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February 2018
Gastroenterology:
Living like an academic athlete: How to improve clinical and academic productivity as a gastroenterologist. Benchimol E et al.
2018 Jan;154(1):8-14. doi: 10.1053/j.gastro.2017.11.017.
“Spending your life wisely”: How to create an asset management plan. Adams MA et al.
2017 Dec;153(6):1469-72. doi: 10.1053/j.gastro.2017.10.032.
How to balance clinical work and research in the current era of academic medicine. Katzka DA.
2017 Nov;153(5):1177-80. doi: 10.1053/j.gastro.2017.09.024.
Clin Gastroenterol Hepatol.:
New models of gastroenterology practice. Allen JI et al.
2018 Jan;16(1):3-6. doi: 10.1016/j.cgh.2017.10.003.
Cracking the clinician educator code in gastroenterology. Shapiro JM et al.
2017 Dec;15(12):1828-32. doi: 10.1016/j.cgh.2017.08.040.
Cell Mol Gastroenterol Hepatol.:
Setting up a lab: The early years. Habtezion A.
2017 Nov; 4(3): 445-6. doi: 10.1016/j.jcmgh.2017.08.003.
Gastroenterology:
Living like an academic athlete: How to improve clinical and academic productivity as a gastroenterologist. Benchimol E et al.
2018 Jan;154(1):8-14. doi: 10.1053/j.gastro.2017.11.017.
“Spending your life wisely”: How to create an asset management plan. Adams MA et al.
2017 Dec;153(6):1469-72. doi: 10.1053/j.gastro.2017.10.032.
How to balance clinical work and research in the current era of academic medicine. Katzka DA.
2017 Nov;153(5):1177-80. doi: 10.1053/j.gastro.2017.09.024.
Clin Gastroenterol Hepatol.:
New models of gastroenterology practice. Allen JI et al.
2018 Jan;16(1):3-6. doi: 10.1016/j.cgh.2017.10.003.
Cracking the clinician educator code in gastroenterology. Shapiro JM et al.
2017 Dec;15(12):1828-32. doi: 10.1016/j.cgh.2017.08.040.
Cell Mol Gastroenterol Hepatol.:
Setting up a lab: The early years. Habtezion A.
2017 Nov; 4(3): 445-6. doi: 10.1016/j.jcmgh.2017.08.003.
Gastroenterology:
Living like an academic athlete: How to improve clinical and academic productivity as a gastroenterologist. Benchimol E et al.
2018 Jan;154(1):8-14. doi: 10.1053/j.gastro.2017.11.017.
“Spending your life wisely”: How to create an asset management plan. Adams MA et al.
2017 Dec;153(6):1469-72. doi: 10.1053/j.gastro.2017.10.032.
How to balance clinical work and research in the current era of academic medicine. Katzka DA.
2017 Nov;153(5):1177-80. doi: 10.1053/j.gastro.2017.09.024.
Clin Gastroenterol Hepatol.:
New models of gastroenterology practice. Allen JI et al.
2018 Jan;16(1):3-6. doi: 10.1016/j.cgh.2017.10.003.
Cracking the clinician educator code in gastroenterology. Shapiro JM et al.
2017 Dec;15(12):1828-32. doi: 10.1016/j.cgh.2017.08.040.
Cell Mol Gastroenterol Hepatol.:
Setting up a lab: The early years. Habtezion A.
2017 Nov; 4(3): 445-6. doi: 10.1016/j.jcmgh.2017.08.003.
Understanding Social Media in GI Practice: Influence, Learn, and Prosper
Gone are the days when social media was primarily used by millennials and those early adopters on the diffusion-of-innovation curve. Now, baby boomers and laggards alike are using social media to communicate with the world around them. Furthermore, health and healthcare issues are common topics in the social media universe. Eight in 10 Internet users seek health information online and 74% of these health information seekers use social media.1,2 Additionally, when they look online, they are more likely to trust information from doctors (61%) than from hospitals (55%), insurers (42%), or pharmaceutical companies (37%).3 Therefore, there is tremendous opportunity for physicians to engage patients, policy makers, advocacy groups, and other health care influencers in order to share reliable information. Yet, we must do so responsibly. There is a considerable degree of misinformation circulated in social media and we believe that physicians should help combat this by providing accurate information.
On a more individual level, social media can help you stay up-to-date on best practices, breakthroughs, and controversies in medicine. It can help you take control of your online reputation rather than letting it be the default Google search results. Social media can also be a vehicle through which you build your offline network of potential colleagues, collaborators, and supporters as well as facilitate speaking, consulting, research, and other professional opportunities.
We that we have convinced you to actively participate in social media professionally. Next, we would like to share our top six best practices for responsible use.
1. Understand and define your goals. We have broadly laid out our rationale but that is different from your specific, desired outcomes. If you do not know what you are trying to accomplish you will have no idea if you are successful or if what you are doing is working versus whether you should try different strategies. Social media does take time; therefore, you should be strategic and goal oriented.
3. Share reliable/vetted information in your area of expertise and interest. Do not try to be all things to all people. Focus on content that distinguishes you and meets your goals. On the other hand, this should not be all about you; this can be boring, difficult, and give the impression that all you care about is self-promotion. No more than a quarter to a third of the content should be about you and the rest should be curated content from other reliable sources. Sharing with attribution helps you build your community. Also, people appreciate vetted content in the great web of misinformation available. You can facilitate audience engagement by including graphics, photos, and videos and by engaging and responding to other posts. Importantly, having a disclaimer on your account (e.g., retweets are not endorsements, posts are not medical advice) is never a substitute for knowing/vetting what you are sharing.
4. Exercise caution when responding to medical questions on social media and/or sharing patient information. While we encourage engagement, you should never answer specific medical questions. This develops a doctor-patient relationship and creates legal “duty.” It could even constitute practicing without a license, if the person asking the question lives in another state. Instead, provide general information about a condition, especially as a link to a reliable site (www.gastro.org/patient-care/patientinfo-center) and suggest seeking care from their local medical professional. Along these lines, do not share any potentially identifiable patient information without documented permission. In addition to the obvious (e.g., patient name, photos, medical documents with identifiers), avoid stories of care, complications, rare conditions, or identifiable specimens. With an approximate date and the location of your practice, it may be very easy for someone to determine the patient’s identity.
6. Know and adhere to the social media policies of your practice, institution, organization, or employer. Most academic institutions have social media policies and they are becoming more widely adapted to other settings. While you may just get a metaphorical slap on the wrist for not following the rules, I think we all would agree that it would be a tragedy to get fired over a social media post.
However, none of the above best practices are a substitute for being intentional and mindful when sharing information on social media, whether it be Facebook, Twitter, Instagram, Youtube, or another platform. What does being intentional and mindful on social media mean? Absolutely avoid commenting/posting about patients, colleagues, or your workplace in any way that could be perceived to be negative. Declare conflicts of interest where applicable (i.e., if you’re a consultant for a pharma company, avoid endorsing a drug without declaring your conflict). Above all else, don’t post anything that you wouldn’t mind being on a billboard or mainstream news.
Participation is an investment of your most valuable resource: time. Therefore, know your goals and revisit these goals and your success in reaching them regularly. Start small and expand as your time and interest allows. Finally, minimize your exposure to risk by keeping our guidance and your institutional policies in mind and always pause before you post.
You can find out more about the AGA, its programs, and publications via our social media outlets, including:
Twitter:
@amergastroassn
@AGA_CGH
@AGA_CMGH
@AGA_Gastro
Facebook:
@AmerGastroAssn
@cghjournal
@cmghjournal
@gastrojournal
Dr. Fisher is associate professor in the department of medicine, division of gastroenterology, Duke University, Durham, N.C. VA Medical Center. Twitter: @DrDeborahFisher. Dr. Gray is assistant professor, department of medicine, division of gastroenterology, hepatology and nutrition, Ohio State University College of Medicine. Twitter: @DMGrayMD.
This information was presented at a Meet-the-Professor Luncheon at DDW® 2017. More for in-depth details than are described in this article, refer to this session on DDW on Demand (http://www.ddw.org/education/session-recordings).
References
1 Von Muhlen M., Ohno-Machado L. J Am Med Inform Assoc. 2012;19(5):777-81.
2 Childs L.M., Martin C.Y. Am J Health System Pharm. 2012;69(23):2044-50.
3. Social media “likes” healthcare. From marketing to social business – 2012 Report
https://www.pwc.com/us/en/health-industries/health-research-institute/publications/health-care-social-media.html.
4. www.martinsights.com/social-media-marketing/social-media-strategy/new-global-social-media-research/.
5. Online Medical Professionalism: Patient and Public Relationships: Policy Statement From the American College of Physicians and the Federation of State Medical Boards. Ann Intern Med. 2013;158(8):620-7.
Gone are the days when social media was primarily used by millennials and those early adopters on the diffusion-of-innovation curve. Now, baby boomers and laggards alike are using social media to communicate with the world around them. Furthermore, health and healthcare issues are common topics in the social media universe. Eight in 10 Internet users seek health information online and 74% of these health information seekers use social media.1,2 Additionally, when they look online, they are more likely to trust information from doctors (61%) than from hospitals (55%), insurers (42%), or pharmaceutical companies (37%).3 Therefore, there is tremendous opportunity for physicians to engage patients, policy makers, advocacy groups, and other health care influencers in order to share reliable information. Yet, we must do so responsibly. There is a considerable degree of misinformation circulated in social media and we believe that physicians should help combat this by providing accurate information.
On a more individual level, social media can help you stay up-to-date on best practices, breakthroughs, and controversies in medicine. It can help you take control of your online reputation rather than letting it be the default Google search results. Social media can also be a vehicle through which you build your offline network of potential colleagues, collaborators, and supporters as well as facilitate speaking, consulting, research, and other professional opportunities.
We that we have convinced you to actively participate in social media professionally. Next, we would like to share our top six best practices for responsible use.
1. Understand and define your goals. We have broadly laid out our rationale but that is different from your specific, desired outcomes. If you do not know what you are trying to accomplish you will have no idea if you are successful or if what you are doing is working versus whether you should try different strategies. Social media does take time; therefore, you should be strategic and goal oriented.
3. Share reliable/vetted information in your area of expertise and interest. Do not try to be all things to all people. Focus on content that distinguishes you and meets your goals. On the other hand, this should not be all about you; this can be boring, difficult, and give the impression that all you care about is self-promotion. No more than a quarter to a third of the content should be about you and the rest should be curated content from other reliable sources. Sharing with attribution helps you build your community. Also, people appreciate vetted content in the great web of misinformation available. You can facilitate audience engagement by including graphics, photos, and videos and by engaging and responding to other posts. Importantly, having a disclaimer on your account (e.g., retweets are not endorsements, posts are not medical advice) is never a substitute for knowing/vetting what you are sharing.
4. Exercise caution when responding to medical questions on social media and/or sharing patient information. While we encourage engagement, you should never answer specific medical questions. This develops a doctor-patient relationship and creates legal “duty.” It could even constitute practicing without a license, if the person asking the question lives in another state. Instead, provide general information about a condition, especially as a link to a reliable site (www.gastro.org/patient-care/patientinfo-center) and suggest seeking care from their local medical professional. Along these lines, do not share any potentially identifiable patient information without documented permission. In addition to the obvious (e.g., patient name, photos, medical documents with identifiers), avoid stories of care, complications, rare conditions, or identifiable specimens. With an approximate date and the location of your practice, it may be very easy for someone to determine the patient’s identity.
6. Know and adhere to the social media policies of your practice, institution, organization, or employer. Most academic institutions have social media policies and they are becoming more widely adapted to other settings. While you may just get a metaphorical slap on the wrist for not following the rules, I think we all would agree that it would be a tragedy to get fired over a social media post.
