November 4th, 2008
Whither Gastroenterology?
What does it mean to be a gastroenterologist in 2008? Is our field moving in the right direction?
I suspect that most gastroenterologists were and are attracted to the specialty because it offered the opportunity to deal with multiple organs and diseases. My generation of gastroenterologists came of age along with the exciting and emerging ability to diagnose–and later manage–aspects of GI diseases with endoscopy. However, most of our days were still spent as consultants seeing patients in the clinics and inpatient units, ordering radiographic and laboratory studies, and occasionally performing endoscopy. Many of our patients belonged to us–they had IBD, chronic pancreatitis, peptic ulcer disease, peptic esophageal strictures, chronic liver disease, etc. We knew them and they knew us.
The world of medicine has changed, however, and with it the practice of gastroenterology. For many of us, most of our days are now spent “scoping” patients we have never met. Many of these patients don’t even have what would traditionally be thought of as a GI disorder. When we are not performing screening tests, we are often evaluating patients with chronic pain located somewhere in the abdomen. Many gastroenterologists no longer see patients with complex IBD or liver disease. For that matter, some of us don’t see hospital patients anymore, leaving this population to the newly arrived GI hospitalist. While these trends have invariably led to greater efficiency and more widespread cancer prevention screening they have also removed us from the primary care of patients with acute and chronic GI disorders.
I miss the old days! I think the new paradigm of open endoscopy, a one-time consult and then dismiss the patient back to the PCP, etc. has diminished our specialty. Endoscopy is an amazing and wonderful tool that has improved the health of our patients, but it also has become a barrier to the practice of gastroenterology. How do we take the best of modern technologies and efficiencies without losing the best of the old connection with our patients and our primary role in managing gastrointestinal diseases? My own take is that, as individuals, we need to re-embrace providing primary care to patients with GI diseases and convince our colleagues to see the value of the “old-fashioned” gastroenterologist and make it easier for us to be one again.
What do you think? Should gastroenterologists be more involved in patient care? How did we lose our way? How do we find it again? Are we gastroenterologists or just endoscopists? And primary care physicians, what role do you see for the gastroenterologist in the management of GI disease?
7 Responses to “Whither Gastroenterology?”
M. Brian Fennerty, MD
Editor-in-Chief
NEJM Journal Watch Gastroenterology
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I couldn’t agree more. I am an endocrinologist, in which subspecialty it is also very easy to become a pure consultative physician, with subsequent return to the PCP. Or, a little more, one can see only the disease, not the patient. Both thyroidology, and diabetes care could allow an endocrinologist to focus only on therapy changes.
Like Dr. Fennerty, I have always chosen the other path; that is, I have always done primary Internal Medicine care on every one of my patients. One benefit of this is that I use all of my Internal Medicine knowledge, and it helps me stay current in this Queen of the clinical specialties.
Further, it affords the understanding of everything about each patient. How can one manage diabetes without knowing all of the personal issues, and coincident other diagnoses? I have been rewarded richly, not financially, but spiritualy and professionally.
As an R.N. I also see great benefit to GI physicians truly being able to work closely with their patients. The Dr. should not be just another endo consult on the patients seemingly endless list of consults that the primary hospitalist has written. I see many serious health issues looked over on a daily basis due to the fact that the consult is not taken seriously. The GI Doc writes a one time order for Pepcid IVP, Pepcid BID or a Nexium gtt BID without ever speaking with the patient for more than 2 minutes or doing an assessment that goes into any greater detail than I, as an R.N. do in my assessment. I am not just speaking about GI Docs, I am talking about Physicians in general, consults or hospitalists. Instead of the patient seeing the Dr. post D/C, their are generally no follow-up orders written. Maybe if physicians would take more pride in their specialties, patients problems would be fixed, instead of masked on a short term basis and decrease truly unnecessary hospitalizations, thus giving true specialists with a love of their specialty an opportunity to practice it.
unfortunately the whole trend in US in regards to the training primary care physician as gone wrong. Many Primary care physicians are treating cough & cold with antibiotics , which doesn’t require in majority of the cases. Many GI are interested in doing more unnecessary biopsy of the colon otherwise not much reimursement and Many cardiologists are doing more & more unnecessary stress echo etc. Only way to solve this is to let mid level practictioner handle cough and cold and produce more high quality primary care physicians , who can do this procedure comfortably and patients don’t ends up run around. Also reduce reimursement of the all the tests and treatment which doesn’t have strong evidence base support. There is no easy fix.
I ‘m still not completely sold on colonoscopy as the best choice over sigmoidoscopy. Thought on the subject.
