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IBD Drive Time: Michael Dolinger, MD, on Using Intestinal Ultrasound
Guest Michael Dolinger, MD, from the Icahn School of Medicine at Mount Sinai, talks to host Millie Long, MD, about the use and advantages of intestinal ultrasound for monitoring inflammatory bowel disease.
Millie Long, MD, is a professor of medicine, vice chief of education and director of the fellowship program in the Division of Gastroenterology and Hepatology at the University of North Carolina at Chapel Hill. Michael Dolinger, MD, is assistant professor of Pediatric Gastroenterology at the Icahn School of Medicine and Mount Sinai Kravis Children's Hospital.
TRANSCRIPT:
Any views and opinions expressed are those of the authors and/or participants, and do not necessarily reflect the views policy or position of the Gastroenterology Learning Network or HMP Global its employees and affiliates.
Millie Long:
Hello and welcome to this edition of IBD Drive Time. This is Millie Long from University of North Carolina, one of the cohosts, and I'm thrilled to have with me today really the leading US expert in intestinal ultrasound, Dr. Mike Dolinger from Mount Sinai. So Mike, welcome to the program.
Michael Dolinger: Thank you so much for having me, honored to be invited.
Millie Long:
And just as a reminder to our listeners, this program is sponsored by the Advances in IBD meeting as well as the Gastroenterology Learning Network. And just to get it out there, remember that December 14th to 16th is our large national meeting in Orlando, Florida and we hope that you'll join us there.
So Mike, let's take it away. Can you tell us a little bit—I think most of our listeners have probably not held an ultrasound probe. They don't know the utility of ultrasound and IBD. Can you give us a little bit of background on this and what your impressions are of the utility in inflammatory bowel disease?
Michael Dolinger:
Absolutely. In fairness, before 2019, I did not know that you could use ultrasound to assess the colon and small bowel. And that's exactly what we do. We use an ultrasound probe. Any ultrasound machine that gets high enough resolution to visualize the colon and small intestine can be used. And this is a limited abdominal ultrasound, meaning we put the probe on a patient's abdomen as they're lying flat.
They don't have to be fasting, they don't have to undergo any preparation. We always start with the exact same technique and we visualize the bowel wall and specifically the bowel wall layers in the entire colon starting from the distal sigmoid colon—limited views of the rectum but we can see it—working our way all the way around like a colonoscopy following the entire colon to the end of the small intestine, the terminal ileum, just as we would do in any other endoscopic procedure when we're assessing inflammation. And for us, this really adds a real-time biomarker to in-person visits; it's an additive assessment, direct and precise, of if there is any bowel inflammation or not that matches or doesn't match a patient's symptoms.
Millie Long:
So that's really intriguing and I have to admit, I've started some of this training process, so I know a little bit about this, but I obviously need to learn more as do many in our community. Can you tell us what does it take to get trained in this? What kind of training did you undergo?
Michael Dolinger:
So for me, my training was interrupted during the pandemic, so it took a bit longer than most. But the training is through right now through the International Bowel Ultrasound Group, which is an international organization which I'm a part of, and almost every other country that does ultrasound. And the training consists of 3 modules, an introductory hands-on course in which you go, you do didactics and you get hands-on experience with live IBD patient volunteers in which you see pathology, you see normal bowel and you really understand how this can be used and all the nuances and the basics.
But the real gist of the training occurs over the next 2 to 4 weeks that you're going to go to an expert center and you're really going to do longitudinal exams on IBD patients in the real-world setting. And this is where you're going to start to practice to build your competency level and you're going to have left this training really feeling competent that you can assess IBD activity.
Are you going to be an expert? By no means; if you do 50 colonoscopies, are you an expert? No. But you can make your way through a colon and you can probably know what's going on. And then there's a different learning curve for everyone else. Some people may get it in 20, some people may take 200, some people may never get it.
And for us, that training really right now is through that process, and there isn't a way to standardize the experiences between different centers and different trainees. And most of that expertise comes when you're able to go back home after you've had that basic level of training and then you're able to practice on your own IBD patients.
