Demand for colonoscopies and other endoscopic procedures keeps climbing, but many centers find themselves unable to absorb volume as the workforce struggles to keep pace with anesthesia needs.
Amy Oxentenko, MD, vice dean of practice and chief patient experience officer at Rochester, Minn.-based Mayo Clinic, heard that concern repeatedly in the years leading up to her term as president of the American College of Gastroenterology. At meetings of the society’s board of governors, which includes physician representatives from nearly every state, members described practices with ASCs and endoscopy centers that had to close for the day because they could not get adequate anesthesia support.
Those reports helped shape a task force Dr. Oxentenko convened in 2025 to address GI workforce needs. Its report, published Sept. 22 in a supplement to the American Journal of Gastroenterology, examined three related pressures: the physician workforce, advanced practice providers and anesthesia. Anesthesia may be the hardest of the three to untangle, because easing it requires changes to training, state legislation and buy-in from another specialty.
Dr. Oxentenko said the pressure is especially acute in rural areas, where gastroenterologists are increasingly pulled into procedures.
“You have gastroenterologists in rural areas who are being pulled more into the procedure aspect, but again, their dependencies on anesthesia is very strong and is a rate-limiting step of how much they can do in terms of endoscopic procedures,” she said.
Part of the problem, she said, is that GI built that dependency itself.
“We’ve created a very strong dependency on another specialty that has its own workforce challenges, and so that is going to perpetually limit what our opportunities are if we continue that dependency,” Dr. Oxentenko told Becker’s.
The shift happened gradually. When Dr. Oxentenko trained, gastroenterologists sedated most of their own patients using moderate sedation, which they could administer in the procedure room alongside a nurse.
Over time, as endoscopic procedures became longer and more complex, so did patients. Clinicians grew more mindful of who needed deeper, anesthesia-supported sedation because of factors such as body mass index or airway concerns. Dr. Oxentenko said those are legitimate considerations, but the habit spread beyond them.
“Now, that has become almost reflexive, where it’s just easier to just have someone else do the anesthesia rather than us holding ourselves accountable to do it,” she said.
The consequences are showing up in training. Many GI fellowship programs do not train fellows in moderate sedation or give them meaningful exposure to it, Dr. Oxentenko said, even though fellows are essentially expected to leave training competent in the practice.
“And so, what happens is those clinicians go out into their first practice, and they’re looking for practices that have anesthesia-supported sedation because they have not been trained in administering it themselves, so now we’ve started to perpetuate the problem, which is only going to get worse,” she said.
Endoscopy nurses face a similar erosion. Nurses who have worked only in centers where someone else administers propofol have had fewer opportunities to give and manage conscious sedation during procedures, and any new sedation model will depend on them.
“There’s also a level of making sure our endoscopy nurses feel comfortable with whatever modalities we move forward in, because again, we’re going to be reliant on them helping to administer some of that sedation as well,” Dr. Oxentenko said.
Operational economics reinforce the status quo. Propofol-based sedation is a quicker on and off than moderate sedation, Dr. Oxentenko said. With a certified registered nurse anesthetist working a room ahead, the patient can be asleep moments after the gastroenterologist finishes the consent, allowing the physician to complete the scope and move straight to the next room. Moderate sedation relies on the gastroenterologist to come in and administer it, takes longer to take effect and wears off more slowly, which can crowd recovery areas.
“I can’t argue with the fact that we want endoscopy centers to be rapid turnover to get all the patients in they need, but if that’s going to be the solution, then we need to equip ourselves and train ourselves in different levels of sedation without the dependency that we have right now,” she said.
The obvious answer, asking anesthesia to train more of its own physicians and nurse anesthetists, will not close the gap alone, Dr. Oxentenko said.
“We’re not going to train and recruit our way out of this issue,” she said.
Instead, the task force’s anesthesia work group focused on what GI can change. The first step is returning to fellowship programs to ensure fellows become competent in moderate sedation, with the society potentially offering that training when a program cannot provide it internally. The second is a harder question: whether gastroenterologists and nurses could be trained, and legally permitted, to administer propofol-based sedation for the cases that need it.
“Is there a way that gastroenterologists and nurses can be trained and allowed to do propofol-based sedation, assuming there’s all the safety and guardrails in place to make sure that we don’t take a step back in quality and safety of our procedures?” Dr. Oxentenko said. “We need to be thinking outside our current paradigm because this will continue to get worse before it gets better unless we put clear mechanisms in place.”
That path is not simple. Nurse-administered propofol is not uniformly permitted across states, so it would require legislative changes, along with buy-in from endoscopy nurses, gastroenterologists and anesthesia professionals, who currently control that part of GI practice. New training programs would also need to be designed.
Dr. Oxentenko said the task force chose to study physicians, advanced practice providers and anesthesia together because each constraint feeds the others. When rural gastroenterologists are consumed by procedures and limited by anesthesia capacity, outpatient care shifts to advanced practice providers, who need training and support to stay.
“It’s this equation that we need to address all three of those because if we only address one at the expense of the others, we’re not going to really be holistically looking at how we’re going to provide the best care to all areas of our country,” she said.
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