The New Gastroenterologist

Medicine is an evolving field, and in this era of ever-changing medicine, physicians-in-training often lag behind in understanding the nuances of “real-world” medicine. From negotiating job contracts to understanding medical billing, coding systems, and performance metrics, physicians who are fresh out of training often feel ill prepared to deal with these issues that are rarely discussed during fellowship.

The American Gastroenterological Association’s Regional Practice Skills Workshops are designed to fill this void and provide the tools necessary to navigate the challenging transition from training into practice. Since the first pilot workshops were held in 2014, AGA’s Trainee and Early Career Committee has been diligently working to expand the number of workshop sites so that more trainees can benefit from them. This year, workshops will be held in Columbus, Ohio (Feb. 24), and in Philadelphia (April 11). An exciting development in 2017 was the opportunity to live stream the event held at the University of California, Los Angeles, to Stanford (Calif.) University and the University of Iowa, Iowa City.

This aforementioned workshop at UCLA was divided into two sessions. The first was focused on “Practice Options,” with talks geared toward highlighting the different practice models available in the GI market, including positions in academia, private practice, and mixed environments.

William Chey, MD, a professor of medicine at the University of Michigan, Ann Arbor, shared his experience as an academic gastroenterologist as well as his experience in managing a GI consulting firm. His advice to young gastroenterologists was to diversify. He suggested options such as working for pharmaceutical companies, being involved in drug trials, working in the innovation industry, and proactively seeking leadership positions in different organizations. V. Raman Muthusamy MD, AGAF, a clinical professor of medicine at UCLA, led the discussion with the million-dollar question: What is my net worth? He suggested doing some homework before negotiating one’s salary by visiting the Medical Group Management Association’s website. Having this information can provide a trainee with a head start in the negotiation process. Dr. Muthusamy recommended recalculating one’s net worth every 5 years and renegotiating your contract based on this information. In addition to possibly leading to a salary boost, such knowledge will render internal validation and boost self-confidence about one’s skill set. Keep in mind however, that checking this too often can be adversely distracting. Lynn S. Connolly, MD, also of UCLA brought to light the important fact that female gastroenterologists are often paid lower salaries than their male counterparts, even after adjusting for vacation time, practice type, and work hours. She urged female gastroenterologists not to undervalue themselves and avoid falling into this pitfall. Lin Chang, MD, a professor of medicine at UCLA, reinforced the need for young GI fellows to be passionate about the path they choose and to not make random choices or decisions based on convenience alone.

Gareth Dulai, MD, a gastroenterologist with Kaiser Permanente in Downey, CA, discussed the advantages of working in a big company, including salaries that are transparent and match the national average. One also does not have to worry about hiring staff and managing overhead costs. Martha Hierro, MD, who has been in private practice since fellowship, felt that a private group practice enables a higher salary potential and better flexibility with one’s schedule. Her group also has a pathology lab, research lab, and imaging center, which further augments the group’s earnings. The downsides to private practice, compared with bigger academic settings, include cumbersome negotiations with insurance companies and financial constraints when purchasing new technology. She advised young GI physicians to go through the partnership clause very carefully before joining any private practice. She recommended being prepared and fully informed before negotiating a contract, including speaking to other practicing gastroenterologists in the area about the earning potential in the practice. In the end, both speakers agreed that all types of practices have pros and cons and one can always move from one setting to another.

For young GI fellows who want to work as administrators, the common consensus among the panel members was that fellows should attend leadership courses at national meetings early in training and participate in the committees of national organizations like the AGA. Reaching out to educators and mentors is of key importance. Dr. Chey recommended that, when fellows are provided with an opportunity to work with a potential mentor, they should think it through before accepting the opportunity and, if they do accept it, make sure they finish the task in a timely manner.

The second session of the workshop was geared toward the interview process. James H. Tabibian, MD, PhD, of the University of California, Davis, shared some useful tips for job hunting. It is never too early to start the process of job hunting, and timing depends on the type of position one is seeking. For a competitive position, it may be best to start the process early. When looking for jobs, contact methods could include in-person encounters at national meetings, such as Digestive Disease Week, or through a mutual colleague or mentor. Emails to potential future employers should be succinct with an updated resume attached. Most importantly, make sure to follow up in a professional manner.

Dr. Connolly, who also spoke about interviewing, pointed out that one should always ask questions about the program and never offer any negative information about oneself. Discussing salary potential during an interview may not be perceived as a positive sign. One might ask the interviewer about what things the interviewer enjoys the most at work, what defines success in this position at the institution, what constitutes an ideal candidate for the program, and what is the growth plan for the program over the next 5-10 years. For subspecialty interviews, some questions that are good to ask include the volume of procedures done at the institute, what might a typical day for a fellow look like, where do fellows typically work after finishing, and how is the call schedule set up. In the end, look confident, be humble, and believe in yourself. You control how you are perceived.
 

Once you are offered a job, the next big task is contract negotiation. Negotiating a contract can be very time consuming and stressful. Some key concepts to keep in mind are: a) prepare ahead of time and know the institution well; b) the more offers you have, the more leverage you can get; c) take adequate time to evaluate the contract before signing; d) establish which clauses are nonnegotiable for you; e) try to get something back for everything you give up during negotiations; f) do not negotiate with yourself; g) keep calm and be flexible; and h) know what you want out of your job. Always keep in mind base salary and bonuses, student loan repayment, relocation expenses, medical and disability insurance, and malpractice insurance coverage. Always consider the possibility of buying into the practice. Be wary of indemnification and unreasonable noncompete clauses.

Overall, my colleagues and I found the workshop to be extremely informative. The live stream format was very well received, and as an audience, we felt engaged and encouraged to participate. We certainly appreciated the opportunity to ask questions in real time. This format allowed all our fellows to participate without needing to travel and to gain access to invaluable content that will surely help us in making important career decisions.
 

Dr. Ashat is a first-year gastroenterology fellow at The University of Iowa, Iowa City.

Medicine is an evolving field, and in this era of ever-changing medicine, physicians-in-training often lag behind in understanding the nuances of “real-world” medicine. From negotiating job contracts to understanding medical billing, coding systems, and performance metrics, physicians who are fresh out of training often feel ill prepared to deal with these issues that are rarely discussed during fellowship.

The American Gastroenterological Association’s Regional Practice Skills Workshops are designed to fill this void and provide the tools necessary to navigate the challenging transition from training into practice. Since the first pilot workshops were held in 2014, AGA’s Trainee and Early Career Committee has been diligently working to expand the number of workshop sites so that more trainees can benefit from them. This year, workshops will be held in Columbus, Ohio (Feb. 24), and in Philadelphia (April 11). An exciting development in 2017 was the opportunity to live stream the event held at the University of California, Los Angeles, to Stanford (Calif.) University and the University of Iowa, Iowa City.

This aforementioned workshop at UCLA was divided into two sessions. The first was focused on “Practice Options,” with talks geared toward highlighting the different practice models available in the GI market, including positions in academia, private practice, and mixed environments.

William Chey, MD, a professor of medicine at the University of Michigan, Ann Arbor, shared his experience as an academic gastroenterologist as well as his experience in managing a GI consulting firm. His advice to young gastroenterologists was to diversify. He suggested options such as working for pharmaceutical companies, being involved in drug trials, working in the innovation industry, and proactively seeking leadership positions in different organizations. V. Raman Muthusamy MD, AGAF, a clinical professor of medicine at UCLA, led the discussion with the million-dollar question: What is my net worth? He suggested doing some homework before negotiating one’s salary by visiting the Medical Group Management Association’s website. Having this information can provide a trainee with a head start in the negotiation process. Dr. Muthusamy recommended recalculating one’s net worth every 5 years and renegotiating your contract based on this information. In addition to possibly leading to a salary boost, such knowledge will render internal validation and boost self-confidence about one’s skill set. Keep in mind however, that checking this too often can be adversely distracting. Lynn S. Connolly, MD, also of UCLA brought to light the important fact that female gastroenterologists are often paid lower salaries than their male counterparts, even after adjusting for vacation time, practice type, and work hours. She urged female gastroenterologists not to undervalue themselves and avoid falling into this pitfall. Lin Chang, MD, a professor of medicine at UCLA, reinforced the need for young GI fellows to be passionate about the path they choose and to not make random choices or decisions based on convenience alone.

Gareth Dulai, MD, a gastroenterologist with Kaiser Permanente in Downey, CA, discussed the advantages of working in a big company, including salaries that are transparent and match the national average. One also does not have to worry about hiring staff and managing overhead costs. Martha Hierro, MD, who has been in private practice since fellowship, felt that a private group practice enables a higher salary potential and better flexibility with one’s schedule. Her group also has a pathology lab, research lab, and imaging center, which further augments the group’s earnings. The downsides to private practice, compared with bigger academic settings, include cumbersome negotiations with insurance companies and financial constraints when purchasing new technology. She advised young GI physicians to go through the partnership clause very carefully before joining any private practice. She recommended being prepared and fully informed before negotiating a contract, including speaking to other practicing gastroenterologists in the area about the earning potential in the practice. In the end, both speakers agreed that all types of practices have pros and cons and one can always move from one setting to another.

For young GI fellows who want to work as administrators, the common consensus among the panel members was that fellows should attend leadership courses at national meetings early in training and participate in the committees of national organizations like the AGA. Reaching out to educators and mentors is of key importance. Dr. Chey recommended that, when fellows are provided with an opportunity to work with a potential mentor, they should think it through before accepting the opportunity and, if they do accept it, make sure they finish the task in a timely manner.

The second session of the workshop was geared toward the interview process. James H. Tabibian, MD, PhD, of the University of California, Davis, shared some useful tips for job hunting. It is never too early to start the process of job hunting, and timing depends on the type of position one is seeking. For a competitive position, it may be best to start the process early. When looking for jobs, contact methods could include in-person encounters at national meetings, such as Digestive Disease Week, or through a mutual colleague or mentor. Emails to potential future employers should be succinct with an updated resume attached. Most importantly, make sure to follow up in a professional manner.

Dr. Connolly, who also spoke about interviewing, pointed out that one should always ask questions about the program and never offer any negative information about oneself. Discussing salary potential during an interview may not be perceived as a positive sign. One might ask the interviewer about what things the interviewer enjoys the most at work, what defines success in this position at the institution, what constitutes an ideal candidate for the program, and what is the growth plan for the program over the next 5-10 years. For subspecialty interviews, some questions that are good to ask include the volume of procedures done at the institute, what might a typical day for a fellow look like, where do fellows typically work after finishing, and how is the call schedule set up. In the end, look confident, be humble, and believe in yourself. You control how you are perceived.
 

Once you are offered a job, the next big task is contract negotiation. Negotiating a contract can be very time consuming and stressful. Some key concepts to keep in mind are: a) prepare ahead of time and know the institution well; b) the more offers you have, the more leverage you can get; c) take adequate time to evaluate the contract before signing; d) establish which clauses are nonnegotiable for you; e) try to get something back for everything you give up during negotiations; f) do not negotiate with yourself; g) keep calm and be flexible; and h) know what you want out of your job. Always keep in mind base salary and bonuses, student loan repayment, relocation expenses, medical and disability insurance, and malpractice insurance coverage. Always consider the possibility of buying into the practice. Be wary of indemnification and unreasonable noncompete clauses.

Overall, my colleagues and I found the workshop to be extremely informative. The live stream format was very well received, and as an audience, we felt engaged and encouraged to participate. We certainly appreciated the opportunity to ask questions in real time. This format allowed all our fellows to participate without needing to travel and to gain access to invaluable content that will surely help us in making important career decisions.
 

Dr. Ashat is a first-year gastroenterology fellow at The University of Iowa, Iowa City.

Medicine is an evolving field, and in this era of ever-changing medicine, physicians-in-training often lag behind in understanding the nuances of “real-world” medicine. From negotiating job contracts to understanding medical billing, coding systems, and performance metrics, physicians who are fresh out of training often feel ill prepared to deal with these issues that are rarely discussed during fellowship.

The American Gastroenterological Association’s Regional Practice Skills Workshops are designed to fill this void and provide the tools necessary to navigate the challenging transition from training into practice. Since the first pilot workshops were held in 2014, AGA’s Trainee and Early Career Committee has been diligently working to expand the number of workshop sites so that more trainees can benefit from them. This year, workshops will be held in Columbus, Ohio (Feb. 24), and in Philadelphia (April 11). An exciting development in 2017 was the opportunity to live stream the event held at the University of California, Los Angeles, to Stanford (Calif.) University and the University of Iowa, Iowa City.

This aforementioned workshop at UCLA was divided into two sessions. The first was focused on “Practice Options,” with talks geared toward highlighting the different practice models available in the GI market, including positions in academia, private practice, and mixed environments.

William Chey, MD, a professor of medicine at the University of Michigan, Ann Arbor, shared his experience as an academic gastroenterologist as well as his experience in managing a GI consulting firm. His advice to young gastroenterologists was to diversify. He suggested options such as working for pharmaceutical companies, being involved in drug trials, working in the innovation industry, and proactively seeking leadership positions in different organizations. V. Raman Muthusamy MD, AGAF, a clinical professor of medicine at UCLA, led the discussion with the million-dollar question: What is my net worth? He suggested doing some homework before negotiating one’s salary by visiting the Medical Group Management Association’s website. Having this information can provide a trainee with a head start in the negotiation process. Dr. Muthusamy recommended recalculating one’s net worth every 5 years and renegotiating your contract based on this information. In addition to possibly leading to a salary boost, such knowledge will render internal validation and boost self-confidence about one’s skill set. Keep in mind however, that checking this too often can be adversely distracting. Lynn S. Connolly, MD, also of UCLA brought to light the important fact that female gastroenterologists are often paid lower salaries than their male counterparts, even after adjusting for vacation time, practice type, and work hours. She urged female gastroenterologists not to undervalue themselves and avoid falling into this pitfall. Lin Chang, MD, a professor of medicine at UCLA, reinforced the need for young GI fellows to be passionate about the path they choose and to not make random choices or decisions based on convenience alone.

Gareth Dulai, MD, a gastroenterologist with Kaiser Permanente in Downey, CA, discussed the advantages of working in a big company, including salaries that are transparent and match the national average. One also does not have to worry about hiring staff and managing overhead costs. Martha Hierro, MD, who has been in private practice since fellowship, felt that a private group practice enables a higher salary potential and better flexibility with one’s schedule. Her group also has a pathology lab, research lab, and imaging center, which further augments the group’s earnings. The downsides to private practice, compared with bigger academic settings, include cumbersome negotiations with insurance companies and financial constraints when purchasing new technology. She advised young GI physicians to go through the partnership clause very carefully before joining any private practice. She recommended being prepared and fully informed before negotiating a contract, including speaking to other practicing gastroenterologists in the area about the earning potential in the practice. In the end, both speakers agreed that all types of practices have pros and cons and one can always move from one setting to another.

For young GI fellows who want to work as administrators, the common consensus among the panel members was that fellows should attend leadership courses at national meetings early in training and participate in the committees of national organizations like the AGA. Reaching out to educators and mentors is of key importance. Dr. Chey recommended that, when fellows are provided with an opportunity to work with a potential mentor, they should think it through before accepting the opportunity and, if they do accept it, make sure they finish the task in a timely manner.

The second session of the workshop was geared toward the interview process. James H. Tabibian, MD, PhD, of the University of California, Davis, shared some useful tips for job hunting. It is never too early to start the process of job hunting, and timing depends on the type of position one is seeking. For a competitive position, it may be best to start the process early. When looking for jobs, contact methods could include in-person encounters at national meetings, such as Digestive Disease Week, or through a mutual colleague or mentor. Emails to potential future employers should be succinct with an updated resume attached. Most importantly, make sure to follow up in a professional manner.

Dr. Connolly, who also spoke about interviewing, pointed out that one should always ask questions about the program and never offer any negative information about oneself. Discussing salary potential during an interview may not be perceived as a positive sign. One might ask the interviewer about what things the interviewer enjoys the most at work, what defines success in this position at the institution, what constitutes an ideal candidate for the program, and what is the growth plan for the program over the next 5-10 years. For subspecialty interviews, some questions that are good to ask include the volume of procedures done at the institute, what might a typical day for a fellow look like, where do fellows typically work after finishing, and how is the call schedule set up. In the end, look confident, be humble, and believe in yourself. You control how you are perceived.
 

Once you are offered a job, the next big task is contract negotiation. Negotiating a contract can be very time consuming and stressful. Some key concepts to keep in mind are: a) prepare ahead of time and know the institution well; b) the more offers you have, the more leverage you can get; c) take adequate time to evaluate the contract before signing; d) establish which clauses are nonnegotiable for you; e) try to get something back for everything you give up during negotiations; f) do not negotiate with yourself; g) keep calm and be flexible; and h) know what you want out of your job. Always keep in mind base salary and bonuses, student loan repayment, relocation expenses, medical and disability insurance, and malpractice insurance coverage. Always consider the possibility of buying into the practice. Be wary of indemnification and unreasonable noncompete clauses.

Overall, my colleagues and I found the workshop to be extremely informative. The live stream format was very well received, and as an audience, we felt engaged and encouraged to participate. We certainly appreciated the opportunity to ask questions in real time. This format allowed all our fellows to participate without needing to travel and to gain access to invaluable content that will surely help us in making important career decisions.
 

Dr. Ashat is a first-year gastroenterology fellow at The University of Iowa, Iowa City.

While constipation is one of the most common symptoms managed by practicing gastroenterologists, it can also be among the most challenging. As a presenting complaint, constipation manifests with widely varying degrees of severity and may be seen in all age groups, ethnicities, and socioeconomic backgrounds. Its implications can include chronic and serious functional impairment as well as protracted and often excessive health care utilization. A growing number of pharmacologic and nonpharmacologic interventions have become available and proven to be effective when appropriately deployed. As such, health care providers and particularly gastroenterologists should strive to develop logical and efficient strategies for addressing this common disorder.

Clinical importance

While there are a variety of etiologies for constipation (Table 1), a large proportion of chronic cases fall within the framework of functional gastrointestinal disorders, a category with a substantial burden of disease across the population. Prevalence estimates vary, but constipation likely affects between 12% and 20% of the North American population.¹ Research has demonstrated significant health care expenditures associated with chronic constipation management; U.S. estimates suggest direct costs on the order of hundreds of millions of dollars per year, roughly half of which are attributable to inpatient care.² The financial burden of constipation also includes indirect costs associated with absenteeism as well as the risks of hospitalization and invasive procedures.³

Physical and emotional complications can be likewise significant and affect all age groups, from newborns to patients in the last days of life. Hirschsprung’s disease, for example, can lead to life-threatening sequelae in infancy, such as spontaneous perforation or enterocolitis, or more prolonged functional impairments when it remains undiagnosed. Severe constipation in childhood can lead to encopresis, translating in turn into ostracism and impaired social functioning. Fecal incontinence associated with overflow diarrhea is common and debilitating, particularly in the elderly population.
 

The potential mechanical complications of constipation lead to its overlap with a variety of other gastrointestinal complaints. For example, the difficulties of passing inspissated stool can provoke lower gastrointestinal bleeding from irritated hemorrhoids, anal fissures, stercoral ulcers, or prolapsed rectal tissue. Retained stool can also lead to upper gastrointestinal symptoms such as postprandial bloating or early satiety.⁴ Delayed fecal discharge can promote an increase in fermentative microbiota, associated in turn with the production of short-chain fatty acids, methane, and other gaseous byproducts.

The initial assessment

History

Taking an appropriate history is an essential step toward achieving a successful outcome. Presenting concerns related to constipation can range from hard, infrequent, or small-volume stools; abdominal or rectal pain associated with the process of elimination; and bloating, nausea, or early satiety. A sound diagnosis requires a keen understanding of what patients mean when they indicate that they are constipated, an accurate assessment of its impact on quality of life, and a careful inventory of potentially associated complications.

It is critical to define the duration of the problem. Not infrequently, patients will focus on recent events while failing to reveal that altered bowel habits or other functional symptoms have been problematic for years. Reminding the patients to “begin at the beginning” can aid enormously in contextualizing their complaints. Individuals with longstanding symptoms and previously negative evaluations are much less likely to present with a new organic disease than are those in whom symptoms have truly arisen de novo.

Defining constipation by frequency of bowel eliminations alone has proved inaccurate at predicting actual severity. This is in part because the bowel movement frequency varies widely in healthy individuals (anywhere from thrice daily to once every 3 days) and in part because the primary indicator of effective evacuation is not frequency but volume – a much more difficult quantity for patients to gauge.⁵ The Bristol Stool Scale is a simple, standardized tool that more accurately evaluates the presence or absence of colonic dysfunction. For example, patients passing Type 1-2 (hard or lumpy) stools often have an element of constipation that needs to be addressed.⁶ However, the interpretation of stool consistency assessments is still aided by awareness of both frequency and volume. A patient passing multiple small-volume Type 6-7 (loose or watery) stools may be the most constipated, presenting with overflow or paradoxical diarrhea attributable to fecal impaction.

