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Child of The New Gastroenterologist
Gastroenterology practice evaluations: Can patients get satisfaction?
Although largely untouched by the first and second industrial revolutions in the 18th and 20th centuries, the practice of medicine in the 21st century is increasingly susceptible to the vast transformative power of the third – and rapidly approaching fourth – industrial revolutions. New technological advances and their associated distribution of knowledge and connectedness have allowed patients unprecedented access to health care information. The salutary effects of this change is manifest in a diversity of areas, including registries that facilitate participation in state of the art research such as ClinicalTrials.gov and the ability to track nascent trends in infectious diseases with Google searches.1
Although the stakes may seem lower when patients go online to choose a practitioner, the reality demonstrates just how important those search results can be. With parallels of similar trends in other sectors, there is an increasing emphasis on ranking health care facilities, practitioners, and medical experiences. This phenomenon extends beyond private Internet sites into government scorecards, which has significant implications. But even with widespread access to information, there is frequently a lack of context for interpreting these data. Consequently, it is worth exploring why measuring satisfaction can be important, how patients can rate practitioners, and what to do with the available information to improve care delivery.
The idea to measure patient satisfaction of delivered health care began in earnest during the 1980s with Irwin Press and Rodney Ganey collaborating to create formal processes for collecting data on the “salient aspects of ... health care experience, [involving] the interaction of expectations, preferences, and satisfaction with medical care.”2,3 The enthusiasm for collecting these data has grown greatly since that time. More recently, the federal government began obtaining data in 2002 when the Centers for Medicaid & Medicare Services and the Agency for Healthcare Research and Quality (AHRQ) collaborated to develop a standardized questionnaire for hospitalized patients known as the Hospital Consumer Assessment of Healthcare Providers and Systems, or HCAHPS.4 Subsequently, standardized survey instruments have been developed for nearly every phase of care, including outpatient care (CG-CAHPS), emergency care (ED-CAHPS), and ambulatory surgery care (OAS-CAHPS). These instruments are particularly relevant to gastroenterologists, with questions querying patients about preprocedure instructions, surgery center check-in processes, comfort of procedure and waiting rooms, friendliness of providers, and quality of postprocedure information.
The focus on rating satisfaction intensified in 2010 after the passage of the Affordable Care Act (ACA). Around this time, patient satisfaction and health outcomes became more deeply integrated concepts in health care quality. As part of a broader emphasis in this area, CMS initiated the hospital value-based purchasing (VBP) program, which tied incentive payments for Medicare beneficiaries to hospital-based health care quality and patient satisfaction. Within this schema, 25% of performance, and its associated economic stakes, is measured by HCAHPS scores.5 Other value programs such as the Merit-Based Incentive Payment Program (MIPS) include CAHPS instruments as optional assessments of quality.
Given the financial risks linked to satisfaction rankings and their online visibility, many argue that patient satisfaction is prioritized in organizations above more clinically meaningful metrics. Studies have shown, however, that high levels of patient satisfaction can lead to increased patient loyalty, treatment adherence, patient retention, staff morale, and personal and professional satisfaction.6,7 In fact, not surprisingly, there is an inverse correlation between patient satisfaction and the rates of malpractice lawsuits.7-10
Despite the growing relevance of patient perceptions to clinical practice, measuring satisfaction remains a challenge. While current metrics are particular to an individual patient’s experiences, underlying health conditions influence opinions of these episodes of care. Specifically, patients with depression and anxiety are, in general, less satisfied with the care they receive.11,12 Similarly, patients with chronic diseases on multiple medications and those with more severe symptoms are commonly less satisfied with their care than are patients with acute issues2 and with milder symptoms.3 As gastroenterologists, seeing sicker patients with chronic conditions is not uncommon, and this could serve as a disadvantage when compared with peers in other specialties because scores are not typically adjusted.
Since patient-centered metrics are likely to remain relevant in the future, and with the unique challenges this can present to practicing gastroenterologists, achieving higher degrees of patient satisfaction remains both aspirational and difficult. We will be asked to reconcile and manage not only clinical conundrums but also seemingly conflicting realities of patient preferences. For example, it has been shown that, among patients with irritable bowel syndrome (IBS), more testing led to higher satisfaction only until that testing was performed within the context of a gastroenterologist’s care.13 In contrast, within the endoscopy setting, a preprocedure diagnosis of IBS did not increase the risk for procedure-related dissatisfaction, provided patients were not prescribed chronic psychotropic medication, nervous prior to the procedure, distressed or in pain during the procedure, or had unmet physical or emotional needs during the procedure.14 Furthermore, there is poor correlation between endoscopic quality measures with strong evidence – such as adenoma detection rate, withdrawal time, and cecal intubation rate – and patient satisfaction.15
So, when considering these conflicting findings and evidence that patients’ global rating of their health care is not reliably associated with the quality of the care they receive,16 should we emphasize experience over outcome? As clinicians practicing in an increasingly transparent and value-based health care environment, we are subject to many priorities contending for our attention. We strive to provide care that is at once patient centric, evidence based, and low cost; however, achieving these goals often requires different strategies. At the end of the day, our primary aim is to provide consistently excellent patient care. We believe that quality and experience are not competing principles. Patient satisfaction is relevant and important, but it should not preclude adherence to our primary responsibility of providing high-quality care.
When trying to make clinical decisions that may compromise one of these goals for another, it can be helpful to recall the “me and my family” rule: What kind of care would I want for myself or my loved ones in this situation?
Acknowledgement
We thank Dr. Ziad Gellad (Duke University, Durham, N.C.) for his assistance in reviewing and providing feedback on this manuscript.
1. Proc Natl Acad Sci U S A. 2015;112(47):14473-8. 2. Am J Manag Care. 1997;3(4):579-94.
3. Gut. 2004;53(SUPPL. 4):40-4.
4. Virtual Mentor. 2013;15(11):982-7.
5. J Hosp Med. 2013;8(5):271-7.
6. Int J Health Care Qual Assur. 2011;24(4):266-73.
7. J Cutan Aesthet Surg. 2010;3(3):151-5.
8. Am J Med. 2005;118(10):1126-33.
9. JAMA. 2002;287(22):2951-7. 10. JAMA. 1994;272(20):1583-7.
11. J Diabetes Metab. 2012;3(7):1000210.
12. Am Heart J. 2000;140(1):105-10.
13. J Clin Gastroenterol. 2018;52(7):614-21.
14. Dig Dis Sci. 2005;50(10):1860-71.15. Am J Gastroenterol. 2014;109(7):1089-91.
16. Ann Intern Med. 2006;144(9):665-72.
Dr. Finn is a gastroenterologist with the Palo Alto Medical Foundation, Mountain View, Calif.; Dr. Leiman is assistant professor of medicine, director of esophageal research and quality in the division of gastroenterology, Duke University, Duke Clinical Research Institute, and chair-elect of the AGA Quality Committee.
Although largely untouched by the first and second industrial revolutions in the 18th and 20th centuries, the practice of medicine in the 21st century is increasingly susceptible to the vast transformative power of the third – and rapidly approaching fourth – industrial revolutions. New technological advances and their associated distribution of knowledge and connectedness have allowed patients unprecedented access to health care information. The salutary effects of this change is manifest in a diversity of areas, including registries that facilitate participation in state of the art research such as ClinicalTrials.gov and the ability to track nascent trends in infectious diseases with Google searches.1
Although the stakes may seem lower when patients go online to choose a practitioner, the reality demonstrates just how important those search results can be. With parallels of similar trends in other sectors, there is an increasing emphasis on ranking health care facilities, practitioners, and medical experiences. This phenomenon extends beyond private Internet sites into government scorecards, which has significant implications. But even with widespread access to information, there is frequently a lack of context for interpreting these data. Consequently, it is worth exploring why measuring satisfaction can be important, how patients can rate practitioners, and what to do with the available information to improve care delivery.
The idea to measure patient satisfaction of delivered health care began in earnest during the 1980s with Irwin Press and Rodney Ganey collaborating to create formal processes for collecting data on the “salient aspects of ... health care experience, [involving] the interaction of expectations, preferences, and satisfaction with medical care.”2,3 The enthusiasm for collecting these data has grown greatly since that time. More recently, the federal government began obtaining data in 2002 when the Centers for Medicaid & Medicare Services and the Agency for Healthcare Research and Quality (AHRQ) collaborated to develop a standardized questionnaire for hospitalized patients known as the Hospital Consumer Assessment of Healthcare Providers and Systems, or HCAHPS.4 Subsequently, standardized survey instruments have been developed for nearly every phase of care, including outpatient care (CG-CAHPS), emergency care (ED-CAHPS), and ambulatory surgery care (OAS-CAHPS). These instruments are particularly relevant to gastroenterologists, with questions querying patients about preprocedure instructions, surgery center check-in processes, comfort of procedure and waiting rooms, friendliness of providers, and quality of postprocedure information.
The focus on rating satisfaction intensified in 2010 after the passage of the Affordable Care Act (ACA). Around this time, patient satisfaction and health outcomes became more deeply integrated concepts in health care quality. As part of a broader emphasis in this area, CMS initiated the hospital value-based purchasing (VBP) program, which tied incentive payments for Medicare beneficiaries to hospital-based health care quality and patient satisfaction. Within this schema, 25% of performance, and its associated economic stakes, is measured by HCAHPS scores.5 Other value programs such as the Merit-Based Incentive Payment Program (MIPS) include CAHPS instruments as optional assessments of quality.
Given the financial risks linked to satisfaction rankings and their online visibility, many argue that patient satisfaction is prioritized in organizations above more clinically meaningful metrics. Studies have shown, however, that high levels of patient satisfaction can lead to increased patient loyalty, treatment adherence, patient retention, staff morale, and personal and professional satisfaction.6,7 In fact, not surprisingly, there is an inverse correlation between patient satisfaction and the rates of malpractice lawsuits.7-10
Despite the growing relevance of patient perceptions to clinical practice, measuring satisfaction remains a challenge. While current metrics are particular to an individual patient’s experiences, underlying health conditions influence opinions of these episodes of care. Specifically, patients with depression and anxiety are, in general, less satisfied with the care they receive.11,12 Similarly, patients with chronic diseases on multiple medications and those with more severe symptoms are commonly less satisfied with their care than are patients with acute issues2 and with milder symptoms.3 As gastroenterologists, seeing sicker patients with chronic conditions is not uncommon, and this could serve as a disadvantage when compared with peers in other specialties because scores are not typically adjusted.
Since patient-centered metrics are likely to remain relevant in the future, and with the unique challenges this can present to practicing gastroenterologists, achieving higher degrees of patient satisfaction remains both aspirational and difficult. We will be asked to reconcile and manage not only clinical conundrums but also seemingly conflicting realities of patient preferences. For example, it has been shown that, among patients with irritable bowel syndrome (IBS), more testing led to higher satisfaction only until that testing was performed within the context of a gastroenterologist’s care.13 In contrast, within the endoscopy setting, a preprocedure diagnosis of IBS did not increase the risk for procedure-related dissatisfaction, provided patients were not prescribed chronic psychotropic medication, nervous prior to the procedure, distressed or in pain during the procedure, or had unmet physical or emotional needs during the procedure.14 Furthermore, there is poor correlation between endoscopic quality measures with strong evidence – such as adenoma detection rate, withdrawal time, and cecal intubation rate – and patient satisfaction.15
So, when considering these conflicting findings and evidence that patients’ global rating of their health care is not reliably associated with the quality of the care they receive,16 should we emphasize experience over outcome? As clinicians practicing in an increasingly transparent and value-based health care environment, we are subject to many priorities contending for our attention. We strive to provide care that is at once patient centric, evidence based, and low cost; however, achieving these goals often requires different strategies. At the end of the day, our primary aim is to provide consistently excellent patient care. We believe that quality and experience are not competing principles. Patient satisfaction is relevant and important, but it should not preclude adherence to our primary responsibility of providing high-quality care.
When trying to make clinical decisions that may compromise one of these goals for another, it can be helpful to recall the “me and my family” rule: What kind of care would I want for myself or my loved ones in this situation?
Acknowledgement
We thank Dr. Ziad Gellad (Duke University, Durham, N.C.) for his assistance in reviewing and providing feedback on this manuscript.
1. Proc Natl Acad Sci U S A. 2015;112(47):14473-8. 2. Am J Manag Care. 1997;3(4):579-94.
3. Gut. 2004;53(SUPPL. 4):40-4.
4. Virtual Mentor. 2013;15(11):982-7.
5. J Hosp Med. 2013;8(5):271-7.
6. Int J Health Care Qual Assur. 2011;24(4):266-73.
7. J Cutan Aesthet Surg. 2010;3(3):151-5.
8. Am J Med. 2005;118(10):1126-33.
9. JAMA. 2002;287(22):2951-7. 10. JAMA. 1994;272(20):1583-7.
11. J Diabetes Metab. 2012;3(7):1000210.
12. Am Heart J. 2000;140(1):105-10.
13. J Clin Gastroenterol. 2018;52(7):614-21.
14. Dig Dis Sci. 2005;50(10):1860-71.15. Am J Gastroenterol. 2014;109(7):1089-91.
16. Ann Intern Med. 2006;144(9):665-72.
Dr. Finn is a gastroenterologist with the Palo Alto Medical Foundation, Mountain View, Calif.; Dr. Leiman is assistant professor of medicine, director of esophageal research and quality in the division of gastroenterology, Duke University, Duke Clinical Research Institute, and chair-elect of the AGA Quality Committee.
Although largely untouched by the first and second industrial revolutions in the 18th and 20th centuries, the practice of medicine in the 21st century is increasingly susceptible to the vast transformative power of the third – and rapidly approaching fourth – industrial revolutions. New technological advances and their associated distribution of knowledge and connectedness have allowed patients unprecedented access to health care information. The salutary effects of this change is manifest in a diversity of areas, including registries that facilitate participation in state of the art research such as ClinicalTrials.gov and the ability to track nascent trends in infectious diseases with Google searches.1
Although the stakes may seem lower when patients go online to choose a practitioner, the reality demonstrates just how important those search results can be. With parallels of similar trends in other sectors, there is an increasing emphasis on ranking health care facilities, practitioners, and medical experiences. This phenomenon extends beyond private Internet sites into government scorecards, which has significant implications. But even with widespread access to information, there is frequently a lack of context for interpreting these data. Consequently, it is worth exploring why measuring satisfaction can be important, how patients can rate practitioners, and what to do with the available information to improve care delivery.
The idea to measure patient satisfaction of delivered health care began in earnest during the 1980s with Irwin Press and Rodney Ganey collaborating to create formal processes for collecting data on the “salient aspects of ... health care experience, [involving] the interaction of expectations, preferences, and satisfaction with medical care.”2,3 The enthusiasm for collecting these data has grown greatly since that time. More recently, the federal government began obtaining data in 2002 when the Centers for Medicaid & Medicare Services and the Agency for Healthcare Research and Quality (AHRQ) collaborated to develop a standardized questionnaire for hospitalized patients known as the Hospital Consumer Assessment of Healthcare Providers and Systems, or HCAHPS.4 Subsequently, standardized survey instruments have been developed for nearly every phase of care, including outpatient care (CG-CAHPS), emergency care (ED-CAHPS), and ambulatory surgery care (OAS-CAHPS). These instruments are particularly relevant to gastroenterologists, with questions querying patients about preprocedure instructions, surgery center check-in processes, comfort of procedure and waiting rooms, friendliness of providers, and quality of postprocedure information.
