Physicians' Explanatory Models of Pediatric Inflammatory Bowel Disease: A Qualitative Interview Study.

Explanatory models are culturally informed representations of illness that convey understandings of the etiology and expected course of disease. Substantial research has explored lay explanatory models, but examining physicians' clinical explanatory models can also provide insight into patients' understandings of illness because physicians are a foundational source of authoritative knowledge that shapes lay concepts of illness and disease. This study characterized the explanatory models used by pediatric gastroenterologists when explaining inflammatory bowel disease (IBD) to children. We conducted semi-structured qualitative interviews with 20 pediatric gastroenterologists across the United States about their clinical communication and explanatory models. We identified two primary explanatory models used to describe immune dysregulation in pediatric IBD: the defense and protection model, which characterizes the immune system as an army that erroneously sees the body as "non-self" and attacks it; and the switch model, which conceptualizes treatment as activating a switch that turns off a faulty immune response. We also identified two models used by some physicians to describe inflammation: the scratch and scrape model, which compares IBD inflammation to scratches or scrapes on the skin; and the bonfire model, which compares inflammation to a fire in need of extinguishing. While the use of militaristic metaphors is pervasive in medicine, describing autoimmunity as a battle against the self may lead children to perceive their body as the enemy. This may be compounded by describing the immune system as "confused" while noting its ongoing protective function. Use of these explanatory models may nevertheless improve patient disease-related knowledge.

[The influence of gastroenterologists' intrinsic motivation on work burnout and the mediating effects of work stress].

Objective: To analyze the influence of intrinsic motivation on work burnout and the mediating effects of work stress. Methods: In 2020, questionnaire survey was conducted in 1 655 gastroenterologists working in 28 provinces of China. Mediation model was used to analyze the mediating effects of work stress in the relationship between intrinsic motivation and burnout. Resutls 1655 valid questionnaires were collected, including 1 132 women and 523 men, with an average age of 39.26. Intrinsic motivation was related to reduced level of burnout, including emotional exhaustion, dehumanization and low sense of accomplishment (ß=-2.06, -1, 77 and-4.20;P<0.001). Job stress partially mediated the negative correlation between intrinsic motivation and job burnout in three dimensions, accounting for 40%, 15% and 5% (ß=-1.58, -0.36 and-0.21;P<0.05), respectively. In female physicians, the intrinsic motivation was more directly related to the reduction of burnout, especially in the dimension"emotional exhaustion"(direct effect accounting for 62% in female gastroenterologists and 46% in male). Conclusions: Enhancing the intrinsic motivation of gastroenterologists can directly reduce burnout and indirectly reduce burnout by alleviating work stress. In the same work environment, female physicians' intrinsic motivation had a greater and more direct effect on reducing burnout.

Drivers of Variation in Diagnosis and Management of Eosinophilic Esophagitis: A Survey of Pediatric Gastroenterologists.

BACKGROUND: Widespread variation in the diagnosis and treatment of eosinophilic esophagitis (EoE) has previously been reported among adult gastroenterologists; however, variation in EoE practice in among pediatric populations is poorly characterized. The study objectives were to describe guideline adherence and understand reasons for variation in EoE practice among pediatric gastroenterologists following publication of the updated 2018 international EoE guidelines. METHODS: We developed and administered a 28-item survey to pediatric gastroenterologists via an email listserv using the PEDGI Bulletin Board from 03/2019 to 04/2019. The survey was developed using evidence-based review, expert validation, and cognitive interviews. Survey domains included respondent knowledge of and adherence to published guidelines, diagnostic and management approach and rationale, and participant demographics. Analysis included descriptive statistics and tests for association. RESULTS: A total of 288 pediatric gastroenterologists completed the survey, most of whom practiced in an academic center (73%). More than half (63%) reported knowledge of the 2018 updated guidelines; however, only 52% agreed with them and 50% reported adherence. Respondents who reported not agreeing with updated guidelines cited concerns regarding increasing number of endoscopies (72%), misdiagnosing eosinophilia from reflux (56%), and insufficient data (23%). The most common drivers of decision making with respect to therapy choice were patient/family preference, evidence/guidelines, and symptom burden. CONCLUSIONS: Many physicians are not adherent to current guidelines for reasons which include lack of knowledge of updated guidelines and concern regarding the strength of the supporting evidence. This study elucidates several areas to enhance education regarding these guidelines to promote widespread adherence.

