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Physician-Scientist Taps into Microbiome to Fight Cancer
The lowest point in the nascent career of Neelendu Dey, MD, helped seal his fate as a physician-scientist.
He had just started his first year as a resident at University of California, San Francisco. One of his patients was a 30-year-old woman who was dying of metastatic colorectal cancer. “I was in my mid-20s interacting with an individual just a few years older than I am, going through one of the most terrible health outcomes one could imagine,” Dr. Dey said.
He remembers asking the patient what he could do for her, how he could make her feel more comfortable. “That feeling of helplessness, particularly as we think about young people developing cancer, it really stuck with me through the years,” he said.
In an interview, he talked about his dual role as a physician and scientist, and how those two interests are guiding his research in precancerous conditions of the colon.
Cases like that of the young woman with colon cancer “really help drive the urgency of the work we do, and the research questions we ask, as we try to move the ball forward and help folks at earlier stages,” he said.
Q: Why did you choose GI?
When you think about what sorts of chronic diseases really impact your quality of life, gut health is one of the chief contributors among various aspects of health. And that really appealed to me — the ability to take someone who is essentially handicapped by a series of illnesses and symptoms that derive from the GI tract and enable them to return to the person they want to be, to be productive in the way that they want to be, and have a rewarding life.
As I thought about how I wanted to contribute to the future of medicine, one of the ways in which I’ve always thought that I would do that is through research. When I considered the fields that really appealed to me, both from that clinical standpoint and research standpoint, GI was one that really stood out. There has been a lot of exciting research going on in GI. My lab currently studies the microbiome, and I feel like this is an area in which we can contribute.
Q: What role does digestive health play in overall health?
Obviously, the direct answer is gut health is so critical in something like nutritional intake. Some GI symptoms, if your gut health has gone awry, can really be detrimental in terms of quality of life. But one less obvious role that digestive health plays is its long-term effects. We’re starting to appreciate that gut health, the gut microbiome, and gut immune education are probably long-term players. Some experiences in early life might shape our immunity in ways that have consequences for us much later in life. Whether we get early life antibiotics, for example, may potentially contribute to colorectal cancer down the line. Thinking about the long-term players is more challenging, but it’s also an appealing opportunity as we think about how we can shape medicine moving forward.
Q: What practice challenges have you faced in your career?
First, being a physician-scientist. It’s challenging to be either a physician alone or to be a researcher alone. And trying to do both includes the challenges of both individual worlds. It just takes more time to get all the prerequisite training. And second, there are just challenges with getting the opportunities to contribute in the ways that you want — to get the research funding, to get the papers out, things like that.
Q: Tell me about the work you’ve been doing in your lab to develop microbiome-based strategies for preventing and treating cancer.
The microbiome presents several opportunities when it comes to cancer prevention. One is identifying markers of cancer risk, or of general good health down the line. Some of those biomarkers could — potentially — feed directly into personalized risk assessment and maybe even inform a future screening strategy. The second opportunity the microbiome presents is if we identify a microbe that influences your cancer risk, can we then understand and exploit, or utilize, that mechanism to mitigate cancer risk in the future? Our lab has done work looking at subspecies levels of microbes that track with health or cancer. We’ve done some work to identify what these subspecies groupings are and have identified some links to certain precancerous changes in the colon. We think that there’s an opportunity here for future interventions.
Q: Have you published other papers?
We recently published another paper describing how some microbes can interact with a tumor suppressor gene and are influenced in a sex-biased manner to drive tumorigenesis in a mouse model. We think, based on what we’re seeing in human data, that there may be some relationships and we’re exploring that now as well.
Q: What is your vision for the future in GI, and in your career?
The vision that I have is to create clinical tools that can expand our reach and our effectiveness and cancer prevention. I think that there are opportunities for leveraging microbiome research to accomplish this. And one outcome I could imagine is leveraging some of these insights to expand noninvasive screening at even earlier ages than we do now. I mean, we just dialed back the recommended age for colonoscopy for average risk individuals to 45. But I could envision a future in which noninvasive screening starts earlier, in which the first stool-based tests that we deploy to assess personalized risk are used in the pediatric clinic.
Lightning Round
Texting or talking?
Talking
Favorite city in the United States besides the one you live in?
St. Louis
Cat or dog person?
Both
If you weren’t a GI, what would you be?
Musician
Best place you went on vacation?
Borneo
Favorite sport?
Soccer
Favorite ice cream?
Cashew-based salted caramel
What song do you have to sing along with when you hear it?
Sweet Child of Mine
Favorite movie or TV show?
25th Hour or Shawshank Redemption
Optimist or Pessimist?
Optimist
The lowest point in the nascent career of Neelendu Dey, MD, helped seal his fate as a physician-scientist.
He had just started his first year as a resident at University of California, San Francisco. One of his patients was a 30-year-old woman who was dying of metastatic colorectal cancer. “I was in my mid-20s interacting with an individual just a few years older than I am, going through one of the most terrible health outcomes one could imagine,” Dr. Dey said.
He remembers asking the patient what he could do for her, how he could make her feel more comfortable. “That feeling of helplessness, particularly as we think about young people developing cancer, it really stuck with me through the years,” he said.
In an interview, he talked about his dual role as a physician and scientist, and how those two interests are guiding his research in precancerous conditions of the colon.
Cases like that of the young woman with colon cancer “really help drive the urgency of the work we do, and the research questions we ask, as we try to move the ball forward and help folks at earlier stages,” he said.
Q: Why did you choose GI?
When you think about what sorts of chronic diseases really impact your quality of life, gut health is one of the chief contributors among various aspects of health. And that really appealed to me — the ability to take someone who is essentially handicapped by a series of illnesses and symptoms that derive from the GI tract and enable them to return to the person they want to be, to be productive in the way that they want to be, and have a rewarding life.
As I thought about how I wanted to contribute to the future of medicine, one of the ways in which I’ve always thought that I would do that is through research. When I considered the fields that really appealed to me, both from that clinical standpoint and research standpoint, GI was one that really stood out. There has been a lot of exciting research going on in GI. My lab currently studies the microbiome, and I feel like this is an area in which we can contribute.
Q: What role does digestive health play in overall health?
Obviously, the direct answer is gut health is so critical in something like nutritional intake. Some GI symptoms, if your gut health has gone awry, can really be detrimental in terms of quality of life. But one less obvious role that digestive health plays is its long-term effects. We’re starting to appreciate that gut health, the gut microbiome, and gut immune education are probably long-term players. Some experiences in early life might shape our immunity in ways that have consequences for us much later in life. Whether we get early life antibiotics, for example, may potentially contribute to colorectal cancer down the line. Thinking about the long-term players is more challenging, but it’s also an appealing opportunity as we think about how we can shape medicine moving forward.
Q: What practice challenges have you faced in your career?
First, being a physician-scientist. It’s challenging to be either a physician alone or to be a researcher alone. And trying to do both includes the challenges of both individual worlds. It just takes more time to get all the prerequisite training. And second, there are just challenges with getting the opportunities to contribute in the ways that you want — to get the research funding, to get the papers out, things like that.
Q: Tell me about the work you’ve been doing in your lab to develop microbiome-based strategies for preventing and treating cancer.
The microbiome presents several opportunities when it comes to cancer prevention. One is identifying markers of cancer risk, or of general good health down the line. Some of those biomarkers could — potentially — feed directly into personalized risk assessment and maybe even inform a future screening strategy. The second opportunity the microbiome presents is if we identify a microbe that influences your cancer risk, can we then understand and exploit, or utilize, that mechanism to mitigate cancer risk in the future? Our lab has done work looking at subspecies levels of microbes that track with health or cancer. We’ve done some work to identify what these subspecies groupings are and have identified some links to certain precancerous changes in the colon. We think that there’s an opportunity here for future interventions.
Q: Have you published other papers?
We recently published another paper describing how some microbes can interact with a tumor suppressor gene and are influenced in a sex-biased manner to drive tumorigenesis in a mouse model. We think, based on what we’re seeing in human data, that there may be some relationships and we’re exploring that now as well.
Q: What is your vision for the future in GI, and in your career?
The vision that I have is to create clinical tools that can expand our reach and our effectiveness and cancer prevention. I think that there are opportunities for leveraging microbiome research to accomplish this. And one outcome I could imagine is leveraging some of these insights to expand noninvasive screening at even earlier ages than we do now. I mean, we just dialed back the recommended age for colonoscopy for average risk individuals to 45. But I could envision a future in which noninvasive screening starts earlier, in which the first stool-based tests that we deploy to assess personalized risk are used in the pediatric clinic.
Lightning Round
Texting or talking?
Talking
Favorite city in the United States besides the one you live in?
St. Louis
Cat or dog person?
Both
If you weren’t a GI, what would you be?
Musician
Best place you went on vacation?
Borneo
Favorite sport?
Soccer
Favorite ice cream?
Cashew-based salted caramel
What song do you have to sing along with when you hear it?
Sweet Child of Mine
Favorite movie or TV show?
25th Hour or Shawshank Redemption
Optimist or Pessimist?
Optimist
The lowest point in the nascent career of Neelendu Dey, MD, helped seal his fate as a physician-scientist.
He had just started his first year as a resident at University of California, San Francisco. One of his patients was a 30-year-old woman who was dying of metastatic colorectal cancer. “I was in my mid-20s interacting with an individual just a few years older than I am, going through one of the most terrible health outcomes one could imagine,” Dr. Dey said.
He remembers asking the patient what he could do for her, how he could make her feel more comfortable. “That feeling of helplessness, particularly as we think about young people developing cancer, it really stuck with me through the years,” he said.
In an interview, he talked about his dual role as a physician and scientist, and how those two interests are guiding his research in precancerous conditions of the colon.
Cases like that of the young woman with colon cancer “really help drive the urgency of the work we do, and the research questions we ask, as we try to move the ball forward and help folks at earlier stages,” he said.
Q: Why did you choose GI?
When you think about what sorts of chronic diseases really impact your quality of life, gut health is one of the chief contributors among various aspects of health. And that really appealed to me — the ability to take someone who is essentially handicapped by a series of illnesses and symptoms that derive from the GI tract and enable them to return to the person they want to be, to be productive in the way that they want to be, and have a rewarding life.
As I thought about how I wanted to contribute to the future of medicine, one of the ways in which I’ve always thought that I would do that is through research. When I considered the fields that really appealed to me, both from that clinical standpoint and research standpoint, GI was one that really stood out. There has been a lot of exciting research going on in GI. My lab currently studies the microbiome, and I feel like this is an area in which we can contribute.
Q: What role does digestive health play in overall health?
