AGA Institute Future Trends Committee Report: The Future of Gastroenterology Training Programs in the United States

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AGA INSTITUTE AGA Institute Future Trends Committee Report: The Future of Gastroenterology Training Programs in the United States The American Gastroenterological Association (AGA) Institute Future Trends Committee (FTC) developed this report based on a consensus conference it convened on March 8 –9, 2008, in Washington, DC. The report was prepared for the FTC by Carol Regueiro, MD, MSc, a medical writer under contract to the AGA Institute, and Michael Stolar, PhD, staff liaison to the FTC. This report was approved by the FTC on July 1, 2008, and accepted by the AGA Institute Governing Board on July 26, 2008.

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n March 7– 8, 2008, the Future Trends Committee (FTC) of the American Gastroenterological Association (AGA) Institute convened a consensus conference to (1) assess scientific, technological, social, and economic changes affecting the practice of gastroenterology and (2) consider changes to fellowship training that might better prepare future gastroenterologists individually and the field as a whole to meet the demands of coming years. At the conference, the FTC heard presentations from invited experts who summarized how recent changes to the economic, social, educational, and research environment have challenged traditional training and practice paradigms. These experts also presented potential strategies for coping with these challenges. This report contains the FTC’s interpretation of key points from these presentations and the conclusions that it derived from them. It presents a series of recommendations from the panel directed to the profession at large and to the AGA/AGA Institute. The recommendations include changes to the structure, content, and delivery of fellowship training with an emphasis on increased flexibility within fellowship to tailor education to trainees’ specific career goals. In addressing the identity and training of hepatologists, the panel believes that although hepatology must remain part of the broader field of gastroenterology, significant changes in gastroenterology training should be made to accommodate those fellows who wish to specialize in this area. The panel also suggests that the AGA Institute explore combined training options in advanced endoscopy and surgery, and gastroenterology and oncology, as well as support efforts to bolster and stabilize fellowship funding in general. Future gastroenterologists face many challenges posed by changing economic, political, and social forces affecting medicine. Changes to fellowship training can help ensure these physicians are well equipped to successfully navigate these forces and capitalize on the many opportunities that scientific, technological, and clinical advances provide for these physicians to pursue rewarding careers.

Executive Summary The gastroenterologist of the future will face great changes in the scope and delivery of health care, driven by

significant economic and demographic pressures, social trends, and technological innovations and scientific advances. Successful physicians will need to understand and accommodate these changes to continue to thrive professionally. The changing economics of health care is a major driver of change. Because health care costs have been rising at unsustainable rates for businesses and families, payers and consumers are increasingly demanding demonstrable transparency, quality, and value. In addition, rising consumerism and competition within the health care system will demand that gastroenterologists add demonstrable value to health care through differentiation of skills, innovation, and demonstrable quality, defined as both traditional measures of morbidity and mortality and through measures of patient access and satisfaction as well as cost efficiency. Future gastroenterologists will have substantial opportunities to add health care value because advances in genetics, proteomics, and related fields hold the promise of improved disease prevention and targeted pharmacologic interventions. Advances in information technology, imaging, and endoscopy will make data increasingly available and will facilitate improved disease diagnosis and management. Gastroenterologists will play important roles in both clinical arenas, providing advanced endoscopic procedures and managing broad-based health care teams caring for individuals with complex gastrointestinal (GI) problems, and in management arAbbreviations used in this paper: AASLD, American Association for the Study of Liver Diseases; ABIM, American Board of Internal Medicine; ACGME, Accreditation Council for Graduate Medical Education; AGA, American Gastroenterological Association; CTC, computed tomographic colonography; DGME, direct graduate medical education; DRG, diagnosis-related group; EGD, esophagogastroduodenoscopy; ERCP, endoscopic retrograde cholangiopancreatography; EUS, endoscopic ultrasonography; FTC, Future Trends Committee; GI, gastrointestinal; GME, graduate medical education; IME, indirect medical education; NIDDK, National Institute of Diabetes and Digestive and Kidney Diseases; NIH, National Institutes of Health; NOTES, natural orifice transluminal surgery; NRSA, National Research Service Awards; PRA, perresident amount. © 2008 by the AGA Institute 0016-5085/08/$34.00 doi:10.1053/j.gastro.2008.09.021

eas, such as creating and administering wellness programs that address costly chronic diseases such as alcohol abuse, obesity, and other common problems. Still other opportunities will be found for those with expertise in the rapidly evolving technology of education and electronic health records. To successfully navigate the changing health care milieu, gastroenterology trainees will need to leave fellowship with extensive knowledge of new scientific fields and with business and management skills. Changes in fellowship and postgraduate training will be necessary to equip gastroenterologists to capitalize on new health care opportunities. Gastroenterology-specific information that trainees will be expected to master will continue to increase in depth and breadth. Advanced training in areas such as clinical genetics, obesity and nutrition, women’s health, geriatrics, GI malignancies, hepatology, and global health issues such as liver diseases and diarrhea will grow in importance. To allow time for increased gastroenterology training demands, novel approaches such as potentially reducing the length of internal medicine residency and increasing fellowship training time may be necessary. Specifically, the panel recommends that all fellows receive more training about clinical genetics, GI oncology, GI imaging, and the business of gastroenterology practice whether in a community or academic setting. Furthermore, the panel suggests that the structure of fellowship be modified to allow trainees with identified interests to tailor their education to specific clinical areas such as hepatology or to basic, clinical, or translational research areas after the completion of a common general gastroenterology year. In other areas, it may eventually be most logical to support creation of combined fellowships; the panel recommends that the AGA Institute explore combined training options in advanced endoscopy and surgery, and gastroenterology and oncology, to meet growing demands. In addition, the panel suggests that the AGA Institute support efforts to bolster and stabilize fellowship funding in general. Future fellowship programs will need to creatively address the concerns of new physicians who are likely to enter medical residencies and fellowships with substantial debt loads and competing family priorities. Successful programs will exploit technological advances to offer more efficient and effective medical training and will meet the education and lifestyle needs of individual trainees through improved flexibility in fellowship scheduling and part-time options. Gastroenterology trainees face a range of challenges and opportunities that will profoundly change gastroenterology practice. Fellowship training cannot anticipate or completely buffer trainees from political, economic, and social forces that affect medicine. Revisions to the delivery and content of fellowship training, however, can help ensure that individual trainees and practicing gastroenterologists have the knowledge and skills to anticipate and successfully

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navigate these changes and that the field as a whole continues to attract and retain high-quality physicians.

Summary of Formal Recommendations to the AGA Institute The FTC recommends that the AGA Institute should do the following: 1. Conduct a survey of how gastroenterology fellowship programs are financed throughout the United States to better understand the current structure and to inform future policy discussion. 2. Advocate for increased attention in the Gastroenterology Core Curriculum to clinical genetics and genetic counseling. In addition, it suggests that the AGA Institute develop continuing medical education programs for those already in practice to develop these competencies. 3. Work to alter the existing structure of the 3-year fellowship curriculum to accommodate trainees who wish to specialize in a specific disease area, procedure, or type of research. 4. Convene a work group to explore the potential advantages and disadvantages of reducing the internal medicine component of training to allow 4 years of gastroenterology subspecialty education within the current 6-year “3 plus 3” training model. 5. Advocate that the diagnosis and treatment of liver disease remain an integral part of gastroenterology training and practice. 6. Endorse the concept that, for trainees who wish to become hepatologists, fellowship should be structured as follows: ● Fellowship year 1: devoted to a “survey” of common GI diseases and procedures such as colonoscopy. This would be the standard gastroenterology training year for all gastroenterology fellows. ● Fellowship years 2–3: devoted to in-depth training in hepatobiliary disease. This most likely would include a few additional months of gastroenterology rotations. 7. Develop a well-defined advanced oncology curriculum that extends beyond that contained in the 2007 Gastroenterology Core Curriculum. In doing so, it should investigate development of GI oncology fellowship options that could include the following: ● Fellowship years 1–2: devoted to common nonmalignant GI diseases and procedures such as colonoscopy. ● Fellowship year 3: devoted to in-depth oncology training including chemotherapy, cancer staging, and treatment as well as procedural training about the appropriate use and performance of techniques such as endoscopic ultrasonography (EUS) and endoscopic mucosal resection. ● Alternatively, an entirely new training curriculum could be introduced, perhaps in cooperation with

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the American Society for Clinical Oncology, that would create a 3-year combined gastroenterologyoncology fellowship program devoted to the prevention, diagnosis, and treatment of GI and hepatobiliary malignancies. 8. Develop a defined curriculum in GI imaging that includes understanding the indications for, limitations of, and interpretation of computed tomographic colonography (CTC) scans as well as other types of imaging and technology (eg, capsule endoscopy) as they evolve and become more widely applicable. 9. Develop a model of an interventional endoscopy track curriculum that could be incorporated into the existing 3-year time frame to train interested fellows in more advanced, nonroutine interventional procedures such as endoscopic retrograde cholangiopancreatography (ERCP), EUS, and other techniques. 10. In cooperation with a GI surgery society, develop a model for a joint gastroenterology-surgery natural orifice transluminal surgery (NOTES) fellowship program. 11. Endorse changes in fellowship programs that will facilitate the training of gastroenterology clinical and basic scientists. In this regard, the committee recommends the following: ● Fellowship year 1: devoted to a “survey” of common GI diseases and procedures such as colonoscopy. ● Fellowship years 2–3 designated as follows: ● Basic science trainees: 2 years devoted to basic research focused in a particular area of GI physiology or disease (eg, GI motility or inflammatory bowel disease [IBD]). ● Clinical and translational research trainees: 2 years devoted to research training integrated with formal coursework in relevant areas. Further, the AGA Institute should facilitate the development of a standard curriculum for those trainees interested in pursuing master’s degrees in clinical gastroenterological research. 12. Develop educational programming for third-year trainees that would educate and orient them to the requirements and realities of community practice. 13. Produce an overview of the content and quality of online resources for gastroenterology trainees and clinicians. (NOTE. The foregoing recommendations are not in order of priority.) AGA INSTITUTE

Introduction Consensus Conference Purpose, Structure, and Process The FTC of the AGA Institute is charged with identifying and characterizing important trends in clinical practice and scientific and technological developments in medicine, and specifically gastroenterology, that

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will potentially affect the specialty in the coming 3–5 years and beyond. In addition, the FTC is asked to make strategic recommendations to the AGA Institute Board about how it should deal with these trends and developments, whether economic, demographic, practice based, scientific/technological, or political in nature. In this most recent FTC report, the committee attempts to characterize scientific, technological, social, and economic changes affecting the practice of gastroenterology, assess the challenges and opportunities these changes might present, and recommend concrete steps that can enable gastroenterology fellowship training to continue to prepare trainees for a range of subsequent careers. The overriding purpose of the conference was to produce and disseminate to gastroenterologists a report based on expert opinions (1) about the scope, nature, and impact of scientific, technological, social, and economic changes facing gastroenterology; (2) about the current and potential future impact of these changes on fellowship training; and (3) providing recommendations to the AGA Institute to allow gastroenterology training to continue to proactively address the needs of gastroenterologists. The Consensus Panel (“the panel”) consisted of members of the FTC . Several leaders of the AGA Institute and American Association for the Study of Liver Diseases (AASLD) attended; however, there was no audience. Invited experts (Appendix 1; see supplementary material online at www.gastrojournal.org) presented information from a broad agenda (Appendix 2; see supplementary material online at www.gastrojournal.org) that highlighted some of the current scientific, technological, social, and economic pressures on current gastroenterology training and practice. During the second day of the meeting, the panel discussed the presentations, made general conclusions about the current state of and anticipated changes within gastroenterology, and specifically discussed what, if any, changes were necessary in gastroenterology fellowship training. Lastly, the panel recommended measures that the AGA Institute could take to help support continued recognition of emerging training needs for fellows and gastroenterologists in practice. After the conference, Dr Carol Regueiro, a professional medical writer, prepared the manuscript in collaboration with Dr Michael Stolar, AGA Institute staff liaison to the FTC. This manuscript was revised and approved by the FTC on July 1, 2008.

