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Gastroenterology training grows increasingly, perhaps unnecessarily, specialized
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PHILADELPHIA — Advances in technology and trends toward more narrow specialization have led to a dramatic shift in the way gastroenterology specialists are trained, according to this year’s J. Edward Berk Distinguished Lecturer.
Richard A. Kozarek, MD, who serves as the executive director of the Digestive Diseases Institute at Virginia Mason Medical Center in Seattle, warned that these advances may come with a price. “We have seen an explosion in medical knowledge and technology,” he said. “The consequences of all this are a prolongation of the GI training period and too much subspecialization within the discipline.”
As an example of the trade-offs made for prolonged training, Kozarek noted the number of colonoscopies required to reach expert status. In 1992, that number was 100 procedures. By 1996, it had jumped to 140, and later studies showed that fellows performed as many as 770 colonoscopies to more than 90% procedure completion.
“Now the magic number is 500 colonoscopies for a 90% colonoscopy independence rate,” he said. “So what’s the right number? The right number is that there is no right number. Procedure indicators need to be tracked, along with adenoma detection rates, completion rates, complication rates, patient satisfaction. We need to look at this stuff.”
In short, more may not necessarily be better.
Specialized study, too, may not always be better, according to Kozarek. Ultimately, the need to focus on hepatitis or non-hepatitis, IBD, motility, absorption or therapeutic endoscopy could have a downstream detrimental impact on patients. He paraphrased Joseph J.Y. Sung, MBBS, PhD, MD, FRCP, FACG, of Chinese University in Hong Kong, who said that the proliferation of experts in all of the various disciplines can make a patient feel like a piece of luggage being passed from specialist to specialist.
The constant evaluation and reevaluation has also “spawned a cottage industry of acronyms” relating to patient safety and quality of care, Kozarek said. He cited the Clinical Learning Environment Review (CLER) program; the Next Accreditation System (NAS); Entrustable Professional Activities (EPAs), among others. Findings from these various performance measures must be reported to the Accreditation Council for Graduate Medical Education (ACGME).
As a counterpoint to the domestic bureaucracy, Kozarek has spent a significant amount of time training fellows in the developing world.
“These experiences in the developing world have taught me that GI training does not require a huge investment,” he said. “It requires support and students committed to learning.”
For more information: Kozarek RA. J. Edward Berk Distinguished Lecture. Presented at: ACG Annual Scientific Meeting, Oct. 20-22, 2014; Philadelphia, PA.
Disclosures: Kozarek reports associations with Blackwell, Elsevier, Springer and Taewoong.