PRACTICE MANAGEMENT: THE ROAD AHEAD John I. Allen, Section Editor
Is Advanced Endoscopy Training Worth it? Harry R. Aslanian, Ali M. Ahmed, and Priya A. Jamidar Section of Digestive Diseases, Yale University School of Medicine, New Haven, Connecticut
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 US 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 approached 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, MD, MBA, AGAF Special Section Editor wenty-five years ago there were only 5 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.
T
Resources for Practical Application To view additional online resources about this topic and to access our Coding Corner, visit www.cghjournal.org/content/ practice_management.
Clinical Gastroenterology and Hepatology 2015;13:1218–1220
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% to 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, Abbreviations used in this paper: ERCP, endoscopic retrograde cholangiopancreatography; EUS, endoscopic ultrasound. © 2015 by the AGA Institute 1542-3565/$36.00 http://dx.doi.org/10.1016/j.cgh.2015.05.003
PRACTICE MANAGEMENT: THE ROAD AHEAD, continued Table 1. Advanced Endoscopy and General Gastroenterology Fellowships Matriculation year 2013 2014 2015
Programs available
Positions, n
51 59 58
60 70 66
Applicants
Received their fellowship choice, %
Gastroenterology positions, n
Advanced endoscopy or gastroenterology positions, %
91 105 108
66 67 61
NA 433 461
NA 16 14
Reprinted with permission from the American Society for Gastrointestinal Endoscopy and The American Gastroenterological Association.
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 $7093 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. There have been many significant changes in the environment surrounding advanced endoscopy practice.
Although there are almost 60 graduating fourth-year fellows, there are usually fewer than 12 employment opportunities at tertiary centers each year based on discussion with current fourth-year fellows and endoscopy directors. The Yale University Medical Center recently received approximately 12 unsolicited applications from qualified applicants for a faculty position in 2012. Are there too many advanced endoscopy training programs? We hope, somewhat unrealistically, that a practice environment, with adequate volume and ongoing mentorship, will be available for physicians completing fellowships in interventional endoscopy. Mentorship is important for professional development—endoscopic skill and maturity increase greatly during the first few years after an advanced endoscopy training program, therefore suitable positions need to be available. Additional data should be collected from recent advanced endoscopy fellows on their current practice settings, patient volume, and job satisfaction. Potentially underserved regions also should be identified—this information likely would be of assistance to applicants and gastroenterology societies that are developing training policies. Potential advanced endoscopy fellows also should consider how this career will affect their lifestyle. Many ERCPs are performed under urgent conditions, during nights and weekends. Interventional endoscopy, although gratifying, can be stressful because of the potential for significant complications.8 Medical centers typically have small groups of interventional endoscopists, resulting in a significant call burden. At the Yale University School of Medicine, for example, 3 endoscopists are responsible for all the interventional endoscopy procedures, in addition to general gastroenterology responsibilities. Although interventional endoscopists generally are expected to be available 24 hours/day, 7 days/week, and a large proportion of procedures require urgent scheduling, there often is insufficient infrastructure for 1219
PRACTICE MANAGEMENT: THE ROAD AHEAD, continued support (inadequate access to endoscopes, skilled assistants, and anesthesia providers). Most interventional procedures are performed under anesthesia, but variations in turnaround time and availability of providers (especially after hours and on weekends), and their lack of familiarity with endoscopic sedation, can prolong cases or even lead to cancellation of procedures. It also is important to appreciate the significant opportunity costs of a career in advanced endoscopy practice. For many practicing gastroenterologists, an equity ownership in an endoscopy center generates a significant proportion of their income and also confers a large measure of security and independence. Most fulltime interventional endoscopists have no access to or benefit from this venture. Based on a survey of 12 of 13 graduates of the Yale University Medical Center advanced endoscopy fellowship program, all believed that the advanced training accelerated their professional development. The mostvalued benefits of the additional training included the following: a year to focus on endoscopy, the opportunity to have dedicated training from experts, and the career development fostered through fourth-year fellowship branding. Ninety-two percent of respondents said that an advanced fellowship made them more competitive in applying for jobs, and the same percentage said they would make the same decision again (to proceed with fourth-year advanced endoscopy training). The value of advanced endoscopy training should not be determined by simply comparing the cost of the lost year of income with future income. The training is valuable in that it provides an opportunity to perform research in advanced endoscopic techniques, to gain leadership skills, and to refine endoscopy skills. Although there are challenges to the practice of advanced endoscopy, many endoscopists are driven by them and have great passion for their work. Given the complexities of procedures and patients, we recommend an advanced endoscopy fellowship for physicians wanting to dedicate their practice to advanced
1220
endoscopy. A dedicated year of advanced endoscopy training at a high-volume center, with access to the practices of several experienced endoscopists committed to training, is invaluable. These procedures and challenges will continue to increase in complexity, so ultimately the journey must be fueled by passion for the field of endoscopy.
