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New initiative aims to test investigational OA treatments in high-risk patients after knee injury
David Felson, MD, MPH, often steps out of his physician’s role to help patients with osteoarthritis (OA). “I have one now who needed me to write to her landlord to get her to a ground floor apartment because she’s unable to navigate the stairs,” said Dr. Felson, a professor of medicine and epidemiology at Boston University.
Rheumatologists don’t have a lot of options to treat patients with OA, Dr. Felson said. The most effective treatments are NSAIDs. While reasonably effective, they have a lot of side effects and are not always safe to use, he said.
Exercise also works, but people don’t adhere to it after a while. “Another useful strategy is getting cortisone injections into the affected joint, but that doesn’t last for very long, and I think we’re all reluctant to do it over and over again,” Dr. Felson said.
Some might say, “Well, why can’t they just get a knee replacement?” Many patients don’t want the surgery, and others are too frail to qualify. They’re also not 100% successful. Patients after the surgery sometimes say that they’re still in pain.
There’s an urgent need for more effective therapies, said Dr. Felson, who’s been working on a unique approach to target patients at high risk for OA by studying two specific populations who sustain knee injury.
Previous clinical trials have failed
Clinical trials to test OA treatments have run into some roadblocks. The market for this is enormous, with the potential to benefit millions of patients, Dr. Felson continued.
However, very few large pharmaceutical companies or even biotech companies are pursuing treatment development in osteoarthritis because there have been a lot of expensive failures. “It’s made them gun shy,” Dr. Felson noted.
One issue is OA has a long disease course, taking decades to progress and see changes, said Jason Kim, PhD, vice president for osteoarthritis research at the Arthritis Foundation in Atlanta.
The typical clinical trial window runs just 2-5 years, which is insufficient to see adequate results in a disease like OA. Longer trials are prohibitively costly, especially for corporations with near-term pressures, Dr. Kim said.
Many of these trials also apply disease-modifying drugs to participants with OA who are “too far gone” and beyond repair. By the time older people present with OA to the doctor, their disease is far advanced, and it may not be reversible or even stoppable, Dr. Felson said.
Finding patients with ACL reconstruction with ‘bad outcomes’
Dr. Kim and Dr. Felson have joined other researchers to test a new approach, using people with anterior cruciate ligament (ACL) reconstruction as a starting block to sleuth out OA tendencies years before it even begins.
When someone gets an ACL or meniscal tear, the knee in many cases begins the process of developing OA. However, that process can take 10-20 years, or sometimes even longer.
“We can’t do trials that last that long,” Dr. Felson said. But there are a few people who do quickly develop OA when they sustain those injuries. “If we can grab those people and get them involved in a study where we test treatments, we could probably figure out what kinds of treatments would be effective,” Dr. Felson explained.
The challenge is finding enough patients with ACL reconstruction with bad outcomes to effectively study OA prevention and treatment. While that sounds unfortunate, “it’s what we needed,” Dr. Felson said.
A longitudinal study known as the MOON trial that tracked 2,340 ACL reconstruction cases offered some initial clues, providing a foundation for future research. Dr. Felson and Dr. Kim joined lead researcher Kurt Spindler, MD, to create the “MOON” cohort for people who underwent surgery after an ACL tear, following them for a decade.
Through the MOON trial, Spindler et al. were able to assess how many people developed OA over 2, 6, and 10 years of follow-up, and how many experienced pain.
“It allowed us to guesstimate whether we were going to have enough numbers of people getting bad outcomes to see if we could get enough numbers to treat,” Dr. Felson said.
Clinical trial to test FastOA criteria
The Arthritis Foundation, which funded the MOON trial along with the National Institutes of Health and The American Orthopaedic Society for Sports Medicine, launched the FastOA initiative, based on its findings.
FastOA is defined as “the rapid development of OA in those who have sustained a major joint injury.” One criterion for FastOA is older age. Eighteen- to 25-year-olds generally don’t have high risk for injury or OA. “It’s only when you get to your late 20s and 30s where your risk really starts to increase substantially, just like the risk of osteoarthritis does,” Dr. Felson said.
The other major risk factor for FastOA is pain. Pain after ACL reconstruction usually takes a long time to surface. Many people never experience pain. However, for a subgroup of people who get ACL reconstruction, their pain never goes away. “What the MOON data told us was that those are the people who continue to have pain later and who get osteoarthritis quicker,” he added.
The MOON results also informed researchers on the types of patients they should seek out for a future trial. “We wouldn’t just take everybody with ACL reconstructions. We’d take selected people who we knew based on the MOON data were at really high likelihood of developing FastOA,” Dr. Felson said .
Armed with these risk factors, Dr. Felson and colleagues plan to apply FastOA to a new clinical trial, Post-Injury Knee Arthritis Severity Outcomes (PIKASO), that will test the use of metformin, a well-known diabetes drug, in 500 patients at high risk of developing post-traumatic OA in the knee following ACL reconstruction.
Two groups will participate in the PIKASO trial, an initiative of the Arthritis Foundation’s Osteoarthritis Clinical Trials Network (OA-CTN).
“If you have pain at the time of ACL reconstruction, we are interested in you. And if even you don’t have pain, if you’re among older people who need ACL reconstruction, we’re also interested in you,” Dr. Felson said.
People aged 25-40 are eligible for the older category and those 18-40 are eligible for the pain group. It’s important to include younger people in the study, Dr. Felson said. One of his colleagues, a physical therapist, was disabled by a sports injury in her late teens. Now in her 30s, she’s disabled by OA and will have to wait up to 15 years to qualify for a knee replacement.
“It’s a good idea for us to focus in on the younger folks who develop osteoarthritis at a very early age where there’s nothing we can do for them in terms of surgical options for a few years,” he said.
Targeting specific groups means fewer patients will need to be followed over the period of the study, which will lower costs, Dr. Kim said.
Metformin, a popular diabetes drug with a good safety profile, is an ideal treatment for this trial, Dr. Felson said. It’s been tested in multiple animal models and has been shown to protect against OA in all those models.
Researchers will employ imaging and biomechanics measurements to assess changes in joint structure. Eight institutions will participate, including Mass General Brigham, the trial’s clinical coordinating center, and the Cleveland Clinic and University of North Carolina at Chapel Hill, which will coordinate the collection and analysis of MRI data and biomechanical and function assessments, respectively.
“Positive results from this trial would have the potential to enable surgeons to immediately prescribe the drug before a patient undergoes surgery to slow the disease progression, or even fully prevent” post-traumatic OA, according to a statement from the Arthritis Foundation.
‘We’re taking a leap’
PIKASO doesn’t come without its challenges. “There’s a lot of dangers here,” Dr. Felson acknowledged.
Even with the application of the FastOA risk factors, not enough people may end up getting OA. “We could do an expensive study with 500 people and not get enough people with OA to be able to test a treatment,” he said.
Another risk is metformin might not work in these participants to prevent disease. “We’re taking a leap and we’re hoping that leap works out,” Dr. Felson added.
Physicians outside of this project are hopeful that FastOA will facilitate the development of new OA therapeutic strategies.
“We all intuitively understand that a joint injury will increase our risk of arthritis in 5, 10 years, even 20 years if we’re lucky,” said Dominik R. Haudenschild, PhD, professor and director of translational orthopaedic research at Houston Methodist Academic Institute.
Most patients with a painful joint can recall when an injury took place. Focusing on treatments closer to the time of injury before irreversible disease sets in makes sense, he added.
The MOON researchers found that pain is not uncommon in patients with ACL reconstruction, making them an excellent choice for analysis, Dr. Haudenschild continued.
PIKASO could face some limitations, specifically with respect to the effect size – how big of a difference a treatment can make the moment a measurement is taken.
“If we’re looking at earlier disease, the intensity of pain is likely lower, or pain isn’t felt as frequently, or the extent of structural damage in the joint is smaller,” he explained. Even a perfect treatment would only make a smaller difference at the moment measurements are taken, which can be harder to measure.
“But I expect that many of the limitations can likely be overcome by making sure the appropriate outcomes are chosen,” he said.
Nancy E. Lane, MD, professor of medicine and rheumatology at UC Davis Health System, is hoping the research will better inform physicians and patients about ACL tears. They should be aware “that within a few months of an ACL injury, the bone structure around the joint changes and there are cartilage changes,” Dr. Lane said.
While early changes may not necessarily lead to OA, patients who develop joint pain with activity or joint swelling would benefit from education, additional imaging, and modifying their activities to prevent progression, she said.
“Hopefully, within a few years we will have effective treatments to slow or reverse the development of knee OA,” Dr. Lane said.
The PIKASO trial is scheduled to begin enrollment at the end of this year or in early 2024.
Dr. Felson is a board member and past and current awardee of the Arthritis Foundation. Dr. Kim is a staff member of the Arthritis Foundation. Dr. Haudenschild received a grant from the Arthritis Foundation and participates in local, regional, and national activities with the Arthritis Foundation. Dr. Lane had no disclosures.
David Felson, MD, MPH, often steps out of his physician’s role to help patients with osteoarthritis (OA). “I have one now who needed me to write to her landlord to get her to a ground floor apartment because she’s unable to navigate the stairs,” said Dr. Felson, a professor of medicine and epidemiology at Boston University.
Rheumatologists don’t have a lot of options to treat patients with OA, Dr. Felson said. The most effective treatments are NSAIDs. While reasonably effective, they have a lot of side effects and are not always safe to use, he said.
Exercise also works, but people don’t adhere to it after a while. “Another useful strategy is getting cortisone injections into the affected joint, but that doesn’t last for very long, and I think we’re all reluctant to do it over and over again,” Dr. Felson said.
Some might say, “Well, why can’t they just get a knee replacement?” Many patients don’t want the surgery, and others are too frail to qualify. They’re also not 100% successful. Patients after the surgery sometimes say that they’re still in pain.
There’s an urgent need for more effective therapies, said Dr. Felson, who’s been working on a unique approach to target patients at high risk for OA by studying two specific populations who sustain knee injury.
Previous clinical trials have failed
Clinical trials to test OA treatments have run into some roadblocks. The market for this is enormous, with the potential to benefit millions of patients, Dr. Felson continued.
However, very few large pharmaceutical companies or even biotech companies are pursuing treatment development in osteoarthritis because there have been a lot of expensive failures. “It’s made them gun shy,” Dr. Felson noted.
One issue is OA has a long disease course, taking decades to progress and see changes, said Jason Kim, PhD, vice president for osteoarthritis research at the Arthritis Foundation in Atlanta.
The typical clinical trial window runs just 2-5 years, which is insufficient to see adequate results in a disease like OA. Longer trials are prohibitively costly, especially for corporations with near-term pressures, Dr. Kim said.
Many of these trials also apply disease-modifying drugs to participants with OA who are “too far gone” and beyond repair. By the time older people present with OA to the doctor, their disease is far advanced, and it may not be reversible or even stoppable, Dr. Felson said.
Finding patients with ACL reconstruction with ‘bad outcomes’
Dr. Kim and Dr. Felson have joined other researchers to test a new approach, using people with anterior cruciate ligament (ACL) reconstruction as a starting block to sleuth out OA tendencies years before it even begins.
When someone gets an ACL or meniscal tear, the knee in many cases begins the process of developing OA. However, that process can take 10-20 years, or sometimes even longer.
“We can’t do trials that last that long,” Dr. Felson said. But there are a few people who do quickly develop OA when they sustain those injuries. “If we can grab those people and get them involved in a study where we test treatments, we could probably figure out what kinds of treatments would be effective,” Dr. Felson explained.
The challenge is finding enough patients with ACL reconstruction with bad outcomes to effectively study OA prevention and treatment. While that sounds unfortunate, “it’s what we needed,” Dr. Felson said.
A longitudinal study known as the MOON trial that tracked 2,340 ACL reconstruction cases offered some initial clues, providing a foundation for future research. Dr. Felson and Dr. Kim joined lead researcher Kurt Spindler, MD, to create the “MOON” cohort for people who underwent surgery after an ACL tear, following them for a decade.
Through the MOON trial, Spindler et al. were able to assess how many people developed OA over 2, 6, and 10 years of follow-up, and how many experienced pain.
“It allowed us to guesstimate whether we were going to have enough numbers of people getting bad outcomes to see if we could get enough numbers to treat,” Dr. Felson said.
Clinical trial to test FastOA criteria
The Arthritis Foundation, which funded the MOON trial along with the National Institutes of Health and The American Orthopaedic Society for Sports Medicine, launched the FastOA initiative, based on its findings.
FastOA is defined as “the rapid development of OA in those who have sustained a major joint injury.” One criterion for FastOA is older age. Eighteen- to 25-year-olds generally don’t have high risk for injury or OA. “It’s only when you get to your late 20s and 30s where your risk really starts to increase substantially, just like the risk of osteoarthritis does,” Dr. Felson said.
The other major risk factor for FastOA is pain. Pain after ACL reconstruction usually takes a long time to surface. Many people never experience pain. However, for a subgroup of people who get ACL reconstruction, their pain never goes away. “What the MOON data told us was that those are the people who continue to have pain later and who get osteoarthritis quicker,” he added.
The MOON results also informed researchers on the types of patients they should seek out for a future trial. “We wouldn’t just take everybody with ACL reconstructions. We’d take selected people who we knew based on the MOON data were at really high likelihood of developing FastOA,” Dr. Felson said .
Armed with these risk factors, Dr. Felson and colleagues plan to apply FastOA to a new clinical trial, Post-Injury Knee Arthritis Severity Outcomes (PIKASO), that will test the use of metformin, a well-known diabetes drug, in 500 patients at high risk of developing post-traumatic OA in the knee following ACL reconstruction.
Two groups will participate in the PIKASO trial, an initiative of the Arthritis Foundation’s Osteoarthritis Clinical Trials Network (OA-CTN).
“If you have pain at the time of ACL reconstruction, we are interested in you. And if even you don’t have pain, if you’re among older people who need ACL reconstruction, we’re also interested in you,” Dr. Felson said.
People aged 25-40 are eligible for the older category and those 18-40 are eligible for the pain group. It’s important to include younger people in the study, Dr. Felson said. One of his colleagues, a physical therapist, was disabled by a sports injury in her late teens. Now in her 30s, she’s disabled by OA and will have to wait up to 15 years to qualify for a knee replacement.
“It’s a good idea for us to focus in on the younger folks who develop osteoarthritis at a very early age where there’s nothing we can do for them in terms of surgical options for a few years,” he said.
Targeting specific groups means fewer patients will need to be followed over the period of the study, which will lower costs, Dr. Kim said.
Metformin, a popular diabetes drug with a good safety profile, is an ideal treatment for this trial, Dr. Felson said. It’s been tested in multiple animal models and has been shown to protect against OA in all those models.
Researchers will employ imaging and biomechanics measurements to assess changes in joint structure. Eight institutions will participate, including Mass General Brigham, the trial’s clinical coordinating center, and the Cleveland Clinic and University of North Carolina at Chapel Hill, which will coordinate the collection and analysis of MRI data and biomechanical and function assessments, respectively.
“Positive results from this trial would have the potential to enable surgeons to immediately prescribe the drug before a patient undergoes surgery to slow the disease progression, or even fully prevent” post-traumatic OA, according to a statement from the Arthritis Foundation.
‘We’re taking a leap’
PIKASO doesn’t come without its challenges. “There’s a lot of dangers here,” Dr. Felson acknowledged.
Even with the application of the FastOA risk factors, not enough people may end up getting OA. “We could do an expensive study with 500 people and not get enough people with OA to be able to test a treatment,” he said.
Another risk is metformin might not work in these participants to prevent disease. “We’re taking a leap and we’re hoping that leap works out,” Dr. Felson added.
Physicians outside of this project are hopeful that FastOA will facilitate the development of new OA therapeutic strategies.
“We all intuitively understand that a joint injury will increase our risk of arthritis in 5, 10 years, even 20 years if we’re lucky,” said Dominik R. Haudenschild, PhD, professor and director of translational orthopaedic research at Houston Methodist Academic Institute.
Most patients with a painful joint can recall when an injury took place. Focusing on treatments closer to the time of injury before irreversible disease sets in makes sense, he added.
The MOON researchers found that pain is not uncommon in patients with ACL reconstruction, making them an excellent choice for analysis, Dr. Haudenschild continued.
PIKASO could face some limitations, specifically with respect to the effect size – how big of a difference a treatment can make the moment a measurement is taken.
“If we’re looking at earlier disease, the intensity of pain is likely lower, or pain isn’t felt as frequently, or the extent of structural damage in the joint is smaller,” he explained. Even a perfect treatment would only make a smaller difference at the moment measurements are taken, which can be harder to measure.
“But I expect that many of the limitations can likely be overcome by making sure the appropriate outcomes are chosen,” he said.
Nancy E. Lane, MD, professor of medicine and rheumatology at UC Davis Health System, is hoping the research will better inform physicians and patients about ACL tears. They should be aware “that within a few months of an ACL injury, the bone structure around the joint changes and there are cartilage changes,” Dr. Lane said.
While early changes may not necessarily lead to OA, patients who develop joint pain with activity or joint swelling would benefit from education, additional imaging, and modifying their activities to prevent progression, she said.
“Hopefully, within a few years we will have effective treatments to slow or reverse the development of knee OA,” Dr. Lane said.
The PIKASO trial is scheduled to begin enrollment at the end of this year or in early 2024.
Dr. Felson is a board member and past and current awardee of the Arthritis Foundation. Dr. Kim is a staff member of the Arthritis Foundation. Dr. Haudenschild received a grant from the Arthritis Foundation and participates in local, regional, and national activities with the Arthritis Foundation. Dr. Lane had no disclosures.
David Felson, MD, MPH, often steps out of his physician’s role to help patients with osteoarthritis (OA). “I have one now who needed me to write to her landlord to get her to a ground floor apartment because she’s unable to navigate the stairs,” said Dr. Felson, a professor of medicine and epidemiology at Boston University.
Rheumatologists don’t have a lot of options to treat patients with OA, Dr. Felson said. The most effective treatments are NSAIDs. While reasonably effective, they have a lot of side effects and are not always safe to use, he said.
Exercise also works, but people don’t adhere to it after a while. “Another useful strategy is getting cortisone injections into the affected joint, but that doesn’t last for very long, and I think we’re all reluctant to do it over and over again,” Dr. Felson said.
Some might say, “Well, why can’t they just get a knee replacement?” Many patients don’t want the surgery, and others are too frail to qualify. They’re also not 100% successful. Patients after the surgery sometimes say that they’re still in pain.
There’s an urgent need for more effective therapies, said Dr. Felson, who’s been working on a unique approach to target patients at high risk for OA by studying two specific populations who sustain knee injury.
Previous clinical trials have failed
Clinical trials to test OA treatments have run into some roadblocks. The market for this is enormous, with the potential to benefit millions of patients, Dr. Felson continued.
However, very few large pharmaceutical companies or even biotech companies are pursuing treatment development in osteoarthritis because there have been a lot of expensive failures. “It’s made them gun shy,” Dr. Felson noted.
One issue is OA has a long disease course, taking decades to progress and see changes, said Jason Kim, PhD, vice president for osteoarthritis research at the Arthritis Foundation in Atlanta.
The typical clinical trial window runs just 2-5 years, which is insufficient to see adequate results in a disease like OA. Longer trials are prohibitively costly, especially for corporations with near-term pressures, Dr. Kim said.
Many of these trials also apply disease-modifying drugs to participants with OA who are “too far gone” and beyond repair. By the time older people present with OA to the doctor, their disease is far advanced, and it may not be reversible or even stoppable, Dr. Felson said.
Finding patients with ACL reconstruction with ‘bad outcomes’
Dr. Kim and Dr. Felson have joined other researchers to test a new approach, using people with anterior cruciate ligament (ACL) reconstruction as a starting block to sleuth out OA tendencies years before it even begins.
When someone gets an ACL or meniscal tear, the knee in many cases begins the process of developing OA. However, that process can take 10-20 years, or sometimes even longer.
“We can’t do trials that last that long,” Dr. Felson said. But there are a few people who do quickly develop OA when they sustain those injuries. “If we can grab those people and get them involved in a study where we test treatments, we could probably figure out what kinds of treatments would be effective,” Dr. Felson explained.
The challenge is finding enough patients with ACL reconstruction with bad outcomes to effectively study OA prevention and treatment. While that sounds unfortunate, “it’s what we needed,” Dr. Felson said.
A longitudinal study known as the MOON trial that tracked 2,340 ACL reconstruction cases offered some initial clues, providing a foundation for future research. Dr. Felson and Dr. Kim joined lead researcher Kurt Spindler, MD, to create the “MOON” cohort for people who underwent surgery after an ACL tear, following them for a decade.
Through the MOON trial, Spindler et al. were able to assess how many people developed OA over 2, 6, and 10 years of follow-up, and how many experienced pain.
“It allowed us to guesstimate whether we were going to have enough numbers of people getting bad outcomes to see if we could get enough numbers to treat,” Dr. Felson said.
Clinical trial to test FastOA criteria
The Arthritis Foundation, which funded the MOON trial along with the National Institutes of Health and The American Orthopaedic Society for Sports Medicine, launched the FastOA initiative, based on its findings.
FastOA is defined as “the rapid development of OA in those who have sustained a major joint injury.” One criterion for FastOA is older age. Eighteen- to 25-year-olds generally don’t have high risk for injury or OA. “It’s only when you get to your late 20s and 30s where your risk really starts to increase substantially, just like the risk of osteoarthritis does,” Dr. Felson said.
The other major risk factor for FastOA is pain. Pain after ACL reconstruction usually takes a long time to surface. Many people never experience pain. However, for a subgroup of people who get ACL reconstruction, their pain never goes away. “What the MOON data told us was that those are the people who continue to have pain later and who get osteoarthritis quicker,” he added.
The MOON results also informed researchers on the types of patients they should seek out for a future trial. “We wouldn’t just take everybody with ACL reconstructions. We’d take selected people who we knew based on the MOON data were at really high likelihood of developing FastOA,” Dr. Felson said .
Armed with these risk factors, Dr. Felson and colleagues plan to apply FastOA to a new clinical trial, Post-Injury Knee Arthritis Severity Outcomes (PIKASO), that will test the use of metformin, a well-known diabetes drug, in 500 patients at high risk of developing post-traumatic OA in the knee following ACL reconstruction.
Two groups will participate in the PIKASO trial, an initiative of the Arthritis Foundation’s Osteoarthritis Clinical Trials Network (OA-CTN).
“If you have pain at the time of ACL reconstruction, we are interested in you. And if even you don’t have pain, if you’re among older people who need ACL reconstruction, we’re also interested in you,” Dr. Felson said.
People aged 25-40 are eligible for the older category and those 18-40 are eligible for the pain group. It’s important to include younger people in the study, Dr. Felson said. One of his colleagues, a physical therapist, was disabled by a sports injury in her late teens. Now in her 30s, she’s disabled by OA and will have to wait up to 15 years to qualify for a knee replacement.
“It’s a good idea for us to focus in on the younger folks who develop osteoarthritis at a very early age where there’s nothing we can do for them in terms of surgical options for a few years,” he said.
