The field of gastroenterology in the United States has undergone a significant transformation over the past 5 to 10 years, driven by a confluence of historical changes in training programs, changing demographics among GI doctors due to the relatively new specialty of GI endoscopy, and a dwindling supply of gastroenterologists. These factors have culminated in a notable impact on gastroenterology physician salaries and have raised important questions about the future of this vital specialty.

Historical training programs: a shift in focus

To understand the basic problems in GI training programs and the demographics of GI doctors, you have to understand the history of the clinical specialty. Clinical gastroenterology is based on the introduction of the first viable flexible colonoscope in 1972. Early training programs were really going strong in the early 1980s. By the 1990s, few if any GI doctors were over the age of 45. It was unheard of for a gastroenterologist to have retired, and there were 1,000 newly minted GI doctors completing training each year.

The roots of the current challenges faced by the gastroenterology workforce can be traced back to decisions made several decades ago. In the early 1990s, a decision was made to extend the GI fellowship training from two to three years, followed by the addition of a fourth year for advanced procedures like ERCP. This initiative aimed to enhance the proficiency of gastroenterologists in performing specialized procedures and providing comprehensive care to patients. However, this extension of training had unforeseen consequences for the number of doctors entering the field and forced GI training programs to reduce the number of fellows being trained each year due to CMS not increasing funding to meet the growing educational demands of the specialty.

Demographic changes and a shrinking workforce

The landscape of medicine has changed dramatically over the past few decades, with shifting demographics among medical professionals. In the early 1990s, the majority of medical school graduates were men, and this influenced the specialization choices they made. Gastroenterology, along with other procedure-oriented specialties, saw a higher concentration of male doctors. However, the gradual increase in the number of women entering the medical field has led to a shift in specialization preferences, adding to the challenges to the supply of gastroenterologists.

Supply-demand mismatch: impact on salaries

The present scenario in gastroenterology is characterized by a significant supply-demand mismatch. The demand for gastroenterologists has surged due to population growth, an aging population, and increased awareness of gastrointestinal health. However, the supply of gastroenterologists has failed to keep pace due to various reasons, primarily related to the lack of funding to grow the number of GI fellowship positions by CMS. The situation has resulted in the number of GI doctors becoming board-certified in the 1990s decreasing from about 1,000 per year to about 600 per year in more recent years. Many qualified practicing GI doctors left the full-time practice of gastroenterology and only return if the salary incentive is adequate to take them away from their other interests. Over time, the number of those willing to return to work has been shrinking as the demand has been increasing. The popularly reported average income of gastroenterologists in this country is not a true representation of the current state of affairs and is a common source of humor amongst GI doctors, none of whom would consider working for the reported “average” salaries we read about.

Changes in government policy resulted in a boom in private outpatient endoscopy centers in the early 2000s and then further government policy changes in the mid-2010s resulted in the now aging group of established GI doctors selling their practices, outpatient endoscopy centers, anesthesia services, and pathology services due to increasing regulatory burden placed on those practices by the government. Those doctors often had 5-year contracts to continue working for the new owners, hospitals, and private equity companies. Those 5-year contracts have now started to end, and many of those doctors have retired early or significantly cut back the number of hours they work.
This shortage of gastroenterologists has had a direct impact on compensation dynamics. Hospitals and health care facilities are vying for the limited pool of GI doctors, resulting in a situation where the law of supply and demand governs compensation negotiations. Hospitals, especially in densely populated urban areas, are feeling the pinch of this imbalance to a greater extent as they have negotiated lower and lower fees in order to compete with a shrinking pool of hospital systems to win patient volume. In an attempt to attract and retain gastroenterologists, facilities are compelled to offer competitive compensation packages that reflect the changing market dynamics by using revenue generated not just by physician fees but also based on the value of the ancillary services that the GI doctor can refer and generate for the hospital.

A not-so-complex solution

Addressing the current manpower and compensation challenges in gastroenterology requires a multifaceted approach but must start with increasing the funding by CMS to train new gastroenterologists so that we can start having at least as many new GI doctors completing training as are retiring each year. Additionally, removing private corporations and hospitals from owning gastroenterology practices would allow doctors to again have the independence and pride in their practice that kept them working much longer careers than they now work.

Investment in training programs, including efforts to increase the number of gastroenterologists entering the field, is crucial to bridging the supply-demand gap. Encouraging diversity and inclusion can help attract a wider range of medical professionals to the specialty.

In conclusion, the current state of manpower and salary expectations in gastroenterology reflects the intricate interplay of historical decisions, demographic shifts, and the evolving health care landscape. While the challenges are significant, we are basically left waiting for our elected representatives to do the right thing: to increase funding for medical training, reduce the burdens of regulatory compliance, and once again reward doctors to own and work in their own private practice.

Brian Hudes is a gastroenterologist.