also identified an increase polyp yield with increased withdrawal time.¹⁸ These data drive the recommendation for a minimum withdrawal time of 6 minutes, with 2 minutes spent examining each colonic segment.

Bowel preparation

Diagnosis of colonic lesions is dependent on adequate visualization of the colon. Poor bowel preparation can limit the yield of colonoscopy and lead to missed lesions. It also leads to canceled and rescheduled procedures that reduce efficiency, increase cost, and pose an undue burden on the patient.

The quality of bowel preparation should be assessed after washing and suctioning of colonic mucosa has been completed. Adequate preparation is that which allows identification of lesions greater than 5 mm in size.¹⁹

Quality of preparation is assessed subjectively by the endoscopists and often listed as excellent, good, fair, or poor. An alternative method of reporting bowel preparation quality is the Boston Bowel Preparation Score (BBPS) (Table 3).²⁰ This scoring system allows for a more descriptive assessment of each colonic segment by assigning a score from 0 to 3 for the right, transverse, and left colon, leading to a total score between 0 and 9. The BBPS also helps standardize reporting of bowel preparation. The polyp detection rate associated with a BBPS of 5 or greater was 40%, compared with 24% associated with BBPS less than 5.¹⁹ A split-dose bowel preparation regimen with at least half of the preparation ingested on the day of the procedure is recommended to optimize quality of bowel preparation.⁶

The American Society for Gastrointestinal Endoscopy and American College of Gastroenterology task force on quality assurance in endoscopy recommends that bowel preparation should be adequate in 85% of all colonoscopy exams on a per-provider basis.⁷ One study of completed colonoscopy with inadequate preparation showed an adenoma miss rate of 48%.²¹ In the setting of inadequate bowel preparation, another study reported 42% of all adenomas detected were only found on repeat colonoscopy. When considering advanced adenomas, there was a 27% miss rate, a relatively high percentage.²²
 

When poor bowel preparation precludes the exam, colonoscopy is appropriately aborted, and the patient asked to return. However, there are situations in which the exam can be completed but the bowel preparation is still inadequate to identify polyps larger than 5 mm. In this setting, the colonoscopy should be repeated with a more aggressive bowel preparation regimen within 1 year.¹⁹ Shorter intervals are recommended if advanced neoplasm is detected within an inadequate bowel preparation.¹⁹

The appropriate surveillance interval can be unclear when bowel preparation is considered adequate to identify polyps greater than or equal to 5 mm, yet still suboptimal. “Adequate” or “fair” bowel preparation often leads to shorter-than-recommended surveillance intervals because of the concern for small missed lesions. For example, patients with normal colonoscopy results and a fair prep were recommended to undergo a screening colonoscopy in 5 years at 57.4%, while only 23.1% received a 10-year recommendation.²³ This increased frequency of colonoscopy leads to increased costs and procedural risks for the patient. Furthermore, a meta-analysis evaluating the effects of bowel preparation reported no significant difference in ADR between adequate and excellent prep.²⁴ These findings suggest that patients with adequate bowel preparation may be followed at guideline-recommended surveillance intervals without significantly affecting colonoscopy quality as measured by ADR.

Endoscopist feedback and report cards

Awareness of quality metrics among individuals and endoscopy practices is crucial to ensuring adequate performance. Several studies have shown improvement with feedback and monitoring of endoscopists.^25,26 Some strategies to improve colonoscopy technique and efficiency include having recorded or observed procedures, computer software that measures image resolution/velocity, and scorecards with quality measures. A representation of the scorecards used in our practice is shown in Table 4. Feedback measures both make endoscopists aware of how their performance compares with recommended goals for colonoscopy and help track their improvement. We recommend such feedback should be provided quarterly for most providers and more frequently for providers not meeting benchmarks.

Conclusion

Given we rely on colonoscopy to identify and clear the colon of potential malignancy, it is imperative that we provide high-value exams for our patients. The basis for a quality colonoscopy is complete intubation and careful inspection of the mucosa on withdrawal. Several quality measures are used as surrogates of a good exam such that endoscopists can assess themselves in relation to their peers. These metrics can help us in our goal of remaining mindful during each procedure we are completing and providing the best exam possible.

Dr. Shamsi is a third-year GI fellow. Dr. Malhotra is an assistant professor in the division of gastroenterology at the University of Minnesota, Minneapolis. Dr. Shaukat is a professor of medicine in the division of gastroenterology at the University of Minnesota, Minneapolis, and the GI Section Chief at the Minneapolis VA Medical Center.

References

1. Siegel R et al. CA Cancer J Clin. 2012 Jan-Feb;62(1):10-29.

2. Edwards BK et al. Cancer. 2010 Feb 1;116(3):544-73.

3. Hosokawa O et al. Endoscopy. 2003 Jun;35(6):506-10.

4. Morris EJ et al. Gut. 2015(Aug);64(2):1248-56.

5. Bressler B et al. Gastroenterology. 2004 Aug;127(2):452-6.

6. Rex DK et al. Am J Gastroenterol. 2017 July;12(7):1016-30.

7. Rex DK et al. Gastrointest Endosc. 2015 Jan;81(1):31-53.

8. Anderson J et al. Clin Transl Gastroenterol. 2015 Feb 26;6:e77.

9. Kaminski M et al. N Engl J Med. 2010 May 13;362(19):1795-803.

10. Corley DA et al. N Engl J Med. 2014 Apr 3;370(4):1298-306.

11. Hunt RH. Colonoscopy intubation techniques without fluoroscopy. In: Colonoscopy techniques clinical practice and color atlas. Edited by Hunt RH, Waye JD. London: Chapman and Hall; 1981. p. 109-46.

12. Waye JD. Colonoscopy intubation techniques without fluoroscopy. In: Colonoscopy techniques clinical practice and color atlas. Edited by Hunt RH, Waye JD. London: Chapman and Hall; 1981. p. 147-78.

13. Williams CB et al. In: Colonoscopy principles & techniques. Edited by Raskin J, Juergen NH. New York: Igaku-Shoin Medical Publishers; 1995. p. 121-42.

14. Baillie J. Colonoscopy. In: Gastrointestinal endoscopy basic principles and practice. Oxford (UK): Butterworth-Heinemann; 1992. p. 63-92.

15. Rex DK. Gastrointest Endosc. 2000 Jan;51(1):33-6.

16. Shaukat A et al. Gastroenterol. 2015;149(4):952-7.

17. Barclay R et al. N Engl J Med. 2006 Dec 14;355(24):2533-41.

18. Simmons DT et al. Gastrointest Endosc. 2007;65(5):AB94.

19. Johnson DA et al. Gastrointest Endosc. 2014;80(4):543-62.

20. Calderwood A et al. Gastrointest Endosc. 2010 Oct;72(4):686-92.

21. Chokshi R et al. Gastrointest Endosc. 2012 Jun;75(6):1197-203.

22. Lebwohl B et al. Gastrointest Endosc. 2011 Jun;73(6):1207-14.

23. Menees SB et al. Gastrointest Endosc. 2013 Sep;78(3): 510-6.

24. Clark B et al. Am J Gastroenterol. 2014 Nov;109(11):1714-23.

25. Nielson A et al. BMJ Open Gastro. 2017 Jun. doi: 10.1136/bmjgast-2017-000142.

26. Gurudu S et al. J Gastroenterol Hepatol. 2018 Mar;33(3):645-9.

Editor's Note: 

As quality metrics are becoming increasingly significant throughout all of medicine, our field is no exception. Recent evidence has demonstrated the importance of quality measures in colonoscopy; understanding, reporting, and improving these metrics has become a hot topic of discussion.