The focus on rating satisfaction intensified in 2010 after the passage of the Affordable Care Act (ACA). Around this time, patient satisfaction and health outcomes became more deeply integrated concepts in health care quality. As part of a broader emphasis in this area, CMS initiated the hospital value-based purchasing (VBP) program, which tied incentive payments for Medicare beneficiaries to hospital-based health care quality and patient satisfaction. Within this schema, 25% of performance, and its associated economic stakes, is measured by HCAHPS scores.5 Other value programs such as the Merit-Based Incentive Payment Program (MIPS) include CAHPS instruments as optional assessments of quality.
Given the financial risks linked to satisfaction rankings and their online visibility, many argue that patient satisfaction is prioritized in organizations above more clinically meaningful metrics. Studies have shown, however, that high levels of patient satisfaction can lead to increased patient loyalty, treatment adherence, patient retention, staff morale, and personal and professional satisfaction.6,7 In fact, not surprisingly, there is an inverse correlation between patient satisfaction and the rates of malpractice lawsuits.7-10
Despite the growing relevance of patient perceptions to clinical practice, measuring satisfaction remains a challenge. While current metrics are particular to an individual patient’s experiences, underlying health conditions influence opinions of these episodes of care. Specifically, patients with depression and anxiety are, in general, less satisfied with the care they receive.11,12 Similarly, patients with chronic diseases on multiple medications and those with more severe symptoms are commonly less satisfied with their care than are patients with acute issues2 and with milder symptoms.3 As gastroenterologists, seeing sicker patients with chronic conditions is not uncommon, and this could serve as a disadvantage when compared with peers in other specialties because scores are not typically adjusted.
Since patient-centered metrics are likely to remain relevant in the future, and with the unique challenges this can present to practicing gastroenterologists, achieving higher degrees of patient satisfaction remains both aspirational and difficult. We will be asked to reconcile and manage not only clinical conundrums but also seemingly conflicting realities of patient preferences. For example, it has been shown that, among patients with irritable bowel syndrome (IBS), more testing led to higher satisfaction only until that testing was performed within the context of a gastroenterologist’s care.13 In contrast, within the endoscopy setting, a preprocedure diagnosis of IBS did not increase the risk for procedure-related dissatisfaction, provided patients were not prescribed chronic psychotropic medication, nervous prior to the procedure, distressed or in pain during the procedure, or had unmet physical or emotional needs during the procedure.14 Furthermore, there is poor correlation between endoscopic quality measures with strong evidence – such as adenoma detection rate, withdrawal time, and cecal intubation rate – and patient satisfaction.15
So, when considering these conflicting findings and evidence that patients’ global rating of their health care is not reliably associated with the quality of the care they receive,16 should we emphasize experience over outcome? As clinicians practicing in an increasingly transparent and value-based health care environment, we are subject to many priorities contending for our attention. We strive to provide care that is at once patient centric, evidence based, and low cost; however, achieving these goals often requires different strategies. At the end of the day, our primary aim is to provide consistently excellent patient care. We believe that quality and experience are not competing principles. Patient satisfaction is relevant and important, but it should not preclude adherence to our primary responsibility of providing high-quality care.
When trying to make clinical decisions that may compromise one of these goals for another, it can be helpful to recall the “me and my family” rule: What kind of care would I want for myself or my loved ones in this situation?
Acknowledgement
We thank Dr. Ziad Gellad (Duke University, Durham, N.C.) for his assistance in reviewing and providing feedback on this manuscript.
1. Proc Natl Acad Sci U S A. 2015;112(47):14473-8. 2. Am J Manag Care. 1997;3(4):579-94.
3. Gut. 2004;53(SUPPL. 4):40-4.
4. Virtual Mentor. 2013;15(11):982-7.
5. J Hosp Med. 2013;8(5):271-7.
6. Int J Health Care Qual Assur. 2011;24(4):266-73.
7. J Cutan Aesthet Surg. 2010;3(3):151-5.
8. Am J Med. 2005;118(10):1126-33.
9. JAMA. 2002;287(22):2951-7. 10. JAMA. 1994;272(20):1583-7.
11. J Diabetes Metab. 2012;3(7):1000210.
12. Am Heart J. 2000;140(1):105-10.
13. J Clin Gastroenterol. 2018;52(7):614-21.
14. Dig Dis Sci. 2005;50(10):1860-71.15. Am J Gastroenterol. 2014;109(7):1089-91.
16. Ann Intern Med. 2006;144(9):665-72.
Dr. Finn is a gastroenterologist with the Palo Alto Medical Foundation, Mountain View, Calif.; Dr. Leiman is assistant professor of medicine, director of esophageal research and quality in the division of gastroenterology, Duke University, Duke Clinical Research Institute, and chair-elect of the AGA Quality Committee.
Mentoring during fellowship to improve career fit, decrease burnout, and optimize career satisfaction among young gastroenterologists
Introduction
Burnout in physicians has received significant attention within the past several years, particularly among trainees and early-career physicians. The subspecialties of gastroenterology and hepatology are not immune to burnout, with multiple studies indicating that early career gastroenterologists may be disproportionately affected, compared with their more-established counterparts.1-4 Although the drivers of depersonalization, emotional exhaustion, and a reduced sense of personal accomplishment among trainees and early-career gastroenterologists are not fully understood, maximizing career fit during the transition from fellowship into the first posttraining position has been promoted as a potential method to decrease burnout in this population.4,5
While most trainees enter gastroenterology fellowships with a set of predefined career goals, mentorship during fellowship can provide critical guidance along with exposure to new areas and career tracks that were not previously considered. In a survey of gastroenterology and transplant hepatology fellows, 94% of participants with a mentor reported that the mentor significantly influenced their career decision.6 Effective mentoring also has been identified as one possible method to decrease burnout among trainees.7,8
Formal mentoring in gastroenterology fellowship programs might decrease burnout through effectively identifying risk factors such as work hour violations or a lack of social support. Additionally, when fellows are being prepared for transition to their first positions as attending gastroenterologists, there is a critical opportunity to improve career fit and decrease burnout rates among early-career gastroenterologists. Making the correct choice of subsequent career path after fellowship might be a source of stress, but this should allow early-career gastroenterologists to maximize the time spent doing those activities they feel are the most rewarding. A formal mentoring system and an accessible career mentor can be invaluable in allowing the mentee to identify and select that position.
Career fit
The concept of career fit has been described as the ability of individuals to focus their effort on the aspect or aspects of their work that they find most meaningful.5 Multiple specialties have recognized the importance of career fit and the need to choose appropriately when selecting a position and career path upon completing fellowship. In one evaluation of faculty members from the department of medicine at a large academic medical center, those individuals who spent less than 20% of their time working on the activity that they found most meaningful were significantly more likely to demonstrate burnout.5
In a relatively short time period, gastroenterology fellows are required to gather multiple new skill sets, including functioning as a consultant, performing endoscopic procedures, and potentially gaining formal training in clinical, basic, or translational research methods. During this same period, an intense phase of self-assessment should begin, with one critical aim of training being to identify those factors most likely to lead to a long, satisfying career. The growth that occurs during fellowship may allow for the identification of a career track that is likely to be the most rewarding, such as a career as a clinical investigator, clinician educator, or in clinical practice. Importantly, the trainee must decide which career track will most likely lead to self-fulfillment, even if the chosen path does not align with a mentor or advisor. Additionally, self-assessment also may aid in the identification of a niche that an individual finds most intellectually stimulating, which may lead to an area of research or clinical expertise.
While the demonstrated relationship between career fit and burnout is only an association without demonstrated causation, this does merit further consideration. For the first time in most trainees’ careers, the position after fellowship represents an opportunity to choose a job as opposed to going through a “match” process. Therefore, the trainee must strongly consider the factors that will ultimately lead to career satisfaction. If a large disconnect is present between self-identified career goals and the actual tasks required within daily workflow, this may lead to burnout relatively early in a career. Perhaps more importantly, if an individual did not perform adequate self-reflection when choosing a career path or did not receive effective guidance from career mentors, this also might lead to decreased career satisfaction, poor career fit, and an increased risk for burnout as an early-career gastroenterologist.
The mentor’s role
Although a structured career mentoring program is in place within many gastroenterology training programs, other fellowships encourage the mentee to select from a pool of potential mentors. In many cases, trainees and early career gastroenterologists will benefit from building a mentorship team, including career mentor or mentors, research mentors, and other advisors.9
While the mentor-mentee relationship can be an extremely rewarding experience for both parties, the effective mentor must meet a high standard. Several qualities have been identified that will maximize the benefit of the mentor-mentee relationship for the trainee, including the mentor taking a selfless approach to the relationship, working to assist the mentee in choosing a career path that will be the most rewarding, and then aiding the mentee in making helpful connections to promote growth along that chosen path.9 A good mentors should inspire a mentees, but also should be willing to provide honest and at times critical feedback to ensure that mentees maximizes their potential and ultimately assume the appropriate career trajectory. Unbiased mentorship, as well as continued reevaluations of strengths, weaknesses, and career goals by the mentor and mentee, will ultimately offer an opportunity to ensure the best combination of career fit,5 work-life balance,10 and satisfaction with career choice.11
The mentor-mentee relationship after training is complete
Once a trainee has completed gastroenterology fellowship, another stressful transition to the role of an attending physician commences. It is critical that early-career gastroenterologists not only have confidence in the guidance that their mentor has provided to ensure appropriate career fit in their new role but also maintain these critical mentor-mentee relationships during this transition. A good mentor does not disappear because one phase of training is complete. The need for effective mentoring at the junior faculty level also is well recognized,12 and early-career gastroenterologists should continue to rely on established mentoring relationships when new decision points are encountered.
Depending on the career track of an early-career gastroenterologist, formal mentoring also may be offered in the new role as a junior faculty member.12 Additionally, external mentoring can exist within foundations or other subspecialty groups. One example of extramural mentoring is the Career Connection Program offered through the Crohn’s & Colitis Foundation’s Rising Educators Academics and Clinicians Helping IBD (REACH-IBD) platform. In this program, early-career gastroenterologists are selected and paired with national opinion leaders for one-on-one mentoring relationships. Such a program offers further opportunities for career growth, establishing connections within a smaller subspecialty of gastroenterology, and maximizing career fit.
Conclusion
In an era where the toll of burnout and other influences on early-career gastroenterologists are increasingly being recognized, the importance of career fit during the transition into the role of an attending should not be underestimated. In conjunction with appropriate self-reflection, unbiased and critical mentorship during fellowship can promote significant growth among trainees and allow for the ultimate selection of a career track or career path that will promote happiness, work-life balance, and long-term success as defined by the mentee.
Edward L. Barnes, MD, MPH, is with the Multidisciplinary Center for Inflammatory Bowel Diseases and the Center for Gastrointestinal Biology and Disease in the division of gastroenterology and hepatology at the University of North Carolina at Chapel Hill. Dr. Barnes reports no relevant disclosures.
References
1. Keswani RN et al. Am J Gastroenterol. 2011;106(10):1734-40.
2. Burke C et al. Am J Gastroenterol. 2017;112:S593-4.
3. DeCross AJ. AGA Perspectives. 2017.
4. Barnes EL et al. Dig Dis Sci. 2019;64(2):302-6.
5. Shanafelt TD et al. Arch Intern Med. 2009;169(10):990-5.
6. Ordway SM et al. Hepatol Commun. 2017;1(4):347-53.
7. Janko MR, Smeds MR. J Vasc Surg. 2019;69(4):1233-42.
8. Eckleberry-Hunt J et al. Acad Med. 2009;84(2):269-77.
9. Lieberman D. Gastroenterology. 2016;151(1):17-9.
10. Shanafelt TD et al. Mayo Clin Proc. 2015;90(12):1600-13.
11. Shanafelt TD et al. Ann Surg. 2009;250(3):463-71.
12. Shaheen NJ, Sandler RS. Gastroenterology. 2018;155(5):1293-7.
Introduction
Burnout in physicians has received significant attention within the past several years, particularly among trainees and early-career physicians. The subspecialties of gastroenterology and hepatology are not immune to burnout, with multiple studies indicating that early career gastroenterologists may be disproportionately affected, compared with their more-established counterparts.1-4 Although the drivers of depersonalization, emotional exhaustion, and a reduced sense of personal accomplishment among trainees and early-career gastroenterologists are not fully understood, maximizing career fit during the transition from fellowship into the first posttraining position has been promoted as a potential method to decrease burnout in this population.4,5
While most trainees enter gastroenterology fellowships with a set of predefined career goals, mentorship during fellowship can provide critical guidance along with exposure to new areas and career tracks that were not previously considered. In a survey of gastroenterology and transplant hepatology fellows, 94% of participants with a mentor reported that the mentor significantly influenced their career decision.6 Effective mentoring also has been identified as one possible method to decrease burnout among trainees.7,8
Formal mentoring in gastroenterology fellowship programs might decrease burnout through effectively identifying risk factors such as work hour violations or a lack of social support. Additionally, when fellows are being prepared for transition to their first positions as attending gastroenterologists, there is a critical opportunity to improve career fit and decrease burnout rates among early-career gastroenterologists. Making the correct choice of subsequent career path after fellowship might be a source of stress, but this should allow early-career gastroenterologists to maximize the time spent doing those activities they feel are the most rewarding. A formal mentoring system and an accessible career mentor can be invaluable in allowing the mentee to identify and select that position.
Career fit
The concept of career fit has been described as the ability of individuals to focus their effort on the aspect or aspects of their work that they find most meaningful.5 Multiple specialties have recognized the importance of career fit and the need to choose appropriately when selecting a position and career path upon completing fellowship. In one evaluation of faculty members from the department of medicine at a large academic medical center, those individuals who spent less than 20% of their time working on the activity that they found most meaningful were significantly more likely to demonstrate burnout.5
In a relatively short time period, gastroenterology fellows are required to gather multiple new skill sets, including functioning as a consultant, performing endoscopic procedures, and potentially gaining formal training in clinical, basic, or translational research methods. During this same period, an intense phase of self-assessment should begin, with one critical aim of training being to identify those factors most likely to lead to a long, satisfying career. The growth that occurs during fellowship may allow for the identification of a career track that is likely to be the most rewarding, such as a career as a clinical investigator, clinician educator, or in clinical practice. Importantly, the trainee must decide which career track will most likely lead to self-fulfillment, even if the chosen path does not align with a mentor or advisor. Additionally, self-assessment also may aid in the identification of a niche that an individual finds most intellectually stimulating, which may lead to an area of research or clinical expertise.
While the demonstrated relationship between career fit and burnout is only an association without demonstrated causation, this does merit further consideration. For the first time in most trainees’ careers, the position after fellowship represents an opportunity to choose a job as opposed to going through a “match” process. Therefore, the trainee must strongly consider the factors that will ultimately lead to career satisfaction. If a large disconnect is present between self-identified career goals and the actual tasks required within daily workflow, this may lead to burnout relatively early in a career. Perhaps more importantly, if an individual did not perform adequate self-reflection when choosing a career path or did not receive effective guidance from career mentors, this also might lead to decreased career satisfaction, poor career fit, and an increased risk for burnout as an early-career gastroenterologist.