Obviously, the direct answer is gut health is so critical in something like nutritional intake. Some GI symptoms, if your gut health has gone awry, can really be detrimental in terms of quality of life. But one less obvious role that digestive health plays is its long-term effects. We’re starting to appreciate that gut health, the gut microbiome, and gut immune education are probably long-term players. Some experiences in early life might shape our immunity in ways that have consequences for us much later in life. Whether we get early life antibiotics, for example, may potentially contribute to colorectal cancer down the line. Thinking about the long-term players is more challenging, but it’s also an appealing opportunity as we think about how we can shape medicine moving forward.
Q: What practice challenges have you faced in your career?
First, being a physician-scientist. It’s challenging to be either a physician alone or to be a researcher alone. And trying to do both includes the challenges of both individual worlds. It just takes more time to get all the prerequisite training. And second, there are just challenges with getting the opportunities to contribute in the ways that you want — to get the research funding, to get the papers out, things like that.
Q: Tell me about the work you’ve been doing in your lab to develop microbiome-based strategies for preventing and treating cancer.
The microbiome presents several opportunities when it comes to cancer prevention. One is identifying markers of cancer risk, or of general good health down the line. Some of those biomarkers could — potentially — feed directly into personalized risk assessment and maybe even inform a future screening strategy. The second opportunity the microbiome presents is if we identify a microbe that influences your cancer risk, can we then understand and exploit, or utilize, that mechanism to mitigate cancer risk in the future? Our lab has done work looking at subspecies levels of microbes that track with health or cancer. We’ve done some work to identify what these subspecies groupings are and have identified some links to certain precancerous changes in the colon. We think that there’s an opportunity here for future interventions.
Q: Have you published other papers?
We recently published another paper describing how some microbes can interact with a tumor suppressor gene and are influenced in a sex-biased manner to drive tumorigenesis in a mouse model. We think, based on what we’re seeing in human data, that there may be some relationships and we’re exploring that now as well.
Q: What is your vision for the future in GI, and in your career?
The vision that I have is to create clinical tools that can expand our reach and our effectiveness and cancer prevention. I think that there are opportunities for leveraging microbiome research to accomplish this. And one outcome I could imagine is leveraging some of these insights to expand noninvasive screening at even earlier ages than we do now. I mean, we just dialed back the recommended age for colonoscopy for average risk individuals to 45. But I could envision a future in which noninvasive screening starts earlier, in which the first stool-based tests that we deploy to assess personalized risk are used in the pediatric clinic.
Lightning Round
Texting or talking?
Talking
Favorite city in the United States besides the one you live in?
St. Louis
Cat or dog person?
Both
If you weren’t a GI, what would you be?
Musician
Best place you went on vacation?
Borneo
Favorite sport?
Soccer
Favorite ice cream?
Cashew-based salted caramel
What song do you have to sing along with when you hear it?
Sweet Child of Mine
Favorite movie or TV show?
25th Hour or Shawshank Redemption
Optimist or Pessimist?
Optimist
Elevate Your Career: AGA Women in GI Regional Workshops Await
As a woman in a dynamic and ever-changing profession, balancing life as a powerhouse physician or scientist is no easy feat. AGA recognizes the challenges you face and is committed to addressing them directly at the AGA Women in GI Regional Workshops. The program has been expanded to six workshops in 2024.
. Participate in candid discussions regarding the challenges you face as a woman navigating the 21st century healthcare environment. Derive inspiration from your community and cultivate meaningful connections that will carry you beyond the workshop.
You may choose to join us in person or virtually, whatever fits into your busy schedule. We are also pleased to offer grants of $300 to support travel and registration fees for trainee and early career women. Additional details for the Maria Leo-Lieber Travel Award may be found in your confirmation email.
Register today for the final three workshops.
Rocky Mountain West
Saturday, Sept. 8
Colorado Springs, Colorado
Deadline to apply for a travel grant: Aug. 23
Deadline to register: Aug. 30
Southwest
Saturday, Sept. 14
Houston, Texas
Deadline to apply for a travel grant: Aug. 30
Deadline to register: Sept. 6
Southeast
Saturday, Nov. 2
Coral Gables, Florida
Deadline to apply for a travel grant: Oct. 8
Deadline to register: Oct. 25
This program is supported by Janssen.
As a woman in a dynamic and ever-changing profession, balancing life as a powerhouse physician or scientist is no easy feat. AGA recognizes the challenges you face and is committed to addressing them directly at the AGA Women in GI Regional Workshops. The program has been expanded to six workshops in 2024.
. Participate in candid discussions regarding the challenges you face as a woman navigating the 21st century healthcare environment. Derive inspiration from your community and cultivate meaningful connections that will carry you beyond the workshop.
You may choose to join us in person or virtually, whatever fits into your busy schedule. We are also pleased to offer grants of $300 to support travel and registration fees for trainee and early career women. Additional details for the Maria Leo-Lieber Travel Award may be found in your confirmation email.
Register today for the final three workshops.
Rocky Mountain West
Saturday, Sept. 8
Colorado Springs, Colorado
Deadline to apply for a travel grant: Aug. 23
Deadline to register: Aug. 30
Southwest
Saturday, Sept. 14
Houston, Texas
Deadline to apply for a travel grant: Aug. 30
Deadline to register: Sept. 6
Southeast
Saturday, Nov. 2
Coral Gables, Florida
Deadline to apply for a travel grant: Oct. 8
Deadline to register: Oct. 25
This program is supported by Janssen.
As a woman in a dynamic and ever-changing profession, balancing life as a powerhouse physician or scientist is no easy feat. AGA recognizes the challenges you face and is committed to addressing them directly at the AGA Women in GI Regional Workshops. The program has been expanded to six workshops in 2024.
. Participate in candid discussions regarding the challenges you face as a woman navigating the 21st century healthcare environment. Derive inspiration from your community and cultivate meaningful connections that will carry you beyond the workshop.
You may choose to join us in person or virtually, whatever fits into your busy schedule. We are also pleased to offer grants of $300 to support travel and registration fees for trainee and early career women. Additional details for the Maria Leo-Lieber Travel Award may be found in your confirmation email.
Register today for the final three workshops.
Rocky Mountain West
Saturday, Sept. 8
Colorado Springs, Colorado
Deadline to apply for a travel grant: Aug. 23
Deadline to register: Aug. 30
Southwest
Saturday, Sept. 14
Houston, Texas
Deadline to apply for a travel grant: Aug. 30
Deadline to register: Sept. 6
Southeast
Saturday, Nov. 2
Coral Gables, Florida
Deadline to apply for a travel grant: Oct. 8
Deadline to register: Oct. 25
This program is supported by Janssen.
How To Navigate Your First Job
In a special episode live from Digestive Disease Week® (DDW) 2024, host Dr. Matthew Whitson talks with returning guest Dr. Janice Jou. Dr. Jou is a transplant hematologist at the Portland VA and currently serves as professor of medicine and fellowship program director at Oregon Health & Science University. Don’t miss her insight as she shares advice all about what she wishes she knew when going into her first job in gastroenterology. Dr. Jou also answers questions from the audience on topics including “when to say no” and the importance of encouraging emotional transparency with fellows and faculty.
Catch up with past episodes and subscribe wherever you listen to podcasts. You can also listen by clicking on the episode name below.
- Episode 5: Janice Jou: Live from #DDW2024 with tips for your first job
- Episode 4: Loren Rabinowitz and Rachel Issaka: Building research collaborations
- Episode 3: Andy Tau: How to treat GI emergencies
- Episode 2: Laurel Fisher and Asma Khapra: Advancing and advocating for women in GI
- Episode 1: Barbara Jung: Unpacking mentorship with AGA’s president
In a special episode live from Digestive Disease Week® (DDW) 2024, host Dr. Matthew Whitson talks with returning guest Dr. Janice Jou. Dr. Jou is a transplant hematologist at the Portland VA and currently serves as professor of medicine and fellowship program director at Oregon Health & Science University. Don’t miss her insight as she shares advice all about what she wishes she knew when going into her first job in gastroenterology. Dr. Jou also answers questions from the audience on topics including “when to say no” and the importance of encouraging emotional transparency with fellows and faculty.
Catch up with past episodes and subscribe wherever you listen to podcasts. You can also listen by clicking on the episode name below.
- Episode 5: Janice Jou: Live from #DDW2024 with tips for your first job
- Episode 4: Loren Rabinowitz and Rachel Issaka: Building research collaborations
- Episode 3: Andy Tau: How to treat GI emergencies
- Episode 2: Laurel Fisher and Asma Khapra: Advancing and advocating for women in GI
- Episode 1: Barbara Jung: Unpacking mentorship with AGA’s president
In a special episode live from Digestive Disease Week® (DDW) 2024, host Dr. Matthew Whitson talks with returning guest Dr. Janice Jou. Dr. Jou is a transplant hematologist at the Portland VA and currently serves as professor of medicine and fellowship program director at Oregon Health & Science University. Don’t miss her insight as she shares advice all about what she wishes she knew when going into her first job in gastroenterology. Dr. Jou also answers questions from the audience on topics including “when to say no” and the importance of encouraging emotional transparency with fellows and faculty.
Catch up with past episodes and subscribe wherever you listen to podcasts. You can also listen by clicking on the episode name below.
- Episode 5: Janice Jou: Live from #DDW2024 with tips for your first job
- Episode 4: Loren Rabinowitz and Rachel Issaka: Building research collaborations
- Episode 3: Andy Tau: How to treat GI emergencies
- Episode 2: Laurel Fisher and Asma Khapra: Advancing and advocating for women in GI
- Episode 1: Barbara Jung: Unpacking mentorship with AGA’s president
AGA Issues Guidance on Identifying, Treating Cyclic Vomiting Syndrome
, according to a new clinical practice update from the American Gastroenterological Association.
CVS affects up to 2% of U.S. adults and is more common in women, young adults, and those with a personal or family history of migraine headaches. However, most patients don’t receive a diagnosis or often experience years of delay in receiving effective treatment.
“A diagnosis is a powerful tool. Not only does it help patients make sense of debilitating symptoms, but it allows healthcare providers to create an effective treatment plan,” said author David J. Levinthal, MD, AGAF, director of the Neurogastroenterology and Motility Center at the University of Pittsburgh Medical Center.
The update was published online in Gastroenterology.
Understanding Cyclic Vomiting Syndrome
CVS is a chronic disorder of gut-brain interaction (DGBI), which is characterized by acute episodes of nausea and vomiting, separated by time without symptoms. Patients can usually identify a pattern of symptoms that show up during and between episodes.
CVS can vary, ranging from mild — with less than four episodes per year and lasting less than 2 days — to moderate-severe — with more than four episodes per year, lasting more than 2 days, and requiring at least one emergency department visit or hospitalization.
The disorder has four distinct phases — inter-episodic, prodromal, emetic, and recovery — that align with distinct treatment and management strategies. Between episodes, patients typically don’t experience repetitive vomiting but may experience symptoms such as mild nausea, indigestion, and occasional vomiting. Although CVS episodes can happen at any time, most tend to occur in the early morning.
