The New Gastroenterologist

Adopting new evidence into practice – a guide for the new gastroenterologist


 

The transition from gastroenterology fellowship to independent practice can be daunting. There may be concerns about procedural competency and increased levels of responsibility. Recent trainees have to manage their newly busy clinical schedules while trying to integrate evidence from a rapidly evolving landscape of medical literature into daily practice. Many recent graduates also are expected to participate in financial decisions or contribute to assessments about resource allocation regarding new technologies. These are challenges faced by those in both community and academic positions but may be more keenly felt in the first years of practice regardless of setting.

Dr. David A. Leiman, Duke University, Durham N.C.

Dr. David A. Leiman

Without the benefit of experience, incorporating pertinent evidence from both within and outside of the field of gastroenterology as well as identifying disruptive technologies can be particularly difficult. There is scant guidance in this area, either during fellowship or from the existing literature1. Yet these are skills that, when properly developed, can be lifelong assets and, as a result, an evaluation of this process is warranted. Herein, we identify recent developments relevant to gastroenterologists to illustrate a conceptual framework for judging novel information.

A practical concern for the new gastroenterologist is learning to efficiently evaluate the merits of the latest research and then implement this knowledge in the clinic. Maintaining active society membership often includes access to scholarly journals. For example, AGA members receive Gastroenterology, Clinical Gastroenterology and Hepatology, and Cellular and Molecular Gastroenterology and Hepatology as part of their member benefits and have the opportunity to receive alerts when new content is published. Social media outlets such as Twitter and Facebook also simplify the process for readers to identify high-impact studies2 (see social media urls at the end of the story). In addition to reading, however, a critical review of these studies can prevent premature enthusiasm for modifying practice. The evolving evidence base for understanding proton pump inhibitor (PPI) risks is illustrative. Several studies attracted widespread media attention describing serious associated side effects, ranging from MI3 to dementia4 and stroke5. These studies were provocative but a decision to withhold PPIs from patients based on these concerns alone could lead to unintended consequences with poor outcomes. Ultimately, subsequent studies published only months later challenged these associations.6-8 Instead, thoughtful disclosure to patients of known risks and appropriate indications for PPI therapy based on resources such as the AGA Best Practice Advice9 is prudent. Reading more may be necessary but is insufficient; finding a forum to discuss novel research topics, such as in a monthly journal club10 or group practice meeting, can lead to stimulating discussion about how to apply pertinent research to change practice. The AGA Community is an excellent venue for this kind of interaction.

In many situations, keeping informed of updates about the risks and safety of medications prescribed by nongastroenterologists, particularly as they relate to GI conditions, can be even more difficult. A prime example of this is the rapidly expanding literature on indications and risks of direct oral anticoagulants. Rotating on the inpatient consultation service, with the chance to interact with multiple non-GI providers, affords an excellent opportunity to stay up to date. With the increased prevalence of atrial fibrillation as well as the potential expanded indications for direct oral anticoagulants based on recent randomized, controlled trials11,12, practicing gastroenterologists will be comanaging increasing numbers of patients hospitalized with gastrointestinal bleeding (GIB). Our understanding of the availability and indication for targeted reversal agents, such as idarucizumab, as well as nonspecific reversal agents, such as prothrombin complex concentrates, for those with life-threatening GIB is critical to optimal management of these patients. Multidisciplinary collaborations, such as with cardiogastroenterology clinics13, can be leveraged for optimal management of direct oral anticoagulants in the periendoscopy period.

Traditional outpatient consultative approaches are sometimes necessary but frequent reference to consensus societal guidelines on endoscopy in patients on antithrombotics14 should be made, particularly if they are printed and readily available in the ambulatory clinic and endoscopy suites. When information may be too new or sparse to utilize a national guideline, employing local data or experience to create a hospital-specific algorithm can ensure the delivery of high-quality, collaborative patient care.

Dr. Neil Sengupta University of Chicago Medical Center

Dr. Neil Sengupta

Much like reviewing the literature, evaluating new technologies poses its own challenges. Changes in clinical practice may be slow, as in the adoption of noninvasive methods for Barrett’s esophagus screening.15 But in an age when news of advances and updates in management spreads at tremendous speed through the use of social media, the ability to pivot or assimilate new discoveries and techniques will become increasingly relevant and important. A professional society’s endorsement can provide a framework for a decision, but other principles at play include sensible, critical analyses of the outcomes and costs as well as a balance of organizational and societal perspectives.16 The use of impedance planimetry is one such example. This is a relatively new technology, but it has received increasing interest recently.17 The first questions when considering adopting this type of device likely will be about its supporting evidence and the risk for causing harm. The pace of publications regarding its use for measuring esophageal distensibility has accelerated18. But good data does not necessarily translate into extensive uptake. Other important factors also are practical, e.g., whether a technology committee’s approval is needed and what is the learning curve, available technical support, need for capital purchases, reimbursement, etc. Functional luminal imaging probe (FLIP®) technology was developed to assess compliance in primary esophageal disorders and now has been applied to several other areas including anorectal disease, bariatric surgery, and therapeutic endoscopy19,20. Although seemingly a niche market, there is potential widespread application and an opportunity for collaborations that might not have been evident at first blush. Ultimately, any evaluation of new technology is to a certain extent speculation. Is the technology mature or novel? If it is the latter, this may provide a marketing advantage and facilitate a relationship that could lead to academic partnerships.

Embracing new devices and modifications to existing practice paradigms happens on a spectrum21. We are reminded of the maxim, “never be the first or last to adopt change.” One must be on the lookout for revolutionary or game-changing advances but be cautious to avoid irresponsible enthusiasm. Whether it is incorporating evidence from a recent study into everyday practice or judging the potential of new equipment, a balance must be achieved between detailed evaluation of the literature and understanding the practical consequences and feasibility of implementing change. Although these may be competing interests, achieving this is a pivotal step in success for the new gastroenterologist.

Pages

Next Article: