In this physician profile, we spoke with Edwin Liu, MD, a pediatric gastroenterologist and director of the Colorado Center for Celiac Disease at Children’s Hospital Colorado. Dr Liu also serves as Taplin Endowed Chair for Celiac Disease and is a founding member of the Society for the Study of Celiac Disease and board member for the International Society for the Study of Celiac Disease. In our conversation, Dr Liu talked about his beginnings as a clinician, the value of great mentors, and how his extensive research in the field of celiac disease has helped shaped his approach to patient care.
Did you always know you wanted to become a physician? What drew you to the field?
Dr Liu: My father was a physician but was always very busy, and I don’t really think I knew what it would be like. But my older sister and brother entered medicine, and almost by default I did the same thing. So, I don’t know that I really knew what I was getting myself into, but [I’m] so fortunate that I really love what I do.
Entering the field of pediatrics I think was a natural for me — my first experience in pediatrics was a medical student at the old Boston City Hospital. The pediatricians there did a lot of outreach and they were so caring. To me, I realized that these were good role models, and that drew me into the field. In terms of gastroenterology, once again, it’s all about role models. As a resident, I turned to Kevin Kelly, MD, (old-school pediatric gastroenterologist) as a wonderful role model and mentor, and he guided me to where I am now — I’ll always be grateful for his guidance.
As a gastroenterologist, my interest in celiac disease started as a fellow trainee, when I did my research years at the Barbara Davis Center for Diabetes [in Aurora, Colorado]. There is a significant link between type 1 diabetes and celiac disease, and the diabetologists were doing all kinds of screening for type 1 diabetes in the general population, and they were finding that a lot of the kids had or developed celiac disease. I joined the group to initially study vaccine therapy in the lab for diabetes, but my research grew in the field of celiac disease given our patient population, and my career was able to take off from there.
What is a moment that has changed your perspective in the way you approach patient care or management of celiac disease?
Dr Liu: It’s not any single transformative moment, but as we continued to screen patients for celiac disease in our research, we found a couple important points that greatly affect patient care:
- Many patients can be relatively asymptomatic yet still have full-blown celiac disease. The approach in how you talk to patients and discuss options can be very different compared to working with a patient who feels sick. We cannot take the prescription of the gluten-free diet [GFD] for granted. It is a major life-changing decision and it takes a thoughtful conversation with the patient and family always, but especially when the patient feels fine.
- The notion of hypervigilance with the [GFD]. During a conference years ago, concerns for hypervigilance [were] raised, and that really stuck with me. It’s important to have a good balance of being safe from gluten while still living a normal life without excessive fear of gluten. Of course, some worry is helpful. As a result, our team tries to support families on the GFD and we watch for signs of hypervigilance (excessive worry about being exposed to gluten, maladaptive behaviors around eating and avoiding gluten). The awareness of the potential for hypervigilance has changed my approach for how I educate families about celiac disease.
What is a patient experience you’ve had during your career that stays with you?
Dr Liu: Probably one of my earliest patients as a celiac disease provider — this child was very ill in clinic, [and] his parents were extremely worried. At the first visit, I screened him for celiac disease and within a few days we had the diagnosis. The parents were relieved but also uncertain because the diagnosis came so quickly that it was almost “too easy.” It took them a while to accept the diagnosis as the only reason for his illness, but as soon as he transformed into a bright, engaging child with the GFD, they were convinced and elated at the change.
I still see him in the community, and, of course, he is much taller than me. It was just memorable that the family did not have to go through months [or] years of a complicated work-up to get the diagnosis, and I feel that this is how it should be for everyone with celiac disease, but, unfortunately, this is not always the case.
What is a study or research that has changed or you anticipate will change how you manage patients with celiac disease?
Dr Liu: There’s exciting data coming out of Australia where you can start to distinguish patients with celiac disease from those who don’t with just a single dose of gluten. This single-dose gluten challenge measures an increase in an inflammatory protein called IL-2 [interleukin-2] that spikes up in the blood within 4 hours in those who have celiac disease but stays stable in those who do not have celiac disease. The exciting part of this is that it really seems to work in people who are already gluten-free! So, that means in the future, if this pans out, it could help us diagnose celiac disease through just an immunologic test in people who are already on a GFD.
Normally, when people are already on a GFD, it is very difficult for us to tell if they have celiac disease or not, unless we rechallenge with gluten for 8 to 12 weeks. And many people simply cannot tolerate a prolonged challenge. So, I am hopeful that this work will progress and someday enable us to make the diagnosis through immunologic testing like this and hopefully eliminate the need for a gluten challenge in those who are already [gluten-free] by the time they see you in clinic before they have had proper evaluation.
What role has a mentor played in your career, and what is one piece of advice you would give medical students or physicians starting their careers?
Dr Liu: Clearly, for me, mentorship and having good role models is everything. It helped me choose pediatrics, it helped me choose gastroenterology, it brought me to the field of celiac disease — all [of] which may have been in part fortuitous but also through great mentorship. I think one important piece of advice for everyone (in general, not just celiac disease) is that we all have bias, and we have to recognize it. When caring for a patient, every little thing can bias us to think one way or another, [so] be aware of this in order to make the best decisions for your patient.
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