Transitioning from the Mountains to the Mecca: One Gastroenterologist's Journey.

Over the course of their careers, gastroenterologists not infrequently move from one practice setting to another. Perhaps the most uncommon path is for a gastroenterologist well established in private practice to transition to a high-powered academic setting in late career. Below is a description of the career path that I chose, written in part to provide career and personal guidance to the next generation of gastroenterologists.

Gastroenterologists attitude in various clinical settings in the era of COVID-19 pandemic: An online Uni-National Israeli Survey.

ABSTRACT: Coronavirus disease 2019 (COVID-19) pandemic has impacted our clinical practice. Many gastroenterologists have changed their attitudes toward various gastroenterological clinical settings. The aim of the present study is to explore the gastroenterologist's attitudes in several clinical settings encountered in the clinical practice.An online based survey was completed by 101 of 250 Israeli gastroenterologists (40.5%).Most of the participants were males (76.2%), and most of them were in the age range of 40 to 50 (37.6%). For all questionnaire components, the 2 most common chosen options were "I perform endoscopy with N95 mask, gloves and gown protection in a standard endoscopy room without preendoscopy severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) testing" and "Tend to postpone endoscopy until SARS-CoV-2 test is performed because of fear from being infected, or virus spreading in the endoscopy suite." Notably, 12 (11.9%) gastroenterologists were infected by Coronavirus disease 2019 during their work. Classifying the clinical settings to either elective and non-elective, most gastroenterologists (77.4%) chose the attitude of "I perform endoscopy with N95 mask, gloves and gown protection in a standard endoscopy room without SARS-COV-2 testing" in the nonelective settings as compared to 54.2% for the elective settings, (P < .00001), whereas 32.9% of the responders chose the attitude of "Tend to postpone endoscopy until SARS-COV-2 test is performed because of fear from being infected, or virus spreading in the endoscopy suite" in the elective settings (P < .00001).Gastroenterologists' attitude in various gastroenterological settings was based on the clinical indication. Further studies are needed to assess the long-term consequences of the different attitudes.

A Review of the Evidence and Recommendations on Communication Skills and the Patient-Provider Relationship: A Rome Foundation Working Team Report.

BACKGROUND & AIMS: Over several decades, changes in health care have negatively impacted meaningful communication between the patient and provider and adversely affected their relationship. Under increasing time pressure, physicians rely more on technology than face-to-face time gathering data to make clinical decisions. As a result, they find it more challenging to understand the illness context and fully address patient needs. Patients experience dissatisfaction and a diminution of their role in the care process. For patients with disorders of gut-brain interaction, stigma leads to greater care dissatisfaction, as there is no apparent structural basis to legitimize the symptoms. Recent evidence suggests that practical communication skills can improve the patient-provider relationship (PPR) and clinical outcomes, but these data are limited. METHODS: The Rome Foundation convened a multidisciplinary working team to review the scientific evidence with the following aims: a) to study the effect of communication skills on patient satisfaction and outcomes by performing an evidence-based review; b) to characterize the influence of sociocultural factors, health care system constraints, patient perspective, and telehealth on the PPR; c) to review the measurement and impact of communication skills training on these outcomes; and d) to make recommendations to improve communication skills training and the PPR. RESULTS: Evidence supports the fact that interventions targeting patient-provider interactions improve population health, patient and provider experience, and costs. Communication skills training leads to improved patient satisfaction and outcomes. The following are relevant factors to consider in establishing an effective PPR: addressing health care system constraints; incorporating sociocultural factors and the role of gender, age, and chronic illness; and considering the changing role of telehealth on the PPR. CONCLUSIONS: We concluded that effective communication skills can improve the PPR and health outcomes. This is an achievable goal through training and system change. More research is needed to confirm these findings.

