Mixed Topics

As the medical field continues to evolve, so do policies and laws designed to accommodate a growing population, and physicians are once again called upon to expand their role in health care. The American Board of Internal Medicine has called for “a commitment to the promotion of public health and preventative medicine, as well as public advocacy on the part of each physician.”¹ In our responsibility to preserve and promote human life, physicians are not only uniquely positioned for advocacy but also inherently assume the role of becoming health care activists.

The American Medical Association has defined physician advocacy as promoting “social, economic, educational, and political changes that ameliorate suffering and contribute to human well being.”² For health care professionals, this translates into ensuring the concerns and best interests of patients are at the core of all decisions.³ For generations, physicians have taken extra steps for patient care in daily practice, including submitting prior authorizations, performing peer review, and taking part in family meetings. Many doctors also participate on hospital committees and boards for quality improvement measures and are leaders in designing strategies to improve patient safety and health care experiences. Although these examples may be viewed as a fundamental part of daily practice, in fact, these roles are consistent with advocacy on a local level. A significant number of physicians participate in medical education, research, and societal duties, which include formulating and reviewing guidelines for medical practice. Participation in conference organizing committees and reviewing medical journals are likewise not uncommon roles among medical practitioners. These efforts to provide education to improve patient care are also forms of advocacy on a national or regional level but often viewed as a standard in professionalism.⁴

It is on the federal and political level in advocacy where physician representation is critical. Health legislation is enacted by Congress and signed into law by the president of the United States.⁵ These laws can drastically affect clinical practice and patient care, especially in the realm of preventive medicine and pharmaceuticals. Gastroenterology is a unique field in which a large portion of practice is dedicated to cancer prevention, by screening age-appropriate individuals and monitoring high-risk patients. The field is rapidly expanding in the pharmaceutical area with new medications for inflammatory bowel disease and groundbreaking treatments for viral hepatitis. The breadth of practice in gastroenterology calls for antiquated laws to be changed to accommodate the development of patient care guidelines. With physicians representing less than 3% of Congress,⁶ the rules that govern our practice are largely left to those unfamiliar with the delivery of health care.

Lack of experience, limited time, and a tradition in medicine that prefers physicians to be apolitical are each contributing factors for reduced participation in federal advocacy.⁷ Professional GI societies, including the American Gastroenterological Association, American College of Gastroenterology, American Society for Gastrointestinal Endoscopy, and American Association for the Study of Liver Disease, have a presence in public policy to educate lawmakers and promote statutes in gastroenterology. The involvement of these organizations in legislation is critical since public policy directly affects the interests and well-being of patients.

• Reducing the administrative burden of prior authorizations.
• Implementing timely appeals for non–first-line therapies as determined by payers (step therapy).
• Eliminating surprise billing and cost-sharing for screening colonoscopy.
• Preserving patient protections, including for preexisting conditions and preventive services.
• Increasing federal funding and research appropriations for gastrointestinal research.

Communication with and development of relationships with legislators are essential to effective advocacy.^7,8 Health professionals should be well-informed resources for members of Congress and therefore it is pivotal to provide factual information when presenting topics. There are various ways to reach congressional representatives, including personal visits, writing letters, making phone calls, or attending town halls.

Of the aforementioned, in-person meetings are the best way to directly connect with legislators. These allow for time to discuss a legislative issue, including the background and societal impact, proposed initiative, and personal accounts relating to the topic. Attending town halls also will give face-time with legislators, although the format to ask questions often is abbreviated. GI societies use letter writing as a way to increase support for a proposed bill or measure. The efficacy of letter writing increases with higher involvement. Letters are often generated in an online forum that requires the user’s zip code (so the letter can be routed to the appropriate legislator) and name with electronic signature, which are designed for easy use to boost participation.

Understanding that physicians are advocates in daily practice and that federal initiatives have significant impact on patients and clinical practice is the first step to getting involved. Participation at the local level includes connecting with the district offices of congressional leaders through letter writing, making phone calls, or in-person visits. On regional and national levels, involvement with state legislators, GI societies, or personal like-minded groups are ways to initiate federal advocacy. GI societies have federal policy committees, political action committees, and opportunities for early-career gastroenterologists to become involved in advocacy, including the Congressional Advocates Program from the AGA and the Young Physician Leadership Scholars Program from the ACG. Be sure to visit AGA’s Advocacy & Policy page to keep informed about current and future opportunities.

As the population grows and human life expectancy increases, the practice of medicine is a prime target for legislative changes, which ultimately affect patient care and clinical practice. Physicians are respected members of society, have expansive knowledge in disease processes and the delivery of health care to patients, and are naturally patient advocates. For these reasons, it is imperative for doctors to rise to the calling of federal advocacy, to continue to preserve the best interests and dignity of our patients.
 

References

1. ABIM Foundation. Ann Intern Med. 2002;136:243-6.

2. Earnest MA et al. Academic Med. 2010;85(1):63-7.

3. Schwartz L. J Med Ethics. 2002;28:37-40.

4. Howell BA et al. J Gen Intern Med. 2019 Aug 5. https://doi.org/10.1007/s11606-019-05184-3. [epub ahead of print]

5. The House of Representatives.

6. AGA News: https://www.gastro.org/news/new-congress-includes-22-health-care-providers

7. Kupfer SS et al. Gastroenterology. 2019;156(4)8:834-7.

8. Grace ND and LB Dennis. Hepatology. 2007;45(6):1337-9.
 

Dr. Abbasi is a gastroenterologist who works in inflammatory bowel diseases at Cedars-Sinai Medical Center and Santa Monica Gastroenterology, Calif.

As the medical field continues to evolve, so do policies and laws designed to accommodate a growing population, and physicians are once again called upon to expand their role in health care. The American Board of Internal Medicine has called for “a commitment to the promotion of public health and preventative medicine, as well as public advocacy on the part of each physician.”¹ In our responsibility to preserve and promote human life, physicians are not only uniquely positioned for advocacy but also inherently assume the role of becoming health care activists.

The American Medical Association has defined physician advocacy as promoting “social, economic, educational, and political changes that ameliorate suffering and contribute to human well being.”² For health care professionals, this translates into ensuring the concerns and best interests of patients are at the core of all decisions.³ For generations, physicians have taken extra steps for patient care in daily practice, including submitting prior authorizations, performing peer review, and taking part in family meetings. Many doctors also participate on hospital committees and boards for quality improvement measures and are leaders in designing strategies to improve patient safety and health care experiences. Although these examples may be viewed as a fundamental part of daily practice, in fact, these roles are consistent with advocacy on a local level. A significant number of physicians participate in medical education, research, and societal duties, which include formulating and reviewing guidelines for medical practice. Participation in conference organizing committees and reviewing medical journals are likewise not uncommon roles among medical practitioners. These efforts to provide education to improve patient care are also forms of advocacy on a national or regional level but often viewed as a standard in professionalism.⁴

It is on the federal and political level in advocacy where physician representation is critical. Health legislation is enacted by Congress and signed into law by the president of the United States.⁵ These laws can drastically affect clinical practice and patient care, especially in the realm of preventive medicine and pharmaceuticals. Gastroenterology is a unique field in which a large portion of practice is dedicated to cancer prevention, by screening age-appropriate individuals and monitoring high-risk patients. The field is rapidly expanding in the pharmaceutical area with new medications for inflammatory bowel disease and groundbreaking treatments for viral hepatitis. The breadth of practice in gastroenterology calls for antiquated laws to be changed to accommodate the development of patient care guidelines. With physicians representing less than 3% of Congress,⁶ the rules that govern our practice are largely left to those unfamiliar with the delivery of health care.

Lack of experience, limited time, and a tradition in medicine that prefers physicians to be apolitical are each contributing factors for reduced participation in federal advocacy.⁷ Professional GI societies, including the American Gastroenterological Association, American College of Gastroenterology, American Society for Gastrointestinal Endoscopy, and American Association for the Study of Liver Disease, have a presence in public policy to educate lawmakers and promote statutes in gastroenterology. The involvement of these organizations in legislation is critical since public policy directly affects the interests and well-being of patients.

• Reducing the administrative burden of prior authorizations.
• Implementing timely appeals for non–first-line therapies as determined by payers (step therapy).
• Eliminating surprise billing and cost-sharing for screening colonoscopy.
• Preserving patient protections, including for preexisting conditions and preventive services.
• Increasing federal funding and research appropriations for gastrointestinal research.

Communication with and development of relationships with legislators are essential to effective advocacy.^7,8 Health professionals should be well-informed resources for members of Congress and therefore it is pivotal to provide factual information when presenting topics. There are various ways to reach congressional representatives, including personal visits, writing letters, making phone calls, or attending town halls.

Of the aforementioned, in-person meetings are the best way to directly connect with legislators. These allow for time to discuss a legislative issue, including the background and societal impact, proposed initiative, and personal accounts relating to the topic. Attending town halls also will give face-time with legislators, although the format to ask questions often is abbreviated. GI societies use letter writing as a way to increase support for a proposed bill or measure. The efficacy of letter writing increases with higher involvement. Letters are often generated in an online forum that requires the user’s zip code (so the letter can be routed to the appropriate legislator) and name with electronic signature, which are designed for easy use to boost participation.

Understanding that physicians are advocates in daily practice and that federal initiatives have significant impact on patients and clinical practice is the first step to getting involved. Participation at the local level includes connecting with the district offices of congressional leaders through letter writing, making phone calls, or in-person visits. On regional and national levels, involvement with state legislators, GI societies, or personal like-minded groups are ways to initiate federal advocacy. GI societies have federal policy committees, political action committees, and opportunities for early-career gastroenterologists to become involved in advocacy, including the Congressional Advocates Program from the AGA and the Young Physician Leadership Scholars Program from the ACG. Be sure to visit AGA’s Advocacy & Policy page to keep informed about current and future opportunities.

As the population grows and human life expectancy increases, the practice of medicine is a prime target for legislative changes, which ultimately affect patient care and clinical practice. Physicians are respected members of society, have expansive knowledge in disease processes and the delivery of health care to patients, and are naturally patient advocates. For these reasons, it is imperative for doctors to rise to the calling of federal advocacy, to continue to preserve the best interests and dignity of our patients.
 

References

1. ABIM Foundation. Ann Intern Med. 2002;136:243-6.

2. Earnest MA et al. Academic Med. 2010;85(1):63-7.

3. Schwartz L. J Med Ethics. 2002;28:37-40.

4. Howell BA et al. J Gen Intern Med. 2019 Aug 5. https://doi.org/10.1007/s11606-019-05184-3. [epub ahead of print]

5. The House of Representatives.

6. AGA News: https://www.gastro.org/news/new-congress-includes-22-health-care-providers

7. Kupfer SS et al. Gastroenterology. 2019;156(4)8:834-7.

8. Grace ND and LB Dennis. Hepatology. 2007;45(6):1337-9.
 

Dr. Abbasi is a gastroenterologist who works in inflammatory bowel diseases at Cedars-Sinai Medical Center and Santa Monica Gastroenterology, Calif.

As the medical field continues to evolve, so do policies and laws designed to accommodate a growing population, and physicians are once again called upon to expand their role in health care. The American Board of Internal Medicine has called for “a commitment to the promotion of public health and preventative medicine, as well as public advocacy on the part of each physician.”¹ In our responsibility to preserve and promote human life, physicians are not only uniquely positioned for advocacy but also inherently assume the role of becoming health care activists.

The American Medical Association has defined physician advocacy as promoting “social, economic, educational, and political changes that ameliorate suffering and contribute to human well being.”² For health care professionals, this translates into ensuring the concerns and best interests of patients are at the core of all decisions.³ For generations, physicians have taken extra steps for patient care in daily practice, including submitting prior authorizations, performing peer review, and taking part in family meetings. Many doctors also participate on hospital committees and boards for quality improvement measures and are leaders in designing strategies to improve patient safety and health care experiences. Although these examples may be viewed as a fundamental part of daily practice, in fact, these roles are consistent with advocacy on a local level. A significant number of physicians participate in medical education, research, and societal duties, which include formulating and reviewing guidelines for medical practice. Participation in conference organizing committees and reviewing medical journals are likewise not uncommon roles among medical practitioners. These efforts to provide education to improve patient care are also forms of advocacy on a national or regional level but often viewed as a standard in professionalism.⁴

It is on the federal and political level in advocacy where physician representation is critical. Health legislation is enacted by Congress and signed into law by the president of the United States.⁵ These laws can drastically affect clinical practice and patient care, especially in the realm of preventive medicine and pharmaceuticals. Gastroenterology is a unique field in which a large portion of practice is dedicated to cancer prevention, by screening age-appropriate individuals and monitoring high-risk patients. The field is rapidly expanding in the pharmaceutical area with new medications for inflammatory bowel disease and groundbreaking treatments for viral hepatitis. The breadth of practice in gastroenterology calls for antiquated laws to be changed to accommodate the development of patient care guidelines. With physicians representing less than 3% of Congress,⁶ the rules that govern our practice are largely left to those unfamiliar with the delivery of health care.

