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A heartwarming welcome
Dear colleagues,
This November issue of The New Gastroenterologist marks my official transition as the new Editor in Chief! I am humbled with this opportunity to be a part of such a unique publication and have received immense support from Dr. Vijaya Rao, the TNG staff, as well as my mentors and colleagues. With its foundation built by Dr. Bryson Katona and then taken to the next level by Dr. Rao, TNG has grown over the years, and I hope that I can continue to extend its reach to more trainees and early faculty.
In this issue’s In Focus, Dr. Wenfei Wang and Dr. Neil Sengupta (both from University of Chicago) review the management of antithrombotic medications in elective endoscopic procedures and emphasize individualizing the approach while providing guideline recommendations on how to navigate the gastrointestinal bleeding risk and cardiovascular disease in this day and age.
With endoscopic bariatric therapy and antiobesity medications burgeoning within gastroenterology, Dr. Singrid Young (New York University), Dr. Cameron Zenger (New York University), Dr. Erik Holzwanger (Harvard Medical School in Boston), and Dr. Violeta Popov (New York University) review how their multidisciplinary approach has made their endoscopic bariatric program successful in treating patients struggling with obesity. In our Ethics section, Dr. David Ney (Thomas Jefferson University Hospital, Philadelphia) and Dr. Jason Karlawish (University of Pennsylvania, Philadelphia) delve into patient capacity, particularly when consenting for procedures.
Being involved with national society committees may seem daunting to a lot of trainees and early faculty, but Dr. Peter S. Liang (New York University Langone Health) and Dr. Stephanie D. Pointer (Tristar Hendersonville Medical Center in Tennessee) describe their journeys to becoming AGA committee chairs as early-career physicians. While you ponder whether to join a committee, it may be a good time to learn new ways to increase your financial portfolio through passive income, detailed by Dr. Latifat Alli-Akintade (Kaiser Permanente South Sacramento Medical Center in California).
Last but not least, I am excited to introduce a personal favorite in this newsletter – a piece on females supporting female gastroenterologists in career development and more. Dr. Tonya Adams outlines action items on how to create a culture that fosters professional and leadership development among females, using the Gastro Health Women’s Network as an example of how this network has succeeded in cultivating such an environment.
If you are interested in contributing or have ideas for future TNG topics, please contact me ([email protected]), or Jillian Schweitzer ([email protected]), managing editor of TNG.
Until next time, I leave you with an interesting historical fact: William Beaumont, the father of Gastroenterology, published the first findings on the digestive system after performing experiments on Alexis St. Martin when he developed a large gastrocutaneous fistula from an abdominal gunshot wound.
Yours truly,
Judy A. Trieu, MD, MPH
Editor in Chief
Advanced Endoscopy Fellow, University of North Carolina at Chapel Hill, Division of Gastroenterology & Hepatology
Dear colleagues,
This November issue of The New Gastroenterologist marks my official transition as the new Editor in Chief! I am humbled with this opportunity to be a part of such a unique publication and have received immense support from Dr. Vijaya Rao, the TNG staff, as well as my mentors and colleagues. With its foundation built by Dr. Bryson Katona and then taken to the next level by Dr. Rao, TNG has grown over the years, and I hope that I can continue to extend its reach to more trainees and early faculty.
In this issue’s In Focus, Dr. Wenfei Wang and Dr. Neil Sengupta (both from University of Chicago) review the management of antithrombotic medications in elective endoscopic procedures and emphasize individualizing the approach while providing guideline recommendations on how to navigate the gastrointestinal bleeding risk and cardiovascular disease in this day and age.
With endoscopic bariatric therapy and antiobesity medications burgeoning within gastroenterology, Dr. Singrid Young (New York University), Dr. Cameron Zenger (New York University), Dr. Erik Holzwanger (Harvard Medical School in Boston), and Dr. Violeta Popov (New York University) review how their multidisciplinary approach has made their endoscopic bariatric program successful in treating patients struggling with obesity. In our Ethics section, Dr. David Ney (Thomas Jefferson University Hospital, Philadelphia) and Dr. Jason Karlawish (University of Pennsylvania, Philadelphia) delve into patient capacity, particularly when consenting for procedures.
Being involved with national society committees may seem daunting to a lot of trainees and early faculty, but Dr. Peter S. Liang (New York University Langone Health) and Dr. Stephanie D. Pointer (Tristar Hendersonville Medical Center in Tennessee) describe their journeys to becoming AGA committee chairs as early-career physicians. While you ponder whether to join a committee, it may be a good time to learn new ways to increase your financial portfolio through passive income, detailed by Dr. Latifat Alli-Akintade (Kaiser Permanente South Sacramento Medical Center in California).
Last but not least, I am excited to introduce a personal favorite in this newsletter – a piece on females supporting female gastroenterologists in career development and more. Dr. Tonya Adams outlines action items on how to create a culture that fosters professional and leadership development among females, using the Gastro Health Women’s Network as an example of how this network has succeeded in cultivating such an environment.
If you are interested in contributing or have ideas for future TNG topics, please contact me ([email protected]), or Jillian Schweitzer ([email protected]), managing editor of TNG.
Until next time, I leave you with an interesting historical fact: William Beaumont, the father of Gastroenterology, published the first findings on the digestive system after performing experiments on Alexis St. Martin when he developed a large gastrocutaneous fistula from an abdominal gunshot wound.
Yours truly,
Judy A. Trieu, MD, MPH
Editor in Chief
Advanced Endoscopy Fellow, University of North Carolina at Chapel Hill, Division of Gastroenterology & Hepatology
Dear colleagues,
This November issue of The New Gastroenterologist marks my official transition as the new Editor in Chief! I am humbled with this opportunity to be a part of such a unique publication and have received immense support from Dr. Vijaya Rao, the TNG staff, as well as my mentors and colleagues. With its foundation built by Dr. Bryson Katona and then taken to the next level by Dr. Rao, TNG has grown over the years, and I hope that I can continue to extend its reach to more trainees and early faculty.
In this issue’s In Focus, Dr. Wenfei Wang and Dr. Neil Sengupta (both from University of Chicago) review the management of antithrombotic medications in elective endoscopic procedures and emphasize individualizing the approach while providing guideline recommendations on how to navigate the gastrointestinal bleeding risk and cardiovascular disease in this day and age.
With endoscopic bariatric therapy and antiobesity medications burgeoning within gastroenterology, Dr. Singrid Young (New York University), Dr. Cameron Zenger (New York University), Dr. Erik Holzwanger (Harvard Medical School in Boston), and Dr. Violeta Popov (New York University) review how their multidisciplinary approach has made their endoscopic bariatric program successful in treating patients struggling with obesity. In our Ethics section, Dr. David Ney (Thomas Jefferson University Hospital, Philadelphia) and Dr. Jason Karlawish (University of Pennsylvania, Philadelphia) delve into patient capacity, particularly when consenting for procedures.
Being involved with national society committees may seem daunting to a lot of trainees and early faculty, but Dr. Peter S. Liang (New York University Langone Health) and Dr. Stephanie D. Pointer (Tristar Hendersonville Medical Center in Tennessee) describe their journeys to becoming AGA committee chairs as early-career physicians. While you ponder whether to join a committee, it may be a good time to learn new ways to increase your financial portfolio through passive income, detailed by Dr. Latifat Alli-Akintade (Kaiser Permanente South Sacramento Medical Center in California).
Last but not least, I am excited to introduce a personal favorite in this newsletter – a piece on females supporting female gastroenterologists in career development and more. Dr. Tonya Adams outlines action items on how to create a culture that fosters professional and leadership development among females, using the Gastro Health Women’s Network as an example of how this network has succeeded in cultivating such an environment.
If you are interested in contributing or have ideas for future TNG topics, please contact me ([email protected]), or Jillian Schweitzer ([email protected]), managing editor of TNG.
Until next time, I leave you with an interesting historical fact: William Beaumont, the father of Gastroenterology, published the first findings on the digestive system after performing experiments on Alexis St. Martin when he developed a large gastrocutaneous fistula from an abdominal gunshot wound.
Yours truly,
Judy A. Trieu, MD, MPH
Editor in Chief
Advanced Endoscopy Fellow, University of North Carolina at Chapel Hill, Division of Gastroenterology & Hepatology
Management of antithrombotic medications in elective endoscopy
Antithrombotic therapy is increasingly used to either reduce the risk of or treat thromboembolic episodes in patients with various medical conditions such as ischemic and valvular heart disease, atrial fibrillation (AF), cerebrovascular disease, peripheral arterial disease, venous thromboembolism (VTE) and hypercoagulable diseases. Antithrombotics include medications classified as anticoagulants or antiplatelets. Anticoagulants work by interfering with the native clotting cascade and consist of four main classes: vitamin K antagonists (VKA), heparin derivatives, direct factor Xa inhibitors, and direct thrombin inhibitors. Direct oral anticoagulants (DOACs) refer to dabigatran (a direct thrombin inhibitor) and the factor Xa inhibitors (apixaban, rivaroxaban, and edoxaban).
Antiplatelets, on the other hand, work by decreasing platelet aggregation and thus preventing thrombus formation; they include P2Y12 receptor inhibitors, protease-activated receptor-1 inhibitors, glycoprotein IIb/IIIa receptor inhibitors, acetylsalicylic acid (ASA), and nonsteroidal anti-inflammatory drugs. All of these agents may directly cause or increase the risk of gastrointestinal (GI) bleeding from luminal sources such as ulcers or diverticula, as well as after endoscopic interventions such as polypectomy. However, there is also a risk of thromboembolic consequences if some of these agents are withheld. Thus, the management of patients receiving antithrombotic agents and undergoing GI endoscopy represents an important clinical challenge and something that every GI physician has to deal with routinely.
The goal of this review is to discuss the optimal strategy for managing antithrombotics in patients undergoing elective endoscopy based on current available evidence and published clinical guidelines.1-4 Much of our discussion will review recommendations from the recently published joint American College of Gastroenterology (ACG) and Canadian Association of Gastroenterology (CAG) guidelines on management of anticoagulants and antiplatelets in the periendoscopic period by Abraham et al.4
Factors that guide decision-making
The two most vital factors to consider prior to performing endoscopic procedures in patients receiving antithrombotic therapy are to assess the risk of bleeding associated with the procedure and to assess the risk of thromboembolism associated with the underlying medical condition for which the antithrombotic agents are being used. In addition, it is also important to keep in mind the individual characteristics of the antithrombotic agent(s) used when making these decisions.
Estimating procedure-related bleeding risk
Various endoscopic procedures have different risks of associated bleeding. Although guidelines from GI societies may differ when classifying procedures into low or high risk, it is important to know that most of the original data on postprocedural bleeding risks are from studies conducted in patients who are not on complex antithrombotic regimens and thus may not accurately reflect the bleeding risk of patients using newer antithrombotic therapies.1,4-7
Traditionally, some of the common low-risk procedures have included diagnostic EGD and colonoscopy with or without biopsy, ERCP without sphincterotomy, biliary stent placement, and push or balloon-assisted enteroscopy. On the other hand, endoscopic procedures associated with interventions are known to have higher bleeding risk, and other procedural factors can influence this risk as well.8 For example, polypectomy, one of the most common interventions during endoscopy, is associated with bleeding risk ranging from 0.3% to 10% depending on multiple factors including polyp size, location, morphology (nonpolypoid, sessile, pedunculated), resection technique (cold or hot forceps, cold or hot snare), and type of cautery used.9 For some procedures, such as routine screening colonoscopy, however, the preprocedure estimate of bleeding risk can be uncertain because it is unclear if a high risk intervention (e.g., polypectomy of large polyp) will be necessary. For example, in the most recent ACG/CAG guidelines, colonoscopy with polypectomy < 1cm is considered a low/moderate risk bleeding procedure, whereas polypectomy > 1cm is considered high risk for bleeding.4 In these situations, the management of antithrombotic medications may depend on the individual patient’s risk of thrombosis and the specific antithrombotic agent. In the example of a patient undergoing colonoscopy while on antithrombotic medications, the bleeding risk associated with polypectomy can potentially be reduced by procedural techniques such as preferential use of cold snare polypectomy. Further high-quality data on the optimal procedural technique to reduce postpolypectomy bleeding in patients on antithrombotic medications is needed to help guide management.
Estimating thromboembolic risk
The risk of thromboembolic events in patients who are withholding their antithrombotic therapy for an endoscopic procedure depends on their underlying condition and individual characteristics. In patients who are on antithrombotic therapy for stroke prevention in non-valvular AF, the risk of cerebral thromboembolism in these patients is predictable using the CHA2DS2Vasc index.10 This scoring index includes heart failure, hypertension, age 75 years or older, diabetes mellitus, prior stroke or transient ischemic attack (TIA), vascular disease, age 65-74 years, and sex categories.
Patients with previous VTE on anticoagulation or those who have mechanical heart valves may have different risk factors for thromboembolic episodes. Among patients with VTE, time from initial VTE, history of recurrent VTE with antithrombotic interruption, and presence of underlying thrombophilia are most predictive of future thromboembolic risk. And for patients with mechanical heart valves, presence of a mitral valve prosthesis, and the presence or absence of associated heart failure and AF determine the annual risk of thromboembolic events. Bioprosthetic valves are generally considered low risk.
In patients with coronary artery disease (CAD), high thrombosis risk scenarios with holding antiplatelets include patients within 3 months of an acute coronary syndrome (ACS) event, within 6 months of a drug-eluting stent (DES) placement, or within 1 month of a bare metal coronary stent (BMS) placement. In addition, patients with ACS that occurred within the past 12 months of DES placement or within 2 months of BMS placement are also considered high risk.11,12 Even beyond these periods, certain patients may still be at high risk of stent occlusion. In particular, patients with a prior history of stent occlusion, ACS or ST elevation myocardial infection, prior multivessel percutaneous coronary intervention, diabetes, renal failure, or diffuse CAD are at higher risk of stent occlusion or ACS events with alteration of antithrombotic therapy.13 Thus, modification of antithrombotic regimens in these patients should be cautiously approached.
Management of antithrombotics prior to elective endoscopy
In patients who need elective endoscopic procedures, if the indication for antithrombotic therapy is short-term, the procedure is probably best delayed until after that period.13 For patients on long-term or lifelong antithrombotic treatment, the decision to temporarily hold the treatment for endoscopy should occur after a discussion with the patient and all of the involved providers. In some high-risk patients, these agents cannot be interrupted; therefore, clinicians must carefully weigh the risks and benefits of the procedure before proceeding with endoscopy. For patients who are known to be undergoing an elective endoscopic procedure, antithrombotic medications may or may not need to be held prior to the procedure depending on the type of therapy. For example, according to the recent ACG/CAG guidelines, warfarin should be continued, whereas DOACs should be temporarily stopped for patients who are undergoing elective/planned endoscopic GI procedures.
Unfractionated heparin (UFH) administered as a continuous intravenous infusion can generally be held 3-4 hours before the procedure, given its short half-life. Low molecular weight heparin (LMWH), including enoxaparin and dalteparin, should be stopped 24 hours prior to the procedure.2,14 Fondaparinux is a synthetic X-a inhibitor that requires discontinuation at least 36 hours preceding a high risk procedure. For patients on warfarin who are undergoing elective endoscopic procedures that are low risk for inducing bleeding, warfarin can be continued, as opposed to temporarily interrupted, although the dose should be omitted the morning of the procedure.4 For those who are undergoing high-risk endoscopic procedures (including colonoscopy with possible polypectomy > 1 cm), 5 days of temporary interruption without periprocedural bridging is appropriate in most patients. This is contrary to previous guidelines, which had recommended bridging for patients with a CHA2DS2Vasc score ≥ 2. Recent impactful randomized trials (BRIDGE and PERIOP-2) have called into question the benefit of periprocedural bridging with LMWH. Avoiding bridging anticoagulation was generally found to be similar to bridging in regard to prevention of thromboembolic complications, but importantly was associated with a decreased risk of major bleeding.15,16 Of note, periprocedural bridging may still be appropriate in a small subset of patients, including those with mechanical valves, AF with CHADS2 score > 5, and previous thromboembolism during temporary interruption of VKAs. The decision to bridge or not should ideally be made in a multidisciplinary fashion.15-20
Data are lacking on the ideal strategy for periendoscopic DOAC management. As mentioned above, for patients on DOACs who are undergoing elective endoscopic GI procedures, temporarily interrupting DOACs rather than continuing them is recommended. Currently, there are no randomized controlled trials addressing the management of DOACs in the periendoscopic period. However, based on five cohort studies, the ideal duration of DOAC interruption before endoscopic procedures may be between 1 and 2 days, excluding the day of the procedure.21-25 This strategy allows for a short preprocedural duration of DOAC interruption and likely provides a balance between bleeding and thromboembolism risk. Importantly, there are no reliable laboratory assays to assess the anticoagulant effect of DOACs, and an individual patient’s degree of renal dysfunction may impact how long the DOAC should be held. In general, the anti-Xa drugs should be held for 1-2 days if the creatinine clearance (CrCl) is ≥ 60 mL/min, for 3 days if the CrCl is between 30 mL/min and 59 mL/min, and for 4 days if the CrCl is less than 30 mL/min.26 For edoxaban, the recommendation is to hold at least 24 hours before high-risk procedures. The recommendation for stopping dabigatran is 2-3 days before a high-risk procedure in patients with CrCl more than 80 mL/min, 3-4 days prior if between 30 and 49 mL/min, and 4-6 days prior if less than 30 mL/min respectively.27
In regard to antiplatelet management, ASA and the P2Y12 receptor inhibitors (e.g. clopidogrel, prasugrel, and ticagrelor) are the most commonly utilized antiplatelets in patients undergoing endoscopic procedures. For patients who are on ASA monotherapy, whether 81 mg or 325 mg daily, for secondary cardiovascular prevention, no interruption of ASA therapy is necessary for elective procedures. The benefit of ASA for secondary cardiovascular prevention and the possible reduction in thrombotic events seen in RCTs of nonendoscopic surgical procedures is well known. However, there may be certain exceptions in which aspirin should be temporarily held. For example, short-term interruption of ASA could be considered in high risk procedures such as biliary or pancreatic sphincterotomy, ampullectomy, and peroral endoscopic myotomy. For patients on single antiplatelet therapy with a P2Y12 receptor inhibitor who are undergoing elective endoscopic GI procedures, the recent CAG/ACG guidelines did not provide a clear recommendation for or against temporary interruption of the P2Y12 receptor inhibitor. Although interruption of a P2Y12 receptor inhibitor should theoretically decrease a patient’s risk of bleeding, the available evidence reported a nonsignificant increased bleeding risk in patients who stop a P2Y12 receptor inhibitor for an elective endoscopic procedure compared with those who continue the medication.28,29 Therefore, until further data are available, for patients on P2Y12 receptor monotherapy, a reasonable strategy would be to temporarily hold therapy prior to high risk endoscopic procedures, assuming the patients are not at high cardiovascular risk. Clopidogrel and prasugrel have to be stopped 5-7 days prior to allow normal platelet aggregation to resume as opposed to ticagrelor, a reversible P2Y12 receptor inhibitor that can be stopped 3-5 days prior.30
Lastly, for patients who are on dual antiplatelet therapy (DAPT) for secondary prevention, continuation of ASA and temporary interruption of the P2Y12 receptor inhibitor is recommended while undergoing elective endoscopy. Studies have shown that those who discontinued both had a much higher incidence of stent thrombosis compared with those who remained on aspirin alone.4,28,31
Resumption of antithrombotic therapy after endoscopy
In general, antithrombotic therapy should be resumed upon completion of the procedure unless there remains a persistent risk of major bleeding.1,14 This consensus is based on studies available on warfarin and heparin products, with minimal literature available regarding the resumption of DOACs. The benefits of immediate re-initiation of antithrombotic therapy for the prevention of thromboembolic events should be weighed against the risk of hemorrhage associated with the specific agent, the time to onset of the medication, and procedure-specific circumstances. For the small subset of patients on warfarin with a high risk of thromboembolism (e.g., mechanical heart valve), bridging with LMWH should be started at the earliest possible time when there is no risk of major bleeding and continued until the international normalized ratio (INR) reaches a therapeutic level with warfarin. For patients at a lower risk of thromboembolism, warfarin should be restarted within 24 hours of the procedure. In addition, because of the shorter duration of DOACs, if treatment with these agents cannot resume within 24 hours of a high-risk procedure, bridge therapy should be considered with UFH or LMWH in patients with a high risk of thrombosis.18 In patients receiving DOACs for stroke prophylaxis in AF, the DOACS can be safely resumed 1 day after low-risk procedures and 2-3 days after high-risk procedures without the need for bridging.25 All antiplatelet agents should be resumed as soon as hemostasis is achieved.
Conclusion
Antithrombotic therapy is increasingly used given the aging population, widespread burden of cardiovascular comorbidities, and expanding indications for classes of medications such as direct oral anticoagulants. Given the association with antithrombotic medications and gastrointestinal bleeding, it is essential for gastroenterologists to understand the importance, necessity, and timing when holding these medications for endoscopic procedures. Even with the practice guidelines available today to help clinicians navigate certain situations, each patient’s antithrombotic management may be different, and communication with the prescribing physicians and including patients in the decision-making process is essential before planned procedures.
Dr. Wang is a gastroenterology fellow at the University of Chicago. Dr. Sengupta is an associate professor at the University of Chicago. They reported no funding or conflicts of interest.
References
1. ASGE Standards of Practice Committee, Acosta RD et al. The management of antithrombotic agents for patients undergoing GI endoscopy. Gastrointest Endosc. 2016;83(1):3-16.
2. Veitch AM et al. Endoscopy in patients on antiplatelet or anticoagulant therapy, including direct oral anticoagulants: British Society of Gastroenterology (BSG) and European Society of Gastrointestinal Endoscopy (ESGE) guidelines. Endoscopy. 2016;48(4):c1. doi: 10.1055/s-0042-122686.
3. Chan FKL et al. Management of patients on antithrombotic agents undergoing emergency and elective endoscopy: Joint Asian Pacific Association of Gastroenterology (APAGE) and Asian Pacific Society for Digestive Endoscopy (APSDE) practice guidelines. Gut. 2018;67(3):405-17.
4. Abraham NS et al. American College of Gastroenterology – Canadian Association of Gastroenterology clinical practice guideline: Management of anticoagulants and antiplatelets during acute gastrointestinal bleeding and the periendoscopic period. Am J Gastroenterol. 2022;117(4):542-58.
5. Boustière C et al. Endoscopy and antiplatelet agents. European Society of Gastrointestinal Endoscopy (ESGE) guideline. Endoscopy. 2011;43(5):445-61.
6. Fujimoto K et al. Guidelines for gastroenterological endoscopy in patients undergoing antithrombotic treatment. Dig Endosc. 2014;26(1):1-14.
7. Wilke T et al. Patient preferences for oral anticoagulation therapy in atrial fibrillation: A systematic literature review. Patient 2017;10(1):17-37.
8. Gerson LB et al. Adverse events associated with anticoagulation therapy in the periendoscopic period. Gastrointest Endosc. 2010 Jun;71(7):1211-17.e2.
9. Horiuchi A et al. Removal of small colorectal polyps in anticoagulated patients: A prospective randomized comparison of cold snare and conventional polypectomy. Gastrointest Endosc 2014;79(3):417-23.
10. Lip GYH et al. Refining clinical risk stratification for predicting stroke and thromboembolism in atrial fibrillation using a novel risk factor-based approach: The euro heart survey on atrial fibrillation. Chest. 2010;137(2):263-72.
11. 2012 Writing Committee Members, Jneid H et al. 2012 ACCF/AHA focused update of the guideline for the management of patients with unstable angina/non-ST-elevation myocardial infarction (Updating the 2007 guideline and replacing the 2011 focused update): A report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines. Circulation. 2012;126(7):875-910.
12. Douketis JD et al. Perioperative management of antithrombotic therapy: Antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2012 Feb;141(2 Suppl):e326S-e350S.
13. Becker RC et al. Management of platelet-directed pharmacotherapy in patients with atherosclerotic coronary artery disease undergoing elective endoscopic gastrointestinal procedures. J Am Coll Cardiol. 2009;54(24):2261-76.
14. Kwok A and Faigel DO. Management of anticoagulation before and after gastrointestinal endoscopy. Am J Gastroenterol. 2009;104(12):3085-97; quiz 3098.
15. Douketis JD et al. Perioperative bridging anticoagulation in patients with atrial fibrillation. N Engl J Med. 2015;373(9):823-33.
16. Kovacs MJ et al. Postoperative low molecular weight heparin bridging treatment for patients at high risk of arterial thromboembolism (PERIOP2): Double blind randomised controlled trial. BMJ 2021;373:n1205.
17. Tafur A and Douketis J. Perioperative management of anticoagulant and antiplatelet therapy. Heart 2018;104(17):1461-7.
18. Kato M et al. Guidelines for gastroenterological endoscopy in patients undergoing antithrombotic treatment: 2017 appendix on anticoagulants including direct oral anticoagulants. Dig Endosc. 2018;30(4):433-40.
19. Inoue T et al. Clinical features of postpolypectomy bleeding associated with heparin bridge therapy. Dig Endosc. 2014;26(2):243-9.
20. Takeuchi Y et al. Continuous anticoagulation and cold snare polypectomy versus heparin bridging and hot snare polypectomy in patients on anticoagulants with subcentimeter polyps: A randomized controlled trial. Ann Intern Med. 2019;171(4):229-37.
21. Ara N et al. Prospective analysis of risk for bleeding after endoscopic biopsy without cessation of antithrombotics in Japan. Dig Endosc. 2015;27(4):458-64.
22. Yanagisawa N et al. Postpolypectomy bleeding and thromboembolism risks associated with warfarin vs. direct oral anticoagulants. World J Gastroenterol. 2018;24(14):1540-9.