In this month’s In Focus article, brought to you by The New Gastroenterologist, Nabiha Shamsi, Ashish Malhotra, and Aasma Shaukat (University of Minnesota/Minneapolis VAMC) provide an outstanding overview of the evidence as well as recommended goals for important quality metrics in colonoscopy. Ultimately, improving colonoscopy quality amongst all gastroenterologists will increase colonoscopy value and lead to further decreases in the incidence and mortality of colorectal cancer.

Bryson W. Katona, MD, PhD
Editor in Chief, The New Gastroenterologist

Introduction

Colonoscopy is a widely used modality to evaluate colorectal cancer because it allows for both identification of early malignancies and removal of precancerous lesions. The increased use of colonoscopy in the last 20 years has been associated with a decline in the incidence and mortality from colorectal cancer.^1,2 However, colonoscopy has its limitations. It is an invasive test with inherent risks. Additionally, studies have reported rates of post-colonoscopy cancers, also referred to as interval cancers, of 2%-7%, and miss-rates for adenomas by tandem colonoscopy of 2%-26%.^3-5

High-quality exams can maximize the value of colonoscopy, and it is important to consider the factors that contribute to high-quality colonoscopies. While there are many metrics proposed,^6,7 here we discuss the most evidence-based ones, outlined in Table 1, along with their goal values.
 

Cecal intubation rate

A high-quality colonoscopy should include a complete examination of the colon. To achieve this, it is necessary to fully intubate the cecum, passing the colonoscope past the ileocecal valve to examine the medial wall of the cecum.⁸

There are several factors that may contribute to an incomplete colonoscopy, including bowel preparation, anatomy, body habitus, and endoscopist’s skill. To calculate cecal intubation rate as a quality measure, colonoscopies that are incomplete because of poor bowel preparation, severe colitis, or known obstructing lesion are usually excluded.

The U.S. Multi-Society Task Force on Colorectal Cancer recommends a cecal intubation rate of at least 95% for screening colonoscopy and 90% for all colonoscopies.⁶ There is an expectation of photodocumentation of the ileocecal valve and appendiceal orifice to establish completion of the colonoscopy.⁶

Some methods used to assist with cecal intubation include changing patient position, applying abdominal pressure, stiffening the colonoscope, and alternating between adult or pediatric colonoscopes.
 

Adenoma detection rate

Adenoma detection rate (ADR), is defined as the proportion of patients over the age of 50 years undergoing first-time screening colonoscopies in which at least one adenomatous polyp is detected for a given endoscopist in a given time period.

Adenomas are tracked because clearing the colon of neoplasm is the goal of screening colonoscopies; adenomas are tracked instead of more advanced lesions because the higher frequency of adenomas allows for better tracking of variation between endoscopists. Tracking ADR also utilizes the assumption that, if small lesions are identified, larger ones will be as well.

ADR is the only current quality indicator reported to be significantly associated with the risk of interval cancers. In 2010, a study of 45,000 screening colonoscopies by 186 endoscopists validated the use of ADR, finding that patients who underwent colonoscopy by physicians with ADRs below 20% had hazard ratios for development of postcolonoscopy cancer greater than 10 times higher than patients of physicians with ADRs above 20%.⁹ However, this study had limited power to establish that cancer protection continues to improve when ADRs rise above 20%. Another study, which evaluated the association of ADR in 224,000 patients undergoing colonoscopies by 136 gastroenterologists, showed each 1% increase in ADR is associated with 3% decrease in the risk of interval CRC and 5% decrease in the risk of fatal interval cancers.¹⁰

Most recent guidelines propose an adequate ADR for asymptomatic individuals aged 50 years or older undergoing screening colonoscopy should be greater than 30% in men and greater than 20% in women.⁶ It remains unknown whether there is a threshold for maximum benefit of ADR, in which a very high ADR is not associated with further protective benefit. The answer to this question may depend on why a low ADR is associated with a higher rate of interval cancers and whether every missed polyp, independent of size, is a potential interval cancer or whether hasty, inadequate, or incomplete examinations of the colon are the underlying concern.

Withdrawal time

Optimizing identification of colonic lesions requires a careful and thorough exam of the colon on withdrawal. While this may seem obvious, there is often little focus on the approach to withdrawal. In four chapters on colonoscopy technique from textbooks, the number of pages describing insertion ranged from 20 to 38, while the number of pages focused on withdrawal ranged from 0.5 to 1.5.^11-14

A study examining the difference in withdrawal technique between two endoscopists who were known to differ in adenoma miss rates by tandem colonoscopy proposed the scoring system listed in Table 2 that can assess quality of examination on withdrawal. There was a statistically significant difference in quality scores for the two endoscopists, as assessed by expert review of video recordings of their colonoscopies.¹⁵

The endoscopist with the lower adenoma miss rate was also found to have an average withdrawal time of 8 minutes and 55 seconds versus 6 minutes and 41 seconds for the endoscopist with the higher adenoma miss rate. A large, community-based study with over 76,000 colonoscopies found a statistically significant correlation between interval colorectal cancer and withdrawal times shorter than 6 minutes.¹⁶ However, there was no association between ADR and colorectal cancer, suggesting that, for practices with optimal ADRs (that is, rates greater than 25%), withdrawal time may be a more sensitive marker of quality of colonoscopy than ADR is.¹⁶Intuitively, adequate examination of the colon that includes examining the proximal side of folds, washing and suctioning stool, and even repositioning the patient would likely increase withdrawal time. In a 2008 study examining 2,000 screening colonoscopies of 12 endoscopists, those with withdrawal times greater than 6 minutes had significantly higher rates of detecting adenomas and advanced neoplasia, compared with those with faster withdrawal times.¹⁷ The average ADR in this group was 28.3%, compared with 11.8% for physicians who had a withdrawal time less than 6 minutes.¹⁷ An evaluation of nearly 11,000 colonoscopies done by 43 endoscopists also identified an increase polyp yield with increased withdrawal time.¹⁸ These data drive the recommendation for a minimum withdrawal time of 6 minutes, with 2 minutes spent examining each colonic segment.

Bowel preparation

Diagnosis of colonic lesions is dependent on adequate visualization of the colon. Poor bowel preparation can limit the yield of colonoscopy and lead to missed lesions. It also leads to canceled and rescheduled procedures that reduce efficiency, increase cost, and pose an undue burden on the patient.

The quality of bowel preparation should be assessed after washing and suctioning of colonic mucosa has been completed. Adequate preparation is that which allows identification of lesions greater than 5 mm in size.¹⁹

Quality of preparation is assessed subjectively by the endoscopists and often listed as excellent, good, fair, or poor. An alternative method of reporting bowel preparation quality is the Boston Bowel Preparation Score (BBPS) (Table 3).²⁰ This scoring system allows for a more descriptive assessment of each colonic segment by assigning a score from 0 to 3 for the right, transverse, and left colon, leading to a total score between 0 and 9. The BBPS also helps standardize reporting of bowel preparation. The polyp detection rate associated with a BBPS of 5 or greater was 40%, compared with 24% associated with BBPS less than 5.¹⁹ A split-dose bowel preparation regimen with at least half of the preparation ingested on the day of the procedure is recommended to optimize quality of bowel preparation.⁶

The American Society for Gastrointestinal Endoscopy and American College of Gastroenterology task force on quality assurance in endoscopy recommends that bowel preparation should be adequate in 85% of all colonoscopy exams on a per-provider basis.⁷ One study of completed colonoscopy with inadequate preparation showed an adenoma miss rate of 48%.²¹ In the setting of inadequate bowel preparation, another study reported 42% of all adenomas detected were only found on repeat colonoscopy. When considering advanced adenomas, there was a 27% miss rate, a relatively high percentage.²²
 

