The New Gastroenterologist

 

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.

As with many other aspiring gastroenterologists, Kevin took out more than $200,000 in federal and private student loans to pay his way through medical school. He recently refinanced these loans and picked up some lessons along the way. Below, he offers some tips for getting free of debt; taking Kevin’s advice to heart can help you worry less about your loans and focus instead on serving your patients.
 

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?

BrianAJackson/Thinkstock

Frustrating and stressful. I struggled to understand the complex application processes, the best type of loan for my personal situation, and to find the lowest rates. In addition, I later learned that my loans’ interest capitalized while I was still in school, which made the volume of my debt greater than what I initially borrowed. It would have been helpful to know that up front, as I could have made small, monthly payments earlier.
 

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?

I initially had a 15-year student loan with a 5.75% APR. When I refinanced with CommonBond, I secured a 7-year, fixed-rate student loan with a 4.2% APR. I made this choice because I’ll be saving $30,000 to $40,000 over the life of my loan, and my monthly payment stays stable, regardless of how the market fluctuates. Refinancing my student loan has put me on the path to becoming debt free, which will allow me to focus more on my career.
 

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.

As with many other aspiring gastroenterologists, Kevin took out more than $200,000 in federal and private student loans to pay his way through medical school. He recently refinanced these loans and picked up some lessons along the way. Below, he offers some tips for getting free of debt; taking Kevin’s advice to heart can help you worry less about your loans and focus instead on serving your patients.
 

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?

BrianAJackson/Thinkstock

Frustrating and stressful. I struggled to understand the complex application processes, the best type of loan for my personal situation, and to find the lowest rates. In addition, I later learned that my loans’ interest capitalized while I was still in school, which made the volume of my debt greater than what I initially borrowed. It would have been helpful to know that up front, as I could have made small, monthly payments earlier.
 

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?

I initially had a 15-year student loan with a 5.75% APR. When I refinanced with CommonBond, I secured a 7-year, fixed-rate student loan with a 4.2% APR. I made this choice because I’ll be saving $30,000 to $40,000 over the life of my loan, and my monthly payment stays stable, regardless of how the market fluctuates. Refinancing my student loan has put me on the path to becoming debt free, which will allow me to focus more on my career.
 

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.

As with many other aspiring gastroenterologists, Kevin took out more than $200,000 in federal and private student loans to pay his way through medical school. He recently refinanced these loans and picked up some lessons along the way. Below, he offers some tips for getting free of debt; taking Kevin’s advice to heart can help you worry less about your loans and focus instead on serving your patients.
 

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?

BrianAJackson/Thinkstock

Frustrating and stressful. I struggled to understand the complex application processes, the best type of loan for my personal situation, and to find the lowest rates. In addition, I later learned that my loans’ interest capitalized while I was still in school, which made the volume of my debt greater than what I initially borrowed. It would have been helpful to know that up front, as I could have made small, monthly payments earlier.
 

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?

I initially had a 15-year student loan with a 5.75% APR. When I refinanced with CommonBond, I secured a 7-year, fixed-rate student loan with a 4.2% APR. I made this choice because I’ll be saving $30,000 to $40,000 over the life of my loan, and my monthly payment stays stable, regardless of how the market fluctuates. Refinancing my student loan has put me on the path to becoming debt free, which will allow me to focus more on my career.
 

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 correct answer is C: colonic ischemia.

AGA Institute

The endoscopic findings are notable for colon single-stripe sign (CSSS), which is a highly specific feature of colonic ischemia (Figure A). The diagnosis of colon ischemia is further supported by the histologic features of cryptitis, focal fibrosis, and hemorrhage within the lamina propria (Figure B). In this case, the patient’s history of radiation exposure and hypotension were both likely predisposing factors for colonic hypoperfusion and subsequent colon ischemia. With conservative medical therapy, the patient experienced complete resolution of symptoms.

AGA Institute

Diverticular disease-associated colitis (answer A) is less likely given the lack of interdiverticular mucosal involvement and linear ulceration pattern, which also contrasts with the deep, “punched-out” appearance typically associated with ulceration of cytomegalovirus colitis (answer B). The endoscopic findings associated with chronic radiation colitis (answer D) characteristically include evidence of mucosal scarring, friability, and scattered angioectasias. The CSSS was initially described as a manifestation of colonic ischemia by Zuckerman et al. who hypothesized the linear nature of this lesion likely reflected segmental vascular compromise.1 Concordant with the presented case, of the 26 patients with CSSS included in the Zuckerman et al. study, all had a stripe measuring 5 cm in length while a minority (4 patients) had transverse colon involvement.1 Also in parallel with this case, others have reported successful nonoperative management of patients with CSSS in the setting of ischemia.1,2 Overall, the comparatively favorable outcome in patients with CSSS compared to those with circumferential colonic ischemia suggests this finding may reflect a more mild form of disease.1 n
 

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.

AGA Institute

The endoscopic findings are notable for colon single-stripe sign (CSSS), which is a highly specific feature of colonic ischemia (Figure A). The diagnosis of colon ischemia is further supported by the histologic features of cryptitis, focal fibrosis, and hemorrhage within the lamina propria (Figure B). In this case, the patient’s history of radiation exposure and hypotension were both likely predisposing factors for colonic hypoperfusion and subsequent colon ischemia. With conservative medical therapy, the patient experienced complete resolution of symptoms.

AGA Institute

Diverticular disease-associated colitis (answer A) is less likely given the lack of interdiverticular mucosal involvement and linear ulceration pattern, which also contrasts with the deep, “punched-out” appearance typically associated with ulceration of cytomegalovirus colitis (answer B). The endoscopic findings associated with chronic radiation colitis (answer D) characteristically include evidence of mucosal scarring, friability, and scattered angioectasias. The CSSS was initially described as a manifestation of colonic ischemia by Zuckerman et al. who hypothesized the linear nature of this lesion likely reflected segmental vascular compromise.1 Concordant with the presented case, of the 26 patients with CSSS included in the Zuckerman et al. study, all had a stripe measuring 5 cm in length while a minority (4 patients) had transverse colon involvement.1 Also in parallel with this case, others have reported successful nonoperative management of patients with CSSS in the setting of ischemia.1,2 Overall, the comparatively favorable outcome in patients with CSSS compared to those with circumferential colonic ischemia suggests this finding may reflect a more mild form of disease.1 n
 

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.

AGA Institute

The endoscopic findings are notable for colon single-stripe sign (CSSS), which is a highly specific feature of colonic ischemia (Figure A). The diagnosis of colon ischemia is further supported by the histologic features of cryptitis, focal fibrosis, and hemorrhage within the lamina propria (Figure B). In this case, the patient’s history of radiation exposure and hypotension were both likely predisposing factors for colonic hypoperfusion and subsequent colon ischemia. With conservative medical therapy, the patient experienced complete resolution of symptoms.

AGA Institute

Diverticular disease-associated colitis (answer A) is less likely given the lack of interdiverticular mucosal involvement and linear ulceration pattern, which also contrasts with the deep, “punched-out” appearance typically associated with ulceration of cytomegalovirus colitis (answer B). The endoscopic findings associated with chronic radiation colitis (answer D) characteristically include evidence of mucosal scarring, friability, and scattered angioectasias. The CSSS was initially described as a manifestation of colonic ischemia by Zuckerman et al. who hypothesized the linear nature of this lesion likely reflected segmental vascular compromise.1 Concordant with the presented case, of the 26 patients with CSSS included in the Zuckerman et al. study, all had a stripe measuring 5 cm in length while a minority (4 patients) had transverse colon involvement.1 Also in parallel with this case, others have reported successful nonoperative management of patients with CSSS in the setting of ischemia.1,2 Overall, the comparatively favorable outcome in patients with CSSS compared to those with circumferential colonic ischemia suggests this finding may reflect a more mild form of disease.1 n
 

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.
 

 

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.

Throughout my career I focused on medical education, preparing my senior resident talk on “the resident as teacher” – not yet a hot topic. My path as a GI fellow, including a chief fellow year at the Cleveland Clinic, reconfirmed my interest in education leadership. During my first postfellowship position at the University of Pittsburgh, I was able to lead the GI second-year course, oversee GI electives for students and residents, and work on the GI fellowship curriculum. It was at that time that I began my involvement in AGA with committee work related to education and women’s issues in GI. I also refocused my scholarly work in education, eventually editing a textbook in GI and hepatobiliary pathophysiology, and working on other projects.
 

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.

Throughout my career I focused on medical education, preparing my senior resident talk on “the resident as teacher” – not yet a hot topic. My path as a GI fellow, including a chief fellow year at the Cleveland Clinic, reconfirmed my interest in education leadership. During my first postfellowship position at the University of Pittsburgh, I was able to lead the GI second-year course, oversee GI electives for students and residents, and work on the GI fellowship curriculum. It was at that time that I began my involvement in AGA with committee work related to education and women’s issues in GI. I also refocused my scholarly work in education, eventually editing a textbook in GI and hepatobiliary pathophysiology, and working on other projects.
 

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.

Throughout my career I focused on medical education, preparing my senior resident talk on “the resident as teacher” – not yet a hot topic. My path as a GI fellow, including a chief fellow year at the Cleveland Clinic, reconfirmed my interest in education leadership. During my first postfellowship position at the University of Pittsburgh, I was able to lead the GI second-year course, oversee GI electives for students and residents, and work on the GI fellowship curriculum. It was at that time that I began my involvement in AGA with committee work related to education and women’s issues in GI. I also refocused my scholarly work in education, eventually editing a textbook in GI and hepatobiliary pathophysiology, and working on other projects.
 

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.
 

 

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.

A 2007-2008 survey of 5,825 physicians, not limited by subspecialty, showed that 42.2% of all physicians had a malpractice claim filed against them at some point in their career.³ Of all physicians aged 55 and older, 60.5% of respondents had been sued at some point during their career.³ Incidents of medical liability claims were much higher among men (47.5%) than among women (23.9%). ³ The average cost to defend these cases through trial is more than $100,000, but the average cost diminishes to $21,163 with cases that are dropped, dismissed, or withdrawn prior to trial.³

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

JAMA also reported that between 2004 and 2014, diagnostic error served as the most prevalent basis for allegations of medical negligence against all physicians.⁴ These allegations comprised 31.8% of claims during this period.⁴ With respect to gastroenterologists, prior data from 1985-2004 similarly suggests that diagnostic interview, evaluation, or consultation results in the most claims against this group of physicians.⁴ The most common allegations specific to gastroenterologists involve malignant neoplasms of the colon and rectum, followed by abdominal and pelvic symptoms, regional enteritis, colitis, and malignant neoplasms of the stomach.² Errors in diagnosing stomach, colon, and rectal cancers resulted in the highest average indemnity payment.²

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.

Informed consent: Another theory is informed consent. A physician must obtain full, knowing, and voluntary informed consent from her patient for any nonemergency surgical procedure. A patient’s lack of consent claim is premised on the allegation that the physician failed to reveal a significant risk, which caused harm to the plaintiff, and that had the potential risk been disclosed, a reasonable person would not have consented to the treatment or procedure. Informed consent requires more from a physician than simply having the patient sign a form. The physician performing the procedure for which consent is required must ensure that the patient is aware of the benefits of the proposed treatment, the material risks of the treatment, alternative options to the proposed treatment, and possible consequences of declining the treatment. This information must be communicated to a patient so that she clearly understands it.

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

Opportunities exist to decrease the chances of being sued. One major area involves documentation, as the patient’s records will serve as the basis of the litigation. Accordingly, physicians should ensure notations are legible so that lawyers, jurors, and others participating in the patient’s care do not misunderstand the records. This has been made easier by the recent implementation of electronic health records. Records should also be comprehensive and kept contemporaneously with treatment to maintain accuracy and to avoid the appearance of impropriety. Subsequent entries must be clearly identified and dated. Never change records after a patient commences a suit against you. Remember that everything you write can come out during the investigation phase of the lawsuit.

 

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.

Finally, physicians should be aware of how relationships with the patient, institutions, and health care providers can affect liability. Communication is key to fostering a good doctor-patient relationship, and studies support that the quality of the doctor-patient relationship is a primary factor in determining whether a patient will sue her physician.² You should also understand how your relationship with your workplace affects your potential liability. For example, your workplace may be vicariously liable for negligence found on your part, and therefore, deemed ultimately responsible for any verdict or settlement amount. Conversely, you could be found vicariously liable for the actions of health care providers with whom you work. In the surgery context, the basis for this type of liability is that the surgeon is in a position of highest authority and has ultimate control over everything that occurs during the course of surgery. Therefore, you should understand the consequences of your relationships with the patients, facilities, and providers with which you work.⁵

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.