The mentor’s role
Although a structured career mentoring program is in place within many gastroenterology training programs, other fellowships encourage the mentee to select from a pool of potential mentors. In many cases, trainees and early career gastroenterologists will benefit from building a mentorship team, including career mentor or mentors, research mentors, and other advisors.9
While the mentor-mentee relationship can be an extremely rewarding experience for both parties, the effective mentor must meet a high standard. Several qualities have been identified that will maximize the benefit of the mentor-mentee relationship for the trainee, including the mentor taking a selfless approach to the relationship, working to assist the mentee in choosing a career path that will be the most rewarding, and then aiding the mentee in making helpful connections to promote growth along that chosen path.9 A good mentors should inspire a mentees, but also should be willing to provide honest and at times critical feedback to ensure that mentees maximizes their potential and ultimately assume the appropriate career trajectory. Unbiased mentorship, as well as continued reevaluations of strengths, weaknesses, and career goals by the mentor and mentee, will ultimately offer an opportunity to ensure the best combination of career fit,5 work-life balance,10 and satisfaction with career choice.11
The mentor-mentee relationship after training is complete
Once a trainee has completed gastroenterology fellowship, another stressful transition to the role of an attending physician commences. It is critical that early-career gastroenterologists not only have confidence in the guidance that their mentor has provided to ensure appropriate career fit in their new role but also maintain these critical mentor-mentee relationships during this transition. A good mentor does not disappear because one phase of training is complete. The need for effective mentoring at the junior faculty level also is well recognized,12 and early-career gastroenterologists should continue to rely on established mentoring relationships when new decision points are encountered.
Depending on the career track of an early-career gastroenterologist, formal mentoring also may be offered in the new role as a junior faculty member.12 Additionally, external mentoring can exist within foundations or other subspecialty groups. One example of extramural mentoring is the Career Connection Program offered through the Crohn’s & Colitis Foundation’s Rising Educators Academics and Clinicians Helping IBD (REACH-IBD) platform. In this program, early-career gastroenterologists are selected and paired with national opinion leaders for one-on-one mentoring relationships. Such a program offers further opportunities for career growth, establishing connections within a smaller subspecialty of gastroenterology, and maximizing career fit.
Conclusion
In an era where the toll of burnout and other influences on early-career gastroenterologists are increasingly being recognized, the importance of career fit during the transition into the role of an attending should not be underestimated. In conjunction with appropriate self-reflection, unbiased and critical mentorship during fellowship can promote significant growth among trainees and allow for the ultimate selection of a career track or career path that will promote happiness, work-life balance, and long-term success as defined by the mentee.
Edward L. Barnes, MD, MPH, is with the Multidisciplinary Center for Inflammatory Bowel Diseases and the Center for Gastrointestinal Biology and Disease in the division of gastroenterology and hepatology at the University of North Carolina at Chapel Hill. Dr. Barnes reports no relevant disclosures.
References
1. Keswani RN et al. Am J Gastroenterol. 2011;106(10):1734-40.
2. Burke C et al. Am J Gastroenterol. 2017;112:S593-4.
3. DeCross AJ. AGA Perspectives. 2017.
4. Barnes EL et al. Dig Dis Sci. 2019;64(2):302-6.
5. Shanafelt TD et al. Arch Intern Med. 2009;169(10):990-5.
6. Ordway SM et al. Hepatol Commun. 2017;1(4):347-53.
7. Janko MR, Smeds MR. J Vasc Surg. 2019;69(4):1233-42.
8. Eckleberry-Hunt J et al. Acad Med. 2009;84(2):269-77.
9. Lieberman D. Gastroenterology. 2016;151(1):17-9.
10. Shanafelt TD et al. Mayo Clin Proc. 2015;90(12):1600-13.
11. Shanafelt TD et al. Ann Surg. 2009;250(3):463-71.
12. Shaheen NJ, Sandler RS. Gastroenterology. 2018;155(5):1293-7.
Introduction
Burnout in physicians has received significant attention within the past several years, particularly among trainees and early-career physicians. The subspecialties of gastroenterology and hepatology are not immune to burnout, with multiple studies indicating that early career gastroenterologists may be disproportionately affected, compared with their more-established counterparts.1-4 Although the drivers of depersonalization, emotional exhaustion, and a reduced sense of personal accomplishment among trainees and early-career gastroenterologists are not fully understood, maximizing career fit during the transition from fellowship into the first posttraining position has been promoted as a potential method to decrease burnout in this population.4,5
While most trainees enter gastroenterology fellowships with a set of predefined career goals, mentorship during fellowship can provide critical guidance along with exposure to new areas and career tracks that were not previously considered. In a survey of gastroenterology and transplant hepatology fellows, 94% of participants with a mentor reported that the mentor significantly influenced their career decision.6 Effective mentoring also has been identified as one possible method to decrease burnout among trainees.7,8
Formal mentoring in gastroenterology fellowship programs might decrease burnout through effectively identifying risk factors such as work hour violations or a lack of social support. Additionally, when fellows are being prepared for transition to their first positions as attending gastroenterologists, there is a critical opportunity to improve career fit and decrease burnout rates among early-career gastroenterologists. Making the correct choice of subsequent career path after fellowship might be a source of stress, but this should allow early-career gastroenterologists to maximize the time spent doing those activities they feel are the most rewarding. A formal mentoring system and an accessible career mentor can be invaluable in allowing the mentee to identify and select that position.
Career fit
The concept of career fit has been described as the ability of individuals to focus their effort on the aspect or aspects of their work that they find most meaningful.5 Multiple specialties have recognized the importance of career fit and the need to choose appropriately when selecting a position and career path upon completing fellowship. In one evaluation of faculty members from the department of medicine at a large academic medical center, those individuals who spent less than 20% of their time working on the activity that they found most meaningful were significantly more likely to demonstrate burnout.5
In a relatively short time period, gastroenterology fellows are required to gather multiple new skill sets, including functioning as a consultant, performing endoscopic procedures, and potentially gaining formal training in clinical, basic, or translational research methods. During this same period, an intense phase of self-assessment should begin, with one critical aim of training being to identify those factors most likely to lead to a long, satisfying career. The growth that occurs during fellowship may allow for the identification of a career track that is likely to be the most rewarding, such as a career as a clinical investigator, clinician educator, or in clinical practice. Importantly, the trainee must decide which career track will most likely lead to self-fulfillment, even if the chosen path does not align with a mentor or advisor. Additionally, self-assessment also may aid in the identification of a niche that an individual finds most intellectually stimulating, which may lead to an area of research or clinical expertise.
While the demonstrated relationship between career fit and burnout is only an association without demonstrated causation, this does merit further consideration. For the first time in most trainees’ careers, the position after fellowship represents an opportunity to choose a job as opposed to going through a “match” process. Therefore, the trainee must strongly consider the factors that will ultimately lead to career satisfaction. If a large disconnect is present between self-identified career goals and the actual tasks required within daily workflow, this may lead to burnout relatively early in a career. Perhaps more importantly, if an individual did not perform adequate self-reflection when choosing a career path or did not receive effective guidance from career mentors, this also might lead to decreased career satisfaction, poor career fit, and an increased risk for burnout as an early-career gastroenterologist.
The mentor’s role
Although a structured career mentoring program is in place within many gastroenterology training programs, other fellowships encourage the mentee to select from a pool of potential mentors. In many cases, trainees and early career gastroenterologists will benefit from building a mentorship team, including career mentor or mentors, research mentors, and other advisors.9
While the mentor-mentee relationship can be an extremely rewarding experience for both parties, the effective mentor must meet a high standard. Several qualities have been identified that will maximize the benefit of the mentor-mentee relationship for the trainee, including the mentor taking a selfless approach to the relationship, working to assist the mentee in choosing a career path that will be the most rewarding, and then aiding the mentee in making helpful connections to promote growth along that chosen path.9 A good mentors should inspire a mentees, but also should be willing to provide honest and at times critical feedback to ensure that mentees maximizes their potential and ultimately assume the appropriate career trajectory. Unbiased mentorship, as well as continued reevaluations of strengths, weaknesses, and career goals by the mentor and mentee, will ultimately offer an opportunity to ensure the best combination of career fit,5 work-life balance,10 and satisfaction with career choice.11
The mentor-mentee relationship after training is complete
Once a trainee has completed gastroenterology fellowship, another stressful transition to the role of an attending physician commences. It is critical that early-career gastroenterologists not only have confidence in the guidance that their mentor has provided to ensure appropriate career fit in their new role but also maintain these critical mentor-mentee relationships during this transition. A good mentor does not disappear because one phase of training is complete. The need for effective mentoring at the junior faculty level also is well recognized,12 and early-career gastroenterologists should continue to rely on established mentoring relationships when new decision points are encountered.
Depending on the career track of an early-career gastroenterologist, formal mentoring also may be offered in the new role as a junior faculty member.12 Additionally, external mentoring can exist within foundations or other subspecialty groups. One example of extramural mentoring is the Career Connection Program offered through the Crohn’s & Colitis Foundation’s Rising Educators Academics and Clinicians Helping IBD (REACH-IBD) platform. In this program, early-career gastroenterologists are selected and paired with national opinion leaders for one-on-one mentoring relationships. Such a program offers further opportunities for career growth, establishing connections within a smaller subspecialty of gastroenterology, and maximizing career fit.
Conclusion
In an era where the toll of burnout and other influences on early-career gastroenterologists are increasingly being recognized, the importance of career fit during the transition into the role of an attending should not be underestimated. In conjunction with appropriate self-reflection, unbiased and critical mentorship during fellowship can promote significant growth among trainees and allow for the ultimate selection of a career track or career path that will promote happiness, work-life balance, and long-term success as defined by the mentee.
Edward L. Barnes, MD, MPH, is with the Multidisciplinary Center for Inflammatory Bowel Diseases and the Center for Gastrointestinal Biology and Disease in the division of gastroenterology and hepatology at the University of North Carolina at Chapel Hill. Dr. Barnes reports no relevant disclosures.
References
1. Keswani RN et al. Am J Gastroenterol. 2011;106(10):1734-40.
2. Burke C et al. Am J Gastroenterol. 2017;112:S593-4.
3. DeCross AJ. AGA Perspectives. 2017.
4. Barnes EL et al. Dig Dis Sci. 2019;64(2):302-6.
5. Shanafelt TD et al. Arch Intern Med. 2009;169(10):990-5.
6. Ordway SM et al. Hepatol Commun. 2017;1(4):347-53.
7. Janko MR, Smeds MR. J Vasc Surg. 2019;69(4):1233-42.
8. Eckleberry-Hunt J et al. Acad Med. 2009;84(2):269-77.
9. Lieberman D. Gastroenterology. 2016;151(1):17-9.
10. Shanafelt TD et al. Mayo Clin Proc. 2015;90(12):1600-13.
11. Shanafelt TD et al. Ann Surg. 2009;250(3):463-71.
12. Shaheen NJ, Sandler RS. Gastroenterology. 2018;155(5):1293-7.
A career in industry: Is it right for me?
As gastroenterology fellows ponder their futures, one career path is often overlooked. Working in the pharmaceutical or biotechnology industry is a path that is not often at the top of career option lists. It is a rare occurrence for fellows to transition immediately into an industry position as opposed to a clinical or academic post. Initial clinical experience, caring for patients, and gaining experience with health economic challenges in today’s complex environment are considered invaluable assets for job applicants seeking industry positions. A minimum of 3-5 years of real-world clinical care experience will greatly enhance applicants’ marketability as “clinical experts” who can provide meaningful value to industry employers.
What exactly does “industry” mean? Traditionally it includes pharmaceutical and/or biotechnology (discovery, development, manufacture, sales, and marketing of small or large molecules), contract research organizations (CROs), and medical device companies. The variety in terms of size, scope, and reach of these companies is truly staggering and includes: entrepreneurial small startups (fewer than 20 employees, one location), midsize companies (more than 200 employees), and global multinational worldwide behemoths (“big pharma” with more than 50,000 employees and numerous facilities with diverse geographic locations). There are certain geographic regions of the United States where many companies’ headquarters are concentrated. At present (although this certainly can change over time), Cambridge, Mass.; New Jersey; Philadelphia; Raleigh-Durham, N.C.; and the San Francisco Bay Area are “hot areas.”
The breadth of “specialty” areas in industry for experienced clinicians is wide and includes: discovery, translational medicine, early- and late-stage clinical development, medical affairs, patient safety, epidemiology, and commercial development. For those interested in transitioning into industry, it is ideal to have a preferred area in mind so that training and education while in fellowship and clinical practice can be directed to that topic.
Discovery and translational medicine
These areas focus on preclinical development of small and large molecules from first concept until first-in-human studies and filing of an investigational new drug application (IND) with regulatory agencies. Translation of basic science concepts into potentially clinically useful “candidate” molecules requires a strong basic knowledge of science in addition to clinical experience. A passion for bridging novel concepts from “bench” to nonhuman studies is critical for success in this area.
Early-stage clinical development
Early-stage clinical development focuses on progressing discovery candidates to first-in-human studies (phase 1 in healthy volunteers) through phase 2 proof-of-concept studies (PoC). PoC studies typically involve first proof in a clinical trial in the target population that the drug under development may provide clinical benefit. These studies typically include 50-200 subjects with tight inclusion and exclusion controls. Intellectual rigor and scientific curiosity, as well as a passion for protecting patient safety, are essential for success as an early-stage drug developer.
Late-stage clinical development
Late-stage clinical development involves designing, conducting, and executing very large clinical studies (typically with hundreds to thousands of patients) that will provide the necessary rigorous pivotal clinical data supporting new drug marketing applications (NDAs). Relatively few drug candidates successfully make it to this stage of development and these studies are extremely expensive (sometimes hundreds of millions of dollars). This stage of development requires close collaboration with numerous company functions including regulatory, biostatistics, patient safety, clinical pharmacology, clinical operations, and manufacturing, as well as commercial colleagues. In addition to strong clinical expertise, this stage of drug development requires excellent communication, with leadership skills and attention to detail as well. Successfully shepherding a drug candidate through to Food and Drug Administration or other regulatory agency approval is an extremely satisfying experience, which can lead to meaningful differences for patients.
Medical affairs
This is a very important and challenging specialty area that, at its core, demands value demonstration of a medicine and communication to key stakeholders such as patients, physicians, and payers. This objective has become increasingly challenging over the past decade while evolving from a qualitative specialty to a rigorous quantitative one. Scientific and commercial success depends on efficient design, execution, and dissemination of results for real-world evidence and postapproval studies. Ideally, these data will demonstrate the medicine’s benefit-risk profile and how it fits into treatment algorithms. Communication requires leadership of physician and payer advisory boards, as well as publication planning. Close collaboration with marketing teams to advise on ethical and scientifically accurate promotional activities is another key component.
Patient safety
As the name implies, patient safety focuses on evaluating signals both from clinical trials and from literature that can accurately map out risks to patients that can arise from taking these medications. This is a critical function for proper and ethical prescription and use of medicine in today’s society. In addition to signal recognition and consultation with clinical development teams, collaboration with regulatory agencies is an important component.