Lack of experience, limited time, and a tradition in medicine that prefers physicians to be apolitical are each contributing factors for reduced participation in federal advocacy.⁷ Professional GI societies, including the American Gastroenterological Association, American College of Gastroenterology, American Society for Gastrointestinal Endoscopy, and American Association for the Study of Liver Disease, have a presence in public policy to educate lawmakers and promote statutes in gastroenterology. The involvement of these organizations in legislation is critical since public policy directly affects the interests and well-being of patients.

• Reducing the administrative burden of prior authorizations.
• Implementing timely appeals for non–first-line therapies as determined by payers (step therapy).
• Eliminating surprise billing and cost-sharing for screening colonoscopy.
• Preserving patient protections, including for preexisting conditions and preventive services.
• Increasing federal funding and research appropriations for gastrointestinal research.

Communication with and development of relationships with legislators are essential to effective advocacy.^7,8 Health professionals should be well-informed resources for members of Congress and therefore it is pivotal to provide factual information when presenting topics. There are various ways to reach congressional representatives, including personal visits, writing letters, making phone calls, or attending town halls.

Of the aforementioned, in-person meetings are the best way to directly connect with legislators. These allow for time to discuss a legislative issue, including the background and societal impact, proposed initiative, and personal accounts relating to the topic. Attending town halls also will give face-time with legislators, although the format to ask questions often is abbreviated. GI societies use letter writing as a way to increase support for a proposed bill or measure. The efficacy of letter writing increases with higher involvement. Letters are often generated in an online forum that requires the user’s zip code (so the letter can be routed to the appropriate legislator) and name with electronic signature, which are designed for easy use to boost participation.

Understanding that physicians are advocates in daily practice and that federal initiatives have significant impact on patients and clinical practice is the first step to getting involved. Participation at the local level includes connecting with the district offices of congressional leaders through letter writing, making phone calls, or in-person visits. On regional and national levels, involvement with state legislators, GI societies, or personal like-minded groups are ways to initiate federal advocacy. GI societies have federal policy committees, political action committees, and opportunities for early-career gastroenterologists to become involved in advocacy, including the Congressional Advocates Program from the AGA and the Young Physician Leadership Scholars Program from the ACG. Be sure to visit AGA’s Advocacy & Policy page to keep informed about current and future opportunities.

As the population grows and human life expectancy increases, the practice of medicine is a prime target for legislative changes, which ultimately affect patient care and clinical practice. Physicians are respected members of society, have expansive knowledge in disease processes and the delivery of health care to patients, and are naturally patient advocates. For these reasons, it is imperative for doctors to rise to the calling of federal advocacy, to continue to preserve the best interests and dignity of our patients.
 

References

1. ABIM Foundation. Ann Intern Med. 2002;136:243-6.

2. Earnest MA et al. Academic Med. 2010;85(1):63-7.

3. Schwartz L. J Med Ethics. 2002;28:37-40.

4. Howell BA et al. J Gen Intern Med. 2019 Aug 5. https://doi.org/10.1007/s11606-019-05184-3. [epub ahead of print]

5. The House of Representatives.

6. AGA News: https://www.gastro.org/news/new-congress-includes-22-health-care-providers

7. Kupfer SS et al. Gastroenterology. 2019;156(4)8:834-7.

8. Grace ND and LB Dennis. Hepatology. 2007;45(6):1337-9.
 

Dr. Abbasi is a gastroenterologist who works in inflammatory bowel diseases at Cedars-Sinai Medical Center and Santa Monica Gastroenterology, Calif.

Artificial intelligence (AI) and machine learning (ML) are promoted as the solution to many health care problems, but the area risks becoming technology led – with only secondary consideration to the safe clinical application of the technology, says Robert Challen, PhD.

Dr. Challen, of the University of Exeter (England), is the lead author of a recent paper that examines the short-, medium-, and long-term issues with medical applications of AI. “In the short term, AI systems will effectively function like laboratory screening tests, identifying patients who are at higher risk than others of disease, or who could benefit more from a particular treatment,” Dr. Challen said. “We usually accept that laboratory tests are useful to help make a diagnosis; however, clinicians are aware that they might not always be accurate and interpret their output in the clinical context. AI systems are no different in that they will be a useful tool so long as they are designed with safety in mind and used with a pragmatic attitude to their interpretation.”

The paper also suggests a set of short-and medium-term clinical safety issues that need addressing when bringing these systems from laboratory to bedside.

In the longer term, as more continuously learning and autonomous systems are developed, the safety risks will need to be continuously reevaluated, he added. “Any new technology comes with limitations and understanding those limitations is key to safe use of that technology. In the same way a new screening test has limitations on its sensitivity and specificity that define how it can be used, AL and ML systems have limitations on accuracy and which patients they can be used on,” Dr. Challen said. If hospitalists understand these limitations, they can participate better in their development.

Dr. Challen recommends that hospitalists help the development of AI tools by participating in studies that assess AI applications in the clinical environment. “Try to make sure that where AI research is taking place, there is strong clinical involvement.”

Reference

1. Challen R et al. Artificial intelligence, bias and clinical safety. BMJ Qual Saf. 2019 Jan 12. doi: 10.1136/bmjqs-2018-008370.

Artificial intelligence (AI) and machine learning (ML) are promoted as the solution to many health care problems, but the area risks becoming technology led – with only secondary consideration to the safe clinical application of the technology, says Robert Challen, PhD.

Dr. Challen, of the University of Exeter (England), is the lead author of a recent paper that examines the short-, medium-, and long-term issues with medical applications of AI. “In the short term, AI systems will effectively function like laboratory screening tests, identifying patients who are at higher risk than others of disease, or who could benefit more from a particular treatment,” Dr. Challen said. “We usually accept that laboratory tests are useful to help make a diagnosis; however, clinicians are aware that they might not always be accurate and interpret their output in the clinical context. AI systems are no different in that they will be a useful tool so long as they are designed with safety in mind and used with a pragmatic attitude to their interpretation.”

The paper also suggests a set of short-and medium-term clinical safety issues that need addressing when bringing these systems from laboratory to bedside.

In the longer term, as more continuously learning and autonomous systems are developed, the safety risks will need to be continuously reevaluated, he added. “Any new technology comes with limitations and understanding those limitations is key to safe use of that technology. In the same way a new screening test has limitations on its sensitivity and specificity that define how it can be used, AL and ML systems have limitations on accuracy and which patients they can be used on,” Dr. Challen said. If hospitalists understand these limitations, they can participate better in their development.

Dr. Challen recommends that hospitalists help the development of AI tools by participating in studies that assess AI applications in the clinical environment. “Try to make sure that where AI research is taking place, there is strong clinical involvement.”

Reference

1. Challen R et al. Artificial intelligence, bias and clinical safety. BMJ Qual Saf. 2019 Jan 12. doi: 10.1136/bmjqs-2018-008370.

Artificial intelligence (AI) and machine learning (ML) are promoted as the solution to many health care problems, but the area risks becoming technology led – with only secondary consideration to the safe clinical application of the technology, says Robert Challen, PhD.

Dr. Challen, of the University of Exeter (England), is the lead author of a recent paper that examines the short-, medium-, and long-term issues with medical applications of AI. “In the short term, AI systems will effectively function like laboratory screening tests, identifying patients who are at higher risk than others of disease, or who could benefit more from a particular treatment,” Dr. Challen said. “We usually accept that laboratory tests are useful to help make a diagnosis; however, clinicians are aware that they might not always be accurate and interpret their output in the clinical context. AI systems are no different in that they will be a useful tool so long as they are designed with safety in mind and used with a pragmatic attitude to their interpretation.”

The paper also suggests a set of short-and medium-term clinical safety issues that need addressing when bringing these systems from laboratory to bedside.

In the longer term, as more continuously learning and autonomous systems are developed, the safety risks will need to be continuously reevaluated, he added. “Any new technology comes with limitations and understanding those limitations is key to safe use of that technology. In the same way a new screening test has limitations on its sensitivity and specificity that define how it can be used, AL and ML systems have limitations on accuracy and which patients they can be used on,” Dr. Challen said. If hospitalists understand these limitations, they can participate better in their development.

Dr. Challen recommends that hospitalists help the development of AI tools by participating in studies that assess AI applications in the clinical environment. “Try to make sure that where AI research is taking place, there is strong clinical involvement.”

Reference

1. Challen R et al. Artificial intelligence, bias and clinical safety. BMJ Qual Saf. 2019 Jan 12. doi: 10.1136/bmjqs-2018-008370.

MINNEAPOLIS -- Medical professionals within the US Department of Veterans Affairs (VA) can’t prescribe cannabis or certify patients to be able to get it. VA pharmacists can’t dispense it. Still, “we’re asked about it plenty,” a hospice and palliative care specialist told colleagues, at the annual meeting of the Association of VA Hematology/Oncology (AVAHO).

That brings up a big question, said Michael Stellini, MD, MS, FACP, FAAHPM, of Wayne State University, Karmanos Cancer Center, and the John D. Dingell VA Medical Center, in Detroit Michigan: “Should sick people be smoking pot?”

Even the question itself isn’t a simple one to answer since smoking isn’t the only way to consume cannabis for medical purposes. And figuring out the best advice is difficult. As Dr. Stellini said, there’s plenty of uncertainty about crucial cannabis topics like safety and benefits.

Dr. Stellini offered a number of facts and tips about cannabis in medicine.

Understand ‘qualifying conditions’ in your state

In states with legal medical marijuana, he said, physicians do not prescribe marijuana. However, they may certify that patients are eligible to get the drug for medical purposes if they meet certain qualifications.

A typical list of qualifying conditions includes diseases such as cancer, glaucoma, HIV/AIDS and Crohn’s disease. Qualifying conditions also tend to include treatments for severe diseases that produce wasting syndrome, severe and chronic pain, severe nausea, seizures and severe and persistent muscle spasm.

In Michigan, where Dr. Stellini practices, a panel in 2018 approved a long list of added qualifying conditions such as chronic pain, obsessive compulsive disorder and arthritis. But the panel rejected other conditions such as anxiety, asthma, panic attacks and schizophrenia.

Vaporizers are an alternative to joints, but...

Vaporizers are commonly used as an alternative to smoking marijuana joints, Dr. Stellini said, and they don’t significantly release tars or much if any carbon monoxide. While research is limited, he said, use of vaporizers hasn’t been linked to more lung cancer or chronic obstructive pulmonary disease.

“Vaping” is another option, but it’s been linked to dozens of deaths and hundreds of cases of illness in recent weeks. Many patients have reported using products that contain THC, a component of marijuana.

Other delivery methods exist

Marijuana can be ingested in liquid and solid food. “But edibles can have a slow onset of action compared to vaporizing or smoking,” Dr. Stellini said. “You might over-indulge. When users get to their steady state, they might have some adverse effects [AEs].”

Marijuana still has risks

Cannabis use has a long list of well-known AEs linked to the THC component. The most common are drowsiness, fatigue, dizziness, dry mouth, anxiety, cognitive effects, cough, and nausea, Dr. Stellini said. More serious AEs such as psychosis have been reported.

And, of course, users of cannabis with THC get high if they use enough.

A 2017 National Academies of Sciences, Engineering and Medicine report linked cannabis use to a higher risk of motor vehicle accidents. Still, Dr. Stellini said, “it’s relatively safe with respect to mortality, especially compared to opioids.”¹

Risk of use in cancer may be low

Research suggest that patients with cancer use cannabis as much as other people and perhaps even more, Dr. Stellini said. But are they facing any extra risks? In general, he said, it doesn’t appear that way.

Cannabis seems to be safe when used with chemotherapy, he said, and drug-drug interactions in cancer appear to be rare. Some studies have suggested that cannabinoids—a component of marijuana—may be an effective treatment for chemotherapy-induced peripheral neuropathy.

