The New Gastroenterologist

In July, I had my annual physical with my primary care physician, whose practice is based out of a large urban academic medical center. As she concluded my visit and directed me to the lab to have my blood work done, she said, “You’ll be receiving an automatic notice from MyChart by 9 am tomorrow that your medical records from today’s visit are available. I apologize if I have not yet had the opportunity to review them and enter my note, but you’ll get access to all of that, as well, as soon as it is in the system.”

This sort of interaction is increasingly common across the United States as health care institutions implement policies and procedures to comply with new regulations promulgated by the Office of the National Coordinator for Health Information Technology (ONC), which went into effect on April 5, 2021. These rules were promulgated in accordance with the 21st Century Cures Act of 2016 (Cures Act).¹ The regulations, known as the Interoperability, Information Blocking, and the ONC Health IT Certification Program, implement provisions of the Cures Act intended to “support the access, exchange, and use of electronic health information.” The rule is considered a significant step in the “open notes” movement, which is intended to make health care more transparent by enabling patients to access their medical records. The drafters of the ONC regulations have carved out certain exceptions to the information blocking rule. For example, one exception allows some patient information to be withheld where making that information available might cause physical harm to the patient or another person.

Thus far, few patients have been informed about the new regulation.² By forbidding “information blocking,” the rule enables patients to more easily access and control their health information. Currently, the rule requires that physicians allow automatic access, without charge, to a patient’s own personal health information, including clinical notes, medication lists, laboratory results, and other diagnostic reports. Records must be provided “without delay,” or at least as soon as the physician’s office receives an electronic copy. In 2022, it will be required that access to even more of a patient’s personal electronic health record be provided in real-time through a patient portal and that electronic health information be shareable across third-party apps.

The Cures Act and the regulations governing its implementation highlight the inherent tension between two core principles of bioethical inquiry: autonomy and beneficence. The first principle, autonomy, champions allowing patient access and control over their own personal information. Beneficence, which is often expressed as paternalism, ensures that the experts are able to analyze and interpret data so that patients are in the best position to then make informed decisions.

With these principles in mind, arguments against open notes have generally fallen into three related categories. First, critics worry that immediate access to one’s medical record will increase patient anxiety caused by feelings of being inundated with complex medical information that patients may be ill-equipped to analyze and understand. This is a common refrain any time policies are implemented to improve medical information sharing. For example, critics of direct-to-consumer genetic testing caution that permitting unfettered access to complex information, particularly without an intermediary to interpret the data, could lead to confusion and poor medical choices.

There may be validity to this claim. One study found that 3% of patients reported feeling very confused when granted access to their medical notes.³ Another study concluded that direct release of medical test results “sometimes leads to unnecessary anxiety.”⁴ While the drafters of the ONC regulations have carved out certain exceptions to the information blocking rule, those exceptions do not allow for withholding of information because of concerns about patient anxiety or psychological harms.

The second common critique of open notes is that requiring release of all clinical notes will lead to clinician self-censorship, effectively muzzling or silencing the experts whose responsibility it is to objectively interpret results in order to provide the best care for their patients. Some have expressed concern that clinicians will be forced to “code” their records to avoid addressing “sensitive” subjects that might make patients feel offended or judged. This, in turn, might lead to less complete, reliable, or useful clinician communication.³

In fact, open notes has led to changes in the documentation process for some clinicians. They have reported modifying the way they document patient visits by changing their use of critical language and sensitive information.⁵ One study found that open notes led physicians to adjust “their language to avoid being perceived as critical of patients; omitting certain terms, such as ‘noncompliant’ and ‘patient denies’; and modifying how they document sensitive information.”³

In response, experts recommend focusing on precise and empathetic patient notes; in other words, the clinician should not write something in the note that they would not say directly to the patient. For example, they recommend that clinicians use precise language (for example, identifying the patient’s BMI) rather than using terms that could be offensive (for example, labeling the patient as “obese”).⁶ The shift to more empathetic note-taking could be seen less as a burden and more as a valuable tool in the shared decision-making endeavor: It could allow physicians to document both their clinical judgments and the patient’s values and preferences, which could lead to better medical decision-making.

Third, critics of open notes point to concerns about the burden it places on clinicians’ already limited time. The ONC rule requires automatic release of test results regardless of whether the clinician has had the opportunity to review them and offer their interpretation and insight. Because physician interpretation of results has known benefits,⁴ this puts additional pressure on clinicians to review results and enter notes in a timely manner. But physicians have reported that often open notes necessitates that they spend more time on documentation than they would otherwise.⁵

Despite critiques of open notes, the benefits of allowing patients access to their medical records have been repeatedly demonstrated. And research has shown that patients benefit from accessing open notes by allowing them to access and control their own personal medical information.⁵ Patients report that they understand and value the information provided to them in their medical records,⁷ and they feel empowered to participate in their medical decision-making. In surveys, patients report that reading their doctors’ notes is useful for taking care of their health and for remembering their care plans, understanding why a medication was prescribed, and reinforcing the need to take their medications and adhere to treatment plans.⁸

Importantly, open notes can increase patient engagement and patients’ trust in their physicians,⁹ thereby improving the doctor-patient relationship.³ And allowing patients to share their medical records with care partners enables supported decision-making, particularly for older and chronically ill individuals.³ Additionally, it is predicted that open notes may, in fact, decrease legal liability.⁹ By improving both trust in the doctor-patient relationship and safety, some experts expect that legal claims against clinicians will, in turn, decrease.¹⁰

The modern practice of medicine necessitates a more empathetic approach to clinical note-taking, even in the absence of regulation requiring it. As the regulations implementing the Cures Act roll out, patients will have easier, and more immediate, access to their medical records. Despite earlier hesitancy, clinicians are steadily beginning to support sharing access to notes with patients.⁵ Change can be hard. But the change expected of clinicians because of these new regulations appears to be less onerous than originally anticipated.

Prof. Koch is codirector of Health Law & Policy Institute and assistant professor at the University of Houston Law Center, as well as director of law and ethics at the MacLean Center for Clinical Medical Ethics at the University of Chicago. She has no disclosures.

This article was updated Sept. 9, 2021.

References

1. Fed Regist. 2020 May;85(85):25642-961.

2. The Petrie-Flom Center Staff. “New Rule Puts Medical Data in Patients’ Hands.” Bill of Health. July 12, 2021. Accessed August 30, 2021. https://blog.petrieflom.law.harvard.edu/2021/07/12/new-rule-puts-medical-data-in-patients-hands/.

3. Blease C et al. Ann Intern Med. 2021 Jan;174(1):101-2.

4. Pillemer F et al. PLoS One. 2016 Jun. doi: 10.1371/journal.pone.0154743.

5. DesRoches CM et al. JAMA Netw Open. 2020 Mar. doi: 10.1001/jamanetworkopen.2020.1753.

6. Heath S. “Most Patients Understand Clinical Notes, Patient Data Access.” Patient Engagement HIT. July 29, 2020. Accessed August 30, 2021. https://patientengagementhit.com/news/most-patients-understand-clinical-notes-patient-data-access

7. Leveille SG et al. J Gen Intern Med. 2020 Dec;35(12):3510-6.

8. Walker J et al. J Med Internet Res. 2019 May. doi: 10.2196/13876.

9. Bell SK et al. BMJ Qual Saf. 2017 Apr;26(4):262-70.

10. Kachalia A, Mello MM. N Engl J Med. 2011 Apr;364(16):1564-72.

In July, I had my annual physical with my primary care physician, whose practice is based out of a large urban academic medical center. As she concluded my visit and directed me to the lab to have my blood work done, she said, “You’ll be receiving an automatic notice from MyChart by 9 am tomorrow that your medical records from today’s visit are available. I apologize if I have not yet had the opportunity to review them and enter my note, but you’ll get access to all of that, as well, as soon as it is in the system.”

This sort of interaction is increasingly common across the United States as health care institutions implement policies and procedures to comply with new regulations promulgated by the Office of the National Coordinator for Health Information Technology (ONC), which went into effect on April 5, 2021. These rules were promulgated in accordance with the 21st Century Cures Act of 2016 (Cures Act).¹ The regulations, known as the Interoperability, Information Blocking, and the ONC Health IT Certification Program, implement provisions of the Cures Act intended to “support the access, exchange, and use of electronic health information.” The rule is considered a significant step in the “open notes” movement, which is intended to make health care more transparent by enabling patients to access their medical records. The drafters of the ONC regulations have carved out certain exceptions to the information blocking rule. For example, one exception allows some patient information to be withheld where making that information available might cause physical harm to the patient or another person.

Thus far, few patients have been informed about the new regulation.² By forbidding “information blocking,” the rule enables patients to more easily access and control their health information. Currently, the rule requires that physicians allow automatic access, without charge, to a patient’s own personal health information, including clinical notes, medication lists, laboratory results, and other diagnostic reports. Records must be provided “without delay,” or at least as soon as the physician’s office receives an electronic copy. In 2022, it will be required that access to even more of a patient’s personal electronic health record be provided in real-time through a patient portal and that electronic health information be shareable across third-party apps.

The Cures Act and the regulations governing its implementation highlight the inherent tension between two core principles of bioethical inquiry: autonomy and beneficence. The first principle, autonomy, champions allowing patient access and control over their own personal information. Beneficence, which is often expressed as paternalism, ensures that the experts are able to analyze and interpret data so that patients are in the best position to then make informed decisions.

With these principles in mind, arguments against open notes have generally fallen into three related categories. First, critics worry that immediate access to one’s medical record will increase patient anxiety caused by feelings of being inundated with complex medical information that patients may be ill-equipped to analyze and understand. This is a common refrain any time policies are implemented to improve medical information sharing. For example, critics of direct-to-consumer genetic testing caution that permitting unfettered access to complex information, particularly without an intermediary to interpret the data, could lead to confusion and poor medical choices.

There may be validity to this claim. One study found that 3% of patients reported feeling very confused when granted access to their medical notes.³ Another study concluded that direct release of medical test results “sometimes leads to unnecessary anxiety.”⁴ While the drafters of the ONC regulations have carved out certain exceptions to the information blocking rule, those exceptions do not allow for withholding of information because of concerns about patient anxiety or psychological harms.

The second common critique of open notes is that requiring release of all clinical notes will lead to clinician self-censorship, effectively muzzling or silencing the experts whose responsibility it is to objectively interpret results in order to provide the best care for their patients. Some have expressed concern that clinicians will be forced to “code” their records to avoid addressing “sensitive” subjects that might make patients feel offended or judged. This, in turn, might lead to less complete, reliable, or useful clinician communication.³

In fact, open notes has led to changes in the documentation process for some clinicians. They have reported modifying the way they document patient visits by changing their use of critical language and sensitive information.⁵ One study found that open notes led physicians to adjust “their language to avoid being perceived as critical of patients; omitting certain terms, such as ‘noncompliant’ and ‘patient denies’; and modifying how they document sensitive information.”³

In response, experts recommend focusing on precise and empathetic patient notes; in other words, the clinician should not write something in the note that they would not say directly to the patient. For example, they recommend that clinicians use precise language (for example, identifying the patient’s BMI) rather than using terms that could be offensive (for example, labeling the patient as “obese”).⁶ The shift to more empathetic note-taking could be seen less as a burden and more as a valuable tool in the shared decision-making endeavor: It could allow physicians to document both their clinical judgments and the patient’s values and preferences, which could lead to better medical decision-making.

Third, critics of open notes point to concerns about the burden it places on clinicians’ already limited time. The ONC rule requires automatic release of test results regardless of whether the clinician has had the opportunity to review them and offer their interpretation and insight. Because physician interpretation of results has known benefits,⁴ this puts additional pressure on clinicians to review results and enter notes in a timely manner. But physicians have reported that often open notes necessitates that they spend more time on documentation than they would otherwise.⁵

Despite critiques of open notes, the benefits of allowing patients access to their medical records have been repeatedly demonstrated. And research has shown that patients benefit from accessing open notes by allowing them to access and control their own personal medical information.⁵ Patients report that they understand and value the information provided to them in their medical records,⁷ and they feel empowered to participate in their medical decision-making. In surveys, patients report that reading their doctors’ notes is useful for taking care of their health and for remembering their care plans, understanding why a medication was prescribed, and reinforcing the need to take their medications and adhere to treatment plans.⁸

Importantly, open notes can increase patient engagement and patients’ trust in their physicians,⁹ thereby improving the doctor-patient relationship.³ And allowing patients to share their medical records with care partners enables supported decision-making, particularly for older and chronically ill individuals.³ Additionally, it is predicted that open notes may, in fact, decrease legal liability.⁹ By improving both trust in the doctor-patient relationship and safety, some experts expect that legal claims against clinicians will, in turn, decrease.¹⁰

The modern practice of medicine necessitates a more empathetic approach to clinical note-taking, even in the absence of regulation requiring it. As the regulations implementing the Cures Act roll out, patients will have easier, and more immediate, access to their medical records. Despite earlier hesitancy, clinicians are steadily beginning to support sharing access to notes with patients.⁵ Change can be hard. But the change expected of clinicians because of these new regulations appears to be less onerous than originally anticipated.

Prof. Koch is codirector of Health Law & Policy Institute and assistant professor at the University of Houston Law Center, as well as director of law and ethics at the MacLean Center for Clinical Medical Ethics at the University of Chicago. She has no disclosures.

This article was updated Sept. 9, 2021.

References

1. Fed Regist. 2020 May;85(85):25642-961.

2. The Petrie-Flom Center Staff. “New Rule Puts Medical Data in Patients’ Hands.” Bill of Health. July 12, 2021. Accessed August 30, 2021. https://blog.petrieflom.law.harvard.edu/2021/07/12/new-rule-puts-medical-data-in-patients-hands/.

3. Blease C et al. Ann Intern Med. 2021 Jan;174(1):101-2.

4. Pillemer F et al. PLoS One. 2016 Jun. doi: 10.1371/journal.pone.0154743.

5. DesRoches CM et al. JAMA Netw Open. 2020 Mar. doi: 10.1001/jamanetworkopen.2020.1753.

6. Heath S. “Most Patients Understand Clinical Notes, Patient Data Access.” Patient Engagement HIT. July 29, 2020. Accessed August 30, 2021. https://patientengagementhit.com/news/most-patients-understand-clinical-notes-patient-data-access

7. Leveille SG et al. J Gen Intern Med. 2020 Dec;35(12):3510-6.

8. Walker J et al. J Med Internet Res. 2019 May. doi: 10.2196/13876.

9. Bell SK et al. BMJ Qual Saf. 2017 Apr;26(4):262-70.

10. Kachalia A, Mello MM. N Engl J Med. 2011 Apr;364(16):1564-72.

In July, I had my annual physical with my primary care physician, whose practice is based out of a large urban academic medical center. As she concluded my visit and directed me to the lab to have my blood work done, she said, “You’ll be receiving an automatic notice from MyChart by 9 am tomorrow that your medical records from today’s visit are available. I apologize if I have not yet had the opportunity to review them and enter my note, but you’ll get access to all of that, as well, as soon as it is in the system.”

This sort of interaction is increasingly common across the United States as health care institutions implement policies and procedures to comply with new regulations promulgated by the Office of the National Coordinator for Health Information Technology (ONC), which went into effect on April 5, 2021. These rules were promulgated in accordance with the 21st Century Cures Act of 2016 (Cures Act).¹ The regulations, known as the Interoperability, Information Blocking, and the ONC Health IT Certification Program, implement provisions of the Cures Act intended to “support the access, exchange, and use of electronic health information.” The rule is considered a significant step in the “open notes” movement, which is intended to make health care more transparent by enabling patients to access their medical records. The drafters of the ONC regulations have carved out certain exceptions to the information blocking rule. For example, one exception allows some patient information to be withheld where making that information available might cause physical harm to the patient or another person.

Thus far, few patients have been informed about the new regulation.² By forbidding “information blocking,” the rule enables patients to more easily access and control their health information. Currently, the rule requires that physicians allow automatic access, without charge, to a patient’s own personal health information, including clinical notes, medication lists, laboratory results, and other diagnostic reports. Records must be provided “without delay,” or at least as soon as the physician’s office receives an electronic copy. In 2022, it will be required that access to even more of a patient’s personal electronic health record be provided in real-time through a patient portal and that electronic health information be shareable across third-party apps.

The Cures Act and the regulations governing its implementation highlight the inherent tension between two core principles of bioethical inquiry: autonomy and beneficence. The first principle, autonomy, champions allowing patient access and control over their own personal information. Beneficence, which is often expressed as paternalism, ensures that the experts are able to analyze and interpret data so that patients are in the best position to then make informed decisions.

With these principles in mind, arguments against open notes have generally fallen into three related categories. First, critics worry that immediate access to one’s medical record will increase patient anxiety caused by feelings of being inundated with complex medical information that patients may be ill-equipped to analyze and understand. This is a common refrain any time policies are implemented to improve medical information sharing. For example, critics of direct-to-consumer genetic testing caution that permitting unfettered access to complex information, particularly without an intermediary to interpret the data, could lead to confusion and poor medical choices.

There may be validity to this claim. One study found that 3% of patients reported feeling very confused when granted access to their medical notes.³ Another study concluded that direct release of medical test results “sometimes leads to unnecessary anxiety.”⁴ While the drafters of the ONC regulations have carved out certain exceptions to the information blocking rule, those exceptions do not allow for withholding of information because of concerns about patient anxiety or psychological harms.

The second common critique of open notes is that requiring release of all clinical notes will lead to clinician self-censorship, effectively muzzling or silencing the experts whose responsibility it is to objectively interpret results in order to provide the best care for their patients. Some have expressed concern that clinicians will be forced to “code” their records to avoid addressing “sensitive” subjects that might make patients feel offended or judged. This, in turn, might lead to less complete, reliable, or useful clinician communication.³

In fact, open notes has led to changes in the documentation process for some clinicians. They have reported modifying the way they document patient visits by changing their use of critical language and sensitive information.⁵ One study found that open notes led physicians to adjust “their language to avoid being perceived as critical of patients; omitting certain terms, such as ‘noncompliant’ and ‘patient denies’; and modifying how they document sensitive information.”³

In response, experts recommend focusing on precise and empathetic patient notes; in other words, the clinician should not write something in the note that they would not say directly to the patient. For example, they recommend that clinicians use precise language (for example, identifying the patient’s BMI) rather than using terms that could be offensive (for example, labeling the patient as “obese”).⁶ The shift to more empathetic note-taking could be seen less as a burden and more as a valuable tool in the shared decision-making endeavor: It could allow physicians to document both their clinical judgments and the patient’s values and preferences, which could lead to better medical decision-making.

Third, critics of open notes point to concerns about the burden it places on clinicians’ already limited time. The ONC rule requires automatic release of test results regardless of whether the clinician has had the opportunity to review them and offer their interpretation and insight. Because physician interpretation of results has known benefits,⁴ this puts additional pressure on clinicians to review results and enter notes in a timely manner. But physicians have reported that often open notes necessitates that they spend more time on documentation than they would otherwise.⁵

Despite critiques of open notes, the benefits of allowing patients access to their medical records have been repeatedly demonstrated. And research has shown that patients benefit from accessing open notes by allowing them to access and control their own personal medical information.⁵ Patients report that they understand and value the information provided to them in their medical records,⁷ and they feel empowered to participate in their medical decision-making. In surveys, patients report that reading their doctors’ notes is useful for taking care of their health and for remembering their care plans, understanding why a medication was prescribed, and reinforcing the need to take their medications and adhere to treatment plans.⁸

Importantly, open notes can increase patient engagement and patients’ trust in their physicians,⁹ thereby improving the doctor-patient relationship.³ And allowing patients to share their medical records with care partners enables supported decision-making, particularly for older and chronically ill individuals.³ Additionally, it is predicted that open notes may, in fact, decrease legal liability.⁹ By improving both trust in the doctor-patient relationship and safety, some experts expect that legal claims against clinicians will, in turn, decrease.¹⁰

The modern practice of medicine necessitates a more empathetic approach to clinical note-taking, even in the absence of regulation requiring it. As the regulations implementing the Cures Act roll out, patients will have easier, and more immediate, access to their medical records. Despite earlier hesitancy, clinicians are steadily beginning to support sharing access to notes with patients.⁵ Change can be hard. But the change expected of clinicians because of these new regulations appears to be less onerous than originally anticipated.

Prof. Koch is codirector of Health Law & Policy Institute and assistant professor at the University of Houston Law Center, as well as director of law and ethics at the MacLean Center for Clinical Medical Ethics at the University of Chicago. She has no disclosures.

This article was updated Sept. 9, 2021.

References

1. Fed Regist. 2020 May;85(85):25642-961.

2. The Petrie-Flom Center Staff. “New Rule Puts Medical Data in Patients’ Hands.” Bill of Health. July 12, 2021. Accessed August 30, 2021. https://blog.petrieflom.law.harvard.edu/2021/07/12/new-rule-puts-medical-data-in-patients-hands/.

3. Blease C et al. Ann Intern Med. 2021 Jan;174(1):101-2.

4. Pillemer F et al. PLoS One. 2016 Jun. doi: 10.1371/journal.pone.0154743.

5. DesRoches CM et al. JAMA Netw Open. 2020 Mar. doi: 10.1001/jamanetworkopen.2020.1753.

6. Heath S. “Most Patients Understand Clinical Notes, Patient Data Access.” Patient Engagement HIT. July 29, 2020. Accessed August 30, 2021. https://patientengagementhit.com/news/most-patients-understand-clinical-notes-patient-data-access

7. Leveille SG et al. J Gen Intern Med. 2020 Dec;35(12):3510-6.

8. Walker J et al. J Med Internet Res. 2019 May. doi: 10.2196/13876.

9. Bell SK et al. BMJ Qual Saf. 2017 Apr;26(4):262-70.

10. Kachalia A, Mello MM. N Engl J Med. 2011 Apr;364(16):1564-72.

Due to broad social changes and efforts from leaders in GI, there is renewed interest in family planning and parental leave policies for GI trainees. The American Board of Medical Specialties now permits trainees a minimum of 6 weeks away during training, without automatically requiring an extension of training time or completely depleting vacation time, for boards eligibility.^1,2 However, national and institutional guidance for family planning and pregnancy during GI fellowship is lacking. How can gastroenterology fellowship programs support fellows taking parental leave and enact fair policies? We review the scope of the problem, describe our experience in developing resources within our GI fellowship program, and highlight areas that require further development.

The scope of the issue

There is no national data yet on the number of GI fellows that are parents prior to starting fellowship or who become parents during fellowship. We estimate that approximately 25% of fellows enter training as parents or become parents during fellowship, although 40%-50% may have an intention to have children.^3,4 Fellows may be worried that they will “fall behind” or be perceived as less committed if they devote time to childrearing or take parental leave.^5-7 Indeed, worries about discrimination based on pregnancy and parental leave are borne out by the experiences of older physicians (in particular, female physicians).^8,9

State- and institution-specific benefits vary from program to program. Nationally, the Family and Medical Leave Act provides only unpaid leave and applies only to trainees who have been employed for greater than 12 months.¹⁰ Benefits may not always be well advertised, and even when they are, trainees (and attendings) may feel uncomfortable taking full advantage. One survey of GIs revealed that, although two-thirds believed that 6-8 weeks of maternity leave was inadequate, half took less than that amount due to fears about financial and professional consequences.⁸

Pregnancy during GI fellowship is a special concern. GI fellowship consists of long work hours, includes night call, and can be physically demanding. All three of these factors have been associated with preterm delivery, infertility, and miscarriage.^11,12 In addition, there are no guidelines for ergonomic adjustments or infection precautions for pregnant endoscopists. We have compiled information about infection prevention guidance in pregnancy (available from the authors on request) derived from guidance from the National Institute for Occupational Safety and Health, which recommends the same precautions for pregnant health care workers as for nonpregnant health care workers.¹³ In regards to SARS-CoV-2, we believe that the decision to perform procedures on patients with COVID-19 infection should be individualized, although vaccinated endoscopists should be reassured by the exceedingly low rates of infection after vaccination and with appropriate personal protective equipment. Radiation is yet another concern. There are limited data on radiation dosages incurred by workers in the endoscopy suite and no pregnancy-specific data, which may lead trainees to avoid fluoroscopic procedures and unnecessarily double up on lead gowns.^8,11,14-17

Breastfeeding accommodations, and access to lactation rooms for trainees, are required by federal law for a minimum of 12 months.¹⁸ Should a trainee choose to breastfeed, education of staff and attendings is critical because many may be unaware of the specific needs pertaining to lactation. Staff should be aware that 30-45 minutes are needed to prepare, pump, and store milk. Trainees should not be solely responsible for educating their attendings and staff.
 

Our Experience in Creating a Policy

We developed a formal fellowship program policy on parental leave and pregnancy in the setting of a broader discussion about fellow workload and wellness. We agreed that trainees should be allowed to make changes to their schedule with co-fellows as needed for medical appointments or procedures and that our backup policy should be flexible enough to provide spot coverage for unexpected complications and family emergencies. We also incorporated a GI psychologist to provide wellness resources and suggestions for reducing burnout for our fellows.

We strove to follow certain principles in creating this policy. Trainees who are parents should have a comparable clinical experience to their nonparenting colleagues and should take the lead in rearranging their own schedule. Nonbirthing parents, adopting parents, and parents using surrogacy should be included in any parental leave policy. Fellowship leaders have an important responsibility in helping fellows proactively plan to meet requirements for graduation and maximize learning and exposure (Figure). We also recognized the importance of equitable coverage. For example, there is sometimes a perception that fellows with children “burden” fellows who are not parents.^3,19 On the other hand, fellows without children may feel that they are called on more than their colleagues with children to cover those with childcare issues. In addition, as a recent study of general surgery residency program directors indicates, there are complex interpersonal issues that play into a colleague’s willingness to provide coverage.²⁰ It behooves program leadership to be cognizant of group dynamics that might cause conflict over what should be a straightforward coverage situation.

We first researched national and societal guidelines if available, as well as our institution’s graduate medical education (GME) website. We categorized benefits by whether they were federal, state-mandated, or institutional. It is important to note that any concerns about trainee salaries should be discussed with one’s GME office to ensure the leave policy is in accordance with federal funding policies.²¹ We solicited experiences and advice from former and current fellows who had gone through, or were planning, pregnancy and parental leave. A few faculty members volunteered to serve as a resource for fellows; these “ambassadors” discussed their experiences during a lunchtime panel, as well as offered to provide one-on-one advice and participate in future panels. We also reached out to our infection control experts to review the literature and federal policies on infections of special consideration during pregnancy and endoscopy. As for radiation safety, given the importance of education and active monitoring, we offer the option of reaching out to our radiation safety officer for individualized counseling.²²

Based on these efforts, we drafted a written policy designed for pregnant fellows and fellows planning parental leave on expectations for the program and fellows, benefits, and advice, including childcare options, lactation room locations, and financial planning tips. We shared this document with fellows and incorporated feedback. As a “living document” it is subject to change and will be updated as needed (at least annually).
 

Additional planning considerations for fellows

Research childcare options (ideally 6 months or more before leave).

• Start to explore your institution’s resources for leave and childcare options (daycare waitlists may be greater than 1 year in some cities).

Inform your program director (4-5 months before leave).

• Consider informing your program director about pregnancy at the beginning of the second trimester.
• Discuss Accreditation Council for Graduate Medical Education requirements and scheduling responsibilities.
• Explicitly discuss whether you plan to graduate on time or extend fellowship.

Inform your colleagues and patients (at least 3-4 months before leave).

• If comfortable, consider getting advice from a co-fellow and/or faculty mentor parent to facilitate transition to parenthood.
• When you feel ready, begin trading rotations and calls with co-fellows. If you have a results inbox or pager, discuss who can help cover those during your leave.
• Inform research collaborators about your leave and make preparations to keep projects progressing during your leave.
• If you have “active” clinic patients, when appropriate, begin to inform them that you will be away and provide reassurance that a colleague will be covering you. Leave clear plans with contingencies for these patients in your last progress notes.

Complete institutional paperwork and map out facilities (at least 2-3 months before leave).

• Review your options for using time toward leave, including vacation, research, or Family and Medical Leave Act–provided leave (unpaid), and what paperwork you need to fill out.
• Contact your payroll and/or human resources office to inform them of birth/adoption.
• Research potential program parental benefits, such as dependent daycare and/or health care flexible spending accounts.
• If choosing to breastfeed, explore the lactation rooms that are closest to your workroom and endoscopy suite and determine how much time you will need to set aside for pumping.

