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ACG PRESIDENTIAL ADDRESS Major Changes: Rising to Face the Challenges and Opportunities for Clinical Gastroenterology Amy E. Foxx-Orenstein, DO, FACG1 Am J Gastroenterol 2009;104:5–8; doi:10.1038/ajg.2008.135

2008 has been a remarkable year thus far, with a great deal of enthusiasm radiating from the approaching presidential election tempered by recent market fragility. Historical barriers have been breached, the political environment is charged, and the country is clamoring for a change in direction along with change to our health-care delivery system. Whichever party wins the election, coupled with a new Congress, there is bound to be significant activity on health-care policy in the coming year that will profoundly impact the way we practice clinical gastroenterology. The year has been no less remarkable for the American College of Gastroenterology. It would be difficult to discuss Division of Gastroenterology and Hepatology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA

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© 2009 by the American College of Gastroenterology

the breadth and depth of the work of our College this past year in the context of this address. Rather, I will try to highlight examples of where the College has provided unique leadership and the most impact for our specialty and beyond. Back in 2002, the College published a major strategic plan. It has been a guide as we have grown from strength to strength in the years since. 2008 presented an opportunity to take stock of how the College did in meeting the goals and objectives of the plan and take steps to chart our course for the future. Developing the new plan was a broad community effort. Representatives from all aspects of College life came together to take stock of the organization, gastroenterology, and medicine in general to encapsulate the role the College would pursue in its mission of highestquality education and patient care. The group worked to draw out what makes the ACG unique and to identify fundamental priorities that constitute the core mission of the College. Tough questions were posed about the future of our specialty and our College, which were ultimately shared with the College leadership for input. In the end, they came together around the issues of education, research, public policy, membership, administration, publications, and governance. You can look to the 2008 Strategic Plan document that was included with your registration materials and take pride in both what the College as an organization stands for and what our collective goals and objectives are for the future.

It is through the prism of the Strategic Plan that the activities of the College should be viewed. A project that reflects the full range of priority areas from the plan is the College’s Obesity Initiative. This multifaceted initiative really began when members of Congress, representatives of a wide range of consumer and disease advocacy groups, and the ACG convened at an Obesity Summit to develop policy recommendations for federal lawmakers on how to address the challenges presented by obesity. The Summit ultimately made recommendations for change in three areas: nutrition, physical activity, and the health-care system. It was recommended that the federal government recognize obesity as a complex disease with strong adverse health effects, establish diagnosis codes, and require coverage for prevention, screening, diagnosis, and multitreatment programs that are coupled to measurement of health outcomes. The Summit also recommended increased obesity-related research support across all agencies of the federal government to bring it in line with investments aimed at solving other major medical problems. The ongoing work of the Summit is being carried on by the Campaign to End Obesity, and the ACG is proud to serve as co-chair of the Health System Restructuring work group. The ACG’s involvement in this national effort that includes leaders from medicine, government, and industry is contributing to the development of legislative and regulatory strategies to address obesity in the United States. The American Journal of Gastroenterology

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At the same time, the College saw a pressing need for physician leadership in the health crisis of obesity. The magnitude of the obesity epidemic and an escalating awareness of obesity-related GI health risks, along with our new understanding of the role of intestinal microorganisms in metabolism and the role of gut hormones in appetite regulation, warranted a call to action. As a next step in the College’s action plan on obesity, clinical and scientific expertise of gastroenterologists was brought together to start to formulate solutions to the obesity epidemic in terms of advancing clinical practice. The world-class experts who make up the ACG Task Force on Obesity have developed materials for both GI physicians and their patients. Among these resources, which are available here at the meeting at the ACG booth and will be sent to ACG members’ offices, are a wide-ranging, accessible physician resource to emphasize the relevance of obesity to the gastroenterologist, patient education and resource materials, a BMI and waist circumference calculator, public policy messages, tools for counseling patients, links to CME and to government agencies, and access to key obesity articles for the busy clinician, among other offerings. I hope you and your patients will find the resources valuable, and I look forward to your comments. In an effort to encourage research in this important area, the College has created an abstract award for original research on obesity this year. The winning abstract is “Increased Soluble FAS and FAS Ligand Levels in Patients With Nonalcoholic Steatohepatitis,” Ariel Feldstein, MD, Cleveland Clinic Foundation. Congratulations to Dr. Feldstein and his team. This year’s Postgraduate Course and ACG Annual Meeting are featuring lectures and symposia on obesity where one can garner strategies for managing obesity and its complications and be updated on scientific advances. The role of the GI specialist in managing obesity-related complications of GI disorders is expanding. GIs must engage The American Journal of Gastroenterology

