What Will Technology Do to Gastroenterology?

Medicine owes as much to technology as it does to basic science. Endoscopy, for good and for bad, changed gastroenterology more than any other technology. In 1985, the eminent English gastroenterologist, Sir Christopher Booth, wrote a long essay1Booth C.C. A point of view: what has technology done to gastroenterology?.Gut. 1985; 26: 1088-1094Google Scholar for Gut, asking "What has technology done to gastroenterology?" This article was based on a lecture he had given in Berlin the year before. Booth (1924–2012) was one of the great beasts of British academic medicine during its glory years in the decades after World War II. Early in his career, he elucidated the mechanism of absorption of the intrinsic factor–vitamin B12 complex in the terminal ileum. Booth was also an historian, journal editor, and medical politician (he was president of several organizations, including the British Medical Association). He was both a maverick and a pillar of the medical establishment, variously described as "rumbustious," "convivial," and "colorful."2Lock S. Christopher Booth.BMJ. 2012; 345: 35Google Scholar Although acknowledging all the boons of endoscopy, Booth expressed concerns about its impact on gastroenterology as a discipline:Is too much endoscopy being carried out, the technique too often providing nothing more than occupational therapy or financial advantage to the gastroenterologist? Has the new technology been beneficial to the patients whom we treat? Is it too expensive? Is it safe? And has the gastroenterologist simply become a medical technician who carries out a series of complex but personally satisfying techniques? . . . There is a real danger that some gastroenterologists are allowing themselves to become technicians rather than professional colleagues to be consulted when their help is needed (p. 1091).1Booth C.C. A point of view: what has technology done to gastroenterology?.Gut. 1985; 26: 1088-1094Google Scholar Booth belonged to that last generation of nonendoscoping gastroenterologists. He famously boasted that his interests "started at the pylorus and ended at the ileo-caecal valve."3Sir Christopher Charles BoothMunk's roll, Royal College of Physicians of London.https://history.rcplondon.ac.uk/inspiring-physicians/sir-christopher-charles-boothDate accessed: August 18, 2023Google Scholar In his jeremiad, he did not mention that he had once tried, and failed, to learn endoscopy, an experience that might have colored his views on the technology. He admitted in a 1988 interview that he had made one half-hearted attempt in the late 1950s to learn how to "put that tube down into the stomach" when he was being groomed for the post of gastroenterologist at the Royal Postgraduate Medical School at London's Hammersmith Hospital. Sir John McMichael, the fearsome chief of medicine at the Royal Postgraduate Medical School (who Booth eventually succeeded), told him "when you come to the interview I want you to be able to say you've done one." Booth asked the great Dr Francis Avery Jones at the Central Middlesex Hospital to train him in endoscopy: "He tried to teach me. It was a lost cause. I was never any good at that sort of thing but I was able to say I'd done one."4Sir Christopher Booth in interview with Sir Gordon Wolstenholme, Oxford, 10 FebruaryThe Royal College of Physicians and Oxford Brookes University, Medical Sciences Video Archive MSVA 034.1988https://radar.brookes.ac.uk/radar/file/b0bfd86d-f438-4a58-800a-a28f581ab0e9/1/Booth%2CC.pdfDate accessed: August 17, 2023Google Scholar Many of Booth's contemporaries were suspicious of endoscopy; some were openly contemptuous. There was more than a touch of snobbery behind these attitudes: Many of the older gastroenterologists viewed the young endoscopists as mere technicians. In the same year as Booth's essay, Michael Clark, a gastroenterologist at St Bartholomew's Hospital, London and co-author of a best-selling textbook of medicine, wrote in the Lancet, expressing the opinion held by many older gastroenterologists:Most young gastroenterologists want to do endoscopy because they know that eventually, however unnecessary it may be, it will earn them a lot of money . . . The young men of the 1960s became gastroenterologists because it was an exciting and expanding specialty with an intellectual challenge to understand more about gut physiology and apply this to clinical practice. The young gastroenterologist of today is only happy if he can learn another endoscopic technique: the excitement of the sixties has been replaced by the decade of the Peeping Tom (p. 629).5Clark M.L. Point of view: upper intestinal endoscopy.Lancet. 