References 1.
Trindade AJ, Faulx A, DiMaio CJ. Perspectives on the advanced endoscopy fellowship match. Gastrointest Endosc 2012; 75:650–652.
2.
Trindale AJ, Gonzalez S, Tinsley A, et al. Characteristics, goals, and motivations of applicants pursuing a fourth-year advanced endoscopy fellowship. Gastrointest Endosc 2012; 76:939–944.
3.
Rosenthal L. Is a fourth year of training necessary to become competent in EUS and ERCP? Notes from the 2008 class of advanced endoscopy fellows. Gastrointest Endosc 2008; 68:1150–1152.
4.
Wani S, Hall M, Keswani RN, et al. Variation in aptitude of trainees in endoscopic ultrasonography, based on cumulative sum analysis. Clin Gastroenterol Hepatol 2014; 14:S1542–S3565.
5.
Singh S, Sedlack RE, Cook DA. Effects of simulation-based training in gastrointestinal endoscopy: a systematic review and meta-analysis. Clin Gastroenterol Hepatol 2014;10:1611–1623.
6.
Savides TJ. Impact of the relative value unit-based system on academic centers. Gastrointest Endosc 2014;80:1142–1144.
7.
Harewood GC, Stemmer W, Roth J, et al. Resource-intensive endoscopy: revenue source or cash drain? Gastrointest Endosc 2009;70:272–277.
8.
Elta GH, Jorgensen J, Coyle WJ. Training in interventional endoscopy: current and future state. Gastroenterology 2015; 148:488–490.
Reprint requests Address requests for reprints to: Priya Jamidar, MD, FACG, FASGE, Section of Digestive Diseases, Yale University School of Medicine, 333 Cedar Street, 1080 LMP, PO Box 208019, New Haven, Connecticut 06520-8019. e-mail: [email protected]; fax: (203) 737-1755. Conflicts of interest The authors disclose no conflicts.
Is Advanced Endoscopy Training Worth it? Harry R. Aslanian, Ali M. Ahmed, and Priya A. Jamidar Section of Digestive Diseases, Yale University School of Medicine, New Haven, Connecticut
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 US 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 approached 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, MD, MBA, AGAF Special Section Editor wenty-five years ago there were only 5 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.
T
Resources for Practical Application To view additional online resources about this topic and to access our Coding Corner, visit www.cghjournal.org/content/ practice_management.
Clinical Gastroenterology and Hepatology 2015;13:1218–1220
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% to 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, Abbreviations used in this paper: ERCP, endoscopic retrograde cholangiopancreatography; EUS, endoscopic ultrasound. © 2015 by the AGA Institute 1542-3565/$36.00 http://dx.doi.org/10.1016/j.cgh.2015.05.003
PRACTICE MANAGEMENT: THE ROAD AHEAD, continued Table 1. Advanced Endoscopy and General Gastroenterology Fellowships Matriculation year 2013 2014 2015
Programs available
Positions, n
51 59 58
60 70 66
Applicants
Received their fellowship choice, %
Gastroenterology positions, n
Advanced endoscopy or gastroenterology positions, %
91 105 108
66 67 61
NA 433 461
NA 16 14
Reprinted with permission from the American Society for Gastrointestinal Endoscopy and The American Gastroenterological Association.
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 $7093 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. There have been many significant changes in the environment surrounding advanced endoscopy practice.