in efforts to refine existing approaches to care, improve management of associated complications, and define new treatment options. Key to this is a new focus on research and keeping up on new discoveries in the field, including rapid advances in endoscopic intervention. Gastroenterologists must take a lead role in managing this condition, including an emphasis on prevention, as well as the related GI disorders. The Strategic Plan continues to highlight the area of advocacy—on behalf of both our patients and our specialty. This has been a hallmark of the College for years. At the same time, it has always presented the challenge of identifying places where meaningful improvements can be made by the College or our specialty and those areas where we can play an important complementary role with the greater community of organized medicine. Whether it is with policy makers, insurance companies, or even other specialties, the College remains focused on identifying the best role to further digestive health and clinical gastroenterology. One example is the Sustainable Growth Rate system—the so-called SGR—that sets the Medicare reimbursement rates for medicine, which then form the foundation of the payment system for private insurers. This year a 10% cut went into place before it was reversed through override of a presidential veto. The constant temporary fixes do nothing to repair a fundamentally broken system that impacts patient care. The College continues to work with the AMA and others in organized medicine to find a permanent solution that reflects the financial realities of running a practice today and doesn’t pit specialty against specialty or internists against proceduralists like the current system does. ACG members must be prepared to answer the call to communicate with your representatives in Washington on these issues, or the manner in which you practice, or your ability to maintain a practice at all may be fundamentally altered. The fact that GI has experienced far more than its fair share of

cuts carries no weight in the debates in Washington if we are not engaged, and the strength of the College’s voice comes directly from you. When the College calls, you must answer—for your patients and for yourself. For the College, advocacy on behalf of the membership has included an enormous effort in the public policy arena. As was the case with our leadership in obtaining Medicare coverage for colorectal cancer screening via colonoscopy more than a decade ago, the College is committed to working in the best interests of our patients based on sound science—both with our elected representatives in Washington and elsewhere. It is not always an easy task. Whether it is controversial issues such as who sedates our patients or what type of colon cancer screening technologies are being used, we will continue to be guided by these key principles: sound science and the patient’s best interest. Our goal is to maximize the number of patients who are screened for colon cancer. If a new technology such as CT colonography or fecal DNA testing has the science to support its use, we will embrace it and work to create opportunities for our members, who understand the gut better than anyone, to use these tests. At the same time, we will fight to keep people willing to use the gold standard of testing from using less sensitive technologies. We must all work to give our patients and our referring physicians the facts so that scientifically sound, informed decisions are made. I also want to add that, notwithstanding the fact that the ACG has a unique, clinically focused perspective, we strive to find opportunities to work cooperatively with our sister societies in GI as well as other specialty organizations. Later this week a joint paper will be published by the ACG, in collaboration with the American College of Cardiology and the American Heart Association, offering consensus guidelines outlining a stepwise approach for reducing the risk of ulcers and gastrointestinal bleeding among patients using NSAIDs along with antiplatelet agents. Volume 104 | january 2009 www.amjgastro.com


It has been part of an ongoing effort to reach our colleagues in other specialties with whom we share patients to make sure that our patients are getting the best possible care no matter what other conditions they may be treated for. In the area of sedation, the ACG has been working with our sister societies to preserve and expand the ability of clinical gastroenterologists to provide sedation services in the manner deemed most appropriate for a particular patient using the sedation agent that they determine is best. Whether it is with policy makers in Washington, insurance companies, or state nursing and medical boards, we will fight for the right of our well-trained members and our colleagues to provide these essential services in a safe and economical fashion. As noted in the Strategic Plan for the College, education continues to be the driving force for what we do. Our College is committed to professional and patient education that meets the needs of the busy clinician. This is why we have worked to develop innovative programs that help meet these educational needs where and when you need them. I speak not only of the Annual Meeting and Postgraduate Course, but also of our numerous regional courses across the country. Our vision to create innovative educational programs was realized last year with the educational series entitled Saturday With GI Experts and a spinoff called Evening With GI Experts. Not only were these programs innovative in structure—with some 30 highly interactive learning modules on a wide variety of clinically relevant topics—but they provided an opportunity to bring world-renowned experts to small and mid-sized locations that are not able to support larger meetings. This series, which was made possible by the generous support of AstraZeneca, also provided an opportunity for the College to explore uses for technology, such as interactive webcasts used in these daylong and evening programs that are archived for future use and CME by the membership. © 2009 by the American College of Gastroenterology