1985; 325: 629Google Scholar The British Society of Gastroenterology (BSG) was initially so skeptical of endoscopy that a group of Young Turks set up their own society, the British Society for Digestive Endoscopy (BSDE), in 1971. This new society was grudgingly recognized by the BSG only because the endoscopists persuaded the eminent Dr Sidney Truelove, one of the first physicians to carry out gastroscopy in Britain, to be its first president. Truelove met with some resistance from BSG grandees who viewed this new society as schismatic. He recalled in 1987: "At first, BSDE did not always find that its attempts to work closely with BSG were fully encouraged or supported. Suspicion and distrust withered, however, as the membership of BSDE grew and as its achievements, and of endoscopy in general, began to speak for themselves."6Truelove S.C. British Society for Digestive Endoscopy.Gut. 1987; 28: 34-36Google Scholar The two societies would eventually merge in 1980. This boom in endoscopy came with many new problems. Training was ad-hoc, haphazard, and unregulated; audit, quality assurance, and outcomes research were almost nonexistent. In the 1970s, nearly all British gastroenterologists were also generalists. The older physicians in the final third of their careers did not generally take on endoscopy, but anyone under 40 wishing to claim the title of gastroenterologist felt obliged to learn. More than a few were caught between 2 generations and 2 cultures and had to learn endoscopy "on the job," with little training and no supervision. During the early years of my training, I worked with several such disadvantaged late adopters, some of whom were ill suited to procedural work. In my native country of Ireland, more than a few unsuitable practitioners were attracted to endoscopy for financial reasons; their cecal intubation rates may have been lamentable, but nobody was counting. Gastroenterology became infected with the disease of proceduralism: Endoscopy, instead of being an aid to diagnosis and management, became an end in itself, the tail that came to wag the dog. By the 1980s, endoscopy had become the dominant concern for gastroenterology trainees. Nearly every senior trainee in Britain, for example, demanded instruction in endoscopic retrograde cholangiopancreatography (ERCP), because most of the new consultant posts stipulated this skill. Some never achieved an acceptable level of competence. Every hospital wanted its own ERCP service, when regional centers with a high patient throughput would have concentrated expertise and equipment and improved outcomes. It took many years, and several large national audits, before ERCP in the United Kingdom became concentrated in high-volume centers, and only few candidates were accepted as trainees.7The British Society of GastroenterologyERCP—the way forward, a standards framework. 2014.https://www.bsg.org.uk/clinical-resource/ercp-the-way-forward-a-standards-framework/Date accessed: August 18, 2023Google Scholar Although there was a Gadarene rush for tuition in ERCP, few sought out supplementary training in nonprocedural areas of gastroenterology. Trainees were subliminally encouraged to act rather than think and became more interested in doing procedures than learning how to manage, say, irritable bowel syndrome. A pervasive culture took root within the discipline: Gastroenterologists began to think they were just like surgeons. They had "lists"; they carried out therapies that were previously within the realm of surgery; they had complications. Endoscopists were the first nonsurgical doctors in the United Kingdom to take to theater scrubs as their everyday working apparel. Some (such as the ERCPists) even began to swagger like surgeons. But surgeons are different—in their thinking, their training, their working culture. Surgeons also enjoy the backup of the operating theatre and the anesthesiologists. Had ERCP, for example, been developed and dominated by surgeons, they would not have persisted for so many years (as gastroenterologists did) with conscious sedation alone for most cases: They would not dream of carrying out a surgical procedure of comparable complexity and risk under such circumstances. With the arrival of every new endoscopic modality in the 1970s and 1980s, there was pressure on the individual gastroenterologist, regardless of his or her existing workload, to take it on. When urgent endoscopy, for example, was shown to play an important role in the management of upper gastrointestinal hemorrhage, yet another onerous demand was placed on gastroenterologists but without a corresponding investment in the service. Many British endoscopists found themselves committed to an on-call rota for acute gastrointestinal bleeding without skilled nursing support. Later, in the late 1990s and early 2000s, we witnessed the emergence of the super-specialists, who devoted themselves almost exclusively to a single endoscopic modality. They set performance standards that jobbing general gastroenterologists struggled to match. The