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Be Kind to Yourself: Preventing Burnout in New GIs Through Self-Compassion
Physician burnout is a growing epidemic, particularly in the early careers of gastroenterologists. Up to 50% of new physicians and trainees experience burnout with the first 3 years of independent practice.1 The negative consequences of burnout are well known – medical errors, depression, substance abuse, and even suicide.2,3 To meet criteria for burnout syndrome (Table 1), one must have two of three core symptoms, often experienced as phases: 1) physical and emotional exhaustion; 2) cynicism and detachment; and 3) feelings of ineffectiveness and lack of accomplishment.4
Emotional exhaustion, one of the earliest symptoms of burnout syndrome was reported to be as high as 63% among gastroenterologists in a survey study I conducted with colleagues a few years ago.5 Similar findings are noted amongst colorectal surgeons.6 We also noted in our study that burnout levels were highest in junior versus senior attendings, with junior attendings reporting more stress related to performing endoscopies and making split-second decisions. Interventional endoscopists may have been disproportionately affected by the latter, reporting that they were more likely to think about possible mistakes they made after work, have difficulty sleeping due to thinking about their day, and have difficulty separating work and personal life.5 Male and female physicians may progress through the phases of burnout differently, with men being more likely to experience cynicism and depersonalization first, followed by fatigue. Men may also not necessarily experience the third phase of feeling ineffective, which can be particularly dangerous because they will continue to push until there is a serious consequence. Women tend to go through all three phases of burnout beginning with emotional exhaustion, with a more rapid progression through the cynicism phase, and may end up spending the majority of their time feeling ineffective and limited in their accomplishments, a recipe for leaving medicine entirely.7
Prevention of burnout through self-compassion
Even though it may sometimes be easy to forget, most of us chose medicine as our profession because of our inherent compassion towards others and desire to care for those in need. But have we properly learned how to apply that same compassion to ourselves?
Self-compassion is one of the primary qualities of a happy, flourishing, resilient individual.8 Self-compassion is a psychological skill that can be applied to feelings of inadequacy, failure, or lack of control and includes: 1) self-kindness, 2) belief in a common humanity, and 3) mindfulness.8
Are you self-compassionate? Take a quiz!
Self-kindness requires us to treat ourselves as kindly as we would a friend or patient in the same situation. We must consciously choose not to use harsh, self-critical language when we make mistakes. We are taught not to berate our trainees for mistakes in the clinical setting – we can be taught not to berate ourselves for shortcomings as well. Self-kindness also requires that we provide ourselves with sympathy when we experience disappointments through no fault of our own (e.g. despite all my best efforts, this clinical initiative failed) and give ourselves the opportunity to nurture and soothe ourselves when we experience pain.6 Belief in a common humanity fosters engagement with others, recognizing that nobody is perfect and that others suffer as well. Isolating ourselves because we feel ashamed, embarrassed, or “crazy” in our experience of a situation only increases our suffering. As we engage with others, we are able to view things from a different perspective and also recognize that others around us have problems too. Indeed, social support may be one of the best buffers against burnout, particularly cynicism.12 A recent meta-analysis concluded that a combination of institutional engagement techniques including reduced hours and support groups as well as access to individual behavioral techniques such as mindfulness could reduce or prevent burnout.13
I have previously commented on the practice of mindfulness in the AGA Community forums and, as a potentially stand-alone component of self-compassion training,14 recommend it here as well. In addition to traditional mindfulness-based stress-reduction courses and mindfulness meditation practice found in many hospitals and community centers, individual meditation focused on loving kindness or gratitude as well as mindful exercises such as writing a self-compassionate letter or statements to yourself can be used to offset burnout in daily life.15 From the perspective of reducing burnout, mindfulness allows us to look at our feelings of cynicism, exhaustion, and inadequacy without judgment, to view them as symptoms rather than ugly truths about ourselves and that rather than avoid or suppress these feelings, to be mindful and compassionate toward them.
Finally, in the spirit of self-compassion, we must not judge ourselves for needing the help of others to navigate adversity – whether that support comes from our personal or professional life, or is provided by a mental health professional, we deserve to be taken care of as much as our patients do.
For more information, please visit the following, helpful resources: www.CenterForMSC.org, www.Self-Compassion.org, and www.MindfulSelfCompassion.org.
Dr. Keefer is director, psychobehavioral research, Icahn School of Medicine at Mount Sinai, division of gastroenterology, New York, N.Y.
References
1. West C.P., Shanafelt T.D., Kolars J.C. JAMA. 2011;306[9]:952-60.
2. Maslach C., Leiter M.P. World Psychiatry. 2016;15[2]:103-11.
3. Ahola K., Honkonen T., Kivimaki M., et al. J Occup Environ Med. 2006;48[10]:1023-30.
4. Ahola K., Honkonen T., Isometsa E., et al. Soc Psychiatry Psychiatr Epidemiol. 2006;41[1]:11-7.
5. Farber B.A. J Clin Psychol. 2000;56[5]:589-94.
6. Keswani R.N., Taft T.H., Cote G.A., Keefer L. Am J Gastroenterol. 2011;106[10]:1734-40.
7. Sharma A., Sharp D.M., Walker L.G., Monson J.R. Psychooncology. 2008;17[6]:570-6.
8. Houkes I., Winants Y., Twellaar M., Verdonk P. BMC Public Health. 2011;11:240.
9. Neff K.D. Hum Dev. 2009;52[4]:211-4.
10. de Vente W., van Amsterdam J.G., Olff M., Kamphuis J.H., Emmelkamp P.M. Biomed Res Int. 2015;2015:431725.
11. Rockliff H., Karl A., McEwan K., Gilbert J., Matos M., Gilbert P. Effects of intranasal oxytocin on ‘compassion focused imagery’. Emotion. 2011;11[6]:1388-96.
12. Porges S.W. Biol Psychol. 2007;74[2]:301-7.
13. Breines J.G., Chen S. Pers Soc Psychol Bull. 2012;38[9]:1133-43.
14. Heffernan M., Quinn G.M.T., Sister R.M., Fitzpatrick JJ. Int J Nurs Pract. 2010;16[4]:366-73.
15. Crocker J., Canevello A. J Pers Soc Psychol. 2008;95[3]:555-75.
16. Thompson G., McBride R.B., Hosford C.C., Halaas G. Teach Learn Med. 2016;28[2]:174-82.
17. Nie Z., Jin Y., He L., et al. Int J Clin Exp Med. 2015;8[10]:19144-9.
18. West C.P., Dyrbye L.N., Erwin P.J., Shanafelt T.D. Lancet. 2016. Nov 5;388(10057)2272-81.
19. Luchterhand C., Rakel D., Haq C., et al. WMJ. 2015;114[3]:105-9.
20. Montero-Marin J., Tops M., Manzanera R, Piva Demarzo MM, Alvarez de Mon M, Garcia-Campayo J. Front Psychol. 2015;6:1895.
Physician burnout is a growing epidemic, particularly in the early careers of gastroenterologists. Up to 50% of new physicians and trainees experience burnout with the first 3 years of independent practice.1 The negative consequences of burnout are well known – medical errors, depression, substance abuse, and even suicide.2,3 To meet criteria for burnout syndrome (Table 1), one must have two of three core symptoms, often experienced as phases: 1) physical and emotional exhaustion; 2) cynicism and detachment; and 3) feelings of ineffectiveness and lack of accomplishment.4
Emotional exhaustion, one of the earliest symptoms of burnout syndrome was reported to be as high as 63% among gastroenterologists in a survey study I conducted with colleagues a few years ago.5 Similar findings are noted amongst colorectal surgeons.6 We also noted in our study that burnout levels were highest in junior versus senior attendings, with junior attendings reporting more stress related to performing endoscopies and making split-second decisions. Interventional endoscopists may have been disproportionately affected by the latter, reporting that they were more likely to think about possible mistakes they made after work, have difficulty sleeping due to thinking about their day, and have difficulty separating work and personal life.5 Male and female physicians may progress through the phases of burnout differently, with men being more likely to experience cynicism and depersonalization first, followed by fatigue. Men may also not necessarily experience the third phase of feeling ineffective, which can be particularly dangerous because they will continue to push until there is a serious consequence. Women tend to go through all three phases of burnout beginning with emotional exhaustion, with a more rapid progression through the cynicism phase, and may end up spending the majority of their time feeling ineffective and limited in their accomplishments, a recipe for leaving medicine entirely.7
Prevention of burnout through self-compassion
Even though it may sometimes be easy to forget, most of us chose medicine as our profession because of our inherent compassion towards others and desire to care for those in need. But have we properly learned how to apply that same compassion to ourselves?
Self-compassion is one of the primary qualities of a happy, flourishing, resilient individual.8 Self-compassion is a psychological skill that can be applied to feelings of inadequacy, failure, or lack of control and includes: 1) self-kindness, 2) belief in a common humanity, and 3) mindfulness.8
Are you self-compassionate? Take a quiz!
Self-kindness requires us to treat ourselves as kindly as we would a friend or patient in the same situation. We must consciously choose not to use harsh, self-critical language when we make mistakes. We are taught not to berate our trainees for mistakes in the clinical setting – we can be taught not to berate ourselves for shortcomings as well. Self-kindness also requires that we provide ourselves with sympathy when we experience disappointments through no fault of our own (e.g. despite all my best efforts, this clinical initiative failed) and give ourselves the opportunity to nurture and soothe ourselves when we experience pain.6 Belief in a common humanity fosters engagement with others, recognizing that nobody is perfect and that others suffer as well. Isolating ourselves because we feel ashamed, embarrassed, or “crazy” in our experience of a situation only increases our suffering. As we engage with others, we are able to view things from a different perspective and also recognize that others around us have problems too. Indeed, social support may be one of the best buffers against burnout, particularly cynicism.12 A recent meta-analysis concluded that a combination of institutional engagement techniques including reduced hours and support groups as well as access to individual behavioral techniques such as mindfulness could reduce or prevent burnout.13
I have previously commented on the practice of mindfulness in the AGA Community forums and, as a potentially stand-alone component of self-compassion training,14 recommend it here as well. In addition to traditional mindfulness-based stress-reduction courses and mindfulness meditation practice found in many hospitals and community centers, individual meditation focused on loving kindness or gratitude as well as mindful exercises such as writing a self-compassionate letter or statements to yourself can be used to offset burnout in daily life.15 From the perspective of reducing burnout, mindfulness allows us to look at our feelings of cynicism, exhaustion, and inadequacy without judgment, to view them as symptoms rather than ugly truths about ourselves and that rather than avoid or suppress these feelings, to be mindful and compassionate toward them.
Finally, in the spirit of self-compassion, we must not judge ourselves for needing the help of others to navigate adversity – whether that support comes from our personal or professional life, or is provided by a mental health professional, we deserve to be taken care of as much as our patients do.
For more information, please visit the following, helpful resources: www.CenterForMSC.org, www.Self-Compassion.org, and www.MindfulSelfCompassion.org.
Dr. Keefer is director, psychobehavioral research, Icahn School of Medicine at Mount Sinai, division of gastroenterology, New York, N.Y.
References
1. West C.P., Shanafelt T.D., Kolars J.C. JAMA. 2011;306[9]:952-60.
2. Maslach C., Leiter M.P. World Psychiatry. 2016;15[2]:103-11.
3. Ahola K., Honkonen T., Kivimaki M., et al. J Occup Environ Med. 2006;48[10]:1023-30.
4. Ahola K., Honkonen T., Isometsa E., et al. Soc Psychiatry Psychiatr Epidemiol. 2006;41[1]:11-7.
5. Farber B.A. J Clin Psychol. 2000;56[5]:589-94.
6. Keswani R.N., Taft T.H., Cote G.A., Keefer L. Am J Gastroenterol. 2011;106[10]:1734-40.
7. Sharma A., Sharp D.M., Walker L.G., Monson J.R. Psychooncology. 2008;17[6]:570-6.
8. Houkes I., Winants Y., Twellaar M., Verdonk P. BMC Public Health. 2011;11:240.
9. Neff K.D. Hum Dev. 2009;52[4]:211-4.
10. de Vente W., van Amsterdam J.G., Olff M., Kamphuis J.H., Emmelkamp P.M. Biomed Res Int. 2015;2015:431725.
11. Rockliff H., Karl A., McEwan K., Gilbert J., Matos M., Gilbert P. Effects of intranasal oxytocin on ‘compassion focused imagery’. Emotion. 2011;11[6]:1388-96.
12. Porges S.W. Biol Psychol. 2007;74[2]:301-7.
13. Breines J.G., Chen S. Pers Soc Psychol Bull. 2012;38[9]:1133-43.
14. Heffernan M., Quinn G.M.T., Sister R.M., Fitzpatrick JJ. Int J Nurs Pract. 2010;16[4]:366-73.
15. Crocker J., Canevello A. J Pers Soc Psychol. 2008;95[3]:555-75.
16. Thompson G., McBride R.B., Hosford C.C., Halaas G. Teach Learn Med. 2016;28[2]:174-82.
17. Nie Z., Jin Y., He L., et al. Int J Clin Exp Med. 2015;8[10]:19144-9.
18. West C.P., Dyrbye L.N., Erwin P.J., Shanafelt T.D. Lancet. 2016. Nov 5;388(10057)2272-81.
19. Luchterhand C., Rakel D., Haq C., et al. WMJ. 2015;114[3]:105-9.
20. Montero-Marin J., Tops M., Manzanera R, Piva Demarzo MM, Alvarez de Mon M, Garcia-Campayo J. Front Psychol. 2015;6:1895.
Physician burnout is a growing epidemic, particularly in the early careers of gastroenterologists. Up to 50% of new physicians and trainees experience burnout with the first 3 years of independent practice.1 The negative consequences of burnout are well known – medical errors, depression, substance abuse, and even suicide.2,3 To meet criteria for burnout syndrome (Table 1), one must have two of three core symptoms, often experienced as phases: 1) physical and emotional exhaustion; 2) cynicism and detachment; and 3) feelings of ineffectiveness and lack of accomplishment.4
Emotional exhaustion, one of the earliest symptoms of burnout syndrome was reported to be as high as 63% among gastroenterologists in a survey study I conducted with colleagues a few years ago.5 Similar findings are noted amongst colorectal surgeons.6 We also noted in our study that burnout levels were highest in junior versus senior attendings, with junior attendings reporting more stress related to performing endoscopies and making split-second decisions. Interventional endoscopists may have been disproportionately affected by the latter, reporting that they were more likely to think about possible mistakes they made after work, have difficulty sleeping due to thinking about their day, and have difficulty separating work and personal life.5 Male and female physicians may progress through the phases of burnout differently, with men being more likely to experience cynicism and depersonalization first, followed by fatigue. Men may also not necessarily experience the third phase of feeling ineffective, which can be particularly dangerous because they will continue to push until there is a serious consequence. Women tend to go through all three phases of burnout beginning with emotional exhaustion, with a more rapid progression through the cynicism phase, and may end up spending the majority of their time feeling ineffective and limited in their accomplishments, a recipe for leaving medicine entirely.7
Prevention of burnout through self-compassion
Even though it may sometimes be easy to forget, most of us chose medicine as our profession because of our inherent compassion towards others and desire to care for those in need. But have we properly learned how to apply that same compassion to ourselves?
Self-compassion is one of the primary qualities of a happy, flourishing, resilient individual.8 Self-compassion is a psychological skill that can be applied to feelings of inadequacy, failure, or lack of control and includes: 1) self-kindness, 2) belief in a common humanity, and 3) mindfulness.8
Are you self-compassionate? Take a quiz!