Targeting specific groups means fewer patients will need to be followed over the period of the study, which will lower costs, Dr. Kim said.
Metformin, a popular diabetes drug with a good safety profile, is an ideal treatment for this trial, Dr. Felson said. It’s been tested in multiple animal models and has been shown to protect against OA in all those models.
Researchers will employ imaging and biomechanics measurements to assess changes in joint structure. Eight institutions will participate, including Mass General Brigham, the trial’s clinical coordinating center, and the Cleveland Clinic and University of North Carolina at Chapel Hill, which will coordinate the collection and analysis of MRI data and biomechanical and function assessments, respectively.
“Positive results from this trial would have the potential to enable surgeons to immediately prescribe the drug before a patient undergoes surgery to slow the disease progression, or even fully prevent” post-traumatic OA, according to a statement from the Arthritis Foundation.
‘We’re taking a leap’
PIKASO doesn’t come without its challenges. “There’s a lot of dangers here,” Dr. Felson acknowledged.
Even with the application of the FastOA risk factors, not enough people may end up getting OA. “We could do an expensive study with 500 people and not get enough people with OA to be able to test a treatment,” he said.
Another risk is metformin might not work in these participants to prevent disease. “We’re taking a leap and we’re hoping that leap works out,” Dr. Felson added.
Physicians outside of this project are hopeful that FastOA will facilitate the development of new OA therapeutic strategies.
“We all intuitively understand that a joint injury will increase our risk of arthritis in 5, 10 years, even 20 years if we’re lucky,” said Dominik R. Haudenschild, PhD, professor and director of translational orthopaedic research at Houston Methodist Academic Institute.
Most patients with a painful joint can recall when an injury took place. Focusing on treatments closer to the time of injury before irreversible disease sets in makes sense, he added.
The MOON researchers found that pain is not uncommon in patients with ACL reconstruction, making them an excellent choice for analysis, Dr. Haudenschild continued.
PIKASO could face some limitations, specifically with respect to the effect size – how big of a difference a treatment can make the moment a measurement is taken.
“If we’re looking at earlier disease, the intensity of pain is likely lower, or pain isn’t felt as frequently, or the extent of structural damage in the joint is smaller,” he explained. Even a perfect treatment would only make a smaller difference at the moment measurements are taken, which can be harder to measure.
“But I expect that many of the limitations can likely be overcome by making sure the appropriate outcomes are chosen,” he said.
Nancy E. Lane, MD, professor of medicine and rheumatology at UC Davis Health System, is hoping the research will better inform physicians and patients about ACL tears. They should be aware “that within a few months of an ACL injury, the bone structure around the joint changes and there are cartilage changes,” Dr. Lane said.
While early changes may not necessarily lead to OA, patients who develop joint pain with activity or joint swelling would benefit from education, additional imaging, and modifying their activities to prevent progression, she said.
“Hopefully, within a few years we will have effective treatments to slow or reverse the development of knee OA,” Dr. Lane said.
The PIKASO trial is scheduled to begin enrollment at the end of this year or in early 2024.
Dr. Felson is a board member and past and current awardee of the Arthritis Foundation. Dr. Kim is a staff member of the Arthritis Foundation. Dr. Haudenschild received a grant from the Arthritis Foundation and participates in local, regional, and national activities with the Arthritis Foundation. Dr. Lane had no disclosures.
GI docs’ nutrition education deficit may shortchange patients
Yevgenia Pashinsky, MD, has seen her share of patients who have bounced from one gastroenterologist to the next after becoming frustrated when food elimination, supplements, or medications don’t alleviate their gastrointestinal symptoms.
In most cases, their decision to switch gastroenterologists comes down to a simple fact: No one dissected their diets.
The situation underscores how essential it is for gastroenterologists to be comfortable with nutrition concepts, said Dr. Pashinsky, a gastroenterologist with New York Gastroenterology Associates and affiliated with Mount Sinai Hospital in New York.
“There should be a focus in recognizing patterns that will help the physician pinpoint triggers, thereby helping identify the underlying disorder and guide further diagnostic and treatment options,” she said.
Although many common digestive diseases and their corresponding outcomes are linked to dietary quality and are complicated by poor nutrition and/or obesity, nutrition often gets pushed to the wayside in GI education, write Carolyn Newberry, MD, Brandon Sprung, MD, and Octavia Pickett-Blakely, MD, MHS, in a recent analysis.
“Gastroenterology fellows report limited exposure to nutrition topics leading to knowledge deficit on assessment,” they add.
One 2022 studybased on a survey of 279 GI clinicians treating patients with irritable bowel syndrome (IBS) reported that only 56% felt that they were trained to provide nutrition education, and 46% said that they sometimes, rarely, or never offered to help patients with their menu planning, label reading, or grocery shopping. And 77% said that they spent 10 minutes or less counseling patients on nutrition. Though almost all respondents (91%) said that having access to a dietitian would help them better manage patients with IBS, 42% said that they lack access to one.
But some gastroenterology professors are working to incorporate nutrition into GI training and integrating dietitians in their work with fellows as well as collaborating with dietitians to improve care in their own practices.
Nutrition overlooked in procedure-heavy specialty
In 1985, the National Academies of Sciences, Engineering, and Medicine made recommendations to upgrade nutrition education programs in U.S. medical schools.
Still, medical schools often don’t have the faculty or infrastructure to integrate and teach foundational nutrition concepts. These topics include clinical concepts, such as protein, carbohydrate and fat digestion/absorption, weight loss/gain, and symptoms related to food intake, as well as physical examination, which can help identify nutritional risks, said Dr. Pickett-Blakely, an associate professor of clinical medicine at the University of Pennsylvania and director of the Penn Center for GI Nutrition, both in Philadelphia.
Standardized medical exams include only about five questions on nutrition, and they’re all geared toward pathology, Dr. Pashinsky noted.
GI training, which includes 3 years of internal medicine residency and 3 years of GI fellowship, typically doesn’t focus on nutrition beyond total and peripheral parenteral nutrition and nutritional deficiencies, Dr. Pashinsky said. Instead, it focuses on the recognition, diagnosis, and medical management of GI diseases.
The Accreditation Council for Graduate Medical Education requires that fellows demonstrate core competency in nutrition and in the prevention, evaluation, and management of disorders of nutrient assimilation. The council also has incorporated the opportunity to interact with and learn from dietitians in its requirements for GI fellowship programs. Fellows in the dual GI/transplant hepatology pathway, created in 2021, must show competency in nutritional support for patients with chronic liver disease and in the factors involved in nutrition and malnutrition and their management.
Despite these requirements, the education that fellows receive often falls short for several reasons, said Dr. Sprung, an associate professor of medicine at the University of Rochester Medical Center’s gastroenterology and hepatology division in New York.
Gastroenterology faculties have generally shown a lack of interest in nutrition, translating into fewer faculty members able to train the future generations of physicians, he said. Training institutions have limited nutrition and obesity resources, staff, and support.
Gastroenterology is also a very procedure-focused specialty, and many students and trainees come to fellowships for procedural training, Dr. Sprung noted. Nutrition and obesity training don’t fit as well into what is traditionally an organ- or disease-specific style of education and training and, as a result, are superseded, he added.
It is possible that some fellowships are just not teaching these core concepts, Dr. Pickett-Blakely said. “The depth and breath of coverage of these concepts varies from program to program,” she added.
Exacerbating the problem is the growth of numerous subspecialties, including inflammatory bowel diseases, hepatobiliary disease, neurogastroenterology, and gastrointestinal motility, Dr. Pickett-Blakely said. Emphasis has dwindled over time on an in-depth understanding of core gastrointestinal functions, like digestion and absorption, and how these functions can be supported for optimal wellness and are affected by diseases.
“With the loss of those with the ability to educate trainees, nutrition sort of falls out of curricula, and trainees aren’t able to be exposed to those educational concepts,” she said.
It would be ideal if foundational concepts of nutrition were integrated into the subspecialty GI fellowships, which are 1-year fellowships that take place before or after the 3-year traditional fellowship, Dr. Pickett-Blakely said.
GI fellows interested in incorporating nutrition and obesity in their clinical practice on a routine basis could investigate getting board certified in nutrition, Dr. Sprung said. The National Board of Physician Nutrition Specialists, the National Board for Nutrition Support, and several other organizations offer certifications in nutrition.
If more physicians became board certified in nutritional or obesity specialties, teaching faculty numbers would increase, and that could help training grow, he noted.
Weaving more nutrition into training
To further increase knowledge, Dr. Sprung and Dr. Newberry, who is an assistant professor and director of GI nutrition at Weill Cornell Medicine’s Innovative Center for Health and Nutrition in Gastroenterology in New York, have created a free online resource covering core nutrition and obesity concepts that is available to GI fellowship programs.
Key components of the curriculum include online pre- and postlearning tests, self-directed reading materials, virtual recorded lectures, and case-based learning modules. It also provides a section on care coordination with a GI dietitian.
“Because the curriculum spans all facets of gastroenterology practice, the information can enhance clinical care experiences on general rotations,” write Dr. Newberry and colleagues in their recent analysis in Gastroenterology.
GI fellows can look at the content at their own pace and complete the curriculum as part of a formal elective.
The developers can see who’s taken the tests, and test participation indicates that several GI programs across the country are already using the program, Dr. Sprung said.
But it hasn’t been as widely adopted as hoped, he said.
“We’re trying to put some spotlight on it through articles, presentations during Digestive Disease Week, and emails to program directors, things like that,” Dr. Sprung said. “So it’s great to spread the word and get the message out there.”
Collaboration in practice
Ultimately, helping a patient with functional GI problems takes a village, and many practices are now including multidisciplinary teams.
Having these dietitians available to them, as well as seeing the benefit to their patients first-hand, has helped encourage the attending gastroenterologists’ interest, said Nancee Jaffe, RD, MS, who is senior supervisor for the GI nutrition program at UCLA Health’s Vatche & Tamar Manoukian Division of Digestive Diseases in Beverly Hills, Calif.
“We all subspecialize, which allows both doctors and patients access to the best nutrition information for a myriad of GI conditions,” Ms. Jaffe said.
In the spirit of teamwork, the university also has an integrative digestive health and wellness program, which is inclusive of doctors, dietitians, and psychologists. These teams meet monthly to discuss cases involving disorders of gut-brain interaction using a multicentered approach, she said.
In New York, one of the first things Dr. Newberry, who is also a clinical gastroenterologist with advanced training in nutrition and obesity sciences, did when she accepted her job at Weill Cornell was to advocate for a multidisciplinary team. At the Innovative Center for Health and Nutrition in Gastroenterology, she works with a group of dietitians, a hepatologist, an endocrinologist, and a team of surgeons to take care of patients. The focus is on treating patients’ GI issues while helping them lose weight.
The clinic sees a lot of patients with reflux disease and fatty liver disease. When patients come in, they’ll see the gastroenterologist, the dietitian, the endocrinologist, and possibly the bariatric surgeon. The team approach, which calls for constant communication among the physicians, improves outcomes, Dr. Newberry said.
It has been shown in the literature that multidisciplinary teams are effective for chronic diseases like nonalcoholic fatty liver disease (now known as metabolic dysfunction-associated steatotic liver disease) and inflammatory bowel disease, she added.
At the University of Rochester, Dr. Sprung and his fellow gastroenterologists coordinate with dietitians and nutrition experts for nutrition support services, as well as liver and transplant nutritional services.
We have nurse practitioners and physician assistants who run our nutritional support services for people who need such specialized care, such as total parenteral nutrition or tube feeds, or for those who need advanced therapies, like for short-gut syndrome, he said.
At NYGA, Dr. Pashinsky works with a team of registered dietitians who have specialized in gastroenterology. The dietitians help with identifying which foods in a patient’s diet are problematic and making recommendations to replace them with nutritionally equivalent staples to avoid dietary gaps, she said.
Dietitians inform patient care because they’re trained in food compounds and how foods pass through the GI tract, said Tamara Duker Freuman, RD, MS, CDN, who leads the group of registered dietitians at NYGA. Ms. Freuman comanages many patients with Dr. Pashinsky.
Oftentimes, the patient provides insights they never tell the doctor, and the dietitian gets a better idea of the patient’s life and eating habits, she said. “We’re able to spend more time with patients than physicians are, and we ask different questions.”
“Any detective work I do informs any future diagnostics [Dr. Pashinsky] does. It’s a team sport,” Ms. Freuman said.Dr. Pickett-Blakely has been a consultant for Novo Nordisk and WebMD. Dr. Newberry has received a speaking honorarium for Baxter and InBody. Dr. Sprung, Dr. Pashinsky, Ms. Freuman, and Ms. Jaffe reported no disclosures.
A version of this article first appeared on Medscape.com.
Yevgenia Pashinsky, MD, has seen her share of patients who have bounced from one gastroenterologist to the next after becoming frustrated when food elimination, supplements, or medications don’t alleviate their gastrointestinal symptoms.
In most cases, their decision to switch gastroenterologists comes down to a simple fact: No one dissected their diets.
The situation underscores how essential it is for gastroenterologists to be comfortable with nutrition concepts, said Dr. Pashinsky, a gastroenterologist with New York Gastroenterology Associates and affiliated with Mount Sinai Hospital in New York.
“There should be a focus in recognizing patterns that will help the physician pinpoint triggers, thereby helping identify the underlying disorder and guide further diagnostic and treatment options,” she said.
Although many common digestive diseases and their corresponding outcomes are linked to dietary quality and are complicated by poor nutrition and/or obesity, nutrition often gets pushed to the wayside in GI education, write Carolyn Newberry, MD, Brandon Sprung, MD, and Octavia Pickett-Blakely, MD, MHS, in a recent analysis.
“Gastroenterology fellows report limited exposure to nutrition topics leading to knowledge deficit on assessment,” they add.
One 2022 studybased on a survey of 279 GI clinicians treating patients with irritable bowel syndrome (IBS) reported that only 56% felt that they were trained to provide nutrition education, and 46% said that they sometimes, rarely, or never offered to help patients with their menu planning, label reading, or grocery shopping. And 77% said that they spent 10 minutes or less counseling patients on nutrition. Though almost all respondents (91%) said that having access to a dietitian would help them better manage patients with IBS, 42% said that they lack access to one.
But some gastroenterology professors are working to incorporate nutrition into GI training and integrating dietitians in their work with fellows as well as collaborating with dietitians to improve care in their own practices.
Nutrition overlooked in procedure-heavy specialty
In 1985, the National Academies of Sciences, Engineering, and Medicine made recommendations to upgrade nutrition education programs in U.S. medical schools.
Still, medical schools often don’t have the faculty or infrastructure to integrate and teach foundational nutrition concepts. These topics include clinical concepts, such as protein, carbohydrate and fat digestion/absorption, weight loss/gain, and symptoms related to food intake, as well as physical examination, which can help identify nutritional risks, said Dr. Pickett-Blakely, an associate professor of clinical medicine at the University of Pennsylvania and director of the Penn Center for GI Nutrition, both in Philadelphia.
Standardized medical exams include only about five questions on nutrition, and they’re all geared toward pathology, Dr. Pashinsky noted.
GI training, which includes 3 years of internal medicine residency and 3 years of GI fellowship, typically doesn’t focus on nutrition beyond total and peripheral parenteral nutrition and nutritional deficiencies, Dr. Pashinsky said. Instead, it focuses on the recognition, diagnosis, and medical management of GI diseases.
The Accreditation Council for Graduate Medical Education requires that fellows demonstrate core competency in nutrition and in the prevention, evaluation, and management of disorders of nutrient assimilation. The council also has incorporated the opportunity to interact with and learn from dietitians in its requirements for GI fellowship programs. Fellows in the dual GI/transplant hepatology pathway, created in 2021, must show competency in nutritional support for patients with chronic liver disease and in the factors involved in nutrition and malnutrition and their management.
Despite these requirements, the education that fellows receive often falls short for several reasons, said Dr. Sprung, an associate professor of medicine at the University of Rochester Medical Center’s gastroenterology and hepatology division in New York.
Gastroenterology faculties have generally shown a lack of interest in nutrition, translating into fewer faculty members able to train the future generations of physicians, he said. Training institutions have limited nutrition and obesity resources, staff, and support.
Gastroenterology is also a very procedure-focused specialty, and many students and trainees come to fellowships for procedural training, Dr. Sprung noted. Nutrition and obesity training don’t fit as well into what is traditionally an organ- or disease-specific style of education and training and, as a result, are superseded, he added.
It is possible that some fellowships are just not teaching these core concepts, Dr. Pickett-Blakely said. “The depth and breath of coverage of these concepts varies from program to program,” she added.
Exacerbating the problem is the growth of numerous subspecialties, including inflammatory bowel diseases, hepatobiliary disease, neurogastroenterology, and gastrointestinal motility, Dr. Pickett-Blakely said. Emphasis has dwindled over time on an in-depth understanding of core gastrointestinal functions, like digestion and absorption, and how these functions can be supported for optimal wellness and are affected by diseases.
“With the loss of those with the ability to educate trainees, nutrition sort of falls out of curricula, and trainees aren’t able to be exposed to those educational concepts,” she said.
It would be ideal if foundational concepts of nutrition were integrated into the subspecialty GI fellowships, which are 1-year fellowships that take place before or after the 3-year traditional fellowship, Dr. Pickett-Blakely said.
GI fellows interested in incorporating nutrition and obesity in their clinical practice on a routine basis could investigate getting board certified in nutrition, Dr. Sprung said. The National Board of Physician Nutrition Specialists, the National Board for Nutrition Support, and several other organizations offer certifications in nutrition.
If more physicians became board certified in nutritional or obesity specialties, teaching faculty numbers would increase, and that could help training grow, he noted.
Weaving more nutrition into training
To further increase knowledge, Dr. Sprung and Dr. Newberry, who is an assistant professor and director of GI nutrition at Weill Cornell Medicine’s Innovative Center for Health and Nutrition in Gastroenterology in New York, have created a free online resource covering core nutrition and obesity concepts that is available to GI fellowship programs.
Key components of the curriculum include online pre- and postlearning tests, self-directed reading materials, virtual recorded lectures, and case-based learning modules. It also provides a section on care coordination with a GI dietitian.
“Because the curriculum spans all facets of gastroenterology practice, the information can enhance clinical care experiences on general rotations,” write Dr. Newberry and colleagues in their recent analysis in Gastroenterology.
GI fellows can look at the content at their own pace and complete the curriculum as part of a formal elective.
The developers can see who’s taken the tests, and test participation indicates that several GI programs across the country are already using the program, Dr. Sprung said.
But it hasn’t been as widely adopted as hoped, he said.
“We’re trying to put some spotlight on it through articles, presentations during Digestive Disease Week, and emails to program directors, things like that,” Dr. Sprung said. “So it’s great to spread the word and get the message out there.”
Collaboration in practice
Ultimately, helping a patient with functional GI problems takes a village, and many practices are now including multidisciplinary teams.
Having these dietitians available to them, as well as seeing the benefit to their patients first-hand, has helped encourage the attending gastroenterologists’ interest, said Nancee Jaffe, RD, MS, who is senior supervisor for the GI nutrition program at UCLA Health’s Vatche & Tamar Manoukian Division of Digestive Diseases in Beverly Hills, Calif.
“We all subspecialize, which allows both doctors and patients access to the best nutrition information for a myriad of GI conditions,” Ms. Jaffe said.
In the spirit of teamwork, the university also has an integrative digestive health and wellness program, which is inclusive of doctors, dietitians, and psychologists. These teams meet monthly to discuss cases involving disorders of gut-brain interaction using a multicentered approach, she said.
In New York, one of the first things Dr. Newberry, who is also a clinical gastroenterologist with advanced training in nutrition and obesity sciences, did when she accepted her job at Weill Cornell was to advocate for a multidisciplinary team. At the Innovative Center for Health and Nutrition in Gastroenterology, she works with a group of dietitians, a hepatologist, an endocrinologist, and a team of surgeons to take care of patients. The focus is on treating patients’ GI issues while helping them lose weight.
The clinic sees a lot of patients with reflux disease and fatty liver disease. When patients come in, they’ll see the gastroenterologist, the dietitian, the endocrinologist, and possibly the bariatric surgeon. The team approach, which calls for constant communication among the physicians, improves outcomes, Dr. Newberry said.
It has been shown in the literature that multidisciplinary teams are effective for chronic diseases like nonalcoholic fatty liver disease (now known as metabolic dysfunction-associated steatotic liver disease) and inflammatory bowel disease, she added.
At the University of Rochester, Dr. Sprung and his fellow gastroenterologists coordinate with dietitians and nutrition experts for nutrition support services, as well as liver and transplant nutritional services.
We have nurse practitioners and physician assistants who run our nutritional support services for people who need such specialized care, such as total parenteral nutrition or tube feeds, or for those who need advanced therapies, like for short-gut syndrome, he said.
At NYGA, Dr. Pashinsky works with a team of registered dietitians who have specialized in gastroenterology. The dietitians help with identifying which foods in a patient’s diet are problematic and making recommendations to replace them with nutritionally equivalent staples to avoid dietary gaps, she said.
Dietitians inform patient care because they’re trained in food compounds and how foods pass through the GI tract, said Tamara Duker Freuman, RD, MS, CDN, who leads the group of registered dietitians at NYGA. Ms. Freuman comanages many patients with Dr. Pashinsky.
Oftentimes, the patient provides insights they never tell the doctor, and the dietitian gets a better idea of the patient’s life and eating habits, she said. “We’re able to spend more time with patients than physicians are, and we ask different questions.”
“Any detective work I do informs any future diagnostics [Dr. Pashinsky] does. It’s a team sport,” Ms. Freuman said.Dr. Pickett-Blakely has been a consultant for Novo Nordisk and WebMD. Dr. Newberry has received a speaking honorarium for Baxter and InBody. Dr. Sprung, Dr. Pashinsky, Ms. Freuman, and Ms. Jaffe reported no disclosures.
A version of this article first appeared on Medscape.com.
Yevgenia Pashinsky, MD, has seen her share of patients who have bounced from one gastroenterologist to the next after becoming frustrated when food elimination, supplements, or medications don’t alleviate their gastrointestinal symptoms.
In most cases, their decision to switch gastroenterologists comes down to a simple fact: No one dissected their diets.
The situation underscores how essential it is for gastroenterologists to be comfortable with nutrition concepts, said Dr. Pashinsky, a gastroenterologist with New York Gastroenterology Associates and affiliated with Mount Sinai Hospital in New York.
“There should be a focus in recognizing patterns that will help the physician pinpoint triggers, thereby helping identify the underlying disorder and guide further diagnostic and treatment options,” she said.
Although many common digestive diseases and their corresponding outcomes are linked to dietary quality and are complicated by poor nutrition and/or obesity, nutrition often gets pushed to the wayside in GI education, write Carolyn Newberry, MD, Brandon Sprung, MD, and Octavia Pickett-Blakely, MD, MHS, in a recent analysis.
“Gastroenterology fellows report limited exposure to nutrition topics leading to knowledge deficit on assessment,” they add.