removal of large sessile colonic polyps, for example, may be routine for the new breed of colonoscopy specialist, but now every colonoscopist feels obliged to take on such challenges. In the 1990s, with the advent of screening colonoscopy, there was a significant expansion of the gastroenterology workforce. Demand for endoscopy and endoscopists has grown steadily since then, particularly in countries where doctors are remunerated on a fee-per-item basis. Most gastroenterologists privately admit that a great deal—it would be difficult to quantify—of unnecessary endoscopy is carried out, particularly in insurance-based health systems. Over the last 2 decades, gastroenterology has been consumed by 1 procedure: colonoscopy. Many US gastroenterologists now devote a substantial portion (for some, the majority) of their working week to this procedure. And so the gastroenterologist became a professional chiefly defined in the minds of the public, their patients, and their colleagues as a doctor who carries out endoscopy. Letters to gastroenterologists from referring doctors nearly always begin with a request for an endoscopy; patients come to the clinic with an expectation of it. Endoscopy training gradually became standardized and regulated; the practice of endoscopy became governed by guidelines and core quality indicators and was rigorously and regularly audited. The nonendoscoping gastroenterologist (apart from a few rare, exotic specimens in academe) disappeared. As the demands of endoscopy increased with every passing year, the "cognitive," or nonprocedural, aspects of gastroenterology were neglected. Insurers and managers could easily quantify (and remunerate) a colonoscopy, but how do you gauge a consult on a surgical inpatient with a complex fistula? Or the treatment of refractory inflammatory bowel disease? Or the management of the most challenging patients with functional disease? Perverse incentives, financial and professional, encouraged endoscopic activity at the expense of work at the bedside and in the clinic. Various plausible scenarios have been outlined for the future of endoscopy. These include wireless capsule endoscopy replacing most routine esophagogastroduodenoscopy and colonoscopy, artificial intelligence (AI)-assisted characterization of lesions, and therapeutic endoscopy performed by a combination of robotics and AI. A 2021 review on robotics and AI in gastrointestinal endoscopy concluded:Although these two fields [robotics and AI] are evolving independently, there is a strict connection between them. Today's endoscopic systems with AI mostly have a first or second degree of automation. This means that while the endoscopist is advancing the colonoscope the AI system recognizes polyps. For comparison, self-driving cars already have a fourth degree of automation onboard. This means that these cars can recognize the road and can drive in autonomy, commanded by AI systems. The connection between robotic endoscopy and AI will inevitably bring endoscopes to the fourth degree of automation. This means that the endoscope will advance, recognize, and resect the lesion alone (p. 44).8Boškoski I. Orlandini B. Papparella L.G. et al.Robotics and artificial intelligence in gastrointestinal endoscopy: updated review of the literature and state of the art.Curr Robot Rep. 2021; 2: 43-54Google Scholar It is possible, therefore, that much or even most of the routine work currently performed by endoscopists will, in the unknowable future, be taken over by other modalities or carried out by machines. A great deal has been written about the threat of AI to the traditional professions, particularly medicine. Gastroenterologists should be unperturbed. The new technology, paradoxically, could free the discipline from the shackles of proceduralism. AI may take over much of endoscopy, but it is unlikely to replace satisfactorily the human interaction between patient and doctor. AI will be far better at most tasks than error-prone human beings but will never possess the quality we acquire so arduously and painfully: clinical judgement. Prediction is a dangerous game, but let's imagine a future where the machines do the procedures: What would gastroenterologists do? They would still be doctors but no longer technicians; the gastroenterologist of the future may be financially poorer but professionally richer. I think Sir Christopher Booth would approve. Toward the end of his life, he wrote "On being a patient," based on his own experience of prolonged illness in old age: "Practical and important though many procedures are, requiring both skill and experience, for the patient, nothing can replace the compassion and sympathy that the caring professions owe the afflicted" (p. 3).9Booth C. On being a patient.in: Warrell D.A. Oxford textbook of medicine. 5th ed. Oxford University Press, Oxford2010: 3-5Google Scholar