Let’s be honest here. People with esophageal conditions are often overlooked and neglected by the healthcare system. Even worse, some patients with known esophageal conditions undergo unnecessary or wrong treatments and suffer significant long-term complications or remain under-treated and suffering unnecessarily for long periods of time. Why is that? I believe it is neglect on the part of physicians and our healthcare system, albeit benign neglect (not on purpose), but unnecessary and getting worse as our healthcare system moves more toward a business and profit model rather than a caring for people’s health model (possibly more on that in a future Post).
The Esophagus
The esophagus is a very simple organ whose primary function is to move food from your mouth to your stomach. Different than the rest of the GI tract, there is no breakdown, processing or absorption of what is swallowed, only movement of what is swallowed into the stomach. For this to occur there are two basic mechanical actions, the esophagus helps push that food to its end (gravity also does some of this) and a valve at the end of the esophagus regulates how the food passes into the stomach and helps keep it in the stomach. When it is working normally, we are all completely unaware of what the esophagus does. However, when it is not working normally, the implications to quality of life and overall health can be huge.
Over the years the consequence of esophagus dysfunction has been under appreciated and overlooked by physicians. In part because of the lack of understanding and inability to diagnose the cause of abnormal function (e.g., acid reflux or GERD, esophageal cancer, or food getting stuck when swallowing), but also because there is no formal medical specialty dedicated solely to esophageal diseases. With such significant implications, why is there no specialty dedicated to esophageal disease?
In this post, I’ll offer my views and opinions as to the reasons behind the absence of an esophageal specialty, how related fields address esophageal conditions, and why someone like me who focuses exclusively on esophageal conditions is, in my opinion, so critical to getting the best outcomes when managing these conditions.
The Value of Being a Generalist
Today, the more established and “general” a problem is, the easier it is to scale the delivery of care. Let me explain. Scaling means to continually increase the number of patients cared for by a given doctor. For example, you have all experienced the change in your Primary Care Physician’s (PCP) practice. You will see a physician’s assistant, nurse or other allied health person, and only see your doctor for a few minutes, if at all. This is because a busy PCP will see a lot of routine problems that can easily be managed by a physician assistant, nurse or physician extender. Protocols can be established, and the doctor’s direct involvement can be limited to a few minutes for each visit, or even not seeing the patient at all. This allows a single doctor to see dozens of patients each day. Heads up, artificial Intelligence promises to even further standardize care and increase this patient throughput – scaling. This can be a very efficient and beneficial form of care, but only for those more routine conditions for which a standard protocol can be effective for most patients.
Specialization has some similar features. Established specialties like cardiology and neurology also have enough patient volume and standardization of care within a specialty to allow similar scaling of the practice. Allied health professionals can provide a significant amount of care using standard protocols, and the physician’s involvement can then be limited. This model in specialty practices where procedures are performed allows an opportunity to perform more procedures. By the way, doctors generate more money for their practice with procedures. For example, a gastroenterologist will have allied health providers do much of the office and direct face-to-face care and focus much of their time performing endoscopy for any and all conditions of the GI tract. This further dilutes the doctor’s direct involvement with all aspects of a patient’s care and focuses their thinking and efforts toward the more routine, well understood conditions, and those managed entirely within their specialty where procedures can be offered.
To be fair, this is a very efficient and effective method for delivery of care for routine and well understood conditions, AND conditions that fall entirely within that doctor’s specialty. For more complicated, incompletely understood conditions, or those that span many specialties, this model of care overlooks and neglects many patients.
Esophageal Problems Are Typically Shared Responsibility Across Specialties
Esophageal diseases span several medical disciplines, and with that remain incompletely understood with a more fragmented approach to management:
Gastroenterology: Focuses on disorders of the gastrointestinal (GI) tract, including esophageal issues. This specialty has the greatest opportunity to provide comprehensive esophageal care, but gastroenterology management is primarily medical (prescriptions) or procedural to make a diagnosis. A gastroenterologist cannot perform surgery to correct abnormal anatomy of help correct most causes of esophageal dysfunction. Patients who need more than a prescription are referred to a surgeon.
