ACG Magazine | Vol. 10, No. 3 | Fall 2026

ACG MAGAZINE FALL 2026

MEMBERS. MEDICINE. MEANING.

Rooted in Gratitude

GI IN THE FAMILY

APPLY for an

ACG Clinical Research Award Deadline: Monday, December 7, 2026 Junior Faculty Development Award

Clinical Research Award

$150,000 a year for three years

Up to $100,000 for clinical research

Established Investigator Bridge Funding Award

Clinical Research Pilot Award

Up to $150,000 a year for two years NOTE: Required pre-qualification form, bitly/33guW6k, due November 6

Up to $30,000 for pilot projects

Leonidas Berry Health Equity Research Award

Resident Clinical Research Award

Up to $75,000 (50k year-one, 25k year-two based on progress) for actionable science that will reduce health and/or healthcare disparities

ACG/ASGE Epidemiologic Research Award in Gastrointestinal Endoscopy Up to $50,000 for research utilizing the GIQuIC database DEADLINE: December 4

Up to $10,000, plus travel to ACG Annual Scientific Meeting

Medical Student Research Award

Up to $5,000 for 6–10 week summer project, plus travel to ACG Annual Scientific Meeting

Learn more about ACG 2027 Clinical Research Opportunities and Submit Your Application: GI.ORG/RESEARCH-AWARDS LEARN MORE ABOUT THE ACG INSTITUTE The ACG Clinical Research Awards are a project of the ACG Institute and are supported by charitable contributions to the ACG’s ongoing fundraising campaign - The G.U.T. Fund.

FALL 2026 // VOLUME 10, NUMBER 3

FEATURED CONTENTS

AFTER HOURS

COVER STORY

GI IN THE FAMILY

The Umar-Bilal family shares what keeps them grounded, their journey from Pakistan to the US, and what it’s like to grow up in a GI family

PAGE 20

The ACG Women in GI Committee discusses the value of side gigs and career diversification

PAGE 11

GETTING IT RIGHT 5 things every GI fellow and early career attending should know about finances

PAGE 36

|1

ACG MAGAZINE MAGAZINE STAFF

CONNECT WITH ACG youtube.com/ACGastroenterology

Executive Director Bradley C. Stillman, JD

facebook.com/AmCollegeGastro Editor-in-Chief | Vice President, Communications Brian C. Davis

Managing Editor | Senior Manager, Communications Becky Abel

Art Director Emily Garel

x.com/amcollegegastro

bit.ly/ACG-Linked-In

@AmCollegeGastro

ACG

CONTACT BOARD OF TRUSTEES President: William D. Chey, MD, MACG

IDEAS & FEEDBACK We'd love to hear from you. Send us your ideas, stories, and comments.

ACGMag@ @gi.org

President-Elect: Costas H. Kefalas, MD, MMM, MS-PopH, FACG Vice President: Nicholas J. Shaheen, MD, MPH, MACG Secretary: Jean-Paul Achkar, MD, FACG Treasurer: Neil H. Stollman, MD, FACG Immediate Past President: Amy S. Oxentenko, MD, MACG Past President: Jonathan A. Leighton, MD, MACG

CONTACT ACG American College of Gastroenterology 11333 Woodglen Drive, Suite 100 North Bethesda, MD 20852 (301) 263-9000 | gi.org

Director, ACG Institute: Neena S. Abraham, MD, MSc, MACG Co-Editors, The American Journal of Gastroenterology: Jasmohan S. Bajaj, MD, MS, FACG Millie D. Long, MD, MPH, FACG

DIGITAL EDITIONS

GI.ORG/ACG-MAGAZINE

Chair, Board of Governors: Sita S. Chokhavatia, MD, MACG Vice Chair, Board of Governors: Harish K. Gagneja, MD, MACG Trustee for Administrative Affairs: Sunanda V. Kane, MD, MSPH, MACG

TRUSTEES Brooks D. Cash, MD, FACG Dayna S. Early, MD, FACG Jill K. J. Gaidos, MD, FACG Seth A. Gross, MD, FACG David J. Hass, MD, FACG James C. Hobley, MD, MSc, FACG Vonda G. Reeves, MD, MBA, FACG Aasma Shaukat, MD, MPH, FACG Jay N. Yepuri, MD, MS, FACG Patrick E. Young, MD, FACG

2 | GI.ORG/ACG-MAGAZINE

American College of Gastroenterology is an organization with an international membership of over 21,000 individuals from 86 countries. The College's vision is to be the preeminent organization supporting health care professionals who provide compassionate, equitable, high-quality, state-of-the-art, and personalized care to promote digestive health. The mission of the College is to provide tools, services, and accelerate advances in patient care, education, research, advocacy, practice management, professional development, and clinician wellness, enabling our members to improve patients’ digestive health and to build personally fulfilling careers that foster wellbeing, meaning, and purpose.

FALL 2026 // VOLUME 10, NUMBER 3

CONTENTS

“...medicine was something that was always very near and dear to our hearts. They had always taught us the value of service and that’s all we knew, honestly—how to take care of patients.” ­—Dr. Mohammad Bilal, GI in the Family, PG 20

4 // MESSAGE FROM THE PRESIDENT

11 // ACG PERSPECTIVES

33 // GETTING IT RIGHT

Dr. William Chey with updates on two task forces and reflections on a presidential year gone by the in blink of an eye

11 SIDE GIGS Side gigs and career diversification in GI from the ACG Women in GI Committee

33 HOW TO WRITE A CV Guidance on making a good impression with your resume or CV

16 CRC SCREENING FOR PAKISTANI WOMEN Dr. Lubna Kamani and Dr. Pooja Ameet share the challenges of screening women in Pakistan for CRC and ways to reach underserved communities

36 FINANCIAL TIPS FOR EARLY CAREERS Five things every trainee and early-career attending should know about finances

6 // NOVEL & NOTEWORTHY Jr. faculty grantees receive NIH funding, ACG joins physician network Roon, welcome new EBGI Associate Editors, APPs at ACG 2026, and congrats to an ECLP alum 8 INSIDE THE JOURNALS Introducing the 2026–2027 ACGCRJ Editorial Board, new clinical guidelines on colonic diverticulitis and adenomatous colorectal polyposis syndromes in AJG, and the utility of ultrasound in clinical esophagology in CTG 10 REFLECTION Dr. Neena Abraham reflects on the advancements of the ACG Institute during her six-year term as Director

20 // COVER STORY GI IN THE FAMILY The Umar-Bilal family’s journey from helping establish the GI specialty in Pakistan to tackling challenging cases in the US

29 // TRAINEE HUB

38 LAW MIND How to keep a physician employed at your company

41 // GUIDELINE HIGHLIGHTS 41 Colonic Diverticulitis (July 2026) 42 Diagnosis & Management of Adenomatous Colorectal Polyposis Syndromes (Sept. 2026)

EXPLAINING NORMAL RESULTS Dr. Prachi Mann and Dr. Sanjeevani Tomar offer practical communication lessons for trainees caring for patients with DGBI

Above: Dr. Muhammad Umar and daughter Dr. Shifa Umar on the steps of the Mayo Clinic Rochester, where she completed her advanced pancreas fellowship.

|3

Between Blinks: Advancing Educational and Medical Innovation William D. Chey, MD, MACG

AS I GET OLDER, each year seems to pass by more quickly than the last. Everyone has their own theory on why time seemingly speeds up as we age. My theory is that as we get older, each year occupies a smaller percentage of our lives. So, in relative terms, it makes sense that each successive year seems to pass more quickly than the last. In my first presidential address, I wrote that, “while it took many years to become ACG President, my time as President will come and go in the blink of an eye.” So, what has happened between blinks? In two words: “A lot.”

The Task Force, chaired by ACG Trustee David J. Hass, MD, FACG, was composed of a diverse, experienced group of leaders in medical education:

ACG Education Innovation Task Force The ACG Education Innovation Task Force (EITF) was commissioned to modernize and optimize educational content for the College membership in the digital era. The mission of EITF was to empower learners with adaptive, immersive, and human-centered educational experiences that enhance knowledge, empathy, and clinical excellence in gastroenterology and hepatology.

• Brian S. Levitt, MD, FACG

• Anita Afzali, MD, MPH, MHCM, FACG, ACG Institute Board of Directors • Mohammad Bilal, MD, FACG, Chair, Training Committee • Brooks D. Cash, MD, FACG, ACG Board of Trustees • Sarah M. Enslin, PA-C, MS, Chair, Advanced Practice Providers Committee • Jennifer Katz, MD, FACG • Laurie A. Keefer, PhD, FACG, CEO, Rome Foundation, GI Psychologist • Lisa B. Malter, MD, FACG, Chair, ACG Education Universe • V. Raman Muthusamy, MD, MAS, FACG, Chair, Educational Affairs Committee • Beth Rosen, RD • Brennan Spiegel, MD, MSHS, FACG, ACG Governor for Southern California - A EITF started by conducting a survey of the ACG membership’s opinions

“Everyone has their own theory on why time seemingly speeds up as we age. My theory is that as we get older, each year occupies a smaller percentage of our lives.” 4 | GI.ORG/ACG-MAGAZINE

and interest in various novel learning techniques. The data collected served as a needs assessment and guided EITF’s deliberations and recommendations on new education initiatives. EITF’s innovative spirit, collaboration, and teamwork have led to several new education initiatives which reflect the evolving ways in which our members choose to learn. These include a newly expanded “ACG Question of the Week,” which will test members’ knowledge, keep them current on the latest clinical care recommendations, including ACG clinical practice guidelines, and allow them to earn CME credit. We also hope that the Question of the Week will be fun and foster a sense of community by stimulating dialogue between members and groups. We can envision conversations on the ACG GI Circle and team competitions between fellowship programs or practices. The College will also be launching microlearning videos featuring key points from highyield Postgraduate Course lectures, highlights from seminal articles published in The American Journal of Gastroenterology, practical endoscopic tips designed for every busy gastroenterologist, and more. We will also use this microlearning format to address important, evolving topics such as evidencebased diagnosis and treatment of disorders of gut-brain interaction as well as the emerging role of diet and nutrition, behavioral health, and complementary and integrative medicine in GI and hepatology. Both the Question of the Week and the microlearning videos will debut in the 2026–2027 academic year. The Task Force recommended that the College explore an interactive, AI-powered training and assessment platform. A pilot program is currently

being developed for this platform to initially serve as a fellowship training tool. Medical Innovation Task Force An important theme for this year has been a forward-looking focus on how biomedical innovation can help shape the future of GI practice and, ultimately, improve the lives of patients with digestive and liver disorders. As part of this effort, the ACG Medical Innovation Task Force (MITF) considered how the College can play a distinctive role in a rapidly evolving healthcare environment increasingly influenced by artificial intelligence, digital tools, workflow solutions, and advances in endoscopic and non-endoscopic diagnostics and therapeutics. MITF was chaired by ACG Trustee Seth A. Gross, MD, FACG, and members were leaders in a wide range of areas of biomedical innovation: • Sameer K. Berry, MD, MBA, Chief Medical Officer, Oshi Health • Ian Bund, Co-Founder, Plymouth Growth • Robert A. Ganz, MD, Physician Entrepreneur • Larry R. Kosinski, MD, MBA, FACG, Physician Entrepreneur • Vladimir M. Kushnir, MD, FACG, Chair, Innovation and Technology Committee • Paul J. Limburg, MD, Chief Medical Officer for Screening, Abbott Cancer Diagnostics (formerly Exact Sciences) • Swati Pawa, MD, FACG, Interventional Endoscopist • Tom Shehab, MD, Partner, Arboretum Ventures • Mike Shetzline, MD, Chief Medical Officer, Ironwood Pharmaceuticals • Stephen Steinberg, MD, Physician Entrepreneur • Neil H. Stollman, MD, FACG, ACG Treasurer

“An important theme for this year has been a forward-looking focus on how biomedical innovation can help shape the future of GI practice and, ultimately, improve the lives of patients.”

MITF engaged in multiple discussions addressing ways in which ACG could aid and accelerate in the process of biomedical innovation. This included a review of the remaining gaps in the innovation process that could benefit from ACG’s support. Following these deliberations, MITF recommended that ACG focus on creating the support and infrastructure to validate biomedical innovations in realworld GI practice. Initiatives include Biomedical Innovation Grants (BIG) to support promising inventors and start-up companies, innovation mentorship resources, a Practice Innovation Engine (PIE) to help evaluate selected solutions through practical pilots, and an Innovation Sandbox Network of community-, ASC-, and academic-affiliated sites where emerging technologies can be tested in real-world clinical settings. This suite of biomedical innovation resources will allow the ACG to build, support, and sustain a GI innovation ecosystem centered on real-world validation, implementation, and adoption. I’m excited to announce that in June, the ACG Board of Trustees approved establishing two RFPs for Innovation in GI of up to $100,000 per year for three years. The RFPs will be developed in collaboration with the ACG Institute and ACG Innovation and Technology Committee, with a targeted launch during the 2028 grant cycle. To the members of both Task Forces, ACG offers its unsolicited and boundless gratitude. Your

collective expertise and wisdom, often donated on nights and weekends, allowed the whole to exceed the sum of its parts. Special thanks to Dr. Hass and Dr. Gross for sharing my vision and bringing to heel what must have initially seemed a daunting task. Finally, I want to offer my thanks and admiration to the entire Board of Trustees and ACG staff, without whom none of this would have been possible. My presidency may have only lasted the blink of an eye, but our memories and friendships will last a lifetime. I end my fourth and final presidential address with the statement—slightly updated— that ended my first presidential address: “The ACG is above all else my professional family and it has indeed been an honor to sit at the head of the table for the past year.” Thank you for the honor of a lifetime and good luck and best wishes to my friend and our next President, Dr. Costas Kefalas. —Bill

MESSAGE FROM THE PRESIDENT | 5

NOVEL

& NOTEWORTHY [EVIDENCE-BASED GI]

[APPs IN ACTION]

Co-Editors-in-Chief Joseph C. Anderson, MD, FACG, and Paul Y. Kwo, MD, FACG, are pleased to welcome 12 new Associate Editors to EBGI:

The ACG 2026 Annual Scientific Meeting and Postgraduate Course includes programming, events, and networking opportunities exclusively for Advanced Practice Providers (APPs). This year, the ACG Board of Trustees approved 13 training grants providing partial financial support to APP members attending ACG 2026. In Nashville, take advantage of these APP-only opportunities (all times CT).

 Daniyal Abbas, MD

 Hamidreza Moein, MD

 Zaid Ansari, MD

 Maliha Naseer, MD

 Christina Awad, MD

 Sanjeevani Tomar, MD

 Albert Do, MD, MPH

 Jonathan Xia MD, PhD

 Yifei Hu, MD, PhD

 Muhammad Nadeem

 A. Ali Khalifa MD, MSc

Yousaf, MD

 Joy Liu, MD

APP Leadership Summit  Friday, October 9 |  1:30–6:00 pm APP Reception  Friday, October 9 |  6:00–7:30 pm APP Lunch Session  Saturday, October 10 |  12:20–1:35 pm APP Lounge  Saturday, October 10–Tuesday, October 13 |  8:00 am–5:00 pm Meet the ACG APP Leadership  Monday, October 12 |  10:30–11:30 am APP Networking Hour  Tuesday, October 13 |  10:35–11:35 am

[FUTURE OF GI]

Christina N. Awad, MD, was recently appointed to two leadership positions at UT Health San Antonio: Medical Director of Hepatology and Faculty Director of AI and Innovation. In these roles, she leads both the continued growth of the institution’s hepatology program and broader efforts to thoughtfully integrate artificial intelligence and emerging technologies into clinical care, education, and research. Dr. Awad is a 2025 ACG Institute Early Career Leadership Program (ECLP) participant and credits the Leadership YOU ECLP with helping to prepare her for these new roles.

“Leadership YOU played an important role in preparing me for this transition. It encouraged me to be more intentional about my leadership style— understanding how to build consensus, develop others, navigate complex organizations, and translate a vision into meaningful action…I am incredibly grateful for the investment Leadership YOU made in my development. The lessons, mentorship, and community from the program have remained relevant as my responsibilities have grown.” The Leadership YOU application portal is open! Submit by November 13 for most programs. Emerging Leadership Program applications are due November 23, to accommodate ABIM Gastroenterology exam dates.

 GI.ORG/LEADERSHIP-YOU

6 | GI.ORG/ACG-MAGAZINE

[K AWARD]

ACG congratulates Erica J. Brenner, MD, and Phillip Gu, MD, who were each awarded a Mentored Patient-Oriented Research Career Development Award (K23) from the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). Dr. Brenner and Dr. Gu are 2026 Clinical Research Leadership Program participants and 2025 ACG Junior Faculty Development Award recipients whose ACG-funded research transitioned into their current projects supported by the K Awards. Dr. Brenner aims to develop patient-reported outcome measures tailored to women with Crohn’s disease and menstrual cramps, capturing symptom severity while accounting for overlap with Crohn’s disease symptoms, and lead a single-center pilot randomized controlled trial to inform the design of a future multi-center study comparing ibuprofen and acetaminophen for menstrual pain in women with Crohn’s disease. She received an ACG Junior Faculty Development Award for her project, Safety and Effectiveness of Nonsteroidal Anti-Inflammatory Drugs in Women with Crohn’s Disease. Dr. Gu’s research aims to integrate computational imaging and genetics to improve risk stratification for medically refractory acute severe ulcerative colitis (MR-ASUC) and better understand the underlying biology of this severe disease phenotype. He received an ACG Junior Faculty Development Award for his project, A Multiorgan Radiomic Approach Towards Precision Medicine in Acute Severe Ulcerative Colitis.