When poor bowel preparation precludes the exam, colonoscopy is appropriately aborted, and the patient asked to return. However, there are situations in which the exam can be completed but the bowel preparation is still inadequate to identify polyps larger than 5 mm. In this setting, the colonoscopy should be repeated with a more aggressive bowel preparation regimen within 1 year.¹⁹ Shorter intervals are recommended if advanced neoplasm is detected within an inadequate bowel preparation.¹⁹

The appropriate surveillance interval can be unclear when bowel preparation is considered adequate to identify polyps greater than or equal to 5 mm, yet still suboptimal. “Adequate” or “fair” bowel preparation often leads to shorter-than-recommended surveillance intervals because of the concern for small missed lesions. For example, patients with normal colonoscopy results and a fair prep were recommended to undergo a screening colonoscopy in 5 years at 57.4%, while only 23.1% received a 10-year recommendation.²³ This increased frequency of colonoscopy leads to increased costs and procedural risks for the patient. Furthermore, a meta-analysis evaluating the effects of bowel preparation reported no significant difference in ADR between adequate and excellent prep.²⁴ These findings suggest that patients with adequate bowel preparation may be followed at guideline-recommended surveillance intervals without significantly affecting colonoscopy quality as measured by ADR.

Endoscopist feedback and report cards

Awareness of quality metrics among individuals and endoscopy practices is crucial to ensuring adequate performance. Several studies have shown improvement with feedback and monitoring of endoscopists.^25,26 Some strategies to improve colonoscopy technique and efficiency include having recorded or observed procedures, computer software that measures image resolution/velocity, and scorecards with quality measures. A representation of the scorecards used in our practice is shown in Table 4. Feedback measures both make endoscopists aware of how their performance compares with recommended goals for colonoscopy and help track their improvement. We recommend such feedback should be provided quarterly for most providers and more frequently for providers not meeting benchmarks.

Conclusion

Given we rely on colonoscopy to identify and clear the colon of potential malignancy, it is imperative that we provide high-value exams for our patients. The basis for a quality colonoscopy is complete intubation and careful inspection of the mucosa on withdrawal. Several quality measures are used as surrogates of a good exam such that endoscopists can assess themselves in relation to their peers. These metrics can help us in our goal of remaining mindful during each procedure we are completing and providing the best exam possible.

Dr. Shamsi is a third-year GI fellow. Dr. Malhotra is an assistant professor in the division of gastroenterology at the University of Minnesota, Minneapolis. Dr. Shaukat is a professor of medicine in the division of gastroenterology at the University of Minnesota, Minneapolis, and the GI Section Chief at the Minneapolis VA Medical Center.

References

1. Siegel R et al. CA Cancer J Clin. 2012 Jan-Feb;62(1):10-29.

2. Edwards BK et al. Cancer. 2010 Feb 1;116(3):544-73.

3. Hosokawa O et al. Endoscopy. 2003 Jun;35(6):506-10.

4. Morris EJ et al. Gut. 2015(Aug);64(2):1248-56.

5. Bressler B et al. Gastroenterology. 2004 Aug;127(2):452-6.

6. Rex DK et al. Am J Gastroenterol. 2017 July;12(7):1016-30.

7. Rex DK et al. Gastrointest Endosc. 2015 Jan;81(1):31-53.

8. Anderson J et al. Clin Transl Gastroenterol. 2015 Feb 26;6:e77.

9. Kaminski M et al. N Engl J Med. 2010 May 13;362(19):1795-803.

10. Corley DA et al. N Engl J Med. 2014 Apr 3;370(4):1298-306.

11. Hunt RH. Colonoscopy intubation techniques without fluoroscopy. In: Colonoscopy techniques clinical practice and color atlas. Edited by Hunt RH, Waye JD. London: Chapman and Hall; 1981. p. 109-46.

12. Waye JD. Colonoscopy intubation techniques without fluoroscopy. In: Colonoscopy techniques clinical practice and color atlas. Edited by Hunt RH, Waye JD. London: Chapman and Hall; 1981. p. 147-78.

13. Williams CB et al. In: Colonoscopy principles & techniques. Edited by Raskin J, Juergen NH. New York: Igaku-Shoin Medical Publishers; 1995. p. 121-42.

14. Baillie J. Colonoscopy. In: Gastrointestinal endoscopy basic principles and practice. Oxford (UK): Butterworth-Heinemann; 1992. p. 63-92.

15. Rex DK. Gastrointest Endosc. 2000 Jan;51(1):33-6.

16. Shaukat A et al. Gastroenterol. 2015;149(4):952-7.

17. Barclay R et al. N Engl J Med. 2006 Dec 14;355(24):2533-41.

18. Simmons DT et al. Gastrointest Endosc. 2007;65(5):AB94.

19. Johnson DA et al. Gastrointest Endosc. 2014;80(4):543-62.

20. Calderwood A et al. Gastrointest Endosc. 2010 Oct;72(4):686-92.

21. Chokshi R et al. Gastrointest Endosc. 2012 Jun;75(6):1197-203.

22. Lebwohl B et al. Gastrointest Endosc. 2011 Jun;73(6):1207-14.

23. Menees SB et al. Gastrointest Endosc. 2013 Sep;78(3): 510-6.

24. Clark B et al. Am J Gastroenterol. 2014 Nov;109(11):1714-23.

25. Nielson A et al. BMJ Open Gastro. 2017 Jun. doi: 10.1136/bmjgast-2017-000142.

26. Gurudu S et al. J Gastroenterol Hepatol. 2018 Mar;33(3):645-9.

Dear Colleagues,

In the August issue of The New Gastroenterologist, we have some fantastic articles that I hope you will find both interesting and useful.

First, as quality metrics are becoming increasingly important in all aspects of health care, it is critical that we have a good understanding of quality metrics within our field. This issue’s “In Focus” article, written by Nabiha Shamsi, Ashish Malhotra, and Aasma Shaukat (University of Minnesota/Minnesota VAMC), provides a helpful overview of the currently accepted quality metrics for colonoscopy as well as the data that support their use. This article can be found online as well as in print in the August issue of GI & Hepatology News.
 

Additionally, in this issue, we have several articles highlighting important AGA programs that are great opportunities for those of us in our early careers. First, Jennifer Weiss (University of Wisconsin) discusses her experience in the Future Leaders Program, which just graduated its second class at DDW this year. Additionally, Sarah Lieber (UNC Chapel Hill) and Ana Maldonado-Contreras (University of Massachusetts) chronicle their experiences at the AGA Academic Skills Workshop which was held in Charlotte earlier this year. Finally, Eric Shah (University of Michigan), who served as this past year’s Gastroenterology Editorial Fellow, provides insights from his experience in this new position designed specifically for those in their early career.

Also in this issue is an article about pursuing a career in the innovation industry, authored by Chang Hee Kim (GoDx) and Wendy Henderson (NINR/NIH), who were winners of this year’s AGA Shark Tank. Finally, as many will be looking for new jobs in the coming year, one of the most important parts of this process will be the contract. Scott Roman, an attorney with significant expertise in contract law, provides an overview highlighting the important points about contracts that should not be overlooked.

As with prior installments of The New Gastroenterologist e-newsletter, please check out the “In Case You Missed It” section to see recent articles published in the AGA journals that have pertinence to those of us in our early careers. If you have any ideas or are interested in contributing to The New Gastroenterologist, please contact me at [email protected] or the managing editor, Ryan Farrell, at [email protected].

Sincerely,

Bryson W. Katona, MD, PhD
Editor in Chief

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

Dear Colleagues,

In the August issue of The New Gastroenterologist, we have some fantastic articles that I hope you will find both interesting and useful.