The impact of the coronavirus disease 2019 pandemic on gastroenterologists in Southeast Asia: A mixed-methods study.

BACKGROUND AND AIM: The coronavirus disease 2019 pandemic has impacted gastroenterology practices worldwide; however, its protracted effects within Southeast Asia were unknown. The primary aim of the study was to determine the impact of the pandemic on clinical demands including burnout among gastroenterologists within the region. The secondary aim was to identify risk factors for burnout and determine regional stressors. METHODS: This was a mixed-methods study. Gastroenterologists were surveyed electronically between September 1 and December 7, 2020, via gastroenterology and endoscopy societies of Brunei, Indonesia, Malaysia, Philippines, Singapore, and Thailand. Quantitative and qualitative data were collected. The 22-item Maslach Burnout Inventory-Human Services Survey (MBI-HSS) was used to detect burnout. Quantitative data were non-parametric; non-parametric methods were used for statistical comparisons. Logistic regression was used to determine risk factors for burnout. Content analysis method was used to analyze qualitative data. Ethical approval was obtained. RESULTS: A total of 73.0% reported that they were still significantly affected by the pandemic. Of these, 40.5% reported increased workload and 59.5% decreased workload. Statistically significant differences in weekly working hours, endoscopy, and inpatient volumes were present. No differences were observed in outpatient volumes, likely because of telemedicine. Burnout was common; however, 50.1% of gastroenterologists were unaware of or did not have access to mental health support. This, as well as depression, being a trainee, and public sector work, increased burnout risk significantly. CONCLUSION: The effects of the pandemic are multifaceted, and burnout is common among Southeast Asian gastroenterologists. Safeguards for mental health are suboptimal, and improvements are urgently needed.

National Early Career Transplant Hepatologist Survey: Compensation, Burnout, and Job Satisfaction.

Despite the growth of transplant hepatology as a subspecialty over the past decade, data on professional roles and compensation models remain lacking. Furthermore, the prevalence of physician burnout and job satisfaction are unknown in this profession. We aimed to conduct a comprehensive assessment of early career transplant hepatologists to fill these voids in knowledge and to inform current and future transplant hepatologists. An online survey designed to quantify clinical and nonclinical roles, compensation and structure, job satisfaction, and burnout was sent to 256 early career transplant hepatologists. Respondents were divided into three practice settings: university hospital clinical (n = 79), non-university hospital clinical (n = 35), and research (n = 25). The median age of respondents was 38 (interquartile range [IQR] 36-40) years, and 44% were women. The median half-days/week spent in clinic was 4 (IQR 3-6) and in endoscopy was 1 (IQR 1-2). Most of the respondents provided inpatient care (88%) for a median of 9 (IQR 6.5-10) weeks/year. The median base compensation was $300,000 (IQR US $263,750-$326,250), and most (76%) had salary-based compensation. Although only 8% of respondents were dissatisfied with their position, the prevalence of burnout was high at 35%. Conclusion: This survey is a comprehensive assessment focusing on early career transplant hepatologists, is reflective of the current training paradigm and practice of transplant hepatology, and provides transparency to guide professional negotiations and empower both trainees pursuing careers in transplant hepatology and early career transplant hepatologists.

The prevalence of burnout, risk factors, and job-related stressors in gastroenterologists: A systematic review.

