Looking to the Future of Gastroenterology: Where Are We Headed?

Dr. Buch:
Welcome to GI Insights on ReachMD. I’m your host, Dr. Peter Buch. And if you’ve ever wondered what the practice of GI will look like in 10 years, then you’re going to want to stick around because joining us today to help clear up that crystal ball is Dr. Eamonn Quigley, who’s the David M. Underwood Chair of Medicine in Digestive Disorders, Chief of the Division of Gastroenterology and Hepatology, and Professor of Medicine at Weill Cornell Medical College at Houston Methodist Hospital. Dr. Quigley’s publications and honors are absolutely legendary.

Welcome to the program, Dr. Quigley.

Dr. Quigley:
Thank you very much.

Dr. Buch:
Let’s dive right in, Dr. Quigley. In the future, will gastroenterologists spend more or less time doing procedures?

Dr. Quigley:
That’s a very essential question for many, many reasons because it will dictate the organization of the practice of medicine. It will also dictate the economics of gastroenterology. It’s a difficult one to predict, but let me give you some thoughts which may help to explain where I’m coming from. What we’ve seen over the course of my career with one particular procedure, which is ERCP, is that that has moved from being a diagnostic procedure to being purely a therapeutic procedure and performed only by those with expertise in that area. It has not meant that people are doing fewer ERCPs. It’s just that a smaller number of people are doing more and doing it as an interventional procedure.

In terms of colonoscopy, which is currently probably the major or the most frequently performed procedure in gastroenterology, I would predict that advances in molecular diagnostics will limit the role of colonoscopy as a diagnostic procedure. What I mean by that is that I think screening colonoscopy may be replaced by a stool test or blood test or maybe some combination of these. However, colonoscopy will then become largely a therapeutic procedure and being performed in people who have a positive screening test, be it stool, blood, or some combination of these, and therefore will be largely playing a role in removing polyps or identifying polyps or dealing with other lesions which were predicted by the stool test. So will that mean a reduction in the number of colonoscopies? Probably, yes. Will it mean an increase in the intensity of colonoscopy and the need for expertise in dealing with polyps when they are found? So I would predict that gastroenterologists will spend less time doing procedures in terms of numerical number of procedures, but they may spend the same amount of time because the duration of these procedures may actually increase.

Dr. Buch:
Thank you very much for that. Now, Dr. Quigley, how will virtual care be utilized in the future?

Dr. Quigley:
This is a very interesting question. Of course, we’ve all had to face this during the COVID pandemic because so many of our consultations at one time or another were transferred to being virtual. From my own experience, I believe that a lot of GI care, particularly follow-up care, can be provided virtually. And I know that some of my colleagues who specialize in inflammatory bowel disease, for example, have been doing that for some time, way before the pandemic arrived. How this will translate into the post-pandemic era remains to be seen.

Of course, one of the big unknowns here is reimbursement. If reimbursement is very low for virtual consultations, then that obviously will have an enormous impact because it will become uneconomical to continue to do these, but I would hope that we will manage to weave the virtual consultation into the overall care package for the patient because given distances involved, given the work commitments of patients, etc., I think virtual consultation should have a role in the future, particularly for following up on test results, for following up on imaging results, or just following up on if medications are working and whether medications need to be changed because a lot of the time the real meat, if you like, of the consultation is the discussion between the patient and the physician, and that actually, in my opinion, works very well virtually, as long as your connection is good and as long as you don’t have these glitches, which unfortunately can still be a problem and can make it a major headache.

Dr. Buch:
Thank you. For those just tuning in, you’re listening to GI Insights on ReachMD. I’m Dr. Peter Buch, and I’m speaking with Dr. Eamonn Quigley about what the future of gastroenterology might look like.

So something that I bet you have insight on is the changes that you expect for GI fellowship training in the future.