Physical examination

An expert physical exam is another essential aspect of the initial assessment. Alarm features can be elicited in this context as well via signs of pallor, weight loss, blood in the stool, physical abuse, or advanced psychological distress. Attention should also be paid to signs of a systemic disorder that might be associated with gastrointestinal dysmotility including previously unrecognized signs of Raynaud’s syndrome, sclerodactyly, amyloidosis, surgical scars, and joint hypermobility.^7,8 Abdominal bloating, a frequently vague symptomatic complaint, can be correlated with the presence or absence of distention as perceived by the patient and/or the examiner.⁹

Any initial evaluation of constipation should also include a detailed digital rectal exam. A complete examination should include a careful visual assessment of the perianal region for external lesions and of the degree and directional appropriateness of pelvic floor excursion (perineal elevation and descent) during squeeze and simulated defecation maneuvers, respectively. Digital examination should include palpation for the presence or absence of pain as well as stool, blood, or masses in the rectal vault, as well as an assessment of sphincter tone at baseline, with squeeze, and with simulated defecation. Rectal pressure generation with the latter maneuver can also be qualitatively assessed. Research has suggested moderate agreement between the digital rectal examination and formal manometric evaluation in diagnosing dyssynergic defecation, underscoring the former’s utility in guiding initial management decisions.¹⁰

Testing

It is reasonable to exclude metabolic, inflammatory, or other secondary etiologies of constipation in patients in whom history or examination raises suspicion. Likewise, colonoscopy should be considered in patients with alarm features or who are due for age-appropriate screening. That said, in the absence of risk factors or ancillary signs and symptoms, a detailed diagnostic work-up is often unnecessary. The AGA’s Medical Position Statement on Constipation recommends a complete blood count as the only test to be ordered on a standard basis in the work-up of constipation.¹¹

In patients new to one’s practice, the diligent retrieval of prior records is one of the most efficient ways to avoid wasting health care resources. Locating an old abdominal radiograph that demonstrates extensive retained stool can not only secure the diagnosis for vague symptomatic complaints but also obviate the need for more extensive testing. One should instead consider how symptom duration and the associated changes in objectives measures such as weight and laboratory parameters can be used to justify or refute the need for repeating costly or invasive studies.

It is important to consider the potential contribution of defecatory dyssynergy to chronic constipation early in a patient’s presentation, and to return to this possibility in the future if initial therapeutic interventions are unsuccessful. An abnormal qualitative assessment on digital rectal examination should trigger a more formal characterization of the patient’s defecatory mechanics via anorectal manometry (ARM) and balloon expulsion testing (BET). Likewise, a lack of response to initial pharmacotherapy should prompt suspicion for outlet dysfunction, which can be queried with functional testing even if a rectal examination is qualitatively unrevealing.

Initial approach to the chronically constipated patient

The aforementioned AGA Medical Position Statement provides a helpful algorithm regarding the diagnostic approach to constipation (Figure 1). In the absence of concern for secondary etiologies of constipation, an initial therapeutic trial of dietary, lifestyle, and medication-based intervention is reasonable for mild symptoms. Patients should be encouraged to strive for 25-30 grams of dietary fiber intake per day. For patients unable to reach this goal via high-fiber foods alone, psyllium husk is a popular supplement, but it should be initiated at modest doses to mitigate the risk of bloating. Fiber may be supplemented with the use of osmotic laxatives (e.g., polyethylene glycol) with instructions that the initial dose may be modified as needed to optimal effectiveness. Selective response to rectal therapies (e.g., bisacodyl or glycerin suppositories) over osmotic laxatives may also suggest utility in early queries of outlet dysfunction.

An abdominal radiograph can be helpful not only to diagnose constipation but also to assess the stool burden present at the time of beginning treatment. For patients presenting with a significant degree of fecal loading, an initial bowel cleanse with four liters of osmotically balanced polyethylene glycol can be a useful means of eliminating background fecal impactions that might have mitigated the effectiveness of initial therapies in the past or that might reduce the effectiveness of daily laxative therapy moving forward.

Patients with a diagnosis of defecatory dyssynergy made via ARM/BET should be referred to pelvic floor physical therapy with biofeedback. Recognizing that courses of therapy are highly individualized in practice, randomized controlled trials suggest symptom improvement in 70%-80% of patients, with the majority also demonstrating maintenance of response.¹² Biofeedback appears to be an essential component of this modality based on meta-analysis data and should be requested specifically by the referring provider.¹³

Pharmacologic agents

For those patients with more severe initial presentations or whose symptoms persist despite initial medical management, there are several pharmacologic agents that may be considered on a prescription basis (Table 2). Linaclotide, a minimally absorbed guanylate cyclase agonist, is approved by the Food and Drug Administration for patients with irritable bowel syndrome with constipation (IBS-C) and chronic idiopathic constipation (CIC). Improvements in constipation tend to occur over a slightly shorter timeline than in abdominal pain, though both have been demonstrated in comparison to placebo.^14,15 Plecanatide, a newer agent with a similar mechanism of action, has demonstrated improvements in bowel movement frequency and was recently approved for CIC.¹⁶ Lubiprostone, a chloride channel agonist, has demonstrated benefit for IBS-C and CIC as well, though its side effect profile is more varied, including dose-related nausea in up to 30% of patients.¹⁷

For patients with opioid-induced constipation who cannot wean from the opioid medications, the peripheral acting mu-opioid receptor antagonists may be quite helpful. These include injectable as well as oral formulations (e.g., methylnaltrexone and naloxegol, respectively) with additional agents under active investigation in particular clinical subsets (e.g., naldemedine for patients with cancer-related pain).^18,19 Prucalopride, a selective serotonin receptor agonist, has also demonstrated benefit for constipation; it is available abroad but not yet approved for use in the United States.²⁰ Prucalopride shares its primary mechanism of action (selective agonism of the 5HT4 serotonin receptor) with cisapride, a previously quite popular gastrointestinal motility agent that was subsequently withdrawn from the U.S. market because of arrhythmia risk.²¹ This risk is likely attributable to cisapride’s dual binding affinity for potassium channels, a feature that prucalopride does not share; as such, cardiotoxicity is not an active concern with the latter agent.²²

Still other pharmacologic agents with novel mechanisms of action are currently under investigation. Tenapanor, an inhibitor of a particular sodium/potassium exchanger in the gut lumen, mitigates intestinal sodium absorption, which increases fluid volume and transit. A recent phase 2 study demonstrated significantly increased stool frequency relative to placebo in patients with IBS-C.²³ Elobixibat, an ileal bile acid transport inhibitor, promotes colonic retention of bile acids and, in placebo-controlled studies, has led to accelerated colonic transit and an increased number of spontaneous bowel movements in patients with CIC.²⁴

Persistent constipation

In cases of refractory constipation (in practical terms, symptoms that persist despite trials of escalating medical therapy over at least 6 weeks), it is worth revisiting the question of etiology. Querying defecatory dyssynergy via ARM/BET, if not pursued prior to trials of newer pharmacologic agents, should certainly be explored in the event that such trials fail. Inconclusive results of ARM and BET testing, or BET abnormalities that persist despite a course of physical therapy with biofeedback, may raise suspicion for pelvic organ prolapse, which may be formally evaluated with defecography. Additional testing for metabolic or structural predispositions toward constipation may also be reasonable at this juncture.

Formal colonic transit testing via radio-opaque markers, scintigraphy, or the wireless motility capsule is often inaccurate in the setting of dyssynergic defecation and should be pursued only after this entity has been excluded or successfully treated.²⁵ While there are not many practical distinctions at present in the therapeutic management of slow-transit versus normal-transit constipation, the use of novel medications with an explicitly prokinetic mechanism of action may be reasonable to consider in the setting of a document delay in colonic transit. Such delays can also help justify further specialized diagnostic testing (e.g., colonic manometry), and, in rare refractory cases, surgical intervention.

Consideration of colectomy should be reserved for highly selected patients with delayed colonic transit, normal defecatory mechanics, and the absence of potentially explanatory background conditions (e.g., connective tissue disease). Clear evidence of an underlying colonic myopathy or neuropathy may militate in favor of a more targeted surgical intervention (e.g., subtotal colectomy) or guide one’s clinical evaluation toward alternative systemic diagnoses. A diverting loop ileostomy with interval assessment of symptoms may be useful to clarify the potential benefits of colectomy while preserving the option of operative reversal. Proximal transit delays should be definitively excluded before pursuing colonic resections given evidence that multisegment transit delays portend significantly worse postoperative outcomes.²⁶

Conclusion

Constipation is a common, sometimes confusing presenting complaint and the variety of established and emergent options for diagnosis and therapy can lend themselves to haphazard application. Patients and providers both are well served by a clinical approach, rooted in a comprehensive history and examination, that begins to organize these options in thoughtful sequence.



Dr. Ahuja is assistant professor of clinical medicine, division of gastroenterology; Dr. Reynolds is professor of clinical medicine, and director of the program in neurogastroenterology and motility, division of gastroenterology, Perelman School of Medicine, University of Pennsylvania, Philadelphia.

References

1. Higgins P.D., Johanson J.F. Epidemiology of constipation in North America: a systematic review. Am J Gastroenterol. 2004 Apr;99(4):750-9. PubMed PMID: 15089911.

2. Martin B.C., Barghout V., Cerulli A. Direct medical costs of constipation in the United States. Manage Care Interface. 2006 Dec;19(12):43-9. PubMed PMID: 17274481.

3. Sun S.X., Dibonaventura M., Purayidathil F.W., et al. Impact of chronic constipation on health-related quality of life, work productivity, and healthcare resource use: an analysis of the National Health and Wellness Survey. Dig Dis Sc. 2011 Sep;56(9):2688-95. PubMed PMID: 21380761.

4. Heidelbaugh J.J., Stelwagon M., Miller S.A., et al. The spectrum of constipation-predominant irritable bowel syndrome and chronic idiopathic constipation: US survey assessing symptoms, care seeking, and disease burden. Am J Gastroenterol. 2015 Apr;110(4):580-7.

5. Mitsuhashi S., Ballou S., Jiang Z.G., et al. Characterizing normal bowel frequency and consistency in a representative sample of adults in the United States (NHANES). Am J Gastroenterol. 2017 Aug 01. PubMed PMID: 28762379.

6. Saad R.J., Rao S.S., Koch K.L., et al. Do stool form and frequency correlate with whole-gut and colonic transit? Results from a multicenter study in constipated individuals and healthy controls. Am J Gastroenterol. 2010 Feb;105(2):403-11. PubMed PMID: 19888202.

7. Castori M., Morlino S., Pascolini G., et al. Gastrointestinal and nutritional issues in joint hypermobility syndrome/Ehlers-Danlos syndrome, hypermobility type. American Journal of Medical Genetics Part C, Semin Med Genet. 2015 Mar;169C(1):54-75. PubMed PMID: 25821092.

8. Nagaraja V., McMahan Z.H., Getzug T., Khanna D. Management of gastrointestinal involvement in scleroderma. Curr Treatm Opt Rheumatol. 2015 Mar 01;1(1):82-105. PubMed PMID: 26005632. Pubmed Central PMCID: 4437639.

9. Malagelada J.R., Accarino A., Azpiroz F. Bloating and abdominal distension: Old misconceptions and current knowledge. Am J Gastroenterol. 2017 Aug;112(8):1221-31. PubMed PMID: 28508867.

10. Soh J.S., Lee H.J., Jung K.W., et al. The diagnostic value of a digital rectal examination compared with high-resolution anorectal manometry in patients with chronic constipation and fecal incontinence. Am J Gastroenterol. 2015 Aug;110(8):1197-204. PubMed PMID: 26032152.

11. American Gastroenterological Association, Bharucha A.E., Dorn S.D., Lembo A., Pressman A. American Gastroenterological Association medical position statement on constipation. Gastroenterology. 2013 Jan;144(1):211-7. PubMed PMID: 23261064.

12. Skardoon G.R., Khera A.J., Emmanuel A.V., Burgell R.E. Review article: dyssynergic defaecation and biofeedback therapy in the pathophysiology and management of functional constipation. Aliment Pharmacol Therapeut. 2017 Aug;46(4):410-23. PubMed PMID: 28660663.

13. Koh C.E., Young C.J., Young J.M., Solomon M.J. Systematic review of randomized controlled trials of the effectiveness of biofeedback for pelvic floor dysfunction. Br J Surg. 2008 Sep;95(9):1079-87. PubMed PMID: 18655219.

14. Rao S., Lembo A.J., Shiff S.J., et al. A 12-week, randomized, controlled trial with a 4-week randomized withdrawal period to evaluate the efficacy and safety of linaclotide in irritable bowel syndrome with constipation. Am J Gastroenterol. 2012 Nov;107(11):1714-24; quiz p 25. PubMed PMID: 22986440. Pubmed Central PMCID: 3504311.

15. Lacy B.E., Schey R., Shiff S.J., et al. Linaclotide in chronic idiopathic constipation patients with moderate to severe abdominal bloating: A randomized, controlled trial. PloS One. 2015;10(7):e0134349. PubMed PMID: 26222318. Pubmed Central PMCID: 4519259.

16. Miner P.B., Jr., Koltun W.D., Wiener G.J., et al. A randomized phase III clinical trial of plecanatide, a uroguanylin analog, in patients with chronic idiopathic constipation. Am J Gastroenterol. 2017 Apr;112(4):613-21. PubMed PMID: 28169285. Pubmed Central PMCID: 5415706.

17. Johanson J.F., Drossman D.A., Panas R., Wahle A., Ueno R. Clinical trial: phase 2 study of lubiprostone for irritable bowel syndrome with constipation. Aliment Pharmacol Therapeut. 2008 Apr;27(8):685-96. PubMed PMID: 18248656.

18. Chey W.D., Webster L., Sostek M., Lappalainen J., Barker P.N., Tack J. Naloxegol for opioid-induced constipation in patients with noncancer pain. N Engl J Med. 2014 Jun 19;370(25):2387-96. PubMed PMID: 24896818.

19. Katakami N., Oda K., Tauchi K., et al. Phase IIb, randomized, double-blind, placebo-controlled study of naldemedine for the treatment of opioid-induced constipation in patients with cancer. J Clin Oncol. 2017 Jun 10;35(17):1921-8. PubMed PMID: 28445097.

20. Sajid M.S., Hebbar M., Baig M.K., Li A., Philipose Z. Use of prucalopride for chronic constipation: A systematic review and meta-analysis of published randomized, controlled trials. J Neurogastroenterol Motil. 2016 Jul 30;22(3):412-22. PubMed PMID: 27127190. Pubmed Central PMCID: 4930296.

21. Quigley E.M. Cisapride: What can we learn from the rise and fall of a prokinetic? J Dig Dis. 2011 Jun;12(3):147-56. PubMed PMID: 21615867.

22. Conlon K., De Maeyer J.H., Bruce C., et al. Nonclinical cardiovascular studies of prucalopride, a highly selective 5-hydroxytryptamine 4 receptor agonist. J Pharmacol Exp Therapeut. 2017 Nov; doi: 10.1124/jpet.117.244079 [epub ahead of print].

23. Chey W.D., Lembo A.J., Rosenbaum D.P. Tenapanor treatment of patients with constipation-predominant irritable bowel syndrome: a phase 2, randomized, placebo-controlled efficacy and safety trial. Am J Gastroenterol. 2017;112:763-74.

24. Simren M., Bajor A., Gillberg P-G, Rudling M., Abrahamsson H. Randomised clinical trial: the ileal bile acid transporter inhibitor A3309 vs. placebo in patients with chronic idiopathic constipation – a double-blind study. Aliment Pharmacol Ther. 2011 Jul;34(1):41-50.

25. Zarate N., Knowles C.H., Newell M., et al. In patients with slow transit constipation, the pattern of colonic transit delay does not differentiate between those with and without impaired rectal evacuation. Am J Gastroenterol. 2008 Feb;103(2):427-34. PubMed PMID: 18070233.

26. Redmond J.M., Smith G.W., Barofsky I., et al. Physiological tests to predict long-term outcome of total abdominal colectomy for intractable constipation. Am J Gastroenterol. 1995 May;90(5):748-53. PubMed PMID: 7733081.

While constipation is one of the most common symptoms managed by practicing gastroenterologists, it can also be among the most challenging. As a presenting complaint, constipation manifests with widely varying degrees of severity and may be seen in all age groups, ethnicities, and socioeconomic backgrounds. Its implications can include chronic and serious functional impairment as well as protracted and often excessive health care utilization. A growing number of pharmacologic and nonpharmacologic interventions have become available and proven to be effective when appropriately deployed. As such, health care providers and particularly gastroenterologists should strive to develop logical and efficient strategies for addressing this common disorder.

Clinical importance

While there are a variety of etiologies for constipation (Table 1), a large proportion of chronic cases fall within the framework of functional gastrointestinal disorders, a category with a substantial burden of disease across the population. Prevalence estimates vary, but constipation likely affects between 12% and 20% of the North American population.¹ Research has demonstrated significant health care expenditures associated with chronic constipation management; U.S. estimates suggest direct costs on the order of hundreds of millions of dollars per year, roughly half of which are attributable to inpatient care.² The financial burden of constipation also includes indirect costs associated with absenteeism as well as the risks of hospitalization and invasive procedures.³

Physical and emotional complications can be likewise significant and affect all age groups, from newborns to patients in the last days of life. Hirschsprung’s disease, for example, can lead to life-threatening sequelae in infancy, such as spontaneous perforation or enterocolitis, or more prolonged functional impairments when it remains undiagnosed. Severe constipation in childhood can lead to encopresis, translating in turn into ostracism and impaired social functioning. Fecal incontinence associated with overflow diarrhea is common and debilitating, particularly in the elderly population.
 

The potential mechanical complications of constipation lead to its overlap with a variety of other gastrointestinal complaints. For example, the difficulties of passing inspissated stool can provoke lower gastrointestinal bleeding from irritated hemorrhoids, anal fissures, stercoral ulcers, or prolapsed rectal tissue. Retained stool can also lead to upper gastrointestinal symptoms such as postprandial bloating or early satiety.⁴ Delayed fecal discharge can promote an increase in fermentative microbiota, associated in turn with the production of short-chain fatty acids, methane, and other gaseous byproducts.

The initial assessment

History

Taking an appropriate history is an essential step toward achieving a successful outcome. Presenting concerns related to constipation can range from hard, infrequent, or small-volume stools; abdominal or rectal pain associated with the process of elimination; and bloating, nausea, or early satiety. A sound diagnosis requires a keen understanding of what patients mean when they indicate that they are constipated, an accurate assessment of its impact on quality of life, and a careful inventory of potentially associated complications.

It is critical to define the duration of the problem. Not infrequently, patients will focus on recent events while failing to reveal that altered bowel habits or other functional symptoms have been problematic for years. Reminding the patients to “begin at the beginning” can aid enormously in contextualizing their complaints. Individuals with longstanding symptoms and previously negative evaluations are much less likely to present with a new organic disease than are those in whom symptoms have truly arisen de novo.

Defining constipation by frequency of bowel eliminations alone has proved inaccurate at predicting actual severity. This is in part because the bowel movement frequency varies widely in healthy individuals (anywhere from thrice daily to once every 3 days) and in part because the primary indicator of effective evacuation is not frequency but volume – a much more difficult quantity for patients to gauge.⁵ The Bristol Stool Scale is a simple, standardized tool that more accurately evaluates the presence or absence of colonic dysfunction. For example, patients passing Type 1-2 (hard or lumpy) stools often have an element of constipation that needs to be addressed.⁶ However, the interpretation of stool consistency assessments is still aided by awareness of both frequency and volume. A patient passing multiple small-volume Type 6-7 (loose or watery) stools may be the most constipated, presenting with overflow or paradoxical diarrhea attributable to fecal impaction.