23. Arimoto J et al. Safety of cold snare polypectomy in patients receiving treatment with antithrombotic agents. Dig Dis Sci. 2019;64(11):3247-55.
24. Heublein V et al. Gastrointestinal endoscopy in patients receiving novel direct oral anticoagulants: Results from the prospective Dresden NOAC registry. J Gastroenterol. 2018;53(2):236-46.
25. Douketis JD et al. Perioperative management of patients with atrial fibrillation receiving a direct oral anticoagulant. JAMA Intern Med. 2019;179(11):1469-78.
26. Dubois V et al. Perioperative management of patients on direct oral anticoagulants. Thromb J. 2017;15:14.
27. Weitz JI et al. Periprocedural management and approach to bleeding in patients taking dabigatran. Circulation. 2012 Nov 13;126(20):2428-32.
28. Chan FKL et al. Risk of postpolypectomy bleeding with uninterrupted clopidogrel therapy in an industry-independent, double-blind, randomized trial. Gastroenterology. 2019;156(4):918-25.
29. Watanabe K et al. Effect of antiplatelet agent number, types, and pre-endoscopic management on postpolypectomy bleeding: Validation of endoscopy guidelines. Surg Endosc. 2021;35(1):317-25.
30. Gurbel PA et al. Randomized double-blind assessment of the ONSET and OFFSET of the antiplatelet effects of ticagrelor versus clopidogrel in patients with stable coronary artery disease: The ONSET/OFFSET study. Circulation. 2009;120(25):2577-85.
31. Eisenberg MJ et al. Safety of short-term discontinuation of antiplatelet therapy in patients with drug-eluting stents. Circulation. 2009;119(12):1634-42.
Antithrombotic therapy is increasingly used to either reduce the risk of or treat thromboembolic episodes in patients with various medical conditions such as ischemic and valvular heart disease, atrial fibrillation (AF), cerebrovascular disease, peripheral arterial disease, venous thromboembolism (VTE) and hypercoagulable diseases. Antithrombotics include medications classified as anticoagulants or antiplatelets. Anticoagulants work by interfering with the native clotting cascade and consist of four main classes: vitamin K antagonists (VKA), heparin derivatives, direct factor Xa inhibitors, and direct thrombin inhibitors. Direct oral anticoagulants (DOACs) refer to dabigatran (a direct thrombin inhibitor) and the factor Xa inhibitors (apixaban, rivaroxaban, and edoxaban).
Antiplatelets, on the other hand, work by decreasing platelet aggregation and thus preventing thrombus formation; they include P2Y12 receptor inhibitors, protease-activated receptor-1 inhibitors, glycoprotein IIb/IIIa receptor inhibitors, acetylsalicylic acid (ASA), and nonsteroidal anti-inflammatory drugs. All of these agents may directly cause or increase the risk of gastrointestinal (GI) bleeding from luminal sources such as ulcers or diverticula, as well as after endoscopic interventions such as polypectomy. However, there is also a risk of thromboembolic consequences if some of these agents are withheld. Thus, the management of patients receiving antithrombotic agents and undergoing GI endoscopy represents an important clinical challenge and something that every GI physician has to deal with routinely.
The goal of this review is to discuss the optimal strategy for managing antithrombotics in patients undergoing elective endoscopy based on current available evidence and published clinical guidelines.1-4 Much of our discussion will review recommendations from the recently published joint American College of Gastroenterology (ACG) and Canadian Association of Gastroenterology (CAG) guidelines on management of anticoagulants and antiplatelets in the periendoscopic period by Abraham et al.4
Factors that guide decision-making
The two most vital factors to consider prior to performing endoscopic procedures in patients receiving antithrombotic therapy are to assess the risk of bleeding associated with the procedure and to assess the risk of thromboembolism associated with the underlying medical condition for which the antithrombotic agents are being used. In addition, it is also important to keep in mind the individual characteristics of the antithrombotic agent(s) used when making these decisions.
Estimating procedure-related bleeding risk
Various endoscopic procedures have different risks of associated bleeding. Although guidelines from GI societies may differ when classifying procedures into low or high risk, it is important to know that most of the original data on postprocedural bleeding risks are from studies conducted in patients who are not on complex antithrombotic regimens and thus may not accurately reflect the bleeding risk of patients using newer antithrombotic therapies.1,4-7
Traditionally, some of the common low-risk procedures have included diagnostic EGD and colonoscopy with or without biopsy, ERCP without sphincterotomy, biliary stent placement, and push or balloon-assisted enteroscopy. On the other hand, endoscopic procedures associated with interventions are known to have higher bleeding risk, and other procedural factors can influence this risk as well.8 For example, polypectomy, one of the most common interventions during endoscopy, is associated with bleeding risk ranging from 0.3% to 10% depending on multiple factors including polyp size, location, morphology (nonpolypoid, sessile, pedunculated), resection technique (cold or hot forceps, cold or hot snare), and type of cautery used.9 For some procedures, such as routine screening colonoscopy, however, the preprocedure estimate of bleeding risk can be uncertain because it is unclear if a high risk intervention (e.g., polypectomy of large polyp) will be necessary. For example, in the most recent ACG/CAG guidelines, colonoscopy with polypectomy < 1cm is considered a low/moderate risk bleeding procedure, whereas polypectomy > 1cm is considered high risk for bleeding.4 In these situations, the management of antithrombotic medications may depend on the individual patient’s risk of thrombosis and the specific antithrombotic agent. In the example of a patient undergoing colonoscopy while on antithrombotic medications, the bleeding risk associated with polypectomy can potentially be reduced by procedural techniques such as preferential use of cold snare polypectomy. Further high-quality data on the optimal procedural technique to reduce postpolypectomy bleeding in patients on antithrombotic medications is needed to help guide management.
Estimating thromboembolic risk
The risk of thromboembolic events in patients who are withholding their antithrombotic therapy for an endoscopic procedure depends on their underlying condition and individual characteristics. In patients who are on antithrombotic therapy for stroke prevention in non-valvular AF, the risk of cerebral thromboembolism in these patients is predictable using the CHA2DS2Vasc index.10 This scoring index includes heart failure, hypertension, age 75 years or older, diabetes mellitus, prior stroke or transient ischemic attack (TIA), vascular disease, age 65-74 years, and sex categories.
Patients with previous VTE on anticoagulation or those who have mechanical heart valves may have different risk factors for thromboembolic episodes. Among patients with VTE, time from initial VTE, history of recurrent VTE with antithrombotic interruption, and presence of underlying thrombophilia are most predictive of future thromboembolic risk. And for patients with mechanical heart valves, presence of a mitral valve prosthesis, and the presence or absence of associated heart failure and AF determine the annual risk of thromboembolic events. Bioprosthetic valves are generally considered low risk.
In patients with coronary artery disease (CAD), high thrombosis risk scenarios with holding antiplatelets include patients within 3 months of an acute coronary syndrome (ACS) event, within 6 months of a drug-eluting stent (DES) placement, or within 1 month of a bare metal coronary stent (BMS) placement. In addition, patients with ACS that occurred within the past 12 months of DES placement or within 2 months of BMS placement are also considered high risk.11,12 Even beyond these periods, certain patients may still be at high risk of stent occlusion. In particular, patients with a prior history of stent occlusion, ACS or ST elevation myocardial infection, prior multivessel percutaneous coronary intervention, diabetes, renal failure, or diffuse CAD are at higher risk of stent occlusion or ACS events with alteration of antithrombotic therapy.13 Thus, modification of antithrombotic regimens in these patients should be cautiously approached.
Management of antithrombotics prior to elective endoscopy
In patients who need elective endoscopic procedures, if the indication for antithrombotic therapy is short-term, the procedure is probably best delayed until after that period.13 For patients on long-term or lifelong antithrombotic treatment, the decision to temporarily hold the treatment for endoscopy should occur after a discussion with the patient and all of the involved providers. In some high-risk patients, these agents cannot be interrupted; therefore, clinicians must carefully weigh the risks and benefits of the procedure before proceeding with endoscopy. For patients who are known to be undergoing an elective endoscopic procedure, antithrombotic medications may or may not need to be held prior to the procedure depending on the type of therapy. For example, according to the recent ACG/CAG guidelines, warfarin should be continued, whereas DOACs should be temporarily stopped for patients who are undergoing elective/planned endoscopic GI procedures.
Unfractionated heparin (UFH) administered as a continuous intravenous infusion can generally be held 3-4 hours before the procedure, given its short half-life. Low molecular weight heparin (LMWH), including enoxaparin and dalteparin, should be stopped 24 hours prior to the procedure.2,14 Fondaparinux is a synthetic X-a inhibitor that requires discontinuation at least 36 hours preceding a high risk procedure. For patients on warfarin who are undergoing elective endoscopic procedures that are low risk for inducing bleeding, warfarin can be continued, as opposed to temporarily interrupted, although the dose should be omitted the morning of the procedure.4 For those who are undergoing high-risk endoscopic procedures (including colonoscopy with possible polypectomy > 1 cm), 5 days of temporary interruption without periprocedural bridging is appropriate in most patients. This is contrary to previous guidelines, which had recommended bridging for patients with a CHA2DS2Vasc score ≥ 2. Recent impactful randomized trials (BRIDGE and PERIOP-2) have called into question the benefit of periprocedural bridging with LMWH. Avoiding bridging anticoagulation was generally found to be similar to bridging in regard to prevention of thromboembolic complications, but importantly was associated with a decreased risk of major bleeding.15,16 Of note, periprocedural bridging may still be appropriate in a small subset of patients, including those with mechanical valves, AF with CHADS2 score > 5, and previous thromboembolism during temporary interruption of VKAs. The decision to bridge or not should ideally be made in a multidisciplinary fashion.15-20
Data are lacking on the ideal strategy for periendoscopic DOAC management. As mentioned above, for patients on DOACs who are undergoing elective endoscopic GI procedures, temporarily interrupting DOACs rather than continuing them is recommended. Currently, there are no randomized controlled trials addressing the management of DOACs in the periendoscopic period. However, based on five cohort studies, the ideal duration of DOAC interruption before endoscopic procedures may be between 1 and 2 days, excluding the day of the procedure.21-25 This strategy allows for a short preprocedural duration of DOAC interruption and likely provides a balance between bleeding and thromboembolism risk. Importantly, there are no reliable laboratory assays to assess the anticoagulant effect of DOACs, and an individual patient’s degree of renal dysfunction may impact how long the DOAC should be held. In general, the anti-Xa drugs should be held for 1-2 days if the creatinine clearance (CrCl) is ≥ 60 mL/min, for 3 days if the CrCl is between 30 mL/min and 59 mL/min, and for 4 days if the CrCl is less than 30 mL/min.26 For edoxaban, the recommendation is to hold at least 24 hours before high-risk procedures. The recommendation for stopping dabigatran is 2-3 days before a high-risk procedure in patients with CrCl more than 80 mL/min, 3-4 days prior if between 30 and 49 mL/min, and 4-6 days prior if less than 30 mL/min respectively.27
In regard to antiplatelet management, ASA and the P2Y12 receptor inhibitors (e.g. clopidogrel, prasugrel, and ticagrelor) are the most commonly utilized antiplatelets in patients undergoing endoscopic procedures. For patients who are on ASA monotherapy, whether 81 mg or 325 mg daily, for secondary cardiovascular prevention, no interruption of ASA therapy is necessary for elective procedures. The benefit of ASA for secondary cardiovascular prevention and the possible reduction in thrombotic events seen in RCTs of nonendoscopic surgical procedures is well known. However, there may be certain exceptions in which aspirin should be temporarily held. For example, short-term interruption of ASA could be considered in high risk procedures such as biliary or pancreatic sphincterotomy, ampullectomy, and peroral endoscopic myotomy. For patients on single antiplatelet therapy with a P2Y12 receptor inhibitor who are undergoing elective endoscopic GI procedures, the recent CAG/ACG guidelines did not provide a clear recommendation for or against temporary interruption of the P2Y12 receptor inhibitor. Although interruption of a P2Y12 receptor inhibitor should theoretically decrease a patient’s risk of bleeding, the available evidence reported a nonsignificant increased bleeding risk in patients who stop a P2Y12 receptor inhibitor for an elective endoscopic procedure compared with those who continue the medication.28,29 Therefore, until further data are available, for patients on P2Y12 receptor monotherapy, a reasonable strategy would be to temporarily hold therapy prior to high risk endoscopic procedures, assuming the patients are not at high cardiovascular risk. Clopidogrel and prasugrel have to be stopped 5-7 days prior to allow normal platelet aggregation to resume as opposed to ticagrelor, a reversible P2Y12 receptor inhibitor that can be stopped 3-5 days prior.30
Lastly, for patients who are on dual antiplatelet therapy (DAPT) for secondary prevention, continuation of ASA and temporary interruption of the P2Y12 receptor inhibitor is recommended while undergoing elective endoscopy. Studies have shown that those who discontinued both had a much higher incidence of stent thrombosis compared with those who remained on aspirin alone.4,28,31
Resumption of antithrombotic therapy after endoscopy
In general, antithrombotic therapy should be resumed upon completion of the procedure unless there remains a persistent risk of major bleeding.1,14 This consensus is based on studies available on warfarin and heparin products, with minimal literature available regarding the resumption of DOACs. The benefits of immediate re-initiation of antithrombotic therapy for the prevention of thromboembolic events should be weighed against the risk of hemorrhage associated with the specific agent, the time to onset of the medication, and procedure-specific circumstances. For the small subset of patients on warfarin with a high risk of thromboembolism (e.g., mechanical heart valve), bridging with LMWH should be started at the earliest possible time when there is no risk of major bleeding and continued until the international normalized ratio (INR) reaches a therapeutic level with warfarin. For patients at a lower risk of thromboembolism, warfarin should be restarted within 24 hours of the procedure. In addition, because of the shorter duration of DOACs, if treatment with these agents cannot resume within 24 hours of a high-risk procedure, bridge therapy should be considered with UFH or LMWH in patients with a high risk of thrombosis.18 In patients receiving DOACs for stroke prophylaxis in AF, the DOACS can be safely resumed 1 day after low-risk procedures and 2-3 days after high-risk procedures without the need for bridging.25 All antiplatelet agents should be resumed as soon as hemostasis is achieved.
Conclusion
Antithrombotic therapy is increasingly used given the aging population, widespread burden of cardiovascular comorbidities, and expanding indications for classes of medications such as direct oral anticoagulants. Given the association with antithrombotic medications and gastrointestinal bleeding, it is essential for gastroenterologists to understand the importance, necessity, and timing when holding these medications for endoscopic procedures. Even with the practice guidelines available today to help clinicians navigate certain situations, each patient’s antithrombotic management may be different, and communication with the prescribing physicians and including patients in the decision-making process is essential before planned procedures.
Dr. Wang is a gastroenterology fellow at the University of Chicago. Dr. Sengupta is an associate professor at the University of Chicago. They reported no funding or conflicts of interest.
References
1. ASGE Standards of Practice Committee, Acosta RD et al. The management of antithrombotic agents for patients undergoing GI endoscopy. Gastrointest Endosc. 2016;83(1):3-16.
2. Veitch AM et al. Endoscopy in patients on antiplatelet or anticoagulant therapy, including direct oral anticoagulants: British Society of Gastroenterology (BSG) and European Society of Gastrointestinal Endoscopy (ESGE) guidelines. Endoscopy. 2016;48(4):c1. doi: 10.1055/s-0042-122686.
3. Chan FKL et al. Management of patients on antithrombotic agents undergoing emergency and elective endoscopy: Joint Asian Pacific Association of Gastroenterology (APAGE) and Asian Pacific Society for Digestive Endoscopy (APSDE) practice guidelines. Gut. 2018;67(3):405-17.
4. Abraham NS et al. American College of Gastroenterology – Canadian Association of Gastroenterology clinical practice guideline: Management of anticoagulants and antiplatelets during acute gastrointestinal bleeding and the periendoscopic period. Am J Gastroenterol. 2022;117(4):542-58.
5. Boustière C et al. Endoscopy and antiplatelet agents. European Society of Gastrointestinal Endoscopy (ESGE) guideline. Endoscopy. 2011;43(5):445-61.
6. Fujimoto K et al. Guidelines for gastroenterological endoscopy in patients undergoing antithrombotic treatment. Dig Endosc. 2014;26(1):1-14.
7. Wilke T et al. Patient preferences for oral anticoagulation therapy in atrial fibrillation: A systematic literature review. Patient 2017;10(1):17-37.
8. Gerson LB et al. Adverse events associated with anticoagulation therapy in the periendoscopic period. Gastrointest Endosc. 2010 Jun;71(7):1211-17.e2.
9. Horiuchi A et al. Removal of small colorectal polyps in anticoagulated patients: A prospective randomized comparison of cold snare and conventional polypectomy. Gastrointest Endosc 2014;79(3):417-23.
10. Lip GYH et al. Refining clinical risk stratification for predicting stroke and thromboembolism in atrial fibrillation using a novel risk factor-based approach: The euro heart survey on atrial fibrillation. Chest. 2010;137(2):263-72.
11. 2012 Writing Committee Members, Jneid H et al. 2012 ACCF/AHA focused update of the guideline for the management of patients with unstable angina/non-ST-elevation myocardial infarction (Updating the 2007 guideline and replacing the 2011 focused update): A report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines. Circulation. 2012;126(7):875-910.
12. Douketis JD et al. Perioperative management of antithrombotic therapy: Antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2012 Feb;141(2 Suppl):e326S-e350S.
13. Becker RC et al. Management of platelet-directed pharmacotherapy in patients with atherosclerotic coronary artery disease undergoing elective endoscopic gastrointestinal procedures. J Am Coll Cardiol. 2009;54(24):2261-76.
14. Kwok A and Faigel DO. Management of anticoagulation before and after gastrointestinal endoscopy. Am J Gastroenterol. 2009;104(12):3085-97; quiz 3098.
15. Douketis JD et al. Perioperative bridging anticoagulation in patients with atrial fibrillation. N Engl J Med. 2015;373(9):823-33.
16. Kovacs MJ et al. Postoperative low molecular weight heparin bridging treatment for patients at high risk of arterial thromboembolism (PERIOP2): Double blind randomised controlled trial. BMJ 2021;373:n1205.
17. Tafur A and Douketis J. Perioperative management of anticoagulant and antiplatelet therapy. Heart 2018;104(17):1461-7.
18. Kato M et al. Guidelines for gastroenterological endoscopy in patients undergoing antithrombotic treatment: 2017 appendix on anticoagulants including direct oral anticoagulants. Dig Endosc. 2018;30(4):433-40.
19. Inoue T et al. Clinical features of postpolypectomy bleeding associated with heparin bridge therapy. Dig Endosc. 2014;26(2):243-9.
20. Takeuchi Y et al. Continuous anticoagulation and cold snare polypectomy versus heparin bridging and hot snare polypectomy in patients on anticoagulants with subcentimeter polyps: A randomized controlled trial. Ann Intern Med. 2019;171(4):229-37.
21. Ara N et al. Prospective analysis of risk for bleeding after endoscopic biopsy without cessation of antithrombotics in Japan. Dig Endosc. 2015;27(4):458-64.
22. Yanagisawa N et al. Postpolypectomy bleeding and thromboembolism risks associated with warfarin vs. direct oral anticoagulants. World J Gastroenterol. 2018;24(14):1540-9.
23. Arimoto J et al. Safety of cold snare polypectomy in patients receiving treatment with antithrombotic agents. Dig Dis Sci. 2019;64(11):3247-55.
24. Heublein V et al. Gastrointestinal endoscopy in patients receiving novel direct oral anticoagulants: Results from the prospective Dresden NOAC registry. J Gastroenterol. 2018;53(2):236-46.
25. Douketis JD et al. Perioperative management of patients with atrial fibrillation receiving a direct oral anticoagulant. JAMA Intern Med. 2019;179(11):1469-78.
26. Dubois V et al. Perioperative management of patients on direct oral anticoagulants. Thromb J. 2017;15:14.
27. Weitz JI et al. Periprocedural management and approach to bleeding in patients taking dabigatran. Circulation. 2012 Nov 13;126(20):2428-32.
28. Chan FKL et al. Risk of postpolypectomy bleeding with uninterrupted clopidogrel therapy in an industry-independent, double-blind, randomized trial. Gastroenterology. 2019;156(4):918-25.
29. Watanabe K et al. Effect of antiplatelet agent number, types, and pre-endoscopic management on postpolypectomy bleeding: Validation of endoscopy guidelines. Surg Endosc. 2021;35(1):317-25.
30. Gurbel PA et al. Randomized double-blind assessment of the ONSET and OFFSET of the antiplatelet effects of ticagrelor versus clopidogrel in patients with stable coronary artery disease: The ONSET/OFFSET study. Circulation. 2009;120(25):2577-85.
31. Eisenberg MJ et al. Safety of short-term discontinuation of antiplatelet therapy in patients with drug-eluting stents. Circulation. 2009;119(12):1634-42.
Antithrombotic therapy is increasingly used to either reduce the risk of or treat thromboembolic episodes in patients with various medical conditions such as ischemic and valvular heart disease, atrial fibrillation (AF), cerebrovascular disease, peripheral arterial disease, venous thromboembolism (VTE) and hypercoagulable diseases. Antithrombotics include medications classified as anticoagulants or antiplatelets. Anticoagulants work by interfering with the native clotting cascade and consist of four main classes: vitamin K antagonists (VKA), heparin derivatives, direct factor Xa inhibitors, and direct thrombin inhibitors. Direct oral anticoagulants (DOACs) refer to dabigatran (a direct thrombin inhibitor) and the factor Xa inhibitors (apixaban, rivaroxaban, and edoxaban).
Antiplatelets, on the other hand, work by decreasing platelet aggregation and thus preventing thrombus formation; they include P2Y12 receptor inhibitors, protease-activated receptor-1 inhibitors, glycoprotein IIb/IIIa receptor inhibitors, acetylsalicylic acid (ASA), and nonsteroidal anti-inflammatory drugs. All of these agents may directly cause or increase the risk of gastrointestinal (GI) bleeding from luminal sources such as ulcers or diverticula, as well as after endoscopic interventions such as polypectomy. However, there is also a risk of thromboembolic consequences if some of these agents are withheld. Thus, the management of patients receiving antithrombotic agents and undergoing GI endoscopy represents an important clinical challenge and something that every GI physician has to deal with routinely.
The goal of this review is to discuss the optimal strategy for managing antithrombotics in patients undergoing elective endoscopy based on current available evidence and published clinical guidelines.1-4 Much of our discussion will review recommendations from the recently published joint American College of Gastroenterology (ACG) and Canadian Association of Gastroenterology (CAG) guidelines on management of anticoagulants and antiplatelets in the periendoscopic period by Abraham et al.4
Factors that guide decision-making
The two most vital factors to consider prior to performing endoscopic procedures in patients receiving antithrombotic therapy are to assess the risk of bleeding associated with the procedure and to assess the risk of thromboembolism associated with the underlying medical condition for which the antithrombotic agents are being used. In addition, it is also important to keep in mind the individual characteristics of the antithrombotic agent(s) used when making these decisions.
Estimating procedure-related bleeding risk
Various endoscopic procedures have different risks of associated bleeding. Although guidelines from GI societies may differ when classifying procedures into low or high risk, it is important to know that most of the original data on postprocedural bleeding risks are from studies conducted in patients who are not on complex antithrombotic regimens and thus may not accurately reflect the bleeding risk of patients using newer antithrombotic therapies.1,4-7
Traditionally, some of the common low-risk procedures have included diagnostic EGD and colonoscopy with or without biopsy, ERCP without sphincterotomy, biliary stent placement, and push or balloon-assisted enteroscopy. On the other hand, endoscopic procedures associated with interventions are known to have higher bleeding risk, and other procedural factors can influence this risk as well.8 For example, polypectomy, one of the most common interventions during endoscopy, is associated with bleeding risk ranging from 0.3% to 10% depending on multiple factors including polyp size, location, morphology (nonpolypoid, sessile, pedunculated), resection technique (cold or hot forceps, cold or hot snare), and type of cautery used.9 For some procedures, such as routine screening colonoscopy, however, the preprocedure estimate of bleeding risk can be uncertain because it is unclear if a high risk intervention (e.g., polypectomy of large polyp) will be necessary. For example, in the most recent ACG/CAG guidelines, colonoscopy with polypectomy < 1cm is considered a low/moderate risk bleeding procedure, whereas polypectomy > 1cm is considered high risk for bleeding.4 In these situations, the management of antithrombotic medications may depend on the individual patient’s risk of thrombosis and the specific antithrombotic agent. In the example of a patient undergoing colonoscopy while on antithrombotic medications, the bleeding risk associated with polypectomy can potentially be reduced by procedural techniques such as preferential use of cold snare polypectomy. Further high-quality data on the optimal procedural technique to reduce postpolypectomy bleeding in patients on antithrombotic medications is needed to help guide management.
Estimating thromboembolic risk
The risk of thromboembolic events in patients who are withholding their antithrombotic therapy for an endoscopic procedure depends on their underlying condition and individual characteristics. In patients who are on antithrombotic therapy for stroke prevention in non-valvular AF, the risk of cerebral thromboembolism in these patients is predictable using the CHA2DS2Vasc index.10 This scoring index includes heart failure, hypertension, age 75 years or older, diabetes mellitus, prior stroke or transient ischemic attack (TIA), vascular disease, age 65-74 years, and sex categories.
Patients with previous VTE on anticoagulation or those who have mechanical heart valves may have different risk factors for thromboembolic episodes. Among patients with VTE, time from initial VTE, history of recurrent VTE with antithrombotic interruption, and presence of underlying thrombophilia are most predictive of future thromboembolic risk. And for patients with mechanical heart valves, presence of a mitral valve prosthesis, and the presence or absence of associated heart failure and AF determine the annual risk of thromboembolic events. Bioprosthetic valves are generally considered low risk.
