Gastroenterology's biggest threats

Many gastroenterologists are worried about a physician shortage and colonoscopy backlogs in the coming years. 

Eight leaders in gastroenterology spoke with Becker's ASC Review about these threats and others they perceive to be the biggest in the industry. 

Editor's note: These responses were edited lightly for clarity and brevity. 

Question: What are the biggest threats to gastroenterology?

Vonda Reeves, MD. Gastroenterologist at GI Associates & Endoscopy Center (Flowood, Miss.):​ An increasing inability to meet the needs of the population, as more and more aging GI doctors leave practice. Supply will now meet the demand. A second concern is the role that insurance companies play in patient decision-making via physician assistants. Third, cutbacks in reimbursement by federal and private payers will create even larger financial burdens on practices that will ultimately influence practice decisions. 

Pankaj Jay Pasricha, MD. Professor of Medicine and Neurosciences at Johns Hopkins University School of Medicine (Baltimore, Md.): The biggest [somewhat philosophical] threat to gastroenterology is that we do not have a robust pipeline for innovation. This is because of a combination of factors — complacency/status quo [largely driven by the demand for simple screening colonoscopies]; commoditization of GI services by large scale acquisition of practices by PE groups; and a legacy of failures of adoption of truly disruptive, as opposed to incremental, technology by the specialty as whole that discourages entrepreneurs.

George Dickstein, MD. Gastroenterologist at Greater Boston Gastroenterology: Many of the threats to gastroenterology are not new:

  • A push toward finding clinically relevant and financially secure ways to participate in bundled payments or pay-for-performance models of care, while taking care not to sacrifice quality for efficiency.
  • The annual and sometimes erratic pressures of rate reduction from CMS and commercial plans [with some draconian and sudden reductions by some large regional commercial plans being a more important driver of risk this year than usual].
  • A continued lack of integration of many electronic health systems, which still leads to fragmented and suboptimally coordinated care.
  • The proliferation of blood and stool tests for colorectal cancer screening as opposed to colonoscopy. These are now covered by many federal and commercial payers. What financial impact will this have on practices? More importantly, what is the societal cost of false positive exams and missed cancers that are more common with these tests?

Lawrence Schiller, MD. Program Director of the gastroenterology fellowship at Baylor University Medical Center (Dallas): The biggest threat is an inadequate workforce. Even though the demand for gastroenterology services continues to increase, due to population growth and increased demand for services, the number of training slots has been relatively static for the last 15 years, presaging a shortage of gastroenterologists in the near future. Also, capacity limits due to physical infrastructure and inadequate staffing. Although the number of ASCs has increased, capacity lags behind anticipated demand. This lack of capacity is due to both lack of physical space and staffing with trained endoscopy nurses and technicians.

Christopher DiMaio, MD. Professor of Medicine at Icahn School of Medicine at Mount Sinai (New York City): There is a major disconnect between the explosion of innovative endoscopic tools and techniques, such as endoscopic submucosal dissection, minimally invasive internal drainage procedures, endoscopic weight loss interventions and the use of artificial intelligence to improve colon polyp detection, but no parallel establishment of procedure codes and reimbursements. Many of these procedures eliminate the need for surgery and/or improve clinical outcome parameters, yet in the current environment they are not billable, and thus they may result in major cost issues for patients, hospitals and providers. Ultimately, these factors will hinder their widespread adoption and thus availability to patients.

Giuseppe Aliperti, MD. Gastroenterologist at Midwest Therapeutic Endoscopy Consultants (St. Louis): Paradoxically, I see the advent of screening colonoscopy as one of the biggest threats to gastroenterology ever. The GI community, called to perform one of the largest preventive tasks by performing screening colonoscopies, is less able to attend to other GI diseases with the same intensity. Colonoscopy, a safe, relatively easy, yet tedious procedure, has taken new graduates' enthusiasm away from exciting pursuits that might require longer term intellectual investment or stronger procedural focus. Many current GI applicants see themselves as future volume performers, shunning interventional endoscopy, nonprocedural GI care and pursuits in GI research. Most clinical graduates will only consider jobs including ownership in an ASC. 

Brian Dooreck, MD. Gastrointestinal Diagnostic Centers and the Memorial Healthcare System (Miami): Clearly, the biggest threat not only to gastroenterology — but more so to patients — is "misinformation." Misinformation, or better yet, a "misunderstanding," that stool testing with the [at-home colon cancer screenings] "prevents" cancer when what it does is detect the presence of colorectal cancer or advanced adenoma. Look, any screening is better than no screening. Agreed. However, I choose colonoscopy because I’d rather prevent colorectal cancer than be told I have it. 

Pankaj Vashi MD. Department Head of gastroenterology/nutrition and Vice Chief of Staff at CTCA Chicago: The biggest challenge facing gastroenterology as a subspeciality is shortage of physicians and the impact of COVID-19 on screening for colon cancer. Over the past two decades, the United States has seen a steady decline in the number of people aged 50 and older who have been diagnosed with colorectal cancer — a trend experts largely credit to more widespread awareness and screening.

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