Self-kindness requires us to treat ourselves as kindly as we would a friend or patient in the same situation. We must consciously choose not to use harsh, self-critical language when we make mistakes. We are taught not to berate our trainees for mistakes in the clinical setting – we can be taught not to berate ourselves for shortcomings as well. Self-kindness also requires that we provide ourselves with sympathy when we experience disappointments through no fault of our own (e.g. despite all my best efforts, this clinical initiative failed) and give ourselves the opportunity to nurture and soothe ourselves when we experience pain.6 Belief in a common humanity fosters engagement with others, recognizing that nobody is perfect and that others suffer as well. Isolating ourselves because we feel ashamed, embarrassed, or “crazy” in our experience of a situation only increases our suffering. As we engage with others, we are able to view things from a different perspective and also recognize that others around us have problems too. Indeed, social support may be one of the best buffers against burnout, particularly cynicism.12 A recent meta-analysis concluded that a combination of institutional engagement techniques including reduced hours and support groups as well as access to individual behavioral techniques such as mindfulness could reduce or prevent burnout.13
I have previously commented on the practice of mindfulness in the AGA Community forums and, as a potentially stand-alone component of self-compassion training,14 recommend it here as well. In addition to traditional mindfulness-based stress-reduction courses and mindfulness meditation practice found in many hospitals and community centers, individual meditation focused on loving kindness or gratitude as well as mindful exercises such as writing a self-compassionate letter or statements to yourself can be used to offset burnout in daily life.15 From the perspective of reducing burnout, mindfulness allows us to look at our feelings of cynicism, exhaustion, and inadequacy without judgment, to view them as symptoms rather than ugly truths about ourselves and that rather than avoid or suppress these feelings, to be mindful and compassionate toward them.
Finally, in the spirit of self-compassion, we must not judge ourselves for needing the help of others to navigate adversity – whether that support comes from our personal or professional life, or is provided by a mental health professional, we deserve to be taken care of as much as our patients do.
For more information, please visit the following, helpful resources: www.CenterForMSC.org, www.Self-Compassion.org, and www.MindfulSelfCompassion.org.
Dr. Keefer is director, psychobehavioral research, Icahn School of Medicine at Mount Sinai, division of gastroenterology, New York, N.Y.
References
1. West C.P., Shanafelt T.D., Kolars J.C. JAMA. 2011;306[9]:952-60.
2. Maslach C., Leiter M.P. World Psychiatry. 2016;15[2]:103-11.
3. Ahola K., Honkonen T., Kivimaki M., et al. J Occup Environ Med. 2006;48[10]:1023-30.
4. Ahola K., Honkonen T., Isometsa E., et al. Soc Psychiatry Psychiatr Epidemiol. 2006;41[1]:11-7.
5. Farber B.A. J Clin Psychol. 2000;56[5]:589-94.
6. Keswani R.N., Taft T.H., Cote G.A., Keefer L. Am J Gastroenterol. 2011;106[10]:1734-40.
7. Sharma A., Sharp D.M., Walker L.G., Monson J.R. Psychooncology. 2008;17[6]:570-6.
8. Houkes I., Winants Y., Twellaar M., Verdonk P. BMC Public Health. 2011;11:240.
9. Neff K.D. Hum Dev. 2009;52[4]:211-4.
10. de Vente W., van Amsterdam J.G., Olff M., Kamphuis J.H., Emmelkamp P.M. Biomed Res Int. 2015;2015:431725.
11. Rockliff H., Karl A., McEwan K., Gilbert J., Matos M., Gilbert P. Effects of intranasal oxytocin on ‘compassion focused imagery’. Emotion. 2011;11[6]:1388-96.
12. Porges S.W. Biol Psychol. 2007;74[2]:301-7.
13. Breines J.G., Chen S. Pers Soc Psychol Bull. 2012;38[9]:1133-43.
14. Heffernan M., Quinn G.M.T., Sister R.M., Fitzpatrick JJ. Int J Nurs Pract. 2010;16[4]:366-73.
15. Crocker J., Canevello A. J Pers Soc Psychol. 2008;95[3]:555-75.
16. Thompson G., McBride R.B., Hosford C.C., Halaas G. Teach Learn Med. 2016;28[2]:174-82.
17. Nie Z., Jin Y., He L., et al. Int J Clin Exp Med. 2015;8[10]:19144-9.
18. West C.P., Dyrbye L.N., Erwin P.J., Shanafelt T.D. Lancet. 2016. Nov 5;388(10057)2272-81.
19. Luchterhand C., Rakel D., Haq C., et al. WMJ. 2015;114[3]:105-9.
20. Montero-Marin J., Tops M., Manzanera R, Piva Demarzo MM, Alvarez de Mon M, Garcia-Campayo J. Front Psychol. 2015;6:1895.
Diversity in GI Training: A Timely Goal
There is no denying that practicing medicine calls us to serve a population that is diverse in many aspects. We live and work in a world that is evolving so quickly that medical workforce demographics fail to keep pace. In the U.S. in particular, racial and ethnic diversity has already exceeded many previous forecasts and will likely continue to do so.
The American Gastroenterological Association (AGA) recognizes that broader representation in the GI workforce requires increasing diversity at the trainee level and values this change for reasons beyond diversity for diversity’s sake. Based on education research, improving diversity at the trainee level helps learners thrive through the sharing of varied perspectives and enhancement of complex, critical thinking5. Moreover, diverse learning environments promote a culture of tolerance and understanding, tools needed to prepare trainees for future patient interactions. Diversity also translates into better patient satisfaction, as several studies have shown that physician-patient concordance on race, ethnicity, and gender result in higher patient satisfaction scores6. Additionally, minority physicians are more likely to practice in underserved areas and to conduct research addressing health care disparities, an area that will require an even greater investment as the U.S. population demographic continues to evolve3,7.
The AGA is committed to diversity, which is an inclusive concept that encompasses race, ethnicity, national origin, religion, gender, age, sexual orientation, and disability. We strive to cultivate diversity within the organization at all levels, including governance, committee structure, staffing, and program and policy development. We are committed to the following goals intended to reflect the interests of the diverse patient population we serve:
1) Promotion of diversity within the practice of gastroenterology and in the individual care of patients of all backgrounds.
2) Recruitment and retention of GI providers and researchers from diverse backgrounds and the support of the advancement of their careers.
3) Elimination of disparities in GI diseases through community engagement, research, and advocacy.
Gastroenterology has been the most competitive fellowship specialty for the past 4 consecutive years, above pediatric surgery and cardiology8. We are privileged to practice an exciting, fascinating specialty that demands diversity of skill, acuity of care, and knowledge of pathophysiology. Increased diversity among those who research, teach, and practice in this wonderful field will only enhance it, and being mindful of this goal in our recruitment and retention efforts will help us achieve it.
For more information on the AGA Institute Diversity Committee and its ongoing initiatives, please visit http://www.gastro.org/about/people/committees/diversity-committee. Additionally, any specific enquiries should be addressed to Taylor Monson ([email protected]).
Dr. Quezeda is assistant dean for admissions, assistant professor of medicine, division of gastroenterology and hepatology, University of Maryland School of Medicine, Baltimore, and a member of the AGA Institute Diversity Committee.
On behalf of the AGA Institute Diversity Committee: Rotonya M. Carr, MD (Chair, AGA Diversity Committee; assistant professor of medicine, division of gastroenterology, University of Pennsylvania, Philadelphia), Karen A. Chachu, MD, PhD (assistant professor of medicine, Duke University, Durham, N.C.), Elizabeth Coss, MD (clinical assistant professor, University of Texas Health Science Center at San Antonio), Maria Cruz-Correa, MD PhD (associate professor of medicine, biochemistry and surgery, University of Puerto Rico Comprehensive Cancer Center), Lukejohn Day, MD (associate clinical professor, University of California, San Francisco), Darrell M. Gray II, MD, MPH (assistant professor of medicine, The Ohio State University Wexner Medical Center), Esi Lamouse-Smith, MD, PhD (assistant professor of pediatrics, Columbia University, New York), Antonio Mendoza Ladd, MD (assistant professor, Texas Tech University Health Sciences Center, El Paso), and Celena NuQuay (AGA staff liaison).
References
1. Projections of the Size and Composition of the U.S. Population: 2014 to 2060 Population Estimates and Projections Current Population Reports. Colby S, Ortman JM. Issued March 2015.
2. Association of American Medical Colleges 2016 Physician Specialty Databook, https://www.aamc.org/data/workforce/reports/457712/2016-specialty-databook.html.
3. Association of American Medical Colleges Diversity in the Physician Workforce: Facts and Figures 2010.
4. Deville C, Hwang WT, Burgos R. Diversity in Graduate Medical Education in the United States by Race, Ethnicity, and Sex, 2012. JAMA Intern Med. 2015;175(10):1706-8.
5. Wells AS, Fox L, Cordova-Cobo D. How Racially Diverse Schools and Classrooms Can Benefit All Students. The Century Foundation, Feb 2016. https://tcf.org/content/report/how-racially-diverse-schools-and-classrooms-can-benefit-all-students/.
6. Johnson RL, Saha S, Arbelaez JJ et al. Racial and ethnic differences in patient perceptions of bias and cultural competence in health care. J Gen Intern Med. 2004 Feb;19(2):101-10.
7. Saha S, Guiton G, Wimmers PF et al. Student body racial and ethnic composition and diversity-related outcomes in US medical schools. JAMA. 2008 Sep 10;300(10):1135-45.
8. Association of American Medical Colleges, ERAS Data. https://www.aamc.org/services/eras/stats/359278/stats.html.
There is no denying that practicing medicine calls us to serve a population that is diverse in many aspects. We live and work in a world that is evolving so quickly that medical workforce demographics fail to keep pace. In the U.S. in particular, racial and ethnic diversity has already exceeded many previous forecasts and will likely continue to do so.
The American Gastroenterological Association (AGA) recognizes that broader representation in the GI workforce requires increasing diversity at the trainee level and values this change for reasons beyond diversity for diversity’s sake. Based on education research, improving diversity at the trainee level helps learners thrive through the sharing of varied perspectives and enhancement of complex, critical thinking5. Moreover, diverse learning environments promote a culture of tolerance and understanding, tools needed to prepare trainees for future patient interactions. Diversity also translates into better patient satisfaction, as several studies have shown that physician-patient concordance on race, ethnicity, and gender result in higher patient satisfaction scores6. Additionally, minority physicians are more likely to practice in underserved areas and to conduct research addressing health care disparities, an area that will require an even greater investment as the U.S. population demographic continues to evolve3,7.
The AGA is committed to diversity, which is an inclusive concept that encompasses race, ethnicity, national origin, religion, gender, age, sexual orientation, and disability. We strive to cultivate diversity within the organization at all levels, including governance, committee structure, staffing, and program and policy development. We are committed to the following goals intended to reflect the interests of the diverse patient population we serve:
1) Promotion of diversity within the practice of gastroenterology and in the individual care of patients of all backgrounds.
2) Recruitment and retention of GI providers and researchers from diverse backgrounds and the support of the advancement of their careers.
3) Elimination of disparities in GI diseases through community engagement, research, and advocacy.
Gastroenterology has been the most competitive fellowship specialty for the past 4 consecutive years, above pediatric surgery and cardiology8. We are privileged to practice an exciting, fascinating specialty that demands diversity of skill, acuity of care, and knowledge of pathophysiology. Increased diversity among those who research, teach, and practice in this wonderful field will only enhance it, and being mindful of this goal in our recruitment and retention efforts will help us achieve it.
For more information on the AGA Institute Diversity Committee and its ongoing initiatives, please visit http://www.gastro.org/about/people/committees/diversity-committee. Additionally, any specific enquiries should be addressed to Taylor Monson ([email protected]).
Dr. Quezeda is assistant dean for admissions, assistant professor of medicine, division of gastroenterology and hepatology, University of Maryland School of Medicine, Baltimore, and a member of the AGA Institute Diversity Committee.
On behalf of the AGA Institute Diversity Committee: Rotonya M. Carr, MD (Chair, AGA Diversity Committee; assistant professor of medicine, division of gastroenterology, University of Pennsylvania, Philadelphia), Karen A. Chachu, MD, PhD (assistant professor of medicine, Duke University, Durham, N.C.), Elizabeth Coss, MD (clinical assistant professor, University of Texas Health Science Center at San Antonio), Maria Cruz-Correa, MD PhD (associate professor of medicine, biochemistry and surgery, University of Puerto Rico Comprehensive Cancer Center), Lukejohn Day, MD (associate clinical professor, University of California, San Francisco), Darrell M. Gray II, MD, MPH (assistant professor of medicine, The Ohio State University Wexner Medical Center), Esi Lamouse-Smith, MD, PhD (assistant professor of pediatrics, Columbia University, New York), Antonio Mendoza Ladd, MD (assistant professor, Texas Tech University Health Sciences Center, El Paso), and Celena NuQuay (AGA staff liaison).
References
1. Projections of the Size and Composition of the U.S. Population: 2014 to 2060 Population Estimates and Projections Current Population Reports. Colby S, Ortman JM. Issued March 2015.
2. Association of American Medical Colleges 2016 Physician Specialty Databook, https://www.aamc.org/data/workforce/reports/457712/2016-specialty-databook.html.
3. Association of American Medical Colleges Diversity in the Physician Workforce: Facts and Figures 2010.
4. Deville C, Hwang WT, Burgos R. Diversity in Graduate Medical Education in the United States by Race, Ethnicity, and Sex, 2012. JAMA Intern Med. 2015;175(10):1706-8.
5. Wells AS, Fox L, Cordova-Cobo D. How Racially Diverse Schools and Classrooms Can Benefit All Students. The Century Foundation, Feb 2016. https://tcf.org/content/report/how-racially-diverse-schools-and-classrooms-can-benefit-all-students/.
6. Johnson RL, Saha S, Arbelaez JJ et al. Racial and ethnic differences in patient perceptions of bias and cultural competence in health care. J Gen Intern Med. 2004 Feb;19(2):101-10.
7. Saha S, Guiton G, Wimmers PF et al. Student body racial and ethnic composition and diversity-related outcomes in US medical schools. JAMA. 2008 Sep 10;300(10):1135-45.
8. Association of American Medical Colleges, ERAS Data. https://www.aamc.org/services/eras/stats/359278/stats.html.
There is no denying that practicing medicine calls us to serve a population that is diverse in many aspects. We live and work in a world that is evolving so quickly that medical workforce demographics fail to keep pace. In the U.S. in particular, racial and ethnic diversity has already exceeded many previous forecasts and will likely continue to do so.
The American Gastroenterological Association (AGA) recognizes that broader representation in the GI workforce requires increasing diversity at the trainee level and values this change for reasons beyond diversity for diversity’s sake. Based on education research, improving diversity at the trainee level helps learners thrive through the sharing of varied perspectives and enhancement of complex, critical thinking5. Moreover, diverse learning environments promote a culture of tolerance and understanding, tools needed to prepare trainees for future patient interactions. Diversity also translates into better patient satisfaction, as several studies have shown that physician-patient concordance on race, ethnicity, and gender result in higher patient satisfaction scores6. Additionally, minority physicians are more likely to practice in underserved areas and to conduct research addressing health care disparities, an area that will require an even greater investment as the U.S. population demographic continues to evolve3,7.