[LIKE & SUBSCRIBE]

FIND ACG ON ROON! ACG has joined Roon, a verified, physician-only platform built for conversations between doctors. Gastroenterologists can connect with one another and engage with physicians across specialties. Follow us and share your plans for #ACG2026, updates from Nashville, and reflections on the science that was presented at the meeting. As the community grows, access will expand to international physicians and other healthcare professionals. We’ll share updates as verification becomes available.

[40 UNDER 40]

Eleazar Montalvan Sanchez, MD, was recently honored with a “40 Under 40” Award by the National Hispanic Medical Association (NHMA). The award acknowledges outstanding physicians under the age of 40 who demonstrate leadership, innovation, and commitment to advancing Hispanic health and health equity. Award recipients were recognized at the 2026 NHMA Annual Conference & Gala in Washington, DC. The College congratulates Dr. Montalvan Sanchez and thanks him for serving as Associate Editor for ACG Magazine’s Trainee Hub section.

Novel & Noteworthy | 7

Meet the 2026–2027 ACGCRJ Editorial Board A



ACGCRJ is a fully open access journal. View all published case reports for free:

CG CASE RE PO S J O U RRT N ACGCASEREP ORTS.COM

L

VOLUME 6

ACGCASEREPORTS.COM An Online Journal of Case Gastroentero logy & Hepat Reports edited by ology Fellow s

Thanks to outgoing ACGCRJ Editorial Board members! We thank the outgoing members of the Editorial Board for their outstanding service to the Journal and wish them continued success in their careers. Arjun Chatterjee, MD Editor-in-Chief Cleveland Clinic Cleveland, OH

Linda Jiang, MD Editor-in-Chief University of Michigan Ann Arbor, MI

Enoch Abbey, MD, MPH Harlem Hospital Center New York, NY

Hassam Ali, MD East Carolina University Health Medical Center Greenville, NC

Udita Gupta, MBBS University of New Mexico Albuquerque, NM

Yash Shah, MD University of Arkansas for Medical Sciences Little Rock, AR

8 | GI.ORG/ACG-MAGAZINE

Daniyal Abbas, MD (Co-EIC) Dushyant Dahiya, MD (Co-EIC) Zaid Ansari, MD Umer Farooq, MD

Fouad Jaber, MD, MS Abel Joseph, MD Rahul Karna, MD Faisal Nimri, MBBS

Sanjeevani Tomar, MD Harsimran Kalsi, MD (Lead SMA) Aya Akhras, MBBS (Assoc. SMA) Taha Bin Arif, MD (Assoc. SMA)

Saqr Alsakarneh, MD, MS Mayo Clinic Rochester Rochester, MN

Aastha Bharwad, MD University of Texas Health Science Center Houston, TX

Taranika Sarkar Das, MD Brooklyn Hospital Center New York, NY

Anas Khouri, MD Cleveland Clinic Florida Weston, FL

Maya Mahmoud, MD St. Louis University Hospital St. Louis, MO

Clive Miranda, DO, MSc Creighton University Omaha, NE

Ahmed Nadeem, MD Cleveland Clinic Foundation Cleveland, OH

Rutwik Pradeep Sharma, MD University of Michigan, Sparrow Lansing, MI

Amy Kumar, DO, MA Lead Social Media Ambassador HCA Florida Largo Hospital Largo, FL

Avneet Kaur, MBBS Associate Social Media Ambassador SUNY Upstate Medical University Syracuse, NY

Cinthia Reyes Cruz, MD Associate Social Media Ambassador University of Miami at Holy Cross Miami, FL

N&N // INSIDE THE JOURNALS

121 | Number 8

Volume 121 | Number

1973 Global Prevalence, Characterization, 2040 Efficacy and Safety of Gelatin Tannate

1944 Delayed Remission With Advanced

Therapies Is Not Associated With Worse 1-Year Inflammatory Bowel Disease Outcomes in

Functional Bowel Disorders

EDITORS: Jasmohan S. Bajaj,

MD, MS, FACG and Millie

• More selective use of post-diverticulitis colonoscopy • Shifts toward quality-of-life–based decision-making for elective surgery  READ: bit.ly/acg-diverticulitis-26  LISTEN: bit.ly/ajg-podcast-diverticulitis  HIGHLIGHT: bit.ly/acg-diverticulitis-26-highlight

and Impact of

and Tyndallized Acid Lactic Bacteria in Adults and Altered Gut Microbiota: With Chronic Diarrhea A Randomized, Double-Blind, Placebo-Controlled Study

D. Long, MD, MPH, FACG

Key Updates • Expanded use of multigene panel testing

2086 ACG Clinical Guideline: Diagnosis Adenomatous Colorectal

pages 2063-2356

Reflux Symptoms in Nonerosive Gastroesophageal Reflux Disease

Infusion for Acute Esophageal Variceal Bleeding: A Randomized Controlled Trial

1885 One vs Five Days of Octreotide

9 | September 2026

GASTROENTEROLOGY

• Stronger emphasis on CT imaging to confirm diagnosis

Mankaney, et al. 1866 Vonoprazan Improves Nocturnal

pages 1789-2061

• Advises against routine antibiotics for low-risk, uncomplicated diverticulitis

GASTROENTEROLOGY

Key Updates

Diagnosis and Management of Adenomatous Colorectal Polyposis Syndromes

Volume 121 | Number

The American Journal of

The American Journal of

Peery, et al.

8 | August 2026

Official Journal of the American College of Gastroenterology

121 | Number 9

Official Journal of the American College of Gastroenterology

September 2026 | Volume

August 2026 | Volume

ACG Clinical Guideline: Colonic Diverticulitis

and Management of Polyposis Syndromes

2198 Empirical Antifungal Therapy Improves

Survival in Patients With Acute-on-Chronic Liver Failure With Suspected Invasive Fungal Infections: A Pragmatic Randomized Trial

2231 Poor Sensitivity of the Fatty Liver Individuals

2293 The Time-Dependent Association

Bowel Syndrome and All-Cause Between Irritable and Cause-Specific Mortality in the NIH-AARP Cohort Study

2335 Cost-Effectiveness of First-Line Helicobacter pylori Infection

Regimens for in the United States

Index Among Lean

EDITORS: Jasmohan S. Bajaj,

MD, MS, FACG and Millie

D. Long, MD, MPH, FACG

• Includes newly characterized hereditary polyposis syndromes beyond APC and MUTYH • Formal management recommendations for colonic polyposis of unknown etiology • Enhanced guidance on upper GI surveillance and cancer prevention (particularly gastric, duodenal, and ampullary neoplasia)  READ: bit.ly/acg-polyposis-syndromes-26  LISTEN: bit.ly/ajg-podcast-polyposis  HIGHLIGHT: bit.ly/acg-polyposis-26-highlight

SUBMISSION DEADLINE: DECEMBER 15, 2026 GI.ORG/CALL-FOR-PAPERS

Esophageal Sonography: A Review of the Utility of Ultrasound in Clinical Esophagology Cohen, et al.

 READ: bit.ly/ctg-esophageal-us

Novel & Noteworthy | 9

N&N // REFLECTION

Six Years, One Expanded Mission: Reflections on Serving as ACG Institute Director By Neena S. Abraham, MD, MSc(Epid), MACG

WHEN THEN-ACG PRESIDENT Mark B. Pochapin, MD, MACG, asked me to take this on in 2020, I agreed almost before I had fully thought it through. I had served as a Trustee from 2009 to 2015, so I knew the College’s heart well. What I did not fully anticipate was that I would be stepping into this role on the Institute’s 25th anniversary and as its first female Director—amid a global pandemic. Looking back, the ACG Institute of today looks nothing like what Dr. Pochapin or I could have imagined when I accepted this role in October 2020. My predecessor, Nicholas J. Shaheen, MD, MPH, MACG, left me a solid foundation in research on which to build. In that first year, we increased research funding well beyond its previous level—to more than $1.9 million. This achievement marked an unprecedented milestone for the ACG Institute and our College. In 2026, we funded over $3 million. Somewhere in this country, a GI investigator is asking a better question or running an important clinical study that would not exist without that growth. That is not an abstraction to me. It is the core business of the ACG Institute. But 2020–2021 demanded more from us than research funding alone could provide. We were gastroenterologists living through a pandemic. Simultaneously, the country was confronting, openly and uncomfortably, disparities in clinical care and society. The Institute needed to respond, not just with a statement but with structure. With the support of ACG’s senior leadership, we built and launched the Center for Leadership, Ethics, and Equity (LE&E) at the 2021 ACG Annual Scientific Meeting. The LE&E Center has surpassed all the expectations we set during those early planning meetings. We have trained over 400 gastroenterologists, from senior fellows to physicians with 20 years of experience, in ethical leadership that is culturally sensitive and comprehensive. We established the Leonidas Berry Health Equity Research Award, which provides two years of funding to healthcare researchers working to reduce disparities across all areas of gastroenterology and hepatology. We also launched a Visiting Scholars Program in Ethics and Equity to ensure training programs nationwide had access to talented member speakers who have dedicated their lives to studying and improving the lives of the diverse populations we serve. What began as a response to a challenging year has evolved into a lasting legacy we can all be proud of: a Center that prepares future leaders, educates our members, and funds research to address real gaps in care today. Our educational footprint also grew. Endoscopy School, Esophagus School, and Obesity and Metabolic School joined our existing Hepatology, IBD, and Motility Schools, giving practicing gastroenterologists direct access to the people shaping the leading edge of these fields. We also sponsored the creation of more published monographs than ever before. With the support

10 | GI.ORG/ACG-MAGAZINE

of industry sponsors and talented member authors, we tackled topics as varied as early life and pregnancy in GI, geriatric care, and the microbiome. Real, practical guidance, placed directly in members’ hands. We expanded the Edgar Achkar Visiting Professorship program with topics in ethics and equity, sending visiting professors to institutions and local GI clubs. Good teaching and thoughtful engagement with content experts should not depend on your zip code. Most importantly, the last six years have marked the growth of the Institute and built its recognition as the vehicle for supporting research and physician leadership and learning: with an expanded portfolio of competitive and impactful clinical research opportunities, a deep and diverse leadership pipeline, six topic-specific schools, a growing collection of monographs, work in ethics and equity, along with the expansion of a visiting professor program that sends content experts to training programs across the country. Members see the Institute in their own training, in who mentors them, in who stands before them at the podium, and in the clinically pragmatic research that informs their practice. That shift did not happen on its own. It took a clear vision for what this Institute could become, and six years of steady work, one budget cycle at a time, to build toward it. What the ACG Institute is today, reaching further into careers and patient care than it ever has, is what happens when a clear vision meets people willing to build it alongside you. The ACG Executive Committee and Board of Trustees, along with the ACG Institute Board, supported this vision when it was still in rough drafts and open questions. Mr. Brad Stillman, Ms. Meridith Phillips, Ms. Sarah Richman, and our program managers, Ms. Vaidehi Mehta and Ms. Maddie Kachurak, did the hard work of transforming ideas into actual programs, while keeping up with an Institute Director full of ideas, energy, and vision for the future. Mr. David Stein helped build the funding base that made every new center and school possible, rather than just theoretical. And our industry partners kept believing in this mission, year after year, donating generously to support our programs. Thank you for the immense privilege of serving as the ACG Institute Director for the last six years. I am proud of what we built, and I am even more excited for what comes next. Why? Because the Institute’s foundation and expanded mission are stronger now than they ever have been, and this Institute is only getting started.

Dr. Abraham is Professor of Medicine and Consultant, Division of Gastroenterology and Hepatology, Mayo Clinic. She is the ACG Institute Director and an ACG Trustee.

Beyondlinic the C

Side Gigs and Career Diversification in Gastroenterology

By Maithili Chitnavis, MD, FACG; Sanjeevani Tomar, MD & Tessa Herman, MD. Edited by Katie Dunleavy, MB BCh, BAO

THE GROWING LANDSCAPE OF CAREER DIVERSIFICATION IN GASTROENTEROLOGY No matter what you call it, a side job, side hustle, or side gig, physicians have long pursued work outside of the exam room. In recent years, however, interest amongst medical professionals in having a side gig has surged. What once served as a source of supplemental income or professional enrichment has, for some physicians, evolved into an entirely new career path. According to the 2026 Medscape Physician Compensation Report, 40% of all physicians supplemented their regular work with other paid opportunities. The motivations for pursuing a side gig are as varied as the physicians themselves. For some,

it supplements their income to fund travel, contribute to a child’s education, build retirement savings, or pay off student loans. Others seek novel ways to use their medical expertise for non-clinical work, often driven by career burnout, administrative responsibilities, and long hours. And for many, a side gig begins simply as an interest or hobby that gradually grows into something more. Traditionally, popular side gigs have closely aligned with a clinical career in medicine, such as locum tenens, pharmaceutical consulting/speaking, and medical record review (e.g., for insurance companies, hospitals, etc.) But as physicians have recognized the value of their unique perspectives and

ACG Perspectives | 11

// PERSPECTIVES

skill sets, career diversification has followed—including entrepreneurship, education, media, coaching, writing, advocacy, sustainability, technology, and countless other fields. Women in gastroenterology are no exception. Founded in 2016, the popular Facebook group “Physician Side Gigs” now has over 135,000 members as of June 2026. The group and its accompanying website— physiciansidegigs.com—serve as a forum for physicians interested in career diversification to exchange ideas and give each other advice. Its founder, Nisha Mehta, MD, is a radiologist who has built a multifaceted career as a consultant, writer, and keynote speaker, with the goals of improving financial literacy among physicians, addressing the complexities of physician burnout, and improving overall career satisfaction. “There’s value in diversifying income streams, but also in diversifying your career. Side gigs allow you to use another part of your brain, keep you learning and excited, expand your networks, and give you leverage to walk away from a bad situation or to create a life in medicine on your terms. In a healthcare landscape where it’s becoming easier to feel like a cog in the wheel, side gigs give you autonomy and empowerment,” Dr. Mehta said. To better understand the motivations, challenges, and rewards of pursuing work beyond clinical medicine, we interviewed seven women gastroenterologists who shared their experiences building meaningful careers both inside and outside the field of gastroenterology.

WHY WOMEN IN GI PURSUE CAREER DIVERSIFICATION For many women in gastroenterology, career diversification is not about stepping away from medicine. Rather, it is about expanding their impact, exploring new interests, and building careers that align with their evolving professional and personal goals. While some physicians pursue consulting, coaching, entrepreneurship, advocacy, media, volunteer and foundation

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“There’s value in diversifying income streams, but also in diversifying your career. Side gigs allow you to use another part of your brain, keep you learning and excited, expand your networks, and give you leverage to walk away from a bad situation or to create a life in medicine on your terms.” —Dr. Mehta work, or creative endeavors, a common theme emerged from our interviews: these pursuits are rarely driven solely by financial considerations. Instead, they often stem from a desire for purpose, creativity, leadership, systems-level impact, and longterm career fulfillment. Several physicians described pursuing nonclinical work to address unmet needs they encountered throughout their careers. Dr. Rabia de Latour’s work in environmental sustainability grew from recognizing healthcare’s substantial contribution to climate change and the lack of dialogue surrounding sustainability in procedural medicine. As she explained, “I was motivated by the desire for improvement and saw a massive opportunity to implement change where there was very little dialogue surrounding [environmental sustainability].” What began as a fellowship project ultimately led to her becoming the first Chief Sustainability Officer at Bellevue Hospital Center. Similarly, ACG Institute Board

Member Dr. Anita Afzali was motivated by the belief that healthcare’s most pressing challenges require perspectives beyond traditional clinical practice, leading her to pursue healthcare consulting, leadership development, and organizational transformation initiatives. Reflecting on these experiences, she noted that they have, “allowed me to broaden my impact beyond individual patient care while continuing to contribute to healthcare improvement at a systems level.” Others found fulfillment in supporting fellow physicians and helping shape the future of the profession. Dr. Dawn Sears transitioned from clinical education into physician well-being, leadership, and executive coaching, driven by a desire to help women physicians thrive and remain engaged in medicine. For Dr. Sears, this work became meaningful because, “this impact is much further reaching

than me simply curing hepatitis C or removing a polyp in a few patients every day.” Likewise, ACG Institute Director Dr. Neena Abraham’s coaching practice emerged from recognizing a gap in career guidance specifically tailored to physicians. After years of investing in leadership coaching herself, she launched a coaching practice focused on helping colleagues create sustainable and fulfilling careers. Reflecting on her experience, she shared, “I was good at this, and it gave me genuine satisfaction in a way I hadn’t felt in years.” Career diversification can also provide opportunities for creativity and personal expression. Dr. Mayada Ismail’s baking initiative, May’s Cookies, began as a creative outlet outside medicine and evolved into a community-building and fundraising effort supporting colon cancer screening initiatives. As she observed, “Something as simple as baking can still bring people together and create community.” Her experience highlights an important lesson: not every meaningful pursuit outside medicine needs to begin with a business plan or revenue goal.