And for some people, they need an additional 6 months to gain proficiency. And there's a big difference for competency in which you feel like you can do something, and proficiency, in which you really feel confident that you can assess inflammation and be accurate enough to use it to make clinical decisions. And that occurs beyond the training. And so after that 2 to 4 weeks, you then take an exam and you get a certificate that says you're trained in ultrasound, but really that doesn't enable you to use it for clinical decision making.
That really comes after some more longitudinal practice at your own center. And that's where we rely on our IBD patient volunteers to say, okay, we're going to do this in the clinic. We may not use it for decision-making. You're going to benchmark it with an MRI or a colonoscopy or a stool test or multiple other tests. And then when you start realizing you're always accurate and these are the patients, you're not accurate and you're going to understand who it benefits and who it doesn't, you're really going to start using it without these other tools eventually when you feel really comfortable and you haven't made a mistake or anything like that after 10 or 20 patients in a row.
Millie Long:
And that makes sense. And just for our listeners, an expert like Mike, it doesn't actually take him that long to do an ultrasound. So you're kind of doing this operationally as part of your visits, you're seeing the patient, you're assessing them and follow up, and then you're putting the probe on to look at their bowel wall thickness as an adjunct. Is that right?
Michael Dolinger:
Yeah. We do this within almost every routine visit. As we're talking to the patient, they're lying on the table getting ultrasound. For me to do a normal ultrasound takes between 60 and 90 seconds. And so it really actually adds zero time to the visit. Most people think, how am I going to have time to do this all day? It's going to eat away from my clinic time. It's going to compromise my work productivity.
In fact, we find that it's the opposite. I'm actually able to do my own clinic, a full clinic template ultrasound and then add additional ultrasounds on top of that of other providers who want them because their patients are having symptoms and they want to see activity and they didn't plan on that ahead of time. And to assess inflammation can take anywhere from 5 to 10 minutes, but you imagine when can you do anything in 5 to 10 minutes and get real valuable information of precise disease activity right there? It's actually pretty incredible.
And for us, it facilitates treatment changes, it facilitates the need for colonoscopy. We might triage someone to earlier colonoscopy or earlier MRI, even admission. And so it really is super valuable and doesn't add at this point any time to the clinic visit when you're learning it takes 20 to 30 minutes to do a complete exam. But that's again, with anything, you get faster over time. And when you do this routinely, it really is very additive to the visit but doesn't add that time.
Millie Long:
And I think that there are more and more sites in the US that are getting trained to do this. And if you're thinking about starting out, let's say some of our listeners do see a large number of IBD patients and they're interested in learning more about adding this to their practice, what would you say, what would be the best next step for them?
Michael Dolinger:
I would say the best step is to talk to your division leadership in chief because this is not something you just say, I want to learn ultrasound. Let me go and see what this course is all about. There is a real importance I think to bring this to as many IBD patients as fast as possible, but also keep a standard level in which you have everyone who's doing ultrasound, the results are pretty much the same.
And that's really hard to achieve is the standard level of competency while spreading it. And so that really requires a lot of division leadership support to support your time, your efforts, and to have something to go back to clinic with an ultrasound machine that's in your clinic, in your own use to practice on your patients without having the time off to go train and the support when you come back to clinic to practice, without needing to necessarily bill for productivity during that time really comes from the top and without that support from everyone, you can't have that.
And so I would say start that conversation. Say, "Hey, everyone's doing this. There's a lot of IBD centers. I think there may be such value. I really want to learn this. What do you think about our division bringing this to our IBD patients? Could this be a valuable tool and maybe this could be my early career path, maybe I could be the one to help bring it here. What do you think about that?" And I think that is where you gauge that division leadership kind of support.
Millie Long:
So certainly there's an upfront investment in time and machinery and the things to kind of get the program going certainly, but there are also some real rewards. I mean patients come to you because of this. Is this right? From a patient's perspective, they really like having this piece of information and helping them with medical decision making.