Physical examination

An expert physical exam is another essential aspect of the initial assessment. Alarm features can be elicited in this context as well via signs of pallor, weight loss, blood in the stool, physical abuse, or advanced psychological distress. Attention should also be paid to signs of a systemic disorder that might be associated with gastrointestinal dysmotility including previously unrecognized signs of Raynaud’s syndrome, sclerodactyly, amyloidosis, surgical scars, and joint hypermobility.^7,8 Abdominal bloating, a frequently vague symptomatic complaint, can be correlated with the presence or absence of distention as perceived by the patient and/or the examiner.⁹

Any initial evaluation of constipation should also include a detailed digital rectal exam. A complete examination should include a careful visual assessment of the perianal region for external lesions and of the degree and directional appropriateness of pelvic floor excursion (perineal elevation and descent) during squeeze and simulated defecation maneuvers, respectively. Digital examination should include palpation for the presence or absence of pain as well as stool, blood, or masses in the rectal vault, as well as an assessment of sphincter tone at baseline, with squeeze, and with simulated defecation. Rectal pressure generation with the latter maneuver can also be qualitatively assessed. Research has suggested moderate agreement between the digital rectal examination and formal manometric evaluation in diagnosing dyssynergic defecation, underscoring the former’s utility in guiding initial management decisions.¹⁰

Testing

It is reasonable to exclude metabolic, inflammatory, or other secondary etiologies of constipation in patients in whom history or examination raises suspicion. Likewise, colonoscopy should be considered in patients with alarm features or who are due for age-appropriate screening. That said, in the absence of risk factors or ancillary signs and symptoms, a detailed diagnostic work-up is often unnecessary. The AGA’s Medical Position Statement on Constipation recommends a complete blood count as the only test to be ordered on a standard basis in the work-up of constipation.¹¹

In patients new to one’s practice, the diligent retrieval of prior records is one of the most efficient ways to avoid wasting health care resources. Locating an old abdominal radiograph that demonstrates extensive retained stool can not only secure the diagnosis for vague symptomatic complaints but also obviate the need for more extensive testing. One should instead consider how symptom duration and the associated changes in objectives measures such as weight and laboratory parameters can be used to justify or refute the need for repeating costly or invasive studies.

It is important to consider the potential contribution of defecatory dyssynergy to chronic constipation early in a patient’s presentation, and to return to this possibility in the future if initial therapeutic interventions are unsuccessful. An abnormal qualitative assessment on digital rectal examination should trigger a more formal characterization of the patient’s defecatory mechanics via anorectal manometry (ARM) and balloon expulsion testing (BET). Likewise, a lack of response to initial pharmacotherapy should prompt suspicion for outlet dysfunction, which can be queried with functional testing even if a rectal examination is qualitatively unrevealing.

Initial approach to the chronically constipated patient

The aforementioned AGA Medical Position Statement provides a helpful algorithm regarding the diagnostic approach to constipation (Figure 1). In the absence of concern for secondary etiologies of constipation, an initial therapeutic trial of dietary, lifestyle, and medication-based intervention is reasonable for mild symptoms. Patients should be encouraged to strive for 25-30 grams of dietary fiber intake per day. For patients unable to reach this goal via high-fiber foods alone, psyllium husk is a popular supplement, but it should be initiated at modest doses to mitigate the risk of bloating. Fiber may be supplemented with the use of osmotic laxatives (e.g., polyethylene glycol) with instructions that the initial dose may be modified as needed to optimal effectiveness. Selective response to rectal therapies (e.g., bisacodyl or glycerin suppositories) over osmotic laxatives may also suggest utility in early queries of outlet dysfunction.

An abdominal radiograph can be helpful not only to diagnose constipation but also to assess the stool burden present at the time of beginning treatment. For patients presenting with a significant degree of fecal loading, an initial bowel cleanse with four liters of osmotically balanced polyethylene glycol can be a useful means of eliminating background fecal impactions that might have mitigated the effectiveness of initial therapies in the past or that might reduce the effectiveness of daily laxative therapy moving forward.

Patients with a diagnosis of defecatory dyssynergy made via ARM/BET should be referred to pelvic floor physical therapy with biofeedback. Recognizing that courses of therapy are highly individualized in practice, randomized controlled trials suggest symptom improvement in 70%-80% of patients, with the majority also demonstrating maintenance of response.¹² Biofeedback appears to be an essential component of this modality based on meta-analysis data and should be requested specifically by the referring provider.¹³

Pharmacologic agents

For those patients with more severe initial presentations or whose symptoms persist despite initial medical management, there are several pharmacologic agents that may be considered on a prescription basis (Table 2). Linaclotide, a minimally absorbed guanylate cyclase agonist, is approved by the Food and Drug Administration for patients with irritable bowel syndrome with constipation (IBS-C) and chronic idiopathic constipation (CIC). Improvements in constipation tend to occur over a slightly shorter timeline than in abdominal pain, though both have been demonstrated in comparison to placebo.^14,15 Plecanatide, a newer agent with a similar mechanism of action, has demonstrated improvements in bowel movement frequency and was recently approved for CIC.¹⁶ Lubiprostone, a chloride channel agonist, has demonstrated benefit for IBS-C and CIC as well, though its side effect profile is more varied, including dose-related nausea in up to 30% of patients.¹⁷

For patients with opioid-induced constipation who cannot wean from the opioid medications, the peripheral acting mu-opioid receptor antagonists may be quite helpful. These include injectable as well as oral formulations (e.g., methylnaltrexone and naloxegol, respectively) with additional agents under active investigation in particular clinical subsets (e.g., naldemedine for patients with cancer-related pain).^18,19 Prucalopride, a selective serotonin receptor agonist, has also demonstrated benefit for constipation; it is available abroad but not yet approved for use in the United States.²⁰ Prucalopride shares its primary mechanism of action (selective agonism of the 5HT4 serotonin receptor) with cisapride, a previously quite popular gastrointestinal motility agent that was subsequently withdrawn from the U.S. market because of arrhythmia risk.²¹ This risk is likely attributable to cisapride’s dual binding affinity for potassium channels, a feature that prucalopride does not share; as such, cardiotoxicity is not an active concern with the latter agent.²²

Still other pharmacologic agents with novel mechanisms of action are currently under investigation. Tenapanor, an inhibitor of a particular sodium/potassium exchanger in the gut lumen, mitigates intestinal sodium absorption, which increases fluid volume and transit. A recent phase 2 study demonstrated significantly increased stool frequency relative to placebo in patients with IBS-C.²³ Elobixibat, an ileal bile acid transport inhibitor, promotes colonic retention of bile acids and, in placebo-controlled studies, has led to accelerated colonic transit and an increased number of spontaneous bowel movements in patients with CIC.²⁴

Persistent constipation

In cases of refractory constipation (in practical terms, symptoms that persist despite trials of escalating medical therapy over at least 6 weeks), it is worth revisiting the question of etiology. Querying defecatory dyssynergy via ARM/BET, if not pursued prior to trials of newer pharmacologic agents, should certainly be explored in the event that such trials fail. Inconclusive results of ARM and BET testing, or BET abnormalities that persist despite a course of physical therapy with biofeedback, may raise suspicion for pelvic organ prolapse, which may be formally evaluated with defecography. Additional testing for metabolic or structural predispositions toward constipation may also be reasonable at this juncture.

Formal colonic transit testing via radio-opaque markers, scintigraphy, or the wireless motility capsule is often inaccurate in the setting of dyssynergic defecation and should be pursued only after this entity has been excluded or successfully treated.²⁵ While there are not many practical distinctions at present in the therapeutic management of slow-transit versus normal-transit constipation, the use of novel medications with an explicitly prokinetic mechanism of action may be reasonable to consider in the setting of a document delay in colonic transit. Such delays can also help justify further specialized diagnostic testing (e.g., colonic manometry), and, in rare refractory cases, surgical intervention.

Consideration of colectomy should be reserved for highly selected patients with delayed colonic transit, normal defecatory mechanics, and the absence of potentially explanatory background conditions (e.g., connective tissue disease). Clear evidence of an underlying colonic myopathy or neuropathy may militate in favor of a more targeted surgical intervention (e.g., subtotal colectomy) or guide one’s clinical evaluation toward alternative systemic diagnoses. A diverting loop ileostomy with interval assessment of symptoms may be useful to clarify the potential benefits of colectomy while preserving the option of operative reversal. Proximal transit delays should be definitively excluded before pursuing colonic resections given evidence that multisegment transit delays portend significantly worse postoperative outcomes.²⁶

Conclusion

Constipation is a common, sometimes confusing presenting complaint and the variety of established and emergent options for diagnosis and therapy can lend themselves to haphazard application. Patients and providers both are well served by a clinical approach, rooted in a comprehensive history and examination, that begins to organize these options in thoughtful sequence.



Dr. Ahuja is assistant professor of clinical medicine, division of gastroenterology; Dr. Reynolds is professor of clinical medicine, and director of the program in neurogastroenterology and motility, division of gastroenterology, Perelman School of Medicine, University of Pennsylvania, Philadelphia.

References

1. Higgins P.D., Johanson J.F. Epidemiology of constipation in North America: a systematic review. Am J Gastroenterol. 2004 Apr;99(4):750-9. PubMed PMID: 15089911.

2. Martin B.C., Barghout V., Cerulli A. Direct medical costs of constipation in the United States. Manage Care Interface. 2006 Dec;19(12):43-9. PubMed PMID: 17274481.

3. Sun S.X., Dibonaventura M., Purayidathil F.W., et al. Impact of chronic constipation on health-related quality of life, work productivity, and healthcare resource use: an analysis of the National Health and Wellness Survey. Dig Dis Sc. 2011 Sep;56(9):2688-95. PubMed PMID: 21380761.

4. Heidelbaugh J.J., Stelwagon M., Miller S.A., et al. The spectrum of constipation-predominant irritable bowel syndrome and chronic idiopathic constipation: US survey assessing symptoms, care seeking, and disease burden. Am J Gastroenterol. 2015 Apr;110(4):580-7.

5. Mitsuhashi S., Ballou S., Jiang Z.G., et al. Characterizing normal bowel frequency and consistency in a representative sample of adults in the United States (NHANES). Am J Gastroenterol. 2017 Aug 01. PubMed PMID: 28762379.

6. Saad R.J., Rao S.S., Koch K.L., et al. Do stool form and frequency correlate with whole-gut and colonic transit? Results from a multicenter study in constipated individuals and healthy controls. Am J Gastroenterol. 2010 Feb;105(2):403-11. PubMed PMID: 19888202.

7. Castori M., Morlino S., Pascolini G., et al. Gastrointestinal and nutritional issues in joint hypermobility syndrome/Ehlers-Danlos syndrome, hypermobility type. American Journal of Medical Genetics Part C, Semin Med Genet. 2015 Mar;169C(1):54-75. PubMed PMID: 25821092.

8. Nagaraja V., McMahan Z.H., Getzug T., Khanna D. Management of gastrointestinal involvement in scleroderma. Curr Treatm Opt Rheumatol. 2015 Mar 01;1(1):82-105. PubMed PMID: 26005632. Pubmed Central PMCID: 4437639.

9. Malagelada J.R., Accarino A., Azpiroz F. Bloating and abdominal distension: Old misconceptions and current knowledge. Am J Gastroenterol. 2017 Aug;112(8):1221-31. PubMed PMID: 28508867.

10. Soh J.S., Lee H.J., Jung K.W., et al. The diagnostic value of a digital rectal examination compared with high-resolution anorectal manometry in patients with chronic constipation and fecal incontinence. Am J Gastroenterol. 2015 Aug;110(8):1197-204. PubMed PMID: 26032152.

11. American Gastroenterological Association, Bharucha A.E., Dorn S.D., Lembo A., Pressman A. American Gastroenterological Association medical position statement on constipation. Gastroenterology. 2013 Jan;144(1):211-7. PubMed PMID: 23261064.

12. Skardoon G.R., Khera A.J., Emmanuel A.V., Burgell R.E. Review article: dyssynergic defaecation and biofeedback therapy in the pathophysiology and management of functional constipation. Aliment Pharmacol Therapeut. 2017 Aug;46(4):410-23. PubMed PMID: 28660663.

13. Koh C.E., Young C.J., Young J.M., Solomon M.J. Systematic review of randomized controlled trials of the effectiveness of biofeedback for pelvic floor dysfunction. Br J Surg. 2008 Sep;95(9):1079-87. PubMed PMID: 18655219.

14. Rao S., Lembo A.J., Shiff S.J., et al. A 12-week, randomized, controlled trial with a 4-week randomized withdrawal period to evaluate the efficacy and safety of linaclotide in irritable bowel syndrome with constipation. Am J Gastroenterol. 2012 Nov;107(11):1714-24; quiz p 25. PubMed PMID: 22986440. Pubmed Central PMCID: 3504311.

15. Lacy B.E., Schey R., Shiff S.J., et al. Linaclotide in chronic idiopathic constipation patients with moderate to severe abdominal bloating: A randomized, controlled trial. PloS One. 2015;10(7):e0134349. PubMed PMID: 26222318. Pubmed Central PMCID: 4519259.

16. Miner P.B., Jr., Koltun W.D., Wiener G.J., et al. A randomized phase III clinical trial of plecanatide, a uroguanylin analog, in patients with chronic idiopathic constipation. Am J Gastroenterol. 2017 Apr;112(4):613-21. PubMed PMID: 28169285. Pubmed Central PMCID: 5415706.

17. Johanson J.F., Drossman D.A., Panas R., Wahle A., Ueno R. Clinical trial: phase 2 study of lubiprostone for irritable bowel syndrome with constipation. Aliment Pharmacol Therapeut. 2008 Apr;27(8):685-96. PubMed PMID: 18248656.

18. Chey W.D., Webster L., Sostek M., Lappalainen J., Barker P.N., Tack J. Naloxegol for opioid-induced constipation in patients with noncancer pain. N Engl J Med. 2014 Jun 19;370(25):2387-96. PubMed PMID: 24896818.

19. Katakami N., Oda K., Tauchi K., et al. Phase IIb, randomized, double-blind, placebo-controlled study of naldemedine for the treatment of opioid-induced constipation in patients with cancer. J Clin Oncol. 2017 Jun 10;35(17):1921-8. PubMed PMID: 28445097.

20. Sajid M.S., Hebbar M., Baig M.K., Li A., Philipose Z. Use of prucalopride for chronic constipation: A systematic review and meta-analysis of published randomized, controlled trials. J Neurogastroenterol Motil. 2016 Jul 30;22(3):412-22. PubMed PMID: 27127190. Pubmed Central PMCID: 4930296.

21. Quigley E.M. Cisapride: What can we learn from the rise and fall of a prokinetic? J Dig Dis. 2011 Jun;12(3):147-56. PubMed PMID: 21615867.

22. Conlon K., De Maeyer J.H., Bruce C., et al. Nonclinical cardiovascular studies of prucalopride, a highly selective 5-hydroxytryptamine 4 receptor agonist. J Pharmacol Exp Therapeut. 2017 Nov; doi: 10.1124/jpet.117.244079 [epub ahead of print].

23. Chey W.D., Lembo A.J., Rosenbaum D.P. Tenapanor treatment of patients with constipation-predominant irritable bowel syndrome: a phase 2, randomized, placebo-controlled efficacy and safety trial. Am J Gastroenterol. 2017;112:763-74.

24. Simren M., Bajor A., Gillberg P-G, Rudling M., Abrahamsson H. Randomised clinical trial: the ileal bile acid transporter inhibitor A3309 vs. placebo in patients with chronic idiopathic constipation – a double-blind study. Aliment Pharmacol Ther. 2011 Jul;34(1):41-50.

25. Zarate N., Knowles C.H., Newell M., et al. In patients with slow transit constipation, the pattern of colonic transit delay does not differentiate between those with and without impaired rectal evacuation. Am J Gastroenterol. 2008 Feb;103(2):427-34. PubMed PMID: 18070233.

26. Redmond J.M., Smith G.W., Barofsky I., et al. Physiological tests to predict long-term outcome of total abdominal colectomy for intractable constipation. Am J Gastroenterol. 1995 May;90(5):748-53. PubMed PMID: 7733081.

While constipation is one of the most common symptoms managed by practicing gastroenterologists, it can also be among the most challenging. As a presenting complaint, constipation manifests with widely varying degrees of severity and may be seen in all age groups, ethnicities, and socioeconomic backgrounds. Its implications can include chronic and serious functional impairment as well as protracted and often excessive health care utilization. A growing number of pharmacologic and nonpharmacologic interventions have become available and proven to be effective when appropriately deployed. As such, health care providers and particularly gastroenterologists should strive to develop logical and efficient strategies for addressing this common disorder.

Clinical importance

While there are a variety of etiologies for constipation (Table 1), a large proportion of chronic cases fall within the framework of functional gastrointestinal disorders, a category with a substantial burden of disease across the population. Prevalence estimates vary, but constipation likely affects between 12% and 20% of the North American population.¹ Research has demonstrated significant health care expenditures associated with chronic constipation management; U.S. estimates suggest direct costs on the order of hundreds of millions of dollars per year, roughly half of which are attributable to inpatient care.² The financial burden of constipation also includes indirect costs associated with absenteeism as well as the risks of hospitalization and invasive procedures.³

Physical and emotional complications can be likewise significant and affect all age groups, from newborns to patients in the last days of life. Hirschsprung’s disease, for example, can lead to life-threatening sequelae in infancy, such as spontaneous perforation or enterocolitis, or more prolonged functional impairments when it remains undiagnosed. Severe constipation in childhood can lead to encopresis, translating in turn into ostracism and impaired social functioning. Fecal incontinence associated with overflow diarrhea is common and debilitating, particularly in the elderly population.
 

The potential mechanical complications of constipation lead to its overlap with a variety of other gastrointestinal complaints. For example, the difficulties of passing inspissated stool can provoke lower gastrointestinal bleeding from irritated hemorrhoids, anal fissures, stercoral ulcers, or prolapsed rectal tissue. Retained stool can also lead to upper gastrointestinal symptoms such as postprandial bloating or early satiety.⁴ Delayed fecal discharge can promote an increase in fermentative microbiota, associated in turn with the production of short-chain fatty acids, methane, and other gaseous byproducts.

The initial assessment

History

Taking an appropriate history is an essential step toward achieving a successful outcome. Presenting concerns related to constipation can range from hard, infrequent, or small-volume stools; abdominal or rectal pain associated with the process of elimination; and bloating, nausea, or early satiety. A sound diagnosis requires a keen understanding of what patients mean when they indicate that they are constipated, an accurate assessment of its impact on quality of life, and a careful inventory of potentially associated complications.

It is critical to define the duration of the problem. Not infrequently, patients will focus on recent events while failing to reveal that altered bowel habits or other functional symptoms have been problematic for years. Reminding the patients to “begin at the beginning” can aid enormously in contextualizing their complaints. Individuals with longstanding symptoms and previously negative evaluations are much less likely to present with a new organic disease than are those in whom symptoms have truly arisen de novo.

Defining constipation by frequency of bowel eliminations alone has proved inaccurate at predicting actual severity. This is in part because the bowel movement frequency varies widely in healthy individuals (anywhere from thrice daily to once every 3 days) and in part because the primary indicator of effective evacuation is not frequency but volume – a much more difficult quantity for patients to gauge.⁵ The Bristol Stool Scale is a simple, standardized tool that more accurately evaluates the presence or absence of colonic dysfunction. For example, patients passing Type 1-2 (hard or lumpy) stools often have an element of constipation that needs to be addressed.⁶ However, the interpretation of stool consistency assessments is still aided by awareness of both frequency and volume. A patient passing multiple small-volume Type 6-7 (loose or watery) stools may be the most constipated, presenting with overflow or paradoxical diarrhea attributable to fecal impaction.

Physical examination

An expert physical exam is another essential aspect of the initial assessment. Alarm features can be elicited in this context as well via signs of pallor, weight loss, blood in the stool, physical abuse, or advanced psychological distress. Attention should also be paid to signs of a systemic disorder that might be associated with gastrointestinal dysmotility including previously unrecognized signs of Raynaud’s syndrome, sclerodactyly, amyloidosis, surgical scars, and joint hypermobility.^7,8 Abdominal bloating, a frequently vague symptomatic complaint, can be correlated with the presence or absence of distention as perceived by the patient and/or the examiner.⁹

Any initial evaluation of constipation should also include a detailed digital rectal exam. A complete examination should include a careful visual assessment of the perianal region for external lesions and of the degree and directional appropriateness of pelvic floor excursion (perineal elevation and descent) during squeeze and simulated defecation maneuvers, respectively. Digital examination should include palpation for the presence or absence of pain as well as stool, blood, or masses in the rectal vault, as well as an assessment of sphincter tone at baseline, with squeeze, and with simulated defecation. Rectal pressure generation with the latter maneuver can also be qualitatively assessed. Research has suggested moderate agreement between the digital rectal examination and formal manometric evaluation in diagnosing dyssynergic defecation, underscoring the former’s utility in guiding initial management decisions.¹⁰

Testing

It is reasonable to exclude metabolic, inflammatory, or other secondary etiologies of constipation in patients in whom history or examination raises suspicion. Likewise, colonoscopy should be considered in patients with alarm features or who are due for age-appropriate screening. That said, in the absence of risk factors or ancillary signs and symptoms, a detailed diagnostic work-up is often unnecessary. The AGA’s Medical Position Statement on Constipation recommends a complete blood count as the only test to be ordered on a standard basis in the work-up of constipation.¹¹

In patients new to one’s practice, the diligent retrieval of prior records is one of the most efficient ways to avoid wasting health care resources. Locating an old abdominal radiograph that demonstrates extensive retained stool can not only secure the diagnosis for vague symptomatic complaints but also obviate the need for more extensive testing. One should instead consider how symptom duration and the associated changes in objectives measures such as weight and laboratory parameters can be used to justify or refute the need for repeating costly or invasive studies.