A 2007-2008 survey of 5,825 physicians, not limited by subspecialty, showed that 42.2% of all physicians had a malpractice claim filed against them at some point in their career.³ Of all physicians aged 55 and older, 60.5% of respondents had been sued at some point during their career.³ Incidents of medical liability claims were much higher among men (47.5%) than among women (23.9%). ³ The average cost to defend these cases through trial is more than $100,000, but the average cost diminishes to $21,163 with cases that are dropped, dismissed, or withdrawn prior to trial.³

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

JAMA also reported that between 2004 and 2014, diagnostic error served as the most prevalent basis for allegations of medical negligence against all physicians.⁴ These allegations comprised 31.8% of claims during this period.⁴ With respect to gastroenterologists, prior data from 1985-2004 similarly suggests that diagnostic interview, evaluation, or consultation results in the most claims against this group of physicians.⁴ The most common allegations specific to gastroenterologists involve malignant neoplasms of the colon and rectum, followed by abdominal and pelvic symptoms, regional enteritis, colitis, and malignant neoplasms of the stomach.² Errors in diagnosing stomach, colon, and rectal cancers resulted in the highest average indemnity payment.²

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.

Informed consent: Another theory is informed consent. A physician must obtain full, knowing, and voluntary informed consent from her patient for any nonemergency surgical procedure. A patient’s lack of consent claim is premised on the allegation that the physician failed to reveal a significant risk, which caused harm to the plaintiff, and that had the potential risk been disclosed, a reasonable person would not have consented to the treatment or procedure. Informed consent requires more from a physician than simply having the patient sign a form. The physician performing the procedure for which consent is required must ensure that the patient is aware of the benefits of the proposed treatment, the material risks of the treatment, alternative options to the proposed treatment, and possible consequences of declining the treatment. This information must be communicated to a patient so that she clearly understands it.

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

Opportunities exist to decrease the chances of being sued. One major area involves documentation, as the patient’s records will serve as the basis of the litigation. Accordingly, physicians should ensure notations are legible so that lawyers, jurors, and others participating in the patient’s care do not misunderstand the records. This has been made easier by the recent implementation of electronic health records. Records should also be comprehensive and kept contemporaneously with treatment to maintain accuracy and to avoid the appearance of impropriety. Subsequent entries must be clearly identified and dated. Never change records after a patient commences a suit against you. Remember that everything you write can come out during the investigation phase of the lawsuit.

 

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.

Finally, physicians should be aware of how relationships with the patient, institutions, and health care providers can affect liability. Communication is key to fostering a good doctor-patient relationship, and studies support that the quality of the doctor-patient relationship is a primary factor in determining whether a patient will sue her physician.² You should also understand how your relationship with your workplace affects your potential liability. For example, your workplace may be vicariously liable for negligence found on your part, and therefore, deemed ultimately responsible for any verdict or settlement amount. Conversely, you could be found vicariously liable for the actions of health care providers with whom you work. In the surgery context, the basis for this type of liability is that the surgeon is in a position of highest authority and has ultimate control over everything that occurs during the course of surgery. Therefore, you should understand the consequences of your relationships with the patients, facilities, and providers with which you work.⁵

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.

A 2007-2008 survey of 5,825 physicians, not limited by subspecialty, showed that 42.2% of all physicians had a malpractice claim filed against them at some point in their career.³ Of all physicians aged 55 and older, 60.5% of respondents had been sued at some point during their career.³ Incidents of medical liability claims were much higher among men (47.5%) than among women (23.9%). ³ The average cost to defend these cases through trial is more than $100,000, but the average cost diminishes to $21,163 with cases that are dropped, dismissed, or withdrawn prior to trial.³

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

JAMA also reported that between 2004 and 2014, diagnostic error served as the most prevalent basis for allegations of medical negligence against all physicians.⁴ These allegations comprised 31.8% of claims during this period.⁴ With respect to gastroenterologists, prior data from 1985-2004 similarly suggests that diagnostic interview, evaluation, or consultation results in the most claims against this group of physicians.⁴ The most common allegations specific to gastroenterologists involve malignant neoplasms of the colon and rectum, followed by abdominal and pelvic symptoms, regional enteritis, colitis, and malignant neoplasms of the stomach.² Errors in diagnosing stomach, colon, and rectal cancers resulted in the highest average indemnity payment.²

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.

Informed consent: Another theory is informed consent. A physician must obtain full, knowing, and voluntary informed consent from her patient for any nonemergency surgical procedure. A patient’s lack of consent claim is premised on the allegation that the physician failed to reveal a significant risk, which caused harm to the plaintiff, and that had the potential risk been disclosed, a reasonable person would not have consented to the treatment or procedure. Informed consent requires more from a physician than simply having the patient sign a form. The physician performing the procedure for which consent is required must ensure that the patient is aware of the benefits of the proposed treatment, the material risks of the treatment, alternative options to the proposed treatment, and possible consequences of declining the treatment. This information must be communicated to a patient so that she clearly understands it.

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

Opportunities exist to decrease the chances of being sued. One major area involves documentation, as the patient’s records will serve as the basis of the litigation. Accordingly, physicians should ensure notations are legible so that lawyers, jurors, and others participating in the patient’s care do not misunderstand the records. This has been made easier by the recent implementation of electronic health records. Records should also be comprehensive and kept contemporaneously with treatment to maintain accuracy and to avoid the appearance of impropriety. Subsequent entries must be clearly identified and dated. Never change records after a patient commences a suit against you. Remember that everything you write can come out during the investigation phase of the lawsuit.

 

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.

Finally, physicians should be aware of how relationships with the patient, institutions, and health care providers can affect liability. Communication is key to fostering a good doctor-patient relationship, and studies support that the quality of the doctor-patient relationship is a primary factor in determining whether a patient will sue her physician.² You should also understand how your relationship with your workplace affects your potential liability. For example, your workplace may be vicariously liable for negligence found on your part, and therefore, deemed ultimately responsible for any verdict or settlement amount. Conversely, you could be found vicariously liable for the actions of health care providers with whom you work. In the surgery context, the basis for this type of liability is that the surgeon is in a position of highest authority and has ultimate control over everything that occurs during the course of surgery. Therefore, you should understand the consequences of your relationships with the patients, facilities, and providers with which you work.⁵

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.

 

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).

Susan Reynolds, MD, PhD (President and CEO of The Institute for Medical Leadership) led the meeting in her characteristically dynamic and open style. Dr. Reynolds presented content that highlighted key success factors for women physicians and scientists including the ability to build trust, encourage teamwork, and inspire vision.

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.

The early-career track women gathered with Dr. Proctor to share stories of their own mentorship. From this discussion, it emerged that excellent mentorship is critical for successful career development. Women shared examples of how strong mentors can guide us to opportunities, offer important career advice, and provide encouragement. Mentors can provide specific feedback on clinical skills as well as managing relationships with challenging patients and colleagues. Research mentors help guide research projects, identify funding opportunities, and develop grants. Moreover, they can play pivotal roles in finding job opportunities and encouraging a greater work-life balance. Connecting with a mentor, or a group of mentors for different aspects of one’s life and career, can be challenging: Creating space for mentorship through local gatherings with other gastroenterologists or researchers is a key part of success. Women were encouraged to reach out to others to deepen those supportive relationships after returning home.

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 more experienced women GIs participated in a classroom style discussion led by Dr. Reynolds. The topic, “Keys to Association and Career Advancement: Reinvigorating Your Career,” effectively conveyed the concept of leading through shared anecdotal experiences and related strategies. Dr. Reynolds also addressed skills for working with mentees of different generations including open communication and the importance of engagement.

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.

Two important and timely topics were added to this year’s leadership conference. First, the subject of advocacy was presented by Dr. Latha Alaparthi. In this presentation, Dr. Alaparthi explained to the group the meaning of advocacy in general, types of advocacy groups, political action committees, and ways in which we can become involved. Examples of laws affecting our patients, clinics, endoscopy centers, hospitals, medication coverage, payments, and funding for research were shared. Then, Dr. Proctor shared her personal experience at the 2016 AGA Advocacy Day. One conference attendee noted that while she had participated in advocacy as a student, she hadn’t understood that the AGA relies upon its members to meet with representatives at local, state, and national levels. We also learned how AGA’s Governmental Affairs Office manages financial contributions to promote advocacy for high-quality care and utilizes NIH funding to promote research in digestive diseases.

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.

Once created, a personal brand can be disseminated through professional social media accounts. Tweets can link to websites with additional content such as a summary of a recent presentation or highlights from a published manuscript. Participants were encouraged to closely monitor their professional profiles and, if needed, work with a firm to establish an online presence. These strategies can be useful for connecting with potential patients and collaborators.

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).

Susan Reynolds, MD, PhD (President and CEO of The Institute for Medical Leadership) led the meeting in her characteristically dynamic and open style. Dr. Reynolds presented content that highlighted key success factors for women physicians and scientists including the ability to build trust, encourage teamwork, and inspire vision.

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.

The early-career track women gathered with Dr. Proctor to share stories of their own mentorship. From this discussion, it emerged that excellent mentorship is critical for successful career development. Women shared examples of how strong mentors can guide us to opportunities, offer important career advice, and provide encouragement. Mentors can provide specific feedback on clinical skills as well as managing relationships with challenging patients and colleagues. Research mentors help guide research projects, identify funding opportunities, and develop grants. Moreover, they can play pivotal roles in finding job opportunities and encouraging a greater work-life balance. Connecting with a mentor, or a group of mentors for different aspects of one’s life and career, can be challenging: Creating space for mentorship through local gatherings with other gastroenterologists or researchers is a key part of success. Women were encouraged to reach out to others to deepen those supportive relationships after returning home.

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 more experienced women GIs participated in a classroom style discussion led by Dr. Reynolds. The topic, “Keys to Association and Career Advancement: Reinvigorating Your Career,” effectively conveyed the concept of leading through shared anecdotal experiences and related strategies. Dr. Reynolds also addressed skills for working with mentees of different generations including open communication and the importance of engagement.

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.

Two important and timely topics were added to this year’s leadership conference. First, the subject of advocacy was presented by Dr. Latha Alaparthi. In this presentation, Dr. Alaparthi explained to the group the meaning of advocacy in general, types of advocacy groups, political action committees, and ways in which we can become involved. Examples of laws affecting our patients, clinics, endoscopy centers, hospitals, medication coverage, payments, and funding for research were shared. Then, Dr. Proctor shared her personal experience at the 2016 AGA Advocacy Day. One conference attendee noted that while she had participated in advocacy as a student, she hadn’t understood that the AGA relies upon its members to meet with representatives at local, state, and national levels. We also learned how AGA’s Governmental Affairs Office manages financial contributions to promote advocacy for high-quality care and utilizes NIH funding to promote research in digestive diseases.

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.

Once created, a personal brand can be disseminated through professional social media accounts. Tweets can link to websites with additional content such as a summary of a recent presentation or highlights from a published manuscript. Participants were encouraged to closely monitor their professional profiles and, if needed, work with a firm to establish an online presence. These strategies can be useful for connecting with potential patients and collaborators.

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).

Susan Reynolds, MD, PhD (President and CEO of The Institute for Medical Leadership) led the meeting in her characteristically dynamic and open style. Dr. Reynolds presented content that highlighted key success factors for women physicians and scientists including the ability to build trust, encourage teamwork, and inspire vision.

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.

The early-career track women gathered with Dr. Proctor to share stories of their own mentorship. From this discussion, it emerged that excellent mentorship is critical for successful career development. Women shared examples of how strong mentors can guide us to opportunities, offer important career advice, and provide encouragement. Mentors can provide specific feedback on clinical skills as well as managing relationships with challenging patients and colleagues. Research mentors help guide research projects, identify funding opportunities, and develop grants. Moreover, they can play pivotal roles in finding job opportunities and encouraging a greater work-life balance. Connecting with a mentor, or a group of mentors for different aspects of one’s life and career, can be challenging: Creating space for mentorship through local gatherings with other gastroenterologists or researchers is a key part of success. Women were encouraged to reach out to others to deepen those supportive relationships after returning home.

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 more experienced women GIs participated in a classroom style discussion led by Dr. Reynolds. The topic, “Keys to Association and Career Advancement: Reinvigorating Your Career,” effectively conveyed the concept of leading through shared anecdotal experiences and related strategies. Dr. Reynolds also addressed skills for working with mentees of different generations including open communication and the importance of engagement.

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.

Two important and timely topics were added to this year’s leadership conference. First, the subject of advocacy was presented by Dr. Latha Alaparthi. In this presentation, Dr. Alaparthi explained to the group the meaning of advocacy in general, types of advocacy groups, political action committees, and ways in which we can become involved. Examples of laws affecting our patients, clinics, endoscopy centers, hospitals, medication coverage, payments, and funding for research were shared. Then, Dr. Proctor shared her personal experience at the 2016 AGA Advocacy Day. One conference attendee noted that while she had participated in advocacy as a student, she hadn’t understood that the AGA relies upon its members to meet with representatives at local, state, and national levels. We also learned how AGA’s Governmental Affairs Office manages financial contributions to promote advocacy for high-quality care and utilizes NIH funding to promote research in digestive diseases.

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.

Once created, a personal brand can be disseminated through professional social media accounts. Tweets can link to websites with additional content such as a summary of a recent presentation or highlights from a published manuscript. Participants were encouraged to closely monitor their professional profiles and, if needed, work with a firm to establish an online presence. These strategies can be useful for connecting with potential patients and collaborators.

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.