Epidemiology
Epidemiologists with clinical expertise have become an increasingly important need for pharmaceutical and biotech companies over the past decade – specifically, for the design of real-world studies that demonstrate benefit-risk profiles for medicines in real-world use. These data are in demand for both private and governmental payers, as well as for regulatory agencies who are interested in evolving postapproval safety data. Successful epidemiologists often have acquired MPH degrees and expertise in study design and biostatistics.
Commercial development
Those with more financial or business acumen and clinical experience sometimes staff commercial careers. Typically commercial leads also have an MBA degree and are responsible for assessing commercial markets and forecasting and executing a path to commercial viability. Ultimately this career path can lead to a CEO position.
A career in industry is a perfect fit for some, but not so much for others. Table 1 outlines some pros and cons. Commercial factors do come into play with regard to corporate objectives and areas of focus. The top pharmaceutical product therapeutic categories, according to the number of drugs under development in 2017, were cancer, vaccines, diabetes, ophthalmology, gene therapy, anti-inflammatory, and antivirals and immunosuppressants; inflammatory bowel disease was 15th. Therapeutic research and development areas in gastroenterology that are relatively in demand in 2019 include IBD, irritable bowel syndrome, and nonalcoholic steatohepatitis. The high demand areas seem to change with the science and also payers’ willingness to reimburse.
Is industry a good career choice for you? Consider the following factors:
- Travel capabilities.
- Small biotech versus big pharma versus CRO.
- Capability to function in a team environment.
- Communication skills, resilience, self-awareness.
- Therapeutic area and category.
- Early stage versus late stage versus translational versus medical affairs.
- Additional education: MBA, MPH, PhD.
- Geography.
The pharmaceutical industry evolves and undergoes transformation extremely quickly in response to changes in the external environment. If you are considering a current or future career in industry, staying informed about changes in the delivery of health care and health economics is important. There is an ongoing need in industry for trainees and experienced gastroenterologists who can deploy their clinical expertise in development and communication of new medicines and devices that will make a positive difference in patients’ lives.
As gastroenterology fellows ponder their futures, one career path is often overlooked. Working in the pharmaceutical or biotechnology industry is a path that is not often at the top of career option lists. It is a rare occurrence for fellows to transition immediately into an industry position as opposed to a clinical or academic post. Initial clinical experience, caring for patients, and gaining experience with health economic challenges in today’s complex environment are considered invaluable assets for job applicants seeking industry positions. A minimum of 3-5 years of real-world clinical care experience will greatly enhance applicants’ marketability as “clinical experts” who can provide meaningful value to industry employers.
What exactly does “industry” mean? Traditionally it includes pharmaceutical and/or biotechnology (discovery, development, manufacture, sales, and marketing of small or large molecules), contract research organizations (CROs), and medical device companies. The variety in terms of size, scope, and reach of these companies is truly staggering and includes: entrepreneurial small startups (fewer than 20 employees, one location), midsize companies (more than 200 employees), and global multinational worldwide behemoths (“big pharma” with more than 50,000 employees and numerous facilities with diverse geographic locations). There are certain geographic regions of the United States where many companies’ headquarters are concentrated. At present (although this certainly can change over time), Cambridge, Mass.; New Jersey; Philadelphia; Raleigh-Durham, N.C.; and the San Francisco Bay Area are “hot areas.”
The breadth of “specialty” areas in industry for experienced clinicians is wide and includes: discovery, translational medicine, early- and late-stage clinical development, medical affairs, patient safety, epidemiology, and commercial development. For those interested in transitioning into industry, it is ideal to have a preferred area in mind so that training and education while in fellowship and clinical practice can be directed to that topic.
Discovery and translational medicine
These areas focus on preclinical development of small and large molecules from first concept until first-in-human studies and filing of an investigational new drug application (IND) with regulatory agencies. Translation of basic science concepts into potentially clinically useful “candidate” molecules requires a strong basic knowledge of science in addition to clinical experience. A passion for bridging novel concepts from “bench” to nonhuman studies is critical for success in this area.
Early-stage clinical development
Early-stage clinical development focuses on progressing discovery candidates to first-in-human studies (phase 1 in healthy volunteers) through phase 2 proof-of-concept studies (PoC). PoC studies typically involve first proof in a clinical trial in the target population that the drug under development may provide clinical benefit. These studies typically include 50-200 subjects with tight inclusion and exclusion controls. Intellectual rigor and scientific curiosity, as well as a passion for protecting patient safety, are essential for success as an early-stage drug developer.
Late-stage clinical development
Late-stage clinical development involves designing, conducting, and executing very large clinical studies (typically with hundreds to thousands of patients) that will provide the necessary rigorous pivotal clinical data supporting new drug marketing applications (NDAs). Relatively few drug candidates successfully make it to this stage of development and these studies are extremely expensive (sometimes hundreds of millions of dollars). This stage of development requires close collaboration with numerous company functions including regulatory, biostatistics, patient safety, clinical pharmacology, clinical operations, and manufacturing, as well as commercial colleagues. In addition to strong clinical expertise, this stage of drug development requires excellent communication, with leadership skills and attention to detail as well. Successfully shepherding a drug candidate through to Food and Drug Administration or other regulatory agency approval is an extremely satisfying experience, which can lead to meaningful differences for patients.
Medical affairs
This is a very important and challenging specialty area that, at its core, demands value demonstration of a medicine and communication to key stakeholders such as patients, physicians, and payers. This objective has become increasingly challenging over the past decade while evolving from a qualitative specialty to a rigorous quantitative one. Scientific and commercial success depends on efficient design, execution, and dissemination of results for real-world evidence and postapproval studies. Ideally, these data will demonstrate the medicine’s benefit-risk profile and how it fits into treatment algorithms. Communication requires leadership of physician and payer advisory boards, as well as publication planning. Close collaboration with marketing teams to advise on ethical and scientifically accurate promotional activities is another key component.
Patient safety
As the name implies, patient safety focuses on evaluating signals both from clinical trials and from literature that can accurately map out risks to patients that can arise from taking these medications. This is a critical function for proper and ethical prescription and use of medicine in today’s society. In addition to signal recognition and consultation with clinical development teams, collaboration with regulatory agencies is an important component.
Epidemiology
Epidemiologists with clinical expertise have become an increasingly important need for pharmaceutical and biotech companies over the past decade – specifically, for the design of real-world studies that demonstrate benefit-risk profiles for medicines in real-world use. These data are in demand for both private and governmental payers, as well as for regulatory agencies who are interested in evolving postapproval safety data. Successful epidemiologists often have acquired MPH degrees and expertise in study design and biostatistics.
Commercial development
Those with more financial or business acumen and clinical experience sometimes staff commercial careers. Typically commercial leads also have an MBA degree and are responsible for assessing commercial markets and forecasting and executing a path to commercial viability. Ultimately this career path can lead to a CEO position.
A career in industry is a perfect fit for some, but not so much for others. Table 1 outlines some pros and cons. Commercial factors do come into play with regard to corporate objectives and areas of focus. The top pharmaceutical product therapeutic categories, according to the number of drugs under development in 2017, were cancer, vaccines, diabetes, ophthalmology, gene therapy, anti-inflammatory, and antivirals and immunosuppressants; inflammatory bowel disease was 15th. Therapeutic research and development areas in gastroenterology that are relatively in demand in 2019 include IBD, irritable bowel syndrome, and nonalcoholic steatohepatitis. The high demand areas seem to change with the science and also payers’ willingness to reimburse.
Is industry a good career choice for you? Consider the following factors:
- Travel capabilities.
- Small biotech versus big pharma versus CRO.
- Capability to function in a team environment.
- Communication skills, resilience, self-awareness.
- Therapeutic area and category.
- Early stage versus late stage versus translational versus medical affairs.
- Additional education: MBA, MPH, PhD.
- Geography.
The pharmaceutical industry evolves and undergoes transformation extremely quickly in response to changes in the external environment. If you are considering a current or future career in industry, staying informed about changes in the delivery of health care and health economics is important. There is an ongoing need in industry for trainees and experienced gastroenterologists who can deploy their clinical expertise in development and communication of new medicines and devices that will make a positive difference in patients’ lives.
As gastroenterology fellows ponder their futures, one career path is often overlooked. Working in the pharmaceutical or biotechnology industry is a path that is not often at the top of career option lists. It is a rare occurrence for fellows to transition immediately into an industry position as opposed to a clinical or academic post. Initial clinical experience, caring for patients, and gaining experience with health economic challenges in today’s complex environment are considered invaluable assets for job applicants seeking industry positions. A minimum of 3-5 years of real-world clinical care experience will greatly enhance applicants’ marketability as “clinical experts” who can provide meaningful value to industry employers.
What exactly does “industry” mean? Traditionally it includes pharmaceutical and/or biotechnology (discovery, development, manufacture, sales, and marketing of small or large molecules), contract research organizations (CROs), and medical device companies. The variety in terms of size, scope, and reach of these companies is truly staggering and includes: entrepreneurial small startups (fewer than 20 employees, one location), midsize companies (more than 200 employees), and global multinational worldwide behemoths (“big pharma” with more than 50,000 employees and numerous facilities with diverse geographic locations). There are certain geographic regions of the United States where many companies’ headquarters are concentrated. At present (although this certainly can change over time), Cambridge, Mass.; New Jersey; Philadelphia; Raleigh-Durham, N.C.; and the San Francisco Bay Area are “hot areas.”
The breadth of “specialty” areas in industry for experienced clinicians is wide and includes: discovery, translational medicine, early- and late-stage clinical development, medical affairs, patient safety, epidemiology, and commercial development. For those interested in transitioning into industry, it is ideal to have a preferred area in mind so that training and education while in fellowship and clinical practice can be directed to that topic.
Discovery and translational medicine
These areas focus on preclinical development of small and large molecules from first concept until first-in-human studies and filing of an investigational new drug application (IND) with regulatory agencies. Translation of basic science concepts into potentially clinically useful “candidate” molecules requires a strong basic knowledge of science in addition to clinical experience. A passion for bridging novel concepts from “bench” to nonhuman studies is critical for success in this area.
Early-stage clinical development
Early-stage clinical development focuses on progressing discovery candidates to first-in-human studies (phase 1 in healthy volunteers) through phase 2 proof-of-concept studies (PoC). PoC studies typically involve first proof in a clinical trial in the target population that the drug under development may provide clinical benefit. These studies typically include 50-200 subjects with tight inclusion and exclusion controls. Intellectual rigor and scientific curiosity, as well as a passion for protecting patient safety, are essential for success as an early-stage drug developer.
Late-stage clinical development
Late-stage clinical development involves designing, conducting, and executing very large clinical studies (typically with hundreds to thousands of patients) that will provide the necessary rigorous pivotal clinical data supporting new drug marketing applications (NDAs). Relatively few drug candidates successfully make it to this stage of development and these studies are extremely expensive (sometimes hundreds of millions of dollars). This stage of development requires close collaboration with numerous company functions including regulatory, biostatistics, patient safety, clinical pharmacology, clinical operations, and manufacturing, as well as commercial colleagues. In addition to strong clinical expertise, this stage of drug development requires excellent communication, with leadership skills and attention to detail as well. Successfully shepherding a drug candidate through to Food and Drug Administration or other regulatory agency approval is an extremely satisfying experience, which can lead to meaningful differences for patients.
Medical affairs
This is a very important and challenging specialty area that, at its core, demands value demonstration of a medicine and communication to key stakeholders such as patients, physicians, and payers. This objective has become increasingly challenging over the past decade while evolving from a qualitative specialty to a rigorous quantitative one. Scientific and commercial success depends on efficient design, execution, and dissemination of results for real-world evidence and postapproval studies. Ideally, these data will demonstrate the medicine’s benefit-risk profile and how it fits into treatment algorithms. Communication requires leadership of physician and payer advisory boards, as well as publication planning. Close collaboration with marketing teams to advise on ethical and scientifically accurate promotional activities is another key component.
Patient safety
As the name implies, patient safety focuses on evaluating signals both from clinical trials and from literature that can accurately map out risks to patients that can arise from taking these medications. This is a critical function for proper and ethical prescription and use of medicine in today’s society. In addition to signal recognition and consultation with clinical development teams, collaboration with regulatory agencies is an important component.
Epidemiology
Epidemiologists with clinical expertise have become an increasingly important need for pharmaceutical and biotech companies over the past decade – specifically, for the design of real-world studies that demonstrate benefit-risk profiles for medicines in real-world use. These data are in demand for both private and governmental payers, as well as for regulatory agencies who are interested in evolving postapproval safety data. Successful epidemiologists often have acquired MPH degrees and expertise in study design and biostatistics.
Commercial development
Those with more financial or business acumen and clinical experience sometimes staff commercial careers. Typically commercial leads also have an MBA degree and are responsible for assessing commercial markets and forecasting and executing a path to commercial viability. Ultimately this career path can lead to a CEO position.
A career in industry is a perfect fit for some, but not so much for others. Table 1 outlines some pros and cons. Commercial factors do come into play with regard to corporate objectives and areas of focus. The top pharmaceutical product therapeutic categories, according to the number of drugs under development in 2017, were cancer, vaccines, diabetes, ophthalmology, gene therapy, anti-inflammatory, and antivirals and immunosuppressants; inflammatory bowel disease was 15th. Therapeutic research and development areas in gastroenterology that are relatively in demand in 2019 include IBD, irritable bowel syndrome, and nonalcoholic steatohepatitis. The high demand areas seem to change with the science and also payers’ willingness to reimburse.
Is industry a good career choice for you? Consider the following factors:
- Travel capabilities.
- Small biotech versus big pharma versus CRO.
- Capability to function in a team environment.
- Communication skills, resilience, self-awareness.
- Therapeutic area and category.
- Early stage versus late stage versus translational versus medical affairs.
- Additional education: MBA, MPH, PhD.
- Geography.
The pharmaceutical industry evolves and undergoes transformation extremely quickly in response to changes in the external environment. If you are considering a current or future career in industry, staying informed about changes in the delivery of health care and health economics is important. There is an ongoing need in industry for trainees and experienced gastroenterologists who can deploy their clinical expertise in development and communication of new medicines and devices that will make a positive difference in patients’ lives.
Dealing with difficult people
Dealing with difficult people is not a new problem. As long as there are at least two people, the potential for conflict will arise. Unfortunately, the workplace or hospital is not immune from tragedies that are born out of poor conflict resolution. Before we go further, please do not ignore the fact that more than 1 million workers are assaulted each year, and more than 60% of Americans are aware of some type of abusive conduct occurring on the job.
Who are those difficult people we may encounter? Anyone and everyone. Difficult people may include our significant others, family members, supervisors, department chairs, colleagues, competitors, trainees, patients and their families, and ancillary personnel. Looking at this list, it is amazing that we aren’t either stymied by never-ending conflict resolution seminars, or rendered completely ineffective in all aspects of life. Daily conflicts can vary in intensity and degree. At one end one can be disgruntled at the person who secured the last doughnut in the break room, and at the other extreme end one is committed to moving forward with a multimillion dollar lawsuit against the company.
Conflicts arise because of a multiplicity of reasons – work style differences, background differences, attitude difference, personality types, and competitive versus cooperative differences. To be effective, each of us must realize that we are more alike than different, and it is our differences that should fuel our passion for providing excellent patient care and customer service.