First, as quality metrics are becoming increasingly important in all aspects of health care, it is critical that we have a good understanding of quality metrics within our field. This issue’s “In Focus” article, written by Nabiha Shamsi, Ashish Malhotra, and Aasma Shaukat (University of Minnesota/Minnesota VAMC), provides a helpful overview of the currently accepted quality metrics for colonoscopy as well as the data that support their use. This article can be found online as well as in print in the August issue of GI & Hepatology News.
 

Additionally, in this issue, we have several articles highlighting important AGA programs that are great opportunities for those of us in our early careers. First, Jennifer Weiss (University of Wisconsin) discusses her experience in the Future Leaders Program, which just graduated its second class at DDW this year. Additionally, Sarah Lieber (UNC Chapel Hill) and Ana Maldonado-Contreras (University of Massachusetts) chronicle their experiences at the AGA Academic Skills Workshop which was held in Charlotte earlier this year. Finally, Eric Shah (University of Michigan), who served as this past year’s Gastroenterology Editorial Fellow, provides insights from his experience in this new position designed specifically for those in their early career.

Also in this issue is an article about pursuing a career in the innovation industry, authored by Chang Hee Kim (GoDx) and Wendy Henderson (NINR/NIH), who were winners of this year’s AGA Shark Tank. Finally, as many will be looking for new jobs in the coming year, one of the most important parts of this process will be the contract. Scott Roman, an attorney with significant expertise in contract law, provides an overview highlighting the important points about contracts that should not be overlooked.

As with prior installments of The New Gastroenterologist e-newsletter, please check out the “In Case You Missed It” section to see recent articles published in the AGA journals that have pertinence to those of us in our early careers. If you have any ideas or are interested in contributing to The New Gastroenterologist, please contact me at [email protected] or the managing editor, Ryan Farrell, at [email protected].

Sincerely,

Bryson W. Katona, MD, PhD
Editor in Chief

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

Dear Colleagues,

In the August issue of The New Gastroenterologist, we have some fantastic articles that I hope you will find both interesting and useful.

First, as quality metrics are becoming increasingly important in all aspects of health care, it is critical that we have a good understanding of quality metrics within our field. This issue’s “In Focus” article, written by Nabiha Shamsi, Ashish Malhotra, and Aasma Shaukat (University of Minnesota/Minnesota VAMC), provides a helpful overview of the currently accepted quality metrics for colonoscopy as well as the data that support their use. This article can be found online as well as in print in the August issue of GI & Hepatology News.
 

Additionally, in this issue, we have several articles highlighting important AGA programs that are great opportunities for those of us in our early careers. First, Jennifer Weiss (University of Wisconsin) discusses her experience in the Future Leaders Program, which just graduated its second class at DDW this year. Additionally, Sarah Lieber (UNC Chapel Hill) and Ana Maldonado-Contreras (University of Massachusetts) chronicle their experiences at the AGA Academic Skills Workshop which was held in Charlotte earlier this year. Finally, Eric Shah (University of Michigan), who served as this past year’s Gastroenterology Editorial Fellow, provides insights from his experience in this new position designed specifically for those in their early career.

Also in this issue is an article about pursuing a career in the innovation industry, authored by Chang Hee Kim (GoDx) and Wendy Henderson (NINR/NIH), who were winners of this year’s AGA Shark Tank. Finally, as many will be looking for new jobs in the coming year, one of the most important parts of this process will be the contract. Scott Roman, an attorney with significant expertise in contract law, provides an overview highlighting the important points about contracts that should not be overlooked.

As with prior installments of The New Gastroenterologist e-newsletter, please check out the “In Case You Missed It” section to see recent articles published in the AGA journals that have pertinence to those of us in our early careers. If you have any ideas or are interested in contributing to The New Gastroenterologist, please contact me at [email protected] or the managing editor, Ryan Farrell, at [email protected].

Sincerely,

Bryson W. Katona, MD, PhD
Editor in Chief

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

In March 2018, the American Gastroenterological Association (AGA) and American Association for the Study of Liver Diseases (AASLD) sponsored the Academic Skills Workshop in Charlotte, N.C. This year’s chairs Barbara Jung, MD, and Michael W. Fried, MD, FAASLD, as well as codirectors Marcia Cruz-Correa, MD, PhD, AGAF, FASGE, and Raymond Chung, MD, FAASLD, led a 2-day workshop featuring educational sessions and opportunities for mentorship and networking in academic gastroenterology and hepatology. The workshop featured sessions on how to navigate the job market, map out a career trajectory, develop fruitful mentoring relationships, apply for grant funding, and showcase research through manuscripts and oral presentations. Fellows and junior faculty from academic institutions across the United States were able to come together. Herein, two participants share their experiences at this event.

Clinical perspective from Sarah R. Lieber, MD

As a second-year gastroenterology fellow and aspiring transplant hepatologist, I found that this workshop provided an excellent framework and foundation for launching a career in academics and clinical research. It was especially effective at providing practical tips and tools for fellows and junior faculty on how to find an academic job, apply for research funding, and conduct written and oral presentations.

I was particularly moved by the personal stories and anecdotes from faculty members – many of whom are renowned leaders in the fields of GI and hepatology – who divulged the challenges and insecurities they had to overcome early in their careers. Sheila E. Crowe, MD, FRCPC, FACP, FACG, AGAF, gave an especially poignant talk on her career path from fellowship to becoming AGA president. She discussed the challenges unique to women in academic GI and hepatology, but left me feeling empowered and inspired by showcasing the many talents and success stories of her female colleagues and herself as well.

On Saturday, the AASLD held a special session that highlighted the personal stories and career trajectories of clinicians and researchers in the forefront of the field of hepatology – including AASLD president-elect Michael W. Fried, MD, FAASLD, and current AASLD President Ana Lok MD, FAASLD – among others. They emphasized the power of collaborative research that included harnessing the tools of molecular biology and Big Data to investigate the role of the microbiome and other novel subjects in liver disease. They advised us to seek out formal training when available, including master degrees or biostatistics training, to help us develop the skill sets necessary as independent researchers. They elaborated about their experiences serving on professional committees and giving oral presentations – essential to their career development – which allowed them to carve out a research niche and gain recognition as experts in their fields.

There were several powerful lessons and important themes that I take away from this workshop. The first is the importance of citizenship: Being a successful academician means not only putting in the clinical hours and being a prolific researcher but also being a good citizen. Supporting your colleagues, teaching mentees, and being a “team player” are all elements crucial to forming meaningful relationships and standing out as a valuable individual in your department. Second, perseverance is equally important; whether you are resubmitting applications for grant funding or reaching out to mentors in your area of interest, perseverance is the key to a successful career in academics. Third, remember that there is the important distinction between mentorship and sponsorship. While it is essential to have a selfless and supportive mentor who helps you cultivate your clinical and research interests, it is equally important to find a sponsor: an influential academician who can help you launch your career by acting as your advocate and opening doors to professional opportunities. Finally,you must always deliver. When mentors and sponsors give you opportunities to showcase your talents, always invest the time and effort to provide a high-quality performance. Be a good citizen who perseveres, seek out influential mentorship and sponsorship, and deliver on important professional tasks which will prime you to succeed as an academic clinical researcher in GI and hepatology.
 

Basic scientist perspective from Ana Maldonado-Contreras, PhD

The AGA-AASLD Workshop represented an ideal opportunity to regain perspective on my overall career plan. This year, Dr. Jung restructured the format of the program by substituting “lecture-style” sessions with fully interactive discussion panels in which trainees had the opportunity to initiate discussions about various topics of interest. The faculty leading these interactive sessions were committed to providing honest and clear answers to all of our questions. I believe this was a unique opportunity to go beyond PowerPoint presentations to actually gain insights on the dynamics of an academic department. We learned from department chairs what is considered during hiring, promoting, or allocating funds to make their team successful. Among the topics discussed, collegiality and selfless peer support were highlighted among the qualities of an appreciated department member. Panelists insisted that a balancing act between team support and one’s productivity is fundamental to thriving and maintaining focus.

