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The role of the hospitalist is multidisciplinary and one of the primary responsibilities in your role is to notice and act on the changes you notice regarding your patients, including mental awareness and acuity.

"Evaluation of orientation and level of awareness is a core component of any hospitalist's daily evaluation," said Tara Scribner, MD, an internal medicine hospitalist, The University of Vermont Medical Center; associate program director for POCUS and Procedure Curriculum, UVMMC Internal Medicine Residency Program; and an assistant professor, Robert Larner, M.D. College of Medicine, Burlington, Vermont. "Beyond this, a broader assessment of executive function and functional abilities always occurs at some point during a hospital admission as discharge location and situation depends on this."

While it's relatively easy to identify signs of dementia using information from collateral sources, she also noted it's often difficult to determine whether a patient is experiencing progressive dementia or a more acute encephalopathy such as delirium if collateral sources are not available.

"Once a baseline has been established, hospitalists are in a unique position to identify subtle and acute shifts in mental acuity over the course of a hospital stay," Scribner said. "Unlike our primary care colleagues, who are well-positioned to observe for signs of dementia, we see our patients on a daily basis, sometimes more than once daily, and can track changes which occur over a matter of hours or days."

What Are Signs to Watch

During examinations and assessments, pay attention to shifts in the behavior of patients.

"Subtle signs of delirium and/or declining mental awareness can include disorientation about date, location, reason for admission," said Meghana R. Medavaram, MD, associate director of Consultation Liaison and Emergency Psychiatry, Weiler Hospital at Montefiore Health System in Bronx, New York.

Another sign would be mild inattention, such as drifting off during conversations or even having a hard time understanding and following multistep commands, she also said.

"We can also see sudden irritability or even the opposite, odd politeness or familiarity. We notice these changes occur as fluctuations throughout the day, sometimes with a clinician seeing a different 'personality' in the morning vs afternoon or evening," Medavaram said. "A key message we emphasize for our hospitalist colleagues is to not wait for overt agitation, or hallucinations to step in when assessing a patient and coming up with a treatment plan."

How Would Diet Play a Role

Excess consumption of alcohol is the most common way a patient's diet can affect changes in mental status, said Scribner. "Excess alcohol use has been linked to a significantly increased risk of dementia including both Alzheimer's and to alcohol-related brain damage including Korsakoff syndrome, as well as to the more acute Wernicke encephalopathy through vitamin B1 deficiency."

Also, vitamin deficiencies such as B12 have been linked to development of dementia and other cognitive impairment and can be related to alcohol consumption as well as to dietary habits such as vegetarianism, even in the absence of alcohol intake. Identification and treatment of B12 deficiency is a potentially reversible cause of cognitive impairment, she also said.

Do Medications Affect Mental State

Medications can be a significant cause of acute changes in mental status. "These changes are often reversible and include somnolence and both hypoactive and hyperactive delirium. Adjustment of a patient's usual medications is often necessary in hospitalized patients experiencing acute encephalopathy," Scribner said.

What About Depression

The relationship between dementia and development of dementia is complex and poorly understood, she said, however, those who deal with depression are at a higher risk of developing dementia, and also that patients with dementia are at a higher risk for development of depression.

How to Distinguish Between Short- and Long-term Issues

A thorough hospitalist is typically able to identify the acuity of mental status changes by the time of discharge and therefore predict the likelihood of recovery.

Progressive mental status changes occurring over months to years are almost always representative of dementia and are irreversible, whereas most (but not all) acute encephalopathies are recoverable over days to weeks or months.

Determining which of these is present involves interrogation of collateral sources such as family and friends, assessment of orientation and other signs of delirium, and observation of recovery during the period of hospital admission. It is worth noting that episodes of delirium are associated with a higher risk for long-term cognitive decline and development of dementia.

Written by Erica Lamberg.

A version of this article first appeared on Medscape.com.

The role of the hospitalist is multidisciplinary and one of the primary responsibilities in your role is to notice and act on the changes you notice regarding your patients, including mental awareness and acuity.

"Evaluation of orientation and level of awareness is a core component of any hospitalist's daily evaluation," said Tara Scribner, MD, an internal medicine hospitalist, The University of Vermont Medical Center; associate program director for POCUS and Procedure Curriculum, UVMMC Internal Medicine Residency Program; and an assistant professor, Robert Larner, M.D. College of Medicine, Burlington, Vermont. "Beyond this, a broader assessment of executive function and functional abilities always occurs at some point during a hospital admission as discharge location and situation depends on this."

While it's relatively easy to identify signs of dementia using information from collateral sources, she also noted it's often difficult to determine whether a patient is experiencing progressive dementia or a more acute encephalopathy such as delirium if collateral sources are not available.

"Once a baseline has been established, hospitalists are in a unique position to identify subtle and acute shifts in mental acuity over the course of a hospital stay," Scribner said. "Unlike our primary care colleagues, who are well-positioned to observe for signs of dementia, we see our patients on a daily basis, sometimes more than once daily, and can track changes which occur over a matter of hours or days."

What Are Signs to Watch

During examinations and assessments, pay attention to shifts in the behavior of patients.

"Subtle signs of delirium and/or declining mental awareness can include disorientation about date, location, reason for admission," said Meghana R. Medavaram, MD, associate director of Consultation Liaison and Emergency Psychiatry, Weiler Hospital at Montefiore Health System in Bronx, New York.

Another sign would be mild inattention, such as drifting off during conversations or even having a hard time understanding and following multistep commands, she also said.

"We can also see sudden irritability or even the opposite, odd politeness or familiarity. We notice these changes occur as fluctuations throughout the day, sometimes with a clinician seeing a different 'personality' in the morning vs afternoon or evening," Medavaram said. "A key message we emphasize for our hospitalist colleagues is to not wait for overt agitation, or hallucinations to step in when assessing a patient and coming up with a treatment plan."

How Would Diet Play a Role

Excess consumption of alcohol is the most common way a patient's diet can affect changes in mental status, said Scribner. "Excess alcohol use has been linked to a significantly increased risk of dementia including both Alzheimer's and to alcohol-related brain damage including Korsakoff syndrome, as well as to the more acute Wernicke encephalopathy through vitamin B1 deficiency."

Also, vitamin deficiencies such as B12 have been linked to development of dementia and other cognitive impairment and can be related to alcohol consumption as well as to dietary habits such as vegetarianism, even in the absence of alcohol intake. Identification and treatment of B12 deficiency is a potentially reversible cause of cognitive impairment, she also said.

Do Medications Affect Mental State

Medications can be a significant cause of acute changes in mental status. "These changes are often reversible and include somnolence and both hypoactive and hyperactive delirium. Adjustment of a patient's usual medications is often necessary in hospitalized patients experiencing acute encephalopathy," Scribner said.

What About Depression

The relationship between dementia and development of dementia is complex and poorly understood, she said, however, those who deal with depression are at a higher risk of developing dementia, and also that patients with dementia are at a higher risk for development of depression.

How to Distinguish Between Short- and Long-term Issues

A thorough hospitalist is typically able to identify the acuity of mental status changes by the time of discharge and therefore predict the likelihood of recovery.

Progressive mental status changes occurring over months to years are almost always representative of dementia and are irreversible, whereas most (but not all) acute encephalopathies are recoverable over days to weeks or months.

Determining which of these is present involves interrogation of collateral sources such as family and friends, assessment of orientation and other signs of delirium, and observation of recovery during the period of hospital admission. It is worth noting that episodes of delirium are associated with a higher risk for long-term cognitive decline and development of dementia.

Written by Erica Lamberg.

A version of this article first appeared on Medscape.com.

The role of the hospitalist is multidisciplinary and one of the primary responsibilities in your role is to notice and act on the changes you notice regarding your patients, including mental awareness and acuity.

"Evaluation of orientation and level of awareness is a core component of any hospitalist's daily evaluation," said Tara Scribner, MD, an internal medicine hospitalist, The University of Vermont Medical Center; associate program director for POCUS and Procedure Curriculum, UVMMC Internal Medicine Residency Program; and an assistant professor, Robert Larner, M.D. College of Medicine, Burlington, Vermont. "Beyond this, a broader assessment of executive function and functional abilities always occurs at some point during a hospital admission as discharge location and situation depends on this."

While it's relatively easy to identify signs of dementia using information from collateral sources, she also noted it's often difficult to determine whether a patient is experiencing progressive dementia or a more acute encephalopathy such as delirium if collateral sources are not available.

"Once a baseline has been established, hospitalists are in a unique position to identify subtle and acute shifts in mental acuity over the course of a hospital stay," Scribner said. "Unlike our primary care colleagues, who are well-positioned to observe for signs of dementia, we see our patients on a daily basis, sometimes more than once daily, and can track changes which occur over a matter of hours or days."

What Are Signs to Watch

During examinations and assessments, pay attention to shifts in the behavior of patients.

"Subtle signs of delirium and/or declining mental awareness can include disorientation about date, location, reason for admission," said Meghana R. Medavaram, MD, associate director of Consultation Liaison and Emergency Psychiatry, Weiler Hospital at Montefiore Health System in Bronx, New York.

Another sign would be mild inattention, such as drifting off during conversations or even having a hard time understanding and following multistep commands, she also said.

"We can also see sudden irritability or even the opposite, odd politeness or familiarity. We notice these changes occur as fluctuations throughout the day, sometimes with a clinician seeing a different 'personality' in the morning vs afternoon or evening," Medavaram said. "A key message we emphasize for our hospitalist colleagues is to not wait for overt agitation, or hallucinations to step in when assessing a patient and coming up with a treatment plan."

How Would Diet Play a Role

Excess consumption of alcohol is the most common way a patient's diet can affect changes in mental status, said Scribner. "Excess alcohol use has been linked to a significantly increased risk of dementia including both Alzheimer's and to alcohol-related brain damage including Korsakoff syndrome, as well as to the more acute Wernicke encephalopathy through vitamin B1 deficiency."

Also, vitamin deficiencies such as B12 have been linked to development of dementia and other cognitive impairment and can be related to alcohol consumption as well as to dietary habits such as vegetarianism, even in the absence of alcohol intake. Identification and treatment of B12 deficiency is a potentially reversible cause of cognitive impairment, she also said.

Do Medications Affect Mental State

Medications can be a significant cause of acute changes in mental status. "These changes are often reversible and include somnolence and both hypoactive and hyperactive delirium. Adjustment of a patient's usual medications is often necessary in hospitalized patients experiencing acute encephalopathy," Scribner said.

What About Depression

The relationship between dementia and development of dementia is complex and poorly understood, she said, however, those who deal with depression are at a higher risk of developing dementia, and also that patients with dementia are at a higher risk for development of depression.

How to Distinguish Between Short- and Long-term Issues

A thorough hospitalist is typically able to identify the acuity of mental status changes by the time of discharge and therefore predict the likelihood of recovery.

Progressive mental status changes occurring over months to years are almost always representative of dementia and are irreversible, whereas most (but not all) acute encephalopathies are recoverable over days to weeks or months.

Determining which of these is present involves interrogation of collateral sources such as family and friends, assessment of orientation and other signs of delirium, and observation of recovery during the period of hospital admission. It is worth noting that episodes of delirium are associated with a higher risk for long-term cognitive decline and development of dementia.

Written by Erica Lamberg.

A version of this article first appeared on Medscape.com.

According to the National Institute on Drug Abuse, > 1 in 10 veterans have been diagnosed with substance use disorder (SUD). Additionally, 7 out of every 100 veterans will have posttraumatic stress disorder (PTSD) at some point in their life, per research from the US Department of Veterans Affairs (VA). However, a common and perhaps unsuspected parallel is found in those statistics: loneliness.

Of the 4069 veterans who participated in the 2019-2020 National Health and Resilience in Veterans Survey, 56.9% reported they felt lonely sometimes or often, while 1 in 5 reported feeling lonely often.

An Epidemic

In his 2023 advisory, Former US Surgeon General Vivek Murthy called it an epidemic noting that when he spoke with veterans during a cross-country listening tour, he heard how they felt “isolated, invisible, and insignificant.” About 1 in 2 adults in America experience loneliness, even before the COVID-19 pandemic isolation.

Loneliness can have individual and synergistic ill effects, including a greater risk of cardiovascular disease, dementia, stroke, depression, anxiety, and premature death. It also can both trigger and exacerbate substance use and PTSD.

A study using data from the RAND Health and Retirement Study Longitudinal File 2020 (N = 5259) found significant associations between loneliness and being unmarried/unpartnered, and greater depressive symptoms for both veterans and civilians, as well as significant negative associations between loneliness and greater life satisfaction and positive affect. Health conditions that limited an individual's ability to work was a “unique risk factor for loneliness among veterans.”

The National Health and Resilience in Veterans Study found that those aged ≤ 50 years were 3 times more likely to screen positive for PTSD compared to older veterans. In a survey of 409 veterans, many who engaged in problematic substance use during the COVID-19 pandemic reported that despite having social supports they still felt lonely. In regression analyses, higher levels of loneliness were associated with more negative impacts of the pandemic, greater substance use, and poorer physical and mental health functioning.

Addressing Loneliness

Researchers believe an answer to some mental health and substance abuse problems may lie in addressing loneliness. Positive psychology is providing promising results in the treatment of SUD. Bryant Stone, from the Johns Hopkins Bloomberg School of Public Health, emphasizes focusing on well-being and quality of life rather than solely on abstinence with “positive psychological interventions,” or activities and behavioral interventions that target positive variables to promote adaptive functioning.

Veterans can face tough challenges as they rejoin civilian life. How successfully they meet and conquer those challenges, especially if they include drug problems, may directly relate to their general feeling of well-being.

The PERMA model outlines 5 core elements to assess well-being: Positive emotions, Engagement, Relationships, Meaning, and Accomplishment. A study based on that model found loneliness to be a “particularly significant factor” among key variables influencing the prevention and treatment of SUDs. The study of 156 veterans with self-reported mental health conditions found the ability to engage in social roles and activities was positively correlated with overall well-being and negatively correlated with degree of problems related to drug abuse. 

Rural Veterans

The estimated 4.4 million veterans living in rural communities may benefit most from interventions that tackle isolation. Compared with urban counterparts, they’re more likely to be older, have more complex medical issues, have a service-connected disability, and be unemployed. Those factors, compounded by geographical and social isolation, can have a substantial impact on well-being.

A study centered on the initial validation of a short (5-item) version of PERMA found that individuals who scored higher on the short form tended to report higher levels of optimism, resilience, and happiness. Thus, the short form may be particularly useful for rural veterans who do not always have easy access to health care.

VA has instituted a variety of programs to encourage and support social connection. During the COVID-19 pandemic, telehealth interventions targeted social support and loneliness among veterans—albeit with mixed results. VA CONNECT, a 10-session group telehealth intervention that integrated peer support, did not show significant changes in loneliness, but did significantly reduce perceived stress. 

Another initiative, Compassionate Contact Corps, trained volunteers made weekly phone calls aimed at reducing loneliness and fostering social connection. Started in Columbus, Ohio, in 2020, > 80 sites had adopted the initiative by 2021, with 310 volunteers, 5320 visits, and 4757 hours spent with veterans.

In 2014, VA peer specialists developed and co-hosted Veterans Socials through community partnerships between VA, veteran-serving organizations, and veteran community leaders. As of 2025, 178 known Veterans Socials were spread across 26 states and territories.

The researchers say their case examples collectively demonstrate that Veterans Socials have the potential to serve as a vital platform for peer support, resource sharing, and health service use among veterans. Virtual Veterans Socials also provided hosts with a channel to reach potentially isolated veterans who might not otherwise access services while simultaneously offering veterans an opportunity for social connection.

According to the National Institute on Drug Abuse, > 1 in 10 veterans have been diagnosed with substance use disorder (SUD). Additionally, 7 out of every 100 veterans will have posttraumatic stress disorder (PTSD) at some point in their life, per research from the US Department of Veterans Affairs (VA). However, a common and perhaps unsuspected parallel is found in those statistics: loneliness.