The AGA is committed to diversity, which is an inclusive concept that encompasses race, ethnicity, national origin, religion, gender, age, sexual orientation, and disability. We strive to cultivate diversity within the organization at all levels, including governance, committee structure, staffing, and program and policy development. We are committed to the following goals intended to reflect the interests of the diverse patient population we serve:
1) Promotion of diversity within the practice of gastroenterology and in the individual care of patients of all backgrounds.
2) Recruitment and retention of GI providers and researchers from diverse backgrounds and the support of the advancement of their careers.
3) Elimination of disparities in GI diseases through community engagement, research, and advocacy.
Gastroenterology has been the most competitive fellowship specialty for the past 4 consecutive years, above pediatric surgery and cardiology8. We are privileged to practice an exciting, fascinating specialty that demands diversity of skill, acuity of care, and knowledge of pathophysiology. Increased diversity among those who research, teach, and practice in this wonderful field will only enhance it, and being mindful of this goal in our recruitment and retention efforts will help us achieve it.
For more information on the AGA Institute Diversity Committee and its ongoing initiatives, please visit http://www.gastro.org/about/people/committees/diversity-committee. Additionally, any specific enquiries should be addressed to Taylor Monson ([email protected]).
Dr. Quezeda is assistant dean for admissions, assistant professor of medicine, division of gastroenterology and hepatology, University of Maryland School of Medicine, Baltimore, and a member of the AGA Institute Diversity Committee.
On behalf of the AGA Institute Diversity Committee: Rotonya M. Carr, MD (Chair, AGA Diversity Committee; assistant professor of medicine, division of gastroenterology, University of Pennsylvania, Philadelphia), Karen A. Chachu, MD, PhD (assistant professor of medicine, Duke University, Durham, N.C.), Elizabeth Coss, MD (clinical assistant professor, University of Texas Health Science Center at San Antonio), Maria Cruz-Correa, MD PhD (associate professor of medicine, biochemistry and surgery, University of Puerto Rico Comprehensive Cancer Center), Lukejohn Day, MD (associate clinical professor, University of California, San Francisco), Darrell M. Gray II, MD, MPH (assistant professor of medicine, The Ohio State University Wexner Medical Center), Esi Lamouse-Smith, MD, PhD (assistant professor of pediatrics, Columbia University, New York), Antonio Mendoza Ladd, MD (assistant professor, Texas Tech University Health Sciences Center, El Paso), and Celena NuQuay (AGA staff liaison).
References
1. Projections of the Size and Composition of the U.S. Population: 2014 to 2060 Population Estimates and Projections Current Population Reports. Colby S, Ortman JM. Issued March 2015.
2. Association of American Medical Colleges 2016 Physician Specialty Databook, https://www.aamc.org/data/workforce/reports/457712/2016-specialty-databook.html.
3. Association of American Medical Colleges Diversity in the Physician Workforce: Facts and Figures 2010.
4. Deville C, Hwang WT, Burgos R. Diversity in Graduate Medical Education in the United States by Race, Ethnicity, and Sex, 2012. JAMA Intern Med. 2015;175(10):1706-8.
5. Wells AS, Fox L, Cordova-Cobo D. How Racially Diverse Schools and Classrooms Can Benefit All Students. The Century Foundation, Feb 2016. https://tcf.org/content/report/how-racially-diverse-schools-and-classrooms-can-benefit-all-students/.
6. Johnson RL, Saha S, Arbelaez JJ et al. Racial and ethnic differences in patient perceptions of bias and cultural competence in health care. J Gen Intern Med. 2004 Feb;19(2):101-10.
7. Saha S, Guiton G, Wimmers PF et al. Student body racial and ethnic composition and diversity-related outcomes in US medical schools. JAMA. 2008 Sep 10;300(10):1135-45.
8. Association of American Medical Colleges, ERAS Data. https://www.aamc.org/services/eras/stats/359278/stats.html.
Ten Financial Tips for a Worry-Free Retirement
As a contract and tax attorney for physicians for over 30 years, I have reviewed many asset summaries of late-career physicians. Although most have historically strong annual incomes of $200,000 to $400,000, accumulated wealth varies tremendously. Some physicians in their 60s have a home, a small retirement plan, and little else. Others have cash equivalents of $5,000,000 or more, no debt, real estate, and other assets. In my experience, this variance usually does not relate primarily to income differences but rather spending control and financial knowledge. If you are interested in having the opportunity to retire and not worry about finding an “early bird” special at your favorite restaurant, this article provides ten tips to help you achieve that dream.
2. Contribute to an employer retirement plan. Contribute to your employer’s Roth 401-K or regular 401-K. Add money starting the first day you are eligible at the rate of at least 5% of your compensation. By age 35, contribute no less than 10% of your compensation up to the legal maximum. In a Roth 401-K, you will have decades of tax-free accumulation. You may also enjoy the employer matching contribution, which varies from job to job. Do not take loans on 401-K plans. If you borrow and then terminate employment before completing repayment, the borrowed funds are treated as a plan distribution, subjecting them to taxation and possibly a penalty if you are under age 59.5. If switching jobs, move your 401-K retirement plan account into an IRA; do not cash it out. If necessary, you usually can withdraw funds to make a down payment on a home or for an emergency, but plan contributions should be viewed as “tomorrow” money. You can borrow to purchase a home and to finance your children’s educations but you cannot borrow to retire.
3. Be debt-free. It is easier to accumulate wealth if you are debt-free. Mortgages, student loans, and car payments should be minimized and eliminated as quickly as possible so that available net income is used to invest both through retirement plans and on an after-tax basis. Cars should be purchased, not leased as the “tax benefit” of leasing is a myth. Leasing a car is an expensive way of borrowing money, as you are effectively purchasing only the most expensive depreciating years of the car’s useful life (the initial few years). You should also not have credit card debt at any time as credit card debt means you are spending money before you earn it. Borrowing for clothing or a vacation reflects the inability to control one’s spending.
4. Use tax-advantaged investment vehicles. Interest income on your investments is taxed at ordinary income rates, perhaps 30% or more, but dividends issued from stock or stock mutual funds are taxed at lower long-term capital gains rates. Similarly, when you sell a stock or a stock mutual fund, the appreciation is taxed at long-term capital gains rates under most circumstances. As you are able to set funds aside, make sure that you are using tax-advantaged investment vehicles.
5. Consider no-load mutual funds. When investing in the stock market or otherwise, consider no-load mutual funds such as those offered by Vanguard that do not require an “investment advisor.” Such funds do not have sales charges and save you money. The greatest chance you have of underperforming the market relates to the expenses associated with investment, more so than the particular investments selected. Since almost all advisors underperform the market, you should consider investing on your own, minimizing costs, and watching your funds grow. As a younger physician with many high-income years in front of you, a good portion of your investments should be in equities to enjoy their appreciation over decades. With bank interest rates being minuscule, there is no reasonable alternative.
6. Develop a budget. If you or your spouse has an issue with shopping or overspending, it is imperative that you develop a budget: first allocating funds to long-term savings such as a retirement plan, next to short-term savings, then to unavoidable recurring costs such as rent or mortgage, student loans, food, and discretionary expenditures. The perfect time to put this in place is when you go from the salary of a resident or fellow into a full-time job and your pay increases by multifold. Read the book The Millionaire Next Door: The Surprising Secrets of America’s Wealthy by Thomas J. Stanley and gain control, as it is easy to do otherwise with an unprecedented and significant salary jump. If you start to live on your new salary, you will never be in a position to amass wealth and retire comfortably.
7. Send your kids to public, not private school. For each of your children, would you rather pay astronomic tuition bills for 4-8 years of college or 16-20 years counting grades 1-12 in private school? When you have children approaching school age, choose an A+ school district and send your kids to public school, not private school – they will still get into competitive colleges. This can save hundreds of thousands of dollars per child.
8. Fund a 529 plan. Whether or not you currently have children, you can fund a 529 plan to enjoy tax-free growth and plan for education expenses of children or future children. If you do not have children yet, you can name yourself or a different party as the beneficiary and then change it after children are born. If you do not have children, you can either use the 529 for someone else or cash the investment and recover the money including growth/loss thereon. Trying to fund college educations out of current income is difficult and it is better to prefund than to pay back student loans over many years.
9. Draft a will. If you are married or have children or both, it is imperative that you have wills drafted so that your wishes are implemented upon your passing. Many tax advantages are available without using complicated trusts and it is important that you maintain up-to-date wills should the unforeseen occur.
10. Purchase disability and life insurance. Your most valuable financial asset is your income stream over the coming years. Protect it with adequate private disability and life insurance policies. Policies provided by your employer typically end upon termination of employment and having a portable policy is important.
These tips will help you maximize your financial position over your work life and through retirement. The best time to get on the right track is yesterday; the second best time is today. Staying in shape financially is easier than messing up and then attempting to fix it.
Mr. Schiller is a physician contract and tax attorney and has practiced in Norristown, Penn. for the past 30 years. He can be contacted at 610-277-5900 or www.schillerlawassociates.com or [email protected].
As a contract and tax attorney for physicians for over 30 years, I have reviewed many asset summaries of late-career physicians. Although most have historically strong annual incomes of $200,000 to $400,000, accumulated wealth varies tremendously. Some physicians in their 60s have a home, a small retirement plan, and little else. Others have cash equivalents of $5,000,000 or more, no debt, real estate, and other assets. In my experience, this variance usually does not relate primarily to income differences but rather spending control and financial knowledge. If you are interested in having the opportunity to retire and not worry about finding an “early bird” special at your favorite restaurant, this article provides ten tips to help you achieve that dream.
2. Contribute to an employer retirement plan. Contribute to your employer’s Roth 401-K or regular 401-K. Add money starting the first day you are eligible at the rate of at least 5% of your compensation. By age 35, contribute no less than 10% of your compensation up to the legal maximum. In a Roth 401-K, you will have decades of tax-free accumulation. You may also enjoy the employer matching contribution, which varies from job to job. Do not take loans on 401-K plans. If you borrow and then terminate employment before completing repayment, the borrowed funds are treated as a plan distribution, subjecting them to taxation and possibly a penalty if you are under age 59.5. If switching jobs, move your 401-K retirement plan account into an IRA; do not cash it out. If necessary, you usually can withdraw funds to make a down payment on a home or for an emergency, but plan contributions should be viewed as “tomorrow” money. You can borrow to purchase a home and to finance your children’s educations but you cannot borrow to retire.
3. Be debt-free. It is easier to accumulate wealth if you are debt-free. Mortgages, student loans, and car payments should be minimized and eliminated as quickly as possible so that available net income is used to invest both through retirement plans and on an after-tax basis. Cars should be purchased, not leased as the “tax benefit” of leasing is a myth. Leasing a car is an expensive way of borrowing money, as you are effectively purchasing only the most expensive depreciating years of the car’s useful life (the initial few years). You should also not have credit card debt at any time as credit card debt means you are spending money before you earn it. Borrowing for clothing or a vacation reflects the inability to control one’s spending.
4. Use tax-advantaged investment vehicles. Interest income on your investments is taxed at ordinary income rates, perhaps 30% or more, but dividends issued from stock or stock mutual funds are taxed at lower long-term capital gains rates. Similarly, when you sell a stock or a stock mutual fund, the appreciation is taxed at long-term capital gains rates under most circumstances. As you are able to set funds aside, make sure that you are using tax-advantaged investment vehicles.
5. Consider no-load mutual funds. When investing in the stock market or otherwise, consider no-load mutual funds such as those offered by Vanguard that do not require an “investment advisor.” Such funds do not have sales charges and save you money. The greatest chance you have of underperforming the market relates to the expenses associated with investment, more so than the particular investments selected. Since almost all advisors underperform the market, you should consider investing on your own, minimizing costs, and watching your funds grow. As a younger physician with many high-income years in front of you, a good portion of your investments should be in equities to enjoy their appreciation over decades. With bank interest rates being minuscule, there is no reasonable alternative.
6. Develop a budget. If you or your spouse has an issue with shopping or overspending, it is imperative that you develop a budget: first allocating funds to long-term savings such as a retirement plan, next to short-term savings, then to unavoidable recurring costs such as rent or mortgage, student loans, food, and discretionary expenditures. The perfect time to put this in place is when you go from the salary of a resident or fellow into a full-time job and your pay increases by multifold. Read the book The Millionaire Next Door: The Surprising Secrets of America’s Wealthy by Thomas J. Stanley and gain control, as it is easy to do otherwise with an unprecedented and significant salary jump. If you start to live on your new salary, you will never be in a position to amass wealth and retire comfortably.
7. Send your kids to public, not private school. For each of your children, would you rather pay astronomic tuition bills for 4-8 years of college or 16-20 years counting grades 1-12 in private school? When you have children approaching school age, choose an A+ school district and send your kids to public school, not private school – they will still get into competitive colleges. This can save hundreds of thousands of dollars per child.
8. Fund a 529 plan. Whether or not you currently have children, you can fund a 529 plan to enjoy tax-free growth and plan for education expenses of children or future children. If you do not have children yet, you can name yourself or a different party as the beneficiary and then change it after children are born. If you do not have children, you can either use the 529 for someone else or cash the investment and recover the money including growth/loss thereon. Trying to fund college educations out of current income is difficult and it is better to prefund than to pay back student loans over many years.
9. Draft a will. If you are married or have children or both, it is imperative that you have wills drafted so that your wishes are implemented upon your passing. Many tax advantages are available without using complicated trusts and it is important that you maintain up-to-date wills should the unforeseen occur.
10. Purchase disability and life insurance. Your most valuable financial asset is your income stream over the coming years. Protect it with adequate private disability and life insurance policies. Policies provided by your employer typically end upon termination of employment and having a portable policy is important.
These tips will help you maximize your financial position over your work life and through retirement. The best time to get on the right track is yesterday; the second best time is today. Staying in shape financially is easier than messing up and then attempting to fix it.
Mr. Schiller is a physician contract and tax attorney and has practiced in Norristown, Penn. for the past 30 years. He can be contacted at 610-277-5900 or www.schillerlawassociates.com or [email protected].
As a contract and tax attorney for physicians for over 30 years, I have reviewed many asset summaries of late-career physicians. Although most have historically strong annual incomes of $200,000 to $400,000, accumulated wealth varies tremendously. Some physicians in their 60s have a home, a small retirement plan, and little else. Others have cash equivalents of $5,000,000 or more, no debt, real estate, and other assets. In my experience, this variance usually does not relate primarily to income differences but rather spending control and financial knowledge. If you are interested in having the opportunity to retire and not worry about finding an “early bird” special at your favorite restaurant, this article provides ten tips to help you achieve that dream.
2. Contribute to an employer retirement plan. Contribute to your employer’s Roth 401-K or regular 401-K. Add money starting the first day you are eligible at the rate of at least 5% of your compensation. By age 35, contribute no less than 10% of your compensation up to the legal maximum. In a Roth 401-K, you will have decades of tax-free accumulation. You may also enjoy the employer matching contribution, which varies from job to job. Do not take loans on 401-K plans. If you borrow and then terminate employment before completing repayment, the borrowed funds are treated as a plan distribution, subjecting them to taxation and possibly a penalty if you are under age 59.5. If switching jobs, move your 401-K retirement plan account into an IRA; do not cash it out. If necessary, you usually can withdraw funds to make a down payment on a home or for an emergency, but plan contributions should be viewed as “tomorrow” money. You can borrow to purchase a home and to finance your children’s educations but you cannot borrow to retire.