In patients with coronary artery disease (CAD), high thrombosis risk scenarios with holding antiplatelets include patients within 3 months of an acute coronary syndrome (ACS) event, within 6 months of a drug-eluting stent (DES) placement, or within 1 month of a bare metal coronary stent (BMS) placement. In addition, patients with ACS that occurred within the past 12 months of DES placement or within 2 months of BMS placement are also considered high risk.11,12 Even beyond these periods, certain patients may still be at high risk of stent occlusion. In particular, patients with a prior history of stent occlusion, ACS or ST elevation myocardial infection, prior multivessel percutaneous coronary intervention, diabetes, renal failure, or diffuse CAD are at higher risk of stent occlusion or ACS events with alteration of antithrombotic therapy.13 Thus, modification of antithrombotic regimens in these patients should be cautiously approached.
Management of antithrombotics prior to elective endoscopy
In patients who need elective endoscopic procedures, if the indication for antithrombotic therapy is short-term, the procedure is probably best delayed until after that period.13 For patients on long-term or lifelong antithrombotic treatment, the decision to temporarily hold the treatment for endoscopy should occur after a discussion with the patient and all of the involved providers. In some high-risk patients, these agents cannot be interrupted; therefore, clinicians must carefully weigh the risks and benefits of the procedure before proceeding with endoscopy. For patients who are known to be undergoing an elective endoscopic procedure, antithrombotic medications may or may not need to be held prior to the procedure depending on the type of therapy. For example, according to the recent ACG/CAG guidelines, warfarin should be continued, whereas DOACs should be temporarily stopped for patients who are undergoing elective/planned endoscopic GI procedures.
Unfractionated heparin (UFH) administered as a continuous intravenous infusion can generally be held 3-4 hours before the procedure, given its short half-life. Low molecular weight heparin (LMWH), including enoxaparin and dalteparin, should be stopped 24 hours prior to the procedure.2,14 Fondaparinux is a synthetic X-a inhibitor that requires discontinuation at least 36 hours preceding a high risk procedure. For patients on warfarin who are undergoing elective endoscopic procedures that are low risk for inducing bleeding, warfarin can be continued, as opposed to temporarily interrupted, although the dose should be omitted the morning of the procedure.4 For those who are undergoing high-risk endoscopic procedures (including colonoscopy with possible polypectomy > 1 cm), 5 days of temporary interruption without periprocedural bridging is appropriate in most patients. This is contrary to previous guidelines, which had recommended bridging for patients with a CHA2DS2Vasc score ≥ 2. Recent impactful randomized trials (BRIDGE and PERIOP-2) have called into question the benefit of periprocedural bridging with LMWH. Avoiding bridging anticoagulation was generally found to be similar to bridging in regard to prevention of thromboembolic complications, but importantly was associated with a decreased risk of major bleeding.15,16 Of note, periprocedural bridging may still be appropriate in a small subset of patients, including those with mechanical valves, AF with CHADS2 score > 5, and previous thromboembolism during temporary interruption of VKAs. The decision to bridge or not should ideally be made in a multidisciplinary fashion.15-20
Data are lacking on the ideal strategy for periendoscopic DOAC management. As mentioned above, for patients on DOACs who are undergoing elective endoscopic GI procedures, temporarily interrupting DOACs rather than continuing them is recommended. Currently, there are no randomized controlled trials addressing the management of DOACs in the periendoscopic period. However, based on five cohort studies, the ideal duration of DOAC interruption before endoscopic procedures may be between 1 and 2 days, excluding the day of the procedure.21-25 This strategy allows for a short preprocedural duration of DOAC interruption and likely provides a balance between bleeding and thromboembolism risk. Importantly, there are no reliable laboratory assays to assess the anticoagulant effect of DOACs, and an individual patient’s degree of renal dysfunction may impact how long the DOAC should be held. In general, the anti-Xa drugs should be held for 1-2 days if the creatinine clearance (CrCl) is ≥ 60 mL/min, for 3 days if the CrCl is between 30 mL/min and 59 mL/min, and for 4 days if the CrCl is less than 30 mL/min.26 For edoxaban, the recommendation is to hold at least 24 hours before high-risk procedures. The recommendation for stopping dabigatran is 2-3 days before a high-risk procedure in patients with CrCl more than 80 mL/min, 3-4 days prior if between 30 and 49 mL/min, and 4-6 days prior if less than 30 mL/min respectively.27
In regard to antiplatelet management, ASA and the P2Y12 receptor inhibitors (e.g. clopidogrel, prasugrel, and ticagrelor) are the most commonly utilized antiplatelets in patients undergoing endoscopic procedures. For patients who are on ASA monotherapy, whether 81 mg or 325 mg daily, for secondary cardiovascular prevention, no interruption of ASA therapy is necessary for elective procedures. The benefit of ASA for secondary cardiovascular prevention and the possible reduction in thrombotic events seen in RCTs of nonendoscopic surgical procedures is well known. However, there may be certain exceptions in which aspirin should be temporarily held. For example, short-term interruption of ASA could be considered in high risk procedures such as biliary or pancreatic sphincterotomy, ampullectomy, and peroral endoscopic myotomy. For patients on single antiplatelet therapy with a P2Y12 receptor inhibitor who are undergoing elective endoscopic GI procedures, the recent CAG/ACG guidelines did not provide a clear recommendation for or against temporary interruption of the P2Y12 receptor inhibitor. Although interruption of a P2Y12 receptor inhibitor should theoretically decrease a patient’s risk of bleeding, the available evidence reported a nonsignificant increased bleeding risk in patients who stop a P2Y12 receptor inhibitor for an elective endoscopic procedure compared with those who continue the medication.28,29 Therefore, until further data are available, for patients on P2Y12 receptor monotherapy, a reasonable strategy would be to temporarily hold therapy prior to high risk endoscopic procedures, assuming the patients are not at high cardiovascular risk. Clopidogrel and prasugrel have to be stopped 5-7 days prior to allow normal platelet aggregation to resume as opposed to ticagrelor, a reversible P2Y12 receptor inhibitor that can be stopped 3-5 days prior.30
Lastly, for patients who are on dual antiplatelet therapy (DAPT) for secondary prevention, continuation of ASA and temporary interruption of the P2Y12 receptor inhibitor is recommended while undergoing elective endoscopy. Studies have shown that those who discontinued both had a much higher incidence of stent thrombosis compared with those who remained on aspirin alone.4,28,31
Resumption of antithrombotic therapy after endoscopy
In general, antithrombotic therapy should be resumed upon completion of the procedure unless there remains a persistent risk of major bleeding.1,14 This consensus is based on studies available on warfarin and heparin products, with minimal literature available regarding the resumption of DOACs. The benefits of immediate re-initiation of antithrombotic therapy for the prevention of thromboembolic events should be weighed against the risk of hemorrhage associated with the specific agent, the time to onset of the medication, and procedure-specific circumstances. For the small subset of patients on warfarin with a high risk of thromboembolism (e.g., mechanical heart valve), bridging with LMWH should be started at the earliest possible time when there is no risk of major bleeding and continued until the international normalized ratio (INR) reaches a therapeutic level with warfarin. For patients at a lower risk of thromboembolism, warfarin should be restarted within 24 hours of the procedure. In addition, because of the shorter duration of DOACs, if treatment with these agents cannot resume within 24 hours of a high-risk procedure, bridge therapy should be considered with UFH or LMWH in patients with a high risk of thrombosis.18 In patients receiving DOACs for stroke prophylaxis in AF, the DOACS can be safely resumed 1 day after low-risk procedures and 2-3 days after high-risk procedures without the need for bridging.25 All antiplatelet agents should be resumed as soon as hemostasis is achieved.
Conclusion
Antithrombotic therapy is increasingly used given the aging population, widespread burden of cardiovascular comorbidities, and expanding indications for classes of medications such as direct oral anticoagulants. Given the association with antithrombotic medications and gastrointestinal bleeding, it is essential for gastroenterologists to understand the importance, necessity, and timing when holding these medications for endoscopic procedures. Even with the practice guidelines available today to help clinicians navigate certain situations, each patient’s antithrombotic management may be different, and communication with the prescribing physicians and including patients in the decision-making process is essential before planned procedures.
Dr. Wang is a gastroenterology fellow at the University of Chicago. Dr. Sengupta is an associate professor at the University of Chicago. They reported no funding or conflicts of interest.
References
1. ASGE Standards of Practice Committee, Acosta RD et al. The management of antithrombotic agents for patients undergoing GI endoscopy. Gastrointest Endosc. 2016;83(1):3-16.
2. Veitch AM et al. Endoscopy in patients on antiplatelet or anticoagulant therapy, including direct oral anticoagulants: British Society of Gastroenterology (BSG) and European Society of Gastrointestinal Endoscopy (ESGE) guidelines. Endoscopy. 2016;48(4):c1. doi: 10.1055/s-0042-122686.
3. Chan FKL et al. Management of patients on antithrombotic agents undergoing emergency and elective endoscopy: Joint Asian Pacific Association of Gastroenterology (APAGE) and Asian Pacific Society for Digestive Endoscopy (APSDE) practice guidelines. Gut. 2018;67(3):405-17.
4. Abraham NS et al. American College of Gastroenterology – Canadian Association of Gastroenterology clinical practice guideline: Management of anticoagulants and antiplatelets during acute gastrointestinal bleeding and the periendoscopic period. Am J Gastroenterol. 2022;117(4):542-58.
5. Boustière C et al. Endoscopy and antiplatelet agents. European Society of Gastrointestinal Endoscopy (ESGE) guideline. Endoscopy. 2011;43(5):445-61.
6. Fujimoto K et al. Guidelines for gastroenterological endoscopy in patients undergoing antithrombotic treatment. Dig Endosc. 2014;26(1):1-14.
7. Wilke T et al. Patient preferences for oral anticoagulation therapy in atrial fibrillation: A systematic literature review. Patient 2017;10(1):17-37.
8. Gerson LB et al. Adverse events associated with anticoagulation therapy in the periendoscopic period. Gastrointest Endosc. 2010 Jun;71(7):1211-17.e2.
9. Horiuchi A et al. Removal of small colorectal polyps in anticoagulated patients: A prospective randomized comparison of cold snare and conventional polypectomy. Gastrointest Endosc 2014;79(3):417-23.
10. Lip GYH et al. Refining clinical risk stratification for predicting stroke and thromboembolism in atrial fibrillation using a novel risk factor-based approach: The euro heart survey on atrial fibrillation. Chest. 2010;137(2):263-72.
11. 2012 Writing Committee Members, Jneid H et al. 2012 ACCF/AHA focused update of the guideline for the management of patients with unstable angina/non-ST-elevation myocardial infarction (Updating the 2007 guideline and replacing the 2011 focused update): A report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines. Circulation. 2012;126(7):875-910.
12. Douketis JD et al. Perioperative management of antithrombotic therapy: Antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2012 Feb;141(2 Suppl):e326S-e350S.
13. Becker RC et al. Management of platelet-directed pharmacotherapy in patients with atherosclerotic coronary artery disease undergoing elective endoscopic gastrointestinal procedures. J Am Coll Cardiol. 2009;54(24):2261-76.
14. Kwok A and Faigel DO. Management of anticoagulation before and after gastrointestinal endoscopy. Am J Gastroenterol. 2009;104(12):3085-97; quiz 3098.
15. Douketis JD et al. Perioperative bridging anticoagulation in patients with atrial fibrillation. N Engl J Med. 2015;373(9):823-33.
16. Kovacs MJ et al. Postoperative low molecular weight heparin bridging treatment for patients at high risk of arterial thromboembolism (PERIOP2): Double blind randomised controlled trial. BMJ 2021;373:n1205.
17. Tafur A and Douketis J. Perioperative management of anticoagulant and antiplatelet therapy. Heart 2018;104(17):1461-7.
18. Kato M et al. Guidelines for gastroenterological endoscopy in patients undergoing antithrombotic treatment: 2017 appendix on anticoagulants including direct oral anticoagulants. Dig Endosc. 2018;30(4):433-40.
19. Inoue T et al. Clinical features of postpolypectomy bleeding associated with heparin bridge therapy. Dig Endosc. 2014;26(2):243-9.
20. Takeuchi Y et al. Continuous anticoagulation and cold snare polypectomy versus heparin bridging and hot snare polypectomy in patients on anticoagulants with subcentimeter polyps: A randomized controlled trial. Ann Intern Med. 2019;171(4):229-37.
21. Ara N et al. Prospective analysis of risk for bleeding after endoscopic biopsy without cessation of antithrombotics in Japan. Dig Endosc. 2015;27(4):458-64.
22. Yanagisawa N et al. Postpolypectomy bleeding and thromboembolism risks associated with warfarin vs. direct oral anticoagulants. World J Gastroenterol. 2018;24(14):1540-9.
23. Arimoto J et al. Safety of cold snare polypectomy in patients receiving treatment with antithrombotic agents. Dig Dis Sci. 2019;64(11):3247-55.
24. Heublein V et al. Gastrointestinal endoscopy in patients receiving novel direct oral anticoagulants: Results from the prospective Dresden NOAC registry. J Gastroenterol. 2018;53(2):236-46.
25. Douketis JD et al. Perioperative management of patients with atrial fibrillation receiving a direct oral anticoagulant. JAMA Intern Med. 2019;179(11):1469-78.
26. Dubois V et al. Perioperative management of patients on direct oral anticoagulants. Thromb J. 2017;15:14.
27. Weitz JI et al. Periprocedural management and approach to bleeding in patients taking dabigatran. Circulation. 2012 Nov 13;126(20):2428-32.
28. Chan FKL et al. Risk of postpolypectomy bleeding with uninterrupted clopidogrel therapy in an industry-independent, double-blind, randomized trial. Gastroenterology. 2019;156(4):918-25.
29. Watanabe K et al. Effect of antiplatelet agent number, types, and pre-endoscopic management on postpolypectomy bleeding: Validation of endoscopy guidelines. Surg Endosc. 2021;35(1):317-25.
30. Gurbel PA et al. Randomized double-blind assessment of the ONSET and OFFSET of the antiplatelet effects of ticagrelor versus clopidogrel in patients with stable coronary artery disease: The ONSET/OFFSET study. Circulation. 2009;120(25):2577-85.
31. Eisenberg MJ et al. Safety of short-term discontinuation of antiplatelet therapy in patients with drug-eluting stents. Circulation. 2009;119(12):1634-42.
AGA News – November 2022
Vaccine recommendations for your patients with IBD
It’s cold and flu season – are your patients with inflammatory bowel disease (IBD) properly informed about increased risk of infections?
It is especially important for patients with IBD to receive the flu vaccine every year. With IBD, you can only get the shot (and not the spray in the nose).
The AGA GI Patient Center provides additional recommendations about vaccines in adults with IBD. Talk to your patients with IBD about what vaccines are needed for their treatment regimen, age and sex.
Review vaccines and vaccine-preventable diseases the patient had when first diagnosed with IBD, no matter the age and continue discussing vaccines during regular health care visits.
Give patients vaccine(s) for infections they are not immune as soon as possible.
Make sure patients are up to date or receive any live vaccines prior to starting some immunosuppressive treatments, such as biologics.
Help drive HCV testing, treatment, and eradication
AGA has been working with the Centers for Medicare & Medicaid Services and the Centers for Disease Control and Prevention to help drive the national priority for hepatitis C virus (HCV) testing, treatment and eradication.
Updates to QPP measure 400
In July 2022, CMS contacted AGA to modify measure 400 – to update the coverage for one-time screening for HCV to include a referral for treatment for patients with positive antibodies. CMS also advised that confirmation of eradication is a priority and we have started working with the CDC to modify AGA’s sustained virologic response measure for future consideration in the Quality Payment Program.
The modifications to measure 400 have been drafted and given the substantial changes to the measure specification, the measure needs to be retested and submitted to the National Quality Forum for consideration by the Measures Application Partnership. The CMS contractor for this project, Mathematica, will be leading this testing initiative and selected test sites will qualify for up to $2,000 to participate.
Additionally, there will be a second phase of testing to use deidentified patient-level data to assess the measure’s validity and reliability, which will be contracted separately. Our hope is that testing sites recruited for the first phase of testing will stay on through the second phase.
Participants in the second phase of testing are expected to have at least 2 years of patient data available containing data elements needed to calculate the measure. Ideally, each of the participating clinicians at the prospective testing sites would see at least 40 confirmed HCV-positive cases annually.
Vaccine recommendations for your patients with IBD
It’s cold and flu season – are your patients with inflammatory bowel disease (IBD) properly informed about increased risk of infections?
It is especially important for patients with IBD to receive the flu vaccine every year. With IBD, you can only get the shot (and not the spray in the nose).
The AGA GI Patient Center provides additional recommendations about vaccines in adults with IBD. Talk to your patients with IBD about what vaccines are needed for their treatment regimen, age and sex.
Review vaccines and vaccine-preventable diseases the patient had when first diagnosed with IBD, no matter the age and continue discussing vaccines during regular health care visits.
Give patients vaccine(s) for infections they are not immune as soon as possible.
Make sure patients are up to date or receive any live vaccines prior to starting some immunosuppressive treatments, such as biologics.
Help drive HCV testing, treatment, and eradication
AGA has been working with the Centers for Medicare & Medicaid Services and the Centers for Disease Control and Prevention to help drive the national priority for hepatitis C virus (HCV) testing, treatment and eradication.
Updates to QPP measure 400
In July 2022, CMS contacted AGA to modify measure 400 – to update the coverage for one-time screening for HCV to include a referral for treatment for patients with positive antibodies. CMS also advised that confirmation of eradication is a priority and we have started working with the CDC to modify AGA’s sustained virologic response measure for future consideration in the Quality Payment Program.
The modifications to measure 400 have been drafted and given the substantial changes to the measure specification, the measure needs to be retested and submitted to the National Quality Forum for consideration by the Measures Application Partnership. The CMS contractor for this project, Mathematica, will be leading this testing initiative and selected test sites will qualify for up to $2,000 to participate.
Additionally, there will be a second phase of testing to use deidentified patient-level data to assess the measure’s validity and reliability, which will be contracted separately. Our hope is that testing sites recruited for the first phase of testing will stay on through the second phase.
Participants in the second phase of testing are expected to have at least 2 years of patient data available containing data elements needed to calculate the measure. Ideally, each of the participating clinicians at the prospective testing sites would see at least 40 confirmed HCV-positive cases annually.
Vaccine recommendations for your patients with IBD
It’s cold and flu season – are your patients with inflammatory bowel disease (IBD) properly informed about increased risk of infections?
It is especially important for patients with IBD to receive the flu vaccine every year. With IBD, you can only get the shot (and not the spray in the nose).
The AGA GI Patient Center provides additional recommendations about vaccines in adults with IBD. Talk to your patients with IBD about what vaccines are needed for their treatment regimen, age and sex.
Review vaccines and vaccine-preventable diseases the patient had when first diagnosed with IBD, no matter the age and continue discussing vaccines during regular health care visits.
Give patients vaccine(s) for infections they are not immune as soon as possible.
Make sure patients are up to date or receive any live vaccines prior to starting some immunosuppressive treatments, such as biologics.
Help drive HCV testing, treatment, and eradication
AGA has been working with the Centers for Medicare & Medicaid Services and the Centers for Disease Control and Prevention to help drive the national priority for hepatitis C virus (HCV) testing, treatment and eradication.
Updates to QPP measure 400
In July 2022, CMS contacted AGA to modify measure 400 – to update the coverage for one-time screening for HCV to include a referral for treatment for patients with positive antibodies. CMS also advised that confirmation of eradication is a priority and we have started working with the CDC to modify AGA’s sustained virologic response measure for future consideration in the Quality Payment Program.
The modifications to measure 400 have been drafted and given the substantial changes to the measure specification, the measure needs to be retested and submitted to the National Quality Forum for consideration by the Measures Application Partnership. The CMS contractor for this project, Mathematica, will be leading this testing initiative and selected test sites will qualify for up to $2,000 to participate.
Additionally, there will be a second phase of testing to use deidentified patient-level data to assess the measure’s validity and reliability, which will be contracted separately. Our hope is that testing sites recruited for the first phase of testing will stay on through the second phase.
Participants in the second phase of testing are expected to have at least 2 years of patient data available containing data elements needed to calculate the measure. Ideally, each of the participating clinicians at the prospective testing sites would see at least 40 confirmed HCV-positive cases annually.
Supporting career development for women in gastroenterology
When I was in fellowship in the late 1990s, it was rare to see women at many of the big gastroenterology conferences. And in terms of presentations, there was maybe one session led by or for women at lunchtime. These conferences were the only events I had ever been to where the line for the men’s room was longer than the line for the women’s room.
Over the years, the lines for the women’s room have gotten longer, and the sessions led by female gastroenterologists have grown exponentially. However, women are still underrepresented in our field. Two out of five GI fellows are women, but women constitute less than 18% of practicing gastroenterologists. And the number of women in leadership positions is even lower.
Women in medicine face many challenges
According to a report in JAMA Network Open, women have lower starting salaries more than 90% of the time, which can create income disparities in earning potential throughout our entire careers.
Other studies suggest that female physicians also spend more time with patients and answering messages from patients and colleagues as well. This extra time, although it is done in small increments, adds up quickly and could suggest the pay gap between women and men is wider than we think.
Of course, female physicians still spend more time parenting children and doing household labor. A study found that female physicians spent 8.5 hours more per week on activities that support the family and household.
We’ve been discussing equity for women in medicine, and in the workplace, for decades. But events over the past several years – such as the killing of George Floyd and the formation of the #MeToo movement in response to workplace sexual harassment – have accelerated a paradigm shift in how organizations are focusing on diversity, equity, and inclusion (DEI) and creating cultures that support leadership development for women.
The Gastro Health Women’s Network
In 2020, the leadership of Gastro Health reiterated its commitment to fight discrimination and support equity by sending out a company-wide correspondence that encouraged us to be good stewards within our communities during these turbulent times.
This led to the development of the Gastro Health DEI Council and the Gastro Health Women’s Network, led by Dr. Asma Khapra and based on the framework developed by Dr. Dawn Sears. The programs developed by Dr. Sears are focused on facilitating authentic and supportive relationships, and they helped us create a network for women focused on recruitment, mentorship and retention, networking and social events, and leadership development.
Our network started with a meet & greet, inviting all women in Gastro Health to join a virtual call and get to know each other in an informal setting. This was a great way to introduce people to each other in our natural elements. It was wonderful to see how people are when they are at home and not working.
Recruiting female gastroenterologists
Even though about half of gastroenterology fellows choose independent GI, most fellowship programs don’t educate students about private practice careers or promote that path. In addition, a lot of the national GI conferences are geared toward the academic experience.
It’s incumbent on those of us in private practice to educate students about the benefits and challenges we face as members of independent GI groups, and Gastro Health set out to hold networking and recruitment events at different national conferences with GI fellows and residents.
We’re also working to develop partnerships with fellowship programs. This past year, we’ve held several educational dinners for fellows and residents. Most recently, Dr. Khapra and others took a road trip to New York for dinners with fellows from Mount Sinai, Westchester Medical Center, and the Albert Einstein College of Medicine.
While it was beneficial for Gastro Health to provide information about life as private practice gastroenterologists, it was also helpful for us to hear how the GI leaders of tomorrow are navigating their career choices and what is impacting their decisions about the future.
Mentorship and retention are vital to practice sustainability
Once you’ve recruited physicians to join your practice, how do you ensure their success? Many practices are rightly concerned about their long-term sustainability and are exploring ways to help early-career physicians maintain the clinical skills they need to treat patients and learn the business skills they need to succeed in private practice.
Sometimes it’s as simple as reaching out to new associates on the first day to let them know you’re glad they’ve joined the practice and to let them know you’re available if they need anything. But there’s also growing recognition that implementing a formal mentorship program can help people feel included and supported.
The Women’s Network worked to pair its members with Gastro Health partners as mentors, and we’ve learned some things along the way. Initially, we tried to pair people with similar lifestyles and interests. What we found is that while this sometimes works, we may have overcomplicated the process. We learned that sometimes people would prefer mentors who have backgrounds that are different from their own. We were reminded that mentorship has many faces, and letting those relationships develop naturally can sometimes be more effective.
Networking and social events deter isolation and keep people engaged
Private practice can be different from working within a hospital because oftentimes your colleagues are working in different offices or facilities. In the case of our organization, those offices may be in different states hundreds of miles away. Within a hospital, there might be more potential to interact with your colleagues, whether in clinical conferences or through a chance encounter in the cafeteria.
In private practice, you may need to be more intentional about creating opportunities for people to network and get to know each other outside of work. This year, we developed an email and WhatsApp group so that women throughout the network can connect with each other. We have used it to disseminate information about upcoming events, fellowship opportunities with the national GI societies, interesting articles, and anything important that we think other women within Gastro Health would like to know.
In March, Gastro Health sponsored five women to attend the Scrubs & Heels Summit, which was developed by Dr. Anita Afzali and Dr. Aline Charabaty to create opportunities for women in GI at different stages of their GI careers and help them succeed and achieve their professional goals. There were 2 days of educational talks, but it also included plenty of events for our colleagues to get to know each other and network with other amazing female GI leaders from across the nation.
Where’s the boardroom?
A recent study found that the percentage of women on the boards of the 1,000 largest public companies in America is a little more than 28%, even though research shows that S&P 500 companies headquartered in California with 30% or more women on their boards had 29% higher revenue.
We’re working to develop opportunities for women to be in leadership positions, within our practices and on the national stage in terms of representation, within our national GI societies. It’s very exciting that we have women in leadership within AGA and ASGE, and that Dr. Latha Alaparthi has made increasing the focus on leadership and pipeline development one of her main priorities as the president and board chair of the Digestive Health Physicians Association (DHPA).
