Interview with Dr. Ellen Scherl: “We must reclaim our roles as healers”


Interview with Dr. Ellen Scherl: “We must reclaim our roles as healers”

Dr. Ellen Scherl is the Research Director and Founding Director of the Jill Roberts Center for Inflammatory Bowel Disease (IBD), Weill Cornell Medicine. Dr. Scherl has recently been honored with the Rosenthal Humanitarian Award from the Crohn’s and Colitis Foundation. Dr. Scherl is known nationally and internationally for her work in the field of IBD.
When I asked Dr. Scherl about her journey from English literature to gastroenterology and IBD, she surprised me talking about Virginia Woolf and the exploration of self. She also revealed how she stays on top of her game – even during a pandemic. From digital food and hydration apps to her research on meditation and IBD, listen to this fascinating interview completely.
Finally, Dr. Scherl described her vision for the future of gastroenterology. She says, it’s time for gastroenterologists to approach GI care comprehensively and reclaim their role as healers.
◘  Dr. Janowitz: The art of the GI consultation (“listening to the patient is key”)
◘  Dr. Scherl’s journey from literature to medicine and then onward to IBD
◘  “The hope from what I’ve learned as a literature major to telemedicine in the pandemic is that we can reach more people”
◘  What is “self” and its correlation in medicine?
◘  “We are a minority of ourselves” (microbiome)
◘  “Personalized medicine and comprehensive care in gastroenterology and in IBD”
◘  “The future of gastroenterology is to reclaim our role in society as healers” 
◘  Advice for gastroenterologists to stay on top of the game
“Sempre avanti: Always look forward”
◘  What is the future of gastroenterology?
◘ “We need to increase efficiencies and break away from silo management”
◘  Convergence 1.2 to Convergence 1.3 (digital biology)
◘  Advancing care amidst COVID-19
◘  Business of medicine and the healing when it’s in conflict
“We cannot do this if there’s no incentive”
“We all want to be better than we are now”
◘  Changing patterns in IBD

 


 