However, none of the above best practices are a substitute for being intentional and mindful when sharing information on social media, whether it be Facebook, Twitter, Instagram, Youtube, or another platform. What does being intentional and mindful on social media mean? Absolutely avoid commenting/posting about patients, colleagues, or your workplace in any way that could be perceived to be negative. Declare conflicts of interest where applicable (i.e., if you’re a consultant for a pharma company, avoid endorsing a drug without declaring your conflict). Above all else, don’t post anything that you wouldn’t mind being on a billboard or mainstream news.
Participation is an investment of your most valuable resource: time. Therefore, know your goals and revisit these goals and your success in reaching them regularly. Start small and expand as your time and interest allows. Finally, minimize your exposure to risk by keeping our guidance and your institutional policies in mind and always pause before you post.
You can find out more about the AGA, its programs, and publications via our social media outlets, including:
Twitter:
@amergastroassn
@AGA_CGH
@AGA_CMGH
@AGA_Gastro
Facebook:
@AmerGastroAssn
@cghjournal
@cmghjournal
@gastrojournal
Dr. Fisher is associate professor in the department of medicine, division of gastroenterology, Duke University, Durham, N.C. VA Medical Center. Twitter: @DrDeborahFisher. Dr. Gray is assistant professor, department of medicine, division of gastroenterology, hepatology and nutrition, Ohio State University College of Medicine. Twitter: @DMGrayMD.
This information was presented at a Meet-the-Professor Luncheon at DDW® 2017. More for in-depth details than are described in this article, refer to this session on DDW on Demand (http://www.ddw.org/education/session-recordings).
References
1 Von Muhlen M., Ohno-Machado L. J Am Med Inform Assoc. 2012;19(5):777-81.
2 Childs L.M., Martin C.Y. Am J Health System Pharm. 2012;69(23):2044-50.
3. Social media “likes” healthcare. From marketing to social business – 2012 Report
https://www.pwc.com/us/en/health-industries/health-research-institute/publications/health-care-social-media.html.
4. www.martinsights.com/social-media-marketing/social-media-strategy/new-global-social-media-research/.
5. Online Medical Professionalism: Patient and Public Relationships: Policy Statement From the American College of Physicians and the Federation of State Medical Boards. Ann Intern Med. 2013;158(8):620-7.
Gone are the days when social media was primarily used by millennials and those early adopters on the diffusion-of-innovation curve. Now, baby boomers and laggards alike are using social media to communicate with the world around them. Furthermore, health and healthcare issues are common topics in the social media universe. Eight in 10 Internet users seek health information online and 74% of these health information seekers use social media.1,2 Additionally, when they look online, they are more likely to trust information from doctors (61%) than from hospitals (55%), insurers (42%), or pharmaceutical companies (37%).3 Therefore, there is tremendous opportunity for physicians to engage patients, policy makers, advocacy groups, and other health care influencers in order to share reliable information. Yet, we must do so responsibly. There is a considerable degree of misinformation circulated in social media and we believe that physicians should help combat this by providing accurate information.
On a more individual level, social media can help you stay up-to-date on best practices, breakthroughs, and controversies in medicine. It can help you take control of your online reputation rather than letting it be the default Google search results. Social media can also be a vehicle through which you build your offline network of potential colleagues, collaborators, and supporters as well as facilitate speaking, consulting, research, and other professional opportunities.
We that we have convinced you to actively participate in social media professionally. Next, we would like to share our top six best practices for responsible use.
1. Understand and define your goals. We have broadly laid out our rationale but that is different from your specific, desired outcomes. If you do not know what you are trying to accomplish you will have no idea if you are successful or if what you are doing is working versus whether you should try different strategies. Social media does take time; therefore, you should be strategic and goal oriented.
3. Share reliable/vetted information in your area of expertise and interest. Do not try to be all things to all people. Focus on content that distinguishes you and meets your goals. On the other hand, this should not be all about you; this can be boring, difficult, and give the impression that all you care about is self-promotion. No more than a quarter to a third of the content should be about you and the rest should be curated content from other reliable sources. Sharing with attribution helps you build your community. Also, people appreciate vetted content in the great web of misinformation available. You can facilitate audience engagement by including graphics, photos, and videos and by engaging and responding to other posts. Importantly, having a disclaimer on your account (e.g., retweets are not endorsements, posts are not medical advice) is never a substitute for knowing/vetting what you are sharing.
4. Exercise caution when responding to medical questions on social media and/or sharing patient information. While we encourage engagement, you should never answer specific medical questions. This develops a doctor-patient relationship and creates legal “duty.” It could even constitute practicing without a license, if the person asking the question lives in another state. Instead, provide general information about a condition, especially as a link to a reliable site (www.gastro.org/patient-care/patientinfo-center) and suggest seeking care from their local medical professional. Along these lines, do not share any potentially identifiable patient information without documented permission. In addition to the obvious (e.g., patient name, photos, medical documents with identifiers), avoid stories of care, complications, rare conditions, or identifiable specimens. With an approximate date and the location of your practice, it may be very easy for someone to determine the patient’s identity.
6. Know and adhere to the social media policies of your practice, institution, organization, or employer. Most academic institutions have social media policies and they are becoming more widely adapted to other settings. While you may just get a metaphorical slap on the wrist for not following the rules, I think we all would agree that it would be a tragedy to get fired over a social media post.
However, none of the above best practices are a substitute for being intentional and mindful when sharing information on social media, whether it be Facebook, Twitter, Instagram, Youtube, or another platform. What does being intentional and mindful on social media mean? Absolutely avoid commenting/posting about patients, colleagues, or your workplace in any way that could be perceived to be negative. Declare conflicts of interest where applicable (i.e., if you’re a consultant for a pharma company, avoid endorsing a drug without declaring your conflict). Above all else, don’t post anything that you wouldn’t mind being on a billboard or mainstream news.
Participation is an investment of your most valuable resource: time. Therefore, know your goals and revisit these goals and your success in reaching them regularly. Start small and expand as your time and interest allows. Finally, minimize your exposure to risk by keeping our guidance and your institutional policies in mind and always pause before you post.
You can find out more about the AGA, its programs, and publications via our social media outlets, including:
Twitter:
@amergastroassn
@AGA_CGH
@AGA_CMGH
@AGA_Gastro
Facebook:
@AmerGastroAssn
@cghjournal
@cmghjournal
@gastrojournal
Dr. Fisher is associate professor in the department of medicine, division of gastroenterology, Duke University, Durham, N.C. VA Medical Center. Twitter: @DrDeborahFisher. Dr. Gray is assistant professor, department of medicine, division of gastroenterology, hepatology and nutrition, Ohio State University College of Medicine. Twitter: @DMGrayMD.
This information was presented at a Meet-the-Professor Luncheon at DDW® 2017. More for in-depth details than are described in this article, refer to this session on DDW on Demand (http://www.ddw.org/education/session-recordings).
References
1 Von Muhlen M., Ohno-Machado L. J Am Med Inform Assoc. 2012;19(5):777-81.
2 Childs L.M., Martin C.Y. Am J Health System Pharm. 2012;69(23):2044-50.
3. Social media “likes” healthcare. From marketing to social business – 2012 Report
https://www.pwc.com/us/en/health-industries/health-research-institute/publications/health-care-social-media.html.
4. www.martinsights.com/social-media-marketing/social-media-strategy/new-global-social-media-research/.
5. Online Medical Professionalism: Patient and Public Relationships: Policy Statement From the American College of Physicians and the Federation of State Medical Boards. Ann Intern Med. 2013;158(8):620-7.
Advocacy in Action: Meeting Congressman Gene Green
The hospital is often the intersection between a patient’s medical illness and their social and financial issues. As physicians, it is important to recognize that patient care encompasses not only prescribing medications and performing procedures but also practicing systems-based medicine; ensuring social and financial barriers do not impede access to, and delivery of, care. Some of these barriers cannot be eliminated by one individual practitioner; they can only be improved by working with government representatives and policy makers to make systemic changes. For gastroenterologists, advocacy involves educating patients, practitioners, and our government representatives about issues related to GI illnesses and the importance of ensuring access to GI specialty care and treatment for all patients who require it.
As physicians, we are uniquely positioned to represent the needs of our patients. We appreciate the AGA facilitating that voice by providing updates on legislation and coordinating meetings between senators and members of Congress and practicing gastroenterologists and GI fellows. These meetings are an important opportunity to network and share our experiences. Congressman Green was very interested to hear our perspectives as health care providers. It was enlightening to hear about his experiences on the Health Subcommittee and learn about its procedures. We would strongly encourage other AGA members to take advantage of this important program. n
Dr. Natarajan is assistant professor, Dr. Shukla is assistant professor, and Dr. Shapiro is a second-year fellow; all are in the section of gastroenterology and hepatology, Baylor College of Medicine, Houston.
References
1. Ehrlich E. (2017). NIH’S Role in Sustaining the U.S. Economy. United for Medical Research. Accessed at http://www.unitedformedicalresearch.com/wp-content/uploads/2017/03/NIH-Role-in-the-Economy-FY2016.
2. AGA Position Statement on Research Funding. Accessed at http://www.gastro.org/take-action/top-issues/research-funding.
3. El-Serag H.B., Kanwal F., Davila J.A., Kramer J., Richardson P. A new laboratory-based algorithm to predict development of hepatocellular carcinoma in patients with hepatitis C and cirrhosis. Gastroenterology. 2014;May146(5):1249-55.
4. White D.L., Richardson P., Tayoub N., Davila J.A., Kanwal F., El-Serag H.B. The updated model: An adjusted serum alpha-fetoprotein-based algorithm for hepatocellular carcinoma detection with hepatitis C virus-related cirrhosis. Gastroenterology. 2015;Dec 149(7):1986-7.
5. AGA Position Statement on Patient Cost-Sharing for Screening Colonoscopy. Accessed a: http://www.gastro.org/take-action/top-issues/patient-cost-sharing-for-screening-colonoscopy.
The hospital is often the intersection between a patient’s medical illness and their social and financial issues. As physicians, it is important to recognize that patient care encompasses not only prescribing medications and performing procedures but also practicing systems-based medicine; ensuring social and financial barriers do not impede access to, and delivery of, care. Some of these barriers cannot be eliminated by one individual practitioner; they can only be improved by working with government representatives and policy makers to make systemic changes. For gastroenterologists, advocacy involves educating patients, practitioners, and our government representatives about issues related to GI illnesses and the importance of ensuring access to GI specialty care and treatment for all patients who require it.
As physicians, we are uniquely positioned to represent the needs of our patients. We appreciate the AGA facilitating that voice by providing updates on legislation and coordinating meetings between senators and members of Congress and practicing gastroenterologists and GI fellows. These meetings are an important opportunity to network and share our experiences. Congressman Green was very interested to hear our perspectives as health care providers. It was enlightening to hear about his experiences on the Health Subcommittee and learn about its procedures. We would strongly encourage other AGA members to take advantage of this important program. n
Dr. Natarajan is assistant professor, Dr. Shukla is assistant professor, and Dr. Shapiro is a second-year fellow; all are in the section of gastroenterology and hepatology, Baylor College of Medicine, Houston.
References
1. Ehrlich E. (2017). NIH’S Role in Sustaining the U.S. Economy. United for Medical Research. Accessed at http://www.unitedformedicalresearch.com/wp-content/uploads/2017/03/NIH-Role-in-the-Economy-FY2016.
2. AGA Position Statement on Research Funding. Accessed at http://www.gastro.org/take-action/top-issues/research-funding.