 

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

Therefore, when symptoms persist despite seemingly adequate PPI therapy, esophageal investigation may start with endoscopy but continues with ambulatory reflux and motility testing.⁷ At endoscopy, exclusion of eosinophilic esophagitis with esophageal biopsies represents an important component of initial evaluation when symptoms are refractory to PPIs.⁸ Further, the more atypical the presentation, the greater the need for esophageal testing prior to long-term PPI therapy. Esophageal function testing is also indicated when confirmation of GERD is needed prior to surgical or endoscopic reflux procedures.
 

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 three available modalities of ambulatory reflux monitoring consist of catheter-based pH, wireless pH, and combined catheter-based pH-impedance monitoring. Catheter-based pH monitoring, introduced in the 1970s, requires transnasal catheter placement and typically records for 24 hours before catheter removal. The catheter is positioned with the distal pH sensor 5 cm proximal to the upper margin of the manometrically identified lower esophageal sphincter (LES). New guidelines suggest AET less than 4% is reliably normal, while AET greater than 6% is pathologic; values in between are considered borderline and require alternate evidence for GERD, such as endoscopic findings.⁷ Wireless pH probes are placed 6 cm proximal to the squamocolumnar junction at endoscopy and communicate with a pager-sized receiver worn by the patient.⁹ Patient comfort is not compromised, with less restriction of typical patient activities compared to catheter-based testing, facilitating longer recording periods of 48-96 hours, which can overcome day-to-day variations in esophageal reflux burden.⁷ With catheter-based pH-impedance monitoring, multiple pairs of impedance sensors measure the resistance to flow of a tiny electrical current between sensors. Since resistance to flow (that is, impedance) is low in the presence of a bolus or refluxate in the esophageal lumen, the impedance tracing drops during reflux events in a retrograde fashion across the esophageal impedance sensor pairs, regardless of the acidity of the reflux (Figure 1).¹⁰ Combined pH-impedance testing thus detects refluxate in the esophagus regardless of pH, improving the sensitivity of detection of reflux events over pH testing alone, thereby promoting greater yield of SRA. However, there remains wide inter-observer variation on the designation of impedance reflux events.¹¹

The two most commonly utilized SRA metrics are the symptom index (SI) and symptom-association probability (SAP). Individual symptom episodes are designated as related to preceding reflux events if they occur within 2 minutes of the reflux events. The SI represents the simple ratio of the number of reflux-related symptoms to the total number of symptom episodes reported during the ambulatory reflux study, with values above 50% designated as positive.¹² For calculation of the SAP, the ambulatory reflux study is divided into 2-minute intervals. For each interval, the presence or absence of a reflux event and a symptom episode is assessed; the final counts are tabulated on a 2 x 2 table, and a Fisher exact test is applied to generate a “P” value. The SAP is positive if P is less than 0.05, corresponding to an SAP of greater than 95%, or a less than 5% chance that the observed association between symptoms and reflux events occurred by chance.¹³ The SAP can also be calculated post-hoc with data typically extracted during a pH study, using statistical modeling; termed the Ghillebert Probability Estimate,¹⁴ this corresponds well with the former method of SAP calculation.¹⁵

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

Copyright Elsevier/AGA

Along with reflux testing, an esophageal high-resolution manometry (HRM) study is typically performed to establish the location of the LES for placement of reflux catheters. Beyond this primary indication, HRM serves the important role of excluding significant esophageal motor disorders in these patients, particularly achalasia spectrum disorders.²⁰ Despite a diametrically opposite pathophysiology compared to GERD, achalasia can present with retrosternal discomfort (often interpreted as heartburn) and esophageal regurgitation (potentially interpreted as acid regurgitation).²¹ Therefore, achalasia spectrum disorders can be mistaken for GERD and managed with acid suppression, thereby contributing to the pool of symptomatic patients refractory to PPI therapy. HRM has high accuracy and specificity for the diagnosis of achalasia and other major esophageal motor disorders.²² Other foregut disorders diagnosed using HRM (typically combined HRM and impedance, or HRiM) include rumination and supragastric belching. The exclusion of a major esophageal motor disorder is also a requirement for the diagnosis of a functional esophageal disorder, where esophageal reflux testing is normal.²³

 

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

Reflux testing, especially 24-hour catheter-based monitoring, offers cross-sectional assessment of reflux burden and does not take day-to-day variations in reflux exposure into account in a disease characterized by chronic symptoms and long-term management implications. This shortcoming has prompted interest in novel reflux diagnostics that may afford further insight into longitudinal reflux exposure. Baseline mucosal impedance, which can be gleaned from pH-impedance tracings during nocturnal resting periods²⁸ or by using prototype devices at endoscopy,²⁹ can segregate erosive and nonerosive GERD from controls and may serve as a surrogate marker for reflux-induced mucosal changes and esophageal mucosal integrity.^29-32 Postreflux swallow-induced peristaltic wave index, or the frequencies with which reflux events are followed by clearing esophageal peristaltic waves, represents another novel reflux metric extracted from pH-impedance tracings that may be a marker of refluxate clearance and resolution of esophageal mucosal acidification.³³ Finally, there has been revived interest in the value of dilated intercellular spaces on electron microscopy to assess esophageal mucosal integrity to provide evidence of longitudinal – rather than cross-sectional – reflux exposure.³⁴

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

Therefore, when symptoms persist despite seemingly adequate PPI therapy, esophageal investigation may start with endoscopy but continues with ambulatory reflux and motility testing.⁷ At endoscopy, exclusion of eosinophilic esophagitis with esophageal biopsies represents an important component of initial evaluation when symptoms are refractory to PPIs.⁸ Further, the more atypical the presentation, the greater the need for esophageal testing prior to long-term PPI therapy. Esophageal function testing is also indicated when confirmation of GERD is needed prior to surgical or endoscopic reflux procedures.
 

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 three available modalities of ambulatory reflux monitoring consist of catheter-based pH, wireless pH, and combined catheter-based pH-impedance monitoring. Catheter-based pH monitoring, introduced in the 1970s, requires transnasal catheter placement and typically records for 24 hours before catheter removal. The catheter is positioned with the distal pH sensor 5 cm proximal to the upper margin of the manometrically identified lower esophageal sphincter (LES). New guidelines suggest AET less than 4% is reliably normal, while AET greater than 6% is pathologic; values in between are considered borderline and require alternate evidence for GERD, such as endoscopic findings.⁷ Wireless pH probes are placed 6 cm proximal to the squamocolumnar junction at endoscopy and communicate with a pager-sized receiver worn by the patient.⁹ Patient comfort is not compromised, with less restriction of typical patient activities compared to catheter-based testing, facilitating longer recording periods of 48-96 hours, which can overcome day-to-day variations in esophageal reflux burden.⁷ With catheter-based pH-impedance monitoring, multiple pairs of impedance sensors measure the resistance to flow of a tiny electrical current between sensors. Since resistance to flow (that is, impedance) is low in the presence of a bolus or refluxate in the esophageal lumen, the impedance tracing drops during reflux events in a retrograde fashion across the esophageal impedance sensor pairs, regardless of the acidity of the reflux (Figure 1).¹⁰ Combined pH-impedance testing thus detects refluxate in the esophagus regardless of pH, improving the sensitivity of detection of reflux events over pH testing alone, thereby promoting greater yield of SRA. However, there remains wide inter-observer variation on the designation of impedance reflux events.¹¹

The two most commonly utilized SRA metrics are the symptom index (SI) and symptom-association probability (SAP). Individual symptom episodes are designated as related to preceding reflux events if they occur within 2 minutes of the reflux events. The SI represents the simple ratio of the number of reflux-related symptoms to the total number of symptom episodes reported during the ambulatory reflux study, with values above 50% designated as positive.¹² For calculation of the SAP, the ambulatory reflux study is divided into 2-minute intervals. For each interval, the presence or absence of a reflux event and a symptom episode is assessed; the final counts are tabulated on a 2 x 2 table, and a Fisher exact test is applied to generate a “P” value. The SAP is positive if P is less than 0.05, corresponding to an SAP of greater than 95%, or a less than 5% chance that the observed association between symptoms and reflux events occurred by chance.¹³ The SAP can also be calculated post-hoc with data typically extracted during a pH study, using statistical modeling; termed the Ghillebert Probability Estimate,¹⁴ this corresponds well with the former method of SAP calculation.¹⁵

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

Copyright Elsevier/AGA

Along with reflux testing, an esophageal high-resolution manometry (HRM) study is typically performed to establish the location of the LES for placement of reflux catheters. Beyond this primary indication, HRM serves the important role of excluding significant esophageal motor disorders in these patients, particularly achalasia spectrum disorders.²⁰ Despite a diametrically opposite pathophysiology compared to GERD, achalasia can present with retrosternal discomfort (often interpreted as heartburn) and esophageal regurgitation (potentially interpreted as acid regurgitation).²¹ Therefore, achalasia spectrum disorders can be mistaken for GERD and managed with acid suppression, thereby contributing to the pool of symptomatic patients refractory to PPI therapy. HRM has high accuracy and specificity for the diagnosis of achalasia and other major esophageal motor disorders.²² Other foregut disorders diagnosed using HRM (typically combined HRM and impedance, or HRiM) include rumination and supragastric belching. The exclusion of a major esophageal motor disorder is also a requirement for the diagnosis of a functional esophageal disorder, where esophageal reflux testing is normal.²³

 

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

Reflux testing, especially 24-hour catheter-based monitoring, offers cross-sectional assessment of reflux burden and does not take day-to-day variations in reflux exposure into account in a disease characterized by chronic symptoms and long-term management implications. This shortcoming has prompted interest in novel reflux diagnostics that may afford further insight into longitudinal reflux exposure. Baseline mucosal impedance, which can be gleaned from pH-impedance tracings during nocturnal resting periods²⁸ or by using prototype devices at endoscopy,²⁹ can segregate erosive and nonerosive GERD from controls and may serve as a surrogate marker for reflux-induced mucosal changes and esophageal mucosal integrity.^29-32 Postreflux swallow-induced peristaltic wave index, or the frequencies with which reflux events are followed by clearing esophageal peristaltic waves, represents another novel reflux metric extracted from pH-impedance tracings that may be a marker of refluxate clearance and resolution of esophageal mucosal acidification.³³ Finally, there has been revived interest in the value of dilated intercellular spaces on electron microscopy to assess esophageal mucosal integrity to provide evidence of longitudinal – rather than cross-sectional – reflux exposure.³⁴

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

Therefore, when symptoms persist despite seemingly adequate PPI therapy, esophageal investigation may start with endoscopy but continues with ambulatory reflux and motility testing.⁷ At endoscopy, exclusion of eosinophilic esophagitis with esophageal biopsies represents an important component of initial evaluation when symptoms are refractory to PPIs.⁸ Further, the more atypical the presentation, the greater the need for esophageal testing prior to long-term PPI therapy. Esophageal function testing is also indicated when confirmation of GERD is needed prior to surgical or endoscopic reflux procedures.
 

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 three available modalities of ambulatory reflux monitoring consist of catheter-based pH, wireless pH, and combined catheter-based pH-impedance monitoring. Catheter-based pH monitoring, introduced in the 1970s, requires transnasal catheter placement and typically records for 24 hours before catheter removal. The catheter is positioned with the distal pH sensor 5 cm proximal to the upper margin of the manometrically identified lower esophageal sphincter (LES). New guidelines suggest AET less than 4% is reliably normal, while AET greater than 6% is pathologic; values in between are considered borderline and require alternate evidence for GERD, such as endoscopic findings.⁷ Wireless pH probes are placed 6 cm proximal to the squamocolumnar junction at endoscopy and communicate with a pager-sized receiver worn by the patient.⁹ Patient comfort is not compromised, with less restriction of typical patient activities compared to catheter-based testing, facilitating longer recording periods of 48-96 hours, which can overcome day-to-day variations in esophageal reflux burden.⁷ With catheter-based pH-impedance monitoring, multiple pairs of impedance sensors measure the resistance to flow of a tiny electrical current between sensors. Since resistance to flow (that is, impedance) is low in the presence of a bolus or refluxate in the esophageal lumen, the impedance tracing drops during reflux events in a retrograde fashion across the esophageal impedance sensor pairs, regardless of the acidity of the reflux (Figure 1).¹⁰ Combined pH-impedance testing thus detects refluxate in the esophagus regardless of pH, improving the sensitivity of detection of reflux events over pH testing alone, thereby promoting greater yield of SRA. However, there remains wide inter-observer variation on the designation of impedance reflux events.¹¹

The two most commonly utilized SRA metrics are the symptom index (SI) and symptom-association probability (SAP). Individual symptom episodes are designated as related to preceding reflux events if they occur within 2 minutes of the reflux events. The SI represents the simple ratio of the number of reflux-related symptoms to the total number of symptom episodes reported during the ambulatory reflux study, with values above 50% designated as positive.¹² For calculation of the SAP, the ambulatory reflux study is divided into 2-minute intervals. For each interval, the presence or absence of a reflux event and a symptom episode is assessed; the final counts are tabulated on a 2 x 2 table, and a Fisher exact test is applied to generate a “P” value. The SAP is positive if P is less than 0.05, corresponding to an SAP of greater than 95%, or a less than 5% chance that the observed association between symptoms and reflux events occurred by chance.¹³ The SAP can also be calculated post-hoc with data typically extracted during a pH study, using statistical modeling; termed the Ghillebert Probability Estimate,¹⁴ this corresponds well with the former method of SAP calculation.¹⁵