Otolaryngology (ENT): Addresses swallowing disorders and throat-related complications. Typically manage the consequences of esophageal problems on the voice and throat. Like a gastroenterologist, ENTs will do diagnostics (primarily rule out non-esophageal reasons for symptoms) and then refer to a GI or surgeon.
Surgery: Two types of surgeons offer esophageal surgery.
Thoracic Surgery: Handles surgical interventions for organs in the chest like the esophagus. Focus is not specifically the esophagus, just the surgical approach to the esophagus thru the chest. Also focus on lung disease and any other disease of the chest.
General & Bariatric Surgery: Handles surgical interventions for organs in the abdomen. Focus is not on all aspects of esophageal disease, just the surgical approach to the esophagus thru the abdomen, and especially skilled with the use of laparoscopy (minimally invasive surgery) for abdominal condition. Primary focus is more general or weight loss surgery.
Others: Allergists, nutritionist, naturopaths and homeopathic care givers often get involved as patients seek solutions for their symptoms. These care givers can offer life-style change recommendation, but like others cannot provide comprehensive diagnosis and treatment.
These overlapping interests and responsibilities mean that no single specialty has claimed the esophagus as its exclusive domain, and with that we continue to have fragmented understanding and management of the esophagus and its dysfunction.
Why No Esophageal Specialty Exists
Multidisciplinary Nature
The esophagus is connected to both the upper GI system and the respiratory tract, blurring the lines of responsibility. This overlap makes it challenging to carve out a distinct specialty without encroaching on others.
Breadth vs. Focus
While esophageal diseases are significant, they represent a subset of disorders within gastroenterology and surgery. Many professionals believe the current system allows for sufficient coverage without creating a new specialty. This ignores the unique problems of the esophagus and the need for more sophisticated diagnostic & management strategies.
Training Pathways
Existing training programs in gastroenterology and surgery already address esophageal diseases, though not exclusively. Again, the belief that the esophagus and its diseases are not complicated or important enough to warrant exclusive, focused attention.
Limited Demand for Exclusivity
Unlike cardiology or neurology, where focused specialties emerged due to high patient volume and complex care needs, esophageal diseases have historically not been seen as that prevalent, complicated, or impactful to justify a standalone specialty. This is ironic when considering that one of the most prescribed medicines today are those used to manage GERD, and the leading GI condition in terms of healthcare cost.
Challenges in Comprehensive Esophageal Care
Patients with esophageal diseases often experience fragmented care. For example:
A patient with GERD may see a gastroenterologist, but if medicine fails to control symptoms, they may require input from a surgeon for corrective surgery.
Patients with chronic cough, breathing issues or voice change will see a pulmonologist or ENT who will diagnose GERD and refer to a GI. A GI will use medication to try and alleviate those symptoms. When that doesn’t work the GI will claim it is not GERD and send patient back to GI. If a surgeon gets involved an operation may be offered without the full integration of all of all of the data leading to a poor outcome.
Surgeons will be able to perform operations to correct GERD but rarely have a comprehensive understanding of esophageal function and disease, resulting in misdiagnosis and possible unnecessary surgery.
Disagreements between specialties seeing patients with esophageal disease can lead to competition for these patients and management strategies confounded by this competition.
This fragmentation highlights the need for an integrated, comprehensive understanding and approach to management. Someone who can guide a patient through the diagnostic testing to find the problem and offer all treatment options, not just the ones typically limited to their specialty.
Conclusion
With no dedicated specialty for esophageal diseases today and a fragmented approach, with each specialty involved (GI, Surgery, ENT, etc.) only addressing their part of the problem and offering treatment limited by their specialty, esophageal conditions today are frequently overlooked and neglected. Patients embark on a scavenger hunt to find someone who will listen to their problems and integrate knowledge from all the specialties when mapping out a diagnostic and treatment plan. Regrettably, such a person is rare and can be very hard to find.
C. Daniel Smith, MD
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