Touching Base with the ASGE’s Incoming President

In May, during the 2019 Digestive Disease Week meeting in San Diego, Cleveland Clinic gastroenterologist John Vargo, MD, MPH, will become president of the American Society for Gastrointestinal Endoscopy (ASGE), the world’s leading endoscopy society. Dr. Vargo, an international expert in therapeutic endoscopy, is the Digestive Disease & Surgery Institute’s Director of Enterprise Endoscopy Operations, head of the Section of Advanced Endoscopy and Director of Endoscopic Research and Innovation.

Consult QD asked Dr. Vargo to discuss his ASGE leadership plans and the state of the specialty.

Q: How does it feel to take over the leadership of the society?

Dr. Vargo: I am very humbled. Thirty years ago, when I became an ASGE member, I never would have thought of this as being possible. Two of my mentors from Cleveland Clinic have been presidents of the society — Michael Sivak and Gary Falk. It’s an achievement that I share with my family, my colleagues and my patients.

Q: What role does the ASGE president play?

Dr. Vargo: The American Society for Gastrointestinal Endoscopy is the largest endoscopy society in the world, with more than 15,000 members. The president’s role is to lead that community forward, with the goal of optimizing patient care. I’m blessed to have many committees in this regard, from research to standards of practice to postgraduate education. I have been busy appointing committee members, setting up our major national education courses for next year and becoming involved in the regulatory issues that are at the forefront of GI endoscopy.

Q: To lead the society, you have to do some assessment of the state of endoscopy as a medical specialty. What’s your take?

Dr. Vargo: There’s always been flux and, actually, that’s a great place to be. I’ve got a saying I firmly believe in: “Complacency should never be in your lexicon.” We’ve watched endoscopic procedures take on the realm of surgical procedures. We’re doing procedures now that 10, 15 years ago were relegated to surgery. Barrett’s esophagus with high-grade dysplasia used to be treated with subtotal esophagectomy, which carried a small but real risk of morbidity and mortality. Now with ablative technologies, the vast majority of these patients are cured of their high-grade dysplasia, and many times their Barrett’s esophagus, by endoscopic procedures. The management of severe acute pancreatitis was a disorder to be treated surgically, but we’re finding many inroads into treating it endoscopically, to save those patients a laparotomy. There’s also a huge surge with artificial intelligence in endoscopy. A recent paper assessed artificial intelligence in colon polyp recognition, and it looks like that technology can augment even the most astute observer, at least on video, in detecting polyps. Down the road, artificial intelligence may not only identify the polyp, but it may give you a probability-based assessment of what type of polyp it is and whether it can be removed endoscopically. When it comes to treating the obesity epidemic, endoscopic approaches are going to be at the forefront. We’re starting to see a range of endoscopically-driven procedures such as endoscopic sleeve gastrectomy and, for milder forms of obesity, the placement of intragastric balloons or duodenal mucosal resurfacing. In patients who’ve had bypass procedures for obesity and have developed complications or changes in surgical anatomy, there’s an armamentarium of endoscopic approaches we can use to revise those and save patients a revision surgery.

Q: It sounds like a renaissance.

Dr. Vargo: It’s a great time to be a therapeutic endoscopist.

Q: Do those endoscopic advances pose a challenge in terms of standardization or optimization?

Dr. Vargo: Yes. One of our challenges is that, when a technology starts emerges, matures and is ready to be distributed, how do you train established gastroenterologists? At ASGE, we are looking into two avenues. One of them is a virtual component, where you’re building the bedrock of your knowledge of how to do the procedure, and the next stage would be hands-on. I think you’re going to see a renaissance in simulators as well as the development of regional centers of excellence where training will happen. We have programs right now for, endoscopic mucosal resection at our training headquarters outside of Chicago. Those models need to migrate into other areas.

Q: You’re leading an effort at Cleveland Clinic to standardize endoscopy. Has that been helpful in preparing for your ASGE role?

Dr. Vargo: Yes. We have 23 sites of service and perform more than 90,000 endoscopies annually in Northeastern Ohio alone. The goal of our team is that wherever a patient goes for a procedure, they receive the same quality of care — that the physicians and nurses and technicians have the same level of competence, the same equipment. We’re measuring all the outcomes. But it’s a little more complicated than that. Do we need to have all of our leading-edge procedures done at all 23 sites of service? The answer is no. In a value-based environment, we need to have centers of excellence for the more advanced procedures, where they can be done repeatedly within a center-of-excellence constellation. So when a new element of technology emerges, we need to determine if it make sense for our patients and for our overall practice. If it does, who do we train, how do we train them and where do we establish the initial practice? You allow that practice to mature and then you can start looking at outcomes and compare them to established methods of therapy. Once you’ve done that, then you have to determine scalability — where else in the enterprise should we be doing the procedure?

Q: What other priorities do you have as ASGE president?

Dr. Vargo: One of my major priorities is to ensure that we evolve our educational portfolio to meet the needs of our members. We need to have virtual access to information. I want to amplify our portfolio for virtual access. I may not be able to travel somewhere for a course and be away from my family and practice for two or three days, but maybe I can take a virtual course on nights and weekends and receive the same educational value. Another group I think is extremely important is our cohort of fellows coming out of training and becoming members of the ASGE. It’s important to me to assure that the ASGE is a solid value proposition for them. Their educational needs and wants are maybe much different than, those of a 50-year-old practitioner in Cleveland, Ohio. To that end, I’ve set up a new virtual advisory committee made up exclusively of GI fellows. We call it the ASGE’s trainee caucus. All of our educational committees will be tasked to utilize this virtual committee, to run ideas and curricula by them to ensure that we pass that litmus test. I think it will lead to some great opportunities to develop the curriculum that our junior partners need.

Q: A year from now, when you’re handing the gavel to your successor, how will you measure your success?

Dr. Vargo: A year is a fleeting period of time. I’ve been fortunate to work very closely with the current president, Dr. Steven Edmundowicz, and with the president-elect, Klaus Mergener. When I need to discuss ideas, I can ask past and future ASGE presidents for sage advice. So my tenure is more of a continuation. I think if we continue to evolve the educational resources for our members, to meet their needs, that would be a lasting accomplishment. I also think that supporting emerging technologies is extremely important. I’m blessed to be at Cleveland Clinic, where early adopters and pioneers in technology walk through all these hallways. It’s important that maintain the vibrancy of this culture of innovation and research, that ultimately begets world-class care for our patients. This is in our DNA. Hopefully, at the end of my year, people can say that the society is in a better place. I couldn’t ask for anything more than that.