Another topic with personal relevance was securing funding for my newly formed laboratory – and I was not alone! Prior to the meeting, participants were divided into small groups and assigned to a faculty mentor. Each participant was asked to share a research proposal and CV with her respective mentor. Then, each group had the opportunity to meet during the afternoon mentoring sessions. My group was composed of four participants interested in learning more about National Institutes of Health (NIH) funding strategies based on our current situations. Our assigned mentor, John Inadomi, MD – who thoroughly read our proposals and knew who we were before our encounter – provided practical advice about grant mechanisms to pursue given our current positions and provided detailed tips for successful applications. Dr. Inadomi also was greatly insightful about NIH study sessions and the entire review process. This person-to-person interaction was extremely helpful as it opened the possibility of discussing singularities of each participant’s career plans. Similarly, on the next day we had face time with David Saslowsky, PhD, program director of the National Institute of Diabetes and Digestive and Kidney Diseases at NIH. Dr. Saslowsky also reviewed our research proposals and discussed potential venues for funding within the NIDDK based on individual career trajectories.

Most of the second day was dedicated to reviewing grant opportunities and pertinent tips on how to get funded. We discussed the “most common mistakes” made by junior faculty on grant applications and ways to avoid them. All panelists agreed that the most common mistake is overambition. They advised us to critically consider the aims and activities proposed and, more importantly, seek out advice from mentors with more experience in grant writing.

Undoubtedly, networking with other peers represented an essential part of the experience at this academic workshop. As trainees, we were able to connect with not only seasoned colleagues but also with peers facing the same career challenges. Senior faculty were amazingly personable and committed to sharing experiences with the next generation of clinicians and scientists. They shared their failures, frustrations, and fears as well as their successes. Each story and the words of encouragement from this great community of scientists and clinicians helped me realize my hidden strengths and how to build from my past accomplishments to excel on my path toward becoming a fully independent researcher.
 

Dr. Lieber is a clinical epidemiology fellow, department of medicine, division of gastroenterology and hepatology, University of North Carolina (UNC), Chapel Hill; Dr. Maldonado-Contreras is an instructor in the department of microbiology and physiological systems and the Center for Microbiome Research, University of Massachusetts, Worcester.

In March 2018, the American Gastroenterological Association (AGA) and American Association for the Study of Liver Diseases (AASLD) sponsored the Academic Skills Workshop in Charlotte, N.C. This year’s chairs Barbara Jung, MD, and Michael W. Fried, MD, FAASLD, as well as codirectors Marcia Cruz-Correa, MD, PhD, AGAF, FASGE, and Raymond Chung, MD, FAASLD, led a 2-day workshop featuring educational sessions and opportunities for mentorship and networking in academic gastroenterology and hepatology. The workshop featured sessions on how to navigate the job market, map out a career trajectory, develop fruitful mentoring relationships, apply for grant funding, and showcase research through manuscripts and oral presentations. Fellows and junior faculty from academic institutions across the United States were able to come together. Herein, two participants share their experiences at this event.

Clinical perspective from Sarah R. Lieber, MD

As a second-year gastroenterology fellow and aspiring transplant hepatologist, I found that this workshop provided an excellent framework and foundation for launching a career in academics and clinical research. It was especially effective at providing practical tips and tools for fellows and junior faculty on how to find an academic job, apply for research funding, and conduct written and oral presentations.

I was particularly moved by the personal stories and anecdotes from faculty members – many of whom are renowned leaders in the fields of GI and hepatology – who divulged the challenges and insecurities they had to overcome early in their careers. Sheila E. Crowe, MD, FRCPC, FACP, FACG, AGAF, gave an especially poignant talk on her career path from fellowship to becoming AGA president. She discussed the challenges unique to women in academic GI and hepatology, but left me feeling empowered and inspired by showcasing the many talents and success stories of her female colleagues and herself as well.

On Saturday, the AASLD held a special session that highlighted the personal stories and career trajectories of clinicians and researchers in the forefront of the field of hepatology – including AASLD president-elect Michael W. Fried, MD, FAASLD, and current AASLD President Ana Lok MD, FAASLD – among others. They emphasized the power of collaborative research that included harnessing the tools of molecular biology and Big Data to investigate the role of the microbiome and other novel subjects in liver disease. They advised us to seek out formal training when available, including master degrees or biostatistics training, to help us develop the skill sets necessary as independent researchers. They elaborated about their experiences serving on professional committees and giving oral presentations – essential to their career development – which allowed them to carve out a research niche and gain recognition as experts in their fields.

There were several powerful lessons and important themes that I take away from this workshop. The first is the importance of citizenship: Being a successful academician means not only putting in the clinical hours and being a prolific researcher but also being a good citizen. Supporting your colleagues, teaching mentees, and being a “team player” are all elements crucial to forming meaningful relationships and standing out as a valuable individual in your department. Second, perseverance is equally important; whether you are resubmitting applications for grant funding or reaching out to mentors in your area of interest, perseverance is the key to a successful career in academics. Third, remember that there is the important distinction between mentorship and sponsorship. While it is essential to have a selfless and supportive mentor who helps you cultivate your clinical and research interests, it is equally important to find a sponsor: an influential academician who can help you launch your career by acting as your advocate and opening doors to professional opportunities. Finally,you must always deliver. When mentors and sponsors give you opportunities to showcase your talents, always invest the time and effort to provide a high-quality performance. Be a good citizen who perseveres, seek out influential mentorship and sponsorship, and deliver on important professional tasks which will prime you to succeed as an academic clinical researcher in GI and hepatology.
 

Basic scientist perspective from Ana Maldonado-Contreras, PhD

The AGA-AASLD Workshop represented an ideal opportunity to regain perspective on my overall career plan. This year, Dr. Jung restructured the format of the program by substituting “lecture-style” sessions with fully interactive discussion panels in which trainees had the opportunity to initiate discussions about various topics of interest. The faculty leading these interactive sessions were committed to providing honest and clear answers to all of our questions. I believe this was a unique opportunity to go beyond PowerPoint presentations to actually gain insights on the dynamics of an academic department. We learned from department chairs what is considered during hiring, promoting, or allocating funds to make their team successful. Among the topics discussed, collegiality and selfless peer support were highlighted among the qualities of an appreciated department member. Panelists insisted that a balancing act between team support and one’s productivity is fundamental to thriving and maintaining focus.

Another topic with personal relevance was securing funding for my newly formed laboratory – and I was not alone! Prior to the meeting, participants were divided into small groups and assigned to a faculty mentor. Each participant was asked to share a research proposal and CV with her respective mentor. Then, each group had the opportunity to meet during the afternoon mentoring sessions. My group was composed of four participants interested in learning more about National Institutes of Health (NIH) funding strategies based on our current situations. Our assigned mentor, John Inadomi, MD – who thoroughly read our proposals and knew who we were before our encounter – provided practical advice about grant mechanisms to pursue given our current positions and provided detailed tips for successful applications. Dr. Inadomi also was greatly insightful about NIH study sessions and the entire review process. This person-to-person interaction was extremely helpful as it opened the possibility of discussing singularities of each participant’s career plans. Similarly, on the next day we had face time with David Saslowsky, PhD, program director of the National Institute of Diabetes and Digestive and Kidney Diseases at NIH. Dr. Saslowsky also reviewed our research proposals and discussed potential venues for funding within the NIDDK based on individual career trajectories.