Of the 4069 veterans who participated in the 2019-2020 National Health and Resilience in Veterans Survey, 56.9% reported they felt lonely sometimes or often, while 1 in 5 reported feeling lonely often.

An Epidemic

In his 2023 advisory, Former US Surgeon General Vivek Murthy called it an epidemic noting that when he spoke with veterans during a cross-country listening tour, he heard how they felt “isolated, invisible, and insignificant.” About 1 in 2 adults in America experience loneliness, even before the COVID-19 pandemic isolation.

Loneliness can have individual and synergistic ill effects, including a greater risk of cardiovascular disease, dementia, stroke, depression, anxiety, and premature death. It also can both trigger and exacerbate substance use and PTSD.

A study using data from the RAND Health and Retirement Study Longitudinal File 2020 (N = 5259) found significant associations between loneliness and being unmarried/unpartnered, and greater depressive symptoms for both veterans and civilians, as well as significant negative associations between loneliness and greater life satisfaction and positive affect. Health conditions that limited an individual's ability to work was a “unique risk factor for loneliness among veterans.”

The National Health and Resilience in Veterans Study found that those aged ≤ 50 years were 3 times more likely to screen positive for PTSD compared to older veterans. In a survey of 409 veterans, many who engaged in problematic substance use during the COVID-19 pandemic reported that despite having social supports they still felt lonely. In regression analyses, higher levels of loneliness were associated with more negative impacts of the pandemic, greater substance use, and poorer physical and mental health functioning.

Addressing Loneliness

Researchers believe an answer to some mental health and substance abuse problems may lie in addressing loneliness. Positive psychology is providing promising results in the treatment of SUD. Bryant Stone, from the Johns Hopkins Bloomberg School of Public Health, emphasizes focusing on well-being and quality of life rather than solely on abstinence with “positive psychological interventions,” or activities and behavioral interventions that target positive variables to promote adaptive functioning.

Veterans can face tough challenges as they rejoin civilian life. How successfully they meet and conquer those challenges, especially if they include drug problems, may directly relate to their general feeling of well-being.

The PERMA model outlines 5 core elements to assess well-being: Positive emotions, Engagement, Relationships, Meaning, and Accomplishment. A study based on that model found loneliness to be a “particularly significant factor” among key variables influencing the prevention and treatment of SUDs. The study of 156 veterans with self-reported mental health conditions found the ability to engage in social roles and activities was positively correlated with overall well-being and negatively correlated with degree of problems related to drug abuse. 

Rural Veterans

The estimated 4.4 million veterans living in rural communities may benefit most from interventions that tackle isolation. Compared with urban counterparts, they’re more likely to be older, have more complex medical issues, have a service-connected disability, and be unemployed. Those factors, compounded by geographical and social isolation, can have a substantial impact on well-being.

A study centered on the initial validation of a short (5-item) version of PERMA found that individuals who scored higher on the short form tended to report higher levels of optimism, resilience, and happiness. Thus, the short form may be particularly useful for rural veterans who do not always have easy access to health care.

VA has instituted a variety of programs to encourage and support social connection. During the COVID-19 pandemic, telehealth interventions targeted social support and loneliness among veterans—albeit with mixed results. VA CONNECT, a 10-session group telehealth intervention that integrated peer support, did not show significant changes in loneliness, but did significantly reduce perceived stress. 

Another initiative, Compassionate Contact Corps, trained volunteers made weekly phone calls aimed at reducing loneliness and fostering social connection. Started in Columbus, Ohio, in 2020, > 80 sites had adopted the initiative by 2021, with 310 volunteers, 5320 visits, and 4757 hours spent with veterans.

In 2014, VA peer specialists developed and co-hosted Veterans Socials through community partnerships between VA, veteran-serving organizations, and veteran community leaders. As of 2025, 178 known Veterans Socials were spread across 26 states and territories.

The researchers say their case examples collectively demonstrate that Veterans Socials have the potential to serve as a vital platform for peer support, resource sharing, and health service use among veterans. Virtual Veterans Socials also provided hosts with a channel to reach potentially isolated veterans who might not otherwise access services while simultaneously offering veterans an opportunity for social connection.

According to the National Institute on Drug Abuse, > 1 in 10 veterans have been diagnosed with substance use disorder (SUD). Additionally, 7 out of every 100 veterans will have posttraumatic stress disorder (PTSD) at some point in their life, per research from the US Department of Veterans Affairs (VA). However, a common and perhaps unsuspected parallel is found in those statistics: loneliness.

Of the 4069 veterans who participated in the 2019-2020 National Health and Resilience in Veterans Survey, 56.9% reported they felt lonely sometimes or often, while 1 in 5 reported feeling lonely often.

An Epidemic

In his 2023 advisory, Former US Surgeon General Vivek Murthy called it an epidemic noting that when he spoke with veterans during a cross-country listening tour, he heard how they felt “isolated, invisible, and insignificant.” About 1 in 2 adults in America experience loneliness, even before the COVID-19 pandemic isolation.

Loneliness can have individual and synergistic ill effects, including a greater risk of cardiovascular disease, dementia, stroke, depression, anxiety, and premature death. It also can both trigger and exacerbate substance use and PTSD.

A study using data from the RAND Health and Retirement Study Longitudinal File 2020 (N = 5259) found significant associations between loneliness and being unmarried/unpartnered, and greater depressive symptoms for both veterans and civilians, as well as significant negative associations between loneliness and greater life satisfaction and positive affect. Health conditions that limited an individual's ability to work was a “unique risk factor for loneliness among veterans.”

The National Health and Resilience in Veterans Study found that those aged ≤ 50 years were 3 times more likely to screen positive for PTSD compared to older veterans. In a survey of 409 veterans, many who engaged in problematic substance use during the COVID-19 pandemic reported that despite having social supports they still felt lonely. In regression analyses, higher levels of loneliness were associated with more negative impacts of the pandemic, greater substance use, and poorer physical and mental health functioning.

Addressing Loneliness

Researchers believe an answer to some mental health and substance abuse problems may lie in addressing loneliness. Positive psychology is providing promising results in the treatment of SUD. Bryant Stone, from the Johns Hopkins Bloomberg School of Public Health, emphasizes focusing on well-being and quality of life rather than solely on abstinence with “positive psychological interventions,” or activities and behavioral interventions that target positive variables to promote adaptive functioning.

Veterans can face tough challenges as they rejoin civilian life. How successfully they meet and conquer those challenges, especially if they include drug problems, may directly relate to their general feeling of well-being.

The PERMA model outlines 5 core elements to assess well-being: Positive emotions, Engagement, Relationships, Meaning, and Accomplishment. A study based on that model found loneliness to be a “particularly significant factor” among key variables influencing the prevention and treatment of SUDs. The study of 156 veterans with self-reported mental health conditions found the ability to engage in social roles and activities was positively correlated with overall well-being and negatively correlated with degree of problems related to drug abuse. 

Rural Veterans

The estimated 4.4 million veterans living in rural communities may benefit most from interventions that tackle isolation. Compared with urban counterparts, they’re more likely to be older, have more complex medical issues, have a service-connected disability, and be unemployed. Those factors, compounded by geographical and social isolation, can have a substantial impact on well-being.

A study centered on the initial validation of a short (5-item) version of PERMA found that individuals who scored higher on the short form tended to report higher levels of optimism, resilience, and happiness. Thus, the short form may be particularly useful for rural veterans who do not always have easy access to health care.

VA has instituted a variety of programs to encourage and support social connection. During the COVID-19 pandemic, telehealth interventions targeted social support and loneliness among veterans—albeit with mixed results. VA CONNECT, a 10-session group telehealth intervention that integrated peer support, did not show significant changes in loneliness, but did significantly reduce perceived stress. 

Another initiative, Compassionate Contact Corps, trained volunteers made weekly phone calls aimed at reducing loneliness and fostering social connection. Started in Columbus, Ohio, in 2020, > 80 sites had adopted the initiative by 2021, with 310 volunteers, 5320 visits, and 4757 hours spent with veterans.

In 2014, VA peer specialists developed and co-hosted Veterans Socials through community partnerships between VA, veteran-serving organizations, and veteran community leaders. As of 2025, 178 known Veterans Socials were spread across 26 states and territories.

The researchers say their case examples collectively demonstrate that Veterans Socials have the potential to serve as a vital platform for peer support, resource sharing, and health service use among veterans. Virtual Veterans Socials also provided hosts with a channel to reach potentially isolated veterans who might not otherwise access services while simultaneously offering veterans an opportunity for social connection.

Nearly half of physicians in Canada report high levels of burnout, according to preliminary data from the 2025 National Physician Health Survey (NPHS). The new data show that 46% of physicians report high levels of burnout, down from 2021 (53%) but significantly above the level of 2017 (30%), when the first survey was conducted. The full NPHS 2025 Foundational Report will be released later this year.

Other significant findings include the following:

• 74% of physicians reported experiencing bullying, harassment, microaggressions, or discrimination, a slight but meaningful reduction form 78% in 2021.
• 64% of physicians reported spending significant time on electronic medical records outside regular hours.
• 46% of physicians said that their mental health is worse than it was before the start of the pandemic, down 14% from 2021.
• 60% reported being satisfied or very satisfied with work-life balance, an improvement from 49% in 2021, though slightly below 2017 (62%).
• 37% of physicians plan to reduce their clinical hours in the next 2 years.

Margot Burnell, MD, president of the Canadian Medical Association (CMA), told Medscape Medical News that she was "disappointed" with the results.

"I hoped that the burnout numbers would decrease more than they have," she said. "Physicians are still under extreme stress in trying to provide the care for patients that they wish to give."

Reductions in Hours

The most distressing finding is that > one-third of physicians (37%) plan to reduce their hours within 24 hours -- at a time of growing physician shortages -- said Burnell.

"The one positive (finding) that stands out is that physicians are taking care of their own health and wellness and report that it's helping," she said. About 65% of physicians reported having accessed at least 1 wellness support in the past 5 years, up 11% since 2021.

The NPHS includes responses from about 3300 practicing physicians, medical residents, and fellows who were surveyed from March 14 to April 15.

Among the CMA's top priorities is to reduce the administrative burden because that tops the list of what physicians say would help them with burnout, said Burnell.

"The other area is to provide and encourage team-based care," she continued. "That provides some relief for physicians." It also is important to promote the approaches that seem to be helping, such as wellness support and artificial intelligence (AI), she said. In this survey, 59% of respondents who used AI said that it decreased their time spent on administrative tasks.

Burnout by Specialty

Future analyses will examine burnout by specialty, Burnell said. Burnout is particularly high among emergency physicians, regardless of province, according to previous work by Kerstin de Wit, MD, emergency physician and research director for the Department of Emergency Medicine at Queen's University in Kingston, Ontario, and colleagues.

The NPHS findings are not surprising, she told Medscape Medical News. "We resurveyed all our emergency physicians in January and found similar results, in that the levels of burnout were marginally less than they were in 2022 but still significantly higher than they were in 2020. Still, a majority of (emergency department) physicians qualify as having high burnout levels."

The Pandemic's Role

A telling finding of her team's research is that emergency physician burnout levels are now higher than they were in December 2020, the first year of the COVID pandemic, said De Wit. "I don't think you can say burnout is because of COVID. It's because of the problems in the medical system."

Among those problems in hospitals are a shortage of beds, physicians, and nurses and inadequate numbers of physicians in outpatient clinics "so patients are waiting for years" for conditions to be treated, she added.

"We don't have the resources that we need to maintain the standards that we had even 10, 15 years ago. The whole system is collapsing. Government underfunding is huge. Routinely, our emergency department is 100% full of ward patients, so we don't have a room with a door or a curtain to see patients in. All the emergency patients are seen in corridors or the waiting room in full view of everyone else. We have people with serious medical conditions who are dying in waiting rooms because we can't get them in."

The issues are complex, but the overarching problem is chronic underfunding that results in physicians "feeling overworked and powerless to help patients," said De Wit.

Burnell and de Wit reported having no relevant financial relationships.

Marcia Frellick is an independent health care journalist and a regular contributor to Medscape Medical News.

A version of this article first appeared on Medscape.com.

Nearly half of physicians in Canada report high levels of burnout, according to preliminary data from the 2025 National Physician Health Survey (NPHS). The new data show that 46% of physicians report high levels of burnout, down from 2021 (53%) but significantly above the level of 2017 (30%), when the first survey was conducted. The full NPHS 2025 Foundational Report will be released later this year.

Other significant findings include the following:

• 74% of physicians reported experiencing bullying, harassment, microaggressions, or discrimination, a slight but meaningful reduction form 78% in 2021.
• 64% of physicians reported spending significant time on electronic medical records outside regular hours.
• 46% of physicians said that their mental health is worse than it was before the start of the pandemic, down 14% from 2021.
• 60% reported being satisfied or very satisfied with work-life balance, an improvement from 49% in 2021, though slightly below 2017 (62%).
• 37% of physicians plan to reduce their clinical hours in the next 2 years.

Margot Burnell, MD, president of the Canadian Medical Association (CMA), told Medscape Medical News that she was "disappointed" with the results.

"I hoped that the burnout numbers would decrease more than they have," she said. "Physicians are still under extreme stress in trying to provide the care for patients that they wish to give."

Reductions in Hours

The most distressing finding is that > one-third of physicians (37%) plan to reduce their hours within 24 hours -- at a time of growing physician shortages -- said Burnell.

"The one positive (finding) that stands out is that physicians are taking care of their own health and wellness and report that it's helping," she said. About 65% of physicians reported having accessed at least 1 wellness support in the past 5 years, up 11% since 2021.

The NPHS includes responses from about 3300 practicing physicians, medical residents, and fellows who were surveyed from March 14 to April 15.

Among the CMA's top priorities is to reduce the administrative burden because that tops the list of what physicians say would help them with burnout, said Burnell.

"The other area is to provide and encourage team-based care," she continued. "That provides some relief for physicians." It also is important to promote the approaches that seem to be helping, such as wellness support and artificial intelligence (AI), she said. In this survey, 59% of respondents who used AI said that it decreased their time spent on administrative tasks.

Burnout by Specialty

Future analyses will examine burnout by specialty, Burnell said. Burnout is particularly high among emergency physicians, regardless of province, according to previous work by Kerstin de Wit, MD, emergency physician and research director for the Department of Emergency Medicine at Queen's University in Kingston, Ontario, and colleagues.

The NPHS findings are not surprising, she told Medscape Medical News. "We resurveyed all our emergency physicians in January and found similar results, in that the levels of burnout were marginally less than they were in 2022 but still significantly higher than they were in 2020. Still, a majority of (emergency department) physicians qualify as having high burnout levels."

The Pandemic's Role

A telling finding of her team's research is that emergency physician burnout levels are now higher than they were in December 2020, the first year of the COVID pandemic, said De Wit. "I don't think you can say burnout is because of COVID. It's because of the problems in the medical system."

Among those problems in hospitals are a shortage of beds, physicians, and nurses and inadequate numbers of physicians in outpatient clinics "so patients are waiting for years" for conditions to be treated, she added.

"We don't have the resources that we need to maintain the standards that we had even 10, 15 years ago. The whole system is collapsing. Government underfunding is huge. Routinely, our emergency department is 100% full of ward patients, so we don't have a room with a door or a curtain to see patients in. All the emergency patients are seen in corridors or the waiting room in full view of everyone else. We have people with serious medical conditions who are dying in waiting rooms because we can't get them in."

The issues are complex, but the overarching problem is chronic underfunding that results in physicians "feeling overworked and powerless to help patients," said De Wit.

Burnell and de Wit reported having no relevant financial relationships.

Marcia Frellick is an independent health care journalist and a regular contributor to Medscape Medical News.

A version of this article first appeared on Medscape.com.