Another way private practices can support women who are leaders is by making recommendations for committees within our national societies and by recognizing that time spent developing presentations and speaking at national conferences is beneficial to the practice in terms of thought leadership, branding, and recruitment of the next generation of practice leaders.
While we have a long way to go, we’re also making strides in the board room at the practice level. I’m the first woman, and notably a woman of color, to join the Gastro Health board of directors under the guidance of support of CEO Joseph Garcia. Dr. Aja McCutchen, who serves as the chair of the DHPA Diversity, Equity, and Inclusion committee, is similarly the first woman and woman of color on the board of directors for United Digestive in Atlanta.
What to look for in joining a practice
When determining which practice you might join, ask how committed the leadership of the organization is to supporting career development for women. Does the practice have a network, a committee or other internal group that supports female physicians? What steps does the practice leadership take to support women who are interested in executive opportunities?
If the practice does have an internal organization, how does it measure progress? For example, we’ve implemented focus groups to measure what is working and where we face the most challenges. Gastro Health partnered with a consultant to hold three confidential sessions with 10 women at a time. This will allow for us to collect depersonalized data that can be compiled into a report for the Gastro Health Board and leadership.
If you’re a woman who is considering a career in independent GI, seek out women in private practice and ask about their experiences. Ask about their path and what opportunities they sought out when starting their careers. They may know of some great opportunities that are available to build your leadership skills.
By creating a network for women, Gastro Health is hoping to make it easier to develop relationships and create productive partnerships. We are certain that working to address the specific challenges that female physicians face in their careers will strengthen our group, and ultimately independent gastroenterology overall.
Dr. Adams is a practicing gastroenterologist and partner at Gastro Health Fairfax in Virginia and serves on the Digestive Health Physicians Association’s Diversity, Equity, and Inclusion Committee. Dr. Adams has no conflicts to declare.
When I was in fellowship in the late 1990s, it was rare to see women at many of the big gastroenterology conferences. And in terms of presentations, there was maybe one session led by or for women at lunchtime. These conferences were the only events I had ever been to where the line for the men’s room was longer than the line for the women’s room.
Over the years, the lines for the women’s room have gotten longer, and the sessions led by female gastroenterologists have grown exponentially. However, women are still underrepresented in our field. Two out of five GI fellows are women, but women constitute less than 18% of practicing gastroenterologists. And the number of women in leadership positions is even lower.
Women in medicine face many challenges
According to a report in JAMA Network Open, women have lower starting salaries more than 90% of the time, which can create income disparities in earning potential throughout our entire careers.
Other studies suggest that female physicians also spend more time with patients and answering messages from patients and colleagues as well. This extra time, although it is done in small increments, adds up quickly and could suggest the pay gap between women and men is wider than we think.
Of course, female physicians still spend more time parenting children and doing household labor. A study found that female physicians spent 8.5 hours more per week on activities that support the family and household.
We’ve been discussing equity for women in medicine, and in the workplace, for decades. But events over the past several years – such as the killing of George Floyd and the formation of the #MeToo movement in response to workplace sexual harassment – have accelerated a paradigm shift in how organizations are focusing on diversity, equity, and inclusion (DEI) and creating cultures that support leadership development for women.
The Gastro Health Women’s Network
In 2020, the leadership of Gastro Health reiterated its commitment to fight discrimination and support equity by sending out a company-wide correspondence that encouraged us to be good stewards within our communities during these turbulent times.
This led to the development of the Gastro Health DEI Council and the Gastro Health Women’s Network, led by Dr. Asma Khapra and based on the framework developed by Dr. Dawn Sears. The programs developed by Dr. Sears are focused on facilitating authentic and supportive relationships, and they helped us create a network for women focused on recruitment, mentorship and retention, networking and social events, and leadership development.
Our network started with a meet & greet, inviting all women in Gastro Health to join a virtual call and get to know each other in an informal setting. This was a great way to introduce people to each other in our natural elements. It was wonderful to see how people are when they are at home and not working.
Recruiting female gastroenterologists
Even though about half of gastroenterology fellows choose independent GI, most fellowship programs don’t educate students about private practice careers or promote that path. In addition, a lot of the national GI conferences are geared toward the academic experience.
It’s incumbent on those of us in private practice to educate students about the benefits and challenges we face as members of independent GI groups, and Gastro Health set out to hold networking and recruitment events at different national conferences with GI fellows and residents.
We’re also working to develop partnerships with fellowship programs. This past year, we’ve held several educational dinners for fellows and residents. Most recently, Dr. Khapra and others took a road trip to New York for dinners with fellows from Mount Sinai, Westchester Medical Center, and the Albert Einstein College of Medicine.
While it was beneficial for Gastro Health to provide information about life as private practice gastroenterologists, it was also helpful for us to hear how the GI leaders of tomorrow are navigating their career choices and what is impacting their decisions about the future.
Mentorship and retention are vital to practice sustainability
Once you’ve recruited physicians to join your practice, how do you ensure their success? Many practices are rightly concerned about their long-term sustainability and are exploring ways to help early-career physicians maintain the clinical skills they need to treat patients and learn the business skills they need to succeed in private practice.
Sometimes it’s as simple as reaching out to new associates on the first day to let them know you’re glad they’ve joined the practice and to let them know you’re available if they need anything. But there’s also growing recognition that implementing a formal mentorship program can help people feel included and supported.
The Women’s Network worked to pair its members with Gastro Health partners as mentors, and we’ve learned some things along the way. Initially, we tried to pair people with similar lifestyles and interests. What we found is that while this sometimes works, we may have overcomplicated the process. We learned that sometimes people would prefer mentors who have backgrounds that are different from their own. We were reminded that mentorship has many faces, and letting those relationships develop naturally can sometimes be more effective.
Networking and social events deter isolation and keep people engaged
Private practice can be different from working within a hospital because oftentimes your colleagues are working in different offices or facilities. In the case of our organization, those offices may be in different states hundreds of miles away. Within a hospital, there might be more potential to interact with your colleagues, whether in clinical conferences or through a chance encounter in the cafeteria.
In private practice, you may need to be more intentional about creating opportunities for people to network and get to know each other outside of work. This year, we developed an email and WhatsApp group so that women throughout the network can connect with each other. We have used it to disseminate information about upcoming events, fellowship opportunities with the national GI societies, interesting articles, and anything important that we think other women within Gastro Health would like to know.
In March, Gastro Health sponsored five women to attend the Scrubs & Heels Summit, which was developed by Dr. Anita Afzali and Dr. Aline Charabaty to create opportunities for women in GI at different stages of their GI careers and help them succeed and achieve their professional goals. There were 2 days of educational talks, but it also included plenty of events for our colleagues to get to know each other and network with other amazing female GI leaders from across the nation.
Where’s the boardroom?
A recent study found that the percentage of women on the boards of the 1,000 largest public companies in America is a little more than 28%, even though research shows that S&P 500 companies headquartered in California with 30% or more women on their boards had 29% higher revenue.
We’re working to develop opportunities for women to be in leadership positions, within our practices and on the national stage in terms of representation, within our national GI societies. It’s very exciting that we have women in leadership within AGA and ASGE, and that Dr. Latha Alaparthi has made increasing the focus on leadership and pipeline development one of her main priorities as the president and board chair of the Digestive Health Physicians Association (DHPA).
Another way private practices can support women who are leaders is by making recommendations for committees within our national societies and by recognizing that time spent developing presentations and speaking at national conferences is beneficial to the practice in terms of thought leadership, branding, and recruitment of the next generation of practice leaders.
While we have a long way to go, we’re also making strides in the board room at the practice level. I’m the first woman, and notably a woman of color, to join the Gastro Health board of directors under the guidance of support of CEO Joseph Garcia. Dr. Aja McCutchen, who serves as the chair of the DHPA Diversity, Equity, and Inclusion committee, is similarly the first woman and woman of color on the board of directors for United Digestive in Atlanta.
What to look for in joining a practice
When determining which practice you might join, ask how committed the leadership of the organization is to supporting career development for women. Does the practice have a network, a committee or other internal group that supports female physicians? What steps does the practice leadership take to support women who are interested in executive opportunities?
If the practice does have an internal organization, how does it measure progress? For example, we’ve implemented focus groups to measure what is working and where we face the most challenges. Gastro Health partnered with a consultant to hold three confidential sessions with 10 women at a time. This will allow for us to collect depersonalized data that can be compiled into a report for the Gastro Health Board and leadership.
If you’re a woman who is considering a career in independent GI, seek out women in private practice and ask about their experiences. Ask about their path and what opportunities they sought out when starting their careers. They may know of some great opportunities that are available to build your leadership skills.
By creating a network for women, Gastro Health is hoping to make it easier to develop relationships and create productive partnerships. We are certain that working to address the specific challenges that female physicians face in their careers will strengthen our group, and ultimately independent gastroenterology overall.
Dr. Adams is a practicing gastroenterologist and partner at Gastro Health Fairfax in Virginia and serves on the Digestive Health Physicians Association’s Diversity, Equity, and Inclusion Committee. Dr. Adams has no conflicts to declare.
When I was in fellowship in the late 1990s, it was rare to see women at many of the big gastroenterology conferences. And in terms of presentations, there was maybe one session led by or for women at lunchtime. These conferences were the only events I had ever been to where the line for the men’s room was longer than the line for the women’s room.
Over the years, the lines for the women’s room have gotten longer, and the sessions led by female gastroenterologists have grown exponentially. However, women are still underrepresented in our field. Two out of five GI fellows are women, but women constitute less than 18% of practicing gastroenterologists. And the number of women in leadership positions is even lower.
Women in medicine face many challenges
According to a report in JAMA Network Open, women have lower starting salaries more than 90% of the time, which can create income disparities in earning potential throughout our entire careers.
Other studies suggest that female physicians also spend more time with patients and answering messages from patients and colleagues as well. This extra time, although it is done in small increments, adds up quickly and could suggest the pay gap between women and men is wider than we think.
Of course, female physicians still spend more time parenting children and doing household labor. A study found that female physicians spent 8.5 hours more per week on activities that support the family and household.
We’ve been discussing equity for women in medicine, and in the workplace, for decades. But events over the past several years – such as the killing of George Floyd and the formation of the #MeToo movement in response to workplace sexual harassment – have accelerated a paradigm shift in how organizations are focusing on diversity, equity, and inclusion (DEI) and creating cultures that support leadership development for women.
The Gastro Health Women’s Network
In 2020, the leadership of Gastro Health reiterated its commitment to fight discrimination and support equity by sending out a company-wide correspondence that encouraged us to be good stewards within our communities during these turbulent times.
This led to the development of the Gastro Health DEI Council and the Gastro Health Women’s Network, led by Dr. Asma Khapra and based on the framework developed by Dr. Dawn Sears. The programs developed by Dr. Sears are focused on facilitating authentic and supportive relationships, and they helped us create a network for women focused on recruitment, mentorship and retention, networking and social events, and leadership development.
Our network started with a meet & greet, inviting all women in Gastro Health to join a virtual call and get to know each other in an informal setting. This was a great way to introduce people to each other in our natural elements. It was wonderful to see how people are when they are at home and not working.
Recruiting female gastroenterologists
Even though about half of gastroenterology fellows choose independent GI, most fellowship programs don’t educate students about private practice careers or promote that path. In addition, a lot of the national GI conferences are geared toward the academic experience.
It’s incumbent on those of us in private practice to educate students about the benefits and challenges we face as members of independent GI groups, and Gastro Health set out to hold networking and recruitment events at different national conferences with GI fellows and residents.
We’re also working to develop partnerships with fellowship programs. This past year, we’ve held several educational dinners for fellows and residents. Most recently, Dr. Khapra and others took a road trip to New York for dinners with fellows from Mount Sinai, Westchester Medical Center, and the Albert Einstein College of Medicine.
While it was beneficial for Gastro Health to provide information about life as private practice gastroenterologists, it was also helpful for us to hear how the GI leaders of tomorrow are navigating their career choices and what is impacting their decisions about the future.
Mentorship and retention are vital to practice sustainability
Once you’ve recruited physicians to join your practice, how do you ensure their success? Many practices are rightly concerned about their long-term sustainability and are exploring ways to help early-career physicians maintain the clinical skills they need to treat patients and learn the business skills they need to succeed in private practice.
Sometimes it’s as simple as reaching out to new associates on the first day to let them know you’re glad they’ve joined the practice and to let them know you’re available if they need anything. But there’s also growing recognition that implementing a formal mentorship program can help people feel included and supported.
The Women’s Network worked to pair its members with Gastro Health partners as mentors, and we’ve learned some things along the way. Initially, we tried to pair people with similar lifestyles and interests. What we found is that while this sometimes works, we may have overcomplicated the process. We learned that sometimes people would prefer mentors who have backgrounds that are different from their own. We were reminded that mentorship has many faces, and letting those relationships develop naturally can sometimes be more effective.
Networking and social events deter isolation and keep people engaged
Private practice can be different from working within a hospital because oftentimes your colleagues are working in different offices or facilities. In the case of our organization, those offices may be in different states hundreds of miles away. Within a hospital, there might be more potential to interact with your colleagues, whether in clinical conferences or through a chance encounter in the cafeteria.
In private practice, you may need to be more intentional about creating opportunities for people to network and get to know each other outside of work. This year, we developed an email and WhatsApp group so that women throughout the network can connect with each other. We have used it to disseminate information about upcoming events, fellowship opportunities with the national GI societies, interesting articles, and anything important that we think other women within Gastro Health would like to know.
In March, Gastro Health sponsored five women to attend the Scrubs & Heels Summit, which was developed by Dr. Anita Afzali and Dr. Aline Charabaty to create opportunities for women in GI at different stages of their GI careers and help them succeed and achieve their professional goals. There were 2 days of educational talks, but it also included plenty of events for our colleagues to get to know each other and network with other amazing female GI leaders from across the nation.
Where’s the boardroom?
A recent study found that the percentage of women on the boards of the 1,000 largest public companies in America is a little more than 28%, even though research shows that S&P 500 companies headquartered in California with 30% or more women on their boards had 29% higher revenue.
We’re working to develop opportunities for women to be in leadership positions, within our practices and on the national stage in terms of representation, within our national GI societies. It’s very exciting that we have women in leadership within AGA and ASGE, and that Dr. Latha Alaparthi has made increasing the focus on leadership and pipeline development one of her main priorities as the president and board chair of the Digestive Health Physicians Association (DHPA).
Another way private practices can support women who are leaders is by making recommendations for committees within our national societies and by recognizing that time spent developing presentations and speaking at national conferences is beneficial to the practice in terms of thought leadership, branding, and recruitment of the next generation of practice leaders.
While we have a long way to go, we’re also making strides in the board room at the practice level. I’m the first woman, and notably a woman of color, to join the Gastro Health board of directors under the guidance of support of CEO Joseph Garcia. Dr. Aja McCutchen, who serves as the chair of the DHPA Diversity, Equity, and Inclusion committee, is similarly the first woman and woman of color on the board of directors for United Digestive in Atlanta.
What to look for in joining a practice
When determining which practice you might join, ask how committed the leadership of the organization is to supporting career development for women. Does the practice have a network, a committee or other internal group that supports female physicians? What steps does the practice leadership take to support women who are interested in executive opportunities?
If the practice does have an internal organization, how does it measure progress? For example, we’ve implemented focus groups to measure what is working and where we face the most challenges. Gastro Health partnered with a consultant to hold three confidential sessions with 10 women at a time. This will allow for us to collect depersonalized data that can be compiled into a report for the Gastro Health Board and leadership.
If you’re a woman who is considering a career in independent GI, seek out women in private practice and ask about their experiences. Ask about their path and what opportunities they sought out when starting their careers. They may know of some great opportunities that are available to build your leadership skills.
By creating a network for women, Gastro Health is hoping to make it easier to develop relationships and create productive partnerships. We are certain that working to address the specific challenges that female physicians face in their careers will strengthen our group, and ultimately independent gastroenterology overall.
Dr. Adams is a practicing gastroenterologist and partner at Gastro Health Fairfax in Virginia and serves on the Digestive Health Physicians Association’s Diversity, Equity, and Inclusion Committee. Dr. Adams has no conflicts to declare.
November 2022 - ICYMI
Gastroenterology
August 2022
Johnson-Laghi KA, Mattar MC. Integrating cognitive apprenticeship into gastroenterology clinical training. Gastroenterology. 2022 Aug;163(2):364-7. doi: 10.1053/j.gastro.2022.06.013.
Wood LD et al. Pancreatic cancer: Pathogenesis, screening, diagnosis, and treatment. Gastroenterology. 2022 Aug;163(2):386-402.e1. doi: 10.1053/j.gastro.2022.03.056.
Calderwood AH and Robertson DJ. Stopping surveillance in gastrointestinal conditions: Thoughts on the scope of the problem and potential solutions. Gastroenterology. 2022 Aug;163(2):345-9. doi: 10.1053/j.gastro.2022.04.009.
September 2022
Donnangelo LL et al. Disclosure and reflection after an adverse event: Tips for training and practice. Gastroenterology. 2022 Sep;163(3):568-71. doi: 10.1053/j.gastro.2022.07.003.
Chey WD et al. Vonoprazan triple and dual therapy for Helicobacter pylori infection in the United States and Europe: Randomized clinical trial. Gastroenterology. 2022 Sep;163(3):608-19. doi: 10.1053/j.gastro.2022.05.055.
Bushyhead D and Quigley EMM. Small intestinal bacterial overgrowth-pathophysiology and its implications for definition and management. Gastroenterology. 2022 Sep;163(3):593-607. doi: 10.1053/j.gastro.2022.04.002.
Long MT et al. AGA Clinical practice update: Diagnosis and management of nonalcoholic fatty liver disease in lean individuals: Expert review. Gastroenterology. 2022 Sep;163(3):764-74.e1. doi: 10.1053/j.gastro.2022.06.023.
CGH
August 2022
Lennon AM and Vege SS. Pancreatic cyst surveillance. Clin Gastroenterol Hepatol. 2022 Aug;20(8):1663-7.e1. doi: 10.1016/j.cgh.2022.03.002.
Crockett SD et al. Large Polyp Study Group Consortium. Clip closure does not reduce risk of bleeding after resection of large serrated polyps: Results from a randomized trial. Clin Gastroenterol Hepatol. 2022 Aug;20(8):1757-17--65.e4. doi: 10.1016/j.cgh.2021.12.036.
Martin P et al. Treatment algorithm for managing chronic hepatitis b virus infection in the United States: 2021 update. Clin Gastroenterol Hepatol. 2022 Aug;20(8):1766-75. doi: 10.1016/j.cgh.2021.07.036.
September 2022
Pawlak KM et al. How to train the next generation to provide high-quality peer-reviews. Clin Gastroenterol Hepatol. 2022 Sep;20(9):1902-6. doi: 10.1016/j.cgh.2022.05.018.
Choung RS et al. Collagenous gastritis: Characteristics and response to topical budesonide. Clin Gastroenterol Hepatol. 2022 Sep;20(9):1977-85.e1. doi: 10.1016/j.cgh.2021.11.033.
Basnayake C et al. Long-term outcome of multidisciplinary versus standard gastroenterologist care for functional gastrointestinal disorders: A randomized trial. Clin Gastroenterol Hepatol. 2022 Sep;20(9):2102-11.e9. doi: 10.1016/j.cgh.2021.12.005.
Deutsch-Link S et al. Alcohol-associated liver disease mortality increased from 2017 to 2020 and accelerated during the COVID-19 pandemic. Clin Gastroenterol Hepatol. 2022 Sep;20(9):2142-4.e2. doi: 10.1016/j.cgh.2022.03.017.
TIGE
Nakamatsu, Dai et al. Safety of cold snare polypectomy for small colorectal polyps in patients receiving antithrombotic therapy. Tech Innov Gastrointest Endosc. 2022 Apr 8;24[3]:246-53. doi: 10.1016/j.tige.2022.03.008.
Gastro Hep Advances
Brindusa Truta et al. Outcomes of continuation vs. discontinuation of adalimumab therapy during third trimester of pregnancy in inflammatory bowel disease. Gastro Hep Advances. 2022 Jan 1;1[5]:785-91. doi: 10.1016/j.gastha.2022.04.009.
Gastroenterology
August 2022
Johnson-Laghi KA, Mattar MC. Integrating cognitive apprenticeship into gastroenterology clinical training. Gastroenterology. 2022 Aug;163(2):364-7. doi: 10.1053/j.gastro.2022.06.013.
Wood LD et al. Pancreatic cancer: Pathogenesis, screening, diagnosis, and treatment. Gastroenterology. 2022 Aug;163(2):386-402.e1. doi: 10.1053/j.gastro.2022.03.056.
Calderwood AH and Robertson DJ. Stopping surveillance in gastrointestinal conditions: Thoughts on the scope of the problem and potential solutions. Gastroenterology. 2022 Aug;163(2):345-9. doi: 10.1053/j.gastro.2022.04.009.
September 2022
Donnangelo LL et al. Disclosure and reflection after an adverse event: Tips for training and practice. Gastroenterology. 2022 Sep;163(3):568-71. doi: 10.1053/j.gastro.2022.07.003.
Chey WD et al. Vonoprazan triple and dual therapy for Helicobacter pylori infection in the United States and Europe: Randomized clinical trial. Gastroenterology. 2022 Sep;163(3):608-19. doi: 10.1053/j.gastro.2022.05.055.
Bushyhead D and Quigley EMM. Small intestinal bacterial overgrowth-pathophysiology and its implications for definition and management. Gastroenterology. 2022 Sep;163(3):593-607. doi: 10.1053/j.gastro.2022.04.002.
Long MT et al. AGA Clinical practice update: Diagnosis and management of nonalcoholic fatty liver disease in lean individuals: Expert review. Gastroenterology. 2022 Sep;163(3):764-74.e1. doi: 10.1053/j.gastro.2022.06.023.
CGH
August 2022
Lennon AM and Vege SS. Pancreatic cyst surveillance. Clin Gastroenterol Hepatol. 2022 Aug;20(8):1663-7.e1. doi: 10.1016/j.cgh.2022.03.002.
Crockett SD et al. Large Polyp Study Group Consortium. Clip closure does not reduce risk of bleeding after resection of large serrated polyps: Results from a randomized trial. Clin Gastroenterol Hepatol. 2022 Aug;20(8):1757-17--65.e4. doi: 10.1016/j.cgh.2021.12.036.
Martin P et al. Treatment algorithm for managing chronic hepatitis b virus infection in the United States: 2021 update. Clin Gastroenterol Hepatol. 2022 Aug;20(8):1766-75. doi: 10.1016/j.cgh.2021.07.036.
September 2022
Pawlak KM et al. How to train the next generation to provide high-quality peer-reviews. Clin Gastroenterol Hepatol. 2022 Sep;20(9):1902-6. doi: 10.1016/j.cgh.2022.05.018.
Choung RS et al. Collagenous gastritis: Characteristics and response to topical budesonide. Clin Gastroenterol Hepatol. 2022 Sep;20(9):1977-85.e1. doi: 10.1016/j.cgh.2021.11.033.
Basnayake C et al. Long-term outcome of multidisciplinary versus standard gastroenterologist care for functional gastrointestinal disorders: A randomized trial. Clin Gastroenterol Hepatol. 2022 Sep;20(9):2102-11.e9. doi: 10.1016/j.cgh.2021.12.005.
Deutsch-Link S et al. Alcohol-associated liver disease mortality increased from 2017 to 2020 and accelerated during the COVID-19 pandemic. Clin Gastroenterol Hepatol. 2022 Sep;20(9):2142-4.e2. doi: 10.1016/j.cgh.2022.03.017.
TIGE
Nakamatsu, Dai et al. Safety of cold snare polypectomy for small colorectal polyps in patients receiving antithrombotic therapy. Tech Innov Gastrointest Endosc. 2022 Apr 8;24[3]:246-53. doi: 10.1016/j.tige.2022.03.008.
Gastro Hep Advances
Brindusa Truta et al. Outcomes of continuation vs. discontinuation of adalimumab therapy during third trimester of pregnancy in inflammatory bowel disease. Gastro Hep Advances. 2022 Jan 1;1[5]:785-91. doi: 10.1016/j.gastha.2022.04.009.
Gastroenterology
August 2022
Johnson-Laghi KA, Mattar MC. Integrating cognitive apprenticeship into gastroenterology clinical training. Gastroenterology. 2022 Aug;163(2):364-7. doi: 10.1053/j.gastro.2022.06.013.
Wood LD et al. Pancreatic cancer: Pathogenesis, screening, diagnosis, and treatment. Gastroenterology. 2022 Aug;163(2):386-402.e1. doi: 10.1053/j.gastro.2022.03.056.
Calderwood AH and Robertson DJ. Stopping surveillance in gastrointestinal conditions: Thoughts on the scope of the problem and potential solutions. Gastroenterology. 2022 Aug;163(2):345-9. doi: 10.1053/j.gastro.2022.04.009.
September 2022
Donnangelo LL et al. Disclosure and reflection after an adverse event: Tips for training and practice. Gastroenterology. 2022 Sep;163(3):568-71. doi: 10.1053/j.gastro.2022.07.003.
Chey WD et al. Vonoprazan triple and dual therapy for Helicobacter pylori infection in the United States and Europe: Randomized clinical trial. Gastroenterology. 2022 Sep;163(3):608-19. doi: 10.1053/j.gastro.2022.05.055.
Bushyhead D and Quigley EMM. Small intestinal bacterial overgrowth-pathophysiology and its implications for definition and management. Gastroenterology. 2022 Sep;163(3):593-607. doi: 10.1053/j.gastro.2022.04.002.