3. Be debt-free. It is easier to accumulate wealth if you are debt-free. Mortgages, student loans, and car payments should be minimized and eliminated as quickly as possible so that available net income is used to invest both through retirement plans and on an after-tax basis. Cars should be purchased, not leased as the “tax benefit” of leasing is a myth. Leasing a car is an expensive way of borrowing money, as you are effectively purchasing only the most expensive depreciating years of the car’s useful life (the initial few years). You should also not have credit card debt at any time as credit card debt means you are spending money before you earn it. Borrowing for clothing or a vacation reflects the inability to control one’s spending.
4. Use tax-advantaged investment vehicles. Interest income on your investments is taxed at ordinary income rates, perhaps 30% or more, but dividends issued from stock or stock mutual funds are taxed at lower long-term capital gains rates. Similarly, when you sell a stock or a stock mutual fund, the appreciation is taxed at long-term capital gains rates under most circumstances. As you are able to set funds aside, make sure that you are using tax-advantaged investment vehicles.
5. Consider no-load mutual funds. When investing in the stock market or otherwise, consider no-load mutual funds such as those offered by Vanguard that do not require an “investment advisor.” Such funds do not have sales charges and save you money. The greatest chance you have of underperforming the market relates to the expenses associated with investment, more so than the particular investments selected. Since almost all advisors underperform the market, you should consider investing on your own, minimizing costs, and watching your funds grow. As a younger physician with many high-income years in front of you, a good portion of your investments should be in equities to enjoy their appreciation over decades. With bank interest rates being minuscule, there is no reasonable alternative.
6. Develop a budget. If you or your spouse has an issue with shopping or overspending, it is imperative that you develop a budget: first allocating funds to long-term savings such as a retirement plan, next to short-term savings, then to unavoidable recurring costs such as rent or mortgage, student loans, food, and discretionary expenditures. The perfect time to put this in place is when you go from the salary of a resident or fellow into a full-time job and your pay increases by multifold. Read the book The Millionaire Next Door: The Surprising Secrets of America’s Wealthy by Thomas J. Stanley and gain control, as it is easy to do otherwise with an unprecedented and significant salary jump. If you start to live on your new salary, you will never be in a position to amass wealth and retire comfortably.
7. Send your kids to public, not private school. For each of your children, would you rather pay astronomic tuition bills for 4-8 years of college or 16-20 years counting grades 1-12 in private school? When you have children approaching school age, choose an A+ school district and send your kids to public school, not private school – they will still get into competitive colleges. This can save hundreds of thousands of dollars per child.
8. Fund a 529 plan. Whether or not you currently have children, you can fund a 529 plan to enjoy tax-free growth and plan for education expenses of children or future children. If you do not have children yet, you can name yourself or a different party as the beneficiary and then change it after children are born. If you do not have children, you can either use the 529 for someone else or cash the investment and recover the money including growth/loss thereon. Trying to fund college educations out of current income is difficult and it is better to prefund than to pay back student loans over many years.
9. Draft a will. If you are married or have children or both, it is imperative that you have wills drafted so that your wishes are implemented upon your passing. Many tax advantages are available without using complicated trusts and it is important that you maintain up-to-date wills should the unforeseen occur.
10. Purchase disability and life insurance. Your most valuable financial asset is your income stream over the coming years. Protect it with adequate private disability and life insurance policies. Policies provided by your employer typically end upon termination of employment and having a portable policy is important.
These tips will help you maximize your financial position over your work life and through retirement. The best time to get on the right track is yesterday; the second best time is today. Staying in shape financially is easier than messing up and then attempting to fix it.
Mr. Schiller is a physician contract and tax attorney and has practiced in Norristown, Penn. for the past 30 years. He can be contacted at 610-277-5900 or www.schillerlawassociates.com or [email protected].
How One GI Is Tackling His Student Debt – And the Lessons He’s Learned Along the Way
The AGA recently partnered with CommonBond (studentloans.gastro.org) to help its members save thousands by refinancing their student loans. Kevin Tin, MD, who is an AGA member, has a student loan story that can certainly offer guidance and perspective to others. Kevin earned his B.S. in health sciences from Stony Brook University and his M.D. from American University of Antigua. He completed his residency at Maimonides Medical Center in Brooklyn, N.Y., where he is currently a gastroenterology fellow.
How was your medical school experience?
My medical school experience was memorable for many reasons, particularly because I had an opportunity to study in Antigua. My time there allowed me to experience a different culture and, ultimately, a different perspective. I believe this taught me how to relate to each of my patients’ individual situations and to see things from their eyes. But, the overall cost of medical school (i.e., tuition, cost of living, medical supplies, and study resources) caught me off guard. By the time I graduated, I had amassed more than $200,000 in student loans; this was not something that I felt prepared to deal with.
How would you describe your initial experience with student loans?
What strategies have you implemented to pay off your student loans?
I’ve learned a few crucial strategies that any physician could, and should, take advantage of to save money on their student loans. First, be sure to spend responsibly while in medical school. I focused on finding free study resources and medical supplies as well as sharing materials with friends and roommates whenever possible. As I mentioned earlier, make small payments when you can; as soon as I entered residency, I started making interest payments on my loans. I wanted to contribute as much as I could, as early as I could, to get out of debt. Second, after graduation, endeavor to live frugally. Although I knew my salary would ultimately increase, I saved as much money as I could and put money toward paying off my loans. Finally, try to refinance your student loans; I refinanced mine with CommonBond. It was an unexpectedly pleasant experience: the website was extremely easy to navigate and any time I needed help, a representative was available to answer my questions. CommonBond also gave me the best rates I could find.
What were the benefits of refinancing your student loans?
What is your advice to early-career GIs who have or need to take out loans?
Do your research and do it early. While in medical school, understand what options are available to you and learn to live within your means. In your residency, plan to use a portion of your salary for paying off your student loans, even if it is only a small amount each month. This will reduce the volume of interest that will capitalize, so your loan balance doesn’t grow over time. When you start your full-time job, be financially responsible and limit your spending so you can devote additional funds to paying off your student loans.
If you would like to learn more about student loan refinancing with CommonBond, please visit studentloans.gastro.org. AGA members get a $200 cash bonus for refinancing!
Ms. Duggal is vice president of marketing for CommonBond.
The AGA recently partnered with CommonBond (studentloans.gastro.org) to help its members save thousands by refinancing their student loans. Kevin Tin, MD, who is an AGA member, has a student loan story that can certainly offer guidance and perspective to others. Kevin earned his B.S. in health sciences from Stony Brook University and his M.D. from American University of Antigua. He completed his residency at Maimonides Medical Center in Brooklyn, N.Y., where he is currently a gastroenterology fellow.
How was your medical school experience?
My medical school experience was memorable for many reasons, particularly because I had an opportunity to study in Antigua. My time there allowed me to experience a different culture and, ultimately, a different perspective. I believe this taught me how to relate to each of my patients’ individual situations and to see things from their eyes. But, the overall cost of medical school (i.e., tuition, cost of living, medical supplies, and study resources) caught me off guard. By the time I graduated, I had amassed more than $200,000 in student loans; this was not something that I felt prepared to deal with.
How would you describe your initial experience with student loans?
What strategies have you implemented to pay off your student loans?
I’ve learned a few crucial strategies that any physician could, and should, take advantage of to save money on their student loans. First, be sure to spend responsibly while in medical school. I focused on finding free study resources and medical supplies as well as sharing materials with friends and roommates whenever possible. As I mentioned earlier, make small payments when you can; as soon as I entered residency, I started making interest payments on my loans. I wanted to contribute as much as I could, as early as I could, to get out of debt. Second, after graduation, endeavor to live frugally. Although I knew my salary would ultimately increase, I saved as much money as I could and put money toward paying off my loans. Finally, try to refinance your student loans; I refinanced mine with CommonBond. It was an unexpectedly pleasant experience: the website was extremely easy to navigate and any time I needed help, a representative was available to answer my questions. CommonBond also gave me the best rates I could find.
What were the benefits of refinancing your student loans?
What is your advice to early-career GIs who have or need to take out loans?
Do your research and do it early. While in medical school, understand what options are available to you and learn to live within your means. In your residency, plan to use a portion of your salary for paying off your student loans, even if it is only a small amount each month. This will reduce the volume of interest that will capitalize, so your loan balance doesn’t grow over time. When you start your full-time job, be financially responsible and limit your spending so you can devote additional funds to paying off your student loans.
If you would like to learn more about student loan refinancing with CommonBond, please visit studentloans.gastro.org. AGA members get a $200 cash bonus for refinancing!
Ms. Duggal is vice president of marketing for CommonBond.
The AGA recently partnered with CommonBond (studentloans.gastro.org) to help its members save thousands by refinancing their student loans. Kevin Tin, MD, who is an AGA member, has a student loan story that can certainly offer guidance and perspective to others. Kevin earned his B.S. in health sciences from Stony Brook University and his M.D. from American University of Antigua. He completed his residency at Maimonides Medical Center in Brooklyn, N.Y., where he is currently a gastroenterology fellow.
How was your medical school experience?
My medical school experience was memorable for many reasons, particularly because I had an opportunity to study in Antigua. My time there allowed me to experience a different culture and, ultimately, a different perspective. I believe this taught me how to relate to each of my patients’ individual situations and to see things from their eyes. But, the overall cost of medical school (i.e., tuition, cost of living, medical supplies, and study resources) caught me off guard. By the time I graduated, I had amassed more than $200,000 in student loans; this was not something that I felt prepared to deal with.
How would you describe your initial experience with student loans?
What strategies have you implemented to pay off your student loans?
I’ve learned a few crucial strategies that any physician could, and should, take advantage of to save money on their student loans. First, be sure to spend responsibly while in medical school. I focused on finding free study resources and medical supplies as well as sharing materials with friends and roommates whenever possible. As I mentioned earlier, make small payments when you can; as soon as I entered residency, I started making interest payments on my loans. I wanted to contribute as much as I could, as early as I could, to get out of debt. Second, after graduation, endeavor to live frugally. Although I knew my salary would ultimately increase, I saved as much money as I could and put money toward paying off my loans. Finally, try to refinance your student loans; I refinanced mine with CommonBond. It was an unexpectedly pleasant experience: the website was extremely easy to navigate and any time I needed help, a representative was available to answer my questions. CommonBond also gave me the best rates I could find.
What were the benefits of refinancing your student loans?
What is your advice to early-career GIs who have or need to take out loans?
Do your research and do it early. While in medical school, understand what options are available to you and learn to live within your means. In your residency, plan to use a portion of your salary for paying off your student loans, even if it is only a small amount each month. This will reduce the volume of interest that will capitalize, so your loan balance doesn’t grow over time. When you start your full-time job, be financially responsible and limit your spending so you can devote additional funds to paying off your student loans.
If you would like to learn more about student loan refinancing with CommonBond, please visit studentloans.gastro.org. AGA members get a $200 cash bonus for refinancing!
Ms. Duggal is vice president of marketing for CommonBond.
A Rare Endoscopic Clue to a Common Clinical Condition
The correct answer is C: colonic ischemia.
References
1. Zuckerman G.R., et al. Am J Gastroenterol. 2003;98:2018-22.
2. Tanapanpanit O., Pongpirul K. BMJ Case Rep. 2015 Sept. 17;2015.
This article has an accompanying continuing medical education activity, also eligible for MOC credit (see gastrojournal.org for details). Learning Objective: Upon completion of this activity, successful learners will be able to recognize colon single-stripe sign as an endoscopic feature of colonic ischemia.
The correct answer is C: colonic ischemia.
References
1. Zuckerman G.R., et al. Am J Gastroenterol. 2003;98:2018-22.
2. Tanapanpanit O., Pongpirul K. BMJ Case Rep. 2015 Sept. 17;2015.
This article has an accompanying continuing medical education activity, also eligible for MOC credit (see gastrojournal.org for details). Learning Objective: Upon completion of this activity, successful learners will be able to recognize colon single-stripe sign as an endoscopic feature of colonic ischemia.
The correct answer is C: colonic ischemia.
References
1. Zuckerman G.R., et al. Am J Gastroenterol. 2003;98:2018-22.
2. Tanapanpanit O., Pongpirul K. BMJ Case Rep. 2015 Sept. 17;2015.
This article has an accompanying continuing medical education activity, also eligible for MOC credit (see gastrojournal.org for details). Learning Objective: Upon completion of this activity, successful learners will be able to recognize colon single-stripe sign as an endoscopic feature of colonic ischemia.
Published previously in Gastroenterology (2017;152:492-3)
Dr. Anderson and Dr. Sweetser are in the Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, Minn.
Blazing A Trail in Medical Education
What led you to pursue a career in medical education?
Believe it or not, I pursued my path in medical education even prior to attending medical school. I was a high school teacher with a master’s in education, working during the summer of 1979 under the auspices of the Student Conservation Association at Grand Canyon National Park. Sitting on the edge of the canyon at sunset, I made the momentous decision to attend medical school, requiring attendance at a postbaccalaureate program at Columbia University. While considering medical schools, I knew that I wanted to combine my interest in education with medicine and I therefore chose to attend Case Western University School of Medicine. Since the mid-1950s, Case had been committed to innovative educational programs with a systems-based approach to the curriculum.
What do you enjoy most about working in medical education?
There are so many aspects of medical education that make work fun and rewarding. Perhaps the most rewarding is the ability to make a difference that affects the learner as well as the patients and communities that they will serve. I also enjoy the diverse experiences and opportunities in education and the ability to work with others in creative endeavors.
What are your responsibilities in a typical week?
One of the great things about a focus in education is that there never is a typical week. In the 32 years since my graduation from medical school, I have had the great fortune to fill many different roles: course director, electives director, fellowship program director, associate dean for student affairs, associate dean for undergraduate medical education, and associate dean for continuing medical education. For the past 6 years, I have been the senior associate dean for education at the University of Connecticut School of Medicine, overseeing undergraduate medical education, graduate medical education, continuing medical education, and the graduate school.
Over time I have had less interaction with students and residents as my administrative responsibilities have grown, but I know it is critical to maintain a presence with learners and I endeavor to do so in limited ways. Since our current priorities are in implementing a new curriculum and in planning for an accreditation visit, there are many days that are filled with meetings, planning, organizing, and writing. To me, the most precious responsibility is shaping a vision and bringing together a team to operationalize that vision in a collaborative and creative way, with learners, teachers, and administrators working together.
What are the different career options available for early-career GIs who are interested in medical education?
There are so many options in medical education for early-career gastroenterologists. For those working in private, group, or community practices, there are opportunities to precept students, residents, and fellows. For those working in an academic setting, opportunities abound. It is often a good idea to start within the division: get involved in teaching fellows in a clinical setting, or creating a new simulation experience or case workshop for fellows. There are opportunities to teach and supervise students. One of my first opportunities was in teaching in the physical diagnosis course. There are options to be involved in curriculum committees, admissions, CME, and to engage in educational initiatives at your institution.
The Association of American Medical Colleges has defined five areas of scholarship in education, and it is possible to get promoted to full professor – and even to attain academic tenure, as I have – if you fulfill the requirements for promotion at your institution. These areas include teaching, curriculum development, assessment, mentorship/advising, and leadership. There are also many ways to get involved in the AGA (http://www.gastro.org/trainees) and other organizations.1,2
Are there advanced training options available for those interested in medical education?