One 2022 studybased on a survey of 279 GI clinicians treating patients with irritable bowel syndrome (IBS) reported that only 56% felt that they were trained to provide nutrition education, and 46% said that they sometimes, rarely, or never offered to help patients with their menu planning, label reading, or grocery shopping. And 77% said that they spent 10 minutes or less counseling patients on nutrition. Though almost all respondents (91%) said that having access to a dietitian would help them better manage patients with IBS, 42% said that they lack access to one.
But some gastroenterology professors are working to incorporate nutrition into GI training and integrating dietitians in their work with fellows as well as collaborating with dietitians to improve care in their own practices.
Nutrition overlooked in procedure-heavy specialty
In 1985, the National Academies of Sciences, Engineering, and Medicine made recommendations to upgrade nutrition education programs in U.S. medical schools.
Still, medical schools often don’t have the faculty or infrastructure to integrate and teach foundational nutrition concepts. These topics include clinical concepts, such as protein, carbohydrate and fat digestion/absorption, weight loss/gain, and symptoms related to food intake, as well as physical examination, which can help identify nutritional risks, said Dr. Pickett-Blakely, an associate professor of clinical medicine at the University of Pennsylvania and director of the Penn Center for GI Nutrition, both in Philadelphia.
Standardized medical exams include only about five questions on nutrition, and they’re all geared toward pathology, Dr. Pashinsky noted.
GI training, which includes 3 years of internal medicine residency and 3 years of GI fellowship, typically doesn’t focus on nutrition beyond total and peripheral parenteral nutrition and nutritional deficiencies, Dr. Pashinsky said. Instead, it focuses on the recognition, diagnosis, and medical management of GI diseases.
The Accreditation Council for Graduate Medical Education requires that fellows demonstrate core competency in nutrition and in the prevention, evaluation, and management of disorders of nutrient assimilation. The council also has incorporated the opportunity to interact with and learn from dietitians in its requirements for GI fellowship programs. Fellows in the dual GI/transplant hepatology pathway, created in 2021, must show competency in nutritional support for patients with chronic liver disease and in the factors involved in nutrition and malnutrition and their management.
Despite these requirements, the education that fellows receive often falls short for several reasons, said Dr. Sprung, an associate professor of medicine at the University of Rochester Medical Center’s gastroenterology and hepatology division in New York.
Gastroenterology faculties have generally shown a lack of interest in nutrition, translating into fewer faculty members able to train the future generations of physicians, he said. Training institutions have limited nutrition and obesity resources, staff, and support.
Gastroenterology is also a very procedure-focused specialty, and many students and trainees come to fellowships for procedural training, Dr. Sprung noted. Nutrition and obesity training don’t fit as well into what is traditionally an organ- or disease-specific style of education and training and, as a result, are superseded, he added.
It is possible that some fellowships are just not teaching these core concepts, Dr. Pickett-Blakely said. “The depth and breath of coverage of these concepts varies from program to program,” she added.
Exacerbating the problem is the growth of numerous subspecialties, including inflammatory bowel diseases, hepatobiliary disease, neurogastroenterology, and gastrointestinal motility, Dr. Pickett-Blakely said. Emphasis has dwindled over time on an in-depth understanding of core gastrointestinal functions, like digestion and absorption, and how these functions can be supported for optimal wellness and are affected by diseases.
“With the loss of those with the ability to educate trainees, nutrition sort of falls out of curricula, and trainees aren’t able to be exposed to those educational concepts,” she said.
It would be ideal if foundational concepts of nutrition were integrated into the subspecialty GI fellowships, which are 1-year fellowships that take place before or after the 3-year traditional fellowship, Dr. Pickett-Blakely said.
GI fellows interested in incorporating nutrition and obesity in their clinical practice on a routine basis could investigate getting board certified in nutrition, Dr. Sprung said. The National Board of Physician Nutrition Specialists, the National Board for Nutrition Support, and several other organizations offer certifications in nutrition.
If more physicians became board certified in nutritional or obesity specialties, teaching faculty numbers would increase, and that could help training grow, he noted.
Weaving more nutrition into training
To further increase knowledge, Dr. Sprung and Dr. Newberry, who is an assistant professor and director of GI nutrition at Weill Cornell Medicine’s Innovative Center for Health and Nutrition in Gastroenterology in New York, have created a free online resource covering core nutrition and obesity concepts that is available to GI fellowship programs.
Key components of the curriculum include online pre- and postlearning tests, self-directed reading materials, virtual recorded lectures, and case-based learning modules. It also provides a section on care coordination with a GI dietitian.
“Because the curriculum spans all facets of gastroenterology practice, the information can enhance clinical care experiences on general rotations,” write Dr. Newberry and colleagues in their recent analysis in Gastroenterology.
GI fellows can look at the content at their own pace and complete the curriculum as part of a formal elective.
The developers can see who’s taken the tests, and test participation indicates that several GI programs across the country are already using the program, Dr. Sprung said.
But it hasn’t been as widely adopted as hoped, he said.
“We’re trying to put some spotlight on it through articles, presentations during Digestive Disease Week, and emails to program directors, things like that,” Dr. Sprung said. “So it’s great to spread the word and get the message out there.”
Collaboration in practice
Ultimately, helping a patient with functional GI problems takes a village, and many practices are now including multidisciplinary teams.
Having these dietitians available to them, as well as seeing the benefit to their patients first-hand, has helped encourage the attending gastroenterologists’ interest, said Nancee Jaffe, RD, MS, who is senior supervisor for the GI nutrition program at UCLA Health’s Vatche & Tamar Manoukian Division of Digestive Diseases in Beverly Hills, Calif.
“We all subspecialize, which allows both doctors and patients access to the best nutrition information for a myriad of GI conditions,” Ms. Jaffe said.
In the spirit of teamwork, the university also has an integrative digestive health and wellness program, which is inclusive of doctors, dietitians, and psychologists. These teams meet monthly to discuss cases involving disorders of gut-brain interaction using a multicentered approach, she said.
In New York, one of the first things Dr. Newberry, who is also a clinical gastroenterologist with advanced training in nutrition and obesity sciences, did when she accepted her job at Weill Cornell was to advocate for a multidisciplinary team. At the Innovative Center for Health and Nutrition in Gastroenterology, she works with a group of dietitians, a hepatologist, an endocrinologist, and a team of surgeons to take care of patients. The focus is on treating patients’ GI issues while helping them lose weight.
The clinic sees a lot of patients with reflux disease and fatty liver disease. When patients come in, they’ll see the gastroenterologist, the dietitian, the endocrinologist, and possibly the bariatric surgeon. The team approach, which calls for constant communication among the physicians, improves outcomes, Dr. Newberry said.
It has been shown in the literature that multidisciplinary teams are effective for chronic diseases like nonalcoholic fatty liver disease (now known as metabolic dysfunction-associated steatotic liver disease) and inflammatory bowel disease, she added.
At the University of Rochester, Dr. Sprung and his fellow gastroenterologists coordinate with dietitians and nutrition experts for nutrition support services, as well as liver and transplant nutritional services.
We have nurse practitioners and physician assistants who run our nutritional support services for people who need such specialized care, such as total parenteral nutrition or tube feeds, or for those who need advanced therapies, like for short-gut syndrome, he said.
At NYGA, Dr. Pashinsky works with a team of registered dietitians who have specialized in gastroenterology. The dietitians help with identifying which foods in a patient’s diet are problematic and making recommendations to replace them with nutritionally equivalent staples to avoid dietary gaps, she said.
Dietitians inform patient care because they’re trained in food compounds and how foods pass through the GI tract, said Tamara Duker Freuman, RD, MS, CDN, who leads the group of registered dietitians at NYGA. Ms. Freuman comanages many patients with Dr. Pashinsky.
Oftentimes, the patient provides insights they never tell the doctor, and the dietitian gets a better idea of the patient’s life and eating habits, she said. “We’re able to spend more time with patients than physicians are, and we ask different questions.”
“Any detective work I do informs any future diagnostics [Dr. Pashinsky] does. It’s a team sport,” Ms. Freuman said.Dr. Pickett-Blakely has been a consultant for Novo Nordisk and WebMD. Dr. Newberry has received a speaking honorarium for Baxter and InBody. Dr. Sprung, Dr. Pashinsky, Ms. Freuman, and Ms. Jaffe reported no disclosures.
A version of this article first appeared on Medscape.com.
New York GI advocates for team approach in GI care
“I was a little kid, so I wasn’t helping him,” but he said he learned a great deal by sitting in the hallways and listening to his father talk to patients. “I could clearly hear the human suffering on the other side.”
This experience had a big impact on Dr. Berry, who continues the family trade. Like his father, talking with patients about their condition is his favorite part of the job, but especially talking about the role of diet, lifestyle, and stress on GI health, said Dr. Berry, who is a gastroenterologist and clinical assistant professor of medicine at New York University’s Grossman School of Medicine.
In addition to his clinical practice, Dr.Berry serves as the co-founder & chief medical officer at Oshi Health. Oshi is an integrative healthcare clinic that is entirely virtual and entirely and solely about GI health. The clinic works with GI clinicians and other healthcare providers, allowing patients access to multidisciplinary care that has proven to reduce healthcare costs and improve patient outcomes. The company was recently named a recipient of funding through the American College of Gastroenterology and the American Gastroenterological Association’s Center for GI Innovation & Technology’s GI Opportunity Fund.
The Oshi model is a whole-person, multidisciplinary GI care model, which includes traditional medical care for GI conditions but also provides access to health coaching, nutrition and diet support, and behavioral and mental health services. Research shows the approach is effective in mitigating symptoms. A 2020 randomized controlled trial published in Lancet Gastroenterology and Hepatology demonstrated that integrated multidisciplinary care led to improvement in symptoms, quality of life, and cost of care for complex GI conditions, as compared with the traditional GI specialist care model. Numerous similar studies have found that integrated care teams were better equipped to meet the needs of patients with inflammatory bowel disease (IBD) and patients with disorders of gut-brain interaction (DGBIs), patient outcomes and satisfaction were better, overall direct and indirect costs were lower and psychological health needs better addressed.
Q: What was the inspiration behind Oshi Health?
Dr. Berry: Gastroenterologists continue to witness unnecessary patient suffering due to antiquated care delivery models and perverse incentives in our healthcare system. Oshi’s care model was designed to align incentives and provide patients with access to clinicians who are traditionally not reimbursed in fee-for-service healthcare while also helping GI practices provide this care to their patients. During my clinical training it was easy for me to order expensive and invasive testing for my patients, but very difficult for me to get them the multidisciplinary care they needed. Many of the patients I would see didn’t need more MRIs, CT scans, or expensive medications. They needed access to a team of clinicians to help with all the aspects of GI care, including diet, behavioral, and medical.
Q: Why is multidisciplinary care the right approach?
Dr. Berry: GI is a very complex field with many nuances that can impact a patient’s symptoms. As physicians, our role is now evolving to oversee a team of clinicians working together to maximize expertise in nutrition and the gut-brain axis. With these new multidisciplinary care models, GI practices can expand their capabilities. At Oshi Health, every single patient has access to a nurse practitioner, dietician, psychologist, and health coach — all overseen by a gastroenterologist — as a covered benefit through their health plan. Providing multidisciplinary care through a virtual-first model solves some of the scalability challenges of these intensive care models and can significantly improve access to care.
Q: What grant-funded clinical research are you doing right now?
Dr. Berry: Most of my research focuses on evaluating the impact of novel care delivery models in GI and the evaluation of digital technologies in GI and how we can incorporate those digital technologies into clinical practice. How can we determine what type of care can be done remotely via video visits? What can be done on the phone or via text messaging? How can we get these new services paid for so patients can reap the benefits of seeing their doctor more frequently?
Q: What teacher or mentor had the greatest impact on you?
Dr. Berry: Dr. John Allen, MD, MBA has had an incredible impact on my career. He’s the former president of the American Gastroenterological Association, and was the chief clinical officer and a professor at the University of Michigan. He’s one of the rare GI doctors that has both a strong clinical and leadership role in GI. I can’t thank him enough for planting the seeds to encourage me to focus on improving the ways we deliver care to patients.
Q: Describe how you would spend a free Saturday afternoon.
Dr. Berry: Roaming around and exploring a new neighborhood either in New York City or anywhere in the world. If I wasn’t going to be a doctor, I’d probably be an anthropologist. I love observing people in their element, and exploring new neighborhoods that are off the beaten path is a great way to do that.
Lightning round! Do you prefer texting or talking?
Texting
What’s high on your list of travel destinations?
Antarctica
Where was your most memorable vacation?
Patagonia
How many cups of coffee do you drink daily?
Four
What’s your favorite holiday?
Halloween
What’s your favorite junk food?
In-N-Out Burger
If you weren’t a gastroenterologist, what would you be?
Anthropologist
“I was a little kid, so I wasn’t helping him,” but he said he learned a great deal by sitting in the hallways and listening to his father talk to patients. “I could clearly hear the human suffering on the other side.”
This experience had a big impact on Dr. Berry, who continues the family trade. Like his father, talking with patients about their condition is his favorite part of the job, but especially talking about the role of diet, lifestyle, and stress on GI health, said Dr. Berry, who is a gastroenterologist and clinical assistant professor of medicine at New York University’s Grossman School of Medicine.
In addition to his clinical practice, Dr.Berry serves as the co-founder & chief medical officer at Oshi Health. Oshi is an integrative healthcare clinic that is entirely virtual and entirely and solely about GI health. The clinic works with GI clinicians and other healthcare providers, allowing patients access to multidisciplinary care that has proven to reduce healthcare costs and improve patient outcomes. The company was recently named a recipient of funding through the American College of Gastroenterology and the American Gastroenterological Association’s Center for GI Innovation & Technology’s GI Opportunity Fund.
The Oshi model is a whole-person, multidisciplinary GI care model, which includes traditional medical care for GI conditions but also provides access to health coaching, nutrition and diet support, and behavioral and mental health services. Research shows the approach is effective in mitigating symptoms. A 2020 randomized controlled trial published in Lancet Gastroenterology and Hepatology demonstrated that integrated multidisciplinary care led to improvement in symptoms, quality of life, and cost of care for complex GI conditions, as compared with the traditional GI specialist care model. Numerous similar studies have found that integrated care teams were better equipped to meet the needs of patients with inflammatory bowel disease (IBD) and patients with disorders of gut-brain interaction (DGBIs), patient outcomes and satisfaction were better, overall direct and indirect costs were lower and psychological health needs better addressed.
Q: What was the inspiration behind Oshi Health?
Dr. Berry: Gastroenterologists continue to witness unnecessary patient suffering due to antiquated care delivery models and perverse incentives in our healthcare system. Oshi’s care model was designed to align incentives and provide patients with access to clinicians who are traditionally not reimbursed in fee-for-service healthcare while also helping GI practices provide this care to their patients. During my clinical training it was easy for me to order expensive and invasive testing for my patients, but very difficult for me to get them the multidisciplinary care they needed. Many of the patients I would see didn’t need more MRIs, CT scans, or expensive medications. They needed access to a team of clinicians to help with all the aspects of GI care, including diet, behavioral, and medical.
Q: Why is multidisciplinary care the right approach?
Dr. Berry: GI is a very complex field with many nuances that can impact a patient’s symptoms. As physicians, our role is now evolving to oversee a team of clinicians working together to maximize expertise in nutrition and the gut-brain axis. With these new multidisciplinary care models, GI practices can expand their capabilities. At Oshi Health, every single patient has access to a nurse practitioner, dietician, psychologist, and health coach — all overseen by a gastroenterologist — as a covered benefit through their health plan. Providing multidisciplinary care through a virtual-first model solves some of the scalability challenges of these intensive care models and can significantly improve access to care.
Q: What grant-funded clinical research are you doing right now?
Dr. Berry: Most of my research focuses on evaluating the impact of novel care delivery models in GI and the evaluation of digital technologies in GI and how we can incorporate those digital technologies into clinical practice. How can we determine what type of care can be done remotely via video visits? What can be done on the phone or via text messaging? How can we get these new services paid for so patients can reap the benefits of seeing their doctor more frequently?
Q: What teacher or mentor had the greatest impact on you?
Dr. Berry: Dr. John Allen, MD, MBA has had an incredible impact on my career. He’s the former president of the American Gastroenterological Association, and was the chief clinical officer and a professor at the University of Michigan. He’s one of the rare GI doctors that has both a strong clinical and leadership role in GI. I can’t thank him enough for planting the seeds to encourage me to focus on improving the ways we deliver care to patients.
Q: Describe how you would spend a free Saturday afternoon.
Dr. Berry: Roaming around and exploring a new neighborhood either in New York City or anywhere in the world. If I wasn’t going to be a doctor, I’d probably be an anthropologist. I love observing people in their element, and exploring new neighborhoods that are off the beaten path is a great way to do that.
Lightning round! Do you prefer texting or talking?
Texting
What’s high on your list of travel destinations?
Antarctica
Where was your most memorable vacation?
Patagonia
How many cups of coffee do you drink daily?
Four
What’s your favorite holiday?
Halloween
What’s your favorite junk food?
In-N-Out Burger
If you weren’t a gastroenterologist, what would you be?
Anthropologist
“I was a little kid, so I wasn’t helping him,” but he said he learned a great deal by sitting in the hallways and listening to his father talk to patients. “I could clearly hear the human suffering on the other side.”
This experience had a big impact on Dr. Berry, who continues the family trade. Like his father, talking with patients about their condition is his favorite part of the job, but especially talking about the role of diet, lifestyle, and stress on GI health, said Dr. Berry, who is a gastroenterologist and clinical assistant professor of medicine at New York University’s Grossman School of Medicine.
In addition to his clinical practice, Dr.Berry serves as the co-founder & chief medical officer at Oshi Health. Oshi is an integrative healthcare clinic that is entirely virtual and entirely and solely about GI health. The clinic works with GI clinicians and other healthcare providers, allowing patients access to multidisciplinary care that has proven to reduce healthcare costs and improve patient outcomes. The company was recently named a recipient of funding through the American College of Gastroenterology and the American Gastroenterological Association’s Center for GI Innovation & Technology’s GI Opportunity Fund.
The Oshi model is a whole-person, multidisciplinary GI care model, which includes traditional medical care for GI conditions but also provides access to health coaching, nutrition and diet support, and behavioral and mental health services. Research shows the approach is effective in mitigating symptoms. A 2020 randomized controlled trial published in Lancet Gastroenterology and Hepatology demonstrated that integrated multidisciplinary care led to improvement in symptoms, quality of life, and cost of care for complex GI conditions, as compared with the traditional GI specialist care model. Numerous similar studies have found that integrated care teams were better equipped to meet the needs of patients with inflammatory bowel disease (IBD) and patients with disorders of gut-brain interaction (DGBIs), patient outcomes and satisfaction were better, overall direct and indirect costs were lower and psychological health needs better addressed.
Q: What was the inspiration behind Oshi Health?
Dr. Berry: Gastroenterologists continue to witness unnecessary patient suffering due to antiquated care delivery models and perverse incentives in our healthcare system. Oshi’s care model was designed to align incentives and provide patients with access to clinicians who are traditionally not reimbursed in fee-for-service healthcare while also helping GI practices provide this care to their patients. During my clinical training it was easy for me to order expensive and invasive testing for my patients, but very difficult for me to get them the multidisciplinary care they needed. Many of the patients I would see didn’t need more MRIs, CT scans, or expensive medications. They needed access to a team of clinicians to help with all the aspects of GI care, including diet, behavioral, and medical.
Q: Why is multidisciplinary care the right approach?
Dr. Berry: GI is a very complex field with many nuances that can impact a patient’s symptoms. As physicians, our role is now evolving to oversee a team of clinicians working together to maximize expertise in nutrition and the gut-brain axis. With these new multidisciplinary care models, GI practices can expand their capabilities. At Oshi Health, every single patient has access to a nurse practitioner, dietician, psychologist, and health coach — all overseen by a gastroenterologist — as a covered benefit through their health plan. Providing multidisciplinary care through a virtual-first model solves some of the scalability challenges of these intensive care models and can significantly improve access to care.
Q: What grant-funded clinical research are you doing right now?
Dr. Berry: Most of my research focuses on evaluating the impact of novel care delivery models in GI and the evaluation of digital technologies in GI and how we can incorporate those digital technologies into clinical practice. How can we determine what type of care can be done remotely via video visits? What can be done on the phone or via text messaging? How can we get these new services paid for so patients can reap the benefits of seeing their doctor more frequently?
Q: What teacher or mentor had the greatest impact on you?
Dr. Berry: Dr. John Allen, MD, MBA has had an incredible impact on my career. He’s the former president of the American Gastroenterological Association, and was the chief clinical officer and a professor at the University of Michigan. He’s one of the rare GI doctors that has both a strong clinical and leadership role in GI. I can’t thank him enough for planting the seeds to encourage me to focus on improving the ways we deliver care to patients.
Q: Describe how you would spend a free Saturday afternoon.
Dr. Berry: Roaming around and exploring a new neighborhood either in New York City or anywhere in the world. If I wasn’t going to be a doctor, I’d probably be an anthropologist. I love observing people in their element, and exploring new neighborhoods that are off the beaten path is a great way to do that.
Lightning round! Do you prefer texting or talking?
Texting
What’s high on your list of travel destinations?
Antarctica
Where was your most memorable vacation?
Patagonia
How many cups of coffee do you drink daily?
Four
What’s your favorite holiday?
Halloween
What’s your favorite junk food?
In-N-Out Burger
If you weren’t a gastroenterologist, what would you be?
Anthropologist
Bridging the gap between GI disorders and nutrition
The gluten-free section in the grocery store didn’t exist when Renee Euler, MS, RD, LD, was diagnosed with celiac disease 30 years ago. A physician handed her a fax about the gluten-free diet from a national support group and said: “Here, read this.”
There was no Google to inform decisions. Patients had to rely on fact sheets or a book from the library.
“I didn’t realize how much nutrition was going to change my world,” said Ms. Euler, who worked as a landscape architect for 15 years before making a pivotal decision to go back to school and train as a dietitian.
Volunteering as a support group leader, and volunteering with the University of Chicago Celiac Disease Center guided this important career change. Ms. Euler discovered she enjoyed teaching people how to live a gluten-free life and that they could enjoy travel and social functions while adhering to dietary restrictions.
she emphasized.
Ms. Euler has made it her life’s work to navigate GI disorders with physicians and patients alike.
She runs her own business, Nutrition Redefined, in Albuquerque and is the chair of the National Celiac Association Celiac/Gluten Intolerance Support Group in Albuquerque. Previously, she chaired the Dietitians in Medical Nutrition Therapy Dietetic Practice Group, a part of the Academy of Nutrition and Dietetics.
In an interview, she talked about the unique dietary struggles people with celiac and other gastrointestinal conditions face, and the strategies she uses to help these patients overcome hurdles and live a more normal life.
Q: What fears did you have to push past to get to where you are in your career?
Ms. Euler: Leaving a successful career as a landscape architect and going back to school was definitely a huge hurdle. When I started my practice in 2017, in my area there were no outpatient GI dietitians providing specialized care for adults with conditions like celiac disease, irritable bowel syndrome (IBS), and inflammatory bowel disease (IBD). I was starting out with no real support.