Most of the second day was dedicated to reviewing grant opportunities and pertinent tips on how to get funded. We discussed the “most common mistakes” made by junior faculty on grant applications and ways to avoid them. All panelists agreed that the most common mistake is overambition. They advised us to critically consider the aims and activities proposed and, more importantly, seek out advice from mentors with more experience in grant writing.

Undoubtedly, networking with other peers represented an essential part of the experience at this academic workshop. As trainees, we were able to connect with not only seasoned colleagues but also with peers facing the same career challenges. Senior faculty were amazingly personable and committed to sharing experiences with the next generation of clinicians and scientists. They shared their failures, frustrations, and fears as well as their successes. Each story and the words of encouragement from this great community of scientists and clinicians helped me realize my hidden strengths and how to build from my past accomplishments to excel on my path toward becoming a fully independent researcher.
 

Dr. Lieber is a clinical epidemiology fellow, department of medicine, division of gastroenterology and hepatology, University of North Carolina (UNC), Chapel Hill; Dr. Maldonado-Contreras is an instructor in the department of microbiology and physiological systems and the Center for Microbiome Research, University of Massachusetts, Worcester.

In March 2018, the American Gastroenterological Association (AGA) and American Association for the Study of Liver Diseases (AASLD) sponsored the Academic Skills Workshop in Charlotte, N.C. This year’s chairs Barbara Jung, MD, and Michael W. Fried, MD, FAASLD, as well as codirectors Marcia Cruz-Correa, MD, PhD, AGAF, FASGE, and Raymond Chung, MD, FAASLD, led a 2-day workshop featuring educational sessions and opportunities for mentorship and networking in academic gastroenterology and hepatology. The workshop featured sessions on how to navigate the job market, map out a career trajectory, develop fruitful mentoring relationships, apply for grant funding, and showcase research through manuscripts and oral presentations. Fellows and junior faculty from academic institutions across the United States were able to come together. Herein, two participants share their experiences at this event.

Clinical perspective from Sarah R. Lieber, MD

As a second-year gastroenterology fellow and aspiring transplant hepatologist, I found that this workshop provided an excellent framework and foundation for launching a career in academics and clinical research. It was especially effective at providing practical tips and tools for fellows and junior faculty on how to find an academic job, apply for research funding, and conduct written and oral presentations.

I was particularly moved by the personal stories and anecdotes from faculty members – many of whom are renowned leaders in the fields of GI and hepatology – who divulged the challenges and insecurities they had to overcome early in their careers. Sheila E. Crowe, MD, FRCPC, FACP, FACG, AGAF, gave an especially poignant talk on her career path from fellowship to becoming AGA president. She discussed the challenges unique to women in academic GI and hepatology, but left me feeling empowered and inspired by showcasing the many talents and success stories of her female colleagues and herself as well.

On Saturday, the AASLD held a special session that highlighted the personal stories and career trajectories of clinicians and researchers in the forefront of the field of hepatology – including AASLD president-elect Michael W. Fried, MD, FAASLD, and current AASLD President Ana Lok MD, FAASLD – among others. They emphasized the power of collaborative research that included harnessing the tools of molecular biology and Big Data to investigate the role of the microbiome and other novel subjects in liver disease. They advised us to seek out formal training when available, including master degrees or biostatistics training, to help us develop the skill sets necessary as independent researchers. They elaborated about their experiences serving on professional committees and giving oral presentations – essential to their career development – which allowed them to carve out a research niche and gain recognition as experts in their fields.

There were several powerful lessons and important themes that I take away from this workshop. The first is the importance of citizenship: Being a successful academician means not only putting in the clinical hours and being a prolific researcher but also being a good citizen. Supporting your colleagues, teaching mentees, and being a “team player” are all elements crucial to forming meaningful relationships and standing out as a valuable individual in your department. Second, perseverance is equally important; whether you are resubmitting applications for grant funding or reaching out to mentors in your area of interest, perseverance is the key to a successful career in academics. Third, remember that there is the important distinction between mentorship and sponsorship. While it is essential to have a selfless and supportive mentor who helps you cultivate your clinical and research interests, it is equally important to find a sponsor: an influential academician who can help you launch your career by acting as your advocate and opening doors to professional opportunities. Finally,you must always deliver. When mentors and sponsors give you opportunities to showcase your talents, always invest the time and effort to provide a high-quality performance. Be a good citizen who perseveres, seek out influential mentorship and sponsorship, and deliver on important professional tasks which will prime you to succeed as an academic clinical researcher in GI and hepatology.
 

Basic scientist perspective from Ana Maldonado-Contreras, PhD

The AGA-AASLD Workshop represented an ideal opportunity to regain perspective on my overall career plan. This year, Dr. Jung restructured the format of the program by substituting “lecture-style” sessions with fully interactive discussion panels in which trainees had the opportunity to initiate discussions about various topics of interest. The faculty leading these interactive sessions were committed to providing honest and clear answers to all of our questions. I believe this was a unique opportunity to go beyond PowerPoint presentations to actually gain insights on the dynamics of an academic department. We learned from department chairs what is considered during hiring, promoting, or allocating funds to make their team successful. Among the topics discussed, collegiality and selfless peer support were highlighted among the qualities of an appreciated department member. Panelists insisted that a balancing act between team support and one’s productivity is fundamental to thriving and maintaining focus.

Another topic with personal relevance was securing funding for my newly formed laboratory – and I was not alone! Prior to the meeting, participants were divided into small groups and assigned to a faculty mentor. Each participant was asked to share a research proposal and CV with her respective mentor. Then, each group had the opportunity to meet during the afternoon mentoring sessions. My group was composed of four participants interested in learning more about National Institutes of Health (NIH) funding strategies based on our current situations. Our assigned mentor, John Inadomi, MD – who thoroughly read our proposals and knew who we were before our encounter – provided practical advice about grant mechanisms to pursue given our current positions and provided detailed tips for successful applications. Dr. Inadomi also was greatly insightful about NIH study sessions and the entire review process. This person-to-person interaction was extremely helpful as it opened the possibility of discussing singularities of each participant’s career plans. Similarly, on the next day we had face time with David Saslowsky, PhD, program director of the National Institute of Diabetes and Digestive and Kidney Diseases at NIH. Dr. Saslowsky also reviewed our research proposals and discussed potential venues for funding within the NIDDK based on individual career trajectories.

Most of the second day was dedicated to reviewing grant opportunities and pertinent tips on how to get funded. We discussed the “most common mistakes” made by junior faculty on grant applications and ways to avoid them. All panelists agreed that the most common mistake is overambition. They advised us to critically consider the aims and activities proposed and, more importantly, seek out advice from mentors with more experience in grant writing.

Undoubtedly, networking with other peers represented an essential part of the experience at this academic workshop. As trainees, we were able to connect with not only seasoned colleagues but also with peers facing the same career challenges. Senior faculty were amazingly personable and committed to sharing experiences with the next generation of clinicians and scientists. They shared their failures, frustrations, and fears as well as their successes. Each story and the words of encouragement from this great community of scientists and clinicians helped me realize my hidden strengths and how to build from my past accomplishments to excel on my path toward becoming a fully independent researcher.
 

Dr. Lieber is a clinical epidemiology fellow, department of medicine, division of gastroenterology and hepatology, University of North Carolina (UNC), Chapel Hill; Dr. Maldonado-Contreras is an instructor in the department of microbiology and physiological systems and the Center for Microbiome Research, University of Massachusetts, Worcester.

Tell us about your recent experience at the AGA Tech Summit.