“I was motivated by the desire for improvement and saw a massive opportunity to implement change where there was very little dialogue surrounding [environmental sustainability].” —Dr. de Latour For some physicians, diversification is motivated by a desire for greater financial literacy and professional autonomy. Dr. Latifat Akintade’s work in real estate investing and physician financial education grew from her own experiences navigating wealth building without formal guidance. Through MoneyFitMD, she now helps women physicians better understand investing, financial planning, and longterm wealth creation. Her work was inspired, in part, by recognizing that, “there was no community specifically built for women physicians who wanted to learn about money in a shame-free space that understood our actual experience.” Others are motivated by intellectual curiosity and a willingness to explore opportunities beyond traditional career paths. Dr. Anjuli Luthra expanded from therapeutic endoscopy into consulting, speaking, financial education, and

writing after mentors introduced her to possibilities she had not previously considered. Reflecting on these experiences, she noted that, “these roles have given me additional fulfillment that a singular job in medicine cannot.” Her experience reflects a recurring theme among many women leaders in gastroenterology: career diversification often develops organically through curiosity, mentorship, and openness to new experiences rather than through a predefined roadmap. Taken together, these experiences demonstrate that career diversification is rarely about simply adding more work. Instead, it is often about aligning one’s career with personal values, passions, and evolving goals. Whether the objective is broader impact, creativity, leadership, financial empowerment, community building,

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HOW TO GET STARTED: PRACTICAL ADVICE FROM WOMEN GASTROENTEROLOGISTS There is no single roadmap for career diversification, but several practical lessons emerged consistently from the experiences of women leaders across gastroenterology.

1

Start with Purpose The most successful pursuits often begin with a genuine interest, an unmet need, or a problem worth solving. Dr. de Latour emphasized that, “most important is having a clear-cut goal.” While that goal may evolve over time, having a clear direction makes it easier to identify opportunities that align with your values and interests.

2

Build a Strong Foundation Several interviewees emphasized that credibility in clinical medicine often creates opportunities in leadership, consulting, education, advocacy, and entrepreneurship. As Dr. Afzali advised, “Build credibility and excellence in your primary role first, then pursue opportunities that authentically align with your skills, interests, and long-term goals.”

3

Seek Mentors and Learn From Others Professional relationships frequently open doors to new possibilities. Dr. Luthra encourages physicians to "reach out to those already doing or in close proximity to what you're interested in." Connecting with people already doing this work can provide practical guidance, valuable introductions, and a clearer understanding of potential pathways.

4

Start Small and Embrace Being a Beginner Not every project needs to become a business or major professional commitment. Dr. Ismail observed that, “sometimes you just try something because you genuinely enjoy it and see where it goes.” Likewise, Dr. Akintade reminds physicians that, “clarity almost always comes from starting.” Whether learning business principles, investing, leadership, or content creation, physicians should be prepared to step outside their comfort zones and develop new skills along the way.

5

Protect Your Time and Be Selective Successful physician entrepreneurs, educators, and leaders consistently emphasize the importance of setting boundaries and prioritizing opportunities that align with their goals. As Dr. Akintade described, success often depends on, “protecting small pockets of time with the same ferocity I applied to clinical commitments.” Not every opportunity deserves a yes.

6

Expect Setbacks and Keep Going Meaningful opportunities rarely develop overnight. Dr. de Latour advises physicians to recognize that, “it’s important to understand if that ‘no’ really means ‘not right now,’ but maybe in the future we can regroup.” Persistence, adaptability, and patience are often just as important as the original idea itself.

7

Focus on Impact and Authenticity A common thread among the interviewees was that their most meaningful pursuits were driven by purpose rather than financial gain alone. Dr. Sears encourages physicians to, “continually evolve, be curious, and be a relentless problem solver.” Similarly, Dr. Abraham reminds us that career diversification, “does not have to generate revenue. It just has to be yours.”

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or personal fulfillment, opportunities beyond the clinic can provide physicians with new avenues for growth while complementing their commitment to patient care.

COMMON CHALLENGES AND PITFALLS While career diversification can be professionally rewarding, the physicians interviewed consistently highlighted several challenges that aspiring physician entrepreneurs, educators, consultants, and advocates should anticipate (See infographic on page 13).

CONCLUSIONS The women featured here demonstrate that career diversification can take many forms, from coaching and consulting to sustainability advocacy, financial education, entrepreneurship, writing, volunteer and foundation work, and creative pursuits. Although their paths differ, they share a common goal: creating a meaningful impact while building careers that align with their values, interests, and evolving aspirations. Their experiences underscore an important lesson—career diversification is not about stepping away from medicine but expanding how physicians contribute to it. When pursued thoughtfully and authentically, opportunities beyond the clinic can foster professional fulfillment, broaden leadership influence, and support longterm career sustainability—all while deepening the sense of purpose that drew many of us to gastroenterology in the first place.

“Build credibility and excellence in your primary role first, then pursue opportunities that authentically align with your skills, interests, and long-term goals.” —Dr. Afzali

THE FELLOWS’ CORNER As trainees, pursuing side gigs can feel particularly challenging given the demands of GI fellowship. However, these opportunities can provide an important sense of purpose and creativity beyond clinical work. While these pursuits require intentionality and balance during fellowship, they can help trainees cultivate passions that enrich both personal and professional identity and may shape future career paths.

Adesola Oje, MD Staff Gastroenterologist, RWJ Barnabas Health Dr. Adesola Oje, a recent GI fellowship graduate of Vanderbilt University Medical Center, pursued multiple creative avenues outside traditional clinical training. During residency, she launched a podcast exploring her experience in medicine through the lens of her identities as a woman, a minority, an immigrant, and the first physician in her family. She reflected on, “how medicine was seeing me and how patients were seeing me.” She also completed a four-week rotation with the ABC News Medical Unit, gaining experience in medical journalism and learning how to translate complex scientific literature into accessible, public-facing information.

AUTHORS & EDITOR The following authors and editors all serve on ACG’s Women in GI Committee: Dr. Chitnavis is an Associate Professor in the Division of Gastroenterology and Hepatology at Atrium Health Wake Forest University School of Medicine in Charlotte, NC, where she specializes in inflammatory bowel disease. She also serves on the ACG Public Relations Committee. Dr. Tomar is an Assistant Professor in the Department of Gastroenterology & Hepatology at UT Health McGovern School of Medicine. She previously served as an Associate Editor for the ACG Case Reports Journal (2025–2026). Dr. Tomar was selected for the North American Conference of GI Fellows in 2025 and the ACG Center for Leadership, Ethics and Equity’s Emerging Leadership Program in 2026.

Dr. Herman is a GI fellow at Vanderbilt University Medical Center in Nashville, TN. She currently serves as a Social Media Ambassador for Evidence-Based GI.

Dr. Dunleavy, who edited this piece, practices at the Crohn’s and Colitis Center at Massachusetts General Hospital in Boston, MA. She also serves on the ACG Digital Communications & Publications Committee. In 2026, Dr. Dunleavy received an ACG Junior Faculty Development Grant.

Clive Miranda, DO, MSc GI Fellow Physician, Creighton University Dr. Clive Miranda, current GI fellow at Creighton University, built a social media platform centered on mentorship, networking, and personal branding. He was motivated by the belief that, “there are so many people out there who do not have the resources or personnel around them to guide them into making themselves the best version of what they can possibly be.” Through short-form media, he delivers educational content in formats that modern audiences can readily consume.

CONTRIBUTORS Dr. Afzali is James F. Heady Endowed Chair and Professor of Medicine; Interim Chair, Department of Internal Medicine, University of Cincinnati College of Medicine; Physician Operations Executive, UC Health System; Board Member, ACG Institute; Secretary General, World Gastroenterology Organisation; Founder & Managing Principal, Platform Consulting, LLC; Founder, CEO, The Clinical Executives; and Co-Founder, Board Member, Scrubs & Heels Foundation; Board Member, ASCEND. Dr. Afzali’s side gigs are Platform Consulting and The Clinical Executive. Dr. Akintade is a physician and wealth coach. Dr. Akintade’s side gig is MoneyFitMD (real estate investing).

Dr. Abraham is Professor of Medicine and Consultant, Division of Gastroenterology and Hepatology, Mayo Clinic. She is the ACG Institute Director and an ACG Trustee. Dr. Abraham’s side gig is Bounce Up Coaching, LLC (physician career and leadership coaching).

Dr. Ismail is Assistant Professor, Clinical Medicine, Director, Temple Endobariatrics Program Department of Medicine, Section of Gastroenterology, Lewis Katz School of Medicine at Temple University/Fox Chase Cancer Center. Dr. Ismail’s side gig is May’s Cookies (baking and community fundraising initiative). Dr. Luthra is a therapeutic endoscopist and physician entrepreneur in Tampa, FL. Her side gigs are personal finance expertise, medical device consulting, and creative writing. Dr. Luthra recently transitioned from employed gastroenterology practice to locums in order to facilitate her roles as a small business owner providing financial education for healthcare professionals and young women, medical device consulting, and creative writing. Dr. Sears is Clinical Professor of Medicine at UT Southwestern and Faculty at North Texas Veterans Administration. Her side gigs are executive coaching and women in medicine leadership consulting.

Dr. de Latour is Director of Endoscopy, Bellevue Hospital Center, and Associate Professor of Medicine, NYU Grossman School of Medicine. Dr. de Latour’s side gigs are healthcare sustainability leadership, medical media, and hosting SiriusXM Doctor Radio.

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Challenges of Screening for Colorectal Cancer in Women of Pakistan By Lubna Kamani, MD, FACG, FCPS, MRCP, FRCP & Pooja Ameet, MD, FCPS

COLORECTAL CANCER (CRC) IS ONE OF THE MOST COMMON MALIGNANCIES GLOBALLY, responsible for nearly two million new cases and over 930,000 deaths in 2020, with significant impacts in both high- and low-income regions. While effective screening significantly decreases incidence and mortality, Pakistan lacks organized CRC screening programs. Uptake remains extremely low— particularly among women—due to multifactorial barriers including limited awareness, sociocultural stigma, financial constraints, and a severe shortage of female gastroenterologists. Misconceptions that CRC predominantly affects men further reduce screening uptake. This article explores recent evidence on CRC in Pakistani women, outlines key challenges in screening, and proposes actionable strategies to improve early detection and outcomes.

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INTRODUCTION Female Population in Pakistan and Cancer Burden in Women Pakistan is the world’s fifth most populous country, and women constitute nearly half of the population, with estimates placing them at 48–49% of the total population.1 Globally, women experience a substantial cancer burden. Among all cancers, CRC ranks prominently, representing one of the top three cancers in women worldwide, after breast and lung cancers.2 Global Burden of Colorectal Cancer in Women In 2020, more than 1.9 million new CRC cases were reported worldwide alongside the aforementioned nearly 930,000 deaths. CRC accounts for approximately 10% of all global cancer diagnoses and 9.4% of cancer deaths. The burden of CRC is projected to increase to 3.2 million new cases and 1.6 million deaths by 2040.2,3,4 Effective screening, including colonoscopy and fecal testing, has led to dramatic

reductions in incidence and mortality in high-income countries but remains underutilized globally.5 CRC in Pakistan CRC incidence in Pakistan has been increasing, mirroring lifestyle shifts, dietary changes, and growing prevalence of risk factors. Although historically categorized as a “lowincidence” region, available hospital data and cancer registries suggest rising CRC cases, especially in urban centers, including early-onset disease affecting patients under 40 years.6 Pakistan’s National Cancer Registry Report (2015–2019) analyzed 269,707 cancer cases, among which CRC was the fifth most common cancer in females at 3.36%.7 Karachi Cancer Registry data shows an agestandardized incidence rate of 7.7 per 100,000 in females, underscoring that CRC is a significant cause of cancer burden in women locally.8

Screening programs in high-income countries have significantly reduced incidence and mortality; however, in many regions of South Asia, uptake remains extremely low.8 National screening guidelines and organized programs are absent, and documented CRC screening uptake among eligible individuals (≥50 years) is as low as 2.6%.6 Despite the large numberof cases, there is a very small population who possess knowledge about CRC and its screening. A landmark nationwide survey conducted across all provinces in Pakistan concluded that only 23.2% of participants claimed to know about CRC, while 31.5% had some awareness, and awareness was low across age, gender, and region, with younger, female, and Balochistan residents (the least-developed province) showing less knowledge.9

DISCUSSION Women in Pakistan make up approximately half of the population, yet they face disproportionate barriers in health access and preventive care. Literacy levels among women are substantially lower than men, especially in rural areas, impacting health literacy and awareness of non-communicable diseases such as CRC. National surveys show rural female literacy as low as 36%. Even though the rate of CRC is lower in females, there is a misconception that females are not affected. As there is a significant increasing trend of CRC incidence in females in recent years7 (Figure 1), there is also a trend noted in early-onset CRC8 (Figure 2). Figure 1: Colorectal Cancer Proportion by Gender in Pakistan

Figure 2: Early-Onset Colorectal Cancer in Pakistan

Chart shows percentage of patients <40 years.

Lack of Female Gastroenterologists Gender disparity within gastroenterology significantly affects women’s willingness to undergo CRC screening in culturally conservative environments. Several international workforce analyses show that only 19–25% of practicing gastroenterologists are female, with even fewer in leadership roles.10 Key factors for this decreased female representation include: work-life balance, maternity impact, long hours of on-call duties, pay promotion, and leadership gaps.11 A large survey conducted among trainee and attending physicians in South Asia concluded that gender bias, radiation hazards for fertility, pregnancy, and childcare were among the important factors for women not choosing gastroenterology.12 A Pakistan-specific report highlights an acute scarcity of female practitioners in gastroenterology, a situation that may discourage women from seeking invasive procedures like colonoscopy performed by male providers (Table 1).13 Healthcare experts note that many women avoid male clinicians for intimate procedures, leading to delays in diagnosis and referral. Local conferences on gastrointestinal health have highlighted the urgent need for more female endoscopy specialists to improve screening participation among women.

Table 1.

Female CRC proportion: 3.36 % of all female cancers Male CRC proportion: ~6.4 % of male cancers7

Location

Female GI Consultants (%)

Female GI Fellows (%)

Global

13–25

25–30

Pakistan

Very limited

Low representation

ECONOMIC AND INFRASTRUCTURE BARRIERS Pakistan’s healthcare system lacks national CRC screening policies, and organized screening programs such as organized FOBT/FIT testing at age thresholds are non-existent. Screening facilities and endoscopy units are limited and concentrated in major cities, leaving rural populations underserved. High out-of-pocket costs for colonoscopy and advanced diagnostics discourage participation, especially among low-income women.6

POOR AWARENESS AND HEALTH LITERACY Awareness of CRC risk factors, symptoms (e.g., blood in stool, altered bowel habits), and screening tools is limited among the general population in Pakistan. A survey in Karachi found that only approximately 44% of participants were aware of even one CRC screening method, and only 14.9% expressed willingness to undergo screening in the future.6 Fear of the procedure and lack of knowledge about its preventive value were major deterrents.14

CULTURAL AND PSYCHOLOGICAL BARRIERS Cultural norms around modesty and personal privacy play a significant role in women’s health behavior. In conservative communities, discussing bowel habits or cancer screening is socially uncomfortable. A large multicenter study in Pakistan concluded that most Muslims in Pakistan expressed a gender preference, and both female and male patients showed a preference for a same-gender endoscopist. Lack of education was associated with having a gender preference.14 Many women report embarrassment, fear of stigma, or anxiety about potential results, leading to reluctance in pursuing CRC screening. While embarrassment was not strongly reported in all studies, fear of abnormal results—a form of anticipatory anxiety—was significant among women. Physicians, critical in influencing health behavior, often do not proactively recommend CRC screening due to time constraints or

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competing priorities, though 72.3% of individuals expressed willingness to screen if advised by a doctor.6, 15

MISCONCEPTIONS: “CRC DOESN’T HAPPEN IN FEMALES” A pervasive hypothesis in some communities is that CRC is predominantly a male disease. Yet global epidemiology clearly shows women face almost comparable CRC risks and are a major affected demographic.2 This misconception reduces perceived susceptibility and discourages adherence to screening recommendations. Regional data also shows that females represent a significant share of CRC cases (~36– 45% in some registries), underlining that CRC is not gender exclusive.16

PHYSICIAN PRACTICES AND THERAPEUTIC ADVANCEMENTS Physicians play a critical role in CRC screening uptake. Evidence suggests that doctor recommendation greatly increases willingness to screen, yet many practitioners in Pakistan seldom discuss CRC screening with eligible patients due to limited training, time constraints, or competing clinical priorities.17 Additionally, therapeutic infrastructure and advanced treatment options remain less accessible outside tertiary centers, further reducing incentives to screen.

