It was great to be back at DDW in person this year. Despite the lower than usual turnout, the meeting was a lot of fun, and it was great seeing old friends and making new ones. The content was excellent, and it was especially encouraging to see further progress towards promoting diversity and our younger faculty. However, there is still much more room to improve, and hopefully, next year’s program will be even more inclusive.
This meeting also had a definite déjà vu sense for me as I found myself debating whether a new technology had value compared to our current standards. In fact, it was even more at odds because I found myself discussing the same topic twice with two of my friends. This prompted me to reflect on all of my previous DDW experiences, where I found myself examining the value of new technologies.
In the early 2000s, I argued multiple times that wireless pH monitoring using Bravo had benefits beyond standard catheter-based pH monitoring due to improvements in patient comfort and the ability to study for multiple days. I confronted with comments such as, “wireless was not worriless,” until about seven years later, when these same critics finally acquiesced and jumped on the bandwagon. Now, wireless pH monitoring is the most common reflux test performed in the United States.
We encountered the same resistance when we first brought high-resolution manometry (HRM) into clinical practice (2006–2012). Even though HRM was much easier to perform and provided more accurate assessments of anatomical landmarks and physiology, there was push-back from the motility community. We first used this technology to subtype achalasia, and — as expected — outspoken critics at DDW argued that HRM had no value and it could not predict the outcome or inform treatment. Their argument echoed a familiar catch-22: the data is too limited, and, of course, there is limited data when the technology has only been around a few years. Today, as we know, the achalasia subtypes are the standard, and we choose therapy based on these patterns. We continued to push the technology and organized the Chicago Classification to develop more consensus, and this seemed to help somewhat. However, we were confronted with critics stating that this was “not a better mousetrap.” Regardless, high-resolution manometry eventually replaced conventional manometry and is the current gold standard.
It struck me as funny that as soon as we were back at DDW, I was again debating the merits of a new technology that threatened the old standard. Functional luminal imaging probe panometry is a technique that allows one to assess the motility of the esophagus and opening dynamics of the esophagogastric junction. This is essentially what HRM does. However, it has the benefit of doing it during endoscopy, so the patient is spared a very uncomfortable procedure, and they get their answer almost immediately. Now, I have to tread lightly here because I actually have the IP on this technology, and I certainly have a conflict of interest (COI). However, my COI is not all that different than my COI with Bravo or HRM, as I was paid by the company to work on these techniques. I was also directly involved in their development. That being said, there is certainly more sensitivity regarding these issues today than there was in 2002 and 2012. Today, in 2022, I am cognizant of the COI, and even more sensitive to my own professional bias as I have been working with balloon technologies for over 20 years, trying to develop a new technique to study the esophagus. The same people who fought me on HRM 10 years ago are now struggling with the idea of possibly replacing the very same “old technology” that they used to fear: they are holding onto those HRM catheters like they are holding on for dear life.
I understand the need to critique and evaluate new technology so that we do what is in the patient's best interest. We also need to acknowledge that we are inherently fearful of change. There is a great book entitled, “Wired to Resist,” by Dr. Britt Andreatta, who explains that we are all biologically wired to resist change as part of our survival instinct. However, this resistance gets in the way of our success and progress. In the end, I guess I should not expect that bringing new technologies into clinical practice will be easy and accept that I will likely encounter resistance at every DDW until I retire. It’s a good thing I have great mentees who are fresher than me.
Dr. Pandolfino is employed by Northwestern University. He has received grants from Medtronic, Takeda, Ironwood, and the NIH and has received consulting fees from Medtronic, Takeda, Ironwood, Ethicon-Torax, Endogastric solutions, Diversatek, Astra Zeneca, Phathom, and Neurogastrx. He has lectured for Medtronic, Takeda, Ethicon-Torax, Endogastric solutions, Diversatek, and Astra Zeneca. He receives royalties and holds patents from Medtronic.
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