Be prepared to make adjustments as needed.

• Endoscopy-heavy rotations may be more difficult in the third trimester of pregnancy.
• Make contingency plans for early or late delivery dates, as well as if you undergo a cesarean that requires additional recovery time.
• Consider scheduling elective rotations (research, clinic) toward the end of leave and for the first month of “return to work.”
• If you plan to join limited clinic or outpatient endoscopy blocks later in your leave, make early arrangements to work regularly with these attendings.

Conclusion

Trainee needs assessments in gastroenterology fellowship similar to those in other specialties should be performed, and are in fact underway.^19,23,24 There is a lack of data regarding the availability of fellowship program guidance and, specifically, adherence to required policies, and more data from program directors at a national level need to be collected.²⁰ We recommend that programs engage in identifying specific needs at their institutions with the goal of eventually sharing this knowledge with other programs. Gastroenterology society recommendations for performing endoscopy while pregnant, with regard to ergonomics, infection control, and radiation exposure, would be instrumental. GI fellowships should consolidate institutional knowledge and engage key stakeholders – including trainees, prior trainees, occupational safety experts, radiation safety offices, wellness experts, and GME – to create program-specific policies that are flexible but rigorous and generous but equitable.

Dr. Liu and Dr. Summa are gastroenterology fellows at Northwestern University, Chicago. Dr. Patel is an assistant professor of medicine and a gastroenterology fellowship assistant program director at Northwestern University, Chicago. Dr. Donnan and Dr. Guentner are assistant professors of medicine at Northwestern University. Dr. Kia is an assistant professor of medicine and the gastroenterology fellowship program director at Northwestern University. They have no conflicts of interest to disclose. The authors would like to thank Michelle Clermont, MD, and Maureen K. Bolon, MD, for their discussion and assistance during the drafting of this article.

References

1. Section on Medical Students, Residents, and Fellowship Trainees; Committee on Early Childhood. Pediatrics. 2013;131(2):387-90.

2. American Board of Medical Specialties. ABMS Announces Progressive Leave Policy for Residents and Fellows. July 13, 2020. Accessed May 1, 2021. https://www.abms.org/news-events/abms-announces-progressive-leave-policy-for-residents-and-fellows/.

3. Magudia K et al. J Grad Med Educ. 2020;12(2):162-7.

4. Blair JE et al. Acad Med. 2016;91(7):972-8.

5. Feld LD. Am J Gastroenterol. 2021;116(3):505-8.

6. Roubaud MS. Plast Reconstr Surg Glob Open. 2019. doi: 10.1097/GOX.0000000000002104.

7. Price J, Dunbar K. Gastrointest Endosc. 2009;69(1):121-3.

8. David YN et al. Gastrointest Endosc. 2020;91(6):AB75-AB76.

9. Webb AMB et al. Acad Med J Assoc Am Med Coll. 2019;94(11):1631-4.

10. Weinstein DF et al. N Engl J Med. 2019 Sep 12;381(11):995-7.

11. Anderson M, Goldman RH. JAMA Surg. 2020;155(3):243-9.

12. Palmer KT et al. Occup Environ Med. 2013;70(4):213-22.

13. Siegel JD et al; Healthcare Infection, Control Practices Advisory Committee. Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings (2007). 2007. Last reviewed July 22, 2019. Accessed April 28, 2021. https://www.cdc.gov/infectioncontrol/guidelines/isolation/index.html

14. David YN et al. Am J Gastroenterol. 2021;116(3):539-50.

15. Sethi S et al. Dig Dis Sci. 2019;64(9):2455-66.

16. Alzimami K et al. Gastroenterol Res Pract. 2013;2013:587574.

17. Hayashi S et al. World J Clin Cases. 2018;6(16):1087-93.

18. U.S. Department of Labor, Wage and Hour Division. “Frequently Asked Questions – Break Time for Nursing Mothers.” Accessed May 1, 2021. https://www.dol.gov/agencies/whd/nursing-mothers/faq.

19. Mwakyanjala EJ et al. J Am Heart Assoc. 2019. doi: 10.1161/JAHA.119.012137.

20. Castillo-Angeles M et al. JAMA Surg. 2021 Jul 1;156(7):647-53.

21. Prasad S et al. J Grad Med Educ. 2021 Jun;13(3):349-54.

22. Ho IKH et al. Am J Gastroenterol. 2014;109(8):1180-94.

23. Sherbaf FG et al. AJNR Am J Neuroradiol. 2020;41(8):1348-54.

24. Altieri MS et al. JAMA Surg. 2019;154(10):952-58.

Due to broad social changes and efforts from leaders in GI, there is renewed interest in family planning and parental leave policies for GI trainees. The American Board of Medical Specialties now permits trainees a minimum of 6 weeks away during training, without automatically requiring an extension of training time or completely depleting vacation time, for boards eligibility.^1,2 However, national and institutional guidance for family planning and pregnancy during GI fellowship is lacking. How can gastroenterology fellowship programs support fellows taking parental leave and enact fair policies? We review the scope of the problem, describe our experience in developing resources within our GI fellowship program, and highlight areas that require further development.

The scope of the issue

There is no national data yet on the number of GI fellows that are parents prior to starting fellowship or who become parents during fellowship. We estimate that approximately 25% of fellows enter training as parents or become parents during fellowship, although 40%-50% may have an intention to have children.^3,4 Fellows may be worried that they will “fall behind” or be perceived as less committed if they devote time to childrearing or take parental leave.^5-7 Indeed, worries about discrimination based on pregnancy and parental leave are borne out by the experiences of older physicians (in particular, female physicians).^8,9

State- and institution-specific benefits vary from program to program. Nationally, the Family and Medical Leave Act provides only unpaid leave and applies only to trainees who have been employed for greater than 12 months.¹⁰ Benefits may not always be well advertised, and even when they are, trainees (and attendings) may feel uncomfortable taking full advantage. One survey of GIs revealed that, although two-thirds believed that 6-8 weeks of maternity leave was inadequate, half took less than that amount due to fears about financial and professional consequences.⁸

Pregnancy during GI fellowship is a special concern. GI fellowship consists of long work hours, includes night call, and can be physically demanding. All three of these factors have been associated with preterm delivery, infertility, and miscarriage.^11,12 In addition, there are no guidelines for ergonomic adjustments or infection precautions for pregnant endoscopists. We have compiled information about infection prevention guidance in pregnancy (available from the authors on request) derived from guidance from the National Institute for Occupational Safety and Health, which recommends the same precautions for pregnant health care workers as for nonpregnant health care workers.¹³ In regards to SARS-CoV-2, we believe that the decision to perform procedures on patients with COVID-19 infection should be individualized, although vaccinated endoscopists should be reassured by the exceedingly low rates of infection after vaccination and with appropriate personal protective equipment. Radiation is yet another concern. There are limited data on radiation dosages incurred by workers in the endoscopy suite and no pregnancy-specific data, which may lead trainees to avoid fluoroscopic procedures and unnecessarily double up on lead gowns.^8,11,14-17

Breastfeeding accommodations, and access to lactation rooms for trainees, are required by federal law for a minimum of 12 months.¹⁸ Should a trainee choose to breastfeed, education of staff and attendings is critical because many may be unaware of the specific needs pertaining to lactation. Staff should be aware that 30-45 minutes are needed to prepare, pump, and store milk. Trainees should not be solely responsible for educating their attendings and staff.
 

Our Experience in Creating a Policy

We developed a formal fellowship program policy on parental leave and pregnancy in the setting of a broader discussion about fellow workload and wellness. We agreed that trainees should be allowed to make changes to their schedule with co-fellows as needed for medical appointments or procedures and that our backup policy should be flexible enough to provide spot coverage for unexpected complications and family emergencies. We also incorporated a GI psychologist to provide wellness resources and suggestions for reducing burnout for our fellows.

We strove to follow certain principles in creating this policy. Trainees who are parents should have a comparable clinical experience to their nonparenting colleagues and should take the lead in rearranging their own schedule. Nonbirthing parents, adopting parents, and parents using surrogacy should be included in any parental leave policy. Fellowship leaders have an important responsibility in helping fellows proactively plan to meet requirements for graduation and maximize learning and exposure (Figure). We also recognized the importance of equitable coverage. For example, there is sometimes a perception that fellows with children “burden” fellows who are not parents.^3,19 On the other hand, fellows without children may feel that they are called on more than their colleagues with children to cover those with childcare issues. In addition, as a recent study of general surgery residency program directors indicates, there are complex interpersonal issues that play into a colleague’s willingness to provide coverage.²⁰ It behooves program leadership to be cognizant of group dynamics that might cause conflict over what should be a straightforward coverage situation.

We first researched national and societal guidelines if available, as well as our institution’s graduate medical education (GME) website. We categorized benefits by whether they were federal, state-mandated, or institutional. It is important to note that any concerns about trainee salaries should be discussed with one’s GME office to ensure the leave policy is in accordance with federal funding policies.²¹ We solicited experiences and advice from former and current fellows who had gone through, or were planning, pregnancy and parental leave. A few faculty members volunteered to serve as a resource for fellows; these “ambassadors” discussed their experiences during a lunchtime panel, as well as offered to provide one-on-one advice and participate in future panels. We also reached out to our infection control experts to review the literature and federal policies on infections of special consideration during pregnancy and endoscopy. As for radiation safety, given the importance of education and active monitoring, we offer the option of reaching out to our radiation safety officer for individualized counseling.²²

Based on these efforts, we drafted a written policy designed for pregnant fellows and fellows planning parental leave on expectations for the program and fellows, benefits, and advice, including childcare options, lactation room locations, and financial planning tips. We shared this document with fellows and incorporated feedback. As a “living document” it is subject to change and will be updated as needed (at least annually).
 

Additional planning considerations for fellows

Research childcare options (ideally 6 months or more before leave).

• Start to explore your institution’s resources for leave and childcare options (daycare waitlists may be greater than 1 year in some cities).

Inform your program director (4-5 months before leave).

• Consider informing your program director about pregnancy at the beginning of the second trimester.
• Discuss Accreditation Council for Graduate Medical Education requirements and scheduling responsibilities.
• Explicitly discuss whether you plan to graduate on time or extend fellowship.

Inform your colleagues and patients (at least 3-4 months before leave).

• If comfortable, consider getting advice from a co-fellow and/or faculty mentor parent to facilitate transition to parenthood.
• When you feel ready, begin trading rotations and calls with co-fellows. If you have a results inbox or pager, discuss who can help cover those during your leave.
• Inform research collaborators about your leave and make preparations to keep projects progressing during your leave.
• If you have “active” clinic patients, when appropriate, begin to inform them that you will be away and provide reassurance that a colleague will be covering you. Leave clear plans with contingencies for these patients in your last progress notes.

Complete institutional paperwork and map out facilities (at least 2-3 months before leave).

• Review your options for using time toward leave, including vacation, research, or Family and Medical Leave Act–provided leave (unpaid), and what paperwork you need to fill out.
• Contact your payroll and/or human resources office to inform them of birth/adoption.
• Research potential program parental benefits, such as dependent daycare and/or health care flexible spending accounts.
• If choosing to breastfeed, explore the lactation rooms that are closest to your workroom and endoscopy suite and determine how much time you will need to set aside for pumping.

Be prepared to make adjustments as needed.

• Endoscopy-heavy rotations may be more difficult in the third trimester of pregnancy.
• Make contingency plans for early or late delivery dates, as well as if you undergo a cesarean that requires additional recovery time.
• Consider scheduling elective rotations (research, clinic) toward the end of leave and for the first month of “return to work.”
• If you plan to join limited clinic or outpatient endoscopy blocks later in your leave, make early arrangements to work regularly with these attendings.

Conclusion

Trainee needs assessments in gastroenterology fellowship similar to those in other specialties should be performed, and are in fact underway.^19,23,24 There is a lack of data regarding the availability of fellowship program guidance and, specifically, adherence to required policies, and more data from program directors at a national level need to be collected.²⁰ We recommend that programs engage in identifying specific needs at their institutions with the goal of eventually sharing this knowledge with other programs. Gastroenterology society recommendations for performing endoscopy while pregnant, with regard to ergonomics, infection control, and radiation exposure, would be instrumental. GI fellowships should consolidate institutional knowledge and engage key stakeholders – including trainees, prior trainees, occupational safety experts, radiation safety offices, wellness experts, and GME – to create program-specific policies that are flexible but rigorous and generous but equitable.

Dr. Liu and Dr. Summa are gastroenterology fellows at Northwestern University, Chicago. Dr. Patel is an assistant professor of medicine and a gastroenterology fellowship assistant program director at Northwestern University, Chicago. Dr. Donnan and Dr. Guentner are assistant professors of medicine at Northwestern University. Dr. Kia is an assistant professor of medicine and the gastroenterology fellowship program director at Northwestern University. They have no conflicts of interest to disclose. The authors would like to thank Michelle Clermont, MD, and Maureen K. Bolon, MD, for their discussion and assistance during the drafting of this article.

References

1. Section on Medical Students, Residents, and Fellowship Trainees; Committee on Early Childhood. Pediatrics. 2013;131(2):387-90.

2. American Board of Medical Specialties. ABMS Announces Progressive Leave Policy for Residents and Fellows. July 13, 2020. Accessed May 1, 2021. https://www.abms.org/news-events/abms-announces-progressive-leave-policy-for-residents-and-fellows/.

3. Magudia K et al. J Grad Med Educ. 2020;12(2):162-7.

4. Blair JE et al. Acad Med. 2016;91(7):972-8.

5. Feld LD. Am J Gastroenterol. 2021;116(3):505-8.

6. Roubaud MS. Plast Reconstr Surg Glob Open. 2019. doi: 10.1097/GOX.0000000000002104.

7. Price J, Dunbar K. Gastrointest Endosc. 2009;69(1):121-3.

8. David YN et al. Gastrointest Endosc. 2020;91(6):AB75-AB76.

9. Webb AMB et al. Acad Med J Assoc Am Med Coll. 2019;94(11):1631-4.

10. Weinstein DF et al. N Engl J Med. 2019 Sep 12;381(11):995-7.

11. Anderson M, Goldman RH. JAMA Surg. 2020;155(3):243-9.

12. Palmer KT et al. Occup Environ Med. 2013;70(4):213-22.

13. Siegel JD et al; Healthcare Infection, Control Practices Advisory Committee. Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings (2007). 2007. Last reviewed July 22, 2019. Accessed April 28, 2021. https://www.cdc.gov/infectioncontrol/guidelines/isolation/index.html

14. David YN et al. Am J Gastroenterol. 2021;116(3):539-50.

15. Sethi S et al. Dig Dis Sci. 2019;64(9):2455-66.

16. Alzimami K et al. Gastroenterol Res Pract. 2013;2013:587574.

17. Hayashi S et al. World J Clin Cases. 2018;6(16):1087-93.

18. U.S. Department of Labor, Wage and Hour Division. “Frequently Asked Questions – Break Time for Nursing Mothers.” Accessed May 1, 2021. https://www.dol.gov/agencies/whd/nursing-mothers/faq.

19. Mwakyanjala EJ et al. J Am Heart Assoc. 2019. doi: 10.1161/JAHA.119.012137.

20. Castillo-Angeles M et al. JAMA Surg. 2021 Jul 1;156(7):647-53.

21. Prasad S et al. J Grad Med Educ. 2021 Jun;13(3):349-54.

22. Ho IKH et al. Am J Gastroenterol. 2014;109(8):1180-94.

23. Sherbaf FG et al. AJNR Am J Neuroradiol. 2020;41(8):1348-54.

24. Altieri MS et al. JAMA Surg. 2019;154(10):952-58.

Due to broad social changes and efforts from leaders in GI, there is renewed interest in family planning and parental leave policies for GI trainees. The American Board of Medical Specialties now permits trainees a minimum of 6 weeks away during training, without automatically requiring an extension of training time or completely depleting vacation time, for boards eligibility.^1,2 However, national and institutional guidance for family planning and pregnancy during GI fellowship is lacking. How can gastroenterology fellowship programs support fellows taking parental leave and enact fair policies? We review the scope of the problem, describe our experience in developing resources within our GI fellowship program, and highlight areas that require further development.

The scope of the issue

There is no national data yet on the number of GI fellows that are parents prior to starting fellowship or who become parents during fellowship. We estimate that approximately 25% of fellows enter training as parents or become parents during fellowship, although 40%-50% may have an intention to have children.^3,4 Fellows may be worried that they will “fall behind” or be perceived as less committed if they devote time to childrearing or take parental leave.^5-7 Indeed, worries about discrimination based on pregnancy and parental leave are borne out by the experiences of older physicians (in particular, female physicians).^8,9

State- and institution-specific benefits vary from program to program. Nationally, the Family and Medical Leave Act provides only unpaid leave and applies only to trainees who have been employed for greater than 12 months.¹⁰ Benefits may not always be well advertised, and even when they are, trainees (and attendings) may feel uncomfortable taking full advantage. One survey of GIs revealed that, although two-thirds believed that 6-8 weeks of maternity leave was inadequate, half took less than that amount due to fears about financial and professional consequences.⁸

Pregnancy during GI fellowship is a special concern. GI fellowship consists of long work hours, includes night call, and can be physically demanding. All three of these factors have been associated with preterm delivery, infertility, and miscarriage.^11,12 In addition, there are no guidelines for ergonomic adjustments or infection precautions for pregnant endoscopists. We have compiled information about infection prevention guidance in pregnancy (available from the authors on request) derived from guidance from the National Institute for Occupational Safety and Health, which recommends the same precautions for pregnant health care workers as for nonpregnant health care workers.¹³ In regards to SARS-CoV-2, we believe that the decision to perform procedures on patients with COVID-19 infection should be individualized, although vaccinated endoscopists should be reassured by the exceedingly low rates of infection after vaccination and with appropriate personal protective equipment. Radiation is yet another concern. There are limited data on radiation dosages incurred by workers in the endoscopy suite and no pregnancy-specific data, which may lead trainees to avoid fluoroscopic procedures and unnecessarily double up on lead gowns.^8,11,14-17

Breastfeeding accommodations, and access to lactation rooms for trainees, are required by federal law for a minimum of 12 months.¹⁸ Should a trainee choose to breastfeed, education of staff and attendings is critical because many may be unaware of the specific needs pertaining to lactation. Staff should be aware that 30-45 minutes are needed to prepare, pump, and store milk. Trainees should not be solely responsible for educating their attendings and staff.
 

Our Experience in Creating a Policy

We developed a formal fellowship program policy on parental leave and pregnancy in the setting of a broader discussion about fellow workload and wellness. We agreed that trainees should be allowed to make changes to their schedule with co-fellows as needed for medical appointments or procedures and that our backup policy should be flexible enough to provide spot coverage for unexpected complications and family emergencies. We also incorporated a GI psychologist to provide wellness resources and suggestions for reducing burnout for our fellows.

We strove to follow certain principles in creating this policy. Trainees who are parents should have a comparable clinical experience to their nonparenting colleagues and should take the lead in rearranging their own schedule. Nonbirthing parents, adopting parents, and parents using surrogacy should be included in any parental leave policy. Fellowship leaders have an important responsibility in helping fellows proactively plan to meet requirements for graduation and maximize learning and exposure (Figure). We also recognized the importance of equitable coverage. For example, there is sometimes a perception that fellows with children “burden” fellows who are not parents.^3,19 On the other hand, fellows without children may feel that they are called on more than their colleagues with children to cover those with childcare issues. In addition, as a recent study of general surgery residency program directors indicates, there are complex interpersonal issues that play into a colleague’s willingness to provide coverage.²⁰ It behooves program leadership to be cognizant of group dynamics that might cause conflict over what should be a straightforward coverage situation.

We first researched national and societal guidelines if available, as well as our institution’s graduate medical education (GME) website. We categorized benefits by whether they were federal, state-mandated, or institutional. It is important to note that any concerns about trainee salaries should be discussed with one’s GME office to ensure the leave policy is in accordance with federal funding policies.²¹ We solicited experiences and advice from former and current fellows who had gone through, or were planning, pregnancy and parental leave. A few faculty members volunteered to serve as a resource for fellows; these “ambassadors” discussed their experiences during a lunchtime panel, as well as offered to provide one-on-one advice and participate in future panels. We also reached out to our infection control experts to review the literature and federal policies on infections of special consideration during pregnancy and endoscopy. As for radiation safety, given the importance of education and active monitoring, we offer the option of reaching out to our radiation safety officer for individualized counseling.²²

Based on these efforts, we drafted a written policy designed for pregnant fellows and fellows planning parental leave on expectations for the program and fellows, benefits, and advice, including childcare options, lactation room locations, and financial planning tips. We shared this document with fellows and incorporated feedback. As a “living document” it is subject to change and will be updated as needed (at least annually).
 

Additional planning considerations for fellows

Research childcare options (ideally 6 months or more before leave).

• Start to explore your institution’s resources for leave and childcare options (daycare waitlists may be greater than 1 year in some cities).

Inform your program director (4-5 months before leave).

• Consider informing your program director about pregnancy at the beginning of the second trimester.
• Discuss Accreditation Council for Graduate Medical Education requirements and scheduling responsibilities.
• Explicitly discuss whether you plan to graduate on time or extend fellowship.

Inform your colleagues and patients (at least 3-4 months before leave).

• If comfortable, consider getting advice from a co-fellow and/or faculty mentor parent to facilitate transition to parenthood.
• When you feel ready, begin trading rotations and calls with co-fellows. If you have a results inbox or pager, discuss who can help cover those during your leave.
• Inform research collaborators about your leave and make preparations to keep projects progressing during your leave.
• If you have “active” clinic patients, when appropriate, begin to inform them that you will be away and provide reassurance that a colleague will be covering you. Leave clear plans with contingencies for these patients in your last progress notes.

Complete institutional paperwork and map out facilities (at least 2-3 months before leave).

• Review your options for using time toward leave, including vacation, research, or Family and Medical Leave Act–provided leave (unpaid), and what paperwork you need to fill out.
• Contact your payroll and/or human resources office to inform them of birth/adoption.
• Research potential program parental benefits, such as dependent daycare and/or health care flexible spending accounts.
• If choosing to breastfeed, explore the lactation rooms that are closest to your workroom and endoscopy suite and determine how much time you will need to set aside for pumping.

Be prepared to make adjustments as needed.

• Endoscopy-heavy rotations may be more difficult in the third trimester of pregnancy.
• Make contingency plans for early or late delivery dates, as well as if you undergo a cesarean that requires additional recovery time.
• Consider scheduling elective rotations (research, clinic) toward the end of leave and for the first month of “return to work.”
• If you plan to join limited clinic or outpatient endoscopy blocks later in your leave, make early arrangements to work regularly with these attendings.

Conclusion

Trainee needs assessments in gastroenterology fellowship similar to those in other specialties should be performed, and are in fact underway.^19,23,24 There is a lack of data regarding the availability of fellowship program guidance and, specifically, adherence to required policies, and more data from program directors at a national level need to be collected.²⁰ We recommend that programs engage in identifying specific needs at their institutions with the goal of eventually sharing this knowledge with other programs. Gastroenterology society recommendations for performing endoscopy while pregnant, with regard to ergonomics, infection control, and radiation exposure, would be instrumental. GI fellowships should consolidate institutional knowledge and engage key stakeholders – including trainees, prior trainees, occupational safety experts, radiation safety offices, wellness experts, and GME – to create program-specific policies that are flexible but rigorous and generous but equitable.

Dr. Liu and Dr. Summa are gastroenterology fellows at Northwestern University, Chicago. Dr. Patel is an assistant professor of medicine and a gastroenterology fellowship assistant program director at Northwestern University, Chicago. Dr. Donnan and Dr. Guentner are assistant professors of medicine at Northwestern University. Dr. Kia is an assistant professor of medicine and the gastroenterology fellowship program director at Northwestern University. They have no conflicts of interest to disclose. The authors would like to thank Michelle Clermont, MD, and Maureen K. Bolon, MD, for their discussion and assistance during the drafting of this article.

References

1. Section on Medical Students, Residents, and Fellowship Trainees; Committee on Early Childhood. Pediatrics. 2013;131(2):387-90.

2. American Board of Medical Specialties. ABMS Announces Progressive Leave Policy for Residents and Fellows. July 13, 2020. Accessed May 1, 2021. https://www.abms.org/news-events/abms-announces-progressive-leave-policy-for-residents-and-fellows/.

3. Magudia K et al. J Grad Med Educ. 2020;12(2):162-7.

4. Blair JE et al. Acad Med. 2016;91(7):972-8.

5. Feld LD. Am J Gastroenterol. 2021;116(3):505-8.

6. Roubaud MS. Plast Reconstr Surg Glob Open. 2019. doi: 10.1097/GOX.0000000000002104.

7. Price J, Dunbar K. Gastrointest Endosc. 2009;69(1):121-3.

8. David YN et al. Gastrointest Endosc. 2020;91(6):AB75-AB76.

9. Webb AMB et al. Acad Med J Assoc Am Med Coll. 2019;94(11):1631-4.

10. Weinstein DF et al. N Engl J Med. 2019 Sep 12;381(11):995-7.

11. Anderson M, Goldman RH. JAMA Surg. 2020;155(3):243-9.

12. Palmer KT et al. Occup Environ Med. 2013;70(4):213-22.

13. Siegel JD et al; Healthcare Infection, Control Practices Advisory Committee. Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings (2007). 2007. Last reviewed July 22, 2019. Accessed April 28, 2021. https://www.cdc.gov/infectioncontrol/guidelines/isolation/index.html

14. David YN et al. Am J Gastroenterol. 2021;116(3):539-50.

15. Sethi S et al. Dig Dis Sci. 2019;64(9):2455-66.

16. Alzimami K et al. Gastroenterol Res Pract. 2013;2013:587574.

17. Hayashi S et al. World J Clin Cases. 2018;6(16):1087-93.

18. U.S. Department of Labor, Wage and Hour Division. “Frequently Asked Questions – Break Time for Nursing Mothers.” Accessed May 1, 2021. https://www.dol.gov/agencies/whd/nursing-mothers/faq.

19. Mwakyanjala EJ et al. J Am Heart Assoc. 2019. doi: 10.1161/JAHA.119.012137.

20. Castillo-Angeles M et al. JAMA Surg. 2021 Jul 1;156(7):647-53.

21. Prasad S et al. J Grad Med Educ. 2021 Jun;13(3):349-54.

22. Ho IKH et al. Am J Gastroenterol. 2014;109(8):1180-94.

23. Sherbaf FG et al. AJNR Am J Neuroradiol. 2020;41(8):1348-54.

24. Altieri MS et al. JAMA Surg. 2019;154(10):952-58.

AGA journals’ reach record-high Impact Factors

AGA is proud to announce that its journals have maintained their exceptional standing in the field of gastroenterology and hepatology, based on Impact Factor. The Impact Factor is a measure of the frequency with which articles published in the previous 2 years are cited and is commonly used to rank the significance of journals within their fields.

Gastroenterology, AGA’s flagship journal, received a record-high Impact Factor of 22.682, a substantial increase from its 2019 Impact Factor of 17.37. Gastroenterology maintains its position among an elite group of journals focused on publishing original research, spanning basic to clinical, in our field. Co–Editors in Chief (EICs) Richard M. Peek Jr., MD, and Douglas A. Corley, MD, PhD, remarked, “We would like to thank our entire board of editors and reviewers, as well as the incredible AGA editorial staff, for their exceptional work in this challenging pandemic year as we continue to publish articles and reviews of outstanding quality that are widely used by our readership. It is an honor to be part of such a remarkable team.”

Clinical Gastroenterology and Hepatology (CGH), AGA’s clinically focused journal, also reached a record high with an Impact Factor of 11.382, pulling ahead as the field’s top exclusively clinically oriented journal. This puts CGH at a rank of 8th among 92 journals in the field. Fasiha Kanwal, MD, MSHS, EIC of CGH, noted, “We are delighted that CGH remains in a strong position in the top 10 GI journals in terms of Impact Factor. On behalf of the CGH board of editors, I want to extend a warm and most heartfelt thanks to our authors, reviewers, and readers!  We would not have been able to achieve this milestone without your support, contributions, and the faith that you place in us.”