In particular, be aware of things that can accelerate the potential for conflicts – performance ratings, evaluations, recommendation for promotion, absence of role models or mentors, lack of support amongst colleagues, and failures on the part of leadership to keep promises, appreciate people, maintain personal integrity, or take responsibility for their own errors.
When conflict arises – deal with it! Identify the problem, and if it is legitimate address it as soon as possible. Always remember to document the details in writing; never forget the old adage most of us learned during training: “If it’s not written/documented it wasn’t done or didn’t happen.” More than likely you won’t need to retrieve your written documents concerning a particular conflict, but if the conflict escalates, this type of documentation will prove invaluable.
Communicate with the person or persons with whom you have the conflict – it is essential that you have the “difficult” conversation. This conversation must be done face-to-face and in private. Never communicate by email, social media, or through gossip. Remain calm, professional, and show respect even if the other person does not. At this meeting detail the problem, but also come prepared with suggestions as to how the conflict might be resolved.
Take responsibility – you can’t control situations or people – but you can choose how you will respond to every situation. This is the appropriate time to establish boundaries; avoid any behavior that might be considered bullying or harassment. Redirect negativity that emanates from the person with whom you have the conflict as well as any potentially self-imposed negativity. Make every effort to avoid statements that include “you never” and “you always,” as there are very few absolutes in life. Consider the other person’s perspective as well; try to see it from their point of view because your “personal truth” is not the only “truth.” Our individual personal life experiences form the foundation for much of our opinions and views; therefore, it should be obvious that persons from widely varied backgrounds and cultures will differ in their approaches. If at all possible, give the person another chance; even the most difficult person has good attributes.
Once you have had the “difficult” conversation and there is still no resolution in sight you should take it to management. Everyone has a boss – even the Boss! There is much to gain from involving an impartial party or mediator. This impartial individual is able to understand the viewpoint of all parties involved and frequently that person’s solution may be considered acceptable because it is coming from someone not directly affected by the conflict.
Unresolved conflicts result in many negative effects – interference with one’s career is foremost – and that alone can be a source of undue stress. Other negative effects are the development of a hostile work environment, diminished productivity, low morale, and high employee turnover. Physicians in particular are prone to experiencing an increase in medical errors, litigation claims, and poor patient care when there are unresolved conflicts on the table.
In an ideal world, there are no difficult people; there are either no conflicts or all conflicts are resolved immediately without any lasting deleterious effects. Unfortunately, the world abounds in conflict at varying stages of resolution. As a final bit of advice, in dealing with difficult persons, do not allow conflicts to obscure your goals for successful patient care and/or customer service. Focus on why you decided to join your place of employment and realize that everyone has a role in making the team work! If you are dedicated to addressing conflicts as they arise, and utilizing the strategies outlined, you will often find that foes can truly become friends.
Dr. Cole is associate section chief, gastroenterology, and chief, GI endoscopy, Michael E. DeBakey VA Medical Center; and associate professor, internal medicine, Baylor College of Medicine, Houston.
Dealing with difficult people is not a new problem. As long as there are at least two people, the potential for conflict will arise. Unfortunately, the workplace or hospital is not immune from tragedies that are born out of poor conflict resolution. Before we go further, please do not ignore the fact that more than 1 million workers are assaulted each year, and more than 60% of Americans are aware of some type of abusive conduct occurring on the job.
Who are those difficult people we may encounter? Anyone and everyone. Difficult people may include our significant others, family members, supervisors, department chairs, colleagues, competitors, trainees, patients and their families, and ancillary personnel. Looking at this list, it is amazing that we aren’t either stymied by never-ending conflict resolution seminars, or rendered completely ineffective in all aspects of life. Daily conflicts can vary in intensity and degree. At one end one can be disgruntled at the person who secured the last doughnut in the break room, and at the other extreme end one is committed to moving forward with a multimillion dollar lawsuit against the company.
Conflicts arise because of a multiplicity of reasons – work style differences, background differences, attitude difference, personality types, and competitive versus cooperative differences. To be effective, each of us must realize that we are more alike than different, and it is our differences that should fuel our passion for providing excellent patient care and customer service.
In particular, be aware of things that can accelerate the potential for conflicts – performance ratings, evaluations, recommendation for promotion, absence of role models or mentors, lack of support amongst colleagues, and failures on the part of leadership to keep promises, appreciate people, maintain personal integrity, or take responsibility for their own errors.
When conflict arises – deal with it! Identify the problem, and if it is legitimate address it as soon as possible. Always remember to document the details in writing; never forget the old adage most of us learned during training: “If it’s not written/documented it wasn’t done or didn’t happen.” More than likely you won’t need to retrieve your written documents concerning a particular conflict, but if the conflict escalates, this type of documentation will prove invaluable.
Communicate with the person or persons with whom you have the conflict – it is essential that you have the “difficult” conversation. This conversation must be done face-to-face and in private. Never communicate by email, social media, or through gossip. Remain calm, professional, and show respect even if the other person does not. At this meeting detail the problem, but also come prepared with suggestions as to how the conflict might be resolved.
Take responsibility – you can’t control situations or people – but you can choose how you will respond to every situation. This is the appropriate time to establish boundaries; avoid any behavior that might be considered bullying or harassment. Redirect negativity that emanates from the person with whom you have the conflict as well as any potentially self-imposed negativity. Make every effort to avoid statements that include “you never” and “you always,” as there are very few absolutes in life. Consider the other person’s perspective as well; try to see it from their point of view because your “personal truth” is not the only “truth.” Our individual personal life experiences form the foundation for much of our opinions and views; therefore, it should be obvious that persons from widely varied backgrounds and cultures will differ in their approaches. If at all possible, give the person another chance; even the most difficult person has good attributes.
Once you have had the “difficult” conversation and there is still no resolution in sight you should take it to management. Everyone has a boss – even the Boss! There is much to gain from involving an impartial party or mediator. This impartial individual is able to understand the viewpoint of all parties involved and frequently that person’s solution may be considered acceptable because it is coming from someone not directly affected by the conflict.
Unresolved conflicts result in many negative effects – interference with one’s career is foremost – and that alone can be a source of undue stress. Other negative effects are the development of a hostile work environment, diminished productivity, low morale, and high employee turnover. Physicians in particular are prone to experiencing an increase in medical errors, litigation claims, and poor patient care when there are unresolved conflicts on the table.
In an ideal world, there are no difficult people; there are either no conflicts or all conflicts are resolved immediately without any lasting deleterious effects. Unfortunately, the world abounds in conflict at varying stages of resolution. As a final bit of advice, in dealing with difficult persons, do not allow conflicts to obscure your goals for successful patient care and/or customer service. Focus on why you decided to join your place of employment and realize that everyone has a role in making the team work! If you are dedicated to addressing conflicts as they arise, and utilizing the strategies outlined, you will often find that foes can truly become friends.
Dr. Cole is associate section chief, gastroenterology, and chief, GI endoscopy, Michael E. DeBakey VA Medical Center; and associate professor, internal medicine, Baylor College of Medicine, Houston.
Dealing with difficult people is not a new problem. As long as there are at least two people, the potential for conflict will arise. Unfortunately, the workplace or hospital is not immune from tragedies that are born out of poor conflict resolution. Before we go further, please do not ignore the fact that more than 1 million workers are assaulted each year, and more than 60% of Americans are aware of some type of abusive conduct occurring on the job.
Who are those difficult people we may encounter? Anyone and everyone. Difficult people may include our significant others, family members, supervisors, department chairs, colleagues, competitors, trainees, patients and their families, and ancillary personnel. Looking at this list, it is amazing that we aren’t either stymied by never-ending conflict resolution seminars, or rendered completely ineffective in all aspects of life. Daily conflicts can vary in intensity and degree. At one end one can be disgruntled at the person who secured the last doughnut in the break room, and at the other extreme end one is committed to moving forward with a multimillion dollar lawsuit against the company.
Conflicts arise because of a multiplicity of reasons – work style differences, background differences, attitude difference, personality types, and competitive versus cooperative differences. To be effective, each of us must realize that we are more alike than different, and it is our differences that should fuel our passion for providing excellent patient care and customer service.
In particular, be aware of things that can accelerate the potential for conflicts – performance ratings, evaluations, recommendation for promotion, absence of role models or mentors, lack of support amongst colleagues, and failures on the part of leadership to keep promises, appreciate people, maintain personal integrity, or take responsibility for their own errors.
When conflict arises – deal with it! Identify the problem, and if it is legitimate address it as soon as possible. Always remember to document the details in writing; never forget the old adage most of us learned during training: “If it’s not written/documented it wasn’t done or didn’t happen.” More than likely you won’t need to retrieve your written documents concerning a particular conflict, but if the conflict escalates, this type of documentation will prove invaluable.
Communicate with the person or persons with whom you have the conflict – it is essential that you have the “difficult” conversation. This conversation must be done face-to-face and in private. Never communicate by email, social media, or through gossip. Remain calm, professional, and show respect even if the other person does not. At this meeting detail the problem, but also come prepared with suggestions as to how the conflict might be resolved.
Take responsibility – you can’t control situations or people – but you can choose how you will respond to every situation. This is the appropriate time to establish boundaries; avoid any behavior that might be considered bullying or harassment. Redirect negativity that emanates from the person with whom you have the conflict as well as any potentially self-imposed negativity. Make every effort to avoid statements that include “you never” and “you always,” as there are very few absolutes in life. Consider the other person’s perspective as well; try to see it from their point of view because your “personal truth” is not the only “truth.” Our individual personal life experiences form the foundation for much of our opinions and views; therefore, it should be obvious that persons from widely varied backgrounds and cultures will differ in their approaches. If at all possible, give the person another chance; even the most difficult person has good attributes.
Once you have had the “difficult” conversation and there is still no resolution in sight you should take it to management. Everyone has a boss – even the Boss! There is much to gain from involving an impartial party or mediator. This impartial individual is able to understand the viewpoint of all parties involved and frequently that person’s solution may be considered acceptable because it is coming from someone not directly affected by the conflict.
Unresolved conflicts result in many negative effects – interference with one’s career is foremost – and that alone can be a source of undue stress. Other negative effects are the development of a hostile work environment, diminished productivity, low morale, and high employee turnover. Physicians in particular are prone to experiencing an increase in medical errors, litigation claims, and poor patient care when there are unresolved conflicts on the table.
In an ideal world, there are no difficult people; there are either no conflicts or all conflicts are resolved immediately without any lasting deleterious effects. Unfortunately, the world abounds in conflict at varying stages of resolution. As a final bit of advice, in dealing with difficult persons, do not allow conflicts to obscure your goals for successful patient care and/or customer service. Focus on why you decided to join your place of employment and realize that everyone has a role in making the team work! If you are dedicated to addressing conflicts as they arise, and utilizing the strategies outlined, you will often find that foes can truly become friends.
Dr. Cole is associate section chief, gastroenterology, and chief, GI endoscopy, Michael E. DeBakey VA Medical Center; and associate professor, internal medicine, Baylor College of Medicine, Houston.
Eosinophilic esophagitis: Faces and facets of a new disease
A dramatic rise in the recognition of eosinophilic esophagitis (EoE) has followed the case series by Stephen Attwood, MD, and Alex Straumann, MD, which first characterized the disease 25 years ago. While still a young disease, EoE has evolved from esoterica to a leading cause of dysphagia and food impaction worldwide (Gastroenterology. 2018 Jan;154[2]:319-32.). The typical face of EoE is a 30- to 40-year-old white man, but EoE afflicts both men and women of all ages and ethnic groups.
Guidelines prior to 2017 excluded proton pump inhibitor–responsive esophageal eosinophilia (PPIREE) from a formal diagnosis of EoE. The last decade, however, has witnessed the rise of fall of PPIREE, which was first reported in 2006 in a case series of three pediatric patients with presentations consistent with EoE, but symptom and histologic resolution after treatment with omeprazole. At the time, these cases were viewed as rare curiosities. Subsequent to a prospective series by Javier Molina-Infante, MD, in 2011, however, multiple studies have demonstrated that 30%-50% of patients suspected of having EoE respond to proton pump inhibitor (PPI). Clearly, PPIREE is not rare. Clinical and translational studies have investigated the phenomenon of PPIREE, noting that EoE and PPIREE share demographic, symptom, endoscopic, and pathologic features as well as biomarker expression and gene profiles that are distinct from gastroesophageal reflux disease (GERD). Furthermore, studies have identified intriguing, acid-independent properties of PPIs that inhibit allergic inflammation in cultured EoE cell lines. Together, these clinical and translational studies led to a 2016 European task force recommendation to remove the PPI trial from the diagnostic criteria for EoE (Gut 2016 Mar;65[3]:524-31). At Digestive Disease Week 2017®, an international consortium sponsored by the International Gastrointestinal Eosinophil Researchers (TIGERS) convened in Chicago to review this controversy. The consensus from this meeting was in line with the European position statement. For patients with a clinical presentation suggestive of EoE and esophageal eosinophilia, clinicians should carefully consider non-EoE causes of esophageal eosinophilia but would not be required to use PPIs to establish a diagnosis of EoE.
Assessment of disease activity in EoE has largely focused on counting eosinophils on esophageal biopsies, but the mucosa may be the tip of the EoE iceberg. There is increasing evidence that the inflammation and remodeling aspects of EoE extend beneath the mucosa. If you “dig a little deeper” and sample the subepithelial space, a different face of EoE emerges, with eosinophilic inflammation and fibrosis in EoE that are distinct from GERD. This subepithelial remodeling forms the basis for the strictures and narrow caliber esophagus that are major complications of EoE.
Treatment of EoE involves a multifaceted approach that includes medications, dietary therapy, and esophageal dilation. No drugs have yet been approved by the Food and Drug Administration for EoE. Off-label use of topical corticosteroids are a mainstay of therapy, with 10 double-blind, placebo-controlled randomized trials demonstrating efficacy for both histology and symptoms. Novel therapeutic approaches to EoE are targeting allergic cytokine mediators including interleukin-4, 5, and 13 with promising results. The role of biologic therapies in the management of EoE is yet undefined but the increasing recognition of steroid-refractory patients as well as potential effects on esophageal remodeling are unmet needs. Diet therapy continues to be an important, first-line option for motivated patients and clinicians, with removal of the six most common food allergens associated with a 70% histologic response in both pediatric and adult studies. Less-restrictive diets have been devised to reduce the need for repeated endoscopies. At the same time, several office-based tests of disease activity are undergoing validation, including the esophageal string test, Cytosponge, mucosal impedance, transnasal endoscopy, and confocal microscopy capsule. These technologies will lead to fewer endoscopies and may shift EoE management to the primary care or allergist’s office.
Finally, it is important to acknowledge that EoE is not a “GI disease,” but one that is best managed by a multifaceted approach that integrates allergists, immunologists, pathologists, radiologists, dietitians, patient advocacy, and epidemiologists who are confronting this new disease. The Consortium of Eosinophilic Gastrointestinal Disease Researchers, funded by the National Institutes of Health and the Rare Diseases Clinical Research Network, is an example of a multidisciplinary collaboration that addresses fundamental questions regarding the natural history and optimal management of EoE.