Long MT et al. AGA Clinical practice update: Diagnosis and management of nonalcoholic fatty liver disease in lean individuals: Expert review. Gastroenterology. 2022 Sep;163(3):764-74.e1. doi: 10.1053/j.gastro.2022.06.023.
CGH
August 2022
Lennon AM and Vege SS. Pancreatic cyst surveillance. Clin Gastroenterol Hepatol. 2022 Aug;20(8):1663-7.e1. doi: 10.1016/j.cgh.2022.03.002.
Crockett SD et al. Large Polyp Study Group Consortium. Clip closure does not reduce risk of bleeding after resection of large serrated polyps: Results from a randomized trial. Clin Gastroenterol Hepatol. 2022 Aug;20(8):1757-17--65.e4. doi: 10.1016/j.cgh.2021.12.036.
Martin P et al. Treatment algorithm for managing chronic hepatitis b virus infection in the United States: 2021 update. Clin Gastroenterol Hepatol. 2022 Aug;20(8):1766-75. doi: 10.1016/j.cgh.2021.07.036.
September 2022
Pawlak KM et al. How to train the next generation to provide high-quality peer-reviews. Clin Gastroenterol Hepatol. 2022 Sep;20(9):1902-6. doi: 10.1016/j.cgh.2022.05.018.
Choung RS et al. Collagenous gastritis: Characteristics and response to topical budesonide. Clin Gastroenterol Hepatol. 2022 Sep;20(9):1977-85.e1. doi: 10.1016/j.cgh.2021.11.033.
Basnayake C et al. Long-term outcome of multidisciplinary versus standard gastroenterologist care for functional gastrointestinal disorders: A randomized trial. Clin Gastroenterol Hepatol. 2022 Sep;20(9):2102-11.e9. doi: 10.1016/j.cgh.2021.12.005.
Deutsch-Link S et al. Alcohol-associated liver disease mortality increased from 2017 to 2020 and accelerated during the COVID-19 pandemic. Clin Gastroenterol Hepatol. 2022 Sep;20(9):2142-4.e2. doi: 10.1016/j.cgh.2022.03.017.
TIGE
Nakamatsu, Dai et al. Safety of cold snare polypectomy for small colorectal polyps in patients receiving antithrombotic therapy. Tech Innov Gastrointest Endosc. 2022 Apr 8;24[3]:246-53. doi: 10.1016/j.tige.2022.03.008.
Gastro Hep Advances
Brindusa Truta et al. Outcomes of continuation vs. discontinuation of adalimumab therapy during third trimester of pregnancy in inflammatory bowel disease. Gastro Hep Advances. 2022 Jan 1;1[5]:785-91. doi: 10.1016/j.gastha.2022.04.009.
Lean and clean: Minimally invasive endoscopic and pharmacologic approaches to obesity
Obesity currently affects more than 40% of the U.S. population. It is the second-leading preventable cause of mortality behind smoking with an estimated 300,000 deaths per year.1,2 Weight loss can reduce the risk of metabolic comorbidities such as diabetes, heart disease, and stroke. However, 5%-10% total body weight loss (TBWL) is required for risk reduction.3 Sustained weight loss involves dietary alterations and physical activity, although it is difficult to maintain long term with lifestyle changes alone. Less than 10% of Americans with a BMI greater than 30 kg/m2 will achieve 5% TBWL each year, and nearly 80% of people will regain the weight within 5 years, a phenomenon known as “weight cycling.”4,5 Not only can these weight fluctuations make future weight-loss efforts more difficult, but they can also negatively impact cardiometabolic health in the long term.5 Thus, additional therapies are typically needed in conjunction with lifestyle interventions to treat obesity.
Current guidelines recommend bariatric surgery for patients unable to achieve or maintain weight loss through lifestyle changes.6 Surgeries like Roux-en-Y gastric bypass and sleeve gastrectomy lead to improvements in morbidity and mortality from metabolic diseases but are often only approved for select patients with a BMI of at least 40 or at least 35 with obesity-related comorbidities.7 These restrictions exclude patients at lower BMIs who may have early metabolic disease. Furthermore, only a small proportion of eligible patients are referred or willing to undergo surgery because of access issues, socioeconomic barriers, and concerns about adverse events.8,9 Endoscopic bariatric therapy and antiobesity medications (AOMs) have blossomed because of the need for other less-invasive options to stimulate weight loss.
Minimally invasive and noninvasive therapies in obesity
Endoscopic bariatric and metabolic therapies
Endoscopic bariatric and metabolic therapies (EBMTs) are used for the treatment of obesity in patients with a BMI of 30 kg/m2, a cohort that may be ineligible for bariatric surgery.10,11 EBMTs involve three categories: space-occupying devices (intragastric balloons [IGBs], transpyloric shuttle [TPS]), aspiration therapy, and gastric remodeling (endoscopic sleeve gastroplasty [ESG]).21,13 Presently, TPS and aspiration therapy are not commercially available in the United States. There are three types of IGB approved by the Food and Drug Administration, and Apollo ESGTM recently received de novo marketing authorization for the treatment of obesity. TBWL with EBMTs is promising at 12 months post procedure. Ranges include 7%-12% TBWL for IGBs and 15%-19% for ESG, with low rates of serious adverse events (AEs).13-18 Weight loss often reaches or exceeds the 10% TBWL needed to improve or completely reverse metabolic complications.
Obesity pharmacotherapy
Multiple professional societies support the use of obesity pharmacotherapy as an effective adjunct to lifestyle interventions.19 AOMs are classified as peripherally-acting to prevent nutrition absorption (e.g. orlistat), centrally acting to suppress appetite and/or cravings (e.g., phentermine/topiramate or naltrexone/bupropion), or incretin mimetics such as glucagonlike peptide–1 agonists (e.g., liraglutide, semaglutide).20 With the exception of orlistat, most agents have some effects on the hypothalamus to suppress appetite.21 Obesity medications tend to lead to a minimum weight loss of 3-10 kg after 12 months of treatment, and newer medications have even greater efficacy.22 Despite these results, discontinuation rates of the popular GLP-1 agonists can be as high as 47.7% and 70.1% at 12 and 24 months, respectively, because of the high cost of medications, gastrointestinal side effects, and poor tolerance.23,24
An ongoing challenge for patients is maintaining weight loss following cessation of pharmacotherapy when weight loss goals have been achieved. In this context, the combination of obesity pharmacotherapy and EBMTs can be utilized for long-term weight loss and weight maintenance given the chronic, relapsing, and complex nature of obesity.25
Advantages of less-invasive therapies in obesity management
The advantages of both pharmacologic and endoscopic weight-loss therapies are numerous. Pharmacotherapies are noninvasive, and their multiple mechanisms allow for combined use to synergistically promote weight reduction.26,27 Medications can be used in both the short- and long-term management of obesity, allowing for flexibility in use for patients pending fluctuations in weight. Furthermore, medications can improve markers of cardiovascular health including total cholesterol, LDL cholesterol, blood pressure, and glycemic control.28
As minimally invasive therapies, EBMTs have less morbidity and mortality, compared with bariatric surgeries.29 The most common side effects of IGBs or ESG include abdominal pain, nausea, and worsening of acid reflux symptoms, which can be medically managed unlike some of the AEs associated with surgery, such as bowel obstruction, anastomotic dehiscence, fistulization, and postoperative infections.30 Long-term AEs from surgery also include malabsorption, nutritional deficiencies, cholelithiasis, and anastomotic stenosis.31 Even with improvement in surgical techniques, the rate of perioperative and postoperative mortality in Roux-en-Y gastric bypass is estimated to be 0.4% and 0.7%, respectively, compared with only 0.08% with IGBs.30,32
In addition, EBMTs are also more cost effective than surgery, as they are often same-day outpatient procedures, leading to decreased length of stay (LOS) for patients. In ongoing research conducted by Sharaiha and colleagues, it was found that patients undergoing ESG had an average LOS of only 0.13 days, compared with 3.09 days for laparoscopic sleeve gastrectomy and 1.68 for laparoscopic gastric banding. The cost for ESG was approximately $12,000, compared with $15,000-$22,000 for laparoscopic bariatric surgeries.33 With their availability to patients with lower BMIs and their less-invasive nature, EBMTs and pharmacotherapy can be utilized on the spectrum of obesity care as bridge therapies both before and after surgery.
Our clinical approach
In 2015, the first Veterans Affairs hospital-based endoscopic bariatric program was established at the VA New York Harbor Healthcare System utilizing IGBs and weight loss pharmacotherapy in conjunction with the VA MOVE! Program to treat obesity and metabolic comorbidities in veterans. Since then, EBMTs have expanded to include ESG and novel medications. Our treatment algorithm accounts for the chronic nature of obesity, the risk of weight regain after any intervention, and the need for longitudinal patient care.
Patients undergo work-up by a multidisciplinary team (MD team) with a nutritionist, psychologist, primary care physician, gastroenterologist, and endocrinologist to determine the optimal treatment plan (Fig. 1).29
Patients are required to attend multiple information sessions, where all weight-loss methods are presented, including surgery, bariatric endoscopy, and pharmacotherapy. Other specialists also help manage comorbid conditions. Prior to selecting an initial intervention, patients undergo intensive lifestyle and behavioral therapy (Fig. 2 and 3). Depending on the selected therapy, initial treatment lasts between 3 and 12 months with ongoing support from the MD team.
If patients do not achieve their targeted weight loss after initial treatment, a new strategy is selected. This includes a different EBMT such as ESG, alternate pharmacotherapy, or surgery until the weight and health goals of the patient are achieved and sustained (Fig. 3). From the start, patients are informed that our program is a long-term intervention and that active participation in the MOVE! Program, as well as follow-up with the MD team are keys to success. EBMTs and medications are presented as effective tools that only work to enhance the effects of lifestyle changes.
Our multidisciplinary approach provides flexibility for patients to trial different options depending on their progress. Research on long-term outcomes with weight loss and metabolic parameters is ongoing, though early results are promising. Thus far, we have observed that patients undergoing a combination therapy of EBMTs and AOMs have greater weight loss than patients on a single therapeutic approach with either EBMT or AOMs alone.34 Racial and socioeconomic disparities in referrals to bariatric surgery are yet another barrier for patients to access weight reduction and improvement in cardiovascular health.35 EBMTs and pharmacotherapy are no longer just on the horizon; they are here as accessible, effective, and long-term treatments for all patients with obesity. More expansive insurance coverage is needed for EBMTs and AOMs in order to prevent progression of obesity-related comorbidities, reduce high costs, and ensure more equitable access to these effective therapies.
Dr. Young and Dr. Zenger are resident physicians in the department of internal medicine at New York University. Dr. Holzwanger is an advanced endoscopy fellow in the division of gastroenterology at Beth Israel Deaconess Medical Center and Harvard Medical School, both in Boston. Dr. Popov is director of bariatric endoscopy at VA New York Harbor Healthcare System, and assistant professor of medicine at New York University. Dr. Popov reported relationships with Obalon, Microtech, and Spatz, but the remaining authors reported no competing interests.
References
1. Ward ZJ et al. N Engl J Med. 2019;381(25):2440-50.
2. Stein CJ and Colditz GA. J Clin Endocrinol Metab. 2004;89(6):2522-5.
3. Ryan DH and Yockey SR. Curr Obes Rep. 2017;6(2):187-94.
4. Fildes A et al. Am J Public Health. 2015;105(9):e54-9.
5. Rhee E-J. J Obes Metab Syndr. 2017;26(4):237-42.
6. American College of Cardiology/American Heart Association Task Force on Practice Guidelines OEP. Obesity (Silver Spring). 2014;22 Suppl 2:S5-39.
7. Adams TD et al. N Engl J Med. 2018;378(1):93-6.
8. Wharton S et al. Clin Obes. 2016;6(2):154-60.
9. Iuzzolino E and Kim Y. Obes Res Clin Pract. 2020;14(4):310-20.
10. Goyal D, Watson RR. Endoscopic Bariatric Therapies. Curr Gastroenterol Rep. 2016;18(6):26.
11. Ali MR et al. Surg Obes Relat Dis. 2016;12(3):462-467.
12. Turkeltaub JA, Edmundowicz SA. Curr Treat Options Gastroenterol. 2019;17(2):187-201.
13. Reja D et al. Transl Gastroenterol Hepatol. 2022;7:21.
14. Force ABET et al. Gastrointest Endosc. 2015;82(3):425-38e5.
15. Thompson CC et al. Am J Gastroenterol. 2017;112(3):447-57.
16. Nystrom M et al. Obes Surg. 2018;28(7):1860-8.
17. Abu Dayyeh BK et al. Surg Obes Relat Dis. 2019;15(8):1423-4.
18. Sharaiha RZ et al. Clin Gastroenterol Hepatol. 2017;15(4):504-10.
19. Apovian CM et al. J Clin Endocrinol Metab. 2015;100(2):342-62.
20. Son JW and Kim S. Diabetes Metab J. 2020;44(6):802-18.
21. Holst JJ. Int J Obes (Lond). Int J Obes (Lond). 2013;37(9):1161-8.
22. Joo JK and Lee KS. J Menopausal Med. 2014;20(3):90-6.
23. Weiss T et al. Patient Prefer Adherence. 2020;14:2337-45.
24. Sikirica MV et al. Diabetes Metab Syndr Obes. 2017;10:403-12.
25. Kahan S et al. Tech Innov Gastrointest Endosc. 2020;22(3):154-8.
26. Bhat SP and Sharma A. Curr Drug Targets. 2017;18(8):983-93.
27. Pendse J et al. Obesity (Silver Spring). 2021;29(2):308-16.
28. Rucker D et al. BMJ. 2007;335(7631):1194-9.
29. Jirapinyo P and Thompson CC. Clin Gastroenterol Hepatol. 2017;15(5):619-30.
30. Abu Dayyeh BK et al. Gastrointest Endosc. 2015;81(5):1073-86.
31. Schulman AR and Thompson CC. Am J Gastroenterol. 2017;112(11):1640-55.
32. Ma IT and Madura JA, 2nd. Gastroenterol Hepatol (NY). 2015;11(8):526-35.
33. Sharaiha RZ. Endoscopic sleeve gastroplasty as a nonsurgical weight loss alternative. Digestive Disease Week, oral presentation. 2017.
34. Young S et al. Long-term efficacy of a multidisciplinary minimally invasive approach to weight management compared to single endoscopic therapy: A cohort study. P0865. American College of Gastroenterology Meeting, Abstract P0865. 2021.
35. Johnson-Mann C et al. Surg Obes Relat Dis. 2019;15(4):615-20.
Obesity currently affects more than 40% of the U.S. population. It is the second-leading preventable cause of mortality behind smoking with an estimated 300,000 deaths per year.1,2 Weight loss can reduce the risk of metabolic comorbidities such as diabetes, heart disease, and stroke. However, 5%-10% total body weight loss (TBWL) is required for risk reduction.3 Sustained weight loss involves dietary alterations and physical activity, although it is difficult to maintain long term with lifestyle changes alone. Less than 10% of Americans with a BMI greater than 30 kg/m2 will achieve 5% TBWL each year, and nearly 80% of people will regain the weight within 5 years, a phenomenon known as “weight cycling.”4,5 Not only can these weight fluctuations make future weight-loss efforts more difficult, but they can also negatively impact cardiometabolic health in the long term.5 Thus, additional therapies are typically needed in conjunction with lifestyle interventions to treat obesity.
Current guidelines recommend bariatric surgery for patients unable to achieve or maintain weight loss through lifestyle changes.6 Surgeries like Roux-en-Y gastric bypass and sleeve gastrectomy lead to improvements in morbidity and mortality from metabolic diseases but are often only approved for select patients with a BMI of at least 40 or at least 35 with obesity-related comorbidities.7 These restrictions exclude patients at lower BMIs who may have early metabolic disease. Furthermore, only a small proportion of eligible patients are referred or willing to undergo surgery because of access issues, socioeconomic barriers, and concerns about adverse events.8,9 Endoscopic bariatric therapy and antiobesity medications (AOMs) have blossomed because of the need for other less-invasive options to stimulate weight loss.
Minimally invasive and noninvasive therapies in obesity
Endoscopic bariatric and metabolic therapies
Endoscopic bariatric and metabolic therapies (EBMTs) are used for the treatment of obesity in patients with a BMI of 30 kg/m2, a cohort that may be ineligible for bariatric surgery.10,11 EBMTs involve three categories: space-occupying devices (intragastric balloons [IGBs], transpyloric shuttle [TPS]), aspiration therapy, and gastric remodeling (endoscopic sleeve gastroplasty [ESG]).21,13 Presently, TPS and aspiration therapy are not commercially available in the United States. There are three types of IGB approved by the Food and Drug Administration, and Apollo ESGTM recently received de novo marketing authorization for the treatment of obesity. TBWL with EBMTs is promising at 12 months post procedure. Ranges include 7%-12% TBWL for IGBs and 15%-19% for ESG, with low rates of serious adverse events (AEs).13-18 Weight loss often reaches or exceeds the 10% TBWL needed to improve or completely reverse metabolic complications.
Obesity pharmacotherapy
Multiple professional societies support the use of obesity pharmacotherapy as an effective adjunct to lifestyle interventions.19 AOMs are classified as peripherally-acting to prevent nutrition absorption (e.g. orlistat), centrally acting to suppress appetite and/or cravings (e.g., phentermine/topiramate or naltrexone/bupropion), or incretin mimetics such as glucagonlike peptide–1 agonists (e.g., liraglutide, semaglutide).20 With the exception of orlistat, most agents have some effects on the hypothalamus to suppress appetite.21 Obesity medications tend to lead to a minimum weight loss of 3-10 kg after 12 months of treatment, and newer medications have even greater efficacy.22 Despite these results, discontinuation rates of the popular GLP-1 agonists can be as high as 47.7% and 70.1% at 12 and 24 months, respectively, because of the high cost of medications, gastrointestinal side effects, and poor tolerance.23,24
An ongoing challenge for patients is maintaining weight loss following cessation of pharmacotherapy when weight loss goals have been achieved. In this context, the combination of obesity pharmacotherapy and EBMTs can be utilized for long-term weight loss and weight maintenance given the chronic, relapsing, and complex nature of obesity.25
Advantages of less-invasive therapies in obesity management
The advantages of both pharmacologic and endoscopic weight-loss therapies are numerous. Pharmacotherapies are noninvasive, and their multiple mechanisms allow for combined use to synergistically promote weight reduction.26,27 Medications can be used in both the short- and long-term management of obesity, allowing for flexibility in use for patients pending fluctuations in weight. Furthermore, medications can improve markers of cardiovascular health including total cholesterol, LDL cholesterol, blood pressure, and glycemic control.28
As minimally invasive therapies, EBMTs have less morbidity and mortality, compared with bariatric surgeries.29 The most common side effects of IGBs or ESG include abdominal pain, nausea, and worsening of acid reflux symptoms, which can be medically managed unlike some of the AEs associated with surgery, such as bowel obstruction, anastomotic dehiscence, fistulization, and postoperative infections.30 Long-term AEs from surgery also include malabsorption, nutritional deficiencies, cholelithiasis, and anastomotic stenosis.31 Even with improvement in surgical techniques, the rate of perioperative and postoperative mortality in Roux-en-Y gastric bypass is estimated to be 0.4% and 0.7%, respectively, compared with only 0.08% with IGBs.30,32
In addition, EBMTs are also more cost effective than surgery, as they are often same-day outpatient procedures, leading to decreased length of stay (LOS) for patients. In ongoing research conducted by Sharaiha and colleagues, it was found that patients undergoing ESG had an average LOS of only 0.13 days, compared with 3.09 days for laparoscopic sleeve gastrectomy and 1.68 for laparoscopic gastric banding. The cost for ESG was approximately $12,000, compared with $15,000-$22,000 for laparoscopic bariatric surgeries.33 With their availability to patients with lower BMIs and their less-invasive nature, EBMTs and pharmacotherapy can be utilized on the spectrum of obesity care as bridge therapies both before and after surgery.
Our clinical approach
In 2015, the first Veterans Affairs hospital-based endoscopic bariatric program was established at the VA New York Harbor Healthcare System utilizing IGBs and weight loss pharmacotherapy in conjunction with the VA MOVE! Program to treat obesity and metabolic comorbidities in veterans. Since then, EBMTs have expanded to include ESG and novel medications. Our treatment algorithm accounts for the chronic nature of obesity, the risk of weight regain after any intervention, and the need for longitudinal patient care.
Patients undergo work-up by a multidisciplinary team (MD team) with a nutritionist, psychologist, primary care physician, gastroenterologist, and endocrinologist to determine the optimal treatment plan (Fig. 1).29
Patients are required to attend multiple information sessions, where all weight-loss methods are presented, including surgery, bariatric endoscopy, and pharmacotherapy. Other specialists also help manage comorbid conditions. Prior to selecting an initial intervention, patients undergo intensive lifestyle and behavioral therapy (Fig. 2 and 3). Depending on the selected therapy, initial treatment lasts between 3 and 12 months with ongoing support from the MD team.
If patients do not achieve their targeted weight loss after initial treatment, a new strategy is selected. This includes a different EBMT such as ESG, alternate pharmacotherapy, or surgery until the weight and health goals of the patient are achieved and sustained (Fig. 3). From the start, patients are informed that our program is a long-term intervention and that active participation in the MOVE! Program, as well as follow-up with the MD team are keys to success. EBMTs and medications are presented as effective tools that only work to enhance the effects of lifestyle changes.
Our multidisciplinary approach provides flexibility for patients to trial different options depending on their progress. Research on long-term outcomes with weight loss and metabolic parameters is ongoing, though early results are promising. Thus far, we have observed that patients undergoing a combination therapy of EBMTs and AOMs have greater weight loss than patients on a single therapeutic approach with either EBMT or AOMs alone.34 Racial and socioeconomic disparities in referrals to bariatric surgery are yet another barrier for patients to access weight reduction and improvement in cardiovascular health.35 EBMTs and pharmacotherapy are no longer just on the horizon; they are here as accessible, effective, and long-term treatments for all patients with obesity. More expansive insurance coverage is needed for EBMTs and AOMs in order to prevent progression of obesity-related comorbidities, reduce high costs, and ensure more equitable access to these effective therapies.
Dr. Young and Dr. Zenger are resident physicians in the department of internal medicine at New York University. Dr. Holzwanger is an advanced endoscopy fellow in the division of gastroenterology at Beth Israel Deaconess Medical Center and Harvard Medical School, both in Boston. Dr. Popov is director of bariatric endoscopy at VA New York Harbor Healthcare System, and assistant professor of medicine at New York University. Dr. Popov reported relationships with Obalon, Microtech, and Spatz, but the remaining authors reported no competing interests.
References
1. Ward ZJ et al. N Engl J Med. 2019;381(25):2440-50.
2. Stein CJ and Colditz GA. J Clin Endocrinol Metab. 2004;89(6):2522-5.
3. Ryan DH and Yockey SR. Curr Obes Rep. 2017;6(2):187-94.
4. Fildes A et al. Am J Public Health. 2015;105(9):e54-9.
5. Rhee E-J. J Obes Metab Syndr. 2017;26(4):237-42.
6. American College of Cardiology/American Heart Association Task Force on Practice Guidelines OEP. Obesity (Silver Spring). 2014;22 Suppl 2:S5-39.
7. Adams TD et al. N Engl J Med. 2018;378(1):93-6.
8. Wharton S et al. Clin Obes. 2016;6(2):154-60.
9. Iuzzolino E and Kim Y. Obes Res Clin Pract. 2020;14(4):310-20.
10. Goyal D, Watson RR. Endoscopic Bariatric Therapies. Curr Gastroenterol Rep. 2016;18(6):26.
11. Ali MR et al. Surg Obes Relat Dis. 2016;12(3):462-467.
12. Turkeltaub JA, Edmundowicz SA. Curr Treat Options Gastroenterol. 2019;17(2):187-201.
13. Reja D et al. Transl Gastroenterol Hepatol. 2022;7:21.
14. Force ABET et al. Gastrointest Endosc. 2015;82(3):425-38e5.
15. Thompson CC et al. Am J Gastroenterol. 2017;112(3):447-57.
16. Nystrom M et al. Obes Surg. 2018;28(7):1860-8.
17. Abu Dayyeh BK et al. Surg Obes Relat Dis. 2019;15(8):1423-4.
18. Sharaiha RZ et al. Clin Gastroenterol Hepatol. 2017;15(4):504-10.
19. Apovian CM et al. J Clin Endocrinol Metab. 2015;100(2):342-62.
20. Son JW and Kim S. Diabetes Metab J. 2020;44(6):802-18.
21. Holst JJ. Int J Obes (Lond). Int J Obes (Lond). 2013;37(9):1161-8.
22. Joo JK and Lee KS. J Menopausal Med. 2014;20(3):90-6.
23. Weiss T et al. Patient Prefer Adherence. 2020;14:2337-45.
24. Sikirica MV et al. Diabetes Metab Syndr Obes. 2017;10:403-12.
25. Kahan S et al. Tech Innov Gastrointest Endosc. 2020;22(3):154-8.
26. Bhat SP and Sharma A. Curr Drug Targets. 2017;18(8):983-93.
27. Pendse J et al. Obesity (Silver Spring). 2021;29(2):308-16.
28. Rucker D et al. BMJ. 2007;335(7631):1194-9.
29. Jirapinyo P and Thompson CC. Clin Gastroenterol Hepatol. 2017;15(5):619-30.
30. Abu Dayyeh BK et al. Gastrointest Endosc. 2015;81(5):1073-86.
31. Schulman AR and Thompson CC. Am J Gastroenterol. 2017;112(11):1640-55.
32. Ma IT and Madura JA, 2nd. Gastroenterol Hepatol (NY). 2015;11(8):526-35.
33. Sharaiha RZ. Endoscopic sleeve gastroplasty as a nonsurgical weight loss alternative. Digestive Disease Week, oral presentation. 2017.