To round things out, Cellular and Molecular Gastroenterology and Hepatology (CMGH), AGA’s basic and translational open-access journal also reached a record high with an Impact Factor of 9.225, placing it 13th, and second among nonclinical journals in that topic area. EICs Klaus Kaestner, PhD, and Michael Pack, MD, stated, “As co-EICs of CMGH, we send congratulations to the journal’s board of editors, editorial board, reviewers, and superb editorial staff on this year’s Impact Factor. We are honored to work with these outstanding colleagues and to provide our readership with highly impactful and cutting-edge research and review articles.”

In its online announcement, AGA congratulates and thanks the boards of all three journals for their editorial leadership. We also thank our authors, readers, and reviewers for their continued support of AGA’s journals. We look forward to continuing to push the envelope in scientific publishing in the upcoming year.
 

AGA journals select new editorial fellows

The AGA journals Gastroenterology, Clinical Gastroenterology and Hepatology (CGH), Cellular and Molecular Gastroenterology and Hepatology (CMGH), and Techniques and Innovations in Gastrointestinal Endoscopy (TIGE) recently selected the recipients of their editorial fellowships, which will run from July 2021 through June 2022. The AGA editorial fellowship program is in its 4th year. 

• Amisha Ahuja, MD (Gastroenterology)
• Helenie Kefalalkes, MD (Gastroenterology)
• Katherine Falloon, MD (CGH)
• Judy Trieu, MD, MPH (CGH)
• Lindsey Kennedy, PhD (CMGH)
• Vivian Ortiz, MD (CMGH)  
• Sagarika Satyavada, MD (TIGE)
• Eric Swei, MD (TIGE)

Gain perspectives, insights, and experience in diagnostic and therapeutic GI care

Accurately diagnosing and treating GI disorders such as irritable bowel syndrome, inflammatory bowel disease, or eosinophilic esophagitis are challenging for any health care practitioners. Why not be the advanced practice provider (APP) in your practice that others look to for providing the best course of action for patients? The all-virtual 2021 Principles of GI for the NP and PA, Aug. 14-15, 2021, explores these GI conditions in detail, as well as colorectal cancer and disorders of the liver and pancreas, to give you a foundation in which to provide superlative patient care.

The virtual format also offers a safe and affordable forum for learning from your home or office as the impact of the COVID-19 pandemic continues to be felt throughout 2021. You’ll also benefit from on-demand access for 2 years after the live course so you can reference and refresh what you learned.

Take the opportunity to refine your skills and improve your patient care outcomes. 
 

Honor your peers with an AGA Recognition Award

When you think about outstanding GI educators, clinicians, investigators, and mentors, who comes to mind?  

Share your appreciation by nominating your colleagues for a prestigious 2022 AGA Recognition Award! 

Make your nominee stand out by sharing specific examples of how they have devoted themselves to eradicating the world of digestive disease, demonstrated innovation in bettering our community, and made a lasting impact, all of which exemplifies an outstanding AGA member. 

Need some inspiration? Read about our 2021 winners before submitting your nomination. 

AGA journals’ reach record-high Impact Factors

AGA is proud to announce that its journals have maintained their exceptional standing in the field of gastroenterology and hepatology, based on Impact Factor. The Impact Factor is a measure of the frequency with which articles published in the previous 2 years are cited and is commonly used to rank the significance of journals within their fields.

Gastroenterology, AGA’s flagship journal, received a record-high Impact Factor of 22.682, a substantial increase from its 2019 Impact Factor of 17.37. Gastroenterology maintains its position among an elite group of journals focused on publishing original research, spanning basic to clinical, in our field. Co–Editors in Chief (EICs) Richard M. Peek Jr., MD, and Douglas A. Corley, MD, PhD, remarked, “We would like to thank our entire board of editors and reviewers, as well as the incredible AGA editorial staff, for their exceptional work in this challenging pandemic year as we continue to publish articles and reviews of outstanding quality that are widely used by our readership. It is an honor to be part of such a remarkable team.”

Clinical Gastroenterology and Hepatology (CGH), AGA’s clinically focused journal, also reached a record high with an Impact Factor of 11.382, pulling ahead as the field’s top exclusively clinically oriented journal. This puts CGH at a rank of 8th among 92 journals in the field. Fasiha Kanwal, MD, MSHS, EIC of CGH, noted, “We are delighted that CGH remains in a strong position in the top 10 GI journals in terms of Impact Factor. On behalf of the CGH board of editors, I want to extend a warm and most heartfelt thanks to our authors, reviewers, and readers!  We would not have been able to achieve this milestone without your support, contributions, and the faith that you place in us.”

To round things out, Cellular and Molecular Gastroenterology and Hepatology (CMGH), AGA’s basic and translational open-access journal also reached a record high with an Impact Factor of 9.225, placing it 13th, and second among nonclinical journals in that topic area. EICs Klaus Kaestner, PhD, and Michael Pack, MD, stated, “As co-EICs of CMGH, we send congratulations to the journal’s board of editors, editorial board, reviewers, and superb editorial staff on this year’s Impact Factor. We are honored to work with these outstanding colleagues and to provide our readership with highly impactful and cutting-edge research and review articles.”

In its online announcement, AGA congratulates and thanks the boards of all three journals for their editorial leadership. We also thank our authors, readers, and reviewers for their continued support of AGA’s journals. We look forward to continuing to push the envelope in scientific publishing in the upcoming year.
 

AGA journals select new editorial fellows

The AGA journals Gastroenterology, Clinical Gastroenterology and Hepatology (CGH), Cellular and Molecular Gastroenterology and Hepatology (CMGH), and Techniques and Innovations in Gastrointestinal Endoscopy (TIGE) recently selected the recipients of their editorial fellowships, which will run from July 2021 through June 2022. The AGA editorial fellowship program is in its 4th year. 

• Amisha Ahuja, MD (Gastroenterology)
• Helenie Kefalalkes, MD (Gastroenterology)
• Katherine Falloon, MD (CGH)
• Judy Trieu, MD, MPH (CGH)
• Lindsey Kennedy, PhD (CMGH)
• Vivian Ortiz, MD (CMGH)  
• Sagarika Satyavada, MD (TIGE)
• Eric Swei, MD (TIGE)

Gain perspectives, insights, and experience in diagnostic and therapeutic GI care

Accurately diagnosing and treating GI disorders such as irritable bowel syndrome, inflammatory bowel disease, or eosinophilic esophagitis are challenging for any health care practitioners. Why not be the advanced practice provider (APP) in your practice that others look to for providing the best course of action for patients? The all-virtual 2021 Principles of GI for the NP and PA, Aug. 14-15, 2021, explores these GI conditions in detail, as well as colorectal cancer and disorders of the liver and pancreas, to give you a foundation in which to provide superlative patient care.

The virtual format also offers a safe and affordable forum for learning from your home or office as the impact of the COVID-19 pandemic continues to be felt throughout 2021. You’ll also benefit from on-demand access for 2 years after the live course so you can reference and refresh what you learned.

Take the opportunity to refine your skills and improve your patient care outcomes. 
 

Honor your peers with an AGA Recognition Award

When you think about outstanding GI educators, clinicians, investigators, and mentors, who comes to mind?  

Share your appreciation by nominating your colleagues for a prestigious 2022 AGA Recognition Award! 

Make your nominee stand out by sharing specific examples of how they have devoted themselves to eradicating the world of digestive disease, demonstrated innovation in bettering our community, and made a lasting impact, all of which exemplifies an outstanding AGA member. 

Need some inspiration? Read about our 2021 winners before submitting your nomination. 

AGA journals’ reach record-high Impact Factors

AGA is proud to announce that its journals have maintained their exceptional standing in the field of gastroenterology and hepatology, based on Impact Factor. The Impact Factor is a measure of the frequency with which articles published in the previous 2 years are cited and is commonly used to rank the significance of journals within their fields.

Gastroenterology, AGA’s flagship journal, received a record-high Impact Factor of 22.682, a substantial increase from its 2019 Impact Factor of 17.37. Gastroenterology maintains its position among an elite group of journals focused on publishing original research, spanning basic to clinical, in our field. Co–Editors in Chief (EICs) Richard M. Peek Jr., MD, and Douglas A. Corley, MD, PhD, remarked, “We would like to thank our entire board of editors and reviewers, as well as the incredible AGA editorial staff, for their exceptional work in this challenging pandemic year as we continue to publish articles and reviews of outstanding quality that are widely used by our readership. It is an honor to be part of such a remarkable team.”

Clinical Gastroenterology and Hepatology (CGH), AGA’s clinically focused journal, also reached a record high with an Impact Factor of 11.382, pulling ahead as the field’s top exclusively clinically oriented journal. This puts CGH at a rank of 8th among 92 journals in the field. Fasiha Kanwal, MD, MSHS, EIC of CGH, noted, “We are delighted that CGH remains in a strong position in the top 10 GI journals in terms of Impact Factor. On behalf of the CGH board of editors, I want to extend a warm and most heartfelt thanks to our authors, reviewers, and readers!  We would not have been able to achieve this milestone without your support, contributions, and the faith that you place in us.”

To round things out, Cellular and Molecular Gastroenterology and Hepatology (CMGH), AGA’s basic and translational open-access journal also reached a record high with an Impact Factor of 9.225, placing it 13th, and second among nonclinical journals in that topic area. EICs Klaus Kaestner, PhD, and Michael Pack, MD, stated, “As co-EICs of CMGH, we send congratulations to the journal’s board of editors, editorial board, reviewers, and superb editorial staff on this year’s Impact Factor. We are honored to work with these outstanding colleagues and to provide our readership with highly impactful and cutting-edge research and review articles.”

In its online announcement, AGA congratulates and thanks the boards of all three journals for their editorial leadership. We also thank our authors, readers, and reviewers for their continued support of AGA’s journals. We look forward to continuing to push the envelope in scientific publishing in the upcoming year.
 

AGA journals select new editorial fellows

The AGA journals Gastroenterology, Clinical Gastroenterology and Hepatology (CGH), Cellular and Molecular Gastroenterology and Hepatology (CMGH), and Techniques and Innovations in Gastrointestinal Endoscopy (TIGE) recently selected the recipients of their editorial fellowships, which will run from July 2021 through June 2022. The AGA editorial fellowship program is in its 4th year. 

• Amisha Ahuja, MD (Gastroenterology)
• Helenie Kefalalkes, MD (Gastroenterology)
• Katherine Falloon, MD (CGH)
• Judy Trieu, MD, MPH (CGH)
• Lindsey Kennedy, PhD (CMGH)
• Vivian Ortiz, MD (CMGH)  
• Sagarika Satyavada, MD (TIGE)
• Eric Swei, MD (TIGE)

Gain perspectives, insights, and experience in diagnostic and therapeutic GI care

Accurately diagnosing and treating GI disorders such as irritable bowel syndrome, inflammatory bowel disease, or eosinophilic esophagitis are challenging for any health care practitioners. Why not be the advanced practice provider (APP) in your practice that others look to for providing the best course of action for patients? The all-virtual 2021 Principles of GI for the NP and PA, Aug. 14-15, 2021, explores these GI conditions in detail, as well as colorectal cancer and disorders of the liver and pancreas, to give you a foundation in which to provide superlative patient care.

The virtual format also offers a safe and affordable forum for learning from your home or office as the impact of the COVID-19 pandemic continues to be felt throughout 2021. You’ll also benefit from on-demand access for 2 years after the live course so you can reference and refresh what you learned.

Take the opportunity to refine your skills and improve your patient care outcomes. 
 

Honor your peers with an AGA Recognition Award

When you think about outstanding GI educators, clinicians, investigators, and mentors, who comes to mind?  

Share your appreciation by nominating your colleagues for a prestigious 2022 AGA Recognition Award! 

Make your nominee stand out by sharing specific examples of how they have devoted themselves to eradicating the world of digestive disease, demonstrated innovation in bettering our community, and made a lasting impact, all of which exemplifies an outstanding AGA member. 

Need some inspiration? Read about our 2021 winners before submitting your nomination. 

Dear colleagues,

I’m thrilled to introduce the August edition of The New Gastroenterologist, which features an excellent line-up of articles! Summer has been in full swing, and gradually, we eased into aspects of our prepandemic routine. The fear, caution, and isolation that characterized the last year and a half was less pervasive, and the ability to reconnect in person felt both refreshing and liberating. While new threats of variants and rising infection rates have emerged, there is hope that, with the availability of vaccines, the worst of the pandemic may still be behind us.

One of the most difficult aspects of treating patients with inflammatory bowel disease is acute pain management. Dr. Jami Kinnucan and Dr. Mehwish Ahmed (University of Michigan) outline an expert approach on differentiating between visceral and somatic pain and how to manage each accordingly.

The diagnosis of microscopic colitis can be elusive because colonic mucosa typically appears endoscopically normal and the pathognomonic findings are histologic. Management can also be challenging given the frequently relapsing and remitting nature of its clinical course. The “In Focus” feature for August, written by Dr. June Tome, Dr. Amrit Kamboj, and Dr. Darrell Pardi (Mayo Clinic), is an absolute must-read as it provides a detailed review on the diagnosis, management, and therapeutic options for microscopic colitis.

As gastroenterologists, we are often asked to place percutaneous endoscopic gastrostomy (PEG) tubes. This can be a difficult situation to navigate especially when the indication or timing of placement seems questionable. In our ethics case for this quarter, Dr. David Seres and Dr. Jane Cowan (Columbia University) unpack the ethical considerations of PEG tube placement in order to facilitate discharge to subacute nursing facilities.

Months in quarantine have incited many to crave larger living spaces, lending to a chaotic housing market. Jon Solitro (FinancialMD) offers sound financial advice for physicians interested purchasing a home – including factors to consider when choosing a home, how much to spend, and whether or not to consider a doctor’s loan.

Success in research can be particularly difficult for fellows and early career gastroenterologists as they juggle the many responsibilities inherent to busy training programs or adjust to independent practice. Dr. Dionne Rebello and Dr. Michelle Long (Boston University) compile a list of incredibly helpful tips on how to optimize productivity. For those interested in ways to harness experiences in clinical medicine into health technology, Dr. Simon Matthews (Johns Hopkins) discusses his role as chief medical officer in a health tech start-up in our postfellowship pathways section.

Lastly, our DHPA Private Practice Perspectives article, written by Dr. George Dickstein (Greater Boston Gastroenterology), nicely summarizes lessons learned from the pandemic and how a practice can be adequately prepared for a post-pandemic surge of procedures.

If you have interest in contributing or have ideas for future TNG topics, please contact me ([email protected]) or Ryan Farrell ([email protected]), managing editor of TNG.

Stay well,

Vijaya L. Rao, MD
Editor in Chief
Assistant Professor of Medicine, University of Chicago, Section of Gastroenterology, Hepatology & Nutrition

Dear colleagues,

I’m thrilled to introduce the August edition of The New Gastroenterologist, which features an excellent line-up of articles! Summer has been in full swing, and gradually, we eased into aspects of our prepandemic routine. The fear, caution, and isolation that characterized the last year and a half was less pervasive, and the ability to reconnect in person felt both refreshing and liberating. While new threats of variants and rising infection rates have emerged, there is hope that, with the availability of vaccines, the worst of the pandemic may still be behind us.

One of the most difficult aspects of treating patients with inflammatory bowel disease is acute pain management. Dr. Jami Kinnucan and Dr. Mehwish Ahmed (University of Michigan) outline an expert approach on differentiating between visceral and somatic pain and how to manage each accordingly.

The diagnosis of microscopic colitis can be elusive because colonic mucosa typically appears endoscopically normal and the pathognomonic findings are histologic. Management can also be challenging given the frequently relapsing and remitting nature of its clinical course. The “In Focus” feature for August, written by Dr. June Tome, Dr. Amrit Kamboj, and Dr. Darrell Pardi (Mayo Clinic), is an absolute must-read as it provides a detailed review on the diagnosis, management, and therapeutic options for microscopic colitis.

As gastroenterologists, we are often asked to place percutaneous endoscopic gastrostomy (PEG) tubes. This can be a difficult situation to navigate especially when the indication or timing of placement seems questionable. In our ethics case for this quarter, Dr. David Seres and Dr. Jane Cowan (Columbia University) unpack the ethical considerations of PEG tube placement in order to facilitate discharge to subacute nursing facilities.

Months in quarantine have incited many to crave larger living spaces, lending to a chaotic housing market. Jon Solitro (FinancialMD) offers sound financial advice for physicians interested purchasing a home – including factors to consider when choosing a home, how much to spend, and whether or not to consider a doctor’s loan.

Success in research can be particularly difficult for fellows and early career gastroenterologists as they juggle the many responsibilities inherent to busy training programs or adjust to independent practice. Dr. Dionne Rebello and Dr. Michelle Long (Boston University) compile a list of incredibly helpful tips on how to optimize productivity. For those interested in ways to harness experiences in clinical medicine into health technology, Dr. Simon Matthews (Johns Hopkins) discusses his role as chief medical officer in a health tech start-up in our postfellowship pathways section.

Lastly, our DHPA Private Practice Perspectives article, written by Dr. George Dickstein (Greater Boston Gastroenterology), nicely summarizes lessons learned from the pandemic and how a practice can be adequately prepared for a post-pandemic surge of procedures.

If you have interest in contributing or have ideas for future TNG topics, please contact me ([email protected]) or Ryan Farrell ([email protected]), managing editor of TNG.

Stay well,

Vijaya L. Rao, MD
Editor in Chief
Assistant Professor of Medicine, University of Chicago, Section of Gastroenterology, Hepatology & Nutrition

Dear colleagues,

I’m thrilled to introduce the August edition of The New Gastroenterologist, which features an excellent line-up of articles! Summer has been in full swing, and gradually, we eased into aspects of our prepandemic routine. The fear, caution, and isolation that characterized the last year and a half was less pervasive, and the ability to reconnect in person felt both refreshing and liberating. While new threats of variants and rising infection rates have emerged, there is hope that, with the availability of vaccines, the worst of the pandemic may still be behind us.

One of the most difficult aspects of treating patients with inflammatory bowel disease is acute pain management. Dr. Jami Kinnucan and Dr. Mehwish Ahmed (University of Michigan) outline an expert approach on differentiating between visceral and somatic pain and how to manage each accordingly.

The diagnosis of microscopic colitis can be elusive because colonic mucosa typically appears endoscopically normal and the pathognomonic findings are histologic. Management can also be challenging given the frequently relapsing and remitting nature of its clinical course. The “In Focus” feature for August, written by Dr. June Tome, Dr. Amrit Kamboj, and Dr. Darrell Pardi (Mayo Clinic), is an absolute must-read as it provides a detailed review on the diagnosis, management, and therapeutic options for microscopic colitis.

As gastroenterologists, we are often asked to place percutaneous endoscopic gastrostomy (PEG) tubes. This can be a difficult situation to navigate especially when the indication or timing of placement seems questionable. In our ethics case for this quarter, Dr. David Seres and Dr. Jane Cowan (Columbia University) unpack the ethical considerations of PEG tube placement in order to facilitate discharge to subacute nursing facilities.

Months in quarantine have incited many to crave larger living spaces, lending to a chaotic housing market. Jon Solitro (FinancialMD) offers sound financial advice for physicians interested purchasing a home – including factors to consider when choosing a home, how much to spend, and whether or not to consider a doctor’s loan.

Success in research can be particularly difficult for fellows and early career gastroenterologists as they juggle the many responsibilities inherent to busy training programs or adjust to independent practice. Dr. Dionne Rebello and Dr. Michelle Long (Boston University) compile a list of incredibly helpful tips on how to optimize productivity. For those interested in ways to harness experiences in clinical medicine into health technology, Dr. Simon Matthews (Johns Hopkins) discusses his role as chief medical officer in a health tech start-up in our postfellowship pathways section.

Lastly, our DHPA Private Practice Perspectives article, written by Dr. George Dickstein (Greater Boston Gastroenterology), nicely summarizes lessons learned from the pandemic and how a practice can be adequately prepared for a post-pandemic surge of procedures.

If you have interest in contributing or have ideas for future TNG topics, please contact me ([email protected]) or Ryan Farrell ([email protected]), managing editor of TNG.

Stay well,

Vijaya L. Rao, MD
Editor in Chief
Assistant Professor of Medicine, University of Chicago, Section of Gastroenterology, Hepatology & Nutrition

Microscopic colitis is an inflammatory disease of the colon and a frequent cause of chronic or recurrent watery diarrhea, particularly in older persons. MC consists of two subtypes, collagenous colitis (CC) and lymphocytic colitis (LC). While the primary symptom is diarrhea, other signs and symptoms such as abdominal pain, weight loss, and dehydration or electrolyte abnormalities may also be present depending on disease severity.¹ In MC, the colonic mucosa usually appears normal on colonoscopy, and the diagnosis is made by histologic findings of intraepithelial lymphocytosis with (CC) or without (LC) a prominent subepithelial collagen band. The management approaches to CC and LC are similar and should be directed based on the severity of symptoms.² We review the epidemiology, risk factors, pathophysiology, diagnosis, and clinical management for this condition, as well as novel therapeutic approaches.

Epidemiology

Although the incidence of MC increased in the late twentieth century, more recently, it has stabilized with an estimated incidence varying from 1 to 25 per 100,000 person-years.^3-5 A recent meta-analysis revealed a pooled incidence of 4.85 per 100,000 persons for LC and 4.14 per 100,000 persons for CC.6 Proposed explanations for the rising incidence in the late twentieth century include improved clinical awareness of the disease, possible increased use of drugs associated with MC, and increased performance of diagnostic colonoscopies for chronic diarrhea. Since MC is now well-recognized, the recent plateau in incidence rates may reflect decreased detection bias.

The prevalence of MC ranges from 10%-20% in patients undergoing colonoscopy for chronic watery diarrhea.^6,7 The prevalence of LC is approximately 63.1 cases per 100,000 person-years and, for CC, is 49.2 cases per 100,000 person-years.^6-8 Recent studies have demonstrated increasing prevalence of MC likely resulting from an aging population.^9,10
 

Risk stratification

Female gender, increasing age, concomitant autoimmune disease, and the use of certain drugs, including NSAIDs, proton pump inhibitors (PPIs), statins, and selective serotonin reuptake inhibitors (SSRIs), have been associated with an increased risk of MC.^11,12 Autoimmune disorders, including celiac disease (CD), rheumatoid arthritis, hypothyroidism, and hyperthyroidism, are more common in patients with MC. The association with CD, in particular, is clinically important, as CD is associated with a 50-70 times greater risk of MC, and 2%-9% of patients with MC have CD.^13,14

Several medications have been associated with MC. In a British multicenter prospective study, MC was associated with the use of NSAIDs, PPIs, and SSRIs;¹⁵ however, recent studies have questioned the association of MC with some of these medications, which might worsen diarrhea but not actually cause MC.¹⁶

An additional risk factor for MC is smoking. A recent meta-analysis demonstrated that current and former smokers had an increased risk of MC (odds ratio, 2.99; 95% confidence interval, 2.15-4.15 and OR, 1.63; 95% CI, 1.37-1.94, respectively), compared with nonsmokers.¹⁷ Smokers develop MC at a younger age, and smoking is associated with increased disease severity and decreased likelihood of attaining remission.^18,19

Pathogenesis

The pathogenesis of MC remains largely unknown, although there are several hypotheses. The leading proposed mechanisms include reaction to luminal antigens, dysregulated collagen metabolism, genetic predisposition, autoimmunity, and bile acid malabsorption.

MC may be caused by abnormal epithelial barrier function, leading to increased permeability and reaction to luminal antigens, including dietary antigens, certain drugs, and bacterial products, ^20,21 which themselves lead to the immune dysregulation and intestinal inflammation seen in MC. This mechanism may explain the association of several drugs with MC. Histological changes resembling LC are reported in patients with CD who consume gluten; however, large population-based studies have not found specific dietary associations with the development of MC.²²

Another potential mechanism of MC is dysregulated collagen deposition. Collagen accumulation in the subepithelial layer in CC may result from increased levels of fibroblast growth factor, transforming growth factor–beta and vascular endothelial growth factor.²³ Nonetheless, studies have not found an association between the severity of diarrhea in patients with CC and the thickness of the subepithelial collagen band.

Thirdly, autoimmunity and genetic predisposition have been postulated in the pathogenesis of MC. As previously discussed, MC is associated with several autoimmune diseases and predominantly occurs in women, a distinctive feature of autoimmune disorders. Several studies have demonstrated an association between MC and HLA-DQ2 and -DQ3 haplotypes,²⁴ as well as potential polymorphisms in the serotonin transporter gene promoter.²⁵ It is important to note, however, that only a few familial cases of MC have been reported to date.²⁶

Lastly, bile acid malabsorption may play a role in the etiology of MC. Histologic findings of inflammation, along with villous atrophy and collagen deposition, have been reported in the ileum of patients with MC;^27,28 however, because patients with MC without bile acid malabsorption may also respond to bile acid binders such as cholestyramine, these findings unlikely to be the sole mechanism explaining the development of the disease.

Despite the different proposed mechanisms for the pathogenesis of MC, no definite conclusions can be drawn because of the limited size of these studies and their often conflicting results.

Vidyard Video

Clinical features

Clinicians should suspect MC in patients with chronic or recurrent watery diarrhea, particularly in older persons. Other risk factors include female gender, use of certain culprit medications, smoking, and presence of other autoimmune diseases. The clinical manifestations of MC subtypes LC and CC are similar with no significant clinical differences.^1,2 In addition to diarrhea, patients with MC may have abdominal pain, fatigue, and dehydration or electrolyte abnormalities depending on disease severity. Patients may also present with fecal urgency, incontinence, and nocturnal stools. Quality of life is often reduced in these patients, predominantly in those with severe or refractory symptoms.^29,30 The natural course of MC is highly variable, with some patients achieving spontaneous resolution after one episode and others developing chronic symptoms.

Diagnosis

The differential diagnosis of chronic watery diarrhea is broad and includes malabsorption/maldigestion, inflammatory bowel disease (IBD), irritable bowel syndrome, and medication side effects. In addition, although gastrointestinal infections typically cause acute or subacute diarrhea, some can present with chronic diarrhea. Malabsorption/maldigestion may occur because of CD, lactose intolerance, and pancreatic insufficiency, among other conditions. A thorough history, regarding recent antibiotic and medication use, travel, and immunosuppression, should be obtained in patients with chronic diarrhea. Additionally, laboratory and endoscopic evaluation with random biopsies of the colon can further help differentiate these diseases from MC. A few studies suggest fecal calprotectin may be used to differentiate MC from other noninflammatory conditions such as irritable bowel syndrome, as well as to monitor disease activity. This test is not expected to distinguish MC from other inflammatory causes of diarrhea, such as IBD, and therefore, its role in clinical practice is uncertain.³¹

 

 

The diagnosis of MC is made by biopsy of the colonic mucosa demonstrating characteristic pathologic features.³² Unlike in diseases such as Crohn’s disease or ulcerative colitis, the colon usually appears normal in MC, although mild nonspecific changes, such as erythema or edema, may be visualized. There is no consensus on the ideal location to obtain biopsies for MC or whether biopsies from both the left and the right colon are required.^2,33 The procedure of choice for the diagnosis of MC is colonoscopy with random biopsies taken throughout the colon. More limited evaluation by flexible sigmoidoscopy with biopsies may miss cases of MC as inflammation and collagen thickening are not necessarily uniform throughout the colon; however, in a patient that has undergone a recent colonoscopy for colon cancer screening without colon biopsies, a flexible sigmoidoscopy may be a reasonable next test for evaluation of MC, provided biopsies are obtained above the rectosigmoid colon.³⁴

Courtesy Dr. Catherine Hagen/Mayo Clinic

The MC subtypes are differentiated based on histology. The hallmark of LC is less than 20 intraepithelial lymphocytes per 100 surface epithelial cells (normal, less than 5) (Figure 1A). CC is characterized by a thickened subepithelial collagen band greater than 7-10 micrometers (normal, less than 5) (Figure 1B). For a subgroup of patients with milder abnormalities that do not meet these histological criteria, the terms “microscopic colitis, not otherwise specified” or “microscopic colitis, incomplete” may be used.³⁵ These patients often respond to standard treatments for MC. There is an additional subset of patients with biopsy demonstrating features of both CC and LC simultaneously, as well as patients transitioning from one MC subtype to another over time.^32,35

Courtesy Dr. Catherine Hagen/Mayo Clinic

 

Management approach

The first step in management of patients with MC includes stopping culprit medications if there is a temporal relationship between the initiation of the medication and the onset of diarrhea, as well as encouraging smoking cessation. These steps alone, however, are unlikely to achieve clinical remission in most patients. A stepwise pharmacological approach is used in the management of MC based on disease severity (Figure 2). For patients with mild symptoms, antidiarrheal medications, such as loperamide, may be helpful.³⁶ Long-term use of loperamide at therapeutic doses no greater than 16 mg daily appears to be safe if required to maintain symptom response. For those with persistent symptoms despite antidiarrheal medications, bismuth subsalicylate at three 262 mg tablets three times daily for 6-8 weeks can be considered. Long-term use of bismuth subsalicylate is not advised, especially at this dose, because of possible neurotoxicity.³⁷

For patients refractory to the above treatments or those with moderate-to-severe symptoms, an 8-week course of budesonide at 9 mg daily is the first-line treatment.³⁸ The dose was tapered before discontinuation in some studies but not in others. Both strategies appear effective. A recent meta-analysis of nine randomized trials demonstrated pooled ORs of 7.34 (95% CI, 4.08-13.19) and 8.35 (95% CI, 4.14-16.85) for response to budesonide induction and maintenance, respectively.³⁹

Cholestyramine is another medication considered in the management of MC and warrants further investigation. To date, no randomized clinical trials have been conducted to evaluate bile acid sequestrants in MC, but they should be considered before placing patients on immunosuppressive medications. Some providers use mesalamine in this setting, although mesalamine is inferior to budesonide in the induction of clinical remission in MC.⁴⁰

Despite high rates of response to budesonide, relapse after discontinuation is frequent (60%-80%), and time to relapse is variable^41,42 The American Gastroenterological Association recommends budesonide for maintenance of remission in patients with recurrence following discontinuation of induction therapy. The lowest effective dose that maintains resolution of symptoms should be prescribed, ideally at 6 mg daily or lower.³⁸ Although budesonide has a greater first-pass metabolism, compared with other glucocorticoids, patients should be monitored for possible side effects including hypertension, diabetes, and osteoporosis, as well as ophthalmologic disease, including cataracts and glaucoma.