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

Copyright Elsevier/AGA

Along with reflux testing, an esophageal high-resolution manometry (HRM) study is typically performed to establish the location of the LES for placement of reflux catheters. Beyond this primary indication, HRM serves the important role of excluding significant esophageal motor disorders in these patients, particularly achalasia spectrum disorders.²⁰ Despite a diametrically opposite pathophysiology compared to GERD, achalasia can present with retrosternal discomfort (often interpreted as heartburn) and esophageal regurgitation (potentially interpreted as acid regurgitation).²¹ Therefore, achalasia spectrum disorders can be mistaken for GERD and managed with acid suppression, thereby contributing to the pool of symptomatic patients refractory to PPI therapy. HRM has high accuracy and specificity for the diagnosis of achalasia and other major esophageal motor disorders.²² Other foregut disorders diagnosed using HRM (typically combined HRM and impedance, or HRiM) include rumination and supragastric belching. The exclusion of a major esophageal motor disorder is also a requirement for the diagnosis of a functional esophageal disorder, where esophageal reflux testing is normal.²³

 

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

Reflux testing, especially 24-hour catheter-based monitoring, offers cross-sectional assessment of reflux burden and does not take day-to-day variations in reflux exposure into account in a disease characterized by chronic symptoms and long-term management implications. This shortcoming has prompted interest in novel reflux diagnostics that may afford further insight into longitudinal reflux exposure. Baseline mucosal impedance, which can be gleaned from pH-impedance tracings during nocturnal resting periods²⁸ or by using prototype devices at endoscopy,²⁹ can segregate erosive and nonerosive GERD from controls and may serve as a surrogate marker for reflux-induced mucosal changes and esophageal mucosal integrity.^29-32 Postreflux swallow-induced peristaltic wave index, or the frequencies with which reflux events are followed by clearing esophageal peristaltic waves, represents another novel reflux metric extracted from pH-impedance tracings that may be a marker of refluxate clearance and resolution of esophageal mucosal acidification.³³ Finally, there has been revived interest in the value of dilated intercellular spaces on electron microscopy to assess esophageal mucosal integrity to provide evidence of longitudinal – rather than cross-sectional – reflux exposure.³⁴

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.
 

 

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.

AGA Institute

Throughout my career, and especially in the early years, AGA provided invaluable support. For example, it provides a diverse array of professional and educational tools and offers us many opportunities to enhance our knowledge and expertise no matter the path we take, whether it be academia or clinical practice.

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.

AGA Institute

Throughout my career, and especially in the early years, AGA provided invaluable support. For example, it provides a diverse array of professional and educational tools and offers us many opportunities to enhance our knowledge and expertise no matter the path we take, whether it be academia or clinical practice.

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.

AGA Institute

Throughout my career, and especially in the early years, AGA provided invaluable support. For example, it provides a diverse array of professional and educational tools and offers us many opportunities to enhance our knowledge and expertise no matter the path we take, whether it be academia or clinical practice.

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 Colleagues,

Congratulations to the new gastroenterology fellows who have just begun their fellowships and also to those who have just finished and are starting their careers. It is certainly an exciting time of year for so many! A letter from AGA President Sheila Crowe, included in this issue, details the benefits and opportunities our organization offers GIs entering practice and academia.

In this issue’s feature article, Amit Patel (Duke University) and Prakash Gyawali (Washington University in St. Louis) provide a fantastic overview of ambulatory reflux testing. They outline the basics of the different methods of reflux testing, discuss whether testing should be done on or off PPI therapy, and provide useful tips for patient management.

This issue also contains an informative perspective about pursuing a career in medical education by Suzanne Rose (University of Connecticut), an incredibly passionate educator who has dedicated her career to this endeavor. Additionally, Katherine Garman (Duke University) and Latha Alaparthi (Gastroenterology Center of Connecticut/Yale University) provide a recap of this year’s AGA Women’s Leadership conference, which brought together a large group of early-career and experienced women from many different career pathways within the field of gastroenterology.

As student loans are an issue for many, Common Bond, the AGA’s official student loan partner, highlights an early-career gastroenterologist’s experience with student loans, as well as important factors in refinancing and paying off student loans. Finally, in the first of a two-part series on medical malpractice, an experienced group of attorneys from Eckert Seamans Cherin & Mellott, LLC (Philadelphia) provide a concise overview of the basics of malpractice as well as tips to help minimize your risk of being sued.

I hope that you enjoy this issue of The New Gastroenterologist. For those in the early-career group on the AGA Community (http://community.gastro.org/), these articles will be posted to the library to further enhance access. You can also find The New Gastroenterologist online and via the free app. If you have ideas for future issues or would be interested in contributing, please e-mail either me at [email protected] or Managing Editor Ryan Farrell at [email protected].
 

Sincerely,

Bryson W. Katona, MD, PhD

Editor in Chief

Dr. Bryson W. Katona is an instructor of medicine in the division of gastroenterology at the University of Pennsylvania.

 

Dear Colleagues,

Congratulations to the new gastroenterology fellows who have just begun their fellowships and also to those who have just finished and are starting their careers. It is certainly an exciting time of year for so many! A letter from AGA President Sheila Crowe, included in this issue, details the benefits and opportunities our organization offers GIs entering practice and academia.

In this issue’s feature article, Amit Patel (Duke University) and Prakash Gyawali (Washington University in St. Louis) provide a fantastic overview of ambulatory reflux testing. They outline the basics of the different methods of reflux testing, discuss whether testing should be done on or off PPI therapy, and provide useful tips for patient management.

This issue also contains an informative perspective about pursuing a career in medical education by Suzanne Rose (University of Connecticut), an incredibly passionate educator who has dedicated her career to this endeavor. Additionally, Katherine Garman (Duke University) and Latha Alaparthi (Gastroenterology Center of Connecticut/Yale University) provide a recap of this year’s AGA Women’s Leadership conference, which brought together a large group of early-career and experienced women from many different career pathways within the field of gastroenterology.

As student loans are an issue for many, Common Bond, the AGA’s official student loan partner, highlights an early-career gastroenterologist’s experience with student loans, as well as important factors in refinancing and paying off student loans. Finally, in the first of a two-part series on medical malpractice, an experienced group of attorneys from Eckert Seamans Cherin & Mellott, LLC (Philadelphia) provide a concise overview of the basics of malpractice as well as tips to help minimize your risk of being sued.

I hope that you enjoy this issue of The New Gastroenterologist. For those in the early-career group on the AGA Community (http://community.gastro.org/), these articles will be posted to the library to further enhance access. You can also find The New Gastroenterologist online and via the free app. If you have ideas for future issues or would be interested in contributing, please e-mail either me at [email protected] or Managing Editor Ryan Farrell at [email protected].
 

Sincerely,

Bryson W. Katona, MD, PhD

Editor in Chief

Dr. Bryson W. Katona is an instructor of medicine in the division of gastroenterology at the University of Pennsylvania.

 

Dear Colleagues,

Congratulations to the new gastroenterology fellows who have just begun their fellowships and also to those who have just finished and are starting their careers. It is certainly an exciting time of year for so many! A letter from AGA President Sheila Crowe, included in this issue, details the benefits and opportunities our organization offers GIs entering practice and academia.

In this issue’s feature article, Amit Patel (Duke University) and Prakash Gyawali (Washington University in St. Louis) provide a fantastic overview of ambulatory reflux testing. They outline the basics of the different methods of reflux testing, discuss whether testing should be done on or off PPI therapy, and provide useful tips for patient management.

This issue also contains an informative perspective about pursuing a career in medical education by Suzanne Rose (University of Connecticut), an incredibly passionate educator who has dedicated her career to this endeavor. Additionally, Katherine Garman (Duke University) and Latha Alaparthi (Gastroenterology Center of Connecticut/Yale University) provide a recap of this year’s AGA Women’s Leadership conference, which brought together a large group of early-career and experienced women from many different career pathways within the field of gastroenterology.

As student loans are an issue for many, Common Bond, the AGA’s official student loan partner, highlights an early-career gastroenterologist’s experience with student loans, as well as important factors in refinancing and paying off student loans. Finally, in the first of a two-part series on medical malpractice, an experienced group of attorneys from Eckert Seamans Cherin & Mellott, LLC (Philadelphia) provide a concise overview of the basics of malpractice as well as tips to help minimize your risk of being sued.

I hope that you enjoy this issue of The New Gastroenterologist. For those in the early-career group on the AGA Community (http://community.gastro.org/), these articles will be posted to the library to further enhance access. You can also find The New Gastroenterologist online and via the free app. If you have ideas for future issues or would be interested in contributing, please e-mail either me at [email protected] or Managing Editor Ryan Farrell at [email protected].
 

Sincerely,

Bryson W. Katona, MD, PhD

Editor in Chief

Dr. Bryson W. Katona is an instructor of medicine in the division of gastroenterology at the University of Pennsylvania.

 

We are a group of six adult Inflammatory bowel disease (IBD) patients who serve as the Patient Governance Committee for CCFA Partners – a patient powered research network that assists IBD patients, researchers, and healthcare providers to partner in finding the answers to questions patients care about and improving the health and lives of patients living with these conditions. To find out more about us, please visit our website at https://ccfa.med.unc.edu/ or send an email to [email protected].

monkeybusinessimages/Thinkstock

The foundation of good quality of care is the patient/physician relationship; and as patients we understand that foundation must be based on mutual respect, trust, and communication. There are a few themes that emerge when thinking about these salient qualities:
 

Open communication between patient and physician

Perhaps the single most important quality of a physician is a willingness to listen. IBD patients often don’t feel like they are being heard. Starting with a conversation about the patient’s goals in terms of managing the disease as well as their goals in life will help the physician understand the patient’s unique situation and concerns. This is really a twofold proposition: what are the patient’s short-term and long-term goals? What is the most effective treatment plan to help them? How do the physician and the patient define treatment success?

Sometimes the most effective treatment strategy isn’t the one that will improve overall quality of life. For example, adding immunomodulators to a biologic therapy may potentially increase the effectiveness or prolong treatment success; yet the adverse effects of immunomodulators on quality of life could outweigh any therapeutic benefits. Doctors should educate patients on the pros and cons of appropriate treatments, and should serve as a guide toward those plans that will have the most positive impact on overall well-being, as opposed to adopting a narrow focus on treating symptoms. We use the term “guide” with a very specific intent: if a patient comes to an appointment asking about a potential therapy, the doctor should take the time to discuss the topic with an open mind and help critically assess any potential benefits or hazards. The ability to guide treatments without dictating options or being closed minded requires a certain finesse.

At times, physicians and patients might disagree on treatment goals and patients will want their decisions respected, even if they differ from the physician’s preference. Patients want the ability to be unreservedly open with their doctors and for their doctors to listen without being defensive. Having a chronic, incurable illness is a lifelong journey, and they need someone who will respect their autonomy as well as help them weather the ups and downs of a life with IBD.

Another key consideration in building trust with patients is honesty. Being clear about the prognosis of the disease, the side effects of particular therapies, and how quickly to expect symptom relief and/or remission are all critical in empowering patients to be active participants in their disease management. Beyond the technical aspects of caring for a patient, the physician should also be honest about their capacity to care for the patient’s disease complexity and be able to devote the necessary time to developing a treatment strategy. This can be an issue especially in smaller towns, where some gastroenterologists who practice in a more generalist setting may be uncomfortable with therapy management that is outside the typical treatment algorithms. In those settings, it is highly appreciated when practitioners recommend second opinions or provide referrals.
 

Coordinating care and transitions

Ensuring coordinated care when making a transition – whether it is because of a geographic relocation, from pediatric care to adult, or a change in insurance – remains critical. While effective communication with patients is always important, it is especially so during a transition. It is valuable when physicians can work in a coordinated effort to manage care as a team. Patients are not always able to travel to a specialist or get an appointment every time treatments need reconsideration. The ability to access coordinated, specialized care in the local setting is very important. In recent years, the ability to seek medical advice via email check-ins (without the delay of office appointments) has become a tremendous value as diseases can sometimes flare out of control quickly and unpredictably.

When a patient needs to transfer to a new physician it’s important to help them find the right fit for their particular circumstances. Ask what is most important to patients. Is it the distance between their residence and their provider? Is it ability to manage complex disease? Is the physician in-network? All of these are important factors in helping the patient find the right care.

These considerations are not limited to times of transition. Despite advancements in electronic medical record systems, there continues to be poor documentation and communication between providers. Often, when patients initiate care with a new physician, that physician has not reviewed the medical history in depth and relies on the patient’s explanation. This kind of communication carries with it a risk of important findings from another doctor falling through the cracks.
 