For diagnosis, clinicians should consider CVS in adults presenting with episodic bouts of repetitive vomiting, following criteria established by the Rome Foundation. Rome IV criteria include acute-onset vomiting lasting less than 7 days, at least three discrete episodes in a year with two in the previous 6 months, and an absence of vomiting between episodes separated by at least 1 week of baseline health.
About 65% of patients with CVS experience prodromal symptoms, which last for about an hour before the onset of vomiting and may include panic, a sense of doom, and an inability to communicate effectively. During prodromal or emetic phases, patients have also reported fatigue, brain fog, restlessness, anxiety, headache, bowel urgency, abdominal pain, flushing, or shakiness.
As with migraines, CVS episodes may often be triggered by psychological and physiological factors, particularly stress. Episodes can stem from both negative stress, such as a death or relationship conflicts, as well as positive stress, such as birthdays and vacations. Other triggers include sleep deprivation, hormonal fluctuations linked to the menstrual cycle, travel, motion sickness, or acute infections.
Adult CVS is associated with several conditions, particularly mood disorders, including anxiety, depression, and panic disorder. Patients may also experience migraines, seizure disorders, or autonomic imbalances, such as postural orthostatic tachycardia syndrome, which may indicate pathophysiological mechanisms and routes for management.
The American Neurogastroenterology and Motility Society recommends testing to rule out similar or overlapping conditions, such as Addison’s disease, hypothyroidism, and hepatic porphyria. Diagnostic workup should include blood work, urinalysis, and one-time esophagogastroduodenoscopy or upper gastrointestinal imaging. Repeated imaging and gastric emptying scans should be avoided.
Providing Treatment and Prevention
For treatment, knowing the CVS phase is “essential,” the authors wrote. For instance, during the prodromal phase, abortive therapies can halt the transition to the emetic phase, and earlier intervention is associated with a higher probability of stopping an episode. The authors recommend intranasal sumatriptan, ondansetron, antihistamines, and sedatives.
During the emetic phase, supportive therapy can help terminate the episode. This may include continuing the abortive regimen and going to the emergency department for hydration and antiemetic medications. Patients may also find relief in a quiet, darker room in the emergency department, along with IV benzodiazepines, with the goal of inducing sedation.
During the recovery phase, patients should rest and focus on rehydration and nutrition to return to the well phase.
During the well or inter-episodic phase, patients can follow lifestyle measures to identify and avoid triggers, such as taking prophylactic medication (tricyclic antidepressants, anticonvulsants, and neurokinin-1 receptor antagonists such as aprepitant), reducing stress, and implementing a good sleep routine.
As part of patient education, clinicians can discuss the four phases and rehearse the actions to take to prevent or stop an episode.
“CVS has a significant impact on patients, families, and the healthcare system. The unpredictable and disruptive nature of episodes can result in reduced health-related quality of life, job loss precipitated by work absenteeism, and even divorce,” said Rosita Frazier, MD, a gastroenterologist at Mayo Clinic Arizona in Scottsdale who specializes in DGBI and CVS. Dr. Frazier, who wasn’t involved with the clinical practice update, has previously written about CVS diagnosis and management.
“Providing an individualized care plan for all patients could potentially address this problem and improve the physician-patient interaction,” she said. “Educational efforts to raise awareness among the medical community and increase both patient and provider engagement can optimize outcomes and are needed to address this critical problem.”
The authors received no specific funding for this update. Dr. Levinthal is a consultant for Takeda Pharmaceuticals and Mahana. Dr. Frazier reported no relevant financial disclosures.
, according to a new clinical practice update from the American Gastroenterological Association.
CVS affects up to 2% of U.S. adults and is more common in women, young adults, and those with a personal or family history of migraine headaches. However, most patients don’t receive a diagnosis or often experience years of delay in receiving effective treatment.
“A diagnosis is a powerful tool. Not only does it help patients make sense of debilitating symptoms, but it allows healthcare providers to create an effective treatment plan,” said author David J. Levinthal, MD, AGAF, director of the Neurogastroenterology and Motility Center at the University of Pittsburgh Medical Center.
The update was published online in Gastroenterology.
Understanding Cyclic Vomiting Syndrome
CVS is a chronic disorder of gut-brain interaction (DGBI), which is characterized by acute episodes of nausea and vomiting, separated by time without symptoms. Patients can usually identify a pattern of symptoms that show up during and between episodes.
CVS can vary, ranging from mild — with less than four episodes per year and lasting less than 2 days — to moderate-severe — with more than four episodes per year, lasting more than 2 days, and requiring at least one emergency department visit or hospitalization.
The disorder has four distinct phases — inter-episodic, prodromal, emetic, and recovery — that align with distinct treatment and management strategies. Between episodes, patients typically don’t experience repetitive vomiting but may experience symptoms such as mild nausea, indigestion, and occasional vomiting. Although CVS episodes can happen at any time, most tend to occur in the early morning.
For diagnosis, clinicians should consider CVS in adults presenting with episodic bouts of repetitive vomiting, following criteria established by the Rome Foundation. Rome IV criteria include acute-onset vomiting lasting less than 7 days, at least three discrete episodes in a year with two in the previous 6 months, and an absence of vomiting between episodes separated by at least 1 week of baseline health.
About 65% of patients with CVS experience prodromal symptoms, which last for about an hour before the onset of vomiting and may include panic, a sense of doom, and an inability to communicate effectively. During prodromal or emetic phases, patients have also reported fatigue, brain fog, restlessness, anxiety, headache, bowel urgency, abdominal pain, flushing, or shakiness.
As with migraines, CVS episodes may often be triggered by psychological and physiological factors, particularly stress. Episodes can stem from both negative stress, such as a death or relationship conflicts, as well as positive stress, such as birthdays and vacations. Other triggers include sleep deprivation, hormonal fluctuations linked to the menstrual cycle, travel, motion sickness, or acute infections.
Adult CVS is associated with several conditions, particularly mood disorders, including anxiety, depression, and panic disorder. Patients may also experience migraines, seizure disorders, or autonomic imbalances, such as postural orthostatic tachycardia syndrome, which may indicate pathophysiological mechanisms and routes for management.
The American Neurogastroenterology and Motility Society recommends testing to rule out similar or overlapping conditions, such as Addison’s disease, hypothyroidism, and hepatic porphyria. Diagnostic workup should include blood work, urinalysis, and one-time esophagogastroduodenoscopy or upper gastrointestinal imaging. Repeated imaging and gastric emptying scans should be avoided.
Providing Treatment and Prevention
For treatment, knowing the CVS phase is “essential,” the authors wrote. For instance, during the prodromal phase, abortive therapies can halt the transition to the emetic phase, and earlier intervention is associated with a higher probability of stopping an episode. The authors recommend intranasal sumatriptan, ondansetron, antihistamines, and sedatives.
During the emetic phase, supportive therapy can help terminate the episode. This may include continuing the abortive regimen and going to the emergency department for hydration and antiemetic medications. Patients may also find relief in a quiet, darker room in the emergency department, along with IV benzodiazepines, with the goal of inducing sedation.
During the recovery phase, patients should rest and focus on rehydration and nutrition to return to the well phase.
During the well or inter-episodic phase, patients can follow lifestyle measures to identify and avoid triggers, such as taking prophylactic medication (tricyclic antidepressants, anticonvulsants, and neurokinin-1 receptor antagonists such as aprepitant), reducing stress, and implementing a good sleep routine.
As part of patient education, clinicians can discuss the four phases and rehearse the actions to take to prevent or stop an episode.
“CVS has a significant impact on patients, families, and the healthcare system. The unpredictable and disruptive nature of episodes can result in reduced health-related quality of life, job loss precipitated by work absenteeism, and even divorce,” said Rosita Frazier, MD, a gastroenterologist at Mayo Clinic Arizona in Scottsdale who specializes in DGBI and CVS. Dr. Frazier, who wasn’t involved with the clinical practice update, has previously written about CVS diagnosis and management.
“Providing an individualized care plan for all patients could potentially address this problem and improve the physician-patient interaction,” she said. “Educational efforts to raise awareness among the medical community and increase both patient and provider engagement can optimize outcomes and are needed to address this critical problem.”
The authors received no specific funding for this update. Dr. Levinthal is a consultant for Takeda Pharmaceuticals and Mahana. Dr. Frazier reported no relevant financial disclosures.
, according to a new clinical practice update from the American Gastroenterological Association.
CVS affects up to 2% of U.S. adults and is more common in women, young adults, and those with a personal or family history of migraine headaches. However, most patients don’t receive a diagnosis or often experience years of delay in receiving effective treatment.
“A diagnosis is a powerful tool. Not only does it help patients make sense of debilitating symptoms, but it allows healthcare providers to create an effective treatment plan,” said author David J. Levinthal, MD, AGAF, director of the Neurogastroenterology and Motility Center at the University of Pittsburgh Medical Center.
The update was published online in Gastroenterology.
Understanding Cyclic Vomiting Syndrome
CVS is a chronic disorder of gut-brain interaction (DGBI), which is characterized by acute episodes of nausea and vomiting, separated by time without symptoms. Patients can usually identify a pattern of symptoms that show up during and between episodes.
CVS can vary, ranging from mild — with less than four episodes per year and lasting less than 2 days — to moderate-severe — with more than four episodes per year, lasting more than 2 days, and requiring at least one emergency department visit or hospitalization.
The disorder has four distinct phases — inter-episodic, prodromal, emetic, and recovery — that align with distinct treatment and management strategies. Between episodes, patients typically don’t experience repetitive vomiting but may experience symptoms such as mild nausea, indigestion, and occasional vomiting. Although CVS episodes can happen at any time, most tend to occur in the early morning.
For diagnosis, clinicians should consider CVS in adults presenting with episodic bouts of repetitive vomiting, following criteria established by the Rome Foundation. Rome IV criteria include acute-onset vomiting lasting less than 7 days, at least three discrete episodes in a year with two in the previous 6 months, and an absence of vomiting between episodes separated by at least 1 week of baseline health.
About 65% of patients with CVS experience prodromal symptoms, which last for about an hour before the onset of vomiting and may include panic, a sense of doom, and an inability to communicate effectively. During prodromal or emetic phases, patients have also reported fatigue, brain fog, restlessness, anxiety, headache, bowel urgency, abdominal pain, flushing, or shakiness.
As with migraines, CVS episodes may often be triggered by psychological and physiological factors, particularly stress. Episodes can stem from both negative stress, such as a death or relationship conflicts, as well as positive stress, such as birthdays and vacations. Other triggers include sleep deprivation, hormonal fluctuations linked to the menstrual cycle, travel, motion sickness, or acute infections.