For those who are intolerant to budesonide or have refractory symptoms, concomitant disorders such as CD that may be contributing to symptoms must be excluded. Immunosuppressive medications – such as thiopurines and biologic agents, including tumor necrosis factor–alpha inhibitors or vedolizumab – may be considered in refractory cases.^43,44 Of note, there are limited studies evaluating the use of these medications for MC. Lastly, surgeries including ileostomy with or without colectomy have been performed in the most severe cases for resistant disease that has failed numerous pharmacological therapies.⁴⁵

Patients should be counseled that, while symptoms from MC can be quite bothersome and disabling, there appears to be a normal life expectancy and no association between MC and colon cancer, unlike with other inflammatory conditions of the colon such as IBD.^46,47

 

 

Conclusion and future outlook

As a common cause of chronic watery diarrhea, MC will be commonly encountered in primary care and gastroenterology practices. The diagnosis should be suspected in patients presenting with chronic or recurrent watery diarrhea, especially with female gender, autoimmune disease, and increasing age. The management of MC requires an algorithmic approach directed by symptom severity, with a subgroup of patients requiring maintenance therapy for relapsing symptoms. The care of patients with MC will continue to evolve in the future. Further work is needed to explore long-term safety outcomes with budesonide and the role of immunomodulators and newer biologic agents for patients with complex, refractory disease.

Dr. Tome is with the department of internal medicine at the Mayo Clinic, Rochester, Minn. Dr. Kamboj, and Dr. Pardi are with the division of gastroenterology and hepatology at the Mayo Clinic. Dr. Pardi has grant funding from Pfizer, Vedanta, Seres, Finch, Applied Molecular Transport, and Takeda and has consulted for Vedanta and Otsuka. The other authors have no conflicts of interest to report.

References

1. Nyhlin N et al. Aliment Pharmacol Ther. 2014;39:963-72.

2. Miehlke S et al. United European Gastroenterol J. 2020;20-8.

3. Pardi DS et al. Gut. 2007;56:504-8.

4. Fernández-Bañares F et al. J Crohn’s Colitis.2016;10(7):805-11.

5. Gentile NM et al. Clin Gastroenterol Hepatol. 2014;12(5):838-42.

6. Tong J et al. Am J Gastroenterol. 2015;110:265-76.

7. Olesen M et al. Gut. 2004;53(3):346-50.

8. Bergman D et al. Aliment Pharmacol Ther. 2019;49(11):1395-400.

9. Guagnozzi D et al. Dig Liver Dis. 2012;44(5):384-8.

10. Münch A et al. J Crohns Colitis. 2012;6(9):932-45.

11. Macaigne G et al. Am J Gastroenterol. 2014; 09(9):1461-70.

12. Verhaegh BP et al. Aliment Pharmacol Ther. 2016;43(9):1004-13.

13. Stewart M et al. Aliment Pharmacol Ther. 2011;33(12):1340-9.

14. Green PHR et al. Clin Gastroenterol Hepatol. 2009;7(11):1210-6.

15. Masclee GM et al. Am J Gastroenterol. 2015;110:749-59.

16. Zylberberg H et al. Ailment Pharmacol Ther. 2021 Jun;53(11)1209-15.

17. Jaruvongvanich V et al. Inflamm Bowel Dis. 2019;25(4):672-8.

18. Fernández-Bañares F et al. Inflamm Bowel Dis. 2013; 19(7):1470-6.

19. Yen EF et al. Inflamm Bowel Dis. 2012;18(10):1835-41.

20. Barmeyer C et al. J Gastroenterol. 2017;52(10):1090-100.

21. Morgan DM et al. Clin Gastroenterol Hepatol. 2020;18(4):984-6.

22. Larsson JK et al. Eur J Clin Nutr. 2016;70:1309-17.

23. Madisch A et al.. Inflamm Bowel Dis. 2011;17(11):2295-8.

24. Stahl E et al. Gastroenterology. 2020;159(2):549-61.

25. Sikander A et al. Dig Dis Sci. 2015; 60:887-94.

26. Abdo AA et al. Can J Gastroenterol. 2001;15(5):341-3.

27. Fernandez-Bañares F et al. Dig Dis Sci.2001;46(10):2231-8.

28. Lyutakov I et al. Eur J Gastroenterol Hepatol. 2021;1;33(3):380-7.

29. Hjortswang H et al. Dig Liver Dis. 2011 Feb;43(2):102-9.

30. Cotter TG= et al. Gut. 2018;67(3):441-6.

31. Von Arnim U et al. Clin Exp Gastroenterol. 2016;9:97-103.

32. Langner C et al. Histopathology. 2015;66:613-26.

33. ASGE Standards of Practice Committee and Sharaf RN et al. Gastrointest Endosc. 2013;78:216-24.

34. Macaigne G et al. Clin Res Hepatol Gastroenterol. 2017;41(3):333-40.

35. Bjørnbak C et al. Aliment Pharmacol Ther. 2011;34(10):1225-34.

36. Pardi DS et al. Gastroenterology. 2016;150(1):247-74.

37. Masannat Y and Nazer E. West Virginia Med J. 2013;109(3):32-4.

38. Nguyen GC et al. Gastroenterology. 2016; 150(1):242-6.

39. Sebastian S et al. Eur J Gastroenterol Hepatol. 2019 Aug;31(8):919-27.

40. Miehlke S et al. Gastroenterology. 2014;146(5):1222-30.

41. Gentile NM et al. Am J Gastroenterol. 2013;108:256-9.

42. Münch A et al. Gut. 2016; 65(1):47-56.

43. Cotter TG et al. Aliment Pharmacol Ther. 2017; 46(2):169-74.

44. Esteve M et al. J Crohns Colitis. 2011;5(6):612-8.

45. Cottreau J et al. Clin J Gastroenterol. 2016;9:140-4.

46. Kamboj AK et al. Program No. P1876. ACG 2018 Annual Scientific Meeting Abstracts. Philadelphia, Pennsylvania: American College of Gastroenterology.

47. Yen EF et al. Dig Dis Sci. 2012;57:161-9.

Microscopic colitis is an inflammatory disease of the colon and a frequent cause of chronic or recurrent watery diarrhea, particularly in older persons. MC consists of two subtypes, collagenous colitis (CC) and lymphocytic colitis (LC). While the primary symptom is diarrhea, other signs and symptoms such as abdominal pain, weight loss, and dehydration or electrolyte abnormalities may also be present depending on disease severity.¹ In MC, the colonic mucosa usually appears normal on colonoscopy, and the diagnosis is made by histologic findings of intraepithelial lymphocytosis with (CC) or without (LC) a prominent subepithelial collagen band. The management approaches to CC and LC are similar and should be directed based on the severity of symptoms.² We review the epidemiology, risk factors, pathophysiology, diagnosis, and clinical management for this condition, as well as novel therapeutic approaches.

Epidemiology

Although the incidence of MC increased in the late twentieth century, more recently, it has stabilized with an estimated incidence varying from 1 to 25 per 100,000 person-years.^3-5 A recent meta-analysis revealed a pooled incidence of 4.85 per 100,000 persons for LC and 4.14 per 100,000 persons for CC.6 Proposed explanations for the rising incidence in the late twentieth century include improved clinical awareness of the disease, possible increased use of drugs associated with MC, and increased performance of diagnostic colonoscopies for chronic diarrhea. Since MC is now well-recognized, the recent plateau in incidence rates may reflect decreased detection bias.

The prevalence of MC ranges from 10%-20% in patients undergoing colonoscopy for chronic watery diarrhea.^6,7 The prevalence of LC is approximately 63.1 cases per 100,000 person-years and, for CC, is 49.2 cases per 100,000 person-years.^6-8 Recent studies have demonstrated increasing prevalence of MC likely resulting from an aging population.^9,10
 

Risk stratification

Female gender, increasing age, concomitant autoimmune disease, and the use of certain drugs, including NSAIDs, proton pump inhibitors (PPIs), statins, and selective serotonin reuptake inhibitors (SSRIs), have been associated with an increased risk of MC.^11,12 Autoimmune disorders, including celiac disease (CD), rheumatoid arthritis, hypothyroidism, and hyperthyroidism, are more common in patients with MC. The association with CD, in particular, is clinically important, as CD is associated with a 50-70 times greater risk of MC, and 2%-9% of patients with MC have CD.^13,14

Several medications have been associated with MC. In a British multicenter prospective study, MC was associated with the use of NSAIDs, PPIs, and SSRIs;¹⁵ however, recent studies have questioned the association of MC with some of these medications, which might worsen diarrhea but not actually cause MC.¹⁶

An additional risk factor for MC is smoking. A recent meta-analysis demonstrated that current and former smokers had an increased risk of MC (odds ratio, 2.99; 95% confidence interval, 2.15-4.15 and OR, 1.63; 95% CI, 1.37-1.94, respectively), compared with nonsmokers.¹⁷ Smokers develop MC at a younger age, and smoking is associated with increased disease severity and decreased likelihood of attaining remission.^18,19

Pathogenesis

The pathogenesis of MC remains largely unknown, although there are several hypotheses. The leading proposed mechanisms include reaction to luminal antigens, dysregulated collagen metabolism, genetic predisposition, autoimmunity, and bile acid malabsorption.

MC may be caused by abnormal epithelial barrier function, leading to increased permeability and reaction to luminal antigens, including dietary antigens, certain drugs, and bacterial products, ^20,21 which themselves lead to the immune dysregulation and intestinal inflammation seen in MC. This mechanism may explain the association of several drugs with MC. Histological changes resembling LC are reported in patients with CD who consume gluten; however, large population-based studies have not found specific dietary associations with the development of MC.²²

Another potential mechanism of MC is dysregulated collagen deposition. Collagen accumulation in the subepithelial layer in CC may result from increased levels of fibroblast growth factor, transforming growth factor–beta and vascular endothelial growth factor.²³ Nonetheless, studies have not found an association between the severity of diarrhea in patients with CC and the thickness of the subepithelial collagen band.

Thirdly, autoimmunity and genetic predisposition have been postulated in the pathogenesis of MC. As previously discussed, MC is associated with several autoimmune diseases and predominantly occurs in women, a distinctive feature of autoimmune disorders. Several studies have demonstrated an association between MC and HLA-DQ2 and -DQ3 haplotypes,²⁴ as well as potential polymorphisms in the serotonin transporter gene promoter.²⁵ It is important to note, however, that only a few familial cases of MC have been reported to date.²⁶

Lastly, bile acid malabsorption may play a role in the etiology of MC. Histologic findings of inflammation, along with villous atrophy and collagen deposition, have been reported in the ileum of patients with MC;^27,28 however, because patients with MC without bile acid malabsorption may also respond to bile acid binders such as cholestyramine, these findings unlikely to be the sole mechanism explaining the development of the disease.

Despite the different proposed mechanisms for the pathogenesis of MC, no definite conclusions can be drawn because of the limited size of these studies and their often conflicting results.

Vidyard Video

Clinical features

Clinicians should suspect MC in patients with chronic or recurrent watery diarrhea, particularly in older persons. Other risk factors include female gender, use of certain culprit medications, smoking, and presence of other autoimmune diseases. The clinical manifestations of MC subtypes LC and CC are similar with no significant clinical differences.^1,2 In addition to diarrhea, patients with MC may have abdominal pain, fatigue, and dehydration or electrolyte abnormalities depending on disease severity. Patients may also present with fecal urgency, incontinence, and nocturnal stools. Quality of life is often reduced in these patients, predominantly in those with severe or refractory symptoms.^29,30 The natural course of MC is highly variable, with some patients achieving spontaneous resolution after one episode and others developing chronic symptoms.

Diagnosis

The differential diagnosis of chronic watery diarrhea is broad and includes malabsorption/maldigestion, inflammatory bowel disease (IBD), irritable bowel syndrome, and medication side effects. In addition, although gastrointestinal infections typically cause acute or subacute diarrhea, some can present with chronic diarrhea. Malabsorption/maldigestion may occur because of CD, lactose intolerance, and pancreatic insufficiency, among other conditions. A thorough history, regarding recent antibiotic and medication use, travel, and immunosuppression, should be obtained in patients with chronic diarrhea. Additionally, laboratory and endoscopic evaluation with random biopsies of the colon can further help differentiate these diseases from MC. A few studies suggest fecal calprotectin may be used to differentiate MC from other noninflammatory conditions such as irritable bowel syndrome, as well as to monitor disease activity. This test is not expected to distinguish MC from other inflammatory causes of diarrhea, such as IBD, and therefore, its role in clinical practice is uncertain.³¹

 

 

The diagnosis of MC is made by biopsy of the colonic mucosa demonstrating characteristic pathologic features.³² Unlike in diseases such as Crohn’s disease or ulcerative colitis, the colon usually appears normal in MC, although mild nonspecific changes, such as erythema or edema, may be visualized. There is no consensus on the ideal location to obtain biopsies for MC or whether biopsies from both the left and the right colon are required.^2,33 The procedure of choice for the diagnosis of MC is colonoscopy with random biopsies taken throughout the colon. More limited evaluation by flexible sigmoidoscopy with biopsies may miss cases of MC as inflammation and collagen thickening are not necessarily uniform throughout the colon; however, in a patient that has undergone a recent colonoscopy for colon cancer screening without colon biopsies, a flexible sigmoidoscopy may be a reasonable next test for evaluation of MC, provided biopsies are obtained above the rectosigmoid colon.³⁴

Courtesy Dr. Catherine Hagen/Mayo Clinic

The MC subtypes are differentiated based on histology. The hallmark of LC is less than 20 intraepithelial lymphocytes per 100 surface epithelial cells (normal, less than 5) (Figure 1A). CC is characterized by a thickened subepithelial collagen band greater than 7-10 micrometers (normal, less than 5) (Figure 1B). For a subgroup of patients with milder abnormalities that do not meet these histological criteria, the terms “microscopic colitis, not otherwise specified” or “microscopic colitis, incomplete” may be used.³⁵ These patients often respond to standard treatments for MC. There is an additional subset of patients with biopsy demonstrating features of both CC and LC simultaneously, as well as patients transitioning from one MC subtype to another over time.^32,35

Courtesy Dr. Catherine Hagen/Mayo Clinic

 

Management approach

The first step in management of patients with MC includes stopping culprit medications if there is a temporal relationship between the initiation of the medication and the onset of diarrhea, as well as encouraging smoking cessation. These steps alone, however, are unlikely to achieve clinical remission in most patients. A stepwise pharmacological approach is used in the management of MC based on disease severity (Figure 2). For patients with mild symptoms, antidiarrheal medications, such as loperamide, may be helpful.³⁶ Long-term use of loperamide at therapeutic doses no greater than 16 mg daily appears to be safe if required to maintain symptom response. For those with persistent symptoms despite antidiarrheal medications, bismuth subsalicylate at three 262 mg tablets three times daily for 6-8 weeks can be considered. Long-term use of bismuth subsalicylate is not advised, especially at this dose, because of possible neurotoxicity.³⁷

For patients refractory to the above treatments or those with moderate-to-severe symptoms, an 8-week course of budesonide at 9 mg daily is the first-line treatment.³⁸ The dose was tapered before discontinuation in some studies but not in others. Both strategies appear effective. A recent meta-analysis of nine randomized trials demonstrated pooled ORs of 7.34 (95% CI, 4.08-13.19) and 8.35 (95% CI, 4.14-16.85) for response to budesonide induction and maintenance, respectively.³⁹

Cholestyramine is another medication considered in the management of MC and warrants further investigation. To date, no randomized clinical trials have been conducted to evaluate bile acid sequestrants in MC, but they should be considered before placing patients on immunosuppressive medications. Some providers use mesalamine in this setting, although mesalamine is inferior to budesonide in the induction of clinical remission in MC.⁴⁰

Despite high rates of response to budesonide, relapse after discontinuation is frequent (60%-80%), and time to relapse is variable^41,42 The American Gastroenterological Association recommends budesonide for maintenance of remission in patients with recurrence following discontinuation of induction therapy. The lowest effective dose that maintains resolution of symptoms should be prescribed, ideally at 6 mg daily or lower.³⁸ Although budesonide has a greater first-pass metabolism, compared with other glucocorticoids, patients should be monitored for possible side effects including hypertension, diabetes, and osteoporosis, as well as ophthalmologic disease, including cataracts and glaucoma.

For those who are intolerant to budesonide or have refractory symptoms, concomitant disorders such as CD that may be contributing to symptoms must be excluded. Immunosuppressive medications – such as thiopurines and biologic agents, including tumor necrosis factor–alpha inhibitors or vedolizumab – may be considered in refractory cases.^43,44 Of note, there are limited studies evaluating the use of these medications for MC. Lastly, surgeries including ileostomy with or without colectomy have been performed in the most severe cases for resistant disease that has failed numerous pharmacological therapies.⁴⁵

Patients should be counseled that, while symptoms from MC can be quite bothersome and disabling, there appears to be a normal life expectancy and no association between MC and colon cancer, unlike with other inflammatory conditions of the colon such as IBD.^46,47

 

 

Conclusion and future outlook

As a common cause of chronic watery diarrhea, MC will be commonly encountered in primary care and gastroenterology practices. The diagnosis should be suspected in patients presenting with chronic or recurrent watery diarrhea, especially with female gender, autoimmune disease, and increasing age. The management of MC requires an algorithmic approach directed by symptom severity, with a subgroup of patients requiring maintenance therapy for relapsing symptoms. The care of patients with MC will continue to evolve in the future. Further work is needed to explore long-term safety outcomes with budesonide and the role of immunomodulators and newer biologic agents for patients with complex, refractory disease.

Dr. Tome is with the department of internal medicine at the Mayo Clinic, Rochester, Minn. Dr. Kamboj, and Dr. Pardi are with the division of gastroenterology and hepatology at the Mayo Clinic. Dr. Pardi has grant funding from Pfizer, Vedanta, Seres, Finch, Applied Molecular Transport, and Takeda and has consulted for Vedanta and Otsuka. The other authors have no conflicts of interest to report.

References

1. Nyhlin N et al. Aliment Pharmacol Ther. 2014;39:963-72.

2. Miehlke S et al. United European Gastroenterol J. 2020;20-8.

3. Pardi DS et al. Gut. 2007;56:504-8.

4. Fernández-Bañares F et al. J Crohn’s Colitis.2016;10(7):805-11.

5. Gentile NM et al. Clin Gastroenterol Hepatol. 2014;12(5):838-42.

6. Tong J et al. Am J Gastroenterol. 2015;110:265-76.

7. Olesen M et al. Gut. 2004;53(3):346-50.

8. Bergman D et al. Aliment Pharmacol Ther. 2019;49(11):1395-400.

9. Guagnozzi D et al. Dig Liver Dis. 2012;44(5):384-8.

10. Münch A et al. J Crohns Colitis. 2012;6(9):932-45.

11. Macaigne G et al. Am J Gastroenterol. 2014; 09(9):1461-70.

12. Verhaegh BP et al. Aliment Pharmacol Ther. 2016;43(9):1004-13.

13. Stewart M et al. Aliment Pharmacol Ther. 2011;33(12):1340-9.

14. Green PHR et al. Clin Gastroenterol Hepatol. 2009;7(11):1210-6.

15. Masclee GM et al. Am J Gastroenterol. 2015;110:749-59.

16. Zylberberg H et al. Ailment Pharmacol Ther. 2021 Jun;53(11)1209-15.

17. Jaruvongvanich V et al. Inflamm Bowel Dis. 2019;25(4):672-8.

18. Fernández-Bañares F et al. Inflamm Bowel Dis. 2013; 19(7):1470-6.

19. Yen EF et al. Inflamm Bowel Dis. 2012;18(10):1835-41.

20. Barmeyer C et al. J Gastroenterol. 2017;52(10):1090-100.

21. Morgan DM et al. Clin Gastroenterol Hepatol. 2020;18(4):984-6.

22. Larsson JK et al. Eur J Clin Nutr. 2016;70:1309-17.

23. Madisch A et al.. Inflamm Bowel Dis. 2011;17(11):2295-8.

24. Stahl E et al. Gastroenterology. 2020;159(2):549-61.

25. Sikander A et al. Dig Dis Sci. 2015; 60:887-94.

26. Abdo AA et al. Can J Gastroenterol. 2001;15(5):341-3.

27. Fernandez-Bañares F et al. Dig Dis Sci.2001;46(10):2231-8.

28. Lyutakov I et al. Eur J Gastroenterol Hepatol. 2021;1;33(3):380-7.

29. Hjortswang H et al. Dig Liver Dis. 2011 Feb;43(2):102-9.

30. Cotter TG= et al. Gut. 2018;67(3):441-6.

31. Von Arnim U et al. Clin Exp Gastroenterol. 2016;9:97-103.

32. Langner C et al. Histopathology. 2015;66:613-26.

33. ASGE Standards of Practice Committee and Sharaf RN et al. Gastrointest Endosc. 2013;78:216-24.

34. Macaigne G et al. Clin Res Hepatol Gastroenterol. 2017;41(3):333-40.

35. Bjørnbak C et al. Aliment Pharmacol Ther. 2011;34(10):1225-34.

36. Pardi DS et al. Gastroenterology. 2016;150(1):247-74.

37. Masannat Y and Nazer E. West Virginia Med J. 2013;109(3):32-4.

38. Nguyen GC et al. Gastroenterology. 2016; 150(1):242-6.

39. Sebastian S et al. Eur J Gastroenterol Hepatol. 2019 Aug;31(8):919-27.

40. Miehlke S et al. Gastroenterology. 2014;146(5):1222-30.

41. Gentile NM et al. Am J Gastroenterol. 2013;108:256-9.

42. Münch A et al. Gut. 2016; 65(1):47-56.

43. Cotter TG et al. Aliment Pharmacol Ther. 2017; 46(2):169-74.

44. Esteve M et al. J Crohns Colitis. 2011;5(6):612-8.

45. Cottreau J et al. Clin J Gastroenterol. 2016;9:140-4.

46. Kamboj AK et al. Program No. P1876. ACG 2018 Annual Scientific Meeting Abstracts. Philadelphia, Pennsylvania: American College of Gastroenterology.

47. Yen EF et al. Dig Dis Sci. 2012;57:161-9.

Microscopic colitis is an inflammatory disease of the colon and a frequent cause of chronic or recurrent watery diarrhea, particularly in older persons. MC consists of two subtypes, collagenous colitis (CC) and lymphocytic colitis (LC). While the primary symptom is diarrhea, other signs and symptoms such as abdominal pain, weight loss, and dehydration or electrolyte abnormalities may also be present depending on disease severity.¹ In MC, the colonic mucosa usually appears normal on colonoscopy, and the diagnosis is made by histologic findings of intraepithelial lymphocytosis with (CC) or without (LC) a prominent subepithelial collagen band. The management approaches to CC and LC are similar and should be directed based on the severity of symptoms.² We review the epidemiology, risk factors, pathophysiology, diagnosis, and clinical management for this condition, as well as novel therapeutic approaches.

Epidemiology

Although the incidence of MC increased in the late twentieth century, more recently, it has stabilized with an estimated incidence varying from 1 to 25 per 100,000 person-years.^3-5 A recent meta-analysis revealed a pooled incidence of 4.85 per 100,000 persons for LC and 4.14 per 100,000 persons for CC.6 Proposed explanations for the rising incidence in the late twentieth century include improved clinical awareness of the disease, possible increased use of drugs associated with MC, and increased performance of diagnostic colonoscopies for chronic diarrhea. Since MC is now well-recognized, the recent plateau in incidence rates may reflect decreased detection bias.

The prevalence of MC ranges from 10%-20% in patients undergoing colonoscopy for chronic watery diarrhea.^6,7 The prevalence of LC is approximately 63.1 cases per 100,000 person-years and, for CC, is 49.2 cases per 100,000 person-years.^6-8 Recent studies have demonstrated increasing prevalence of MC likely resulting from an aging population.^9,10
 

Risk stratification

Female gender, increasing age, concomitant autoimmune disease, and the use of certain drugs, including NSAIDs, proton pump inhibitors (PPIs), statins, and selective serotonin reuptake inhibitors (SSRIs), have been associated with an increased risk of MC.^11,12 Autoimmune disorders, including celiac disease (CD), rheumatoid arthritis, hypothyroidism, and hyperthyroidism, are more common in patients with MC. The association with CD, in particular, is clinically important, as CD is associated with a 50-70 times greater risk of MC, and 2%-9% of patients with MC have CD.^13,14

Several medications have been associated with MC. In a British multicenter prospective study, MC was associated with the use of NSAIDs, PPIs, and SSRIs;¹⁵ however, recent studies have questioned the association of MC with some of these medications, which might worsen diarrhea but not actually cause MC.¹⁶

An additional risk factor for MC is smoking. A recent meta-analysis demonstrated that current and former smokers had an increased risk of MC (odds ratio, 2.99; 95% confidence interval, 2.15-4.15 and OR, 1.63; 95% CI, 1.37-1.94, respectively), compared with nonsmokers.¹⁷ Smokers develop MC at a younger age, and smoking is associated with increased disease severity and decreased likelihood of attaining remission.^18,19

Pathogenesis

The pathogenesis of MC remains largely unknown, although there are several hypotheses. The leading proposed mechanisms include reaction to luminal antigens, dysregulated collagen metabolism, genetic predisposition, autoimmunity, and bile acid malabsorption.

MC may be caused by abnormal epithelial barrier function, leading to increased permeability and reaction to luminal antigens, including dietary antigens, certain drugs, and bacterial products, ^20,21 which themselves lead to the immune dysregulation and intestinal inflammation seen in MC. This mechanism may explain the association of several drugs with MC. Histological changes resembling LC are reported in patients with CD who consume gluten; however, large population-based studies have not found specific dietary associations with the development of MC.²²

Another potential mechanism of MC is dysregulated collagen deposition. Collagen accumulation in the subepithelial layer in CC may result from increased levels of fibroblast growth factor, transforming growth factor–beta and vascular endothelial growth factor.²³ Nonetheless, studies have not found an association between the severity of diarrhea in patients with CC and the thickness of the subepithelial collagen band.