These Saturday With GI Experts programs were so popular that the agenda was expanded for a final CME event of the year, Weekend With GI Experts, to be held on December 12–14 at the Mandalay Bay in Las Vegas. Rest assured that the College is hard at work to identify opportunities for other programs like this one and the ACG Education

ation as an opportunity to look at, and audit, our own infection-control practices. You each received a card with the CDC infection-control guidelines in your registration bags. I urge each of you to take it back to your practices, and to review your sedation procedures with your colleagues and staff, and to guarantee appropriate standards are

The fact that GI has experienced far more than its fair share of cuts carries no weight in the debates in Washington if we are not engaged, and the strength of the College’s voice comes directly from you. When the College calls, you must answer—for your patients and for yourself. Universe that are available to the busy clinician and the hardworking trainee wherever they live, and whenever they need them. This year we also learned that our role as educators must extend beyond CME programming, as we were forced to confront and respond to the troubling and tragic situation in Las Vegas, where more than 80 people were infected with hepatitis C at an endoscopy center. This unfortunate event stemmed from the fact that the certified registered nurse anesthetists providing anesthesia services at the center apparently failed to follow the CDC infection-control guidelines. Beyond our serious concern over the alarming consequences for the infected patients, the College remains deeply concerned about the potential for fears about unsafe injection practices to deter patients from undergoing colorectal cancer screening and other essential diagnostic and therapeutic procedures. The College immediately reached out to the ACG membership, the CDC, and concerned members of Congress to help explain the situation and to educate policy makers and the public about the issue. The College encouraged our members to use this unfortunate situ-

being followed in all cases. It is our collective responsibility to help prevent any recurrence of this dreadful situation, which has served to damage the health of the patients we are pledged to heal, as well as undermining public confidence in potentially lifesaving endoscopic procedures. I want to bring to your attention a new Web feature that highlights the outstanding accomplishments and significant achievements of ACG physicians. In the “Profiles in Gastroenterology” section, you can learn about your colleagues and their remarkable experiences and contributions. The College seeks to profile ACG members who have made notable contributions to medicine, to their communities, to our nation, or to our world in areas such as public health, public policy, education, public service, and private practice. We are interested in your story. Please consider submitting a short narrative of what has moved you or shaped your life and let us know if you enjoy this feature. I am very proud of the work of the ACG IBS Task Force, which this year, under the leadership of Larry Brandt, and with contributions from some of our leading experts on functional GI disorThe American Journal of Gastroenterology

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ders, accomplished a remarkable feat on a tight timeline, and in an example of scholarly collaboration. They produced a comprehensive systematic review of the evidence on the management of IBS. The ACG’s new IBS monograph, which will be published as a supplement to the Red Journal in early 2009, reflects conclusions derived from this new meta-analysis and includes expert assessments of traditional therapies, as well as probiotics, antibiotics, and other emerging therapies. I congratulate this group and believe that their position statement, which updates the College’s 2002 monograph, will provide clinical GI practitioners with graded recommendations for approaching one of the most commonly seen GI complaints. I am honored to announce a new ACG Leadership Development and Training Initiative. The goal of this exciting new offering is to cultivate excellence in physician leadership—and ultimately to enhance the life of the College and

The American Journal of Gastroenterology

our work together through developing the qualities of leadership. The inaugural offering for the ACG Leadership program comes through a partnership with Salix whereby current and future leaders in GI will have the opportunity to attend executive leadership training courses at some of the nation’s premier educational institutions. There are many exciting possibilities for expanding this program and developing our own offerings for ACG members. I am optimistic that our investment in leadership training will pay remarkable dividends in the future. Before I close, I want to honor a special individual who passed away recently, ACG Past President Dr J. Edward Berk, who died at the age of 96 on February 8, 2008. Few leaders have made such important or enduring contributions to the College as Jack Berk. His generous contributions include noteworthy examples of service and philanthropy. A longtime leader and supporter of the

College, Dr. Berk was a giant in clinical gastroenterology and the ACG. We sorely miss him, but I believe we are enriched by having known him. Finally, it is clear that by any measure the state of the College is strong. Membership growth is steady, our mission is on track with a recently updated strategic plan, and we are continually innovating in dynamic ways, including interactive professional and patient education. It is equally clear that the forces of change and turmoil have beset our nation, the health-care system, and related industries. Organized medicine and gastroenterologists in particular will continue to face enormous challenges for the foreseeable future. Rest assured that the College remains committed to leading the fight to meet the needs of our membership in these times of great uncertainty, and we will work to be a resource to each of you as conditions inside and outside the organization change.

Volume 104 | january 2009 www.amjgastro.com