34. Young S et al. Long-term efficacy of a multidisciplinary minimally invasive approach to weight management compared to single endoscopic therapy: A cohort study. P0865. American College of Gastroenterology Meeting, Abstract P0865. 2021.
35. Johnson-Mann C et al. Surg Obes Relat Dis. 2019;15(4):615-20.
Obesity currently affects more than 40% of the U.S. population. It is the second-leading preventable cause of mortality behind smoking with an estimated 300,000 deaths per year.1,2 Weight loss can reduce the risk of metabolic comorbidities such as diabetes, heart disease, and stroke. However, 5%-10% total body weight loss (TBWL) is required for risk reduction.3 Sustained weight loss involves dietary alterations and physical activity, although it is difficult to maintain long term with lifestyle changes alone. Less than 10% of Americans with a BMI greater than 30 kg/m2 will achieve 5% TBWL each year, and nearly 80% of people will regain the weight within 5 years, a phenomenon known as “weight cycling.”4,5 Not only can these weight fluctuations make future weight-loss efforts more difficult, but they can also negatively impact cardiometabolic health in the long term.5 Thus, additional therapies are typically needed in conjunction with lifestyle interventions to treat obesity.
Current guidelines recommend bariatric surgery for patients unable to achieve or maintain weight loss through lifestyle changes.6 Surgeries like Roux-en-Y gastric bypass and sleeve gastrectomy lead to improvements in morbidity and mortality from metabolic diseases but are often only approved for select patients with a BMI of at least 40 or at least 35 with obesity-related comorbidities.7 These restrictions exclude patients at lower BMIs who may have early metabolic disease. Furthermore, only a small proportion of eligible patients are referred or willing to undergo surgery because of access issues, socioeconomic barriers, and concerns about adverse events.8,9 Endoscopic bariatric therapy and antiobesity medications (AOMs) have blossomed because of the need for other less-invasive options to stimulate weight loss.
Minimally invasive and noninvasive therapies in obesity
Endoscopic bariatric and metabolic therapies
Endoscopic bariatric and metabolic therapies (EBMTs) are used for the treatment of obesity in patients with a BMI of 30 kg/m2, a cohort that may be ineligible for bariatric surgery.10,11 EBMTs involve three categories: space-occupying devices (intragastric balloons [IGBs], transpyloric shuttle [TPS]), aspiration therapy, and gastric remodeling (endoscopic sleeve gastroplasty [ESG]).21,13 Presently, TPS and aspiration therapy are not commercially available in the United States. There are three types of IGB approved by the Food and Drug Administration, and Apollo ESGTM recently received de novo marketing authorization for the treatment of obesity. TBWL with EBMTs is promising at 12 months post procedure. Ranges include 7%-12% TBWL for IGBs and 15%-19% for ESG, with low rates of serious adverse events (AEs).13-18 Weight loss often reaches or exceeds the 10% TBWL needed to improve or completely reverse metabolic complications.
Obesity pharmacotherapy
Multiple professional societies support the use of obesity pharmacotherapy as an effective adjunct to lifestyle interventions.19 AOMs are classified as peripherally-acting to prevent nutrition absorption (e.g. orlistat), centrally acting to suppress appetite and/or cravings (e.g., phentermine/topiramate or naltrexone/bupropion), or incretin mimetics such as glucagonlike peptide–1 agonists (e.g., liraglutide, semaglutide).20 With the exception of orlistat, most agents have some effects on the hypothalamus to suppress appetite.21 Obesity medications tend to lead to a minimum weight loss of 3-10 kg after 12 months of treatment, and newer medications have even greater efficacy.22 Despite these results, discontinuation rates of the popular GLP-1 agonists can be as high as 47.7% and 70.1% at 12 and 24 months, respectively, because of the high cost of medications, gastrointestinal side effects, and poor tolerance.23,24
An ongoing challenge for patients is maintaining weight loss following cessation of pharmacotherapy when weight loss goals have been achieved. In this context, the combination of obesity pharmacotherapy and EBMTs can be utilized for long-term weight loss and weight maintenance given the chronic, relapsing, and complex nature of obesity.25
Advantages of less-invasive therapies in obesity management
The advantages of both pharmacologic and endoscopic weight-loss therapies are numerous. Pharmacotherapies are noninvasive, and their multiple mechanisms allow for combined use to synergistically promote weight reduction.26,27 Medications can be used in both the short- and long-term management of obesity, allowing for flexibility in use for patients pending fluctuations in weight. Furthermore, medications can improve markers of cardiovascular health including total cholesterol, LDL cholesterol, blood pressure, and glycemic control.28
As minimally invasive therapies, EBMTs have less morbidity and mortality, compared with bariatric surgeries.29 The most common side effects of IGBs or ESG include abdominal pain, nausea, and worsening of acid reflux symptoms, which can be medically managed unlike some of the AEs associated with surgery, such as bowel obstruction, anastomotic dehiscence, fistulization, and postoperative infections.30 Long-term AEs from surgery also include malabsorption, nutritional deficiencies, cholelithiasis, and anastomotic stenosis.31 Even with improvement in surgical techniques, the rate of perioperative and postoperative mortality in Roux-en-Y gastric bypass is estimated to be 0.4% and 0.7%, respectively, compared with only 0.08% with IGBs.30,32
In addition, EBMTs are also more cost effective than surgery, as they are often same-day outpatient procedures, leading to decreased length of stay (LOS) for patients. In ongoing research conducted by Sharaiha and colleagues, it was found that patients undergoing ESG had an average LOS of only 0.13 days, compared with 3.09 days for laparoscopic sleeve gastrectomy and 1.68 for laparoscopic gastric banding. The cost for ESG was approximately $12,000, compared with $15,000-$22,000 for laparoscopic bariatric surgeries.33 With their availability to patients with lower BMIs and their less-invasive nature, EBMTs and pharmacotherapy can be utilized on the spectrum of obesity care as bridge therapies both before and after surgery.
Our clinical approach
In 2015, the first Veterans Affairs hospital-based endoscopic bariatric program was established at the VA New York Harbor Healthcare System utilizing IGBs and weight loss pharmacotherapy in conjunction with the VA MOVE! Program to treat obesity and metabolic comorbidities in veterans. Since then, EBMTs have expanded to include ESG and novel medications. Our treatment algorithm accounts for the chronic nature of obesity, the risk of weight regain after any intervention, and the need for longitudinal patient care.
Patients undergo work-up by a multidisciplinary team (MD team) with a nutritionist, psychologist, primary care physician, gastroenterologist, and endocrinologist to determine the optimal treatment plan (Fig. 1).29
Patients are required to attend multiple information sessions, where all weight-loss methods are presented, including surgery, bariatric endoscopy, and pharmacotherapy. Other specialists also help manage comorbid conditions. Prior to selecting an initial intervention, patients undergo intensive lifestyle and behavioral therapy (Fig. 2 and 3). Depending on the selected therapy, initial treatment lasts between 3 and 12 months with ongoing support from the MD team.
If patients do not achieve their targeted weight loss after initial treatment, a new strategy is selected. This includes a different EBMT such as ESG, alternate pharmacotherapy, or surgery until the weight and health goals of the patient are achieved and sustained (Fig. 3). From the start, patients are informed that our program is a long-term intervention and that active participation in the MOVE! Program, as well as follow-up with the MD team are keys to success. EBMTs and medications are presented as effective tools that only work to enhance the effects of lifestyle changes.
Our multidisciplinary approach provides flexibility for patients to trial different options depending on their progress. Research on long-term outcomes with weight loss and metabolic parameters is ongoing, though early results are promising. Thus far, we have observed that patients undergoing a combination therapy of EBMTs and AOMs have greater weight loss than patients on a single therapeutic approach with either EBMT or AOMs alone.34 Racial and socioeconomic disparities in referrals to bariatric surgery are yet another barrier for patients to access weight reduction and improvement in cardiovascular health.35 EBMTs and pharmacotherapy are no longer just on the horizon; they are here as accessible, effective, and long-term treatments for all patients with obesity. More expansive insurance coverage is needed for EBMTs and AOMs in order to prevent progression of obesity-related comorbidities, reduce high costs, and ensure more equitable access to these effective therapies.
Dr. Young and Dr. Zenger are resident physicians in the department of internal medicine at New York University. Dr. Holzwanger is an advanced endoscopy fellow in the division of gastroenterology at Beth Israel Deaconess Medical Center and Harvard Medical School, both in Boston. Dr. Popov is director of bariatric endoscopy at VA New York Harbor Healthcare System, and assistant professor of medicine at New York University. Dr. Popov reported relationships with Obalon, Microtech, and Spatz, but the remaining authors reported no competing interests.
References
1. Ward ZJ et al. N Engl J Med. 2019;381(25):2440-50.
2. Stein CJ and Colditz GA. J Clin Endocrinol Metab. 2004;89(6):2522-5.
3. Ryan DH and Yockey SR. Curr Obes Rep. 2017;6(2):187-94.
4. Fildes A et al. Am J Public Health. 2015;105(9):e54-9.
5. Rhee E-J. J Obes Metab Syndr. 2017;26(4):237-42.
6. American College of Cardiology/American Heart Association Task Force on Practice Guidelines OEP. Obesity (Silver Spring). 2014;22 Suppl 2:S5-39.
7. Adams TD et al. N Engl J Med. 2018;378(1):93-6.
8. Wharton S et al. Clin Obes. 2016;6(2):154-60.
9. Iuzzolino E and Kim Y. Obes Res Clin Pract. 2020;14(4):310-20.
10. Goyal D, Watson RR. Endoscopic Bariatric Therapies. Curr Gastroenterol Rep. 2016;18(6):26.
11. Ali MR et al. Surg Obes Relat Dis. 2016;12(3):462-467.
12. Turkeltaub JA, Edmundowicz SA. Curr Treat Options Gastroenterol. 2019;17(2):187-201.
13. Reja D et al. Transl Gastroenterol Hepatol. 2022;7:21.
14. Force ABET et al. Gastrointest Endosc. 2015;82(3):425-38e5.
15. Thompson CC et al. Am J Gastroenterol. 2017;112(3):447-57.
16. Nystrom M et al. Obes Surg. 2018;28(7):1860-8.
17. Abu Dayyeh BK et al. Surg Obes Relat Dis. 2019;15(8):1423-4.
18. Sharaiha RZ et al. Clin Gastroenterol Hepatol. 2017;15(4):504-10.
19. Apovian CM et al. J Clin Endocrinol Metab. 2015;100(2):342-62.
20. Son JW and Kim S. Diabetes Metab J. 2020;44(6):802-18.
21. Holst JJ. Int J Obes (Lond). Int J Obes (Lond). 2013;37(9):1161-8.
22. Joo JK and Lee KS. J Menopausal Med. 2014;20(3):90-6.
23. Weiss T et al. Patient Prefer Adherence. 2020;14:2337-45.
24. Sikirica MV et al. Diabetes Metab Syndr Obes. 2017;10:403-12.
25. Kahan S et al. Tech Innov Gastrointest Endosc. 2020;22(3):154-8.
26. Bhat SP and Sharma A. Curr Drug Targets. 2017;18(8):983-93.
27. Pendse J et al. Obesity (Silver Spring). 2021;29(2):308-16.
28. Rucker D et al. BMJ. 2007;335(7631):1194-9.
29. Jirapinyo P and Thompson CC. Clin Gastroenterol Hepatol. 2017;15(5):619-30.
30. Abu Dayyeh BK et al. Gastrointest Endosc. 2015;81(5):1073-86.
31. Schulman AR and Thompson CC. Am J Gastroenterol. 2017;112(11):1640-55.
32. Ma IT and Madura JA, 2nd. Gastroenterol Hepatol (NY). 2015;11(8):526-35.
33. Sharaiha RZ. Endoscopic sleeve gastroplasty as a nonsurgical weight loss alternative. Digestive Disease Week, oral presentation. 2017.
34. Young S et al. Long-term efficacy of a multidisciplinary minimally invasive approach to weight management compared to single endoscopic therapy: A cohort study. P0865. American College of Gastroenterology Meeting, Abstract P0865. 2021.
35. Johnson-Mann C et al. Surg Obes Relat Dis. 2019;15(4):615-20.
Passive income for the astute gastroenterologist
I don’t think I heard the term “passive income” until I was already an attending gastroenterologist.
That was no surprise. Why would I as a gastroenterologist with a focus in inflammatory bowel diseases be even remotely interested in that term?
Like most physicians, I went into medicine to take care of patients. That was my entire dream. It was a pleasant surprise to hear that gastroenterologists were relatively well paid compared to many other internal medicine specialties.
That was a bonus. I was not practicing medicine for the money. I was here to do good, only. Money was the evil one. It’s no surprise money remained a taboo topic amongst physicians.
This is reflected in the lack of financial education in our training.
I went through all my medical training without getting any financial education. In my last year of training, I wondered how I was going to not end up being a burned out, overworked physician mom. I knew I was going to work in a large hospital-based practice or academic center. I was already aware that employed physicians had a higher burnout rate compared to independent physicians. My desperation to avoid what looked like the natural history of most physicians in medicine was what led me to my financial awakening, as you could call it.
I became curious about where my money was going as it hit my bank account. Where was I investing? How was I going to ensure that I wasn’t putting all my financial eggs in one basket by relying solely on my clinical income? This road led me into a world that I didn’t know existed. It was the world of physician entrepreneurs.
I began thinking more critically of how I was spending my time outside of the hospital. As a busy physician mom, there already were a lot of competing needs and demands on the 24 hours that I was limited to within a day. How could I get things done and increase my earnability without needing to exchange more time for money in a one-to-one ratio?
Passive income!
First of all, what exactly is passive income?
It refers to money earned that does not require you to physically and actively pump in time in order to get money out. For instance, seeing patients clinically is not passive. Performing procedures is not passive.
What are some examples of passive income?
• Dividend paying stocks or funds
• Investing through retirement accounts
• Passive real estate investment through syndications, crowdfunding, REITs
• Book writing
• Business partnership or ownership such as surgery center co-ownership
• Peer-to-peer lending
• Affiliate marketing
• House hacking
• Rent out your car
• Rent out your backyard/ swimming pool
• Invention with royalty payment
• Podcasting
There are some myths about passive income that are worth exploring
1. Passive income is completely passive: This is relative passivity, meaning that for every investment, there is a phase of learning, acquiring knowledge, vetting, and possibly researching that is not passive. After the initial phase of set up, most passive sources of income may require some monitoring or checking in. However, what makes an investment passive is the absence of that one-to-one ratio of input to output that would normally exist in a more active income source.
2. Making passive income is lazy: If you are a physician, you are probably not lazy. Yes, we have a high standard of expectation for ourselves, but anyone that is able to withstand the rigors of medical training, residency, and fellowship is not lazy in my books. Burnout can present in various ways, including apathy. Let’s not confuse that as lazy because, if we do, that would qualify as gaslighting and self-splaining. As someone that teaches physicians how to have money, here is my opinion: In order to make money ethically, there has to be exchange in value. One person gives value, the other gives money as a thank you. Value can be physical as seen in clinical work. Value can also be monetary. For example, I could give $100,000 to a start-up company that needs that money to execute their brilliant idea, and, in return for my investment, they could give me a 15% return per year. Is that lazy? Without this, their brilliant idea may not see daylight. Value exchange is the key. Giving value comes in different ways.
3. Finding ideas for passive income is hard: Many of us are invested in the stock market, most commonly through retirement accounts. This would qualify as passive income. Typically, we have simply elected that the growth in our investment or dividends be reinvested as we are choosing to use this money long term. In other words, if you have a retirement account, you already have passive income. The question now is how you can find additional passive ways to invest.
What are the benefits to passive income as a gastroenterologist?
1. Changing landscape of medicine: Over the last few decades, we have seen a growing shift in the landscape of medicine. There has been an increase in administrations surpassing the increase in physicians. There seem to be more and more growing bodies that are wedging between physicians and patients. This has led to increasing dissatisfaction for patients and physicians alike. In order to respond to these changes and create lasting changes, there is a need for a change in the leadership. It is fair to say that when you have a more diversified source of income, there is less pressure on a single source of income to provide “food and shelter” for your family. Physician leaders that are liberated have to have a sense of financial liberation.
2. Not putting eggs in one basket: At the beginning of the COVID-19 pandemic, there was significant fear of the unknown. Elective procedures were canceled, leading to financial strain for physicians. Gastroenterologists were not spared. When your income source is diverse, it provides more peace of mind.
3. Mental resourcefulness: This is an understated benefit of passive income and diversified income. As physicians, we went through a lot of hard work to get to where we are today. An average incoming medical student has had extensive demonstration of activity, volunteerism, and problem solving. Yet, as attending physicians, because of the burden of everyday clinical responsibilities and endless paperwork, as well as the platform and “warehouse” and “administrative-type involvement” in medicine, the average physician isn’t creating avenues to expend their cognitive abilities in a way that is diverse outside of the clinical setting. Having passive income opportunities creates a gym for mental resourcefulness that increases work satisfaction and may positively impact burnout.
4. Relationship building: As physicians, we tend to stick with our own. After working 60-80 hours per week, it is no surprise that most of your social network may end up being those that you work with. Passive income opportunities expose physicians to networking and social opportunities that may be critical for relationship building. This may improve mental wellness and overall sense of well-being.
5. Longevity in medicine: As more physicians elect to be employed by larger organizations outside of academics, sabbaticals are becoming less and less available. Having passive sources of income may permit a physician who would otherwise not be able to suffer loss of income the opportunity to take a leave of absence in the short term that may provide long-term longevity in medicine, while promoting wellness.
6. Wealth building: Wealth has had a negative reputation in the world. We seem to equate wealth as bad and being the source of evil. We forget that money is simply a tool that takes the shape of the container you place it in. If you are good, money becomes a tool for more good. Having passive income can help accelerate the journey to wealth building. This can be a great resource as physicians can support unique lifesaving, community-building, and environment-protecting initiatives, as well as support political candidates who will have a positive effect on patient care and the future of medicine.
I hope you are convinced that, Gastroenterologists have to do their due diligence to ensure that their finances are future proof to the best of their abilities.
Dr. Alli-Akintade, a gastroenterologist with Kaiser Permanente South Sacramento (Calif.) Medical Center, is founder of The MoneyFitMD and creator of The MoneyFitMD podcast (www.moneyfitmd.com).
I don’t think I heard the term “passive income” until I was already an attending gastroenterologist.
That was no surprise. Why would I as a gastroenterologist with a focus in inflammatory bowel diseases be even remotely interested in that term?
Like most physicians, I went into medicine to take care of patients. That was my entire dream. It was a pleasant surprise to hear that gastroenterologists were relatively well paid compared to many other internal medicine specialties.
That was a bonus. I was not practicing medicine for the money. I was here to do good, only. Money was the evil one. It’s no surprise money remained a taboo topic amongst physicians.
This is reflected in the lack of financial education in our training.
I went through all my medical training without getting any financial education. In my last year of training, I wondered how I was going to not end up being a burned out, overworked physician mom. I knew I was going to work in a large hospital-based practice or academic center. I was already aware that employed physicians had a higher burnout rate compared to independent physicians. My desperation to avoid what looked like the natural history of most physicians in medicine was what led me to my financial awakening, as you could call it.
I became curious about where my money was going as it hit my bank account. Where was I investing? How was I going to ensure that I wasn’t putting all my financial eggs in one basket by relying solely on my clinical income? This road led me into a world that I didn’t know existed. It was the world of physician entrepreneurs.
I began thinking more critically of how I was spending my time outside of the hospital. As a busy physician mom, there already were a lot of competing needs and demands on the 24 hours that I was limited to within a day. How could I get things done and increase my earnability without needing to exchange more time for money in a one-to-one ratio?
Passive income!
First of all, what exactly is passive income?
It refers to money earned that does not require you to physically and actively pump in time in order to get money out. For instance, seeing patients clinically is not passive. Performing procedures is not passive.
What are some examples of passive income?
• Dividend paying stocks or funds
• Investing through retirement accounts
• Passive real estate investment through syndications, crowdfunding, REITs
• Book writing
• Business partnership or ownership such as surgery center co-ownership
• Peer-to-peer lending
• Affiliate marketing
• House hacking
• Rent out your car
• Rent out your backyard/ swimming pool
• Invention with royalty payment
• Podcasting
There are some myths about passive income that are worth exploring
1. Passive income is completely passive: This is relative passivity, meaning that for every investment, there is a phase of learning, acquiring knowledge, vetting, and possibly researching that is not passive. After the initial phase of set up, most passive sources of income may require some monitoring or checking in. However, what makes an investment passive is the absence of that one-to-one ratio of input to output that would normally exist in a more active income source.
2. Making passive income is lazy: If you are a physician, you are probably not lazy. Yes, we have a high standard of expectation for ourselves, but anyone that is able to withstand the rigors of medical training, residency, and fellowship is not lazy in my books. Burnout can present in various ways, including apathy. Let’s not confuse that as lazy because, if we do, that would qualify as gaslighting and self-splaining. As someone that teaches physicians how to have money, here is my opinion: In order to make money ethically, there has to be exchange in value. One person gives value, the other gives money as a thank you. Value can be physical as seen in clinical work. Value can also be monetary. For example, I could give $100,000 to a start-up company that needs that money to execute their brilliant idea, and, in return for my investment, they could give me a 15% return per year. Is that lazy? Without this, their brilliant idea may not see daylight. Value exchange is the key. Giving value comes in different ways.
3. Finding ideas for passive income is hard: Many of us are invested in the stock market, most commonly through retirement accounts. This would qualify as passive income. Typically, we have simply elected that the growth in our investment or dividends be reinvested as we are choosing to use this money long term. In other words, if you have a retirement account, you already have passive income. The question now is how you can find additional passive ways to invest.
What are the benefits to passive income as a gastroenterologist?
1. Changing landscape of medicine: Over the last few decades, we have seen a growing shift in the landscape of medicine. There has been an increase in administrations surpassing the increase in physicians. There seem to be more and more growing bodies that are wedging between physicians and patients. This has led to increasing dissatisfaction for patients and physicians alike. In order to respond to these changes and create lasting changes, there is a need for a change in the leadership. It is fair to say that when you have a more diversified source of income, there is less pressure on a single source of income to provide “food and shelter” for your family. Physician leaders that are liberated have to have a sense of financial liberation.
2. Not putting eggs in one basket: At the beginning of the COVID-19 pandemic, there was significant fear of the unknown. Elective procedures were canceled, leading to financial strain for physicians. Gastroenterologists were not spared. When your income source is diverse, it provides more peace of mind.
3. Mental resourcefulness: This is an understated benefit of passive income and diversified income. As physicians, we went through a lot of hard work to get to where we are today. An average incoming medical student has had extensive demonstration of activity, volunteerism, and problem solving. Yet, as attending physicians, because of the burden of everyday clinical responsibilities and endless paperwork, as well as the platform and “warehouse” and “administrative-type involvement” in medicine, the average physician isn’t creating avenues to expend their cognitive abilities in a way that is diverse outside of the clinical setting. Having passive income opportunities creates a gym for mental resourcefulness that increases work satisfaction and may positively impact burnout.
4. Relationship building: As physicians, we tend to stick with our own. After working 60-80 hours per week, it is no surprise that most of your social network may end up being those that you work with. Passive income opportunities expose physicians to networking and social opportunities that may be critical for relationship building. This may improve mental wellness and overall sense of well-being.
5. Longevity in medicine: As more physicians elect to be employed by larger organizations outside of academics, sabbaticals are becoming less and less available. Having passive sources of income may permit a physician who would otherwise not be able to suffer loss of income the opportunity to take a leave of absence in the short term that may provide long-term longevity in medicine, while promoting wellness.
6. Wealth building: Wealth has had a negative reputation in the world. We seem to equate wealth as bad and being the source of evil. We forget that money is simply a tool that takes the shape of the container you place it in. If you are good, money becomes a tool for more good. Having passive income can help accelerate the journey to wealth building. This can be a great resource as physicians can support unique lifesaving, community-building, and environment-protecting initiatives, as well as support political candidates who will have a positive effect on patient care and the future of medicine.
I hope you are convinced that, Gastroenterologists have to do their due diligence to ensure that their finances are future proof to the best of their abilities.
Dr. Alli-Akintade, a gastroenterologist with Kaiser Permanente South Sacramento (Calif.) Medical Center, is founder of The MoneyFitMD and creator of The MoneyFitMD podcast (www.moneyfitmd.com).
I don’t think I heard the term “passive income” until I was already an attending gastroenterologist.
That was no surprise. Why would I as a gastroenterologist with a focus in inflammatory bowel diseases be even remotely interested in that term?
Like most physicians, I went into medicine to take care of patients. That was my entire dream. It was a pleasant surprise to hear that gastroenterologists were relatively well paid compared to many other internal medicine specialties.
That was a bonus. I was not practicing medicine for the money. I was here to do good, only. Money was the evil one. It’s no surprise money remained a taboo topic amongst physicians.
This is reflected in the lack of financial education in our training.
I went through all my medical training without getting any financial education. In my last year of training, I wondered how I was going to not end up being a burned out, overworked physician mom. I knew I was going to work in a large hospital-based practice or academic center. I was already aware that employed physicians had a higher burnout rate compared to independent physicians. My desperation to avoid what looked like the natural history of most physicians in medicine was what led me to my financial awakening, as you could call it.
I became curious about where my money was going as it hit my bank account. Where was I investing? How was I going to ensure that I wasn’t putting all my financial eggs in one basket by relying solely on my clinical income? This road led me into a world that I didn’t know existed. It was the world of physician entrepreneurs.