Realizing that I was going to start a private practice of my own to help the people I wanted to help, was another big fear. “Am I going to succeed? Am I going to fail? What’s going to happen?” But over the years, my practice has grown as I learned to bill insurance and started receiving referrals from a large local GI practice, both of which have been the keys to my success. I have also limited my practice to GI clients so that I can focus my attention on this specialized area of nutrition and stay up to date on the latest developments.
Q: What interests you about the intersection between diet and GI disorders?
Ms. Euler: It’s not just about diet. We’re learning so much about how the gut microbiome can have a potential impact [on other parts of our health]. It’s interesting in terms of how we respond to certain foods, for instance, could affect our mental health. This especially applies to IBS and how the microbiome might be connected to these conditions.
It’s very challenging. There is so much information out there that is not super accurate, or it’s misleading.
Q: You serve as a liaison between the American Gastroenterological Association and the Academy of Nutrition and Dietetics. As a nutritionist with a focus on GI, how do you work with gastroenterologists to manage GI disorders?
Ms. Euler: Some of the dietary therapies that GI doctors recommend don’t provide sufficient guidance. They hand out that two-page fact sheet about diet and send the patient on their way. A lot of these diets have more nuance than what can be expressed in a two-page handout.
Many times, the physician doesn’t know the nuance, or they don’t have time to go over it. That’s where we can really help.
Patients often want diet to be the answer. They want to be told: “You need to eat this and only this, and everything will be fine, and diet’s going to change your world, and you won’t have to take medication.”
What they often don’t realize and understand, is a lot of these dietary therapies are not black and white. Celiac disease means a gluten-free diet for life. But a lot of these dietary therapies that get thrown out to patients as a possibility, like low FODMAPs (fermentable oligosaccharides, disaccharides, monosaccharides, and polyols), are not lifetime diets. They’re tools for us to use to find out what the offending foods are for this person, and what can we do to get their symptoms under control.
Q: What is the biggest practice-related challenge in getting patients to alter their diet to improve their symptoms?
Ms. Euler: A lot of patients that come to me already have over restricted diets. They’re trying to solve things themselves. Rightfully so, a lot of them have a lot of food fears because they have been living with very uncomfortable symptoms for years, and they’re trying to find answers. Those food fears unfortunately are reinforced by social media and the news.
One of my biggest challenges with those clients is working through that process of building their confidence to broaden their diets and add foods back in, without causing their symptoms to flare up. The goal is to get them back on track to having a nutritious diet while trying to manage symptoms.
Q: Can you give me an anecdotal example of a case that wasn’t easy, and you ended up helping that person?
Ms. Euler: I had a patient who had been listening to all the wellness gurus. She was overrestricted to the point of eating just 10 different foods due to allergic and GI symptoms. Patients like this are definitely a challenge because you have to reorient them to the fact that what they’re doing isn’t necessarily working,
My initial assessments are 90 minutes long, so I have a lot of time to sit with a patient and hear their story and understand their background.
I suggested to the patient: “Why don’t we try adding these foods back in, but eliminating these other types of foods and see whether that would help?” 48 hours later, she sent me an email, telling me that she and her husband had talked this through, and they thought I hit the nail on the head: She was focusing on the wrong foods which were causing problems. Those are always great messages to get from patients, when they say: “Oh my gosh, I hadn’t even considered that.”
Q: Describe how you would spend a free Saturday afternoon.
Ms. Euler: They’re so rare – those free Saturday afternoons, but it would probably be a good book that would turn into a nap on the couch.
LIGHTNING ROUND
Do you prefer texting or talking?
Talking in person
What’s your favorite breakfast?
Greek yogurt with fiber, flax seeds, and berries
What’s your favorite junk food?
Ice cream
What’s your favorite fruit?
Garden grown strawberries
What’s your favorite holiday?
Thanksgiving
What’s your favorite type of music?
Jazz
If you weren’t a GI nutritionist, what would you be?
Probably a landscape architect.
The gluten-free section in the grocery store didn’t exist when Renee Euler, MS, RD, LD, was diagnosed with celiac disease 30 years ago. A physician handed her a fax about the gluten-free diet from a national support group and said: “Here, read this.”
There was no Google to inform decisions. Patients had to rely on fact sheets or a book from the library.
“I didn’t realize how much nutrition was going to change my world,” said Ms. Euler, who worked as a landscape architect for 15 years before making a pivotal decision to go back to school and train as a dietitian.
Volunteering as a support group leader, and volunteering with the University of Chicago Celiac Disease Center guided this important career change. Ms. Euler discovered she enjoyed teaching people how to live a gluten-free life and that they could enjoy travel and social functions while adhering to dietary restrictions.
she emphasized.
Ms. Euler has made it her life’s work to navigate GI disorders with physicians and patients alike.
She runs her own business, Nutrition Redefined, in Albuquerque and is the chair of the National Celiac Association Celiac/Gluten Intolerance Support Group in Albuquerque. Previously, she chaired the Dietitians in Medical Nutrition Therapy Dietetic Practice Group, a part of the Academy of Nutrition and Dietetics.
In an interview, she talked about the unique dietary struggles people with celiac and other gastrointestinal conditions face, and the strategies she uses to help these patients overcome hurdles and live a more normal life.
Q: What fears did you have to push past to get to where you are in your career?
Ms. Euler: Leaving a successful career as a landscape architect and going back to school was definitely a huge hurdle. When I started my practice in 2017, in my area there were no outpatient GI dietitians providing specialized care for adults with conditions like celiac disease, irritable bowel syndrome (IBS), and inflammatory bowel disease (IBD). I was starting out with no real support.
Realizing that I was going to start a private practice of my own to help the people I wanted to help, was another big fear. “Am I going to succeed? Am I going to fail? What’s going to happen?” But over the years, my practice has grown as I learned to bill insurance and started receiving referrals from a large local GI practice, both of which have been the keys to my success. I have also limited my practice to GI clients so that I can focus my attention on this specialized area of nutrition and stay up to date on the latest developments.
Q: What interests you about the intersection between diet and GI disorders?
Ms. Euler: It’s not just about diet. We’re learning so much about how the gut microbiome can have a potential impact [on other parts of our health]. It’s interesting in terms of how we respond to certain foods, for instance, could affect our mental health. This especially applies to IBS and how the microbiome might be connected to these conditions.
It’s very challenging. There is so much information out there that is not super accurate, or it’s misleading.
Q: You serve as a liaison between the American Gastroenterological Association and the Academy of Nutrition and Dietetics. As a nutritionist with a focus on GI, how do you work with gastroenterologists to manage GI disorders?
Ms. Euler: Some of the dietary therapies that GI doctors recommend don’t provide sufficient guidance. They hand out that two-page fact sheet about diet and send the patient on their way. A lot of these diets have more nuance than what can be expressed in a two-page handout.
Many times, the physician doesn’t know the nuance, or they don’t have time to go over it. That’s where we can really help.
Patients often want diet to be the answer. They want to be told: “You need to eat this and only this, and everything will be fine, and diet’s going to change your world, and you won’t have to take medication.”
What they often don’t realize and understand, is a lot of these dietary therapies are not black and white. Celiac disease means a gluten-free diet for life. But a lot of these dietary therapies that get thrown out to patients as a possibility, like low FODMAPs (fermentable oligosaccharides, disaccharides, monosaccharides, and polyols), are not lifetime diets. They’re tools for us to use to find out what the offending foods are for this person, and what can we do to get their symptoms under control.
Q: What is the biggest practice-related challenge in getting patients to alter their diet to improve their symptoms?
Ms. Euler: A lot of patients that come to me already have over restricted diets. They’re trying to solve things themselves. Rightfully so, a lot of them have a lot of food fears because they have been living with very uncomfortable symptoms for years, and they’re trying to find answers. Those food fears unfortunately are reinforced by social media and the news.
One of my biggest challenges with those clients is working through that process of building their confidence to broaden their diets and add foods back in, without causing their symptoms to flare up. The goal is to get them back on track to having a nutritious diet while trying to manage symptoms.
Q: Can you give me an anecdotal example of a case that wasn’t easy, and you ended up helping that person?
Ms. Euler: I had a patient who had been listening to all the wellness gurus. She was overrestricted to the point of eating just 10 different foods due to allergic and GI symptoms. Patients like this are definitely a challenge because you have to reorient them to the fact that what they’re doing isn’t necessarily working,
My initial assessments are 90 minutes long, so I have a lot of time to sit with a patient and hear their story and understand their background.
I suggested to the patient: “Why don’t we try adding these foods back in, but eliminating these other types of foods and see whether that would help?” 48 hours later, she sent me an email, telling me that she and her husband had talked this through, and they thought I hit the nail on the head: She was focusing on the wrong foods which were causing problems. Those are always great messages to get from patients, when they say: “Oh my gosh, I hadn’t even considered that.”
Q: Describe how you would spend a free Saturday afternoon.
Ms. Euler: They’re so rare – those free Saturday afternoons, but it would probably be a good book that would turn into a nap on the couch.
LIGHTNING ROUND
Do you prefer texting or talking?
Talking in person
What’s your favorite breakfast?
Greek yogurt with fiber, flax seeds, and berries
What’s your favorite junk food?
Ice cream
What’s your favorite fruit?
Garden grown strawberries
What’s your favorite holiday?
Thanksgiving
What’s your favorite type of music?
Jazz
If you weren’t a GI nutritionist, what would you be?
Probably a landscape architect.
The gluten-free section in the grocery store didn’t exist when Renee Euler, MS, RD, LD, was diagnosed with celiac disease 30 years ago. A physician handed her a fax about the gluten-free diet from a national support group and said: “Here, read this.”
There was no Google to inform decisions. Patients had to rely on fact sheets or a book from the library.
“I didn’t realize how much nutrition was going to change my world,” said Ms. Euler, who worked as a landscape architect for 15 years before making a pivotal decision to go back to school and train as a dietitian.
Volunteering as a support group leader, and volunteering with the University of Chicago Celiac Disease Center guided this important career change. Ms. Euler discovered she enjoyed teaching people how to live a gluten-free life and that they could enjoy travel and social functions while adhering to dietary restrictions.
she emphasized.
Ms. Euler has made it her life’s work to navigate GI disorders with physicians and patients alike.
She runs her own business, Nutrition Redefined, in Albuquerque and is the chair of the National Celiac Association Celiac/Gluten Intolerance Support Group in Albuquerque. Previously, she chaired the Dietitians in Medical Nutrition Therapy Dietetic Practice Group, a part of the Academy of Nutrition and Dietetics.
In an interview, she talked about the unique dietary struggles people with celiac and other gastrointestinal conditions face, and the strategies she uses to help these patients overcome hurdles and live a more normal life.
Q: What fears did you have to push past to get to where you are in your career?
Ms. Euler: Leaving a successful career as a landscape architect and going back to school was definitely a huge hurdle. When I started my practice in 2017, in my area there were no outpatient GI dietitians providing specialized care for adults with conditions like celiac disease, irritable bowel syndrome (IBS), and inflammatory bowel disease (IBD). I was starting out with no real support.
Realizing that I was going to start a private practice of my own to help the people I wanted to help, was another big fear. “Am I going to succeed? Am I going to fail? What’s going to happen?” But over the years, my practice has grown as I learned to bill insurance and started receiving referrals from a large local GI practice, both of which have been the keys to my success. I have also limited my practice to GI clients so that I can focus my attention on this specialized area of nutrition and stay up to date on the latest developments.
Q: What interests you about the intersection between diet and GI disorders?
Ms. Euler: It’s not just about diet. We’re learning so much about how the gut microbiome can have a potential impact [on other parts of our health]. It’s interesting in terms of how we respond to certain foods, for instance, could affect our mental health. This especially applies to IBS and how the microbiome might be connected to these conditions.
It’s very challenging. There is so much information out there that is not super accurate, or it’s misleading.
Q: You serve as a liaison between the American Gastroenterological Association and the Academy of Nutrition and Dietetics. As a nutritionist with a focus on GI, how do you work with gastroenterologists to manage GI disorders?
Ms. Euler: Some of the dietary therapies that GI doctors recommend don’t provide sufficient guidance. They hand out that two-page fact sheet about diet and send the patient on their way. A lot of these diets have more nuance than what can be expressed in a two-page handout.
Many times, the physician doesn’t know the nuance, or they don’t have time to go over it. That’s where we can really help.
Patients often want diet to be the answer. They want to be told: “You need to eat this and only this, and everything will be fine, and diet’s going to change your world, and you won’t have to take medication.”
What they often don’t realize and understand, is a lot of these dietary therapies are not black and white. Celiac disease means a gluten-free diet for life. But a lot of these dietary therapies that get thrown out to patients as a possibility, like low FODMAPs (fermentable oligosaccharides, disaccharides, monosaccharides, and polyols), are not lifetime diets. They’re tools for us to use to find out what the offending foods are for this person, and what can we do to get their symptoms under control.
Q: What is the biggest practice-related challenge in getting patients to alter their diet to improve their symptoms?
Ms. Euler: A lot of patients that come to me already have over restricted diets. They’re trying to solve things themselves. Rightfully so, a lot of them have a lot of food fears because they have been living with very uncomfortable symptoms for years, and they’re trying to find answers. Those food fears unfortunately are reinforced by social media and the news.
One of my biggest challenges with those clients is working through that process of building their confidence to broaden their diets and add foods back in, without causing their symptoms to flare up. The goal is to get them back on track to having a nutritious diet while trying to manage symptoms.
Q: Can you give me an anecdotal example of a case that wasn’t easy, and you ended up helping that person?
Ms. Euler: I had a patient who had been listening to all the wellness gurus. She was overrestricted to the point of eating just 10 different foods due to allergic and GI symptoms. Patients like this are definitely a challenge because you have to reorient them to the fact that what they’re doing isn’t necessarily working,
My initial assessments are 90 minutes long, so I have a lot of time to sit with a patient and hear their story and understand their background.
I suggested to the patient: “Why don’t we try adding these foods back in, but eliminating these other types of foods and see whether that would help?” 48 hours later, she sent me an email, telling me that she and her husband had talked this through, and they thought I hit the nail on the head: She was focusing on the wrong foods which were causing problems. Those are always great messages to get from patients, when they say: “Oh my gosh, I hadn’t even considered that.”
Q: Describe how you would spend a free Saturday afternoon.
Ms. Euler: They’re so rare – those free Saturday afternoons, but it would probably be a good book that would turn into a nap on the couch.
LIGHTNING ROUND
Do you prefer texting or talking?
Talking in person
What’s your favorite breakfast?
Greek yogurt with fiber, flax seeds, and berries
What’s your favorite junk food?
Ice cream
What’s your favorite fruit?
Garden grown strawberries
What’s your favorite holiday?
Thanksgiving
What’s your favorite type of music?
Jazz
If you weren’t a GI nutritionist, what would you be?
Probably a landscape architect.
Florida GI gets candid about imposter syndrome, insurers, starting a GI fellowship
Her first faculty position as assistant program director for the gastroenterology fellowship program at the University of Iowa offered some inspiration. “I loved teaching and working with trainees and knew I always wanted to remain in this realm,” Dr. Naveed said.
When she moved to Orlando to join AdventHealth, she noticed there was no gastroenterology training program. “I was strictly in private practice. Though I love working with patients, I constantly felt like something was missing. When the opportunity to start a fellowship program came, I was highly motivated to bring it to fruition.”
The AdventHealth fellowship is almost done with its inaugural year.
“Starting a fellowship at a new institution is a very challenging yet incredibly rewarding experience,” she said. In this Q&A, she discusses her strategies for dealing with insurance companies and imposter syndrome, and why she looks to her father as her role model in medicine.
Q: Why did you choose GI?
Dr. Naveed: Gastroenterology is a rapidly evolving field which makes it incredibly fascinating. The initial draw was that I was always excited to learn about GI physiology and disease. I also was fortunate to train with amazing gastroenterologists during residency. I had great examples of strong and successful female GIs to look up to. Lastly, for the most part, gastroenterologists are all fairly laid back and have an interesting sense of humor.
Q: What gives you the most joy in your day-to-day practice?
Dr. Naveed: I love learning and teaching. As a program director, I am directly involved with fellows, residents, and students, but there are always additional enrichment opportunities beyond these interactions. I value teaching clinic medical assistants so they feel more confident and empowered in their work. I also try to educate my nurse practitioners. The best compliment at the end of a long day is that they learned something valuable.
Q: How do you stay current with advances in your field?
Dr. Naveed: Between my role as a physician and as an educator, I owe it to my patients and trainees to stay current with advances in the field. But of course, this is challenging, and at times it feels like there are not enough hours in the day. While reading journal articles and attending conferences are great ways to refresh one’s knowledge, the winner for me has been social media (specifically Twitter). It’s easy to find a “Tweetorial” on almost any topic. There are some excellent initiatives on Twitter such as Monday Night IBD, ACG Evidence-Based GI Doc, Scoping Sundays, and GI Journal Club where important articles, new treatment options, and challenging cases are discussed. Of course, I also learn a lot from my fellows and residents.
Q: What fears did you have to push past to get to where you are in your career?
Dr. Naveed: Pushing past imposter syndrome, which is a feeling of self-doubt despite education, experience, and accomplishments. It is something many of us deal with. I’ve had to retire the notion that I am not experienced enough to achieve a particular career goal.
Q: What habits have you established that have benefited your career most?
Dr. Naveed: It’s a challenge to not immediately say “yes” to every opportunity or project. It’s also difficult to learn to delegate. I am lucky to have a great team, and I have learned that delegating certain tasks or projects helps everyone grow. Also, if I say no to an opportunity, I still try to suggest another colleague or mentee who may be interested and/or a good fit.
Q: Describe your biggest practice-related challenge and what you are doing to address it.
Dr. Naveed: Pushback from insurance companies to approve medications or interventions is incredibly frustrating for myself and the patient. It is also incredibly time consuming and requires significant clinical bandwidth that could otherwise be used in other capacities. While not a solution, I at least try to make sure the patient is kept updated and understands causes of delay, and more importantly, what we are doing to address the issue. I have realized that it’s always preferable to empower the patient, rather than leave them uninformed, which can foster frustration and dissatisfaction.
Q: What teacher or mentor had the greatest impact on you?
Dr. Naveed: I have been blessed with many mentors at different points in my medical career that have greatly impacted and shaped my journey. During my fellowship at University of Texas Southwestern (UTSW), Nisa Kubiliun, MD, was not only a mentor, but also an incredible sponsor. She saw potential in me and encouraged involvement in activities critical for career advancement. Arjmand Mufti, MD, the former program director of the UTSW GI fellowship, is still always just a call away when I need advice regarding my GI fellowship program at AdventHealth. I also have mentors and sponsors within my own institution who invest time and energy into my success.
Q: Outside of teachers and mentors, who or what has had the strongest influence in your life?
Dr. Naveed: My father, who is also a physician, has had a profound influence on my personal and professional development. His own medical journey has been incredibly unique. He has practiced medicine internationally, trained and worked in a traditional academic setting, established a very successful private practice, and now has transitioned to running a hospital-based practice. He has seen it all (and he’s also a brilliant physician), and he is always able to talk me through any situation.
Q: What principles guide you?
Dr. Naveed: Treating my patients how I would want a physician to treat my family is central to my practice. Also, I try to approach any successes with gratitude, and likewise, be patient with inevitable failures. It can be challenging, but I try to find the lesson in every failed venture.
Q: What would you do differently if you had a chance?
Dr. Naveed: I have always had an interest in international medical missions but have yet to participate in one. I have previously passed on such opportunities, thinking it was not the right time, but in hindsight I wish I had taken the leap. I still hope to eventually accomplish this goal.
Q: Describe a scene of your vision for the future.
Dr. Naveed: I hope that our GI fellowship continues to flourish and attract exceptional faculty and candidates. I want to remain involved in graduate medical education, but I hope to continue to challenge myself and advance within this domain. Most importantly, I hope I can continue to balance my career aspirations with my personal goals. I want to continue to be present for my family and kids.
Q: Describe how you would spend a free Saturday afternoon.
Dr. Naveed: You can usually find me at the local farmer’s market with my husband and kids. Afterwards, we’re definitely going to get Chick-fil-A followed by ice cream.
Lightning round
If you weren’t a gastroenterologist, what would you be?
International event planner.
How many cups of coffee do you drink per day?
Usually three.
Favorite breakfast?
Eggs, corned beef hash, toast.
Texting or talking?
Texting always unless it’s Mom or Dad. They always get a call.
Place you most want to travel?
Japan.
Follow Dr. Naveed on Twitter at @MN_GIMD
Her first faculty position as assistant program director for the gastroenterology fellowship program at the University of Iowa offered some inspiration. “I loved teaching and working with trainees and knew I always wanted to remain in this realm,” Dr. Naveed said.
When she moved to Orlando to join AdventHealth, she noticed there was no gastroenterology training program. “I was strictly in private practice. Though I love working with patients, I constantly felt like something was missing. When the opportunity to start a fellowship program came, I was highly motivated to bring it to fruition.”
The AdventHealth fellowship is almost done with its inaugural year.
“Starting a fellowship at a new institution is a very challenging yet incredibly rewarding experience,” she said. In this Q&A, she discusses her strategies for dealing with insurance companies and imposter syndrome, and why she looks to her father as her role model in medicine.
Q: Why did you choose GI?
Dr. Naveed: Gastroenterology is a rapidly evolving field which makes it incredibly fascinating. The initial draw was that I was always excited to learn about GI physiology and disease. I also was fortunate to train with amazing gastroenterologists during residency. I had great examples of strong and successful female GIs to look up to. Lastly, for the most part, gastroenterologists are all fairly laid back and have an interesting sense of humor.
Q: What gives you the most joy in your day-to-day practice?
Dr. Naveed: I love learning and teaching. As a program director, I am directly involved with fellows, residents, and students, but there are always additional enrichment opportunities beyond these interactions. I value teaching clinic medical assistants so they feel more confident and empowered in their work. I also try to educate my nurse practitioners. The best compliment at the end of a long day is that they learned something valuable.
Q: How do you stay current with advances in your field?
Dr. Naveed: Between my role as a physician and as an educator, I owe it to my patients and trainees to stay current with advances in the field. But of course, this is challenging, and at times it feels like there are not enough hours in the day. While reading journal articles and attending conferences are great ways to refresh one’s knowledge, the winner for me has been social media (specifically Twitter). It’s easy to find a “Tweetorial” on almost any topic. There are some excellent initiatives on Twitter such as Monday Night IBD, ACG Evidence-Based GI Doc, Scoping Sundays, and GI Journal Club where important articles, new treatment options, and challenging cases are discussed. Of course, I also learn a lot from my fellows and residents.
Q: What fears did you have to push past to get to where you are in your career?
Dr. Naveed: Pushing past imposter syndrome, which is a feeling of self-doubt despite education, experience, and accomplishments. It is something many of us deal with. I’ve had to retire the notion that I am not experienced enough to achieve a particular career goal.
Q: What habits have you established that have benefited your career most?
Dr. Naveed: It’s a challenge to not immediately say “yes” to every opportunity or project. It’s also difficult to learn to delegate. I am lucky to have a great team, and I have learned that delegating certain tasks or projects helps everyone grow. Also, if I say no to an opportunity, I still try to suggest another colleague or mentee who may be interested and/or a good fit.
