Gastroenterology, a historical specialty with a great future
Aparato digestivo; una especialidad histórica con mucho futuro
Javier Crespo1 and Francisco Jorquera-Plaza2
1Department of Digestive Diseases. Hospital Universitario Marqués de Valdecilla. Instituto de Investigación Valdecilla (IDIVAL). Santander, Spain.
2Department of Digestive Diseases. Complejo Asistencial y Universitario de León. León, Spain
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The specialty of gastroenterology (SGI) deals with the conditions involving the gut (esophagus, stomach, bowels, anorectal region), liver, bile ducts, pancreas, and peritoneum, specifically with their etiology, epidemiology, pathophysiology, semiology, diagnosis, prognosis, prevention, and treatment (1). As shown by Dr. Curbelo et al. in the present issue of The Spanish Journal of Digestive Diseases (Revista Española de Enfermedades Digestivas) (2), our SGI has progressively grown as a specialty training option, and is now one of the five most commonly requested residency programs. Data suggest a higher predilection for bigger institutions, greater care complexity, and higher university teaching and research activity levels. Similarly, recent data provided by the "Ministerio de Sanidad" show that SGI is the specialty where demand has grown most strongly amongst MIR examination passers, now being third in number of residents among the 700 highest-scoring examinees. This is no isolated event but an established tendency, ranging from 20 requests among the 700 highest-scoring MIR passers in 2011 to 55 residents in 2016, second only to cardiology and dermatology.
What reasons underlie the growing popularity of our beloved specialty? There is likely no single reason but multiple synergic factors that may account for this fact. A glance at the most relevant health-related news in recent years identifies gastroenterology as one of the most innovating, challenging specialties of medicine. The development of latest-generation therapies against hepatitis C virus, which are capable of curing a chronic viral infection in a few weeks, represents a landmark in modern medicine with an enormous social impact. Such is also the case with the unequivocal demonstration that colonoscopy prevents colorectal cancer, this likely being the cancer prevention program with the best results to date; the evidence that certain foods play a role in the genesis and course of many disorders; the development of newer tools that provided a way to gain insight into our microbioma as a key "new organ" for the appropriate development not only of the intestine but also of the immune, vascular, and nervous systems. Fatty liver disease, a new health challenge where a multidisciplinar approach led by hepatologists will be key for disease control; disruptive advances in the field of diagnostic and therapeutic endoscopy; ultrasonography; and the extraordinary advances in solid organ transplantation also represent some of the scientific reasons that account for our specialty's appeal among young physicians. Ours is a specialty with a natural mix of cognitive and instrumental skills.
Excellence research in hepatic and digestive diseases, preferentially translational in nature, facilitating a collection of results applicable to clinical practice and biotechnology, and promoted by clinical research networks (CIBERehd) no doubt contribute to our specialty's selectability. Such quality of research in gastroenterology and hepatology may be ascertained in the many scientific papers reported yearly by Spanish teams in journals with the highest impact factor worldwide.
Quality training, as offered by an increasing number of Spanish centers, is the third leg on which SGI training selection stands. Such training is day after day harmonized not only within our frontiers but also through common European programs, allowing a common assessment as described in the EBGH Blue Book (3). This European curriculum, whose implementation in Spain should be a short-term goal for our specialty, relevantly supplements the national training schedule in the field of gastroenterology.
Finally, the low rate of unemployment among newly licensed GI specialists, with good job prospects in both the public and private sectors, is to be underscored. Newly trained specialists usually find a job, and the SGI deficit might well be moderate in a few years (4). Such data do not apply only in Spain - the results of a recent US survey, the Physician Compensation Report (5), reveal that SGI is fourth in average annual income after orthopedic surgery, cardiology, and dermatology, a finding similar to our country regarding preferences (obviously not so regarding income).
Risks and threats
However, the relative optimism regarding the health of our specialty should not make us oblivious to the path of excellence that is required of us, identifying areas for improvement and anticipating the needs of both our future colleagues and society as a whole.
The excellent paper by Curbelo et al. does not discuss the quality of care or teaching at the various centers, nor resident satisfaction. In the future clinical practice should be based on an analysis of health outcomes, and be responsive to the needs of patients and health professionals from a technology standpoint. In this field we must doubtless become pioneers in order to develop standards allowing center comparisons regarding health outcomes, education, and research to better inform resident decisions in selecting gastroenterology or any other specialty for a career.