BACKGROUND AND AIMS: Burnout is an important occupational hazard, and the scale of the problem within gastroenterology remains poorly understood. The primary objective of this study was to understand the prevalence of burnout in gastroenterology and ascertain if there was a common prevalence within the field. The secondary objective was to identify factors and job-related stressors that commonly contribute to burnout in gastroenterologists. METHODS: Systematic searches were conducted in PubMed, Scopus, Cochrane, and PsycINFO by two reviewers independently for articles published to 1 September 2020. The primary outcome measure was the reported prevalence of burnout in gastroenterologists. The secondary outcome measures were (i) the prevalence of non-somatic burnout symptoms (emotional exhaustion, depersonalization, and low personal accomplishment) and (ii) the frequency of risk factors and stressors reported in studies. Data were presented, and limited meta-analyses discussed. RESULTS: Data were extracted from 11 studies. 54.5% (6/11) of these studies reported the prevalence of burnout in gastroenterologists; this ranged from 18.3% to 64.4%. Similar to burnout prevalence, burnout symptoms showed geographical variation and were common in gastroenterologists (up to 63.9%). Factors associated with work volume, age, and female gender were the three most frequently reported risk factors for increased levels of stress and burnout in 72.7% (8/11), 54.5% (6/11), and 45.5% (5/11) of studies, respectively. Significant methodological and clinical heterogeneity was observed. CONCLUSIONS: Burnout and its non-somatic symptoms are common in gastroenterologists, but the syndrome is understudied within the field. Further research and good quality data are needed to help address the problem.

Provider Viewpoints in the Management and Referral of Rectal Cancer.

BACKGROUND: Patients with rectal cancer treated at specialized or high-volume hospitals have better outcomes, but a minority of these patients are treated there. Physician recommendations are important considerations for patients with rectal cancer when making treatment decisions, yet little is known about the factors that affect these physician referral patterns. METHODS: Semistructured telephone interviews were conducted in 2018-2019 with Iowa gastroenterologists (GIs) and general surgeons (GSs) who performed colonoscopies in a community setting. A thematic approach was used to analyze and code qualitative data. RESULTS: We interviewed 10 GIs and 6 GSs with self-reported averages of 15.5 y in practice, 1100 endoscopic procedures annually, and 6 rectal cancer diagnoses annually. Physicians believed surgeon experience and colorectal specialization were directly related to positive outcomes in rectal cancer resections. Most GSs performed resections on patients they diagnosed and typically only referred patients to colorectal surgeons (CRS) in complex cases. Conversely, GIs generally referred to CRS in all cases. Adhering to existing referral patterns due to the pressure of health care networks was a salient theme for both GIs and GSs. CONCLUSIONS: While respondents believe that high volume/specialization is related to improved surgical outcomes, referral recommendations are heavily influenced by existing referral networks. Referral practices also differ by diagnosing specialty and suggest rural patients may be less likely to be referred to a CRS because more GSs perform colonoscopies in rural areas and tend to keep patients for resection. System-level interventions that target referral networks may improve rectal cancer outcomes at the population level.

Motivations, Barriers, and Outcomes of Patient-Reported Shared Decision Making in Eosinophilic Esophagitis.

BACKGROUND: Little is known about patient choice in treatment of eosinophilic esophagitis (EoE). AIM: Determine motivators and barriers to using common EoE therapies and describe patient-reported shared decision making (SDM) and satisfaction with treatment. METHODS: We developed and administered a Web-based survey on factors influencing EoE treatment choice, SDM, and satisfaction. Adults with EoE and adult caregivers of pediatric EoE patients were recruited via patient advocacy groups and at two centers. Descriptive statistics of multiple response questions and multivariable logistic regression were performed to identify predictors of SDM and satisfaction with treatment. RESULTS: A total of 243 adults (mean age 38.7 years) and 270 adult caregivers of children (mean age 9.5 years) completed the survey. Preventing worsening disease was the most common motivator to treat EoE. Barriers to topical steroids were potential side effects, cost, and preferring a medication-free approach. Inconvenience and quality of life were barriers to diet. Potential adverse events, discomfort, and cost were barriers to dilation. Nearly half (42%) of patients experienced low SDM, but those followed by gastroenterologists were more likely to experience greater SDM compared to non-specialists (OR 1.81; 95% CI 1.03-3.15). Patients receiving more SDM were more satisfied with treatment, regardless of provider or treatment type (OR 2.62, 95% CI 1.76-3.92). CONCLUSIONS: Patients with EoE pursue treatment mostly to prevent worsening disease. Common barriers to treatment are inconvenience and financial costs. SDM is practiced most by gastroenterologists, but nearly half of patients do not experience SDM, indicating a substantial area of need in EoE.

Psychological Health Among Gastroenterologists During the COVID-19 Pandemic: A National Survey.