Adult CVS is associated with several conditions, particularly mood disorders, including anxiety, depression, and panic disorder. Patients may also experience migraines, seizure disorders, or autonomic imbalances, such as postural orthostatic tachycardia syndrome, which may indicate pathophysiological mechanisms and routes for management.
The American Neurogastroenterology and Motility Society recommends testing to rule out similar or overlapping conditions, such as Addison’s disease, hypothyroidism, and hepatic porphyria. Diagnostic workup should include blood work, urinalysis, and one-time esophagogastroduodenoscopy or upper gastrointestinal imaging. Repeated imaging and gastric emptying scans should be avoided.
Providing Treatment and Prevention
For treatment, knowing the CVS phase is “essential,” the authors wrote. For instance, during the prodromal phase, abortive therapies can halt the transition to the emetic phase, and earlier intervention is associated with a higher probability of stopping an episode. The authors recommend intranasal sumatriptan, ondansetron, antihistamines, and sedatives.
During the emetic phase, supportive therapy can help terminate the episode. This may include continuing the abortive regimen and going to the emergency department for hydration and antiemetic medications. Patients may also find relief in a quiet, darker room in the emergency department, along with IV benzodiazepines, with the goal of inducing sedation.
During the recovery phase, patients should rest and focus on rehydration and nutrition to return to the well phase.
During the well or inter-episodic phase, patients can follow lifestyle measures to identify and avoid triggers, such as taking prophylactic medication (tricyclic antidepressants, anticonvulsants, and neurokinin-1 receptor antagonists such as aprepitant), reducing stress, and implementing a good sleep routine.
As part of patient education, clinicians can discuss the four phases and rehearse the actions to take to prevent or stop an episode.
“CVS has a significant impact on patients, families, and the healthcare system. The unpredictable and disruptive nature of episodes can result in reduced health-related quality of life, job loss precipitated by work absenteeism, and even divorce,” said Rosita Frazier, MD, a gastroenterologist at Mayo Clinic Arizona in Scottsdale who specializes in DGBI and CVS. Dr. Frazier, who wasn’t involved with the clinical practice update, has previously written about CVS diagnosis and management.
“Providing an individualized care plan for all patients could potentially address this problem and improve the physician-patient interaction,” she said. “Educational efforts to raise awareness among the medical community and increase both patient and provider engagement can optimize outcomes and are needed to address this critical problem.”
The authors received no specific funding for this update. Dr. Levinthal is a consultant for Takeda Pharmaceuticals and Mahana. Dr. Frazier reported no relevant financial disclosures.
FROM GASTROENTEROLOGY
We’re Making Progress in the Fight Against GI Cancers
The House Appropriations Committee has included AGA-provided language on gastric and esophageal cancers in the FY25 Labor, Health, and Human Services report.
Gastric and esophageal cancers rates are rising and have a low 5-year survival rate and are highly fatal due to the lack of screening — despite both cancers typically being associated with reduced mortality. Delays in diagnosis lead to poor prognoses when the cancer is already at an advanced stage.
These cancers receive disproportionately low funding and have the lowest ratio of funding to lethality to any other cancer.
That’s why it’s crucial to close the gap and increase screening for GI cancers that are less commonly screened for.
AGA’s provided language encourages NIH to develop, test and implement screening strategies for gastric and esophageal cancers using non-endoscopic screening modalities, personalized clinical risk stratification for screenings and biomarker-based risk-stratification.
Why is this important?
This submission is the first time AGA language on gastric and esophageal cancer has been requested and included in the committee’s report. This illustrates the Committee’s recognition of the importance of GI cancer detection and the work being done by NIH.
What does this mean for GI?
This is an important first step to increasing access to cancer screenings! We look forward to working with our champions on Capitol Hill to increase patient access GI cancer screenings.
The House Appropriations Committee has included AGA-provided language on gastric and esophageal cancers in the FY25 Labor, Health, and Human Services report.
Gastric and esophageal cancers rates are rising and have a low 5-year survival rate and are highly fatal due to the lack of screening — despite both cancers typically being associated with reduced mortality. Delays in diagnosis lead to poor prognoses when the cancer is already at an advanced stage.
These cancers receive disproportionately low funding and have the lowest ratio of funding to lethality to any other cancer.
That’s why it’s crucial to close the gap and increase screening for GI cancers that are less commonly screened for.
AGA’s provided language encourages NIH to develop, test and implement screening strategies for gastric and esophageal cancers using non-endoscopic screening modalities, personalized clinical risk stratification for screenings and biomarker-based risk-stratification.
Why is this important?
This submission is the first time AGA language on gastric and esophageal cancer has been requested and included in the committee’s report. This illustrates the Committee’s recognition of the importance of GI cancer detection and the work being done by NIH.
What does this mean for GI?
This is an important first step to increasing access to cancer screenings! We look forward to working with our champions on Capitol Hill to increase patient access GI cancer screenings.
The House Appropriations Committee has included AGA-provided language on gastric and esophageal cancers in the FY25 Labor, Health, and Human Services report.
Gastric and esophageal cancers rates are rising and have a low 5-year survival rate and are highly fatal due to the lack of screening — despite both cancers typically being associated with reduced mortality. Delays in diagnosis lead to poor prognoses when the cancer is already at an advanced stage.
These cancers receive disproportionately low funding and have the lowest ratio of funding to lethality to any other cancer.
That’s why it’s crucial to close the gap and increase screening for GI cancers that are less commonly screened for.
AGA’s provided language encourages NIH to develop, test and implement screening strategies for gastric and esophageal cancers using non-endoscopic screening modalities, personalized clinical risk stratification for screenings and biomarker-based risk-stratification.
Why is this important?
This submission is the first time AGA language on gastric and esophageal cancer has been requested and included in the committee’s report. This illustrates the Committee’s recognition of the importance of GI cancer detection and the work being done by NIH.
What does this mean for GI?
This is an important first step to increasing access to cancer screenings! We look forward to working with our champions on Capitol Hill to increase patient access GI cancer screenings.
Check Out Our New Ulcerative Colitis Clinician Toolkit
Check out and bookmark AGA’s new ulcerative colitis toolkit, which compiles all our ulcerative colitis clinical guidance, continuing education resources, patient education, and FAQs into one convenient toolkit.
Curious about our other toolkits? Check out our toolkit on Crohn’s disease.
The new UC toolkit includes clinical guidance on:
- Role of biomarkers for the management of ulcerative colitis
- Medical management of moderate to severe ulcerative colitis
- Management of pouchitis and inflammatory pouch disorders
For more resources for ulcerative colitis patients, visit the Patient Center on the AGA website.
The AGA Patient Center has a variety of information that can be shared with your patients, including tips on diet, vaccine recommendations, and information on biosimilars.
Check out and bookmark AGA’s new ulcerative colitis toolkit, which compiles all our ulcerative colitis clinical guidance, continuing education resources, patient education, and FAQs into one convenient toolkit.
Curious about our other toolkits? Check out our toolkit on Crohn’s disease.
The new UC toolkit includes clinical guidance on:
- Role of biomarkers for the management of ulcerative colitis
- Medical management of moderate to severe ulcerative colitis
- Management of pouchitis and inflammatory pouch disorders
For more resources for ulcerative colitis patients, visit the Patient Center on the AGA website.
The AGA Patient Center has a variety of information that can be shared with your patients, including tips on diet, vaccine recommendations, and information on biosimilars.
Check out and bookmark AGA’s new ulcerative colitis toolkit, which compiles all our ulcerative colitis clinical guidance, continuing education resources, patient education, and FAQs into one convenient toolkit.
Curious about our other toolkits? Check out our toolkit on Crohn’s disease.
The new UC toolkit includes clinical guidance on:
- Role of biomarkers for the management of ulcerative colitis
- Medical management of moderate to severe ulcerative colitis
- Management of pouchitis and inflammatory pouch disorders
For more resources for ulcerative colitis patients, visit the Patient Center on the AGA website.
The AGA Patient Center has a variety of information that can be shared with your patients, including tips on diet, vaccine recommendations, and information on biosimilars.
Announcing Our 2024 AGA Council Chair and Section Leaders
Meet Our New Chair
Douglas J. Robertson, MD, MPH, AGAFAGA Institute Council Chair
VA Medical Center, White River Junction, Vermont
Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
Dr. Robertson will serve as council chair for 3 years (May 2024-May 2027; DDW 2025, 2026 and 2027).
Section Leadership
, the driving force behind AGA’s programming at Digestive Disease Week (DDW). We welcome 8 members into their new roles as section vice chairs, joining the existing 17 Council members. Each new vice chair will serve a 2-year term that began immediately following this year’s DDW meeting and extends through DDW 2026. Following their term as vice chair, they will move into the role of section chair for an additional 2 years through DDW 2028. 
We are also pleased to announce the members joining nominating committees during the 2026 nomination/election cycle. The chairs of the nominating committee will be the immediate past section chairs, whom we also recognize and thank for their service and dedication to the section and the council.