THE FUTURE OF GASTROENTEROLOGY IN PAKISTAN Recent literature from Pakistan and South Asia suggests that the landscape of gastroenterology is gradually changing, with a steady increase in the number of women entering training programs and advancing into academic and leadership positions. While gender disparities persist, these encouraging trends reflect growing opportunities for female physicians in the field. The expanding presence of women gastroenterologists is particularly important in Pakistan, where many female patients may feel more comfortable discussing sensitive gastrointestinal and hepatobiliary health concerns with female specialists. Greater female

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representation is expected to improve access to care, strengthen patientphysician communication, and enhance healthcare outcomes. Although challenges remain, there is now a clear light at the end of the tunnel, offering hope for a more inclusive workforce and better patient care in the years ahead.18,19

RECOMMENDATIONS

Prof. Kamani is Professor & Director, GI Residency Program, Liaquat National Hospital, Karachi, Pakistan; President, Pakistan GI and Liver Diseases Society; and Member, ACG Women in GI Committee. Dr. Kamani has earned an ACG SCOPY Award and a Healio Women Disruptor Award.

Dr. Ameet is Senior Registrar, Liaquat National Hospital, Karachi, Pakistan.

To overcome barriers and improve CRC outcomes among Pakistani women, the following strategies are essential: 1. National Screening Program • Establish government-supported CRC screening guidelines (e.g., FOBT/FIT at 45–50 years) • Integrate CRC screening with existing non-communicable disease programs. 2. Expand Female Workforce • Incentivize women to pursue gastroenterology and endoscopy training. • Provide safe and supportive clinical environments to retain female practitioners. 3. Awareness Campaigns • Launch culturally sensitive education targeting women through community health workers and media. • Partner with NGOs and women’s groups to reduce stigma. 4. Physician Training • Strengthen training for primary care physicians on CRC risk assessment and screening recommendations. 5. Affordable Access • Subsidize screening tests and expand mobile screening clinics in rural areas.

CONCLUSION CRC poses an increasing health burden for women in Pakistan, yet screening remains limited due to intertwined socioeconomic, cultural, and health system barriers. Addressing these challenges requires coordinated efforts spanning policy, workforce development, public education, and expanded healthcare access. Prioritizing women-centric strategies could significantly enhance early detection and reduce CRC morbidity and mortality across the country.

1. “Pakistan demographics 2021 - StatisticsTimes.com”. statisticstimes. com. Retrieved 2023-03-27. 2. Morgan E, Arnold M, Gini A, et al. Global burden of colorectal cancer in 2020 and 2040: incidence and mortality estimates from GLOBOCAN. Gut. 2023;72(2):338-344. doi:10.1136/gutjnl-2022-327736 3. Sung H, Ferlay J, Siegel RL, et al. Global Cancer Statistics 2020: GLOBOCAN Estimates of Incidence and Mortality Worldwide for 36 Cancers in 185 Countries. CA Cancer J Clin. 2021;71(3):209-249. doi:10.3322/caac.21660. 4. World Cancer Research Fund/American Institute for Cancer Research. Colorectal cancer statistics worldwide. Updated 2023. 5. Gupta S. Screening for Colorectal Cancer. Hematol Oncol Clin North Am. 2022;36(3):393-414. doi:10.1016/j.hoc.2022.02.001. 6. Hasan F, Mahmood Shah SM, Munaf M, et al. Barriers to Colorectal Cancer Screening in Pakistan. Cureus. 2017;9(7):e1477. Published 2017 Jul 16. doi:10.7759/cureus.1477. 7. Ikram A, Pervez S, Khadim MT, et al. National Cancer Registry of Pakistan: First Comprehensive Report of Cancer Statistics 2015-2019. J Coll Physicians Surg Pak. 2023;33(6):625-632. doi:10.29271/ jcpsp.2023.06.625. 8. Colorectal cancer survival and prognostic factors in Karachi, Pakistan. JCPSP. 2025. JCPSP. 9. Kamani L, Shaikh T, Yousaf MS, et al. Colorectal Cancer Screening Knowledge and Associated Willingness and Barriers to Screening in Nationwide Pakistan Cohort. Euroasian J Hepato-Gastroenterol 2025;15(2):156–163. 10. Devi J, Chan TT, Lui R, Ali RAR; Women in GI Focus Group, Emerging Leaders Committee, Asian Pacific Association of Gastroenterology. Fixing the leaky pipeline: gender imbalance in gastroenterology in the Asia-Pacific region. J Gastroenterol Hepatol.2023;38:2047-2049. doi:10.1111/jgh.16353. 11. Gahra, A.K., Mathur, S., Banerjee, R. et al. Challenges in the uptake of advanced endoscopy among women gastroenterologists: A survey. Indian J Gastroenterol 45, 312–314 (2026). https://doi.org/10.1007/ s12664-024-01599-x. 12. Mishra, S., Jena, A., Rabinowitz, L.G. et al. Perceptions regarding the impact of gender on training and career advancement among gastroenterologists in India and other South Asian countries. Indian J Gastroenterol 45, 268–277 (2026) https://doi.org/10.1007/s12664024-01523-3. 13. Gender preference of colorectal cancer patients: implications for screening. JCPSP. 2025. JCPSP. 14. Kamani L, Butt N, Taufiq F, de Paredes AG, Rajan E. Unique perspective of Muslim patients on gender preference for GI endoscopists: a multicenter survey. GastrointestEndosc. 2021;94(6):1110-1115. doi:10.1016/j.gie.2021.06.030. 15. Ahmed F. Barriers to colorectal cancer screening in the developing world: The view from Pakistan. World J GastrointestPharmacol Ther. 2013;4(4):83-85. doi:10.4292/wjgpt.v4.i4.83 16. Bhurgri Y, Khan T, Kayani N, et al. Incidence and current trends of colorectal malignancies in an unscreened, low risk Pakistan population. Asian Pac J Cancer Prev. 2011;12(3):703-708. 17. Mahmood FA, Ali AAM, Alsayyad AS, Alalwan NF, Ali MAM. Knowledge, attitude, practice, and perceived barriers of colorectal cancer screening among primary care physicians in the Kingdom of Bahrain. Int J Community Med Public Health. 2023;10(6):2015-2023. doi:10.18203/2394-6040.ijcmph20231676. 18. Kamani L, Hooft JEV. Rising Trend of Women in Gastroenterology: A Paradigm Shift. J Coll Physicians Surg Pak. 2021;31(2):121-122. doi:10.29271/jcpsp.2021.02.121. 19. Kedia D, Kamani L, Begum MR, Nagral A, Mahtab MA, Singh SP. Journey of Women in Gastroenterology in South Asian Countries: From Training to Leadership. Euroasian J Hepatogastroenterol. 2023;13(1):41-43. doi:10.5005/jp-journals-10018-1391.

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Rooted in Gratitude

GI IN THE FAMILY  THE MORE TIME YOU SPEND IN GI, THE MORE YOU DISCOVER “GI FAMILIES”—parents, spouses,

siblings, or children from the same family who have a shared passion—practicing GI. We introduce a new ACG Magazine series, GI in the Family, to highlight these families and gain insight from their journeys. To kick off this series, incoming ACG Digital Communications and Publications Committee Chair Dr. Katie Falloon met with the robust GI family of Dr. Muhammad Umar (father), Dr. Bushra Umar (mother), Dr. Mohammad Bilal (son), Dr. Javeria Khan (daughter-in-law), and Dr. Shifa Umar (daughter) to learn about their early lives, greatest values, and accomplishments.

Dr. Katie Falloon: My first question is, did you both decide to go into GI together or did one go first? Dr. Muhammad Umar: So, that’s [Dr. Bushra]. Dr. Bushra Umar: It was a shared journey of gastroenterology. MU: She was the first and I followed the footprint, I confess. At that time, we were assistant professors and she was working in another division of the same medical school. I was in another hospital affiliated with the same medical school. Because she was in charge there, she started a gastroenterology practice. A couple of years later, we were in one hospital, and we started doing procedures and gastroenterology in a department which was shared by both of us. We were doing a private clinic focusing on gastroenterology also at the same site. So, she rightly said this is a shared journey over decades. Dr. Shifa Umar: I remember you guys telling us about how you both got the first endoscopes.

BU: It started just by chance, initially, because when I was in the hospital there was an endoscope present which was not being used. Obviously, you have to use the instruments because they are very costly. I started using it and I started getting training in endoscopy, since the practice of GI endoscopy and gastroenterology was very new in Pakistan back then. There were a couple of foreigntrained physicians who could perform endoscopy and I started to learn from them. Since we had the equipment and there was a huge need in our patients, I started performing basic endoscopy. The interest developed and I liked it because it’s not only cognitive medicine we practice but procedural medicine. It improves your satisfaction because the outcome is very quick and then you can do a lot of things with that. Then I had the interest and, as we were both in the same medical school and we did residency in the same unit, we were very much acquainted to discuss the cases. He then also became interested in the field of gastroenterology. SU: First came the scope, then came the gastroenterologist.

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MU: Another reason was that we were internal medicine [physicians] and, in our school, in our region, there was no formal specialty of gastroenterology. We used to see patients with GI bleeding, or those had liver disease, so we thought that we should add a new specialty because there’s a lot of hepatitis C in Pakistan and hence many patients would present with variceal bleeding. This is how this journey started—by accident, but as well as thoughtful planning. Now, remember it is 1985 or 1986 and at that time in Pakistan, there were no

Dr. Mohammad Bilal: Basically, back then internal medicine was a specialty, and GI didn’t exist as a specialty. They sort of had to build that specialty, so the internists would do everything— cardiology, GI, until specialties developed. Gastroenterology only started really picking up in the last two to three decades. They both were in that initial group of people who helped develop that specialty in Pakistan along with other key leaders. That’s why it was a more chance decision than anything.

That is basically my duty being a mother, especially in our country. It was obviously a very difficult job because I had to do the government job in the morning and private practice in the evening.” —Dr. Bushra Umar

gastroenterology units, there was no gastroenterology training. We can’t say that we chose gastroenterology, but it obviously chose us and then we developed an interest and it became a passion. Not a profession, but a passion. SU: Katie, fun fact, my mom actually matched into a fellowship in Japan for cardiology.

KF: Did you really? And then pivoted? Wow! That is a fun fact. MU: That was the time that we had not seen gastroenterology in Pakistan. It was an evolving healthcare system as well as training system in Pakistan. After decades, there was a definite specialty established by the College of Physicians and Surgeons of Pakistan and people started taking it as a specialty, but initially it was a journey shared with other patients, other specialties.

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KF: What was it like, being at the forefront of that and working to build a whole new specialty in your country? MU: That was very exciting and satisfying, particularly in the perspective of patients. When the patients are [treated] by internists, as Professor Bushra already said, procedures were not so developed. Intervention was not there. We saw so many people who were not properly managed by the general physician. This was how it was in our mind that we had to develop the specialty to save so many human lives by simple intervention. It is very satisfying when you do interventions and stop bleeding, and so much mortality and morbidity goes down. Then came the second thing, how do we learn gastroenterology when there is no proper training? There

were no structured training programs. We planned to learn it from the UK and the first unit we visited was King’s College London because that was a renowned center for liver transplant as well as other interventions. I remember Bilal and Shifa were too little and they were looked after by a hospital coordinator there in King’s College Hospital for a good nine hours. SU: I remember as a three- to five-yearold kid, this was a new specialty, GI in Pakistan. Our parents were always trying to go traveling abroad, going to China, Europe, and the USA attending meetings— UEG, EASL, DDW, ACG—to develop expertise. MU: We all were first in King’s College University Hospital to learn gastroenterology, followed by Massachusetts General Hospital. We were introduced to Dr. [William] Brugge, who was a pioneer in doing EUS; then Dr. Peter Kelsey, an excellent, amazing person in gastroenterology and interventional endoscopy; and Dr. David Carr-Locke, who was at that time at Brigham & Women’s Hospital. This is how we had international exposure. Several of these individuals came to Pakistan, to our center, and this was how we developed international collaboration, especially Dr. Carr-Locke who was crucial in helping build GI endoscopy services in Pakistan. BU: We had a very exciting and memorable journey of starting gastroenterology as pioneers in Pakistan, not only in our center, but we were part of training in different centers and internationally. Now we could say at least in our region, all types of procedures had been introduced from our center and we taught and trained the people to do all those procedures. It’s very satisfying that we have a big part in the training of young gastroenterologists.

KF: Absolutely. What about the training of these two gastroenterologists here? What was it like working full-time and raising two children? BU: That is basically my duty being a mother, especially in our country. It was obviously a very difficult job because I had to do the government job in the morning and private practice in the evening. And

There are two things that I learned from my parents. One, gratitude is the right attitude. You have to be grateful of everything that you have. You should not forget your roots. The second thing is to always pay it forward, whether it’s in the form of supporting other people, mentoring, teaching, educating, training, or patient care.” —Dr. Shifa Umar

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with that were two kids just two years apart. We had some home help. My mother-in-law was with us, and it was a blessing that she was with us. She was taking care of them in the evening and other times. They were very nice children. I used to make them get up early in the morning because I had to go to the hospital in time and I had to drop them off at the school. That was the best time, when they were in the car, because then they couldn’t go

have chosen this specialty not by our pressure. But it was always my ambition in my heart that they should be highly educated, highly trained, and they should be trained by world leaders. And God was very kind to us that he has fulfilled all our desires. They have been trained in the best centers of the USA and are doing great. MU: We are blessed that this training didn’t [only] spread into regional

[in Pakistan] but they have training in the best centers and come back home. Bilal was recently back in Pakistan at the Holy Family Hospital at our Center of Liver and Digestive Diseases, and it was a great blessing that he did the most difficult procedure just two months [ago] back at our international meeting of GI. It is not only the national horizon, it is a personal pursuit also, for excellence in gastroenterology.

I used to make them get up early in the morning because I had to go to the hospital in time and I had to drop them off at the school. That was the best time, when they were in the car, because then they couldn’t go anywhere else! They couldn’t run away. I could talk about anything with them and they had to listen. That was the best time of giving them moral and ethical training.” —Dr. Bushra Umar anywhere else! They couldn’t run away. I could talk about anything with them and they had to listen. That was the best time of giving them moral and ethical training. They themselves became very independent and realized that their parents are very busy and they’re working all the time. It’s God’s gift that they have been on a right path, and they

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and national training, but it spread to the family training also! We are proud parents that they followed in the same footsteps. What we [did] with a lot of difficulty, I’m sure they have easy access to, the international centers and many of the mentors in the UK and USA. We feel very proud of both of them. They are not living

KF: You should be very proud, yes. BU: My duty was to have a close watch on them. Are they doing good? Are they doing the right thing? It was not only watching over both of them, but the mother is going to look after them and train them.

The biggest challenge is that we’re all family but we’re also all very passionate and ambitious. Oftentimes, even discussing something normal can turn into a heated, evidence-based discussion or a hot debate. We just have to remind ourselves that when we’re together we’re a family.” —Dr. Mohammad Bilal SU: From my early memories, yes, our mom used to always drive us to school. That was very important to her. We had family support like my mom mentioned. We had home help as well; she had delegated tasks to a person who would cook, a person who would do the cleaning. That’s how she was doing it. That help is necessary. MB: We would be at the school even before the school opened. They used to have someone who would stand in front of the school and we were the first two people there because our mom had to get to work. She would drop us at school an hour before anyone else got to school. Then after 40 minutes, other kids would start rolling in. It was good bonding time for me and Shifa. [Dr. Bushra] was so committed to her job and still making sure that she wanted to drop us off herself. That was a full-on commitment.

KF: Bilal and Shifa, growing up, did you both know early on that you wanted to go into medicine or gastroenterology or did you come to it over time? MB: I don’t think we were sure about gastroenterology, but yes, medicine was always near and dear because both of our parents were, and still are, working. My mom’s 71, dad’s touching 70, and they’re still working 16- to

18-hour days. The only people we knew were doctors, so that’s the only profession we really knew growing up. There were always those teenage years when I wanted to be an astronaut, a pilot, or something like that. But medicine was something that was always very near and dear to our hearts. They had always taught us the value of service and that’s all we knew, honestly—how to take care of patients. GI was more of a gradual shift. They never had the pressure or influence that we needed to do GI but I’m sure somewhere in the subconscious that influenced it and the inspiration was there. I tried to fall in love with cardiology or critical care, but I couldn’t. Eventually, all roads just led to GI. SU: We were so integrated in their lives, even though they were both full-time working parents. We used to come to their practice with them. I would sometimes sit in a separate room while my mom was seeing patients and do my homework. When they would go for all these meetings, EASL, UEG, those were like family vacations. They would take us, and that’s what we grew up around. They used to do a lot of welfare medical camps in their younger days, and Bilal and I were a big part of it. I think that really helped build early on in this experience that we’re part of something big. I think that was a real influence for me, personally. If you ever get a chance to read my elementary school essays, I wanted to be a doctor.