Thirdly, autoimmunity and genetic predisposition have been postulated in the pathogenesis of MC. As previously discussed, MC is associated with several autoimmune diseases and predominantly occurs in women, a distinctive feature of autoimmune disorders. Several studies have demonstrated an association between MC and HLA-DQ2 and -DQ3 haplotypes,²⁴ as well as potential polymorphisms in the serotonin transporter gene promoter.²⁵ It is important to note, however, that only a few familial cases of MC have been reported to date.²⁶

Lastly, bile acid malabsorption may play a role in the etiology of MC. Histologic findings of inflammation, along with villous atrophy and collagen deposition, have been reported in the ileum of patients with MC;^27,28 however, because patients with MC without bile acid malabsorption may also respond to bile acid binders such as cholestyramine, these findings unlikely to be the sole mechanism explaining the development of the disease.

Despite the different proposed mechanisms for the pathogenesis of MC, no definite conclusions can be drawn because of the limited size of these studies and their often conflicting results.

Vidyard Video

Clinical features

Clinicians should suspect MC in patients with chronic or recurrent watery diarrhea, particularly in older persons. Other risk factors include female gender, use of certain culprit medications, smoking, and presence of other autoimmune diseases. The clinical manifestations of MC subtypes LC and CC are similar with no significant clinical differences.^1,2 In addition to diarrhea, patients with MC may have abdominal pain, fatigue, and dehydration or electrolyte abnormalities depending on disease severity. Patients may also present with fecal urgency, incontinence, and nocturnal stools. Quality of life is often reduced in these patients, predominantly in those with severe or refractory symptoms.^29,30 The natural course of MC is highly variable, with some patients achieving spontaneous resolution after one episode and others developing chronic symptoms.

Diagnosis

The differential diagnosis of chronic watery diarrhea is broad and includes malabsorption/maldigestion, inflammatory bowel disease (IBD), irritable bowel syndrome, and medication side effects. In addition, although gastrointestinal infections typically cause acute or subacute diarrhea, some can present with chronic diarrhea. Malabsorption/maldigestion may occur because of CD, lactose intolerance, and pancreatic insufficiency, among other conditions. A thorough history, regarding recent antibiotic and medication use, travel, and immunosuppression, should be obtained in patients with chronic diarrhea. Additionally, laboratory and endoscopic evaluation with random biopsies of the colon can further help differentiate these diseases from MC. A few studies suggest fecal calprotectin may be used to differentiate MC from other noninflammatory conditions such as irritable bowel syndrome, as well as to monitor disease activity. This test is not expected to distinguish MC from other inflammatory causes of diarrhea, such as IBD, and therefore, its role in clinical practice is uncertain.³¹

 

 

The diagnosis of MC is made by biopsy of the colonic mucosa demonstrating characteristic pathologic features.³² Unlike in diseases such as Crohn’s disease or ulcerative colitis, the colon usually appears normal in MC, although mild nonspecific changes, such as erythema or edema, may be visualized. There is no consensus on the ideal location to obtain biopsies for MC or whether biopsies from both the left and the right colon are required.^2,33 The procedure of choice for the diagnosis of MC is colonoscopy with random biopsies taken throughout the colon. More limited evaluation by flexible sigmoidoscopy with biopsies may miss cases of MC as inflammation and collagen thickening are not necessarily uniform throughout the colon; however, in a patient that has undergone a recent colonoscopy for colon cancer screening without colon biopsies, a flexible sigmoidoscopy may be a reasonable next test for evaluation of MC, provided biopsies are obtained above the rectosigmoid colon.³⁴

Courtesy Dr. Catherine Hagen/Mayo Clinic

The MC subtypes are differentiated based on histology. The hallmark of LC is less than 20 intraepithelial lymphocytes per 100 surface epithelial cells (normal, less than 5) (Figure 1A). CC is characterized by a thickened subepithelial collagen band greater than 7-10 micrometers (normal, less than 5) (Figure 1B). For a subgroup of patients with milder abnormalities that do not meet these histological criteria, the terms “microscopic colitis, not otherwise specified” or “microscopic colitis, incomplete” may be used.³⁵ These patients often respond to standard treatments for MC. There is an additional subset of patients with biopsy demonstrating features of both CC and LC simultaneously, as well as patients transitioning from one MC subtype to another over time.^32,35

Courtesy Dr. Catherine Hagen/Mayo Clinic

 

Management approach

The first step in management of patients with MC includes stopping culprit medications if there is a temporal relationship between the initiation of the medication and the onset of diarrhea, as well as encouraging smoking cessation. These steps alone, however, are unlikely to achieve clinical remission in most patients. A stepwise pharmacological approach is used in the management of MC based on disease severity (Figure 2). For patients with mild symptoms, antidiarrheal medications, such as loperamide, may be helpful.³⁶ Long-term use of loperamide at therapeutic doses no greater than 16 mg daily appears to be safe if required to maintain symptom response. For those with persistent symptoms despite antidiarrheal medications, bismuth subsalicylate at three 262 mg tablets three times daily for 6-8 weeks can be considered. Long-term use of bismuth subsalicylate is not advised, especially at this dose, because of possible neurotoxicity.³⁷

For patients refractory to the above treatments or those with moderate-to-severe symptoms, an 8-week course of budesonide at 9 mg daily is the first-line treatment.³⁸ The dose was tapered before discontinuation in some studies but not in others. Both strategies appear effective. A recent meta-analysis of nine randomized trials demonstrated pooled ORs of 7.34 (95% CI, 4.08-13.19) and 8.35 (95% CI, 4.14-16.85) for response to budesonide induction and maintenance, respectively.³⁹

Cholestyramine is another medication considered in the management of MC and warrants further investigation. To date, no randomized clinical trials have been conducted to evaluate bile acid sequestrants in MC, but they should be considered before placing patients on immunosuppressive medications. Some providers use mesalamine in this setting, although mesalamine is inferior to budesonide in the induction of clinical remission in MC.⁴⁰

Despite high rates of response to budesonide, relapse after discontinuation is frequent (60%-80%), and time to relapse is variable^41,42 The American Gastroenterological Association recommends budesonide for maintenance of remission in patients with recurrence following discontinuation of induction therapy. The lowest effective dose that maintains resolution of symptoms should be prescribed, ideally at 6 mg daily or lower.³⁸ Although budesonide has a greater first-pass metabolism, compared with other glucocorticoids, patients should be monitored for possible side effects including hypertension, diabetes, and osteoporosis, as well as ophthalmologic disease, including cataracts and glaucoma.

For those who are intolerant to budesonide or have refractory symptoms, concomitant disorders such as CD that may be contributing to symptoms must be excluded. Immunosuppressive medications – such as thiopurines and biologic agents, including tumor necrosis factor–alpha inhibitors or vedolizumab – may be considered in refractory cases.^43,44 Of note, there are limited studies evaluating the use of these medications for MC. Lastly, surgeries including ileostomy with or without colectomy have been performed in the most severe cases for resistant disease that has failed numerous pharmacological therapies.⁴⁵

Patients should be counseled that, while symptoms from MC can be quite bothersome and disabling, there appears to be a normal life expectancy and no association between MC and colon cancer, unlike with other inflammatory conditions of the colon such as IBD.^46,47

 

 

Conclusion and future outlook

As a common cause of chronic watery diarrhea, MC will be commonly encountered in primary care and gastroenterology practices. The diagnosis should be suspected in patients presenting with chronic or recurrent watery diarrhea, especially with female gender, autoimmune disease, and increasing age. The management of MC requires an algorithmic approach directed by symptom severity, with a subgroup of patients requiring maintenance therapy for relapsing symptoms. The care of patients with MC will continue to evolve in the future. Further work is needed to explore long-term safety outcomes with budesonide and the role of immunomodulators and newer biologic agents for patients with complex, refractory disease.

Dr. Tome is with the department of internal medicine at the Mayo Clinic, Rochester, Minn. Dr. Kamboj, and Dr. Pardi are with the division of gastroenterology and hepatology at the Mayo Clinic. Dr. Pardi has grant funding from Pfizer, Vedanta, Seres, Finch, Applied Molecular Transport, and Takeda and has consulted for Vedanta and Otsuka. The other authors have no conflicts of interest to report.

References

1. Nyhlin N et al. Aliment Pharmacol Ther. 2014;39:963-72.

2. Miehlke S et al. United European Gastroenterol J. 2020;20-8.

3. Pardi DS et al. Gut. 2007;56:504-8.

4. Fernández-Bañares F et al. J Crohn’s Colitis.2016;10(7):805-11.

5. Gentile NM et al. Clin Gastroenterol Hepatol. 2014;12(5):838-42.

6. Tong J et al. Am J Gastroenterol. 2015;110:265-76.

7. Olesen M et al. Gut. 2004;53(3):346-50.

8. Bergman D et al. Aliment Pharmacol Ther. 2019;49(11):1395-400.

9. Guagnozzi D et al. Dig Liver Dis. 2012;44(5):384-8.

10. Münch A et al. J Crohns Colitis. 2012;6(9):932-45.

11. Macaigne G et al. Am J Gastroenterol. 2014; 09(9):1461-70.

12. Verhaegh BP et al. Aliment Pharmacol Ther. 2016;43(9):1004-13.

13. Stewart M et al. Aliment Pharmacol Ther. 2011;33(12):1340-9.

14. Green PHR et al. Clin Gastroenterol Hepatol. 2009;7(11):1210-6.

15. Masclee GM et al. Am J Gastroenterol. 2015;110:749-59.

16. Zylberberg H et al. Ailment Pharmacol Ther. 2021 Jun;53(11)1209-15.

17. Jaruvongvanich V et al. Inflamm Bowel Dis. 2019;25(4):672-8.

18. Fernández-Bañares F et al. Inflamm Bowel Dis. 2013; 19(7):1470-6.

19. Yen EF et al. Inflamm Bowel Dis. 2012;18(10):1835-41.

20. Barmeyer C et al. J Gastroenterol. 2017;52(10):1090-100.

21. Morgan DM et al. Clin Gastroenterol Hepatol. 2020;18(4):984-6.

22. Larsson JK et al. Eur J Clin Nutr. 2016;70:1309-17.

23. Madisch A et al.. Inflamm Bowel Dis. 2011;17(11):2295-8.

24. Stahl E et al. Gastroenterology. 2020;159(2):549-61.

25. Sikander A et al. Dig Dis Sci. 2015; 60:887-94.

26. Abdo AA et al. Can J Gastroenterol. 2001;15(5):341-3.

27. Fernandez-Bañares F et al. Dig Dis Sci.2001;46(10):2231-8.

28. Lyutakov I et al. Eur J Gastroenterol Hepatol. 2021;1;33(3):380-7.

29. Hjortswang H et al. Dig Liver Dis. 2011 Feb;43(2):102-9.

30. Cotter TG= et al. Gut. 2018;67(3):441-6.

31. Von Arnim U et al. Clin Exp Gastroenterol. 2016;9:97-103.

32. Langner C et al. Histopathology. 2015;66:613-26.

33. ASGE Standards of Practice Committee and Sharaf RN et al. Gastrointest Endosc. 2013;78:216-24.

34. Macaigne G et al. Clin Res Hepatol Gastroenterol. 2017;41(3):333-40.

35. Bjørnbak C et al. Aliment Pharmacol Ther. 2011;34(10):1225-34.

36. Pardi DS et al. Gastroenterology. 2016;150(1):247-74.

37. Masannat Y and Nazer E. West Virginia Med J. 2013;109(3):32-4.

38. Nguyen GC et al. Gastroenterology. 2016; 150(1):242-6.

39. Sebastian S et al. Eur J Gastroenterol Hepatol. 2019 Aug;31(8):919-27.

40. Miehlke S et al. Gastroenterology. 2014;146(5):1222-30.

41. Gentile NM et al. Am J Gastroenterol. 2013;108:256-9.

42. Münch A et al. Gut. 2016; 65(1):47-56.

43. Cotter TG et al. Aliment Pharmacol Ther. 2017; 46(2):169-74.

44. Esteve M et al. J Crohns Colitis. 2011;5(6):612-8.

45. Cottreau J et al. Clin J Gastroenterol. 2016;9:140-4.

46. Kamboj AK et al. Program No. P1876. ACG 2018 Annual Scientific Meeting Abstracts. Philadelphia, Pennsylvania: American College of Gastroenterology.

47. Yen EF et al. Dig Dis Sci. 2012;57:161-9.

Gastroenterology

May 2021
Understanding GI Twitter and its major contributors. Elfanagely Y et al. Gastroenterology. 2021 May;160(6):1917-21. doi: 10.1053/j.gastro.2021.01.232.

Long-term safety of fecal microbiota transplantation for recurrent Clostridioides difficile infection. Saha S et al. Gastroenterology. 2021 May;160(6):1961-9.e3. doi: 10.1053/j.gastro.2021.01.010.

How to incorporate health equity training into gastroenterology and hepatology fellowships. Lee-Allen J, Shah BJ. Gastroenterology. 2021 May;160(6):1924-8. doi: 10.1053/j.gastro.2021.03.018.

Functional dyspepsia and gastroparesis in tertiary care are interchangeable syndromes with common clinical and pathologic features. Pasricha PJ et al. Gastroenterology. 2021 May;160(6):2006-17. doi: 10.1053/j.gastro.2021.01.230.

June 2021
How to manage the large nonpedunculated colorectal polyp. Shahidi N, Bourke MJ. Gastroenterology. 2021 Jun;160(7):2239-43.e1. doi: 10.1053/j.gastro.2021.04.029.

Mortality, reoperation, and hospital stay within 90 days of primary and secondary antireflux surgery in a population-based multinational study. Yanes M et al. Gastroenterology. 2021 Jun;160(7):2283-90. doi: 10.1053/j.gastro.2021.02.022.

Endoscopic submucosal dissection in north america: A large prospective multicenter study. Draganov PV et al. Gastroenterology. 2021 Jun;160(7):2317-27.e2. doi: 10.1053/j.gastro.2021.02.036.

July 2021
Gluten degradation, pharmacokinetics, safety, and tolerability of TAK-062, an engineered enzyme to treat celiac disease. Pultz IG et al. Gastroenterology. 2021 Jul;161(1):81-93.e3. doi: 10.1053/j.gastro.2021.03.019.

Paternal exposure to immunosuppressive and/or biologic agents and birth outcomes in patients with immune-mediated inflammatory diseases. Meserve J et al. Gastroenterology. 2021 Jul;161(1):107-115.e3. doi: 10.1053/j.gastro.2021.03.020.

Ethnicity associations with food sensitization are mediated by gut microbiota development in the first year of life. Tun Hm et al. Gastroenterology. 2021 Jul;161(1):94-106. doi: 10.1053/j.gastro.2021.03.016.

How to incorporate bariatric training into your fellowship program. Jirapinyo P, Thompson CC. Gastroenterology. 2019 Jul;157(1):9-13. doi: 10.1053/j.gastro.2019.05.034.

CGH

May 2021
Intestinal failure: What all gastroenterologists should know. Jansson-Knodell CL et al. Clin Gastroenterol Hepatol. 2021 May;19(5):885-8. doi: 10.1016/j.cgh.2021.01.038.

When and how to use endoscopic tattooing in the colon: An international Delphi agreement. Medina-Prado L et al. Clin Gastroenterol Hepatol. 2021 May;19(5):1038-50. doi: 10.1016/j.cgh.2021.01.024.

Five-year outcomes of endoscopic sleeve gastroplasty for the treatment of obesity. Sharaiha RZ et al. Clin Gastroenterol Hepatol. 2021 May;19(5):1051-57.e2. doi: 10.1016/j.cgh.2020.09.055.

June 2021
GA Clinical Practice Update on management of bleeding gastric varices: Expert review. Henry Z et al. Clin Gastroenterol Hepatol. 2021 Jun;19(6):1098-107.e1. doi: 10.1016/j.cgh.2021.01.027.

Inter- and intra-individual variation, and limited prognostic utility, of serum alkaline phosphatase in a trial of patients with primary sclerosing cholangitis

Palak J. Trivedi PJ et al. Clin Gastroenterol Hepatol. 2021 Jun;19(6):1248-57. doi: 10.1016/j.cgh.2020.07.032.

Low-fat, high-fiber diet reduces markers of inflammation and dysbiosis and improves quality of life in patients with ulcerative colitis. Julia Fritsch J et al. Clin Gastroenterol Hepatol. 2021 Jun;19(6):1189-99.e30. doi: 10.1016/j.cgh.2020.05.026.

July 2021
Scoping out a better parental leave policy for gastroenterology fellows. Wegermann K. Clin Gastroenterol Hepatol. 2021 Jul;19(7):1307-9. doi: 10.1016/j.cgh.2021.01.040.

An impetus for change: How COVID-19 will transform the delivery of GI health care. Leiman DA et al. Clin Gastroenterol Hepatol. 2021 Jul;19(7):1310-1313. doi: 10.1016/j.cgh.2021.03.042.

Untangling nonerosive reflux disease from functional heartburn. Patel D et al. Clin Gastroenterol Hepatol. 2021 Jul;19(7):1314-26. doi: 10.1016/j.cgh.2020.03.057.
 

AGA Clinical Practice Update on chemoprevention for colorectal neoplasia: Expert review. Liang PS et al. Clin Gastroenterol Hepatol. 2021 Jul;19(7):1327-36. doi: 10.1016/j.cgh.2021.02.014.
 

CMGH

Drug inhibition of SARS-CoV-2 replication in human pluripotent stem cell–derived intestinal organoids. Krüger J et al. Cell Mol Gastroenterol Hepatol. 2021;11(4):935-48. doi: 10.1016/j.jcmgh.2020.11.003.
 

TIGE

Virtual interviews during the COVID-19 Pandemic: A survey of advanced endoscopy fellowship applicants and programs. Amrit K. Kamboj AK et al. Tech Innov Gastrointest Endosc. 2021;23(2):159-68. doi: 10.1016/j.tige.2021.02.001.

Triage of general gastrointestinal endoscopic procedures during the COVID-19 pandemic: Results from a national Delphi consensus panel. Feuerstein JD et al. Tech Innov Gastrointest Endosc. 2021;23(2):113-21. doi: 10.1016/j.tige.2020.12.005.

Development of a scoring system to predict a positive diagnosis on video capsule endoscopy for suspected small bowel bleeding. Marya NB et al. Tech Innov Gastrointest Endosc. 2021;22(4):178-84. doi: 10.1016/j.tige.2020.06.001.

Gastroenterology

May 2021
Understanding GI Twitter and its major contributors. Elfanagely Y et al. Gastroenterology. 2021 May;160(6):1917-21. doi: 10.1053/j.gastro.2021.01.232.

Long-term safety of fecal microbiota transplantation for recurrent Clostridioides difficile infection. Saha S et al. Gastroenterology. 2021 May;160(6):1961-9.e3. doi: 10.1053/j.gastro.2021.01.010.

How to incorporate health equity training into gastroenterology and hepatology fellowships. Lee-Allen J, Shah BJ. Gastroenterology. 2021 May;160(6):1924-8. doi: 10.1053/j.gastro.2021.03.018.

Functional dyspepsia and gastroparesis in tertiary care are interchangeable syndromes with common clinical and pathologic features. Pasricha PJ et al. Gastroenterology. 2021 May;160(6):2006-17. doi: 10.1053/j.gastro.2021.01.230.

June 2021
How to manage the large nonpedunculated colorectal polyp. Shahidi N, Bourke MJ. Gastroenterology. 2021 Jun;160(7):2239-43.e1. doi: 10.1053/j.gastro.2021.04.029.

Mortality, reoperation, and hospital stay within 90 days of primary and secondary antireflux surgery in a population-based multinational study. Yanes M et al. Gastroenterology. 2021 Jun;160(7):2283-90. doi: 10.1053/j.gastro.2021.02.022.

Endoscopic submucosal dissection in north america: A large prospective multicenter study. Draganov PV et al. Gastroenterology. 2021 Jun;160(7):2317-27.e2. doi: 10.1053/j.gastro.2021.02.036.

July 2021
Gluten degradation, pharmacokinetics, safety, and tolerability of TAK-062, an engineered enzyme to treat celiac disease. Pultz IG et al. Gastroenterology. 2021 Jul;161(1):81-93.e3. doi: 10.1053/j.gastro.2021.03.019.

Paternal exposure to immunosuppressive and/or biologic agents and birth outcomes in patients with immune-mediated inflammatory diseases. Meserve J et al. Gastroenterology. 2021 Jul;161(1):107-115.e3. doi: 10.1053/j.gastro.2021.03.020.

Ethnicity associations with food sensitization are mediated by gut microbiota development in the first year of life. Tun Hm et al. Gastroenterology. 2021 Jul;161(1):94-106. doi: 10.1053/j.gastro.2021.03.016.

How to incorporate bariatric training into your fellowship program. Jirapinyo P, Thompson CC. Gastroenterology. 2019 Jul;157(1):9-13. doi: 10.1053/j.gastro.2019.05.034.

CGH

May 2021
Intestinal failure: What all gastroenterologists should know. Jansson-Knodell CL et al. Clin Gastroenterol Hepatol. 2021 May;19(5):885-8. doi: 10.1016/j.cgh.2021.01.038.

When and how to use endoscopic tattooing in the colon: An international Delphi agreement. Medina-Prado L et al. Clin Gastroenterol Hepatol. 2021 May;19(5):1038-50. doi: 10.1016/j.cgh.2021.01.024.

Five-year outcomes of endoscopic sleeve gastroplasty for the treatment of obesity. Sharaiha RZ et al. Clin Gastroenterol Hepatol. 2021 May;19(5):1051-57.e2. doi: 10.1016/j.cgh.2020.09.055.

June 2021
GA Clinical Practice Update on management of bleeding gastric varices: Expert review. Henry Z et al. Clin Gastroenterol Hepatol. 2021 Jun;19(6):1098-107.e1. doi: 10.1016/j.cgh.2021.01.027.

Inter- and intra-individual variation, and limited prognostic utility, of serum alkaline phosphatase in a trial of patients with primary sclerosing cholangitis

Palak J. Trivedi PJ et al. Clin Gastroenterol Hepatol. 2021 Jun;19(6):1248-57. doi: 10.1016/j.cgh.2020.07.032.

Low-fat, high-fiber diet reduces markers of inflammation and dysbiosis and improves quality of life in patients with ulcerative colitis. Julia Fritsch J et al. Clin Gastroenterol Hepatol. 2021 Jun;19(6):1189-99.e30. doi: 10.1016/j.cgh.2020.05.026.

July 2021
Scoping out a better parental leave policy for gastroenterology fellows. Wegermann K. Clin Gastroenterol Hepatol. 2021 Jul;19(7):1307-9. doi: 10.1016/j.cgh.2021.01.040.

An impetus for change: How COVID-19 will transform the delivery of GI health care. Leiman DA et al. Clin Gastroenterol Hepatol. 2021 Jul;19(7):1310-1313. doi: 10.1016/j.cgh.2021.03.042.

Untangling nonerosive reflux disease from functional heartburn. Patel D et al. Clin Gastroenterol Hepatol. 2021 Jul;19(7):1314-26. doi: 10.1016/j.cgh.2020.03.057.
 

AGA Clinical Practice Update on chemoprevention for colorectal neoplasia: Expert review. Liang PS et al. Clin Gastroenterol Hepatol. 2021 Jul;19(7):1327-36. doi: 10.1016/j.cgh.2021.02.014.
 

CMGH

Drug inhibition of SARS-CoV-2 replication in human pluripotent stem cell–derived intestinal organoids. Krüger J et al. Cell Mol Gastroenterol Hepatol. 2021;11(4):935-48. doi: 10.1016/j.jcmgh.2020.11.003.
 

TIGE

Virtual interviews during the COVID-19 Pandemic: A survey of advanced endoscopy fellowship applicants and programs. Amrit K. Kamboj AK et al. Tech Innov Gastrointest Endosc. 2021;23(2):159-68. doi: 10.1016/j.tige.2021.02.001.

Triage of general gastrointestinal endoscopic procedures during the COVID-19 pandemic: Results from a national Delphi consensus panel. Feuerstein JD et al. Tech Innov Gastrointest Endosc. 2021;23(2):113-21. doi: 10.1016/j.tige.2020.12.005.

Development of a scoring system to predict a positive diagnosis on video capsule endoscopy for suspected small bowel bleeding. Marya NB et al. Tech Innov Gastrointest Endosc. 2021;22(4):178-84. doi: 10.1016/j.tige.2020.06.001.

Gastroenterology

May 2021
Understanding GI Twitter and its major contributors. Elfanagely Y et al. Gastroenterology. 2021 May;160(6):1917-21. doi: 10.1053/j.gastro.2021.01.232.

Long-term safety of fecal microbiota transplantation for recurrent Clostridioides difficile infection. Saha S et al. Gastroenterology. 2021 May;160(6):1961-9.e3. doi: 10.1053/j.gastro.2021.01.010.

How to incorporate health equity training into gastroenterology and hepatology fellowships. Lee-Allen J, Shah BJ. Gastroenterology. 2021 May;160(6):1924-8. doi: 10.1053/j.gastro.2021.03.018.

Functional dyspepsia and gastroparesis in tertiary care are interchangeable syndromes with common clinical and pathologic features. Pasricha PJ et al. Gastroenterology. 2021 May;160(6):2006-17. doi: 10.1053/j.gastro.2021.01.230.

June 2021
How to manage the large nonpedunculated colorectal polyp. Shahidi N, Bourke MJ. Gastroenterology. 2021 Jun;160(7):2239-43.e1. doi: 10.1053/j.gastro.2021.04.029.

Mortality, reoperation, and hospital stay within 90 days of primary and secondary antireflux surgery in a population-based multinational study. Yanes M et al. Gastroenterology. 2021 Jun;160(7):2283-90. doi: 10.1053/j.gastro.2021.02.022.

Endoscopic submucosal dissection in north america: A large prospective multicenter study. Draganov PV et al. Gastroenterology. 2021 Jun;160(7):2317-27.e2. doi: 10.1053/j.gastro.2021.02.036.

July 2021
Gluten degradation, pharmacokinetics, safety, and tolerability of TAK-062, an engineered enzyme to treat celiac disease. Pultz IG et al. Gastroenterology. 2021 Jul;161(1):81-93.e3. doi: 10.1053/j.gastro.2021.03.019.

Paternal exposure to immunosuppressive and/or biologic agents and birth outcomes in patients with immune-mediated inflammatory diseases. Meserve J et al. Gastroenterology. 2021 Jul;161(1):107-115.e3. doi: 10.1053/j.gastro.2021.03.020.

Ethnicity associations with food sensitization are mediated by gut microbiota development in the first year of life. Tun Hm et al. Gastroenterology. 2021 Jul;161(1):94-106. doi: 10.1053/j.gastro.2021.03.016.

How to incorporate bariatric training into your fellowship program. Jirapinyo P, Thompson CC. Gastroenterology. 2019 Jul;157(1):9-13. doi: 10.1053/j.gastro.2019.05.034.

CGH

May 2021
Intestinal failure: What all gastroenterologists should know. Jansson-Knodell CL et al. Clin Gastroenterol Hepatol. 2021 May;19(5):885-8. doi: 10.1016/j.cgh.2021.01.038.

When and how to use endoscopic tattooing in the colon: An international Delphi agreement. Medina-Prado L et al. Clin Gastroenterol Hepatol. 2021 May;19(5):1038-50. doi: 10.1016/j.cgh.2021.01.024.

Five-year outcomes of endoscopic sleeve gastroplasty for the treatment of obesity. Sharaiha RZ et al. Clin Gastroenterol Hepatol. 2021 May;19(5):1051-57.e2. doi: 10.1016/j.cgh.2020.09.055.

June 2021
GA Clinical Practice Update on management of bleeding gastric varices: Expert review. Henry Z et al. Clin Gastroenterol Hepatol. 2021 Jun;19(6):1098-107.e1. doi: 10.1016/j.cgh.2021.01.027.

Inter- and intra-individual variation, and limited prognostic utility, of serum alkaline phosphatase in a trial of patients with primary sclerosing cholangitis

Palak J. Trivedi PJ et al. Clin Gastroenterol Hepatol. 2021 Jun;19(6):1248-57. doi: 10.1016/j.cgh.2020.07.032.

Low-fat, high-fiber diet reduces markers of inflammation and dysbiosis and improves quality of life in patients with ulcerative colitis. Julia Fritsch J et al. Clin Gastroenterol Hepatol. 2021 Jun;19(6):1189-99.e30. doi: 10.1016/j.cgh.2020.05.026.

July 2021
Scoping out a better parental leave policy for gastroenterology fellows. Wegermann K. Clin Gastroenterol Hepatol. 2021 Jul;19(7):1307-9. doi: 10.1016/j.cgh.2021.01.040.

An impetus for change: How COVID-19 will transform the delivery of GI health care. Leiman DA et al. Clin Gastroenterol Hepatol. 2021 Jul;19(7):1310-1313. doi: 10.1016/j.cgh.2021.03.042.

Untangling nonerosive reflux disease from functional heartburn. Patel D et al. Clin Gastroenterol Hepatol. 2021 Jul;19(7):1314-26. doi: 10.1016/j.cgh.2020.03.057.
 

AGA Clinical Practice Update on chemoprevention for colorectal neoplasia: Expert review. Liang PS et al. Clin Gastroenterol Hepatol. 2021 Jul;19(7):1327-36. doi: 10.1016/j.cgh.2021.02.014.
 

CMGH

Drug inhibition of SARS-CoV-2 replication in human pluripotent stem cell–derived intestinal organoids. Krüger J et al. Cell Mol Gastroenterol Hepatol. 2021;11(4):935-48. doi: 10.1016/j.jcmgh.2020.11.003.
 

TIGE

Virtual interviews during the COVID-19 Pandemic: A survey of advanced endoscopy fellowship applicants and programs. Amrit K. Kamboj AK et al. Tech Innov Gastrointest Endosc. 2021;23(2):159-68. doi: 10.1016/j.tige.2021.02.001.

Triage of general gastrointestinal endoscopic procedures during the COVID-19 pandemic: Results from a national Delphi consensus panel. Feuerstein JD et al. Tech Innov Gastrointest Endosc. 2021;23(2):113-21. doi: 10.1016/j.tige.2020.12.005.

Development of a scoring system to predict a positive diagnosis on video capsule endoscopy for suspected small bowel bleeding. Marya NB et al. Tech Innov Gastrointest Endosc. 2021;22(4):178-84. doi: 10.1016/j.tige.2020.06.001.

Congratulations! You have matched in a competitive medical subspecialty or you have secured your first faculty position. But what do you do now? Success in your early career – as a new fellow or a new attending – requires both hard work and perseverance. We present our top 12 tips for how to be successful as you transition into your new position.

Tip #1: Be kind to yourself

As you transition from medical resident to GI fellow or from GI fellow to first-time attending, it is important to recognize that you are going through a major career transition (not as major as fourth year to intern, but probably a close second). First and foremost, remember to be kind to yourself and set reasonable expectations. You need to allow yourself time to transition to a new role which may also be in a new city or state. Take care of yourself – don’t forget to exercise, eat well, and sleep. You are in the long game now. Work to get yourself in a routine that is sustainable. Block out time to exercise, explore your new city, meal plan, and pursue your interests outside of medicine.

Tip #2: Set up for success

Since you are going through this major life/career transition, it is really helpful if you can set yourself up for success by having some projects that are easily completed during this challenging time so that you can demonstrate success. If you have projects in different stages of development, you will always have something you can work on when some projects are delayed for reasons outside of your control. In particular, it is great to have a few papers ready to go during late fellowship so they are published during your first year as an academic attending! This will allow you to continue your research trajectory as you learn the ropes of your new position.

Tip #3: Ask for help

It turns out you cannot do everything on your own! Make sure you are getting help professionally and personally so that you are set up for success. It’s okay to feel overwhelmed or confused; we all do at some point or another. Fellowship and early academic faculty years are stressful and nobody expects you to do it alone. Chances are your mentors or cofellows have had similar struggles, and in opening up, this dialogue may help you both.
 

Tip #4: Write out your 5-year plan

You need to know where you are going before you can figure out how to get there. Take some time for “soul searching”: Think about where you would like to be in 5 years and work backward (along with help from your mentors; see Tip #5) to determine how best to get there. If you think a career in academia might be for you, it’s never too soon to start networking and involving yourself in research. If a specific institution or clinical position draws your attention, check out the current faculty. You can use their CVs as a roadmap of types of experiences and honors that should be on your radar throughout these 5 years. Remember that your 5-year plan is not written in stone – this is something that you should re-evaluate as your interests and priorities change throughout your career.
 

Tip #5: Develop your personal ‘Board of Directors’

Instead of trying to find the perfect mentor, we suggest you seek out a personal “Board of Directors” who can serve as your mentoring team. There will never be a single perfect mentor for you and it is likely that you will need separate mentors to help guide you on different aspects of your career. I personally have separate individuals serving as my clinical mentor, my research content mentor, my research methods mentor, my career mentor, and my personal/life mentor. Having multiple mentors allows you to maximize the impact of your different mentors’ strengths across each component of your career. Further, your mentors themselves may have past histories of collaboration that you may then leverage to buoy your own fledgling career. When deciding on who to choose as a mentor, it is important to talk to prior mentees about their experiences with a mentor to help you decide if you may be a good match.
 

Tip #6: Master the art of “Menteering”

Now that you have identified mentors, you need to do your part in nurturing this mentee-mentor relationship. Be an excellent mentee: Show up, stick to a timeline, bring ideas and enthusiasm, and make it easy for your mentor. Your mentors want to see you succeed and sometimes this requires you to help them help you. If you know your own learning style and how you like to interact, have that conversation with your mentor upfront (for example, you may need strict deadlines or you may prefer having more time to develop ideas). Having these conversations before you start a project or a relationship will help set the expectations and ensure effective communication with your mentor. If you find that your mentor is doing something that hinders your progress, such as asking for updates too often or not checking in enough, have a constructive conversation with them about how you feel. Come prepared for meetings with your mentor with an agenda and timeline. Be specific if there is something you need from your mentor and be respectful of their other commitments. For example, if you would like your mentor to review your grant application, let them know the grant deadline and find out when you need to get them a draft so that they will have time to provide meaningful feedback.
 

Tip #7: Identify sponsors

Equally, if not more important than your mentoring team, are sponsors. These are people in positions of power who will promote you and help push your career forward. Sponsors can be people more senior to you, cofellows, or even acquaintances in industry or pharmaceuticals. Your mentor may also be your sponsor, but not always. As early academic faculty, it is important to get your name out there with speaking engagements related to your clinical and research niche, and that is one way a sponsor can help bolster your career.

Tip #8: Develop your personal brand – what is on your T-shirt?

As medicine becomes more and more subspecialized, finding your brand is becoming increasingly important. A brand could be anything from your academic niche to social justice, or even social media utilization. Your brand should encompass what you are naturally excited by within your field. Finding your brand will not only distinguish you from your peers but will also provide you with expertise which you can then offer to your colleagues, near and far. Practice the “elevator pitch” of your personal brand so that you can effectively (and efficiently) describe yourself and your interests when meeting new people and networking.
 

Tip #9: Meet thought leaders in your field

Think of the top five or six most prominent and influential people in your area of clinical or research interest and introduce yourself. This can be done at a national meeting or simply over email, though in person is always best if possible. Although thought leaders are busy, in my experience, if you are persistent, you can always find a few minutes to make an introduction. I’ve shared cab rides just to get a few minutes of someone’s time. In my first few years on faculty, I met with most of the thought leaders in my field; some of these meetings led to fruitful collaborations and important introductions (see tip #7). Meet others at your career level too. They can be great to bounce ideas off, and they will be future leaders in the field. Inviting thought leaders to come to your institution to give talks (in-person or virtually) is another great way to show your interest in their work and also find time to introduce yourself.
 

Tip #10: Apply, apply, apply

Remember that feedback is a gift and the best way to receive feedback is to apply to as many opportunities as you can. Any successful person in GI will have a ‘CV of failures’ far longer than their actual CV documenting their successes. I applied to 8 grants before landing my first one, but I received invaluable feedback and improved my writing skills in the process. Success in fellowship and early faculty takes immense grit – work on building a thick skin and finding the learning opportunity within any outcome.
 

Tip #11: Don’t get sucked into the email abyss

It is easy to fill your time completing low priority, but easy to complete, tasks such as responding to emails. Time management is key and you need to make sure that you dedicate time to more time-consuming tasks – such as writing and developing projects/grants – that have a high reward. Dedicate time on your calendar for high-priority tasks and make sure you don’t open your email during this time. Turn off the email pop-up window and do emails at the end of the day (or whenever you are done writing and thinking). Limiting distractions will help get your creative juices flowing.
 

Tip #12: Don’t always say yes

In fact, don’t ever say yes to a career or research opportunity within the first 24 hours to allow yourself time to weigh the pros and cons of the commitment, to assess the timeline feasibility, and to decide it fits into your 5-year plan. You can say you need to talk to your mentor about it first. If you decide you cannot accept an opportunity, a great way to mitigate that is to simply say “I’d love to, but my mentor says no.” Act as a sponsor to someone else by suggesting a potential colleague who might be interested in the opportunity. As you accept more responsibilities, think about what you might be able to give up to give yourself time to be successful in this new opportunity (and not distract from yourself or your 5-year plan).  
 

Conclusion

Success in research and early academic faculty years takes planning and determination. We hope these tips provide a broad outline for what to think about and how to approach planning your future career. First and foremost, you must put in the time to think about what you really want and what will make you happy in the long run. Academic success is a broad term that each of us defines differently. What does it mean to you? Once you figure that out, make your 5-year plan and run with it!

Dr. Rebello and Dr. Long are with section of gastroenterology at Boston Medical Center and Boston University. They have no conflicts to report.

Congratulations! You have matched in a competitive medical subspecialty or you have secured your first faculty position. But what do you do now? Success in your early career – as a new fellow or a new attending – requires both hard work and perseverance. We present our top 12 tips for how to be successful as you transition into your new position.

Tip #1: Be kind to yourself

As you transition from medical resident to GI fellow or from GI fellow to first-time attending, it is important to recognize that you are going through a major career transition (not as major as fourth year to intern, but probably a close second). First and foremost, remember to be kind to yourself and set reasonable expectations. You need to allow yourself time to transition to a new role which may also be in a new city or state. Take care of yourself – don’t forget to exercise, eat well, and sleep. You are in the long game now. Work to get yourself in a routine that is sustainable. Block out time to exercise, explore your new city, meal plan, and pursue your interests outside of medicine.

Tip #2: Set up for success

Since you are going through this major life/career transition, it is really helpful if you can set yourself up for success by having some projects that are easily completed during this challenging time so that you can demonstrate success. If you have projects in different stages of development, you will always have something you can work on when some projects are delayed for reasons outside of your control. In particular, it is great to have a few papers ready to go during late fellowship so they are published during your first year as an academic attending! This will allow you to continue your research trajectory as you learn the ropes of your new position.

Tip #3: Ask for help

It turns out you cannot do everything on your own! Make sure you are getting help professionally and personally so that you are set up for success. It’s okay to feel overwhelmed or confused; we all do at some point or another. Fellowship and early academic faculty years are stressful and nobody expects you to do it alone. Chances are your mentors or cofellows have had similar struggles, and in opening up, this dialogue may help you both.
 

Tip #4: Write out your 5-year plan

You need to know where you are going before you can figure out how to get there. Take some time for “soul searching”: Think about where you would like to be in 5 years and work backward (along with help from your mentors; see Tip #5) to determine how best to get there. If you think a career in academia might be for you, it’s never too soon to start networking and involving yourself in research. If a specific institution or clinical position draws your attention, check out the current faculty. You can use their CVs as a roadmap of types of experiences and honors that should be on your radar throughout these 5 years. Remember that your 5-year plan is not written in stone – this is something that you should re-evaluate as your interests and priorities change throughout your career.
 

Tip #5: Develop your personal ‘Board of Directors’

Instead of trying to find the perfect mentor, we suggest you seek out a personal “Board of Directors” who can serve as your mentoring team. There will never be a single perfect mentor for you and it is likely that you will need separate mentors to help guide you on different aspects of your career. I personally have separate individuals serving as my clinical mentor, my research content mentor, my research methods mentor, my career mentor, and my personal/life mentor. Having multiple mentors allows you to maximize the impact of your different mentors’ strengths across each component of your career. Further, your mentors themselves may have past histories of collaboration that you may then leverage to buoy your own fledgling career. When deciding on who to choose as a mentor, it is important to talk to prior mentees about their experiences with a mentor to help you decide if you may be a good match.
 

Tip #6: Master the art of “Menteering”

Now that you have identified mentors, you need to do your part in nurturing this mentee-mentor relationship. Be an excellent mentee: Show up, stick to a timeline, bring ideas and enthusiasm, and make it easy for your mentor. Your mentors want to see you succeed and sometimes this requires you to help them help you. If you know your own learning style and how you like to interact, have that conversation with your mentor upfront (for example, you may need strict deadlines or you may prefer having more time to develop ideas). Having these conversations before you start a project or a relationship will help set the expectations and ensure effective communication with your mentor. If you find that your mentor is doing something that hinders your progress, such as asking for updates too often or not checking in enough, have a constructive conversation with them about how you feel. Come prepared for meetings with your mentor with an agenda and timeline. Be specific if there is something you need from your mentor and be respectful of their other commitments. For example, if you would like your mentor to review your grant application, let them know the grant deadline and find out when you need to get them a draft so that they will have time to provide meaningful feedback.
 

Tip #7: Identify sponsors

Equally, if not more important than your mentoring team, are sponsors. These are people in positions of power who will promote you and help push your career forward. Sponsors can be people more senior to you, cofellows, or even acquaintances in industry or pharmaceuticals. Your mentor may also be your sponsor, but not always. As early academic faculty, it is important to get your name out there with speaking engagements related to your clinical and research niche, and that is one way a sponsor can help bolster your career.

Tip #8: Develop your personal brand – what is on your T-shirt?

As medicine becomes more and more subspecialized, finding your brand is becoming increasingly important. A brand could be anything from your academic niche to social justice, or even social media utilization. Your brand should encompass what you are naturally excited by within your field. Finding your brand will not only distinguish you from your peers but will also provide you with expertise which you can then offer to your colleagues, near and far. Practice the “elevator pitch” of your personal brand so that you can effectively (and efficiently) describe yourself and your interests when meeting new people and networking.
 

Tip #9: Meet thought leaders in your field

Think of the top five or six most prominent and influential people in your area of clinical or research interest and introduce yourself. This can be done at a national meeting or simply over email, though in person is always best if possible. Although thought leaders are busy, in my experience, if you are persistent, you can always find a few minutes to make an introduction. I’ve shared cab rides just to get a few minutes of someone’s time. In my first few years on faculty, I met with most of the thought leaders in my field; some of these meetings led to fruitful collaborations and important introductions (see tip #7). Meet others at your career level too. They can be great to bounce ideas off, and they will be future leaders in the field. Inviting thought leaders to come to your institution to give talks (in-person or virtually) is another great way to show your interest in their work and also find time to introduce yourself.
 

Tip #10: Apply, apply, apply

Remember that feedback is a gift and the best way to receive feedback is to apply to as many opportunities as you can. Any successful person in GI will have a ‘CV of failures’ far longer than their actual CV documenting their successes. I applied to 8 grants before landing my first one, but I received invaluable feedback and improved my writing skills in the process. Success in fellowship and early faculty takes immense grit – work on building a thick skin and finding the learning opportunity within any outcome.
 

Tip #11: Don’t get sucked into the email abyss

It is easy to fill your time completing low priority, but easy to complete, tasks such as responding to emails. Time management is key and you need to make sure that you dedicate time to more time-consuming tasks – such as writing and developing projects/grants – that have a high reward. Dedicate time on your calendar for high-priority tasks and make sure you don’t open your email during this time. Turn off the email pop-up window and do emails at the end of the day (or whenever you are done writing and thinking). Limiting distractions will help get your creative juices flowing.
 

Tip #12: Don’t always say yes

In fact, don’t ever say yes to a career or research opportunity within the first 24 hours to allow yourself time to weigh the pros and cons of the commitment, to assess the timeline feasibility, and to decide it fits into your 5-year plan. You can say you need to talk to your mentor about it first. If you decide you cannot accept an opportunity, a great way to mitigate that is to simply say “I’d love to, but my mentor says no.” Act as a sponsor to someone else by suggesting a potential colleague who might be interested in the opportunity. As you accept more responsibilities, think about what you might be able to give up to give yourself time to be successful in this new opportunity (and not distract from yourself or your 5-year plan).  
 

Conclusion

Success in research and early academic faculty years takes planning and determination. We hope these tips provide a broad outline for what to think about and how to approach planning your future career. First and foremost, you must put in the time to think about what you really want and what will make you happy in the long run. Academic success is a broad term that each of us defines differently. What does it mean to you? Once you figure that out, make your 5-year plan and run with it!

Dr. Rebello and Dr. Long are with section of gastroenterology at Boston Medical Center and Boston University. They have no conflicts to report.

Congratulations! You have matched in a competitive medical subspecialty or you have secured your first faculty position. But what do you do now? Success in your early career – as a new fellow or a new attending – requires both hard work and perseverance. We present our top 12 tips for how to be successful as you transition into your new position.

Tip #1: Be kind to yourself

As you transition from medical resident to GI fellow or from GI fellow to first-time attending, it is important to recognize that you are going through a major career transition (not as major as fourth year to intern, but probably a close second). First and foremost, remember to be kind to yourself and set reasonable expectations. You need to allow yourself time to transition to a new role which may also be in a new city or state. Take care of yourself – don’t forget to exercise, eat well, and sleep. You are in the long game now. Work to get yourself in a routine that is sustainable. Block out time to exercise, explore your new city, meal plan, and pursue your interests outside of medicine.

Tip #2: Set up for success

Since you are going through this major life/career transition, it is really helpful if you can set yourself up for success by having some projects that are easily completed during this challenging time so that you can demonstrate success. If you have projects in different stages of development, you will always have something you can work on when some projects are delayed for reasons outside of your control. In particular, it is great to have a few papers ready to go during late fellowship so they are published during your first year as an academic attending! This will allow you to continue your research trajectory as you learn the ropes of your new position.

Tip #3: Ask for help

It turns out you cannot do everything on your own! Make sure you are getting help professionally and personally so that you are set up for success. It’s okay to feel overwhelmed or confused; we all do at some point or another. Fellowship and early academic faculty years are stressful and nobody expects you to do it alone. Chances are your mentors or cofellows have had similar struggles, and in opening up, this dialogue may help you both.
 

Tip #4: Write out your 5-year plan

You need to know where you are going before you can figure out how to get there. Take some time for “soul searching”: Think about where you would like to be in 5 years and work backward (along with help from your mentors; see Tip #5) to determine how best to get there. If you think a career in academia might be for you, it’s never too soon to start networking and involving yourself in research. If a specific institution or clinical position draws your attention, check out the current faculty. You can use their CVs as a roadmap of types of experiences and honors that should be on your radar throughout these 5 years. Remember that your 5-year plan is not written in stone – this is something that you should re-evaluate as your interests and priorities change throughout your career.
 

Tip #5: Develop your personal ‘Board of Directors’

Instead of trying to find the perfect mentor, we suggest you seek out a personal “Board of Directors” who can serve as your mentoring team. There will never be a single perfect mentor for you and it is likely that you will need separate mentors to help guide you on different aspects of your career. I personally have separate individuals serving as my clinical mentor, my research content mentor, my research methods mentor, my career mentor, and my personal/life mentor. Having multiple mentors allows you to maximize the impact of your different mentors’ strengths across each component of your career. Further, your mentors themselves may have past histories of collaboration that you may then leverage to buoy your own fledgling career. When deciding on who to choose as a mentor, it is important to talk to prior mentees about their experiences with a mentor to help you decide if you may be a good match.
 

Tip #6: Master the art of “Menteering”

Now that you have identified mentors, you need to do your part in nurturing this mentee-mentor relationship. Be an excellent mentee: Show up, stick to a timeline, bring ideas and enthusiasm, and make it easy for your mentor. Your mentors want to see you succeed and sometimes this requires you to help them help you. If you know your own learning style and how you like to interact, have that conversation with your mentor upfront (for example, you may need strict deadlines or you may prefer having more time to develop ideas). Having these conversations before you start a project or a relationship will help set the expectations and ensure effective communication with your mentor. If you find that your mentor is doing something that hinders your progress, such as asking for updates too often or not checking in enough, have a constructive conversation with them about how you feel. Come prepared for meetings with your mentor with an agenda and timeline. Be specific if there is something you need from your mentor and be respectful of their other commitments. For example, if you would like your mentor to review your grant application, let them know the grant deadline and find out when you need to get them a draft so that they will have time to provide meaningful feedback.
 

Tip #7: Identify sponsors

Equally, if not more important than your mentoring team, are sponsors. These are people in positions of power who will promote you and help push your career forward. Sponsors can be people more senior to you, cofellows, or even acquaintances in industry or pharmaceuticals. Your mentor may also be your sponsor, but not always. As early academic faculty, it is important to get your name out there with speaking engagements related to your clinical and research niche, and that is one way a sponsor can help bolster your career.

Tip #8: Develop your personal brand – what is on your T-shirt?

As medicine becomes more and more subspecialized, finding your brand is becoming increasingly important. A brand could be anything from your academic niche to social justice, or even social media utilization. Your brand should encompass what you are naturally excited by within your field. Finding your brand will not only distinguish you from your peers but will also provide you with expertise which you can then offer to your colleagues, near and far. Practice the “elevator pitch” of your personal brand so that you can effectively (and efficiently) describe yourself and your interests when meeting new people and networking.
 

Tip #9: Meet thought leaders in your field

Think of the top five or six most prominent and influential people in your area of clinical or research interest and introduce yourself. This can be done at a national meeting or simply over email, though in person is always best if possible. Although thought leaders are busy, in my experience, if you are persistent, you can always find a few minutes to make an introduction. I’ve shared cab rides just to get a few minutes of someone’s time. In my first few years on faculty, I met with most of the thought leaders in my field; some of these meetings led to fruitful collaborations and important introductions (see tip #7). Meet others at your career level too. They can be great to bounce ideas off, and they will be future leaders in the field. Inviting thought leaders to come to your institution to give talks (in-person or virtually) is another great way to show your interest in their work and also find time to introduce yourself.
 

Tip #10: Apply, apply, apply

Remember that feedback is a gift and the best way to receive feedback is to apply to as many opportunities as you can. Any successful person in GI will have a ‘CV of failures’ far longer than their actual CV documenting their successes. I applied to 8 grants before landing my first one, but I received invaluable feedback and improved my writing skills in the process. Success in fellowship and early faculty takes immense grit – work on building a thick skin and finding the learning opportunity within any outcome.
 

Tip #11: Don’t get sucked into the email abyss

It is easy to fill your time completing low priority, but easy to complete, tasks such as responding to emails. Time management is key and you need to make sure that you dedicate time to more time-consuming tasks – such as writing and developing projects/grants – that have a high reward. Dedicate time on your calendar for high-priority tasks and make sure you don’t open your email during this time. Turn off the email pop-up window and do emails at the end of the day (or whenever you are done writing and thinking). Limiting distractions will help get your creative juices flowing.
 

Tip #12: Don’t always say yes

In fact, don’t ever say yes to a career or research opportunity within the first 24 hours to allow yourself time to weigh the pros and cons of the commitment, to assess the timeline feasibility, and to decide it fits into your 5-year plan. You can say you need to talk to your mentor about it first. If you decide you cannot accept an opportunity, a great way to mitigate that is to simply say “I’d love to, but my mentor says no.” Act as a sponsor to someone else by suggesting a potential colleague who might be interested in the opportunity. As you accept more responsibilities, think about what you might be able to give up to give yourself time to be successful in this new opportunity (and not distract from yourself or your 5-year plan).  
 

Conclusion

Success in research and early academic faculty years takes planning and determination. We hope these tips provide a broad outline for what to think about and how to approach planning your future career. First and foremost, you must put in the time to think about what you really want and what will make you happy in the long run. Academic success is a broad term that each of us defines differently. What does it mean to you? Once you figure that out, make your 5-year plan and run with it!

Dr. Rebello and Dr. Long are with section of gastroenterology at Boston Medical Center and Boston University. They have no conflicts to report.

It is not an exaggeration to say that everything in my gastroenterology practice changed in response to COVID-19.

Due to the overwhelming surge that Massachusetts saw in the early days of the pandemic, the Department of Public Health issued a moratorium on elective procedures in mid-March of 2020, for both hospitals and ambulatory surgery centers. The moratorium included colorectal cancer (CRC) screenings and other procedures that make up a significant portion of the services we provide to our community. Greater Boston Gastroenterology treats patients in and around the area of Framingham, Mass. – not too far outside of Boston. In our practice, we have seven physicians and three nurse practitioners, with one main office and two satellite offices. By national standards, our practice would be considered small, but it is on the larger side of independent GI physician practices in the commonwealth.

Nationally, moratoria on elective procedures led to one of the steepest drop-offs in screenings for cancers, including colorectal cancer. In late summer of 2020, it was estimated that CRC screenings dropped by 86 percent. Two-thirds of independent GI practices saw a significant decline in patient volume, and many believe that they may not get it back.

However, I’m an optimist in this situation, and I believe that as life gets more normal, people will get back to screenings. With the recommendation by the U.S. Preventative Services Task Force that CRC screening should begin at age 45, I expect that there will be an additional increase in screening soon.
 

Pivoting and developing a reopening plan

Almost immediately after the Department of Public Health issued the moratorium, Greater Boston Gastroenterology began putting together a reopening plan that would allow us to continue treating some patients and prepare for a surge once restrictions were lifted.

Part of our plan was to stay informed by talking with other practices about what they were doing and to stay abreast of policy changes at the local, state, and federal levels.

We also needed to keep our patients informed to alleviate safety concerns. Just prior to our reopening, we developed videos of the precautions that we were taking in all our facilities to assure our patients that we were doing everything possible to keep them safe. We also put information on our website through every stage of reopening so patients could know what to expect at their visits.

Helping our staff feel safe as they returned to work was also an important focus of our reopening plan. We prepared for our eventual reopening by installing safety measures such as plexiglass barriers and HEPA filter machines for our common areas and exam rooms. We also procured access to rapid turnaround polymerase chain reaction (PCR) testing that allowed us to regularly test all patients seeking elective procedures. Additionally, we invested in point-of-care antigen tests for the office, and we regularly test all our patient-facing staff.

We had corralled enough personal protective equipment to keep our office infusion services operating with our nurses and patients feeling safe. The preparation allowed us to resume in-person visits almost immediately after the Department of Public Health allowed us to reopen.

Once we reopened, we concentrated on in-office visits for patients who were under 65 and at lower risk for COVID-19, while focusing our telemedicine efforts on patients who were older and at higher risk. We’re now back to seeing all patients who want to have in-office visits and are actually above par for our visits. The number of procedures we have performed in the last 3 months is similar to the 3 months before the pandemic.

During the pandemic, Massachusetts had the best conversion to telehealth in the nation, and it worked well for patients and providers. The key was to use several telehealth apps, as using only one may not work for everyone. Having several options made it likely that we would be able to do complete visits and connect with patients. When we needed to, we switched to telephone visits.

All the physicians and staff in our practice are telemedicine enthusiasts, and it will remain a significant part of our practices as long as Medicare, the state health plans, and commercial payers remain supportive.
 

Planning for a surge in screenings

There may be a surge in screenings once more people are vaccinated and comfortable getting back into the office, and we’re planning for this as well. We’ve recruited new physicians and have expanded our available hours for procedures at our ambulatory surgery centers (ASCs). Surprisingly, we have found that there is a lot of interest from physicians for weekend shifts at the ASC, and we now have a physician waiting list for Saturday procedure time.

With the new lower age for recommended screening, there will be a lag with primary care physicians referring their younger patients. This may provide some time to prepare for an increase in screenings resulting from this new policy.

Another strategy that has worked well for us is to train and develop our advanced practitioners into nonphysician experts in GI and liver disease. Greater Boston Gastroenterology has used this strategy since its founding, and we think our most experienced nurse practitioners could rival any office-based gastroenterologist in their acumen and capabilities.

Over the last 3 years we have transitioned our nonphysician practitioners into the inpatient setting. As a result, consults are completed earlier in the day, and we are better able to help coordinate inpatient procedure scheduling, discharge planning, and outpatient follow-up.

The time we spend on training is worth it. It improves customer service, allows us to book appointments with shorter notice, and overall has a positive effect on our bottom line. Utilizing our advanced providers in this capacity will help us manage any volume increases we see in the near future. In addition, most patients in our community are used to seeing advanced providers in their physician’s office, so the acceptance among our patients is high.
 