Background and Landscape What Patients and Society Expect Any alterations to gastroenterology fellowship training must account for changing expectations of patients and society. In the coming years, physicians will face great changes in the scope and delivery of health

care. These changes are being fueled by significant economic and demographic pressures, social trends, and technological innovations that physicians must understand and accommodate to continue to thrive professionally. The economics of health care has become increasingly untenable, with fewer dollars available to support growing and more expensive needs. Health care costs have been rising at unsustainable rates for businesses and families. Health care is the most costly benefit that American companies provide, placing them at a significant competitive disadvantage in the global marketplace.1 Individuals also expend increasing amounts on health care. For the insured, the median annual premium for family insurance now approaches $12,000, approximately 30% of the median family income.2,3 Such cost pressures will continue to rise as the US population becomes increasingly “gray,” incurring greater health care needs with fewer workers to support programs such as Medicare. It is estimated that in 2050, there will be only 2 taxpaying workers to fund each Social Security beneficiary, in stark contrast to the 17 workers who supported each beneficiary in 1950.4,5 As health care costs rise, payers and consumers are increasingly demanding demonstrable transparency, quality, and value. Health care payers require greater data about costs, utilization, and complications, and these data have become an integral measure of quality. Coupled with this economically driven change has been the rise of consumerism. Many patients feel dissatisfied due to often limited physician access, increasingly abbreviated physician “face time,” especially for education and counseling activities, and a perceived physician eagerness to perform procedures, the latter of particular concern to procedure-oriented specialists such as gastroenterologists.6,7 Through information available on the Internet and other readily accessible media, consumers are increasingly armed with information about the quality of, access to, and satisfaction with health care upon which to judge physician and hospital services. Few physicians’ groups currently monitor or respond to patient satisfaction. Furthermore, innovations in technology and processes of care have increased health care options and competition. A range of new businesses has emerged to meet changing health care needs. For example, consumer interest in physician access has led to the creation in many regions of urgent care centers placed in or near familiar retail establishments. There are currently more than 2000 retail clinics in the United States, and the numbers continue to rise.8 Some hospitals have begun outsourcing radiology services to other regions both within and outside of the United States to meet growing demand.9 Patients themselves have begun to pursue elective and often uncovered medical procedures in foreign countries where care is substantially cheaper and often of high quality.10 Insur-

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ers in some areas have already taken the initiative to form medical travel divisions and affiliations. Blue Cross/Blue Shield of South Carolina has such an affiliate, and their subscribers are covered for medical and surgical care outside of the United States.8 Shrinking health care margins have also led to increased competition between health care providers. The numbers of specialty hospitals and ambulatory surgical centers have increased dramatically in recent years,11 often providing care to lower cost, less complicated patients.12 This has often created greater challenges for the hospitals and physicians caring for the remaining, more complicated patients. Physicians have also crossed traditional specialty lines to render care. For example, radiologists initially pioneered peripheral vascular interventions13; however, interventional cardiologists currently perform significant numbers of these procedures. As simplified endoscopy continues to evolve and new technology such as CTC becomes more accurate, it is possible that health care services currently rendered by gastroenterologists, particularly screening colonoscopy, will be performed by other physicians and nonphysician health care providers. For physicians to thrive in this rapidly changing environment, they must understand, embrace, and ultimately catalyze appropriate and necessary changes in health care. Gastroenterologists of the future will need to demonstrate the specific value they add to health care through differentiation of skills, innovation, and demonstrable quality, defined as both traditional measures of morbidity and mortality, and through measures of patient access and satisfaction and cost efficiency. Contracting and payment is increasingly based on such data. In the future, physicians and hospitals will likely face increased pay-for-performance remuneration and “no pay” for care in which preventable complications occur. Some physicians and health care systems, however, have been slow to embrace the challenges of differentiation. For example, in the area of health care quality and patient satisfaction, physicians often voice concern that quality measures remain only crude tools to assess overall quality.14 Despite physician reluctance, such quality measurement efforts have moved forward, often without significant leadership input from physicians. Future gastroenterologists will have substantial opportunities to add health care value. Advances in genetics, proteomics, and related fields hold the promise of improved disease preventions and targeted pharmacologic interventions. Advances in information technology will make data increasingly available and will facilitate improved disease diagnosis and management. Advances in imaging and endoscopy will further augment the tools gastroenterologists have to combat disease. Future valueadded activities may be skills based, such as providing advanced endoscopic procedures, and some will be management based, such as leading and coordinating teams

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caring for individuals with complex GI problems. Other opportunities will exist beyond traditional individual patient care as businesses face rising costs from both direct medical care and from indirect costs associated with absenteeism. The management of chronic diseases now accounts for 75% of health care expenditures.15 In this milieu, providers who can create and successfully deliver disease management, nutrition, or GI wellness programs to address alcohol abuse, obesity, and other common problems or who have expertise in electronic health records and the implementation of evidence-based or guideline-recommended care will find significant and growing demand. Future gastroenterologists will need to appreciate the increasing sophistication and attendant demands of their patients and understand how cost, quality, and competition will directly affect their practice. To successfully navigate the changing scientific, technological, economic, and social milieu of health care, and to successfully meet and exceed the changing expectations of consumers, payers, and referring physicians, gastroenterology trainees will need to leave fellowship with extensive knowledge of new scientific fields as well as business and management skills. Changes in fellowship and postgraduate training can facilitate the evolution of the field and help gastroenterologists capitalize on new health care opportunities.

Demographic and Attitudinal Changes Among Patients and Physicians

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Changes in the demographics of US society will profoundly impact health care demand and delivery and thus influence future training needs in gastroenterology fellowship programs. The population is increasing in both size and in relative proportion of the elderly, particular older women.16 This has been accompanied by a shift in the demographics of patients presenting to physicians, with increasing numbers of those aged 45– 64 years.17 The health care demands of this growing older population are poised to outstrip the resources of physicians in general and gastroenterologists specifically. An explosion of new technologies has driven a rapid expansion of procedural time. Previously, cognitive activities predominated gastroenterologists’ professional lives; currently, procedures account for more than 50% of gastroenterologists’ activities.18 Despite this large and growing demand, the number of federally funded gastroenterology fellowship training positions has decreased from 500 per year in 1991 to 320 per year in 2006.18 Furthermore, the average age of gastroenterologists is currently 50 years and continues to rise, portending substantial reductions in available gastroenterologists in coming years.18 Against this backdrop, technology is rapidly transforming society in general, and patients and future physicians specifically, with significant implications for medical education and medical practice. Today’s 21-year-old men and women have been and continue to be exposed

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to a tidal wave of new information. It is estimated that 1.5 exabytes (1.5 ⫻ 1018) of unique new information will be generated worldwide this year, more than the sum from the previous 5000 years.19 The amount of technical information is doubling every 2 years; by 2010, the doubling will occur every 72 hours. Technology has changed how patients approach health care. They increasingly rely on the Internet for health care information. In a survey of patients with IBD, more than 80% had access to the Internet at home, and nearly 75% used it to gather health-related information including disease-specific information (74.4%) and medication information (62%), to identify recommended treatment options (50.4%) and alternative treatments (34.7%), and to access information about preventative health (43.0%), weight control (19%), and more.20 While patients are largely satisfied with physician encounters, trust their physicians, and feel involved in decision making, today’s patients are more likely to ask for medications or testing than referral to specialists.21 Demographic, technological, and economic factors are also transforming the nature of medical students, their educational experiences, and their professional goals. Less than 5% of current gastroenterology fellows are black, American Indian/Alaskan Native, or Native Hawaiian/Pacific Islander residents/fellows.22 However, the proportion of women in gastroenterology continues to rise. In 1996, only 4% of the members of the American Society for Gastrointestinal Endoscopy, 9% of the members of the AGA, 10% of the members of the Canadian Association for Gastroenterology, and 12% of the gastroenterology diplomates of the Royal College of Physicians and Surgeons were women; today, women comprise 25% of gastroenterology fellows.23 Female gastroenterology trainees are more likely to choose fellowship programs according to parental leave policies, and their experiences during fellowship vary from those of their male colleagues, with significant rates of perceived gender discrimination (39%) and sexual harassment (19%) during training.24 Female trainees are more likely to receive less training in advanced endoscopy. During their professional lives, female gastroenterologists are more likely to remain unmarried compared with their male peers (21.1% vs 8.6% men), are more likely to remain childless or have fewer children, and report significantly less personal income and greater difficulties pursuing academic careers.25 Generational differences among medical students, trainees, and practicing physicians and faculty can generate significant tension and warrant closer examination.26 –31 Physicians born between 1922 and 1943 are members of the “Silent Generation,” whose formative experiences included the Depression, the advent of Social Security, World War II, and the relative prosperity of the 1950s. Character traits ascribed to this generation include conservatism, respect for authority, clear gender

roles, and emphasis on hard work. Physicians of this generation comprise the majority of senior physicians, chairs, chiefs, professors, deans, hospital presidents, and organizational leadership.26,27 “Baby boomers,” those born between 1943 and 1960, are described as optimistic workaholics who were willing to “pay dues” early on to succeed but who also value experience over expertise. Physicians from this generation often are peak-career practitioners, group practice leaders, associate professors, chairs, chiefs, and leaders in health care organizations.26,27 “Generation X” describes those born between 1960 and 1980. This generation defines professional success by competence and does not value rank, hierarchy, chain of command, or authority figures whose position is not based on proven competence. Physicians of this era are usually young practitioners, assistant professors and instructors, residents, fellows, or older medical students.26,27 The “Millennials” were born between 1980 and 2000. This “Internet” generation is confident and achievement oriented, valuing honesty, personal integrity, and hard work. They work hard and feel a sense of civic duty but still want balance in their lives.26,27 Millennials comprise the majority of medical students. In addition to the generational differences they bring to medical school, they also undergo training that is markedly different from that of their faculty. Trainees are subject to monitored hours for training and, increasingly, students receive fewer lecture hours and more training using standardized patients or patient simulation technology. Curricula are less hierarchical and emphasize team-based learning and patient-centered learning with basic science integrated throughout medical school and clinical exposure occurring earlier. Today’s medical students and young trainees also face significantly greater financial pressures, leaving medical school with greater debt loads. In 2001, the average debt incurred by students of public medical schools was $86,000; among those who graduated from private schools, this number was $120,000. By 2006, these numbers were $120,000 and $160,000, respectively. Recent data suggest that debt loads continue to increase between 6% and 7% annually in the face of medical school costs that are rising between 4.7% (private) and 11% (public) annually.32 Generational issues will have a significant impact on the workforce. Younger physicians appear no different from others in their generation, viewing their profession as a component of but not a defining factor in their lives. A study of specialists indicated that fully 50% preferred a part-time practice; however, this group was composed of younger physicians and women. Home-related concerns did not predict a female physician’s desire for part-time work. Gender alone, however, did not drive interest in part-time work. More than 40% of men preferred a part-

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time focus. Full-time work was preferred by older male physicians. Younger male physicians who indicated a preference to start full-time desired a transition to parttime work after 5 years.33 Successfully integrating physicians, trainees, and students from various generations can be challenging.26,27 Physicians may fail to see the relative strengths that characterize other generations and fail to understand the relative constraints of those from different backgrounds. This may manifest as conflicts over workload, working hours, compensation, performance evaluations, recruitment and retention, and attendance at required meetings. Furthermore, facilitating a robust future gastroenterology workforce will require planning that accounts for the changing needs and preferences of young physicians. Although applications to gastroenterology fellowships remain extremely high, resident survey data indicate that gastroenterology does not enjoy the same popularity as other medical subspecialties such as cardiology and hematology-oncology, in part because residents perceive that other subspecialties are more intellectually intriguing, that the job market for gastroenterology is poor, or that gastroenterologists in practice work too hard.34 To remain competitive, gastroenterology training in the future will need to undergo a paradigm shift. Future gastroenterology fellowship training will need to incorporate changes in the type and depth of knowledge about which trainees are trained and the manner in which this knowledge is delivered. Fellowships should capitalize on the efficiencies that may be gained through shared training across specialties. For example, opportunities exist to train fellows in the areas of consultative skills, academic skills, law and medicine, and business and medicine, and for those interested in an academic career, grant, poster, manuscript, and lecture preparation. Fellowships can also maximize the use of technology to develop a patientfocused curriculum that allows trainees to undergo mentored but self-directed, individualized education based on competencies and milestones. Although patients should remain the context for medical education, alternative modalities such as simulation, Web-based training, and standardized patients will be increasingly required. Gastroenterology-specific knowledge that trainees will be expected to master will continue to increase in depth and breadth. Opportunities for advanced training in areas such as obesity and nutrition, women’s health, geriatrics, GI malignancies, hepatology, and global health issues such as liver diseases and diarrhea will be increasingly important. To allow time for such training, novel approaches such as potentially reducing the length of internal medicine residency and increasing fellowship training time may be necessary. This may be particularly relevant because internal medicine has continued to lose popularity among medical students compared with other specialties such as dermatology, plastic surgery, otolaryn-

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gology, ophthalmology, and radiology.35 Currently, gastroenterology and cardiology attract more young trainees than general internal medicine or its related noninvasive specialties, and they compete well in attracting applicants compared with non–medicine-based specialties such as dermatology. One approach discussed by the panel would be to increase the acceptance of medical students directly into combined medicine-gastroenterology fellowship tracks. In this scenario, gastroenterology training would evolve into a 6-year program (2 years of medicine and 4 years of gastroenterology) into which students could match directly from medical school. Currently this is done for occasional research-oriented short-trackers, but the possibility of securing a gastroenterology fellowship might be more attractive to the very top medical students who graduate each year. The possible disadvantage of this approach would be to further dampen enthusiasm for standard internal medicine programs if fellowship spots in gastroenterology and/or cardiology were no longer available. In addition, many among the panel acknowledged that excellence in gastroenterology practice is predicated on an excellent foundation in general internal medicine. These potential changes in content and training will need to be accompanied by attention to operational issues such as improved flexibility in fellowship scheduling and part-time options to continue to attract and retain high-quality medical students and residents into gastroenterology.

