It has been just under 25 years since Google went live with a search engine that would forever change our lives. In a very short time, such transformative innovation has gone from outlandish to self-evident. The term “innovation” has a variety of meanings for the different stakeholders in gastroenterology and hepatology. It goes well beyond the latest new widget or medication and encompasses every aspect of daily clinical practice. Entering an era of medicine infiltrated by artificial intelligence and digital health, we as gastroenterologists will soon face a crossroads. We will be asked to balance value-based care, innovation, resource reduction, and equitable provision of care for all patients. The golden years of practices solely focused on screening colonoscopy may soon be replaced by other opportunities allowed by more accurate stool- and blood-based testing.

This is a far cry from the rhetoric of years past— that we will be replaced by robots and supercomputers that will obviate the need for physicians. In fact, the shift in gastroenterology from a diagnostic to a therapeutic focus likely will increase the need for our services if we can simply accept the evolution of our field. This evolution involves advances ranging from personalized diagnostics to new avenues for cancer screening, AI-based tools to reduce electronic health record burden, novel endosurgical devices, and much more.^1,2 Are we prepared for this?

Barriers in the Adoption Of Innovation

While innovation in gastroenterology slowed during the COVID-19 era, that offered an opportunity for the healthcare industry to reset and reprioritize for a new vision for patient care. The pandemic opened up many doors—from telemedicine to home-based diagnostics for patients. Medical device companies were compelled to reanalyze their portfolios and streamline innovative technology and products that would have the most impact on physicians and their patients in this new world order. In the GI field, this has led to innovations in novel noninvasive diagnostic testing to AI solutions to augment the accuracy of endoscopy. Despite this growth, numerous barriers continue to prevent the integration and adoption of novel innovation into clinical practice.³

“Show Me the Data”

The foundation of clinical practice has been built on evidence-based medicine. However, a large percentage of our practice in gastroenterology is not always driven by the highest degree of evidence. For example, the rigorous methodology of clinical guideline development is not structured to foster the clinical adoption of novel innovation in medicine. As such, many important new advances are delayed in reaching clinical practice. To bridge this gap, societies have developed technology and innovation committees, as well as documents such as clinical practice updates, to provide best-practice statements related to innovation. Additional multisociety efforts facilitating and advising on the integration of innovation in practice are needed.⁴

Training and Education

The current practice paradigm supports the vast majority of therapeutic endoscopy being performed by advanced endoscopists. Many procedures once under the purview of “general” gastroenterologists now are referred to their specialized colleagues. Many of these were once considered the “bread and butter” of general GI practice, such as large colon polyp resection, esophageal stricture dilation, and endoscopic hemostasis. Unfortunately, many GI fellows may have limited amounts of time training with advanced endoscopists during the 3-year fellowship and graduate without confidence in these important skills. This lack of training and the perpetuated mantra that these procedures are “advanced” compounds concern for medicolegal risk and anxiety for the general GI endoscopists that may be difficult to overcome.

Beyond super specialization, the majority of academic medical centers and fellowship training programs have shifted to productivity-based compensation, either a relative value unit (RVU) model or salary with an incentive system. Whatever the pathway, it results in an underlying pressure for efficiency in endoscopy. This introduces time constraints, which translate to less “scope time” for trainees, particularly when important therapeutic interventions are performed. This deficiency may not be immediately apparent in our traditional quantitative methods of assessing fellowship competency, but they become abundantly clear once the trainee enters clinical practice. Ultimately, we are creating a situation in which graduating fellows are not as comfortable with core therapeutic endoscopic procedures. These hurdles in endoscopy training limit their exposure to novel innovation in endoscopy and, most importantly, reduce their confidence in the adoption of such tools once they start their own practices.⁵

Supply Chain and Value Analysis

Although the pandemic has led to a plethora of innovation in our field, the implementation of value-based care and tighter budgets have created an environment in which it can be very challenging to adopt new technology and innovation. The time line to demonstrate the value of novel innovation to the local supply chain and value analysis committee, navigate reimbursement issues, and then work through the red tape to obtain final approval can take months and has reduced the enthusiasm of many physicians for adopting novel tools that would benefit their patients.

Future Directions: Where Do We Go From Here?

The future of our field is in our hands. It is imperative that we recognize that transformative change in gastroenterology is coming, and we can choose to play an integral role or simply be left in the dust. We should recognize that the vast majority of innovation in GI will provide great opportunities for our growth and reduce much of the documentation burden we now face. There is a light at the end of the tunnel, and we must together decide to ambitiously run toward it or be left behind to reminisce with the old dogs.

References

1. Komanduri S, Sethi A, Muthusamy VR. Future implications of innovation in gastroenterology for clinical practice: a call to action. Am J Gastroenterol. 2023;118(8):1307-1310.
2. Klang E, Soffer S, Tsur A, et al. Innovation in gastroenterology—can we do better? Biomimetics (Basel). 2022;7(1):33.
3. Muthusamy VR, Komanduri S. Innovating in your practice: overcoming barriers to create new opportunities. Clin Gastroenterol Hepatol. 2019;17(4):580-583.
4. Shah ED, Sethi A, Thaker AM, et al. 2022 American Gastroenterological Association-Center for Gastrointestinal Innovation and Technology Tech Summit. Clin Gastroenterol Hepatol. 2023;21(2):245-249.
5. Grover SC, Walsh CM. Integrating artificial intelligence into endoscopy training: opportunities, challenges, and strategies. Lancet Gastroenterol Hepatol. 2024;9(1):11-13.

Dr. Komanduri reported no relevant financial disclosures.