Although there are almost 60 graduating fourth-year fellows, there are usually fewer than 12 employment opportunities at tertiary centers each year based on discussion with current fourth-year fellows and endoscopy directors. The Yale University Medical Center recently received approximately 12 unsolicited applications from qualified applicants for a faculty position in 2012. Are there too many advanced endoscopy training programs? We hope, somewhat unrealistically, that a practice environment, with adequate volume and ongoing mentorship, will be available for physicians completing fellowships in interventional endoscopy. Mentorship is important for professional development—endoscopic skill and maturity increase greatly during the first few years after an advanced endoscopy training program, therefore suitable positions need to be available. Additional data should be collected from recent advanced endoscopy fellows on their current practice settings, patient volume, and job satisfaction. Potentially underserved regions also should be identified—this information likely would be of assistance to applicants and gastroenterology societies that are developing training policies. Potential advanced endoscopy fellows also should consider how this career will affect their lifestyle. Many ERCPs are performed under urgent conditions, during nights and weekends. Interventional endoscopy, although gratifying, can be stressful because of the potential for significant complications.8 Medical centers typically have small groups of interventional endoscopists, resulting in a significant call burden. At the Yale University School of Medicine, for example, 3 endoscopists are responsible for all the interventional endoscopy procedures, in addition to general gastroenterology responsibilities. Although interventional endoscopists generally are expected to be available 24 hours/day, 7 days/week, and a large proportion of procedures require urgent scheduling, there often is insufficient infrastructure for 1219
PRACTICE MANAGEMENT: THE ROAD AHEAD, continued support (inadequate access to endoscopes, skilled assistants, and anesthesia providers). Most interventional procedures are performed under anesthesia, but variations in turnaround time and availability of providers (especially after hours and on weekends), and their lack of familiarity with endoscopic sedation, can prolong cases or even lead to cancellation of procedures. It also is important to appreciate the significant opportunity costs of a career in advanced endoscopy practice. For many practicing gastroenterologists, an equity ownership in an endoscopy center generates a significant proportion of their income and also confers a large measure of security and independence. Most fulltime interventional endoscopists have no access to or benefit from this venture. Based on a survey of 12 of 13 graduates of the Yale University Medical Center advanced endoscopy fellowship program, all believed that the advanced training accelerated their professional development. The mostvalued benefits of the additional training included the following: a year to focus on endoscopy, the opportunity to have dedicated training from experts, and the career development fostered through fourth-year fellowship branding. Ninety-two percent of respondents said that an advanced fellowship made them more competitive in applying for jobs, and the same percentage said they would make the same decision again (to proceed with fourth-year advanced endoscopy training). The value of advanced endoscopy training should not be determined by simply comparing the cost of the lost year of income with future income. The training is valuable in that it provides an opportunity to perform research in advanced endoscopic techniques, to gain leadership skills, and to refine endoscopy skills. Although there are challenges to the practice of advanced endoscopy, many endoscopists are driven by them and have great passion for their work. Given the complexities of procedures and patients, we recommend an advanced endoscopy fellowship for physicians wanting to dedicate their practice to advanced
1220
endoscopy. A dedicated year of advanced endoscopy training at a high-volume center, with access to the practices of several experienced endoscopists committed to training, is invaluable. These procedures and challenges will continue to increase in complexity, so ultimately the journey must be fueled by passion for the field of endoscopy.
References 1.
Trindade AJ, Faulx A, DiMaio CJ. Perspectives on the advanced endoscopy fellowship match. Gastrointest Endosc 2012; 75:650–652.
2.
Trindale AJ, Gonzalez S, Tinsley A, et al. Characteristics, goals, and motivations of applicants pursuing a fourth-year advanced endoscopy fellowship. Gastrointest Endosc 2012; 76:939–944.
3.
Rosenthal L. Is a fourth year of training necessary to become competent in EUS and ERCP? Notes from the 2008 class of advanced endoscopy fellows. Gastrointest Endosc 2008; 68:1150–1152.
4.
Wani S, Hall M, Keswani RN, et al. Variation in aptitude of trainees in endoscopic ultrasonography, based on cumulative sum analysis. Clin Gastroenterol Hepatol 2014; 14:S1542–S3565.
5.
Singh S, Sedlack RE, Cook DA. Effects of simulation-based training in gastrointestinal endoscopy: a systematic review and meta-analysis. Clin Gastroenterol Hepatol 2014;10:1611–1623.
6.
Savides TJ. Impact of the relative value unit-based system on academic centers. Gastrointest Endosc 2014;80:1142–1144.
7.
Harewood GC, Stemmer W, Roth J, et al. Resource-intensive endoscopy: revenue source or cash drain? Gastrointest Endosc 2009;70:272–277.
8.
Elta GH, Jorgensen J, Coyle WJ. Training in interventional endoscopy: current and future state. Gastroenterology 2015; 148:488–490.
Reprint requests Address requests for reprints to: Priya Jamidar, MD, FACG, FASGE, Section of Digestive Diseases, Yale University School of Medicine, 333 Cedar Street, 1080 LMP, PO Box 208019, New Haven, Connecticut 06520-8019. e-mail: [email protected]; fax: (203) 737-1755. Conflicts of interest The authors disclose no conflicts.