Advances in Media and Technology and Impact on Education

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Technological advances, especially the Internet and Web-based resources, present important opportunities to improve gastroenterology training. Rapidly evolving technology is changing students (gastroenterology trainees and students) and teachers (the gastroenterology faculty). It also provides new educational opportunities for gastroenterologists at all stages of their careers to more efficiently acquire rapidly expanding medical knowledge. Today’s medical students are always connected through technology both in educational and social settings. They can access information nearly instantaneously as needed through online curricula, “podcasts,” online databases, commercial sites such as eMedicine.com, and collaborative learning spaces. The latter are particularly useful and democratizing, allowing communities of learners to surmount the potential barriers between students and faculty or between students and attending physicians by allowing more direct interaction around shared interests. Teachers are changing in response to these new opportunities as well. For example, in the Massachusetts Institute of Technology Open Courseware Initiative, course materials including free lecture notes, examinations, and other resources from more than 1800 courses spanning

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the entire curriculum at Massachusetts Institute of Technology are freely available through the Internet.36 Similar changes in access are beginning to occur in medical school and are likely to become more widespread over the coming years. These changes may lead to more effective learning as well. Learning research shows that traditional didactic interventions improve a learner’s knowledge base but change neither behavior nor patient outcomes.37 In contrast, knowledge gained through case-solving, role-playing, or discussion groups appears to improve practice and outcomes.38 This finding complements studies of how physicians practice and learn. Research shows that physicians learn in order to solve problems. Specifically, much of clinical practice involves scanning for problems, deciding which to pursue, and acquiring and using knowledge, skill, and experience to subsequently manage them.39,40 Technological advances in education had already improved access to and convenience of medical educational programs. Programs are available as podcasts— digital media files that can be downloaded from the Internet and played on portable media. Other materials provide comprehensive information previously only available in paper formats; however, Web-based platforms allow frequent updating that is impossible to perform in printed materials. For example, UpToDate is a subscription based, Web-accessible program described as a “tool designed to quickly and easily answer clinical questions that arise in daily practice.”41 Another such Web resource, the DAVE Project, an acronym for the Digital Atlas of Video Education, is a collection of teaching tools provided by gastroenterologists across the country.42 The project consists of a GI endoscopy video atlas and medical lectures and presentations. Physicians are encouraged to submit material for consideration to continue to enrich and expand the atlas. A GI Wikipedia site has been created that is a collaborative resource for gastroenterology and hepatology trainees and practitioners. It describes itself as follows: a free electronic resource that includes content (clinical pearls, reference to landmark original or review articles and links to GI formulae and calculations, drugs search, PowerPoint presentations etc) relevant to GI training or practice. The resource is modeled after the core curriculum developed by the AGA Institute, American Association for the Study of Liver Diseases (AASLD), American College of Gastroenterology (ACG) and American Society for Gastrointestinal Endoscopy (ASGE). Our hope is that this collective knowledge resource will become a free, current reference and teaching resource for GI practitioners and training programs.43

As the Web continues to evolve, user-specific content will be increasingly common and characterized by decentralized content production and portable, device-independent knowledge that becomes more tailored to the user’s interests with continued use. For example, the National Institutes of Health (NIH) has funded a $1.1

million educational project in palliative care wherein students on a clinical rotation who encounter a patient with a potential palliative care issue can enter the patient’s major diagnoses into a case log on the Web or in his or her handheld device. Tailored “just-in-time” learning modules are then sent to the student, and special resident and faculty versions of the same modules are sent in parallel to the student’s preceptors.44 Besides affording new ways to deliver education, the Web now houses resources to assess and track medical education needs and progress. Self-assessment modules, such as those available on the AGA Web site, allow learners to identify knowledge gaps, tailor learning goals, access targeted educational materials, confirm competence, and finally track continued education in a “learning portfolio.” These so-called “ePortfolios” are increasingly used by training programs as a single repository for a range of information about medical residents’ and fellows’ training and include updated curriculum vitae and a record of required residency and fellowship procedures. Technology has changed medical education in areas besides the Internet as well, with the development of “virtual patients,” mannequin simulators, and task trainers that can be particularly useful in assisting trainees to acquire technical skills. Cohen et al conducted a randomized trial to evaluate the effect of colonoscopy simulation on subsequent performance and found that those trainees who had undergone simulation had significantly higher objective competence ratings during their first 80 real colonoscopies.45 Simulation may provide a useful tool for fellowship and continuing medical education in the future, but given the significant investment required, more information about its benefits will be required before it is more widely adopted. Technological advances will offer increasing opportunities to make medical education more efficient and effective by targeting user needs and increasing convenience. The AGA Institute strives to continue to be in the vanguard of these educational efforts, providing global access to high-quality online gastroenterology content and providing collaboration tools for trainees and members. Successful educational programs in general and fellowship training programs specifically will need to exploit emerging opportunities, particularly GI Wikipedia, ePortfolios, and training simulators; the AGA Institute is well positioned to assist in the development and/or adoption of these tools and to provide objective evaluations of existing online resources and simulation technologies.

Organization and Accreditation of Specialty Training Federal Funding of Specialty Training Because much of medicine is now based on business plans that are mission driven, proposed changes to

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gastroenterology fellowship training must account for the manner by which gastroenterology fellowships are financed and supported. Gastroenterology fellows are supported by a patchwork of sources that includes hospital funding (much of which is government financed), research support (often from NIH training grants), various federal agencies, and occasionally departmental and faculty practice revenue. When considering all graduate medical education (GME), including both residents and fellows, funding for GME and research training specifically comes in large measure from government sources. These sources include Medicare, Medicaid, the Veterans Affairs Administration, the Department of Defense, and a number of smaller programs. Medicare, the largest explicit payer of GME, makes 2 educational payments: a direct GME (DGME) payment, which partially compensates teaching hospitals for residency and fellowship education costs, and an indirect medical education (IME) payment, which partially compensates teaching hospitals for higher patient care costs associated with the presence of teaching programs. These payments were estimated to cost slightly more than $8 billion in 2007 (personal communication from the Centers for Medicare & Medicaid Services Office of the Actuary to Karen Fisher, Association of American Medical Colleges, August 2007). DGME payments are intended to compensate teaching institutions for Medicare’s share of direct costs related to approved residency education programs, including residents’ salaries and benefits, salaries and benefits of supervising faculty, and other direct and allocated overhead costs. Specific DGME payments are determined using a base year, typically 1984, which is adjusted to the current year to account for inflation; this creates a per-resident amount (PRA) that is then multiplied by the actual number of residents in a program, subject to a maximum cap. This sum is finally multiplied by the hospital’s ratio of Medicare inpatient days to total hospital inpatient days to arrive at the DGME payment. It is important to note, however, that not all residents count equally for DGME payments. Trainees in their initial residency period are counted as 1.0 full-time equivalent. Those in fellowship training are counted as 0.5 full-time equivalent, as are physicians who reenter training in another specialty after having completed other training. Additionally, the PRA was frozen in 1996 and 1995 for all except primary care residencies; subsequently, payments are slightly higher for these trainees. Lastly, for a variety of reasons, some hospitals had significantly lower PRAs and others had significantly higher PRAs. To address these issues, Congress increased the low PRAs to 85% of a “locally adjusted” national average in 2002. Those with PRAs greater than 140% of the national average have been frozen and will not receive payment increases until 2014. Thus, at many if not most hospitals, the cost of gastroenterology fellowship training is not fully reimbursed by Medicare DGME payments.

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IME payments are intended to compensate hospitals for higher inpatient operating costs associated with both the complexity of Medicare patients who may remain uncaptured by the diagnosis-related group (DRG) system and the higher “general” operating costs associated with being a teaching hospital, such as lower productivity and greater standby capacity. This payment is calculated as a percentage of the basic Medicare per case DRG payment. This IME adjustment is based on a statistical analysis using intern- and resident-to-bed ratios and a formula that includes a “multiplier” figure that varies and is determined by Congress. At a broad level, the IME payment yields an additional 5.5% increase in DRG payments for every 10 resident increase per 100 beds. Generally, the number of full-time equivalent residents that a hospital may count for DGME and IME payments is limited to 1996 Medicare cost report counts; however, the caps may be different between DGME and IME. The Medicare statute provides few exceptions from these caps; generally these exceptions affect rural teaching hospitals, new teaching hospitals, or temporary adjustments related to closing of hospitals or programs. Costs associated with training residents in nonhospital settings may be covered though DGME and IME payments if “all or substantially all” of the costs associated with these activities are borne by the hospital and if the activities involve patient care. These requirements can complicate reimbursement for training costs that relate to didactic activities that occur outside of the hospital or that derive from activities in the offices of volunteer faculty. State Medicaid programs have contributed substantially to GME. A survey conducted by an independent consultant indicated that, in 2005, Medicaid programs in all but one state contributed DGME and IME payments.46 The estimated total Medicaid DGME and IME payments in 2005 were $3.2 billion. This support, however, is currently slated for elimination. Specifically, a proposed regulation would eliminate Medicaid GME payments, citing that no express authority exists in the Medicaid statute to support GME and clarifying that GME is “not an allowable cost or payment under the approved Medicaid State Plan.” The Association of American Medical Colleges has actively lobbied against this change, noting that this would constitute a substantial and abrupt reversal of existing and long-standing Centers for Medicare & Medicaid Services Medicaid policy. The potential for large GME funding variation highlights existing and potential problems posed by the current funding system. Despite data that suggest an impending physician shortage,47 resources to educate physicians remain unstable and unpredictable. Furthermore, as concerns about the solvency of Medicare grow, questions arise about whether a Medicare-based system of GME funding will remain tenable. Although Medicare reform may not necessitate reform in medical education subsi-

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dies, these reforms may provide an opportunity to consider alternative funding arrangements. In the future, hospitals, medicine departments, and gastroenterology divisions will need to find innovative ways to support the training of gastroenterology fellows. The AGA Institute could assist in these efforts by compiling and disseminating information on the various ways in which different programs support and finance their gastroenterology fellowship programs and identifying particularly successful or promising models.

Accreditation Council for Graduate Medical Education Perspectives on Gastroenterology Training To consider changes to the design and structure of gastroenterology fellowship training, it is important to consider the various boards and government agencies that accredit training programs or provide certification for this training. In this context, training programs undergo periodic reviews to ensure that training goals remain consistent with advances in science and changing societal needs and that training programs effectively meet these goals. Gastroenterology training falls under the purview of the Accreditation Council for Graduate Medical Education (ACGME), and gastroenterology trainees upon completion of fellowship undergo certification through the American Board of Internal Medicine (ABIM). The ACGME is a private nonprofit council that evaluates and accredits medical residency and fellowship programs in the United States to ensure that programs meet the needs of trainees. Its mandate is distinct from the ABIM, whose mission is to ensure that fellows who graduate from these programs are clinically competent physicians who meet the needs of patients and the larger health care system. The ABIM provides patients with assurance about practitioners’ clinical competence and their ability to deliver excellent patient care through evaluation of clinical judgment, skills, and attitudes of those practicing in internal medicine and its subspecialties. The ACGME is currently reviewing medical residency and fellowship training, including assessing how current training meets educational goals and whether revisions to either medical residency and/or fellowships can better achieve these goals. This iterative process entails significant input from specialty groups and is expected to take through July 2010 to complete. The ACGME training review will address general fellowship requirements as well as program-specific requirements, with particular focus on educational components, related personnel and infrastructure resources, and evaluation tools. The general fellowship review will evaluate whether existing general requirements remain relevant to medical fellows across specialty areas and attempt to eliminate inconsistencies such as faculty-to-fellow ratios. Program-specific requirements will be reviewed to con-

sider whether any may be “folded into” general requirements. Existing “sub-subspecialty training programs” within gastroenterology, such as advanced endoscopy, will be evaluated to consider if and how these should be structured into training and whether additional areas such as IBD merit differentiated training as well. The intent of these ACGME revisions is to simplify and reduce the number of requirements and allow increased flexibility for fellows and program directors while maintaining educational goals. Ultimately, while changes to the “common requirements” are unlikely, the ACGME appears open to greater flexibility in designing training programs. As the ACGME streamlines the accreditation process and increases flexibility for fellowship programs, its evaluation process will intensify to provide proof of effectiveness beyond documentation of procedure numbers and participation. Fellowship programs will be given broad latitude to demonstrate educational attainment using multisource evaluations. Increasingly, these evaluations will need to move away from the current processbased standards to outcomes-focused evaluations that demonstrate competence. Fellowship programs themselves will play a key role in creating these new metrics by evaluating and modifying existing evaluation tools and identifying and describing new tools from which ACGME will select acceptable measures.

ABIM Perspectives on Gastroenterology Training As noted, the mission of the ABIM varies from that of the ACGME. The ABIM is primarily accountable to the public to ensure that ABIM diplomates are competent to deliver high-quality clinical care. The ABIM strives through its certification and maintenance of certification programs to provide relevant and useful information to patients and hospitals through a process that physicians find useful and relevant to their clinical practices. The ABIM currently certifies physicians in internal medicine, medical subspecialties, and so-called “secondary subspecialties,” formerly called “added qualifications”; it is considering recognizing areas of “focused practice.” The ABIM recognizes a subspecialty as a discipline that encompasses a unique body of knowledge not fully incorporated into and may be practiced as a distinct clinical entity from the parent discipline and serves an important social need. Furthermore, the ABIM requires that evidence must support that the practice of a recognized subspecialty improves patient care; that to attain competency, clinicians need formalized training with direct observation and supervision during a minimum training period of 12 months; and that the positive value of subspecialty certification outweighs any negative impacts on practice and training in existing subspecialties. In practice, subspecialty medicine often involves complex technology or site-specific care.

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The ABIM recognizes focused practice as a discipline within internal medicine composed of large numbers of clinicians who center their practice only in the discipline. A focused practice must fulfill an important social need and improve patient care. Proficiency in focused practice areas requires a significant practice volume with specific thresholds; in contrast, however, to specialty certification, expertise in focused practice areas can be gained through rigorous demonstration of self-directed continuous learning and self-evaluation and does not require direct observation. Potential areas of focused practice include hospital medicine, comprehensive care internal medicine (advanced medical home), and human immunodeficiency virus medicine. Within gastroenterology, potential areas of focused practice include nontransplant hepatology, pancreaticobiliary disease, IBD, and motility disorders. Overall, the ABIM is open to focused practices within a subspecialty but appears less ready to embrace new secondary subspecialties, particularly if they impact existing subspecialties. Currently, the ABIM Subspecialty Board of Gastroenterology does not favor training or certification in hepatology that is separate from gastroenterology because of concerns about potential fragmentation of gastroenterology, the creation of different classes of hepatologists based on different durations of training, the development of hepatology as a “back door” to gastroenterology, and a range of training issues including concerns about endoscopy volume, faculty availability, and hospital coverage. The ABIM Subspecialty Board of Gastroenterology is exploring recognition of focused hepatology practice and will continue to explore other areas of focused practice as needs arise.