 

Holistic approach to treatment

Treating an IBD patient means treating the patient as a whole, not only their symptoms. IBD can lead to many challenges for patients and that is why treatment plans must consider not only physical, but also emotional and mental health, needs. One underserved area is pain management. While the dangers of opiates have been well documented, it seems the pendulum has swung too far in the opposite direction: some doctors are ignoring the topic of pain management altogether or establishing policies against prescribing any narcotic pain medications. This trend is troubling. Pain management is not an issue that goes away by ignoring it and remains a very important part of overall care needs. Doctors should be encouraged to take the time to learn about the many different approaches to pain management, including nonnarcotic and nonmedication therapies.

There are so many concerns that patients have beyond IBD symptom management, but a compassionate approach and asking the right questions can immeasurably improve outcomes. Engaging with patients on the topic of navigating the 21st century American medical system – and the time, energy, and expense inherent to being a patient in that system – can help foster an appreciation for the myriad challenges patients face.
 

Conclusion

The mark of a high-functioning patient/physician relationship is that the patient feels empowered to be engaged with the management of their disease. An empowered patient is one who feels comfortable asking about new therapeutic options, explores new approaches to managing their disease without fear of being judged, and sticks with a treatment plan. By treating patients as partners in the fight against IBD, you can help patients accomplish their goals through a relationship based on mutual trust.

As a final note, we want to express our deepest thanks to gastroenterologists for the work that they do. Learning to manage IBD has been very challenging and the support and guidance of our doctors over the years has been so important. Thank you for choosing a career in helping people.
 

Patient Accounts

Since my diagnosis 15 years ago, the gastroenterologists who have cared for me were all effective clinicians who improved my quality of life. However, the best physicians asked me directly what aspects of my life I found most important.

My answer to this “life priority” question has changed over time. As a teenager, I wanted to fit in with my peer group as much as I could. In my early 20s, I wanted to take part in physical activity and reduce my pain as much as possible. Today, I prioritize being mentally sharp and reliable for those who depend on me professionally and maintaining empathy for those who depend on me emotionally.

I can imagine that my priorities are more easily relatable to an adult physician now than when I was in my teens, but the best gastroenterologists have empathetically listened and respected my wishes, within reason, throughout my entire experience of illness.

To me, what makes an excellent gastroenterologist is the ability to understand a patient’s greatest priorities, the activities or feelings or connections that make that person feel most whole, and, whenever possible, to direct treatment strategy according to these priorities.

– Jessica Burris
 

As young physicians, you may feel the need to know the answers to all our questions or a thorny diagnostic problem we present. The truth is we don’t expect you to know all the answers in the moment, it’s OK to stay you don’t know, but stay curious in finding a solution.

Also, at times there is a third presence in the room with you and your patient: the electronic medical record. It can be easy to become distracted and not make eye contact with us, which can seem as if you aren’t paying attention. Remember to always be fully present with your patient. Your patient will truly appreciate it.

– David Walter
 

 

We are a group of six adult Inflammatory bowel disease (IBD) patients who serve as the Patient Governance Committee for CCFA Partners – a patient powered research network that assists IBD patients, researchers, and healthcare providers to partner in finding the answers to questions patients care about and improving the health and lives of patients living with these conditions. To find out more about us, please visit our website at https://ccfa.med.unc.edu/ or send an email to [email protected].

monkeybusinessimages/Thinkstock

The foundation of good quality of care is the patient/physician relationship; and as patients we understand that foundation must be based on mutual respect, trust, and communication. There are a few themes that emerge when thinking about these salient qualities:
 

Open communication between patient and physician

Perhaps the single most important quality of a physician is a willingness to listen. IBD patients often don’t feel like they are being heard. Starting with a conversation about the patient’s goals in terms of managing the disease as well as their goals in life will help the physician understand the patient’s unique situation and concerns. This is really a twofold proposition: what are the patient’s short-term and long-term goals? What is the most effective treatment plan to help them? How do the physician and the patient define treatment success?

Sometimes the most effective treatment strategy isn’t the one that will improve overall quality of life. For example, adding immunomodulators to a biologic therapy may potentially increase the effectiveness or prolong treatment success; yet the adverse effects of immunomodulators on quality of life could outweigh any therapeutic benefits. Doctors should educate patients on the pros and cons of appropriate treatments, and should serve as a guide toward those plans that will have the most positive impact on overall well-being, as opposed to adopting a narrow focus on treating symptoms. We use the term “guide” with a very specific intent: if a patient comes to an appointment asking about a potential therapy, the doctor should take the time to discuss the topic with an open mind and help critically assess any potential benefits or hazards. The ability to guide treatments without dictating options or being closed minded requires a certain finesse.

At times, physicians and patients might disagree on treatment goals and patients will want their decisions respected, even if they differ from the physician’s preference. Patients want the ability to be unreservedly open with their doctors and for their doctors to listen without being defensive. Having a chronic, incurable illness is a lifelong journey, and they need someone who will respect their autonomy as well as help them weather the ups and downs of a life with IBD.

Another key consideration in building trust with patients is honesty. Being clear about the prognosis of the disease, the side effects of particular therapies, and how quickly to expect symptom relief and/or remission are all critical in empowering patients to be active participants in their disease management. Beyond the technical aspects of caring for a patient, the physician should also be honest about their capacity to care for the patient’s disease complexity and be able to devote the necessary time to developing a treatment strategy. This can be an issue especially in smaller towns, where some gastroenterologists who practice in a more generalist setting may be uncomfortable with therapy management that is outside the typical treatment algorithms. In those settings, it is highly appreciated when practitioners recommend second opinions or provide referrals.
 

Coordinating care and transitions

Ensuring coordinated care when making a transition – whether it is because of a geographic relocation, from pediatric care to adult, or a change in insurance – remains critical. While effective communication with patients is always important, it is especially so during a transition. It is valuable when physicians can work in a coordinated effort to manage care as a team. Patients are not always able to travel to a specialist or get an appointment every time treatments need reconsideration. The ability to access coordinated, specialized care in the local setting is very important. In recent years, the ability to seek medical advice via email check-ins (without the delay of office appointments) has become a tremendous value as diseases can sometimes flare out of control quickly and unpredictably.

When a patient needs to transfer to a new physician it’s important to help them find the right fit for their particular circumstances. Ask what is most important to patients. Is it the distance between their residence and their provider? Is it ability to manage complex disease? Is the physician in-network? All of these are important factors in helping the patient find the right care.

These considerations are not limited to times of transition. Despite advancements in electronic medical record systems, there continues to be poor documentation and communication between providers. Often, when patients initiate care with a new physician, that physician has not reviewed the medical history in depth and relies on the patient’s explanation. This kind of communication carries with it a risk of important findings from another doctor falling through the cracks.
 

 

Holistic approach to treatment

Treating an IBD patient means treating the patient as a whole, not only their symptoms. IBD can lead to many challenges for patients and that is why treatment plans must consider not only physical, but also emotional and mental health, needs. One underserved area is pain management. While the dangers of opiates have been well documented, it seems the pendulum has swung too far in the opposite direction: some doctors are ignoring the topic of pain management altogether or establishing policies against prescribing any narcotic pain medications. This trend is troubling. Pain management is not an issue that goes away by ignoring it and remains a very important part of overall care needs. Doctors should be encouraged to take the time to learn about the many different approaches to pain management, including nonnarcotic and nonmedication therapies.

There are so many concerns that patients have beyond IBD symptom management, but a compassionate approach and asking the right questions can immeasurably improve outcomes. Engaging with patients on the topic of navigating the 21st century American medical system – and the time, energy, and expense inherent to being a patient in that system – can help foster an appreciation for the myriad challenges patients face.
 

Conclusion

The mark of a high-functioning patient/physician relationship is that the patient feels empowered to be engaged with the management of their disease. An empowered patient is one who feels comfortable asking about new therapeutic options, explores new approaches to managing their disease without fear of being judged, and sticks with a treatment plan. By treating patients as partners in the fight against IBD, you can help patients accomplish their goals through a relationship based on mutual trust.

As a final note, we want to express our deepest thanks to gastroenterologists for the work that they do. Learning to manage IBD has been very challenging and the support and guidance of our doctors over the years has been so important. Thank you for choosing a career in helping people.
 

Patient Accounts

Since my diagnosis 15 years ago, the gastroenterologists who have cared for me were all effective clinicians who improved my quality of life. However, the best physicians asked me directly what aspects of my life I found most important.

My answer to this “life priority” question has changed over time. As a teenager, I wanted to fit in with my peer group as much as I could. In my early 20s, I wanted to take part in physical activity and reduce my pain as much as possible. Today, I prioritize being mentally sharp and reliable for those who depend on me professionally and maintaining empathy for those who depend on me emotionally.

I can imagine that my priorities are more easily relatable to an adult physician now than when I was in my teens, but the best gastroenterologists have empathetically listened and respected my wishes, within reason, throughout my entire experience of illness.

To me, what makes an excellent gastroenterologist is the ability to understand a patient’s greatest priorities, the activities or feelings or connections that make that person feel most whole, and, whenever possible, to direct treatment strategy according to these priorities.

– Jessica Burris
 

As young physicians, you may feel the need to know the answers to all our questions or a thorny diagnostic problem we present. The truth is we don’t expect you to know all the answers in the moment, it’s OK to stay you don’t know, but stay curious in finding a solution.

Also, at times there is a third presence in the room with you and your patient: the electronic medical record. It can be easy to become distracted and not make eye contact with us, which can seem as if you aren’t paying attention. Remember to always be fully present with your patient. Your patient will truly appreciate it.

– David Walter
 

 

We are a group of six adult Inflammatory bowel disease (IBD) patients who serve as the Patient Governance Committee for CCFA Partners – a patient powered research network that assists IBD patients, researchers, and healthcare providers to partner in finding the answers to questions patients care about and improving the health and lives of patients living with these conditions. To find out more about us, please visit our website at https://ccfa.med.unc.edu/ or send an email to [email protected].

monkeybusinessimages/Thinkstock

The foundation of good quality of care is the patient/physician relationship; and as patients we understand that foundation must be based on mutual respect, trust, and communication. There are a few themes that emerge when thinking about these salient qualities:
 

Open communication between patient and physician

Perhaps the single most important quality of a physician is a willingness to listen. IBD patients often don’t feel like they are being heard. Starting with a conversation about the patient’s goals in terms of managing the disease as well as their goals in life will help the physician understand the patient’s unique situation and concerns. This is really a twofold proposition: what are the patient’s short-term and long-term goals? What is the most effective treatment plan to help them? How do the physician and the patient define treatment success?

Sometimes the most effective treatment strategy isn’t the one that will improve overall quality of life. For example, adding immunomodulators to a biologic therapy may potentially increase the effectiveness or prolong treatment success; yet the adverse effects of immunomodulators on quality of life could outweigh any therapeutic benefits. Doctors should educate patients on the pros and cons of appropriate treatments, and should serve as a guide toward those plans that will have the most positive impact on overall well-being, as opposed to adopting a narrow focus on treating symptoms. We use the term “guide” with a very specific intent: if a patient comes to an appointment asking about a potential therapy, the doctor should take the time to discuss the topic with an open mind and help critically assess any potential benefits or hazards. The ability to guide treatments without dictating options or being closed minded requires a certain finesse.

At times, physicians and patients might disagree on treatment goals and patients will want their decisions respected, even if they differ from the physician’s preference. Patients want the ability to be unreservedly open with their doctors and for their doctors to listen without being defensive. Having a chronic, incurable illness is a lifelong journey, and they need someone who will respect their autonomy as well as help them weather the ups and downs of a life with IBD.

Another key consideration in building trust with patients is honesty. Being clear about the prognosis of the disease, the side effects of particular therapies, and how quickly to expect symptom relief and/or remission are all critical in empowering patients to be active participants in their disease management. Beyond the technical aspects of caring for a patient, the physician should also be honest about their capacity to care for the patient’s disease complexity and be able to devote the necessary time to developing a treatment strategy. This can be an issue especially in smaller towns, where some gastroenterologists who practice in a more generalist setting may be uncomfortable with therapy management that is outside the typical treatment algorithms. In those settings, it is highly appreciated when practitioners recommend second opinions or provide referrals.
 

Coordinating care and transitions

Ensuring coordinated care when making a transition – whether it is because of a geographic relocation, from pediatric care to adult, or a change in insurance – remains critical. While effective communication with patients is always important, it is especially so during a transition. It is valuable when physicians can work in a coordinated effort to manage care as a team. Patients are not always able to travel to a specialist or get an appointment every time treatments need reconsideration. The ability to access coordinated, specialized care in the local setting is very important. In recent years, the ability to seek medical advice via email check-ins (without the delay of office appointments) has become a tremendous value as diseases can sometimes flare out of control quickly and unpredictably.

When a patient needs to transfer to a new physician it’s important to help them find the right fit for their particular circumstances. Ask what is most important to patients. Is it the distance between their residence and their provider? Is it ability to manage complex disease? Is the physician in-network? All of these are important factors in helping the patient find the right care.

These considerations are not limited to times of transition. Despite advancements in electronic medical record systems, there continues to be poor documentation and communication between providers. Often, when patients initiate care with a new physician, that physician has not reviewed the medical history in depth and relies on the patient’s explanation. This kind of communication carries with it a risk of important findings from another doctor falling through the cracks.
 