The AGA Academy of Educators (http://www.gastro.org/about/initiatives/aga-academy-of-educators)3 is a wonderful resource for networking. It has a competitive process for educational project grants as well as faculty development sessions and networking events at DDW®. There are also national leadership academies in medicine that have a focus in medical education. The Harvard Macy Institute is one such opportunity. Many medical schools have their own academies to support educators and teachers. I have been privileged to be one of the co-leaders of the AGA Future Leaders Program (http://www.gastro.org/about/initiatives/aga-future-leaders-program) and those with a niche interest in education can benefit and pursue related projects.4 One group was successful in publishing an educational article after completing the Future Leaders program.5 There are also several master’s programs for further education and training in educational theory. Some of these programs are available online or largely online, with limited requirements for onsite classes.
How do you go about finding a job in medical education?
First of all, you have to do your “day job.” In order to be a credible medical clinician-educator you must have clinical experience in patient care. It is important for the first years of your career to make sure that you have at least 70% clinical roles that can be reduced over time to accommodate advancing educational responsibilities. Get involved in teaching fellows. If you are in a practice, reach out to your local medical school or hospital to see how you might participate in educational programs. If you are in an academic setting, meet with the deans in education to express your interest and look for opportunities to get involved in an area of interest. If you are in academia, you have to make your work “count twice:” being productive in a scholarly way is not only important as a role model for learners, but it is important for you as a faculty member to grow and advance in your professional career.
It is always wise to think about when to say “yes” and when to say “no.” An important point is not to overextend yourself. Your reputation of completing tasks not only well, but on time, and thoroughly, is critical to your success. This includes making sure your learner evaluations are submitted on time, that you complete the administrative work in order to participate in CME programs, and that you honor your commitments by attending committee meetings.
What are the resources available to early-career GIs interested in medical education?
It is easy to find resources within your practice, your institution, or externally. The AGA has many resources available with a good start being the AGA Academy of Educators. Opportunities for creativity are numerous and with new advances in team-based learning, simulation, and interprofessional learning, there are new areas for involvement evolving all the time.6,7
Finally, pursuing a career in education is exciting, fun, and fulfilling. Having the opportunity to influence learners, which in turn will impact patient care, is an awesome privilege.
Dr. Rose is a professor of medicine and senior associate dean for education at the University of Connecticut School of Medicine.
References
1. Gusic M, et al. MedEdPORTAL; 2013. Available from: http://www.mededportal.org/publication/9313.
2. Gusic ME, et al. Acad Med. 2014;89(7):1006-11.
3. Pfeil SA, et al. Gastroenterology 2015;149(6):1309-14.
4. Cryer B, Rose S. Gastroenterology 2015;149:246-8.
5. Shah BJ, et al. Gastroenterology 2016;151(2):218-21.
6. Shah BJ, Rose S. Gastroenterology 2012;142:684-9.
7. Shah BJ, Rose S. AGA Perspectives 2012;April-May:20-21.
What led you to pursue a career in medical education?
Believe it or not, I pursued my path in medical education even prior to attending medical school. I was a high school teacher with a master’s in education, working during the summer of 1979 under the auspices of the Student Conservation Association at Grand Canyon National Park. Sitting on the edge of the canyon at sunset, I made the momentous decision to attend medical school, requiring attendance at a postbaccalaureate program at Columbia University. While considering medical schools, I knew that I wanted to combine my interest in education with medicine and I therefore chose to attend Case Western University School of Medicine. Since the mid-1950s, Case had been committed to innovative educational programs with a systems-based approach to the curriculum.
What do you enjoy most about working in medical education?
There are so many aspects of medical education that make work fun and rewarding. Perhaps the most rewarding is the ability to make a difference that affects the learner as well as the patients and communities that they will serve. I also enjoy the diverse experiences and opportunities in education and the ability to work with others in creative endeavors.
What are your responsibilities in a typical week?
One of the great things about a focus in education is that there never is a typical week. In the 32 years since my graduation from medical school, I have had the great fortune to fill many different roles: course director, electives director, fellowship program director, associate dean for student affairs, associate dean for undergraduate medical education, and associate dean for continuing medical education. For the past 6 years, I have been the senior associate dean for education at the University of Connecticut School of Medicine, overseeing undergraduate medical education, graduate medical education, continuing medical education, and the graduate school.
Over time I have had less interaction with students and residents as my administrative responsibilities have grown, but I know it is critical to maintain a presence with learners and I endeavor to do so in limited ways. Since our current priorities are in implementing a new curriculum and in planning for an accreditation visit, there are many days that are filled with meetings, planning, organizing, and writing. To me, the most precious responsibility is shaping a vision and bringing together a team to operationalize that vision in a collaborative and creative way, with learners, teachers, and administrators working together.
What are the different career options available for early-career GIs who are interested in medical education?
There are so many options in medical education for early-career gastroenterologists. For those working in private, group, or community practices, there are opportunities to precept students, residents, and fellows. For those working in an academic setting, opportunities abound. It is often a good idea to start within the division: get involved in teaching fellows in a clinical setting, or creating a new simulation experience or case workshop for fellows. There are opportunities to teach and supervise students. One of my first opportunities was in teaching in the physical diagnosis course. There are options to be involved in curriculum committees, admissions, CME, and to engage in educational initiatives at your institution.
The Association of American Medical Colleges has defined five areas of scholarship in education, and it is possible to get promoted to full professor – and even to attain academic tenure, as I have – if you fulfill the requirements for promotion at your institution. These areas include teaching, curriculum development, assessment, mentorship/advising, and leadership. There are also many ways to get involved in the AGA (http://www.gastro.org/trainees) and other organizations.1,2
Are there advanced training options available for those interested in medical education?
The AGA Academy of Educators (http://www.gastro.org/about/initiatives/aga-academy-of-educators)3 is a wonderful resource for networking. It has a competitive process for educational project grants as well as faculty development sessions and networking events at DDW®. There are also national leadership academies in medicine that have a focus in medical education. The Harvard Macy Institute is one such opportunity. Many medical schools have their own academies to support educators and teachers. I have been privileged to be one of the co-leaders of the AGA Future Leaders Program (http://www.gastro.org/about/initiatives/aga-future-leaders-program) and those with a niche interest in education can benefit and pursue related projects.4 One group was successful in publishing an educational article after completing the Future Leaders program.5 There are also several master’s programs for further education and training in educational theory. Some of these programs are available online or largely online, with limited requirements for onsite classes.
How do you go about finding a job in medical education?
First of all, you have to do your “day job.” In order to be a credible medical clinician-educator you must have clinical experience in patient care. It is important for the first years of your career to make sure that you have at least 70% clinical roles that can be reduced over time to accommodate advancing educational responsibilities. Get involved in teaching fellows. If you are in a practice, reach out to your local medical school or hospital to see how you might participate in educational programs. If you are in an academic setting, meet with the deans in education to express your interest and look for opportunities to get involved in an area of interest. If you are in academia, you have to make your work “count twice:” being productive in a scholarly way is not only important as a role model for learners, but it is important for you as a faculty member to grow and advance in your professional career.
It is always wise to think about when to say “yes” and when to say “no.” An important point is not to overextend yourself. Your reputation of completing tasks not only well, but on time, and thoroughly, is critical to your success. This includes making sure your learner evaluations are submitted on time, that you complete the administrative work in order to participate in CME programs, and that you honor your commitments by attending committee meetings.
What are the resources available to early-career GIs interested in medical education?
It is easy to find resources within your practice, your institution, or externally. The AGA has many resources available with a good start being the AGA Academy of Educators. Opportunities for creativity are numerous and with new advances in team-based learning, simulation, and interprofessional learning, there are new areas for involvement evolving all the time.6,7
Finally, pursuing a career in education is exciting, fun, and fulfilling. Having the opportunity to influence learners, which in turn will impact patient care, is an awesome privilege.
Dr. Rose is a professor of medicine and senior associate dean for education at the University of Connecticut School of Medicine.
References
1. Gusic M, et al. MedEdPORTAL; 2013. Available from: http://www.mededportal.org/publication/9313.
2. Gusic ME, et al. Acad Med. 2014;89(7):1006-11.
3. Pfeil SA, et al. Gastroenterology 2015;149(6):1309-14.
4. Cryer B, Rose S. Gastroenterology 2015;149:246-8.
5. Shah BJ, et al. Gastroenterology 2016;151(2):218-21.
6. Shah BJ, Rose S. Gastroenterology 2012;142:684-9.
7. Shah BJ, Rose S. AGA Perspectives 2012;April-May:20-21.
What led you to pursue a career in medical education?
Believe it or not, I pursued my path in medical education even prior to attending medical school. I was a high school teacher with a master’s in education, working during the summer of 1979 under the auspices of the Student Conservation Association at Grand Canyon National Park. Sitting on the edge of the canyon at sunset, I made the momentous decision to attend medical school, requiring attendance at a postbaccalaureate program at Columbia University. While considering medical schools, I knew that I wanted to combine my interest in education with medicine and I therefore chose to attend Case Western University School of Medicine. Since the mid-1950s, Case had been committed to innovative educational programs with a systems-based approach to the curriculum.
What do you enjoy most about working in medical education?
There are so many aspects of medical education that make work fun and rewarding. Perhaps the most rewarding is the ability to make a difference that affects the learner as well as the patients and communities that they will serve. I also enjoy the diverse experiences and opportunities in education and the ability to work with others in creative endeavors.
What are your responsibilities in a typical week?
One of the great things about a focus in education is that there never is a typical week. In the 32 years since my graduation from medical school, I have had the great fortune to fill many different roles: course director, electives director, fellowship program director, associate dean for student affairs, associate dean for undergraduate medical education, and associate dean for continuing medical education. For the past 6 years, I have been the senior associate dean for education at the University of Connecticut School of Medicine, overseeing undergraduate medical education, graduate medical education, continuing medical education, and the graduate school.
Over time I have had less interaction with students and residents as my administrative responsibilities have grown, but I know it is critical to maintain a presence with learners and I endeavor to do so in limited ways. Since our current priorities are in implementing a new curriculum and in planning for an accreditation visit, there are many days that are filled with meetings, planning, organizing, and writing. To me, the most precious responsibility is shaping a vision and bringing together a team to operationalize that vision in a collaborative and creative way, with learners, teachers, and administrators working together.
What are the different career options available for early-career GIs who are interested in medical education?
There are so many options in medical education for early-career gastroenterologists. For those working in private, group, or community practices, there are opportunities to precept students, residents, and fellows. For those working in an academic setting, opportunities abound. It is often a good idea to start within the division: get involved in teaching fellows in a clinical setting, or creating a new simulation experience or case workshop for fellows. There are opportunities to teach and supervise students. One of my first opportunities was in teaching in the physical diagnosis course. There are options to be involved in curriculum committees, admissions, CME, and to engage in educational initiatives at your institution.
The Association of American Medical Colleges has defined five areas of scholarship in education, and it is possible to get promoted to full professor – and even to attain academic tenure, as I have – if you fulfill the requirements for promotion at your institution. These areas include teaching, curriculum development, assessment, mentorship/advising, and leadership. There are also many ways to get involved in the AGA (http://www.gastro.org/trainees) and other organizations.1,2
Are there advanced training options available for those interested in medical education?
The AGA Academy of Educators (http://www.gastro.org/about/initiatives/aga-academy-of-educators)3 is a wonderful resource for networking. It has a competitive process for educational project grants as well as faculty development sessions and networking events at DDW®. There are also national leadership academies in medicine that have a focus in medical education. The Harvard Macy Institute is one such opportunity. Many medical schools have their own academies to support educators and teachers. I have been privileged to be one of the co-leaders of the AGA Future Leaders Program (http://www.gastro.org/about/initiatives/aga-future-leaders-program) and those with a niche interest in education can benefit and pursue related projects.4 One group was successful in publishing an educational article after completing the Future Leaders program.5 There are also several master’s programs for further education and training in educational theory. Some of these programs are available online or largely online, with limited requirements for onsite classes.
How do you go about finding a job in medical education?
First of all, you have to do your “day job.” In order to be a credible medical clinician-educator you must have clinical experience in patient care. It is important for the first years of your career to make sure that you have at least 70% clinical roles that can be reduced over time to accommodate advancing educational responsibilities. Get involved in teaching fellows. If you are in a practice, reach out to your local medical school or hospital to see how you might participate in educational programs. If you are in an academic setting, meet with the deans in education to express your interest and look for opportunities to get involved in an area of interest. If you are in academia, you have to make your work “count twice:” being productive in a scholarly way is not only important as a role model for learners, but it is important for you as a faculty member to grow and advance in your professional career.
It is always wise to think about when to say “yes” and when to say “no.” An important point is not to overextend yourself. Your reputation of completing tasks not only well, but on time, and thoroughly, is critical to your success. This includes making sure your learner evaluations are submitted on time, that you complete the administrative work in order to participate in CME programs, and that you honor your commitments by attending committee meetings.
What are the resources available to early-career GIs interested in medical education?
It is easy to find resources within your practice, your institution, or externally. The AGA has many resources available with a good start being the AGA Academy of Educators. Opportunities for creativity are numerous and with new advances in team-based learning, simulation, and interprofessional learning, there are new areas for involvement evolving all the time.6,7
Finally, pursuing a career in education is exciting, fun, and fulfilling. Having the opportunity to influence learners, which in turn will impact patient care, is an awesome privilege.
Dr. Rose is a professor of medicine and senior associate dean for education at the University of Connecticut School of Medicine.
References
1. Gusic M, et al. MedEdPORTAL; 2013. Available from: http://www.mededportal.org/publication/9313.
2. Gusic ME, et al. Acad Med. 2014;89(7):1006-11.
3. Pfeil SA, et al. Gastroenterology 2015;149(6):1309-14.
4. Cryer B, Rose S. Gastroenterology 2015;149:246-8.
5. Shah BJ, et al. Gastroenterology 2016;151(2):218-21.
6. Shah BJ, Rose S. Gastroenterology 2012;142:684-9.
7. Shah BJ, Rose S. AGA Perspectives 2012;April-May:20-21.
Legal Issues for the Gastroenterologist: Part I
An unfortunate fact for many physicians practicing in the United States is that they will contend with medical malpractice suits at some point in their careers. While data specific to gastroenterology malpractice claims is difficult to find,1 the Physician Insurers Association of America has reported that out of the 28 specialty fields of medicine analyzed from 1985 to 2004, gastroenterology ranked 21st in the number of claims reported2, representing about 2% of the total overall number of claims.
In 2017, JAMA Internal Medicine published additional statistical findings related to medical malpractice claims.4JAMA reported that the rate of claims paid on behalf of all physicians had declined by 55.7% between 1992 and 2014; from 20.1 per 1,000 physicians to 8.9 per 1000 physicians.4 The mean payment for the 280,368 claims reported in the National Practitioner Data Bank during this time frame was $329,565 (adjusted to 2014 dollars).4
Professional liability
Patients can allege or establish malpractice liability against a doctor based on a number of things; we will discuss a few of the most common types of liability, offer suggestions as to how you might minimize your risk of being sued, and how best to cope when you are sued.
Negligence: One of the most common theories you may be sued under is negligence. To state a negligence claim against a physician, a plaintiff must show that the doctor owed the patient a duty recognized by law, that the physician breached that duty, that the alleged breach resulted in injury to the patient, and that the patient sustained legally recognized damages as a result. In a lawsuit brought on the basis of claimed medical negligence, a patient claims that a physician, in the course of rendering treatment, failed to meet the applicable standard of care.
Contractual liability of doctor to patient: Physicians and patients can enter into express written contracts regarding the care provided. These contracts can include various treatment plans, the likelihood of success, and even the physician’s promise to cure. Traditionally, courts have respected a physician’s freedom to contract as he or she chooses. However, once a contract is formed, a plaintiff may have a cause of action for breach of contract if the outcome of the treatment is not what was promised.