What Are Some of the Special Clinical or Research Tracks That Highlight the Need for More Flexible or Specialized Training? Hepatology Training Data suggest a growing mismatch between hepatology service demands and workforce supply. This mismatch, in conjunction with the increasingly complex nature of liver disease and its management, has occasioned discussions about how best to prepare future hepatologists. The burden of liver disease in the United States is large and growing. In 2007, approximately 6500 liver transplantations were performed.48 The epidemic of viral hepatitis continues; more than 4 million people in the United States have hepatitis C virus infection, and the majority is likely undiagnosed.49 In parallel to rising obesity rates, nonalcoholic fatty liver disease is estimated to affect 30% of the US population,50,51 and of these about 5 million are expected to develop cirrhosis. The complexity of liver disease management is also increasing. In addition to increasing numbers of liver transplant recipients, the treatment of viral hepatitis has

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become more complex, requiring multidrug regimens and frequent monitoring for response and resistance. New medications and procedures continue to be developed for liver diseases such as portal hypertension and hepatobiliary malignancies, and entirely new areas involving genetic testing have emerged. In the face of this rapidly rising demand, manpower studies indicate significant current and looming shortages of hepatologists. In 1999, the AASLD commissioned the Lewin Group, a national health care consulting firm, to evaluate the situation. Their data confirmed the shortage of practicing hepatologists and suggested that separate disciplines in transplant and advanced hepatology might be warranted.52,53 Subsequently, subspecialty training and certification tracks were developed for transplant hepatology, the first certification examinations for which were administered in November 2006. Despite these efforts to train more specialized hepatologists, evidence suggests that a significant shortage of hepatologists remains. Significant numbers of academic hepatology positions remain unfilled; in 2007 alone, 45 hepatology faculty positions were advertised. Furthermore, many hepatology training programs have unfilled positions. Perceived barriers to hepatology subspecialization include the current need for board certification in gastroenterology, the duration of training, and the related “real-life” economics many trainees face. Specifically, under current hepatology certification procedures, hepatology training occurs after 3 years of internal medicine training and 3 years of gastroenterology training. Many fellows enter residency programs encumbered with substantial debts; when given the choice between entering lucrative private gastroenterology practice and continuing fellowship for an additional year, economics may drive them away from initial interest in hepatology. Leaders in hepatology have considered revisions to hepatology training. These potential revisions have been guided by assumptions that changes to hepatology training would not impact current training for the general gastroenterologist. Instead, potential changes in hepatology training would mirror those under consideration for gastroenterology training generally. In this model, the first fellowship year would include training in general gastroenterology and basic endoscopic procedures such as esophagogastroduodenoscopy (EGD) and colonoscopy. Subsequent training years would be customized to reflect the trainee’s interest and could include a subspecialty track focus, such as hepatology; advanced endoscopy; basic, clinical, or translational research; and potential other areas such as IBD or motility. This approach would shorten the current hepatology training duration and minimize attendant issues of attrition and economic hardships, allow hepatologists to maintain procedural competence, and keep hepatology as part of gastroenterology. However, it limits potential hepatologists to a portion of gastroenterology trainees, thus excluding

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those physicians in training who have an interest in hepatology but may not desire procedural training and limiting the overall numbers of hepatologists who could be trained. Currently, the applicant pool to gastroenterology programs far exceeds available training positions, and thus the potential limiting factor would be the ability to increase and fund the number of ACGME gastroenterology fellowships. In addition, this training model does not easily accommodate the training of physicianscientists. This concern, however, rests on the notion that a career in clinical transplant hepatology can be combined with bench research. Increasingly, this model, similar to the notion of combining interventional endoscopy with bench research, may no longer be viable. The alternative proposal, to designate hepatology as a completely separate subspecialty, is more problematic because it would appear likely to impact training for general gastroenterologists, since many gastroenterologists would like to continue to also practice some hepatology. In addition, given the standards required for training in gastroenterology, it is unlikely that hepatologists could acquire sufficient training to allow certification in endoscopy without completing the same requirements as gastroenterology trainees. The absence of endoscopic training would likely decrease the economic viability and/or attractiveness of a liver training program. In the end, carving out hepatology as a separate track within gastroenterology training, and perhaps prioritizing recruitment of liver-oriented trainees, may be the most viable solution and the one potentially most acceptable to both ACGME and ABIM. It would not lead immediately to separate board examinations, because trainees would still have to undergo both gastroenterology and liver certification, but it might allow the elimination of the fourth year of training in the near future. In addition, this could serve as a model for other subsubspecialty tracks.

Interventional Endoscopy/NOTES The continued evolution of endoscopic tools for diagnosing and treating GI diseases has raised questions about how gastroenterology fellowship programs might change to incorporate advanced endoscopic training and whether some combined gastroenterology-surgery training might be advantageous for those interested in pursuing careers in advanced endoscopy. Distinct from basic endoscopic procedures, such as diagnostic EGD, colonoscopy, hemostasis, polypectomy, foreign body removal, and percutaneous endoscopic gastrostomy placement, “advanced endoscopy” currently encompasses a broad range of procedures, such as ERCP and all of its associated procedures, EUS and its associated procedures, procedures associated with the treatment of complex esophageal strictures and achalasia, enteral stent placement, endoscopic tumor ablation, resection and photodynamic therapy, and laparoscopy.

Emerging endoscopic procedures in the early stages of clinical evaluation include full-thickness resections, intraluminal anastomoses, and endoluminal treatments for gastroesophageal reflux disease and obesity as part of NOTES. As described by the Natural Orifice Surgery Consortium for Assessment and Research, a range of procedures might be performed this way, such as gastric bypass, fallopian tubal ligation, removal of the ovaries, and diagnostic procedures. Such NOTES-based surgeries might be performed via the rectum, vagina, urethra, or bladder as well.54 The evolution of the role of endoscopy in diagnosis or treatment of GI and potentially non-GI diseases has raised questions about what role endoscopy will play in the future, who will perform endoscopy, and how many endoscopists may ultimately be needed. The evolution of endoscopy to date is illustrative. A wide range of surgeries and procedures historically performed by general surgeons has become the purview of endoscopists in recent decades. Examples include esophageal foreign body removal, intestinal stricture dilation, malignancy resection and/or palliation, enteral feeding tube placements, common bile duct stone extractions, and colonic polypectomy and the management of variceal bleeding, achalasia, Barrett’s esophagus, upper and lower GI bleeding, pyloric obstruction, biliary strictures, gastroesophageal reflux disease, obesity, acute and chronic pancreatitis, and pancreatic pseudocysts. However, the further expansion of interventional endoscopy into NOTES, with endoscopists performing procedures previously conducted by laparoscopy or laparotomy, raises more difficult issues. Predicting the potential impact of advanced endoscopy on medical care is fraught with challenges and further complicated by workforce issues. Will malpractice costs associated with such procedures be so large as to deter nonsurgeons from this area? Who will want to perform these procedures, and how should they be trained? The theoretical skill set required for successful advanced endoscopists will likely include the ability to determine indications and contraindications for diagnostic and therapeutic interventions and, if intra-abdominal procedures continue to evolve, the ability to convert and complete endoscopic procedures to open surgeries as required and in-depth knowledge of anatomic considerations and postprocedural management. For those interested more broadly in NOTES, greater knowledge of abdominal, pelvic, and thoracic anatomy will be paramount. Currently, gastroenterology and surgical training programs differ in their coverage of this theoretical skill set. Current gastroenterology fellowship training encompasses exposure to GI superficial, functional, and endoscopic anatomy; GI physiology and pathophysiology; endoluminal diagnosis and treatment of GI diseases; and the medical treatment of GI disease. Gastroenterology trainees have familiarity with intraluminal anatomy and

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endoscopic tools. Many gastroenterology trainees, however, have suboptimal exposure to existing advanced endoscopic procedures and have limited exposure to or skills in laparoscopy. Furthermore, gastroenterology fellows currently receive no training in preoperative or postoperative assessment or management or exposure to intra-abdominal anatomic considerations or development of surgical skills required should a planned endoscopically based procedure require conversion to an open procedure. General surgical training is currently structured very differently from gastroenterology training and provides a more standardized exposure for surgical residents. During a 5-year residency, at least 42 months must be completed in essential content that includes the alimentary tract, abdomen and its contents, breast skin and soft tissue, endocrine system, head and neck, pediatric surgery, critical care, surgical oncology, transplantation, trauma and burns, and vascular system. Furthermore, surgical residents are required to have experience in a range of endoscopic procedures, including EGD and colonoscopy, as well as laparoscopy and bronchoscopy. Mandated resources include simulation and skills laboratories, features not currently required of gastroenterology fellowship programs. The differences in current training make the needs of surgical residents interested in advanced endoscopic careers different from the needs of gastroenterology fellows. Potential approaches to address the training of advanced endoscopists include the creation of a dedicated advanced interventional endoscopy track within gastroenterology fellowships or the development of a shared gastroenterology-surgery program, perhaps culminating in the training of a “minimally invasive GI specialist.” While the former holds the appeal that trainees could begin directed subspecialty training early within fellowship, the 3-year fellowship training period is considered insufficient to serve as a base for total clinical and research training, with the risk of losing fundamental knowledge and research skills. While an additional year of training may be sufficient to allow focused training in ERCP and EUS, it would not be adequate to train fellows in more advanced and invasive surgeries, such as fullthickness and transmural surgeries. The latter skills may best be acquired through a joint gastroenterology-surgery fellowship. The creation of a joint gastroenterology-surgery fellowship would be predicated on assumptions that neither a surgeon nor a gastroenterologist is currently equipped for advanced endosurgical procedures and that board recognition, acquisition of hospital privileges, and insurance reimbursement would be uncomplicated. Furthermore, the appropriate components of such a program would need to be defined, especially as NOTES and related endoscopic and laparoscopic procedures evolve. Current training paradigms might be modified to encompass this

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content by allowing surgeons to undergo advanced endoscopic training after a traditional 5-year residency or allowing gastroenterology fellows to undergo 2 years of additional training in surgical anatomy, laparoscopy, and surgical principles after completing gastroenterology fellowship. For those more specifically interested in NOTES, training including 3 years of gastroenterology and 1 year of advanced endoscopy could be followed by 1 additional year of training in open and laparoscopic abdominal surgery (eighth year from medical school graduation) or by completing 3 years of general surgery training followed by 2 additional years of gastroenterology and advanced endoscopy training (5 years after medical school graduation). Clearly such a training duration could have a significant impact on fellows’ interest or ability to pursue advanced endoscopic careers if this format were codified. Although rapid innovations in endoscopic diagnosis and treatments have fueled significant changes in medical practice, it is not clear which of the procedures under development now should be incorporated into general gastroenterology training and, if incorporated, in what way. Currently, some programs offer a separate nonintegrated advanced track to interested fellows who have attained core gastroenterology competencies. Such postfellowship training requires significant local resources and should include ERCP, EUS, and their related procedures as well as the acquisition of skills required to repair via an endoluminal approach complications of EGD and colonoscopy. While NOTES and other transluminal surgeries remain too new to incorporate into general gastroenterology training, the AGA should periodically readdress the state of these and other advanced endoscopic procedures and their clinical applications to ensure appropriate training of both general gastroenterologists and advanced endoscopists. In the short term, the AGA Institute should consider working with general surgery training organizations to create a curriculum for endoscopically oriented clinical gastroenterology trainees that could offer a 1- to 3-month rotation on the general surgery service, with the opportunity to scrub into surgical and laparoscopic cases. This would allow these interested trainees an opportunity to begin to acquire more anatomic knowledge as well as to understand preoperative and postoperative care and potential complications of invasive surgery.