Nearly half of physicians in Canada report high levels of burnout, according to preliminary data from the 2025 National Physician Health Survey (NPHS). The new data show that 46% of physicians report high levels of burnout, down from 2021 (53%) but significantly above the level of 2017 (30%), when the first survey was conducted. The full NPHS 2025 Foundational Report will be released later this year.

Other significant findings include the following:

• 74% of physicians reported experiencing bullying, harassment, microaggressions, or discrimination, a slight but meaningful reduction form 78% in 2021.
• 64% of physicians reported spending significant time on electronic medical records outside regular hours.
• 46% of physicians said that their mental health is worse than it was before the start of the pandemic, down 14% from 2021.
• 60% reported being satisfied or very satisfied with work-life balance, an improvement from 49% in 2021, though slightly below 2017 (62%).
• 37% of physicians plan to reduce their clinical hours in the next 2 years.

Margot Burnell, MD, president of the Canadian Medical Association (CMA), told Medscape Medical News that she was "disappointed" with the results.

"I hoped that the burnout numbers would decrease more than they have," she said. "Physicians are still under extreme stress in trying to provide the care for patients that they wish to give."

Reductions in Hours

The most distressing finding is that > one-third of physicians (37%) plan to reduce their hours within 24 hours -- at a time of growing physician shortages -- said Burnell.

"The one positive (finding) that stands out is that physicians are taking care of their own health and wellness and report that it's helping," she said. About 65% of physicians reported having accessed at least 1 wellness support in the past 5 years, up 11% since 2021.

The NPHS includes responses from about 3300 practicing physicians, medical residents, and fellows who were surveyed from March 14 to April 15.

Among the CMA's top priorities is to reduce the administrative burden because that tops the list of what physicians say would help them with burnout, said Burnell.

"The other area is to provide and encourage team-based care," she continued. "That provides some relief for physicians." It also is important to promote the approaches that seem to be helping, such as wellness support and artificial intelligence (AI), she said. In this survey, 59% of respondents who used AI said that it decreased their time spent on administrative tasks.

Burnout by Specialty

Future analyses will examine burnout by specialty, Burnell said. Burnout is particularly high among emergency physicians, regardless of province, according to previous work by Kerstin de Wit, MD, emergency physician and research director for the Department of Emergency Medicine at Queen's University in Kingston, Ontario, and colleagues.

The NPHS findings are not surprising, she told Medscape Medical News. "We resurveyed all our emergency physicians in January and found similar results, in that the levels of burnout were marginally less than they were in 2022 but still significantly higher than they were in 2020. Still, a majority of (emergency department) physicians qualify as having high burnout levels."

The Pandemic's Role

A telling finding of her team's research is that emergency physician burnout levels are now higher than they were in December 2020, the first year of the COVID pandemic, said De Wit. "I don't think you can say burnout is because of COVID. It's because of the problems in the medical system."

Among those problems in hospitals are a shortage of beds, physicians, and nurses and inadequate numbers of physicians in outpatient clinics "so patients are waiting for years" for conditions to be treated, she added.

"We don't have the resources that we need to maintain the standards that we had even 10, 15 years ago. The whole system is collapsing. Government underfunding is huge. Routinely, our emergency department is 100% full of ward patients, so we don't have a room with a door or a curtain to see patients in. All the emergency patients are seen in corridors or the waiting room in full view of everyone else. We have people with serious medical conditions who are dying in waiting rooms because we can't get them in."

The issues are complex, but the overarching problem is chronic underfunding that results in physicians "feeling overworked and powerless to help patients," said De Wit.

Burnell and de Wit reported having no relevant financial relationships.

Marcia Frellick is an independent health care journalist and a regular contributor to Medscape Medical News.

A version of this article first appeared on Medscape.com.

Dear colleagues,

Since our last Perspectives feature on artificial intelligence (AI) in gastroenterology and hepatology, the field has experienced remarkable growth in both innovation and clinical adoption. AI tools that were once conceptual are now entering everyday practice, with many more on the horizon poised to transform how we diagnose, treat, and manage patients. In this issue of Perspectives, we present two timely essays that explore how AI is reshaping clinical care—while also emphasizing the need for caution, thoughtful integration, and ongoing oversight.

Dr. Yuvaraj Singh, Dr. Alessandro Colletta, and Dr. Neil Marya discuss how purpose-built AI models can reduce diagnostic uncertainty in advanced endoscopy. From cholangioscopy systems that outperform standard ERCP sampling in distinguishing malignant biliary strictures to EUS-based platforms that differentiate autoimmune pancreatitis from pancreatic cancer, they envision a near-term future in which machine intelligence enhances accuracy, accelerates decision-making, and refines interpretation—without replacing the clinician’s expertise.

Complementing this, Dr. Dennis Shung takes a broader view across the endoscopy unit and outpatient clinic. He highlights the promise of AI for polyp detection, digital biopsy, and automated reporting, while underscoring the importance of human oversight, workflow integration, and safeguards against misinformation. Dr. Shung also emphasizes the pivotal role professional societies can play in establishing clear standards, ethical boundaries, and trusted frameworks for AI deployment in GI practice.

We hope these perspectives spark practical conversations about when—and how—to integrate AI in your own practice. As always, we welcome your feedback and real-world experience. Join the conversation on X at @AGA_GIHN.

Gyanprakash A. Ketwaroo, MD, MSc, is associate professor of medicine, Yale University, New Haven, and chief of endoscopy at West Haven VA Medical Center, both in Connecticut. He is an associate editor for GI & Hepatology News.

AI Models in Advanced Endoscopy

BY YUVARAJ SINGH, MD; ALESSANDRO COLLETTA, MD; NEIL MARYA, MD

As the adage goes, “if tumor is the rumor, then tissue is the issue, because cancer may be the answer.”

Establishing an accurate diagnosis is the essential first step toward curing or palliating malignancy. From detecting an early neoplastic lesion, to distinguishing between malignant and benign pathology, or to determining when and where to obtain tissue, endoscopists are frequently faced with the challenge of transforming diagnostic suspicion into certainty.

Artificial intelligence (AI), designed to replicate human cognition such as pattern recognition and decision-making, has emerged as a technology to assist gastroenterologists in addressing a variety of different tasks during endoscopy. AI research in gastrointestinal endoscopy has initially focused on computer-aided detection (CADe) of colorectal polyps. More recently, however, there has been increased emphasis on developing AI to assist advanced endoscopists.

For instance, in biliary endoscopy, AI is being explored to improve the notoriously challenging diagnosis of cholangiocarcinoma, where conventional tissue sampling often falls short of providing a definitive diagnosis. Similarly, in the pancreas, AI models are showing potential to differentiate autoimmune pancreatitis (AIP) from pancreatic ductal adenocarcinoma (PDAC), a distinction with profound therapeutic implications. Even pancreatic cysts are beginning to benefit from AI models that refine risk stratification and guide management. Together, these advances underscore how AI is not merely an adjunct but a potentially massive catalyst for reimagining the diagnostic role of advanced endoscopists.

Classifying biliary strictures (MBS) accurately remains a challenge. Standard ERCP-based sampling techniques (forceps biopsy and brush cytology) are suboptimal diagnostic tools with false negative rates for detecting MBS of less than 50%. The diagnostic uncertainty related to biliary stricture classification carries significant consequences for patients. For example, patients with biliary cancer without positive cytology have treatments delayed until a malignant diagnosis is established. 

Ancillary technologies to enhance ERCP-based tissue acquisition are still weighed down by low sensitivity and accuracy; even with ancillary use of fluorescent in situ hybridization (FISH), diagnostic yield remains limited. EUS-FNA can help with distal biliary strictures, but this technique risks needle-tract seeding in cases of perihilar disease. Cholangioscopy allows for direct visualization and targeted sampling; however, cholangioscopy-guided forceps biopsies are burdened by low sensitivities.¹ Additionally, physician interpretation of visual findings during cholangioscopy often suffers from poor interobserver agreement and poor accuracy.²

To improve the classification of biliary strictures, several groups have studied the application of AI for cholangioscopy footage of biliary pathology. In our lab, we trained an AI incorporating over 2.3 million cholangioscopy still images and nearly 20,000 expert-annotated frames to enhance its development. The AI closely mirrored expert labeling of cholangioscopy images of malignant pathology and, when tested on full cholangioscopy videos of indeterminate biliary strictures, the AI achieved a diagnostic accuracy of 91%—outperforming both brush cytology (63%) and forceps biopsy (61%).³

The results from this initial study were later validated across multiple centers. AI-assisted cholangioscopy could thus offer a reproducible, real-world solution to one of the most persistent diagnostic dilemmas advanced endoscopists face—helping clinicians act earlier and with greater confidence when evaluating indeterminate strictures.

Moving from the biliary tree to the pancreas, autoimmune pancreatitis (AIP) is a benign fibro-inflammatory disease that often frustrates advanced endoscopists as it closely mimics the appearance of pancreatic ductal adenocarcinoma (PDAC). The stakes are high: despite modern diagnostic techniques, including advanced imaging, some patients with pancreatic resections for “suspected PDAC” are still found to have AIP on final pathology. Conventional tools to distinguish AIP from PDAC have gaps: serum IgG4 and EUS-guided biopsies are both specific but insensitive.

Using EUS videos and images of various pancreas pathologies at Mayo Clinic, we developed an AI to tackle this dilemma. After intensive training, the EUS AI achieved a greater accuracy for distinguishing AIP from PDAC than a group of expert Mayo clinic endosonographers.⁵ In practice, an EUS-AI can identify AIP patterns in real-time, guiding clinicians toward steroid trials or biopsies and reducing the need for unnecessary surgeries.

Looking ahead, there are multiple opportunities for integration of AI into advanced endoscopy practices. Ongoing research suggests that AI could soon assist with identification of pancreas cysts most at risk for malignant transformation, classification of high risk Barrett’s esophagus, and even help with rapid on-site assessment of cytologic specimens obtained during EUS. Beyond diagnosis, AI could likely play an important role in guiding therapeutic interventions. For example, an ERCP AI in the future may be able to provide cannulation assistance or an AI assistant could help endosonographers during deployments of lumen apposing metal stents.

By enhancing image interpretation and procedural consistency, AI has the potential to uphold the fundamental principle of primum non nocere, enabling us to intervene with precision while minimizing harm. AI can also bridge grey zones in clinical practice and narrow diagnostic uncertainty in real time. Importantly, these systems can help clinicians achieve expertise in a fraction of the time it traditionally takes to acquire comparable human proficiency, while offering wider availability across practice settings and reducing interobserver variability that has long challenged endoscopic interpretation.

Currently, adoption is limited by high bias risk, lack of external validation, and interpretability Still, the trajectory of AI suggests a future where these computer technologies will not only support but also elevate human expertise, reshaping the standards of care of diseases managed by advanced endoscopists.

Dr. Singh, Dr. Colletta, and Dr. Marya are based at the Division of Gastroenterology and Hepatology, UMass Chan Medical School, Worcester, Massachusetts. Dr. Marya is a consultant for Boston Scientific, and has no other disclosures. Dr. Singh and Dr. Colletta have no disclosures.

References

1. Navaneethan U, et al. Comparative effectiveness of biliary brush cytology and intraductal biopsy for detection of malignant biliary strictures: a systematic review and meta-analysis. Gastrointest Endosc. 2015 Jan. doi: 10.1016/j.gie.2014.09.017.

2. Stassen PMC, et al. Diagnostic accuracy and interobserver agreement of digital single-operator cholangioscopy for indeterminate biliary strictures. Gastrointest Endosc 2021 Dec. doi: 10.1016/j.gie.2021.06.027.

3. Marya NB, et al. Identification of patients with malignant biliary strictures using a cholangioscopy-based deep learning artificial intelligence (with video). Gastrointest Endosc. 2023 Feb. doi: 10.1016/j.gie.2022.08.021.

4. Marya NB, et al. Multicenter validation of a cholangioscopy artificial intelligence system for the evaluation of biliary tract disease. Endoscopy. 2025 Aug. doi: 10.1055/a-2650-0789.

5. Marya NB, et al. Utilisation of artificial intelligence for the development of an EUS-convolutional neural network model trained to enhance the diagnosis of autoimmune pancreatitis. Gut. 2021 Jul. doi: 10.1136/gutjnl-2020-322821.

AI in General GI and Endoscopy

BY DENNIS L. SHUNG, MD, MHS, PHD

The practice of gastroenterology is changing, but much of it will be rooted in the same – careful, focused attention on endoscopic procedures, and compassionate, attentive care in clinic. Artificial intelligence (AI), like the Industrial Revolution before, is going to transform our practice. This comes with upsides and downsides, and highlights the need for strong leadership from our societies to safeguard the technology for practitioners and patients.

What are the upsides? 

AI has the potential to serve as a second set of eyes in detecting colon polyps, increasing the adenoma detection rate (ADR).¹ AI can be applied to all areas of the gastrointestinal tract, providing digital biopsies, guiding resection, and ensuring quality, which are all now possible with powerful new endoscopy foundation models, such as GastroNet-5M.²

Additionally. the advent of automating the collection of data into reports may herald the end of our days as data entry clerks. Generative AI also has the potential to give us all the best information at our fingertips, suggesting guideline-based care, providing the most up to date evidence, and guiding the differential diagnosis. The potential for patient-facing AI systems could lead to better health literacy, more meaningful engagement, and improved patient satisfaction.³

What are the downsides? 

For endoscopy, AI cannot make up for poor technique to ensure adequate mucosal exposure by the endoscopist, and an increase in AI-supported ADR does not yet convincingly translate into concrete gains in colorectal cancer-related mortality. For the foreseeable future, AI cannot make a connection with the patient in front of us, which is critical in diagnosing and treating patients.

Currently, AI appears to worsen loneliness⁴, and does not necessarily deepen the bonds or provide the positive touch that can heal, and which for many of us, was the reason we became physicians. Finally, as information proliferates, the information risk to patients and providers is growing – in the future, trusted sources to monitor, curate, and guide AI will be ever more important.

 

Black Swans

As AI begins to mature, there are risks that lurk beneath the surface. When regulatory bodies begin to look at AI-assisted diagnostics or therapeutics as the new standard of care, reimbursement models may adjust, and providers may be left behind. The rapid proliferation and haphazard adoption of AI could lead to overdependence and deskilling or result in weird and as yet unknown errors that are difficult to troubleshoot.

What is the role of the GI societies? 

Specialty societies like AGA are taking leadership roles in determining the bounds of where AIs may tread, not just in providing information to their membership but also in digesting evidence and synthesizing recommendations. Societies must balance the real promise of AI in endoscopy with the practice realities for members, and provide living guidelines that reflect the consensus of members regarding scope of practice with the ability to update as new data become available.⁵

Societies also have a role as advocates for safety, taking ownership of high-quality content to prevent misinformation. AGA recently announced the development of a chat interface that will be focused on providing its members the highest quality information, and serve as a portal to identify and respond to its members’ information needs. By staying united rather than fragmenting, societies can maintain bounds to protect its members and their patients and advance areas where there is clinical need, together.

Dr. Shung is senior associate consultant, Division of Gastroenterology and Hepatology, and director of clinical generative artificial intelligence and informatics, Department of Medicine, at Mayo Clinic Rochester, Minnesota. He has no disclosures in regard to this article.

References

1. Soleymanjahi S, et al. Artificial Intelligence-Assisted Colonoscopy for Polyp Detection : A Systematic Review and Meta-analysis. Ann Intern Med. 2024 Dec. doi:10.7326/annals-24-00981.

2. Jong MR, et al. GastroNet-5M: A Multicenter Dataset for Developing Foundation Models in Gastrointestinal Endoscopy. Gastroenterology. 2025 Jul. doi: 10.1053/j.gastro.2025.07.030.