Dr. Hirano is a professor of medicine, division of gastroenterology, Northwestern University, Chicago. He has received grant support from the NIH Consortium of Eosinophilic Gastrointestinal Disease Researchers (CEGIR, U54 AI117804). CEGIR is also supported by patient advocacy groups including the American Partnership for Eosinophilic Disorders, the CURED Foundation, and the Eosinophilic Family Coalition. Dr. Hirano has received consulting fees and research funding from Celgene, Regeneron, and Shire among others. Dr. Hirano made his comments during the AGA Institute Presidential Plenary at the Annual Digestive Disease Week.
A dramatic rise in the recognition of eosinophilic esophagitis (EoE) has followed the case series by Stephen Attwood, MD, and Alex Straumann, MD, which first characterized the disease 25 years ago. While still a young disease, EoE has evolved from esoterica to a leading cause of dysphagia and food impaction worldwide (Gastroenterology. 2018 Jan;154[2]:319-32.). The typical face of EoE is a 30- to 40-year-old white man, but EoE afflicts both men and women of all ages and ethnic groups.
Guidelines prior to 2017 excluded proton pump inhibitor–responsive esophageal eosinophilia (PPIREE) from a formal diagnosis of EoE. The last decade, however, has witnessed the rise of fall of PPIREE, which was first reported in 2006 in a case series of three pediatric patients with presentations consistent with EoE, but symptom and histologic resolution after treatment with omeprazole. At the time, these cases were viewed as rare curiosities. Subsequent to a prospective series by Javier Molina-Infante, MD, in 2011, however, multiple studies have demonstrated that 30%-50% of patients suspected of having EoE respond to proton pump inhibitor (PPI). Clearly, PPIREE is not rare. Clinical and translational studies have investigated the phenomenon of PPIREE, noting that EoE and PPIREE share demographic, symptom, endoscopic, and pathologic features as well as biomarker expression and gene profiles that are distinct from gastroesophageal reflux disease (GERD). Furthermore, studies have identified intriguing, acid-independent properties of PPIs that inhibit allergic inflammation in cultured EoE cell lines. Together, these clinical and translational studies led to a 2016 European task force recommendation to remove the PPI trial from the diagnostic criteria for EoE (Gut 2016 Mar;65[3]:524-31). At Digestive Disease Week 2017®, an international consortium sponsored by the International Gastrointestinal Eosinophil Researchers (TIGERS) convened in Chicago to review this controversy. The consensus from this meeting was in line with the European position statement. For patients with a clinical presentation suggestive of EoE and esophageal eosinophilia, clinicians should carefully consider non-EoE causes of esophageal eosinophilia but would not be required to use PPIs to establish a diagnosis of EoE.
Assessment of disease activity in EoE has largely focused on counting eosinophils on esophageal biopsies, but the mucosa may be the tip of the EoE iceberg. There is increasing evidence that the inflammation and remodeling aspects of EoE extend beneath the mucosa. If you “dig a little deeper” and sample the subepithelial space, a different face of EoE emerges, with eosinophilic inflammation and fibrosis in EoE that are distinct from GERD. This subepithelial remodeling forms the basis for the strictures and narrow caliber esophagus that are major complications of EoE.
Treatment of EoE involves a multifaceted approach that includes medications, dietary therapy, and esophageal dilation. No drugs have yet been approved by the Food and Drug Administration for EoE. Off-label use of topical corticosteroids are a mainstay of therapy, with 10 double-blind, placebo-controlled randomized trials demonstrating efficacy for both histology and symptoms. Novel therapeutic approaches to EoE are targeting allergic cytokine mediators including interleukin-4, 5, and 13 with promising results. The role of biologic therapies in the management of EoE is yet undefined but the increasing recognition of steroid-refractory patients as well as potential effects on esophageal remodeling are unmet needs. Diet therapy continues to be an important, first-line option for motivated patients and clinicians, with removal of the six most common food allergens associated with a 70% histologic response in both pediatric and adult studies. Less-restrictive diets have been devised to reduce the need for repeated endoscopies. At the same time, several office-based tests of disease activity are undergoing validation, including the esophageal string test, Cytosponge, mucosal impedance, transnasal endoscopy, and confocal microscopy capsule. These technologies will lead to fewer endoscopies and may shift EoE management to the primary care or allergist’s office.
Finally, it is important to acknowledge that EoE is not a “GI disease,” but one that is best managed by a multifaceted approach that integrates allergists, immunologists, pathologists, radiologists, dietitians, patient advocacy, and epidemiologists who are confronting this new disease. The Consortium of Eosinophilic Gastrointestinal Disease Researchers, funded by the National Institutes of Health and the Rare Diseases Clinical Research Network, is an example of a multidisciplinary collaboration that addresses fundamental questions regarding the natural history and optimal management of EoE.
Dr. Hirano is a professor of medicine, division of gastroenterology, Northwestern University, Chicago. He has received grant support from the NIH Consortium of Eosinophilic Gastrointestinal Disease Researchers (CEGIR, U54 AI117804). CEGIR is also supported by patient advocacy groups including the American Partnership for Eosinophilic Disorders, the CURED Foundation, and the Eosinophilic Family Coalition. Dr. Hirano has received consulting fees and research funding from Celgene, Regeneron, and Shire among others. Dr. Hirano made his comments during the AGA Institute Presidential Plenary at the Annual Digestive Disease Week.
A dramatic rise in the recognition of eosinophilic esophagitis (EoE) has followed the case series by Stephen Attwood, MD, and Alex Straumann, MD, which first characterized the disease 25 years ago. While still a young disease, EoE has evolved from esoterica to a leading cause of dysphagia and food impaction worldwide (Gastroenterology. 2018 Jan;154[2]:319-32.). The typical face of EoE is a 30- to 40-year-old white man, but EoE afflicts both men and women of all ages and ethnic groups.
Guidelines prior to 2017 excluded proton pump inhibitor–responsive esophageal eosinophilia (PPIREE) from a formal diagnosis of EoE. The last decade, however, has witnessed the rise of fall of PPIREE, which was first reported in 2006 in a case series of three pediatric patients with presentations consistent with EoE, but symptom and histologic resolution after treatment with omeprazole. At the time, these cases were viewed as rare curiosities. Subsequent to a prospective series by Javier Molina-Infante, MD, in 2011, however, multiple studies have demonstrated that 30%-50% of patients suspected of having EoE respond to proton pump inhibitor (PPI). Clearly, PPIREE is not rare. Clinical and translational studies have investigated the phenomenon of PPIREE, noting that EoE and PPIREE share demographic, symptom, endoscopic, and pathologic features as well as biomarker expression and gene profiles that are distinct from gastroesophageal reflux disease (GERD). Furthermore, studies have identified intriguing, acid-independent properties of PPIs that inhibit allergic inflammation in cultured EoE cell lines. Together, these clinical and translational studies led to a 2016 European task force recommendation to remove the PPI trial from the diagnostic criteria for EoE (Gut 2016 Mar;65[3]:524-31). At Digestive Disease Week 2017®, an international consortium sponsored by the International Gastrointestinal Eosinophil Researchers (TIGERS) convened in Chicago to review this controversy. The consensus from this meeting was in line with the European position statement. For patients with a clinical presentation suggestive of EoE and esophageal eosinophilia, clinicians should carefully consider non-EoE causes of esophageal eosinophilia but would not be required to use PPIs to establish a diagnosis of EoE.
Assessment of disease activity in EoE has largely focused on counting eosinophils on esophageal biopsies, but the mucosa may be the tip of the EoE iceberg. There is increasing evidence that the inflammation and remodeling aspects of EoE extend beneath the mucosa. If you “dig a little deeper” and sample the subepithelial space, a different face of EoE emerges, with eosinophilic inflammation and fibrosis in EoE that are distinct from GERD. This subepithelial remodeling forms the basis for the strictures and narrow caliber esophagus that are major complications of EoE.
Treatment of EoE involves a multifaceted approach that includes medications, dietary therapy, and esophageal dilation. No drugs have yet been approved by the Food and Drug Administration for EoE. Off-label use of topical corticosteroids are a mainstay of therapy, with 10 double-blind, placebo-controlled randomized trials demonstrating efficacy for both histology and symptoms. Novel therapeutic approaches to EoE are targeting allergic cytokine mediators including interleukin-4, 5, and 13 with promising results. The role of biologic therapies in the management of EoE is yet undefined but the increasing recognition of steroid-refractory patients as well as potential effects on esophageal remodeling are unmet needs. Diet therapy continues to be an important, first-line option for motivated patients and clinicians, with removal of the six most common food allergens associated with a 70% histologic response in both pediatric and adult studies. Less-restrictive diets have been devised to reduce the need for repeated endoscopies. At the same time, several office-based tests of disease activity are undergoing validation, including the esophageal string test, Cytosponge, mucosal impedance, transnasal endoscopy, and confocal microscopy capsule. These technologies will lead to fewer endoscopies and may shift EoE management to the primary care or allergist’s office.
Finally, it is important to acknowledge that EoE is not a “GI disease,” but one that is best managed by a multifaceted approach that integrates allergists, immunologists, pathologists, radiologists, dietitians, patient advocacy, and epidemiologists who are confronting this new disease. The Consortium of Eosinophilic Gastrointestinal Disease Researchers, funded by the National Institutes of Health and the Rare Diseases Clinical Research Network, is an example of a multidisciplinary collaboration that addresses fundamental questions regarding the natural history and optimal management of EoE.
Dr. Hirano is a professor of medicine, division of gastroenterology, Northwestern University, Chicago. He has received grant support from the NIH Consortium of Eosinophilic Gastrointestinal Disease Researchers (CEGIR, U54 AI117804). CEGIR is also supported by patient advocacy groups including the American Partnership for Eosinophilic Disorders, the CURED Foundation, and the Eosinophilic Family Coalition. Dr. Hirano has received consulting fees and research funding from Celgene, Regeneron, and Shire among others. Dr. Hirano made his comments during the AGA Institute Presidential Plenary at the Annual Digestive Disease Week.
What does burnout cost?
How are you feeling today? Simple words but a bit of introspection can go a long way. P It affects a physician’s well-being, effectiveness, productivity, and the ability to provide quality care. It also carries personal consequences for physicians including broken relationships, substance abuse, suicide, and depression.
Burnout may affect at least one-third of gastroenterologists. At greater risk are younger physicians, physicians performing high-risk procedures, and physicians experiencing work-life conflicts.
While the root cause of physician burnout varies from provider to provider, an overarching theme is work stress. Work stress may develop for a number of reasons, including issues at the level of the health care system (shifts in reimbursement or payment models, increasing clerical burden of the electronic medical record), organizational issues (e.g., dysfunctional administration, system-wide communication issues), and personal issues.
The key to preventing burnout is to first recognize that it can happen. Because initial symptoms build up internally, it can be easy to overlook. These seven steps can help you prevent burnout:
- Be self-aware and stay vigilant.
- Take care of yourself first.
- Stay connected to family, friends, and coworkers.
- Exercise.
- Ensure adequate sleep.
- Use your vacation time and ensure you disconnect yourself from work.
- Learn to say no.
A case study published in Clinical Gastroenterology and Hepatology delves deeper into how burnout develops, why it matters, and provides pathways to successfully combat it.
How are you feeling today? Simple words but a bit of introspection can go a long way. P It affects a physician’s well-being, effectiveness, productivity, and the ability to provide quality care. It also carries personal consequences for physicians including broken relationships, substance abuse, suicide, and depression.
Burnout may affect at least one-third of gastroenterologists. At greater risk are younger physicians, physicians performing high-risk procedures, and physicians experiencing work-life conflicts.
While the root cause of physician burnout varies from provider to provider, an overarching theme is work stress. Work stress may develop for a number of reasons, including issues at the level of the health care system (shifts in reimbursement or payment models, increasing clerical burden of the electronic medical record), organizational issues (e.g., dysfunctional administration, system-wide communication issues), and personal issues.
The key to preventing burnout is to first recognize that it can happen. Because initial symptoms build up internally, it can be easy to overlook. These seven steps can help you prevent burnout:
- Be self-aware and stay vigilant.
- Take care of yourself first.
- Stay connected to family, friends, and coworkers.
- Exercise.
- Ensure adequate sleep.
- Use your vacation time and ensure you disconnect yourself from work.
- Learn to say no.
A case study published in Clinical Gastroenterology and Hepatology delves deeper into how burnout develops, why it matters, and provides pathways to successfully combat it.
How are you feeling today? Simple words but a bit of introspection can go a long way. P It affects a physician’s well-being, effectiveness, productivity, and the ability to provide quality care. It also carries personal consequences for physicians including broken relationships, substance abuse, suicide, and depression.
Burnout may affect at least one-third of gastroenterologists. At greater risk are younger physicians, physicians performing high-risk procedures, and physicians experiencing work-life conflicts.
While the root cause of physician burnout varies from provider to provider, an overarching theme is work stress. Work stress may develop for a number of reasons, including issues at the level of the health care system (shifts in reimbursement or payment models, increasing clerical burden of the electronic medical record), organizational issues (e.g., dysfunctional administration, system-wide communication issues), and personal issues.
The key to preventing burnout is to first recognize that it can happen. Because initial symptoms build up internally, it can be easy to overlook. These seven steps can help you prevent burnout:
- Be self-aware and stay vigilant.
- Take care of yourself first.
- Stay connected to family, friends, and coworkers.
- Exercise.
- Ensure adequate sleep.
- Use your vacation time and ensure you disconnect yourself from work.
- Learn to say no.
A case study published in Clinical Gastroenterology and Hepatology delves deeper into how burnout develops, why it matters, and provides pathways to successfully combat it.
Be Kind to Yourself: Preventing Burnout in New GIs Through Self-Compassion
Physician burnout is a growing epidemic, particularly in the early careers of gastroenterologists. Up to 50% of new physicians and trainees experience burnout with the first 3 years of independent practice.1 The negative consequences of burnout are well known – medical errors, depression, substance abuse, and even suicide.2,3 To meet criteria for burnout syndrome (Table 1), one must have two of three core symptoms, often experienced as phases: 1) physical and emotional exhaustion; 2) cynicism and detachment; and 3) feelings of ineffectiveness and lack of accomplishment.4
Emotional exhaustion, one of the earliest symptoms of burnout syndrome was reported to be as high as 63% among gastroenterologists in a survey study I conducted with colleagues a few years ago.5 Similar findings are noted amongst colorectal surgeons.6 We also noted in our study that burnout levels were highest in junior versus senior attendings, with junior attendings reporting more stress related to performing endoscopies and making split-second decisions. Interventional endoscopists may have been disproportionately affected by the latter, reporting that they were more likely to think about possible mistakes they made after work, have difficulty sleeping due to thinking about their day, and have difficulty separating work and personal life.5 Male and female physicians may progress through the phases of burnout differently, with men being more likely to experience cynicism and depersonalization first, followed by fatigue. Men may also not necessarily experience the third phase of feeling ineffective, which can be particularly dangerous because they will continue to push until there is a serious consequence. Women tend to go through all three phases of burnout beginning with emotional exhaustion, with a more rapid progression through the cynicism phase, and may end up spending the majority of their time feeling ineffective and limited in their accomplishments, a recipe for leaving medicine entirely.7
Prevention of burnout through self-compassion
Even though it may sometimes be easy to forget, most of us chose medicine as our profession because of our inherent compassion towards others and desire to care for those in need. But have we properly learned how to apply that same compassion to ourselves?