CTC and Imaging AGA INSTITUTE

Increasingly, imaging plays a role in the diagnosis and management of gastroenterological diseases, complementing the information provided by conventional endoscopy. Currently, many medical residents and gastroenterology fellows receive extensive exposure to standard abdominal computed tomographic imaging, but most do not receive formal training in interpretation of CT scans. As the use of imaging increases and the range

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of imaging tools expands to include new modalities such as CTC and wireless capsule endoscopy, questions have been raised about whether gastroenterology fellows should undergo some formal imaging training and, if so, encompassing what? Answering these questions is particularly challenging as the sophistication of, availability of, and indications for these tests grow. CTC provides an important example of a rapidly evolving modality with potential significant impact on the scope of practice of future gastroenterologists. CTC has been the subject of intense research and medical and lay press attention in recent years. It has the potential to provide a relatively noninvasive diagnostic evaluation of the colon with increasingly high rates of accuracy, good patient acceptability, and relative safety. Ongoing research continues to clarify specific issues, such as the significance of flat or small polyps, the longterm significance of CTC-associated radiation exposure, clinical acceptability, and management of extracolonic findings. It is clear, however, that CTC will become an option for colon cancer screening for at least some of the estimated 40 – 60 million screening-eligible patients who currently remain unscreened.55 Currently, it is estimated that as few as 1000 physicians have been trained to read CTC scans, and of these, only 400 are active readers who dedicate significant clinical time to such work.56 Thus, even working at maximum rates, interpreting approximately 24 cases daily, only a small percentage of the colorectal cancer screening backlog could be accommodated. More realistic work estimates, which assume that CTC-trained physicians would likely read only 4 scans as part of their daily work, further shrink the potential of CTC to diminish the colorectal cancer screening gap. The limited number of physicians trained to read these studies will remain a significant hurdle to broader adoption of this screening approach and has led to discussion of who should train to read CTC scans (radiologists, gastroenterologists, others?) and how such physicians should be trained. Gastroenterologists, as specialists in the prevention and treatment of GI diseases, are well positioned to adopt the practice of CTC, particularly if findings warrant subsequent colonoscopy. Thus, it is logical to consider gastroenterology fellowship training in the use of this tool. The AGA Institute convened a recent conference to address the training issues surrounding CTC. Experts recommended that trainees read at least 75 CTC scans to gain competency. Furthermore, CTC readers must work in conjunction with radiologists to ensure proper recognition and assessment of extracolonic findings. Given the current uncertainties about the ultimate role of CTC and the manpower shortages that will inevitably limit the faculty available for CTC training, the goal of developing expertise and competency in CTC cannot be routinely incorporated into gastroenterology fellowships at this

time, although it merits continued assessment and consideration. However, the committee did agree that some exposure to CTC should eventually become a standard part of the gastroenterology fellowship curriculum. More broadly, basic training in imaging could greatly enhance gastroenterology training and more in-depth training electives could provide a firmer knowledge foundation for those interested in careers in diagnostic gastroenterology. Fellowships could offer training in general computed tomography, ultrasonography, and magnetic resonance imaging as one of many specialized options for fellows after completion of an initial year of basic gastroenterology clinical training. Such a track would then be in place to accommodate newer technologies such as CTC as they are more broadly adopted.

Oncology In recent years, gastroenterology leaders have considered the potential benefits of joint gastroenterologyoncology training. As the population ages, increasing numbers of patients present with GI tumors. At the same time, the diagnostic and therapeutic options now available for GI cancers increasingly involve staging, followup, and often treatment by gastroenterologists. Thus, the rationale for shared training includes the increasing portion of gastroenterology that oncology comprises and the growing needs for gastroenterology expertise in both the individual patient’s cancer management and in overall management, such as tumor boards, as treatment options rapidly expand and change. A spectrum of GI oncology functions are currently performed by many gastroenterologists, including cancer risk assessment and prevention through screening, diet and lifestyle counseling, and, in some instances, chemoprevention. When cancer has been diagnosed, gastroenterologists often play a key role in staging, particularly of esophageal, gastric, pancreas, and colorectal disease. Gastroenterologists have increasingly broad roles managing tumors and their complications through interventions such as resection and ablation, photodynamic therapy, bleeding management, and feeding tube and stent placements. Emerging oncology therapies require expertise that gastroenterologists often already have, such as familiarity with the use and side effects of biologic therapies, a rapidly expanding area of cancer therapy. In addition, knowledge of intraluminal anatomy and endoscopic skills uniquely equips gastroenterologists to administer intralesional treatments. These advantages, coupled with a projected shortage of oncologists, further support the concept of joint training that would allow a gastroenterologist to become a specialist in GI oncology. Clearly, joint training would require a new approach to fellowship education. The structure of such a new approach requires an understanding of what oncology training currently occurs during fellowship and what might be

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possible either within the current time constraints or perhaps in an additional training period. Current gastroenterology training stipulates that “trainees should . . . become familiar with the principles of chemotherapy for GI cancer and radiation therapy for early and advanced lesions.” This education, however, is not standardized. While fellows and practicing gastroenterologists generally have strong exposure to therapeutic endoscopy, exposure to other oncology training is variable. Advances in GI tumor management have further rendered this approach too narrow. For example, the development of new surgical approaches and neoadjuvant therapies requires that gastroenterologists understand the spectrum of surgical as well as medical and radiation therapy approaches to GI malignancies. Within the existing framework, a better developed, well-defined oncology curriculum needs to be presented to all gastroenterology fellows that covers the spectrum of cancer treatment options and provides an overview of chemotherapy administration and toxicities. In addition, a more in-depth GI oncology experience could be offered as a third-year fellowship elective. Gastroenterology trainees and faculty should participate more actively in multidisciplinary tumor boards. Currently, gastroenterologists generally participate very little in GI oncology society meetings. Participation might be facilitated through greater gastroenterology involvement in the governance and operations of these groups, with attention to operational barriers. For example, the AGA Institute currently does not allow abstracts that have been previously presented to be re-presented at Digestive Disease Week, thus sometimes forcing oncology-focused gastroenterologists to present at either oncology-focused meetings or the broader gastroenterology meetings. If additional training were included, a combined gastroenterology/medical oncology or gastroenterology/surgical oncology fellowship might more comprehensively meet the identified oncology education goals. Precedents for combined training exist in other specialties. Gynecologic oncologists, who commence training as gynecologists and undergo additional oncology training, manage gynecologic cancer care, including selecting and administering chemotherapy. This fellowship training has a nationally standardized curriculum and culminates in board certification. Similarly, neurooncology fellowships exist to which medical oncologists, neurologists, neurosurgeons, and radiation oncologists can apply. While these fellowships are not ACGME accredited and fellows do not receive board certification, the curriculum is nationally standardized. In Europe, oncology training and practice is generally delivered as part of subspecialty education in gastroenterology, gynecology, neurology, pulmonary, renal, and other areas. Within the existing framework, a better developed, well-defined GI oncology curriculum needs to be presented to all gastroenterology fellows that covers the

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staging and diagnosis of gastroenterological cancers (including EUS) and the spectrum of treatment options, including surgery, biologic therapy, chemotherapy, radiation therapy, and toxicities. As endoscopic treatments advance, training will need to include didactic sessions about endoscopic mucosal resection and the potential role it and other endoscopic therapies may play in cancer management. Such training could be imparted through didactic lectures, focused gastroenterology grand rounds, fellow participation in oncology tumor board programs, and an increased emphasis on oncology on the gastroenterology board examinations. Given the significant overlap between gastroenterology and oncology in many areas of GI cancer prevention, diagnosis, and management, future fellowship training will need to incorporate more extensive oncology training for all fellows. For fellows with particular career interests in GI oncology, options for more in-depth training need to be explored for which support by the American Society of Clinical Oncology would be desirable.

IBD

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The care of patients with IBD has grown increasingly complex in recent years as a range of new diagnostic tools and therapeutic options have become clinically available. Furthermore, research into the immunology and genetics of IBD is expected to yield new insights into the mechanisms of these diseases and potentially add to the diagnostic and therapeutic armamentarium. The practice of high-quality, cost-efficient IBD care requires familiarity with a growing number of new radiologic tools such as CT enterography and magnetic resonance enterography, endoscopic approaches, including capsule endoscopy and balloon-assisted endoscopy, and serologic testing. In addition, many new drugs, including several biologic agents, have been approved for IBD treatment. These drugs are often significantly more expensive than other therapies and may require close clinical follow-up for unique and/or potentially serious complications. Currently, the need for gastroenterologists with specialized IBD training remains unmet. Several programs offer a fourth year of specialized IBD training to help meet this need and to train academicians to pursue clinical, translational, and basic IBD research. Alternatively, a focused IBD track contained within the existing 3 years of a standard gastroenterology fellowship could also help expand the pool of gastroenterologists interested in and experienced in the care of patients with IBD.

Research Training Overview NIH Research Training Programs To consider improvements in gastroenterology fellow research training, we first need to examine how basic and clinical research training is funded. Research is

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the foundation for advances in understanding, preventing, and treating GI diseases. As such, the NIH, mostly through its National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), has played a critical role and provided the majority of support for research endeavors, research training, and career development in gastroenterology. The NIH and NIDDK facilitate research using a range of programs that target researchers across the spectrum from graduate and medical students to independent investigators. National Research Service Awards (NRSA), institutional training grants (T), and individual fellowship (F) awards as well as career development (K) awards, loan repayment programs, intramural research programs, international programs, and diversity programs are targeted to ensure that research funding reaches a range of institutions and researchers. Research project grants comprise 52.7% or more than $15 billion of the current NIH budget, while trainingrelated costs account for 2.7% or $764 million. Between 1997 and 2006, the number of research training positions on Kirschstein-NRSA training grants and fellowships remained fairly stable. Within the NIDDK, data from 2005 indicate that the portion of the budget spent on supporting extramural Kirschstein-NRSA training grants is slightly above the median for other NIH institutes and centers at approximately 4%.57 Digestive diseases research is conducted across NIH institutes. Besides the NIDDK, the National Cancer Institute and the National Institute of Allergy and Infectious Diseases comprise the major players in digestive disease research. Other institutes and centers conducting gastroenterology-related research include the National Institute of Dental and Craniofacial Research, National Institute of Environmental Health Sciences, National Center for Research Resources, and National Institute on Alcohol Abuse and Alcoholism. The NIH has made efforts to understand the effectiveness of its investment into research career development. It has little digestive diseases–specific information available regarding the success of the NRSA-T, -F, or -K programs. In an attempt to evaluate the success of these awards in developing career researchers, NIH managers analyzed data on the retention of T32 trainees, K awardees, F32 awardees, and R03 awardees with particular emphasis on underrepresented minorities as well as supplemental T32 slot programs in academics and success in subsequent grant applications. Using 10-year summary data, among T32 trainees, 60% of trainees remained in academics. NIH data indicate that, among K awardees, 74% remained in research, 54% had received NIH funding, and these investigators had an average of 9.4 publications each. More than 90% of diversity R03 awardees applied for NIH funding, and 52% were successful. For those who had received T32 grants, 51% remained in research, 60% remained at academic institutions, and 34%

had applied for NIH funding, of which 72% were funded. The NIH does not have data about the number of R01 recipients who remain in research 10 years after their award; the FTC urges the NIH to attempt to compile these data to further inform research funding discussions. Data available at the NIDDK level suggest the 2007 Loan Repayment Program has effectively reached many gastroenterology researchers, as applicants from the NIDDK’s Division of Digestive Diseases and Nutrition comprise 42% of NIDDK applications and contracts (personal communication, Dr Stephen James, March 8, 2008). Significant questions remain about the most effective approaches to attract, develop, and retain talented basic scientists in gastroenterology research. In addition to supporting training, individual fellowships, and career development research programs, other strategies have been suggested. These include support of mentorship, continued career development support through educational workshops and conferences, reduction in the financial burden for young investigators, efforts to assure a diverse workforce, and encouragement for entry of PhD scientists to pursue translational and clinical research in digestive diseases. Although the NIH budget has plateaued somewhat in recent years after a period of rapid growth, the NIH training programs (T32, K grants, F32 grants, and RO3 grants) continue to have a good record of supporting research careers. The challenge for gastroenterology training programs will be to improve research training in the future given constraints on NIH funding.

Basic Science Training Continued progress in clinical gastroenterology is predicated on continued advances in basic science and on a core of physicians trained to perform and understand the implications of such work. While some programs continue to train and produce outstanding young faculty in basic research, this remains a weakness at many other programs, and there is general consensus that most gastroenterology fellowship programs can do a better job training fellows in basic research. Furthermore, in recent decades, basic medical science has advanced at an unprecedented rate. Key developments include expanded understanding of systems biology and integrated approaches to the study of model organisms, expanded capacity for molecular profiling, expanded technology for molecular imaging with both cell- and tissue-based, real-time, dynamic in vivo readout, and expanded application of genetics and epigenetics. In particular, genetic counseling will become more important in the future and trainees will need expanded education in clinical genetics. Thus, future training programs will need to prepare young gastroenterology faculty to build on and extend these exciting new fields.

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In contrast to previous eras, recent scientific breakthroughs are often highly visible and marketed to the public. The development of whole genome sequencing illustrates this transition. Human genetics is in the public domain and holds the promise of personalized medicine. While much remains to bring this promise to fruition in the daily practice of medicine, businesses have already emerged to capitalize on the public’s growing interest. More than 1000 direct-to-consumer kits are now available for genetic testing in the United States. Of these, none have been validated by the Food and Drug Administration. Physicians face significant challenges in navigating the postgenomic era specifically and this rapidly changing scientific world more generally. The challenges, however, are accompanied by unparalleled opportunities as the connections between bench and bedside strengthen and societal awareness grows. As a profession, the ability to meet these challenges and embrace these opportunities will require substantial revision in our approach to training physicians in general and physician-scientists specifically. Successfully training basic physician-scientists requires an expensive institutional commitment to infrastructure and faculty that crosses traditional departmental and school of medicine boundaries. Core laboratory facilities and a critical mass of research faculty are essential, and while these may span divisions and departments, physician-scientists within gastroenterology will continue to need mentors and advocates with the gastroenterology division itself. For physician-scientists, success often requires a prolonged postfellowship training period before entering a tenure-track position. Uncertainties about the availability of research funding make this period particularly stressful, especially as data from 2006 indicate that the average medical student had educational debts between $120,000 and $160,000 upon graduation.32 Some successful programs can support physician-scientists through these early years; however, the financial realities of academic institutions limit the applicability of this approach. A broader approach to debt relief will be an increasingly important component of programs to attract and train high-caliber physician-scientists. Basic gastroenterology researchers will be charged with advancing the knowledge of complex diseases such as IBD, nonalcoholic fatty liver disease, dysfunctional bowel syndromes, GI cancers, and other conditions that will dominate the care of an aging and increasingly obese population. In addition, basic physician-scientist gastroenterology trainees should be comfortable with the emerging concepts of personalized genetic medicine and have knowledge that provides the framework to integrate genetic and environmental risk factors with other complex modifiers (diet, bacteria/other flora, medication, race, gender, and so on) for patient care.

