I began my GI career in 1980, at the Minneapolis VA Medical Center, and I worked alongside Jack Vennes and Steve Silvis, two of the original U.S. pioneers in endoscopic retrograde cholangiopancreatography (ERCP). Many physicians from around the world made a pilgrimage to Minneapolis to learn these new procedures. Practicing gastroenterologists complained about the lack of training in ERCP and surgeons jousted with us for first crack at patients septic with common bile duct stones. Now, the field of advanced endoscopy includes not only ERCP, but endoscopic ultrasound, emerging bariatric and anti-reflux endoscopic procedures, Barrett’s ablation, and endomucosal resections of various upper and lower track lesions. Combined, these procedures require training beyond the usual 3-year fellowship. The question broached in this month’s practice management article is whether the extra year of deferred practice is worthwhile. The advanced endoscopists at Yale University School of Medicine have performed a valuable survey and researched facts and figures that should help GI fellows to answer this question.John I. Allen, M.D., MBA, AGAF, Special Section Editor
Twenty-five years ago there were only five recognized advanced fellowship positions for endoscopists in North America, even though there was a high demand for interventional endoscopists at academic and private centers. Interest in advanced endoscopy training is now at an all-time high, and many gastroenterology fellows are willing to invest in an additional year of training to increase their endoscopy skills.
The American Society for Gastrointestinal Endoscopy lists 56 fellowship programs (Table 1). For fellowships beginning July 1, 2014, there were 105 candidates who applied for 70 interventional endoscopy fellowship positions – a 15% increase from 2013. These positions account for 16% of the total gastroenterology fellowships that began in 2014.
A survey of applicants for advanced endoscopy fellowships in 2011 found that most applicants applied for these fellowships to gain access to procedures (92%) and mentors (46%), and to learn a new skill set (43%).1,2 Some gastroenterology fellows have asked whether they can receive mentorship in advanced procedures at an academic institution or private practice in lieu of a fourth-year fellowship.3
Endoscopy-associated techniques and technologies have advanced rapidly. In addition to endoscopic retrograde cholangiopancreatography (ERCP), endoscopic ultrasound (EUS), and endoscopic mucosal resection, recent therapeutic developments include endoscopic submucosal dissection, per-oral esophageal myotomy, EUS-guided pancreas and biliary therapy, and EUS-guided gastrojejunostomy – as well as endoscopic treatment of obesity. These procedures require high levels of training (typically beyond what can be accomplished in an additional year), are time consuming, and have the potential to cause significant complications.4,5
Ironically, these technologies have developed as health care budgets have been curtailed; there have been significant reductions in reimbursements for endoscopic procedures. Approximately 1 year ago, reimbursements for EUS and ERCP procedures were reduced by 20%-35%. Many newer advanced procedures, such as endoscopic submucosal dissection and per-oral esophageal myotomy, do not have specific codes and are billed as unlisted procedures. Reimbursement is uncertain or does not occur, or the procedure is described as an upper endoscopy, which undervalues the endoscopist’s skill, time, and risk taken. Although advanced endoscopists exercise great patience and dedication in performing complex, demanding, and time-consuming procedures, their value may not be readily appreciated by current health care systems. Some academic gastroenterology programs use Medicare work relative value units to monitor physician productivity.6
The reduction in relative value units for interventional procedures may challenge the physician’s ability to advocate for resource allocation to support interventional procedures.
Many advanced fellows may not appreciate the significance and challenges of communicating the benefits and value of advanced endoscopic practice to medical and hospital administrators. An analysis from a tertiary referral center calculated downstream revenues of 120 patients undergoing advanced endoscopic procedures. Although these procedures were costly to the center, they generated revenues from radiology and pathology analyses and surgeries. For example, each patient undergoing EUS generated a net profit of $7,093 for the center, primarily through surgical procedures.7
Most importantly, these procedures functioned as an entry point for new patients into the medical center. Advanced endoscopists must be able to communicate the value of their procedures clearly to hospital leaders to secure appropriate support.
Advanced endoscopy procedures not only increase a medical center’s financial bottom line, but a center’s ability to offer a full spectrum of these procedures as part of a multidisciplinary team marks it as a center of excellence. Many high-profile and important hospital services, such as gastrointestinal oncology, liver transplantation, and surgery, depend on advanced endoscopy services and expect around-the-clock availability from the interventional team. The current health care environment will require increased effort to document quality, outcomes, and procedure difficulty and to quantify downstream revenue.