Dr. Quigley:
It’s a very interesting question. First of all, there’s the issue of subspecialization. We already have this happening, of course, with transplant hepatology, which you can now do this hybrid fellowship in gastroenterology whereby you do your 3 years, but the third year is if you like a concentration in hepatology and transplant hepatology, the idea being that by the end of your 3 years, you will be board-eligible not just in gastroenterology but also in transplant hepatology, which is very important if you’re going to go on and have a career as a hepatologist. If we look at other specialties which are interventional, such as cardiology, we can see they have already developed a variety of subspecialization pathways, whether it be interventional cardiology, noninterventional cardiology etc. That’s one trend I can see developing and that there may be more emphasis on subspecialization.

Now at the moment, the problem with that is that they’re not ACGME accredited, which means that if an institution is going to set up a fourth year to do IBD or to do esophageal disease, for example, they have to find the funding for that, which is a major limitation. One way, perhaps, that could get around that will be to do the same as has been done with transplant hepatology, namely, to allow a fellow to do a “concentration” in their third year whereby they focus on esophageal disease, inflammatory bowel disease, or interventional gastroenterology. Now the interventional part is probably unlikely to take that format because at the moment there are numerous interventional fellowships around the country, again not ACGME accredited but which are all a fourth year, and there’s an increasing recognition that if you’re going to do advanced endoscopy, in other words interventional GI, that you probably do need a fourth year, but that’s one trend that I can see occurring.

The other trend that I can see developing, and I already see developing, is a shift in emphasis during the fellowship program from inpatient to more outpatient or ambulatory care and that’s just a recognition of the fact that the average gastroenterologist spends far more time in their office seeing patients than they do in the hospital seeing patients, just as the way GI is practiced. However, our fellowship programs have traditionally been very heavy on inpatient care rather than outpatient experience, and I think we will see that shift occurring.

Dr. Buch:
Great. You’ve got me thinking about another subtopic with regard to that: the use of APRNs and PAs in GI practice. What do you anticipate for the future of that?

Dr. Quigley:
Growth, undoubtedly growth, and we’re seeing that ourselves. There is a real role, particularly in subspecialty areas for advanced practitioners who develop a real expertise. Inflammatory bowel disease is a good example, where there’s a real need for continuity of care, for integration of care, and use of people who really know the field, know exactly what needs to be done, and when it needs to be done. I think there’s going to be a growing role for these individuals and a very important role for them in gastroenterology. I know that particularly in private practice that’s already become established, and I think it’s becoming more and more important in academic practices as well.

Dr. Buch:
Great. And before we conclude, Dr. Quigley, are there any other thoughts you would like to share with our audience?

Dr. Quigley:
I think we’re at an interesting juncture in terms of gastroenterology. What I would like to see is a greater emphasis on the more cognitive aspects of gastroenterology, namely more emphasis on looking at quality measures, looking at outcomes, and engagement in clinical research. I think these would become increasingly important and, unfortunately, almost across the board are being pushed to the side because of the demands of everyday clinical practice, so that’s one area that I would like to see more emphasis on.

And one of the other areas that I think is going to be very, very interesting to watch over the next two years—again, it’s an artifact of the pandemic—is what happens to CME. Will CME in gastroenterology go towards a more hybrid format, or will virtual learning become more and more important? I think some of us have really missed the in-person meetings, not so much for the educational aspect of it but for the ability to engage with people, to meet with people, to hear what’s going on, be able to have those conversations off-line if you like about new developments in gastroenterology. We’ve missed that. On the other hand, I think with incredible advances in technology and better and better platforms for delivering CME, we’ve become more accustomed to sitting in our office or sitting at home and doing our education. It will be very interesting to see how that translates in the medium to long-term and to attendance at the major meetings and whether that has a negative impact on attendance or whether eventually people want to come back and just meet their friends again. I think that’s going to be another area that we need to watch very carefully.

Dr. Buch:
This was a superb discussion and a fascinating look into what might be ahead. And I want to thank my guest, Dr. Eamonn Quigley, for sharing his insights. Dr. Quigley, it was a pleasure having you on the program today.

Dr. Quigley:
Thank you very much. I enjoyed it very much.

Dr. Buch:
For ReachMD, I’m Dr. Peter Buch. To access this and other episodes in this series, visit ReachMD.com/GIInsights where you can Be Part of the Knowledge. Thanks for listening and see you next time.