A new study suggests current standards for GI fellowship training in the U.S. may no longer be enough.
Productivity-based compensation in academic medical centers has affected the time available for procedural training, and post-fellowship assessment remains focused on written exams rather than hands-on skills. Sri Komanduri, MD, associate chief of the division of gastroenterology and hepatology at Northwestern Medicine in Chicago, conducted a study to evaluate whether simulation could help close the gap. His team’s findings, published in Gastroenterology with funding from the National Institutes of Health, suggest it can.
Post-fellowship assessment in the U.S. is largely driven by written exams. Without a skills-based benchmark to meet, practicing gastroenterologists have little incentive to continue sharpening their technical abilities, even as the techniques used in colonoscopy and polyp removal continue to evolve, Dr. Komanduri told Becker’s.
Compounding the assessment gap is a structural shift in how academic medical centers, the same institutions where GI fellows are trained, compensate their physicians. Over the last decade, productivity-based compensation has reshaped the attending-fellow relationship in ways that could have major implications for training quality.
“Time is money, and the ability to train our fellows has gone down dramatically because we just can’t afford to give them the same amount of time for procedural learning,” Dr. Komanduri said. “We then continue to hire junior faculty who have progressively fewer skill sets. So we’re developing a scenario where training, even for fellows, is not optimal, and we need other ways to augment that.”
A gastroenterologist who is compensated by volume may deprioritize complex polyp removals, Dr. Komanduri said. If that same physician is also training the next generation of fellows, the skill gap compounds.
“If a basic gastroenterologist who is training our fellows doesn’t have the comfort or skill set to remove even a moderately sized polyp, you can imagine the next generation doesn’t develop that skill set either,” Dr. Komanduri said.
The problem is not unique to Northwestern. In 2018, Montreal-based McGill University’s Kevin Waschke, MD, and San Diego-based Scripps Clinic’s Walter Coyle, MD, wrote a paper published in Gastroenterology identifying rising productivity requirements as a systemic threat to the training environment.
“As healthcare delivery evolves, with rising patient complexity and increasing productivity requirements, there is mounting pressure on the time available for training in the clinical setting,” they wrote.
This pressure is compounded by an expanding procedural landscape that demands more of trainees at the same time faculty have less bandwidth to teach, according to the paper.
Traditional GI fellowship follows a three-year “see one, do one, teach one” model, according to Dr. Komanduri, which is a structure built around cognitive learning first, with procedural complexity added gradually. Dr. Komanduri’s study aimed to test whether a different educational framework could raise the floor.
He and his colleagues concluded the most effective method would be mastery learning, which he described as “the highest rigor in medical education in 2026.” Unlike conventional competency scales, mastery learning is binary: A physician either performed a skill correctly or they did not.
“If you’re having a colonoscopy tomorrow and there are 10 key skills a doctor should have, you don’t really want them at two or three,” he said. “That’s how mastery works, and that’s why, when you look at the percentages in our study, it’s not that Northwestern produces poor doctors, it’s that we set a very high bar, which patients deserve.”
One of the study’s most clinically significant findings involved incomplete polyp removal. Before training, only 49% of procedures demonstrated proper identification and treatment of residual polyp tissue. That number is critical considering incomplete polypectomy is a leading cause of interval colorectal cancers, tumors that develop between scheduled screenings, often in patients who believed they were protected.
“Looking back at interval cancers, incomplete resection of larger polyps tends to be one of the highest risk factors,” Dr. Komanduri said. “Prior to the study, a lot of our doctors were not achieving complete resection of some polyps — and what we ultimately showed is that it improved dramatically.”
After simulation training, that rate rose to 80%. Overall, the share of polypectomies meeting the minimum passing standard nearly doubled, from 37% to 74%, and median checklist scores improved from 87% to 100% of items performed correctly.
The study was conducted across roughly 20 gastroenterologists at a single academic center. Dr. Komanduri said the team plans to scale the intervention across Northwestern Medicine’s 11-hospital network, which includes more than 100 gastroenterologists practicing in rural and non-academic settings.
“That would really represent the country as a whole,” he said.
That expansion also speaks to a broader access problem, as the skills gap Dr. Komanduri described is not confined to prestigious academic centers. Community and rural settings face greater barriers to ongoing training and fewer resources to address them.
More than two-thirds of U.S. counties do not have a practicing gastroenterologist, according to a November 2024 report from Medicus Healthcare Solutions. About 7 million people live more than 50 miles from a GI specialist, and healthcare organizations are taking a median of 186 days to fill an open gastroenterologist position as demand continues to outpace supply.
The gastroenterology workforce faces additional structural strain. More than half of practicing gastroenterologists are 55 or older, and long-term projections show a shortage of nearly 1,400 physicians by 2037. Growing demand for geriatric care, chronic disease management and oncology-related services is expected to accelerate that gap, while rising patient volumes and administrative burden are contributing to burnout.
Outside of the training issues Dr. Komanduri highlighted, other leaders point to the absence of business education in fellowship as another significant gap.
“Academic programs shy away or even actively discourage discussion about the business and economics of medicine,” Naveen Reddy, MD, gastroenterologist at Jupiter, Fla.-based Palm Beach GI, told Becker’s. “I’m not sure if it is because the people in academics don’t have the knowledge to discuss business/economics or feel it is an indelicate subject, but failing to address these issues is a disservice to their trainees and the future of medicine, as it leaves graduates unprepared and susceptible to business people who will take advantage of them.”
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