How Will We Address the Crucial Questions Facing Our Field?
Article Outline
- Abstract
- Evidence
- Guidelines
- Quality
- Research
- Education and Training
- Advocacy
- The Future
- References
- Copyright
The following is an edited reprint of the presidential address delivered by Robert S. Sandler, MD, MPH, AGAF, during the American Gastroenterological Association Plenary Session at Digestive Disease Week 2009.
Robert S. Sandler
In this presidential address, I will describe some of the ways that the AGA will help members answer the crucial questions facing our field to the betterment of our patients. The topics that I will cover include evidence, guidelines, quality, research, education, advocacy, and the future of gastroenterology.
Evidence
Evidence is the fundamental pillar for our therapies for patients. I recently ran across a provocative quote in a book called Beautiful Evidence by Edward Tufte, a professor of architecture at Yale University.1 The quote first appeared in a journal called Medical World News in September 1972. Medical World News from 1972 is not available electronically, so I actually walked over to the library, where I discovered that the print collection started in 1973. However, I was able to procure the article from interlibrary loan; ironically, it was delivered to me by e-mail.
When I was finally able to read the paper, I discovered that the quote appeared at the beginning of a news article about clinical trials. Curious to learn more about the quote, I managed to track down the author who, amazingly, now lives in my town of Chapel Hill, North Carolina. The author, Erle E. Peacock, Jr, MD, confirmed that everything in the quote was true; the events happened in an auditorium at the Brigham Hospital when he was a medical student more than 50 years ago. As you will see, the quote is still relevant today.
One day when I was a junior medical student, a very important Boston surgeon visited the school and delivered a great treatise on a large number of patients who had undergone successful operations for vascular reconstruction. At the end of the lecture, a young student at the back of the room timidly asked, ‘Do you have any controls?’
Well, the great surgeon drew himself up to his full height, hit the desk and said, ‘Do you mean did I not operate on half of the patients?’ The hall grew very quiet then. The voice at the back of the room very hesitantly replied, ‘Yes, that's what I had in mind.' Then the visitor's fist really came down as he thundered ‘Of course not. That would have doomed half of them to their death.' God, it was quiet then, and one could scarcely hear the small voice ask, ‘Which half?’
Guidelines
We have come a long way. We have much more evidence today on which to base our decisions. But which evidence? Sometimes the evidence that we require is incomplete and conflicting. To help organize that evidence, various organizations have developed guidelines. As of February 8, 2009, there were 2441 individual guidelines produced by 285 organizations listed on www.guidelines.gov. The AGA is responsible for 20 of those guidelines, more than any other gastroenterology organization.
While guidelines are widely assumed to be evidence based and unbiased, that is often not the case. Most often, guidelines are commissioned by professional societies, written by experts selected by the societies, and published in prestigious medical journals, usually the publication of the society that commissioned the guideline. Often the guidelines are not peer reviewed. As a consequence, the results are not always unbiased or completely evidence based.
The AGA has a better way. In 2006, then-President of the AGA, Mark Donowitz, convened a task force to revise the guideline process. The new process includes the following steps:
The first AGA medical position statement and technical review to use this process concerned the management of gastroesophageal reflux disease and was published in Gastroenterology in October 2008.2, 3 The members of the medical position panel and their area of expertise were prominently listed.
Allan Sniderman and Curt Furberg recently wrote a commentary in JAMA calling for reform in the guideline process.4 I am pleased to report that the process that the AGA has developed for guidelines is consistent with all of their recommendations. The AGA adheres to the highest standards of guideline production to help our members and our patients. We are justifiably proud of the AGA process for guideline development.
Quality
Part of the motivation for guidelines is to improve quality. The Institute of Medicine has defined quality as the degree to which the delivery of health care is consistent with practices that have been shown to improve clinical outcomes.5
Attention to quality is not a new phenomenon. Florence Nightingale was one of the first promoters of quality. When she arrived in Scutari Albania in 1855 during the Crimean War, she cut military hospital mortality rates from 42.7% to 2.2% by introducing sanitary measures to reduce the toll of cholera, dysentery, and typhus. When she returned to England, she was one of first to use statistics on hospitals showing that mortality rates varied from hospital to hospital.6
In 1910, Ernest Avery Codman, an orthopedic surgeon, promoted the common sense notion that every patient should be followed up long enough to determine whether or not treatment was successful. He believed that to improve, hospitals had to compare their results with those of other hospitals and must welcome publicity not only for their successes but also for their failures. Codman resigned his position at the Massachusetts General Hospital and opened his own hospital, the Codman Hospital (which he marketed as the “End Results Hospital”). He developed the policy that bad risk patients would not pay unless they lived. The hospital was not a financial success and closed.7
The AGA recognized the importance of quality in practice when it convened the Task Force on Quality in Practice in 2005, chaired by former AGA President Martin Brotman.8 As a direct result of the task force, the AGA developed the Center for Quality in Practice in July 2005. The mission of the center is to enhance the quality and safety in the practice of gastroenterology.