Q: Describe your biggest practice-related challenge and what you are doing to address it.
Dr. Naveed: Pushback from insurance companies to approve medications or interventions is incredibly frustrating for myself and the patient. It is also incredibly time consuming and requires significant clinical bandwidth that could otherwise be used in other capacities. While not a solution, I at least try to make sure the patient is kept updated and understands causes of delay, and more importantly, what we are doing to address the issue. I have realized that it’s always preferable to empower the patient, rather than leave them uninformed, which can foster frustration and dissatisfaction.
Q: What teacher or mentor had the greatest impact on you?
Dr. Naveed: I have been blessed with many mentors at different points in my medical career that have greatly impacted and shaped my journey. During my fellowship at University of Texas Southwestern (UTSW), Nisa Kubiliun, MD, was not only a mentor, but also an incredible sponsor. She saw potential in me and encouraged involvement in activities critical for career advancement. Arjmand Mufti, MD, the former program director of the UTSW GI fellowship, is still always just a call away when I need advice regarding my GI fellowship program at AdventHealth. I also have mentors and sponsors within my own institution who invest time and energy into my success.
Q: Outside of teachers and mentors, who or what has had the strongest influence in your life?
Dr. Naveed: My father, who is also a physician, has had a profound influence on my personal and professional development. His own medical journey has been incredibly unique. He has practiced medicine internationally, trained and worked in a traditional academic setting, established a very successful private practice, and now has transitioned to running a hospital-based practice. He has seen it all (and he’s also a brilliant physician), and he is always able to talk me through any situation.
Q: What principles guide you?
Dr. Naveed: Treating my patients how I would want a physician to treat my family is central to my practice. Also, I try to approach any successes with gratitude, and likewise, be patient with inevitable failures. It can be challenging, but I try to find the lesson in every failed venture.
Q: What would you do differently if you had a chance?
Dr. Naveed: I have always had an interest in international medical missions but have yet to participate in one. I have previously passed on such opportunities, thinking it was not the right time, but in hindsight I wish I had taken the leap. I still hope to eventually accomplish this goal.
Q: Describe a scene of your vision for the future.
Dr. Naveed: I hope that our GI fellowship continues to flourish and attract exceptional faculty and candidates. I want to remain involved in graduate medical education, but I hope to continue to challenge myself and advance within this domain. Most importantly, I hope I can continue to balance my career aspirations with my personal goals. I want to continue to be present for my family and kids.
Q: Describe how you would spend a free Saturday afternoon.
Dr. Naveed: You can usually find me at the local farmer’s market with my husband and kids. Afterwards, we’re definitely going to get Chick-fil-A followed by ice cream.
Lightning round
If you weren’t a gastroenterologist, what would you be?
International event planner.
How many cups of coffee do you drink per day?
Usually three.
Favorite breakfast?
Eggs, corned beef hash, toast.
Texting or talking?
Texting always unless it’s Mom or Dad. They always get a call.
Place you most want to travel?
Japan.
Follow Dr. Naveed on Twitter at @MN_GIMD
Her first faculty position as assistant program director for the gastroenterology fellowship program at the University of Iowa offered some inspiration. “I loved teaching and working with trainees and knew I always wanted to remain in this realm,” Dr. Naveed said.
When she moved to Orlando to join AdventHealth, she noticed there was no gastroenterology training program. “I was strictly in private practice. Though I love working with patients, I constantly felt like something was missing. When the opportunity to start a fellowship program came, I was highly motivated to bring it to fruition.”
The AdventHealth fellowship is almost done with its inaugural year.
“Starting a fellowship at a new institution is a very challenging yet incredibly rewarding experience,” she said. In this Q&A, she discusses her strategies for dealing with insurance companies and imposter syndrome, and why she looks to her father as her role model in medicine.
Q: Why did you choose GI?
Dr. Naveed: Gastroenterology is a rapidly evolving field which makes it incredibly fascinating. The initial draw was that I was always excited to learn about GI physiology and disease. I also was fortunate to train with amazing gastroenterologists during residency. I had great examples of strong and successful female GIs to look up to. Lastly, for the most part, gastroenterologists are all fairly laid back and have an interesting sense of humor.
Q: What gives you the most joy in your day-to-day practice?
Dr. Naveed: I love learning and teaching. As a program director, I am directly involved with fellows, residents, and students, but there are always additional enrichment opportunities beyond these interactions. I value teaching clinic medical assistants so they feel more confident and empowered in their work. I also try to educate my nurse practitioners. The best compliment at the end of a long day is that they learned something valuable.
Q: How do you stay current with advances in your field?
Dr. Naveed: Between my role as a physician and as an educator, I owe it to my patients and trainees to stay current with advances in the field. But of course, this is challenging, and at times it feels like there are not enough hours in the day. While reading journal articles and attending conferences are great ways to refresh one’s knowledge, the winner for me has been social media (specifically Twitter). It’s easy to find a “Tweetorial” on almost any topic. There are some excellent initiatives on Twitter such as Monday Night IBD, ACG Evidence-Based GI Doc, Scoping Sundays, and GI Journal Club where important articles, new treatment options, and challenging cases are discussed. Of course, I also learn a lot from my fellows and residents.
Q: What fears did you have to push past to get to where you are in your career?
Dr. Naveed: Pushing past imposter syndrome, which is a feeling of self-doubt despite education, experience, and accomplishments. It is something many of us deal with. I’ve had to retire the notion that I am not experienced enough to achieve a particular career goal.
Q: What habits have you established that have benefited your career most?
Dr. Naveed: It’s a challenge to not immediately say “yes” to every opportunity or project. It’s also difficult to learn to delegate. I am lucky to have a great team, and I have learned that delegating certain tasks or projects helps everyone grow. Also, if I say no to an opportunity, I still try to suggest another colleague or mentee who may be interested and/or a good fit.
Q: Describe your biggest practice-related challenge and what you are doing to address it.
Dr. Naveed: Pushback from insurance companies to approve medications or interventions is incredibly frustrating for myself and the patient. It is also incredibly time consuming and requires significant clinical bandwidth that could otherwise be used in other capacities. While not a solution, I at least try to make sure the patient is kept updated and understands causes of delay, and more importantly, what we are doing to address the issue. I have realized that it’s always preferable to empower the patient, rather than leave them uninformed, which can foster frustration and dissatisfaction.
Q: What teacher or mentor had the greatest impact on you?
Dr. Naveed: I have been blessed with many mentors at different points in my medical career that have greatly impacted and shaped my journey. During my fellowship at University of Texas Southwestern (UTSW), Nisa Kubiliun, MD, was not only a mentor, but also an incredible sponsor. She saw potential in me and encouraged involvement in activities critical for career advancement. Arjmand Mufti, MD, the former program director of the UTSW GI fellowship, is still always just a call away when I need advice regarding my GI fellowship program at AdventHealth. I also have mentors and sponsors within my own institution who invest time and energy into my success.
Q: Outside of teachers and mentors, who or what has had the strongest influence in your life?
Dr. Naveed: My father, who is also a physician, has had a profound influence on my personal and professional development. His own medical journey has been incredibly unique. He has practiced medicine internationally, trained and worked in a traditional academic setting, established a very successful private practice, and now has transitioned to running a hospital-based practice. He has seen it all (and he’s also a brilliant physician), and he is always able to talk me through any situation.
Q: What principles guide you?
Dr. Naveed: Treating my patients how I would want a physician to treat my family is central to my practice. Also, I try to approach any successes with gratitude, and likewise, be patient with inevitable failures. It can be challenging, but I try to find the lesson in every failed venture.
Q: What would you do differently if you had a chance?
Dr. Naveed: I have always had an interest in international medical missions but have yet to participate in one. I have previously passed on such opportunities, thinking it was not the right time, but in hindsight I wish I had taken the leap. I still hope to eventually accomplish this goal.
Q: Describe a scene of your vision for the future.
Dr. Naveed: I hope that our GI fellowship continues to flourish and attract exceptional faculty and candidates. I want to remain involved in graduate medical education, but I hope to continue to challenge myself and advance within this domain. Most importantly, I hope I can continue to balance my career aspirations with my personal goals. I want to continue to be present for my family and kids.
Q: Describe how you would spend a free Saturday afternoon.
Dr. Naveed: You can usually find me at the local farmer’s market with my husband and kids. Afterwards, we’re definitely going to get Chick-fil-A followed by ice cream.
Lightning round
If you weren’t a gastroenterologist, what would you be?
International event planner.
How many cups of coffee do you drink per day?
Usually three.
Favorite breakfast?
Eggs, corned beef hash, toast.
Texting or talking?
Texting always unless it’s Mom or Dad. They always get a call.
Place you most want to travel?
Japan.
Follow Dr. Naveed on Twitter at @MN_GIMD
Launching an entirely virtual health care GI practice
that partners with health systems to offer GI care services throughout the country.
Dr. Arjal, who as a cofounder of Telebelly Health also serves as chief medical officer and president of the practice, previously served as vice president of Puget Sound Gastroenterology and practiced in the Seattle area for 13 years. He served as vice president of clinical affairs for Gastro Health, the nation’s second-largest gastroenterology group, which acquired the Puget Sound practice in 2019. But then in 2021, he founded Telebelly with Sheri Rudberg, MBA, JD, who serves as CEO of the business; Alex Brown, who leads product development; and Nakort Valles, who serves as the company’s chief technology officer.
Building a new business whose goal is to transform GI health care delivery has been his biggest challenge to date. “I am proud of Telebelly because its goals are goals we all share, which is to try to get people in the door and take good care of them,” Dr. Arjal said.
Through virtual care clinics like Telebelly Health, patients can see a provider who is affiliated with a practice, even if the provider is in another state provided he or she is licensed in the patient’s home state. Some states have passed legislation to permanently allow out-of-state physicians to practice telehealth in their state if they follow the state’s requirements. In some states, that may amount to accepting an out-of-state medical license or requiring out-of-state clinicians to pass an exam.
Telebelly Health has served thousands of patients since September when the practice was launched. “We are scaling pretty quickly and will be doubling the number of providers in the next couple of months,” Dr. Arjal said.
In this Q&A, he talks more about his new business venture and his vision for the future of medicine.
Question: Why did you choose GI?
Answer: I wanted to do something that was cognitive where I interacted with and really got to know patients. I also wanted to be a proceduralist. I never wanted to be a surgeon – I knew that wasn’t for me. I fell in love with GI the first year in med school. I thought the pathology was interesting, and what GIs did in the acute setting as well as the outpatient setting was compelling.
Q. What achievement are you most proud of?
A. Prior to Telebelly, I led a large regional GI group in a competitive marketplace. Now, with Telebelly, building a team with a vision to transform the space has been the biggest challenge I have taken on. It’s still a work in progress, but we’ve had a great start. Starting a company wasn’t easy. It was something that I didn’t know a lot about, so I had to take a fair bit of risk. I wasn’t sure if I had it in me at the beginning. It’s not something I’d ever done before, so I was testing myself. I am proud that we were able to launch the company and have successfully scaled it. It’s been more successful than I expected.
Q. Describe your biggest practice-related challenge and what you are doing to address it.
A. Access to care. I think it’s very hard to see somebody with GI expertise and it certainly got worse during the pandemic. In my previous role, we used advanced practice providers. We tried to implement technology, sometimes effectively, sometimes not. But in general, we wanted to try to increase the supply of providers and compress these patient journeys to get people in the door. But that’s still a very difficult challenge we’re all trying to solve.
Q. What teacher or mentor had the greatest impact on you?
A. I would say two: James Trotter, MD, a hepatologist at the University of Colorado where I trained. He had a terrific impact in the sense that he was 100% focused on patients and got to know them as people. This taught me what it meant to be a clinician that was sort of a humanist. He cared so much for his patients that I still think about what Jim would do in a room today, 15 years after I finished my fellowship.
When I started my first job at Puget Sound Gastroenterology in the Seattle area, Robin Sloane, MD, was one of the senior partners of the group. I had a lot to learn after finishing fellowship. He was wonderful and gracious and really taught me a ton about the practical aspects of medicine. I felt this was an extension of my training in that he was a real clinician who really cared deeply for his patients. If I hadn’t met those two, my career and maybe my view of just what I did day-to-day would be different. They were both very, very impactful for me.
Q. Outside of teachers and mentors, who has had the strongest influence on your life?
A. Two people: my mother and my wife. My mother was a single parent and we were immigrants to the country. She was an ambitious woman who didn’t let anything stop her. I certainly learned a ton about resilience, work ethic. She’s somebody who always treated people well. My wife also supported and believed in me, and without her, I would not have had the courage to start a company.
Q. Describe a scene of your vision for the future.
A. I think we need to change our mindset in terms of how we interact with patients. I think there’s going to be a lot of clinical testing that is performed away from the physician’s office. It’s going to become more democratized and more decentralized. And I think in the future, patients will have more agency in how they interact with the system. I think artificial intelligence will potentially augment all of this as well. We’ll have patients who are more engaged, have more choice and easier access to expert care. They’ll come in with more information on their hands and they won’t have to wait as long. I think the wait times to get to a GI clinic now are way too long.
What I’d also like to see are providers spending more time doing things that they’re trained to do rather than documentation, summarizing data, and dealing with administrative headaches. I think almost everybody has that goal, but I think that’s achievable.
I want providers to have an iron man or iron woman suit when they see a patient, to have more data at their fingertips, to spend more time with the patients and have smarter visits.
Q. What did you fear most early in your career?
A. Failure for the most part, and comfort. For a long time, I wanted to start a company and change the space. Fear of failure has been ingrained in me and I think that’s true for a lot of physicians. I had always been a perfectionist.
Q. What gives you the most joy in your day-to-day practice?
A. Seeing patients is by far the thing I enjoy most. I don’t love documenting or digging up information, but I like getting to know folks. In general, I’m a social person and my outpatient clinic gives me the most joy, probably more than anything else.
Q. How do you stay current with advances in your field?
A. I’m curious about all new things, so I stay current through traditional means: I go to conferences regularly, I take postgraduate courses, I listen to podcasts, talk to colleagues, and read journals on a regular basis. But there are a lot of adjacent sources I pay attention to as well, such as nonmedical journals and nonmedical podcasts. I talk to folks outside the space and try to learn from them as well.
Q. What habits have you established that have benefited your career?
A. I do the same thing every day before my clinic days or my endoscopy days. I make reading a part of each day so I can slow down and be more present. Every day I try not to perform just what I do workwise, but I try to find some balance either with my family, or through exercise. I think I’ve been pretty good at separating work life from personal life.
Lightning round questions
Texting or talking? Talking.
Favorite junk food? Peanut butter M&Ms.
How many cups of coffee do you drink per day? Three.
If you weren’t a gastroenterologist, what would you be? Venture capitalist.
Introvert or extrovert? Both.
that partners with health systems to offer GI care services throughout the country.
Dr. Arjal, who as a cofounder of Telebelly Health also serves as chief medical officer and president of the practice, previously served as vice president of Puget Sound Gastroenterology and practiced in the Seattle area for 13 years. He served as vice president of clinical affairs for Gastro Health, the nation’s second-largest gastroenterology group, which acquired the Puget Sound practice in 2019. But then in 2021, he founded Telebelly with Sheri Rudberg, MBA, JD, who serves as CEO of the business; Alex Brown, who leads product development; and Nakort Valles, who serves as the company’s chief technology officer.
Building a new business whose goal is to transform GI health care delivery has been his biggest challenge to date. “I am proud of Telebelly because its goals are goals we all share, which is to try to get people in the door and take good care of them,” Dr. Arjal said.
Through virtual care clinics like Telebelly Health, patients can see a provider who is affiliated with a practice, even if the provider is in another state provided he or she is licensed in the patient’s home state. Some states have passed legislation to permanently allow out-of-state physicians to practice telehealth in their state if they follow the state’s requirements. In some states, that may amount to accepting an out-of-state medical license or requiring out-of-state clinicians to pass an exam.
Telebelly Health has served thousands of patients since September when the practice was launched. “We are scaling pretty quickly and will be doubling the number of providers in the next couple of months,” Dr. Arjal said.
In this Q&A, he talks more about his new business venture and his vision for the future of medicine.
Question: Why did you choose GI?
Answer: I wanted to do something that was cognitive where I interacted with and really got to know patients. I also wanted to be a proceduralist. I never wanted to be a surgeon – I knew that wasn’t for me. I fell in love with GI the first year in med school. I thought the pathology was interesting, and what GIs did in the acute setting as well as the outpatient setting was compelling.
Q. What achievement are you most proud of?
A. Prior to Telebelly, I led a large regional GI group in a competitive marketplace. Now, with Telebelly, building a team with a vision to transform the space has been the biggest challenge I have taken on. It’s still a work in progress, but we’ve had a great start. Starting a company wasn’t easy. It was something that I didn’t know a lot about, so I had to take a fair bit of risk. I wasn’t sure if I had it in me at the beginning. It’s not something I’d ever done before, so I was testing myself. I am proud that we were able to launch the company and have successfully scaled it. It’s been more successful than I expected.
Q. Describe your biggest practice-related challenge and what you are doing to address it.
A. Access to care. I think it’s very hard to see somebody with GI expertise and it certainly got worse during the pandemic. In my previous role, we used advanced practice providers. We tried to implement technology, sometimes effectively, sometimes not. But in general, we wanted to try to increase the supply of providers and compress these patient journeys to get people in the door. But that’s still a very difficult challenge we’re all trying to solve.
Q. What teacher or mentor had the greatest impact on you?
A. I would say two: James Trotter, MD, a hepatologist at the University of Colorado where I trained. He had a terrific impact in the sense that he was 100% focused on patients and got to know them as people. This taught me what it meant to be a clinician that was sort of a humanist. He cared so much for his patients that I still think about what Jim would do in a room today, 15 years after I finished my fellowship.
When I started my first job at Puget Sound Gastroenterology in the Seattle area, Robin Sloane, MD, was one of the senior partners of the group. I had a lot to learn after finishing fellowship. He was wonderful and gracious and really taught me a ton about the practical aspects of medicine. I felt this was an extension of my training in that he was a real clinician who really cared deeply for his patients. If I hadn’t met those two, my career and maybe my view of just what I did day-to-day would be different. They were both very, very impactful for me.
Q. Outside of teachers and mentors, who has had the strongest influence on your life?
A. Two people: my mother and my wife. My mother was a single parent and we were immigrants to the country. She was an ambitious woman who didn’t let anything stop her. I certainly learned a ton about resilience, work ethic. She’s somebody who always treated people well. My wife also supported and believed in me, and without her, I would not have had the courage to start a company.
Q. Describe a scene of your vision for the future.
A. I think we need to change our mindset in terms of how we interact with patients. I think there’s going to be a lot of clinical testing that is performed away from the physician’s office. It’s going to become more democratized and more decentralized. And I think in the future, patients will have more agency in how they interact with the system. I think artificial intelligence will potentially augment all of this as well. We’ll have patients who are more engaged, have more choice and easier access to expert care. They’ll come in with more information on their hands and they won’t have to wait as long. I think the wait times to get to a GI clinic now are way too long.
What I’d also like to see are providers spending more time doing things that they’re trained to do rather than documentation, summarizing data, and dealing with administrative headaches. I think almost everybody has that goal, but I think that’s achievable.
I want providers to have an iron man or iron woman suit when they see a patient, to have more data at their fingertips, to spend more time with the patients and have smarter visits.
Q. What did you fear most early in your career?
A. Failure for the most part, and comfort. For a long time, I wanted to start a company and change the space. Fear of failure has been ingrained in me and I think that’s true for a lot of physicians. I had always been a perfectionist.
Q. What gives you the most joy in your day-to-day practice?
A. Seeing patients is by far the thing I enjoy most. I don’t love documenting or digging up information, but I like getting to know folks. In general, I’m a social person and my outpatient clinic gives me the most joy, probably more than anything else.
Q. How do you stay current with advances in your field?
A. I’m curious about all new things, so I stay current through traditional means: I go to conferences regularly, I take postgraduate courses, I listen to podcasts, talk to colleagues, and read journals on a regular basis. But there are a lot of adjacent sources I pay attention to as well, such as nonmedical journals and nonmedical podcasts. I talk to folks outside the space and try to learn from them as well.
Q. What habits have you established that have benefited your career?
A. I do the same thing every day before my clinic days or my endoscopy days. I make reading a part of each day so I can slow down and be more present. Every day I try not to perform just what I do workwise, but I try to find some balance either with my family, or through exercise. I think I’ve been pretty good at separating work life from personal life.
Lightning round questions
Texting or talking? Talking.
Favorite junk food? Peanut butter M&Ms.
How many cups of coffee do you drink per day? Three.
If you weren’t a gastroenterologist, what would you be? Venture capitalist.
Introvert or extrovert? Both.
that partners with health systems to offer GI care services throughout the country.
Dr. Arjal, who as a cofounder of Telebelly Health also serves as chief medical officer and president of the practice, previously served as vice president of Puget Sound Gastroenterology and practiced in the Seattle area for 13 years. He served as vice president of clinical affairs for Gastro Health, the nation’s second-largest gastroenterology group, which acquired the Puget Sound practice in 2019. But then in 2021, he founded Telebelly with Sheri Rudberg, MBA, JD, who serves as CEO of the business; Alex Brown, who leads product development; and Nakort Valles, who serves as the company’s chief technology officer.
Building a new business whose goal is to transform GI health care delivery has been his biggest challenge to date. “I am proud of Telebelly because its goals are goals we all share, which is to try to get people in the door and take good care of them,” Dr. Arjal said.
Through virtual care clinics like Telebelly Health, patients can see a provider who is affiliated with a practice, even if the provider is in another state provided he or she is licensed in the patient’s home state. Some states have passed legislation to permanently allow out-of-state physicians to practice telehealth in their state if they follow the state’s requirements. In some states, that may amount to accepting an out-of-state medical license or requiring out-of-state clinicians to pass an exam.
Telebelly Health has served thousands of patients since September when the practice was launched. “We are scaling pretty quickly and will be doubling the number of providers in the next couple of months,” Dr. Arjal said.
In this Q&A, he talks more about his new business venture and his vision for the future of medicine.
Question: Why did you choose GI?
Answer: I wanted to do something that was cognitive where I interacted with and really got to know patients. I also wanted to be a proceduralist. I never wanted to be a surgeon – I knew that wasn’t for me. I fell in love with GI the first year in med school. I thought the pathology was interesting, and what GIs did in the acute setting as well as the outpatient setting was compelling.
Q. What achievement are you most proud of?
A. Prior to Telebelly, I led a large regional GI group in a competitive marketplace. Now, with Telebelly, building a team with a vision to transform the space has been the biggest challenge I have taken on. It’s still a work in progress, but we’ve had a great start. Starting a company wasn’t easy. It was something that I didn’t know a lot about, so I had to take a fair bit of risk. I wasn’t sure if I had it in me at the beginning. It’s not something I’d ever done before, so I was testing myself. I am proud that we were able to launch the company and have successfully scaled it. It’s been more successful than I expected.