KF: You both touched on this a little bit already, but what are some of the biggest lessons that you took away from your parents as you were growing up, either directly or by watching them? MB: They both came from very humble backgrounds. They were both from families that were not privileged at all. They had to work really hard to create opportunities for us to be able to get the best education. I think the thing that we learned was basically work ethic—working really hard and remembering their backgrounds, even though our parents were physicians. We had better access to resources, books, school, TV, the internet early on in our lives, which are luxuries back home in Pakistan, but I think it was having both of them value hard work and remind us to always stay humble. We would go back to visit our dad’s village, and we would do free volunteer camps. Even as kids, they would make us partake in that. That value was always to remember hard work, be humble, and the biggest thing my mom was really passionate about was education. When they would go abroad, technology and healthcare resources that were available there were not yet available back home. While they worked really hard to bring a lot of those things back home, they always

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aspired that we would get the best possible education there is—that inspired our journeys to move to the US. SU: If I had to summarize it, there are two things that I learned from my parents. One, gratitude is the right attitude. You have to be grateful of everything that you have. You should not forget your roots. The second thing is to always pay it forward, whether it’s in the form of supporting other people, mentoring, teaching, educating, training, or patient care. Pay it forward.

KF: That’s wonderful. What are some of the best parts of having multiple gastroenterologists in the family? What are some challenges associated with that? MB: I would say the biggest challenge is that we’re all family but we’re also all very passionate and ambitious. Oftentimes, even discussing something normal can turn into a heated, evidence-based discussion or a hot debate. We just have to remind ourselves that when we’re together we’re a family and not just GI doctors who are very passionate about how they would do things. The fun part is that we can all relate with what each other does—understand our lives, our timings, our schedules, and our challenges. If we have a complication, we can share with each other and that’s been really nice.

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As the youngest gastroenterologist in the group, the biggest challenge has been to make the world see me as an individual. It’s been a goal for me, personally, to make my own place in GI.”

MU: Let me add here that Javeria was another addition to this whole journey. We had the pleasure to work with her in our GI department and she is excellent.

—Dr. Shifa Umar

KF: Bilal mentioned that [Dr. M. Umar] was the first ACG Governor for Pakistan. I would love to hear more about that.

SU: Our parents have done a good job of making sure that we also separate [the GI discussions] from our lives and be like a normal family. For me personally, as the youngest gastroenterologist in the group, the biggest challenge has been to make the world see me as an individual. It’s been a goal for me, personally, to make my own place in GI, and I’m grateful to have amazing parents and Bilal and Javeria, but I also want to be seen as my own person.

KF: I think you’ve done an amazing job of that. MB: You know, my dad was actually the first ACG Governor for Pakistan. He loves sharing that story and how he advocated with the ACG leaders back in the day and how that transpired into him founding that chapter. That was sort of our first introduction to ACG, hearing at home that there’s an organization that he’s a Governor for. It seems like a lifetime ago. SU: I just received an email—I’ve been a member for 10 years, but I feel like I’ve been a member of the organization for like 25 years.

KF: Did you meet the parents first and then Bilal, or the other way around? JK: Actually, I was mentored by them. SU: It was love at first endoscopy.

MU: Thank you, yes. That was a very exciting time when we were first working at the national level and then at the international level. I met the person who brought us into ACG, Dr. Eamonn Quigley, almost two decades ago. We both were speakers in Egypt and this journey started. MB: [My parents] found out that, at that point, a lot of countries had ACG Governors, including India, and India is a neighboring country for Pakistan. So, they were like, ‘What about Pakistan?’ and then he worked with Professor Eamonn Quigley. My dad was on the ACG International Relations Committee and Maria Susano, Deputy Director of ACG, knew him. When Dr. Quigley mentioned he was a President or President-Elect, [my parents] mentioned that they wanted to become part of [ACG] more and more. So, they approved a chapter for Pakistan, and he was the founding ACG Governor for Pakistan. Also, my mom was one of the first female gastroenterologists in Pakistan to perform an ERCP.

KF: Since birth, maybe! Bilal, how did you and Javeria meet? You’re kind of a power couple in GI.

KF: Now both children are also in leadership and ACG, not just GI!

Dr. Javeria Khan: Actually, we met at a GI conference back in Pakistan, that was our first ever meeting. It was a live course, and I asked him some very tough questions— which he intentionally skipped and later explained to me—but that was the fun part.

MB: They don’t come as often to the ACG Annual Meeting because for the last decade my dad has been dean of a medical school and vice chancellor of a university and they focus a lot on medical education. But we have pictures at our home from them being at almost every ACG meeting for a

Now, remember it is 1985 or 1986 and at that time in Pakistan, there were no gastroenterology units, there was no gastroenterology training. We can’t say that we chose gastroenterology, but it obviously chose us and then we developed an interest and it became a passion. Not a profession, but a passion.” —Dr. Muhammad Umar

decade, and my dad received the ACG Freshman Governor’s Award. He also got one of the highest honors that the Government of Pakistan bestows on a civilian, and he’s a past president of the Pakistan GI Society and Pakistan Hepatology Society.

KF: Shifa, growing up with a female role model like your mom, did that influence how you approached GI and the ways it can still be male dominated in some capacity? SU: Like Bilal mentioned, my mom is one of the first female gastroenterologists in Pakistan to perform ERCP. She’s kind of a pioneer in interventional gastroenterology for women in Pakistan. I think it’s notable that she practices in the northern part of Pakistan. In our culture there’s a big stigma about exposing yourself in front of men. Women from Afghanistan would travel all the way to Rawalpindi (Pakistan)—that’s

where my mom practices—to get their procedures done, specifically colonoscopies from a female gastroenterologist. My mom currently serves as Professor, she retired as a Professor of Medicine. Contrary to what people may think, when I came to the US, I was a little surprised to read about how hard it is for women to be recognized and reach the position of Professor because at home, my mom was Professor of Medicine. She was mom and she was Professor of Medicine. They talk about breaking the glass ceiling, and it was long done at her home. There was no glass ceiling, only sky is the limit. So, yes, I’m lucky and blessed to have a role model like her.

KF: Is there anything else you wanted to mention or tell me about? MB: We’re very fortunate. I was the first one to come to the US, and we didn’t have any family here. We knew a couple of people that my dad knew and that was it. Shifa, Javeria, and I are very fortunate that we’ve been so blessed at every place that we’ve trained and worked. Now, through our training programs, institutions we've worked at, and through ACG and other GI organizations, people like you and many others who’ve become a part of our friends, our circle, our families, have never made us feel like we’re outsiders or that we’re foreigners in this country. We’re very grateful for that experience because, as an immigrant, it’s hard sometimes—a new culture, you leave everything behind and start working.

MU: I am really thankful to all the people who have joined this journey with my kids in different institutions. I am really thankful to all of them because they have never made us feel that our kids are away from us. They have taken care of them like family. I am really thankful to all those people.

KF: You all are so wonderful and are such an inspiration; it’s really my privilege. Thank you all. Katie A. Falloon, MD Staff Gastroenterologist Cleveland Clinic Cleveland, OH

Muhammad Umar, MBBS, FCPS, FRCP, FACG Vice Chancellor Professor of Medicine Rawalpindi Medical University Rawalpindi, Punjab, Pakistan

Bushra Umar, MBBS, FCPS, FRCP, FACG Professor of Medicine (Emeritus) Consultant Gastroenterologist & Hepatologist Center for Liver & Digestive Disease, Holy Family Hospital Rawalpindi, Punjab, Pakistan

Mohammad Bilal, MD, FACG Associate Professor of Medicine Director of Endoscopy Section Lead, Interventional Endoscopy University of Colorado Anschutz Medical Campus Aurora, CO

Javeria Khan, MBBS, FCPS Consultant Gastroenterologist & Hepatologist

Shifa Umar, MD Assistant Professor of Medicine Interventional Gastroenterologist Director of Pancreas Center of Excellence Michael E DeBakey VA Medical Center Baylor College of Medicine Houston, TX

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TRAINEE HUB

Explaining Normal Results to Symptomatic Patients: Practical Communication Lessons for Trainees Caring for Patients with Disorders of Gut-Brain Interaction By Prachi Mann, MD, & Sanjeevani Tomar, MD

ONE OF THE MOST CHALLENGING CONVERSATIONS FOR TRAINEES is not explaining abnormal findings but explaining normal test results to patients who remain highly symptomatic. For patients with disorders of gutbrain interaction (DGBI), formerly known as functional bowel disorders, being told that, “everything looks normal” is often met not with relief, but with confusion, frustration, and disbelief. DGBIs account for a substantial proportion of outpatient gastroenterology practice, and patients frequently undergo extensive diagnostic evaluation only to learn that no structural pathology has been identified. Although diagnostically reassuring,

normal results may fail to reflect patients’ lived experiences of pain, altered bowel habits, and impaired quality of life. In this setting, the clinical challenge shifts from diagnostic reasoning to effective communication, reassurance, and longitudinal care. Learning to navigate this conversation is an essential yet underemphasized clinical skill, with important implications for patient outcomes, healthcare utilization, and the therapeutic relationship. A recent commentary has highlighted gaps in gastroenterology training related to the care

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of patients with DGBIs, noting that many trainees feel insufficiently prepared to manage these conditions in the outpatient setting.¹ A national survey of U.S. gastroenterology fellows found that about 20% experienced frustration or burnout when caring for patients with DGBIs, and nearly 40% of senior fellows preferred not to see these patients in clinic. Confidence in management was also limited—approximately one half were uncomfortable initiating a neuromodulator, and one quarter were uncomfortable titrating one.2 This work emphasizes the need for more formalized DGBI education, increased clinical exposure, and deliberate training in empathetic, patient-centered communication.¹ Within this broader emphasis on evolving training needs, one practical skill that warrants focused attention is how trainees communicate normal diagnostic results to patients who remain highly symptomatic. Here, we outline practical steps for trainees to navigate this challenge (Box 1). It is important to set expectations early. Preparing patients for the possibility of normal results before testing reduces anxiety, aligns expectations, and fosters trust when results are discussed. Framing diagnostic testing as a means to exclude serious disease, rather than to identify a single abnormality, clarifies the purpose of the evaluation and helps patients understand that normal findings remain clinically meaningful. This reframes normal results as a transition rather than an endpoint, shifting the narrative from “nothing was found” to “something important was learned” and thereby fostering continued engagement. When explaining results, language matters (Box 2). Phrases such as, “Everything is normal” or “Nothing is wrong,” though intended to reassure, can unintentionally minimize symptoms or imply the absence of an underlying physiological basis. Instead, normal findings should be used to support a positive diagnosis of a DGBI. The diagnosis should be made confidently using standardized criteria and communicated with clear, unequivocal language that validates the patient’s suffering. Qualified phrasing, such as “We think you have irritable bowel syndrome” rather than “You have irritable bowel syndrome,”

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signals uncertainty and undermines validation of the patient’s experience. Explanations should be structured to briefly review what has been ruled out, define functional disorders, and clarify why symptoms persist despite normal testing. Simple analogies, such as describing visceral hypersensitivity as “a volume knob turned up” on otherwise normal gut signals, further enhance understanding while keeping explanations brief, intentional, and patient centered. Empathy and validation are essential when explaining normal results to symptomatic patients. Acknowledging suffering affirms symptom legitimacy and strengthens the therapeutic relationship, particularly for patients with DGBIs who often report feeling dismissed in prior healthcare encounters. Simple statements such as, “Your symptoms are real and common” reinforce validation, and an

empathic stance encourages patients to disclose underlying stressors or fears that may amplify symptoms. Trainees should pause to assess understanding, asking, “Does this explanation make sense to you?” or “What concerns do you still have?,” as these questions can uncover misunderstandings or unspoken fears. Survey data show that many patients with IBS believe their condition could progress to serious disease, including colitis (43%) or cancer (21%), highlighting the importance of explicitly addressing these misconceptions.3 Equally important is pairing explanation with a clear management plan, including dietary, pharmacologic, neuromodulatory, and behavioral interventions. When discussing neuromodulators, trainees may find it helpful to explain that these medications are often prescribed at

BOX 1. Practical Tips for Trainees on Communicating Normal Test Results to Symptomatic Patients Before Testing • Normalize the possibility of normal results early • Explain that many GI symptoms reflect disordered gut-brain function and not structural damage • Introduce the concept of a positive diagnostic approach based on symptom-based criteria and limited targeted testing, rather than a diagnosis of exclusion. • Clarify the goal of testing is to rule out serious conditions When Reviewing Results • Avoid phrases like “Nothing is wrong.” or “All your tests are normal.” • State what the tests ruled out, then explain what they suggest • Use simple analogies (e.g., visceral hypersensitivity as a “Volume knob turned up”) During the Conversation • Explicitly validate symptoms (e.g., “Your symptoms are real and common.”) • Ask a check-in question e.g. “What concerns do you have?” • Pause and allow silence to give patients time to process After Explaining Results • Present a clear, stepwise treatment plan • Emphasize that disorders of gut–brain interaction are treatable • Arrange follow-up to reinforce that care is ongoing For Trainee Development • Observe attending physicians model these conversations • Ask for feedback on your counseling style • Reflect on encounters that felt uncomfortable or unsatisfying

lower doses for DGBI to regulate gut-brain signaling and reduce pain sensitivity, rather than to treat depression. Using the term neuromodulator and providing this explanation may help reduce stigma and improve acceptance of treatment recommendations. Importantly, presenting a clear, stepwise treatment plan reinforces that symptoms are treatable and that follow-up will be meaningful rather than perfunctory. Providing patients with educational leaflets or written explanations in the after-visit summary offers an additional medium for patients to review and process information outside the clinical encounter. Emphasizing that symptom improvement is gradual and requires longitudinal care sets realistic expectations and reinforces that normal results are not the endpoint of care. Regular follow-up to reassess symptoms and adjust treatment is essential, as no single intervention is likely to be sufficient. A multidisciplinary approach involving gastroenterology, behavioral health, and nutrition is particularly valuable in this setting, as it prioritizes function and quality of life over complete symptom resolution. Developing proficiency in these conversations requires intentional training and reflection. Equally important is recognizing the value of supervised modeling. Observing attending physicians navigate these conversations provides trainees with practical examples of effective communication in complex encounters. Effective communication extends beyond the content of explanations and includes skills such as active listening and nonverbal communication—eye contact, posture, facial expression, and attentiveness—both of which influence trust, understanding, and perception of clinician empathy.4,5 Similarly, active listening techniques, such as allowing uninterrupted patient narratives, reflecting concerns, and checking understanding, improve engagement and uncover misconceptions.6 Importantly, these communication behaviors are observable, teachable, and responsive to structured training, reinforcing the need for intentional instruction rather than relying on informal role modeling alone.7 Fellows and residents should actively seek feedback on their verbal and nonverbal communication skills, observe difficult

BOX 2. What Trainees Should Say When Explaining Normal Results Name the Diagnosis Clearly “Based on your symptoms and testing, you have irritable bowel syndrome.” Avoid Minimizing Language Instead of “Everything is normal,” say, “Your tests ruled out serious disease, which helps us understand what is causing your symptoms.” Explain the Biology Simply “Your symptoms come from how the gut functions, not from damage we can see on tests.” Use a Relatable Analogy “It’s like the nerves in your gut have the volume turned up, so normal signals feel painful.” Validate Symptoms Explicitly “Your symptoms are real, common, and medically recognized.” Frame Normal Results as Informative “Normal tests tell us what this condition is and what it is not, and help guide treatment.” Reassure About Next Steps “Now that we understand what’s happening, we can focus on managing your symptoms and improving your quality of life.”

counseling encounters, and reflect on interactions that felt uncomfortable. Communicating normal results is a core clinical skill and a therapeutic intervention in its own right. Excellence in gastroenterology is defined not only by diagnostic precision but also by the ability to explain findings in a way that supports patients and builds trust. Developing this skill during training prepares clinicians for the realities of practice and improves care for patients who are often misunderstood.

1. Sahu S, Bharadwaj HR, Khan S, Ali H, Dahiya DS. From Endoscopy to Empathy: Redefining Gastroenterology Training for the Gut-Brain Era. ACG Case Rep J. 2026;13(1):e01957. doi:10.14309/crj.01957. 2. Luo Y, Dixon RE, Shah BJ, Keefer LA. Gastroenterology trainees' attitudes and knowledge towards patients with disorders of gut-brain interaction. Neurogastroenterol Motil. 2022;34(11):e14410. doi:10.1111/ nmo.14410 3. Halpert A, Dalton CB, Palsson O, et al. What patients know about irritable bowel syndrome (IBS) and what they would like to know. National Survey on Patient Educational Needs in IBS and development and validation of the Patient Educational Needs Questionnaire (PEQ). Am J Gastroenterol. 2007;102(9):1972-1982. doi:10.1111/j.15720241.2007.01254.x. 4. Mast MS. On the importance of nonverbal communication in the physician–patient interaction. Patient Educ Couns. 2007;67(3):315-318. doi:10.1016/j.pec.2007.03.005. 5. Street RL Jr, Makoul G, Arora NK, Epstein RM. How does communication heal? Pathways linking clinician–patient communication to health outcomes. Patient Educ Couns. 2009;74(3):295-301. doi:10.1016/j.pec.2008.11.015. 6. Beckman HB, Frankel RM. The effect of physician behavior on the collection of data. Ann Intern Med. 1984;101(5):692-696. doi:10.7326/0003-4819-101-5-692. 7. Berkhof M, van Rijssen HJ, Schellart AJM, Anema JR, van der Beek AJ. Effective training strategies for teaching communication skills to physicians: an overview of systematic reviews. Patient Educ Couns. 2011;84(2):152-162. doi:10.1016/j.pec.2010.06.010.