However, he said, 1 study has raised a red flag about a possible interaction with cancer immunotherapy. Researchers found evidence that patients who used cannabis had lower tumor response rates to nivolomab for advanced melanoma, non-small cell lung cancer, and renal clear cell carcinoma. However, survival wasn’t affected.²

Meanwhile, he said, there’s no strong evidence that cannabis is a useful treatment for cancer, he said, although it’s worth investigating.

Cannabidiol is the hot new product

Cannabidiol, also known as CBD, has become hugely popular, Dr. Stellini said. It is derived from hemp and doesn’t cause a “buzz” like cannabis.

Due to lack of regulation, he said, buyers should beware. And, he said, CBD has multiple EAs. Standard doses can cause drowsiness, fatigue, dizziness, dry mouth, hypotension and lightheadedness.

Dr. Stellini reports no relevant disclosures.

MINNEAPOLIS -- Medical professionals within the US Department of Veterans Affairs (VA) can’t prescribe cannabis or certify patients to be able to get it. VA pharmacists can’t dispense it. Still, “we’re asked about it plenty,” a hospice and palliative care specialist told colleagues, at the annual meeting of the Association of VA Hematology/Oncology (AVAHO).

That brings up a big question, said Michael Stellini, MD, MS, FACP, FAAHPM, of Wayne State University, Karmanos Cancer Center, and the John D. Dingell VA Medical Center, in Detroit Michigan: “Should sick people be smoking pot?”

Even the question itself isn’t a simple one to answer since smoking isn’t the only way to consume cannabis for medical purposes. And figuring out the best advice is difficult. As Dr. Stellini said, there’s plenty of uncertainty about crucial cannabis topics like safety and benefits.

Dr. Stellini offered a number of facts and tips about cannabis in medicine.

Understand ‘qualifying conditions’ in your state

In states with legal medical marijuana, he said, physicians do not prescribe marijuana. However, they may certify that patients are eligible to get the drug for medical purposes if they meet certain qualifications.

A typical list of qualifying conditions includes diseases such as cancer, glaucoma, HIV/AIDS and Crohn’s disease. Qualifying conditions also tend to include treatments for severe diseases that produce wasting syndrome, severe and chronic pain, severe nausea, seizures and severe and persistent muscle spasm.

In Michigan, where Dr. Stellini practices, a panel in 2018 approved a long list of added qualifying conditions such as chronic pain, obsessive compulsive disorder and arthritis. But the panel rejected other conditions such as anxiety, asthma, panic attacks and schizophrenia.

Vaporizers are an alternative to joints, but...

Vaporizers are commonly used as an alternative to smoking marijuana joints, Dr. Stellini said, and they don’t significantly release tars or much if any carbon monoxide. While research is limited, he said, use of vaporizers hasn’t been linked to more lung cancer or chronic obstructive pulmonary disease.

“Vaping” is another option, but it’s been linked to dozens of deaths and hundreds of cases of illness in recent weeks. Many patients have reported using products that contain THC, a component of marijuana.

Other delivery methods exist

Marijuana can be ingested in liquid and solid food. “But edibles can have a slow onset of action compared to vaporizing or smoking,” Dr. Stellini said. “You might over-indulge. When users get to their steady state, they might have some adverse effects [AEs].”

Marijuana still has risks

Cannabis use has a long list of well-known AEs linked to the THC component. The most common are drowsiness, fatigue, dizziness, dry mouth, anxiety, cognitive effects, cough, and nausea, Dr. Stellini said. More serious AEs such as psychosis have been reported.

And, of course, users of cannabis with THC get high if they use enough.

A 2017 National Academies of Sciences, Engineering and Medicine report linked cannabis use to a higher risk of motor vehicle accidents. Still, Dr. Stellini said, “it’s relatively safe with respect to mortality, especially compared to opioids.”¹

Risk of use in cancer may be low

Research suggest that patients with cancer use cannabis as much as other people and perhaps even more, Dr. Stellini said. But are they facing any extra risks? In general, he said, it doesn’t appear that way.

Cannabis seems to be safe when used with chemotherapy, he said, and drug-drug interactions in cancer appear to be rare. Some studies have suggested that cannabinoids—a component of marijuana—may be an effective treatment for chemotherapy-induced peripheral neuropathy.

However, he said, 1 study has raised a red flag about a possible interaction with cancer immunotherapy. Researchers found evidence that patients who used cannabis had lower tumor response rates to nivolomab for advanced melanoma, non-small cell lung cancer, and renal clear cell carcinoma. However, survival wasn’t affected.²

Meanwhile, he said, there’s no strong evidence that cannabis is a useful treatment for cancer, he said, although it’s worth investigating.

Cannabidiol is the hot new product

Cannabidiol, also known as CBD, has become hugely popular, Dr. Stellini said. It is derived from hemp and doesn’t cause a “buzz” like cannabis.

Due to lack of regulation, he said, buyers should beware. And, he said, CBD has multiple EAs. Standard doses can cause drowsiness, fatigue, dizziness, dry mouth, hypotension and lightheadedness.

Dr. Stellini reports no relevant disclosures.

MINNEAPOLIS -- Medical professionals within the US Department of Veterans Affairs (VA) can’t prescribe cannabis or certify patients to be able to get it. VA pharmacists can’t dispense it. Still, “we’re asked about it plenty,” a hospice and palliative care specialist told colleagues, at the annual meeting of the Association of VA Hematology/Oncology (AVAHO).

That brings up a big question, said Michael Stellini, MD, MS, FACP, FAAHPM, of Wayne State University, Karmanos Cancer Center, and the John D. Dingell VA Medical Center, in Detroit Michigan: “Should sick people be smoking pot?”

Even the question itself isn’t a simple one to answer since smoking isn’t the only way to consume cannabis for medical purposes. And figuring out the best advice is difficult. As Dr. Stellini said, there’s plenty of uncertainty about crucial cannabis topics like safety and benefits.

Dr. Stellini offered a number of facts and tips about cannabis in medicine.

Understand ‘qualifying conditions’ in your state

In states with legal medical marijuana, he said, physicians do not prescribe marijuana. However, they may certify that patients are eligible to get the drug for medical purposes if they meet certain qualifications.

A typical list of qualifying conditions includes diseases such as cancer, glaucoma, HIV/AIDS and Crohn’s disease. Qualifying conditions also tend to include treatments for severe diseases that produce wasting syndrome, severe and chronic pain, severe nausea, seizures and severe and persistent muscle spasm.

In Michigan, where Dr. Stellini practices, a panel in 2018 approved a long list of added qualifying conditions such as chronic pain, obsessive compulsive disorder and arthritis. But the panel rejected other conditions such as anxiety, asthma, panic attacks and schizophrenia.

Vaporizers are an alternative to joints, but...

Vaporizers are commonly used as an alternative to smoking marijuana joints, Dr. Stellini said, and they don’t significantly release tars or much if any carbon monoxide. While research is limited, he said, use of vaporizers hasn’t been linked to more lung cancer or chronic obstructive pulmonary disease.

“Vaping” is another option, but it’s been linked to dozens of deaths and hundreds of cases of illness in recent weeks. Many patients have reported using products that contain THC, a component of marijuana.

Other delivery methods exist

Marijuana can be ingested in liquid and solid food. “But edibles can have a slow onset of action compared to vaporizing or smoking,” Dr. Stellini said. “You might over-indulge. When users get to their steady state, they might have some adverse effects [AEs].”

Marijuana still has risks

Cannabis use has a long list of well-known AEs linked to the THC component. The most common are drowsiness, fatigue, dizziness, dry mouth, anxiety, cognitive effects, cough, and nausea, Dr. Stellini said. More serious AEs such as psychosis have been reported.

And, of course, users of cannabis with THC get high if they use enough.

A 2017 National Academies of Sciences, Engineering and Medicine report linked cannabis use to a higher risk of motor vehicle accidents. Still, Dr. Stellini said, “it’s relatively safe with respect to mortality, especially compared to opioids.”¹

Risk of use in cancer may be low

Research suggest that patients with cancer use cannabis as much as other people and perhaps even more, Dr. Stellini said. But are they facing any extra risks? In general, he said, it doesn’t appear that way.

Cannabis seems to be safe when used with chemotherapy, he said, and drug-drug interactions in cancer appear to be rare. Some studies have suggested that cannabinoids—a component of marijuana—may be an effective treatment for chemotherapy-induced peripheral neuropathy.

However, he said, 1 study has raised a red flag about a possible interaction with cancer immunotherapy. Researchers found evidence that patients who used cannabis had lower tumor response rates to nivolomab for advanced melanoma, non-small cell lung cancer, and renal clear cell carcinoma. However, survival wasn’t affected.²

Meanwhile, he said, there’s no strong evidence that cannabis is a useful treatment for cancer, he said, although it’s worth investigating.

Cannabidiol is the hot new product

Cannabidiol, also known as CBD, has become hugely popular, Dr. Stellini said. It is derived from hemp and doesn’t cause a “buzz” like cannabis.

Due to lack of regulation, he said, buyers should beware. And, he said, CBD has multiple EAs. Standard doses can cause drowsiness, fatigue, dizziness, dry mouth, hypotension and lightheadedness.

Dr. Stellini reports no relevant disclosures.

Age-adjusted mortality from antineutrophil cytoplasmic autoantibody–associated vasculitides (AAV) in the United States declined by nearly 2% each year between 1999 and 2017, based on data from the Centers for Disease Control and Prevention.

Significant morbidity and mortality are associated with untreated AAV, wrote Alexander W. Steinberg, MD, of Saint Joseph Hospital, Denver, Colo., and colleagues.

“Although population data from the United Kingdom have shown decreased AAV-related mortality during the past 20 years, it is unknown whether this pattern has occurred in the United States,” they wrote.

In a study published in Annals of Internal Medicine, the researchers identified 11,316 AAV-related deaths from 1999 to 2017 in the CDC data.

Overall, age-adjusted mortality was 1.86 per 1,000,000 persons, with highest rates among non-Hispanic whites, men, and residents of the Midwest. Mortality from AAV declined by an average of 1.6% in each year of the study period, and changes in subgroups stratified by gender, race, and geographic region were similar.

Mortality increased with age and was highest among individuals aged 75-84 years, but a significant decline in mortality occurred among individuals aged 65-74 years. “The decrease in overall mortality and mortality among persons aged 65 to 74 years may reflect increased longevity due to improved treatment of AAV and common comorbid conditions,” the researchers said.

“Surprisingly, the authors found much lower age-adjusted mortality rates for non-Hispanic black persons (0.77) and moderately lower mortality rates for Hispanic persons (1.57) than for non-Hispanic white persons (2.03),” wrote John R. Stone, MD, PhD, of Creighton University, Omaha, Neb., in an accompanying editorial.

“Suppose the mortality rate differences reported by Steinberg and colleagues are statistically significant, accurately represent death certificate diagnoses, and match people’s racial/ethnic self-identification. The data then show neither that the vasculitides actually have lower mortality rates in blacks or Hispanics compared with whites, nor that the diseases are indeed less frequent in blacks and Hispanics,” he said. “Rather, these differences probably signify how social inequities, social structural violence, and inferior health care access adversely influence diagnosis of rare diseases and promote health inequity,” Dr. Stone added. The findings suggest that clinicians should remain alert to AAV in some ethnic groups to improve diagnostic accuracy, he said.

“Moreover, improved AAV diagnosis in such groups is key to recruiting participants for research investigating whether therapies should differ among populations,” he emphasized.

The study findings were limited by possible under- or overreporting of AAV on death certificates, but they were strengthened by the large sample size, the researchers noted. “We hope that the mortality patterns presented here can be used to direct future research on the driving forces behind these trends,” they said.

Dr. Steinberg had no financial conflicts to disclose. Dr. Stone had no financial conflicts to disclose.

SOURCES: Steinberg AW et al. Ann Intern Med. 2019 Oct 8. doi: 10.7326/M19-1564; and Stone JR. Ann Intern Med. 2019 Oct 8. doi: 10.7326/M19-2755.

Age-adjusted mortality from antineutrophil cytoplasmic autoantibody–associated vasculitides (AAV) in the United States declined by nearly 2% each year between 1999 and 2017, based on data from the Centers for Disease Control and Prevention.

Significant morbidity and mortality are associated with untreated AAV, wrote Alexander W. Steinberg, MD, of Saint Joseph Hospital, Denver, Colo., and colleagues.