Basic & Clinical Intestinal Disorders (BCID)
Uma Sundaram, MDVice chair
Marshall University School of Medicine, Huntington, West Virginia
Nominating committee members
- Colleen Renee Kelly, MD, AGAF, Chair
- Amy C. Engevik, PhD, Medical University of South Carolina
- Ravinder Gill, PhD, University of Illinois at Chicago
- Madhusudan Grover, MD, Mayo Clinic, Rochester, Minnesota
- Lisa L. Strate, MD, Harborview Medical Center, Seattle
Clinical Practice (CP)
Linda Anh Nguyen, MDVice Chair
Stanford (Calif.) University School of Medicine
Nominating committee members
- Gary W. Falk, MD, MS, AGAF, Chair
- Megan Adams, MD, JD, MSc, VA Ann Arbor Healthcare System Endoscopy Unit
- Mohammad Bilal, MD, Minneapolis VA Health Care System
- Carolyn Newberry, MD, Weill Cornell Medical Center, New York
- Adam Weizman, MD, MSc, Mount Sinai Hospital, Toronto
Endoscopy, Technology & Imaging (ETI)
Vivek Kaul, MD, AGAFVice Chair
University of Rochester (N.Y.) Medical Center
Nominating committee members
- Irving Waxman, MD, Chair
- Sushovan Guha, MD, PhD, University of Texas at Houston
- Pichamol Jirapinyo, MD, MPH, Brigham and Women’s Hospital, Boston
- Vladimir Kushnir, MD, Washington University St. Louis Barnes–Jewish West County Hospital
- Andrew C. Storm, MD, Mayo Clinic, Rochester, Minnesota
Immunology, Microbiology & Inflammatory Bowel Diseases (IMIBD)
Florian Rieder, MDVice Chair
Cleveland Clinic Foundation
Nominating committee members
- Fernando S. Velayos, MD, AGAF, Chair
- Brigid S. Boland, MD, University of California, San Diego
- Karen L. Edelblum, PhD, Icahn School of Medicine at Mount Sinai, New York
- Michael Kattah, MD, PhD, UCSF Gastroenterology
- Andres J. Yarur, MD, Cedars Sinai Medical Center. Los Angeles
Liver & Biliary (LB)
Don Rockey, MDVice Chair
Medical University of South Carolina, Charleston
Nominating committee members
- Gyongyi Szabo, MD, PhD, AGAF, Chair
- Brett Fortune, MD, MSc, Montefiore Medical Center
- Ruben Hernaez, MD, MPH, PhD, Baylor College of Medicine, Houston
- Cynthia Ann Moylan, MD, MHS, MS, Duke University, Durham, North Carolina
- Douglas A. Simonetto, MD, Mayo Clinic, Rochester, Minnesota
Microbiome & Microbial Therapy (MMT)
Jessica Allegretti, MD, MPHVice Chair
Brigham and Women’s Hospital, Boston
Nominating committee members
- Purna C. Kashyap, MBBS, AGAF, Chair
- Melinda Engevik, PhD, Medical University of South Carolina
- Christian Jobin, PhD, University of Florida
- Vanessa Leone, PhD, The University of Wisconsin–Madison
- Jun Yu, MD, PhD, The Chinese University of Hong Kong
Obesity, Metabolism & Nutrition (OMN)
Berkeley M. Limketkai, MD, PhDVice Chair
University of California Los Angeles
Nominating committee members
- Andres Jose Acosta, MD, PhD, Chair
- Barham K. Abu Dayyeh, MD, MPH, Mayo Clinic, Rochester, Minnesota
- Alan L. Buchman, MD, MSPH, University of Illinois at Chicago
- Octavia Pickett-Blakely, MD, MHS, Hospital of the University of Pennsylvania
- Robert Shulman, MD, Texas Children’s Hospital, Baylor College of Medicine
Pediatric Gastroenterology & Developmental Biology (PGDB)
Kelli L. VanDussen, PhDVice Chair
Cincinnati Children’s Hospital Medical Center
Meet Our New Chair
Douglas J. Robertson, MD, MPH, AGAFAGA Institute Council Chair
VA Medical Center, White River Junction, Vermont
Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
Dr. Robertson will serve as council chair for 3 years (May 2024-May 2027; DDW 2025, 2026 and 2027).
Section Leadership
, the driving force behind AGA’s programming at Digestive Disease Week (DDW). We welcome 8 members into their new roles as section vice chairs, joining the existing 17 Council members. Each new vice chair will serve a 2-year term that began immediately following this year’s DDW meeting and extends through DDW 2026. Following their term as vice chair, they will move into the role of section chair for an additional 2 years through DDW 2028.
We are also pleased to announce the members joining nominating committees during the 2026 nomination/election cycle. The chairs of the nominating committee will be the immediate past section chairs, whom we also recognize and thank for their service and dedication to the section and the council.
Basic & Clinical Intestinal Disorders (BCID)
Uma Sundaram, MDVice chair
Marshall University School of Medicine, Huntington, West Virginia
Nominating committee members
- Colleen Renee Kelly, MD, AGAF, Chair
- Amy C. Engevik, PhD, Medical University of South Carolina
- Ravinder Gill, PhD, University of Illinois at Chicago
- Madhusudan Grover, MD, Mayo Clinic, Rochester, Minnesota
- Lisa L. Strate, MD, Harborview Medical Center, Seattle
Clinical Practice (CP)
Linda Anh Nguyen, MDVice Chair
Stanford (Calif.) University School of Medicine
Nominating committee members
- Gary W. Falk, MD, MS, AGAF, Chair
- Megan Adams, MD, JD, MSc, VA Ann Arbor Healthcare System Endoscopy Unit
- Mohammad Bilal, MD, Minneapolis VA Health Care System
- Carolyn Newberry, MD, Weill Cornell Medical Center, New York
- Adam Weizman, MD, MSc, Mount Sinai Hospital, Toronto
Endoscopy, Technology & Imaging (ETI)
Vivek Kaul, MD, AGAFVice Chair
University of Rochester (N.Y.) Medical Center
Nominating committee members
- Irving Waxman, MD, Chair
- Sushovan Guha, MD, PhD, University of Texas at Houston
- Pichamol Jirapinyo, MD, MPH, Brigham and Women’s Hospital, Boston
- Vladimir Kushnir, MD, Washington University St. Louis Barnes–Jewish West County Hospital
- Andrew C. Storm, MD, Mayo Clinic, Rochester, Minnesota
Immunology, Microbiology & Inflammatory Bowel Diseases (IMIBD)
Florian Rieder, MDVice Chair
Cleveland Clinic Foundation
Nominating committee members
- Fernando S. Velayos, MD, AGAF, Chair
- Brigid S. Boland, MD, University of California, San Diego
- Karen L. Edelblum, PhD, Icahn School of Medicine at Mount Sinai, New York
- Michael Kattah, MD, PhD, UCSF Gastroenterology
- Andres J. Yarur, MD, Cedars Sinai Medical Center. Los Angeles
Liver & Biliary (LB)
Don Rockey, MDVice Chair
Medical University of South Carolina, Charleston
Nominating committee members
- Gyongyi Szabo, MD, PhD, AGAF, Chair
- Brett Fortune, MD, MSc, Montefiore Medical Center
- Ruben Hernaez, MD, MPH, PhD, Baylor College of Medicine, Houston
- Cynthia Ann Moylan, MD, MHS, MS, Duke University, Durham, North Carolina
- Douglas A. Simonetto, MD, Mayo Clinic, Rochester, Minnesota
Microbiome & Microbial Therapy (MMT)
Jessica Allegretti, MD, MPHVice Chair
Brigham and Women’s Hospital, Boston
Nominating committee members
- Purna C. Kashyap, MBBS, AGAF, Chair
- Melinda Engevik, PhD, Medical University of South Carolina
- Christian Jobin, PhD, University of Florida
- Vanessa Leone, PhD, The University of Wisconsin–Madison
- Jun Yu, MD, PhD, The Chinese University of Hong Kong
Obesity, Metabolism & Nutrition (OMN)
Berkeley M. Limketkai, MD, PhDVice Chair
University of California Los Angeles
Nominating committee members
- Andres Jose Acosta, MD, PhD, Chair
- Barham K. Abu Dayyeh, MD, MPH, Mayo Clinic, Rochester, Minnesota
- Alan L. Buchman, MD, MSPH, University of Illinois at Chicago
- Octavia Pickett-Blakely, MD, MHS, Hospital of the University of Pennsylvania
- Robert Shulman, MD, Texas Children’s Hospital, Baylor College of Medicine
Pediatric Gastroenterology & Developmental Biology (PGDB)
Kelli L. VanDussen, PhDVice Chair
Cincinnati Children’s Hospital Medical Center
Meet Our New Chair
Douglas J. Robertson, MD, MPH, AGAFAGA Institute Council Chair
VA Medical Center, White River Junction, Vermont
Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
Dr. Robertson will serve as council chair for 3 years (May 2024-May 2027; DDW 2025, 2026 and 2027).
Section Leadership
, the driving force behind AGA’s programming at Digestive Disease Week (DDW). We welcome 8 members into their new roles as section vice chairs, joining the existing 17 Council members. Each new vice chair will serve a 2-year term that began immediately following this year’s DDW meeting and extends through DDW 2026. Following their term as vice chair, they will move into the role of section chair for an additional 2 years through DDW 2028.
We are also pleased to announce the members joining nominating committees during the 2026 nomination/election cycle. The chairs of the nominating committee will be the immediate past section chairs, whom we also recognize and thank for their service and dedication to the section and the council.
Basic & Clinical Intestinal Disorders (BCID)
Uma Sundaram, MDVice chair
Marshall University School of Medicine, Huntington, West Virginia
Nominating committee members
- Colleen Renee Kelly, MD, AGAF, Chair
- Amy C. Engevik, PhD, Medical University of South Carolina
- Ravinder Gill, PhD, University of Illinois at Chicago
- Madhusudan Grover, MD, Mayo Clinic, Rochester, Minnesota
- Lisa L. Strate, MD, Harborview Medical Center, Seattle
Clinical Practice (CP)
Linda Anh Nguyen, MDVice Chair
Stanford (Calif.) University School of Medicine
Nominating committee members
- Gary W. Falk, MD, MS, AGAF, Chair
- Megan Adams, MD, JD, MSc, VA Ann Arbor Healthcare System Endoscopy Unit
- Mohammad Bilal, MD, Minneapolis VA Health Care System
- Carolyn Newberry, MD, Weill Cornell Medical Center, New York
- Adam Weizman, MD, MSc, Mount Sinai Hospital, Toronto
Endoscopy, Technology & Imaging (ETI)
Vivek Kaul, MD, AGAFVice Chair
University of Rochester (N.Y.) Medical Center
Nominating committee members
- Irving Waxman, MD, Chair
- Sushovan Guha, MD, PhD, University of Texas at Houston
- Pichamol Jirapinyo, MD, MPH, Brigham and Women’s Hospital, Boston
- Vladimir Kushnir, MD, Washington University St. Louis Barnes–Jewish West County Hospital
- Andrew C. Storm, MD, Mayo Clinic, Rochester, Minnesota
Immunology, Microbiology & Inflammatory Bowel Diseases (IMIBD)
Florian Rieder, MDVice Chair
Cleveland Clinic Foundation
Nominating committee members
- Fernando S. Velayos, MD, AGAF, Chair
- Brigid S. Boland, MD, University of California, San Diego
- Karen L. Edelblum, PhD, Icahn School of Medicine at Mount Sinai, New York
- Michael Kattah, MD, PhD, UCSF Gastroenterology
- Andres J. Yarur, MD, Cedars Sinai Medical Center. Los Angeles
Liver & Biliary (LB)
Don Rockey, MDVice Chair
Medical University of South Carolina, Charleston
Nominating committee members
- Gyongyi Szabo, MD, PhD, AGAF, Chair
- Brett Fortune, MD, MSc, Montefiore Medical Center
- Ruben Hernaez, MD, MPH, PhD, Baylor College of Medicine, Houston
- Cynthia Ann Moylan, MD, MHS, MS, Duke University, Durham, North Carolina
- Douglas A. Simonetto, MD, Mayo Clinic, Rochester, Minnesota
Microbiome & Microbial Therapy (MMT)
Jessica Allegretti, MD, MPHVice Chair
Brigham and Women’s Hospital, Boston
Nominating committee members
- Purna C. Kashyap, MBBS, AGAF, Chair
- Melinda Engevik, PhD, Medical University of South Carolina
- Christian Jobin, PhD, University of Florida
- Vanessa Leone, PhD, The University of Wisconsin–Madison
- Jun Yu, MD, PhD, The Chinese University of Hong Kong
Obesity, Metabolism & Nutrition (OMN)
Berkeley M. Limketkai, MD, PhDVice Chair
University of California Los Angeles
Nominating committee members
- Andres Jose Acosta, MD, PhD, Chair
- Barham K. Abu Dayyeh, MD, MPH, Mayo Clinic, Rochester, Minnesota
- Alan L. Buchman, MD, MSPH, University of Illinois at Chicago
- Octavia Pickett-Blakely, MD, MHS, Hospital of the University of Pennsylvania
- Robert Shulman, MD, Texas Children’s Hospital, Baylor College of Medicine
Pediatric Gastroenterology & Developmental Biology (PGDB)
Kelli L. VanDussen, PhDVice Chair
Cincinnati Children’s Hospital Medical Center
AGA Research Scholar Awards Advance the GI Field
The AGA Research Foundation plays an important role in medical research by providing grants to talented scientists at a critical time in their career.