The COVID-19 pandemic poses unprecedented and unique challenges to gastroenterologists eager to maintain clinical practice, patients' health, and their own physical/mental well-being. We aimed to estimate the prevalence and critical determinants of psychological distress in gastroenterologists during the COVID-19 pandemic.

[Current state of under- and postgraduate education in abdominal ultrasonography at German university hospitals. A panel study over 20 years]. / Die Aus- und Weiterbildungssituation der Abdomensonografie an den deutschen Universitätskliniken. Eine Längsschnittstudie über 20 Jahre.

OBJECTIVE: In Germany, there is no standardized ultrasound training. This study aims to provide a survey into the current state of abdominal ultrasonography training at German university hospitals as well as a comparative analysis of the results from studies conducted in 1999 and 2009. METHODS: Chief gastroenterologists from Germany's 34 university hospitals were invited to respond to a postal survey asking about technical equipment, the number of ultrasound scans, the role of professional societies and undergraduate as well as postgraduate training. The response rate was 79 %. In addition, 1183 medical students from 34 faculties completed a complementary online teaching evaluation. RESULTS: At university hospitals, abdominal ultrasonography is conducted in an increasingly interdisciplinary context. Today, 29 % of university hospitals have interdisciplinary ultrasound centers. The study shows that the number of available ultrasound machines has increased - each hospital has an average of 5.2 systems. This is an increase of 30 % in comparison to 2009 and of 27 % in comparison to 1999. However, the willingness to invest in modern ultrasound machines has decreased. The total number of ultrasound scans as well as the number of contrast-enhanced ultrasound scans have steadily increased over the past years - with a maximum increase of 28 % between 2009 and 2018. The German Society of Ultrasound in Medicine (DEGUM) is increasingly present at university hospitals. It has further strengthened its prominent role in quality assurance and specialist training. Today, 96 % of the chief gastroenterologists are members of DEGUM and 89 % have obtained further qualification offered by the society. Concerning the duration of the training, the number of mandatory examinations and the amount of supervision, there are still considerable differences among the departments. On average, more doctors are trained per department and year. A 6-month full-time training has been established at most hospitals. Sonography enjoys a high standing among students and the findings show a strong readiness for work in that field. The number of practical courses and students has been increasing over the past years. However, there is often an imbalance between the number of courses offered and students who want to enroll. CONCLUSIONS: Training conditions have improved for medical staff as well as students despite the fact that there are still considerable differences in quality among the hospitals. The number of ultrasound scans is steadily increasing in all departments. The study did not show any adequate improvement in the availability of technical equipment. The German Society of Ultrasound in Medicine (DEGUM) has further strengthened its leading position in the field of sonography.

Hepatocellular carcinoma from the view of gastroenterologist/hepatologist.

Hepatocellular carcinoma (HCC) is one of the major complications of chronic liver disease, mostly of liver cirrhosis. Liver diseases from different causes differ in the risks of HCC development. Different mechanisms of carcinogenesis are involved in HCC development in different liver diseases as well. Generally, two main pathways are distinguished: the cause of liver disease itself (e.g. viral infections, accumulation of heavy metals etc.) and chronic liver inflammation and fibrogenesis, including mechanisms of oxidative stress. Rare cases of HCC in liver without underlying cirrhosis are likely the consequences of the mechanisms directly linked with particular etiological factor (e.g. protein X in chronic hepatitis B virus (HBV) infection). The key approach which can lead to significantly better results of any treatment used in HCC cases is HCC screening and surveillance. The appropriate method of HCC surveillance is abdominal ultrasonography in 6-month intervals. There is still one question to be solved: the correct definition of target population which should undergo this method of surveillance. Currently, the target population in the developed world is defined as all patients with liver cirrhosis. Unfortunately, the only method of primary prevention of HCC is available: universal HBV vaccination. Antiviral treatment of hepatitis B or C is considered as a method of secondary prevention. Adjuvant therapy of HCC after its primary therapy (antiviral therapy after HCC resection etc.) and other measures able to reduce HCC recurrence risk are usually mentioned as tertiary prevention approach. The BCLC staging system is the most common system used in Europe for the classification of HCC at the dia-gnosis. This classification combines the stage of HCC itself with other parameters, such as liver disease severity (Child - Pugh classification), portal hypertension etc. BCLC is a system which guides the physicians to optimal treatment options in every HCC stage. The only potentially curable approaches are surgical resection or liver transplantation. These options may be used in 1/3 of all HCC patients. Unfortunately, the vast majority of HCC patients can be treated only by palliative treatment options with transarterial chemoembolisation being the most common one.