3. El-Serag H.B., Kanwal F., Davila J.A., Kramer J., Richardson P. A new laboratory-based algorithm to predict development of hepatocellular carcinoma in patients with hepatitis C and cirrhosis. Gastroenterology. 2014;May146(5):1249-55.
4. White D.L., Richardson P., Tayoub N., Davila J.A., Kanwal F., El-Serag H.B. The updated model: An adjusted serum alpha-fetoprotein-based algorithm for hepatocellular carcinoma detection with hepatitis C virus-related cirrhosis. Gastroenterology. 2015;Dec 149(7):1986-7.
5. AGA Position Statement on Patient Cost-Sharing for Screening Colonoscopy. Accessed a: http://www.gastro.org/take-action/top-issues/patient-cost-sharing-for-screening-colonoscopy.
The hospital is often the intersection between a patient’s medical illness and their social and financial issues. As physicians, it is important to recognize that patient care encompasses not only prescribing medications and performing procedures but also practicing systems-based medicine; ensuring social and financial barriers do not impede access to, and delivery of, care. Some of these barriers cannot be eliminated by one individual practitioner; they can only be improved by working with government representatives and policy makers to make systemic changes. For gastroenterologists, advocacy involves educating patients, practitioners, and our government representatives about issues related to GI illnesses and the importance of ensuring access to GI specialty care and treatment for all patients who require it.
As physicians, we are uniquely positioned to represent the needs of our patients. We appreciate the AGA facilitating that voice by providing updates on legislation and coordinating meetings between senators and members of Congress and practicing gastroenterologists and GI fellows. These meetings are an important opportunity to network and share our experiences. Congressman Green was very interested to hear our perspectives as health care providers. It was enlightening to hear about his experiences on the Health Subcommittee and learn about its procedures. We would strongly encourage other AGA members to take advantage of this important program. n
Dr. Natarajan is assistant professor, Dr. Shukla is assistant professor, and Dr. Shapiro is a second-year fellow; all are in the section of gastroenterology and hepatology, Baylor College of Medicine, Houston.
References
1. Ehrlich E. (2017). NIH’S Role in Sustaining the U.S. Economy. United for Medical Research. Accessed at http://www.unitedformedicalresearch.com/wp-content/uploads/2017/03/NIH-Role-in-the-Economy-FY2016.
2. AGA Position Statement on Research Funding. Accessed at http://www.gastro.org/take-action/top-issues/research-funding.
3. El-Serag H.B., Kanwal F., Davila J.A., Kramer J., Richardson P. A new laboratory-based algorithm to predict development of hepatocellular carcinoma in patients with hepatitis C and cirrhosis. Gastroenterology. 2014;May146(5):1249-55.
4. White D.L., Richardson P., Tayoub N., Davila J.A., Kanwal F., El-Serag H.B. The updated model: An adjusted serum alpha-fetoprotein-based algorithm for hepatocellular carcinoma detection with hepatitis C virus-related cirrhosis. Gastroenterology. 2015;Dec 149(7):1986-7.
5. AGA Position Statement on Patient Cost-Sharing for Screening Colonoscopy. Accessed a: http://www.gastro.org/take-action/top-issues/patient-cost-sharing-for-screening-colonoscopy.
Legal Issues for the Gastroenterologist: Part II
In the previous issue of The New Gastroenterologist, we discussed statistics and the basis on which most gastroenterologists are sued as well as what you can do to minimize this risk. In this second article, we discuss steps to assist in your defense in the event you have been sued. The following suggestions are based on our experience as defense attorneys who practice in the arena of medical malpractice.
Do not, under any circumstances, add or alter the plaintiff’s medical records. Although you have continued access to electronic medical records, accessing or altering these documents leaves an electronic trail. Attorneys are now frequently requesting an “audit trail” during discovery, which shows who and when someone accessed or altered relevant medical records. Additionally, it is likely that the plaintiff’s counsel has already obtained and reviewed records for their client. As such, counsel will notice any alterations and will require an explanation as to the same. If you did alter any medical records, it is important that you notify your attorney about the specifics of such.
After you have secured an attorney, it is critical that you arrange a meeting to develop a positive relationship early in the litigation process. This is important for many reasons. A medical malpractice case can be a long and arduous process which requires that you be involved with your attorney during the course of the litigation. For the attorney-client relationship to be successful, it is imperative that you know and feel comfortable with your attorney and develop confidence and trust in her. Without this trust, it will be difficult for you to accept various decisions or suggestions that the attorney believes are in your best interest. Conversely, the attorney should get to know you and understand your background, as this will assist in your representation.
A good relationship with you will also aid your attorney in educating herself on medical concepts relating to your case. Remember, your attorney most likely has not attended medical school and many of the medical concepts will initially be new to her. By the time trial arrives, however, your attorney will be very familiar with the medical issues in your case. This learning process can be expedited with your assistance and research.
Your deposition
At some point during the lawsuit, the plaintiff’s attorney will take your deposition. The plaintiff’s attorney will strive to obtain concessions that establish the standard of care, breach of the standard, causation, and damages. Your deposition is not the time for you to provide explanations. It is the time for you to concisely answer specific questions posed by counsel without volunteering any additional information. Ultimately, trials build on what occurs during depositions. Preparation is key. Be open to advice or criticisms from your lawyer. Try to eliminate any quirks or habits that interfere with the substance of your testimony or perceived credibility. A deposition is not a casual conversation, nor is it a test of your memory. Limit your answers to personal knowledge; never guess or speculate. If you do not know the answer to a question, or do not remember something, it is perfectly acceptable for you to say so. Only answer questions that you understand. You are allowed to ask the plaintiff’s counsel to repeat or rephrase questions.
Finally, and most importantly, always tell the truth. Discuss any anticipated issues or concerns with your lawyer before your deposition.
Preparing for trial
Conclusion
In summary, remember that there are things you can do both before and after you are sued to minimize litigation and its impact. As mentioned previously, before a lawsuit, and as a regular part of your practice, it is important that you stay current with medical advances, that you take the time to create a relationship with your patients involving quality communication, and that you thoroughly and legibly document all aspects of care provided. After a suit is filed against you, make sure you notify your insurer immediately, do not alter any records or discuss the case with anyone other than your lawyer or spouse, and do all you can to create a productive and honest relationship with your lawyer. This relationship will be invaluable as you do the difficult and time-consuming work of preparing for your deposition and trial, and it can help you endure and successfully navigate the litigation process.
The Importance of Follow-Up: Further Advice on How to Decrease the Risk of Being Sued
A common basis for establishing a malpractice liability claim against a physician is the failure to follow-up or track a patient’s test results. In today’s world, there is an increasing number of moving parts involved in any given patient’s care. A particular patient may treat with numerous physicians, all of whom use different record systems. Electronic medical record systems have made records more accessible and easier to track, but they also present a new set of challenges.
Every physician needs to determine how they plan to track test results. The ideal system would allow a physician to quickly get back any lab or diagnostic test that he or she orders. All staff members should know how the physician’s system works. Otherwise, test results might accidentally be filed before the physician reviews them or a miscommunication could prevent test results from being delivered. Whatever choice of system, it is key to follow and effectively use the program every time.
Additionally, it can be beneficial to let the patient know when he or she can expect to hear about their results, as failure to keep the patient reasonably informed can create a new set of patient concerns and anxiety. Ultimately, establishing a well-defined system for record-tracking can help physicians avoid malpractice liability claims because of a failure to follow-up.
In the previous issue of The New Gastroenterologist, we discussed statistics and the basis on which most gastroenterologists are sued as well as what you can do to minimize this risk. In this second article, we discuss steps to assist in your defense in the event you have been sued. The following suggestions are based on our experience as defense attorneys who practice in the arena of medical malpractice.
Do not, under any circumstances, add or alter the plaintiff’s medical records. Although you have continued access to electronic medical records, accessing or altering these documents leaves an electronic trail. Attorneys are now frequently requesting an “audit trail” during discovery, which shows who and when someone accessed or altered relevant medical records. Additionally, it is likely that the plaintiff’s counsel has already obtained and reviewed records for their client. As such, counsel will notice any alterations and will require an explanation as to the same. If you did alter any medical records, it is important that you notify your attorney about the specifics of such.
After you have secured an attorney, it is critical that you arrange a meeting to develop a positive relationship early in the litigation process. This is important for many reasons. A medical malpractice case can be a long and arduous process which requires that you be involved with your attorney during the course of the litigation. For the attorney-client relationship to be successful, it is imperative that you know and feel comfortable with your attorney and develop confidence and trust in her. Without this trust, it will be difficult for you to accept various decisions or suggestions that the attorney believes are in your best interest. Conversely, the attorney should get to know you and understand your background, as this will assist in your representation.
A good relationship with you will also aid your attorney in educating herself on medical concepts relating to your case. Remember, your attorney most likely has not attended medical school and many of the medical concepts will initially be new to her. By the time trial arrives, however, your attorney will be very familiar with the medical issues in your case. This learning process can be expedited with your assistance and research.
Your deposition
At some point during the lawsuit, the plaintiff’s attorney will take your deposition. The plaintiff’s attorney will strive to obtain concessions that establish the standard of care, breach of the standard, causation, and damages. Your deposition is not the time for you to provide explanations. It is the time for you to concisely answer specific questions posed by counsel without volunteering any additional information. Ultimately, trials build on what occurs during depositions. Preparation is key. Be open to advice or criticisms from your lawyer. Try to eliminate any quirks or habits that interfere with the substance of your testimony or perceived credibility. A deposition is not a casual conversation, nor is it a test of your memory. Limit your answers to personal knowledge; never guess or speculate. If you do not know the answer to a question, or do not remember something, it is perfectly acceptable for you to say so. Only answer questions that you understand. You are allowed to ask the plaintiff’s counsel to repeat or rephrase questions.
Finally, and most importantly, always tell the truth. Discuss any anticipated issues or concerns with your lawyer before your deposition.
Preparing for trial
Conclusion
In summary, remember that there are things you can do both before and after you are sued to minimize litigation and its impact. As mentioned previously, before a lawsuit, and as a regular part of your practice, it is important that you stay current with medical advances, that you take the time to create a relationship with your patients involving quality communication, and that you thoroughly and legibly document all aspects of care provided. After a suit is filed against you, make sure you notify your insurer immediately, do not alter any records or discuss the case with anyone other than your lawyer or spouse, and do all you can to create a productive and honest relationship with your lawyer. This relationship will be invaluable as you do the difficult and time-consuming work of preparing for your deposition and trial, and it can help you endure and successfully navigate the litigation process.
The Importance of Follow-Up: Further Advice on How to Decrease the Risk of Being Sued
A common basis for establishing a malpractice liability claim against a physician is the failure to follow-up or track a patient’s test results. In today’s world, there is an increasing number of moving parts involved in any given patient’s care. A particular patient may treat with numerous physicians, all of whom use different record systems. Electronic medical record systems have made records more accessible and easier to track, but they also present a new set of challenges.
Every physician needs to determine how they plan to track test results. The ideal system would allow a physician to quickly get back any lab or diagnostic test that he or she orders. All staff members should know how the physician’s system works. Otherwise, test results might accidentally be filed before the physician reviews them or a miscommunication could prevent test results from being delivered. Whatever choice of system, it is key to follow and effectively use the program every time.
Additionally, it can be beneficial to let the patient know when he or she can expect to hear about their results, as failure to keep the patient reasonably informed can create a new set of patient concerns and anxiety. Ultimately, establishing a well-defined system for record-tracking can help physicians avoid malpractice liability claims because of a failure to follow-up.
In the previous issue of The New Gastroenterologist, we discussed statistics and the basis on which most gastroenterologists are sued as well as what you can do to minimize this risk. In this second article, we discuss steps to assist in your defense in the event you have been sued. The following suggestions are based on our experience as defense attorneys who practice in the arena of medical malpractice.