Minimizing risk
Another opportunity to decrease your chances of being sued is to keep informed about recent developments in your field. Make a point to read pertinent literature, attend seminars, and do whatever is necessary to stay aware of, and to incorporate into your practice, current methods of treatment and diagnosis.
Physicians should also be cognizant of contractual liability. When discussing treatment, never guarantee results. Additionally, once a physician-patient relationship is established, you cannot withdraw from the relationship without providing adequate notice to the patient in time to obtain alternative care. Terminating the relationship without such is called abandonment, and can result in professional discipline and civil liability.
Conclusion
Before a lawsuit, and as a regular part of your practice, it is important that you thoroughly and legibly document all aspects of care provided, stay current with medical advances, and take the time to create a relationship with your patients involving quality communication. It is impossible for us to provide you with enough information to adequately prepare you for the day on which you may be sued. We nevertheless hope that following the aforementioned suggestions will be of some help.
References
1. Medical Malpractice Claims and Risk Management in Gastroenterology and Gastrointestinal Endoscopy. American Society for Gastrointestinal Endoscopy, 2017. <www.asge.org>.
2. Physician Insurers Association of America. PIAA Claim Trend Analysis: Gastroenterology, iv. Lawrenceville, N.J.: PIAA, 2004. <http://www.piaa.us>.
3. Kane C., Policy Research Perspective: Medical Liability Claim Frequency: 2007-2008 Snapshot of Physicians, American Medical Association, 2010.
4. Schaffer A.C., et al. JAMA Internal Med. 2017;177(5):710-8.
5. Dodge A.M. Wilsonville, Ore. Book Partners, Inc. 2001.
An unfortunate fact for many physicians practicing in the United States is that they will contend with medical malpractice suits at some point in their careers. While data specific to gastroenterology malpractice claims is difficult to find,1 the Physician Insurers Association of America has reported that out of the 28 specialty fields of medicine analyzed from 1985 to 2004, gastroenterology ranked 21st in the number of claims reported2, representing about 2% of the total overall number of claims.
In 2017, JAMA Internal Medicine published additional statistical findings related to medical malpractice claims.4JAMA reported that the rate of claims paid on behalf of all physicians had declined by 55.7% between 1992 and 2014; from 20.1 per 1,000 physicians to 8.9 per 1000 physicians.4 The mean payment for the 280,368 claims reported in the National Practitioner Data Bank during this time frame was $329,565 (adjusted to 2014 dollars).4
Professional liability
Patients can allege or establish malpractice liability against a doctor based on a number of things; we will discuss a few of the most common types of liability, offer suggestions as to how you might minimize your risk of being sued, and how best to cope when you are sued.
Negligence: One of the most common theories you may be sued under is negligence. To state a negligence claim against a physician, a plaintiff must show that the doctor owed the patient a duty recognized by law, that the physician breached that duty, that the alleged breach resulted in injury to the patient, and that the patient sustained legally recognized damages as a result. In a lawsuit brought on the basis of claimed medical negligence, a patient claims that a physician, in the course of rendering treatment, failed to meet the applicable standard of care.
Contractual liability of doctor to patient: Physicians and patients can enter into express written contracts regarding the care provided. These contracts can include various treatment plans, the likelihood of success, and even the physician’s promise to cure. Traditionally, courts have respected a physician’s freedom to contract as he or she chooses. However, once a contract is formed, a plaintiff may have a cause of action for breach of contract if the outcome of the treatment is not what was promised.
Minimizing risk
Another opportunity to decrease your chances of being sued is to keep informed about recent developments in your field. Make a point to read pertinent literature, attend seminars, and do whatever is necessary to stay aware of, and to incorporate into your practice, current methods of treatment and diagnosis.
Physicians should also be cognizant of contractual liability. When discussing treatment, never guarantee results. Additionally, once a physician-patient relationship is established, you cannot withdraw from the relationship without providing adequate notice to the patient in time to obtain alternative care. Terminating the relationship without such is called abandonment, and can result in professional discipline and civil liability.
Conclusion
Before a lawsuit, and as a regular part of your practice, it is important that you thoroughly and legibly document all aspects of care provided, stay current with medical advances, and take the time to create a relationship with your patients involving quality communication. It is impossible for us to provide you with enough information to adequately prepare you for the day on which you may be sued. We nevertheless hope that following the aforementioned suggestions will be of some help.
References
1. Medical Malpractice Claims and Risk Management in Gastroenterology and Gastrointestinal Endoscopy. American Society for Gastrointestinal Endoscopy, 2017. <www.asge.org>.
2. Physician Insurers Association of America. PIAA Claim Trend Analysis: Gastroenterology, iv. Lawrenceville, N.J.: PIAA, 2004. <http://www.piaa.us>.
3. Kane C., Policy Research Perspective: Medical Liability Claim Frequency: 2007-2008 Snapshot of Physicians, American Medical Association, 2010.
4. Schaffer A.C., et al. JAMA Internal Med. 2017;177(5):710-8.
5. Dodge A.M. Wilsonville, Ore. Book Partners, Inc. 2001.
An unfortunate fact for many physicians practicing in the United States is that they will contend with medical malpractice suits at some point in their careers. While data specific to gastroenterology malpractice claims is difficult to find,1 the Physician Insurers Association of America has reported that out of the 28 specialty fields of medicine analyzed from 1985 to 2004, gastroenterology ranked 21st in the number of claims reported2, representing about 2% of the total overall number of claims.
In 2017, JAMA Internal Medicine published additional statistical findings related to medical malpractice claims.4JAMA reported that the rate of claims paid on behalf of all physicians had declined by 55.7% between 1992 and 2014; from 20.1 per 1,000 physicians to 8.9 per 1000 physicians.4 The mean payment for the 280,368 claims reported in the National Practitioner Data Bank during this time frame was $329,565 (adjusted to 2014 dollars).4
Professional liability
Patients can allege or establish malpractice liability against a doctor based on a number of things; we will discuss a few of the most common types of liability, offer suggestions as to how you might minimize your risk of being sued, and how best to cope when you are sued.
Negligence: One of the most common theories you may be sued under is negligence. To state a negligence claim against a physician, a plaintiff must show that the doctor owed the patient a duty recognized by law, that the physician breached that duty, that the alleged breach resulted in injury to the patient, and that the patient sustained legally recognized damages as a result. In a lawsuit brought on the basis of claimed medical negligence, a patient claims that a physician, in the course of rendering treatment, failed to meet the applicable standard of care.
Contractual liability of doctor to patient: Physicians and patients can enter into express written contracts regarding the care provided. These contracts can include various treatment plans, the likelihood of success, and even the physician’s promise to cure. Traditionally, courts have respected a physician’s freedom to contract as he or she chooses. However, once a contract is formed, a plaintiff may have a cause of action for breach of contract if the outcome of the treatment is not what was promised.
Minimizing risk
Another opportunity to decrease your chances of being sued is to keep informed about recent developments in your field. Make a point to read pertinent literature, attend seminars, and do whatever is necessary to stay aware of, and to incorporate into your practice, current methods of treatment and diagnosis.
Physicians should also be cognizant of contractual liability. When discussing treatment, never guarantee results. Additionally, once a physician-patient relationship is established, you cannot withdraw from the relationship without providing adequate notice to the patient in time to obtain alternative care. Terminating the relationship without such is called abandonment, and can result in professional discipline and civil liability.
Conclusion
Before a lawsuit, and as a regular part of your practice, it is important that you thoroughly and legibly document all aspects of care provided, stay current with medical advances, and take the time to create a relationship with your patients involving quality communication. It is impossible for us to provide you with enough information to adequately prepare you for the day on which you may be sued. We nevertheless hope that following the aforementioned suggestions will be of some help.
References
1. Medical Malpractice Claims and Risk Management in Gastroenterology and Gastrointestinal Endoscopy. American Society for Gastrointestinal Endoscopy, 2017. <www.asge.org>.
2. Physician Insurers Association of America. PIAA Claim Trend Analysis: Gastroenterology, iv. Lawrenceville, N.J.: PIAA, 2004. <http://www.piaa.us>.
3. Kane C., Policy Research Perspective: Medical Liability Claim Frequency: 2007-2008 Snapshot of Physicians, American Medical Association, 2010.
4. Schaffer A.C., et al. JAMA Internal Med. 2017;177(5):710-8.
5. Dodge A.M. Wilsonville, Ore. Book Partners, Inc. 2001.
AGA’s 2017 Women’s Leadership Conference: Developing Skills in Advocacy and Personal Branding
The 2017 AGA Women’s Leadership Conference brought together 38 women from across the United States and Mexico for an inspiring and productive meeting. The group included 21 early-career and 17 experienced track women in GI. Among the attendees were 3 PhDs, 9 private practitioners, 1 pediatric gastroenterologist, and 25 academic gastroenterologists. We were particularly fortunate to benefit from the strong representation of AGA leadership, including Marcia Cruz-Correa, MD, PhD, AGAF (At-Large Councillor) and Deborah Proctor, MD, AGAF (Education and Training Councillor), as well as Ellen Zimmermann, MD, AGAF (Chair of the Women’s Committee) and Sheila Crowe, MD, AGAF (President, AGA Institute Governing Board).
The program included lively problem-solving sessions and a passionate discussion about negotiating skills. The latter topic was of particular interest given data indicating that pay inequity still exists. The group engaged in animated conversation about advocating for fair pay in academics and private practice.
In addition to strong mentorship, the early-career group discussed the importance of discerning one’s own individual passions. Identifying professional and personal ambitions can allow us to focus our energy and activities. We were encouraged to write down one personal and one professional goal on an annual basis. These goals can offer clarity for a range of decisions such as when to accept new responsibilities and how to structure activities and manage time at work and at home.
The AGA leaders in attendance shared inspiring stories of their own paths to leadership. These paths were not linear and it was reassuring to discover common themes of finding and developing personal strengths, identifying passions, and building areas of expertise. We learned, how once identified, strengths and passions can be connected to areas of need within a home institution or an organization such as the AGA. Dr. Zimmermann offered moving commentary about her own journey as a clinician, scientist, and mother. She encouraged those in attendance with small children to take the time to be present at home, knowing that there will be opportunities to assume leadership roles in the future. Of course, for others, the time to assume leadership roles may be now, and the Women’s Leadership Conference offered the chance to network and forge new connections within the AGA.
The second new topic was addressed in a powerful session on personal branding by Dr. Cruz-Correa. Personal branding involves identifying and communicating who one is to the world in a memorable way. Dr. Cruz-Correa emphasized that creating a personal brand is essential for leadership and critically important for advancing one’s career. Developing a personal brand should include crafting a statement of one to two sentences that considers both one’s values and the target audience. The statement should be memorable and punchy with an emphasis on solutions. Branding expands beyond indicating an area of interest; a personal brand should demonstrate consistent delivery of high-quality work. An example of a personal brand could be “Physician, fitness fanatic, and fearless foodie empowering patients and colleagues to lead healthy fulfilling lives.” An alternative might be: “Physician, teacher, empowering colleagues, advocating for patients, and evolving with the times.” Creating a personal brand that highlights action and solutions emphasizes a theme of the meeting: Follow-through after accepting responsibilities is critically important.
In summary, the 2017 AGA Women’s Leadership Conference provided an invigorating curriculum as well as many opportunities for establishing new networks of strong women in our field. Participants were charged with bringing some of the content back home, and we’re already receiving reports about these local events. Be sure to look for future content from the AGA at http://www.gastro.org/about/people/committees/womens-committee.
Acknowledgments: Dr. Garman and Dr. Alaparthi would like to offer heartfelt thanks to the AGA as well as to Celena NuQuay and Carol Brown for their support.
Dr. Garman is an assistant professor of medicine in the division of gastroenterology at Duke University, Durham, N.C. Dr. Alaparthi is managing partner of Gastroenterology Center of Connecticut and assistant clinical professor of medicine at Yale School of Medicine, Conn., and Frank Netter School of Medicine, Conn.
The 2017 AGA Women’s Leadership Conference brought together 38 women from across the United States and Mexico for an inspiring and productive meeting. The group included 21 early-career and 17 experienced track women in GI. Among the attendees were 3 PhDs, 9 private practitioners, 1 pediatric gastroenterologist, and 25 academic gastroenterologists. We were particularly fortunate to benefit from the strong representation of AGA leadership, including Marcia Cruz-Correa, MD, PhD, AGAF (At-Large Councillor) and Deborah Proctor, MD, AGAF (Education and Training Councillor), as well as Ellen Zimmermann, MD, AGAF (Chair of the Women’s Committee) and Sheila Crowe, MD, AGAF (President, AGA Institute Governing Board).
The program included lively problem-solving sessions and a passionate discussion about negotiating skills. The latter topic was of particular interest given data indicating that pay inequity still exists. The group engaged in animated conversation about advocating for fair pay in academics and private practice.
In addition to strong mentorship, the early-career group discussed the importance of discerning one’s own individual passions. Identifying professional and personal ambitions can allow us to focus our energy and activities. We were encouraged to write down one personal and one professional goal on an annual basis. These goals can offer clarity for a range of decisions such as when to accept new responsibilities and how to structure activities and manage time at work and at home.
The AGA leaders in attendance shared inspiring stories of their own paths to leadership. These paths were not linear and it was reassuring to discover common themes of finding and developing personal strengths, identifying passions, and building areas of expertise. We learned, how once identified, strengths and passions can be connected to areas of need within a home institution or an organization such as the AGA. Dr. Zimmermann offered moving commentary about her own journey as a clinician, scientist, and mother. She encouraged those in attendance with small children to take the time to be present at home, knowing that there will be opportunities to assume leadership roles in the future. Of course, for others, the time to assume leadership roles may be now, and the Women’s Leadership Conference offered the chance to network and forge new connections within the AGA.
The second new topic was addressed in a powerful session on personal branding by Dr. Cruz-Correa. Personal branding involves identifying and communicating who one is to the world in a memorable way. Dr. Cruz-Correa emphasized that creating a personal brand is essential for leadership and critically important for advancing one’s career. Developing a personal brand should include crafting a statement of one to two sentences that considers both one’s values and the target audience. The statement should be memorable and punchy with an emphasis on solutions. Branding expands beyond indicating an area of interest; a personal brand should demonstrate consistent delivery of high-quality work. An example of a personal brand could be “Physician, fitness fanatic, and fearless foodie empowering patients and colleagues to lead healthy fulfilling lives.” An alternative might be: “Physician, teacher, empowering colleagues, advocating for patients, and evolving with the times.” Creating a personal brand that highlights action and solutions emphasizes a theme of the meeting: Follow-through after accepting responsibilities is critically important.
In summary, the 2017 AGA Women’s Leadership Conference provided an invigorating curriculum as well as many opportunities for establishing new networks of strong women in our field. Participants were charged with bringing some of the content back home, and we’re already receiving reports about these local events. Be sure to look for future content from the AGA at http://www.gastro.org/about/people/committees/womens-committee.
Acknowledgments: Dr. Garman and Dr. Alaparthi would like to offer heartfelt thanks to the AGA as well as to Celena NuQuay and Carol Brown for their support.
Dr. Garman is an assistant professor of medicine in the division of gastroenterology at Duke University, Durham, N.C. Dr. Alaparthi is managing partner of Gastroenterology Center of Connecticut and assistant clinical professor of medicine at Yale School of Medicine, Conn., and Frank Netter School of Medicine, Conn.