I began thinking more critically of how I was spending my time outside of the hospital. As a busy physician mom, there already were a lot of competing needs and demands on the 24 hours that I was limited to within a day. How could I get things done and increase my earnability without needing to exchange more time for money in a one-to-one ratio?
Passive income!
First of all, what exactly is passive income?
It refers to money earned that does not require you to physically and actively pump in time in order to get money out. For instance, seeing patients clinically is not passive. Performing procedures is not passive.
What are some examples of passive income?
• Dividend paying stocks or funds
• Investing through retirement accounts
• Passive real estate investment through syndications, crowdfunding, REITs
• Book writing
• Business partnership or ownership such as surgery center co-ownership
• Peer-to-peer lending
• Affiliate marketing
• House hacking
• Rent out your car
• Rent out your backyard/ swimming pool
• Invention with royalty payment
• Podcasting
There are some myths about passive income that are worth exploring
1. Passive income is completely passive: This is relative passivity, meaning that for every investment, there is a phase of learning, acquiring knowledge, vetting, and possibly researching that is not passive. After the initial phase of set up, most passive sources of income may require some monitoring or checking in. However, what makes an investment passive is the absence of that one-to-one ratio of input to output that would normally exist in a more active income source.
2. Making passive income is lazy: If you are a physician, you are probably not lazy. Yes, we have a high standard of expectation for ourselves, but anyone that is able to withstand the rigors of medical training, residency, and fellowship is not lazy in my books. Burnout can present in various ways, including apathy. Let’s not confuse that as lazy because, if we do, that would qualify as gaslighting and self-splaining. As someone that teaches physicians how to have money, here is my opinion: In order to make money ethically, there has to be exchange in value. One person gives value, the other gives money as a thank you. Value can be physical as seen in clinical work. Value can also be monetary. For example, I could give $100,000 to a start-up company that needs that money to execute their brilliant idea, and, in return for my investment, they could give me a 15% return per year. Is that lazy? Without this, their brilliant idea may not see daylight. Value exchange is the key. Giving value comes in different ways.
3. Finding ideas for passive income is hard: Many of us are invested in the stock market, most commonly through retirement accounts. This would qualify as passive income. Typically, we have simply elected that the growth in our investment or dividends be reinvested as we are choosing to use this money long term. In other words, if you have a retirement account, you already have passive income. The question now is how you can find additional passive ways to invest.
What are the benefits to passive income as a gastroenterologist?
1. Changing landscape of medicine: Over the last few decades, we have seen a growing shift in the landscape of medicine. There has been an increase in administrations surpassing the increase in physicians. There seem to be more and more growing bodies that are wedging between physicians and patients. This has led to increasing dissatisfaction for patients and physicians alike. In order to respond to these changes and create lasting changes, there is a need for a change in the leadership. It is fair to say that when you have a more diversified source of income, there is less pressure on a single source of income to provide “food and shelter” for your family. Physician leaders that are liberated have to have a sense of financial liberation.
2. Not putting eggs in one basket: At the beginning of the COVID-19 pandemic, there was significant fear of the unknown. Elective procedures were canceled, leading to financial strain for physicians. Gastroenterologists were not spared. When your income source is diverse, it provides more peace of mind.
3. Mental resourcefulness: This is an understated benefit of passive income and diversified income. As physicians, we went through a lot of hard work to get to where we are today. An average incoming medical student has had extensive demonstration of activity, volunteerism, and problem solving. Yet, as attending physicians, because of the burden of everyday clinical responsibilities and endless paperwork, as well as the platform and “warehouse” and “administrative-type involvement” in medicine, the average physician isn’t creating avenues to expend their cognitive abilities in a way that is diverse outside of the clinical setting. Having passive income opportunities creates a gym for mental resourcefulness that increases work satisfaction and may positively impact burnout.
4. Relationship building: As physicians, we tend to stick with our own. After working 60-80 hours per week, it is no surprise that most of your social network may end up being those that you work with. Passive income opportunities expose physicians to networking and social opportunities that may be critical for relationship building. This may improve mental wellness and overall sense of well-being.
5. Longevity in medicine: As more physicians elect to be employed by larger organizations outside of academics, sabbaticals are becoming less and less available. Having passive sources of income may permit a physician who would otherwise not be able to suffer loss of income the opportunity to take a leave of absence in the short term that may provide long-term longevity in medicine, while promoting wellness.
6. Wealth building: Wealth has had a negative reputation in the world. We seem to equate wealth as bad and being the source of evil. We forget that money is simply a tool that takes the shape of the container you place it in. If you are good, money becomes a tool for more good. Having passive income can help accelerate the journey to wealth building. This can be a great resource as physicians can support unique lifesaving, community-building, and environment-protecting initiatives, as well as support political candidates who will have a positive effect on patient care and the future of medicine.
I hope you are convinced that, Gastroenterologists have to do their due diligence to ensure that their finances are future proof to the best of their abilities.
Dr. Alli-Akintade, a gastroenterologist with Kaiser Permanente South Sacramento (Calif.) Medical Center, is founder of The MoneyFitMD and creator of The MoneyFitMD podcast (www.moneyfitmd.com).
A case for when, how, and why to evaluate capacity
Case
Ms. F. is a 68-year-old woman who presented to the hospital with sepsis, developed delirium, and stopped eating. Her clinicians recommended a PEG tube. Although she was inconsistently oriented to self, time, and place, she reiterated the same decision across multiple discussions: She did not want the PEG tube. Her replies to what would happen if she didn’t have the procedure and continued not to eat were consistent, too: “I’ll wither away.”
Ms. F. had impaired cognition. Do these impairments mean her clinicians should over-rule her choice? What evidence indicates whether she lacks decision-making capacity? This case of a patient refusing a potentially life-saving procedure amplifies the importance of asking these questions and integrating capacity assessments into clinical care. In this article, we will describe what capacity is, when and how to assess it, and the alternatives when a patient does not have capacity.
The ethical background
Before starting a medical treatment or procedure, a physician must obtain the patient’s informed consent. This is a core ethic of medicine. Informed consent describes the voluntary decision made by a competent patient following the disclosure of necessary information. Informed consent is key to achieving a balance between promoting patient self-determination and protecting vulnerable patients from harm. In most clinical encounters, informed consent unfolds effortlessly. However, in the care of patients who are acutely ill, particularly those in hospitals, fulfilling the ethic can be challenging.
It is important to have skills to recognize and address these challenges. One of the most common challenges to practicing the ethic of informed consent is the impact of illness on a person’s decision-making capacity. A patient who retains capacity ought to make his or her decisions and does not need someone else (a friend or a family member) to help with the decision.
Incapacity is unfortunately common among the acutely ill medical inpatient population, which typically skews older with more comorbidities.1 Impairments frequently are overlooked for a variety of reasons,2-6 including that many hospitalized patients do not challenge their doctors’ decisions. Doctors may be reluctant to assess capacity because the assessment may medically, legally, or ethically complicate the patient’s care.
Two common terms describe the outcome of an assessment of a patient’s decision-making abilities: competency and capacity. Competency describes a legal principle. It is granted or withdrawn by judicial review. The consequences of a judge rescinding competency are severe: A patient would need a guardian to make choices on his or her behalf.
Capacity, on the other hand, is a clinical concept. A physician assesses whether the patient can make a specific decision in a specific context. The difference between the two terms – competency and capacity – delineates what are the consequences of the assessment and which authority, a judge or a physician, has the right to withdraw a person’s decision-making authority.
The judge offers a global assessment that can lead to a guardianship. The physician’s decision is temporal and situational. Patients can lack capacity when they are ill and recover it when they are healed. Capacity is specific to each medical decision that the patient makes and so a person can lack capacity to make some decisions but not others.
Ethical framework to make assessment
Capacity is described by four decisional abilities: 1) communicate a choice, 2) understand relevant information, 3) appreciation, and 4) reasoning.7
Communication of a choice may be verbal or nonverbal, but the patient must be able to indicate the treatment choice clearly and consistently. Understanding describes knowing essential information a physician has conveyed. This is assessed by having the patients say back what they were told, such as: “Can you tell me in your own words what is a PEG tube?”
The components of appreciation are: the diagnosis or disorder and the benefits and risks of the proposed intervention as it relates to the diagnosis or disorder. Patients who appreciate their disorder have insight into their condition: “I’m not eating because I have an infection.” This can be assessed with a question such as: “Can you tell me in your own words what are the risks or downsides to you?” This prompt assesses the patient’s appreciation of risk. Reframing the question to ask, “Can you tell me about the upsides of this intervention?” will assess the patient’s appreciation of benefit.
Reasoning assesses the thought process and rationale for a person’s decision. It has two components – comparative and consequential reasoning. The first compares the different choices presented about the proposed intervention: “How does having a PEG tube compare to not having it?” The second asks about the consequences of each choice: “What might happen to a person who has the PEG tube?”
The capacity assessment evaluates a patient's performance on these decision-making abilities. This informs the clinician’s judgment of whether the patient has the capacity to make a decision. A patient who has capacity makes the choice, regardless of the physician’s preference or recommendation.
The physician’s duty is to decide which decision-making abilities to assess. Choice and understanding are essential. In riskier or more consequential decisions, a physician may raise the rigor of the assessment to include appreciation and reasoning.8 It is common practice for physicians to raise the standard for when to evaluate and how extensive their evaluation is when the decision is life-altering, as with a PEG tube versus a more routine, non–life-altering decision such as drawing blood for a routine wellness visit.
A simple scoring rubric determines the patient’s ability to answer each question along a range from adequate = 2, marginal = 1, to inadequate = 0. The extremes or adequate or inadequate are straightforward. Judgment is needed when performance is marginal. In the case of repeated marginal answers, a physician must strongly consider whether the patient lacks capacity to make the decision in question.9
Who receives a capacity assessment and when?
A good doctor is a good teacher. A doctor should therefore check that patients understand what is happening with their health. Assessing understanding is simply good medicine; for example, a good teacher ought to be asking an unimpaired patient without impaired cognition, “Can you say back to me the key points of what I explained?” With this approach, every patient is effectively “screened” for a capacity impairment.
Certain patients ought to trigger a more thorough examination of decisional abilities. Across multiple articles, the strongest factors associated with incapacity are older age and diminished cognitive function (often detected by MMSE scores below the low 20s).1,7,10 Other factors that may amplify these deficits and thus should raise clinician concern would be patients with brain diseases such as Alzheimer’s or Parkinson’s, persons with lower education levels, or those who already have someone who helps them make decisions. To be sure, many older adults, even those with cognitive impairments, retain capacity, but extra protection should be in place to ensure their well-being.
Consequences of incapacity
If a careful assessment shows a patient has sound decision-making abilities, the patient is free to make the choice. On the other hand, a person does not have the capacity to make the decision at hand if he or she cannot communicate a choice or understand relevant information. Whether appreciation or reasoning ought to be assessed depends on the complexity and the significance of the decision. An assessment of decisional ability is not the end of the decision-making process. The goal is to maximize the patient’s autonomy.
Capacity can change over time. Factors that may inhibit capacity, such as medications, time of day, and even illness acuity, need to be accounted for and, if possible, addressed. The decision ought to be delayed, if possible, to a time when the patient has better chances of having capacity. If it is unlikely that patients’ status will change in the time frame needed to make the choice and they are found to not have capacity, then the decision making can be aided by advance directives or substitute decision makers such as family members or legal guardians.
Revisiting the case
Ms. F., who was delirious, retained notable decisional abilities. She understood the procedure of receiving the PEG tube and how the risk of continuing to not eat and not receive the PEG would result in dying by starvation. She appreciated her own diagnosis and how the proposed intervention could alter her condition. She appreciated how not having a PEG would lead to her death. Her choice to refuse the procedure was consistent. Ms. F. showed she retained capacity to make this decision. It was the physician’s duty to respect her autonomy and so to respect her refusal of the PEG.
Dr. Ney is a physician resident, department of psychiatry and human behavior, Thomas Jefferson University Hospital, Philadelphia. He has no conflicts to disclose. Dr. Karlawish is a professor in the departments of medicine, medical ethics and health policy, and neurology, University of Pennsylvania, Philadelphia. He is a site investigator for clinical trials sponsored by Biogen, Eisai, and Lilly.
References
1. Raymont V et al. Prevalence of mental incapacity in medical inpatients and associated risk factors: Cross-sectional study. Lancet. 2004;364(9443):1421-7. doi: 10.1016/S0140-6736(04)17224-3.
2. Hanson M and Pitt D. Informed consent for surgery: risk discussion and documentation. Can J Surg. 2017;60(1):69-70. doi: 10.1503/cjs.004816.
3. Dahlberg J et al. Lack of informed consent for surgical procedures by elderly patients with inability to consent: A retrospective chart review from an academic medical center in Norway. Patient Saf Surg. 2019;13:24. doi: 10.1186/s13037-019-0205-5.
4. Sessums LL et al. Does this patient have medical decision-making capacity? JAMA. 2011;306(4):420-7. doi: 10.1001/jama.2011.1023.
5. Terranova C et al. Ethical and medicolegal implications of capacity of patients in geriatric surgery. Med Sci Law. 2013;53(3):166-71. doi: 10.1177/0025802412473963.
6. John S et al. Assessing patients decision-making capacity in the hospital setting: A literature review. Aust J Rural Health. 2020;28(2):141-8. doi: 10.1111/ajr.12592.
7. Kim SYH et al. Do clinicians follow a risk-sensitive model of capacity-determination? An experimental video survey. Psychosomatics. 2006;47(4):325-9. doi: 10.1176/appi.psy.47.4.325.
8. Appelbaum PS. Assessment of patients’ competence to consent to treatment. N Engl J Med. 2007;357(18):1834-40. doi: 10.1056/NEJMcp074045.
9. Karlawish J. Measuring decision-making capacity in cognitively impaired individuals. Neurosignals. 2008;16(1):91-8. doi: 10.1159/000109763.
10. Christensen K et al. Decision-making capacity for informed consent in the older population. Bull Am Acad Psychiatry Law. 1995;23(3):353-65.
Case
Ms. F. is a 68-year-old woman who presented to the hospital with sepsis, developed delirium, and stopped eating. Her clinicians recommended a PEG tube. Although she was inconsistently oriented to self, time, and place, she reiterated the same decision across multiple discussions: She did not want the PEG tube. Her replies to what would happen if she didn’t have the procedure and continued not to eat were consistent, too: “I’ll wither away.”
Ms. F. had impaired cognition. Do these impairments mean her clinicians should over-rule her choice? What evidence indicates whether she lacks decision-making capacity? This case of a patient refusing a potentially life-saving procedure amplifies the importance of asking these questions and integrating capacity assessments into clinical care. In this article, we will describe what capacity is, when and how to assess it, and the alternatives when a patient does not have capacity.
The ethical background
Before starting a medical treatment or procedure, a physician must obtain the patient’s informed consent. This is a core ethic of medicine. Informed consent describes the voluntary decision made by a competent patient following the disclosure of necessary information. Informed consent is key to achieving a balance between promoting patient self-determination and protecting vulnerable patients from harm. In most clinical encounters, informed consent unfolds effortlessly. However, in the care of patients who are acutely ill, particularly those in hospitals, fulfilling the ethic can be challenging.
It is important to have skills to recognize and address these challenges. One of the most common challenges to practicing the ethic of informed consent is the impact of illness on a person’s decision-making capacity. A patient who retains capacity ought to make his or her decisions and does not need someone else (a friend or a family member) to help with the decision.
Incapacity is unfortunately common among the acutely ill medical inpatient population, which typically skews older with more comorbidities.1 Impairments frequently are overlooked for a variety of reasons,2-6 including that many hospitalized patients do not challenge their doctors’ decisions. Doctors may be reluctant to assess capacity because the assessment may medically, legally, or ethically complicate the patient’s care.
Two common terms describe the outcome of an assessment of a patient’s decision-making abilities: competency and capacity. Competency describes a legal principle. It is granted or withdrawn by judicial review. The consequences of a judge rescinding competency are severe: A patient would need a guardian to make choices on his or her behalf.
Capacity, on the other hand, is a clinical concept. A physician assesses whether the patient can make a specific decision in a specific context. The difference between the two terms – competency and capacity – delineates what are the consequences of the assessment and which authority, a judge or a physician, has the right to withdraw a person’s decision-making authority.
The judge offers a global assessment that can lead to a guardianship. The physician’s decision is temporal and situational. Patients can lack capacity when they are ill and recover it when they are healed. Capacity is specific to each medical decision that the patient makes and so a person can lack capacity to make some decisions but not others.
Ethical framework to make assessment
Capacity is described by four decisional abilities: 1) communicate a choice, 2) understand relevant information, 3) appreciation, and 4) reasoning.7
Communication of a choice may be verbal or nonverbal, but the patient must be able to indicate the treatment choice clearly and consistently. Understanding describes knowing essential information a physician has conveyed. This is assessed by having the patients say back what they were told, such as: “Can you tell me in your own words what is a PEG tube?”
The components of appreciation are: the diagnosis or disorder and the benefits and risks of the proposed intervention as it relates to the diagnosis or disorder. Patients who appreciate their disorder have insight into their condition: “I’m not eating because I have an infection.” This can be assessed with a question such as: “Can you tell me in your own words what are the risks or downsides to you?” This prompt assesses the patient’s appreciation of risk. Reframing the question to ask, “Can you tell me about the upsides of this intervention?” will assess the patient’s appreciation of benefit.
Reasoning assesses the thought process and rationale for a person’s decision. It has two components – comparative and consequential reasoning. The first compares the different choices presented about the proposed intervention: “How does having a PEG tube compare to not having it?” The second asks about the consequences of each choice: “What might happen to a person who has the PEG tube?”
The capacity assessment evaluates a patient's performance on these decision-making abilities. This informs the clinician’s judgment of whether the patient has the capacity to make a decision. A patient who has capacity makes the choice, regardless of the physician’s preference or recommendation.
The physician’s duty is to decide which decision-making abilities to assess. Choice and understanding are essential. In riskier or more consequential decisions, a physician may raise the rigor of the assessment to include appreciation and reasoning.8 It is common practice for physicians to raise the standard for when to evaluate and how extensive their evaluation is when the decision is life-altering, as with a PEG tube versus a more routine, non–life-altering decision such as drawing blood for a routine wellness visit.
A simple scoring rubric determines the patient’s ability to answer each question along a range from adequate = 2, marginal = 1, to inadequate = 0. The extremes or adequate or inadequate are straightforward. Judgment is needed when performance is marginal. In the case of repeated marginal answers, a physician must strongly consider whether the patient lacks capacity to make the decision in question.9
Who receives a capacity assessment and when?
A good doctor is a good teacher. A doctor should therefore check that patients understand what is happening with their health. Assessing understanding is simply good medicine; for example, a good teacher ought to be asking an unimpaired patient without impaired cognition, “Can you say back to me the key points of what I explained?” With this approach, every patient is effectively “screened” for a capacity impairment.
Certain patients ought to trigger a more thorough examination of decisional abilities. Across multiple articles, the strongest factors associated with incapacity are older age and diminished cognitive function (often detected by MMSE scores below the low 20s).1,7,10 Other factors that may amplify these deficits and thus should raise clinician concern would be patients with brain diseases such as Alzheimer’s or Parkinson’s, persons with lower education levels, or those who already have someone who helps them make decisions. To be sure, many older adults, even those with cognitive impairments, retain capacity, but extra protection should be in place to ensure their well-being.
Consequences of incapacity
If a careful assessment shows a patient has sound decision-making abilities, the patient is free to make the choice. On the other hand, a person does not have the capacity to make the decision at hand if he or she cannot communicate a choice or understand relevant information. Whether appreciation or reasoning ought to be assessed depends on the complexity and the significance of the decision. An assessment of decisional ability is not the end of the decision-making process. The goal is to maximize the patient’s autonomy.
Capacity can change over time. Factors that may inhibit capacity, such as medications, time of day, and even illness acuity, need to be accounted for and, if possible, addressed. The decision ought to be delayed, if possible, to a time when the patient has better chances of having capacity. If it is unlikely that patients’ status will change in the time frame needed to make the choice and they are found to not have capacity, then the decision making can be aided by advance directives or substitute decision makers such as family members or legal guardians.
Revisiting the case
Ms. F., who was delirious, retained notable decisional abilities. She understood the procedure of receiving the PEG tube and how the risk of continuing to not eat and not receive the PEG would result in dying by starvation. She appreciated her own diagnosis and how the proposed intervention could alter her condition. She appreciated how not having a PEG would lead to her death. Her choice to refuse the procedure was consistent. Ms. F. showed she retained capacity to make this decision. It was the physician’s duty to respect her autonomy and so to respect her refusal of the PEG.
Dr. Ney is a physician resident, department of psychiatry and human behavior, Thomas Jefferson University Hospital, Philadelphia. He has no conflicts to disclose. Dr. Karlawish is a professor in the departments of medicine, medical ethics and health policy, and neurology, University of Pennsylvania, Philadelphia. He is a site investigator for clinical trials sponsored by Biogen, Eisai, and Lilly.
References
1. Raymont V et al. Prevalence of mental incapacity in medical inpatients and associated risk factors: Cross-sectional study. Lancet. 2004;364(9443):1421-7. doi: 10.1016/S0140-6736(04)17224-3.
2. Hanson M and Pitt D. Informed consent for surgery: risk discussion and documentation. Can J Surg. 2017;60(1):69-70. doi: 10.1503/cjs.004816.
3. Dahlberg J et al. Lack of informed consent for surgical procedures by elderly patients with inability to consent: A retrospective chart review from an academic medical center in Norway. Patient Saf Surg. 2019;13:24. doi: 10.1186/s13037-019-0205-5.
4. Sessums LL et al. Does this patient have medical decision-making capacity? JAMA. 2011;306(4):420-7. doi: 10.1001/jama.2011.1023.
5. Terranova C et al. Ethical and medicolegal implications of capacity of patients in geriatric surgery. Med Sci Law. 2013;53(3):166-71. doi: 10.1177/0025802412473963.
6. John S et al. Assessing patients decision-making capacity in the hospital setting: A literature review. Aust J Rural Health. 2020;28(2):141-8. doi: 10.1111/ajr.12592.
7. Kim SYH et al. Do clinicians follow a risk-sensitive model of capacity-determination? An experimental video survey. Psychosomatics. 2006;47(4):325-9. doi: 10.1176/appi.psy.47.4.325.
8. Appelbaum PS. Assessment of patients’ competence to consent to treatment. N Engl J Med. 2007;357(18):1834-40. doi: 10.1056/NEJMcp074045.
9. Karlawish J. Measuring decision-making capacity in cognitively impaired individuals. Neurosignals. 2008;16(1):91-8. doi: 10.1159/000109763.
10. Christensen K et al. Decision-making capacity for informed consent in the older population. Bull Am Acad Psychiatry Law. 1995;23(3):353-65.
Case
Ms. F. is a 68-year-old woman who presented to the hospital with sepsis, developed delirium, and stopped eating. Her clinicians recommended a PEG tube. Although she was inconsistently oriented to self, time, and place, she reiterated the same decision across multiple discussions: She did not want the PEG tube. Her replies to what would happen if she didn’t have the procedure and continued not to eat were consistent, too: “I’ll wither away.”
Ms. F. had impaired cognition. Do these impairments mean her clinicians should over-rule her choice? What evidence indicates whether she lacks decision-making capacity? This case of a patient refusing a potentially life-saving procedure amplifies the importance of asking these questions and integrating capacity assessments into clinical care. In this article, we will describe what capacity is, when and how to assess it, and the alternatives when a patient does not have capacity.
The ethical background
Before starting a medical treatment or procedure, a physician must obtain the patient’s informed consent. This is a core ethic of medicine. Informed consent describes the voluntary decision made by a competent patient following the disclosure of necessary information. Informed consent is key to achieving a balance between promoting patient self-determination and protecting vulnerable patients from harm. In most clinical encounters, informed consent unfolds effortlessly. However, in the care of patients who are acutely ill, particularly those in hospitals, fulfilling the ethic can be challenging.
It is important to have skills to recognize and address these challenges. One of the most common challenges to practicing the ethic of informed consent is the impact of illness on a person’s decision-making capacity. A patient who retains capacity ought to make his or her decisions and does not need someone else (a friend or a family member) to help with the decision.
Incapacity is unfortunately common among the acutely ill medical inpatient population, which typically skews older with more comorbidities.1 Impairments frequently are overlooked for a variety of reasons,2-6 including that many hospitalized patients do not challenge their doctors’ decisions. Doctors may be reluctant to assess capacity because the assessment may medically, legally, or ethically complicate the patient’s care.
Two common terms describe the outcome of an assessment of a patient’s decision-making abilities: competency and capacity. Competency describes a legal principle. It is granted or withdrawn by judicial review. The consequences of a judge rescinding competency are severe: A patient would need a guardian to make choices on his or her behalf.
Capacity, on the other hand, is a clinical concept. A physician assesses whether the patient can make a specific decision in a specific context. The difference between the two terms – competency and capacity – delineates what are the consequences of the assessment and which authority, a judge or a physician, has the right to withdraw a person’s decision-making authority.
The judge offers a global assessment that can lead to a guardianship. The physician’s decision is temporal and situational. Patients can lack capacity when they are ill and recover it when they are healed. Capacity is specific to each medical decision that the patient makes and so a person can lack capacity to make some decisions but not others.
Ethical framework to make assessment
Capacity is described by four decisional abilities: 1) communicate a choice, 2) understand relevant information, 3) appreciation, and 4) reasoning.7
Communication of a choice may be verbal or nonverbal, but the patient must be able to indicate the treatment choice clearly and consistently. Understanding describes knowing essential information a physician has conveyed. This is assessed by having the patients say back what they were told, such as: “Can you tell me in your own words what is a PEG tube?”