The Transcribed Interview:
Praveen Suthrum: Dr. Scherl, thank you so much for joining me today. And I want to welcome you to our conversation. But before getting started I want to convey my deepest congratulations on the Rosenthal Humanitarian Award that you’re going to receive from the Crohn’s and Colitis Foundation. So, congratulations and welcome.
Dr. Ellen Scherl: So, I started out always actually doing science – Chemistry, Biology but literature was something that I thought I needed to improve my analytics skills with. So, I became a literature major and my area of concentration was actually Virginia Woolf and her symbolist novels. One of the things that always struck me as I was reading her books, novels, as well as her biography, was that despite her connection or seeming connection she was very much alone very isolated. And despite reaching out to the medical professionals I’ve always been struck that they could not help her. Virginia Woolf also talked about thinking in wholes, understanding things from A to Z. And I think that one of the aspects of her medical care was that there was no comprehensive care at the time that she was writing and living. And the hope is that what I’ve learned as a literature major to telemedicine in the pandemic is that we can reach more people.
In terms of my interest in inflammatory bowel disease, I think that from literature I’ve always been fascinated by the ‘self’, the evolution of self, inward introspection, reflection. And so, it is only natural that number one, I should select a subspecialty where I can do just that but also a subspecialty that allows us to actually look inside through endoscopy which you have written about in your Scope Forward. But also a field that focuses on immunology. In 2002 the cover of the science magazine, of Narcissus gazing into a pond looking at his reflection, it’s a painting by Caravaggio but it speaks to the importance of self and self-recognition, the importance of immune surveillance, the importance of self and reproduction, how we reflect and then of course how that impacts communities and engagement of communities and then the introspection of defining who you are as an individual by looking at yourself. And that is how I sort of got from literature and listening to stories that have to do with self to becoming fascinated by the immunology of inflammation and inflammatory bowel disease and how it affects individuals and then of course the importance of endoscopy.
Praveen Suthrum: Quite fascinating and it just compels me to probe further on you know on this topic of self. And then when you consider the cell you can look at it in multiple directions here and you alluded to it. From a very science standpoint and look at the microbiome. Put into question you know are we really human or you know, 90 plus percent is the microbiome. So, we’re all microorganisms more than we’re human like so if that’s our DNA. So, then what is the self from that context.
Dr. Ellen Scherl: So, the concept of the microbiome is critical to our understanding who we are and as you say we have more bacterial DNA, more bacterial cells than we do immune cells or human DNA. So, in fact, as you said we are a microcosm of who we are. We are a minority of our self. So, it is important to help us to redefine ourselves from a scientific molecular cellular basis. If we look at artistic renditions of who we are… we go back to the Klimt painting – woman of gold which was Adele Bauer where if you look at her dress it is multiple triangular and circular cells namely sperm and egg cells. So, again the concept of cells and self and in reproduction. So, the idea of redefining ourselves not only by more bacterial DNA but also through the human genome where we understand that 99.9% of our DNA is all the same. We are more alike than we are different. The 0.1 that codes for difference, that is different… codes for disease susceptibility and therapeutic response. So, again what does that mean today for gastroenterology for IBD? That we have to be talking about personalized individualized medicine. And looking at the cells and molecules that drive different inflammatory pathways if we’re looking at IBD but of course, there are other chronic diseases and illnesses where this is also at play now.
But step back and look at personalized medicine, individualized medicine, what is it really about? Yes, it’s about cells and molecules and how we define ourselves scientifically and diversity plays into that. But most importantly personalized medicine is about the person it’s about comprehensive care. It’s about healing. And I think that one of my hopes is that telemedicine can bring us closer to healing. I think that the future of medicine, gastroenterology is to reclaim our role in society and with individuals as healers. And for that to happen we need to recognize that’s not the way we as gastroenterologists are viewed. We are looked at as you know people who are pushing tests and medications and patients trust their individual gastroenterologist but they don’t necessarily trust the field of gastroenterology or medicine and we need to reclaim that. So, if we go back to the Greek heal means to make whole that is what comprehensive medicine is and I think that part of the future that telemedicine can help to accelerate is by making those connections so that we can reclaim healing for our individual patients and for communities at large locally, regionally, nationally, and actually globally.
Praveen Suthrum: From the time I’ve known you know, I think it’s eight to ten years now. So, I’ve always observed that you’ve been on top of your game. Observed that your interactions are very compassionate and at the same time as far as the science is concerned you’ve been on top of your game. And even listening to your recent interview you know, you’re testing new things, new ideas, new technologies, applications, and so on. So, what advice do you have for gastroenterologists out there who are watching this on how do they stay on top of the game?
Dr. Ellen Scherl: In the continuity of what we were saying, it’s that self-actualization you know, be true to yourself in the Shakespearean sense know who you are as a physician. Because we can’t really heal unless we have that focus of who we are as defined by our important most important connections – family, friends, and then we widen it to our workplace which is of course being redefined and our patients and their families and friends. What are the support structures? Where are the weaknesses? How can we strengthen them? So, that’s the first thing I think to take time for ourselves.
And the second is to find young people who can help us learn the technology, learn how to use digital apps, the healthcare electronic medical records. Sempre Avanti: always forward. So, we’re always looking for how we cannot only improve ourselves but improve ourselves as we are defined by the technology which is here to help us make connections with the people that we reach out to. They can be younger medical students, fellows, young attendings, but also our technicians our staff and it becomes much more fun and much more respectful because we are really talking about people. Yes, degrees are still important. Of course, algorithmic medicine is still important. But it’s making those social connections and figuring out how we can widen those social connections to reach people even around the globe but in our own societies who may not have the ability to reach out and come in for even a televisit.