The 2017 AGA Women’s Leadership Conference brought together 38 women from across the United States and Mexico for an inspiring and productive meeting. The group included 21 early-career and 17 experienced track women in GI. Among the attendees were 3 PhDs, 9 private practitioners, 1 pediatric gastroenterologist, and 25 academic gastroenterologists. We were particularly fortunate to benefit from the strong representation of AGA leadership, including Marcia Cruz-Correa, MD, PhD, AGAF (At-Large Councillor) and Deborah Proctor, MD, AGAF (Education and Training Councillor), as well as Ellen Zimmermann, MD, AGAF (Chair of the Women’s Committee) and Sheila Crowe, MD, AGAF (President, AGA Institute Governing Board).
The program included lively problem-solving sessions and a passionate discussion about negotiating skills. The latter topic was of particular interest given data indicating that pay inequity still exists. The group engaged in animated conversation about advocating for fair pay in academics and private practice.
In addition to strong mentorship, the early-career group discussed the importance of discerning one’s own individual passions. Identifying professional and personal ambitions can allow us to focus our energy and activities. We were encouraged to write down one personal and one professional goal on an annual basis. These goals can offer clarity for a range of decisions such as when to accept new responsibilities and how to structure activities and manage time at work and at home.
The AGA leaders in attendance shared inspiring stories of their own paths to leadership. These paths were not linear and it was reassuring to discover common themes of finding and developing personal strengths, identifying passions, and building areas of expertise. We learned, how once identified, strengths and passions can be connected to areas of need within a home institution or an organization such as the AGA. Dr. Zimmermann offered moving commentary about her own journey as a clinician, scientist, and mother. She encouraged those in attendance with small children to take the time to be present at home, knowing that there will be opportunities to assume leadership roles in the future. Of course, for others, the time to assume leadership roles may be now, and the Women’s Leadership Conference offered the chance to network and forge new connections within the AGA.
The second new topic was addressed in a powerful session on personal branding by Dr. Cruz-Correa. Personal branding involves identifying and communicating who one is to the world in a memorable way. Dr. Cruz-Correa emphasized that creating a personal brand is essential for leadership and critically important for advancing one’s career. Developing a personal brand should include crafting a statement of one to two sentences that considers both one’s values and the target audience. The statement should be memorable and punchy with an emphasis on solutions. Branding expands beyond indicating an area of interest; a personal brand should demonstrate consistent delivery of high-quality work. An example of a personal brand could be “Physician, fitness fanatic, and fearless foodie empowering patients and colleagues to lead healthy fulfilling lives.” An alternative might be: “Physician, teacher, empowering colleagues, advocating for patients, and evolving with the times.” Creating a personal brand that highlights action and solutions emphasizes a theme of the meeting: Follow-through after accepting responsibilities is critically important.
In summary, the 2017 AGA Women’s Leadership Conference provided an invigorating curriculum as well as many opportunities for establishing new networks of strong women in our field. Participants were charged with bringing some of the content back home, and we’re already receiving reports about these local events. Be sure to look for future content from the AGA at http://www.gastro.org/about/people/committees/womens-committee.
Acknowledgments: Dr. Garman and Dr. Alaparthi would like to offer heartfelt thanks to the AGA as well as to Celena NuQuay and Carol Brown for their support.
Dr. Garman is an assistant professor of medicine in the division of gastroenterology at Duke University, Durham, N.C. Dr. Alaparthi is managing partner of Gastroenterology Center of Connecticut and assistant clinical professor of medicine at Yale School of Medicine, Conn., and Frank Netter School of Medicine, Conn.
Reflux Diagnostics: Modern Techniques and Future Directions
Introduction
Chronic esophageal symptoms attributed to gastroesophageal reflux disease (GERD) are common presenting symptoms in gastroenterology, leading to high healthcare costs and adverse quality of life globally.1,2 The clinical diagnosis of GERD hinges on the presence of “troublesome” compatible typical symptoms (heartburn, acid regurgitation) or evidence of mucosal injury on endoscopy (esophagitis, Barrett’s esophagus, peptic stricture).3 With the growing availability of proton pump inhibitors (PPIs), patients and clinicians often utilize an empiric therapeutic trial of PPI as an initial test, with symptom improvement in the absence of alarm symptoms indicating a high likelihood of GERD.4 A meta-analysis of studies that used objective measures of GERD (in this case, 24-hour pH monitoring) showed that the “PPI test” has a sensitivity of 78%, but a specificity of only 54%, as a diagnostic approach to GERD symptoms.5 Apart from noncardiac chest pain, the diagnostic yield is even lower for atypical and extra-esophageal symptoms such as cough or laryngeal symptoms.6
The “nuts and bolts” of reflux testing
Ambulatory reflux testing assesses esophageal reflux burden and symptom-reflux association (SRA). Individual reflux events are identified as either a drop in esophageal pH to less than 4 (acid reflux events), or a sharp decrease in esophageal impedance measurements in a retrograde fashion (impedance-detected reflux events), with subsequent recovery to the baseline in each instance. Ambulatory reflux testing affords insight into three areas: 1) measurement of esophageal acid exposure time (AET); the cumulative time duration when distal esophageal pH is less than 4 at the recording site, reported as a percentage of the recording period; 2) measurement of the number of reflux events both acidic (from pH monitoring) and weakly acidic/alkaline (from impedance monitoring); and 3) quantitative evaluation of the association between reported symptom episodes and reflux events.
The SI and SAP can be calculated individually for acid-detected reflux events and for impedance-detected reflux events. Since reflux events are better detected with impedance, combined pH-impedance testing increases the yield of detecting positive SRA, especially when performed off PPI therapy.16,17 Because these indices are heavily reliant on patient reporting of symptom episodes, SRA can be overinterpreted;18 positive associations are more clinically useful than negative results in the evaluation of symptoms attributed to GERD.19 Despite these concerns, the two most consistent predictors of symptomatic outcome with antireflux therapy on pH-impedance testing are abnormal AET and positive SAP with impedance-detected reflux events.17
Testing on or off PPI?
For symptoms attributable to GERD that persist despite properly administered PPI therapy, the 2013 American College of Gastroenterology guidelines suggest upper endoscopy with esophageal biopsies for typical symptoms and appropriate referrals for atypical symptoms.24 However, if these evaluations are unremarkable, reflux monitoring is recommended, with PPI status for testing guided by the pre-test probability of GERD: with a low pre-test probability of GERD, reflux testing is best performed off PPI with either pH or combined pH-impedance testing. In contrast, with a high pre-test probability of GERD, testing is best performed on PPI with combined pH-impedance testing. A similar concept is proposed in the Rome IV approach (Figure 2)23 and on GERD consensus guidelines:7 when heartburn or chest pain persists despite PPI therapy and endoscopy and esophageal biopsies are normal, evidence for GERD (past esophagitis, Barrett’s esophagus, peptic stricture, or prior positive reflux testing) prompts pH-impedance monitoring on PPI therapy (i.e., proven GERD). Those without this evidence for proven GERD (i.e., unproven GERD) are best tested off PPI, and the test utilized can be either pH alone or combined pH-impedance.
GERD phenotypes and management
The presence or absence of the two core metrics on ambulatory reflux monitoring – abnormal AET and positive SRA – can stratify symptomatic GERD patients into phenotypes that predict symptomatic improvement with antireflux therapy and guide management of symptoms (Figure 3).25,26 The presence of both abnormal AET and positive SRA suggests “strong” evidence for GERD, for which symptom improvement is likely with maximization of antireflux therapy, which can include BID PPI, baclofen (to decrease transient LES relaxations), alginates (such as Gaviscon), and consideration of endosopic or surgical antireflux procedures such as fundoplication or magnetic sphincter augmentation. Abnormal AET but negative SRA is regarded as “good” evidence for GERD, for which similar antireflux therapies can be advocated. Normal AET but positive SRA is designated as “reflux hypersensitivity,”23 with increasing proportions of patients meeting this phenotype when tested with combined pH-impedance and off PPI therapy.27 Both normal AET and negative SRA suggest equivocal evidence for GERD and the likely presence of a functional esophageal disorder, such as functional heartburn.23 For reflux hypersensitivity and especially functional esophageal disorders, antireflux therapy is unlikely to be as effective and management can include pharmacologic neuromodulation (such as tricyclic antidepressants administered at bedtime) as well as adjunctive nonpharmacologic approaches (such as stress reduction, relaxation, hypnosis, or cognitive-behavioral therapy).
The future of reflux diagnostics
Conclusions
For esophageal symptoms potentially attributable to GERD that persist despite optimized PPI therapy, esophageal testing should be undertaken, starting with endoscopy and biopsies and proceeding to ambulatory reflux monitoring with HRM. The decisions between pH testing alone versus combined pH-impedance monitoring, and between testing on or off PPI therapy, can be guided either by the pre-test probability of GERD or whether GERD has been proven or unproven in prior evaluations (Figure 2). Elevated AET and positive SRA with impedance-detected reflux events can predict the likelihood of successful management outcomes from antireflux therapy. These two core metrics can be utilized to phenotype GERD and guide management approaches for persisting symptoms (Figure 3). Novel impedance metrics (baseline mucosal impedance, postreflux swallow-induced peristaltic wave index) and markers for esophageal mucosal damage continue to be studied as potential markers for evidence of longitudinal reflux exposure.
Dr. Patel is assistant professor of medicine, division of gastroenterology, Duke University School of Medicine and the Durham Veterans Affairs Medical Center, Durham, N.C. Dr. Gyawali is professor of medicine, division of gastroenterology, Washington University School of Medicine, St. Louis, Mo.
References
1. Shaheen N.J., et al. Am J Gastroenterol. 2006;101:2128-38.
2. Patel A., Gyawali C.P.. Switzerland: Springer International, 2016.
3. Vakil N., et al. Am J Gastroenterol. 2006;101:1900-20; quiz 1943.
4. Fass R., et al. Arch Intern Med. 1999;159:2161-8.
5. Numans M.E., et al. Ann Intern Med. 2004;140:518-27.
6. Shaheen N.J., et al. Aliment Pharmacol Ther. 2011;33:225-34.
7. Roman S., et al. Neurogastroenterol Motil Mar 31. doi: 10.1111/nmo.13067. [Epub ahead of print] 2017.
8. Dellon E.S., et al. Am J Gastroenterol. 2013;108:679-92; quiz 693.
9. Pandolfino JE, Vela MF. Gastrointest Endosc. 2009;69:917-30, 930 e1.
10. Shay S., et al. Am J Gastroenterol. 2004;99:1037-43.
11. Zerbib F., et al. Clin Gastroenterol Hepatol. 2013;11:366-72.
12. Wiener G.J., et al. Am J Gastroenterol 1988;83:358-61.
13. Weusten B.L., et al. Gastroenterology. 1994;107:1741-5.
14. Ghillebert G., et al. Gut 1990;31:738-44.
15. Kushnir V.M., et al. Aliment Pharmacol Ther. 2012;35(9):1080-7.
16. Bredenoord A.J., et al. Am J Gastroenterol. 2006;101:453-9.
17. Patel A., et al. Clin Gastroenterol Hepatol. 2015;13:884-91.
18. Slaughter J.C., et al. Clin Gastroenterol Hepatol. 2011;9:868-74.
19. Kavitt R.T., et al. Am J Gastroenterol. 2012;107:1826-32.
20. Kahrilas P.J., et al. Gastroenterology 2008;135:1383-91, 1391 e1-5.
21. Kessing B.F., et al. Clin Gastroenterol Hepatol. 2011;9:1020-4.
22. Kahrilas P.J., et al. Neurogastroenterol Motil. 2015;27:160-74.
23. Aziz A, et al. Esophageal disorders. Gastroenterology 2016;150:1368-79.
24. Katz P.O., et al. Am J Gastroenterol. 2013;108:308-28; quiz 329.
25. Boeckxstaens G., et al. Gut 2014;63:1185-93.
26. Patel A., et al. Neurogastroenterol Motil. 2016;28:513-21.
27. Patel A., et al. Neurogastroenterol Motil. 2016;28:1382-90.
28. Martinucci I., et al. Neurogastroenterol Motil. 2014;26:546-55.
29. Ates F., et al. Gastroenterology 2015;148:334-43.
30. Kessing B.F., et al. Am J Gastroenterol. 2011;106:2093-7.
31. Patel A., et al. Aliment Pharmacol Ther. 2016;44:890-8.
32. Frazzoni M., et al. Neurogastroenterol Motil. 2016.
33. Frazzoni M., et al. Neurogastroenterol Motil. 2013;25:399-406, e295.
34. Vela M.F., et al. Am J Gastroenterol. 2011;106:844-50.
Introduction
Chronic esophageal symptoms attributed to gastroesophageal reflux disease (GERD) are common presenting symptoms in gastroenterology, leading to high healthcare costs and adverse quality of life globally.1,2 The clinical diagnosis of GERD hinges on the presence of “troublesome” compatible typical symptoms (heartburn, acid regurgitation) or evidence of mucosal injury on endoscopy (esophagitis, Barrett’s esophagus, peptic stricture).3 With the growing availability of proton pump inhibitors (PPIs), patients and clinicians often utilize an empiric therapeutic trial of PPI as an initial test, with symptom improvement in the absence of alarm symptoms indicating a high likelihood of GERD.4 A meta-analysis of studies that used objective measures of GERD (in this case, 24-hour pH monitoring) showed that the “PPI test” has a sensitivity of 78%, but a specificity of only 54%, as a diagnostic approach to GERD symptoms.5 Apart from noncardiac chest pain, the diagnostic yield is even lower for atypical and extra-esophageal symptoms such as cough or laryngeal symptoms.6
The “nuts and bolts” of reflux testing
Ambulatory reflux testing assesses esophageal reflux burden and symptom-reflux association (SRA). Individual reflux events are identified as either a drop in esophageal pH to less than 4 (acid reflux events), or a sharp decrease in esophageal impedance measurements in a retrograde fashion (impedance-detected reflux events), with subsequent recovery to the baseline in each instance. Ambulatory reflux testing affords insight into three areas: 1) measurement of esophageal acid exposure time (AET); the cumulative time duration when distal esophageal pH is less than 4 at the recording site, reported as a percentage of the recording period; 2) measurement of the number of reflux events both acidic (from pH monitoring) and weakly acidic/alkaline (from impedance monitoring); and 3) quantitative evaluation of the association between reported symptom episodes and reflux events.
The SI and SAP can be calculated individually for acid-detected reflux events and for impedance-detected reflux events. Since reflux events are better detected with impedance, combined pH-impedance testing increases the yield of detecting positive SRA, especially when performed off PPI therapy.16,17 Because these indices are heavily reliant on patient reporting of symptom episodes, SRA can be overinterpreted;18 positive associations are more clinically useful than negative results in the evaluation of symptoms attributed to GERD.19 Despite these concerns, the two most consistent predictors of symptomatic outcome with antireflux therapy on pH-impedance testing are abnormal AET and positive SAP with impedance-detected reflux events.17
Testing on or off PPI?
For symptoms attributable to GERD that persist despite properly administered PPI therapy, the 2013 American College of Gastroenterology guidelines suggest upper endoscopy with esophageal biopsies for typical symptoms and appropriate referrals for atypical symptoms.24 However, if these evaluations are unremarkable, reflux monitoring is recommended, with PPI status for testing guided by the pre-test probability of GERD: with a low pre-test probability of GERD, reflux testing is best performed off PPI with either pH or combined pH-impedance testing. In contrast, with a high pre-test probability of GERD, testing is best performed on PPI with combined pH-impedance testing. A similar concept is proposed in the Rome IV approach (Figure 2)23 and on GERD consensus guidelines:7 when heartburn or chest pain persists despite PPI therapy and endoscopy and esophageal biopsies are normal, evidence for GERD (past esophagitis, Barrett’s esophagus, peptic stricture, or prior positive reflux testing) prompts pH-impedance monitoring on PPI therapy (i.e., proven GERD). Those without this evidence for proven GERD (i.e., unproven GERD) are best tested off PPI, and the test utilized can be either pH alone or combined pH-impedance.