“Although population data from the United Kingdom have shown decreased AAV-related mortality during the past 20 years, it is unknown whether this pattern has occurred in the United States,” they wrote.

In a study published in Annals of Internal Medicine, the researchers identified 11,316 AAV-related deaths from 1999 to 2017 in the CDC data.

Overall, age-adjusted mortality was 1.86 per 1,000,000 persons, with highest rates among non-Hispanic whites, men, and residents of the Midwest. Mortality from AAV declined by an average of 1.6% in each year of the study period, and changes in subgroups stratified by gender, race, and geographic region were similar.

Mortality increased with age and was highest among individuals aged 75-84 years, but a significant decline in mortality occurred among individuals aged 65-74 years. “The decrease in overall mortality and mortality among persons aged 65 to 74 years may reflect increased longevity due to improved treatment of AAV and common comorbid conditions,” the researchers said.

“Surprisingly, the authors found much lower age-adjusted mortality rates for non-Hispanic black persons (0.77) and moderately lower mortality rates for Hispanic persons (1.57) than for non-Hispanic white persons (2.03),” wrote John R. Stone, MD, PhD, of Creighton University, Omaha, Neb., in an accompanying editorial.

“Suppose the mortality rate differences reported by Steinberg and colleagues are statistically significant, accurately represent death certificate diagnoses, and match people’s racial/ethnic self-identification. The data then show neither that the vasculitides actually have lower mortality rates in blacks or Hispanics compared with whites, nor that the diseases are indeed less frequent in blacks and Hispanics,” he said. “Rather, these differences probably signify how social inequities, social structural violence, and inferior health care access adversely influence diagnosis of rare diseases and promote health inequity,” Dr. Stone added. The findings suggest that clinicians should remain alert to AAV in some ethnic groups to improve diagnostic accuracy, he said.

“Moreover, improved AAV diagnosis in such groups is key to recruiting participants for research investigating whether therapies should differ among populations,” he emphasized.

The study findings were limited by possible under- or overreporting of AAV on death certificates, but they were strengthened by the large sample size, the researchers noted. “We hope that the mortality patterns presented here can be used to direct future research on the driving forces behind these trends,” they said.

Dr. Steinberg had no financial conflicts to disclose. Dr. Stone had no financial conflicts to disclose.

SOURCES: Steinberg AW et al. Ann Intern Med. 2019 Oct 8. doi: 10.7326/M19-1564; and Stone JR. Ann Intern Med. 2019 Oct 8. doi: 10.7326/M19-2755.

Age-adjusted mortality from antineutrophil cytoplasmic autoantibody–associated vasculitides (AAV) in the United States declined by nearly 2% each year between 1999 and 2017, based on data from the Centers for Disease Control and Prevention.

Significant morbidity and mortality are associated with untreated AAV, wrote Alexander W. Steinberg, MD, of Saint Joseph Hospital, Denver, Colo., and colleagues.

“Although population data from the United Kingdom have shown decreased AAV-related mortality during the past 20 years, it is unknown whether this pattern has occurred in the United States,” they wrote.

In a study published in Annals of Internal Medicine, the researchers identified 11,316 AAV-related deaths from 1999 to 2017 in the CDC data.

Overall, age-adjusted mortality was 1.86 per 1,000,000 persons, with highest rates among non-Hispanic whites, men, and residents of the Midwest. Mortality from AAV declined by an average of 1.6% in each year of the study period, and changes in subgroups stratified by gender, race, and geographic region were similar.

Mortality increased with age and was highest among individuals aged 75-84 years, but a significant decline in mortality occurred among individuals aged 65-74 years. “The decrease in overall mortality and mortality among persons aged 65 to 74 years may reflect increased longevity due to improved treatment of AAV and common comorbid conditions,” the researchers said.

“Surprisingly, the authors found much lower age-adjusted mortality rates for non-Hispanic black persons (0.77) and moderately lower mortality rates for Hispanic persons (1.57) than for non-Hispanic white persons (2.03),” wrote John R. Stone, MD, PhD, of Creighton University, Omaha, Neb., in an accompanying editorial.

“Suppose the mortality rate differences reported by Steinberg and colleagues are statistically significant, accurately represent death certificate diagnoses, and match people’s racial/ethnic self-identification. The data then show neither that the vasculitides actually have lower mortality rates in blacks or Hispanics compared with whites, nor that the diseases are indeed less frequent in blacks and Hispanics,” he said. “Rather, these differences probably signify how social inequities, social structural violence, and inferior health care access adversely influence diagnosis of rare diseases and promote health inequity,” Dr. Stone added. The findings suggest that clinicians should remain alert to AAV in some ethnic groups to improve diagnostic accuracy, he said.

“Moreover, improved AAV diagnosis in such groups is key to recruiting participants for research investigating whether therapies should differ among populations,” he emphasized.

The study findings were limited by possible under- or overreporting of AAV on death certificates, but they were strengthened by the large sample size, the researchers noted. “We hope that the mortality patterns presented here can be used to direct future research on the driving forces behind these trends,” they said.

Dr. Steinberg had no financial conflicts to disclose. Dr. Stone had no financial conflicts to disclose.

SOURCES: Steinberg AW et al. Ann Intern Med. 2019 Oct 8. doi: 10.7326/M19-1564; and Stone JR. Ann Intern Med. 2019 Oct 8. doi: 10.7326/M19-2755.

Hospitalization can be a challenging and vulnerable time for patients and their families. While challenges associated with the quality and safety of hospital care are well documented, perspectives of patients, families, caregivers, and other stakeholders are not as easily understood and are important targets of improvement research.

This led to the initiation of the i-HOPE Patient Engagement Study, a collaboration including the Society for Hospital Medicine’s Center for Quality Improvement. The team completed a systematic and broad engagement process with patients, families, and caregivers, followed by an in-person prioritization meeting to generate a priority list of research topics that describe the most important gaps in the care of hospitalized patients.

The Hospitalist recently spoke with Luci Leykum, MD, MSc, MBA, SFHM, principal investigator for the i-HOPE Study, professor of medicine and investigator in the South Texas Veterans Health Care System and incoming associate chair for clinical innovation at the University of Texas at Austin.

Why is it so important to include the perspective of the patient during a hospital stay?

We cannot optimally improve outcomes of hospitalized patients if we don’t have patients’ perspectives on what needs to be improved. Hearing these perspectives also provides insights into how we can address gaps in hospital care.

How were patients and other stakeholders engaged during the i-HOPE program?

Patients, caregivers, and stakeholders were engaged throughout the entire project, from conceptualization to dissemination of results.

We worked with seven patient partners to develop the proposal that we submitted to the Patient-Centered Outcomes Research Institute. They were involved in all phases of the project, from developing the informational webinars and surveys to analyzing our results.

We engaged additional patients, caregivers, and stakeholders to submit their highest priority unanswered research questions for improving hospital care. A total of 117 patients and 127 caregivers submitted questions. Our patient partners and more than 30 stakeholders were involved in prioritizing those research questions to develop our final agenda.

What is unique about the approach in the i-HOPE project, compared with other projects that may have had similar intended objectives?

Our project is unique in several respects. First, it was completely patient partnered. Having patients as equal members of the team changed our approach at every level – from how we communicated with patients and stakeholders to how we analyzed and presented our data. Second, we worked with a larger number of stakeholders representing a broad range of constituencies, from professional societies to health care delivery systems to payers.

How has SHM’s Center for Quality Improvement helped the i-HOPE program to realize its goals?

The Center for Quality Improvement helped considerably with the execution of the project. The researchers involved in i-HOPE were all members of the SHM Research Committee and were familiar with SHM’s capability as a partner in these larger-scale projects. The SHM Meetings team was instrumental in making our in-person patient and stakeholder prioritization meeting happen as well.

How can the findings of the i-HOPE program be applied?

We hope everyone can utilize our findings. Patients, families, and caregivers can use our results to improve their own care. Providers and delivery systems can target their improvement efforts using our findings to ensure that their work has the greatest impact on patients. Policy makers and funders can use our findings to direct work to the priority areas we identified. And finally, we hope the hospital research community uses our results to develop novel interventions to improve care.

For more information on the i-HOPE Patient Engagement Study, visit hospitalmedicine.org/ihope.

Hospitalization can be a challenging and vulnerable time for patients and their families. While challenges associated with the quality and safety of hospital care are well documented, perspectives of patients, families, caregivers, and other stakeholders are not as easily understood and are important targets of improvement research.

This led to the initiation of the i-HOPE Patient Engagement Study, a collaboration including the Society for Hospital Medicine’s Center for Quality Improvement. The team completed a systematic and broad engagement process with patients, families, and caregivers, followed by an in-person prioritization meeting to generate a priority list of research topics that describe the most important gaps in the care of hospitalized patients.

The Hospitalist recently spoke with Luci Leykum, MD, MSc, MBA, SFHM, principal investigator for the i-HOPE Study, professor of medicine and investigator in the South Texas Veterans Health Care System and incoming associate chair for clinical innovation at the University of Texas at Austin.

Why is it so important to include the perspective of the patient during a hospital stay?

We cannot optimally improve outcomes of hospitalized patients if we don’t have patients’ perspectives on what needs to be improved. Hearing these perspectives also provides insights into how we can address gaps in hospital care.

How were patients and other stakeholders engaged during the i-HOPE program?

Patients, caregivers, and stakeholders were engaged throughout the entire project, from conceptualization to dissemination of results.

We worked with seven patient partners to develop the proposal that we submitted to the Patient-Centered Outcomes Research Institute. They were involved in all phases of the project, from developing the informational webinars and surveys to analyzing our results.

We engaged additional patients, caregivers, and stakeholders to submit their highest priority unanswered research questions for improving hospital care. A total of 117 patients and 127 caregivers submitted questions. Our patient partners and more than 30 stakeholders were involved in prioritizing those research questions to develop our final agenda.

What is unique about the approach in the i-HOPE project, compared with other projects that may have had similar intended objectives?

Our project is unique in several respects. First, it was completely patient partnered. Having patients as equal members of the team changed our approach at every level – from how we communicated with patients and stakeholders to how we analyzed and presented our data. Second, we worked with a larger number of stakeholders representing a broad range of constituencies, from professional societies to health care delivery systems to payers.

How has SHM’s Center for Quality Improvement helped the i-HOPE program to realize its goals?

The Center for Quality Improvement helped considerably with the execution of the project. The researchers involved in i-HOPE were all members of the SHM Research Committee and were familiar with SHM’s capability as a partner in these larger-scale projects. The SHM Meetings team was instrumental in making our in-person patient and stakeholder prioritization meeting happen as well.

How can the findings of the i-HOPE program be applied?

We hope everyone can utilize our findings. Patients, families, and caregivers can use our results to improve their own care. Providers and delivery systems can target their improvement efforts using our findings to ensure that their work has the greatest impact on patients. Policy makers and funders can use our findings to direct work to the priority areas we identified. And finally, we hope the hospital research community uses our results to develop novel interventions to improve care.

For more information on the i-HOPE Patient Engagement Study, visit hospitalmedicine.org/ihope.

Hospitalization can be a challenging and vulnerable time for patients and their families. While challenges associated with the quality and safety of hospital care are well documented, perspectives of patients, families, caregivers, and other stakeholders are not as easily understood and are important targets of improvement research.

This led to the initiation of the i-HOPE Patient Engagement Study, a collaboration including the Society for Hospital Medicine’s Center for Quality Improvement. The team completed a systematic and broad engagement process with patients, families, and caregivers, followed by an in-person prioritization meeting to generate a priority list of research topics that describe the most important gaps in the care of hospitalized patients.

The Hospitalist recently spoke with Luci Leykum, MD, MSc, MBA, SFHM, principal investigator for the i-HOPE Study, professor of medicine and investigator in the South Texas Veterans Health Care System and incoming associate chair for clinical innovation at the University of Texas at Austin.

Why is it so important to include the perspective of the patient during a hospital stay?

We cannot optimally improve outcomes of hospitalized patients if we don’t have patients’ perspectives on what needs to be improved. Hearing these perspectives also provides insights into how we can address gaps in hospital care.

How were patients and other stakeholders engaged during the i-HOPE program?

Patients, caregivers, and stakeholders were engaged throughout the entire project, from conceptualization to dissemination of results.

We worked with seven patient partners to develop the proposal that we submitted to the Patient-Centered Outcomes Research Institute. They were involved in all phases of the project, from developing the informational webinars and surveys to analyzing our results.