]]> Our specialty's complexity and high number of responsibilities sometimes leads SGI to colide with other specialties, as is somewhat common with anesthesiology and more recently oncology as well. We must clearly define and delineate our competence profile in order to avoid arguments that do nothing for patient care. In this regard, it is key that a newer SGI training program explicitly detail responsibilities regarding sedation and the necessarily multidisciplinary management of cancer patients. Such program must clearly establish how these skills are to be obtained, which will endow SGI with legal safeguards.There is little doubt that the training period must be increased - the current 4-year period is clearly insufficient, and the "Comisión Nacional" for our specialty is working on a program extension where specific training should never last less than 4 years. In this regard quality standards should also be in place for both instructors and centers. The so-called "core curriculum" scheme ("troncalidad"), currently held up but with governmental commitment to fully develop it in compliance with the LOPS ("Ley de Ordenación de las Profesiones Sanitarias"), will drive specialty training with skills development. Therefore, in the new SGI training program competences thus far overlooked but highly significant in the upcoming future should be clearly defined, including endoscopy sedation, digestive oncology, nutrition, etc. We must understand this "coreness" as an opportunity to better face the future of our specialty.
However, when thinking of quality training tutors, as key components of specialty training, come to mind. Lack of time, absence of professional recognition, and nonexistent specific training paths represent key issues in need of immediate repair. The "Sociedad Española de Patología Digestiva" has pusblished an important position statement on the competences of gastroenterology tutors (6), which we expect will open a much needed debate and further promote their role and functions, a requirement for a system aiming at total quality. Alliances may be here of much import, and seeking alliances with societies whose raison d'être is health specialty training may be significantly useful. Therefore, the "Sociedad Española de Formación Sanitaria Especializada" (Sefse-Areda), which brings together tutors and head teachers from all over the country, and has played a major role in the whole training process, may be of great help to us in the present setting.
Medicine humanization and "big data"represent the future of health innovation. We must struggle to become part of the "digital health movement" - remotely monitoring patients with mobile apps (mHealth), electronic health registry portals, social media, and biosensors allowing health care outside the clinical trenches (7), anticipating disease. While this editorial is not meant to be comprehensive, we must advance our specialty into precision medicine, defined as a medicine that is predictive, preventive, individualized, participative, and patient-centered.
Considering the fine results of SGI training selection, and the potential reasons underlying SGI career training appeal, we wish and expect our specialty to maintain or even surpass its current status in the upcoming calls. This will undoubtedly be a reason for joy for our specialty and, most importantly, for our patients.
References
1. Programa oficial de la especialidad de Aparato Digestivo. Ministerio de Sanidad y Política Social. Orden SAS/2854/2009, de 9 de octubre, por la que se aprueba y publica el programa formativo de la especialidad de Aparato Digestivo. BOE no 258 de lunes 26 de octubre de 2009, sección III, página 89582. [ Links ]
2. Curbelo J, Galván-Román JM, Sánchez-Lasheras F, et al. Aparato Digestivo: evolución de la elección de la especialidad en los últimos años. Rev Esp Enferm Dig 2017;109(9):614-8. DOI: 10.1016/j.medin.2017.02.006. [ Links ]
3. Castro V, Cremers Tavares MI. United European Gastroenterol J. Young GI Angle - Harmonised education: the EBGH Blue Book. United European Gastroenterol J 2017;5:457-8. DOI: 10.1177/2050640617699747. [ Links ]
4. González López-Valcárcel B, Barber Pérez P. Oferta y necesidad de médicos especialistas en España (2006-2030) Universidad de Las Palmas de Gran Canaria. Grupo de Investigación en Economía de la Salud Universidad de Las Palmas de Gran Canaria; 2007. [ Links ]
5. Grisham S, senior editor, editorial services. Medscape Physician Compensation Report 2017. New York: Art Science Code LLC; 2017. [ Links ]
6. Alberca de las Parras F, Alonso López S, Betés Ibáñez M, et al. Competencias de los tutores de aparato digestivo. Posicionamiento de la Sociedad Española de Patología Digestiva. SEPD; 2017. DOI: 10.17235/reed.2017.4358/2016. [ Links ]
7. Spiegel B. How digital health will transform gastroenterology. Am J Gastroenterol 2016;111:624-30. DOI: 10.1038/ajg.2016.68. [ Links ]
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