I have been in family practice for 33 years.I have seen all my gastroenterology consultants move from primary gastroenterology to scoping primarily-and leaving the scut work to the nurse practioner.I personally resent trying to decipher some GI problem without success and then being embarassed by my patients being evaluated by a nurse.Someone commented about primary care docs prescibing inappropriately antibiotics for colds.In my area the NPs have siphoned off many of the URIs which in days of yore helped pay the bills and I am left with the older patient with 8 major diagnoses and 16 needed meds!I think doctors should doctor which involves talking to a patient,personally examining that patient,and arriving at a diagnosis with that patient’s input-not running into a procedure room,scoping a sedated patient,and taking his money and running.NPs are needed but they should have gone to med school if they are to function as MDs.
I am a retired Physician Assistant who practiced both in Internal Med and Specialty med for twenty years, until 1997.
I was trained as a PA at Duke in 1975-1977. I later practiced with UCLA surgeons. Both experiences taught me the value of treating the entire patient, no matter what their chief complaint was. We were not allowed to ask for a consult unless it was an emergent situation and/or you had ordered the preliminary work-up that you knew the consultant would require. My personal practice with complex patients was to have face to face or telephonic contact with the consultant both prior to and after the consult. This way, the consultant somewhat “knew” the patient prior to seeing him/her and also they knew ultimately who would be sharing the care of the patient with them. This sharing the care was key, because both the primary provider and the Specialist became invested in the patient. Further, if the patient ran into trouble, they were better known by the Specialist and usually got seen again more quickly.
As an aside, I need to voice my opinion on Nurse Practitioners. Most people forget the big difference between PAs and NPs. PAs are trained by physicians, NPs are trained by nurses. NPS can be superior in certain areas when they stay within their specialty e.g. Peds, OB, Family Med. However, Physician Assistants have a broader scope of knowledge across the board. They are trained and evaluated right alongside medical students and residents, which can be pretty tough competition ( and is something that I have always been grateful for).
As a former mid-level provider, I am still agast that Nurse Practitioners can open their own clinics and have that level of independence. I too had the experience of working up a complex patient and sending them to a consultant only for them to be seen by a nurse! In most of the cases, I either continued a more intense work-up until I found an answer ( in consultation with a physician) or sent the patient to a different consultant.
I have been disabled since 1997 and have complicated multiple medical problems. One of my problems is Barrett’s. The only reason that I go for
repeat endoscopies is because I was told to do so by the first GI guy that found it. My GI guy now leaves it up to me to call and schedule one because I am a “PA” and I should know to I had a botched lap cholecystectomy— ( after finally convincing another GI guy that the gallbladder was my problem) in 1999 with my gallbladder falling back down the scope and seeding my abdomen with stones, bacteria and fungi. This was followed by a leaking cystic duct which had to be stented and a large biloma which had to be externally drained. I co-incidentally have auto-immune polyendocrinopathy syndrome with a rising PTH ( I am s/p one neck exploration). So, now I’ve been having the same RUQ pain that I had prior to my cholecyctectomy for the last six months. I finally went to my primary who felt that I may have recurrent stones or some other biliary duct problem. I called my GI guy whom I’ve been seeing for 3yrs. and was given an appointment 6wks away. Since then I’ve been in the ER once had a CAT scan with IV and oral contrast 6days ago, found out the results
just today (-) and now am waiting on an MRCP “someone will call you to schedule it” with no office follow-up.
He had my chart in front of him and should have considered me a higher risk patient with RUQ pain. Whatever my final diagnosis is, I’ve been seeing this Specialist for 3 years and yet, when I called him for help, I felt like a stranger. In defense of this physician, I’m surprised that he gets a chance to see any patients in the office. Procedures take up the majority of his time. He’s doing the best that he can with what he has. Possibly, the answer for the GI guy and others is to hire a mid-level to screen his patients (under his supervision) and to bite the bullet and restrict patient load and procedures.
Many practitioners forget that a patient is putting their life and their quality of life in your hands and it is expected that you be available in their time of need–no the ER is not your partner on call!!!!!!!!!!
A further breakdown in the system is the new policy of non-communication between physicians and between physicians and mid-levels–whazzup with that? My care has been allocated to several mid-levels, both PAs and NPs. The ones I see I feel are competent and caring. However, they are afraid to call my treating M.D.s because “why would they listen to a mid-level”
My M.D.s don’t even call each other. Apparently this is a new practice which is not only detrimental but dangerous to patients under the care of several providers. I feel that a physician should at least evaluate the mid-level’s scope of general knowledge before relegating them to a lesser level when discussing patient concerns with them. Secondly, as formerly stated, all parties treating the same patient would be more invested and informed if they communicated with each other when problems arise or a patient is labled “complicated”.
Thank you for allowing me to voice my opinions on the above.
still the gold standerde way to strongly suggest disease in general & gastroentrology spescifically is by history &physical examination, then obliged to arrange for investigation ,on tope is to scopy pataints i GID, &OTHER BRANCHES OF MEDICINE .
Iagree,the change is in change in behavoure of doctor ,&the tradinding of imedical ethics rather than the siceefic target in developing area .