It is important to consider the potential contribution of defecatory dyssynergy to chronic constipation early in a patient’s presentation, and to return to this possibility in the future if initial therapeutic interventions are unsuccessful. An abnormal qualitative assessment on digital rectal examination should trigger a more formal characterization of the patient’s defecatory mechanics via anorectal manometry (ARM) and balloon expulsion testing (BET). Likewise, a lack of response to initial pharmacotherapy should prompt suspicion for outlet dysfunction, which can be queried with functional testing even if a rectal examination is qualitatively unrevealing.

Initial approach to the chronically constipated patient

The aforementioned AGA Medical Position Statement provides a helpful algorithm regarding the diagnostic approach to constipation (Figure 1). In the absence of concern for secondary etiologies of constipation, an initial therapeutic trial of dietary, lifestyle, and medication-based intervention is reasonable for mild symptoms. Patients should be encouraged to strive for 25-30 grams of dietary fiber intake per day. For patients unable to reach this goal via high-fiber foods alone, psyllium husk is a popular supplement, but it should be initiated at modest doses to mitigate the risk of bloating. Fiber may be supplemented with the use of osmotic laxatives (e.g., polyethylene glycol) with instructions that the initial dose may be modified as needed to optimal effectiveness. Selective response to rectal therapies (e.g., bisacodyl or glycerin suppositories) over osmotic laxatives may also suggest utility in early queries of outlet dysfunction.

An abdominal radiograph can be helpful not only to diagnose constipation but also to assess the stool burden present at the time of beginning treatment. For patients presenting with a significant degree of fecal loading, an initial bowel cleanse with four liters of osmotically balanced polyethylene glycol can be a useful means of eliminating background fecal impactions that might have mitigated the effectiveness of initial therapies in the past or that might reduce the effectiveness of daily laxative therapy moving forward.

Patients with a diagnosis of defecatory dyssynergy made via ARM/BET should be referred to pelvic floor physical therapy with biofeedback. Recognizing that courses of therapy are highly individualized in practice, randomized controlled trials suggest symptom improvement in 70%-80% of patients, with the majority also demonstrating maintenance of response.¹² Biofeedback appears to be an essential component of this modality based on meta-analysis data and should be requested specifically by the referring provider.¹³

Pharmacologic agents

For those patients with more severe initial presentations or whose symptoms persist despite initial medical management, there are several pharmacologic agents that may be considered on a prescription basis (Table 2). Linaclotide, a minimally absorbed guanylate cyclase agonist, is approved by the Food and Drug Administration for patients with irritable bowel syndrome with constipation (IBS-C) and chronic idiopathic constipation (CIC). Improvements in constipation tend to occur over a slightly shorter timeline than in abdominal pain, though both have been demonstrated in comparison to placebo.^14,15 Plecanatide, a newer agent with a similar mechanism of action, has demonstrated improvements in bowel movement frequency and was recently approved for CIC.¹⁶ Lubiprostone, a chloride channel agonist, has demonstrated benefit for IBS-C and CIC as well, though its side effect profile is more varied, including dose-related nausea in up to 30% of patients.¹⁷

For patients with opioid-induced constipation who cannot wean from the opioid medications, the peripheral acting mu-opioid receptor antagonists may be quite helpful. These include injectable as well as oral formulations (e.g., methylnaltrexone and naloxegol, respectively) with additional agents under active investigation in particular clinical subsets (e.g., naldemedine for patients with cancer-related pain).^18,19 Prucalopride, a selective serotonin receptor agonist, has also demonstrated benefit for constipation; it is available abroad but not yet approved for use in the United States.²⁰ Prucalopride shares its primary mechanism of action (selective agonism of the 5HT4 serotonin receptor) with cisapride, a previously quite popular gastrointestinal motility agent that was subsequently withdrawn from the U.S. market because of arrhythmia risk.²¹ This risk is likely attributable to cisapride’s dual binding affinity for potassium channels, a feature that prucalopride does not share; as such, cardiotoxicity is not an active concern with the latter agent.²²

Still other pharmacologic agents with novel mechanisms of action are currently under investigation. Tenapanor, an inhibitor of a particular sodium/potassium exchanger in the gut lumen, mitigates intestinal sodium absorption, which increases fluid volume and transit. A recent phase 2 study demonstrated significantly increased stool frequency relative to placebo in patients with IBS-C.²³ Elobixibat, an ileal bile acid transport inhibitor, promotes colonic retention of bile acids and, in placebo-controlled studies, has led to accelerated colonic transit and an increased number of spontaneous bowel movements in patients with CIC.²⁴

Persistent constipation

In cases of refractory constipation (in practical terms, symptoms that persist despite trials of escalating medical therapy over at least 6 weeks), it is worth revisiting the question of etiology. Querying defecatory dyssynergy via ARM/BET, if not pursued prior to trials of newer pharmacologic agents, should certainly be explored in the event that such trials fail. Inconclusive results of ARM and BET testing, or BET abnormalities that persist despite a course of physical therapy with biofeedback, may raise suspicion for pelvic organ prolapse, which may be formally evaluated with defecography. Additional testing for metabolic or structural predispositions toward constipation may also be reasonable at this juncture.

Formal colonic transit testing via radio-opaque markers, scintigraphy, or the wireless motility capsule is often inaccurate in the setting of dyssynergic defecation and should be pursued only after this entity has been excluded or successfully treated.²⁵ While there are not many practical distinctions at present in the therapeutic management of slow-transit versus normal-transit constipation, the use of novel medications with an explicitly prokinetic mechanism of action may be reasonable to consider in the setting of a document delay in colonic transit. Such delays can also help justify further specialized diagnostic testing (e.g., colonic manometry), and, in rare refractory cases, surgical intervention.

Consideration of colectomy should be reserved for highly selected patients with delayed colonic transit, normal defecatory mechanics, and the absence of potentially explanatory background conditions (e.g., connective tissue disease). Clear evidence of an underlying colonic myopathy or neuropathy may militate in favor of a more targeted surgical intervention (e.g., subtotal colectomy) or guide one’s clinical evaluation toward alternative systemic diagnoses. A diverting loop ileostomy with interval assessment of symptoms may be useful to clarify the potential benefits of colectomy while preserving the option of operative reversal. Proximal transit delays should be definitively excluded before pursuing colonic resections given evidence that multisegment transit delays portend significantly worse postoperative outcomes.²⁶

Conclusion

Constipation is a common, sometimes confusing presenting complaint and the variety of established and emergent options for diagnosis and therapy can lend themselves to haphazard application. Patients and providers both are well served by a clinical approach, rooted in a comprehensive history and examination, that begins to organize these options in thoughtful sequence.



Dr. Ahuja is assistant professor of clinical medicine, division of gastroenterology; Dr. Reynolds is professor of clinical medicine, and director of the program in neurogastroenterology and motility, division of gastroenterology, Perelman School of Medicine, University of Pennsylvania, Philadelphia.

References

1. Higgins P.D., Johanson J.F. Epidemiology of constipation in North America: a systematic review. Am J Gastroenterol. 2004 Apr;99(4):750-9. PubMed PMID: 15089911.

2. Martin B.C., Barghout V., Cerulli A. Direct medical costs of constipation in the United States. Manage Care Interface. 2006 Dec;19(12):43-9. PubMed PMID: 17274481.

3. Sun S.X., Dibonaventura M., Purayidathil F.W., et al. Impact of chronic constipation on health-related quality of life, work productivity, and healthcare resource use: an analysis of the National Health and Wellness Survey. Dig Dis Sc. 2011 Sep;56(9):2688-95. PubMed PMID: 21380761.

4. Heidelbaugh J.J., Stelwagon M., Miller S.A., et al. The spectrum of constipation-predominant irritable bowel syndrome and chronic idiopathic constipation: US survey assessing symptoms, care seeking, and disease burden. Am J Gastroenterol. 2015 Apr;110(4):580-7.

5. Mitsuhashi S., Ballou S., Jiang Z.G., et al. Characterizing normal bowel frequency and consistency in a representative sample of adults in the United States (NHANES). Am J Gastroenterol. 2017 Aug 01. PubMed PMID: 28762379.

6. Saad R.J., Rao S.S., Koch K.L., et al. Do stool form and frequency correlate with whole-gut and colonic transit? Results from a multicenter study in constipated individuals and healthy controls. Am J Gastroenterol. 2010 Feb;105(2):403-11. PubMed PMID: 19888202.

7. Castori M., Morlino S., Pascolini G., et al. Gastrointestinal and nutritional issues in joint hypermobility syndrome/Ehlers-Danlos syndrome, hypermobility type. American Journal of Medical Genetics Part C, Semin Med Genet. 2015 Mar;169C(1):54-75. PubMed PMID: 25821092.

8. Nagaraja V., McMahan Z.H., Getzug T., Khanna D. Management of gastrointestinal involvement in scleroderma. Curr Treatm Opt Rheumatol. 2015 Mar 01;1(1):82-105. PubMed PMID: 26005632. Pubmed Central PMCID: 4437639.

9. Malagelada J.R., Accarino A., Azpiroz F. Bloating and abdominal distension: Old misconceptions and current knowledge. Am J Gastroenterol. 2017 Aug;112(8):1221-31. PubMed PMID: 28508867.

10. Soh J.S., Lee H.J., Jung K.W., et al. The diagnostic value of a digital rectal examination compared with high-resolution anorectal manometry in patients with chronic constipation and fecal incontinence. Am J Gastroenterol. 2015 Aug;110(8):1197-204. PubMed PMID: 26032152.

11. American Gastroenterological Association, Bharucha A.E., Dorn S.D., Lembo A., Pressman A. American Gastroenterological Association medical position statement on constipation. Gastroenterology. 2013 Jan;144(1):211-7. PubMed PMID: 23261064.

12. Skardoon G.R., Khera A.J., Emmanuel A.V., Burgell R.E. Review article: dyssynergic defaecation and biofeedback therapy in the pathophysiology and management of functional constipation. Aliment Pharmacol Therapeut. 2017 Aug;46(4):410-23. PubMed PMID: 28660663.

13. Koh C.E., Young C.J., Young J.M., Solomon M.J. Systematic review of randomized controlled trials of the effectiveness of biofeedback for pelvic floor dysfunction. Br J Surg. 2008 Sep;95(9):1079-87. PubMed PMID: 18655219.

14. Rao S., Lembo A.J., Shiff S.J., et al. A 12-week, randomized, controlled trial with a 4-week randomized withdrawal period to evaluate the efficacy and safety of linaclotide in irritable bowel syndrome with constipation. Am J Gastroenterol. 2012 Nov;107(11):1714-24; quiz p 25. PubMed PMID: 22986440. Pubmed Central PMCID: 3504311.

15. Lacy B.E., Schey R., Shiff S.J., et al. Linaclotide in chronic idiopathic constipation patients with moderate to severe abdominal bloating: A randomized, controlled trial. PloS One. 2015;10(7):e0134349. PubMed PMID: 26222318. Pubmed Central PMCID: 4519259.

16. Miner P.B., Jr., Koltun W.D., Wiener G.J., et al. A randomized phase III clinical trial of plecanatide, a uroguanylin analog, in patients with chronic idiopathic constipation. Am J Gastroenterol. 2017 Apr;112(4):613-21. PubMed PMID: 28169285. Pubmed Central PMCID: 5415706.

17. Johanson J.F., Drossman D.A., Panas R., Wahle A., Ueno R. Clinical trial: phase 2 study of lubiprostone for irritable bowel syndrome with constipation. Aliment Pharmacol Therapeut. 2008 Apr;27(8):685-96. PubMed PMID: 18248656.

18. Chey W.D., Webster L., Sostek M., Lappalainen J., Barker P.N., Tack J. Naloxegol for opioid-induced constipation in patients with noncancer pain. N Engl J Med. 2014 Jun 19;370(25):2387-96. PubMed PMID: 24896818.

19. Katakami N., Oda K., Tauchi K., et al. Phase IIb, randomized, double-blind, placebo-controlled study of naldemedine for the treatment of opioid-induced constipation in patients with cancer. J Clin Oncol. 2017 Jun 10;35(17):1921-8. PubMed PMID: 28445097.

20. Sajid M.S., Hebbar M., Baig M.K., Li A., Philipose Z. Use of prucalopride for chronic constipation: A systematic review and meta-analysis of published randomized, controlled trials. J Neurogastroenterol Motil. 2016 Jul 30;22(3):412-22. PubMed PMID: 27127190. Pubmed Central PMCID: 4930296.

21. Quigley E.M. Cisapride: What can we learn from the rise and fall of a prokinetic? J Dig Dis. 2011 Jun;12(3):147-56. PubMed PMID: 21615867.

22. Conlon K., De Maeyer J.H., Bruce C., et al. Nonclinical cardiovascular studies of prucalopride, a highly selective 5-hydroxytryptamine 4 receptor agonist. J Pharmacol Exp Therapeut. 2017 Nov; doi: 10.1124/jpet.117.244079 [epub ahead of print].

23. Chey W.D., Lembo A.J., Rosenbaum D.P. Tenapanor treatment of patients with constipation-predominant irritable bowel syndrome: a phase 2, randomized, placebo-controlled efficacy and safety trial. Am J Gastroenterol. 2017;112:763-74.

24. Simren M., Bajor A., Gillberg P-G, Rudling M., Abrahamsson H. Randomised clinical trial: the ileal bile acid transporter inhibitor A3309 vs. placebo in patients with chronic idiopathic constipation – a double-blind study. Aliment Pharmacol Ther. 2011 Jul;34(1):41-50.

25. Zarate N., Knowles C.H., Newell M., et al. In patients with slow transit constipation, the pattern of colonic transit delay does not differentiate between those with and without impaired rectal evacuation. Am J Gastroenterol. 2008 Feb;103(2):427-34. PubMed PMID: 18070233.

26. Redmond J.M., Smith G.W., Barofsky I., et al. Physiological tests to predict long-term outcome of total abdominal colectomy for intractable constipation. Am J Gastroenterol. 1995 May;90(5):748-53. PubMed PMID: 7733081.

As pediatric patients with chronic gastrointestinal (GI) disorders mature into adulthood, they require a seamless transition of care into an adult practice. Health care transition is more than a simple transfer of care to an adult provider; it is a purposeful, planned movement of young adults with chronic medical conditions from a child-centered health care system to adult-oriented one.¹ Many adolescents with chronic GI disorders are at increased risk of developmental and psychosocial delays and depressive disorders.^2-6 A successful transition program can mitigate some of the psychosocial impacts of chronic disorders by improving self-efficacy and autonomy.⁷

Timing of transition

Unlike other nations where legislation often mandates the age of transition to adult care, the United States leaves decisions about the appropriate time to transition to the discretion of individual patients and pediatricians. While the actual transfer of care may not happen until later, it is prudent to start planning when the patient is in early adolescence. The pediatric gastroenterologist should initiate the discussion with patients and caregivers when the child is 13-15 years of age.^12,13 Since health care transition is a complex and lengthy process, it should be approached within a framework that is appropriate for the developmental stage of the patient and at a time when their disease is in remission.¹⁴

During the initial discussions, the idea of transition should be introduced to the patient and his or her family by emphasizing the benefits of improved self-management skills, adherence to therapy, and normalization of development. The pediatrician should encourage a greater sense of independence and self-reliance by seeing the patient alone for at least a portion of the clinic visit and encourage future independent visits.
 

Developing a transition plan

Once the concept of transition of care has been introduced, it is prudent to devise a transition plan tailored to the specific needs and goals of the patient and family.²⁴ Each plan should include who the adult provider will be, the tasks the adolescent must master before entering adult care, and how the care will be financed (because insurance coverage and options may change).²⁵ A well-planned transition should enhance self-efficacy and self-management skills, increase knowledge of medical states, ensure adherence to therapy, and encourage independent decision making.¹²

Assessing transition readiness

Once the process of transitioning has been initiated, it is helpful to assess transition readiness at regular intervals. This will identify gaps in knowledge and inform appropriate interventions for individual patients. There are several questionnaires that can be administered at regular intervals and be made an integral part of routine clinic visits for adolescent patients. These assessments are now billable under CPT Code 99420 (administration and interpretation of health risk assessment). A standardized instrument should be used and the results recorded in the clinical encounter to ensure billing compliance.

The Transition Readiness Assessment Questionnaire (available online at www.GotTransition.org) is a validated tool that assesses an individual’s awareness of his or her medical needs, treatment plan, and ability to communicate effectively with his or her health care provider.^26-28 While not specific to GI disorders, it has been validated in IBD patients and shown to correlate well with the IBD Self-Efficacy Scale for Adolescents.^29,30 The University of North Carolina’s TRxANSITION Index^{, as well as} the Social-Ecological Model of Adolescent and Young Adult Readiness for Transition, can be used for patients with various chronic diseases.^31,32 Instruments specifically developed to assess transition readiness among patients with IBD include the “IBD-Yourself” questionnaire and MyHealth Passport for IBD.^33,34 Additionally, Hait et al. provide a checklist of age-appropriate tasks for patients and their providers.¹⁴ The North American Society for Pediatric Gastroenterology, Hepatology and Nutrition has created the “Healthcare Provider Transition Checklist,” which is applicable to all chronic GI disorders.³⁵
 

Transfer of care

The actual transfer of care is the culmination of the transition process. While the onus of initiating and monitoring a patient’s progress is driven by his or her pediatric provider, a responsive adult provider is integral, so it is vital to identify an adult gastroenterologist ahead of time. This can be especially difficult because most adult gastroenterologists feel uncomfortable about addressing adolescent developmental and mental health issues.³⁶

Local chapters of societies such as the Crohn’s and Colitis Foundation, the American Liver Foundation, and statewide GI societies affiliated with the American College of Gastroenterology, as well as local or regional teaching institutions, are all good resources to identify adult providers interested in a coordinated transition of young adults into their practices. Depending on the availability of a local adult gastroenterologist, one approach to minimize the “growing pains” of transition can be to establish joint clinic visits with pediatric and adult providers; this strategy can help foster trust in the new physician and is generally well-received by patients.^37,38 Other institutions may offer alternating visits with adult and pediatric providers during the first year of transition.

Regardless of the manner of the actual transfer of care, it is imperative the adult gastroenterologist be well versed with the natural history and disease complications of the pediatric onset of the specific GI disorder and also appreciate nutrition and concerns regarding growth and radiation. Moreover, they must recognize the convergence and divergence of traditional pediatric and adult care models, as well as the move from a family-centered to an individual-focused environment.³⁹

At the time of the patient’s initial visit, the adult gastroenterologist needs a detailed history of the patient’s disease, a list of past and present medications, the details of any disease- or treatment-related complications or surgeries, and so on. The transfer of relevant medical records is an often overlooked, yet easily remediable, aspect of transfer of care.³⁶ The overall process is best completed by eliciting posttransfer feedback from patients and families after they have established care with the adult provider.
 

Developing a transition model

In the absence of standard, disease-specific models of transition, most institutions adapt available resources to develop their own protocols. In 2011, a joint task force of the American Academy of Pediatrics, the American Academy of Family Physicians, and the American College of Physicians published a clinical report on transition. Based on recommendations put forth by the Center for Health Care Transition Improvement – a joint endeavor of the Maternal and Child Health Bureau and the National Alliance to Advance Adolescent Health – the aforementioned task force developed a “Got Transition” model that incorporates six core elements of health care transition (Table 1).

References

1. Blum RW et al. J Adolesc Health. 1993 Nov;14(7):570-6.

2. Greenley RN et al. J Pediatr Psychol. 2010 Sep;35(8):857-69.

3. Simsek S et al. J Pediatr Gastroenterol Nutr. 2015 Sep;61(3):303-6.

4. Kanof ME et al. Gastroenterology. 1988 Dec;95(6):1523-7.

5. Mackner LM et al. Inflamm Bowel Dis. 2006 Mar;12(3):239-44.

6. Hummel TZ et al. J Pediatr Gastroenterol Nutr. 2013 Aug;57(2):219-24.

7. Rosen DS et al. J Adolesc Health. 2003 Oct;33(4):309-11.

8. Bollegala N et al. J Crohns Colitis. 2013 Mar;7(2):e55-60.

9. Reed-Knight B et al. J Pediatr Psychol. 2011 Apr;36(3):308-17.

10. Holmes-Walker DJ et al. Diabet Med. 2007 Jul;24(7):764-9.

11. Dabadie A et al. Gastroenterol Clin Biol. 2008 May;32(5 Pt 1):451-9.

12. A consensus statement on health care transitions for young adults with special health care needs. Pediatrics. 2002 Dec;110(6 Pt 2):1304-6.

