Gastroenterology 2000: The perfect storm

Comment From the Editors Gastroenterology 2000: The Perfect Storm he millennial threshold has made the instinct to look backward and forward almost irresistible and ubiquitous. With this month’s GASTROENTEROLOGY, it is appropriate to consider for a moment the state of gastroenterology— the field. The state is, in a word, unsettled. The condition is both general and specific. Medicine in general might be best characterized by analogy with the so-called perfect storm described in a novel by that name written by Sebastian Junger. In 1989, a storm formed in the North Atlantic from the convergence of hurricane Grace and massive storm systems moving from the west to yield nearly the most powerful storm physically possible. Medicine in the United States arguably faces the perfect storm—convergence of challenges that include constraints on patient and physician choice imposed by third parties and fiscal pressure of every sort. The lack of any comprehensive organization to the delivery and financing of health care inevitably contributes to pervasive anxiety. In academic centers, these stresses are compounded by special financial strains that derive in part from the nature of their clinical mission but also uncertainty about government commitment to the support of education and training and the unpredictability of research funding. These factors threaten to result in a summative wave that will leave medicine truly at sea. Although in many respects our subspecialty is thriving with a continued demand for more well-trained gastroenterologists (in the United States), gastroenterologists and gastroenterology, the field, do not in fact have safe haven, and we face additional challenges superimposed on the factors facing medicine in general. In the broadest terms, these are both sociopolitical and technical challenges to the franchise of gastroenterologists as the preeminent providers of digestive disease care. Thus, several physician groups are prepared, given the opportunity, to take ownership of

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care that is core to our field. These include generalist, most obviously the family practitioner, and specialist physicians at the interface with gastroenterology including radiologists as well as nonphysician providers. We ignore the potential for nurses and other nonphysician providers to pursue an enlarging role for themselves untethered from physicians at our peril. In the technical dimension, several waves are building that could deliver a heavy blow. For example, virtual colonoscopy has the potential to finesse the need for endoscopic screening for colorectal cancer. Laparoscopic Nissen fundoplication may indeed offer better cost-effective relief for chronic gastroesophageal reflux disease in many individuals than lifelong medical treatment. With this perfect storm building in the distance, what course should gastroenterology take at the threshold of the millennium? Despite these many and real challenges, I believe the best days for gastroenterology are still in the future. However, complacency is incompatible with realizing this possibility. First, we should recall the adage that ‘‘the secret for caring for the patient is to care for the patient.’’ In the broadest sense, we must retain the prerogative of being the primary caregiver for patients with digestive diseases by being the primary advocate for patients with digestive disease. We should take responsibility to be sure that the overriding interests of patients in best medical care are preeminent in the public debate. We should also not shrink from expressing our confidence in our expertise and its value. We should also aggressively pursue an expanded view of gastroenterology to encompass natural extensions of the current domain of gastroenterology. To point to one example: Why should the role of the gastroenterologist stop once the diagnosis of a GI tract cancer has been established? Though the cynic might perhaps question the motivation, we will do well by doing good. An obvious example is the overriding need to achieve universal colorectal cancer screening of all individuals older than

50 years. We should be clear that our first priority is that these individuals actually get screened for polyps and colon cancer irrespective of which of the available tests is used to accomplish this. Most importantly, we must welcome rigorous evaluation of the value of the care we provide. Ultimately, no advocacy will offset the eventual judgment of history. Finally, and arguably most importantly, we should seek growth through innovation. Ultimately, I believe our future will be secured by progress made through basic and applied clinical research. A better understanding of disease mechanism and causation will enable the gastroenterologist to bring better treatment for patient needs. While we might wonder what the middle-term impact of virtual colonoscopy will be on GI practice (although even here, it is reasonably possible that it will enlarge the demand for gastroenterologists for colonoscopic polypectomy), we should take an even longer view. I believe that virtual colonoscopy too will eventually be superceded. Research, possibly/hopefully by gastroenterologists, will result in diagnostic tests that are truly noninvasive and identify individuals with neoplasms that could be treated ‘‘noninvasively’’ by drugs used by gastroenterologists with specialty knowledge. Research will also open new opportunities for treatment that should further enlarge the value of the gastroenterologist, e.g., delineation of the mechanisms of the many varieties of motility/functional disorders will enable the development of a corresponding pharmacopoeia of effective agents. Yes, looking into the new century, we can expect to be buffeted by the storms in the evolving landscape of health care, but there is a safe port if we set the right course. This depends on unflinching commitment to the best interests of patient care, vigorous advocacy, and aggressive pursuit of research and innovation in the laboratory and the clinic. DANIEL K. PODOLSKY, M.D. Editor