 

Holistic approach to treatment

Treating an IBD patient means treating the patient as a whole, not only their symptoms. IBD can lead to many challenges for patients and that is why treatment plans must consider not only physical, but also emotional and mental health, needs. One underserved area is pain management. While the dangers of opiates have been well documented, it seems the pendulum has swung too far in the opposite direction: some doctors are ignoring the topic of pain management altogether or establishing policies against prescribing any narcotic pain medications. This trend is troubling. Pain management is not an issue that goes away by ignoring it and remains a very important part of overall care needs. Doctors should be encouraged to take the time to learn about the many different approaches to pain management, including nonnarcotic and nonmedication therapies.

There are so many concerns that patients have beyond IBD symptom management, but a compassionate approach and asking the right questions can immeasurably improve outcomes. Engaging with patients on the topic of navigating the 21st century American medical system – and the time, energy, and expense inherent to being a patient in that system – can help foster an appreciation for the myriad challenges patients face.
 

Conclusion

The mark of a high-functioning patient/physician relationship is that the patient feels empowered to be engaged with the management of their disease. An empowered patient is one who feels comfortable asking about new therapeutic options, explores new approaches to managing their disease without fear of being judged, and sticks with a treatment plan. By treating patients as partners in the fight against IBD, you can help patients accomplish their goals through a relationship based on mutual trust.

As a final note, we want to express our deepest thanks to gastroenterologists for the work that they do. Learning to manage IBD has been very challenging and the support and guidance of our doctors over the years has been so important. Thank you for choosing a career in helping people.
 

Patient Accounts

Since my diagnosis 15 years ago, the gastroenterologists who have cared for me were all effective clinicians who improved my quality of life. However, the best physicians asked me directly what aspects of my life I found most important.

My answer to this “life priority” question has changed over time. As a teenager, I wanted to fit in with my peer group as much as I could. In my early 20s, I wanted to take part in physical activity and reduce my pain as much as possible. Today, I prioritize being mentally sharp and reliable for those who depend on me professionally and maintaining empathy for those who depend on me emotionally.

I can imagine that my priorities are more easily relatable to an adult physician now than when I was in my teens, but the best gastroenterologists have empathetically listened and respected my wishes, within reason, throughout my entire experience of illness.

To me, what makes an excellent gastroenterologist is the ability to understand a patient’s greatest priorities, the activities or feelings or connections that make that person feel most whole, and, whenever possible, to direct treatment strategy according to these priorities.

– Jessica Burris
 

As young physicians, you may feel the need to know the answers to all our questions or a thorny diagnostic problem we present. The truth is we don’t expect you to know all the answers in the moment, it’s OK to stay you don’t know, but stay curious in finding a solution.

Also, at times there is a third presence in the room with you and your patient: the electronic medical record. It can be easy to become distracted and not make eye contact with us, which can seem as if you aren’t paying attention. Remember to always be fully present with your patient. Your patient will truly appreciate it.

– David Walter
 

Your next patient is a 67-year-old Medicare beneficiary with corticosteroid-dependent ulcerative colitis. Despite 4 months of maximally dosed mesalamine, his colitis flares with prednisone taper below 20 mg daily. Hepatitis B serologies and tuberculin skin test were negative 10 months ago. Which of the following do you recommend?

A. Steroid-sparing therapy initiation

B. Repeat latent tuberculosis screening in anticipation of anti–tumor necrosis factor (TNF) therapy

C. Bone loss assessment

D. Pneumococcal vaccination

E. Tobacco use screening

All of the above may be appropriate for optimal clinical care, but only two (C and E) will impact your bottom line when using the new GI Measures Set to report quality measures through the Merit-Based Incentive Payment System (MIPS). For the 75.1% of physicians who have not heard of – or don’t know much about – MIPS,1 the gastroenterology world will come to know it as the dominant of two Quality Payment Program (QPP) tracks introduced as part of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). Starting in 2017, the QPP handles quality measure reporting and reimbursement adjustments based on the quality and cost of care provided to Medicare beneficiaries. MIPS replaces the Physician Quality Reporting System (PQRS), Value-Based Payment Modifier, and electronic health record Meaningful Use programs that previously executed these tasks.

Quality measure reporting is a costly undertaking, with medical practices spending an average of 15.1 hours per physician per week ($40,069 per physician annually) dealing with external quality measures.2 How did this expensive alphabet soup of quality measure reporting arise and how does it impact inflammatory bowel disease (IBD) care?
 

Why are IBD quality measures needed?

There is substantial variation in care provided to IBD patients. Examples include geographic variation in rates of prolonged corticosteroid3 and biologic therapy use (Figure 1),4 hospitalization, and colectomy.5 IBD experts and community gastroenterologists manage IBD differently.6,7 This variation reflects more than mere “art of medicine” stylistic differences. Patient, provider, and system-level factors contribute to practice variation, including the heterogeneity of IBD phenotypes, lack of knowledge about best practices, insufficient evidence on which to base treatment decisions, and variable access to care. Variation likely indicates resource underuse, overuse, and misuse and may be a marker of poor quality care.8,9 Closing the gap between current and ideal IBD care – by reducing unnecessary variation – may reduce suboptimal outcomes, preventable complications, care costs, and waste. Financially incentivized quality metrics have been proposed as a performance improvement and standardization strategy.

What makes a good quality measure?

Quality must be defined and measured before it can be improved. This is easier said than done, especially for IBD where a gold standard in “ideal care” is ill defined and continually evolving as new research emerges. Nonetheless, hundreds of health care quality measures have been proposed. Desirable quality measure attributes should satisfy three broad categories: importance, scientific soundness, and feasibility.10 Quality measures should address relevant and important aspects of health that are highly prevalent and for which evidence indicates a need for improvement. There should be strong evidence supporting the beneficial impact of adhering to a given measure.

From a practicality standpoint, measures should relate to actions that are under the control of the providers whose performance is being measured. Measures should also be parsimonious with a goal of minimizing the number of measures needed to adequately represent performance in a given area.11 More simply stated, a good quality measure reflects consensus about a minimally acceptable level of care that applies broadly to all patients.

Quality measures are commonly classified as process measures or outcome measures. Process measures (“doing the right thing”) are steps taken by providers in the care of an individual patient. These often derive from evidence-based best practices. Outcome measures (“having the desired result”) identify what happens to patients as a result of care received.8 Outcome measures may be more meaningful, but there are limitations in using them to study quality of IBD care. For example, factors beyond physician control affect patient outcomes and long delays may exist between care decisions and subsequent outcomes (e.g., surgery, malnutrition).8
 

What IBD quality measures already exist?

Expert panels from the AGA and the Crohn’s & Colitis Foundation of America (CCFA) produced IBD quality measure sets comprising mostly process measures (Table 1). The original 10 AGA measures released in 2011 address aspects of disease assessment, treatment, complication prevention, and health care maintenance.12 They include seven IBD-specific measures, three cross-cutting measures – defined by Centers for Medicare & Medicaid Services (CMS) as being broadly applicable across multiple clinical settings – and two inpatient measures. A major goal of the AGA measures was to facilitate quality reporting to the former PQRS program.

 

The 2013 CCFA “Top 10” highly rated process measures were selected from over 500 candidate measures.13 Five of these measures closely match the AGA measures; two unique items address dysplasia surveillance. Real-world studies demonstrate variable adherence to these quality measures across multiple care settings (individual measure compliance ranging from 17% to 90%),14 supporting the need for improvement. Interventions can improve adherence by up to 20%,15 which provides face validity that these measures capture aspects of care that can be improved. The CCFA also developed an aspirational list of 10 highly rated outcome measures (Table 2), the selection of which included patient input.13 The CCFA measures are not eligible for use in CMS quality reporting programs but are incorporated into the IBD Qorus national quality improvement initiative.16
 

What are some quality measure limitations?

Quality measure development has an evidence base but designing an optimal measure and demonstrating impact can be challenging. Few IBD process measures are validated and thus there is often logic but not data linking process measure adherence to improved outcomes. The denominator (number of eligible patients) and potential impact of broad adherence vary for each quality measure. For example, only a small fraction of IBD patients are infected with hepatitis B and fewer than 10% will experience viral reactivation during anti-TNF therapy.17,18 Even with optimal adherence to the hepatitis B measure, few reactivations will be prevented. The wording of some measures lacks precision, allowing physicians to potentially claim credit without improving care. For example, ordering a bone density scan satisfies the bone loss assessment measure, even if osteoporosis goes unrecognized and untreated. Finally, some measures relate to actions that may not be under the control of the gastroenterologist whose performance is being measured (e.g., administering vaccinations).

IBD quality measures under MIPS

Table 1 depicts the evolution of IBD process measures from 2011 to 2017. Rather than building upon initial experience to revise and refine IBD quality measures, the measures have instead been progressively culled with the changing pay-for-performance landscape. In 2016, AGA eliminated the two inpatient measures.19 Seven of the remaining eight measures formed the IBD Measures Group which was reportable under PQRS. In 2017, MIPS brought a seismic shift in quality measure focus. The PQRS IBD Measures Group was abolished – as were all Measures Groups – and replaced by a 16-item GI Measures Set. Although AGA advocated for all of the IBD measures to be included, the new GI Measures Set deemphasized the IBD-specific measures in favor of expanded cross-cutting measures (e.g., screening for abnormal body mass index, documenting current medications, sending specialist report to referring provider).20 This reflected a previously observed trend that gastroenterologists more often reported on cross-cutting measures than specialist-specific measures.21 However, there was no evidence-based justification for dropping certain IBD-specific measures (especially the steroid-sparing therapy measure) in favor of retaining the two chosen IBD-specific measures – bone loss assessment and hepatitis B screening – which apply to only a subset of IBD patients and have limited potential to impact clinical outcomes. Although it is not mandatory to report using the GI Measures Set, we suspect that many gastroenterologists will use this set to guide their initial reporting.

AGA Institute

During the 2017 MACRA transition year, physicians need report only one quality measure to avoid a penalty. Even after the “pick your pace” MACRA program testing period concludes in 2018, MACRA-eligible clinicians will need to report their performance only on six quality measures. This low bar and shifting focus away from IBD-specific measures is disconcerting for IBD quality enthusiasts. Although MIPS applies only to the 26% of Medicare-eligible IBD patients who are at least 65 years old,22 private payers are likely to adopt similar reimbursement programs.

There are formidable regulatory obstacles to improving the IBD quality measures included in MIPS. CMS requires that new quality measures proposed for inclusion in MIPS be fully specified and tested for validity and reliability by the individual measure developers (such as AGA). This is a costly and time-intensive process that has complicated efforts to successfully advocate for inclusion of GI-specific quality measures in MIPS, as there is no existing infrastructure for quality measure testing.

A word about Alternative Payment Models (APMs)

APMs represent the non-MIPS pathway for participating in the QPP. APMs focus on chronic disease care coordination and qualify for lump-sum incentive payments by adhering to stringent standards and financial risk-sharing requirements. A detailed overview of APMs is beyond the scope of this discussion, as the vast majority of MACRA-eligible gastroenterologists will participate in MIPS and there are currently no GI-specific APMs. However, this is an evolving area and Project Sonar has been submitted to the Physician-Focused Payment Model Technical Advisory Committee for consideration as an APM for Crohn’s disease.23

 

Conclusion

Quality measurement and reporting are at a crossroads. Ideally, performance improvement should be an internally driven process that addresses specific local priorities and needs. Most medical practices (73%) believe that current externally driven quality measures do not represent care quality and only 28% use their quality scores to focus their internal quality improvement activities.2 The burden and cost of external quality reporting demand better alignment with local priorities as resources are currently being diverted away from internally driven efforts that might have the greatest potential to improve patient outcomes.24 The dawn of the MACRA era presents an opportunity to shape the future of the IBD quality movement. Through validating and prioritizing existing measures and developing novel, precisely stated, and high-value metrics, there remains vast (and measurable) potential to enhance patient outcomes.

Dr. McConnell is a fellow in gastroenterology and advanced inflammatory bowel disease, division of gastroenterology, University of California, San Francisco. Dr. Velayos is professor of medicine, co–medical director, Center for Crohn’s and Colitis, University of California, San Francisco.

References

1. September 2016 Medscape survey summary. Available at http://www.healthcaredive.com/news/survey-29-of-physicians-still-havent-heard-of-macra/429322/. Accessed March 23, 2017.

2. Casalino L.P., et al. Health Aff. 2016;35:401-6.

3. Rubin D.T., et al. Curr Med Res Opin. 2017;33:529-36.

4. David G., et al. Gastroenterology. 2013;144:S-647.

5. Nguyen G.C., et al. Clin Gastroenterol Hepatol. 2006;4:1507-13.

6. Esrailian E., et al. Aliment Pharmacol Ther. 2007;26:1005-18.

7. Spiegel B.M., et al. Clin Gastroenterol Hepatol. 2009;7:68-74.

8. Kappelman M.D., et al. Inflamm Bowel Dis. 2010;16:125-133.

9. Reddy S.I., et al. Am J Gastroenterol. 2005;100:1357-61.

10. National Quality Measures Clearinghouse. Available at https://www.qualitymeasures.ahrq.gov/help-and-about/quality-measure-tutorials/desirable-attributes-of-a-quality-measure. Accessed March 23, 2017.

