GI fellows have decisions to make.

What kind of career track do they want, academic or private practice? And in what setting? Private practice and academic institutions offer various settings with a mix of advantages and disadvantages.

For instance, there are two tracks in academia, the clinician educator and the physician scientist, explained Lin Chang, MD, AGAF, one of several veteran GI professionals who spoke at an AGA symposium on career and professional-related issues on Monday, May 8, at DDW^® 2017.

“The clinician educator is primarily a clinician,” said Dr. Chang, professor medicine and director of the GI fellowship program at the David Geffen School of Medicine at the University of California, Los Angeles. “The physician scientist is primarily a researcher. You need to devote at least 80 percent of your time to research to be successful in getting independent funding. With the decline in federal, institutional and industry funding, the clinician educator is a dying breed.”

Success rates for grant applications to the National Institute of Diabetes and Digestive and Kidney Diseases in FY 2016 ranged from 44.6 percent for K08 grants down to 9.7 percent for R21 grants, Dr. Chang said. K08 is a career development award for mentored clinical scientists; R21 is an exploratory/developmental grant.

Meanwhile, only 19.5 percent of R01 applications were successful in 2016, Dr. Chang said, while the average investigator age at their initial R01 or equivalent award has climbed to 42 years.

“It’s important for our leadership to know these grant application statistics,” she said. “They have to support early career individuals much longer than they may realize based on their own experiences.”

What makes researchers successful? They must know their own interests, strengths and skills, Dr. Chang said. They must know their current skill set and the types of skills they need. And they must know the type of environment they want to work in and have a plan to get there.

Fellows should choose a research niche early in their fellowship, if not before. And the most successful researchers have two key qualities: flexibility and grit.

“You have to be able to change and adapt to the opportunities that are there,” Dr. Chang said. “You have to be able to move with the opportunities. It’s the most tenacious people, the ones who stay in the game, who have success, not the smartest.”

Private practice

The private practice world can also be challenging to navigate. A chief difference between academia, employment and private practice is the variety of potential income streams. Private practice GIs may have income from professional fees, facility fees, pathology, anesthesia, infusion, pharmacy, research activities and more.

“Only 20 percent of health care spending goes to physicians,” said Rajeev Jain, MD, AGAF, of Texas Digestive Disease Consultants, Dallas. “We are the gateway for the other 80 percent.”

The challenges of private practice are clear.

Reimbursement continues to shrink as operating expenses continue to rise. In constant dollars, Medicare reimbursement for colonoscopy, the primary revenue stream for most private practices, fell between 16 and 24 percent from 2010 to 2016.

Anesthesia service models are under increasing scrutiny from the Health and Human Services Office of the Inspector General.

In-office ancillary services are vulnerable to legislative changes.

The Centers for Medicare and Medicaid Services (CMS) wants to reduce Medicare Part B drug payments.

The Stark Law inhibits the consolidation and integration needed to meet changing market forces.

And health systems and payors are consolidating, with payors establishing narrow networks in an effort to control their costs. The Affordable Care Act remains in flux.

“One thing that’s not in flux is MACRA, the Medicare Access and CHIP Reauthorization Act of 2015,” Dr. Jain said. “Starting in 2019, CMS will connect payment to quality. Physicians have been very good at managing our performance risk — we are very good at taking care of our patients. What we are not equipped to do is manage insurance risk, which is what MACRA has us do.”

Innovative GIs are creating their own vehicles to navigate the new health care landscape. Project Sonar, a Crohn’s disease-focused medical home, showed an 11 percent reduction in total treatment costs in its demonstration phase. Much of the savings resulted from a 50 percent reduction in emergency room and in-patient payments. Part of that savings becomes new revenue to the practice.

Project Sonar has gone national with 20 practices and more than 600 GIs, Dr. Jain reported. A colonoscopy payment bundle model will be submitted later this year.

“In the face of challenges, practices have responded by consolidating, integrating and innovating,” Dr. Jain said. “There’s a strong future for independent practice.”

Click here to read more about MACRA and Project Sonar

Work-life balance

GIs are busier than ever. Shifts in technology, regulation, reimbursement and culture have shifted work from office staff to physicians.

“I used to dictate my notes after seeing a patient and a nurse would type them up,” said AGA President Sheila E. Crowe, MD, AGAF. “Now I enter everything into the EMR myself. The freedom of the physician is not what it used to be.”

For every hour spent with patients, GIs now spend two hours working with electronic medical records and other nonclinical tasks, Dr. Crowe said. So it’s no surprise that half of GIs have symptoms of burnout.

The perfect work-life balance does not exist, Dr. Crowe continued. Balancing work and life is more like juggling multiple balls than balancing opposing forces.

“If you’re juggling six or eight balls, you have to decide which ball you are willing to drop first,” she said. “It’s easy to say yes to every request and overextend yourself. Getting enough sleep can help, getting exercise can help. But you have to prioritize. Decide what you must do and let go of the things that are not productive, helpful or fun.”

The best way to deal with burnout is to eliminate and avoid the stresses that create it, she said. Build a support network to help with tasks like childcare and schedule time to spend with your family and partner. And never jump to say yes when asked to serve on a committee or take on a new task.

“Never say yes until you have found out precisely what’s involved,” Dr. Crowe said. “Chose to do what you are passionate about, not what someone asks you to do. In work and in life, your passion has to drive you.”