We attended our first AGA Tech Summit in Boston on March 21-23, flying between New England Nor’easter snowstorms this year. We had been selected as one of the five Shark Tank competition finalists after submitting our application and a video of our technology. We pitched a rapid paper diagnostic that we are developing to detect a multiplex of gastrointestinal pathogens. These pathogens cause infectious diarrhea and are detected from stool in 15 minutes without any instruments or electric power at the point of care (See Figure 1).

Courtesy GoDx Inc.

What led you to go into the innovation industry?

My collaborator, Dr. Henderson, had a dream to create diagnostic products that can be used in real time to diagnose and treat patients with diarrhea during the clinician-patient encounter. The product would be low cost and be run without an electrical power source, making it useful for resource-limited settings. The product would be especially helpful in rural, outbreak, and global settings where mortality from diarrhea is the highest. Approximately 525,000 children a year die of diarrheal diseases, and the elderly and immunocompromised also are significantly affected.

To realize our dream, we invented this technology through a public-private partnership called a Clinical Cooperative Research and Development Agreement between the National Institute of Nursing Research, National Institutes of Health, and GoDx Inc. GoDx, Inc. is a start-up company that Dr. Kim incorporated to develop and commercialize global health technologies into products. Through this partnership, we co-invented the technology, which we patented as a joint invention. We have also obtained IRB approval of a clinical protocol to test our “Stool Tool” on patient samples. Dr. Henderson is the principal investigator of this NIH clinical protocol. Last year, GoDx, Inc. was awarded a Phase 1 Small Business Innovation Research grant by the National Center for Advancing Translational Sciences (NCATS), NIH. They were recently awarded a $1.93 million Phase 2 SBIR grant from the NCATS to further develop the product; we will serve as co-PIs.

What do you enjoy most about the innovation industry?

What we enjoy the most about developing innovative products is the potential to help millions of people. It’s exhilarating to think that the discoveries we make in the lab can turn into innovative and useful new products that help save lives and improve health.

What are important factors for success in the innovation industry?

The first step is having the personal drive and vision toward an innovation. As clinicians and scientists our patients, families, and life experiences give us the drive on a daily basis as we strive to improve patient outcomes through more efficient, patient centered, less costly methods. The next step is having the training to know how to innovate. Dr. Henderson was part of a cohort trained in clinical and translational team science.¹ Dr. Kim left the NIH to join his first startup company called Dxterity Diagnostics to learn product development and commercialization firsthand before starting GoDx.

What are the biggest challenges to getting a new product on the market?

One of the biggest challenges for getting a new product to the market is building something that people want to buy. “Technology is the easy part” is a common mantra among bioentrepreneurs. Another mantra is “The market kills innovation.” To address this, GoDx applied for and was awarded a grant supplement to their NCATS Phase 1 SBIR grantto participate in the NIH Innovation Corps (I-Corps) program. As part of the I-Corps program GoDX conducted more than 100 interviews with potential customers and stakeholders for our product. This allowed GoDx to focus their business canvas (an evolving sketch of a business plan) and make key pivots in their customer segments and our technology in order to better achieve a “product-market” fit. While GoDx had thought of the idea from reading journals, when they met real customers and potential strategic partners, GoDx gained a real understanding of who the customers would be and the unmet needs they have. Through the coaching in this I-Corps course and the interviews, GoDx was able to develop a realistic go-to-market strategy. We highly recommend physician entrepreneurs to take part in I-Corps or other Lean Startup courses.

We are so thankful that our innovation was selected as the AGA Shark Tank winner! It garnered us lot of publicity and interest from potential investors and accelerators, and we highly recommend the AGA Tech Summit to all AGA members and GI health professionals who are interested in innovation in the GI space.⁴ The AGA Tech Summit is an excellent meeting that covers significant practical aspects of innovating technologies in health care including raising capital, patents, commercialization, regulatory approvals, reimbursement, and adoption. The AGA Center for GI Innovation and Technology is an excellent support group that can provide guidance on the different aspects of innovation and commercialization. See you in San Francisco at the 2019 AGA Tech Summit, April 10-12!

Research reported in this publication was supported by the National Center for Advancing Translational Sciences of the National Institutes of Health under Award Number R44TR001912 and the National Institute of Nursing Research of the National Institutes of Health Intramural Research Program. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

References

1. Robinson GF et al. Development, implementation, and evaluation of an interprofessional course in translational research. Clin Transl Sci. 2013;6(1):50-6.

2. Nearing KA et al. Solving the puzzle of recruitment and retention: strategies for building a robust clinical and translational research workforce. Clin Transl Sci. 2015 Oct;8(5):563-7.

3. Manson SM et al. Vision, identity, and career in the clinical and translational sciences: Building upon the formative years. Clin Transl Sci. 2015 Oct;8(5):568-72.

4. Nimgaonkar A, Yock PG, Brinton TJ, et al. Gastroenterology and biodesign: contributing to the future of our specialty. Gastroenterology. 2013 Feb;144(2):258-62.

Dr. Kim is CEO of GoDx. Dr. Henderson is Investigator & Chief, Digestive Disorder Unit, Biobehavioral Branch, National Institute of Nursing Research, National Institutes of Health.

Tell us about your recent experience at the AGA Tech Summit.

We attended our first AGA Tech Summit in Boston on March 21-23, flying between New England Nor’easter snowstorms this year. We had been selected as one of the five Shark Tank competition finalists after submitting our application and a video of our technology. We pitched a rapid paper diagnostic that we are developing to detect a multiplex of gastrointestinal pathogens. These pathogens cause infectious diarrhea and are detected from stool in 15 minutes without any instruments or electric power at the point of care (See Figure 1).

Courtesy GoDx Inc.

What led you to go into the innovation industry?

My collaborator, Dr. Henderson, had a dream to create diagnostic products that can be used in real time to diagnose and treat patients with diarrhea during the clinician-patient encounter. The product would be low cost and be run without an electrical power source, making it useful for resource-limited settings. The product would be especially helpful in rural, outbreak, and global settings where mortality from diarrhea is the highest. Approximately 525,000 children a year die of diarrheal diseases, and the elderly and immunocompromised also are significantly affected.

To realize our dream, we invented this technology through a public-private partnership called a Clinical Cooperative Research and Development Agreement between the National Institute of Nursing Research, National Institutes of Health, and GoDx Inc. GoDx, Inc. is a start-up company that Dr. Kim incorporated to develop and commercialize global health technologies into products. Through this partnership, we co-invented the technology, which we patented as a joint invention. We have also obtained IRB approval of a clinical protocol to test our “Stool Tool” on patient samples. Dr. Henderson is the principal investigator of this NIH clinical protocol. Last year, GoDx, Inc. was awarded a Phase 1 Small Business Innovation Research grant by the National Center for Advancing Translational Sciences (NCATS), NIH. They were recently awarded a $1.93 million Phase 2 SBIR grant from the NCATS to further develop the product; we will serve as co-PIs.

What do you enjoy most about the innovation industry?

What we enjoy the most about developing innovative products is the potential to help millions of people. It’s exhilarating to think that the discoveries we make in the lab can turn into innovative and useful new products that help save lives and improve health.

What are important factors for success in the innovation industry?

The first step is having the personal drive and vision toward an innovation. As clinicians and scientists our patients, families, and life experiences give us the drive on a daily basis as we strive to improve patient outcomes through more efficient, patient centered, less costly methods. The next step is having the training to know how to innovate. Dr. Henderson was part of a cohort trained in clinical and translational team science.¹ Dr. Kim left the NIH to join his first startup company called Dxterity Diagnostics to learn product development and commercialization firsthand before starting GoDx.

What are the biggest challenges to getting a new product on the market?

