2010-07-06 15:25:22 UTC

Procedural Training Should Be Emphasized

July 6, 2010

Pankaj Jay Pasricha, MD

Pankaj Jay Pasricha, MD

Professor of Medicine; Chief, Division of Gastroenterology and Hepatology, Stanford University School of Medicine, CA  


The modern specialty of gastroenterology owes much of its clinical, academic and scientific success to endoscopic procedures: endoscopic extraction of gallstones, control of gastrointestinal bleeding, biopsy demonstrating the link between Helicobacter pylori and peptic ulceration, monitoring of patients with propensity to develop colorectal cancer (CRC), etc. Our patients have benefited tremendously from these procedures and so have we as gastroenterologists. Private practitioners have seen astounding increases in their income with the adoption of endoscopy, while academic gastroenterologists have enjoyed the prestige and political clout that comes with being a major contributor to departmental and institutional finances. All of these considerations, along with the instant gratification that comes from performing a successful procedure with diagnostic or curative intent, has attracted the best and brightest in the medical profession to our field.

So why is there so much angst about endoscopy? Since more than half of the workday of a practicing gastroenterologist is spent doing mundane and undemanding procedures like screening colonoscopy, it can be argued that our emphasis on procedural training has turned out a generation of technicians who have lost touch with the cognitive aspects of their specialty. Further, the dependence predominantly on a single procedure (screening colonoscopy) has left us financially and intellectually vulnerable to any major shifts in the current paradigm of CRC screening techniques or their reimbursement. However, as I will discuss, pointing the finger at the procedure itself misplaces the blame for the current state of affairs. Indeed, attempts to “de-emphasize” procedures and procedural training across the board will have unintended and significantly adverse consequences for our specialty.

Linkage between gastroenterology and procedures is necessary, and will only become stronger with time

The GI tract is inherently amenable to procedures because of its unique accessibility via the endoscope. I have often compared the GI tract to the skin in this regard: the vast majority of skin diseases are diagnosed by direct visualization and biopsy and treated topically; similarly, many digestive disorders can potentially be managed endoscopically. However, we are a long way from realizing that goal, and it is only by continuing to emphasize endoscopic approaches that we will attain the goal. In the future, there should be no need to treat conditions such as IBD, ulcers or pancreatic disorders with systemic drugs when local approaches might prove just as effective, with fewer side effects and costs.

Procedures are also likely to grow in importance as the GI tract is increasingly recognized as the portal to other organs, as in Natural Orifice Translumenal Endoscopic Surgery®, which can provide access to the peritoneal cavity and, at least experimentally, to the heart, pelvic organs, etc. Most importantly, physio-anatomical modifications of the GI tract have immense therapeutic potential for important systemic diseases such as obesity, diabetes and their health consequences. Such procedures are increasingly being attempted endoscopically and it is quite likely that, in the foreseeable future, they will replace traditional surgery for such procedures as gastric bypass for obesity. Who will blaze this trail and lead us forward into this brave new world?

An artist and his tool are inseparable

The endoscope is a very important and unique tool that provides easy access to the GI tract, is generally safe and, unlike surgery, lends itself to iterative, re-doable and reversible procedures. The true potential has not yet been fully exploited in gastroenterology. Indeed, the vast majority of digestive diseases (dysmotility syndromes, painful and so-called functional conditions, and inflammatory disorders) have not been considered to be amenable to endoscopic approaches for diagnosis or therapy. This reflects a failure of our imagination, not the tools. Failure to make significant headway in this group of disorders is a reflection of the lack of emphasis on procedures, rather than the opposite. We have not done a good job inspiring our trainees to harness the full power of the endoscope by acquiring the procedural skills and knowledge base to test physiological hypotheses, obtain original information that identifies the biological insight, identify novel targets for treatment, and develop novel procedures to address the unmet needs of their patients.


Elevate, not eliminate procedural emphasis in training programs

Technology holds the key to advances in medicine, and this is especially true for specialties like ours. However, technology development should not be a tinkerer’s weekend effort in the garage or, at the other extreme, left to the capability of corporate research and development teams. The development of new procedures and devices to address unmet needs is an intensely cognitive exercise that needs to be formally incorporated into the training program of future gastroenterologists. Cognitive training should not only involve traditional aspects of gastroenterology, but also encompass the art and science of technological tools and their development. At Stanford, we have introduced such training by initiating within our fellowship a GI bio-design track, which is offered in partnership with the Stanford bio-design program. The objective is to teach the trainee how to identify unmet medical needs, harness resources to come up with creative solutions, take these concepts to proof-of-principle and put together a team that could bring forth a successful clinical product. The fruits of this program will take many years to be apparent, but it is a reflection of our philosophy that separation of the cognitive and procedural aspects of gastroenterology is artificial and should increasingly become irrelevant.


Medicine in general, and gastroenterology in particular, have become so technology dependent that reverting to a pure “cognitive” era is no longer possible or desirable. We must take advantage of all that technology offers and use it for improving the lives of our patients. In the future, the intellectualization of technology development should become the basis of a major cognitive discipline that we must teach our trainees.

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