Three gastroenterologists describe a few of the most interesting clinical and business issues in the GI field.
William Katkov, MD, Providence Saint John’s Health Center (Santa Monica, Calif.): There are a number of clinical areas that are central to the practice of Gastroenterology including screening for colorectal cancer, the emerging importance of the gut microbiome and its role in the pathophysiology of GI diseases as well as the metabolic syndrome. The realization of a safe and highly effective oral treatment with few side effects for the treatment of chronic hepatitis C virus infection is not only a major advance in hepatology, but is a potentially monumental public health achievement. Irritable bowel syndrome and inflammatory bowel disease are both areas that concern all gastroenterologists because they are prevalent chronic diseases.
There is little doubt that the defining "business" issue for gastroenterologists in this era is the sustainability of the practice of GI in an era of consolidation and value driven medicine. Strategies to cope with these changes vary, however alignment with health systems and hospitals continues to accelerate as physicians look for a hedge against uncertainty in the future. This is a seismic shift as all practitioners learn to cope with performance metrics and population health management.
David L. Vastola, DO, Your Good Health Medical Group (Palm Beach Gardens, Fla.): Perhaps the most interesting and relevant issues with gastroenterology today has to do with the Ebola virus. Besides fever and generalized symptoms of most viruses, it targets the gastrointestinal system with massive vomiting, diarrhea and GI bleeding of five to10 quarts per day.
Dehydration is of paramount importance, but at this level with the massive viral load, it represents a very dangerous stage of the disease for communication to nurses and doctors. In Africa, approximately 350 doctors and nurses have died from this virus in taking care of patients and I'm sure that the massive viral load is the reason why. In one-quarter teaspoon of blood, there are 10 billion virus particles as compared to 100,000 HIV virus in the same quantity. The answer is not masks and gowns, but bio containment suits with powered air purifiers and air supply since a droplet of any of these fluids can stay airborne for one hour and the virus lives for 11 and a half hours (it degrades 3 percent per minute). Even flushing the toilet will create air droplets. The second most interesting issue with gastroenterology is the myth surrounding gluten. The gluten diet is a myth initiated and perpetuated by the entertainment world, which has created an avalanche of diets and gurus to hopefully make a lot of money.
Celiac disease is a malabsorption syndrome characterized by massive diarrhea and weight loss. Most of the supposed patients with celiac disease are overweight without diarrhea and hardly any malabsorbtion. They are generally eating too much. Blood tests are confirmatory for the disease like anitgliadin antibodies, transglutamase levels and genetic DQ 2 and 8 levels. If there are any questions, a small bowl biopsy can be done for confirmation. By and large, as a busy gastroenterologist here in South Florida, I will see one to two confirmed cases and not the frenzy of media driven hypochondriacs. The worst thing is for these patients to be labeled as celiac patients, when in fact they have an undiagnosed cancer.
Lindsey Albenberg, DO, Children's Hospital of Philadelphia: In the past five years, there have been significant advances in the field of pediatric inflammatory bowel disease which have positively impacted our ability to treat these complex patients. However, there is still much work to be done and there are still many clinical challenges. One major challenge faced by providers is the optimization of medical therapy. For both pediatric and adult patients with IBD, the goals of therapy are to achieve and maintain disease remission, to prevent complications disease such as hospitalization and surgery, and to minimize medication-related side effects and adverse events. Particularly in pediatric and young adult patients who are diagnosed at a young age and who presumably will have many years of disease, optimization of medical therapy to reduce both disease complications and medication-related adverse events is critical.
One important consideration to optimization of medical therapy is improving our understanding that achieving clinical remission, e.g. getting our patients to feel well, is likely no longer good enough. As providers, to prevent disease complications, we need to follow more objective outcomes such as laboratories, fecal inflammatory markers, imaging, and endoscopy. The adult literature is beginning to demonstrate the importance of achieving mucosal healing, but we need more pediatric research in this area. Specifically, methods to monitor success of therapies in the pediatric population needs to be a research priority. From a day-to-day treatment perspective, providers need to focus on individualized therapy and need to utilize the tools that are currently available in order to customize medication dosages and frequencies.
However, the lack of evidence makes it difficult for providers to discuss diet with patients and this, I believe, leads our patients to explore the Internet. In this unregulated space, there is a complete lack of credible information. I have been working with the CCFA and Janssen on a website, www.getyourfullcourse.com, which is a source of reliable dietary information for patients with IBD which I hope will help patients to better understand the importance of appropriate medical therapy for IBD and what we currently know regarding diet and IBD.