Do not, under any circumstances, add or alter the plaintiff’s medical records. Although you have continued access to electronic medical records, accessing or altering these documents leaves an electronic trail. Attorneys are now frequently requesting an “audit trail” during discovery, which shows who and when someone accessed or altered relevant medical records. Additionally, it is likely that the plaintiff’s counsel has already obtained and reviewed records for their client. As such, counsel will notice any alterations and will require an explanation as to the same. If you did alter any medical records, it is important that you notify your attorney about the specifics of such.
After you have secured an attorney, it is critical that you arrange a meeting to develop a positive relationship early in the litigation process. This is important for many reasons. A medical malpractice case can be a long and arduous process which requires that you be involved with your attorney during the course of the litigation. For the attorney-client relationship to be successful, it is imperative that you know and feel comfortable with your attorney and develop confidence and trust in her. Without this trust, it will be difficult for you to accept various decisions or suggestions that the attorney believes are in your best interest. Conversely, the attorney should get to know you and understand your background, as this will assist in your representation.
A good relationship with you will also aid your attorney in educating herself on medical concepts relating to your case. Remember, your attorney most likely has not attended medical school and many of the medical concepts will initially be new to her. By the time trial arrives, however, your attorney will be very familiar with the medical issues in your case. This learning process can be expedited with your assistance and research.
Your deposition
At some point during the lawsuit, the plaintiff’s attorney will take your deposition. The plaintiff’s attorney will strive to obtain concessions that establish the standard of care, breach of the standard, causation, and damages. Your deposition is not the time for you to provide explanations. It is the time for you to concisely answer specific questions posed by counsel without volunteering any additional information. Ultimately, trials build on what occurs during depositions. Preparation is key. Be open to advice or criticisms from your lawyer. Try to eliminate any quirks or habits that interfere with the substance of your testimony or perceived credibility. A deposition is not a casual conversation, nor is it a test of your memory. Limit your answers to personal knowledge; never guess or speculate. If you do not know the answer to a question, or do not remember something, it is perfectly acceptable for you to say so. Only answer questions that you understand. You are allowed to ask the plaintiff’s counsel to repeat or rephrase questions.
Finally, and most importantly, always tell the truth. Discuss any anticipated issues or concerns with your lawyer before your deposition.
Preparing for trial
Conclusion
In summary, remember that there are things you can do both before and after you are sued to minimize litigation and its impact. As mentioned previously, before a lawsuit, and as a regular part of your practice, it is important that you stay current with medical advances, that you take the time to create a relationship with your patients involving quality communication, and that you thoroughly and legibly document all aspects of care provided. After a suit is filed against you, make sure you notify your insurer immediately, do not alter any records or discuss the case with anyone other than your lawyer or spouse, and do all you can to create a productive and honest relationship with your lawyer. This relationship will be invaluable as you do the difficult and time-consuming work of preparing for your deposition and trial, and it can help you endure and successfully navigate the litigation process.
The Importance of Follow-Up: Further Advice on How to Decrease the Risk of Being Sued
A common basis for establishing a malpractice liability claim against a physician is the failure to follow-up or track a patient’s test results. In today’s world, there is an increasing number of moving parts involved in any given patient’s care. A particular patient may treat with numerous physicians, all of whom use different record systems. Electronic medical record systems have made records more accessible and easier to track, but they also present a new set of challenges.
Every physician needs to determine how they plan to track test results. The ideal system would allow a physician to quickly get back any lab or diagnostic test that he or she orders. All staff members should know how the physician’s system works. Otherwise, test results might accidentally be filed before the physician reviews them or a miscommunication could prevent test results from being delivered. Whatever choice of system, it is key to follow and effectively use the program every time.
Additionally, it can be beneficial to let the patient know when he or she can expect to hear about their results, as failure to keep the patient reasonably informed can create a new set of patient concerns and anxiety. Ultimately, establishing a well-defined system for record-tracking can help physicians avoid malpractice liability claims because of a failure to follow-up.
The Light at the End of the Tunnel: Recent Advances in Endoscopic Retrograde Cholangiopancreatograpy
Introduction
Direct visualization of the biliary ductal system is quickly gaining importance among gastroenterologists. Since the inception of cholangioscopy in the 1970s, the technology has progressed, allowing for ease of use, better visualization, and a growing number of indications. Conventional endoscopic retrograde cholangiopancreatography (ERCP) is successful for removal of bile duct stones (with success rates over 90%);1 however, its use in the evaluation of potential biliary neoplasia has been somewhat disappointing. The diagnostic yield of ERCP-guided biliary brushings can range from 30% to 40%.2-4 An alternative to ERCP-guided biliary brushings for biliary strictures is endoscopic ultrasound (EUS)-directed fine needle aspiration (FNA), but the reported sensitivity remains poor, ranging from 43% to 77% with negative predictive values of less than 30%.5-7 These results leave much to be desired for diagnostic yield.
Clinical indications
DSOCP appears to have improved accuracy over fiberoptic equipment. In a recent multicenter observational study in patients undergoing digital cholangioscopy, the guided biopsies resulted in adequate tissue for histologic evaluation in 98% of patients. In addition, the sensitivity and specificity of digital cholangioscope-guided biopsies for diagnosis of malignancy was 85% and 100%, respectively.11
Other less common diagnostic indications for DSOCP include evaluation of cystic lesions of the biliary tract, verifying clearance of bile duct stones, bile duct ischemia evaluation after liver transplantation, hemobilia evaluation, removal of a bile duct foreign body, and evaluation of bile duct involvement in the presence of an ampullary adenoma.3,14,15,20,26,27
Risks and complications
Conclusions
Direct visualization of the biliary and pancreatic ductal system with fiber-optic and now digital-based platforms have greatly expanded the diagnostic and therapeutic capabilities available to gastroenterologists in the diagnosis and management of biliary and pancreatic disorders. The digital single-operator cholangiopancreatascope system offers greater diagnostic yield of pancreaticobiliary disorders over conventional diagnostic sampling techniques. In addition, direct visualization has expanded our therapeutic ability in complex stone disease allowing laser-based therapies that are not available with traditional fluoroscopic based techniques. Cholangiopancreatoscopic techniques and indications are rapidly expanding and will continue to expand the diagnostic and therapeutic armamentarium available to gastroenterologists.
Dr. Sonnier is a general gastroenterology fellow, division of gastroenterology, University of South Alabama. Dr. Mizrahi is director of advanced endoscopy, division of gastroenterology, University of South Alabama. Dr. Pleskow, is clinical chief, department of gastroenterology, Beth Israel Deaconess Medical Center, and associate professor of medicine, Harvard Medical School, Boston. Dr. Sonnier and Dr. Mizrahi have no conflicts of interest. Dr. Pleskow serves as a consultant to Boston Scientific.
References
1. Cohen S., et al. Gastrointest Endosc. 2002;56:803–9
2. Lee J.G., et al. Am J Gastroenterol. 1995;90:722-6.
3. De Bellis M., et al. Gastrointest Endosc. 2003;58:176-82
4. Fritcher E.G., et al. Gastroenterology. 2009;136:2180-6.
5. Rosch T., et al. Gastrointest Endosc. 2004;60:390-6.
6. Byrne M.F., et al. Endoscopy. 2004;36:715-9.
7. DeWitt J., et al. Gastrointest Endosc. 2006;64:325-33.
8. Rosch W., Endoscopy. 1976;8:172-5.
9. Takekoshi T., Takagi K. Gastrointest Endosc. 1975;17:678-83.
10. Chen Y.K. Gastrointest Endosc 2007;65:303-11.
11. Navaneethan U., et al. Gastrointest Endosc 2016;84:649-55.
12. Navaneethan U., et al. Gastrointest Endosc 2015;82: 608-14.
13. Chen Y.K., Pleskow DK. Gastrointest Endosc. 2007;65:832-41.
14. Draganov P.V., et al. Gastrointest Endosc. 2011;73:971-9.
15. Ramchandani M., et al. Gastrointest Endosc. 2011;74:511-9.
16. Chen Y.K., et al. Gastrointest Endosc. 2011;74:805-14.
17. Draganov P.V., et al. Gastrointest Endosc. 2012;75:347-53.
18. Classen M., et al. Endoscopy 1988;20:21-6.
19. Parsi M.A., et al. Gastrointest Endosc 2008;67:AB102.
20. Fishman D.S., et al. World J Gastroenterol. 2009;15:1353-8.
21. Maydeo A., et al. Gastrointest Endosc. 2011;74:1308-14.
22. Yamao K., et al. Gastrointest Endosc 2003;57:205-9.
23. Hara T., et al. Gastroenterology 2002;122:34-43.
24. Rösch T., et al. Endoscopy. 2002;34:765–71.
25. Bekkali N.L., et al. Pancreas. 2017;46:528-30.
26. Adwan H., et al. Dig Endosc. 2011;23:199-200.
27. Ransibrahmanakul K., et al. Clin Gastroenterol Hepatol. 2010;8:e9.
28. Pereira P., et al. J Gastrointestin Liver Dis, June 2017;Vol. 26(No 2):165-70.
29. Kawakubo K., et al. Endoscopy 2011;43:E241-2.
Introduction
Direct visualization of the biliary ductal system is quickly gaining importance among gastroenterologists. Since the inception of cholangioscopy in the 1970s, the technology has progressed, allowing for ease of use, better visualization, and a growing number of indications. Conventional endoscopic retrograde cholangiopancreatography (ERCP) is successful for removal of bile duct stones (with success rates over 90%);1 however, its use in the evaluation of potential biliary neoplasia has been somewhat disappointing. The diagnostic yield of ERCP-guided biliary brushings can range from 30% to 40%.2-4 An alternative to ERCP-guided biliary brushings for biliary strictures is endoscopic ultrasound (EUS)-directed fine needle aspiration (FNA), but the reported sensitivity remains poor, ranging from 43% to 77% with negative predictive values of less than 30%.5-7 These results leave much to be desired for diagnostic yield.
Clinical indications
DSOCP appears to have improved accuracy over fiberoptic equipment. In a recent multicenter observational study in patients undergoing digital cholangioscopy, the guided biopsies resulted in adequate tissue for histologic evaluation in 98% of patients. In addition, the sensitivity and specificity of digital cholangioscope-guided biopsies for diagnosis of malignancy was 85% and 100%, respectively.11
Other less common diagnostic indications for DSOCP include evaluation of cystic lesions of the biliary tract, verifying clearance of bile duct stones, bile duct ischemia evaluation after liver transplantation, hemobilia evaluation, removal of a bile duct foreign body, and evaluation of bile duct involvement in the presence of an ampullary adenoma.3,14,15,20,26,27
Risks and complications
Conclusions
Direct visualization of the biliary and pancreatic ductal system with fiber-optic and now digital-based platforms have greatly expanded the diagnostic and therapeutic capabilities available to gastroenterologists in the diagnosis and management of biliary and pancreatic disorders. The digital single-operator cholangiopancreatascope system offers greater diagnostic yield of pancreaticobiliary disorders over conventional diagnostic sampling techniques. In addition, direct visualization has expanded our therapeutic ability in complex stone disease allowing laser-based therapies that are not available with traditional fluoroscopic based techniques. Cholangiopancreatoscopic techniques and indications are rapidly expanding and will continue to expand the diagnostic and therapeutic armamentarium available to gastroenterologists.