3. Soroush A, et al. Generative Artificial Intelligence in Clinical Medicine and Impact on Gastroenterology. Gastroenterology. 2025 Aug. doi: 10.1053/j.gastro.2025.03.038.

4. Mengying Fang C, et al. How AI and Human Behaviors Shape Psychosocial Effects of Extended Chatbot Use: A Longitudinal Randomized Controlled Study. arXiv e-prints. 2025 Mar. doi: 10.48550/arXiv.2503.17473.

5. Sultan S, et al. AGA Living Clinical Practice Guideline on Computer-Aided Detection-Assisted Colonoscopy. Gastroenterology. 2025 Apr. doi:10.1053/j.gastro.2025.01.002.

Dear colleagues,

Since our last Perspectives feature on artificial intelligence (AI) in gastroenterology and hepatology, the field has experienced remarkable growth in both innovation and clinical adoption. AI tools that were once conceptual are now entering everyday practice, with many more on the horizon poised to transform how we diagnose, treat, and manage patients. In this issue of Perspectives, we present two timely essays that explore how AI is reshaping clinical care—while also emphasizing the need for caution, thoughtful integration, and ongoing oversight.

Dr. Yuvaraj Singh, Dr. Alessandro Colletta, and Dr. Neil Marya discuss how purpose-built AI models can reduce diagnostic uncertainty in advanced endoscopy. From cholangioscopy systems that outperform standard ERCP sampling in distinguishing malignant biliary strictures to EUS-based platforms that differentiate autoimmune pancreatitis from pancreatic cancer, they envision a near-term future in which machine intelligence enhances accuracy, accelerates decision-making, and refines interpretation—without replacing the clinician’s expertise.

Complementing this, Dr. Dennis Shung takes a broader view across the endoscopy unit and outpatient clinic. He highlights the promise of AI for polyp detection, digital biopsy, and automated reporting, while underscoring the importance of human oversight, workflow integration, and safeguards against misinformation. Dr. Shung also emphasizes the pivotal role professional societies can play in establishing clear standards, ethical boundaries, and trusted frameworks for AI deployment in GI practice.

We hope these perspectives spark practical conversations about when—and how—to integrate AI in your own practice. As always, we welcome your feedback and real-world experience. Join the conversation on X at @AGA_GIHN.

Gyanprakash A. Ketwaroo, MD, MSc, is associate professor of medicine, Yale University, New Haven, and chief of endoscopy at West Haven VA Medical Center, both in Connecticut. He is an associate editor for GI & Hepatology News.

AI Models in Advanced Endoscopy

BY YUVARAJ SINGH, MD; ALESSANDRO COLLETTA, MD; NEIL MARYA, MD

As the adage goes, “if tumor is the rumor, then tissue is the issue, because cancer may be the answer.”

Establishing an accurate diagnosis is the essential first step toward curing or palliating malignancy. From detecting an early neoplastic lesion, to distinguishing between malignant and benign pathology, or to determining when and where to obtain tissue, endoscopists are frequently faced with the challenge of transforming diagnostic suspicion into certainty.

Artificial intelligence (AI), designed to replicate human cognition such as pattern recognition and decision-making, has emerged as a technology to assist gastroenterologists in addressing a variety of different tasks during endoscopy. AI research in gastrointestinal endoscopy has initially focused on computer-aided detection (CADe) of colorectal polyps. More recently, however, there has been increased emphasis on developing AI to assist advanced endoscopists.

For instance, in biliary endoscopy, AI is being explored to improve the notoriously challenging diagnosis of cholangiocarcinoma, where conventional tissue sampling often falls short of providing a definitive diagnosis. Similarly, in the pancreas, AI models are showing potential to differentiate autoimmune pancreatitis (AIP) from pancreatic ductal adenocarcinoma (PDAC), a distinction with profound therapeutic implications. Even pancreatic cysts are beginning to benefit from AI models that refine risk stratification and guide management. Together, these advances underscore how AI is not merely an adjunct but a potentially massive catalyst for reimagining the diagnostic role of advanced endoscopists.

Classifying biliary strictures (MBS) accurately remains a challenge. Standard ERCP-based sampling techniques (forceps biopsy and brush cytology) are suboptimal diagnostic tools with false negative rates for detecting MBS of less than 50%. The diagnostic uncertainty related to biliary stricture classification carries significant consequences for patients. For example, patients with biliary cancer without positive cytology have treatments delayed until a malignant diagnosis is established. 

Ancillary technologies to enhance ERCP-based tissue acquisition are still weighed down by low sensitivity and accuracy; even with ancillary use of fluorescent in situ hybridization (FISH), diagnostic yield remains limited. EUS-FNA can help with distal biliary strictures, but this technique risks needle-tract seeding in cases of perihilar disease. Cholangioscopy allows for direct visualization and targeted sampling; however, cholangioscopy-guided forceps biopsies are burdened by low sensitivities.¹ Additionally, physician interpretation of visual findings during cholangioscopy often suffers from poor interobserver agreement and poor accuracy.²

To improve the classification of biliary strictures, several groups have studied the application of AI for cholangioscopy footage of biliary pathology. In our lab, we trained an AI incorporating over 2.3 million cholangioscopy still images and nearly 20,000 expert-annotated frames to enhance its development. The AI closely mirrored expert labeling of cholangioscopy images of malignant pathology and, when tested on full cholangioscopy videos of indeterminate biliary strictures, the AI achieved a diagnostic accuracy of 91%—outperforming both brush cytology (63%) and forceps biopsy (61%).³

The results from this initial study were later validated across multiple centers. AI-assisted cholangioscopy could thus offer a reproducible, real-world solution to one of the most persistent diagnostic dilemmas advanced endoscopists face—helping clinicians act earlier and with greater confidence when evaluating indeterminate strictures.

Moving from the biliary tree to the pancreas, autoimmune pancreatitis (AIP) is a benign fibro-inflammatory disease that often frustrates advanced endoscopists as it closely mimics the appearance of pancreatic ductal adenocarcinoma (PDAC). The stakes are high: despite modern diagnostic techniques, including advanced imaging, some patients with pancreatic resections for “suspected PDAC” are still found to have AIP on final pathology. Conventional tools to distinguish AIP from PDAC have gaps: serum IgG4 and EUS-guided biopsies are both specific but insensitive.

Using EUS videos and images of various pancreas pathologies at Mayo Clinic, we developed an AI to tackle this dilemma. After intensive training, the EUS AI achieved a greater accuracy for distinguishing AIP from PDAC than a group of expert Mayo clinic endosonographers.⁵ In practice, an EUS-AI can identify AIP patterns in real-time, guiding clinicians toward steroid trials or biopsies and reducing the need for unnecessary surgeries.

Looking ahead, there are multiple opportunities for integration of AI into advanced endoscopy practices. Ongoing research suggests that AI could soon assist with identification of pancreas cysts most at risk for malignant transformation, classification of high risk Barrett’s esophagus, and even help with rapid on-site assessment of cytologic specimens obtained during EUS. Beyond diagnosis, AI could likely play an important role in guiding therapeutic interventions. For example, an ERCP AI in the future may be able to provide cannulation assistance or an AI assistant could help endosonographers during deployments of lumen apposing metal stents.

By enhancing image interpretation and procedural consistency, AI has the potential to uphold the fundamental principle of primum non nocere, enabling us to intervene with precision while minimizing harm. AI can also bridge grey zones in clinical practice and narrow diagnostic uncertainty in real time. Importantly, these systems can help clinicians achieve expertise in a fraction of the time it traditionally takes to acquire comparable human proficiency, while offering wider availability across practice settings and reducing interobserver variability that has long challenged endoscopic interpretation.

Currently, adoption is limited by high bias risk, lack of external validation, and interpretability Still, the trajectory of AI suggests a future where these computer technologies will not only support but also elevate human expertise, reshaping the standards of care of diseases managed by advanced endoscopists.

Dr. Singh, Dr. Colletta, and Dr. Marya are based at the Division of Gastroenterology and Hepatology, UMass Chan Medical School, Worcester, Massachusetts. Dr. Marya is a consultant for Boston Scientific, and has no other disclosures. Dr. Singh and Dr. Colletta have no disclosures.

References

1. Navaneethan U, et al. Comparative effectiveness of biliary brush cytology and intraductal biopsy for detection of malignant biliary strictures: a systematic review and meta-analysis. Gastrointest Endosc. 2015 Jan. doi: 10.1016/j.gie.2014.09.017.

2. Stassen PMC, et al. Diagnostic accuracy and interobserver agreement of digital single-operator cholangioscopy for indeterminate biliary strictures. Gastrointest Endosc 2021 Dec. doi: 10.1016/j.gie.2021.06.027.

3. Marya NB, et al. Identification of patients with malignant biliary strictures using a cholangioscopy-based deep learning artificial intelligence (with video). Gastrointest Endosc. 2023 Feb. doi: 10.1016/j.gie.2022.08.021.

4. Marya NB, et al. Multicenter validation of a cholangioscopy artificial intelligence system for the evaluation of biliary tract disease. Endoscopy. 2025 Aug. doi: 10.1055/a-2650-0789.

5. Marya NB, et al. Utilisation of artificial intelligence for the development of an EUS-convolutional neural network model trained to enhance the diagnosis of autoimmune pancreatitis. Gut. 2021 Jul. doi: 10.1136/gutjnl-2020-322821.

AI in General GI and Endoscopy

BY DENNIS L. SHUNG, MD, MHS, PHD

The practice of gastroenterology is changing, but much of it will be rooted in the same – careful, focused attention on endoscopic procedures, and compassionate, attentive care in clinic. Artificial intelligence (AI), like the Industrial Revolution before, is going to transform our practice. This comes with upsides and downsides, and highlights the need for strong leadership from our societies to safeguard the technology for practitioners and patients.

What are the upsides? 

AI has the potential to serve as a second set of eyes in detecting colon polyps, increasing the adenoma detection rate (ADR).¹ AI can be applied to all areas of the gastrointestinal tract, providing digital biopsies, guiding resection, and ensuring quality, which are all now possible with powerful new endoscopy foundation models, such as GastroNet-5M.²

Additionally. the advent of automating the collection of data into reports may herald the end of our days as data entry clerks. Generative AI also has the potential to give us all the best information at our fingertips, suggesting guideline-based care, providing the most up to date evidence, and guiding the differential diagnosis. The potential for patient-facing AI systems could lead to better health literacy, more meaningful engagement, and improved patient satisfaction.³

What are the downsides? 

For endoscopy, AI cannot make up for poor technique to ensure adequate mucosal exposure by the endoscopist, and an increase in AI-supported ADR does not yet convincingly translate into concrete gains in colorectal cancer-related mortality. For the foreseeable future, AI cannot make a connection with the patient in front of us, which is critical in diagnosing and treating patients.

Currently, AI appears to worsen loneliness⁴, and does not necessarily deepen the bonds or provide the positive touch that can heal, and which for many of us, was the reason we became physicians. Finally, as information proliferates, the information risk to patients and providers is growing – in the future, trusted sources to monitor, curate, and guide AI will be ever more important.

 

Black Swans

As AI begins to mature, there are risks that lurk beneath the surface. When regulatory bodies begin to look at AI-assisted diagnostics or therapeutics as the new standard of care, reimbursement models may adjust, and providers may be left behind. The rapid proliferation and haphazard adoption of AI could lead to overdependence and deskilling or result in weird and as yet unknown errors that are difficult to troubleshoot.

What is the role of the GI societies? 

Specialty societies like AGA are taking leadership roles in determining the bounds of where AIs may tread, not just in providing information to their membership but also in digesting evidence and synthesizing recommendations. Societies must balance the real promise of AI in endoscopy with the practice realities for members, and provide living guidelines that reflect the consensus of members regarding scope of practice with the ability to update as new data become available.⁵

Societies also have a role as advocates for safety, taking ownership of high-quality content to prevent misinformation. AGA recently announced the development of a chat interface that will be focused on providing its members the highest quality information, and serve as a portal to identify and respond to its members’ information needs. By staying united rather than fragmenting, societies can maintain bounds to protect its members and their patients and advance areas where there is clinical need, together.

Dr. Shung is senior associate consultant, Division of Gastroenterology and Hepatology, and director of clinical generative artificial intelligence and informatics, Department of Medicine, at Mayo Clinic Rochester, Minnesota. He has no disclosures in regard to this article.

References

1. Soleymanjahi S, et al. Artificial Intelligence-Assisted Colonoscopy for Polyp Detection : A Systematic Review and Meta-analysis. Ann Intern Med. 2024 Dec. doi:10.7326/annals-24-00981.

2. Jong MR, et al. GastroNet-5M: A Multicenter Dataset for Developing Foundation Models in Gastrointestinal Endoscopy. Gastroenterology. 2025 Jul. doi: 10.1053/j.gastro.2025.07.030.

3. Soroush A, et al. Generative Artificial Intelligence in Clinical Medicine and Impact on Gastroenterology. Gastroenterology. 2025 Aug. doi: 10.1053/j.gastro.2025.03.038.

4. Mengying Fang C, et al. How AI and Human Behaviors Shape Psychosocial Effects of Extended Chatbot Use: A Longitudinal Randomized Controlled Study. arXiv e-prints. 2025 Mar. doi: 10.48550/arXiv.2503.17473.

5. Sultan S, et al. AGA Living Clinical Practice Guideline on Computer-Aided Detection-Assisted Colonoscopy. Gastroenterology. 2025 Apr. doi:10.1053/j.gastro.2025.01.002.

Dear colleagues,

Since our last Perspectives feature on artificial intelligence (AI) in gastroenterology and hepatology, the field has experienced remarkable growth in both innovation and clinical adoption. AI tools that were once conceptual are now entering everyday practice, with many more on the horizon poised to transform how we diagnose, treat, and manage patients. In this issue of Perspectives, we present two timely essays that explore how AI is reshaping clinical care—while also emphasizing the need for caution, thoughtful integration, and ongoing oversight.

Dr. Yuvaraj Singh, Dr. Alessandro Colletta, and Dr. Neil Marya discuss how purpose-built AI models can reduce diagnostic uncertainty in advanced endoscopy. From cholangioscopy systems that outperform standard ERCP sampling in distinguishing malignant biliary strictures to EUS-based platforms that differentiate autoimmune pancreatitis from pancreatic cancer, they envision a near-term future in which machine intelligence enhances accuracy, accelerates decision-making, and refines interpretation—without replacing the clinician’s expertise.

Complementing this, Dr. Dennis Shung takes a broader view across the endoscopy unit and outpatient clinic. He highlights the promise of AI for polyp detection, digital biopsy, and automated reporting, while underscoring the importance of human oversight, workflow integration, and safeguards against misinformation. Dr. Shung also emphasizes the pivotal role professional societies can play in establishing clear standards, ethical boundaries, and trusted frameworks for AI deployment in GI practice.

We hope these perspectives spark practical conversations about when—and how—to integrate AI in your own practice. As always, we welcome your feedback and real-world experience. Join the conversation on X at @AGA_GIHN.

Gyanprakash A. Ketwaroo, MD, MSc, is associate professor of medicine, Yale University, New Haven, and chief of endoscopy at West Haven VA Medical Center, both in Connecticut. He is an associate editor for GI & Hepatology News.

AI Models in Advanced Endoscopy

BY YUVARAJ SINGH, MD; ALESSANDRO COLLETTA, MD; NEIL MARYA, MD

As the adage goes, “if tumor is the rumor, then tissue is the issue, because cancer may be the answer.”

Establishing an accurate diagnosis is the essential first step toward curing or palliating malignancy. From detecting an early neoplastic lesion, to distinguishing between malignant and benign pathology, or to determining when and where to obtain tissue, endoscopists are frequently faced with the challenge of transforming diagnostic suspicion into certainty.