The major initiatives of the center are to
The AGA has a deep commitment to quality, with the expectation that our patients will benefit.
Many believe that a key to improving quality is through the electronic medical record that is available to providers in real time at the point of care. In the past year, the AGA Institute has developed a monograph to describe the functionality needed by gastroenterology practices in an electronic medical record and published the EMR Field Guide for Gastroenterology9 to help select and implement electronic medical records in a gastroenterology practice.
While it is uncertain whether the electronic medical record will cut costs or improve quality, there is no debate that it will eliminate difficulties from bad handwriting because most of the information in the electronic record is typed. The problems that can result from bad handwriting are illustrated by a scene from the 1969 Woody Allen movie Take the Money and Run. In that scene, Allen plays an inept character named Virgil Starkwell who is broke and in love. He decides to rob a bank. He passes a note to the teller who cannot read the handwriting. “Is this ‘gub’ or ‘gun’?” People who are grumpy about the electronic medical record should watch this movie—it might cheer them up.
Research
To improve quality, we need research. Early research led to the invention of the electrocardiogram by the Dutch physiologist William Einthoven in 1902.10 An old photograph shows a man with one foot in a bucket, with both hands in pails, and wearing a suit. Those were the days when people got dressed up for their electrocardiogram rather than undressed. Shortly after the industrial revolution, a number of mechanical devices were developed to treat constipation. These too, in some cases, involved fashionable wardrobes. We have made important advances in research, but there has been a notable deterioration in our sense of style.
The AGA is committed to research. We support research through our foundation, the Foundation for Digestive Health and Nutrition chaired by Sidney Cohen. Each year, the foundation provides more than $3 million in funding that is primarily devoted to career development and the fragile transition from fellowship to faculty. Since its inception, the foundation has donated $38 million to support research.
Recently, the AGA has taken over all of the administrative expenses for the foundation. That means that all of the money donated to the foundation goes to support research and faculty development.
When Daniel Podolsky was president, the AGA promoted legislation that created the National Commission on Digestive Diseases. The final report of the commission was published in March 2009. We are already seeing the impact of the commission. Several of the recommendations from the commission report were suggested as topics for challenge grants as part of the stimulus package to the National Institutes of Health.
The legislation that created the National Commission on Digestive Diseases also led to a report on the burden of digestive diseases in the United States. That report, edited by James Everhart from the National Institutes of Health, has also been released.11 The annual burden of digestive disease in the United States is $141.8 billion. We can use this large figure as leverage to make sure that we are getting our fair share of research dollars to fund digestive disease research.
Education and Training
In a provocative article in the July/August 2008 issue of the Atlantic, Nicholas Carr asked the question “Is Google Making Us Stupid?” He describes research conducted by scholars from University College London that suggested we may well be in the midst of a sea change in the way we read and think. They found that people used “a form of skimming activity,” hopping from one source to another and rarely returning to any source they'd already visited.12
It is very clear that current and future gastroenterologists will embrace nontraditional educational tools, particularly the Internet, in order to learn. One effort by the AGA to help members harness the power of the Internet is the Lifelong Education and Resource Network, or GI LEARN. This Web portal makes it possible for members to set up a personal learning portfolio and learning library. Clinicians can create their own quick reference list of guidelines, articles, or learning goals. Researchers can store and organize digital documents. There are also self-assessment modules for maintenance of certification.
In 2008, during the presidency of Nick LaRusso, the AGA Future Trends Committee issued a report on the future of gastroenterology training programs in the United States.13 This report called for important changes in the way we train gastroenterologists. One of my proudest accomplishments as president of the AGA Institute has been to convene a Multi-society Task Force on GI Training. A report from the task force will have important implications on the duration and details of training.14
The AGA has expanded its educational offerings with a clinical congress that will be held each winter. The congress provides a comprehensive summary of the latest information in gastroenterology and hepatology.
Advocacy
The AGA works on behalf of its members though its political action committee (PAC). The AGA PAC gives gastroenterologists a greater presence on Capitol Hill and a more effective voice on policy discussions that affect the science and practice of gastroenterology. The AGA PAC is the only political action committee supported by a national gastroenterology society. Under the leadership of former AGA President Ralph Gianella, the PAC works to obtain reasonable Medicare reimbursement rates, increase federal funding for biomedical research, encourage medical liability reform, and ease regulatory burdens on gastroenterologists.
