It's my honor now to introduce our next moderator, Dr. Inessa Kaikis from Vanguard Gastroenterology and NYU Grossman School of Medicine. Ladies and gentlemen, truly a principal figure in the field of gastrointestinal endoscopy and related diseases, ASGE honors the late Dr. Basil Hershkowitz for his leadership and accomplishments through this annual lectureship. The lecture is presented by the ASGE Foundation and was established by the generous support of ASGE friends, trainees, and colleagues. Dr. Hershkowitz led some of the most important initiatives in gastroenterology and endoscopy and reached the pinnacle of academic success as a teacher, basic scientist, mentor, clinician, and one of the fathers of modern medicine. In January of 1957, Dr. Hershkowitz assembled the original prototype, flexible fibro-optic endoscope. This invention revolutionized the practice of gastroenterology and provided the basis for optical fiber communication in multiple industries. Please join me in welcoming Dr. Joseph Baikari, Clinical Assistant Professor of Medicine at Rockford Gastroenterology to present their Basil Hershkowitz Endowed Lecture, Strategies for Success in Challenging Healthcare Environments. Thank you, Ines, and thank you to the course directors for the honor of giving this lecture. I don't have any disclosures for this talk. My objectives this morning are to focus on four areas that include the future of ambulatory endoscopy centers, consolidation and growth that we've seen in the field of gastroenterology, staffing challenges, both from the perspective of physicians and nursing, and what the future of gastroenterologists may look like in the coming years, and the impact that these variables may have on the field of gastroenterology. As we look at the future of ASCs, the future is promising. There's going to be a growth in both volume and revenue, and this will be one of the important drivers of strategies for success in the future. Market size by 2026 is expected to be around $10.8 billion. There's a number of reasons we're going to see growth in volume in the endoscopy centers. That includes payer preference to drive patients to the high-quality, low-cost centers and low-cost compared to the hospital outpatient department. We have an aging population in the United States and a population that has an increasing burden of chronic disease, and both of these factors will lead to an increased demand for endoscopic services. This growth in services will provide a real challenge to the already increasing burden of access, and specifically the problem of timely access to endoscopic services. So what are some of the reasons that we're going to see consolidation and growth, which we've seen a real trend over the last few years? There are a number of market forces in place, including the growth for demand in services, and also physician preference to join larger groups that are operated by management teams. Other important advantages include the leverage of size when it comes to payer negotiations, developing favorable contracts that provide better reimbursement. There's also a competitive edge at both the local and regional level, and in some practice models at the national level. There's an overall advantage of economies of scale when it comes to practice management and practice operations with consolidation and growth. With consolidation and growth, we've seen a real change in practice models in the United States. About 60% of physicians in the United States are in employed models, so there's been some consolidation in the employed models. And in the non-employed models, most of the consolidation has been driven by private equity, which has also seen growth in both physician growth and patient services growth. Traditional independent private practice, which now makes up about 20% of patients, has really seen an out-migration of physicians, but has seen a significant growth in patient services. So we hope to see these trends continue. The greatest impact, I think, we're going to see on the landscape of medicine comes into the timely access or the lack of timely access we're seeing now for endoscopic service. And I think there are four factors that greatly influence access to services. I already mentioned the aging population, the increasing burden of chronic disease. We now have colorectal cancer screening starting at age 45. There's about 20 million people in the United States between the age of 45 and 49, and regardless of the modality used to screen for colon cancer, we're going to see a significant increase in the need for colonoscopy services. This increase in service demand comes at a time when we have a significant shortage in gastroenterologists and a significant nursing shortage. Right now, if you look across the board, we have a shortage of about 2,600 gastroenterologists in the United States, and this number is likely to worsen. We're an aging specialty with what I would call perhaps age traditional retirement at around 65. But we're also seeing some early retirement between the age of 58 and 64. So we have an out-migration, and we have a static supply of fellows. We're not replacing it out-migration. This is only going to further impact our access to timely services. The problem of access is compounded by the problem of the nursing shortage in the United States. There's a shortage of about 1.2 million nurses expected by 2030. A number of reasons for the shortage of nurses includes a lack of nurse educators and nursing schools. There's a high turnover that has been compounded by the pandemic. And like gastroenterology, there's an aging workforce. This will impact all aspects of our practice, including operations, efficiency, and access. But there's some interesting developments going on in artificial intelligence. There are three pilot projects going on right now at the University of California, San Diego, University of Wisconsin at Madison. I believe one just started at Stanford this week that's looking at the role of artificial intelligence to start to offload some of the burden of nursing duties. For example, prescription ordering and