Artificial intelligence (AI), designed to replicate human cognition such as pattern recognition and decision-making, has emerged as a technology to assist gastroenterologists in addressing a variety of different tasks during endoscopy. AI research in gastrointestinal endoscopy has initially focused on computer-aided detection (CADe) of colorectal polyps. More recently, however, there has been increased emphasis on developing AI to assist advanced endoscopists.

For instance, in biliary endoscopy, AI is being explored to improve the notoriously challenging diagnosis of cholangiocarcinoma, where conventional tissue sampling often falls short of providing a definitive diagnosis. Similarly, in the pancreas, AI models are showing potential to differentiate autoimmune pancreatitis (AIP) from pancreatic ductal adenocarcinoma (PDAC), a distinction with profound therapeutic implications. Even pancreatic cysts are beginning to benefit from AI models that refine risk stratification and guide management. Together, these advances underscore how AI is not merely an adjunct but a potentially massive catalyst for reimagining the diagnostic role of advanced endoscopists.

Classifying biliary strictures (MBS) accurately remains a challenge. Standard ERCP-based sampling techniques (forceps biopsy and brush cytology) are suboptimal diagnostic tools with false negative rates for detecting MBS of less than 50%. The diagnostic uncertainty related to biliary stricture classification carries significant consequences for patients. For example, patients with biliary cancer without positive cytology have treatments delayed until a malignant diagnosis is established. 

Ancillary technologies to enhance ERCP-based tissue acquisition are still weighed down by low sensitivity and accuracy; even with ancillary use of fluorescent in situ hybridization (FISH), diagnostic yield remains limited. EUS-FNA can help with distal biliary strictures, but this technique risks needle-tract seeding in cases of perihilar disease. Cholangioscopy allows for direct visualization and targeted sampling; however, cholangioscopy-guided forceps biopsies are burdened by low sensitivities.¹ Additionally, physician interpretation of visual findings during cholangioscopy often suffers from poor interobserver agreement and poor accuracy.²

To improve the classification of biliary strictures, several groups have studied the application of AI for cholangioscopy footage of biliary pathology. In our lab, we trained an AI incorporating over 2.3 million cholangioscopy still images and nearly 20,000 expert-annotated frames to enhance its development. The AI closely mirrored expert labeling of cholangioscopy images of malignant pathology and, when tested on full cholangioscopy videos of indeterminate biliary strictures, the AI achieved a diagnostic accuracy of 91%—outperforming both brush cytology (63%) and forceps biopsy (61%).³

The results from this initial study were later validated across multiple centers. AI-assisted cholangioscopy could thus offer a reproducible, real-world solution to one of the most persistent diagnostic dilemmas advanced endoscopists face—helping clinicians act earlier and with greater confidence when evaluating indeterminate strictures.

Moving from the biliary tree to the pancreas, autoimmune pancreatitis (AIP) is a benign fibro-inflammatory disease that often frustrates advanced endoscopists as it closely mimics the appearance of pancreatic ductal adenocarcinoma (PDAC). The stakes are high: despite modern diagnostic techniques, including advanced imaging, some patients with pancreatic resections for “suspected PDAC” are still found to have AIP on final pathology. Conventional tools to distinguish AIP from PDAC have gaps: serum IgG4 and EUS-guided biopsies are both specific but insensitive.

Using EUS videos and images of various pancreas pathologies at Mayo Clinic, we developed an AI to tackle this dilemma. After intensive training, the EUS AI achieved a greater accuracy for distinguishing AIP from PDAC than a group of expert Mayo clinic endosonographers.⁵ In practice, an EUS-AI can identify AIP patterns in real-time, guiding clinicians toward steroid trials or biopsies and reducing the need for unnecessary surgeries.

Looking ahead, there are multiple opportunities for integration of AI into advanced endoscopy practices. Ongoing research suggests that AI could soon assist with identification of pancreas cysts most at risk for malignant transformation, classification of high risk Barrett’s esophagus, and even help with rapid on-site assessment of cytologic specimens obtained during EUS. Beyond diagnosis, AI could likely play an important role in guiding therapeutic interventions. For example, an ERCP AI in the future may be able to provide cannulation assistance or an AI assistant could help endosonographers during deployments of lumen apposing metal stents.

By enhancing image interpretation and procedural consistency, AI has the potential to uphold the fundamental principle of primum non nocere, enabling us to intervene with precision while minimizing harm. AI can also bridge grey zones in clinical practice and narrow diagnostic uncertainty in real time. Importantly, these systems can help clinicians achieve expertise in a fraction of the time it traditionally takes to acquire comparable human proficiency, while offering wider availability across practice settings and reducing interobserver variability that has long challenged endoscopic interpretation.

Currently, adoption is limited by high bias risk, lack of external validation, and interpretability Still, the trajectory of AI suggests a future where these computer technologies will not only support but also elevate human expertise, reshaping the standards of care of diseases managed by advanced endoscopists.

Dr. Singh, Dr. Colletta, and Dr. Marya are based at the Division of Gastroenterology and Hepatology, UMass Chan Medical School, Worcester, Massachusetts. Dr. Marya is a consultant for Boston Scientific, and has no other disclosures. Dr. Singh and Dr. Colletta have no disclosures.

References

1. Navaneethan U, et al. Comparative effectiveness of biliary brush cytology and intraductal biopsy for detection of malignant biliary strictures: a systematic review and meta-analysis. Gastrointest Endosc. 2015 Jan. doi: 10.1016/j.gie.2014.09.017.

2. Stassen PMC, et al. Diagnostic accuracy and interobserver agreement of digital single-operator cholangioscopy for indeterminate biliary strictures. Gastrointest Endosc 2021 Dec. doi: 10.1016/j.gie.2021.06.027.

3. Marya NB, et al. Identification of patients with malignant biliary strictures using a cholangioscopy-based deep learning artificial intelligence (with video). Gastrointest Endosc. 2023 Feb. doi: 10.1016/j.gie.2022.08.021.

4. Marya NB, et al. Multicenter validation of a cholangioscopy artificial intelligence system for the evaluation of biliary tract disease. Endoscopy. 2025 Aug. doi: 10.1055/a-2650-0789.

5. Marya NB, et al. Utilisation of artificial intelligence for the development of an EUS-convolutional neural network model trained to enhance the diagnosis of autoimmune pancreatitis. Gut. 2021 Jul. doi: 10.1136/gutjnl-2020-322821.

AI in General GI and Endoscopy

BY DENNIS L. SHUNG, MD, MHS, PHD

The practice of gastroenterology is changing, but much of it will be rooted in the same – careful, focused attention on endoscopic procedures, and compassionate, attentive care in clinic. Artificial intelligence (AI), like the Industrial Revolution before, is going to transform our practice. This comes with upsides and downsides, and highlights the need for strong leadership from our societies to safeguard the technology for practitioners and patients.

What are the upsides? 

AI has the potential to serve as a second set of eyes in detecting colon polyps, increasing the adenoma detection rate (ADR).¹ AI can be applied to all areas of the gastrointestinal tract, providing digital biopsies, guiding resection, and ensuring quality, which are all now possible with powerful new endoscopy foundation models, such as GastroNet-5M.²

Additionally. the advent of automating the collection of data into reports may herald the end of our days as data entry clerks. Generative AI also has the potential to give us all the best information at our fingertips, suggesting guideline-based care, providing the most up to date evidence, and guiding the differential diagnosis. The potential for patient-facing AI systems could lead to better health literacy, more meaningful engagement, and improved patient satisfaction.³

What are the downsides? 

For endoscopy, AI cannot make up for poor technique to ensure adequate mucosal exposure by the endoscopist, and an increase in AI-supported ADR does not yet convincingly translate into concrete gains in colorectal cancer-related mortality. For the foreseeable future, AI cannot make a connection with the patient in front of us, which is critical in diagnosing and treating patients.

Currently, AI appears to worsen loneliness⁴, and does not necessarily deepen the bonds or provide the positive touch that can heal, and which for many of us, was the reason we became physicians. Finally, as information proliferates, the information risk to patients and providers is growing – in the future, trusted sources to monitor, curate, and guide AI will be ever more important.

 

Black Swans

As AI begins to mature, there are risks that lurk beneath the surface. When regulatory bodies begin to look at AI-assisted diagnostics or therapeutics as the new standard of care, reimbursement models may adjust, and providers may be left behind. The rapid proliferation and haphazard adoption of AI could lead to overdependence and deskilling or result in weird and as yet unknown errors that are difficult to troubleshoot.

What is the role of the GI societies? 

Specialty societies like AGA are taking leadership roles in determining the bounds of where AIs may tread, not just in providing information to their membership but also in digesting evidence and synthesizing recommendations. Societies must balance the real promise of AI in endoscopy with the practice realities for members, and provide living guidelines that reflect the consensus of members regarding scope of practice with the ability to update as new data become available.⁵

Societies also have a role as advocates for safety, taking ownership of high-quality content to prevent misinformation. AGA recently announced the development of a chat interface that will be focused on providing its members the highest quality information, and serve as a portal to identify and respond to its members’ information needs. By staying united rather than fragmenting, societies can maintain bounds to protect its members and their patients and advance areas where there is clinical need, together.

Dr. Shung is senior associate consultant, Division of Gastroenterology and Hepatology, and director of clinical generative artificial intelligence and informatics, Department of Medicine, at Mayo Clinic Rochester, Minnesota. He has no disclosures in regard to this article.

References

1. Soleymanjahi S, et al. Artificial Intelligence-Assisted Colonoscopy for Polyp Detection : A Systematic Review and Meta-analysis. Ann Intern Med. 2024 Dec. doi:10.7326/annals-24-00981.

2. Jong MR, et al. GastroNet-5M: A Multicenter Dataset for Developing Foundation Models in Gastrointestinal Endoscopy. Gastroenterology. 2025 Jul. doi: 10.1053/j.gastro.2025.07.030.

3. Soroush A, et al. Generative Artificial Intelligence in Clinical Medicine and Impact on Gastroenterology. Gastroenterology. 2025 Aug. doi: 10.1053/j.gastro.2025.03.038.

4. Mengying Fang C, et al. How AI and Human Behaviors Shape Psychosocial Effects of Extended Chatbot Use: A Longitudinal Randomized Controlled Study. arXiv e-prints. 2025 Mar. doi: 10.48550/arXiv.2503.17473.

5. Sultan S, et al. AGA Living Clinical Practice Guideline on Computer-Aided Detection-Assisted Colonoscopy. Gastroenterology. 2025 Apr. doi:10.1053/j.gastro.2025.01.002.

Despite the ongoing shutdown of the US federal government, the Indian Health Service (IHS) continues to maintain the status quo while operating on an island of relatively insulated stability.

“IHS will continue to operate business-as-usual during a lapse of appropriations,” US Department of Health and Human Services press secretary Emily G. Hilliard said at a recent meeting with the National Congress of American Indians (NCAI). “100% of IHS staff will report for work, and health care services across Indian Country will not be impacted.” 

The protective cocoon around IHS and its services provided is largely due to advance appropriations, and lessons learned from previous government shutdowns. During the historically long 35-day government shutdown in 2018 and 2019, all federal government operations had to halt operations unless they were deemed indispensable. IHS was not considered indispensable and consequently, about 60% of IHS employees did not receive a paycheck.

In preparation for another potential shutdown in 2023, IHS was more proactive. “Because of the fact that now we have advanced appropriations for Indian Health Services, on Oct. 1, whether or not there’s a federal budget in place, will continue providing services,” then-HHS Secretary Xavier Becerra, said at the time.

The safeguards have held for the current shutdown, aided by tribal pressure. As the federal shutdown loomed in September, a delegation led by NCAI spent 3 days lobbying Congress—focusing primarily on the new leadership in the Senate Indian Affairs Committee—to guarantee some protection for federal employees who work with tribal governments.

At the quarterly meeting of the United Indian Nations of Oklahoma (UINO) in Tulsa, Rear Adm. Travis Watts, director of the IHS Oklahoma City Area and a citizen of the Choctaw Nation of Oklahoma, told attendees, “The advance appropriations allow us to keep our doors open at this particular time. We want to thank the tribal nations for their advocacy for those advance appropriations.”

IHS is funded through 2026. All 14,801 IHS staff will be paid through advance appropriations, multi-year or supplemental appropriations, third-party collections, or carryover balances. 

However, according to the proposed 2026 budget some key health-related funding is at risk, including about $128 million in Tribal set-aside funding for mental and behavioral health funding: $60 million from the Tribal Opioid Response Grants, $22.75 million from Tribal Behavioral Health Grants, $14.5 million from Medication-Assisted Treatment for Prescription and Opioid Addiction, and $3.4 million Tribal set-aside for the Zero Suicide program. Six IHS accounts are not funded by advance appropriations: Electronic Health Record System, Indian Health Care Improvement Fund, Contract Support Costs, Payments for Tribal Leases, Sanitation Facilities Construction, and Health Care Facilities Construction.

In a public statement, Cherokee Nation Principal Chief Chuck Hoskin Jr. said, “[W]e’re hopeful that Congress’ foresight to provide an advance appropriation for the Indian Health Service will prevent any severe disruptions as experienced during the 2013 and 2018 shutdowns. I urge both sides of the aisle to work on a path forward and reopen the government as soon as possible and call on the administration to honor the government’s Treaty and Trust responsibilities, avoid needless cuts to Tribal programs and personnel, and use its authorities to minimize harm to tribes and tribal citizens.”

Hoskin Jr. cautioned, though, that not every tribe has the same resources. Many smaller, direct-service tribes depend entirely on IHS to deliver care.

“Thank goodness for forward funding,” he said. “But we have to make that permanent in federal statute. No one in this country should be at the mercy of political dysfunction to get health care. “The United States can keep its lights off,” Hoskin Jr. said. “We’ll still be moving forward.”

Despite the ongoing shutdown of the US federal government, the Indian Health Service (IHS) continues to maintain the status quo while operating on an island of relatively insulated stability.

“IHS will continue to operate business-as-usual during a lapse of appropriations,” US Department of Health and Human Services press secretary Emily G. Hilliard said at a recent meeting with the National Congress of American Indians (NCAI). “100% of IHS staff will report for work, and health care services across Indian Country will not be impacted.” 

The protective cocoon around IHS and its services provided is largely due to advance appropriations, and lessons learned from previous government shutdowns. During the historically long 35-day government shutdown in 2018 and 2019, all federal government operations had to halt operations unless they were deemed indispensable. IHS was not considered indispensable and consequently, about 60% of IHS employees did not receive a paycheck.

In preparation for another potential shutdown in 2023, IHS was more proactive. “Because of the fact that now we have advanced appropriations for Indian Health Services, on Oct. 1, whether or not there’s a federal budget in place, will continue providing services,” then-HHS Secretary Xavier Becerra, said at the time.

The safeguards have held for the current shutdown, aided by tribal pressure. As the federal shutdown loomed in September, a delegation led by NCAI spent 3 days lobbying Congress—focusing primarily on the new leadership in the Senate Indian Affairs Committee—to guarantee some protection for federal employees who work with tribal governments.

At the quarterly meeting of the United Indian Nations of Oklahoma (UINO) in Tulsa, Rear Adm. Travis Watts, director of the IHS Oklahoma City Area and a citizen of the Choctaw Nation of Oklahoma, told attendees, “The advance appropriations allow us to keep our doors open at this particular time. We want to thank the tribal nations for their advocacy for those advance appropriations.”

IHS is funded through 2026. All 14,801 IHS staff will be paid through advance appropriations, multi-year or supplemental appropriations, third-party collections, or carryover balances. 

However, according to the proposed 2026 budget some key health-related funding is at risk, including about $128 million in Tribal set-aside funding for mental and behavioral health funding: $60 million from the Tribal Opioid Response Grants, $22.75 million from Tribal Behavioral Health Grants, $14.5 million from Medication-Assisted Treatment for Prescription and Opioid Addiction, and $3.4 million Tribal set-aside for the Zero Suicide program. Six IHS accounts are not funded by advance appropriations: Electronic Health Record System, Indian Health Care Improvement Fund, Contract Support Costs, Payments for Tribal Leases, Sanitation Facilities Construction, and Health Care Facilities Construction.