One of the biggest challenges for getting a new product to the market is building something that people want to buy. “Technology is the easy part” is a common mantra among bioentrepreneurs. Another mantra is “The market kills innovation.” To address this, GoDx applied for and was awarded a grant supplement to their NCATS Phase 1 SBIR grantto participate in the NIH Innovation Corps (I-Corps) program. As part of the I-Corps program GoDX conducted more than 100 interviews with potential customers and stakeholders for our product. This allowed GoDx to focus their business canvas (an evolving sketch of a business plan) and make key pivots in their customer segments and our technology in order to better achieve a “product-market” fit. While GoDx had thought of the idea from reading journals, when they met real customers and potential strategic partners, GoDx gained a real understanding of who the customers would be and the unmet needs they have. Through the coaching in this I-Corps course and the interviews, GoDx was able to develop a realistic go-to-market strategy. We highly recommend physician entrepreneurs to take part in I-Corps or other Lean Startup courses.

We are so thankful that our innovation was selected as the AGA Shark Tank winner! It garnered us lot of publicity and interest from potential investors and accelerators, and we highly recommend the AGA Tech Summit to all AGA members and GI health professionals who are interested in innovation in the GI space.⁴ The AGA Tech Summit is an excellent meeting that covers significant practical aspects of innovating technologies in health care including raising capital, patents, commercialization, regulatory approvals, reimbursement, and adoption. The AGA Center for GI Innovation and Technology is an excellent support group that can provide guidance on the different aspects of innovation and commercialization. See you in San Francisco at the 2019 AGA Tech Summit, April 10-12!

Research reported in this publication was supported by the National Center for Advancing Translational Sciences of the National Institutes of Health under Award Number R44TR001912 and the National Institute of Nursing Research of the National Institutes of Health Intramural Research Program. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

References

1. Robinson GF et al. Development, implementation, and evaluation of an interprofessional course in translational research. Clin Transl Sci. 2013;6(1):50-6.

2. Nearing KA et al. Solving the puzzle of recruitment and retention: strategies for building a robust clinical and translational research workforce. Clin Transl Sci. 2015 Oct;8(5):563-7.

3. Manson SM et al. Vision, identity, and career in the clinical and translational sciences: Building upon the formative years. Clin Transl Sci. 2015 Oct;8(5):568-72.

4. Nimgaonkar A, Yock PG, Brinton TJ, et al. Gastroenterology and biodesign: contributing to the future of our specialty. Gastroenterology. 2013 Feb;144(2):258-62.

Dr. Kim is CEO of GoDx. Dr. Henderson is Investigator & Chief, Digestive Disorder Unit, Biobehavioral Branch, National Institute of Nursing Research, National Institutes of Health.

Tell us about your recent experience at the AGA Tech Summit.

We attended our first AGA Tech Summit in Boston on March 21-23, flying between New England Nor’easter snowstorms this year. We had been selected as one of the five Shark Tank competition finalists after submitting our application and a video of our technology. We pitched a rapid paper diagnostic that we are developing to detect a multiplex of gastrointestinal pathogens. These pathogens cause infectious diarrhea and are detected from stool in 15 minutes without any instruments or electric power at the point of care (See Figure 1).

Courtesy GoDx Inc.

What led you to go into the innovation industry?

My collaborator, Dr. Henderson, had a dream to create diagnostic products that can be used in real time to diagnose and treat patients with diarrhea during the clinician-patient encounter. The product would be low cost and be run without an electrical power source, making it useful for resource-limited settings. The product would be especially helpful in rural, outbreak, and global settings where mortality from diarrhea is the highest. Approximately 525,000 children a year die of diarrheal diseases, and the elderly and immunocompromised also are significantly affected.

To realize our dream, we invented this technology through a public-private partnership called a Clinical Cooperative Research and Development Agreement between the National Institute of Nursing Research, National Institutes of Health, and GoDx Inc. GoDx, Inc. is a start-up company that Dr. Kim incorporated to develop and commercialize global health technologies into products. Through this partnership, we co-invented the technology, which we patented as a joint invention. We have also obtained IRB approval of a clinical protocol to test our “Stool Tool” on patient samples. Dr. Henderson is the principal investigator of this NIH clinical protocol. Last year, GoDx, Inc. was awarded a Phase 1 Small Business Innovation Research grant by the National Center for Advancing Translational Sciences (NCATS), NIH. They were recently awarded a $1.93 million Phase 2 SBIR grant from the NCATS to further develop the product; we will serve as co-PIs.

What do you enjoy most about the innovation industry?

What we enjoy the most about developing innovative products is the potential to help millions of people. It’s exhilarating to think that the discoveries we make in the lab can turn into innovative and useful new products that help save lives and improve health.

What are important factors for success in the innovation industry?

The first step is having the personal drive and vision toward an innovation. As clinicians and scientists our patients, families, and life experiences give us the drive on a daily basis as we strive to improve patient outcomes through more efficient, patient centered, less costly methods. The next step is having the training to know how to innovate. Dr. Henderson was part of a cohort trained in clinical and translational team science.¹ Dr. Kim left the NIH to join his first startup company called Dxterity Diagnostics to learn product development and commercialization firsthand before starting GoDx.

What are the biggest challenges to getting a new product on the market?

One of the biggest challenges for getting a new product to the market is building something that people want to buy. “Technology is the easy part” is a common mantra among bioentrepreneurs. Another mantra is “The market kills innovation.” To address this, GoDx applied for and was awarded a grant supplement to their NCATS Phase 1 SBIR grantto participate in the NIH Innovation Corps (I-Corps) program. As part of the I-Corps program GoDX conducted more than 100 interviews with potential customers and stakeholders for our product. This allowed GoDx to focus their business canvas (an evolving sketch of a business plan) and make key pivots in their customer segments and our technology in order to better achieve a “product-market” fit. While GoDx had thought of the idea from reading journals, when they met real customers and potential strategic partners, GoDx gained a real understanding of who the customers would be and the unmet needs they have. Through the coaching in this I-Corps course and the interviews, GoDx was able to develop a realistic go-to-market strategy. We highly recommend physician entrepreneurs to take part in I-Corps or other Lean Startup courses.

We are so thankful that our innovation was selected as the AGA Shark Tank winner! It garnered us lot of publicity and interest from potential investors and accelerators, and we highly recommend the AGA Tech Summit to all AGA members and GI health professionals who are interested in innovation in the GI space.⁴ The AGA Tech Summit is an excellent meeting that covers significant practical aspects of innovating technologies in health care including raising capital, patents, commercialization, regulatory approvals, reimbursement, and adoption. The AGA Center for GI Innovation and Technology is an excellent support group that can provide guidance on the different aspects of innovation and commercialization. See you in San Francisco at the 2019 AGA Tech Summit, April 10-12!

Research reported in this publication was supported by the National Center for Advancing Translational Sciences of the National Institutes of Health under Award Number R44TR001912 and the National Institute of Nursing Research of the National Institutes of Health Intramural Research Program. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

References

1. Robinson GF et al. Development, implementation, and evaluation of an interprofessional course in translational research. Clin Transl Sci. 2013;6(1):50-6.

2. Nearing KA et al. Solving the puzzle of recruitment and retention: strategies for building a robust clinical and translational research workforce. Clin Transl Sci. 2015 Oct;8(5):563-7.

3. Manson SM et al. Vision, identity, and career in the clinical and translational sciences: Building upon the formative years. Clin Transl Sci. 2015 Oct;8(5):568-72.

4. Nimgaonkar A, Yock PG, Brinton TJ, et al. Gastroenterology and biodesign: contributing to the future of our specialty. Gastroenterology. 2013 Feb;144(2):258-62.

Dr. Kim is CEO of GoDx. Dr. Henderson is Investigator & Chief, Digestive Disorder Unit, Biobehavioral Branch, National Institute of Nursing Research, National Institutes of Health.