medication refills, allowing nurses to spend more face-to-face time with patients. We'll have to see how that data evolves, and I think it could be a very interesting partial solution to the nursing shortage. So how are we going to deal with our gastroenterology shortage, which I think is really the main driver of our access problem? A long-term solution, a simple one, would be to increase the number of fellows and fellowship programs in the United States. I think if we want to get creative, I think we could start looking at the alternative of looking at some high-quality private practice groups that may be able to run fellowship programs. I think the challenge will be funding, who will pay for this, and how it will be paid. And then this is a longer-term solution. At the time period, if you start a fellowship program, on average, by the time you start the administrative process to the actual time the first fellow graduates, you're looking at five to potentially six years. So I think it's a viable long-term strategy and solution, but nothing that's going to help us in the short term. So I want to start to think outside of the box as I go through my last few slides and look at some short-term and long-term solutions. And one is how we define ourselves as gastroenterologists. Traditionally, as gastroenterologists, we've had a clinic practice and we've had our endoscopic practice. I think in the future, in order to deal with some of the challenges we face in access, we're going to become endoscopists, and the majority of our time will be spent performing endoscopy. For those in the outpatient world, there'll be limited clinic time, perhaps focusing on subspecialty clinics, and we'll have separate hospital teams that will focus on hospital work. They will not cross over into the outpatient world. And how would we accomplish this? I think the only way we accomplish this is by building quality, robust teams that are made up of advanced practice providers and gastroenterologists. Advanced practice providers will function in the outpatient, seeing mostly general GI disease, and some will develop subspecialty interests. We have some examples of subspecialty APPs at academic institutions and in private practice. The hospital teams will be run by an APP and a gastroenterologist. The APP will be the team leader, may have a number of APPs working together, running the hospital inpatient service. The physician will be the endoscopist, focusing on endoscopy procedures, and perhaps seeing more complicated inpatients. The only way forward to do this is to build quality APPs, and so we need robust APP education programs that are directed towards the needs of APPs, and I'm happy to say that ASGE is one of the leaders in developed education programs for APPs. I think it's time we consider a widespread APP gastroenterology fellowship. We have examples at Johns Hopkins and at Mayo Clinic. I think we need a curriculum that can be applied nationally, both at the academic level and private practice level, so that we appropriately educate our APPs to reach our ultimate goal of providing high-quality care to our patients. I think using this model, the gastroenterologist becomes the endoscopist, and we could really start to decrease the burden of timely, or lack of timely access. I want to leave you with a thought outside of the box. I'm sure it'll be controversial and provocative, but we do have some examples in other fields, such as orthopedics, where APPs play an important part of the orthopedic operative team, where they actually are involved in performing procedures. So I realize many of you may think I'm perhaps off my rock of presenting this, but I think we have to start thinking proactively of how we're going to deal with our physician shortage. So in my mind, I've thought of this theoretical model. An APP completes an APP endoscopy fellowship, perhaps focusing only on diagnostic upper endoscopy, perhaps focusing on colonoscopy, and perhaps having even a subspecialty where they're dealing with hemorrhoidal care and performing banding and sigmoidoscopy. I think you can think a number of ways where you can build an APP physician endoscopy team. They would go through traditional education methods, but also have the advantage of the AI being part of their teaching program, both from a procedure standpoint and from the standpoint of computer-aided diagnosis. So what if we had an APP physician endoscopy team? What could it look like? I could envision a physician endoscopy leader, perhaps sitting in a room with two or three monitors, where an APP performs a procedure with computer-aided diagnosis assistance. There's visual and audio communication between the team. And when a therapeutic intervention is needed, the endoscopist really becomes the therapeutic general endoscopist. Again, I realize this is controversial and provocative, but I really want to start thinking about solutions on how are we going to address our physician shortage and start to deal with the problems of timely access for our patients to endoscopic services. In summary, the future of ASCs are bright, and I think they'll be an important part of our strategic plan moving forward. Consolidation and growth will continue. I think the consolidation and growth will be across all models. I think the future gastroenterologists will be more endoscopists than they are gastroenterologists, spending most of their time performing endoscopy and spending most of their clinic time performing subspecialty work. I think we really need to concentrate on building high-quality APP gastroenterologist teams. Even if we never move beyond the clinic, we need to make sure we have high-quality education for our APPs. And I'd ask all of us, beyond the local level, I think we've been somewhat reactive in trying to deal with some of these problems of access and provider shortage. I think we start to need to think of new solutions and new paradigms for how we're going to deliver timely and quality endoscopic services. Thank you.

gastroenterology

ambulatory endoscopy centers

physician shortage

nursing shortage

timely access