COVID-19 from the Perspective of a Gastroenterologist.

The World Health Organization (WHO) declared the worldwide pandemic of Coronavirus disease-2019 (COVID-19) On March 11, 2020, just three months after the first outbreak of COVID-19 caused by Severe Acute Respiratory Syndrome Coronavirus 2 in China in December 2019. COVID-19 is a contagious disease that can affect anyone, anytime, anywhere, and has had a huge impact on our lives, including social, economic, educational, and cultural life. In this paper, I would like to explore the issues related to COVID-19 in the gastroenterology and share the experiences of domestic and overseas gastroenterologists, and ultimately to seek ways to effectively prepare for and cope with the pandemic era of COVID-19.

Work satisfaction and burnout risk of gastroenterologists in Germany: results of a nationwide survey.

BACKGROUND: More and more gastroenterologists are not satisfied with their working conditions and run the risk of developing burnout symptoms. Little is known about the job satisfaction and burnout risk among physicians working in endoscopy units in Germany. This study examines the risk of burnout and job satisfaction among gastroenterologists in Germany. METHODS: An electronic survey was distributed to gastroenterologists organized mainly in the Federal Organization of Gastroenterology in Germany (BVGD, Berufsverband Gastroenterologie Deutschland e. V.). In addition to general demographic variables, job satisfaction was determined using the Work Satisfaction Questionnaires (WSQ), and burnout risk was determined using the Maslach Burnout Inventory (MBI). RESULTS: A representative sample of gastroenterologists organized in the BVGD (Berufsverband Gastroenterologie Deutschland e. V.) took part in the study (n = 683, 22 %). Above all, we could demonstrate relevant differences with regard to burnout risk and job satisfaction depending on the place of work, clinic structure, position in the clinic, and age. Younger physicians had significantly higher depersonalization (p < 0.001) and exhaustion scores (p < 0.001) with almost medium and small effect sizes (δt = 0.45 and -0.31). The higher the position in the clinic, the higher the accomplishment scores (medium effect size 0.27). Older physicians were especially more satisfied in the areas of patient care (p < 0.001, medium effect size δt = -0.53). Employed doctors show a higher level of satisfaction in terms of "burden" compared to practice owners (p < 0.001, δt = -0.69). Compared to norms used in the EGPRN study which were adapted to physicians, almost one-third of our sample had high depersonalization scores, about 17 % had high exhaustion scores, and about half had low personal accomplishment scores showing a higher general burden among German gastroenterologists. CONCLUSION: Decreased work satisfaction and risk of burnout are important issues among German gastroenterologists. Specific actions should address this problem in order to avoid negative consequences, respectively.

Outrunning Burnout in a GI Fellowship Program During the COVID-19 Pandemic.

Many GI training programs have needed to adjust to the serious disruption to the training and education of fellows worldwide due to the COVID-19 pandemic. A silent problem that has arisen within programs is the issue of burnout among their trainees. Burnout is common among gastroenterologists, especially in fellows (Keswani et al. in Gastroenterology 147(1):11-14, 2014. https://doi.org/10.1053/j.gastro.2014.05.023 , Am J Gastroenterol 106(10):1734-1740, 2011. https://doi.org/10.1038/ajg.2011.148 ), with negative consequences to patient care and the safety of the trainees if not effectively dealt with. In this article, the author describes several additional factors potentially contributing to the intensifying burnout of the fellows in their home institution during this pandemic. Moreover, he describes specific practical interventions that the hospital and program have taken in order to address these factors.