Dr. Mann is an internal medicine resident and Chief Resident at AdventHealth Orlando with a passion for gastroenterology. Her interests include clinical outcomes research and health equity, with a particular focus on improving access, early diagnosis, and continuity of care for patients with gastrointestinal malignancies and inflammatory bowel disease. Dr. Tomar is an Assistant Professor in the Department of Gastroenterology & Hepatology at UT Health McGovern School of Medicine. She is actively involved with the ACG Women in GI Committee and previously served as an Associate Editor for the ACG Case Reports Journal (2025–2026). She was selected for the North American Conference of GI Fellows in 2025 and the ACG Center for Leadership, Ethics and Equity (LE&E Center) Emerging Leadership Program in 2026.

Trainee Hub | 31

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GETTING IT RIGHT

How to Write a CV By Abraham Z. Cheloff, MD, MS; Karan Yagnik, MBBS; Vonda Reeves, MD, MBA, FACG & Saurabh Chawla, MD, FACG

Download templates for a cover letter, academic CV, and private practice CV.

COVER LETTER A cover letter is a personalized document sent along with the curriculum vitae (CV) or resume that introduces the applicant, explains interest in the role, and demonstrates why their background aligns with the employer’s needs. It doesn’t list qualifications but answers some critical questions like ‘who’ and ‘why.’ Historically, cover letters originated as formal business correspondence in the pre-digital hiring era, when applications were mailed physically. Later they became standard in professional recruitment, often expected alongside a CV. Today, cover letters are no longer universally mandatory, but they are far from obsolete. In the era

of electronic applications, they may not be required but offer a strategic advantage when utilized appropriately. Applicants not only introduce themselves and explain their interest in the role, but can further use this opportunity to establish a connection with the hiring team by highlighting prior meetings, mutual connections, or other pertinent information that may not be readily available in the CV or resume. With AI-assisted recruiting environments on the rise—where resumes and CVs are screened rapidly—a concise and targeted cover letter can humanize an application and signal intent. It is not compulsory but can be used as a selective tool of influence. Applicants should treat it as an

Getting It Right | 33

// GETTING IT RIGHT opportunity to strengthen—rather than duplicate—the CV.

DECISION POINT: RESUME OR CV An important yet often overlooked step in the application process is determining whether to submit a resume or a full CV. Although the terms are sometimes used interchangeably in clinical settings, they serve distinct purposes and convey different levels of detail. Selecting the appropriate format can meaningfully influence how your training, scholarly work, and clinical competencies are perceived. A resume is a concise (one- to twopage), targeted document that emphasizes relevant experiences. It highlights your most pertinent qualifications, work experience, and accomplishments aligned specifically with the position sought. For GI fellows pursuing roles in private practice, non-academic hospitals, administrative positions, or industry settings, a resume is often the more appropriate format. These environments prioritize efficiency and clarity and tend to focus on procedural competencies, clinical productivity, and leadership potential. A resume allows you to foreground these dimensions without overwhelming the reviewer with exhaustive scholarly detail. Conversely, a full CV is expected in academic medicine, where hiring decisions weigh heavily on research productivity, teaching experience, service contributions, and scholarly trajectory. Most large academic institutions have a template for an academic CV which is standardized and has sections including grant funding, peer-reviewed publications, abstract presentations, invited talks, teaching activities, and committee roles—in addition to for enlisting education and training— prior work experience, board certifications, quality initiatives, and ongoing learning activities such as courses taken after initial employment. Frequently, the candidates may be asked to further subdivide the relevant sections into their institutional, regional, and national/international scope. Because academic reviewers examine candidates holistically, a CV provides the breadth necessary to contextualize your interests and potential for long-term scholarly contribution.

STRUCTURING YOUR RESUME OR CV A physician’s resume or CV should be concise, organized, and easy to review. Clean formatting, consistent fonts, clear headings,

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and reverse chronological order are essential. The document should be submitted as a PDF with a professional file name. The opening section should include full name, degree, city/state, phone number, professional email address, and, optionally a LinkedIn profile. Some resumes and almost all CVs are followed by a brief professional summary of three to four lines that introduce the candidate’s key skills, achievements, and experiences as a written elevator pitch. Additional sections should include Education and Training as well as Board Certification and Licensure. For those applying to procedurally heavy practices, an additional section on Clinical and Procedural Experience, highlighting volumes of general and advanced procedures where applicable, may provide evidence of readiness for independent practice, though not all practices look for this information. Depending on your experience, other sections may include Research and Publications, Quality Improvement Initiatives, Teaching Experience, Leadership Roles, Professional Memberships, and Awards. It may be easy to forget, but membership to the American College of Gastroenterology (ACG), American Gastroenterological Association (AGA), American Association for the Study of Liver Diseases (AASLD), and/or American Society for Gastrointestinal Endoscopy (ASGE) reflects professional engagement and can be listed on your resume or CV. Proficiency in additional languages may be included if you routinely communicate in that language and are sufficiently fluent to use the language professionally. Equally important is knowing what to exclude. A physician CV should not include photographs, age, marital status, irrelevant hobbies, excessive medical school detail, or exaggerated claims. Dense paragraphs and outdated accomplishments can distract from stronger qualifications. Similarly, details on immigration status shouldn’t be included, though you may need to discuss separately with interested employers.

TAILORING YOUR APPLICATION TO THE POSITION A CV or resume is not a static document but rather should be tailored to the specific role, institution, and clinical or academic environment to which you are applying. By strategically customizing how your experiences are framed and prioritized, you can demonstrate intent and understanding of the position to which you are applying.

The first step in tailoring involves analyzing the position description and institutional culture. Academic divisions may emphasize a research focus, culture, or subspecialty expertise. Private practices may value procedural efficiency, highvolume clinical experience, and patientcentered outcomes. Mapping your experiences to these priorities allows you to craft a document that resonates with the readers’ expectations. Next, selectively elevate the most relevant work to the top of your document. For example, a candidate applying for an academic hepatology position should emphasize publications, abstracts, and quality-improvement initiatives related to liver disease, even if they represent a subset of broader scholarly activity. Conversely, applicants to private practice settings may highlight endoscopic proficiency or productivity metrics. This selective emphasis does not require altering the content of your CV but rather strategically ordering and titling to guide the reviewer’s attention. Employers value candidates who can articulate how their training experiences prepare them to contribute immediately while also demonstrating capacity for long-term growth within the institution. By being thoughtful about the emphasis, structure, and language of your CV or resume, you communicate not only your qualifications but also your strategic insight into the demands of the position.

Authors Dr. Cheloff is a GI and hepatology fellow at NYU Langone Health in New York, NY, who serves on the ACG Professionalism Committee. His research focuses on CRC prevention, AI applications in GI, endoscopy quality improvement, and innovations in clinical workflow and medical education. Dr. Yagnik practices at Rutgers Health/ Monmouth Medical Center in Long Branch, NJ, and is a member of the ACG Professionalism Committee.

Dr. Reeves practices at Digestive Health Clinic in Ocean Springs, MS, and is an ACG Trustee.

Dr. Chawla practices at Emory University School of Medicine and Emory St Joseph’s Hospital in Atlanta, GA. He is the incoming ACG Governor for Georgia and serves on the ACG Training Committee.

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Getting It Right | 35

// GETTING IT RIGHT

1

Five Things

Every Trainee and Early Career Attending Should Know About Finances By Brian D. Ginnebaugh, MD, & David J. Hass, MD, FACG

S

INCE GRADUATION FROM FELLOWSHIP, I have worked with many trainees and have found that as a group we need to continue to improve financial education across gastroenterology. Why? Financial education is unfortunately sparse, at best, throughout medical education. As doctors or clinicians, we start our careers much later than most professions, are often burdened by a large amount of highinterest student loan debt, and are taught little throughout our training to save money, invest, pay back debt, and create a financially successful future for ourselves. As clinicians, we need to realize that financial education and financial planning are not only essential, but can make us better doctors, parents, and spouses. When our finances are organized, discussed, and planned, we are better able to focus on our patients, our families, and ourselves.

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FINANCES ARE PART OF OUR JOB As physicians and clinicians, our training has consumed most of our 20s and, for gastroenterology, much of our 30s as well. From the moment we decided to enter the medical field, our focus has been on taking care of our patients. While doing so, we paid an opportunity cost of not being employed during most of those years, not saving for retirement, and most likely accruing debt. Over 75% of medical school graduates leave medical school with student loan debt averaging $200K-250K. If that debt continues to accumulate interest (e.g., at 6%) over the next six to eight years of gastroenterology training, a gastroenterologist can start their career easily a half million dollars in debt from education loans alone. This number can rise substantially if training is at a private institution or abroad. We are also taught to not talk about money amongst our peers, as this can come off as avaricious or greedy, which further increases our lack of financial education. Lastly, we experience delayed gratification throughout training, often watching our non-medical colleagues buy homes or new cars and/or start a family well before we do. This can often lead to pent-up frustration and lifestyle inflation (explosion) soon after graduation, further increasing our spending. If we are not careful, debt can continue to grow after we start our careers at an excessive pace and cripple our ability to save. This feeling can lead to personal worries, family strife, and hinder our ability to focus on our job. To set ourselves up for success, we should start planning early in our career.

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SAVE 20% OF YOUR INCOME This is referred to as “paying yourself first.” As previously mentioned, we must be proactive to save for our retirement. Retirement options are diverse; however, most employers usually offer one to two plans. In the United States, these are commonly referred to as 401k, 403b, 401a, and 457b plans. Each plan has a unique set of contribution limits set by the government; however, the overall concept remains the same: money is taken (typically pre-tax) from your paycheck by your employer and put into investments which grow over time. Let’s briefly discuss investment options. In the simplest form, we are talking about stocks and bonds. While there are certainly other options (commodities, metals, cryptocurrency, and real estate), the beginning investor should understand these basics: a stock is partial ownership in a company. If the company does well, the value of the stock will rise (share price) and pay out dividends to those that own the stock. These investments tend to pay off more in the long run but can be risky (i.e., if the company performs poorly, the stock will go down). Stock returns over time tend to pay off higher (historically 8-10% annually, but this can certainly vary). Bonds on the other hand are a loan to a company. By buying (holding) a bond, you are loaning money to a company that needs it. That company will have to pay it back over a certain time with interest. These are less risky and, as a result, they have historically paid lower rates (3-6%).

Inside of our retirement plan, we are usually selecting groups of stocks or bonds called mutual funds. These funds comprise large numbers of stocks (companies) or bonds. One common mutual fund is the S&P 500, which means the purchaser will own a small part of each of the largest 500 companies in the United States. Owning many companies rather than one makes mutual funds much less risky than picking individual stocks (not usually advised). Thankfully, most retirement plans have simplified investments into target date funds. This is a mutual fund comprised of stocks and bonds that over time automatically changes from a riskier (more stock) ownership to less risky (more bond ownership) closer to retirement. For example, if you purchase a target date fund of 2050, you will own many stocks and bonds over time that will decrease your investment risk as you get closer to retirement. This money can also save on your taxes during the current year (traditional) or can be withdrawn tax free in retirement (Roth). Perhaps the best part is that most employers offer a “match” of your investment into the retirement plan, which increases your salary and retirement savings!

3

OPEN A ROTH IRA A Roth Individual Retirement Arrangement (IRA) is a separate retirement account opened independent of your employer. It works like this: online, you select a brokerage firm of your choosing (e.g., Charles Schwab, Vanguard, Fidelity, etc.) where you will put in post-tax dollars (i.e., money sitting in a bank account that was already taxed by your employer) up to an IRS contribution limit. For 2026, the contribution limit is $7,500 if you are under 50 and $8,600 if you are over. A spouse is also able to contribute, even if they do not have reported income. For the more-advanced investor, it is important to note that if you are making over $153,000 filing single or $242,000 filing jointly, the IRS does not allow you to directly contribute the full amount to the IRA. Instead, you will have to do a “backdoor Roth” IRA. Please refer to the many articles on the internet that walk you through this process. My favorite resource is the White Coat Investor website. Again, the investment options inside of a Roth IRA include mutual funds, exchange-traded funds (ETFs), and target date funds. These earnings grow tax free over time and are withdrawn tax free in retirement. Furthermore, with Roth IRAs there is no required minimal distribution at any age, so wealth can accumulate tax free and even be passed to children. Putting this together, if a married attending is making $200,000 annually, they should aim to save approximately $40,000 toward retirement. The contributions can go into employer plans and IRAs (i.e., $24,500 into a 403b and $15,000 combined into IRAs for them and their spouse).

4

PROTECT AGAINST DISABILITY AND DEATH Not only are we higher earners, but we have a significantly high income potential throughout our career. If a disability prevents us from doing our job, this would be crippling for our future earnings. To protect against this, we should obtain specialty-specific disability insurance that would pay a monthly income in this event. Although expensive, we must protect our

future earning potential. There are several companies that offer personal disability plans in the United States, and the plans must be purchased through a broker that can provide quotes from several companies. Many residency and fellowships offer resources and access to a broker. Several things to note: • The younger you are when you purchase, the more you will save. • Individual plans cover us in the event we change jobs, and the income generated is not taxed (unlike a group policy). • Make sure to have certain riders, including residual/ partial disability, cost-of-living adjustment (goes up with inflation), and a future purchase option (add more to the plan as income goes up over time). • This is expensive, especially in your early career. Lastly, if you have people that depend on your income (spouse, children, etc.), then you should have term (not whole or universal) life insurance. Most should have between $2 million to $5 million.

5

CONTINUE YOUR FINANCIAL EDUCATION Our final point in today’s article for trainees and earlycareer clinicians is to treat financial education like you do continuous medical education (CME). We should continue to learn about finances often throughout our career. As clinicians, we cannot be financially successful if we focus solely on medicine. Instead, a few of my preferred resources have included books such as The White Coat Investor by Jim Dahle, MD; Bogleheads’ Guide to Investing by Lindauer, LeBeeuf, and Larimore; A Random Walk Down Wall Street by Burton Malkiel; and William Berinstein’s If You Can, which is free and available at etf.com/docs/IfYouCan.pdf. There are also countless free resources available such as podcasts, physician finance websites, and videos. In a future article, we plan to cover topics such as paying back student loans, avoiding lifestyle inflation, the burden of owning a home (and when renting may be preferred), as well as the importance of a written financial plan. Lastly, I am not a financial planner or accountant, nor do I have professional training in physician finance. Please remember that investing comes with risk and can cause potential loss of investment. I hope this article has motivated you to start planning and investing for retirement today. Please reach out to us with any questions!

Dr. Ginnebaugh is a Senior Staff Gastroenterologist at Henry Ford Health in Detroit, MI, and a member of the ACG Training Committee. He has a clinical focus in neurogastroenterology and motility and a teaching focus in physician finance.

Dr. Hass is Clinical Professor of Medicine, Yale University School of Medicine, and practices at PACT Gastroenterology Center in Hamden, CT. Dr. Hass is an ACG Trustee.

Getting It Right | 37

// GETTING IT RIGHT

opinion. Physicians are not widgets. They have different needs attenuated to their different subspecialties and locations. They, more than the service-like leader with an MBA, know what they need to be successful. It is not rocket science, heavy lifting, or hazardous for a physician enterprise to have slightly different employment contract terms for different physicians.