In a public statement, Cherokee Nation Principal Chief Chuck Hoskin Jr. said, “[W]e’re hopeful that Congress’ foresight to provide an advance appropriation for the Indian Health Service will prevent any severe disruptions as experienced during the 2013 and 2018 shutdowns. I urge both sides of the aisle to work on a path forward and reopen the government as soon as possible and call on the administration to honor the government’s Treaty and Trust responsibilities, avoid needless cuts to Tribal programs and personnel, and use its authorities to minimize harm to tribes and tribal citizens.”

Hoskin Jr. cautioned, though, that not every tribe has the same resources. Many smaller, direct-service tribes depend entirely on IHS to deliver care.

“Thank goodness for forward funding,” he said. “But we have to make that permanent in federal statute. No one in this country should be at the mercy of political dysfunction to get health care. “The United States can keep its lights off,” Hoskin Jr. said. “We’ll still be moving forward.”

Despite the ongoing shutdown of the US federal government, the Indian Health Service (IHS) continues to maintain the status quo while operating on an island of relatively insulated stability.

“IHS will continue to operate business-as-usual during a lapse of appropriations,” US Department of Health and Human Services press secretary Emily G. Hilliard said at a recent meeting with the National Congress of American Indians (NCAI). “100% of IHS staff will report for work, and health care services across Indian Country will not be impacted.” 

The protective cocoon around IHS and its services provided is largely due to advance appropriations, and lessons learned from previous government shutdowns. During the historically long 35-day government shutdown in 2018 and 2019, all federal government operations had to halt operations unless they were deemed indispensable. IHS was not considered indispensable and consequently, about 60% of IHS employees did not receive a paycheck.

In preparation for another potential shutdown in 2023, IHS was more proactive. “Because of the fact that now we have advanced appropriations for Indian Health Services, on Oct. 1, whether or not there’s a federal budget in place, will continue providing services,” then-HHS Secretary Xavier Becerra, said at the time.

The safeguards have held for the current shutdown, aided by tribal pressure. As the federal shutdown loomed in September, a delegation led by NCAI spent 3 days lobbying Congress—focusing primarily on the new leadership in the Senate Indian Affairs Committee—to guarantee some protection for federal employees who work with tribal governments.

At the quarterly meeting of the United Indian Nations of Oklahoma (UINO) in Tulsa, Rear Adm. Travis Watts, director of the IHS Oklahoma City Area and a citizen of the Choctaw Nation of Oklahoma, told attendees, “The advance appropriations allow us to keep our doors open at this particular time. We want to thank the tribal nations for their advocacy for those advance appropriations.”

IHS is funded through 2026. All 14,801 IHS staff will be paid through advance appropriations, multi-year or supplemental appropriations, third-party collections, or carryover balances. 

However, according to the proposed 2026 budget some key health-related funding is at risk, including about $128 million in Tribal set-aside funding for mental and behavioral health funding: $60 million from the Tribal Opioid Response Grants, $22.75 million from Tribal Behavioral Health Grants, $14.5 million from Medication-Assisted Treatment for Prescription and Opioid Addiction, and $3.4 million Tribal set-aside for the Zero Suicide program. Six IHS accounts are not funded by advance appropriations: Electronic Health Record System, Indian Health Care Improvement Fund, Contract Support Costs, Payments for Tribal Leases, Sanitation Facilities Construction, and Health Care Facilities Construction.

In a public statement, Cherokee Nation Principal Chief Chuck Hoskin Jr. said, “[W]e’re hopeful that Congress’ foresight to provide an advance appropriation for the Indian Health Service will prevent any severe disruptions as experienced during the 2013 and 2018 shutdowns. I urge both sides of the aisle to work on a path forward and reopen the government as soon as possible and call on the administration to honor the government’s Treaty and Trust responsibilities, avoid needless cuts to Tribal programs and personnel, and use its authorities to minimize harm to tribes and tribal citizens.”

Hoskin Jr. cautioned, though, that not every tribe has the same resources. Many smaller, direct-service tribes depend entirely on IHS to deliver care.

“Thank goodness for forward funding,” he said. “But we have to make that permanent in federal statute. No one in this country should be at the mercy of political dysfunction to get health care. “The United States can keep its lights off,” Hoskin Jr. said. “We’ll still be moving forward.”

BERLIN — Diet drinks may not be “healthier” than sugary drinks when it comes to liver health.

A large UK Biobank study found that higher intakes of both sugar-sweetened beverages (SSBs) and low- and non-SSBs (LNSSBs) were significantly associated with a higher risk of developing metabolic dysfunction-associated steatotic liver disease (MASLD).

In fact, low- or artificially sweetened beverages were actually linked to a higher risk for MASLD than sugar-laden drinks, even at modest intake levels such as a single can per day.

“These findings challenge the common perception that these drinks are harmless and highlight the need to reconsider their role in diet and liver health, especially as MASLD emerges as a global health concern,” lead author Lihe Liu, a graduate student in the Department of Gastroenterology at The First Affiliated Hospital of Soochow University in Suzhou, China, said in a news release.

She presented her research at the United European Gastroenterology (UEG) Week 2025 in Berlin, Germany.

 

Stick With Water

MASLD affects 38% of the global population and has become a leading cause of cirrhosis, liver cancer, and liver-related death. Lifestyle modification remains “a cornerstone” of MASLD management. Current guidelines advise against SSBs, but the evidence regarding LNSSBs remains “limited,” Liu explained in her presentation.

To investigate, the researchers analyzed data of 123,788 UK Biobank participants without liver disease at baseline who were followed for an average of 10.3 years. Beverage consumption was assessed through repeated 24-hour dietary questionnaires using the question: “How many glasses, cans, or cartons containing 250 mL (roughly 250 g) of SSBs or LNSSBs did you drink yesterday?”

Intake was averaged across at least two recalls, and participants were grouped into three intake categories: none, more than 0 to one serving per day, or more than one serving per day.

The primary outcome was incident MASLD, and secondary outcomes included liver-related mortality and liver fat content measured using MRI-derived proton density fat fraction.

In the fully adjusted multivariable Cox model, compared with no consumption, consuming more than one serving of LNSSBs daily was associated with a 60% higher risk for MASLD (hazard ratio [HR], 1.599). The level of consumption of SSBs was associated with a 50% higher risk (HR, 1.469).

Consuming more than one serving of LNSSBs daily was also associated with a higher risk for severe liver outcomes (HR, 1.555), while SSBs showed no significant association after adjustment.

Neither SSBs nor LNSSBs showed significant associations with all-cause mortality in fully adjusted models.

Substituting either beverage with water reduced the risk for MASLD by 12.8% for SSBs and 15.2% for LNSSBs, Liu reported.

Both beverage types were positively associated with higher liver fat content. Consumption of more than one serving of SSBs and LNSSBs daily was associated with about 5% and 7% higher liver fat levels, respectively, than nonconsumption.

“The higher sugar content in SSBs can cause rapid spikes in blood glucose and insulin, promote weight gain, and increase uric acid levels, all of which contribute to liver fat accumulation. LNSSBs, on the other hand, may affect liver health by altering the gut microbiome, disrupting the feeling of fullness, driving sweet cravings, and even stimulating insulin secretion,” Liu said.

“The safest approach is to limit both sugar-sweetened and artificially sweetened drinks. Water remains the best choice as it removes the metabolic burden and prevents fat accumulation in the liver, whilst hydrating the body,” she concluded.

 

More Study Needed

Reached for comment, Sujit V. Janardhan, MD, PhD, director of the steatotic liver disease program, Rush University Medical Center, Chicago, said the findings “certainly should cause one to take pause from the popular notion that diet or non-sugar-sweetened beverages are healthier than their sugar-sweetened alternatives.”

He cautioned, however, that it would be “important to confirm confounders are adequately addressed in this large population-based study.”

“We must better understand what other exposure and characteristics were present in patients who had increased intake of non-sugar-sweetened beverages,” Janardhan told GI & Hepatology News.

“For example, it’s possible people who drank more non-sugar-sweetened beverages had more cardiovascular or metabolic risk factors (which prompted them to switch to the ‘diet’ alternative) and that it is these comorbidities that drove an association with increased MASLD incidence and liver-related mortality,” Janardhan noted.

“If there is one finding that seems easy to take away from this study, it’s that people who drank more water in place of sweetened beverages had reduced risk of MASLD,” he told GI & Hepatology News.

Therefore, while awaiting results of mechanistic studies and careful confounder analysis, “plain old boring water is your best bet,” Janardhan said.

The study had no specific funding. Liu and Janardhan had no relevant disclosures.

 

A version of this article appeared on Medscape.com.

BERLIN — Diet drinks may not be “healthier” than sugary drinks when it comes to liver health.

A large UK Biobank study found that higher intakes of both sugar-sweetened beverages (SSBs) and low- and non-SSBs (LNSSBs) were significantly associated with a higher risk of developing metabolic dysfunction-associated steatotic liver disease (MASLD).

In fact, low- or artificially sweetened beverages were actually linked to a higher risk for MASLD than sugar-laden drinks, even at modest intake levels such as a single can per day.

“These findings challenge the common perception that these drinks are harmless and highlight the need to reconsider their role in diet and liver health, especially as MASLD emerges as a global health concern,” lead author Lihe Liu, a graduate student in the Department of Gastroenterology at The First Affiliated Hospital of Soochow University in Suzhou, China, said in a news release.

She presented her research at the United European Gastroenterology (UEG) Week 2025 in Berlin, Germany.

 

Stick With Water

MASLD affects 38% of the global population and has become a leading cause of cirrhosis, liver cancer, and liver-related death. Lifestyle modification remains “a cornerstone” of MASLD management. Current guidelines advise against SSBs, but the evidence regarding LNSSBs remains “limited,” Liu explained in her presentation.

To investigate, the researchers analyzed data of 123,788 UK Biobank participants without liver disease at baseline who were followed for an average of 10.3 years. Beverage consumption was assessed through repeated 24-hour dietary questionnaires using the question: “How many glasses, cans, or cartons containing 250 mL (roughly 250 g) of SSBs or LNSSBs did you drink yesterday?”

Intake was averaged across at least two recalls, and participants were grouped into three intake categories: none, more than 0 to one serving per day, or more than one serving per day.

The primary outcome was incident MASLD, and secondary outcomes included liver-related mortality and liver fat content measured using MRI-derived proton density fat fraction.

In the fully adjusted multivariable Cox model, compared with no consumption, consuming more than one serving of LNSSBs daily was associated with a 60% higher risk for MASLD (hazard ratio [HR], 1.599). The level of consumption of SSBs was associated with a 50% higher risk (HR, 1.469).

Consuming more than one serving of LNSSBs daily was also associated with a higher risk for severe liver outcomes (HR, 1.555), while SSBs showed no significant association after adjustment.

Neither SSBs nor LNSSBs showed significant associations with all-cause mortality in fully adjusted models.

Substituting either beverage with water reduced the risk for MASLD by 12.8% for SSBs and 15.2% for LNSSBs, Liu reported.

Both beverage types were positively associated with higher liver fat content. Consumption of more than one serving of SSBs and LNSSBs daily was associated with about 5% and 7% higher liver fat levels, respectively, than nonconsumption.

“The higher sugar content in SSBs can cause rapid spikes in blood glucose and insulin, promote weight gain, and increase uric acid levels, all of which contribute to liver fat accumulation. LNSSBs, on the other hand, may affect liver health by altering the gut microbiome, disrupting the feeling of fullness, driving sweet cravings, and even stimulating insulin secretion,” Liu said.

“The safest approach is to limit both sugar-sweetened and artificially sweetened drinks. Water remains the best choice as it removes the metabolic burden and prevents fat accumulation in the liver, whilst hydrating the body,” she concluded.

 

More Study Needed

Reached for comment, Sujit V. Janardhan, MD, PhD, director of the steatotic liver disease program, Rush University Medical Center, Chicago, said the findings “certainly should cause one to take pause from the popular notion that diet or non-sugar-sweetened beverages are healthier than their sugar-sweetened alternatives.”

He cautioned, however, that it would be “important to confirm confounders are adequately addressed in this large population-based study.”

“We must better understand what other exposure and characteristics were present in patients who had increased intake of non-sugar-sweetened beverages,” Janardhan told GI & Hepatology News.

“For example, it’s possible people who drank more non-sugar-sweetened beverages had more cardiovascular or metabolic risk factors (which prompted them to switch to the ‘diet’ alternative) and that it is these comorbidities that drove an association with increased MASLD incidence and liver-related mortality,” Janardhan noted.

“If there is one finding that seems easy to take away from this study, it’s that people who drank more water in place of sweetened beverages had reduced risk of MASLD,” he told GI & Hepatology News.

Therefore, while awaiting results of mechanistic studies and careful confounder analysis, “plain old boring water is your best bet,” Janardhan said.

The study had no specific funding. Liu and Janardhan had no relevant disclosures.

 

A version of this article appeared on Medscape.com.

BERLIN — Diet drinks may not be “healthier” than sugary drinks when it comes to liver health.

A large UK Biobank study found that higher intakes of both sugar-sweetened beverages (SSBs) and low- and non-SSBs (LNSSBs) were significantly associated with a higher risk of developing metabolic dysfunction-associated steatotic liver disease (MASLD).

In fact, low- or artificially sweetened beverages were actually linked to a higher risk for MASLD than sugar-laden drinks, even at modest intake levels such as a single can per day.

“These findings challenge the common perception that these drinks are harmless and highlight the need to reconsider their role in diet and liver health, especially as MASLD emerges as a global health concern,” lead author Lihe Liu, a graduate student in the Department of Gastroenterology at The First Affiliated Hospital of Soochow University in Suzhou, China, said in a news release.

She presented her research at the United European Gastroenterology (UEG) Week 2025 in Berlin, Germany.

 

Stick With Water

MASLD affects 38% of the global population and has become a leading cause of cirrhosis, liver cancer, and liver-related death. Lifestyle modification remains “a cornerstone” of MASLD management. Current guidelines advise against SSBs, but the evidence regarding LNSSBs remains “limited,” Liu explained in her presentation.

To investigate, the researchers analyzed data of 123,788 UK Biobank participants without liver disease at baseline who were followed for an average of 10.3 years. Beverage consumption was assessed through repeated 24-hour dietary questionnaires using the question: “How many glasses, cans, or cartons containing 250 mL (roughly 250 g) of SSBs or LNSSBs did you drink yesterday?”

Intake was averaged across at least two recalls, and participants were grouped into three intake categories: none, more than 0 to one serving per day, or more than one serving per day.

The primary outcome was incident MASLD, and secondary outcomes included liver-related mortality and liver fat content measured using MRI-derived proton density fat fraction.

In the fully adjusted multivariable Cox model, compared with no consumption, consuming more than one serving of LNSSBs daily was associated with a 60% higher risk for MASLD (hazard ratio [HR], 1.599). The level of consumption of SSBs was associated with a 50% higher risk (HR, 1.469).

Consuming more than one serving of LNSSBs daily was also associated with a higher risk for severe liver outcomes (HR, 1.555), while SSBs showed no significant association after adjustment.

Neither SSBs nor LNSSBs showed significant associations with all-cause mortality in fully adjusted models.

Substituting either beverage with water reduced the risk for MASLD by 12.8% for SSBs and 15.2% for LNSSBs, Liu reported.

Both beverage types were positively associated with higher liver fat content. Consumption of more than one serving of SSBs and LNSSBs daily was associated with about 5% and 7% higher liver fat levels, respectively, than nonconsumption.

“The higher sugar content in SSBs can cause rapid spikes in blood glucose and insulin, promote weight gain, and increase uric acid levels, all of which contribute to liver fat accumulation. LNSSBs, on the other hand, may affect liver health by altering the gut microbiome, disrupting the feeling of fullness, driving sweet cravings, and even stimulating insulin secretion,” Liu said.