We engaged additional patients, caregivers, and stakeholders to submit their highest priority unanswered research questions for improving hospital care. A total of 117 patients and 127 caregivers submitted questions. Our patient partners and more than 30 stakeholders were involved in prioritizing those research questions to develop our final agenda.

What is unique about the approach in the i-HOPE project, compared with other projects that may have had similar intended objectives?

Our project is unique in several respects. First, it was completely patient partnered. Having patients as equal members of the team changed our approach at every level – from how we communicated with patients and stakeholders to how we analyzed and presented our data. Second, we worked with a larger number of stakeholders representing a broad range of constituencies, from professional societies to health care delivery systems to payers.

How has SHM’s Center for Quality Improvement helped the i-HOPE program to realize its goals?

The Center for Quality Improvement helped considerably with the execution of the project. The researchers involved in i-HOPE were all members of the SHM Research Committee and were familiar with SHM’s capability as a partner in these larger-scale projects. The SHM Meetings team was instrumental in making our in-person patient and stakeholder prioritization meeting happen as well.

How can the findings of the i-HOPE program be applied?

We hope everyone can utilize our findings. Patients, families, and caregivers can use our results to improve their own care. Providers and delivery systems can target their improvement efforts using our findings to ensure that their work has the greatest impact on patients. Policy makers and funders can use our findings to direct work to the priority areas we identified. And finally, we hope the hospital research community uses our results to develop novel interventions to improve care.

For more information on the i-HOPE Patient Engagement Study, visit hospitalmedicine.org/ihope.

MINNEAPOLIS -- Ignore the big health claims about vitamin supplements, pork, and nitrate-free food products. Meet patients “where they are,” even if that means you focus first on helping a morbidly obese patient maintain her weight instead of losing pounds. And use nutrition to empower patients and reduce the risk of cancer recurrence.

Dianne Piepenburg, MS, RDN, CSO, a certified oncology nutritionist at the Malcolm Randall VA Medical Center in Gainesville, Florida, offered these tips and more in a presentation about nutrition for cancer survivors. She spoke at the annual meeting of the Association of VA Hematology/Oncology (AVAHO).

According to the National Institutes of Health, an estimated 17 million cancer survivors live in the US, accounting for 5% of the population. Nearly two-thirds are aged ≥ 65 years.¹

Piepenburg highlighted the existence of certified specialists in oncology nutrition (CSOs). To be certified, registered dietitian nutritionists must have worked in that job for at least 2 years, have at least 2,000 hours of practice experience within the past 5 years and pass a board exam every 5 years.

Oncology nutritionists seek to empower cancer survivors to regain equilibrium in their lives, she said. “When a patient is told what scan to have next, what blood work they have to have, what treatment they need to be on, they feel they’re losing control,” she said. “Nutrition gives the power back to them, and they feel like there’s something they can do that’s in their control.”

Piepenburg urged colleagues to “meet patients where they are.” She gave the example of a patient with breast cancer whose body mass index is in the 50s, making her morbidly obese. “Our discussion wasn’t, ‘Let’s start [losing weight] today.’ Instead, I said, ‘Can we at least prevent you from gaining any more weight?’ She thought she could at least do that, try to recuperate a bit, and then start looking at a healthy weight loss. We’ll start there and circle back in a few months and see where we’re at.”

Piepenburg urged colleagues to bring exercise into the discussion. “We need people to be physically active no matter what phase of their survivorship journey they are in,” she said.

What about people who say, “I’ve never exercised a day in my life”? Her response: “I tell folks that we need them to move more. Maybe they’re walking to the mailbox or 3 laps around the house that day.”

Oncology patients should also watch sugar, meat, and processed foods. Refined sugar, fast food and processed food should be limited, Piepenburg said, along with red meats, such as beef, pork and lamb.

“Pork is not the ‘other white meat.’ How many of you grew up seeing and hearing that in the 1970s and 1980s? It’s a red meat, and it’s metabolized like a red meat.”

Advise patients to limit bacon, sausage, and lunch meat, she said, “even if they say, ‘I bought the nitrate-free and it’s really healthy for me.’”

It’s okay to eat some red meat, she said, “but there’s a tipping point. Tell them they can have some red meat but have it as a treat and please focus more on plant-based proteins—nuts, beans, legumes. But it’s tough for a lot of our veterans who grew up on meat and potatoes, and the only vegetable they eat is corn.”

It’s tough to limit grilling in a place like Minnesota, Piepenburg said, where the prime grilling season is short, and locals go a bit nuts when it’s nice enough outside. “I tell them to at least marinate the meat and put it on indirect heat.”

Finally, she encouraged oncology care providers to not fall for vitamin hype. Don’t rely on supplements for cancer prevention, she said. With some exceptions, she said, research has suggested they don’t work, and a 1990s study of beta-carotene and retinyl palmitate (vitamin A) in lung cancer was halted because patients actually fared worse on the regimen, although the effects didn’t seem to persist.²

MINNEAPOLIS -- Ignore the big health claims about vitamin supplements, pork, and nitrate-free food products. Meet patients “where they are,” even if that means you focus first on helping a morbidly obese patient maintain her weight instead of losing pounds. And use nutrition to empower patients and reduce the risk of cancer recurrence.

Dianne Piepenburg, MS, RDN, CSO, a certified oncology nutritionist at the Malcolm Randall VA Medical Center in Gainesville, Florida, offered these tips and more in a presentation about nutrition for cancer survivors. She spoke at the annual meeting of the Association of VA Hematology/Oncology (AVAHO).

According to the National Institutes of Health, an estimated 17 million cancer survivors live in the US, accounting for 5% of the population. Nearly two-thirds are aged ≥ 65 years.¹

Piepenburg highlighted the existence of certified specialists in oncology nutrition (CSOs). To be certified, registered dietitian nutritionists must have worked in that job for at least 2 years, have at least 2,000 hours of practice experience within the past 5 years and pass a board exam every 5 years.

Oncology nutritionists seek to empower cancer survivors to regain equilibrium in their lives, she said. “When a patient is told what scan to have next, what blood work they have to have, what treatment they need to be on, they feel they’re losing control,” she said. “Nutrition gives the power back to them, and they feel like there’s something they can do that’s in their control.”

Piepenburg urged colleagues to “meet patients where they are.” She gave the example of a patient with breast cancer whose body mass index is in the 50s, making her morbidly obese. “Our discussion wasn’t, ‘Let’s start [losing weight] today.’ Instead, I said, ‘Can we at least prevent you from gaining any more weight?’ She thought she could at least do that, try to recuperate a bit, and then start looking at a healthy weight loss. We’ll start there and circle back in a few months and see where we’re at.”

Piepenburg urged colleagues to bring exercise into the discussion. “We need people to be physically active no matter what phase of their survivorship journey they are in,” she said.

What about people who say, “I’ve never exercised a day in my life”? Her response: “I tell folks that we need them to move more. Maybe they’re walking to the mailbox or 3 laps around the house that day.”

Oncology patients should also watch sugar, meat, and processed foods. Refined sugar, fast food and processed food should be limited, Piepenburg said, along with red meats, such as beef, pork and lamb.

“Pork is not the ‘other white meat.’ How many of you grew up seeing and hearing that in the 1970s and 1980s? It’s a red meat, and it’s metabolized like a red meat.”

Advise patients to limit bacon, sausage, and lunch meat, she said, “even if they say, ‘I bought the nitrate-free and it’s really healthy for me.’”

It’s okay to eat some red meat, she said, “but there’s a tipping point. Tell them they can have some red meat but have it as a treat and please focus more on plant-based proteins—nuts, beans, legumes. But it’s tough for a lot of our veterans who grew up on meat and potatoes, and the only vegetable they eat is corn.”

It’s tough to limit grilling in a place like Minnesota, Piepenburg said, where the prime grilling season is short, and locals go a bit nuts when it’s nice enough outside. “I tell them to at least marinate the meat and put it on indirect heat.”

Finally, she encouraged oncology care providers to not fall for vitamin hype. Don’t rely on supplements for cancer prevention, she said. With some exceptions, she said, research has suggested they don’t work, and a 1990s study of beta-carotene and retinyl palmitate (vitamin A) in lung cancer was halted because patients actually fared worse on the regimen, although the effects didn’t seem to persist.²

MINNEAPOLIS -- Ignore the big health claims about vitamin supplements, pork, and nitrate-free food products. Meet patients “where they are,” even if that means you focus first on helping a morbidly obese patient maintain her weight instead of losing pounds. And use nutrition to empower patients and reduce the risk of cancer recurrence.

Dianne Piepenburg, MS, RDN, CSO, a certified oncology nutritionist at the Malcolm Randall VA Medical Center in Gainesville, Florida, offered these tips and more in a presentation about nutrition for cancer survivors. She spoke at the annual meeting of the Association of VA Hematology/Oncology (AVAHO).

According to the National Institutes of Health, an estimated 17 million cancer survivors live in the US, accounting for 5% of the population. Nearly two-thirds are aged ≥ 65 years.¹

Piepenburg highlighted the existence of certified specialists in oncology nutrition (CSOs). To be certified, registered dietitian nutritionists must have worked in that job for at least 2 years, have at least 2,000 hours of practice experience within the past 5 years and pass a board exam every 5 years.

Oncology nutritionists seek to empower cancer survivors to regain equilibrium in their lives, she said. “When a patient is told what scan to have next, what blood work they have to have, what treatment they need to be on, they feel they’re losing control,” she said. “Nutrition gives the power back to them, and they feel like there’s something they can do that’s in their control.”

Piepenburg urged colleagues to “meet patients where they are.” She gave the example of a patient with breast cancer whose body mass index is in the 50s, making her morbidly obese. “Our discussion wasn’t, ‘Let’s start [losing weight] today.’ Instead, I said, ‘Can we at least prevent you from gaining any more weight?’ She thought she could at least do that, try to recuperate a bit, and then start looking at a healthy weight loss. We’ll start there and circle back in a few months and see where we’re at.”

Piepenburg urged colleagues to bring exercise into the discussion. “We need people to be physically active no matter what phase of their survivorship journey they are in,” she said.

What about people who say, “I’ve never exercised a day in my life”? Her response: “I tell folks that we need them to move more. Maybe they’re walking to the mailbox or 3 laps around the house that day.”

Oncology patients should also watch sugar, meat, and processed foods. Refined sugar, fast food and processed food should be limited, Piepenburg said, along with red meats, such as beef, pork and lamb.

“Pork is not the ‘other white meat.’ How many of you grew up seeing and hearing that in the 1970s and 1980s? It’s a red meat, and it’s metabolized like a red meat.”

Advise patients to limit bacon, sausage, and lunch meat, she said, “even if they say, ‘I bought the nitrate-free and it’s really healthy for me.’”

It’s okay to eat some red meat, she said, “but there’s a tipping point. Tell them they can have some red meat but have it as a treat and please focus more on plant-based proteins—nuts, beans, legumes. But it’s tough for a lot of our veterans who grew up on meat and potatoes, and the only vegetable they eat is corn.”

It’s tough to limit grilling in a place like Minnesota, Piepenburg said, where the prime grilling season is short, and locals go a bit nuts when it’s nice enough outside. “I tell them to at least marinate the meat and put it on indirect heat.”

Finally, she encouraged oncology care providers to not fall for vitamin hype. Don’t rely on supplements for cancer prevention, she said. With some exceptions, she said, research has suggested they don’t work, and a 1990s study of beta-carotene and retinyl palmitate (vitamin A) in lung cancer was halted because patients actually fared worse on the regimen, although the effects didn’t seem to persist.²

CHICAGO – A care model that uses hospitalists to comanage vascular surgery patients cut myocardial infarction rates by more than half and reduced hospital stays by about 12%, according to results of a study of the hospitalist comanagement model from Loyola University Chicago, Maywood, Ill., presented at the annual meeting of the Midwestern Vascular Surgery Society.

“Hospitalist comanagement was associated with decreased length of stay without affecting readmission for patients undergoing amputation, embolectomy, and infected graft,” said Kaavya Adam, a third-year medical student at Loyola University Chicago. “In the overall population, there was a reduction in cases of MI, 30-day readmissions, and overall length of stay.”

In 2014, Loyola implemented a program that used 11 hospitalists to rotate through the vascular surgery service. The hospitalists call on any patient who stays more than 24 hours on the non-ICU floors. Adam said hospitalist duties include evaluating patient comorbidities, adjusting medication, talking with family about medical management, seeing patients on the day of surgery, ordering preoperative labs, and meeting with the anesthesiology and vascular surgery teams.

The study compared outcomes in 866 patients admitted during 2007-2013, before the comanagement model was put into place, and 572 admitted during 2014-2017.

Rates of diabetes, hypertension, chronic kidney disease, coronary artery disease, hyperlipidemia, and malnutrition were similar between the groups. However, the pre-comanagement group had significantly higher rates of ischemic pain (27.8% vs. 10.7%), gangrene (21.3% vs. 13.6%) and ulceration (30.6% vs. 21.9%), while the comanaged group had significantly higher rates of claudication (34.3% vs. 13.2%). The statistical analysis accounted for these variations, Adam said.

“We did find significant results for the reduction in the odds of MI at 30 days; there was a 61% reduction,” he said.

The reduction in hospital stay was even more pronounced for patients with complex cases, Adam said. In amputation, the length of stay was reduced by 3.77 days (P = .01); in embolectomy, by 7.35 (P = .004); and in infected graft, by 8.35 (P = .007).

Continuing research will evaluate the cost effectiveness of the hospitalist model and define a comanagement model that is most beneficial, Mr. Adam said. He had no relevant financial disclosures.

SOURCE: Adam K et al. Midwestern Vascular 2019, Abstract 14.

CHICAGO – A care model that uses hospitalists to comanage vascular surgery patients cut myocardial infarction rates by more than half and reduced hospital stays by about 12%, according to results of a study of the hospitalist comanagement model from Loyola University Chicago, Maywood, Ill., presented at the annual meeting of the Midwestern Vascular Surgery Society.

“Hospitalist comanagement was associated with decreased length of stay without affecting readmission for patients undergoing amputation, embolectomy, and infected graft,” said Kaavya Adam, a third-year medical student at Loyola University Chicago. “In the overall population, there was a reduction in cases of MI, 30-day readmissions, and overall length of stay.”

In 2014, Loyola implemented a program that used 11 hospitalists to rotate through the vascular surgery service. The hospitalists call on any patient who stays more than 24 hours on the non-ICU floors. Adam said hospitalist duties include evaluating patient comorbidities, adjusting medication, talking with family about medical management, seeing patients on the day of surgery, ordering preoperative labs, and meeting with the anesthesiology and vascular surgery teams.

The study compared outcomes in 866 patients admitted during 2007-2013, before the comanagement model was put into place, and 572 admitted during 2014-2017.

Rates of diabetes, hypertension, chronic kidney disease, coronary artery disease, hyperlipidemia, and malnutrition were similar between the groups. However, the pre-comanagement group had significantly higher rates of ischemic pain (27.8% vs. 10.7%), gangrene (21.3% vs. 13.6%) and ulceration (30.6% vs. 21.9%), while the comanaged group had significantly higher rates of claudication (34.3% vs. 13.2%). The statistical analysis accounted for these variations, Adam said.

“We did find significant results for the reduction in the odds of MI at 30 days; there was a 61% reduction,” he said.

The reduction in hospital stay was even more pronounced for patients with complex cases, Adam said. In amputation, the length of stay was reduced by 3.77 days (P = .01); in embolectomy, by 7.35 (P = .004); and in infected graft, by 8.35 (P = .007).

Continuing research will evaluate the cost effectiveness of the hospitalist model and define a comanagement model that is most beneficial, Mr. Adam said. He had no relevant financial disclosures.

SOURCE: Adam K et al. Midwestern Vascular 2019, Abstract 14.

CHICAGO – A care model that uses hospitalists to comanage vascular surgery patients cut myocardial infarction rates by more than half and reduced hospital stays by about 12%, according to results of a study of the hospitalist comanagement model from Loyola University Chicago, Maywood, Ill., presented at the annual meeting of the Midwestern Vascular Surgery Society.

“Hospitalist comanagement was associated with decreased length of stay without affecting readmission for patients undergoing amputation, embolectomy, and infected graft,” said Kaavya Adam, a third-year medical student at Loyola University Chicago. “In the overall population, there was a reduction in cases of MI, 30-day readmissions, and overall length of stay.”

In 2014, Loyola implemented a program that used 11 hospitalists to rotate through the vascular surgery service. The hospitalists call on any patient who stays more than 24 hours on the non-ICU floors. Adam said hospitalist duties include evaluating patient comorbidities, adjusting medication, talking with family about medical management, seeing patients on the day of surgery, ordering preoperative labs, and meeting with the anesthesiology and vascular surgery teams.

The study compared outcomes in 866 patients admitted during 2007-2013, before the comanagement model was put into place, and 572 admitted during 2014-2017.

Rates of diabetes, hypertension, chronic kidney disease, coronary artery disease, hyperlipidemia, and malnutrition were similar between the groups. However, the pre-comanagement group had significantly higher rates of ischemic pain (27.8% vs. 10.7%), gangrene (21.3% vs. 13.6%) and ulceration (30.6% vs. 21.9%), while the comanaged group had significantly higher rates of claudication (34.3% vs. 13.2%). The statistical analysis accounted for these variations, Adam said.

“We did find significant results for the reduction in the odds of MI at 30 days; there was a 61% reduction,” he said.

The reduction in hospital stay was even more pronounced for patients with complex cases, Adam said. In amputation, the length of stay was reduced by 3.77 days (P = .01); in embolectomy, by 7.35 (P = .004); and in infected graft, by 8.35 (P = .007).

Continuing research will evaluate the cost effectiveness of the hospitalist model and define a comanagement model that is most beneficial, Mr. Adam said. He had no relevant financial disclosures.

SOURCE: Adam K et al. Midwestern Vascular 2019, Abstract 14.

Stanley Patrick Weber, a former Indian Health Service (IHS) pediatrician, was convicted September 27 on 8 counts of sexual abuse of 4 Native American boys under his care at the Pine Ridge Indian Reservation, Oglala Lakota County, South Dakota.

Weber was an employee of the IHS from 1986 until he resigned in 2016. During that time, although suspicions were rampant that he was abusing young patients, he was moved from one reservation to another. An investigation by The Wall Street Journal and PBS/Frontline found officials in the IHS chain of command “ignored warning signs” and tried to silence whistleblowers.

Weber also was convicted last year and served time for abusing 2 boys at another government hospital in Montana before he arrived at Pine Ridge.

The Pine Ridge Reservation is home to some of the poorest communities in the US, with a dropout rate of > 70%, and a teen suicide rate 150% higher than America’s as a whole. Many of the youths testifying in the case described difficult childhoods, according to the Frontline program. In addition to assaulting them during health care visits, Weber lured them to his home with offers of alcohol and cash.

A White House task force was created to address the agency’s failures. In a statement, Rear Adm Michael Weahkee, IHS principal deputy director, said the IHS is “doing all we can throughout our agency to strengthen our protection for patients.” Steps taken include reinforcing with staff the prohibitions against inappropriate contact with children, reminding staff of the protections for whistleblowers, and hiring Integritas Creative Solutions to conduct a medical quality assurance review to examine whether laws, policies and procedures have been followed with regard to protecting patients from sexual abuse. The review complements work done by the Presidential Task Force on Protecting Native American Children in the Indian Health Service System and a separate review by the HHS Office of the Inspector General.

The IHS also is providing professional counseling for victims. Services do not have to be at an IHS facility or with an IHS provider. A confidential hot line has been established at 301-443-0658.

Weahkee calls the verdict “a long-awaited victory.” But, he adds, “we know that it will not completely heal the wounds inflicted on Dr. Weber’s victims.”

Stanley Patrick Weber, a former Indian Health Service (IHS) pediatrician, was convicted September 27 on 8 counts of sexual abuse of 4 Native American boys under his care at the Pine Ridge Indian Reservation, Oglala Lakota County, South Dakota.

Weber was an employee of the IHS from 1986 until he resigned in 2016. During that time, although suspicions were rampant that he was abusing young patients, he was moved from one reservation to another. An investigation by The Wall Street Journal and PBS/Frontline found officials in the IHS chain of command “ignored warning signs” and tried to silence whistleblowers.

Weber also was convicted last year and served time for abusing 2 boys at another government hospital in Montana before he arrived at Pine Ridge.

The Pine Ridge Reservation is home to some of the poorest communities in the US, with a dropout rate of > 70%, and a teen suicide rate 150% higher than America’s as a whole. Many of the youths testifying in the case described difficult childhoods, according to the Frontline program. In addition to assaulting them during health care visits, Weber lured them to his home with offers of alcohol and cash.

A White House task force was created to address the agency’s failures. In a statement, Rear Adm Michael Weahkee, IHS principal deputy director, said the IHS is “doing all we can throughout our agency to strengthen our protection for patients.” Steps taken include reinforcing with staff the prohibitions against inappropriate contact with children, reminding staff of the protections for whistleblowers, and hiring Integritas Creative Solutions to conduct a medical quality assurance review to examine whether laws, policies and procedures have been followed with regard to protecting patients from sexual abuse. The review complements work done by the Presidential Task Force on Protecting Native American Children in the Indian Health Service System and a separate review by the HHS Office of the Inspector General.

The IHS also is providing professional counseling for victims. Services do not have to be at an IHS facility or with an IHS provider. A confidential hot line has been established at 301-443-0658.

Weahkee calls the verdict “a long-awaited victory.” But, he adds, “we know that it will not completely heal the wounds inflicted on Dr. Weber’s victims.”

Stanley Patrick Weber, a former Indian Health Service (IHS) pediatrician, was convicted September 27 on 8 counts of sexual abuse of 4 Native American boys under his care at the Pine Ridge Indian Reservation, Oglala Lakota County, South Dakota.

Weber was an employee of the IHS from 1986 until he resigned in 2016. During that time, although suspicions were rampant that he was abusing young patients, he was moved from one reservation to another. An investigation by The Wall Street Journal and PBS/Frontline found officials in the IHS chain of command “ignored warning signs” and tried to silence whistleblowers.

Weber also was convicted last year and served time for abusing 2 boys at another government hospital in Montana before he arrived at Pine Ridge.

The Pine Ridge Reservation is home to some of the poorest communities in the US, with a dropout rate of > 70%, and a teen suicide rate 150% higher than America’s as a whole. Many of the youths testifying in the case described difficult childhoods, according to the Frontline program. In addition to assaulting them during health care visits, Weber lured them to his home with offers of alcohol and cash.

A White House task force was created to address the agency’s failures. In a statement, Rear Adm Michael Weahkee, IHS principal deputy director, said the IHS is “doing all we can throughout our agency to strengthen our protection for patients.” Steps taken include reinforcing with staff the prohibitions against inappropriate contact with children, reminding staff of the protections for whistleblowers, and hiring Integritas Creative Solutions to conduct a medical quality assurance review to examine whether laws, policies and procedures have been followed with regard to protecting patients from sexual abuse. The review complements work done by the Presidential Task Force on Protecting Native American Children in the Indian Health Service System and a separate review by the HHS Office of the Inspector General.

The IHS also is providing professional counseling for victims. Services do not have to be at an IHS facility or with an IHS provider. A confidential hot line has been established at 301-443-0658.

Weahkee calls the verdict “a long-awaited victory.” But, he adds, “we know that it will not completely heal the wounds inflicted on Dr. Weber’s victims.”

“The American Gastroenterological Association (AGA) has worked diligently and effectively to expand the pool of underrepresented in medicine physicians who provide care for patients with digestive diseases,” remarks Byron Cryer, MD, FORWARD principal investigator and associate dean for the office of faculty diversity & development, University of Texas Southwestern Medical Center, Dallas.

This long history of promoting and encouraging diversity in the field is notable; however, the society recognizes that there is still more to be done to prepare and sponsor underrepresented in medicine physician-scientists to assume leadership positions in the field.

“As of 2017, only 3.2% of gastroenterology fellows were African American and 8.5% were Hispanic,” remarked Sandra Quezada, MD, AGA Chair, Diversity Committee. These statistics closely correspond to AGA’s membership demographics, where only 3.36% of AGA members are African American and 5.53% are Hispanic, among those reporting ethnicity.

Under the leadership of principal investigators Byron Cryer, MD, and Sheila Crowe, MD, and coinvestigators Juanita Merchant, MD, and Jesus Rivera-Nieves, MD, AGA developed the FORWARD (Fostering Opportunities Resulting in Workforce and Research Diversity) program.

This program was funded by the National Institute of Diabetes and Digestive and Kidney Diseases through an education project (R25) grant.

The overall objective of the grant is to enhance the diversity of the biomedical science research workforce in gastroenterology and to prepare individuals to assume leadership positions within the AGA and in academic medicine.

1. Provide skill development in leadership – including general leadership development, executive coaching, and opportunities for leadership experience within the society.

2. Implement a diversity management plan focused on active mentoring approaches, using both one-on-one and networking approaches, to provide opportunities for broad support and sponsorship.

3. Provide training for skill development in research careers including training in research development, management of research groups, scientific manuscript, and grant writing.

The program targets fellows and early-career faculty and was promoted broadly to society membership and to past participants in AGA diversity programs. Through a rigorous selection process, 10 physician-scientists were selected among a qualified pool of applicants. Participants were matched with experienced academic gastroenterologists who committed to serve as their professional mentors throughout the course of their participation in the FORWARD program.

Leadership development

The first FORWARD cohort kicked off in March 2019 and will conclude May 2020. They convened at AGA’s inaugural 2½ day Leadership Development Conference. During the conference, the 10 FORWARD scholars joined with 18 AGA Future Leader program participants and 40 Women’s Leadership Conference attendees to participate in leadership development training that addressed such topics as building resilience, presentation skills, negotiation, career success in an ever-changing scientific environment, emotional intelligence, and other key topics designed to bolster their skills as emerging leaders in gastroenterology. With seven past and current AGA presidents in attendance, the FORWARD participants had the unique opportunity to learn about the career paths and gain advice from key leaders in the field while also networking with fellow emerging leaders in both the Future Leaders program and Women’s Leadership Conference.

To further prepare the FORWARD scholars to assume future leadership positions within the society, they’ve begun “internships” that included shadowing AGA committee meetings during Digestive Disease Week (DDW^®) 2019 in San Diego and participating in networking events with AGA leaders at receptions and various events.
 

Mentoring and coaching

In addition to leadership development training at the conference, each FORWARD scholar identified a research topic that they would work on with their mentor and a grant-writing expert to develop into a full grant proposal by the conclusion of the program. The FORWARD mentors have committed to provide mentoring that addresses scientific research content as well as career guidance. The active mentoring provided to the FORWARD scholars is extensive and includes regular contact with their mentors as well as one-on-one executive coaching by a professional coach committed to learning about their needs and guiding them through an individual development plan.

To facilitate the coaching for their individual development plan, each FORWARD scholar completed a Self-Assessment for Physician Leaders and a 360° assessment, which informed the executive coaching that the scholars receive. For many of the scholars, this is the first time that they have benefited from individual executive coaching.
 

Academic research skills development

In addition to leadership development training and networking opportunities along with executive coaching and mentoring, the FORWARD scholars benefit from direct evaluation and consultation on grant writing. FORWARD scholars have access to a private learning management system where they participate in online grant-writing skills training designed by a grant-writing expert. Based on their training, they are developing various segments of an actual grant proposal and are receiving both virtual peer critiques as well as individualized critiques and guidance from the grant-writing consultant, their program mentor, and their home institution mentor. Future training modules will include lab management and manuscript writing.

Jesus Rivera-Nieves, MD, FORWARD coinvestigator, stated, “I have had the honor of monitoring the progress of our first class of scholars recently. I am incredibly proud of the caliber of these early-career professionals and have no doubt that they will emerge as leaders in our field, where more diversity is greatly needed.”

The scholars and their mentors will reconvene at DDW^® 2020 for an opportunity to give a presentation and participate in a commencement ceremony concluding their involvement in the program. Following the graduation of this first cohort, there will be a period of evaluation prior to recruitment of the second cohort of FORWARD scholars.
 

The 2018-2020 FORWARD Cohort includes:

Yelina Alvarez, MD, PhD University of Pennsylvania Health System, Philadelphia

Dominique Bailey, MD Columbia University Medical Center, New York

Veroushka Ballester, MD, MSc Columbia University Medical Center, New York

Oriana M. Damas, MD University of Miami

Patricia D. Jones, MD, MSCR University of Miami

Folasade (Fola) May, MD, PhD, MPhil University of California, Los Angeles; Veterans Affairs

Antonio Mendoza Ladd, MD, FACG, FASGE Texas Tech Univ. Health Sciences Center, El Paso

Akinbowale Oyalowo, MD University of Pennsylvania, Philadelphia

Nneka Ufere, MD Massachusetts General Hospital, Boston

Eric J. Vargas, MD Mayo Clinic, Rochester, Minn.

The 2018-2020 – FORWARD Program Mentors

Maria Abreu, MD, AGAF University of Miami

C. Rick Boland, MD, AGAF University of California, San Diego

John Carethers, MD, AGAF University of Michigan, Ann Arbor

Darwin Conwell, MD, MS Ohio State University Wexner Medical Center, Columbus

Gail Hecht, MD, MS, AGAF Loyola University Medical Center, Maywood, Ill.

John Inadomi, MD, AGAF University of Washington, Seattle

David Lieberman, MD, AGAF Oregon Health and Science University, Portland

Jorge Marrero, MD, MS, AGAF University of Texas Southwestern Medical Center, Dallas

Robert Sandler, MD, MPH, AGAF University of North Carolina at Chapel Hill

Gary Wu, MD University of Pennsylvania, Philadelphia

Dr. Cryer is associate dean for faculty diversity and development, UT Southwestern Medical Center, Dallas; Dr. Rivera-Nieves, is professor of medicine, University of California, San Diego; and Ms. NuQuay, is senior director, member relations and constituency programs, American Gastroenterological Association, Bethesda, Md.

“The American Gastroenterological Association (AGA) has worked diligently and effectively to expand the pool of underrepresented in medicine physicians who provide care for patients with digestive diseases,” remarks Byron Cryer, MD, FORWARD principal investigator and associate dean for the office of faculty diversity & development, University of Texas Southwestern Medical Center, Dallas.

This long history of promoting and encouraging diversity in the field is notable; however, the society recognizes that there is still more to be done to prepare and sponsor underrepresented in medicine physician-scientists to assume leadership positions in the field.

“As of 2017, only 3.2% of gastroenterology fellows were African American and 8.5% were Hispanic,” remarked Sandra Quezada, MD, AGA Chair, Diversity Committee. These statistics closely correspond to AGA’s membership demographics, where only 3.36% of AGA members are African American and 5.53% are Hispanic, among those reporting ethnicity.

Under the leadership of principal investigators Byron Cryer, MD, and Sheila Crowe, MD, and coinvestigators Juanita Merchant, MD, and Jesus Rivera-Nieves, MD, AGA developed the FORWARD (Fostering Opportunities Resulting in Workforce and Research Diversity) program.

This program was funded by the National Institute of Diabetes and Digestive and Kidney Diseases through an education project (R25) grant.

The overall objective of the grant is to enhance the diversity of the biomedical science research workforce in gastroenterology and to prepare individuals to assume leadership positions within the AGA and in academic medicine.

1. Provide skill development in leadership – including general leadership development, executive coaching, and opportunities for leadership experience within the society.

2. Implement a diversity management plan focused on active mentoring approaches, using both one-on-one and networking approaches, to provide opportunities for broad support and sponsorship.

3. Provide training for skill development in research careers including training in research development, management of research groups, scientific manuscript, and grant writing.

The program targets fellows and early-career faculty and was promoted broadly to society membership and to past participants in AGA diversity programs. Through a rigorous selection process, 10 physician-scientists were selected among a qualified pool of applicants. Participants were matched with experienced academic gastroenterologists who committed to serve as their professional mentors throughout the course of their participation in the FORWARD program.

Leadership development

The first FORWARD cohort kicked off in March 2019 and will conclude May 2020. They convened at AGA’s inaugural 2½ day Leadership Development Conference. During the conference, the 10 FORWARD scholars joined with 18 AGA Future Leader program participants and 40 Women’s Leadership Conference attendees to participate in leadership development training that addressed such topics as building resilience, presentation skills, negotiation, career success in an ever-changing scientific environment, emotional intelligence, and other key topics designed to bolster their skills as emerging leaders in gastroenterology. With seven past and current AGA presidents in attendance, the FORWARD participants had the unique opportunity to learn about the career paths and gain advice from key leaders in the field while also networking with fellow emerging leaders in both the Future Leaders program and Women’s Leadership Conference.

To further prepare the FORWARD scholars to assume future leadership positions within the society, they’ve begun “internships” that included shadowing AGA committee meetings during Digestive Disease Week (DDW^®) 2019 in San Diego and participating in networking events with AGA leaders at receptions and various events.
 

Mentoring and coaching

In addition to leadership development training at the conference, each FORWARD scholar identified a research topic that they would work on with their mentor and a grant-writing expert to develop into a full grant proposal by the conclusion of the program. The FORWARD mentors have committed to provide mentoring that addresses scientific research content as well as career guidance. The active mentoring provided to the FORWARD scholars is extensive and includes regular contact with their mentors as well as one-on-one executive coaching by a professional coach committed to learning about their needs and guiding them through an individual development plan.

To facilitate the coaching for their individual development plan, each FORWARD scholar completed a Self-Assessment for Physician Leaders and a 360° assessment, which informed the executive coaching that the scholars receive. For many of the scholars, this is the first time that they have benefited from individual executive coaching.
 

Academic research skills development

In addition to leadership development training and networking opportunities along with executive coaching and mentoring, the FORWARD scholars benefit from direct evaluation and consultation on grant writing. FORWARD scholars have access to a private learning management system where they participate in online grant-writing skills training designed by a grant-writing expert. Based on their training, they are developing various segments of an actual grant proposal and are receiving both virtual peer critiques as well as individualized critiques and guidance from the grant-writing consultant, their program mentor, and their home institution mentor. Future training modules will include lab management and manuscript writing.

Jesus Rivera-Nieves, MD, FORWARD coinvestigator, stated, “I have had the honor of monitoring the progress of our first class of scholars recently. I am incredibly proud of the caliber of these early-career professionals and have no doubt that they will emerge as leaders in our field, where more diversity is greatly needed.”

The scholars and their mentors will reconvene at DDW^® 2020 for an opportunity to give a presentation and participate in a commencement ceremony concluding their involvement in the program. Following the graduation of this first cohort, there will be a period of evaluation prior to recruitment of the second cohort of FORWARD scholars.
 

The 2018-2020 FORWARD Cohort includes:

Yelina Alvarez, MD, PhD University of Pennsylvania Health System, Philadelphia

Dominique Bailey, MD Columbia University Medical Center, New York

Veroushka Ballester, MD, MSc Columbia University Medical Center, New York

Oriana M. Damas, MD University of Miami

Patricia D. Jones, MD, MSCR University of Miami

Folasade (Fola) May, MD, PhD, MPhil University of California, Los Angeles; Veterans Affairs

Antonio Mendoza Ladd, MD, FACG, FASGE Texas Tech Univ. Health Sciences Center, El Paso

Akinbowale Oyalowo, MD University of Pennsylvania, Philadelphia

Nneka Ufere, MD Massachusetts General Hospital, Boston

Eric J. Vargas, MD Mayo Clinic, Rochester, Minn.

The 2018-2020 – FORWARD Program Mentors

Maria Abreu, MD, AGAF University of Miami

C. Rick Boland, MD, AGAF University of California, San Diego

John Carethers, MD, AGAF University of Michigan, Ann Arbor

Darwin Conwell, MD, MS Ohio State University Wexner Medical Center, Columbus

Gail Hecht, MD, MS, AGAF Loyola University Medical Center, Maywood, Ill.

John Inadomi, MD, AGAF University of Washington, Seattle

David Lieberman, MD, AGAF Oregon Health and Science University, Portland

Jorge Marrero, MD, MS, AGAF University of Texas Southwestern Medical Center, Dallas

Robert Sandler, MD, MPH, AGAF University of North Carolina at Chapel Hill

Gary Wu, MD University of Pennsylvania, Philadelphia

Dr. Cryer is associate dean for faculty diversity and development, UT Southwestern Medical Center, Dallas; Dr. Rivera-Nieves, is professor of medicine, University of California, San Diego; and Ms. NuQuay, is senior director, member relations and constituency programs, American Gastroenterological Association, Bethesda, Md.

“The American Gastroenterological Association (AGA) has worked diligently and effectively to expand the pool of underrepresented in medicine physicians who provide care for patients with digestive diseases,” remarks Byron Cryer, MD, FORWARD principal investigator and associate dean for the office of faculty diversity & development, University of Texas Southwestern Medical Center, Dallas.