Dr. Sonnier is a general gastroenterology fellow, division of gastroenterology, University of South Alabama. Dr. Mizrahi is director of advanced endoscopy, division of gastroenterology, University of South Alabama. Dr. Pleskow, is clinical chief, department of gastroenterology, Beth Israel Deaconess Medical Center, and associate professor of medicine, Harvard Medical School, Boston. Dr. Sonnier and Dr. Mizrahi have no conflicts of interest. Dr. Pleskow serves as a consultant to Boston Scientific.
References
1. Cohen S., et al. Gastrointest Endosc. 2002;56:803–9
2. Lee J.G., et al. Am J Gastroenterol. 1995;90:722-6.
3. De Bellis M., et al. Gastrointest Endosc. 2003;58:176-82
4. Fritcher E.G., et al. Gastroenterology. 2009;136:2180-6.
5. Rosch T., et al. Gastrointest Endosc. 2004;60:390-6.
6. Byrne M.F., et al. Endoscopy. 2004;36:715-9.
7. DeWitt J., et al. Gastrointest Endosc. 2006;64:325-33.
8. Rosch W., Endoscopy. 1976;8:172-5.
9. Takekoshi T., Takagi K. Gastrointest Endosc. 1975;17:678-83.
10. Chen Y.K. Gastrointest Endosc 2007;65:303-11.
11. Navaneethan U., et al. Gastrointest Endosc 2016;84:649-55.
12. Navaneethan U., et al. Gastrointest Endosc 2015;82: 608-14.
13. Chen Y.K., Pleskow DK. Gastrointest Endosc. 2007;65:832-41.
14. Draganov P.V., et al. Gastrointest Endosc. 2011;73:971-9.
15. Ramchandani M., et al. Gastrointest Endosc. 2011;74:511-9.
16. Chen Y.K., et al. Gastrointest Endosc. 2011;74:805-14.
17. Draganov P.V., et al. Gastrointest Endosc. 2012;75:347-53.
18. Classen M., et al. Endoscopy 1988;20:21-6.
19. Parsi M.A., et al. Gastrointest Endosc 2008;67:AB102.
20. Fishman D.S., et al. World J Gastroenterol. 2009;15:1353-8.
21. Maydeo A., et al. Gastrointest Endosc. 2011;74:1308-14.
22. Yamao K., et al. Gastrointest Endosc 2003;57:205-9.
23. Hara T., et al. Gastroenterology 2002;122:34-43.
24. Rösch T., et al. Endoscopy. 2002;34:765–71.
25. Bekkali N.L., et al. Pancreas. 2017;46:528-30.
26. Adwan H., et al. Dig Endosc. 2011;23:199-200.
27. Ransibrahmanakul K., et al. Clin Gastroenterol Hepatol. 2010;8:e9.
28. Pereira P., et al. J Gastrointestin Liver Dis, June 2017;Vol. 26(No 2):165-70.
29. Kawakubo K., et al. Endoscopy 2011;43:E241-2.
Introduction
Direct visualization of the biliary ductal system is quickly gaining importance among gastroenterologists. Since the inception of cholangioscopy in the 1970s, the technology has progressed, allowing for ease of use, better visualization, and a growing number of indications. Conventional endoscopic retrograde cholangiopancreatography (ERCP) is successful for removal of bile duct stones (with success rates over 90%);1 however, its use in the evaluation of potential biliary neoplasia has been somewhat disappointing. The diagnostic yield of ERCP-guided biliary brushings can range from 30% to 40%.2-4 An alternative to ERCP-guided biliary brushings for biliary strictures is endoscopic ultrasound (EUS)-directed fine needle aspiration (FNA), but the reported sensitivity remains poor, ranging from 43% to 77% with negative predictive values of less than 30%.5-7 These results leave much to be desired for diagnostic yield.
Clinical indications
DSOCP appears to have improved accuracy over fiberoptic equipment. In a recent multicenter observational study in patients undergoing digital cholangioscopy, the guided biopsies resulted in adequate tissue for histologic evaluation in 98% of patients. In addition, the sensitivity and specificity of digital cholangioscope-guided biopsies for diagnosis of malignancy was 85% and 100%, respectively.11
Other less common diagnostic indications for DSOCP include evaluation of cystic lesions of the biliary tract, verifying clearance of bile duct stones, bile duct ischemia evaluation after liver transplantation, hemobilia evaluation, removal of a bile duct foreign body, and evaluation of bile duct involvement in the presence of an ampullary adenoma.3,14,15,20,26,27
Risks and complications
Conclusions
Direct visualization of the biliary and pancreatic ductal system with fiber-optic and now digital-based platforms have greatly expanded the diagnostic and therapeutic capabilities available to gastroenterologists in the diagnosis and management of biliary and pancreatic disorders. The digital single-operator cholangiopancreatascope system offers greater diagnostic yield of pancreaticobiliary disorders over conventional diagnostic sampling techniques. In addition, direct visualization has expanded our therapeutic ability in complex stone disease allowing laser-based therapies that are not available with traditional fluoroscopic based techniques. Cholangiopancreatoscopic techniques and indications are rapidly expanding and will continue to expand the diagnostic and therapeutic armamentarium available to gastroenterologists.
Dr. Sonnier is a general gastroenterology fellow, division of gastroenterology, University of South Alabama. Dr. Mizrahi is director of advanced endoscopy, division of gastroenterology, University of South Alabama. Dr. Pleskow, is clinical chief, department of gastroenterology, Beth Israel Deaconess Medical Center, and associate professor of medicine, Harvard Medical School, Boston. Dr. Sonnier and Dr. Mizrahi have no conflicts of interest. Dr. Pleskow serves as a consultant to Boston Scientific.
References
1. Cohen S., et al. Gastrointest Endosc. 2002;56:803–9
2. Lee J.G., et al. Am J Gastroenterol. 1995;90:722-6.
3. De Bellis M., et al. Gastrointest Endosc. 2003;58:176-82
4. Fritcher E.G., et al. Gastroenterology. 2009;136:2180-6.
5. Rosch T., et al. Gastrointest Endosc. 2004;60:390-6.
6. Byrne M.F., et al. Endoscopy. 2004;36:715-9.
7. DeWitt J., et al. Gastrointest Endosc. 2006;64:325-33.
8. Rosch W., Endoscopy. 1976;8:172-5.
9. Takekoshi T., Takagi K. Gastrointest Endosc. 1975;17:678-83.
10. Chen Y.K. Gastrointest Endosc 2007;65:303-11.
11. Navaneethan U., et al. Gastrointest Endosc 2016;84:649-55.
12. Navaneethan U., et al. Gastrointest Endosc 2015;82: 608-14.
13. Chen Y.K., Pleskow DK. Gastrointest Endosc. 2007;65:832-41.
14. Draganov P.V., et al. Gastrointest Endosc. 2011;73:971-9.
15. Ramchandani M., et al. Gastrointest Endosc. 2011;74:511-9.
16. Chen Y.K., et al. Gastrointest Endosc. 2011;74:805-14.
17. Draganov P.V., et al. Gastrointest Endosc. 2012;75:347-53.
18. Classen M., et al. Endoscopy 1988;20:21-6.
19. Parsi M.A., et al. Gastrointest Endosc 2008;67:AB102.
20. Fishman D.S., et al. World J Gastroenterol. 2009;15:1353-8.
21. Maydeo A., et al. Gastrointest Endosc. 2011;74:1308-14.
22. Yamao K., et al. Gastrointest Endosc 2003;57:205-9.
23. Hara T., et al. Gastroenterology 2002;122:34-43.
24. Rösch T., et al. Endoscopy. 2002;34:765–71.
25. Bekkali N.L., et al. Pancreas. 2017;46:528-30.
26. Adwan H., et al. Dig Endosc. 2011;23:199-200.
27. Ransibrahmanakul K., et al. Clin Gastroenterol Hepatol. 2010;8:e9.
28. Pereira P., et al. J Gastrointestin Liver Dis, June 2017;Vol. 26(No 2):165-70.
29. Kawakubo K., et al. Endoscopy 2011;43:E241-2.
An Unusual Cause of Recurrent Severe Abdominal Colic
We carefully reviewed the patient’s history and found that he had been using jineijin, a traditional Chinese medicine (TCM) drug, which is made with dried endothelium corneum gigeriae galli (Figure E), at about 500 g/month and squama mantis (a TCM drug, at less than 5 g/month) as dietary supplements for 3 years. 
Acknowledgments
We thank Linshen Xie, MD, department of environmental health and occupational diseases, No. 4 West China Teaching Hospital, Sichuan University, for offering some clinical data. We thank the patient for giving permission to share his information.
References
1. National Research Council (US). Safe Drinking Water Committee. Drinking water and health. National Academy Press. Washington, D.C. 1977;1:309.
2. State Administration of Traditional Chinese Medicine. Advanced Textbook on Traditional Chinese Medicine and Pharmacology. New World Press, Beijing. 1995. (vol. 2).
3. Hui Hu, Q.J., Kavan, P. A study of heavy metal pollution in China: Current status, pollution-control policies and countermeasures. Sustainability. 2014;6:5820-38.
This article has an accompanying continuing medical education activity, also eligible for MOC credit, Learning objective: Upon completion of this examination, successful learners will be able to identify the features of lead poisoning.
We carefully reviewed the patient’s history and found that he had been using jineijin, a traditional Chinese medicine (TCM) drug, which is made with dried endothelium corneum gigeriae galli (Figure E), at about 500 g/month and squama mantis (a TCM drug, at less than 5 g/month) as dietary supplements for 3 years.
Acknowledgments
We thank Linshen Xie, MD, department of environmental health and occupational diseases, No. 4 West China Teaching Hospital, Sichuan University, for offering some clinical data. We thank the patient for giving permission to share his information.
References
1. National Research Council (US). Safe Drinking Water Committee. Drinking water and health. National Academy Press. Washington, D.C. 1977;1:309.
2. State Administration of Traditional Chinese Medicine. Advanced Textbook on Traditional Chinese Medicine and Pharmacology. New World Press, Beijing. 1995. (vol. 2).
3. Hui Hu, Q.J., Kavan, P. A study of heavy metal pollution in China: Current status, pollution-control policies and countermeasures. Sustainability. 2014;6:5820-38.
This article has an accompanying continuing medical education activity, also eligible for MOC credit, Learning objective: Upon completion of this examination, successful learners will be able to identify the features of lead poisoning.
We carefully reviewed the patient’s history and found that he had been using jineijin, a traditional Chinese medicine (TCM) drug, which is made with dried endothelium corneum gigeriae galli (Figure E), at about 500 g/month and squama mantis (a TCM drug, at less than 5 g/month) as dietary supplements for 3 years.
Acknowledgments
We thank Linshen Xie, MD, department of environmental health and occupational diseases, No. 4 West China Teaching Hospital, Sichuan University, for offering some clinical data. We thank the patient for giving permission to share his information.
References
1. National Research Council (US). Safe Drinking Water Committee. Drinking water and health. National Academy Press. Washington, D.C. 1977;1:309.
2. State Administration of Traditional Chinese Medicine. Advanced Textbook on Traditional Chinese Medicine and Pharmacology. New World Press, Beijing. 1995. (vol. 2).
3. Hui Hu, Q.J., Kavan, P. A study of heavy metal pollution in China: Current status, pollution-control policies and countermeasures. Sustainability. 2014;6:5820-38.
This article has an accompanying continuing medical education activity, also eligible for MOC credit, Learning objective: Upon completion of this examination, successful learners will be able to identify the features of lead poisoning.
Published previously in Gastroenterology (2016;151:819-21)
Dr. Deng, Dr. Hu, and Dr. Zhang are in the department of gastroenterology, West China Hospital, Sichuan University, Sichuan Province, China.