Q. Describe your biggest practice-related challenge and what you are doing to address it.
A. Access to care. I think it’s very hard to see somebody with GI expertise and it certainly got worse during the pandemic. In my previous role, we used advanced practice providers. We tried to implement technology, sometimes effectively, sometimes not. But in general, we wanted to try to increase the supply of providers and compress these patient journeys to get people in the door. But that’s still a very difficult challenge we’re all trying to solve.
Q. What teacher or mentor had the greatest impact on you?
A. I would say two: James Trotter, MD, a hepatologist at the University of Colorado where I trained. He had a terrific impact in the sense that he was 100% focused on patients and got to know them as people. This taught me what it meant to be a clinician that was sort of a humanist. He cared so much for his patients that I still think about what Jim would do in a room today, 15 years after I finished my fellowship.
When I started my first job at Puget Sound Gastroenterology in the Seattle area, Robin Sloane, MD, was one of the senior partners of the group. I had a lot to learn after finishing fellowship. He was wonderful and gracious and really taught me a ton about the practical aspects of medicine. I felt this was an extension of my training in that he was a real clinician who really cared deeply for his patients. If I hadn’t met those two, my career and maybe my view of just what I did day-to-day would be different. They were both very, very impactful for me.
Q. Outside of teachers and mentors, who has had the strongest influence on your life?
A. Two people: my mother and my wife. My mother was a single parent and we were immigrants to the country. She was an ambitious woman who didn’t let anything stop her. I certainly learned a ton about resilience, work ethic. She’s somebody who always treated people well. My wife also supported and believed in me, and without her, I would not have had the courage to start a company.
Q. Describe a scene of your vision for the future.
A. I think we need to change our mindset in terms of how we interact with patients. I think there’s going to be a lot of clinical testing that is performed away from the physician’s office. It’s going to become more democratized and more decentralized. And I think in the future, patients will have more agency in how they interact with the system. I think artificial intelligence will potentially augment all of this as well. We’ll have patients who are more engaged, have more choice and easier access to expert care. They’ll come in with more information on their hands and they won’t have to wait as long. I think the wait times to get to a GI clinic now are way too long.
What I’d also like to see are providers spending more time doing things that they’re trained to do rather than documentation, summarizing data, and dealing with administrative headaches. I think almost everybody has that goal, but I think that’s achievable.
I want providers to have an iron man or iron woman suit when they see a patient, to have more data at their fingertips, to spend more time with the patients and have smarter visits.
Q. What did you fear most early in your career?
A. Failure for the most part, and comfort. For a long time, I wanted to start a company and change the space. Fear of failure has been ingrained in me and I think that’s true for a lot of physicians. I had always been a perfectionist.
Q. What gives you the most joy in your day-to-day practice?
A. Seeing patients is by far the thing I enjoy most. I don’t love documenting or digging up information, but I like getting to know folks. In general, I’m a social person and my outpatient clinic gives me the most joy, probably more than anything else.
Q. How do you stay current with advances in your field?
A. I’m curious about all new things, so I stay current through traditional means: I go to conferences regularly, I take postgraduate courses, I listen to podcasts, talk to colleagues, and read journals on a regular basis. But there are a lot of adjacent sources I pay attention to as well, such as nonmedical journals and nonmedical podcasts. I talk to folks outside the space and try to learn from them as well.
Q. What habits have you established that have benefited your career?
A. I do the same thing every day before my clinic days or my endoscopy days. I make reading a part of each day so I can slow down and be more present. Every day I try not to perform just what I do workwise, but I try to find some balance either with my family, or through exercise. I think I’ve been pretty good at separating work life from personal life.
Lightning round questions
Texting or talking? Talking.
Favorite junk food? Peanut butter M&Ms.
How many cups of coffee do you drink per day? Three.
If you weren’t a gastroenterologist, what would you be? Venture capitalist.
Introvert or extrovert? Both.
Unraveling the mechanisms behind FMT efficacy needed to expand its use
A deeper understanding of the mechanisms underlying the success of fecal microbiota transplantation (FMT) is needed to further improve its effectiveness, according to two recent reviews published in Cell Host and Microbe.
how closely the donor’s microbial composition matches the patient’s existing microbiome, and the presence of nonbacterial gut inhabitants like viruses and fungi – affect FMT success, according to a press release.
FMT is most often used to treat recurrent Clostridioides difficile infections, which don’t always respond to antibiotics. Success rates range from 60% to 90%, depending on the administration route and study design, notes an international research team led by Abbas Yadegar, PhD, a medical bacteriologist at the Shahid Beheshti University of Medical Sciences in Tehran, Iran.
The understanding of how FMT works is incomplete, however, and the reasons some patients fail to benefit is unclear, note Dr. Yadegar and colleagues. Little attention has been paid to the role that other components of the patient’s microbiome, along with outside factors, play in the treatment’s success, they add.
“We wanted other researchers to look beyond changes in stool microbial composition and function, which have been the focus of research in the past few years,” Dr. Yadegar’s team said in a statement provided to this news organization.
Dr. Yadegar and colleagues’ review of more than 130 studies summarizes recent evidence on the mechanisms contributing to FMT success against recurrent C. difficile infection, highlights knowledge gaps, and proposes future research directions in the field.
Factors that influence FMT’s effectiveness and the potential the procedure holds for treatment of other diseases associated with gut dysbiosis are the subject of a review of 149 studies by a team of researchers led by Serena Porcari, MD, a gastroenterologist at the Fondazione Policlinico Universitario Gemelli and Università Cattolica del Sacro Cuore, in Rome.
“Our main goal was not only to unravel the different mechanisms of FMT efficacy but also to introduce some mindset shifts that are needed to bring FMT forward, mainly covering the gap that exists between basic scientists and clinicians,” Gianluca Ianiro, MD, PhD, a senior researcher in digestive diseases who works with Dr. Porcari and is the review’s lead author, told this news organization.
Engraftment may influence success
Engraftment of donor microbial strains in recipients appears to be key to the therapeutic success of FMT, both reviews note.
Three factors influence engraftment: the donor’s bacteria fitness relative to the recipient, the bacteria already present in the recipient, and whether antibiotics are used prior to FMT to open a niche for the incoming donor microbes, according to Dr. Yadegar and colleagues.
How to calculate strain engraftment has not yet been standardized in the field, and the number of strains detected in the recipient’s fecal sample is dependent on the depth of sequencing techniques, Dr. Porcari and colleagues note.
The use of whole-genome sequencing has enabled more precise evaluation of engraftment, they add.
“With this approach, microbial engraftment has been associated with clinical success, regardless of the disease, in a large metagenomic metanalysis of 24 FMT trials and almost 1,400 fecal samples,” Dr. Porcari and colleagues write. However, these results have not been replicated, likely because of differences between the studies.
More study on the topic is needed, both articles note.
“Because the recent metagenomics studies compared pre- and post-FMT only in cases with successful treatment outcomes, it is not possible to link engraftment to clinical outcomes,” Dr. Yadegar and colleagues write in their statement to this news organization.
A closer look at donor-recipient pairings
Clinicians usually enlist healthy, carefully screened individuals as FMT donors.
However, both research groups conclude that fine-scale taxonomic and metabolic analyses of donor and recipient microbiomes would better inform clinical decisions, especially when treating diseases other than C. difficile.
This may call for a more personalized approach to choosing donor-recipient pairings. Investigators should assess the patient’s diet and genetic background and how closely the donor’s microbiome matches that of the patient.
“Most studies focused on profiling stool samples before and after FMT without also including functional analyses; therefore, there are still a lot of aspects of host microbial interactions that remain unknown,” write Dr. Yadegar and colleagues in their statement.
Ecologic factors, including diet and host genetics, are often not included in clinical studies of C. difficile, but they “may potentially be the missing links” to treatment failure in the small portion of patients whose condition doesn’t respond to FMT, they write.
Pairing donor-recipient combinations on the basis of dietary patterns and preferences could improve FMT efficacy because the donor microbiota would be preadapted to the recipient’s diet, Dr. Yadegar and colleagues write. The team is examining how donor and recipient diet may affect outcomes.
Dr. Porcari and colleagues add that while some studies support the existence of shared characteristics that make up super-donors, others found that the optimal donor is more patient specific. They call for personalized selection strategies that employ microbiome sequencing tools rather than a “one stool fits all” approach.
Currently, many clinicians aren’t familiar with microbiome sequencing and analysis, but they’ll need to be in the near future, note Dr. Porcari and colleagues.
“Identifying microbiome characteristics that maximize strain engraftment in the FMT will allow clinicians to select the best donor for each single patient,” they write.
The possible role of viruses and fungi
In FMT research, investigators tend to focus on the bacteria in the human microbiome. However, viruses and fungi also appear to play a role, both articles note.
“Other microbial kingdoms that inhabit the intestine should be taken into account when considering predictors of post-FMT microbial transfer,” write Dr. Porcari and colleagues.
Although few studies have examined the gut virome’s impact on FMT effectiveness against C. difficile, the existing research, although limited, indicates that bacteriophage viruses could play a role, Dr. Yadegar and colleagues note. For example, high levels of donor-derived Caudoviralesbacteriophages in recipients were associated with FMT efficacy in one preliminary study, they write.
In a small human study, fecal filtrate from healthy donors who had bacteriophages but no live bacteria successfully treated five patients with recurrent C. difficile infection, Dr. Yadegar and colleagues write.
“Therefore, the idea that viruses may play a role is very provocative,” write Dr. Yadegar’s team in their statement.
It’s important to note that these studies are associative, which means they can’t definitively answer the question of how or whether viruses play a role, Dr. Yadegar’s team added.
Researchers “know even less about how fungi may or may not play a role,” write Dr. Yadegar and colleagues. However, in early research that involved patients who had successfully undergone FMT for C. difficile, there was higher relative abundance of Saccharomyces and Aspergillus, whereas Candida, if prominent, may impede response, they write in their article.
Additionally, to explore whether live bacteria are necessary for FMT to work, Dr. Yadegar and colleagues informed this news organization that they are conducting a study “comparing traditional FMT to a fecal filtrate that contains no live bacteria, but has all other components, to see if we can achieve similar success rates in recurrent C. difficile infection.”
Repeat treatment for sustained response
Dr. Yadegar’s team offered another important takeaway: A single FMT treatment will not sustain a positive response, especially when treating chronic noncommunicable conditions in which intestinal dysbiosis may play a role. Repeat treatment will be needed, as with other chronic conditions. This has been shown even in C. difficile infection.
“Recent studies have documented a significant advantage of repeated FMT over single FMT on the cure rates of recurrent C. difficile,” especially for patients with inflammatory bowel disorder, Dr. Yadegar’s team told this news organization.
“What we don’t know is which patient is likely to respond to microbial-based therapy, or what the dose or frequency should be, or which bacteria are responsible for the effects,” Dr. Yadegar and team said.
Dr. Porcari and colleagues are examining whether FMT could be refined to improve its success against other diseases. This may involve selecting specific donors, monitoring the gut microbiome of both donors and recipients, or using a specific means of delivery, such as lyophilized capsules, Dr. Ianiro said.
A response to FMT for chronic, noncommunicable disorders typically is not sustained long term, note Dr. Porcari and colleagues. However, they add that “sequential transplants have been applied in this setting with promising results, suggesting that chronic modulation of the patient microbiome may be beneficial in noncommunicable chronic disorders.” Dr. Porcari and colleagues point to the success of repeated, long-term FMT in studies of patients with ulcerative colitis and irritable bowel syndrome.
The use of cutting-edge technologies for microbiome assessment and a change in the view of FMT as only an acute, single-use therapy could improve FMT protocols and outcomes for noncommunicable conditions, they write.
Expanding FMT beyond C. difficile
Dr. Yadegar and colleagues’ article “really breaks down what is known about the mechanisms of FMT in C. difficile infection, which is important as other live biotherapeutic products are developed,” Colleen Kelly, MD, an associate professor of medicine at Brown University in Providence, R.I., who was not involved with the reviews, said in an interview.
Dr. Yadegar and colleagues concur. They note in a press release that as the mechanisms behind FMT success are understood, that information should be used to design new standardized therapies.
“Although highly effective, there are substantial drawbacks with [FMT], including infectious risks and sparse long-term safety data,” they write. “Better treatment options for recurrent C. difficile infections that are targeted, safe, and donor-independent are thus desired.”
In December 2022, the U.S. Food and Drug Administration approved the first fecal microbiota product, Rebyota, to prevent recurrence of C. difficile. More recently, in April 2023, the FDA approved Vowst, a pill for treating recurrent C. difficile infections.
Dr. Kelly also noted that the article by Dr. Yadegar and colleagues “may help us understand why a small percentage of patients fail to achieve cure after FMT.”
Regarding Dr. Porcari and colleagues’ article, Dr. Kelly said, “There is a lot of hope that FMT or other gut microbiome therapies will be beneficial for conditions outside of C. difficile.
“They do a good job reviewing the state of the science of FMT and highlight the many unknowns around the use of FMT in conditions outside of C. difficile,” added Dr. Kelly, who has been using FMT to treat C. difficile for more than 15 years.
Data supporting FMT for conditions such as ulcerative colitis and autism are compelling, Dr. Kelly acknowledged. But in her view, FMT isn’t ready for “prime time” outside of C. difficile – at least not yet.
“Academic investigators and those in industry are actively conducting research in many non–C. difficile indications, and I predict we will see the emergence of gut microbiome–based therapies for other indications within the next 5-10 years,” Dr. Kelly said.
Dr. Yadegar reports no relevant financial relationships. One coauthor of the Yadegar study has served on the adjudication board for Finch Therapeutics and has received consulting fees and a speaking honorarium from Rebiotix/Ferring Pharmaceuticals. Dr. Ianiro reports no relevant financial relationships. Dr. Kelly has consulted for Sebela Pharmaceuticals and is one of the principal investigators for the FMT National Patient Registry funded by the National Institute of Allergy and Infectious Diseases of the National Institutes of Health.
A version of this article originally appeared on Medscape.com.
A deeper understanding of the mechanisms underlying the success of fecal microbiota transplantation (FMT) is needed to further improve its effectiveness, according to two recent reviews published in Cell Host and Microbe.
how closely the donor’s microbial composition matches the patient’s existing microbiome, and the presence of nonbacterial gut inhabitants like viruses and fungi – affect FMT success, according to a press release.
FMT is most often used to treat recurrent Clostridioides difficile infections, which don’t always respond to antibiotics. Success rates range from 60% to 90%, depending on the administration route and study design, notes an international research team led by Abbas Yadegar, PhD, a medical bacteriologist at the Shahid Beheshti University of Medical Sciences in Tehran, Iran.
The understanding of how FMT works is incomplete, however, and the reasons some patients fail to benefit is unclear, note Dr. Yadegar and colleagues. Little attention has been paid to the role that other components of the patient’s microbiome, along with outside factors, play in the treatment’s success, they add.
“We wanted other researchers to look beyond changes in stool microbial composition and function, which have been the focus of research in the past few years,” Dr. Yadegar’s team said in a statement provided to this news organization.
Dr. Yadegar and colleagues’ review of more than 130 studies summarizes recent evidence on the mechanisms contributing to FMT success against recurrent C. difficile infection, highlights knowledge gaps, and proposes future research directions in the field.
Factors that influence FMT’s effectiveness and the potential the procedure holds for treatment of other diseases associated with gut dysbiosis are the subject of a review of 149 studies by a team of researchers led by Serena Porcari, MD, a gastroenterologist at the Fondazione Policlinico Universitario Gemelli and Università Cattolica del Sacro Cuore, in Rome.
“Our main goal was not only to unravel the different mechanisms of FMT efficacy but also to introduce some mindset shifts that are needed to bring FMT forward, mainly covering the gap that exists between basic scientists and clinicians,” Gianluca Ianiro, MD, PhD, a senior researcher in digestive diseases who works with Dr. Porcari and is the review’s lead author, told this news organization.
Engraftment may influence success
Engraftment of donor microbial strains in recipients appears to be key to the therapeutic success of FMT, both reviews note.
Three factors influence engraftment: the donor’s bacteria fitness relative to the recipient, the bacteria already present in the recipient, and whether antibiotics are used prior to FMT to open a niche for the incoming donor microbes, according to Dr. Yadegar and colleagues.
How to calculate strain engraftment has not yet been standardized in the field, and the number of strains detected in the recipient’s fecal sample is dependent on the depth of sequencing techniques, Dr. Porcari and colleagues note.
The use of whole-genome sequencing has enabled more precise evaluation of engraftment, they add.
“With this approach, microbial engraftment has been associated with clinical success, regardless of the disease, in a large metagenomic metanalysis of 24 FMT trials and almost 1,400 fecal samples,” Dr. Porcari and colleagues write. However, these results have not been replicated, likely because of differences between the studies.
More study on the topic is needed, both articles note.
“Because the recent metagenomics studies compared pre- and post-FMT only in cases with successful treatment outcomes, it is not possible to link engraftment to clinical outcomes,” Dr. Yadegar and colleagues write in their statement to this news organization.
A closer look at donor-recipient pairings
Clinicians usually enlist healthy, carefully screened individuals as FMT donors.
However, both research groups conclude that fine-scale taxonomic and metabolic analyses of donor and recipient microbiomes would better inform clinical decisions, especially when treating diseases other than C. difficile.
This may call for a more personalized approach to choosing donor-recipient pairings. Investigators should assess the patient’s diet and genetic background and how closely the donor’s microbiome matches that of the patient.
“Most studies focused on profiling stool samples before and after FMT without also including functional analyses; therefore, there are still a lot of aspects of host microbial interactions that remain unknown,” write Dr. Yadegar and colleagues in their statement.
Ecologic factors, including diet and host genetics, are often not included in clinical studies of C. difficile, but they “may potentially be the missing links” to treatment failure in the small portion of patients whose condition doesn’t respond to FMT, they write.
Pairing donor-recipient combinations on the basis of dietary patterns and preferences could improve FMT efficacy because the donor microbiota would be preadapted to the recipient’s diet, Dr. Yadegar and colleagues write. The team is examining how donor and recipient diet may affect outcomes.
Dr. Porcari and colleagues add that while some studies support the existence of shared characteristics that make up super-donors, others found that the optimal donor is more patient specific. They call for personalized selection strategies that employ microbiome sequencing tools rather than a “one stool fits all” approach.
Currently, many clinicians aren’t familiar with microbiome sequencing and analysis, but they’ll need to be in the near future, note Dr. Porcari and colleagues.
“Identifying microbiome characteristics that maximize strain engraftment in the FMT will allow clinicians to select the best donor for each single patient,” they write.
The possible role of viruses and fungi
In FMT research, investigators tend to focus on the bacteria in the human microbiome. However, viruses and fungi also appear to play a role, both articles note.
“Other microbial kingdoms that inhabit the intestine should be taken into account when considering predictors of post-FMT microbial transfer,” write Dr. Porcari and colleagues.
Although few studies have examined the gut virome’s impact on FMT effectiveness against C. difficile, the existing research, although limited, indicates that bacteriophage viruses could play a role, Dr. Yadegar and colleagues note. For example, high levels of donor-derived Caudoviralesbacteriophages in recipients were associated with FMT efficacy in one preliminary study, they write.
In a small human study, fecal filtrate from healthy donors who had bacteriophages but no live bacteria successfully treated five patients with recurrent C. difficile infection, Dr. Yadegar and colleagues write.
“Therefore, the idea that viruses may play a role is very provocative,” write Dr. Yadegar’s team in their statement.
It’s important to note that these studies are associative, which means they can’t definitively answer the question of how or whether viruses play a role, Dr. Yadegar’s team added.
Researchers “know even less about how fungi may or may not play a role,” write Dr. Yadegar and colleagues. However, in early research that involved patients who had successfully undergone FMT for C. difficile, there was higher relative abundance of Saccharomyces and Aspergillus, whereas Candida, if prominent, may impede response, they write in their article.
Additionally, to explore whether live bacteria are necessary for FMT to work, Dr. Yadegar and colleagues informed this news organization that they are conducting a study “comparing traditional FMT to a fecal filtrate that contains no live bacteria, but has all other components, to see if we can achieve similar success rates in recurrent C. difficile infection.”
Repeat treatment for sustained response
Dr. Yadegar’s team offered another important takeaway: A single FMT treatment will not sustain a positive response, especially when treating chronic noncommunicable conditions in which intestinal dysbiosis may play a role. Repeat treatment will be needed, as with other chronic conditions. This has been shown even in C. difficile infection.
“Recent studies have documented a significant advantage of repeated FMT over single FMT on the cure rates of recurrent C. difficile,” especially for patients with inflammatory bowel disorder, Dr. Yadegar’s team told this news organization.
“What we don’t know is which patient is likely to respond to microbial-based therapy, or what the dose or frequency should be, or which bacteria are responsible for the effects,” Dr. Yadegar and team said.
Dr. Porcari and colleagues are examining whether FMT could be refined to improve its success against other diseases. This may involve selecting specific donors, monitoring the gut microbiome of both donors and recipients, or using a specific means of delivery, such as lyophilized capsules, Dr. Ianiro said.
A response to FMT for chronic, noncommunicable disorders typically is not sustained long term, note Dr. Porcari and colleagues. However, they add that “sequential transplants have been applied in this setting with promising results, suggesting that chronic modulation of the patient microbiome may be beneficial in noncommunicable chronic disorders.” Dr. Porcari and colleagues point to the success of repeated, long-term FMT in studies of patients with ulcerative colitis and irritable bowel syndrome.
The use of cutting-edge technologies for microbiome assessment and a change in the view of FMT as only an acute, single-use therapy could improve FMT protocols and outcomes for noncommunicable conditions, they write.
Expanding FMT beyond C. difficile
Dr. Yadegar and colleagues’ article “really breaks down what is known about the mechanisms of FMT in C. difficile infection, which is important as other live biotherapeutic products are developed,” Colleen Kelly, MD, an associate professor of medicine at Brown University in Providence, R.I., who was not involved with the reviews, said in an interview.
Dr. Yadegar and colleagues concur. They note in a press release that as the mechanisms behind FMT success are understood, that information should be used to design new standardized therapies.
“Although highly effective, there are substantial drawbacks with [FMT], including infectious risks and sparse long-term safety data,” they write. “Better treatment options for recurrent C. difficile infections that are targeted, safe, and donor-independent are thus desired.”
In December 2022, the U.S. Food and Drug Administration approved the first fecal microbiota product, Rebyota, to prevent recurrence of C. difficile. More recently, in April 2023, the FDA approved Vowst, a pill for treating recurrent C. difficile infections.
Dr. Kelly also noted that the article by Dr. Yadegar and colleagues “may help us understand why a small percentage of patients fail to achieve cure after FMT.”
Regarding Dr. Porcari and colleagues’ article, Dr. Kelly said, “There is a lot of hope that FMT or other gut microbiome therapies will be beneficial for conditions outside of C. difficile.
“They do a good job reviewing the state of the science of FMT and highlight the many unknowns around the use of FMT in conditions outside of C. difficile,” added Dr. Kelly, who has been using FMT to treat C. difficile for more than 15 years.
Data supporting FMT for conditions such as ulcerative colitis and autism are compelling, Dr. Kelly acknowledged. But in her view, FMT isn’t ready for “prime time” outside of C. difficile – at least not yet.