Being flexible and favoring strategic planning

Overall, I think the greatest thing we learned during the pandemic is that we need to be flexible. It was a helpful reminder that, in medicine, things are constantly changing. I remember when passing the GI boards seemed like my final step, but everyone comes to realize it is just the first step in the journey.

As an early-career physician, you should remember the hard work that helped you get to medical school, land a good residency, stand out to get a fellowship, and master your specialty. Harness that personal drive and energy and keep moving forward. Remember that your first job is unlikely to be your last. Try not to see your choices as either/or – either academic or private practice, hospital-employed or self-employed. The boundaries are blurring. We have long careers and face myriad opportunities for professional advancement.

Be patient. Some goals take time to achieve. At each stage be prepared to work hard, use your time wisely, and try not to lose sight of maximizing your professional happiness.
 

Dr. Dickstein is a practicing gastroenterologist at Greater Boston Gastroenterology in Framingham, Mass., and serves on the executive committee of the Digestive Health Physicians Association. He has no conflicts to declare.

It is not an exaggeration to say that everything in my gastroenterology practice changed in response to COVID-19.

Due to the overwhelming surge that Massachusetts saw in the early days of the pandemic, the Department of Public Health issued a moratorium on elective procedures in mid-March of 2020, for both hospitals and ambulatory surgery centers. The moratorium included colorectal cancer (CRC) screenings and other procedures that make up a significant portion of the services we provide to our community. Greater Boston Gastroenterology treats patients in and around the area of Framingham, Mass. – not too far outside of Boston. In our practice, we have seven physicians and three nurse practitioners, with one main office and two satellite offices. By national standards, our practice would be considered small, but it is on the larger side of independent GI physician practices in the commonwealth.

Nationally, moratoria on elective procedures led to one of the steepest drop-offs in screenings for cancers, including colorectal cancer. In late summer of 2020, it was estimated that CRC screenings dropped by 86 percent. Two-thirds of independent GI practices saw a significant decline in patient volume, and many believe that they may not get it back.

However, I’m an optimist in this situation, and I believe that as life gets more normal, people will get back to screenings. With the recommendation by the U.S. Preventative Services Task Force that CRC screening should begin at age 45, I expect that there will be an additional increase in screening soon.
 

Pivoting and developing a reopening plan

Almost immediately after the Department of Public Health issued the moratorium, Greater Boston Gastroenterology began putting together a reopening plan that would allow us to continue treating some patients and prepare for a surge once restrictions were lifted.

Part of our plan was to stay informed by talking with other practices about what they were doing and to stay abreast of policy changes at the local, state, and federal levels.

We also needed to keep our patients informed to alleviate safety concerns. Just prior to our reopening, we developed videos of the precautions that we were taking in all our facilities to assure our patients that we were doing everything possible to keep them safe. We also put information on our website through every stage of reopening so patients could know what to expect at their visits.

Helping our staff feel safe as they returned to work was also an important focus of our reopening plan. We prepared for our eventual reopening by installing safety measures such as plexiglass barriers and HEPA filter machines for our common areas and exam rooms. We also procured access to rapid turnaround polymerase chain reaction (PCR) testing that allowed us to regularly test all patients seeking elective procedures. Additionally, we invested in point-of-care antigen tests for the office, and we regularly test all our patient-facing staff.

We had corralled enough personal protective equipment to keep our office infusion services operating with our nurses and patients feeling safe. The preparation allowed us to resume in-person visits almost immediately after the Department of Public Health allowed us to reopen.

Once we reopened, we concentrated on in-office visits for patients who were under 65 and at lower risk for COVID-19, while focusing our telemedicine efforts on patients who were older and at higher risk. We’re now back to seeing all patients who want to have in-office visits and are actually above par for our visits. The number of procedures we have performed in the last 3 months is similar to the 3 months before the pandemic.

During the pandemic, Massachusetts had the best conversion to telehealth in the nation, and it worked well for patients and providers. The key was to use several telehealth apps, as using only one may not work for everyone. Having several options made it likely that we would be able to do complete visits and connect with patients. When we needed to, we switched to telephone visits.

All the physicians and staff in our practice are telemedicine enthusiasts, and it will remain a significant part of our practices as long as Medicare, the state health plans, and commercial payers remain supportive.
 

Planning for a surge in screenings

There may be a surge in screenings once more people are vaccinated and comfortable getting back into the office, and we’re planning for this as well. We’ve recruited new physicians and have expanded our available hours for procedures at our ambulatory surgery centers (ASCs). Surprisingly, we have found that there is a lot of interest from physicians for weekend shifts at the ASC, and we now have a physician waiting list for Saturday procedure time.

With the new lower age for recommended screening, there will be a lag with primary care physicians referring their younger patients. This may provide some time to prepare for an increase in screenings resulting from this new policy.

Another strategy that has worked well for us is to train and develop our advanced practitioners into nonphysician experts in GI and liver disease. Greater Boston Gastroenterology has used this strategy since its founding, and we think our most experienced nurse practitioners could rival any office-based gastroenterologist in their acumen and capabilities.

Over the last 3 years we have transitioned our nonphysician practitioners into the inpatient setting. As a result, consults are completed earlier in the day, and we are better able to help coordinate inpatient procedure scheduling, discharge planning, and outpatient follow-up.

The time we spend on training is worth it. It improves customer service, allows us to book appointments with shorter notice, and overall has a positive effect on our bottom line. Utilizing our advanced providers in this capacity will help us manage any volume increases we see in the near future. In addition, most patients in our community are used to seeing advanced providers in their physician’s office, so the acceptance among our patients is high.
 

Being flexible and favoring strategic planning

Overall, I think the greatest thing we learned during the pandemic is that we need to be flexible. It was a helpful reminder that, in medicine, things are constantly changing. I remember when passing the GI boards seemed like my final step, but everyone comes to realize it is just the first step in the journey.

As an early-career physician, you should remember the hard work that helped you get to medical school, land a good residency, stand out to get a fellowship, and master your specialty. Harness that personal drive and energy and keep moving forward. Remember that your first job is unlikely to be your last. Try not to see your choices as either/or – either academic or private practice, hospital-employed or self-employed. The boundaries are blurring. We have long careers and face myriad opportunities for professional advancement.

Be patient. Some goals take time to achieve. At each stage be prepared to work hard, use your time wisely, and try not to lose sight of maximizing your professional happiness.
 

Dr. Dickstein is a practicing gastroenterologist at Greater Boston Gastroenterology in Framingham, Mass., and serves on the executive committee of the Digestive Health Physicians Association. He has no conflicts to declare.

It is not an exaggeration to say that everything in my gastroenterology practice changed in response to COVID-19.

Due to the overwhelming surge that Massachusetts saw in the early days of the pandemic, the Department of Public Health issued a moratorium on elective procedures in mid-March of 2020, for both hospitals and ambulatory surgery centers. The moratorium included colorectal cancer (CRC) screenings and other procedures that make up a significant portion of the services we provide to our community. Greater Boston Gastroenterology treats patients in and around the area of Framingham, Mass. – not too far outside of Boston. In our practice, we have seven physicians and three nurse practitioners, with one main office and two satellite offices. By national standards, our practice would be considered small, but it is on the larger side of independent GI physician practices in the commonwealth.

Nationally, moratoria on elective procedures led to one of the steepest drop-offs in screenings for cancers, including colorectal cancer. In late summer of 2020, it was estimated that CRC screenings dropped by 86 percent. Two-thirds of independent GI practices saw a significant decline in patient volume, and many believe that they may not get it back.

However, I’m an optimist in this situation, and I believe that as life gets more normal, people will get back to screenings. With the recommendation by the U.S. Preventative Services Task Force that CRC screening should begin at age 45, I expect that there will be an additional increase in screening soon.
 

Pivoting and developing a reopening plan

Almost immediately after the Department of Public Health issued the moratorium, Greater Boston Gastroenterology began putting together a reopening plan that would allow us to continue treating some patients and prepare for a surge once restrictions were lifted.

Part of our plan was to stay informed by talking with other practices about what they were doing and to stay abreast of policy changes at the local, state, and federal levels.

We also needed to keep our patients informed to alleviate safety concerns. Just prior to our reopening, we developed videos of the precautions that we were taking in all our facilities to assure our patients that we were doing everything possible to keep them safe. We also put information on our website through every stage of reopening so patients could know what to expect at their visits.

Helping our staff feel safe as they returned to work was also an important focus of our reopening plan. We prepared for our eventual reopening by installing safety measures such as plexiglass barriers and HEPA filter machines for our common areas and exam rooms. We also procured access to rapid turnaround polymerase chain reaction (PCR) testing that allowed us to regularly test all patients seeking elective procedures. Additionally, we invested in point-of-care antigen tests for the office, and we regularly test all our patient-facing staff.

We had corralled enough personal protective equipment to keep our office infusion services operating with our nurses and patients feeling safe. The preparation allowed us to resume in-person visits almost immediately after the Department of Public Health allowed us to reopen.

Once we reopened, we concentrated on in-office visits for patients who were under 65 and at lower risk for COVID-19, while focusing our telemedicine efforts on patients who were older and at higher risk. We’re now back to seeing all patients who want to have in-office visits and are actually above par for our visits. The number of procedures we have performed in the last 3 months is similar to the 3 months before the pandemic.

During the pandemic, Massachusetts had the best conversion to telehealth in the nation, and it worked well for patients and providers. The key was to use several telehealth apps, as using only one may not work for everyone. Having several options made it likely that we would be able to do complete visits and connect with patients. When we needed to, we switched to telephone visits.

All the physicians and staff in our practice are telemedicine enthusiasts, and it will remain a significant part of our practices as long as Medicare, the state health plans, and commercial payers remain supportive.
 

Planning for a surge in screenings

There may be a surge in screenings once more people are vaccinated and comfortable getting back into the office, and we’re planning for this as well. We’ve recruited new physicians and have expanded our available hours for procedures at our ambulatory surgery centers (ASCs). Surprisingly, we have found that there is a lot of interest from physicians for weekend shifts at the ASC, and we now have a physician waiting list for Saturday procedure time.

With the new lower age for recommended screening, there will be a lag with primary care physicians referring their younger patients. This may provide some time to prepare for an increase in screenings resulting from this new policy.

Another strategy that has worked well for us is to train and develop our advanced practitioners into nonphysician experts in GI and liver disease. Greater Boston Gastroenterology has used this strategy since its founding, and we think our most experienced nurse practitioners could rival any office-based gastroenterologist in their acumen and capabilities.

Over the last 3 years we have transitioned our nonphysician practitioners into the inpatient setting. As a result, consults are completed earlier in the day, and we are better able to help coordinate inpatient procedure scheduling, discharge planning, and outpatient follow-up.

The time we spend on training is worth it. It improves customer service, allows us to book appointments with shorter notice, and overall has a positive effect on our bottom line. Utilizing our advanced providers in this capacity will help us manage any volume increases we see in the near future. In addition, most patients in our community are used to seeing advanced providers in their physician’s office, so the acceptance among our patients is high.
 

Being flexible and favoring strategic planning

Overall, I think the greatest thing we learned during the pandemic is that we need to be flexible. It was a helpful reminder that, in medicine, things are constantly changing. I remember when passing the GI boards seemed like my final step, but everyone comes to realize it is just the first step in the journey.

As an early-career physician, you should remember the hard work that helped you get to medical school, land a good residency, stand out to get a fellowship, and master your specialty. Harness that personal drive and energy and keep moving forward. Remember that your first job is unlikely to be your last. Try not to see your choices as either/or – either academic or private practice, hospital-employed or self-employed. The boundaries are blurring. We have long careers and face myriad opportunities for professional advancement.

Be patient. Some goals take time to achieve. At each stage be prepared to work hard, use your time wisely, and try not to lose sight of maximizing your professional happiness.
 

Dr. Dickstein is a practicing gastroenterologist at Greater Boston Gastroenterology in Framingham, Mass., and serves on the executive committee of the Digestive Health Physicians Association. He has no conflicts to declare.

How did your career pathway lead you to working at a health tech startup?

I’ve always had an interest in technology – in fact, it was part of the reason I chose gastroenterology. When I finished GI fellowship, I decided to stay in academics because of an opportunity to lead clinical innovation efforts at my institution’s patient safety institute. This role provided protected time to foster external and internal partnerships around technology. It also gave me an opportunity to pursue clinical research and administrative experiences. While I enjoyed all three paths, it became clear that health technology was my passion. While the opportunity to join a startup was largely serendipitous – I met the founder of the company after presenting at a digital medicine conference – it also happened as a result of the steps outlined in a subsequent question. Not long after learning about the company, I made the transition to part-time faculty/clinical status and full-time chief medical officer (CMO).

What do you do as CMO?

There is no one answer to this question. It will depend on a number of variables, especially the type of business (for example, diagnostic, drug, digital, direct care management, and so on), stage of company (for example, concept, seed, series A/B/C, public), and the existing background of company founders (for example, technical, clinical, operations, and so on). Generally speaking, the earlier the stage of the company, the more hats you’ll wear (though this also means more risk; more on that later). An early-stage company was appealing to me because it gave me an opportunity to apply many of the same critical-thinking and problem-solving skills in clinical medicine to a host of other challenges. For example, as a practicing gastroenterologist, I know the pain points in the delivery of GI care and the challenges that my patients encounter. I then ask how can I develop our technology and product platform to address these issues. Also understanding how value and quality are measured in GI practice makes it easier to convey the effect of the solutions that are built and prioritize their development. In my current role I contribute to the following areas:

• Clinical strategy and vision. This means understanding the clinical need the company is trying to address at a fundamental level and designing how the technology or solution can address that need in a meaningful way. This includes working directly with technology and product teams to create a roadmap for how the technology/solution will continue to drive impact.
• Clinical care leadership. If the company employs or works with health professionals in any capacity, this usually involves developing clinical protocols and providing clinical direction. 
• Clinical outcomes. This means being responsible for understanding and/or developing the metrics that will be used to demonstrate impact of the technology/solution. This includes designing clinical studies and being responsible for their execution.
• Stakeholder engagement. This means interfacing internally with nearly every aspect of the company and interacting externally with customers (usually medical peers and executives), investors, other companies, and key opinion leaders in the field.
• Regulatory. For companies pursuing Food and Drug Administration clearance or approval for their product, this entails developing a strategy and executing it.
• Research & development. This involves creating and executing a roadmap for integrating new technologies/ideas that generally complement the initial problem you are trying to solve.  

What do you enjoy most about working at a startup?

The variety of experience, the flexibility, the fast pace, the ability to work creatively, and the potential to make a large-scale impact are all aspects of the job that I enjoy. The ability to continue clinical practice is important to me and is a major plus. 
 

What do you find most challenging about working at a startup?

One of the biggest differences between a startup and a traditional clinical role is the degree of uncertainty that permeates the entire experience. It took some time for me to adjust to the relative volatility/risk associated with this type of work. Unlike an academic, administrative, or private practice job, things can change very quickly (as in a 24-hour period or less!). This can encompass a number of changes, such as funding, leadership, strategic direction, business model, and staffing, to name a few. What I’ve learned is that this doesn’t always mean changing for the worse, but it does mean things changing near constantly. Being mentally prepared to adapt quickly and frequently to big changes is part of the experience. 
 

What are the ways that GIs can get involved in startups?

Gastroenterologists have more opportunities than most physicians due to the diversity of conditions we treat and the large corresponding number of unmet needs we encounter. There is also the inherent innovation potential associated with new applications in endoscopy, diagnostics, and drug therapies. As a result, there are a number of ways to get involved:

• This often takes the form of “spinning out” research from an academic institution but can also be done successfully from private practice, particularly in the context of new devices/services. Another related option is to license your technology to a company, which offloads the operational aspects of running a business.
• Provide consulting/advisory support. Many early-stage companies cannot afford to hire a full-time physician, but they are open to consulting arrangements (and of course volunteer work). Don’t hesitate to directly contact companies that are interesting to you. These opportunities are possible even while in clinical training.
• Work part time or full time. The majority of startups are supportive of physicians continuing to practice clinically. This makes engaging in a part-time position financially feasible for both parties. Given the relatively high remuneration for gastroenterologists working clinically, a full-time position at a startup may require a financial tradeoff (that is, lower short-term salary for a potential larger long-term gain – note the emphasis on “potential”).  
• Invest in early-stage companies. Physicians can become angel investors for early-stage companies. Given the relatively time-intensive process of finding new opportunities and conducting due diligence, this often takes the form of pooling funds into angel networks that can distribute the execution of investments more efficiently. 

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

The first step I recommend is self-reflection – what about the startup experience is interesting to you? Not all aspects appeal to everyone, and not all options provide the same opportunities. Spending time deciding which specific aspects of the startup experience appeal to you will make it easier to find the right opportunity. A concurrent step is to build expertise. This can take many forms, including traditional basic science or clinical research, but also includes implementation, evaluation/analysis, design, education, regulation, policy, and so on. The next step is to proactively meet people who are doing what you are interested in doing. Reach out to mentors, alumni, faculty, and friends. Conferences and social media are also great places to network. Other potential paths can include developing expertise in an allied functional area that can be later leveraged into a startup role (for example, experience at pharma, payer, regulatory, and so on). Many of these organizations have programs specifically geared toward physicians making a transition. In addition, another potential option is to seek additional education through an MBA where internships, recruitment programs, and robust alumni networks can be helpful in finding placement.

What if I want to learn more about the health technology startup experience?

The AGA Center for GI Innovation and Technology (CGIT) has a number of programs throughout the year, including the annual Tech Summit where you can learn about new companies, ideas, and technologies from like-minded individuals. I also invite you to reach out to me directly via Twitter, LinkedIn, or email with specific questions. As gastroenterologists, we are fortunate to work in a field full of innovation and new ideas. As a result, there are many meaningful career paths available to those interested in gastroenterology and technology. Whether providing direct clinical care with the latest endoscopic techniques or developing the next digital therapy, the opportunities for gastroenterologists will only continue to grow.

Dr. Mathews is chief medical officer at Vivante Health and assistant professor of medicine at Johns Hopkins Medicine in Baltimore. He is an officer at Vivante Health with stock options, but he reports having nothing else to disclose.

How did your career pathway lead you to working at a health tech startup?

I’ve always had an interest in technology – in fact, it was part of the reason I chose gastroenterology. When I finished GI fellowship, I decided to stay in academics because of an opportunity to lead clinical innovation efforts at my institution’s patient safety institute. This role provided protected time to foster external and internal partnerships around technology. It also gave me an opportunity to pursue clinical research and administrative experiences. While I enjoyed all three paths, it became clear that health technology was my passion. While the opportunity to join a startup was largely serendipitous – I met the founder of the company after presenting at a digital medicine conference – it also happened as a result of the steps outlined in a subsequent question. Not long after learning about the company, I made the transition to part-time faculty/clinical status and full-time chief medical officer (CMO).

What do you do as CMO?

There is no one answer to this question. It will depend on a number of variables, especially the type of business (for example, diagnostic, drug, digital, direct care management, and so on), stage of company (for example, concept, seed, series A/B/C, public), and the existing background of company founders (for example, technical, clinical, operations, and so on). Generally speaking, the earlier the stage of the company, the more hats you’ll wear (though this also means more risk; more on that later). An early-stage company was appealing to me because it gave me an opportunity to apply many of the same critical-thinking and problem-solving skills in clinical medicine to a host of other challenges. For example, as a practicing gastroenterologist, I know the pain points in the delivery of GI care and the challenges that my patients encounter. I then ask how can I develop our technology and product platform to address these issues. Also understanding how value and quality are measured in GI practice makes it easier to convey the effect of the solutions that are built and prioritize their development. In my current role I contribute to the following areas:

• Clinical strategy and vision. This means understanding the clinical need the company is trying to address at a fundamental level and designing how the technology or solution can address that need in a meaningful way. This includes working directly with technology and product teams to create a roadmap for how the technology/solution will continue to drive impact.
• Clinical care leadership. If the company employs or works with health professionals in any capacity, this usually involves developing clinical protocols and providing clinical direction. 
• Clinical outcomes. This means being responsible for understanding and/or developing the metrics that will be used to demonstrate impact of the technology/solution. This includes designing clinical studies and being responsible for their execution.
• Stakeholder engagement. This means interfacing internally with nearly every aspect of the company and interacting externally with customers (usually medical peers and executives), investors, other companies, and key opinion leaders in the field.
• Regulatory. For companies pursuing Food and Drug Administration clearance or approval for their product, this entails developing a strategy and executing it.
• Research & development. This involves creating and executing a roadmap for integrating new technologies/ideas that generally complement the initial problem you are trying to solve.  

What do you enjoy most about working at a startup?

The variety of experience, the flexibility, the fast pace, the ability to work creatively, and the potential to make a large-scale impact are all aspects of the job that I enjoy. The ability to continue clinical practice is important to me and is a major plus. 
 

What do you find most challenging about working at a startup?

One of the biggest differences between a startup and a traditional clinical role is the degree of uncertainty that permeates the entire experience. It took some time for me to adjust to the relative volatility/risk associated with this type of work. Unlike an academic, administrative, or private practice job, things can change very quickly (as in a 24-hour period or less!). This can encompass a number of changes, such as funding, leadership, strategic direction, business model, and staffing, to name a few. What I’ve learned is that this doesn’t always mean changing for the worse, but it does mean things changing near constantly. Being mentally prepared to adapt quickly and frequently to big changes is part of the experience. 
 

What are the ways that GIs can get involved in startups?

Gastroenterologists have more opportunities than most physicians due to the diversity of conditions we treat and the large corresponding number of unmet needs we encounter. There is also the inherent innovation potential associated with new applications in endoscopy, diagnostics, and drug therapies. As a result, there are a number of ways to get involved:

• This often takes the form of “spinning out” research from an academic institution but can also be done successfully from private practice, particularly in the context of new devices/services. Another related option is to license your technology to a company, which offloads the operational aspects of running a business.
• Provide consulting/advisory support. Many early-stage companies cannot afford to hire a full-time physician, but they are open to consulting arrangements (and of course volunteer work). Don’t hesitate to directly contact companies that are interesting to you. These opportunities are possible even while in clinical training.
• Work part time or full time. The majority of startups are supportive of physicians continuing to practice clinically. This makes engaging in a part-time position financially feasible for both parties. Given the relatively high remuneration for gastroenterologists working clinically, a full-time position at a startup may require a financial tradeoff (that is, lower short-term salary for a potential larger long-term gain – note the emphasis on “potential”).  
• Invest in early-stage companies. Physicians can become angel investors for early-stage companies. Given the relatively time-intensive process of finding new opportunities and conducting due diligence, this often takes the form of pooling funds into angel networks that can distribute the execution of investments more efficiently. 

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

The first step I recommend is self-reflection – what about the startup experience is interesting to you? Not all aspects appeal to everyone, and not all options provide the same opportunities. Spending time deciding which specific aspects of the startup experience appeal to you will make it easier to find the right opportunity. A concurrent step is to build expertise. This can take many forms, including traditional basic science or clinical research, but also includes implementation, evaluation/analysis, design, education, regulation, policy, and so on. The next step is to proactively meet people who are doing what you are interested in doing. Reach out to mentors, alumni, faculty, and friends. Conferences and social media are also great places to network. Other potential paths can include developing expertise in an allied functional area that can be later leveraged into a startup role (for example, experience at pharma, payer, regulatory, and so on). Many of these organizations have programs specifically geared toward physicians making a transition. In addition, another potential option is to seek additional education through an MBA where internships, recruitment programs, and robust alumni networks can be helpful in finding placement.

What if I want to learn more about the health technology startup experience?

The AGA Center for GI Innovation and Technology (CGIT) has a number of programs throughout the year, including the annual Tech Summit where you can learn about new companies, ideas, and technologies from like-minded individuals. I also invite you to reach out to me directly via Twitter, LinkedIn, or email with specific questions. As gastroenterologists, we are fortunate to work in a field full of innovation and new ideas. As a result, there are many meaningful career paths available to those interested in gastroenterology and technology. Whether providing direct clinical care with the latest endoscopic techniques or developing the next digital therapy, the opportunities for gastroenterologists will only continue to grow.

Dr. Mathews is chief medical officer at Vivante Health and assistant professor of medicine at Johns Hopkins Medicine in Baltimore. He is an officer at Vivante Health with stock options, but he reports having nothing else to disclose.

How did your career pathway lead you to working at a health tech startup?

I’ve always had an interest in technology – in fact, it was part of the reason I chose gastroenterology. When I finished GI fellowship, I decided to stay in academics because of an opportunity to lead clinical innovation efforts at my institution’s patient safety institute. This role provided protected time to foster external and internal partnerships around technology. It also gave me an opportunity to pursue clinical research and administrative experiences. While I enjoyed all three paths, it became clear that health technology was my passion. While the opportunity to join a startup was largely serendipitous – I met the founder of the company after presenting at a digital medicine conference – it also happened as a result of the steps outlined in a subsequent question. Not long after learning about the company, I made the transition to part-time faculty/clinical status and full-time chief medical officer (CMO).

What do you do as CMO?

There is no one answer to this question. It will depend on a number of variables, especially the type of business (for example, diagnostic, drug, digital, direct care management, and so on), stage of company (for example, concept, seed, series A/B/C, public), and the existing background of company founders (for example, technical, clinical, operations, and so on). Generally speaking, the earlier the stage of the company, the more hats you’ll wear (though this also means more risk; more on that later). An early-stage company was appealing to me because it gave me an opportunity to apply many of the same critical-thinking and problem-solving skills in clinical medicine to a host of other challenges. For example, as a practicing gastroenterologist, I know the pain points in the delivery of GI care and the challenges that my patients encounter. I then ask how can I develop our technology and product platform to address these issues. Also understanding how value and quality are measured in GI practice makes it easier to convey the effect of the solutions that are built and prioritize their development. In my current role I contribute to the following areas:

• Clinical strategy and vision. This means understanding the clinical need the company is trying to address at a fundamental level and designing how the technology or solution can address that need in a meaningful way. This includes working directly with technology and product teams to create a roadmap for how the technology/solution will continue to drive impact.
• Clinical care leadership. If the company employs or works with health professionals in any capacity, this usually involves developing clinical protocols and providing clinical direction. 
• Clinical outcomes. This means being responsible for understanding and/or developing the metrics that will be used to demonstrate impact of the technology/solution. This includes designing clinical studies and being responsible for their execution.
• Stakeholder engagement. This means interfacing internally with nearly every aspect of the company and interacting externally with customers (usually medical peers and executives), investors, other companies, and key opinion leaders in the field.
• Regulatory. For companies pursuing Food and Drug Administration clearance or approval for their product, this entails developing a strategy and executing it.
• Research & development. This involves creating and executing a roadmap for integrating new technologies/ideas that generally complement the initial problem you are trying to solve.  

What do you enjoy most about working at a startup?

The variety of experience, the flexibility, the fast pace, the ability to work creatively, and the potential to make a large-scale impact are all aspects of the job that I enjoy. The ability to continue clinical practice is important to me and is a major plus. 
 

What do you find most challenging about working at a startup?

One of the biggest differences between a startup and a traditional clinical role is the degree of uncertainty that permeates the entire experience. It took some time for me to adjust to the relative volatility/risk associated with this type of work. Unlike an academic, administrative, or private practice job, things can change very quickly (as in a 24-hour period or less!). This can encompass a number of changes, such as funding, leadership, strategic direction, business model, and staffing, to name a few. What I’ve learned is that this doesn’t always mean changing for the worse, but it does mean things changing near constantly. Being mentally prepared to adapt quickly and frequently to big changes is part of the experience. 
 

What are the ways that GIs can get involved in startups?

Gastroenterologists have more opportunities than most physicians due to the diversity of conditions we treat and the large corresponding number of unmet needs we encounter. There is also the inherent innovation potential associated with new applications in endoscopy, diagnostics, and drug therapies. As a result, there are a number of ways to get involved:

• This often takes the form of “spinning out” research from an academic institution but can also be done successfully from private practice, particularly in the context of new devices/services. Another related option is to license your technology to a company, which offloads the operational aspects of running a business.
• Provide consulting/advisory support. Many early-stage companies cannot afford to hire a full-time physician, but they are open to consulting arrangements (and of course volunteer work). Don’t hesitate to directly contact companies that are interesting to you. These opportunities are possible even while in clinical training.
• Work part time or full time. The majority of startups are supportive of physicians continuing to practice clinically. This makes engaging in a part-time position financially feasible for both parties. Given the relatively high remuneration for gastroenterologists working clinically, a full-time position at a startup may require a financial tradeoff (that is, lower short-term salary for a potential larger long-term gain – note the emphasis on “potential”).  
• Invest in early-stage companies. Physicians can become angel investors for early-stage companies. Given the relatively time-intensive process of finding new opportunities and conducting due diligence, this often takes the form of pooling funds into angel networks that can distribute the execution of investments more efficiently. 