Michael Dolinger:
Absolutely. The shared understanding and decision-making component of ultrasound is transformative. And I always tell people when you see this done in a visit, even when it's normal over and over in the course of a 3-hour morning and you see the lights go off, patients have this honest interaction and you develop a bond in this short period of time, you turn the lights on, they're crying when it's normal and you thought it was a routine normal exam. It's really magical for them to see their inflammation or healing on the screen and something they've never done before for most of our IBD patients.
And within the IBD community, this is kind of spread amongst patients that this really does add this kind of value they're looking for in these visits in which they want to come in person and get a different experience than they can't get on telehealth. They can do labs locally, they can do stool tests locally. They want to see their disease activity assessed in person and make a decision right there.
And so we have patients coming from all over just to get ultrasounds in our routine patient visit, which is kind of what we don't want. We want them to be able to get this close to home. We don't want them to have to go out of their way. But right now while it's spreading, there are only few centers. And so patients come here and is a big draw for us to offer that to our patients, but I would like it so that is no longer a draw and they are staying with their local institutions that can offer ultrasound.
Millie Long:
No, and I think what you just described is the reason why so many centers, ours included, are starting on this training pathway to really help with that shared decision-making process for patients to help us in terms of benchmarking and making real-time decisions. But I think from your perspective, it doesn't necessarily reduce colonoscopy. Colonoscopy is still needed. This is just an adjunct to therapy management. Would you agree?
Michael Dolinger:
I would agree. It completely changes who needs a colonoscopy and when, in my opinion, we often facilitate patients who are coming in for potential diagnosis to get a really much earlier colonoscopy than they would've if I see inflammation on an ultrasound, they're going for a diagnostic colonoscopy that week and they're convinced and they're not putting it off. We see patients with unexpected inflammation who we haven't had a colonoscopy and weren't going and they feel great. You know what? It's been 3 years since your last one. You feel great, but we see inflammation. You're going to get a colonoscopy when you wouldn't have got one before.
But then we have plenty of patients who are now 18 months after therapy have had an ultrasound at 6 months, they feel good. Maybe another provider would scope them again, we have a normal calpro normal ultrasound. We see them another year later. A normal calpro, a normal ultrasound. We're not going to scope that patient until we need tissue for colon cancer screening.
And so we're going to really follow the guidelines and say, do we need dysplasia screening or not? And if so, then we'll scope you and if not, we'll follow you with ultrasound and calpro unless one of those tests are abnormal. And it really changes how you use colonoscopy. It doesn't reduce it. It actually prioritizes it in the right patients, I think.
Millie Long:
And I think that obviously we talked about there are many reasons holistically why we want to do this, but just to touch on it, is there reimbursement for this? Is this something, obviously it's time you're spending in terms of doing the ultrasound. Tell us a little bit about that side of things?
Michael Dolinger:
Yeah, so we bill for this as we do any other exam or test. And so it's a limited abdominal ultrasound that we bill. We use these results to make clinical decisions and just like anything else, an MRI or colonoscopy, it gets billed to the payer and there's specific CPT codes that we use for a limited abdominal ultrasound at the point of care. It's 76705 not to get into the specifics. And then we also bill for the Doppler when we do that, which is a separate component. And both of these get revenue value units and provide facility fees for our clinic.
And what people think is not sustainable actually is very sustainable in a clinical practice model. It varies by state location, volume, payer mix, et cetera, but it really is very much a business plan you can put in place and fund your capital equipment, fund your time and your productivity without issue. And I think that's one of the biggest misconceptions is that this is not a sustainable business model in the United States health care system when it really is from a work productivity standpoint incredibly sustainable.
Millie Long:
Great. I think that just to put a plug out there, I believe you and other colleagues have written a guide to implementation of intestinal ultrasound that is available in the American Journal of Gastroenterology?