13. Baldassano R et al. J Pediatr Gastroenterol Nutr. 2002 Mar;34(3):245-8.

14. Hait E et al. Inflamm Bowel Dis. 2006 Jan;12(1):70-3.

15. Gray WN et al. Inflamm Bowel Dis. 2015 May;21(5):1125-31.

16. Whitfield EP et al. J Pediatr Gastroenterol Nutr. 2015 Jan;60(1):36-41.

17. Rosen D et al. Inflamm Bowel Dis. 2016 Mar;22(3):702-8.

18. Fishman LN et al. J Pediatr Gastroenterol Nutr. 2014 Aug;59(2):221-4.

19. Huang JS et al. Clin Gastroenterol Hepatol. 2012 Jun;10(6):626-32.

20. Habibi H et al. Clin Nurse Spec. 2017 Nov;31(6):329-34.

21. Yerushalmy-Feler A et al. Eur J Gastroenterol Hepatol. 2017 Jul;29(7):831-7.

22. Shanske S et al. Soc Work Health Care. 2012;51(4):279-95.

23. Fredericks EM et al. J Clin Psychol Med Settings. 2015 Sep;22(2-3):150-9.

24. Hardin AP et al. Pediatrics. 2017. doi: 10.1542/peds.2017-2151.

25. Leung Y et al. Inflamm Bowel Dis. 2011 Oct;17(10):2169-73.

26. Wood DL et al. Acad Pediatr. 2014 Jul-Aug;14(4):415-22.

27. Sample Transition Readiness Assessment for Youth. Got Transition/Center for Health Care Transition Improvement, Jan 2014. Accessed Jan 4, 2017, at http://www.gottransition.org/resourceGet.cfm?id=224.

28. Sawicki GS et al. J Pediatr Psychol. 2011 Mar;36(2):160-71.

29. Izaguirre MR et al. J Pediatr Gastroenterol Nutr. 2017 Nov;65(5):546-50.

30. Carlsen K et al. Inflamm Bowel Dis. 2017 Mar;23(3):341-6.

31. Ferris ME et al. Ren Fail. 2012;34(6):744-53.

32. Schwartz LA et al. Child Care Health Dev. 2011 Nov;37(6):883-95.
 

33. Zijlstra M et al. J Crohns Colitis. 2013 Oct;7(9):e375-85.

34. Benchimol EI et al. Inflamm Bowel Dis. 2011 May;17(5):1131-7.

35. Heath Care Provider Transitioning Checklist. NASPGHAN. Accessed Jan 4, 2018, at https://www.naspghan.org/files/documents/pdfs/medical-resources/ibd/Checklist_PatientandHealthcareProdiver_TransitionfromPedtoAdult.pdf.

36. Hait EJ et al. J Pediatr Gastroenterol Nutr. 2009 Jan;48(1):61-5.

37. Escher JC. Dig Dis. 2009;27(3):382-6.

38. Crowley R et al. Arch Dis Child. 2011 Jun;96(6):548-53.

39. Trivedi I et al. Gastroenterol Res Pract. 2015;2015:260807.

40. O’Leary C et al. Am J Gastroenterol. 2004 Dec;99(12):2437-41.

41. de Silva PSA et al. Pediatr Clin North Am. 2017 Jun;64(3):707-20.

42. Eluri S et al. J Pediatr Gastroenterol Nutr. 2017 Jul;65(1):53-7.

43. Dellon ES et al. Dis Esophagus. 2013 Jan;26(1):7-13.
 

As pediatric patients with chronic gastrointestinal (GI) disorders mature into adulthood, they require a seamless transition of care into an adult practice. Health care transition is more than a simple transfer of care to an adult provider; it is a purposeful, planned movement of young adults with chronic medical conditions from a child-centered health care system to adult-oriented one.¹ Many adolescents with chronic GI disorders are at increased risk of developmental and psychosocial delays and depressive disorders.^2-6 A successful transition program can mitigate some of the psychosocial impacts of chronic disorders by improving self-efficacy and autonomy.⁷

Timing of transition

Unlike other nations where legislation often mandates the age of transition to adult care, the United States leaves decisions about the appropriate time to transition to the discretion of individual patients and pediatricians. While the actual transfer of care may not happen until later, it is prudent to start planning when the patient is in early adolescence. The pediatric gastroenterologist should initiate the discussion with patients and caregivers when the child is 13-15 years of age.^12,13 Since health care transition is a complex and lengthy process, it should be approached within a framework that is appropriate for the developmental stage of the patient and at a time when their disease is in remission.¹⁴

During the initial discussions, the idea of transition should be introduced to the patient and his or her family by emphasizing the benefits of improved self-management skills, adherence to therapy, and normalization of development. The pediatrician should encourage a greater sense of independence and self-reliance by seeing the patient alone for at least a portion of the clinic visit and encourage future independent visits.
 

Developing a transition plan

Once the concept of transition of care has been introduced, it is prudent to devise a transition plan tailored to the specific needs and goals of the patient and family.²⁴ Each plan should include who the adult provider will be, the tasks the adolescent must master before entering adult care, and how the care will be financed (because insurance coverage and options may change).²⁵ A well-planned transition should enhance self-efficacy and self-management skills, increase knowledge of medical states, ensure adherence to therapy, and encourage independent decision making.¹²

Assessing transition readiness

Once the process of transitioning has been initiated, it is helpful to assess transition readiness at regular intervals. This will identify gaps in knowledge and inform appropriate interventions for individual patients. There are several questionnaires that can be administered at regular intervals and be made an integral part of routine clinic visits for adolescent patients. These assessments are now billable under CPT Code 99420 (administration and interpretation of health risk assessment). A standardized instrument should be used and the results recorded in the clinical encounter to ensure billing compliance.

The Transition Readiness Assessment Questionnaire (available online at www.GotTransition.org) is a validated tool that assesses an individual’s awareness of his or her medical needs, treatment plan, and ability to communicate effectively with his or her health care provider.^26-28 While not specific to GI disorders, it has been validated in IBD patients and shown to correlate well with the IBD Self-Efficacy Scale for Adolescents.^29,30 The University of North Carolina’s TRxANSITION Index^{, as well as} the Social-Ecological Model of Adolescent and Young Adult Readiness for Transition, can be used for patients with various chronic diseases.^31,32 Instruments specifically developed to assess transition readiness among patients with IBD include the “IBD-Yourself” questionnaire and MyHealth Passport for IBD.^33,34 Additionally, Hait et al. provide a checklist of age-appropriate tasks for patients and their providers.¹⁴ The North American Society for Pediatric Gastroenterology, Hepatology and Nutrition has created the “Healthcare Provider Transition Checklist,” which is applicable to all chronic GI disorders.³⁵
 

Transfer of care

The actual transfer of care is the culmination of the transition process. While the onus of initiating and monitoring a patient’s progress is driven by his or her pediatric provider, a responsive adult provider is integral, so it is vital to identify an adult gastroenterologist ahead of time. This can be especially difficult because most adult gastroenterologists feel uncomfortable about addressing adolescent developmental and mental health issues.³⁶

Local chapters of societies such as the Crohn’s and Colitis Foundation, the American Liver Foundation, and statewide GI societies affiliated with the American College of Gastroenterology, as well as local or regional teaching institutions, are all good resources to identify adult providers interested in a coordinated transition of young adults into their practices. Depending on the availability of a local adult gastroenterologist, one approach to minimize the “growing pains” of transition can be to establish joint clinic visits with pediatric and adult providers; this strategy can help foster trust in the new physician and is generally well-received by patients.^37,38 Other institutions may offer alternating visits with adult and pediatric providers during the first year of transition.

Regardless of the manner of the actual transfer of care, it is imperative the adult gastroenterologist be well versed with the natural history and disease complications of the pediatric onset of the specific GI disorder and also appreciate nutrition and concerns regarding growth and radiation. Moreover, they must recognize the convergence and divergence of traditional pediatric and adult care models, as well as the move from a family-centered to an individual-focused environment.³⁹

At the time of the patient’s initial visit, the adult gastroenterologist needs a detailed history of the patient’s disease, a list of past and present medications, the details of any disease- or treatment-related complications or surgeries, and so on. The transfer of relevant medical records is an often overlooked, yet easily remediable, aspect of transfer of care.³⁶ The overall process is best completed by eliciting posttransfer feedback from patients and families after they have established care with the adult provider.
 

Developing a transition model

In the absence of standard, disease-specific models of transition, most institutions adapt available resources to develop their own protocols. In 2011, a joint task force of the American Academy of Pediatrics, the American Academy of Family Physicians, and the American College of Physicians published a clinical report on transition. Based on recommendations put forth by the Center for Health Care Transition Improvement – a joint endeavor of the Maternal and Child Health Bureau and the National Alliance to Advance Adolescent Health – the aforementioned task force developed a “Got Transition” model that incorporates six core elements of health care transition (Table 1).

References

1. Blum RW et al. J Adolesc Health. 1993 Nov;14(7):570-6.

2. Greenley RN et al. J Pediatr Psychol. 2010 Sep;35(8):857-69.

3. Simsek S et al. J Pediatr Gastroenterol Nutr. 2015 Sep;61(3):303-6.

4. Kanof ME et al. Gastroenterology. 1988 Dec;95(6):1523-7.

5. Mackner LM et al. Inflamm Bowel Dis. 2006 Mar;12(3):239-44.

6. Hummel TZ et al. J Pediatr Gastroenterol Nutr. 2013 Aug;57(2):219-24.

7. Rosen DS et al. J Adolesc Health. 2003 Oct;33(4):309-11.

8. Bollegala N et al. J Crohns Colitis. 2013 Mar;7(2):e55-60.

9. Reed-Knight B et al. J Pediatr Psychol. 2011 Apr;36(3):308-17.

10. Holmes-Walker DJ et al. Diabet Med. 2007 Jul;24(7):764-9.

11. Dabadie A et al. Gastroenterol Clin Biol. 2008 May;32(5 Pt 1):451-9.

12. A consensus statement on health care transitions for young adults with special health care needs. Pediatrics. 2002 Dec;110(6 Pt 2):1304-6.

13. Baldassano R et al. J Pediatr Gastroenterol Nutr. 2002 Mar;34(3):245-8.

14. Hait E et al. Inflamm Bowel Dis. 2006 Jan;12(1):70-3.

15. Gray WN et al. Inflamm Bowel Dis. 2015 May;21(5):1125-31.

16. Whitfield EP et al. J Pediatr Gastroenterol Nutr. 2015 Jan;60(1):36-41.

17. Rosen D et al. Inflamm Bowel Dis. 2016 Mar;22(3):702-8.

18. Fishman LN et al. J Pediatr Gastroenterol Nutr. 2014 Aug;59(2):221-4.

19. Huang JS et al. Clin Gastroenterol Hepatol. 2012 Jun;10(6):626-32.

20. Habibi H et al. Clin Nurse Spec. 2017 Nov;31(6):329-34.

21. Yerushalmy-Feler A et al. Eur J Gastroenterol Hepatol. 2017 Jul;29(7):831-7.

22. Shanske S et al. Soc Work Health Care. 2012;51(4):279-95.

23. Fredericks EM et al. J Clin Psychol Med Settings. 2015 Sep;22(2-3):150-9.

24. Hardin AP et al. Pediatrics. 2017. doi: 10.1542/peds.2017-2151.

25. Leung Y et al. Inflamm Bowel Dis. 2011 Oct;17(10):2169-73.

26. Wood DL et al. Acad Pediatr. 2014 Jul-Aug;14(4):415-22.

27. Sample Transition Readiness Assessment for Youth. Got Transition/Center for Health Care Transition Improvement, Jan 2014. Accessed Jan 4, 2017, at http://www.gottransition.org/resourceGet.cfm?id=224.

28. Sawicki GS et al. J Pediatr Psychol. 2011 Mar;36(2):160-71.

29. Izaguirre MR et al. J Pediatr Gastroenterol Nutr. 2017 Nov;65(5):546-50.

30. Carlsen K et al. Inflamm Bowel Dis. 2017 Mar;23(3):341-6.

31. Ferris ME et al. Ren Fail. 2012;34(6):744-53.

32. Schwartz LA et al. Child Care Health Dev. 2011 Nov;37(6):883-95.
 

33. Zijlstra M et al. J Crohns Colitis. 2013 Oct;7(9):e375-85.

34. Benchimol EI et al. Inflamm Bowel Dis. 2011 May;17(5):1131-7.

35. Heath Care Provider Transitioning Checklist. NASPGHAN. Accessed Jan 4, 2018, at https://www.naspghan.org/files/documents/pdfs/medical-resources/ibd/Checklist_PatientandHealthcareProdiver_TransitionfromPedtoAdult.pdf.

36. Hait EJ et al. J Pediatr Gastroenterol Nutr. 2009 Jan;48(1):61-5.

37. Escher JC. Dig Dis. 2009;27(3):382-6.

38. Crowley R et al. Arch Dis Child. 2011 Jun;96(6):548-53.

39. Trivedi I et al. Gastroenterol Res Pract. 2015;2015:260807.

40. O’Leary C et al. Am J Gastroenterol. 2004 Dec;99(12):2437-41.

41. de Silva PSA et al. Pediatr Clin North Am. 2017 Jun;64(3):707-20.

42. Eluri S et al. J Pediatr Gastroenterol Nutr. 2017 Jul;65(1):53-7.

43. Dellon ES et al. Dis Esophagus. 2013 Jan;26(1):7-13.
 

As pediatric patients with chronic gastrointestinal (GI) disorders mature into adulthood, they require a seamless transition of care into an adult practice. Health care transition is more than a simple transfer of care to an adult provider; it is a purposeful, planned movement of young adults with chronic medical conditions from a child-centered health care system to adult-oriented one.¹ Many adolescents with chronic GI disorders are at increased risk of developmental and psychosocial delays and depressive disorders.^2-6 A successful transition program can mitigate some of the psychosocial impacts of chronic disorders by improving self-efficacy and autonomy.⁷

Timing of transition

Unlike other nations where legislation often mandates the age of transition to adult care, the United States leaves decisions about the appropriate time to transition to the discretion of individual patients and pediatricians. While the actual transfer of care may not happen until later, it is prudent to start planning when the patient is in early adolescence. The pediatric gastroenterologist should initiate the discussion with patients and caregivers when the child is 13-15 years of age.^12,13 Since health care transition is a complex and lengthy process, it should be approached within a framework that is appropriate for the developmental stage of the patient and at a time when their disease is in remission.¹⁴

During the initial discussions, the idea of transition should be introduced to the patient and his or her family by emphasizing the benefits of improved self-management skills, adherence to therapy, and normalization of development. The pediatrician should encourage a greater sense of independence and self-reliance by seeing the patient alone for at least a portion of the clinic visit and encourage future independent visits.
 

Developing a transition plan

Once the concept of transition of care has been introduced, it is prudent to devise a transition plan tailored to the specific needs and goals of the patient and family.²⁴ Each plan should include who the adult provider will be, the tasks the adolescent must master before entering adult care, and how the care will be financed (because insurance coverage and options may change).²⁵ A well-planned transition should enhance self-efficacy and self-management skills, increase knowledge of medical states, ensure adherence to therapy, and encourage independent decision making.¹²

Assessing transition readiness

Once the process of transitioning has been initiated, it is helpful to assess transition readiness at regular intervals. This will identify gaps in knowledge and inform appropriate interventions for individual patients. There are several questionnaires that can be administered at regular intervals and be made an integral part of routine clinic visits for adolescent patients. These assessments are now billable under CPT Code 99420 (administration and interpretation of health risk assessment). A standardized instrument should be used and the results recorded in the clinical encounter to ensure billing compliance.

The Transition Readiness Assessment Questionnaire (available online at www.GotTransition.org) is a validated tool that assesses an individual’s awareness of his or her medical needs, treatment plan, and ability to communicate effectively with his or her health care provider.^26-28 While not specific to GI disorders, it has been validated in IBD patients and shown to correlate well with the IBD Self-Efficacy Scale for Adolescents.^29,30 The University of North Carolina’s TRxANSITION Index^{, as well as} the Social-Ecological Model of Adolescent and Young Adult Readiness for Transition, can be used for patients with various chronic diseases.^31,32 Instruments specifically developed to assess transition readiness among patients with IBD include the “IBD-Yourself” questionnaire and MyHealth Passport for IBD.^33,34 Additionally, Hait et al. provide a checklist of age-appropriate tasks for patients and their providers.¹⁴ The North American Society for Pediatric Gastroenterology, Hepatology and Nutrition has created the “Healthcare Provider Transition Checklist,” which is applicable to all chronic GI disorders.³⁵
 

Transfer of care

The actual transfer of care is the culmination of the transition process. While the onus of initiating and monitoring a patient’s progress is driven by his or her pediatric provider, a responsive adult provider is integral, so it is vital to identify an adult gastroenterologist ahead of time. This can be especially difficult because most adult gastroenterologists feel uncomfortable about addressing adolescent developmental and mental health issues.³⁶

Local chapters of societies such as the Crohn’s and Colitis Foundation, the American Liver Foundation, and statewide GI societies affiliated with the American College of Gastroenterology, as well as local or regional teaching institutions, are all good resources to identify adult providers interested in a coordinated transition of young adults into their practices. Depending on the availability of a local adult gastroenterologist, one approach to minimize the “growing pains” of transition can be to establish joint clinic visits with pediatric and adult providers; this strategy can help foster trust in the new physician and is generally well-received by patients.^37,38 Other institutions may offer alternating visits with adult and pediatric providers during the first year of transition.

Regardless of the manner of the actual transfer of care, it is imperative the adult gastroenterologist be well versed with the natural history and disease complications of the pediatric onset of the specific GI disorder and also appreciate nutrition and concerns regarding growth and radiation. Moreover, they must recognize the convergence and divergence of traditional pediatric and adult care models, as well as the move from a family-centered to an individual-focused environment.³⁹

At the time of the patient’s initial visit, the adult gastroenterologist needs a detailed history of the patient’s disease, a list of past and present medications, the details of any disease- or treatment-related complications or surgeries, and so on. The transfer of relevant medical records is an often overlooked, yet easily remediable, aspect of transfer of care.³⁶ The overall process is best completed by eliciting posttransfer feedback from patients and families after they have established care with the adult provider.
 

Developing a transition model

In the absence of standard, disease-specific models of transition, most institutions adapt available resources to develop their own protocols. In 2011, a joint task force of the American Academy of Pediatrics, the American Academy of Family Physicians, and the American College of Physicians published a clinical report on transition. Based on recommendations put forth by the Center for Health Care Transition Improvement – a joint endeavor of the Maternal and Child Health Bureau and the National Alliance to Advance Adolescent Health – the aforementioned task force developed a “Got Transition” model that incorporates six core elements of health care transition (Table 1).

References

1. Blum RW et al. J Adolesc Health. 1993 Nov;14(7):570-6.

2. Greenley RN et al. J Pediatr Psychol. 2010 Sep;35(8):857-69.

3. Simsek S et al. J Pediatr Gastroenterol Nutr. 2015 Sep;61(3):303-6.

4. Kanof ME et al. Gastroenterology. 1988 Dec;95(6):1523-7.

5. Mackner LM et al. Inflamm Bowel Dis. 2006 Mar;12(3):239-44.

6. Hummel TZ et al. J Pediatr Gastroenterol Nutr. 2013 Aug;57(2):219-24.

7. Rosen DS et al. J Adolesc Health. 2003 Oct;33(4):309-11.

8. Bollegala N et al. J Crohns Colitis. 2013 Mar;7(2):e55-60.

9. Reed-Knight B et al. J Pediatr Psychol. 2011 Apr;36(3):308-17.

10. Holmes-Walker DJ et al. Diabet Med. 2007 Jul;24(7):764-9.

11. Dabadie A et al. Gastroenterol Clin Biol. 2008 May;32(5 Pt 1):451-9.

12. A consensus statement on health care transitions for young adults with special health care needs. Pediatrics. 2002 Dec;110(6 Pt 2):1304-6.

13. Baldassano R et al. J Pediatr Gastroenterol Nutr. 2002 Mar;34(3):245-8.

14. Hait E et al. Inflamm Bowel Dis. 2006 Jan;12(1):70-3.

15. Gray WN et al. Inflamm Bowel Dis. 2015 May;21(5):1125-31.

16. Whitfield EP et al. J Pediatr Gastroenterol Nutr. 2015 Jan;60(1):36-41.

17. Rosen D et al. Inflamm Bowel Dis. 2016 Mar;22(3):702-8.

18. Fishman LN et al. J Pediatr Gastroenterol Nutr. 2014 Aug;59(2):221-4.

19. Huang JS et al. Clin Gastroenterol Hepatol. 2012 Jun;10(6):626-32.

20. Habibi H et al. Clin Nurse Spec. 2017 Nov;31(6):329-34.

21. Yerushalmy-Feler A et al. Eur J Gastroenterol Hepatol. 2017 Jul;29(7):831-7.

22. Shanske S et al. Soc Work Health Care. 2012;51(4):279-95.

23. Fredericks EM et al. J Clin Psychol Med Settings. 2015 Sep;22(2-3):150-9.

24. Hardin AP et al. Pediatrics. 2017. doi: 10.1542/peds.2017-2151.

25. Leung Y et al. Inflamm Bowel Dis. 2011 Oct;17(10):2169-73.

26. Wood DL et al. Acad Pediatr. 2014 Jul-Aug;14(4):415-22.

27. Sample Transition Readiness Assessment for Youth. Got Transition/Center for Health Care Transition Improvement, Jan 2014. Accessed Jan 4, 2017, at http://www.gottransition.org/resourceGet.cfm?id=224.