“The safest approach is to limit both sugar-sweetened and artificially sweetened drinks. Water remains the best choice as it removes the metabolic burden and prevents fat accumulation in the liver, whilst hydrating the body,” she concluded.

 

More Study Needed

Reached for comment, Sujit V. Janardhan, MD, PhD, director of the steatotic liver disease program, Rush University Medical Center, Chicago, said the findings “certainly should cause one to take pause from the popular notion that diet or non-sugar-sweetened beverages are healthier than their sugar-sweetened alternatives.”

He cautioned, however, that it would be “important to confirm confounders are adequately addressed in this large population-based study.”

“We must better understand what other exposure and characteristics were present in patients who had increased intake of non-sugar-sweetened beverages,” Janardhan told GI & Hepatology News.

“For example, it’s possible people who drank more non-sugar-sweetened beverages had more cardiovascular or metabolic risk factors (which prompted them to switch to the ‘diet’ alternative) and that it is these comorbidities that drove an association with increased MASLD incidence and liver-related mortality,” Janardhan noted.

“If there is one finding that seems easy to take away from this study, it’s that people who drank more water in place of sweetened beverages had reduced risk of MASLD,” he told GI & Hepatology News.

Therefore, while awaiting results of mechanistic studies and careful confounder analysis, “plain old boring water is your best bet,” Janardhan said.

The study had no specific funding. Liu and Janardhan had no relevant disclosures.

 

A version of this article appeared on Medscape.com.

BERLIN — Women who use menopausal hormone therapy (MHT; ie, hormone replacement therapy ) have an up to 30% reduction in the risk of developing esophageal and gastric cancers compared to nonusers, according to a large population-based study across five Nordic countries. The association appeared strongest for combined estrogen-progestin and systemic formulations.

“This is one of the largest and most comprehensive studies to date supporting the hypothesis of an inverse association between MHT and risk of esophago-gastric cancer,” said Victoria Wocalewski, MD, from the Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, who presented the findings at United European Gastroenterology (UEG) Week 2025. 

There was a decreased risk for all investigated cancers in MHT users, but the strongest association was observed for esophageal adenocarcinoma (EAC), said Wocalewski. In addition, “there were discrete dose-dependent results for [EAC] and gastric adenocarcinoma (GAC) but not for esophageal squamous cell carcinoma (ESCC).”

 

Large Population-Based Study 

Previous research has suggested that hormonal changes could partly explain the male predominance in esophageal and gastric cancers, but evidence from large, well-controlled datasets has been limited. 

“Cancer rates in women increase significantly after age of 60, so it has been hypothesized that this pattern is linked to declined levels of estrogen that comes with menopause,” said Wocalewski, explaining the rationale for the study.

“Some studies looking at MHT use have indicated a possible protective effect, but with some contradictory results and type-specific variations,” Wocalewski noted. “Our study aimed to investigate these previous findings using a larger study sample.”

The population-based case-control study drew on prospectively collected data from the NordGETS database including national prescription, cancer, and population registries in Denmark, Finland, Iceland, Norway, and Sweden spanning 1994-2020. In total, 19,518 women with esophago-gastric cancer were compared with 195,094 controls randomly selected from the general population, and matched for age, calendar year, and country (in a 1:10 ratio). Women were 45 years or over with a diagnosis of EAC, ESCC, or GAC. 

In total there were 5000 cases of EAC, 4401 of ESCC, and 10,117 of GAC, with the median ages being 74, 72, and 75 years, respectively; most cases of EAC and ESCC were found in Denmark, and most cases of GAC were in Sweden. 

The investigators categorized participants by defined daily doses (DDDs) of MHT into three equal sized categories: low (< 158 DDDs), intermediate (158-848 DDDs), and high (> 848 DDDs). MHT was defined as systemic or local, and estrogen only or combined with progesterone. Odds ratios (ORs) were calculated for three major cancer outcomes of EAC, ESCC, and GAC, adjusted for known confounders such as age, obesity, smoking, alcohol consumption, reflux disease, Helicobacter pylori eradication, and concomitant use of statins or non-steroidal anti-inflammatory drugs (NSAIDs). However, Wocalewski noted that they did not adjust for socio-economic factors. 

 

Significant Reductions Across Esophago-Gastric Cancers

Compared with nonusers, women with any MHT exposure had a markedly reduced risk of EAC with adjusted ORs (aORs) of 0.74 (95% CI, 0.67-0.81) for low-use, 0.68 (95% CI, 0.61-0.75) for intermediate-use, and 0.68 (95% CI, 0.61-0.75) for high-use groups. Various adjustments were made for obesity, reflux, statins, and NSAIDs, as well as smoking, alcohol use, and H pylori eradication.

Similar inverse associations were seen for ESCC with aORs of 0.69 (95% CI, 0.62-0.77), 0.70 (95% CI, 0.62-0.77), and 0.71 (95% CI, 0.64-0.79) across the dose categories, and for GAC where risk decreased progressively from 0.90 (95% CI, 0.84-0.96) to 0.80 (95% CI, 0.74-0.86) across increasing MHT doses.

When stratified by hormone formulation, combined estrogen-progesterone therapy and systemic MHT conferred the strongest risk reduction. For example, systemic MHT use was associated with aORs of 0.67 (95% CI, 0.61-0.74) for EAC and 0.82 (95% CI, 0.76-0.88) for GAC, while local (vaginal) preparations showed slightly weaker associations at 0.72 (95% CI, 0.66-0.78) and 0.87 (95% CI, 0.83-0.92), respectively. 

In EAC, combined estrogen-progesterone therapy led to an OR of 0.68 (95% CI, 0.63-0.73) and 0.77 (95% CI, 0.69-0.87) for women on estrogen alone. Similar results were found for ESCC. For GAC, combination resulted in an aOR of 0.85 (95% CI, 0.80-0.89) and 0.88 (95% CI, 0.81-0.97) in estrogen only therapy respectively.

“Our results reinforce the concept that estrogenic signaling may influence tumor development in the upper GI tract,” said Wocalewski. “Understanding these mechanisms could help identify at-risk populations and inform prevention strategies,” she added, noting that, “hormonal effects on epithelial tight junctions and nitric oxide synthesis in the gastrointestinal tract” would have an influence on smooth muscle cells.

 

Link Between Hormones and GI Pathology

Commenting on the study for GI & Hepatology News, Jan Bornschein, MD, University of Oxford, UK, who was not involved in the research, said the results are “highly relevant.” 

“We’ve seen for a long time a link between hormones and GI pathology, however, it has been poorly investigated and the whole mechanisms are not understood, so it’s welcome that this group is moving forward and investigating this in a structured way,” he said.

Another delegate cautioned that MHT was associated with a risk for other non- gastrointestinal cancers. “I think it’s extremely important, because there are data on associations [of MHT] with breast cancer and also endometrial cancer. It’s good to see that it may help and reduce this cancer, but we have to be really careful about the others.”

Wocalewski reports no relevant conflicts of interest. Bornschein has no disclosures relevant to this study. The study was funded by Karolinska Institutet and supported by national cancer and prescription registry data from Denmark, Finland, Iceland, Norway, and Sweden.

 

A version of this article appeared on Medscape.com.

BERLIN — Women who use menopausal hormone therapy (MHT; ie, hormone replacement therapy ) have an up to 30% reduction in the risk of developing esophageal and gastric cancers compared to nonusers, according to a large population-based study across five Nordic countries. The association appeared strongest for combined estrogen-progestin and systemic formulations.

“This is one of the largest and most comprehensive studies to date supporting the hypothesis of an inverse association between MHT and risk of esophago-gastric cancer,” said Victoria Wocalewski, MD, from the Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, who presented the findings at United European Gastroenterology (UEG) Week 2025. 

There was a decreased risk for all investigated cancers in MHT users, but the strongest association was observed for esophageal adenocarcinoma (EAC), said Wocalewski. In addition, “there were discrete dose-dependent results for [EAC] and gastric adenocarcinoma (GAC) but not for esophageal squamous cell carcinoma (ESCC).”

 

Large Population-Based Study 

Previous research has suggested that hormonal changes could partly explain the male predominance in esophageal and gastric cancers, but evidence from large, well-controlled datasets has been limited. 

“Cancer rates in women increase significantly after age of 60, so it has been hypothesized that this pattern is linked to declined levels of estrogen that comes with menopause,” said Wocalewski, explaining the rationale for the study.

“Some studies looking at MHT use have indicated a possible protective effect, but with some contradictory results and type-specific variations,” Wocalewski noted. “Our study aimed to investigate these previous findings using a larger study sample.”

The population-based case-control study drew on prospectively collected data from the NordGETS database including national prescription, cancer, and population registries in Denmark, Finland, Iceland, Norway, and Sweden spanning 1994-2020. In total, 19,518 women with esophago-gastric cancer were compared with 195,094 controls randomly selected from the general population, and matched for age, calendar year, and country (in a 1:10 ratio). Women were 45 years or over with a diagnosis of EAC, ESCC, or GAC. 

In total there were 5000 cases of EAC, 4401 of ESCC, and 10,117 of GAC, with the median ages being 74, 72, and 75 years, respectively; most cases of EAC and ESCC were found in Denmark, and most cases of GAC were in Sweden. 

The investigators categorized participants by defined daily doses (DDDs) of MHT into three equal sized categories: low (< 158 DDDs), intermediate (158-848 DDDs), and high (> 848 DDDs). MHT was defined as systemic or local, and estrogen only or combined with progesterone. Odds ratios (ORs) were calculated for three major cancer outcomes of EAC, ESCC, and GAC, adjusted for known confounders such as age, obesity, smoking, alcohol consumption, reflux disease, Helicobacter pylori eradication, and concomitant use of statins or non-steroidal anti-inflammatory drugs (NSAIDs). However, Wocalewski noted that they did not adjust for socio-economic factors. 

 

Significant Reductions Across Esophago-Gastric Cancers

Compared with nonusers, women with any MHT exposure had a markedly reduced risk of EAC with adjusted ORs (aORs) of 0.74 (95% CI, 0.67-0.81) for low-use, 0.68 (95% CI, 0.61-0.75) for intermediate-use, and 0.68 (95% CI, 0.61-0.75) for high-use groups. Various adjustments were made for obesity, reflux, statins, and NSAIDs, as well as smoking, alcohol use, and H pylori eradication.

Similar inverse associations were seen for ESCC with aORs of 0.69 (95% CI, 0.62-0.77), 0.70 (95% CI, 0.62-0.77), and 0.71 (95% CI, 0.64-0.79) across the dose categories, and for GAC where risk decreased progressively from 0.90 (95% CI, 0.84-0.96) to 0.80 (95% CI, 0.74-0.86) across increasing MHT doses.

When stratified by hormone formulation, combined estrogen-progesterone therapy and systemic MHT conferred the strongest risk reduction. For example, systemic MHT use was associated with aORs of 0.67 (95% CI, 0.61-0.74) for EAC and 0.82 (95% CI, 0.76-0.88) for GAC, while local (vaginal) preparations showed slightly weaker associations at 0.72 (95% CI, 0.66-0.78) and 0.87 (95% CI, 0.83-0.92), respectively. 

In EAC, combined estrogen-progesterone therapy led to an OR of 0.68 (95% CI, 0.63-0.73) and 0.77 (95% CI, 0.69-0.87) for women on estrogen alone. Similar results were found for ESCC. For GAC, combination resulted in an aOR of 0.85 (95% CI, 0.80-0.89) and 0.88 (95% CI, 0.81-0.97) in estrogen only therapy respectively.

“Our results reinforce the concept that estrogenic signaling may influence tumor development in the upper GI tract,” said Wocalewski. “Understanding these mechanisms could help identify at-risk populations and inform prevention strategies,” she added, noting that, “hormonal effects on epithelial tight junctions and nitric oxide synthesis in the gastrointestinal tract” would have an influence on smooth muscle cells.

 

Link Between Hormones and GI Pathology

Commenting on the study for GI & Hepatology News, Jan Bornschein, MD, University of Oxford, UK, who was not involved in the research, said the results are “highly relevant.” 

“We’ve seen for a long time a link between hormones and GI pathology, however, it has been poorly investigated and the whole mechanisms are not understood, so it’s welcome that this group is moving forward and investigating this in a structured way,” he said.

Another delegate cautioned that MHT was associated with a risk for other non- gastrointestinal cancers. “I think it’s extremely important, because there are data on associations [of MHT] with breast cancer and also endometrial cancer. It’s good to see that it may help and reduce this cancer, but we have to be really careful about the others.”

Wocalewski reports no relevant conflicts of interest. Bornschein has no disclosures relevant to this study. The study was funded by Karolinska Institutet and supported by national cancer and prescription registry data from Denmark, Finland, Iceland, Norway, and Sweden.

 

A version of this article appeared on Medscape.com.

BERLIN — Women who use menopausal hormone therapy (MHT; ie, hormone replacement therapy ) have an up to 30% reduction in the risk of developing esophageal and gastric cancers compared to nonusers, according to a large population-based study across five Nordic countries. The association appeared strongest for combined estrogen-progestin and systemic formulations.

“This is one of the largest and most comprehensive studies to date supporting the hypothesis of an inverse association between MHT and risk of esophago-gastric cancer,” said Victoria Wocalewski, MD, from the Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, who presented the findings at United European Gastroenterology (UEG) Week 2025. 

There was a decreased risk for all investigated cancers in MHT users, but the strongest association was observed for esophageal adenocarcinoma (EAC), said Wocalewski. In addition, “there were discrete dose-dependent results for [EAC] and gastric adenocarcinoma (GAC) but not for esophageal squamous cell carcinoma (ESCC).”

 

Large Population-Based Study 

Previous research has suggested that hormonal changes could partly explain the male predominance in esophageal and gastric cancers, but evidence from large, well-controlled datasets has been limited. 

“Cancer rates in women increase significantly after age of 60, so it has been hypothesized that this pattern is linked to declined levels of estrogen that comes with menopause,” said Wocalewski, explaining the rationale for the study.

“Some studies looking at MHT use have indicated a possible protective effect, but with some contradictory results and type-specific variations,” Wocalewski noted. “Our study aimed to investigate these previous findings using a larger study sample.”

The population-based case-control study drew on prospectively collected data from the NordGETS database including national prescription, cancer, and population registries in Denmark, Finland, Iceland, Norway, and Sweden spanning 1994-2020. In total, 19,518 women with esophago-gastric cancer were compared with 195,094 controls randomly selected from the general population, and matched for age, calendar year, and country (in a 1:10 ratio). Women were 45 years or over with a diagnosis of EAC, ESCC, or GAC. 

In total there were 5000 cases of EAC, 4401 of ESCC, and 10,117 of GAC, with the median ages being 74, 72, and 75 years, respectively; most cases of EAC and ESCC were found in Denmark, and most cases of GAC were in Sweden. 

The investigators categorized participants by defined daily doses (DDDs) of MHT into three equal sized categories: low (< 158 DDDs), intermediate (158-848 DDDs), and high (> 848 DDDs). MHT was defined as systemic or local, and estrogen only or combined with progesterone. Odds ratios (ORs) were calculated for three major cancer outcomes of EAC, ESCC, and GAC, adjusted for known confounders such as age, obesity, smoking, alcohol consumption, reflux disease, Helicobacter pylori eradication, and concomitant use of statins or non-steroidal anti-inflammatory drugs (NSAIDs). However, Wocalewski noted that they did not adjust for socio-economic factors. 

 

Significant Reductions Across Esophago-Gastric Cancers

Compared with nonusers, women with any MHT exposure had a markedly reduced risk of EAC with adjusted ORs (aORs) of 0.74 (95% CI, 0.67-0.81) for low-use, 0.68 (95% CI, 0.61-0.75) for intermediate-use, and 0.68 (95% CI, 0.61-0.75) for high-use groups. Various adjustments were made for obesity, reflux, statins, and NSAIDs, as well as smoking, alcohol use, and H pylori eradication.