Michael Dolinger:
Yes. A lot of the questions that come to me can be answered in that guide. I get a lot of the same questions from centers who are starting up and I'm always happy to walk people through every step of the way if they want, but I'm often just sending them the link or the paper from the American Journal of Gastroenterology that myself, Noa Cleveland, Dave Rubin, and Marla Dubinsky wrote from the University of Chicago and Mount Sinai to say, this is how we do it.
This is how we get credentialed to use equipment in the hospital in the point-of-care setting, and this is how you bill for it. This is how you get reimbursed and this is how you cover your time. Really focused simple paper answering a lot of the biggest questions that providers have when they're initially starting ultrasound in their clinic.
Millie Long:
Fantastic. So it sounds like we're moving forward in this field in the United States. Europe is far ahead of us. They've been using intestinal ultrasound for longer. If you had to look in a crystal ball, what would you say, how well providers 5, 10 years from now be utilizing this resource in the management of their patients?
Michael Dolinger:
Yeah, it's a great question because I think the field, especially imaging, is advancing so fast that we probably can't even keep up with the advancements. I ultimately think that ultrasound technology is also improving rapidly. Handheld ultrasound probes, which now don't have near the same resolution quality as bigger machines, have significantly lower cost and the resolution is increasing. And I think as the resolution improves, we will see more clinics adopt lower cost machines that provide the same quality measurements.
Ultimately, the distant future I think is that patients may be able to monitor their bowel activity themselves with AI-guided assistance at home. And I think that pilot study with handheld probes is not too far off and that it may come out of the expert hands completely, and if you have complications, other things, that's a different story. But if you're monitoring response to treatment, I think we may have patients be able to do this at home, let alone different advanced practitioners, nurse practitioners, junior faculty.
I think there's going to be different models for different clinics based on your IBD patient complexity and what those specific patient needs are, and they'll be able to be triaged to different levels of ultrasound care. But I think the value of directly monitoring inflammation of the bowel is unmistakable. I just think how that looks will be fascinating over the next 10 years.
Millie Long:
No, that's great. And hopefully that will come to fruition. I'd love having the ability to monitor more and more home-based monitoring for ways for us to help to modify things earlier for our patients and improve outcomes. Just as a reminder to our listeners at the advances in IBD meeting, which will be December 14th to 16th, 2023, in Orlando, Florida, we're actually going to be able to have an opportunity for individuals to learn more about intestinal ultrasound.
Dr. Dolinger will be there at the meeting and running some sessions. So we look forward to having you there, Mike. But before I let you go, tradition on IBD Drive Time is to ask you a question—we call it our fun question—which is there something about yourself that I and our other listeners don't know that you'd like to share with us?
Michael Dolinger:
Yeah. I initially wanted to be a veterinarian and not a doctor, and so I did a lot of research with wildlife and animals before I ever went to med school. And the publication I'm most proud of and all the work I've done today is my first ever research that I did as a high school student in the Jamaica Bay Wildlife Refuge in New York in Queens, in which I spent all summer trying to understand why raccoons ate turtle nests and destroyed all turtle eggs in an effort to preserve a rare species of turtle.
And so I was able to uncover that it was actually the human scent that drove raccoons to these turtle nests because they were attracted to it in this wildlife refuge which had all these visitors. And I'm proud because we actually completely stopped raccoons from eating these turtle nests by changing the walking paths and different things to avoid these turtle predation areas and nesting areas at the wildlife refuge. And to me, that was one of the most impactful things I ever did at a young age and still is. And it's in the Journal of Herpetology, and I'm so proud of it, and no one knows it exists, but I always like to tell people about it.
Millie Long:
That is great. I love it. You have truly saved the turtles. That is amazing. Well, with that, thanks so much Dr. Dolinger for being with us on this episode of IBD Drive Time and again for our listeners, check out his publication in the American Journal of Gastroenterology on implementation of intestinal ultrasound and hopefully we'll see you live and in person at the advances in IBD meeting in December. Thanks.
Michael Dolinger:
Thank you.
