The Best of Times and the Worst of Times: Sustaining the Future of Academic Gastroenterology in the United States-Report of a Consensus Conference Conducted by the AGA Institute Future Trends Committee

Academic GI divisions train the majority of GI physicians in the United States and perform important research, educational, and patient care roles. These varied activities allow the field as a whole to continue its recent rapid pace of scientific and clinical breakthroughs, to remain in the vanguard of the medical community, and ultimately to deliver high-quality patient care. Significant challenges, however, confront academic divisions as they face increasing service demands, decreasing revenues, difficulty recruiting and retaining faculty, and changing needs of their fellows. Increasingly, GI fellows require exposure to a growing range of procedural and cognitive areas within a limited training period. Attempts to modify fellowship requirements ultimately impact GI divisions through effects on the scope of faculty activities and on the supply of future faculty members. An in-depth exploration of these challenges and potential solutions was the premise of the AGA Institute's FTC consensus conference and this report. Academic GI divisions have changed significantly in recent decades. The division of 30 years ago was small, was mainly tenured, and had both funded basic and clinical research. Reimbursement rates were high, overhead and department of medicine (DOM) taxation were low, and alternative funding sources existed. In recent years, much of this situation has reversed, with low reimbursement rates, high and growing overhead, and significantly fewer sources of alternative funding. The daily practice of many academic gastroenterologists increasingly mirrors that of their private practice peers while the salary gap between the groups continues to widen. Thus, faculty recruitment and retention have suffered. Concurrently, collaboration between industry and academia has increased, fostered in part by significant changes in technology transfer laws. These partnerships, while presenting opportunities, also present challenges for academic divisions, such as conflicts of interest, potential loss of control of the research agenda, and concerns of data suppression. To navigate these increasing challenges, divisions will need to implement a range of changes in their business and staffing models and in the training of fellows. The division will need to be run as a business, albeit one with noble, academic goals, where financial viability will be a necessary prerequisite for all mission-based activities. Thus, the division director and other senior members of the division will need to have formal training in leadership skills and in sound business practices and concepts. In this regard, the committee recommends that the AGA Institute offer its academic members education and training in relevant business and management topics. (Business-oriented education for trainees who plan to enter community practice will also be beneficial and would be well received.) GI clinical centers will integrate the services of general internists, hospitalists, and midlevel providers (nurse practitioners and physician assistants) to more efficiently deliver inpatient and outpatient care. Divisions will pursue novel revenue streams, including fund-raising and industry partnerships. Realistically, however, for some institutions, none of these changes will be enough to overcome a continued increase in the demand for uncompensated care. Future GI training will need to be modified to allow fellows to most efficiently achieve the depth of training that their career pursuits warrant, whether such training entails greater procedural, research, or educational training. In addition, to meet the demand for academically oriented physician-scientists and educators in gastroenterology, GI division directors will need to recruit, mentor, and retain faculty through new definitions of academic success and through more flexible faculty management. Such efforts will need to be supported by a better understanding of the reasons why current fellows have chosen gastroenterology and the barriers, real and perceived, to academic careers. The ideal academic GI division of the future will continue to pursue independent research, education, and patient care in the face of many challenges in a cost-effective manner. GI divisions that account for the changing nature of the health care economy, and that capitalize on the changing nature of the workforce, will be poised to maximize their success. A range of initiatives will be necessary to provide academic divisions with the information and infrastructure to continue their missions. This report has attempted to better define the challenges that academic divisions face and to propose potential solutions. The AGA will need to continue to advocate for greater funding for research and unreimbursed care, foster career tracks for researchers and professional educators, and encourage interest in and help define and reduce potential barriers among students and trainees to careers in academic gastroenterology. Among the committee's specific recommendations to the AGA Institute to achieve these objectives are the following: (1) developing a system for routinely collecting representative demographic and financial data from GI divisions, (2) offering management training as described previously, (3) providing education on concierge services and fund-raising, (4) advocating for increased federal support for specialty training, (5) investigating ways for GI divisions to collaborate with community practitioners vis-à-vis their educational mission, (6) expanding programs such as "Investing in the Future" for internal medicine residents and GI fellows that promote gastroenterology in general and academic gastroenterology in particular, (7) establishing a GI educator academy to train full-time GI educators, and (8) developing guidelines and recommendations for collaboration with the pharmaceutical and device industries for joint clinical research and product development activities. The FTC recognizes that the AGA has very limited ability to affect many of the fundamental problems facing academic medicine and academic gastroenterology. However, it believes that adoption of the recommendations put forth in this report can help the science and practice of gastroenterology to continue to flourish.