News from AGA
Advice on Achieving Work-Life Balance
Successfully maintaining a balance between your personal and professional lives is a difficult concept to grasp and practice to enforce. Is this thing called “work-life balance” within reach or just some elusive circumstance people talk about? The AGA Community Early Career Group was the hub for discussions on ways early-career gastroenterologists can modify their day-to-day approach to help prevent burnout.
We consolidated the advice and tips shared into a series of articles and resources to help students, trainees, and early career members get a little closer to balancing their work and professional lives. Here are some highlights:
Choose work-life “integration”
If your career and your personal life were a successful relationship, remember that it’s not always 50/50, and be sure to allow forgiveness and reparation when needed.
Maternity leave
When it comes to starting a family, think about your current training or career climate and how you can make it work. Be transparent with your supervisor so there aren’t any surprises, and plans can be made in advance to cover for your time away. Prepare to be flexible from the beginning.
Learn when to say “no”
Saying “yes” to too many things not only leads to overextending yourself beyond your capabilities, but you could also be losing time on what is important to you. Choose one night a week when you can work late – pack a snack, and give yourself a hard stop the rest of the week. Keep patient documentation as a daytime/work task.
Communication is key
When your partner or spouse is just as busy, it’s important to keep a joint calendar up to date and make plans far in advance. Also, create a routine: Try making time once a month to discuss calendars and anticipated events, face-to-face. When life throws a divot in your path, don’t lose sight of your priorities.
Make time for family and friends
Your career can take over as much of your life as you will allow. Making time for family and friends is rewarding and vacations, staycations, long weekends or even day trips can be great “resets.”
View the tip sheet and other work-life balance resources in the AGA Community Early Career Group library at http://community.gastro.org/WorkLife.
New Clinical Guidelines and Practice Updates
The latest AGA Clinical Practice Guideline, published in Gastroenterology, is on the role of therapeutic drug monitoring (TDM) in the management of IBD. It focuses on the application of TDM for biologic therapy, specifically anti-tumor necrosis factor-α (TNF) agents, and for thiopurines, and addresses questions on the risks and benefits of reactive TDM, routine proactive TDM, or no TDM in guiding treatment changes.
View the full guideline, technical review, and patient guide at www.gastro.org/guidelines.
In addition to guidelines, please check out the most recent Clinical Practice Updates (CPU) in Gastroenterology and Clinical Gastroenterology and Hepatology (CGH), which are often accompanied by a practice quiz from one of the authors, via the AGA Community. Visit http://community.gastro.org/guidelinecpu to test your knowledge. The most recent CPU, published in the September issue of CGH, focuses on GI side effects related to opioid medications.
Be Part of the Meeting to Transform IBD
If you treat patients with inflammatory bowel disease, conduct IBD research, or plan to pursue a career in IBD, join us for the inaugural Crohn’s & Colitis Congress™, taking place Jan. 18-20, 2018, in Las Vegas, NV. The Crohn’s & Colitis Foundation (formerly CCFA) and AGA have joined together to develop a must-attend program for the entire IBD care team. Expand your knowledge, network with your peers as well as IBD leaders across multiple disciplines, and get inspired to improve care for patients with Crohn’s disease and ulcerative colitis.
You may also be interested in the free precongress workshop – The Lloyd Mayer, MD, Young IBD Investigators Clinical, Basic, and Translational Research Workshop. This half-day precongress workshop is targeted to early-career clinical, basic, and translational researchers as well as senior researchers and will feature a mix of research presentations by young investigator colleagues, keynote presentations, and panel discussion, featuring established IBD researchers. The theme this year is focused around grant proposals and will include two mock grant review sessions.
Learn more about the Crohn’s & Colitis Congress and register: http://crohnscolitiscongress.org.
Advice on Achieving Work-Life Balance
Successfully maintaining a balance between your personal and professional lives is a difficult concept to grasp and practice to enforce. Is this thing called “work-life balance” within reach or just some elusive circumstance people talk about? The AGA Community Early Career Group was the hub for discussions on ways early-career gastroenterologists can modify their day-to-day approach to help prevent burnout.
We consolidated the advice and tips shared into a series of articles and resources to help students, trainees, and early career members get a little closer to balancing their work and professional lives. Here are some highlights:
Choose work-life “integration”
If your career and your personal life were a successful relationship, remember that it’s not always 50/50, and be sure to allow forgiveness and reparation when needed.
Maternity leave
When it comes to starting a family, think about your current training or career climate and how you can make it work. Be transparent with your supervisor so there aren’t any surprises, and plans can be made in advance to cover for your time away. Prepare to be flexible from the beginning.
Learn when to say “no”
Saying “yes” to too many things not only leads to overextending yourself beyond your capabilities, but you could also be losing time on what is important to you. Choose one night a week when you can work late – pack a snack, and give yourself a hard stop the rest of the week. Keep patient documentation as a daytime/work task.
Communication is key
When your partner or spouse is just as busy, it’s important to keep a joint calendar up to date and make plans far in advance. Also, create a routine: Try making time once a month to discuss calendars and anticipated events, face-to-face. When life throws a divot in your path, don’t lose sight of your priorities.
Make time for family and friends
Your career can take over as much of your life as you will allow. Making time for family and friends is rewarding and vacations, staycations, long weekends or even day trips can be great “resets.”
View the tip sheet and other work-life balance resources in the AGA Community Early Career Group library at http://community.gastro.org/WorkLife.
New Clinical Guidelines and Practice Updates
The latest AGA Clinical Practice Guideline, published in Gastroenterology, is on the role of therapeutic drug monitoring (TDM) in the management of IBD. It focuses on the application of TDM for biologic therapy, specifically anti-tumor necrosis factor-α (TNF) agents, and for thiopurines, and addresses questions on the risks and benefits of reactive TDM, routine proactive TDM, or no TDM in guiding treatment changes.
View the full guideline, technical review, and patient guide at www.gastro.org/guidelines.
In addition to guidelines, please check out the most recent Clinical Practice Updates (CPU) in Gastroenterology and Clinical Gastroenterology and Hepatology (CGH), which are often accompanied by a practice quiz from one of the authors, via the AGA Community. Visit http://community.gastro.org/guidelinecpu to test your knowledge. The most recent CPU, published in the September issue of CGH, focuses on GI side effects related to opioid medications.
Be Part of the Meeting to Transform IBD
If you treat patients with inflammatory bowel disease, conduct IBD research, or plan to pursue a career in IBD, join us for the inaugural Crohn’s & Colitis Congress™, taking place Jan. 18-20, 2018, in Las Vegas, NV. The Crohn’s & Colitis Foundation (formerly CCFA) and AGA have joined together to develop a must-attend program for the entire IBD care team. Expand your knowledge, network with your peers as well as IBD leaders across multiple disciplines, and get inspired to improve care for patients with Crohn’s disease and ulcerative colitis.
You may also be interested in the free precongress workshop – The Lloyd Mayer, MD, Young IBD Investigators Clinical, Basic, and Translational Research Workshop. This half-day precongress workshop is targeted to early-career clinical, basic, and translational researchers as well as senior researchers and will feature a mix of research presentations by young investigator colleagues, keynote presentations, and panel discussion, featuring established IBD researchers. The theme this year is focused around grant proposals and will include two mock grant review sessions.
Learn more about the Crohn’s & Colitis Congress and register: http://crohnscolitiscongress.org.
Advice on Achieving Work-Life Balance
Successfully maintaining a balance between your personal and professional lives is a difficult concept to grasp and practice to enforce. Is this thing called “work-life balance” within reach or just some elusive circumstance people talk about? The AGA Community Early Career Group was the hub for discussions on ways early-career gastroenterologists can modify their day-to-day approach to help prevent burnout.
We consolidated the advice and tips shared into a series of articles and resources to help students, trainees, and early career members get a little closer to balancing their work and professional lives. Here are some highlights:
Choose work-life “integration”
If your career and your personal life were a successful relationship, remember that it’s not always 50/50, and be sure to allow forgiveness and reparation when needed.
Maternity leave
When it comes to starting a family, think about your current training or career climate and how you can make it work. Be transparent with your supervisor so there aren’t any surprises, and plans can be made in advance to cover for your time away. Prepare to be flexible from the beginning.
Learn when to say “no”
Saying “yes” to too many things not only leads to overextending yourself beyond your capabilities, but you could also be losing time on what is important to you. Choose one night a week when you can work late – pack a snack, and give yourself a hard stop the rest of the week. Keep patient documentation as a daytime/work task.
Communication is key
When your partner or spouse is just as busy, it’s important to keep a joint calendar up to date and make plans far in advance. Also, create a routine: Try making time once a month to discuss calendars and anticipated events, face-to-face. When life throws a divot in your path, don’t lose sight of your priorities.
Make time for family and friends
Your career can take over as much of your life as you will allow. Making time for family and friends is rewarding and vacations, staycations, long weekends or even day trips can be great “resets.”
View the tip sheet and other work-life balance resources in the AGA Community Early Career Group library at http://community.gastro.org/WorkLife.
New Clinical Guidelines and Practice Updates
The latest AGA Clinical Practice Guideline, published in Gastroenterology, is on the role of therapeutic drug monitoring (TDM) in the management of IBD. It focuses on the application of TDM for biologic therapy, specifically anti-tumor necrosis factor-α (TNF) agents, and for thiopurines, and addresses questions on the risks and benefits of reactive TDM, routine proactive TDM, or no TDM in guiding treatment changes.
View the full guideline, technical review, and patient guide at www.gastro.org/guidelines.
In addition to guidelines, please check out the most recent Clinical Practice Updates (CPU) in Gastroenterology and Clinical Gastroenterology and Hepatology (CGH), which are often accompanied by a practice quiz from one of the authors, via the AGA Community. Visit http://community.gastro.org/guidelinecpu to test your knowledge. The most recent CPU, published in the September issue of CGH, focuses on GI side effects related to opioid medications.
Be Part of the Meeting to Transform IBD
If you treat patients with inflammatory bowel disease, conduct IBD research, or plan to pursue a career in IBD, join us for the inaugural Crohn’s & Colitis Congress™, taking place Jan. 18-20, 2018, in Las Vegas, NV. The Crohn’s & Colitis Foundation (formerly CCFA) and AGA have joined together to develop a must-attend program for the entire IBD care team. Expand your knowledge, network with your peers as well as IBD leaders across multiple disciplines, and get inspired to improve care for patients with Crohn’s disease and ulcerative colitis.
You may also be interested in the free precongress workshop – The Lloyd Mayer, MD, Young IBD Investigators Clinical, Basic, and Translational Research Workshop. This half-day precongress workshop is targeted to early-career clinical, basic, and translational researchers as well as senior researchers and will feature a mix of research presentations by young investigator colleagues, keynote presentations, and panel discussion, featuring established IBD researchers. The theme this year is focused around grant proposals and will include two mock grant review sessions.
Learn more about the Crohn’s & Colitis Congress and register: http://crohnscolitiscongress.org.
Cholangiopancreatoscopy
Dear Colleagues,
In this issue of The New Gastroenterologist, the feature article examines recent advances in the field of cholangiopancreatoscopy. In this article, William Sonnier, Meir Mizrahi (University of South Alabama), and Douglas Pleskow (Beth Israel Deaconess) provide a fantastic overview of the technologic advances in the field of cholangiopancreatoscopy as well as the clinical indications for this procedure and the risks involved. Also in this issue, Deborah Fisher (Duke University) and Darrell Gray (Ohio State University) provide advice about how to appropriately and responsibly handle social media. This is an incredibly important topic, given the increasing pervasiveness of social media in many aspects of our personal and professional lives.
Finally, in this issue is the second part in a series on legal issues for gastroenterologists. In this article, which is again authored by a very experienced group of attorneys, many important issues are covered, including what steps should be taken if you are sued, what you should and should not do after being sued, as well as tips on how to best prepare for both deposition and trial.