28. Sawicki GS et al. J Pediatr Psychol. 2011 Mar;36(2):160-71.

29. Izaguirre MR et al. J Pediatr Gastroenterol Nutr. 2017 Nov;65(5):546-50.

30. Carlsen K et al. Inflamm Bowel Dis. 2017 Mar;23(3):341-6.

31. Ferris ME et al. Ren Fail. 2012;34(6):744-53.

32. Schwartz LA et al. Child Care Health Dev. 2011 Nov;37(6):883-95.
 

33. Zijlstra M et al. J Crohns Colitis. 2013 Oct;7(9):e375-85.

34. Benchimol EI et al. Inflamm Bowel Dis. 2011 May;17(5):1131-7.

35. Heath Care Provider Transitioning Checklist. NASPGHAN. Accessed Jan 4, 2018, at https://www.naspghan.org/files/documents/pdfs/medical-resources/ibd/Checklist_PatientandHealthcareProdiver_TransitionfromPedtoAdult.pdf.

36. Hait EJ et al. J Pediatr Gastroenterol Nutr. 2009 Jan;48(1):61-5.

37. Escher JC. Dig Dis. 2009;27(3):382-6.

38. Crowley R et al. Arch Dis Child. 2011 Jun;96(6):548-53.

39. Trivedi I et al. Gastroenterol Res Pract. 2015;2015:260807.

40. O’Leary C et al. Am J Gastroenterol. 2004 Dec;99(12):2437-41.

41. de Silva PSA et al. Pediatr Clin North Am. 2017 Jun;64(3):707-20.

42. Eluri S et al. J Pediatr Gastroenterol Nutr. 2017 Jul;65(1):53-7.

43. Dellon ES et al. Dis Esophagus. 2013 Jan;26(1):7-13.
 

Dr. Shah is chief medical officer, Mount Sinai Queens, director of quality and patient safety education, Mount Sinai Health System, associate professor of medicine/GI and geriatrics/palliative medicine, Icahn School of Medicine at Mount Sinai, New York, N.Y.

How did your career pathway lead you into hospital administration?

My career pathway into hospital administration was not by design. Since college, I have always enjoyed building and managing programs. As chief resident, I was exposed to operational and managerial aspects of running an internal medicine residency program as well as an outpatient clinic. This program first exposed me to quality improvement and patient-safety functions within a hospital. I continued to build on this during my GI fellowship and in my first few years as faculty in our division. Patient safety and quality improvement involve the critical thinking and quantitative aspects of research applied to problems in the workplace. This interest and skill, along with my growing experience in management, led me to explore opportunities in hospital administration.

What are your responsibilities in a typical week?

As a chief medical officer at a smaller hospital, my scope of responsibilities includes overseeing health care quality and patient safety, building our outpatient practice and new clinical service lines, building a cohesive medical staff, handling disciplinary and professionalism issues, and overseeing six support departments. I work closely with our chief operating officer, chief nursing officer, executive director, and site chiefs.

What do you enjoy most about working in hospital administration?

I enjoy the work I do related to making care safer for our patients and for those who work in our hospital. I take each patient-safety event personally. The teamwork necessary to understand these events and develop creative solutions is extremely rewarding. I enjoy mentoring our faculty and hospital managers to achieve their own goals. Lastly, I have enjoyed working with professionals with backgrounds that differ from my own. I have learned an incredible amount about hospital operations, leadership, financing, as well as legal and labor-relations issues from our staff in other departments.

What do you find most challenging about working in hospital administration?

The scope of work in my role at my current hospital is very broad. It can be a challenge to focus on long-term goals given the number of “fires” that creep up during the week. I always try to keep patients and staff at the center of my decision making. However, a hospital is a complex organism and decisions also have a financial and operational impact. One challenge is to know and understand this impact and then work with other leaders to develop a solution that works for all.

The other challenge is managing conflict in a way that leads to creative solutions satisfying the needs of multiple stakeholders. We are constantly challenged by limited resources (including time). These challenges are inherent to any leadership position. I am fortunate to work within a leadership team that is collaborative; they are an invaluable resource when these issues arise.
 

What are the different hospital administration positions that are available to GIs?

More than ever, the options for administrative work in health care have expanded. There are hospital-based roles within a department (e.g., director of endoscopy, clinical chief, director of quality improvement/patient safety for GI) and larger roles in the hospital-at-large (e.g., chief operating officer, chief medical officer, chief quality officer). These roles require certain technical skills and knowledge as well as experience within patient care. Other opportunities include the medical board, credentials committee, or serving as a member of a hospital committee (e.g., pharmacy, perioperative, infection control, process improvement). Since hospitals and health systems have expanded into the outpatient setting, additional positions include medical director for a practice, director of population health, or a leadership role in clinical operations.

Physicians from many different specialties have entered these roles based on their local hospital needs. In addition to clinical experience, leadership and interpersonal skills are critical for success.
 

How would a fellow or early-career GI who is interested in hospital medicine pursue this career pathway?

My first suggestion is to get involved in local efforts based on your interest. For example, if you are interested in quality improvement, seek to be a member of your department or hospital quality improvement committee. In GI and hepatology, natural places to get involved are around the development of care pathways, readmission committees, and initiatives to increase screening and treatment of hepatitis C or colon cancer. If you are interested in operations, look to see if there is an endoscopy or clinic operations committee you can get involved in. Get to know your medical board and medical staff structure. I gained exposure to this world by observing some of these meetings and then being asked to join them. These are valuable groups that help to create policy, raise important issues, and work with administration in the management of the hospital.

I am also a big fan of informational interviewing. If there are leaders who do the type of work you are interested in, consider reaching out with a call or email and asking to meet with them to talk about their role and career path.

As a fellow, there is an Accreditation Council for Graduate Medical Education requirement to incorporate residents and fellows onto hospital committees. This requirement has been a great way to have fellows incorporated into hospital work. You will find that those in hospital administration are eager to have interested and collegial partners in the work that is being done.


 

Are there any advanced training options available for those interested in hospital administration?

Depending on the position, there are numerous certificate and master’s programs that can provide formal education. CEOs and COOs may seek an MBA or master’s in Health Care Administration. There are programs that focus on Health Care Leadership or Quality and Patient Safety that are applicable to many leadership positions. These are offered in in-person and online formats. However, many physicians in these positions have a combination of informal and experiential learning programs that developed their skill set.

Some hospital systems offer an internal physician leadership training program to develop early and midcareer physician executives. There are professional organizations that offer courses for leadership development (e.g., American College of Physician Executives). Some business schools offer shorter-format programs that are geared toward health care leaders and focus on finance, operations, or quality.

I received some of my training through the Clinical Quality Fellowship Program, which is a 14-month experiential learning program in quality and patient safety that is run locally in New York City. In addition, I had some leadership training through the Association of American Medical Colleges and through the AGA Future Leaders Program (http://www.gastro.org/about/initiatives/aga-future-leaders-program).



Hospitals, outpatient practices, and health systems offer career paths including patient safety, quality improvement, or hospital management. I have enjoyed stretching my existing skill set in these roles while learning about how health facilities work, gaining knowledge of health care financing, and making care safer while ensuring high quality. These roles require teamwork across professions and specialties. As a gastroenterologist or hepatologist, we bring our own clinical and professional experience, which can be invaluable to the overall health care management team.

Dr. Shah is chief medical officer, Mount Sinai Queens, director of quality and patient safety education, Mount Sinai Health System, associate professor of medicine/GI and geriatrics/palliative medicine, Icahn School of Medicine at Mount Sinai, New York, N.Y.

How did your career pathway lead you into hospital administration?

My career pathway into hospital administration was not by design. Since college, I have always enjoyed building and managing programs. As chief resident, I was exposed to operational and managerial aspects of running an internal medicine residency program as well as an outpatient clinic. This program first exposed me to quality improvement and patient-safety functions within a hospital. I continued to build on this during my GI fellowship and in my first few years as faculty in our division. Patient safety and quality improvement involve the critical thinking and quantitative aspects of research applied to problems in the workplace. This interest and skill, along with my growing experience in management, led me to explore opportunities in hospital administration.

What are your responsibilities in a typical week?

As a chief medical officer at a smaller hospital, my scope of responsibilities includes overseeing health care quality and patient safety, building our outpatient practice and new clinical service lines, building a cohesive medical staff, handling disciplinary and professionalism issues, and overseeing six support departments. I work closely with our chief operating officer, chief nursing officer, executive director, and site chiefs.

What do you enjoy most about working in hospital administration?

I enjoy the work I do related to making care safer for our patients and for those who work in our hospital. I take each patient-safety event personally. The teamwork necessary to understand these events and develop creative solutions is extremely rewarding. I enjoy mentoring our faculty and hospital managers to achieve their own goals. Lastly, I have enjoyed working with professionals with backgrounds that differ from my own. I have learned an incredible amount about hospital operations, leadership, financing, as well as legal and labor-relations issues from our staff in other departments.

What do you find most challenging about working in hospital administration?

The scope of work in my role at my current hospital is very broad. It can be a challenge to focus on long-term goals given the number of “fires” that creep up during the week. I always try to keep patients and staff at the center of my decision making. However, a hospital is a complex organism and decisions also have a financial and operational impact. One challenge is to know and understand this impact and then work with other leaders to develop a solution that works for all.

The other challenge is managing conflict in a way that leads to creative solutions satisfying the needs of multiple stakeholders. We are constantly challenged by limited resources (including time). These challenges are inherent to any leadership position. I am fortunate to work within a leadership team that is collaborative; they are an invaluable resource when these issues arise.
 

What are the different hospital administration positions that are available to GIs?

More than ever, the options for administrative work in health care have expanded. There are hospital-based roles within a department (e.g., director of endoscopy, clinical chief, director of quality improvement/patient safety for GI) and larger roles in the hospital-at-large (e.g., chief operating officer, chief medical officer, chief quality officer). These roles require certain technical skills and knowledge as well as experience within patient care. Other opportunities include the medical board, credentials committee, or serving as a member of a hospital committee (e.g., pharmacy, perioperative, infection control, process improvement). Since hospitals and health systems have expanded into the outpatient setting, additional positions include medical director for a practice, director of population health, or a leadership role in clinical operations.

Physicians from many different specialties have entered these roles based on their local hospital needs. In addition to clinical experience, leadership and interpersonal skills are critical for success.
 

How would a fellow or early-career GI who is interested in hospital medicine pursue this career pathway?

My first suggestion is to get involved in local efforts based on your interest. For example, if you are interested in quality improvement, seek to be a member of your department or hospital quality improvement committee. In GI and hepatology, natural places to get involved are around the development of care pathways, readmission committees, and initiatives to increase screening and treatment of hepatitis C or colon cancer. If you are interested in operations, look to see if there is an endoscopy or clinic operations committee you can get involved in. Get to know your medical board and medical staff structure. I gained exposure to this world by observing some of these meetings and then being asked to join them. These are valuable groups that help to create policy, raise important issues, and work with administration in the management of the hospital.

I am also a big fan of informational interviewing. If there are leaders who do the type of work you are interested in, consider reaching out with a call or email and asking to meet with them to talk about their role and career path.

As a fellow, there is an Accreditation Council for Graduate Medical Education requirement to incorporate residents and fellows onto hospital committees. This requirement has been a great way to have fellows incorporated into hospital work. You will find that those in hospital administration are eager to have interested and collegial partners in the work that is being done.


 

Are there any advanced training options available for those interested in hospital administration?

Depending on the position, there are numerous certificate and master’s programs that can provide formal education. CEOs and COOs may seek an MBA or master’s in Health Care Administration. There are programs that focus on Health Care Leadership or Quality and Patient Safety that are applicable to many leadership positions. These are offered in in-person and online formats. However, many physicians in these positions have a combination of informal and experiential learning programs that developed their skill set.

Some hospital systems offer an internal physician leadership training program to develop early and midcareer physician executives. There are professional organizations that offer courses for leadership development (e.g., American College of Physician Executives). Some business schools offer shorter-format programs that are geared toward health care leaders and focus on finance, operations, or quality.

I received some of my training through the Clinical Quality Fellowship Program, which is a 14-month experiential learning program in quality and patient safety that is run locally in New York City. In addition, I had some leadership training through the Association of American Medical Colleges and through the AGA Future Leaders Program (http://www.gastro.org/about/initiatives/aga-future-leaders-program).



Hospitals, outpatient practices, and health systems offer career paths including patient safety, quality improvement, or hospital management. I have enjoyed stretching my existing skill set in these roles while learning about how health facilities work, gaining knowledge of health care financing, and making care safer while ensuring high quality. These roles require teamwork across professions and specialties. As a gastroenterologist or hepatologist, we bring our own clinical and professional experience, which can be invaluable to the overall health care management team.

Dr. Shah is chief medical officer, Mount Sinai Queens, director of quality and patient safety education, Mount Sinai Health System, associate professor of medicine/GI and geriatrics/palliative medicine, Icahn School of Medicine at Mount Sinai, New York, N.Y.

How did your career pathway lead you into hospital administration?

My career pathway into hospital administration was not by design. Since college, I have always enjoyed building and managing programs. As chief resident, I was exposed to operational and managerial aspects of running an internal medicine residency program as well as an outpatient clinic. This program first exposed me to quality improvement and patient-safety functions within a hospital. I continued to build on this during my GI fellowship and in my first few years as faculty in our division. Patient safety and quality improvement involve the critical thinking and quantitative aspects of research applied to problems in the workplace. This interest and skill, along with my growing experience in management, led me to explore opportunities in hospital administration.

What are your responsibilities in a typical week?

As a chief medical officer at a smaller hospital, my scope of responsibilities includes overseeing health care quality and patient safety, building our outpatient practice and new clinical service lines, building a cohesive medical staff, handling disciplinary and professionalism issues, and overseeing six support departments. I work closely with our chief operating officer, chief nursing officer, executive director, and site chiefs.

What do you enjoy most about working in hospital administration?

I enjoy the work I do related to making care safer for our patients and for those who work in our hospital. I take each patient-safety event personally. The teamwork necessary to understand these events and develop creative solutions is extremely rewarding. I enjoy mentoring our faculty and hospital managers to achieve their own goals. Lastly, I have enjoyed working with professionals with backgrounds that differ from my own. I have learned an incredible amount about hospital operations, leadership, financing, as well as legal and labor-relations issues from our staff in other departments.

What do you find most challenging about working in hospital administration?

The scope of work in my role at my current hospital is very broad. It can be a challenge to focus on long-term goals given the number of “fires” that creep up during the week. I always try to keep patients and staff at the center of my decision making. However, a hospital is a complex organism and decisions also have a financial and operational impact. One challenge is to know and understand this impact and then work with other leaders to develop a solution that works for all.

The other challenge is managing conflict in a way that leads to creative solutions satisfying the needs of multiple stakeholders. We are constantly challenged by limited resources (including time). These challenges are inherent to any leadership position. I am fortunate to work within a leadership team that is collaborative; they are an invaluable resource when these issues arise.
 

What are the different hospital administration positions that are available to GIs?

More than ever, the options for administrative work in health care have expanded. There are hospital-based roles within a department (e.g., director of endoscopy, clinical chief, director of quality improvement/patient safety for GI) and larger roles in the hospital-at-large (e.g., chief operating officer, chief medical officer, chief quality officer). These roles require certain technical skills and knowledge as well as experience within patient care. Other opportunities include the medical board, credentials committee, or serving as a member of a hospital committee (e.g., pharmacy, perioperative, infection control, process improvement). Since hospitals and health systems have expanded into the outpatient setting, additional positions include medical director for a practice, director of population health, or a leadership role in clinical operations.

Physicians from many different specialties have entered these roles based on their local hospital needs. In addition to clinical experience, leadership and interpersonal skills are critical for success.
 

How would a fellow or early-career GI who is interested in hospital medicine pursue this career pathway?

My first suggestion is to get involved in local efforts based on your interest. For example, if you are interested in quality improvement, seek to be a member of your department or hospital quality improvement committee. In GI and hepatology, natural places to get involved are around the development of care pathways, readmission committees, and initiatives to increase screening and treatment of hepatitis C or colon cancer. If you are interested in operations, look to see if there is an endoscopy or clinic operations committee you can get involved in. Get to know your medical board and medical staff structure. I gained exposure to this world by observing some of these meetings and then being asked to join them. These are valuable groups that help to create policy, raise important issues, and work with administration in the management of the hospital.

I am also a big fan of informational interviewing. If there are leaders who do the type of work you are interested in, consider reaching out with a call or email and asking to meet with them to talk about their role and career path.

As a fellow, there is an Accreditation Council for Graduate Medical Education requirement to incorporate residents and fellows onto hospital committees. This requirement has been a great way to have fellows incorporated into hospital work. You will find that those in hospital administration are eager to have interested and collegial partners in the work that is being done.


 

Are there any advanced training options available for those interested in hospital administration?

Depending on the position, there are numerous certificate and master’s programs that can provide formal education. CEOs and COOs may seek an MBA or master’s in Health Care Administration. There are programs that focus on Health Care Leadership or Quality and Patient Safety that are applicable to many leadership positions. These are offered in in-person and online formats. However, many physicians in these positions have a combination of informal and experiential learning programs that developed their skill set.

Some hospital systems offer an internal physician leadership training program to develop early and midcareer physician executives. There are professional organizations that offer courses for leadership development (e.g., American College of Physician Executives). Some business schools offer shorter-format programs that are geared toward health care leaders and focus on finance, operations, or quality.

I received some of my training through the Clinical Quality Fellowship Program, which is a 14-month experiential learning program in quality and patient safety that is run locally in New York City. In addition, I had some leadership training through the Association of American Medical Colleges and through the AGA Future Leaders Program (http://www.gastro.org/about/initiatives/aga-future-leaders-program).



Hospitals, outpatient practices, and health systems offer career paths including patient safety, quality improvement, or hospital management. I have enjoyed stretching my existing skill set in these roles while learning about how health facilities work, gaining knowledge of health care financing, and making care safer while ensuring high quality. These roles require teamwork across professions and specialties. As a gastroenterologist or hepatologist, we bring our own clinical and professional experience, which can be invaluable to the overall health care management team.

The readership of Gastroenterology includes a broad distribution of stakeholders in digestive health, including those with vested interests in clinical practice, education, policy, clinical investigation, and basic research. One of our most critical constituencies, however, is trainees and early-career GIs. In an effort to support such individuals, our editorial team has developed a freshly minted 1-year editorial fellowship for Gastroenterology. The overarching purpose of this fellowship is to mentor an outstanding trainee for future editorial leadership roles in scientific publishing, as a means to promote the interests of trainee and early-career GI constituencies within the AGA and Gastroenterology. This fellowship is available to exceptional second- or third-year fellows through an application process. The intent of this training is to allow the selected applicant to become intimately involved with Gastroenterology’s entire editorial process, including peer review, editorial oversight, manuscript selection for publication, production, and postpublication activities. Our first fellow, Eric Shah, MD, MBA, was selected from a highly competitive pool of exceptional applicants, and began his fellowship on July 1, 2017.

AGA Institute

This year, we have been delighted to work with Dr. Shah as our inaugural Gastroenterology fellow. Dr. Shah has a unique background, having pursued a joint MD and MBA (earning both concurrently), while also following venture-oriented interests in developing GI technology from academia. Dr. Shah began his research career under the mentorship of Mark Pimentel, MD, and Gil Melmed, MD, at Cedars-Sinai as part of a Research Honors Program. Since that time, he has focused on evaluating the comparative efficacy, durability, and harm associated with pharmacotherapy in functional bowel disorders. Dr. Shah was accepted into the GI fellowship training program at the University of Michigan and received a slot on the T32 training grant to study cost-effectiveness and qualitative research techniques to address gaps in the care of functional bowel disorders. His work under the mentorship of William Chey, MD, Ryan Stidham, MD, and Philip S. Schoenfeld, MD, has flourished and culminated in an oral presentation and several posters for DDW 2017, as well as several first-author manuscripts that have been submitted. Dr. Shah has fully embraced the Gastroenterology fellowship and has far surpassed our high expectations for this position.
 