This long history of promoting and encouraging diversity in the field is notable; however, the society recognizes that there is still more to be done to prepare and sponsor underrepresented in medicine physician-scientists to assume leadership positions in the field.

“As of 2017, only 3.2% of gastroenterology fellows were African American and 8.5% were Hispanic,” remarked Sandra Quezada, MD, AGA Chair, Diversity Committee. These statistics closely correspond to AGA’s membership demographics, where only 3.36% of AGA members are African American and 5.53% are Hispanic, among those reporting ethnicity.

Under the leadership of principal investigators Byron Cryer, MD, and Sheila Crowe, MD, and coinvestigators Juanita Merchant, MD, and Jesus Rivera-Nieves, MD, AGA developed the FORWARD (Fostering Opportunities Resulting in Workforce and Research Diversity) program.

This program was funded by the National Institute of Diabetes and Digestive and Kidney Diseases through an education project (R25) grant.

The overall objective of the grant is to enhance the diversity of the biomedical science research workforce in gastroenterology and to prepare individuals to assume leadership positions within the AGA and in academic medicine.

1. Provide skill development in leadership – including general leadership development, executive coaching, and opportunities for leadership experience within the society.

2. Implement a diversity management plan focused on active mentoring approaches, using both one-on-one and networking approaches, to provide opportunities for broad support and sponsorship.

3. Provide training for skill development in research careers including training in research development, management of research groups, scientific manuscript, and grant writing.

The program targets fellows and early-career faculty and was promoted broadly to society membership and to past participants in AGA diversity programs. Through a rigorous selection process, 10 physician-scientists were selected among a qualified pool of applicants. Participants were matched with experienced academic gastroenterologists who committed to serve as their professional mentors throughout the course of their participation in the FORWARD program.

Leadership development

The first FORWARD cohort kicked off in March 2019 and will conclude May 2020. They convened at AGA’s inaugural 2½ day Leadership Development Conference. During the conference, the 10 FORWARD scholars joined with 18 AGA Future Leader program participants and 40 Women’s Leadership Conference attendees to participate in leadership development training that addressed such topics as building resilience, presentation skills, negotiation, career success in an ever-changing scientific environment, emotional intelligence, and other key topics designed to bolster their skills as emerging leaders in gastroenterology. With seven past and current AGA presidents in attendance, the FORWARD participants had the unique opportunity to learn about the career paths and gain advice from key leaders in the field while also networking with fellow emerging leaders in both the Future Leaders program and Women’s Leadership Conference.

To further prepare the FORWARD scholars to assume future leadership positions within the society, they’ve begun “internships” that included shadowing AGA committee meetings during Digestive Disease Week (DDW^®) 2019 in San Diego and participating in networking events with AGA leaders at receptions and various events.
 

Mentoring and coaching

In addition to leadership development training at the conference, each FORWARD scholar identified a research topic that they would work on with their mentor and a grant-writing expert to develop into a full grant proposal by the conclusion of the program. The FORWARD mentors have committed to provide mentoring that addresses scientific research content as well as career guidance. The active mentoring provided to the FORWARD scholars is extensive and includes regular contact with their mentors as well as one-on-one executive coaching by a professional coach committed to learning about their needs and guiding them through an individual development plan.

To facilitate the coaching for their individual development plan, each FORWARD scholar completed a Self-Assessment for Physician Leaders and a 360° assessment, which informed the executive coaching that the scholars receive. For many of the scholars, this is the first time that they have benefited from individual executive coaching.
 

Academic research skills development

In addition to leadership development training and networking opportunities along with executive coaching and mentoring, the FORWARD scholars benefit from direct evaluation and consultation on grant writing. FORWARD scholars have access to a private learning management system where they participate in online grant-writing skills training designed by a grant-writing expert. Based on their training, they are developing various segments of an actual grant proposal and are receiving both virtual peer critiques as well as individualized critiques and guidance from the grant-writing consultant, their program mentor, and their home institution mentor. Future training modules will include lab management and manuscript writing.

Jesus Rivera-Nieves, MD, FORWARD coinvestigator, stated, “I have had the honor of monitoring the progress of our first class of scholars recently. I am incredibly proud of the caliber of these early-career professionals and have no doubt that they will emerge as leaders in our field, where more diversity is greatly needed.”

The scholars and their mentors will reconvene at DDW^® 2020 for an opportunity to give a presentation and participate in a commencement ceremony concluding their involvement in the program. Following the graduation of this first cohort, there will be a period of evaluation prior to recruitment of the second cohort of FORWARD scholars.
 

The 2018-2020 FORWARD Cohort includes:

Yelina Alvarez, MD, PhD University of Pennsylvania Health System, Philadelphia

Dominique Bailey, MD Columbia University Medical Center, New York

Veroushka Ballester, MD, MSc Columbia University Medical Center, New York

Oriana M. Damas, MD University of Miami

Patricia D. Jones, MD, MSCR University of Miami

Folasade (Fola) May, MD, PhD, MPhil University of California, Los Angeles; Veterans Affairs

Antonio Mendoza Ladd, MD, FACG, FASGE Texas Tech Univ. Health Sciences Center, El Paso

Akinbowale Oyalowo, MD University of Pennsylvania, Philadelphia

Nneka Ufere, MD Massachusetts General Hospital, Boston

Eric J. Vargas, MD Mayo Clinic, Rochester, Minn.

The 2018-2020 – FORWARD Program Mentors

Maria Abreu, MD, AGAF University of Miami

C. Rick Boland, MD, AGAF University of California, San Diego

John Carethers, MD, AGAF University of Michigan, Ann Arbor

Darwin Conwell, MD, MS Ohio State University Wexner Medical Center, Columbus

Gail Hecht, MD, MS, AGAF Loyola University Medical Center, Maywood, Ill.

John Inadomi, MD, AGAF University of Washington, Seattle

David Lieberman, MD, AGAF Oregon Health and Science University, Portland

Jorge Marrero, MD, MS, AGAF University of Texas Southwestern Medical Center, Dallas

Robert Sandler, MD, MPH, AGAF University of North Carolina at Chapel Hill

Gary Wu, MD University of Pennsylvania, Philadelphia

Dr. Cryer is associate dean for faculty diversity and development, UT Southwestern Medical Center, Dallas; Dr. Rivera-Nieves, is professor of medicine, University of California, San Diego; and Ms. NuQuay, is senior director, member relations and constituency programs, American Gastroenterological Association, Bethesda, Md.

AFM cases continue to rise

Cases of Acute Flaccid Myelitis (AFM) are on the rise, with 210 confirmed cases of AFM in 40 states in 2018, up from 35 confirmed cases in 2017. AFM is a rare but serious condition that usually affects children, causing polio-like symptoms – focal extremity weakness, hyporeflexia, and sometimes cranial nerve dysfunction. The Centers for Disease Control and Prevention encourage all health care providers to contact their local health departments with any suspected cases of AFM.

Citation: Centers for Disease Control and Prevention. AFM Investigation. 2019 Jan. https://www.cdc.gov/acute-flaccid-myelitis/afm-surveillance.html.

HHS recommends prescribing naloxone to patients at high risk for opioid overdose

The U.S. Department of Health & Human Services recommends clinicians strongly consider prescribing or coprescribing naloxone to patients at high risk of opioid overdose. This includes patients who are on relatively high doses of opioids, take other medications which enhance opioid complications, or have underlying health conditions. Clinicians are also advised to educate patients and those likely to respond to an overdose on when and how to use naloxone in its variety of forms.

Citation: U.S. Department of Health & Human Services. HHS recommends prescribing or co-prescribing naloxone to patients at high risk for an opioid overdose. 2018 Dec 18. https://www.hhs.gov/about/news/2018/12/19/hhs-recommends-prescribing-or-co-prescribing-naloxone-to-patients-at-high-risk-for-an-opioid-overdose.html.

Fentanyl tops the list of opioid overdose drugs

The total number of drug overdose deaths per year in the United States increased 54%, from 41,340 deaths in 2011 to 63,632 deaths in 2016. Among opioids, mention of fentanyl increased during 2011-2016; that drug took the lead in 2016 with 29% of all drug overdose deaths. Among the drug overdose deaths involving fentanyl, 69% also involved one or more other drugs.

Citation: Hedegaard H et al. Drugs most frequently involved in drug overdose deaths: United States, 2011–2016. Natl Vital Stat Rep. 2018 Dec;67(9):1-14.

AFM cases continue to rise

Cases of Acute Flaccid Myelitis (AFM) are on the rise, with 210 confirmed cases of AFM in 40 states in 2018, up from 35 confirmed cases in 2017. AFM is a rare but serious condition that usually affects children, causing polio-like symptoms – focal extremity weakness, hyporeflexia, and sometimes cranial nerve dysfunction. The Centers for Disease Control and Prevention encourage all health care providers to contact their local health departments with any suspected cases of AFM.

Citation: Centers for Disease Control and Prevention. AFM Investigation. 2019 Jan. https://www.cdc.gov/acute-flaccid-myelitis/afm-surveillance.html.

HHS recommends prescribing naloxone to patients at high risk for opioid overdose

The U.S. Department of Health & Human Services recommends clinicians strongly consider prescribing or coprescribing naloxone to patients at high risk of opioid overdose. This includes patients who are on relatively high doses of opioids, take other medications which enhance opioid complications, or have underlying health conditions. Clinicians are also advised to educate patients and those likely to respond to an overdose on when and how to use naloxone in its variety of forms.

Citation: U.S. Department of Health & Human Services. HHS recommends prescribing or co-prescribing naloxone to patients at high risk for an opioid overdose. 2018 Dec 18. https://www.hhs.gov/about/news/2018/12/19/hhs-recommends-prescribing-or-co-prescribing-naloxone-to-patients-at-high-risk-for-an-opioid-overdose.html.

Fentanyl tops the list of opioid overdose drugs

The total number of drug overdose deaths per year in the United States increased 54%, from 41,340 deaths in 2011 to 63,632 deaths in 2016. Among opioids, mention of fentanyl increased during 2011-2016; that drug took the lead in 2016 with 29% of all drug overdose deaths. Among the drug overdose deaths involving fentanyl, 69% also involved one or more other drugs.

Citation: Hedegaard H et al. Drugs most frequently involved in drug overdose deaths: United States, 2011–2016. Natl Vital Stat Rep. 2018 Dec;67(9):1-14.

AFM cases continue to rise

Cases of Acute Flaccid Myelitis (AFM) are on the rise, with 210 confirmed cases of AFM in 40 states in 2018, up from 35 confirmed cases in 2017. AFM is a rare but serious condition that usually affects children, causing polio-like symptoms – focal extremity weakness, hyporeflexia, and sometimes cranial nerve dysfunction. The Centers for Disease Control and Prevention encourage all health care providers to contact their local health departments with any suspected cases of AFM.

Citation: Centers for Disease Control and Prevention. AFM Investigation. 2019 Jan. https://www.cdc.gov/acute-flaccid-myelitis/afm-surveillance.html.

HHS recommends prescribing naloxone to patients at high risk for opioid overdose

The U.S. Department of Health & Human Services recommends clinicians strongly consider prescribing or coprescribing naloxone to patients at high risk of opioid overdose. This includes patients who are on relatively high doses of opioids, take other medications which enhance opioid complications, or have underlying health conditions. Clinicians are also advised to educate patients and those likely to respond to an overdose on when and how to use naloxone in its variety of forms.

Citation: U.S. Department of Health & Human Services. HHS recommends prescribing or co-prescribing naloxone to patients at high risk for an opioid overdose. 2018 Dec 18. https://www.hhs.gov/about/news/2018/12/19/hhs-recommends-prescribing-or-co-prescribing-naloxone-to-patients-at-high-risk-for-an-opioid-overdose.html.

Fentanyl tops the list of opioid overdose drugs

The total number of drug overdose deaths per year in the United States increased 54%, from 41,340 deaths in 2011 to 63,632 deaths in 2016. Among opioids, mention of fentanyl increased during 2011-2016; that drug took the lead in 2016 with 29% of all drug overdose deaths. Among the drug overdose deaths involving fentanyl, 69% also involved one or more other drugs.

Citation: Hedegaard H et al. Drugs most frequently involved in drug overdose deaths: United States, 2011–2016. Natl Vital Stat Rep. 2018 Dec;67(9):1-14.