It is estimated between 60 and 70 million people in the U.S. are affected by digestive diseases and gastrointestinal endoscopy has played an increasingly major role in management of those disorders.

While safer than, and often preferable to, invasive surgery, endoscopic procedures ranging from routine colonoscopy to more advanced procedures like endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography (ERCP) are not without risk. Physician competency is paramount to patient safety and can prevent misdiagnosis or poor treatment.

Competency in GI endoscopy is often measured by number of procedures completed in formal training programs, like post-residency fellowships. However, there is no formal specialized endoscopy board for the discipline, meaning training varies greatly across the nation and globe.

As the popularity of the discipline grows and endoscopic technology and techniques continue to evolve over time, it’s worth looking at what training opportunities are available, particularly for endoscopists who may choose later in their career to pursue more advanced endoscopic therapies in their practice.

Measuring Competency in EUS

EUS is an advanced endoscopic procedure used to assess and treat digestive and lung diseases (EBUS). Endoscopists use a specialized endoscope to take ultrasound images of the lining of walls of digestive system or lungs, or obtain images of organs like the pancreas and liver. These images can prove essential in the diagnosis of digestive or respiratory diseases. Additionally, endoscopists can perform therapies during more complex EUS procedures.

The American Society for Gastrointestinal Endoscopy (ASGE) recommends at least 24 months of GI or formal surgical training for GI endoscopists seeking competency in EUS. Further procedural requirements for competency, as outlined by the society, include:

  • Mucosal tumors: 75
  • Submucosal lesions only: 40
  • Mucosal and submucosal lesions: 100
  • Pancreaticobiliary: 75
  • EUS-guided FNA
    • Non-pancreatic: 25
    • Pancreatic: 25
  • Comprehensive competence: 50

The society also notes that competency in one type of advanced endoscopic procedure, such as EUS, does not guarantee competency in another like ERCP. Unique procedural requirements are set forth for each, as the skillsets required are quite different.

While EUS is typically performed at high-volume medical centers, especially given the procedural requirements for competency, there has been increased interest in smaller centers for physicians to take on the diagnostic and therapeutic practice.

Dr. Stephen Steinberg, co-founder and president of EndoSound, describes EUS as an “incremental skill.” There are less complex EUS procedures that can be performed competently with fewer training hours than the more advanced practices, he said. Still, beginning with these less complex procedures can be a pathway to improving skills and offer a way for  endoscopists to gather the imagery that will still be helpful in diagnoses and recommendations for care.

EUS Training Post-Medical School

There are currently 86 fellowship programs for advanced endoscopy, according to the American College of Gastroenterology (ACG). But, after fellowship, options become more limited.

“In the U.S., it’s really hard to get hands on experience,” Steinberg said, especially if the endoscopist is not part of a formal training program or fellowship. “Getting temporary privileges to work in another state for training isn’t typically available in the U.S.”

This leads many physicians to pursue advanced endoscopy training abroad.

In a 2014 op-ed penned by Dr. Todd Baron of the University of North Carolina, Dr. Baron explores the roadblocks he faced in pursuing EUS competency mid-career. Given how nationwide post-residency fellowship programs are geared to newly trained physicians, Dr. Baron said he did much of his training outside of the U.S. He said many physicians may find the same path challenging given the year needed to complete a fellowship and a medical center’s reluctance to losing a practicing physician for that length of time.

The COVID-19 pandemic has put even more pressure on developing new opportunities for EUS training that fall outside the realm of a traditional post-residency fellowship. During pandemic-era lockdowns, most non-emergency endoscopy procedures were delayed or postponed, greatly impacting the ability to train new endoscopists in the field. Thus, hands-on models and simulators, virtual conferences, and endoscopic video rounds were used more commonly.

Additionally, Steinberg said the availability of online videos or virtual training sessions and web streaming of live events can help those seeking new EUS skills learn techniques or see the latest available technologies.

Looking Forward

A recent article for the ACG Case Reports Journal outlined some avenues in which advanced endoscopy training could change to provide greater access to more physicians, including:

  • Incorporating EUS and ERCP training into the final year of residency
  • Standardizing advanced endoscopy training across fellowship programs
  • More exploration of non-traditional methods of training

GI endoscopy offers a safe and viable way for patients to receive preventative and therapeutic care without invasive surgery. More advanced procedures like EUS allow physicians to get a detailed look at the advancement of digestive and respiratory illnesses with minimal risk and discomfort to often quite ill patients.

