2010-07-06 15:22:01 UTC

Cognitive GI Must Be Resurrected

July 6, 2010

Lawrence S. Friedman, MD, AGAF

Lawrence S. Friedman, MD, AGAF

Professor of Medicine, Harvard Medical School; Professor of Medicine, Tufts University School of Medicine; Chair, Department of Medicine, Newton-Wellesley Hospital, Newton, MA; Assistant Chief of Medicine, Massachusetts General Hospital, Boston, MA  


For me, gastroenterology has always been a cognitive discipline. I was drawn to the field by the breadth of clinical problems; multitude of laboratory, imaging and endoscopic tools available to address clinical challenges; expanding application of technological and basic innovations to patient care; and potential to study a broad array of research questions that were — and in many cases remain — unanswered.

Surely, the introduction of endoscopy to the study and practice of gastroenterology has been transformational. It is hard to imagine practicing gastroenterology today without endoscopy.1 Now, we take for granted the capability to remove polyps and thereby prevent colon cancer by colonoscopy, apply a variety of methods to stem ulcer or variceal bleeding and reduce the risk of rebleeding by upper endoscopy, relieve bile duct obstruction and remove stones by ERCP, detect the smallest pancreatic neoplasms by endoscopic ultrasonography, and examine every inch of the gastrointestinal lumen, now that capsule endoscopy and deep enteroscopy are available.


Cognitive GI is central to practice

Clearly, none of these techniques is, or should be, done by technicians, but by fully trained gastroenterologists (or surgeons) who understand the implications of endoscopic findings, pitfalls of interpretation, treatment alternatives and potential complications (and their management) of therapeutic interventions.2 On the other hand, we also recognize that endoscopy alone does not necessarily solve a patient’s problem. My consultative practice derives in large part from patients referred after endoscopy has failed to address their concerns adequately. Challenging cases are familiar to all gastroenterologists and span a gamut that includes unexplained abdominal pain, diarrhea and liver biochemical test abnormalities. When the final diagnoses are familial Mediterranean fever, bile salt malabsorption and celiac disease, respectively, it is easy to appreciate that endoscopy may be non-diagnostic or not considered in the evaluation. We all have memorable cases that were not solved by endoscopy, like my patient with rectal burning that proved to be a manifestation of pancreatic insufficiency or the one with throat spasms who turned out to have reflex headache syndrome that responded to NSAIDs. The component of functional gastrointestinal disease (FGID) that makes up a large part of gastroenterology practice further increases the challenges of diagnosis and management considerably, and demonstrates the failure of endoscopy to significantly impact the diagnosis or management of the patient with FGID.

But the premise that cognitive gastroenterology and endoscopic skill represent a dichotomy is false; both are central to the practice of gastroenterology.3 As our armamentarium of interventions available to help patients expands, so does the cognitive base required for rational decision making. The endoscopist must have answers to many “cognitive” questions. How should we manage Barrett’s esophagus with low-grade dysplasia? What is the significance of a serrated polyp in the cecum? Is genetic testing indicated in a patient with multiple hyperplastic polyps throughout the colon? When is endoscopic therapy appropriate in a patient with pancreatic necrosis? Endoscopy plays a role in each of these disorders, but the application of endoscopy requires an understanding of the significance of the findings, natural history of the disease and consideration of alternative or additional approaches. There is no substitute for expertise — both technical and cognitive.

It has been argued that the combination of open-access endoscopy and market forces that limit access to expert consultative services may ultimately be detrimental to patient care.4 Moreover, an endoscopic intervention may remove a lesion, but may not fully address a patient’s concerns and anxieties. Fully effective therapy often requires dialogue, compassion, understanding and, above all, time. Clinicians are most likely to be successful when they utilize both cognitive and technical skills to treat the patient’s illness, rather than merely technical approaches to address a disease or lesion.5, 6

The future of cognitive GI

The frontiers of gastroenterology are expanding at a rapid pace, and the knowledge required of a gastroenterologist is growing proportionately. Essential now to gastroenterologic practice is an understanding of the role of genetic testing in colon cancer, metabolic liver diseases, pancreatic disorders and drug prescribing; second- and third-line therapeutic regimens for eradication of Helicobacter pylori; serologic testing in IBD; an expanding repertoire of antiviral agents for hepatitis B and C, and biologic agents for IBD; and various approaches to the management of portal hypertension and end-stage liver disease, as well as hepatocellular carcinoma; to name a few. Even the most motivated primary care physician will not have the expertise needed to manage this array of problems.

These advances are occurring as endoscopic progress is accelerating. Intriguingly, as we press the boundaries of endoscopic intervention with Natural Orifice Translumenal Endoscopy®, we are learning that exploration of the final frontiers is not for the faint-hearted. Most endoscopists continue to perform non-complex endoscopic procedures, particularly screening colonoscopy. Few, I suspect, will master the high-end or complex techniques. Clearly, endoscopic specialization mirrors specialization within the field of gastroenterology. Many gastroenterologists who “do endoscopy” will want to be stimulated and challenged by the expanding knowledge base of the field.



We risk making ourselves irrelevant if we focus solely on our role as technicians or proceduralists. Technology evolves, procedures come and go, and methods just emerging or not yet imagined may render endoscopy a fading option, but the field of gastroenterology will remain vibrant because of its rich cognitive base. We all became gastroenterologists to take care of patients, not merely to do procedures. We need to embrace the entire field for our patients’ sakes and for our own.


1. DiSario JA, Waring JP, Sanowski, RA, Wadas DD. The gastroenterologist: physician or technician? Gastrointest Endosc 1991; 37:315-8.
2. Standards of Training Committee, American Society for Gastrointestinal Endoscopy. Principles of training in gastrointestinal endoscopy. Gastrointest Endosc 1999; 49:485-52.
3. Spiro HM. Parsnips and pomegranates—training in gastroenterology then and now. Am J Gastroenterol 1983; 78:57-62.
4. Shaheen NJ, Bozymski EM. Open access endoscopy: cognition, technician, or some of both? Gastrointest Endosc 1997; 46:85-7.
5. Brandt LJ. Thank you for taking time to listen to me: a reflection on clinical practice in the era of patient consumerism. Am J Gastroenterol 2005; 100:1224-5.
6. Rogers AI. The cornerstone of medicine: the physician-patient relationship. Am J Gastroenterol 2007; 102:1594-5.


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