“The AGA Research Scholar Award will have a significant impact on my career,” said Dr. Jason (Yanjia) Zhang, 2024 AGA Research Scholar Award grant recipient, and a gastroenterologist at Boston Children’s Hospital. “I aspire to lead a laboratory studying the impact of the microbiome on human gastroenterological diseases. Our lab will focus on the molecular mechanisms underlying how microbes activate gut signaling. The AGA Research Foundation grant will support my transition to independence and build key capacities that will be the foundation of my future lab.”
Funded by the generosity of donors, the AGA Research Foundation’s research award program ensures that AGA is building a community of researchers whose work serves the greater community and benefits all our patients.
By joining other AGA members in supporting the AGA Research Foundation, you will ensure that young researchers have opportunities to continue their life-saving work. Your tax-deductible contribution supports the foundation’s research award program, including the RSA, which ensures that studies are funded, discoveries are made and patients are treated.
Learn more or make a contribution at www.foundation.gastro.org.
The AGA Research Foundation plays an important role in medical research by providing grants to talented scientists at a critical time in their career.
“The AGA Research Scholar Award will have a significant impact on my career,” said Dr. Jason (Yanjia) Zhang, 2024 AGA Research Scholar Award grant recipient, and a gastroenterologist at Boston Children’s Hospital. “I aspire to lead a laboratory studying the impact of the microbiome on human gastroenterological diseases. Our lab will focus on the molecular mechanisms underlying how microbes activate gut signaling. The AGA Research Foundation grant will support my transition to independence and build key capacities that will be the foundation of my future lab.”
Funded by the generosity of donors, the AGA Research Foundation’s research award program ensures that AGA is building a community of researchers whose work serves the greater community and benefits all our patients.
By joining other AGA members in supporting the AGA Research Foundation, you will ensure that young researchers have opportunities to continue their life-saving work. Your tax-deductible contribution supports the foundation’s research award program, including the RSA, which ensures that studies are funded, discoveries are made and patients are treated.
Learn more or make a contribution at www.foundation.gastro.org.
The AGA Research Foundation plays an important role in medical research by providing grants to talented scientists at a critical time in their career.
“The AGA Research Scholar Award will have a significant impact on my career,” said Dr. Jason (Yanjia) Zhang, 2024 AGA Research Scholar Award grant recipient, and a gastroenterologist at Boston Children’s Hospital. “I aspire to lead a laboratory studying the impact of the microbiome on human gastroenterological diseases. Our lab will focus on the molecular mechanisms underlying how microbes activate gut signaling. The AGA Research Foundation grant will support my transition to independence and build key capacities that will be the foundation of my future lab.”
Funded by the generosity of donors, the AGA Research Foundation’s research award program ensures that AGA is building a community of researchers whose work serves the greater community and benefits all our patients.
By joining other AGA members in supporting the AGA Research Foundation, you will ensure that young researchers have opportunities to continue their life-saving work. Your tax-deductible contribution supports the foundation’s research award program, including the RSA, which ensures that studies are funded, discoveries are made and patients are treated.
Learn more or make a contribution at www.foundation.gastro.org.
Bringing trainee wellness to the forefront
Researching the impact of reflection in medical training
Before the spread of COVID-19, and increasingly during the pandemic, Ilana Krumm, MD, noticed a burgeoning focus on wellness for trainees and how to combat burnout in the medical space.
But Dr. Krumm also noticed that most of the existing programs focused on the individual level, rather than the system level. The onus was on the trainees to manage their wellness and burnout.
“I wanted to look at something that could be instituted at a systems level as opposed to putting all the burden of this wellness on the resident, as someone who already has a huge burden of work, stress, and time constraints as they try to learn their discipline,” Dr. Krumm said. “Asking them to meditate on their own time seemed very impractical.”
Eager to research this idea, Dr. Krumm applied for the CHEST Research Grant in Medical Education.
“The fact that CHEST is willing to support medical education research is really important for all those trying to better the educational environment. Although there’s a movement toward more support for medical education research and more recognition of its value, I think the fact that CHEST has already done so has helped advance the field and the support for the field as a whole,” Dr. Krumm said.
“Having the support from a reputable institution like CHEST inherently gave the work that I was doing value,” Dr. Krumm said. “It gave folks an understanding that this research in medical education has importance.”
Dr. Krumm’s project focused on the monthly Reflection Rounds between the ICU, palliative care, and chaplaincy staff that were held at the Seattle VA Medical Center, where residents could discuss the challenges of caring for critically ill patients during a protected time. While similar interventions around death and dying have been shown to help residents reduce burnout in medical intensive care rotations, it was unknown which aspects of these sessions would be most effective.
Participant interviews were conducted before and after the residents’ monthly sessions to understand the impact these sessions had on wellness and burnout levels.
“With the grant funding from CHEST, our team was able to purchase the recording equipment, transcription, and software necessary to complete a thorough qualitative research project, which greatly accelerated the project timeline,” she said.
Through these interviews, Dr. Krumm’s team identified three key themes that shed light on the impact of Reflection Rounds.
1. Cultural precedent
Participants were encouraged to participate as little or as much as they wanted during the session. Despite some residents being less vocal during these discussions, every resident agreed that this type of session set an important cultural precedent in their program and acknowledged the value of a program that encouraged space for decompression and reflection.
2. Shared experiences
During this project, many residents experienced an increased sense of isolation, as COVID-19 precautions were stricter in the ICU. Having this protected time together allowed residents to discover their shared experiences and find comfort in them while feeling supported.
“A lot of residents commented that it was nice to know that others were going through this as well or that they were also finding this particular instance difficult,” Dr. Krumm said.
3. Ritual
At the opening of each hour-long session, participants were invited to light a candle and say aloud or think to themselves the name of a patient they had lost, had a hard time with, or cared for during their time in the ICU.
“Every single person pointed to that moment as meaningful and impactful,” Dr. Krumm said.
This ritual gave the residents time to center and have a common focus with their peers to think about patient stories that they were carrying with them.
“Maybe just incorporating a small moment like that, a point of reflection, could potentially have a big impact on the weight we carry as providers who care for [patients who are] critically ill,” Dr. Krumm said. “What I’ve learned from this project will make me a better leader in the ICU, not only in taking care of critically ill individuals but also in taking care of the team doing that work.”
Dr. Krumm credits the CHEST grant funding and subsequent research project with helping her join a highly competitive fellowship program at the University of California San Francisco, where she can continue to conduct research in the field of medical education.
“I am working closely with medical education faculty and peers to design new research studies and further establish myself in the field of medical education, leading to my ultimate goal of becoming a program director at a strong med-ed-focused program.”
This article was adapted from the Spring 2024 online issue of CHEST Advocates. For the full article—and to engage with the other content from this issue—visit chestnet.org/chest-advocates.
Support CHEST grants like this
Through clinical research grants, CHEST assists in acquiring vital data and clinically important results that can advance medical care. You can help support projects like this by making a gift to CHEST.
MAKE A GIFT » | LEARN ABOUT CHEST PHILANTHROPY »
Researching the impact of reflection in medical training
Researching the impact of reflection in medical training
Before the spread of COVID-19, and increasingly during the pandemic, Ilana Krumm, MD, noticed a burgeoning focus on wellness for trainees and how to combat burnout in the medical space.
But Dr. Krumm also noticed that most of the existing programs focused on the individual level, rather than the system level. The onus was on the trainees to manage their wellness and burnout.
“I wanted to look at something that could be instituted at a systems level as opposed to putting all the burden of this wellness on the resident, as someone who already has a huge burden of work, stress, and time constraints as they try to learn their discipline,” Dr. Krumm said. “Asking them to meditate on their own time seemed very impractical.”
Eager to research this idea, Dr. Krumm applied for the CHEST Research Grant in Medical Education.
“The fact that CHEST is willing to support medical education research is really important for all those trying to better the educational environment. Although there’s a movement toward more support for medical education research and more recognition of its value, I think the fact that CHEST has already done so has helped advance the field and the support for the field as a whole,” Dr. Krumm said.
“Having the support from a reputable institution like CHEST inherently gave the work that I was doing value,” Dr. Krumm said. “It gave folks an understanding that this research in medical education has importance.”
Dr. Krumm’s project focused on the monthly Reflection Rounds between the ICU, palliative care, and chaplaincy staff that were held at the Seattle VA Medical Center, where residents could discuss the challenges of caring for critically ill patients during a protected time. While similar interventions around death and dying have been shown to help residents reduce burnout in medical intensive care rotations, it was unknown which aspects of these sessions would be most effective.
Participant interviews were conducted before and after the residents’ monthly sessions to understand the impact these sessions had on wellness and burnout levels.
“With the grant funding from CHEST, our team was able to purchase the recording equipment, transcription, and software necessary to complete a thorough qualitative research project, which greatly accelerated the project timeline,” she said.
Through these interviews, Dr. Krumm’s team identified three key themes that shed light on the impact of Reflection Rounds.
1. Cultural precedent
Participants were encouraged to participate as little or as much as they wanted during the session. Despite some residents being less vocal during these discussions, every resident agreed that this type of session set an important cultural precedent in their program and acknowledged the value of a program that encouraged space for decompression and reflection.
2. Shared experiences
During this project, many residents experienced an increased sense of isolation, as COVID-19 precautions were stricter in the ICU. Having this protected time together allowed residents to discover their shared experiences and find comfort in them while feeling supported.
“A lot of residents commented that it was nice to know that others were going through this as well or that they were also finding this particular instance difficult,” Dr. Krumm said.
3. Ritual
At the opening of each hour-long session, participants were invited to light a candle and say aloud or think to themselves the name of a patient they had lost, had a hard time with, or cared for during their time in the ICU.
“Every single person pointed to that moment as meaningful and impactful,” Dr. Krumm said.
