Twenty years ago, a survey of solo practitioner Virginian gastroenterologists indicated that the three leading diagnoses that occupied their time were functional gastrointestinal disorders (including irritable bowel syndrome), acid peptic disorders (predominantly duodenal ulcer disease), and gastrointestinal reflux disease (GERD), which in those days was known by the term symptomatic hiatal hernia.1 The current survey by Russo et al. in this issue of the Journal of Clinical Gastroenterology looks at the scope of practice as we move into the new millennium.2
What has happened in the past 20 years? First, there has been an increase in the proportion of gastroenterologists who are in group practice. However, the diagnoses we treat now (1997)1 are much the same as 20 years ago2: 30 to 40% of diagnoses were and are functional gastrointestinal diseases, including irritable bowel syndrome (19%) and nonulcerous dyspepsia (8%); 20 to 30% of patients continue to suffer from acid/peptic disease, including GERD (17%) and gastroduodenal acid/peptic diseases (10%). Inflammatory bowel disease constitute 10 to 15%; liver diseases, 10%; pancreatic and biliary diseases, <10%; and miscellaneous diseases, <10% of reported diagnoses. Furthermore, the current survey indicates that the gastroenterologist spends only approximately 30% of his or her time performing procedures.2 Previous studies of a fee-for-service practice suggested that endoscopy accounts for 20% of billings, but approximately 50% of the gastroenterologists' fee-for-service income.3 Thus, one must conclude that the answer to the question, What does the gastroenterologist do all day, in this changing world is: The more things change, the more they stay the same.
Scope-of-practice studies such as this one are of some interest to the profession itself. Everyone likes to engage in "navel gazing" now and then. Such studies are also of interest to health profession workforce analysts, to program directors who must train our young, and to accreditors who must test them. Caution is recommended to each group as they consider such studies as this one.
For the practicing gastroenterologist, consideration of the past is useful, but the past is only the historic basis for the future. Practitioners should take some time to address and to contemplate the future.4 Opportunities await those who can foresee changes in the times and, more importantly, can change with them. The workforce analyst should realize that the diagnoses seen by the gastroenterologist are the same as those seen by the generalist. The difference is in the acuity of disease (case-mix index) that results in these patients being referred (or self-referred) to the gastroenterologist. None of the scope-of-practice studies referenced in the current article,2 or studies published by the profession itself,3 address the issue of case-mix index. The program director should be warned that the training of the gastroenterologist should not sacrifice learning about the disorders that make up less than 10% of those presenting to our profession. The essence of a subspecialist is the broad and detailed training that allows them to diagnose the unusual and to treat the difficult. I see no reason, based on the scope-of-practice studies, to alter our training curriculum, which has been recently studied and established so thoroughly.5 Furthermore, surveys such as the one used here cannot define clearly what proportion of functional disease patients might have other diagnoses (e.g., whether some patients with nonulcerous dyspepsia truly have Helicobacter pylori gastritis or whether some with the diagnosis of irritable bowel syndrome truly have painful diverticular disease). Finally, accrediting bodies want to test their potential diplomates in proportion to the diseases seen, and the results of the current survey are useful in that regard. However, this survey does not address the need to train for and test for the ability of the gastroenterologist to deal with the problem patient who is so prevalent in the group of referred functional bowel disease diagnoses, or to teach and test for communication skills that are deemed to be so important in a managed care world.6
Will the scope of practice change for the future gastroenterologist? It will be interesting to see whether the hepatitis C epidemic increases the proportion of liver disease patients treated by the gastroenterologist. Will the fact that Medicare now pays for colorectal screening increase either the time spent by the gastroenterologist doing endoscopy or the percentage of diagnoses dealing with neoplastic disease? Will the interest of the American public in preventative medicine convince the gastroenterologist to add nutrition to their scope of practice? A survey of practicing gastroenterologists in another 20 years from now will be very interesting.
D.W. Powell, M.D.
Department of Internal Medicine; University of Texas Medical Branch; Galveston, TX
1. Russo MW, Gaynes BN, Drossman DA. A national survey of practice patterns of gastroenterologists with comparison to the past two decades. J Clin Gastroenterol
2. Switz DM. What the gastroenterologist does all day. A survey of a state society's practice. Gastroenterology
3. Meyer GS, Jacoby I, Krakauer H, Powell DW, Aurand J, McCardle P. Gastroenterology workforce modeling. JAMA
4. Powell DW. The future(s) of gastroenterology and hepatology: four scenarios for digestive health in 2010. Gastroenterology
5. The Gastroenterology Leadership Council. Training the gastroenterologist of the future: the gastroenterology core curriculum. Gastroenterology
6. McFadden D. How should subspecialists be trained for clinical careers? Am J Med