If there are topics that you would be interested in writing or hearing about in The New Gastroenterologist, please let us know. You can contact me ([email protected]) or the Managing Editor of The New Gastroenterologist, Ryan Farrell ([email protected]).
Sincerely,
Bryson W. Katona, MD, PhD
Editor in Chief
Bryson W. Katona is an instructor of medicine in the division of gastroenterology at the University of Pennsylvania.
Dear Colleagues,
In this issue of The New Gastroenterologist, the feature article examines recent advances in the field of cholangiopancreatoscopy. In this article, William Sonnier, Meir Mizrahi (University of South Alabama), and Douglas Pleskow (Beth Israel Deaconess) provide a fantastic overview of the technologic advances in the field of cholangiopancreatoscopy as well as the clinical indications for this procedure and the risks involved. Also in this issue, Deborah Fisher (Duke University) and Darrell Gray (Ohio State University) provide advice about how to appropriately and responsibly handle social media. This is an incredibly important topic, given the increasing pervasiveness of social media in many aspects of our personal and professional lives.
Finally, in this issue is the second part in a series on legal issues for gastroenterologists. In this article, which is again authored by a very experienced group of attorneys, many important issues are covered, including what steps should be taken if you are sued, what you should and should not do after being sued, as well as tips on how to best prepare for both deposition and trial.
If there are topics that you would be interested in writing or hearing about in The New Gastroenterologist, please let us know. You can contact me ([email protected]) or the Managing Editor of The New Gastroenterologist, Ryan Farrell ([email protected]).
Sincerely,
Bryson W. Katona, MD, PhD
Editor in Chief
Bryson W. Katona is an instructor of medicine in the division of gastroenterology at the University of Pennsylvania.
Dear Colleagues,
In this issue of The New Gastroenterologist, the feature article examines recent advances in the field of cholangiopancreatoscopy. In this article, William Sonnier, Meir Mizrahi (University of South Alabama), and Douglas Pleskow (Beth Israel Deaconess) provide a fantastic overview of the technologic advances in the field of cholangiopancreatoscopy as well as the clinical indications for this procedure and the risks involved. Also in this issue, Deborah Fisher (Duke University) and Darrell Gray (Ohio State University) provide advice about how to appropriately and responsibly handle social media. This is an incredibly important topic, given the increasing pervasiveness of social media in many aspects of our personal and professional lives.
Finally, in this issue is the second part in a series on legal issues for gastroenterologists. In this article, which is again authored by a very experienced group of attorneys, many important issues are covered, including what steps should be taken if you are sued, what you should and should not do after being sued, as well as tips on how to best prepare for both deposition and trial.
If there are topics that you would be interested in writing or hearing about in The New Gastroenterologist, please let us know. You can contact me ([email protected]) or the Managing Editor of The New Gastroenterologist, Ryan Farrell ([email protected]).
Sincerely,
Bryson W. Katona, MD, PhD
Editor in Chief
Bryson W. Katona is an instructor of medicine in the division of gastroenterology at the University of Pennsylvania.
Trustworthy Recommendations: A Closer Look Inside the AGA’s Clinical Guideline Development Process
The AGA understands how important it is for busy physicians to have access to the most trustworthy, actionable, and evidence-based guidelines in order to achieve the highest possible quality of patient care. According to a 2016 survey, AGA members ranked guidelines as the most important of all AGA-specific benefits, giving guidelines an average of 4.61 out of 5 (where 5 was defined as “extremely important”). The AGA’s guidelines landing page (www.gastro.org/guidelines) has long been the most frequently accessed page on the AGA website.
The life cycle of an AGA guideline
In 2010, the AGA Institute officially adopted the GRADE (Grades of Recommendation Assessment, Development, and Evaluation) methodology for the development of all future guidelines. Since the publication of our first GRADE-based guideline in 2013, the AGA has developed and published 12 guidelines with an additional 11 more to be published by 2019. Based on the systematic rigor of the GRADE approach, the AGA’s guideline development process was created to result in clinical recommendations that are not only evidence based but actionable and responsive to varying patient needs and preferences at the point of care.
All told, a single AGA guideline costs around $45,000 and takes approximately 24 months to complete and publish. Currently, the AGA is working to pilot new methods of shortening the time to publication through the development of rapid reviews within a focused topic (e.g., opioid-induced constipation).1 The development of each guideline requires a team of one or more specially trained GRADE methodologists, two or more content experts, a medical librarian, a panel of three or more guideline authors, two AGA staff members, and the Clinical Guidelines Committee Chair.
Determining the focused questions. First, the entire team of physician-authors determines a list of focused questions that the guideline will address. This list of focused questions is translated into a table of Population, Intervention, Comparison, Outcomes (PICOs) that operationalize the general questions into search terms utilized by the medical librarian to run the systematic search as well as define the final scope of the guideline. The focused questions and related PICOs are sent to the Governing Board for review and approval.
Developing the technical review. Over the next several months, the methodologist and content experts meet on a weekly basis to review the search results question-by-question and develop the technical review of evidence that will form the basis of the clinical recommendations. For each PICO, the technical review assesses the entire body of evidence and rates the overall quality of evidence gathered for each outcome related to the PICOs (from “very low” to “low” to “moderate” to “high”).
Drafting the clinical recommendations. The technical review presents the findings of the literature along with the authors’ assessment of the evidence quality. At a face-to-face meeting, these results are presented by the technical review authors to the guideline panel, who are responsible for developing the official guideline document. The role of the guideline panel is to understand the quality of evidence and determine an ultimate list of clinical recommendations and assign a strength (strong or conditional) to each recommendation, all while considering important factors such as the balance between benefits and downsides, potential variability in patients’ values and preferences, and impact on resource utilization. Oftentimes, but not always, recommendations based on higher-quality evidence for which most patients would request the recommended course of action translate into strong recommendations. Recommendations based on lower-quality evidence and those for which there is a higher variability in patient values or issues surrounding resource utilization are more likely to be conditional.
In addition to the guideline document, the guideline panel also drafts a Clinical Decision Support Tool, which illustrates the clinical recommendations within a visual algorithm. At the same time, AGA staff draft a patient summary that explains the recommendations in plain language. This summary can be used by physicians to improve clinical communication and shared decision making with their patients.2
Revising the guideline. Each AGA technical review goes through two layers of review: once by an anonymous peer-review panel of three content experts, and again during a 30-day public comment period in which both the technical review and guideline are posted for public input. The authors take all input into consideration while finalizing the documents, which are sent to the Governing Board for final approval. Once approved by the Board, the technical review, guideline, and all related materials are submitted for publication in Gastroenterology. In addition to print publication, each guideline is disseminated on the AGA website and through the official Clinical Guidelines mobile app (available via the App Store and Google Play), which includes interactive versions of the Clinical Decision Support Tools and plain-language summaries that can be sent via e-mail to patients at the point of care. The AGA is currently pursuing future directions for the dissemination and implementation of our guidelines, such as the seamless integration of clinical recommendations into electronic health records to further improve decision making and facilitate quality measurement and improvement.
Conclusion
Not all clinical guidelines are created with equal rigor. Clinicians should examine guidelines closely and consider whether or not they follow the Institute of Medicine’s standards for trustworthy clinical guidelines: Is the focus on transparency? Is a rigorous conflict of interest system in place that eliminates major sources of financial and intellectual conflict? Was an unconflicted GRADE-trained methodologist involved in ensuring that a systematic review process is followed and the method of rating the quality of evidence and strength of recommendation follows published principles? Are the recommendations clear and actionable?3 AGA Institute guidelines are developed with the goal of striking a balance between presenting the highest ideals of evidence-based medicine while remaining responsive to the needs of everyday practitioners dealing with real patients in real clinical settings.
Ms. Siedler is the director of clinical practice at the AGA Institute national office in Bethesda, Md.; Dr. Falck-Ytter is a professor of medicine at Case-Western Reserve University, Cleveland, chair of the AGA Institute Clinical Guidelines Committee, and chief of the division of gastroenterology at the Louis Stokes VA Medical Center in Cleveland. The authors disclose no conflicts of interest.
References
1. Hanson B., Siedler M., Falck-Ytter Y., Sultan S. Introducing the rapid review: How the AGA is working to get trustworthy clinical guidelines to practitioners in less time. AGA Perspectives. 2017; in press.
2. Siedler M., Allen J., Falck-Ytter Y., Weinberg D. AGA clinical practice guidelines: Robust, evidence-based tools for guiding clinical care decisions. Gastroenterology. 2015;149:493-5.
3. Institute of Medicine: Standards for developing trustworthy clinical practice guidelines. Available at http://www.nationalacademies.org/hmd/Reports/2011/Clinical-Practice-Guidelines-We-Can-Trust/Standards.aspx. Last accessed May 2017.Process for the selection of new guideline topics
The AGA understands how important it is for busy physicians to have access to the most trustworthy, actionable, and evidence-based guidelines in order to achieve the highest possible quality of patient care. According to a 2016 survey, AGA members ranked guidelines as the most important of all AGA-specific benefits, giving guidelines an average of 4.61 out of 5 (where 5 was defined as “extremely important”). The AGA’s guidelines landing page (www.gastro.org/guidelines) has long been the most frequently accessed page on the AGA website.
The life cycle of an AGA guideline
In 2010, the AGA Institute officially adopted the GRADE (Grades of Recommendation Assessment, Development, and Evaluation) methodology for the development of all future guidelines. Since the publication of our first GRADE-based guideline in 2013, the AGA has developed and published 12 guidelines with an additional 11 more to be published by 2019. Based on the systematic rigor of the GRADE approach, the AGA’s guideline development process was created to result in clinical recommendations that are not only evidence based but actionable and responsive to varying patient needs and preferences at the point of care.
All told, a single AGA guideline costs around $45,000 and takes approximately 24 months to complete and publish. Currently, the AGA is working to pilot new methods of shortening the time to publication through the development of rapid reviews within a focused topic (e.g., opioid-induced constipation).1 The development of each guideline requires a team of one or more specially trained GRADE methodologists, two or more content experts, a medical librarian, a panel of three or more guideline authors, two AGA staff members, and the Clinical Guidelines Committee Chair.
Determining the focused questions. First, the entire team of physician-authors determines a list of focused questions that the guideline will address. This list of focused questions is translated into a table of Population, Intervention, Comparison, Outcomes (PICOs) that operationalize the general questions into search terms utilized by the medical librarian to run the systematic search as well as define the final scope of the guideline. The focused questions and related PICOs are sent to the Governing Board for review and approval.
Developing the technical review. Over the next several months, the methodologist and content experts meet on a weekly basis to review the search results question-by-question and develop the technical review of evidence that will form the basis of the clinical recommendations. For each PICO, the technical review assesses the entire body of evidence and rates the overall quality of evidence gathered for each outcome related to the PICOs (from “very low” to “low” to “moderate” to “high”).
Drafting the clinical recommendations. The technical review presents the findings of the literature along with the authors’ assessment of the evidence quality. At a face-to-face meeting, these results are presented by the technical review authors to the guideline panel, who are responsible for developing the official guideline document. The role of the guideline panel is to understand the quality of evidence and determine an ultimate list of clinical recommendations and assign a strength (strong or conditional) to each recommendation, all while considering important factors such as the balance between benefits and downsides, potential variability in patients’ values and preferences, and impact on resource utilization. Oftentimes, but not always, recommendations based on higher-quality evidence for which most patients would request the recommended course of action translate into strong recommendations. Recommendations based on lower-quality evidence and those for which there is a higher variability in patient values or issues surrounding resource utilization are more likely to be conditional.