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In the future, successful young gastroenterology researchers will need to focus their work on emerging areas of science, not necessarily areas shared by older physician-scientists. Success in the “real world” of science will require specific skills, such as familiarity with syntax, applications, methodology, limitations, ethics, and interpretation of advances in human genetics as well as the ability to translate knowledge of molecular genetics into testable hypotheses. Trainees will need specific education about grant, manuscript, and presentation preparation. Furthermore, because much of this will be in the human genomics/translational field, trainees interested in careers in basic research will need didactic training about clinical-translational research and the ability to collaborate within and outside traditional academic divisions as part of a team that may include clinicians and basic scientists. Gastroenterology divisions will need to ensure that research trainees have access to key core laboratories, which may be within or outside of the gastroenterology division. To further foster a successful transition from research trainee to faculty, fellows need early positive feedback in order to gain confidence and young faculty will need assurances of funding and salary support, which will require creativity on the part of division chiefs. In view of the ACGME requirements for 18 months of clinical work, programs need to find ways to carve out additional time for basic research training. Some programs have adopted a fourth training year; however, this additional time commitment will pose a barrier to some trainees. Programs should also offer the ability to “stop the tenure clock,” particularly in the postfellowship period, because many young faculty may have competing demands during this time frame, such as commitments to young families. A vigorous pipeline of well-trained basic physicianscientists will be essential for the continued viability of academic gastroenterology divisions and for the field as a whole to continue to provide high-quality, innovative patient care. Some friction between the goals and missions of clinical training and research training will likely be unavoidable, but the physician-scientist is and will remain an integral part of future advances in medicine and gastroenterology.

Clinical and Translational Research AGA INSTITUTE

In recent decades, a range of non– bench research fields have emerged, encompassing clinical trials, outcomes research, health services research, and translational research. Gastroenterology research has been an integral component of these areas, and many gastroenterology programs now offer master of public health and master of science degrees that entail additional formal coursework and training in a variety of clinical research fields.

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Most clinicians are familiar with clinical trials; however, fewer understand the distinctions between these other fields of translation, outcomes, and health services research. Familiarity and training in these areas will gain increasing importance in clinical practice and public policy. Future gastroenterologists will need exposure to these areas and, for those with career interests in these areas, more training opportunities. Clinical trials involve studying patients to see if a given treatment or therapy works, answering the question “does it work?” In contrast, outcomes research entails evaluating the effects of an intervention or treatment on broader populations, answering the question “should we do this?” Health services research involves delivery of health care and addresses the question “how do we do this?” Translational research, as its name suggests, involves the application of bench research to clinical research (so-called “T1”) and the application of clinical research to practice (T2). Variable definitions of translation research exist. The National Cancer Institute defines it as follows: “Translational research transforms scientific discoveries arising from laboratory, clinical, or population studies into clinical applications to reduce cancer incidence, morbidity, and mortality.”58 The National Institute of Neurological Disorders and Stroke states that “Translational research is the process of applying ideas, insights, and discoveries generated through basic scientific inquiry to the treatment or prevention of human disease.”59 Training for clinical and translational research may overlap with but is distinct from that of basic scientists. Trainees interested in clinical or epidemiologic research need didactic coursework in clinical epidemiology, biostatistics, statistical computing in clinical research, and computer software packages. Those focused on T1 translational work need skills in molecular and genetic epidemiology and practical laboratory experience in using these skills in real research endeavors, while those focused on T2 require decision and cost-effectiveness analysis skills, knowledge of systematic reviews and outcomes research, and an understanding of how to translate evidence into practice. Trainees interested in careers in clinical or translational research may benefit from instruction in grant writing tailored to obtain research and career development awards, database management systems for clinical research, medical informatics, and qualitative research methods. The didactic work required of successful trainees in clinical and translational research may form the basis for master-level degrees. While such formal degrees are not uniformly required of successful clinical and translational researchers, the practical requirements of these programs often entail activities that facilitate subsequent career development, such as performing a comprehensive literature review, producing a first-authored oral or poster presentation at a national or international meet-

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Figure 1. Components of clinical and translational research training, University of Michigan.

Figure 2. Components of clinical and translational research training, University of North Carolina at Chapel Hill.

outcomes of these training programs and many questions remain about the best way to train clinical-translational researchers.

What Are Training Needs With Respect to Clinical Practice? Community Practice Questions have been raised regarding how to best train fellows for community practice. Despite the fact that the majority of fellows ultimately join private practices, the current training environment does not address many aspects of such practices. Gastroenterology training typically involves rotations between consultative services, during which patients with complex diseases or who require complex procedures are seen. Often, trainees are buffered from the demands of ongoing patient care by other physicians and by the episodic nature of hospital practice, and the practice environment is typical low volume. In private practice, clinicians often work independently in the absence of colleagues or other ancillary support to provide ongoing care to patients, many with complicated, chronic problems that can be emotionally demanding. Fellows themselves recognize this educational gap and have approached the AGA Institute with requests for programs about quality measurement in private and academic practice and about the transition from training to practice. Ideally, all fellows need education about the business and practice of medicine beyond fellowship. This education should include skills in assessing potential job opportunities and negotiating with potential employers; understanding practical business matters such as varying practice structures, coding, and the structure of outpatient and inpatient services including call, coverage, and team management; understanding quality measurement, risk management, and liability issues; interpreting business plans and profit-loss statements; developing skills in

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ing, submitting as a first author of a peer-reviewed manuscript, participating as an instructor in clinical research, holding office hours for students, and grading homework assignments and projects. While some level of didactic education is critical, in isolation it is not enough. Trainees need practical experience and dedicated mentoring. This may be accomplished by a “master’s committee” composed of a range of faculty representing the scholar’s academic field and other areas such as biostatistics and epidemiology. Examples of successful clinical and translational research training programs and their components include the University of Michigan (Figure 1) and the University of North Carolina at Chapel Hill (Figure 2). Future training programs will need to ensure that gastroenterologists are familiar with scientific advances in fields such as experimental and clinical genetics and their relation to translational research and clinical medicine. The clinical investigator track is an emerging discipline, but more information is needed regarding the

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dealing with patient deaths; and developing lifelong learning strategies. Some fellowships have attempted to incorporate aspects of such education into fellowship training. Trainees in the University of Minnesota gastroenterology fellowship program rotate 3– 6 months within a large private gastroenterology practice, performing inpatient, tertiary consultative care and attending to outpatients in the private specialty hepatology and IBD clinics. This rotation successfully exposes fellows to a variety of patients and practitioners in a private practice setting; however, this rotation does not provide continuity of care or exposure to private practice– based procedures. An alternative approach has been the creation of a “community track.” This approach, however, is difficult for most practices to integrate because of patient expectations, time pressures, legal issues, and concerns about quality of teaching and quality of patient care. The unmet needs of fellows who are transitioning to private practice may be met in a variety of other ways. A community practice track might be appropriate for some programs, particularly those in which a majority of trainees consistently enter community practice. Such a track may be more difficult to implement at some academically oriented programs where the focus of training differs and/or community practice is not the predominant career choice for graduates. Nevertheless, many of these topics would be highly useful for all trainees, and additional didactic teaching about practice management could be incorporated into fellowship in lieu of some inpatient gastroenterology training. Such fellowship training could include a “lifelong learning” module, training for interested fellows in quality measurement and management (a “quality track” within fellowship), to provide exposure to and opportunities to participate in research or administrative functions related to practice management of quality of care. Complementing potential training-based education, a focused conference could be created, “Transitioning to Community Practice,” covering the business of gastroenterology, including practice models, practice governance, negotiating a contract, and coding; community practice of gastroenterology, including how to work with a health care team and quality measurement; personal aspects of managing professional life, such as stress management and dealing with patient death and the professional and personal needs of a spouse or significant other; and future trends in gastroenterology. Finally, the lifelong needs of gastroenterologists in community practice could be supported through the addition of practice management and health care quality articles in society publications.

Hospital-Based Practice: “Gastroenterology Hospitalists” Because the demands on the gastroenterology workforce have exceeded the available gastroenterology

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workforce in some locales, some institutions have reorganized inpatient care using gastroenterology and/or liver hospitalist physicians and midlevel providers such as nurse practitioners and physician assistants.60 Traditionally, gastroenterology has been a specialty defined “vertically,” that is, by practitioners whose expertise may be narrow but very in-depth. Many gastroenterology practices both in the academic and community settings, however, have moved toward the use of hospitalist teams to provide high-quality, efficient inpatient care. The hospitalist movement represents the evolution of a “horizontally oriented” specialty in which practitioners are more knowledgeable than others except vertical specialists in a broad range of clinical areas. Hospitalists are inpatient specialists who provide 24-hour availability and a unique knowledge about inpatient clinical care and the workings of increasingly complicated hospitals. For gastroenterology inpatient care, dedicated gastroenterology hospitalists can often rapidly perform consults, can perform or arrange for endoscopies, and have special expertise in the care of clinical problems such as GI bleeding, liver failure, transplant hepatology, and postsurgical complications. This approach makes sense, because most gastroenterologists have overextended outpatient practices that continue to constrain time available for inpatient patient care and teaching. In addition, when gastroenterologists do rotate on inpatient services, their time is increasingly consumed with performing necessary inpatient procedures, thus limiting their role in primary inpatient care. Gastroenterology hospitalist care may be provided by gastroenterology-trained physicians or dedicated internists who have undergone rotations on gastroenterology and/or hepatology inpatient services. The work of these physicians is often supported by nurse practitioners and/or physician assistants who can assess and follow up with many inpatients, particularly those with uncomplicated diagnoses. The degree to which the use of gastroenterology hospitalists can help efficiently render much needed inpatient services is unclear. Concerns also remain about potential patient dissatisfaction with weakened continuity of care, potential outpatient physician dissatisfaction about who ultimately renders treatment decisions and potential loss of inpatient skills, and potential hospitalist dissatisfaction with the extended hours and more limited scope of practice associated with a hospitalist career. Nevertheless, it is clear that the hospitalist model has been embraced by most large hospitals, and thus gastroenterology, as a specialty, will need to decide how best to approach inpatient care and service. In addition, gastroenterology training programs will need to consider whether to train some gastroenterologists to focus primarily on inpatient care as gastroenterology-trained hospitalists or to partner with internists with a gastroenter-

ology focus who will cover these gastroenterology inpatients. Thus, the notion of a dedicated inpatient gastroenterology specialist or hospitalist may eventually emerge as a distinct discipline.

Business and Management Training Most gastroenterology trainees graduate from their fellowship and start their careers with minimal knowledge of finances or business principles and little experience in managing assistants or staff. This is increasingly untenable, however, as the economic pressures placed on health care delivery increasingly require physicians in all settings to have a broader understanding of the business of medicine. Such demands are reflected in the ABIM’s core competencies, which include knowledge about practice-based learning and improvement as well as systems-based practice. The skills required of physician-executives are even greater. To succeed in today’s health care field, physician-executives must develop innovative strategies and communicate a compelling vision of high quality, cost-effective care. While education about the business of health care is now widely available, business training is seldom pursued by trainees. Questions arise as to what training all fellows should receive about the business of medicine and, for those with a particular interest in the business and management of either academic or community practice medicine, what additional knowledge is required. For trainees and practicing physicians who are interested in careers that encompass significant levels of management, traditional business schools and alternative institutions are offering both degree-oriented programs, such as combined MD/MBA programs, master of health care administration degrees, and executive MBA programs, as well as nondegree, topic-specific education programs tailored to physician-executives. Degree-oriented programs typically include instruction on leadership and organizational management, financial analysis and control, communication, strategy and policy, marketing and brand management, and conflict resolution and negotiation. As the training requirements of gastroenterology fellowship undergo review, it is clear that all trainees would benefit from and should receive some general knowledge about the business of medicine. The specific content and delivery of such knowledge, however, is not clear. For example, such education could be delivered from an institutional or personal perspective and have a private practice or academic focus. Topics could include health care economics, policy and financing, payment models for facilities and providers, quality improvement, costeffectiveness, ethics, communication skills, conflict resolution, and personal health and safety. How such training would be delivered and by whom also remains unanswered. Ideally, faculty should be drawn from interested and experienced faculty involved

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in hospital leadership (ie, division chief, department chair, physician leadership of practice plan, medical school dean, as well as specialized faculty in associated schools of business, economics, and politics). Much of this training is relevant to all physicians and as such could be delivered during residency or fellowship through ongoing sessions, similar to “journal clubs,” through voluntary evening or weekend sessions distributed throughout training or through intensive episodic sessions. For example, the Mayo Clinic provides a concentrated program conducted over 2 evenings that focuses on the transition from training to practice and is aimed at individual success. Its contents emphasize debt management and security insurance; practice search, interviewing, and resume preparation; employment contracts; promotion guidelines; and general success tips. While the content may need to be tailored to each fellowship, its trainees, and available teaching venues and resources, it is clear that training curricula need to incorporate basic business and management education to prepare young physicians for successful careers.