The components of appreciation are: the diagnosis or disorder and the benefits and risks of the proposed intervention as it relates to the diagnosis or disorder. Patients who appreciate their disorder have insight into their condition: “I’m not eating because I have an infection.” This can be assessed with a question such as: “Can you tell me in your own words what are the risks or downsides to you?” This prompt assesses the patient’s appreciation of risk. Reframing the question to ask, “Can you tell me about the upsides of this intervention?” will assess the patient’s appreciation of benefit.
Reasoning assesses the thought process and rationale for a person’s decision. It has two components – comparative and consequential reasoning. The first compares the different choices presented about the proposed intervention: “How does having a PEG tube compare to not having it?” The second asks about the consequences of each choice: “What might happen to a person who has the PEG tube?”
The capacity assessment evaluates a patient's performance on these decision-making abilities. This informs the clinician’s judgment of whether the patient has the capacity to make a decision. A patient who has capacity makes the choice, regardless of the physician’s preference or recommendation.
The physician’s duty is to decide which decision-making abilities to assess. Choice and understanding are essential. In riskier or more consequential decisions, a physician may raise the rigor of the assessment to include appreciation and reasoning.8 It is common practice for physicians to raise the standard for when to evaluate and how extensive their evaluation is when the decision is life-altering, as with a PEG tube versus a more routine, non–life-altering decision such as drawing blood for a routine wellness visit.
A simple scoring rubric determines the patient’s ability to answer each question along a range from adequate = 2, marginal = 1, to inadequate = 0. The extremes or adequate or inadequate are straightforward. Judgment is needed when performance is marginal. In the case of repeated marginal answers, a physician must strongly consider whether the patient lacks capacity to make the decision in question.9
Who receives a capacity assessment and when?
A good doctor is a good teacher. A doctor should therefore check that patients understand what is happening with their health. Assessing understanding is simply good medicine; for example, a good teacher ought to be asking an unimpaired patient without impaired cognition, “Can you say back to me the key points of what I explained?” With this approach, every patient is effectively “screened” for a capacity impairment.
Certain patients ought to trigger a more thorough examination of decisional abilities. Across multiple articles, the strongest factors associated with incapacity are older age and diminished cognitive function (often detected by MMSE scores below the low 20s).1,7,10 Other factors that may amplify these deficits and thus should raise clinician concern would be patients with brain diseases such as Alzheimer’s or Parkinson’s, persons with lower education levels, or those who already have someone who helps them make decisions. To be sure, many older adults, even those with cognitive impairments, retain capacity, but extra protection should be in place to ensure their well-being.
Consequences of incapacity
If a careful assessment shows a patient has sound decision-making abilities, the patient is free to make the choice. On the other hand, a person does not have the capacity to make the decision at hand if he or she cannot communicate a choice or understand relevant information. Whether appreciation or reasoning ought to be assessed depends on the complexity and the significance of the decision. An assessment of decisional ability is not the end of the decision-making process. The goal is to maximize the patient’s autonomy.
Capacity can change over time. Factors that may inhibit capacity, such as medications, time of day, and even illness acuity, need to be accounted for and, if possible, addressed. The decision ought to be delayed, if possible, to a time when the patient has better chances of having capacity. If it is unlikely that patients’ status will change in the time frame needed to make the choice and they are found to not have capacity, then the decision making can be aided by advance directives or substitute decision makers such as family members or legal guardians.
Revisiting the case
Ms. F., who was delirious, retained notable decisional abilities. She understood the procedure of receiving the PEG tube and how the risk of continuing to not eat and not receive the PEG would result in dying by starvation. She appreciated her own diagnosis and how the proposed intervention could alter her condition. She appreciated how not having a PEG would lead to her death. Her choice to refuse the procedure was consistent. Ms. F. showed she retained capacity to make this decision. It was the physician’s duty to respect her autonomy and so to respect her refusal of the PEG.
Dr. Ney is a physician resident, department of psychiatry and human behavior, Thomas Jefferson University Hospital, Philadelphia. He has no conflicts to disclose. Dr. Karlawish is a professor in the departments of medicine, medical ethics and health policy, and neurology, University of Pennsylvania, Philadelphia. He is a site investigator for clinical trials sponsored by Biogen, Eisai, and Lilly.
References
1. Raymont V et al. Prevalence of mental incapacity in medical inpatients and associated risk factors: Cross-sectional study. Lancet. 2004;364(9443):1421-7. doi: 10.1016/S0140-6736(04)17224-3.
2. Hanson M and Pitt D. Informed consent for surgery: risk discussion and documentation. Can J Surg. 2017;60(1):69-70. doi: 10.1503/cjs.004816.
3. Dahlberg J et al. Lack of informed consent for surgical procedures by elderly patients with inability to consent: A retrospective chart review from an academic medical center in Norway. Patient Saf Surg. 2019;13:24. doi: 10.1186/s13037-019-0205-5.
4. Sessums LL et al. Does this patient have medical decision-making capacity? JAMA. 2011;306(4):420-7. doi: 10.1001/jama.2011.1023.
5. Terranova C et al. Ethical and medicolegal implications of capacity of patients in geriatric surgery. Med Sci Law. 2013;53(3):166-71. doi: 10.1177/0025802412473963.
6. John S et al. Assessing patients decision-making capacity in the hospital setting: A literature review. Aust J Rural Health. 2020;28(2):141-8. doi: 10.1111/ajr.12592.
7. Kim SYH et al. Do clinicians follow a risk-sensitive model of capacity-determination? An experimental video survey. Psychosomatics. 2006;47(4):325-9. doi: 10.1176/appi.psy.47.4.325.
8. Appelbaum PS. Assessment of patients’ competence to consent to treatment. N Engl J Med. 2007;357(18):1834-40. doi: 10.1056/NEJMcp074045.
9. Karlawish J. Measuring decision-making capacity in cognitively impaired individuals. Neurosignals. 2008;16(1):91-8. doi: 10.1159/000109763.
10. Christensen K et al. Decision-making capacity for informed consent in the older population. Bull Am Acad Psychiatry Law. 1995;23(3):353-65.
AGA News – August 2022
Huge win for patients: CRC screening coverage continuum is complete
In a huge win for patients, Medicare will begin covering colonoscopies after a positive noninvasive stool test starting next year. Medicare was previously the only insurer who did not cover this critical prevention procedure.
This change comes after a year of advocacy led by AGA – including multiple meetings with senior officials at Health & Human Services and legislative pressure by members across the country.
“Cost-sharing is a well-recognized barrier to screening and has resulted in disparities. Patients can now engage in CRC screening programs and be confident that they will not face unexpected cost-sharing for colonoscopy after a positive noninvasive screening test,” says David Lieberman, MD, AGAF, who met with Centers for Medicare & Medicaid Services officials multiple times to push this policy forward. “AGA knows that increased participation in screening will further reduce the burden of colorectal cancer.”
“This is a win for all patients and should elevate our nation’s screening rates while lowering the overall cancer burden, saving lives. Importantly, the CMS proposed rule changes will lessen colorectal cancer disparities eliminating a financial burden for many patients,” says AGA president John Carethers, MD, AGAF, who met with CMS earlier this month to advocate for this change.
Thank you to everyone in the GI community who advocated for this important change!
CMS announced the coverage change as part of the 2023 Medicare proposed rule, which was released July 7, 2022. The rule must be finalized this Fall before taking effect Jan. 2, 2023.
What you need to know about proposed changes to Medicare payment policies
On July 7, CMS released the calendar year (CY) 2023 Medicare Physician Fee Schedule (MPFS) Proposed Rule. The rule will be posted in the Federal Register no later than July 11.
Good news!
In a win for patients and thanks to collective advocacy efforts from AGA and partner societies, CMS is proposing to expand the regulatory definition of “colorectal cancer screening tests” and waive cost sharing for a necessary follow-up colonoscopy after a positive stool-based screening test.
Looming cuts
The rule proposes 4% cuts to Medicare physician reimbursement through required decreases in the conversion factor and expiration of temporary fixes passed by Congress. AGA will continue to work with a coalition of national and state medical societies in urging Congress to prevent these cuts before Jan. 1, 2023.
What to know
CMS expands CRC screening in a proposal to waive cost-sharing for a follow-up colonoscopy to a positive stool-based colorectal cancer screening test and to cover the service for individuals 45 years of age and above.
Medicare payment cuts are looming with cuts to the proposed CY 2023 conversion factor.
Split/shared visits policy delayed until CY 2024.
Payment rates for new bariatric device codes proposed.
Don’t let insurance policies burden GI practices
Join us at AGA Advocacy Day on Thursday, Sept. 22, 2022, to virtually meet with your members of Congress to urge them to rein in insurance policies like prior authorization and step therapy.
If GI providers don’t have a seat at the table and engage with lawmakers, these decisions will be influenced by payers and other parties that do not have you or your patients’ best interests at heart.
AGA Advocacy Day is held shortly before the end of the fiscal year – prime time to educate policymakers and their staff about your everyday challenges and the reality of GI patient care in your state. We will also discuss the need for robust federal funding for GI research and the devastating impact that Medicare cuts could have on your practice.
Register today and AGA will take care of the rest, including scheduling your meetings and providing comprehensive advocacy training. Now more than ever, your voice needs to be heard on Capitol Hill.
Huge win for patients: CRC screening coverage continuum is complete
In a huge win for patients, Medicare will begin covering colonoscopies after a positive noninvasive stool test starting next year. Medicare was previously the only insurer who did not cover this critical prevention procedure.
This change comes after a year of advocacy led by AGA – including multiple meetings with senior officials at Health & Human Services and legislative pressure by members across the country.
“Cost-sharing is a well-recognized barrier to screening and has resulted in disparities. Patients can now engage in CRC screening programs and be confident that they will not face unexpected cost-sharing for colonoscopy after a positive noninvasive screening test,” says David Lieberman, MD, AGAF, who met with Centers for Medicare & Medicaid Services officials multiple times to push this policy forward. “AGA knows that increased participation in screening will further reduce the burden of colorectal cancer.”
“This is a win for all patients and should elevate our nation’s screening rates while lowering the overall cancer burden, saving lives. Importantly, the CMS proposed rule changes will lessen colorectal cancer disparities eliminating a financial burden for many patients,” says AGA president John Carethers, MD, AGAF, who met with CMS earlier this month to advocate for this change.
Thank you to everyone in the GI community who advocated for this important change!
CMS announced the coverage change as part of the 2023 Medicare proposed rule, which was released July 7, 2022. The rule must be finalized this Fall before taking effect Jan. 2, 2023.
What you need to know about proposed changes to Medicare payment policies
On July 7, CMS released the calendar year (CY) 2023 Medicare Physician Fee Schedule (MPFS) Proposed Rule. The rule will be posted in the Federal Register no later than July 11.
Good news!
In a win for patients and thanks to collective advocacy efforts from AGA and partner societies, CMS is proposing to expand the regulatory definition of “colorectal cancer screening tests” and waive cost sharing for a necessary follow-up colonoscopy after a positive stool-based screening test.
Looming cuts
The rule proposes 4% cuts to Medicare physician reimbursement through required decreases in the conversion factor and expiration of temporary fixes passed by Congress. AGA will continue to work with a coalition of national and state medical societies in urging Congress to prevent these cuts before Jan. 1, 2023.
What to know
CMS expands CRC screening in a proposal to waive cost-sharing for a follow-up colonoscopy to a positive stool-based colorectal cancer screening test and to cover the service for individuals 45 years of age and above.
Medicare payment cuts are looming with cuts to the proposed CY 2023 conversion factor.
Split/shared visits policy delayed until CY 2024.
Payment rates for new bariatric device codes proposed.
Don’t let insurance policies burden GI practices
Join us at AGA Advocacy Day on Thursday, Sept. 22, 2022, to virtually meet with your members of Congress to urge them to rein in insurance policies like prior authorization and step therapy.
If GI providers don’t have a seat at the table and engage with lawmakers, these decisions will be influenced by payers and other parties that do not have you or your patients’ best interests at heart.
AGA Advocacy Day is held shortly before the end of the fiscal year – prime time to educate policymakers and their staff about your everyday challenges and the reality of GI patient care in your state. We will also discuss the need for robust federal funding for GI research and the devastating impact that Medicare cuts could have on your practice.
Register today and AGA will take care of the rest, including scheduling your meetings and providing comprehensive advocacy training. Now more than ever, your voice needs to be heard on Capitol Hill.
Huge win for patients: CRC screening coverage continuum is complete
In a huge win for patients, Medicare will begin covering colonoscopies after a positive noninvasive stool test starting next year. Medicare was previously the only insurer who did not cover this critical prevention procedure.
This change comes after a year of advocacy led by AGA – including multiple meetings with senior officials at Health & Human Services and legislative pressure by members across the country.
“Cost-sharing is a well-recognized barrier to screening and has resulted in disparities. Patients can now engage in CRC screening programs and be confident that they will not face unexpected cost-sharing for colonoscopy after a positive noninvasive screening test,” says David Lieberman, MD, AGAF, who met with Centers for Medicare & Medicaid Services officials multiple times to push this policy forward. “AGA knows that increased participation in screening will further reduce the burden of colorectal cancer.”
“This is a win for all patients and should elevate our nation’s screening rates while lowering the overall cancer burden, saving lives. Importantly, the CMS proposed rule changes will lessen colorectal cancer disparities eliminating a financial burden for many patients,” says AGA president John Carethers, MD, AGAF, who met with CMS earlier this month to advocate for this change.
Thank you to everyone in the GI community who advocated for this important change!
CMS announced the coverage change as part of the 2023 Medicare proposed rule, which was released July 7, 2022. The rule must be finalized this Fall before taking effect Jan. 2, 2023.
What you need to know about proposed changes to Medicare payment policies
On July 7, CMS released the calendar year (CY) 2023 Medicare Physician Fee Schedule (MPFS) Proposed Rule. The rule will be posted in the Federal Register no later than July 11.
Good news!
In a win for patients and thanks to collective advocacy efforts from AGA and partner societies, CMS is proposing to expand the regulatory definition of “colorectal cancer screening tests” and waive cost sharing for a necessary follow-up colonoscopy after a positive stool-based screening test.
Looming cuts
The rule proposes 4% cuts to Medicare physician reimbursement through required decreases in the conversion factor and expiration of temporary fixes passed by Congress. AGA will continue to work with a coalition of national and state medical societies in urging Congress to prevent these cuts before Jan. 1, 2023.
What to know
CMS expands CRC screening in a proposal to waive cost-sharing for a follow-up colonoscopy to a positive stool-based colorectal cancer screening test and to cover the service for individuals 45 years of age and above.
Medicare payment cuts are looming with cuts to the proposed CY 2023 conversion factor.
Split/shared visits policy delayed until CY 2024.
Payment rates for new bariatric device codes proposed.
Don’t let insurance policies burden GI practices
Join us at AGA Advocacy Day on Thursday, Sept. 22, 2022, to virtually meet with your members of Congress to urge them to rein in insurance policies like prior authorization and step therapy.
If GI providers don’t have a seat at the table and engage with lawmakers, these decisions will be influenced by payers and other parties that do not have you or your patients’ best interests at heart.
AGA Advocacy Day is held shortly before the end of the fiscal year – prime time to educate policymakers and their staff about your everyday challenges and the reality of GI patient care in your state. We will also discuss the need for robust federal funding for GI research and the devastating impact that Medicare cuts could have on your practice.
Register today and AGA will take care of the rest, including scheduling your meetings and providing comprehensive advocacy training. Now more than ever, your voice needs to be heard on Capitol Hill.
A bittersweet farewell
Dear colleagues,
It is with bittersweet sentiments that I introduce my last issue of The New Gastroenterologist as its Editor-in-Chief. As I reflect on my time as EIC, I am immensely grateful to the AGA for this opportunity and am proud of the journal’s continuing evolution.
To begin with this issue’s content, our “In Focus” clinical feature reviews nonalcoholic fatty liver disease (NAFLD) and is written by Dr. Naga Chalasani and Dr. Eduardo Vilar-Gomez (Indiana University). This is an excellent, comprehensive piece that details the diagnosis of NAFLD and a multifaceted management approach including dietary and lifestyle modifications, pharmacotherapy, and surgical options.
Learning endoscopy is hard, but so is teaching it. Dr. Navin Kumar (Brigham and Women’s Hospital) lends tangible advice to faculty on how to optimize their endoscopy teaching skills.
Our short clinical review for this quarter, brought to you by Dr. Grace Kim and Dr. Uzma Siddiqui (University of Chicago), offers a helpful discussion on appropriate endoscopic management of duodenal and ampullary adenomas.
Statistical concepts can often be difficult to understand; Dr. Manol Jovani (University of Kentucky) provides a useful, practical explanation of effect modification.
The AGA editorial fellowship is a wonderful opportunity and we are fortunate to have two current fellows share their experience in this issue. Dr. Judy Trieu (Loyola University Chicago) discusses her experience with Clinical Gastroenterology and Hepatology and Dr. Helenie Kefalakes (Hannover Medical School – Germany) reports on her time with Gastroenterology.
Ethics manifests itself in gastroenterology in many ways, and I am happy to have introduced a case-based ethics series to our publication. For my last issue, Dr. Ariel Sims (University of Chicago) and I discuss a case of repeated deliberate foreign body ingestion and the ethical considerations for us as endoscopists.
It can be difficult to navigate the many options that exist within the realm of disability insurance. Dr. Trevor Smith (Advanced EyeCare Professionals) reviews the reasons to obtain disability insurance, how to apply and what to look for in a policy.
Lastly, the DHPA Private Practice Perspectives article for this issue is written by Dr. Marc Sonenshine (Atlanta Gastroenterology Associates) who shares his practice’s innovative approach to implementing a formalized mentorship program for physicians early in their career.
As my editorship comes to a close, I would be remiss not to thank several key people who have been instrumental in the last 3 years. First, Dr. Gautham Reddy, an important mentor of mine and former program director who sent me this opportunity and encouraged me to apply. In addition, I am grateful to the chief of our Section at the University of Chicago, Dr. David Rubin, for his collaboration and support. Ryan Farrell, the managing editor of TNG, has been nothing short of amazing to work with and is the true backbone of our publication. I would also like to thank the staff of our publisher, Frontline Medical Communications, especially Kathy Scarbeck and Christopher Palmer, as well as the EIC and former EIC of our parent publication, GI & Hepatology News, Dr. Megan Adams and Dr. John Allen. Finally, thank you to our readers, whose continued interest has made TNG a success.
Taken together, my experience as EIC of TNG for the last 3 years has been unparalleled. The opportunity to translate the questions, challenges, and experiences of early-career gastroenterologists into written pieces that would be shared with the international community is one I truly never thought I would find within a career in medicine. I am excited for the future and growth of TNG in the hands of a new EIC.
If you have interest in contributing or have ideas for future TNG topics, please contact me ([email protected]) or Ryan Farrell ([email protected]), managing editor of TNG.
Respectfully,
Vijaya L. Rao, MD
Editor-in-Chief
Dear colleagues,
It is with bittersweet sentiments that I introduce my last issue of The New Gastroenterologist as its Editor-in-Chief. As I reflect on my time as EIC, I am immensely grateful to the AGA for this opportunity and am proud of the journal’s continuing evolution.
To begin with this issue’s content, our “In Focus” clinical feature reviews nonalcoholic fatty liver disease (NAFLD) and is written by Dr. Naga Chalasani and Dr. Eduardo Vilar-Gomez (Indiana University). This is an excellent, comprehensive piece that details the diagnosis of NAFLD and a multifaceted management approach including dietary and lifestyle modifications, pharmacotherapy, and surgical options.
Learning endoscopy is hard, but so is teaching it. Dr. Navin Kumar (Brigham and Women’s Hospital) lends tangible advice to faculty on how to optimize their endoscopy teaching skills.
Our short clinical review for this quarter, brought to you by Dr. Grace Kim and Dr. Uzma Siddiqui (University of Chicago), offers a helpful discussion on appropriate endoscopic management of duodenal and ampullary adenomas.
Statistical concepts can often be difficult to understand; Dr. Manol Jovani (University of Kentucky) provides a useful, practical explanation of effect modification.
The AGA editorial fellowship is a wonderful opportunity and we are fortunate to have two current fellows share their experience in this issue. Dr. Judy Trieu (Loyola University Chicago) discusses her experience with Clinical Gastroenterology and Hepatology and Dr. Helenie Kefalakes (Hannover Medical School – Germany) reports on her time with Gastroenterology.
Ethics manifests itself in gastroenterology in many ways, and I am happy to have introduced a case-based ethics series to our publication. For my last issue, Dr. Ariel Sims (University of Chicago) and I discuss a case of repeated deliberate foreign body ingestion and the ethical considerations for us as endoscopists.
It can be difficult to navigate the many options that exist within the realm of disability insurance. Dr. Trevor Smith (Advanced EyeCare Professionals) reviews the reasons to obtain disability insurance, how to apply and what to look for in a policy.
Lastly, the DHPA Private Practice Perspectives article for this issue is written by Dr. Marc Sonenshine (Atlanta Gastroenterology Associates) who shares his practice’s innovative approach to implementing a formalized mentorship program for physicians early in their career.
As my editorship comes to a close, I would be remiss not to thank several key people who have been instrumental in the last 3 years. First, Dr. Gautham Reddy, an important mentor of mine and former program director who sent me this opportunity and encouraged me to apply. In addition, I am grateful to the chief of our Section at the University of Chicago, Dr. David Rubin, for his collaboration and support. Ryan Farrell, the managing editor of TNG, has been nothing short of amazing to work with and is the true backbone of our publication. I would also like to thank the staff of our publisher, Frontline Medical Communications, especially Kathy Scarbeck and Christopher Palmer, as well as the EIC and former EIC of our parent publication, GI & Hepatology News, Dr. Megan Adams and Dr. John Allen. Finally, thank you to our readers, whose continued interest has made TNG a success.
Taken together, my experience as EIC of TNG for the last 3 years has been unparalleled. The opportunity to translate the questions, challenges, and experiences of early-career gastroenterologists into written pieces that would be shared with the international community is one I truly never thought I would find within a career in medicine. I am excited for the future and growth of TNG in the hands of a new EIC.
If you have interest in contributing or have ideas for future TNG topics, please contact me ([email protected]) or Ryan Farrell ([email protected]), managing editor of TNG.
Respectfully,
Vijaya L. Rao, MD
Editor-in-Chief
Dear colleagues,
It is with bittersweet sentiments that I introduce my last issue of The New Gastroenterologist as its Editor-in-Chief. As I reflect on my time as EIC, I am immensely grateful to the AGA for this opportunity and am proud of the journal’s continuing evolution.
To begin with this issue’s content, our “In Focus” clinical feature reviews nonalcoholic fatty liver disease (NAFLD) and is written by Dr. Naga Chalasani and Dr. Eduardo Vilar-Gomez (Indiana University). This is an excellent, comprehensive piece that details the diagnosis of NAFLD and a multifaceted management approach including dietary and lifestyle modifications, pharmacotherapy, and surgical options.
Learning endoscopy is hard, but so is teaching it. Dr. Navin Kumar (Brigham and Women’s Hospital) lends tangible advice to faculty on how to optimize their endoscopy teaching skills.
Our short clinical review for this quarter, brought to you by Dr. Grace Kim and Dr. Uzma Siddiqui (University of Chicago), offers a helpful discussion on appropriate endoscopic management of duodenal and ampullary adenomas.
Statistical concepts can often be difficult to understand; Dr. Manol Jovani (University of Kentucky) provides a useful, practical explanation of effect modification.
The AGA editorial fellowship is a wonderful opportunity and we are fortunate to have two current fellows share their experience in this issue. Dr. Judy Trieu (Loyola University Chicago) discusses her experience with Clinical Gastroenterology and Hepatology and Dr. Helenie Kefalakes (Hannover Medical School – Germany) reports on her time with Gastroenterology.
Ethics manifests itself in gastroenterology in many ways, and I am happy to have introduced a case-based ethics series to our publication. For my last issue, Dr. Ariel Sims (University of Chicago) and I discuss a case of repeated deliberate foreign body ingestion and the ethical considerations for us as endoscopists.
It can be difficult to navigate the many options that exist within the realm of disability insurance. Dr. Trevor Smith (Advanced EyeCare Professionals) reviews the reasons to obtain disability insurance, how to apply and what to look for in a policy.
Lastly, the DHPA Private Practice Perspectives article for this issue is written by Dr. Marc Sonenshine (Atlanta Gastroenterology Associates) who shares his practice’s innovative approach to implementing a formalized mentorship program for physicians early in their career.
As my editorship comes to a close, I would be remiss not to thank several key people who have been instrumental in the last 3 years. First, Dr. Gautham Reddy, an important mentor of mine and former program director who sent me this opportunity and encouraged me to apply. In addition, I am grateful to the chief of our Section at the University of Chicago, Dr. David Rubin, for his collaboration and support. Ryan Farrell, the managing editor of TNG, has been nothing short of amazing to work with and is the true backbone of our publication. I would also like to thank the staff of our publisher, Frontline Medical Communications, especially Kathy Scarbeck and Christopher Palmer, as well as the EIC and former EIC of our parent publication, GI & Hepatology News, Dr. Megan Adams and Dr. John Allen. Finally, thank you to our readers, whose continued interest has made TNG a success.
Taken together, my experience as EIC of TNG for the last 3 years has been unparalleled. The opportunity to translate the questions, challenges, and experiences of early-career gastroenterologists into written pieces that would be shared with the international community is one I truly never thought I would find within a career in medicine. I am excited for the future and growth of TNG in the hands of a new EIC.
If you have interest in contributing or have ideas for future TNG topics, please contact me ([email protected]) or Ryan Farrell ([email protected]), managing editor of TNG.
Respectfully,
Vijaya L. Rao, MD
Editor-in-Chief