Praveen Suthrum: What is the future of GI from the lens that you’re seeing?
Dr. Ellen Scherl: So, the future… it breaks down into three things but just taking this comprehensive care that is the future of GI. So, we have not really embraced it, although we talk about it we have not really reached patients in the sense of healing and in the sense of comprehensive care. So, in 2006 we opened the Jill Roberts center. Again, Jill Roberts was a grateful patient who was an inspired collaborator and I know you met her so you understand that it was not just her understanding that the secret in patient-care is caring for the patient which she really did she was a tremendous patient advocate but she also was a program builder and she was able to delve into the science which is true for all physicians but she was also interested as you know in the finances and the economics too. When you came in and this is the future of medicine, you came in maybe 10 years ago or so as a consultant but it was really to increase efficiencies and break away from silo management which Jill felt was a real hindrance to delivering comprehensive care. And seeing Jill progress from patient to patient advocate to scientists to economist to really everything, has been a labor of love but also underscores an important point for all of us there was no task that was too small for Jill and no project that was too large. And I think we need to think about that as we look towards the future.
So, one future is comprehensive care both real and virtual. The second future is when we talk about convergence. How do discoveries get made? Susan Hockfield’s book ‘The Age of Living Machines’ the impact of biology on technological revolution is applicable to gastroenterology and specifically endoscopy when we bring the surgeons and the endoscopists together so that we can merge that field as Bo Shen, MD is doing with the surgical knowledge of anatomy it’s beyond advanced endoscopy. It really requires close collaboration with a surgeon and we’re fortunate to work with Bo Shen at Columbia with Ravi Kiran, MD who is the head of their colorectal surgery program and actually the fact that the two of them are so interconnected is wonderful for pushing this field forward.  It also raises the question of what is the role of nanotechnology. What can we deliver through the endoscope? And we need forward-thinking advanced surgical endoscopists to help to move that field forward and redefine that frontier.
Convergence 1.2 is the interaction of biology and technology and that’s where we are now. But I think convergence 1.3 is going to be the interaction of biology and nutrition, food, exercise, hydration, the science of all of those. And of course the impact of or the interconnectivity between biology and economics which is where you come in and you are helping to move this forward. First is comprehension two is combined surgery endoscopy and the third is the concept of personalized medicine where we’re talking about the definition of molecular and cellular phenotypes that define for our case in inflammatory bowel disease the immune response, the immunology of inflammation, where does the microbiome you know activate this, and this is something that Randy Longman, MD who is the current director of the Jill Roberts center. He is a card-carrying immunologist and gastroenterologist so talk about convergence that’s converging. And he has set up a smart IBD program where we look at the cells and molecules before and after an intervention of a biologic therapy so that we can determine which patients are going to respond or conversely not respond and because IBD is a lifelong disease this is a longitudinal project so that as their responses change and as the science advances we might be able to predict more targeted therapies in a wise or smart way instead of just saying this is the algorithm.
Praveen Suthrum: Very interesting and I know that you advanced some of this during the COVID period. Can you share a little bit about how this whole phase has been for you?
Dr. Ellen Scherl: So, first of all very difficult the pandemic has been monumental. Much in the way as other disruptive technologies have occurred because of major disruptions and upheavals. When this started and we were all quarantined we didn’t know how to reach our patients and of course, telemedicine was the only way to do it. And during those three months, I sat and did back-to-back televisits and I found that several things happened. First of all, it was a lifeline for patients and it was very reassuring for them to be able to talk, to share their lives, share their family, and have their medical questions answered but also some social questions. And it became apparent that this was a way of reaching other systems that might address some of their concerns like Dr. Richard Brown and Dr. Patricia Gerbarg’s site which is a practice of sort of breathing meditation where the breath exercises are specific for the gut. We’ve worked with Dr. Brown and Pat Gerbarg and did an original study where we paired patients with each other and did a comparative it was a controlled trial where either the intervention was this breathing mind-body exercise or education for the same amount of time, the same food was served, everything was exactly the same the only difference was the intervention and we were able to show that there was no question that the quality of life.
Depression improved, insomnia, anxiety, all improved there was a glimmer that maybe inflammation improved which is something that we still want to do. And as Drs. Brown and Gerbarg have moved their practice from real to virtual, this becomes a lifeline for patients and I realized that as we were doing these three-month intensive video visits. So, that was one thing that I could recommend Wellness by Food was another app for IBD that they found helpful and interactive. And the third is this Plant Nanny which was a hydration app. What I’m still looking for is an exercise app. But the point is that during that intensive, non-stop, back-to-back video visits at the end of the three months with Dr. Dana Lukin and Dr. Randy Longman we were able to collate our data and publish in gastroenterology May 2020. We could show the question that we were all so concerned about at the beginning of this pandemic which was – are our patients at increased risk if they’re on biologics? And we were able to show that it was very reassuring you weren’t at lower risk but you also were not at higher risk.