Summary and Recommendations Future gastroenterologists will need to train and work in a rapidly changing society that poses new demands, challenges, and opportunities on health care. These broad-based changes will encompass the spectrum of practice from scientifically and technologically driven changes in the scope of practice; demographically and economically driven changes in the demand for, organization of, and payment for health care delivery; and socially driven changes in patients’ and referring physicians’ expectations. Future gastroenterologists will have differing personal expectations and needs and will demand more work-life balance, particularly in the face of mounting medical school debt, 2-career couples, and competing interests. Fellowship training programs need to evolve in both how and what education is delivered. Although professional regulatory bodies such as ACGME and ABIM will continue to play a large collaborative role with training programs to ensure that gastroenterology fellowships continue to produce highly trained, well-qualified physicians able to meet the professional obligations of patients and payers, fellowship programs will need to take the lead in preparing gastroenterologists. The following text summarizes perceived needs and proposed recommendations.

Potential Changes in Content Both changing demographics and increasing scientific knowledge about many clinical areas in gastroenterology will require more in-depth training in areas such as GI malignancies, hepatology, IBD, and genetic counseling and clinical genetics. Growing payer and consumer interest in preventive health and “GI wellness” will create

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opportunities that, ideally, fellowships can help prepare gastroenterologists to exploit. Furthermore, it is clear that fellows require better preparation for the business of medicine, regardless of ultimate practice venue. Some of this additional education could be delivered within the existing medical education framework. For example, basic business and managerial training for fellows could be included in periodic workshops, regular conferences, and/or conference attendance. Some emerging science areas of relevance to all physicians, such as information about genetics, wellness, and “personalized” medicine, could arguably be included into medical school curricula. Other required knowledge about topics such as successful grant writing, manuscript writing, and oral presentations as well as the business of medicine could be important to some fellows across medicine disciplines and could potentially be delivered efficiently to fellows across disciplines. In other clinical areas, expertise may require more time and warrant more specific changes to fellowship or postfellowship education, as described in the following text.

Potential Changes in Structure and Delivery of Fellowship Education To allow time for the increasing breadth of training, novel multifaceted approaches must be considered, including using technology to deliver learner-focused content efficiently and effectively throughout medical education. The cost-effectiveness of training simulators should be further explored, and training programs should maximize their use of existing Internet resources to augment and customize fellowship training and track progress. Structural changes to fellowship could include the following:

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1. Reducing the length of internal medicine residency training to afford more time in specialty training without increasing the overall duration of postgraduate training. 2. Restructuring fellowship training to afford more flexibility within the existing 3-year training period such that those with research interests could pursue these after an initial clinical fellowship year and those with focused clinical interests could elect to dedicate much of their final fellowship year to training in areas such as obesity and nutrition, motility, IBDs, geriatric gastroenterology, women’s GI health, or training in quality management and administrative aspects of gastroenterology practice. 3. Creating dedicated, standardized postfellowship training programs in areas such as GI oncology, transplant hepatology, interventional endoscopy, and GI imaging and CTC. Such programs would require coordinated efforts with other disciplines such as radiology or oncology.

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Recommendations to the AGA Institute General conclusions and recommendations. Given the rapidly changing economic health care environment and the vulnerability of training programs to policy changes, the panel supports the AGA Institute’s continued advocacy efforts. The panel suggests that the AGA Institute should conduct a survey of how gastroenterology fellowship programs are financed throughout the United States to better understand the current structure and to inform future policy discussion. The panel believes that there is a need for both “gastroenterologist generalists” (the prototypical 3-year fellowship graduate) and gastroenterologists who have received more extensive education and training in research or in defined areas of gastroenterology practice. It expects that in the future, training in most gastroenterology fellowship programs will be quite variable, with some fellows following specific tracks and others receiving very individualized training, but with all fellows meeting some minimum clinical training standards. The panel believes that knowledge of clinical genetics and genetic counseling should be incorporated into the minimum clinical training standards for fellows. In addition, it suggests that the AGA Institute develop continuing medical education programs for those already in practice to develop these competencies. For fellows interested in more specialized gastroenterology careers, training curricula and organization should be flexible and structured so as to accommodate comprehensive in-depth training in (1) basic research or clinical investigation, (2) liver disease, (3) IBD, (4) treating cancers of the digestive system, (5) imaging of the digestive system, or (6) interventional endoscopy. Such training should be conducted as necessary with the cooperation of other divisions within the institution such as radiology, oncology, or surgery. To successfully create these new paradigms, the AGA Institute will need to work with the ACGME and ABIM to modify training requirements and processes. Questions of what board certification these subspecialists would receive are particularly important to answer. The panel recommends that the AGA endorse efforts to alter the existing structure of the 3-year fellowship curriculum to accommodate trainees who wish to specialize in a specific disease area, procedure, or type of research. The panel suggests that the AGA convene a work group to explore the potential advantages and disadvantages of reducing the internal medicine component of training to allow 4 years of gastroenterology subspecialty education within the current 6-year training model. The panel recognizes that technological advances will continue to rapidly change the way medical education is delivered to and tracked for physicians at all stages of

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Hepatology: conclusions and recommendations.

The panel believes that the treatment of liver disease must remain an integral part of gastroenterology training and practice; however, it recognized that the diagnosis and management of liver disease have become complicated enough to warrant more extensive training than is currently provided in most fellowship programs. In addition, given growing numbers of patients with hepatitis and other liver disease, the panel supports efforts to expand the numbers of gastroenterologists with expertise in hepatology. The panel suggests developing a fellowship track for “focused practice” in hepatology, which could limit total training duration and potentially boost the numbers of gastroenterology fellows who choose to become trained as hepatologists. The panel recommends that the AGA Institute advocate that the diagnosis and treatment of liver disease remain an integral part of gastroenterology training and practice. The panel recommends that for trainees who wish to become hepatologists, fellowship be comprised of the following: ●

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Fellowship year 1: devoted to a “survey” of common GI diseases and procedures such as colonoscopy. This would be the standard gastroenterology training year for all gastroenterology fellows. Fellowship years 2–3: devoted to in-depth training in hepatobiliary disease. Most likely would include a few additional months of gastroenterology rotations.

The panel recognizes that fellows graduating from this program may not be ideally trained to become gastroenterology generalists but would have the minimum qualifications (eg, 18 clinical months) needed to become board certified in gastroenterology and thus practice general gastroenterology in addition to hepatology. At least initially, additional training (eg, a fourth year) may be needed to gain competency in transplant hepatology. Over time, however, it is hoped that curricular refinements might allow focused 3-year training programs to encompass the training provided in the current fourth year of fellowship in transplant hepatology. Oncology: conclusions and recommendations. Screening, surveillance, diagnosis, and staging of cancers comprise a large portion of gastroenterology practice. There is a strong rationale for augmenting gastroenterology training in the area of pharmacologic and endoscopic treatments of digestive cancers, because a GI oncologist would be in a prime position to coordinate and manage the care and follow-up of these patients. Further,

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several specialties (eg, obstetrics-gynecology) train oncology specialists within their broader training programs. Currently, many gastroenterology services and divisions have only a limited presence on tumor boards, and much greater involvement in these programs by gastroenterology trainees is needed. In addition, the panel recommends that fellowship programs consider ways to incorporate advanced training in GI oncology into existing programs for interested trainees. It should be noted, however, that the practice of oncology requires the clinician’s total commitment and the panel has noted in previous work that oncology cannot be pursued as a small clinical piece of a broader practice.61 The panel recommends that the AGA develop a welldefined advanced oncology curriculum that extends beyond that contained in the 2007 Gastroenterology Core Curriculum. The panel suggests that the AGA support development of GI oncology fellowship options. These could include the following: ●

Fellowship years 1–2: devoted to common nonmalignant GI diseases and procedures such as colonoscopy.

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Fellowship year 3: devoted to in-depth oncology training including chemotherapy, cancer staging, and treatment as well as procedural training about the appropriate use and performance of techniques such as EUS and endoscopic mucosal resection.

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Alternatively, an entirely new training curriculum could be created, perhaps in cooperation with the American Society for Clinical Oncology, that would create a 3-year combined gastroenterology-oncology fellowship program devoted to the prevention, diagnosis, and treatment of GI and hepatobiliary malignancies.

The panel also encourages the AGA Institute to expand its interaction with oncology societies (eg, American Society for Clinical Oncology) and allow AGA members’ abstracts that have been presented at oncology conferences to also be presented at Digestive Diseases Week. GI imaging: conclusions and recommendations. The panel notes that various imaging technologies are or will soon be a basic element of gastroenterological care and interpretation of GI images will be an important component of training. For more established imaging modalities, trainees should be competent in their uses and interpretation. For emerging techniques such as CTC, the panel recommends that trainees have a basic familiarity with their indications and interpretation and, where resources are available, that interested trainees have access to more in-depth training. This will need to be done with the cooperation of radiology departments and will require the development of training standards.

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their careers. The panel encourages the AGA Institute to assist both fellowship programs and individuals in capitalizing on the potential benefits of these developments. The panel suggests that the AGA Institute produce an overview of the content and quality of online resources for gastroenterology trainees and clinicians.

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The panel encourages the AGA to develop a defined curriculum in GI imaging that includes understanding the indications for, limitations of, and interpretation of CTC scans as well as other types of imaging and technology (eg, capsule endoscopy) as they evolve and become more widely applicable. Advanced interventional endoscopy: conclusions and recommendations. The panel concurs that all train-

ees should continue to receive training in routine endoscopic diagnostic procedures (eg, colonoscopy). Other more challenging procedures such as ERCP should be reserved for those trainees with a special interest. Additionally, new, more advanced endoscopic interventions continue to be developed for the treatment of a range of conditions (ie, obesity). The panel feels strongly that these should remain the purview of gastroenterologists; thus, fellowship programs must accommodate training for these procedures. The panel recommends that the AGA Institute develop a model of an interventional endoscopy track curriculum that could be incorporated into the existing 3-year time frame to train interested fellows in more advanced, nonroutine interventional procedures such as ERCP, EUS, and other techniques. The field of NOTES warrants explicit discussion. While currently experimental, the panel notes that it holds considerable promise as a replacement for many conventional surgeries and may rapidly evolve, similar to the evolution seen with laparoscopic procedures. While NOTES training may become very desirable, the panel believes it would not be feasible for a trainee to become proficient in NOTES as simply one part of a general gastroenterology curriculum. Because NOTES combines the techniques and competencies of both endoscopy and surgery, competency in these areas would require joint gastroenterological and surgical training. As a first step toward this joint training model, gastroenterology fellowships should consider offering elective rotations in general surgery. The panel suggests that the AGA Institute, in cooperation with one of the GI surgery societies, develop a model for a future joint gastroenterology-surgery NOTES fellowship program. Gastroenterologist-scientist: conclusions and recommendations. The need for gastroenterologist-scientists

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is well recognized and has been addressed in previous panel reports and elsewhere.62 The panel concurs that all trainees need some minimum “hands-on” exposure to either clinical or basic science research. In particular, all trainees need education in the basics of study design, biostatistics, and the principles of evidence-based medicine; these should be incorporated into all training programs. For those interested in pursuing a research career, their fellowship needs are different. Training of physician-

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scientists is distinguished from that of other gastroenterology subspecialists in that a “critical mass” of researchers and mentors is required and there is heavy reliance on external funding from the NIH and elsewhere, especially for advanced scientific training. The limitations on such funding are also well recognized. For trainees with a strong interest in basic science, the panel recommends the following structure: ●

Fellowship year 1: devoted to a “survey” of common GI diseases and procedures such as colonoscopy.

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Fellowship years 2–3 X Basic science trainees: Two years devoted to basic research focused in a particular area of gastroenterology physiology or disease (eg, GI motility or IBD). X Clinical and translational research trainees: 2 years devoted to research training integrated with formal coursework in relevant areas.

The AGA Institute should facilitate the development of a standard curriculum for those trainees interested in pursuing master’s degrees in clinical gastroenterological research. Community practice gastroenterologist: conclusions and recommendations. The panel recognizes that

most trainees enter community practice and feels strongly that most trainees do not receive adequate preparation for the community practice environment, which differs significantly from the academic centers in which they have trained. In addition to being oriented to the differences between patients in private practice settings and those in academic facilities, those entering community practice need to understand its unique business and management aspects. The panel considered the desirability of creating a dedicated community track within training programs but ultimately rejected this as a general recommendation. While some programs may have the resources and interest in creating this type of training option, the panel suggested that other approaches to orienting and educating trainees about community practice should be developed that would ease their transitions into their first jobs and the private practice environment. The committee recommends that the AGA Institute develop educational programming for third-year trainees that would educate and orient them to the requirements and realities of community practice. This could be by conferences, Webcasts, podcasts, or other means. Accommodating other disease-focused training programs. The panel believes that training programs

with above-average strengths and capabilities in treating certain GI diseases, such as IBD or motility disorders, should offer specialized disease-specific tracks within the current 3-year time frame. Such tracks would provide advanced training and experience in diagnosing and treating these diseases, although it is recognized that this

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Conclusions Fellowship training programs are faced with looming challenges and opportunities that will profoundly change gastroenterology training. These potential changes require significant revisions in fellowship content and structure to allow programs to meet the individual trainee’s education and lifestyle needs and include attention to operational issues such as improved flexibility in fellowship scheduling and part-time options. Technological advances will offer increasing opportunities to make medical education more efficient and effective by targeting user needs and increasing convenience. While fellowship training cannot anticipate or completely buffer trainees from political, economic, and social forces that affect medicine, revisions to the delivery and content of fellowship training can help ensure that individual trainees and practicing gastroenterologists have the knowledge and skills to anticipate and successfully navigate these changes and that the field as a whole continues to attract and retain high-quality young physicians.