GERD phenotypes and management
The presence or absence of the two core metrics on ambulatory reflux monitoring – abnormal AET and positive SRA – can stratify symptomatic GERD patients into phenotypes that predict symptomatic improvement with antireflux therapy and guide management of symptoms (Figure 3).25,26 The presence of both abnormal AET and positive SRA suggests “strong” evidence for GERD, for which symptom improvement is likely with maximization of antireflux therapy, which can include BID PPI, baclofen (to decrease transient LES relaxations), alginates (such as Gaviscon), and consideration of endosopic or surgical antireflux procedures such as fundoplication or magnetic sphincter augmentation. Abnormal AET but negative SRA is regarded as “good” evidence for GERD, for which similar antireflux therapies can be advocated. Normal AET but positive SRA is designated as “reflux hypersensitivity,”23 with increasing proportions of patients meeting this phenotype when tested with combined pH-impedance and off PPI therapy.27 Both normal AET and negative SRA suggest equivocal evidence for GERD and the likely presence of a functional esophageal disorder, such as functional heartburn.23 For reflux hypersensitivity and especially functional esophageal disorders, antireflux therapy is unlikely to be as effective and management can include pharmacologic neuromodulation (such as tricyclic antidepressants administered at bedtime) as well as adjunctive nonpharmacologic approaches (such as stress reduction, relaxation, hypnosis, or cognitive-behavioral therapy).
The future of reflux diagnostics
Conclusions
For esophageal symptoms potentially attributable to GERD that persist despite optimized PPI therapy, esophageal testing should be undertaken, starting with endoscopy and biopsies and proceeding to ambulatory reflux monitoring with HRM. The decisions between pH testing alone versus combined pH-impedance monitoring, and between testing on or off PPI therapy, can be guided either by the pre-test probability of GERD or whether GERD has been proven or unproven in prior evaluations (Figure 2). Elevated AET and positive SRA with impedance-detected reflux events can predict the likelihood of successful management outcomes from antireflux therapy. These two core metrics can be utilized to phenotype GERD and guide management approaches for persisting symptoms (Figure 3). Novel impedance metrics (baseline mucosal impedance, postreflux swallow-induced peristaltic wave index) and markers for esophageal mucosal damage continue to be studied as potential markers for evidence of longitudinal reflux exposure.
Dr. Patel is assistant professor of medicine, division of gastroenterology, Duke University School of Medicine and the Durham Veterans Affairs Medical Center, Durham, N.C. Dr. Gyawali is professor of medicine, division of gastroenterology, Washington University School of Medicine, St. Louis, Mo.
References
1. Shaheen N.J., et al. Am J Gastroenterol. 2006;101:2128-38.
2. Patel A., Gyawali C.P.. Switzerland: Springer International, 2016.
3. Vakil N., et al. Am J Gastroenterol. 2006;101:1900-20; quiz 1943.
4. Fass R., et al. Arch Intern Med. 1999;159:2161-8.
5. Numans M.E., et al. Ann Intern Med. 2004;140:518-27.
6. Shaheen N.J., et al. Aliment Pharmacol Ther. 2011;33:225-34.
7. Roman S., et al. Neurogastroenterol Motil Mar 31. doi: 10.1111/nmo.13067. [Epub ahead of print] 2017.
8. Dellon E.S., et al. Am J Gastroenterol. 2013;108:679-92; quiz 693.
9. Pandolfino JE, Vela MF. Gastrointest Endosc. 2009;69:917-30, 930 e1.
10. Shay S., et al. Am J Gastroenterol. 2004;99:1037-43.
11. Zerbib F., et al. Clin Gastroenterol Hepatol. 2013;11:366-72.
12. Wiener G.J., et al. Am J Gastroenterol 1988;83:358-61.
13. Weusten B.L., et al. Gastroenterology. 1994;107:1741-5.
14. Ghillebert G., et al. Gut 1990;31:738-44.
15. Kushnir V.M., et al. Aliment Pharmacol Ther. 2012;35(9):1080-7.
16. Bredenoord A.J., et al. Am J Gastroenterol. 2006;101:453-9.
17. Patel A., et al. Clin Gastroenterol Hepatol. 2015;13:884-91.
18. Slaughter J.C., et al. Clin Gastroenterol Hepatol. 2011;9:868-74.
19. Kavitt R.T., et al. Am J Gastroenterol. 2012;107:1826-32.
20. Kahrilas P.J., et al. Gastroenterology 2008;135:1383-91, 1391 e1-5.
21. Kessing B.F., et al. Clin Gastroenterol Hepatol. 2011;9:1020-4.
22. Kahrilas P.J., et al. Neurogastroenterol Motil. 2015;27:160-74.
23. Aziz A, et al. Esophageal disorders. Gastroenterology 2016;150:1368-79.
24. Katz P.O., et al. Am J Gastroenterol. 2013;108:308-28; quiz 329.
25. Boeckxstaens G., et al. Gut 2014;63:1185-93.
26. Patel A., et al. Neurogastroenterol Motil. 2016;28:513-21.
27. Patel A., et al. Neurogastroenterol Motil. 2016;28:1382-90.
28. Martinucci I., et al. Neurogastroenterol Motil. 2014;26:546-55.
29. Ates F., et al. Gastroenterology 2015;148:334-43.
30. Kessing B.F., et al. Am J Gastroenterol. 2011;106:2093-7.
31. Patel A., et al. Aliment Pharmacol Ther. 2016;44:890-8.
32. Frazzoni M., et al. Neurogastroenterol Motil. 2016.
33. Frazzoni M., et al. Neurogastroenterol Motil. 2013;25:399-406, e295.
34. Vela M.F., et al. Am J Gastroenterol. 2011;106:844-50.
Introduction
Chronic esophageal symptoms attributed to gastroesophageal reflux disease (GERD) are common presenting symptoms in gastroenterology, leading to high healthcare costs and adverse quality of life globally.1,2 The clinical diagnosis of GERD hinges on the presence of “troublesome” compatible typical symptoms (heartburn, acid regurgitation) or evidence of mucosal injury on endoscopy (esophagitis, Barrett’s esophagus, peptic stricture).3 With the growing availability of proton pump inhibitors (PPIs), patients and clinicians often utilize an empiric therapeutic trial of PPI as an initial test, with symptom improvement in the absence of alarm symptoms indicating a high likelihood of GERD.4 A meta-analysis of studies that used objective measures of GERD (in this case, 24-hour pH monitoring) showed that the “PPI test” has a sensitivity of 78%, but a specificity of only 54%, as a diagnostic approach to GERD symptoms.5 Apart from noncardiac chest pain, the diagnostic yield is even lower for atypical and extra-esophageal symptoms such as cough or laryngeal symptoms.6
The “nuts and bolts” of reflux testing
Ambulatory reflux testing assesses esophageal reflux burden and symptom-reflux association (SRA). Individual reflux events are identified as either a drop in esophageal pH to less than 4 (acid reflux events), or a sharp decrease in esophageal impedance measurements in a retrograde fashion (impedance-detected reflux events), with subsequent recovery to the baseline in each instance. Ambulatory reflux testing affords insight into three areas: 1) measurement of esophageal acid exposure time (AET); the cumulative time duration when distal esophageal pH is less than 4 at the recording site, reported as a percentage of the recording period; 2) measurement of the number of reflux events both acidic (from pH monitoring) and weakly acidic/alkaline (from impedance monitoring); and 3) quantitative evaluation of the association between reported symptom episodes and reflux events.
The SI and SAP can be calculated individually for acid-detected reflux events and for impedance-detected reflux events. Since reflux events are better detected with impedance, combined pH-impedance testing increases the yield of detecting positive SRA, especially when performed off PPI therapy.16,17 Because these indices are heavily reliant on patient reporting of symptom episodes, SRA can be overinterpreted;18 positive associations are more clinically useful than negative results in the evaluation of symptoms attributed to GERD.19 Despite these concerns, the two most consistent predictors of symptomatic outcome with antireflux therapy on pH-impedance testing are abnormal AET and positive SAP with impedance-detected reflux events.17
Testing on or off PPI?
For symptoms attributable to GERD that persist despite properly administered PPI therapy, the 2013 American College of Gastroenterology guidelines suggest upper endoscopy with esophageal biopsies for typical symptoms and appropriate referrals for atypical symptoms.24 However, if these evaluations are unremarkable, reflux monitoring is recommended, with PPI status for testing guided by the pre-test probability of GERD: with a low pre-test probability of GERD, reflux testing is best performed off PPI with either pH or combined pH-impedance testing. In contrast, with a high pre-test probability of GERD, testing is best performed on PPI with combined pH-impedance testing. A similar concept is proposed in the Rome IV approach (Figure 2)23 and on GERD consensus guidelines:7 when heartburn or chest pain persists despite PPI therapy and endoscopy and esophageal biopsies are normal, evidence for GERD (past esophagitis, Barrett’s esophagus, peptic stricture, or prior positive reflux testing) prompts pH-impedance monitoring on PPI therapy (i.e., proven GERD). Those without this evidence for proven GERD (i.e., unproven GERD) are best tested off PPI, and the test utilized can be either pH alone or combined pH-impedance.
GERD phenotypes and management
The presence or absence of the two core metrics on ambulatory reflux monitoring – abnormal AET and positive SRA – can stratify symptomatic GERD patients into phenotypes that predict symptomatic improvement with antireflux therapy and guide management of symptoms (Figure 3).25,26 The presence of both abnormal AET and positive SRA suggests “strong” evidence for GERD, for which symptom improvement is likely with maximization of antireflux therapy, which can include BID PPI, baclofen (to decrease transient LES relaxations), alginates (such as Gaviscon), and consideration of endosopic or surgical antireflux procedures such as fundoplication or magnetic sphincter augmentation. Abnormal AET but negative SRA is regarded as “good” evidence for GERD, for which similar antireflux therapies can be advocated. Normal AET but positive SRA is designated as “reflux hypersensitivity,”23 with increasing proportions of patients meeting this phenotype when tested with combined pH-impedance and off PPI therapy.27 Both normal AET and negative SRA suggest equivocal evidence for GERD and the likely presence of a functional esophageal disorder, such as functional heartburn.23 For reflux hypersensitivity and especially functional esophageal disorders, antireflux therapy is unlikely to be as effective and management can include pharmacologic neuromodulation (such as tricyclic antidepressants administered at bedtime) as well as adjunctive nonpharmacologic approaches (such as stress reduction, relaxation, hypnosis, or cognitive-behavioral therapy).
The future of reflux diagnostics
Conclusions
For esophageal symptoms potentially attributable to GERD that persist despite optimized PPI therapy, esophageal testing should be undertaken, starting with endoscopy and biopsies and proceeding to ambulatory reflux monitoring with HRM. The decisions between pH testing alone versus combined pH-impedance monitoring, and between testing on or off PPI therapy, can be guided either by the pre-test probability of GERD or whether GERD has been proven or unproven in prior evaluations (Figure 2). Elevated AET and positive SRA with impedance-detected reflux events can predict the likelihood of successful management outcomes from antireflux therapy. These two core metrics can be utilized to phenotype GERD and guide management approaches for persisting symptoms (Figure 3). Novel impedance metrics (baseline mucosal impedance, postreflux swallow-induced peristaltic wave index) and markers for esophageal mucosal damage continue to be studied as potential markers for evidence of longitudinal reflux exposure.
Dr. Patel is assistant professor of medicine, division of gastroenterology, Duke University School of Medicine and the Durham Veterans Affairs Medical Center, Durham, N.C. Dr. Gyawali is professor of medicine, division of gastroenterology, Washington University School of Medicine, St. Louis, Mo.
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President’s Letter
Dear Trainees and Early-Career GIs,
As I begin my time as President of AGA, I am reflecting on other new beginnings in my career. Though time has passed, I vividly recall the excitement and uncertainty of beginning training and, subsequently, my career. It’s a career that I’ve enjoyed immensely and I hope that you will as well.
All our resources are available online at www.gastro.org and we have a suite of apps including guidelines, image challenges, DDSEP, and publications that you can download to your mobile device. You can learn more about those at www.gastro.org/mobile-offerings.
Another great resource is the AGA Community, where you can join a private online conversation with other early-career gastroenterologists. You can access a library of resources there and talk with gastroenterologists who are in the same career phase as you are. Join the conversation at community.gastro.org.
The New Gastroenterologist is the perfect place to start your professional journey and to stay on the cutting edge of the field. It provides a wealth of information you won’t find in other publications. Its unique focus promises that you’ll read content that meets your immediate needs as a trainee or early-career gastroenterologist.
On behalf of the AGA Governing Board, I wish you great success in this exciting field!
Sincerely,
Sheila E. Crowe, MD, AGAF
President, AGA Institute
Professor of Medicine and Director of Research, University of California, San Diego
Dear Trainees and Early-Career GIs,
As I begin my time as President of AGA, I am reflecting on other new beginnings in my career. Though time has passed, I vividly recall the excitement and uncertainty of beginning training and, subsequently, my career. It’s a career that I’ve enjoyed immensely and I hope that you will as well.
All our resources are available online at www.gastro.org and we have a suite of apps including guidelines, image challenges, DDSEP, and publications that you can download to your mobile device. You can learn more about those at www.gastro.org/mobile-offerings.
Another great resource is the AGA Community, where you can join a private online conversation with other early-career gastroenterologists. You can access a library of resources there and talk with gastroenterologists who are in the same career phase as you are. Join the conversation at community.gastro.org.
The New Gastroenterologist is the perfect place to start your professional journey and to stay on the cutting edge of the field. It provides a wealth of information you won’t find in other publications. Its unique focus promises that you’ll read content that meets your immediate needs as a trainee or early-career gastroenterologist.
On behalf of the AGA Governing Board, I wish you great success in this exciting field!
Sincerely,
Sheila E. Crowe, MD, AGAF
President, AGA Institute
Professor of Medicine and Director of Research, University of California, San Diego
Dear Trainees and Early-Career GIs,
As I begin my time as President of AGA, I am reflecting on other new beginnings in my career. Though time has passed, I vividly recall the excitement and uncertainty of beginning training and, subsequently, my career. It’s a career that I’ve enjoyed immensely and I hope that you will as well.
All our resources are available online at www.gastro.org and we have a suite of apps including guidelines, image challenges, DDSEP, and publications that you can download to your mobile device. You can learn more about those at www.gastro.org/mobile-offerings.
Another great resource is the AGA Community, where you can join a private online conversation with other early-career gastroenterologists. You can access a library of resources there and talk with gastroenterologists who are in the same career phase as you are. Join the conversation at community.gastro.org.
The New Gastroenterologist is the perfect place to start your professional journey and to stay on the cutting edge of the field. It provides a wealth of information you won’t find in other publications. Its unique focus promises that you’ll read content that meets your immediate needs as a trainee or early-career gastroenterologist.
On behalf of the AGA Governing Board, I wish you great success in this exciting field!
Sincerely,
Sheila E. Crowe, MD, AGAF
President, AGA Institute
Professor of Medicine and Director of Research, University of California, San Diego