How to Keep a Physician Employed at Your CompanY By Ann Bittinger, Esq. I read the May 2026 American Medical Association study, published in The Permanente Journal, with little surprise. It found that physicians are leaving the practice of medicine entirely at a much younger age than in the past. Their reasons for leaving have also changed. I was in my 10th year of my health law practice representing physicians when the 2008 study was published, stating that the average age for leaving medicine was 57. Now—as I’m in my 28th year negotiating physician contracts—the average age is 48.1 years. And now, the reasons for changing have shifted to what they call the “hassle factor” of administrative work, as well as overwhelming workplace stress. After almost three decades of practice, I’ve witnessed this change, as my clients come to me for advice on how to leave practice. My anecdotal experience supports the study’s findings: physicians are not leaving because they can no longer stand

38 | GI.ORG/ACG-MAGAZINE

treating patients. In my experience, the factors boil down to one fundamental issue: lack of control of their work. It’s not my job to convince them to stay. But it is my job to help them obtain and maintain control. How? Their physician employment agreement. I believe that if physicians wholeheartedly negotiated their employment offers and agreements and if employers seized the opportunity during the contract negotiation process to listen to physicians about what they want from the job and how they can be successful, fewer physicians would leave the practice. The Association of American Medical Colleges stated that the United States faces a severe and growing physician shortage, with national deficits projected to reach between 86,000 and 141,000 in the next 10 years. To the employers who say to physicians, “This is our template contract and we can’t change a word of it,” please understand that in taking this stance you are contributing to this shortage, in my

THE NEGOTIATION PROCESS The physician recruitment-toemployment process starts with in-person interviews with colleagues in the physician’s department or office and maybe with a physician executive. An offer is then made, usually consisting of a non-binding letter of intent or offer letter with very basic terms: salary, signing bonus, professional liability insurance, and a general description of department, location, and benefits. The physician is asked to sign the letter, expressing intent to agree to the terms. There’s some psychological weight to signing the letter, even if it is not binding. I analogize it to a car salesman giving a car shopper the keys and encouraging the shopper to take the car home, show it to the spouse, and see how it fits in the garage. In your mind, you bought the car. In your mind, you’re going to this employer—even before you have seen the contract. That is not good. Often the person administering the offer letter is a recruiter who was not present during the interviews and who is not a physician. It can be a little difficult for the recruiter to answer the physician’s questions. The recruiter often acts as an intermediary between the recruited physician and the employer. This makes communication about the things that really matter to the physician difficult. It’s not just about money. I often start my physician client initial background calls (which I call my “What Lights You Up and What Keeps You Up About This Offer” calls) with “Tell me what they have told you a typical day, week, and month would be like at this job.” You might be surprised that many clients give a long

pause before trying to remember what was said. The employer talked about a lot of things, but not about a typical day. I feel like this question evokes more than any other what the physician thinks is important. What lights the physician up? What keeps the physician up? Why don’t the employers ask these questions? Why don’t the offer letters and contracts answer it? A typical contract is 20 pages long, with very little addressing a day in the clinical life of that physician. The offer letter doesn’t describe a typical day, week, and month, and the employment agreement typically doesn’t either. Try to find a surgery schedule or call frequency cap in your employment agreement? Reserved block time for administrative work every Friday afternoon? Reserved OR space in set intervals? How about the appointment template—are new patient visits 30 minutes or 15?). A dedicated physician assistant assigned to you? It’s probably not in your contract. Why? My thought is that it is because employer operations are not planned with as much thought as to what physicians need as they should be. The hospital or surgery center—which may or may not be in the same corporate entity as the physician’s employer—is not physiciancentric. Sure, there may be physician executives, but until facilities become more physician-centric, physicians will continue to retire earlier. They become more physician-centric by listening to physicians and keeping their promises to them by way of employment agreement provisions. THE OBJECTION “We can’t” is what I typically hear that employers say when physicians ask for things that are important to them: • We can’t manage a call schedule that protects you with only eight calls a month. • We can’t manage staffing to ensure that a physician assistant will be assigned to you. • We can’t manage our scheduling and volume to give you every Friday for administrative time. • We can’t control the OR and assure you that you will have eight half days per week in the OR.

I don’t think physician and employer needs are diametrically opposed. Indeed, I believe they can be synergized, if the employers would curate forums to ascertain and entertain physician needs before implementing operational structures and processes. I’m not talking about town hall meetings with all physicians in a specialty, in which a physician leader gives a PowerPoint presentation. I’m talking about a Chief Medical Officer—or how about a physician or attorney who is a Chief Recruitment Officer—listening to physicians before they become employed and then committing to them with tailored physician employment contract terms. IT’S ABOUT CONTROL Keep in mind that a vast majority of physicians now work for employers that are not owned by physicians. It’s about the control. It’s about a physician-centric employment agreement. Listening will make physicians feel valued for their contributions, provide financial certainty, support autonomy in making choices that align with their mission and values, promote engagement with their team and the organization, and ensure fairness and equal opportunity. Enterprises need skilled individuals to liaise between the clinical, administrative, legal, and financial silos at the employer to reasonably tailor contracts to reflect physician needs. From my limited perspective as a physician contract attorney, if systems would employ contract specialists—perhaps they are lawyers or paralegals—to add to contracts the things that physicians care about, the physician early-retirement trend might start to lessen. The flip side is that physicians must not take, “We can’t change this” for an answer. I advise my physician clients to proceed in a contract negotiation with this golden rule: if the employer won’t put something in a contract that you reasonably ask for, the employer doesn’t feel strongly enough about it or you to put it in writing.

FALSE PROMISES “Trust me to make this work,” physicians often hear. “It’s just that our lawyers won’t let us put that in the contract.” Could the legal department be used as a scapegoat, when really the clinical leader just doesn’t want their verbal assurance to be binding and legally enforceable? You may have heard of the phrase, “If they wanted to, they would.” If an organization wants to keep a promise, it would put it in the contract. If they don’t put it in the contract, it’s likely because they don’t want to, not because they can’t. So many times in my career I have worked with highly sought after physician clients who get their contracts tailored when others working for the same system do not. Everything is negotiable, if you have leverage and the other side has a need to negotiate. PHYSICIAN SHORTAGE Yet—amid the dire physician shortage trend—health systems and physician groups are still saying that their contracts are not negotiable. My prediction is that there will be a direct correlation between the downfall of those systems and their stance in refusing to negotiate contracts. I see it, anecdotally, in the microcosm of my practice. Some health systems’ contracts are like a revolving door in my practice. I can often predict which physician clients will be back to me in a year or two, unhappy in their jobs and asking for help with exit plans, based on what I see in their contracts before they sign and the lack of specificity around things that are important to the physician. If the employer says no to reasonably requested contract changes, walk away. I have also seen health systems negotiate fewer changes once they stop their expansion mode. The more they need physicians, the more they negotiate and the more physicianfriendly their employment agreements are. It’s simple economics, to a degree—supply and demand. But some of that is being ignored. Without negating the physician

Getting It Right | 39

// GETTING IT RIGHT

shortage data, I might say that healthcare doesn’t have a physician shortage as much as it has a physician value shortage. Physicians may be replaceable, but they’re a very expensive replacement. VALUE AND VENUE FOR INTERACTION To value something is to understand its worth and to assess or assign that value to the ways you interact with it. The interaction is the problem. And the employment agreement is the venue to have that interaction. I am not suggesting bespoke employment agreements for everyone. But I suggest that if an employer’s contract does not tailor itself to these four questions, that employer likely has or will have a very expensive physician retention and satisfaction problem (which, of course, isn’t just an isolated expense): • Where? Where will the physician work? What street address is the clinic? At what facilities will the physicians have privileges? So many clients of mine get burnt out because they are shifted around to various workplaces, impacting commutes, teamwork, referrals, and risk management. • When? For proceduralists, when will they be in procedures or surgeries, versus when will they be in clinic? It’s often helpful to either break down the work week into 10 half-day time blocks or to put a ceiling or cap on different categories. To me, it is disingenuous to hold a surgeon to a wRVU productivity standard but not guarantee that surgeon time in the OR to reach that standard. • How Much? If there is one dealbreaker that I emphasize to clients, it is the unilateral right of the employer to alter a physician’s pay. Some health systems’ contracts state that right very clearly. Others are coyer, with a two-year guarantee and then something ambiguous about relying on a “Compensation Plan” that isn’t attached but is whatever the employer says it is at that point in time. It is simply unrealistic to expect to have a good relationship with physicians if the physicians have no idea what their compensation formula will be. No other industry that I know utilizes contracts that allow one side to unilaterally

40 | GI.ORG/ACG-MAGAZINE

change the payment terms. Why is this so common for physicians? • Call? How many days will the physician be on call each month, on average? Certainly flexibility is required with different numbers of days per month, with vacations and other leave, but can’t an “average” number be stated in almost every employment agreement? What’s the scope of call? Is it for the hospital only? For all of the employer’s six locations in the metro area? For the physician’s office site only? If you are thinking about leaving the practice of medicine or your job, don’t mistake futility with leverage. Ask for these things to make your transition easier or to get more leverage for future negotiations: • Termination. Shorten the notice period for termination without cause. I’m seeing these periods lengthen up to 180 days, which I find ridiculous. Once you find a new job, the possibility of that employer holding the position open for you for six months is low. With these longer notice periods, the employers are simply making it more difficult for you to leave. They are decreasing your leverage. If the employer knows your position could be empty in 90 days, you have more leverage to request changes in your contract. • Location. Make the contract require your consent to change your office location. Having the ability to object to something that the employer wants increases your leverage. This also helps limit your postemployment non-compete area. • Non-Compete. If you are in a state that allows a post-employment non-compete, try to negotiate some exceptions or carveouts. You’d be surprised how many employers that insist on uniform non-compete as to time and geographic area will allow certain exceptions, like allowing physicians to work for private practices but not for hospital-owned systems, or carving out a geographic area or type of

practice. Or perhaps a non-compete should not apply if the employee is let go in the first few years of employment. • Tail Insurance. Tail insurance in gastroenterology can be a $50,000+ expense to the physician, just for a gastroenterologist to leave a job. Try to negotiate exceptions to that, like if a certain thing happens, then you don’t have to pay for tail insurance, or perhaps you pay a lower percentage of the premium. Perhaps the longer you stay, the greater the percentage of the insurance premium the employer will pay. Another tactic is to get your next employer to transition your signing bonus into a tail insurance payment, so you don’t have to pay out of pocket. Anything you can do to terminate your contract easier and faster gives you leverage in negotiating other terms in your contract. Employers do not want physicians to resign. According to CI Health Group, the average direct cost to recruit, interview, and onboard a new physician ranges from $60,000 to $80,000, though total expenses can exceed six figures when accounting for incentive packages and lost revenue. If a health system loses 100 physicians per year, at $80,000 per recruited physician to fill those slots, that totals $8 million. Hiring a physician contract attorney or a physician who is a Chief Recruiting and Retention Officer to listen to physicians as they are being hired and to address their “day-in-thelife” basic needs in a contract would cost a fraction of that amount. It’s more than a value proposition. It’s a measure of how an organization values physicians.

Ann Bittinger, Esq., is a physician contract attorney who has contributed Law Mind articles to ACG Magazine for nearly a decade. She can be reached at ann@bittingerlaw.com.

s t g h ACG GUIDELINE i s t h l g h i ACG GUIDELINE g H ACG GUIDELINE s ACG GUIDELINE Highlight Diagnosis & Management of Adenomatous Diagnosis and Management of Diverticulitis Diagnosis and Management of Colorectal Polyposis Syndromes Diagnosis and Management of Diverticulitis Diverticulitis Concept and Content: EricaMD Duh, MD | Reviewer: Andrew M. Moon, MPH, FACGGautam & Anne Mankaney, F. Peery, MD, MSCR Concept & Content: Carl Kay, & Andrew M. Moon, MD, MPH, FACGMD, | Reviewers: MD & Carol A. Burke, MD, MACG Concept and Content: Erica Duh, MD | Reviewer: Andrew M. Moon, MD, MPH, FACG & Anne F. Peery, MD, MSCR Concept and Content: Erica Duh, MD | Reviewer: Andrew M. Moon, MD, MPH, FACG & Anne F. Peery, MD, MSCR

Disease Informative Disease Phenotypes Disease Genetic Phenotypes Phenotypes Testing Results and Management Pearls of Pearls of Management Pearls of Management Management

Negative Germline Test Endoscopic and Surgical Management

Uncomplicated Diverticulitis Chronic or Smoldering Diverticulitis Complicated Diverticulitis TRIGGERS FOR GERMLINE TESTING in individuals with adenomatous colorectal polyposis Uncomplicated Diverticulitis Chronic or Smoldering Diverticulitis Complicated Diverticulitis Localized inflammation of Inflammation persists for Diverticulitis wks to months. Diverticular Complicated inflammation Diverticulitis accompanied by Uncomplicated Diverticulitis Chronicthat orFAP Smoldering ≥20 cumulative adenomas Extracolonic features (Desmoid, Bilateral/multifocal 10–19 cumulative adenomas Localized inflammation of Inflammation that persists for wks to months. Diverticular inflammation accompanied by and colonic diverticula w/o abscess, Often symptomatically improve partially or phlegmon, abscess, or perforation; strictures CHRPE, Hepatoblastoma, CMTC thyroid) Diverticular inflammation[Conditional [Strong / Low] of / Low] Localized inflammation Inflammation that persists for wks to months. accompanied by and colonic diverticula w/oorabscess, Often symptomatically improve partially phlegmon, strictures perforation, stricture, fistula completely, but relapse[Strong after abx stoppedor fistulas mayabscess, developor asperforation; delayed complication / Low] colonic diverticula w/oorabscess, Often symptomatically phlegmon, strictures and perforation, stricture, fistula completely, but relapse improve after abxpartially stoppedor fistulas mayabscess, developor asperforation; delayed complication perforation, stricture, or fistula completely, but relapse after abx stopped fistulas may develop as delayed complication MULTIGENE PANEL TESTING (MGPT) Diagnosis Natural History Elective Surgery Diagnosis Natural History Elective Surgery Germline MGPT is recommended with the following minimum set of genes (APC, AXIN2, BMPR1A, EPCAM, GREM1, MLH1, MSH2, MSH3, MSH6, Diagnosis Natural History is highest Elective Surgery Recurrent that • Clinical alone is • Risk of complicated MUTYH,evaluation NTHL1, POLD1, POLE, PMS2, PTEN, SMAD4, anddiverticulitis STK11); results of MGPT and•other familyuncomplicated history guide diverticulitis patient management. • Recurrent uncomplicated diverticulitis thatfor • Clinical evaluation alone is • Risk is highest impacts quality of life = referral to surgery often inaccurate. with of thecomplicated first episodediverticulitis and decreases with • Recurrent uncomplicated diverticulitis thatfor • Clinical evaluation alone is • Risk of is highest impacts quality of life = referral to surgery often inaccurate. with thecomplicated first episodediverticulitis and decreases with discussion recurrences. FAP AFAP MAP PPAP Other Rare Syndromes • CT at first presentation to impacts quality of life = referral to surgery for often inaccurate. with the first episode and decreases with discussion recurrences. • CT at first presentation to out • Elective resection lowers, but does not confirm diverticulitis, rule • Recurrence discussion recurrences.risk: APC APC MUTYH (biallelic) POLD1 / POLE NTHL1 | AXIN2 | MLH3 | MBD4 | MSH3 • CT at first presentation to out • Elective resection lowers, confirm diverticulitis, • Recurrence eliminate, recurrence risk. but does not alternative dx, assess rule severity,  22% afterrisk: a first episode • Elective resection lowers, but does not confirm diverticulitis, out • Recurrence risk: eliminate, recurrence risk. alternative dx, assess rule severity,  22% after a first episode and localize disease 55% second after a Age 18–20 | q1–3 yr Age 10–15 | q1–3assess yr Age 18–20 | q1–3 yrafter Age 25–30eliminate, | q1–3 yrrecurrence Age 25–30* | q1–3 yr risk. alternative  22% aa first episode and localizedx, disease severity,  55% after second  High after 3+ episodes and localize disease  55% after a second High after 3+ episodes Age 20–25 Age 20–25  Age 30–35 Age 25–30 No routine  High after 3+ episodes Colonoscopy Antibiotics Yes · By age 18 Colonoscopy Yes · By age 18 No routine Multisystem Multisystem Antibiotics Antibiotics • After complicatedColonoscopy diverticulitis—colonoscopy Acute uncomplicated diverticulitis can Abx advised for acute uncomplicated • After complicated diverticulitis—colonoscopy Acute uncomplicated diverticulitis canConsult Abx advised for acute uncomplicated recommended to rule out missedmanifestations cancer or requiring be managed without patients diverticulitis patients who are:  Many syndromes carry extraintestinal specialized screeningabx andinsurveillance. guideline forin syndrome-specific recommendations. • After complicated diverticulitis—colonoscopy Acute uncomplicated diverticulitis can Abx advised in forpatients acute uncomplicated recommended to rule out missed be managed withoutdxabx patients diverticulitis who are: premalignant *lesions. who are: Colonoscopy start agecancer or 5 yrsorbefore youngest FDR polyposis / 10inyrs before FDR CRC whichever is earlier. 1.diagnosis, Immunocompromised recommended to rule out missed cancer or be managed without abx in patients diverticulitis in patients who are: premalignant lesions. who are: 1. 1. Immunocompetent 2. Immunocompromised Frail • After uncomplicated premalignant lesions.diverticulitis—colonoscopy who are: 1. Immunocompromised 1. Immunocompetent 2. 2. Hemodynamically stable 3.Frail Medically • After uncomplicated diverticulitis—colonoscopy NEGATIVE GPV ON MGPT = COLONIC POLYPOSIS OF UNCERTAIN ETIOLOGY (CPUE)* Considercomplex APC mosaicism testing ONLY if alarm symptoms are present or patient 1. Immunocompetent 2. Frail • After uncomplicated diverticulitis—colonoscopy 2. Hemodynamically stable 3. Medically complex 3. Outpatient 4. Unable tomanage tolerate according oral intake to FAP ONLY symptoms are present or patient CPUE to cumulative number2.ofHemodynamically colorectal & duodenal adenomas; If APC mosaic, notManage upiftoalarm date withaccording colorectal cancer screening. stable 3. Medically complex ONLY are present or patient 3. Outpatient 4. Unable to tolerate oral intake 4. Able to tolerate oral intake 5. Worsening clinically not upiftoalarm date symptoms with colorectal cancer screening. *Also referred to as Multiple Colorectal Adenomas (MCRA), Idiopathic Adenomatous Polyposis (IAP) oral intake 3. 4. to tolerate not up to date with colorectal cancer screening. 4. Outpatient Able to tolerate oral intake disease 5. Worsening clinically without SIRS or complicated 6. Unable Have markedly elevated inflammatory 4. Able to tolerate oral intake disease 5. clinically SIRS orfrail complicated 6. Worsening Have markedly elevated inflammatory 5. without Not medically markers or higher-risk imaging features Gastric Polyposis – Report Polyposis Features Duodenal – Report Spigelman Features without SIRS or complicated disease Polyposis 6. Have markedly elevated inflammatory * 5. or higher-risk imaging features 6. Not Ablemedically to follow frail up reliably 7. markers Lack reliable follow-up/support 5. Not medically frail markers or higher-risk imaging features Finding Management* Feature 1 ptreliable follow-up/support 2 pts 3 pts 6. Able to follow up reliably 7. Lack  Alarm symptoms include: 6. Able to follow up reliably 7. Lack reliable follow-up/support # Polyps 1–4 5–20 >20 Number, size, and location of FGPs Resect if ≥10 mm 1. Alarm symptoms include: Unintentional weight loss