The Future
In 2006, during the presidency of David Peura, the AGA convened a conference with the provocative title “Will Screening Colonoscopy Disappear and Transform Gastroenterology Practice: Threats to Clinical Practice and Recommendations to Reduce Their Impact.”15 The conference adopted the metaphor “The Perfect Storm” after the best-selling book by Sebastian Junger. Although gastroenterologists are understandably concerned about the implications of widespread computed tomographic colonoscopy, the conference speakers identified a number of growth areas for gastroenterologists, including management of hepatitis, obesity (including endoscopic therapy), motility and pacing, oncology (eg, treating liver cancer), reading computed tomographic colonography (instead of radiologists), advanced imaging, and other new technologies. Many gastroenterologists may wish to return to largely cognitive activities rather than procedure-based activities.
Computed tomographic colonography is a potentially disruptive technology. There are a number of industries that have faced seemingly disruptive technologies. The bicycle was invented in the mid-1800s as a mode of transportation. One of the earliest bicycles was called the “penny-farthing,” with a large front wheel and a much smaller rear wheel. The description “penny-farthing” refers to British penny and farthing coins, one much larger than the other. Advanced forms of transportation have been developed since the bicycle, but many of us still own bicycles. My bicycle is all carbon and weighs 17 lb. I don't need it for transportation; I use it for amusement. The bicycle has evolved but has not vanished. The radio was pronounced dead in 1953, yet all of us have radios in our cars and in our homes.
Catherine Rampell, writing in the New York Times on November 16, 2008, observed that “companies that have survived technological challenges have in common some combination of perseverance, creativity, versatility, and luck.”16
Gastroenterologists are known for their perseverance, creativity, and versatility. We are also lucky. We are lucky to be in a profession that is challenging, exciting, and rewarding. We are lucky to be in a specialty with an attractive mix of cognitive and procedural activities and with a broad range of diseases and treatments.
I feel particularly lucky. I have been lucky to have had the opportunity to serve as the President of the AGA for the past year. I have had the privilege to work with an extremely talented staff and with dedicated volunteers. I have had the honor of collaborating with the leadership of the other gastroenterology societies. I have also been lucky to have the support of my wife, Dale, and my sons, David and Michael.
In summary, the AGA is working to help answer the crucial questions facing our field. We have high-quality guidelines, we promote quality through our Center for Quality in Practice, we advance education through our GI LEARN Web site and our courses, and we support research through our foundation and advocacy through our PAC.
The AGA is working tirelessly to help meet the challenges that face our profession and to answer the crucial questions facing our field. I am optimistic about the future of our specialty.
References
- . Beautiful evidence. Cheshire, CT: Graphics Press, LLC; 2006;
- American Gastroenterological Association medical position statement on the management of gastroesophageal reflux disease. Gastroenterology. 2008;135:1383–1391
- . American Gastroenterological Association Institute technical review on the management of gastroesophageal reflux disease. Gastroenterology. 2008;135:1392–1413
- . Why guideline-making requires reform. JAMA. 2009;301:429–431
- . Medicare: a strategy for quality assurance (V: Quality of care in a changing health care environment). QRB Qual Rev Bull. 1992;18:120–126
- . Florence Nightingale. Sci Am. 1984;250:128–137
- . Health care quality improvement across Baylor Health Care System: the first century. Proc (Bayl Univ Med Cent). 2004;17:277–288
- AGA Task Force on Quality in Practice: a national overview and implications for GI practice. Gastroenterology. 2005;129:361–369
- . EMR Field Guide for Gastroenterology. Bethesda, MD: AGA Institute Press; 2009;
- . Tracing atrial fibrillation—100 years. N Engl J Med. 2006;355:1412–1414
- In: Everhart JE editors. The burden of digestive diseases in the United States (US Department of Health and Human Services, Public Health Service, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases). Washington, DC: US Government Printing Office; 2008;NIH Publication No. 09-6443
- . Is Google making us stupid? (What the Internet is doing to our brains. The Atlantic). http://www.theatlantic.com/doc/200807/googleJuly/August 2008;Accessed November 5, 2009
- AGA Institute Future Trends Committee report: the future of gastroenterology training programs in the United States. Gastroenterology. 2008;135:1764–1789
- Report of the multisociety task force on GI training. Gastroenterology. 2009;137:1839–1843
- . Will screening colonoscopy disappear and transform gastroenterology practice? (Threats to clinical practice and recommendations to reduce their impact: report of a consensus conference conducted by the AGA Institute Future Trends Committee). Gastroenterology. 2006;131:1287–1312
- . How industries survive change (If they do). In: New York Times; November 16, 2008;p. WK3
PII: S0016-5085(09)01844-7
doi:10.1053/j.gastro.2009.10.022
© 2009 AGA Institute. Published by Elsevier Inc. All rights reserved.