Like most fields of medicine, endoscopy is ever evolving, making further opportunities for training increasingly important. There’s a real appetite for more training in EUS, especially as the procedure becomes more critical to endoscopic treatment, Steinberg said. This is especially noticeable as the ASGE training program for EUS is oversubscribed, he added.

New techniques and technologies are being developed all the time; to keep pace post fellowship training must accompany these advancements to continue to progress endoscopy.  Endoscopists and patients alike would benefit from more exposure to new techniques and advanced technologies.

 

 

 

 

 

 

The first Ambulatory Surgery Center (ASC) in the U.S. opened in 1970, offering an opportunity for patients to have access to the quality care they needed, without the wait time and cost often associated with hospitals.

Fast forward 50 years and the global COVID-19 pandemic fueled an already growing trend of patient preference for the convenience of ASCs. Today, more than 30 million surgeries and procedures are performed at more than 5,800 ASCs nationwide every year.

Large investments from MedTech industry giants may help fuel the still growing trend for out of hospital care. A recent partnership of GE Healthcare and Medtronic announced in April promises “cost-effective advanced technology” support for the growing suite of ASCs across the country.

The question remains how ASCs will be able to adapt to the increased demand for outpatient care when it comes to more advanced procedures – especially those performed by physicians with specialized training and requiring costly equipment, typically only found in hospitals.

GI Care in the ASC

In gastroenterology, there has been a huge uptick to procedures in ASCs, especially for routine endoscopy. Since ASCs typically offer a more convenient location, time-saving, and cost-saving alternative, they can be especially attractive to patients needing a routine colonoscopy.

The ASC Association lists endoscopy as one the primary specialties certain ASCs may offer (about 32 percent). Definitive Healthcare reported colonoscopies topped the list of reported procedures charged at ASCs in 2018 – approximately $3.2 billion in submitted claims.

Since average costs for colonoscopies can range from around $3,000 to as high as $19,000, it’s not surprising patients are choosing ASCs over the hospital for routine care.

As another example, a review of South Carolina colonoscopy rates and locations found that while the number of procedures stayed constant between 2001 and 2017, there was an 125 percent increase in colonoscopies performed in urban ASCs in that timespan.

EUS Outside of the Hospital

As the number of ASC sites grows and advanced medical technology becomes more readily available, there have been signs that more specialized gastroenterological endoscopy procedures may become more popular at the ASC as well.

Endoscopic ultrasound (EUS) is a minimally invasive procedure used to diagnose disease in the digestive and respiratory tracts. An alternative to surgery, EUS tools allow physicians to take images and samples for biopsies with specialized endoscopes. EUS is typically performed in the hospital endoscopy unit with patients under general anesthesia.

Given the expense of EUS technology and specialization required from physicians, transitioning procedures to an ASC could prove burdensome, with few doctors able to perform the procedures at these locations. A 2016 study from Dr. Shaffer R. S. Mok, et al, out of the MD Anderson Cancer Center in Jersey shows the feasibility and safety of EUS in the ASC, and the idea has gained more traction in recent years.

Continued innovation of EUS technology could be one of the ways to help move procedures to the ASC from the hospital, at great benefit to patients.

Endosound awarded AGA Shark Tank winner 2022

May 5th, 2022.  In April in San Francisco, CA, home to inventors, innovators, and investors, the 2022 AGA Center for GI Innovation and Technology (CGIT) Summit got underway.  There was a lot of great interaction among medical providers, investors and industry and one of the highlights was the Shark Tank style competition among start-up companies in the GI space.

Twenty companies applied for 6 spots to compete live in San Francisco and Endosound was selected among the 6 finalists.  Competitors each presented a 5-minute elevator pitch to a panel of GIs and investors, followed by 5-10 minutes of questions. Our founder, Steven Steinberg, MD, did a fabulous job pin-pointing the important details the panelists were seeking.

Without further delay,…

We won!

https://www.linkedin.com/company/endosound/posts/?feedView=all&viewAsMember=true

This win further validates that our technology is ready to disrupt the EUS market. Along with the award recognition, we will also receive guidance from the AGA CGIT committee, providing access to additional funding and partnering opportunities.  We could not be more excited!

As the 2022 AGA CGIT Shark Tank winner, we will represent the AGA CGIT in the Shark Tank competition at Digestive Disease Week (DDW) on May 21st, 2022, in San Diego, CA.  Once again Dr. Steinberg will be there to demonstrate our disruptive product and business plan.

Stay tuned for more information as we get closer to realizing our goals and more collaboration between the professional societies, strategic partners, and the GI community.