In addition to the guideline document, the guideline panel also drafts a Clinical Decision Support Tool, which illustrates the clinical recommendations within a visual algorithm. At the same time, AGA staff draft a patient summary that explains the recommendations in plain language. This summary can be used by physicians to improve clinical communication and shared decision making with their patients.2
Revising the guideline. Each AGA technical review goes through two layers of review: once by an anonymous peer-review panel of three content experts, and again during a 30-day public comment period in which both the technical review and guideline are posted for public input. The authors take all input into consideration while finalizing the documents, which are sent to the Governing Board for final approval. Once approved by the Board, the technical review, guideline, and all related materials are submitted for publication in Gastroenterology. In addition to print publication, each guideline is disseminated on the AGA website and through the official Clinical Guidelines mobile app (available via the App Store and Google Play), which includes interactive versions of the Clinical Decision Support Tools and plain-language summaries that can be sent via e-mail to patients at the point of care. The AGA is currently pursuing future directions for the dissemination and implementation of our guidelines, such as the seamless integration of clinical recommendations into electronic health records to further improve decision making and facilitate quality measurement and improvement.
Conclusion
Not all clinical guidelines are created with equal rigor. Clinicians should examine guidelines closely and consider whether or not they follow the Institute of Medicine’s standards for trustworthy clinical guidelines: Is the focus on transparency? Is a rigorous conflict of interest system in place that eliminates major sources of financial and intellectual conflict? Was an unconflicted GRADE-trained methodologist involved in ensuring that a systematic review process is followed and the method of rating the quality of evidence and strength of recommendation follows published principles? Are the recommendations clear and actionable?3 AGA Institute guidelines are developed with the goal of striking a balance between presenting the highest ideals of evidence-based medicine while remaining responsive to the needs of everyday practitioners dealing with real patients in real clinical settings.
Ms. Siedler is the director of clinical practice at the AGA Institute national office in Bethesda, Md.; Dr. Falck-Ytter is a professor of medicine at Case-Western Reserve University, Cleveland, chair of the AGA Institute Clinical Guidelines Committee, and chief of the division of gastroenterology at the Louis Stokes VA Medical Center in Cleveland. The authors disclose no conflicts of interest.
References
1. Hanson B., Siedler M., Falck-Ytter Y., Sultan S. Introducing the rapid review: How the AGA is working to get trustworthy clinical guidelines to practitioners in less time. AGA Perspectives. 2017; in press.
2. Siedler M., Allen J., Falck-Ytter Y., Weinberg D. AGA clinical practice guidelines: Robust, evidence-based tools for guiding clinical care decisions. Gastroenterology. 2015;149:493-5.
3. Institute of Medicine: Standards for developing trustworthy clinical practice guidelines. Available at http://www.nationalacademies.org/hmd/Reports/2011/Clinical-Practice-Guidelines-We-Can-Trust/Standards.aspx. Last accessed May 2017.Process for the selection of new guideline topics
The AGA understands how important it is for busy physicians to have access to the most trustworthy, actionable, and evidence-based guidelines in order to achieve the highest possible quality of patient care. According to a 2016 survey, AGA members ranked guidelines as the most important of all AGA-specific benefits, giving guidelines an average of 4.61 out of 5 (where 5 was defined as “extremely important”). The AGA’s guidelines landing page (www.gastro.org/guidelines) has long been the most frequently accessed page on the AGA website.
The life cycle of an AGA guideline
In 2010, the AGA Institute officially adopted the GRADE (Grades of Recommendation Assessment, Development, and Evaluation) methodology for the development of all future guidelines. Since the publication of our first GRADE-based guideline in 2013, the AGA has developed and published 12 guidelines with an additional 11 more to be published by 2019. Based on the systematic rigor of the GRADE approach, the AGA’s guideline development process was created to result in clinical recommendations that are not only evidence based but actionable and responsive to varying patient needs and preferences at the point of care.
All told, a single AGA guideline costs around $45,000 and takes approximately 24 months to complete and publish. Currently, the AGA is working to pilot new methods of shortening the time to publication through the development of rapid reviews within a focused topic (e.g., opioid-induced constipation).1 The development of each guideline requires a team of one or more specially trained GRADE methodologists, two or more content experts, a medical librarian, a panel of three or more guideline authors, two AGA staff members, and the Clinical Guidelines Committee Chair.
Determining the focused questions. First, the entire team of physician-authors determines a list of focused questions that the guideline will address. This list of focused questions is translated into a table of Population, Intervention, Comparison, Outcomes (PICOs) that operationalize the general questions into search terms utilized by the medical librarian to run the systematic search as well as define the final scope of the guideline. The focused questions and related PICOs are sent to the Governing Board for review and approval.
Developing the technical review. Over the next several months, the methodologist and content experts meet on a weekly basis to review the search results question-by-question and develop the technical review of evidence that will form the basis of the clinical recommendations. For each PICO, the technical review assesses the entire body of evidence and rates the overall quality of evidence gathered for each outcome related to the PICOs (from “very low” to “low” to “moderate” to “high”).
Drafting the clinical recommendations. The technical review presents the findings of the literature along with the authors’ assessment of the evidence quality. At a face-to-face meeting, these results are presented by the technical review authors to the guideline panel, who are responsible for developing the official guideline document. The role of the guideline panel is to understand the quality of evidence and determine an ultimate list of clinical recommendations and assign a strength (strong or conditional) to each recommendation, all while considering important factors such as the balance between benefits and downsides, potential variability in patients’ values and preferences, and impact on resource utilization. Oftentimes, but not always, recommendations based on higher-quality evidence for which most patients would request the recommended course of action translate into strong recommendations. Recommendations based on lower-quality evidence and those for which there is a higher variability in patient values or issues surrounding resource utilization are more likely to be conditional.
In addition to the guideline document, the guideline panel also drafts a Clinical Decision Support Tool, which illustrates the clinical recommendations within a visual algorithm. At the same time, AGA staff draft a patient summary that explains the recommendations in plain language. This summary can be used by physicians to improve clinical communication and shared decision making with their patients.2
Revising the guideline. Each AGA technical review goes through two layers of review: once by an anonymous peer-review panel of three content experts, and again during a 30-day public comment period in which both the technical review and guideline are posted for public input. The authors take all input into consideration while finalizing the documents, which are sent to the Governing Board for final approval. Once approved by the Board, the technical review, guideline, and all related materials are submitted for publication in Gastroenterology. In addition to print publication, each guideline is disseminated on the AGA website and through the official Clinical Guidelines mobile app (available via the App Store and Google Play), which includes interactive versions of the Clinical Decision Support Tools and plain-language summaries that can be sent via e-mail to patients at the point of care. The AGA is currently pursuing future directions for the dissemination and implementation of our guidelines, such as the seamless integration of clinical recommendations into electronic health records to further improve decision making and facilitate quality measurement and improvement.
Conclusion
Not all clinical guidelines are created with equal rigor. Clinicians should examine guidelines closely and consider whether or not they follow the Institute of Medicine’s standards for trustworthy clinical guidelines: Is the focus on transparency? Is a rigorous conflict of interest system in place that eliminates major sources of financial and intellectual conflict? Was an unconflicted GRADE-trained methodologist involved in ensuring that a systematic review process is followed and the method of rating the quality of evidence and strength of recommendation follows published principles? Are the recommendations clear and actionable?3 AGA Institute guidelines are developed with the goal of striking a balance between presenting the highest ideals of evidence-based medicine while remaining responsive to the needs of everyday practitioners dealing with real patients in real clinical settings.
Ms. Siedler is the director of clinical practice at the AGA Institute national office in Bethesda, Md.; Dr. Falck-Ytter is a professor of medicine at Case-Western Reserve University, Cleveland, chair of the AGA Institute Clinical Guidelines Committee, and chief of the division of gastroenterology at the Louis Stokes VA Medical Center in Cleveland. The authors disclose no conflicts of interest.
References
1. Hanson B., Siedler M., Falck-Ytter Y., Sultan S. Introducing the rapid review: How the AGA is working to get trustworthy clinical guidelines to practitioners in less time. AGA Perspectives. 2017; in press.
2. Siedler M., Allen J., Falck-Ytter Y., Weinberg D. AGA clinical practice guidelines: Robust, evidence-based tools for guiding clinical care decisions. Gastroenterology. 2015;149:493-5.
3. Institute of Medicine: Standards for developing trustworthy clinical practice guidelines. Available at http://www.nationalacademies.org/hmd/Reports/2011/Clinical-Practice-Guidelines-We-Can-Trust/Standards.aspx. Last accessed May 2017.Process for the selection of new guideline topics
Advice on Choosing Your GI Career Path
Mariam Naveed, MD, opened a discussion in the Early Career Group forum in AGA Community that invited GIs to share how or when they knew which career path was the best fit. Among those sharing their stories were Peter Liang, MD, MPH; Avinash Ketwaroo, MD; Maisa Abdalla, MD, MPH; Tara Altepeter, MD; Elliot Tapper, MD; and Brijen Shah, MD. Their expertise spans across the GI spectrum, including academia, research, drug development, and regulatory science.
For Dr. Liang, the key to succeeding on the research path is to be passionate about your topic(s), enjoy reading and writing, and be able to accept constructive criticism and rejection. Dr. Altepeter encourages all GIs early in their career to be open to exploring a variety of career options, as regulatory science was not a career path she was aware of at the beginning of training.
The conversation continued when trainee and early career members brought their career-specific questions, including the possibility of achieving tenure without publishing.
View a summary of advice shared at http://community.gastro.org/calling. The discussions around finding your GI calling are in the AGA Community Early Career Group, at http://community.gastro.org/EarlyCareerGroup.
Mariam Naveed, MD, opened a discussion in the Early Career Group forum in AGA Community that invited GIs to share how or when they knew which career path was the best fit. Among those sharing their stories were Peter Liang, MD, MPH; Avinash Ketwaroo, MD; Maisa Abdalla, MD, MPH; Tara Altepeter, MD; Elliot Tapper, MD; and Brijen Shah, MD. Their expertise spans across the GI spectrum, including academia, research, drug development, and regulatory science.
For Dr. Liang, the key to succeeding on the research path is to be passionate about your topic(s), enjoy reading and writing, and be able to accept constructive criticism and rejection. Dr. Altepeter encourages all GIs early in their career to be open to exploring a variety of career options, as regulatory science was not a career path she was aware of at the beginning of training.
The conversation continued when trainee and early career members brought their career-specific questions, including the possibility of achieving tenure without publishing.
View a summary of advice shared at http://community.gastro.org/calling. The discussions around finding your GI calling are in the AGA Community Early Career Group, at http://community.gastro.org/EarlyCareerGroup.
Mariam Naveed, MD, opened a discussion in the Early Career Group forum in AGA Community that invited GIs to share how or when they knew which career path was the best fit. Among those sharing their stories were Peter Liang, MD, MPH; Avinash Ketwaroo, MD; Maisa Abdalla, MD, MPH; Tara Altepeter, MD; Elliot Tapper, MD; and Brijen Shah, MD. Their expertise spans across the GI spectrum, including academia, research, drug development, and regulatory science.
For Dr. Liang, the key to succeeding on the research path is to be passionate about your topic(s), enjoy reading and writing, and be able to accept constructive criticism and rejection. Dr. Altepeter encourages all GIs early in their career to be open to exploring a variety of career options, as regulatory science was not a career path she was aware of at the beginning of training.
The conversation continued when trainee and early career members brought their career-specific questions, including the possibility of achieving tenure without publishing.
View a summary of advice shared at http://community.gastro.org/calling. The discussions around finding your GI calling are in the AGA Community Early Career Group, at http://community.gastro.org/EarlyCareerGroup.