VIDEO SOURCE: AMERICAN GASTROENTEROLOGICAL ASSOCIATION

In addition to creating an editorial fellowship, our team has also developed other components within the journal that specifically target trainees and early-career GIs. The Mentoring, Education and Training section – initiated in 2011 through the vision and insight of Bishr Omary MD, PhD, and John Del Valle, MD, at the University of Michigan – has been extremely effective in highlighting critical issues relevant to trainees, young faculty, and early-career GIs. Topics have included mentoring advice not only for individuals in academic or private practice careers but also industry careers and midlevel providers. Other topics have included Accreditation Council for Graduate Medical Education milestones, career advancement for clinician-educators, sex and ethnic diversity, and maintenance of certification, as well as guidance regarding nontraditional funding mechanisms such as philanthropy. Potential future topics will include information about major new public and private funding initiatives, comments and input from National Institutes of Health officials, and reports of funding trends relevant to both physician scientists and clinicians. We are fortunate to have Prateek Sharma, MD, lead this section, and his depth of experience as an exceptional mentor has provided the requisite expertise.

Additionally, we offer a reduction in page charges to junior investigators (within 7 years of fellowship) who are the corresponding authors of exceedingly important original Gastroenterology manuscripts. These manuscripts from junior investigators will be highlighted in both print and online versions of Gastroenterology. We are using the journal to expand electronic access to educational offerings for new technologies, training, self-assessment, and practice improvement to establish the AGA as the ultimate resource for junior academicians and practicing physicians. We are also currently integrating Gastroenterology more closely into other AGA educational efforts that target young physicians, such as the AGA Education and Training Committee.

At Gastroenterology, we are acutely aware of the needs and obstacles facing trainees, young faculty, and early-career GIs. We have boldly adopted a multidimensional approach to provide guidance and opportunities to overcome these challenges, including the creation of the nascent Editorial Fellowship. We welcome applications for the next fellowship, which will be announced by the AGA in the spring of 2018!
 

Dr. Peek is the Mina Wallace Professor of Medicine, Cancer Biology, and Pathology, Microbiology, and Immunology, and director, division of gastroenterology, hepatology and nutrition, Vanderbilt University Medical Center, Nashville, Tenn. He has no conflicts of interest.

The readership of Gastroenterology includes a broad distribution of stakeholders in digestive health, including those with vested interests in clinical practice, education, policy, clinical investigation, and basic research. One of our most critical constituencies, however, is trainees and early-career GIs. In an effort to support such individuals, our editorial team has developed a freshly minted 1-year editorial fellowship for Gastroenterology. The overarching purpose of this fellowship is to mentor an outstanding trainee for future editorial leadership roles in scientific publishing, as a means to promote the interests of trainee and early-career GI constituencies within the AGA and Gastroenterology. This fellowship is available to exceptional second- or third-year fellows through an application process. The intent of this training is to allow the selected applicant to become intimately involved with Gastroenterology’s entire editorial process, including peer review, editorial oversight, manuscript selection for publication, production, and postpublication activities. Our first fellow, Eric Shah, MD, MBA, was selected from a highly competitive pool of exceptional applicants, and began his fellowship on July 1, 2017.

AGA Institute

This year, we have been delighted to work with Dr. Shah as our inaugural Gastroenterology fellow. Dr. Shah has a unique background, having pursued a joint MD and MBA (earning both concurrently), while also following venture-oriented interests in developing GI technology from academia. Dr. Shah began his research career under the mentorship of Mark Pimentel, MD, and Gil Melmed, MD, at Cedars-Sinai as part of a Research Honors Program. Since that time, he has focused on evaluating the comparative efficacy, durability, and harm associated with pharmacotherapy in functional bowel disorders. Dr. Shah was accepted into the GI fellowship training program at the University of Michigan and received a slot on the T32 training grant to study cost-effectiveness and qualitative research techniques to address gaps in the care of functional bowel disorders. His work under the mentorship of William Chey, MD, Ryan Stidham, MD, and Philip S. Schoenfeld, MD, has flourished and culminated in an oral presentation and several posters for DDW 2017, as well as several first-author manuscripts that have been submitted. Dr. Shah has fully embraced the Gastroenterology fellowship and has far surpassed our high expectations for this position.
 

VIDEO SOURCE: AMERICAN GASTROENTEROLOGICAL ASSOCIATION

In addition to creating an editorial fellowship, our team has also developed other components within the journal that specifically target trainees and early-career GIs. The Mentoring, Education and Training section – initiated in 2011 through the vision and insight of Bishr Omary MD, PhD, and John Del Valle, MD, at the University of Michigan – has been extremely effective in highlighting critical issues relevant to trainees, young faculty, and early-career GIs. Topics have included mentoring advice not only for individuals in academic or private practice careers but also industry careers and midlevel providers. Other topics have included Accreditation Council for Graduate Medical Education milestones, career advancement for clinician-educators, sex and ethnic diversity, and maintenance of certification, as well as guidance regarding nontraditional funding mechanisms such as philanthropy. Potential future topics will include information about major new public and private funding initiatives, comments and input from National Institutes of Health officials, and reports of funding trends relevant to both physician scientists and clinicians. We are fortunate to have Prateek Sharma, MD, lead this section, and his depth of experience as an exceptional mentor has provided the requisite expertise.

Additionally, we offer a reduction in page charges to junior investigators (within 7 years of fellowship) who are the corresponding authors of exceedingly important original Gastroenterology manuscripts. These manuscripts from junior investigators will be highlighted in both print and online versions of Gastroenterology. We are using the journal to expand electronic access to educational offerings for new technologies, training, self-assessment, and practice improvement to establish the AGA as the ultimate resource for junior academicians and practicing physicians. We are also currently integrating Gastroenterology more closely into other AGA educational efforts that target young physicians, such as the AGA Education and Training Committee.

At Gastroenterology, we are acutely aware of the needs and obstacles facing trainees, young faculty, and early-career GIs. We have boldly adopted a multidimensional approach to provide guidance and opportunities to overcome these challenges, including the creation of the nascent Editorial Fellowship. We welcome applications for the next fellowship, which will be announced by the AGA in the spring of 2018!
 

Dr. Peek is the Mina Wallace Professor of Medicine, Cancer Biology, and Pathology, Microbiology, and Immunology, and director, division of gastroenterology, hepatology and nutrition, Vanderbilt University Medical Center, Nashville, Tenn. He has no conflicts of interest.

The readership of Gastroenterology includes a broad distribution of stakeholders in digestive health, including those with vested interests in clinical practice, education, policy, clinical investigation, and basic research. One of our most critical constituencies, however, is trainees and early-career GIs. In an effort to support such individuals, our editorial team has developed a freshly minted 1-year editorial fellowship for Gastroenterology. The overarching purpose of this fellowship is to mentor an outstanding trainee for future editorial leadership roles in scientific publishing, as a means to promote the interests of trainee and early-career GI constituencies within the AGA and Gastroenterology. This fellowship is available to exceptional second- or third-year fellows through an application process. The intent of this training is to allow the selected applicant to become intimately involved with Gastroenterology’s entire editorial process, including peer review, editorial oversight, manuscript selection for publication, production, and postpublication activities. Our first fellow, Eric Shah, MD, MBA, was selected from a highly competitive pool of exceptional applicants, and began his fellowship on July 1, 2017.

AGA Institute

This year, we have been delighted to work with Dr. Shah as our inaugural Gastroenterology fellow. Dr. Shah has a unique background, having pursued a joint MD and MBA (earning both concurrently), while also following venture-oriented interests in developing GI technology from academia. Dr. Shah began his research career under the mentorship of Mark Pimentel, MD, and Gil Melmed, MD, at Cedars-Sinai as part of a Research Honors Program. Since that time, he has focused on evaluating the comparative efficacy, durability, and harm associated with pharmacotherapy in functional bowel disorders. Dr. Shah was accepted into the GI fellowship training program at the University of Michigan and received a slot on the T32 training grant to study cost-effectiveness and qualitative research techniques to address gaps in the care of functional bowel disorders. His work under the mentorship of William Chey, MD, Ryan Stidham, MD, and Philip S. Schoenfeld, MD, has flourished and culminated in an oral presentation and several posters for DDW 2017, as well as several first-author manuscripts that have been submitted. Dr. Shah has fully embraced the Gastroenterology fellowship and has far surpassed our high expectations for this position.
 

VIDEO SOURCE: AMERICAN GASTROENTEROLOGICAL ASSOCIATION

In addition to creating an editorial fellowship, our team has also developed other components within the journal that specifically target trainees and early-career GIs. The Mentoring, Education and Training section – initiated in 2011 through the vision and insight of Bishr Omary MD, PhD, and John Del Valle, MD, at the University of Michigan – has been extremely effective in highlighting critical issues relevant to trainees, young faculty, and early-career GIs. Topics have included mentoring advice not only for individuals in academic or private practice careers but also industry careers and midlevel providers. Other topics have included Accreditation Council for Graduate Medical Education milestones, career advancement for clinician-educators, sex and ethnic diversity, and maintenance of certification, as well as guidance regarding nontraditional funding mechanisms such as philanthropy. Potential future topics will include information about major new public and private funding initiatives, comments and input from National Institutes of Health officials, and reports of funding trends relevant to both physician scientists and clinicians. We are fortunate to have Prateek Sharma, MD, lead this section, and his depth of experience as an exceptional mentor has provided the requisite expertise.

Additionally, we offer a reduction in page charges to junior investigators (within 7 years of fellowship) who are the corresponding authors of exceedingly important original Gastroenterology manuscripts. These manuscripts from junior investigators will be highlighted in both print and online versions of Gastroenterology. We are using the journal to expand electronic access to educational offerings for new technologies, training, self-assessment, and practice improvement to establish the AGA as the ultimate resource for junior academicians and practicing physicians. We are also currently integrating Gastroenterology more closely into other AGA educational efforts that target young physicians, such as the AGA Education and Training Committee.

At Gastroenterology, we are acutely aware of the needs and obstacles facing trainees, young faculty, and early-career GIs. We have boldly adopted a multidimensional approach to provide guidance and opportunities to overcome these challenges, including the creation of the nascent Editorial Fellowship. We welcome applications for the next fellowship, which will be announced by the AGA in the spring of 2018!
 

Dr. Peek is the Mina Wallace Professor of Medicine, Cancer Biology, and Pathology, Microbiology, and Immunology, and director, division of gastroenterology, hepatology and nutrition, Vanderbilt University Medical Center, Nashville, Tenn. He has no conflicts of interest.

Trainee and early-career members made an impact in the GI field this past year, especially through contributing to and engaging in various collaborations via the American Gastroenterological Association’s member-only online discussion forum – the AGA Community.

We’re proud to announce that the title of 2017 top contributor is held by an early-career member: Meet Dmitriy Kedrin, MD, PhD, of Elliot Hospital in Manchester, N.H., and find out a little more about how the AGA Community is an important part of his routine in this brief Q&A session.

Thanks for being such an active member of the AGA Community! Why do you contribute?

“I think it is important for GI docs to be a part of a larger community, stay informed on the latest guidelines, research publications, and approaches to difficult cases, where more than one road can be taken. I feel that it is a great forum for someone like me, a relatively junior gastroenterologist.”

Why do you enjoy being part of the AGA Community?

“I find the case discussions informative. I learn a great deal about current trends and opinions on important topics in the GI world.”

What do you like to do in your free time?

“I bake bread and run a gastroenterology literature review podcast called ‘GI Pearls.’ ”

What’s your approach to handling a difficult patient case you come across in your practice?

“I often seek advice of other clinicians, some with more expertise in a particular area. I also go to the literature and try to learn more that way, to help expand my differential as well as figure out the best therapeutic approach.”

Was there a conversation in the AGA Community in 2017 that was your favorite?

“Oh, there were several. I recall a patient case where there were several thought leaders in the field who had a disagreement about the best approach to treatment. The work-life balance conversation was also very good. I also enjoyed reading about different opinions regarding the values of clinical versus observational trials that happened a while back.”



Here are other trainee and early-career members who made the list of top contributors in the AGA Community last year:

• Avinash Ketwaroo, MD
• Hüseyin Bozkurt, MD
• Peter Liang, MD, MPH
• Fola May, MD, PhD
• Richa Shukla, MD
• Arthur Beyder, MD, PhD
• Shazia Siddique, MD
• Brigid Boland, MD

Check the achievements section of your AGA Community profile to see whether you made the list. We look forward to seeing you all in the forum in 2018!

Trainee and early-career members made an impact in the GI field this past year, especially through contributing to and engaging in various collaborations via the American Gastroenterological Association’s member-only online discussion forum – the AGA Community.

We’re proud to announce that the title of 2017 top contributor is held by an early-career member: Meet Dmitriy Kedrin, MD, PhD, of Elliot Hospital in Manchester, N.H., and find out a little more about how the AGA Community is an important part of his routine in this brief Q&A session.

Thanks for being such an active member of the AGA Community! Why do you contribute?

“I think it is important for GI docs to be a part of a larger community, stay informed on the latest guidelines, research publications, and approaches to difficult cases, where more than one road can be taken. I feel that it is a great forum for someone like me, a relatively junior gastroenterologist.”

Why do you enjoy being part of the AGA Community?

“I find the case discussions informative. I learn a great deal about current trends and opinions on important topics in the GI world.”

What do you like to do in your free time?

“I bake bread and run a gastroenterology literature review podcast called ‘GI Pearls.’ ”

What’s your approach to handling a difficult patient case you come across in your practice?

“I often seek advice of other clinicians, some with more expertise in a particular area. I also go to the literature and try to learn more that way, to help expand my differential as well as figure out the best therapeutic approach.”

Was there a conversation in the AGA Community in 2017 that was your favorite?

“Oh, there were several. I recall a patient case where there were several thought leaders in the field who had a disagreement about the best approach to treatment. The work-life balance conversation was also very good. I also enjoyed reading about different opinions regarding the values of clinical versus observational trials that happened a while back.”



Here are other trainee and early-career members who made the list of top contributors in the AGA Community last year:

• Avinash Ketwaroo, MD
• Hüseyin Bozkurt, MD
• Peter Liang, MD, MPH
• Fola May, MD, PhD
• Richa Shukla, MD
• Arthur Beyder, MD, PhD
• Shazia Siddique, MD
• Brigid Boland, MD

Check the achievements section of your AGA Community profile to see whether you made the list. We look forward to seeing you all in the forum in 2018!

Trainee and early-career members made an impact in the GI field this past year, especially through contributing to and engaging in various collaborations via the American Gastroenterological Association’s member-only online discussion forum – the AGA Community.

We’re proud to announce that the title of 2017 top contributor is held by an early-career member: Meet Dmitriy Kedrin, MD, PhD, of Elliot Hospital in Manchester, N.H., and find out a little more about how the AGA Community is an important part of his routine in this brief Q&A session.

Thanks for being such an active member of the AGA Community! Why do you contribute?

“I think it is important for GI docs to be a part of a larger community, stay informed on the latest guidelines, research publications, and approaches to difficult cases, where more than one road can be taken. I feel that it is a great forum for someone like me, a relatively junior gastroenterologist.”

Why do you enjoy being part of the AGA Community?

“I find the case discussions informative. I learn a great deal about current trends and opinions on important topics in the GI world.”

What do you like to do in your free time?

“I bake bread and run a gastroenterology literature review podcast called ‘GI Pearls.’ ”

What’s your approach to handling a difficult patient case you come across in your practice?

“I often seek advice of other clinicians, some with more expertise in a particular area. I also go to the literature and try to learn more that way, to help expand my differential as well as figure out the best therapeutic approach.”

Was there a conversation in the AGA Community in 2017 that was your favorite?

“Oh, there were several. I recall a patient case where there were several thought leaders in the field who had a disagreement about the best approach to treatment. The work-life balance conversation was also very good. I also enjoyed reading about different opinions regarding the values of clinical versus observational trials that happened a while back.”



Here are other trainee and early-career members who made the list of top contributors in the AGA Community last year:

• Avinash Ketwaroo, MD
• Hüseyin Bozkurt, MD
• Peter Liang, MD, MPH
• Fola May, MD, PhD
• Richa Shukla, MD
• Arthur Beyder, MD, PhD
• Shazia Siddique, MD
• Brigid Boland, MD

Check the achievements section of your AGA Community profile to see whether you made the list. We look forward to seeing you all in the forum in 2018!

Each year, the American Gastroenterological Association travels throughout the country, hosting Regional Practice Skills Workshops to answer tough and practical questions that are rarely addressed during fellowship. Presentations from several of the 2017 workshops are now available on the AGA website for you to watch at your leisure (login required). Each presentation is 20 minutes or less and provides expert advice to help you succeed in your career.

Here’s a selection of what you’ll find at www.gastro.org/education:

• Physician Contracts and Negotiations – Jon Appino from Contract Diagnostics discusses the anatomy of physician employment agreements. He shares questions that are important for you to ask when reviewing a contract.
• Career in Hybrid Practice – John S. Hanson, MD, AGAF, from Carolinas HealthCare System reviews different practice types and provides insight into “hybrid practice” and how it compares to private practice and academic practice.
• Career in Private Practice – Rig S. Patel, MD, the president of Digestive Healthcare PA, builds a clear picture of what life is like in private practice and shares nine things to consider when reviewing a private practice.
• Wealth Management Perspectives – Two financial advisors from Morgan Stanley provide tips and strategies to help early career physicians stay “financially fit.”

See all of AGA’s on-demand education for trainees and early career GIs by visiting www.gastro.org/education and searching for the series Trainees and Early Career GIs.

The AGA Regional Practice Skills Workshops are organized by the AGA Trainee & Early Career Committee in support of early career GIs. In December 2017, workshops were held in California, Iowa, and New York. The spring 2018 workshops will take place in Columbus, Ohio (Feb. 24), and Philadelphia, Penn. (April 11).
 

Each year, the American Gastroenterological Association travels throughout the country, hosting Regional Practice Skills Workshops to answer tough and practical questions that are rarely addressed during fellowship. Presentations from several of the 2017 workshops are now available on the AGA website for you to watch at your leisure (login required). Each presentation is 20 minutes or less and provides expert advice to help you succeed in your career.

Here’s a selection of what you’ll find at www.gastro.org/education:

• Physician Contracts and Negotiations – Jon Appino from Contract Diagnostics discusses the anatomy of physician employment agreements. He shares questions that are important for you to ask when reviewing a contract.
• Career in Hybrid Practice – John S. Hanson, MD, AGAF, from Carolinas HealthCare System reviews different practice types and provides insight into “hybrid practice” and how it compares to private practice and academic practice.
• Career in Private Practice – Rig S. Patel, MD, the president of Digestive Healthcare PA, builds a clear picture of what life is like in private practice and shares nine things to consider when reviewing a private practice.
• Wealth Management Perspectives – Two financial advisors from Morgan Stanley provide tips and strategies to help early career physicians stay “financially fit.”

See all of AGA’s on-demand education for trainees and early career GIs by visiting www.gastro.org/education and searching for the series Trainees and Early Career GIs.

The AGA Regional Practice Skills Workshops are organized by the AGA Trainee & Early Career Committee in support of early career GIs. In December 2017, workshops were held in California, Iowa, and New York. The spring 2018 workshops will take place in Columbus, Ohio (Feb. 24), and Philadelphia, Penn. (April 11).
 

Each year, the American Gastroenterological Association travels throughout the country, hosting Regional Practice Skills Workshops to answer tough and practical questions that are rarely addressed during fellowship. Presentations from several of the 2017 workshops are now available on the AGA website for you to watch at your leisure (login required). Each presentation is 20 minutes or less and provides expert advice to help you succeed in your career.

Here’s a selection of what you’ll find at www.gastro.org/education:

• Physician Contracts and Negotiations – Jon Appino from Contract Diagnostics discusses the anatomy of physician employment agreements. He shares questions that are important for you to ask when reviewing a contract.
• Career in Hybrid Practice – John S. Hanson, MD, AGAF, from Carolinas HealthCare System reviews different practice types and provides insight into “hybrid practice” and how it compares to private practice and academic practice.
• Career in Private Practice – Rig S. Patel, MD, the president of Digestive Healthcare PA, builds a clear picture of what life is like in private practice and shares nine things to consider when reviewing a private practice.
• Wealth Management Perspectives – Two financial advisors from Morgan Stanley provide tips and strategies to help early career physicians stay “financially fit.”

See all of AGA’s on-demand education for trainees and early career GIs by visiting www.gastro.org/education and searching for the series Trainees and Early Career GIs.

The AGA Regional Practice Skills Workshops are organized by the AGA Trainee & Early Career Committee in support of early career GIs. In December 2017, workshops were held in California, Iowa, and New York. The spring 2018 workshops will take place in Columbus, Ohio (Feb. 24), and Philadelphia, Penn. (April 11).
 

We held a contest in the AGA Community forum asking members to share a piece of advice they learned or heard in the past year for a chance to win free registration to this year’s AGA Postgraduate Course in Washington, D.C., on June 2 and 3.