This ritual gave the residents time to center and have a common focus with their peers to think about patient stories that they were carrying with them.
“Maybe just incorporating a small moment like that, a point of reflection, could potentially have a big impact on the weight we carry as providers who care for [patients who are] critically ill,” Dr. Krumm said. “What I’ve learned from this project will make me a better leader in the ICU, not only in taking care of critically ill individuals but also in taking care of the team doing that work.”
Dr. Krumm credits the CHEST grant funding and subsequent research project with helping her join a highly competitive fellowship program at the University of California San Francisco, where she can continue to conduct research in the field of medical education.
“I am working closely with medical education faculty and peers to design new research studies and further establish myself in the field of medical education, leading to my ultimate goal of becoming a program director at a strong med-ed-focused program.”
This article was adapted from the Spring 2024 online issue of CHEST Advocates. For the full article—and to engage with the other content from this issue—visit chestnet.org/chest-advocates.
Support CHEST grants like this
Through clinical research grants, CHEST assists in acquiring vital data and clinically important results that can advance medical care. You can help support projects like this by making a gift to CHEST.
MAKE A GIFT » | LEARN ABOUT CHEST PHILANTHROPY »
Before the spread of COVID-19, and increasingly during the pandemic, Ilana Krumm, MD, noticed a burgeoning focus on wellness for trainees and how to combat burnout in the medical space.
But Dr. Krumm also noticed that most of the existing programs focused on the individual level, rather than the system level. The onus was on the trainees to manage their wellness and burnout.
“I wanted to look at something that could be instituted at a systems level as opposed to putting all the burden of this wellness on the resident, as someone who already has a huge burden of work, stress, and time constraints as they try to learn their discipline,” Dr. Krumm said. “Asking them to meditate on their own time seemed very impractical.”
Eager to research this idea, Dr. Krumm applied for the CHEST Research Grant in Medical Education.
“The fact that CHEST is willing to support medical education research is really important for all those trying to better the educational environment. Although there’s a movement toward more support for medical education research and more recognition of its value, I think the fact that CHEST has already done so has helped advance the field and the support for the field as a whole,” Dr. Krumm said.
“Having the support from a reputable institution like CHEST inherently gave the work that I was doing value,” Dr. Krumm said. “It gave folks an understanding that this research in medical education has importance.”
Dr. Krumm’s project focused on the monthly Reflection Rounds between the ICU, palliative care, and chaplaincy staff that were held at the Seattle VA Medical Center, where residents could discuss the challenges of caring for critically ill patients during a protected time. While similar interventions around death and dying have been shown to help residents reduce burnout in medical intensive care rotations, it was unknown which aspects of these sessions would be most effective.
Participant interviews were conducted before and after the residents’ monthly sessions to understand the impact these sessions had on wellness and burnout levels.
“With the grant funding from CHEST, our team was able to purchase the recording equipment, transcription, and software necessary to complete a thorough qualitative research project, which greatly accelerated the project timeline,” she said.
Through these interviews, Dr. Krumm’s team identified three key themes that shed light on the impact of Reflection Rounds.
1. Cultural precedent
Participants were encouraged to participate as little or as much as they wanted during the session. Despite some residents being less vocal during these discussions, every resident agreed that this type of session set an important cultural precedent in their program and acknowledged the value of a program that encouraged space for decompression and reflection.
2. Shared experiences
During this project, many residents experienced an increased sense of isolation, as COVID-19 precautions were stricter in the ICU. Having this protected time together allowed residents to discover their shared experiences and find comfort in them while feeling supported.
“A lot of residents commented that it was nice to know that others were going through this as well or that they were also finding this particular instance difficult,” Dr. Krumm said.
3. Ritual
At the opening of each hour-long session, participants were invited to light a candle and say aloud or think to themselves the name of a patient they had lost, had a hard time with, or cared for during their time in the ICU.
“Every single person pointed to that moment as meaningful and impactful,” Dr. Krumm said.
This ritual gave the residents time to center and have a common focus with their peers to think about patient stories that they were carrying with them.
“Maybe just incorporating a small moment like that, a point of reflection, could potentially have a big impact on the weight we carry as providers who care for [patients who are] critically ill,” Dr. Krumm said. “What I’ve learned from this project will make me a better leader in the ICU, not only in taking care of critically ill individuals but also in taking care of the team doing that work.”
Dr. Krumm credits the CHEST grant funding and subsequent research project with helping her join a highly competitive fellowship program at the University of California San Francisco, where she can continue to conduct research in the field of medical education.
“I am working closely with medical education faculty and peers to design new research studies and further establish myself in the field of medical education, leading to my ultimate goal of becoming a program director at a strong med-ed-focused program.”
This article was adapted from the Spring 2024 online issue of CHEST Advocates. For the full article—and to engage with the other content from this issue—visit chestnet.org/chest-advocates.
Support CHEST grants like this
Through clinical research grants, CHEST assists in acquiring vital data and clinically important results that can advance medical care. You can help support projects like this by making a gift to CHEST.
MAKE A GIFT » | LEARN ABOUT CHEST PHILANTHROPY »
Coding & billing: A look into G2211 for visit complexities
This add-on code is for new (99202-99205) and established (99212-99215) office visits. CMS created this add-on code to address the additional costs and resources associated with providing longitudinal care.
G2211 – Visit complexity inherent to evaluation and management (E/M) associated with medical care services that serve as the continuing focal point for all needed health care services and/or with medical care services that are part of ongoing care related to a patient’s single, serious condition, or a complex condition (Add-on code; list separately in addition to office/outpatient (O/O) E/M visit, new or established)
The documentation should demonstrate the intent and need for ongoing care. Otherwise, no additional documentation is required. CMS pays $16.04 for each service (wRVU = 0.33). It may be reported each time the patient is seen, and there is currently no limit to how often it may be used. Also, there is no additional copay requirement for patients.
Do’s and don’ts
Do report in the following situations when longitudinal care is provided:
- The provider has or intends to have a long-term, ongoing relationship with the patient (ie, G2211 can be used for a new patient visit)
- Audio/video virtual visits
- May be reported with Prolonged Care Services G2212
- When advanced practice providers or physician colleagues in the same specialty practice see the patient (ie, if you see the patient for an urgent visit, but the patient is usually followed by your partner, you can still use G2211)
- When working with graduate medical education trainees (along with the -GC modifier), and as long as the conditions described in the description of G2211 are met
Do NOT report in the following situations:
- If modifier -25 is appended to the E/M service when another service is provided on the same day (eg, pulmonary function tests, 6-minute walk tests, immunization)
- Audio-only virtual visits, hospital, skilled nursing facility, or long-term acute care hospital
- If the patient is not expected to return for ongoing care
- If the reason for longitudinal care does not include a “single, serious condition or a complex condition” (eg, annual visits for a stable 6 mm lung nodule)
CMS expects that this will be billed with 38% of all E/M services initially and potentially up to 54% over time. We feel this is reimbursement for the work being done to care for our patients with single, serious, or complex conditions. Both Medicare and Medicare Advantage plans are expected to reimburse for this service. Whether other payers will do the same is unclear, but it will become clear with time and further negotiation at the local level. In the meantime, members are encouraged to report this code for all appropriate patient encounters.
Questions and answers — G2211
Question: What private insurances cover G2211?
Answer: As of March 1, 2024, four national payers have confirmed coverage of G2211:
- Cigna (Medicare Advantage only),
- Humana (commercial and Medicare Advantage),
- United Healthcare (commercial and Medicare Advantage), and
- Aetna (Medicare Advantage).
Question: What needs to be documented for G2211?
Answer: CMS states, “You must document the reason for billing the office and outpatient (O/O) and evaluation and management (E/M). The visits themselves would need to be medically reasonable and necessary for the practitioner to report G2211. In addition, the documentation would need to illustrate medical necessity of the O/O E/M visit. We [CMS] haven’t required additional documentation.”
American Thoracic Society (ATS) and CHEST also recommend including a detailed assessment and plan for the visit, as well as any follow-up. The complexity of the visit should be clear in your documentation to support the medical necessity for reporting the G2211.
Question: How can a provider show that a new patient visit (99202-99205) is part of continuing care?
Answer: The treating practitioner should make sure their documentation supports their intent to provide ongoing care to the patient. Establishing such intent goes beyond a statement that the provider plans to provide ongoing care or schedule a follow-up visit. The circumstances of the visit should support the extra work involved in becoming the focal point of the patient’s care or providing ongoing care for a serious or complex condition.
Question: Dr. Red works at a primary care practice, is the focal point for a patient’s care, and has reported G2211. If Dr. Yellow, who is in the same specialty, or Mr. Green, a nurse practitioner, is covering for Dr. Red, and the patient comes in for a visit, can they report G2211 for that visit?
Answer: Yes. The same specialty/same provider rules would apply in this situation. But remember that Dr. Yellow’s or Mr. Green’s documentation for that encounter must support the code.
Question: Can a resident report G2211 under the primary care exemption?
Answer: Yes, according to CMS staff, so long as the service and the documentation meet all the requirements for the exemption and the visit complexity code. For example, the resident can only report low-level E/M codes, and the resident must be “the focal point for that person’s care.”
Question: Are there frequency limits for how often we can report G2211, either for a single patient in a given time period or by a provider or a practice?
Answer: Not at this time, but make sure your providers are following the rules for reporting the code. “There’s got to be documentation that suggests why the practitioner believes they are treating the patient on this long-standing, longitudinal trajectory, and we’ll be able to see how that interaction is happening,” senior CMS staff said. CMS staff further issued a subtle warning to providers by reminding them that CMS has a very strong integrity program. Your practice can avoid problems with thorough training, frequent chart review, and encouraging the team to ask questions until you feel that everyone is comfortable with the code.
Question: Are there any limits on the specialties that can report the code? Is it just for primary care providers?
Answer: No. Remember that a provider who is managing a single serious or complex condition can also report the code. But CMS expects the documentation to support the ongoing nature of the treatment. If a patient sees a provider as a one-off encounter, perhaps to manage an acute problem, that visit wouldn’t qualify. But if the provider clearly documents that they are actively managing the patient’s condition, the encounters could qualify.
Question: Will CMS issue a list of conditions that meet the code’s serious or complex condition requirement?
Answer: CMS has included the examples of HIV and sickle cell anemia in existing guidance, and it plans to issue a few more examples “that help folks understand what is expected.” However, it won’t be a complete list of every condition that might qualify.
Originally published in the May 2023 issue of the American Thoracic Society’s ATS Coding & Billing Quarterly. Republished with permission from the American Thoracic Society.
This add-on code is for new (99202-99205) and established (99212-99215) office visits. CMS created this add-on code to address the additional costs and resources associated with providing longitudinal care.