“Academic investigators and those in industry are actively conducting research in many non–C. difficile indications, and I predict we will see the emergence of gut microbiome–based therapies for other indications within the next 5-10 years,” Dr. Kelly said.
Dr. Yadegar reports no relevant financial relationships. One coauthor of the Yadegar study has served on the adjudication board for Finch Therapeutics and has received consulting fees and a speaking honorarium from Rebiotix/Ferring Pharmaceuticals. Dr. Ianiro reports no relevant financial relationships. Dr. Kelly has consulted for Sebela Pharmaceuticals and is one of the principal investigators for the FMT National Patient Registry funded by the National Institute of Allergy and Infectious Diseases of the National Institutes of Health.
A version of this article originally appeared on Medscape.com.
A deeper understanding of the mechanisms underlying the success of fecal microbiota transplantation (FMT) is needed to further improve its effectiveness, according to two recent reviews published in Cell Host and Microbe.
how closely the donor’s microbial composition matches the patient’s existing microbiome, and the presence of nonbacterial gut inhabitants like viruses and fungi – affect FMT success, according to a press release.
FMT is most often used to treat recurrent Clostridioides difficile infections, which don’t always respond to antibiotics. Success rates range from 60% to 90%, depending on the administration route and study design, notes an international research team led by Abbas Yadegar, PhD, a medical bacteriologist at the Shahid Beheshti University of Medical Sciences in Tehran, Iran.
The understanding of how FMT works is incomplete, however, and the reasons some patients fail to benefit is unclear, note Dr. Yadegar and colleagues. Little attention has been paid to the role that other components of the patient’s microbiome, along with outside factors, play in the treatment’s success, they add.
“We wanted other researchers to look beyond changes in stool microbial composition and function, which have been the focus of research in the past few years,” Dr. Yadegar’s team said in a statement provided to this news organization.
Dr. Yadegar and colleagues’ review of more than 130 studies summarizes recent evidence on the mechanisms contributing to FMT success against recurrent C. difficile infection, highlights knowledge gaps, and proposes future research directions in the field.
Factors that influence FMT’s effectiveness and the potential the procedure holds for treatment of other diseases associated with gut dysbiosis are the subject of a review of 149 studies by a team of researchers led by Serena Porcari, MD, a gastroenterologist at the Fondazione Policlinico Universitario Gemelli and Università Cattolica del Sacro Cuore, in Rome.
“Our main goal was not only to unravel the different mechanisms of FMT efficacy but also to introduce some mindset shifts that are needed to bring FMT forward, mainly covering the gap that exists between basic scientists and clinicians,” Gianluca Ianiro, MD, PhD, a senior researcher in digestive diseases who works with Dr. Porcari and is the review’s lead author, told this news organization.
Engraftment may influence success
Engraftment of donor microbial strains in recipients appears to be key to the therapeutic success of FMT, both reviews note.
Three factors influence engraftment: the donor’s bacteria fitness relative to the recipient, the bacteria already present in the recipient, and whether antibiotics are used prior to FMT to open a niche for the incoming donor microbes, according to Dr. Yadegar and colleagues.
How to calculate strain engraftment has not yet been standardized in the field, and the number of strains detected in the recipient’s fecal sample is dependent on the depth of sequencing techniques, Dr. Porcari and colleagues note.
The use of whole-genome sequencing has enabled more precise evaluation of engraftment, they add.
“With this approach, microbial engraftment has been associated with clinical success, regardless of the disease, in a large metagenomic metanalysis of 24 FMT trials and almost 1,400 fecal samples,” Dr. Porcari and colleagues write. However, these results have not been replicated, likely because of differences between the studies.
More study on the topic is needed, both articles note.
“Because the recent metagenomics studies compared pre- and post-FMT only in cases with successful treatment outcomes, it is not possible to link engraftment to clinical outcomes,” Dr. Yadegar and colleagues write in their statement to this news organization.
A closer look at donor-recipient pairings
Clinicians usually enlist healthy, carefully screened individuals as FMT donors.
However, both research groups conclude that fine-scale taxonomic and metabolic analyses of donor and recipient microbiomes would better inform clinical decisions, especially when treating diseases other than C. difficile.
This may call for a more personalized approach to choosing donor-recipient pairings. Investigators should assess the patient’s diet and genetic background and how closely the donor’s microbiome matches that of the patient.
“Most studies focused on profiling stool samples before and after FMT without also including functional analyses; therefore, there are still a lot of aspects of host microbial interactions that remain unknown,” write Dr. Yadegar and colleagues in their statement.
Ecologic factors, including diet and host genetics, are often not included in clinical studies of C. difficile, but they “may potentially be the missing links” to treatment failure in the small portion of patients whose condition doesn’t respond to FMT, they write.
Pairing donor-recipient combinations on the basis of dietary patterns and preferences could improve FMT efficacy because the donor microbiota would be preadapted to the recipient’s diet, Dr. Yadegar and colleagues write. The team is examining how donor and recipient diet may affect outcomes.
Dr. Porcari and colleagues add that while some studies support the existence of shared characteristics that make up super-donors, others found that the optimal donor is more patient specific. They call for personalized selection strategies that employ microbiome sequencing tools rather than a “one stool fits all” approach.
Currently, many clinicians aren’t familiar with microbiome sequencing and analysis, but they’ll need to be in the near future, note Dr. Porcari and colleagues.
“Identifying microbiome characteristics that maximize strain engraftment in the FMT will allow clinicians to select the best donor for each single patient,” they write.
The possible role of viruses and fungi
In FMT research, investigators tend to focus on the bacteria in the human microbiome. However, viruses and fungi also appear to play a role, both articles note.
“Other microbial kingdoms that inhabit the intestine should be taken into account when considering predictors of post-FMT microbial transfer,” write Dr. Porcari and colleagues.
Although few studies have examined the gut virome’s impact on FMT effectiveness against C. difficile, the existing research, although limited, indicates that bacteriophage viruses could play a role, Dr. Yadegar and colleagues note. For example, high levels of donor-derived Caudoviralesbacteriophages in recipients were associated with FMT efficacy in one preliminary study, they write.
In a small human study, fecal filtrate from healthy donors who had bacteriophages but no live bacteria successfully treated five patients with recurrent C. difficile infection, Dr. Yadegar and colleagues write.
“Therefore, the idea that viruses may play a role is very provocative,” write Dr. Yadegar’s team in their statement.
It’s important to note that these studies are associative, which means they can’t definitively answer the question of how or whether viruses play a role, Dr. Yadegar’s team added.
Researchers “know even less about how fungi may or may not play a role,” write Dr. Yadegar and colleagues. However, in early research that involved patients who had successfully undergone FMT for C. difficile, there was higher relative abundance of Saccharomyces and Aspergillus, whereas Candida, if prominent, may impede response, they write in their article.
Additionally, to explore whether live bacteria are necessary for FMT to work, Dr. Yadegar and colleagues informed this news organization that they are conducting a study “comparing traditional FMT to a fecal filtrate that contains no live bacteria, but has all other components, to see if we can achieve similar success rates in recurrent C. difficile infection.”
Repeat treatment for sustained response
Dr. Yadegar’s team offered another important takeaway: A single FMT treatment will not sustain a positive response, especially when treating chronic noncommunicable conditions in which intestinal dysbiosis may play a role. Repeat treatment will be needed, as with other chronic conditions. This has been shown even in C. difficile infection.
“Recent studies have documented a significant advantage of repeated FMT over single FMT on the cure rates of recurrent C. difficile,” especially for patients with inflammatory bowel disorder, Dr. Yadegar’s team told this news organization.
“What we don’t know is which patient is likely to respond to microbial-based therapy, or what the dose or frequency should be, or which bacteria are responsible for the effects,” Dr. Yadegar and team said.
Dr. Porcari and colleagues are examining whether FMT could be refined to improve its success against other diseases. This may involve selecting specific donors, monitoring the gut microbiome of both donors and recipients, or using a specific means of delivery, such as lyophilized capsules, Dr. Ianiro said.
A response to FMT for chronic, noncommunicable disorders typically is not sustained long term, note Dr. Porcari and colleagues. However, they add that “sequential transplants have been applied in this setting with promising results, suggesting that chronic modulation of the patient microbiome may be beneficial in noncommunicable chronic disorders.” Dr. Porcari and colleagues point to the success of repeated, long-term FMT in studies of patients with ulcerative colitis and irritable bowel syndrome.
The use of cutting-edge technologies for microbiome assessment and a change in the view of FMT as only an acute, single-use therapy could improve FMT protocols and outcomes for noncommunicable conditions, they write.
Expanding FMT beyond C. difficile
Dr. Yadegar and colleagues’ article “really breaks down what is known about the mechanisms of FMT in C. difficile infection, which is important as other live biotherapeutic products are developed,” Colleen Kelly, MD, an associate professor of medicine at Brown University in Providence, R.I., who was not involved with the reviews, said in an interview.
Dr. Yadegar and colleagues concur. They note in a press release that as the mechanisms behind FMT success are understood, that information should be used to design new standardized therapies.
“Although highly effective, there are substantial drawbacks with [FMT], including infectious risks and sparse long-term safety data,” they write. “Better treatment options for recurrent C. difficile infections that are targeted, safe, and donor-independent are thus desired.”
In December 2022, the U.S. Food and Drug Administration approved the first fecal microbiota product, Rebyota, to prevent recurrence of C. difficile. More recently, in April 2023, the FDA approved Vowst, a pill for treating recurrent C. difficile infections.
Dr. Kelly also noted that the article by Dr. Yadegar and colleagues “may help us understand why a small percentage of patients fail to achieve cure after FMT.”
Regarding Dr. Porcari and colleagues’ article, Dr. Kelly said, “There is a lot of hope that FMT or other gut microbiome therapies will be beneficial for conditions outside of C. difficile.
“They do a good job reviewing the state of the science of FMT and highlight the many unknowns around the use of FMT in conditions outside of C. difficile,” added Dr. Kelly, who has been using FMT to treat C. difficile for more than 15 years.
Data supporting FMT for conditions such as ulcerative colitis and autism are compelling, Dr. Kelly acknowledged. But in her view, FMT isn’t ready for “prime time” outside of C. difficile – at least not yet.
“Academic investigators and those in industry are actively conducting research in many non–C. difficile indications, and I predict we will see the emergence of gut microbiome–based therapies for other indications within the next 5-10 years,” Dr. Kelly said.
Dr. Yadegar reports no relevant financial relationships. One coauthor of the Yadegar study has served on the adjudication board for Finch Therapeutics and has received consulting fees and a speaking honorarium from Rebiotix/Ferring Pharmaceuticals. Dr. Ianiro reports no relevant financial relationships. Dr. Kelly has consulted for Sebela Pharmaceuticals and is one of the principal investigators for the FMT National Patient Registry funded by the National Institute of Allergy and Infectious Diseases of the National Institutes of Health.
A version of this article originally appeared on Medscape.com.
Brooklyn gastroenterologist: Good listening skills make a doctor a better teacher, person
After the 2004 Indian Ocean earthquake and tsunami, he traveled to his home country of Sri Lanka to help people who were in need and establish an orphanage. He has applied his skills as a gastroenterologist in the U.S. military and the New York City Police Department.
He was in New York during the 9-11 terrorist attacks. To this day, he treats patients with residual GI problems and precancerous changes associated with 9-11. “I’m involved in screening those people who were the first responders referred by the NYPD,” he says.
This year Dr. Iswara earned the Distinguished Clinician Award in Private Practice from the American Gastroenterological Association. “He puts his patients first in every endeavor – and every question that he asks with regards to research and education is linked to the ultimate measuring stick of improving patient care,” according to an AGA announcement of the award.
When dealing with patients and colleagues, he offers this simple pearl of advice: Listen and then listen some more.
“Once you listen more, you can find out their issues much more in depth, and you can give a satisfying answer to them and their problems. Listening is a kindness and a compassionate thing. It not only makes you become a better teacher, but a better person,” said Dr. Iswara, attending gastroenterologist at Maimonides Medical Center in New York.
In an interview, he talked more in depth about his GI beginnings, his role as a mentor, and why he always starts the day with a prayer. He also confided about the useful time management habit kept from his military days that gives him energy.
Question: What gives you joy in day-to-day practice?
Dr. Iswara: One of the main joys is my colleagues, coworkers, fellows, and my patients. The patients come No. 1. As I walk into my practice area or in the hospital, there is a sense of inner happiness in my mind to see the smiles of the patients and the greetings I get from the patients and all the coworkers. I also see smiling patients with anxiety in their face, trying to get my attention to take care of them.
After I see the patient, I change to a different mode, a kind of a professional mode to give the best to the people whom I’m caring for, who are trusting me with their lives.
One thing I do in my mind before I even start the day, I do a silent prayer to guide me, to give compassionate care and safe care. I will not harm anyone who is depending on my care.
Q: Who was your mentor?
Dr. Iswara: I was lucky enough to have been trained by Baroukh El Kodsi, MD, at Maimonides Medical Center. He recently passed away and was a legend in Brooklyn. I was his first-generation trainee, and I was able to pass on my skills to my trainees. Now so many people who are in Brooklyn; they were trained by me, so it’s kind of growth by generations.
When I finished the training with Dr. Kodsi, he hired me as an associate director of the GI department at Maimonides. I became the program director, then division chief, then I became a director of advanced endoscopy. All these gastroenterology procedures started after 1975 while I was doing the training, so I was one of the pioneers to bring all this new technology to our hospital. I’m still involved in fellowship education.
Q: Can we talk more about your accomplishments? Perhaps you can discuss your AGA award and what you received it for.
Dr. Iswara: I’m humbled and honored by this role, and I’ll be forever grateful to AGA for this prestigious honor at the late stage of my career.
I have been a continuous AGA member for the last 45 years. I probably have one of the longest durations of being an actively practicing gastroenterologist in Brooklyn. I’ve also done academic work, teaching so many young gastroenterologists, motivating several of them to become leading gastroenterologists.
Q: If you could describe a scene of your vision for the future, what it would it be in terms of how gastroenterology is practiced?
Dr. Iswara: I’d like to see the newer generation practice more of a clinical medicine than technical medicine. Sometimes when I see the young people, they sit in front of the computer more than talking and touching the patient. There has to be some sort of a balance where the newer people should be taught more bedside personal care, touching the patient, looking at the patient’s face. They are kind of under pressure to write longer notes than to examine the patient, so I think this has to change.
Q: Describe how you would spend a free Saturday afternoon.
Dr. Iswara: When I was in the military, I was told that to prevent battle fatigue you had to take a rest. I really try to take a rest almost 2 hours every day in the daytime. This rejuvenates me.
We live in New York, and I love to go to shows, especially magic shows. I love magic and illusion.
On free Saturday evenings, I also spend time with my grandchildren in the city, watching them in their baseball, soccer, swimming, and other activities. I love to spend time with them.
Lightning round
Texting or talking?
Texting
Favorite city in the U.S. besides the one you live?
Naples, Fla.
Favorite breakfast?
Pancakes
Dark Chocolate or milk chocolate?
Cadbury from England
Last movie you watched?
“To Sir, With Love”
After the 2004 Indian Ocean earthquake and tsunami, he traveled to his home country of Sri Lanka to help people who were in need and establish an orphanage. He has applied his skills as a gastroenterologist in the U.S. military and the New York City Police Department.
He was in New York during the 9-11 terrorist attacks. To this day, he treats patients with residual GI problems and precancerous changes associated with 9-11. “I’m involved in screening those people who were the first responders referred by the NYPD,” he says.
This year Dr. Iswara earned the Distinguished Clinician Award in Private Practice from the American Gastroenterological Association. “He puts his patients first in every endeavor – and every question that he asks with regards to research and education is linked to the ultimate measuring stick of improving patient care,” according to an AGA announcement of the award.
When dealing with patients and colleagues, he offers this simple pearl of advice: Listen and then listen some more.
“Once you listen more, you can find out their issues much more in depth, and you can give a satisfying answer to them and their problems. Listening is a kindness and a compassionate thing. It not only makes you become a better teacher, but a better person,” said Dr. Iswara, attending gastroenterologist at Maimonides Medical Center in New York.
In an interview, he talked more in depth about his GI beginnings, his role as a mentor, and why he always starts the day with a prayer. He also confided about the useful time management habit kept from his military days that gives him energy.
Question: What gives you joy in day-to-day practice?
Dr. Iswara: One of the main joys is my colleagues, coworkers, fellows, and my patients. The patients come No. 1. As I walk into my practice area or in the hospital, there is a sense of inner happiness in my mind to see the smiles of the patients and the greetings I get from the patients and all the coworkers. I also see smiling patients with anxiety in their face, trying to get my attention to take care of them.
After I see the patient, I change to a different mode, a kind of a professional mode to give the best to the people whom I’m caring for, who are trusting me with their lives.
One thing I do in my mind before I even start the day, I do a silent prayer to guide me, to give compassionate care and safe care. I will not harm anyone who is depending on my care.
Q: Who was your mentor?
Dr. Iswara: I was lucky enough to have been trained by Baroukh El Kodsi, MD, at Maimonides Medical Center. He recently passed away and was a legend in Brooklyn. I was his first-generation trainee, and I was able to pass on my skills to my trainees. Now so many people who are in Brooklyn; they were trained by me, so it’s kind of growth by generations.
When I finished the training with Dr. Kodsi, he hired me as an associate director of the GI department at Maimonides. I became the program director, then division chief, then I became a director of advanced endoscopy. All these gastroenterology procedures started after 1975 while I was doing the training, so I was one of the pioneers to bring all this new technology to our hospital. I’m still involved in fellowship education.
Q: Can we talk more about your accomplishments? Perhaps you can discuss your AGA award and what you received it for.
Dr. Iswara: I’m humbled and honored by this role, and I’ll be forever grateful to AGA for this prestigious honor at the late stage of my career.
I have been a continuous AGA member for the last 45 years. I probably have one of the longest durations of being an actively practicing gastroenterologist in Brooklyn. I’ve also done academic work, teaching so many young gastroenterologists, motivating several of them to become leading gastroenterologists.
Q: If you could describe a scene of your vision for the future, what it would it be in terms of how gastroenterology is practiced?
Dr. Iswara: I’d like to see the newer generation practice more of a clinical medicine than technical medicine. Sometimes when I see the young people, they sit in front of the computer more than talking and touching the patient. There has to be some sort of a balance where the newer people should be taught more bedside personal care, touching the patient, looking at the patient’s face. They are kind of under pressure to write longer notes than to examine the patient, so I think this has to change.
Q: Describe how you would spend a free Saturday afternoon.
Dr. Iswara: When I was in the military, I was told that to prevent battle fatigue you had to take a rest. I really try to take a rest almost 2 hours every day in the daytime. This rejuvenates me.
We live in New York, and I love to go to shows, especially magic shows. I love magic and illusion.
On free Saturday evenings, I also spend time with my grandchildren in the city, watching them in their baseball, soccer, swimming, and other activities. I love to spend time with them.
Lightning round
Texting or talking?
Texting
Favorite city in the U.S. besides the one you live?
Naples, Fla.
Favorite breakfast?
Pancakes
Dark Chocolate or milk chocolate?
Cadbury from England
Last movie you watched?
“To Sir, With Love”
After the 2004 Indian Ocean earthquake and tsunami, he traveled to his home country of Sri Lanka to help people who were in need and establish an orphanage. He has applied his skills as a gastroenterologist in the U.S. military and the New York City Police Department.
He was in New York during the 9-11 terrorist attacks. To this day, he treats patients with residual GI problems and precancerous changes associated with 9-11. “I’m involved in screening those people who were the first responders referred by the NYPD,” he says.
This year Dr. Iswara earned the Distinguished Clinician Award in Private Practice from the American Gastroenterological Association. “He puts his patients first in every endeavor – and every question that he asks with regards to research and education is linked to the ultimate measuring stick of improving patient care,” according to an AGA announcement of the award.
When dealing with patients and colleagues, he offers this simple pearl of advice: Listen and then listen some more.
“Once you listen more, you can find out their issues much more in depth, and you can give a satisfying answer to them and their problems. Listening is a kindness and a compassionate thing. It not only makes you become a better teacher, but a better person,” said Dr. Iswara, attending gastroenterologist at Maimonides Medical Center in New York.
In an interview, he talked more in depth about his GI beginnings, his role as a mentor, and why he always starts the day with a prayer. He also confided about the useful time management habit kept from his military days that gives him energy.
Question: What gives you joy in day-to-day practice?
Dr. Iswara: One of the main joys is my colleagues, coworkers, fellows, and my patients. The patients come No. 1. As I walk into my practice area or in the hospital, there is a sense of inner happiness in my mind to see the smiles of the patients and the greetings I get from the patients and all the coworkers. I also see smiling patients with anxiety in their face, trying to get my attention to take care of them.
After I see the patient, I change to a different mode, a kind of a professional mode to give the best to the people whom I’m caring for, who are trusting me with their lives.
One thing I do in my mind before I even start the day, I do a silent prayer to guide me, to give compassionate care and safe care. I will not harm anyone who is depending on my care.
Q: Who was your mentor?
Dr. Iswara: I was lucky enough to have been trained by Baroukh El Kodsi, MD, at Maimonides Medical Center. He recently passed away and was a legend in Brooklyn. I was his first-generation trainee, and I was able to pass on my skills to my trainees. Now so many people who are in Brooklyn; they were trained by me, so it’s kind of growth by generations.
When I finished the training with Dr. Kodsi, he hired me as an associate director of the GI department at Maimonides. I became the program director, then division chief, then I became a director of advanced endoscopy. All these gastroenterology procedures started after 1975 while I was doing the training, so I was one of the pioneers to bring all this new technology to our hospital. I’m still involved in fellowship education.
Q: Can we talk more about your accomplishments? Perhaps you can discuss your AGA award and what you received it for.
Dr. Iswara: I’m humbled and honored by this role, and I’ll be forever grateful to AGA for this prestigious honor at the late stage of my career.
I have been a continuous AGA member for the last 45 years. I probably have one of the longest durations of being an actively practicing gastroenterologist in Brooklyn. I’ve also done academic work, teaching so many young gastroenterologists, motivating several of them to become leading gastroenterologists.
Q: If you could describe a scene of your vision for the future, what it would it be in terms of how gastroenterology is practiced?
Dr. Iswara: I’d like to see the newer generation practice more of a clinical medicine than technical medicine. Sometimes when I see the young people, they sit in front of the computer more than talking and touching the patient. There has to be some sort of a balance where the newer people should be taught more bedside personal care, touching the patient, looking at the patient’s face. They are kind of under pressure to write longer notes than to examine the patient, so I think this has to change.
Q: Describe how you would spend a free Saturday afternoon.
Dr. Iswara: When I was in the military, I was told that to prevent battle fatigue you had to take a rest. I really try to take a rest almost 2 hours every day in the daytime. This rejuvenates me.
We live in New York, and I love to go to shows, especially magic shows. I love magic and illusion.
On free Saturday evenings, I also spend time with my grandchildren in the city, watching them in their baseball, soccer, swimming, and other activities. I love to spend time with them.
Lightning round
Texting or talking?
Texting
Favorite city in the U.S. besides the one you live?
Naples, Fla.
Favorite breakfast?