Here are some of our favorite responses from early career members, including our winner, Hüseyin Bozkurt from Medical Park Private Tarsus Hospital, Turkey:

• “We can provide healthy gut microbiome, don’t lose your hope. The future is changeable.” Hüseyin Bozkurt Sr., MD, contest winner.
• “Ambulatory reflux monitoring modalities can help phenotype GERD and guide optimal management.” Amit Patel, MD, 2018 AGA Postgraduate Course faculty.
• “One tip I heard from an attending in the first year of fellowship, which is particularly useful for IBS patients, is to set realistic expectations from the outset, for e.g. – when diagnosing patients with IBS and giving them advice, telling them ‘We are not looking to cure your GI symptoms, but to control them – you will have GI symptoms off and on despite treatment, my goal is to make sure you have more good days, than bad.’” Aakash Aggarwal, MD

Registration for the popular 1.5-day course is now open. Learn more at pgcourse.gastro.org and save $75 by registering before April 18.

The AGA Postgraduate Course takes place during AGA’s annual meeting Digestive Disease Week®, which is cosponsored by AASLD, ASGE, and SSAT. Learn more and register at www.ddw.org.

We held a contest in the AGA Community forum asking members to share a piece of advice they learned or heard in the past year for a chance to win free registration to this year’s AGA Postgraduate Course in Washington, D.C., on June 2 and 3.

Here are some of our favorite responses from early career members, including our winner, Hüseyin Bozkurt from Medical Park Private Tarsus Hospital, Turkey:

• “We can provide healthy gut microbiome, don’t lose your hope. The future is changeable.” Hüseyin Bozkurt Sr., MD, contest winner.
• “Ambulatory reflux monitoring modalities can help phenotype GERD and guide optimal management.” Amit Patel, MD, 2018 AGA Postgraduate Course faculty.
• “One tip I heard from an attending in the first year of fellowship, which is particularly useful for IBS patients, is to set realistic expectations from the outset, for e.g. – when diagnosing patients with IBS and giving them advice, telling them ‘We are not looking to cure your GI symptoms, but to control them – you will have GI symptoms off and on despite treatment, my goal is to make sure you have more good days, than bad.’” Aakash Aggarwal, MD

Registration for the popular 1.5-day course is now open. Learn more at pgcourse.gastro.org and save $75 by registering before April 18.

The AGA Postgraduate Course takes place during AGA’s annual meeting Digestive Disease Week®, which is cosponsored by AASLD, ASGE, and SSAT. Learn more and register at www.ddw.org.

We held a contest in the AGA Community forum asking members to share a piece of advice they learned or heard in the past year for a chance to win free registration to this year’s AGA Postgraduate Course in Washington, D.C., on June 2 and 3.

Here are some of our favorite responses from early career members, including our winner, Hüseyin Bozkurt from Medical Park Private Tarsus Hospital, Turkey:

• “We can provide healthy gut microbiome, don’t lose your hope. The future is changeable.” Hüseyin Bozkurt Sr., MD, contest winner.
• “Ambulatory reflux monitoring modalities can help phenotype GERD and guide optimal management.” Amit Patel, MD, 2018 AGA Postgraduate Course faculty.
• “One tip I heard from an attending in the first year of fellowship, which is particularly useful for IBS patients, is to set realistic expectations from the outset, for e.g. – when diagnosing patients with IBS and giving them advice, telling them ‘We are not looking to cure your GI symptoms, but to control them – you will have GI symptoms off and on despite treatment, my goal is to make sure you have more good days, than bad.’” Aakash Aggarwal, MD

Registration for the popular 1.5-day course is now open. Learn more at pgcourse.gastro.org and save $75 by registering before April 18.

The AGA Postgraduate Course takes place during AGA’s annual meeting Digestive Disease Week®, which is cosponsored by AASLD, ASGE, and SSAT. Learn more and register at www.ddw.org.

A career in inflammatory bowel disease promises to be challenging, exciting, at times frustrating, and always educational. We asked our expert faculty at the inaugural Crohn’s & Colitis Congress, which took place Jan. 18-20 in Las Vegas, to reflect on why a career in IBD is an excellent path to take.

Why pursue a career in IBD

1. “IBD is the fastest moving area of GI to integrate science (genomics, microbiome, immunology) into care that will change the natural history of disease. The physicians and scientists have an unusually collegial culture, and the patients really care.” – Jonathan G. Braun, MD, PhD



2. “Managing patients with IBD is becoming ever more complex. When patients move beyond having mild disease, complex decisions need to be made. Choosing the right medication at the right time for the right patient will lead to the best outcomes for patients with IBD. I have every reason to believe that specializing in the clinical care of patients with IBD will be intellectually challenging while offering great personal satisfaction in taking care of these ill patients.” – Francis A. Farraye, MD, MSc



3. “IBD research findings and the implications for patient care are evolving rapidly. Many recommendations that we made 5-10 years ago have changed as we are learning more about IBD every day. There are so many opportunities to participate in the expansion of that knowledge base and help us reach our goal of a cure for IBD in the lifetime of many of our patients. Take the challenge.” – Teri Lynn Jackson, MSN, ARNP



4. “IBD is an outstanding field led by great people who want to see fellows and junior faculty succeed. Identify a mentor and listen to them, meet and engage with new people, be curious, think big, and work hard!” – Michael J. Rosen, MD, MSCI



5. “The best career in the world! Such variety. A home for everyone with any interest. It won’t always be smooth, but it will be incredibly rewarding with hardly a dull moment.” – Dermot McGovern, MD, PhD, FRCP



For additional tips and advice, visit the AGA Community.
 

A career in inflammatory bowel disease promises to be challenging, exciting, at times frustrating, and always educational. We asked our expert faculty at the inaugural Crohn’s & Colitis Congress, which took place Jan. 18-20 in Las Vegas, to reflect on why a career in IBD is an excellent path to take.

Why pursue a career in IBD

1. “IBD is the fastest moving area of GI to integrate science (genomics, microbiome, immunology) into care that will change the natural history of disease. The physicians and scientists have an unusually collegial culture, and the patients really care.” – Jonathan G. Braun, MD, PhD



2. “Managing patients with IBD is becoming ever more complex. When patients move beyond having mild disease, complex decisions need to be made. Choosing the right medication at the right time for the right patient will lead to the best outcomes for patients with IBD. I have every reason to believe that specializing in the clinical care of patients with IBD will be intellectually challenging while offering great personal satisfaction in taking care of these ill patients.” – Francis A. Farraye, MD, MSc



3. “IBD research findings and the implications for patient care are evolving rapidly. Many recommendations that we made 5-10 years ago have changed as we are learning more about IBD every day. There are so many opportunities to participate in the expansion of that knowledge base and help us reach our goal of a cure for IBD in the lifetime of many of our patients. Take the challenge.” – Teri Lynn Jackson, MSN, ARNP



4. “IBD is an outstanding field led by great people who want to see fellows and junior faculty succeed. Identify a mentor and listen to them, meet and engage with new people, be curious, think big, and work hard!” – Michael J. Rosen, MD, MSCI



5. “The best career in the world! Such variety. A home for everyone with any interest. It won’t always be smooth, but it will be incredibly rewarding with hardly a dull moment.” – Dermot McGovern, MD, PhD, FRCP



For additional tips and advice, visit the AGA Community.
 

A career in inflammatory bowel disease promises to be challenging, exciting, at times frustrating, and always educational. We asked our expert faculty at the inaugural Crohn’s & Colitis Congress, which took place Jan. 18-20 in Las Vegas, to reflect on why a career in IBD is an excellent path to take.

Why pursue a career in IBD

1. “IBD is the fastest moving area of GI to integrate science (genomics, microbiome, immunology) into care that will change the natural history of disease. The physicians and scientists have an unusually collegial culture, and the patients really care.” – Jonathan G. Braun, MD, PhD



2. “Managing patients with IBD is becoming ever more complex. When patients move beyond having mild disease, complex decisions need to be made. Choosing the right medication at the right time for the right patient will lead to the best outcomes for patients with IBD. I have every reason to believe that specializing in the clinical care of patients with IBD will be intellectually challenging while offering great personal satisfaction in taking care of these ill patients.” – Francis A. Farraye, MD, MSc



3. “IBD research findings and the implications for patient care are evolving rapidly. Many recommendations that we made 5-10 years ago have changed as we are learning more about IBD every day. There are so many opportunities to participate in the expansion of that knowledge base and help us reach our goal of a cure for IBD in the lifetime of many of our patients. Take the challenge.” – Teri Lynn Jackson, MSN, ARNP



4. “IBD is an outstanding field led by great people who want to see fellows and junior faculty succeed. Identify a mentor and listen to them, meet and engage with new people, be curious, think big, and work hard!” – Michael J. Rosen, MD, MSCI



5. “The best career in the world! Such variety. A home for everyone with any interest. It won’t always be smooth, but it will be incredibly rewarding with hardly a dull moment.” – Dermot McGovern, MD, PhD, FRCP



For additional tips and advice, visit the AGA Community.
 

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

UPCOMING EVENTS

Feb. 22, 2018; March 22, 2018
Reimbursement, Coding and Compliance for Gastroenterology
Improve the efficiency and performance of your practice by staying current on the latest reimbursement, coding, and compliance changes.
2/22 (Edison, NJ); 3/22 (St. Charles, MO)

April 11, 2018
AGA Regional Practice Skills Workshop – Pennsylvania
During this free workshop, senior and junior GI leaders will guide you through various practice options and address topics rarely discussed during fellowship, such as employment models, partnerships, hospital politics, billing and coding, compliance, contracts, and more. Find out more at http://www.gastro.org/in-person/regional-practice-skills-workshop-philadelphia.
Philadelphia

May 10-11, 2018
HIV and Hepatitis Management: THE NEW YORK COURSE
This advanced CME activity will provide participants with state-of-the-art information and practical guidance on progress in managing HIV, hepatitis B, and hepatitis C and will enable practitioners to deliver the highest-quality care in all practice settings.
New York City

Jun. 2-5, 2018

DIGESTIVE DISEASE WEEK^® (DDW) 2018 – WASHINGTON, DC

AGA Trainee and Early-Career GI Sessions
Join your colleagues at special sessions to meet the unique needs of physicians who are new to the field. Participants will learn about all aspects of starting a career in clinical practice or research, have the opportunity to network with mentors and peers, and review board material.

• June 2, 8:15 a.m.-5:30 p.m.; June 3, 8:30 a.m.-12:35 p.m.
AGA Postgraduate Course: From Abstract to Reality
Attend this multi-topic course to get practical, applicable information to push your practice to the next level. The 2018 course will provide a comprehensive look at the latest medical, surgical, and technological advances over the past 12 months that aim to keep you up to date in a rapidly changing field. Each presenter will turn abstract ideas into concrete action items that you can implement in your practice immediately. AGA member trainees and early-career GIs receive discounted pricing for this course.

• June 3, 4-5:30 p.m.
Difficult Conversations: Navigating People, Negotiations, Promotions, and Complications
During this session, attendees will obtain effective negotiation techniques and learn how to navigate difficult situations in clinical and research environments.

• June 4, 4-5:30 p.m.
Advancing Clinical Practice: Gastroenterology Fellow–Directed Quality-Improvement Projects
This trainee-focused session will showcase selected abstracts from GI fellows based on quality improvement with a state-of-the-art lecture. Attendees will be provided with information that defines practical approaches to quality improvement from start to finish. A limited supply of coffee and tea will be provided during the session.

• June 5, 1:30-5:30 p.m.
Board Review Course
This session, designed around content from DDSEP^® 8, serves as a primer for third-year fellows preparing for the board exam as well as a review course for others wanting to test their knowledge. Session attendees will receive a $50 coupon to use at the AGA Store at DDW to purchase DDSEP 8.

• TBD
AGA Early-Career Networking Hour
Date, time, and location to be announced soon.

June 4-8, 2018
Exosomes/Microvesicles: Heterogeneity, Biogenesis, Function, and Therapeutic Developments (E2)
Deepen your understanding of the structural and functional complexity of extracellular vesicles, their biogenesis and function in health and disease, cargo enrichment, potential as ideal biomarkers, and breakthroughs in their use as therapeutic targets/agents.

Breckenridge, CO
 

AWARDS APPLICATION DEADLINES

AGA Fellow Abstract Award
This travel award provides $500 and one $1,000 prize to recipients who are MD and/or PhD postdoctoral fellows presenting posters/oral sessions at DDW.
Application Deadline: Feb. 16, 2018

AGA-Moti L. & Kamla Rustgi International Travel Awards
This travel award provides $750 to recipients who are young basic, translational, or clinical investigators residing outside North America to support travel and related expenses to attend DDW.
Application Deadline: Feb. 16, 2018

AGA Student Abstract Award
This travel award provides $500 and one $1,000 prize to recipients who are high school, undergraduate, graduate, medical students, or residents (residents up to year 3 postgraduates) presenting posters/oral sessions at DDW.
Application Deadline: Feb. 16, 2018
 

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

UPCOMING EVENTS

Feb. 22, 2018; March 22, 2018
Reimbursement, Coding and Compliance for Gastroenterology
Improve the efficiency and performance of your practice by staying current on the latest reimbursement, coding, and compliance changes.
2/22 (Edison, NJ); 3/22 (St. Charles, MO)

April 11, 2018
AGA Regional Practice Skills Workshop – Pennsylvania
During this free workshop, senior and junior GI leaders will guide you through various practice options and address topics rarely discussed during fellowship, such as employment models, partnerships, hospital politics, billing and coding, compliance, contracts, and more. Find out more at http://www.gastro.org/in-person/regional-practice-skills-workshop-philadelphia.
Philadelphia

May 10-11, 2018
HIV and Hepatitis Management: THE NEW YORK COURSE
This advanced CME activity will provide participants with state-of-the-art information and practical guidance on progress in managing HIV, hepatitis B, and hepatitis C and will enable practitioners to deliver the highest-quality care in all practice settings.
New York City

Jun. 2-5, 2018

DIGESTIVE DISEASE WEEK^® (DDW) 2018 – WASHINGTON, DC

AGA Trainee and Early-Career GI Sessions
Join your colleagues at special sessions to meet the unique needs of physicians who are new to the field. Participants will learn about all aspects of starting a career in clinical practice or research, have the opportunity to network with mentors and peers, and review board material.

• June 2, 8:15 a.m.-5:30 p.m.; June 3, 8:30 a.m.-12:35 p.m.
AGA Postgraduate Course: From Abstract to Reality
Attend this multi-topic course to get practical, applicable information to push your practice to the next level. The 2018 course will provide a comprehensive look at the latest medical, surgical, and technological advances over the past 12 months that aim to keep you up to date in a rapidly changing field. Each presenter will turn abstract ideas into concrete action items that you can implement in your practice immediately. AGA member trainees and early-career GIs receive discounted pricing for this course.

• June 3, 4-5:30 p.m.
Difficult Conversations: Navigating People, Negotiations, Promotions, and Complications
During this session, attendees will obtain effective negotiation techniques and learn how to navigate difficult situations in clinical and research environments.

• June 4, 4-5:30 p.m.
Advancing Clinical Practice: Gastroenterology Fellow–Directed Quality-Improvement Projects
This trainee-focused session will showcase selected abstracts from GI fellows based on quality improvement with a state-of-the-art lecture. Attendees will be provided with information that defines practical approaches to quality improvement from start to finish. A limited supply of coffee and tea will be provided during the session.

• June 5, 1:30-5:30 p.m.
Board Review Course
This session, designed around content from DDSEP^® 8, serves as a primer for third-year fellows preparing for the board exam as well as a review course for others wanting to test their knowledge. Session attendees will receive a $50 coupon to use at the AGA Store at DDW to purchase DDSEP 8.

• TBD
AGA Early-Career Networking Hour
Date, time, and location to be announced soon.

June 4-8, 2018
Exosomes/Microvesicles: Heterogeneity, Biogenesis, Function, and Therapeutic Developments (E2)
Deepen your understanding of the structural and functional complexity of extracellular vesicles, their biogenesis and function in health and disease, cargo enrichment, potential as ideal biomarkers, and breakthroughs in their use as therapeutic targets/agents.

Breckenridge, CO
 

AWARDS APPLICATION DEADLINES

AGA Fellow Abstract Award
This travel award provides $500 and one $1,000 prize to recipients who are MD and/or PhD postdoctoral fellows presenting posters/oral sessions at DDW.
Application Deadline: Feb. 16, 2018

AGA-Moti L. & Kamla Rustgi International Travel Awards
This travel award provides $750 to recipients who are young basic, translational, or clinical investigators residing outside North America to support travel and related expenses to attend DDW.
Application Deadline: Feb. 16, 2018

AGA Student Abstract Award
This travel award provides $500 and one $1,000 prize to recipients who are high school, undergraduate, graduate, medical students, or residents (residents up to year 3 postgraduates) presenting posters/oral sessions at DDW.
Application Deadline: Feb. 16, 2018
 

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

UPCOMING EVENTS

Feb. 22, 2018; March 22, 2018
Reimbursement, Coding and Compliance for Gastroenterology
Improve the efficiency and performance of your practice by staying current on the latest reimbursement, coding, and compliance changes.
2/22 (Edison, NJ); 3/22 (St. Charles, MO)

April 11, 2018
AGA Regional Practice Skills Workshop – Pennsylvania
During this free workshop, senior and junior GI leaders will guide you through various practice options and address topics rarely discussed during fellowship, such as employment models, partnerships, hospital politics, billing and coding, compliance, contracts, and more. Find out more at http://www.gastro.org/in-person/regional-practice-skills-workshop-philadelphia.
Philadelphia

May 10-11, 2018
HIV and Hepatitis Management: THE NEW YORK COURSE
This advanced CME activity will provide participants with state-of-the-art information and practical guidance on progress in managing HIV, hepatitis B, and hepatitis C and will enable practitioners to deliver the highest-quality care in all practice settings.
New York City

Jun. 2-5, 2018

DIGESTIVE DISEASE WEEK^® (DDW) 2018 – WASHINGTON, DC

AGA Trainee and Early-Career GI Sessions
Join your colleagues at special sessions to meet the unique needs of physicians who are new to the field. Participants will learn about all aspects of starting a career in clinical practice or research, have the opportunity to network with mentors and peers, and review board material.

• June 2, 8:15 a.m.-5:30 p.m.; June 3, 8:30 a.m.-12:35 p.m.
AGA Postgraduate Course: From Abstract to Reality
Attend this multi-topic course to get practical, applicable information to push your practice to the next level. The 2018 course will provide a comprehensive look at the latest medical, surgical, and technological advances over the past 12 months that aim to keep you up to date in a rapidly changing field. Each presenter will turn abstract ideas into concrete action items that you can implement in your practice immediately. AGA member trainees and early-career GIs receive discounted pricing for this course.

• June 3, 4-5:30 p.m.
Difficult Conversations: Navigating People, Negotiations, Promotions, and Complications
During this session, attendees will obtain effective negotiation techniques and learn how to navigate difficult situations in clinical and research environments.

• June 4, 4-5:30 p.m.
Advancing Clinical Practice: Gastroenterology Fellow–Directed Quality-Improvement Projects
This trainee-focused session will showcase selected abstracts from GI fellows based on quality improvement with a state-of-the-art lecture. Attendees will be provided with information that defines practical approaches to quality improvement from start to finish. A limited supply of coffee and tea will be provided during the session.

• June 5, 1:30-5:30 p.m.
Board Review Course
This session, designed around content from DDSEP^® 8, serves as a primer for third-year fellows preparing for the board exam as well as a review course for others wanting to test their knowledge. Session attendees will receive a $50 coupon to use at the AGA Store at DDW to purchase DDSEP 8.

• TBD
AGA Early-Career Networking Hour
Date, time, and location to be announced soon.

June 4-8, 2018
Exosomes/Microvesicles: Heterogeneity, Biogenesis, Function, and Therapeutic Developments (E2)
Deepen your understanding of the structural and functional complexity of extracellular vesicles, their biogenesis and function in health and disease, cargo enrichment, potential as ideal biomarkers, and breakthroughs in their use as therapeutic targets/agents.

Breckenridge, CO
 

AWARDS APPLICATION DEADLINES

AGA Fellow Abstract Award
This travel award provides $500 and one $1,000 prize to recipients who are MD and/or PhD postdoctoral fellows presenting posters/oral sessions at DDW.
Application Deadline: Feb. 16, 2018

AGA-Moti L. & Kamla Rustgi International Travel Awards
This travel award provides $750 to recipients who are young basic, translational, or clinical investigators residing outside North America to support travel and related expenses to attend DDW.
Application Deadline: Feb. 16, 2018

AGA Student Abstract Award
This travel award provides $500 and one $1,000 prize to recipients who are high school, undergraduate, graduate, medical students, or residents (residents up to year 3 postgraduates) presenting posters/oral sessions at DDW.
Application Deadline: Feb. 16, 2018