Praveen Suthrum: One question I want to ask you Dr. Scherl is how do you reconcile between the business aspect of medicine and the care aspect or the healing aspect of medicine? And sometimes, these two goals can come in conflict. Because that’s the way we have structured our health system for good or for worst. When you combine some of these therapeutic interventions that you’re mentioning, we’re talking about disease reversal here. Gastroenterologists do recognize this that if they don’t do that then they miss out on the future direction of where the patients want all of healthcare to go but then it is also going to come at the cost of how the health system gets compensated today.
Dr. Ellen Scherl: So, the way that that health care gets compensated today has changed with the pandemic. In 1991 PDFs were available and yet we could not implement that into our Electronic Medical Records because of compensation. There was no compensation for a video visit or a telephone visit or an electronic PDF assessment. And what the pandemic has done is to reimburse we can see across borders state borders. So, it has opened up our ability to reach larger groups of population of patients and maybe we can even start to do that globally. So, the reimbursement structure is going to need to help and I know you’re going to be on the forefront of that but it is critical from an economic standpoint.
We can’t do this if there’s not some economic reimbursement and incentive for keeping our patients connected and healthy all of our patients. And one of the things that the pandemic has done while it does advance the economics arguably of telemedicine it also underscores the disparity in gastroenterology, liver diseases, and IBD that the pandemic is bringing to the fore. So, these societal issues need to be addressed. We talk about disruptive technologies the pandemic has accelerated the disruptive technology of telecommunication, telehealth. The hope is that we’ll move away from the complexity of silo management and reduce complexity and allow us to connect with people which is comprehensive care and what needs to happen and it needs to be rewarded. So, this is restructuring the economics of what we do and because we all want to be better than we are now. Better than ourselves, we want to believe in something that’s larger than ourselves. Larger than ourselves is using our techniques as endoscopists but understanding that they may be more targeted.
Praveen Suthrum: Now, in your field of IBD what are some of the changing patterns that you’re observing?
Dr. Ellen Scherl: We talked a little bit about how this is becoming a global disease where patient populations or populations that never saw Ulcerative Colitis or Crohn’s disease are now seeing Ulcerative Colitis first and within a decade Crohn’s disease follows. But we also are recognizing that it crosses the spectrum of socio-economic divides. And in many ways, you can look at Inflammatory Bowel Disease as an equal opportunity employer. It has most recently affected the Prime Minister of Japan Shinzo Abe. It affected President Eisenhower. President Kennedy, we think might have had Crohn’s disease may be overlap with Celiac but all these intestinal diseases… And then, of course, going way back King Alfred. So, Kings, Prime Ministers, Presidents, and then everybody along the social spectrum. So, it really affects everybody and that’s something that we need to address in our treatment algorithms and when we look at evidence-based medicine and how we can improve the experience and healing for patients.
Praveen Suthrum: So, I want to go back and complete our conversation by reflecting on the point about the self that you brought up right in the beginning. So, there’s a part of the self that resists change. And any sort of change. And this self can be an institution this self can be an individual or a physician, a patient, or even society at large. If I’m resistant to change what’s going to happen next?
Dr. Ellen Scherl: So let’s look at our genes okay. So, 99.9% of our DNA is all the same. Our genes evolve very slowly. Over maybe hundreds or thousands of years. And yet we are seeing diseases evolve much more rapidly and if you take IBD it looks like a global pandemic. It is now all over the world. We used to think that it was mostly northern Europe, the Ashkenazi Jewish population but now we see that it is in populations that were never affected by IBD – Japan, the Arab nations, China, India and the incidence is escalating. So, yes the genes don’t change. You have your genes whether they confer susceptibility to IBD or not. Your genes come with you and they stay stable, they resist change however or they change very slowly. What accelerates the change is epigenetics what turns those genes on and off. And right now with the escalating Diabesity epidemic with Inflammatory Bowel Disease becoming like a global epidemic and I’m saying global because there’s it acts almost like an infectious disease or a stealth infection we know it’s not. But the point is things are changing whether we like it or not the more things change the more they stay the same but they are changing. And what’s making the epigenetic changes we think is our food supply. We don’t know what we’re marinating in the processed food what’s even added to foods that we don’t think are processed? And what about climate change? So, all that is going to be changed by the pandemic, right? Less carbon emission, less travel because patients are having more time with video visits or working from home, the workplace is going to change and with that, there are going to be changes in our communities and we need to reach out to patients and people who may not be directly changed but they are our brothers and sisters and we need to help everybody because this is a global change accelerated by the pandemic. But before the pandemic, we were seeing an increased acceleration in chronic illnesses. And the economics of healthcare is going to need to change accordingly.
Praveen Suthrum:  Definitely and hopefully for the better. So, Dr. Scherl, thank you so much for sharing your views our conversation was totally fascinating… reflections from the self to institutions, and society, and science. So, was there anything else that you wish to share before we close?
Dr. Ellen Scherl: Well, I do want to say that the idea of computer science moving these fields forward, looking at digital apps, looking at some of the work that Deborah Estrin has done in our tri-institutional endeavor is all going to move the field forward and we have a lot of forward-thinking gastroenterologists. How we can use telemedicine and I don’t want to say artificial intelligence but certainly technological intelligence to help individual patients I think that’s the key.
Praveen Suthrum: Thank you for what you do and thank you so much once again for sharing your perspective.
Dr. Ellen Scherl: Thank you Praveen, it’s been a pleasure working with you always.

 

 


Links to references that Dr. Scherl provided:

 

 

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By Praveen Suthrum, President & Co-Founder, NextServices. 

COVID-19: The Way Forward for Gastroenterology Practices
COVID-19 is a double whammy of both clinical and business disruption. This ebook will help you explore possible scenarios and be a guide in your plans for the future.
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