 Alarm symptoms include: 1. weight loss  Options for abx for acute uncomplicated diverticulitis (for 4–7 days): 2. Unintentional Change in bowel habits Size (mm) 1–4 5–10 >10 Resect  Options forwith: abx for acute uncomplicated diverticulitis (fortherapy 4–7 days): 3. Iron-deficiency anemia Monotherapy Combination with: 2. Change in bowel habits  Options for abx for acute uncomplicated diverticulitis (for 4–7 days): 3. Iron-deficiency anemia Bloody stools White High 4. risk features: mucosal patch (WMP), polypoid mounds, Monotherapy with: Combination therapy Histology TA TVA • Amoxicillin-clavulanic acid • Metronidazole 500 with: mg PO q 8 hrs PLUS VA 3. Iron-deficiency anemia Monotherapy Combination therapy with: 4. Persistent Bloody stools 5. abdominal pain 875 mg/125with: mg PO q 12 hrs • Amoxicillin-clavulanic acid • Metronidazole 500 mg PO q 8 hrs PLUS carpeting 1. Trimethoprim-sulfamethoxazole 4. Bloody stools Amoxicillin-clavulanic acid • Metronidazole mg— PO qq 8 hrs PLUS 5. Persistent abdominal pain mg/125 mg q Dysplasia 12 hrs (1 DS tablet, 500 160/800 mg) 12 hrs or HGD •• 875 Moxifloxacin 400PO mg PO daily 1. LGD Trimethoprim-sulfamethoxazole 5. Persistent abdominal pain 875 mg/125 mg PO q 12 hrs Resect; Consider 1. (1 Trimethoprim-sulfamethoxazole DS tablet, 160/800 • Moxifloxacin 400 mg PO daily 2. Ciprofloxacin 500 mgmg) PO q 12 12 hrs hrs or or WMP, polypoid mounds (1 DS tablet, 160/800 mg) q 12 hrs or • Moxifloxacin PO daily high-risk center 400 mg Spigelman Stage: 0 (0 pt);2. pts); II (5–6 (7–8 IV (9–12 pts) Ciprofloxacin 500pts); mgqIII PO qhrs 12pts); hrs or 3.I (1–4 Levofloxacin 500 mg 24 2. Ciprofloxacin 500 mg PO q 12 hrs or 3. Levofloxacin 500 mg qfor 24 Stage hrs IV Interval based on Stage; consider duodenectomy Multi-focal HGD or adenocarcinoma Gastrectomy 3. Levofloxacin 500 mg q 24 hrs

Number, size, and location of gastric adenomas 1. Unintentional weight loss 2. Change in bowel habits

Prevention of Prevention of Diverticulitis Prevention of Diverticulitis Diverticulitis

 Upper GIaSurveillance: determined polyposis, is more advanced. *See guideline for details. 1. Recommend high-fiber, Interval plant-forward dietby severity of gastric or duodenal 5. Weight losswhichever if overweight/obese 1. a high-fiber, plant-forward 5. if overweight/obese 2. Recommend Do not routinely avoid nuts, seeds, corn, diet or popcorn 6. Weight Regular loss physical activity 1. Recommend a high-fiber, plant-forward 5. Weight loss if overweight/obese 2. notregular routinely avoiduse nuts, seeds, corn, diet or popcorn 6. physical activity 3. Do Avoid NSAID when possible 7. Regular Encourage smoking cessation Colorectal Polyposis 2. Do notregular routinely avoiduse nuts, seeds, corn, or popcorn 6. physical activity 3. 7. Regular Encourage smoking cessation 4. Avoid Moderation ofNSAID alcohol usewhen possible 3. regular use Encourage smoking cessationburden, symptoms associated with Colonoscopy Resect adenomas ≥10possible mm, ≥4 mm if feasible. Multi-focal HGD,7.endoscopically unmanageable 4. Avoid Moderation ofNSAID alcohol usewhen 4. Moderationpolyposis, of alcoholoruse CRC warrant surgical referral.

Abx = = antibiotics antibiotics Dx = = diagnosis diagnosis PO = = by by mouth/orally mouth/orally SIRS = = Systemic Systemic inflammatory inflammatory response response syndrome syndrome Abx Dx PO SIRS CRC colorectal Hrs = hours w/o without CRC == = antibiotics colorectal cancer cancer Surgery Hrs=approach =diagnosis hours q= =polyp every w/o = ==risk, without Abx Dx =every by mouth/orally SIRS Systemic response syndrome Surgical individualized based on rectalqPO burden, colon polyp burden, desmoid andinflammatory patient preferences— DS = double strength NSAIDS = nonsteroidal anti-inflammatory drugs Wks = weeks DS = double strength NSAIDS = nonsteroidal anti-inflammatory drugs Wks = weeks Abx Dx ==diagnosis PO by mouth/orally SIRS Systemic inflammatory response syndrome CRC == antibiotics colorectal cancer Hrsguideline. hours q = =every w/o = without Consult CRC colorectal cancer Hrs = hours q = every w/o DS = =double strength NSAIDS = nonsteroidal anti-inflammatory drugs Wks==without weeks DS = double strength = nonsteroidal anti-inflammatory Wks = weeks Anne F. Peery, MD, MSCR; Lisa L. Strate, MD, MPH;NSAIDS Neil Stollman, MD; Gautam Mankaney,drugs MD; Joy W. Chang, MD, MS; Shilpa Grover, MD, MPH AFAPThe = attenuated FDR = first-degree relative LGD low-grade TA = tubular adenoma American Journal of Gastroenterology Anne F. Peery,FAP MD, MSCR; Lisa L. Strate, MD,| DOI: MPH;10.14309/ajg.0000000000004047 Neil Stollman, MD; Gautam Mankaney, MD; Joy W.=Chang, MD,dysplasia MS; Shilpa Grover, MD, MPH CHRPE congenital hypertrophy of retinal pigment FGP = fundic gland polyp MAP MUTYH-associated polyposis TVA = tubulovillous adenoma Anne F. Peery,Journal MD, MSCR; Lisa L. Strate, MD,|epithelium MPH;10.14309/ajg.0000000000004047 Neil Stollman, MD; Gautam Mankaney, MD; Joy W. =Chang, MD, MS; Shilpa Grover, MD, MPH The= American of Gastroenterology DOI: CMTCThe = cribriform-morular carcinoma GPV = germline pathogenic variant PPAP = polymerase proofreading-associated polyposis VA = villous adenoma American Journalthyroid of Gastroenterology | DOI: 10.14309/ajg.0000000000004047  FAP = familial adenomatous polyposis HGD = high-grade dysplasia SS = Spigelman stage  READ THE GUIDELINE: bit.ly/acg-diverticulitis-26  READ THE GUIDELINE: bit.ly/acg-diverticulitis-26  READ THE GUIDELINE: bit.ly/acg-diverticulitis-26 Gautam Mankaney, MD; Gregory E. Idos, MD; Elena M. Stoffel, MD, MPH; Jennifer M. Weiss, MD; Shailja Shah, MD, MPH; Emad Qayed, MD, MPH, FACG; Mary Pat Harnegie, MLIS; Carol A. Burke, MD, MACG | The American Journal of Gastroenterology | DOI: 10.14309/ajg.0000000000004105

 READ THE GUIDELINE: bit.ly/acg-polyposis-syndromes-26

ACG GUIDELINE Highlighsts ACG GUIDELINE Highlight Diagnosis & Management of Adenomatous Diagnosis & Management of Adenomatous Colorectal Polyposis Syndromes Colorectal Polyposis Syndromes Concept & Content: Carl Kay, MD & Andrew M. Moon, MD, MPH, FACG | Reviewers: Gautam Mankaney, MD & Carol A. Burke, MD, MACG Concept & Content: Carl Kay, MD & Andrew M. Moon, MD, MPH, FACG | Reviewers: Gautam Mankaney, MD & Carol A. Burke, MD, MACG

Informative Genetic Informative Genetic Testing Testing Results and Results and Management Management

TRIGGERS FOR GERMLINE TESTING in individuals with adenomatous colorectal polyposis TRIGGERS FOR GERMLINE TESTING in individuals with adenomatous colorectal polyposis ≥20 cumulative adenomas Extracolonic FAP features (Desmoid, Bilateral/multifocal 10–19 cumulative adenomas CHRPE, Hepatoblastoma, CMTC thyroid) [Strong / Low] [Conditional / Low] ≥20 cumulative adenomas Extracolonic FAP features (Desmoid, Bilateral/multifocal 10–19 cumulative adenomas [Strong / Low] CHRPE, Hepatoblastoma, CMTC thyroid) [Strong / Low]

[Strong / Low]

[Conditional / Low]

MULTIGENE PANEL TESTING (MGPT) MULTIGENE PANEL TESTING (MGPT) Germline MGPT is recommended with the following minimum set of genes (APC, AXIN2, BMPR1A, EPCAM, GREM1, MLH1, MSH2, MSH3, MSH6, Germline MGPT is recommended thePTEN, following minimum set of genes (APC, AXIN2, BMPR1A, EPCAM, GREM1, MLH1, MSH2,management. MSH3, MSH6, MUTYH, NTHL1, POLD1, POLE,with PMS2, SMAD4, and STK11); results of MGPT and other family history guide patient MUTYH, NTHL1, POLD1, POLE, PMS2, PTEN, SMAD4, and STK11); results of MGPT and other family history guide patient management. FAP AFAP MAP PPAP Other Rare Syndromes FAP AFAP MAP PPAP Other Rare Syndromes APC APC MUTYH (biallelic) POLD1 / POLE NTHL1 | AXIN2 | MLH3 | MBD4 | MSH3 APC APC MUTYH (biallelic) POLD1 / POLE NTHL1 | AXIN2 | MLH3 | MBD4 | MSH3 Age 10–15 | q1–3 yr Age 18–20 | q1–3 yr Age 18–20 | q1–3 yr Age 25–30 | q1–3 yr Age 25–30* | q1–3 yr Age 10–15 | q1–3 yr Age 18–20 | q1–3 yr Age 18–20 | q1–3 yr Age 25–30 | q1–3 yr Age 25–30* | q1–3 yr Age 20–25 Age 20–25 Age 30–35 Age 25–30 No routine Age 20–25 Age 20–25 Age 30–35 Age 25–30 No routine Yes · By age 18 Yes · By age 18 No routine Multisystem Multisystem Yes · By age 18 Yes · By age 18 No routine Multisystem Multisystem  Many syndromes carry extraintestinal manifestations requiring specialized screening and surveillance. Consult guideline for syndrome-specific recommendations.  Many syndromes carry extraintestinal manifestations requiring specialized screening and surveillance. Consult guideline for syndrome-specific recommendations. **Colonoscopy start age or 5 yrs before youngest FDR polyposis dx / 10 yrs before FDR CRC diagnosis, whichever is earlier. Colonoscopy start age or 5 yrs before youngest FDR polyposis dx / 10 yrs before FDR CRC diagnosis, whichever is earlier.

Negative Negative Germline GermlineTest Test Endoscopic Endoscopic and Surgical and Surgical Management Management

NEGATIVE POLYPOSISOF OFUNCERTAIN UNCERTAINETIOLOGY ETIOLOGY (CPUE)*  Consider mosaicism testing NEGATIVEGPV GPVON ON MGPT MGPT = = COLONIC COLONIC POLYPOSIS (CPUE)*  Consider APCAPC mosaicism testing Manage numberofofcolorectal colorectal&&duodenal duodenal adenomas; If APC mosaic, manage according to FAP ManageCPUE CPUEaccording according to to cumulative cumulative number adenomas; If APC mosaic, manage according to FAP *Also to as as Multiple MultipleColorectal ColorectalAdenomas Adenomas(MCRA), (MCRA), Idiopathic Adenomatous Polyposis (IAP) *Also referred referred to Idiopathic Adenomatous Polyposis (IAP)

Gastric PolyposisFeatures Features GastricPolyposis Polyposis –– Report Polyposis Finding Finding

**

Duodenal Polyposis – Report Spigelman Features Duodenal Polyposis – Report Spigelman Features

Management* Management*

Feature Feature

1 pt1 pt

2 pts 2 pts

3 pts3 pts

Number,size, size,and andlocation location of of FGPs FGPs Number,

Resect Resectifif≥10 ≥10mm mm

## Polyps Polyps

1–41–4

5–20 5–20

>20 >20

Number,size, size,and andlocation location of of gastric gastric adenomas Number, adenomas

Resect Resect

Size (mm) Size (mm)

1–41–4

5–105–10

>10 >10

Histology Histology

TA TA

TVATVA

VA VA

Dysplasia Dysplasia

LGD LGD

— —

HGDHGD

Highrisk riskfeatures: features:White White mucosal mucosal patch patch (WMP), High (WMP), polypoid polypoidmounds, mounds, carpeting carpeting WMP,polypoid polypoidmounds mounds WMP,

Resect; Resect;Consider Consider high-risk high-riskcenter center

Multi-focalHGD HGDor oradenocarcinoma adenocarcinoma Multi-focal

Gastrectomy Gastrectomy

Spigelman Stage: 0 (0 I (1–4 pts);pts); II (5–6 pts);pts); III (7–8 pts); pts); IV (9–12 pts) pts) Spigelman Stage: 0 pt); (0 pt); I (1–4 II (5–6 III (7–8 IV (9–12 Interval based on Stage; consider duodenectomy for Stage IV Interval based on Stage; consider duodenectomy for Stage IV

 Upper GI Surveillance: Interval determined by severity of gastric or duodenal polyposis, whichever is more advanced. *See guideline for details.  Upper GI Surveillance: Interval determined by severity of gastric or duodenal polyposis, whichever is more advanced. *See guideline for details.

Colorectal Polyposis Colorectal Polyposis Colonoscopy Resect adenomas ≥10 mm, ≥4 mm if feasible. Multi-focal HGD, endoscopically unmanageable burden, symptoms associated with Colonoscopy Resect adenomas mm,surgical ≥4 mmreferral. if feasible. Multi-focal HGD, endoscopically unmanageable burden, symptoms associated with polyposis, or CRC ≥10 warrant polyposis, or CRC warrant surgical referral. Surgery Surgical approach individualized based on rectal polyp burden, colon polyp burden, desmoid risk, and patient preferences— Surgery Surgical Consult approach guideline. individualized based on rectal polyp burden, colon polyp burden, desmoid risk, and patient preferences— Consult guideline. AFAP = attenuated FAP CHRPE = congenital AFAP = attenuated FAPhypertrophy of retinal pigment epithelium CMTC = cribriform-morular thyroid carcinoma CHRPE = congenital hypertrophy of retinal pigment epithelium FAP= =cribriform-morular familial adenomatous polyposis CMTC thyroid carcinoma FAP = familial adenomatous polyposis

FDR = first-degree relative FGP == first-degree fundic gland relative polyp FDR GPV==fundic germline pathogenic FGP gland polyp variant HGD==germline high-grade dysplasia variant GPV pathogenic

HGD = high-grade dysplasia

LGD = low-grade dysplasia TA = tubular adenoma MAP polyposis TVATA = tubulovillous adenoma LGD==MUTYH-associated low-grade dysplasia = tubular adenoma PPAP proofreading-associated polyposis VA =TVA villous adenoma adenoma MAP==polymerase MUTYH-associated polyposis = tubulovillous SS = Spigelman stage proofreading-associated polyposis PPAP = polymerase VA = villous adenoma SS = Spigelman stage

Gautam Mankaney, MD; Gregory E. Idos, MD; Elena M. Stoffel, MD, MPH; Jennifer M. Weiss, MD; Shailja Shah, MD, MPH; Emad Qayed, MD, MPH, FACG; Mary Pat Harnegie, MLIS; Carol E. A. Idos, Burke,MD; MD,Elena MACG The American Journal of Gastroenterology | DOI: 10.14309/ajg.0000000000004105 Gautam Mankaney, MD; Gregory M.| Stoffel, MD, MPH; Jennifer M. Weiss, MD; Shailja Shah, MD, MPH; Emad Qayed, MD, MPH, FACG;

Mary Pat Harnegie, MLIS; Carol A. Burke, MD, MACG | The American Journal of Gastroenterology | DOI: 10.14309/ajg.0000000000004105  READ THE GUIDELINE: bit.ly/acg-polyposis-syndromes-26  READ THE GUIDELINE: bit.ly/acg-polyposis-syndromes-26

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