11. McGlynn E.A. Med Care. 2003;41(1 Suppl):139-47.

12. American Gastroenterological Association. Available at https://www.gastro.org/practice/quality-initiatives/IBD_Measures.pdf. Accessed March 23, 2017.

13. Melmed G.Y., et al. Inflamm Bowel Dis. 2013;19:662-8.

14. Feuerstein J.D., et al. Clin Gastroenterol Hepatol. 2016;14:421-8.

15. Sapir T., et al. Dig Dis Sci. 2016;61:1862-9.

16. Crohn’s & Colitis Foundation of America. IBD Qorus. Available at http://www.ccfa.org/science-and-professionals/ibdqorus/. Accessed March 23, 2017.

17. Hou J.K., et al. Gastroenterology. 2015;148(Suppl 1):S-61.

18. Reddy K.R., et al. Gastroenterology. 2015;48:215-9.

19. American Gastroenterological Association. Available at http://www.gastro.org/practice-management/measures/2016_AGA_Measures_-_IBD.pdf. Accessed March 23, 2017.

20. American Gastroenterological Association. Available at http://www.gastro.org/news_items/gi-quality-measures-for-2017-are-released-in-macra-final-rule. Accessed March 23, 2017.

21. Centers for Medicare & Medicaid Services. Available at https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/Downloads/2014_PQRS_Experience_Rpt.pdf. Accessed March 23, 2017.

22. Dahlhamer J.M., et al. MMWR. 2016;65:1166-9.

23. U.S. Department of Health & Human Services Office of the Assistant Secretary for Planning and Evaluation. Available at https://aspe.hhs.gov/system/files/pdf/253406/ProjectSonarSonarMD.pdf. Accessed March 23, 2017.

24. Meyer G.S., et al. BMJ Qual Saf. 2012;21:964-8.

Your next patient is a 67-year-old Medicare beneficiary with corticosteroid-dependent ulcerative colitis. Despite 4 months of maximally dosed mesalamine, his colitis flares with prednisone taper below 20 mg daily. Hepatitis B serologies and tuberculin skin test were negative 10 months ago. Which of the following do you recommend?

A. Steroid-sparing therapy initiation

B. Repeat latent tuberculosis screening in anticipation of anti–tumor necrosis factor (TNF) therapy

C. Bone loss assessment

D. Pneumococcal vaccination

E. Tobacco use screening

All of the above may be appropriate for optimal clinical care, but only two (C and E) will impact your bottom line when using the new GI Measures Set to report quality measures through the Merit-Based Incentive Payment System (MIPS). For the 75.1% of physicians who have not heard of – or don’t know much about – MIPS,1 the gastroenterology world will come to know it as the dominant of two Quality Payment Program (QPP) tracks introduced as part of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). Starting in 2017, the QPP handles quality measure reporting and reimbursement adjustments based on the quality and cost of care provided to Medicare beneficiaries. MIPS replaces the Physician Quality Reporting System (PQRS), Value-Based Payment Modifier, and electronic health record Meaningful Use programs that previously executed these tasks.

Quality measure reporting is a costly undertaking, with medical practices spending an average of 15.1 hours per physician per week ($40,069 per physician annually) dealing with external quality measures.2 How did this expensive alphabet soup of quality measure reporting arise and how does it impact inflammatory bowel disease (IBD) care?
 

Why are IBD quality measures needed?

There is substantial variation in care provided to IBD patients. Examples include geographic variation in rates of prolonged corticosteroid3 and biologic therapy use (Figure 1),4 hospitalization, and colectomy.5 IBD experts and community gastroenterologists manage IBD differently.6,7 This variation reflects more than mere “art of medicine” stylistic differences. Patient, provider, and system-level factors contribute to practice variation, including the heterogeneity of IBD phenotypes, lack of knowledge about best practices, insufficient evidence on which to base treatment decisions, and variable access to care. Variation likely indicates resource underuse, overuse, and misuse and may be a marker of poor quality care.8,9 Closing the gap between current and ideal IBD care – by reducing unnecessary variation – may reduce suboptimal outcomes, preventable complications, care costs, and waste. Financially incentivized quality metrics have been proposed as a performance improvement and standardization strategy.

What makes a good quality measure?

Quality must be defined and measured before it can be improved. This is easier said than done, especially for IBD where a gold standard in “ideal care” is ill defined and continually evolving as new research emerges. Nonetheless, hundreds of health care quality measures have been proposed. Desirable quality measure attributes should satisfy three broad categories: importance, scientific soundness, and feasibility.10 Quality measures should address relevant and important aspects of health that are highly prevalent and for which evidence indicates a need for improvement. There should be strong evidence supporting the beneficial impact of adhering to a given measure.

From a practicality standpoint, measures should relate to actions that are under the control of the providers whose performance is being measured. Measures should also be parsimonious with a goal of minimizing the number of measures needed to adequately represent performance in a given area.11 More simply stated, a good quality measure reflects consensus about a minimally acceptable level of care that applies broadly to all patients.

Quality measures are commonly classified as process measures or outcome measures. Process measures (“doing the right thing”) are steps taken by providers in the care of an individual patient. These often derive from evidence-based best practices. Outcome measures (“having the desired result”) identify what happens to patients as a result of care received.8 Outcome measures may be more meaningful, but there are limitations in using them to study quality of IBD care. For example, factors beyond physician control affect patient outcomes and long delays may exist between care decisions and subsequent outcomes (e.g., surgery, malnutrition).8
 

What IBD quality measures already exist?

Expert panels from the AGA and the Crohn’s & Colitis Foundation of America (CCFA) produced IBD quality measure sets comprising mostly process measures (Table 1). The original 10 AGA measures released in 2011 address aspects of disease assessment, treatment, complication prevention, and health care maintenance.12 They include seven IBD-specific measures, three cross-cutting measures – defined by Centers for Medicare & Medicaid Services (CMS) as being broadly applicable across multiple clinical settings – and two inpatient measures. A major goal of the AGA measures was to facilitate quality reporting to the former PQRS program.

 

The 2013 CCFA “Top 10” highly rated process measures were selected from over 500 candidate measures.13 Five of these measures closely match the AGA measures; two unique items address dysplasia surveillance. Real-world studies demonstrate variable adherence to these quality measures across multiple care settings (individual measure compliance ranging from 17% to 90%),14 supporting the need for improvement. Interventions can improve adherence by up to 20%,15 which provides face validity that these measures capture aspects of care that can be improved. The CCFA also developed an aspirational list of 10 highly rated outcome measures (Table 2), the selection of which included patient input.13 The CCFA measures are not eligible for use in CMS quality reporting programs but are incorporated into the IBD Qorus national quality improvement initiative.16
 

What are some quality measure limitations?

Quality measure development has an evidence base but designing an optimal measure and demonstrating impact can be challenging. Few IBD process measures are validated and thus there is often logic but not data linking process measure adherence to improved outcomes. The denominator (number of eligible patients) and potential impact of broad adherence vary for each quality measure. For example, only a small fraction of IBD patients are infected with hepatitis B and fewer than 10% will experience viral reactivation during anti-TNF therapy.17,18 Even with optimal adherence to the hepatitis B measure, few reactivations will be prevented. The wording of some measures lacks precision, allowing physicians to potentially claim credit without improving care. For example, ordering a bone density scan satisfies the bone loss assessment measure, even if osteoporosis goes unrecognized and untreated. Finally, some measures relate to actions that may not be under the control of the gastroenterologist whose performance is being measured (e.g., administering vaccinations).

IBD quality measures under MIPS

Table 1 depicts the evolution of IBD process measures from 2011 to 2017. Rather than building upon initial experience to revise and refine IBD quality measures, the measures have instead been progressively culled with the changing pay-for-performance landscape. In 2016, AGA eliminated the two inpatient measures.19 Seven of the remaining eight measures formed the IBD Measures Group which was reportable under PQRS. In 2017, MIPS brought a seismic shift in quality measure focus. The PQRS IBD Measures Group was abolished – as were all Measures Groups – and replaced by a 16-item GI Measures Set. Although AGA advocated for all of the IBD measures to be included, the new GI Measures Set deemphasized the IBD-specific measures in favor of expanded cross-cutting measures (e.g., screening for abnormal body mass index, documenting current medications, sending specialist report to referring provider).20 This reflected a previously observed trend that gastroenterologists more often reported on cross-cutting measures than specialist-specific measures.21 However, there was no evidence-based justification for dropping certain IBD-specific measures (especially the steroid-sparing therapy measure) in favor of retaining the two chosen IBD-specific measures – bone loss assessment and hepatitis B screening – which apply to only a subset of IBD patients and have limited potential to impact clinical outcomes. Although it is not mandatory to report using the GI Measures Set, we suspect that many gastroenterologists will use this set to guide their initial reporting.

AGA Institute

During the 2017 MACRA transition year, physicians need report only one quality measure to avoid a penalty. Even after the “pick your pace” MACRA program testing period concludes in 2018, MACRA-eligible clinicians will need to report their performance only on six quality measures. This low bar and shifting focus away from IBD-specific measures is disconcerting for IBD quality enthusiasts. Although MIPS applies only to the 26% of Medicare-eligible IBD patients who are at least 65 years old,22 private payers are likely to adopt similar reimbursement programs.

There are formidable regulatory obstacles to improving the IBD quality measures included in MIPS. CMS requires that new quality measures proposed for inclusion in MIPS be fully specified and tested for validity and reliability by the individual measure developers (such as AGA). This is a costly and time-intensive process that has complicated efforts to successfully advocate for inclusion of GI-specific quality measures in MIPS, as there is no existing infrastructure for quality measure testing.

A word about Alternative Payment Models (APMs)

APMs represent the non-MIPS pathway for participating in the QPP. APMs focus on chronic disease care coordination and qualify for lump-sum incentive payments by adhering to stringent standards and financial risk-sharing requirements. A detailed overview of APMs is beyond the scope of this discussion, as the vast majority of MACRA-eligible gastroenterologists will participate in MIPS and there are currently no GI-specific APMs. However, this is an evolving area and Project Sonar has been submitted to the Physician-Focused Payment Model Technical Advisory Committee for consideration as an APM for Crohn’s disease.23

 

Conclusion

Quality measurement and reporting are at a crossroads. Ideally, performance improvement should be an internally driven process that addresses specific local priorities and needs. Most medical practices (73%) believe that current externally driven quality measures do not represent care quality and only 28% use their quality scores to focus their internal quality improvement activities.2 The burden and cost of external quality reporting demand better alignment with local priorities as resources are currently being diverted away from internally driven efforts that might have the greatest potential to improve patient outcomes.24 The dawn of the MACRA era presents an opportunity to shape the future of the IBD quality movement. Through validating and prioritizing existing measures and developing novel, precisely stated, and high-value metrics, there remains vast (and measurable) potential to enhance patient outcomes.

Dr. McConnell is a fellow in gastroenterology and advanced inflammatory bowel disease, division of gastroenterology, University of California, San Francisco. Dr. Velayos is professor of medicine, co–medical director, Center for Crohn’s and Colitis, University of California, San Francisco.

References

1. September 2016 Medscape survey summary. Available at http://www.healthcaredive.com/news/survey-29-of-physicians-still-havent-heard-of-macra/429322/. Accessed March 23, 2017.

2. Casalino L.P., et al. Health Aff. 2016;35:401-6.

3. Rubin D.T., et al. Curr Med Res Opin. 2017;33:529-36.

4. David G., et al. Gastroenterology. 2013;144:S-647.

5. Nguyen G.C., et al. Clin Gastroenterol Hepatol. 2006;4:1507-13.

6. Esrailian E., et al. Aliment Pharmacol Ther. 2007;26:1005-18.

7. Spiegel B.M., et al. Clin Gastroenterol Hepatol. 2009;7:68-74.

8. Kappelman M.D., et al. Inflamm Bowel Dis. 2010;16:125-133.

9. Reddy S.I., et al. Am J Gastroenterol. 2005;100:1357-61.

10. National Quality Measures Clearinghouse. Available at https://www.qualitymeasures.ahrq.gov/help-and-about/quality-measure-tutorials/desirable-attributes-of-a-quality-measure. Accessed March 23, 2017.

11. McGlynn E.A. Med Care. 2003;41(1 Suppl):139-47.

12. American Gastroenterological Association. Available at https://www.gastro.org/practice/quality-initiatives/IBD_Measures.pdf. Accessed March 23, 2017.

13. Melmed G.Y., et al. Inflamm Bowel Dis. 2013;19:662-8.

14. Feuerstein J.D., et al. Clin Gastroenterol Hepatol. 2016;14:421-8.

15. Sapir T., et al. Dig Dis Sci. 2016;61:1862-9.

16. Crohn’s & Colitis Foundation of America. IBD Qorus. Available at http://www.ccfa.org/science-and-professionals/ibdqorus/. Accessed March 23, 2017.