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

The first step I recommend is self-reflection – what about the startup experience is interesting to you? Not all aspects appeal to everyone, and not all options provide the same opportunities. Spending time deciding which specific aspects of the startup experience appeal to you will make it easier to find the right opportunity. A concurrent step is to build expertise. This can take many forms, including traditional basic science or clinical research, but also includes implementation, evaluation/analysis, design, education, regulation, policy, and so on. The next step is to proactively meet people who are doing what you are interested in doing. Reach out to mentors, alumni, faculty, and friends. Conferences and social media are also great places to network. Other potential paths can include developing expertise in an allied functional area that can be later leveraged into a startup role (for example, experience at pharma, payer, regulatory, and so on). Many of these organizations have programs specifically geared toward physicians making a transition. In addition, another potential option is to seek additional education through an MBA where internships, recruitment programs, and robust alumni networks can be helpful in finding placement.

What if I want to learn more about the health technology startup experience?

The AGA Center for GI Innovation and Technology (CGIT) has a number of programs throughout the year, including the annual Tech Summit where you can learn about new companies, ideas, and technologies from like-minded individuals. I also invite you to reach out to me directly via Twitter, LinkedIn, or email with specific questions. As gastroenterologists, we are fortunate to work in a field full of innovation and new ideas. As a result, there are many meaningful career paths available to those interested in gastroenterology and technology. Whether providing direct clinical care with the latest endoscopic techniques or developing the next digital therapy, the opportunities for gastroenterologists will only continue to grow.

Dr. Mathews is chief medical officer at Vivante Health and assistant professor of medicine at Johns Hopkins Medicine in Baltimore. He is an officer at Vivante Health with stock options, but he reports having nothing else to disclose.

In the acute care setting, providers of care for inflammatory bowel disease (IBD) patients are often faced with the dilemma of providing effective abdominal pain management in a population that has worse outcomes with both opioid and NSAID therapy. There is increased mortality associated with opioid use and risk of disease relapse with NSAID use in IBD patients.^1,2 Due to this, patients often feel that their pain is inadequately addressed.^3,4 There are multiple sources of abdominal pain in IBD, and understanding the mechanisms and presentations can help identify effective treatments. We will review pharmacologic and supportive therapies to optimize pain management in IBD.

Common pain presentations in IBD

Visceral pain is a dull, poorly localized, cramping pain from intestinal distension. It is associated with inflammation, dysmotility, obstruction, and visceral hypersensitivity. Somatic and parietal pain is sharp, intense, and often localizable. Somatic pain originates from surrounding skin or muscles, and parietal pain arises from irritation of the peritoneum.⁵ We will review two common pain presentations in IBD.

Case 1: Mr. A is a 32-year-old male with stricturing small bowel Crohn’s disease s/p small bowel resection, who presents to the ED with 3 days of abdominal pain, nausea, and vomiting. C-reactive protein is elevated to 6.8 mg/dL (normal 0.0 – 0.6 mg/dL), and CT is consistent with active small bowel inflammation, intraabdominal abscess at the anastomosis, and associated partial small bowel obstruction. He describes a sharp, intense abdominal pain with cramping. His exam is significant for diffuse abdominal tenderness and distension.

Case 2: Ms. B is a 28-year-old female with ulcerative colitis on mesalamine monotherapy who presents to the hospital for rectal bleeding and cramping abdominal pain. After 3 days of IV steroids her rectal bleeding has resolved, and CRP has normalized. However, she continues to have dull, cramping abdominal pain. Ibuprofen has improved this pain in the past.

Mr. A is having somatic pain from inflammation, abscess, and partial bowel obstruction. He also has visceral pain from luminal distension proximal to the obstruction. Ms. B is having visceral pain despite resolution of inflammation, which may be from postinflammatory visceral hypersensitivity.
 

Etiologies of pain

It’s best to group pain etiologies into inflammatory and noninflammatory causes. Inflammatory pain can be secondary to infection, such as abscess or enteric infection, active bowel inflammation, or disease complications (that is, enteric fistula). It is important to recognize that patients with active inflammation may also have noninflammatory pain. These include small bowel obstruction, strictures, adhesions, narcotic bowel syndrome, bacterial overgrowth, and visceral hypersensitivity. See figure 1.

Courtesy Dr. Mehwish Ahmed and Dr. Jami Kinnucan

The brain-gut connection matters

Abdominal pain in IBD patients starts from painful stimuli in the gut. In addition to direct pain pathways, multiple areas of the brain modulate perception of pain.⁶ Patients with psychiatric comorbidities have increased perception of abdominal pain.⁷ In fact, high perceived stress is associated with disease relapse.⁸ Treatment of psychiatric disorders improves these symptoms with lasting effects.⁹ Addressing psychological and psychosocial needs is essential to successful pain management with long-term effect on quality of life and pain perception in IBD patients.
 

What are my options?

When IBD patients present with acute abdominal pain, it is important to directly address their pain as one of your primary concerns and provide them with a management plan. While this seems obvious, it is not routinely done.3-4

Next, it is important to identify the cause, whether it be infection, obstruction, active inflammation, or functional abdominal pain. In the case of active disease, in addition to steroids and optimization of IBD therapies, acetaminophen and antispasmodics can be used for initial pain management. Supportive therapies include sleep hygiene, physical activity, and psychotherapy. If initial treatments are unsuccessful in the acute setting, and presentation is consistent with somatic pain, it may be necessary to escalate to tramadol, opioid, or NSAID therapy. For visceral pain, a neuromodulator, such as a tricyclic antidepressant or gabapentin, may have greater effect. Bupropion, SNRIs, and SSRIs are options; however, they may not be effective in the acute setting. More recent focus in the IBD community has questioned the role of cannabinoids on pain in IBD patients. Cannabis has been shown in a few small studies to provide pain relief in IBD patients with active inflammation.^10-11 In patients with mechanical causes for pain, management of obstruction is an important part of the treatment plan.
 

Let’s talk about opioids in IBD patients

Chronic narcotic use in IBD is associated with worse outcomes. So when is it okay to use opioid therapies in IBD patients? Postoperative patients, patients with severe perianal disease, or those who fail alternative pain management strategies may require opioid medications. The association with mortality and opioids in IBD is with patients who require moderate to heavy use, which is defined as being prescribed opioids more than once a year. Opioid use in IBD patients is also associated with increased risk of readmissions and poor surgical outcomes.^12-13 Tramadol does not have increased mortality risk.¹ If selecting opioid therapy in managing pain in IBD, it is important to define the course of therapy, with a clear goal of discontinuation after the acute episode. Opioids should be used in tandem with alternative strategies. Patients should be counseled on the synergistic effect of acetaminophen with opioids, which may allow lower effective doses of opioids.

What about NSAID use in IBD patients?

NSAIDs have negative effects in the gastrointestinal tract due to inhibition of protective prostaglandins. They also alter the gut microbiome, although clinical implications of this are unknown.¹⁴ A small study showed that IBD patients who used NSAIDs had increased risk of disease relapse.² Symptoms of relapse would present within 2-9 days of exposure; however, most had resolution of symptoms within 2-11 days of discontinuation.² Follow-up studies have not reliably found that NSAIDs are associated with disease relapse.⁸ and thus NSAIDs may be used sparingly if needed in the acute setting.

Case Review: How do we approach Mr. A and Ms. B?

Mr. A presented with a partial small bowel obstruction and abscess. His pain presentation was consistent with both visceral and somatic pain etiologies. In addition to treating active inflammation and infection, bowel rest, acetaminophen, and antispasmodics can be initiated for pain control. Concomitantly, gabapentin, TCA, or SNRI can be initiated for neurobiological pain but may have limited benefit in the acute hospitalized setting. Social work may identify needs that affect pain perception and assist in addressing those needs. If abdominal pain persists, tramadol or hydrocodone-acetaminophen can be considered.

Ms. B presented with disease relapse, but despite improving inflammatory markers she had continued cramping abdominal pain, which can be consistent with visceral hypersensitivity. Antispasmodic and neuromodulating agents, such as a TCA, could be effective. We can recommend discontinuation of chronic ibuprofen due to risk of intestinal inflammation. Patients may inquire about adjuvant cannabis in pain management. While cannabis can be considered, further research is needed to recommend its regular use.
 

Conclusion

Acute abdominal pain management in IBD can be challenging for providers when typical options are limited in this population. Addressing inflammatory, mechanical, neurobiological, and psychological influences is vital to appropriately address pain. Having a structured plan for pain management in IBD can improve outcomes by decreasing recurrent hospitalizations and use of opioids.¹⁵ Figure 2 presents an overview.

Courtesy Dr. Mehwish Ahmed and Dr. Jami Kinnucan

Dr. Ahmed is a second-year internal medicine resident at the University of Michigan, Ann Arbor. Dr. Kinnucan is with the department of internal medicine and the division of gastroenterology and hepatology and is an assistant professor of medicine in the division of gastroenterology, both at the University of Michigan. They have no conflicts of interest.

References

1. Burr NE et al. Clin Gastroenterol Hepatol. 2018 Apr;16(4):534-41.e6.

2. Takeuchi K et al. Clin Gastroenterol Hepatol. 2006 Feb;4(2):196-202.

3. Bernhofer EI et al. Gastroenterol Nurs. 2017 May/Jun;40(3):200-7.

4. Zeitz J et al. PLoS One. 2016 Jun 22;11(6):e0156666.

5. Srinath A et al. Inflamm Bowel Dis. 2014 Dec;20(12):2433-49.

6. Docherty MJ et al. Gastroenterol Hepatol (N Y). 2011 Sep;7(9):592-601.

7. Elsenbruch S et al. Gut. 2010 Apr;59(4):489-95.

8. Bernstein CN et al. Am J Gastroenterol. 2010 Sep;105(9):1994-2002.

9. Palsson OS and Whitehead WE. Clin Gastroenterol Hepatol. 2013 Mar;11(3):208-16; quiz e22-3.

10. Swaminath A et al. Inflamm Bowel Dis. 2019 Mar; 25(3):427-35.

11. Naftali T et al. Clin Gastroenterol Hepatol. 2013 Oct;11(10):1276-80.e1.

12. Sultan K and Swaminath A. J Crohns Colitis. 2020 Sep 16;14(9):1188-89.

13. Hirsch A et al. J Gastrointest Surg. 2015 Oct;19(10):1852-61.

14. Rogers MAM and Aronoff DM. Clin Microbiol Infect. 2016;22(2):178.e1-178.e9.

15. Kaimakliotis P et al. Int J Colorectal Dis. 2021 Jun;36(6):1193-200.
 

In the acute care setting, providers of care for inflammatory bowel disease (IBD) patients are often faced with the dilemma of providing effective abdominal pain management in a population that has worse outcomes with both opioid and NSAID therapy. There is increased mortality associated with opioid use and risk of disease relapse with NSAID use in IBD patients.^1,2 Due to this, patients often feel that their pain is inadequately addressed.^3,4 There are multiple sources of abdominal pain in IBD, and understanding the mechanisms and presentations can help identify effective treatments. We will review pharmacologic and supportive therapies to optimize pain management in IBD.

Common pain presentations in IBD

Visceral pain is a dull, poorly localized, cramping pain from intestinal distension. It is associated with inflammation, dysmotility, obstruction, and visceral hypersensitivity. Somatic and parietal pain is sharp, intense, and often localizable. Somatic pain originates from surrounding skin or muscles, and parietal pain arises from irritation of the peritoneum.⁵ We will review two common pain presentations in IBD.

Case 1: Mr. A is a 32-year-old male with stricturing small bowel Crohn’s disease s/p small bowel resection, who presents to the ED with 3 days of abdominal pain, nausea, and vomiting. C-reactive protein is elevated to 6.8 mg/dL (normal 0.0 – 0.6 mg/dL), and CT is consistent with active small bowel inflammation, intraabdominal abscess at the anastomosis, and associated partial small bowel obstruction. He describes a sharp, intense abdominal pain with cramping. His exam is significant for diffuse abdominal tenderness and distension.

Case 2: Ms. B is a 28-year-old female with ulcerative colitis on mesalamine monotherapy who presents to the hospital for rectal bleeding and cramping abdominal pain. After 3 days of IV steroids her rectal bleeding has resolved, and CRP has normalized. However, she continues to have dull, cramping abdominal pain. Ibuprofen has improved this pain in the past.

Mr. A is having somatic pain from inflammation, abscess, and partial bowel obstruction. He also has visceral pain from luminal distension proximal to the obstruction. Ms. B is having visceral pain despite resolution of inflammation, which may be from postinflammatory visceral hypersensitivity.
 

Etiologies of pain

It’s best to group pain etiologies into inflammatory and noninflammatory causes. Inflammatory pain can be secondary to infection, such as abscess or enteric infection, active bowel inflammation, or disease complications (that is, enteric fistula). It is important to recognize that patients with active inflammation may also have noninflammatory pain. These include small bowel obstruction, strictures, adhesions, narcotic bowel syndrome, bacterial overgrowth, and visceral hypersensitivity. See figure 1.

Courtesy Dr. Mehwish Ahmed and Dr. Jami Kinnucan

The brain-gut connection matters

Abdominal pain in IBD patients starts from painful stimuli in the gut. In addition to direct pain pathways, multiple areas of the brain modulate perception of pain.⁶ Patients with psychiatric comorbidities have increased perception of abdominal pain.⁷ In fact, high perceived stress is associated with disease relapse.⁸ Treatment of psychiatric disorders improves these symptoms with lasting effects.⁹ Addressing psychological and psychosocial needs is essential to successful pain management with long-term effect on quality of life and pain perception in IBD patients.
 

What are my options?

When IBD patients present with acute abdominal pain, it is important to directly address their pain as one of your primary concerns and provide them with a management plan. While this seems obvious, it is not routinely done.3-4

Next, it is important to identify the cause, whether it be infection, obstruction, active inflammation, or functional abdominal pain. In the case of active disease, in addition to steroids and optimization of IBD therapies, acetaminophen and antispasmodics can be used for initial pain management. Supportive therapies include sleep hygiene, physical activity, and psychotherapy. If initial treatments are unsuccessful in the acute setting, and presentation is consistent with somatic pain, it may be necessary to escalate to tramadol, opioid, or NSAID therapy. For visceral pain, a neuromodulator, such as a tricyclic antidepressant or gabapentin, may have greater effect. Bupropion, SNRIs, and SSRIs are options; however, they may not be effective in the acute setting. More recent focus in the IBD community has questioned the role of cannabinoids on pain in IBD patients. Cannabis has been shown in a few small studies to provide pain relief in IBD patients with active inflammation.^10-11 In patients with mechanical causes for pain, management of obstruction is an important part of the treatment plan.
 

Let’s talk about opioids in IBD patients

Chronic narcotic use in IBD is associated with worse outcomes. So when is it okay to use opioid therapies in IBD patients? Postoperative patients, patients with severe perianal disease, or those who fail alternative pain management strategies may require opioid medications. The association with mortality and opioids in IBD is with patients who require moderate to heavy use, which is defined as being prescribed opioids more than once a year. Opioid use in IBD patients is also associated with increased risk of readmissions and poor surgical outcomes.^12-13 Tramadol does not have increased mortality risk.¹ If selecting opioid therapy in managing pain in IBD, it is important to define the course of therapy, with a clear goal of discontinuation after the acute episode. Opioids should be used in tandem with alternative strategies. Patients should be counseled on the synergistic effect of acetaminophen with opioids, which may allow lower effective doses of opioids.

What about NSAID use in IBD patients?

NSAIDs have negative effects in the gastrointestinal tract due to inhibition of protective prostaglandins. They also alter the gut microbiome, although clinical implications of this are unknown.¹⁴ A small study showed that IBD patients who used NSAIDs had increased risk of disease relapse.² Symptoms of relapse would present within 2-9 days of exposure; however, most had resolution of symptoms within 2-11 days of discontinuation.² Follow-up studies have not reliably found that NSAIDs are associated with disease relapse.⁸ and thus NSAIDs may be used sparingly if needed in the acute setting.

Case Review: How do we approach Mr. A and Ms. B?

Mr. A presented with a partial small bowel obstruction and abscess. His pain presentation was consistent with both visceral and somatic pain etiologies. In addition to treating active inflammation and infection, bowel rest, acetaminophen, and antispasmodics can be initiated for pain control. Concomitantly, gabapentin, TCA, or SNRI can be initiated for neurobiological pain but may have limited benefit in the acute hospitalized setting. Social work may identify needs that affect pain perception and assist in addressing those needs. If abdominal pain persists, tramadol or hydrocodone-acetaminophen can be considered.

Ms. B presented with disease relapse, but despite improving inflammatory markers she had continued cramping abdominal pain, which can be consistent with visceral hypersensitivity. Antispasmodic and neuromodulating agents, such as a TCA, could be effective. We can recommend discontinuation of chronic ibuprofen due to risk of intestinal inflammation. Patients may inquire about adjuvant cannabis in pain management. While cannabis can be considered, further research is needed to recommend its regular use.
 

Conclusion

Acute abdominal pain management in IBD can be challenging for providers when typical options are limited in this population. Addressing inflammatory, mechanical, neurobiological, and psychological influences is vital to appropriately address pain. Having a structured plan for pain management in IBD can improve outcomes by decreasing recurrent hospitalizations and use of opioids.¹⁵ Figure 2 presents an overview.

Courtesy Dr. Mehwish Ahmed and Dr. Jami Kinnucan

Dr. Ahmed is a second-year internal medicine resident at the University of Michigan, Ann Arbor. Dr. Kinnucan is with the department of internal medicine and the division of gastroenterology and hepatology and is an assistant professor of medicine in the division of gastroenterology, both at the University of Michigan. They have no conflicts of interest.

References

1. Burr NE et al. Clin Gastroenterol Hepatol. 2018 Apr;16(4):534-41.e6.

2. Takeuchi K et al. Clin Gastroenterol Hepatol. 2006 Feb;4(2):196-202.

3. Bernhofer EI et al. Gastroenterol Nurs. 2017 May/Jun;40(3):200-7.

4. Zeitz J et al. PLoS One. 2016 Jun 22;11(6):e0156666.

5. Srinath A et al. Inflamm Bowel Dis. 2014 Dec;20(12):2433-49.

6. Docherty MJ et al. Gastroenterol Hepatol (N Y). 2011 Sep;7(9):592-601.

7. Elsenbruch S et al. Gut. 2010 Apr;59(4):489-95.

8. Bernstein CN et al. Am J Gastroenterol. 2010 Sep;105(9):1994-2002.

9. Palsson OS and Whitehead WE. Clin Gastroenterol Hepatol. 2013 Mar;11(3):208-16; quiz e22-3.

10. Swaminath A et al. Inflamm Bowel Dis. 2019 Mar; 25(3):427-35.

11. Naftali T et al. Clin Gastroenterol Hepatol. 2013 Oct;11(10):1276-80.e1.

12. Sultan K and Swaminath A. J Crohns Colitis. 2020 Sep 16;14(9):1188-89.

13. Hirsch A et al. J Gastrointest Surg. 2015 Oct;19(10):1852-61.

14. Rogers MAM and Aronoff DM. Clin Microbiol Infect. 2016;22(2):178.e1-178.e9.

15. Kaimakliotis P et al. Int J Colorectal Dis. 2021 Jun;36(6):1193-200.
 

In the acute care setting, providers of care for inflammatory bowel disease (IBD) patients are often faced with the dilemma of providing effective abdominal pain management in a population that has worse outcomes with both opioid and NSAID therapy. There is increased mortality associated with opioid use and risk of disease relapse with NSAID use in IBD patients.^1,2 Due to this, patients often feel that their pain is inadequately addressed.^3,4 There are multiple sources of abdominal pain in IBD, and understanding the mechanisms and presentations can help identify effective treatments. We will review pharmacologic and supportive therapies to optimize pain management in IBD.

Common pain presentations in IBD

Visceral pain is a dull, poorly localized, cramping pain from intestinal distension. It is associated with inflammation, dysmotility, obstruction, and visceral hypersensitivity. Somatic and parietal pain is sharp, intense, and often localizable. Somatic pain originates from surrounding skin or muscles, and parietal pain arises from irritation of the peritoneum.⁵ We will review two common pain presentations in IBD.

Case 1: Mr. A is a 32-year-old male with stricturing small bowel Crohn’s disease s/p small bowel resection, who presents to the ED with 3 days of abdominal pain, nausea, and vomiting. C-reactive protein is elevated to 6.8 mg/dL (normal 0.0 – 0.6 mg/dL), and CT is consistent with active small bowel inflammation, intraabdominal abscess at the anastomosis, and associated partial small bowel obstruction. He describes a sharp, intense abdominal pain with cramping. His exam is significant for diffuse abdominal tenderness and distension.

Case 2: Ms. B is a 28-year-old female with ulcerative colitis on mesalamine monotherapy who presents to the hospital for rectal bleeding and cramping abdominal pain. After 3 days of IV steroids her rectal bleeding has resolved, and CRP has normalized. However, she continues to have dull, cramping abdominal pain. Ibuprofen has improved this pain in the past.

Mr. A is having somatic pain from inflammation, abscess, and partial bowel obstruction. He also has visceral pain from luminal distension proximal to the obstruction. Ms. B is having visceral pain despite resolution of inflammation, which may be from postinflammatory visceral hypersensitivity.
 

Etiologies of pain

It’s best to group pain etiologies into inflammatory and noninflammatory causes. Inflammatory pain can be secondary to infection, such as abscess or enteric infection, active bowel inflammation, or disease complications (that is, enteric fistula). It is important to recognize that patients with active inflammation may also have noninflammatory pain. These include small bowel obstruction, strictures, adhesions, narcotic bowel syndrome, bacterial overgrowth, and visceral hypersensitivity. See figure 1.

Courtesy Dr. Mehwish Ahmed and Dr. Jami Kinnucan

The brain-gut connection matters

Abdominal pain in IBD patients starts from painful stimuli in the gut. In addition to direct pain pathways, multiple areas of the brain modulate perception of pain.⁶ Patients with psychiatric comorbidities have increased perception of abdominal pain.⁷ In fact, high perceived stress is associated with disease relapse.⁸ Treatment of psychiatric disorders improves these symptoms with lasting effects.⁹ Addressing psychological and psychosocial needs is essential to successful pain management with long-term effect on quality of life and pain perception in IBD patients.
 

What are my options?

When IBD patients present with acute abdominal pain, it is important to directly address their pain as one of your primary concerns and provide them with a management plan. While this seems obvious, it is not routinely done.3-4

Next, it is important to identify the cause, whether it be infection, obstruction, active inflammation, or functional abdominal pain. In the case of active disease, in addition to steroids and optimization of IBD therapies, acetaminophen and antispasmodics can be used for initial pain management. Supportive therapies include sleep hygiene, physical activity, and psychotherapy. If initial treatments are unsuccessful in the acute setting, and presentation is consistent with somatic pain, it may be necessary to escalate to tramadol, opioid, or NSAID therapy. For visceral pain, a neuromodulator, such as a tricyclic antidepressant or gabapentin, may have greater effect. Bupropion, SNRIs, and SSRIs are options; however, they may not be effective in the acute setting. More recent focus in the IBD community has questioned the role of cannabinoids on pain in IBD patients. Cannabis has been shown in a few small studies to provide pain relief in IBD patients with active inflammation.^10-11 In patients with mechanical causes for pain, management of obstruction is an important part of the treatment plan.
 

Let’s talk about opioids in IBD patients

Chronic narcotic use in IBD is associated with worse outcomes. So when is it okay to use opioid therapies in IBD patients? Postoperative patients, patients with severe perianal disease, or those who fail alternative pain management strategies may require opioid medications. The association with mortality and opioids in IBD is with patients who require moderate to heavy use, which is defined as being prescribed opioids more than once a year. Opioid use in IBD patients is also associated with increased risk of readmissions and poor surgical outcomes.^12-13 Tramadol does not have increased mortality risk.¹ If selecting opioid therapy in managing pain in IBD, it is important to define the course of therapy, with a clear goal of discontinuation after the acute episode. Opioids should be used in tandem with alternative strategies. Patients should be counseled on the synergistic effect of acetaminophen with opioids, which may allow lower effective doses of opioids.

What about NSAID use in IBD patients?

NSAIDs have negative effects in the gastrointestinal tract due to inhibition of protective prostaglandins. They also alter the gut microbiome, although clinical implications of this are unknown.¹⁴ A small study showed that IBD patients who used NSAIDs had increased risk of disease relapse.² Symptoms of relapse would present within 2-9 days of exposure; however, most had resolution of symptoms within 2-11 days of discontinuation.² Follow-up studies have not reliably found that NSAIDs are associated with disease relapse.⁸ and thus NSAIDs may be used sparingly if needed in the acute setting.

Case Review: How do we approach Mr. A and Ms. B?

Mr. A presented with a partial small bowel obstruction and abscess. His pain presentation was consistent with both visceral and somatic pain etiologies. In addition to treating active inflammation and infection, bowel rest, acetaminophen, and antispasmodics can be initiated for pain control. Concomitantly, gabapentin, TCA, or SNRI can be initiated for neurobiological pain but may have limited benefit in the acute hospitalized setting. Social work may identify needs that affect pain perception and assist in addressing those needs. If abdominal pain persists, tramadol or hydrocodone-acetaminophen can be considered.

Ms. B presented with disease relapse, but despite improving inflammatory markers she had continued cramping abdominal pain, which can be consistent with visceral hypersensitivity. Antispasmodic and neuromodulating agents, such as a TCA, could be effective. We can recommend discontinuation of chronic ibuprofen due to risk of intestinal inflammation. Patients may inquire about adjuvant cannabis in pain management. While cannabis can be considered, further research is needed to recommend its regular use.
 

Conclusion

Acute abdominal pain management in IBD can be challenging for providers when typical options are limited in this population. Addressing inflammatory, mechanical, neurobiological, and psychological influences is vital to appropriately address pain. Having a structured plan for pain management in IBD can improve outcomes by decreasing recurrent hospitalizations and use of opioids.¹⁵ Figure 2 presents an overview.

Courtesy Dr. Mehwish Ahmed and Dr. Jami Kinnucan

Dr. Ahmed is a second-year internal medicine resident at the University of Michigan, Ann Arbor. Dr. Kinnucan is with the department of internal medicine and the division of gastroenterology and hepatology and is an assistant professor of medicine in the division of gastroenterology, both at the University of Michigan. They have no conflicts of interest.

References

1. Burr NE et al. Clin Gastroenterol Hepatol. 2018 Apr;16(4):534-41.e6.

2. Takeuchi K et al. Clin Gastroenterol Hepatol. 2006 Feb;4(2):196-202.

3. Bernhofer EI et al. Gastroenterol Nurs. 2017 May/Jun;40(3):200-7.

4. Zeitz J et al. PLoS One. 2016 Jun 22;11(6):e0156666.

5. Srinath A et al. Inflamm Bowel Dis. 2014 Dec;20(12):2433-49.

6. Docherty MJ et al. Gastroenterol Hepatol (N Y). 2011 Sep;7(9):592-601.

7. Elsenbruch S et al. Gut. 2010 Apr;59(4):489-95.

8. Bernstein CN et al. Am J Gastroenterol. 2010 Sep;105(9):1994-2002.

9. Palsson OS and Whitehead WE. Clin Gastroenterol Hepatol. 2013 Mar;11(3):208-16; quiz e22-3.

10. Swaminath A et al. Inflamm Bowel Dis. 2019 Mar; 25(3):427-35.

11. Naftali T et al. Clin Gastroenterol Hepatol. 2013 Oct;11(10):1276-80.e1.

12. Sultan K and Swaminath A. J Crohns Colitis. 2020 Sep 16;14(9):1188-89.

13. Hirsch A et al. J Gastrointest Surg. 2015 Oct;19(10):1852-61.

14. Rogers MAM and Aronoff DM. Clin Microbiol Infect. 2016;22(2):178.e1-178.e9.

15. Kaimakliotis P et al. Int J Colorectal Dis. 2021 Jun;36(6):1193-200.