Self-compassion is one of the primary qualities of a happy, flourishing, resilient individual.8 Self-compassion is a psychological skill that can be applied to feelings of inadequacy, failure, or lack of control and includes: 1) self-kindness, 2) belief in a common humanity, and 3) mindfulness.8
Are you self-compassionate? Take a quiz!
Self-kindness requires us to treat ourselves as kindly as we would a friend or patient in the same situation. We must consciously choose not to use harsh, self-critical language when we make mistakes. We are taught not to berate our trainees for mistakes in the clinical setting – we can be taught not to berate ourselves for shortcomings as well. Self-kindness also requires that we provide ourselves with sympathy when we experience disappointments through no fault of our own (e.g. despite all my best efforts, this clinical initiative failed) and give ourselves the opportunity to nurture and soothe ourselves when we experience pain.6 Belief in a common humanity fosters engagement with others, recognizing that nobody is perfect and that others suffer as well. Isolating ourselves because we feel ashamed, embarrassed, or “crazy” in our experience of a situation only increases our suffering. As we engage with others, we are able to view things from a different perspective and also recognize that others around us have problems too. Indeed, social support may be one of the best buffers against burnout, particularly cynicism.12 A recent meta-analysis concluded that a combination of institutional engagement techniques including reduced hours and support groups as well as access to individual behavioral techniques such as mindfulness could reduce or prevent burnout.13
I have previously commented on the practice of mindfulness in the AGA Community forums and, as a potentially stand-alone component of self-compassion training,14 recommend it here as well. In addition to traditional mindfulness-based stress-reduction courses and mindfulness meditation practice found in many hospitals and community centers, individual meditation focused on loving kindness or gratitude as well as mindful exercises such as writing a self-compassionate letter or statements to yourself can be used to offset burnout in daily life.15 From the perspective of reducing burnout, mindfulness allows us to look at our feelings of cynicism, exhaustion, and inadequacy without judgment, to view them as symptoms rather than ugly truths about ourselves and that rather than avoid or suppress these feelings, to be mindful and compassionate toward them.
Finally, in the spirit of self-compassion, we must not judge ourselves for needing the help of others to navigate adversity – whether that support comes from our personal or professional life, or is provided by a mental health professional, we deserve to be taken care of as much as our patients do.
For more information, please visit the following, helpful resources: www.CenterForMSC.org, www.Self-Compassion.org, and www.MindfulSelfCompassion.org.
Dr. Keefer is director, psychobehavioral research, Icahn School of Medicine at Mount Sinai, division of gastroenterology, New York, N.Y.
References
1. West C.P., Shanafelt T.D., Kolars J.C. JAMA. 2011;306[9]:952-60.
2. Maslach C., Leiter M.P. World Psychiatry. 2016;15[2]:103-11.
3. Ahola K., Honkonen T., Kivimaki M., et al. J Occup Environ Med. 2006;48[10]:1023-30.
4. Ahola K., Honkonen T., Isometsa E., et al. Soc Psychiatry Psychiatr Epidemiol. 2006;41[1]:11-7.
5. Farber B.A. J Clin Psychol. 2000;56[5]:589-94.
6. Keswani R.N., Taft T.H., Cote G.A., Keefer L. Am J Gastroenterol. 2011;106[10]:1734-40.
7. Sharma A., Sharp D.M., Walker L.G., Monson J.R. Psychooncology. 2008;17[6]:570-6.
8. Houkes I., Winants Y., Twellaar M., Verdonk P. BMC Public Health. 2011;11:240.
9. Neff K.D. Hum Dev. 2009;52[4]:211-4.
10. de Vente W., van Amsterdam J.G., Olff M., Kamphuis J.H., Emmelkamp P.M. Biomed Res Int. 2015;2015:431725.
11. Rockliff H., Karl A., McEwan K., Gilbert J., Matos M., Gilbert P. Effects of intranasal oxytocin on ‘compassion focused imagery’. Emotion. 2011;11[6]:1388-96.
12. Porges S.W. Biol Psychol. 2007;74[2]:301-7.
13. Breines J.G., Chen S. Pers Soc Psychol Bull. 2012;38[9]:1133-43.
14. Heffernan M., Quinn G.M.T., Sister R.M., Fitzpatrick JJ. Int J Nurs Pract. 2010;16[4]:366-73.
15. Crocker J., Canevello A. J Pers Soc Psychol. 2008;95[3]:555-75.
16. Thompson G., McBride R.B., Hosford C.C., Halaas G. Teach Learn Med. 2016;28[2]:174-82.
17. Nie Z., Jin Y., He L., et al. Int J Clin Exp Med. 2015;8[10]:19144-9.
18. West C.P., Dyrbye L.N., Erwin P.J., Shanafelt T.D. Lancet. 2016. Nov 5;388(10057)2272-81.
19. Luchterhand C., Rakel D., Haq C., et al. WMJ. 2015;114[3]:105-9.
20. Montero-Marin J., Tops M., Manzanera R, Piva Demarzo MM, Alvarez de Mon M, Garcia-Campayo J. Front Psychol. 2015;6:1895.
Physician burnout is a growing epidemic, particularly in the early careers of gastroenterologists. Up to 50% of new physicians and trainees experience burnout with the first 3 years of independent practice.1 The negative consequences of burnout are well known – medical errors, depression, substance abuse, and even suicide.2,3 To meet criteria for burnout syndrome (Table 1), one must have two of three core symptoms, often experienced as phases: 1) physical and emotional exhaustion; 2) cynicism and detachment; and 3) feelings of ineffectiveness and lack of accomplishment.4
Emotional exhaustion, one of the earliest symptoms of burnout syndrome was reported to be as high as 63% among gastroenterologists in a survey study I conducted with colleagues a few years ago.5 Similar findings are noted amongst colorectal surgeons.6 We also noted in our study that burnout levels were highest in junior versus senior attendings, with junior attendings reporting more stress related to performing endoscopies and making split-second decisions. Interventional endoscopists may have been disproportionately affected by the latter, reporting that they were more likely to think about possible mistakes they made after work, have difficulty sleeping due to thinking about their day, and have difficulty separating work and personal life.5 Male and female physicians may progress through the phases of burnout differently, with men being more likely to experience cynicism and depersonalization first, followed by fatigue. Men may also not necessarily experience the third phase of feeling ineffective, which can be particularly dangerous because they will continue to push until there is a serious consequence. Women tend to go through all three phases of burnout beginning with emotional exhaustion, with a more rapid progression through the cynicism phase, and may end up spending the majority of their time feeling ineffective and limited in their accomplishments, a recipe for leaving medicine entirely.7
Prevention of burnout through self-compassion
Even though it may sometimes be easy to forget, most of us chose medicine as our profession because of our inherent compassion towards others and desire to care for those in need. But have we properly learned how to apply that same compassion to ourselves?
Self-compassion is one of the primary qualities of a happy, flourishing, resilient individual.8 Self-compassion is a psychological skill that can be applied to feelings of inadequacy, failure, or lack of control and includes: 1) self-kindness, 2) belief in a common humanity, and 3) mindfulness.8
Are you self-compassionate? Take a quiz!
Self-kindness requires us to treat ourselves as kindly as we would a friend or patient in the same situation. We must consciously choose not to use harsh, self-critical language when we make mistakes. We are taught not to berate our trainees for mistakes in the clinical setting – we can be taught not to berate ourselves for shortcomings as well. Self-kindness also requires that we provide ourselves with sympathy when we experience disappointments through no fault of our own (e.g. despite all my best efforts, this clinical initiative failed) and give ourselves the opportunity to nurture and soothe ourselves when we experience pain.6 Belief in a common humanity fosters engagement with others, recognizing that nobody is perfect and that others suffer as well. Isolating ourselves because we feel ashamed, embarrassed, or “crazy” in our experience of a situation only increases our suffering. As we engage with others, we are able to view things from a different perspective and also recognize that others around us have problems too. Indeed, social support may be one of the best buffers against burnout, particularly cynicism.12 A recent meta-analysis concluded that a combination of institutional engagement techniques including reduced hours and support groups as well as access to individual behavioral techniques such as mindfulness could reduce or prevent burnout.13
I have previously commented on the practice of mindfulness in the AGA Community forums and, as a potentially stand-alone component of self-compassion training,14 recommend it here as well. In addition to traditional mindfulness-based stress-reduction courses and mindfulness meditation practice found in many hospitals and community centers, individual meditation focused on loving kindness or gratitude as well as mindful exercises such as writing a self-compassionate letter or statements to yourself can be used to offset burnout in daily life.15 From the perspective of reducing burnout, mindfulness allows us to look at our feelings of cynicism, exhaustion, and inadequacy without judgment, to view them as symptoms rather than ugly truths about ourselves and that rather than avoid or suppress these feelings, to be mindful and compassionate toward them.
Finally, in the spirit of self-compassion, we must not judge ourselves for needing the help of others to navigate adversity – whether that support comes from our personal or professional life, or is provided by a mental health professional, we deserve to be taken care of as much as our patients do.
For more information, please visit the following, helpful resources: www.CenterForMSC.org, www.Self-Compassion.org, and www.MindfulSelfCompassion.org.
Dr. Keefer is director, psychobehavioral research, Icahn School of Medicine at Mount Sinai, division of gastroenterology, New York, N.Y.
References
1. West C.P., Shanafelt T.D., Kolars J.C. JAMA. 2011;306[9]:952-60.
2. Maslach C., Leiter M.P. World Psychiatry. 2016;15[2]:103-11.
3. Ahola K., Honkonen T., Kivimaki M., et al. J Occup Environ Med. 2006;48[10]:1023-30.
4. Ahola K., Honkonen T., Isometsa E., et al. Soc Psychiatry Psychiatr Epidemiol. 2006;41[1]:11-7.
5. Farber B.A. J Clin Psychol. 2000;56[5]:589-94.
6. Keswani R.N., Taft T.H., Cote G.A., Keefer L. Am J Gastroenterol. 2011;106[10]:1734-40.
7. Sharma A., Sharp D.M., Walker L.G., Monson J.R. Psychooncology. 2008;17[6]:570-6.
8. Houkes I., Winants Y., Twellaar M., Verdonk P. BMC Public Health. 2011;11:240.
9. Neff K.D. Hum Dev. 2009;52[4]:211-4.
10. de Vente W., van Amsterdam J.G., Olff M., Kamphuis J.H., Emmelkamp P.M. Biomed Res Int. 2015;2015:431725.
11. Rockliff H., Karl A., McEwan K., Gilbert J., Matos M., Gilbert P. Effects of intranasal oxytocin on ‘compassion focused imagery’. Emotion. 2011;11[6]:1388-96.
12. Porges S.W. Biol Psychol. 2007;74[2]:301-7.
13. Breines J.G., Chen S. Pers Soc Psychol Bull. 2012;38[9]:1133-43.
14. Heffernan M., Quinn G.M.T., Sister R.M., Fitzpatrick JJ. Int J Nurs Pract. 2010;16[4]:366-73.
15. Crocker J., Canevello A. J Pers Soc Psychol. 2008;95[3]:555-75.
16. Thompson G., McBride R.B., Hosford C.C., Halaas G. Teach Learn Med. 2016;28[2]:174-82.
17. Nie Z., Jin Y., He L., et al. Int J Clin Exp Med. 2015;8[10]:19144-9.
18. West C.P., Dyrbye L.N., Erwin P.J., Shanafelt T.D. Lancet. 2016. Nov 5;388(10057)2272-81.
19. Luchterhand C., Rakel D., Haq C., et al. WMJ. 2015;114[3]:105-9.
20. Montero-Marin J., Tops M., Manzanera R, Piva Demarzo MM, Alvarez de Mon M, Garcia-Campayo J. Front Psychol. 2015;6:1895.
Physician burnout is a growing epidemic, particularly in the early careers of gastroenterologists. Up to 50% of new physicians and trainees experience burnout with the first 3 years of independent practice.1 The negative consequences of burnout are well known – medical errors, depression, substance abuse, and even suicide.2,3 To meet criteria for burnout syndrome (Table 1), one must have two of three core symptoms, often experienced as phases: 1) physical and emotional exhaustion; 2) cynicism and detachment; and 3) feelings of ineffectiveness and lack of accomplishment.4
Emotional exhaustion, one of the earliest symptoms of burnout syndrome was reported to be as high as 63% among gastroenterologists in a survey study I conducted with colleagues a few years ago.5 Similar findings are noted amongst colorectal surgeons.6 We also noted in our study that burnout levels were highest in junior versus senior attendings, with junior attendings reporting more stress related to performing endoscopies and making split-second decisions. Interventional endoscopists may have been disproportionately affected by the latter, reporting that they were more likely to think about possible mistakes they made after work, have difficulty sleeping due to thinking about their day, and have difficulty separating work and personal life.5 Male and female physicians may progress through the phases of burnout differently, with men being more likely to experience cynicism and depersonalization first, followed by fatigue. Men may also not necessarily experience the third phase of feeling ineffective, which can be particularly dangerous because they will continue to push until there is a serious consequence. Women tend to go through all three phases of burnout beginning with emotional exhaustion, with a more rapid progression through the cynicism phase, and may end up spending the majority of their time feeling ineffective and limited in their accomplishments, a recipe for leaving medicine entirely.7
Prevention of burnout through self-compassion
Even though it may sometimes be easy to forget, most of us chose medicine as our profession because of our inherent compassion towards others and desire to care for those in need. But have we properly learned how to apply that same compassion to ourselves?
Self-compassion is one of the primary qualities of a happy, flourishing, resilient individual.8 Self-compassion is a psychological skill that can be applied to feelings of inadequacy, failure, or lack of control and includes: 1) self-kindness, 2) belief in a common humanity, and 3) mindfulness.8
Are you self-compassionate? Take a quiz!
Self-kindness requires us to treat ourselves as kindly as we would a friend or patient in the same situation. We must consciously choose not to use harsh, self-critical language when we make mistakes. We are taught not to berate our trainees for mistakes in the clinical setting – we can be taught not to berate ourselves for shortcomings as well. Self-kindness also requires that we provide ourselves with sympathy when we experience disappointments through no fault of our own (e.g. despite all my best efforts, this clinical initiative failed) and give ourselves the opportunity to nurture and soothe ourselves when we experience pain.6 Belief in a common humanity fosters engagement with others, recognizing that nobody is perfect and that others suffer as well. Isolating ourselves because we feel ashamed, embarrassed, or “crazy” in our experience of a situation only increases our suffering. As we engage with others, we are able to view things from a different perspective and also recognize that others around us have problems too. Indeed, social support may be one of the best buffers against burnout, particularly cynicism.12 A recent meta-analysis concluded that a combination of institutional engagement techniques including reduced hours and support groups as well as access to individual behavioral techniques such as mindfulness could reduce or prevent burnout.13
I have previously commented on the practice of mindfulness in the AGA Community forums and, as a potentially stand-alone component of self-compassion training,14 recommend it here as well. In addition to traditional mindfulness-based stress-reduction courses and mindfulness meditation practice found in many hospitals and community centers, individual meditation focused on loving kindness or gratitude as well as mindful exercises such as writing a self-compassionate letter or statements to yourself can be used to offset burnout in daily life.15 From the perspective of reducing burnout, mindfulness allows us to look at our feelings of cynicism, exhaustion, and inadequacy without judgment, to view them as symptoms rather than ugly truths about ourselves and that rather than avoid or suppress these feelings, to be mindful and compassionate toward them.