Pancakes
Dark Chocolate or milk chocolate?
Cadbury from England
Last movie you watched?
“To Sir, With Love”
Taking a global leap into GI technology
Sharmila Anandasabapathy, MD, knew she wanted to focus on endoscopy when she first started her career.
While leading an endoscopy unit in New York City, Dr. Anandasabapathy began developing endoscopic and imaging technologies for underresourced and underserved areas. These technologies eventually made their way into global clinical trials.
“We’ve gone to clinical trial in over 2,000 patients worldwide. When I made that jump into global GI, I was able to make that jump into global health in general,” said Dr. Anandasabapathy.
As vice president for global programs at Baylor College of Medicine in Houston, Dr. Anandasabapathy currently focuses on clinical and translational research.
“We’re looking at the development of new, low-cost devices for early cancer detection in GI globally. I oversee our global programs across the whole college, so it’s GI, it’s surgery, it’s anesthesia, it’s obstetrics, it’s everything.”
In an interview, Dr. Anandasabapathy discussed what attracted her to gastroenterology and why she always takes the time to smile at her patients.
Q: Why did you choose GI?
A: There’s two questions in there: Why I chose GI and why I chose endoscopy.
I chose GI because when I was in my internal medicine training, they seemed like the happiest people in the hospital. They liked what they did. You could make a meaningful impact even at 3 a.m. if you were coming in for a variceal bleed. Everybody seemed happy with their choice of specialty. I was ready to be an oncologist, and I ended up becoming a gastroenterologist.
I chose endoscopy because it was where I wanted to be when I woke up in the morning. I was happy there. I love the procedures; I love the hand-eye coordination. I liked the fact that these were relatively shorter procedures, that it was technology based, and there was infinite growth.
Q: Was there a time when you really helped a patient by doing that endoscopy, preventing Barrett’s esophagus or even cancer?
A: I can think of several times where we had early cancers and it was a question between endoscopic treatment or surgery. It was always discussed with the surgeons. We made the decision within a multidisciplinary group and with the patient, but we usually went with the endoscopic options and the patients have done great. We’ve given them a greater quality of life, and I think that’s really rewarding.
Q: What gives you the most joy in your day-to-day practice?
A: My patients. I work with Barrett’s esophagus patients, and they tend to be well informed about the research and the science. I’m lucky to have a patient population that is really interested and willing to participate in that. I also like my students, my junior faculty. I like teaching and the global application of teaching.
Q: What fears did you have to push past to get to where you are in your career?
A: That I would never become an independent researcher and do it alone. I was able to, over time. The ability to transition from being independent to teaching others and making them independent is a wonderful one.
Early on when I was doing GI, I remember looking at my division, and there were about 58 gastroenterologists and only 2 women. I thought at the time, “Well, can I do it? Is this a field that is conducive with being a woman and having a family?” It turned out that it is. Today, I’m really gratified to see that there are more women in GI than there ever were before.
Q: Have you ever received advice that you’ve ignored?A: Yes. Early in my training in internal medicine, I was told that I smiled too much and that my personality was such that patients and others would think I was too glib. Medicine was a serious business, and you shouldn’t be smiling. That’s not my personality – I’m not Eeyore. I think it’s served me well to be positive, and it’s served me well with patients to be smiling. Especially when you’re dealing with patients who have precancer or dysplasia and are scared – they want reassurance and they want a level of confidence. I’m glad I ignored that advice.
Q: What would be your advice to medical students?
A: Think about where you want to be when you wake up in the morning. If it’s either in a GI practice or doing GI research or doing endoscopy, then you should absolutely do it.
Lightning round
Cat person or dog person
Dog
Favorite sport
Tennis
What song do you have to sing along with when you hear it?
Dancing Queen
Favorite music genre
1980s pop
Favorite movie, show, or book
Wuthering Heights
Dr. Anandasabapathy is on LinkedIn and on Twitter at @anandasabapathy , @bcmglobalhealth , and @bcm_gihep .
Sharmila Anandasabapathy, MD, knew she wanted to focus on endoscopy when she first started her career.
While leading an endoscopy unit in New York City, Dr. Anandasabapathy began developing endoscopic and imaging technologies for underresourced and underserved areas. These technologies eventually made their way into global clinical trials.
“We’ve gone to clinical trial in over 2,000 patients worldwide. When I made that jump into global GI, I was able to make that jump into global health in general,” said Dr. Anandasabapathy.
As vice president for global programs at Baylor College of Medicine in Houston, Dr. Anandasabapathy currently focuses on clinical and translational research.
“We’re looking at the development of new, low-cost devices for early cancer detection in GI globally. I oversee our global programs across the whole college, so it’s GI, it’s surgery, it’s anesthesia, it’s obstetrics, it’s everything.”
In an interview, Dr. Anandasabapathy discussed what attracted her to gastroenterology and why she always takes the time to smile at her patients.
Q: Why did you choose GI?
A: There’s two questions in there: Why I chose GI and why I chose endoscopy.
I chose GI because when I was in my internal medicine training, they seemed like the happiest people in the hospital. They liked what they did. You could make a meaningful impact even at 3 a.m. if you were coming in for a variceal bleed. Everybody seemed happy with their choice of specialty. I was ready to be an oncologist, and I ended up becoming a gastroenterologist.
I chose endoscopy because it was where I wanted to be when I woke up in the morning. I was happy there. I love the procedures; I love the hand-eye coordination. I liked the fact that these were relatively shorter procedures, that it was technology based, and there was infinite growth.
Q: Was there a time when you really helped a patient by doing that endoscopy, preventing Barrett’s esophagus or even cancer?
A: I can think of several times where we had early cancers and it was a question between endoscopic treatment or surgery. It was always discussed with the surgeons. We made the decision within a multidisciplinary group and with the patient, but we usually went with the endoscopic options and the patients have done great. We’ve given them a greater quality of life, and I think that’s really rewarding.
Q: What gives you the most joy in your day-to-day practice?
A: My patients. I work with Barrett’s esophagus patients, and they tend to be well informed about the research and the science. I’m lucky to have a patient population that is really interested and willing to participate in that. I also like my students, my junior faculty. I like teaching and the global application of teaching.
Q: What fears did you have to push past to get to where you are in your career?
A: That I would never become an independent researcher and do it alone. I was able to, over time. The ability to transition from being independent to teaching others and making them independent is a wonderful one.
Early on when I was doing GI, I remember looking at my division, and there were about 58 gastroenterologists and only 2 women. I thought at the time, “Well, can I do it? Is this a field that is conducive with being a woman and having a family?” It turned out that it is. Today, I’m really gratified to see that there are more women in GI than there ever were before.
Q: Have you ever received advice that you’ve ignored?A: Yes. Early in my training in internal medicine, I was told that I smiled too much and that my personality was such that patients and others would think I was too glib. Medicine was a serious business, and you shouldn’t be smiling. That’s not my personality – I’m not Eeyore. I think it’s served me well to be positive, and it’s served me well with patients to be smiling. Especially when you’re dealing with patients who have precancer or dysplasia and are scared – they want reassurance and they want a level of confidence. I’m glad I ignored that advice.
Q: What would be your advice to medical students?
A: Think about where you want to be when you wake up in the morning. If it’s either in a GI practice or doing GI research or doing endoscopy, then you should absolutely do it.
Lightning round
Cat person or dog person
Dog
Favorite sport
Tennis
What song do you have to sing along with when you hear it?
Dancing Queen
Favorite music genre
1980s pop
Favorite movie, show, or book
Wuthering Heights
Dr. Anandasabapathy is on LinkedIn and on Twitter at @anandasabapathy , @bcmglobalhealth , and @bcm_gihep .
Sharmila Anandasabapathy, MD, knew she wanted to focus on endoscopy when she first started her career.
While leading an endoscopy unit in New York City, Dr. Anandasabapathy began developing endoscopic and imaging technologies for underresourced and underserved areas. These technologies eventually made their way into global clinical trials.
“We’ve gone to clinical trial in over 2,000 patients worldwide. When I made that jump into global GI, I was able to make that jump into global health in general,” said Dr. Anandasabapathy.
As vice president for global programs at Baylor College of Medicine in Houston, Dr. Anandasabapathy currently focuses on clinical and translational research.
“We’re looking at the development of new, low-cost devices for early cancer detection in GI globally. I oversee our global programs across the whole college, so it’s GI, it’s surgery, it’s anesthesia, it’s obstetrics, it’s everything.”
In an interview, Dr. Anandasabapathy discussed what attracted her to gastroenterology and why she always takes the time to smile at her patients.
Q: Why did you choose GI?
A: There’s two questions in there: Why I chose GI and why I chose endoscopy.
I chose GI because when I was in my internal medicine training, they seemed like the happiest people in the hospital. They liked what they did. You could make a meaningful impact even at 3 a.m. if you were coming in for a variceal bleed. Everybody seemed happy with their choice of specialty. I was ready to be an oncologist, and I ended up becoming a gastroenterologist.
I chose endoscopy because it was where I wanted to be when I woke up in the morning. I was happy there. I love the procedures; I love the hand-eye coordination. I liked the fact that these were relatively shorter procedures, that it was technology based, and there was infinite growth.
Q: Was there a time when you really helped a patient by doing that endoscopy, preventing Barrett’s esophagus or even cancer?
A: I can think of several times where we had early cancers and it was a question between endoscopic treatment or surgery. It was always discussed with the surgeons. We made the decision within a multidisciplinary group and with the patient, but we usually went with the endoscopic options and the patients have done great. We’ve given them a greater quality of life, and I think that’s really rewarding.
Q: What gives you the most joy in your day-to-day practice?
A: My patients. I work with Barrett’s esophagus patients, and they tend to be well informed about the research and the science. I’m lucky to have a patient population that is really interested and willing to participate in that. I also like my students, my junior faculty. I like teaching and the global application of teaching.
Q: What fears did you have to push past to get to where you are in your career?
A: That I would never become an independent researcher and do it alone. I was able to, over time. The ability to transition from being independent to teaching others and making them independent is a wonderful one.
Early on when I was doing GI, I remember looking at my division, and there were about 58 gastroenterologists and only 2 women. I thought at the time, “Well, can I do it? Is this a field that is conducive with being a woman and having a family?” It turned out that it is. Today, I’m really gratified to see that there are more women in GI than there ever were before.
Q: Have you ever received advice that you’ve ignored?A: Yes. Early in my training in internal medicine, I was told that I smiled too much and that my personality was such that patients and others would think I was too glib. Medicine was a serious business, and you shouldn’t be smiling. That’s not my personality – I’m not Eeyore. I think it’s served me well to be positive, and it’s served me well with patients to be smiling. Especially when you’re dealing with patients who have precancer or dysplasia and are scared – they want reassurance and they want a level of confidence. I’m glad I ignored that advice.
Q: What would be your advice to medical students?
A: Think about where you want to be when you wake up in the morning. If it’s either in a GI practice or doing GI research or doing endoscopy, then you should absolutely do it.
Lightning round
Cat person or dog person
Dog
Favorite sport
Tennis
What song do you have to sing along with when you hear it?
Dancing Queen
Favorite music genre
1980s pop
Favorite movie, show, or book
Wuthering Heights
Dr. Anandasabapathy is on LinkedIn and on Twitter at @anandasabapathy , @bcmglobalhealth , and @bcm_gihep .
GI lends itself to multiple career paths, says Boston physician
Daniel Leffler, MD, MS, AGAF, has some advice for young physicians starting out in their careers: Don’t be afraid of change.
“Just because you’re a doctor doesn’t mean you have to spend the rest of your career doing patient care. We don’t teach that in medical school as well as we should,” said Dr. Leffler. “If you’re interested in a skill set and move in a different direction, that’s totally okay. Many people have major career shifts, whether it’s early, mid- or late career.”
Dr. Leffler followed his own advice in 2016 when he left his longtime job as an associate professor at Harvard Medical School and accepted a position with Takeda Pharmaceuticals. As its medical director, he had a specific goal: To find more therapeutic options for patients with celiac disease.
“Gastroenterology is a fantastic field of medicine, and it somehow continues to get more and more exciting,” said Dr. Leffler, who continues to see patients at Beth Israel Deaconess Medical Center in Boston. “There are just so many careers you can have within gastroenterology, whether you are a full-time endoscopist, in a teaching career, or doing lab work.”
He discussed the events that led to this career change in an interview with GI & Hepatology News.
Q: Why did you choose GI?
Dr. Leffler: I think for a lot of people GI is just an incredibly diverse field where you can see all types of patients and you have an unusually wide armamentarium of diagnostic and therapeutic options. Our ability to see inside in the GI tract relatively easily and obtain tissue and do functional studies is unique. It makes it a very dynamic field.
Q: What gives you the most joy in your day-to-day practice?
Dr. Leffler: I think it’s taking a fresh look at somebody whose symptoms have been incorrectly diagnosed or diagnosed preliminarily as one thing and opening different options and working with the patient to hopefully find a more targeted therapy based on a more definitive diagnosis.
Q: Describe your biggest practice-related challenge and what you are doing to address it.
Dr. Leffler: There are two challenges. For celiac disease, all I have is a gluten-free diet. It would be nice to have other options, the same way we do with almost every other GI disease, whether it’s acid-related disorders or chronic constipation or inflammatory bowel disease. We have a range of therapies we can pick and choose from, tailoring those to the individual. We are not there yet, unfortunately, in celiac disease, so that’s a huge challenge.
Another challenge is awareness of celiac disease. It’s not what it should be. We see a lot of patients who either were misdiagnosed or went many years without getting a proper diagnosis or got diagnosed and did not have proper education or follow up.
Q: How has your job changed since you first began your career? Perhaps we could discuss your switch from Harvard/Beth Israel Deaconess to Takeda Pharmaceuticals.
Dr. Leffler: I became convinced some years ago that the next big thing for celiac disease was an effective therapy beyond the gluten-free diet. Takeda had acquired rights to two of the therapies that I was most interested in, even though they were very early. There was a new glutenase, TAK-062, and a new immune-tolerizing molecule that became TAK-101. Takeda had moved its research center to Boston, and they were looking for someone to work on their celiac program. Moving from an academic position, which I loved, was a really difficult decision.
I didn’t leave without a conversation with the division chief at the time, Tom Lamont, MD. I basically said, “If this doesn’t work out, will you take me back?” I wasn’t sure how much I’d like working in industry. The other thing, on both sides, was that I was allowed to keep a clinic. I still see patients on Fridays and really, to me, I have the best of both worlds.
Q: What teacher or mentor had the greatest impact on you?
Dr. Leffler: I really think of Ciaran Kelly, MD at Beth Israel Deaconess, Detlef Schuppan, MD, who also was at Beth Israel Deaconess, but is now at the University of Mainz in Germany. And Peter Green, MD at Columbia University. These three are the physicians I’ve interacted with the most and learned the most from.
Q: What habits have you established that have benefited your career most?
Dr. Leffler: I do try to focus on being a good collaborator. Playing that long game of working for the good of the project and not necessarily what is next for you, has served me very well over the years.
Lightening round
Superpower?
Optimism
Favorite movie to quote?
The Big Lebowski
What is your favorite form of exercise?
Elliptical
Name one thing on your bucket list.
Ethiopia travel
How many cups of coffee do you drink per day?
Two-ish
Dr. Leffler is on LinkedIn.
Daniel Leffler, MD, MS, AGAF, has some advice for young physicians starting out in their careers: Don’t be afraid of change.
“Just because you’re a doctor doesn’t mean you have to spend the rest of your career doing patient care. We don’t teach that in medical school as well as we should,” said Dr. Leffler. “If you’re interested in a skill set and move in a different direction, that’s totally okay. Many people have major career shifts, whether it’s early, mid- or late career.”
Dr. Leffler followed his own advice in 2016 when he left his longtime job as an associate professor at Harvard Medical School and accepted a position with Takeda Pharmaceuticals. As its medical director, he had a specific goal: To find more therapeutic options for patients with celiac disease.
“Gastroenterology is a fantastic field of medicine, and it somehow continues to get more and more exciting,” said Dr. Leffler, who continues to see patients at Beth Israel Deaconess Medical Center in Boston. “There are just so many careers you can have within gastroenterology, whether you are a full-time endoscopist, in a teaching career, or doing lab work.”
He discussed the events that led to this career change in an interview with GI & Hepatology News.
Q: Why did you choose GI?
Dr. Leffler: I think for a lot of people GI is just an incredibly diverse field where you can see all types of patients and you have an unusually wide armamentarium of diagnostic and therapeutic options. Our ability to see inside in the GI tract relatively easily and obtain tissue and do functional studies is unique. It makes it a very dynamic field.
Q: What gives you the most joy in your day-to-day practice?
Dr. Leffler: I think it’s taking a fresh look at somebody whose symptoms have been incorrectly diagnosed or diagnosed preliminarily as one thing and opening different options and working with the patient to hopefully find a more targeted therapy based on a more definitive diagnosis.
Q: Describe your biggest practice-related challenge and what you are doing to address it.
Dr. Leffler: There are two challenges. For celiac disease, all I have is a gluten-free diet. It would be nice to have other options, the same way we do with almost every other GI disease, whether it’s acid-related disorders or chronic constipation or inflammatory bowel disease. We have a range of therapies we can pick and choose from, tailoring those to the individual. We are not there yet, unfortunately, in celiac disease, so that’s a huge challenge.
Another challenge is awareness of celiac disease. It’s not what it should be. We see a lot of patients who either were misdiagnosed or went many years without getting a proper diagnosis or got diagnosed and did not have proper education or follow up.
Q: How has your job changed since you first began your career? Perhaps we could discuss your switch from Harvard/Beth Israel Deaconess to Takeda Pharmaceuticals.
Dr. Leffler: I became convinced some years ago that the next big thing for celiac disease was an effective therapy beyond the gluten-free diet. Takeda had acquired rights to two of the therapies that I was most interested in, even though they were very early. There was a new glutenase, TAK-062, and a new immune-tolerizing molecule that became TAK-101. Takeda had moved its research center to Boston, and they were looking for someone to work on their celiac program. Moving from an academic position, which I loved, was a really difficult decision.
I didn’t leave without a conversation with the division chief at the time, Tom Lamont, MD. I basically said, “If this doesn’t work out, will you take me back?” I wasn’t sure how much I’d like working in industry. The other thing, on both sides, was that I was allowed to keep a clinic. I still see patients on Fridays and really, to me, I have the best of both worlds.
Q: What teacher or mentor had the greatest impact on you?
Dr. Leffler: I really think of Ciaran Kelly, MD at Beth Israel Deaconess, Detlef Schuppan, MD, who also was at Beth Israel Deaconess, but is now at the University of Mainz in Germany. And Peter Green, MD at Columbia University. These three are the physicians I’ve interacted with the most and learned the most from.
Q: What habits have you established that have benefited your career most?
Dr. Leffler: I do try to focus on being a good collaborator. Playing that long game of working for the good of the project and not necessarily what is next for you, has served me very well over the years.
Lightening round
Superpower?
Optimism
Favorite movie to quote?
The Big Lebowski
What is your favorite form of exercise?
Elliptical
Name one thing on your bucket list.
Ethiopia travel
How many cups of coffee do you drink per day?
Two-ish
Dr. Leffler is on LinkedIn.
Daniel Leffler, MD, MS, AGAF, has some advice for young physicians starting out in their careers: Don’t be afraid of change.
“Just because you’re a doctor doesn’t mean you have to spend the rest of your career doing patient care. We don’t teach that in medical school as well as we should,” said Dr. Leffler. “If you’re interested in a skill set and move in a different direction, that’s totally okay. Many people have major career shifts, whether it’s early, mid- or late career.”
Dr. Leffler followed his own advice in 2016 when he left his longtime job as an associate professor at Harvard Medical School and accepted a position with Takeda Pharmaceuticals. As its medical director, he had a specific goal: To find more therapeutic options for patients with celiac disease.
“Gastroenterology is a fantastic field of medicine, and it somehow continues to get more and more exciting,” said Dr. Leffler, who continues to see patients at Beth Israel Deaconess Medical Center in Boston. “There are just so many careers you can have within gastroenterology, whether you are a full-time endoscopist, in a teaching career, or doing lab work.”
He discussed the events that led to this career change in an interview with GI & Hepatology News.
Q: Why did you choose GI?
Dr. Leffler: I think for a lot of people GI is just an incredibly diverse field where you can see all types of patients and you have an unusually wide armamentarium of diagnostic and therapeutic options. Our ability to see inside in the GI tract relatively easily and obtain tissue and do functional studies is unique. It makes it a very dynamic field.
Q: What gives you the most joy in your day-to-day practice?
Dr. Leffler: I think it’s taking a fresh look at somebody whose symptoms have been incorrectly diagnosed or diagnosed preliminarily as one thing and opening different options and working with the patient to hopefully find a more targeted therapy based on a more definitive diagnosis.
Q: Describe your biggest practice-related challenge and what you are doing to address it.
Dr. Leffler: There are two challenges. For celiac disease, all I have is a gluten-free diet. It would be nice to have other options, the same way we do with almost every other GI disease, whether it’s acid-related disorders or chronic constipation or inflammatory bowel disease. We have a range of therapies we can pick and choose from, tailoring those to the individual. We are not there yet, unfortunately, in celiac disease, so that’s a huge challenge.
Another challenge is awareness of celiac disease. It’s not what it should be. We see a lot of patients who either were misdiagnosed or went many years without getting a proper diagnosis or got diagnosed and did not have proper education or follow up.
Q: How has your job changed since you first began your career? Perhaps we could discuss your switch from Harvard/Beth Israel Deaconess to Takeda Pharmaceuticals.
Dr. Leffler: I became convinced some years ago that the next big thing for celiac disease was an effective therapy beyond the gluten-free diet. Takeda had acquired rights to two of the therapies that I was most interested in, even though they were very early. There was a new glutenase, TAK-062, and a new immune-tolerizing molecule that became TAK-101. Takeda had moved its research center to Boston, and they were looking for someone to work on their celiac program. Moving from an academic position, which I loved, was a really difficult decision.
I didn’t leave without a conversation with the division chief at the time, Tom Lamont, MD. I basically said, “If this doesn’t work out, will you take me back?” I wasn’t sure how much I’d like working in industry. The other thing, on both sides, was that I was allowed to keep a clinic. I still see patients on Fridays and really, to me, I have the best of both worlds.
Q: What teacher or mentor had the greatest impact on you?
Dr. Leffler: I really think of Ciaran Kelly, MD at Beth Israel Deaconess, Detlef Schuppan, MD, who also was at Beth Israel Deaconess, but is now at the University of Mainz in Germany. And Peter Green, MD at Columbia University. These three are the physicians I’ve interacted with the most and learned the most from.
Q: What habits have you established that have benefited your career most?
Dr. Leffler: I do try to focus on being a good collaborator. Playing that long game of working for the good of the project and not necessarily what is next for you, has served me very well over the years.
Lightening round
Superpower?
Optimism
Favorite movie to quote?
The Big Lebowski
What is your favorite form of exercise?
Elliptical
Name one thing on your bucket list.
Ethiopia travel
How many cups of coffee do you drink per day?
Two-ish
Dr. Leffler is on LinkedIn.