17. Hou J.K., et al. Gastroenterology. 2015;148(Suppl 1):S-61.

18. Reddy K.R., et al. Gastroenterology. 2015;48:215-9.

19. American Gastroenterological Association. Available at http://www.gastro.org/practice-management/measures/2016_AGA_Measures_-_IBD.pdf. Accessed March 23, 2017.

20. American Gastroenterological Association. Available at http://www.gastro.org/news_items/gi-quality-measures-for-2017-are-released-in-macra-final-rule. Accessed March 23, 2017.

21. Centers for Medicare & Medicaid Services. Available at https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/Downloads/2014_PQRS_Experience_Rpt.pdf. Accessed March 23, 2017.

22. Dahlhamer J.M., et al. MMWR. 2016;65:1166-9.

23. U.S. Department of Health & Human Services Office of the Assistant Secretary for Planning and Evaluation. Available at https://aspe.hhs.gov/system/files/pdf/253406/ProjectSonarSonarMD.pdf. Accessed March 23, 2017.

24. Meyer G.S., et al. BMJ Qual Saf. 2012;21:964-8.

Your next patient is a 67-year-old Medicare beneficiary with corticosteroid-dependent ulcerative colitis. Despite 4 months of maximally dosed mesalamine, his colitis flares with prednisone taper below 20 mg daily. Hepatitis B serologies and tuberculin skin test were negative 10 months ago. Which of the following do you recommend?

A. Steroid-sparing therapy initiation

B. Repeat latent tuberculosis screening in anticipation of anti–tumor necrosis factor (TNF) therapy

C. Bone loss assessment

D. Pneumococcal vaccination

E. Tobacco use screening

All of the above may be appropriate for optimal clinical care, but only two (C and E) will impact your bottom line when using the new GI Measures Set to report quality measures through the Merit-Based Incentive Payment System (MIPS). For the 75.1% of physicians who have not heard of – or don’t know much about – MIPS,1 the gastroenterology world will come to know it as the dominant of two Quality Payment Program (QPP) tracks introduced as part of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). Starting in 2017, the QPP handles quality measure reporting and reimbursement adjustments based on the quality and cost of care provided to Medicare beneficiaries. MIPS replaces the Physician Quality Reporting System (PQRS), Value-Based Payment Modifier, and electronic health record Meaningful Use programs that previously executed these tasks.

Quality measure reporting is a costly undertaking, with medical practices spending an average of 15.1 hours per physician per week ($40,069 per physician annually) dealing with external quality measures.2 How did this expensive alphabet soup of quality measure reporting arise and how does it impact inflammatory bowel disease (IBD) care?
 

Why are IBD quality measures needed?

There is substantial variation in care provided to IBD patients. Examples include geographic variation in rates of prolonged corticosteroid3 and biologic therapy use (Figure 1),4 hospitalization, and colectomy.5 IBD experts and community gastroenterologists manage IBD differently.6,7 This variation reflects more than mere “art of medicine” stylistic differences. Patient, provider, and system-level factors contribute to practice variation, including the heterogeneity of IBD phenotypes, lack of knowledge about best practices, insufficient evidence on which to base treatment decisions, and variable access to care. Variation likely indicates resource underuse, overuse, and misuse and may be a marker of poor quality care.8,9 Closing the gap between current and ideal IBD care – by reducing unnecessary variation – may reduce suboptimal outcomes, preventable complications, care costs, and waste. Financially incentivized quality metrics have been proposed as a performance improvement and standardization strategy.

What makes a good quality measure?

Quality must be defined and measured before it can be improved. This is easier said than done, especially for IBD where a gold standard in “ideal care” is ill defined and continually evolving as new research emerges. Nonetheless, hundreds of health care quality measures have been proposed. Desirable quality measure attributes should satisfy three broad categories: importance, scientific soundness, and feasibility.10 Quality measures should address relevant and important aspects of health that are highly prevalent and for which evidence indicates a need for improvement. There should be strong evidence supporting the beneficial impact of adhering to a given measure.

From a practicality standpoint, measures should relate to actions that are under the control of the providers whose performance is being measured. Measures should also be parsimonious with a goal of minimizing the number of measures needed to adequately represent performance in a given area.11 More simply stated, a good quality measure reflects consensus about a minimally acceptable level of care that applies broadly to all patients.

Quality measures are commonly classified as process measures or outcome measures. Process measures (“doing the right thing”) are steps taken by providers in the care of an individual patient. These often derive from evidence-based best practices. Outcome measures (“having the desired result”) identify what happens to patients as a result of care received.8 Outcome measures may be more meaningful, but there are limitations in using them to study quality of IBD care. For example, factors beyond physician control affect patient outcomes and long delays may exist between care decisions and subsequent outcomes (e.g., surgery, malnutrition).8
 

What IBD quality measures already exist?

Expert panels from the AGA and the Crohn’s & Colitis Foundation of America (CCFA) produced IBD quality measure sets comprising mostly process measures (Table 1). The original 10 AGA measures released in 2011 address aspects of disease assessment, treatment, complication prevention, and health care maintenance.12 They include seven IBD-specific measures, three cross-cutting measures – defined by Centers for Medicare & Medicaid Services (CMS) as being broadly applicable across multiple clinical settings – and two inpatient measures. A major goal of the AGA measures was to facilitate quality reporting to the former PQRS program.

 

The 2013 CCFA “Top 10” highly rated process measures were selected from over 500 candidate measures.13 Five of these measures closely match the AGA measures; two unique items address dysplasia surveillance. Real-world studies demonstrate variable adherence to these quality measures across multiple care settings (individual measure compliance ranging from 17% to 90%),14 supporting the need for improvement. Interventions can improve adherence by up to 20%,15 which provides face validity that these measures capture aspects of care that can be improved. The CCFA also developed an aspirational list of 10 highly rated outcome measures (Table 2), the selection of which included patient input.13 The CCFA measures are not eligible for use in CMS quality reporting programs but are incorporated into the IBD Qorus national quality improvement initiative.16
 

What are some quality measure limitations?

Quality measure development has an evidence base but designing an optimal measure and demonstrating impact can be challenging. Few IBD process measures are validated and thus there is often logic but not data linking process measure adherence to improved outcomes. The denominator (number of eligible patients) and potential impact of broad adherence vary for each quality measure. For example, only a small fraction of IBD patients are infected with hepatitis B and fewer than 10% will experience viral reactivation during anti-TNF therapy.17,18 Even with optimal adherence to the hepatitis B measure, few reactivations will be prevented. The wording of some measures lacks precision, allowing physicians to potentially claim credit without improving care. For example, ordering a bone density scan satisfies the bone loss assessment measure, even if osteoporosis goes unrecognized and untreated. Finally, some measures relate to actions that may not be under the control of the gastroenterologist whose performance is being measured (e.g., administering vaccinations).

IBD quality measures under MIPS

Table 1 depicts the evolution of IBD process measures from 2011 to 2017. Rather than building upon initial experience to revise and refine IBD quality measures, the measures have instead been progressively culled with the changing pay-for-performance landscape. In 2016, AGA eliminated the two inpatient measures.19 Seven of the remaining eight measures formed the IBD Measures Group which was reportable under PQRS. In 2017, MIPS brought a seismic shift in quality measure focus. The PQRS IBD Measures Group was abolished – as were all Measures Groups – and replaced by a 16-item GI Measures Set. Although AGA advocated for all of the IBD measures to be included, the new GI Measures Set deemphasized the IBD-specific measures in favor of expanded cross-cutting measures (e.g., screening for abnormal body mass index, documenting current medications, sending specialist report to referring provider).20 This reflected a previously observed trend that gastroenterologists more often reported on cross-cutting measures than specialist-specific measures.21 However, there was no evidence-based justification for dropping certain IBD-specific measures (especially the steroid-sparing therapy measure) in favor of retaining the two chosen IBD-specific measures – bone loss assessment and hepatitis B screening – which apply to only a subset of IBD patients and have limited potential to impact clinical outcomes. Although it is not mandatory to report using the GI Measures Set, we suspect that many gastroenterologists will use this set to guide their initial reporting.

AGA Institute

During the 2017 MACRA transition year, physicians need report only one quality measure to avoid a penalty. Even after the “pick your pace” MACRA program testing period concludes in 2018, MACRA-eligible clinicians will need to report their performance only on six quality measures. This low bar and shifting focus away from IBD-specific measures is disconcerting for IBD quality enthusiasts. Although MIPS applies only to the 26% of Medicare-eligible IBD patients who are at least 65 years old,22 private payers are likely to adopt similar reimbursement programs.

There are formidable regulatory obstacles to improving the IBD quality measures included in MIPS. CMS requires that new quality measures proposed for inclusion in MIPS be fully specified and tested for validity and reliability by the individual measure developers (such as AGA). This is a costly and time-intensive process that has complicated efforts to successfully advocate for inclusion of GI-specific quality measures in MIPS, as there is no existing infrastructure for quality measure testing.

A word about Alternative Payment Models (APMs)

APMs represent the non-MIPS pathway for participating in the QPP. APMs focus on chronic disease care coordination and qualify for lump-sum incentive payments by adhering to stringent standards and financial risk-sharing requirements. A detailed overview of APMs is beyond the scope of this discussion, as the vast majority of MACRA-eligible gastroenterologists will participate in MIPS and there are currently no GI-specific APMs. However, this is an evolving area and Project Sonar has been submitted to the Physician-Focused Payment Model Technical Advisory Committee for consideration as an APM for Crohn’s disease.23

 

Conclusion

Quality measurement and reporting are at a crossroads. Ideally, performance improvement should be an internally driven process that addresses specific local priorities and needs. Most medical practices (73%) believe that current externally driven quality measures do not represent care quality and only 28% use their quality scores to focus their internal quality improvement activities.2 The burden and cost of external quality reporting demand better alignment with local priorities as resources are currently being diverted away from internally driven efforts that might have the greatest potential to improve patient outcomes.24 The dawn of the MACRA era presents an opportunity to shape the future of the IBD quality movement. Through validating and prioritizing existing measures and developing novel, precisely stated, and high-value metrics, there remains vast (and measurable) potential to enhance patient outcomes.

Dr. McConnell is a fellow in gastroenterology and advanced inflammatory bowel disease, division of gastroenterology, University of California, San Francisco. Dr. Velayos is professor of medicine, co–medical director, Center for Crohn’s and Colitis, University of California, San Francisco.

References

1. September 2016 Medscape survey summary. Available at http://www.healthcaredive.com/news/survey-29-of-physicians-still-havent-heard-of-macra/429322/. Accessed March 23, 2017.

2. Casalino L.P., et al. Health Aff. 2016;35:401-6.

3. Rubin D.T., et al. Curr Med Res Opin. 2017;33:529-36.

4. David G., et al. Gastroenterology. 2013;144:S-647.

5. Nguyen G.C., et al. Clin Gastroenterol Hepatol. 2006;4:1507-13.

6. Esrailian E., et al. Aliment Pharmacol Ther. 2007;26:1005-18.

7. Spiegel B.M., et al. Clin Gastroenterol Hepatol. 2009;7:68-74.

8. Kappelman M.D., et al. Inflamm Bowel Dis. 2010;16:125-133.

9. Reddy S.I., et al. Am J Gastroenterol. 2005;100:1357-61.

10. National Quality Measures Clearinghouse. Available at https://www.qualitymeasures.ahrq.gov/help-and-about/quality-measure-tutorials/desirable-attributes-of-a-quality-measure. Accessed March 23, 2017.

11. McGlynn E.A. Med Care. 2003;41(1 Suppl):139-47.

12. American Gastroenterological Association. Available at https://www.gastro.org/practice/quality-initiatives/IBD_Measures.pdf. Accessed March 23, 2017.

13. Melmed G.Y., et al. Inflamm Bowel Dis. 2013;19:662-8.

14. Feuerstein J.D., et al. Clin Gastroenterol Hepatol. 2016;14:421-8.

15. Sapir T., et al. Dig Dis Sci. 2016;61:1862-9.

16. Crohn’s & Colitis Foundation of America. IBD Qorus. Available at http://www.ccfa.org/science-and-professionals/ibdqorus/. Accessed March 23, 2017.

17. Hou J.K., et al. Gastroenterology. 2015;148(Suppl 1):S-61.

18. Reddy K.R., et al. Gastroenterology. 2015;48:215-9.

19. American Gastroenterological Association. Available at http://www.gastro.org/practice-management/measures/2016_AGA_Measures_-_IBD.pdf. Accessed March 23, 2017.

20. American Gastroenterological Association. Available at http://www.gastro.org/news_items/gi-quality-measures-for-2017-are-released-in-macra-final-rule. Accessed March 23, 2017.

21. Centers for Medicare & Medicaid Services. Available at https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/Downloads/2014_PQRS_Experience_Rpt.pdf. Accessed March 23, 2017.

22. Dahlhamer J.M., et al. MMWR. 2016;65:1166-9.

23. U.S. Department of Health & Human Services Office of the Assistant Secretary for Planning and Evaluation. Available at https://aspe.hhs.gov/system/files/pdf/253406/ProjectSonarSonarMD.pdf. Accessed March 23, 2017.

24. Meyer G.S., et al. BMJ Qual Saf. 2012;21:964-8.