G2211 – Visit complexity inherent to evaluation and management (E/M) associated with medical care services that serve as the continuing focal point for all needed health care services and/or with medical care services that are part of ongoing care related to a patient’s single, serious condition, or a complex condition (Add-on code; list separately in addition to office/outpatient (O/O) E/M visit, new or established)
The documentation should demonstrate the intent and need for ongoing care. Otherwise, no additional documentation is required. CMS pays $16.04 for each service (wRVU = 0.33). It may be reported each time the patient is seen, and there is currently no limit to how often it may be used. Also, there is no additional copay requirement for patients.
Do’s and don’ts
Do report in the following situations when longitudinal care is provided:
- The provider has or intends to have a long-term, ongoing relationship with the patient (ie, G2211 can be used for a new patient visit)
- Audio/video virtual visits
- May be reported with Prolonged Care Services G2212
- When advanced practice providers or physician colleagues in the same specialty practice see the patient (ie, if you see the patient for an urgent visit, but the patient is usually followed by your partner, you can still use G2211)
- When working with graduate medical education trainees (along with the -GC modifier), and as long as the conditions described in the description of G2211 are met
Do NOT report in the following situations:
- If modifier -25 is appended to the E/M service when another service is provided on the same day (eg, pulmonary function tests, 6-minute walk tests, immunization)
- Audio-only virtual visits, hospital, skilled nursing facility, or long-term acute care hospital
- If the patient is not expected to return for ongoing care
- If the reason for longitudinal care does not include a “single, serious condition or a complex condition” (eg, annual visits for a stable 6 mm lung nodule)
CMS expects that this will be billed with 38% of all E/M services initially and potentially up to 54% over time. We feel this is reimbursement for the work being done to care for our patients with single, serious, or complex conditions. Both Medicare and Medicare Advantage plans are expected to reimburse for this service. Whether other payers will do the same is unclear, but it will become clear with time and further negotiation at the local level. In the meantime, members are encouraged to report this code for all appropriate patient encounters.
Questions and answers — G2211
Question: What private insurances cover G2211?
Answer: As of March 1, 2024, four national payers have confirmed coverage of G2211:
- Cigna (Medicare Advantage only),
- Humana (commercial and Medicare Advantage),
- United Healthcare (commercial and Medicare Advantage), and
- Aetna (Medicare Advantage).
Question: What needs to be documented for G2211?
Answer: CMS states, “You must document the reason for billing the office and outpatient (O/O) and evaluation and management (E/M). The visits themselves would need to be medically reasonable and necessary for the practitioner to report G2211. In addition, the documentation would need to illustrate medical necessity of the O/O E/M visit. We [CMS] haven’t required additional documentation.”
American Thoracic Society (ATS) and CHEST also recommend including a detailed assessment and plan for the visit, as well as any follow-up. The complexity of the visit should be clear in your documentation to support the medical necessity for reporting the G2211.
Question: How can a provider show that a new patient visit (99202-99205) is part of continuing care?
Answer: The treating practitioner should make sure their documentation supports their intent to provide ongoing care to the patient. Establishing such intent goes beyond a statement that the provider plans to provide ongoing care or schedule a follow-up visit. The circumstances of the visit should support the extra work involved in becoming the focal point of the patient’s care or providing ongoing care for a serious or complex condition.
Question: Dr. Red works at a primary care practice, is the focal point for a patient’s care, and has reported G2211. If Dr. Yellow, who is in the same specialty, or Mr. Green, a nurse practitioner, is covering for Dr. Red, and the patient comes in for a visit, can they report G2211 for that visit?
Answer: Yes. The same specialty/same provider rules would apply in this situation. But remember that Dr. Yellow’s or Mr. Green’s documentation for that encounter must support the code.
Question: Can a resident report G2211 under the primary care exemption?
Answer: Yes, according to CMS staff, so long as the service and the documentation meet all the requirements for the exemption and the visit complexity code. For example, the resident can only report low-level E/M codes, and the resident must be “the focal point for that person’s care.”
Question: Are there frequency limits for how often we can report G2211, either for a single patient in a given time period or by a provider or a practice?
Answer: Not at this time, but make sure your providers are following the rules for reporting the code. “There’s got to be documentation that suggests why the practitioner believes they are treating the patient on this long-standing, longitudinal trajectory, and we’ll be able to see how that interaction is happening,” senior CMS staff said. CMS staff further issued a subtle warning to providers by reminding them that CMS has a very strong integrity program. Your practice can avoid problems with thorough training, frequent chart review, and encouraging the team to ask questions until you feel that everyone is comfortable with the code.
Question: Are there any limits on the specialties that can report the code? Is it just for primary care providers?
Answer: No. Remember that a provider who is managing a single serious or complex condition can also report the code. But CMS expects the documentation to support the ongoing nature of the treatment. If a patient sees a provider as a one-off encounter, perhaps to manage an acute problem, that visit wouldn’t qualify. But if the provider clearly documents that they are actively managing the patient’s condition, the encounters could qualify.
Question: Will CMS issue a list of conditions that meet the code’s serious or complex condition requirement?
Answer: CMS has included the examples of HIV and sickle cell anemia in existing guidance, and it plans to issue a few more examples “that help folks understand what is expected.” However, it won’t be a complete list of every condition that might qualify.
Originally published in the May 2023 issue of the American Thoracic Society’s ATS Coding & Billing Quarterly. Republished with permission from the American Thoracic Society.
This add-on code is for new (99202-99205) and established (99212-99215) office visits. CMS created this add-on code to address the additional costs and resources associated with providing longitudinal care.
G2211 – Visit complexity inherent to evaluation and management (E/M) associated with medical care services that serve as the continuing focal point for all needed health care services and/or with medical care services that are part of ongoing care related to a patient’s single, serious condition, or a complex condition (Add-on code; list separately in addition to office/outpatient (O/O) E/M visit, new or established)
The documentation should demonstrate the intent and need for ongoing care. Otherwise, no additional documentation is required. CMS pays $16.04 for each service (wRVU = 0.33). It may be reported each time the patient is seen, and there is currently no limit to how often it may be used. Also, there is no additional copay requirement for patients.
Do’s and don’ts
Do report in the following situations when longitudinal care is provided:
- The provider has or intends to have a long-term, ongoing relationship with the patient (ie, G2211 can be used for a new patient visit)
- Audio/video virtual visits
- May be reported with Prolonged Care Services G2212
- When advanced practice providers or physician colleagues in the same specialty practice see the patient (ie, if you see the patient for an urgent visit, but the patient is usually followed by your partner, you can still use G2211)
- When working with graduate medical education trainees (along with the -GC modifier), and as long as the conditions described in the description of G2211 are met
Do NOT report in the following situations:
- If modifier -25 is appended to the E/M service when another service is provided on the same day (eg, pulmonary function tests, 6-minute walk tests, immunization)
- Audio-only virtual visits, hospital, skilled nursing facility, or long-term acute care hospital
- If the patient is not expected to return for ongoing care
- If the reason for longitudinal care does not include a “single, serious condition or a complex condition” (eg, annual visits for a stable 6 mm lung nodule)
CMS expects that this will be billed with 38% of all E/M services initially and potentially up to 54% over time. We feel this is reimbursement for the work being done to care for our patients with single, serious, or complex conditions. Both Medicare and Medicare Advantage plans are expected to reimburse for this service. Whether other payers will do the same is unclear, but it will become clear with time and further negotiation at the local level. In the meantime, members are encouraged to report this code for all appropriate patient encounters.
Questions and answers — G2211
Question: What private insurances cover G2211?
Answer: As of March 1, 2024, four national payers have confirmed coverage of G2211:
- Cigna (Medicare Advantage only),
- Humana (commercial and Medicare Advantage),
- United Healthcare (commercial and Medicare Advantage), and
- Aetna (Medicare Advantage).
Question: What needs to be documented for G2211?
Answer: CMS states, “You must document the reason for billing the office and outpatient (O/O) and evaluation and management (E/M). The visits themselves would need to be medically reasonable and necessary for the practitioner to report G2211. In addition, the documentation would need to illustrate medical necessity of the O/O E/M visit. We [CMS] haven’t required additional documentation.”
American Thoracic Society (ATS) and CHEST also recommend including a detailed assessment and plan for the visit, as well as any follow-up. The complexity of the visit should be clear in your documentation to support the medical necessity for reporting the G2211.
Question: How can a provider show that a new patient visit (99202-99205) is part of continuing care?
Answer: The treating practitioner should make sure their documentation supports their intent to provide ongoing care to the patient. Establishing such intent goes beyond a statement that the provider plans to provide ongoing care or schedule a follow-up visit. The circumstances of the visit should support the extra work involved in becoming the focal point of the patient’s care or providing ongoing care for a serious or complex condition.
Question: Dr. Red works at a primary care practice, is the focal point for a patient’s care, and has reported G2211. If Dr. Yellow, who is in the same specialty, or Mr. Green, a nurse practitioner, is covering for Dr. Red, and the patient comes in for a visit, can they report G2211 for that visit?
Answer: Yes. The same specialty/same provider rules would apply in this situation. But remember that Dr. Yellow’s or Mr. Green’s documentation for that encounter must support the code.
Question: Can a resident report G2211 under the primary care exemption?
Answer: Yes, according to CMS staff, so long as the service and the documentation meet all the requirements for the exemption and the visit complexity code. For example, the resident can only report low-level E/M codes, and the resident must be “the focal point for that person’s care.”
Question: Are there frequency limits for how often we can report G2211, either for a single patient in a given time period or by a provider or a practice?
Answer: Not at this time, but make sure your providers are following the rules for reporting the code. “There’s got to be documentation that suggests why the practitioner believes they are treating the patient on this long-standing, longitudinal trajectory, and we’ll be able to see how that interaction is happening,” senior CMS staff said. CMS staff further issued a subtle warning to providers by reminding them that CMS has a very strong integrity program. Your practice can avoid problems with thorough training, frequent chart review, and encouraging the team to ask questions until you feel that everyone is comfortable with the code.
Question: Are there any limits on the specialties that can report the code? Is it just for primary care providers?
Answer: No. Remember that a provider who is managing a single serious or complex condition can also report the code. But CMS expects the documentation to support the ongoing nature of the treatment. If a patient sees a provider as a one-off encounter, perhaps to manage an acute problem, that visit wouldn’t qualify. But if the provider clearly documents that they are actively managing the patient’s condition, the encounters could qualify.
Question: Will CMS issue a list of conditions that meet the code’s serious or complex condition requirement?
Answer: CMS has included the examples of HIV and sickle cell anemia in existing guidance, and it plans to issue a few more examples “that help folks understand what is expected.” However, it won’t be a complete list of every condition that might qualify.
Originally published in the May 2023 issue of the American Thoracic Society’s ATS Coding & Billing Quarterly. Republished with permission from the American Thoracic Society.