TIMOTHY C. WANG, MD Division of Liver & Digestive Diseases Columbia University Medical Center New York, New York FABIO COMINELLI, MD, PhD Digestive Health Research Center and Training Program University of Virginia Charlottesville, Virginia DAVID E. FLEISCHER, MD Division of Gastroenterology and Hepatology Mayo Clinic Scottsdale, Arizona JAMES M. GORDON, MD Associated Gastroenterologists Phoenix, Arizona ROBERT M. GLICKMAN, MD New York University School of Medicine New York, New York DAVID LIMSUI, MD Gastroenterology Fellow, Mayo Clinic Rochester, Minnesota

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KENNETH R. MCQUAID, MD Veterans Affairs Medical Center San Francisco, California MARSHALL MONTROSE, PhD Department of Molecular and Cellular Physiology University of Cincinnati Cincinnati, Ohio PANKAJ J. PASRICHA, MD Division of Gastroenterology & Hepatology Stanford University School of Medicine Stanford, California DON W. POWELL, MD University of Texas Medical Branch Galveston, Texas WILLIAM A. ROWE, MD Gastroenterology Associates of Central Pennsylvania Hershey, Pennsylvania WILLIAM J. SANDBORN, MD Mayo Clinic Rochester, Minnesota ANDREA TODISCO, MD University of Michigan Ann Arbor, Michigan Supplementary Data Note: To access the supplementary material accompanying this article, visit the online version of Gastroenterology at www.gastrojournal.org, and at doi:10.1053/j.gastro. 2008.09.021. References 1. Teslik LH, The Council on Foreign Affairs. Healthcare costs and U.S. competitiveness. May 14, 2007. Available at: http://www. cfr.org/publication/13325/#2. Accessed March 12, 2008. 2. Bush GW, The White House. Economic statistics briefing room. Available at: http://www.whitehouse.gov/fsbr/income.html. 3. National Coalition on Health Care. Facts on the cost of health care, 2008. Available at: http://www.nchc.org/facts/cost.shtml. 4. Lamm R. Presentation to North Bay Business Journal annual healthcare meeting. November 8, 2006. 5. Social Security, Greenspan Commission on Social Security Reform. Appendix C of the 1983 Greenspan Commission on Social Security Reform. Available at: http://www.socialsecurity.gov/history/ reports/gspan7.html. 6. Press Ganey Associates, Inc. 2007 nationwide database of patient experiences. CP Time by Overall Sat.ppt (January 1–December 31, 2007). Available at: www.pressganey.com. 7. Clark PA, Drain M, Malone MP. Press Ganey Associates, Inc. Return on investment in satisfaction measurement and improvement. Volume 1, Edition 2 (August 31, 2005). Available at: http://www.pressganey.com/files/roi1.pdf. 8. Nahrwold DL. Medical travel: a burgeoning worldwide industry. Intern Med News 2008;41:5. 9. Tosczak M. Hospitals outsourcing some radiology reading. Business J Greater Triad Area December 2, 2005. Available at:

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would require shortening or omitting other areas of training. The panel did not believe it was necessary to add an additional training year to gain competency in these areas; however, an optional fourth year of training might be useful for fellows without access to specialized diseasespecific training at their home institutions.

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29. Bickel J, Brown AJ. Generation X: implications for faculty recruitment and development in academic health centers. Acad Med 2005;80:205–210. 30. Smith LG. The American College of Physicians. The ACP and Gen X and Y. Available at: http://www.acponline.org/about_acp/ chapters/mt/mtgbog07_smith.pdf. Accessed April 14, 2008. 31. Raines C. Generations at work. Managing millennials. Available at: http://www.generationsatwork.com/articles/millenials.htm. Accessed April 14, 2008. 32. Jolly P. American Association of Medical Colleges. Medical school tuition and young physician indebtedness. October 2007. Available at: https://services.aamc.org/Publications/showfile.cfm? file⫽version103.pdf&prd_id⫽212&prv_id⫽256&pdf_id⫽10 3. Accessed March 13, 2008. 33. Heiligers PJM, Hingstman L. Career preferences and work-family balance in medicine: gender differences among specialists. Soc Sci Med 2000;50:1235–1246. 34. Benya RV. Why are internal medicine residents at university medical centers not pursuing fellowship training in gastroenterology? A survey analysis. Am J Gastroenterol 2000;95:777–783. 35. Singer N. For top medical students, an attractive field. The New York Times March 19, 2008. Available at: http://www.nytimes.com/ 2008/03/19/fashion/19beauty.html?_r⫽1&oref⫽slogin. Accessed July 1, 2008. 36. Massachusetts Institute of Technology, MIT OpenCourseWare. Available at: http://ocw.mit.edu/OcwWeb/web/home/home/index.htm. Accessed April 7, 2008. 37. Davis D, O’Brien MA, Freemantle N, et al. Impact of formal continuing medical education: do conferences, workshops, rounds, and other traditional continuing education activities change physician behavior or health care outcomes? JAMA 1999; 282:867– 874. 38. Bero LA, Grilli R, Grimshaw JM, et al. Closing the gap between research and practice: an overview of systematic reviews of interventions to promote the implementation of research findings. The Cochrane Effective Practice and Organization of Care Review Group. BMJ 1998;317:465– 468. 39. Slotnick HB. How doctors learn: physicians’ self-directed learning episodes. Acad Med 1999;74:1106 –1117. 40. Slotnick HB. Physicians’ learning strategies. Chest 2000;118(2 Suppl):18S–23S. 41. UpToDate. Available at: http://www.uptodate.com/home/index. html. Accessed April 7, 2008. 42. The DAVE Project— gastroenterology. Available at: http:// daveproject.org/index.cfm. Accessed March 27, 2008. 43. GI Wiki: a collaborative resource for GI and hepatology trainees and practitioners. Available at: http://giwiki.org/index.php? title⫽Main_Page. Accessed April 7, 2008. 44. Barnard D, McGee JB. Palliative care/end of life/just-in-time learning system. Available at: http://clinical.nav.pitt.edu. Accessed April 7, 2008. 45. Cohen J, Cohen SA, Vora KC, et al. Multicenter, randomized, controlled trial of virtual-reality simulator training in acquisition of competency in colonoscopy. Gastrointest Endosc 2006;64:361– 368. 46. Henderson T. American Association of Medical Colleges. Medicaid direct and indirect graduate medical education payments: a 50 state survey. November 2006. 47. American Association of Medical Colleges. Recent studies and reports on physician shortages in the U.S. August 2007. Available at: http://www.aamc.org/workforce/recentworkforcestu dies2007.pdf. Accessed April 30, 2008. 48. Mulligan MS, Shearon TH, Weill D, et al. Heart and lung transplantation in the United States, 1997–2006. Am J Transplant 2008;8:958 –976.

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Address requests for reprints to: Michael Stotar, PhD, AGA Institute Future Trends Committee, 4930 Del Ray Avenue, Bethesda, Maryland 20814. email: [email protected]; fax: (301) 654-5920. All the authors are also members of the Consensus Development Panel (Future Trends Committee). The authors disclose no conflicts.

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49. Armstrong GL, Wasley A, Simard EP, et al. The prevalence of hepatitis C virus infection in the United States, 1999 through 2002. Ann Intern Med 2006;144:705–714. 50. Browning JD, Szczepaniak LS, Dobbins R, et al. Prevalence of hepatic steatosis in an urban population in the United States: impact of ethnicity. Hepatology 2004;40:1387–1395. 51. Adams LA, Lymp JF, St Sauver J, et al. The natural history of nonalcoholic fatty liver disease: a population-based cohort study. Gastroenterology 2005;129:113–121. 52. Bacon BR. Hepatology: small steps forward. Gastroenterology 2008;134:381. 53. Bacon BR, Grosso LJ, Freedman N, et al. Subspecialty certification in transplant hepatology. Liver Transpl 2007;13:1479 –1481. 54. Natural Orifice Surgery Consortium for Assessment and Research (NOSCAR). What is NOTES? Available at: http://www.noscar.org/ faq.php. Accessed March 19, 2008. 55. Hur C, Gazelle GS, Zalis ME, et al. An analysis of the potential impact of computed tomographic colonography (virtual colonoscopy) on colonoscopy demand. Gastroenterology 2004;127: 1312–1321. 56. Rockey DC. Colon cancer screening, polyp size, and CT colonography: making sense of it all? Gastroenterology 2006;131: 2006 –2009. 57. National Institutes of Health. Trends in NIH training and fellowships. Available at: http://grants.nih.gov/training/data/tf_trends. ppt. Accessed April 8, 2008. 58. National Cancer Institute. Translational Research Working Group (TRWG) definition of translational research. Available at: http://

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Appendix 1. Conference Presenters John I. Allen, MD Medical Director Minnesota Gastroenterology PA Minneapolis, Minnesota

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Jeffrey M. Marks, MD Director of Surgical Endoscopy Department of General Surgery University Hospitals Cleveland, Ohio

Martin Brotman, MD President and CEO California Pacific Medical Center San Francisco, California

James B. McGee Jr, MD Associate Professor University of Pittsburgh Pittsburgh, Pennsylvania

David J. Bjorkman, MD, MSPH Dean University of Utah School of Medicine Salt Lake City, Utah

Jane Onken, MD Director, IBD Clinic & GI Fellowship Program Duke University Durham, North Carolina

Randall Burt, MD Senior Director of Prevention and Outreach Huntsman Cancer Institute–University of Utah Salt Lake City, Utah

Don C. Rockey, MD Chief, Division of Digestive and Liver Diseases Southwestern School of Medicine Dallas, Texas

Nicholas Davidson, MD Chief, Division of Gastroenterology Washington University School of Medicine St Louis, Missouri

Suzanne Rose, MD, MSEd Associate Dean for Student Affairs & Medical Education Mt. Sinai School of Medicine New York, New York

Karen Fisher, JD Senior Associate Vice President Division of Health Care Affairs Association of American Medical Colleges Washington, DC Lawrence S. Friedman, MD Chair, Department of Medicine Newton-Wellesley Hospital Newton, Massachusetts Gregory J. Gores, MD Chair, Division of Gastroenterology & Hepatology Mayo Clinic Rochester, Minnesota John M. Inadomi, MD Director, GI Health Outcomes, Policy and Economics University of California San Francisco, California Stephen P. James, MD Director, Division of Digestive Diseases and Nutrition NIDDK, NIH Bethesda, Maryland Michael L. Kochman, MD Professor of Medicine Endoscopy Training Director Hospital of the University of Pennsylvania Philadelphia, Pennsylvania Charles Maltz, MD Director, Gastroenterology/Hepatology Inpatient Services New York-Presbyterian Hospital New York, New York

Other Attendees Darrell S. Pardi, MD Member, AGA Institute Education & Training Committee Nicholas F. LaRusso, MD AGA Institute President, 2007–2008 Steven K. Herrine, MD Chair, AASLD Training & Clinical Policy Committee Michael R. Lucey, MD AASLD Treasurer

Appendix 2. Conference Agenda Day 1 I. Introduction: The 2013 GI Environment 1. What will patients and society at large need and expect from the GI specialty (as a whole) in 2013 and beyond, especially as compared with the present?—Martin Brotman, MD 2. How should GI training programs accommodate the demographic and attitudinal changes in the US population and, especially, in young physicians?—Suzanne Rose, MD, MSEd 3. What is the future of federal funding of medical specialty training?—Karen Fisher, JD 4. What are the NIH research training programs and what are their effects on and implications to the research component of GI training programs?—Stephen James, MD

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II. Changes in GI Science and Technology: How Should They Be Incorporated Into GI Training Programs? 1. How should advances in basic science (eg, genetics, molecular biology) be incorporated into GI training and how should GI physician-basic scientists be trained?—Nicholas Davidson, MD, DSc 2. How should GI clinical and translational investigators be trained and what should that training include?— John Inadomi, MD 3. How can hepatology training best be accomplished within the broader context of gastroenterology? The view from AASLD.—Greg Gores, MD 4. Should GI training programs include a discrete imaging track and, if so, what would it look like? Don Rockey, MD 5. Should GI training programs include a discrete advanced interventional endoscopy track and what would it look like? a. Would a joint gastroenterology-surgery fellowship be desirable? A surgeon=s view.—Jeffrey Marks, MD b. Would a joint gastroenterology-surgery fellowship be desirable? A gastroenterologist=s view.—Michael L. Kochman, MD 7. Would establishing joint gastroenterology-oncology training programs be desirable?—Randall Burt, MD 8. How can advances in educational media, formats, technology (e.g., the shift from print to digital, Webbased education and self-evaluation, procedure simulators) best be utilized in GI training programs?—J.B. McGee, MD

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III. Changes in Physician Education and Certification: What Do the National Organizations That Guide Training and Certification Think GI Training Should Be? 1. What is ACGME=s view of the future of GI training programs?—Jane Onken, MD 2. What is ABIM=s view of GI training needs?—Lawrence Friedman, MD Day 2 IV. Changes in the Practice Environment: How Can GI Training Programs Help Ensure the Economic Viability of GI Practice? 1. Given that most GI trainees enter community practice, should there be community practice tracks or training programs and, if so, what should they include?—John Allen, MD, MBA 2. How can appropriate education in the business/managerial aspects of academic and community practice be incorporated into GI training programs and what should that education encompass?—David Bjorkman, MD, MBA 3. Utilization of “midlevel providers” and hospitalists in GI practice is increasing. Should GI training programs participate in the training of nurse practitioners, physician assistants and hospitalists and what do they need to be taught?—Charles Maltz, MD V. What Conclusions Can Be Drawn From the Presentations on Days 1 and 2, and What Recommendations, If Any, Can Be Given to the AGA Institute Governing Board— Future Trends Committee