Similar inverse associations were seen for ESCC with aORs of 0.69 (95% CI, 0.62-0.77), 0.70 (95% CI, 0.62-0.77), and 0.71 (95% CI, 0.64-0.79) across the dose categories, and for GAC where risk decreased progressively from 0.90 (95% CI, 0.84-0.96) to 0.80 (95% CI, 0.74-0.86) across increasing MHT doses.

When stratified by hormone formulation, combined estrogen-progesterone therapy and systemic MHT conferred the strongest risk reduction. For example, systemic MHT use was associated with aORs of 0.67 (95% CI, 0.61-0.74) for EAC and 0.82 (95% CI, 0.76-0.88) for GAC, while local (vaginal) preparations showed slightly weaker associations at 0.72 (95% CI, 0.66-0.78) and 0.87 (95% CI, 0.83-0.92), respectively. 

In EAC, combined estrogen-progesterone therapy led to an OR of 0.68 (95% CI, 0.63-0.73) and 0.77 (95% CI, 0.69-0.87) for women on estrogen alone. Similar results were found for ESCC. For GAC, combination resulted in an aOR of 0.85 (95% CI, 0.80-0.89) and 0.88 (95% CI, 0.81-0.97) in estrogen only therapy respectively.

“Our results reinforce the concept that estrogenic signaling may influence tumor development in the upper GI tract,” said Wocalewski. “Understanding these mechanisms could help identify at-risk populations and inform prevention strategies,” she added, noting that, “hormonal effects on epithelial tight junctions and nitric oxide synthesis in the gastrointestinal tract” would have an influence on smooth muscle cells.

 

Link Between Hormones and GI Pathology

Commenting on the study for GI & Hepatology News, Jan Bornschein, MD, University of Oxford, UK, who was not involved in the research, said the results are “highly relevant.” 

“We’ve seen for a long time a link between hormones and GI pathology, however, it has been poorly investigated and the whole mechanisms are not understood, so it’s welcome that this group is moving forward and investigating this in a structured way,” he said.

Another delegate cautioned that MHT was associated with a risk for other non- gastrointestinal cancers. “I think it’s extremely important, because there are data on associations [of MHT] with breast cancer and also endometrial cancer. It’s good to see that it may help and reduce this cancer, but we have to be really careful about the others.”

Wocalewski reports no relevant conflicts of interest. Bornschein has no disclosures relevant to this study. The study was funded by Karolinska Institutet and supported by national cancer and prescription registry data from Denmark, Finland, Iceland, Norway, and Sweden.

 

A version of this article appeared on Medscape.com.

The ongoing US government partial shutdown has unintended consequences for seniors and their doctors as most telehealth appointments are now no longer being covered by Medicare.

That's because without a budget deal, federal lawmakers did not renew some pandemic-era telehealth flexibilities allowing Medicare beneficiaries to have medical appointments with doctors over audio or video at home.

This policy was first put into place under the first Trump Administration in 2020 during the COVID-19 pandemic. Previously, Medicare covered very limited telehealth services for rural patients.

For the past 5 years, lawmakers have always managed to renew the telehealth flexibilities in every government funding bill before the expiration date. This year, however, they expired for the first time on October 1.

Federal lawmakers remain at odds on the 2026 federal funding bill, meaning the shutdown could last into more days and even weeks.

But with Congress in a standoff, clinicians and patients outside Washington, DC, are already grappling with the consequences of the funding impasse.

Clinicians, Patients Already Feeling Effects

For the South Dakota-based Sanford Health System, which is the largest rural health system in the country, the past week without the Medicare telehealth waivers being in place has caused a lot of anxiety and uncertainty for both patients and clinicians.

Dave Newman, an endocrinologist and chief medical officer of virtual care at Sanford, said the health system decided to keep providing Medicare telehealth appointments to patients for now.

"We're maintaining telehealth access because we know that's the best thing for our patients. We've got full confidence that reimbursement will follow, but patients can't wait for Congress to act at this point," Newman told Medscape Medical News. "They still need access to their specialists. They still need access to their primary care providers, and this is one of the only ways that a lot of our patients get access. For them, it's either virtual care or no care at all."

Newman said as the shutdown continues, Sanford may reconsidered whether it can keep providing these appointments without reimbursement.

Some health systems have stopped providing an Medicare telehealth appointments, said Alexis Apple, director of federal affairs at the American Telemedicine Association. That means patients must appear in person for their doctor's appointment or cancel.

NYU Langone Health system's website currently has a banner that reads: "Due to the federal government shutdown, Medicare and Medicaid patients are unable to schedule new telehealth/video visits. If you already have a visit scheduled, it will continue as planned. If not, contact your doctor's office to schedule an in-person appointment.

"It's creating lots of confusion in the industry from patients, providers, hospital systems. You know, what do we do next? How do we grapple with this shutdown?" said Apple. "Patients have been able to receive care within their homes over the past 5 years, and now, all of a sudden, they've been stripped of that access."

Medicare patients who continue telehealth after October 1 may find out they're on the hook for the bill, if Congress doesn't act, said Apple.

Some physicians worry that commercial insurance payers may follow suit and no longer cover virtual appointments. Medicare, which is the largest health care payer in the country, is often seen as the standard for what services should be covered.

Patients and doctors have come to rely on telehealth as an integral part of health care, said Richard Chou, an anesthesiologist at the US Department of Veterans Affairs (VA) in Sacramento, California.

"You're seeing that postpandemic, telehealth is kind of a new way of doing things. It's part of the day for us as doctors," said Chou. He said tha tmany of his VA patients do their preliminary surgery appointments via telehealth before coming into the facility.

"Telehealth is that bridge to making sure patients get the care they need, and when these patients don't get that preliminary care they need, this builds up and builds up," said Chou. "And next thing you know, you have people flooding the emergency rooms, and we can't have that."

Will Telehealth Reimbursement See a Permanent Fix?

With Congressional budget negotiations at an impasse, it remains unclear when the shutdown will end.

Health care spending disagreements weigh heavily in negotiations. Democrats are currently unwilling to give the votes to pass the 60-vote threshold in the Senate unless Republicans agree to extend Affordable Care Act subsidies that expire at the end of the year. Democrats also want to reverse the Medicaid cuts that were part of the large Republican domestic tax and spending bill passed by Congress earlier this year.

When lawmakers do reach an agreement and reopen the government, it's likely telehealth flexibilities will be included in any package but for how long remains in question.

A newly introduced bipartisan bill would permanently allow Medicare patients to access telehealth appointments in their homes. But the legislation has been estimated to be very costly.

Federal data does show that telehealth appointments have been popular with Medicare recipients and increased over time since telehealth became more accessible.

"I used to say that virtual care was the future of medicine, and now it's just kind of the present of medicine. It used to be like a cool technology that we used to advertise, now it's just the standard of care," said Newman. "We think that permanent coverage would mean stability for both patients and providers."

Victoria Knight is a freelance reporter based in Washington, DC.

A version of this article first appeared on Medscape.com.

The ongoing US government partial shutdown has unintended consequences for seniors and their doctors as most telehealth appointments are now no longer being covered by Medicare.

That's because without a budget deal, federal lawmakers did not renew some pandemic-era telehealth flexibilities allowing Medicare beneficiaries to have medical appointments with doctors over audio or video at home.

This policy was first put into place under the first Trump Administration in 2020 during the COVID-19 pandemic. Previously, Medicare covered very limited telehealth services for rural patients.

For the past 5 years, lawmakers have always managed to renew the telehealth flexibilities in every government funding bill before the expiration date. This year, however, they expired for the first time on October 1.

Federal lawmakers remain at odds on the 2026 federal funding bill, meaning the shutdown could last into more days and even weeks.

But with Congress in a standoff, clinicians and patients outside Washington, DC, are already grappling with the consequences of the funding impasse.

Clinicians, Patients Already Feeling Effects

For the South Dakota-based Sanford Health System, which is the largest rural health system in the country, the past week without the Medicare telehealth waivers being in place has caused a lot of anxiety and uncertainty for both patients and clinicians.

Dave Newman, an endocrinologist and chief medical officer of virtual care at Sanford, said the health system decided to keep providing Medicare telehealth appointments to patients for now.

"We're maintaining telehealth access because we know that's the best thing for our patients. We've got full confidence that reimbursement will follow, but patients can't wait for Congress to act at this point," Newman told Medscape Medical News. "They still need access to their specialists. They still need access to their primary care providers, and this is one of the only ways that a lot of our patients get access. For them, it's either virtual care or no care at all."

Newman said as the shutdown continues, Sanford may reconsidered whether it can keep providing these appointments without reimbursement.

Some health systems have stopped providing an Medicare telehealth appointments, said Alexis Apple, director of federal affairs at the American Telemedicine Association. That means patients must appear in person for their doctor's appointment or cancel.

NYU Langone Health system's website currently has a banner that reads: "Due to the federal government shutdown, Medicare and Medicaid patients are unable to schedule new telehealth/video visits. If you already have a visit scheduled, it will continue as planned. If not, contact your doctor's office to schedule an in-person appointment.

"It's creating lots of confusion in the industry from patients, providers, hospital systems. You know, what do we do next? How do we grapple with this shutdown?" said Apple. "Patients have been able to receive care within their homes over the past 5 years, and now, all of a sudden, they've been stripped of that access."

Medicare patients who continue telehealth after October 1 may find out they're on the hook for the bill, if Congress doesn't act, said Apple.

Some physicians worry that commercial insurance payers may follow suit and no longer cover virtual appointments. Medicare, which is the largest health care payer in the country, is often seen as the standard for what services should be covered.

Patients and doctors have come to rely on telehealth as an integral part of health care, said Richard Chou, an anesthesiologist at the US Department of Veterans Affairs (VA) in Sacramento, California.

"You're seeing that postpandemic, telehealth is kind of a new way of doing things. It's part of the day for us as doctors," said Chou. He said tha tmany of his VA patients do their preliminary surgery appointments via telehealth before coming into the facility.

"Telehealth is that bridge to making sure patients get the care they need, and when these patients don't get that preliminary care they need, this builds up and builds up," said Chou. "And next thing you know, you have people flooding the emergency rooms, and we can't have that."

Will Telehealth Reimbursement See a Permanent Fix?

With Congressional budget negotiations at an impasse, it remains unclear when the shutdown will end.

Health care spending disagreements weigh heavily in negotiations. Democrats are currently unwilling to give the votes to pass the 60-vote threshold in the Senate unless Republicans agree to extend Affordable Care Act subsidies that expire at the end of the year. Democrats also want to reverse the Medicaid cuts that were part of the large Republican domestic tax and spending bill passed by Congress earlier this year.

When lawmakers do reach an agreement and reopen the government, it's likely telehealth flexibilities will be included in any package but for how long remains in question.

A newly introduced bipartisan bill would permanently allow Medicare patients to access telehealth appointments in their homes. But the legislation has been estimated to be very costly.

Federal data does show that telehealth appointments have been popular with Medicare recipients and increased over time since telehealth became more accessible.

"I used to say that virtual care was the future of medicine, and now it's just kind of the present of medicine. It used to be like a cool technology that we used to advertise, now it's just the standard of care," said Newman. "We think that permanent coverage would mean stability for both patients and providers."

Victoria Knight is a freelance reporter based in Washington, DC.

A version of this article first appeared on Medscape.com.

The ongoing US government partial shutdown has unintended consequences for seniors and their doctors as most telehealth appointments are now no longer being covered by Medicare.

That's because without a budget deal, federal lawmakers did not renew some pandemic-era telehealth flexibilities allowing Medicare beneficiaries to have medical appointments with doctors over audio or video at home.

This policy was first put into place under the first Trump Administration in 2020 during the COVID-19 pandemic. Previously, Medicare covered very limited telehealth services for rural patients.

For the past 5 years, lawmakers have always managed to renew the telehealth flexibilities in every government funding bill before the expiration date. This year, however, they expired for the first time on October 1.

Federal lawmakers remain at odds on the 2026 federal funding bill, meaning the shutdown could last into more days and even weeks.

But with Congress in a standoff, clinicians and patients outside Washington, DC, are already grappling with the consequences of the funding impasse.

Clinicians, Patients Already Feeling Effects

For the South Dakota-based Sanford Health System, which is the largest rural health system in the country, the past week without the Medicare telehealth waivers being in place has caused a lot of anxiety and uncertainty for both patients and clinicians.

Dave Newman, an endocrinologist and chief medical officer of virtual care at Sanford, said the health system decided to keep providing Medicare telehealth appointments to patients for now.

"We're maintaining telehealth access because we know that's the best thing for our patients. We've got full confidence that reimbursement will follow, but patients can't wait for Congress to act at this point," Newman told Medscape Medical News. "They still need access to their specialists. They still need access to their primary care providers, and this is one of the only ways that a lot of our patients get access. For them, it's either virtual care or no care at all."

Newman said as the shutdown continues, Sanford may reconsidered whether it can keep providing these appointments without reimbursement.

Some health systems have stopped providing an Medicare telehealth appointments, said Alexis Apple, director of federal affairs at the American Telemedicine Association. That means patients must appear in person for their doctor's appointment or cancel.

NYU Langone Health system's website currently has a banner that reads: "Due to the federal government shutdown, Medicare and Medicaid patients are unable to schedule new telehealth/video visits. If you already have a visit scheduled, it will continue as planned. If not, contact your doctor's office to schedule an in-person appointment.

"It's creating lots of confusion in the industry from patients, providers, hospital systems. You know, what do we do next? How do we grapple with this shutdown?" said Apple. "Patients have been able to receive care within their homes over the past 5 years, and now, all of a sudden, they've been stripped of that access."

Medicare patients who continue telehealth after October 1 may find out they're on the hook for the bill, if Congress doesn't act, said Apple.

Some physicians worry that commercial insurance payers may follow suit and no longer cover virtual appointments. Medicare, which is the largest health care payer in the country, is often seen as the standard for what services should be covered.

Patients and doctors have come to rely on telehealth as an integral part of health care, said Richard Chou, an anesthesiologist at the US Department of Veterans Affairs (VA) in Sacramento, California.

"You're seeing that postpandemic, telehealth is kind of a new way of doing things. It's part of the day for us as doctors," said Chou. He said tha tmany of his VA patients do their preliminary surgery appointments via telehealth before coming into the facility.

"Telehealth is that bridge to making sure patients get the care they need, and when these patients don't get that preliminary care they need, this builds up and builds up," said Chou. "And next thing you know, you have people flooding the emergency rooms, and we can't have that."

Will Telehealth Reimbursement See a Permanent Fix?

With Congressional budget negotiations at an impasse, it remains unclear when the shutdown will end.

Health care spending disagreements weigh heavily in negotiations. Democrats are currently unwilling to give the votes to pass the 60-vote threshold in the Senate unless Republicans agree to extend Affordable Care Act subsidies that expire at the end of the year. Democrats also want to reverse the Medicaid cuts that were part of the large Republican domestic tax and spending bill passed by Congress earlier this year.

When lawmakers do reach an agreement and reopen the government, it's likely telehealth flexibilities will be included in any package but for how long remains in question.

A newly introduced bipartisan bill would permanently allow Medicare patients to access telehealth appointments in their homes. But the legislation has been estimated to be very costly.

Federal data does show that telehealth appointments have been popular with Medicare recipients and increased over time since telehealth became more accessible.

"I used to say that virtual care was the future of medicine, and now it's just kind of the present of medicine. It used to be like a cool technology that we used to advertise, now it's just the standard of care," said Newman. "We think that permanent coverage would mean stability for both patients and providers."

Victoria Knight is a freelance reporter based in Washington, DC.

A version of this article first appeared on Medscape.com.