Finally, in the spirit of self-compassion, we must not judge ourselves for needing the help of others to navigate adversity – whether that support comes from our personal or professional life, or is provided by a mental health professional, we deserve to be taken care of as much as our patients do.
For more information, please visit the following, helpful resources: www.CenterForMSC.org, www.Self-Compassion.org, and www.MindfulSelfCompassion.org.
Dr. Keefer is director, psychobehavioral research, Icahn School of Medicine at Mount Sinai, division of gastroenterology, New York, N.Y.
References
1. West C.P., Shanafelt T.D., Kolars J.C. JAMA. 2011;306[9]:952-60.
2. Maslach C., Leiter M.P. World Psychiatry. 2016;15[2]:103-11.
3. Ahola K., Honkonen T., Kivimaki M., et al. J Occup Environ Med. 2006;48[10]:1023-30.
4. Ahola K., Honkonen T., Isometsa E., et al. Soc Psychiatry Psychiatr Epidemiol. 2006;41[1]:11-7.
5. Farber B.A. J Clin Psychol. 2000;56[5]:589-94.
6. Keswani R.N., Taft T.H., Cote G.A., Keefer L. Am J Gastroenterol. 2011;106[10]:1734-40.
7. Sharma A., Sharp D.M., Walker L.G., Monson J.R. Psychooncology. 2008;17[6]:570-6.
8. Houkes I., Winants Y., Twellaar M., Verdonk P. BMC Public Health. 2011;11:240.
9. Neff K.D. Hum Dev. 2009;52[4]:211-4.
10. de Vente W., van Amsterdam J.G., Olff M., Kamphuis J.H., Emmelkamp P.M. Biomed Res Int. 2015;2015:431725.
11. Rockliff H., Karl A., McEwan K., Gilbert J., Matos M., Gilbert P. Effects of intranasal oxytocin on ‘compassion focused imagery’. Emotion. 2011;11[6]:1388-96.
12. Porges S.W. Biol Psychol. 2007;74[2]:301-7.
13. Breines J.G., Chen S. Pers Soc Psychol Bull. 2012;38[9]:1133-43.
14. Heffernan M., Quinn G.M.T., Sister R.M., Fitzpatrick JJ. Int J Nurs Pract. 2010;16[4]:366-73.
15. Crocker J., Canevello A. J Pers Soc Psychol. 2008;95[3]:555-75.
16. Thompson G., McBride R.B., Hosford C.C., Halaas G. Teach Learn Med. 2016;28[2]:174-82.
17. Nie Z., Jin Y., He L., et al. Int J Clin Exp Med. 2015;8[10]:19144-9.
18. West C.P., Dyrbye L.N., Erwin P.J., Shanafelt T.D. Lancet. 2016. Nov 5;388(10057)2272-81.
19. Luchterhand C., Rakel D., Haq C., et al. WMJ. 2015;114[3]:105-9.
20. Montero-Marin J., Tops M., Manzanera R, Piva Demarzo MM, Alvarez de Mon M, Garcia-Campayo J. Front Psychol. 2015;6:1895.
The AGA Trainee and Early Career Committee – Shaping the Young GI Experience
AGA’s focus on young GIs
The AGA Trainee and Early Career Committee (formerly Trainee and Young GI Committee) is composed of 12 trainee and early-career AGA members and meets twice a year to develop programs and events specifically targeted to trainees and gastroenterologists (GIs) in their first five years out of fellowship training. The committee was formed by the AGA in February 2013 to address the specific needs of early-career GI professionals and to develop programs to expose younger members to all that the AGA has to offer. The new committee also became a creative space to organize efforts to increase membership among early-career GIs. Trainee and Early Career Committee members are selected for 2-year terms and represent fellowship training programs, universities, and practices from around the nation. Each committee member serves simultaneously on one other AGA committee, which gives young GIs additional opportunities for leadership roles. The committee meets regularly with AGA staff and a governing board liaison to discuss committee goals and the issues most relevant to physicians during and directly after GI fellowship training. The committee also provides feedback to other committees about how programs and initiatives might involve or impact GI fellows and recent graduates. The result is a unique focus group where young GIs from all over the country work collectively to improve the young GI experience through flagship programs like the Regional Practice Skills Workshop, the Young Delegates Program, and Trainee and Early Career events at Digestive Disease Week (DDW)®.
AGA Regional Practice Skills Workshops
The workshop agenda is similar across locations and includes sessions on career options in research and clinical practice, how to evaluate a job, contract negotiation, health care reform, financial planning, and work-life balance. The program is geared toward second- and third-year fellows, recent fellowship graduates, and those considering a job or career change. All workshops include catered meals and are free to both AGA members and non-members. Those interested in attending one of the workshops can find more information at http://www.gastro.org/trainees. The Trainee and Early Career committee is also looking to expand to additional cities in future years so that more trainees and early-career GIs can participate in these workshops.
The AGA Young Delegates program
The AGA highly values the efforts of our Young Delegates, and the Trainee and Early Career Committee considers them a talent pool from which we can elicit input, select committee members, and find future leaders. More importantly, we hope that the program allows young AGA members to increasingly engage with the AGA to refresh, improve, and strengthen the society. To become a Young Delegate, please visit www.gastro.org/youngdelegates to provide us with your information.
Trainee and early career GIs at DDW
The Trainee and Early Career Committee sponsors several events at DDW to bring together fellows and early-career GIs from all over the country. Each year, our committee hosts a DDW Trainee and Early Career symposium to provide practical advice for early-career GIs from all practice settings. Our DDW 2016 symposium was entitled “Surviving The First Years in Clinical Practice – Roundtable with the Experts,” and featured prominent leaders who shared career perspectives with attendees through formal presentations and more casual discussion. Attendees gained insider tips on how to design and run a fiscally prosperous practice, coding and documentation, and building and maintaining a clinical practice referral base from expert AGA leaders. We are now in the process of planning the DDW 2017 Trainee and Early Career symposium that will focus on “The Road to Leadership in GI.”
Come join us!
The success of the AGA depends on the 16,000 members who volunteer their time for committees, councils, and the governing board. Since its inception, the Trainee and Early Career Committee has allowed young GIs to have a role in the AGA as well as benefit from all of the resources that the AGA has to offer in leadership training, networking, and career preparation. In the past three years, participation of young GIs in the Trainee and Early Career Committee events has been on the rise, which we hope is a reflection of our efforts to address the educational needs of early GIs and the transition from fellowship to practice. We would love to see more fellows and early-career GIs involved!
For more information about the Trainee and Early Career committee, becoming a committee member, and our programs, please visit http://www.gastro.org/trainees. If you have any ideas that you think the committee should consider, please let us know at [email protected].
Dr. Liang is an instructor in the division of gastroenterology, New York University School of Medicine, New York, and an attending physician in the VA New York Harbor Healthcare System, New York. Dr. Kushner is a transplant hepatology fellow in the division of gastroenterology, University of California, San Francisco. Dr. May is assistant professor in the division of digestive diseases, David Geffen School of Medicine, University of California, Los Angeles, and an attending physician in the department of gastroenterology in the VA Greater Los Angeles Healthcare System, Los Angeles.
AGA’s focus on young GIs
The AGA Trainee and Early Career Committee (formerly Trainee and Young GI Committee) is composed of 12 trainee and early-career AGA members and meets twice a year to develop programs and events specifically targeted to trainees and gastroenterologists (GIs) in their first five years out of fellowship training. The committee was formed by the AGA in February 2013 to address the specific needs of early-career GI professionals and to develop programs to expose younger members to all that the AGA has to offer. The new committee also became a creative space to organize efforts to increase membership among early-career GIs. Trainee and Early Career Committee members are selected for 2-year terms and represent fellowship training programs, universities, and practices from around the nation. Each committee member serves simultaneously on one other AGA committee, which gives young GIs additional opportunities for leadership roles. The committee meets regularly with AGA staff and a governing board liaison to discuss committee goals and the issues most relevant to physicians during and directly after GI fellowship training. The committee also provides feedback to other committees about how programs and initiatives might involve or impact GI fellows and recent graduates. The result is a unique focus group where young GIs from all over the country work collectively to improve the young GI experience through flagship programs like the Regional Practice Skills Workshop, the Young Delegates Program, and Trainee and Early Career events at Digestive Disease Week (DDW)®.
AGA Regional Practice Skills Workshops
The workshop agenda is similar across locations and includes sessions on career options in research and clinical practice, how to evaluate a job, contract negotiation, health care reform, financial planning, and work-life balance. The program is geared toward second- and third-year fellows, recent fellowship graduates, and those considering a job or career change. All workshops include catered meals and are free to both AGA members and non-members. Those interested in attending one of the workshops can find more information at http://www.gastro.org/trainees. The Trainee and Early Career committee is also looking to expand to additional cities in future years so that more trainees and early-career GIs can participate in these workshops.
The AGA Young Delegates program
The AGA highly values the efforts of our Young Delegates, and the Trainee and Early Career Committee considers them a talent pool from which we can elicit input, select committee members, and find future leaders. More importantly, we hope that the program allows young AGA members to increasingly engage with the AGA to refresh, improve, and strengthen the society. To become a Young Delegate, please visit www.gastro.org/youngdelegates to provide us with your information.
Trainee and early career GIs at DDW
The Trainee and Early Career Committee sponsors several events at DDW to bring together fellows and early-career GIs from all over the country. Each year, our committee hosts a DDW Trainee and Early Career symposium to provide practical advice for early-career GIs from all practice settings. Our DDW 2016 symposium was entitled “Surviving The First Years in Clinical Practice – Roundtable with the Experts,” and featured prominent leaders who shared career perspectives with attendees through formal presentations and more casual discussion. Attendees gained insider tips on how to design and run a fiscally prosperous practice, coding and documentation, and building and maintaining a clinical practice referral base from expert AGA leaders. We are now in the process of planning the DDW 2017 Trainee and Early Career symposium that will focus on “The Road to Leadership in GI.”
Come join us!
The success of the AGA depends on the 16,000 members who volunteer their time for committees, councils, and the governing board. Since its inception, the Trainee and Early Career Committee has allowed young GIs to have a role in the AGA as well as benefit from all of the resources that the AGA has to offer in leadership training, networking, and career preparation. In the past three years, participation of young GIs in the Trainee and Early Career Committee events has been on the rise, which we hope is a reflection of our efforts to address the educational needs of early GIs and the transition from fellowship to practice. We would love to see more fellows and early-career GIs involved!
For more information about the Trainee and Early Career committee, becoming a committee member, and our programs, please visit http://www.gastro.org/trainees. If you have any ideas that you think the committee should consider, please let us know at [email protected].
Dr. Liang is an instructor in the division of gastroenterology, New York University School of Medicine, New York, and an attending physician in the VA New York Harbor Healthcare System, New York. Dr. Kushner is a transplant hepatology fellow in the division of gastroenterology, University of California, San Francisco. Dr. May is assistant professor in the division of digestive diseases, David Geffen School of Medicine, University of California, Los Angeles, and an attending physician in the department of gastroenterology in the VA Greater Los Angeles Healthcare System, Los Angeles.
AGA’s focus on young GIs
The AGA Trainee and Early Career Committee (formerly Trainee and Young GI Committee) is composed of 12 trainee and early-career AGA members and meets twice a year to develop programs and events specifically targeted to trainees and gastroenterologists (GIs) in their first five years out of fellowship training. The committee was formed by the AGA in February 2013 to address the specific needs of early-career GI professionals and to develop programs to expose younger members to all that the AGA has to offer. The new committee also became a creative space to organize efforts to increase membership among early-career GIs. Trainee and Early Career Committee members are selected for 2-year terms and represent fellowship training programs, universities, and practices from around the nation. Each committee member serves simultaneously on one other AGA committee, which gives young GIs additional opportunities for leadership roles. The committee meets regularly with AGA staff and a governing board liaison to discuss committee goals and the issues most relevant to physicians during and directly after GI fellowship training. The committee also provides feedback to other committees about how programs and initiatives might involve or impact GI fellows and recent graduates. The result is a unique focus group where young GIs from all over the country work collectively to improve the young GI experience through flagship programs like the Regional Practice Skills Workshop, the Young Delegates Program, and Trainee and Early Career events at Digestive Disease Week (DDW)®.
AGA Regional Practice Skills Workshops
The workshop agenda is similar across locations and includes sessions on career options in research and clinical practice, how to evaluate a job, contract negotiation, health care reform, financial planning, and work-life balance. The program is geared toward second- and third-year fellows, recent fellowship graduates, and those considering a job or career change. All workshops include catered meals and are free to both AGA members and non-members. Those interested in attending one of the workshops can find more information at http://www.gastro.org/trainees. The Trainee and Early Career committee is also looking to expand to additional cities in future years so that more trainees and early-career GIs can participate in these workshops.
The AGA Young Delegates program
The AGA highly values the efforts of our Young Delegates, and the Trainee and Early Career Committee considers them a talent pool from which we can elicit input, select committee members, and find future leaders. More importantly, we hope that the program allows young AGA members to increasingly engage with the AGA to refresh, improve, and strengthen the society. To become a Young Delegate, please visit www.gastro.org/youngdelegates to provide us with your information.
Trainee and early career GIs at DDW
The Trainee and Early Career Committee sponsors several events at DDW to bring together fellows and early-career GIs from all over the country. Each year, our committee hosts a DDW Trainee and Early Career symposium to provide practical advice for early-career GIs from all practice settings. Our DDW 2016 symposium was entitled “Surviving The First Years in Clinical Practice – Roundtable with the Experts,” and featured prominent leaders who shared career perspectives with attendees through formal presentations and more casual discussion. Attendees gained insider tips on how to design and run a fiscally prosperous practice, coding and documentation, and building and maintaining a clinical practice referral base from expert AGA leaders. We are now in the process of planning the DDW 2017 Trainee and Early Career symposium that will focus on “The Road to Leadership in GI.”
Come join us!
The success of the AGA depends on the 16,000 members who volunteer their time for committees, councils, and the governing board. Since its inception, the Trainee and Early Career Committee has allowed young GIs to have a role in the AGA as well as benefit from all of the resources that the AGA has to offer in leadership training, networking, and career preparation. In the past three years, participation of young GIs in the Trainee and Early Career Committee events has been on the rise, which we hope is a reflection of our efforts to address the educational needs of early GIs and the transition from fellowship to practice. We would love to see more fellows and early-career GIs involved!
For more information about the Trainee and Early Career committee, becoming a committee member, and our programs, please visit http://www.gastro.org/trainees. If you have any ideas that you think the committee should consider, please let us know at [email protected].
Dr. Liang is an instructor in the division of gastroenterology, New York University School of Medicine, New York, and an attending physician in the VA New York Harbor Healthcare System, New York. Dr. Kushner is a transplant hepatology fellow in the division of gastroenterology, University of California, San Francisco. Dr. May is assistant professor in the division of digestive diseases, David Geffen School of Medicine, University of California, Los Angeles, and an attending physician in the department of gastroenterology in the VA Greater Los Angeles Healthcare System, Los Angeles.
